GRAAM (Grassroots Research And Advocacy Movement) · GRAAM (Grassroots Research And Advocacy...

Tracking of NRHM Funds (JSY, Untied & Maintenance) in

Mysore District of Karnataka

Report of a study undertaken by

GRAAM (Grassroots Research And Advocacy Movement)

An SVYM initiative

V-Lead, #CA-2, KIADB Industrial Housing Area Ring Road, Hebbal, Mysore, INDIA – 570016

www.graam.org.in

With the supported of

International Budget Partnership

820 First Street, NE Suite 510 Washington, DC 20002 U.S.

Tel: +1 202 408 1080 ext.859 | Fax: +1 202 408 8173

www.internationalbudget.org

2012

Dedication

Dedicated to every woman who needs support,

emotional, material and financial,

in overcoming the numerous hardships thrown at her by our socio-economic setup

towards becoming a healthy mother of a healthy child

Study Team Shanthi Gopalan

Rekha. D

Narasimhaiah

R. Balasubramaniam

Report Shanthi Gopalan

Rohit Shetti

Administrative Support Basavaraju R

Lakshmi K

GRAAM (Grassroots Research And Advocacy Movement) CA-2 KIADB Industrial Housing Area

Ring Road, Hebbal, Mysore, INDIA – 570016

Tel: +91 821 2410759

Telefax: +91 821 2415412

E-mail: [email protected]

Website: www.graam.org.in

© 2012 GRAAM

Some rights reserved. Contents in this Publication may be freely shared, distributed

or adopted. However, any work, adopted or otherwise, derived from this

publication must be attributed to GRAAM, Mysore. This work may not be used for

Commercial purposes

To be cited as: GRAAM, Mysore 2012: Study report on ‘Tracking of NRHM Funds

(JSY, Untied & Maintenance) in Mysore District of Karnataka’

mailto:[email protected]

http://www.graam.org.in/

i

GRAAM – An SVYM Initiative www.graam.org.in

Acknowledgements

GRAAM would like to place on record its appreciation and gratitude to International

Budget Partnership (IBP) for its financial and technical support in this study. Special

thanks are to Mr. Ravi Duggal, Program Officer, IBP India for his support and inputs

in all the stages of the study.

Our special thanks are to Mr. Selva Kumar (IAS) Mission Director, National Rural

Health Mission (NRHM) – Karnataka, for all the support extended to the study

We acknowledge the support provided by the District Health Society officials of

Mysore District. We would like to place our sincere thanks to Dr. Raju, Dr. Nagaraja

Rao and Dr. Malegowda, the Disrict Health Officers; Dr. Maheshwari and Dr.

Nagendran, District Project Management Officers; Dr. Uma, Reproductive and Child

Health (RCH) Officer; Mr. Prasanna and Mr. Shashidhar, District Accounts

Managers; Ms. Yashaswini, District Program Manager and all others from the

District Health Society.

We would like to thank all the Taluka Health Officers for their support to the study.

Our special thanks to all the Block Program Managers (BPMs) at different Talukas in

the district for their support, inputs & insights into budget intricacies. We place our

sincere thanks to all the Primary Health Centres’ Medical Officers, all the ANMs,

ASHAs and VHSC members contacted during the course of the study, for their time

and inputs.

Our special thanks to all the respondents of the study from different villages across

the District. Without whose support and time, this study would not have been made

possible. GRAAM acknowledges all the members of the villages that the research

team visited and interacted with, for their cooperation and hospitality.

We also acknowledge the contributions of different groups of people who interacted

with us during the course of our work and are immensely thankful to all of them.

ii


Abbreviations

ANC : Ante-Natal Care

ARS : Arogya Raksha Samiti

ASHA : Accredited Social Health Activist

ANM : Auxiliary Nurse and Midwife

AYUSH : Ayurveda, Yoga and Naturopathy, Unani, Siddha, Homeopathy

BPL : Below Poverty Line

BPM : Block Program Manager

CAG : Comptroller and Auditor General

CHC : Community Health Centre

CI : Cash Incentive

CSO : Civil Society Organization

DAM : District Account Manager

DHAP : District Health Action Plan

DHO : District Health Officer

DHS : District Health Society

DLHS : District Level Household and facility Survey

DPMO : District Program Management Officer

DPMU : District Program Management Unit

EDD : Expected Delivery Date

FGD : Focused Group Discussion

FY : Financial Year

GD : Group Discussion

GDP : Gross Domestic Product

GO : Government Order

GoK : Government of Karnataka

GoI : Government of India

GP : Gram Panchayat

GRAAM : Grassroots Research And Advocacy Movement

IBP : International Budget Partnership

IMR : Infant Mortality Rate

IPHS : Indian Public Health Standards

JSY : Janani Suraksha Yojana

MMR : Maternal Mortality Rate

MO : Medical Officer

MoHFW : Ministry of Health and Family Welfare

Tracking of NRHM funds (JSY, Untied and Maintenance)

iii


NCMH : National Commission on Macroeconomics and Health

NDCP : National Disease Control Program

NGO : Non-governmental Organization

NHSRC : National Health System Resource Centre

NMBS : National Maternal Benefit Scheme

NRHM : National Rural Health Mission

OBC : Other Backward Classes

PA : Prasuti Araike

PHC : Primary Health Centre

PIP : Program Implementation Plan

PNC : Post Natal Care

PPP : Public Private Partnership

PRA : Participatory Rural Appraisal

PRI : Panchayati Raj Institution

PUC : Pre-University Course

RCH : Reproductive and Child Health

RKS : Rogi Kalyana Samiti

RP : Resource Person

RTI : Right to Information

SAP : Structural Adjustment Program

SC : Scheduled Caste

SCUF : Sub-centre Untied Fund

SDMC : School Development and Monitoring Committee

SHSRC : State Health System Resource Centre

SoE : Statement of Expenditure

SSLC : Secondary School Leaving Certificate

ST : Scheduled Tribe

SVYM : Swami Vivekananda Youth Movement

THO : Taluka Health Officer

UC : Utilization Certificate

VHC : Village Health Committee

VHSC : Village Health and Sanitation Committee

VHP : Village Health Plan

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Contents

Acknowledgements i

Abbreviations ii

List of Tables vi

List of Figures and Annexure vii

About GRAAM viii

Introduction ix

1

Programs under NRHM 1 - 6

1.1

The National Rural Health Mission 1

1.2

NRHM Fund Flow – an overview 2

1.3

Janani Suraksha Yojana 3

1.4

Maintenance Funds 4

1.5

Untied Funds 4

2

Tracking of funds under NRHM – Study

Characteristics 7 - 16

2.1

Study Objective 7

2.2

Rationale for the study 7

2.2.1 Literature Review 8

2.3

Study setting 12

2.3.1 Study Location: Mysore District 12

2.4

Study Design 13

2.5

Study Tools 14

3

Analysis of Fund related data 17 - 50

3.1

Background 17

3.2

Fund flow and utilization analysis 17

3.2.1 Funds required, received and unspent 17

3.3

JSY Funds 18

3.3.1 JSY fund flow analysis 18

3.3.2

Analysis of JSY funds: requirements, amounts received and

unspent 25

3.3.3 Delay in fund disbursal: Reasons cited 28

3.3.4 Disbursement of Cash Incentives 29

3.3.5 Difficulties faced in availing Cash Incentives 30

3.3.6 Summary of findings – Janani Suraksha Yojana 33

3.4

Untied and Maintenance funds 34

3.4.1 Guidelines for untied funds 35

3.4.2 Issues pertaining to the guidelines 36

3.4.3 Delays in release of funds 37

3.4.4 Funds utilization issues 41


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3.4.5 VHSC Untied Funds 46

3.4.6 Summary of findings – Untied and Maintenance funds 50

4

Background Characteristics of Respondents 51 - 53

4.1

JSY Beneficiaries 51

4.2

Health Service Providers 52

4.2.1 ASHA 52

4.2.2 ANM 53

5

Awareness about NRHM & Cash Incentive Programs 54 – 55

5.1

General Awareness 54

5.2

Awareness of eligibility criteria 54

5.2.1 Eligibility related documents 55

6

Access, Availability and Utilization of Provisions

under NRHM – A Challenging Scenario 56 – 64

6.1

Presence & effectiveness of health functionaries 56

6.2

Impact on maternal health services 57

6.2.1 ANC Registration 57

6.2.2 ANC Visits 58

6.2.3 Institutional Deliveries 58

6.2.4 Managing Expected Delivery Dates 59

6.3

Information on Still-births 60

6.4

Infrastructural facilities 61

6.5

Supply of drugs 62

6.6

‘Cost’ of free services 63

6.7

ASHA: Role Conflicts 63

7

Inferences from the Study 65 - 69

7.1

Key Findings 67

7.2

Recommendations 68

8

Advocacy 70 - 81

8.1

Advocacy mandate 70

8.2

Advocacy points 70

8.3

Advocacy strategy 73

8.4

Initiatives undertaken 75

8.4.1 Community level advocacy 75

8.4.2 Media advocacy 77

8.4.3 Advocacy workshop with CSOs 78

8.4.4 Advocacy with Policy Planners 79

8.5

Scope for further action 80

Annexure 82 - 91

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List of Tables

Table 1 Number of GDs & FGDs held for different categories of Respondents in the

Study 15

Table 2 Categories and number of respondents to whom structured interview

schedule was administered 15

Table 3 Estimated Amount Required Against Amount Released under JSY Funds

for Mysore District between years 2006-2010 21

Table 4 Expenditure Incurred against Available JSY Funds for Mysore District

between years 2006-2010 22

Table 5 Variance in Opening and Closing Balances Pertaining to JSY Funds at the

District Level across different Financial years 23

Table 6 Taluka Wise breakup of JSY Beneficiaries V/S Funds Received (FY 2009-10) 26

Table 7 Taluka Wise breakup of JSY Beneficiaries V/S Funds Received (FY 2010-11) 27

Table 8 Time of receiving fund v/s. Purpose to which the fund was used 32

Table 9 Quarter Wise Untied Funds Received at PHC in FY 2009-10 and 2010-11 37

Table 10 Quarter Wise Untied Funds Received at Sub-centres in FY 2009-10 and

2010-11 38

Table 11 Sub-centre Untied Funds released and Expenditure incurred between 2006 -

2010 at Mysore District 40

Table 12 Breakup of Untied fund expenditure incurred by PHCs in Year 2009-10 45

Table 13 Percentage increase in Expenditure V/S IMR and MMR in Mysore District

from years 2006 to 2010 66

Table 14 Advocacy issues matrix based on NRHM funds tracking study 71

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List of Figures

Figure 1 Study Location 13

Figure 2 Study Tools 14

Figure 3 JSY funds released from Mysore District between the years 2006-07 and

2010 -11 19

Figure 4 Comparative Picture of the JSY fund related to Demand, Receipt and

Shortfall at the District Level between the years 2006-07 and 2010-11 20

Figure 5 Timeliness of Disbursement of JSY Funds 31

Figure 6 Timeliness of Disbursement of PA Funds 31

Figure 7 Level of Expenditure V/S IMR and MMR status in Mysore District 2006 –

2010 66

Annexure

Annexure 1 Slides from Power point presentation shared by DPMO 82

viii


About GRAAM

Grassroots Research And Advocacy Movement (GRAAM) is an initiative of Swami

Vivekananda Youth Movement (SVYM) aimed at bringing about changes in public

policies that make them sound, relevant and ensure that they reflect the real needs

and aspirations of the communities. GRAAM seeks to achieve these goals by making

community participation and engagement an integral part of all its activities and

processes

GRAAM’s core activities include Research, Advocacy, Program Evaluation and

Program Monitoring. Additionally, GRAAM seeks to expand its body of work by

conducting events including multiple stakeholders, publications of its works,

capacity building through community engagement and facilitating a dynamic

network of multi-disciplinary research scholars, development professionals, students

and community members across the world.

Since its inception in Jan 2011, GRAAM has undertaken projects that cover areas

such as health, education, social welfare, technology interventions in improving

service delivery, media-monitoring, etc. The nature of projects also constitute a wide

spectrum including conducting evaluation studies of Government schemes, action

research initiatives involving communities, advocacy through dissemination of

research findings, capacity building, statistical research, and analyses of policy

impact.

GRAAM (Grassroots Research And Advocacy Movement)

CA-2 KIADB Industrial Housing Area

Ring Road, Hebbal, Mysore, INDIA – 570016

Tel: +91 821 2410759

Telefax: +91 821 2415412

E-mail: [email protected]

Website: www.graam.org.in

mailto:[email protected]

http://www.graam.org.in/

ix


Introduction

In the year 1984, Swami Vivekananda Youth Movement (SVYM) began its work in

the remote forest tracks of Heggadadevanakote Taluka of Mysore district by

providing medical care to the tribal and rural population of the region. Since then,

SVYM has expanded its work in the health sector by setting up hospitals, mobile

clinics, conducting health awareness and education programs, etc, which has given

the organization a rich experience and deep insight about the status of health

services in rural settings.

Additionally, SVYM’s continuous fight against corruption and being part of a

movement on Right To Information (RTI) brought forth some information about the

gaps in health services viz. discrepancies in supply of drugs, lack of delivery

facilities for pregnant women, shortage of personnel at health centres, problems in

transportation, etc, that pushed poor rural and tribal families into despair.

It is common knowledge that policies and programs are planned by the State to

improve the lives of its citizens. Further, the government earmarks funds to

translate these policies and programs in to reality. But, the poor, marginalized

sections of the society still are in a deprived state, struggling to survive. Budget

outlays often fail to translate into service delivery to all sections of the society. It

therefore becomes important for civil society to understand and analyse the budget

process and further engage in advocacy activities that enhance the reach and

relevance of government programs.

Such an understanding and the need for advocacy based on empirical evidence

forms the basis of GRAAM’s (a policy research and advocacy initiative of SVYM)

endeavor to undertake a pilot study in tracking the budget under National Rural

Health Mission in Mysore district.

The findings of this study and advocacy activities planned is expected to help the

Government and civil society to work together in identifying different dimensions of

health issues and health policies. This is also an effort to advocate for appropriate

changes to health policies, and ensure that an effective, transparent and inclusive

health system is in place. In particular, these are steps towards realizing some of the

key aspects of NRHM’s vision viz. providing support for safe maternity and

empowering community to monitor the health services that it is entitled to.


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This study has led GRAAM to take up community level advocacy with 3 VHSCs

under the purview of one PHC and develop need based health plans for the

respective villages. Though these plans focus primarily on monitoring of health

services and facilities available to the villages, the planning process itself has been an

exercise in understanding and being aware of resources, programs and budgets that

a village community is entitled to. In the long run, it is hoped that community

involvement in the preparation of health plan will evolve to a level where it is

empowered enough to prepare and propose need-based health budgets for the

villages and work with different government departments to secure the budget

allocation.

In fact, such a need based approach is suggested by NRHM itself (GoI, 20061) as one

of the three approaches for equity based allocation of resources – which in turn is

crucial to realize the vision and missions of NRHM.

Inferences on NRHM Fund flow as a result of this study:

Though NRHM emphasizes on linking decentralized planning with fund releases to

ensure effective and efficient delivery of health services, the ground reality provides

a different picture. In the manual titled “NRHM: Broad Frame Work for Preparation

of District Health Action Plans” from MoHFW, it is suggested that the state could

adopt any one of the three approaches that it has identified.2 Though the document

elaborates on the second approach and gives a cursory note on the third, the need

based approach emerges as the most appropriate to translate its goals. While the

centre suggests three approaches to the states so that they may adopt any one, the

centre itself shows a lack of consistency in its approach as it does not seem to follow

any of these approaches when it allocates funds to the states. The study shows lack

of such consistency at district levels also when it comes to handling of funds and

maintenance of data.

A concerted effort to address this could result in a manifold enhancement of the

effectiveness and efficiency of budget allocation as well as funds utilization

processes.

1 Government of India (GoI) (2006): ―NRHM: Broad Framework for Preparation of District Health

Action Plans‖, National Rural Health Mission, New Delhi, Ministry of Health and Family Welfare 2 a. Equal Distribution of resources to all districts; b. Equity based distribution based on socio-

demographic characteristics; c. Need based approach.

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1

Programs under National Rural Health Mission

1.1 The National Rural Health Mission

The current health situation in India is a sad story of inequity and deprivation3.

Accesses to healthy living conditions and good quality health care for all citizens are

not only basic human rights, but also essential prerequisites for socio-economic

development. However, inequality in social, economical or political context between

various population groups in society has a direct bearing on its health indicators.

In a country claiming a booming economy, more than 47% of its children are under

weight (UNICEF, 2011)4, medical professionals working in government health

departments are in severe short-supply, and the prevalence of high levels of IMR

and MMR are indicators that policy outreach with regard to health has a long way to

go. Limited health care infrastructure on one hand and poverty levels that prevent

the poor from availing medical treatment on the other, are responsible for a large

section of people being excluded from access to quality health care. (InfoChange,

2006)5

The Government of India launched the National Rural Health Mission (NRHM) in

April, 2005 to carry out necessary architectural corrections in the primary health care

delivery system. The Mission aims to provide comprehensive and integrated

primary healthcare to the people, especially to the rural poor, women and children.

It adopts a synergic approach by relating health to determinants of good health viz.

nutrition, sanitation, hygiene and safe drinking water. It also aims to mainstream the

Indian system of medicine to facilitate comprehensive health care.

The Mission is an articulation of the commitment of the Government to increase the

outlays for health from 0.9% to 2-3% of GDP by 2012 and to undertake systemic

3 Sovan P. 2004 Health in India: Current Scenario and Future Direction. People’s March, Voices of Indian

Revolution. Vol 5 No.8, Mukherjee.S. 2010. A Study on Effectiveness of NRHM in Terms of Reach and

Social Marketing Initiatives in Rural India.European Journal of Scientific Research Vol 42 No4 Pp.587-

603 4 UNICEF 2011, The Situation of Children in India a Profile. New Delhi 5 www.infochange.org

http://www.infochange.org/


2


correction of the health system to effectively utilize such increased outlays for

sustainable outcomes. The Plan of Action of the Mission aims at reducing regional

imbalances in health outcomes by relating health to the above mentioned

determinants of good health; pooling resources; integrating organizational

structures; optimizing human resource; integrating Ayurveda, Unani, Siddha and

Homeopathy (AYUSH) into the health care system; decentralizing management of

health program and strengthening district management of health program (akin to

Sarva Shikshan Abhiyan); facilitating community participation and ownership of

assets; induction of management and finance personnel into the district health

system, and operationalizing effective referral hospital care at Community Health

Centre [CHC] in each block of the country as per the Indian Public Health Standards

(IPHS) mandate.6

The Mission tries to achieve these goals through a set of core strategies including

decentralized planning and management, appointment of female Accredited Social

Health Activists (ASHA) to facilitate access to health services, up gradation of the

public health facilities to IPHS, reduction of infant and maternal mortality through

Cash Incentive schemes like Janani Suraksha Yojana (JSY), and strengthening

community participation through Village Health and Sanitation Committees

(VHSCs)

1.2 NRHM Fund Flow - An overview

The NRHM integrates all related, inter-linked and standalone schemes in the health

sector including RCH, National Disease Control Program (NDCP), Integrated

Disease Surveillance as well as new initiatives proposed under NRHM and National

Commission on Macro Economics and Health (NCMH). A common and flexible

fiscal pool has been designed to cover all NRHM activities and various financial

resources including external aid have been rationalized and compressed into four

categories. These include:

(i) operational support to states (released through treasury route)

(ii) operational cost of institution supported by MoHFW

(iii) activities centrally implemented; and

(iv) activities in the State Program Implementation Plan (released through

State Health Societies). Support for the District Health Action Plans falls

under the category of support to activities in the State PIP.

6 Prasanna Hota. National Rural Health Mission in, Indian Journal of Pediatrcs. Vol No 73. 2006 Pp:21-

23


3


Funds under NRHM are released to states through integrated health societies under

the following components:

A. Reproductive and Child Health Program (RCH Flexipool)

B. Additionalities under NRHM (Mission Flexipool)

C. Routine Immunization (including Pulse Polio) (RI)

D. National Disease Control Programs (NDCP)

NRHM stresses on providing financial autonomy to states and districts, so that local

requirements are taken care of through immediate health actions. NRHM also aims

to increase public health expenditure by 10% annually during the mission period

and the states are expected to contribute 15% of the outlay annually towards health.

Following the submission of State PIP, the National Program Co-ordination

Committee (NPCC) approves the same and funds are released for the upcoming

financial year. The funds are transferred to the State Health Society in four

components and additionally, the society will receive the state‘s share of 15% of the

total outlay. The funds are generally released to states in 3 or 4 trenches upon

submission of Utilization Certificate and other documents. NRHM has evolved the

concept of ‘funneling’ for effective horizontal integration of programs at the district

level. All activities and programs under RCH are supported by RCH Flexipool and

additional activities under NRHM utilize financial resources in the NRHM

Flexipool. Innovative fund transfer mechanisms such as e-transfer are encouraged

under the mission.

1.3 Janani Suraksha Yojana

JSY under the overall umbrella of NRHM has been initiated by modifying the

existing National Maternal Benefit Scheme (NMBS). While NMBS is linked to

provision of better diet for pregnant women from families living Below Poverty Line

(BPL), JSY integrates the financial/cash assistance with ante-natal care during the

pregnancy period, institutional care during delivery and immediate post-partum

period in a health centre by establishing a system of coordinated care by ASHA, the

field level workers. It is a fully centrally sponsored scheme.

The main objective of JSY is to reduce the overall mortality ratio and infant mortality

rate and to increase institutional deliveries among BPL families. To overcome the

regional disparity, NRHM identifies all 8 North East States, which include; Assam,

Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim and Tripura,


4


for special focus. States are categorized into two groups: states that are high-focus/

low-performing and low-focus/high-performing.

Karnataka is a low-focus/high-performing State where the pregnant mothers

delivering in a government/private hospital recognized under JSY scheme are

entitled for cash incentive of Rs.700 in rural area and Rs. 500 in urban areas for

normal delivery and Rs.1500/- for Caesarean section. Women delivering at home are

entitled to receive Rs.500/- irrespective of place of residence.

JSY cash incentive is disbursed to women belonging to BPL category, and also to

women from SC and ST irrespective of their BPL status. The scheme also lays down

the clause for the high performing states that the beneficiaries should be above

19years of age and the incentive is only up to two live births.

1.4 Maintenance Funds

Health sector reforms under the NRHM aims to increase functional, administrative

and financial resources and autonomy to the field units like PHC and sub-centres, by

providing funds to maintain and upgrade the infrastructural facilities.

PHC: Under this scheme every PHC gets an Annual Maintenance Grant of

Rs.50,000/- and 24X7 PHC gets Rs. 100,000/- for improvement and maintenance of

physical infrastructure of the PHC. This fund is to be used for providing water

facility, building toilets and their maintenance, etc.

At the PHC level, Panchayat Committee/Rogi Kalyan Samiti is the body where

decisions pertaining to expenditure of funds under annual maintenance grant are to

be taken. This committee is also empowered to supervise the work undertaken from

Annual Maintenance Grant.

Sub-centre: Likewise every Sub-centre that has a building gets an Annual

Maintenance Grant of Rs. 20,000/- for improvement and maintenance of physical

infrastructure. This fund is to be used for provision of water, toilets and their

maintenance, etc.

1.5 Untied Funds

PHC: The necessity of introducing untied fund has been felt mainly due to

unavailability of funds for undertaking any innovative health centre-specific need-

based activity. The allotment of funds to the States has traditionally been of the

nature of tied funds. This hardly left any funds with the public health facilities to

plan and/or implement any developmental activity/scheme.


5


This centralized management and schematic inflexibility in the use of funds allotted

to the States, did not provide any scope for local initiative and flexibility for local

action at block and down below level. This led to a situation where most of the PHCs

are unable to procure items based on their needs. To overcome lack of steady fund,

and to make funds locally available for repair/refurbishing of infrastructure and

basic facilities, every PHC under NRHM gets Rs. 25,000/- per year as untied grant.

The guidelines lay down certain basic conditions to be fulfilled for the utilization of

the funds. It notes that since there would be substantial fund flow to the districts to

be utilized for the health centres under NRHM / RCH-II and other programs, the use

of untied funds should not duplicate activities that ought to be taken up under other

programs. Each activity planned by the health centre should have clear rationale so

that the impact of the untied fund can be distinctively assessed. A separate register

be maintained in the PHC giving sources of funds clearly for various activities.

PHC untied fund shall be kept in the bank account of the concerned Rogi Kalyan

Samitti (RKS) / Hospital Management Committee (HMC). Joint signatories

authorized to withdraw fund from this account are PHC Medical Officer and Gram

Panchayat President. The funds will be spent and monitored by RKS. The Centres

are not required to take prior approval before implementing the schemes from the

untied funds but shall have to send quarterly SoE and UC.

Sub-centre: The scheme of providing Untied Funds also addresses the needs of sub-

centres under NRHM. The scheme lays down that the funds be available at the sub-

centre level to facilitate the urgent yet discrete activities that need relatively small

sums of money. For this purpose each sub-centre is provided with Rs 10,000 under

NRHM.

Joint signatories authorized to withdraw fund from this account are the respective

ANM and Gram Panchayat President. It specifies the following conditions for the

use of the funds.

1. Each sub-centre should hold an account operated jointly by the ANM and the

Sarpanch. It is in this account that the fund received is maintained.

2. Decisions on activities for which the funds are to be spent will be approved

by the Village Health Committee (VHC) and be administered by the ANM. In areas

where the sub centre is not co-terminus with the Gram Panchayat (GP) and the Sub-

centre covers more than one GP, the VHC of the GP where the sub-centre is located

will approve the Action Plan. The funds can be used for any of the villages, which

are covered by the sub-centre.


6


3. Untied Funds will be used only for the common good and not for individual

needs, except in the case of referral and transport in emergency situations.

VHSC: Village Health and Sanitation Committee, the end point in NRHM through

which the main vision ‘health for all’ and creation of a healthy society by people’s

participation is realized, is indeed a very positive and inclusive approach. The first

three important core strategies listed in NRHM mainly looks at the involvement of

community level institutions and people, for example,

Training and enhance capacity of Panchayati Raj Institutions (PRIs) to own,

control and manage public health services,

Promotion of access to improved healthcare at household level through the

female health activist (ASHA),

Health Plan for each village through VHC of the Panchayat7.

The mission seeks to empower local governments to plan, facilitate implementation,

manage, control and be accountable for public health services at various levels. The

idea is to realize that the decentralized planning, facilitation of implementation,

oversight and monitoring through community involvement are likely to be more

responsive to the healthcare needs of local communities and will be a step towards

‘communitisation’ – the most important feature of NRHM.

To initiate the community-led action, the implementation framework of NRHM

emphasizes on committees at different levels. The VHSC is perceived as a simple

and effective management structure at the lowest level, comprising representatives

from the village. Its key function is to prepare the village health plan, implement it

and manage the fund which is earmarked as per the need of the community. This

committee is a facilitating body for village level development programs relating to

health and sanitation and reflects the aspirations of the local community. Towards

this, every VHSC receives an annual untied grant of Rs.10,000/-. The amount is

maintained in a separate bank account designated to the VHSC. Joint signatories

authorized to withdraw fund from this account are the village ASHA and the VHSC

President, who is also an elected member of the Gram Panchayat.

7 Government of India (GoI) (2005): "National Rural Health Mission 2005-2012: Mission Document",

New Delhi, Ministry of Health and Family Welfare.

7


2

Tracking of Funds under NRHM: Study Characteristics

2.1 Study Objective

The study aims to understand the timeliness in fund allocation, distribution &

utilization of JSY Incentive, Untied and Maintenance Funds under NRHM in Mysore

District between 2006 07 and 2010-11.

2.2 Rationale for the study

A key strategy under NRHM to fulfill its goals is to increase the public spending on

health from 0.9% GDP to 2-3% of GDP by 2012. This increase in budget allocation is

aimed at reducing regional imbalance in health infrastructure, pooling resources,

integration of organizational structures, optimization of health, human resource,

decentralization and district management of health programs, community

participation and ownership of assets, induction of management and financial

personnel into district health system, and operationalization of community health

centres into functional hospitals meeting IPS in each block of the Country.

The objectives and expectations of programs and schemes under NRHM are set at

different levels for different states based on their health indicators and health care

infrastructure. Karnataka is one of the better placed states with respect to maternal

and infant mortalities. The institutional delivery rate was 65.1% (DLHS 3 -2007/08)8

and maternal mortality ratio was 178 per 100,000 live births (SRS 2007-09)9. The goal

of the RCH program in Karnataka for 2011-12 is to increase institutional deliveries to

99% as per Karnataka NRHM PIP 2009-10.

The official records of Karnataka indicate a steep increase in institutional deliveries

and drastic reductions in number of home deliveries. However, there continues to be

a large rural-urban difference in health indicators. For example, the IMR for urban

areas was 33 compared to 52 in rural areas (SRS 2007); the institutional delivery in

8 http://www.rchiips.org/index.html 9 http://censusindia.gov.in/vital_statistics/SRS_Bulletins/MMR_release_070711.pdf


8


urban areas was 79.8% compared to 59.7% in rural areas (DLHS 3, 2007-08). This

calls for a concentrated effort to improve maternal health care services in rural areas.

2.2.1 Literature Review

Literature pertaining to health related situation in India highlights different

dimensions of health facility and approach of the governments towards health in

India.

Ramani KV, and Dileep Mavalankar (2005)10 note that the critical areas of

management concerns in Indian health care system are mainly, non-

availability of staff, weak referral system, poor service delivery, financial

shortfalls and lack of accountability of quality of care.

Sucha Singh. Gill, Ranjit Singh Ghuman (2005)11 identified the need for

prioritizing rural health care particularly from the preventive aspect.

According to the study, allocating additional investments in the state policy

for sanitary infrastructure and medical personnel in rural areas is essential for

redressing the growing disparity in health care facilities between rural and

urban Punjab. The study concludes that, to improve the health services in the

rural areas, the village community (through Panchayat Raj Institutions) needs

to be involved in the supervision and functioning of the whole system to

make it accountable to the users. However, the study does not address the

execution of the same.

Arvind Pandey, Nandini Roy, D Sahu, Rajib Acharya (2004)12 correlated the

utilisation of antenatal care services and assistance received during delivery

in Chhattisgarh, Jharkhand and Uttaranchal States, which are characterized

with distinct geographical and topographical features. The study focuses on

the particular features of the three states concluding that it is necessary for the

reproductive and child health program to visualize a dynamic strategy giving

due consideration to the geographical and socio-economic factors.

10 Ramani. K.V., Mavalankar Dileep: “ Health System In India: Opportunities And Challenges For

Improvements, Indian Institute Of Management Ahmedabad Working Paper Series, 2005

11 Gill. Sucha Singh, Ghuman Ranjit Singh:“Rural Health: Proactive Role For The State”; Economic

And Political Weekly December 16, 2000 12 Pandey Arvind, Roy Nandini, Sahu D, Acharya Rajib:“Maternal Health Care Services: Observations

From Chhattisgarh, Jharkhand And Uttaranchal”, Economic And Political Weekly February 14, 2004


9


The series of assessment study report on ASHA and JSY in different states of

India (2007)13, discusses the status of ASHA and the JSY schemes after two

years of implementation of the NRHM, The studies indicate that the training

period was not according to the requirement of the program, that there was

some delay in payment to ASHA and that 75 per cent of the JSY beneficiaries

had received funds within a week. The studies also high light that in spite of

the JSY funds related satisfaction being relatively high, it could not be cited as

the major reason for the preference for institutional delivery. Dai (the

traditional mid-wife) assisted home deliveries continued to be the most

preferred practice. This brings to fore some very basic questions about the

thrust on institutional deliveries.

Discussing the out of pocket expenditure and its impact on the rural poor in

India, Ravi Duggal (2005)14 brings forth the fact that in India only 15 percent

of the requirement for the health care system is publicly financed leaving a

large majority out of reach of the health care services. Duggal notes that for

poor it is very difficult to seek health facility from private sector which he

traces had increased 5 times post SAP period. He notes that post SAP period

the public financing in health actually came down, leading to stagnation in

health outcome in the country.

Large disparities have been reported between states in regards to allocation of

funds (Berman & Ahuja, 2008)15. The parameters used for fund allocation such

as population, health infrastructure, disease epidemiology etc. have hardly

contributed towards equity in financing. This is compounded with a lack of

flexibility in moving funds from one head to another, resulting in under-

spending in some heads and over-spending in some. The authors call for

increased focus on reducing regional disparities, while moving from need-

based financing to result-based financing for better outcomes.

The Comptroller and Auditor General’s (CAG)16 report on NRHM, reveals

that funds were allocated to states mainly on the basis of population but not

on a compound index derived from socio-demographic characters of the

13

CORT.2007. Assessment of ASHA and Janani Suraksha Yojana in MP, Orissa and Rajasthan

sponsored by UNFPA, New Delhi, 14

Ravi Duggal. 2005. Out- of- Pocket burden of Health care. Infochange India. www.infochange.org 15

Berman, P and Ahuja, R (2008): ―Government Health Spending in India‖, Economic and Political

Weekly, June 2008, pp. 209-216 16

Comptroller and Auditor General of India (2008):Performance Audit of National Rural Health

Mission‖, New Delhi

http://www.infochange.org/


10


states17. Further, it was observed that states with weaker health indicators

received much lesser funds in comparison with states that are strong in terms

of health indicators. Another interesting observation in the report is that the

allocation of resources to state was done based on the total population of the

state, which includes urban population. This, the report suggests, is not

consistent with the goals of NRHM which seeks to transform rural healthcare.

The report also notes that in many states, untied funds are grossly misused

for purposes that are barred under the guidelines for utilization of untied

funds (NRHM, 2005a), while in several places untied funds are unspent.

Similar observations were made in the rapid appraisal of NRHM in the

district of Hassan, Karnataka. Under-utilization of untied funds was

apparent, which can be attributed to confusion in interpreting the guidelines

for expenditure of untied funds and lack of co-operation from members of

Gram Panchayat (Hammer. J. et al, 2007)18.

A study on fund flow and service delivery in two districts of Karnataka by

Gayithri & Thomas, (2011)19 highlights the mismatch between funds released

and needs of the district. The study focused on two districts - Gulbarga and

Chitradurga, of which the former is considered backward with respect to

health indicators. In terms of per-capita allocation, Gulbarga lags behind

Chitradurga, which is a less needy district. Further, the authors note that

expenditure is not in synchrony with the rise in fund allocation, indicating

lack of skill to utilize resources in the sub-district levels.

Most of the literature addresses the issues of deliverables in the health care system.

Although, there are studies that touch upon fund availability, only few studies look

into the fund disbursement mechanism and the associated variances, and link them

with deficiencies and non-availability of facilities at the receivers’ end. It is in this

direction the present study helps to generate some information

This leads us to the need to look at the financing patterns made available to the

health centres, the mode of expenditure practices adopted and the resultant change

in the health care services. Budget analysis as we know is a tool for understanding

17 Controller and Auditor General of India (2008):Performance Audit of National Rural Health

Mission‖, New Delhi 18 Hammer, J. et al. (2007): Understanding Government Failure in Public Health Services‖, Economic

and Political Weekly, Vol. 42, No. 40, pp. 4049-4057 19

Gayithri, K and Thomas, E (2011): ―District fund flow under NRHM and service delivery: Some

insights from Karnataka‖, Bangalore, Institute for Social and Economic Change


11


the intent and possible impact of governments’ plans for raising and spending public

resources.20 The power of budget analysis is that it can provide evidence needed to

support advocacy, strengthening the ability of civil society organizations (CSOs) and

the public to influence decisions on tax policies and allocation of resources to specific

policies and programs. In addition, by testing the assumptions underlying proposals

and identifying potential pitfalls, budget analysis can help turn policy ideas into

desired outcomes.21

Although the budget receives the most attention from policy-makers, the public and

the media at the time of release of Executive’s Budget Proposal, the same level of

engagement is not shown by them throughout the budget cycle.

It is in this background the present study has been taken up to look at the funds

available at the district and below level under one of the largest and most ambitious

efforts of the Union Government, namely the National Rural Health Mission to

deliver health services to the rural poor in India.

The funds analyzed and tracked under this study are

i. Janani Suraksha Yojana

ii. Maintenance Funds

iii. Untied Funds

These funds and their importance under NRHM have been introduced in the

previous chapter and subsequent chapters of the report give a description of the

fund flow and utilization issues.

In the light of studies showing that significant amount of funds allocated under the

NRHM are being perceptibly under-utilized and also sometimes misused (Hammer.

J. et al. 2007, Gayithri & Thomas,2011) and a lack of awareness amongst the public

about the program (UNFPA supported studies, 2007, 09), the resources and the

outcomes expected raises some important questions.

Does Government responsibility for public health care services end with increasing

the budget alone or is the utilization of funds to reach the intended people equally

important? Why is that, the allocated funds are not being utilized by different levels

of care giving centres? What issues work as stumbling blocks in translating the

20 http://internationalbudget.org/budget-analysis

21 http://internationalbudget.org/budget-analysis

http://internationalbudget.org/budget-analysis

http://internationalbudget.org/budget-analysis


12


visions of the Mission? These are essential questions that need to be answered

especially when it comes to services targeted for the rural women of India.

It is hoped that the analysis of the public expenditure would not only yield a status

report but also enable understanding of the modifications needed in the program

structure and process to achieve the desired results. The lack of proper utilization of

funds is alleged to be due to several factors.

a. Inadequate guidelines for utilization of the funds.

b. Untimely disbursements of the grants

c. Limited competence amongst the field functionaries and the Panchayat (Local

self Government) members in planning, understanding the procedures and

financial management

Funds tracking would also create opportunity for policy advocacy and grassroots

level action for betterment of program processes to achieve the set objectives of

NRHM. The extent of increase and the sources of funding therefore need to be

assessed for their adequacy and relevance for further policy initiatives. It is in this

background the present study tries to capture the effectiveness of the JSY, Untied

and Maintenance schemes of NRHM in the district of Mysore in Karnataka.

2.3 Study Setting

2.3.1 Study Location: Mysore District

According to the 2011 census Mysore district has a population of 2,994,744, This

gives it a ranking of 125th in India (out of a total of 640) and the 3rd largest in the

state. The district has a population density of 437 inhabitants per square kilometer

(1,130 /sq mi). The district stands at 7th position out of the 29 districts in the state in

terms of income, but is 14th in the Human Development Index (HDI) as per District

Human Development Report of 2009.

Some of the health indicators of Mysore district are: Institutional Delivery rate of

93%, IMR of 18 and MMR of 13 per 100000 live births in 2008 as per Karnataka

NRHM-PIP data of 2009-10. PIP data reveals that 85% of women in Mysore district

registered in their first trimester of pregnancy and 92% had at least 3 antenatal care

visits during their last pregnancy; the figures for rural areas were 82% and 93%

respectively. Its population growth rate over the decade 2001-2011 was 13.39 %.

Mysore has a sex ratio of 982 females for every 1000 males, and a literacy rate of

72.56 %.


13


The data for the study was collected from seven Talukas22 of Mysore district in the

state of Karnataka between September 2010 and September 2011.

Figure 1: Study Location

Data collection Period: Feb 2011

to June 2011

• 7 Talukas of Mysore District

in Karnataka

• Total Population of the District: 2,994,744

Study Period: September 2009 to March 2012

2.4 Study Design

The study is descriptive in nature, employing a mix of both qualitative and

quantitative methods.

Sampling: The study units were selected from a list of PHCs provided by the DHO’s

office, as per which there are 138 PHCs spread across 7 Talukas of Mysore District.

For the current study we have emplyed multi-staged random sampling using lottery

method.

In the first stage of sampling, 7 PHCs (one from each Taluka) were chosen by using

lottery mehtod. The second stage involved choosing of sub-centres. In this stage 7

Sub-Centres were selected by lottery method from the list of the sub-centres that fall

within the jurisdiction of the above chosen PHCs, 1 from each Taluka.

22 The seven taluks in the district are; Mysore, T. Narasipur, Heggadadevana Kote, Krishnaraja

Nagara, Periayapatna, Hunsur, Nanjangud.


14


Choosing VHSCs formed the third stage of sampling. For this stage, from the list of 7

VHSCs were chosen from those that fell under the chosen sub-centres, by using

lottery method.

The fourth stage of sampling was undertaken to choose ASHAs from among those

villages that fall under the chosen sub-centres using lottery method. This process

gives us 7 ASHAs across the district

Further, in order to choose the JSY beneficiaries, a base line survey of all the villages

that fall under the chosen sub-centre was undertaken, wherein women who had

delivered between April 1st of 2006 and 31st March 2010 were identified. From this

list keeping the eligibility criteria under JSY CIs in mind, 5 women, who were

willing to be part of the study were chosen from each Taluka.

In addition, 5 men and 5 women utilizing the services of the PHC, and willing to be

part of the study, were randomly chosen under general beneficiaies category from the

villages from where JSY CI beneficiaries were chosen.

2.5 Study Tools

To capture the direction for the Focused group discussions (FGDs) preliminary Group

Discussions (GD), were held with all the categories of the respondents. Based on the

inputs, questions for FGDs and in-depth interviews were developed. These tools were

administered to general beneficiaries, JSY beneficiaries, ANMs, ASHAs, VHSC

members, THOs, and MOs across the district.

Figure 2: Study Tools

• Descriptive study covering Quantitative and Qualitative aspects

• Interview schedules

• GDs &FGDs

• Review of funds related documents at SC, PHC, THOs, District level

• Quantitative Data was analyzed using SPSS software

• Qualitative data was triangulated with data provided by DAM & BPMs

VHSC Members, ASHAs, ANMs, PHC MOs

JSY Beneficiaries


15


Data was elicited from the chosen universe by employing IS after obtaining oral

consent from all the participants. IS for different categories of respondents were

prepared by the research team in English. This was translated into Kannada, the

local language. Field testing of all the IS for different categories of respondents was

undertaken and based on the feedback received, ISs were reworked and finalized.

Tables 1 and 2 provide details pertaining to the number of beneficiaries under

different categories covered for the study.

Table 1: Number of GDs & FGDs held with different categories of respondents of the study

Group discussions

General Beneficiaries Male (GBM)

7

Group discussions

General Beneficiaries Female (GBF)

7

Focused Group discussions GBM 7

Focused Group discussions GBF 7

Focused Group discussions JSY B 7

Discussions with THOs 4

Discussions with Medical Officers 40

DHO, DPMO, DAM 2 Each*

* Within the study period two different persons held office at different times and the study covers

both in each category

Table 2: Categories and number of respondents to whom structured interview schedule was

administered

Category included in the study Sample

Size

Primary Health Centres (MOs) 7

Sub-Centres(ANMs) 7

VHSC in-charge 7

ASHAs 7

GBM (Male) 35

GBF (Female) 35

JSY Beneficiaries 42

Data related to Funds collected from the sub-centres, PHCs and VHSCs have been

analysed against the data collected from THOs’ and DAM offices.


16


In the subsequent sections of the report, findings pertaining to Fund disbursal from

district to Taluka level are presented and the analysis of data available from official

documents versus the information from the field studies is discussed. Issues related

to timeliness of funds made available at all levels and its related implications,

awareness, accessibility and utilization of CIs are also addressed.

17


3

Analysis of the Fund Related Data

3.1 Background

For the present study, secondary data pertaining to chosen categories of funds under

NRHM was obtained from DHO’s office, Mysore, and 7 Taluka Health officer’s

offices. The data pertaining to receipts of fund and expenditure from 7 chosen PHCs,

7 sub-centres and 7 VHSCs each was collected using the interview schedules.

Information related to the following types of Funds was sought from the officials

concerned

a) JSY

b) Untied funds

c) Maintenance funds

The data was collected with the following objectives

a) To study the process of budget preparation and funding for different levels of

health service institutions

b) To assess the timeliness in fund seeking and sanctioning; disbursement and

utilization

c) To understand the fund related reporting mechanisms in operation

3.2. Fund flow and utilization analysis

The analysis of the information shared by officials at different levels brings forth

certain major issues in documentation practices at the ground level. The following

section gives the picture of the fund flow and utilization related issues.

3.2.1. Funds required, received and spent

Introduction of funds to all levels of health care providing units under NRHM has to

a great extent removed the fund crunch always associated with the government

hospitals. But, the pattern of fund flow and the expenditure status has also led to

new issues and questions. Do health care providing units have capacity to absorb the

financial resources? If yes, are the resources made available where and when are


18


they needed? If no, what is needed to equip them to generate the absorption

capability? These questions become crucial in translating the goals of NRHM.

3.3 JSY Funds

The JSY scheme was introduced to provide timely care to pregnant women from

poor sections of the society. The Govt. through NRHM has committed itself to this

cause by allocating funds under this scheme. An understanding of the practices

followed under this scheme will help us in assessing the achievement of the visions

of the Mission.

3.3.1 JSY Fund Flow Analysis

In the following sections an effort is made to answer these questions by comparing

the fund related data provided by DAM, THOs and the from the sample units under

study.

At the outset we present here the JSY related data, which helps us to find the gaps in

issues of receipt and disbursement related procedures followed in the district under

study.

Tables 3 and 4 contain data on the fund that was required and received at the district

level and the period when fund was received and utilized. This has been culled out

of statements provided by the DAM. Yearly estimated requirement of the fund

under JSY has been generated based on the 2001 census population and the growth

rate.

The funds released under JSY scheme, year 2009-10 onwards indicate the effort of

the State to reach the required funds mark (see figures 3 and 4). In spite this increase

we see that there is short fall of funds under the scheme. To add to this backlog

created by shortfall of fund there is at the end of the financial year unspent balance

at the district level. Thus, the number of women who were not covered under JSY

scheme constantly remains high. The field data relating to the wait period under JSY

scheme is discussed in chapter 4. The total of the estimated fund that was required

from the inception of the programe i.e., from 2006-2011 stands at Rs. 7,32,48,413/-.

The total fund released during these years stands at Rs. 7,13,89,745/-, the short fall of

funds is Rs. 18,58,668. Further, the closing balance at the end of 2010-11 financial

year the DHS account stands at Rs. 15,39,349/-. The shortfall and the unused funds

put together stands at Rs. 33,98,017/-. This means that 4854 women still are in the not

received category under the scheme. The information regarding the number of

women not covered is at all stages that gets generated are transferred to the next


19


higher authority. But, the records at the district level does not on the other hand

show this information incorporated into the budgets. These figures do not appear in

the next year’s PIP. We have two issues here, one there is shortfall of funds, and the

other the unused funds available at the district.

Figure 3: JSY Fund released from Mysore District between the years 2006-07 and 2010-11

Questions that were raised in the introductory section pertaining to shortfall of

funds from the State to the district and the problems of absorption get affirmed from

the field evidence. In spite of the increased flow of funds under JSY scheme, the field

data from the Talukas show us that there are still a huge number of JSY beneficiaries

in the ‘not received’ category (see tables 5 and 6.) But, it also emerges that in absence

of information as to when exactly the fund in a month was disbursed and under

what line item? It becomes difficult to conclude that funds were made available well

within the time and the institutions do not have the capacity to absorb the disbursed

funds. This opaqueness is what needs to be addressed in order to make funds

transfer and usage traceable.

0

50,00,000

1,00,00,000

1,50,00,000

2,00,00,000

2,50,00,000

2006-07 2007-08 2008-09 2009-10 2010-11

Estimated fund requirement

Amount released

Short Fall of Funds as against the estimated funds


20


Figure 4: Comparative picture of the JSY Fund related Demand, Receipt, and Short fall

at the district level between years 2006-07 and 2010-11

The tables 3, 4 and 5 also bring forth the accounting discrepancies in SoE without

any explanation given for the same. The closing balance figures in any said year is

understood to be the opening balance figures from the next year and to this the

year’s receipts are added. But the closing and opening balance statement in the SoE

do not match; we have the case of JSY funds related information provided by the

DAM. There is discrepancy in all the years, from 2006-07 financial year to 2010-11

financial year. In table 4 for example in the year 06-07 had Rs. 60, 94,232/- but the

opening balance for the year 07-08 stands at Rs. 50, 87,856/- the variance of Rs.

10,06,376/- . Table 3 and 4 highlights this fact.

-1,00,00,000

-50,00,000

0

50,00,000

1,00,00,000

1,50,00,000

2,00,00,000

2,50,00,000

2006-07 2007-08 2008-09 2009-10 2010-11

Estimated fund requirement

Shortage of funds as against estimated funds

Fund Received (Rs)


21


Table 3: Estimated JSY Fund Required Against fund Released from Mysore District between years 2006 – 2011*

1 2 3 4 5 6 7 8 9 10 11 12 13

Programme Year

Fund

requirement

Estimated at

14.6 % growth

rate based on

2001 census

data

OB

Amount

Released Up

to end of

Month of

Feb

Percentage

of Amount

Released [to

the total

fund

released in

the year] Up

to end of

Month of

Feb

Amount

Released

During the

month of

March

Percentage

of Amount

Released in

the month

of March [to

the total

fund

released in

the year]

Amount

released

during the

year

5+7

Shortage of

amount

against the

estimated

requirement

Percentage

shortfall of

amount

released

against the

estimated

requirement

Balance of

Grant

available on

March 31st

% of

Balance of

Grant

available

for

distribution

JSY 06-07 1,42,28,112 0 5382970 41.78 7500000 58.22 1,28,82,970 13,45,142 9.45 60,94,232 47.3

JSY 07-08 1,44,35,842 50,87,856 12006376 100 0 0 1,20,06,376 24,29,466 16.83 61,97,492 36.25

JSY 08-09 1,46,46,605 56,06,009 219627 1.87 1,15,00,000 98.13 1,17,19,627 29,26,978 19.98 18,50,346 10.68

JSY 09-10 1,48,60,446 6,36,677 14194300 100 0 0 1,41,94,300 6,66,146 4.48 58,07,189 39.16

JSY 10-11 1,50,77,408 6,36,677 NA NA NA NA 2,05,86,472** -55,09,064** -36.3** 15,39,349 7.2

Total

7,32,48,413

7,13,89,745 18,58,668 2.537486

Source: Yearly Financial Progress Report of DHS. Mysore; the funds released in this year is more than the estimated requirement

calculated and hence the shortfall and percentage column shows negative marking


22


Table 4: Expenditure Incurred against Available JSY Funds at the District level between years 2006-2011

1 2 3 4 5 6 7 8 9 10 11 12 13 14

Programme Year OB

Expenditure

incurred Up

to end of

month of

Feb

% of

Expenditure

incurred Up

to end of

month of

Feb

Expenditure

incurred

During the

month of

March

% of

Expenditure

incurred

During the

month of

March

Total

Amount

Available

for

expenditure

in the Year

Total

Expenditure

incurred

during the

Year

Total % of

Expenditure

incurred

During the

Year

% of

Amount

Remitted

to A/c of

PD(RCH )

Amount

Remitted

to A/c of

PD(RCH )

Balance

of Grant

available

on March

31st

% of

Balance of

Grant

available

for

distribution

JSY 06-07 0 4,851,063 71.46 19,37,675 28.54 1,28,8T2,970 67,88,738 52.7 0 0 6094232 47.3

JSY 07-08 50,87,856 86,02,400 78.94 22,94,340 21.06 17,09,4,232 1,08,96,740 63.75 0 0 6197492 36.25

JSY 08-09 56,06,009 1,51,79,890 98.09 2,95,400 1.91 17,3.25,636 1,54,75,290 89.32 0 0 1850346 10.68

JSY 09-10 6,36,677 62,03,888 68.75 28,19,900 31.25 1,48,30,977 90,23,788 60.84 0 0 5807189 39.16

JSY 10-11 6,36,677 1,77,08,000 90 19,75,800 10 2,12,23,149 1,96,83,800 92.74 0 0 15,39,349 7.2

Source: Collated from SoEs of DHS. Mysore


23


Table 5: Variance in Opening and Closing Balances pertaining to JSY Funds at the district

across different Financial Years

Year Opening Balance

(Rs)

Closing Balance

(Rs)

Variance (Rs)

06-07 0 60,94,232 0

07-08 50,87,856 61,97,492 10,06,376

08-09 56,06,009 18,50,346 05,91,483

09-10 6,36,677 58,07,189 12,13,669

10-11 6,36,677 15,39,349 51,70,512

Source: Collated from SoE of DHS. Mysore

The tables clearly show us that the total fund required under JSY scheme and the

amounts released do not match and there is a huge gap in estimated requirement

and the funds released. Equally disturbing is the fact as shown in the table 5, the un-

spent fund in all the years is more than 25%; this implies that there is an increase in

the number of beneficiaries who are not paid when they are supposed to be getting

the financial support. This definitely goes against the main purpose for which

NRHM was visualized; to bring more number of pregnant women who come from

economically and socially marginalized sections of the society into safe and

protected health care system. The number of women who could have been covered

but were not is also big.

JSY scheme is meant to encourage institutional deliveries with an objective to reduce

instances of maternal and infant mortality. Beneficiary mothers are receiving these

benefits much after delivery defeating the very objective of the schemes. Ironically

while on the one hand there are unspent balances under the NRHM program,

coexistent are non/delayed payments for certain schemes.

The scheme does not specifically speak about the inclusion or exclusion of those

cases where still birth has occurred. JSY scheme however, provides for the second

live birth even in those cases where the first birth resulted in twins. The

interpretation of eligibility criteria in different manners by health functionaries at

different levels opens up a scope of exclusion to deserving women.


24


In the case of the State Government sponsored scheme to encourage the practice of

regular ANC among pregnant women (Prasuti Araike) PA23, the GO very clearly

states that if the mother delivered twins during her first delivery, and both are alive

then the woman is not eligible for PA.

The evidence from the field supports this. 14 women under the study did not get any

cash incentives. Majority of the women who did not receive noted that they were

informed by health personnel that they were not being paid CI due to lack of funds.

Other reasons quoted were lack of documents. Detailed discussions are presented in

subsequent sections.

23 While fund related information pertaining to JSY scheme was being collected, some input on

Prasuti Araike (PA) a state component meant for maternal health also emerged. Wherever data for PA

was made available the same is presented. PA is one of the special programs introduced by Karnataka

state for pregnant women is the Prasuti Araike ‘Care for the pregnant woman’ scheme. Prasuti Araike

scheme was initially introduced in six “C” Category districts of Karnataka State, viz, Gulburga, Bidar,

Raichur, Koppal, Bijapur and Bagalkot for the benefit of pregnant women belonging to below poverty

line (BPL), SC and ST families. This has now been extended to all below poverty line pregnant women

of all the districts in the state. The highlight of this scheme is cash incentive for pregnant women

during the antenatal period itself. This is to encourage rest, nutrition and medical care for pregnant

women. The beneficiaries get Rs.1000 during the second trimester ante natal check-up (i.e. between

4th and 6th month of pregnancy) and Rs. 1000 during the third trimester ante natal check-up (i.e.,

between 7th and 9th month of pregnancy), totaling to Rs. 2000 paid through cheque in the bearer’s

name. The benefit is limited to the first two live births. But in the subsequent GO, the State

Government GO in 2009 specifies that the incentive be given in two phases. The first installment of Rs

1000 is to be given during pregnancy period and the second installment to be given within 48 hrs if

delivered in a government institution.


25


3.3.2. Analysis of JSY funds: requirements, amounts received and unspent

The fund related information from different levels show us different figures. And

there is no note or explanation for this difference made available. Tables 6 bring out

this factor. Tables 6 and 7 also provide information pertaining to the JSY fund

requirement, fund received and the backlog picture across seven Talukas of Mysore

district in the financial years 2009-10 and 2010-11. It is important to note that the

percentage of expenditure of the JSY funds in the month of March at the district level

indicates a positive shift. In the 09-10, financial year, it was at 31% but records a 10%

in the 2010-11 financial year. But the corresponding information at the Taluka and

PHC level is not available. Thus it is difficult to specifically pin the point of delay.

Further the MOs, and the DHO’s office said that all JSY beneficiaries have been

covered and the funding situation has improved. But Tables 6 and 7 highlight the

fact that each year there are across Talukas big number of beneficiaries who did not

receive the funds under JSY CI scheme. The field data also corroborates this fact as

described in the subsequent sections of this chapter.


26


Table 6: Taluka Wise breakup of JSY Beneficiaries V/S Funds Received (FY 2009-10)

Year Region /

Taluka

Total

Expected

Deliveries

for the

Year

Total Number

of Expected

Beneficiaries

Eligible in the

Year

Amount

received

During the

Year

Amount

distributed

During the

Year

Total No of

Eligible

Beneficiaries

of JSY who

received the

CI

Total No of

Eligible

Beneficiaries

of JSY who

Did NOT

receive the CI

Refund

Cumulative

balance on

March 31

No. of

beneficiaries

who could

have been

covered @

Rs.700

2009-

10

H.D.Kote 4517 3752 3312200 3313900 4496 -744* 55700 0

Hunasur 5023 3516 2407900 2384702 3377 139 43798 0 62

K.R.Nagar 4564 3195 2203441 2281544 3099 96 0 43282 61

Nanjanagud 5968 4473 3122500 1348800 4188 285 0 1807700 2582

Periyapatna 4360 3052 1384324 1644835 2245 807 0 18445 26

T.Narasipura 5762 4033 2659467 2358605 3358 675 0 348737 498

Mysore 5756 5116 4569875 4935009 NA NA 0 44796

Total 35,950 27,137 1,96,59,707 1,82,67,395 20763 2746 99498 28,99,637

Source: SOEs of 7 Talukas under study as provided by Taluka Health officials


27


Table 7: Taluka Wise breakup of JSY Beneficiaries V/S Funds Received (FY 2010-11)

Year Region /

Taluka

Total

Expected

Deliveries

for the

Year

Total Number of

Expected

Beneficiaries

Eligible in the

Year

Amount

received

in Year

Amount

distributed

in Year

Total No of

Eligible

Beneficiaries

of JSY who

received the

CI

Total No of

Eligible

Beneficiaries

of JSY who

Did NOT

receive the CI

Refund C b on

March 31

No. that could

have been

covered @

Rs.700

2010-11

H.D.Kote 4792 3525 2834300 2579800 3660 135 3,61,100 0

Hunasur 5013 3509 1218400 2161200 3483 26 0 2,22,224 317

K.R.Nagar 4614 3230 2220400 2049200 2725 505 20,000 1,94,482 277

Nanjanagud 6672 5938 3122500 1348800 2677 3261 0 18,07,700 2582

Peryapatna 4353 3049 2100938 1911400 2597 452 1,79,328 20,527 29

T.Narasipura 5831 4082 3392600 3003000 4172 90 6,32,100 1,05,937 151

Mysore NA NA NA NA NA NA NA NA

Total 31,275 23,333 1,48,89,138 1,30,53,400 19,314 4,019 11,92,528 23,50,870

Source: SOEs of 7 Talukas under study as provided by Taluka Health Officials.


28


3.3.3. Delay in funds disbursal: Reasons cited

1. The ASHAs, ANMs and MOs quoted delay in fund release, lack of funds (for

PA in particular), lack of awareness among women and difficulty in

procuring documental evidences as the problem for eligible women not

getting CIs. The JSY and PA fund related data collected from PHCs indicate a

mismatch in time when funds were required and funds received. For PA,

there was a large gap between the time and amount of funds required and

received. This must be addressed since providing adequate and timely funds

are crucial for the success of the program meant for maternal health

2. Further all the THOs, MOs, ANMs and ASHAs contacted for the study said

that non-availability of cheques is one of the many reasons that create delay in

the fund disbursement. The health functionaries noted a frequent shortage of

cheque books and the fact that they need to write cheques not just under JSY

and PA but multiple programs offered by the government. The MOs observed

that it takes the bank on an average 30 to 45 days(instances of 3-4 months wait

was also reported) to issue a cheque book and they say many a time they get a

cheque book with only 25 leaf which will not suffice their demand. Though

this reason gets reaffirmed by officials at all levels, the problem persists. The

only response we got at all the levels is that the problem has been intimated to

their higher officials and it is up to them to pursue the matter. The simplest of

administrative issues that could be solved has spilled over years as major

hurdle in reaching the NRHM’s visions. When contacted the DHO noted that

his office was negotiating with the bank mangers to solve the issue. But this

till this report was being finalized not solved.

3. Non-availability of documentary evidences has been cited as another reason

for not making payment on time. The guide lines on JSY implementation very

clearly indicates that the process of procuring the documentary evidences

should begin as soon as the expecting mother is registered for ANC and the

responsibility of helping the woman concerned to procure the documents

rests on the shoulders of the ASHAs and ANMs.

The DLHS 3 report shows that in Mysore district records 85 percent of women

registering for ANC in the first trimester. The field data also shows that number of

registration during first trimester is high (data discussed under background

characteristics of the beneficiaries). Given this situation the health service providers

viz. ASHAs and ANMs have ample time to collect documentary evidences under


29


FFaaccttss ffrroomm tthhee ffiieelldd

•• 3333//4422 DDeelliivveerreedd iinn IInnssttiittuuttiioonn

•• 99//4422 DDeelliivveerreedd aatt HHoommee

•• 3399 //4422 hhaadd pprroovviiddeedd ddooccuummeennttaarryy EEvviiddeenncceess

•• 77//4422 ggoott PPAA

•• 22//77 ggoott ppaarrttiiaall PPAA

•• 11//77 ggoott PPAA iinn 33rrdd ttrriimmeesstteerr

•• 2200//3333 iinnssttiittuuttiioonnaall ddeelliivveerriieess ggoott JJSSYY

•• 99//99 hhoommee ddeelliivveerriieess ggoott JJSSYY

•• 99 wwhhoo ddeelliivveerreedd aatt hhoommee aanndd ggoott sshhiifftteedd ttoo

HHoossppiittaall ssaaiidd tthheeyy ggoott JJSSYY wwiitthhiinn 1100 ddaayyss

•• 66//77 WWhhoo ggoott PPAA ggoott iitt oonnllyy aafftteerr ddeelliivveerryy

OONNLLYY 55 WWOOMMEENN GGOOTT BBOOTTHH JJSSYY && PPAA

JSY scheme. Hence, denial of cash incentives owing to non-availability of documents

is not a justifiable scenario. It is thus very important to internalize the philosophy

and intent of the program – facilitating safe motherhood for rural women.

3.3.4. Disbursement of Cash Incentives

All women who are registered

with ANM are considered

registered under JSY if they fulfill

the eligibility criteria. They are

expected to give documentary

proof of eligibility to receive cash

incentives. Out of the 40 women

who had registered for care with

ANM, 32 provided documentary

proofs that were required. 1

woman who had not registered

with ANM also applied for CI by

giving documentary proof (at the

time of delivery). Thus, a total of

40 women applied for CIs

All the 42 women under the

study were eligible for CIs. Of the

42 women who were eligible 29

got CI. All women registered

for ANC had received JSY/PA

card known as tai card (mother’s card)

In the sample of 42 women 33 have delivered in the institution and 9 delivered at

home. Interestingly all the 9 women who delivered at home and got shifted to

institution immediately have been recorded as ‘institutional delivery’. This is a

practice of concern. This issue needs field monitoring further. The NRHM guidelines

very clearly indicates that for all those deliveries that occurs at home if assistance is

provided by the trained health attendant and the woman should receive the CI of Rs.

500/- within 48 hours. However, women in these 9 cases got it within 7 to 10 days

and they received JSY of Rs. 700/- which is the CI for institutional delivery.


30


3.3.5. Difficulties faced in availing CIs

Difficulties in applying:

There is no formal mechanism of applying

for CIs. All eligible women who register

with ANM for ANC are considered to

have applied for CIs. Even though 39 out

of 42 women in the study had registered

with ANM between first two trimesters it

took the women many days and multiple

visits to the Sub-Centre/PHC to furnish

the documents. In our study, of the 42

respondents all eligible for availing CIs, 40

registered with ANM. 31 per cent of these

women expressed difficulties in

completing the required formalities to

receive CI. All the women quoted ‘ANM

not available’ and ‘procuring

documentary evidences’ as the reasons for

difficulty. The ANMs and ASHAs are

expected to help them procure

documentary evidences, if the women are

not in a position to do so. Awareness

levels on most issues are low among

socially and economically marginalized communities viz. SCs and STs; hence the

responsibility shown by ANMs and ASHAs ought to be higher. In practice, the

burden of establishing proof rests on the beneficiaries.

Timeliness of Disbursement:

The Mission document lays down that JSY CI should be given immediately (within

48 hours) after the delivery. Of the 42 eligible women covered under the study 28

women received Rs. 700 under JSY scheme. Of the 28 women who received the CI 1

woman received JSY CI before the discharge, 8 women received within a month, 4

women received between 1 to 2 months whereas 15 women had to wait between 4 to

16 months.

According to NRHM, the women

are deemed to have registered

for JSY the moment ANM

identifies and registers them.

NRHM guidelines also mandate

that the ANM with the help of

ASHA prepare the ANC cards for

all women identified as

pregnant.

For women eligible to receive

CIs, the ANM and ASHA should

help procure the documentary

evidences required, and

complete the process before 1

week of expected delivery date.

Further, as per the directions of

the state government is that the

first installment of PA be

disbursed in the second

trimester itself.


31


When we compare the wait period among the sample respondents across the years

the wait period for JSY is decreasing gradually. This is a positive trend. But the same

cannot be said about the state supported PA scheme for the needy women.

Figure 5: Timeliness of Disbursement of JSY Funds

Figure 6: Timeliness of Disbursement of PA Funds

PA scheme still has extensive gaps in timeliness of disbursement. In our study, of 42

women only 7 women got PA. Of them, 1 woman indicated that she got the first

1

8

4

15 14

0

2

4

6

8

10

12

14

16

JSY Fund related Waiting Period

Immediately after Delivery

Within 1 month

1-2 months

4-16 months

Not got

1 3 3

35

0

5

10

15

20

25

30

35

40

PA Fund Related Waiting Period

3rd Trimester

Immediately after Delivery

> 8 months

Not got


32


Respondent’s Observation

on Prasuthi Araike

“I was supposed get the

PA funds before

delivery, now my baby

has just begun to walk,

and I have not got the

money yet”

installment of PA in her 3rd trimester but did not get her second installment. Whereas

3 respondents noted that they got first installment of PA immediately after delivery

and the remaining 3 women got PA after 18 months of wait.

Figures 5 & 6 above clearly show the waiting period for JSY and PA, and number of

people who have not received the fund

The timing of disbursement of funds also significantly

impacts the purpose for which the money is

ultimately utilized. This information is captured

in Table 8 below. The delay in disbursement

under the CI programmes decreases the

motivation of women to access health care

benefits. Reduction in time gap in applying

and receiving funds would be very important in

realizing the vision of NRHM.

Table 8: Time of Receiving Fund v/s Purpose to which the Fund was used

Received immediately after discharge

Paid back the loan raised for

transportation

Bought all the medicines

prescribed

Bought Some fruits

Received between 1-3 months after

delivery

Paid back the loan with interest

Spent on transportation to see

the Doctor

Received between 4-6 months after

delivery

Visit to Doctor

Husband used

Received >7months after delivery Husband used


33


• 6/7 MOs noted that “Clear the back log first”

formula leaves them many a time in fix

• They observed that “The main purpose of giving

small cash incentives is lost if we do this”

• 5/7 MOs noted that the Cash Incentives if not given

on time will not be used for the purpose for which it

is meant

Mounting backlog:

The ANMs,

ASHAs, and the

PHC prepare the

expected deliveries

list for the coming

month by 21st of

every month and

indicate the total

number of women eligible for JSY and PA and send the information to the Taluka

office which consolidates the request to the district. In spite of time consuming

repetitive work done at the Sub-centres and PHCs the funds are not released to

PHCs on time. The fund flow to the PHCs indicates that the funds are not available

to the MOs whenever it is required. This practice creates a backlog every month.

Though all the officials concerned note that the disbursement of JSY has improved

over the years and they do not have any issue with it, the fund disbursed against the

number of beneficiaries information available does not give that picture. The state

government’s commitment of PA funds disbursement therefore leaves much to be

desired. The MOs also concede that it is a tricky business to manage the backlogs

and are aware of the impacts of a delayed payment.

Corruption or ‘Appreciation’?: From among the 42 respondents as many as 37 noted

that there was a demand for payment for receiving the cheque from the ANMs. The

women also brought up this issue during group discussion where they informed the

research team that it was a kind of an accepted factor that they have to pay in return

for receiving either JSY or the PA CIs. They noted that it was called as ‘appreciation

token’ to be given for the help that the ANMs do.

3.3.6. Summary of findings – Janani Suraksha Yojana

The JSY funds allocation and disbursement shows a steady increase. But this

increase is not taking into account the backlogs (amount to be paid to eligible

women from previous months / years) created in the past years.

Activity based fund requisition and expenditure related information are not

available either at the District level or below. The funds received, the activities

planned and the statement of expenditure do not match. This may be attributed to

the fact that these two sets of data are maintained by different sections, which adopt

different reporting and documenting patterns. Hence analysis and evaluation of the


34


impact of the fund flow would be skewed. This also creates a situation where

identification of gaps in programs and their implementation could be missed and

anomalies might get accrued.

Flexi-budget for payment under JSY scheme is not available either at the

District level or at levels below. On the other hand the fixed amount is also not

released. The JSY fund is released by the district as and when it receives the funds

from the state unit.

The fund allocation, receipt and expenditure information available at the PHC

level cannot be cross-verified either wither the Taluka or the District level

information. This might be because of lack of common patterns of documenting or

because of information gaps at different levels. There is no common maintenance of

activity-linked expenditure of funds over the years.

The dis-aggregated data of fund flow to the lowest level on monthly basis was

not available at the Taluka and district levels for all the years in continuity.

The fund flow information indicates that the funds are being disbursed not

according to the need.

There is a constant backlog accrued; but the officials note that the JSY balance

has been cleared. Field data and official data are not aligned to this information.

Data documented are not correctly stored. Data loss is mainly due to

improper storage conditions, change of personnel, and lack of knowledge in

documentation.

Kannada translations of JSY related guidelines and operating manuals

developed by NRHM are not available.

3.3 Untied and Maintenance funds

NRHM has laid out clear instructions for utilization of funds under the Untied Fund

specifying what purposes it might be used for and what activities it should not be

used for. The guideline states, “Health sector reforms under the NRHM aims to

increase functional, administrative and financial resources and autonomy to the field

units under which every PHC will get Rs. 25,000/- p.a. as untied grant for local

health action. Similarly every PHC will get an Annual Maintenance Grant of

Rs.50,000/- for improvement and maintenance of physical infrastructure. For the sub-

centres this grant is fixed at Rs. 10,000/- under both the categories.


35


Provision of water, toilets, their use and maintenance are the priorities under these

funding. Untied funds are envisaged to be used for the need specific activity giving

room for innovative use of the fund for the improvement of the centres. The

guidelines also specify that these funds should not be used for those activities that

are already undertaken both by the state and the centre thus avoiding duplicity.

Each activity planned by the Centre should have a clear rationale so that the impact

of the ‘Untied fund’ can be distinctively assessed. A separate register needs to be

maintained in the PHC giving sources of funds clearly for various activities.

3.4.1 Guidelines for Untied funds

The NRHM guideline gives suggested areas where Untied Fund may be used and

also specifies purposed where these funds should not be used.

Nature of expenditures that CAN BE incurred utilizing Untied funds

• Minor modifications to the Health Centre: E.g. curtains to ensure privacy, repair

of taps, installation of bulbs, other minor repairs, which can be done at the local

level

• Purchase of materials for the centre such as Patient examination table, delivery

table, DP apparatus, hemoglobin meter, copper-T insertion kit, instruments tray,

baby tray, weighing scales for mothers and for newborn babies, plastic/rubber

sheets, dressing scissors, stethoscopes, buckets, attendance stool, mackintosh

sheet

• Provision of running water supply

• Provision of electricity

• Ad hoc payments for cleaning up the Centre, especially after childbirth

• Transport of emergencies to appropriate referral centres

• Transport of samples during epidemics

• Purchase of consumables such as bandages in the Centre

• Purchase of bleaching powder and disinfectants for use in common areas under

the jurisdiction of the Centre

• Labour and supplies for environmental sanitation, such as clearing or larvicidal

measures for stagnant water

• Payment / reward to ASHA for certain identified activities

• Repair / operationalization of soak pits


36


Nature of expenditures that SHOULD NOT BE incurred utilizing Untied funds

• Purchase of Office Stationery and equipments, training-related equipments,

Vehicles etc

• Engagement of full time or part time staff and payment of honorarium /

incentives / wages of any kind

• Purchase of drugs, consumables and furniture

• Payments towards inserting advertisements in any Newspaper / Journal /

Magazine and IEC related expenditure

• Organizing “Swasthya Mela” or giving stalls in any Mela for ostensible purpose

of awareness generation of health schemes / programs

• Payment of incentives to individuals / groups in cash / kind

• Meeting any recurring non-plan expenditure

• Taking up any individual based activity except in the case of referral and

transport in emergency situations

The Centres are not required to take prior approval before implementing the

schemes from the untied funds but shall have to send quarterly SoE and UC.

(Guidelines of funds; MoHFW, GoI)24

3.4.2 Issues Pertaining to the guidelines

The guideline of NRHM very clearly envisages an effective usage of the funds.

But, the guideline does not lay down as to what is the time line for the funds to

be released to District, Taluka, PHCs, Sub-centres and VHSCs. This has led to

untimely and irregular timings in fund releasing. The bureaucratic setup does

not encourage innovation from the grassroots officials as there are no rules under

which these could be rationalized.

Further, there is lot of confusion as to the purposes to which the funds could be

used under the innovative category. The non-availability of the instructions in

the regional language was also one of the main reasons for this confusion. With

an exception of two doctors under the study, the other five doctors had not even

had a look at the mission document guidelines that have been prepared for

different components of the NRHM activities.

24

Government of India (GoI) (2005a): ―Guidelines for Village Health and Sanitation Committees,

Sub Centres, CHCs and CHCs‖, New Delhi, Ministry of Health and Family Welfare.


37


3.4.3 Delays in release of funds

The tables below show the delays in release of funds. These clearly indicate that the

funds have been received by PHCs, Sub-centres in the last quarter of the year. This

untimely disbursement as noted by the BPMs, and MOs gives the utilizing

institution very less time to spend the funds appropriately. The tables 9 & 10 clearly

bring forth the issue of non-availability of funds and untimely release of funds to the

PHCs and Sub-centres.

Table 9: Quarter Wise Untied Funds Received at PHCs 2009-10 and 2010-11

Year PHC Amount received

Quarter

First Second Third Fourth

2009-10 PHC1 0 0 0 25000

PHC 2 0 0 0 25000

PHC 3 0 0 0 0

PHC 4 (24X7) 0 0 0 25000

PHC 5 0 0 0 25000

PHC 6 0 0 25000 0

PHC 7 25000 48472 0 0

2010-11 PHC1 0 0 15000 2600

PHC 2 0 0 15000 8200

PHC 3 0 0 15000 0

PHC 4 (24X7) 0 0 25000 24500

PHC 5 0 0 15000 0

PHC 6 0 0 25000 24500

PHC 7 0 0 0 0


38


Table 10: Quarter Wise Untied Funds Received at Sub-centres in FY 2009-10 and 2010-11

Year Sub-centre Amount received

Quarter

First Second Third Fourth

2009-10 SC 1 0 0 0 0

SC 2 0 0 0 10000

SC 3 10000 - - -

SC 4 0 0 0 0

SC 5 0 0 0 0

SC 6 0 0 0 0

SC 7 0 0 0 0

2010-11 SC 1 0 0 0 0

SC 2 NA NA NA NA

SC 3 NA NA NA NA

SC 4 0 0 0 0

SC 5 0 0 5000 0

SC 6 NA NA NA NA

SC 7 10000 0 0 0

There are no explanations made available for a said Sub-centre not getting funds in a

particular financial year. The non-documentation of the processes of the actions

creates spaces for misuse/abuse or non-using of the funds all of which are bad

governance practices. In the light of the transfers that happen in the government

sector not documenting of the logic of a decision provide a big space for bad practice

in fund usage and decisions made.

The Sub-centre Untied funds distribution related information made available at the

chosen Sub-centres indicate that some of them have not received in certain years. But

the district overall report indicate that all the years there has been fund release under

untied fund category. But, again this information does not show to which Sub-


39


Centre fund was released and how much and which one did not get funds and for

reason.

These are the issues that need to be addressed immediately to bring in openness in

public expenditure.

Data validation: The data collected from each of the chosen PHCs and Sub-centres

were compiled and validated with the PHC and Sub-centre in-charge. A Validation

cum Dissemination workshop was organized in Mysore. The workshop was

attended by an invited group of health officials including The Director NRHM

Karnataka, DHO, DPMO, DAM, THOs and the MOs of chosen PHC. A presentation

of the compiled data was made and the worksheets as well as the presentation were

shared with all the concerned for comments on the data, analysis and interpretation.


40


Table 11: Sub-centre Untied Funds released and Expenditure incurred between 2006 -2010 District Data

Cat

ego

ry

Yea

r

OB

Am

ou

nt

Rel

ease

d U

p t

o e

nd

of

Feb

% o

f A

mo

un

t R

elea

sed

Up

to

en

d

of

Feb

Am

ou

nt

Rel

ease

d D

uri

ng

Mar

ch

% o

f A

mo

un

t R

elea

sed

Du

rin

g

Mar

ch

Am

ou

nt

rele

ased

du

rin

g t

he

yea

r

Exp

end

itu

re i

ncu

rred

Up

to

en

d

of

Feb

% o

f E

xpen

dit

ure

in

curr

ed U

p t

o

end

of

Feb

Exp

end

itu

re i

ncu

rred

in

th

e

mo

nth

of

Mar

ch

% o

f E

xpen

dit

ure

in

curr

ed i

n t

he

mo

nth

of

Mar

ch

Am

ou

nt

Av

aila

ble

fo

r

exp

end

itu

re

To

tal

Exp

end

itu

re i

ncu

rred

To

tal

% o

f E

xpen

dit

ure

in

curr

ed

% o

f A

mo

un

t R

emit

ted

to

A/c

of

PD

(RC

H )

Am

ou

nt

Rem

itte

d t

o A

/c o

f

PD

(RC

H )

Clo

sin

g B

alan

ce

Clo

sin

g B

alan

ce %

SC

UF 06-07 4320000 0 0 0 0 0 1962691 76 608994 23 4320000 2571685 59 0 0 1748315 40.47

SC

UF 07-08 1748315 300000 6 4320000 93 4620000 1463296 91 140256 8 6368315 1603552 25 0 0 4764763 74.82

SC

UF 08-09 4714763 4320000 100 0 0 4320000 9034763 100 0 0 9034763 9034763 100 0 0 0 0

SC

UF 09-10 340608 2316000 100 0 0 2316000 140943 68 64680 31 2656608 205623 7 0 0 2450985 92.26

Source: Yearly Financial Progress Report of DHS. Mysore


41


3.3.4 Funds utilization issues

Funds abuse: Un-timeliness and gaps in information, disinterest on the part of the

MOs, has most often left the Untied funds unused or used for the purposes for

which they are not supposed to have been used or even worse, use maintenance

funds for the same purpose year after year, hence can be counted as a wasting of

funds.

Skewed expenditure: Piling of expenditure towards the close of the financial year

has caused serious service delivery. The field study reveals that funds under NRHM

additionalities do not reach the hospitals on time. Instances such as funds allocated

for the financial year 2009-10 reaching the district in the month of January 2010, two

months close to end of financial year were observed. In addition, officers concerned

at the grassroots level lacked clarity as to what the main expenditure components of

the untied grant were (annual maintenance grant, ARS and untied funds).

Departure from guidelines: In addition, fund utilization is deviating in a significant

manner from the guidelines. How well the untied grants get utilized needs a closer

examination. At times annual untied grants are of purchase of Television sets and

DVD players. These expenditures are classified as patient oriented expenses. The

MOs note that the higher officials call them inactive and ask them as to what is their

problem in spending when the government pays. ‘We are instructed that we either

rework on the floor or repaint or whatever, we are told to spend the money.’ This leaves

much to be desired. The NRHM philosophy is lost in the non-responsive

bureaucratic setup.

Non-availability of information: Fund receipt related information pertaining to

some years was not available at the sub-centre level, but there were vouchers filed

under the said years for expenditure. There were a lot of documentation related

discrepancies. The ANMs are not trained in accounting Even though the sub-centres

have received funds and the amount is spent correctly, in the absence of

documentary evidence it is difficult to accept the statements of the ANMs.

The research team paid multiple visits to the said health centres for the documents

and information collection. But many a time the documents were not in the premise

of the health facility but would be kept either in the MO’s or the ANM’s residence. In

3 PHCs the bank passbooks were not made available as the concerned officials said

that they had lost the passbooks.

Resistance to share data: There is a great deal of ambiguity and fear both at the PHC

and sub-centre level in fund utilisation, and this was found more pronounced at the


42


Some of the PHC buildings require major civil

works that cannot be undertaken in the

yearly funds provided; the MOs noted that

need-specific funding will go a long way in

establishing the IPHS facilities. As this kind of

facility is not available at the moment many

of them noted that they are painting the

same wall every year even though it does not

require any painting.

sub-centre level. The research team had to drop one of the chosen PHCs and its sub-

centre as both the officials and related ANMs would go on leave whenever the team

asked for appointment to look into the fund related documents. It later emerged that

these two officials had not spent funds and had huge back logs and were therefore

not ready to be part of the study. The fear of not using the funds properly /according

to the rules and being caught is very high among the ANMs. This fear is mainly due

to their inability and lack of knowledge in management issues.

Lack of need-based funds disbursal: Of the 7 MOs in the sample 6 MOs stated that

they have been submitting the needs of the PHCs both to the THO and to the PRI

office every year. But till now the needs of the PHCs have not been addressed even

though yearly quota of funds have been released. All the 40 doctors interviewed in

the pilot stage and the 6 MOs taken in the study said that the Maintenance funds in

first 2 years did help build some basic facilities both at the PHC and sub-centre level

but the last 3 years’ expenditures have been ones that really do not cater to the needs

of the concerned PHCs or sub-centres.

Lack of clarity in fund allocation and distribution: Doctors in the pilot interview

said that it is the Untied and Maintenance funds that give greatest scope of mis-

utilisation and misappropriation. There is no clarity in fund allocation and

distribution to PHCs. The inputs given by the DPMO and the THOs do not get

reflected at the PHC level. What factors influences ‘A’ PHC to get a particular

quantum of fund and why it differs from ‘B’ is not very clear. Population does not

seem to influence much; total funds received divided by the number of PHCs also is

not the pattern in use uniformly, definitely there is no need based allocation. This is

an area that needs further

investigation.

Feeling of being Burdened by

PHC Medical Officers: The MOs

feel burdened by the

administrative processes with

respect to handling of NRHM

funds. As per them, core medical

work suffers if they involve too

much in monitoring other

activities.


43


In a particular year, we bought geometry boxes for all the children in the school

Presence of questionable practices: The interaction of the research team with some

of the building contractors [12] who had provided the services to the PHCs found in

the course of conversation that there are a lot of unacceptable practices in finalizing

the civil works related bills, which the engineering department officials have to

certify. The year-end payments the contractors alleged are generally made to extract

money from the contractors. This is something that the contractors said they were

aware of while taking up the contracts. They said very candidly that these expenses

would be recovered in compromising with the quality of work. As this is outside the

scope of the present study much evidence was not collected but the information has

been documented nevertheless.

Most PHCs are receiving funds in the 3rd and 4th quarters of the financial years

This gives the PHC in-charge very little time to spend the amount judiciously in the given year

The demand on the PHCs to have Zero Balance at the end of the year , as noted candidly by MOs, has encouraged spending on wasteful activities

“we understand NRHM has positive components

…but there must be medical administrators to do these

....rather than asking all doctors to be turned into administrators

“We are trained as doctors. How can we understand civil works details?

…Even if we look for details, then we must stop working as doctors for some periods of time.

…We are happy that this program ends in 2012


44


Absence of good practices in accounting: The translation of the expectations of the

mission is mainly missing at the grassroots level. Under NRHM untied funds are

provided so that the immediate/contingent and small needs of the PHCs and sub-

centres are immediately met. But this spirit is not seen at the ground level. The only

guiding factor for the MOs and ANMs is to declare Zero balance status at end of

year.

The records at the PHC level pertaining to the expenditure list indicates that

Furniture, Drugs, Syringe, Photocopying and office expenses are the items for which

the PHCs have spent more than fifty percent of their funds. It thus emerges that the

PHCs have spent the untied funds on those items which they were not supposed to

have spent on. The expenditures could be genuine but they are being spent from the

funds which clearly states that they cannot be used for the purpose for which cited

her. There are no orders available permitting the above said expenses. The MOs note

that they were instructed over the phone or when they attended the meetings with

the higher authorities, that the funds could be used for the said purposes. The issue

becomes serious in the light of the fact that all the PHCs under study noted that the

accounts against the activity were not audited till date.

Some PHC MOs noted that they were using the previous year’s funds. However, this

explanation does not hold merit as it is an essential requirement that funds released

in a particular financial year must be utilized within the same financial year.

Table 12 brings out a few issues pertaining to deviation from the expenditure related

guidelines provided by NRHM. Expenditure on surgical items constitutes a major

portion of the expenses incurred by the PHCs. This is a major deviance as the

guidelines clearly put surgical items under a category for which untied funds

‘SHOULD NOT BE’ used.

This also brings forth the drawbacks in accounting practices. For instance, the table

also shows that some PHCs have more expenditure than the amount received in the

said year. However, there is no explanation about the source of the additional funds,

or information whether these funds were diverted from other heads.


45


Table 12: Breakup of Untied fund expenditure incurred by PHCs in Year 2009-10

Figures in parenthesis represent the percentage of expenditure per item to the total expenditure. Where no expenditure is shown, it indicates lack of

evidence of spending by the respective PHCs.

PHC Quantity

Received

Expen

diture

% of

expend

iture

Balance

in A/c

% of

balance

Surgica

l

Equip

ments

Utilitie

s/

Furnitu

re

Waste

mgmt

Plumbi

ng

Miscell

aneous

Aware

ness

Office

expend

iture

Drugs Total

Rs Rs

Rs

Rs Rs Rs Rs Rs Rs Rs Rs Rs

PHC1 25000 0 0 25000 100 0 0 0 0 0 0 0 0 0

PHC 2 25000 0 0 25000 100 0 0 0 0 0 0 0 0 0

PHC 3 0 0

0

0 0 0 0 0 0 0 0 0

PHC 4

(24X7) 25000 29602 118 -4602 -18

21008

(71)

4495

(15) 0 0

1330

(5)

550

(2) 0

2119

(7) 29502

PHC 5 25000 85701 343 -60701 -243 44271

(52)

33730

(39)

2000

(2)

5700

(7) 0 0 0 0 85701

PHC 6 25000 11034 44 13966 56 0 0 0 0 0 0 0 0 0

PHC 7 73472 25000 34 48472 66 19640

(79) 0 0 0 1139 (5)

3600

(14)

621

(2) 0 25000


46


It is therefore very important to have in place the practice of verifying the

expenditure against the activity rather than simply verifying it against vouchers. The

documents that are maintained by the PHCs and sub-centres, most often did not

have any framework of a voucher, items purchased and date of procurement were

not filled but just had the amount indicated. Many MOs and ANMs did not even

know these basic issues of accounting.

The expenditure ledger/vouchers that the research team verified had some

interesting expenditures documented. In 2 sub-centres the ANMs have used nearly

8,000 rupees under referral transportation. In 4 sub-centres where delivery facility is

not provided, after- delivery cleaning charges are booked repeatedly. There are 3

sub-centres that have 5 vouchers for emergency lamps bought in 2 years.

We note here that from the time of our first visit to the sub-centres for data

collection to the following visits for information gap-filling and validation visits,

there were positive changes in documenting and accounting practices. The visits

could have paved way for an un-intentional but welcome awareness among the

functionaries. It indicates that with a proper capacity building mechanism in place,

a lot could be improved in accounting and documentation – eventually leading to

data accuracy and reliability.

At this juncture it is also very important to note that the concerned office should take

up an evaluation of the work allotted to each category of staff against the number of

hours available to them. This will go a long way in planning for a better and

transparent governance at all levels.

It is also very important to note that while the issue of fund shortage has been

addressed by gradually enhancing resource support; the absorptive capacity at the

grassroots level has not been strengthened. PIPs and the resource support are not

going in tandem, thus defeating the very purpose of need-based health care

financing. Mere transferring of funds does not improve the conditions at the

grassroots; rather, a multiple- pronged approach is needed.

3.4.5 VHSC Untied Funds

Every VHSC committee that is duly constituted and oriented would be entitled to an

annual untied grant of Rs. 10,000/-, which could be used for any of the following

activities: -

As a revolving fund from which households could draw in times of need to be

returned in installments thereafter.


47


For any village level public health activity like cleanliness drive, sanitation drive,

school health activities, ICDS, Anganwadi level activities, household surveys etc.

In extraordinary case of destitute women or very poor household, the Village

Health & Sanitation Committee untied grants could even be used for health care

need of the poor household.

The required grant is a resource for community action at the local level and shall

only be used for community activities that involve and benefit more than one

household. Nutrition, Education & Sanitation, Environmental Protection, Public

Health Measures shall be key areas where these funds could be utilized.

Every village is free to contribute additional grant towards the Village Health &

Sanitation Committee. In villages where the community contributes financial

resources to the Village Health & Sanitation Committee untied grant of

Rs.10,000/-, additional incentive and financial assistance to the village could be

explored. The intention of this untied grant is to enable local action and to ensure

that Public Health activities at the village level receive priority attention.

Accountability aspects expected from VHSCs

Every Village Health & Sanitation Committee needs to maintain updated

Household Survey data to enable need based interventions.

Maintain a register where complete details of activities undertaken, expenditure

incurred etc. will be maintained for public scrutiny. This should be periodically

reviewed by the ANM/Sarpanch.

The Block level Panchayat Samiti will review the functioning and progress of

activities undertaken by the VHSC.

The District Mission in its meeting also through its members/block facilitators

supporting ASHA [wherever ASHA’s are in position] elicit information on the

functioning of the VHSC.

A data base may be maintained on VHCSs by the DPMUs.

VHSC Funds: Evidences from the field

In order to understand the role of VHSC, and how effective are the members of the

VHSCs in translating the vision of the NRHM an effort was made to capture the

awareness levels about the NRHM, Roles and responsibilities of the VHSC members,

involvement of PRI members in VHSC’s affairs. The study covered as noted earlier 7

VHSCs from 7 Talukas of Mysore District. Information was drawn from different

stakeholders; VHSC members, ASHA, ANMs, MOs.


48


Awareness issues: All the ASHAs, ANMs, MOs, were aware of the role of VHSCs in

NRHM, but out of 12 PRI officials contacted only 5 were aware of the roles and

responsibilities of VHSCs in addressing health related issues. Of the 7 VHSCs under

the study, the members of 3 VHSCs under the study were able to give some

information about the role and responsibilities of the VHSCs; whereas the other four

VHSCs could not specify the roles and responsibilities of the VHSCs.

In the process of interaction with above mentioned stakeholders, 12 PRI officials who

were available during the data collection time were also interviewed. All of them

noted that the VHSC was part of the health department and had nothing to do with

the PR, even though the chair person of the VHSCs is the president of the Gram

Sabha.

Every VHSC needs to maintain a register with the number of members, their names

and contact numbers if any. Only 3 out of 7 VHSCs could come up with the names

and details of the VHSC members, while 3 VHSCs did not have sufficient

information as to the number of members and their address / contact number. The

research team had to collect the information pertaining to VHSC members and their

contact details from the respective Taluka Health Offices.

VHSC formation issues: Though NRHM was implemented in the year 2005 the

formation of VHSCs in the sample units had not begun until 2007. 1 VHSC was

formed in the year 2007, whereas 5 VHSCs under the study had been formed in the

financial year (FY) 2008-2009. One VHSC president noted that it was only 5 months

old and was formed in FY2010-11, but the official records with the Sub-Centre, PHC

and at THO levels indicated that it had been formed in FY2008 itself. This confusion

about the year of formation may be attributed to the fact that the VHSCs formed

earlier by the health department officials were not functioning due to various

reasons.

This was set right by re-forming the VHSC six months ago. The concern here is

mainly the absence of fund information pertaining to the VHSCs in the previous

financial year.

Of the 7 VHSCs under study it was noted that 3 were formed by the local NGO. The

said NGO had been working with the health department under a PPP initiative to

form VHSCs in areas where they did not exist, and also strengthen the ones that

were already formed. The other four were formed by the Health department officials

with the help of PRI officials.


49


Fund handling issues: All the VHSCs under study noted that had received untied

funds every year since the year of formation.

All the VHSCs noted that they had opened bank accounts. But, only 4 VHSCs could

produce the bank pass-books issued to them. Of the 3 VHSCs that could not produce

the pass-books, in the case of 1, the ASHA noted that the pass-book was with the

VHSC president while 2 noted that the pass-books were lost. Further, it came to light

that the concerned had neither informed the bank about the lost pass-books nor

applied for duplicates.

The process of utilization of the VHSC untied funds and documentation is clearly

laid down by the mission. All decisions related to VHSC’s untied funds ought to be

taken after consultation within the committee and these discussions are to be

recorded. The VHSC meetings have to be documented in the form of minutes

according to the mission direction. But only 3 VHSCs under the study had registers

where the meeting minutes were recorded. 3 VHSC meetings were recorded in

ASHA’s work diary. The other 1 VHSCs did not have any document to indicate that

a meeting of the members was held.

None of the VHSCs had prepared the meeting Agenda and had not given sufficient

notification to the members to attend the meetings.

The decision making process and practices followed for utilization of untied funds

were very unclear. Though, the VHSC president and ASHA are the joint signatories

authorized to withdraw these funds, they are expected do so after a collective

decision is arrived at through a meeting of VHSC members with a quorum in

attendance.

In all VHSCs under study, there was no evidence of collective decision making;

rather it was the decision of the VHSC president and/or the MO concerned.

Timeliness of funds: All the VHSC presidents under the study noted that the

VHSCs received the untied funds either in the third or the fourth quarter of the

financial year. Only 3 VHSCs had a ledger where they had documented the details of

the funds received, which corroborated with the VHSC presidents’ statements.

Pertaining to the practices of documentation of expenditure, the research team found

extensive gaps. Of the seven VHSCs contacted for the study, only 1 VHSC had all the

necessary documents maintained with regard to the expenses incurred; this included

the accounts and voucher ledgers, sanction orders and SoE. On the other had 2

VHSCs in the sample had maintained all the vouchers but had not maintained


50


accounts ledgers and SoE. 1 VHSC noted that it had not used its funds till date and

every year the funds were being returned to the district office as ‘unspent’. But in

practice ‘refunding’ does not happen, but the quantity of unspent amount will be

deducted from the amount due to the institution the next year. This is popularly

known as ‘top-ups’. The MO under whose jurisdiction this VHSC falls noted that the

VHSC was not active and the signing authority was not agreeing to the heads under

which the funds was to be spent.

Under NRHM, VHSC’s role has been visualized to be much deeper and holistic. But,

this philosophy is still not internalized by either the VHSC members or the health

department officials who transact with community and VHSC. Drafting a health

plan according to the needs of the village, using the available fund, and

collaboration with other departments whose works influence the overall health and

sanitation scenario of the village are not happening. As a result, the budgets are

made without a need based action plan.

It is very important to realize that the health plan that the VHSC drafts should not

revolve around the untied grant of Rs. 10,000/- only. It should take into account the

needs of the villages concerned and see how the needs can be met by involving other

departments’ budgets.

3.4.6 Summary of findings – Untied and Maintenance funds

Lack of clarity in guidelines is resulting in funds being unspent or utilized for

purposes that deviate from the guidelines.

Delay in funds release is putting pressure to exhaust the funds in a limited

period of time – towards the end of the financial year.

PHC medical officers do not have the inclination or the willingness to delve

much into administrative processes.

There is both lack of clarity and sense of equity in fund allocation and

distribution to PHCs.

There is a lot of reluctance among the respondents to share funds related

information.

Appointment of BPMs has helped to a certain extent on streamlining the

process of accounting of NRHM funds.

The health functionaries handling NRHM funds lack an orientation on basic

accounting practices.

51


Background Characteristics of JSY Beneficiaries:

• Mean age: 21, Range: 17-25

• 29/42 Women reported being married

before 18 years

• 5/29 noted that they were married before

16 years of age

• 14/42 women had <7years of schooling

• 20/42 women had >7 years of schooling

• 16 SC, 12 ST, 9 OBCs, 1 G, 4 Muslims

• 26/42 had BPL cards

• All the 16 from SC did not have BPL cards

4

Background Characteristics of the Respondents

4.1 JSY Beneficiaries

Age related information

The JSY CI beneficiaries’ age varied from 19 years to 25 years. The existence of the

official age factor has led to the non-reporting of the presence of teenage pregnancy.

In the study sample of the 42 respondents, 7 women reported less than 19 yrs of age.

All the health personnel said that there is an age factor for the women to be eligible

for CI schemes. In fact all the MOs and ANMs contacted for the study noted that the

need for extra care and nutritious food is higher for the under-aged mothers. Two of

the MOs even noted that the teenage mother’s cases were the most vulnerable as the

risk was too high. They noted that all those who are under age mothers have been

tutored by the elders to indicate their age as 19 years. Teenage pregnancy due to this

reason is grossly under reported or not reported at all.

Education

34 of the 42 women had some schooling

and little more than 1/2 of them had

attended school till class 8 or more.

Education even though perceived as an

empowering tool seems to have had

little effect in the lives of the women

under study. The mean age at marriage

of the women was 21 yrs. 29 women

said that they were married when they

were less than 18 years of age and 5

women among these said they were

married by the age of 16 yrs. Thus,

early marriage is still a prevalent

practice among rural communities.


52


Back ground Characteristics of ASHAs

ASHAs Age Range: 21-43

4 PU Certificate holders

3 had 8-10 years of Schooling

2 SC, 2 ST, 1 General, 1 OBC, 1

Christian

All Recruited in 2008-09 Financial Year

5 went through training of 21 days

1 had 6 days training

1 reported that she did not receive any

training

Socio-economic background

The respondents are drawn from a mixed caste composition. There are women from

SC, ST, OBC, general group and a few from other religions. 35 respondents reported

to have been working as daily wage laborers in the agriculture sector. Only 7

respondents noted that they do not work outside their house. 27 women belonged to

families reported to be living on less than Rs.1500 per month and the average

reported annual income of the families was less than Rs.17000.

26 families were in possession of ration card as against 16 who did not have any

card. All the families from OBC category had BPL card. Whereas none from the SC

category.

Though it is outside the purview of this study, it was observed that there were

families who did not possess the BPL cards and were living under extreme poverty

and some of the families with BPL cards had more than 5 acres of land and modern

gadgets at home. Looking at the situation from a human rights perspective this is a

serious issue that needs to be addressed, as the eligibility for the schemes under CI

are linked with BPL status, there are chances that many excluded families have been

losing out on availing the special schemes meant for the marginalized and poor.

4.2 Health Service Providers

4.2.1 Accredited Social Health

Activist (ASHA)

ASHAs’ age varied between 21 to 41

years of age, majority falling in the

category 36 - 45 age group. All the 7

ASHAs were educated upto primary

level or secondary level. Of them 4 had

passed SSLC. Of the 70 ASHAs who

were part of the FGDs as many as 48

were PUC holders and the rest had

schooling up to 8th standard. Majority

(6) of the ASHAs in the sample were

recruited in the year 2009.

This was also true of the ASHAs who

were part of the FGD. The selection process in the case of 4 ASHAs in the sample

was done through a GD, short listing of names and finalizing one name with consent


53


Background Characteristics of ANMs:

• ANMs Age Range: 25-51

• 3 ANMs have PU Certificate

• 3 ANMs completed SSLC

• 1 ANM holds BA & LLB degrees

• 2 SC, 1 ST, 2 G, 2 Christian

• Average Years of Experience : 23

• On an Average Cover 4 Villages;

Range: 1-8

• Average Commuting Distance : 10

Kms, if on field

from the people present in the Gram Sabha meeting. Of the 7 ASHAs, 4 ASHAs had

worked as community based worker before being chosen as ASHA with some

government program or the other. This process was also found to be similar in the

case of ASHA who participated in the FGD of the current study repeated.

All the 6 ASHAs except 1 noted that they went through a rigorous 21 days training.

On the other hand out of 70 ASHAs who participated in the FGD as many 29 noted

that they were given one week training as the recruitment was delayed and the rest

(41) had 21 days training, as against the 23 days of required training as indicated in

the guidelines for training for ASHAs. The budgetary allocation information

provided by the district does not indicate how much was allocated for training of

ASHAs.

4.2.2 ANM

Of the 7 ANMs under the study 2 were

between 25-26 years of age with 4 years of

experience and 5 were in the age group of

40-51 with an average of 20 years of

experience

On an average, ANMs travels around 10

kms to complete their responsibilities. The

number of days in a month that they spend

on reporting and documentation, attending

meetings and going to THOs office for filing

the information comes to six days

approximately. That leaves them with 20

days to attend to work related to different

programs under the health department.

They cover an average of 4 villages, ranging

from 1-8 villages.

54


5

Awareness about NRHM and Cash Incentive Programs

This section discusses the levels of awareness among JSY scheme beneficiaries and

respondents from the medical fraternity on issues related to NRHM and the CI

programs meant for the marginalized poor. It also discusses the levels of

understanding of the health providers about eligibility criteria of beneficiaries under

the CI schemes, dos and don’ts of using untied and maintenance funds.

5.1 General awareness

“NRHM” nomenclature was familiar to only 13 per cent of the respondents.

However, the local dialect equivalence for the term was familiar to 43 per cent of the

women. 67 per cent of the study respondents had heard about CI programs. All

those who had heard about the CI programs could name JSY while only 21 per cent

of them could name PA. Only 1/3rd of the women knew how much money they

were entitled to. Awareness was higher among women with longer years in school

and younger women. More than 71 per cent of women who had television sets in

their homes had heard about CIs. They said that they knew about the program

through TV advertisements. The rest of the respondents had heard about the

program from ANMs, while none mentioned ASHA as their information source.

Among the health functionaries all the MOs knew about the different schemes

under NRHM program. On an average all the doctors have undergone at least 1

NRHM related training, excepting one MO who said he had not got any. Except 2

MOs all the other 5 MOs said they did not have any literature on NRHM like

Mission document, IPHS Hand Book, Manual on JSY and its implementation, Hand

Books on VHSC operation etc. This scenario was also true of the MOs with whom

the research team had in-depth interviews. All they had was the format of reporting

of activities. Only 2 MOs had copies of some of the GOs issued by the State

Government.

5.2 Awareness of eligibility criteria

All the MOs under the study and participants in the FGDs noted that being SC / ST

automatically provides eligibility for Cash Incentive programs. However, this

information did not seem to have percolated down to ANMs and ASHAs. This has


55


been corroborated in another study as well (Bindu, et.al,)25. Only 2 ANMs contacted

for the study and 4 ASHAs mentioned SC & ST status as an eligibility criterion.

‘Women delivering in Govt. Institution’ has been cited by all the seven ANMs as

eligibility criteria. NRHM guidelines very clearly state that women should have the

right to choose the place of delivery. Even if they deliver at home with assistance,

they are entitled for CIs. The fact that ANMs did not have information about this

makes access to CIs difficult for those women who delivered at home and

documented so.

5.2.1 Eligibility related documents

The ANMs and ASHAs cited the following as eligibility documents to avail CI.

Photographs (ranging from 2 to 10)

Domicile certificate

Ration / BPL card

Proof of all ANC checkups received in government hospital only

These indicate that there is confusion among ANMs and ASHAs about documentary

evidences required and eligibility criteria for receiving CIs. Due to this confusion, in

the absence of documentary evidence like a ration card, immunization card or

photos, it would be difficult for these under-privileged women to get the incentives

and more importantly, avail the ANC & PNC service.

As per the JSY implementation guide book published by the MoHFW, age is not a

factor to be considered under eligibility criteria among SC / ST category women,

even high performing states. All the information boards indicate only a minimum

age of 19 years as the criterion. None of the MOs or ANMs had the copy of the

Implementation Manual are therefore unaware of the age exemption for SC / ST

women.

25 Bindu Balasubramaniam, Shanthi. Gopalan and Bhagavandas unpublished report of Rapid

Assessment Training Programme, “Gaps in NRHM: Do Tribal Women Matter? A Study on access

and utilization of Cash Incentive Programs under NRHM for the Forest Based Tribal women of

Heggadadevanakote Taluk in Mysore District in Karnataka”

56


Of the 9 home deliveries, 3

women who did not get

immediate help are from the

village where ASHAs are not

in position

4 women who registered in 3rd

trimester are from villages

that did not have ASHA

6

Access, Availability & Utilization of Benefits and Services – A

Challenging Scenario

6.1 Presence & effectiveness of health functionaries

The NRHM states that it proposes to transform the health scenario in rural India and

improving the quality of staff at the grassroots is one such target set. The Mission

document states that in addition to providing funds, every PHC has provision for

three staff nurses as against one at present two doctors (one male, one female) and

Ayush practitioner. But at the ground there is much to be desired.

ANMs: From among the 7 sub-centres at the time of interview, 3 sub-centres had

ANMs as in-charge ANMs who were responsible for 2 sub-centres and had to travel

on an average of 9 villages. ANMs therefore had to cover a wider area. None of the

ANMs under study have any kind of personal transport facility, most of the time

they covered the villages by foot. This has resulted in ANM being unavailable in the

villages under her jurisdiction many a time. The frequency of ANM’s visit to the

villages has reduced considerably. The beneficiaries noted that ANMs visited them

once a month. This was also an issue that repeatedly came up in the FGDs where the

pregnant women who are not JSY beneficiaries demanded why they do not get the

same kind of attention that others get. It is true that JSY CI is just a token money to

support those women who mostly are poor to support some of their expenses. The

main thrust is to have safe motherhood. The work

burden for ANMs like all other grassroots

functionaries is very high.

ASHAs: ASHA’s presence has been envisaged as an

important link in maternal health under NRHM. Of

the 25 villages that fall under the chosen 7 sub-

centres 6 villages did not have ASHA appointed.

FGDs with JSY beneficiaries and interviews with

ASHAs indicate that working as ASHA was very

difficult as she has too many bosses to report to and


57


Presence of ANMs & ASHAs goes

a long way in utilizing ANC

facility and institutional delivery

service

not much effort has gone in to popularize her role among the community. Health

department identifies her with VHSC and therefore think she belongs to PRI

whereas the members of the PRI see her as a Health department personnel. There is

intense identity crisis for ASHAs. In course of the FGD it emerged that all the

ASHAs agreed to be one as they were told that this job would have monetary

returns initially if they have to put in 2 years of service. They were told that they

would be holding a government job after 2 years. As they have now realized that it is

not going to be so the family members are averse to ‘permit’ their

daughters/daughters-in-law to work as ASHA.

PHC Medical Officers: All the PHCs had one fulltime MO in position. One PHC

which is open 24X7 has two doctors. 4 PHCs noted that ANMs would be available at

night. 3 PHCs noted that either MO or other medical attendants will be available on

call if need be. Though NRHM’s vision is to have at least 2 doctors and 3 staff nurse

none of the PHCs come up to this standard.

6.2 Impact on maternal health services

Presence of the required health personnel is the most crucial component in

translating the visions of the program. It is evident that presence of ASHA and/or

ANM has significantly encouraged women to utilize ante-natal services and also

register for institutional delivery.

6.2.1 ANC registration

All 42 women under study had registered for

antenatal care, 37 women had registered with

ANM. Since registering with ANM is very

important if they were to receive cash

incentives, the women who did not do so might lose their entitlements. In 4 villages

in which a full time ANM was present, 12 percent had not registered with her.

Among women living in villages having ASHA, all the women had registered with

ANM compared to 62% of women living in villages without an ASHA.

The most common reason for not registering with ANM was “ANM is not regular”.

38 women had registered in their first trimester. All the women living in villages

with a full time ANM registered in the 1st trimester compared to less than 1/3rd of

those living in villages not having a full time ANM. Thus, availability of ANMs

influences early ANC registration.


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Utilization of Ante Natal Care

All the 42 respondents under the study

registered for ANC

41/42 Had documentary evidence

1/42 no evidence

37/42 registered with ANM at Sub-center

5/42 registered with PHC attendant

38/42 registered in 1st trimester

4/42 registered in 3rd trimester

12/42 had at least 3 visits

2/38 registered in 1st trimester had < 3

visits

Of the women who had applied for

CIs, 71per cent said they received help

for applying for CI from ANM or

ASHA, 19 per cent said they received

help from family members and 10 per

cent noted that they received help

from NGO grassroots workers

associated VHSC formation and

training.

Receiving help from ANM had the

highest rate of conversion in terms of

actually receiving CI (19 out of 21). All

those who received CIs are the ones

who registered with ANM.

All the women who received cash had

received Rs.700 under the JSY.

6.2.2 ANC Visits

All the women under study had registered for ANC. 90 percent (38) of women

registered in their first trimester. 38 women noted that they had at least 3 visits. 69

per cent (29) of women reported 5 or more visits to health centres during the

antenatal period. Only 2 women who had registered in the 1st trimester had less than

3 visits. 29 women who had 5 or more ANC checkups had registered in the 1st

trimester. Thus early registration and frequent ANCs seem to go hand in hand. Very

interestingly women preferred to go to the health centres for checkup as it provided

them some space and time of their own.

6.2.3 Institutional deliveries

Of the 42 women interviewed 33 women delivered in an institution and 9 women

had delivered at home. Of the 9 home deliveries, 6 got immediate attention by

ANMs and were shifted to a PHC as soon as the mother was comfortable. In case of

the other 3 women, they got help from elderly women in the village and could reach

health facility the next day. In course of FGD it emerged that most of the women

preferred to go to health facility for delivery as they were aware of the risks

otherwise.


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Utilization of Ante Natal Care &

Delivery Services

33/42 delivered in an institution

9 delivered at home

6 got attention and care within an

hour (Reported as Institutional

Delivery)

3 got help from elderly women

from village & reached health

facility next day (also recorded as

institutional delivery)

In the 25 Villages where base

line survey was undertaken,

there were in all 36 cases of still

birth reported

83 per cent (33) of women who registered in

the first trimester delivered in an institution.

While 17% registering in the 1st trimester has

delivered at home, these women noted that

the non-availability of timely transport and

inability to reach health functionaries for

transport arrangement has been cited as

reasons for delivering at home. Of the 9 who

delivered at home, 5 are from villages where

ASHAs are not in position. All the 9 women

who delivered at home said that either the

ANM who is in position or ANM from

different Sub-centre had provided care within

24 hour. 6 women noted that they got help

within an hour of delivery and were shifted to

the Sub-centre and kept under supervision for

first 8 hours and shifted to the nearest health

centre where the services of the MO is

available for further medical support. 3

women noted that they got help from

ASHA/ANM after 24 hours.

6.2.4 Managing EDDs

There is, it appears improper scheduling of the expected deliveries and also lack of

proper counseling to the pregnant women and the community as to what actions

have to be taken during the crisis situation. Preparation of the woman in question as

the due date approaches becomes very vital and it appears (need further

investigation) that the ANMs and ASHAs are more occupied in administrative

responsibilities that they pay less attention to ANC and PNC. The interview with

ASHAs in the study and those who participated in the FGD noted that they were not

developing the micro plans which help plan their time, place of birth and help

educate the women and her closest relatives about the steps that need to be taken if

the health personnel are not immediately available. Of the 7 ASHAs under study, all

of them knew about the micro plan, but only 2 had prepared one covering all the

pregnant women in their village. From the discussions, it was evident that the last

week tracking of the pregnant woman is not in the priority list. It is very important if

the ANMs and ASHAs are posted on training that a locally identified responsible


60


woman should be given instructions to handle the situation. This goes a long way in

avoiding home deliveries turning fatal. The practice followed by the medical

fraternity as it emerged from the interviews with THOs, MOs is that if the delivery

has occurred at home and immediate help is available to the woman and she gets

shifted to the health facility as soon as the mother is in a movable condition, then the

delivery is reported as institutional delivery.

All the PHCs records showed that there were no home deliveries.

6.3 Information on Still-births

The Mission document lays down certain conditions for eligibility to avail JSY and

the state has also followed the same conditions for PA cash benefits. One of the

conditions laid down is ‘up to 2 live births condition’. As the present study is to look

at the timeliness and accessibility of CIs to women, the respondents are only those

eligible for CIs. But in the course of identifying the eligible women for CI the

research team came across women who fulfill every other requirement except the

live birth criterion. There were 36 women in 56 villages visited across the 7 Talukas

of the district who delivered still-born babies between 2009 and 2010. The

discussions with Taluka Health Officers also supported the findings. This is an issue

which demands immediate attention and advocacy. In English, the statement “Up to

2 live births” is to be interpreted as “all those births up to 2 live births”. This will not

include premature abortions or MTPs conducted. However, the interpretation and

translation of the statement in Kannada is “first 2 live births only”.

Description: A still birth is defined in the medical dictionary as ‘the death of

a foetus at any time after twenty weeks of pregnancy.’ Stillbirth is also

referred to as intrauterine foetal death (IUFD).

It is important to distinguish between a still-birth and other words that describe the

unintentional end of a pregnancy. A pregnancy that ends before the twentieth week

is called a miscarriage even though the death of the foetus is a common cause of

miscarriage. After the twentieth week, the unintended end of a pregnancy is called a

stillbirth if the infant is dead at birth and premature delivery if it is born alive.

Factors that increase a mother's risk of still-birth include: teenage pregnancy, age

over 35, malnutrition, inadequate prenatal care, smoking, and alcohol or drug abuse.

In the light of the above discussion the reasons for still births, needs more

documentation. Still births should be treated as seriously as infant mortality. Given

the fact that early marriage is rampant and teen age pregnancy is the most common


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PHC Infrastructure

6 out of 7 PHCs under study

noted that facility to deliver the

baby is not available

1 PHC (24x7) has the facility

with 1 lady doc & 3 Staff nurse

2 PHCs noted that if the

pregnant woman is in labour

and cannot be shifted to CHC /

24x7 / Taluka Hospital then

they will assist the woman to

deliver (only if it is normal

delivery)

6 PHCs do not have staff nurse

4 PHCs have Lab technicians

occurrence the trauma that a woman goes through is very high. The physical and

psychological assistance and care that is medically required in those cases are more.

All the MOs covered under the study agreed to this. It is therefore very important to

have proper documentation regarding still -birth. Information pertaining to the

socio-economic background of the mothers, kind of work that that they are engaged

in and the sex of the child are very vital. In the FGDs conducted, women narrated

stories where the live birth was declared as still birth. There is no proper evidence to

these statements. But it is equally important to monitor the still birth numbers

recorded and areas from where they are being reported.

6.4 Infrastructural Facilities

Infrastructural development is one of the targets

under NRHM, as noted by all the medical

fraternity and the beneficiaries alike. NRHM has

helped in providing the basic amenities to a

health centre. Majority have been able to make

facilities for seating facility, a decent usable

building, though there are still PHCs without

toilets even for the staff. But majority have

improved.

In our study sample all the PHCs had

government buildings which were in decent

usable condition all the seven had toilet facilities

for the staff. But only 4 PHCs had toilet facilities

made available to patients also.

Excepting one PHC, which is 24X7, the others

do not provide delivery facility. These six PHCs

have only one doctor with no staff nurse and no

overnight stay facility, ether for patients or hospital staff, leave alone facilities to

accommodate the mother and the attendant for 48 hours observation. If the doctors

are expected to provide the services envisaged by the mission then it is equally

important that the state provides the necessary preconditions for the medical officers

to function.


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They tell us that we need to go to either to a 24X7 PHC, CHC, or Taluka Hospital for delivery in our first ANC visit, we have no option”

“Most of the time we have to raise loans”

Out of Pocket Expenses incurred by the CI Beneficiaries *

Different Items on which Women Spend when they go to Hospital for Delivery

Particulars Frequency Amount

Drugs 30 200.00

Payment to Doctors

31 150-300

Payment to Nurse / attendant

39 10-20 (per nurse)

Travel 42 100-200

Food 34 150-175

While calculating approximate out of pocket expenses, FGD participants wanted to include the loss of wages of the attendant also

*CALCULATIONS PRESENTED IS ONLY FOR PHC (24X7) and the cost increases proportionately to higher or distant hospitals

One single doctor cannot be

expected to work for 24 hours and

the Government cannot violate

the labour laws. It is humanly

impossible to work 24 X 7 for 365

days. In absence of facilities to

deliver in the nearby PHC the

expectant mothers need to use the

facility which is farther away. The

shortage of human resource that

existed intensified because of

NRHM due to additional

responsibilities it envisaged for its

personnel. Only 2 PHCs have

Accounts personnel. Male health

visitors are now Account writers.

3 PHCs do not have Group D

Staff. Service infrastructure leaves

huge scope for improvement.

The extra expense incurred by the

pregnant woman and or her

family increases, pushing them into debt. Women in the FGD also discussed the

problems faced by them because of this situation.

NRHM can operate only within the state’s infrastructure, without which it is just a

mockery. Hence the state’s will to provide a base for the program to operate is the

most important spoke in the wheel.

6.5 Supply of Drugs

The doctors noted that the drug supply is according to their requirement. And the

drugs that they ask for and what they get has only 30 -40 % match. Given this

situation they noted that they buy regular drugs from untied funds. And most often

give prescriptions to the patients who come to PHCs.

The quality of the drugs supplied was also challenged by the doctors. One MO

insisted that we collect a few samples and get it tested in private labs, so that their

claim gets established. This is a very serious matter that needs to be taken up for


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“We need to get most of the lab tests done

outside, “

“Costs are high”

Oh yes we pay when we visit the PHC every

time”

“NO they do not ask directly”

“They tell us that there is no drug supply;

and they buy from their pocket; so we pay

“If we do not pay they will not ask us” but,

if non-payment continues, they will not

entertain us

verification by the officials. As administration of spurious or low potency drugs will

have very drastic consequences and lead to morbidity among the patients.

6.6 ‘Cost’ of free services

Further, discussions pertaining to the

payment made by the patients, all

the doctors denied acceptance of

money. But it was observed that the

patients paid the doctors for the

services received. The money offered

varied from Rs 10 to Rs.50 per visit.

The PHCs are supposed to exhibit

the citizen charter in the place where

the patients who visit the PHC can

read it. This is the expectation but in

our sample of 7 PHCs only 2 PHCs

had some board with heading as

citizen’s charter but did not contain

all the details. For the monitoring of JSY, Government has directed that a grievance

redressal mechanism for JSY should be set up at the local level; listing of

beneficiaries outside the PHC/ CHC, etc with a view to ensure transparency and for

facilitating grievance redressal26. But none of the PHCs had this cell in place and no

such information was available for the general public and women who are eligible to

receive the facilities under different schemes to know about it.

It is very important to internalize the vision that has given rise to the steps taken to

enhance spending on health sector otherwise the amount that is now being spent

will not yield any tangible results.

6.7 ASHA: Role conflicts

The ASHA under NRHM is perceived to be the most important link in translating

the visions of NRHM, but much needs to be achieved on the ground. The

background of the recruitment of ASHAs at this point needs to be looked at

critically. The GDs and FGDs brought forth the fact that 90% of the ASHAs were told

that their positions would be internalized by the state health department and they

would have to wait for a few years till that happened and hence their family

26

Karnataka ROP 2009-10 pp;11


64


members had permitted them to work as ASHA. After working as ASHA for a few

months they realized that ASHA had been envisaged as a volunteering community

person to help provide assistance in improving health services. This they noted is

what they were not ready to do. The voluntary nature of the ASHAs’ work might be

one of the reasons for lack of deeper commitment with some of the ASHAs. They

need to be compensated with other innovative forms of recognition and position.

Tapping the social capital component by providing departmental badges, special

ASHA bags with department /government logo could boost their morale to a certain

level motivating ASHAs to look at their positions with pride.

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7

Inferences from the Study

The funds tracking exercise has brought forth some major issues of governance that

needs to be addressed at the war footing if the philosophy of the mission to take

health care to rural India has to materialize.

Providing funds alone does not translate the vision and mission that we set but it is

the internalization of these visions and missions by all care giving personnel at

different stages and cadres.

The fund related information provided by the district level and at differ other sub

levels brings out one major factor that need serious consideration. The accountability

factor pertaining to funds and discharging of the duties there seem to be one sided

expectation. The government does not provide any explanation clearly stated as to

why there is delay to the district level functionaries in disbursing the funds and why

the government does not provide the required personnel to discharge the funds and

the activities committed to by accepting the NRHM’s guidelines.

The fund related data at all levels clearly show us that there are serious

documentation and storage errors. This creates opaqueness in accountability. These

practices throws open many questions. Why is there no system to check the variance

in accounting? Even after 5 years of introduction of the NRHM funds why the

internal auditing has not been taken up. The presence of opaqueness in accounting

suggests that it can provide space for mal-practices in fund utilization.

The absence of information of expenditure against the activity / physical component

does not permit us find out the areas of problem. The information that was shared

by the DPMO regarding the expenditure and the shift in IMR and MMR bring about

this point (See annexure). There are serious issues that need to be addressed in the

health care services. Unless the socio-political milieu changes the maternal health

related indices will not show shifts. The figure shows us that increase in fund purse

will not affect the major health indicators.


66


Figure 7: Level of Expenditure V/S IMR and MMR status in Mysore District 2006-2010

0

10

20

30

40

50

60

70

80

90

2006-07 2007-08 2008-09 2009-10

1 2 3 4

EXPENDITURE ( Rs in Crores)

IMR

MMR

Source: Power-point slide provided by Dr. Maheshwari DPMO of Mysore District (All slides of this

presentation are made available as an annexure to this report)

Table13. Percentage increase in Expenditure V/S IMR and MMR in Mysore District between

2006-2010

YEAR EXPENDITURE

( Rs in Crores) IMR MMR

2006-07 1.36 24.9 60.6

2007-08 2.65 (94.8) 20.8(16.4) 82(-35.3)

2008-09 11.82(346) 20.4(-1.9) 50(39)

2009-10 12.24(3.5) 20.4(0) 40.7 (18.6)

Source: Presentation provided by Dr. Maheshwari DPMO of Mysore District; Figures in parenthesis

indicate the shift in expenditure in percentage

Increase in expenditure of funds across the years is not proportional to shift in IMR

& MMR. With an 800 % increase in funds from 2006 to 2009-10, corresponding the

fall in MMR and IMR are 32.8 % and 18 % respectively. This is a matter of serious

concern indicating not only a need for further investigation, but is also an issue for

advocacy.

The field based evidences when set against the mission’s directions and guidelines

bring forth many advocacy issues. We summarize here the key findings from this

study and certain recommendations.


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7.1 Key findings

The funding under JSY has increased but, this has not been sufficient enough to

address the backlog cases

The mean wait time after delivery is 3.8 months for receipt of money under JSY

and 12.8 months for money under PA.

Women faced difficulties in registering, applying and receiving cash incentives

for various reasons

Shortage of Cheque books have been cited as one of the major reason for delay in

disbursement of funds under CI

The Untied and Maintenance Funds are received in the last quarter of the FY.

VHSCs are forced to maintain a minimum balance in their account as per bank

guidelines. This results in deducting of some funds in the subsequent FY.

There is inconsistency in documentation of financial and physical components of

the funds received

Vouchers are not maintained properly

None of the PHCs and SCs contacted have had any kind of auditing undertaken

Both Financial and Physical auditing is needs to be undertaken

Accounting training for all personnel is essential

There is significant number of vacancies of MOs, ANMs and ASHAs, Staff

Nurses, First divisional Clerks

The health service delivering officials have not read the NRHM documents and guide

lines.

The Mission documents and guidelines are not available in the regional language

There is lack of clarity among ASHAs and ANMs about the eligibility criteria for CIs

under NRHM

Non availability of transport for referral case a major issue

In 6 out of 7 PHCs under study, deliveries were not happening on regular basis

All pregnant mothers are informed in their first visit that they need to go to CHCs or other

centres

There is a significant number of women registering with ANMs for ANC checkup within

the first two trimester


68


Teenage pregnancy still is a reality, but actual teenage pregnancy rate is not captured

All eligible pregnant women who are underage are tutored to declare their age as 19.

The institutional delivery rate was 81%

Absence of fulltime ASHA and ANMs with single Sub Centre increases the chances of

home deliveries.

Still birth documentation needs effective monitoring

7.2 Recommendations

Funds for CIs should be released in advance as it is possible to estimate the

number of eligible women.

Removal of BPL as a criteria for eligibility for JSY & PA

Untied and Maintenance funds should be made available at least in the second

quarter.

The unspent balance should not be deducted from the next year’s allotment

Banks should provide Zero Balance facility to VHSC accounts

A proper evaluation of the reasons for not spending to be undertaken.

Need to see if the yearly release of Maintenance fund is useful or aggregated

need based fund release could be taken up

ASHA @ every village ( 1000) made mandatory

All vacancies of ANM and ASHA to be filled on a war footing

All PHC’s need for second Doctor and at least One staff nurse must be met

immediately

Training for ASHA to be planned locally and it should be periodic and phased

All PHCs must be upgraded to provide Delivery facilities with necessary staff,

resources and equipment

Role of BPMs be internalized by the MOs

All Mission documents must be made available to all MOs ANMs and ASHAs

NRHM related training to all MOs, with special focus on ensuring community

participation in the health-care system


69


Training for ANMs and ASHAs should focus on sensitizing them to the needs of

the community they work with. There is also a need to reorient them at regular

intervals depending on ground realities.

A comprehensive evaluation of the time available to MO, ANM and ASHA and

the responsibilities given to them for discharging should be undertaken to

develop the correct picture of personnel required on field rather than one MO,

ANM per health centre

A detailed study of reporting mechanism should be undertaken to eliminate the

repeated and overlapping reporting of activities.

Training programmes need to clearly spread across the year rather than clouding

at the year end when the officials also need to work on the PIP, Health plan and

budget preparation.

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8

Follow-up and Advocacy

8.1 Advocacy Mandate

During the course of the study, several issues came to light which reflect on the

policy implementation gaps at the field level. The interactions with community

members during study also brought forth certain field realities and an

understanding of the changes needed at the ground level to make the vision of

NRHM attainable. Some of the recommendations are already mentioned in the

previous chapter. These will have to be placed to various authorities in the health

department and followed-up.

The need for undertaking certain actions in response to the field situation was also

felt strongly by the organization and therefore an advocacy plan was formulated as a

second phase of this project. This chapter introduces the advocacy initiatives

planned, and a subsequent report will contain the details of the initiatives and the

initial impact seen.

Further, it is the mandate of GRAAM to take up advocacy at different levels as a

logical and meaningful measure following its research process. It is also recognized

that there are several stakeholders that must be taken into account while making an

advocacy plan. Hence a multi-pronged strategy was evolved covering advocacy

with community, media, Civil society organizations (CSO) and policy makers.

8.2 Advocacy Points

The following matrix of advocacy points was arrived at from the Funds Tracking

study. We however submit here that these are based on the study undertaken in

Mysore District only and when it comes to larger State level advocacy, there is a

need to take into account information and experiences of studies undertaken in

different districts.

This advocacy matrix also takes into account discrepancies of field interpretations of

certain NRHM guidelines. Hence advocacy for correct interpretation of

implementation of a policy is as important as advocacy for relevant policy changes.

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Table 14: Advocacy issues matrix based on NRHM funds tracking study

Advocacy issue Description

Removal of BPL as a

criteria for eligibility

for JSY & PA

The problems associated with the identification and issuing of the BPL

card keeps out many poor families from availing the is card, which is

issued by the food and supplies and consumer affairs department for PDS

use only

ASHA @ every village

( 1000)

ASHA is perceived as the most basic and essential link in taking health for

all target to its desired result. Presence of ASHA in the village and the safe

delivery has been proved to be highly correlated in our study.

Occurrences of Home deliveries are more pronounced in those villages

where ASHAs are absent

Training for ASHA

locally

The recruitment of ASHA as health worker was looked at by many in the

village as a new job creation and hence the traditional decision makers at

home most often men had agreed for the initial training at the district

level. Subsequent training was very difficult as the women were not

allowed to go to district head quarters for training for 21 days.

The dropout rate for ASHA is also very high and new recruits do not

prefer to move away from their home town.

It is therefore more effective to plan training programmes at the local

level.

Periodic/ phased

training

Internalization of the philosophies of NRHM is essential in translating the

visions o f NRHM. The initial 23 days (or 21 days, in some cases) training

is not sufficient enough to understand all the dimensions of health.

Periodic updating and solving the field generated issues is very important

for the ASHAs.

The position of ASHA is not authoritative one but what she is expected to

do is bring about a sea of change. To do this a very strong personality

should evolve. This can happen with more frequent training and support

mechanism development.

Findings

dissemination with

media

The fund and service delivery related activities under NRHM needs a

constant monitoring and the role of media in this is immense. It is very

important to sensitize the media to the kind of issues that both the service

providers and receivers face and highlight the solutions and way forward.


72


Delivery at PHCs The out of pocket expenses for poor families increases if they have to

travel farther than a reasonable distance for delivering the child. This

leads many women to opt for home delivery without trained assistants,

leading to maternal and infant deaths. To avoid this NRHM has planned

for improving the PHCs as the first contact points for safe delivery. Hence

it is very important that all PHCs be provided with 2 trained nurses, so

that deliveries close to their homes are made possible. Further the mother

and child could be shifted to 24*7, CHC. Taluka or district level hospitals

according to the need and availability.

Public hearing

mandatory

The process of public hearing should be made mandatory in the sense that

it is officials who call for this hearing rather than the public.

The NRHM has visualized a clean and transparent governance practice in

providing health for all. To achieve this it is important that the people who

spend the funds for the public cause should call for the public meeting

and give account of the expenses. As it stands now, the VHSCs with the

training of the NGOs organize public hearing and seek clarifications. This

creates friction and conflict among the stakeholders viz. the medical

fraternity, health department and community, rather than making them

work as a unit. It is therefore necessary to put the responsibility on the

health personnel to organize regular public hearing.

MO training (w.r.t

community

participation)

NRHM related training to all MOs with a focus on community

participation is necessary to help realize the 'communitization' component

of NRHM. The PHC MO is an important and influential element in the

health-system and synergies with the community are therefore vital.

Documentation of

funds received and

spent should be

available at the Taluka

& District levels

(disaggregated - line

item wise)

This information must be made available in public domain.

In absence of all the data pertaining to the mode of allocation of funds and

expenditure at different levels under different heads it is not possible to

understand the correctness of fund utilization. Audited statements of

funds and physical auditing are very important to keep track of public

money being spent.

Good governance practices are also an important vision and strategy

under NRHM so that all citizens are covered under health services.


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8.3 Advocacy Strategy

As mentioned earlier, our advocacy strategy was multi-pronged and sought to cover

the below mentioned aspects. We realize and recognize that many of the advocacy

issues mentioned in the above table need long-term and sustained action. The initial

set of actions undertaken by us, within the time period available were based on the

primary idea of triggering processes that can bring change, rather than visible

changes. We are conscious that these initiatives form only a small subset of possible

actions that can be done with more stakeholders joining hands.

Maintenance and

Untied funds should

be disbursed in the

first/second quarter

The untimely disbursement of funds with out accumulation in the account

will lead to wasteful/improper and misuse of funds. The very purpose of

providing funds under NRHM is to increase the contribution of the

government towards health so that the health for all is reached. This goal

will not be a possibility with untimely funds. From yet another angle it is

asking for accountability only from one side that is service provides but no

commitment from the government side is undemocratic.

Funds under JSY & PA

Heads should be

available to the MOs

based on the PIP

number of

beneficiaries

This is to ensure that there is no accrual of backlogs and also to maintain

the timeliness in funds disbursal to all beneficiaries

Preparation /

translation of all

guidelines and NRHM

related Documents

into Kannada

It is very important in a multi-linguist society all information be made

available in the local languages, without which the targets may not be

reaching due to non understanding of the rules, it will also lead to

wrongly interpret the intensions of the original ideas/ instruction/ values

Working with VHSC

to draft

comprehensive health

plan covering

budgetary and health

services monitoring

aspects

The training for VHSCs was felt very essential if the NRHM needs to reach

the goals set. Only when the communities are empowered to understand

the different components involved in reaching a healthy society position.

To make the communities to understand that they need to work with the

departments and to monitor the sevices available to them and collaborate

with governments to reach the said target.


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Community advocacy

Our understanding of community advocacy primarily revolved around

making the community aware of the provisions under NRHM and also to

ensure that they internalize their roles and responsibilities. NRHM seeks to

‘communitise’ the monitoring of health services and has laid down certain

structures to achieve it. There is effort needed from the Government, PRI

members and civil society to ensure that these structures function effectively.

From internal discussions, we envisaged that it may be possible to make it

happen by assisting select VHSCs draft a comprehensive health plan for their

respective villages. We further believed that such an objective would entail

processes that encompass different players at the village level and define the

focus of our community advocacy initiatives.

Media advocacy

Recognizing media as a stakeholder, not only to report the issues on the

ground to the wider public and create opinion, we believed that media also

has a role to play in development. We also needed to build a collaborative

relationship with media and understand their response on the coverage of

development issues. Towards this, we felt the need to create a space for

discourse on development journalism in general and subsequently introduce

specific themes such as Public Health, Community monitoring of services, etc

in the dialog with media.

Advocacy with CSOs

It is imperative that any public policy advocacy initiative must take into

account multiple perspectives and also the knowledge and experience of

multiple organizations and individuals working in the sector. With this

premise as a backdrop, GRAAM also seeks to work with different civil society

organizations in the state and not only share its research findings and

advocacy points, but also look at advocacy points that other organizations feel

are vital.

Further, we also feel the need to stress on the importance of advocacy that is

based on empirical evidence and reliable research data. At the same time,

research data and findings must be taken to the subsequent step of advocacy.

With a view to understand whether advocacy initiatives undertaken by civil

society organizations in the State have sufficient research data to back them


75


and to explore the possibility of networking with research and advocacy

institutions alike, an advocacy workshop with Civil Society organizations has

been conceptualized.

Advocacy with Policy makers

Advocacy with policy planners began in the form of an ‘Initial findings

dissemination workshop’ with stakeholders including NRHM Mission

director, District level Officers from Health Department and funding partner

in October 2012. However, we recognize that there is a need for continuous

engagement with the policy makers and therefore subsequent dissemination

and policy level dialog events with the State Health Secretary and NRHM

Mission director must be taken up.

We believe that the planned advocacy scope covers the immediate stake-holders

with regard to the health-care delivery system and the outcomes and experience

from these activities will help us lay out a plan for a larger and more intensive

advocacy strategy.

8.4 Initiatives undertaken

8.4.1 Community level advocacy

The objectives & scope of community advocacy for this project have been defined as

below

Intensive hand-holding with 3 VHSCs falling under the purview of 1 PHC

to prepare a comprehensive health action plan for their respective villages

Indirect support to all VHSCs of Mysore district through training and

capacity building of Resource Persons of SVYM’s Arogyavardhini27 Project

Continuously contribute towards awareness and empowerment of village

community through progressive dialogue

The following stages were followed as part of community advocacy activities

Identification of PHC and VHSCs: Due to the time-schedule available to carry out

the advocacy project, only one PHC (viz. Maddur Kallahalli) was chosen among the

ones where the initial research was conducted.

27 Arogyavardhini was a project undertaken by SVYM with the GoK for empowering all VHSCs in

two districts of Karnataka viz. Mysore and Hassan. Under this project resource persons were

deployed in the entire districts. 83 RPs were deployed in Mysore district and a training program on

health plan preparation was conducted for all the RPs of Mysore district.


76


Preliminary meetings with 8 VHSCs falling under the purview of M Kallahalli PHC

were conducted.

Following the field visits, village profiles were analysed and 3 VHSCs were

identified based on a combination of VHSC grading and lottery system.

Community follow-up team formation: For the purpose of intensive village level

data analysis using Participatory Rural Analysis technique – a team comprising a

PRA consultant, dedicated field co-ordinator, Co-ordinator for community

consultation and field assistants was constituted. The team’s responsibility was to

gather complete data of the villages and assist the villages in frame a health action

plan.

PRA exercises: PRA exercises comprising social mapping, seasonal mapping,

transact walks, focus group discussions, interviews with SDMC, Anganwadi

committees, ANMs, ASHAs, women’s’ groups, disabled, and other members of the

village community were conducted.

Completion of PRA exercise and subsequent visits to the villages for missing data

collection took on an average 5 days per village. The following villages were covered

under this exercise

1. Chuncharayanahundi

2. Kadanahalli

3. Maddur

4. Maddur Hundi

5. M Kallahalli

Training of Resource Persons

83 Resource persons (RPs) were trained in 3 batches on Village data analysis,

Problems identification and prioritization, actions needed to frame a health plan

with villages, Programs and budgets at the disposal of a village community and

practical implementation challenges. The training was conducted with the objective

of re-orienting and refreshing the knowledge of RPs and providing them specific

inputs with regard to health plan preparation.

Health plan preparation and submission

Subsequent to the PRA exercise, the village data was analyzed and the deficiencies

in the health services faced by village community, and all the other issues within the


77


villages that impact the health and sanitation scenario of the village were mapped.

These deficiencies were then distilled to actionable items and a draft plan was

prepared. In consultation with the VHSC members of the respective villages, the

plans were updated and finalized.

PRI officials were roped in during the submission of the health plans and their role

in ensuring that various components of the village health plans materialize was

stressed upon during the meetings.

Follow-up action: Monitoring of health services and VHSC meetings

Subsequent to the health plan preparation and submission, the below basic follow-

up actions have been identified

Regular and effective VHSC meetings and ensure that all VHSC members

play an active role, especially ex-officio members from SDMC, Anganwadi,

Sub-centre, etc

Evolving a responsibility matrix of community members to monitor health

services

Co-ordination with other committees in the village viz. SDMC, Bal Vikas

Samitis (Anganwadi), Thaayindara Sangha (Mothers’ collective), etc

Following up with the Gram Panchayat officials to set right the infrastructural

issues in the village that affect health such as drains, drinking water sources,

garbage dumps, etc

8.4.2 Media Advocacy

Recognizing that the role of media is vital influencing public policy and shaping

public discourse, GRAAM plans to have a long-term relationship with media. As

part of this relationship building exercise, the first event undertaken by GRAAM

was the conducting of a 1-day workshop on Development Journalism for state level

journalists and media professionals.

The workshop entitled Madhyama Manthana was conducted in Bangalore on 31st

March 2012 with the following objectives.

Create a forum for state level media to deliberate on the theme of development

journalism (with focus on health)

To kindle the interest of young journalists towards development journalism by

stressing on its importance and scope.


78


Share GRAAM’s study/research findings and experiences with community

through its projects

Draw out a framework on what specific steps media houses and media persons

can take towards public policy advocacy while bringing out grassroots

perspective

Schedule and Agenda highlights:

The highlight of the agenda was a Panel discussion on “Present Day Opportunities

and Challenges in Developmental Journalism" with senior editors from print and

electronic media viz. The Hindu, Samaya News, Prajavani. The event was

moderated by well-respected and veteran journalist Mr. Ishwara Daithota. Mr. K

Sathyanarayana, former editor of Kannada Prabha delivered the keynote address

and participated actively in the discussions. Mr. Suresh Kumar, Hon Mins for Law,

Parliamentary affairs and Urban Development observed the panel session and gave

his remarks.

GRAAM also used the opportunity to share its initiatives on public policy research

and community experience focusing on health. The event served to bring the

discourse on development journalism in the fore-front and helped GRAAM in

getting an understanding of how collaborations with media could be made.

Follow-up action: Close contact with media and subsequent events

As a follow-up action to the media advocacy workshop, it has been identified that

close contacts with journalists who are sensitive to development issues must be

developed and there should be a regular update of information on GRAAM

activities. One of the prominent feedbacks from the participants of the workshop

indicated the need to conduct such events at district level, which we as an

organization also believe is important, and hence steps in that direction need to be

initiated.

8.4.3 Advocacy workshop with CSOs

Advocacy activities with Civil Society organizations have been initiated with the

following larger objectives.

Sharing of GRAAM’s research findings with other CSOs working on health

sector, especially community health

Building up collective consensus on health issues that need to be addressed

by the State on priority and explore the scope of working together


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Explore the possibilities of collaborative research on health and allied topics

in a larger geographical spread

Draw out advocacy strategies collectively and work together for positive

changes in public policy

Towards this end, the first workshop on “Evidence based Health Advocacy” was

conducted on 29th May, 2012 in Mysore. The event was co-organized with Public

Affairs Centre (PAC), Bangalore a leading non-profit Think Tank committed to

promoting good governance in India.

8.4.4 Advocacy with Policy Planners

Advocacy with Policy planners is one of the most crucial parts of the strategy as far

as effecting change is concerned.

Advocacy activities with Policy planners and bureaucracy were initiated with the

dissemination workshop held on 12th October 2011. Subsequently GRAAM has been

in contact with Taluka and District level officers for support in proceeding with

certain Community advocacy activities.

The following activities are planned to further the advocacy efforts with the

bureaucracy at District and State level

- Publication of factsheets and sharing of completed findings with NRHM Mission

Director, District and State Level Health officials

- Meeting with Health Secretary upon completion of community advocacy

activities to share highlights of the experience and process level issues

We also recognize the need for analyzing and comparing our study findings and

recommendations with other studies at the State level. This is not only to include

other perspectives, but also to ensure that the advocacy issues raised with policy

makers take into account a macro-picture. Working with other CSOs in the health

sector and incorporating other reliable research data as a basis for advocacy are

crucial aspects of a successful policy advocacy action.

The necessary dialog space with policy planners on the one hand and collaborative

relationship with organizations and individuals in the health sector needs to be built

with time and effort. Most importantly, these activities must progress without losing

the focus on community perspective. With this backdrop, GRAAM views these

advocacy initiatives as part of a larger and continuous advocacy strategy on issues of

Public Health.


80


8.5 Scope for further action

Change is a slow and gradual process and continuous follow-up and monitoring is

imperative to bring about visible and lasting change. From the limited experience of

the Research and Advocacy projected supported by GRAAM, we have observed the

following needs.

1. Working with VHSCs has been an invaluable learning experience for GRAAM

and at the same time, the process has sown seeds of empowerment in the village

community as they are becoming aware of their entitlements through the

dialogue that GRAAM is engaging with them.

There is a huge scope for improvement of health-care delivery systems even if

basic monitoring of services is done by the VHSCs. The VHSCs with which we

are working will eventually have a strong monitoring component in their action

plans, but the need for engaging with them for a longer period is evident from

the gaps that have been observed.

Also, preparing and submitting a comprehensive health action plan is only the

first step in the community’s involvement in safeguarding their health. In reality,

the VHSCs may need continuous inputs on monitoring process itself as

envisaged in their action plans. Hence follow-up is needed not just to convert

plans to actions, but also to prevent a collapse of momentum in the VHSCs.

2. The advocacy matrix developed following the study on Tracking of Funds

consists of advocacy points that need long-term & medium-term follow-up.

Issues such as making available information of funds disbursal at Taluka level

offices, suggested changes in eligibility criteria to receive cash incentives, or

training of Medical Officers in community participation need a long-term follow-

up, possibly with successful experiments as evidence.

GRAAM is in the process of expanding the advocacy matrix with regard to

NRHM and drawing out plans for furthering the activities

3. The current set of activities with different stakeholders must continue over the

new financial year, so that changes and impact can be monitored and

documented. Also, policy level advocacy activity must be a long term affair, to

take into account changing economic and political climates of the State.

4. GRAAM and SVYM are currently undertaking other projects on health and

NRHM in particular. Viz.


81


State level evaluation of NRHM in Karnataka

Community monitoring and ranking of PHCs in Mysore district aided by

technology

Extension of district wide support to VHSCs capacity building and

community participation

In this context, it becomes relevant for us to continue the advocacy activities already

initiated and planned. SVYM & GRAAM would also like to position and prepare

itself to serve the nation by contributing towards positive policy change better policy

implementation and towards this, a dynamic advocacy strategy needs to be worked

out.

GRAAM seeks the support of agencies and organizations that identify with its long-

term advocacy strategy and can support its initiatives technically and financially.

82


Annexure

Slides from Presentation made by DPMO on different

components of NRHM in Mysore District

Slide 1: Overview of Deliveries Scenario in Mysore District from 2006 to 2010

ªÉÄÊ¸ÀÆgÀÄ f¯Áè ºÉjUÉ «ªÀgÀ

PÀæ.¸ÀA

Sl No

ªÀµÀð

Year

MlÄÖ d£À¸ÀASÉå

Total

Population

¸ÀA¸ÉÜ ºÉjUÉ

Institutional

Delivery

ªÀÄ£É ºÉjUÉ

Home

Delivery

MlÄÖ ºÉjUÉ

Total

Deliveries

fÃªÀAvÀ d£À£À

Live Births

MlÄÖ ²±ÀÄªÀÄgÀt

Total Infant

Death

L.JA.Dgï

IMR

MlÄÖ vÁ¬ÄAiÀÄ

ªÀÄgÀt

Total

Maternak

Deaths

JA.JA.Dgï

MMR

1 2006-07 2748306 39843 1616 41459 41227 1027 24.9 25 60.6

2 2007-08 2966616 41393 268 41661 41460 866 20.8 34 82

3 2008-09 2793455 41474 103 41774 41605 850 20.4 21 50

4 2009-10 2970700 44290 62 44352 44133 904 20.4 18 40.7

52010-10 (£ÀªÉA§gï

CAvÀåPÉÌ)

2970700 29258 60 29261 29173 492 18


83


Slide 2: IMR and MMR Details in Mysore District from April 2010 to November 2010

(Taluka wise break-up)

ªÉÄÊ¸ÀÆgÀÄ f¯Áè ºÉjUÉ «ªÀgÀ ªÀÄvÀÄÛ L.JA.Dgï ªÀÄvÀÄÛ JA.JA.Dgï «ªÀgÀ

K¦æ¯ï 2010 jAzÀ £ÀªÉA§gï 2010gÀªÀgÉUÀ

PÀæ.¸ÀA vÁ®ÆèPÀÄ ºÉ¸ÀgÀÄMlÄÖ

d£À¸ÀASÉå¸ÀA¸ÉÜ ºÉjUÉ ªÀÄ£É ºÉjUÉ MlÄÖ ºÉjUÉ fÃªÀAvÀ d£À£À

MlÄÖ

²±ÀÄªÀÄgÀtL.JA.Dgï

MlÄÖ

vÁ¬ÄAiÀÄ

ªÀÄgÀt

JA.JA.Dgï

1 ªÉÄÊ À̧ÆgÀÄ 320325 3705 8 3713 3702 48 12.9 1 2.7

2 n,£ÀgÀ¹Ã¥ÀÄgÀ 293510 3146 7 3153 3120 56 17.9 1 3.2

3 £ÀAd£ÀUÀÆqÀÄ 392035 4149 2 4151 4119 80 19.4 3 7.2

4 ºÉZï.r.PÉÆÃmÉ 271566 3089 28 3117 3082 72 23.3 2 6.4

5 ºÀÄt À̧ÆgÀÄ 287581 3320 6 3326 3307 48 14.5 1 3

6 ¦jAiÀiÁ¥ÀlÖt 243128 2741 5 2746 2724 32 11.7 4 14.6

7 PÉ.Dgï.£ÀUÀgÀ 261397 2535 2 2537 2535 48 18.9 3 11.8

8 ªÉÄÊ À̧ÆgÀÄ (£À) 933206 6573 2 6575 6576 108 16.4 3 4.5

MlÄÖ 3002748 29258 60 29318 29165 492 18


84


Slide 3: Details of Prasuti Araike beneficiaries (SC, ST, Others) and expenditure in

Mysore District from April 2010 to November 2010 (Taluka wise break-up)

2010-11 £ÉÃ ¸Á°£À°è K¦æ¯ï- £ÀªÉA§gï 10gÀ CAvÀåPÉÌ ¥Àæ¸ÀÆw DgÉÊPÉ

AiÉÆÃd£ÉAiÀÄrAiÀÄ°è vÁ®ÆèPÀÄªÁgÀÄ ¥sÀ¯Á£ÀÄ s̈À«UÀ¼À ̧ ÀASÉå

PÀæ.¸ÀA f¯ÉèAiÀÄ ºÉ¸ÀgÀÄ vÁ®ÆèPÀÄUÀ¼À ºÉ¸ÀgÀÄ EvÀgÉ J¸ï.¹ J¸ï.n MlÄÖ MlÄÖ RZÀÄð

1

ªÉÄÊ¸ÀÆgÀÄ

ªÉÄÊ¸ÀÆgÀÄ 269 123 81 473 597000

2n.£ÀgÀ¹Ã¥ÀÄgÀ 5 10 0 15 242000

3£ÀAd£ÀUÀÆqÀÄ 246 127 84 457 855000

4ºÀÉZï.r.PÉÆÃmÉ 266 162 165 593 812000

5ºÀÄt¸ÀÆgÀÄ 64 43 54 161 161000

6¦jAiÀiÁ¥ÀlÖt 72 26 20 118 178000

7PÉ.Dgï.£ÀUÀgÀ 210 135 40 385 396000

MlÄÖ 1132 626 444 2202 3241000


85


Slide 4: Details of Madilu kit* beneficiaries (SC, ST, Others) in Mysore District from

April 2010 to November 2010 (Taluka wise break-up)

*Madilu kit is a kit provided to women who delivered comprising 19 items that are

useful to newborn and its mother like bedsheets, blankets, soaps, warm clothes, etc

under a State Govt sponsored scheme.

2010-11 £ÉÃ ¸Á°£À°è K¦æ¯ï- £ÀªÉA§gï 10gÀ CAvÀåPÉÌ ªÀÄr®Ä

AiÉÆÃd£ÉAiÀÄrAiÀÄ°è vÁ®ÆèPÀÄªÁgÀÄ ¥sÀ¯Á£ÀÄ s̈À«UÀ¼À ̧ ÀASÉå

PÀæ.¸ÀA vÁ®ÄèPÀÄUÀ¼À ºÉ¸ÀgÀÄ

ªÀÄr®Ä Qmï «vÀj¹zÀ ¥sÀ¯Á£ÀÄ¨sÀ«UÀ¼À ¸ÀASÉå

©.¦.J¯ï J¸ï.¹ J¸ï.n MlÄÖ

1 ªÉÄÊ¸ÀÆgÀÄ 1073 302 202 1577

2 n,£ÀgÀ¹Ã¥ÀÄgÀ 1133 752 371 2256

3 £ÀAd£ÀUÀÆqÀÄ 1040 635 451 2126

4 ºÉZï.r.PÉÆÃmÉ 655 617 568 1840

5 ºÀÄt¸ÀÆgÀÄ 1035 382 319 1736

6 ¦jAiÀiÁ¥ÀlÖt 954 298 145 1397

7 PÉ.Dgï.£ÀUÀgÀ 1126 306 122 1554

MlÄÖ 7016 3292 2178 12486


86


Slide 5: Number of beneficiaries of NRHM CI schemes (JSY, Madilu and PA) in

Mysore District and expenditure incurred (in Rs. Lakhs) for FY 2008-09

2008-09, £ÉÃ ¸Á°£À°è gÁ¶ÖçÃAiÀÄ UÁæ«ÄÃt DgÉÆÃUÀå C©üAiÀiÁ£ÀzÀrAiÀÄ°è

PÉÊUÉÆArgÀÄªÀ C©üªÀÈ¢Ý AiÉÆÃd£ÉUÀ¼À «ªÀgÀ

PÀæ.¸ÀA AiÉÆÃd£É «ªÀgÀ

MlÄÖ ¸ÁzsÀ£É gÀÆ.®PÀëUÀ¼À°è

2008-09

¨sËwPÀ DyðPÀ

1 d£À¤ ̧ ÀÄgÀPÁë AiÉÆÃd£É 22103 156.27

2 ªÀÄr®Ä 13662 -

3 ¥Àæ¸ÀÆw DgÉÊPÉ 741 14.81


87


Slide 6: Number of beneficiaries of NRHM CI schemes (JSY, Madilu and PA) in

Mysore District and expenditure incurred (in Rs. Lakhs) for FY 2009-10

2009-10 £ÉÃ ̧ Á°£À°è gÁ¶ÖçÃAiÀÄ UÁæ«ÄÃt DgÉÆÃUÀå C©üAiÀiÁ£ÀzÀrAiÀÄ°è

PÉÊUÉÆArgÀÄªÀ C©üªÀÈ¢Ý Ai ÉÆÃd£ÉUÀ¼À «ªÀgÀ

PÀæ.¸ÀA AiÉÆÃd£É «ªÀgÀ2009-10

¨sËwPÀ DyðPÀ

1 d£À¤ ̧ ÀÄgÀPÁ ë Ai ÉÆÃd£É 28090 204.17

2 ªÀÄr®Ä 16518 -

3 ¥Àæ¸ÀÆw DgÉÊPÉ 9141 132.62


88


Slide 7: Expenditure incurred (Rs. in Crores) under NRHM in Mysore District and

corresponding IMR and MMR figures for FY 2006-07 to FY 2009-10

SL.NO YEAREXPENDITURE ( Rs in Crores)

IMR MMR

1 2006-07 1.36 24.9 60.6

2 2007-08 2.65 20.8 82

3 2008-09 11.82 20.4 50

4 2009-10 12.24 20.4 40.7

0

10

20

30

40

50

60

70

80

90

2006-07 2007-08 2008-09 2009-10

1 2 3 4

1.36 2.65

11.82 12.24

24.920.8 20.4 20.4

60.6

82

50

40.7

EXPENDITURE ( Rs in Crores)

IMR

MMR


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Slide 8: Statement of year-wise number of Home deliveries in Mysore District from

FY 2006-07 to FY 2009-10

STATEMENT OF YEAR WISE HOME DELIVERIES

SL.NO YEAR Home Deliveries

1 2006-07 1616

2 2007-08 268

3 2008-09 103

4 2009-10 62

0

200

400

600

800

1000

1200

1400

1600

1800

2006-07 2007-08 2008-09 2009-10

1 2 3 4

Home Deliveries

Home Deliveries


90


Slide 9: Statement of year-wise number of Institutional deliveries in Mysore District

from FY 2006-07 to FY 2009-10


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Slide 10: Number of people undergoing Family Planning procedures in Mysore

District from FY 2006-07 to FY 2009-10

STATEMENT OF YEAR WISE PROGRESS OF FAMILY PLANNING

SL.NO YEAR Family Planning

1 2006-07 21371

2 2007-08 20766

3 2008-09 20848

4 2009-10 21930

20000

20200

20400

20600

20800

21000

21200

21400

21600

21800

22000

2006-07 2007-08 2008-09 2009-10

1 2 3 4

Family Planning

Family Planning

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