NRHM - NATIONAL RURAL HEALTH MISSION

8/14/2019 NRHM - NATIONAL RURAL HEALTH MISSION

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National Rural Health Mission

(2005-2012)


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Public Health: Background

Progress of the primary Health care system

84376

130165136258 137311

142655

9115

1867122149 22875 23109

0

20000

40000

60000

80000

100000

120000

140000

160000

Sixth plan (1981-85) Seventh plan (1985-90)

Eighth plan (1992-97) Ninth plan (1997-2002)

Tenth plan (upto Sept2004)

SubcentresPrimary Health centers


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(contd..)Progress of the primary Health care system

761

1910

26332900

3222

0500

1000

1500

2000

2500

3000

3500

Sixth plan

(1981-85)

Seventh

plan

(1985-90)

Eighth

plan

(1992-97)

Ninth plan

(1997-

2002)

Tenth plan

(upto Sept

2004)

CHCs


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(contd..)

Percentage of Health centers functioning inGovt buildings

50.84

84.17 86.75

0

10

20

30

40

50

60

70

80

90

P

ercentage

Sub centers PHCs CHCs

Sub centers

PHCs

CHCs


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(contd..)

Public health expenditure has declined from 1.3%of GDP in 1990 to 0.9% of GDP in 1999. The Union

Budgetary allocation for health is 1.3% while the

StatesBudgetary allocation is 5.5%.

1.30%

0.90%

3%

0.00%

1.00%

2.00%

3.00%

1990

1999

NRHM


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(contd..)

Union Government contribution in public healthexpenditure is 15% while States contribution is 85%

85%

15% NationalStates


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(contd..) Vertical Health and Family Welfare Programmes

have limited synergisation at operational levels.

Lack of community ownership of public health

programmes impacts levels of efficiency,

accountability and effectiveness. Integration of sanitation, hygiene, nutrition and

drinking water issues is needed in the overall sectoral

approach for Health.


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(contd..) Striking regional inequalities

The challenge of Population Stabilization especially in

States with weak demographic indicators.

Curative services favour the non-poor.

For every Re.1 spent on poorest 20% population, Rs.3

spent on the richest quintile.

About 10% Indians have some form of health insurance,

mostly inadequate


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(contd..)

Hospitalized Indians spend on an average 58% of theirtotal annual expenditure

Over 40% of hospitalized Indians borrow heavily orsell assets to cover expenses

Over 25% of hospitalized Indians fall below povertyline because of hospital expenses

58%

40%

25%

0%

10%

20%

30%

40%

50%

60%

Total Annual

Expediture

Borrow

heavily or sellAssets

BPL because

hospitalexpenses


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The Vision NRHM was launched on 12thApril 2005

The National Rural Health Mission seeks to provide effectivehealth care to the entire rural population in the country withspecial focus on 18 states which have weak public healthindicators, and/or weak infrastructure.

These 18 States are Arunachal Pradesh, Assam, Bihar,Chhattisgarh, Himachal Pradesh, Jharkhand, Jammu &Kashmir, Manipur, Mizoram, Meghalaya, Madhya Pradesh,Nagaland, Orissa, Rajasthan, Sikkim, Tripura, Uttaranchaland Uttar Pradesh.

The Mission is an articulation of the commitment of the

Government to raise public spending on Health from 0.9% ofGDP to 2-3% of GDP, over the next 5 years.

It aims to undertake architectural correction of the healthsystem to enable it to effectively handle increased allocationsas promised under the National Common Minimum

Programme.


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The Vision (contd..)

It has as its key components provision of a health activist ineach village; a village health plan prepared through a local

team headed by the panchayat representative; strengthening of

the rural hospital for effective curative care and made

measurable through Indian Public Health Standards (IPHS),

and accountable to the community; and integration of vertical

Health & Family Welfare Programmes and Funds for optimal

utilization of funds and infrastructure and strengthening

delivery of primary healthcare.

It seeks to revitalize local health traditions and mainstreamAYUSH into the public health system.

It aims at effective integration of health concerns with

determinants of health like sanitation & hygiene, nutrition, and

safe drinking water through a District Plan for Health.


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The Vision (contd..)

It seeks decentralization of the programme for districtmanagement of health.

It seeks to address the intra-State and inter-districtdisparities, especially among the 18 high focus States,including unmet needs for public health infrastructure.

It shall define time-bound goals and report publicly ontheir progress.

It aims to promote policies that strengthen publichealth management and services in the country.

It shall define time-bound goals and report publicly ontheir progress.

Above all, it seeks to improve access of rural people,especially poor women and children, to equitable,affordable, accountable and effective primaryhealthcare.


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Goals Reduction in Infant Mortality Rate and Maternal Mortality

Rate by 50% from existing levels in next 7 years

Universalize access to public health services : such asWomens health, child health, water, sanitation,immunization, Nutrition.

Prevention and control of communicable and non-communicable diseases, including locally endemic diseases

Access to Integrated comprehensive primary healthcare

Assuring Population stabilization, gender and demographic

balance. Revitalize local health traditions and mainstream AYUSH

Promotion of healthy life styles


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NRHMThe Concept (II)

Health Health Determinants

RCH-II NDCP

AYUSH GeneralCurative

Care

Nutrition Sanitation

& HygieneDrinking

Water

Supply


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Strategies

a) Core Strategies1. Train and enhance capacity of PRIs to own, control and

manage public health services.

2. Promote access to healthcare to household through the

female health activist (ASHA).

3. Health Plan for each village through Village Health Samiti

of the Panchayat.

4. Strengthening sub-centre through an untied fund to enable

local planning and action and more MPWs.

5. Strengthening existing PHCs and CHCs, and provision of30-50 bedded CHC per lakh population for improved

curative care to a normative standard (Indian Public

Health Standards defining personnel, equipment and

management standards).


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Core Strategies (contd..)6. Preparation and Implementation of an inter-sectoral District

Health Plan prepared by the District Health Mission,including drinking water, sanitation & hygiene and nutrition.

7. Integrating vertical Health and Family Welfare programmesat National, State and District levels.

8. Technical Support to National, State and District Health

Missions, for Public Health Management.9. Strengthening capacities for data collection assessment and

review for evidence based planning monitoring andsupervision

10. Formulation of transparent policies for deployment and

career development of Human Resources for health.11. Developing capacities for preventive and promoting health

care at all levels such as healthy life styles, reduction inconsumption of tobacco and alcohol.etc.

12. Promoting non-profit sector particularly in under served

areas.


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b) Supplementary Strategies

1. Regulation of Private Sector, including the informalrural practitioners, to ensure availability of qualityservice to citizens at reasonable cost.

2. Promotion of Public Private Partnerships forachieving public health goals.

3. Mainstreaming AYUSH. revitalizing local healthtraditions.

4. Reorienting medical education to support ruralhealth issues including regulation of Medical care

and Medical Ethics.5. Effective and viable risk pooling and social healthinsurance to provide health security to the poor byensuring accessible, affordable, accountable and goodquality hospital care.


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Plan of Action (Components A-J)

A:Accredited Social Health Activists

B: Strengthening Sub-Centres

C: Strengthening PHCs

D: Strengthening CHCs for First ReferralCare

E: District Health PlanF: Converging Sanitation and Hygiene under

NRHM (I)

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Plan of Action (Components A-J)

G:Strengthening Disease ControlProgramme

H:Public-Private Partnership for publichealth goals, including Regulation ofPrivate Sector

I : New Health Financing MechanismsJ: Reorienting Health/Medical Education to

support Rural Health Issues

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Component A:

Accredited Social Health Activists She will be trained on a pedagogy of public health

developed and mentored through a National ExpertsGroup incorporating best practices and implementedthrough active involvement of community healthresource organisations.

She will facilitate preparation and implementation ofVillage Health Plan alongwith Anganwadi worker,community workers and ANM under the leadership ofthe Panchayat Health Samiti.

She will be promoted all over the country, with special

emphasis on the 18 high focus States. GoI will bear thecost of training, incentives and medical kits. Rest to befunded under Financial Envelope.


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Component A:

Accredited Social Health Activists

She will be given a Drug Kit containing genericAYUSH and allopathic formulations for commonailments. The drug kit would be replenished from timeto time

Induction training of ASHA to be of 23 days in all,

spread over 12 months. On the job training would continue throughout the

year.

Prototype training material to be developed at Nationallevel subject to State level modifications.

Cascade model of training proposed through Trainingof Trainers including contract plus distance learningmodel

Training would require partnership with NGOs/ICDSTraining Centres and State Health Institutes.


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Component B: Strengthening Sub-Centres

Each sub-centre will have an untied fund for

local action @ Rs. 10,000 per annum. This fundwill be held in joint account of ANM andPanchayat Sarpanch.

Supply of essential drugs (allopathic and

AYUSH) to the Sub-centres. In case of additional Outlays, MPWs

(Male)/Additional ANMs wherever needed,sanction of new Sub-centres as per 2001

population norm, and upgrading existing Sub-centres, including buildings for Sub-centresfunctioning in rented premises will beconsidered.


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Component C: Strengthening PHCs

Mission aims at Strengthening PHC for quality preventive,

promotive, curative, supervisory and Outreach services, 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 addressingshortage of doctors, especially in high focus States, through

mainstreaming AYUSH manpower.

Observance of Standard treatment guidelines & protocols.

In case of additional Outlays, intensification of ongoingcommunicable disease control programmes, new programmes

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.


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Component D: Strengthening CHCs for

First Referral Care

Operationalizing 3222 existing Community Health Centres (30-50

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

anaesthetists

Codification of new Indian Public Health Standards, setting

norms for infrastructure, staff, equipment, management etc. CHC

Promotion of Stake-holders Committees (Rogi Kalyan Samitis)

for hospital management

Developing standards of services and costs in hospital care

Develop, display and ensure compliance to Citizens 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.


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Component E : District Health Plan

District Health Plan would be an amalgamation of field

responses through Village Health Plans, State and Nationalpriorities for Health, Water Supply, Sanitation and Nutrition.

Health Plans would form the core unit of action proposed inareas like water supply, sanitation, hygiene and nutrition.Implementing Departments would integrate into DistrictHealth Mission for monitoring.

District becomes core unit of planning, budgeting andimplementation.

Centrally Sponsored Schemes could be rationalized/modified

accordingly in consultation with states.


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Component E : District Health Plan

Concept of funneling to district for effectiveintegration of programmes.

All parallel bodies in Health at District and statelevel merge into one common District Health

Mission at the District level and the StateHealth Missionat the state level

Provision of Project Management Unit for alldistricts, through contractual engagement of

MBA, Inter Charter/Inter Cost and Data EntryOperator, for improved programme management

A i P i Di i L l


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Action Points at District Level

District Health Mission

District, Block and

Village Plan

Integration with

ICDS, TSC

Quality AssuranceCommittee

Rogi Kalyan

Samiti

Strengthening

Immunization

Janani SurakshaYojana

PPP for Health

C t F C i S it ti d


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Component F: Converging Sanitation and

Hygiene under NRHM (I)

The Total Sanitation Campaign (TSC) is presently implemented in

350 districts, and is proposed to cover all 578 districts in 10thPlan.

Components of TSC include IEC activities, rural sanitary marts,

individual household toilets, women sanitary complex, and School

Sanitation Programme.

Similar to the DHM, the TSC is implemented through PRIs. NRHM proposes district and sub-district arrangements for Rural

Sanitation Programme similar to the DHM. The DHM would

guide activities of sanitation at district level.

The District Health Mission would therefore guide activities of

sanitation at district level, and promote joint IEC for publichealth, sanitation and hygiene, through Village Health &

Sanitation Committee, and promote household toilets and School

Sanitation Programme. ASHA would be incentivized for

promoting household toilets by the Mission.


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Component G: Strengthening Disease

Control Programme

National Disease Control Programmes for Malaria, TB,

Kala Azar, Filaria, Blindness & Iodine Deficiency shall

be integrated under the Mission, for improved

programme delivery.

New Initiatives would be launched for control of Non

Communicable Diseases.

Disease surveillance system at village level would be

Strenghthened

Supply of generic drugs (both AYUSH & Allopathic)

for common ailments at village, SC, PHC/CHC level.

Provision of a mobile medical unit at District level for

improved Outreach services.


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Component H: Public-Private Partnershipfor public health goals, including

Regulation of Private Sector Since 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

District Institutional Mechanism for Mission must haverepresentation of private sector

Need to develop guidelines for PPP for 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 andNational levels

Component I: New Health Financing


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Component I: New Health Financing

MechanismsTask Force to examine new health financing mechanisms,including

Risk Pooling for Hospital Care as follows:

Progressively the District Health Missions to move towards payinghospitals for services by way of reimbursement, on the principle ofmoneyfollows the patient.

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

A National Expert Group to monitor these standards and givesuitable advise 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 renderedfrom District Health Fund. Over the Mission period, the CHC

may move towards all costs, including wages reimbursed forservices rendered.

A district health accounting system, and an ombudsman to becreated to monitor the District Health Fund Management , andtake corrective action.

Adequate technical managerial and accounting support to beprovided to DHM in managing risk-pooling and health security.


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Component I: New Health FinancingMechanisms (contd..)

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, andmonitor the schemes.

The IRDA will be approached to promote such

CBHIs which will be periodically evaluated for

effective delivery.


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Funding Arrangements

The Mission is conceived as an umbrella programmesubsuming the existing programmes of health and family

welfare, including the RCHII, National Disease Control

Programmes for Malaria, TB, Kala Azar, Filaria, Blindness

& Iodine Deficiency and Integrated Disease SurveillanceProgramme.

The Budget Head For NRHM shall be created in B.E. 2006-

07 at National and State levels. Initially, the vertical health

and family welfare programmes shall retain their Sub-

Budget Head under the NRHM.

The Outlay of the NRHM for 2005-06 is in the range of

Rs.6700 crores.


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Component J: 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

Need for mainstreaming AYUSH

Task Force to improve guidelines/details.


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Mainstreaming AYUSH The Mission seeks to revitalize local health traditions and

mainstream AYUSH infrastructure, including manpower, anddrugs, to strengthen the public health system at all levels.

AYUSH medications shall be included in the Drug Kit provided at

village levels to ASHA.

The additional supply of generic drugs for common ailments atSubcentre/ PHC/CHC levels under the Mission shall also include

AYUSH formulations.

At the CHC level, two rooms shall be provided for AYUSH

practitioner and pharmacist under the Indian Public HealthSystem (IPHS) model.

Single doctor PHCs shall be upgraded to two doctor PHCs by

mainstreaming AYUSH practitioner at that level.


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National Steering Group

Mission Steering Group

Empowered Programme Committee

State Health Mission

District Health Mission ------------Rogi Kalyan Samitis

Village Health

Committee

Village Health

Committee

Village Health

Committee

Mission Directorate

ORGANOGRAM

Panchayat Raj Institutuions (PRIs)


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Institutional Mechanism (I)

Village Health & Sanitation Samiti (at village levelconsisting of Panchayat Representative/s, ANM/MPW,Anganwadi worker, teacher, ASHA, community healthvolunteers

Rogi Kalyan Samiti (or equivalent) for communitymanagement of public hospitals

District Health Mission under the leadership of ZilaParishad with District

Health Head as Convener and all relevant departments,

NGOs, private professionals etc represented on it. State Health Mission (Chaired by Chief Minister and

co-chaired by Health Minister and with the StateHealth Secretary as Convener- representation ofrelated departments, NGOs, private professionals etc)


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Technical Support

To be effective the Mission needs a strong component

of Technical Support This would include reorientation into public health

management

Reposition existing health resource institutions, likePopulation Research Centre (PRC), Regional Resource

Centre (RRC), State Institute of Health & FamilyWelfare (SIHFW)

Involve NGOs as resource organizations

Improved Health Information System

Support required at all levels: National, State, Districtand Sub district level.

Mission would require two distinct supportmechanisms Program Management Support Centreand Health Trust of India.

Program Management Support


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Program Management Support

centre

For Strengthening Management Systems-basic programmanagement, financial systems, infrastructure

maintenance, procurement systems, MIS, non-lapsable

health pool etc.

For Developing Manpower Systems recruitment(induction of MBAs/CAs /MCAs), training & curr iculum

development (r evitalization of existing insti tuti ons &

partnerships with NGO & pvt. Sector insti tutions),

motivation & performance appraisal etc.

For Improved Governance decentralization &empowerment of communities, induction of I T based

systems like e-banking, social audit and right to

information.

Of


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Health Trust Of I ndia

Proposed as a knowledge insti tution, to be the repository of

innovation research & documentation, health informationsystem, planning, monitoring & evaluation etc.

For establ ishing Public Accountabil i ty Systemsexternalevaluations, community based feedback mechanisms,

participation of PRIs /NGOs etc. For developing a Framework for pro-poor I nnovations

For reviewing Health Legislations.

A base for encouraging exper imentation and action research.

For inter & intra Sector Networking with National andI nternational Organizations.

Think Tank for developing a long-term vision of the Sector &for building planning capaciti es of PRI s, Distr icts etc.


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Role of State Government

State Government

State & District Health Missions

MoU with GoI Integrated HFW Societies

NRHM State Action PlanDecentralization to District level

Merger of Departments of H&FWInvolve PRIs

Programme Management Unit ASHA Model

Role of State Governments under


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Role of State Governments under

NRHM The Mission covers the entire country. The 18 high focus States GoI

would provide funding for key components in these 18 high focusStates. Other States would fund some interventions like ASHA,PMU, upgradation of SC/PHC/CHC through Integrated FinanceEnvelope.

NRHM provides broad conceptual framework. States wouldproject operational modalities in their State Action Plans, to bedecided in consultation with the National Mission Steering Group.

NRHM would prioritize funding for addressing inter-state andintra-district disparities in terms of health infrastructure andindicators.

States would sign Memorandum of Understanding with Government ofIndia, indicating their commitment to increase contribution to PublicHealth Budget (preferably by 10% each year), increased devolution toPanchayati Raj Institutions as per 73rd Constitution (Amendment) Act,and performance benchmarks for release of funds.


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Strategy for North East States

All 8 North East States, including Assam, Arunachal Pradesh,Manipur, Meghalaya, Mizoram, Nagaland, Sikkim andTripura, are among the States selected under the Mission, forspecial focus.

Empowerment to the Mission would mean greater flexibilitiesfor the 10% committed Outlay of the Ministry of Health &

Family Welfare, for North East States. States shall be supported for creation/upgradation of health

infrastructure, increased mobility, contractual engagement,and technical support under the Mission.

Regional Resource Centre is being supported under NRHM

for the North Eastern States. Funding would be available to address local health issues in a

comprehensive manner, through State specific schemes andinitiatives.

R l f PRI


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Role of PRIs The Mission envisages the following roles for PRIs:

States to indicate in their MoUs the commitment fordevolution of funds, functionaries and programmes forhealth, to PRIs.

The District Health Mission to be led by the ZilaParishad. The DHM will control, guide and manage all

public health institutions in the district, Sub-centres,PHCs and CHCs.

ASHAs would be selected by and be accountable to theVillage Panchayat.

The Village Health Committee of the Panchayat would

prepare the Village Health Plan, and promoteintersectoral integration

R l f PRI ( d )


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Role of PRIs (contd..)

Each sub-centre will have an Untied Fund for localaction @ Rs. 10,000 per annum. This Fund will bedeposited in a joint Bank Account of the ANM &Sarpanch and operated by the ANM, in consultationwith the Village Health Committee.

PRI involvement in Rogi Kalyan Samitis for good

hospital management. Provision of training to members of PRIs.

Making available health related databases to allstakeholders, including Panchayats at all levels


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Role of NGOs for the Mission Role of the NGOs for the Mission is as envisaged

as follows: Included in institutional arrangement at National, State

and District levels, including Standing MentoringGroup for ASHA

Member of Task Groups

Provision of Training, BCC and Technical Support forASHAs/DHM

Health Resource Organizations

Service delivery for identified population groups onselect themes

For monitoring, evaluation and social audit

i A


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Funding Arrangements

The Mission envisages an additionality of 30% over existing

Annual Budgetary Outlays, every year, to fulfill the mandateof the National Common Minimum Programme to raise the

Outlays for Public Health from 0.9% of GDP to 2-3% of

GDP

The Outlay for NRHM shall accordingly be determined inthe Annual Budgetary exercise.

The States are expected to raise their contributions to Public

Health Budget by minimum 10% p.a. to support the Mission

activities. Funds shall be released to States through SCOVA, largely in

the form of Financial Envelopes, with weightage to 18 high

focus States.


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Outcomes Contd.

Cataract Operation: increasing to 46 lakhs per yearuntil 2012.

Leprosy prevalence rate: reduce from 1.8/10,000 in2005 to less than 1/10,000 thereafter

Tuberculosis DOTS services: Maintain 85% cure ratethrough entire Mission period.

Upgrading Community Health Centers to IndianPublic Health Standards

Increase utilization of First Referral Units from lessthan 20% to 75%

Engaging 250,000 female Accredited Social Health

Activists (ASHAs) in 10 States.

Outcomes Contd


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Outcomes Contd.b) Community level Provision of trained and supported Village Health Activist in under served

areas as per need (ASHA) Ensuring quality and close supervision ofASHA.

Preparation of health action plans by panchayats as mechanism forinvolving community in health.

Strengthening SC/PHC/CHC by developing Indian Public Health Standards

Institutionalizing and substantially strengthening District level

Management of Health (all districts) Increase utilization of First Referral Units from less than 20% (2002) to

more than 75% by 2010

Strengthening sound local health traditions and local resource based healthpractices related to PHC and public health

Improved facilities for institutional delivery through provision of referral,

transport, escort and improved hospital care subsidized under the JananiSuraksha Yojana (JSY) for the Below Poverty Line families

Availability of assured healthcare at reduced financial risk through pilots ofCommunity Health Insurance under the Mission

Provision of household toilets Improved Outreach services through mobilemedical unit at district level


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Monitoring and Evaluation

Health MIS to be developed and web-enabled for

citizen scrutiny

Annual District Reports on Peoples Health (to be

prepared by Govt/NGO collaboration)

State and National Reports on Peoples Health to be

tabled in Assemblies, Parliament

Sub Centres to Report on performance to Panchayats,

Hospitals to Rogi Kalyan Samitis and District HealthMission to Zila Parishad

External evaluation through professional bodies/NGOs


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Documents

NRHM - NATIONAL RURAL HEALTH MISSION