Evaluation of NRHM in Karnataka

1. Evaluation of NRHM in Karnataka Stakeholder Meeting

2. Agenda • Introduction to the project • Background • Request for support

3. Introduction • T o understand the planning and execution processes of NRHM in Karnataka • To understand the efficacy of allotment and flow of funds keeping the taluk as fundamental unit • To make policy suggestions for effective planning, allocation and utilization of funds for achieving goals of NRHM • Focus of the study • NRHM Fund Allocation, Structure and Design • NRHM’s Current Funding Allocation, its utilization, implementation, and its impact on Karnataka’s Health Indicators 3

4. Proposal • Phase I: NRHM Funds Allocation Structure and Design, current funding and utilization, implementation, and its impact on Karnataka’s Health Indicators • Phase 2: Field validation, stakeholder appraisal of NRHM’s planning processes at the local and regional level

5. Phase I • Study of existing planning and implementation processes • For identifying focus areas and prioritizing fund allocations • Study of current progress at the taluk level, • Health indicators, fund allocation and expenditure, status of physical infrastructure, human resources • What correlates with taluk health indicators? • Overall development status of the taluk • Funding allocated to that taluk • Physical infrastructure • Human resources • Community involvement • Certain combination of the above What is the optimum combination of inputs needed for improvement in health indicators at the taluka level? 5

6. Phase II • Understanding • Local NRHM related processes • NRHM’s planning, fund allocation and expenditures from the local perspective • Levels of community engagement, monitoring and ownership of public health systems • Validation and analysis of regional disparities. • Identification of local challenges and gaps. • Possible policy advocacy options obtained during this study 6

7. Background Study

8. Planning in NRHM Planning process envisioned to be Bottom up Decentralized Participatory Responsive to local needs Need based

9. Fund Flow in NRHM • Funds are released from the Centre through two routes : • Treasury and State Health Society • Funds released under following components through the society route • RCH Flexipool • Mission Flexipool • Routine Immunization • National Disease Control Programmes

10. GoI NRHM Managed by Financial Management Group (FMG) State Govt State Govt. Share (15%) Managed by FMG and State Health Mission (SHM) State Level Expenses State Health Society Managed by FMG and District Health Mission (DHM) District Level Expenses District Health Society Block, CHC, PHC, SC Regular/United/Maintenance Grants

11. A. RCH B. NRHM C. RI D. NDCP NRHM RCH and Mission Flexipool constitute the largest share and as such expected to have the largest impact SHM & SHS DHM & DHS NRHM NRHM RI Malaria TB Leprosy Blindness RCH

12. NRHM in Karnataka Releases and expenditure of the State Health Society from 2005-09 Fund utilization status (and hence absorption) has improved.

13. NRHM in Karnataka • Concerns of under-utilization of funds (James et al, 2009) (Gayithri et al, 2011) • Inadequate understanding of NRHM • Confusion over spending of Untied Funds • Mismatch between releases and expenditure • Regional Disparities (Gayithri et al, 2011) • Allocation to districts • Karnataka lags behind other southern states in terms of MMR (178) (SRS, 2009) • Kerala and TN have reached 100 • Estimated MMR of Karnataka in 2012: 130

14. NRHM – Field experiences • NRHM has played a major role in • improving infrastructure • increasing the reach of health services in rural areas • increasing institutional deliveries • reducing mortality rates • improving the overall general health of pregnant women and new mothers

15. NRHM – Field experiences • Acute shortage of human resources • ASHA, ANMS , Staff Nurses and Medical Officers • D Group, Accounts personnel etc • Issues in disbursal of funds in schemes like Prasuti Araike and Janani Suraksha Yojane • Additional responsibilities: More time spent on documentation and logistics, reduced field time for field workers and MOs • Lack of proper documentation of fund position • Many PHCs, (some lack infrastructure, some are under-utilized) • Availability of drugs • Mismatch in the planned and actual needs of the PHCs • Not many PHCs (and 24 X 7s) handle deliveries • True participation of VHSC and ARS in monitoring and management has a long way to go.

16. Request for Information and Support • Planning and Logistics • Approved Block Health Plans, District Health Action Plans and State PIPs • Additional documents related to Record of Proceedings (ROPs) • Circulars/Notifications/Training Manuals/ Guidelines sent to Districts and Taluks • Planning and logistics details (including roles and responsibilities) at the Taluk and District levels • Logic of Planning • How are targets set? On what basis are DHAPs and BHPs accepted/modified and funded (for all available years and units)

17. Request for Information and Support • Finance and Accounts related data • State level • Quarterly Financial Monitoring Reports (FMRs), Statement of Fund Positions (SFPs), State release of funds, Utilization Certificates (UCs) • State Health Society Audit Reports • District level (all districts) • FMR, SFP, and UC, logic of integrating Taluk SOEs to District FMR • District Health Society Audit Reports • Taluk level (all taluks) • Statement of Expenditures (SOE), SFP, and UC • PHC level • During phase 2, in selected PHCs • Linkage with state funds and Treasury route of NRHM (for all available years and units)

18. Request for Information and Support (for all available years) • Taluk/District level health personnel details and related financial information (salary and other components) • Medical Officers, ANMs, JHWs, ASHAs • Accounts personnel, pharmacists and lab technicians • Taluk/District level physical infrastructure details • District and taluk health outcomes and health indicators • If possible, Read-Only access to HMIS

19. References • Government of India (GoI) (2011), “Report of the Working Group on National Rural Health Mission (NRHM) for the Twelfth Five Year Plan (2012-2017)”, New Delhi, Planning Commission. • Gayithri, K and Thomas, E (2011), “District fund flow under NRHM and service delivery: Some insights from Karnataka, Bangalore, Institute for Social and Economic Change. • James, K.S et al. (2009), Rapid Appraisal of NRHM Implementation, Bangalore, Institute for Social and Economic Change.