Organization

State Health Mission

At the State level, a State Health Mission headed by the Chief Minister has been constituted with similar composition, as that of the National Steering Group. State Health Mission’s role include the following:

• Actively undertake Policy and Institutional Reforms to enable effective implementation of NRHM

The State will review and amend existing policies (cadre management arrangements, financial and administrative authority at various levels, role of PRIs, procurement and logistics systems etc.) to ensure that the policy environment is consistent with the Mission objectives. Additional resources to be provided to the states under the Mission would require policy reforms to be in place.

• State level planning, implementation and monitoring

The State Health Plan (long term/annual) has been developed in accordance with the GoI Guidelines and necessary approvals from GoI and signing of a Memorandum of Understanding (MoU) with the MoHFW need to be taken. Implementation will have to be facilitated in line with the approved plan, monitor and take corrective action as and when necessary and carry out independent impact assessment studies (base-line, periodic) and take appropriate corrective action.

• Support District level planning, implementation and monitoring

The State will provide support in preparation of health plans by districts in accordance with the GoI guidelines through mobilization of technical assistance. The District Action Plans will be assessed on the basis of appropriate evaluation criteria that have to be made available to the districts in advance. A system for monitoring performance of districts against their own work plans and comparison across districts will also be developed.

• Provide Training support to districts

Various training programmes are being developed including management training modules for the programme managers and the staff of the State and district societies, designing “multi-skilling” training packages for doctors (e.g. anesthesia training for MBBS doctors) and paramedical workers (e.g. “multi-skilling” of lab technicians) and facilitate selection and training.

• Coordination across relevant departments

Mechanisms have been put in place to ensure coordination across Departments especially Health and Family Welfare, AYUSH, Department of Women and Children, and the Public Health and Engineering Department; to identify bottlenecks for effective delivery of services and to take necessary action through government orders or other means.

• Sharing of experiences across districts

Workshops will be conducted during various phases to disseminate experiences/ innovations/ lessons learnt across districts.

• Management of cash flows

Processes are being put in place for annual/ quarterly cash flow projections; closely monitoring and highlighting, well in advance, anticipated temporary shortage of funds. It will be ensured that funds are released to districts in accordance with the agreed district plans. The State will ensure that districts send their expenditure reports and other consolidated statements to GoI/ concerned agencies. Stringent monitoring mechanisms will be in place to ensure that all conditions are met for subsequent release of fund tranches.

• Financial accounting/ administration

The State will ensure maintenance of necessary books of accounts and ensure adherence to procedures laid out for procurements and payments. They will carry out audits of a sample of districts in each quarter, and facilitate the sharing of audit findings across all districts.

In order to meet the above objectives/ outcomes and carry out necessary tasks, the state has registered a single State Health Society through merger of all state level societies in the Health and Family Welfare sector, except the State Aids Control Society. These Societies will maintain separate Bank Accounts even under the unified structure. Funds for separate programmes would continue to flow under Sub-Budget Heads of the omnibus NRHM Budget Head. The Integrated State Health and Family Welfare Society has a full-time secretariat to act as the State Programme Management Support Unit (SPMSU), headed by a full time Executive Director. The SPMSU will (a) assist the Directorate of Health & FW in implementation, (b) act as the coordinating agency with other Departments for the Mission and (c) perform the role of the secretariat of the State Health Mission

At the district level all existing societies have been merged into the District Health Society with its apex body performing the functions of the District Health Mission(DHM). NRHM envisages financial autonomy and delegation of powers at the district level, to the District Health Mission led by the Zila Parishad. The DHM controls, guides and manages all public health institutions in the District. The NRHM hasl assisted in setting up the full time secretariat of the DHS. It is envisaged that the Secretariat of the District Health Society should have a small but dedicated unit for inter-sectoral co-ordination, which may directly report to the CEO, Zilla Parishad.

Roles and Responsbality of District Health Mission include:

• District health planning, implementation and monitoring

Districts would have to ensure preparation of a District Action Plan (long term/ annual) in accordance with the guidelines provided by the State (For Generic Guidelines on the District Action Plan please see Annexe 10) and obtain necessary approvals from the State Health Mission. Districts would have to facilitate implementation in line with the approved Plan. They would have to establish a system for monitoring performance against the approved plan, review monitoring reports, identify corrective action to be taken and follow up to ensure implementation. Monthly and quarterly progress reports would be sent to the State Mission while a block-wise monthly report will have to be provided to the members of the Governing Board of the District Health Mission.

• Coordination across relevant Departments

The DHM will have to ensure coordination across Departments especially Health and Family Welfare, AYUSH, Department of Women and Children, Rural Development, and the Public Health and Engineering Department, identify bottlenecks to effective delivery of services and take necessary action through government orders or other means.

• Management of cash flows

Districts will have to prepare annual/ quarterly cash flow projections; closely monitor and highlight, well in advance, anticipated shortage of funds. The DHM will have to follow up with State Mission to ensure that funds are released as per schedule.

• Financial accounting/ administration

Districts will have to ensure maintenance of necessary books of accounts and ensure adherence to procedures laid out for procurements and payments. Districts will provide necessary assistance to the auditors in carrying out their functions as and when required.

Members of District Health Society

State Programe Management Unit(SPMU)

In response to the lessons learnt from RCH-I and programme management support needs of RCH-II and National Rural Health Mission, the State Programme Management Unit (SPMU) have being established. The main objective of establishing this unit is to strengthen the existing management structures/functions at the state and district levels respectively as RCH-II is characterised by allocation of flexible funds to states, preparation of programme implementation plans by States and districts and performance linked disbursement based on MOU. Consultants recruited under SPMU are expected to improve the performance levels of the public health infrastructure and functionaries and to make the system more responsive and transparent. All these positions are on contract basis.

The SPMU consists of following four positions.

1. State Programme Manager
2. State Finance Manager
3. State Accounts Manager
4. State Data Officer

Role of SPMU 
The SPMU is responsible for the overall state level planning and monitoring for NRHM, management of flexipool funds, initiation of health sector reforms, continuous process improvement and for secretarial functions to the State Health Mission and State Health Society.

District Programme Management Unit(DPMU)

In districts, the cornerstone for smooth and successful implementation of NRHMI programme is dependent on the management capacity of District Programme Managers, smooth functioning of District RCH Society and empowerment of the programme implementation structure. The District Health Society is being strengthened through the integration of all societies in the district and this society will be responsible for project management in districts. While the Collector would continue to be the Chairperson of District RCH Society, suitable manpower resources for programme management and finance/accounts functions has been provided. The district level functions include planning, implementation and monitoring of all EAPs including RCH II, finance and accounting, training and capacity building, MIES and district plans etc.

The district PMU is composed of three skilled personnel i.e. Programme Manager, Accounts Manager and Data Assistant have been provided in each district. These personnel are there to provide the basic support for programme implementation and monitoring at district level. The District Programme Manager is responsible for providing support to all programmes and projects in the Districts, planning, implementation and monitoring of all EAPs including RCH II, training and capacity building, MIES, development of district plans, regular reporting and feedback,. The District Accounts Manager is responsible for the finance and accounting function of District RCH Society including grants received from the state society and donors, disbursement of funds to the implementing agencies, preparation of submission of monthly/quarterly/annual SoE, ensuring adherence to laid down accounting standards, ensure timely submission of UCs, periodic internal audit and conduct of external audit and implementation of computerized FMS. The Data Assistant in close consultation with district officials has to facilitate working of District RCH Society, maintain records, create and maintain district resource database for the health sector, inventory management, procurement and logistics, planning and monitoring and evaluation. District Data Assistant is responsible for MIS and data collection and reporting at district level.

District Health Action Plan 2005-2012 is being prepared by each District. The Key strategies suggested for DAP are as follows:

• Block will be the key level for development of decentralized plans so each block will be covered under the

• DAP and a block level plan will be prepared for each block in each district.

• Technical resource agency/ groups will be identified for each block to assist in planning.

• A technical resource agency would be identified for the District to support the implementation of the DAP.

• Four broad categories of programmes have been indicated under NRHM.

  o RCH-II activities and programmes
  o NRHM activities such as IPHS, Untied funds, JSY, and integration, AYUSH, nutrition and child development
  o National Disease Control Programme
  o Immunization

A number of inputs have been suggested under NRHM implementation framework. A detailed plan for additionalities will be incorporated in the DAP.

• Facility survey of the PHCs, CHCs and Sub Centre is a critical part of the DAP. As State has taken the decision to conduct the Facility Survey of health institutions (CHC/PHC) separately, from the DAP but in the frame work of DAP there should be clearly indicated the provision of facility survey under NRHM. Cost for the facility survey will not be the part of DAP.

• Under NRHM there is provision of untied fund for the different levels Village, Block and District. GoI is yet to indicate the amount of untied funds. So under plan there should be the action points for utilizing the untied funds.

• Under NRHM & RCH-II, a list of proposed activities have been worked out and a templates of the activities have been developed this template will be used as worksheet for the action plan for each year activities.

• Intersectoral coordination is the key strategy of the NRHM. Under NRHM DAP will be prepared with involvement of different sectoral departments such as DWCD, PHED and Rural Development, Panchayati Raj and AYUSH etc. All the activities of NRHM related to other departments will be spelt out clearly with budget provisions.

• Six agencies have been selected for preparation of all the District Action Plans and there is a need to ensure uniformity of the Frame Work of DAP and Budget lines. In each District Plan district specific priorities, issues and budget requirements should be indicated but the pattern of Frame Work, structure and guidelines will be on same lines. It is anticipated that DAP will be finalized up to December 2007.

Village Health Sanitation Committee (VHSC)

The NRHM framework support 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 into the 41000 revenue villages of the State. 

Village Health & Sanitation committee (VHSC) feed such groups, which is the fifth committee (Development Committee) of the Gram Panchayat. The VHSC will be 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. 

The State is presently having 9189 Gram Panchayats where such committees exist. It is planned to organize the training of at least 25 % of these committees on village health need identification & local action under NRHM. It is also proposed to provide Rs.10000/- to all VHSC for supporting their efforts in developing Village Health Plans.

Role of Village Health Committee

Activities

• 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. Estimation of the annual expenditure incurred for management of all the morbidities may also be done. The mapping will also take into account the health resources and the unhealthy influences within village boundaries.

• Maaintenance 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.

Composition of the Village Health Committee

This committee would be 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 would consist 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.