II - LETTER OF AS & MD ON

PLANNING PROCESS 2010-

2011
 D.O. No. 10 (2)/2008-NRHM-I
8th October 2009

SUBJECT: NRHM-PLANNING PROCESS 2010-2011

At the outset, I would like to convey my appreciation for the

initiative taken by your State in implementation of the National Rural
Health Mission (NRHM). We are confident that a lot of the priorities that
were set up for the current year shall be achieved under the programme.
As part of the preliminary exercise of planning for next financial year, I
would request the States to carry out a review and focus on some of the
following key priorities in the next few months.

2. The exercise of Plan preparation from the Village to the Block to the
District and finally to the State PIP required to be scaled up as early as
possible. Based on the assumptions that there would be at least 25
percent increase in the allocation of resources in the next financial year, I
would suggest that the State Governments may work out the resource
allocations for districts as well as for blocks to facilitate Block and District
level planning. The appraisal meetings and consultations at Block and
District levels should be taken up so that the State PIP fully reflects the
aspirations of the local level.

3. The planning process for 2010-11 may be initiated in the month of

October 2009 as per the following schedule.

• State to send Resource envelope to Districts –October 2009

• District Plans based on Village/Gram Panchayats /Block Panchayat
Samiti Plans –December 2009.
• First Draft PIP before State Health Mission- First Week January 2010.
• Pre-appraisal meetings in January up to 15th February, 2010.
• Final NPCC meetings between February and 15th March, 2010.

4. The Structure of the PIP would be the same as in the earlier years
which would be in five parts as follows; A. RCH Flexible Pool B. NRHM
Mission Flexible Pool C. Routine Immunisation D Disease Control
Programmes E. Inter-sectoral convergence. The Infrastructure
maintenance through Treasury Transfer which was missed out earlier in
the structure should be reflected. Activities taken up under other Health
programmes (trauma centres, nursing etc) and those supported by
external agencies like World Bank, DFID and also Finance Commission
Awards should also be reflected.
5. The detailed progress to be reflected in the PIP should include the
following:

I. Progress on infrastructure development.

II. Filling up of existing regular vacancies by the State
Government.
III. State Government’s allocation, release and expenditure under
normal health programmes over the years.
IV. Progress of NRHM during 2009-10, (a) in institutional set up
e,g ASHAs, VH&SC, PRIs, RKS, BHS/BHM, DHS/DHM, SHS/SHM
etc, (b) in facility operationalisation 24X7 PHCs, SCs, CHC as
FRUs, DHs, (c) in DHAPs, MMUs, (d) in fund utilization, (e) in
streamlining procurement and logistics, HMIS and training and
skill upgradation.
V. Performance under NRHM over the years on key outcome and
process indicators like IMR, MMR, TFR, full immunisation,
institutional delivery, reduction in malaria, filaria, kalazar ,
leprosy prevalence, TB cure rate, cataract operation etc

6. The following key areas have been identified for priority action in
2010-11;

• Clear Action Plan for Backward Districts as part of the PIP -

The State must identify backward areas for greater attention
(difficult, left wing affected, minority, tribal, SC/ ST gender etc.). We
would also request that special incentive to medicos and para-
medicos for performing duties in difficult areas, which was part of
100 days agenda of this Ministry may be made part of the State PIPs
for the year 2010-2011.

• Clear Action Plan for streamlining of procurement and

logistics - Supply Chain Management System, Procurement
Management Information System (ProMIS) and Rational Drug Use.
To ensure sustainable drug supply at all levels and its
replenishment, logistic and information systems arrangement need
strengthening on a priority. We would request the States to fully
reflect their plans for strengthening logistic arrangements in the
PIPs for 2010-2011.

• Clear Action Plan for Operationalising HMIS up to facility

level - The States must endeavour to have a road map for web
enabled facility based reporting and put in place tracking of
information on pregnant mothers and children’s immunization.

• Capacity Development of all Institutions crafted under

NRHM – ASHA, VHSC, RKS, PRIs, Programme Management Units,
MIS etc
 • Higher utilization of financial resources under NRHM -
Greater thrust should now be on facility specific reporting of
progress on expenditure.

• Clear plan for human resources for health which should

interalia include the steps undertaken by the States in filling up
vacancies.

• Clear Action Plan on Training and Skill Development aiming at

a comprehensive and integrated training plan.

7. The following key priority themes have been identified for priority
action in 2010-11;

 Neo Natal Mortality – Facility and Home based care for newborn.
 Population Stabilization.
 Malaria.
 MDR – TB.
 Making facilities family friendly – water, electricity, clean toilets,
lights, security.
 Vibrant VHSCs and RKSs.
 NABH/ISO certification of government facilities.

I am confident that your personal oversight of the planning process

would go a long way in enriching the quality of the Plan in 2010-11.

Yours sincerely,

( P.K. Pradhan )
To
Mission Directors, NRHM of all the States
(As per list attached)
III – PROGRESS ON REFORMS
AS MANDATED WITH PIP
APPROVAL 2009-2010
 III - PUSHING REFORMS WITH RESOURCES
PROGRESS ON CONDITIONALITIES WITH PIP
APPROVAL
2009-2010
(Please put “Y” for Yes and “N” for No)
1. All posts under NRHM are on contract and based on local criteria. The
contract should be done by the Rogi Kalyan Samiti /District Health
Society. The stay of person so contracted at place of posting is
mandatory. All such contracts are for a particular institution and non
transferable. The contracted person will not be attached for any purpose
at any place.
2. Blended payments comprising of a base salary and a performance
based component, should be encouraged.
3. State Government must fill up its existing vacancies against sanctioned
posts, preferably by contract.
4. Transparent transfer and career progression systems should be
implemented in the State.
5. Delegation of administrative and financial powers should be completed
during the current financial year. If not already done.
6. State shall set up a transparent and credible procurement and Supply
chain management system and Procurement Management Information
System (PAOMIS) [on the lines of the Tamil Nadu Medical Services
Corporation]. State agrees to periodic procurement audit by third party
to ascertain progress in this regard.
7. The State shall undertake institution specific monitoring of performance
of Sub Centre, PHCs, CHCs, DHs, etc.
8. The State shall operationalize an on-line HMIS in partnership with
MOHFW.
9. The State shall take up capacity building exercise of Village Health and
Sanitation Committees, Rogi Kalyan Samitis and other community /PRI
institutions at all levels.
10. The State shall ensure regular meetings of all community
Organizations /District /State Mission with public display of financial
resources received by all health facilities.
11. The State Govts. shall also make contributions to Rogi Kalyan Samitis
and transfer responsibility for maintenance of health institutions to
 them.

12. The State shall endeavour to bring the Budget of Health facilities under
the supervision of the concerned Rogi Kalyan Samitis.
13. The State shall prepare Essential Drug lists of generic drugs and
Standard treatment Protocols, and give it wide publicity.
14. The State shall focus on the health entitlements of vulnerable social
groups like SCs, STs, OBCs, Minorities, Women, migrants etc.
15. The State shall ensure timely performance based payments to
ASHAs/Community Health Workers.
16. The State shall encourage in patient care and fixed day services for
family planning.
17. The State shall ensure effective and regular organization of Monthly
Health and Nutrition Days and set up a mechanism to monitor them.
18. All performance based payments/incentives should be under the
supervision of Community Organizations (PRI)/RKS.
19. The State agrees to follow all the financial management systems under
operation under NRHM and shall submit Audit Reports, FMRs, Statement
of Fund Position, as and when they are due. State also agrees to
undertake Monthly District Audit and periodic assessment of the
financial system.
20. The State agrees to fast track physical infrastructure upgradation by
crafting State specific implementation arrangements. State also agrees
to external evaluation of its civil works programmes.
21. The State Govt. agrees to co-locate AYUSH in PHCs/CHCs, wherever
feasible.
22. The State agrees to focus on quality of services and accreditation of
government facilities.
23. The State/UT agrees to undertake community monitoring on pilot basis,
wherever not tried out as yet, and scale up with suitable model
wherever piloted earlier.
24. The State/UT agrees to undertake continuing medical and continuing
nursing education.
25. The State agrees to make health facilities handling JSY, women and
child friendly to ensure that women and new born children stay in the
 facility for 48 hours.

26. The State Governments shall, within 45 days of the issue of the Record
of proceedings, issue detailed District wise approvals and place them on
their website for public information.
27. The State agrees to return unspent balance against specific releases
made in 2005-06, if any.
28. The State is entitled to engage a second ANM to the extent that it
provides for MPW (Male) or the contractual amount of 2 nd ANM be paid
out of State Budget and Third functionary may be engaged from NRHM
Fund.
IV - BROAD FRAMEWORK FOR
PREPARATION OF PIP 2010-
2011
 Broad framework for Preparation of
State PIPs
2010-11
Background

The Planning process under NRHM has seen significant evolution

from norm based funding in 2005-06 under NRHM to a bottom up
process resulting in 617/643 Integrated District Health Action Plans
for the country in 2009-10. The District Plan as the key instrument of
planning has contributed significantly to the considerable
achievement of NRHM in a short span of 5 years. It’s contribution in
setting up of enabling institutional structures right from the village to
the State level , provision of untied resources for local action,
identifying areas for focused attention through facility and household
surveys, convergence with wider determinants , have been some of
the many achievements of decentralised planning. The Broad
Framework for preparation of District Health Action Plans, issued in
August 2006 by the Ministry of health and Family Welfare, has been
the basis for planning under NRHM. It laid down a comprehensive
structure for the planning process and all programme divisions
provided the basic formats within which information was required for
the effective planning and implementation of NRHM. The broad
contours of the District Health Action Plan, resource allocation and
norms, system of conducting situation analysis, Block level
consultations, setting objectives, district planning workshop, work
plan and average costs, monitoring and programme management
and the structure of the District Health Action Plan, were discussed in
great detail in the Broad planning framework for NRHM. This has
formed the basis for decentralized planning.

The initial journey of resource and input intensive planning has

been essential to galvanise a hitherto underfunded and
underperforming, public health system. The provision of resources
has led to expansion of public health infrastructure, additional human
resources, and creation of community structures for greater
community ownership. This strong push to system strengthening, in a
decentralised and non verticalised framework has also had positive
programmatic impact evident in increased access to public health
systems, evident in increased number of OPD, IPD cases,
immunisation, institutional delivery, reduction in disease related
morbidities etc.

However, now as NRHM enters mid course, focus on

consolidation, accelerated pace of implementation for faster
achievement of health outcomes becomes imperative. In its five
years’ course, a lot of evidence both from primary ( household and
facility survey, community monitoring reports, internal HMIS data etc
) and secondary sources (DLHS-III, SRS, Common/ Joint Review
Mission, Independent Survey and Evaluations etc ) have thrown up
newer challenges which need to become the base for a newer
evidence based planning.

Situational Analysis

The current situation regarding health status, health services, human

resources in health, access and utilisation of services, should be
analysed using all available data sources.

Possible Data Sources:

Trends—NFHS, DLHS, SRS, Census

Current situation –IDSP, HMIS/DHIS, NRHM quarterly reporting
Others--Facility surveys, micro-studies, programme evaluations
Qualitative assessments—CRM, Community monitoring

Triangulating data sets gives reliability to the situational analysis.

Bringing together the analytical findings of these data sets into a
logical coherence provides additional and important insights on
achievements as well as gaps.

Para on the possible use of each one and how they can be analysed
together given in the appendix.

Need Assessment

Based on the situational analysis and broad goals and objectives of

NRHM, priority areas have to be identified for action in the coming
year. Achievements as well as barriers to operationalisation of plans
should be identified and taken into consideration. Adopting the
strategies laid out in the NRHM framework for action, activities should
be planned along with ways of overcoming the barriers to their
operationalisation experienced in the past.

Incremental systems strengthening is a primary goal and requires

assessment of the stage reached by the State/district/block in various
components—infrastructure, human resources recruitment and
trainings, services provided, …..

Operationalising the System for Health Outcomes:

Since we are 4 years into the NRHM, it can be expected that we focus
on some health outcomes as well. While IMR and MMR require longer
periods for impact and measurement, and have multiple
determinants, outcomes contributing towards the lowering of these
indicators, can be planned for within one year. For instance, if water-
borne diseases such as diarhoeal disease and jaundice may be
identified as major health problems in a district, using IDSP data or
block level ANM/MO assessment. [We could think of ASHAs collecting
morbidity data for their village and that would help identify priority
problems and hotspots within a block or even as ‘tolas’ within a
village.]
Strategies & Activities

Besides planning for all the NRHM strategies, planning for control of
the identified priority problem could be done with intensive input.
This would require emphasis on convergent planning with water
department, TSC, ANM/MPW (M), AWW and ASHA. Similarly, if
malnutrition in children is identified as the problem, suitable planning
would have to be done to target it. For MMR, PNC is a commonly
found lacuna and this could be identified as priority.

Each state should identify 1-3 such problems and the

strategies/activities they will undertake, with the expected outcome
by the next year. The outcome could be decreasing the hotspots or
the incidence in these areas. This would be taken as a non-negotiable
outcome for the state. [While initially, low levels of outcome may be
accepted, the scale of outcomes should rise substantially in the
coming year, especially in states where institutional strengthening
has proceeded well.]

For the states/districts which have reached a substantial level of

strengthening of infrastructure, HR and management structures,
outcomes in terms of meeting the full spectrum of service delivery
guarantees must now be insisted upon. Operationalising the system
for horizontally and vertically integrated outputs for achieving
specified health outcomes is now the requirement.

Where capacities are still weak to do so, prioritization of 1 or 2

problems and outcomes against those will give a push to the
strengthening process.

For Targetted, Context-specific, Non-negotiable Outcomes

BLOCK level

A. Each block prepares a SC level plan for delivery of

service guarantees to each of the villages under its
charge.

B. In addition to existing activities, dealing intensively

with one major childhood health problem to contribute to
decline in mortality:
 • Each block to identify major public health problem (eg.
diarrgoel disease, malnutrition, malaria) contributing to child
morbidity and mortality and ensure services for it.

• Identify hotspots (villages or tolas within villages) using IDSP,

MO/ANM/ASHA information and plan intensive convergent
inputs for them.

• Organise use of STGs—as a home to hospital continuum.

• State the committed outputs/outcomes

DISTRICT level

A. Triangulation of data:

• IDSP, HMIS/DHIS to give current data (NRHM concurrent

evaluation in 284 districts to be used when available)

• SRS, DLHS & NFHS to identify trends

• Any other: facility surveys/ ICDS-ANM data on weight of

children/collation of block data/ micro-studies etc.

B. Facilitation and supportive supervision of block

exercise to ensure basic service guarantees. HR and
trainings to be planned accordingly.

C. Facilitate block exercise at identifying major health

problems and dealing with them.

D. Train and supervise use of STGs for at least the

identified major problem.

STATE Level:

A. Develop STGs (Standard Treatment Guidelines) from

home to hospital continuum: for child health + 1 major adult
health problem other than the NHPs.—Plan all inputs to fulfill
these in addition to existing programmes, as system
strengthening activities. For instance:

• Diarhoeal disease—HBNCC + rehyderation at all 24x7

PHCs + convergent inputs
• MH—plan for increase in PNC

• Malnutrition—strengthen VHSCs and VHNDs to identify

mod-severe malnourished children (hotspots?)—link AWW-
ASHA-ANM & SHG—improve child care and feeding in the
village as a whole.
 B. Ensure HR in place and trainings

Log-frame given below may be useful for the Planning

For Block level: Collating data from each village by SC staff

Sl. Issues in Planning Current Activities to Outputs to Time

No for SDHs/ DHs Status be be achieved Frame
. undertaken for 2010-
to achieve 11
targets
Delivery of HMIS/DHIS
service data, PHC &
guarantees in ANM service-
each village mapping
exercise
(toolkit in
appendix)
Identify (i) one IDSP, PHC &
major childhood ANM health
health problem problems-
and its hotspots. mapping
(toolkit in
appendix)
Plan to undertake
intensive
convergent action
for its prevention,
especially in the
hotspots.
Put in use STGs to
deal with patients.

For District level facilitation and supportive supervision of

targeted context-specific outcome

Sl. Issues in Current Status Activities to Outputs to Time

No Planning as per evidence be be Frame
. from data undertaken achieved for 2010-
triangulation to achieve 11
targets

I. Facilitation Triangulate HR and

and larger data sets trainings to
supportive with block level be planned
supervision of data on accordingly.
a) block exercise HR/skills/service Protocols for
to ensure s supportive
basic service supervision
b) guarantees.
Ensure HR /
skills/
Supportive
supervision

II. Facilitate Collate block

block exercise level data on
at identifying childhood health
major health problems and its
problems and hotspots.
dealing with Triangulate with
them. other sources of
data on health
problems (IDSP,
SRS on
IMR/MMR,

III. Orient and a) Training

supervise use for use of
of STGs for at STGs for at
least the least the
identified identified
major major
problem. problem.
b)Preparatio
n of
supervisory
protocol for
use of STGs

IV. Facilitate
intensive
convergent
a) action for
preventive
action.
b) Active
involvement
through DHS of
members from
all concerned
departments/P
 RI.
Strengthening
of VHSC
functioning.

In an effort to facilitate evidence based planning based on data

triangulation, the present framework for 2010-2011 has been
prepared by the Ministry to help in the process of planning focusing
on deliverables and key health outcomes. The focus here is to
facilitate in achievement of “Timelines and Programmatic Targets” of
NRHM to impact on key health indicators. Therefore it is proposed to
accord approval of Annual Plans on the basis of a log frame in the PIP
with the State’s stating quantifiable targets which would then be
monitored not only nationally but also at the state / district and
below level.
V – INSTITUTION SPECIFIC
NRHM WISE DATA NEEDS
(PART B AND E OF PIP)
V - INSTITUTION SPECIFIC NRHM DATA NEEDS
INSTITUTION SPECIFIC TIMELINE TARGETS AIMED AT
INSTITUTIONAL STRENGTHENING/SERVICE GUARANTEES

Some of the specific targets against various activities of NRHM are as

follows:

1. ASHA: Around 7.30 lakh ASHAs have been selected and are
actively engaged in bringing health to the community. However the
issue of selection which was primary at the beginning of NRHM has
now settled down in most states throwing up newer issues with clear
impact on quality of services being provided by her relating to :

 Streamlining delay in payment of performance incentives to

ASHAs.
 Regular upgradation of skill / completion of 5th Module
training
 The timely and sustainable availability of drug kits
 Supervisory structure for ASHAs

Therefore this year’s PIPs would require a logframe, on the

milestones to be achieved in putting in place robust ASHA system on
the above issues. The PIP would require to mention the activities
proposed to be taken to achieve the above milestones within a
timeline which may be specified by the State.

ASHA Timeline: As per timeline for NRHM activities, 100%

fully trained ASHAs with drug kits available for every 1000
population/large isolated habitation by 2008

Sl. Issues in Current Status Activities Outputs to Time

No. Planning in as per to be be Frame for
ASHA evidence from undertake achieved 2010-11
data n to
triangulation achieve
targets

2. Village Health and Sanitation Committee: The VH&SC as the

pivot of Village level Planning has been constituted in almost all the
States except a few. The issues which require a deeper look in terms
of Planning are namely as follows:
 A. The constitution of the Village Health and Sanitation
Committee
B. The capacity of the PRIs in Village Level Planning
C. Utilisation of the Untied fund for the VH&SC and purpose for
which they are utilized
D. The training sessions held for PRIs

VH&SC Timeline: As per timeline for NRHM activities, 100%

VH&SC constituted in over 6 lakhs villages and untied grants
provided to them by 2008

Sl. Issues in Current Status Activities to Outputs to Time

No Planning for as per be be achieved Frame
. VH&SC evidence from undertaken for 2010-
data to achieve 11
triangulation targets

3. Rogi kalyan Smaitis : The Rogi Kalyan Samiti as the pivot of

facility based planning and community involvement and ownership of
the health facilities has by and large been constituted in all States.
RKSs have contributed to local level leadership and need based
decision making. The issues which now need to find a reflection in
planning would interalia relate to:

• Performance and pace of utilisation of funds and

• Activities being under taken by RKS

RKS Timeline: As per timeline for NRHM activities, 100% RKS

constituted in all CHCs, Sub District Hospital/ District
Hospitals by 2009

Sl. Issues in Current Status Activities to Outputs to Time

No. Planning for as per be be achieved Frame
RKS evidence from undertaken for 2010-
data to achieve 11
triangulation targets

4. Sub Centre: The Subcentre as the first facility interface of

community with a health facility under NRHM is the key to improving
access and reach to the remotest and the underserved areas.
Although construction / upgradation and placement of ANMs at
Subcentres have expanded outreach, issues relating to shortfall of
ANM due to non availability of ANM, consolidation of SCs before
further expansion are some issues which need closer deliberation in
the Plans of 2010-11. Full justification for expansion needs to be
provided if consolidation of available infrastructure has not been
achieved. Need based expansion clearly articulating the area of
requirement needs to be highlighted with a clear human resource
placement plan. The number Sub-Centres already upgraded and
underway and number of sub-centres proposed to be taken up should
be spelled out.

The issues which have been highlighted with regard to sub centre
strengthening

a. Construction of subcentres without human resource

deployment
b. Pace of Utilization of untied fund, annual maintenance
grant( only for subcntres in own/government building)
c. Shortage of ANMs
d. Placement of Male Multi Purpose Worker / 2nd ANM

Sub Centre Timelines: As per timeline for NRHM activities,

100%, 2 ANM Sub Health Centres strengthened / established
to provide service guarantees as per IPHS in 1,75000 places
by 2010

Sl. Issues in Current Activities to Outputs to Time

No Planning for Sub Status as per be be achieved Frame
. centres evidence undertaken for 2010-
from data to achieve 11
triangulation targets

5. Primary Health Centre: The PHCs as the first interface of a

medical officer with the community has seen considerable progress
under NRHM with many health facilities delivering 24X7 services and
positioning of 3 staff nurses under NRHM. However issues which need
focus in the current plan relate to:
 1. Placement of human resources esp nurses to ensure 24X7
services
2. feasibility of ensuring 24X 7 services in all the extant PHCs-
redefining the numbers as per evidence and need
3. Consolidating 24X7 PHC s in identified PHCs before further
expansion
4. Quality of care being provided in the PHCs
5. Parameters for monitoring service delivery and quality of care
at the PHCs
6. Pace of utilisation of untied funds , AMG grants in PHCs,
functioning of Rogi Kalyan Samittees

In case of PHC, CHC, District and Sub-District Hospital they

should provide information on number of units taken up for
upgraded – completed, work construction and now provided
to be taken up.

PHC Timelines: As per timeline for NRHM activities, 100%,

Primary Health Centres strengthened / established to provide
service guarantees as per IPHS in 30,000 places by 2010

Sl. Issues in Current Activities to Outputs to Time

No Planning for Status as per be be achieved Frame
. PHCs evidence undertaken for 2010-
from data to achieve 11
triangulation targets

6. Community Health Centre: The Community Health Centre with

the first provision for specialist support and as the First Referral Unit
has witnessed considerable expansion under NRHM. However issues
relating to

• Acute shortage of Specialist and Nurses – norm may have to

be revisited to make it realistic
• Blood storage units operational in 9.2 % of facility- need to be
ensured in all facilities.
• Performance parameters for service delivery and quality of
care needs further improvement and closer monitoring
• Use of untied funds , AMG grants in CHCs, functioning of Rogi
Kalyan Samittees

CHC Timelines: As per timeline for NRHM activities, 100%,

Community Health Centres strengthened / established to
provide service guarantees as per IPHS in 6,500 places by
2010

Sl. Issues in Current Activities to Outputs to Time

No Planning for Status as per be be achieved Frame
. CHCs evidence undertaken for 2010-
from data to achieve 11
triangulation targets

7. Sub District Hospitals/ District Hospitals: The Mission has led

to increase in the number of Sub District Hospitals and District
Hospitals functioning as 24X 7 facilities and as FRUs. Observational
studies have also reported increase in OPD and IPD and bed
occupancy. However issues that remain unresolved are:

1. Limited managerial capacities to manage health facilities

2. Infrastructure expansion without requisite human resource,
equipments supplementation
3. Deployment of human resources not based on need.
Suboptimal or over utilisation of the manpower
4. Limited capacity for supply chain management to ensure
timely supply of drugs and diagnostics
5. Limited referral and mobility arrangements
6. Varied use of RKS , AMG and Untied Funds made available
7. Non standardised treatment protocols leading to adhoc in care
8. Inadequate PPP arrangements with the private sector in the
area

Sub Distirct/ District Hospital Timelines: As per timeline for

NRHM activities, 100%, Sub District Hospital (1800)/ District
Hospital (600) strengthened to provide quality services by
2010

Sl. Issues in Current Status Activities to Outputs to Time

No. Planning for as per be be achieved Frame
SDHs/ DHs evidence from undertaken for 2010-
data to achieve 11
triangulation targets
8.Mobile Medical Units: The provision of MMUs in hard to reach
areas has greatly expanded the reach of NRHM in the hitherto
underserved areas. Apart form the mandatory 354 MMUs in 643
districts as per the mandatory timeline, there are many block / village
level Mobile Medical Units being provided in many States. State
specific requirement of MMUs needs to be assessed realistically. NGO
/ GPS based system with performance monitoring has been found to
be superior than direct implementation arrangements. However the
efficacy of the MMUs depend on the output being delivered by MMUs
in terms of performance.

Performance parameters which help in gauging performance of MMUs

like, a)Frequency of Visit b)Following of Schedule c) Advance
Intimation of Schedule d) Duration of Stay and Timing of MMU
e)Doctors accompanying f)Availability of Medicine g)Cured of illness
in last visit h)People satisfaction about skill and behaviour i)Location
of MMU j)Average distance travelled to MMU k)average time taken
per patient l)Availability of diagnostics m)Follow up of Patients, need
to be reflected in the MMU plan

MMU Timeline: As per timeline for NRHM activities, 100%

MMUs provided to each district of the country by 2009

Sl. Issues in MMUs Current Activities to Outputs to Time

No. Status as per be be Frame
evidence undertaken achieved for 2010-
from data to achieve 11
triangulation targets No.
of camp held
No. of MMUs

9. District Health Action Plans: The DHAP is the key instrument in

decentralised planning. It is observed that in 617 out of 643 districts,
District Health Action Plan have been prepared. However the
endeavour in 2010-11 should be that DHAPs should not remain a
statement of intent but capacity for more evidence based planning
based on data analysis and identification of gaps needs to be
strengthened. Therefore it is important that the district planning
exercise is closely hand held , and implementation of works in
accordance with IDHAP. A monitoring protocol to capture the
progress of District Plan needs to be finalized by the State and
appended to the State PIP and a Quarerly, Distirct wise progress
report on the monitoring indicators be maintained at the State level
for supportive supervision and feedback.
Suggested Monitoring Protocol for the District Action Plans
for NRHM Part B of PIP

Sl. Activity/Process Indicator Current Target for Outcome

No Status 2009-10 Monitorin
. as g
proposed
by the
District
1 ASHA
A ASHAs trained in 5th Module
B ASHA provided with drug kits
C Avg. time taken for ASHA
payment
2 Village Health and Sanitation
Committee
A No. of Village Health and
Sanitation Committee
constituted
B % Untied Grants utilised by
VH&SC
C No of training sessions held for
PRIs at Village Level
3. Rogi Kalyan Samittees
A No. of Rogi Kalyan constituted
B % Fund utilised by Rogi Kalyan
Samittees
C No of RKS meetings held
4 Status of Health Infrastructure
No. of Subcentres functioning in
own building
No of Subcentres proposed for
construction
No of Subcentres proposed for
upgradation
No of PHCs where facility survey
completed
No of PHCs proposed for
construction
No of PHCs taken for
upgradation
No of PHCs conducting at least
10 deliveries per day
No of CHCs where facility survey
completed
No of CHCs proposed for
construction
No of CHCs taken for
 upgradation
No of CHCs conducting
caesarean section
No. of CHCs with blood storage
units
No of District Hospitals where
facility survey completed
No of District Hospital taken up
for Construction
No of District Hospital taken up
for Upgradation
5 Status of Human Resources
No of Subcentres without ANM
No of Subcentres without 2nd
ANM
No of PHCs without 3 staff
nurses
No of CHCs without
Anaesthetists
No of CHCs without Obstetric
and Gynaecologists
No of CHCs without Paediatrician

10. Activities taken up with support under other programmes

such as Donor Partners, Minority Development, Finance

Commission Award, Labour, DONER and any other scheme

etc. to be clearly reflected in Part B of PIP. Similarly details of

PPP activities, Health Insurance scheme and any other district

innovation funds being solicited, details need to be spelt out in

Part B.

11. Intersectoral Convergence activities with line Departments to be

specified in written part E of PIP including with PRI, ICDS, Rural

Development, PHED, Education, Labour, Home etc. Similarly

details of Ayush activities to be also given in Part E .

 Road map for Infrastructure and Human Resource

Strengthening for 2010-11

NRHM has led to considerable expansion of infrastructure in rural

areas and many more health facilities are now functioning 24X7 and
FRUs due to provision of extra resources from NRHM. However the
time to take stock has come. It is presumed that all infrastructure
proposals, both for new construction and expansion are based on
both facility and area mapping exercise and are not just a district
wise allocation exercise. The needs of the underserved areas have to
be taken into consideration and strengthening of facilities in close
contiguity needs to be discouraged unless justified by a heavy case
load. The IPHS norms are under revision. Therefore the focus should
be on consolidation and need based expansion supplemented with a
HR plan.

NRHM has led to provision of considerable contractual human

resources at all levels based on local criteria. However the following
issues in provision of human resources continue to need attention

1. Provision of human resource based on gap analysis with adequate /

incentivised provision for difficult and hard to reach areas.
2. Capacity and skill development of the human resource both
contractual and permanent.
3. Filling up of existing vacancies by the State Government.

Therefore it is proposed that the planning exercise of 2010-11

should reflect gaps in human resources and the effort of the State to
fill it in the following format with clear road map on filling up of
existing vacancies by the State Government if achievement of IPHS
standards may seem a bit too remote and are under revision.

Infrastructure Health Status (District Wise position to be also

attached as Annexure)

State Requirement of Infrastructure DH / CH PH SH

SDH C C C
Required as per IPHS

Existing Facilities

Shortfall against required as per IPHS

Mapping of facilities undertaken

Requirement of new facilities after mapping

exercise

Requirement of facility upgradation after mapping

exercise

Facilities already being undertaken under NRHM

for strengthening

New construction proposed under NRHM after gap

analysis for 2010-11

Facilities proposed for up gradation after gap

analysis for 2010-11

Human Resource Health Status (District Wise position to be also

attached as Annexure)

State Requirement Docto Nurs ANM Pharmaci Lab tech

of HR rs es s sts
Required as per IPHS

Required staff as per

IPHS for the existing
facilities

Sanctioned staff

In Position

Vacancy against
sanctioned

Vacancy against IPHS

Vacancies already filled

up by the State

Proposed filling up of
vacancies by the State
for 2010-11

Contractual
engagement through
NRHM
Contractual
engagement proposed
under NRHM for 2010-
11
 NATIONAL RURAL HEALTH MISSION

Budget Format for NRHM Mission Flexible Pool Part B * and Part E
Total
Number Rate
S.N Amount
Initiative Propose Propose Remarks
o. (in
d d
lakhs)
A ASHAs
A1 Selection & Training of ASHA
A2 ASHA Kit
A3 ASHA Incentives
A4 Others
TOTAL
B Infrastructure related matters
B1 New Construction of DH
B2 Renovation / Upgradation of DH
B3 New Construction of CHCs
B4 Renovation / Upgradation of CHCs
B5 New Construction of CHCs
B6 New Construction of PHCs
B7 Renovation/Upgradation of PHCs
B8 New Construction of SCs
B9 Renovation/ Upgradation of SC
B10 MMU
B11 Emergency & Referral Services
B12 Any others
B13 Others
TOTAL
Human Resources related
C
matters
C1 Contractual Specialists
C2 Contractual Doctors
C3 Contractual paramedical
C4 Contractual ANM
C5 Others
TOTAL
Programme Management related
D
matters
D1 State Programme Management
D2 Divisional PMSU
D3 Block PMSU
D4 District Health Action Plan
D5 Monitoring & Evaluation
D6 Others
TOTAL
Untied Funds, Annual
E Maintainence Grants and RKS
fundsrelated matters
E1 Rogi Kalyan Samiti- DH
E2 Rogi Kalyan Samiti- SDH
E3 Rogi Kalyan Samiti- CHC
E4 Rogi Kalyan Samiti-PHC/APHC
E5 Untied Fund for CHC
 E6 Untied Fund for PHC
E7 Untied Fund for SC
E8 Untied Fund for VHSC
E9 Annual Maintenance Grant -DH
E10 Annual Maintenance Grant -CHC
E11 Annual Maintenance Grant -BPHC
E12 Annual Maintenance Grant -APHC
E13 Annual Maintenance Grant -PHC
E14 Annual Maintenance Grant -SC
E15 Others
TOTAL
Training & Capacity Building
F
related matters
F1 Management Development Trainings
Capacity Building/ Orientation
F2
Workshops
F3 Others
TOTAL
Innovations ( No approval
G
without details)
G1 Health Melas
G2 District innovations
G3 Incentive Scheme
G4 PPP initiative
G5 Others
G6 Health Insurance scheme
G7 Others
TOTAL
Intersectoral Convergence ( Part
H
E) ( No approval without details)
H1 Ayush
H2 Intersectoral Convergence Related
H3 Others
TOTAL

* State may add rows as per need in case specific activity does not find mention
in the format. However, all such rows would need to be as additional rows under
the specific sub head. For example if any row needs to be added under Human
Resource it should be termed as ROW C5, C6 etc.