National Rural Health Mission

1. National Rural Health Mission

2. The Challenges in health sector • Under funded public health system • High and prohibitive out of pocket expenditure • Poor distribution of skilled manpower • Poor quality services in public health system • Poor community participation • People’s needs different from what system offers • Large unregulated private sector • Unwillingness to look for structural change and governance reform • IMR/MMR is high and not declining fast enough

3. Priorities for health under Common Minimum Program • Raise public spending on health to 2-3% of GDP • A national scheme for health insurance for poor families • Responsibility for development schemes to village women • Special attention to poorer sections in matters of health care. • Food and nutrition security • Life saving drugs at reasonable prices

4. Introduction • National Rural Health Mission was launched by on 12 th April, 2005 with an objective to provide effective health care to the rural population, the disadvantaged groups including women and children by • Improving access • Enhancing equity and accountability • Promoting decentralization

5. Coverage • The NRHM covers the entire country, with special focus on 18 states where the challenge of strengthening poor public health systems and thereby improve key health indicators is the greatest. • These are Uttar Pradesh, Uttaranchal, Madhya Pradesh, Chhattisgarh, Bihar, Jharkhand, Orissa, Rajasthan, Himachal Pradesh, Jammu and Kashmir, Assam, Arunachal Pradesh, Manipur, Meghalaya, Nagaland, Mizoram, Sikkim and Tripura.

7. 1. Communitization • Community Participation • Community Monitoring • Community Ownership and Health Action by community • At the village level : Involvement of PRI, village level committee and SHGs • ASHA • At the facility level: hospital management committees • At the management level – health societies

8. ASHA Accredited Social Health Activist • A long felt need • For every village/ covers 1000 population • Chosen by and accountable to the Panchayat • Act as the interface between the community and the public healthcare system • Part of the team responsible to prepare and implement the Village Health Plan along with AWW, ANM under VHSC. • Performance based incentives

9. 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: a Panchayat member Convenor: ASHA / Anganwadi Sevika Formed at level of revenue village

10. PHC Level Committee • 30% members : representatives of Panchayati Raj Institutions • 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: a Panchayat representatives, Executive chairperson: Medical officer of PHC Secretary: one of the NGO / CBO representatives.

11. Decentralized Planning • “District Health Mission” at the District level and the “State Health Mission” at the state level • District Health Plan would be a reflection of synergy between Village Health Plans, State and National priorities for Health, Water Supply, Sanitation and Nutrition. • Involvement of PRIs in planning process

12. 2. IPHS Standards: monitor progress against standard • Indian Public Health Standards (IPHS) are set of standards envisaged to improve the quality of health care delivery in the country under the National Rural Health Mission.

13. 3. Strengthening Public Health Care Sub-centre strengthening • Each sub-centre will have an Untied Fund for local action @ Rs. 10,000 per annum. • Postings of Additional ANMs wherever needed • Maintaining Logistics: Supply of essential drugs to the Subcentres.

14. PHC strengthening • Infrastructure Strengthening as per IPHS guidelines • Provision of Rogi Kalyan Samiti • Adequate and regular supply of essential quality drugs and equipment • Provision of 24 hour service in 50% PHCs

15. CHC strengthening • Infrastructure strengthening by implementation of IPHS standards • Promotion of Rogi Kalyan Samitis for hospital management • Developing standards of services and costs in hospital care.

16. 4. Improved Program Management • District Program Management Unit • Block Program Management Unit • NHSRC/ SHSRC/ DRG/ BRG

17. 5. Flexible Financing Issues with financing • Fund allocation to health sector • The problem of absorption and appropriate use of funds in disadvantaged areas is a critical bottleneck

18. NOW 20% public expenditure (0.9% GDP), often inefficient and ineffective. 80% private expenditure, mostly out of pocket 15-20% MoHFW expenditure – rest by States By 2012 40% public expenditure with improved accountability and efficiency ( 2-3% GDP) Private expenditure by risk pooling/insurance 40% GoI expenditure – rest by States Health Financing

19. Innovative Financial Mechanisms • Funds to all States and UTs being sent electronically. • Time taken in fund transfer brought down from 1-3 months to 1-2 days. • Sanction letters uploaded on website along with e-transfer • Utilization of the principle of “money follows the patient.

20. Supplementary Strategies • Regulation of Private Sector: To ensure quality of service to citizen (includes the informal rural practitioners). • Promotion of Public Private Partnerships: For achieving public health goals. • Mainstreaming AYUSH. • Reorienting medical education: To support rural health issues including regulation of Medical care and Medical Ethics. • Effective and viable risk pooling: To provide health security to the poor by ensuring accessible, accountable and good quality hospital care.

22. Chiranjeevi Scheme - Gujarat

23. Broad Issues • Non - availability of O & G specialists • Accessibility of services-Tribal and urban slums • Poor utilization of services- • Low felt need of health & medical services • Lack of user friendly & quality public health services • Costly private health and medical services • No health insurance coverage

24. Chiranjeevi Yojna - Options • Service Coverage through outsourcing- voucher system Emergency Obstetric Care & Neonatal Care • Private Gynecs in their facility • Payment to Gynecs for working in government hospital

25. SERVICE PACKAGE

26. Outcome of Chiranjeevi Scheme: Mothers & New Born babies saved • Normal Deliveries: 175805 • C-Section: 12414 (6.17%) • Complicated Deliveries: 13092 (6.50%) • Private specialist enrolled: 872/2000

27. Institutional deliveries trend

28. AP Rural Emergency Health Transport • 24x7 Toll-free No. 108 • 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

29. Before Intervention Andhra Pradesh Toopran PHC After Intervention

30. Gujarat Institutional deliveries

31. YEAR WISE DISTRIBUTION OF DELIVERIES (%)

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

33. Bihar- Institutional Deliveries 2006 2007

34. Bihar – Increase in OPD Patients

35. NRHM: The concerns • Village Health and Sanitation Committees • ASHA • IPHS Standards and strengthening of public health care delivery system • Lack of skilled manpower • Lack of technical as well as management capacity