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Item Performance Audit of National Rural Health Mission (NRHM) in Jammu and Kashmir(CAG of India, 2009) CAG of IndiaGovernment of India launched (April 2005) the National Rural Health Mission (NRHM) to carry out necessary architectural correction in the basic health-care delivery system. The Plan of Action includes increasing public expenditure on health, reducing regional imbalance in health infrastructure, decentralization and district management of health programmes, community participation and operationalising community health centres into functional hospitals. The performance audit review of implementation of NRHM in Jammu and Kashmir showed that the status of health profile of the State has been quite encouraging vis-à-vis the performance indicators available for the country. These can be further improved if there is proper fund management/utilisation and various sectors involved are covered in conformity with the guidelines issued for implementation of the Programme. There are large gaps in planning as well as implementation of the Mission activities in the State even after four years of launching the programme. This is evidenced by the findings that no new health centre was put in place, essential services and amenities were not available in many centres and there was critical shortage of technical manpower. Maternal and child health programmes have not made much headway. Planning, implementation and monitoring of the programme through participation of NGOs and community-based organisations was nonexistent.Item Performance Audit of National Rural Health Mission in Delhi(CAG of India, 2010) CAG of IndiaThe National Rural Health Mission (NRHM) was launched on 12 April 2005 to provide health to all in an equitable manner. In National Capital Territory (NCT) of Delhi, the Mission was launched on 2 October 2006. The funds are provided to the State Health Society on the basis of approval of State Programme Implementation Plans (PIPs) by the Government of India. The performance audit on implementation of National Rural Health Mission in NCT (Delhi) revealed that Delhi Health Society did not have clear assessment of health care as evident from the utilization of the funds released by Government of India. There were significant shortages in medical and para-medical staff vis-a-vis requirement as per NRHM norms. Community involvement in the implementation of the scheme was lacking. IEC activities were not implemented uniformly as a few districts were completely ignored while releasing funds for IEC activities. NGOs have also not been actively involved, as no funds were released to them during the year 2008-09.Item Performance Audit of National Rural Health Mission (NRHM) in Chhattisgarh(CAG of India, 2010) CAG of IndiaThe 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 State Government spent Rs 634.55 crore from the inception of the scheme till March 2009. There were savings of Rs 250.96 crore (28 per cent). There were instances of irregular expenditure, stage-wise planning was not done and the availability of health care infrastructure, doctors and supporting staff remained inadequate. While there were significant achievements in some interventions and the health indicators accordingly showed improvements, there were shortfalls in administration of iron-folic acid tablets, gender imbalance in sterilisation, low institutional deliveries, low detection of sputum positive cases and nonachievement of the norms of annual parasitic incidence. The indicators of maternal and infant mortality remained short of interim targets.Item Performance Audit of National Rural Health Mission (NRHM) in West Bengal (2005-2009)(CAG of India, 2010) CAG of IndiaGovernment 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.Item Performance Audit of National Rural Health Mission (NRHM) in Assam(CAG of India, 2008) CAG of IndiaThe 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.Item Performance Audit of National Rural Health Mission (NRHM) in Sikkim(CAG of India, 2009) CAG of IndiaA 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.Item Performance Audit of National Rural Health Mission (NRHM) in Meghalaya(CAG of India, 24-03-2017) CAG of IndiaPerformance 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.Item Performance Audit of National Rural Health Mission (NRHM) in West Bengal (2011-2016)(CAG of India, 07-03-2018) CAG of IndiaA 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.Item Performance Audit of National Rural Health Mission (NRHM) in Madhya Pradesh(CAG of India, 28-07-2010) CAG of IndiaThe National Rural Health Mission (NRHM) was launched in April 2005 by the Government of India to bring about significant improvements in the health status of the rural population. The Mission sought to provide universal access to equitable, affordable and quality health care facilities in rural areas. A performance audit of implementation of NRHM revealed that baseline surveys were not completed, Perspective Plans for the Mission and Annual Plans for districts, blocks and villages were not prepared regularly. The objective of the Mission to bring all health care activities under one umbrella was not achieved. The State Government did not contribute its share of 15 per cent funds during 2007-08. Funds amounting to Rs 2.12 crore were diverted from NRHM’s funds to a State scheme during 2007-08. Funds remained unspent at the State Health Society/ District Health Societies level, thus defeating the goal of improving public spending in the health sector. None of the health care centres in the State were upgraded as per the Indian Public Health Standards. Despite provision of contractual appointments, there was a shortage of medical and para-medical staff. In 10 out of 12 test-checked districts, 101 Primary Health Centres were functioning without doctors. The fifth module training was not imparted to any of the Accredited Social Health Activists in the State. In the test-checked districts, 49 to 58 per cent of pregnant women were not registered in health centres during their first trimester. Targets set for spacing and terminal methods for family planning were not achieved. The current status of maternal mortality rate and infant mortality rate in the State remained high. Spectacles were not supplied to 30,715 out of 57,191 children suffering from refractive errors during 2005-09 in the test-checked districts. Due to non-formation of monitoring and planning committees, appraisal and evaluation of activities could not be ensured.Item Performance Audit of National Rural Health Mission (NRHM) in Bihar (2010-2015)(CAG of India, 18-03-2016) CAG of IndiaFollowing 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.