Type of Review: Annual Review
Project Title: MADHYA PRADESH HEALTH SECTOR REFORM
PROGRAMME (MPHSRP)
Date started: 2007
Date review undertaken: May 2013
Instructions to help complete this template:
Before commencing the annual review you should have to hand:
 the Business Case or earlier project documentation.
 the Log frame
 the detailed guidance (How to Note)- Reviewing and Scoring Projects
 the most recent annual review (where appropriate) and other related monitoring reports
 key data from ARIES, including the risk rating
 the separate project scoring calculation sheet (pending access to ARIES)
You should assess and rate the individual outputs using the following rating scale and
description. ARIES and the separate project scoring calculation sheet will calculate the overall
output score taking account of the weightings and individual outputs scores:
Description
Outputs substantially exceeded expectation
Outputs moderately exceeded expectation
Outputs met expectation
Outputs moderately did not meet expectation
Outputs substantially did not meet expectation
Scale
A++
A+
A
B
C
Introduction and Context
What support is the UK providing?
DFID will provide £120m (over 2007 - 2015) to Govt of Madhya Pradesh (GoMP, India) to increase
provision and use of quality health services, especially by the poorest people. MPHSRP will help the
GoMP to achieve accelerated reduction in maternal mortality, infant mortality and child malnutrition.
What are the expected results?
What will change as a result of our support?
DFID support for MP Health sector reform project aims to achieve the following results by 2015:
 Decrease in Maternal mortality ratio from 335 (in 2005) to 230 per 100,000 live births.
 Decrease in Infant mortality from 76 (in 2006) to 47 per 1000 births.
 Decrease in the proportion of undernourished children from 58% (in 2005) to 45%.
 Increase in deliveries conducted by nurses and doctors from 30% in 2005 to 85%.
 Increase in full immunisation coverage from 36% (2008) to 58%.
 Increase in % of children
o Breastfed within an hour of birth from 43% (2007) to 65%;
o Exclusively breast fed till 6 months from 31% (2007) to 50%;
What are the planned Outputs attributable to UK support?
There 5 priority outputs that are attributable to UK support:
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1. Quality public and private health, sanitation and nutrition services available in underserved districts
2. Improved Human Resource Management in Health Sector
3. Financial management and procurement systems improved
4. Increased Demand for Nutrition, Health and Sanitation Services
5. Monitoring and Evaluation Systems Strengthened
How will we determine whether the expected results have been achieved?
Baseline for key indicators is available and monitoring systems are in place to provide regular
information on progress against expected results. The technical and financial performance of the
programme is assessed on a six-monthly and annual basis, to monitor progress against the log frame
and to agree the plans for subsequent tranches of funding. Additionally, independent measurements of
maternal child health and nutrition service coverage (utilization and quality) is undertaken through
regular surveys, evaluation studies and National Government led Health review missions.
What is the context in which UK support is provided?
What need are we trying to address?
Madhya Pradesh (MP) is one of the poorest states in India, with over 54% of its population living below
the poverty line. Despite progress in recent years, MP is currently off track on MDG 1, 4 and 5
(nutrition, maternal and child mortality).
MP has the highest infant mortality rate of all states in India (76 infant deaths per 1000 live births) as
well as very high Maternal mortality ratio of 335 per 100,000 births (as compared to national value of
254 per 100,000 births). An estimated 160,000 mothers and children die every year because of easily
preventable and treatable medical complications. More than half (58%) the children in MP are
undernourished. Important contributors to under nutrition include access and availability of food, poor
infant and child feeding and caring practices, poor sanitation and repeated diarrhoea. The health
outcomes of tribal and dalit populations and girls/ women are significantly worse than for other groups
due to poverty, social deprivation, illiteracy, lack of information and inadequate access to health
services. There are substantial gender disparities and women and girls are distinctly worse off in
access to food, education, income, and social status compared to men. Existing social norms such as
early marriage and early childbearing also affect health and nutrition outcomes adversely.
The performance of the public health delivery system faces several constraints: per capita expenditure
of public health is low (at $8, against a global standard of $34 for a minimum package of essential
healthcare); high ‘out of pocket’ expenditures (on diagnostics and medicines); staff vacancies and
infrastructure gaps; lack of drugs and other essential supplies at local levels; weak monitoring systems;
poor accountability of health personnel, low motivation and management capacity.
What will we do to tackle this problem?
DFID’s financial and technical assistance will help GoMP in delivery of maternal, child health and
nutrition services in the poorest remote, rural and underserved areas. DFID funds will help in improved
functioning of primary hospitals, child feeding centres, monitoring and supervision, hospital cleanliness
and staff training and health communications. Technical assistance will help Government of Madhya
Pradesh (GoMP) in better health planning and human resource management; improve monitoring and
procurement systems.
Illustrative areas of support for health and nutrition services under include:
 Improved Quality of hospital services for maternal, neonatal and child health.
 Scaling up quality and coverage of monthly Village based health and nutrition days and
strengthening community demand for health and nutrition and sanitation services.
 Promoting behaviour change communications with special focus on the first 1000 days of life and
nutrition behaviours like breast feeding and complementary feeding
 Setting up and functioning of state Nutrition Mission and delivery of district nutrition plans.
 Strengthen drug procurement and distribution systems for continuous availability of essential
medicines at 50 district hospitals and 1400 sub-district hospitals.
 Support in developing a comprehensive Health human resource database and rational deployment
of 14,000 doctors and nurses in remote areas.
 Capacity development at all levels, supportive supervision, IT enabled MIS, strengthening financial
management and procurement systems.
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Who will be implementing the support we provide?
The programme is implemented by the Department of Public Health and Family welfare (DPHFW) and
by Department of Women and Child Development (DWCD) of Govt of Madhya Pradesh. The Technical
and Management Support Agency, placed in MP manages the technical cooperation.
Section A: Detailed Output Scoring
Output 1: Quality public and private health, sanitation and nutrition services available in
underserved districts
Output 1 score and performance description:
A - Outputs met expectation
Progress against expected results:
Indicator
Functional quality
assurance systems
for hospitals providing
emergency obstetric
and neonatal services
Improved Quality of
Village health and
nutrition days (VHND)
in 16 focus districts.
Milestone 2012 -13
Quality Monitoring framework
designed and implementation
started in 13 focus districts.
Status April 2013
Achieved.
Bimonthly quality monitoring done
in 30 hospitals and Actions taken
reports
NGOs contracted in 16 districts to
strengthen VHNDs:
Overachieved
Trainings and VHND Quality
monitoring started in atleast 10
districts.
Partially achieved:
Training plan,
materials finalised.
Session on VHND incorporated
into Village health and sanitation
committee ( VHSC) Training
module.
Achieved
Training on health and Progress against training plans
nutrition supported by
DFID TA
Partially achieved.
44000 ICDS staff
trained on 1000 days
initiative
More than 5000
health staff trained to
mobilise Village health
and sanitation
committees (VHSC).
TA team monitored
training quality of
87000 VHSC
members.
172 hospital staff from
44 districts trained on
hospital infection
prevention and waste
management
240 health staff from 3
districts trained on
anaemia who in turn
3
Score
A+
B
A
Nutrition mission
implemented in the
state
Number of children
and P/L women
reached with nutrition
services (6mths to 72
mths given SN)
TAST support in 16 districts to help
implement district plans.
CMAM approach approved by
steering committee - roll out started
74 lakhs
trained all frontline
service providers in
the 3 districts.
Achieved.
B
Partially achieved
Over achieved. 84
lakhs
A+
Highlights of progress:
Overall progress on this output is on track and significant TA inputs were provided for quality
improvement at 39 high load hospitals: for implementing the state nutrition mission: and trainings for
improving service delivery.
Health:
 DFID TA designed a quality assurance (QA) roadmap, Maternal New born health (MNH tool kit)
and supportive supervision checklist approved by the state health mission and is being
implemented by the state govt QA cell.
 GoMP has initiated large scale hospital quality improvement (QI) under the Kayakalp Scheme,
which includes focus on hygiene and cleanliness, essential drugs, infrastructure, clean potable
water, functional equipment, 24x7 electricity back-up, and biomedical waste management.
DFID TA has developed a monitoring tool for gap assessment and supportive supervision,
being used in the 16 focus districts; ready to be scaled-up in 34 districts in 2013-14.
 Three rounds of quality assessment and quality improvement for 39 health facilities across the
16 focus districts were completed. Quality improvement plans are being implemented, resulting
in visible improvement in hospitals. Data analysis for two rounds shows improvements in: basic
amenities like water, power backup, organisation and lay out of service areas of Antenatal
clinics, labour room, wards, Operation theatres etc. There is improvement in display of
information and clinical protocols, recording system, availability of equipment and drug supplies.
However Human resource gaps are difficult to tackle. A detailed report documenting quality
improvements in four District Hospitals (Satna, Sehore, Sagar, Dindori) is awaited this month.
 The district TA helped revitalize the District Quality Assurance Committees (DQACs): more than
20 meetings have happened in the 16 focus districts since last 4 months. Findings from 39
hospitals (CEmONC and BEmONC) assessment reports and the subsequent facility
improvement plans are discussed during the DQAC meetings.
 It was agreed with DHFW, that DFID FA funds over 2013 -15 will be ring fenced for improving
health service quality and will be largely used for hospital cleanliness, supervision, monitoring
and capacity development.
Nutrition
 The state nutrition mission is being well implemented and all district plans for ICDS and Atal Bal
Mission focus on the crucial 1000 days period for pregnant woman and small children. TAST
supported training of more than 44000 ICDS workers (AWW) and supervisers on first 1000
days (Infant Young Child Feeding, home-based new-born care, Growth Monitoring and
Promotion (GMP), referral and enrichment of locally available foods/recipes).
 DFID TA supported GoMP to develop a detailed Project implementation plan and budgets for
the new GOI supported ICDS mission and helped them leverage funds of about 1000 crores (£
125m and about 55% more than previous years budgets).
 Scaling up quality Village health nutrition days (VHNDs) are now an integral part of health and
nutrition strategy in Madhya Pradesh: annual number of VHNDs has increased to 714,000 from
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500,000 in 2008. However the quality of VHND services needs to be improved. A qualitative
assessment done by DFID TA indicated that VHNDs mainly provide immunization and
important services such as antenatal care, nutrition, growth monitoring and counselling is
negligible. DFID TA has contracted a reputed NGO to support VHND strengthening in
approximately 3,000 villages across 16 focus districts, which will start implementation in June
2013 as part of the Community Based strategy. Meanwhile the district TA teams across the 16
focus districts are helping improve micro-planning, training of nurses and monitoring of VHNDs.
TA has helped document a range of innovations being implemented across the 50 districts:
which include additional meal to pregnant women, malnourished children; health improvement
for children, adolescent girls, anaemic women, web-based monitoring, training to the
Anganwadi Workers and counselling of women, adolescents and children to adopt improved
behavioural practices. Although this was more of process documentation and less of evaluation,
the semi structured research method provided preliminary evidence of good results. GoMP has
agreed to evaluate a subset of these innovations to inform scale up under the new GOI ICDS
Mission.
The pilots for Community-based Management of Acute Malnutrition and local production of
ready-to-use therapeutic food (RUTF) are now approved by the State steering Committee and
the Chief Minister. Memorandum of Understanding (MOU) between MP-AGRO and Valid is
being finalized for technology transfer to initiate the production of ready-to-use therapeutic food.
Major decisions on geographic areas, implementation models, training materials and evaluation
methods are agreed by the stakeholders group and the Technical Core Committee is finalising
all the training materials, operational guidelines and monitoring tools. The implementation of the
pilot is expected to start by September 2013.
It was agreed with DWCD, GoMP that DFID FA funds over 2013 -15 will be ring fenced for
improving nutrition service quality and training systems for under 2 children and will be largely
used for upgrading training centre for supervisors and Anganwadi training centres, concurrent
monitoring, community based management of severe acute malnutrition, innovative pilots, and
Anganwadi centre construction.
Recommendations:




Improve quality of care at 39 hospitals across 16 districts by supportive supervision, mentoring
and TA support for QAC functioning. (TA team and NRHM quality cell)
Using DFID FA and TA set up skills lab across 6 divisions to support skill based training of
doctors and nurses and practice lifesaving clinical protocols. (NRHM maternal health team and
TA team)
Strengthen VHNDs across 3000 villages in 16 focus districts for ANC, Immunisation, FP,
Nutrition counselling, and role clarity among front line workers. Atal Bal Mission implementation
to be accelerated including trainings and supervision. All district plans to be monitored
quarterly. (ICDS Commissioner, NRHM ASHA resource center and TA team)
Start the implementation of CMAM trials and test local production of RUTF. (ICDS
Commissener, MPAGRO and Valid Nutrition)
Impact Weighting (%): 25
Revised since last Annual Review? No
Risk: Medium
Revised since last Annual Review? No
Output 2: Improved quality of Human Resource Management in Health Sector
Output 2 score and performance description:
A. Outputs met expectation
5
Progress against expected results:
Indicator
Better HR
database informs
rational
deployment of
human resources
HR Policy and
Strategy developed
with better capacity
for HR
management
NRHM
restructuring and
HR management
strengthened
Milestone
Doctors database webenabled and put in public
domain.
Regular updation and
quarterly analysis of
doctors database to plan
rational deployment.
HR Cell established &
staffed.
Comprehensive HR
policy developed for
DH&FW
Restructuring study of
NRHM completed and
included in NRHM PIP
Status
Achieved
Score
A
Achieved
Largely achieved. Four
consultants recruited for the
HR cell, but it is yet to be
fully operationalized.
B
Draft available, consensus
with GoMP awaited
Achieved
A
Highlights of progress:
 Regular updation and quarterly analysis of doctors database is a remarkable achievement under
MPHSRP. The Doctors database which includes about 4500 doctors has been updated till Mar
2013. The HR analysis provided useful insights for decision making and they are being used by
the Health Commissioner to fill existing gaps for transfers and rational deployment.
 The HR analysis highlights glaring problems in irrational postings of doctors and specialists and
shows that despite severe shortages of doctors and specialists, there is serious overstaffing in
many preferred urban locations/districts. For example:
o


Against the sanctioned posts of 3789 medical officers, only 2384 are present (62%). There is a
surplus of 497 Medical officers in 299 Healthcare facilities. 209 MOs are posted in 92
healthcare facilities where there is no sanctioned position. There are 602 healthcare facilities
which are without the services of an MO.
o The five critical specialties of Anesthesiology, Surgery, Obstetrics, Pediatrics and General
Medicine have sanctioned posts of 2431 and the combined availability of only 45%. However
there are 31 hospitals where there is no sanctioned position, but there are 40 Anesthetists
posted. There are 105 hospitals where there is an Obstetrician posted, but no Anesthetist.
Hence no caesarian can be done.
The updated information is being used for deployment of doctors in underserved districts but with
low success rates. Using the database, about 78 specialists have been redeployed to underserved
district hospitals. Districts are not allowed for new contractual appointments unless existing staff
are rationally posted. Financial incentives (ranging from 9000 to 15000) for doctors is agreed by the
state govt for posting in remote areas. However it is a severe challenge to achieve rational
deployment despite best technical efforts.
The current database of Doctors has been converted into a web-based on-line system and is
available in the public domain. This has substantially contributed to greater transparency and
accountability for posting decisions. Data can now be updated real time, and quick decisions
regarding optimum utilisation can be taken. The Health Commissioner has requested for
performance monitoring link within the HR database to help link with incentives.
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 HR Cell within DoH&FW has been set up to improve HR management systems with four consultants
who will support HR Planning, recruitments, trainings, promotion, transfers, HRMIS and
performance management.
Recommendations:
 Regular updation and analysis of doctors’ database for rational deployment of doctors should be a
top priority. (Health Commissener and HR cell)
 A comprehensive HR database for all staff (medical & para-medical) to be developed. (TA team
and Health Commissioner)
 The HR cell/Establishment section to be strengthened for enabling better HR management (Health
Commissener)
Impact Weighting (%): 20%
Revised since last Annual Review? No
Risk: High
Revised since last Annual Review? No
Output 3: Financial and procurement systems effectiveness improved
Output 3 score and performance description:
A+. Outputs moderately exceeded expectation
Progress against expected results:
Indicator
FRA & ASP Risk
Ratings,
Milestone
Status
Financial management manual for Achieved. Finance Manual
NRHM developed.
for NRHM developed and
under review by the
Government
Score
A
Achieved
FRA shows improvement in
fiduciary risk ratings.
Achieved
DFID FA agreed with specific
lines of spend as part of budget of
DWCD and DHFW.
Audit analysis and
compliance
enhanced
Procurement and
Drug Management
System
strengthened
Audit analysis of NRHM society
completed.
Strong audit mechanism
established for ABM.
Drug MIS (SDMIS)
institutionalised; Procurement Cell
established and functional; Drug
stock outs reduced by 30%;
Technical Support Units continue
to support O&M
Overachieved for state
level and 9 districts
A+
Over achieved
The 2 milestones for 2013
-14 also achieved: Local
purchase module
implemented and
Procurement corporation
design ready for cabinet
approval
A+
Highlights of Progress:
 Budget lines for DFID FA were agreed as part of budget of DWCD and DoPH&FW for 2012-13
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and 2013-14. However it took significant time to agree on the detailed FA plans for both
departments, mainly because of multiple changes in senior officials and changing govt
priorities. Now it is decided that DFID FA will be projectised, aligned to the reform priorities,
used to fill gaps in the existing fundings, and largely used in the 16 focus districts. DFID funds
for DWCD will be used to a) Strengthen and upgrade Mid-level training centre for supervisors
and Anganwadi training centres in 16 focus districts b) undertake concurrent monitoring, c)
implementation of community based management of severe acute malnutrition and innovative
pilots d) Anganwadi centre construction. The DFID funds for DoPHFW will be used for Hospital
cleanliness, mobility support for supervision, capacity building, setting up skill labs, and
strengthening nursing training institutions. Because of delays in agreement on FA plans, there
was significant underspend. While DHFW has spent about 50% of allocations of £7m, DWCD
has spent a negligible amount under DFID budget line.

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Audit analysis for NRHM is being done by DFID TA. Analysis of statutory audit for the state
health society and 5 District Health Societies for 2011-12 is also completed. Concurrent audit
analysis has been completed for 9 districts. Some of the key audit findings of NRHM relate to
non-adjustment of outstanding advances, non-preparation of bank reconciliation statements,
non-compliance with tax deduction at source, and vacancies of District Accounts Managers.
Based on the audit findings, NRHM MD has instructed districts to ensure compliance and
requested TA team to develop training and capacity building. Strong audit mechanism is now
established for state nutrition mission (ABM) and analysis of statutory audit findings has been
completed for 9 districts and for ABM Society audits for FY 11-12.
Drug MIS (SDMIS) is now fully institutionalised: The SDMIS is operational in 100 nodes, 4
specialty hospitals and 4 Gas Rahat Hospitals. The Health Commissioner has started using
data generated from SDMIS for monitoring drug availability, minimum stock values, payments,
supplies etc. Proposal for expanding the SDMIS till the Primary health center level is finalized
and will be soon put up for cabinet approval. Linking the inventory management through SDMIS
till PHC level will enable better monitoring of stock availability at the frontline.
A local purchase module in the SDMIS was designed and rolled out in March 2013. This will
enable better monitoring of emergency drug purchase funds available to all districts (which is
about 20% of the total 240 crores).
Procurement Cell is now functional: There was a glaring gap in availability of professional staff
for supporting drug and equipment procurement functions in the health department. DFID TA
helped set up a Procurement Cell with six technical positions: Pharmaceutical, Procurement,
Logistics, Quality assurances and a Bio Medical Engineer. DFID TA team supports bid
documents, tender drug list finalisation, demand forecasting, specifications, review of tender
document to make technically and legally robust document. The new Essential Drug List EDL,
long pending since 2006, includes 446 medicines against 247 in the previous EDL.
Design of an independent Procurement Corporation: DFID TA has developed a business plan
for an independent Procurement Corporation including financial feasibility analysis. This
business plan is ready for cabinet approval.
Recommendations:
 Monitor DFID FA expenditures against the FA plan on quarterly basis and feedback to the principal
secretary DHFW and DWCD. (DFID project officer along with NRHM MD, Health Commissioner
and ICDS Commissener)
 Set up a review mechanism for response to audit findings and compliance monitoring. Audit para
tracking system developed by Finance Department under SPMG to be adopted. (TA team, DFID
Governance adviser and Health Commissener and ICDS Commissener)
 Conduct trainings on financial management and internal controls. (TA team)
 Full fiduciary risk assessment exercises by DFID will include procurement audit and fund flow
review on DFID supported expenditure lines. (DFID Governance adviser and DFID Project officer)
 Scale up SDMIS till PHC level. Drug stock-out study to assess impact of new drug policy and
SDMIS roll-out. Improve capacities for warehouse management and quality assurance of drugs.
(TA team and Health Commissener)
Impact Weighting (%): 20%
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Revised since last Annual Review? No
Risk: Medium
Revised since last Annual Review? No
Output 4: Increased demand for Nutrition, Health and Sanitation services
Output 4 score and performance description:
A - Outputs met expectation
Progress against expected results:
Indicator
Strengthened
capacity of
community groups to
monitor community
based health,
nutrition services
and counselling.
Design Community
Volunteer Leader’s
Capacity building
strategy
BCC campaign for
awareness on
maternal health,
IYCF and sanitation
practices
Milestone
State wide trainings of Village health and
sanitation committee (VHSCs) designed
and supported by TAST
Status 2013
Achieved
Score
A
Mentoring group for community action
(MGCA) to monitor ASHA training and
VHND – functional software collates
feedback.
CLV feasibility study report, Base Paper
and Course curriculum prepared.
Achieved
Achieved
A
Prototype of IEC materials developed and
used for BCC. Training of frontline workers
on IPC in 2 districts started.
Over Achieved
A+
Highlights of progress:




GoMP mobilised an ambitious plan in 2012 -13 to strengthen 51,000 Village Health and Sanitation
Committees (VHSC), which are community level structures under NRHM supporting planning and
supervision of health, nutrition, and sanitation with an untied annual fund of Rs 10,000. The capacity
building of VHSCs will result in better health care seeking practices, behaviour change and
accountability of frontline services and outcome indicators like antenatal care, immunisation, child
feeding and hand washing are expected to improve. DFID TA supported the training of VHSCs:
designed all the training materials including flip books, training manuals and health education songs
and directly supported training of about 5000 state and district trainers and is helped monitor
training quality of about 87000 VHSC members.
Mentoring group for community action consists of local leaders, NGOs and retired teachers and
they are actively monitoring ASHA trainings and Village health and nutrition days. They provide
structured feedback which is collated on a software. DFID TA provides analysis of training quality,
logistical arrangements and also payments being made as per guidelines.
DWCD is designing a new strategy on developing “Community Volunteer leaders” to create a cadre
of skilled community volunteers and front line workers to support better nutrition and health related
behaviours in the community. DFID TA conducted a Feasibility study and a Base paper on modular
course. The feasibility study findings confirm a clear demand for the course. Tata Institute for Social
Science (TISS), a reputed academic institution, has agreed to affiliate the course and develop the
course curricula and material.
Behaviour change communications activities by BBC WST are well underway. A Birth Spacing
campaign (Ek teen do) covering 275 villages in 2 districts (Sagar and Damoh) is on going
successfully with very good feedback from govt officials. The campaign used a range of techniques
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including street performance, wall stencils, mobile vans, quizz and a Long Duration Evening Play on
the issue of birth spacing. Capacity building of 2591 community health workers (ASHAs) was also
completed on Inter personal counselling skills related to Birth Spacing.
A radio series, Khirdi Mehendi Wali, is planned for broadcast this month. The different episodes
focus on maternal and child health issues, gender discrimination, female foeticide, child marriage,
nutrition, anaemia, hygiene, sanitation etc.
Recommendations:





Operationalize a comprehensive community mobilization strategy on working with SHG Federations
in 6 districts and continue support to strengthen Frontline service provider skills on 1000 days,
VHNDs and VHSCs across 16 districts. (TA team)
CVL training to be designed and piloted in partnership with TISS. (TA team and PS DWCD)
Monitoring & analysis of VHSC training in the 16 focal districts and feedback to district and state
administration. (TA team and NRHM ASHA resource center)
Engage socially excluded groups such as landless daily wage labourers through the community
mobilization strategy and strengthen their access & use of health, wash and nutrition services. (TA
team)
Implement Behaviour Change Communication campaign in coordination with DWCD and DPHFW.
(BBC WST)
Impact Weighting (%): 15%
Revised since last Annual Review? No
Risk: Medium
Revised since last Annual Review? No
Output 5: GoMP has a state M and E system that enables quality planning.
Output 5 score and performance description:
A - Outputs met expectation
Progress against expected results:
Indicator
Milestone
Timely Health MIS
Facility based reporting started.
reports which are
Strengthened mother child tracking
regularly analysed to
systems being used to send SMS
assess district/facility
reminders and track service uptake
performance
District grading analysis on KPIs
used to rank districts
Strong MIS system for
Revised ICDS MIS with specific
tracking nutrition
focus on feeding behaviours rolled
performance
out with TAST support.
Evaluation studies and
Atleast 2 Reviews/independent
independent
assessment/evaluation studies of
assessments of Health specific initiatives for health and
and Nutrition initiatives
nutrition.
Status 2013
Achieved
Score
A
Achieved
A
Achieved
A
Highlights of progress:
Health
 DFID TA has been instrumental in effectively implementing Web-based Health MIS for all 50
districts of Madhya Pradesh. All 313 blocks are reporting timely monthly progress data with
90% completeness and validation errors considerably reduced. Facility-based reporting
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system is in place in 46 out of 50 districts and 70% of hospitals have started reporting.
NRHM monthly health bulletins are now released. Districts are being ranked on the basis of
performance against critical indicators/score cards, e.g. caesarean, institutional delivery,
measles coverage, family planning and financial achievement. The Principal Secretary
reviews district performance monthly through video conference and gives feedback on
critical gaps.
Reporting on services under mother child tracking systems (MCTS) improved considerably
with Backlogs of 98% brought down to 56% in the last four months. A centrally managed
ICT mechanism is now well established with DFID TA support, for feedback, follow-up and
supervision of MCTS activities. MCTS Call Centre sends SMS reminders to all clients and
frontline health workers to reduce drop outs. This system was recently reviewed by DFID
UK Internal audit team and was much appreciated.
Under DWCD Nutrition programme, DFID TA supported the development of web-based MIS
reporting system. All 90,000 AWCs are now reporting timely and complete data. Feedback
on the monthly MIS data is shared with the District officials to review programme activities
and results. DFID TA is now supporting the roll-out of the revised ICDS MIS , which will help
improve programme focus on critical 1000 days and better monitor behaviour change, child
feeding and home visits. DFID TA has supported the trainings of 180 trainers and 3000
supervisors and completed phase 1 trainings for 92000 Anganwadi workers. All 4 phases of
trainings will be complete by the middle of July 2013.
Two major studies on “Study on Assessment of the Emergency Response Services (ERS)”
and “Process documentation of innovations under Atal Bal Mission” have been done by
DFID TA. The selected nutrition innovations will be scaled up under the new ICDS Mission
funded by Govt of India. The study findings from ERS assessments will be used to scale up
the emergency response systems in a cost effective manner.
Recommendations:
 Data quality assessments to be done periodically for Health and ICDS to improve quality of
data reported. (NRHM MIS cell, TA team and NRHM MD and ICDS Commissener)
 Training of CDPOs and Supervisors on use and analysis of monthly MIS data. (ICDS
Commissener and TA)
 Performance assessment and ranking of health facilities based on critical service delivery
indicators to be introduced. (NRHM MIS cell and TA team)
 Design and implement Evaluation studies for the newly designed Community based models
and for Nutrition innovation being piloted under ABM. (TA team)
Impact Weighting (%): 20%
Revised since last Annual Review? No
Risk: Medium
Revised since last Annual Review? No
Section B: Results and Value for Money.
1. Progress and results
1.1. Has the log frame been updated since last review? Yes
Log frame changes were made during 2012-13 to revise projections of infant mortality rates based on
recent data. Output indicators were also revised to respond effectively to changing programme
requirements to complement strategies under the National rural health mission.
1.2 Overall Output Score and Description:
Score: A (met expectation)
Out of five outputs, One is rated as A+ (with impact weight of 20%), four are rated A (with total impact weight of
80%).
11
Output
Impact weight
Score
Output 1
25%
A
Output 2
20%
A
Output 3
20%
A+
Output 4
15%
A
Output 5
20%
A
Overall score
A
1.3 Direct feedback from beneficiaries
Feedback from a wide range of beneficiaries captures both positive changes and remaining
challenges.
Anjali’s journey from clutches of malnutrition to normal status
Kamala gave birth to a healthy girl child Anjali weighing 3 Kg. Due to family barriers,
she did not take Anjali to the Anganwadi center Samara, district Tikamgarh for
accessing AWC services. The baby was not weighed and not fed appropriately due
to which she became severely underweight.
Anganwadi worker - Rama Sarvaiya identified the problem and played a key role in
bringing Anjali to Anaganwadi center: weighing her, ensured regular and additional
feeding and referred to the hospital Nutrition Rehabilitation Center (NRC) at
Badagaon for 14 days. Anjali came back from NRC and under supervised feeding
and continuous monitoring by the Anganwadi worker, she reached normal weight
status and now plays with other neighbourhood children living a healthy life.
Beneficiaries
Savita Mahesh - Beneficiary from
Sehore district hospital
Pregnant women village Bartala,
district Jabalpur on services at the
CHC.
Auxiliary Nurse Midwife (ANM) of
SHC, Nagada block, district Dhar on
VHSC (GSSGTS) training.
ASHA, village Padwar, district
Jabalpur on improvements in the
hospital
Block Community Mobilizer,
Majhgawa block, district Jabalpur on
Feedback
During labour, I got immediate attention from hospital as
well as blood transfusion. The doctors conducted surgery
and saved me and my baby. In earlier days such cases
were referred to Bhopal Hospital. Thanks to all the doctors
for timely support extended to me.
The behaviour of the hospital staff with us was good and
they made all the medicines and materials available and
meals were also provided on time. There is lot of
improvements in the facility, hospital is cleaner and
drinking water facility is good.
After the VHSC training with panchayat members, I got
inspiration to work with more enthusiasm. Earlier I felt that
I have to do immunization alone but now with the support
of the community I am finding it more convenient to deliver
services more systematically in the village. After attending
the training I am now able to talk to people without
hesitation.
During last 4-5 months there have been many changes in
the Primary health center. Behaviour of staff and facilities
are improved. The labor room is more organized where
essential medicines, materials are available. Earlier when I
used to take along pregnant women, labor room had
nothing and now everything is available there. I had
mobilized five pregnant mothers to this hospital last month
and now people are also more inclined towards getting the
services from this hospital.
TA team provided continuous support for planning and on
conducting VHND sessions. With regular conduct of VHND
12
overall support provided by DFID
TA.
Health Supervior, PHC Bidki, district
Jabalpur on VHND conduction
Civil Surgeon- Satna, Dr BL Gupta,
MD
Chief Medical officer, District Satna,
Dr DN Gautam
Dr Jyoti Chouhan, HOD in Sagar
Dr Manglesh Parste (Dindori)
Dr Sujata Parmar, Gynocologist at
Sehore district hospital
sessions in our block, field workers are demanding more
materials and medicines. VHNDs are now organized with
proper planning and prior preparations. MCTS data
backlog and registration has also improved.
Now we have in-depth understanding of organizing a
VHND like preparing micro plan, what are the essential
materials, what are the essential services to be delivered
and what are the target groups for VHND. Now we are
able to organize the VHND in better manner covering all
the target women and children
Quality improvement (QI) support helped in a miraculous
change in our hospital. The QI Team has lot of experience
and they guide us professionally. All the maternity wings
are having help desks with computers and with glass &
aluminium partitions, we have chambers for breast feeding
demonstrators, record keeper, and duty sister. We have
changed the beds and repaired lot many furniture. All the
bed sheets are now washed properly”
My hospital is so good that my daughter in law delivered a
girl child in this hospital and newly born girl child is in
Neonatal ICU, what else quality issue you want to talk”.
With the QI team, we are able to resolve problems in the
labor room, maternity wards and administration. Now the
civil surgeon and the CMHO and even District Collector
calls us for discussions, listen to our problems and tries to
resolve our problems.
We are working on quality improvement and now we got
six drug trays in labor room and baby radiant warmer but
at diagnostic front if I alone will do all the jobs, how will I
manage.”
With support from QI team, I was able to equip the labor
room with Inverter, Six trays, Auto clave, regular
cleanliness and dustbins for wards.
1.4 Summary of overall progress
MPHSRP has made significant progress against the project milestones and is on track to achieve all
the outcome and impacts. As per available estimates1, DFID support to MPHSRP has directly enabled:

More than 150,000 women to give birth in a health facility attended by skilled healthcare staff,

Over 32000 additional people to use modern family planning methods.

Provided nutrition intervention to nearly half a million children and pregnant women.
GoMP has shown remarkable progress in scaling up hospital services over the last 5 years: functional
delivery points have increased from about 335 to about 900: 39 sick new born units and 276 nutrition
rehabilitation centres set up: more than 3700 nurses, 4000 Auxilliary midwives and 1900 doctors
recruited. However there still remains a non-uniform geographic distribution of doctors and nurses,
infrastructure, logistics and variable quality of services. Since 2010, DWCD has deployed more than
700 additional ICDS block officials/supervisors and additional 13000 Anganwadi workers to support
nutrition services.
MPHSRP has provided substantial assistance under five areas: Quality improvement of services, HR
management, MIS/monitoring systems, procurement and financial systems, and improving demand
and community based provisions. Important initiatives supported by MPHSRP include:

1
Setting up quality improvement mechanisms at district and hospital levels, by defining quality
Using FCPD guidance for calculation methodology
13
management frameworks and implementing them in 39 high load hospitals across 16 focus
districts. To further improve quality and complement TA inputs, DFID FA will now be used to
improve hospital cleanliness, waste management as well as mobility for better supervision.

MPHSRP has helped mobilise a high level of political commitment to tackle malnutrition. GoMP
with DFID support is now implementing a state nutrition mission (Atal Bal Arogya Evam
Poshan Mission) targeted at children under 2 years. MPHSRP funds and TA are used to
Implement district action plans: strengthen training and supervision with focus on first 1000 days
reaching more than 40,000 workers: and initiate community based management of severe acute
malnutrition.

Strengthening of Village Health sanitation and Nutrition Committees and village health and
nutrition days; massive scale up of training of VHSC to reach more than 90,000, which will lead to
better uptake of services and preventive health behaviours like child feeding and immunisations

Streamlined procurement of drugs to achieve best value for money and effective distribution
systems; expanding essential drug lists from 247 to 426: absorbing drug budget increase of more
than 125% from 108 crores to 245 crores:

A functional web enabled real time doctor’s database to enable rational deployment of about
4500 doctors. Though politically challenging, this database helped senior officials to plan
redeployment based on caseloads and skills rather than vested interests and personal preferences.
Better reporting, analysis and use of MIS data for performance management and Mother child
tracking systems: easy availability of user friendly tools like district grading reports, monthly
health bulletins and facility based performance data helps senior health and nutrition officials to
track progress and improve accountability of lagging districts.


Audit analysis of both NRHM and Atal Bal Mission (ABM) societies is to improve compliance to
audit findings and betters systems of internal controls. A full FRA is planned in June 2013 to
include DFID fund flow audit and procurement audit for additional safeguards for DFID funds.
14
1.5 Key challenges

Substantial efforts are needed to improve quality of services and quality assurance systems,
both at hospitals and at village health nutrition days. Rapid mortality and disease reductions will
only occur if health workers have appropriate skills, medicines, functional equipment, follow
infection prevention and good infrastructure. One of the major constraints in providing quality
services is the shortage of medical and paramedical staffs with adequate skills.

Continuing constraints in rational deployment of doctors and specialists to the underserved
districts undermines efforts to improve functionality of hospitals, obstetric and neonatal care. Efforts
to rationalise the allocation of human resources for health through use of an HR MIS system are
on-going, there are severe governance challenges to fill these critical gaps. About 40 out of the
planned 120 first referral units for maternal health care (FRUs) in MP are not functional because of
unavailability of specialist doctors.

Capacity development of service providers and supervisors to effectively deliver quality health
and nutrition services during the first 1000 days in hard to reach districts is an ongoing challenge. A
major effort is required to ensure the hands on skills to perform lifesaving functions like emergency
obstetric care and new born resuscitation. For this, well equipped skill labs are needed with models
and mannequins for adequate practice of skills. .

Strengthening management and monitoring capacity for DWCD at the state, district and block
levels to effectively implement ICDS and ABM is a key challenge. Efforts to strengthen Programme
Management units at the state and district level along with secondment of staff through TA support
to the department will enable the department to address systemic issues and procedural delays.

Ensuring quality implementation of community based models at scale covering over 25000
frontline workers and approx. 1500 self-help groups across the 16 underserved and high burden
districts in a span of two years is a major challenge for the programme.

More efforts are needed for better supply chain management for essential drugs and ensuring
functional equipment at hospitals remain a challenge.

Financial management capacity for budget planning, accounting, auditing and follow ups for audit
reports is a key challenge for effective utilisation of funds within both the departments.
1.6 Annual Outcome Assessment
MPHSRP is well on track to achieving all the outcomes and impact indicators as evident from the latest
available data.
MP has recorded a 13 point decline in Infant mortality rates (IMR) in 4 years from 72 to 59 per 1000
live births between 2007-11. This is good progress considering that IMR was declining by only 2 points
per year prior to 2007. We have revised the 2015 targets for Infant mortality rates (from 52 to 47) to
make it more ambitious based on past trajectory. Latest available data shows that the project is within
striking distance of achieving the 2013 targets for under nutrition, infant mortality, antenatal care and
exclusive breast feeding.
Indicators
Maternal Mortality Ratio
Infant Mortality Rate
Contraceptive Prevalence Rate (any modern method)
Under-weight children (0-5 year)
Deliveries taking place in health facilities
Women who have received 3 ANC check ups
Children aged 12-23 months fully immunized
15
Milestone
(2012-13)
285
56
58%
50%
70%
70%
50%
Progress
269 (SRS 2007-09)
59 (SRS 2011)
57% (AHS 2011)
52% (NIN 2010)
76% (AHS 2011)
68% (AHS 2011)
55% (AHS 2011)
Children breast fed within an hour
Children fully breast fed till 6 months of age
55%
40%
61% (AHS 2011)
37% (AHS 2011)
2. Costs and timescale
2.1 Is the project on-track against financial forecasts: Y/N
Yes. The total project cost for MPHSRP is £120m (FA; £103m and TA; £17m) As of 31st March 2013,
£79m FA and £8,1m TA has been disbursed. During 2012 -13, there was significant underspend of FA
by both the departments and plans for 2013 to 2015 have been revised to ensure effective and timely
spending of FA funds. DFID team is closely tracking the approvals of FA plans and expenditure
patterns.
2.2 Key cost drivers
Key cost drivers of the project come from two separate mechanisms: Financial Aid (FA) and Technical
Cooperation (TC).
Both departments (DoPHFW and DWCD) have a separate budget line earmarked for DFID funds. The
detailed FA plans for both the departments are finalised.
DFID funds for DWCD will be used to a) Strengthen and upgrade Mid-level training centre for
supervisors and Anganwadi training centres in 16 focus districts b) undertake concurrent monitoring, c)
implementation of community based management of severe acute malnutrition and innovative pilots d)
Anganwadi centre construction. The DFID funds for DoPHFW will be used for Hospital cleanliness,
mobility support for supervision, capacity building, setting up skill labs, and strengthening nursing
training institutions.
Cost drivers under TA are the remuneration and travel/logistics costs of expert professionals and
institutions, which help develop capacity of health and nutrition staff, strengthen human resource,
financial management and MIS systems. TA funds are used for improved planning, quality
improvements, capacity building, monitoring, analytic studies, evaluations, and piloting innovations.
2.3 Is the project on-track against original timescale: Y/N
Yes. The project is on-track against the original timescale.
3. Evidence and Evaluation
3.1 Assess any changes in evidence and implications for the project
There are no major changes in evidence underpinning the theory of change.
All the project interventions focussing on continuum of care for pregnant woman and young children
include antenatal care, skilled birth attendance, new born care, immunisation, child feeding and birth
spacing, which are known to have a major impact on reducing maternal and infant deaths and child
malnutrition. There is also growing evidence that health systems strengthening interventions like staff
training, supervision, appropriate staff deployment, procurement, and logistics and monitoring systems
have a more sustainable impact on achieving MDGs.

Based on emerging evidence that rapidly rising coverage of institutional deliveries is not leading to
adequate mortality reductions, MPHSRP is now shifting stronger focus towards quality
improvements, skilled delivery care and emergency obstetric care.

In 2012, a UNFPA study on age specific fertility rates was done in MP, where they analysed the
population structure, the TFR goal, and modelled the contraceptive method mix required to address
the unmet need for family planning. The study concluded that since the big gains had to be made
among young women, there was a need for specific targeting through spacing methods. Therefore
GoMP has prioritised delivery of spacing methods to young woman during 2013 -14 under National
16

Rural Health Mission. DFID TA is planning to support post-partum FP in the focus districts.
Global evidence shows that Severe Acute Malnutrition (SAM) in children can be feasibly treated at
the community levels, using energy dense “Ready to eat therapeutic food”, MPHSRP is now
mobilising support for Govt of MP to trial and scale up CMAM, and locally produce RUTF. The trial
pilots are now approved and ready to start implementation.
3.2 Where an evaluation is planned what progress has been made?
An impact evaluation and operations research with a randomised control trial is planned to test the
effectiveness of using locally available food to treat SAM children. The proposals and designs are
ready.
An evaluation of an innovative pilot being implemented under the ABM is planned over 2013 -2015.
This pilot delivers hot cooked meal to pregnant woman at Anganwadi Centres with an aim to improve
enrolment, pregnancy weight gain, anaemia, birth weight of babies and better hygiene practices.
An evaluation of the community mobilisation strategy is also being designed to assess the impacts of
self help group mobilisation to achieve better health service uptakes.
17
4. Risk
4.1 Output Risk Rating: Low/Medium/High
The programme is judged to be of medium risk with the potential of high return.
4.2 Assessment of the risk level
The key risk factors are assessed as given in the table:
S.no
1.
2.
Risk Factors
Fiduciary risks
substantial
Weak planning and
implementation
capacity
Non-availability of
critical medical staff in
remote areas
Current risk profile
Fiduciary risks reduced to moderate
Improving: TA helping to improve district implementation capacity,
training, supervision, monitoring., besides setting up of units for
Procurement, HR etc
Although large scale recruitment of staff has occurred, there is
slow improvement overall. Large vacancies exist for nurses and
specialists. Govt has taken steps for incentivising doctors and
nurses, flexible recruitment process; along with HR data base for
rational deployment is available.
Change to GoI policies. Low risk: GoI strongly committed to reduce mortality and under
nutrition: contributes about 30% of health resources. GoMP has
enhanced budget significantly. GoI demonstrated commitment at
UK summits for nutrition and FP.
Staff resistance to
Medium risk: High degree of political and bureaucratic
change
commitment to health and nutrition. Incentives in place to attract
talent and reward performance.
3.
4.
5.
4.3 Risk of funds not being used as intended
DFID funds form part of the budget for DPHFW and DWCD. GoMP accounts for the financial aid
through standard GoMP procedures, including approved budgets put up in the Assembly, annual
audits conducted by the Comptroller and Auditor General (CAG), whose reports are also presented
to the legislative assembly.
From April 2012 onwards there are ear-marked budgets lines for DFID funding for DOPHFW and
DWCD and this will further substantially reduce risk of funds not being used as intended. The funds
will be used through societies under the Health and DWCD. The society accounting will be in
accordance with its Financial Management and Procurement (FMP) Manual; ensuring that prudential
norms of double entry book keeping with standard books of accounts is followed. Annual internal
and external audits of the societies will be carried out by approved Chartered Accountants. GoMP will
also conduct periodic statutory audit of DWCD and DPHFW by the CAG and make available such
audit report to DFID.
4.4 Climate and Environment Risk
One of the key climate and environment risks under health sector relates to Biomedical waste
management procedures. Infection management and environment protection guidelines (IMEP) have
been defined by Govt of India and state govt has agreed to implement these guidelines in all
hospitals. GoMP hospitals are segregating biological waste, sharps and non-sharps are being done
in separate colour coded bins. However IMEP guidelines are not consistently followed by all facilities
and the staff needs to be better trained and supervised. DFID TA has supported training on infection
prevention and biomedical waste management practices.
5. Value for Money

Performance on Value for Money (VfM) measures
18
Achieving VfM is described in terms of the 'three Es': Effectiveness, Efficiency, and Economy.
Effectiveness measures:
The effectiveness of this project is measured by timely achievements of project goal and purpose level
indicators. MPHSRP continues to demonstrate value for money on effectiveness parameters like rates
of reductions in infant mortality, and rates of increase health service coverage. For instance:
 The annual increase in number of institutional deliveries during 2008 to 2011 is 10% points per
year as compared to only 3% points per year during 1998 to 2007. While it is mainly because of
the govt cash incentive scheme, MPHSRP TA has supported improved hospital management,
trainings, HR availability, and drug supply and supervision systems for better maternal health.
 The annual increase in full immunisation during 2008 to 2011 is 6.6% points as compared to
1% point reduction per year during 2005 to 2008. MPHSRP TA helped in strengthening micro
planning, cold chain, due lists and VHNDs contributing to improved immunisation.
 There is 13 point decline in Infant mortality rates (IMR) between 2007 and 2011, from 72 per
1,000 births in 2007 to 59 in 2011, much better than the expected target. This is good progress
considering that IMR was declining by only 2 points per year prior to 2007. We have revised the
2015 targets for Infant mortality rates (from 52 to 47) to make it more ambitious based on past
trajectory.
Efficiency measures:
Efficiency is defined as how best inputs are converted to outputs and how resources are optimally used
to get the best results. Technical and Allocative efficiency was measured in terms of: Increased budget
allocations and utilisation patterns; Increased availability and performance of health human resources;
better procurement practices and drug distribution systems.
Efficiency measures under MPHSRP are:
 Budget allocations for DoPHFW increased by 30% annually and doubled for DWCD since 2010
 Budget utilisation for GOI schemes (RCH & NRHM) has more than doubled (from 440 crores in
2007 to about 1000 crores in 2012-13). This shows a stronger absorptive capacity and
management systems at state and district levels to implement health interventions.
 Drug budgets increased by 125% with expansion of essential drug lists from 247 to 446 drugs.
Procurement lead time has reduced by 36% as a result of rate contracts and e-ordering system
thus reducing stock outs. The stock availability, including stock in hand for 3 months monitored
by state procurement cell on daily basis using SDMIS data.
 Additional recruitment and deployment of 1900 doctors, 3700 nurses and 4000 Auxiliary
midwives to improve service availability and optimal use of infrastructure. Substantial increases
in financing and increased doctors and nurses have led to an improvement in service provision:
for instance during 2008 to 2011 per day per hospital increase of 25% for inpatient and 42.6%
for outpatient visits was noted. In addition we observe doubling of institutional deliveries and
about 320,000 more fully immunised children every year.
 Performance monitoring and supportive supervision system initiated for optimal utilisation of
available human and financial resources.
 Quality improvement plans for hospitals are now helping in utilising the available untied funds
for more result oriented tasks which are critical for saving live: for example buying gloves,
suction machine, and blood pressure machine and repair essential equipment.
Economy measures:
 Through rate contract, 56% drugs were procured at a lower cost in 2012 than the year before. All
the drugs are generic and low cost. E tendering is leading to transparent competitive processes
and thereby cost reductions
 Proportion of local purchase of drugs has reduced by a third. This has significant cost savings
implications because local purchase medicines are at higher rates constituting about 20% of total
drug budgets of 240 crores.
5.2 Commercial Improvement and Value for Money
Value for money is being ensured under both Direct and Indirect procurement.
19
Direct Procurement: DFID procures TA under MPHSRP using open competitive bidding through OJEU.
From 2010 onwards, MPHSRP TA contract was revised to an Output based Payment Deliverable
system where reimbursement was provided only when agreed deliverables were achieved to DFID and
Govt satisfaction.
Indirect procurement is done through the TA contract with FHI 360 ensuring compliance with rigorous
procurement and contracting policies.
 Procurement guidelines detailing out the process of procurement are approved by DFID
procurement group. All procurements are undertaken in accordance to the approved procurement
guidelines. There is also an internal process of review and approval of all procurements by FHI 360
that ensures compliance to all legal, statutory and contractual norms including value for money.
 Low value sub-contracts are also assessed for value for money by inviting at least 2-3 quotes,
preferably from local agencies and price negotiations are held on the quoted rates. As far as
possible meetings and trainings are held within the TAST offices or Government premises to
minimize expenses. All costs estimates are approved by the FHI 360 Country Office before
expenditures can be incurred.
 For limited tendering of procurements of more than GBP25, the procurement process from floating
of the RFP to execution of a sub-contract is managed by the Contracts and Grants point person,
thereby ensuring segregation of duties. All technical and financial review committee members are
mandated to sign the Conflict of Interest Certification prior to initiating review of proposals.
 Sub-contracts budgets are negotiated and payment schedules are linked to deliverables in most
cases, barring the sub-contracts with long-term scopes of work where value for money is ensured
by executing cost reimbursable sub-contracts where payments are made against actual spends.
 All deliverables under a sub-contract are reviewed internally for quality check by the assigned
Technical and Project Monitors and wherever necessary are put-up before the concerned
Department for approval before approvals for processing payments are made.
 Most consultants being hired by MP TAST are local nationals where their fee rates are negotiated
on their consultancy history of the past three assignments and their qualifications and experience.
5.3 Role of project partners
MPHSRP is implemented in partnership with Health and Woman and Child departments of Govt of MP.
DFID is the only external donor providing financial assistance to Health and WCD departments. A
technical support team is set up under MPHSRP to help implement the project priorities. Other
technical agencies like Unicef, UNFPA, and Ipas are also providing technical support on maternal child
health; Family planning and nutrition issues and they all work in close collaboration with DFID TA and
GoMP.
DFID India has also ensured strong alignment of MPHSRP with the DFID regional project PMDUP (for
family planning and safe abortion) and forging relationships with private sector partners implementing
PMDUP.
5.4 Does the project still represent Value for Money : Y/N
Yes
5.5. If not, what action will you take?
6. Conditionality
6.1 Update on specific conditions
DFID’s support is based on a shared commitment to three objectives of reducing poverty, respecting
human rights and strengthening financial management and accountability. The project aims to improve
the health and nutrition status of the people of MP, especially the poorest, and to improve the financial
systems and internal performance accountability, as captured in the partnership agreement, the
detailed project report and the Log-frame. The log-frame and milestones matrix include actions to
demonstrate the continuing commitment of the GoMP to poverty reduction and to strengthening
financial management and accountability. GoMP continues to show strong commitment to poverty
20
reduction, human rights and financial accountability issues.
7. Conclusions and actions
Conclusions:
MPHSRP is well on track to achieving all the goal and purpose indicators. The 2013 target for three
indicators (Immunization, Institutional deliveries and breast feeding) is already achieved as per 2011
data. There is a threefold increase in the number of functional delivery points in Madhya Pradesh and
additional 1900 doctors, 3700 nurses and 4000 ANMs deployed to provide an expanded package of
maternal and child health and nutrition services.
MPHSRP TA has provided substantial assistance for setting up quality improvement mechanisms at
district and hospital levels and implementing them in 39 high load hospitals across 16 focus
districts. There is now a well streamlined system of drug procurement of drugs to achieve best
value for money and effective distribution systems. A functional web enabled real time doctors
database to enable rational deployment of more than 4500 doctors. Strengthening of Village Health
sanitation and Nutrition Committees and village health and nutrition days is underway with;
massive scale up of training of VHSC. GoMP with DFID support is now implementing a state
nutrition mission (Atal Bal Arogya Evam Poshan Mission) targeted at children under 2 years.
MPHSRP funds and TA are used to a) Implement district action plans b) strengthen training and
supervision with focus on first 1000 days reaching more than 40,000 ICDS workers d) community
based management of severe acute malnutrition and e) Behavioral Change Communications.
The FRA ASP shows the reduction of risk from substantial to moderate. Audit analysis of both NRHM
and ABM societies is being supported to improve compliance to audit findings and betters systems of
internal controls.
Actions:
 Improve quality of care for maternal and child health services in the selected 39 hospitals across 16
focus districts: Improve skills of health care providers, supportive supervision, better hospital
management, and drug availability. (action: NRHM MD and TA team)

Set up skill labs across 6 divisions to support quality trainings of health staff. (action: NRHM MD
and TA team)

As a state lead partner nominated by Govt of India, DFID team to ensure harmonised DP inputs to
help GoMP deliver RMNCH+A strategy and intensified efforts in the 17 high priority districts.
(action: DFID and TA team)

Scale up community mobilization strategy which includes strengthening of VHNDs across 3000
villages, training of frontline workers and SHGs in 18 blocks across 6 districts. (action: TA team
with NGOs)

Support planning, implementation and monitoring of Atal Bal Mission and ICDS Mission to reach
under 2s. Support GoMP to start implementing pilots on Community management of SAM. (action:
ABM MD, and TA team)

Ensure regular updation and analysis of doctors’ data base and facilitate rational deployment of
doctors at remote rural hospitals. Set up a comprehensive data base for all health staff. (action:
Commissioner Health and TA team)

Implementation of revised ICDS MIS systems and NRHM Facility based monitoring for better
performance management. (action: ABM MD, NRHM MD and TA team)

Continue support to procurement cell, extend functioning of SDMIS to primary health center levels
and monitor drug stock outs. (action: Commissioner Health and TA team)

Regularly conduct audit analysis for district and state society for NRHM and ABM and conduct
21
quarterly expenditure tracking for DFID FA plan to detect under spend. (action: PS, Financial
Adviser and TA team)
8. Review Process
The Joint Annual review was undertaken during May 2013. The review included field visits and state
level presentations and discussions. The review participants included DFID team2, DHFW and DWCD
officials of Govt of MP and Technical support agency. This Annual review report is informed by
independent sources of survey data like Annual health survey, DLHS, NIN survey, SRS as well as Govt
MIS. Field visit observations from Sagar district as well as Common NRHM review mission3
observations from Hoshangabad and Gwalior have informed the review.
2
3
Health Adviser, Governance adviser, Social development adviser, Procurement officer , Program managers and state representative.
Coomon review mission of National Rural Health Mission of Govt of India
22