National Rural Health Mission An Overview

1. 1 NRHM

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3. 3 National goals & MDG context

4. 4 India’s Health Indicators NOTES A SLIDE OF THESE INDICATORS FOR ALL THE STATERS IS ALSO AVAILABLKE TO BE SHOWN ON REQUESTNOTES A SLIDE OF THESE INDICATORS FOR ALL THE STATERS IS ALSO AVAILABLKE TO BE SHOWN ON REQUEST

5. Large inter state variations

7. 7 India’s child survival challenge Birth rate 24.1 (2004) 27 million neonates to take care U5MR 95 (1998-99) 2.5 million die before completing 5 years Globally India accounts for 23% of all U% deaths IMR 57 (2007) 1.6 million die before completing 1 year 64% of infant deaths occur in the first 30 days. More than 50% occur in first 3 days NMR 40 (2002) 1.1 million die before 4 weeks of age

8. 8 Health delivery apparatus Public Sector facilities Private Practitioners ESI, CGHS, PSU Hospitals Railways Hospitals Armed Forces Medical Services Corporate Hospitals Indian System of medicine Informal providers Quacks/Crooks & magico religious practitioners

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13. 13 The Structure of the Public Health System Health is a State Subject Family Welfare is Concurrent. Primary Health care is Local self Government. Most institutions and manpower are in state sector. Most programmes are in the central sector National Programmes address about 25% of all morbidities. No dedicated health functionary at village level. 1st Doctor at PHC (30,000 population),1st Specialist at CHC (80,000 popu).

14. 14 Deep rooted structural issues Sustainable Systems Financing 5.2 % of GDP ( Private 4.3 %, Public 0.9%) Infrastructure (over 2,00,000 facilities yet inadequate) Manpower Workforce Issues: Irrational distribution; Poor work culture; absenteeism; Poor supervision Logistics Management Evaluation Responsive & Equitable to citizens

15. 15 National Rural Health Mission launched in April, 2005

16. 16 Goals of the Mission NOTES Under NRHM support of Rs. 50 per day of hospitalization is given to Kala Azar cases through the Rogi Kalyan samitis.NOTES Under NRHM support of Rs. 50 per day of hospitalization is given to Kala Azar cases through the Rogi Kalyan samitis.

17. 17 The formative years of NRHM Original approval for NRHM in January 2005 Country wide Launch by Prime Minister, 12 April 2005 2005-06 was formative year during which Strategies & Guidelines firmed up Merger of Deptt of Health & family welfare State & District Health Missions constituted Specific Activities funded on Normative basis Framework for Implementation approved July 2006 Highest institutions of NRHM empowered Mission Steering Group Empowered Programme Committee Financial envelopes to states, NPCC Monitoring systems & Management structures put in place.

18. 18 The Paradigm Shift

19. 19 The Paradigm Shift Decentralised planning Outputs and Outcome based Pro-Poor Focus: Equitable systems Quality of Care and the IPHS norms Rights based service delivery Pre stated entitlements at all levels Inputs computed as function of the entitlements and estimated patient load Judicious mix of dedicated budget lines - untied funds Monitor quality Community Participation

20. 20 The Paradigm Shift Bringing the public back into public health At hamlet level : ASHA, VHSC, SHGs, Panchayats. At the facility level: RKS At the management level : health societies Governance reform Manpower, Logistics & Procurement processes. Decision making processes Institutional design, Accountability framework Convergence Water and sanitation Nutrition Education

21. 21 Monitoring & Mentoring Regular review meetings State visits – evaluation teams, SFTs, RDs Integrated MIS (web based) External Surveys Immunisation - UNICEF ASHA & JSY – UNICEF, UNFPA, GTZ Financial protocols- Institute of Public Auditors Concurrent External Evaluations Concurrent Financial Audit at District level by external CAs Financial Audit of SHS/DHS by CAG CAs Community monitoring – AGCA/PFI ASHA Mentoring Group JRM & Common Review Mission

22. Not (only) Community Monitoring but Empowerment Part of over all health sector reform agenda Embed Community ownership within reform processes In programme design of all strategies (PPP, Insurance etc) process monitoring by the community needs to be built in. More than grievance redress forum or adverse impact analysis Covers planning, designing, implementation as well as ongoing concurrent oversight. Does not have large budgetary footprint Not all reforms have budgetary implications. 22

23. 23 Contours of Community empowerment

24. 24 OBJECTIVES Create forums for community ownership VHSC, RKS,DHM,SHM Collect systematic info about community needs provide feedback according to locally developed yardsticks key indicators. Do with salary based systems what seems possible only with passion based systems. Validate sector wide data from other sources Triangulation

25. 25 Tools of Community Monitoring Village Level Village Health Register - Records of ANM - Public dialogue Village Health Calendar- Infant and maternal death audit PHC level Charter of Citizens Rights – IPHS - PHC Health Plan Block level IPHS - Charter of Citizens Rights - Block Health Plan District level Report from the PHC Health committees Report of the District Mission committee Public Dialogue (Jan Samvad) State level Reports of the District Health committees Periodic assessment reports by taskforces / State level committees about the progress made in formulating policies according to IPHS, NHSRC recommendations etc.

26. 26 Issues to be monitored MCH,JSY,ASHA,VHSC Untied funding Disease Surveillance Curative care etc

27. 27 Issues to be monitored Service availability, Quality Equipment, Supplies, Personnel Charges, Corruption RKS Functioning etc

28. 28 Community Monitoring Committees

29. 29 Village Health & Sanitation Committee Gram Panchayat members from the village ASHA, Anganwadi Sevika, ANM SHG leader, the PTA/MTA Secretary, village representative of any Community based organisation working in the village, user group representative Chairperson would be the Panchayat member Convenor would be ASHA / Anganwadi Sevika of the village. Formed at level of revenue village (more than one such village may come under single Gram Panchayat).

30. 30 PHC Level Committee 30% members : representatives of Panchayati Raj Institutions (Panchayat Samiti member from the area; two or more sarpanchs) 20% members - non-official representatives from VHSCs with annual rotation to enable representation from all the villages 20% members representatives from NGOs / CBOs in the area 30% members representatives of providers, MO, ANM Chairperson be one of the Panchayat representatives, Executive chairperson be Medical officer of PHC. Secretary be one of the NGO / CBO representatives.

31. 31 Block level Committee 30% members representatives of the Block Panchayat Samiti (Adhyaksha / Adhyakshika of the Block Panchayat Samiti or members of the Block Panchayat samiti, with at least one woman) 20% members be non-official representatives from the PHC committees with annual rotation to enable representation from all PHCs over time 20% members be representatives from NGOs / CBOs 20% members be officials : BMO, BDO, selected MOs from PHCs etc 10% members should be representatives of the CHC level RKS Chairperson be one of Block Panchayat Samiti reps. Executive chairperson be the BMO. Secretary would be one of the NGO/CBO reps.

32. 32 District Level Committee 30% members be representatives of the Zilla Parishad (esp. convenor and members of its Health committee) 25% members be district health officials, including DHO/ CMO/ Civil Surgeon and representatives from DPMUs 15% members be non-official representatives of block committees, with annual rotation 20% members be representatives from NGOs / CBOs 10% members be representatives of RKSs in the district Chairperson be one of ZP reps preferably convenor of the Zilla Parishad Health committee. Executive chairperson be CMO / CMHO / DHO Secretary be one of the NGO / CBO representatives.

33. 33 State Level Committee 30% members be elected reps in legislative body (MLAs /MLCs) or Convenors of Health committees of ZPs by rotation 15% be non-official members of District committees, by rotation 20% members be representatives from State Health NGO coalitions 25% members would belong to State Health Department incl Secretary HFW, Commissioner Health, officials from Dt. of Health Services, NRHM Mission Director) along with experts from SHRC / SPMU 10% members be officials belonging to other related departments Chairperson be one of the elected members (MLAs). Executive chairperson would be the Secretary HFW. Secretary be one of the NGO representatives.

34. 34 Role of Monitoring Committees

35. 35 Role Of VHSC Create Public Awareness about programmes. Discuss and develop Village Health Plan. Maintenance of a village health register. Ensure that ANM and MPW visit village on fixed days. Get bi-monthly health delivery report from service providers. Discuss every maternal & neonatal death in village. Convener (ASHA or AWW) will sign attendance registers of the AWWs, Mid-Day meal Sanchalak, MPWs, and ANMs. MPWs and ANMs to submit a bi-monthly village report to the committee along with the plan for next two months. Format and contents of the bi-monthly reports would be decided village health committee. The committee will receive funds of Rs.10,000 per year. This fund may be used as per the discretion of the VHC.

36. 36 Role of PHC Committee Consolidation of village health plans Charting out the annual health action plan & a PHC Health Plan Disseminate Charter of citizen’s health rights Monitoring of physical resources at PHC Coordinate with local CBOs and NGOs Review functioning of Sub-centres operating under the PHC Initiate action on instances of denial of right to health care. Contribute to ACRs of MO/ other functionaries at the PHC. Take collective decision about untied funds utilisation.

37. 37 Role of Block level Committe Consolidation of the PHC level plans and preparing block plan. Review of progress difficulties at PHCs and CHC. Analysis of neonatal & maternal deaths & other indicators. Monitoring of the physical resources at the CHC Coordinate with local CBOs and NGOs Review functioning of Sub-centres and PHCs Initiate action on instances of denial of right to health care.

38. 38 Role of District level Committee Monitor Health committees at lower levels, Financial reporting and solving blockages in flow of resources. Monitoring of physical resources at all District Health facilities Progress report of Health facilities esp referral utilisation. Charting out Integrated District Health Aaction Plan Ensuring proper functioning of the RKS. Discussion on Health Policy of the state level – local relevance. Initiate action on instances of denial of right to health care.

39. 39 Role of State level Committee Manage programmatic and policy issues. Review and contribute to State Health Plan & NRHM PIP. Issues arising from District Committees relating to state action. Institute a Health rights redressal mechanism. Assessing progress made in actualization of the Right to health care at the state level. Proactive dissemination of GOI guidelines.

40. Village Health Report Card

41. Village Health Report Card

42. Village Health Report Card

43. Cumulative Report Card - Villages

44. Facility Score Card

45. Facility Score Card

46. Cumulative Facility Score Card

47. 47 Community Monitoring Phase 1

48. Scale of Phase 1 Nine States 38 districts (3-5 districts per state) 114 blocks (three in each district ) 342 PHCs (three in each block. 1710 villages (five revenue villages per PHC). 48

49. 49 Features of Phase I Green field activity Work of Capital nature : Institutions, Committees, Orientation material, formats, channels of reporting to be developed Advisory Group of Community Action is the operational partner AGCA through Population Foundation of India is vehicle for Start up activities in the initiative. Preparation for basic documentation Handholding the finalisation of G Orders/Resolutions Handholding the formation, orientation and operationalisation of committes Phase 1 funding by MoHFW is to PFI. Funds passed to State Nodal NGOs by PFI. District & Block level funds disbursed by State nodal NGO. Sustenance of CM will be through state PIP

50. 50 Features of Phase I MOHFW has allocated funds to PFI for : Support for preparation of orientation material, Travel of mentoring group members to states State preparatory meetings, workshops, orientation material, travel and meeting expenses. District workshops, expenses for committee formation and orientation Village, PHC and Block levels orientation sessions, travel Travel support to mentoring team from AGCA

51. 51 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

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54. 54 Gujarat Institutional deliveries

55. 55 Gujarat Infrastructure Upgradation under NRHM

56. 56 Bihar – Increase in OPD Patients

57. 57 Bihar- Institutional Deliveries

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59. 59 Institutional Deliveries – Madhya Pradesh(approximately 17.6 lakh total deliveries annually)

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66. 66 THANK YOUweb : mohfw.nic.in\nrhm.htmemail : healthmission@nic.in