NRHM - Making a Difference Everywhere

1. NRHM - Making a Difference Everywhere Inter-sectoral Convergence through institutions and activities

2. NRHM’s Key approaches • State led prioritization from resource • Decentralized action – wider determinants • ‘Communitize’ at all levels – PRIs/RKSs. • Provide flexible and adequate financing • Monitor progress against IPH Standards • Build capacity at all levels • Innovative human resource engagement • Strengthen management system

3. Convergence with determinants • Common Committee for water, sanitation, health, nutrition and education – PRI umbrella. • ICDS and Schools not to suffer from any health care deficits – mandate of NRHM. • Expand partnerships of frontline workers/ community organizations – AWW/ASHA/ANM/School Teacher. • Village Health and Nutrition Day at ICDS Centre – Role of ‘TAMASHA’ - WAR ON MALNUTRITION. • Village Health and Sanitation Committee – platform for action – cleanliness, toilets, Behaviour Change.

4. NRHM – 5 MAIN APPROACHES COMMUNITIZE 1. Hospital Management Committee/ PRIs at all levels 2. Untied grants to community/ PRI Bodies 3. Funds, functions & functionaries to local community organizations 4. Decentralized planning, Village Health & Sanitation Committees MONITOR, PROGRESS AGAINST STANDARDS 1. Setting IPHS Standards 2. Facility Surveys 3. Independent Monitoring Committees at Block, District & State levels FLEXIBLE FINANCING 1. Untied grants to institutions 2. NGO sector for public Health goals 3. NGOs as implementers 4. Risk Pooling – money follows patient 5. More resources for more reforms IMPROVED MANAGEMENT THROUGH CAPACITY 1. Block & District Health Office with management skills 2. NGOs in capacity building 3. NHSRC / SHSRC / DRG / BRG 4. Continuous skill development support INNOVATION IN HUMAN RESOURCE MANAGEMENT 1. More Nurses – local Resident criteria 2. 24 X 7 emergencies by Nurses at PHC. AYUSH 3. 24 x 7 medical emergency at CHC 4. Multi skilling

5. NRHM – ILLUSTRATIVE STRUCTURE Health Manager BLOCK LEVEL HEALTH OFFICE –--------------- Accountant Store Keeper Accredit private providers for public health goals 100,000 Population 100 Villages BLOCK LEVEL HOSPITAL Strengthen Ambulance/ transport Services Increase availability of Nurses Provide Telephones Encourage fixed day clinics Ambulance Telephone Obstetric/Surgical Medical Emergencies 24 X 7 Round the Clock Services; 30-40 Villages CLUSTER OF GPs – PHC LEVEL 3 Staff Nurses; 1 LHV for 4-5 SHCs; Ambulance/hired vehicle; Fixed Day MCH/Immunization Clinics; Telephone; MO i/c; Ayush Doctor; Emergencies that can be handled by Nurses – 24 X 7; Round the Clock Services; Drugs; TB / Malaria etc. tests 5-6 Villages GRAM PANCHAYAT – SUB HEALTH CENTRE LEVEL Skill up-gradation of educated RMPs / 2 ANMs, 1 male MPW FOR 5-6 Villages; Telephone Link; MCH/Immunization Days; Drugs; MCH Clinic VILLAGE LEVEL – ASHA, AWW, VH & SC 1 ASHA, AWWs in every village; Village Health Day Drug Kit, Referral chains

6. Swasthya Panchayat – a beginning • Chhatisgarh’s experiment. • Sensitizing PRIs on human development. • Need to present data at local level – nutrition, drop outs, worms, anaemia, under weight, diarrhoea, skin rashes, eye infections, fevour. • VH&SCs have the potential to make public health a local issue. • Fighting public health issues with water and sanitation rather than with antibiotics.

7. Convergence so far --- • ICDS centre as centre for VHNDs. • Role clarity of AWW/ASHA/ANM. • VH&SCs as common community institution. • Untied funds leading to local action – Kerala’s Chikanguniya, AP’s cleanliness drive, Gujarat’s Mamta Abhiyan, Bihar’s Muskaan. • ASHA promoting toilets; BCC for early breast feeding; support for nutrition – AP, MP, WB, Bihar, Rajasthan. • HIV/AIDS – convergence for RTI/STI.

8. Village Health and Sanitation Committees Mixed performance. Constitution taking very long time in some States – Bihar, Assam. Low/no expenditure in many States – HP, Jharkhand, Rajasthan, Haryana. Money given to Gram Panchayat – not to VH&SC – Rajasthan. WB, TN, AP, Gujarat, Karnataka, UP, MP making progress. ALL VH&SCs IN 2008 – ACCOUNTS, MEETINGS, TRAINING, LOCAL ACTION, PUBLIC HEALTH

9. MONTHLY HEALTH AND NUTRITION DAYS AT AANGANWADIS Becoming popular convergence point in many States – Bihar’s Muskaan, Gujarat’s Mamta Abhiyan, etc. Chhattisgarh and Jharkhand need to strengthen the process. Immunization, ANC as focus. Need to develop strong under nutrition focus. Opportunity for Behaviour Change Communication – Communication materials. INSTITUTIONALIZE MONTHLY HEALTH AND NUTRION DAYS IN ALL VILLAGES IN 2008.

10. UNDER-NUTRITION AS THRUST Large number of NRHM activities can make substantial dent in the under nutrition problem. Age at marriage, spacing, control over malaria to prevent LBWs, drug availability at village level, preparedness of PHCs and CHCs for Grade 3 and 4 malnutrition, monitoring children’s weight and height in MHNDs, positive deviance at MHNDs, Behaviour Change Communication on feeding practices by ASHAs, can make a dent in the under nutrition problem – the greatest national emergency !!!! COORDINATE EFFECTIVE LOCAL ACTION AND MONITOR EFFECTIVENESS ON UNDER NUTRITION.

11. FOOD DEFICITS • Ensuring food security of households • Community kitchen • Nutritious food supplementation • Vitamin A, micro Nutrients BEHAVIOUR CHANGE DEFICITS • Breast feeding • Age at marriage and spacing • Nutrition & health education • Sanitation and hygiene • Local Nutritious food/cooking habits TRACKING MALNUTRITION PUBLIC HEALTH DEFICIT • Clean and safe drinking water • Sanitation, toilets • Boiling water during months of contamination • Larvicidal measures • DDT Spray • Waste Disposal VILLAGE HEALTH & SANITATION COMMITTEE ASHA & AWW AT AWC MONTHLY HEALTH DAY SCHOOL HEALTH PROGRAMME REFERRAL CHAIN HEALTH CARE DEFICITS • Basic drugs in village • Hospital entitlements for malnourished • Home and Hospital based care • Immunization • Hospitalization for Grade III & IV cases

12. Nutrition Rehabilitation Center Guna, Madhya Pradesh NRCs making difference for Severely malnourished children in MP (Guna dist) Prahlad August 2005, Garlagird village, Guna Prahlad March 2006

13. Process to establish Nutrition cum day care center Planning meeting Sharing Survey details Pregnant &lactating women Mother-in-laws’oath Mothers nutritional care Day care for children Fixed Nutrition and Health Day

14. 67 % 45 % 34 % 0.4% 9 % 1.4 %

16. RESIDENTIAL ARRANGEMENTS Proposed Child Development and Nutrition Center UNDERSTANDING THE GROWTH CHART

17. Muskan … in Bihar • To achieve 100% immunization of Infants and Pregnant Women • To Ensure 100% Institutional Deliveries • Convergence between ICDS and Health for service delivery. • Anganwadi Center to act as the “service delivery unit” for immunization and as Headquarters from where AWW and ASHA operate • ANM to be ‘Team Leader’ for 8 – 10 AWCs • 1.Tracking of all Pregnant Women and Newborns • House-to-house survey • Registration of Pregnant Women and Children from 0 – 3 age group • 2.Immunization sessions at Anganwadi Centers • 3.‘Mahila Mandal’ Meetings

18. Convergence in PIPs 2008-09 • Karnataka – AYUSH, VHNDs, VH&SCs, 100% Birth and Death Registration, School Health Programme, HIV AIDS. • Bihar – Under nutrition, Muskaan, PRI training, AWW, ASHA, ANM working together, Mahila Mandal meetings. • Rajasthan – AYUSH, MHNDs, NRC, School Health, sanitation and water. • Punjab – With DWCD on nutrition, health, women’s empowerment. ICDS and SACS

19. Convergence in PIPs - II • Chhatisgarh –Total Sanitation Campaign, Swasthya Panchayat, VHSC – PRI, School Health. • Maharashtra- VHND, water, sanitation, health, AYUSH, HIV/AIDS RTI/STI, ARSH Programme with NYK. • Orissa – WCD, AYUSH. • Assam – convergence with WCD and PHED. • Tripura – PRIs, Schools.