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LIST OF ABBREVIATIONS AMC Annual Maintenance Contract ANM Auxilliary Nurse and Midwife ASHA Accredited Social Health Activist AWC Anganwadi Centre BPL Below Poverty Line CHC Community Health Centre CTF Common Treatment Facilities FGD Focussed Group Discussion GoUP Government of Uttar Pradesh HGIS Health Geographical Information Systems HR Human Resource IMR Infant mortality Rate IT Information Technology NABH National Accreditation Board of Hospitals NFHS National Family and Health Survey NGO Non- Government Organisation NSS National Sample Survey OBC Other Backward Castes PC Project Component PDO Project Development Objective PHC Public Health System PIP Project Implementation Plan PIS Personnel Information System PPP Public Private Partnerships PRIs Panchayati Raj Institutions PSO Project Support Officer QA Quality Assurance SC Scheduled Castes SD Standard Deviation SHKC Strategic Health and Knowledge Centre SLI Standard Living Index ST Scheduled Tribe TA Technical Assistance TFR Total Fertility Rate TOR Terms of Reference UPHSSP Uttar Pradesh Health Systems Strengthening Project

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Table of Contents 

List of abbreviations……………………………………………………………………….……..2 F

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Benefit incidence analysis...................................................................................14   F

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SOCIAL ASSESSMENT REPORT 2008 BY AMC: AN UPDATED SUMMARY This executive summary does two things: one, it culls out the key points as presented in the Social Assessment Report carried out by AMS in 2008; and two, it updates the state overview of Uttar Pradesh in view of recently available data from Census 2011, as also other health related data from other sources such as NFHS 3 and NSS. The summary seeks to cater to the specific requirements of UPHSSP, and is not intended to be a summary of the entire assessment exercise, undertaken earlier in 2008 with a significantly different perspective. The earlier social assessment study was carried out when UHSDP II was proposed as follow-on of the UPHSDP I, which aimed at strengthening the public health delivery services. UPHSSP focuses on strengthening health systems, though the ultimate objective remains one of improved efficiency and quality of public health service delivery in the state. 1. Uttar Pradesh: an overview Uttar Pradesh is the most populous state and fifth largest in area; with a population of around 199.5 million (as per Census of India 2001), it accounts for 16.49 percent of the country’s population. This is the result of a decadal growth of 20.09 percent during 2001-2011, one of the highest in India as compared to the national decadal growth of 17.64% during the same period. Though, area wise, the State is fifth largest in the country, it has a high population density of 828 persons per square kilometer, which is more than double the value of national figure (382 persons per Sq. Km.). Women constitute 47.8 percent of the population, attributing a sex ratio of 908. Scheduled Castes population is 21 percent and Scheduled Tribes population is almost negligible (0.1%) confined to pockets of only a few districts. Administratively, Uttar Pradesh state is divided into four regions— Eastern, Western, Central and Bundelkhand. There are 17 Revenue Divisions/Circles comprising of 72 districts. Each district is divided into a number of sub-districts/tehsils (312) comprising of a number of Development Blocks. Each Block has a number of Gram Panchayats, the third and the lowest tier of Panchayati Raj Institutions. Each Gram Panchayat is made up of a single village or a group of smaller villages. As per Census of India 2011, the State has 1.06 lakh villages and 915 urban agglomerations. The State Gross Domestic Product (GSDP) per capita is estimated at Rs. 13,179/- meaning that the State is well below the national average of Rs. 25,907/- (Planning Commission). Literacy rates (69.72%) are below the national average, and there is considerable variation between regions and substantial differences between men (79.24%) and women (59.26%). Low level of literacy in Uttar Pradesh influencing the development scenario is mutually affected by the poverty. The literacy rate of the state is 69.72 percent, which varies for male and female and urban (69.8%) and rural (52.5%) population. Among the urban literates, male and female literacy rates are 76.8 percent and 61.7 percent, respectively, while for their rural counterparts, their proportion stands 66 percent and 36.9 percent, respectively. The gender gap in literacy, especially in the rural areas is alarming (Census of India, 2001). Low sex ratio, lower female literacy and higher infant and child mortality for females are indicative of discrimination against women, while there is a preference for male progeny. Within the household, there are set rules of differential treatment to boys and girls. Ratio of child population to total state population is 14.90% 1.1 Key Health Indicators The most recent provisional data available from NFHS-3 reveals that the overall health status of the population in Uttar Pradesh is much below the national average. As is clear from Chart-1 presented ahead, compared to the National figure of 57, the State has a very high infant mortality rate of 73 deaths per 1000 live births in last five years. Nearly two-third of infant deaths occur in the neonatal period (first month), and the rest in the post-neonatal

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period (1month-1year). Low birth-weight, poor nutrition, and post-birth infectious diseases are the main proximate causes of neonatal deaths. The status of children (12-23 months) having received all recommended vaccination has also been found to be very low. Compared to the National figure of 44 percent, less than a quarter of children have received complete immunization in this age group.

The use of health care services during pregnancy and delivery remains extremely limited due possibly to lack of awareness or inadequate services. While in India three quarters of women received any antenatal care, their proportion for Uttar Pradesh stands at only two-third. Although, the NFHS data suggest that institutional deliveries are steadily increasing. Institutional deliveries increased from 11.2 percent to 15 percent to 22 percent (NFHS-1, NFHS-2, NFHS-3), the current status of women in the State going in for institutional delivery is still abysmally low as against the National average of 41 percent. The maternal mortality in Uttar Pradesh is alarmingly high at 517 deaths per 100,000 live births (SRS 2003). 1.2 Prevalence of Disease Widely attributed to poor sanitation and unhygienic living conditions and practices, there is a seasonal surge in infectious diseases such as gastroenteritis, typhoid, and hepatitis across many parts of the state. The rainy season floods help contaminate water supplies and facilitate the spread of water-borne diseases. NSS 52nd round found that about 56 percent of short duration ailments were due to infectious and parasitic diseases. These communicable diseases still remain major public health problem in the State. (Department of Planning, 2005). Uttar Pradesh is considered as one of the 12 states where leprosy is present at endemic levels. Despite concerted efforts in the past, there are still several districts where the prevalence is over 5 cases per 10,000 population (NCMH 2005). According to NFHS-2 estimates, 3,552 persons per 100,000 population were found to be suffering from malaria. Rural residents are almost 3 times as likely to suffer from malaria as their urban counterparts. Prevalence of tuberculosis of lungs, the most commonly known form, has been reported to be 551 per 100,000 population.

5744

77

41

73

23

67

22

IMR Vaccination (12-23 months)

AnyAntenatal Care

InstitutionalDelivery

India U.P.

Source: NFHS-3

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Further, 963 persons per 100,000 population were reported to have suffered from jaundice, with people from urban area more likely to be its victim than their rural counterparts. National programs in TB control, Malaria Control, HIV/AIDS and the Infectious Disease Vector Control Program are helping to track, prevent, and reduce the incidence of those diseases. Deaths from cardiovascular disease, cancer, and other lifestyle diseases are increasing. The Planning Department estimates that 3.5 million people in India are likely to die from heart disease annually by 2015 with a large number coming from Uttar Pradesh (2005). While obesity is relatively low (7%) in Uttar Pradesh, it is a increasing, mainly in urban areas where it has reached levels of 23 percent in women and 20 percent in men (NFHS-3). 1.3 Poverty and vulnerable population Owing to their socio-economic backwardness, a majority of the Scheduled Castes (SC) and Scheduled Tribes (ST) population in the State is disadvantaged and vulnerable. To a large extent, they are socially excluded and thus, remain mostly deprived of all benefits of development. Scheduled Castes in Uttar Pradesh constitute 21 percent, while the proportion of Scheduled Tribes is barely 0.1 percent. Regionally, Bundelkhand has 25 percent SC population followed by Central region (23%), Eastern region (22%), and Western region (18%). 1.3.1 Living Conditions The State has a high population density of 828 persons per square kilometer, which is more than double the national (382 persons per Sq. Km.). As for the urban areas, all the big towns are inhabited by large slum population with deplorable living conditions. Overall, 1 out of every 3 persons in the State falls in the category of low standard of living index (SLI). Evidently, the situation in rural area is much worse with around 40 percent of the population having low SLI as compared to the urban areas with only around 12 percent of population having low SLI (Table-1).

Table-1 : % Population in Urban & Rural Areas — By SLI

Category Urban Rural Total

Low 11.6 39.6 33.6

Medium 44.8 50.2 49.1

High 42.2 7.9 15.2

Missing 1.4 2.3 2.1

Total Percent 100.0 100.0 100.0

Source : NFHS-2

Overall, the living conditions in Uttar Pradesh vis-a-vis India are significantly poor. The percentage of households with electricity or piped drinking water supply is much below the national figures, as detailed in Table-3.

Table-3 : Living Conditions of Uttar Pradesh vis-a-vis India

Percentage of NFHS-3 sample households that: India

Total

UP Total

India Urban

UP Urban

India Rural

UP Rural

Have electricity 67.9 42.8 93.1 85.4 55.7 28.3

Use piped drinking water 42.0 10.3 71.0 34.8 27.9 2.0

Have access to a toilet facility 44.5 33.1 83.1 83.7 25.9 16.0

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Live in a pucca house 41.4 27.3 74.1 71.9 25.5 12.2

Have a motorized vehicle 18.6 16.6 31.9 31.0 12.1 11.7

Have a television 44.2 34.0 73.2 68.2 30.1 22.4

Own agricultural land 45.6 60.2 19.0 22.3 58.5 73.0

Source: NFHS-3 (2005-06) Fact Sheet India & Uttar Pradesh, 2007

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In Uttar Pradesh, more than a quarter of the population (29%) lives below poverty line (BPL). While the proportion of BPL population in the State is down from 41 percent in 1993-1994, and 47 percent in 1983, its relative position has not changed appreciably and it remains substantially above the India average. Recently poverty levels have decreased less slowly in urban areas, causing urban poverty to overtake rural poverty levels (Chart-3).

According to the Planning Commission Report (2007), in absolute terms, Uttar Pradesh is housing the highest proportion (20%) of BPL population in the country. Tradition combined with myths, beliefs, poor awareness and knowledge of diseases and their treatment limits their chances of survival. Infrastructure such as connecting roads, rail links, communication, media, household electricity, safe potable water, and housing are yet to reach many villages. Region-wise share of BPL population is presented in the table alongside. As already mentioned, the State accounts for one-fifth of the country’s population living below the poverty line. Consequently, the key health and human development indicators in the State are much below the National averages. 1.3.3 Disproportionate Burden of Diseases among Poor It is a well-known fact that the poor suffer from far higher levels of ill health, mortality, and malnutrition than do the better off; and their inadequate health is one of the factors keeping

Table-4 : % BPL Population — By Region

Region Proportion Eastern 44% Western 28% Central 24% Bundelkhand 4%

Source : UP Development Report

0

10

20

30

40

50

60

70

1973-1974 1983-1984 1993-1994 1999-2000 2002-2003

UP Rural UP Urban India Rural India Urban

Source: Planning Commission, Government of India

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them poor or for their being poor in the first place. Prevalence of disease across various social groups in India, as shown in Chart-3, makes it amply clear that compared to the other classes, the number of scheduled castes, scheduled tribes and the other backward castes per 100,000 population is significantly higher.

It is well established that health outcomes are closely related to economic status. Table-5 presented ahead gives the details of key infant and child health indicators in Uttar Pradesh by standard of living index (SLI). It is amply evident from the table that there are wide ranging differentials in the key health indicators between the populations of low and high standard of living index (SLI). For example, the IMR for low SLI is more than two times that for the high SLI. Similarly, the proportion of children experiencing diarrhoea or the proportion of undernourished children have been found to be much higher among the populations with low SLI as compared to the high SLI.

Table-5 : Key Infant & Child Health Indicators by Standard of Living Index (SLI)

Category IMR % Children (< 3 yrs)

experiencing Diarrhea2% Children (< 3 yrs)

Undernourished below –3 SD1

Low SLI 112.2 23.4 29.3

High SLI 45.6 19.2 9.7

U.P. (Overall) 95.4 23.3 21.9 Source : NFHS-2 Note: 1Index is expressed in standard deviation units (SD) from the median of the International

Reference Population, 2Includes diarrhea with blood

As regards the status of women in the State, once again the differentials between the low and high SLI are quite significant. There is a huge difference in total fertility rate between the women belonging to low SLI and high SLI. It is alarming to note that 9 out of 10 deliveries in case of the low SLI are unsafe. Similarly, wide-ranging differentials exist between the low and high SLI for the other indicators (Table-6).

Table-6 : Key Women’s Health Indicators by Standard of Living Index (SLI)

Category Total Fertility

Rate1Unmet Need for

Family Planning2% of Unsafe

Deliveries

Low SLI 4.91 27.3 89.4

Chart-4 : Prevalence of Disease across Social

Source: National Commission on Macroeconomics and Health, MoHFW, GOI, 2005

2413

2604

2367 2355

2468

SC ST OBC Others All

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High SLI 2.80 20.7 43.0

U.P. (Overall) 3.99 25.1 77.7

Note: 1Rate of women aged 15-49 years Source : NFHS-2

The social caste-wise analysis of the recently released NFHS-3 data on the prevalence of under-nourishment and neo-natal mortality is presented in the following chart. As is evident, the proportion of children under five years of age belonging to the SC and ST communities who are under-nourished is much higher than the overall State average. Similarly, the neo-natal mortality rate in the SC/ST communities is also higher than the overall State average.

A similar social caste-wise analysis of the NFHS-3 data on the three key indicators of women’s health, namely, Total Fertility Rate (TFR), unmet need for family planning and the proportion of unsafe deliveries is presented in the following table. The situation of SC and ST communities with respect to all these three indicators has been found to be much poorer than the overall State average.

Table-7 : Key Women’s Health Indicators by Standard of Living Index (SLI)

Category Total Fertility

Rate1Unmet Need for

Family Planning2% of Unsafe

Deliveries

Scheduled Caste 4.46 22% 80%

Scheduled Tribe 5.34 17% 96%

OBC 3.83 22% 75%

Others 3.23 19% 60%

U.P. (Overall) 3.82 21% 73%

Note: 1Rate of women aged 15-49 years Source : NFHS-3

2 Benefit Incidence Analysis A large evidence base highlights the fact that there are widespread inequalities in access to public health facilities. Equity is the underlying premise for the government involvement in the health care delivery. Yet, this goal often remains elusive, especially in the poor resource settings. As is amply clear from the following chart, the benefits of public subsidy for curative care are disproportionately concentrated among the better offs. As a matter of fact, the share of benefits for the highest income quintile is over three times that of the lowest income quintile, implying that the public health services, far from promoting equity, work against it.

48%

61%

44%

32%42%

60% 56%

38%

55%

SC ST OBC Others Total

Under 5 Malnourished Children (% below 2 SD1 by weight for age) Neo-natal Mortality

Source: NFHS-3 1Includes children who are below –3 SD from the International Reference Population Median

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3. Field findings Poor and disadvantaged being the focus of the social assessment study, sampling of villages was done on the basis of the highest concentration of scheduled caste/scheduled tribe population. During the field visits, it was observed that the people in these villages were living in deplorable conditions. Among all the regions, the situation in Bundelkhand region was found to be worst in this regard. It is well-known that the poor suffer from far higher levels of ill health, mortality, and malnutrition than do the better off; and their inadequate health is one of the factors keeping them poor or for their being poor in the first place.(25) The population in general, and women and children in particular in the study area were visibly weak and malnourished. The situation regarding general health condition of the poor was found to be similar across all the four regions of the State. The respondents unanimously mentioned poverty and unhygienic conditions as the two major causes for their poor health. According to them, the prevalence of diseases was more among the poor. They reasoned that the poor lived on inadequate food, and owing to poverty and illiteracy, they were unable to seek and obtain prompt and proper care in case of illnesses. They complained that no developmental activities were undertaken in their village. All the sample villages lacked sources of safe drinking water, electricity and roads. These villages had no drainage system and as a result, water logging at several places was a common sight providing perfect conditions for mosquito breeding and consequently, high incidence of malaria. The woes of the scheduled caste/scheduled tribe communities living in small hamlets or in remote areas are further compounded. The study reveals that the pregnant women and children under 6 years of age are deprived of Anganwadi services as well. In most cases, it was reported that the Anganwadi Centers were operating in the main village and those living in the hamlets were simply ignored and eligible women and children were not provided any supplementary nutrition, nor their children could receive the pre-school education at Anganwadi Center (AWC). As regards the Government primary schools, while school buildings have come up even in far off and remote areas and the issue of accessibility has significantly been resolved, conspicuous absence of teachers in these schools have not been able to make a dent on illiteracy among school children. The above findings reveal that although, health conditions and health needs of the poor and downtrodden are influenced by health services delivery and quality of care, these are more a reflection of other important factors. These include, their access to resources (such as sufficient

10%13%

18%

26%

33%

Poorest 20% 2nd Middle 20% 4th Richest 20%

Income Quintiles

Source: National Council of Applied Economic & Research, 2000

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and nutritionally balanced food and safe water), living conditions, their occupations, life skills and risks and their healthcare seeking behavior. Care seeking for treatment of minor and major illnesses It is found that in all the four regions, for minor ailments, generally, the rural poor approach the nearby provider, who is almost always a quack. According to the male and female participants of FGDs, village Pradhans, ASHAs and ANMs, these quacks are close by and people trust them, as they have been providing services for long in their area. Further, they do not charge much and many a times, if someone is unable to pay right away, they may also allow for the payment to be deferred for some time. However, when asked about the type of provider visited for seeking treatment for major ailments, they mentioned that they almost always approached a qualified provider. Wherever the PHC/CHC is located far away from the village and a qualified private provider is available and accessible more easily and they have the ability to pay, they bypass the PHC/CHC and approach these private providers. They approach PHC/CHC only when it is close by and the patient is in serious condition. S P R P G F

Although, the rural poor are very much aware that the doctors at PHCs/CHCs are highly qualified and competent, many a times they bypass them in favour of a private provider (even a quack). The study reveals a wide spread resentment among men and women against the poor healthcare services at PHC/CHC. According to them, there is no special provision for poor at these Government facilities. Rather, the poor are discriminated in that they have to encounter problems at every stage, from registration at the hospital to being examined. One of their major complaints was that they were not given all the prescribed medicines at the hospital. They complained that only some cheaper medicines were given, while they were required to purchase expensive ones from outside. The general perception in the minds of people is that the medicines provided by Government hospitals are of poor quality and provide them no relief from their ailments.

“....problems are faced. We have to wait...., they are not interested in making registration card. Medicines are not dispensed promptly....... The cheaper ones

are given from there, while the expensive ones are prescribed from outside” Further, the women also mentioned that more often than not, the behavior of doctors and other staff is not polite, especially towards the poor and those belonging to scheduled caste community.

“Behavior is not good....., they do not talk properly.” Complete dissatisfaction and disillusionment from public health services was found to be universal, more so among the male members. This became obvious during the focus group discussions; compared to women, they were more vocal and forthright in condemning the PHC/CHC services. According to them, these facilities cater to the health needs of only better off and are unresponsive to the health needs of poor and downtrodden, as is evident from the following statement made by one of the male participants.

“They give (preferential) treatment to those who are well dressed. The poorly dressed ones are shunned away....., medicines are provided to the better off, the poor are not given.”

As regards the type of provider approached for treatment of minor and major illnesses, the findings are similar to the ones revealed by women and men and mentioned above. To

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summarize, some of the major problems faced by these women at Government facilities, as mentioned by them, are as follows—

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Several studies in the past also have come out with similar findings, as detailed in the secondary information report. Nevertheless, what is surprising is that these problems still persist and the efforts made by the government have not produced the desired effects in this regard. The study findings make it amply evident that while wage loss/loss of domestic labor, costs of transportation, fees and medicines influence the decision making process, the perception of inadequate or ineffective care becomes major barrier in utilizing the public health services, especially by the rural poor. Ironically, these are the people who need them most. From the perspective of poverty and equity, the study reinforces the earlier findings about the public health system conferring greater benefits on rich than the poor.

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Equity Action Plan of UPHSSP Equity Dimension: an overview UPHSSP 

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Project Components: Equity Elements TUP H S S P UPHSSP P I PPIP G U P T PIP 

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Project Components: The project has the following two components: Project Component (PC) 1: strengthening management and accountability systems Project Component (PC) 2: Improving quality of service delivery PC 1: Strengthening management and accountability systems

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• Effectiveness of the Rastriya Suraksha Bima Yojna including recommendations for its improvement and expansion.

• Disease burden pattern of Uttar Pradesh and its prevalence for preparation of a

contingency plan • Development of a referral system based on the current pattern, norms, protocols,

guidelines of referral at various levels

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• Need for disaster management and epidemic preparedness plan at the regional level.  

Other themes that could be included from the point of view of social equity are: barriers in access of the poor to public health services; how to make the public health service delivery attractive for the poor; responsiveness of the health system to the needs of women and children.  A Strategic Health and Knowledge Centre (SKHC) is already set up to help undertake theme based research including action research in critical areas such as public health, health systems, clinical care, and health financing, particularly in view of their linkages to results with a focus on equity. This will generate required evidence for informed decision making, policy planning, budgeting, and monitoring and evaluation of on-going programs and projects in the sector. This component includes the following sub-components:

� Introducing strategic planning functions � Improving use of data for program management � Introducing Health Geographical Information Systems (HGIS) � Strengthening healthcare waste management system � Strengthening CMSD for procurement and supply chain management � Strengthening Public Private Partnerships (PPPs) � Strengthening financial management systems � Introducing and strengthening social and provider accountability in the public sector

It is important to underline here that most of these functions as mentioned above, though apparently equity neutral, can play out in very inequitable ways, if not deliberately targeted and addressed. The equity plan matrix available at the end of this section describes the specific activities proposed to be undertaken to ensure equity in health service delivery.

The UPHSSP proposal recognises the financial management systems to be the key to strengthening accountability systems within the health sector. Improvements in procurement and supply chain management and social accountability systems are two other main features of the accountability strengthening aspects of the project. The need to improve provider accountability has been recognised and addressed in the project implementation plan. A system for motivating health institutions for achieving improved performance and providing high quality services will be developed and operationalised. Instrument to do this is one of an award and incentive system. It is critical to ensure that the provider awards/incentives should explore ways to include weightage for efforts to improve services to previously underserved/vulnerable groups, which include the poor in remote areas.

The long-term objective of this is: to build trust among citizens and involve them in improving health service delivery by holding health service providers accountable and increasing their responsiveness to clients’ health needs. The activity also aims to improve health behaviors at the individual, household and community levels.

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Another specific objective in Phase I is to design and pilot workable approaches to help citizens hold the health system accountable for service provision and be responsive to their health needs .The most successful approach/es would be implemented more widely in the state, following assessment of the appropriate scale and areas for expansion. The project would develop, pilot and evaluate models (action research) to introduce community assessment of health and health care at the local level and use assessment information to stimulate community action to (a) demand better services, (b) enhance positive health behaviors and community actions that improve health, and (c) promote community audits of service delivery and drug and human resource availability. These models would be geared to improving equity in health and in access to and utilization of health care. They may also include Panchayati Raj Institutions but would not be limited to PRIs, as their capacities to address equity issues significantly are suspect due to the political nature of PRI functioning at the local level. PC  I

II

� S Q A I C M DNABH A

� O� O

NABH A� I� I

Investments would support introduction of systematic Quality Assurance (QA) mechanisms in the health Department and support improvement of quality across public sector government hospitals to get accreditation under the National Accreditation Board of Hospitals. It could also support the state, as required, to implement the recently introduced National Clinical Establishment Act, thereby supporting the role of the government to regulate the quality in the private sector as well. This is a component that requires utmost care in planning and execution in order to help achieve the desired results. Issue of quality of health care is intimately linked with issues of efficiency and capacity, which is sought to be addressed by having a substantive engagement with the private sector. It is envisaged that UPHSSP will do so with enough sensitivity and responsiveness to highly inequitable access of people to health care services and the massive crisis of credibility that mars the public health delivery system in UP at the moment.

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Equity Action Plan Matrix Equity Action How Responsibility When Monitoring Sub-component on Strategic Planning Conduct studies that assist the programme to improve access and quality of health care to people who are underserved and who face social or economic barriers to improving their health outcomes

PSO will prepare the TORs for an agency to be contracted (by the TA provider) to carry out the studies. At least four high quality equity-related studies would be completed during the project period.

Project Support Officer in charge of Equity Plan together with officer in charge of Strategic Planning (if different)

Studies would be identified on an on-going basis, and completed according to the time schedule specified in their TORs.

TOR

S

Sub-components on Strengthening Data Development and Use for Decision-making, and Health Geographic Information System Ensure that health data are disaggregated by geographic, social and economic variables and analyzed accordingly, so that programme management decisions are made with a focus on equity and reducing disparities in access to health care

The relevant variables will be identified and incorporated in the design of the health data systems. Reports from these systems and other data sources analyzing socio-economic disparities will be generated for use by programme managers and decision makers. District report cards would include equity variables.

PSO/TA provider to identify useful reports that could be generated for programme managers from other data sources, and work with EDC to have these produced. Consultant agencies hired to develop data systems under TORs prepared by the Project Support Officer in charge of IT.

Within the time schedule for establishment and activities of the Data Resource Centre.

Attention to equity dimensions in: (i) TORs for Consultant agencies; (ii) design of software (iii) data analysis and report generation.

Sub-component on Social and Provider Accountability Develop and pilot social mechanisms to improve

Conduct a study of previous efforts, design 3-4 possible pilots, and

Project Support Officer for Social Accountability will develop TORs for

TORs for study, workshops and design of pilots: Q1 of Project

TOR

S

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service provision and health behaviors, particularly among economically, socially and geographically vulnerable people

pilot them in different areas of U.P. at a significant scale. Assess their progress and results within the project period, and report to policy-makers for scaling-up.

consultants for (i) the study and pilot design, (ii) implementation of pilots; and (iii) evaluation. PSO/TA provider will oversee the consultants hired to carry out the TORs.

Year1. Workshop: Q2 Year 1. Design completed by end of Year 1. Pilots during Years 2 to 4. Assessment: first half Yr 4 Policy-makers workshop: second half Year 4.

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