Type of Review: Annual Review
Project Title: MADHYA PRADESH HEALTH SECTOR REFORM
PROGRAMME (MPHSRP)
Date started: 2008
Date review undertaken: Feb 2012
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 will improve access and quality of health and nutrition services and will enable the state to
achieve the following results by 2015:
 Decrease in Maternal mortality ratio from 335 (in 2005) to 230 per 100,000 live births in 2015
 Decrease in Infant mortality from 76 (in 2006) to 52 per 1000 births in 2015
 Decrease in the proportion of children who are undernourished from 58% (in 2005) to 45% in 2015
 Increase in Contraceptive prevalence rates from 53% (in 2007) to 61%
 Increase in deliveries conducted by nurses and doctors from 30% (in 2005) to 85% In 2015
What are the planned Outputs attributable to UK support?
There 5 priority outputs that are attributable to UK support:
1. Quality public health and nutrition services available in underserved districts
2. More better trained staff working in the underserved districts
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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. Joint Annual Reviews to monitor progress against the
programme log-frame and milestones are undertaken. An independent evaluation is planned to assess
overall impact and capture lessons.
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
poverty line. Despite progress in recent years, MP is currently off track on MDG 1, 4 and 5 (Under
nutrition, maternal and child mortality).
MP has the highest infant mortality rate among all states in India (76 infant deaths per 1000 live births
in 2006), and about 58% of children are undernourished. Women are particularly disadvantaged in MP,
because of high Maternal mortality rate of 310 per 100,000 live births as well as high fertility rates of
3.3. It is estimated that more than 160,000 mothers and children die every year in Madhya Pradesh
because of easily preventable and treatable medical complications. Malaria is a major public health
problem in MP and 5 tribal districts are endemic for malaria.
The health outcomes of tribal and dalit populations and girls/ women are worse than those for other
groups. The reasons for poor health indicators are 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 terms of access to food, education, income, and social
status when compared to men. Existing social norms such as early marriage and early motherhood
also affect health and nutrition outcomes adversely. Median age of marriage for girls in MP is 15.9
years (as per National Family Health Survey 3).
The performance of the public health delivery system in MP faces several constraints: per capita
expenditure of public health is low (at $8 as against global standard of about $34 for minimum package
of essential health), high out of pocket expenditures (due to diagnostics and medicines), vacancies of
staff and infrastructure gaps; lack of drugs and other essential supplies at local levels; weak monitoring
systems; poor accountability of staff and low staff motivation and management capacity.
What will we do to tackle this problem?
The DFID financial and technical assistance will help GoMP in delivery of maternal and child health
and nutrition services in the poorest remote, rural and underserved areas. DFID funds will help in
improved functioning of primary hospitals, provision of obstetric and new-born services, child feeding
centres, more doctors, nurses and medicines at the rural hospitals and provision of malaria bed nets.
Technical assistance will help Government of Madhya Pradesh (GoMP) for better planning; human
resource management; improve monitoring and financial management and procurement systems.
Illustrative areas of support for health and nutrition services under MPHSRP include:
 Quality improvement of maternal and child health services
 Family planning counselling and delivery of post-partum family planning service
 Malaria prevention: distribution and use of Bed nets in malaria endemic districts and IRS spray.
 Setting up and functioning of state Nutrition Mission and district management and monitoring units
 Community mobilization and behaviour change communication
 Setting up of State and divisional Nutrition Resource Centres (based in medical colleges) to help
implement and monitor the nutrition actions.
 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 managed 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 1 : Number of fully functional facilities for Basic and Comprehensive Emergency Obstetrics
and New-born Care (CEmONC and BeMONC)
Milestone 2012: 430 Basic (BEMONC) and 85 Comprehensive (CEMONC) emergency obstetrics and
new-born care hospitals functional.
Progress: Largely achieved
 483 BEmONC facilities (up from 296 in 2006) and 77 CEmONC facilities (up from 41 in 2006) are
functional.
 Independent quality appraisal of CEMONC/BEMONC was done by DFID Technical assistance
(TA). Since large number of maternal deaths happen because of bleeding and fits, the study
highlighted that 84% nurses practice standard procedure to prevent/manage bleeding
complications (AMTSL); Use of Magsulph, which treats fits, was seen in 16% facilities though
available in 74% facilities: Essential Newborn care services available in 98% but functional radiant
warmers only in 30% facilities. There is a need to expand BEmOC training coverage, because
currently 50% doctors out of 491 were BEmOC trained. Safe abortion (MVA) equipment was found
in 32% facilities but in use in 7%.
 Strengthening Quality of services: Quality assurance committees (QAC) have been set up with TA
support and started functioning. TA has facilitated QAC meetings in 14 districts across 4 divisions.
There are expert consultants deployed in 10 districts to support trainings, supervise service quality
and provide mentoring and handholding support for maternal and child health services. Division
level team of Mentors are now set up for supportive supervision of MCH facilities
 There are now 34 Functional Sick newborn care units (up from 2 in 2008) and 262 Nutrition
rehabilitation centers (up from 47 in 2007) in MP.
 Training on technical areas: 4460 nurses were trained in skilled birth attendance. 1300 community
volunteers (ASHAs) have been trained on home based newborn care and counseling. 6885
Frontline providers (ANMs, ASHA and AWWs) were trained in integrated management of childhood
illness (IMNCI) & 2100 were trained in child feeding (IYCF). 87 doctors trained in Emergency
obstetric care (EmOC) & 56 doctors in Life saving anesthesia skills (LSAS). BEmOC Foundation
Course with support from UK Liverpool School was taken by 51 MOs & 102 nurses in four pilot
districts of Anuppur, Tikamgarh, Barwani & Jhabua
Indicator 2 :Number of facilities (private and public) providing safe abortion services
Milestone 2012 : 131 Facilities
Progress: Overachieved
225 (133 CEmONC and 92 BEmONC) public facilities and 380 private facilities are providing safe
abortion services. 573 Doctors have received 12 days training (of whom 60% are providing services)
and 357 doctors have received 6 days training on providing safe abortion services. DFID supported TA
through IPAS is helping to improve quality of safe abortion services.
Indicator 4: Village health and Nutrition days (VHND) providing integrated ANC, nutrition and sanitation
services.
Milestone 2012: 5 districts
Progress: Fully achieved
VHNDs are now an integral part of NRHM strategy in Madhya Pradesh, and the number of reported
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VHNDs has increased to about 680,000 per year from 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 and counseling is negligible. State specific guidelines,
monitoring tool and a training manual were developed and tested in two districts by the TA team and
approved by both the departments. With TA support VHND’s are now in place in five underserved
districts i.e Dindori, Umaria, Sidhi, Sheopur and Tikamgarh) where significant quality improvement
interventions have been undertaken.
Indicator 3: Community based management of Severe Acute Malnutrition (CMAM) started in MP.
Milestone 2012: Framework for effectiveness trials on CMAM finalised
Progress: achieved.
There was major political and civil society resistance to CMAM (in particular use of Ready to use food RUTF) in MP. Therefore GoMP decided to use locally available RUTF and conduct operational trials to
test CMAM. At present state Government in principle has approved piloting CMAM in 2 districts.
Proposals from Valid and RMF are in final stages of approval to trial CMAM. Valid will also support MP
Agro to locally produce RUTF and test efficacy. Approvals from ethical committee are awaited.
Subsequently a letter will be sent to Govt of India (GOI) for approval. Indian Council for Medical
Research (ICMR) and Dept of Biotechnology (GOI) support this trial in principle.
Other areas of progress (beyond the log frame)
Setting up of State Nutrition Mission
 Implementation of state nutrition mission started with 50 Decentralized district plans and funds
allocated.
• State office is staffed with a Mission director, Joint Directors, finance officers, data managers
and nutrition consultants. Five district Facilitators have been placed by DFID TA in 5 districts of
Sagar Division
• District plans include activities for: village Bal Mitra Samuh, Convergence meetings, Trainings,
Health camps, Communications, and additional meals for severely malnourished children.
 Coverage of supplementary nutrition for 6 to 72 months children increased from 38.69 lakh in
2007 to 68 lakhs In 2011 (Source Govt data)
• 76936 frontline workers (AWW), 2958 Supervisors trained on growth monitoring (WHO growth
charts). 2958 supervisors and 38468 AWW are trained on child feeding and counseling in 2010
-11.
Family Planning
 DPHFW is now increasing its commitment for promoting of spacing methods and choices for
younger women Marginal improvements in uptake of spacing methods (IUD and Oral pills) are
being observed. The number of male sterilizations is gradually increasing from about 11, 000 in
2007 to about 42, 000 in 2010. 619 doctors/supervisors & 1541 nurses (ANMs) were trained in
Intrauterine contraceptive device (IUCD) insertion in 2010-11. Implementation of Post-partum IUCD
insertions has started, with training of 19 Master trainers, using Jabalpur medical college hospital
as a pilot site. DFID TA is helping with planning and implementation of FP activities.
 Contraceptive corners are set up in CHCs and District hospitals with support of DFID TA. Asha
workers will now be given incentives for social marketing of OCPs and condoms under National
rural health mission.
Malaria
 DFID TA contracted Regional medical research council (RMRCT) to conduct a clinical trial on
sensitivity, specificity & heat stability of bivalent Rapid diagnostic kit (Bv - RDT). As a result of
preliminary findings National Malaria program has in principle agreed to introduce BV-RDT across
the country.
 Lot Quality Assurance (LQAS) done in 9 World Bank supported districts: Reduction in API noted.
 Malaria bed nets (LLIN) distribution has started, and GoI has provided about 7 lac LLINs for
endemic areas.
ISO certification and implementation of infection prevention guidelines
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DFID TA supported ISO certification for five district hospitals: two District Hospitals (Mandla and
Jhabua) are ISO certified and three district hospitals (Datia, Umaria and Vidisha) are well on-track for
ISO certification. Independent surveillance of both the hospitals (Mandla and Jhabua) which were ISO
certified earlier was done and both continue to be ISO Certified with no major non-conformity.
TA team conducted training on Standard Operating Procedures for Civil Surgeons of all the 50 districts
in 2011. Infection prevention initiatives were undertaken in additional 5 district Hospitals with TA
support. Infection Management Committees are constituted; training organized for all cadres of staff.
The Hospital Committees (RKS) are key facilitators of improved Infection management. Early success
includes: Use of Personnel Protective Equipment (PPE) documented immediately after the training,
observed positive attitude of senior Hospital Managers to implement infection management
Recommendations:
- Improve quality of care at selected Bemonc / Cemonc by supportive supervision, mentoring and post
training follow ups for SBA, Emoc trainees. TA support for QAC functioning (Action: TA team and
NRHM MD)
- Scale up the coverage for Family planning services esp use of spacing methods, IUD and Postpartum family planning counselling. TA support to focus on training, monitoring and BCC. (Action: TA
team and NRHM MD)
- Strengthen VHNDs for ANC, Immunisation, FP, Nutrition counselling, and micro planning and role
clarity among front line workers. (Action: TA team and NRHM MD)
- Atal Bal Mission implementation to be accelerated including recruitment and training of district staff.
All district plans will be monitored quarterly. (Action: TA team and ABM MD)
- Start the implementation of CMAM trials and test local production of RUTF. (Action: TA team and
ABM MD)
Impact Weighting (%): 25
Revised since last Annual Review? No
Risk: Medium
Revised since last Annual Review? No
Output 2: More and better trained staff working in the underserved districts
Output 2 score and performance description:
A. Outputs met expectation
Indicator 1: Vacancies against sanctioned posts in underserved areas:
Milestone for 2011-2012: Medical officers: 30%, Nurses: 35%, ANMs: 30%, AWWS: 35%
Progress: Target achieved despite doubling of sanctioned positions for nurses and doctors. Target
overachieved for ANMs and AWW Supervisors.
The availability of doctors has gone up by about 1,900 doctors (4914 in Sept 2011 from less than 3000
in 2009) and in 2012, 1100 more nurses are available as compared to 2008. The number of sanctioned
posts for doctors has gone up significantly in 4 years from 3790 to 6991. In 12 underserved districts
with 344 hospitals, the number of doctors increased from 465 in 2010 to 613 in 2011
GoMP has more than doubled the sanctioned positions of staff nurses, which has gone up from
approx. 3000 to 7309. The vacancies at the revised sanction levels are at 50% with 3576 nurses in
position. GoMP is planning to recruit large number of nurses to fill up the vacancies.
Under the Nutrition programme (ICDS) the Block officials (CDPOs) vacant position reduced from 39%
to 23%. Out of 453 sanctioned posts, there are now 350 CDPOs in position as compared to 277 in
2010. The ICDS supervisor’s vacancies reduced from 20% to 7%. Out of 3168 sanctioned posts, there
are now 2958 supervisors in position as compared to 2528 in 2010.
Vacancy position:
 Medical officers 30%
 Staff nurses 50%
 ANMs: 0%
 AWWS 7%
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Indicator 2: Training of frontline functionaries (ASHA, AWW, ANMs and supervisors)
Targets: Two MLTCs (Mid-level training centres) upgraded and Two Nutrition resource centres set up.
Achievements of annual training targets up to 80%.
Progress: Target Achieved
Existing 2 MLTCs have been upgraded with TA support: A detailed assessment of two MLTCs was
done and capacity building plan including training for the instructors on communication skills and
training methodology is being implemented in collaboration with Regional Centre of National Institute
for child development (NIPCCD), Indore.
Two State and Divisional Nutrition Resource Centres are functional with TA support: GoMP has
decided to leverage in- house technical expertise from 6 government medical colleges for the nutrition
sector. Each medical college will provide support as divisional Nutrition Resource Centre while Bhopal
Medical College will also act as the State Resource Centre. The State Nutrition Resource Centre at
Gandhi Medical College at Bhopal and Jabalpur Medical College are now functional.
 4460 Nurses, Auxiliary nurse midwives (ANMs) and Nursing supervisors are trained in safe births
(SBA). 6742 Frontline workers have been trained in IMNCI. 1926 ANMs and supervisors have been
trained on new-born care and 4307 ANMs are trained on child feeding ( IYCF). 1541 ANMs trained
in FP and IUD.
 Out of 56,941 ASHAs, more than 80% trained in modules 1 to 5.
 TA team has supported the training of 156 ICDS Supervisors as against the 134 originally planned
and also trained Block officials (CDPOs) from all the 134 projects in 15 high burden districts. . The
training evolved from the community mobilisation pilots that highlighted the need for supportive
supervision and building correct knowledge about core nutrition interventions.
Indicator 3: Human Resources performance appraisal system
Target: HR database for doctors fully functional
Progress: Target achieved. In addition 2013 target for initiating performance management system is
also achieved.
HR Database Management Information System (HRDMIS) has been designed by DFID TA team and is
regularly updated. GoMP has created a four-tier Database Cell at State, Divisional, District and Block
Level with an identified Nodal Officer at each level. By Nov 2011 4700 doctor’s data was captured in
electronic form in HRDMIS software. The updated information has been used in the recent preparation
of gradation list of doctors (for determining the seniority for promotion) as well as deployment of
doctors in underserved districts. However there are persistent problems in rational deployment of
doctors and specialists, and large number of vacancies remain in underserved districts.
A Performance Management Framework has been developed for CEmONC and BEmONC facilities
and is now in use. The Health Department has started an incentive scheme for identified 41 CEmONC
health facilities and linked the financial incentive for the CEmONC Team with the performance
indicators. The Performance Management Framework includes Facility monitoring and individual
monitoring for doctors. The framework is being appraised and fine-tuned as the reports start coming to
the state level.
Recommendations:
 Need for cadre restructuring and development of a HR strategy for better deployment of staff and
service delivery. (Action: TA team and Health Commissioner)
 The doctors database should be effectively used for rational deployment of doctors, particularly in
the underserved districts (Action: TA team and Health Commissioner)
 A comprehensive HR database for all staff (medical & para-medical) to be developed (Action: TA
team and Health Commissioner)
 The HR cell/Establishment section to be strengthened (financial & human resources) for enabling
better HR management (Action: TA team and Principal Secretary Health)
Impact Weighting (%): 20%
Revised since last Annual Review? No
Risk: High
Revised since last Annual Review? No
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Output 3: Financial and procurement systems effectiveness improved
Output 3 score and performance description:
A+. Outputs moderately exceeded expectation
Progress against expected results:
Indicator 1 Financial systems monitored : (1) audits (2) Number of FRA benchmarks
monitored/assessed as substantial or high and action taken for (a) Health and (b) DWCD
Targets: Audit discharge for 2009-2010 and FRA ASP done. Review of concurrent & CAG audit report
recommendations & actions taken
Progress: Targets over achieved. The milestone for 2012 -13, which is state wide implementation of
procurement MIS, is already achieved
 DPHFW has made significant efforts to strengthen internal audit: Ten internal auditors are posted in
the directorate under the Financial Advisor. One accounts officer and two internal auditors have
been posted with each of the Joint Directors (about 12).
 Review of both performance audit and transactions audits was carried out by C&AG in 2007-08 and
2009-10. The performance audit does not point out any serious financial irregularity but points out
weak implementation processes.
Findings of FRA ASP 2012 - Health
 There are 5 areas of low risk, 8 areas of moderate risk, 1 area of substantial risk (audit follow-up)
and 1 area of high risk (risk of corruption).
 Three indicators have improved from substantial risk to moderate risk – inclusion of all government
activities in the budget, extra-budgetary expenditure and procurement.
 Key risk areas identified for mitigation are:
o Financial Management and Internal controls
o Procurement of drugs and management of equipment
o Follow-up on audit findings and compliance
The risk areas will be discussed with the Dept of health in May and risk mitigation actions and TA
support will be agreed.
Findings of FRA ASP 2012 - DWCD
 There are 6 areas of low risk, 8 areas of moderate risk and 1 area of substantial risk (risk of
corruption). Two indicators have improved from substantial risk to moderate risk – government held
to account for mismanagement & audit follow-up.
Key risk areas identified are:
a. Inefficiencies in distribution & procurement of food
b. Monitoring of civil works
c. Follow-up on audit findings and compliance
d. Shortage of human resources and capacity building
The FRA ASP findings and the risk areas have been discussed with the Govt and mitigation measures
for audit compliance, human resources and capacity building have been agreed (points c and d). Since
DFID does not fund the wider ICDS (Integrated child development scheme) the actions for
procurement and civil works were not agreed. However if requested by the GoMP, DFID TA can
provide support to improve procurement and civil works.
Indicator 2: Proportion of facilities facing stock-outs of essential drugs
Milestone: Reduced by 10% from baseline
Progress: Data not yet available. However field observations and data from State drug MIS shows that
the target is likely to be achieved. Data from drug MIS system shows that stock out of essential drugs
at district warehouse levels has reduced from 140 days to 127 days (10% reduction), drug procurement
lead time has reduced from 131 days in 2008 to 83 days in 2011, drug budget utilisation has increased
from 44% in 2008 to 79% in 2011. The number of district warehouses has increased from 27 to 43 to
cover 50 districts.
 The process of decentralised procurement is significantly streamlined with TA support. With the
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finalised rate contracts (as per Tamil Nadu medical services corporation – TNMSC) and roll-out of
the State Drug MIS (SDMIS), the procurement is more convenient, efficient and transparent as was
evident from field visits.
 SDMIS is fully operational with more than 100 nodes. Facilities are better able to forecast needs,
prepare indents, order supplies, manage stocks and monitor stock-outs.
 The expenditure through local purchase has significantly reduced eg. From Rs 1.1 crores last year
to approx Rs. 31 lakhs this year (in Dindori).
 Field visit observations show that pharmacist was well trained on SDMIS functionalities including
indenting, ordering, report generation etc. The store was professionally maintained: Neatly piled
drugs, BIN cards on display with expiry dates, manual indicating receipts, dispatches, stocks
remaining was updated.
While the baseline for the drug stock outs study was done in 2010, the govt has requested that the
study on drug stock out should be deferred for another 6 months, so that the new procurement policy
and the SDMIS system should be well embedded at district levels.
DFID TA has set up Technical support units with Biomedical engineers in two divisions, Indore &
Sagar, for O&M of medical equipment – both are functioning well. Inventory list are being prepared for
both divisions; idle/uninstalled equipment are being restored; repair and maintenance of equipment
being undertaken. Civil surgeon Tikamgarh and BMO Prithvipur appreciated the work of TSU. Gave
example of rapid repair of a baby warmer and portable X ray machine
Indicator 3 (1) Year on Year increase in State’s allocation to health sector at current prices
Target: At least 15% over last FY
Progress – Target overachieved
 Year on Year increase in State’s allocation to health sector increased by 22% from 2175 crores in
2010 -11 to 2710 crores in 2011 -12. State budget allocations since 2008; have shown an average
annual growth rate of 22 percent which is higher than 15% as agreed under MPHSRP. The total
health dept expenditure (state budget plus NRHM) increased from 1467 crores in 2008-09 to 2151
crores in 2010-11.
 Year on Year increase in State’s allocation to Nutrition (DWCD) sector increased by 21% from
2033 crores in 2010 -11 to 2468 crores in 2011 -12. As per the MTEF, there had been substantial
increase in DWCD budget from Rs. 587 crores in 2007 to Rs. 2468 crores in 2011-12 showing an
average annual growth rate of over 43 percent. The massive increase has been due to mainly
three factors i.e. revision of rates of supplementary food, revision of wages of AWWs and
introduction of a girl child scheme (Ladli Laxmi Yojna). The budget allocations in DWCD are more
than MTEF projections and more than the 15% increase per year.
Recommendations:
Health department:
 Set up a review mechanism for response to audit findings and compliance monitoring. Audit para
tracking system developed by Finance Department to be adopted. (Action: TA team and Health
Commissioner)
 Continued focus on training of Drawing disbursing officials (DDOs) on financial management and
internal controls (Action: TA team and Health Commissioner)
 Annual fiduciary risk assessment exercises by DFID will include procurement audit and fund flow
review on DFID supported expenditure lines. (Action: DFID Governance adviser)
 Further capacity building of pharmacists and data entry operators on SDMIS. (Action: TA team and
Health Commissioner)
 Recruitment of pharmacists and data entry operators in vacant positions (Action: TA team and
Health Commissioner)
 Drug stock-out study to assess impact of new drug policy and SDMIS roll-out (Action: TA team)
 Scale up of TSUs across all zones to enable better O&M of medical equipment, inventory
management and upkeep (Action: TA team and Health Commissioner)
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Women and Child department:
 Each district society under ABM will get audit done every year through a CAG empanelled auditor.
In addition, a central audit (on a sample basis) by a CAG empanelled auditor will be commissioned
on an annual basis. (Action: TA team and ABM MD)
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
TALLY system of accounting will be rolled out for financial accounting across all districts. (Action:
TA team and Health Commissioner)
Impact Weighting (%): 20%
Revised since last Annual Review? No
Risk: Medium
Revised since last Annual Review? No
OUTPUT 4: Increased demand for nutrition, health and sanitation services in
underserved districts
Output 4 score and performance description:
A+ Outputs moderately exceeded expectation
Progress against expected results:
Indicator 1 :Number of pilots for community based initiatives to promote nutrition of 0-2 year olds,
sanitation and nutrition of adolescents
Targets: 2 pilots commissioned
Progress: Target overachieved – Two pilots for community based initiatives were implemented,
evaluated, findings disseminated and the learning’s incorporated in the state strategy for community
mobilisation.
 The first pilot (MPRLP/Ekjut) pilot used participatory learning cycles to talk about nutrition and
health issues with the community, facilitated by male livelihood promoter. In the second pilot,
Community Nutrition Educators worked with AWWs and Supervisors to strengthen group
meetings, home visits and better targeting of at-risk families. Process documentation of both
showed increased attendance at AWC, increase in knowledge and better representation of
poorer households.
 An immediate outcome was the design and conduct of training for 156 supervisors and 20 block
officials (CDPOs) from 15 high burden districts on core nutrition issues, equity and working with
communities.
 State level strategy for community mobilisation developed: Drawing from the experiences of the
two DFID supported pilots, discussions with the experts and in-house consultations, WCD
approved a comprehensive community mobilization strategy. Approaches from the strategy
have already been incorporated in the District Action Plans under ABM. Key components of the
strategy include:
o Scaling up Community volunteers strategy
o Working with Self Help Groups through the platform of National rural livelihood mission
(NRLM)
o Capacity building of of ICDS Supervisors, CDPOs and Anganwadi Workers
o Strengthening Swasth Gram Tadarth Samitis (VHSCs).
Indicator 2 : BCC campaign on Health Nutrition and hygiene/sanitation
Target: BCC Campaign initiated
Progress: achieved
An expert TA consortium for BCC is contracted and BCC activities are initiated. Situation analysis is
complete, baseline survey is being designed and district implementation plan is will be launched by
October 2012.
State BCC budget utilization has doubled since 2008-09. In absolute term, it has gone up from INR 50
million/year to 98 Million/year during 2008 to 2011. State IEC cell has developed good messages on
immunization, Child and Maternal Health, Save the Girl Child, and Family Planning. In order to improve
coordination for behaviour change activities, a task force has been constituted involving Development
partners like UNICEF, UNFPA and DFID TAST. An IEC cell is functional in DoPH&FW.
Other areas of progress (beyond the log frame):
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


Rogi Kalyan Samitis (RKS) strengthened in five District Hospitals as reflected through
implementation of Charter guidelines and Infection control practices.
The RKS is a local decentralized management mechanism, set up for all hospitals in Madhya
Pradesh. RKS charter was revised and disseminated through divisional level workshops.
Focused guidelines and increased public participation in the RKS have empowered facility
managers given them more autonomy for approving minor day to day expenditures.
Registration systems have improved, with the introduction of computers and have led to greater
transparency with regard to user fees. Early success of the initiative facilitated the
implementation of infection management guidelines on a pilot basis in 5 district hospitals.
Adolescent girls (Sabla) scheme was rolled out in 15 districts: Master Trainers from NGOs were
trained by DFID TA, Kishori Groups (Adolescent Groups) formed and ICDS Workers trained.
Conditional cash transfer scheme for improving maternal and child nutrition (IGMSY): GoMP
rolled out IGMSY pilots in 2 districts. DFID TA team supported adaptation of guidelines,
preparation of training materials and two rounds of training of govt functionaries.
Recommendations:



Operationalize the community mobilization strategy and support state level convergence with
NRLM and direct implementation in two districts. (Action: TA team and ABM MD)
Collate different community mobilisation interventions under the ABM plans in all the fifty
districts and monitor implementation in 10 selected districts. (Action: TA team)
Implement Behaviour Change Communication campaign in coordination with DWCD and
DPHFW. (Action: BBC WST team)
Impact Weighting (%): 20%
Revised since last Annual Review? No
Risk: Medium
Revised since last Annual Review? No
OUTPUT 5: MP has a state monitoring &evaluation system that enables quality
planning
Output 5 score and performance description:
A+. Outputs moderately exceeded expectation
Progress against expected results:
Indicator 1: No. districts providing timely reports on key indicators.
Target: 35 districts
Progress: Target Overachieved.
Timely and complete reporting in Health is provided by all 50 districts (92% of reporting units). Timely
and complete reporting of DWCD is provided by 92% of the 79000 AWCs across 50 districts.
 DFID TA helped to set up a Monitoring unit within National Rural Health Mission (NRHM) office.
This unit operationalized the statewide web enabled MIS system.
 NRHM monthly health bulletin are now released. Facility wise data management using web portal
is now up-scaled to 20 districts
 Districts are now being ranked on the basis of performance against critical indicators, eg.
Caesarean cases, Institutional delivery, New born corners, Measles coverage, Family planning and
Financial Achievement. The data is shared with the District collectors on monthly basis to review
district performance
 Mother & Child Tracking System (MCTS) is in place (11,55,713 mothers & 15,90,544 children
updated), Call center is set up with DFID TA support to track district wise progress.
Indicator 2: Variation between administrative data and surveys assessed.
Progress: Target achieved
The DWCD has decided to establish a system of regular independent feedback on data from internal
management information systems through verification of data on sample basis in order to improve
quality of routine data generated by the Department. DFID TA conducted the data verification study
10
and shared with DWCD. Actions are being planned to improve quality of data and staff capacity to
analyse and validate MIS data.
There is a consistent Improvement in availability and use of reliable data for decision making in Health
and Nutrition sector. Surveys like National Institute of Nutrition (NIN), Annual Health surveys (AHS),
Sample Registration survey (SRS) and Unicef Coverage Evaluation (CES) continue to give population
based outcome data at regular intervals and DFID TA helps with analysis and use of the survey data
for program planning. In addition the internal monitoring systems are being strengthened, using web
based District health information systems (DHIS) under NRHM.
Indicator: Fully functional IT enabled MIS for Health and DWCD
Progress: Fully achieved
IT enabled MIS for ICDS is now scaled up all over the state, with a dedicated URL created for MIS:
mpwcdmis.org. Every month about 97% of Anganwadi Centres (AWCs) are reporting timely data. 3409
ICDS functionaries were trained during the process. Feedback system has started with video
conferencing, letter from DD-MIS/Director to Collectors, and monthly meeting. Registers have been
designed keeping in view the revised on-line MPR format and the needs of the GOI. Number of
registers was reduced from 9 to 7.
Indicator 3: Evaluations and independent assessments undertaken with findings influencing strategies
Target: 4 studies
Progress: Target achieved
4 studies were undertaken with TA support and were used to influence strategies and programmatic
correction: Immunisation study, Study on State Illness assistance funds (SIAF), Cemonc/Bemonc
assessment and VHND assessments. The findings from Cemonc/Bemonc assessment and VHND
assessments are provided in output 1 descriptions. Both the studies have been extensively used to
inform programmatic actions.
The 2 studies on immunisation and SIAF are described below:
1 Immunisation:
A study was commissioned by DFID TA for the 10 undeserved districts to assess the quality, coverage
and operational challenges under immunisation program. Study revealed gaps in micro planning,
session monitoring, quality of services and supplies. As per recommendations of the study, capacity
building of the district officials was done on issues related to immunisation and maternal and child
health services. Appropriate Session monitoring formats were designed and regular session monitoring
was carried out. Till date about 650 session sites have been monitored across 10 districts. This has
resulted in improving the immunization coverage from 37% to 52% (aggregate of 10 underserved
districts). Similarly, sessions planned vs. sessions actually held have improved from 82% to 95%.
District Coordination Committees are set up and regular meetings are held to oversee progress. The
State Health Directorate issued a formal letter to all districts to take action based on the session
monitoring and to provide feedback to the state Directorate on the actions.
2 Review of the State Illness Assistance Fund(SIAF)
A rapid review of State Illness Assistance Fund scheme was conducted by DFID TA to examine the
extent to which the SIAF is contributing to achieving overall health outcomes and in particular, its
accessibility to the targeted BPL population. The study also assessed how the scope of the SIAF could
be expanded (in terms of its population coverage, budgetary provision and types of diseases covered).
The findings have been disseminated and a roadmap for its strengthening has been accepted by the
Department.
 As recommended, the Scheme is being integrated with upcoming National Insurance scheme
(RSBY).
 A State Level Steering Committee, with relevant sub-committees, has been constituted to
restructure and strengthen the SIAF, especially on issues pertaining to financial governance,
treatment procedures and rates.
 Based on review recommendations, procedures and rates for procedures have been rationalized.
Cost of valve surgery, Angioplasty and coronary heart surgery reduced by about 20% to 50%
 SIAF allocation has increased from 30 crores in 2010-11 to 65 crores in 2011-12
 About 3000 cases have benefitted during 2011 -12 under SIAF
11
Recommendations:

Strengthen existing NRHM MIS, facility and individual performance monitoring, MCTS and data
analysis (Action: TA team and NRHM MD)
 ABM related additional activities to be converted into progress indicators and uploaded on ICDS
MPR format (Action: TA team and ABM MD)
 Training of CDPOs and Supervisors on use and analysis of Monthly MIS data. (Action: TA team,
ABM MD)
 Concurrent monitoring of outcomes and processes to be started: every quarter 8-10 districts to be
monitored with quantitative and qualitative surveys. (Action: TA team and ABM MD)
 NIN survey to be repeated in 2013 to track progress on nutrition outcomes and coverage(Action:
TA team and ABM MD)
Impact Weighting (%): 15%
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? Y/N
No Log frame changes were made for Goal and Purpose indicators during 2011-12. Minor changes
were made in output indicators, related to CMAM and BCC campaign.
1.2 Overall Output Score and Description:
A+. Outputs moderately exceeded expectation. Out of five outputs, three are scoring A+ and two are
scoring A.
1.3 Direct feedback from beneficiaries
Feedback from a wide range of beneficiaries captures the positive change and highlight small steps
with huge impacts. Captured below are a few examples:
After the Infection Prevention Training, housekeeping staff1, technicians and nurses in district
hospitals, followed good practices such as: wearing gloves, correct washing of hands and washing
hands before serving food. Nurses said that they now carried their aprons and uniform in a separate
bag and wash them after soaking in disinfectants. . “We do not want our children to get any infection
which we may carry home with our uniforms”
ISO Certification at Mandla and Jhabua District Hospitals: Both health staff as well as the patients
found that the ISO certification had led to improved infrastructure, cleanliness and quality of services as
well as stringent adherence to the various SOPs.
SushilaBai Maakam admitted in the post-partum ward for the delivery of her second child was
pleasantly surprised “I am very happy with the services rendered in the hospital. There is a lot of
improvement in the cleanliness, services and attitude of the doctors and nursing staff here. Moreover it
is easier to reach a particular place in the hospital as there are clear directions for that place”. The
same sentiment was echoed by Indumati mother of 5year old Arushi admitted in the paediatric ward. “I
had come to the hospital for my delivery 5 years back. Then, the wards were dirty, and staff in the
hospital was careless. Now the wards are clean and the staff is well behaved, There is round the clock
security in the ward. We are getting our medicines on time now. The food in the hospital is better now.”
1
Babu Lal, Housekeeping staff, Mandsaur DH; Savitri Devi, Ward Ayah; Lab Technicians and Housekeeping staff
at Mandsaur District hospital; Nurses in Ujjain District Hospital
12
For Guddi, mother of 10 year Manno the district hospital scored better than the private hospital. “I am
very happy that I have come to the district hospital this time instead of going to the private hospital
where I used to go before for the treatment of my child. The doctors and nurses are well behaved and
are very helpful. The ward is clean and all the staff is responding to my requests promptly. The food
being given to patients is clean and good in taste. I regret not coming to this hospital earlier and I could
have saved a lot of money if I had done so.”
Community response: Women welcomed timely availability of services within their villages. Sangeeta
(Age 23 years, first pregnancy, 4th month of pregnancy going on) – “Around three month back I came
to the VHND and the ANM confirmed my pregnancy. Since then ASHA regularly inform me about the
visit of ANM a previous day of VHND and I reach there for check-up. I am happy to receive services in
my own village .Here I can come alone and save lot of travelling time.”
Participatory learning sessions with the communities showed a remarkable change in feeding
practices. Mothers reported that they now gave only breast milk and had stopped giving water. “We
have a tradition in the villages to give the first meal to a girl child at four months and for a boy child at
five months. My son is five months old now and my family members and other villagers are asking me
to conduct the first meal ritual but I made all of them understand the importance of breastfeeding till six
months and delayed this ritual. I will do this ritual next month when he is six months old. (Mother,
village Tarera, Dindori).
The sessions were also found useful by the frontline workers “After I played the power walk game in
the training, I realized that my efforts should be more on those who are usually left out from all
initiatives. I found that those who do not go to the NRC despite my repeated efforts are from
households of poorest, illiterates, from distant hamlets, etc. They also do not stay for 14 days at the
Nutrition Rehabilitation centre (NRC). My efforts after the training and meetings in village are now more
focused on these groups of people. “(AWW, Chudeli, Jhabua).
13
1.4 Summary of overall progress
Recent data from SRS, NIN survey and UNICEF CES shows that there is a steady and significant drop
in maternal mortality, Infant mortality, child under nutrition and substantial improvement in coverage of
institutional deliveries, immunisation, antenatal care and infant feeding practices.







The number of hospitals providing comprehensive and basic emergency obstetric and
neonatal care has increased from 337 in 2006 to 560 in 2011. Since the last 3 years 30 sick new
born units have been established and 250 nutrition rehabilitation centres have been set up.
DFID TA has helped in major improvements in Human Resource management, including massive
recruitment of doctors, development of HR database, initiation of performance management of
MCH facilities, and training. Availability of doctors has gone up by about 1,900 doctors and about
1100 more nurses have been recruited.
Quality assurance committees have been set up and functioning at state, divisional and district
levels. TA team has facilitated functioning of quality assurance committees in 14 districts and
deployed experts in 10 poorest districts to support supervise quality and provide mentoring for
maternal and child health services. Division level team of Mentors also set up for supportive
supervision.
State Nutrition Mission is now functional: District action plans are under implementation to
improve reach of nutrition services for under 2 children. Skill building training of ICDS supervisors
has been done, so that they become mentors for frontline ICDS workers. Evidence from 2
community mobilisation pilots is being used to scale up support to community groups for promoting
nutrition behaviours. Nutrition surveillance survey conducted by National Institute for Nutrition was
extensively used for district planning. This was an excellent example of rigorous use of evidence in
planning. A Web enabled MIS for ICDS scaled up across all 50 districts is a significant over
achievement against agreed milestones.
Mainstreaming Family planning (FP) and malaria: DFID operational plan priorities on family
planning and Malaria have been fully integrated under the MPHSRP. Milestones on both are
agreed and are under implementation. The proposal submitted to DEA for project extension clearly
highlights commitments to strengthen FP and Malaria interventions during the MPHSRP extension
phase.
The FRA ASP shows the reduction of risk from substantial to moderate. Health FRA ASP shows
that three indicators have improved from substantial risk to moderate risk – inclusion of all
government activities in the budget, extra-budgetary expenditure and procurement.
The process of decentralised procurement is significantly streamlined. With the finalised TNMSC
rate contracts and roll-out of the State Drug MIS (SDMIS), the procurement is more convenient,
efficient and transparent as was evident from field visits.
1.5 Key challenges

A critical challenge for MP Health sector is to improve the quality of services and strengthen quality
assurance systems. Rapid improvements in coverage of key services like institutional deliveries will
not translate in mortality reductions if the quality of services is poor.

Continuing constraints in rational deployment of doctors and specialists to the underserved districts
undermines efforts to improve functionality of hospitals obstetric and neonatal care.

Limited institutional focus for Human Resource management, in the form of HR Management Cell
in DOPHFW, limits sustained improvements in recruitment, performance, promotion and
deployment.

Financial management capacity for budget planning, accounting, auditing and follow ups for audit
reports is a key challenge for effective utilisation of funds.

More efforts are needed for better supply chain management for essential drugs.
14

Sustained effort to overcome equity constraints for marginalised communities with respect to
access and utilisation of services is a key challenge

There is a new DFID TA team in place under MPHSRP. Smooth induction, relationship
management and responding effectively to TA demands from the government will be an on-going
challenge.
1.6 Annual Outcome Assessment
MPHSRP is well on track to achieving all the goal and purpose indicators. The 2013 target for two
indicators (Infant mortality rates and Institutional deliveries) is already achieved. Recent data also
shows that the project is within striking distance of achieving the 2013 targets for under nutrition,
maternal mortality, immunisation and early breast feeding.
• MP has recorded a 10 point decline in Infant mortality rates (IMR) between 2007 and 2010, from 72
per 1,000 births in 2007 to 62 in 2010 (against a target of 62 for 2013). This is good progress
considering that IMR was declining by only 2 points per year prior to 2007.
• The percentage of under-weight children have declined to 52% in 2010 from 60% in 2006 (NFHS),
as against a target of 50% for 2013. ( National Institute of Nutrition survey)
• Maternal mortality ratio (MMR) in MP has reduced from 335 (2004-06) to 269 (2007-09) per
100,000 births as per SRS –RGI data. However Annual Health survey 2010 data shows MMR as
310 per 100,000 live births, as against a target of 275 for 2013.
• Institutional births increased from 47% (2007) to 81% (Unicef CES 2009) as against a target of
80% for 2013.
• Full Immunisation increased from 36% (2007) to 43% (Unicef CES 2009) against the target of 44%
for 2012
• Proportion of children breast fed within hour of birth increased from 13% in 2006 (NFHS 3) to 26%
in 2010 (NIN) against a target of 32% for 2013. Only 16% were given prelacteals in 2010 as
compared to 58% in 2006, which is a harmful practice.
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 2012,
£65m FA and £6,417,124 TA has been spent and the overall forecast is likely to be met.
2.2 Key cost drivers
Key cost drivers of the project come from two separate mechanisms: Financial Aid (FA) and Technical
Aid (TA). The FA is extended to GoMP and is a part of the overall state sector budget. Cost drivers
under FA are salaries of health personnel, purchase of medicines and equipment, trainings,
infrastructure up gradation, monitoring, supervision, mobility costs etc.
TA funds are used to support implementation of the health and nutrition strategy, analytic studies,
evaluations, Quality improvements, Monitoring, capacity building, cross-learning visits, and piloting
innovations. Cost drivers under TA are the remuneration and travel/logistics costs of expert
professionals and institutions, who help develop capacity of health and nutrition staff, strengthen
human resource, financial management and MIS systems.
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
15
There are 3 areas where we see emerging evidence and a strong need for shift in project strategy:
1. Rapid increase in coverage of institutional deliveries with slow reduction in maternal
mortality: The institutional deliveries in MP increased rapidly from 30% in 2006 to 77% in 2010
because of a major cash incentive scheme. However the simultaneous reductions in maternal mortality
were lower than expected. This means that there is need for quality improvements e.g. compliance to
clinical protocols, training, supervision, infection preventions and drug supplies. MPHSRP is now
shifting focus towards quality improvements.
2. Evidence shows that Severe acute malnutrition (SAM) in children can be feasibly treated at the
community levels, and the programme needs to expand its focus from hospital based treatment to
community based treatments: Madhya Pradesh has 1.1 Million SAM children who have a much higher
chance of death and the health department is currently following a facility based model (NRCs) for
managing all SAM children. With 270 functional NRCs (Nutritional rehabilitation centres) the hospitals
are able to respond to only 50,000 SAM children per year when there is a huge need to reach more
than a million children.
Global evidence shows that uncomplicated SAM children can feasibly be treated at community level
using energy dense “Ready to eat therapeutic food”. The international adoption of community-based
management for SAM (CMAM) is based on evidence which shows that average recovery rates of 79%,
and case fatality rates of 4% were dramatically better than inpatient treatment approaches. The
resulting uptake of the community-based approach is now reaching 35 countries and approximately 1
million children.
DFID TA is now mobilising support for Govt of MP to trial and scale up CMAM, and help in dramatic
improvements in infant mortality and under nutrition. The trials are in the final stage of design and
approvals.
3. Evidence shows that both Malaria falciparaum and Vivax strains are prevalent in MP and
there is a need to use bivalent RDT instead of monovalant RDT
Evidence shows that there has been a shift from P. falciparum to P. vivax malaria in some highly
malaria endemic areas of Madhya Pradesh. The Rapid diagnostic kits (RDTs) currently used under the
National malaria control programme are targeting P. falciparum only. WHO studies show that bivalent
RDTs are appropriate for use in areas with significant prevalence of both P. falciparum and P. vivax.
The National programme is considering the introduction of bivalent RDTs in the programme, for which
it requires evidence on the sensitivity, specificity and heat stability of available bivalent RDTs. DFID TA
conducted a study to evaluate the sensitivity, specificity and stability of malaria Bivalent rapid
diagnostic kits: Based on the research findings, national malaria control programme has agreed to
scale up the use of bivalent RDTs
3.2 Where an evaluation is planned what progress has been made?
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. The ethical approvals are being obtained from
research agencies and approvals from Govt of India are applied for. It is estimated that the trials will
commence in 2012 -13, and early results will be available by 2014.
An independent evaluation of MPHSRP will be also be undertaken during 2014 -15.
16
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
Key risks include: fiduciary, weak planning and implementation capacity, non-availability of critical
medical staff particularly for remote areas, staff resistance to change and potential change to GoI
policies.
Fiduciary risks are now reduced from substantial to moderate, technical assistance is helping to
improve implementation capacity and large scale recruitment and deployment of staff is being done.
The state funding for both Health and DWCD has almost doubled in the past 2-3 years. This shows a
high degree of political and bureaucratic commitment to health and nutrition. GoI contributes about
30% of the resources and continues to show strong commitment to health and nutrition, with the 12th
plan goal of investing up to 2.5% of GDP for health (up from 1.3%). We will continue to monitor the
risks.
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 will be 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. DFID has carried
out a fiduciary risk assessment (FRA) as part of the current support to the DWCD and DPHFW.
Steps will be agreed by DFID and GoMP in line with the recommendations of the FRA report to
improve the financial management systems of the DWCD, DPHFW and the societies. 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. Further waste disposal in primary health facilities is done in pits and in
district hospitals it is outsourced for incinerations. 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 and is also
facilitating ISO certification in 5 district hospitals to monitor compliance to IMEP standards.
5. Value for Money

Performance on Value for Money (VfM) measures
17
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.
The available evidence clearly shows that MPHSRP continues to demonstrate value for money on
effectiveness parameters like rates of reductions in infant mortality, and Under nutrition and rates of
increase in institutional deliveries and immunisation coverage.
Effectiveness measures under MPHSRP are:
 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. MPHSRP has supported
improved hospital management, HR availability, and drug supply and supervision systems for
better maternal health.
 The annual increase in full immunisation during 2008 to 2010 is 3.5% points as compared to
1% point reduction per year during 2005 to 2008. MPHSRP helped in strengthening micro
planning, cold chain and Village health and nutrition days, which contributed to improved
immunisation rates.
 The annual reduction in underweight children during 2006 to 2010 is 2% points per year as
compared to increase in 1% point per year during 1999 to 2005. MPHSRP helped in designing
the state nutrition mission, support to improving ICDS services, training, supervision and MIS
systems.
Given below is an illustrated example of a cost effectiveness measure:
There are sharper reductions in infant mortality during 2008 to 2010 as compared to 2004 to 2007.
Number of additional infant lives saved over 2008 to 2010 = 140002
Of these DFID attributable3 infant lives saved are (12%) = 1680
No. of Daly’s gained attributable to DFID (1680x 65) = 109200
Cost per DALYs gained over 2008 to 2010 = INR 140 crores divided by 109200 = INR 12800 or £166
As per WHO benchmarks for cost effectiveness if cost per DALY gained is less than 3 times the per
capita national GDP it is rated as cost effective. The per capita national GDP in India is INR 76000 or
£987. This shows that MPHSRP attributed gains in DALYs is highly cost effective.
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 to health sector have increased 22% on an average annually between 2008 and
2012.
 Budget utilisation for GOI schemes (RCH & NRHM) has improved from 69% in 2007 to 89% in
2010-11, despite 57% increase in budget allocation. This shows a stronger absorptive capacity and
management systems at state and district levels to implement health interventions.
 10% reduction in vacancies for doctors and 18% reduction in vacancies for staff nurses between
2008-09 and 2011-12. More than 1900 additional doctors and 1100 additional nurses recruited to
provide services.
 Performance monitoring system initiated for optimal utilisation of available human and financial
resources.
2
Using the SRS data, the table below shows that 14000 additional infant lives were saved over 2008 to 2010.
2008
2009
2010
Total
133000
123000
117000
373000
Actual No. of infant deaths - Intervention scenario
133000
129000
125000
387000
Counterfactual scenario -No. of infant deaths
3
DFID attribution to additional results is calculated as % of DFID funds against additional govt funds. DFID funds disbursed during 2008 to
2010 = 140 crores, Total additional govt funds during 2008 to 2010 = 1200 crores (from NRHM and state funds)
18


Procurement fund utilisation has increased substantially from 44% in 2008-09 to 80% during 201011 signifying spends on essential drugs and medicines.
Procurement lead time has reduced by a third – from 131 days in 2008-09 to 84 days in 2011-12
Examples of Economy measures:
 Through rate contract, 56% drugs were procured at a lower cost in 2011-12 than the year before.
 Proportion of local purchase of drugs has reduced from 77% in 2010-11 to 49% in 2011-12. This
will have cost savings implications and local purchase medicines are at significantly higher rates.
5.2 Commercial Improvement and Value for Money
Value for money is being ensured under both Direct and Indirect procurement.
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.
Over the 3 year period the MPHSRP technical assistance budget represented an average daily fee rate
of £262 (& £249 in final 3 months). More than 90% of TA was delivered by Indian nationals ensuring
greater sustainability of knowledge transfer. In addition efficiencies were achieved by ensuring cost
sharing for short term consultants working across all the 3 states (MP, Orissa, Bihar), in addition to
excellent knowledge and experience transfer.
Indirect Procurement through subcontracts:
Good procurement procedures complying with DFID guidelines were followed for effective
management of sub contracts
 The Terms of Reference for the subcontract activity approved by both GOMP and by DFID.
 Contracting of TA inputs subject to DFID approved procurement procedures
 Regular reviews of TA work by government and DFID linked to Monthly Reports
 Six monthly procurement review and sample check of subcontracting by DFID Procurement
group.
VfM was maximized through procurement of subcontracts on the open market, the majority through an
open tendering process. Further cost savings were due to negotiation (e.g. the contract awarded for
VHND work was initially valued at over Rs.48 lakhs but, services finally procured at Rs.22.9 lakhs).
Introduction of limited competition: Even in small value contract, where competitive bidding is not
mandatory, major cost savings were made through negotiation. All fee rates are regularly
benchmarked, comparing them to other DFID fee rates, both nationally and internationally. With this
knowledge, we were confident that fee rates represented the correct price for the experience and
compared favourably with other similar projects.
A number of local agencies were identified and awarded contracts for various recurring activities such
as workshops, study tours etc, so as to avoid the dependence on a single firm and to increase
competitiveness. Govt partner facilities were used for trainings and large meetings, resulting in
considerable cost savings.
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
19
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 design and
implementation approach 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 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 two
indicators (Infant mortality rates and Institutional deliveries) is already achieved. The number of
hospitals providing emergency obstetric care has increased from 337 in 2006 to 560 in 2011. Since
the last 3 years 30 sick new born units have been established and 250 nutrition rehabilitation centres
have been set up. There are major improvements in HR management, including massive recruitment
of doctors, development of HR database, initiation of performance management of MCH facilities, and
training. Quality assurance committees have been set up and started functioning, with much greater
focus on training quality, supervision and mentoring support.
Our Op plan priorities on family
planning and Malaria have been fully integrated under the MPHSRP. Milestones on both are agreed
and are under implementation. State Nutrition Mission is now functional: District action plans are
under implementation to improve reach of nutrition services for under 2 children. A Web enabled MIS
for ICDS is now scaled up across all 50 districts, which is a significant over achievement against
agreed milestones.
The FRA ASP shows the reduction of risk from substantial to moderate. Health FRA ASP shows that
three indicators have improved from substantial risk to moderate risk – inclusion of all government
activities in the budget, extra-budgetary expenditure and procurement.
Actions:
Improve quality of care for maternal and child health services - Improve skills of health care providers,
mentoring support, better hospital management, and drug availability. (action: NRHM MD and TA
team)
Scale up implementation of Nutrition mission - greater reach to under 2 children with proven nutrition
interventions, training of frontline staff, and behaviour change communication. ((action: ABM MD))
Support GoMP to start implementing pilots on Community management of SAM. Improve quality of
VHNDs for ANC, Immunisation, FP, and Nutrition counselling. (action: ABM MD, NRHM MD and TA
team)
Strengthen family planning services, expand choices with a particular focus on spacing methods promote IUD use and stronger postpartum family planning counseling. (action: Commissioner Health
and TA team)
Ensure the updation of HR data base and facilitate rational deployment of doctors and nurses at
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remote rural hospitals. Pilot performance management systems to improve quality and accountability.
(action: Commissioner Health and TA team)
Initiate internal audit for all health sector spend and set up a functional internal audit monitoring unit.
(action: PS, Financial Adviser and TA team)
Distribution and use of malaria bed nets in vulnerable districts. (action: Commissioner Health)
8. Review Process
The Joint Annual review was undertaken during January and February 2012 (18th to 20th January and
2nd February). The review included field visits and state level presentations and discussions. The field
visits were conducted in District Tikamgarh and District Dindori.
The review participants included DFID team4, DHFW and DWCD officials of Govt of MP, and
representatives from National govt (MWCD, MoHFW, NIPPCCD and National Health systems resource
centre). Technical agencies like Marie Stopes international, IPAS and BBC WST also participated in
the review.
This Annual review report is informed by independent sources of survey data like DLHS, UNICEF
coverage evaluation, NIN survey, SRS as well as Govt MIS. Field visit observations from Tikamgarh
and Dindori as well as Joint review mission5 (JRM) observations from District Jhabua and Mandsaur
have also informed the review. Detailed progress documentation on MPHSRP outputs, presentation by
GoMP, and findings of the Government of India (GoI) - RCH II joint review mission and FRA -ASP were
reviewed to support the conclusions.
4
Health Adviser, Governance adviser, Senior Health Adviser, Social development adviser, Procurement officer , Program managers and state
representative.
5
Joint review mission of Reproductive and Child Health II Programme of Govt of India
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