National rural health mission

NATIONAL RURAL HEALTH MISSION

BACKGROUNDCharacteristic Urban Rural

Infant mortality rate 39 62

Government beds 68.1% 31.9%

Beds per 1000 population 1.1beds 0.2beds

Graduate doctor diustribution 74% 28%

Shortfall of •8% doctors at PHC’s•65% specialist at community health centers•55.3% male health workers•12.6% female health workers

Because of this inequality of distribution of health in the country the union government launched,

NATIONAL RURAL HEALTH

MISSION on April 2005

ABOUT NRHM… Inaugurated on April 12, 2005 Mission:-Increase spending on health from 0.9% of

GDP to 2-3% of GDP Correct the deficiencies of the health system Focus on 18 states – Northern and Eastern The Mission adopts a synergistic approach by relating

health to determinants of good health viz. segments of nutrition, sanitation, hygiene and safe drinking water.

Intended for 2005 - 2012

AIM.. To provide accessible, affordable, accountable,

effective and reliable primary health care and bridging the gap in rural health care through creation of ASHA.

SCOPE OF NRHM SPECIAL FOCUS ON 18 STATES.

Arunachal Pradesh, Assam, Bihar, Chhattisgarh, Himachal Pradesh, Jharkhand, J&K, Manipur, Mizoram, Meghalaya, MP, Nagaland, Orissa, Rajasthan, Sikkim, Tripura, Uttaranchal, UP.

GOALS… Reduction in Infant Mortality Rate (IMR) and

Maternal Mortality Ratio (MMR)

Universal access to public health services such as

Women’s health, child health, water, sanitation &

hygiene, immunization, and Nutrition.

Prevention and control of communicable and non-

communicable diseases, including locally endemic

diseases

GOALS CONTD… Access to integrated comprehensive primary healthcare

Population stabilization, gender and demographic

balance.

Revitalize local health traditions and mainstream

AYUSH

Promotion of healthy life styles

OBJECTIVES ASHA: Provision of trained and supported village

health activist Health action plan: To involve community in

preparing health action plans by Panchayath IPHS: Strengthening SC/PHC/CHC by developing

IPHS FRU: Increase utilization of first referral units

from less than 20% to 75% Strengthening district level management of health AYUSH

CORE STRATEGIES Train and enhance capacity of Panchayat Raj

institutions to own, control and manage public health services.

Promote access to improved health care at household level through the female health activist.

Health plan for each village through village health committee of the Panchayat.

Strengthening sub center through an united fund to enable local planning and action.

CORE STRATEGIES CONTD.. Strengthening existing PHC’s and CHC’c. Preparation and implementation of an intersect

district health plan prepared by the district health mission .

Strengthening capacities for data collection, assessment and review for evidence based planning, monitoring and supervision.

Developing capacities for preventive health care at all levels by promoting healthy life styles, reduction in tobacco consumption, alcohol etc.

SUPPLEMENTARY STRATEGIES1. Regulation of private sector to ensure

availability of quality service to citizens at reasonable cost.

2. Mainstreaming AYUSH – revitalizing local health traditions.

3. Reorienting medical education to support rural health issues including regulation of Medical care and Medical Ethics.

4. Effective and viable risk pooling and social health insurance to provide health security to the poor by ensuring accessible, affordable, accountable and good quality hospital care.

PLAN OF ACTION/COMPONENTS1. Accredited social health activists2. Strengthening sub-centers3. Strengthening primary health centers4. Strengthening CHCs for first referral c5. District health plan under NRHM6. Strengthening disease control program7. Public-private partnership for public health goals,

including regulation of private sector8. New health financing mechanisms9. Reorienting health/medical education to support rural

health issues

COMPONENTS OF NRHMComponent 1:-ASHA- Resident of the village, a woman (M/W/D)

between 25-45 years, with formal education up to 8th class, having communication skills and leadership qualities.

- One ASHA per 1000 population. - Trained for period of 23 days(induction) over

one year and periodic re-training.

ASHA- Chosen by the panchayat to act as the interface

between the community and the public health system.

- Bridge between the ANM and the village. - Honorary volunteer, receiving performance based

compensation.

RESPONSIBILITY OF ASHA- To create awareness among the community

regarding nutrition, basic sanitation, hygienic practices, healthy living.

- Counsel women on birth preparedness, imp of safe delivery, breast feeding, complementary feeding, immunization, contraception, STDs

- Encourage the community to get involved in health related services.

CONTD.- Escort/ accompany pregnant women, children

requiring treatment and admissions to the nearest PHC’s.

- Drug depot: depot holder like ORS, iron and folic acid, oral pills, condoms etc..

- Primary medical care for minor ailment such as diarrhea, fevers

- Provider of DOTS.

COMPONENTS OF NRHM CONTD.Component 2:-STRENGTHENING SUB-CENTRES Each sub-centre will have an Untied Fund for local

action @ Rs. 10,000 per annum. This Fund will be deposited in a joint Bank Account of the ANM & Sarpanch and operated by the ANM, in consultation with the Village Health Committee.

Supply of essential drugs, both allopathic and AYUSH, to the Sub-centers.

In case of additional Outlays, Multipurpose Workers (Male)/Additional ANMs wherever needed, sanction of new Sub-centers as per 2001 population norm, and upgrading existing Sub-centers, including buildings for Sub-centers functioning in rented premises will be considered

COMPONENTS OF NRHM CONTD.3: STRENGTHENING PRIMARY HEALTH CENTRES Mission aims at Strengthening PHC for quality preventive,

promotive, curative, supervisory and outreach services, through:Adequate and regular supply of essential quality drugs

and equipment including Supply of Auto Disabled Syringes for immunization) to PHCs

Provision of 24 hour service in 50% PHCs by addressing shortage of doctors, especially in high focus States

Observance of Standard treatment guidelines & protocols.

COMPONENT 3 Intensification of ongoing communicable disease

control programs, new programs for control of non communicable diseases, up gradation of 100% PHCs for 24 hours referral service, and provision of 2nd doctor at PHC level (I male, 1 female) would be undertaken on the basis of felt need.

COMPONENTS CONTD.STRENGTHENING CHCs FOR FIRST REFERRAL CAREOperationalizing existing Community Health Centers (30-50

beds) as 24 Hour First Referral Units, including posting of anesthetists.

Codification of new Indian Public Health Standards, setting norms for infrastructure, staff, equipment, management etc. for CHCs.

Promotion of Stakeholder Committees (Rogi Kalyan Samitis) for hospital management.

COMPONENT 4Developing standards of services and costs in

hospital careDevelop, display and ensure compliance to Citizen’s

Charter at CHC/PHC level In case of additional Outlays, creation of new

Community Health Centers (30-50 beds) to meet the population norm as per Census 2001, and bearing their recurring costs for the Mission period could be considered

COMPONENTS CONTD.5: DISTRICT HEALTH PLAN It would be an amalgamation through: Village Health Plans, State and National priorities for

Health, Water Supply, Sanitation and Nutrition. Health Plans would form the core unit of action

proposed in areas like water supply, sanitation, hygiene and nutrition. Implementing. Departments would integrate into District Health Mission for monitoring.

District becomes core unit of planning, budgeting and implementation.

Centrally Sponsored Schemes could be rationalized/modified accordingly in consultation with States.

CONTD. Concept of “funneling” funds to district for effective

integration of programs All vertical Health and Family Welfare Programmes at

District and state level merge into one common “District Health Mission” at the District level and the “State Health Mission” at the state level

Provision of Project Management Unit for all districts, through contractual engagement of MBA, Inter Chartered accountants and Data Entry Operator, for improved program management

COMPONENTS CONTD.6:CONVERGING SANITATION AND HYGIENE UNDER

NRHM

Total Sanitation Campaign (TSC) is presently implemented in 350 districts, and is proposed to cover all districts in 10th Plan.

Components of TSC include IEC activities, rural sanitary marts, individual household toilets, women sanitary complex, and School Sanitation Program.

The TSC is also implemented through Panchayati Raj Institutions (PRIs).

The District Health Mission would guide activities of sanitation at district level, and promote joint IEC for public health, sanitation and hygiene, through Village Health & Sanitation Committee, and promote household toilets and School Sanitation Program ASHA would be incentivized for promoting household toilets by the Mission.

COMPONENTS CONTD.7: STRENGTHENING DISEASE CONTROLPROGRAMMES

National Disease Control Program for Malaria, TB, Kala Azar, Filaria, Blindness & Iodine Deficiency and Integrated Disease Surveillance Program shall be integrated under the Mission, for improved program delivery.

New Initiatives would be launched for control of Non Communicable Diseases.

Disease surveillance system at village level would be strengthened.

Supply of generic drugs (both AYUSH & Allopathic) for common ailment at village, SC, PHC/CHC level.

Provision of a mobile medical unit at District level for improved Outreach services.

COMPONENTS CONTD.8: PUBLIC-PRIVATE PARTNERSHIP FOR PUBLIC

HEALTH GOALS, INCLUDING REGULATION OF PRIVATE SECTOR

Since almost 75% of health services are being currently provided by the private sector, there is a need to refine regulation

Regulation to be transparent and accountable Reform of regulatory bodies/creation where

necessary

CONTD. District Institutional Mechanism for Mission

must have representation of private sector Need to develop guidelines for Public-Private

Partnership (PPP) in health sector. Identifying areas of partnership, which are need based, thematic and geographic.

Public sector to play the lead role in defining the framework and sustaining the partnership

Management plan for PPP initiatives: at District/State and National levels

COMPONENTS CONTD.9: NEW HEALTH FINANCING MECHANISMS A Task Group to examine new health financing mechanisms,

including Risk Pooling for Hospital Care as follows: Progressively the District Health Missions to move towards

paying hospitals for services by way of reimbursement, on the principle of “money follows the patient.”

Standardization of services – outpatient, in-patient, laboratory, surgical interventions- and costs will be done periodically by a committee of experts in each state.

A National Expert Group to monitor these standards and give suitable advice and guidance on protocols and cost comparisons.

All existing CHCs to have wage component paid on monthly basis. Other recurrent costs may be reimbursed for services rendered from District Health Fund. Over the Mission period, the CHC may move towards all costs, including wages reimbursed for services rendered.

CONTD. A district health accounting system, and an ombudsman to

be created to monitor the District Health Fund Management , and take corrective action.

Where credible Community Based Health Insurance Schemes (CBHI)exist/are launched, they will be encouraged as part of the Mission. The Central government will provide subsidies to cover a part of the premiums for the poor, and monitor the schemes.

The IRDA will be approached to promote such CBHIs, which will be periodically evaluated for effective delivery

COMPONENTS CONTD.10:REORIENTING HEALTH/MEDICAL EDUCATION

TO SUPPORT RURAL HEALTH ISSUES While district and tertiary hospitals are necessarily

located in urban centres, they form an integral part of the referral care chain serving the needs of the rural people.

Medical and para-medical education facilities need to be created in states, based on need assessment.

Suggestion for Commission for Excellence in Health Care (Medical Grants Commission), National Institution for Public Health Management etc.

Task Group to improve guidelines/details

MAJOR STAKEHOLDERS Accredited Social Health Activist (ASHA) Auxiliary Nurse Midwife and Anganwadi worker Panchayati Raj Institutions and NGOs District Administration State Governments

VILLAGE LEVEL ASHA

Accredited social health activist Female activist given accreditation after 4 phase

training Ownership of health program given to villagers Village Health Committee prepares village health

Plan

DISTRICT LEVEL District health plan generated by combining

village health plans Elements are drinking water, sanitation, hygiene

and nutrition Strengthen PHC (Primary Health Centers) and

CHC (Community Health Centers)

HIGHER LEVELS Integrate vertical health and family welfare at district,

block, state and national levels Integration of vertical health programs (leprosy, TB,

malarial programs, etc.) All health facilities and infrastructure built based on

Indian Public Health Standards (IPHS) standards Rectify manpower shortage, equipment and other

furnishings in health facilities Strengthen capacities for data collection, processing,

evaluation and supervision

EXPLOIT SYNERGIES AT DIFFERENT LEVELS NGOs and ASHAs work together AYUSH (Ayurvedic, Yogic, Unani, Siddha and

Homoeopathy) - Local health traditions made mainstream

Pass regulations requiring private practitioners to give service at reasonable cost

Public-private partnerships Re-orient medical education (MBBS 6th yr in rural

service?) Social health insurance Health Information System

ROLE OF STATE GOVERNMENTS UNDER NRHM

The Mission covers the entire country (18 state). GoI would provide funding for key components in these 18 high focus States.

Other States would fund interventions like ASHA, Programme Management Unit (PMU), and up gradation of SC/PHC/CHC through Integrated Financial Envelope.

NRHM provides broad conceptual framework. States would project operational modalities in their State Action Plans, to be decided in consultation with the Mission Steering Group.

ROLE OF PANCHAYATI RAJINSTITUTIONSThe Mission envisages the following roles for PRIs:• States to indicate in their MoUs the commitment

for devolution of funds, functionaries and programmes for health, to PRIs.

• The District Health Mission to be led by the Zila Parishad. The DHM will control, guide and manage all public health institutions in the district, Sub-centers, PHCs and CHCs.

• ASHAs would be selected by and be accountable to the Village Panchayat.

CONTD. The Village Health Committee of the Panchayat would

prepare the Village Health Plan, and promote inter sectoral integration

Each sub-centre will have an Untied Fund for local action @ Rs. 10,000 per annum. This Fund will be deposited in a joint Bank Account of the ANM & Sarpanch and operated by the ANM, in consultation with the Village Health Committee.

PRI involvement in Rogi Kalyan Samitis for good hospital management.

Provision of training to members of PRIs.

MONITORING AND EVALUATION· Health MIS to be developed upto CHC level, and web-

enabled for citizen scrutiny· Sub-centres to report on performance to Panchayats,

Hospitals to Rogi Kalyan Samitis and District Health Mission to Zila Parishad

· The District Health Mission to monitor compliance to Citizen’s Charter at CHC level

· Annual District Reports on People’s Health (to be prepared by Govt/NGO collaboration)

· State and National Reports on People’s Health to be tabled in Assemblies, Parliament

· External evaluation/social audit through professional bodies/NGOs

· Mid Course reviews and appropriate correction

SWOT ANALYSIS OF NRHM

STRENGTH Strong political commitment Division into high focus and non high

focus states Flexible financing and scope for

innovation The active involvement of PRI’s ,

community NGO’s and private practitioners

Maximum expansion of human resource by adding 1 lakh service providers and more than 8lakh ASHA workers

STRENGTH Mainstreaming of AYUSH Integration of various health programs Evidence based planning Transparency and accountability in the

system Strengthened infrastructure

WEAKNESS The selection of ASHA is rigorous and time

consuming ASHA’s are overburdened with work and payment is

delayed. Work to them will be delegated by ANM Acute shortage of skilled manpower including

specialists persists Program far from reaching any of its key expected

outcomes Much of the funds are still underutilized. Release of

funds still problematic

WEAKNESS Data collected through HMIS has not been utilized

for local action. Lack of drugs and regular logistics supply Weak supervision

OPPORTUNITIES Utilization of AYUSH doctors at

PHC/CHC/DH Involvement of private sectors Program management support through

recruitment of managers (MBA’s, CA’s) using IT based system

Proper utilization of ANM and MPW Regular monitoring which helps in

correcting deviation Availability of funds

THREATS Lack of motivation of contractual staff Improper facilities to doctors and

paramedics working in rural sector Sustainability of political wills No clear agenda after 2012 Weak quality assurance system Frequent change of bureaucrats

National Urban Health Mission (NUHM)

NATIONAL URBAN HEALTH MISSION (NUHM)Introduction : As per Census 2011, population of India has crossed 121 crores with the urban population at 37.7 crores which is 31.16% of total population. Urban growth has led to rapid increase in no.of urban poor population, many of whom live in slums and other squatter settlements. In order to effectively address the health concerns of the urban poor population, the Union Cabinet gave its approval to launch NUHM as a new sub-mission under the over arching National Health Mission (NHM) on 1st May, 2013.

NUHM Urban Health Mission is implemented through

the Health Department in the urban local bodies except metropolitan cities as these cities forms a registered society and is funded by State Health Society (SHS).

SHS and the society formed will enter into a bipatite MOU regarding the implementation of NUHM and periodical reporting and review of the progress.

NUHM GOAL : Aim to improve the health status of the urban population in general, but particularly of the poor and other disadvantaged sections, by facilitating equitable access to quality health care through a revamped public health system, partnerships, community based mechanism with the active involvement of the urban local bodies

NUHM – OBJECTIVE STRATEGIES Improvising the efficiency of Public Health System

in the cities by strengthening, revamping and rationalizing existing Government Primary Urban Health structure and designated referral facilities

Promotion of access to improved health care at household level through community-based groups : Mahila Arogya Samitis

Strengthening Public Health through innovative preventive and promotive action

NUHM – OBJECTIVE STRATEGIES …..CONTD Increased access to health care through creation

of revolving fund IT enabled services (ITES) and e-governance for

improving access improved surveillance and monitoring

Capacity building of stakeholders Prioritizing the most vulnerable amongst the

poor Ensuring quality health care services

NUHM - OUTCOMESThe NHUM proposes to measure results at different levels with a long term as well as intermediate term view :1. Process/Thoughtput level indicator: Number cities/population where Mission has been

initiated Number of City specific urban health plans developed

and operationalised Number of U-PHCs with outreach made operational Number of Cities/population with all slums and facilities

mapped

NUHM – OUTCOMES ….CONTD Number of Slum/Cluster level Health and Sanitation Day Number of Mahila Arogya Samiti (MAS) formed Number of U-PHCs with programme Managers Number of ASHAs trained and functioning2. Output Level Indicators : Increase in OPD attendance Increase in BPL referrals from U-PHCs/referral availed Increase in institutional deliveries as percentage of total

deliveries Strengthened civil registration system to achieve 100%

registration of births and deaths

NUHM – OUTCOMES ….CONTD Increase in complete immunization among children < 12

months Increase in case detection for malaria through blood

examination Increase in case detection of TB through identification of

Chest symptomatic Increase in referral for sputum microscopy examination for TB Increase in number of cases screened and treated for dental

ailments Increase in ANC check-ups of pregnant women Increased TT (2nd dose) coverage among pregnant women

NUHM – OUTCOMES ….CONTD3. Impact Level Focus on Urban Poor : Reduce IMR by 40% - down to 20 per 1000 live

births by 2017 Reduce MMR by 50% Achieve Universal access to reproductive health

including 100% institutional delivery Achieve replacement level fertility Achieve all targets of Disease Control

Programmes

NUHM – INNOVATIVE STRATEGIES

1. Slum Level Innovations : Community monitoring Creating mentoring groups/support structures for MAS/ASHA through

NGO/CBOs “Healthy Mother”, “Healthy Infant Competitions2. U-PHCs Level Innovations : Involving private practitioners for special drives on immunization. Diabetes

etc Involving schools for public health action like “slum cleaning” , health

promotion etc Special programs for adolescent health

NUHM – INNOVATIVE STRATEGIES …CONTD3. City Level Innovations : Innovations with ICT like ‘sms’ based health promotion, PDA s for

outreach workers “Help-lines” for general health advise/medical emergencies Review/monitoring of quality, regularity of services through NGOs Identification and management/rehabilitation of malnourished

children & Nutrition Resources Centres Special Strategies for addressing anemia among women and girls Special Strategies for addressing malnutrition and neonatal

mortality

NUHM – OTHER STRATEGIES Improving Sanitation and Water Services Addressing Community behaviors pertinent

to the causation of childhood illness in Urban Slums

Community Participation in Prevention and Treatment on Childhood illnesses

Focus on All Aspects of Public Health Inter and Intra Sectorial Co-Ordination

NUHM For effective implementation and monitoring of NUHM, a

National Programme Management Unit (NPMU) is set up to provide technical assistance to the Urban Health Division of the Ministry

The NUHM promotes participation of the urban local bodies in the planning and management of the urban health programmes

City Health and Sanitation Planning Committee in the urban areas work under the umbrella of the District Health Mission and the District Health Society to integrate health service delivery to the urban poor in the urban areas

NUHM The Quality Assurance teams are responsible for

recommending accreditation of clinics/hospitals/nursing homes/diagnostic centers and pharmacies for empanelment for outreach services/U-PHCs/ referral centers

NUHM aims to provide a system for convergence of all communicable and non-communicable disease programmes including HIV/AIDS through integrated planning in the City level