Impact of NHM on Health Systems Governance & Human Resources

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National Health Mission – Impact and
Learnings for the future
Impact of the National Health Mission on Governance, Health
System, and Human Resources for Health
Draft Report
i
Indian Institute of Public Health, Gandhinagar
Indian Institute of Management, Ahmedabad National Health Mission – Impact and
Learnings for the future
Impact of the National Health Mission on Governance, Health
system, and Human Resources for Health
Draft Report by
Indian Institute of Public Health, Gandhinagar & Indian Institute of
Management, Ahmedabad
AUTHORS
Professor Dileep Mavalankar, MD, DrPH
Principal Investigator
Dr. Mahaveer Goleccha, MS, PhD
Project lead and Co-investigator
Professor Sunil Maheshwari, PhD
Co-investigator
Dr Rajesh Chandwani, MD, PhD
Co-investigator
Dr Jallavi Panchamia, PhDMs Tasneem Bohra, MPH
ii ACKNOWLEDGEMENT
The findings presented in this report are the result of months of efforts by researchers at the Indian
Institute of Public Health, Gandhinagar, and the Indian Institute of Management, Ahmedabad. This
report represents a part of NITI Aayog’s vision and comprehensive undertaking to encourage
research into the National Health Mission and its impact on the Indian health system from the time of
its inception in 2005, through 15 years of implementation.
The authors of this report express their gratitude to all the officials and experts at various levels of
government and the NHM, and other organisations who provided invaluable insights into the mission
through their in-depth knowledge of the health system, and exhaustive understanding of its
functioning at various levels.
The aim of this report is to present a stock-taking of the NHM after fifteen years of implementation
across the country, through a wide variety of schemes and programs, some of which preceded the
mission itself and were then brought under its umbrella in order to provide an affordable, seamless,
and comprehensive experience to the Indian healthcare seeker. The authors are confident that this
report will initiate a discussion into the future of the NHM, what directions it should take, and
provide a plethora of lessons, especially in the areas of governance in healthcare, the management of
human resources for health, and the decentralisation and communitisation of health decision making.
We are grateful to Prof. Vinod Paul, Member, NITI Aayog and Shri Alok Kumar, Advisor, NITI
Aayog for their inspiration and guidance that made this report possible, and Dr. K Madan Gopal and
Ms. Nina Badgaiyan for their vital contributions to this research endeavour. We would also like to
acknowledge Dr. Vishal Jani, Assistant Professor, IIPH-Gandhinagar and Priyanka Shah, Research
Associate, IIPH-Gandhinagar for the technical support provided throughout the duration of this
exercise. This study was carried out with the financial support of NITI Aayog, Government of India,
and conducted by Indian Institute of Public Health-Gandhinagar.
DISCLAIMER
The Indian Institute of Public Health-Gandhinagar has received the financial assistance under the
Research Scheme of NITI Aayog (RSNA- 2018) to prepare this report. While due care has been
exercised to prepare the report using the data from various sources, NITI Aayog does not confirm the
authenticity of data and accuracy of the methodology to prepare the report. NITI Aayog shall not be
held responsible for findings or opinions expressed in the document. This responsibility completely
rests with the Indian Institute of Public Health-Gandhinagar.
iii Contents
ACKNOWLEDGEMENT ....................................................................................................................iii
DISCLAIMER......................................................................................................................................iii
List of Tables and Figures....................................................................................................................vii
ABBREVIATIONS................................................................................................................................x
EXECUTIVE SUMMARY ....................................................................................................................1
Background......................................................................................Error! Bookmark not defined.
Objectives.............................................................................................................................................
Findings................................................................................................................................................
1. Structural and coordination issues...............................................................................................
2. Data based strategic planning concerns and M & E Issues for states..........................................
3. Issues related to HRH- Equity and justice concerns....................................................................
Conclusion............................................................................................................................................
INTRODUCTION................................................................................................................................13
OBJECTIVE........................................................................................................................................16
METHODOLOGY ...............................................................................................................................17
Study Setting....................................................................................................................................17
Tool Development............................................................................................................................19
Data Collection.................................................................................................................................23
Data Analysis...................................................................................................................................25
FINDINGS...........................................................................................................................................28
1. Governance......................................................................................................................................28
1.1 Background................................................................................................................................28
1.2 Findings......................................................................................................................................31
1.3 Recommendations......................................................................................................................48
2. Human Resources for Health...........................................................................................................53
iv 2.1 Background................................................................................................................................53
2.2 Findings......................................................................................................................................56
2.3 Recommendations......................................................................................................................65
3 Impact of the National Health Mission on Health Systems..............................................................68
3.1 Background................................................................................................................................68
3.2 Findings......................................................................................................................................69
3.3 Recommendations......................................................................................................................77
4. Procurement and Logistics...............................................................................................................79
4.1 Background................................................................................................................................79
4.2 Findings......................................................................................................................................80
4.3 Recommendations......................................................................................................................85
5 Rogi Kalyan Samitis (RKS) and Untied Funds.................................................................................87
5.1 Background................................................................................................................................87
5.2 Findings......................................................................................................................................90
5.3 Recommendations......................................................................................................................93
6 Monitoring and Evaluation (M&E)...................................................................................................94
6.1 Background................................................................................................................................94
6.2 Findings......................................................................................................................................95
6.3 Recommendations....................................................................................................................100
7 ASHA..............................................................................................................................................103
7.1 Background..............................................................................................................................103
7.2 Findings....................................................................................................................................107
7.3 Recommendations....................................................................................................................111
8 Process Implementation Plans and Budget.....................................................................................114
8.1 Background..............................................................................................................................114
8.2 Findings....................................................................................................................................117
8.3 Recommendations....................................................................................................................121
v 9 Key issues and recommendations...................................................................................................125
9.1 Governance and structural aspects at central and state levels..................................................125
9.1.1 Issues.......................................................................................................................................
9.1.2 Recommendations...................................................................................................................
9.2 Human Resource for Health.....................................................................................................127
9.2.1 Issues.......................................................................................................................................
9.2.2 Recommendations...................................................................................................................
9.3 Preparing a strategic plan for healthcare delivery systems in the states..................................129
9.3.1 Issues.................................................................................................................................129
9.3.2 Recommendations...................................................................................................................
9.4 Technological challenges in HMIS..........................................................................................130
9.4.1 Issues.................................................................................................................................130
9.4.2 Recommendations...................................................................................................................
9.5 Enhancing the effectiveness of PIP process.............................................................................131
9.5.1 Issues.................................................................................................................................131
9.5.2 Recommendations...................................................................................................................
9.6 Monitoring and evaluation mechanisms in the state................................................................134
9.6.1 Issues.......................................................................................................................................
9.6.2 Recommendations.............................................................................................................134
9.7 Procurement and logistics systems...........................................................................................135
9.7.1 Issues.................................................................................................................................135
9.7.2 Recommendations.............................................................................................................135
9.8 ASHA workers.........................................................................................................................137
9.8.1 Issues.......................................................................................................................................
9.8.2 Recommendations...................................................................................................................
9.9 Strengthening local governance and capabilities.....................................................................139
9.9.1 Issues.......................................................................................................................................
vi 9.9.2 Recommendations...................................................................................................................
Conclusion………………………………………………………………………………………… 140
REFERENCES...................................................................................................................................141
ANNEXURE......................................................................................................................................146
List of Tables and Figures
Table 1 Examples of qualitative research aims, objectives and questions in the interview tool for key
informants............................................................................................................................................23
Table 2 Sample of Thematic Network Analysis framework - From global to basic themes..............27
Table 3 Members and Structure of the Empowered Program Committee and the Mission Steering
Group of the NHM...............................................................................................................................32
Table 4 Year Wise number of meetings of State Health Mission Held..............................................34
Table 5 Year Wise number of meetings of District Health Mission Held..........................................41
Table 6 Year wise Number of Districts prepared annual District Health Action Plan (DHAP) under
NHM....................................................................................................................................................42
Table 7 Human Resources under National Health Mission................................................................55
Table 8 Status of Non-Technical Human Resources for Health in Gujarat NHM..............................56
Table 9 Status of Technical Human Resources for Health in Gujarat NHM......................................56
Table 10 Status of Human Resources for Health in Uttar Pradesh Health Department......................57
Table 11 Status of Human Resources for Health in Rajasthan Department of Health........................57
Table 12 Status of Human Resources for Health in National Health Mission Rajasthan at State Level
..............................................................................................................................................................58
Table 13 Status of Human Resources for Health in National Health Mission Rajasthan at Districts
Level.....................................................................................................................................................59
Table 14 Number of ERS vehicles operational in the States/UTs under NHM..................................69
Table 15 Number of Rogi Kalyan Samitis registered across various levels of healthcare in the
country..................................................................................................................................................89
Table 16 Year wise number of ASHAs selected across the country.................................................104
Table 17 Program wise training duration for ASHA.........................................................................107
vii Figure 1 Objectives of the National Health Mission...........................................................................14
Figure 2 Various Phases of the study..................................................................................................17
Figure 3 Map of India with study states..............................................................................................18
Figure 4 Study states with districts.....................................................................................................19
Figure 5 Tool Development Process...................................................................................................20
Figure 6 Terms of reference of the Common Review Missions.........................................................21
Figure 7 Health functionaries interviewed (Various Levels)..............................................................25
Figure 8 Structure of the Governing body of the SHS........................................................................34
Figure 9 Structure of Executive Committee of the SHS ....................................................................35
Figure 10 Organogram of the NHM in the state of Gujarat................................................................36
Figure 11 Organogram of the NHM in the State of Rajasthan ...........................................................38
Figure 12 Organogram of the NHM in Uttar Pradesh (NHM State Programme Management Unit. .40
Figure 13 Structure of the Governing Body and Executive Committee of the District Health Society
..............................................................................................................................................................43
Figure 14 Organogram of the Directorate General of Health Services at National Level, Government
of India.................................................................................................................................................46
Figure 15 Institutional Mechanisms under National Health Mission.................................................54
Figure 16 Percentage reduction in the Infant Mortality Rate in India, Gujarat, Rajasthan, and Uttar
Pradesh (Sample Registration Survey data from 2005-2017)..............................................................70
Figure 17 Percentage reduction in the Maternal Mortality Rate in India, Gujarat, Rajasthan, and
Uttar Pradesh (Sample Registration Survey data from 2005-2017).........................................................
Figure 18 Percentage reduction in the Total Fertility Rate in India, Gujarat, Rajasthan, and Uttar
Pradesh (Sample Registration Survey data from 2005-2017)..............................................................71
Figure 19 Infant Mortality Rate in India and the study states (NFHS - 2005-2006 & 2015-2016)....71
Figure 20 Total fertility rate in India and the study states (NFHS 2005-2006, 2015-2016)...............72
Figure 21 Maternal Mortality Rate for India (1998-2012) (NFHS)....................................................72
Figure 22 Expenditure of NHM from 2005-2018 in crores of rupees................................................73
viii Figure 23 Public-private distribution of in-patient and out-patient treated episodes of illness from the
National Sample Survey Organisation (NSSO)...................................................................................73
Figure 24 Doctors and nursing staff per 10,000 populations in PHCs and CHCs (2005-2018).........75
Figure 25 Structure of RKS at various levels of health system..........................................................89
Figure 26 Decreasing number of public health facilities meeting IPHS norms..................................97
Figure 27 Structure of the Performance Monitoring and Control Centre in Gujarat..........................99
Figure 28 Structure of ASHA supervision and management at state level.......................................105
Figure 29 Key support systems and activities for ASHA at various levels......................................106
ix ABBREVIATIONS
AB Ayushmaan Bharat
ANM Auxiliary Nurse Midwife
ASHA Accredited Social Health Activist
AWC Anganwadi Centre
AWW Anganwadi Worker
AYUSH Ayurveda, Yoga & Naturopathy, Unani, Siddha
BPL Below Poverty Line
BPM Block Program Manager
BPMU Block Program Management Unit
CBR Crude Birth Rate
CD Communicable Diseases
CDHO Chief District Health Officer
CDMO Chief District Medical Officer
CHC Community Health Centre
CMO Chief Medical Officer
CPHC Comprehensive Primary Healthcare
CRS Census Registration System
DDO District Development Officer
DHO District Health Officer
DHM District Health Mission
DHS District Health Society
DM District Magistrate
x DPM District Program Manager
DPMU District Program Management Unit
EPC Empowered Program Committee
FRU First Referral Unit
GoI Government of India
HBNC Home based New born Care
HMIS Health Management Information System
HR Human Resources
HRH Human Resources for Health
HTA Health Technology Assessment
ICDS Indian Child Development Services
IDSP Integrated Disease Surveillance Program
IEC Information, Education and Communication
IMR Infant Mortality Ratio
IPHS Indian Public Health Standards
JSSK Janani Shishu Swasthya Karyakram
JSY Janani Suraksha Yojana
LMIC Low and middle-income countries
MCTS Mother and Child Tracking System
MLA Member of Legislative Assembly
MMR Maternal Mortality Ratio
MNCH Maternal, New born and Child Health
MoHFW Ministry of Health and Family Welfare
xi MSCL Medical Services Corporation Ltd. (in every state)
MSG Mission Steering Group
NCD Non Communicable Diseases
NFHS National Family Health Surveys
NHA National Health Authority
NHM National Health Mission
NHSRC National Health Systems Resource Centre
NIC National Informatics Centre
NPCDCS National Programme for Prevention and Control of Cancers, Diabetes,
Cardiovascular Diseases and Stroke
NRC Nutrition Rehabilitation Centre
NRHM National Rural Health Mission
NSSO National Sample Survey Organization
NUHM National Urban Health Mission
OOP Out-Of-Pocket
OP Outpatient
OPD Outpatient Department
PFMS Public Financial Management System
PHC Primary Health Centres
PM-JAY Pradhan Mantri Jan Arogya Yojana
PPP Public Private Partnership
PRI Panchayati Raj Institutions
RBF Results based financing
RFP Request for Proposals
xii SC Sub Centre (now known as Health and Wellness Centre—HWC under Ayushmaaan
Bharat
SHM State Health Mission
SHRC State Health Systems Resource Centre
SHS State Health Society
SNCU Special New born Care Unit
SRS Sample Registration Survey
TFR Total Fertility Rate
THE Total Health Expenditure
THO Taluka Health Officer (same as Block Health Officer BHO)
UHC Universal Health Coverage
VHND Village Health and Nutrition Day
VHSNC Village Health, Sanitation, and Nutrition Committee
WASH Water, Sanitation and Health
WHO World Health Organization
xiii EXECUTIVE SUMMARY
The National Rural Health Mission (NRHM) was launched in 2005 with a view to shift the focus of
public health in the country from a vertical, disease focused, and programmatic approach towards
one that recognises the complex adaptive nature of the health system. The rationale for the NHM was
to provide India with a coherent and robust nation-wide mission that would create a health system
where healthcare services, and health decision making and planning would be communitised.
As the present phase of the NHM is coming to a close, it was deemed necessary to conduct
assessment of the mission progress, the challenges faced in its implementation, the changes it
brought to the approach used by the country towards healthcare and public health, and the overall
impact of the mission. Therefore, NITI Aayog commissioned this study for evaluating the impact of
National Health Mission on Governance, Health System and Human Resources for Health. The
present study has been implemented by IIPH-Gandhinagar with help from two senior faculty
members of IIM Ahmedabad. This study was one of the three studies commissioned by NITI Aayog
– other two studies were done by PGI Chandigarh, and NIPFP.
The study had the following TORs spanning across various dimensions of governance- at multiple
levels- central, state and district and from top management to the frontline workers. The TORs were:
1.To analyse the strengths and weaknesses of the governance setup of the NHM, identify best
practices going forward in context to the framework of Ayushmaan Bharat, SDGs, Universal Health
Coverage (UHC) and health equity
2.To analyse the systematic, technical capacity and decision making at the National, State-level in
carrying out the NHM, and study the HR Capacities across difference states.
3. To study human resource gaps by looking at the requirements vis-a-vis actual officers posted as a
way of understanding state capacities to carry out the mission.
4. To analyse the State strategies, plans and actions taken to bridge the evident gaps in human
resources and the effectiveness of such actions
The study was executed in three phases: - (i) Document and literature review (ii) Development of a
qualitative tool and data collection via key informant interviews and focus group discussions (iii)
Data analysis and report writing. A mixed-methods approach was used where secondary data was
collected from published reports and other government documents, the experiences of health
functionaries at the central, state and district levels of the health system, including policy makers and
care providers collected through in-depth management focused key informant interviews, and field
visits carried out by researchers for validating qualitative findings. The study was carried out in 3
1 states namely, Gujarat, and Uttar Pradesh and Rajasthan. Additionally, the NITI Aayog team has also
provided input from Andhra Pradesh, Karnataka and Chhattisgarh. Approximately, 120 Key
Informant interviews were conducted spread across all levels central, states and districts/city.
Findings
To structure the findings and the recommendations we draw upon the aspects of good governance.
Based on the literature, good governance relates to following 4 aspects
1.Empowerment plus Accountability
2.Fairness and transparency
3.Coordination amongst diverse stakeholders
4.Organizational Justice- Procedural, distributive and interactional
The following sections represent the findings drawn from the qualitative study conducted in the three
states and the inputs from NITI Aayog team that studied other three states. The sections refer to our
key findings and corresponding recommendations on three aspects:
1.Structure and coordination issues
2.Data based strategic planning and M & E for states
3.Issues related to HRH
These three dimensions span across the TORs along which the study was carried out.
1. Structural and coordination issues
The mission structure is aligned with matrix form of organization with overlapping project and
functional aspects of organizational systems. The advantages of Matrix form and mission mode was
evident in the findings across the states with stakeholders highlighting the important positive aspects
of a matrix structure- namely, Flexibility, Innovativeness and Empowerment. With systematic
structures at centre, state and district levels, NHM has significantly focused on empowerment of the
health facilities and frontline workers. The mission mode was important for building flexibility.
These aspects were evident in increased finances available for the health system, and creating the
space for contractual, temporary staff to fill the gaps in HRH.
However, in a typical matrix structure, the coexistence of the two parallel structures frequently
results in coordination issues, which relate to Role ambiguity, Accountability and Organizational
power and politics. These aspects are especially prominent at the managerial level where there are
dual (or multiple) chains of commands. While the advantages of the mission mode were evident, we
also found evidence for coordination challenges across multiple levels, described below. These
aspects need to be addressed by designing effective coordination mechanisms, monitoring of the
2 system for potential issues such as power play and politics in the organization, and focus on
communication capabilities amongst the managers.
1.1 Coordination between NHM and directorate
Issues of lack of coordination and at times clashes between Mission Director-NHM and Directorate
of Health Services have been reported in some states such as Uttar Pradesh, the directorate does not
participate actively in decision making even though they are the technical wing of the department.
One of the key areas of concern was the disconnection and lack of integration between the State
Health Society and the directorate. With the introduction of NHM, the role of the directorate had
decreased and it now functions merely as a signatory for the SHS on PIPs. The directorate’s lack of
say in the flow of funds into the SHS is often seen as its inability to exercise control over programs.
Due to this there is limited capacity and willingness to manage new programs. Gujarat has a better
SHS-NHM-Directorate integration model where the member-secretary of the state health society is
the Additional Director of health. In Gujarat, where the directorate was well integrated with the SHS,
which led to the effective and efficient delivery of public healthcare services.
There were several other concerns related to governance including short term posting at the MD
NHM level, lack of specialist public health cadre and absence of a formal post for managing the
diverse role of administrative and technical skills in the health sector- MD NHM and directorate,
respectively.
These coordination issues reflected across levels- at the peripheral level, conflicts between cadres
amongst NHM contractual staff and the state employees (permanent), ASHAs and ANMs, have been
noted both, in the outreach and in the healthcare facilities. All this affects performance of services.
1.2 Role ambiguity
We found that the role ambiguity existed both at the institutions level and at the managerial level.
At institution level
Multiple institutions exist with lack of clarity about their respective roles, eg. SHM, SHS, SIFHW,
SHSRC, TSU, especially in Uttar Pradesh where multiple large donor assisted projects were
implemented. Some of their roles are clear and complementary, but at times their efforts are
overlapping, duplicated and also increase the ambiguity about their role. Indeed, some of the
organizations such as SIFHW, SHSRC are struggling due to various reasons including their
identity/purpose in the new schema of the things. We found that there is a need for rationalization of
the institutions, programs and corresponding Human Resources Management. With the NHM getting
matured there is an urgent need to formally redefine the role of institutions rather than allowing them
to search for their own identity. Each new major project, instead of reforming and strengthening the
3 directorate sets up its own organization for fast implementing of the project. In turn this weakens the
directorate further.
At Managerial level
The researchers noted role ambiguity related to a dual chain of command characteristic of a matrix
organization, at the CMO/CHDO level, which is the key stakeholder in district health management,
in many cases, the CMOs office worked directly with NHM, and the directorate is by passed. MD
NHM directly speaks to the CMO and control the function of CMOs. The common perception was
that the money flows from the NHM and the power lies where the money comes from. These
findings can be attributed to a lack of authority with directorate officials in NHM, work flow and
fund flow with standardization of data reporting structure. Capacity building related to coordinating
roles, especially at the level of CMO/CDHO who is a crucial link in the dual reporting structure was
also lacking.
1.3 Money flow and budgeting
Previously, the NHM were getting funds directly in the State Health Society Account. However, this
has been restructured to route funds through state treasury. This had resulted in an average delay of
about 70-80 days. Further, there are multiple program accounts, as much as 30 different accounts
from which the funds are released as per the program requirements, which creates a lot of confusion.
The structural financial bureaucracy thus jeopardises not only flexibility and empowerment but also
accountability.
There were some issues in fund allocation which are based on performance incentives. While this is
welcome as it may result in PHCs performing better to claim the rewards, it also results in
disadvantages to the new PHC and poorly performing PHCs. Indeed, some of the poor performing
PHCs and the newer ones might be in dire need of funds to break the vicious cycle. We noted a lack
of flexible and need based mechanisms for funds allocation catering to the requirements along with
the performance based allocation
NHM has provided financial power to the periphery through the District Health Society model. The
societies are working well. However, we found an urgent need to invest in capacity building amongst
stakeholders who are part of DHS for optimal involvement. It can also improve the coordination
between the periphery and the center.
4 Recommendations: Structural and coordination issues
Coordination and integration mechanisms between NHM and DGHS at central level and /DHS at
state level.
Role clarity
There should be a defined role of both the MD-NHM and directorate officials in the planning,
implementation, monitoring and funding of various programs in the state in context of NHM.
Structures and processes for coordination at central and state levels
Appropriate representation of DGHS in MSG and other decision making bodies is essential and these
may be reflected at all the levels across the state. States should have strategies to build better
coordination and cooperation for directorate and NHM with proactive engagement and involvement
of the directorate officials in planning and execution/review as per official protocols such as in
conducting joint reviews every six months.
Review of Directorate of Health Services and its capacity building
HR Audit of the directorates- Planning and rationalization
The directorates should initiate a detailed HR audit of existing HR and also in terms of manpower
requirement for the next three to four years, leadership pipeline and career planning mechanisms,
preferably carried out by a third party, such as an academic institute, or consulting company. Based
on the recommendations, the directorate can be expanded and improved in capacity.
Career planning and capacity building
Training programs in various aspects of public health management should be conducted for mid-
level and senior officers. Senior officials at the directorate should be appointed for at least 3 years’
tenure. Promotion criteria need to be made more transparent. Lateral entry at some key posts (from
medical colleges, public health institutes and management institutes); for specialized roles such as
logistics and procurement, strategic planning, MIS should be made. State and central government
should make provision for inviting experts from other countries as advisors for short to midterm
periods. Senior academics, consultancy company managers may also be invited for a short time to
take sabbatical from parent organizations and work in directorate or ministry as special advisors.
Building a cadre of Public Health and health management
While the directorates have technical knowhow and the SPMUs have administrative competencies,
there is a need for developing and nurturing public health cadre. For example, it is done in Tamil
Nadu and is being planned in Odisha. Similarly, large hospitals should have professionally trained
5 hospital managers. Health insurance programs should have health managers etc. This can be done by
developing a health management cadre or public health management cadre which combines public
health and health management skills. The vast potential of schools and institutes of public health and
hospital administration can be utilized. The PGDPHM programme implemented under the NHM for
managerial training of government sponsored medical officers at renowned schools of public health
in India is welcome step and till now approximately 1200 medical officers have been trained.
However, there is discontinuity in sending medical officers to this programme and some states are
not following central NHM guidelines pertaining to PGDPHM program. Further, the emphasis
should be on posting PGDPHM graduates on managerial and public health positions rather than as a
medical officer even after 1-year investment on them residential training.
2. Data based strategic planning concerns and M&E Issues for states
One of the important contributions of NHM has been the focus on data based decision making. The
design of the system including PIP process and reporting entails empowerment of the frontline in the
system as well as enables the top management to make data based decisions. Transparency and
accountability, two important pillars of good governance depend upon data based decision making.
NHM put major emphasis on strengthening capacities for data collection, assessment and review for
evidence based planning, monitoring and supervision for achieving its goals. NHM framework
proposed accountability by a three pronged approach of internal monitoring through MIS,
community based monitoring and external surveys like the SRS, DLHS, and household surveys.
The NHM envisages robust monitoring and evaluation mechanisms, ranging from regular reviews by
Central NHM, State NHM, and District Level institutions. The M&E is a key component of the
NHM and various M & E systems helped in identifying and developing mid-course corrections so
that the goals of the NHM and the SDGs could be achieved.
2.1 Data Collection and its use
Capabilities of the frontline staff in using the data system is a significant issue. The ease of data
collection and reporting, considering the fact that the data comes from the frontline health workers,
was reported as a serious concern. There is a need for planning and implementation of training
programs and support systems for the frontline workers regarding data collection and reporting.
Some state like Gujarat have done innovations by using cell-phones to collect data at the ground
level.
2.2 System duplication and redundancy
We found that duplication of data systems is an important aspect in newly designed and evolving
systems, especially of parallel programs. Same data is uploaded on different systems. Sometimes the
6 data does not correlate raising questions about authenticity of data. Further, the data suffers from
lack of standardization that limits its usability in decision making.
2.4 Data analysis and reporting
Data, unless analyzed and used for decision making is useless. There is a significant lack of
capabilities to make sense of data and analyze the data. This is because the existing officers and staff
are not trained in public health and health statistics, and there is very limited or no health data
experts hired in NHM. Even NHSRC has this weakness. This is a major hurdle in data based
decision making. The need is to build a credible public health work-force who are apt at data analysis
and interpretation. Other option is to outsource the data management functions. There is not state
wise or national statistical and narrative report of NHM, which is highly desirable.
2.5 Integration issues
As discussed above, there were multiple platforms and systems running parallel. For example, in UP,
platforms for monitoring maternal and child health indicators were being maintained as a part of a
comprehensive platform as well as part of RMNCH program health. Multiple introductions of
software based programs without linking them to already existing programme led to duplication of
efforts. There is an urgent need to build a standardized data system over which the applications can
be built. Such data based platforms can also help in strategic planning and ignite innovative
solutions. A concentrated effort to make an integrated standardized data system would enable the
stakeholders to design innovations that would use standard and interoperable data. For example,
procurement can be linked to the disease patterns only if the systems and data are interoperable.
2.6 PIP process issues
PIP has been one of the key processes that has resulted in empowerment at the peripheral level as
well as institutionalized flexibility. The NHM needs to strengthen the process of PIP further by
enabling the periphery to make optimal use of the opportunity. One of the issues we found that the
1800 line items of the PIP budget jeopardized flexibility and introduces centralized
micromanagement. Standardization and coding along with instituting mechanisms for capacity
building in terms of the PIP process at the peripheral level will be a key to achieving transparency
and accountability and also enhance the perception of justice- procedural and distributive.
7 Recommendations: Data based strategic planning and M&E for states
Preparing a strategic plan
The states need to prepare a strategic plan for health (Three years at least) based on the current public
health circumstances, the disease burden, infrastructure and human resources aspects. This plan
should guide the health investments and PIP development for NHM.
Longer term PIPs based on strategic plan
PIP need to be forward looking for five or at least three years, with large proportion of activities
being constant for every year. The decentralised planning under PIP may start at village level and
gets integrated into higher-level action plans at district and state levels. This is already initiated in
some states.
Regular Annual Performance Report
A small portion of NHM funds should mandatorily be dedicated to the creation of a standardized
detailed annual statistical and narrative performance report by each state, submitted to the central
government, and made available to the public.; Directorate of Health Services Officials should be
involved in in this. This report can be also used to monitor progress and evaluate the NHM program.
There should be a state-wide M&E plan which should guide the process.
Single standardized system for data collection and reporting
A unified standardized system for data reporting should be created for all processes, ensuring ease of
use as these systems will be used by the frontline workers. The data triangulation and verification
mechanisms need to be implemented to ensure quality of data. Capacity building should be enhanced
at all levels to enhance data based decision making.
Reducing the number of budget heads in PIP
Reduction in the number of heads in PIP/Budgeting is strongly recommended to bring more
flexibility- To bring it down to 1000 from 1800 in the first year and in next 2-3 years make it about
500 budget lines under 5-6 major heads.
Software based planning
PIP/ Budgeting should become online where most of the aggregation and duplication work may be
done by backend software.
8 3. Issues related to HRH- Equity and justice concerns
NHM’s major contribution was expansion of the human resources for Health. NHM brought in
flexibility in recruitment as the process does not depend on state public service commission exams
for recruitment – which is a very slow process. Further, managerial capabilities were built in the
system by designing program management units at multiple levels and hiring managers for these
units. The NHM has improved overall capacity in management, finance, and data by creating the
space for contractual, temporary program management staff, such as the State Program Management
Unit (SPMU) and the District Program Management Unit (DPMU). It should be noted that the
improvement of technical capacities has been achieved by the NHM not only by adding cadres and
personnel to the existing system, but also by creating a dynamic and action oriented health system
culture through induction of young professionals.
To develop a connection with the community about 1 million strong cadre of ASHA workers was
created across the nation. This is seen as a game changing innovation of NHM. It has helped in many
ways – improving coverage of services, improving community contact and establishing village level
presence of health services.
Under NHM funding the deficiencies in HRH were quickly filled by the contractual work force hired
under NHM. However, coexistence of contractual and regular staff in the system posed challenges.
Perception of equity amongst the employees is an important aspect of all three forms of
organizational justice- procedural, distributive as well as interactive. Equity relates to ‘similar pay
for similar work’, equal opportunities for career progression and appropriate allocation of work.
While NHM had enabled decentralization, shifting the power to the district and state level through
the PIP process, there were other issues related to collocation of two different types and levels of
employees- jeopardizing the equity perceptions amongst the employees. These are given below.
3.1 Pay
The pay structure and work allocation in the NHM versus the permanent staff was significantly
different, especially at the senior levels. The perception was that the contractual NHM staff are made
to do all the hard work while their pay is lesser than the permanent staff who enjoyed many benefits
besides higher pay.
3.2 Training and development
Skilling is an important component of empowerment. We found several impediments to this. While
there have been several programs and emphasis on training the real capacity building in is limited,
even the funds allocated for these are limited. Inadequate training budgets and improper allocation of
the allocated budgets are important causes of lack of skills amongst the staff, especially the frontline
9 staff. The training system including NIHFW, SIHFW and regional training centres are weak. While
medical colleges and institutes of public health have been used for capacity building on a limited
scale, except for PGDPHM program.
3.3 Career development
Career progression is yet another dimension of fairness and equity. One of the important dimensions
of work allocation and career progression that we observed at a senior level was lack of
administrative and managerial capacities and public health skills. The role of clinical specialist,
administrator, manager and the public health are intertwined in the system, with one person expected
to perform the three roles from time to time. Many times a one director holds charge of many
different programs and hence not able to do justice to any. Cadre rationalization with creating a
career plan for specialist, administration and public health needs to be undertaken in each state and
central level on urgent basis.
At the frontline level, there were issues related to uncertainty and lack of clarity about career
progression. While there was a provision for periodic regularization of NHM staff in the NHM
blueprint, the same has not been implemented, except in some few states such as Tamil Nadu. It was
reported that the work allocation is asymmetric, with contractual NHM staff doing the majority of
the work.
3.4 Lack of key capabilities
While there are multiple and diverse personnel involved in the implementation of NHM including
the consultants, program managers and technical service delivery employees etc; rationalization of
the staff and the roles was lacking. Some key capabilities are lacking. - for example, there was a
significant gap in capabilities regarding procurement, supply chain, public health, epidemic control
and data sciences.
3.5 ASHA
We found several issues related to ASHA. Concerns were raised about their recruitment and the lack
of the MO’s role in the same. With increasing urbanization and education levels in the communities,
there was a perceived need to take a relook at their qualification levels in urban areas. Further, with
the increasing focus on wellness centres, there was an envisaged need to revamp their training
programs. Furthermore, respondents cited issues related to their performance monitoring and career
planning as it was perceived to be a ‘dead end job’ with no career progression. ASHA management
systems are also week at state and central level.
10 Recommendations
HRH
Establishing a well-resourced professional, efficient HRH cell at the state level
Enhancement of HRH has been one of the significant improvements in the health system brought
about by NHM. We suggest creating an efficient HRH cell at the state level with professionally
trained HR personnel with authority to recruit, train and deploy HR for various cadres of health
department.
HRH as an integral part of HMIS
Implementation of uniform and standard HRH platform should be an integral part of HMIS. The
HRH system should enable tracking and mapping of HRH across the state. Recruitment, training,
performance evaluation, transfers and other HR subsystems need to be managed through HMIS
Uniform HR policy
Uniformity in implementation of HR policies is an important aspect of good governance. NHM
should ensure uniform policies across states such as for recruitment and regularization of NHM staff.
Rationalization of compensation
To ensure equity of pay NHM should ensure rationalization of compensation to decrease the gap
between the pay for similar work and similar cadres.
Objective performance monitoring
One of the important feedbacks that we gathered across states was a need to develop and implement
an objective performance measurement system for different cadres of HRH.
ASHA
ASHA Recruitment and role
Entry qualification criteria into the ASHA program should be standardised. In urban centres, the
entry qualifications for ASHAs could be increased, especially in non-slum areas.
Compensation and recognition
The fixed honorarium amount should not be increased. Performance awards like "ASHA of the
month” could be put in place at the block level to introduce a competitive spirit.
Training and knowledge enhancement
Training modules for ASHAs may be re-examined for contemporary challenges like NCDs,
infections like COVID-19 and skills related to behavioural aspects of the community.
11 Monitoring
ASHAs should be monitored regularly by the ANM or the CHO, and mechanisms should be put in
place to remove non-performing or inactive workers within 3 months.
Career Progression
In long-term open schooling through NIOS should be facilitated to enable ASHAs to pursue higher
level education. Further, few seats for eligible well-performing ASHAs can be reserved in nursing
courses and some relaxations should be given.
Conclusion:
One of the recent events that has overwhelmed the health system in India is COVID-19. The
outcome of the pandemic, among other factors such as virulence, temperature and climate etc,
depends on the strength and effectiveness of the health system. And a defining characteristic of a
strong and effective health system is resilience. Three interconnected factors capture health system
resilience - awareness, adaptiveness, and integration.
NHM with its mission mode of structure and operation has contributed significantly to strengthen the
resilience of the health system in India. The focus on decentralization and empowerment of the
frontline and developing a community connection through an effective cadre of ASHA workers has
been vital for awareness and adaptiveness in the system. NHM has also focused on integration of
subsystems by bringing diverse programs under single umbrella and by instituting mechanisms such
as PIP and enhancing managerial capabilities.
The above study reiterates the need of continuing NHM in the mission mode, albeit with increase in
funding. Further, the study highlights some of the issues that require cognizance and makes
recommendations to address the same. The emphasis on three key aspects- structures and
coordination mechanisms between NHM and the directorates, data based planning and execution.
and the focus on further improvements in HRH can further contribute to building resilient health
systems and also enhance the capabilities to deal with sudden shocks such as COVID-19.
12 INTRODUCTION
At the start of the second millennium, India occupied a unique position on the global health map.
The country was witnessing a demographic shift with a decrease in both mortality and fertility rates.
Simultaneously, an epidemiological transition occurred from morbidities associated with poor
nutrition and communicable disease, towards non-communicable, lifestyle diseases, reflective of the
economic growth in the country, as a result of economic liberalisation in the 90s (Peters et al., 2003).
Despite this, as the Millennium Development Goals were being set, India was still grappling with
23% of all childhood deaths in the world, and a quarter of all maternal deaths (Peters et al., 2003).
The Indian public health system has been made on the foundation of PHC, and CHC, staffed by
health workers including ANM, MHW, and Health Assistants (Kapil, 2006). The Bhore Commission
Report of 1946 can be considered to be the first comprehensive document which focused on the
health of the Indian population, described its problems and suggested a system for health care
services and public health in India (Peters et al., 2003). This was followed by the Srivastava
Committee of 1975 (Purohit and Siddiqui, 1994) which sought to reorganise medical and health
education to bring about reforms that were suited to the health needs of the country at the time
(Sharma, 2014). This committee also led to the creation of the cadres of multipurpose health workers
and health assistants (Sharma, 2014). The Constitution of India has laid out the various services
associated with public health in lists that were divided between the central and state governments
(Gupta and Rani, 2004). In the early post-independence period, policy making and fiscal control was
traditionally the realm of the central government, whereas the implementation of these same policies
was to be decentralised, to the state and local governments (Gupta and Rani, 2004). This meant that
health agendas and resultant policies were often not customised to the requirements of states that
were as divergent in their population and health profiles as they were in geography and culture.
The National Health Policy (NHP) of 1983 aimed to correct the previous problems by emphasising a
needs based approach to health services and a long term focus on providing customised,
comprehensive primary health care at an affordable cost to communities (Ministry of Health and
Family Welfare, Government of India, 1983). Guidelines under this policy also highlighted
prevention and health promotion within primary healthcare. From a governance perspective, the
policy underscored the importance of and need for decentralising services, and planning the location
of health facilities in a manner that was considerate of topography, population density and disease
burden, and connectivity (Purohit and Siddiqui, 1994). The 1983 policy also recognised the value
and aimed to revive traditional Indian systems of medicine that had been previously side-lined
(Ministry of Health and Family Welfare, Government of India, 1983). The Revised 20-Point
Program put forth by the NHP also recognised the importance of tribal health, infant and maternal
13 mortality, malnutrition, and the control of communicable diseases such as Tuberculosis and Leprosy.
It further sought to create an integrated referral system of healthcare services in order to provide a
complete package of services, rather than a mixture of disparate interventions (Ministry of Health
and Family Welfare, Government of India, 1983). It can be said that with these features, the first
attempts at a systems approach to the Indian health system had been taken, which were then put into
practice with the NHM.
The NRHM was thus launched in 2005 with the following goals:- (i) to reduce IMR and MMR, (ii)
to create a comprehensive primary healthcare system, (iii) improve child health by focussing on
Water, Sanitation and Health (WASH) in communities, (iv) to prevent and control communicable
diseases, (v) to stabilise the population, (vi) to invigorate local medical practices, and (vii) to
promote healthful lifestyles in the population (Kapil, 2005).
The NHM also laid down strategies to achieve these goals, including the training of Panchayati Raj
Institutions (PRI) for the management and creation of health in their communities Bringing
Ayurveda, Yoga & Naturopathy, Unani, Siddha (AYUSH) health personnel into mainstream care
was done so that the system may provide 24 hour services in at least 50% of PHCs (Kapil, 2005).
The health system would be strengthened at all levels through inter-sectoral District Health Plans
encompassing health, sanitation, and nutrition. Finally existing vertical programs that addressed
specific health issues would be integrated into the mission at all levels from the centre to the district
(Kapil, 2005).
14
Figure 1 Objecties of thee aÇtooÇl HeÇlthe iNssNoo The NRHM was launched with a view to shift the focus of public health in the country from a
vertical, disease focussed, and programmatic approach towards one that recognises the complex
adaptive nature of the health system. Various schemes and programs were launched under the NHM
in order to improve health outcomes, and enhance access and interaction with the healthcare system.
These include, the Janani Suraksha Yojana (JSY), a conditional cash transfer program that
incentivises rural women for preferring institutional deliveries.
Human resources for health include health workers of all cadres functioning at all levels of the health
system. The Indian Public Health Standards (IPHS) which were created in 2007 under the NHM
made way for the provision of funds to hire contractual health staff including ANMs, nurses, and
additional doctors, all at the level of the PHC (Sundaraman et al., 2011). As of 2018, this has led to
the appointment of 195, 959 ANMs at the sub-centre level, 84, 567 nursing professionals at the
PHCs and CHCs, 27, 567 physicians at the PHC level, and 867 surgeons at CHCs (Rural Health
Statistics, 2018).
By creating a corps of technical and managerial staff at the block, district, and state levels, the
mission significantly improved management across the public health sector. This has led to a
streamlining of operations, fund allocation and expenditure, and decision making throughout the
Indian health system (Department of Health and Family Welfare, 2017).
The rationale for the NHM was to provide India with a systematic and robust nation-wide program
that would enable the country to achieve the MDGs. One of the NHM’s principal governance related
aims was the decentralisation of health system governance to as local a level as possible. This has
been put into practice through the formation of RKS at the PHC, CHC, and SC levels, Village Health
Sanitation and Nutrition Committees (VHSNC) also known as Gaon Kalyan Samitis (GKS) at the
village level, and the involvement of PRIs in health governance. In addition to this, several measures
of accountability have been put into place by the NHM at different levels of the health system, such
as Jan Sunwai and Jan Samvad, public hearings that allow community members an opportunity to
voice their individual concerns (Department of Health and Family Welfare, 2017).
Decentralising the health system also led to the communitisation of healthcare services, and health
decision making and planning. This is reflected in the VHSNCs which work in lock-step with PRIs
and mandatorily include representatives from disadvantaged members of each community, including
women (Department of Health and Family Welfare, 2017). Moreover, a cadre of community health
workers was created to improve access and interaction with the health system in rural India known as
ASHA. These household level activists serve as a well-regarded and trustworthy interface between
the healthcare system and the communities it serves.
15 OBJECTIVES
This study was commissioned by the NITI Aayog to be carried out in 6 predetermined states. Its
primary objective was to evaluate the impact of the NHM on human resources for health, governance
in the Indian health system and the impact of the NHM on the overall health system.
A To analyse the strengths and weaknesses of the governance setup of the NHM, identify best
practices going forward in context to the framework of Ayushmaan Bharat Pradhan Mantri
Jan Arogya Yojana (AB-PMJAY), SDGs, UHC and health equity
i.To analyse the technical capacities and decision making at the central and state levels
ii.To analyse the effectiveness of district and hospital societies in terms of improved and
need based planning and accountability to committed outcomes
iii.To analyse the effectiveness of untied funds in improving quality of medical care and
access to the same
iv.To analyse the effectiveness of investment in the ASHA component of NHM and
suggest solutions for enhancing the effectiveness of this investment
B To analyse the systematic, technical capacity and decision making at the national, state-level
in carrying out the NHM, and study the HR Capacities across difference states
v.Analyse the existing processes of district and city plan preparation and their
aggregation into state PIPs and identify areas of improvement, if any. Suggest
solutions to strengthen the existing systems and processes
vi.Analyse the existing systems and processes of budget preparation and funds allocation
to districts and city annual plans
vii.Analyse the existing monitoring systems and their effectiveness in implementation of
district and city plans and how these are contributing to accountability in terms of their
respective annual plans
viii.Analyse the processes of preparation of capacity development plans and their
implementation with special focus on quality of training and skills developed
ix.Analyse the procurement and logistics management systems at state, district and city
levels to identify bottlenecks, if any and suggest solutions for strengthened and more
accountable procurement & logistic management systems
C To study human resource gaps by looking at the requirements vis-a-vis actual officers posted
as a way of understanding the state capacities to carry out the mission. To analyse the State
strategies, plans and actions taken to bridge the evident gaps in human resources and the
effectiveness of such actions
16 Figure 1 Various Phases of the Study
METHODOLOGY
The study was executed in three phases: -
(i)Document and literature review
(ii)Development of a qualitative tool for key informant interviews and focus group
discussions
(iii) Data analysis and report writing
A mixed-methods approach was used where, published reports and other government documents
were reviewed, and the experiences of health officials at the central, state and district levels of the
health system, including policy makers and care providers provided primary qualitative data. Field
visits were also carried out to complement the document reviews and official interviews, and help
researchers develop independent impressions. In addition, quantitative secondary data from the
National Family Health Services and SRS were analysed for trends in mortality and fertility
indicators.
Study Setting
The study was carried out in 6 states namely, Gujarat, Rajasthan, Uttar Pradesh, Andhra Pradesh,
Chhattisgarh, and Karnataka. These states were chosen in order to get a sample representative of
population, and economic diversity.
The choice of these states is further substantiated by the trends in key health indicators such as IMR,
MMR, and TFR, which present a kaleidoscope of performance across the country. Since the impact
17 of the NHM on human resources is one of the primary objectives of this study, the choice of these
states is unique in that the health system in each follows a different organisational structure, allowing
the researchers to reflect upon the comparative impact as well.
3 districts in Gujarat, Gandhinagar, Rajkot, and Sabarkantha, and 3 in Uttar Pradesh, namely,
Barabanki, Kasganj, and Lucknow were studied. In Rajasthan, Andhra Pradesh, Chhattisgarh, and
Karnataka only one district per state was studied—Dausa, West Godavari, Durg, and Mysuru,
respectively.
18
Figure 2 Map of India with study states Figure 3 Study states with districts
Tool Development
We began with a desk review of documents including various reports of the NHM and the CRM.
Terms of reference delineated in the CRM reports helped to identify broad areas for measuring the
performance of the NHM on human resources and governance. In addition, peer-reviewed scientific
literature; white papers and reports; Common Review Mission reports, National Health Mission
Annual Reports and publications, and other relevant documents were reviewed to understand the
National Health Mission and for developing various tools for this study (Abejirinde et al., 2018;
Programme Evaluation Organistion, 2011; Common Review Mission, National Health Mission,
Government of India). We also took into account the WHO Health Systems Strengthening building
blocks framework (World Health Organization, 2010). This allowed us to include important
questions related to the determinants of governance such as decentralisation, the participation of
various stakeholders at each level of the Indian health system, and to incorporate contextual factors
unique to the Indian setting. It also led to the inclusion of items for assessing governance
performance at the district level and coordination with the higher levels. The determinants of human
resources for health included sufficiency, rational allocation, and remuneration for employed
personnel, and the integration of various programs to ensure optimal utilisation of the health
workforce engaged in both healthcare provision and management. The health system in turn is
characterised by the performance of each sub-system (state, district, block, and individual health
19 facility) within the country, evaluated by the performance of indicators pertaining to each building
block.
Figure 5 Tool Development Process
20 Service Delivery
RMNCH+A
Medicines, Diagnostcs
and BMMP
Communicable Disease Governance
Non-communicable
Disease
Healthcare Financing
Natonal rrban Health
Mission
Informaton and
Knowledge
Community Process,
Gender & Convergence
Human Resources for
Health
Quality of Care
Present study
Tool development was an iterative process starting with the appraisal of available tools for the
assessment of human resource and governance impact in the health system. In order to adapt the
tools to the Indian context, an exhaustive review of all CRM reports was carried out to identify
themes. These included 11 items of which ‘Community Processes and Convergence’, ‘Human
Resources for Health’, and ‘Governance, Accountability, and Healthcare Financing’ were of prime
importance for the purposes of this study. These were then aligned with the objectives of the study
through a review of the terms of reference provided by the NITI Aayog.
21
Figure 6 Terms of reference of the Common Review Missions Based on these, schedules for structured and semi-structured interviews were developed with themes
and sub-themes relevant to each key informant’s position, role, and responsibilities. As a result, the
question guides for senior officials of the central and state governments had items pertaining to
policies and the high level functioning of the mission and individual program components, including
inter-sectoral coordination with other ministries and departments.
On the other hand, the interview and focus group discussion guides for district level officials were
more granular. They included items about resource availability at district and lower levels, creation
and approval of PIPs and to what extent they were representative of local needs post approval, the
use of untied funds by the RKS and VHSNC, the recruitment, training and investment on ASHA and
their interaction with the frontline workers of other programs such as the Indian Child Development
Services (ICDS).
In order to assess and enhance the validity of the tools, they were reviewed by experts in health
systems research and public health. All study instruments were then discussed with officials from the
NITI Aayog, and their inputs on the same were incorporated before pilot testing was carried out with
functionaries of the health department in Gujarat. This enabled the researchers to introduce a higher
level of precision, especially for the district level instrument, by removing items which were not
relevant to their roles and responsibilities, rather including items focusing on the ease of use of PIPs
and specific human resource gaps at the CHC, PHC, and SC levels. Since qualitative research allows
a researcher to investigate the process and rationale of a particular event that has occurred or not as
the result of a program, questions in a qualitative instrument are posed in a manner as to allow for
sub-questions that can reveal effects that may appear to be secondary but are nonetheless important
and reveal relevant findings (Rapport et al., 2018) from a program such as the NHM. Table 1
provides an example of the questions under each research objective.
22 Tools for key informant interviews and focus group discussions were developed in English, and were
verbally translated by the interviewer into the local languages where necessary to facilitate
discussion and allow the respondent to provide detailed responses.
23 Table 1 Examples of qualitative research aims, objectives and questions in the interview tool for key
informants
Research Topic Study Objective Research Question
The impact of NHM on
Governance
To analyse the effectiveness of
district and hospital societies in
terms of improved and need
based planning and
accountability to committed
outcomes.
What is your opinion about
availability of various
resources at district health
society (probe; financial,
managerial capacity, human
resources, infrastructure etc.)
The impact of NHM on
Human Resources for Health
To study human resource gaps
by looking at the requirements
vis-a-vis actual officers posted
as a way of understanding the
state capacities to carry out the
mission. To analyse the State
strategies, plans and actions
taken to bridge the evident
gaps in human resources and
the effectiveness of such
actions.
Briefly tell us about human
resources at various levels
(probe- appointment at various
levels through NHM-
Managerial, technical)
Does state have any plan to
sustain human resources
recruited under NHM? (tool
for senior level officials)
The impact of NHM on the
Health System
To study the impact of the
NHM on the Health System
What is your opinion about
role of NHM in health system
strengthening?
(probe: improvement in human
resources, better managerial
approach, impact on WHO
health systems building blocks,
quality of care, access to
health services, more finance
for health)
Data Collection
Participants were selected in a purposive manner based on their position and knowledge of the health
system, health governance, and human resources for health. They were chosen from different
institutions and levels in order to obtain a complete picture of the health system hierarchy. The
availability and consent of the persons concerned was also taken into account.
At the central level, in-depth interviews were conducted with the managing director of the NHM
(MD-NHM), the Additional and Joint secretaries (AS) (JS), and senior managers in the NHM in the
areas of policy, planning, quality, and monitoring among others. State level health officials included
the Principal Secretary for Health and Family Welfare (PS- HFW), the state MD-NHM, the
Additional Mission Director of the NHM (Ad. MD-NHM); both incumbent and retired, the MD of
24 the MSCL and the Directors of Public Health. Program Managers and coordinators for NHM at state
level were also interviewed in addition to representatives from non-governmental and civil society
organisations. At the district level, key informants included the Chief Medical and Health Officer
(CMHO), District level health functionaries, the District Program Coordinator (DPC) for the NHM
and Logistics Management, the ASHA Coordinator for each district, and representatives from local
non-governmental organisations (NGO).
Focus group discussion participants included Medical Officers (MO) posted in various districts
including tribal areas and urban centres. Interviews were also conducted with Taluka/Block Health
Officers (THO / BHO) to gain perspective from below the district level. Focus group discussions
were also conducted with ASHA supervisors and ASHAs themselves.
The researchers obtained informed verbal consent which was preferred over written consent, as the
key informants, being government employees were reluctant to sign consent forms. This
apprehension can be attributed to a fear of lack of confidentiality, which would subsequently affect
the quality of the research conducted.
25
Figure 7 HeÇlthe fuoctooÇrNes NotheriNewed (VÇrNous Leiels) Data Analysis
In a qualitative approach, respondents’ rapport and faith in the interviewer are of primary importance
in ensuring that research questions are transparently answered (Sharma et al., 2014). Written notes
were taken during the interview by the researcher, which were then transcribed verbatim, translating
from local languages to English where necessary. The translations were carried out by research staff
fluent in both languages. Notes were taken during the focus group discussions and these were
transcribed into a document showcasing a logical flow of ideas from the discussion.
A coding framework was created in accordance with the theoretical constructs in the terms of
reference provided by the NITI Aayog in the objectives of the study. The transcripts of in-depth
interviews were coded individually at first using Microsoft Excel to prevent coding bias. An
inductive approach was used in order to manually derive codes from the transcript of each
respondent. These codes were then aggregated and aligned with the study objectives (Thomas, 2006).
This allowed the study to evaluate actual program effects of the NHM, in juxtaposition with its
expected impact. It resulted in the emergence of themes representing important patterns in the
responses and meaningful in context to the study objectives (Ganle et al., 2014). The coding of data
in this manner was carried till the researchers felt that theoretical saturation had been achieved.
A thematic analysis was then applied to the coded data (Attride-Stirling, 2001). This consisted of a
three level network with basic, organising, and global themes. Thematic networks allow for a high
level of rigour in qualitative research by providing a hierarchical structure to themes that emerge
from the text, which in this case is the interview or the discussion transcript (Attride-Stirling, 2001).
The lowest level is called a basic theme which simply characterises the data. This is then followed by
the organising theme which is a cluster of basic themes that are similar in nature. In this way,
organising themes reveal a clearer and more connected picture of the text. Finally, organising themes
are then condensed into global themes that deliver an interpretation of the text, and answer the
research question(s) (Attride-Stirling, 2001). Table 4 presents an example of the thematic analysis
for a focus group discussion conducted in Gandhinagar with MOs from various districts in Gujarat.
Analyses of all other key informant interviews and discussions are detailed in the results section.
In the human resource area these included subjects like shortages and mismanagement of the
administrative staff in health facilities, the differential treatment of state appointees versus
contractual NHM workers, incentives and benefits offered to medical professionals in rural areas,
and remuneration and opportunities for growth and development. Under governance, the major
themes were, handling of local priorities in the PIP during the various stages of its approval process,
26 coordination with representatives from other departments, the functioning and fund management of
the RKS, the event calendar, and allocation of funds, and existing monitoring mechanisms.
Table 2 Sample of Thematic Network Analysis framework - From global to basic themes
Basic themes identified Organising themes Global Themes
Recruitment of ASHA can be
influenced by local politicians
and even members of the state
Legislative Assembly
Political interference still exists
at various levels
Governance in health has
improved
Fund flexibility may cause a lack
of transparency
Digital reporting has improved
decision making
Technology has reduced
ambiguity and made monitoring
easierEase of auditing
ASHAs have made the health
system more accessible to rural
communities
The ASHA program added much
needed support to the grassroots
level, but the role and
remuneration need a fresh look
There is an expansion of the
health workforce. However,
adequacy in human resources for
health is still distant
There is dissatisfaction about the
payment received by the ASHA
worker
Appropriate deployment of data
entry operators and finance
assistants is needed
Distribution and compensation
of both health and administrative
professionals needs to
streamlinedNexus between contractual
NHM staff and state officials
27 Mamata Divas is observed
regularly
State of the health system and
healthcare facilities is better
The NHM has improved overall
health system performance, but
this is an ongoing processRKS funds allow for timely
infrastructural maintenance and
repairs
Procurement is complex Gaps exist in logistics
Drug distribution system needs
to be more rational
28 FINDINGS
1. Governance
1.1 Background
The NRHM was launched in 2005 by the Government of India with the aim of improving health
services in rural areas by subsuming existing vertical programs and creating a more decentralised
structure for health governance with additional funding by GOI (Pal, 2012). This was essentially
done to decrease the distance between health decision making and the communities and people it
affected, and ensure transparent and customised utilisation of funds allocated to health.
The initial focus states of the NRHM consisted of the Empowered Action Group (EAG), including
Rajasthan, Madhya Pradesh, Chhattisgarh, Uttar Pradesh, Uttarakhand, Bihar, Jharkhand, Odisha,
Himachal Pradesh, Jammu and Kashmir, and the eight North-eastern states (Pandav, 2006). The
NRHM also wished to achieve MDG-4 and 5 (improve child health and Maternal Health) and
improve the epidemiological profile of the country in terms of infectious disease, which was earlier
handled by non-interacting silos of vertical programs, an ineffective legacy of international donors
and development agencies funded programming (Bachani, 2006). One of the principal objectives of
the government at the time was also increasing health expenditure to at least 2%-3% of the gross
domestic product (Chatterjee, 2006). As a result, the value of funds allocated to the Departments of
Health and Family Welfare was increased from INR 8, 420 crores in 2005, to INR 10, 280 in 2006.
The NRHM was meant to reduce the deep chasm in the availability of qualified medical
professionals and care providers, and remedy the crumbling infrastructure of healthcare at the
grassroots level (Pandav, 2006). A lesson that the NRHM aimed to implement from previous
initiatives in health was that coordination with other sectors such as education, nutrition, and
sanitation was essential to ensuring good health. To this end, organisational structures were
revamped, and following decentralisation, management of health programs was given to the district
levels, mimicking the Sarva Shiksha Abhiyan (Pandav, 2006).
Governance Structure of National Health Mission has following major components:
Mission Steering Group (MSG)
Empowered Program Committee (EPC)
Central NHM Secretariat
NHSRC- Technical Support Unit
State Health Mission and State Health Society
State NHM and State Program Management Unit
District Health Mission and District Health Society
District Programme Management Unit
Some of the governance strategies applied for achieving the goals of the NHM include: -
29 Training and capacity building of PRIs to own, control and manage public health services
Creation of health plans for each village through the Village Health Committees of the
Panchayat
Preparation and implementation of an inter-sectoral District Health Plan prepared by the
DHM and DHS, including WASH and nutrition
Integrating vertical health and family welfare programs at national, state, and district levels
The NHM was an important milestone in strengthening primary health care. The NHM has improved
overall capacity in management, finance, and data by creating the space for contractual, temporary
program management staff, such as the State Program Management (SPMU) and the District
Program Management Unit (DPMU). Various new positions and cadres have also been created at the
facility level, such as managers, counsellors, data entry operators, laboratory technicians, technical
consultants, and subject matter experts. Many of these positions did not exist in the regular state
cadre of health department prior to the NHM. Another manner in which the NHM has helped to build
in-house technical capacities is through the hiring specialist consultants as employees of the National
Health Systems Resource Centre (NHSRC) and SHSRC. Dependence on donor partner supported
consultants was high before the NHM, due to which decision making was often influenced by the
aims of their parent donor organisations.
It should be noted that the improvement of technical capacities has been achieved by the NHM not
only by adding cadres and personnel to the existing system, but also by creating a dynamic and
action oriented health system culture through induction of young professionals. The consolidation of
vertical programs under the NHM umbrella has brought significant benefits to the way these
programs are managed and implemented. The state health department and SPMU officials mentioned
that the integration of various program under NHM has improved the management and efficiency.
The integration has also reduced the human resources requirement and duplication of efforts been
prevented.
Qualitative studies conducted on the Revised National Tuberculosis Control Program (RNTCP) and
the National Vector Borne Disease Control Program (NVBDCP) have found that administrative co-
location of these programs within the Department of Health and Family Welfare brought about more
interaction between the managerial officials of the programs, and the general health system (Rao et
al., 2014). This is true even at the state level, as all program implementation now passes through the
NHM Mission Director. It was also noted that various program officers such as the District TB
Officer, District Malaria Officer etc. all serve under the Chief Medical Officer (CMO)/ Chief District
Health Officer (CDHO). This restructuring of reporting hierarchies has improved technical capacities
both for the individual programs, and the health system, at the district level (Rao et al., 2014).
30 Another advantage of the NHM is the administration of program by health system managers at the
PMU at all levels. This has allowed for the rational and effective use of technical personnel such as
laboratory technicians at the facility level. Program managers and supervisors experienced that
sharing resources helped achieve program goals while providing a comprehensive picture of the state
of health in the community (Rao et al., 2014).
While integration has been seen with RNTCP and NVBDCP, the National AIDS Control Program
(NACP) is still structured like a separate program, mostly outside the jurisdiction of the NHM. The
NACP is running as a separate program. Hence, the NACP needs to be integrated within the NHM
umbrella. The published literature also reports health systems managers citing a lack of stewardship
in programs where integration is weak or absent (Rao et al., 2014).
In order to improve governance and technical capacities under NHM, the National Health Authority
(NHA) released Capacity Building Guidelines which were shared with all State Health Agencies
(SHA), in order to integrate the new structures envisioned under the AB-PMJAY with the NHM
(Ministry of Health and Family Welfare Government of India and National Health Authority, 2019).
The NHA will work in tandem with the NHM, and supplement it in terms of technical and
operational input at all levels of the health system. These would include but not be limited to
standard guidelines, standard operating procedures (SOP), various training and knowledge sharing
initiatives, and research and evaluation (Ministry of Health and Family Welfare, Government of
India, 2019). In these guideline the development of technical capacities envisaged as follows:
Policy – Ministers, Additional and Joint Secretaries, Director of National Institute of Health and
Family Welfare (NIHFW), Executive Director of NHSRC
Planning and Monitoring – Mission Directors of the NHM at state level, Chief Medical and Health
Officers at the district level
Program Management Officials – Consultants from the MoHFW, NHSRC, and NIHFW at the
national level, Program Officers, and State Nodal Officers, and District Nodal Officers
Service Delivery – MOs, Public Health Managers, staff nurses, ANM, laboratory technicians and
pharmacists at the district level and below
Ayushmaan Bharat launched in March, 2018, is the latest addition to pantheon of nationwide public
health improvement initiatives. One of its principal aims is to achieve Universal Health Coverage
through the Prime Minister’s Jan Arogya Yojana (PMJAY). The PMJAY is a nationwide health
insurance initiative, aimed at reducing out of pocket expenditure on secondary and tertiary care and
providing financial protection. Both initiatives are meant to supplement NHM efforts in bringing
about Universal Health Coverage in the country (BJ et al., 2019). The other component of AB—the
31 transformation of 1.5 lakh existing SCs, rural and urban PHCs, CHCs across the country to Health
and Wellness Centres will help accomplish the vision of UHC from within the framework of the
NHM (National Health Portal, Government of India, 2019).
1.2 Findings
Technical Capacities of the NHM-Central Structure of the NHM
The development of technical capacities is a fundamental requirement in health systems
strengthening. It requires taking stock of existing institutional structures, human resources and
governance mechanisms, and harnessing these to provide the best possible health to its users. In low
resource settings, it also includes building capacities by creating and training new cadres of
healthcare and techno-managerial officials to deliver and manage public healthcare.
At the centre, the NHM is composed of the Empowered Program Committee (EPC) and The Mission
Steering Group (MSG). They have delegated powers from the union cabinet – which is the most
innovative reform done under NHM. This allows the NHM programs to bypass the regular process of
approval by the cabinet and the Planning commission then and NITI Aayog now which otherwise
applies to other sectors/ministry programs. The MSG conducts annual meetings, where the authority
rests between the ministers and the secretaries. This allows for more innovations to be made. Due to
this structure of the highest echelons of the NHM, it is able to function in “mission mode” and allows
decisions to be made in a timely manner. So much so that this ‘mission’ structure has been adopted
by nearly 10 other ministries, as reported by the current AS-MD of the NHM. Programs such as the
JSY, the RBSK, the Janani Shishu Suraksha Karyakaram (JSSK), and the vaccination program for
viral Hepatitis B could be launched quickly because of mission mode governance structure of NHM.
The MSG and EPC meet regularly once and twice a year respectively. These committees decide
upon new health programs, changes to existing programs and financial allocation. The EPC
discussions tend to be technical, while the MSG also has a political agenda due to the presence of
several ministers. Since both these committees are very high up in the NHM hierarchy, decision
making tends to be more priority setting and financial than strategic or technical. Items on the agenda
of the EPC and MSG range in value from INR 1 crore to INR 2,500 crore – this is a great variation.
They include financial approvals of incentives, honoraria, and program expenditure revisions
adjusted for inflation. In cases where financial norms have not undergone change to the tune of more
than 15 years, proposals are made to triple the expenditure.
While represented in the structure, no role or inputs given by the secretaries from departments other
than health were observed in the minutes of the meetings we reviewed. This indicates that intersect
oral coordination is not occurring at the highest levels of the NHM. Researchers also observed that
32 evidence based public health was not reflected in discussion of these meetings, and decision making
seems to be many a times carried out on the basis of limited field observations, or instructions given
from the highest echelons. On the other hand, it was also seen that some grassroots level issues such
as the appointment of additional Medical Officers at health facilities was being discussed in these
meetings.
Table 3 Members and Structure of the Empowered Program Committee and the Mission Steering
Group of the NHM (National Health Mission, 2020a, 2020b)
EMPOWERED PROGRAM
COMMITTEE
MISSION STEERING GROUP
Secretary of Health and Family Welfare –
Chair
Union Minister for Health and Family Welfare – Chair
Union Minister of Drinking Water & Sanitation
Union Minister of Social Justice & Empowerment
Union Minister of Women & Child Development
Union Minister of Housing and Urban Affairs
Minister of Rural Development
Minister of Human Resource Development
Minister of State for Health & Family Welfare
Minister of Panchayati Raj
Vice Chairman NITI Aayog
CEO – NITI Aayog
Secretary of School Education & Literacy
Secretary of Higher Education
Secretary of Women and Child Development
Secretary of Panchayati Raj
Secretary of Rural Development
Secretary of Development of NE Region
Secretary of Social Justice & Empowerment
Secretary of Drinking Water & Sanitation
Secretary of Housing and Urban Affairs
Secretary of Tribal Affairs
Secretary of AYUSH
Secretary of Expenditure
Members of the Directorate General of Health Services
Additional Secretary Financial Advisor
Additional Secretary Health & Family
Welfare
Secretary Health & Family Welfare
Additional Secretary & Mission Director NHM – Convener
2 Public Health Professionals for 2 years4 Secretaries of Health and Family Welfare of High Focus
States for 1 year
9 Public Health Professionals for 2 years
The senior officials of Central NHM mentioned that one of the important governance feature of
central NHM is preparing Annual Report and sending note to the cabinet. This annual report
comprises of various progress made for various programme under NHM. This report also detailed
33 out improvement in health indicators across various states. This is a welcome initiative for justifying
the investment country is making in health through NHM.
The state health department and SPMU officials mentioned that fund allocation was found to be
arbitrary and occurring at a flat rate. For instance, the SHSRC budget for larger states is valued at
INR 2.5 crores and INR 1 crore for smaller states. This does not align with the populations of these
states (UP population of 20 Crores while Kerala population of 3 Crore), leading to tighter budgets in
more populated states, and large unspent funds in smaller states. The financing pattern of NHM is
largely based on incremental model rather than need-based allocation model.
The importance of the NHM remaining in mission mode was stressed by a number of health
functionaries. They stated that in the absence of the NHM, all money would be spent as per state
norms which would take away the flexibility currently present in both fund allocation, and in the
recruitment of human resources. It was pointed out that the stringency of state norms led to
significant delays in recruitment and fund availability. The NHM has also allowed for various
initiatives to be executed in training, capacity building, and innovations in healthcare service
delivery. A significant reduction in local and state level political interference has also been observed,
as guidelines from the central government are binding. There is also central monitoring of the
program, hence local political interference is under check.
Our interviews clearly showed that the Mission structure is efficient and effective. This has also
served many purposes to strengthen the health system. Hence, we recommend that the mission
structure should continue.
1.2.2 State level Governance Structure of the NHM
At the state level, the NHM functions through the State Health Mission and a State Health Society
(National Health Mission, 2020b). The former is more of a guiding body, whereas functions are
mainly carried out by the latter. The SHS consists of a governing body and an executive committee.
It was constituted by merging the health societies for leprosy, tuberculosis, blindness control, and the
Integrated Disease Surveillance Program (IDSP), except for the State AIDS Control Society (SACS).
The State Health Mission is headed by the Chief Minister and the Health Minister is the Member
Secretary. The SHM has representation from various line departments. The state health mission has
been conceptualised for bringing an inter-sectoral approach in health. However, as mentioned by
senior officials of health department, in most of the states the State Health Mission’s meetings are
not happening regularly and even if these are happening on paper only without any concrete
discussion or decisions. Please see below table for number of State Health Mission meetings held
year wise.
34 Table 4 Year Wise number of meetings of State Health Mission Held
Figure 8 Structure of the Governing body of the SHS (National Health Mission, 2020b)
The State Health Society is one of the important institutional mechanism for efficient administration
and supervising various program under NHM. The SHS has governing body and executive body. As
stipulated by the NHM, the governing body of SHS is required to meet every six months and carry
out the following activities: -
Approval / endorsement of Annual State Action Plan for the NHM
Consideration of proposals for institutional reforms in the Health & Family Welfare sector
Review of implementation of the Annual Action Plan
Inter-sectoral co-ordination with all NHM related sectors and beyond (e.g. administrative
reforms across the state)
35
Year India High Focus-
Non NE (10)
High Focus
NE (8)
Non High
Focus-
Large (11)
Non High
Focus- Small
& UT (7)
2014-15 39 3 12 13 11
2015-16 34 3 9 10 12
2016-17 31 1 8 12 10
2017-18 33 0 7 19 7
2018-19 33 1 11 10 11
2019-20 14 2 5 1 6
Total 184 10 52 65 57 Status of follow up action on decisions of the SHM
Co-ordination with NGOs/donors/other agencies/organisations
The Executive Committee is tasked with monthly meetings and is required to focus on the following
areas: -
Detailed expenditure and implementation review
Approval of proposals from districts and other implementing agencies/District Action Plans
Execution of the approved State Action Plan, including release of funds for programs at State
level as per Annual Action Plan
Release of funds to the DHS
Finalization of working arrangements for intra-sectoral and inter-sectoral co-ordination
Follow up action on decisions of the Governing Body
The SHS is the nodal institution for guiding its functionaries towards receiving NHM funds. The
SHS established under the Department of Health & Family Planning. Functions of the SHS include
performance monitoring, inter-sectoral coordination, advocacy, and accountability to the NHM for
funds received from the MoHFW, Government of India.
The SHS is supported by SPMU, managed mostly by contractual employees, and acts as a technical
support unit for the NHM. The SHS is also technically supported by other organizations such as the
State Institute of Heath & Family Welfare (SIHFW), the State Health System Resource Centre
(SHSRC) and technical agencies of the health systems development projects. The SHS is responsible
for the implementation of vertical programs such as the RNTCP, NVBDCP (Rao et al., 2014). There
are reports in the literature that the SHS model, and the integration of vertical programs therein may
have led to delays in sanctioning funds (Rao et al., 2014). While this could be seen as a performance
36
Figure 9 Structure of Executive Committee of the SHS (National Health Mission, 2020b) issue, it can be argued that the decentralisation in decision making afforded by the SHS model has
increased program responsiveness to local needs rather than vertical objectives. This should be seen
as a positive change brought by the NHM, as states are now able to allocate funds and resources to
various verticals in accordance with their demographic and epidemiological profiles.
In the state officials were found to be in favour of the NHM, and insisted that it should continue to
work in mission mode, following the model of the SHS. They added that the society model affords
them flexibility in decision making as well as fund management. In most states though, SHM
meetings were not observed to be regular and were ill planned.
The State Health Department is headed by Principal Secretary-Health, who is also chairperson of the
State Health Society. The Mission Director-National Health Mission is administrative head of NHM
and also member secretary of the SHS. The State Program Management Unit (SPMU) is headed by
State Program Manager (SPM). The various programs are headed by State Nodal Officer (SNO) in
Rajasthan or General Manager (GM) in Uttar Pradesh.
Gujarat:
Gujarat health department is headed by Principal Secretary. The commissioner of health is next level
health functionary followed by Mission Director, NHM. The Directorate of Health Services has
several Additional Directors, with AD—Public Health usually being the senior most. There are
several Joint and Deputy Director for handling various programs. There is a State Program Manager
(SPM) for the administration of State Program Management Unit-SPMU, NHM. The SPMU in
37
Figure 4 Organogram of the NHM in the state of Gujarat Gujarat was found to report directly to the MD-NHM and also provided the latter with managerial
support in PIP making, and monitoring and supervision.
The NHM is well integrated with state health department in Gujarat. Various senior program
officials have suggested improvement in NHM governance. One of the senior director of the state
proposed a restructuring of the NHM organogram in the state, where one of the senior director would
serve as the MD-NHM. This was suggested due to the technical nature of health programs. This will
help integrate the NHM with other health programs.
District officials from Sabarkantha reported that while the NHM had greatly enhanced technical
capacity by allowing for flexibility in the recruitment of human resources, this was sometimes ill-
used at times, such as in the case of separate laboratory technicians and data entry operators for each
vertical program, at the district level. This was seen as wasteful duplication. Inconsistencies were
also pointed out in the district level PIP which was disproportionately focused on Reproductive,
Maternal, New-born, Child, and Adolescent Health (RMNCH+A), to the neglect of other disease
programs including non-communicable diseases. The Chief District Health Officer (CDHO), under
whom the PIP is prepared was found to be unaware of the program activities and respective budgets
in non-RMNCH areas. Lack of coordination was also reported between the CDHO and the Chief
District Medical Officer (CDMO). It was suggested that a platform should be created for the two
officers to deliberate over the various public health issues of the district. In lieu of the DHM with
separate governing and executive bodies, officials in Sabarkantha felt that a single committee headed
by the District Development Officer (DDO) would be more effective and work faster.
The Rajkot municipal corporation was found to have contractual NHM staff at a majority of public
health facilities in urban areas. The state hired less than 5% staff in these areas, in both clinical and
managerial capacities. As a result, shortages were reported in monitoring and evaluation, data entry,
and financial management.
Rajasthan:
The Rajasthan Health and Family Welfare Department is headed by Principal Secretary of Health,
followed by the Mission Director of the NHM who is also a special secretary to the health and family
welfare department. On the other hand, the state cadre of health officials is headed by Director of
Public Health. Both the MD, NHM and Director, Public Health report to Principal Secretary. It
should be noted that there is no position of a Commissioner of Health in the state, and this was seen
as an advantage by health functionaries as it shortened the chain of reporting. The NHM in Rajasthan
also has a unique structure where every program under the mission has a Program Director, senior
level officer and a State Nodal Officer, relatively junior, both of them are officials of the regular state
38 Figure 5 Organogram of the NHM in the State of Rajasthan (National Health Mission, Rajasthan, 2020)
health services cadre. This has resulted in better coordination between the NHM and the directorate
in the state. It was also reported that there were no management cadre official’s vacancies in the state
under the NHM. However, since officials of the state health services cadre tend to be senior
physicians, their recruitment into non-clinical managerial roles would reduce availability of clinical
staff at health facilities. Therefore, the state should take a call whether it is essential to have
medically trained staff in managerial positions at SPMU.
Interdepartmental coordination with the ICDS was also seen to be good in Rajasthan, and regular
meetings occurred between senior executives from both programs, to ensure accelerated health-
nutrition integration. The other states such coordination is weak.
Uttar Pradesh:
Uttar Pradesh was one of the states included in the EAG at the time of launch of the NRHM, due to
its poverty levels and high population (Gill, 2009). It was also among the states included in an early
evaluation of the NRHM by the then Planning Commission (Gill, 2009). The governance structure of
the NHM in UP consists of the Department of Health and Family Welfare, the Program Management
Units at state, division, district, and block levels (State Programme Management Unit, NHM, 2019),
and the Uttar Pradesh Medical Supplies Corporation Limited. The UPMSCL is composed of
representatives from the NHM (Mission Director-NHM UP), the Department of Health and Family
Welfare (Principal Secretary and Secretary), and the Directorate General of Health Services in the
state (Uttar Pradesh Medical Supplies Corporation, Government of Uttar Pradesh, 2020).
Recent research has also found that the state has significant internal inequalities in health outcomes
and in medical human resources (Singh, 2019), and that despite NHM norms for free maternity and
39 post-natal care in the public healthcare system, the state is plagued by high levels of out of-pocket
expenditures (State Programme Management Unit, NHM, 2019) (Landrian et al., 2020). In our
findings, it was pointed out that states had not taken initiatives to separate clinical and administrative
streams, due to which clinical talent was burdened with administrative duties, even when health
facilities faced a shortage of qualified doctors. On the other hand, notable improvements were seen
in infrastructure and in technical capacity. The State Innovations in Family Planning Services Project
Agency (SIFSPA) has been established with the help of USAID. In Uttar Pradesh there are several
large project been created and are managed by their own agencies- World Bank Health System
Project, BMGF funded TSU etc. They have varying role and lack of coordination between the
agencies. This is negatively affecting the overall governance.
There are 2 Directorate of Health Service in Uttar Pradesh- Medical and Health, and Family Welfare.
The SPMU in Uttar Pradesh was seen to be staffed with general managers in the areas of policy,
planning, human resources, monitoring and evaluation, and community processes. These general
managers’ report to the state program manager and were often deputed from the regular staff of the
DGHS. However, the 12
th
CRM has reported that the positions of Senior Manager, District Account
Managers (DAM), and Block Account Managers (BAM) were still vacant, indicative of lacunae in
the managerial cadre in the state (Common Review Mission, National Health Mission, 2020).
In every district in UP, a District Program Officer is appointed by the NHM below the CMO.
Further, the NHM has also created Block Program Management Unit (BPMU) in the state, with a
Block Program Manager. Moreover, a large number of Additional CMOs were seen, who were put
into managerial roles despite being specialist medical doctors. In UP, this is a huge disadvantage
since the state faces a shortage of specialist doctors in public health facilities and the state
government has no good mechanism for the recruitment of the same.
It was pointed out that in some states initiatives had not been taken to separate clinical and
administrative streams and due to this clinical talent was mired in administrative duties and unable to
actually deliver healthcare services. A feasibility study conducted in Uttar Pradesh found that this
was a context where data driven frameworks had the potential to be implemented (Avan et al., 2016).
40 Figure 6 Organogram of the NHM in Uttar Pradesh (State Programme Management Unit, NHM,
2019)
Tamil Nadu has shown incredible progress in public health management with the establishment of a
separate state level Directorate of Public Health and Preventive Medicine (Gupta et al., 2010). This
organisation, in addition to having a dedicated budget of its own, and significant power and
operational authority, is staffed by a techno-managerial cadre trained and experienced specifically in
public health. Doctors and other health professionals are not absorbed solely on the basis of their
education and clinical experience, rather a specialised training in public health is imparted to them
for a period of three months. Further, employees of the public health cadre enjoy considerable
authority over their medical counterparts, and have fast tracked promotions (Gupta et al., 2010),
thereby making public health government service a lucrative career path in the state.
41 District level governance structure of the NHM
The structure of the NHM at the state level is replicated at the district level with a DHM and a DHS
(National Health Mission, 2020a). The DHS is the primary body at the district level which is
responsible for the planning and management of all programs related to health, in both urban and
rural areas of a district (National Health Mission, 2020a). All vertical programs for individual disease
conditions, and health initiatives were merged into the DHS with the introduction of the NHM. Due
to these structural modifications and increased responsibility, the jurisdiction of the DHS increased
beyond that of the existing Zilla Parishad and Urban Local Bodies (ULB) (Urban Development &
Urban Housing Department, Government of Gujarat, 2016). As a result, this body is required to
maintain a record of all funding received, including the state treasury and other sources.
The District Health Mission is extremely important institute established under NHM for improving
decentralisation and also for bottom-up planning. Across the study states we have observed that
District Health Mission meetings are happening and this institute is also helping the mission in
coordination with other departments.
Table 5 Year Wise number of meetings of District Health Mission Held
Year India High Focus- Non
NE (10)
High Focus
NE (8)
Non High
Focus-
Large (11)
Non High
Focus- Small
& UT (7)
2014-15 1142 432 127 551 32
2015-16 1035 533 135 345 22
2016-17 1343 570 130 609 34
2017-18 1184 285 64 806 29
2018-19 1265 291 74 873 27
2019-20 1060 231 67 744 18
Total 7029 2342 597 3928 162
Source: Executive Summary, National Health Mission, Ministry of Health and Family Welfare,
Government of India (2019).
The role created for the DHS accomplishes the decentralisation of decision making to the district
level. This is achieved through inter-sectoral convergence with other related departments such as
education and sanitation, and by creating integrated plans with these departments. This is reflected in
the membership of the governing body and executive committee of the DHS. In Urban areas-
Municipality, an urban health society was formed at the level of the municipal corporation and this
body was responsible for the implementation of NHM programs.
The NHM lists the following functions for the DHS: -
42 To act as the nodal forum for all stake holders line departments, PRI and NGOs, to participate
in planning, implementation and monitoring of the various health and family welfare
programs and projects in the district
To receive, manage, and account for the funds received from the state government (including
state level societies in the health sector) for implementation of centrally sponsored schemes in
the district
To strengthen the technical / management capacity of the District Health Administration
through recruitment of individual / institutional experts from the open market
To facilitate preparation of integrated district health development plans, for health and its
various determinants like sanitation, nutrition, and safe drinking water, etc.
To guide the functions related to Total Sanitation Campaign at the district level
To mobilise financial and non-financial resources for complementing/supplementing the
health and family welfare activities in the district
To assist hospital management societies in the district
To undertake such other activities for strengthening health and family welfare activities in the
district as may be identified from time to time, including mechanisms for intra and inter-
sectoral convergence of inputs and structures
The DHS is also responsible for preparation of District Health Action Plan.
Table 6 Year wise Number of Districts prepared annual District Health Action Plan (DHAP) under
NHM
Year India High Focus-
Non NE (10)
High Focus
NE (8)
Non High
Focus- Large
(11)
Non High
Focus- Small
& UT (7)
2014-15 670 325 92 233 20
2015-16 674 325 95 233 21
2016-17 678 326 96 234 22
2017-18 676 326 96 234 20
2018-19 672 326 96 229 21
2019-20 673 326 96 230 21
Source: Executive Summary, National Health Mission, Ministry of Health and Family Welfare,
Government of India (2019).
43 Figure 7 Structure of the Governing Body and Executive Committee of the District Health Society
Findings from Uttar Pradesh reveal that the DHS is functioning well and both the governing body
and the executive committees conduct monthly meetings. However, it was noted that in districts
where the chair of the governing body was the District Magistrate (DM), delays were observed in the
decisions of the DHS due to interference from this office. Further, certain blocks containing densely
populated urban districts lacked a dedicated BPMU. This led to a shortfall of techno-managerial
support for public health facilities, as in the case of Lucknow, where upwards of 65% public health
facilities are located in urban areas. Medical colleges, the apex government healthcare providers in a
state, are not overseen by the CMO. Therefore, funds earmarked for these facilities should be
distributed directly to them rather than being routed through the DHS.
Governance Issues related to Finance
The SPMU and Health Department Officials across various states also highlighted that while the
state government was working towards integrated financial management through a dedicated
software, there was a need to streamline financial processes under the NHM. For instance, there is a
delay of 3-4 months in obtaining the Financial Management Reporting (FMR) codes from Central
NHM, which are codes assigned to each operation which needs to be carried out as part of the state
health plan, and to which a budget fund value is assigned. Ideally, these should be available at the
same time as the approved NHM budget is received by the SHS.
The Commissioner of Health in Gujarat stated that the member secretary of the SHS also served as
the Additional Director of the State Health Department for ensuring better integration and
coordination with the directorate. The state achieved higher efficiency and effectiveness in the
delivery of health services due to there being seamless integration between the State Health
Department and the NHM. The executive committee of the SHS is the developer and the
implementer of the state level PIP, while approval for the same was given by the governing body and
the state government itself. During implementation of the state PIP, the governing body and the
SHM served as overseers to ensure appropriate governance standards were being followed.
State level health functionaries in Rajasthan also reiterated that the necessity of the mission mode for
the NHM. They insisted that finances remain under the centre’s control rather than being handed
over to the state government. One point of contention that was highlighted by officials in Rajasthan
was the change in receipt of funds. They cited that earlier funds were transferred directly into the
account of the SHS, whereas after 2014 they are being rerouted through the state treasury. This has
44 led to a delay of 70-80 days in the SHS receiving funds from treasury after the funds were transferred
from central government to the state treasury. This model needs to be changed back to direct receipt
by the SHS, as delays from state treasuries were observed in the pre-NRHM era as well (Sinha,
2009). Further, since the SHS is subject to audits similar to the state treasury, in addition to the
Comptroller and Auditor General’s (CAG) audit under the NHM, issues of transparency and graft are
also addressed (Sinha, 2009). Respondents noted that due to this insertion of the state treasury in the
fund flow, health societies were now dependent on the state government for 100% of the NHM fund
amount, whereas earlier their dependence was closer to 20-40%. Moreover, 21 separate bank
accounts were reported under the NHM at the state level, all of which were routed through the state
treasury.
Another example cited was that of the loyalty bonus for contractual NHM staff. While this was
approved in 2017, due to delays by the state finance department, these bonuses had still not been
disbursed. Further, because the state finance department lacked a mechanism to recall unutilised
funds from lower levels, nearly INR. 1, 200 crore remained unused at the district level in UP.
Respondents said that since the SHS has its own governing body, there was no need to loop in the
state finance department. It was recommended that all NHM funds from the centre be brought into a
single bank account, which would not only reduce duplication of effort and delays, but also make it
easier to disburse the funds to the district societies.
Directorate of Health Services at Central Level
The Director General of Health Services at the centre functions under Ministry of Health and Family
Welfare. The Directorate is headed by Director General of Health Services.
The role of DGHS is to provide evidence based technical support for policy formulation and
programme implementation in matters of Public Health, Healthcare, and Medical Education to the
Government for achieving an acceptable standard of health for the people of India.
The DGHS is a core agency and contribute in developing the health system with quality, excellence,
equity, and righteousness with participation of the people, communities, and all stakeholders for
health and wellbeing of all. The DGHS is supported by several Deputy Director General, Additional
Deputy Director General and Director rank officials.
Senior DGHS officials mentioned that after introduction of NHM, the DGHS office role is
diminishing and most of our administrative powers are taken over by NHM bureaucrats. Although,
we are involved in PIP process and NPCC. However, our role is just to provide technical inputs and
these inputs are not binding on NHM officials. Most programs are looked after by Joint Secretary
rank officials.
45 Central DGHS officials pointed out that the appointment of officials at directorate is in the hands of
bureaucrats and they were found to deliberately appoint senior officials on the verge of
superannuation, which led to very short tenures and hence insufficient time for planning for future
long-term actions or taking up new strategic directions in technical programs.
The Central DGHS officials feel that technical work should only be done by DGHS officials and the
NHM bureaucrat officials should only look after administration and timely disbursement of finance.
Directorate officials stressed that there is an urgent need to reflect and act upon the major constraints
and weaknesses of the DGHS in the public health management system. There is a need to understand
why the directorate has weakened and become dysfunctional.
Figure 8 Organogram of the Directorate General of Health Services (2020) at National Level,
Government of India
Directorate of Health Services at State Level
In our study states Directorate of Health Services are functional in Rajasthan and Uttar Pradesh.
However, in Gujarat the post of Director of Health Services is abolished. The additional director of
public health is senior most official in directorate.
46 The DHS is manned by regular state government employees. The directorate has been traditionally
responsible for the planning and delivery of public health services. The directorate receives funds for
the implementation and monitoring of disease control and eradication programs.
As reported by Directorate officials of Uttar Pradesh and Rajasthan, one of the key areas of concern
was the disconnection and lack of integration between the SHS and the directorate. Respondents
from the latter felt that after the introduction of NHM, the role of the directorate had decreased and it
now functions merely as a signatory for the SHS on PIPs. It was also observed that the directorate
played no role in various administrative and financial functions and that all power resided with the
SHS. This led to a lack of ownership and horizontal integration resulting in inefficient delivery of
public health services over a period of time. A clear disconnect between the SHS and the directorate
was also revealed at the state level. In the state each public health management Institute-State
Institute of Health and Family Welfare (SIHFW) functions as separate establishments with no
communication among them. Each establishment was found to have a different institutional
structure, technical, and managerial competencies. Since all major vertical programs were brought
under the umbrella of the NHM, they are now implemented by the SHS. The directorate is
responsible for the implementation of state funded diseases control and disease eradication programs,
family welfare, school health and universal immunization programs. Serious concerns were
expressed about the lack of coordination in the planning, execution and management of programs. In
this regard, the SPMU was seen as a parallel structure created by the NHM which was given control
over technical aspects of the management of various programs, which had earlier been the ambit of
the directorate. In an ideal scenario, the SHS should oversee financial and administrative aspects of
planning and fund disbursement, while the directorate should be responsible for the technical
implementation of health programs. This was observed in Gujarat, where the directorate was well
integrated with the SHS, which led to the effective and efficient delivery of public healthcare
services.
The directorate’s lack of say in the flow of funds into the SHS is often seen as its inability to exercise
control over programs. Due to this there is limited capacity and willingness to manage new
programs, especially those that are not related to clinical care provision. It was also pointed out that
the central NHM did not give any importance to the directorate and only interacted with the SHS.
Further the directorate and the section teams under each of its various divisions were seen to be
inadequate and inappropriately staffed. They were able to respond only to immediate necessities of
running the programs. They lacked the public health, long term planning and managerial capacity to
deal with multi-dimensional programs under the NHM. Health functionaries also lamented that there
47 were no efforts from the NHM to build such human resource and technical capacity within the
directorate. This has led to dysfunction, inefficiencies, and redundancies in the system.
On the other hand, SPMU officials identified a lack of qualifications, expertise, and necessary
experience in public health among the key functionaries of directorates. Many directors in the state
do not have to have public health qualification. They can be basic doctor or specialist doctors and by
seniority become directors looking after particular technical programs. Further, the short tenure of
key functionaries at all levels on account of superannuation, late promotions, and arbitrary transfers
and postings were seen to be the major issues affecting the performance and efficiency of the
directorate.
1.3 Recommendations
1.3.1 Redesigning the MSG and EPC and their functions
The EPC and MSG should also review the overall strategy of the NHM and national programs, in
addition to the micro-level within program fund allocation issues. A mechanism should also be
created for an annual financial report of the entire NHM to be discussed and approved by the MSG
and EPC, including the overall budget and this should be reflected in the minutes of the meetings.
There is a need for monitoring and evaluation at this level, wherein the achievements of various
individual programs and the NHM as a whole are brought under the lens, and thoroughly discussed
before approvals are given.
The number of departments represented in the MSG should be re-evaluated in terms of their
contribution to NHM. Observations have shown only some discussion on nutrition programming has
happened in MSG/EPC. Moving forward with the NHM, it will be essential to ensure the
involvement of all departments, especially sanitation, women and child development, and rural
development. In addition to inter-departmental coordination, the inclusion of scientific evidence, the
results of monitoring and evaluation programs, and national level data collection initiatives should be
thoroughly integrated into governance mechanisms at this level. The restructuring of the committees
should also include retired public health directors from high performing states like Kerala and Tamil
Nadu. This will not only bring tested and much needed expertise to the highest levels of the NHM,
48 but also ensure that opinions are shared without fear of repercussions as retired officers cannot be
targeted by the system for their frank opinions. In order to enhance the level of technical,
management, and medical expertise at this level, directors from the Indian Institutes of Technology,
Indian Institutes of Management, and All Indian Institutes of Medical Sciences can be appointed to
the EPC and MSG. this should also include the Registrar General and Census Commissioner of
India, the Secretary, Ministry of Statistics and Programme Implementation, representatives from the
Auditor General’s office and other such government officials.
Moreover, all strategic choices should be justified by both committees, and sufficient proof of
alternatives being considered should be made available in the relevant domain before decisions are
made on program strategy and funding. Furthermore, performance of the previously sanctioned
programs should be presented with dispassionate and objective review or progress. Based on this
course corrective measures should be discussed in the EPC and MSG, and should be forwarded to
lower levels, in order to prevent undesirable results from programs and schemes.
While some issues are in the ambit of states, decision making is still highly centralised in NHM.
Fund allocations should take into account various issues like level of urbanisation, differences in
standards and cost of living across states, in order to ensure flexibility and smoothness in program
implementation. Further, financial norms, for the mission as a whole and for individual states should
be derived on the basis of costing analyses, and work and time motion studies and not arbitrary
judgements of key people.
Directorate General of Health Services The involvement of technical personnel of the Ministry of
Health and Family Welfare should be a routine in proposal preparation and discussion. In addition,
due inputs should be taken from officials at the Directorate General of Health Services.
Time and agenda allocation of the meetings of the MSG and EPC should be divided into three
categories. (i) 30% time for program review, (ii) 60%-time proposal making—in order of expense
(budget – large budget items first) and importance of public health issue, and (iii) 10% time for
urgent and miscellaneous issues. Items for the meeting agenda should be set by asking members 2
months in advance for their suggestions, besides the government driven agenda. In addition, non-
member technical experts should be included in proposal discussions, and well researched
background documents for each issue should be prepared and circulated to the members of both
bodies in advance for them to read and come prepared. Each annual meeting of MSG should include
the full narrative, statistical, and financial reporting of the previous year. This report should also be
shared publicly on the NHM website. The same should be done by each state.
49 The EPC should undertake component wise discussions of the NHM, and each program should be
studied by rotation – starting first with the most fund consuming program. For national level
programs that require specialised expertise and specialised technology, such as peritoneal dialysis
program, thorough research should be conducted before being brought to the EPC. The issue must
first undergo examination by a committee of public and private experts and an exhaustive report on
health technology assessment should be done including cost. Such report should be presented by the
technical professionals and it should be discussed by the members before approval. This should be
made a norm for all proposals exceeding INR. 300 crores in value (indicative value – government
could set it higher to 500 Cr or lower to 100 Cr). The principle is before approving large projects
there should be proper technical and cost effectiveness analysis.
Research and Evaluation: In addition, the NHM could benefit from a research and evaluation
inputs from well qualified and independent individuals or groups/ institutions. The MSG and EPC
should recommend and commission independent analyses of data from expert independent individual
or institutions on various key programs and NHM components. This exercise should be conducted
periodically every 3-4 years. In order to facilitate an environment of transparency and progress,
special attention should be paid to research/evaluation highlighting the limitations or failures of
certain programs.
All the document, like minutes of meetings of MSG, EPC and annual report of NHM should be made
public. These document can be published on NHM website. Further, a standardised format for
Annual Report should be design for state to report progress made under various NHM programme. It
should be made mandatory for the state to publish annual report.
1.3.2 Integration of SHS-NHM and Directorate of Health Services
Effective integration and revitalisation of key public health function for improved health status of
states is required. The central NHM should work towards necessary architectural correction in public
health care delivery system and administrative reform for increasing the absorption of funds. The
central NHM should come up with strategies, guidelines, and frameworks for integration of NHM
organization and directorate. There should be a defined role of both the MD-NHM and directorate
officials in the implementation of various program under NHM.
The SHM and SHS should be integrated with the directorate through deputation of appropriate
regular employees to SPMU and SHS. The directive for this should originate from the central NHM,
where appropriate representation of DGHS in MSG and other decision making body is also required.
In addition, the State and District Health Societies should focus on including local patient
representative groups, and civil society. Generating localised funding sources is also essential for
50 ensuring involvement from all sections of the community including those individuals and
organisations capable of philanthropic endeavours. This will be important for drawing attention to
lacunae in the social aspects of public healthcare, such as facilitating food and shelter for the family
of care seekers, engaging social workers for follow-up community based care, and supporting local
blood banks.
Under Central NHM guidelines various measures should be taken for enhancing coordination and
integration. States should have strategies to build joint ownership for directorate and NHM. Further,
there is an urgent need to ensure proactive engagement and involvement of the directorate officials in
planning and execution and review of the NHM. The NHM should conduct joint reviews with the
directorate and some programs should be monitored by the latter. The strengthening of directorate is
also requiring for long-term sustainable system of proper program planning and effective
implementation.
1.3.3 Strengthening and Capacity Building of Directorate of Health Services
Adequate technical, financial, and human resources, and infrastructure should be provided to the
directorate for proper functioning and supporting the SHS. Senior officials of directorate of health
services should be given continuous exposure to short course trainings on various aspects of public
health management- epidemiology, health care financing, hospital management, community process,
human resource management, quality of care, HMIS, and communication etc.
For strengthening of existing directorate a well-designed HR strategy is required. Well trained,
technically competent consultants and officials of the SHS may be deputed in the directorate as
lateral entry officers, and regular cadre officials of the directorate can be placed in the SHS. This
strategy will facilitate instilling work-culture in directorates through development of skilled health
workforce thereby gradually building the ownership of NHM in the directorate.
There is great need to expand the positions in the directorates in various states and at central level.
Currently very few technical officers are looking after many programs. So each major program
should have 3-7 technical officers (directors) in each state depending on the population size of the
state. For example, major program is maternal health, child health, immunization, TB, Malaria/vector
borne diseases, Family planning and reproductive health etc. Smaller programs should have 2-3
technical program officers in each state. All the program officers should be trained in their technical
area and in public health. Expanding the directorate will yield much more returns in terms of
improve technical directions and improved efficiency of the field program implementation.
On the same lines the district health officers should also be strengthened by having public health
management trained officers in the regular cadre and under NHM for specific programs.
51 Other states could benefit by following the example of Gujarat, where the directorate is well
integrated with the SHM and the SHS. This would allow for a convergence of techno-managerial
talent where directorate officials with significant experience could work in tandem with Indian
Administrative Services (IAS) officers in the NHM who have the necessary qualifications for
program administration. Tamil Nadu also has an excellent model. While the State Health Department
is led by an IAS officer with high managerial and administrative acumen, the Director of Public
Health, an independent and authoritative position is responsible for advising the Health and Secretary
and Health Ministry on technical issues. All IAS appointees to public health services are trained and
made aware of the technical issues and basics of public health management and preventive measures,
and are acculturated to work in lock-step with the State Public Health Directorate from the beginning
of their careers.
Further, senior officials at the directorate should be appointed for at least 3 years in the same post.
Promotion criteria need to be made more transparent for selection of the key positions in the
directorate. A major restructuring of the directorate is required in many states.
1.3.4 Enhancing Technical Capacities in states
In Uttar Pradesh, the state government should create a specialist cadre to hire medical specialists at
the district hospital, sub-district hospital, and community health centres. Overall HR rationalisation
should also be conducted to remove additional program managers, data entry operators, and financial
assistants from the district level and prevent verticality and duplication. Moreover, in areas where
healthcare professionals are already low in number, physicians should be removed from
administrative positions and posted to facilities for clinical work – but those who want to do admin
work should be allowed to continue.
A similar approach as taken by Tamil Nadu, should be taken by other states as well, in order to
strengthen the public health cadre and capacities of the state level apparatus. The advantage of
implementing the Tamil Nadu model would be the development of a cadre of workers on equal
footing with those in Medical services and education, with a streamlined career path, growth
opportunities, and commensurate incentives. Another aspect of the Tamil Nadu model that could be
positively adopted by other states is the high level of involvement and accountability of the state
government. However, authority resting with the Department of Health and Family Welfare which in
turn delegates to the various Directorates (Chandran, 2016). It is these directorates which help
implement programs under the NHM.
Strengthening the public health cadre should not be limited to technical and management staff, rather
it should include rigorous programmatic and public health training for physicians employed with the
52 public healthcare system as well. States should recruit doctors, nurses and others with experience and
qualifications in public health, at the same time upgrade their existing clinicians with training
programs dedicated to developing public health management skills. In the longer term, graduate level
qualifications in public health should be mandated for clinicians recruited into the government health
system who are looking after public health functions.
53 2. Human Resources for Health
2.1 Background
The National Health Mission has created several institutions for enhancing HRH capacities at
various levels. At National level, Mission is headed by a Mission Director, of the rank of Additional
Secretary, supported by a team of Joint Secretaries. The Mission handles not just the day-to-day
administrative affairs of the Mission but is also responsible for planning, implementing, and
monitoring mission activities.
Joint secretaries are leading various programs under the NHM and are supported by technical
consultants. Up to 0.5% of NHM Outlay is earmarked for programme management and activities for
policy support at the national level through a National Programme Management Unit (NPMU).
The National Health Systems Resource Centre (NHSRC) created as the apex body for technical
support to the Centre and states. The NHSRC is also helping central NHM in National Program
Coordination Committee meetings and also providing technical support to state NHM in preparing
PIP. Technical support focuses on problem identification, analysis, and problem solving in the
process of implementation. It also includes capacity building for district/city planning, organization
of community processes and over all dimensions of institutional capacity, of which skills is only a
part.
The NHSRC has various divisions HRH, Health Financing, Quality Assurance, Health Technology
etc. The NHSRC is headed by Executive Director and each division is staffed with Senior Advisor,
Advisor, Senior Consultant, Consultant, and other research staff.
At state level similar model of technical support been created in the form of SHSRC. However, in
most of the study state it is not functional.
Under NHM Program Management Unit have been established at various levels:
State Level – SPMU
Regional Level –RPMU
District Level – DPMU
Corporation Level – CPMU
Block Level – BPMU
The State Programme Management Unit has been established at state level for providing technical
support to State Health Society for implementation of NHM. The SPMU is headed by State
Programme Manager-SPM, who is overall in-charge of NHM and reports to Mission Director-
NHM. There are various divisions in SPMU for rolling out various program under the umbrella of
NHM and also managing the mission. The important divisions of SPMU are HR, M & E,
54 Community Processes, and Finance etc. There are state nodal officers for various programs including
RCH, TB, Community Processes, and M&E etc.
Similarly, at regional level Regional Program Management Unit has been created under Regional
Deputy Director/ Deputy Director of Health Services. The Regional Program Coordinator is In-
charge of RPMU and he/she has been supported by Regional Finance officer, M & E Assistant and
Data Entry Operator. The RPMU is responsible for supporting district in PIP preparation and
technical support for implementation of various programs.
At District Level, District Program Management Unit has been created for management of NHM.
The DPMU is headed by District Programme Coordinator (DPC), who reports to Chief Medical and
Health Officer at district level and SPM at state level. He is overall in-charge of various program
under NHM at district level. The District Program Coordinator is seen as the key player not only in
setting up and operationalising the DHS secretariat, but also in arranging managerial and supportive
assistance to the district health administration, including general management and logistic support.
There are some additional positions at district level- DPC- NUHM for urban health, Coordinator-
Community Processes, District Finance Officer, Finance Assistant, M&E Assistant, Data Entry
Operator, and several coordinators for various program- PCPNDT, Tobacco, NCD, Mental Health,
TB etc. At Block Level, Block Program Management Unit has been created for management of
NHM at block level. Block Program Manager heads the BPMU and he/she is supported by Finance
Officer and data entry operator. The below figure depict various institutional mechanisms under
NHM.
Figure 9 Institutional Mechanisms under National Health Mission
55 NHM’s major contribution towards health system strengthening is towards the HRM. NHM does not
depend on state public service commission exams for recruitment, therefore it is able to exercise
flexibility. Walk-in interviews and entrance examinations against posts were publicly advertised for
contractual recruitment in administrative positions. Laboratory technicians, pharmacists, and ANMs
are hired at the district level while specialist doctors and MOs are recruited at the divisional level
through monthly walk-in interviews. Initiatives such as interviews on fixed days every week for
specialists and MOs have been taken in certain states, including Gujarat. HR officials stated that this
would now change and only two recruitment cycles (January and July) could be conducted annually.
It was also observed that for the CHO positions at HWCs, there are transfer camps. This is a platform
which allows this cadre of workers to choose positions of their convenience.
However, in spite of the improvement in HR availability, there is a ubiquitous scarcity of skilled HR
in the healthcare sector in India. While the international norm is a minimum of 25 skilled health
workers per 10,000 populations (doctors, nurses and midwives), in India the density of health
workers is shockingly low—only a little over 8 per 10,000 populations. Of these, 3.8 are allopathic
physicians, 2.4 are nurses or nurse-midwives, and the rest are AYUSH practitioners which are
widely prevalent and recognized by the government (Panda et al., 2016; Adsul, 2016). The
availability of doctor is in the ratio 1:1500 in urban areas and one doctor for 2500 people in rural
areas which is quite low as compared to USA where they have 1 doctor for 250 people (Panda et al.,
2016). Vacancies were seen in the regular cadre at various levels—Medical Officers at PHCs, mostly
in tribal and desert districts, specialist at CHC, SDH and DH. Human resources for health have
increased significantly across the states through NHM. However, still lots of vacancies and scarcity
of human resources exists.
Table 7 Human Resources under National Health Mission
Type of HRH India High Focus-
Non NE (10)
High Focus NE
(8)
Non High
Focus-
Large (11)
Non High Focus-
Small & UT (7)
Medical Officers at
PHC8590 1808 1278 5167 337
Medical Officers at
UPHC2113 654 73 129888
Medical Officers at
UCHC64 170 416
Specialists 2889 557 209 2021 102
ANM at PHC 71560 30738 7177 32618 1027
ANM at UPHC 12517 4572 326 7502 117
District Programme
Manager638 285 98 2469
District Accounts
Manager649 292 107 2428
Block Programme
Manager3725 2503 467 7550
56 Accountant at
facility level 5928 2961 561 236838
Pharmacists 13215 5576 1177 6295 167
Lab Technician 10659 5175 1121 3954 409
Source: Executive Summary, National Health Mission, Ministry of Health and Family Welfare,
Government of India (2019).
2.2 Findings
Shortage of manpower and vacancies
In Gujarat, there are several vacancies across the health workers cadres including that in the category
of specialist doctors. Almost 73 % paediatricians, 65% speech therapists, 69% Optometrists, and
69% Dental technician positions, vacant at District Early Intervention Centres (DEIC) posts are
vacant. Under the NUHM, 71% staff nurses, 92% specialist doctors, and 70% MOs positions were
observed vacant. 55% pharmacist positions were vacant in the RBSK program. The aspects related to
vacancies were specific to cadres, especially that in the specialist category. Please see below tables
for current status of Human Resources of Health across study states.
Table 8 Status of Non-Technical Human Resources for Health in Gujarat NHM
Non- technical Positions at state level
Category/ Type of personnel Sanctioned Filled Vacant
Staff On deputation 3 21
state Programme Managers21 210
Consultants/ Programme Officers 42 411
Staff for civil / infrastructure work 2 20
Programme Assistants35 314
Programme Coordinators14 95
MIS/ IT Staff5 41
Accounts Staff21 210
Administrative Staff3 21
Data Entry Operators448 41236
consultant/Programme Officers 14 95
Accountant 6 60
Administrative3 12
Total617 56156
Source: State Health Profile, National Health Mission, Gujarat.
Table 9 Status of Technical Human Resources for Health in Gujarat NHM
Category/ Type of personnel Sanctioned filled vacant
Nurses and paramedical staff1731 1400 331
Laboratory Technicians569 51950
Pharmacists214 13579
Specialist doctors239 17267
57 occupational therapist22 184
Community health workers/ PMW130 1228
NPPCDCS/RNTCP/NPCC Medical officers 80 6812
AYUSH medical officers (RCH)919 819 100
AYUSH medical officers (RBSK)1984 1718 266
ANMS- RBSK992 760 232
Pharmacists- RBSK992 441 551
DEIC health professionals296 159 137
Staff for NRC565 48382
Staff for SNCU/ NBSU660 518 142
Staff for Obstetric ICUs/HDUs168 9771
Staff for health and wellness centres 2303 781 1522
Counsellors508 47731
Blood Bank/ BSU/Mobile Blood Vehicle staff 90 7713
Administrative staff88 7612
NUHM staff3423 2840 583
Total technical staff16678 12271 4407
Source: State Health Profile, National Health Mission, Gujarat.
Table 10 Status of Human Resources for Health in Uttar Pradesh
Health cadre Sanctioned filled Vacant % Vacant post
Medical officer 18382 12461 5921 32
Staff nurse7770 4578 3192 41
Pharmacists7939 7756 183 2.3
X-ray technicians 1008 934 74 7.34
Lab technicians3003 1846 1157 38
ANMs23656 15264 8392 35
Source: (http://up-health.in/en/) Uttar Pradesh Health Department Website
Table 11 Status of Human Resources for Health in Rajasthan Department of Health
Name of PostSanctioned FilledVacant% Vacant Post
Senior Medical Officer/Medical
Officer
6630 5202 1428 22%
Senior Specialist382 290 92 24%
Junior Specialist3911 2114 1797 46%
Gynaecologists out of total specialist 406 282 124 31%
Anaesthetist out of total specialist 242 174 68 28%
Paediatrician out of total specialist 346 265 81 23%
Staff Nurse (including MN-I & MN-II
and GNM)
23329 18653 4676 20%
Lady Health Visitor (LHV)2697 1597 1100 41%
Female Health Worker (FHW/ANM) 22451 16213 6238 28%
Pharmacist 4201 2257 1944 46%
Lab technician 5215 2676 2539 49%
Source: State Health Profile, National Health Mission, Rajasthan
58 Table 12 Status of Human Resources for Health in National Health Mission Rajasthan at State Level
Name of PostSanctionedPresently
Working
Vacant
status
%
Vacant
Post
State Programme Manager1 1 0 0%
State Finance Manager1 1 0 0%
State Accounts Manager1 1 0 0%
State Data Manager1 1 0 0%
ASPM1 1 0 0%
Consultants42 39 3 7%
Health Manager PCPNDT1 1 0 0%
Legal Advisor PCPNDT1 1 0 0%
State Coordinator PCPNDT2 1 1 50%
Accounts Manager1 1 0 0%
Programme Officer
(HR-2,SPMU,IMEP,RTI,PLAN)RO SHSRC
PO, ARC, VHSC,ASHA,IEC-03 )14 12 2 14%
Data Assistant/Data Officer (Including IMEP
Cell )6 6 0 0%
Health Manager4 4 0 0%
Statistical Data Assistant (ASHA)1 1 0 0%
Programme Officer cum Data Manager (QA) 1 0 1100%
Programme Coordinator (Nursing)1 1 0 0%
Accounts Clerk2 2 0 0%
Accounts Cum Tally Operator4 4 0 0%
Administrative Assistant cum Data Entry
Operator (Clinical Establishment Cell ) 2 2 0 0%
Helper (Clinical Establishment Cell ) 2 2 0 0%
Senior Programme Assistant1 1 0 0%
Programme Assistant14 14 0 0%
Executive Assistant Cum Data Entry Operator 66 66 0 0%
Support Staff50 50 0 0%
Drivers6 6 1 13%
Security Guard8 7 0 0%
Source: State Health Profile, National Health Mission, Rajasthan
59 Table 13 Status of Human Resources for Health in National Health Mission Rajasthan at Districts
Level
Name of PostSanctioned
Presently
Working
Vacant
status
% Vacant
Post
District Programme Manager 34 34 0 0%
District Accounts Manager34 34 0 0%
District Nodal Officer (M&E) 34 34 0 0%
District ASHA Coordinator34 30 4 12%
District IEC Coordinator34 32 2 6%
District PCPNDT Coordinator 34 33 1 3%
Ayush Chikitsak/Ayush MO 1013 910 103 10%
Ayush Compounder401 257 144 36%
Data Entry Operators at District H.Q.68 63 5 7%
Health Manager at District Hospital
(State & District Level) (23 + 3)
22 18 4
18%
Block Programme Managers249 205 44 18%
Accountants (Block/CHC/PHC) 1098 950 148 13%
Data Entry Operators at Block H.Q. 249 218 31 12%
Block ASHA Facilitators249 174 75 30%
PHC ASHA Supervisors1528 1226 302 20%
Nurse Grade-II/GNM4850 1359 3491 72%
Pharmacist186 141 45 24%
Lab Technician158 81 77 49%
PHN (Public Health Nurse)158 99 59 37%
ANM2550 2159 391 15%
Computer Operator (Drugware House) 328 231 97 30%
34 District Coordinator / 34 Administrative
Assistant cum Data Entry Operator (Clinical
Establisment Cell )68 0 68 100%
512 Pharmacist ( Mobile Team under RBSK) 512 501 11 2%
512 ANM ( Mobile Team under RBSK) 512 400 112 22%
1024 MO Ayush ( Mobile Team under RBSK) 1024 927 97 9%
Staff for District Early Intervention Center
(DEIC)
120 39 81
68%
RKSK Coordinator10 10 0 0%
Specialists forFRU122 0 122 100%
Adolescent Health Counsellors
New Positions for RKSK )
141 68 73
52%
Field Monitor in 10 Selected Districts
(Routine Immunization Programme )
10 7 3
30%
RMNCH/ FP Counsellors 52 25 27 52%
eVIN PO IT (Zone)7 0 7 100%
VCCM44 0 44 100%
Counselor Blood Bank30 30 0 0%
LT Blood Bank72 70 2 3%
60 Dakashta Mentor 18 12 6 33%
Data Entry Operator (Immunization) 34 34 0 0%
Nursing Superindentent (ANMTC) 5 1 4 80%
Nursing Tutor (ANMTC)60 31 29 48%
PHN (ANMTC)98 45 53 54%
Sr. Sanitary Inspector (ANMTC) 33 33 0 0%
Nursing Tutor (college of nursing Kota)9 9 0 0%
Programme Assistant (ANMTC-GNMTC) 48 33 15 31%
16407 106055802 35%
Source: State Health Profile, National Health Mission, Rajasthan (2019)
Specialist cadre issues
In all the 3 states, there are a large number of specialist positions seen vacant at various levels of
health systems. This is a long term problem which has not been solved even though NHM provided
flexibility of hiring and salaries. Hence, more detailed work needs to be done in this area of specialist
vacancies.
States lacked a specialist cadre for medical professionals and doctors with postgraduate degrees also
had to join the system at the Medical Officer level and wait for many years to rise in the hierarchy.
Some of this was attributed to the long term rift between the medical officers and the specialists.
Protests by general duty medical officers in senior positions in Uttar Pradesh, exerted pressure to
abolish the recruitment of specialist doctors. As a result, the state now has no mechanism for the
recruitment of specialists in CHCs. This has affected the quality of services being delivered by the
public healthcare system. Two significant human resource problems were identified (i) state policies
are restrictive and specialist doctors from other states, who are not registered in the UP system, were
unable to join public health facilities in the state, (ii) and the Provincial Medical Services is badly
structured with long waiting times in the recruitment process and no waitlists, which leads to a large
number of vacant specialty positions, especially at the CHC level (Kumar, Bothra and Mairembam,
2016). It was also seen that because both specialists and non-specialists were being hired at the entry
level position of MO, there was no incentive for candidates interested in public service to pursue
post-graduate medical education. This further aggravated the problem of specialist shortages in the
state.
Gujarat had initiated special mechanisms for recruiting specialists including flexible duty hours,
additional pay etc. However, similar vacancies were seen in the states of Rajasthan and Gujarat.
Other health professional shortages
61 In case of non-technical staff at various levels, the highest numbers of vacant positions were
observed among data entry operators. Moreover, at health worker level such as FHWs, ANMs,
vacant positions were observed at the district level due to shift/ transfer from contractual to regular
positions among health workers. This happens through the Zilla Panchayat exam, in which
contractual FHWs are absorbed into the regular cadre. The same has been reported in case of lab
technicians, staff nurses, and pharmacists at the PHC/CHC levels. Sometimes staff takes internal
transfer to nearer location to their residence, which leads to vacant positions. However, maximum
vacancies were seen in remote rural and tribal districts. Medical Officers of the regular cadre
expressed disinterest in working in desert and tribal districts. They were of the opinion that they may
not get an opportunity to return from such hardship postings. Further, no clear policy for promotion
was observed in the regular cadre.
The Rajasthan state has initiated training of Mid-Level Health Provider (MLHP) for the management
of HWCs, however this was stopped due to court litigation. Under the NUHM in Rajasthan, out of
140 UPHCs 70 were found to be without doctors. Among health professionals, nursing staff was
especially low in HWCs (67% vacant), and in geriatric care at NPCC (64%). In Gujarat, vacancies of
medical officers have been observed at various levels. Vacancies are more at primary care level. The
state Public Service Commission examination (GPSC) played a large role in determining the
recruitment of personnel.
HRM policy inconsistencies and HRMIS implementation
There is little consistency amongst states in terms of implementing HR policies as mentioned in the
NHM manual. Most of it relates to recruitment, compensation, and cadre management. One of the
major findings across the three states was inconsistency in HRM structure, systems, and processes.
Senior health officials in UP posited that even after the completion of two phases of NHM, there is
no standardised HR policy from the central NHM. Rules changed frequently and there was
significant state to state variation. It was also noticed that within NHM itself, there is a significant
difference between the job description and compensation of various personnel working at similar
levels across different vertical programs.
HR function which is very vital to a well-functioning health system has not been paid attention at
central as well as state level. Many of these issues are arising because HR management units are
inadequate in staff, skills, and competency. Generally, senior govt. officials look after this including
generalist state cadre officers. The three states significantly lacked a cohesive and comprehensive
structure such as an HR cell manned by HR professionals. Uttar Pradesh reported the existence of an
HR Management Cell with an HR General Manager, but there were integration issues as there were
several simultaneous initiatives without proper integration mechanisms. It was reported that BMGF
62 supported TSU is developing a new system of HR management in UP under its HR Sampada
initiative.
We also observed significant inconsistencies in policy implementation. In Rajasthan, State Health
Department and SPMU officials reported that all NHM staff was reported to have received a 5%
increment, which was not uniform earlier. Salary increases have varied from a reasonable 10% to
even 90% in some areas, under the name of flexibility. Consistent policy implementation has
provided results whenever attempted. In the state of Rajasthan, initially, the managerial cadre used to
get 12.5 % increment every year whereas there was no increment for service delivery cadre. In an
attempt to rationalize and enhance consistency, 5 % increments have been proposed for each cadre
across the state. Service delivery staff is satisfied after this change.
While the NHM blueprint provides for the implementation of HRMIS, and the mission is also
providing incentives to states that have designed and implemented HRMIS, it was reported that so
far, the software has been put into use only in few states such as Haryana, Karnataka, and
Chhattisgarh. The three states that we studied had yet to implement a HRMIS. While the HRMIS is a
step in the right direction, it would be important to integrate it with various HR functions such as
planning, recruitment performance monitoring, and payment of staff salaries to ensure its
effectiveness.
HR Rationalization and planning
Duplications, disconnect between job description and tasks allocated, and poor HR planning was
evident across the three states. According to one NHM official, designations have been created in the
NHM without much thought, and all of these personnel are receiving salaries for which the rationale
is difficult to find. In Maharashtra for instance, it was observed that 800 levels of salaries were being
paid to NHM staff. On the other hand, there are sharp imbalances in human resources between rural
and urban areas. It was also observed that with new programs or with increased workload on staff
due to new programs, the states resorted to new hiring and creating a new vertical, which may not be
required and rather distribution of responsibilities would have been a more rational course of action.
For example, Rajasthan has given additional responsibility of data entry for new programs to existing
data entry operators with an additional incentive for the same. It was pointed out that in urban areas
in particular, where only a few public healthcare facilities were present, separate DPMs were not
required. In some of the districts in Rajasthan where there is only 1 or 2 Urban PHC, there were
separate DPMs for Urban areas under NUHM.
State officials from all the states said that contractual management staff is adequate but the
organizational structure has evolved in such a way that it has brought about verticality rather than
63 decentralization. It was observed that there is a duplication of certain categories of staff under
various programs. For instance, laboratory technicians appointed under multiple programs were
found to be working only for a single program. There were also issues of implementing proper
structure. For example, in the state of Gujarat, most NHM staff report to CDHO, but the NCD staff
was the only Programme Officer found reporting to the CDMO, affecting convergence. While
decentralization is beneficial to the health system, one of its disadvantages includes the duplication
of personnel. At some places it was also observed that at the PHC level, whenever new program
initiatives are launched, the facility exhausts the sanctioned limit of human resources. This was seen
to occur due to a perception that the number of personnel approved by central NHM would be much
less than their actual requirement. As a result, they tend to over-quote the number of human
resources required. Further, block level decision making authorities were reported to lack adequate
HR planning which led to random and irrational HR requirements being generated.
District Program Coordinators were found to be improperly allocated. It was pointed out that there is
an urgent need to carry out HR rationalization and redefine the terms of reference for various
positions at the DPMU. At the district and block levels, the same is required for program
coordinators, data entry operators, counsellors, laboratory technicians, and accountants of various
vertical programs.
Regular versus contractual NHM staff
As per senior state officials of all the states, NHM staff was observed to be more competent,
efficient, and displayed a positive attitude toward the work, compared to regular staff of the state
health department. Their contractual arrangement served as stricture to ensure high quality
performance and better control by the CDHO/CMHO. This HR provision under the NHM helped
achieved staffing adequacy at public healthcare facilities which in turn has led to better quality of
services at the primary healthcare level. However, in all the three states, the morale of the contractual
level staff was significantly lower. Nursing staff hired on a contractual basis was found to perform
better due to the threat of removal. The contractual staff always had fear of non-renewal of the
contract or sudden termination. This is largely based on likes and dislikes of the supervisor rather
than performance.
In Uttar Pradesh it was observed that contractual workers in health facilities were often discriminated
against and given odd and longer duty hours, compared to the regular cadre. The same findings were
also echoed by central government NHM consultants. There have been extreme cases of abuse of
flexibility on rare occasions. Further, senior officials at the NHSRC reported that two to three fold
differences were observed in the compensation between regular and contractual ANMs at senior
level or after some years. A district official in Gujarat pointed out that contractual staffs are more
64 efficient and effective compared to regular cadre staff yet there is a huge difference in salary and
benefits for the same position. The apathy extended to the staff in implementing processes. For
example, in Rajasthan, contractual staff complained that while the central NHM had approved a
loyalty bonus in 2017, there was no mechanism for its disbursement from the state government. The
NHM finance team sent the bonus proposal to the finance department of the state government,
although approval was already given by the State Health Society. Moreover, there is no provision of
social security or other benefits like health and accidental insurance, due to which dissatisfaction,
and even strikes have been reported.
While the NHM provided gradual regularization of the staff for eventual strengthening of the
directorate, a framework for regularizing contractual staff was absent in most of the states. While the
NHM has mandated that 15% of contractually recruited staff be regularized, Tamil Nadu is the only
state where this policy is being implemented. In Tamil Nadu, the state’s system for absorbing
contractual workers is robust, wherein permanent positions are created first, which are staffed with
NHM hired staff for a period of 2-5 years, and then the same are absorbed into regular state services.
In the states that we studied, the state policies were reported to be unfavourable to the absorption of
contractual NHM staff into permanent positions. Contractual NHM employees who had significant
experience in a department were not selected for regular appointments because of various reasons,
non-fulfilment of eligibility criteria, low marks in the exams. The NHM contractual staff stressed
that relaxation in the eligibility criteria such as age, additional weightage in the exam because of
their work experience. This was echoed by officials from the NHSRC and SPMU of various states.
These aspects have led to significant deterioration of the morale of many contractual frontline health
workers.
Recruitment
Senior officials of the Department of Health mentioned that the recruitment process for human
resources in health is very vague and not standard across states. Recruitment cycles were found to be
out of sync with requirement. In Uttar Pradesh, district officials reported that the recruitment of
NHM staff is decided by the state headquarters, due to which sometimes the staff does not respond to
them. Significant delays were also observed in the recruitment of NHM staff at the district level. HR
officials cited that late (July/August) PIP approvals in previous years led to delays in the recruitment
process. While the PIP for 2019 was approved in April, such delays in approval can actually be
attributed to the absence of a systematic Human Resource Planning (HRP) process in states.
Currently, a bottom up approach is followed wherein PHCs and CHCs pass on their HR requirements
65 to the state authority. These requirement figures are often generated without appropriate analysis of
human resource processes using the required tools.
Career planning, training and capacity building
Another aspect that was highlighted was the lack of need-based training to different categories of
staff, and their apathetic attitude. Apart from the inadequate training mechanism, the issues were
raised about infrastructure, absence of induction training, and duplication of efforts by different
agencies without much integration. Besides, there are other issues related to training like the lack of a
mechanism for follow-up after training, mismatch between training and job profile, and lack of a
system for training related performance monitoring.
Gujarat has built a training infrastructure with an apex training institute as SIHFW, 4 Divisional
training institutes and 1 Health and Family Welfare Training Centre. There are 6 skill labs
established where 32 skills are demonstrated. Most of these training facilities are focused on
technical cadres to strengthen their service delivery competency. However, gaps were observed in
behavioural, leadership and management training for NHM staff. The state of UP has initiated a
training program module for various cadres of health personnel, including the focus on soft skills.
Interviewed officials at the state, district, and block levels remarked that the quality of managerial
staff is not good, as most of them were MBA or MSW and lacking the public health qualifications.
There is no public health managerial cadre within state structures and the posted managers have little
knowledge, skills and aptitude for working in the public health sphere. Gujarat has attempted to
mitigate this issue by initiating a training and capacity building of mid-level service providers-CHO
in special arrangement with IIPH Gandhinagar and more than 3000 CHOs have been trained and
deployed.
Compensation and performance appraisal
Many senior state officials said that the NHM does not have a robust performance appraisal system
in place. There is no uniform process of measurement of performance across various cadres such as
MOs, ANMs, and managerial staff. Increment and promotion decisions were found to be arbitrary
and not linked to the results of performance appraisal. Some of the HR officials of Rajasthan NHM
mentioned that there is no provision of experience bonus. This tips the ratio of applicants in favour of
newcomers. Sometimes experienced professionals may be offered even less than their previous
compensation. There are no policies to protect and attract experienced staff. For female staff,
maternity and child leaves, and subsequent workload redistribution are not clearly defined. The lack
of proper incentive design can be seen as a major demotivating factor, in addition to the lack of
financial and non-financial incentives, especially for rural postings. Further, the public health system
66 is still unable to offer competitive remuneration that would prevent specialists from preferring the
private healthcare system (Kumar et al., 2016).
2.3 Recommendations
2.3.1 Online information system for HRH and HMIS data
An integrated HRIS and HMIS system need to be designed and implemented to provide data on (lack
of) availability of different cadres of health workers. HIMS data entry and reporting can be made
decentralized by making it attractive to the peripheral health workers and block health officers by
creating user-friendly dashboard.
2.3.2 Uniform policies across states such as for recruitment, regularization
Health professionals need to be hired only from colleges/ institutes with high repute, in order to
maintain quality. (For example, Tamil Nadu hires only from government medical colleges). The
NHSRC can help in developing standard policies for a uniform system across the country. States
should also be mandated to convert a certain percentage of contractual staff in every position to
permanent, every year.
2.3.3 Rationalization of compensation
Systemic rationalization in compensation needs to be implemented to curb the huge gap between
contractual and regular employees. This should come from the central NHM so as to ensure that it is
uniformly implemented. The state of Tamil Nadu presents a model for the regularisation of
contractual employees, especially staff nurses and Medical Officers assigned to Mobile Medical
Units. Remuneration for these employees is routed through the state with the central government
contributing a significant share. Nurses under NHM contracts are made regular employees when
vacancies arise in the system. This practice allows for a suitable probation period, at the same time
preventing pay discrimination.
2.3.4 Building a Public Health Cadre
The public health cadre should be specially trained with multi-disciplinary and multilevel skills
including doctors, social scientists, nursing, management, and statisticians, as in Tamil Nadu and
Odisha. The cadre can be designed similar to the central and state administrative services. The
services should have adequate budget, power, operational authority, and a separate state level
Directorate of Public Health and Preventive Medicine. Further, employees of the public health cadre
should be given authority over their medical counterparts, with fast tracked promotions, making
public health government service a lucrative career path in the state. All IAS appointees to public
67 health services should be trained and made aware of the technical issues in public health
management and preventive measures, and should work in lock-step with the State Public Health
Directorate.
2.3.5 HR mapping and Audit, training and performance monitoring
A robust HR mapping, rationalization, HR audit exercise should be done by third party or
independent academic institute/ organization to ensure that the number of human resources allotted
to a particular program, activity, or health facility is optimal.
2.3.6 Collaborating with academia for enhancing quality of HRH
Respective state councils should be strengthened and given the stewardship of monitoring the quality
of training for various technical positions. Strengthening should consist of an assessment of the
existing knowledge capacities of the faculty at these councils, and extensive training of trainer
programs to ensure high quality training down the pipeline
2.3.7 Need based training programs with special focus on soft skills
Apart from technical and skill-based training, behavioural training should be designed for managerial
and support staff. Orientation training should be strengthened where attrition is high, at the DPC
level for instance. For ANMs posted to rural sub-centres, regular refresher training should be
conducted so as to provide a periodic assessment and update of their skills. The effectiveness of
these training programs needs to be assessed and monitored with course corrections suggested as and
when required
Strategies should also be put in place to monitor the skills and knowledge of the health workforce
from time to time. This should be accompanied by gap assessment exercises and customised
refresher training for different cadres of workers, including techno-managerial staff. Efforts should
also be made to bring in international best practices, and include these in the training of personnel.
2.3.8 Objective performance appraisal mechanism
Performance appraisal mechanisms should be objectively linked to job-specific indicators and the
appraisal process should be linked with contract renewal and the award of performance-based
incentives. There should be a band system in compensation to accommodate candidates with all
levels of experience.
68 3 Impact of the National Health Mission on Health Systems
3.1 Background
Health systems and polices have a critical role in determining the manner in which health services
are delivered, utilized and affect health outcomes. The National Health Mission (NHM) encompasses
its two Sub-Missions-the NRHM and the National Urban Health Mission (NUHM). The main
programmatic components include Health System Strengthening, Reproductive-Maternal- Neonatal-
Child and Adolescent Health (RMNCH+A), and Communicable and Non-Communicable Diseases.
The NHM envisages achievement of universal access to equitable, affordable, and quality health care
services that are accountable and responsive to people’s needs.
The National Health Mission impact on the health system is enormous and the mission has improved
quality of care, made the health system better funded, more responsive and accountable; improved
the health indicators and increased the involvement of communities in public health service delivery.
The National Health Mission aimed at increased public expenditure on health care, decreased
inequity, decentralisation, and community participation in operationalization of health-care facilities
based on IPHS norms. It was also an articulation of the commitment of the government to raise
public spending on health from 0.9% to 2-3% of GDP. Major initiatives have been undertaken under
NRHM for architectural correction of the rural health system-in terms of availability of human
resources, program management, physical infrastructure, community participation, financing health
care and use of information technology (Chokshi et al., 2016). Under, the NHM physical
infrastructure has been increased by creating more health centres, new born care units and renovating
existing centres. The NHM has also enhanced the health system’s capacity to treat more mothers and
children aimed at reducing IMR and MMR. Special efforts were made to strengthen community
participation through the formation of health committees at the village level and patient welfare
committees at public health-care facilities. Information technology-HMIS and MCTS were used to
track delivery of services to the mother and child.
69 3.2 Findings
Senior officials of the Department of Health mentioned that due to NHM, quality of data recording
and reporting improved drastically and it has helped us to plan better and also developed micro-plans
to reach the unreached. It is only because of NHM, that the health system has become more
functional, community engagement and empowerment has increased. Faith in the public healthcare
delivery system has increased significantly. Senior State Level Officials opined that “NHM is the
backbone of our health system and it is only because of NHM we have achieved success in reducing
IMR, MMR and improving other health indicators of our state. It would not be possible to run the
health system in the state without NHM, we cannot think of public health service delivery without
NHM.”
Health Indicators have improved drastically, access and utilisation has also increased. Figures below
show the improvement in various indicators in the three states in comparison to the country. One of
the reasons quoted for improvement in MMR and IMR was emergency transportation services across
states (108 and 102). State Health Department and SPMU officials said, “due to 108 and 102 under
NHM quality of care has also improved, especially reduction in IMR, MMR and the number of
institutional deliveries. There are adequate 108 ambulances available in the district and the state has
a plan to replace the old 108. We are getting new ambulances every year. The state policy is there for
replacing the old ambulances.”
Please see below table for information about increase in number of ERS vehicles across the country.
Table 14 Number of ERS vehicles operational in the States/UTs under NHM
Type of
Vehicle
India High Focus-
Non NE (10)
High Focus
NE (8)
Non High
Focus-
Large (11)
Non High
Focus- Small &
UT (7)
10210017 5467 650 3652 248
104605 604 1 00
1089344 4246 438 4636 24
Others 5484 2106 235 31430
Total 25450 12423 1324 11431 272
Number of Ambulances functioning in the State/UTs other than NHM
(At PHC/CHC/SDH/DH)
11096 2467 273 8189 167
Source: Executive Summary, National Health Mission, Ministry of Health and Family Welfare,
Government of India.
Reforms in infrastructure reforms, service delivery, and human resources such as ASHA were
reported as the determinant of improvement in IMR and MMR. District officials said that quality of
70 care also improved, along with beneficiary targeting. For example, institution delivery incentives and
free treatment can be easily monitored, thereby motivating the community to access services at
public health facilities.
INDIA AP CG GJ KA RJ UP
0
5
10
15
20
25
30
13
14
15
12
17
13
14
17
15 16
20
24
16
21
7
9
5
6 6
7 7
Percentage reduction in the Infant Mortality Rate
2005-2009
2010-2014
2015-2017
States
P
e
r
c
e
n
t
a
g
e
r
e
d
u
c
t
i
o
n
i
n
I
M
R
Figure 10 Percentage reduction in the Infant Mortality Rate in India, Gujarat, Rajasthan, and Uttar
Pradesh (Sample Registration Survey data from 2005-2017) *2015-2017 data is for 2-year interval
INDIAGJRJUP
0
5
10
15
20
25
13
12
13
14
17
20
16
21
7
6
7
7
P ercent age reduct ion in t he Inf ant Mort alit y Rat e
2005-2009
2010-2014
2015-2017
States
P
e
r
c
e
n
t
a
g
e
r
e
d
u
c
t
i
o
n
i
n
I
M
R
Figure 17 Percentage reduction in the Infant Mortality Rate in India, Gujarat, Rajasthan, and Uttar
Pradesh (Sample Registration Survey data from 2005-2017)
71 *The 2015-2017 data is for 2-year interval

INDIA AP CG GJ KA RJ UP
0
2
4
6
8
10
12
14
10
7
12
9
10
10
13
8
0
7
8
10
10
9
4.35
5.88
4.00
0.00
5.56
3.70
3.23
PERCENTAGE REDUCTION IN THE TOTAL FERTILITY RATE
2005-2009
2010-2014
2015-2017
States
P
e
r
c
e
n
t
a
g
e

R
e
d
u
c
t
i
o
n

i
n

T
F
R
Figure 11 Percentage reduction in the Total Fertility Rate in India, Gujarat, Rajasthan, and Uttar
Pradesh (Sample Registration Survey data from 2005-2017)
72 INDIA AP CG GJ KA RJ UP
57
54
71
50
43
65
73
41
35
54
34
27
41
64
INFANT MORTALITY RATE (NFHS)
2005-20062015-2016
I
M
R
Figure 19 Infant Mortality Rate in India and the study states (NFHS - 2005-2006 & 2015-2016)
INDIA AP CG GJ KA RJ UP
2.7
1.8
2.6
2.4
2.1
3.2
3.8
2.2
1.8
2.2
2.0
1.8
2.4
2.7
TOTAL FERTILITY RATE (NFHS)
2005-20062015-2016
T
F
R
Figure 12 Total fertility rate in India and the study states (NFHS 2005-2006, 2015-2016)
73 INDIA
408
300
100
MATERNAL MORTALITY RATE (NFHS)
1998-19992001-20032005-2012
M
M
R
Figure 13 Maternal Mortality Rate for India (1998-2012) (NFHS)
Senior Officials of Ministry of Health and Family Welfare, Government of India mentioned that the
Institutional structure of NHM is very effective and decentralised. Due to Mission at the top and its
delegated powers of cabinet. Therefore, NHM programs do not have to go to the Cabinet and
Planning commission/ NITI Aayog for approval as was earlier needed before NHM. The Mission
Steering Group (MSG) has delegated powers of the union cabinet. The NHM Mission is very
successful and highly recognised at various platforms. Due to its success now 10-11 ministries also
formed and started NHM like missions.
Senior Officials of SHS-NHM stressed that the NHM has made planning more comprehensive and
extensive. Due to NHM, the budget for service delivery, and programs has increased tremendously.
Figure below highlights the increasing contribution of NHM towards investment on health in the
country.
74 Figure 14 Expenditure of NHM from 2005-2018 in crores of rupees
While it was expected that the increase in number of public health facilities would lead to a
subsequent increase in the utilisation of public healthcare, this has not been the case. People continue
to prefer private care providers in large numbers. But there is some increase in the use of public
facilities over time.
Figure 15 Public-private distribution of in-patient and out-patient treated episodes of illness from the
National Sample Survey Organisation (NSSO)
Advantages of the mission mode
Both state as well as the NHM officials across the states opined that NHM should remain in mission
mode and central control from the Government of India is very necessary. They asserted that if the
funds are dispersed without any mission guidelines, then the money will be spent as per state norms,
75 which entails that there will be no flexibility in various aspects and which is very essential for the
efficient and effective functioning of the health system. State Government rules are very stringent
and many times it takes so much time for processes such as recruitment, procurement etc. “That’s
why we need NHM, we can recruit Human Resources for health, and also we can do many more
things- training, capacity building, and innovative things, which are very difficult to carry out with
the State budget”, one state official remarked. In Mission mode, State Government interference is
minimal. Another state official corroborated. “On the Governance side now political interference is
not there, as far NHM is concerned, we can even say no to MLA, Ministers, and even Health
Minister that under NHM recruitment/programme we have to follow Central Government
guidelines.” Another official from NHM noted, “NHM has played a very important role in filling the
gaps in service delivery via providing flexibility in all resources— human, financial, material, and to
carry out innovations. There is no scarcity of money for improving service delivery and
beneficiaries.”
However, with increasing financial and managerial contribution from the centre, there was a
perception about over centralization of the system. Senior Officials of NHSRC pointed out that
“policies should be made citizen focused rather than system focused. NHM leads to more
centralization of all the power and decision making rather than decentralization. All the top
managerial personnel focus on their respective programs. There has been observed a lack of capacity
and understanding at all levels, especially at the state and district levels. No person is willing to take
ownership and accountability and there has been a lack of drive and enthusiasm to bring out an
improvement at personal levels.”
Managerial capabilities
NHM brought the managerial skills and capabilities to the existing health systems which, potentially,
could improve the effectiveness and efficiency of the system. This was done by inducting managers
and consultant at various levels—district, state, and national. As one senior official of the
Department of Health pointed out, “the health system was there, doctors, nurses, infrastructure and
drugs were also available. But NHM has provided managerial, technical support for the system to
work”. Managerial inputs brought various standard operating procedures, guidelines, and
frameworks for ensuring proper recording and reporting of data. In other words, NHM filled the
managerial gaps that existed in the public health service delivery. Few changes which were related to
the increased managerial capacity in health system are highlighted below. The State Health
Department officials mentioned that the NHM has not only improved the availability of managerial
human resources but the number of doctors and nurses have also increased in public health systems.
76 The figure below provides the details of year-wise increase in number of doctor and nurses in the
country.
20052006200720082009201020112012201320142015201620172018
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
Doctors Nurses
Figure 16 Doctors and nursing staff per 10,000 populations in PHCs and CHCs (2005-2018) (Rural
Health Statistics, 2018)
Integration of several vertical programs
Previously, most programs were running independently. The NHM has integrated most vertical
programs under its umbrella. The management of public health facilities and service delivery has
also improved significantly.
Improved focus on monitoring
Earlier, there was less focus on monitoring and evaluation. NHM put major emphasis on
strengthening capacities for data collection, assessment and review for evidence based planning,
monitoring and supervision for achieving its goals. NHM framework proposed accountability by a
three pronged approach of internal monitoring through MIS, community based monitoring and
external surveys like the SRS, DLHS, and household surveys. Officials at the MoHFW mentioned
that the NHM is following a Logical Framework Approach (LFA) in which output and outcome
indicators have been spelled out on the lines of the national PIP.
However, concerns were raised about the integration at the ground level- distribution of work and
rationalization of HR. Officials across the state remarked that “there is duplication of some
categories of staff. For example, a lab technician is hired for a specific task only by each vertical
disease control program like TB, Malaria etc. Single laboratory technician can check samples for
various diseases easily. No need for having different personnel at service delivery level”. The
rationalization was required at all levels including that of doctors, “If a doctor is recruited for NCD
diseases, he denies to perform OPD.” As one senior official of Directorate of Health Services
77 mentioned, “There is an urgent need to carry out Human Resource Rationalization and Justification
exercise. Under NHM at district level we have too many program coordinators, for instance NHM
Program Coordinator, Urban Health Mission Program Coordinator, RBSK Program Coordinator,
NCD Program Coordinator, NMHP Coordinator etc. We have to seriously think- do we really need
so many staff members? There should be a strategy of integration of various HR functions. In some
of the districts we have only 1 or 2 Urban Public Health facilities and we have a District Urban
Health Mission program coordinator.” Thus while there was a definite attempt at integration at
program level, there was substantial need to focus on integration at the implementation level.
Decentralization
NHM significantly increased the focus on decentralization. The local communities and entities were
involved in health expenditure planning through PIP and empowered to take care of the local issues
and challenges through untied funds. District Health Official pointed out that it is only because of
NHM, that the health system has become functional as a decentralized system with increased
community engagement and empowerment. These aspects have enhanced faith in the public
healthcare delivery system has increased significantly.
Increased funding
According to most of the state health officials, the state budget for health services was very limited.
As discussed above, the increasing financial contribution from NHM has filled the gap and provided
more funds for quality improvement, for carrying out various programs, and also improving
infrastructure, data management and monitoring. PHC Medical Officer mentioned that the NHM has
contributed significantly in improving access to health services, given benefits to beneficiaries in
many ways, helping the state government in having more Human Resources for health thus
supplementing the state health efforts.
Innovation
Senior Officials of SPMU mentioned that the NHM has also provided opportunity to carry out
innovative activities for better service delivery. He explained, “We had taken many innovative steps
for improving access to health services. For example, Obstetric ICU, District Early Intervention
Centre, Child Malnutrition Treatment Centre. “There are also funds for innovation, we can propose
new proposals for our local problems and funding can be got from NHM.” In Uttar Pradesh, the
PCPNDT Act has also been implemented in the state. The Mukhbir Yojana has been implemented
successfully in two cases in Agra and Meerut to monitor sex selection.
Senior Officials from the Department of Health mentioned that one of the important achievements
and innovation of NHM/NRHM is creation of cadre for community health worker-ASHAs. ASHAs
78 are the true assets and the achievements we have in our state due to NHM is mainly contributed to
ASHAs.
Focus on chronic diseases
Another aspect was the focus on chronic diseases and addition of new services such as dialysis. A
senior advisor of NHSRC also mentioned that the chronic disease program also got focus and has
been streamlined within the health system. The National Dialysis Program has been started and also
being scaled up. “In the first stage only, haemodialysis support was provided, now we were able to
reach close to 500 districts. Recently the Government has come up with peritoneal dialysis. This was
launched in October only and has reduced Out of Pocket Expenditure in a fair amount.”
Interstate knowledge sharing
One of the major positive impacts of NHM is potential for knowledge transfer amongst states. Senior
Officials of SPMU pointed out that NHM has indeed resulted in transfer of good replicable practices
across states in some cases. However, much needs to be done to enhance this learning process.
Lack of strengthening of directorates
Senior Officials of Directorate of Health Services stressed that the basic idea of NHM was to support
the directorate general of health services, but that purpose has been defeated and NHM has
established a parallel structure to the directorate. In some states, directorate and NHM are well
integrated and their performance is also good, but in some states, both are independent of each other
and there is limited coordination and interaction.
3.3 Recommendations
3.3.1 Continuation of NHM
The impact of NHM on India’s Public Health System is huge and health indicators have also
improved. The NHM should continue for next phase. State does not have capacity to carry out
various program without NHM. The various resources provided NHM- Finance, Human Resources,
Infrastructure, managerial expertise are essential for the health system to perform efficiently for
achieving SDGs and Universal Health Coverage. Without NHM entire health system will be
derailed, and progress achieved so far may be reversed.
3.3.2 NHM under Mission Mode
The NHM should continue in Mission mode only. Due to Mission mode flexibilities are available
and various decision can be taken in time bound manner. The MSG at central level and the SHS at
state level are empowered under mission mode. Under Mission mode the state interference is
minimal and there is no need to follow state norms for various processes of NHM which are very
79 cumbersome, restrictive, and slow. The SHS can take up various decision regarding NHM without
taking into consideration state government norms.
3.3.3 Independent Evaluation of NHM at central and State levels
The common review mission carried out by the Central NHM is one of mechanisms for evaluation of
NHM functioning at state level. However, this is rapid assessment and only carried out in pre
decided districts and limited to 2 districts in each state. Therefore, there is an urgent need to
formulate a policy for independent evaluation of NHM and which should also look into governance,
management, HR, and impact. The independent evaluation can be carried out by reputed academic
institution or third party and there should be a handholding after evaluation.
Similar to CRM by Central NHM, the state can also introduce Review Mission on its own, whereas
officials of one district can go to other district or call officials from well performing states to come
and review the program in the state.
3.3.4 Results Based Financing (RBF)
Results-Based Financing (RBF) is an instrument that links financing to pre-determined results, with
payment made only upon verification that the agreed-upon results have actually been delivered. RBF
can help improve both supply and demand side performance of health systems striving for responsive
and effective public health service delivery. In an RBF program finance are made based on the
quantity and quality of health services delivered after verification. Presently, the financing under
NHM given to states is largely based on activities- number of institutional delivery, and inputs like
ASHA, HR appointed etc. However, this should be based on performance and outcome- like
reduction in IMR, MMR, number of safe deliveries, reduction in malnutrition, number of people put
on treatment for NCDs etc. Results based financing for health, like the Plan Nacer in Argentina
would be a good fit for India. The evidence from a series of countries in Africa (Zambia, Zimbabwe,
Rwanda, and Burundi) also indicates that RBF can strengthen core health system functions,
increasing the efficiency and accountability of the health system. Under NHM, the Central NHM can
formulate a strategy for giving finance to states after pre-agreed results have been achieved and
independently verified. This may not be easy to implement in the short run, but we have to move in
that direction to improve the performance.
80 4. Procurement and Logistics
4.1 Background
An effective and efficient procurement and logistic planning is necessary for maintaining a steady
supply of pharmaceuticals and supplies to health facilities where they are needed, while ensuring that
resources are being used in the most effective way. Distribution costs, which include costs related to
storage and transportation, are a significant component of the expense of running a public health
supply system. Effective pharmaceutical procurement and logistics planning relies on good system
design and good management.
The Government of India, under the National Health Mission, the Ministry is supplementing the
efforts of the States to improve access to free/affordable and quality healthcare. The Government of
India has developed a comprehensive guideline for free drug service initiative and it includes
technical guidelines for various components of initiating free drug schemes in the states (Ministry of
Health and Family Welfare, Government of India, 2015). There are standard operating procedures
for establishing Centralized Procurement Body (CPB) at State Level, tendering and procurement of
drugs, District Drug Warehouses, Storage, Logistic Management Information systems, quality
assurance, and M&E (Ministry of Health and Family Welfare, Government of India, 2015).
NHM supports states for the provision for strengthening/setting up robust systems of procurement,
quality assurance, IT enabled systems like Drugs, and Vaccines Distribution Management Systems
(DVDMS), prescription audit and grievance redress. Senior Advisor of NHSRC mentioned that the
overall accessibility and availability of essential medicines across various levels of the health system
has improved significantly after the introduction of the NHM. Several studies have also suggested
improvement in access to services due to free medicine initiatives (Selvaraj et al., 2014; Chokshi et
al., 2016). Some of the states, like Rajasthan, have done extremely well in this area and availability
of essential medicines at public health facilities is increasing every year. The NHM continues to
provide incentives to those States that notify a policy to provide free essential drugs in public health
facilities. States are free to select those essential drugs that they would wish to provide in their states.
However, some of the states lacked the technical capacity for effective implementation for free drug
service initiative resulting in uneven status of availability of drugs across the nation.
Key Initiatives under NHM
Free Drugs Service Initiative
Under the NHM-Free Drug Service Initiative, substantial funding is being given to States for
provision of free drugs and setting up of systems for drugs procurement, quality assurance, IT based
81 supply chain management systems, training, and grievance redressal etc. subject to States/UTs
meeting certain specified conditions. Detailed Operational Guidelines for NHM- Free Drugs Service
Initiative have also been released to the States on 2nd July 2015. Model IT application Drugs and
Vaccines Distribution Management Systems (DVDMS), has been developed by CDAC and shared
with States. 17 States are implementing DVDMS application. All 36 States / UTs have notified
policy to provide essential drugs free of cost in public health facilities.
Free Diagnostics Service Initiative
Under the National Health Mission Free Diagnostics Service Initiative, substantial funding is
provided to States within their resource envelope to provide free essential diagnostic services at
public health facilities. The Operational Guidelines on Free Diagnostics Service Initiative have been
developed and shared with the States on 2
nd
July, 2015. These guidelines also contain model RFP
documents for a range of PPPs such as Tele radiology, hub and spoke model for lab diagnostics and
CT scan facilities in District Hospitals. Further, to ensure functionality of equipment, comprehensive
biomedical equipment maintenance programme has been shared with States along with model RFP.
Structure of Procurement and logistics systems
The procurement and logistics under the NHM are carried out by the Medical Services Corporation
at state level. Medical services corporations are managed by bureaucrats as an administrative head
and medical officers of regular cadre as a head of various wings, procurement, logistics, supply,
quality assurance, IT etc. However, there are no or very few well trained experts- such as health
economist, logistics planning, procurement, and M & E at medical services corporations. State
officials and senior officials from all the three states mentioned the need to appoint various
specialists for better management of medical services corporations. The lack of specialists was
responsible for inefficient functioning of technical committees- EDL, Procurement etc. Further the
officials stressed that the committees meet once or twice in a year. It was suggested that a committee
composed of technical experts from various streams should be constituted and should meet regularly-
at least quarterly.
4.2 Findings
Rajasthan
Rajasthan had the better functioning drug logistics structure of the three states, as described below.
The technical capacity of Medical Services Corporation in Rajasthan is adequate, and appropriate
resources and infrastructure are available to carry out various tasks effectively and efficiently. Senior
Officials of Rajasthan Medical Services Corporation mentioned that the state has started the Free
Drug Initiative as per NHM guideline in 2011 and they are following technical guidelines provided
82 by the central NHM. “Due to centralized procurement and decentralized distribution model economy
of scale has been achieved and our procurement is highly cost-effective” an official explained.
Senior officials of the SHS reported that the basket of essential medicines across various levels of
health systems-primary, secondary, and tertiary has increased tremendously. Nearly 90% of essential
medicines are available to users at the public health facility where they seek treatment.
They also mentioned that due to the Free Medicine Initiative in the state, access to health services
has increased with almost 100% increase in OPDs and study done by Selvaraj et al also found that
the access to health services and availability of medicines has increased substantially after free
medicine scheme (Selvaraj et al., 2014). Faith in public health facilities has also increased leading to
increased utilisation. There is a need to carry out a robust scientific study to assess the impact of free
drug initiative in reducing inequity and poverty, as out of pocket expenditure has reduced
significantly.
However, the officials from Rajasthan pointed out that the procurement related to NHM programs is
sometimes delayed due to delay in getting funds from SHS to Medical Services Corporation. They
were of the opinion that funds should be released on time for the timely procurement and supply of
drugs and equipment. They also stressed further need of capabilities reiterating that under NHM
various types of technical human resources were provided to the SPMU. However, they do not have
technical experts in the area of procurement and logistics management. “They should have
procurement specialists for helping us in streamlining various procurement related to the NHM
program and this will reduce our burden”.
Uttar Pradesh
The Uttar Pradesh Medical Services Corporation Limited (UPMSCL) has come up as an
organization for the centralized and transparent procurement and distribution of drugs, equipment’s
and other consumables. UPMSCL ensures availability of quality drugs, medical equipment’s at
lowest costs at various warehouses across the state under the charge of UPMSCL.
The UPMSCL is headed by Managing Director, who is overall in-charge of medical corporation
administration. The UPMSCL function under the board of director and chairperson of Board of
Director is Principal Secretary, Medical Health & Family Welfare and other members are Mission
Director, NHM, MD, UPMSCL and other senior officials.
The MD, UPMSCL is supported by executive director and several general managers, managers,
quality assurance officials, finance officials, company secretary and several executives. There are 75
district level warehouse under Chief Medical Officers.
83 In the state of Uttar Pradesh, senior officials of SPMU mentioned that they have a General Manager
and other technical experts for procurement, and they are also carrying out NHM program related
procurement. Procurement technical wing within SPMU is present in UP which also supports the UP
Medical Service Corporation for NHM programs related procurement. Senior officials of the
Medical Services Corporation informed that as the number of medicines and procurement increased,
associated litigation on tendering and selection process also increased. Until all the litigations are
cleared, we cannot procure particular drugs. Due to this many times the entire process of
procurement is delayed and we are not being able to supply some essential medicines to public health
facilities on time. District level health officials from Uttar Pradesh-Barabanki district reported that
there are significant delays in receiving essential medicines from the MSC and many a times
medicine which were not indented were delivered to them. There were stock-outs of many essential
medicines and at any given point of time, at least 30-35 essential medicines were reported to be out
of stock.
Senior Officials of SHS-NHM mentioned that Standard Treatment Guidelines (STGs) are available
and circulated across all the facilities. Procurement is also based on STGs. However, there is no
mechanism to monitor whether public health facilities and medical officers are following STGs.
Officials of Ministry of Health and Family Welfare pointed out that most of the state does not have
any mechanism for prescription audit and it is a very essential mechanism for improving the quality
of care provided by the health facilities. Functionaries of the Medical Service Corporation reported
that prescription audit is very good system for assessing rational use of drugs at public health
facilities. But the scarcity of human resources was reported as the main reason for not implementing
this practice. This also indicates that there is no priority to prescription audit.
Gujarat
The Central Medical Stores Organization (C.M.S.O) was established in 1978 under Health and
Family Welfare Department and was entrusted with the functions of procurement, storage,
distribution of medicines surgical goods medical equipment / instrument and insecticides for the
public health facilities at various levels. With the view to match the changing demands and pace of
development in the sector, CMSO was transformed into "Gujarat Medical Services Corporation
Limited" (GMSCL) as an autonomous body and was incorporated under companies’ act, for
systematic procurement, inventory management, Management information system and to infuse
professional management with establishment, development and strengthening the use of information
technology in medical store organization.
The GMSCL is headed by Chairman and day to day administration is managed by Managing
Director. The managing director is supported by key General Managers- Human Resources,
84 Logistics, Drug Procurement, Quality Control and Equipment, Diagnostic and Services. Each
General Manager is supported by several deputy managers, managers, and executives. Senior
officials of Medical Services Corporation told that the GMSCL is also a nodal agency for free
diagnostic scheme and entrusted with Establishment of Diagnostic Medical Service Centre for early
diagnosis & ease of treatment for beneficiaries.
Senior officials of Gujarat Medical Services Corporation mentioned that the GMSCL is competent
authority and all required resources are available. They also highlighted that many times there are
delays in procurement due to court litigation. Some procurement files go up to Minister level as well
and that has led to delays. They feel that GMSCL should be given more authority for efficient and
effective functioning. Senior SPMU officials told that although procurement is competitive through
GMSCL, however, significant delays in procurement affect the delivery of services. The SPMU
officials also mentioned that SPMU should also have procurement specialist to help GMSCL in
NHM related procurement like in Uttar Pradesh.
The health department officials mentioned that due to improvement in availability of drugs at public
health facilities, the access to public health services has increased significantly in the state.
They also mentioned that the state has also implemented the free diagnostic scheme and free
medicine and diagnostic services will lead to reduction in out of pocket expenditure on health
services. An issue which was highlighted in our visits to states was the lack of possibility of
procurement in between the year. District health officials mentioned that there is no system for
indenting in between the year and sometimes essential medicines which were not indented earlier are
needed urgently. The medical service corporation asks for indents only once in a year. This should be
at least twice in a year.
Another issue was related to the fund flows. Senior officials from Directorate of Health Services told
that most of the procurement done by medical service corporation is under state government budget
(70-80%). Regarding products procured under NHM for various programs, the central NHM can do
the rate contract nationally. The State Government can procure through central contract done by
NHM at national level. Recently, the central government has mandated that all government
procurement should be through GEM- Government E- marketplace. As per health department
procurement is concerned, most products are not listed in GEM. “The central procurement
department should ensure that health department products should be listed in GEM. If it happens
then we can make it mandatory for the state government to procure NHM drugs and other products
through GEM.”
85 Further, issues were reported about the lack of supporting infrastructure. In Uttar Pradesh, District
Drug Warehouses (DDWs) are not yet functional and operated in rental buildings. There are issues
with maintaining quality of drugs and also it is not possible to stock more medicines in rented
premises. Some states also want the Central NHM to support in maintenance and renovation of
DDWs. In Gujarat, DDWs are at regional level- 1 Regional Warehouse for 4-5 districts. The officials
insisted that for better management there should be a DDW at every district head quarter.
Issues in quality checks were present in many states such as Gujarat. Rajasthan, on the other hand,
had an effective quality check mechanism. Senior Officials of Rajasthan Medical Service
Corporation mentioned that quality assurance of drugs is on priority for the state and said that they
are following a scientific system for assuring quality of drugs we procure for public health facilities.
When drugs are received in DDWs, drugs are quarantined in clearly demarcated & segregated areas.
Then samples are drawn for testing from randomly selected cartons, containers, packing from the
supplies of each batch. These should then be sent to the Quality Control wing of the corporation. The
sample is then sent to an empanelled laboratory for testing and once we receive a quality check
report from the laboratory, the quarantined drugs are allowed to be dispatched. If they find a failed
quality check report, immediately information communicated to the pharmaceutical company for
removing the stock and based on committee recommendation action will be taken”. In Gujarat,
quarantined stock is allowed to be used before getting the quality check report. Sometimes after
getting a failure report, public health facilities are informed for not using the drugs from the supply
batch for which failed test report is received, but the drug stocks are not recalled. This is a major
quality issue which needs to be addressed.
Capabilities at the periphery
District Health Officials and PHC Medical Officers mentioned that E-Aushadhi is not functional up-
to primary level. Indenting is largely done at district level and district decides the priority drugs.
However, the drugs district gets is not per indenting and it is based on priority and procurement of
medical service corporation. Further, there is lack of capacity of district level officials, primary care
medical officers, and pharmacist for carrying out quantification exercise for deciding the exact
requirements. Most E-Aushadhi training is for pharmacist and largely on topics related to functioning
of software. In some state E-Aushadhi training are not conducted at primary level. Most officials
pointed out that Logistics Management and Drug Distribution training should be organised for
officials at various levels- State, district, and PHCs. It will improve the drug management systems
and quality of care.
Awareness about drugs availability and quality
86 Central NHM officials also mentioned that the state should take efforts in increasing community
awareness about generic drugs, rational use of drugs, and the dangers of unnecessary and excessive
use of drugs. They emphasized that a well-planned communication strategy with targeted IEC using
interpersonal communication, social media and mass media need to be implemented at various levels
for promotion of generics. Further, states should also notify the policy for essential drugs with wider
dissemination through posters, wall writing, and hoardings in all public health facilities.
In UP, the PHC Medical Officer stressed that the community has low trust on the medicine given at
PHC. The community members feel that the Government is procuring substandard drugs and generic
drugs are not effective. Therefore, we need to sensitize the public about generic drugs and the
misperception about the efficacy of generic drugs/or those provided in government facilities. District
health officials reported that among medical officers’ awareness about rational use of drugs, standard
treatment guidelines, and antimicrobial resistance is poor. “Orientation and training workshops for
doctors should be organised to strengthen their technical capacity”, they emphasized.
District Health Officials mentioned that comparing the current usage of drugs with the standard
treatment guidelines will enhance the efficacy of treatment and improve cost-effectiveness. District
Health Officials also told that we do not have any system of monitoring of adverse drug event-
pharmacovigilance. It is very essential to have such system for improving quality of care. However,
in some states the above practice is not been followed and without getting quality check report ok,
the quarantined stock is being dispatched to public health facilities.
4.3 Recommendations
4.3.1 Strengthening Technical Capacity of Medical Services Corporations
The technical capacity of Medical Service Corporation requires strengthening and training of
existing personnel in the area of Logistic Planning and Drug Distribution is necessary. Further,
restructuring of medical service corporation is also required, in which technical experts- Health
Economist, Procurement Specialist, Logistics Planning Specialist, IT-Expert and M&E expert should
be appointed at medical service corporation. This will improve the functioning and efficiency of
corporations.
4.3.2 Strengthening Quality Assurance System
Ensuing quality of drugs is very essential for patient safety and responsive health systems. The
quality assurance practices should be in accordance with the operation guideline of the Ministry of
Health and Family Welfare, Government of India. Planned and regular monitoring from Central
NHM is necessary for ensuring adoption of efficient quality assurance systems.
4.3.3 Implementing bottom up planning
87 The E-Aushadhi and IT-backed Logistic Management Information System like Drugs and Vaccines
Distribution Management Systems (DVDMS) have been implemented in most of the states.
However, it is not fully functional at the peripheral level that is hampering the bottom-up planning.
The ground level functionaries- Primary Health Centres and Community Health Centres have not
been able to carry out indenting and planning. The bottom-up planning should be implemented with
requisite technological changes and capability building initiatives.
4.3.4 Group Procurement
Drugs such as antibiotics should be procured as a basket of similar products. This will be essential in
order to make drug procurement more efficient and reduce unnecessary paperwork. Group
procurement will also have the advantage of making vendors more amenable to supplying to the
government as the order values will be much higher. For example, if a state is procuring 600
different drugs and formulations – if each drug is procured individually they have to do 600
procurements. But if they make bundles of 10 drugs each then they have to procured only 60
bundles, thus reducing the paperwork very much.
4.3.5 Training and Capacity Building
Training of officials at various levels for implementing E-Aushadhi and carrying out various logistic
activities- forecasting, quantification and inventory management is required for making Logistics
Planning and Drug Distribution system more efficient and effective. Standard training manual and
workshop material along with case studies for training and capacity building can be designed and
implemented. The training of medical officers for rational use of medicine, and managing drugs is
essential.
4.3.6 Community Awareness
The awareness about generic medicine and rational use of medicine among communities is required.
A communication strategy and IEC material can be developed in the local language for wider
awareness. Use of social media, mass media, and electronic media will help in larger awareness.
4.3.7 Implementing Standard Treatment Guidelines and Prescription Audit
The state should implement STGs across all levels of health systems and prescription audit practices
should be initiated for improving quality of care. At least 2% of the annual procurement budget
should be devoted to STG implementation and prescription audit. This will have the advantage of
preventing unnecessary drug consumption, reduce costs and its side effects. 1-3% of prescriptions
made in each facility should be audited periodically to study prescription patterns. The results can be
then used to address supply chain issues and physician strategies can be revised.
88 89 5 Rogi Kalyan Samitis (RKS) and Untied Funds
5.1 Background
Rogi Kalyan Samiti (RKS) or Patient Welfare Societies or Hospital Management Committees are
one of the most important features of the NHM. It aims to increase community involvement in
healthcare service delivery. The RKS were set up at medical facilities as part of restructuring in line
with the IPHS for improving quality of services and better management of public health facilities.
The suggested composition of RKS is as follows:
RKS / HMS would be a registered society set up in all District Hospitals / Sub District Hospitals /
CHCs / FRUs/PHCs. It may consist of the following members: -
Peoples representatives MLA / MP
Health officials (including an AYUSH doctor)
Local district officials
Leading members of the community
Local CHC/ FRU in-charge
Representatives of the Indian Medical Association
Members of the local bodies and Panchayati Raj representative
Leading donors
Associated members: An individual who makes a onetime donation of INR. 100,000 for
District Hospital, INR. 50,000 for a Sub-district hospital/CHC or INR. 25,000 to PHC shall
be offered an associated membership for period of two years. State could adapt the donation
amount appropriate to their context
RKS strengthens the decentralisation of the healthcare system by ensuring that both authority and
resources are transferred from the central government to local governments that are more aware of
the needs of their communities (Singh, 2019). Decentralisation is an important feature of
strengthening a country’s health system. Moreover, the NHM’s focus on decentralisation of
healthcare decision making follows a trend in governance changes, set by the 73
rd
and 74
th
amendments to the Indian Constitution in 1992, which granted power to Gram Panchayats and
municipalities in urban areas (Singh, 2019). Further, the untied funds given to these facilities have
allowed local facilities like SC/HWCs and PHCs greater freedom to fulfil their necessities in a timely
manner, make improvements, and even innovate to provide better healthcare. Figure below depicts
the constitution of RKS at various levels. The RKS consists of a governing body and an executive
90 body (Landrian et al., 2020), although structures may differ across states. It is supported by the
DPMU in its activities (Landrian et al., 2020).
The RKS/HMS will not function as a Government agency, but as an NGO as far as functioning is
concerned. Participation of local staff along with representatives of local population is considered of
prime importance to improve accountability and keep pace with rapidly growing service
requirements. The RKS consists of Governing Body and Executive body.
The meetings of the Governing Body shall be held at least once in every quarter. The Governing
Body will have full control of the affairs of the Society and will have authority to the exercise and
perform all the powers, acts, and deeds of the Society consistent with the aims and objects of the
Society.
The meetings of executive committee shall be held at least once in a month. The executive
committee largely review the service delivery aspects of the health facilities, including review of the
OPD and IPD service performance, service delivery targets, and review of outreach activities. The
minutes of executive committee meetings will be placed before the governing committee.
The account of the Society shall be opened in a bank approved by the Governing Body. The District
Health Society shall review, monitor, and evaluate the performance of the Rogi Kalyan Samiti at the
District/Sub District levels.
Monitoring Committee: A Quality Monitoring and Assessment Committee may be constituted by
the Governing Body. The Committee should have representation of non-official members also. These
committees will be trained in monitoring and conducting assessments, conduct exit interviews of a
predefined sample of Out-patients and Inpatients, collect patient feedback on a fixed day of the
month. The Committee would send a monthly monitoring report to the District Magistrate with copy
to Superintendent.
91 Figure 17 Structure of RKS at various levels of health system
Table 15 Number of Rogi Kalyan Samitis registered across various levels of healthcare in the
country
Level of HealthcareIndia High Focus-
Non NE (10)
High
Focus NE
(8)
Non High
Focus- Large
(11)
Non High
Focus- Small
& UT (7)
District Hospitals
(DHs)
795 416 92 251 36
CHCs5812 2910 347 2540 15
UCHCs94 18 2 65 9
Above block level
but below District
Level facilities
1091 290 29 766 6
PHCs20125 7272 1606 11178 69
UPHCs 3151 1062 80 2007 2
Other health
facilities above SC
but below block
2310 1538 4 768 0
Total 33378 13506 2160 17575 137
Source: Executive summary, National Health Mission, Ministry of Health and Family Welfare,
Government of India (2019).
92 5.2 Findings
Flexibility through untied funds
One of the most effective aspects of RKS was flexibility to spend the ‘untied’ funds according to the
needs of the concerned facility. RKS members are proactive involved in management of facilities for
the health benefits of their entire community. A large majority of the respondents from all levels of
the health system and across states were of the opinion that untied funds had played a crucial role in
improving the quality of services. In their absence, healthcare facilities would be dependent upon
state health department budget approval, even for minor expenditures such as small structural
repairs, procurement of diagnostic instruments, and often medical supplies. They reported that these
funds and the flexibility they provided had greatly improved the efficiency of the healthcare system,
owing to their decentralised nature.
For example, as shared by some officials of the NHSRC, “prior to the introduction of the NHM,
some healthcare facilities lacked basic items like prescription pads etc. Patients seeking treatment at
PHCs were asked to provide the paper for their own prescriptions. The untied funds now available to
the RKS at every PHC and their ease of use has ameliorated such problems to the extent that even
generators can be purchased to provide electricity at health facilities in areas where power outages
are a common feature.” The usefulness of untied funds was also stressed by senior officials of the
central NHM. In some states, RKS members have also taken the responsibility and ownership to
resolve critical issues faced by the facility.
The district level officials in Uttar Pradesh were of the opinion that the RKS has improved quality of
care through better hygiene, management of hospital waste and cleanliness at public health facilities.
Most of the RKS fund is used for upgrading facilities, initiating patient friendly initiative-
construction of waiting areas, improving infrastructure, and ensuring availability of essential
medicines. Due to RKS, the image of public health facilities has changed as now their appearance is
much better and they look much cleaner and patient friendly.
Respondents revealed that untied funds helped health facilities carry out minor renovations, ensure
an uninterrupted supply of utilities, create small-scale infrastructural improvements to increase the
attractiveness of the facility to users, and also purchase stocked out medicines, all of which could not
be done previously as monies for such purposes could not be obtained from the regular state budget.
This has led to an improvement in service utilisation, as well as quality of care. This is in line with
the findings of the 10
th
CRM. Gujarat was among the 95% of states that reached their targets for
constituting VHSNCs, and receiving funds in a timely manner.
93
Figure SEQ Figure \* ARABIC 16 RKS in health facilities at various levels of the health Empowerment and accountability
The constitution of RKS intended to bring empowerment as well as accountability to the grassroots
level. In the state of Gujarat, it was found that the RKS was functioning smoothly and had greatly
improved accountability in healthcare governance. PHC-MOs are member secretaries of the RKS in
Gujarat. These bodies, at various levels of the state healthcare system are reviewed regularly by the
DHS, which provides them with untied funds. Respondents revealed that these committees included
members of PRIs, and conducted regular meetings. This finding is corroborated by research
conducted on RKS in other states as well. A study in Odisha found that the decision making
capacities of the RKS had brought about improvements across various service delivery parameters
and decreased facility staff truancy (Sinha, 2009).
Issues in fund allocation
The officials across the states explained a major issue in allocation of funds to the facilities. The
funds are disbursed in two instalments whereby the first instalment is given to every RKS, and the
amount for the second instalment is variable, based on the performance of the respective health
facility. It was observed that PHCs that performed very well were given larger amounts in the second
instalment which was often not appropriate as they had access to funds from many other schemes
due to their good performance. On the other hand, newly established PHCs received a smaller value
of funds because of low utilisation when their requirements would be more in order to attract more
users and set a standard for services. Further, in urban areas, untied funds for urban PHCs are not
performance linked with each UPHC receiving a flat sum of INR 50,000. (In addition to this amount,
the Gujarat Urban Health Board also grants funds to PHCs in urban areas.)
In addition to the RKS, there are other local level bodies like the Gram Sanjeevni Samiti (GSS) and
Mahila Arogya Samiti in Gujarat. The signatories for these bodies are the ASHA and AWW. It was
pointed out that often lack of coordination between these two functionaries resulted in low utilisation
of untied funds.
Issues in fund flow processes
While the purpose of RKS was decentralization and empowerment, however, due to some procedure
like signing authority there are issues in fund flow and utilisation. Across states, at the village level,
untied funds were under the authorisation of the village head, the Sarpanch/Pradhan who was often
found to ignore these funds due to their small amount and the availability of a large number of other
funding sources. Due to the recent investigations about fund abuse, some village heads were also
found to be fearful of using these funds. At the village level, untied funds were also made available
to VHSNCs, the signatories to which were the village head and the ASHA. Here again, due to the
94 Sarpanch/Pradhan’s scope of duties, this body does not receive the attention it requires, and the
allotted untied funds remain underutilised. This finding was also seconded by the results of the 12
th
CRM.
In the state of Uttar Pradesh, the purpose of decentralisation behind the RKS model, and the NHM at
large was defeated, as funds earmarked for these bodies were given to block superintendents by the
DHS, rather than directly to the PHC. This led to delays in fund disbursement which in turn
hampered planning. Uttar Pradesh was the only study state where this phenomenon was observed.
Issues in capacity building and monitoring of RKS
In some states the capacity building and training of RKS members is lacking as per various
provisions of RKS functioning. RKS members regardless of their committee type identify lack of
adequate training on operations and functioning as a major issue. Further, there were issues with
accountability as the monitoring mechanism for the RKS performance is weak and review by DHS
was ad hoc or only based on financial expenditure. Innovation in RKS system is seen in Uttar
Pradesh in the form of RKS register, a comprehensive document containing guidelines for the RKS,
expenditure protocols and a structure to record the minutes of the committee’s meetings. This has led
to improved functioning of the RKS.
One of the good practices was capacity building of RKS members in three districts in Maharashtra to
improve the utilisation of untied funds, and align the same with community priorities. It was found
that as a result of the training workshops, the functioning of the RKS had regularised and they had
increasingly used participatory processes to decide areas of expenditure for the untied funds
(National Health Mission et al., 2020a). It should be noted though that such programs for the RKS
are effective only when the facility in question already has basic functionality (National Health
Mission et al., 2020a).
Expanding the scope and role of RKS
The role of the RKS was seen to be limited to government provided untied funds. Very few RKS
were able to generate additional funds. Further, the RKS objectives of civil engagement and
community inclusion were lost due to the lack of authority and responsibility afforded to this body.
They have limited say in grievance redress mechanisms.
The constituency of RKS was also not aligned with the need for representation from all sections of
the society, especially the women. Even though NHM is largely focussed on RCH, however,
participation of women in RKS was very minimal.
95 5.3 Recommendations
5.3.1 Capacity building and training of Rogi Kalyan Samiti Members
There is an urgent need to build capacity of RKS members in structural, operational, functional and
finance related areas. There should be a training module for RKS members in the expenditure and
reporting on untied funds. The RKS processes should be carefully monitored and ensured (for
example RKS register made by Uttar Pradesh).
5.3.2 Representation of local communities
The State and District Health Societies should focus on including local patient representative groups,
CSR organizations in the area and civil society. Generating localised funding sources is also essential
for ensuring involvement from all sections of the community including those individuals and
organisations capable of philanthropic endeavours. This will be important for drawing attention to
lacunae in the social aspects of public healthcare, such as facilitating food and shelter for the family
of care seekers, engaging social workers for follow-up community based care, and supplementing
local blood banks via promotion of voluntary blood donation etc.
5.3.3 Participation of Women
A guideline or regulation can be made for increasing participation of women as RKS members. This
will also ensure gender sensitive services at public health facilities.
5.3.4 Proper monitoring of RKS
There should be a monitoring committee at district level for regularly reviewing the performance,
and governance of RKS. The monitoring process needs to be governed by standards and should look
into various structural, operational, functional, and financial aspects of RKS. Scores/points could be
awarded for overall improvement of healthcare facility, conduction of meetings, governance aspects,
RKS membership structure, functionality, fund utilisation, and innovation. The top-ranking RKS
could be rewarded monetarily. Likewise, Swachh School or Kayakalp, award mechanisms should be
set up for RKS. An annual award to all high ranking RKS could act as further motivation. A detailed
analysis of the RKS and the untied funds should also be conducted to understand its functioning and
impact on service delivery and community health improvement.
5.3.5 Communicating membership clearly to local community
The details RKS members the names, phone numbers should be clearly laid out every facility. This
would help patients to know about the committee. RKS has the potential of becoming a strong
patient welfare body and a feedback collection and issue resolving committee.
96 6 Monitoring and Evaluation (M&E)
6.1 Background
Monitoring is a systematic way of collecting and analyzing the data for reviewing the progress of a
project or program over time. It involves a continuous process of data gathering and analysis that
allows adjustments to be made in the objectives and mid-course correction. On the other hand,
Evaluation is a systematic periodic collection and analysis of data about the progress of a project or
program. An evaluation provides credible and useful information to policy-makers, donors and
stakeholders for identifying the barriers and facilitators.
An increasing number of stakeholders, including global health partnerships, bilateral donors, UN
agencies, and academic institutions are involved in health‐related monitoring and evaluation (M&E).
Strategic planning and program implementation should be based on strong monitoring, evaluation
and review of progress and performance as the basis for information, results and accountability
(World Health Organization, 2011).
NHM put major emphasis on strengthening capacities for data collection, assessment and review for
evidence based planning, monitoring and supervision for achieving its goals. NHM framework
proposed accountability by a three pronged approach of internal monitoring through MIS,
community based monitoring and external surveys like the SRS, DLHS, and household surveys.
Officials at the MoHFW mentioned that the NHM is following a Logical Framework Approach
(LFA) in which output and outcome indicators have been spelled out on the lines of the national PIP.
The NHM envisages robust monitoring and evaluation mechanisms, ranging from regular reviews by
Central NHM, State NHM, and District Level institutions. Senior officials of MoHFW highlighted
that M&E is a key component of the NHM and various M&E systems helped in identifying and
developing mid-course corrections so that the goals of the NHM and the SDGs could be achieved.
The Monitoring and Evaluation mechanisms under NHM comprise the following initiatives- HMIS,
IDSP, earlier Joint Review Mission and now Common Review Mission and through various routine
information systems, such as SRS, NFHS, DLHS etc.
Common Review Mission (Common Review Mission, National Health Mission, 2020)
Annual Common Review Mission has been one of the important monitoring mechanisms under
NHM. Thirteen CRMs have been undertaken so far and have provided valuable understanding of the
strategies and programs. The focus of the CRM was to undertake a rapid assessment of the
implementation status of NHM and its key strategies and priority areas, analyze strengths and
challenges with respect to strengthening health systems, identify trends in progress of key indicators,
particularly relating to coverage, equity and affordability. The CRM also document innovations and
97 best practices, evaluate the readiness of the state to undertake implementation of new initiatives, and
review the progress and coordination mechanisms with various partners having focus on aspirational
and NCD districts. This CRM had a different focus where teams assessed the implementation of the
programs from the citizen perspective.
Health Management Information System (HMIS)
Health Management Information System (HMIS) was started by Ministry of Health and Family
Welfare, Govt. of India by 2009 under National Rural Health Mission (NRHM). It is aimed for
assessing the progress, quantifying output as well as outcome of interventions and decision making
as well. It provides how and what health care services delivery is required, availability of man power
as well as beneficiaries at all level of Health institutions as well as in the community. Monthly
reporting is being done from all Health institutions by using software called HMIS Ministry web
portal.
Integrated Disease Surveillance Program (IDSP)
IDSP is one of the major National Health Program under National Health Mission for all States and
UTs. The key objective of the program is to strengthen/maintain decentralized laboratory based IT
enabled disease surveillance system. The IDSP aim is to strengthen the disease surveillance in the
country by establishing a decentralized State based surveillance system for epidemic prone diseases
to detect the early warning signals, so that timely and effective public health actions can be initiated
in response to health challenges in the country at the Districts, State and National level. Under the
project weekly disease surveillance data on epidemic prone disease are being collected from
reporting units such as sub centres, primary health centres, community health centres, hospitals
including government and private sector hospitals and medical colleges.
Mother and Child Tracking System (MCTS)
The MCTS is dedicated portal for Mother and Child Tracking for tracking all pregnant women and
children up to five years of age for appropriate care and immunization / nutrition with special
emphasis on those at high risk.
6.2 Findings
A senior advisor at NHSRC reiterated that under the NHM various mechanisms are available for
M&E, like the annual CRM, periodic field visits, quarterly progress reports, financial monitoring
reports, HMIS, state specific systems, and reviews conducted by the NHSRC itself. The CRM is an
annual exercise by the central NHM for assessing performance of NHM in various states. It includes
senior officials of MoHFW, Public Health experts from civil society and experts from academic
institutes, development partners and officials from related development sectors of the government.
98 Senior officials of health department cited that for routine evaluation a robust HMIS has been
developed under NHM which focuses on NHM priority areas like institutional delivery and maternal
care, routine immunization breast feeding, neo-natal care, Pre-natal Diagnostics Techniques (PNDT)
related issues, and adolescent health.
M&E is also an integral component of national PIP and State PIPs. Senior officials of SPMU
mentioned that the state carries out a regular review of common process, outcome and output
indicators based on the levels of achievements set by state government. State PIPs have well defined
quantifiable physical indicators and efforts are in place for continuous monitoring and reviews. In the
same line district specific objectives and goals are within district plans.
Senior officials of the central NHM mentioned that there is a wide variation between and within state
implementation of various M&E systems under the NHM and the use of data for planning. This may
be due to the lack of capacity and awareness about M&E systems. They also pointed out that
capacity and technical competencies are lacking at various levels for monitoring and evaluation
efforts. M&E was largely limited to data collection and data reporting.
One of the issues that cropped up was too much data, duplication of processes and multiple
applications. Senior officials of the three states health department echoed that there are too many
frameworks, guidelines and data recordings and reporting for various programs under NHM.
Collecting data individually from each program at separate instances from the district level, and then
compiling the same and submitting at the national level was found to be very cumbersome. Officials
commented that different apps and systems for different programs under NHM were redundant. The
issue of overburdening the frontline healthcare workers with data collection responsibility extended
till the village level (ASHA) and district. District health officials stressed that they are overburdened
due to lots of data recording and reporting. They stated “various programs are having their own
M&E systems and there is lack of integration and coordination between various programs”.
The officials in the three states furthered that the M&E is limited largely to monitoring functions,
and very little emphasis is given to evaluation. For example, they exemplified the IPHS norms
monitoring, “though we ‘measure’ the compliance to IPHS norms, what are the key gaps, how to
overcome those gaps, resource requirement and utilization, etc all these aspects are missing.” Very
few special studies are commissioned to understand performance gaps, impact of various
interventions and reasons for success. Further, they emphasized that though there is some
documentation effort towards good innovative practices, the same is limited to oral presentations in
national summits. (These summits have started over the last few years) They highlighted the need to
extend it further in a more formalised form such as case studies, research papers in reputed journals
etc.
99 Figure 18 Decreasing number of public health facilities meeting IPHS norms
Senior officials of SPMU highlighted that the M&E has played in significant role in identifying
number of facilities meeting IPHS norms. This has helped the states in understanding their
performance and taking timely decisions for improvements. There was considerable variation
amongst the three states regarding the perception about M&E. SPMU officials in Uttar Pradesh
mentioned that various innovative initiatives were taken for strengthening and streamlining M&E
Mechanisms-District Level Vigilance and Monitoring Committee (DLVMC) and regular supportive
supervision visits by the state level team. These initiatives were cited as important for improving the
recording and reporting of data. The minutes of these meetings are also put on the website to ensure
transparency and accountability. The regular review by the Principal Secretary and MD-NHM were
cited as very important for mid-term corrections.
However, there was a palpable lack of coordination between NHM and directorate staff in the state
of Uttar Pradesh. Senior officials of state DGHS-Uttar Pradesh stressed that there is no role for the
directorate in M&E activities of various programs under NHM. The SHS does not involve
directorate officials in monitoring and supervision of NHM programs. The entire M&E systems are
carried out by the contractual workforce of the SPMU, DPMU, and BPMU. Directorate officials, on
the other hand, pointed out that the monitoring from the higher levels is not adequate and primarily
consists of inadequate field visits, follow-ups and analysis of data uploaded by the district. They
further mentioned that the quality and reliability of data is poor and the state is not utilising the
potential of available data for making the health system more efficient and responsive. There are
100 several staff at the state level for M&E activities, but they end up in follow-up and coordinating with
the district for data reporting. Not much analysis and systematic preparation of annual reports have
been done.
The state of Gujarat has established the Performance Monitoring and Control Centre (PMCC) under
the Commissioner of Health for integrating medical data analysis with real-time performance
monitoring and reporting, advanced data warehousing, and customizable executive and information
dashboards. The PMCC is equipped with adequate and competent human resources for carrying out
various M&E tasks. It has become the central hub of the department for monitoring prioritized health
indicators from a single point and providing feedback as well. The creation of the PMCC also led to
improved coordination between various program units under the NHM. This unit provides data and
insights to the commissioner office and the directorates whenever they request. However, senior
officials emphasized that their analytical capacity, documentation skills need much improvement.
This unit is largely composed of medical officers and young health management graduates and their
statistical, demographic, public health and data analytics expertise is minimal. They also don’t
produce annual monitoring reports.
Senior SHS officials pointed out that most M&E mechanisms were carried out by health department
officials at the SPMU, DPMU, and the BPMU. Thus, unlike the state of UP, the M&E process
involves officers from state regular cadre, such as state D & E officers. Further there is an
involvement of the Additional Director of Vital Statistics who comes from the department of
economics and statistics of the state government. While they might have understanding of statistics,
the knowledge about public health aspects is limited.
The Government of Gujarat has also implemented an innovative program Innovative Mobile-phone
Technology for Community Health Operations (ImTeCHO) for real time monitoring of MNCH
services and improving the coverage of community-based maternal, neonatal, and child health
(MNCH) services. This mobile-phone–and web-based application, also helping Accredited Social
Health Activists (ASHAs) and Primary Health Center (PHC) staff. Mobile-phone-technology–based
health (mHealth) solutions are promising, innovative strategies with the potential to improve
performance of frontline health workers in controlled settings.
The study by Modi et al., also found effectiveness of “ImTeCHO” to improve delivery of maternal,
neonatal, and child care services. We found that coverage and quality of most of the MNCH services
were significantly higher among PHCs that were served by ASHAs who used mHealth as a job aid
compared to those who did not. The coverage of at least two home visits within first week of birth
was 32.4% in the mHealth intervention group, compared to 22.9% in the control group. A composite
index, which was calculated based on coverage of multiple key MNCH services, was 43.0% in the
101 mHealth intervention group compared to 38.5% in the nonintervention (Modi et al., 2019). This
initiative successfully piloted by SEWA Rural in partnership with the Department of Health and
Family Welfare, Govt. of Gujarat since May 2013 in 22 PHCs (700 villages) in high focus tribal
talukas of Bharuch, Valsad and Narmada districts.
After success of ImTeCHO, an advanced version of it, TeCHO+ Project was launched by the Hon.
Prime Minister on 8th October, 2017 for scaling up in entire state. TeCHO+ has been implemented
as a job-aid for health workers and administrators for improving coverage and quality of health
services related to reproductive and child health, non-communicable diseases, communicable
diseases, mental health. TeCHO+ application provides name based tracking of pregnant women,
children and entire population using mobile phones along AAA (convergence of ANM, ASHA and
Anganwadi) and linkage with health facilities.
Figure 27 Structure of the Performance Monitoring and Control Centre in Gujarat
In the state of Rajasthan, the two major issues highlighted were lack of capabilities and high attrition
amongst the DPMU. District health functionaries mentioned that dedicated human resources are not
available for M&E activities and the capacity of available human resources is also inadequate.
102 Further, due to higher turnover of DPMU staff, continuous monitoring and supervision could not be
carried out. They also highlighted the lack of analytical abilities stating that “most of the officials
know only basis statistical tools and not adequately capacitated for data triangulation and
visualization. District unit also lacks demographic, statistical, and epidemiological and data analytics
expertise.”
DPMU officials of Rajasthan however, pointed out the issues related to data duplication and over
work: “our responsibility is to carry out M&E activities. However, most of our time goes to clerical
work and we are not getting any time for M&E. We are overburdened with the various program and
also doing some of work of regular cadre district health officials.” Senior Officials of SPMU pointed
out about the limitation of the M&E process, emphasizing the lack of integration of HMIS data with
financial data. They said “M&E is largely limited to various indicators of NHM programs and
presently the physical and financial data is collected and reported separately. There is a lack of
integration between the two datasets. Physical and financial performance is inter-related and for
better insight integration is necessary.”
In summary, M&E functions are scattered under various programs and systems. At times ad hoc
systems are also developed without adequate technical skills. There is no annual report (Statistical or
narrative published by the state). Further, DPMU capacity is carrying out M&E is weak. The M&E is
generally happening program wise and input oriented. Survey data is available, coverage is
measured. However, there is no third party evaluation and evaluation by independent agency.
6.3 Recommendations
6.3.1 Regular Annual Performance Report
Under the NHM enormous funds have been made available to the states. A portion of these funds
should mandatorily be dedicated to the creation of a detailed annual report by each state, submitted
to the central government, and made available to the public. This report should be standardised by
the central NHM so that there is uniformity in reporting structure across states. There should also be
some budget for carrying out research studies on situational analysis, diagnosis of the public health
system, documenting best practices under NHM, cost-effectiveness of innovative interventions. This
initiative will help in enhancing the effectiveness of M&E systems and also result in high quality
evidence generation which can be applied to the development of health research capacity in states.
Facility, block, and district wise targets should be set for continuous monitoring.
6.3.2 Independent Evaluation
Every 3 years, 1% of the annual budget of NHM should be spent towards independent evaluation
studies of the mission, and various programs under it. A technical panel compromising multi-
103 disciplinary experts from public health, health policy, health systems, epidemiology, health
financing, and M&E should be constituted by central and state NHM for regular independent review
and evaluation. This will also increase reliability and validity of evaluation. The panel should also be
responsible for developing the study proposal, its design, methodology, and tools for the evaluation
for ensuring uniformity across the states. Academic and public health institutes can also be enshrined
with this responsibility. A well designed centralised strategy should be put in place to ensure
uniformity in the independent evaluations conducted by different states.
6.3.3 Capacity Building and Training
Capacity Building of staff at all levels from facility, district, and state levels is critical for proper
recording and reporting of data. HR should also be trained for utilising strategic data generated in
registers, reports, and HMIS. This will also help in better interpretation of collected data for micro-
planning and initiating actions at local levels in a timely manner. Program managers at all levels
need to be acquainted with the power and features of the HMIS portal and also triangulating various
data. There should also be a clear cut role for carrying out M&E. District health officials should lead
the M&E efforts. The vast potential of academic institute and public health institute needs to be
utilised for quality trainings and they can be developed as a nodal training centre for the states.
Trainings on basic research methodology, analysis tools, and HMIS use may be provided so that key
facility staffs will have the ability to access pertinent data needed to make quality decisions based
upon actual service and performance trends and conditions. All project management should undergo
a week long training program at a regional, national, or international institute of repute.
6.3.4 Involvement of Directorate of Health Services Officials in M&E
Directorate officials and regular state cadre employees should be involved in M&E activities for
better implementation of NHM programs. Regular personnel have a better understanding of health
system and various procedural aspects of programs. Their involvement will improve the
effectiveness of M&E systems and also the ownership by the directorate for NHM programs will
increase. A directorate with its own director should be created for M&E, staffed with demographers,
epidemiologists, and experts in public health, evaluation, and data analysis. The function of this
directorate would be to generate M&E plans and implement the same.
6.3.5 Utilization of existing data from various surveys
A unified system for data reporting should be created under the NHM for all programs. This will
reduce the burden on frontline health workers, and allow for streamlined health system data
reporting. Data should be utilised for micro planning, increasing the reach of services, improving
104 quality of care, and increasing access to healthcare services. Data triangulation efforts are required to
realise the full potential of data recording and reporting under the NHM.
AHS and DLHS could be considered as third party source of information to provide the baseline,
midline and end-line surveys for assessing the impact of the health interventions on the community.
Based on these and other data, a District Health Profile of each district can be prepared. These data
could be used as an input for policy initiatives, making mid-course correction, decision making and
for review of policy planning. Consequently, district and block level rankings can be assigned based
on the District Health Profile and issues related to public health service delivery can be identified.
6.3.6 Integration of physical and financial data
Presently, HMIS web portal captures the physical (health indicators) and financial data (FMR
reports). The MoHFW should formulate a strategy for integration of the physical and financial
reports and performance. As physical and financial performances are inter-related and inter-linked
and the integration will help in getting better insight on what should be precisely tracked,
documented, and analysed. The integration will also help in carrying out cost benefit or cost effective
analysis for different program heads. Further, the central NHM should also review the financial
component of the NHM with state representatives from finance divisions, Mission Directors of NHM
and Health Secretary. It may be undertaken regularly on a six monthly basis.
6.3.7 Expansion and improvement of health indicator data
Efforts should be put towards improving the civil registration of births, deaths, and cause of death.
The NHM should invest in the expansion of the SRS sample to ten times its current size, by paying
funds to the RBI. Every state should be tasked with selecting at least 3 districts with the aim of
improving the Census Registration System (CRS) on a pilot basis, in the coming two years. This
would lead to reliable estimates of IMR, MMR, and CBR. The vision for the next decade should be
to improve the CRS to such an extent that the SRS is made redundant.
105 7 ASHA
7.1 Background
Accredited social health activists (ASHAs) are community health workers introduced under National
Health Mission for increasing community connect with the health system. The MoHFW describes
them as “health activist(s) in the community who will create awareness on health and its social
determinants and mobilize the community towards local health planning and increased utilization
and accountability of the existing health services”. ASHA are married women, who have
experienced both pregnancy and motherhood, and the challenges associated with them. This
characteristic allows them to share increased empathy with women in their communities, thus
leading to empathy-altruism behaviour (Gupta et al., 2009), which makes them influential figures in
the community. The number of ASHAs across various states has increased significantly, currently
approximately 9,75,697 ASHAs in rural areas and 61,822 are appointed in urban areas (as on June,
2019) (Chandran, 2016) representing an enormous pool of personnel warranting proper human
resources management systems and processes to work effectively and efficiently (Please see below
table). As activists, ASHAs are proactively involved in counselling, preventive health education and
health promotion, responding correctly to illness. They are also trained in diagnosing certain
common conditions and providing appropriate care – referral, drugs, home remedies, or counselling.
Training for ASHAs
Senior Officials of Central NHM and NHSRC mentioned that training and capacity building of
ASHAs is adequate and the same has also improved the quality of ASHAs. Up to 2010, ASHAs
received training on five modules, in which modules 1-4 focused on program management and basic
health knowledge. The module 1 is on basics of NRHM, ASHAs tasks, health services, and health
education. The module 2 focuses maternal and child health, module 3 is dealing with Family
Planning, RTI/STIs & HIV/AIDS and ARSH and module 4 is on National Health Programmes,
AYUSH &Management of Minor Ailments. The Module 5 is focused on life skills such as leadership
and community relation building. 2011 onward, module 6 and 7 were also introduced in their
training to impart additional skills such as Home Based New-born Care (HBNC) under skills that
saves lives.
106 Table 16 Year wise number of ASHAs selected across the country
Year India High Focus-
Non NE (10)
High Focus
NE (8)
Non High
Focus-
Large (11)
Non High
Focus- Small
& UT (7)
2014-15 42021 9414 243 31643 721
2015-16 34593 25208 590 8480 315
2016-17 33197 28472 191 4527 7
2017-18 15931 10705 127 4977 122
2018-19 10844 6355 343 4100 46
2019-20 2441 670 0 1771 0
Total 975697 585043 56522 333016 1116
Number of ASHAs in position in Urban Areas- USHAs
61822 20445 2135 33147 6095
Status of ASHAs in Study States
Number of ASHAs in Uttar Pradesh 1,36,094
Number of ASHAs in Gujarat 42,271
Number of ASHAs in Rajasthan 51,743
Source: Executive summary, National Health Mission, Ministry of Health and Family Welfare,
Government of India (2019).
The impact of ASHAs on health indicators has been substantial as indicted by various studies. A
research study conducted by Wagner et al., 2018, has comprehensively evaluated impact of increased
ASHA placement on changes in communities’ access to health services. In 218 districts from 21
states, the average proportion of villages with an ASHA increased from 39.1 to 76.2%, unmet need
for family planning was fulfilled from 14.7 to 22.4% (ASHA has played an important role in
reducing unmet need of the population), institutional delivery increased from 61.6 to 82.5%, and full
immunization coverage increased from 71.2 to 65.1%, between 2007-08 to 2012-13 (Urban
Development & Urban Housing Department, Government of Gujarat, 2016).
For ASHA program, there was a National ASHA mentoring group was formed. In this group very
well-known NGOs were members. This group guided the development of ASHA program. Later on
this group became inactive and hence the national mentoring of the ASHA program weakened.
At state level there was on organization or division created to manage this program. One director
level officer has additional charge to look after ASHA program. There is state level Asha coordinator
and Asha training officer. The whole ASHA program runs on very small central and state level
management staff. This is a major issue. At national level NHSRC provides inputs in to the ASHA
program via Community Processes division.
107 Over the years, the role of ASHAs has been increased and their involvement in several other
programs has drastically increased. Each new program has added various responsibilities to ASHAs
as they are the real ground level functionaries of the health department and live in the village.
ASHAs were trained in a modular fashion with 7 training modules. These modules were prepared at
national level and then translated in regional languages at state level. Each state had its own training
mechanism at district and taluka level to train the ASHAs. ASHAs are paid on an incentive for work
basis. So for each activity she does she is paid fixed amount. Some state has also added a fixed
amount to ASHA as honorarium for some minimum activities. Generally, ASHA earns about INR 3,
000 to 8,000 but some ASHAs have also earned up to INR 15,000 per month.
108
Figure 19 Structure of ASHA supervision and management at state level Figure 29 Key support systems and activities for ASHA at various levels
Training for ASHAs
Senior Officials of Central NHM and NHSRC mentioned that training and capacity building of
ASHAs is adequate and the same has also improved the quality of ASHAs. Up to 2010, ASHAs
received training on five modules, in which modules 1-4 focused on program management and basic
health knowledge. The module 1 is on basics of NRHM, ASHAs tasks, health services and health
education. The module 2 focuses maternal and child health, module 3 is dealing with Family
Planning, RTI/STIs & HIV/AIDS and ARSH and module 4 is on National Health Programmes,
AYUSH & Management of Minor Ailments. The Module 5 is focused on life skills such as
leadership and community relation building. 2011 onward, module 6 and 7 were also introduced in
their training to impart additional skills such as Home Based New-born Care (HBNC) under skills
that saves lives.
The work of ASHAs is not merely mechanical, but a lot of soft skills along with the individual
aptitude and helping attitude are required which must be factored in. Apart from regular and
refresher trainings, each program under the NHM has special training for ASHAs. Initiatives like the
ASHA Sammelan model of Gujarat has acted not only as a knowledge sharing platform for them but
also can be leveraged for replication of innovative practices.
109 Table 17 Program wise training duration for ASHA
ProgramDays
Malaria2
Leprosy2
Tuberculosis2
Yoga5
Non-communicable disease5
Home Based care for Young Children5
7.2 Findings
Impact of the ASHA program on health systems
Many Central and State NHM Officials we interviewed acknowledged and appreciated the important
role of ASHA in health system strengthening. The ASHA has been most effective in the following
areas.
Community focused healthcare
State Health Department Officials are of the opinion that ASHAs are seen as a part of the community
instead of someone from the government health department. This leads to a higher level of trust,
engagement, and support from the community. Women empowerment has been fostered with the
introduction of the ASHA program. The overall social status of ASHAs among the community is
seen more favourable which motivates them to perform better. Apart from the duties of a community
health worker, it has been observed that ASHAs are involved in various activities, besides routine
MCH, Immunization, etc such as helping elderly people, spreading awareness related to general
health, domestic-violence, and child labour on a discretionary basis – for which they are not paid.
ASHAs represent a very capable human resource whose presence at the village level is harnessed to
achieve many goals encompassing healthcare and other domains. They are instrumental in collecting
primary level data from households which can be used for service delivery, program monitoring and
policy formulation, such as TECHO in Gujarat.
State Health Department officials reported that the ASHA program is “a game changer in the health
system”. They emphasized that in last few years it has increased community outreach and also
accessibility of services. ASHAs played a crucial role in securing entitlements, promoting collective
preventive action, and increasing access to services for the most marginalised sections, all of which
come under the activist role. The workload of ANMs and FHWs has reduced as it is shared by the
ASHA. With the introduction of the NHM, the former cadre of healthcare workers has been able to
110 focus on service delivery while awareness generation, community outreach, and mobilization are
done by ASHA. It was also mentioned that at many places medical officers and even ANMs get
transferred frequently but ASHA remain the same, hence provides continuity of community linkage.
In this manner they have become an asset for the health system, as they have a greater awareness
about the needs of communities, which they can communicate to the higher ups. ASHAs Encourage
community members to use a public health facility or attend Village Health and Nutrition Days. In
this manner, ASHAs also play a significant role in identifying individual and community level issues
like malnutrition and disease outbreaks. ASHAs played a crucial role in tracking cases of
malnutrition.
Most of the officials revealed that the ASHA program is functioning well as a community-health
system interface. The ASHAs also have a good assessment of the needs of their communities, and
have actually been instrumental in mobilising the population towards an increased utilisation of
public health services. ASHAs also provide important information to the higher levels. Service
delivery numbers have increased due to the ASHA program.
Interviews with ASHAs and ASHA facilitators, and focus group discussions with ASHAs revealed
that they are playing their activist role well, by bringing voice to their communities’ health concerns
and issues. However, they also pointed out several issues in the program, as listed below.
Issues in implementation of ASHA model
Too much focus on ‘incentivised tasks’
The study shows that the vast majority of ASHAs are functional irrespective of several constraints,
and contextual factors. It was also found that certain Medical Officers and ANMs had become quite
responsive because they now know that ASHAs will not take things easily like, waiting period,
higher absenteeism, shortage of medicine, or any other facilities at health centres. However, this does
not appear to be the norm, and most ASHAs serve merely as subordinates of the MO/ ANM. In many
areas they are called ASHA “worker” implying that they are paid staff of the health department and
not community volunteers or activists. Hence, they don’t raise the concerns of community people,
instead they only do the activities which are largely health system support roles and not activists
roles. It has been observed that ASHAs perform only those activities which generate more incentives
and activities that require more of an activist role and are not incentivised are abandoned by them.
Thus ASHAs have practically become like agents of health department.
In Uttar Pradesh, it was observed that some ASHAs were mobilizing patients to private health
facilities, as they were receiving more incentives compared to public health facilities. However, it
was also highlighted that the reason may not only be incentives; many times during high risk
111 pregnancy/ emergency situations, private health facilities are more reliable and there are assured
services available, while in the government facilities are dysfunctional.
The focus on incentives may be one of the reasons for the wide variation in the exact set of tasks an
ASHA carries out, the percentage of potential users of these services, and the effectiveness with
which this task is done, in terms of several outcomes such as achieving desired behaviour changes, or
recovering from an illness, or access to a service provided by the facility. Such a variation in
functionality occurs within and between districts and states and makes generalisation of any sort
difficult. This variation is largely due to the fact that though the ASHA is tasked with many functions
in theory, in practice she is supported, incentivised, and monitored on very few tasks.
Training for ASHAs and Cross Learning
Senior Officials of Central NHM and NHSRC mentioned that training and capacity building of
ASHAs is adequate and the same has also improved the quality of ASHAs. The work of ASHAs is
not merely mechanical, but a lot of soft skills along with the individual aptitude and helping attitude
are required which must be factored in. Apart from regular and refresher trainings, each program
under the NHM has special training for ASHAs. However, most of training are largely related to
incentive based programme, to make ASHAs as a social change agent, Behavioural Change
Communication training are requiring. The ASHAs role is increasing day by day and however,
capacities are not increasing.
The senior officials of SPMU and Health Department of Gujarat mentioned about innovative
initiatives-ASHA Sammelan. ASHA Resource Centre facilitates planning and organizing these
Sammelans at all three Levels-State, District and Taluka. The ASHA Sammelan has helped the state
of Gujarat in motivating ASHAs in fulfilling their role and also bringing various issues at higher
level. Through this platform, ASHAs are sharing the experiences and cross learning is essentially
required to effectively build the reputation and to generate the feeling of belongingness.
This platform has also provided opportunity to District/Taluka authorities to interact with ASHAs
and learn the issues they face at field level and suggested possible solutions as well. The Sammelans
can be utilized to appraise their work and appreciate/award the well performers.
Work overload
Over the years, ASHAs have become the major stakeholders for implementing multiple health
interventions, including data entry and reporting. Although, ASHAs are not support to do data entry,
however, ANM and other senior functionaries passing their work on ASHAs. In Gujarat, ASHAs are
formally involved in data collection under web based TECHO program. The role and workload of
the ASHA has changed significantly over time and in different parts of India. The expectations of
112 healthcare providers have also increased from these workers. In states like UP, Bihar, Rajasthan, and
MP where the birth rate is high, MCH and FP take up the bulk of the ASHA’s responsibilities. In
these areas, NCD and infectious disease control tend to be neglected. In our interaction with them
many complained of too much workload. They said, “Male health workers only work for malaria;
they don’t get involved in any other program. Whenever other programs come, they divert it to
ASHAs”.
Lack of role clarity
There is role overlap amongst ASHAs, Anganwadis and ANMs – the so called “AAA”. Some
ASHAs claimed that they collect all the data from the field, and FHWs carry out data entry and take
the claim for data collection as well. There is role overlap among FHW, ANM ASHAs, and MHWs,
which leads to ambiguity of responsibility. Thus, ASHA being on the lowest rung tends to become
overburdened as ANMs pass on many of the non-technical roles of community contact and
mobilization to ASHAs. In order to have a clearly defined role, AAA+ training was proposed but it
has not been implemented widely. There is a need to redefine the role of ASHA and similarly role of
ANM, AWW and Male worker and now newly appointed Community Health Officers (CHO).
The support provided by family members of ASHA in terms of sharing family responsibilities, and
thereby enabling the ASHA to perform her job outside home, acts as a catalyst for fulfilling their job
demands, and enriching their work lives. Moreover, dual reporting authorities, the ASHA facilitator
and the ANM, leads to conflicting expectations and other issues.
Recruitment related issues
Political interference in ASHA appointments, and the removal of non-performing ASHAs are a big
issue. Currently the MO, ANM, or the CHO don’t have any say in the ASHA selection process.
Although the minimum qualification for ASHA workers is class 8, literacy and numeracy were found
to be inadequate. Among educated urban populations, such as in Punjab and Kerala, a secondary
school graduate ASHA is not seen as an acceptable health care provider. Such variations exist even
within states, between districts, especially while comparing tribal and urban areas.
Recruitment is done through the Gram Sabha and sometimes, politically backed candidates are
appointed to the ASHA position without regard to their qualifications, community connect, or
experience. ASHAs in difficult geographies are required to exert physical effort because of the
terrain and distribution of the population in villages. Therefore, physical fitness becomes an
important parameter in their selection.
Compensation
113 Innovative ways of processing payments have solved one of the major issues faced by ASHAs-
delays in payment. In Rajasthan, for example, the ASHA receives incentives from 2 departments,
INR. 2, 700 from ICDS as Sahyogini plus incentives from the health department as well. Rajasthan
has initiated online payment of ASHAs through ASHA soft-online payment system. This change has
increased the motivation among ASHAs, as they receive their payment on time every month.
However, most ASHAs also expressed dissatisfaction with their remuneration and the contractual
nature of their employment. Demands for a fixed salary by ASHAs were also noted, especially as
they tend to compare themselves with the Anganwadi workers of the ICDS who are fixed salaried
employees at the village level. This dissatisfaction among ASHAs has led to significant attrition
(Scott, George and Ved, 2019) Our study also revealed issues with ASHAs’ motivation and
enthusiasm to attend their prescribed training sessions.
7.3 Recommendations
7.3.1 ASHA Recruitment, role and future direction
ASHA is very useful system and it must be continued in the present form. There could be minor
changes to the ASHA system to address some of the issues raised above.
Entry qualification criteria into the ASHA program should be standardised – but there should be
some flexibility at local level. The Medical Officer, ANM, or CHO should be given a say in ASHA
appointment in rural areas in order to control the influence of political actors.
In urban centres, the entry qualifications for ASHAs could be increased to 10
th
or 12
th
Passed with
science subjects preferably, especially in non-slum areas. The role of the ASHA could also be
restructured for these areas enhance the acceptance of this cadre of community health workers in the
educated urban middle class population.
While ensuring that the ASHA is a local community resident, other recruitment criteria can be made
flexible across regions considering their socio-geographical complexity and the availability of
suitable candidates. In the long run it is suggested to replace the ASHA with a community health
nurse who would be a high school graduate with 6-12 months of training in community health and
outreach work. In the long run country should plan for one community health nurse per village. The
current ASHA can also gradually be trained to become rural community health nurse and then should
be employed full time at say INR 15,000 per month. The salary burden of these community health
nurses could be divided between centre and states.
7.3.2 Compensation and recognition
114 The fixed honorarium amount should not be increased. As the ASHA model is performance-based
and incentive driven, there should be a balance between the two components, fixed and variable.
This will enhance the motivation and performance of ASHAs. A mixed incentive structure with
checks for complacency will serve a dual purpose—the fixed component ensuring their financial
safety thereby preventing attrition, and the variable component serving to motivate and consequently
maintain the quality of their work.
Performance awards like "ASHA of the month” could be put in place at the block level to introduce a
competitive spirit among these workers. A provision could be made for an increase in the incentive
amount for ASHAs with consistent performance over a period of time, but reasonable caps should be
in place.
7.3.3 Training and knowledge enhancement
While there are standardized training modules for ASHAs, the same may be re-examined for
contemporary challenges like NCDs, and skills related to behavioural aspects of the community.
Further, cross learning and knowledge sharing amongst ASHAs can be promoted by adopting
structural interventions (Such as ASHA Sammelans in Gujarat)
The ASHA Sammelan model of Gujarat could be adopted by other states to facilitate knowledge
sharing among ASHAs of various regions within a state. This would serve as a confidence building
exercise for all ASHAs, and help document best practices at the field level, which could then be
taken up the chain to policymakers. Other replicable features from Gujarat include the ASHA
Resource Centre can plan and organises these Sammelans at the state, district and taluka levels, and a
State ASHA Mentoring Group.
Further, ASHAs could benefit from specialised training in managing the emotional needs of
individuals and communities, and conveying health information in an accurate yet understandable
manner. Integrating good local health practices, and AYUSH remedies into the training curriculum
would increase the ASHA’s community connect, and aid her in providing timely and inexpensive
treatments for common ailments. This would also increase communities’ overall acceptance of the
public healthcare system. Trainer shortfalls can be addressed by either outsourcing the training or
building capacity for MOs to train ASHAs.
7.3.4 Monitoring
ASHAs should be monitored regularly by the ANM or the CHO, and mechanisms should be put in
place to remove non-performing or inactive workers within 3 months. The activities for which
ASHA are incentivised should also be revisited, and the focus should shift in accordance with the
changes in the epidemiological profile of the community they serve. The NRHM’s focus on
115 reproductive and child health has limited the ASHA’s scope of work with increasing focus on select
services. The activist role of this cadre of workers needs to be highlighted more going forward,
especially health promotion activities.
There should be a dedicated full-fledged division for managing ASHA at the Government of India
level. This would aid in the solving of all ASHA related issues and monitoring of performance of
ASHAs. This would lead to more efficiency and accountability in the system. The National ASHA
mentoring group should conduct periodic evaluations and performance measurement uniformly
across all states. There should be a well-staffed division for ASHA Management at state level to
recruit, train and monitor ASHAs.
7.3.5 Career Progression
Open schooling through NIOS should be facilitated to enable ASHAs to pursue university level
education. This is a long term recommendation that will help increase ASHA confidence, and
performance, in the country.
Mechanisms should be put in place to allow ASHAs to progress to ASHA facilitators and ASHA
coordinators as well as if well-educated then to ANM and Nursing. Specialisations like mental
health, family planning, yoga etc. could be offered to ASHAs with aptitude and measurable good
performance in these particular areas. Further, district wise reservations could be made for high
performing ASHAs for admission into ANM/GNM and nursing degree programs where
qualifications are appropriate.
For ASHAs who have served for a long period and are unable to carry out their duties due to age, a
dignified exit or “golden handshake” mechanism with some lump sum payment could be put in place
with due performance monitoring.
116 8 Process Implementation Plans and Budget
8.1 Background
India is the second most populous country in the world characterized by regional imbalances like a
large north–south divide in health and development. The focus on community’s needs and service
delivery requires need based planning rather than top down approach. Hence, the National
Population Policy, 2000 focused on ‘Decentralised Planning and Program Implementation’. The
Government of India has adopted decentralization/devolution as a vehicle for promoting greater
equity and supporting people-centric, responsive health systems. The 73
rd
Constitutional
Amendment Act, 1992, made health, family welfare, and education a responsibility of village
panchayats. The PRIs are an important means of furthering decentralized planning and program
implementation.
One of the main approaches of NHM is to reach communities, which will entail transfer of funds,
functions, and functionaries to Panchayati Raj Institutions (PRIs) and also greater engagement of
Rogi Kalyan Samiti (RKS). For this bottom up approach of planning the health system, the National
Rural Health Mission (NRHM) proposed the decentralisation of health planning so that the state
health plan represents the needs and priorities of respective blocks and districts in the state.
Program Implementation Plans (PIPs), the DNA of decentralized planning, are the most crucial
documents in NHM through which the States/UTs plan, prioritize, and propose strategies and
activities to address the challenges in public health. Based on the plan and the budget proposed, the
appraisals and discussions are carried out which culminate in a National Program Coordination
Committee (NPCC) meeting and approvals are accorded through the Record of Proceedings (RoP)
(Gupta et al., 2019). The NPCC then proposes the release of the budget. Figure 20 below provides
the allocation of budget under NHM for last 7 years. This show some periods of stagnation in the
budget and some periods of increase.
117 2 0 1 2 -1 32 0 1 3 -1 42 0 1 4 -1 52 0 1 5 -1 62 0 1 6 -1 72 0 1 7 -1 82 0 1 8 -1 9
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Plan Wise Allocation & Release Under NHM
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Figure 21 Fund Allocation under National Health Mission
Data source: India Expenditure Budget, Volume 2, Ministry of Health and Family Welfare; Union
Budget, Government of India
Process of Decentralised Planning
As per various NHM documents, the following is the process of the PIP making. The planning is
divided into two phases, (i) Preparation of program implementation plan (PIP) and, (ii) Re-planning
after approval of the PIP. The consultative process is conceptualized in a way that grassroots level
118 health workers – ANMs, ASHAs, MPWs along with VHSNC develop the village plan and the sub-
centre plan. This accounts for the need of the community in the area covered by that particular sub-
centre. These plans are shared with the concerned PHC for incorporating the plan into PHC level
plan documentation.
Figure 22 Stages of development of the Program Implementation Plan
As shown in the figure, the process is taken from the village level to the higher level. The regional
team plays a dual role in the process of PIP planning. First, they review and compile the district and
corporation plans. Secondly, they also prepare the regional health plan reflecting planning of CHCs,
SDHs, DHs, and Medical colleges in the region. The team at the regional level also helps in pre-
screening the action plans, improvising the plans and final submission to the state team. The state
level planning unit reviews the regional, district and corporation plans and based on them prepares
the state level PIP and action plan. Action plans from all levels are essentially inter-linked and
therefore, inputs from respective state divisions become essential for successful program
implementation. In 2017-18, three health systems components, namely, human resources, service
delivery, drugs, and IEC were aggregated and approved at one place. Taking the same approach
further, in 2018-19, all existing PIP budget lines of the preceding year (FY 2017-18) have been
broadly categorized under the following 18 heads to bring in more flexibility in the planning process
and to provide a summarized view of the State PIP for the program planners, program implementers,
decision makers and other stakeholders.
119
Village Level Plan
SC level plan
PHC level plan
Taluka level plan
District level plan
Regional level plan
State level plan & PIP submited to Centre Table 18 Budget Heads of the PIP
1 Service Delivery – Facility based
2 Service Delivery – Community based
3 Community Interventions
4 Untied Funds
5 Infrastructure
6 Procurement
7 Referral transport
8 Service Delivery – Human Resource
9 Training & Capacity Building
10 Review, Research, Surveillance & Surveys
11 IEC/ BCC
12 Printing
13 Quality Assurance
14 Drug Warehousing & Logistics
15 PPP
16 Program Management
17 IT initiatives for strengthening Service Delivery
18 Innovations
8.2 Findings
Capacity issues, especially at lower levels
Government health facilities at the level of blocks and below can become more responsive to
population needs if funds are devolved to the Panchayati Raj Institutions (Village Council or its
equivalent in the Scheduled Areas), and these institutions made responsible for improving public
health outcomes in their area. This was done in Kerala some years ago and it had shown good results.
However, a major issue that came to the light in most of the states is that proper PIP planning and
budgeting process really starts only at the district level and not at the taluka or village level. Levels
below that do send in their action plans based on the incremental target derived from last year’s
achievement. The fact that the lower level institutions were not effective in planning and budgeting,
itself defeats the purpose of PIP which was a tool for decentralized decision making. The officials
mentioned an urgent need to formalise the roles and authority of Local Self-Government bodies in
securing convergence so that these bodies become stakeholders for sustainable improvements in
health standards (Avan et al., 2016).
Incremental budgeting
The preparation of the annual budget for NHM requirement is intertwined with the PIP preparation
process. As unit costs are given to lower level facilities, Sub Centers and PHCs may not play any
active role in budgeting. Based on the target they propose, the total amount for the respective facility
is derived. However, while district level PIP is prepared, based on the priority some of the facility
120 specific items may or may not get reflected in the district PIP. This happens due to the incremental
planning from the last year. This may directly hamper the funds proposed under certain heads like
“Innovation”, “IT support for strengthened service delivery”. This is because these heads do not
directly get reflected in the performance criteria that are based on outcome variables like maternal
and child health indicators or NCD related indicators. Overall it seems that the PIP budgeting is just
incremental over last year without much new strategies or new thinking from district or PHC level. It
is largely an exercise of filling up the table provided from higher levels. The senior officials of
MoHFW and NHM mentioned that in order to incentivise better performance by States, the Mission
Steering Group of NHM had decided that 10% of the total allocation under flexi pools would be kept
apart at the national level as an incentive pool which was subsequently increased to 20% for 2018-
19. It is a step towards promoting performance based disbursement of funds, which the Expenditure
Management Commission too had advocated. This sent a clear message to all the States that good
performance would be monitored, acknowledged, and rewarded. This meant that while 80% of the
resource envelope earmarked for the State would be assuredly available, 20% of the resource
envelope would depend on State’s performance on agreed conditions.
Issues related to flexibility
The common theme, that came out of discussions with different levels of officials involved in the
PIP and budgeting and also those who supervise the process, is flexibility brought by NHM in health
planning. NHM brings funds to the grassroots facility level and allows facilities to decide how the
money should be spent. This financial power is limited but it is better than having nothing in hand
when each and every facility may have different needs and priorities based on the need of the
community being served.
State level officials revealed that as of now, from the village level SC and PHC facilities, an action
plan is proposed. They may identify the various activities to be undertaken and the unit of resources
required for achieving the proposed target for each line item in the Annexures of action plan. There
are Annexures for each of the 18 heads of NHM PIP. However, the unit resource cost is decided by
the higher levels- state level. So, in that sense, the facility may propose to undertake activities that
may address community specific needs but do not have power to propose financial requirements for
the same of modify the unit costs decided by the state level. However, under NHM there is provision
of untied funds that may devolve this financial power to the facility level decision maker to a certain
extent. This untied fund is an extra fund available to facilities over and above approved budget
through PIP. But untied funds are very small proportion of the total budget of the facility. However,
the flexibility lies in the planning and budgeting part and not in the implementation part once the
plan (PIP) is approved for the year. So once the PIP is approved no changes are possible in it during
121 the year. State can send supplementary PIP, but in that also no new line item can be added if it was
not originally budgeted.
Highly cumbersome and complex process
The SPMU and District Level Officials from all the states told that the PIP process has become
cumbersome due to micro-budgeting of 1800 line-items under 18 different heads. The line-item
budgeting and the minute level at which the planning and budgeting has to be done and the approval
process is cumbersome. This affects the efficiency of the PIP process itself. Budget lines increased
from very few initially in 2006 to 600, then to 1800. This was perhaps due to scams related to NHM
funds in UP and other states. Majority of the officials were of the opinion that 1800 line-items are
too many and requires a relook to be reduced drastically in number. However, some officials opined
that this is required in public services to avoid scams like one happened in the state of Uttar Pradesh.
This view of having detailed line item budgeting also advocated due to no monitoring system at the
level of facilities below the block level. It allows flexibility in planning but rigidity in expending post
approval. The tedious process affected the flexibility and utilization adversely, as explained by some
officials.
Flexibility in re-appropriation of funds across various heads of approved budget has very limited
scope. There is limited flexibility to re-appropriate amongst different 18 heads listed above. Some of
the officials suggested to cut down on the number of heads from 18 to 5 by clubbing some of the
heads together and bringing more flexibility. The line-item budgeting process also makes it a
cumbersome process to get approvals for the re-appropriation even within the same head. Moreover,
if more flexibility is provided then a system of monitoring to keep a check on the usage of the
flexibility and funds has to be in place.
Underutilization
The state government officials explained that there was significant underutilization of funds released
under NHM, though the scenario varied across states. There were several reasons for
underutilization.
It may stem from the inflationary tendency while planning and budgeting based on last year's
achievements. At times there is a tendency to over budget due to incremental targets. Additionally,
the underutilization may also be attributed to the huge fund releases in the last quarter of the
financial year. This may not leave enough time for implementing planned actions for what the funds
are budgeted.
The SPMU and NHM Finance Department Senior Officials stressed that the issue of micro-
budgeting of around 1800 line-items has also resulted in some underutilization of funds as well. This
122 is somewhat taken care of with minimal flexibility allowed within a head but due process of approval
of re-appropriation is cumbersome (Das Gupta et al., 2009). The system of not allowing funds to be
used across pools/heads sometimes limits the expenditure made by the facility as they may not see
any extra utility by spending for the activity for the specific activity and limited scope of transfer of
funds for other desired activities.
Routing of funds through treasury leading to delays
The State health department and SPMU officials revealed that initially under NHM, the funds were
transferred directly to SHS from central government. However, this route was changed in 2014 and
now the funds from centre come to state treasury and then devolved to SHS for better monitoring of
the fund utilization. However, this may be a cause of delay in fund transfer. State treasuries have
been asked to transfer these funds to SHS within 15 days of receipt of funds from the centre, but
same is not happening. In the state of Rajasthan, the average time for receiving fund from treasury to
the SHS is 70-80 days, as reported by NHM finance officials. Sometimes, state may not transfer their
share to SHS in stipulated time, or do it partially. On many occasions, funds are transferred to SHS
accounts without any intimation about the budget items for which the funds can be utilised. In this
case, even though SHS may have received funds, it may not get devolved to lower levels as authority
may not know the purpose for which funds can be transferred to facilities. For instance, in Uttar
Pradesh, in the year 2017-18 and 2018-19, on average it took 2-3 months for fund to reach from state
treasury to SHS.
NHM Fund Flow in Uttar Pradesh
On average, in, time taken to release funds from state treasury to SHS was about 2-3 months.
In both the years, the SHS received almost all funds from the state treasury in the 4th quarter.
More than 50 per cent of NHM expenditure was incurred in the last quarter in 2017-18.
In 2017-18, more than 85 per cent of funds received were credited in the last 2 months of the
FY (February and March). Similarly, in 2018-19, around a quarter of the funds received by
SHS was credited in the last 2 months (February and March)
In both 2017-18 and 2018-19, all funds released to state treasury by GoI could not be credited
to SHS bank account within the financial year (FY). In 2018-19, around a quarter of the funds
released to state treasury by GoI could not be released to SHS within the FY. In 2017-18, this
was about 14 per cent.
In 2018-19, nearly 50 per cent of the state share due was not released to SHS.
123 Table 19 Number of days taken to credit Central Share in SHS account of Uttar Pradesh
Between issue of SO by GoI and receipt of funds in
the State treasury
Between receipt of funds in State
treasury and credit to SHS Account
# days
Amount
credited
(Rs.
Crore)
Distribution
(%)
Average
days
Amount
credited
(Rs. Crore)
Distribution
(per cent)
Average
days

2017-18
0-7 810.62 45.90 4 156.52 - 1
8-15 - - - - - -
16-30 955.58 54.10 20 157.05 8.89 22
31-90 - - - 297.38 16.84 83
90-180 - - - 1155.25 65.41 113
180+ - - - - - -
Total 1766.20 100 - 1766.20 100 -
2018-19
0-7 1624.98 100 1 - - -
8-15 0.01 0 12 - - -
16-30 - - - - - -
31-90 - - - 1319.98 81.23 65
90-180 - - - 305.01 18.77 113
180+ - - - - - -
Total 1624.99 100 - 1624.99 100 -
Source: The data on the date of receipt of funds in the State treasury is sourced from Finance Department, Uttar Pradesh.
Data on the date of credit of funds to SHS account and date of SO are collected from SHS, Uttar Pradesh. The dates of
SO were also cross-checked with the list of SO provided by the Ministry of Health and Family Welfare.
Note: *In 2017-18, Rs. 286.15 Crore received in the State treasury could not be credited to the bank account of SHS by
the end of the financial year. It was adjusted in the next financial year. In 2018-19, the amount was about Rs. 574.55
Crore.
Courtesy: Dr. Mita Chaudhry, NIPFP.
8.3 Recommendations
8.3.1 Incremental budgeting to performance based long-term budgeting
Line item budgets were (and in a number of countries still are) associated with an "input-oriented"
budget preparation with detailed ex-ante controls and/or rigid appropriation rules. However, NHM
and health systems across India should be governed towards realization of health indicators in
alignment with the SDGs. So rather than opting for input-based budgeting, we need to move towards
performance-based budgeting. The current system of PIP/budgeting takes care of inputs proposed
vis-à-vis the inputs last year. Whereas, performance budgeting stems from the objective and purpose
of the health system and vision of achieving certain benchmark indicators. It is in alignment with
124 what it ought to be instead of what it was last year. It is a future-looking method of budgeting. All
programs, initiatives and inputs are planned according to what we intend to achieve in the long run.
The core in this process is outcomes and not the inputs. In a performance based budgeting process,
the focus is on target parameters for example reducing the maternal mortality to 50 per 1000 live
births: what all initiatives/activities/ resources will be required and correspondingly how the
expenditure needs to be planned.
8.3.2 Longer term PIPs
PIP action plans need to be forward looking for five or at least three years. Every year, 20 % of the
plan can be modified and approved separately, whereas 80% would remain constant for a period of 3
years and would not require annual re-approvals. This would provide a longer tenure to contractual
staff, thereby alleviating their job security woes. The same would enhance the motivation and
commitment of the staff which is a challenge as described in the section below. It would also help
reduce a lot of planning and paper work which is currently carried out on a yearly basis. Further, it
will also decrease the drastic changes that are often seen in the PIP when senior functionaries
change. Many activities such as construction, training, staffing, system development, take long time
to complete so assured 3-5 year plans will help take up such activities. The vision of the health
system may be defined by top authorities at central level in consonance with all related departments
involved in SDG achievements, as described above. This vision may be devolved and communicated
to the states and then grassroots level. Once this is done, decentralised planning under PIP may start
at village level and gets integrated into higher-level action plans at state and district levels. A 3-5-
year PIP will help in maintaining continuity of such grassroots level planning.
8.3.3 Reducing the number of budget heads
Line item budgets have many advantages like easy to make, easy to monitor and analyse. It is also
efficient in maintaining a track of expenses, even the minute ones as health PIP/Budget has
numerous line-items. However, it brings the culture of non-fluid and short-term planning. It does not
allow any deviation from the approved budget. The clubbing of heads as suggested above may work
to bring some flexibility, albeit limited only. Reduction in the number of heads in PIP/Budgeting is
strongly recommended. This is to bring more flexibility. As of now the re-appropriation is not
allowed across the major heads. However, if the number of heads is reduced the flexibility may
increase. The budget heads related to service delivery may be clubbed and sub-heads of ICT, HR and
innovation may be continued. In a nutshell, from 18 heads, the number of heads should be brought
down to 5 or 6. For instance, under JSSK, there are 13 budget lines which can be merged into one.
Under maternal health equipment, there are 11 budget lines that can be merged. By merging these
line-items, flexibility under a sub-head may increase. This provides the opportunity for ground-level
125 authorities to take decisions as required at their own level. The idea is that beneficiaries should not
suffer from service denial, especially when funds are available, but under other budget heads, and
unutilised. The road map for reduction of 1800 line items could be to bring it down to 1000 in the
first year and in 2-3 years make it about 500 under 5-6 major heads. The fraud and deviance
detections should be done through financial audit and control rather than through budgeting.
8.3.4 Software based planning
PIP/ Budgeting should become online where most of the aggregation and duplication work may be
done by backend software. Program Management Unit may invest their energy in more productive
work. Even monitoring the utilisation of funds post-approval may also be possible real-time. Many
new data variables may be captured that may enhance the efficiency of the process and system.
8.3.5 Restructuring of PIP and Budget to enhance utilization
This is an innovative suggestion. The budget should be split into two main components: first regular
budget of 100% say part A and additional budget of about 30% as part B. Both budgets should be
approved via the regular NHM process. In December total expenditure should be reviewed to see if
Part A will be spent to 100% by March end. If it is not likely then during January-March period Part
B can be activated which should have such items that can be quickly implemented. So that finally
with A and B put together 100% can be spent by March end. Part B could be put to use towards the
procurement of long term assets, large medical equipment, vehicles, and medical supplies including
drugs, which can be used in the next year and year after year.
8.3.6 Allowing space for innovation
NHM allows to propose activities under “Innovation” head but largely this is limited to address day-
to-day operational issues like extra transportation required by patients – this is not innovations. This
fund is meant to be invested in some community needs-based innovation like new forms of outreach
activities, child health, or handling socioeconomic or behavioural issues that directly impact health.
For this health department should involve NGOs, universities and community based organizations.
Especially in difficult areas such as forests, tribal area, deserts etc government health system is not
able to reach effectively. There the funds can be given to NGOs and CBOs to provide basic health
care services.
8.3.7 Exigency funds
There may be some additional fund available at the district or block (taluka) level, or even at the
directorate level to be used in case of exigencies where a facility or group of facilities may want
extra funds for some activities relevant to community needs, and they have utilised their 100% of
budgeted funds. It would be better if a particular amount is sanctioned/entered into PIP budgeting
that allows for this fund at State level with Health Directorate to be used when needed. For example,
126 for some sudden epidemic like COVID-19, or some emergency like floods or cyclone etc. such fund
may be very useful.
8.3.8 Rethinking the distribution of untied funds
It was proposed that the quantity of untied funds should be increased. The overall value of untied
funds needs to be increased in accordance with the number of programs, activities, and the rapidly
growing numbers of beneficiaries. Funding sources and utilisation of high performing PHCs should
be reviewed and the excess funds should be diverted to those centres that are actually in need, though
they might be poor performing facilities and specifically for newly established facilities. It was put
forward that a formula could be worked out to assess fund utilisation and facility performance, in
addition to placing caps on the total amount a single facility could receive in a given time period.
This could then streamline future disbursement to maximise the effectiveness of untied funds.
Moreover, the development of health facilities and the technical and decision making capacities of
their respective RKSs should proceed hand in hand. Different norms for fund disbursement to
UPHCs should be put in place. At the very least, the fund value should be equivalent to that of rural
PHCs. Changing the signatory for untied funds at the village level from the Sarpanch/Pradhan to the
MO of the PHC would ensure their allocation to SC/HWC in need and proper utilisation. Lastly, 5%-
10% of the untied funds should be earmarked for emergency management, innovations, and health
system strengthening.
8.3.9 Funds for external monitoring and evaluation
One to three percent of PIP funds should be earmarked for external monitoring and evaluation. This
can be done by local universities, national institutes, NGOs or an expert team constituted by the govt.
Special focused studies and surveys can also be commissioned by the state to assess the progress.
These funds can be also used by state to pay to SRS system to double or triple the SRS sample in the
state so that maternal mortality, sex ratio, child mortality etc estimates can be obtained with a larger
sample and more detailed analysis.
127 9 Key issues and recommendations
9.1 Governance and structural aspects at central and state levels
9.1.1 Issues
●Lack of coordination between the directorate and NHM
(Exception few states such as TN, Odisha and Gujarat)
●Some of the directorates, indeed, weakened after implementation of NHM
Capacities of directorates in different states is highly variable
No HR planning for future even for the top leadership roles
High turnover at the top due to the structural legacies including pension determination
Lack of proper career planning and related interventions
●Uneven adherence to the proposed frameworks under the blueprint of NHM
9.1.2 Recommendations
Coordination and integration mechanisms between NHM and Directorate of Health Services
NHM implementation should aim towards strengthening the public health care delivery system
including through administrative reforms. The implementation plan should incorporate strategies,
guidelines, and frameworks for integration.
Role clarity
There should be a defined role of both the MD-NHM and directorate officials in the implementation
of various programs in the state. The technical and administrative capabilities of the two stakeholders
can be enhanced with clearly documented roles of respective representatives with no role ambiguity.
Structures for coordination at central and state levels
MGS structure is useful and should be continued. Appropriate representation of DGHS in MSG and
other decision making bodies is essential and the same may be initiated through structural and
process interventions such as adequate representations in committees, MSG also can be expanded to
include adequate representation of “Management and social science expertise” from relevant
academic institutions.
State Health Mission should be structured as a multi-sectoral entity and the meetings should be
regularized and should follow proper planned processes. The SHM and SHS should have adequate
representation of directorate officials. The SPMU should also have representation through deputation
of appropriate regular employees of directorate. Further, adequate representation of experts from
academic institutes and public health experts should be ensured in SHM and SHS.
128 Design of cooperative processes
Under Central NHM guidelines various measures should be taken for enhancing coordination and
integration. States should have strategies to build joint ownership for directorate and NHM with
proactive engagement and involvement of the directorate officials in planning and execution/review
as per official protocols. The NHM should conduct joint reviews with the directorate and some
programs should be monitored by the latter. The joint review can be done every six months. The
strengthening of directorate is also required for a long-term sustainable system of proper program
planning and effective implementation. This is discussed further in the section below.
Capacity Building of Directorate of Health Services
HR Audit of the directorates
Directorates need to plan for adequate technical, financial, human resources and infrastructure. The
directorates should initiate a detailed HR audit in terms of manpower requirement for the next three
to four years, leadership pipeline and career planning mechanisms. The HR audit document then can
serve as a guide for designing systems and processes; and also plan the use of funds and mechanisms
enabled in NHM. These audits need to be carried out by a third party, preferably an academic
institute.
Career planning and capacity building
Senior officials of directorate of health services should be given periodic well-planned exposure to
short course training on various aspects of public health management- epidemiology, health care
financing, hospital management, community process, human resource management, quality of care,
HMIS, and communication etc. For strengthening of directorate a well-designed HR strategy is
required. Well trained, technically competent consultants and officials of the SHS may be deputed in
the directorate and regular cadre officials of the directorate can be placed in the SPMU. This strategy
will facilitate instilling work-culture in directorates through development of skilled health workforce
thereby gradually building the ownership of NHM (Rajasthan has appointed). Ideally capable
directorate officials, who are the technical experts should be owning and driving the programs while
NHM will provide administrative and financial support. Further, senior officials at the directorate
should be appointed for at least 3 years. Promotion criteria need to be made more transparent, and a
major restructuring of the directorate is required. At certain level mid-career positions in the
directorate through lateral entry can be considered (faculty from medical colleges, public health
institutes, and management institutes). Even short term additional senior advisor positions can be
created for specialized roles such as logistics and procurement and other program specific roles such
as immunization, MCH, health communications, health systems, vaccination etc. Even we can
129 envisage some experts from International organisations, international institutes, and experts from
different countries can be deputed in the directorate.
9.2 Human Resource for Health
9.2.1 Issues
●Limited focus on long term planning for HRH
●Uneven distribution of manpower across levels and programs resulting in duplication
●Motivational issues amongst contractual staff
○Significant variation in salary of contractual versus regular staff
○Substantial difference in work allocation with most of the work being done by
contractual staff
○Prestige issues associated with contractual staff
●Processes defined in the blueprint not being followed (Regularization)
●Lack of uniform HR policies across states
9.2.2 Recommendations
Online information system for HRH and HMIS data
An integrated HRIS and HMIS system need to be designed and implemented to provide data on (lack
of) availability of different cadres of health workers. HIMS data entry and reporting can be made
decentralized by making it attractive to the peripheral health workers and block health officers by
creating user-friendly dashboard.
Uniform policies across states such as for recruitment, regularization
Health professionals need to be hired only from colleges/ institutes with high repute, in order to
maintain quality. (For example, Tamil Nadu hires only from government medical colleges). The
NHSRC can help in developing standard policies for a uniform system across the country. States
should also be mandated to convert a certain percentage of contractual staff in every position to
permanent, every year.
Rationalization of compensation
Systemic rationalization in compensation needs to be implemented to curb the huge gap between
contractual and regular employees. This should come from NHM guidelines so as to ensure that it is
uniformly implemented, and the central NHM can be in a position to exert pressure on states. For
example, nurses under NHM contracts can be made regular employees when vacancies arise in the
system. This practice allows for a suitable probation period, at the same time nurses do not feel that
they are discriminated against in terms of pay. The process can be made fair for example by
providing additional weightage to these employees while being considered for regular employment.
130 HR mapping and Audit, training and performance monitoring
A robust HR mapping, rationalization, HR audit exercise should be done by third party or
independent academic institute/ organization to ensure that the number of human resources allotted
to a particular program, activity, or health facility is optimal.
Collaborating with academia for enhancing quality of HRH
Respective state councils should be strengthened and given the stewardship of monitoring the quality
of training for various technical positions. Strengthening should consist of an assessment of the
existing knowledge capacities of the faculty at these councils, and extensive training of trainer
programs to ensure high quality training down the pipeline
Need based training programs with special focus on soft skills
Apart from technical and skill-based training, behavioural training should be designed for managerial
and support staff. Orientation training should be strengthened where attrition is high, at the DPC
level for instance. For ANMs posted to rural sub-centres, regular refresher training should be
conducted so as to provide a periodic assessment and update of their skills. The effectiveness of
these training programs need to be assessed and monitored with course corrections suggested as and
when required
Strategies should also be put in place to monitor the skills and knowledge of the health workforce
from time to time. This should be accompanied by gap assessment exercises and customised
refresher training for different cadres of workers, including techno-managerial staff. Efforts should
also be made to bring in international best practices, and include these in the training of personnel.
Objective performance appraisal mechanism
Performance appraisal mechanisms should be objectively linked to job-specific indicators and the
appraisal process should be linked with contract renewal and the award of performance-based
incentives. There should be a band system in compensation to accommodate candidates with all
levels of experience.
Building a cadre of Public Health
While the directorates have technical knowhow and the SPMUs have administrative competencies,
there is a need for developing and nurturing public health cadre. For example, it is done in Tamil
Nadu and is being planned in Odisha. The public health cadre should be designed and developed as a
multi-disciplinary and multilevel including doctors, social scientists, nursing, management, statistics
etc. The cadre can be designed similar to the central and state administrative services. The services
should have adequate power, prestige and processes, the establishment of a separate state level
131 Directorate of Public Health and Preventive Medicine. This organisation, in addition to having a
dedicated budget of its own, and significant power and operational authority, is staffed by a techno-
managerial cadre trained and experienced specifically in public health.
9.3 Preparing a strategic plan for healthcare delivery systems in the states
9.3.1 Issues
●Lack of roadmaps for planning and monitoring
●Lack of awareness about the health goals and related HR requirements
●Issues in work allocation
○Specialists put in administrative role
○Technical staff not trained in administrative and managerial capabilities
●Motivational concerns amongst the frontline staff (Contractual staff in NHM)
9.3.2 Recommendations
Preparing a strategic plan
The states need to prepare a strategic plan (Three years at least) based on the current public health
circumstances, the health burden, infrastructure and human resources aspects. The plan can
incorporate the current socio-economic and geographical circumstances of the state. This document
can be then used in designing structures, systems and processes for implementation. The strategic
health plan needs to be in tune with state development plan and SDGs. The health plan should also
be in sync with other similar departments with overlapping goals such as women and child
development, social justice etc. The same plan can be used for budgeting, implementation,
monitoring and evaluation, and course corrections if required.
Systematic HR planning
States should have a dedicated division with adequate staff for HR planning, especially forecasting
requirements for different types and specialisations among healthcare workers, and considering the
changing disease profile and dynamics of the population. The cell should not limit itself to public
systems only but also monitor HR available in private sector so that a more holistic view can be
undertaken
It is suggested that nurses and doctors can be distributed across the country from high supply regions
to high demand regions without the need of opening institutes all over India. Provisions should also
be made to ease international hires in areas where the demand for health workforce is very high. On
132 the other hand, available human resources, especially laboratory technicians and physicians should
be utilised to their full potential without creating duplicate positions across vertical programs.
HR Rationalization
The above detailed document can pave the way for overall HR rationalisation. To remove excess
manpower such as additional program managers, data entry operators, and financial assistants.
Moreover, in areas where healthcare professionals are already low in number, physicians should be
removed from administrative positions and posted to facilities for clinical work.
Creation of specialist cadre and role rationalization
State may consider creating a specialist cadre to enhance the recruitment possibilities. There can be a
separate promotion and transfer system for the specialists for example providing a place of choice
after a posting of three years in a remote/ difficult area.
9.4 Technological challenges in HMIS
9.4.1 Issues
●Use of multiple parallel systems
○Duplication of work- Manual and IT
○Lack of Data availability
○Poor interoperability
●Challenges of data based decision making
○Authenticity of data collected
○Data analysis capabilities and communicated
9.4.2 Recommendations
Single standardized system for data collection and reporting
A unified standardized system for data reporting should be created for all processes. The system
design should ensure ease of use as these systems will be used by the frontline workers. The HMIS
design should value the actual situation rather than the desired goals. The same requires a cultural
change and a top down approach. Private sector must be mandated to provide at least minimal data
on a periodic basis on priority health care conditions and outcomes. The state health report should
include private sector data also.
Ensuring quality of data
Data triangulation and verification mechanisms should be designed and implemented to ensure the
quality of data. AHS, NFHS and DLHS could be considered as third party source of periodic
information for assessing the impact of the health interventions on the community. Based on these
133 and other data, a District Health Profile of each district can be prepared. These data could be used as
an input for policy initiatives, making mid-course correction, decision making and for review of
policy planning.
Integration of physical and financial data
Presently, HMIS web portal captures the physical (health indicators) and financial data (FMR
reports). The MoHFW should formulate a strategy for integration of the physical and financial
reports and performance. This will help in getting better insight on what should be precisely tracked,
documented, and analysed. The integration will also help in carrying out cost benefit or cost effective
analysis for different programme heads. Each level of public service delivery should calculate the
cost of various services, so as to develop cost effectiveness culture within the system.
Expansion and improvement of health indicator data
Efforts should be put towards improving the civil registration of births, deaths, and cause of death.
The Government should invest in the expansion of the SRS sample to ten times its current size, by
paying funds to the Registrar General of India. Every state should be tasked with selecting at least 3
districts with the aim of improving the Civil Registration System (CRS) on a pilot basis, in the
coming two years. This would lead to reliable estimates of IMR, MMR, and CBR. This system will
also generate independent data on hospital deliveries, home based deliveries, life expectancy, sex
ratio at birth etc. The vision for the next decade should be to improve the CRS to such an extent that
the SRS is made redundant. The SRS should also collect data on additional variables such as age at
marriage and details of hospitalizations.
Capacity Building and Training
Capacity Building of staff at all levels from facility, district, and state levels is critical for proper
recording, reporting, and analysis of data. This will also help in better interpretation of collected data
for micro-planning and initiating actions at local levels in a timely manner. Programme managers at
all levels need to be acquainted with the power and features of the HMIS portal and also
triangulating various data. The vast potential of academic institutions and universities and public
health institutes needs to be utilised for training on basic research methodology and analysis tools.
9.5 Enhancing the effectiveness of PIP process
9.5.1 Issues
●PIP process is largely based on incremental planning based on last year’s performance
●Long term orientation missing
●Phase wise release of funds causes significant underutilization
134 ●Too much micromanagement by the 1800 line items
●Lack of provisioning for mid-term corrections
●Limited scope for innovation and community based initiatives
9.5.2 Recommendations
Incremental budgeting to performance based long-term budgeting
Line item budgets were (and in a number of countries still are) associated with an "input-oriented"
budget preparation with detailed ex-ante controls and/or rigid appropriation rules. However, NHM
and health systems across India should be governed towards realization of health indicators in
alignment with the SDGs. So rather than opting for input-based budgeting, we need to move towards
performance-based budgeting. The current system of PIP/budgeting takes care of performance vis-à-
vis what was achieved last year. In that sense, it motivates the improvement in outcomes. But it is
not enough.
Whereas, performance budgeting stems from the objective and purpose of the health system and
vision of achieving certain benchmark indicators. It is in alignment with what it ought to be instead
of what it was last year. It is a future-looking method of budgeting. All programs, initiatives and
inputs are planned according to what we intend to achieve in the long run. The core in this process is
outcomes and not the inputs.
Longer term PIPs
PIP action plans need to be forward looking for five or at least three years. Every year, 20 % of the
plan can be modified and approved separately, whereas 80% would remain constant for a period of 3
years and would not require annual re-approvals. This would provide a longer tenure to contractual
staff, thereby alleviating their job security woes. The same would enhance the motivation and
commitment of the staff which is a challenge as described in the section below. It would also help
reduce a lot of planning and paper work which is currently carried out on a yearly basis. Further, it
will also decrease the drastic changes that are often seen in the PIP when senior functionaries
change.
The vision of the health system may be defined by top authorities at central level in consonance with
all related departments involved in SDG achievements, as described above. This vision may be
devolved and communicated to the states and then grassroots level. Once this is done, decentralised
planning under PIP may start at village level and gets integrated into higher-level action plans at state
and district levels.
135 Reducing the number of budget heads
Line item budgets have many advantages like easy to make, easy to monitor and analyse. It is also
efficient in maintaining a track of expenses, even the minute ones as health PIP/Budget has
numerous line-items. However, it brings the culture of non-fluid and short-term planning. It does not
allow any deviation from the approved budget. The clubbing of heads as suggested above may work
to bring some flexibility, albeit limited only. Reduction in the number of heads in PIP/Budgeting is
strongly recommended. This is to bring more flexibility. As of now the re-appropriation is not
allowed across the major heads. However, if the number of heads is reduced the flexibility may
increase.
The road map for reduction of 1800 line items could be to bring it down to 1000 in the first year and
in 2-3 years make it about 500 under 5-6 major heads. The fraud and deviance detections should be
done through financial audit and control rather than through budgeting.
Software based planning
PIP/ Budgeting should become online where most of the aggregation and duplication work may be
done by backend software. Program Management Unit may invest their energy in more productive
work. Even monitoring the utilisation of funds post-approval may also be possible real-time. Many
new data variables may be captured that may enhance the efficiency of the process and system.
Restructuring of PIP and Budget to enhance utilization
The budget should be split into two main components: first regular budget of 100% say part A and
additional budget of about 30% as part B. Both budgets should be approved via the regular process.
In December total expenditure to be reviewed to see if Part A will be sent to 100% by march end. If
it is not likely then during January-March period Part B can be activated which should be such that
can be quickly implemented. So that finally with A and B put together 100% can be spent by March
end. Part B could be put to use towards the procurement of long term assets, large medical
equipment, vehicles, and medical supplies including drugs.
Allowing space for innovation
NHM allows to propose activities under “Innovation” head but largely this is limited to address day-
to-day operational issues like extra transportation required by patients. This fund is meant to be
invested in some community needs-based innovation like outreach activities, child health, or
handling socioeconomic or behavioural issues that directly impact health.
Exigency funds
136 There may be some additional fund available at the district or block (taluka) level, or even at the
directorate level to be used in case of exigencies where a facility or group of facilities may want
extra funds for some activities relevant to community needs, and they have utilised their 100% of
budgeted funds. It would be better if a particular amount is sanctioned/entered into PIP budgeting
that allows for this fund at State level with Health Directorate.
Rethinking the distribution of untied funds
It was suggested that funds should be linked to each healthcare facility in order to be productive. It
was also proposed that the quantity of untied funds should be increased. The overall value of untied
funds needs to be increased in accordance with the number of programs, activities, and the rapidly
growing numbers of beneficiaries.
Funding sources and utilisation of high performing PHCs should be reviewed and the excess funds
should be diverted to those centres that are actually in need, though they might be poor performing
facilities and specifically for newly established facilities. Different norms for fund disbursement to
UPHCs should be put in place. At the very least, the fund value should be equivalent to that of rural
PHCs. Changing the signatory for untied funds at the village level from the Sarpanch/Pradhan to the
MO of the PHC would ensure their allocation to SC/HWC in need and proper utilisation. Lastly, 5%-
10% of the untied funds should be earmarked for emergency management, innovations, and health
system strengthening.
9.6 Monitoring and evaluation mechanisms in the state
9.6.1 Issues
●Based on the lack of a strategic health plan, there is a lack of monitoring and evaluation of
the work done in the state
●No uniform structure for monitoring and evaluation
●Less room for mid-level course correction
9.6.2 Recommendations
Regular Annual Performance Report
A portion of NHM funds should mandatorily be dedicated to the creation of a detailed annual report
by each state, submitted to the central government, and made available to the public. This report
should be standardised by the central NHM so that there is uniformity in reporting structure across
states. There should also be some budget for carrying out research studies on situational analysis,
diagnosis of the public health system, documenting best practices under NHM, cost-effectiveness of
innovative interventions. This initiative will help in enhancing the effectiveness of M&E systems and
137 also result in high quality evidence generation which can be applied to the development of health
research capacity in states. Facility, block, and district wise targets should be set for continuous
monitoring.
Independent Evaluation
Every 3 years, 1% of the annual budget of NHM should be spent towards independent evaluation
studies of the mission, and various programs under it. A technical panel compromising multi-
disciplinary experts from public health, health policy, health systems, epidemiology, health
financing, and M&E should be constituted by central and state NHM for regular independent review
and evaluation. Academic and public health institutes can also be enshrined with this responsibility.
A well designed centralised strategy should be put in place to ensure uniformity in the independent
evaluations conducted at national and state levels.
Involvement of Directorate of Health Services Officials in M&E
Directorate officials and regular state cadre employees should be involved in M&E. This would also
enhance their understanding of the health system and various procedural aspects of programs. This
would also improve the ownership of the programs by the directorate. Involvement of directorate in
M&E can enhance the quality of recommendations and justifications for mid course corrections.
Creating a separate department for M&E
A directorate with its own director should be created for M&E, staffed with demographers,
epidemiologists, and experts in public health, evaluation, and data analysis. The function of this
directorate would be to integrate the current fragmented M&E processes of various divisions and
NHM within the state including SPMUs. The directorate should be tasked with developing the
annual M&E report within two months of the year end. Such reports should also include data from
PPP arrangements and the private sector as much as possible, especially for notifiable diseases,
services provided for health insurance/ Ayushman Bharat schemes, etc.
9.7 Procurement and logistics systems
9.7.1 Issues
●Lack of capabilities in the area of procurement and logistics
●Poor awareness about the use of generic drugs
●Limited adherence to STGs
9.7.2 Recommendations
Strengthening Technical Capacity of Medical Services Corporations
138 The technical capacity of Medical Service Corporation requires strengthening and training of
existing personnel in the area of Logistic Planning and Drug Distribution is necessary. Further,
restructuring of medical service corporation is also required, in which technical experts- Health
Economist, Procurement Specialist, Logistics Planning Specialist, IT-Expert and M&E expert should
be appointed at medical service corporation. This will improve the functioning and efficiency of
corporations.
Strengthening Quality Assurance System
Ensuing quality of drugs is very essential for patient safety and responsive health systems. The
quality assurance practices should be in accordance with the operation guideline of the Ministry of
Health and Family Welfare, Government of India. Planned and regular monitoring from Central
NHM is necessary for ensuring adoption of efficient quality assurance systems.
Implementing Bottom-up planning
The E-Aushadhi and IT-backed Logistic Management Information System like Drugs and Vaccines
Distribution Management Systems (DVDMS) have been implemented in most of the states.
However, it is not fully functional at the peripheral level that is hampering the bottom-up planning.
The ground level functionaries- Primary Health Centres and Community Health Centres have not
been able to carry out indenting and planning. The bottom-up planning should be implemented with
requisite technological changes and capability building initiatives.
Group Procurement
Drugs such as antibiotics should be procured as a basket of similar products. This will be essential in
order to make drug procurement more efficient and reduce unnecessary paperwork. This would
further reduce the wastage/ unutilized drugs. Group procurement will also have the advantage of
making vendors more amenable to supplying to the government as the order values will be much
higher.
Training and Capacity Building
Training of officials at various levels for implementing E-Aushadhi and carrying out various logistic
activities- forecasting, quantification and inventory management is required for making Logistics
Planning and Drug Distribution system more efficient and effective. Standard training manual and
workshop material along with case studies for training and capacity building can be designed and
implemented. The training of medical officers for rational use of medicine, prescription audit and
managing drugs is essential.
Community Awareness
139 The awareness about generic medicine and rational use of medicine among communities is required.
A communication strategy and IEC material can be developed in the local language for wider
awareness. Use of social media, mass media, and electronic media will help in larger awareness.
Implementing Standard Treatment Guidelines and Prescription Audit
The state should implement STGs across all levels of health systems and prescription audit practices
should be initiated for improving quality of care. At least 2% of the annual procurement budget
should be devoted to STG implementation and prescription audit. This will have the advantage of
preventing unnecessary drug consumption and its side effects. 1% of prescriptions made in each
facility should be audited periodically to study prescription patterns. Tee results can be then used to
address supply chain issues and physician strategies can be revised.
9.8 ASHA workers
9.8.1 Issues
●ASHAs are becoming healthcare delivery personnel rather than the envisaged activist role
●Too much workload and duplication of data entry tasks
●Recruitment criteria needs to be revisited, especially in urban areas
●Lack of career path for ASHAs
●Limited supervision and support structure for ASHAs
9.8.2 Recommendations
ASHA Recruitment and role
Entry qualification criteria into the ASHA program should be standardised. The Medical Officer,
ANM, or CHO should be given a say in ASHA appointment in rural areas in order to control the
influence of political actors. In urban centres, the entry qualifications for ASHAs could be increased,
especially in non-slum areas. While ensuring that the ASHA is a local community resident, other
recruitment criteria can be made flexible across regions considering their socio-geographical
complexity and the availability of suitable candidates. In the long run it is suggested to replace the
ASHA with a community health nurse who would be a high school graduate with 6-12 months of
training in community health and outreach work.
Compensation and recognition
The fixed honorarium amount should not be increased. As the ASHA model is performance-based
and incentive driven, there should be a balance between the two components, fixed and variable.
This will enhance the motivation and performance of ASHAs. A mixed incentive structure with
checks for complacency will serve a dual purpose-the fixed component ensuring their financial
140 safety thereby preventing attrition, and the variable component serving to motivate and consequently
maintain the quality of their work. Performance awards like "ASHA of the month” could be put in
place at the block level to introduce a competitive spirit among these workers. A provision could be
made for an increase in the incentive amount for ASHAs with consistent performance over a period
of time, but reasonable caps should be in place.
Training and knowledge enhancement
While there are standardized training modules for ASHAs, the same may be reexamined for
contemporary challenges like NCDs, and skills related to behavioral aspects of the community.
Further, cross learning and knowledge sharing amongst ASHAs can be promoted by adopting
structural interventions (Such as ASHA Sammelans in Gujarat). The ASHA Sammelan model of
Gujarat could be adopted by other states to facilitate knowledge sharing among ASHAs of various
regions within a state. This would serve as a confidence building exercise for all ASHAs, and help
document best practices at the field level, which could then be taken up the chain to policymakers.
Other replicable features from Gujarat include the ASHA Resource Centre plans and organises these
Sammelans at the state, district and taluka levels, and a State ASHA Mentoring Group.
Monitoring
ASHAs should be monitored regularly by the ANM or the CHO, and mechanisms should be put in
place to remove non-performing or inactive workers within 3 months. The activities for which
ASHA are incentivized should also be revisited, and the focus should shift in accordance with the
changes in the epidemiological profile of the community they serve. The NRHM’s focus on
reproductive and child health has limited the ASHA’s scope of work with increasing focus on select
services. The activist role of this cadre of workers needs to be highlighted more going forward,
especially health promotion activities.
There should be a dedicated cell for ASHA at the Government of India level. This would aid in the
consolidation of all ASHA related issues and monitoring would become efficient. The National
ASHA mentoring group should conduct periodic evaluations and performance measurement
uniformly across all states.
Career Progression
Open schooling through NIOS should be facilitated to enable ASHAs to pursue university level
education. This is a long term recommendation that will help increase female literacy in the country,
as well as improve ASHA performance.
Mechanisms should be put in place to allow ASHAs to progress to ASHA facilitators and ASHA
coordinators. Specialisations like mental health, family planning, yoga etc. could be offered to
141 ASHAs with aptitude and measurable good performance in these particular areas. Further, district
wise reservations could be made for high performing ASHAs for admission into ANM/GNM and
nursing degree programs where qualifications are appropriate.
For ASHAs who have served for a long period and are unable to carry out their duties due to age, a
dignified exit or “golden handshake” mechanism with some lump sum payment could be put in place
with due performance monitoring.
9.9 Strengthening local governance and capabilities
9.9.1 Issues
●Local governance structures such as RKS are present but the capabilities are lacking
●Accountability mechanisms are limited
●Poor representation of patients/ women and patient support groups in local
governance
9.9.2 Recommendations
Capacity building and training of Rogi Kalyan Samiti Members
There is an urgent need to build capacity of RKS members in structural, operational, functional, and
finance related areas. There should be a training module for RKS members in the expenditure and
reporting on untied funds. Training should also be linked to membership by ensuring that only
trained members are eligible for RKS membership. The RKS processes should be carefully
monitored and ensured (for example RKS register made by Uttar Pradesh).
Representation of local communities
The State and District Health Societies should focus on including local patient representative groups,
and civil society. Generating localised funding sources is also essential for ensuring involvement
from all sections of the community including those individuals and organisations capable of
philanthropic endeavours. This will be important for drawing attention to lacunae in the social
aspects of public healthcare, such as facilitating food and shelter for the family of care seekers,
engaging social workers for follow-up community based care, and supplementing local blood banks.
Participation of Women
A guideline or regulation can be made for increasing participation of women as RKS members. This
will also ensure gender sensitive services at public health facilities.
Proper monitoring of RKS
There should be a monitoring committee at district level for regularly reviewing the performance,
and governance of RKS. The monitoring process needs to be governed by standards and should look
142 into various structural, operational, functional, and financial aspects of RKS. Scores/points could be
awarded for overall improvement of healthcare facility, conduction of meetings, governance aspects,
RKS membership structure, functionality, fund utilisation, and innovation. The top-ranking RKS
could be rewarded monetarily. Likewise, Swachh School or Kayakalp, award mechanisms should be
set up for RKS. An annual award to all high ranking RKS could act as further motivation. A detailed
analysis of the RKS and the untied funds should also be conducted to understand its functioning and
impact on service delivery and community health improvement
Communicating membership clearly
The details RKS members the names, phone numbers should be clearly laid out every facility. This
would help patients to know about the committee. RKS has the potential of becoming a strong
patient welfare body and a feedback collection and issue resolving committee.
Conclusion:
The NRHM, launched in 2005, was a watershed for the health sector in India. With its core focus to
reduce maternal and child mortality, it aimed at increased public expenditure on health care,
decreased inequity, decentralization and community participation in operationalization of health-care
facilities based on IPHS norms. Gradually the NHM has emerged as a major financing and health
sector reform strategy to strengthen the state health systems in India. The NHM has played a crucial
role in health system strengthening through architectural correction of the rural health system-in
terms of availability of human resources, program management, physical infrastructure, community
participation, financing health care and use of information technology.
The NHM is largely focused on providing comprehensive care to mother and child. It has framed
policies that allow the design and implementation of programs on newborn care in an inclusive
manner. However, considering increasing burden of Non-Communicable Diseases, Climate Sensitive
Disease and emerging infectious diseases. The NHM should also put emphasis on NCDs, Climate
Change and Health, Health System Research, building capacity of public health system and on
framing policies in terms of building capacity of existing human resources, enhancing further
allocation of finances to emerging areas, identifying areas through operational research, which can
enhance quantity and quality. The present report has provided recommendation and set the path for
future National Health Mission and we need to operationalize and move forward.
The focus on decentralization and empowerment of the frontline and developing a community
connection through an effective cadre of ASHA workers has been vital for awareness and
adaptiveness in the system. The present study reiterates the need of continuing NHM in the mission
mode, albeit with increase in funding. The emphasis on three key aspects- structures and
143 coordination mechanisms between NHM and the directorates, data based planning and execution.
and the focus on further improvements in HRH can further contribute to building resilient health
systems.
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ANNEXURE
Annexure A: Terms of Reference – NITI Aayog [Annexure]
A.To analyse the strengths and weaknesses of the governance setup of the NHM,
identify best practices going forward in context to the framework of Aayushmaan
Bharat, SDG, UHC, and health equity.
I.i.To analyse the technical capacities and decision making at the central level.
II.iii.To analyse the effectiveness of district and hospital societies in terms of improved and
need based planning and accountability to committed outcomes.
IV.v.To analyse the effectiveness of untied funds in improving quality of medical care and
access to the same.
VI.vii.To analyse the effectiveness of investment in the ASHA component of NHM and
suggest solutions for enhancing the effectiveness of this investment.
B.To analyse the systematic, technical capacity and decision making at the national, state-
level in carrying out the NHM, and study the HR capacities across difference states
I.ii.Analyse the existing processes of district and city plan preparation and their
aggregation into State PIPs and identify areas of improvement, if any. Suggest
solutions to strengthen the existing systems and processes.
III.iv.Analyse the existing systems and processes of budget preparation and funds allocation
to districts and city annual plans.
V.vi.Analyse the existing monitoring systems and their effectiveness in implementation of
district and city plans and how these are contributing to accountability in terms of their
respective annual plans.
VII.viii.Analyse the processes of preparation of capacity development plans and their
implementation with special focus on quality of training and skills developed.
IX.x.Analyse the procurement and logistics management systems at State, District, and City
Levels to identify bottlenecks, if any and suggest solutions for strengthened and more
accountable procurement & logistic management systems.
C.To study human resource gaps by looking at the requirements vis-a-vis actual officers
posted as a way of understanding the state capacities to carry out the mission. To analyse
the state strategies, plans and actions taken to bridge the evident gaps in human
resources and the effectiveness of such actions.
149 Annexure B:
#Interviewee
1.Additional Secretary and Mission Director, National Health Mission, GoI
2.Joint Secretary, Ministry of Health, GoI
3.Joint Secretary, RCH, Ministry of Health, GoI
4.Director, NHM, Ministry of Health, GoI
5.Director, NHM, Ministry of Health, GoI
6.Director, Finance, Ministry of Health, GoI
7.ED, NHSRC, National Health Mission, GoI
8.Advisor, HR, NHSRC, National Health Mission, GoI
9.Advisor, Policy, Community Processes, NHSRC, National Health Mission, GoI
10.Advisor, Quality, NHSRC, National Health Mission, GoI
11.Consultant, NHSRC, National Health Mission, GoI
12.Principal Secretary- Health- GoG
13.Commissioner of Health- GoG
14.Additional Director- Health Department, GoG
15.Joint Director- Health Department, GoG
16.Programme Officer, Rural Health, GoG
17.Programme Monitoring Unit, Health Department, GoG
18.Senior Consultant, SPMU, National Health Mission, GoG
19.Consultant, Policy Planning, National Health Mission, GoG
20.HR Officer, National Health Mission, GoG
21.Project Officer, SPMU, National Health Mission, GoG
22.Finance Officer, National Health Mission, GoG
23.Chief District Health Officer, Sabarkantha District Gujarat
24.District Programme Officer, Sabarkantha District Gujarat
25.District Finance Officer, Sabarkantha District Gujarat
26.District Programme Officer, Ayushmaan Bharat Sabarkantha District Gujarat
27.Chief District Health Officer, Gandhinagar District Gujarat
28.District Programme Officer, Gandhinagar District Gujarat
29.District Finance Officer, Gandhinagar District Gujarat
30.Additional District Health Officer, Gandhinagar District Gujarat
150 31.Reproductive Child Health Officer, Rajkot District Gujarat
32.District Programme Officer, Rajkot District Gujarat
33.District Finance Officer, Rajkot District Gujarat
34.Regional Deputy Director, Saurashtra Region, Health Department, GoG
35.Regional Finance Officer, RDD Office, Health Department, GoG
36.Primary Health Centre, Medical Officer, Rajkot District
37.Medical Officer of Health, Rajkot Municipal Corporation
38.Corporation Programme Officer, National Health Mission, Rajkot
39.Medical Officer, Urban Health Centre, Rajkot
40.Medical Officer of Health, Ahmedabad Municipal Corporation
41.Corporation Programme Officer, National Health Mission, Ahmedabad
42.State Project Officer, ASHA Resource Cell, Health Department, GoG
43.State ASHA Trainer, Health Department, GoG
44.District Level ASHA Resource Cell Officer, Sabarkantha District
45.Medical Officer, Kathwad, Sabarkantha District
46.Focussed Group Discussion with ASHAs of Kathwad, Sabarkantha District
47.Taluka Health Officer, Jaldpur, Navsari District, GoG
48.Taluka Health Officer, Sojika, Anand District, GoG
49.Focussed Group Discussion, Medical Officer, Various PHC, Gujarat
50.Former Director, State Institute of Family and Health Welfare, Uttar Pradesh
51.Research Associate at International Health, Health Systems Division, John Hopkins Bloomberg School of
Public Health, Uttar Pradesh
52.Director, NHM Office, Lucknow, Uttar Pradesh
53.Principal Health Secretary, Secretariat of Uttar Pradesh
54.Mission Director, National Health Mission, Uttar Pradesh
55.General Manager, HR, National Health Mission, Uttar Pradesh
56.Director General, Medical and Health, Uttar Pradesh
57.PHC Director, Health (Swasthya Bhawan), Lucknow, Uttar Pradesh
58.Advisor, SPMU, National Health Mission, GoUP
59.Director, Family Welfare, GoUP
60.Joint Director, MCH, Directorate of Family Welfare, GoUP
61.Joint Director, FP, Directorate of Family Welfare, GoUP
151 62.Joint Director, Training & RBSK-RKSK, Directorate of Family Welfare, GoUP
63.Joint Director, Coordination, Directorate of Family Welfare, GoUP
64.Joint Director, MCH & Administration, Directorate of Family Welfare, GoUP
65.Disbursement Officer, Directorate of Family Welfare, GoUP
66.General Manager, Policy-Planning, SPMU, National Health Mission, GoUP
67.General Manager, Community Process, SPMU, National Health Mission, GoUP
68.General Manager, M&E, SPMU, National Health Mission, GoUP
69.General Manager, Human Resources, SPMU, National Health Mission, GoUP
70.Deputy General Manager, M&E, SPMU, National Health Mission, GoUP
71.CMO, Barabanki District, Uttar Pradesh
72.ACMO, Immunization, Barabanki District, Uttar Pradesh
73.ACMO, NUHM, Barabanki District, Uttar Pradesh
74.ACMO, Food and Drug, Barabanki District, Uttar Pradesh
75.ACMO, Family Planning, Barabanki District, Uttar Pradesh
76.ACMO, Store, Barabanki District, Uttar Pradesh
77.ACMO, Protocol, Barabanki District, Uttar Pradesh
78.District Leprosy Officer, Barabanki District, Uttar Pradesh
79.Deputy CMO, RBSK-RKSK, Barabanki District, Uttar Pradesh
80.Representative from District Hospital, Barabanki District, Uttar Pradesh
81.District Programme Manager, NHM, Barabanki District, Uttar Pradesh
82.District Community Process Manager, NHM, Barabanki District, Uttar Pradesh
83.District Account Manager, NHM, Barabanki District, Uttar Pradesh
84.Quality Assurance Consultant, Barabanki District, Uttar Pradesh
85.CMO, Lucknow District, Uttar Pradesh
86.ACMO, RCH, Lucknow District, Uttar Pradesh
87.ACMO, NUHM, Lucknow District, Uttar Pradesh
88.ACMO, VBD, Lucknow District, Uttar Pradesh
89.Deputy CMO, Lucknow District, Uttar Pradesh
90.District Programme Manager, NHM, Lucknow District, Uttar Pradesh
91.District Community Process Manager, NHM, Lucknow District, Uttar Pradesh
92.District Account Manager, NHM, Lucknow District, Uttar Pradesh
152 93.Nagar Swasthya Adhikari, Municipal Health Officer, Lucknow Municipal Corporation, Lucknow
94.Executive Director, Lucknow District, Uttar Pradesh
95.Consultant-2, Lucknow District, Uttar Pradesh
96.Finance Controller, SPMU, NHM Uttar Pradesh
97.Senior Manager, Finance, SPMU, NHM Uttar Pradesh
98.MD- National Health Mission, GoR
99.Former, MD, National Health Mission, GoR
100.MD- Rajasthan Medical Services Corporation, GoR
101.Director- Public Health, Health Services, GoR
102.Director, RCH, Health Services, GoR
103.OSD, National Health Mission, GoR
104.Programme Officer, National Urban Health Mission, GoR
105.Assistant State Programme Manager, National Health Mission, GoR
106.State Data Manager, National Health Mission, GoR
107.ED- Logistics, Rajasthan Medical Services Corporation, GoR
108.Director, Finance, National Health Mission, GoR
109.Joint Director, Finance, National Health Mission, GoR
110.State Programme Officer, Finance, National Health Mission, GoR
111.State Nodal Officer, ASHA Cell, National Health Mission, GoR
112.Programme Officer, ASHA Cell, National Health Mission, GoR
113.Senior Consultant, Policy Planning, National Health Mission, GoR
114.PMO, District Hospital, Dausa, GoR
115.Health Manager, NHM, District Hospital, Dausa, GoR
116.Chief Medical and Health Officer, Dausa, GoR
117.District RCHO, Dausa, GoR
118.District Programme Manager, Dausa, National Health Mission, GoR
119.District Nodal Officer, Dausa, National Health Mission, GoR
153 Annexure C: Findings of the States visited by NITI Aayog Officials
Provided by Dr. K Madan Gopal
Written by Dr. Mahaveer Golechha
Andhra Pradesh:
The team has visited state HQ and District West Godavari
The state health department officials mentioned that they are happy with National Health Mission
and its structure. The NHM has helped them in improving access and quality of services.
The important distinction of AP is key personnel working at State Program Management Unit of
NHM are regular cadre staff and other consultants are contractual.
Having regular cadre staff at SPMU helped them in establishing better coordination with directorate
of health officials and CDHO at district head quarter.
However, Directorate of Health Service is not integrated with SPMU-SHS. It would have been better
if both unit are integrated. There is lack of communication and coordination between both.
Appointment of State Program Manager-SPM of SPMU is politically driven and there is no clear cut
guidelines available from central NHM for appointment of SPM.
In AP health department is headed by Principal Secretary Health and below him/her commissioner of
health.
The NHM is headed by MD-NHM, who is most of time very junior to Commissioner of health. This
leads to lack of coordination and communication between MD-NHM and CoH.
There are many issued related to contractual staff of NHM- disparities of salary between regular and
contractual staff is big issues and affecting performance and motivation of contractual staff.
Further, there is no strategy for absorbing contractual staff in health system. The contractual staff
reported lack of grievance redressal system, inefficient performance appraisal mechanisms, heavy
work load etc.
ASHA model is good and working well in the state; also led to improvement in access to health
services and health indicators.
Replacing 108 needs more capital fund. The NHM should provide more fund under capital.
Procurement and Logistics: The Medical Service Corporation been established in the state. The
procurement process is inefficient and delayed. The officials lack the capacity and training in the
area of logistic planning and drug distribution.
154 Frequent stock out of essential medicines; forced Rogi Kalyan Samiti to arrange medicines from
untied fund.
PIP process require modifications; the process is cumbersome.
More flexibility is requiring, there are more than 1800 budget line items, in some program more than
20 budget line item. Rather than too much line items, each program should be considering as single
budget line item and in program we should have flexibility to spend, for example in some program
we need more IEC fund or in some program service delivery is important. Therefore, state should be
given more flexibility.
Recently, Health and Wellness Centres established in the state, Mid-Level Health Provider (MLHP)
Training has also been done. However, monitoring of MLHPs performance is challenging.
Most of the Sub Centers are in rented building, lack of proper space for examination and treatment.
HWC requires highly trained people and HWC cost should be based on the location rather than same
cost of all HWC.
Untied fund is just name, its always with guidelines, therefore it is tied fund.
Conversion of district hospital in medical college has been initiated.
In urban health under PPP model- E-UPHC- tele medicine started, this has been outsourced to the
private partner. The cost effectiveness analysis of this initiative is require.
There are vacancies of specialists at various level, The HR recruitment process is very much delayed.
The MD-NHM has joined recently- 3 months back. Frequent transfer is also a big issues.
The incentives to the health facilities should stopped. Indicator based award to district collector is
also not good, as they only working or more focus on indicator based work and low or no focus on
other indicators.
There is an urgent need to have uniform HR policy of NHM staff.
Trainings are not based on need, follow-up and mentorship is absent in all training program.
Trainings are not effective and efficient without follow up and mentorship.
Monitoring is largely done by Monitoring and Evaluation team based at SPMU. State level
monitoring done at State Health Society EB meeting by Principal Secretary Health.
Regular monitoring by MD- NHM and SPMU team.
Less focus on field visit, more focus on data recording and reporting. Use of data for decision
making is missing.
155 ASHA is doing good work and are effective. Increasing honorarium will hamper entire process.
West Godavari District:
District Program unit is headed by CMHO and managed by District program coordinator.
Lots of meetings, data review, less focus on field visit and innovations, discussion etc.
Self reporting of data should be stopped.
District officials also highlighted lack of proper monitoring system for MLHPs.
State do not have any plan or strategy for absorption of NHM staff. Lack of motivation among NHM
contractual staff.
Recruitment power of NHM is at district level.
DPM is also from regular cadre, it is good and receptivity is more.
Frequent stock out of essential medicine, lack of proper indenting mechanisms, delayed procurement
process.
E-ausahdhi is available. Lack of capacity and training at district level for pharmaceutical
management.
Regional warehouses, ideally each district should have one ware house.
There is lack of coordination between CDMO and CMHO.
At District level HRS is adequate.
Chhattisgarh: CG: State HQ and Durg District
In Chhattisgarh state health department is headed by Principal Secretary health and below
commissioner of health. The NHM is headed by MD-NHM.
MD-NHM is always junior to commissioner of health, due to this there is lack of coordination and
communication between both.
There are frequent changes-transfer in MD-NHM.
Director-Public Health is IAS officer.
HR recruitment is very slow process and the process is delayed and leads to many vacancies at
various levels. Retention is also very poor.
Comprehensive Rural Medical Plan- incentive based.
State is working on Medical Service Recruitment Board.
156 SPMU staff and NHM staffs at district and field are contractual, there is no career progression
opportunity, no state plan for absorption of NHM staff in regular cadre.
NHM contractual staff lacks motivation and reported heavy work load.
108- Govt. is not procuring any vehicle.
HRH- Hardship allowances for personnel working in remote areas. Performance based incentives,
KPIs.
Sukma- Bijapur: The state has plan to give more incentives to the specialists working in hard to
reach areas through District Mineral Fund.
For retaining Human Resources for Health- Transit Hostel Model started in CG. A well planned
accommodation with necessary amenities provided at district HQs.
District Administration is taking personal interest in talent hunting;
Specialist are requested to bring new personal for replacing his/her before they leave the job.
Appointment order issued very rapidly.
There is need for innovation fund under NHM for carrying out more innovative activities.
PIP process is find and state don’t have much issues. However, the process is little bit cumbersome
and lack of flexibility. It should be made more flexible and budget line items needs to be relooked.
CG Rural Service Corporation. Orientation Training not happening.
Hat Bazar Clinic for improving access to services.
Training: Less focus on training, routing training under NHM program is happening, training is not
need based, no post evaluation for impact of training, lack of follow up and mentoring.
Monitoring and Evaluation: As per NHM M & E is happening, however, more focus on review and
data recording. Proper evaluation is missing. Lack of capacity of staff members in M & E.
District Health Score started for motivating districts.
Procurement:
CG Medical Service Corporation is responsible for procurement of drugs and other logistics.
The process is inefficient and ineffective, there are issues with indenting, frequent stock outs.
Lack of coordination between NHM and Medical Service Corporation officials.
157 The state is planning to pay fix honorarium to ASHAs, State Health department officials are not in
favour of this decision, as this will reduce their performance and ultimately hampering health
systems.
The State also reported NHM contractual staff issues- no career progression, no policy for
absorption, lack of motivation, lack of proper annual performance appraisal system.
Contractual staff are doing more administrative work than technical; they are also doing work of
CMHO officials.
SHRC is involved in technical aspects of NHM and working well. The SPMU officials reported that
SHRC is bypassing NHM and directly dealing with PS-Health.
The HWC are managed by trained ANMs and MLHPs training been given to them.
In ASHA- association, groupism started and it negatively affecting health systems, more grievances,
more demanding, the empowerment should be in right direction.
The PIP is top up approach, mostly done at district level, lack of capacity at bottom level for
preparing PIPs.
Ground level capacity building is requiring for making PIP truly bottom up approach.
Promotion avenues for regular cadre staffs are also missing.
SIHFW is doing only NHM program trainings.
SHRC is not function as think tank.
Karnataka: State HQ and Mysore district
The Karnataka Health Department structure is also similar to Andhra Pradesh and Chhattisgarh. The
state health department is headed by Principal Secretary- Health. Commissioner of Health is
responsible for health department program and activities across the state. The national health mission
is headed by MD-NHM. There is a directorate of health services headed by Director.
The state officials reported issues of NHM contractual staff and one of them is pay disparity between
regular cadre and contractual staff.
The contractual staff are not motivated, as they are waiting regularisation since last 10 years.
The regularisation of NHM contractual worker is not possible due to lack of HR policy and state
strategy.
The HR scarcity is affecting the health system negatively. There are huge vacancies of specialist
across various tier of health system.
158 The integration of NHM with directorate of health services is good and it has improved coordination,
communication and cooperation between both.
The state has taken initiative for data integration between RCH and WCD for better evidenced based
decision making.
The state has taken extra efforts and innovation for RBSK program- App based monitoring of service
delivery and data triangulation- integration.
The state has also initiated Village Health Survey, its joint survey of the department.
Digitalisation of various data and record has started.
In the payment provide mechanisms, state has initiated several mechanisms for enhancing efficiency-
case based payment, uniform rates (committee has been constituted for deciding the rates).
Special salary provisions for high priority districts. On call recruitment for specialists.
Tele radiology initiative for improving access to radio diagnosis services at grass root level.
Karnataka Public Service Commission announced 25% waiting list.
HR rationalisation of NHM staff is necessary- salary disparity between NHM staff is also a issues-
lab technician of various program getting different salary.
There too many unnecessary posts been created- separate program coordinator for small programs.
Although PIP process is fine, but more flexibility is requiring. There are too many budget line items
and many times it leads to low fund utilisation. We are always busy with finding a way for spending.
The state has taken initiative for ASHAs career progression through NIOS certification.
Aayogya Bandhu Scheme has been launched by State.
Nutrition Rehabilitation Centres- NRC: 32 require, presently 20 NRCs are functioning.
SNCU- Specialist been trained, however, some specialist been shifted to other places for different
tasks.
Dental Services only reaches upto district level. Ayush doctors are not motivated, due to low salary
and heavy workload.
State has initiated dialysis program under PPP mode. The program is running well.
More number of data entry operators are requires.
Immunisation: some issues with shortage of vaccines. Policy direction is needed for rare diseases.
Procurement of drugs and logistics is efficient and there is less shortage compared to other states.
159 In urban areas ASHAs access to gated community is poor and acceptability of ASHAs is also low.
The Digital PHC concept is started and needs to be evaluated for cost effectiveness of such initiative
before rolling out across the state.
ASHA honorarium is fixed, monitoring and mentoring of ASHA is poor.
Incentive should be linked with outcome.
160