The National Rural Health Mission (NRHM) was launched in April 2005 throughout the country to provide accessible, affordable and reliable healthcare to the rural population, especially the vulnerable sections of the society. The programme envisaged convergence of various existing standalone health programmes, decentralization of the planning process with special emphasis on bottom-up approach in decision making and creating better linkages and cooperation among various social sector departments. A mid-term review of the implementation of the programme in the third year of the Mission period (2005-2012) in Assam is aimed at reviewing the initiatives taken by the State Government to bridge the gaps in healthcare facilities provided in the earlier programmes and highlight the areas and issues of concern, which need to be addressed for successful achievement of the objectives of the Mission by the target date. The performance review brought out several positives relating to maternal and child care services like increase in institutional deliveries as envisaged in the programme guidelines. Diseases like polio were contained and there were no cases of kala azar during 2005-07. There was a significant improvement in the cure rate of tuberculosis and the overall achievement of primary immunization of children in the targeted age group was quite high. There were, however, many areas of concern which require the attention of the State Government on priority basis. Foremost among these is the planning process. Community owned, decentralized planning as envisaged by the Mission, was not achieved as yet in the State. Household survey was not completed at all the levels – village, block and district and time bound action plans were not drawn up to achieve the objectives of the programme. Community based monitoring committees were also not formed at various levels. The State Government increased its outlay on healthcare during the review period in keeping with the programme guidelines. However, it failed to utilize the available funds optimally to strengthen the healthcare infrastructure and delivery at the grass root level. Fund management was quite poor and the State had not released its share of funds for implementation of the programme. Funds were released to the health centres in excess of the prescribed norms and in certain cases, funds were shown to have been released to non-existent dispensaries and subsidiary health centres. Basic accounting records were not maintained at both the State and the district level, leaving scope for fraud and misappropriation. Infrastructure, both physical and human, is an area where the State fared badly in achieving the targets set by the Mission. The number of health centres, especially in the tribal areas, was woefully inadequate resulting in non-achievement of the primary objective of the programme to provide accessible health facilities to the rural population. There was a delay in completing the construction of health centres and the basic facilities and diagnostic services were not available in a number of health centres that were sampled during audit, affecting the quality and reliability of health services in rural areas. There was a shortage of medical and support staff at the health centres, impeding the goal of providing quality healthcare. Procurement of medicines and medical equipments in the State was ad-hoc and the quality of drugs procured remained questionable. Considering that drug management is a critical input, delays, shortages or poor quality of drugs are likely to jeopardize the implementation of the programme. Information, Education and Communication (IEC) activities are meant to promote behavioural changes, increase the awareness of the public about their rights and available health facilities. The State could not achieve this objective of spreading awareness and dissemination of information regarding availability of and access to healthcare facilities for the rural population owing to lack of planning and implementation strategy in this regard. As regards maternal health, while there was a considerable improvement in the registration of pregnant women, they were not administered the prescribed dosage of medicines, due, apparently, to their non availability in sufficient numbers. The overall achievement in terms of maternal health was far from satisfactory and registration of pregnant women for systematic ante-natal check up and tracking was not in place. Scrutiny revealed that essential obstetrics care facilities were lacking in almost all the health centres. Reproductive healthcare was not accorded adequate attention and the complete details in this regard were not available with the district health authorities. There was a wide variation among the districts with regard to achievement of targets for immunization and the overall achievement, especially with regard to secondary immunization, was quite poor.