Summary of Evaluation
1. Outline of the ProjectCountry: India

Project title: Reproductive Health Project in theState of Madhya Pradesh (Phase 2)
Cooperation scheme: Technical Cooperation
Project
Total cost (at the time of the Evaluation):
320 million JPY
Partner Organization: Madhya Pradesh State
Department of Health and Family Welfare(DoHFW)
Supporting Organization:

Issue/sector: Health Sector – Mother and Child
HealthDivision in charge: JICA India office
Period of
Cooperation

January 2007 to January 2011 (4years)

1-1 Background of the Project
Despite India’s emphasis on the maternal child health and rural health as important national policy,
people in north India, considered as less developed area in general, still suffer from high rate of maternal
and neonatal mortality, respectively 254 and 53 (Central Bureau of Health Intelligence, Status of
Mortality Statistics Reporting in India 2004 -2006, 2008).
In order to tackle the threat to life of mother and child, the Government of India announced the
National Rural Health Mission (NRHM) in 2005 for the improvement of national healthcare system inrural areas through strengthening of states’ health system.
The Reproductive and Child Health Program Phase 2 (RCH-Ⅱ) was launched in April of the same
year as a core program toward the acceleration of NRHM. RCH-Ⅱ, based on the reflection of theprevious RCH-Ⅰ, is programmed to promote States’ autonomous self-planning and achieve theoutputs in areas such as 1) populations stabilization; 2) maternal health; 3) sexually transmitted infection
control; 4) newborn and child health; 5)adolescent health; and 6) special consideration for sociallyvulnerable.
In the light of the above government initiatives in health sector, following preparatory phase(Reproductive Health Project Phase 1 2005-2006), Japan International Cooperation Agency (JICA) with
the Government of Madhya Pradesh (GoMP) launched JICA Madhya Pradesh Reproductive Health(JICA/MP RH) Project (phase 2) (hereinafter “the Project”) for the improvement of the quality ofmaternal healthcare in Sagar Division, Madhya Pradesh on January 2007 for 4 years cooperation period.
The Project has been working with GoMP for improvement of maternal healthcare system withemphasis on capacity building of frontline healthcare services providers such as auxiliary nurse midwife(ANM) and lady health visitor (LHV) in a framework of NRHM/ RCH-Ⅱ program. Main focus of the
Project is Human Resource Management (HRM), Total Quality Management (TQM), HealthManagement Information System (HMIS), and Information, Education and Communication (IEC) and
Behaviour Change Communication (BCC).
In February 2009, at the half-way period of the cooperation, the Mid-term Review was conducted by
GoMP and JICA evaluation team. The team confirmed that the Project remained highly relevant as it is
implemented in the framework of NRHM and suggested to focus on the activities for ANM cadres andfunctions. In September 2010, the Joint Evaluation Team was formed in accordance with the JICA
Guideline for Project Evaluation for the purpose of reviewing the Project progress, assessing
achievement level of outputs and providing recommendations for the further realization of the ProjectOutputs, Project Purpose and Overall Goal in a remaining cooperation period. The Terminal Evaluation
has been conducted by the Joint Evaluation Team consisted of the authorities concerned of India andJapanese members.
1-2 Project Overview(1) Overall Goal:
The State health sector ensures quality mother and new born child health services.

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(2) Project Purpose:
To increase the number of pregnant women and mothers who receive quality maternal health services
by the nursing cadres, with special emphasis on the ANMs.
(3) Outputs:
1. ANMs and related cadres are capacitated to conduct quality services.
2. The workplace environment is improved for the quality maternal child health services at the healthfacilities, such as Sub Health Centres (SHC), Primary Health Centres (PHC) and Community HealthCentres (CHC).
3. ANMs become effective data managers.
4. ANMs’ communication capacity is enhanced.
5. Project achievements and lessons learned in the pilot area are disseminated and scaled up to theproject area.
(4) Inputs:
Japanese Side:• Long term experts: 2 persons (Chief Advisor /Project Coordinator)• Short term experts: 2 persons• Local staff: 7 India staff were assigned to the Project office in Bhopal; 8 Indian staff wereassigned as field coordinators at the District/Block level.
• Training in Japan: 2 persons participated in “Midwifery course for Safe Motherhood” and 2
persons participated in “Workshop on Safer Motherhood Strategy for Asia” in FY 2007.
• Training in Jordan: 2 persons and 1 Project local consultant participated in “The Regional
Workshop of Sharing Experiences & Learning from Good/Successful Practices in the IslamicCommunities” in FY2008.
• In-country training:• Operational Expenditure (as of 1st Quarter of FY 2010): Rs. 43,134,500
Indian Side:• Assignment of counterpart personnel• Allocation of Budget: the costs for printing MH cards, improving health facilities and so forth.
2. Review Team
Members

Period of Evaluation

2.1. Indian side(1) Mr. J.N. Kansotiya (I.A.S) Commissioner, Health Services(2) Dr. K.L. Sahu, Regional Joint Director, Bhopal and Sagar Division(3) Dr. J.P. Khare, Deputy Director- Immunization, VHND, Pulse Polio
2.2. Japanese side:(1) Mr. Shohei Hara (Leader) Director, South Asia Department, JICA
(2) Dr. Akiko Hagiwara (Reproductive Health) Senior Advisor for Health, JICA
(3) Ms. Makiko Konohara (Cooperation and Planning) Project Formulation
Advisor, JICA India Office(4) Ms. Junko Sato (Evaluation Analysis) Consultant, TAC International, Inc.
22 August -10 September 2010
Type of Evaluation: Terminal Evaluation

3. Results of Evaluation
3-1. Verification of Performance3-1.1 Activities and Outputs(1) Output 1: ANMs and related cadres* are capacitated to conduct quality services. * Related cadres:
LHVs, Multi-purpose (Health) Worker- males (MPW-males), Male Supervisor
A series of training on maternal health services were conducted and the capacity of participants is
improved, which is confirmed from the result of the external evaluation done by National Institute of
Health and Family Welfare (NIHFW), and the interviews of ANMs, related cadres and supervisors. In
the Districts of Damoh, Tikamgarh and Panna, total 625 ANMs and LHVs (approximately 80% in the2

area) participated in the ANM trainings.
The Project also developed training modules and materials, including Skilled Birth Attendant (SBA)training modules, facilitator guide, antenatal care (ANC) checklist etc. The Project was a part of thenational level “Expert Group Meeting for SBA training methodology”. In order to ensure the quality ofhealth services, the Project provided continues support through supervisions by closely working withcounterparts such as Block Medical Officer (BMO) and Block Programme Manager (BPM). Hence, acollective action motivated ANMs and enabled them to provide better services, Improvement of theirwork environment, which occurred simultaneously with the capacity building of the ANMs, also
promoted ANMs to provide better Maternal Newborn Child Health (MNCH) services.
(2) Output 2: The workplace environment is improved for the quality maternal child health services at
the health facilities (SHCs, PHCs and CHCs).
In order to make sure clean and safe deliveries, the Project provided proper guidance and developed
illustrated guideline and Information Education and Communication (IEC) materials for the
improvement of the Maternity Wing of PHC and CHC, which is in line with Indian Public HealthStandard (IPHS).
Also, the Project facilitated the community health facilities with standardization of the prerequisite ofeach level of centres (following IPHS), actual renovation, rehabilitation, provision of basic equipment
and furniture. And total quality management all initiated by the cooperative work of health facility
director (BMO) and committee members.
Progress has been also seen in Bio Medical Waste (BMW) management at health facilities. The Projectprovided BMW management orientation. The Project provided technical support for BMW management
in collaboration with Madhya Pradesh Pollution Control Board (MPPCB) by dispatching resource
person to the workshop organized by MPPCB at divisional level at Gwalior and Vidisha.
Introducing geographic information system (GIS) was also effective in improving the health facilities.
Mapping the status of Maternal Wing organisation and BMW management by block enabled the local
authorities to recognize the need for further improvement of their facility. It indicated the importance ofvisualizing and demonstrating the steps required. It was reported that this visualization accelerated theprocess of improvement of the health facilities: not only had the director of the health facilities but also
workers of various cadres understood the progress of the facility improvement in comparison with other
health facilities.
Another important factor to be noted is the availability of United Fund of NRHM and related personnel
assigned such as BPM and DPM. It helped to maximize the inputs of the Project in improving healthfacilities. It should be highlighted that the roles of BPM and BMO were enhanced and promoted by theregular contact with Block Coordinators (BCs) who were selected, trained, mentored and consulted by
the Project.
(3) Output 3: ANMs become effective data managers.
Through the activities under Output 3, a series of trainings were organized and ANMs were trained for
effective data management. The Project assisted in designing and revising NRHM reporting format,
which was announced as a single national standard by the central government. The Project was a part of
the national level “Expert Group Meeting for revising NRHM reporting format”, the Project provided its
orientation to ANMs/Staff Nurses (SNs) at block level and data managers (BPM and Data Entry
Operator (DEO) etc.) in Sagar Division.
The Project introduced Maternal Health (MH) cards; by which it made possible to track services seeking
behaviours of mothers by names and reduce the missing opportunity of ANC. According to the result of
the external evaluation by NIHFW and the interviews, ANMs utilize MH cards for ANC and postnatal
care (PNC) of mothers, which enabled them to tell the conditions of each mother and identify/deal withcomplications easily. As for intranatal care (INC). Many facilities use “Obstetric Record Card” that was3

developed by the government. The Project provided guidance how to fill the card.
Data collected at each health facility are compiled in monthly report and submitted to block level andabove on time, which is managed by computer and analysed for future activities. The Project also
initiated Evidenced Based Planning and Management by using GIS. The Project assisted the state toprepare GIS maps on key thematic issues related to MNCH. It was observed by the evaluation study
team that regular monitoring is jointly conducted by BC (the Project), BPM (NRHM). BEE (GoMP) andBMO (GoMP) and the results and proper guidance are given to ANMs at Block meeting or Sector
meeting. The Project provided guidance on supervision to BPM, which was newly created post by
NRHM to support BMO.
As room for improvement, it is necessary to make sure ANMs and related cadres keep records in proper
manner. It was observed in some facilities that necessary information was not kept properly (e.g. lack ofpartograph, no record of blood pressure, pulse).
(4) Output 4: ANMs’ communication capacity is enhanced.
It was confirmed that communication capacity of ANMs was strengthened in providing MNCH services
in communities especially through the implementation of Village Health and Nutrition Days (VHND),
hence it led to the enhancement of community awareness and support for health motherhood.
The Project supported VHND activities by coordinating with Department of Health and Family Welfare(DoHFW). In that sense, BCs played an important role to encourage community mobilization by close
collaboration with BMOs and BPMs. Some of the BCs interviewed stressed that getting cooperationfrom community leaders such as Panchayati Raj Institution (PRI) members was the keys to success forpromoting VHND activities. The Project also produced VHND operation manuals and IEC materials.
VHND video was useful for health workers and PRI to understand the VHND activities. Role-playing
and poster presentation through 6-day ANC training was also effective in strengthening ANM’scommunication capacity.
By getting those supports mentioned above, ANMs could clearly understand their role in outreachactivities and provided good quality of services by making full use of the knowledge and skills acquired
from the activities under Output 1,2, and 3. One of the interviewed Medical Officers (MOs) explainedthat the progress of ANM’s communication skill can been seen in the increased number of referrals to
hospitals. In case ANMs cannot deal with complications, they send them to a hospital with detailed
information of mothers, which makes it easier for doctors to understand the status properly. Availabilityof good quality services by ANMs though VHND led to community trust on ANMs and theirself-confidence to act as a gateways to essential health services in communities. This one of the biggest
achievement of the Project as ANMs are important actors to sustain outreach activities in thecommunities.
(5) Output 5: Project achievements and lessons learned in the pilot area are disseminated and scaled up
to the project area.
The Project shared its experiences and lessons learned with central ministry of health as well as withother development partners as the occasion of health policy meeting and development partners’ meetingsin Delhi. Upon the request made by the Ministry of Health and Family Welfare officials, the Project
coordinated the site visit in Madhya Pradesh and shared some of the project activities with Ministry of
Health and Family Welfare (MoHFW). In that sense, the Project contributed to giving inputs to National
Health Policy indirectly.
The Project outcomes are also shared at monthly meeting at district level, in which all BMOs attend.
Further, the Project outcomes can be also seen in block meeting and sector meeting, in which necessary
technical transfer and face-to-face guidance are provided to ANMs by supervisors such as BMO who get
the support from the Project.
As for scaling up, the following points could be raised as the Project achievements.

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Initiated by the Project, DoHFW (GoMP) started to utilize GIS for Evidence Based Planningand Management;
SBA training is conducted under the initiative of GoMP based on the methodology of TOT
training supported by the Project;“Illustrated guideline to operationalize Delivery Care at District Hospital, CHC, and PHC” and“Illustrated guidelines to operationalize Maternal Health Care at SHC” were accepted by GoMP
as state standard guideline in 2008;
The Project provided the support for drafting the checklist for accreditation of SHC for normaldelivery;
3 audio-visual materials on SHC/CHC with special focus on ANC practices by ANMs,
maternity wing organization at CHC/PHC and conducting VHND by ANMs were adapted by
the state;
Persons on ANC, PNC, Active Management of the Third Stage of Labour (AMTSL) and SHC
protocols were adapted by the state and distributed to 50 districts.

3-1.2 Project Purpose: To increase the number of pregnant women and mothers who receive quality
maternal health services by the nursing cadres, with special emphasis on the ANMs.
 Overall, the quality of MH services has been improved due to capacity development of ANMs
by the Project, which could be reinforced by the following aspects. SHC/PHC/CHC satisfied
the requirement of IPHS, which means quality services is available in these facilities;
 The service improvement was also brought by collaboration between committee and healthfacilities in improving facility and getting necessary equipment; ANMs become empowered and confident as service provider. Ensuring enabling environment
for ANMs was also significant; No. of referral of high-risk cases has increased, which means ANMs more properly identify
high risk cases.
Although the knowledge enhancement by the 6-day ANC training has been monitored by means of preand post- test, such quantitative evaluation has not applied to the 2-days core competency training.
3-2 Implementation Process
3-2.1 Project Management and Monitoring
In addition to Japanese experts, the Project assigned local counterparts and BCs. The Project benefited
from their expertise and local network for its smooth implementation of the Project activities andencouragement of the local stakeholders. While those Project staff played a leading role in providing
training and technical guidance, and making necessary coordination at the initial stage of the Project, thegovernment counterparts have been gradually succeeding their roles. For example, block meetings andsector meetings are utilized as training and peer opportunities for ANMs under the initiative of BMO and
BPM in consultation with the Project staff especially BCs.
In general, the Project activities have been implemented according to PDM. Besides, the Projectsometimes took flexible actions to be aligned with NRHM. The progress of the Project was shared
among stakeholders and development partners by being present at various meetings in Delhi.
Joint Coordination Committee (JCC) meetings have been held three times (2007, 2008 and 2009) by thetime of Terminal Evaluation. Indian counterparts, the Project team and JICA representatives madeannual review of the Project activities and shared the plan of the following year at JCC.
3-2.2 Participation of target groups to the Project
The strategy of the Project focused on the empowerment and entitlement of ANMs’ function, andensured its enabling environment for ANMs in order to provide quality MH services. This could be
multiplied by external factors brought by the government side through NRHM such as provision of
united fund, Janani Suraksha Yojana (JSY), assignment of DPM and BPM, which is fully integrated to
improvement of services provided by ANMs. Such positive impact of the Project further accelerated
ANMs’ motivation and commitment, and created the community demands for quality services andparticipation in promoting MH services. Involving community leaders such as PRI members was also5the key to the successful implementation of the activities.
3-3. Summary of Evaluation Results(1) RelevanceThe relevance of the Project is very high.
・ The Project is integrated into NRHM-RCHⅡ, in which maternal and child health is focused as apriority area and the strategies to improve basic health care delivery system are proposed for equity.
The Project aimed to improve access to quality MNCH services for vulnerable people especially inrural areas by strengthening the services. Management and community mobilization, which isrealization of the mission stated in NRHM.
・ The Project is in line with the context of Global Health as well. Global Health community pays
special attention on maternal, newborn and child health (MNCH) because if the delays inachievement of MDGs 4 and 5. 50% of all maternal deaths occur in Sub Saharan Africa and another
35% in South Asia. In achievement of MDG 5, focus is on 1) the scaling up the package of MNCH
interventions which effects are confirmed with evidence; 2) equity of receiving basic health services
as well as on; 3) the collective efforts of development partners and recipient countries for the better
results.
・ One of the most effective interventions known is promotion of delivery attended by SBA. Global
Health Workforce Alliance (GHWA), which is affiliated in WHO, advocates the significance ofrecruitment, retention, and deployment of SBAs at all levels of health care facilities. The Projectchallenges the capacity development of the most advanced actions in the global efforts in theachievement of MNCH.
・ The Project is also in line with Japan’s foreign aid policies. As endorsed by the Health andDevelopment Initiative launched by Japan in 2005 and the G8 Hokkaido Toyako Summit in 2008,
Japan demonstrated its commitment and support to strengthening health systems and capacity
building for health workers to improve maternal health care. JICA sets “Improvement of BasicSocial Services” as one of the priority areas for assistance to India and improvement of maternal
health in included under the health program. Accordingly, the project concept and strategy are
consistent with these Japan’s policies and JICA strategy.
・ As for the selection of target area, Madhya Pradesh has high MMR and IMR in India and it isplaced as one of the 18 states, which have weak public health indicators need special focus by
Ministry of Health and Family Welfare. Sagar Region has the poorest figures in the state. Further,
ANMs didn’t have training opportunities for their capacity development though their role isimportant to provide health services to communities. In these contexts, the selection of target area
and target group was appropriate.
(2) Effectiveness
Reviewing how the Outputs have contributed to the achievement of the Project Purpose, the Project has
been effective; however. There is room for further improvement and strengthening.
・ Most activities were conducted according to PDM, and its effectiveness has been recognised
particularly in capacity strengthening on ANC checkup, facility management by improving
maternity wing and BMW, outreach activities through VHND, which are all essential tasks of
ANMs. ANMs improved MNCH services through the Project supports, which let to community
appreciation towards their work and brought them the feeling of empowerment and self-esteem.
・ Development of materials such as “Illustrated Guidelines for MH services in SHCs”, “Illustrated
Guidelines to operationalize delivery care at District Hospital/Community Health Centre/Primary
Health Centre”, “10 contents of ANC checkup”. “VHND Operational Manual” gave clear
instruction to front workers “how to do” and proved to be very effective to practice quality
services. Active involvement of community leaders, such as PRI members let to successful
launching of VHND and encouraging community people to utilize MNCH services provided by
ANMs.
・ Accordingly it can be concluded that synergistic effect of all the outputs mentioned above
maximized and boosted the quality of MNCH services conducted by ANMs. In fact, they are
essential components of ANMs routine responsibilities thus it is quite natural for ANMs to copewith all components. This approach was effective to empower ANMs. Comprehensive approach ofhealth system strengthening at policy, management, service delivery at community levels, realised6

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actual improvement of community health system with visible changes for ANMs and community
people made a positive cycle of community health improvement.
The areas to be strengthened for further scaling-up of the Project outcome include standardizationand institutionalization of training system for ANMs, articulation of ANMs’ role and responsibility,
coordination among districts, all of which need stronger initiatives from the State government.

(3) Efficiency
Overall, the Project has been efficient in terms of quality quantity and timing of the provision of most
inputs being adequate and utilized for the achievement of the Outputs.
・ The Project them consists of 2 Japanese experts and 6-7 Project local consultants and 8-9 fieldcoordinators locally assigned. Their expertise and understanding social-cultural context in India
enhanced the achievement of the Project Outputs.
・ It is noteworthy that the Project focused on capacity development of frontline workers, which led toempowerment and entitlement of ANM’s function, and ensured supportive environment for ANMs.
・ In addition, short0-term experts from Japan also contributed to capacity development of ANMs
utilizing their expertise in midwifery, TQM, Gender/Social Analysis.
・ JOCVs assigned to District Program Management Unit and district hospitals in Tikamgarh andDamoh also contributed to the Project activities although they are not officially integrated part of
the Project. They utilized their sills in SBA training and promoting HMIS introducing GIS software.
(4) Impact
There were several positive impacts observed as follows.
・ As stated earlier, the Project outcome was complemented by the maximum use of NRHM scheme
including united fund, JSY scheme, and allocation of DPM/BPM. It can be said that such synergy
effect led to improving the quality of MNCH services provided by ANMs and to demand creation
for institutional delivery. A good example picked up during the field interview was that community
people come to health facilities with quality of service instead of going to District Hospital where
people used to prefer for having delivery service.
・ Some of the project resources and outcome were utilized and shared at national level. For example,
HRM consultant of the Project was assigned as trainer for Basic Emergency Obstetric and Newborn
Care (BEmONC) training at national level, and also became a member of National Task Force forConsultation on JSY. Further, TQM consultant was invited to national meeting on quality
improvement, which was organized by Lal Bahadur Shastri National Academy of Administration,and made a presentation on TQM activities of the Project. HMIS consultant contributed todeveloping new NRHM form based on the analysis of existing recording and reporting formats.
・ It is difficult to tell through set indicator (MMR) that Overall Goal “The state health sector ensuresquality mother and new born child health services” can be achieved within several years aftertermination of the Project. However, if training of ANMs and related cadres, facility improvement
and good data management are carried on with the initiative of GoMP, it will be possible to achieve
Overall Goal.
(5) Sustainability
Government commitment to achieving MDGs on maternal health is expected to be sustained. In
addition, the Project is integrated in NRHM-RCHⅡ, in which maternal health care is included as one ofthe priority issues. Accordingly, sustainability will be ensured if collective actions are taken in line with
NRHM.
For technical sustainability, roles of skilled supervisors are essential in providing ANMs with technicalsupport and mentoring (supportive supervision) through regular supervision. Effective use of
institutional capacity such as State Institute of Health Management & Communication (SIHMC) might
be worth considering for sustainability in capacity development of health personnel.
4. Conclusion
As a result of series of meetings, interviews and surveys involving beneficiaries, organisations,stakeholders, experts and other personnel related to the Project, it is found that the whole set of theresults and impacts produced by the Project has been outstandingly valuable in the light of improving

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reproductive health in Madhya Pradesh. Regulations and policies related to the health systemstrengthening at the community level are already there in the NRHM; however the technical capacity tomaterialise the written norms were scarce in the State, Division, District and Block levels. JICA Project
took initiatives in implementation of the written norms at the most difficult rural areas where the healthand economic indicators were deteriorating. Achievements of the JICA Project in Madhya Pradesh are
getting special attention from the central government.
First of all, the Project succeeded in the materialization of NRHM with the concrete operation in thefields. Secondly, the Project succeeded in capacity building and empowerment of the ANMs. Various
innovations were introduced in the Project such as teaching methodology, training materials, supportive
supervision system as well as the empowerment strategies of ANMs.
The Project assisted in designing and revising NRHM reporting format, which was announced as asingle national standard by the central government. The Project was invited series of orientation on theaccurate usage of the new format conducted by the State. Community Health activities were also
promoted by the Project such as VHNDs. All of these achievements are inter-related and contributed tothe improvement of the MNCH services as well as the increase of the users of those services. In fact,
they are essential components of ANM’s routine responsibilities and thus it was quite natural for ANMs
to cope with all components.
Some of the Project activities are taken over by GoMP. Training methodology of SBA developed andtested by the Project in 5 districts was disseminated to other districts through state level TOT.
Audio-visual training materials 1) Antenatal Care at Health Post; 2) How to organize Maternity Wing at
Peripheral Hospital (CHC/PHC); 3) Hoe to conduct VHND were already approved by the State anddistributed to all 50 districts in Madhya Pradesh; 4) Biomedical Waste Management is also going to becompleted and distributed. Some the audio-visual materials are used outside of Madhya Pradesh as well.
Project achievement had impact on the national level. The Project consultants joined 1) “Expert Group
Meeting for review of SBA Training Package” and 2) National Task Force for Consultation on JSY 3)“Expert Group Meeting for revising NRHM reporting format”. The Project gradually gained influenceon the MNCH issues at the national level. Achievements of the Project were also presented at theinternational conferences, such as 4th Asia Pacific Conference on Sexual, Reproductive Health andRights (2007) in Hyderabad, International Conference on Midwifery (2009). In addition, presentations
by the Project local consultants are scheduled at Asian Network of Quality Congress, Annual
Conference in October 2010.
The achievements of the Project are well documented by the external evaluation conducted by NIHFW
and the positive implications of the Project were confirmed by NIHFW.
5. Promoting factors: the success of the Project is attributed to the following factors.
・ The Project initiated various small-scale “plan-do-see” cycles in order to visualise the changes inpromotion of quality MNCH services at the sub-health centre level. Small visible changes
encouraged and motivated project staff, local administration officers and target population toparticipate in the project activities with more enthusiasm.
・ Project activities were implemented by the Project local consultants who were knowledgeable aboutsocio-cultural context in India. Cultural norms are particularly important in the rural areas.
・ Chief Advisor (Project Manager) was knowledgeable about management, group dynamics as well as
local culture and language so that he was able to make maximum use of capacity of the Project local
consultants and run the Project smoothly.
・ Training method as well as training materials for ANMs’ in-service technical training wereappropriate.
・ Audio-visual teaching materials (such as DVD) provided better learning opportunity for ANMs aswell as for the community.
・ ANM training program was comprehensive as well as short enough to focus on the most essential
skills and stronger attention was paid for the follow-up supportive supervision, such as on-the-job
coaching, mentoring and consultation.

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・ Rapport was established among instructors and ANMs at the training so that the follow-up
consultation was smoothly conducted by the instructors.
・ NRHM fund (united fund) was available on time in improvement of the health facilities in thevillage.
・ Assignment of DPM, BPM and other NRHM staff contributed to the improvement of healthfacilities as well as community health activities.
・ There may be synergistic effect with JSY scheme. The Project contributed to ensure the quality ofservices of MNCH as JSY scheme promotes the institutional delivery.
・ Active participation of the community organization in health sector meeting and community healthactivities were facilitated by BCs.
・ Synergetic effect of ANMs’ training and supportive environment of ANMs generated by NRHM
such as health facility improvement, cooperation with the community organization, promoted theempowerment of the ANMs, which led to the improvement of the MNCH services provided by
ANMs.
・ Demand of the quality MNCH services was created among community members.
・ Introduction of GIS motivated health manager to improve the health facilities and health services.
・ The Project took strategy for scaling-up by contacting some key officials at central as well as statelevel by showing the achievement of the Project for policy advocacy.
6. Constraints:
・ Human Resources for Health are scares and there are various disparities in coverage of the basic
MNCH services.
・ Tutors and Supervisor for ANMs are particularly needed.
・ Absence of the min-, long-term strategies of development of Human Resources for Health atnational and state level.
・ Job Description of ANM, LHV and SN are not clear and thus it is not easy for them to work as ateam.
・ Although there is no clear job description for ANMs, expected responsibility for ANMs is
expanding and their workload is increasing. Population growth is another factor for overloading
ANMs. As a result, busy with other community outreach activities such as immunization, nutrition
and family planning counselling, and health education.
7. Recommendations
Based on the above conclusion, the following points should be taken into consideration before
completing the entire project period. Now it is time to generalize the accumulated small success into theknowledge and package of techniques for the public use.

(1) Documentation and packaging of Pilot District experiences
・ Uniqueness and innovation ideas of the Project should be shared by other districts, states, central
government and development partners firstly by direct observation of the project site and secondly
by documentation. While site visits can be arranged to share Project activities and achievement, it
may be more feasible to prepare reports and audio-visual materials which summarizes the essenceof the activities and achievements.
・ Teaching methodology, training materials, supportive supervision system as well as theempowerment strategies of ANMs should be complied into the minimum package.
・ These documentation processes are indeed the significant first step towards scale-up.
(2) Confirm the impact of some interventions with evidence・ A case control study (e.g. 20 ANMs with JICA 2-days core competency training and 20 ANMs
without JICA 2-days core competency training ) on the ANM’s actual performance is recommended
to confirm the impact of the synergetic effect of all four outputs that the Project produced (HRH,
TYQM, HMIS, IWC/BCC). Performance of the ANM should be evaluated by the ANM checklist
that the Project developed.
・ It may be useful for scaling up TQM/BMW if the impact of TQM/BMW on the health indicators(impact) is evaluated, since this approach is unique especially at the level of CHC/PHC.
・ Since VHND is conducted in all the districts in India, the impact and the uniqueness of VHND in
the Project sites should be demonstrated with objective indicators.

9(3) Re-production of IEC-BCC materials
・ Posters for SBA skills, maternity wing organization, BMW, VHND etc. can be shared with all the
districts without constraints as they were developed according to the national standards. These
posters should be re-produced for sustaining the activities in the pilot districts as well as for sharing
them beyond pilot districts.
・ Since the demand is high, the Project may coordinate with other development partners for reprinting
posters with the condition of acknowledgement of GoMP and JICA Project for any reproduction.
(4) Project Achievements and good practices should be shared with stakeholders in India as well as
developing counties and development partners outside of India.
・ Achievements of the Project may be presented at International conferences, such as 1) Global
Health Workforce Alliance Forum, at Bangkok (2011) 2) Global Forum for Maternal and Child
Health, New Delhi (2010).
(5) Tentative ideas for future directions
・ Further strengthening of the community health in rural areas with the special focus on capacity
development of ANM/LHV/SN and community health workers (ASHA). Training method andtraining materials can be scaled up to the national level. The cadre for supervision is currently
conducted by BPM and other staff, skill supervision, supportive supervision and follow-up technicaltraining should be further strengthened.
・ Strengthening of the planning, implementation and evaluation process at District level based upon
the data obtained by HMIS. The Project together with the central government is currently
conducting a pilot in Tikamgarh district in Madhya Pradesh utilizing the HMIS for district planning.
・ Further strengthening of the HMIS utilizing the GIS is especially useful for District Health Society
to plan and manage the health services. GIS may be also useful for the State in planning andmonitoring distribution and coverage of health services, health human resources as well as the drugand other logistics.

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