National Rural Health Mission (NRHM)

1

Nati onal Rural Health Mission (NRHM)

Review Meeting with State’s Health Secretaries, Mission Directors &

Directors of Health Services11th& 12th Sept. 2012

--- JS (Policy)

• MMR (212 as per RGI report 2007-09)

– Annual Rate of decline between 2004-06 and 2007-09 is 23% higher than annual rate of decline between 1999-2001 and 2004-06

– EAG States showed a decline of 67 points in MMR (in 2007-09 compared to 2004-06) against a National Decline of 42 points 2

GujaratKerala

T N Andra Pradesh

Punjab Maharashtra

HaryanaKarnataka

INDIA Orissa

Bihar/Jh. M P/Chhattisgarh

RajasthanU P/Uttarakhand

Assam

0 10 20 30 40 50 60 70 80 9012

1414

2020

263335

4245

5166

7081

90

Status of Drop in MMR (in points) from 2004-06 to 2007-09

ACHIEVEMENTS, SO FAR…

• IMR reduced from 58 in 2005 to 47 as per SRS 2010

– Rate of Decline of IMR accelerated by 29 % between 2005-10 as compared to 2000-2005

– Decline in Rural IMR and U5MR is higher than the decline in urban areas, thereby narrowing the Rural - Urban Gap

– Decline of U5MR & IMR is more in EAG States

• India has remained free of Wild Polio for more than a year

3

ACHIEVEMENTS, SO FAR…

Category State SRS-2005 SRS-2010 Point Change

Very High Focus states for FP

Bihar 4.3 3.7 -0.6UP 4.2 3.5 -0.7MP 3.6 3.2 -0.4Rajasthan 3.7 3.1 -0.6Jharkhand 3.5 3.0 -0.5Chhattisgarh 3.4 2.8 -0.6

All India 2.9 2.5 0.4

• Nationally Rate of Decline of TFR between 2005-2010 increased by 47 % as compared to 2000-2005

• All the 6 very high focus states have shown a decline equal to or better than All India average

• Steepest decline in annual growth rate from 1.97 to 1.64 since independence 4

TFR declined to 2.5 in 2010 as against 2.9 in 2005 ACHIEVEMENTS, SO FAR…

5

Malaria Mortality Reduction Rate

55% mortality reduction in malaria in 2010 as against 2006

Dengue Mortality Reduction Rate

26% mortality reduction in dengue in 2010 as against 2006

Cataract operations

More than 60 Lakh Cataract Operations every year

Leprosy Prevalence Rate

Reduced from 1.8 per 10000 in 2005 to less than 1 per 10000

Tuberculosis 73% case detection rate and 88% Cure rate

Disease Control ProgrammesACHIEVEMENTS, SO FAR…

STRENGTHENING OF HEALTH SYSTEMS/ SERVICES - PROGRESS

• Over 1.5 lakh Human Resource added (on a baseline of 2.17 lakh)

• 2315 Referral Hospitals strengthened to act as First Referral Units (FRUs) with capacity to provide comprehensive obstetric emergency care

• 8475 PHCs upgraded as 24x7 PHCs

• 2012 Mobile Medical Units (MMUs) provided in 449 districts for delivery of health care in difficult areas

• 7218 Emergency Response / basic ambulance service vehicles

• Nation-wide system of HMIS and MCTS set up to ensure and monitor health interventions 6

HOWEVER…

UP

ODISHA

DELHI

UTTARAKHAND

CHATTISGARH

INDIA

0%10%20%30%40%50%60%70%80%

64%73%

63% 60%

72%

23%

SHORT FALL OF NURSING STAFFS IN PHC AND CHC

SHORT FALL OF DOCTORS, SPECIALISTS AND NURSING STAFFS(IN PERCENTAGE OF TOTAL REQUIREMENT)

SOURCE: RHS 2011

ARU ODI GUJ JHA CHA MP INDIA0%

10%20%30%40%50%60%70%80%

68% 65% 64% 63% 62% 58%

35%

SHORT FALLS OF DOCTORS IN PHCs AND SPECIALISTS IN CHCs

SHORT FALL OF PARAMEDICS AND MPW (In % of total requirement)

BIHAR

WB HP M

P

ANDHRA PRADESHIN

DIA0%

10%20%30%40%50%60%70%80%90%

100% 92%82%

70%57% 56%

42%

SHORT FALL OF PARAMEDICS IN CHCS

DELHI

PODUCHERY

PUNJAB HP

J& K

INDIA

0%

20%

40%

60%

80%

100%

120%100%100%

92% 89% 86%

65%

SHORT FALL OF MPW (MALE) IN SUB CENTERS

SOURCE: RHS 2011

INFRASTRUCTURE STRENGTHENING- INew Construction (Completion Rate < 30%)

• J&K, CHATTISHGARH• ANDHRA PRADESHSUB CENTRE (SC)

• ANDHRA PRADESH, W.BENGAL, MAH., TN, DELHI• JHARKHAND, ODISHA, UTTARAKHAND, • ARUNACHAL PRADESH, MEGH. , NAGALAND, TRIPURAPRIMARY HEALTH

CENTER (PHC)

• KERALA, W. BENGAL, HARYANA, KARNATAKA, MAHARASHTRA, UTTARAKHAND, UP

• NAGALAND, ASSAM, MIZORAMCOMMUNITY HEALTH CENTER (CHC)

• KERALA• ODISHA, UTTARAKHAND, J&KDISTRICT HOSPITAL

(DH)

INFRASTRUCTURE STRENGTHENING- IIRenovation And Up gradation

(Completion Rate < 30%)• CHHATTISGARH, J&K, UTTARAKHAND• ARUNACHAL PRADESH, SIKKIM• A&N ISLANDS

SUB CENTER (SC)

• CHATTISHGARH, JAMMU & KASHMIR, SIKKIM• ANDAMAN & NICOBER , CHANDIGARH, DELHI,

PODUCHERRYPRIMARY HEALTH CENTER (PHC)

• BIHAR, J&K, MANIPUR, GOA, WEST BENGAL

• A&N ISLANDS, DELHICOMMUNITY HEALTH

CENTER(CHC)

• UP, J&K, MANIPUR, NAGALAND, ANDHRA PRADESH, HARYANA, KERALA, WEST BENGAL

• A&N ISLANDS, CHANDIGARH, DELHIDISTRICT HOSPITAL (DH)

CONSTITUTION OF VILLAGE HEALTH SANITATION AND NUTRITION COMMITTEE (VHSNC)

HP UP

Laksh

dweep

Aru. Prad

.MP

INDIA

Jharkhan

d

Rajasth

an

Gujarat

Mizoram

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

16%

49% 50%54%

72%78%

93%97% 97% 98%

SOURCE: RHS 2011

PERCENT OF VHSNC CONSTITUTED OUT OF TOTAL VHSNC REQUIRED

STRENGTHENING HEALTH INSTITUTIONS- I

(24X7 PHCs)

Orissa

Uttar Pradesh

Delhi

Chattisgarh

Jharkhand

West

Bengal

INDIA

Tripura

Puducherry

Sikkim

Tamil Nadu

0%

20%

40%

60%

80%

100%

120%

4%10% 13% 14% 14% 19%

35%

77%

96% 100% 100%States with less than 50% of total PHCs as 24X7 PHCs

STRENGTHENING HEALTH INSTITUTIONS- II (FRUs) States with less then 50% of DH, SDH &CHC as FRUs

Manipur

Jharkhand

Himach

al Pradesh

A & N Is

lands

Meghalaya

Madhya Pradesh

Arunachal P

radeshIN

DIA

Andhra Pradesh

Tamil Nadu

Puducherry

Jammu & Kash

mir

Punjab0%

10%20%30%40%50%60%70%80%90%

100%

4%11% 13% 14% 18% 18% 19%

36%

55%

69% 71%

91% 92%

Action Plan for the Year 2012-13

UP Bihar

Andhra P.

Assam W

B TN

Karnatala CH

Delhi

Sikkim0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000 474.41

113.41185.74134.64 53.52 31.58

35.7246.04

92.3412.4

RESOURCE ENVELOPE AMOUNT APPROVED CUSHION AVAILABLE

In Crores

STATES WITH CUSHION MORE THAN Rs 10 Crores

CONDITIONALITIES: IMPLEMENTATION FRAMEWORK1. Rational deployment of HR with the highest priority accorded to high focus districts and delivery points (Non compliance would lead to reduction of up to 7½ %)

Conditionalities and incentives Progress by the State % incentive/Disincentive

Method of verification

1.1 Rational deployment policy including- Posting of staff on the basis of case load, rational deployment of specialists, priority to HF districts

In place by October, 2012

Otherwise, deduction of 2% of MFP

Policy notification ; Website posting

1.2.1 Preparation of baseline data for HR

Minimum for all delivery points and SCs in high focus districts; by Nov

2012

Otherwise, deduction of 2% of MFP.

Website posting and state report

1.2.2 Evidence of corrective action in line with the policy

90% of all delivery points staffed as per norms, 90% of all SCs in high focus districts should

have at least one ANM

Otherwise, deduction of

2% and 1.5% of MFP

respectively.

State report; website posting by December 2012.

CONDITIONALITIES: IMPLEMENTATION FRAMEWORK2. Facility wise performance audit and corrective action based thereon. (Non compliance would lead to reduction of up to 7 ½% of MFP)



2.1.1 Range of services (as in MNH guidelines for RCH services, OPD, IPD and other services to be determined by the State) specified at least for delivery points

By September, 2012Up to 2½ % of

MFP

State report and Website posting by September, 2012

2.2.1 Facility wise reporting on HMIS portal by all priority facilities/delivery points for October( SC data if needed be uploaded from PHC)

By November, 2012 Up to 2½ % of

MFP

State report ; State HMIS October data to be uploaded by November

2.2.2 Corrective action (priority to be given to high focus districts) based on facility wise reporting.

By November, 2012 Up to 2½ % of MFP

State reports on corrective action by Nov, 2012. State visits

CONDITIONALITIES: IMPLEMENTATION FRAMEWORK3. Gaps in implementation of JSSK (May lead to a reduction in outlay upto 10% of RCH base flexi-pool)

Conditionalities and incentivesProgress

by the State

% incentive/Disincentive


3.1.1 Government order for coverage of entire State regarding JSSK

By Sept’ 2012

Upto 2½% of RCH base flexi-pool

Copy of GO ; Website posting

3.2.1 State wide dissemination of GO/policy, visible IEC in facilities and community awareness

By Oct’ 2012

Up to 2½% of RCH base flexi-pool

Sample community visits

3.2.2 No user charges. Free Drugs, diagnostics, diet. Grievance redressal system operational

By Oct’ 2012

Upto 2½% of RCH base flexi-pool

Field visits; exit interviews grievance redressal records.

3.2.3 At least 50% of pregnant women and sick newborns coming in should be using assured and cashless means of transport- and getting a similar drop back home

By Nov’ 2012,

Upto 2½% of RCH base flexi-pool -do-

CONDITIONALITIES: IMPLEMENTATION FRAMEWORK4. Continued support under NRHM for 2nd ANM would be contingent on improvement on ANC coverage and immunization as reflected in MCTS. Vaccines, logistics and other operational costs would also be calculable on the basis of MCTS data

Conditionalities and incentives Progress by the State Method of verification

4.1 Increase in ANC coverage ( first ANC and full ANC) as per MCTS data in (1) State (2) High Focus districts

Increase in April-December 2012 over the same period last

year

MCTS website ; state report by January, 2013

4.2 Increase in full immunization as per MCTS data in (1) State (2)High Focus districts

Increase in April-December 2012 over the same period last

year

MCTS website ; state report by January, 2013

5. Responsiveness, transparency and accountability ( incentive upto 8% of MFP)

Conditionalities and incentives Progress by the State


Method of

verification

5.1 Demonstrated including innovations for responsiveness in particular to local health needs e.g use of epidemiological data, active participation of public representatives in DHS / RKS meetings , etc.

Innovation implemented and impact demonstrated; State to send brief report in format suggested by November, 2012. ( one innovation in each of the three areas)

Up to 8% of

MFP

State report (format in Annex 1) by November, 2012 ; state visits for rapid appraisal

5.2 Demonstrated evidence/innovation for transparency e.g. mandatory disclosures and other important information including HR posting etc. to be displayed in the State NRHM websites etc.

5.3 Demonstrated evidence/innovation for accountability: e.g. initiatives in community monitoring, Jan sunwai etc

CONDITIONALITIES: IMPLEMENTATION FRAMEWORK

6. Quality assurance (incentive upto 3% of MFP)



6.1.1 States notify quality policy/strategy (align to national policy) as well as standards

In place by November 2012

Up to 3% of MFP

Notification and state report by November, 2012

6.2.1 Constitute dedicated teams. Training of state and district quality team and DH quality team completed

State team trained by November 2012

6.2.2 Current levels of quality measured for all “priority facilities” and scored and available on public domain. Deadlines for each facility to achieve quality standards declared

Quality scores of all priority facilities available in public domain


7. Inter-sectoral convergence (incentive upto 3% of MFP)




7.1.1 Implementation frame work for intersectoral convergence with allied sectors/departments

By November

2012

Up to 1% of MFP

State report (copy of implementation framework )

7.2.1 Intersectoral convergence opportunities identified with WCD, PHED, education, etc. and action initiated.

By November

2012

Up to 2% of MFP

Government order , State report


8. Recording of vital events including strengthening of civil registration of births and deaths (incentive upto 2% of MFP).



8.1 A strategy paper identifying reasons and the road map for increasing registration

By October 2012 Up to 1% of MFP

Strategy document and policy statement.

8.2 Death reports with cause of death (especially any under 5 child or any woman in 15 to 49 age group) shared with district health team on monthly basis.

By November 2012 Up to 1% of MFP

Death reports received at district level- verified in sample of districts.


9. Creation of a public health cadre (by states which do not have it already) (incentive upto 10% of MFP)



9.1.1 Stated policy and road map (including career path on creation of a public health cadre)

Policy & road map in place by November ,

2012

Up to 4% of MFP

State report website posting by November , 2012

9.2.1 Notification for creation of public health cadre

Government order in place.

Up to 6% of MFP

Website posting / state report


10. Policy and systems to provide free generic medicines to all in public health facilities( incentive upto 5% of MFP )




10.1.1 Clear policy articulation of free generic medicines to all in public health facilities

By October 2012 Upto 2% of

MFP

Website posting / state report

10.2.1 EDLs finalised and drug formulary published and made available in all public health facilities

By November

2012

Up to 3% of MFP

Notification/ Publication/ Web posting

10.2.2. Overall procurement and logistics strategy in place. Detailed design and plan for rate contracting, regular stock up dates, indent management, warehousing, promotion of rational drug use, contingency funds with devolution of financial powers etc. in place.

By November

2012

State report/ strategy document


Responsiveness, transparency and accountability Format for state report

State to provide a brief write up (<3 pages) on the best practice on Responsiveness, transparency and accountability separately Suggested structure: – Background: (Elaborate on the problem, which the innovation seeks to

address; and in particular, provide details of target group/ base line data, if available)

– Description of the innovation: (Including date of commencement and current status; coverage in terms of districts/ blocks/ villages; overall approach / strategy; implementation/ institutional arrangements; whether pilot / scaled up)

– Costs: (Broad break up of one-time and recurring costs; assessment of cost effectiveness)

– Sustainability: (Assess organisational and financial sustainability and approach to ensuring the same)

– Outcome: (Extent to which base-line conditions have improved; results of third party evaluations, if carried out)

Thank You

Documents

National Rural Health Mission (NRHM)