National Rural Health Mission
FRAMWORK
Why NRHM ? How it is different from earlier programmes? Objectives of NRHM At village level At Block level At District level At State levelAt National levelTechnical supportFunding arrangementsProgress so far
State/UTIMRSRS 2005
MMR SRS 01-03
TFR SRS 2005
Kerala 14 110 1.7
Tamil Nadu 37 134 1.7
Madhya Pradesh 76 379 3.6
Orissa 75 358 2.6
Uttar Pradesh 73 517 4.2
All India 58 301 2.9
Large inter state variations in India’s Health Indicators
Why NRHM?
Epidemiological & Demographical Transition
Lack of accountability
Lack of Holistic Approach
Under funded, under utilised
Shortage of infrastructure & human resources
Lack of basic amenities Food, Drinking water, Sanitation
X -FY Plan2007
NPP 2010
MDG2015
Current
Infant MR 45 <30 2758
(SRS 2005)
Maternal MR 200 <100 100301 (SRS
01-03)
Total fertility R 2.1 2.1 2.9
Institutional deliveries
80% 80% 40.7 (NFHS III)
Why NRHM?
NATIONAL GOALS & MDG
Non responsiveness to Citizen
Non integration of Disease Control programmes
Lack of community ownership
Weaker section not able to access- Poor, rural, Women, Child
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
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
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
NRHM – The Concept
Health Health Determinants
RCH-II NDCP Nutrition Water Supply AYUSH
Sanitation
General CurativeCare
NRHM – 5 MAIN APPROACHES
COMMUNITIZE
1. PRIs at all levels 2. Decentralized planning,
monitoring(VHNSC)
4. NGO involvment
IMPROVEDMANAGEMENT
THROUGH CAPACITY
1. Block & District HealthOffice with management skills2. NGOs in capacity building
3. NHSRC / SHSRC 4. Continuous skill development
& support
FLEXIBLE FINANCING
1. Untied fund2. Risk Pooling – money
follows patient3. More resources for
more reforms
INNOVATION INHUMAN RESOURCE
MANAGEMENT
1. More health worker2. 24 X 7 emergencies
management at PHC & CHC
MONITOR,PROGRESS &STANDARDS
1. IPHS Standards2. Facility Surveys
3. Independent MonitoringCommittees at block,
district & Statelevels
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.
AT VILLAGE LEVEL
Creation of cadre of ASHA
Village Health, Nutrition & Sanitation Committee
Role of ANM and Anganwadi Worker
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
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.
Village Health, Nutrition & Sanitation Committee (VHNSC)
Yardsticks for monitoring at the village level
NRHM indicators translated into Village health indicatorsVillage Health Plan
Tool of Planning & Monitoring
Household surveyVillage health RegisterRecords of the ANMVillage Health CalendarVillage Health PlanInfant and Maternal death auditPublic dialogue (Jan Samvad)
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
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.
Rogi Kalyan Samiti
Effective convergence of all programmes
MANAGEMENT & PLANNING: ROGI KALYAN SAMITI
Composition of RKS 30%- representative of PRI(Panchayat samiti member,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
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
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
Rogi Kalyan Samitis 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
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/DHOSecretary – 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.
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.
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 PlanNew interventions under NRHMRCH II, Strengthening of ImmunisationDisease Control / Surveillance Programmes such as NVBDCP ,
RNTCP, NPCB, IDD ,NLEP and IDSP Intersectoral convergence activities including Nutrition, Safe
Drinking Water etc
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, Zila Parishad, 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
STATE HEALTH SOCIETY
A. Governing Body Chairperson: Chief Secretary/Development CommissionerCo-Chair: Development CommissionerVice-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 & FWConvener : 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)
COMPOSITE ORGANOGRAM OF THE STATE MISSION AND THE STATE SOCIETY
Executive Committee, State Health Society
Programme Committees (Headed by Director/
Director General)(Optional)
SPMSU
(Headed by Executive Director/Mission Director)
Governing Body, State Health Society
State Health Mission
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 Rogi kalyan samiti Issue Government Order to facilitate a fixed Health Day at
Aanganwadi level every month
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 evaluationInternal evaluation
AT NATIONAL LEVEL
Administration
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
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
o National Health System Resource Centre (NHSRC)o State Institute of Health & Family Welfare (SIHFW) o Population Research Centre (PRC)o Regional Resource Centre (RRC)o NGOs & Expert groupso Improved Health Information System
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
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.
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 Janani Suraksha Yojana (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
PROGRESS SO FAR
INDICATOR Gain under NRHM
IMR Down to 55(2007)
Institutional delivery Increased by 66.4 in MP50.2 - Rajasthan 43.3 - Bihar43.8 - Orissa20.9 - AP12.4 - UP DLHS II(2004)--DLHS III (2007)
Immunization Full immunization increased 20.7 to 41.4 in Bihar (DLHS II(2004)--DLHS III (2007))
TFR 2.7 (NFHS-III)
Number of ASHA selected during 52852 (2008)Total Number of PHCs functioning as 24x7 basis
6397 (31/3/2008)
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.
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