National Rural Health Mission

1. National Rural Health Mission

2. Framwork • Why NRHM ? • How it is different from earlier programmes? • Objectives of NRHM • At village level • At Block level • At District level • At State level • At National level • Technical support • Funding arrangements • Progress so far

3. Why NRHM? Epidemiological & Demographical Transition Under funded, under utilised Lack of Holistic Approach Lack of accountability Shortage of infrastructure & human resources Lack of basic amenities Food, Drinking water, Sanitation Large inter state variations in India’s Health Indicators

4. Why NRHM? Non integration of Disease Control programmes Lack of community ownership Non responsiveness to Citizen Weaker section not able to access- Poor, rural, Women, Child NATIONAL GOALS & MDG

5. National Rural Health Mission • Launched on 12th April, 2005. • Rejuvenate the Health delivery System • Access • Affordability • Equity • Quality • Universal Health Care • Reduce IMR, MMR, TFR • Improve disease control

6. There was decrease in public health expenditure from 1.3 % GDP in 1990 to 0.9% in 1999. • So to increase public health expenditure from 0.9 to 2-3% GDP

7. How it is different from earlier programmes? • Decentralized planning & Community participation • At village level: ASHA, VHNSC, SHGs, Panchayat • At facility level: RKS • At manager level: Health societies • Outcome based • Pro-poor focus: equitable system • Governance reform • Convergence of services related to health determinants- • Nutrition • Water supply • Sanitation • Quality of care & IPHS norms • Right based services delivery • Pre-stated entitlement at all level • Judicious mix of dedicated budget line: Untied fund • Quality Monitoring

8. NRHM – The Concept Health Health Determinants RCH-II NDCP Nutrition Water Supply AYUSH Sanitation General Curative Care

9. NRHM – 5 MAIN APPROACHES COMMUNITIZE 1.PRIs at all levels 2.Decentralized planning, monitoring (VHNSC) 4. NGO involvment MONITOR, PROGRESS & STANDARDS 1.IPHS Standards 2. Facility Surveys 3. Independent Monitoring Committees at block, district & State levels FLEXIBLE FINANCING Untied fund 2.Risk Pooling – money follows patient 3.More resources for more reforms INNOVATION IN HUMAN RESOURCE MANAGEMENT 1. More health worker 2. 24 X 7 emergencies management at PHC & CHC IMPROVED MANAGEMENT THROUGH CAPACITY 1. Block & District Health Office with management skills 2. NGOs in capacity building 3. NHSRC / SHSRC 4. Continuous skill development & support

10. The Objectives of the Mission • Reduction in child and maternal mortality • Universal access to public services for health, food and nutrition, sanitation and special focus on services addressing women’s and Children’s health and universal immunization. • Prevention and control of communicable and non-communicable diseases, including locally endemic diseases. • Access to integrated comprehensive primary health care. • Population stabilization, gender and demographic balance. • Revitalize local health traditions & mainstream AYUSH. • Promotion of healthy life styles.

11. AT village level • Creation of cadre of ASHA • Village Health, Nutrition & Sanitation Committee • Role of ANM and Anganwadi Worker

12. ASHA • Selection criteria's: • One ASHA /1000 population • Woman resident of village • Education - Eighth Class • Process of selection • Monitoring of selection process • Training & capacity building • Payment • Roles & responsibilities

13. Village Health, Nutrition & Sanitation Committee (VHNSC) • At revenue village • Consist of: • Gram Panchayat members from the village. • ASHA, Anganwadi Sevika, ANM • SHG leader, village representative of CBO, NGO Chairperson - Panchayat member (preferably woman of SC/ST) Convener – ASHA or AWW • Activities • Create Public Awareness -health programmes. • Participatory Rapid Assessment of health, nutrition, sanitation & taking action • Maintenance -village health register & health information board/calendar • Discuss and develop a Village Health Plan • Ensure ANM, MPW, ASHA, AWW visit. • Bi-monthly halth delivery report from health team • Discuss every maternal death or neonatal death • Managing the Village health fund.

14. Yardsticks for monitoring at the village level NRHM indicators translated into Village health indicators Village Health Plan • Tool of Planning & Monitoring Household survey Village health Register Records of the ANM Village Health Calendar Village Health Plan Infant and Maternal death audit Public dialogue (Jan Samvad)

15. At Sub-center level Strengthening of sub-centers • Sanctioning of new Sub-centres as per 2001 population norm • Constructing buildings Sub-centres which in rented premises • Additional ANMs wherever needed • Supply of essential drugs- allopathic and AYUSH • Untied Fund -Rs. 10,000 per annum

16. At PHC level • Strengthening Primary Health Centres • Adequate and regular supply of essential drugs (allopathy & AYUSH) and equipment • Provision of 24 X 7 PHCs • IPH Standards • 2nd doctor at PHC level • two Staff Nurses • Additional and not substitute fund. • RogiKalyanSamiti • Effective convergence of all programmes

17. Management & Planning: RogiKalyanSamiti Composition of RKS • 30%- representative of PRI(Panchayatsamitimember,two or more Sarpanch) • 20% - non-officials from VHNSC with annual rotation for representation from all village • 20%- representative of NGO/ CBOs • 30%- health provider MO, ANM Chairperson- One of the Panchayat representative Executive chairperson- MO Secretary – from one of the NGO/CBO

18. Activities of RKS • To ensure discipline & monitor accountability. • Putting user charges in consultation with People’s representatives. • Ambulance services for emergency. • Provide free treatment to BPL. • Arrange for good quality diet, & drugs. • Proper maintenance of Hospital, Wards, Beds, Equipments, cleanliness of premises. • Organize training & workshops for  staff members • Waste disposal. • Up gradation of facilities • Commercial use of extra  unused land • Monitoring of National Health programmes. • Loan from bank for improvement in facility. • Wardha district PHC at Anji, Devali, Dahegaon, Nachani, Talegaon D, Sindhi Re, Rohana

19. At CHC/ block level • Strengthening CHCs for first referral care • Operationalizing CHC as 24 Hour FRU • Indian Public Health Standards • Under RCH II, Basic Emergency Obstructive Care for women and ARI treatment for children • Provision of 7 Specialists & 9staff nurses • Separate AYUSH set up • RogiKalyanSamitis for hospital management • Citizen’s Charter • Supply of generic drugs (both AYUSH & Allopathic) • Wardha district CHC at Arvi, Hinganghat, Pulgaon & Med. coll. Sevagram • Planning at CHC/ block level: Block Health Plan. • Block Health Teams - supervise household and health facility surveys, organize public hearings and health camps

20. At District level: District Health Mission • Integration of Departments into District Health Mission • Composition of District health society : 30%- Representative of ZP (Esp. convener & member of health committee) 25% - District officials including DHO, CMO, civil surgeon & representative from DPMUs 15%- Non-official representative of block committee with annual rotation 20%- Representative of NGO/ CBOs 10% -member of RKSs in district • Chairperson- One ZP representative( Preferably convener of ZP health committee ) Executive chairperson- CMO/DHO Secretary – from one of the NGO/CBO • Project Management Unit at districts- Contractual engagement of MBA, Inter Charter/Inter Cost and Data Entry Operator. • “Funneling” of funds for effective integration of programmes.

21. The role of the District Health Mission • Responsible for planning, implementing, monitoring and evaluating progress of Mission. • Preparation of Annual and Perspective Plans for the district. • Suggesting district specific interventions. • Partnerships with NGOs, Panchayats for effective action. • Strengthening training institutions for ANMs/Nurses, etc. • Provide leadership to village, Gram Panchayat, Cluster & Block level teams. • Experiment with risk pooling for hospitalization. • Ensure referral chain and timely payment of all claims. • Arrange for technical support to the blocks teams and for itself. • Arrange for epidemiological studies and operational research to guide district level planning. • Activate women’s groups, adolescent girls’ fora to ensure gender sensitive approach • Provide data analysis and compilation facility to meet regular MIS needs. • Carry out Health Facility Surveys and supervision of household surveys.

22. Planning at District level: District Health Plan • Two-way process & Cumulative • Situational analysis of the district, objectives and interventions, work plan and budgets and an M&E plan. • Components of the District Health Plan • New interventions under NRHM • RCH II, Strengthening of Immunisation • Disease Control / Surveillance Programmes such as NVBDCP , RNTCP, NPCB, IDD ,NLEP and IDSP • Intersectoral convergence activities including Nutrition, Safe Drinking Water etc

23. At State level: State health mission • Composition of State Health Mission • Chairperson : Chief Minister • Co-Chairperson : Minister of Health & Family Welfare, State Government • Convener: Principal Secretary/Secretary (Family Welfare) • Members Ministers of Departments Nominated public representatives (MPs, MLAs, Chairmen, ZilaParishad, urban local bodies) Official representative Nominated non-official members- health experts(IMA),NGOs, etc Representatives of Development Partners • Frequency of meetings: At least once in six months

24. State health society • A. Governing Body   Chairperson: Chief Secretary/Development Commissioner Co-Chair: Development Commissioner Vice-Chair: Principal/Secretary (Health & Family Welfare) Convener: Officer designated as Mission Director of State Health Mission • B. Executive Committee Chairperson : Principal Secretary/Secretary, FW Co-Chair (s) : Principal Secretary/Secretary, Health/FW (in case of separate secretaries in the State) Vice Chair: Director, Health & FW Convener : Executive Director/Mission Director (To be an IAS Officer • C. Programme Committee for Health & FW Sector Chairperson: Director Member-Secretary: Concerned State Programme Manager Members: Finance Manager (SPMSU), 2-3 related State Programme Managers and Consultants • D. State Programme Management Support Unit (SPMSU)

25. Executive Committee, State Health Society Programme Committees (Headed by Director/ Director General) (Optional) SPMSU (Headed by Executive Director/Mission Director) Composite Organogram of the State Mission and the State Society State Health Mission Governing Body, State Health Society

26. FUNCTIONS OF STATE HEALTH MISSION • Merging societies of Health and Family Programmes: integrated State Health Action Plan • Organizing workshops for State and Divisional/District level stakeholder • Identify core performance indicators and time frames • Strategy for addressing vulnerable population groups and underserved • Ensuring key role of Panchayati Raj Institutions at all levels • Guidelines for constitution of Rogikalyansamiti • Issue Government Order to facilitate a fixed Health Day at Aanganwadi level every month

27. Planning & Monitoring at state level: State health action plan Planning • State health society & State health mission • District Health action plan • National guidelines • Involving State Resource Centre / Planning Cell Monitoring: State Health society External evaluation Internal evaluation

28. At National level Administration

29. Function • Integrating Heath & Family welfare services • Provoding technical support to State • Provide fund to states under NRHM budget head including programmes like TB, Vector Borne diseases, Leprosy, Malaria, Disease Surveillance etc, over the Mission period annually. • Indicate priorities and normative framework under which planning exercise is to be taken up. • Public-private partnership for public health goals, including regulation of private sector

30. New health financing mechanism in nrhm • Risk Pooling • “Money follows the patient” • District Health Fund • Funds under National disease control programme, RCH II, IDSP • Community Based Health Insurance Schemes (CBHI) TECHNICAL SUPPORT FOR NRHM • National Health System Resource Centre (NHSRC) • State Institute of Health & Family Welfare (SIHFW) • Population Research Centre (PRC) • Regional Resource Centre (RRC) • NGOs & Expert groups • Improved Health Information System

31. Monitoring of NRHM • Community based monitoring VHNSC, Health society • Internal monitoring Periodic progress monitoring- Mission steering group, Empowered programme committee & Planning commission Mentoring group – ASHA Web based MIS Annual audit by CAG • External surveys – • Immunisation – UNICEF will monitor • ASHA & JSY – UNICEF, UNFPA, GTZ • Financial protocols- Institute of Public Auditors • External Evaluations by reputed agencies

32. EVALUATION: National Level • IMR reduced to 30/1000 live births • MMR reduced to 100/100,000 • Total Fertility Rate reduced to 2.1 • Malaria mortality reduction rate –50% upto 2010, additional 10% by 2012 • Kala Azar mortality reduction rate: 100% by 2010 and sustaining elimination until 2012 • Filaria/Microfilaria reduction rate: 70% by 2010, 80% by 2012 and elimination by 2015 • Dengue mortality reduction rate: 50% by 2010 and sustaining at that level until 2012 • Japanese Encephalitis mortality reduction rate: 50% by 2010 and sustaining at that level until 2012 • Cataract Operation: increasing to 46 lakhs per year until 2012. • Leprosy prevalence rate: reduce from 1.8/10,000 in 2005 to less than 1/10,000 thereafter • Tuberculosis DOTS services: Maintain 85% cure rate through entire Mission period. • Upgrading Community Health Centers to Indian Public Health Standards • Increase utilization of First Referral Units from less than 20% to 75% • Engaging 250,000 female Accredited Social Health Activists (ASHAs) in 10 States.

33. Evaluation: Community Level • Avalabilty of generic drugs, Health care worker • Good hospital care through assured availability of doctors, drugs and quality services at PHC/CHC level. • Improved access to Universal Immunization through induction of Auto Disabled Syringes, alternate vaccine delivery and improved mobilization services under the programme. • Improved facilities for institutional delivery through provision of referral, transport, escort and improved hospital care subsidized under the JananiSurakshaYojana (JSY) for the Below Poverty Line families • Availability of assured healthcare at reduced financial risk through pilots of Community Health Insurance under the Mission • Provision of household toilets • Improved Outreach services through mobile medical unit at district level

34. Progress so far

35. References: • Mission document. [Online].[cited 2009 April 12]. Available from: URL: http://mohfw.nic.in/NRHM/Mission Documents. pdf. • NRHM implementation framework. [Online]. [cited 2009 April19]. Available from:URL:http://mohfw.nic.in/NRHM/Documents/NRHM%20-20Framework%20for%20Implementation.pdf. • NRHM Maharashtra. [Online]. [cited 2009 April 26]. Available from: URL:http://www.maha-arogya.gov.in/programs/nhp/nrhm/default.htm. • Progress – so far. [Online]. [cited 2009 April12]. Available from: URL:http://mohfw.nic.in/NRHM/Documents/NRHM_The_Progress_so_far.pdf. • District Health Action Plan, Wardha. [cited 2009 April12]. Available from: • URL:http://mohfw.nic.in/NRHM/DHAP/DHAP.htm#MH • Sukla A. NRHM: Hopes or disappointment? Indian J Pub health 2005 Jul-Sept; 49(3): 127-132.