National Rural Health Mission : National Rural Health Mission Dr. M.S. Durga Prasad
Post graduate in community medicine
OSMANIA MEDICAL COLLEGE Introduction : Introduction Public spending on preventive health services has a low priority over curative health in the country as a whole. Indian public spending on health is amongst the lowest in the world, whereas its proportion of private spending on health is one of the highest.
The challenge of quality health services in remote rural regions has to be met with a sense of urgency. The urgent need is to transform the public health system into an accountable, accessible and affordable system of quality services. Slide 3: The large disparity across India places the burden of these conditions mostly on the poor, and on women, scheduled castes and tribes especially on those who live in the rural areas of the country.
After grouping these challenges and threats especially to rural and to most vulnerable groups of population union government has launched a comprehensive programme called as National rural health mission on 12th April 2005. VISION OF THE MISSION : VISION OF THE MISSION To provide effective health care to rural population throughout the country with special focus on 18 states, which have weak public health indicators and weak infrastructure.
18 special focus states are Arunachal Pradesh, Assam, Bihar, Chattisgarh, Himachal Pradesh, Jharkhand, Jammu & Kashmir, Manipur, Mizoram, Meghalaya, Madhya Pradesh, Nagaland, Orissa, Rajasthan, Sikkim, Tripura, Uttaranchal and Uttar Pradesh. Slide 6: The main aim is improve access to rural people, especially poor women and children to equitable, affordable, accountable and effective primary health care. The objectives of the mission : The objectives of the mission 1. Reduction in child and maternal mortality.
2. Universal access to public services for food and nutrition, sanitation and hygiene and universal access to public health care services with emphasis on services
3. Addressing women’s and children’s health and universal immunization
4. Prevention and control of communicable and non-communicable diseases, including locally endemic diseases Slide 8: 5. Access to integrated comprehensive primary health care.
6. Population stabilization, gender and demographic balance.
7. Revitalize local health traditions & mainstream AYUSH.
8. Promotion of healthy life styles. The expected outcomes or targets at national level : The expected outcomes or targets at national level 1. Infant mortality rate reduced to 30/1000 live births by 2012.
( IMR was 58 in 2005 and its 53 in 2008.)
2. Maternal Mortality reduced to 100/100,000 live births by 2012.
( MMR was 301 in 2001 – 03, it was 254 in 2oo4 – 06, kerala was already at 95)
3. Total fertility rate reduced to 2.1 by 2012.
(TFR was 2.9 in 2005, reduced to 2.6 in 2008) The expected outcomes or targets at national level : The expected outcomes or targets at national level 4. Malaria Mortality Reduction Rate - 50% up to 2010, additional 10% by 2012.
(45.23 % reduction in malaria mortality reported in 1st two years, 2006 -2008)
5. Kala Azar Mortality Reduction Rate - 100% by 2010 and sustaining elimination until 2012.
( 21.93% reduction in deaths from 2006 to 2008) Slide 11: 6. Filaria /Microfilaria Reduction Rate - 70% by 2010, 80% by 2012 and elimination by 2015. ( 26.74% reduction from 2006 – 2008.)
7. Dengue Mortality Reduction Rate - 50% by 2010 and sustaining at that level until 2012.
( 56.52% reduction of deaths from 2006 – 2008.)
8. Cataract operations-increasing to 46 lakhs until 2012.
( already being achieved every year ) The expected outcomes or targets at national level : The expected outcomes or targets at national level 9. Leprosy Prevalence Rate –reduce from 1.8 per 10,000 in 2005 to less than 1 per 10,000 thereafter
( target achieved in Dec. 2005 & maintained thereafter.)
10. Tuberculosis DOTS series - maintain 85% cure rate through entire Mission Period and also sustain planned case detection rate.
( 87% cure rate has been maintained . Case detection rate has moved from 70% to 72%.) Slide 13: 11. Upgrading all Community Health Centers to Indian Public Health Standards. ( physical infrastructure up gradation, human resource augmentation, equipment provision taken up in nearly all CHC’s)
12. Increase utilization of First Referral units from bed occupancy by referred cases of less than 20% to over 75%.
( No separate data on utilization levels )
13. Engaging over 4 lakh female Accredited Social Health Activists (ASHAs).
(7.49 lakh ASHAs in all states / UTs have been selected. 5.65 lakh have completed training upto IV module & 5.2 lakh have been provided with drug kits.) The expected outcomes at community level : The expected outcomes at community level Availability of trained community level worker at village level, with a drug kit for generic ailments.
Health Day at anganwadi level on a fixed day / month for provision of immunization, ante/post natal check ups and services related to mother & child health care, including nutrition.
Availability of generic drugs for common ailments at sub centre and hospital level. Slide 15: Access to good hospital care through assured availability of doctors, drugs and quality services at PHC / CHC level & assured referral – transport – communication systems to reach these facilities in time.
Improved access to universal immunization through introduction of auto disabled syringes, alternate vaccine delivery and improved mobilization services under the programme. Slide 16: Improved facilities for institutional delivery through provision of referral transport, escort & improved hospital care subsidized under the janani surakshya yojana (JSY) for the below poverty line families.
Availability of assured health care at reduced financial risk through pilots of community health insurance under the mission.
Availability of safe drinking water.
Provision of household toilets.
Improved outreach services to medically under served remote areas through mobile medical units. The core strategies of the mission : The core strategies of the mission 1.Train and enhance capacity of panchayati Raj Institutions (PRIs)
2. Promote access to improved healthcare at household level
3. Health Plan for each village through Village Health Committee
4. Strengthening sub-centre
5. Strengthening existing primary health centre
6. Provision of 30-50 bedded community health centre per lakh population Slide 18: 7. Preparation and implementation of an inter sector District Health Plan
8. Integrating vertical Health and Family Welfare programmes
9. Strengthening capacities for data collection, assessment and review
10. Developing capacities for preventive health care at all levels
11. Promoting non-profit sector Supplementary strategies : Supplementary strategies Regulation for Private sector .
Promotion of public private partnerships
Mainstreaming AYUSH – revitalizing local health traditions
Reorienting medical education to support rural health issues
social health insurance Plan of action : Plan of action Component 1 : ASHA
Component 2 : strengthening sub centres
Current pop. Norms
Going by the population of 2001, the requirement increases to 1,58,702 & the deficit increases to 21,983.
Sanction of new sub centres & upgrading existing subcentres
Need to construct own buildings.
Link the no. of s.c’s not to the pop. But to caseload & the distance of villages / habitations which comprise the subcentre. Component 2 : strengthening sub centres : Untied fund
Supply of essential drugs (allopathic & ayush)
Contractual appointment of AYUSH practitoners.
Additional ANM wherever needed.
Dispensing O.P services Component 2 : strengthening sub centres Component 3 : Strengthening PHC : Component 3 : Strengthening PHC Going by the pop. Of 2001, the requirement of phc ‘s goes upto 26022 & the deficit increases to 4436.
Provision of 24hrs services in 50% phc ‘s by adressing shortage of staff .
Need to have own buildings
To link the no. of phc’s not to the population but to caseload.
Hospital development committee (HDC) / RKS would be constituted at PHC level within the overall panchayat raj framework. Component 3 : Strengthening PHC : Component 3 : Strengthening PHC The RKS will be free to appoint an AYUSH doctor on contract basis with its own funds.
Convergence of all programmes.
IEC for all health programmes (preventive & curative) will be continued.
Adequate & regular supply of both allopathic & AYUSH drugs & equipment to PHC’s.
Standard treatment guideline & protocols
Supply of autodisabled syringes for immunization. Component 4 : Strengthening CHC’s for first referral care : Component 4 : Strengthening CHC’s for first referral care 1/1,20,000 pop. In general areas,
1/80,000 pop. In tribal / desert areas.
Going by the pop. Of 2001, the requirement goes upto 6491 & the deficit increases to 3332.
Strengthen the existing CHC’s & build up new ones .
Under the RCH II, upgradation of chc’s as FRU”S.
Rogi kalyan samiti would be a group of users with PRI ‘s , NGO’s & health professionals represented In them. Component 4 : Strengthening CHC’s for first referral care : Component 4 : Strengthening CHC’s for first referral care A Charter of citizens health rights would be prominently displayed outside all the chc’s.
Outreach services : in medically underserved areas thru mobile medical units.
Codification of new indian public health standards. Component 5 : district health plan : Component 5 : district health plan District health plans are to be prepared by an aggregation & consolidation of village health plans.
Block plans will be the basis for the district plan.
Health monitoring & planning committee . A draft plan will be formulated by the district health team, & presented for discussion to the broader committee.
The zila parishad adhayaksha, the DMO, the district Magistrate will be the key functionaries of the district team.
Perspective plans and annual plans. Component 5 : District health plan : The district health action plan is the key strategy for integrated action under NRHM.
Other departments would be integrated into ‘district health mission’ for monitoring.
Household facility survey – act as the baseline for the mission.
PROJECT MANAGEMENT UNIT (PMU). To have IT enabled monitoring a computerised network is being set up under IDSP linking all the districts of the country.
Based on the appraised district health plans , the state health mission would get the state plan prepared. Component 5 : District health plan Component 5 : District health plan : District becomes the core unit of planning , budget
ing & implementation.
Centrally sponsored schemes could be rationalized / modified accordingly in consultation with states.
District RCH status compared with state average & NRHM objectives.
Last year’s budget & expenditure analysis.
Meeting at the district level with PRI members to understand their perception of health needs & role of PRI in addressing them. Component 5 : District health plan Component 6 : converging sanitation & hygiene under NRHM : Component 6 : converging sanitation & hygiene under NRHM Components of TSC include IEC activities, rural sanitary marts, individual household toilets, women sanitary complex, & school sanitation program.
The TSC’s implented thru PRI’s.
The DHM will promote joint IEC for public health, sanitation & hygiene . ASHA would be given incentive for promoting household toilets by the mission. Component 7 : strengthening disease control programs : Component 7 : strengthening disease control programs Health programs shall be horizontally integrated under the mission, for improved programme delivery.
Strengthening disease surveillance system at village level. Integration of programmes : Integration of programmes The following vertical programs are integrated under NRHM:
Reproductive and child health II programme
National vector borne disease control programme
National leprosy eradication programme
Revised national tuberculosis control progamme
National programme for control of blindness
Iodine deficiency disorder control programme and
Integrated disease surveillance programme Component 8 : PPP for public health goals including regulation of private sector : Component 8 : PPP for 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.
Management plan for PPP initiatives at district or state or national levels.
Identifying areas of partnerships which are need based, thematic and geographic. Component 8 : PPP for public health goals including regulation of private sector : Component 8 : PPP for public health goals including regulation of private sector The immunization and polio eradication programmes effectively make use of partnerships with WHO, UNICEF, the Rotary International, NGOs, etc.,
The JSY has also factored in accreditation of private facility for promotion of institutional deliveries Component 9: New health financing mechanisms : Component 9: New health financing mechanisms Progressively the district health missions to move towards paying hospitals for services by the way of re-imbursements, on the principles of “money follows the patient”.
Standardization of services.
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 or are launched, they will be encouraged as part of the mission. Component 10 : Reorienting Health or Medical education to support rural health issues : Component 10 : Reorienting Health or Medical education to support rural health issues Medical and paramedical education facilities need to be created in states, based on needs assessment.
A fresh look also needs to be given on the norms for setting up new medical colleges under the regulation framed under Indian Medical Council Act to see whether any relaxation is necessary for such areas.
The viability of using the case load at district hospital for setting up Govt. or Private medical colleges Component 10 : Reorienting Health or Medical education to support rural health issues : Component 10 : Reorienting Health or Medical education to support rural health issues The Mission recognizes the need for training medical officers in short term courses specially for anesthesia, emergency obstetrics, emergency pediatrics, esp., newborn care, safe MTP services, mental health, eye care, trauma care, etc.,
Strengthening of nursing colleges
Need of CME programmes Institutional mechanism or Institutional arrangement : Institutional mechanism or Institutional arrangement The most important requirement for the success of the NRHM is to be able to develop a block level health management team along with a strong district health mission Local to national - Institutional arrangements : Local to national - Institutional arrangements Village health and sanitation committee( at village level )
Gram panchayat or subcentre level committee of panchayat
PHC or Cluster of panchayat level committee
Chairperson: Panchayat representative
Executive chairperson: Medical officer of PHC
Secretary: NGO or CBO representative. Local to national - Institutional arrangements : Local to national - Institutional arrangements Block level PRI committee for approval of block health plan
Chairperson: one of the block panchayat samithi representative
Executive chairperson: Block Medical officer
Secretary: NGO or CBO representative
Zilla Parishad level for approval of district health plan
Independent monitoring committees at block, district and national levels. Local to national - Institutional arrangements : Local to national - Institutional arrangements Hospital Management Committee or Rogi Kalyan Samithi (RKS) for community management of public hospitals.
District health mission under the leadership of ZP with District Health Head as convener and all related departments, NGOs, Pvt professionals etc., represented on it.
State health mission
Integration of Dept. of Health and Family Welfare at national and state levels. Local to national - Institutional arrangements : Local to national - Institutional arrangements National Mission steering group (MSG)
Empowered Programme Committee (EPC)
National programme consultative committee under AS and Mission Director.
Standing Mentoring group for ASHA.
Taskforce for selected tasks (time bound) Organogram : Organogram MSG EPC MISSION DIRECTORATE STATE HEALTH MISSION DISTRICT HEALTH MISSION - RKS VILLAGE HEALTH COMMITTEE(PANCHAYAT) Technical Support : Technical Support Programme management Support Centre:
For strengthening management systems
For developing man power systems
For improved governance
National health system resource centre (NHSRC):
Mandated as a single window for consultancy support, the NHSRC would quickly respond to the requests of centre or state or districts for providing technical assistance for capacity building, not only for NRHM but also for improving service delivery in the health sector in general Strategy for NE States : Strategy for NE States Empowerment of the Mission would mean greater flexibilities for the 10% committed outlay of the MoH&FW for North East (NE) states.
Increased technical support for the programme
States to project specific interventions under the mission, in their action plans Role of state governments under NRHM : Role of state governments under NRHM The mission covers the entire country.
GoI would provide funding for key components in eighteen high focus states.
Other states would fund some interventions like ASHA, PMU, up gradation of SC or PHC or CHC through integrated finance envelope.
States would project operational modalities in their state action plans, to be decided in consultation with MSG.
Prioritized funding. Role of PRIs : Role of PRIs A task force would look at the process of making Panchayats central to the implementation of NRHM, in accordance with their mandated functions.
ASHAs would be selected by and be accountable to the village panchayats.
The untied fund at SC to be deposited in a bank account, jointly operated by ANM and Sarpanch.
District health mission to be led by the ZP. The DHM would also guide activities of sanitation.
PRI involvement in RKS for good hospital management.
Training given to members of PRIs. Role of NGOs : Role of NGOs In institutional arrangements
Standing mentoring groups for ASHA
Member of taskforces
Health resource organisations
For monitoring, evaluation and social audit Mainstreaming AYUSH : Mainstreaming AYUSH Many people have faith in Indian systems of medicine and should be utilized for the delivery of preventive and promotive health services through them. Funding for the mission : Funding for the mission Funds are fully available within the outlay of MoH&FW for undertaking specific Mission Components.
There is an indication of likely enhancement of the current availability of budget for the Ministry, in keeping with the NCMP mandate of increased allocation for public health expenditure.
HMIS to be developed and web enabled for citizen’s scrutiny. New initiatives in IEC : New initiatives in IEC Branding of NRHM through multimedia tools (logo, visual, message, audio-video spots)
Launch of NRHM newsletter
Theme based campaign
Integration of IEC on AIDS, RCH etc.,
Innovative IEC AP Rural Emergency Health Transport : AP Rural Emergency Health Transport Transport to pregnant women, infants, children & emergencies.
Toll-free No.108 365x24x7.
502 ambulances in 1107 mandals.
Average time for reaching hospital 16 min. in Urban & 22 min. in Rural areas.
Total emergencies attended per day is 2,806 (97% are Medical)
In two years, REHTS has saved 20,394 lives by attending to them in the crucial Golden hour Andhra Pradesh – Toopran PHC : Andhra Pradesh – Toopran PHC Before intervention After intervention TIME LINE FOR NRHM MILESTONES : TIME LINE FOR NRHM MILESTONES Health provider (ASHA) in each village with drug kits : 2005 – 2008
Upgrading of rural hospitals : 2005 – 2007
Creation of new hospitals : 2005- 2008
District planning operational : 2005 -2007
Village health plans : 2006
MMU at districts : 2005 – 2008
Operational PMUs : 2005 – 2006
Teachnical support : 2005 - 2007 Progress achieved so far…upto 2010. : Progress achieved so far…upto 2010. State health missions constituted in all states or UTs.
Merger of departments of Health and Family Welfare completed in all the states Progress achieved so far…upto 2010 : Progress achieved so far…upto 2010 1) Human resources :
7.49 lakh ASHAs selected .
5.65 lakh ASHA s trained upto 4 th module.
46,690 ANMs appointed on contract.
26,793 staff nurses appointed on contract.
8,624 MBBS doctors appointed on contract.
7,692 AYUSH Doctors appointed on contract. Progress achieved so far…upto 2010 : Progress achieved so far…upto 2010 2) Infrastructure :
All district hospitals provided Rs. 20 Lakh as initial grant for up gradation of facilities to meet increased case load.
District hospitals in NE States provided Rs. 1 crore for up gradation.
1009 PHCs taken up for construction & 2081 PHC s taken up for renovation.
Besides initial grants to all district hospitals , Rs. 5 lakhs every year to RKS of district hospitals have been provided. Progress achieved so far…upto 2010 : Progress achieved so far…upto 2010 3) MMU s, ambulances, emergency transport:
1031 MMU s operational under NRHM in states.
Emergency transport sysrem operational in 12 states with the assistance of 2919 ambulances. Progress achieved so far…upto 2010 : Progress achieved so far…upto 2010 4) Communitisation under NRHM :
4,51,473 V.H & S.C set up under NRHM.
29,223 RKS setup under NRHM
5) Service gurantees under NRHM
23,458 PHCs functional , of these 8,324 have been made 24 x 7.
2,463 FRUs in the country. Progress achieved so far…upto 2010 : Progress achieved so far…upto 2010 6) Financing of NRHM :
While expenditure of state and central govt. has increased it is not enough to reach 2- 3% GDP.
As per economic survey 2010, the increase is from 1.19% in 2004 – 05 to 1.45 % in 2009 – 10.
In 2008 – 09, Rs. 11,930 crores was allotted & the expenditure was Rs. 11,260 crores.
1n 2009 -10, Rs 15040 crores was alloted . BIBILOGRAPHY : BIBILOGRAPHY 1. National Rural Health Mission:
capacity building of medical college faculty in RCH II / NRHM
2.National health programmes of India – by J.Kishore.
3. Park Text book of preventive and social medicine 20th edition page 379-380
4. NRHM – meeting people’s health needs in partnership with states (2005 – 2010, M.O.H.& F.W, G.O.I) THANK YOU : 61 THANK YOU