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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’
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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.
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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
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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
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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
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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
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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
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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,
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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.
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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.
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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.
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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
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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
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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
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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
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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
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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 %.
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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.
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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
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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.
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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.
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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
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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
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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
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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)
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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
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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
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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.
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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.
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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.
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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
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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.
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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
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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.
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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.
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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
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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
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• 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
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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.
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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
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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.
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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
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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-
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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.
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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
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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
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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.
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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
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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.
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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
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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.
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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.
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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.
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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
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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.
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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.
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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
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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.
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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
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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”
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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
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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
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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
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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.
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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
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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
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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.
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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
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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.
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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
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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.
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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.
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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.
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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.
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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
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Sl No
ªÀµÀð
Year
MlÄÖ d£À¸ÀASÉå
Total
Population
¸ÀA¸ÉÜ ºÉjUÉ
Institutional
Delivery
ªÀÄ£É ºÉjUÉ
Home
Delivery
MlÄÖ ºÉjUÉ
Total
Deliveries
fêÀAvÀ d£À£À
Live Births
MlÄÖ ²±ÀĪÀÄgÀt
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
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Slide 2: IMR and MMR Details in Mysore District from April 2010 to November 2010
(Taluka wise break-up)
ªÉÄʸÀÆgÀÄ 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
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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
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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 £Éà ¸Á°£À°è K¦æ¯ï- £ÀªÉA§gï 10gÀ CAvÀåPÉÌ ¥Àæ¸ÀÆw DgÉÊPÉ
AiÉÆÃd£ÉAiÀÄrAiÀÄ°è vÁ®ÆèPÀĪÁgÀÄ ¥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
ªÉÄʸÀÆgÀÄ
ªÉÄʸÀÆgÀÄ 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
Tracking of NRHM funds (JSY, Untied and Maintenance)
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GRAAM – An SVYM Initiative www.graam.org.in
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 £Éà ¸Á°£À°è K¦æ¯ï- £ÀªÉA§gï 10gÀ CAvÀåPÉÌ ªÀÄr®Ä
AiÉÆÃd£ÉAiÀÄrAiÀÄ°è vÁ®ÆèPÀĪÁgÀÄ ¥sÀ¯Á£ÀÄ s̈À«UÀ¼À ̧ ÀASÉå
PÀæ.¸ÀA vÁ®ÄèPÀÄUÀ¼À ºÉ¸ÀgÀÄ
ªÀÄr®Ä Qmï «vÀj¹zÀ ¥sÀ¯Á£ÀĨsÀ«UÀ¼À ¸ÀASÉå
©.¦.J¯ï J¸ï.¹ J¸ï.n MlÄÖ
1 ªÉÄʸÀÆgÀÄ 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
Tracking of NRHM funds (JSY, Untied and Maintenance)
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GRAAM – An SVYM Initiative www.graam.org.in
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, £Éà ¸Á°£À°è gÁ¶ÖçÃAiÀÄ UÁæ«ÄÃt DgÉÆÃUÀå C©üAiÀiÁ£ÀzÀrAiÀÄ°è
PÉÊUÉÆArgÀĪÀ 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
Tracking of NRHM funds (JSY, Untied and Maintenance)
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GRAAM – An SVYM Initiative www.graam.org.in
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 £Éà ̧ Á°£À°è gÁ¶ÖçÃAiÀÄ UÁæ«ÄÃt DgÉÆÃUÀå C©üAiÀiÁ£ÀzÀrAiÀÄ°è
PÉÊUÉÆArgÀĪÀ 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
Tracking of NRHM funds (JSY, Untied and Maintenance)
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GRAAM – An SVYM Initiative www.graam.org.in
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
Tracking of NRHM funds (JSY, Untied and Maintenance)
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GRAAM – An SVYM Initiative www.graam.org.in
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
Tracking of NRHM funds (JSY, Untied and Maintenance)
90
GRAAM – An SVYM Initiative www.graam.org.in
Slide 9: Statement of year-wise number of Institutional deliveries in Mysore District
from FY 2006-07 to FY 2009-10
Tracking of NRHM funds (JSY, Untied and Maintenance)
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GRAAM – An SVYM Initiative www.graam.org.in
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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GRAAM – An SVYM Initiative www.graam.org.in