National Rural Health Mission (NRHM)

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Performance Audit of National Rural Health Mission in Kerala (2012-2017)
(CAG of India, 18-06-2018) CAG of India
The Performance Audit was conducted to assess whether the interventions of the National Health Mission in the areas of maternal health, child health, family planning and immunisation during 2012-17 were effective in improving the health standards of women and children in the State. The Performance Audit attempted to assess whether the physical and human resources were adequate, the procurement of drugs and equipment were efficient and economical and whether the overall financial management was efficient and effective. The Performance Audit revealed deficiencies in providing delivery services to women, setting up facilities for newborn at delivery points, shortfall in infrastructure, etc., as detailed below. Government of Kerala did not release proportionate share of assistance of INR 323.22 crore during 2012-17. (Paragraph 2.7) Over 12 per cent of 24.95 lakh pregnant women who registered for Ante-Natal Care did not receive Iron and Folic Acid tablets. There was also shortfall in the percentage of women who received Tetanus Toxoid shots. (Paragraph 2.8.1) Thirty seven per cent of 24.95 lakh pregnant women were not tested for HIV. (Paragraph 2.8.2) Delivery facility was available only in 15 out of test-checked 65 institutions in selected districts, viz. Wayanad, Malappuram, Thrissur and Alappuzha. (Paragraph 2.8.4) There were deficiencies in providing free diet and other facilities to pregnant women under Janani Shishu Suraksha Karyakram. (Paragraph 2.8.8.1) Facilities like Newborn Care Corner and Newborn Stabilisation Units were not set up at all delivery points. (Paragraph 2.9.1) The objectives of District Early Intervention Centres for early detection, free treatment and management of children with health conditions were not attained as almost 83 per cent of 9,588 children identified in Alappuzha, Malappuram, Wayanad and Thrissur districts during 2016-17 did not report for further treatment. (Paragraph 2.9.3.1)
Performance Audit of National Rural Health Mission in Chhattisgarh (2012-2017)
(CAG of India, 10-01-2019) CAG of India
Audit reviewed the National Rural Health Mission (NRHM) scheme aimed to provide accessible, affordable, accountable, effective and reliable health care facilities in rural areas to strengthen public health systems. The State suffers from shortages of human resources in critical positions in the District Hospitals (DHs), Community Health Centres (CHCs) and Primary Health Centres (PHCs) which adversely affected the delivery of mandate of NRHM. These included shortages of specialist doctors to the extent of 89 per cent, Medical Officers (MO) by 36 per cent, staff nurses by 34 per cent and paramedics by 12 per cent against their sanctioned strengths. These shortages could not be bridged as 752 doctors appointed during 2012-13 to 2017-18 (February 2018) did not join the Department, for reasons not known to the Department. Even where doctors were available, the patients were still deprived of necessary treatments for various illnesses and diagnostic services in these health centres due to shortages of medical equipment, drugs and consumables, laboratory services, and were referred to other hospitals such as Dr. Bhim Rao Ambedkar Hospital, Raipur, Chhattisgarh Institute of Medical Sciences, Bilaspur etc., as observed from the indoor patient department (IPD) registers. The State could not create sufficient infrastructure to bridge the gaps between requirement and available health facilities as 186 construction works could not be completed by the Department despite lapse of 20 to 56 months from the date of sanction on grounds of non-participation of bidders, high tender premiums, delays in identification and finalisation of availability of land. The State suffered from significant shortages of essential drugs, consumables and equipment at various levels of health centers as Chhattisgarh Medical Services Corporation limited tasked with these supply failed on grounds of non-availability of rate contract for medicines, non-receipt of tenders, late receipt of annual demand from Directorate of Health Services etc. Due to shortage of specialists and MOs, the Department could not upgrade 39 per cent of targeted CHCs as first referral units and 45 per cent of targeted PHCs to provide 24x7 services.
Performance Audit of National Rural Health Mission (NRHM) in Rajasthan (2005-2008)
(CAG of India, 2009) CAG of India
Government of India launched the National Rural Health Mission in April 2005 throughout the country for providing accessible, affordable, accountable, effective and reliable health care facilities in rural areas. This performance audit of implementation of Mission in Rajasthan revealed that household survey and facility survey were not done adequately. Large number of building construction works was incomplete/ not started. Mobile Medical Units were not in operation. Blood storage units were not started. There were cases of denial and delayed payment of cash assistance to the beneficiaries under Janani Suraksha Yojana. The important findings are indicated below: 1. During 2005-08, only 65 per cent of the total available funds were utilised. Three District Health Societies had taken three to thirty months in transferring funds of Rs 16.87 crore to the implementing agencies. 2. Household survey and facility survey required to identify the health care needs of the rural areas were not conducted adequately. The test checked District Health Societies did not prepare Perspective Plan for the Mission period. Health Action Plan was not prepared in most of the villages, blocks and districts. Village Health and Sanitation Committees were formed in 16 per cent villages against the targets of 30 per cent upto 2007. 3. While 493 residential buildings completed at a cost of Rs 24.81 crore were not taken over even after two to ten months of their completion, 565 buildings were incomplete after incurring an expenditure of Rs 19.34 crore. Construction of 364 new sub-centre buildings was not started. 4. Against 46,624 Accredited Social Health Activists required to be selected by December 2007, 39,325 were selected by March 2008. Eighty per cent medical staff and 60 per cent para-medical staff were not imparted necessary training. There were gross deficiencies in upgradation of Community Health Centers in respect of manpower, infrastructure and equipment, as compared to Indian Public Health Standards norms. 5. Fifty-two Mobile Medical Units could not be made operational for want of vehicles for carrying equipment and diagnostic facilities. 6. Out of 137 blood storage units, 126 could not be set up as the generator sets and other equipment (Rs 2.56 crore) were not installed/ utilised for want of copper cable, earthing pits and construction of platforms. 7. There was significant shortfall (48 to 64 per cent) in DT and TT immunisation. Male participation in family planning was poor (24 per cent of targets). 8. Though there was an increasing trend in institutional delivery, shortfall was 45 per cent of the targets in 2007-08. Under Janani Suraksha Yojana, 2.78 lakh women were not provided cash assistance during 2006-08. In 614 cases, payment of cash assistance delayed by one to 18 months.
Performance Audit of National Rural Health Mission (NRHM) in Bihar (2010-2015)
(CAG of India, 18-03-2016) CAG of India
Following are the main audit findings of this performance review of National Rural Health Mission in Bihar covering the period 2010-2015: 1. The financial statements of State Health Society, Bihar did not represent the true status of NRHM in the State as different figures were indicated in different financial statements as opening balances, funds received and expenditure for the same components. 2. Action plans were not decentralised with a bottom-up approach resulting in scant community participation in the Mission. 3. Despite completion of Mission period of 2005-12, nearly half of the pregnant women in the State failed to register in the first trimester of pregnancy. This resulted in inadequate antenatal care which along with deliveries at home in nearly half of the cases due to insufficient healthcare facilities caused the Mission to miss the targeted Maternal and Infant mortality rates. 4. Despite shortage of physical infrastructure and availability of funds, construction of buildings for health care units and trauma centres were not completed. 5. Procurement system of drugs was not efficient as liquidated damages and undue advances were not recovered from agencies. Quality of biological drugs were not ensured in the State; 6. AYUSH set up was not provided in each RH/PHC and regular supply of AYUSH drugs were not ensured. 7. The Kala-azar Elimination Programme was marred with shortage of manpower and delayed spray of DDT etc. and missed the target date; 8. National Programme for Control of Blindness Suffered due to inadequate infrastructure and shortage of manpower. National Leprosy Eradication Programme missed the goal of leprosy elimination due to shortage of specialised medical staff. 9. Fifty seven per cent posts of Medical/Specialist Medical Officers was lying vacant while there was shortage of 29 to 72 per cent of para-medical staff in the State. 10. Monitoring and evaluation was deficient due to non- constitution of Health Monitoring Committees at various levels.
Impact of National Rural Health Mission on Reproductive and Child Health in Assam (2011-2016)
(CAG of India, 15-09-2017) CAG of India
Reproductive and Child Health (RCH) is the most important programme under NRHM for improvement of Maternal and Child Health care. Considering the substantial expenditure (Rs 4,461.92 crore) incurred by the State Government of Assam under the programme during 2011-16 and with a view to assess the impact of NRHM on RCH, the Performance Audit (PA) of the programme was taken up. In the PA, efforts of the State Health Mission (SHM) on improving RCH in terms of availability of infrastructure, health care personnel, the quality of health care provided, achievement relating to Infant Mortality Rate (IMR), Maternal Mortality Rate (MMR) and Total Fertility Rate (TFR) and related health information and management system under the programme were reviewed highlighting the areas of concern which need to be addressed for achieving the intended goals. It was noticed in audit that 98.13 per cent children up to one year of age were immunised and 98.57 per cent of the target for pulse polio administration was achieved under the programme which was high but 100 per cent immunisation to eradicate Polio from the State was yet to be achieved. Increase in institutional deliveries and providing Post Natal Care facility was also seen. The percentage of Pregnant Women (PW) who received 3rd Ante Natal Care (ANC) in the 28 to 32 weeks of pregnancy increased from 71 to 87 per cent during 2012-16. The rate of still birth had also reduced simultaneously and came down from 2.55 to 2.05 per cent. There were, however, areas of concern like shortfall in infrastructure and health care professionals, 85 per cent of home deliveries remained unattended by Skilled Birth Attendant (SBA), PW/mothers had to spend their own money for conducting deliveries in government health centres against the norm of free and no expense delivery, non-achievement of target of reduction in MMR, IMR and TFR and some other related issues which would require action on the part of the NRHM, Assam on priority basis.
Performance Audit of National Rural Health Mission (NRHM) in West Bengal (2011-2016)
(CAG of India, 07-03-2018) CAG of India
A performance audit of the NRHM implementation in West Bengal, covering a period from 2011-12 to 2015-16, has thrown light on various areas of deficiencies, which call for immediate attention of the Government. The State had not set any benchmark of its own in respect of availability of health facilities vis-à-vis population or distances. However, as compared to the Indian Public Health Standards (IPHS) norms, there was shortfall in the number of health centres resulting in health centres being burdened with far larger population than recommended as per the IPHS norms. Even the existing health centres lacked basic facilities e.g. running water supply, uninterrupted electricity, staff quarters, etc. Progress in the construction of buildings for health facilities lagged behind the targets. Failure in sorting out land problems as well as under-performance of implementing agencies factored behind such slow progress. Even a good number of the created/ upgraded infrastructure like Primary Health Centres (PHCs) with round the clock delivery service etc. could not be made functional depriving the public of the emergency obstetric care. This had in turn put additional pressure of patients on the Sub-Divisional Hospitals/ District Hospitals affecting the quality of service at those points too. Round the clock services were further affected by reluctance of the health centre staff in staying in quarters attached to the hospitals. While a large number of quarters constructed for Auxiliary Nursing Midwives remained vacant, a number of staff quarters also remained in dilapidated conditions. Installation of New Born Care Corner and New Born Stabilisation Units without proper planning and necessary training of the doctors/ staff resulted in a number of such facilities remaining idle. Shortage of doctors, Nurse and other support staff were observed at every level. Not only the number of posts fell short of the posts required under IPHS norms, but also there were substantial vacancies against the sanctioned posts. Ante-natal and Post-natal care and other health related services could not be extended to a considerable number of villages due to shortfall in appointment of ASHA workers. Though the Quality Control Committee and the Quality Control Team were formed up to district level, these were yet to start functioning in a meaningful way. Village Health & Sanitation and Nutrition Committees and Rogi Kalyan Samities were found to have been either not formed or non-functional in the test-checked districts.
Performance Audit of National Rural Health Mission (NRHM) in West Bengal (2005-2009)
(CAG of India, 2010) CAG of India
Government of India launched National Rural Health Mission (NRHM) for providing accessible, affordable, effective and reliable health care facilities in rural areas. This performance audit of NRHM in West Bengal for the period 2005-2009 revealed that implementation of NRHM was affected by the absence of reliable baseline data, as household and facilities surveys were not conducted. Village Health and Sanitation Committees (VHSCs) had not been formed by Gram Unnayan Samitis. Rogi Kalyan Samitis are yet to adequately fulfill their role in monitoring and supervising the functioning of health care centres. The population-health centre ratio was much higher than that prescribed under NRHM. Health centres often lacked basic infrastructure (good quality building, electricity and water supply, etc.) as well as guaranteed facilities (inpatient services, operation theatre, labour room, pathological tests, X-ray, emergency care, etc.). Shortage of specialist medical and nursing staff at different levels of health centres continued to be a cause for concern. There was also substantial shortfall in engagement and training of Accredited Social Health Activists.
Performance Audit of National Rural Health Mission (NRHM) in Uttarakhand (2008-2013)
(CAG of India, 27-11-2014) CAG of India
This performance audit of National Rural Health Mission (NRHM) in Uttarakhand for the period 2008-2013 revealed that Household surveys and facility surveys intended for identifying the healthcare needs of the people at bottom level were not conducted in the State. District Health Action Plans for the year 2008-09 to 2012-13 were prepared without aggregating the Block and Village Health Action Plans. Against the availability of Rs 778.28 crore during 2008-09 to 2012-13, Rs 650.10 crore were spent and Rs 12.41 crore were returned to Gol, thereby, leaving Rs 115.77 crore unspent. Despite incurring an expenditure of Rs 64.23 crore, the Department failed to get any input in planning and monitoring of implementation of NRHM from VHSSCs, besides utilization certificates for Rs 330.44 crore were also not obtained from VHSSCs. Under Janani Suraksha Yojana, the Department made delayed payment of Rs 32.98 crore to the beneficiaries. Due to excessive procurement, Drug Kits (A&B) valued at Rs 1.21 crore expired in Drug Warehouse and equipment worth Rs 2.18 crore were lying idle in the test-checked CHCs and PHCs. An undue payment of Rs 7.95 crore was made to a service provider (108-emergency response services) and operational cost of Rs 3.20 crore was also not recovered from it.
Performance Audit of National Rural Health Mission (NRHM) in Uttarakhand (2005-2008)
(CAG of India, 2009) CAG of India
Performance review of the National Rural Health Mission (NRHM) activities in Uttarakhand for the period 2005-08 brought out several positives like introduction of ‘Dial-108’ emergency ambulance service, which has got overwhelming response from the public. In maternal and child health care, there was a marginal increase in institutional deliveries. ‘ASHA-Plus’ scheme introduced in two districts, is a unique feature run with NGO collaboration. The cure rate targeted for tuberculosis and cataract operations was achieved in all the three years, while the State has brought down the leprosy prevalence rate in the year 2005 itself. However, there were major areas of concern requiring corrective measures as brought out below: The objective of decentralized planning with community participation was not achieved. The community was not involved in any aspect of health care system neither in planning nor in implementation and monitoring. Block and village plans, which were to form the basis for district plans, were not prepared. District health authorities did not own up the district level plans prepared with outside support. Baseline survey of availability of services at various levels of heath care system was incomplete. Household survey was not conducted. Convergence with other departments in implementation of the programme was also ineffective. The Village Health and Sanitation Committees (VHSC) at villages and Rogi Kalyan Samitis (RKS) at PHCs were not formed and public hearings (Jan Sunwai) were not conducted. NRHM envisaged streamlining the fund flow for health care services and improving coordination by merging all the existing societies and providing a single window for all the Mission activities. However, independent societies are functioning for disease control programmes in the State. Although the State has increased the expenditure on health in all the three years, it failed to contribute its share of 15 per cent to NRHM kitty in the year 2007-08. Fund releases to the districts were not proportionate to the population of the district and the State was unable to absorb the increased funding. 35 per cent of the funds remained unutilized even as the infrastructure in the health centres remained inadequate. Basic records of accounts were not maintained properly either at the State or the district level. Infrastructure creation/up-gradation- both physical and human, is an area where the State fared poorly in achieving the targets set by the Mission. In the absence of critical equipment in Operation Theatres and diagnostic and laboratory services, the viability of upgrading CHCs as the First Referral Unit (FRU) remained questionable and the provision of reliable and quality health service at an affordable cost remained unfulfilled. This also resulted in low bed occupancy at the PHCs and CHCs, thus shifting the burden to district hospitals. Mobile Medical Units (MMU) were not purchased despite availability of funds. Severe shortage of skilled manpower and skewed deployment of the available manpower appears to cripple health infrastructure in the State. Delay in completion of construction of health centres led to cost overrun. Centralized purchase of drugs, not linked to field level requirements, led to several anomalies. In all the sampled districts, the ANMs/ Pharmacists were distributed Schedule H drugs, which are to be issued only on the prescription of Registered Medical Practitioners. Expired ORS sachets were dumped in large quantities in the backyard of the State Health Society building. RCH was plagued with considerable over-reporting in achievements especially in immunization and distribution of Iron Folic Acid (IFA) tablets among expectant mothers. 55 per cent of women in the State are reported to be anaemic and 300 women in every one lakh pregnancies die in labour in the State. In the three sampled districts, the stock of IFA tablets was sufficient to cover only 3.4 per cent of the registered pregnant women but the number reported was 25 times the actual. Janani Suraksha Yojana, meant to incentivize women to opt for institutional delivery through payment at the time of discharge from the hospital, could not ensure that payments were released to the beneficiaries on time, despite availability of funds. The beneficiary-survey revealed that awareness of NRHM and benefits flowing through it were confined to a small section of the society, indicating ineffective coverage of IEC activities. Visits by the ANMs to the villages were not being undertaken at the prescribed intervals due to excess workload and topographical conditions of the areas and large population coverage. There were delays in payment to ASHAs and lack of facilities in the sub district health centres and distance factor forced the beneficiaries to prefer home deliveries. Availability of medicines through the hospitals was inadequate and the beneficiaries had to partially pay for the medicines on each visit. Lack of coordination among AWW, ASHA and ANMs was also noticeable in some areas. Training to school teachers regarding NRHM is yet to be imparted. The findings of the performance audit indicate that the Mission goal of providing affordable, accountable, effective and reliable healthcare facilities is not moving at the desired pace. The State Government needs to initiate adequate measures and take appropriate corrective action expeditiously to ensure that the objectives of the Mission are achieved by the end of the Mission period (2012).
Performance Audit of National Rural Health Mission (NRHM) in Tripura (2011-2016)
(CAG of India, 15-03-2017) CAG of India
This performance audit of National Rural Health Mission in Tripura for the period 2011-2016 revealed that the State Government did not conduct household surveys to identify the local needs of health care. Village Health Action Plans were not prepared. Lack of proper assessment by the State Health Society (SHS) led to short release of Rs 273.46 crore by Government of India (GoI). Even out of the funds provided by GoI, SHS could utilise only 51 to 69 per cent during 2011-16. Rs 1.51 crore advanced to 116 officials was lying outstanding. The number of Sub Centres (SCs), Primary Health Centres (PHCs) and Community Health Centres (CHCs) were below the prescribed level by 12, 47 and 56 per cent respectively in the State. In the three test checked districts, there was a shortage of SCs, PHCs and CHCs by 11, 42 and 53 per cent respectively. 69.57 per cent test checked SCs were running without water supply and electricity and 34.78 per cent without toilets. There were no specialists in CHCs and Sub Divisional Hospitals. In 279 SCs there was no Auxiliary Nursing Midwife/Female health worker. Four test checked CHCs did not have facilities for Caesarean Section delivery and none of the 23 test checked SCs had facilities for institutional delivery. Although there was a high prevalence rate of Anaemia amongst pregnant women (54.4 per cent) in the State, 36 per cent of pregnant women did not receive three Ante Natal check ups, and 40 per cent did not receive 100 Iron & Folic Acid tablets. State Quality Assurance Committee had not met even once till June 2016. Internal assessment and patient satisfaction survey was not done in any of the test checked facilities. Health Management Information System lacks data integrity. Hence internal control, supervision and monitoring were inadequate.
Performance Audit of National Rural Health Mission (NRHM) in Tripura (2005-2008)
(CAG of India, 2009) CAG of India
A mid-term review of the functioning of the State machinery in the third year of the National Rural Health Mission period (2005-2012) was an attempt to highlight the areas and issues which need to be addressed, for successful achievement of the objectives set out for the Mission. Preparation of the State and District plans was outsourced and the objective of community participation in planning process could not be ensured. The basic village level data used for preparation of District and State plans were not available with the Society, casting doubts over the reliability of the inputs in the planning process. Health Management Information System (HMIS) phase-1 could not be made functional even after expending the entire project funds and expiry of the stipulated time schedule. ASHA network could not materialise even after three years of implementation of NRHM as the training requirements could not be completed. Despite transferring funds to various implementing agencies (BDO, DM and PWD) for development of infrastructure, most of the construction works remained incomplete, due to non-stipulation of the timeframe for their completion.
Performance Audit of Reproductive and Child Health under National Rural Health Mission (NRHM) in Telangana
(CAG of India, 29-03-2018) CAG of India
The Reproductive and Child Health (RCH) programme initiated under NRHM in Telangana emphasised public health measures essential for enhanced maternal and child survival and lower RCH morbidity. The performance audit of Reproductive and Child Health under National Rural Health Mission was conducted (during April to August 2017), covering the period from 2012-13 to 2016-17. Annual Facility level surveys for identification and fixing of decentralised monitorable goals, indicators and gaps/deficiencies in the existing healthcare facilities and areas of interventions were not conducted. Bottom-up and community owned approach to public health planning was also not followed in preparation of State Program Implementation Plans (SPIPs). The Department had not utilised fully the funds released in any of the years under review. Utilisation ranged between 38 and 44 per cent only during 2012-14 and between 39 and 46 per cent only during 2014-17. Shortfall in spending on maternal health ranged between 31 to 50 per cent during 2014-17. The expenditure on child health component did not exceed 26 per cent of the approved outlay in any year during the period 2014-17. The institutional deliveries declined from 69 per cent (2013-14) to 42 per cent (2016-17) in public health facilities as compared to deliveries in private health facilities which registered an increase from 31 to 58 per cent. Telangana had a very high rate of Caesarean-section deliveries at 45 per cent out of the total deliveries reported in the State. In private health institutions it was higher at 67 per cent. Adequate attention on availability of required physical as well as human infrastructure in the health facilities was not accorded. Maternal Death Review (MDR) and the Infant Death Review (IDR) were largely not conducted. In other cases, these Reviews were ineffective. The State had achieved 100 per cent immunisation of children of 0 – 1 year age group. Maternal Mortality Ratio and Total Fertility Rate was satisfactory at State level.
Performance Audit of National Rural Health Mission (NRHM) in Tamil Nadu
(CAG of India, 2009) CAG of India
A performance audit of the implementation of NRHM in Tamil Nadu revealed that though baseline surveys were completed, Perspective Plans for the Mission, Annual Plans for districts, blocks and villages were not prepared regularly. Rupees 62 crore, meant for activities such as hiring private anaesthetists and paediatricians and providing facilities for basic emergency obstetrics and newborn care were not utilised in the seven test-checked districts. Funds amounting to Rs 53.95 crore were diverted from NRHM’s funds to various State and Central schemes during 2006-09. Block Primary Health Centres, Primary Health Centres and Health Sub Centres were not provided with adequate staff as per Indian Public Health Standards. None of the 21 test checked Block Primary Health Centres in the seven districts had blood storage facilities, 18 of the 21 Block Primary Health Centres and 41 of the 42 test checked Primary Health Centres did not have casualty rooms and 39 of the 42 Primary Health Centres did not have operation theatres. Against 1,242 personnel required for programme management units, only 52 persons were appointed. Spectacles were not supplied to 1,89,695 out of 3,53,575 children suffering from refractive errors during 2005-09.
Performance Audit of National Rural Health Mission (NRHM) in Sikkim
(CAG of India, 2009) CAG of India
A mid-term review of National Rural Health Mission (NRHM) in Sikkim in the third year of the Mission period (2005-2012) revealed that the State was performing fairly well in the areas of demographic goals (infant mortality rate, total fertility rate, immunisation etc.) and implementation of National Disease Control Programmes (NDCP) (control over blindness/ tuberculosis/ leprosy/ vector borne diseases etc.). The State has adequate physical infrastructure at the PHSC and PHC level and deployment of paramedical staff is adequate. However, the implementation of NRHM suffered from deficient financial management resulting in huge unspent balance to the tune of Rs. 44.43 crore (82 per cent) as on 31 March 2008. While the progress of civil works relating to the health infrastructure is very slow, health care remained mainly dependent on the health institutions of the Government due to very low number of private health facilities in the State and the number of referral cases to outside the State remained quite high.
Performance Audit of National Rural Health Mission (NRHM) in Rajasthan
(CAG of India, 30-03-2017) CAG of India
This performance audit of National Rural Health Mission in Rajasthan for the Period 2011-2016 revealed that the Department of Medical, Health and Family Welfare did not follow"bottom up approach. Baseline survey comprising of Household Survey and Annual Facility Survey was not conducted in the State during 2011-16. Annual State Programme Implementation Plans were submitted with delays and consequently approval of GoI were also delayed. Health centres were constructed at inaccessible and uninhabited locations and contracts for construction of buildings were awarded to the contractors without ensuring the availability of land. Less number of health centres were provided in the tribal areas as compared to non-tribal areas. Rural Health Centres (Community Health Centres (CHCs), Primary Health Centres (PHCs) and Sub Centres (SCs)) were having more shortages of essential equipment as compared to District Hospitals. Further, equipment were lying unutilised due non-availability of trained staff. There were shortages in the availability of essential drugs particularly at CHCs and PHCs. There was a 62.93 per cent shortage of manpower in health centres located in rural areas. Only 64.73 and 58.45 per cent persons were appointed on contractual basis during 2014-16 respectively. There was shortage of 12.73 per cent in selection of Accredited Social Health Activists (ASHAs) and only 42.90 per cent of ASHAs could be imparted induction training in the State. The percentage of women registered in first trimester of the pregnancy, though increased from 46.59 per cent to 60 per cent during 2011-16, yet 26.93 per cent to 31.02 per cent pregnant women did not get all three mandatory checkups. Only 67.77 per cent pregnant women were given Iron Folic Acid tablets. There was no significant variation in institutional deliveries in the State during 2011-16.There was significant shortfall in Measles, Oral Polio Vaccine booster, Diphtheria, Pertussis and Tetanus booster and Tetanus Toxoid 10/16 immunisation. Involvement of men in the family planning process continued to be abysmally low. State Health Society utilised 75.11 per cent fund during 2011-16. Instances of delay in release of proportionate share by the State Government, diversion of funds, huge unadjusted advances were noticed. State Health Mission did not hold any meeting during 2011-16 and only two meetings of Governing Body were conducted. The State continues to lag behind the All India Average and stood at 23rd position (out of 28) in Infant Mortality Ratio, 25th position (out of 28) in Maternal Mortality Ratio and 17th (out of 20) in Total Fertility Rate.
Performance Audit of National Rural Health Mission (NRHM) in Pondicherry
(CAG of India, 2010) CAG of India
The National Rural Health Mission was launched in April 2005 with the aim of providing accessible, affordable, accountable, effective and reliable health care facilities in rural areas. The Pondicherry State Health Society could spend only Rs 13.37 crore (56 per cent) out of Rs 23.79 crore made available to them during 2005-09. The objective of long-term and bottom-up approach in planning was not attained. There were instances of inadequate health care services and infrastructure as well as shortages of medical and paramedical staff. There were shortfalls in administration of iron-folic acid tablets and Vitamin A solution. Cases of gender imbalance in sterilisation, decline in the number of institutional deliveries and treatment of in-patients in community health centres/primary health centres were noticed. The infant mortality rate and the total fertility rate did not show any improvement since the inception of the Mission.
Performance Audit of National Rural Health Mission (NRHM) in Odisha
(CAG of India, 28-07-2014) CAG of India
This performance audit of National Rural Health Mission in Odisha for the period 2007-08 to 2012-13 revealed that planning was deficient due to non preparation of perspective plans and annual action plans at the State, District and Block level, District Health Action Plan was prepared for only four out of 30 districts. Gaon Kalyan Samiti (GKS) meant to work as community level platform to facilitate public health activities were belatedly formed and still 63 GKSs remained to be formed in targeted villages. Also delay in formation of GKS led to short receipt of GoI assistance of Rs 18.52 crore. There were delays in release of GoI installments upto 157 days due to delay in submission of Project Implementation Plan (PIP) by State. Spending efficiency at State Level ranged between 36 and 66 per cent of funds available during 2007-13. State healthcare spending remained below three percent of total budget against prescribed eight per cent due to less allocation by the State. Though maternal mortality rate was reduced from 303 in 2007-08 to 237 in 2011-12, yet the same was above the national average. Similarly, infant mortality rate was reduced from 71 to 57 against the national average of 55 to 44 during 2007-12. Despite increasing trend of institutional deliveries in the State, position was not satisfactory in Koraput, Nabarangpur, and Kalahandi districts where it remained between 13 to 64 per cent. Delivery of Health care was affected due to absence of required health institutions in the State as per Indian Public Health Standards (IPHS) norms. There were shortages of 3284 SHCs (33 per cent) and 370 PHCs (23 per cent). Despite stipulation in IPHS to have their own buildings, 91 PHCs and 2969 SHCs were functioning in private buildings in the State. Due to lack of adequate monitoring, progress on infrastructure was not satisfactory as only 2491 (50 per cent) works were completed out of 5028 works sanctioned during 2007-13. Of the above, 1051(21 per cent) works were lying incomplete after incurring expenditure of Rs 40.01 crore and the balance 1486 (29 per cent) works were not yet started. Facilities for pathological tests were not available in 13 (54 per cent) test checked CHCs whereas X-ray and Electro Cardiogram (ECG) were not available in all the 24 test checked CHCs. Against IPHS norms for posting of 10,594 doctors in the State, 5077 doctors were sanctioned and 3435 (32 per cent) were in position as of March 2013. Though 1075 specialist under 17 categories were essential for DHHs, only 603 specialists were available. Similarly, as against requirement of 20,064 health workers for SHCs in the State, 10914 (54 per cent) were in position. No staff nurse and lab technicians (LTs) were posted despite stipulation in IPHS to post five Staff Nurses and two LTs in each PHC. Besides, 59 per cent (1534) of pharmacists were found short in PHCs. Training programme for skill development fell short of the target by 29 percent during 2007-13. Services of trained doctors were not utilised as 17 trained doctors in Skilled Birth Attendance (SBA) and 11 in Life Saving Anesthesia Skill (LSAS) were not deployed for respective service. All types of essential drugs were not available in sampled DHHs, CHCs and PHCs. Drugs of Not of Standard Quality (NSQ) of Rs 5.80 lakh and Life expired drugs of Rs 0.74 lakh were administered to patients. Monitoring was weak, inadequate holding of meetings by State and District Health Missions, non formation of Health Planning and Monitoring Committee were noticed. Thus, the objectives of the mission t o provide accessible, affordable, reliable and quality health care to the rural population sought to be achieved through NRHM remained largely unfulfilled.
Performance Audit of National Rural Health Mission (NRHM) in Meghalaya
(CAG of India, 24-03-2017) CAG of India
Performance audit of National Rural Health Mission in Meghalaya for the period 2011-2016 disclosed shortages in availability of required healthcare facilities such as Public Health Centres and Sub Centres, unavailability of essential drugs, lack of infrastructure in the health facilities, equipment lying unutilised etc. Required infrastructural facilities viz. operation theatres, blood bank facility, water supply, telephone connections, etc. were not found available in selected healthcare facilities. In other cases, infrastructure was created but were lying unutilised for want of required personnel to operate them. Shortages in availability of required manpower, especially medical specialists was a serious impediment in the proper delivery of healthcare services. A large number of pregnant women did not show up for antenatal care while a number of them did not receive the full dose of Iron Folic Acid tablets. 47 per cent to 51 per cent of registered pregnant women preferred delivery at home rather than at health facilities. There was shortfall in achievement of immunisation as well as sterilisations. There was shortfall in payment of Janani Suraksha Yojana incentive despite availability of funds. All these indicated that the State Government had failed to connect the scheme with the people who are the stakeholders. The Quality Assurance Committees at various levels did not meet at the prescribed intervals to assess the quality of the services being delivered. Mismatch of data as per Health Management Information System and data as per original records maintained at the healthcare facilities was noticed. Monitoring of the Mission by State Health Mission headed by the Chief Minister was absent while monitoring by State Health Society headed by the Chief Secretary was minimal thus indicating that adequate priority was not being accorded to the health sector in the State. Considering that there is a strong correlation between facilities created and health outcomes (infant mortality rate, maternal mortality ratio and total fertility rate), the deficiencies were responsible in preventing the State from achieving the targets set by GoI.
Performance Audit of National Rural Health Mission (NRHM) in Manipur
(CAG of India, 24-03-2011) CAG of India
The National Rural Health Mission was launched in the Manipur in November 2005. The review revealed that the Department did not achieve the goal set for the health indicators i.e. Infant Mortality Rate, Maternal Mortality Rate and Total Fertility Rate by March 2010. Planning process was inadequate as it was prepared without baseline survey inputs. As of March 2010, the State was yet to carry out a comprehensive household and facility survey to identify the gaps in health care facilities. Up-gradation of Community Health Centres, Primary Health Centres and Sub-Centres to the level of Indian Public Health Standards had not been achieved. While the percentage of fully immunized infants ranged between 69 and 81 per cent during 2005-06 and 2007-10, it exceeded the target during 2006-07. There was an absence of monitoring and evaluation mechanism. As of December 2010 all the vertical diseases control programmes had not been merged with the Mission.
Performance Audit of National Rural Health Mission (NRHM) in Maharashtra
(CAG of India, 2010) CAG of India
This performance audit reveals that even after four years of its launch in April 2005 and a mammoth spending of Rs 1130 crore, the Government of India sponsored National Rural Health Mission programme in Maharashtra has still not been able to come out of its initial hurdles, such as lack of reliable beneficiary database, improper planning etc. The performance audit noted serious gaps in the delivery of mission objectives. Although the mission made considerable progress in achieving Revised National Tuberculosis Control Programme, Infant Mortality Rate and Total Fertility Ratio targets, these were overshadowed by suboptimal use of the available health care infrastructure such as mobile medical units. The Mission needs to seriously introspect into the functioning of the Rugna Kalyan Samitis besides upgrading the standards of PHCs and Sub-centres to the level of Indian Public Health Standards.