This report has been synthesised and published on behalf of the National Health Mission by its technical support institution; National Health Systems Resource Centre (NHSRC) located at NIHFW campus, Baba Gangnath Marg, New Delhi-110 067. We gratefully acknowledge the contributions made by consultants and officers in the NHM Division of the MoHFW. We also place on record our deep appreciation and gratitude to participants from other Ministries, Public Health Institutions, Civil Society and Development Partners who have all contributed to this Common Review Mission Report. ©2015 Ministry of Health and Family Welfare Government of India, Nirman Bhawan New Delhi-110 011 Reproduction of any excerpts from this documents does not require permission from the publisher so long it is verbatim, is meant for free distribution and the source is acknowledged. ISBN: 978-93-82655-17-6 Designed by: Macro Graphics Pvt. Ltd. www.macrographics.com CONTENTS Executive Summary 1 Mandate and Methodology of the 9th CRM 23 TOR 1-11 29 State Positives and Challenges 231 Abbreviations AGCA Advisory Group on Community Action DOTS Direct Observation Therapy - Short- AMTSL Active Management of Third Stage of course Labour DPM District Programme Manager ANC Ante-Natal Care DPMU District Programme Manager Unit ANM Auxiliary Nurse Midwife DTC District Training Centre ANMTC Auxiliary Nurse Midwife Training Centre DWCD Department Women & Child APHC Additional Primary Health Centre Development API Annual Parasite Index EDL Essential Drug List ARC ASHA Resource Centre EmONC Emergency Obstetric & Neonatal Care ART Anti retroviral Treatment EMRI Emergency Management and Research Institute ASHA Accredited Social Health Activist FMG Financial Management Group AWC Anganwadi Centre FP Family Planning AWW Anganwadi Worker FRU First Referral Unit AYUSH Ayurveda, Yoga & Naturopathy, Unani, Siddha, Homeopathy GNM General Nursing Midwife BCC Behaviour Change Communication HMIS Health Management Information System BEmONC Basic Emergency Obstetric & Neonatal HMRI Health Management & Research Institute Care HR Human Resource BMO Block Medical Officer HRD Human Resource Development BMWM Bio-Medical Waste Management HRIS Human Resource Information System BPHC Block PHC HSC Health Sub-centre BPM Block Programme Manager ICDS Integrated Child Development Scheme BPMU Block Programme Management Unit ICTC Integrated Counselling and Testing BPL Below Poverty Line Centre CBOs Community Based Organizations IDSP Integrated Disease Surveillance Project CEmONC Comprehensive Emergency Obstetric & IEC Information Education Communication Neonatal Care IMNCI Integrated Management of Neonatal CHC Community Health Centre and Childhood Illnesses CMO Chief Medical Officer IMR Infant Mortality Rate CMOH Chief Medical Officer Health IPD In Patient Department CRM Common Review Mission IPHS Indian Public Health Standards CT Scan Computed Tomography Scan ISO International Organization for Standardization DH District Hospital IUCD Intra-uterine Contraceptive Device DHAP District Health Action Plan JE Japanese Encephalitis DLHS District Level Household Survey 9TH COMMON REVIEW missiON | REPOrt 2015 iv JPHN Junior Public Health Nurse OPD Out Patient Department JSSK Janani Shishu Suraksha Karyakram PCPNDT Pre-Conception and Pre Natal Diagnostic JSY Janani Suraksha Yojana Techniques (Prohibition of Sex-selection) Act - 1994 LHV Lady Health Visitor PHC Primary Health Centre LLIN Long Lasting Insecticide Treated Nets PHN Public Health Nurse LR Labour Room PIP Programme Implementation Plan LSAS Life Saving Anaesthesia Skills PMU Programme Management Unit LT Laboratory Technician PPP Public Private Partnership MB Multi-bacillary cases PRI Panchayati Raj Institutions MCTS Mother and Child Tracking System PWD Public Works Department MDR Multi-drug Resistant (TB) RCH Reproductive and Child Health MIS Management Information System RDK Rapid Diagnostic Kit MHW Male Health Worker RHFWTC Regional Health & Family Welfare MMR Maternal Mortality Ratio Training Centre MMU Mobile Medical Unit RHP Rural Health Practitioner MO Medical Officer RKS Rogi Kalyan Samiti MoHFW Ministry of Health & Family Welfare RMP Rural Medical Practioner MOIC Medical Officer In-charge RMSCL Rajasthan Medical Services Corporation MoU Memorandum of Understanding Limited MPW Multi-purpose Worker RNTCP Revised National Tuberculosis Control MTP Medical Termination of Pregnancy Programme NFHS National Family Health Survey RSBY Rashtriya Swasthya Bima Yojana NGO Non-Government Organisation SBA Skilled Birth Attendant NHSRC National Health Systems Resource Centre SDH Sub Divisional Hospital NICU Neonatal Intensive Care Unit SHC Sub Health Centre NIHFW National Institute of Health & Family SHSRC State Health Systems Resource Centre Welfare SIHFW State Institute of Health and Family NIPI Norway India Partnership Initiative Welfare NPCB National Programme for Control of SIMS Softline Intelligent Micro Systems Blindness SNCU Special Newborn Care Unit NLEP National Leprosy Eradication Programme SPMU State Programme Management Unit NRC Nutritional Rehabilitation Centre STG Standard Treatment Guideline NRHM National Rural Health Mission TB Tuberculosis NSSK Navjat Shishu Suraksha Karyakram TNMSC Tamil Nadu Medical Services Corporation NSV Non-scalpel Vasectomy Limited NUHM National Urban Health Mission VHND Village Health and Nutrition Day NVBDCP National Vector Borne Disease Control VHSNC Village Health and Sanitation and Programme Nutrition Committee 9TH COMMON REVIEW missiON | REPOrt 2015 v EXecUTIVE SUMMARY BACKGroUND The growth of National Rural Health Mission now subsumed as part of National Health Mission (NHM) over a period of last 10 years has also been marked by shifting focus of programme implementation and expanded scope of service programmes run by the Mission. These changes must be captured for in-depth reviews and mid-course corrections. Annual Common Review Mission (CRM) has been one of the important monitoring mechanisms under NHM and so far nine Common Review Missions (2007- 2015) have been undertaken. The Ninth Common Review Mission was held from 30th October to 6th November 2015. The mission was carried out in 18 States.( Andhra Pradesh, Assam, Chhattisgarh, Delhi, Himachal Pradesh, Haryana, Jharkhand, Karnataka, Madhya Pradesh, Maharashtra, Manipur, Meghalaya, Odisha, Punjab, Rajasthan, Uttar Pradesh, Uttarakhand and West Bengal). The Terms of Reference (TOR) for 9th CRM were developed by the MoHFW involving different stakeholders and technical experts from the programme divisions and covered various dimensions of NHM ranging from service delivery to governance issues. The TORs however, focused on implementation status of new initiatives and guidelines issued by MoHFW in terms of Kayakalp for Public Health Facilities, Rogi Kalyan Samiti (RKS), National Urban Health Mission (NUHM), Free Drugs and Diagnostics initiatives, Performance Enhancement of Multipurpose Workers (F), Rashtriya Kishore Swasthya Karyakram (RKSK) and Non Communicable Diseases (NCD) programmes. The broad objective of each TOR has been to understand and assess the process, outcome and impact of relevant interventions being carried under NHM. The members of the Mission included senior officials of MoHFW, Public Health experts from Civil Societies and Academic Institutes, Development Partners and officials from related development sectors of the government like Social Welfare, Women and Child Development, Water and Sanitation department etc. The team members were thoroughly briefed on the objectives and methodology of conducting CRM by the senior officials and technical experts from MoHFW and divided into different state –teams to be led by a senior officer of MoHFW to carry out study visits to the allotted states. The report is based on the findings of different state teams enriched by the observations and suggestions made by the representatives of the state governments and development partners during the course of discussion and presentations of the report in different states visited by CRM teams. KEY FINDINGS TOR 1: Service Delivery: Reaching the Unreached Key objectives of the TOR were to review the adequacy of health infrastructure, its utilization and status of health system strengthening, with a focus on, drugs, diagnostics, biomedical equipment, AYUSH services and Public Private Partnerships. Considerable progress has been made in ensuring physical access to health care institutions during the NHM period. This is reflected in an increase of about 5.2% in Sub Health Centers (SHC), 8.9% in Primary Health Centre (PHCs) and 61.3% in Community Health Centre (CHCs) as compared to 2005.However, shortfalls are still reported from Andhra Pradesh, Rajasthan, Karnataka, Jharkhand, Maharashtra and West-Bengal (CHCs and PHCs) as well as from Himachal Pradesh, Chhattisgarh, 9TH COMMON REVIEW missiON | REPOrt 2015 3 Haryana and Karnataka (Sub- health centres). Irrespective of shortfalls in infrastructure, almost all States except Manipur report an increase in utilization of OPD and IPD services All states report progress towards free drugs initiative. Better access to drugs is notable in the States of Rajasthan, West Bengal, Uttar Pradesh, and Madhya Pradesh. Interactions with beneficiaries in these states indicate thatO ut of Pocket Expenditure (OOPE) on account of drugs has reduced. West Bengal and Karnataka have established generic drugs stores/ fair price shops to meet demands of medicines. All states report free diagnostics under JSSK. On the other hand, Himachal Pradesh,