How to evaluate MCH services in your district in light of NRHM

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evaluation of MCH services district level NRHM indicators India

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Evaluation of MCH Services in Your District in Light of NRHM

Evaluating MCH (Maternal and Child Health) services at the district level under the National Rural Health Mission (NRHM) requires a systematic, multi-dimensional approach covering inputs, process, outputs, and outcomes. The framework below is drawn from Park's Textbook of Preventive and Social Medicine and NRHM programme guidelines.

1. Understanding the Framework: What NRHM Promises for MCH

NRHM (launched 2005) specifically targeted MCH services through:

ASHA deployment (1 per 1,000 population; 1 per habitation in tribal/hilly areas)
Janani Suraksha Yojana (JSY) - cash assistance for institutional deliveries
Janani Shishu Suraksha Karyakram (JSSK) - free delivery including C-section at public institutions (from June 2011)
Village Health Sanitation and Nutrition Committees (VHSNCs)
Rogi Kalyan Samitis (RKS) at all DHs, CHCs, PHCs
Mobile Medical Units (NMMUs) for hard-to-reach areas
Untied grants to sub-centres for ANC equipment

(Park's Textbook of Preventive and Social Medicine, p. 648)

2. Evaluation Domains and Indicators

A. INPUT Evaluation (Infrastructure and Human Resources)

Assess whether NRHM norms (IPHS - Indian Public Health Standards) are met:

Input	What to Assess
Sub-centres	1 per 5,000 population (plains); 1 per 3,000 (hilly/tribal). BP apparatus, Hb meter, weighing machine, stethoscope available?
PHC	1 per 30,000 (plains). 24x7 delivery services? ANM, nurse, doctor posted?
CHC (FRU)	Fully equipped for obstetric emergencies - O.T., blood bank, EmOC?
ASHA coverage	1 per 1,000 villages; training module completion (7 modules); drug kit availability
JSY funds flow	Registration of pregnant women, disbursement within 7 days of delivery?
JSSK	Zero out-of-pocket for deliveries; free drugs, diagnostics, diet, transport

Method: Physical verification of facilities, HMIS/MCTS data, facility surveys using DLHS or NFHS tools.

B. PROCESS Evaluation (Service Delivery)

Assess whether services are actually being delivered as planned:

Antenatal Care (ANC):

% of pregnant women registered in 1st trimester (early registration)
% receiving 4+ ANC visits (WHO-recommended)
% receiving full ANC (3 visits + 1 TT + 100 IFA tablets or equivalent syrup)
% tested for Hb, blood group, blood pressure, urine
% screened for RTI/STI, HIV (under PPTCT)

Intranatal Care:

% institutional deliveries (overall and by skill level)
% deliveries conducted by SBA (Skilled Birth Attendant)
% C-section rate (national average ~17%; district should approach 10-15% range if all high-risk cases are reached)
Referral completeness from SC/PHC to FRU

Postnatal Care:

% women receiving 3 PNC visits (within 48 hours, 3-7 days, 42 days)
% newborns receiving ENBC (essential newborn care): cord care, warmth, breastfeeding within 1 hour
% LBW newborns identified and managed (SNCU utilization)
Home-based newborn care visits by ASHA (HBNC)

Child Health:

% full immunization by 1 year (BCG, OPV, DPT, Measles/MR, Hep B)
% receiving Vitamin A supplementation
% ORS + Zinc use in diarrhoea
% children with SAM enrolled in NRC (Nutritional Rehabilitation Centre)
IMNCI implementation status

Family Planning:

Couple Protection Rate (CPR)
Total Fertility Rate (TFR) vs. national target of 2.1
Unmet need for family planning

C. OUTPUT Evaluation (Coverage Achieved)

Compare district performance against national benchmarks from Park's Table 11 (MCH Goals):

Indicator	India Level (2018)	NHP 2017 Target	SDG 2030
IMR	32/1,000	<28 by 2019	-
NMR	23/1,000	16 by 2025	<12
MMR	113/1,00,000	100 by 2020	70
U5MR	36/1,000	23 by 2025	≤25
TFR	2.2	2.1 by 2025	-
Full immunization	80-92% (varies by antigen)	>90% by 2025	-

(Park's Textbook, p. 648)

Your district data should be plotted against these benchmarks to identify gaps.

D. OUTCOME Evaluation (Health Status Indicators)

The ultimate measure of MCH service quality - from Park's indicators of MCH care:

Mortality indicators:

Maternal Mortality Ratio (MMR) - direct + indirect obstetric deaths per 1,00,000 live births
Perinatal Mortality Rate (stillbirths + deaths in 1st week per 1,000 births)
Neonatal Mortality Rate (NMR) - deaths in first 28 days per 1,000 live births
Post-neonatal Mortality Rate
Infant Mortality Rate (IMR) - deaths <1 year per 1,000 live births
1-4 year mortality rate
Under-5 Mortality Rate (U5MR)
Child survival rate

Morbidity and growth indicators:

Prevalence of LBW (<2.5 kg) in district
Stunting, wasting, underweight rates in <5 children (using ICDS/CNNS data)
Anaemia prevalence in pregnant women and children 6-59 months
District-level TFR and CBR (Crude Birth Rate)

(Park's Textbook of Preventive and Social Medicine, p. 647)

3. Data Sources for District-Level Evaluation

Source	Data Available
HMIS (Health Management Information System)	Monthly facility-level data on ANC, delivery, immunization
MCTS/RCH Portal	Individual tracking of pregnant women and children
DLHS (District Level Household Survey)	Coverage gaps at district level
NFHS (National Family Health Survey)	Trend data, disaggregated by wealth/residence
SRS (Sample Registration System)	MMR, IMR, NMR estimates
ASHA/ANM Registers	Village-level outreach data
SNCU/NBCC registers	Neonatal morbidity and management data
Facility assessment (NQAS/LaQshya)	Quality of care at delivery points

4. Special Focus Areas Under NRHM Evaluation

Equity Assessment: NRHM specifically targeted high-focus states and marginalized populations. Evaluate:

Rural vs. urban disparity in institutional delivery
SC/ST coverage compared to general population
Coverage in hard-to-reach and tribal areas
BPL beneficiary identification under JSY/JSSK

Quality of Care:

LaQshya certification status of delivery points (labour rooms and maternity OT)
NQAS (National Quality Assurance Standards) compliance
Availability of EmOC (Emergency Obstetric Care) at FRUs
Maternal Death Review (MDR) conducted? Causes analyzed?

Community Participation (NRHM cornerstone):

VHSNCs functional? Quarterly meetings held?
Village Health and Nutrition Days (VHNDs) conducted monthly?
RKS funds utilized for patient welfare?

ASHA Performance:

% pregnant women accompanied by ASHA for institutional delivery
ASHA incentive disbursement timely?
HBNC visits completed (6 visits in first month)?

5. Evaluation Methodology

A comprehensive district MCH evaluation combines:

Quantitative review - HMIS data, line-listing of maternal/infant deaths
Facility survey - verification of IPHS norms at SC, PHC, CHC, DH
Household survey - community-level coverage (similar to DLHS/NFHS methodology)
Maternal Death Review (MDR) - confidential enquiry into every maternal death
Process observation - observe ANC sessions, VHND, delivery practices
Key informant interviews - with ANMs, ASHAs, PHC MOs, District CMO
Common Review Mission (CRM) approach - joint teams of officials, academics, civil society

The Government of India's NRHM evaluation in 7 states used all these methods and examined performance across levels of the health system.

6. Summary: Key Evaluation Questions for a District CMO/PHO

Are all sub-centres, PHCs, and CHCs staffed and equipped as per IPHS?
What is the institutional delivery rate, and is JSSK being implemented (zero OOP)?
Is full ANC coverage >80%? What are the drop-out rates across ANC visits?
What is the district IMR and MMR? Are maternal death reviews being conducted?
Is full immunization >90%? Which antigens are lagging?
Are ASHAs trained, equipped, and receiving timely incentives?
Are VHNDs conducted every month at sub-centre level?
Is the FRU functional 24x7 with EmOC capacity?
What is the unmet need for family planning? Has TFR reached 2.1?
Are nutrition services (ICDS, NRCs) integrated and functional?

Reference: Park's Textbook of Preventive and Social Medicine (23rd Ed.), Chapter on Maternal and Child Health, pp. 610, 647-648 | NRHM Programme Implementation Guidelines, MoHFW, GoI

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