Type of Review: Annual Review
Project Title: MADHYA PRADESH HEALTH SECTOR REFORM PROGRAMME (MPHSRP)
Date started: 2007
Date review undertaken: May - June 2014
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 MPHSRP aims to help Govt of MP 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 Ratio 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 47% in 2008 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% (2008) to 65%;
o Exclusively breast fed till 6 months from 31% (2008) to 50%;
What are the planned Outputs attributable to UK support?
There 5 priority outputs that are attributable to UK support:
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.
1
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, although it has declined from 76 to 56 infant
deaths per 1000 live births over 2006 to 2012. A high maternal mortality ratio of 335 per 100,000 births in
2006 has now declined to 230 per 100,000 births in 2012: however it is much higher than the national
average of 178 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.
Indicators
2006
Progress
Maternal Mortality Ratio
335 per 100,000 births
230 (SRS 2010 -12)
Infant Mortality Rate
76 per 1000 live births
56 (SRS 2012)
Contraceptive Prevalence Rate
53%
59.3% (AHS 2012)
Under-weight children (0-5 year)
58%
52% (NIN 2011)
Deliveries taking place in health facilities
47%
79.7% (AHS 2012)
Children aged 12-23 months fully immunized
36%
59.7% (AHS 2012)
Children fully breast fed till 6 months of age
31%
39.7% (AHS 2012)
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, community
mobilisation, staff training and health communications. Technical assistance will help Government of
Madhya Pradesh (GoMP) in better health planning and human resource management; improved
monitoring and procurement systems.
Areas of support for health and nutrition services include the following:
 Improved Quality of hospital services for maternal, neonatal and child health;
 Scaling up quality and coverage of monthly integrated 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 availability of essential medicines at 50
district hospitals and 1400 sub-district hospitals;
 Support in developing a health human resource database and rational deployment of 12,000 doctors
and nurses in remote areas; and
 Capacity development at all levels, supportive supervision, IT enabled MIS, strengthening financial
management and procurement systems.
Who will be implementing the support we provide?
The programme is implemented by the Department of Public Health and Family Welfare (DPHFW),
Department of Women and Child Development (DWCD) and the Departments of Panchayati Raj and
Rural Development, Govt of Madhya Pradesh. The Technical and Management Support Agency, placed
in MP manages the technical cooperation.
2
Section A: Detailed Output Scoring
Output 1: Quality public health and nutrition services available in underserved districts.
Output 1 score and performance description:
A
Progress against expected results:
Indicator
Milestone 2013 -14
Status May 2014
Score
Functional quality
Achieved across 16 TAST
A+
- Quality assurance
assurance systems for
districts, 5 high priority
committee functional in 16
CEmONC and BEmONC
districts and state quality
focus districts.
assurance committee
functional to track Model
Maternity Wings across 51
districts
Over Achieved. QI inputs to
94 high load delivery
A+
- QI inputs to 60 high load
points.
delivery points and
bimonthly actions taken
report.
Achieved
A
- Functional facility based
performance monitoring
using QA MIS
Improved Quality of
Achieved
A
- Quality monitoring and
Village Health and
micro-planning of VHND in
Nutrition Days (VHND) in
16 focus districts by TAST,
focus districts.
NGOs, VHSCs and MGCAs.
Number of staff trainings
supported by DFID TAST
on Health, Nutrition and
management issues
- Progress against planned
- Suposhan
- VHND
- SBA and Hospital quality
- Programme Management
(PMUs)
Number of children and
pregnant women reached
with nutrition services
Source – ICDS MIS
Nutrition mission
implemented in the state
- 78 Lakhs
Overachieved; 1340
VHNDs covered and supply
gaps addressed
Achieved. 12000 health
and nutrition staff directly
trained by DFID TA on
health and nutrition. TA
team monitored quality of
cascade training for 51000
frontline providers
74 lakhs
- District plans being
implemented and monitored
in 16 districts.
Achieved: including Design,
delivery and appraisal of
Suposhan Abhiyan.
A
- 350 AWC assessments and
supervision every quarter
starting Oct 2013, for
improved quality of nutrition
services.
- 50 Model AWCs set up in 16
focus districts
Achieved
A
Partly achieved. Protocols,
budgets and site selection
completed: GoI approval
awaited.
B
- Direct VHND support to
1000 villages
A+
A
B*
*Drop in coverage numbers is observed 2013 -14, because more stringent criteria are being applied for reporting coverage numbers; only those who availed
supplementary nutrition for 21 days or more per month will be reported.
Highlights of progress
Health
 MPHSRP TA helped institutionalize state and district quality monitoring using GoI’s
maternal new born health (MNH) tool kit across 51 districts including setting up and
3
certification of Model Maternity Wings at District Hospitals. The quality improvement
strategy in MP has gained momentum due to intensive demonstration by DFID TA in 94
hospitals. Specific actions supported by TA include: gap assessment, on site correction,
trainings, supportive supervision, feedback to blocks and districts for HR, supplies,
equipment and funding gaps. DFID FA is also being used for hospital cleanliness and
mobility support for supportive supervision to complement the TA inputs on quality
improvement.The budget allocation for quality improvements in NRHM plans (PIP)
increased from INR 1.8m in 2013-14 to 225.8m in 2014-15.

TA supported the development of Model Maternity Wings (MMW) in 48 district hospitals.
Out of the 46 maternity wings assessed against benchmarks, nine district hospitals are now
certified as Model Maternity Wings.

Periodic rounds of quality assessments conducted in 94 high load delivery points and gaps
shared with district quality assurance committees; significant improvement in physical layout
of labor rooms, display of protocols, and logistics and supplies; all these aspects were
appreciated by a recent GoI review mission. The TA also helped in providing hands-on
trainings to staff on operating the radiant warmer for newborns, and infection prevention
practices.

During the field visit to district Chattarpur and Tikamgarh, there was ample evidence of QI
inputs provided by TAST, for instance:
o Repair of radiant warmers. New radiant warmers and delivery tables
o Renovations, mike/intercom, curtains
o Labour room Trey arrangements,
o Organized ANC area with the OPDs.
o Additional toilets, tap connections
o Protocols in the Labour room for life saving obstetric procedures
o BCC materials in the waiting areas, wards

Three health facilities are being developed as Centre of excellence in Sehore district where
there is a 45% point improvement in proper disposal of needles, 60% point improvement in
waste segregation practices, 40% point reduction in mothers leaving hospital before 48 hrs
of delivery. Functional Taps improved from 63 to 89% and functional toilets from 53 to 94%;
average OPD waiting time reduced from 20 minutes to 3 minutes.

Both TA and FA provided under MPHSRP has helped operationalize two Skills labs (five
more in the pipeline): two training batches completed using Mannequins to practice hands
on skills. The participants are assessed on objectively structured clinical examination
(OSCE) for skill retention.

Under the national RMNCH+A strategy, DFID TA provided leadership to conduct gap
assessment across the 17 High priority districts on quality parameters and used the findings
to develop the plans and budgets for addressing the quality gaps. Currently monthly block
monitoring visits are ongoing. A good analysis of gaps was presented to our review team in
district Chattarpur, where all 13 gaps identified at district hospital during Feb14 were closed
in May14, which is a good achievement.
4
Nutrition
 MPHSRP aims to reduce undernutrition among children under two and deliver the 10
evidence based interventions recommended by Lancet nutrition series. The following
strategies are being prioritised under MPHSRP:
a. Strengthen the quality, coverage and functionality of services provided by village
based feeding centers (AWCs) under ICDS for improved feeding (IYCF) and
hygiene. This includes training and supervision for frontline ICDS staff.
b. Improve coverage and uptake of community based integrated health and nutrition
services through monthly Village health nutrition days and health volunteers (ASHA)
to deliver immunisation, micronutrients (Iron and Vitamin A and Zinc) and
management of childhood infections (Diaarrhea and Pnuemonia).
c. Improved coverage and uptake of Water, Sanitation and Hygiene programme.
d. Mobilising Village self help groups through participatory learning and action cycles
for demand generation and utilisation of health and nutrition and sanitation services.
 MPHSRP TA is supporting the roll out of an ambitious Suposhan strategy for management
of moderate and severe malnourished children and includes AWC based supervised
feeding followed by home based care and improved counselling of mothers for child feeding
practices. TA designed the training modules/guidelines including a matrix of 20 nutritionhealth education sessions; flash cards and job aids and implementation of first phase of
Sneh Shivirs (special VHNDs) reaching 3200 AWCs and helped train more than 2000 ICDS
officials, 3,200 AWWs and 1,500 village volunteers. DFID TA also completed a rapid
appraisal of the first phase of Suposhan(findings provided in output 5) and is now
supporting the design of Suposhan evaluation. It was observed during field visit that nearly
1200 severely underweight children were identified and treated (supervised feeding,
micronutrients) in 120 Sneh Shivirs in Chatarpur and Tikamgarh. TAST helped in planning,
training, monitoring of Sneh Shivirs as well as rapid appraisal.

The project milestone for setting up 50 Model AWCs could not be achieved because of
delays in the approval of ICDS Mission budgets. Nearly 1000 Model AWCs are now planned
under ICDS Mission. Protocols including budget estimates are ready and 453 Model AWC
sites identified. Setting up model AWCs will complement DFID FA use for AWC
construction.

DFID TA designed the Chief Minister’s Community Leadership Development (CLD) course
to increase availability of trained personnel for community social welfare schemes. The
proposal and syllabus was approved by cabinet and an expert committee (Tata Institute of
Social Sciences) and MP Bhoj University will manage the study centers and certifications.
GoMP has allocated INR 106 crores; approval awaited from the Finance commission. The
course will benefit nearly 10,000 village volunteers every year, starting July 2014.

DFID TA helps to strengthen VHNDs through micro-planning, training, monitoring and
addressing skills and supply gaps. Manuals were prepared for Supervisors and Frontline
Workers (ASHAs, ANMs and AWWs), with specific attention to nutrition counselling and
micronutrients (Zinc and Iron). The functionality assessment of 1340 VHND sites suggests
that 80 percent were held at AWCs in presence of all three workers (ANM, ASHA and
AWW) indicating good convergence. Gaps were observed in terms of privacy for ANC
(50%), hand-washing facility (35%), focus on adolescent girls (41%) and identification of
5
high risk cases (42%). The skills on Blood pressure measurement and anaemia detection
were weak. District specific actions taken to strengthen VHND are:
o In districts Jhabua, Alirajpur and Dindori, 882 ANMs were trained to enhance skills
on measuring of Blood Pressure, Haemoglobin for pregnant women.
o In Dindori, ANC table and curtain were not available and Pachayats were supported
to utilize untied fund to buy ANC table, curtain and hub cutter.
o In Tikamgarh, adolescent girls were not present at VHND sites. Anganwadi workers
motivated to call adolescent girls and provide with deworming and iron tablets.

Anganwadi Center quality improvement process was undertaken in 16 districts through
regular monitoring and supportive supervision. The functionality of about 900 AWCs across
the 16 districts was assessed on 20 key indicators and the assessment tool is now being
incorporated in the ICDS monitoring policy to strengthen supervision. Using the data
analysed from the AWC assessments the following actions are being taken:
o Quality visits by Supervisory staff
o Timings for opening AWCs, SNP supply and coverage
o Identify children with growth faltering with emphasis on Counseling on feeding.
o Cleanliness of AWCs, Hand washing practices
o Increase Home contact
o Improve quality of Food (Hot cooked meal)
DFID TA is also supporting training reforms through Training Needs Assessment (TNA);
assessments of Mid-level Training Center (MLTC) and Anganwadi Training Center (AWTC):
revision of modules and curriculum digitization of training content. Rapid Appraisals of two
MLTCs (Jabalpur and Indore) and three AWTC revealed near absence of nutrition related
resource materials, weak training skills of trainers, dilapidated infrastructure and equipment.
 MPTAST has designed and conducted the Training needs assessment (TNA) for 415
districts and block staff and 2485 sector supervisors. Performance across the levels were
graded and following categories of staffs have evolved:
o To be developed as State / District Resource Persons pool
o Staffs requiring specific core areas of training identified (GMP, ECCE etc.)
o Staff requiring basic training on all the thematic areas
Based on the findings of training center assessments and TNA, a range of training reforms are planned
under the ICDS Mission to be supported during 2014 -15 through both DFID TA and FA.
Recommendations
Health
 Quality implementation of RMNCH+A strategy in all 17 High priority districts; conduct 34
BMVs every month for supportive supervision and quality improvements at delivery points
and community centers (GAK and VHNDs).
 Scale up Skill labs to 5 divisions
 Support development of Model Maternity Wing across all 51 District hospitals as per MNH
toolkit
Nutrition
 Set up 50 model AWCs in 16 focus districts
 Quality improvement of AWCs and institutionalise QI process under ICDS Mission
 Implementation and evaluation support for Suposhan
 Training reforms and strengthen MLTCs and AWTCs (Use of TA and FA)
a. Develop quality teaching/training aids (charts, case studies, job aids, audio visuals)
b. Strengthen trainer competency and develop modular format for trainings
c. Help improve attendance and batch saturation (e.g. credit system, training calendar)
d. Systematic evaluation of trainer and trainee feed back
e. Develop system for field practical during trainings
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
6
Progress against expected results:
Indicator
Milestone 2013 -14
Better HR database - Quarterly analysis of doctors’
informs
rational
database with evidence of
deployment
of
use of data and rational
human resources
deployment.
- Comprehensive HR database
designed.
Status May 2014
Achieved
Score
A
Partly achieved. Software B
designed and data updation
for nurses is 60% complete.
HR
Policy
and - HR cell undertakes regular Achieved.
HR
Cell A
Strategy developed
HR analysis, and supports undertakes quarterly analysis
along
with
recruitment
and
training and shares the report with
departmental
GoMP. One of the major
planning.
capacity
achievement
during
the
augmentation
reporting period has been
rational
deployment
and
recruitment of more than
12000 staff
Highlights of progress;
 The doctors’ database covering 4800 doctors is now supplemented by a “Work Performance
Module” to monitor the performance of Doctors ie. OPDs, IPDs, minor and major surgeries,
caesareans etc. This has improved the attendance of Doctors and is also used for ACRs
(Annual Confidential ratings).
 All transfers, promotions and decision for fresh recruitment of Doctors and further counselling
for deployment are informed by gap analysis using the HRMIS tool. As a result of using the
HRMIS, the following improvements in HR availability are seen;
 190 MBBS Doctors appointed at PHCs where earlier no doctors appointed
 164 MBBS additional doctors appointed in 17 focus Districts
 To improve the functionality of level 31 delivery points and enable emergency obstetric care;
o 42 new Anaesthetists appointed where there was no Anaesthetist posted
o 71 new Paediatricians appointed at sick new born care units and 21 paediatricians
deployed at L3 block hospitals for improving newborn care
o 72 new Obstetricians deployed at L-3 facilities
o 57 (Anaesthetists, Obs & Gynae and Paediatrician) specialists redeployed at District
Hospital and 40 Doctors redeployed at subdistrict L-3 Hospitals.
 There is slow progress in compilation of comprehensive HR database. The existing software for
the doctor’s database is being expanded to make it comprehensive including all Nurses, paramedical staff: likely to be completed by end July 2014. As per current priority of GoMP, the
database of the Nurses is being updated with 60% completion till now.
Recruitment Support:
 Recruitment support was provided to DoPHFW and NRHM to recruit more than 12000 positions
(doctors, specialists, nurses, counsellors, programme management staff). TA support included;
developing the rule books, processing applications and counselling for postings.
Nursing Reforms
 DFID TA organized a State level workshop in Apr 2014 to help improved planning, deployment
monitoring and supportive supervision of nursing cadre. A draft manual proposing restructuring
and nursing reforms is awaiting approval and operationalization. The proposed reforms include:
- Identify staffing norms for Nurses
- Introduction of new positions like Nurse Practitioner and midwifery, Block PHN, Chief
Superintendent, Deputy Director and Joint Director Positions.
- Re-structuring for better planning, monitoring, and supportive supervision of nurses
- Career progression and growth
- Plans for filling the HR gaps of nurses in difficult and hard to reach areas
- Safety and security issues
- Continuous Education of Nurses
- Registration of Nurses – both in the public and private
1 Level 3 delivery points are considered functional only if all 3 specialists are available ie. Obstetrics, Paediatrics and anaesthetist.
7
Recommendations
a. HRMIS to be completed and operationalized to cover doctors and nurses.
b. Consolidate the result due to regular HR analysis and its institutionalization
c. Transition the roles of HR data analysis to the existing govt staff by Oct 2014
d. Help operationalize nursing reforms especially in the areas of staffing norms, career
progression and setting up of a nursing directorate.
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:
8
A
Progress against expected results:
Indicator
FRA & ASP
Risk Ratings
Audit analysis
and
compliance
enhanced
Procurement
and Drug
Management
System
strengthened
Milestone 2013 -14
- Financial management action plan for
NRHM implemented.
- FRA undertaken along with fund flow audit
& procurement review and action plan
agreed
- TAST provides FA spend tracking every
quarter.
- Audit tracking of DH&FW and DWCD (5
districts every quarter)
- Compliance with audit findings for
DH&FW, NRHM and ABM enhanced.
- Local purchase module in SDMIS.
- Cabinet approval of Procurement
Corporation, budgets allocated, Legal
options for operationalizing corporation
available.
- Drug stock out study completed and
shows reduced stock outs.
Status May 2014
All achieved
Score
A
Achieved.
In addition to
audit tracking and
compliance, TA
helped in
improved FM
practices
Achieved.
A
A
Overachieved.
Corporation
registered, MD
appointed,
recruitments
ongoing.
Achieved
- TSUs scaled up across all divisions.
Achieved
Highlights of progress;
The Fiduciary risk rating for both DoPH&FW and DWCD have reduced from substantial in 2010 to
moderate in 2013.
FRA findings 2013 for DoHFW
 There are 4 benchmarks of low risk, 7 benchmarks of moderate risk and 4 benchmarks of
substantial risk. The overall risk rating is Moderate. The key areas with substantial risk are o Accounting policies and Account code classifications are published and applied.
o In year reporting of actual expenditure.
o Criticisms and recommendations made by the auditors are followed up.
o Effective action taken to identify and eliminate corruption.
FRA findings 2013 for DWCD
 There are 6 benchmarks of low risk, 6 benchmarks of moderate risk and 3 benchmarks of
substantial risk. The overall risk rating is Moderate. The key areas with substantial risk are o In year reporting of actual expenditure.
o Appropriate use of competitive tendering rules and decision-making is recorded and
auditable.
o Effective action taken to identify and eliminate Corruption.
 TA support provided to mitigate the risk identified in the FRA –
Health:
o Draft Finance Manuals prepared for NRHM Finance Division.
o Audit analysis of Concurrent Auditors and Statutory Auditors is shared quarterly with
GoMP to identify areas for improvement in PFM.
o Risk analysis and reporting format issued to the Concurrent Auditors for compliance.
o Framework for Village Health Sanitation Nutrition Committee audit
o Standard Bid documents being used to improve transparency in procurement process. All
procurement is being undertaken through online tendering system supported by TAST.
DWCD:
o Supported State and district ABM unit in the appointment of statutory auditors with welldefined terms of reference, guidelines and formats for financial statements.
o Preparation of Finance and Procurement Manual for ICDS Mission.
9
o Capacity Building on Financial systems pertaining to procurement
 Audit analysis of Atal Bal Mission;
o Statutory Audit finding analysis of 30 districts and State ABM unit was done during the
year 2013-14 and four reports were submitted.
o Based on ABM Audit Finding Analysis, Key issues and intervention by MPTAST are
described in the following table:
Key Issue
Intervention
Result areas
Audit analysis in 2013 for 2011- Guidelines on the appointment Audit analysis done in March
12 found 66% of the sample of auditors and formats for 2014 for 5 sample districts
districts had not prepared preparation
of
financial found that all 5 districts have
Balance Sheet and Income and statements for District ABM prepared Balance Sheet and
Expenditure account.
units
Income Expenditure account
Auditors report on Financial Guidelines on the appointment Financial statements are now
Statements of District ABM of auditors and formats for being prepared as per the
Society lack uniformity. The preparation
of
financial format leading to uniformity and
level of assurance provided by statements for District ABM comparability of the financial
the audit reports vary in the units
information across Districts.
nature, scope and type of audit
procedures performed.
District ABM Societies in which Support provided to Finance Audited Financial Statements of
the auditors have reported audit adviser, ABM for tracking the District ABM Unit are being
findings were not being tracked audit findings and identifying scrutinized on a regular basis
at State ABM Society
key issues. TAST led audit and
non-compliances
and
analysis was used as a deviations
are
being
background
document
for communicated to the respective
review.
Districts.
 Analysis of Concurrent Audit and Statutory Audit reports of NRHM (5 districts per quarter).
o Audit finding analysis of 21 districts was done during the year 2013-14 and four reports
were submitted to NRHM, highlighting the problem areas and changes observed.
o Audit finding analysis was done for 5 districts statutory audit reports and 16 districts
concurrent audit reports. 5 districts out of these were repeat districts which were used to
analyse the change in the financial management system.
o Based on Audit Finding Analysis, Key issues and intervention by MPTAST are described
in the following table:
Key Issue
Intervention
Result areas
Compliance with Tax Deduction Guidelines on Tax Deduction at Guidelines
issued
and
at Source under Income Tax Source under Income Tax Act compliance observed in audit
and Vat needs to be improved
for state and district units
finding analysis
System of tracking compliances NRHM staff tracking the Concurrent
audit
report
with the audit findings reported compliances of each report. A compliance and audit findings
by the Statutory Auditor needs CA is fully dedicated to being tracked by NRHM
to be put in place.
handling this work in NRHM Finance Division
Finance Division
Bank reconciliation statements Guideline for reversal of Time Guideline for reversal of time
are not prepared mainly due to Barred cheques prepared by barred cheques is under review
huge number of time barred MPTAST.
Engaged
in by State Health Society, M.P.
cheques which are to be continuous dialogue with NRHM Staff appointment in process
reconciled and also due to Finance Division for filling up of and was delayed due to code of
vacant staff position
vacancies.
conduct during the year
Advance adjustment is not Guideline for preparing ageing Under review by State Health
being done timely and properly, schedule of advances prepared Society, M.P.
advance reconciliation and by MPTAST and shared with
ageing of advances is also not State Health Society, M.P.
being done
Concurrent
Audit
reports State Health Society, M.P. Concurrent audit reports are
submission delayed by
3 appointed
the
Concurrent now submitted within one
months
auditors for 2013-14 at the state month to the State Health
level for all the Districts.
Society
Concurrent audit reports are not Format for risk analysis and Risk reporting started by many
uniform in the content and reporting by Concurrent auditors concurrent auditors from Q3
format of reporting
prepared
by
MPTAST report
onwards
although
10
Instructions issued to the reporting needs to be improved
concurrent auditors.
further.
Procurement and Drug Management Systems
 Cabinet approval for Procurement Corporation obtained and incorporated under Companies Act,
1956. First Board of Director meeting held in March 2014. Recruitments are ongoing.
 SDMIS is being used for e-monitoring for drug availability, stock outs, expiry, and supply and
payment position. This year two additional features have been added; Local purchase modules
and Equipment MIS to help inventorize equipment and faster repairs. Further, expansion of
SDMIS till PHC level is being undertaken through DFID TA support. TAST working with Center for
Development of Advanced Computing (A scientific society of DoIT, Ministry of Communication &
Information Technology, GoI) for customizing “e-aushadhi” systems for expansion till PHC level
and Drug Distribution Counter.
 The drug availability study done as part of evaluation of ‘Free dugs for All’ scheme showed;
o The average drug count in district stores increased from 95 in 2012 to 220 in 2013.
o Incomplete supplies reduced from an average 57.6% to 36.6% over 2012 to 2013.
o Access to free medicines has improved for both OPD and IPD patients through Drug
Distribution counters. The OPD and IPD footfall increased by average of 37 per cent in
OPD and 13.7% in IPD across all levels.
o Procurement order value for the centrally rate contracted items increased from INR 64
crores 2011 to INR 128 crores in 2013-14 showing a 99% increase.
o The budget utilized for the state rate contracted drugs has changed from 28% in 2011-12
to 59% in 2012-13: a reduction in local purchase by 31% in one year.
o The overall medicine availability has increased 3 times whereas the budget utilization for
procurement of centrally rate contracted drugs by the districts has doubled.
Recommendations
 Support GoMP in operationalization of the Drug Procurement Corporation
 Ensure smooth transition of functions of the procurement cell and biomedical engineers to the
Drug Procurement Corporation.
 Achieving one cycle of drug procurement via the corporation by March 2014.
 Commission a third party diagnostic report on existing procurement systems.
 Customizing “e-aushadhi” systems for expansion till PHC level and Drug Distribution Counter
 Undertake Warehouse Management Training for ensuring good storage and QA of drugs
 Strengthening Quality Assurance of drugs i.e. regular sampling, testing etc.
 Statutory and Concurrent Audit Analysis at NRHM
 Capacity building of finance and account personnel through NIFM
 Close tracking of FA fund spend and progress on ICDS infrastructure
Impact Weighting (%): 20%
Revised since last Annual Review? No
Risk: Medium
Revised since last Annual Review? No
11
Output 4: Increased demand for Nutrition, Health and Sanitation services
Output 4 score and performance description:
A
Progress against expected results:
Indicator
Milestone 2013 -14
Strengthened capacity of
community
groups
to
monitor community based
health, nutrition and wash
services and counselling.
Status
April Score
2014
A
- High level committee for CBA-PLA Achieved
constituted
A
- SRLM and GoMP approved the CBA- Achieved
PLA plan (Sanjhi Sehat) and budgets
A
- CBA-PLA (Sanjhi Sehat) model Achieved;
covered
3650
initiated in 3 of the 8 districts and
covered 3000 SHGs members spread SHGs in 499
villages
across 500 villages
BCC
campaign
for - 2 districts implement stronger IPC.
Achieved
awareness on maternal - 360 media campaign started.
health,
IYCF
and - Innovative
BCC
strategies Achieved
sanitation practices
implemented across districts
A
Highlights of progress:
 State Rural Livelihood Mission (SRLM) approved Sanjhi-Sehat (Participatory Learning and Action
PLA) in eight districts of Madhya Pradesh. Sanjhi Sehat is designed to demonstrate the impact of
woman’s group mobilisation on health, nutrition and WASH outcomes and influence GoMP to
scale up this strategy under the rural livelihood Mission and the new ICDS Mission as a
community based innovation. Sanjhi Sehat will cover 1,034 villages by capacitating
approximately 7,500 SHGs across eight districts in MP to inform potential scale up across 51
districts through SRLM.
 To date the programme has started implementing only in the three districts managed by
MPTAST namely Chattarpur, Tikamgarh & Sagar covering 3643 SHGs in 499 villages. The
remaining five districts Barwani, Shivpuri, Raisen, Dindori and Panna to be supported by SRLM
using DFID FA funds is yet to roll-out. The main challenge was in getting agreement from SRLM
on a mechanism for hiring and contracting staff to deliver Sanji Sehat in its focus districts. After
lengthy negotiation this has been finally resolved albeit belatedly in June 2014 and is expected
to get underway in August 2014.
 Other achievements include Formation of a State Level Monitoring Committee chaired by the
Chief Executive Officer (CEO) of SRLM and two meetings convened with SRLM, Health, WCD
and PR&RD.
o Partnerships with NGOs to implement Sanjhi Sehat in three of the eight districts.
o Induction and orientation of NGO and SRLM staff; adaptation of the 20 PLA cycle
modules; development of a communication package for Sanjhi Sehat
o Implementation started in district Chattarpur, Tikamgarh and Sagar to cover 3643 SHGs,
first 3 PLA cycles in 499 villages. Training of 73 PLA facilitators completed to roll-out the
first three PLA cycles. Expert agency hired to provide training, monitoring and onsite
mentoring support.
 Other initiatives by DFID TA to promote community mobilisation;
o Training of Village health nutrition and sanitation committee (VHSNC)
o Establish and support the community action website to help track the functioning of
ASHAs (training, incentive payments), VHSNC and Gram Arogya Kendra.
o Strengthening of Gram Aarogya Kendra
BCC activities;
o Khirki Mehendi Wali, (KMW) a long format radio programme was developed by BBC Media Action on
maternal child health nutrition issues with women empowerment theme. 37 episodes were aired in 9
All India Radio and 11 Community radio stations across MP. Following the broadcast, listeners clubs
are being created in 207 Kasturba Gandhi Balika Vidyalayas and 322 girls’ hostels in partnership
with Dept of Education. Orientation of 1100 wardens was done to enable facilitated discussions. The
Dept of Women Empowerment is keen to introduce KMW through Tejaswini program with 12000
12
SHGs in six districts.
o
‘Jeet Jaruri Hai’ based on the Snakes and Ladders Game was developed on exclusive breastfeeding
and complementary feeding to aid Frontline workers for counselling. The tool is recommended for
inclusion in the annual Plan for ICDS Mission, and is also being included in NRHM Toolkit for all
49000 Gram Arogya Kendras.
o
Pet puja campaign on nutrition; focussed on cultural beliefs, barriers and misconceptions related to
child Feeding, complementing the Suposhan Campaign covered two districts with an estimated
audience reach of more than half a million.
o
Swasthya Sargam: Compilation of songs on various health issues promoting hand washing,
complete ANC and breastfeeding was developed by DFID TA; around 10,000 CDs of Swasthya
Sargam are now available at all the Health Facilities.
o
A set of audio jingles on the maternal and child health issues, and non-communicable diseases were
developed for radio broadcast. It is proposed that these jingles would be broadcast through all the 14
primary channels of All India Radio and FM channels which has an estimated 93% reach.
o
Training for district functionaries of govt IEC Bureau and ANM Training center trainers on 360
degree Communication was organised covering 46 districts. Following the training, the IPC Tool on
Birth Spacing ‘Fayde ka Mantar’ was distributed to all the 60,000 ASHAs and ANMs with guidelines
on their training and use.
Recommendations:
 Complete 8 of the 22PLA modules of Sanjhi Sehat in the five SRLM districts by March 2015.
 Complete at least 10 out of the 22 PLA modules with WASH integration, in the three TAST
supported districts by March 2015.
 Set-up trouble shooting mechanism to resolve operational challenges vis a vis Sanji Sehat
especially in SRLM districts were MPTAST is not operational
 Mobile Kunji implementation (Training of frontline workers and back end technology) in the 17
high priority districts. Mobile Kunji is a multimedia job aid to ensure delivery of standardized,
messages about maternal, neonatal and child health.
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:
B
Progress against expected results:
Indicator
Milestone 2013 -14
Status April 2014
Timely Health MIS
Achieved
- NRHM data effectively used for
reports which are
tracking district progress.
regularly analysed to
- Training of district and Block staff
assess district/facility
on improving data quality.
performance
- Block monitoring visits by district
mentors for RMNCH+A strategy.
- Quarterly score cards analysed and
shared with GOI.
Strong MIS system for
Achieved
- ICDS data effectively used for
tracking nutrition
tracking district progress.
performance
Partly achieved
- District analysis/grading reports
and KPIs tracked
Evaluation studies,
Over achieved: 4
- At least 2 Reviews/independent
reviews and
evaluations/assess
assessment/evaluation studies of
independent
ment done
specific initiatives for health and
13
Score
A
A
B
A
A
B
A+
assessments of Health
and Nutrition initiatives
nutrition.
Highlights of progress

GoMP is making steady progress in setting up robust monitoring systems to enable quality
planning. There is strong emphasis on e –monitoring and use of data for decision making.
At present 12 Monitoring softwares are being used for key programmatic processes.
 MPHSRP TA is directly supporting the six out of the 12 softwares (HMIS, MCTS, HRMIS,
SDMIS, EqMIS and ASHA) for data updation and analysis. Using the software the
performance of districts is reviewed by senior govt officials during weekly meetings
convened by the PS (Health). TAST is providing inputs for improving data collection,
reporting and compilation: however much more efforts are needed for better analysis and
use of information and informing decision making. For instance there is limited progress on
capturing short term intermediate results of TA inputs, for instance impacts of trainings, QI
inputs, hospital functionality, drug availability at peripheral health centers,
 Analysis and use of AHS data:
TAST helped analyse periodic AHS data for concurrent monitoring and trend analysis. Key trends
shared with GoMP officials include:
 Maternal Health data reflects low 100 IFA consumption and Full ANC (Hb, BP
measurement). Low coverage means that pregnant woman will remain anaemic, will have
high risk of deaths due to Heamrrahge and Eclampsia and low birth weight babies.
 Child feeding practices and Immunization coverage was low in many districts.
 High FP use but so is high fertility, which means that majority use sterilisation and more
uptake of spacing methods needed. Based on this Prerna scheme was launched to promote
spacing counselling through ASHA.
 High Institutional delivery, but lower rates of early breast feeding. This is an example of
missed opportunity for providing child feeding counselling and FP services.
All the above data analysis has led to high priority to quality ANC, RMNCH counsellers, supplies
and diagnostics (Hb kits, BP and Urine testing) at Gram Arogya Kendras.
 Strengthen NRHM HMIS
Earlier facility based reporting was not in place. With support from DFID TA, the reporting on the
facility based HMIS has improved eg. Only 35% of health facilities were reporting in June 2013, this
increased to 100% for all facilities except Sub health centers (98 percent reporting). TAST is
supporting analysis of facility based data to track facility specific performance.
To ensure data completeness and its quality, DFID TA supported the NRHM Divisional level
workshops with 600 staff to clean the data, address discrepancies, data validation, and score cards.
 Score card in 17 HPDs under RMNCH+A – using HMIS data
Under RMNCH+A block monitoring visits have been conducted in 32 out of 53 blocks across the 17
HPDs. Quarterly RMNCH+A progress Score Card prepared for last three quarters based on
composite scores of 16 RMNCH+A indicators and discussed during the State Resource Unit
meeting. Facility and community level gap assessment was completed, data analysed and the
major findings are incorporated in the district PIP.
Revised ICDS MIS
 DFID TA was provided to scale-up the IT-enabled MIS for ICDS across the State with a
dedicated URL created for MIS- mpwcdmis.gov.in. This ensured monthly reporting from
AWCs on infrastructure, human resources and the services. About 3,400 ICDS functionaries
were trained for implementation of new MIS. A feedback mechanism was started with video
conferencing and monthly meetings which focused primarily on completion and submission
of MPR and major data gaps. Registers were designed keeping in view the revised on-line
reporting format and the numbers of registers were reduced.
 A Validation Module is now added to the online reporting systems, to improve the data
quality. The divisional, district and block ICDS officials are each validating 18 MPRs per
month and the state officers validate two MPRs per month: nearly 10,000 MPR are being
validated every month across the state.
 Using the new ICDS MIS, a Take Home Ration (THR) stock report is being developed
monthly to get accurate forecast for THR requirement per AWC as per the number of
beneficiaries. This has helped rationalize the demand and supply of THR and curtailing
14
excess supply/wastage in almost all districts.
Assessments, Evaluations and reviews conducted in 2013 -14;
 Four large scale assessments and evaluations were conducted through MPHSRP TA during
2013 -14;
o Evaluation of free drug for All scheme
o Evaluation of Hot cooked meal pilot
o Rapid assessment of Suposhan Shivirs
o Assessment of Model Maternity wings
o Gram Arogya Kendra assessment study.
All these evaluations were done at the request of GoMP and findings are informing the annual
plans with corrective actions.
 Using the evidence generated from all the above, DFID TA documented several papers and
case studies (co authored by TA consultants and Govt officials) for wider sharing and
publications;
o State drug MIS (SDMIS) model for IT Department E-Governance best practice paper
o Free Drug for All scheme for PM’s Award
o Case Study for Mid-term Appraisal of 12th Five-Year Plan on Gram Arogya Kendra
and ‘Free Drug for All’ Scheme
o Three abstracts selected for South Asian Nutrition conference and Transform
nutrition conference.
o Five abstracts submitted to World congress on Public Health
 A rapid appraisal of SuPoSHaN campaign was undertaken to inform the strategies for the
next phase and the findings were;
o Supplies and infrastructure available in about 70% centres
o Visual aids not available in most centres - IEC material development in-process
o Poshan Sahyogini appointed and working; but health team seen in only 30% coordination needs strengthening
o Weighing children is a challenge - further training and supervision support is needed
o MIS – data transfer to sector needs to be streamlined
o Home visits - carried-out post shivir but guidance needed on making them focused

Study to assess the MCH services in 48 District hospitals as per the 39 points checklist
(MNH toolkit) with an aim for certification as Model Maternity Wing. Results;
o 40% had labour room arranged as per MNH toolkit, 71% had drugs and instrument
trays as per protocols, 54% had labour room protocols displayed,
o 92% had functional radiant warmers and only 40% had adequate no. of beds.
o HR: 69% had SBA trained ANM/staff nurse posted at Labour rooms and 35% had
female security staff posted for the maternity.
o Knowledge and skills assessment: 75% had skills on new born resuscitation, 71%
had knowledge about AMTSL and 73% correctly filled partograph for all deliveries.
o Service delivery: 85 % had uninterrupted electric and water supply, 88% had facility
for zero dose in PNC ward and 98% had provision for PPIUCD services.
From March to May 2014 after rigorous follow-ups and corrections, 9 DH resolved all the gaps
and are certified as Model Maternity wing. More certifications are ongoing.
Recommendations:
 Preparations of analytical reports with data from E-Health soft wares, Block monitoring visits
and surveys and help improve decision making for RMNCH+A..
 Support ICDS for better analysis and use of data eg. Dashboard for key indicators (eg.
Nutritional status, SNP coverage), district grading reports.
Evaluations to be designed and conducted during 2014 -15:
 NIN nutrition survey (using DFID FA) to assess the mid-term impacts of Atal Bal Mission on
stunting and wasting and nutrition specific and sensitive indicators
 Process Evaluation of QA work
 Evaluation of Suposhan Abhiyan
 CBA/PLA evaluation – baseline completion and qualitative assessments
Impact Weighting (%): 20%
Revised since last Annual Review? No
Risk: Medium
15
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.
We have revised the 2015 impact target for Infant mortality rate from 51 to 47 per 1000 because of the
faster trajectory of decline noted in 2011 and 2012. Output indicators were also revised to align with
changing govt strategies for instance the new RMNCH+A strategy, change in CMAM approach, model
AWC strategy in ICDS Mission.
1.2 Overall Output Score and Description:
Score:
Output
Output 1
Output 2
Output 3
Output 4
Output 5
Overall score
Impact weight
25%
20%
20%
15%
20%
Score
A
A
A
A
B
A
1.3 Direct feedback from beneficiaries :
Beneficiary
Feed back
Pregnant women
We receive all the medicines from hospital free of cost. Meals were
Ms. Guddi
also provided on time and hospital is cleaner. I came though Janani
Kaluya, Panna
Express and also hospital assured to arrange JE after discharge. I
am very happy with this hospital and my child is also healthy.
Lactating Mother Larkui
Here children are learning lot of things that they did not know.
village, Sehore, during
We like all the things that are told here on feeding and caring for
Suposhan, Sneh Shivir.
the child.
Lactating Mother at Tilkan Earlier we were not aware of the benefits of the recipe and also
Village Rewa
didn’t know how to improve the quality of the same. But now we
During Sneh Shivir.
can prepare at home and serve to our children
MPW, Jamuna prasad
MPTAST has been monitoring VHND session and they provided
SHC- Baraithi,
feedback on the VHND and directly supported in organizing VHND.
District- chhatarpur
Guidelines on preparation of due list, micro plan, essential
materials, essential services to be provided to beneficiaries on
VHNDs. Now we are able to organize the VHND in better manner
covering all the target women and children.
ANM of SHC (Level 1)
Binnaeki, Patan Block,
District Jabalpur.
This is SHC having L1 facility; I am able to conduct delivery.
Because of facility available at SHC pregnancy cases come from
nearby villages like Panagar, Sukha. People said this is the proper
place to avail treatment easily and on time. Now i know how to
maintain and keep the instrument sterilized and place it in right way
and at right place after receiving guidance from MPTAST.
o Summary of overall progress
MPHSRP has made good progress against the project milestones and is on track to achieve all the
outcome and impacts. As per available estimates2, DFID support to MPHSRP has directly enabled:
 More than 190,000 women give birth in a health facility attended by skilled staff,
 Over 42000 additional people to use modern family planning methods.
 Provision of nutrition services to nearly 535,000 (half a million) children and pregnant women.
Overall sector level progress;
GoMP has shown substantial progress in access to facility and community services over last 7 years:
 Functional delivery points have increased from 335 to 1400 since 2007: which has led to 79%
institutional deliveries, up from 43% in 2007. There is also a massive improvement in OPD (7.9m to
2
Using FCPD guidance for calculation methodology
16
31.6m per year) and IPD (0.4m to 3.7m per year) use over 2008 to 2013.
 53 sick new born units and 312 nutrition rehabilitation centres set up: highest in the country.
 GoMP has established village level health units with Anganwadi centers, named as Gram Arogya
Kendra. These units are functional in 49000 villages with 16 essential drugs and 5 diagnostics along
with ANC table/curtains and adult weighing scales. Labelling AWCs as Gram Arogaya Kendra and
providing additional resources has strengthened the availability of basic services/supplies at AWCs,
promoted convergent action between Health & DWCD and institutionalize VHNDs.
 More than 4800 nurses, 4000 Auxiliary midwives and 2300 doctors recruited since 2009.
 Since 2009, DWCD has deployed more than 750 additional ICDS block officials/supervisors and
additional 16000 Anganwadi workers to support nutrition services resulting in increased coverage of
under 6 children from 52% in 2008 to 82% in 2013.
However there still remains a non-uniform geographic distribution of doctors and nurses, infrastructure,
logistics and variable quality of services as evidenced by various gap analysis studies.
MPHSRP attributed progress in MP
MPHSRP has provided substantial assistance under five areas: Quality improvement of health and
nutrition services, HR management, monitoring systems, procurement, and improving demand and
community mobilisation.
 Mobilised delivery of the flagship Govt of India’s RMNCH+A strategy as the state lead partner. The
District Monitors were deployed; gap assessment informed annual plans (PIP) and block supportive
supervision started.
 Quality improvements of health services at both facility and community levels; across 94 high load
delivery points, 1340 village health nutrition days and helping GoMP to certify Model Maternity
wings. DFID FA is supplementing the quality improvement efforts funding hospital cleanliness and
mobility for better supportive supervision. MPHSRP TA and FA enabled two fully functional Skills
labs and five more in the pipeline to improve clinical skills of nurses for maternal neonatal care.
 Supporting the ambitious Suposhan campaign for prevention of malnutrition and supervised
feeding for malnourished children reaching 3200 AWCs; also completed a rapid appraisal of the first
phase and is now supporting the design of Suposhan evaluation.
 Designed the Chief Minister’s Community Leadership Development (CLD) course which is now
cabinet approved, affiliated with Bhoj University to benefit nearly 10,000 village volunteers every
year, starting July 2014.
 State Rural Livelihood Mission (SRLM) approved Sanjhi-Sehat (Participatory Learning and Action
PLA) in eight districts to improve Health nutrition and WASH outcomes to capacitate 7,500 SHGs:
implementation ongoing in 3 districts reaching 3600 SHGs.

All recruitments, postings, transfers and promotion of Doctors are informed by HRMIS designed and
managed by DFID TA. During 2013 -14, TA supported the recruitment of more than 12000 clinical
staff, counsellors, and mission management staff.

Helped GoMP set up an independent procurement corporation to streamline procurement of drugs
and equipment to achieve best value for money. The corporation is approved by the cabinet,
budgets allocated, registered under companies act and staff recruitment is ongoing. In the
meantime MPHSRP TA has helped operationalise the local purchase modules in SDMIS;
equipment MIS; expanding essential drug lists from 247 to 426: absorbing drug budget increase of
more than 136% from 123 crores to 291 crores.

DFIDTA is directly supporting six of the 12 e - monitoring softwares (HMIS, MCTS, HRMIS, SDMIS,
EqMIS and ASHA) for data updation, analysis and its use for improvement in services.
DFID TA has supported a number of evaluations and independent assessments and lessons are
being widely shared at national, regional and international forums.

o



Key challenges
During 2013 -14, there were two successive elections (National and State) and due to code of
conduct, several key processes and approvals were delayed. (Sanjhi sehat)
Delayed start-up of Sanjhi Sehat community mobilisation initiative and short time available for
completing all the PLA cycles. Though the Sanjhi Sehat proposal was passed by SRLM in October
2013, recruitment of staff and implementation in 5 SRLM led districts has not yet taken off.
Although significant progress is seen in setting up monitoring systems with data flow and data
management, more efforts are needed for analysis and use of data for decision making. There is
also a need to monitor short term results of various activities like training, supervision, and drug
supply systems.
17






Sustainability of roles played by embedded consultants across Health and ICDS department will be
a challenge. Currently there are about 40 consultants working on key operational roles, of which
about 17 positions are already agreed to be funded by NRHM.
Delays in setting up of a Comprehensive HRMIS because of negotiations with govt on SRS
designs and appropriate softwares.
Operationalising the newly set up procurement Corporation will take atleast one year to ensure
adequate staffing and handhold atleast one procurement cycle. Use of E-Aushadhi (SDMIS till
primary health centre) needs to be customised to MP systems.
High attrition rate of district level MPTAST on account of the launch of large long-term projects
funded by BMGF in UP and Bihar. Hiring replacements for one-year tenure up to March 2015 will
remain a challenge.
Strengthening management and monitoring capacity for DWCD at the state, district and block
levels to effectively implement the new ICDS Mission and World Bank funded ISSNIP is a key
challenge. Efforts to strengthen Programme Management units at the state and district level will
enable the department to address systemic issues and procedural delays.
More targeted strategies to reach the most vulnerable and migrant population’s needs to be defined
within the overall health and nutrition sector interventions.
1.4 Annual Outcome Assessment
MPHSRP is well on track to achieve most of the outcomes and impact targets as evident from the
available data: however the updated nutritional status data is not available after 2011.
The annual reduction of infant mortality during 2007 to 2012 is 5.3% compared to 2% annual reduction
during 1990 to 2007. Similarly MMR has declined from 335 in 2004- 06 to 230 in 2010 - 12 with annual
reductions of 5.2% as compared to 3.1% annual reductions during 1990 to 2006. Based on faster
trajectory of reductions of Infant and maternal mortality we will revise the 2015 targets to 47 and 200
respectively. The project has also achieved the 2015 targets for immunisation and early breast feeding.
Indicators
Baseline
Target
2015
Milestone
(2013-14)
Progress
Maternal Mortality Ratio
335 per
100,000
births
230
250
230 (SRS 2010 -12)
Infant Mortality Rate
76 per 1000
live births
47
50
56 (SRS 2012)
Contraceptive
Prevalence Rate (any
modern method)
53%
60
58%
(for 12-13)
59.3% (AHS 2012)
Under-weight children
(0-5 year)
58%
45
50%
(for 12-13)
52% (NIN 2011)
Deliveries taking place in
health facilities
47%
85
75%
79.7% (AHS 2012)
Women who received 3
ANCs
34%
80
70%
(for 12-13)
70.7% (AHS 2012)
Children aged 12-23
months fully immunized
36%
58
54%
59.7% (AHS 2012)
Children breast fed
within an hour
43%
65
55%
(for 12-13)
65% (AHS 2012)
Children fully breast fed
till 6 months of age
31%
50
40%
(for 12-13)
39.7% (AHS 2012)
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 June 2014, £93m
FA and £12.62m TA has been spent and the overall forecast is likely to be met. During 2013 -14, the
FA spend was £14m and TA spend was £3.75m.
• DFID has so far disbursed £93 million to MPHSRP FA over 2007 -2013: Of which £ 30 m was
18
earmarked for DWCD (Nutrition).
• During 2007 -12 and there was no separate budget line for DFID funds and DFID funds of
£65m were routed through the State Treasury as part of sector budgets with commitment from
GoMP of 10% annual increase in overall govt budgets.
• In the second phase of the project (2012 -2015), additional safeguard was added as a separate
budget line within DHFW and DWCD with detailed plans to ensure additionality of resources.
During 2012 -13 and 2013-14, about 42% of this additional money have been spent. The
reasons for slow spending was delays in approvals of plans and activities: designing of
Infrastructure plans, layouts and spending guidelines. We expect that pace of spending will
improve during 2014 -15 as all preparatory activities are completed.
• The TA pipeline spend is projected to be high and overall TA spend is expected to cross the
£17m allocated budgets. The agreement to vire £5m from FA to TA is agreed with GoMP and
discussions with Govt of India, DEA are ongoing.
2.2 Key cost drivers:
Key cost drivers of the project come from two separate mechanisms: Financial and Technical Aid.
Both departments (DoPHFW and DWCD) have a separate budget line earmarked for DFID funds to
ensure additionality. The detailed FA plans for both the departments are finalised.
Additional funds for DWCD is being used to a) Strengthen and upgrade Mid-level training centre (for
supervisors) and Anganwadi training centres (for Anganwadi workers) b) undertake concurrent
monitoring/NIN survey, c) implementation of innovative pilots d) Anganwadi centre construction. The
additional 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. TA funds are used for improved planning, quality improvements, capacity building,
monitoring, analytic studies, evaluations, and piloting innovations. The TA support team includes: 15
member core team across technical thematic areas: 45 member district teams across 16 underserved
districts: 50 consultants placed within GoMP to support planning, quality issues, monitoring,
procurement and HR functions.
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.
Lancet series on nutrition was released in 2013 which endorses10 evidence based nutrition intervention
with high impact on child health and nutrition. All the 10 Lancet endorsed interventions are already part
of the Madhya Pradesh’s Atal Bal Nutrition Mission strategy and implementation guidelines supported
under MPHSRP. During 2013 -14, Govt of India launched its RMNCH+A strategy compiling all the latest
evidence. MPHSRP has aligned its operational actions to focus on the 17 High priority districts
harmonising with other development partners and provide district mentoring support.
What is the latest evidence telling us?
 Globally, gaps are maximum around institutional care but MP has done the difficult part better, eg. :
o Institutional Delivery : 79%
o Facility Based New Born Care and SNCUs : 90% coverage at District level
o Facility management of malnutrition (NRCs) : 96% coverage at Block level.
o Free referral transport and level 1 MCH centers in remote areas.
 However evidence shows that coverage of community interventions is poor in MP eg. :
o Full ANC coverage : 13.3% (only 17% women consuming 100 IFA tablets)
o Exclusive Breast Feeding : 39%
o Full Immunization : 59%
o Oral Rehydration therapy or increased fluid in diarrhea : 45%
o Spacing Methods; only 0.5% use of IUCD
 Ensuring Quality amidst Quantity…… ie. MP has demonstrated numeric coverage results, but need
to focus more on quality of services:
o 68% receive 3 ANC & 78% institutional delivery but Maternal and neonatal mortality high.
o 1400 delivery points operationalized: however low complication management and LSCS rate
(3.8% in public sector).
o Sick new born units (SNCUs): 60,000 Admissions per year with 12% mortality; Birth Asphyxia
19
and Sepsis are major newborn killers…. need to improve quality in labor rooms.
o Missed opportunity: 79% institutional deliveries, but only 65% early breast feeding. High
unmet need for spacing and limiting FP methods, but Postpartum FP coverage is low.
In summary, coverage of facility based institutional care is better than community based care in MP:
therefore significant realignment of strategies is needed.
Way Ahead and implications for the programme:
o Close monitoring of High Priority Districts through score card and regular block monitoring for
quality of delivery points.
o Renewed focus on community based interventions (Child feeding, home based newborn care,
Diarrhea and childhood pneumonia, antenatal care)
o Promotion of spacing methods at both institutions and community
o Addressing HR gaps on priority and task shifting.
o Strengthening supportive supervision and use of protocols for improving quality.
o Use data for tracking progress and initiating action (HRMIS, Drug MIS, MCTS, SNCU data)
3.2 Where an evaluation is planned what progress has been made?
Section A, output 5 describes the progress on evaluations and independent assessments. Four
assessments and evaluations were conducted through MPHSRP TA during 2013 -14;
o Evaluation of free drug for All scheme
o Evaluation of Hot cooked meal pilot
o Rapid assessment of Suposhan Shivirs
o Assessment of Model Maternity wings
o Gram Arogya Kendra assessment study.
MPHSRP also hosted an ICAI nutrition review during Feb 2014 and draft report is available.
Evaluations to be designed and conducted during 2014 -15:
 National Institute of Nutrition (NIN) nutrition survey to assess the mid term impacts of Atal Bal
Mission on stunting and wasting and nutrition specific and sensitive indicators
 Process Evaluation of QA work
 Evaluation of Suposhan Abhiyan
 CBA/PLA evaluation; baseline completion and qualitative assessments
An endline evaluation of MPHSRP is also planned during 2015 -16.
20
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
3.
Non-availability of
critical medical staff in
remote areas
4.
Change to GoI policies.
5.
Staff resistance to
change
Current risk profile
Fiduciary risks reduced to moderate.
Significant improvements: TA is helping in planning and
implementation quality, especially at the district level. The district
teams are strengthening district level implementation; capacity
building, supervision, and monitoring. TA is also strengthening the
human resources and procurement systems in the state.
The staff inadequacies continue to be of concern. However, large
scale recruitments and rationalisation in staff deployment has
improved the situation at district, and sub-district level. Govt has
taken steps for incentivising doctors and nurses, flexible recruitment.
Low risk: GoI strongly committed to reduce maternal and child
mortality and under nutrition: contributes about 30% of health
resources.
Medium risk: High degree of political and bureaucratic commitment
to health and nutrition. Incentives in place to attract talent and
reward performance.
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 is earmarked scheme code for DFID funding for DOPHFW and DWCD
and this has substantially reduced the risk of funds not being used as intended. The funds are being
used through societies under the Health and through treasury route in DWCD. The society accounting in
NRHM is in accordance with its Financial Management Manual which is provided by Government of
India. This ensures that prudential norms of double entry book keeping with standard books of
accounts are followed.
The accounting in DWCD is done as per the Treasury rules as per the accounting procedures prescribed
by the CAG. Quarterly Concurrent and Annual external audits of the State Health Society and District
Health Societies is carried out by CAG empanelled Chartered Accountants who are appointed as
prescribed by GOI. Audit of DWCD is conducted by audit parties from CAG on a routine basis and
treasury system does a pre audit before passing the bills. CAG conducts periodic transaction audit and
performance audit of DoHFW and DWCD which GoMP makes available to DFID.
FRA of DoHFW done in July 2013 has given the overall risk rating as Moderate. FRA also identifies 4
(four) benchmarks which have substantial risk which also have a positive trajectory of change. FRA of
DWCD done in July 2013 has given the overall risk rating as Moderate. FRA also identifies 2(two)
benchmarks which have substantial risk which also have a positive trajectory of change. The overall risk
rating is moderate with positive trajectory of change.
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.
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
Achieving VfM is described in terms of the 'three Es': Effectiveness, Efficiency, and Economy.
Effectiveness measures:
21
MPHSRP continues to demonstrate value for money on effectiveness parameters like rate of reduction
in infant mortality, and rates of increase of health service coverage.
As mentioned in section1.5, the trajectory of decline of Infant and maternal mortality has doubled since
2007. There is also an accelerated increase in coverage of critical lifesaving interventions like
Institutional deliveries, immunisation and early breast feeding rates.
 The annual increase in number of institutional deliveries during 2008 to 2012 is 8.25 % points per
year as compared to only 2.7% points per year during 1998 to 2007. While it is mainly because
of the govt cash incentive scheme, TA has supported improved maternity/labour room care.
 The annual increase in full immunisation during 2008 to 2012 is 6% points as compared to 1%
point reduction per year during 2005 to 2008. TA helped in strengthening micro planning, mother
and child tracking systems and VHNDs contributing to improved immunisation.
Efficiency measures:
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:
 The GoMP budget of DoPHFW has grown at an average of 22% to INR 3113.72 crores in 201314. The growth in DWCD budget has been on an average 42% to INR 3688.26 crore in 2013-14.
The off budget receipts for the DoPHFW has increased by 40% from INR 1077.58 crores in
2008-09 to INR 1508.03 crores in 2013-14.
 In DoPHFW, the average year on year growth of expenditure is around 23% during the period
2008-09 to 2011-12 with the average utilisation percentage around 98% of the budget estimate.
 In DWCD, the average year on year growth of expenditure is 54% during the period 2008-09 to
2011-12 with the average utilisation around 98% of the budget estimate.
 Substantial increase in drug budget (136%) from 123 crores in 2011 to 291 crores in 2014 with
expansion of essential drug lists from 247 to 446 drugs. Average total drug count in CMHO
stores increased from 95 in 2012 to 251 in 2014; 2.2 times increase in the drug budgets from
2011 to 2014 resulted in 2.7 times increase in the average drug count availability. Incomplete
supplies reduced from an average 57.6% to 36.6% over 2012 to 2013
 Substantial increases in financing and increased numbers of doctors and nurses have led to
improved service provision: for instance there is doubling of institutional deliveries and about
460,000 more fully immunised children every year. There is also a massive improvement in OPD
(7.9m to 31.6m per year) and IPD (0.4m to 3.7m per year) use over 2008 to 2013.
 Since 2009, DWCD has deployed more than 750 additional ICDS block officials/supervisors and
additional 16000 Anganwadi workers to support nutrition services resulting in increased coverage
of under 6 children from 52% in 2008 to 82% in 2013.
Economy measures:
 MPHSRP contributes to overall economy of the health systems by expanding provision of low
unit cost primary preventive services (Nutrition, antenatal care, anaemia, immunisation etc). For
instance this project is helping strengthen village level services (at AWC, VHND, Subcenters)
and train frontline community workers: which aims to cover more clients with less unit cost.
(Global evidence proves that unit costs of community level services are much lower than at block
or district hospitals).
 E tendering is leading to transparent competitive processes. This has reduced monopoly and
discretion and enhanced accountability in procurement processes.
 The market credibility of GoMP is steadily improving as evident from increasing tender
participation: the vendor participation has increased from 57% in 2011-12 to 69 % in 2013-14.
 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.
 All the rate contracted medicines are generic. The number of generic drugs under the EDL has
steadily increased from 240 in 2011-12 to 305 in 2013-14.
 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 290 crores.
5.2 Commercial Improvement and Value for Money
Value for money is being ensured under both direct and indirect procurement.
22
Direct Procurement: DFID procured 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 are approved by DFID procurement group. All procurements are
undertaken using approved procurement guidelines.
 Low value sub-contracts are 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.
 For limited tendering of procurements of more than GBP25k, the procurement process is
managed by the Contracts and Grants point person, thereby ensuring segregation of duties.
 Sub-contracts budgets are negotiated and payments are linked to deliverables in most cases. All
deliverables are reviewed by the assigned Technical Monitors before processing payments.
 Most consultants 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.
In the past year there was an incidence of falsified travel receipts submitted by 3 consultants, which was
tracked as part of internal finance/administrative review and verification process. FHI 360 investigated
the matter and has terminated the consultant contracts and the funds will be returned to DFID.
There was also an instance of termination of an NGO contract because of weak accounting practices
and poor performance. During the annual Finance and Administrative review conducted for all NGO
partners, it was revealed that one of the NGO had weak accounting practices that did not meet
standards as well as weak project management/leadership. It was decided to terminate the NGO
contract, with a savings of approximately GBP 80,000.
5.3 Role of project partners
MPHSRP is implemented in partnership with Health and Woman and Child Departments of Govt of MP
and TA support team managed by FHI360. Other technical agencies like Unicef, UNFPA, MI 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 TAST and GoMP. Under the GoIs RMNCH+A strategy,
strong efforts for donor harmonisation have been undertaken with DFID as the lead state partner. All the
development partners share their plans and progress on RMNCH+A in the 17 high priority districts
during the state coordination meetings on a regular basis.
5.4 Does the project still represent Value for Money : Y/N
Yes.
DFID India commissioned an independent evaluation in 2014 to assess the performance of state health
sector projects on Value for Money (VfM) measures such as Effectiveness, Efficiency and Economy.
The draft report concludes that; notwithstanding the high risk of underestimation, DFID’s investment in
MP’s health sector is expected to bring a high return and stands out as a very cost-effective intervention.
The cost of a DALY gained works out to £400 which is lower than WHO’s suggested threshold for very
cost-effective interventions.
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. GoMP continues to show strong commitment to poverty
reduction, human rights and financial accountability issues.
7. Conclusions and actions
Conclusions:
23
MPHSRP is well on track to achieving all the goal and purpose indicators. The project has already
achieved or within striking distance of achieving 2015 targets for 4 (out of 9) indicators in 2012 itself.
MPHSRP TA has provided substantial assistance for setting up and implementing quality improvement
mechanisms in 94 high load hospitals across 16 districts as well as certifying Model Maternity Wings.
GoMP with DFID support is implementing the state nutrition mission targeted at children under 2 years
where MPHSRP funds and TA are being used to a) improve quality and functionality of AWC and
VHND services b) rapid scale up of Suposhan campaign for preventing malnutrition c) improving
monitoring and supportive supervision and d) Behavioural Change Communications. State Rural
Livelihood Mission (SRLM) has approved Sanjhi-Sehat in eight districts to improve Health nutrition and
WASH and implementation has reached 3600 SHGs.
All recruitments, transfers and promotion of Doctors are initiated as informed by the HRMIS designed
and managed by DFID TA. During 2013 -14, TA supported the recruitment of more than 12000 clinical
staff, counsellors, and mission management staff. MPHSRP TA helped GoMP set up an independent
procurement corporation to achieve best value for money and effective distribution systems. The
corporation is registered under companies act and staff recruitment is ongoing. DFID TA has supported
a number of evaluations and independent assessments and lessons are being widely shared at
national, regional and international forums.
During the last year of MPHSRP, it is critical to ensure sustainability of project inputs and strategies
and achieve a responsible exit. While it is evident that GoMP will be able to compensate for the loss of
our budget support through the state and GoI provisions, the project team needs to support GoMP to
continue to use the improved management and monitoring systems created by the project; and help
Scale-up the community level work on nutrition and sanitation that the project is piloting.
Actions:
Output 1.
Health (NRHM MD and TAST)
 Quality implementation of RMNCH+A strategy in all 17 High priority districts; conduct 34 BMVs
every month for supportive supervision and quality improvements at delivery points and
community centers (GAK and VHNDs).
 Scale up Skill labs to 5 divisions
 Support development of Model Maternity Wing as per MNH toolkit
Nutrition (ICDS Commissioner and TAST)
 Set up 50 model AWCs in 16 focus districts
 Quality improvement of AWCs in 16 districts and institutionalise QI process under ICDS Mission
 Training reforms and strengthen MLTCs and AWTCs
 Implementation and evaluation support for Suposhan
Output 2. (Health Commissioner and TAST)
 HRMIS to be operationalized to cover doctors and nurses.
 Consolidate the result due to regular HR analysis and its institutionalization
 Help operationalize nursing reforms especially in the areas of staffing norms, career
progression and setting up of a nursing directorate.
Output 3. (Health Commissioner and TAST)
 Support full operationalization of the Procurement Corporation
 Transition of procurement cell and Biomedical engineers to the Drug Procurement corporation.
 Achieving one cycle of drug procurement via the corporation by March 2014.
 Commission a third party diagnostic report on existing procurement systems.
 Statutory and Concurrent Audit Analysis at NRHM. Capacity building of finance and account
personnel through NIFM
Output 4. (NRHM MD, SRLM CEO, ICDS Commissioner and TAST)
 Complete 8 of the 22PLA modules of Sanjhi Sehat in the five SRLM districts.
 Complete at least 10 out of the 22 PLA modules with WASH integration, in the three TAST
supported districts
 Set-up trouble shooting mechanism to resolve operational challenges vis a vis Sanji Sehat
especially in SRLM districts were MPTAST is not operational
 Mobile Kunji implementation in the 17 high priority districts. Mobile Kunji is a multimedia job aid
to ensure standardized, messages about maternal, neonatal and child health.
Output 5. (NRHM MD, ICDS Commissioner and TAST)
 Preparations of analytical reports with data from E-Health soft wares, Block monitoring visits
24
and surveys and help improve decision making for RMNCH+A..
 Support ICDS for better analysis and use of data eg. Dashboard for key indicators (eg.
Nutritional status, SNP coverage), district grading reports.
Evaluations to be designed and conducted during 2014 -15:
 NIN nutrition survey (using DFID FA) to assess the mid term impacts of Atal Bal Mission on
stunting and wasting and nutrition specific and sensitive indicators
 Process Evaluation of QA work
 Evaluation of Suposhan Abhiyan
 CBA/PLA evaluation – baseline completion and qualitative assessments
Responsible exit and sustainability (DFID Task team and PS Health and PS DWCD)
 Procedural/Administrative Actions
o MoU revision with GoI to agree virement of £5m FA to TA.
o Extension of FHI contract from March 2015 to Dec 2015.
o Include the provision of embedded consultants under NRHM and ICDS Mission
budgets. Communicate with GoMP about the withdrawal of consultants by Dec 2014.
 Sustainability plan
o Rapid scale up of Sanjhi Sehat (SHG/PLA Model), evaluation and sharing evidence with
GoMP to include under ICDS and NRHM.
o Wider stakeholder communication on 3 key technical areas – QI, Skills Lab,
Procurement reforms, Sanjhi Sehat model
o TA for planning and roll out of new ICDS Mission and ISSNIP. Support recruitments and
orientation of district and state PMU staff to sustain TAST functions
o Under Health NRHM, PMUs at state and districts to be strengthened (tools, guidelines,
MIS systems and QI protocols) to sustain TAST functions
o Communicate with MoHFW regarding options for transition of Lead partner role for
RMNCH+A.
8. Review Process
The Joint Annual review was undertaken during May and June 2014. The review included field visits to
two underserved districts and state level presentations and discussions. The review participants
included DFID team3, DHFW and DWCD officials of Govt of MP, MoHFW official of GoI 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. In addition field assessments, gap
analysis, thematic reviews and evaluations (eg. RMNCH+A gap analysis, Model maternity wing
assessments, Suposhan assessment, Evaluation of the drug scheme) done by TA support team also
informed the review. Field visit observations from Chhatarpur and Tikamgarh have informed the review.
EDRM: 41552153 Field visit observations and recommendations
EDRM: 4552140 State meeting presentations and next steps
3
Health Adviser, Governance adviser, Social development adviser, Program managers, Project Officer and state representative.
25