National Rural Health Mission

Dr. Bhuwan Sharma

Asst. Professor (Grant Medical College, Mumbai)

The Challenges in Rural health sector Under funded public health system (0.9% GDP) High and prohibitive out of pocket expenditure Inequitable distribution of skilled manpower in rural

areas with 70% of total population(R-28%, U-74%). Poor quality services in public health system Poor community participation People’s needs different from what system offers Large unregulated private sector Minimal Insurance coverage (10%) Unregulated population growth.

Introduction

National Rural Health Mission was launched by our Hon’ble Prime Minister launched in 12 th April, 2005 with an objective to provide effective health care to the rural population, by

Improving access to health care Enhancing equity and accountability Promoting decentralization

Preamble of NRHM Provide effective health care to entire rural

population with special focus on 18 states. Raise public spending on health to 2-3% of GDP Health activist in each village, preparation of health

plans in collaboration with PRIs. Integration of vertical health and family welfare

programme. Integration of other determinants of health like

sanitation, hygiene, nutrition and safe drinking water through a district health plan.

Decentralization of health programmes at district level and involvement of local bodies.

Defined time bound goals To provide equitable, accessible, affordable,

accountable, effective and reliable primary health care especially to poor women and children.

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

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 Health Action Plan IPHS FRU District health plans AYUSH

EXPECTED OUTCOMES•Universal Health care, well functioning health care delivery system.

•IMR to be reduced to 30/1000 live births by 2012

•MMR to be reduced to 100/100,000 live births by 2012

•TFR to be reduced to 2.1 by 2012

•Malaria Mortality Reduction Rate – 60% upto 2012

•Kala Azar to be eliminated by 2010, Filaria reduced by 80 % by 2010

•Dengue Mortality reduced by 50%, JE mortality reduction by 50% 2012

•RNTCP-2 – maintain 85% cure rate, leprosy prevalence rate to reduce from 1.8/10,000 to less than 1/ 10,000.

•Upgrading all SCs, PHCs and CHCs to IPHS levels,

•Increase utilization of FRUs from below 20% to over 75%.

Plan of action/Components Accredited social health activists Strengthening sub-centers Strengthening primary health centers Strengthening CHCs for first referral centres District health plan under NRHM Strengthening disease control program Public-private partnership for public health goals, including

regulation of private sector New health financing mechanisms Reorienting health/medical education to support rural

health issues

Components of NRHM

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. - Around one 100,000 ASHA’s are already selected.

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

Contd.

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

- Escort/ accompany pregnant women, children requiring treatment and admissions to the nearest PHC’s.

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

- Provider of DOTS.

Janani Suraksha Yojana and ASHA

NRHM JSY

Antenatal Check up

Institutional Care during delivery

Immediate post-partum

(coordinated care)

↑↑Institutional Deliveries

in BPL families

↓↓ all MMR & IMR

Cash assistance

Components of NRHM contd.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.

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.4. STRENGTHENING CHCs FOR FIRST REFERRAL

CARE Operationalizing 3222 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.

Developing standards of services and costs in hospital care Develop, display and ensure compliance to Citizen’s Charter at

CHC/PHC level In case of additional Outlays, creation of new Community Health

Centres(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 Charter/Inter Cost 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.

Similar to the DHM, 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.

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.

Mainstreaming AYUSH. Task Group to improve guidelines/details

NRHM Main Approaches

Communitization

•Village Health & Sanitation Committee• ASHA• Panchayati Raj Institutions• Rogi Kalyan Samiti

Flexible Financing

• Untied grants• NGOs as implementers• Risk Pooling• Money follows patient• More resources for more reforms

Monitor progress against standard

•IPHS Standard• Facility Surveys• Independent Monitoring Committee

Innovations in Health Management

• Additional manpower• Emergency services• Multi-skilling

NRHM- The progress so far (2012)

IMR – 47/ 1000 live births (58 in 2005) MMR- 212/ 100,000 live births (301 in 2003) TFR- 2.2 (2.7 in 2005) Leprosy eliminated Malaria and Dengue mortality reduced to below

50% as apposed to 2005. DOTS progress maintained SC/PHC/CHC up-gradation according to IPHS is

increasing. Institutional deliveries increased manifold (2.7 crore

beneficiary under JSY ).

MCQs Q1. The year of launching of NRHM ?

a) 2003

b) 2005

c) 2001

d) 2007

Q2. The goal of NRHM to reduce TFR by 2012 upto ?

a) 2.7

b) 2.5

c) 2.3

d) 2.1

Q3. IMR of India as per the 2012 census ?

a) 58/ 1000 live births

b) 52/ 1000 live births

c) 47/ 1000 live births

d) 45/ 1000 live births

Q4. Monetary incentive to ASHA under Janani Suraksha Yojana in Mumbai district ?

a) 1000/- Rs

b) 600 /- Rs

c) 200 /- Rs

d) Nil

Q5. Benefits of JSY are extended to females of SC/ST category in high performance states upto ?

a) Two live births

b) Three live births

c) Four live births

d) All births

Q6. Under NRHM, there should be provision of one Accredited Social Health Activist for __________ population.

a) 500

b) 1000

c) 1500

d) 5000

Q7. ASHA is selected by ?

a. ANM under Sub Centre

b. Medical Officer of PHC

c. Gram Panchayat

d. CBOs/ NGOs

Thank you