Arogya bandhu scheme ppp model

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GOVERNMENT OF KARNATAKA
AROGYA BANDHUAROGYA BANDHUAROGYA BANDHUAROGYA BANDHU
SCHEME FOR INVOLVINGSCHEME FOR INVOLVINGSCHEME FOR INVOLVINGSCHEME FOR INVOLVING
PRIVATE MEDICAL COLLEGESPRIVATE MEDICAL COLLEGESPRIVATE MEDICAL COLLEGESPRIVATE MEDICAL COLLEGES
ANDANDANDAND
OTHER AGENCIES IN THEOTHER AGENCIES IN THEOTHER AGENCIES IN THEOTHER AGENCIES IN THE
MANAGEMENT OF PHCsMANAGEMENT OF PHCsMANAGEMENT OF PHCsMANAGEMENT OF PHCs
UnderUnderUnderUnder
Partnership AgreementPartnership AgreementPartnership AgreementPartnership Agreement
AugustAugustAugustAugust 2008200820082008

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GOVERNMENT OF KARNATAKA
DEPARTMENT OF HEALTH & FAMILY WELFARE
Scheme for involving All Medical Colleges (Govt. /Private) and
others Agencies in the Management of PHCs
1. This scheme provides an opportunities for Private Medical Colleges, Non-
Governmental Organisation (NGOs), Trusts, other Charitable Institutions and
Philanthropic Organisations etc. either to fully manage the PHCs with
financial assistance by Govt. of Karnataka or to contribute to the
improvement of the facilities or to improve of service delivery without
directly managing the PHCs.
2. Primary Health Centres (PHCs) as per criteria laid down in 3 below can be
given on partnership agreement , on contribution or any innovation within
the state policy (Refer Para No. 20):
3. PHCs shall be selected as under:
(a) PHCs which are low in performance i.e., having high IMR & MMR and low
coverage on immunisation or low institutional delivery.
(b) PHCs with more number of vacancies for long duration.
(c) C’ category PHCs which are more than 15kms. away from highways.
(d) The proposal should be approved by the District Health Society of the
concerned District.
4. The PHCs with above said criteria can be given on Partnership Agreement.
The initial contract will be for five years with clause of renewal every year
based on review of performance.
5. If, for the purpose of improving either the infrastructure or the service
delivery, any institution comes forward with contribution in cash or kind, the
same will be permitted for any PHC in the State.
6. Eligibility Criteria:
a) All govt./private medical colleges are eligible to take up the PHCs for
management, under this scheme.
b) Any Non-Governmental Organisation willing to participate in this scheme:
i) Should be working in rural areas with legal status of a society registered
for three years under the Societies Registration Act or any
corresponding State Act or as a Trust registered under the Indian
Trust Act, 1882 or the Charitable and Religious Trusts Act, 1920.
ii) The NGO Should be active and its financial position should be sound.
This should be evident from the audited statements of accounts for
the past three years.

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Note: ‘A’ category PHCs which are located within 10kms of the taluka or District Headquarters,
‘B’ category PHCs which are located between 10 to 15kms. of taluka and District Headquarters,
‘C’ category PHC which are located more than 15kms. of taluka and District Headquarters.
iii) The NGO should be a reputed one with demonstrated capacity and
dedicated management body.
iv) The NGO should not have been a defaulter in respect of any funds
received from any of the Government Departments.
v) The NGO should have been working in the same district, at least for
two years, where it proposes to take a PHC for management.
c) The Trusts sponsored by the reputed corporate bodies, with proven
managerial capacities, are also eligible to take PHCs for management.
7. Procedure for submission of Proposals on invitation of the Expression of
Interest by the Department:
a) The govt./private medical colleges or the Trusts, running the Medical
Colleges, shall submit their applications to the Commissioner of Health and
Family Welfare Services, Ananda Rao Cirlce, Bangalore, through the
District Health Society.
b) A Medical College can submit the proposals to manage upto a maximum
of three PHCs in the first phase.
c) The NGOs and corporate bodies shall submit their application to the
Commissioner, Health & Family Welfare Services through the District Health
Society of concerned District.
d) An NGO can submit a proposal to manage one PHC per district in the first
phase.
e) A Trust sponsored by a corporate body can submit a proposal to manage
upto two PHCs in the first phase.
f) All applications, from medical colleges, shall be accompanied by the
information to be furnished in the manner provided Appendix-I.
g) The applications of NGOs shall be accompanied by the information to be
furnished in the manner provided in Appendix-II.
h) The applications of Trust, sponsored by the corporate bodies shall be
accompanied by the information to be furnished in the manner provided
in Appendix-III.
8. Evaluation and Selection :
a) The proposal of the Medical Colleges or NGOs or the Corporate Bodies
shall be first scrutinized by the District Health Society, with reference to the
eligibility criteria’s. The PHC should be selected by the department within
the above said ‘C’ category area. The applications will be forwarded to
the Commissioner, Health & Family Welfare Services after duly recording of
opinion on the above points.

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b) In respect of the NGOs, the CEO should also record his / her opinion
clearly indicating whether the NGO is working in the District atleast for 2
years and qualify as per his assessment.
c) Selection Committee: A selection committee, with the following
composition, shall consider all the proposal received in the Commissioner’s
Office and take a final decision within one month of the receipt of the
proposal by the Commissioner. The Committee shall consist of:
i. Commissioner, HFWS - Chairman
ii. Mission Director - Co-Chairman
iii. Director – HFWS - Member
iv. Chief Executive Officer ZP concerned - Member
v. Additional Director (PHC) - Member
vi. Chief Accounts Officer & Financial Advisor - Member
vii. Deputy Director (PPP) - Member
viii. A reputed doctor - Member
ix. A reputed person in the field of - Member
Public Health
x. The Selection Committee will also have - Member
Director, Medical Education as member for
Considering the proposals received from
the Medical Colleges on invitation
xi. Joint Director, Health and Planning - Member
Convenor
d) The Committee will evaluate the proposals with reference to the
information furnished by the medical colleges / NGO / Trust and the
recommendations of the District Health Society and then take a final
decision.
e) The Director Health & family Welfare Services shall communicate the
sanction /rejection of the proposal to the Medical College/NGO/Trust. The
approved agency shall enter into a contract with the Director of Health &
Family Welfare Services in the form given at Appendix-V.
9. Constitution of Arogya Raksha Samithi:
These PHCs will also have a Arogya Raksha Samithi as per the guidelines
issued by the department.
10. Management of the PHCs by the Agency:
a) The agency i.e. Medical College / NGO/ Trust shall take full responsibility
for providing all personnel at the PHC and the sub-centres coming within
its jurisdiction.
b) All personnel working in the PHC shall be employees of the agencies.
c) All existing staff of the government, working within the jurisdiction of the
PHC, may be withdrawn by the Department for re-deployment elsewhere.

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However some personnel may be retained, on deputation basis, by
mutual consent of the agency.
d) All personnel appointed, by the agency, has to be in accordance with
the staffing norms of the department in the PHC / sub-centre and have
the qualification prescribed in the department for such personnel.
e) The agency shall employ the personnel with at least minimum qualification
prescribed by the Government.
f) The agency shall be free to fix the remuneration of its employees not less
than fixed by the govt., However the salaries of the employees, on
deputation from Government, shall be governed by the terms of
deputation. The agency shall furnish to the Commissioner, Health & Family
Welfare Services, the details of remuneration it is paying to its employees in
the PHC.
g) Every PHC should have a minimum staffing pattern like a Medical Officer,
Staff nurse, Pharmacist, Lab technician and LHV to render good services in
preventive, promotive and curative aspect.
11. Responsibilities of the Agency:
a) The agency shall be responsible for the implementation of all the
National and State Health & Family Welfare Programmes and the Health
Care Service delivery within the PHC. No patient shall be charged any
amount for diagnosis, treatment, and drugs or for any other purpose
except in accordance with the Government policy.
b) The agency will be responsible to treat the Medico legal cases as per
the guidelines.
12. Assets of the PHCs:
a) The existing assets of the PHCs and Sub-Centres, coming under its
jurisdiction are to be handed over to the agency for the duration of the
entrustment.
b) The assets shall be maintained by the agency.
c) After the agreement period, all assets shall be returned to the
Government, in proper condition, subject to normal wear and tear.
d) The Agency will be free to make any additions to the fixed assets, with
prior written consent of the District Health & Family Welfare Officer, by
furnishing the details of the proposed changes to the fixed assets.
However, any such additions shall be without costs to the Government.
e) The agency shall ensure adequate stocks of all essential drugs, at all times,
for supplying them free of cost to the patients.
f) If any of the staff appointed in the PHC proceeds on a long leave, beyond
15 days, the agency should make alternate arrangements to ensure
continuity of services.
13. Funding from the Government:
For the services rendered by the agency, the Government would reimburse
the costs as per the following norms:

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a) 100% reimbursement of the actual remuneration, in respect of the staff
employed by the agency subject to a maximum of the midpoint of the
pay scale in the Govt. of that category. Remuneration paid to staff in
excess of the staffing norms of the department, will be met by the agency.
b) Leave salary of the female employees, on account of maternity leave, up
to a maximum of 135 days per delivery, restricted to a maximum of two
deliveries in the case of govt. deputed staff.
c) The liabilities, if any, that may arise on account, of or in the course of
employment of the persons appointed by the Agency will be solely that of
the Agency and their services will stand automatically terminated in the
event of the Agency handing back the PHC to the Department for any
reasons whatsoever.
d) POL charges with a ceiling of 100 litres per month, if the agency provides
an exclusive vehicle to the PHC.
e) Full reimbursement of Phone, water and electricity charges subject to a
maximum of Rs. 1,500/- a month.
f) Budget for drugs in the scale determined by the Government from time to
time for all PHCs in the State (the present scale is Rs. 1 lakh per annum).
g) Advance for one quarter will be placed at the disposal of the agency out
of NRHM/KHSDRP fund and subsequently recouped from ZP funds. The
grants for 2nd quarters will be released when UCs/SOEs for the 1st quarter is
furnished. This system will be rolled for every subsequent quarter.
h) Any assistance given from NRHM, Central govt. or State govt. to any govt.
PHCs, the same assistance will also be given to the PHCs is under the
Partnership Agreement. This will be managed by the THO in consultation
with the managing NGO/ administrative doctor.
i) The funds to the agency shall be released by the District Health & Family
Welfare Officer as per (g) above from out of the District/State sector
budget.
14. Monitoring:
The District Health & Family Welfare Officer, Taluk Health Officer and District
Project Management Officer shall monitor the working of the PHC with
reference to the services rendered by the PHC under the National and State
Health & Family Welfare Programmes and provisions of general health care
services in the PHC as per the general directions of the Government. The
suggested indicator for monitoring the performance is given in a Appendix iV,
Table 1.
15. Co-ordination:
To ensure there is proper co-ordination between the agencies to whom the
PHCs are entrusted for management, the District Health & Family Welfare
Officer and the Zilla Panchayat, there shall be a Co-ordination Committee
with the following composition:
a) Commissioner, HFWS - Chairman
b) Mission Director - Co-Chairman

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c) Chief Executive Officers of the respective ZP - Member
d) Chief Accounts Officer and Financial Advisor - Member
e) Deputy Director (PPP) - Member
f) Joint Director (Planning) - Member
Convenor
The Co-ordination Committee shall meet at least once in three months in the first year
and at least once in six months thereafter to address all issues of co-ordination
between different agencies. The Committee is fully empowered to issue any
clarifications and administrative directions which will be binding on all concerned.
16. Period of Entrustment:
The entrustment of PHCs to Medical Colleges / NGOs / Trusts will be for a
period of two years subject to review and confirmation of the arrangement
after one year and can be extended upto five years. Each intervention shall
be evaluated in fifth year on the basis of the experience of the past four
years. Renewal of the entrustment will be considered on the basis of the
evaluation conducted by an external agency.
17. Power to give directions:
During the period of entrustment, Government may, in public interest, give
directions to the agency and these directions would be binding on the
agency. However such directions can be given under specific extraordinary
situations and will be related only to service delivery. The reasons for such
directions should be included in the communication sent to the agency. Only
the Director, Health & Family Welfare Services or any higher authority would
be competent to issue any such directions.
18. Accounts:
The agency entrusted with the management of the PHC shall maintain
separate accounts and cash book for the PHC.
19. Audit:
Every agency, to which the management of a PHC is entrusted, shall furnish
Annual Audited Statement of Accounts within three months after the closure
of the Financial year. Government reserves the right to order special audit of
the accounts at any time during the period of entrustment or within one year
after the closure of the entrustment.
20. Termination:
Government may, at any time, terminate the contract for violation of the
conditions of contract by the agency, after due enquiry into such violations.
The selection committee, under the Chairmanship of the Commissioner, is
empowered to consider the report of enquiry and take a final decision in the
matter. Similarly the agency may also terminate the contract by giving 90
days notice in writing Termination of Contract by the agency, without notice,
will entail penalties equal to the amounts due for such duration.

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21. Closure:
Either on completion of the entrustment period or on termination of contract
by either side, the agency shall hand over the possession of all assets originally
given to the agency, by the Government, as well as the any assets added to
the institution with the prior written consent of the District Health and family
Welfare Officer.
22. Contribution to the PHCs and Sub-Centres:
Any charitable or philanthropic organisation, Trusts, NGOs, Corporate Groups
and individuals can contribute to the improvement of infrastructure / service
delivery at the PHCs and sub-centres. The nature and extent of such
contribution will be decided between the concerned donor and the
Committee. For permanent development works donors will be permitted to
put up a stone slab in that institution inscribing thereon the name of the donor
and the nature of the contribution. If the contribution is towards the
improvement of services for certain duration, the Donor is permitted to put up
a board for that duration, with details of the contribution and the purpose.
23. The components for contribution:
The contribution may be given for any of the following component:
• Equipments and furniture’s.
• Computers.
• Additional requirement of drugs and chemicals.
• Water and toilet facility to the hospital.
• Construction and renovation of the existing building.
• Provision of developing hospital garden and fencing or compound.
• Strengthening of Laboratory.
• Provision of solar water heaters.
• Providing non-clinical services – PHC complex.
• Provision of Ambulance Services in PHC area (Taluk).
• Provision for water purification system.
• Provision for Bio-medical waste management.
• Building maintenance.
• Provision of Specialist Services.
• Conducting camps.
24. Acceptance of Contributions:
• The proposal of contribution will be made by the donor to the Arogya Raksha
Samithi. The Arogya Raksha Samithi will take a decision on such contribution
and accept such contribution, if they are without any attached
conditionalities (except the conditionality of proper use).
• If any conditionalities are attached to the donation/contribution which
imposes financial liabilities on the Arogya Raksha Samithi either in short term or
long term, then the proposal will be referred to the District Health Society for
appraising the proposal.

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• If contribution is for civil works (construction or renovation) it will be decided
by Arogya Raksha Saminthi if it is within Rs. One lakhs . Beyond this it will be
referred to District Health Society for Approval.
• If contribution is with condition of displaying the name of the donor, the same
will be referred to the District Health Society for decision.
25. Application of the Contribution:
Where the Contribution is for additions to the building, the work shall be
executed either by the ZP Engineering division or by the Contractor engaged
by the Donor under the supervision of the ZP Engineering Division. If the
contribution is for adding any equipments etc. or providing drugs, the donor
may provide the same as per the specifications; requirements to be furnished
by the District Health and Family Welfare Officer. If the contribution is in the
form of providing the services of Medical / Paramedical personnel the donor
could make available only person of integrity and required qualifications and
position them in the PHC. Such persons shall be paid directly by him. Once
positioned for a specified period the persons sent shall work under the control
and supervision of the Taluk Health Officer / PHC Medical Officer as the case
may be.
APPENDIX – I
Important Instructions
1. Please ensure that the following documents are enclosed while submitting the
proposal.
i. Memorandum and Articles of Association / Bye Laws of your
organisation.
ii. Copy of registration certificate under these Acts, whichever
applicable.
a) Societies Registration Act, 1960.
b) Indian Trusts Act, 1882.

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c) Charitable and Religious Trusts Act, 1920.
d) Foreign Contribution (Regulation) Act, 1976.
e) Any other Act.
iii. Copies of exemptions granted by Government / Local Bodies for Sales
Tax, Income Tax etc.
2. Person signing this form should be the one so authorised by the Articles of
Association / Bye Laws of the Institution. Otherwise authorisation by resolution
of the executive body for the person signing should be enclosed.
3. Please state how you propose to bring any value addition to the services
rendered from the PHC.

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APPENDIXAPPENDIXAPPENDIXAPPENDIX----IIII
FORM IFORM IFORM IFORM I
ORGANISATION DETAILSORGANISATION DETAILSORGANISATION DETAILSORGANISATION DETAILS
1. Name of the Organisation :
2. Registered Address :
3. Name and Address of Branch Offices
in the District (if any)
:
4. Contact Numbers
Phone
Fax
E-mail
Any other
:
:
:
:
:
5. Names of contact persons
Name
Designation
Name
Designation
:
:
:
:
:
6. Details of Registration (Copies of
relevant Registration Certificates
under Societies, Registration Act,
1860, State District Indian Trust Act,
1882 to be enclosed)
If registered under any other Act,
please specify
Registration No.
Date of Original Registration
Registration valid up to
:
:
:
:
:
:
7. Are there any criminal cases pending
against the organisation or office
bearers (Yes/No) if yes details to be
furnished
:
8. Details of Registration under Foreign
Contributions (Regulation) Act 1976
(If applicable enclose copy of the
certificate)
Original Registration No.
:
:
:
:

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APPENDIX – II
Important Instructions
4. Please ensure that the following documents are enclosed while submitting the
proposal.
i. Annual Report Audited i) Income / Expenditure Account (ii) Receipts /
Payments Account and iii) Balance Sheet for the last 3 financial years.
ii. Memorandum and Articles of Association / Bye Laws of your
organisation
iii. Copy of registration certificate under these Acts, whichever
applicable.
f) Societies Registration Act, 1960.
g) Indian Trusts Act, 1882.
h) Charitable and Religious Trusts Act, 1920.
i) Foreign Contribution (Regulation) Act, 1976.
j) Any other Act.
iv. List of movable and immovable assets.
v. Copies of exemptions granted by Government / Local Bodies for Sales
Tax, Income Tax etc.
5. Person signing this form should be the one so authorised by the Articles of
Association / Bye Laws of the Institution. Otherwise authorisation by resolution
of the executive body for the person signing should be enclosed.

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APPENDIXAPPENDIXAPPENDIXAPPENDIX----IIIIIIII
:
4. Contact Numbers
Phone
Fax
E-mail
Any other
:
:
:
:
:
Name
Designation
Name
Designation
:
:
:
:
:
6. Details of Registration (Enclose
Copies of relevant Registration
Certificates)
Societies Registration Act, 1860
State District Indian Trust Act, 1882)
please specify
Registration No.
Registration valid up to be furnished
:
:
:
:
:
furnished
:
certificate)
:
:
:
:

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APPENAPPENAPPENAPPENDIXDIXDIXDIX----IIIIIIII
FORM IIFORM IIFORM IIFORM II
INFORMATION REGARDING MEMBERS OF PRESENT EXECUTIVEINFORMATION REGARDING MEMBERS OF PRESENT EXECUTIVEINFORMATION REGARDING MEMBERS OF PRESENT EXECUTIVEINFORMATION REGARDING MEMBERS OF PRESENT EXECUTIVE
BODYBODYBODYBODY
Sl.
No.
Name /
Address
Designation Qualification
Whether
related to
other office
bearers
Money value
of all benefits
from NGO (in
Rupees p.a.)
Age Occupation
Office held in other
NGOs with Address
1 2 3 4 5 6 7 8 9
1. For column 6: Salary / Honorarium / any other perks / housing /transport.
2. Write F for farmer / B for Business / G for Government, Semi-Government Employee
/ H for House-Wife / P for Professional / O for others.

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FORM IIIFORM IIIFORM IIIFORM III
DETAILS OF FUNCTIONARIESDETAILS OF FUNCTIONARIESDETAILS OF FUNCTIONARIESDETAILS OF FUNCTIONARIES
1. Name of the Office Bearer :
2. Date of becoming Office Bearer :
3. State whether the office held in other
NGOs assisted by Government
: Yes / No
4. Details of the offices held in other
NGOs assisted by Government:
(a) Name of the Organisations
(b) Address of the
Organisations
:
:
:
:
5. Are there any members of the family
of the Chief Functionary who receive
salary from the Organisations?
If yes, give details
: Yes / No
6. Is the Chief Functionary the founder
of the Organisation?
: Yes / No
7. If No, how many years has he been
working in Rural Areas? (His / Her
Bio-data to be attached)
:

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FORM IVFORM IVFORM IVFORM IV
DETAILS OF ACTIVITIESDETAILS OF ACTIVITIESDETAILS OF ACTIVITIESDETAILS OF ACTIVITIES
Sl.
No.
Titla of Scheme Funded by District Amount in Rupees
Completed on
going
Measures taken for
sustainability
1 2 3 4 5 6 7
Geographical area of operation :
No. of Staff working on :
Full time basis :
Part time basis :
Voluntary basis :
Total No. :
Are there any paid staff related to office bearers / board members / executive members of
NGO. If yes, furnish detail.

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APPENDIX II
FORM V
FINANCIAL STATUS OF ORGANISATION
Please provide copies of (i) Annual Reports Audited Income /Expenditure Account (ii)
Receipts / Payments Account (iii) Balance Sheet & (iv) Bank Pass Book for the past 3
years.
Income and Expenditure:
Sl. No. Year Income (Rs. In Lakhs) Expenditure (Rs. In Lakhs)
1
2
3
Major assets of Organisation as per last Audited Balance Sheet (this includes land value,
building with plinth area etc.)
Sl. No. Assets Expenditure (Rs. In Lakhs)
1 Cash Deposits
2 Movable Assets
3 Immovable Assets
(Please attach list of all movable and immovable assets of value over Rs. 2,000/-)
Any exemptions received from Government Yes / No.
(If yes, specify)......................................................................................................................
Details of Bank Accounts from which Government funds are proposed to be operated:
Account in the name of: ..................................................................................................
Details of Bank Account: ...............................................................................................
Sl.
No.
Items Details Details Details
1 Name of the Bank
2 Full Branch Address
3 Account No.
4 Type of Accounts
5 Name of the Signatory (1)
6 Post held in organisation
7 Relationship to Chief functionary
10 Relationship to Chief Functionary
11 Name of Signatory (3) post held in
organisation

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APPENDIX II
FORM VI
SUMMARY OF RECEIPTS
Year Year Year
Receipts
Amount
(Rupees)
%
Amount
(Rupees)
%
Amount
(Rupees)
%
Total Funds received 100 100
From Government
From Foreign Sources
Own Sources
By Community Contributions
What percentage of total expenditure was spent on Administration last year ?
Break up of Administration expenditure in percentage:
Sl. No. Administrative Expenditure Amount (in Rupees) Percentage
1 Salary / Emoluments
2 Facilities for staff
3 Fuel, oil, lubricants
4 Travel
5 Telephone
6 Office Expenses
7 Any other
Total
Has your organisation been blacklisted / put under FAS by the Government / any other
organisation: Yes / No
Compensation Structure:
Highest paid employees: Designation............................. Rupees.................................
Salary + cost value of perks in Rupees............................................................................
Lowest paid employee: .....................................................Rupees..................................
Salary + cost value of perks in Rupees..........................................................................
Facilities / benefits provided to office bearers...............................................................
Facilities / benefits provided to other employees..........................................................

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Are Annual Report and Audited Statements freely available to any member of the public ?
Yes / No.
If no, the reasons thereof: ................................................................................................
..........................................................................................................................................
Certified that the information given in this form is correct to the best of our knowledge. It is
understood that tendering false information will result in Government recalling / recovering
the assistance and stopping further funding of the NGO.
Counter signed by Member of the Executive Body.
Signature and seal of Authorised
Signatory
Name Name
Designation
Designation
Place: (Attach copy of authorisation by
Date: Executive body for signature

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APPENDIXAPPENDIXAPPENDIXAPPENDIX----IIIIIIIIIIII
IMPORTANT INSTRUCTIONSIMPORTANT INSTRUCTIONSIMPORTANT INSTRUCTIONSIMPORTANT INSTRUCTIONS
1. Please ensure that the following documents are enclosed while submitting the form.
(i) Memorandum and Articles of Association / Bye Laws of your organisation.
(ii) Copy of registration under these Acts whichever applicable.
a) Societies Registration Act, 1960.
b) Indian Trusts Act, 1882.
c) Charitable and Religious Trusts Act, 1920.
d) Foreign Contribution (Regulation) Act, 1976.
e) Any other Act.
vi. List of movable and immovable assets.
vii. Copies of exemptions granted by Government / Local Bodies for
Sales Tax, Income Tax etc.
2. Person signing this form should be the one so authorised by the Articles
of Association / Bye Laws of the Institution. Otherwise authorisation by
resolution of the executive body for the person signing should be
enclosed.

21
:
4. Contact Numbers
Phone
Fax
E-mail
Any other
:
:
:
:
:
Name
Designation
Name
Designation
:
:
:
:
:
6. Details of Registration (Enclose
Copies of relevant Registration
Certificates)
Societies Registration Act, 1860
State District Indian Trust Act, 1882)
please specify
Registration No.
Registration valid upto be furnished
:
:
:
:
:
furnished
:
certificate)
Registration valid upto
:
:
:
:

22
FORM IIFORM IIFORM IIFORM II
INFORMATION REGARDING MEMBERS OF PRESENT EXECUTIVEINFORMATION REGARDING MEMBERS OF PRESENT EXECUTIVEINFORMATION REGARDING MEMBERS OF PRESENT EXECUTIVEINFORMATION REGARDING MEMBERS OF PRESENT EXECUTIVE
BODYBODYBODYBODY
Sl.
No.
Name /
Address
Designation Qualification
Whether
related to
other office
bearers
Money value
of all benefits
from NGO (in
Rupees p.a.)
Age Occupation
Office held in other
NGOs with Address
1 2 3 4 5 6 7 8 9
1. For column 6: Salary / Honorarium / any other perks / housing /transport.
2. Write F for farmer / B for Business / G for Government, Semi-Government Employee
/ H for House-Wife / P for Professional / O for others.

23
APPENDIX III
FORM III
FINANCIAL STATUS OF ORGANISATION
Please provide copies of (i) Annual Reports Audited Income /Expenditure Account (ii)
Receipts / Payments Account (iii) Balance Sheet & (iv) Bank Pass Book for the past 3
years.
Income and Expenditure:
Sl. No. Year Income (Rs. In Lakhs) Expenditure (Rs. In Lakhs)
1
2
3
Major assets of Organisation as per last Audited Balance Sheet (this includes land value,
building with plinth area etc.)
Sl. No. Assets Expenditure (Rs. In Lakhs)
1 Cash Deposits
2 Movable Assets
3 Immovable Assets
(Please attach list of all movable and immovable assets of value over Rs. 2,000/-)
Any exemptions received from Government Yes / No.
(If yes, specify)......................................................................................................................
Details of Bank Accounts from which Government funds are proposed to be operated:
Account in the name of: ..................................................................................................
Details of Bank Account: ...............................................................................................
Sl.
No.
Items Details Details Details
1 Name of the Bank
2 Full Branch Address
3 Account No.
4 Type of Accounts
10 Relationship to Chief Functionary
11 Name of Signatory (3) post held in
organisation

24
APPENDIX III
FORM IV
SUMMARY OF RECEIPTS
Year Year Year
Receipts
Amount
(Rupees)
%
Amount
(Rupees)
%
Amount
(Rupees)
%
Total Funds received 100 100 100
From Government
From Foreign Sources
Own Sources
By Community Contributions
What percentage of total expenditure was spent on Administration last year?
Break up of Administration expenditure in percentage:
Sl. No. Administrative Expenditure Amount (in Rupees) Percentage
1 Salary / Emoluments
2 Facilities for staff
3 Fuel, oil, lubricants
4 Travel
5 Telephone
6 Office Expenses
7 Any other
Total
Has your organisation been blacklisted / put under FAS by the Government / any other
organisation: Yes / No
Compensation Structure:
Highest paid employees: Designation............................. Rupees.................................
Salary + cost value of perks in Rupees............................................................................
Lowest paid employee: .....................................................Rupees..................................
Salary + cost value of perks in Rupees..........................................................................
Facilities / benefits provided to office bearers...............................................................
Facilities / benefits provided to other employees..........................................................

25
Are Annual Report and Audited Statements freely available to any member of the public?
Yes / No.
If no, the reasons thereof: ................................................................................................
..........................................................................................................................................
Certified that the information given in this form is correct to the best of our knowledge. It is
understood that tendering false information will result in Government recalling / recovering
the assistance and stopping further funding of the NGO.
Counter signed by Member of the Executive Body.
Signature and seal of Authorised
Signatory
Name Name
Designation
Designation
Place: (Attach copy of authorisation by
Date: Executive body for signature

26
APPENDIXAPPENDIXAPPENDIXAPPENDIX IVIVIVIV
Table 1: Proposed Indicators for the Partnership Agreement
Indicator Baseline data
data for project
area
Target for
end
.................yea
r
Means of
measuring
indicator
Maternal Mortality Rate- (NRHM goal less
than 100 per lakh deliveries)
a) % of safe deliveries
b) % of institutional deliveries
c) % of identification of high risk
pregnancy
d) % of pregnant woman treated for
anaemia
e) % of pregnant woman fully
immunised against tetanus
f) % of Post natal visits within two
weeks of delivery
DLHS/RCH
Survey/HMIS
Infant Mortality Rate-
a) % of children exclusively breast fed
b) % of fully immunised children
c) % of children treated for ARI
d) % of children treated for Acute
diahorea
e) % of low birth weight babies born
f) % of children immunised against
measles
DLHS/RCH
Survey/HMIS
Percentage of out patients treated DLHS/RCH
Survey/HMIS
Percentage of in patients treated DLHS/RCH
Survey/HMIS
Tuberculosis (RNTCP guidelines)
a) Screening of chest symptomatics
(2% of the new adult OPD- Sputum
referral)
b) Smear collection rate (three
samples)
c) TB detection rate
d) sputam conversion rate
e) TB cure rate
f) Dropout rate
DLHS/RCH
Survey/HMIS
Malaria
a) Active surveillance (1% of the
population)
b) Passive surveillance (15% of the new
OPD)
c) API
d) Annual blood examination rate
DLHS/RCH
Survey/HMIS

27
(ABER)
e) Slide Positivity rate
f) Slide Falci Parum rate
Leprosy
a) Prevalence rate per ten thousand
population
b) Detection rate per 1 lakh population
(ANCDR- Annual New Case
Detection Rate)
DLHS/RCH
Survey/HMIS
Filaria- Filaria Endemicity Rate (clinical
case or slide positive case or both)
DLHS/RCH
Survey/HMIS
HIV/AIDS/STD
a) Incidence of HIV positive cases
b) Incidence of STD positive case
DLHS/RCH
Survey/HMIS
Blindness Programme- Percentage of
cataract operation done or no. of cataract
operation done.
DLHS/RCH
Survey/HMIS
Mental Health- Prevalence of mental illness DLHS/RCH
Survey/HMIS
Iodine Deficiency Disorder- Prevalence IDD
cases or goitre
DLHS/RCH
Survey/HMIS
Health related programmes
ICDS-
a) Percentage of Anganawadi Health
check-up
b) Distribution of Iron and Folic acid
DLHS/RCH
Survey/HMIS
Water supply and sanitation
a) Percentage of villages /families
access to safe drinking water supply
b) Percentage of villages/families
having a sanitation facility
DLHS/RCH
Survey/HMIS
NA=not available, HHS=household survey, HMIS=health management information system,
HFA=health facility assessment,, FIC = fully immunized child
NOTE: The targets in this table are meant to be indicative and not exact. What will matter is
significant progress along these parameters in the Partnership Agreement area.
Additional indicators to be followed are outcome indicators. They are influenced by many
factors, PHC services being one of them. They are typically:
- Under five mortality rate,
- Maternal mortality rate,
- HIV prevalence rate,
- Malaria prevalence rate.

28
Stamp Paper Worth Rs.200.00
APPENDIX V
CONTRACT FORM
THIS AGREEMENT made the..................................................................................Between
Governor of Karnataka represented by the Director of Health and Family Welfare Services,
Government of Karnataka, (hereinafter referred to as the “first party”) of the other part.
WHEREAS the First Party has formulated a scheme for involvement of the Private Medical
Colleges and Non-Government Organisations in management of Primary Health Centres in
the State. The Second Party who is................................... (Nature of the agency) is desirous
of participating in the scheme and offered its services in terms formulated by the
Government.
NOW THIS AGREEMENT WITNESSETH AS FOLLOWS:
1. Words and expression used in the agreement shall have the same
meanings as are respectively assigned to them in the Scheme notified
by the Government Organisations in Management of Primary Health
Centres.
2. The Scheme notified by the Government of Karnataka for involvement
of Private Medical Colleges and Non-Government Organisations in
Management of Primary Health Centres shall be deemed to form and
be read and constructed as part of this agreement.
3. In consideration of the payments to be made by the First Party to the
Second party as hereinafter mentioned, the Second Party hereby
covenants with the First Party to manage the Primary Health Centres
at............................. (Place and District) and the sub-centre coming
under its jurisdiction and provide the services in conformity with all
conditions laid down under the said schemes of the Government of
Karnataka.
4. The first party hereby covenants to reimburse the amounts to the
second Party in consideration of the provision the Services stated
above once a quarter as provided in the Scheme notified by the
Government of Karnataka.
IN WITNESS: where of the parties here to have caused this Agreement to be executed in
accordance with their respective laws the day and year first above written.
Signed, sealed and Delivered by the Signed, sealed and delivered by
the
Said........................ (for the First Party) Said........................ (for the First
Party)

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