National Rural Health
Mission
Draft
Memorandum of Understanding (MoU) Between Ministry of Health & Family
Welfare, Government of India And The Government of the State of …………..
[NOTE: Explanatory
Footnotes and Sample Annexes are for purposes of clarification and illustration
only.]
1. Preamble
1.1
WHEREAS the National Rural Health Mission,
hereinafter referred to as NRHM, has been launched for nation-wide
implementation with effect from April, 2005[1];
1.2
WHEREAS the NRHM aims at providing
accessible, affordable, effective, accountable and reliable health care to all
citizens and in particular to the poorer and vulnerable sections of the
population; consistent with the outcomes envisioned in the Millennium
Development Goals and general principles laid down in the National and State
policies, including the National Health Policy, 2002 and National Population
Policy, 2000;
1.3
AND WHEREAS the ‘architectural correction’ of the
health sector is a key objective for the NRHM, to be carried out through integration
of vertical programs and structures; delegation and decentralization of
authority; involvement of Panchayati Raj Institutions and other supportive
policy reform measures in the areas of medical education, public health
management, incorporation of Indian Systems of Medicine, regulation of health
care providers and new health financing mechanisms;
1.4
NOW THEREFORE the signatories to this Memorandum
of Understanding (hereinafter referred to as MoU) have agreed as set out
hereinbelow.
2. Duration of the MoU
1.5
This
MoU will be operative with effect from April, 2005 or the date of its signing
by the parties concerned whichever is later and will remain in force till
March, 2012 or till its renewal through mutual agreement whichever is earlier.
3.
State Sector PIP and its financing
3.1
The
MoHFW will provide a resource envelope to support the implementation of an
agreed State NRHM Sector Programme Implementation Plan (PIP), hereinafter
referred to as Sector PIP, reflecting (a) all sources of funding for the health
sector, including State’s own contribution[2],
(b) a convergence plan for NRHM related sectors[3]
and (c) proposals and time frame for institutional reforms referred to in para
1.3 hereinabove[4].
3.2
The
agreed outlay for the Sector PIP for financial year 2005-06 and 2006-07 and the
sources for the funding of the same will be as given at Appendix-I[5] hereto.
3.3
Each
State will prepare a Programme Implementation Programme (PIP) and a Log Frame
based upon the quantum of funds provided to it. The PIP will be consistent with the general principles laid down
in the National and State policies relevant to the Sector and other agreed
action plans. The Log Frame will, in
particular, reflect the core indicators agreed to be adopted by the programme.
3.4
Based
upon its PIP and Log Frame, each State will set its own annual level of
achievement for the programme core indicators in consultation with GoI and
subsequently, States will have similar arrangements with the Districts.
3.5
The
Government of India may issue mandatory core financial and programme indicators
as well as institutional process as well as output indicators, which would need
to be adhered to by the States.
3.6
The
implementation of the action plan as set out in the PIP shall be reviewed at
the State level once every month at the level of all States and UTs.
3.7
A
review would be held every (quarter/six months) by the MoHFW (for the EAG
States, NE States and the State of Jammu & Kashmir)/(every six
months/annually) (for other States/UTs).
Corresponding State level reviews of Districts would need to be carried
out by the States/UTs.
3.8
The
Sector PIP will be jointly reviewed to arrive at an agreed Sector PIP for the
subsequent year.
3.9
The
NRHM contribution to support the Sector PIP will cover, among others,
implementation of RCH phase II, National Vector Borne Disease Control Program,
National Leprosy Eradication Program, National Iodine Deficiency Disorder
Program, Revised National Tuberculosis Program, National Blindness Control
Program, AYUSH scheme on hospitals and dispensaries, Integrated Disease
Surveillance Program and the thrust areas identified under the NRHM.
3.10
The NRHM would operate as an omnibus broadband programme by
integrating all vertical programmes of the Departments of Health and Family
Welfare. However, independent
sub-budget lines may be retained to provide independent ‘financial’ identity
till the expiry of existing bilateral agreements.
3.11
Although
the AIDS control program and the National Cancer Control Program shall not be
merged into the NRHM budget head, the planning and monitoring functions for
these shall remain a specific task for the institutional arrangements agreed
through this MoU.
4. Funds Flow arrangements
4.1.
The
first installment of grant-in-aid under this MoU shall be made during the
second half year of financial year 2005-06[6]
and will be contingent upon execution of this MoU[7].
4.2
Subsequent
six-monthly releases shall be regulated on the basis of a written report to be
submitted by the State indicating the progress of the agreed State Sector PIP
including the following:
·
Documentary
evidence indicating achievement of targets / milestones for the agreed
performance indicators referred to in para 5 hereinbelow,
·
Statement
of Expenditure confirming utilization of at least 50% of the previous release(s),
·
Utilization
Certificate(s) and Audit reports wherever they have become due as per agreed
procedures under General Financial Rules (GFR).
5. Performance
Indicators
5.1. Release of grants-in-aid will be subject to
satisfactory progress of agreed Performance Indicators relating to
implementation of agreed State PIP including institutional reforms.
5.2 The agreed Performance Indicators are as given
at Appendix-II[8]
hereto.
6. Performance Awards
6.1 The State shall be eligible to receive an Annual
‘performance award’ to the tune of 10% of its actual utilization of cash assistance in the previous financial
year provided that the State has successfully achieved the criteria set out in
para 5.2 above.
6.2 The releases under the performance award
mechanism will be over and above the agreed allocations for supporting the
agreed State Sector PIP and will become an untied pool which may be used for
such purposes as may be agreed by the State Mission Steering Group referred to
in para 8.1 hereinbelow.
7. Institutional Arrangements :
National Level
7.1
At the
National level, Mission implementation will be steered by a Mission Steering
Group (MSG) headed by the Union Minister for Health & Family Welfare and an
Empowered Programme Committee (EPC) headed by the Union Secretary for Health
& Family Welfare.
7.2 The State Sector PIPs shall be appraised for
approval and sanctioned by duly authorized Committee.
7.4 The representatives of the concerned State
Government(s) shall also be invited to the meeting of the Committee whenever
their proposal are listed for consideration / approval.
7.5 The Committee may also seek written feedback
on the State Plan(s) from the representatives of the Development Partners
providing financial and technical assistance to the Mission in the concerned
State(s).
8.
Institutional Arrangements : State,
District and Hospital Levels
8.1.
The
State Government has set up the State Health Mission headed by the Chief
Minister for providing guidance to State Health Mission activities. The
constitution and terms of reference of the State Health Mission are as given at
Appendix-III hereto.
8.2 The State has merged existing State level
vertical societies in the health sector and has created an integrated Society,
called ………………………………… The said society
shall receive the funds from the MoH&FW and other sources. The Society
shall also perform the functions of a flexible mechanism for sourcing program
management support for the State Directorate and district health administration
in the State[9]. The Rules and bye-laws of the State Society
as filed with relevant registration authorities are as given at Appendix-IV hereto.
8.3. The State has completed the merger of the
Departments in the Health and Family Welfare sector and has issued necessary
orders for appointing the State Mission Director.[10]
8.4 The State has ordered merger of all District
level vertical societies into an integrated District Health and Family Welfare
Society called………….. The District Health Mission shall guide the Integrated
District Health Society in policy and operations. The (model) Rules / bye-laws
of the district Society as notified through Resolution / Notification are as
given at Appendix-V hereto.
8.5. The State has also ordered creation of a
Hospital Management Society called ……………………………The model Rules / bye-laws of the
hospital level society to be registered / filed with relevant registration
authorities are as given at Appendix-VI
hereto[11].
9.1. The Department of Health & Family Welfare
shall convene national level meetings to review progress of implementation of
the agreed State Sector PIP.
9.2 The department of Health and Family Welfare
may also organize a State level review[12].
9.3 The review meetings may lead to proposals for
adding to or modifying one or more Appendices of this MoU. These will
always be in writing and will form part of the minutes of meetings referred to
hereinabove.
10 Government of India Commitments
10.1
The funds committed through this MoU
may be enhanced or reduced, depending on the pace of implementation of the
agreed State PIP and achievement of the milestones relating to the agreed Performance Indicators.
10.2 The MoH&FW also commits itself to:
(a)
Ensuring
that the resources available under the State Partnership Programs outside the
MoH&FW budgets are directed towards complementing and supplementing the
resources made available through the MoH&FW budget and are not used to
replace the recurring expenses hitherto provided for under the Centrally
Sponsored Schemes under the health and family welfare sector.
(b)
Ensuring
that multilateral and bilateral development partners co-ordinate their
assistance, monitoring and evaluation arrangements, data requirements and
procurement rules etc. within the framework of an integrated State Health
Plan.
(c)
Facilitating
establishment of District Health Missions and development of District Action
Plans through such means as may be mutually agreed.
(d)
Assisting
the States in mobilizing technical assistance inputs to the State Government
including in the matter of recruitment of staff for the State and district
societies.
(e)
Developing
social / equity audit capacity of the States through joint development of
protocols for assessing access levels for the most disadvantaged groups.
(f)
Developing
and disseminating protocols, standards, training modules and other such
materials for improving implementation of the program.
(g)
Consultation
with States, at least once a year, on the reform agenda and review of progress.
(h)
Prompt
consideration and response to requests from states for policy, procedural and
programmatic changes.
(i)
Release
of funds on attainment of agreed performance indicators, within an agreed time.
(j)
Holding
joint annual reviews with the State, other interested Central Departments and
participating Development Partners; and prompt corrective action consequent on
such reviews.
(k)
Dissemination
of and discussion on any evaluations, reports etc., that have a bearing on
policy and/or have the potential to cause a change of policy.
11. State
Government Commitments:
11.1 The State Government commits to ensure that
the funds made available to support the agreed State Sector PIP under this MoU
are:
(a)
used for financing the agreed State Sector PIP in accordance with agreed
financing schedule and not used to substitute routine expenditures which is the
responsibility of the State Government.
(b) kept intact and
not diverted for meeting ways and means crises.
11.2 The State Government also commits to
ensure that:
(a)
The share of public spending on Health from state’s own budgetary
sources will be enhanced at least at the rate of 10% every year[13].
(b)
Its own resources and the resources provided through this MoU flow to
the districts on an even basis so as to ensure regular availability of budget
at the district and lower levels. Of
these, at least …..% of funds will be
devolved to the Districts with provision for flexible programming.
(c)
Structures for the program management are fully staffed and the key
staff related to the design and implementation of the agreed State Sector PIP,
and other related activities at the State (including Directorate) and district
level are retained in their present positions at least for three years[14].
(d)
Representative of the MoH&FW and/or development partners providing
financial assistance under the MoU mechanism as may be duly authorized by the
MoH&FW from time to time, are allowed to undertake field visits in any part
of the State and have access to such information as may be necessary to make an
assessment of the progress of the health sector in general and the activities
related to the activities included under this MoU, subject to such arrangements
as may be mutually agreed.
(e)
The utilization certificates (duly audited) are sent to the Ministry of
Health & after close of the financial year, within the period stipulated in
the General Financial Rules.
(f)
The State shall take steps for decentralization and promotion of
District level planning and implementation of various activities, under the
leadership of Panchayati Raj Institutions.
(g)
The State shall endeavour to implement models of ‘Community Health
Insurance’.
11.3 The State Govt. agrees to abide by all the
existing manuals, guidelines, instructions and circulars issued in connection
with implementation of the NRHM, which are not contrary to the provisions of
this MOU.
11.4 The State Government also commits to take prompt corrective action in the event of any discrepancies or deficiencies being pointed out in the audit. Every audit report and the report of action taken thereon shall be tabled in the next ensuing meeting of the Governing Body of the State Society.
12. Bank
Accounts of the Societies and their Audit:
12.1 State and district society funds will be
kept in interest bearing accounts in any designated nationalized bank or such
bank as may be specified by the MoHFW[15].
12.2 The State will organize the audit of the
State and district societies within six-months of the close of every financial
year. The State Government will prepare and provide to the MoH&FW, a
consolidated statement of expenditure, including the interest that may have accrued.
12.3 The funds routed through the MoU mechanism
will also be liable to statutory audit by the Comptroller and Auditor General
of India.
13.1
Non compliance of the commitments and obligations set hereunder and/or
upon failure to make satisfactory progress may require Ministry of Health &
Family Welfare to review the assistance committed through this MOU leading to
suspension, reduction or cancellation thereof. The MoH&FW commits to issue sufficient alert to the State
Government before contemplating any such action.
Signed this day, the ……. of ……….
200 .
|
For and on behalf of the Government of …….. |
For and on behalf of the Government of India, Ministry of Health & Family Welfare, |
|
Principal Secretary (HFW) Government of ………… Date:_____________ |
Secretary, Ministry of Health & Family
Welfare, Government of India
Date:_____________ |
Appendices which
form part of this MoU:
Appendix-I: Agreed outlays
and financing plan for the agreed State Sector PIP
Appendix-II: Agreed
Performance Indicators
Appendix-III: Constitution and
Terms of Reference of the State Health Mission
Appendix-IV: Certified copies
of the Rules / bye-laws of the State Society
Appendix-V: State Government Resolution / Notification
ordering registration of integrated
District
Society
Appendix-VI: State Government Resolution / Notification
ordering registration of Hospital
Management
Society.
Appendix-I
Agreed Financing Plan for the Agreed State Sector PIP for FY 2005-06 and 2006-07
(Year-wise, separately,)
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# |
Item /
purpose |
Agreed outlays and source of
funding (Rs lakh) |
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Grant-in-aid from MoHFW |
State share |
Other sources (*) |
Total |
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A:
RCH-II Resource Envelope |
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B: NRHM
related activities |
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C: Immunization |
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D:
Implementation of (on-going) National Disease Control Programmes |
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E:
Intersectoral Convergence |
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F: Activities not included in A, B or C above |
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(*): Includes State Health
Systems projects, State Partnership Projects, Finance Commission awards,
projects / schemes funded through Global Funds and/or Global Partnerships in
the health sector and projects / schemes being (or proposed to be) funded
outside the State budget.
APPENDIX
II(a)
FINANCIAL MANAGEMENT INDICATORS
A. Finance and HRD related
indicators
1.
Qualified and skilled
finance manpower in place & trained:
-
At State level
-
At District level
2.
Vacancy Position of the
Finance and Accounts Staff:
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|
No.
of Sanctioned Posts |
No.
of Staff in position |
No.
of Vacancy |
Since
when Vacant (Give
date) |
Reason
for Vacancy |
Action
Plan & time frame for filling up
the vacancy |
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State
level |
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District
level |
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3.
Integration and
empowerment of finance personnel into the system:
-
Organograms of State and
District level finance staff submitted to GoI
-
GO issued specifying
duties and channel of reporting.
4.
Training of Finance
personnel completed:
-
State level finance and
accounts staff trained by GoI
-
District level finance
and accounts staff trained by State Government.
5.
Dotted line relationship
with the Central FMG:
- Performance
of contractual Finance and Accounts staff evaluated on yearly basis and evaluation
sheet forwarded to FMG, MoH&FW, GoI.
- Concurrence
of central FMG taken for yearly extension of tenure of finance and accounts
staff.
1. Delegation of adequate Financial and Administrative
Powers:
- Govt. Order (GO) or resolution of SCOVA delegating
the financial and administrative powers submitted to GoI:
- At
State level adequate powers delegated to the ED/Project Director
- At
District level adequate powers delegated to the CMO
- At PHC/CHC levels, retention and full powers for use
of User charges collected there.
2. Adequate
infrastructure facilities, e.g. computers, printers, telephone, fax, internet
connection, etc. provided to Finance and Accounts staff:
- at State level
- at
District level.
1.
Financial Report
(Quarterly, in the format prescribed)
QUARTERLY
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State |
Timely (within a month
after the end of quarter) |
Delay of 1 Month |
Delay of 2 Months |
Delay over 2 Months |
No. of Districts omitted |
Quality of Financial
Reports |
Action taken to overcome
delays in future |
2. Audited Statement of Accounts & Audit reports
ANNUAL
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State |
Timely by 31st July |
Delay of 1 Month |
Delay of 2 Months |
Delay over 2 Months |
No. of Districts omitted |
Quality of audit Reports |
No. of Audit observations |
Action taken to overcome
delays in future |
3. Utilisation Certificates
ANNUAL
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State |
Timely, along with Audited
Statements of Accounts by 31st July |
Delay of 1 Month |
Delay of 2 Months |
Delay over 2 Months |
Quality of UCs submitted |
Action taken to overcome
delays in future |
Appendix - II (b)
Performance Indicators
Institutional
process performance targets whereby release of [2006/7] flexible pool resources
will be decided
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Indicator |
Source |
Target level of
achievement set by the state* |
Date on which the
indicator is to be measured |
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1. |
%
of ANM positions filled |
State
reports and quarterly management reviews |
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2. |
%
of ASHAs selected |
State
reports and quarterly management reviews |
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3. |
%
of ASHAs trained |
State
reports and quarterly management reviews |
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4. |
%
of Sub-centres submitted UC for
Untied Fund |
State
reports and quarterly management reviews |
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5. |
%
of State and districts having full time program officers including Programme
Manager for RCH with financial and administrative powers delegated |
Same
as above |
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6.
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%
of sample State and District Program Managers received training as prescribed
under the programme |
Management
review |
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7.
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% of sampled state
and district program managers whose performance was reviewed during the past
six months |
Management
review |
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8.
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%
of Districts not having at least one month stocks of essential drugs supplied by various
programmes, e.g. (a)
Anti-TB drugs (b)
Measles vaccine (c)
Oral Contraceptive pills (d) Gloves |
MIS |
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9. |
%
of Districts with integrated societies |
MIS |
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10. |
%
of Districts with Quality Assurance Committees |
MIS |
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11. |
%
of District Action Plans ready |
MIS |
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12. |
%
of facilities with Hospital Management Society |
MIS |
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13. |
%
of districts reporting quarterly financial performance in time |
FMR |
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14. |
%
of district plans with specific activities to reach vulnerable communities |
Management
reviews |
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15. |
%
of sampled districts that were able to implement M&E triangulation
involving communities |
Management
reviews |
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16. |
%
of sampled outreach sessions where guidelines for AD syringe use and safe
disposal are followed |
Quality
reviews |
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17.
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%
of sampled FRUs following agreed infection control and healthcare waste
disposal procedures |
Quality
reviews |
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18. |
%
of 24 hrs PHCs conducting minimum of 10 deliveries/month |
MIS
and quality reviews |
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19. |
%
of upgraded FRUs offering 24 hr. emergency obstetric care services |
MIS
and quality reviews |
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20. |
%
of CHCs upgraded to IPHS |
MIS |
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APPENDIX II-C
Output indicators from Mid Term and End Line Surveys,
to be used to determine releases from 2008/9 onwards.
The
states are to set target levels of achievement for these indicators based on
their own assessments.
Indicators suggested
for Performance Bonus
|
% of allocated funds
for the year used |
<10% |
10-20% |
20-30% |
30-40% |
40-50% |
50-60% |
60-70% |
70-80% |
80-90% |
>90% |
|
Score |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
|
% contributed by SC/ST
populations among deliveries reported by public facilities (Non EAG states)* |
<10% |
10-20% |
>20% |
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Score |
3 |
6 |
10 |
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% achievement of
planned immunization coverage among SC/ST population (EAG states)* |
<10% |
10-20% |
20-30% |
30-40% |
40-50% |
50-60% |
60-70% |
70-80% |
80-90% |
>90% |
|
Score |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
It is proposed to give equal weight for disbursements and improved
program performance. The focus of performance would be on improving
immunization performance in EAG states while for non-EAG states, institutional
deliveries which also cover early newborn care could be considered. For both,
the attention would be on improving coverage for SC/ST populations which has to
be validated by independent agencies. These indicators would be appropriately
modified to suit the needs of the states.
Performance based disbursements
From fiscal year 2006/7 onwards the MoH&FW would decide whether to release an amount of flexible pool resources in addition to that specified above for encouraging good performance. The release to [state or UT] would be set by the following formula :
Release = Rs [ ] crore x
{ (50 x % of funds allocated by the
state and central government for the previous year disbursed) +
(25 x % of SC/ST deliveries attended by
ANM/nurse/doctor) +
(25 x % achieved of planned
measles coverage among [SC/ST/Below Poverty-Line] population)}
[1] The NRHM MoUs are to be executed by September, 2005 on the basis of a State NRHM Action Plan.
[2] The Sector Action Plan is to be evolved from the agreed RCH-II PIPs to include National Disease Control Programmes, AYUSH and State’s share (including the resources sought to be accessed from the funds directly flowing under the State Health Systems Projects of the World Bank 12th Finance Commission, and State Partnership Programmes of other Development Partners).
[3] At least water, sanitation and nutrition sectors. The convergence plan has to list out specific action points and the time schedule for their implementation.
[4] Institutional reforms would relate to the ‘architectural correction’ referred to in the NRHM documents such as re-structuring and decentralization of cadres, delegation of financial and administrative authority to the PRIs, streamlining and strengthening of support systems (logistics, MIS, IEC etc.) etc.
[5] The financing plan shall be drawn on the basis of the agreed State PIP.
[6] The MoHFW
will switch over to a six-monthly funds release
system with effect from April, 2005. The first six-monthly installment will be
released on the basis of the agreed RCH-II PIP and the agreed outlays for the
other on-going programmes after submission of a Letter of Undertaking by the
State (As per Annexure B1 of RCHII National PIP).
[7] Second
installment of FY 2005-06 shall be made after submission of the following:
[8] Every State has to propose a set of performance indicators while submitting its State Sector PIP. An illustrative list is given at the draft Appendix-II which is arranged under two categories: mandatory performance indicators and voluntary. It be noted that many of the actions on the mandatory indicators may be completed well within FY 2005-06 itself, even before the NRHM MoU is executed. These have been listed in the mandatory list to remind the States of their importance.
[9] The Governing
Body of the State Health Society is to be headed by the Chief
Secretary/Development Commissioner. The
Rules / bye-laws of State Health Society provide for a permanent secretariat
headed by the Mission Director and having a multi-disciplinary team of experts
and consultants to provide management support to mainstream implementing
agencies / line Departments. The
secretariat of the State Health Society shall also perform the functions of the
secretariat of the State Health Mission.
[10] The MoHFW
recommends that the various Departments under the Health and Family Welfare
sector may be brought under a single Secretary / Principal Secretary.
[11] Specific State level arrangements will have to be specified in the draft State Sector PIP and certified copies of the rules / bye-laws appended to the MoU.
[12] Especially in the 18 high focus States.
[13] Mandatory performance indicator.