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.