EFFECTIVENESS OF FUND ALLOCATION AND SPENDING FOR THE NATIONAL RURAL HEALTH MISSION IN UTTARAKHAND, INDIA Block and Facility Report March 2014 HEALTH POLICY PROJECT The Health Policy Project is a five-year cooperative agreement funded by the U.S. Agency for International Development under Agreement No. AID-OAA-A-10-00067, beginning September 30, 2010. The project’s HIV activities are supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). It is implemented by Futures Group, in collaboration with CEDPA (part of Plan International USA), Futures Institute, Partners in Population and Development, Africa Regional Office (PPD ARO), Population Reference Bureau (PRB), RTI International, and the White Ribbon Alliance for Safe Motherhood (WRA). Effectiveness of Fund Allocation and Spending for the National Rural Health Mission in Uttarakhand, India Block and Facility Report The document was prepared by Catherine Barker, Alexander Paxton, Ashish Mishra, and Arin Dutta of the Health Policy Project, and Ayusmati Das and Jay Prakash of the Policy Unit, NIHFW. MARCH 2014 CONTENTS ACKNOWLEDGEMENTS .............................................................................................................iv EXECUTIVE SUMMARY .............................................................................................................. v Phase 2 Study Findings ............................................................................................................................. v Recommendations .................................................................................................................................... vi ABBREVIATIONS ...................................................................................................................... viii INTRODUCTION ......................................................................................................................... 1 1.1 Study Objectives ........................................................................................................................... 2 1.2 Background ................................................................................................................................... 3 1.3 Results of Phase 1 Analysis .......................................................................................................... 5 1.4 Phase 2 Methodology .................................................................................................................... 6 1.5 Phase 2 Study Limitations............................................................................................................. 8 1.6 Report Outline ............................................................................................................................... 8 NRHM FUND PLANNING AND ALLOCATION ............................................................................ 9 2.1 Ideal Planning Process under NRHM ........................................................................................... 9 2.2 Is There Evidence for Bottom-Up Planning? .............................................................................. 10 2.3 Is There Evidence of Community Participation in Planning? ..................................................... 11 2.4 What Is the Relationship Between Planning and Actual Allocation? ......................................... 12 2.5 Conclusion .................................................................................................................................. 13 FUND FLOW AND DISBURSEMENT ........................................................................................... 14 3.1 Ideal NRHM Fund Flow Process ................................................................................................ 14 3.2 Key Challenges in Fund Disbursement Processes ...................................................................... 15 3.3 How Do NRHM Fund Allocations Vary by Year and Facility? ................................................. 17 3.5 Conclusion .................................................................................................................................. 19 NRHM FUND UTILISATION ....................................................................................................... 20 4.2 Fund Utilisation by Budget Heading .......................................................................................... 20 4.3 What Are the Barriers to Fund Utilisation? ................................................................................ 23 4.4 Are There Effective Systems to Monitor Fund Utilisation? ....................................................... 25 4.5 Conclusion .................................................................................................................................. 26 ALIGNMENT OF EXPENDITURE WITH PERFORMANCE ............................................................. 27 5.1 JSY .............................................................................................................................................. 27 5.2 Routine Immunisation ................................................................................................................. 29 5.3 Family Planning .......................................................................................................................... 30 5.4 Conclusion .................................................................................................................................. 32 SUMMARY AND RECOMMENDATIONS .................................................................................. 33 6.1 Summary ..................................................................................................................................... 33 6.2 Recommendations ....................................................................................................................... 34 ANNEX .................................................................................................................................... 36 Pilot Testing of Tools ......................................................................................................................... 36 Orientation of the Team for Data Collection ...................................................................................... 36 REFERENCES ............................................................................................................................ 40 iii ACKNOWLEDGEMENTS The authors are grateful to the National Health Systems Resource Centre (NHSRC), the Policy Unit of the National Institute of Health and Family Welfare (NIHFW), and the USAID-funded Health Policy Project (HPP) for technical support and for financing the data collection activities under this study. Specifically, we appreciate the contribution of Dr. T. Sundararaman (former Executive Director, NHSRC) for assistance in finalising the study tools and facilitating field work. Our sincere appreciation goes to Mr. Piyush Singh (former Mission Director, NRHM) for initiating the process, facilitating the discussions, and encouraging critical thinking on developing comprehensive areas of enquiry. We also thank Mr. Om Prakash, Principal Secretary Health and Family Welfare and Mr. Senthil Pandiyan, Mission Director NRHM, for inputs and suggestions. We gratefully acknowledge the participation of all the officials, health workers, and members of the community who provided their time to the study. We give special thanks to Dr. R.K. Srivastava, Senior Policy Analyst, Policy Unit, who supported and facilitated several consultations on this study. We also thank the USAID India team and other colleagues at the Health Policy Project for their valuable support and guidance. We acknowledge the guidance and facilitation provided by Himani Sethi, Team Leader (India), Health Policy Project. We are thankful to Dr. Jayachandran AA, Senior Technical Specialist Research and M&E, HPP India, who provided review and comments and participated in the data collection, and Dr. Bhupinder Aulakh, Country Director, Futures Group, who provided review and comments. Finally, we acknowledge the hard work of the other members of the working group, Dr. Honey Tanwar, Project Associate, Policy Unit; and Mr. Ripunjay Kumar, Technical Assistant, Policy Unit, who undertook the analysis and fieldwork. iv EXECUTIVE SUMMARY The National Rural Health Mission (NRHM) has been very effective in making more funds available for delivering essential healthcare services to India’s rural population. As per the NRHM mandate, at least 70 percent of funds should be spent at the block level and below. To understand the effectiveness of NRHM financing in terms of allocation, disbursement, and utilisation, the Policy Unit of the National Institute of Health and Family Welfare (NIHFW), the USAID-funded Health Policy Project (HPP), the National Health Systems Resource Centre (NHSRC), and the Government of the State of Uttarakhand conducted this study jointly. The study was designed to understand the barriers in the flow of NRHM funds from state to district, and sub-district levels of the public health system in Uttarakhand State. The present study was designed and executed in two phases. In the first phase, a state- and district-wise analysis of fund allocation and spending was carried out using secondary sources: financial records of the NRHM funds obtained from all 13 districts of the state of Uttarakhand. The Phase 1 analysis found that the amount of NRHM