NRHM_Flagship Report_GUNA_MP

FLAGSHIP REPORT - NRHM
Submitted to:
Tata Institute of Social Sciences
July 2008
This Flagship study of NRHM in Guna
District of Madhya Pradesh was a part of
Training by TISS and supported by
UNICEF
Abhishek Singh
Dr. Anoop Tripathi
Arun Kumar

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ACKKNOWLEDGEMENT
We are grateful to TISS and UNICEF for providing us the opportunity to spend five weeks to
understand the administration of the district, block, panchayat and village in the state of MP.
These five weeks also provided the opportunity to develop a detailed understanding of NRHM
as a flagship programme and one Village in Guna District of Madhya Pradesh.
Our Sincere thanks goes to UNICEF Bhopal team. We cannot forget to mention Ms. Anita
Dadlani, District Support Officer, UNICEF, Bhopal for her support and special care during
this entire internship period.
Our heartfelt thanks to District Collector, Guna and all the other officials at the State, Guna
District and Chachaura Block; without whose support this study would not have been
possible. Our thanks to all the other stakeholders including Civil Society Organisations who
provided us an in depth understanding of the various development programmes and took us
closer to the community.
Last but not the least; we extend our thanks to the people especially women and children of
Village Umarthana. It was because of them we could stay close to them and fulfil the
purpose of village study.
At the end, our thanks to all the other people whose names may not have found a mention
here. We sincerely thank all of them for helping us in completing this study on time.
Abhishek Singh
Anoop Tripathi
Arun Kumar

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Abbreviations
NRHM National Rural Health Mission
IMR Infant Mortality Rate
MMR Maternal Mortality Rate
TFR Total Fertility Rate
RKS/HMS Rogi Kalyan Samiti/Hospital Management Society
VHSC Village Health and Sanitation Committee
SC/ST/OBC Scheduled Caste/Scheduled Tribe/Other Backward Caste
NFHS National Family Health Survey
GOI Government of India
PIP Programme Implementation Plan
DHAP District Health Action Plan
MOU Memorandum of Understanding
ANM Auxilary Nurse Midwife
ASHA Accredited Social Health Activist
BEMONC Block Emergency Medical Obstetric and New Born Care
CEOMNC Community Emergency Medical Obstetric and New Born Care
JSY Janani Suraksha Yojna
SNCU Sick New Born Care Unit
NRC Nutrition Rehabilitation Centre
CHC Community Health Centre
PHC Primary Health Centre
SHC Sub Health Centre
AWC/AWW Anganwari Centre/Anganwari Worker
ICDS Integtrated Child Development Scheme
TSC Total Sanitation Campaign
PRI Panchayati Raj Institutions
AYUSH Ayurvedic, Unani, Sidhha and Homeopathy
DH District Health
BMO Block Medical Officer
CMHO Chief Medical Health Officer
CS Civil Surgeon
DPMU District Programme Management Unit
RCH Reproductive and Child Health
HMIS Health Management Information System
BMI Body Mass Index
IMNCI Integrated Management of Neonatal and Childhood Illness
ANC/PNC Ante Natal Care/Post Natal Care
DLHS/NSSO District Level Household Survey/National Sample Survey Organisation
FSW Field Social Worker
IPHS Indian Public Health Standard
LHV Lady Health Volinteer
SBA Skilled Birth Attendant
BPL Bellow Poverty Line
MNGO Mother NGO
BCC Behaviour Change Communication

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Table of Contents
INTRODUCTION...............................................................................................................................................................................................................................................5
METHODOLOGY ..............................................................................................................................................................................................................................................5
BACKGROUND OF NRHM ...............................................................................................................................................................................................................................5
SITUATION IN MP............................................................................................................................................................................................................................................5
Current Status of Health Outcomes and Health Systems in Madhya Pradesh ....................................................................................................................................6
Status of Health Outcomes......................................................................................................................................................................................................................6
Status of Social determinants of health..................................................................................................................................................................................................7
Health Problems in Tribal regions ...........................................................................................................................................................................................................7
PROFILE OF GUNA DISTRICT...........................................................................................................................................................................................................................8
Health Situation in Guna..........................................................................................................................................................................................................................9
Health infrastructure in the District......................................................................................................................................................................................................10
District Hospital at Guna........................................................................................................................................................................................................................11
HEALTH INFRASTRUCTURE AT THE BLOCK LEVEL.......................................................................................................................................................................................11
Status of Community Health Centres ...................................................................................................................................................................................................11
Status of Primary Health Centres (PHCs)..............................................................................................................................................................................................13
Status of Sub Health Centres (SHCs).....................................................................................................................................................................................................13
ROGI KALYAN SAMITI....................................................................................................................................................................................................................................15
Composition of Rogi Kalyan Samiti (PHC).............................................................................................................................................................................................15
Role of Rogi Kalyan Samiti .....................................................................................................................................................................................................................16
VILLAGE HEALTH SANITATION COMMITTEE (VHSC)...................................................................................................................................................................................17
Composition of the Village Health Committee ....................................................................................................................................................................................17
Role of Village Health Committee.........................................................................................................................................................................................................18
ASHA- ACCREDITED SOCIAL HEALTH ACTIVIST ...........................................................................................................................................................................................18
Honorarium.............................................................................................................................................................................................................................................19
Selection of ASHA...................................................................................................................................................................................................................................19
Training of ASHA.....................................................................................................................................................................................................................................20
Drug Kit....................................................................................................................................................................................................................................................20
Coordination with Other Departments.................................................................................................................................................................................................20
JANANI SURAKSHA YOJANA .........................................................................................................................................................................................................................21
Entitlements under JSY ..........................................................................................................................................................................................................................21
National Maternity Benefit Scheme (NMBS) Vs Janani Suraksha Yojana...........................................................................................................................................21
Delivery benefits of JSY..........................................................................................................................................................................................................................22
Problems with Institutional Birth under JSY.........................................................................................................................................................................................22
Difficult to reach public health facility..................................................................................................................................................................................................22
Low Quality of Care................................................................................................................................................................................................................................22
MAINSTREAMING OF AYUSH .......................................................................................................................................................................................................................23
DISTRICT HEALTH SOCIETY ...........................................................................................................................................................................................................................23
CONVERGENCE..............................................................................................................................................................................................................................................23
ROLE OF NON GOVERNMENTAL ORGANIZATIONS.....................................................................................................................................................................................24
FINANCIAL PERFORMANCE FY-2007-2008..................................................................................................................................................................................................24
INNOVATIONS ...............................................................................................................................................................................................................................................25
Nutrition Rehabilitation Centre.............................................................................................................................................................................................................25
Bal Shakti Yojna:.....................................................................................................................................................................................................................................26
Sick New Born Care Unit (SNCU)...........................................................................................................................................................................................................27
Call Centre...............................................................................................................................................................................................................................................28
Janani Express Yojna ..............................................................................................................................................................................................................................29
Deendayal Antyodaya Upchar Yojna.....................................................................................................................................................................................................30
CONCLUSION.................................................................................................................................................................................................................................................30

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INTRODUCTION
Government of India is implementing different Flagship Programmes to improve the quality
of life of people. Tata Institute of Social Science with support from UNICEF organised a 5
week field internship programme to critically understand the different flagship programmes
across the country. Different teams were assigned one major flagship programme is one of
the integrated districts of UNICEF. National Rural Health Mission is one such ambitious
programme which aims at improving the health status of the populace with a special focus for
people living in rural areas. The progress of implementation of NRHM has been varied across
the country. Though there have been many positive outcomes but there also have been many
critiques of the program at the National & State level.
Guna district in Madhya Pradesh was selected for studying National Rural Health Mission.
The Objectives of the study were:
1. To understand the current health status at State & District level.
2. To understand the delivery structure of the program at the district level
3. To study various components of the program and its implementation in the district.
4. To understand the reasons for success & failures of the program in the district.
5. To examine different innovations, if any, in the district under the program
METHODOLOGY
To enable access to complete and factual information about the program different
methodologies were adopted as per the requirement. These included:
1. Formal & Informal Discussions with service providers
2. Desk review of reports & publications
3. Facility visits
4. Unstructured interview of the beneficiaries
5. Observation
BACKGROUND OF NRHM
The National Rural Health Mission was launched in 2005, to provide accessible, affordable
and accountable quality health services even to the poorest households in the remotest rural
regions. The difficult areas with unsatisfactory health indicators were classified as special
focus States to ensure greatest attention where needed. The thrust of the Mission was on
establishing a fully functional, community owned, decentralized health delivery system with
inter sectoral convergence at all levels, to ensure simultaneous action on a wide range of
determinants of health like water, sanitation, education, nutrition, social and gender equality.
Institutional integration within the fragmented health sector was expected to provide a focus
on outcomes, measured against Indian Public Health Standards for all health facilities. From
narrowly defined schemes, the NRHM was shifting the focus to a functional health system at
all levels, from the village to the district.
SITUATION IN MP
MP is one of the poorer states of the country with more than 37% of its population (22
million) living below poverty line. SCs and STs constituting 35% of the population, account
for the majority of the poor. State has low sex ratio (920 as compared to 933 for the country)
and low female literacy (50% as compared to 54% for the country). Health status is
characterized by high maternal and child mortality (MMR of 498 as compared to 409 for the

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country, IMR of 79 as compared to 64 for the country), high fertility (TFR of 3.3 as
compared to 2.9 for the country), high burden of vector borne and communicable diseases
and weak public health system with extremely low per capita public expenditure (Rs 132 as
compared to Rs 207 for the country).
State has taken many steps in the recent past to improve the functioning of the health system
and facilities. These efforts have acquired a new focus and thrust with the launch of the
National Rural Health Mission that has become the umbrella programme for all vertical
disease control programmes, including RCH. State has already signed MOU with the GOI
committing itself to increasing public expenditure on health, increased decentralization and
community participation, provision of community level health worker (ASHA) and granting
functional autonomy to local health facilities. State has also prepared a Programme
Implementation Plan (PIP) for NRHM and RCH covering the period up to 2012. These PIPs
outline the operational plans of the government to reform the health systems for providing
equitable and quality health care to its people.
Current Status of Health Outcomes and Health Systems in Madhya Pradesh
State has made significant progress in reduction in MMR, IMR and CMR over the last few
years. However, these are still worse than national averages and quite poor as compared to
better performing states. Inequities in access and health outcomes extremely low expenditure
on health and that too largely as out of pocket and high incidence of communicable diseases
like TB and Malaria characterise the health status of the state.
Status of Health Outcomes
The salient health indicators are detailed in the following table:
Sl.
No. MP MP All India Kerala UP
(NFHS 3) (NFHS 2) (NFHS 2) (NFHS 3) (NFHS 3)
1 MMR (SRS 1998) 498 407
2 IMR 70 88 68 15 73
3 Under 5 mortality rate 142 95
4 TFR 3.1 3.4 2.9 1.9 3.8
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Women receiving 3 Antenatal
Check ups 40% 27% 20% 94% 26%
6 % of children fully immunized 40% 22% 42% 75% 23%
7 Institutional Deliveries 30% 22% 33% 100% 22%
8 % of child malnourished 60% 54% 50% 29% 47%
9 Unmet need for FP 12% 17% 16% 9% 22%
Based on the above, the major highlights of the health outcomes and key intermediate
indicators are:
• High MMR and IMR with significant rural-urban, socio-economic group wise and
inter-district variation both in health outcomes and utilisation of health services.
• High level of malnutrition amongst children and anaemia amongst women.
• High Gender disparity – CMR for girl child is 87.5 as compared to 49.2 for boys.
• IMR is double and CMR is more than five times in poor families as compared to well
off families. Similarly, 12% of children in poor families were vaccinated as compared
to 50% of well off.

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• Only 11% of ST children were fully immunized as compared to 22.4% for the state as
a whole.
• Poor awareness of ORS therapy, while 28% of the state’s IMR was due to diarrhoea.
• MP contributes 24% of malaria cases, 40% of PF cases and 20% of malaria deaths in
the country.
• Poor coverage of sanitation facilities in rural areas.
• Increasing prevalence of TB with poor detection as well as cure rates in majority of
districts.
Status of Social determinants of health
Madhya Pradesh is one of the India’s poorer states, with a per capita income in 2003-04 of
Rs. 8,284 compared to the all-India average of Rs. 11,799. More than 37% of its population
live in poverty. For Scheduled Tribes (20% of the population) and Scheduled Castes (15%),
the poverty levels are higher, at 57% and 40% respectively. Gender inequalities are reflected
in the low sex ratio (920/1,000, against a national average of 933), female literacy of 50%
and lower Human Development Indices for women. Within the state, there are significant
regional inequalities, with extremely high poverty levels in southern and south-western
districts compared to northern districts. High levels of poverty and gender inequalities impact
on key social determinants of health:
• 53% of women are married before the legal age of marriage (18 years) with this
indicator as high as 72% for women with no education.
• 13.6% of the women in the age group of 15-19 years were either pregnant or were
mothers.
• IMR (125) of youngest mothers was twice that of mothers aged 30-35 (64).
• Prevalence of high anaemia (57.6%) and nutritional deficiency (40% women have
BMI <18) amongst women in reproductive age.
• 70% of ST women are anaemic.
• More than 60% children are malnourished; 40% are stunted and 33% are wasted.
• Only 15% of children were breastfed within one hour of birth and only 21% of
children (0-5 months) were exclusively breastfed.
• 86% of habitations are covered by safe drinking water sources. However, inadequate
arrangements for preventive maintenance of hand pumps contribute to poor
availability of safe drinking water.
• Rural sanitation is still a concern as less than 8% of all rural households are estimated
to have an IHL. This situation is likely to improve with implementation of ‘Swajal
Dhara’ scheme. However, attitudinal awareness and constraints due to non-
availability of water for flushing need to be tackled.
Health Problems in Tribal regions
• MP has a large tribal population, majority of who reside in 8 tribal districts. These
tribal districts are characterised by extreme poverty (more than 57% tribal population
is poor), remoteness, inaccessibility and extremely weak public health infrastructure.
The health outcomes in these areas are, understandably, extremely poor as compared
to other regions and groups:
• CMR was 87 for ST children as compared to 57 for the state (NFHS 2).
• TFR was 3.9 for SC, 3.7 for ST against 3.3 for the state (NFHS 2).
• More than 70% ST women were anaemic as compared to 54% for the state (NFHS 2).
• 60% of ST children were anaemic as compared to 51% for the state (NFHS 2).

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• 91% tribal women delivered at home as compared to 78% for the state as a whole.
• Special strategies for improving access and availability of services and health
outcomes in tribal areas will be devised as a part of the health reform programme.
PROFILE OF GUNA DISTRICT
Guna , district of Madhya Pradesh, is the gateway of Malwa. Chambal is located on the
north-eastern part of Malwa Plateau. The western boundary of the District is well defined
by the river Parbati. Parbati is the main river flowing along the western boundary touching
Rajgarh District of M.P. and Jhalawarh and Kota District of Rajasthan. Shivpuri & Kota
are located in north where as Vidisha, Bhopal, and Rajgarh lies to the South. The total area
of District is 6307.66.63 sq. km. with a population of 977827 (Census 2001).
-
S. No Indicator Year Guna Source
1 Population (thousands) 2001 1667 Census
2 Population (thousands) 2005 1801 Population Projection
Report 2001-2026,
Census 2001
3 Child population (0-6 years) (thousands) 2001 327 Census
4 Sex ratio (Females per 1000 males) 2001 885 --do--
5 Child sex ratio
(0-6 years; girls per 1000 boys)
2001 931 --do--
6 Scheduled Castes (thousands) 2001 294 --do--
7 Scheduled Tribes (thousands) 2001 204 --do--
8 Annual number of births (thousand) 2005 57.8 Population Projection
Report 2001-2026,
Census 2001 and SRS

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The district is divided into 5 blocks which are: Guna, Chachaura, Raghogarh, Aron and
Bamori. The blocks are further sub divided into 425 Gram Panchayats. The total number of
revenue villages in the district is 1260. Total number of ICDS centres in the district is 1011
which are located across 1260 villages covering the 0-6 child population. The total number of
schools in the district is 2658 which constitute of all the government, aided and private
schools. The majority of the schools at the primary level and nearly 80 percent at the upper
primary level are comprised by government and government aided schools.
Nearly three fourth of the total population of the district resides in the rural area thus making
it a predominantly rural district. The population density of the district is low (155 persons per
sq. km.) when compared to the other neighbouring states such as Bihar and Uttar Pradesh.
The sex ratio of the district is 885 females per thousand male which is much below the
national average of 933. However the district fares slightly better off in the child sex ratio
which is 931 as per census 2001.
The tribal population of the district is 15 percent and the scheduled caste population is 16%.
Combined together nearly one third of the population comprises of the deprived section. The
population of such groups is not evenly distributed and some areas have high proportion of
the tribal population. Incidentally, these areas are the bordering blocks of the district and are
extremely backward. The DLHS 2002 – 04 round shows that nearly 60 percent of the
population has low standard of living.
The overall literacy rate of the district is sixty percent out of which the male literacy is 75
percent and the female literacy is 43 percent. The literacy gap in the district is more than 30
percent. It is evident from the fact that in the district the overall ST female literacy is less
than 18 percent and the rural female literacy is 25 percent.
Health Situation in Guna
Guna district had some very poor health indicators particularly related to child survival and
safe motherhood. The DLHS round 2002 -04 indicated that the institutional delivery was only
30 percent. The complete immunisation among children in the age group 12 – 35 months was
as low as 11%. Only 16 percent children were receiving ORS during an episode of diarrhoea
and the use of iodised salt in households was less that 50 percent. The IMR of the district was
98 (census estimates) and exclusive breastfeeding (including colostrum feeding) to children
was only 40 percent. One third of the children were born with low birth weight and the
Vitamin A supplementation among children was 5 percent.
In the case of some of the critical maternal health indicators the district does not fare well
either. The MMR estimated for the district is close to 7 per 1000 live births. As per NSSO
estimates, nearly 70 percent of the women get married before attaining legal age in the rural
areas. Less than 40 percent of the pregnant women received at least one ANC and IFA
tablets. Deliveries attended by skilled professional were less than 30 percent and out of this
only 24 percent were institutional deliveries in the rural areas. Some of the other institutional
difficulties included lack of adequate infrastructure at the block level and higher travel time
9 Annual number infant deaths (thousand) 2005 4.7 --do--
10 Households with low standard of living (%) 2002-04 59.9 DLHS
11 Household using iodized salt (> 15 ppm)
(%)
2002-04 43.5 DLHS

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to reach to the facility and congestion at the facility to render immediate delivery related
services.
Against this backdrop, UNICEF piloted integrated approach to improve the maternal and
child health indicators in the district. A set of activities were initiated simultaneously to
combat the health challenge and improve services. Some of these initiatives included training
the local health workers (ANM, AWW) in Integrated Management of Neonatal and
Childhood Illness (IMNCI), strengthening of Routine Immunisation, Improved diarrhoea
management and establishing call centre for 24x7 referral transport. To support such efforts
existing institutions such as SHCs, PHCs and CHCs have been strengthened and new
facilities have been set up such as Nutrition Rehabilitation Centre (NRC), Sick New Born
Care Unit (SNCU) and some of the sub health centres and primary health centres have been
upgraded to provide 24x7 delivery facilities and referral services. The details of these
initiatives are discussed in the later section of this report.
Due to such concerted efforts the district has shown progressive trends in last 2 – 3 years. As
per the data provided by the District Health Society, the institutional delivery has gone up to
95 percent with more than 70, 000 deliveries being conducted in the last three years. Out of
this more than 47000 mothers got the benefit under Janani Suraksha Yojna. The district
administration has also accredited two private hospitals for promoting institutional delivery
under public private partnership. The immunisation coverage has also improved considerably
with complete immunisation being more than 85 percent. The district has not reported any
polio case in the last year.
However, family planning efforts seem to be bearing very limited results in the district. The
use of any modern method of contraception is very low. Though some progress can be
observed with female sterilisation being promoted under National Maternity Benefit Scheme,
but the male sterilisation rates are abysmally low being reported at less than 5 percent of the
target spelt out for the current year. This clearly indicates that family planning is still the
prerogative of females and male participation is very poor. The government has started Deen
Dayal Antyodaya Upchar Yojna which provides a onetime cash benefit of Rs.20000 per
household to BPL families for in patient admission. Under this scheme more than 2200
households have benefitted in the current year.
The progress on the other national programmes which have been integrated under the
umbrella can be found to be satisfactory. Though this is a very generic statement as the
estimates of denominator of beneficiaries is not available. But mainstreaming of AYUSH into
the umbrella programme is another area of concern. The AYUSH practitioners have not yet
been placed at the facility level. Neither they have been included in the Rogi Kalyan Samitis
or Health Society or as master trainers of ASHA.
Health infrastructure in the District
The district has one district hospital at Guna and one civil hospital situated at Chachaura.
Guna has five Community Health Centres (CHCs), 14 Primary Health Centres (PHCs) and
119 Sub Health Centres (SHCs) catering to the 10 lakh population of the district. 150 Village
Health and Sanitation Committees (VHSCs) have been constituted and are operational in the
district. 20 Hospital Management Societies (Rogi Kalyan Samitis) have been registered and
are operational. The Rogi Kalyan Samitis (RKS) have been constituted up to the PHC level as
per the NRHM guidelines and the state PIP.

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District Hospital at Guna
The district hospital at Guna is a 280 bedded hospital located at the district headquarters. The
hospital provides health services to the 10 lakh population of the state. The hospital is
equipped with state of art facilities including blood storage and transfusion facilities and is
the only facility in the public sector to provide specialised and emergency services to the
people. The outpatient load of the hospital is 600 on an average per day.
The district hospital has a blood bank with blood storage facility, maternity ward with
emergency and obstetric care, sick and new born care unit, TB ward, immunisation ward, eye
care ward, burn unit, trauma centre, OT, physiotherapy unit and facilities such as x-ray, CT
scan and sonography facilities. Thus the hospital is well equipped to deliver all types of
health care services as has been designated by IPHS under NRHM.
However, due to lack of human resource, the hospital is not able to function at its full
capacity and only 50-60 percent of the beds are occupied. The facility has sanctioned position
of 41 doctors out of which only 23 doctors are in position. Out of the 20 sanctioned positions
for specialist doctors only 7 were occupied at the time of observation. Similar is the case for
other key staff positions such as anaesthetists, radiologists, sonographers, paramedics etc.
Overall, nearly 50 percent of the staff positions are only in position.
HEALTH INFRASTRUCTURE AT THE BLOCK LEVEL
Chachaura has 1 Community Health Centre at Beenaganj, which is the block headquarter.
This facility acts as the first referral unit and the centre for specialised treatment to the people
of the block. Under NRHM, this CHC is proposed to be converted into CEmONC for
conducting complicated deliveries and provide other high end treatment to the patients. Other
health facilities include 1 Civil Hospital at Chachaura, CHC at Kumbhraj which is a
BEmONC providing basic emergency obstetric and new born care, 1 primary Health Centre
at Mrigwas, 1 PHC at Teligaon (SHC converted into PHC, notified a month back) and 31 Sub
Health Centres.
Status of Community Health Centres
The secondary level of health care essentially includes Community Health Centres(CHCs),
constituting the First Referral Units(FRUs) and the district hospitals. The CHCs are designed
to provide referral health care for cases from the primary level and for cases in need of
specialist care approaching the centre directly. Approximately 4 -6 PHCs are included under
each CHC thus catering to approximately 80,000 population in tribal / hilly areas and 1,
20,000 population in plain areas. CHC is a 30- bedded hospital providing specialist care in
medicine, Obstetrics and Gynaecology, Surgery and Paediatrics.
NRHM envisages bringing up the CHC services to the level of Indian Public Health
Standards. Under the NRHM, the Accredited Social Health Activist (ASHA) is being
envisaged in each village to promote the health activities. With ASHA in place, there is
bound to be a groundswell of demands for health services and the system needs to be geared
to face the challenge. Not only does the system require upgradation to handle higher patient
load, but emphasis also needs to be given to quality aspects to increase the level of patient
satisfaction. In order to ensure quality of services, the Indian Public Health Standards are
being set up for CHCs so as to provide a yardstick to measure the services being provided
there.

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Under NRHM, the state has planned to provide all the Community Health Centres into 24x7
Community level Emergency Medical Obstetric and New Born Care (CEmNOC) by year
2009. These centres are to be well equipped to provide specialist services along with delivery
through caesarean section and new born care. For ensuring this, certain guidelines have been
laid out such as positioning of doctors (obstetric/gynaecologist), anaesthetist and essential
medicines, blood storage facility and consumables. The detailed checklist is provided in the
IPHS document for CHCs.
Though the CHC has been given the status of CEmONC, it was observed that the facility
does not even fulfil the basic criteria of provision of adequate staff. The position of specialist
doctor and anaesthetist is vacant. Though in the facility 5-6 normal deliveries are being
conducted every day, complicated delivery cases are being referred to District hospital in the
absence of adequate facilities. Blood storage facility is also not currently available at the
CHC. Other key staff position such as staff nurse (only 4 out of 9 are in position), ANM,
LHV, ultrasonographer and radiocardiologist which are essential positions for emergency
care are also vacant. Other consumables such as proper availability of gloves, supply of water
(no tap water) and adequate back up of electricity (one CFL bulb) is also missing at the
centre.
In the CHC a provision of 30 beds has been made under Bureau of Indian Standards and
IPHS but due to lack of space, only 20 beds are available for inpatient admission. The
delivery rooms had only 2 beds which seemed to be inadequate considering the case load of
the facility. The hygiene condition (foul smell) in the delivery room was also not proper. The
two delivery tables in the delivery room did not have cushions.
NACO has developed Universal Precaution and Safety guidelines under which all the
deliveries have to be considered as risk deliveries with respect to HIV and adequate
precautions have to be ensured. This is one of the strongest convergence points between the
SACS and NRHM. However, no training of such sort has been imparted to the staff and the
staff is not aware about any such programme. The staff nurse have been trained on IMNCI
and SBA and no other training such as on family planning methods, EmOC etc has been
imparted. Training appears to be a weak component in the implementation NRHM in the
district.
One of the important other purpose of the CEmONC is to increase institutional delivery and
safe delivery with adequate provisioning of staff and consumables. In this facility, all the
complicated cases of pregnancy are referred to Guna, which is the district hospital. In case,
complications such as post partum haemorrhage, retained placenta etc arise at the centre,
management of such cases is not possible. These cases are referred to the district hospital
which is at a distance of 60 kilometres and the travel time is one and half hours. Such cases
get more complicated by the time the patient reaches to the district hospital.
Essential new born care is also an important and integrated component of NRHM. The
district has done well by making novel and innovative provisions of Nutrition Rehabilitation
Centre (NRC) and Sick New Born Care Unit (SNCU) at the district as well as at the block
level. Chachaura block has one 10 bedded NRC and 2 bedded SNCU for treatment and care
of extremely malnourished children (Grade III and IV) and underweight new born children,
premature birth having birth complications such as birth asphyxia and neonatal jaundice and
ARI.

13
When observed, the NRC had only 4 beds occupied out of the 10 beds which seemed to be
inadequate considering the fact that in the last Bal Sanjeevan Campaign (held in the month of
January 2008) the number of Grade III and Grade IV children was 229. It is important here to
note the fact that the NRC in Guna is overloaded with such beneficiaries and in some cases
some wards are not admitted.
The SNCU with 2 beds at the Chachuara CHC was not occupied. It is clear that since all the
complicated delivery cases are referred to the District SNCU children are not being admitted.
One of the other reason could be the fact that the incharge of the SNCU was away for
training, the beds were not occupied. However, the district SNCU has higher caseload
indicating to the fact that provision of such a state of the art facility at the block level is not
helping the cause by reducing the case load at the district facility.
Status of Primary Health Centres (PHCs)
PHCs are organised on the basis of one PHC for every 30,000 rural population in the plains
and one PHC for every 20,000 population in hilly, tribal and backward areas for more
effective coverage. PHCs are the cornerstone of rural health services- a first port of call to a
qualified doctor of the public sector in rural areas for the sick and those who directly report or
referred from Sub-centres for curative, preventive and promotive health care. It acts as a
referral unit for nearly 6 sub-centres and refers out cases to Community Health Centres
(CHCs-30 bedded hospital) and higher order public hospitals at sub-district and district
hospitals. It has 6 indoor beds for patients.
The nomenclature of a PHC varies from State to State that include a Block level PHCs
(located at block HQ and covering about 100,000 population and with varying number of
indoor beds) and additional PHCs/New PHCs covering a population of 20,000-30,000. The
standards prescribed as per GOI norms is PHC covering 20,000 to 30,000 populations
with 6 beds, as all the block level PHCs are ultimately going to be upgraded as Community
Health Centres with 30 beds for providing specialized services.
In the district 14 PHCs are located at different places and providing services to the rural
population of the district. On an average one PHC is catering to nearly 75000 population in
the district which is far above the GOI norm and the Indian Public Health Standard (IPHS)
prescribed under NRHM. Going by the population norm there is a requirement of 35 PHCs in
the district (considering the 30000 population norm).
As PHCs are the first port of call for health services, servicing a population of 75000 with
only 6 indoor beds seems to be a huge challenge.
Status of Sub Health Centres (SHCs)
In the public sector, a Sub-health Centre (Sub-centre) is the most peripheral and first contact
point between the primary health care system and the community. As per the population
norms, one Sub-centre is established for every 5000 population in plain areas and for every
3000 population in hilly/tribal/desert areas.
A Sub-centre provides interface with the community at the grass-root level, providing all the
primary health care services. Of particular importance are the packages of services such as
immunization, antenatal, natal and postnatal care, prevention of malnutrition and common
childhood diseases, family planning services & counselling and in time referrals
of EMoC cases. It also provides elementary drugs for minor ailments such as Acute
Respiratory Infection (ARI), diarrhoea, fever, worm infestation etc. and carries out

14
community needs assessment. Besides the above, the government implements several
national health and family welfare programmes which again are delivered through these
health centres.
A Sub-centre is staffed by one Female Health Worker commonly known as Auxiliary Nurse
Midwife (ANM) and one Male Health Worker commonly known as Multi Purpose Worker
(Male). One Health Assistant (Female) commonly known as Lady Health Visitor (LHV) and
one Health Assistant (Male) located at the PHC level are entrusted with the task of
supervision of all the Sub centres (roughly six sub centres) under a PHC.
In Guna district, the number of SHCs is 119. These SHCs are catering to nearly 9000
population which is almost double the population norms. The total requirement for the district
is 212 SHCs considering 5000 population norm for plain areas and discounting the norm of
3000 population for hilly/tribal areas. Though in certain pockets there is high concentration of
tribal population in the district.
As per the Programme Implementation Plan (PIP) target of the state, it was planned to have at
least 25% SHCs with 2 ANMs by the end of year 2008. The district has currently 35 SHCs
with 2 ANMs which fulfils the above target set by the state. All the other SHCs have one
ANM. In 97 of the Sub Health Centres joint account with the Sarpanch has been opened. This
account is used to remit the untied fund of Rupees ten thousand for the purpose of upkeep
and maintenance of the SHCs.
However, owing to the operational difficulties, from the current year Sarpanch has been
removed from the joint account and the Medical Officer in charge of the SHC has been added
as a signatory to the account. It was found out that under the previous arrangement some
malpractices at the level of Sarpanch were occurring. Therefore, this new system has been
worked out to streamline the utilisation of untied funds provided to the SHC.
The village, Umarthana, which was the selected village for study, has one sub health centre
(SHC) located within the boundaries of the village. The SHC covers 10 villages with the
farthest village being at a distance of 8 kilometres. The sub health centre provides OPD,
immunisation, counselling for FP services, referral and other requisite services as per the
guidelines of IPHS. This SHC is staffed with one FSW and one ANM. The FSW is staying in
the sub centre for the last 13 years whereas the ANM has recently shifted her base. The ANM
has received training in IMNCI organised by UNICEF.
As per the records available with the sub health centre, currently 8 women are pregnant in the
village. Five births have been recorded since the beginning of this year and 4 women are
under post natal care. As informed, the SHC has been able to promote institutional delivery
and all the births in the last two years have occurred in the Beenaganj CHC or district
hospital at Guna. This has been successful after the implementation of the JSY and the Janani
Suraksha Express schemes in the district. Immunisation status of children was also observed
to be good as verified by the records available with the AWC and the SHC. It is important
here to note that there is considerable focus of the government for promoting complete
immunisation and institutional delivery.
Other important services such as home visits for ANC and PNC, essential new born care,
vitamin A supplementation, ARI and Diarrhoea care etc were also emerged to be of
satisfactory level during interactions with the community members of the village. However,

15
counselling for promoting the use of FP methods, counselling to adolescents for reproductive
and sexual health care and convergence with schools and on issues of water and sanitation
was found to be weak. Waste disposal was another area where guidelines for disposal of
waste were not being followed and it requires immediate attention.
The supply component was also found to be satisfactory. The SHC had all the essential
medicines available with it. The supply as verified from the stock register has been regular
except for two occasions when the supply was delayed by two weeks after placing the indent.
However, as the SHC has the flexibility to use the untied fund, in case of such delays, this
fund is used with discretion in such cases. Convergence with the ASHA and the AWW was
also found to be extremely good reflecting in the high institutional delivery and high
immunisation rates. During the discussion with ASHA and ANM it came out that adequate
handholding to them is being done.
The SHC has used the untied fund to renovate the centre and build toilet so that the ANM
could stay at the centre. Overall, the SHC at Umarthana was observed to delivering services
better than what had been expected. However, one of the weak link was the lack of adequate
IEC material at the Centre. Display of not much IEC material could be observed neither such
materials were present in the stock despite the fact the there has been ever increasing
emphasis on this. Also, since the SHC is located within the village people of all castes, class,
power and gender are getting the benefits. But one needs to verify the reach of these services
to the other nine villages the SHC caters.
ROGI KALYAN SAMITI
Madhya Pradesh is the pioneering state where hospital management societies (Rogi Kalyan
Samitis) were established and operationalized at all health institutions up to the level of
primary health centres. Rogi Kalyan Samiti are the registered societies constituted in the
hospitals as an innovative mechanism to involve the peoples representatives in the
management of the hospital with a view to improve its functioning through levying user
charges.
The RKS/HMS does not function as a Government agency, but as an NGO as far as
functioning is concerned. It may utilize all Government assets and services to impose user
charges and is free to determine the quantum of charges on the basis of local circumstances.
It also raises funds additionally through donations, loans from financial institutions, grants
from government as well as other donor agencies. Moreover, funds received by the RKS /
HMS are not be deposited in the State exchequer but are available to be spent by the
Executive Committee constituted by the RKS/HMS. Private organizations offering high tech
services like pathology, MRI, CAT SCAN, Sonography etc. are permitted to set up their units
within the hospital premises in return for providing their services at a rate fixed by the RKS/
HMS.
Composition of Rogi Kalyan Samiti (PHC)
General Body
Janpad Panchayat member of area Chairman
President Gram Panchayat
President of Health Committee of Gram Panchayat
Gram Panchayat female Member
Sub Eng.. PWD & MPEB
All Donors ( donated Rs.10,000)
Member

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Tehsildar (SDM)
I/C MO Hosp.. Member Secretary
For managing day to day functioning of the Rogi Kalyan Samiti Executive committee have
been constituted. The composition of executive Body is as following:-
Executive Body
Tehsildar (SDM) Chairman
President of Health Committee of Gram Panchayat
Sub Eng.. PWD & MPEB
Member
I/C MO Hosp..
Two Donors who are member of General Body and
nominated by President.
Member Secretary
Role of Rogi Kalyan Samiti
• Ensure compliance to minimal standard for facility and hospital care and protocols of
treatment as issued by the Government.
• Ensure accountability of the public health providers to the community;
• Introduce transparency with regard to management of funds;
• Upgrade and modernize the health services provided by the hospital and any
associated outreach services;
• Supervise the implementation of National Health Programmes at the hospital and
other health institutions that may be placed under its administrative jurisdiction;
• Organize outreach services / health camps at facilities under the jurisdiction of the
hospital;
• Display a Citizens’ Charter in the Health facility and ensure its compliance through
operationalisation of a Grievance Redressal Mechanism;
• Generate resources locally through donations, user fees and other means;
• Establish affiliations with private institutions to upgrade services;
• Undertake construction and expansion in the hospital building;
• Ensure optimal use of hospital land as per govt. guidelines;
• Improve participation of the Society in the running of the hospital;
• Ensure scientific disposal of hospital waste;
• Ensure proper training for doctors and staff;
• Ensure subsidized food, medicines and drinking water and cleanliness to the patients
and their attendants;
• Ensure proper use, timely maintenance and repair of hospital building equipment and
machinery;
As a matter of fact, the concept of the Rogi Kalyan Samiti emerged at the Beenaganj CHC in
the year 1994. This was an era when public health care was neglected by the policy makers
and not enough funds were flowing down for improving the health services. In this period of
little funding and lesser flexibility, the then Deputy Collector of the district started leasing the
unused hospital space by constructing shops in the premise. The fund generated through this
mechanism was given to a registered society which later came to be known as Rogi Kalyan
Samiti (RKS). The RKS apart from managing this fund also started charging minimal user
fees from the patients visiting this facility. The user charges were fixed as Rs.1/- for

17
outpatient registration and Rs. 10/- for inpatient registration. For delivery cases additional
charge of Rs. 25/- was fixed. Later on registration charges for BPL patients and delivery
cases was waived off.
Through this process the RKS started generating additional funds which could be used for
upkeep, maintenance, upgradation and maintenance of the facility. Over the years the RKS at
Beenaganj facility has constructed Delivery rooms and gynae wards, Nutrition Rehabilitation
Centre Building, additional OT, a general purpose hall and internal concrete road for better
connectivity. The RKS has also supported the CHC by procuring modern equipments and
building office annexe.
The RKS at the Beenaganj CHC has been to set up a model of local community action for
management of a public health facility. This model has been adopted as an important
component of NRHM under comunitisation. But, the RKS has not been able to expand its
scope beyond institutional upgradtion of the health facility. Some of the equally important
issues such as increasing outreach services, management of other health programmes such as
TB, Malaria, HIV etc, accreditation and coordination with private health facilities, improving
waste disposal, increasing community awareness through camps etc is not clearly visible. The
district has been able to constitute RKS in all the facilities as per the target set out in the State
PIP. However, the same vigour and empowerment of RKS needs to be verified at other
facilities.
VILLAGE HEALTH SANITATION COMMITTEE (VHSC)
The NRHM framework supports decentralized planning & monitoring up to the grass root
level. Therefore it was decided to entrust village level committees of the users group,
community based organization for the planning monitoring & implementation of NRHM
activities upto the village level. The Village Health and Sanitation Committee (VHSC) is be
formed in each village under each Gram Sabha ensuring adequate representation to the
disadvantaged categories like women, SC / ST / OBC /minority communities.
Village Health & Sanitation committee (VHSC) feed such groups, which is the fifth
committee (Development Committee) of the Gram Panchayat. The VHSC is the key agency
for developing Village Health Plan & the entire planning of village Panchayat for NRHM.
This committee comprises of Panchayat representatives, ANM, MTW, Aganwari workers,
Teachers, Community health volunteers, ASHA. VHSCs are provided with Rs.10000/- for
supporting their efforts in developing Village Health Plans.
Composition of the Village Health Committee
This committee is formed at the level of the revenue village (more than one such villages may
come under a single Gram Panchayat).
Composition: The Village Health Committee consists of:
• Gram Panchayat members from the village.
• ASHA, Anganwadi Sevika, ANM
• SHG leader, the PTA/MTA Secretary, village representative of any community based
organization working in the village, user group representative.
• The chairperson would be the Panchayat member (preferably woman of SC/ST
member) and the convener would be ASHA; where ASHA is not in position it could
be the Anganwadi worker of the village.

18
Role of Village Health Committee
• Create Public Awareness about the essentials of health programmes.
• Discuss and develop a Village Health Plan based on an assessment of the village
situation and priorities identified by the village community.
• Analyze key issues and problems related to village level health and nutrition
activities, give feedback on these to relevant functionaries and officials. Present
annual health report of the village in the Gram Sabha.
• Participatory Rapid Assessment: to ascertain the major health problems and health
related issues in the village.
• Maintenance of a village health register and health information board/calendar: The
health register and board put up at the most frequented section of the village will have
information about mandated services, along with services actually rendered to all
pregnant women, new born and infants, people suffering from chronic diseases etc.
• Ensure that the ANM and MPW visit the village on the fixed days and perform the
stipulated activity; oversee the work of village health and nutrition functionaries like
ANM, MPW and AWW.
• Get a bi-monthly health delivery report from health service providers during their visit
to the village.
• Take into consideration of the problems of the community and the health and nutrition
care providers and suggest mechanisms to solve it.
• Discuss every maternal death or neonatal death that occurs in their village, analyze it
and suggest necessary action to prevent such deaths. Get these deaths registered in the
Panchayat.
• Managing the Village health fund.
Up to the time of this observation only 5 village health and sanitation committee have been
constituted in the block as against a target of 25 percent villages having such committees by
the end of year 2008. Thus the district has failed in its benchmark of communitising the
process of health planning. All such committees have been entrusted the responsibility of
prepare local and need based village plans, but in the absence of such committees the local
action for health has not happened in the district. The untied grant of Rs. 10,000/- was
provided to the 5 committees but the block has not received the utilisation certification from
these committees. The real empowerment of these 5 VHSCs is also to be seen in the future.
ASHA- ACCREDITED SOCIAL HEALTH ACTIVIST
ASHA is envisaged as an activist from the community which is the first port of call for any
health related demands of deprived sections (especially women and children) who find it
difficult to access health services. Her major role being of creating awareness on health and
its social determinants and mobilize the community towards local health planning and
increased utilization and accountability of the existing health services. She is a promoter of
good health practices and also provides a minimum package of curative care as appropriate
and feasible for that level and makes timely referrals. Following roles by ASHA is envisaged
through continuous training and up gradation of her skills
1. Counsel women on birth preparedness, importance of safe delivery, breast feeding
and complementary feeding, immunizations, contraception and prevention of common
infections including RTI/STI and care of young child.

19
2. Mobilize the community and facilitate them in accessing health and health related
services available at the Anganwadi/Sub-centre/primary health centres, being
provided by the Government.
3. Work with the Village health & sanitation committee of the Gram panchayat to
develop a comprehensive village health plan.
4. Accompany pregnant women & children requiring treatment / admission to the
nearest pre-identified health facility i.e. PHC/CHC/FRU.
5. Provide primary medical care for minor ailments such as diarrhoea, fevers, and first
aid for minor injuries, work as provider of DOTS under RNTCP.
6. Act as depot holder for essential provisions being made available to every habitation
like ORS, Iron folic acid tablet, chloroqunine, Disposable delivery Kits, Oral pills &
condoms, etc.
7. Providing newborn care and management of a range of Common ailments particularly
childhood illnesses and its timely referrals.
8. Inform about the births and deaths in her village
9. Promote construction of household toilets under Total Sanitation Campaign.
It was found in the discussion that there is no clarity on roles and responsibilities of ASHA at
the grassroots level. Even concerned persons like AWWs, ANMs, PRI members, VHC
members, and staff at PHC or CHC do not have a clear idea.
Honorarium
ASHAs are visualized as harmony volunteers who are not paid monthly salaries and are
reimbursed on performance based incentives. Previously it was indicated in the JSY
guidelines, the package for ASHA (or an equivalent worker) where ASHA has not been
recruited) includes:
♦ The referral transport assistance to go to the nearest health centre (Rs 250)
♦ Compensation of ASHA if she stays with the pregnant women in the health centre
for delivery. (Rs 350)
Against this honorarium, a lot of expectations have been heaped on ASHA - identifying cases
for subsidies and compensations (to be made by the ANM), reporting to the health system,
functioning as an activist and facilitating people's access to health service. This according to
the officials led to lack of motivation among ASHA. It is only after introduction of new
guidelines of incentives, which has resulted in increased endeavours by ASHA. These
incentives include:
♦ Alternate vaccine delivery – Rs. 50
♦ Immunization – Rs. 150 per session
♦ Nutrition Rehabilitation Centre (NRC) referrals – Rs.100
Selection of ASHA
The selection of ASHA in the district has been conducted as per guidelines. For the selection
of ASHA CMHO has been declared as the District nodal officer and at the Block level Block
Medical Officer declared as Block Nodal Officer who facilitates the selection process of
ASHA and organizing training for trainers. In Guna, Facilitators (Surakarta) were selected at
each Panchayat level. They were trained after which they facilitated the identification and
selection of ASHA with the Panchayat in Gram Sabha. There was no active involvement of
BMO in the selection of ASHA in Chachoda block only the names proposed by panchayat is

20
approved by them. Ideally the desired education for ASHA is upto class VIII but
operationally majority of them are educated upto class V.
In the State PIP it was envisaged that selection of ASHA would be made 100% by 2008 as
per the norms of one ASHA at the population of 1000, but only around 723(68%) have been
currently selected. The reasons quoted by the DPM for this shortfall was dropout among the
selected ASHA and expulsion of some ASHAs, whose performance was not satisfactory.
Further probing for the reasons of the dropout could not be answered. In the shortage of
required number of ASHA, desired services could not be catered to many villages.
In Chachoda block 198 ASHA have been selected so far and 39 places are still to be filled.
Most of the ASHA have sustained, but it was shared that the selection in few places was
influenced by the powerful people and ASHA is not delivering. Although BMO is authorized
to take action if ASHA is not working with a copy of order marked to CMHO & CEO but
such action has not happened so far.
Training of ASHA
The training of ASHAs also leaves a lot to be desired. In the State PIP it was forseen that
80% of the ASHA would be fully trained by 2008. Owing to the fact that the target for the
selection of ASHA could not be met, the no Trained ASHA is also insufficient. Of the
selected ASHA only 540 ASHA have completed their training till module 4, remaining have
been trained upto module 2. None of the ASHA has been imparted training upto module 5
(final module). In Chachoda block, all 198 ASHA have been trained. The lack of training was
accounted to the lack of adequate infrastructure.
The training includes more of her role as a community mobilizer. The technical issues like
identification of complicated deliveries are not part of the training. This at some places has
resulted in low credibility of ASHA among the community as compared to AWW or DAIs in
the area.
The general impression is that training is being rushed as the government is under pressure to
show results. There has been criticism that civil society organisations were not consulted in
the training process of ASHA. Often, it is just the PHC/CHC staff who are unwilling trainers
and have little time to devote conduct the training for ASHA. Also, they have little pedagogic
orientation. On the other hand, the recipients (ASHAs) have no background or understanding
of health issues, which may result in low level of learning and internalization.
Drug Kit
There is a provision to provide ASHA with a drug kit consisting of medicines for routine
health problems like diarrhoea. 240 ASHA have been equipped with drug kit in the State,
though BMO of Chachoda block claimed of having provided drug kit to all 198 ASHA in the
block. It is still to be observed that how efficiently this facility is being utilized by ASHA at
the grass-root. Also, there has been a discussion on why the AYUSH doctors involved under
NRHM are not legitimatized to provide modern drugs considering the fact of lack of medical
faculty at the centres.
Coordination with Other Departments
As the role of ASHA and AWW overlaps, there have been many incidents of conflict
between the two. This is mostly due to the perceived threat of losing her job in near future by
the AWW. It was also observed that AWW feels that most of the work is done by the ANM

21
and herself for organizing immunization day. As it is part of their job responsibility, there is
no extra incentive for them. ASHA on the other hand receives incentive of Rs 150 per session
for bringing children to the site. Also, there have been conflicts for claiming the amount
under JSY for referrals of pregnant women. The current practice to resolve such dispute is
distribution of amount equally among them, which is unfair on part of ASHA as she is not
entitled to receive fixed honorarium. Additionally, ASHA is being pressurised by AWWs and
ANMs to work as their assistants.
JANANI SURAKSHA YOJANA
Background
In the past, National Maternity Benefit Scheme (NMBS) came into effect in August 1995 as
part of the National Social Assistance Program (NSAP). It provided 500 Rs in cash assistance
to pregnant women living below the poverty line for her first two births provided she is 19
years or older. The benefit was given several weeks before delivery and was used for
nutrition and other needs.
With the launching of NRHM in April, 2005 Janani Suraksha Yojana (JSY) scheme came
into existence that provisioned cash incentives for pregnant women to seek an institutional
birth.
Entitlements under JSY
Janani Suraksha Yojana provides hiring of specialists of OBGY and Anaesthesia to provide
specialist care in managing complicated obstetric cases. Using the similar norms, CEmONC
and BEmONC facilities would be able to hire the services of OBGY and Anaesthesia
specialists on case-to-case basis.
Under Janani Suraksha Yojana (JSY) the government provides a cash incentive for pregnant
mothers to have institutional births as well as pre- and ante-natal care. According to the
October 2006 JSY guidelines, all women in Low Performing States (LPS), like Madhya
Pradesh, receive cash assistance if they have their baby in a government health centre or
accredited private institution. In rural areas they receive 1400 Rs and in urban areas 1000 Rs.
The money is to be dispersed at the time of delivery in the institution.
Under JSY, below poverty line pregnant women older than 19 also receive 500 Rs cash
assistance for their first two births if these deliveries are at home. The cash is to be given at
birth or around 7 days before for “care during delivery or to meet incidental expenses of
delivery.”
Few of the critical observations of JSY were as follows:
National Maternity Benefit Scheme (NMBS) Vs Janani Suraksha Yojana
As part of the right to food case, the Supreme Court ordered on November 11, 2001 that the
state governments fully implement the National Maternity Benefit Scheme. It was observed
that despite the Supreme Court’s orders to the contrary the State government is no longer
implementing the National Maternity Benefit Scheme (NMBS).Instead; NMBS has been
replaced with JSY.
Importantly, unlike NMBS which provided cash assistance 8-12 weeks before delivery to
help with nutrition and other expenses the government states that “the cash assistance to the
mother [under JSY] is mainly to meet the cost of delivery.”Although JSY was created to
pursue a worthy goal – the safe delivery of babies – it does not address the nutritional needs
of women during pregnancy like NMBS was designed to do.

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The Integrated Child Development Service (ICDS), operated through local Anganwadi
Centres, is a critical component of the government’s strategy to combat malnutrition in
pregnant women and children by providing supplementary nutrition to pregnant and lactating
women and children under five. However, during our discussion it was revealed that several
ICDS centres could not properly reach out pregnant women majorly due to lack of timely
supply or inadequate quantity of supplementary nutrition. This breakdown of the ICDS
system is particularly troubling given the implementation problems surrounding the pre-birth
benefit program and the home delivery benefit of JSY.
Delivery benefits of JSY
It was observed, below poverty line women rarely receive the money for home delivery
actually envisioned under JSY. The state’s own numbers support these field observations
concerning the massive under-utilization of the home delivery benefit of JSY. According to
the government, during 2006-2007 only 1687 women in Madhya Pradesh who had a home
delivery received a benefit from JSY. This is especially troubling since women who have a
home birth are more likely to be poor and malnourished.
Also, in most of the occasions it was husbands, brothers, or fathers who often made most of
the important medical decisions for pregnant women. They decided to take the woman for
ante-natal care or not. They decided whether to have the birth at an institution or at home.
They took the money received under JSY and decided what to use it for. It was not that
women always had no voice in these decisions, but this voice was often filtered through, or
could be easily vetoed by, men.
Problems with Institutional Birth under JSY
While both the pre-birth benefit program and the home-delivery aspect of JSY were
massively under-implemented in the state, JSY benefits are widely received for institutional
births. With the implementation of Janani Suraksha Yojana in the State there has been a
remarkable increase in the number of institutional deliveries particularly in the district
hospitals. Although the Government data claimed to have achieved 94% institutional
deliveries in Guna district, there is no concrete data available for the denominator (Actual
number of pregnancies and deliveries in the area).
Difficult to reach public health facility
With establishment of call centre, Ambulances and 26 delivery points, there is improved
access to institutional delivery. But Primary Health Centres are still too difficult to reach
from many villages making them effectively useless to these villagers.
Low Quality of Care
Most of the infrastructure in much of the state is old and outdated. Additionally, many
hospitals, even district hospitals, lack even the most basic equipment. Fear over spreading
HIV/AIDS has rightly increased quality-control measures for blood supplies. This has made
it more difficult to have blood banks in remote areas.
Moreover, there is a frightening scarcity of trained medical personnel throughout the public
health system. This shortage is particularly acute for highly trained medical staff. For e.g. in
Chachoda block hospital, although it’s a CMOC there is no gynaecologist and anaesthetist.
There is no facility for caesarians for obstructed labours. In lack of up-to-date public health
facilities staffed by quality medical personnel, JSY is dubious reduce infant and maternal
mortality in the dramatic way that is necessary.

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MAINSTREAMING OF AYUSH
Mainstreaming of AYUSH under NRHM is a non- starter in the District as is evident from
the absence of any linkage of the Ayurvedic and Unani activities with the district health
services despite provision of space for Ayurvedic and Unani facilities in the medical
institutions. The Office of the CMHO and the Divisional Ayurvedic and Unani office were
found to be functioning in complete isolation of each other. Despite the fact that a large
number of Ayurvedic and Unani facilities are reportedly active in the District. The AYUSH
division has no communication about NRHM in the District with no allocation of funds for
the same. The infrastructure available to AYUSH institutions is extremely deficient both in
terms of buildings and funds for maintenance and rentals. There are wide gaps between
sanctioned posts and in-position staff. There are no staff nurses and no residential facilities at
Centres. Training of Ayurvedic and homeopathic Officers in NRHM under the District
Health services is being conducted by the CMHO without involvement of the respective
departments at the State/ district levels. There are many vacant AYUSH posts in the district
health program.
DISTRICT HEALTH SOCIETY
The focus of the programme was to improve the impact of the health programmes. One of the
strategies for this was streamlining the delivery structure at the state as well as at the district
level. District level structures were created in the form of District Health Societies and it was
planned to merge all the other vertical programme delivery structures such as RNTCP,
NBCP, NVBDCP etc. Professional staffs having key competencies were hired to expedite the
process of integration and reach the outcomes as envisaged in the design of the programme.
The state has done well in creating the District Health Society and merging all the vertical
programme societies which existed prior to implementation of NRHM. However, the funding
mechanism of these societies has not changed. The funds are still routed to the individual
societies. The only change which has occurred is that the societies have been converted into
sub committees under the DHS with one nodal officer heading the committee. Thus, the
objective of the merger has not completely been achieved.
CONVERGENCE
Under NRHM convergence was sought at two levels: 1. Within the health department
2.convergence with other line departments. The attempt to converge within the health
department was aimed at bringing the entire disease control program within NRHM which
would improve delivery and impact. The intention of convergence within the Health
Department was also to reorganize human resources in a more effective and efficient way
under the umbrella of the common District Health Society. Such integration within the Health
Department would make available more human resources with the same financial allocations.
It would also promote more effective interventions for health care. Though the convergence
within the health system seems to have appeared in terms of merger of the disease control
societies, the functioning of these societies is still discrete in nature. HIV and AIDS is still
outside the purview of DHS. Below the district level convergence in form has occurred.
The indicators of health depend as much on drinking water, female literacy, nutrition, early
childhood development, sanitation, women’s empowerment etc. as they do on hospitals and
functional health systems. Realizing the importance of wider determinants of health, NRHM
seeks to adopt a convergent approach for intervention under the umbrella of the district plan.
The Anganwadi Centre under the ICDS at the village level is envisaged as the principal hub

24
for health action. Likewise village committees have to be constituted for convergence with
for drinking water, sanitation, ICDS etc. NRHM attempts to move towards one common
Village Health Committee covering all these activities. Panchayati Raj institutions were to be
involved in this convergent approach so that the gains of integrated action can be reflected in
District Plans.
Under the leadership of Collector, weekly time limits meetings are organised at the district
level where representatives from the all the above mentioned departments meet and discuss
on the issues of convergence. However, in the absence of village plans which were the
starting point of convergence the action gets limited to the district level. The Village Health
and Sanitation Committees have also not been constituted which can take forward the vision
of convergence at the village level. The role of PRIs is also a very weak link and the
empowerment of PRIs to converge cannot be established as no efforts have been taken on this
front. Thus, convergence, currently is limited at the district level and that too within the
department and on some specific components only.
ROLE OF NON GOVERNMENTAL ORGANIZATIONS
The Non-governmental Organizations are established as critical for the success of NRHM.
The role of NGOs was envisaged as improve the reach of the programme and act as eyes and
ears of the government and build capacities at all levels for effective implementation of
Programme. For this, Mother NGO scheme was supposed to be strengthened. The Mother
NGO scheme is being implemented in the district with identification of MNGO and Field
NGOs completed two years back. However, it was noted during the discussion with MNGO
that that even the first instalment of funds has not been released. Thus, NGOs are yet to be
integrated into the umbrella programme of NRHM.
FINANCIAL PERFORMANCE FY-2007-2008
Intervention / Activity Budget
Planned
Budget
Achieved
Balance
Budget
%
TOTAL - RCH-II, NRHM,
ADDIONALITIES,
IMMUNIZATION
120768000 92025000 28743000 76.20
Total RCH- II 73347500 68383315 4964185 93.23
TOTAL Maternal Health 58595500 57945595 649905 99
TOTAL Child Health 534000 713055 -179055 134
Running Cost NRCs 384000 254190 129810 66.20
Total Family Planning - Population
Stabilization
8380000 7481101 898899 89
Total Infrastructure & Human
Resource
2944000 659885 2284115 22
Repair and renovation of PHCs
Annual
160000 103373 56627 64.61
Repair and renovation for District
hospital Annual
200000 95028 104972 47.51
TOTAL IEC & BCC 1408000 997516 410484 71
TOTAL PROGRAMME 796000 524003 271997 66
TOTAL NRHM 41354800 19534921 21819879 47.24
Village Health & Sanitation 6250000 15423 6234577 0.25

25
Committee – United Fund to 15462
VHSC’s @ 10,000
TOTAL Strengthening SHC’s 12930500 5638002 7292498 43.60
United Fund @10,000 per SHC’s per
year
1190000 178886 1011114 15.03
TOTAL Strengthening CHC’s
750000 1006695 -256695
134.2
3
Maintenance grant @ Rs.1 Lack per
CHC per year
500000 700000 -200000
140.0
0
United Fund @ Rs.50,000 per CHC
per year
250000 306695 -56695
122.6
8
TOTAL Strengthening PHC’s 8898000 1975175 6922825 22.20
Maintenance grant @ Rs.50,000 per
PHC per year
700000 490057 209943 70.01
United Fund @ Rs.25,000 per PHC
per year
325000 268513 56487 82.62
District Hospital Rs. 5,00,000 per DH 500000 209192 290808 41.84
Total RKS 3200000 2539853 660147 79.37
One of the important initiatives under NRHM program was combined utilization of RCH II
and NRHM program fund. The analysis of expenditure of budget reveals that though the
utilization of RCH fund is substantial, utilization of NRHM fund has been less than 50%.
Also the combined program fund utilization is only 66% which reflects poor management of
the finances.
The expenditure on maternal health & child health is quite heartening but at the same time
expenditure on other components of NRHM is inadequate thus confining NRHM to Maternal
& child health defeating the purpose of the program to have comprehensive health
development. Expenditure on strengthening CHC is more than what was budgeted whereas
on the other hand expenditure on strengthening SHC and PHC, which are the door step
services of the community have been poor. Also fund allocated to the grass-root point of
service delivery i.e. SHC & Village Health & sanitation committee has been poorly utilized.
Clearly, overall financial management needs to be fortified.
INNOVATIONS
Nutrition Rehabilitation Centre
The nutritional status of the population is an important indicator of the development of the
society. Mortality rates, micronutrient deficiencies and malnutrition status are some of the
important indicators that can be used to assess the health status of a specific area. Overall
nutritional status is poor in the state as reflected by the occurrence of 82.6% anaemia in
children aged 6-35 months while about 57.9% women in the reproductive age group were
anaemic. Vitamin A supplementation (VAS) efforts in the state could not improve the uptake
and only 16.1% of children aged 12-35 months received a dose of vitamin A during the last 6
months. As well, 44.2 % of the rural women have BMI lower than the normal as against the
national average of 38%.
The state level situation of malnutrition among children is well represented by the Guna
District. The Infant Mortality Rate of the district is 98 per thousand live births. The
malnutrition rate is about 50%. The severity of the situation is captured well in the recently

26
concluded ninth round of Bal Sanjivan Campaign held during the month of January –
February 2008. The details are summarised below in the table:
Sr.
no.
Grade Guna
(R)
Guna
(U)
Bamori Aron Raghogarh Chanchora Total
1. Normal 13560 9137 10733 7584 15311 15953 72278
2. Grade-1 9246 5014 7111 5260 10593 7805 45029
3. Grade-2 4067 2294 2893 4307 5868 4128 23557
4. Grade-3 182 80 161 48 48 97 616
5. Grade-4 37 18 41 19 15 27 157
6. Total 27092 16543 20939 17218 31835 28010 141637
Thus for improving the overall health status of children in the age group 0 -5 years was one
of the biggest challenge in the state as well as Guna District.
Bal Shakti Yojna:
(Scheme for Medical Treatment and Nutritional Rehabilitation of Severely
Malnourished Children)
Bal Sanjeevni Campaign is organised in the state of Madhya Pradesh in two rounds every
year. This scheme of Bal Shakti Yojna has been envisioned following the Bal Sanjeevni
Campaigns under which as many as 10913 under-5 children were identified to be suffering
from Grade 4 level of malnutrition and 67352 from Grade 3 level malnutrition and that
majority of these children belong to poor and weaker sections.
Purpose
The scheme aimed at arresting the rate of severe malnutrition seeks to bring about reduction
in Grade 4 and Grade 3 levels of malnutrition among all children by one per cent.
Essential Features
• All children identified as Grade 4 and Grade 3 levels of malnutrition under each round
of Bal Sanjeevni Campaign are provided requisite medical treatment.
• Parents/guardians of the identified malnourished children are provided counselling
regarding the significance of nutritional diet. Also, they are trained in preparing
nutritional diet from low-cost and locally available foods.
The Scheme is implemented in following stages:
Stage I: Organising of Health Check Camps
One day health check camps are held at block levels wherein all malnourished children. The
camps are organised by CM&HOs in coordination with DWCDOs. Services of 2
pediatricians are made available at these camps and if required private pediatrician's services
are hired @Rs.800/- per day. A provision of Rs. 20,000/- per camp is made for organising
these camps. The amount includes expenditure in respect of mobilizing doctors, camp
arrangements, transport of children from their homes to camp and back, camp to hospital and
back to home and medicines. Children requiring emergency medical attention are admitted in
nearby appropriate hospitals on the same day. Children who are not admitted, their parents
are advised regarding home based care, given medicines and their mothers are included in
training on nutritional rehabilitation.

27
Stage II: Training in Nutritional Rehabilitation
One member of each family of those children who are not admitted, particularly the mother
are given a one day training at the sector level. The training includes care of malnourished
children and preparation of low-cost and local foods based nutritional diet. A provision of
Rs.60/- per participant is made for these trainings.
Stage III: Institutional Medical Care and Nutritional Rehabilitation in NRC
This includes hospitalization of children from 7 to 14 days under the care of pediatricians.
Mothers of these children are required to be with the children who are given training in
preparation of low cost nutritional diet. Mothers are given an amount of Rs.100/- per child for
expenses in respect of transportation of children to the hospital.
At the time of discharge, a follow up card is given to the mother and the ANM. The children
are followed up by the ANM and AWW for 6 months during which 4 visits are made, one in
the first week, second in the first month, third in the third month and fourth in the sixth
month. As per the scheme, the motivator who brings the malnourished grade III or IV child to
the NRC is given an incentive of Rs. 100 per child. As the mother of the child has to stay
with the child at the centre, she is given an amount of Rs. 35 per day towards compensation
of wages for the period of stay. Additionally, Rs. 300 is provided towards transportation cost
and Rs. 700 so that the child can continue with the nutritional diet.
Under this scheme a total of 93 NRCs have been operationalised at District and sub district
level in the premises of the government health facility. In Guna district, 2 NRCs are
operational located at the district hospital and Beenaganj CHC. The NRC at Guna is a 20
bedded facility and the NRC at Beenaganj is a 10 bedded facility. At the time of observation
all the beds were occupied at the Guna NRC. However, only 4 out of 10 beds were occupied
at the Beenaganj NRC. It was observed that the demand for such service is quite high at the
community and mostly the deprived sections are getting benefit out of it. At the Guna NRC,
all the 20 beds remain occupied and there are situations when the children have to wait to get
admitted. However, in critical case, the children are admitted even if the occupancy is full.
One important component of the scheme is the motivation amount being provided to the
ICDS worker for identification of malnourished children and referral to the NRC. Sometimes
in the lure of the incentive amount, some grade I and II children are being referred. There are
some similar operational issues which are cropping up which should not dampen the overall
spirit with which this novel scheme has been designed. Overall, in the longer duration this
scheme will contribute in reducing the malnutrition in the state if it is continued with same
vision and vigour.
Sick New Born Care Unit (SNCU)
Sick Newborn Care unit is a State of Art started in Guna on 14th
December 2007 with a
motive to bring remarkable improvement in infant mortality rate. It’s a 20 bedded Intensive
care unit for the new born (0-1 month) covered in 2000 square feet inside the campus of
District Hospital. The unit is equipped with modern equipments and machines to ensure
regulated temperature and intensive care to the sick new born.
Since its inception it has had approx 700 admissions with mortality rate of the admitted
children to approx 20%. When we visited the unit, only 1 bed was vacant i.e. 19 children
were under treatment. Though, the capacity of the unit is low as compared to the demand.

28
Informer
Driver
Delivery
Center
Call Center
software Call Center
Call Center
register
Informs
Driver
Details
Call
from
village
Informs
patient
Details
Transport
patient
Informs
Delivery
details
Delivery
details
are Filled
Patient
details
are Filled
Sometimes the number of critical children is more and bed has to be shared between 2
children so as not to deny the poor people.
The Unit is divided into three parts.
1. In Born unit – Children with critical condition born in the Hospital are kept in this
unit
2. Out Born unit – Children with critical condition born out of the hospital are kept here
3. Step Down Section - The Children whose condition becomes stable are kept in the
Step Down section for few days and then discharged.
There are 4 Doctors placed in SNCU supported by 14 Nursing Staff and 2 lab technician.
UNICEF has extended a financial support of approximately 25 lakhs for the set up of the unit
at the district. UNICEF also supports the salary of the doctors in SNCU. The other running
cost of the care unit is covered under NRHM. A similar two bedded set up has been
established at Beenaganj CHC but there is no specialized doctor to run the unit although,
there is one paediatrician who was out for training for the same at the time of our visit. It is
proposed to scale up the initiative to all IMNCI districts. The sustainability of the unit is a
challenge.
Call Centre
Call Centre is a 24 hours service established Under Janani Suraksha Yojana on 9th September
2007 to provide free of Cost round the clock Transport Service to Pregnant Mother’s and
severely sick children below the age of 6 years. The main objective behind the initiative was:
1. To optimize and regulate the use of Delivery Van’s stationed at District Health
Center’s.
2. To monitor the progress of No. Of Institutional Deliveries month wise in District
Health Center’s.
3. To accumulate the ANS List for all the blocks in the District
How it Works
Patients in need of Free Emergency Transport contact Call Centre on a Toll Free number 102
& 251560. 24 vehicles pooled from various sources for emergency transport of pregnant
women and sick children. All vehicles are equipped with Mobile phones for coordination.
Besides this UNICEF has given Mobile to Kotwars (Chokidars) under BCC Project earlier in
the villages. These are helpful in informing about expected delivery in remote areas and also
to triangulate information of any call received directly in call centre. These phones are under
BSNL corporate connection so the inter-calling is free.

29
MONTH WISE JSY FREE TRANSPORTATION COMPARISON GRAPH
Call Center, Guna(M.P)
0
62
128 125
234
292
386
771
546
645
602
587
648
0
701
767
0
100
200
300
400
500
600
700
800
900
A
pril
m
ay
june
july
A
ugust
septem
ber
O
ctober
N
ovem
ber
D
ecem
ber
January
February
M
arch
No.ofCasesTransported
JSY 2007-08
JSY 2008-09
The details of the delivery are entered into the software available at the call centre. Call
Centre Software is developed to automate and monitor the working of Call Centre. The sole
objective is to accumulate the free transportation details and generate Monthly Free
transportation report for the sectors, block & District. The patients details are filled in a
register maintained at the call centre.
The initial set-up cost was supported by UNICEF which included equipments (2 computer &
other furniture) and salary of 3 operators & Coordinator and Telephone & AC Bills. Later the
running cost was booked under NRHM. Only salary of the coordinator is supported by
UNICEF. Call centre has made remarkable difference as currently approximately 700-800
deliveries out of approx 2000 deliveries in the district are being conducted through call
centre.
Janani Express Yojna
The purpose of Janani Express Yojna is to ensure 24 hours transport availability at field level
in order to bring the pregnant women to CEmONC & BEmONC facility. The objective was
that the number of women missing on the benefits of Institutional delivery in absence of
transport facilities should be brought down to minimum. Transport is hired locally on
contractual basis for a period of one year on the basis of outsource criteria and made available
in the concerned area of Govt. Hospital, CHC, and PHC. 28 such vehicles are in place. All
the drivers have mobile and the process is coordinated through the call centre. All the
subcentres in the catchment area of the vehicle also have the driver’s number. Rogi Kalyan
Samitis play the key role in the all issues related with maintenance & operations of
contractual vehicle. The amount is recovered from the money designated for transport under
Janani Suraksha Yojna. Monthly supervision is done by the ANM in their respective area to
make it sure that the vehicle is made available on call. The patient’s details and the delivery
details have to be informed at the call centre, which is entered in software at the call centre.
Linking of these vehicles with the call centre has ensured effective and timely outreach to
pregnant women and effective monitoring of the deliveries in the area.

30
Deendayal Antyodaya Upchar Yojna
The Government of Madhya Pradesh has designed and implemented an innovative scheme
for socially and economically disadvantaged people of the society for providing access to
quality health care to the needy people like SC, ST and BPL families. The Scheme, known as
Deendayal Antyodaya Upchar Yojana was instituted on 25th
September 2004. It was further
modified in the month July, 2006 to extend the coverage to all below poverty line (BPL)
people in the state.
The scheme aims to provide access to SC, ST and BPL population to health care services.
Under the scheme free of charge health services upto the maximum limit of Rs. 20000/- in a
financial year in government health institutions is provided to all BPL families of the state.
One family health card is issued to each BPL family. This unique card consists of a
photograph of the head of household with details of all other family members. Hospitalization
and medical checkup details are registered in the card.
CONCLUSION
NRHM has identified communitization, flexible financing, innovations in human resource
management, monitoring against IPH Standards, and building capacities at all levels as the
principal approaches to ensure quality service delivery, efficient utilization of scarce
resources, and most of all, to ensure service guarantees at the doorsteps.
While there have been many positive outcomes like improved institutional delivery,
infrastructure & Neo-natal care under NRHM in Guna, but there has been vital support from
UNICEF at the same time. There are still many start-up activities that need to be initiated.
There is a lack of information and a need for widespread dissemination of information on all
aspects of the NRHM, especially ASHA. Community-level stakeholders like the Gram
Pradhan, ASHA and Village Health Committees need to be involved in planning,
implementation and monitoring of the NRHM through systematic inputs and capacity
building.
The institutional platform of Village Health and Sanitation Committees, the Rogi Kalyan
Samitis and the Panchayati Raj Institution committees at various levels is providing a rare
opportunity for convergent action on all determinants of health. Also, the other components
like AYUSH and Communicable/non-communicable diseases need to be strengthened.
The experience of the last three years gives the confidence that the program has the right
motive but we need to deepen institutional reforms and effective decentralization. Ultimately,
the success of NRHM will depend on the ability of the Mission interventions to galvanize
State Governments into action, pursuing innovations and flexibility in all spheres and
ensuring availability of fully trained and equipped resident health functionaries at all levels
and large scale demand side financing.

NRHM_Flagship Report_GUNA_MP

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