Let us first discuss the major challenges in our health sector. India has one of the lowest funded public health system. The public expenditure on health is a mere 0.9% of the GDP of the country and the out of pocket expenditure incurred is very high. There is a poor distribution of the skilled manpower in the country. 70% of our population lives in the villages while 70% of the doctors are serving in the urban areas. Quality of health services is very poor and therefore it fails to attract the people. Enough efforts had not been put for community participation and the health needs of the people are different from what the system offers. There had been unwillingness in the system to look for structural changes and governance reforms wherever required.
In this background our Hon’ble Prime Minister, Dr. Manmohan Singh launched the National Rural Health Mission (NRHM) in April 2005 with a clear objective of providing quality health care in the remotest rural areas. This will be done through improving access, enhancing the equity and accountability of the health care system and promoting decentralization.
To correct these maladies, the priorities fixed under the Common Minimum Program of the UPA government is to …………
Sub Centre: Peripheral most unit available at the Village level to take care of the Health needs of the community. A Health Sub centre covers a population of 5000 in plain areas and 3000 in Hilly and difficult terrains. All Primary Health Care Services are being provided at the door steps of the community Each Health sub centre is manned by a pair of Health Workers. The Female Worker (VHN) takes care of MCH activities, including Immunization.
Primary Health Centers (PHC) are the cornerstone of rural healthcare. Primary health centers and their sub-centers are supposed to meet the health care needs of rural population. Each primary health centre covers a population of 30,000 and is spread over about 100 villages. A Medical Officer, Block Extension Educator, one female Health Assistant, nurse, a driver and laboratory technician look after the PHC. It is equipped with a jeep and necessary facilities to carry out small surgeries
Community Health Centers are located at the Block level ( population of 1,00,000- 1,20,000. it is essentially a 30 bedded hospital with provision for specialized care in medicine, surgery, obstetrics and pediatrics. It is the first level referral centre in the district.
Historically the district, in some form or the other has been the most important unit of administration in the Indian sub-continent. The population covered by a district may range from 20- 30,00,000. India has 28 States and 7 Union Territories: There are total 626 Districts In most of the States, the District Collector was the head of the government at the district level, responsible for a diverse portfolio of functions ranging from delivery of essential services, land revenue administration, execution of rural development programs, disaster management, maintenance of law and order and collection of excise and transport revenue. As such, virtually all the instruments of the State Government that operated at the local levels did so in conjunction with the Collector’s office either formally or informally. In this regard, structurally diverse arrangements were built up over time. The relationships and reporting structures range from the Collectors undertaking broad oversight/supervision of the activities undertaken by line departments- to specific day-today management of some services.
The five main approaches of NRHM are Communitization, Flexible Financing, Improved Management through capacity, Monitoring progress against standards and Innovations in Health Management. The concept of ‘Communitization’ is a high degree of community participation where the community gets the ownership of the public health services and has a say in how health services are organized at community level. It builds a system of community monitoring of health and involves people for health action at village level. Under NRHM, Village Health and Sanitation Committee has been constituted in each village of the country. There is a provision of ASHA for every 1000 population. She is chosen by the community itself and is accountable to the Gram Panchayat. She will act as an interface between the community and the public health system
National Rural Health Mission Dr. Bhuwan Sharma Asst. Professor (Grant Medical College, Mumbai)
The Challenges in Rural health sector Under funded public health system (0.9% GDP) High and prohibitive out of pocket expenditure Inequitable distribution of skilled manpower in rural areas with 70% of total population(R-28%, U-74%). Poor quality services in public health system Poor community participation People’s needs different from what system offers Large unregulated private sector Minimal Insurance coverage (10%) Unregulated population growth.
Introduction National Rural Health Mission was launched by our Hon’ble Prime Minister launched in 12 th April, 2005 with an objective to provide effective health care to the rural population, by Improving access to health care Enhancing equity and accountability Promoting decentralization
Preamble of NRHM Provide effective health care to entire rural population with special focus on 18 states. Raise public spending on health to 2-3% of GDP Health activist in each village, preparation of health plans in collaboration with PRIs. Integration of vertical health and family welfare programme. Integration of other determinants of health like sanitation, hygiene, nutrition and safe drinking water through a district health plan.
Decentralization of health programmes at district level and involvement of local bodies. Defined time bound goals To provide equitable, accessible, affordable, accountable, effective and reliable primary health care especially to poor women and children.
Scope of NRHM SPECIAL FOCUS ON 18 STATES. Arunachal Pradesh, Assam, Bihar, Chhattisgarh, Himachal Pradesh, Jharkhand, J&K, Manipur, Mizoram, Meghalaya, MP, Nagaland, Orissa, Rajasthan, Sikkim, Tripura, Uttaranchal, UP.
Goals Reduction in Infant Mortality Rate (IMR) and Maternal Mortality Ratio (MMR) Universal access to public health services such as Women’s health, child health, water, sanitation & hygiene, immunization, and Nutrition. Prevention and control of communicable and non-communicable diseases, including locally endemic diseases
Contd. Access to integrated comprehensive primary healthcare Population stabilization, gender and demographic balance. Revitalize local health traditions and mainstream AYUSH Promotion of healthy life styles
Objectives ASHA Health Action Plan IPHS FRU District health plans AYUSH
EXPECTED OUTCOMES•Universal Health care, well functioning health care delivery system.•IMR to be reduced to 30/1000 live births by 2012•MMR to be reduced to 100/100,000 live births by 2012•TFR to be reduced to 2.1 by 2012•Malaria Mortality Reduction Rate – 60% upto 2012•Kala Azar to be eliminated by 2010, Filaria reduced by 80 % by 2010•Dengue Mortality reduced by 50%, JE mortality reduction by 50% 2012•RNTCP-2 – maintain 85% cure rate, leprosy prevalence rate to reduce from 1.8/10,000 to lessthan 1/ 10,000.•Upgrading all SCs, PHCs and CHCs to IPHS levels,•Increase utilization of FRUs from below 20% to over 75%.
Plan of action/Components Accredited social health activists Strengthening sub-centers Strengthening primary health centers Strengthening CHCs for first referral centres District health plan under NRHM Strengthening disease control program Public-private partnership for public health goals, including regulation of private sector New health financing mechanisms Reorienting health/medical education to support rural health issues
Components of NRHM1. ASHA- Resident of the village, a woman (M/W/D) between 25-45 years, with formal education up to 8th class, having communication skills and leadership qualities.- One ASHA per 1000 population.- Around one 100,000 ASHA’s are already selected.
ASHA- Chosen by the panchayat to act as the interface between the community and the public health system.- Bridge between the ANM and the village.- Honorary volunteer, receiving performance based compensation .
Responsibility of ASHA- To create awareness among the community regarding nutrition, basic sanitation, hygienic practices, healthy living.- Counsel women on birth preparedness, imp of safe delivery, breast feeding, complementary feeding, immunization, contraception, STDs
Contd.- Encourage the community to get involved in health related services.- Escort/ accompany pregnant women, children requiring treatment and admissions to the nearest PHC’s.- Primary medical care for minor ailment such as diarrhea, fevers- Provider of DOTS.
Janani Suraksha Yojana and ASHA NRHM JSY↓↓ all MMR Antenatal Check up & IMR Institutional Care during delivery Immediate post-partum (coordinated care)↑↑Institutional Deliveriesin BPL families Cash assistance
Components of NRHM contd.2. STRENGTHENING SUB-CENTRES Each sub-centre will have an Untied Fund for local action @ Rs. 10,000 per annum. This Fund will be deposited in a joint Bank Account of the ANM & Sarpanch and operated by the ANM, in consultation with the Village Health Committee. Supply of essential drugs, both allopathic and AYUSH, to the Sub-centers. In case of additional Outlays, Multipurpose Workers (Male)/Additional ANMs wherever needed, sanction of new Sub-centers as per 2001 population norm, and upgrading existing Sub-centers, including buildings for Sub- centers functioning in rented premises will be considered
Components of NRHM contd.3. STRENGTHENING PRIMARY HEALTH CENTRES Mission aims at Strengthening PHC for quality preventive, promotive, curative, supervisory and outreach services, through: Adequate and regular supply of essential quality drugs and equipment including Supply of Auto Disabled Syringes for immunization) to PHCs Provision of 24 hour service in 50% PHCs by addressing shortage of doctors, especially in high focus States Observance of Standard treatment guidelines & protocols. Intensification of ongoing communicable disease control programs, new programs for control of non communicable diseases, up gradation of 100% PHCs for 24 hours referral service, and provision of 2nd doctor at PHC level (I male, 1 female) would be undertaken on the basis of felt need.
Components contd.4. STRENGTHENING CHCs FOR FIRST REFERRAL CARE Operationalizing 3222 existing Community Health Centers (30-50 beds) as 24 Hour First Referral Units, including posting of anesthetists. Codification of new Indian Public Health Standards, setting norms for infrastructure, staff, equipment, management etc. for CHCs. Promotion of Stakeholder Committees (Rogi Kalyan Samitis) for hospital management. Developing standards of services and costs in hospital care Develop, display and ensure compliance to Citizen’s Charter at CHC/PHC level In case of additional Outlays, creation of new Community Health Centres(30-50 beds) to meet the population norm as per Census 2001, and bearing their recurring costs for the Mission period could be considered
Components contd.5. DISTRICT HEALTH PLANIt would be an amalgamation through: Village Health Plans, State and National priorities for Health, Water Supply, Sanitation and Nutrition. Health Plans would form the core unit of action proposed in areas like water supply, sanitation, hygiene and nutrition. Implementing. Departments would integrate into District Health Mission for monitoring. District becomes core unit of planning, budgeting and implementation. Centrally Sponsored Schemes could be rationalized/modified accordingly in consultation with States.
Contd. Concept of “funneling” funds to district for effective integration of programs All vertical Health and Family Welfare Programmes at District and state level merge into one common “District Health Mission” at the District level and the “State Health Mission” at the state level Provision of Project Management Unit for all districts, through contractual engagement of MBA, Inter Charter/Inter Cost and Data Entry Operator, for improved program management
Components contd.6. CONVERGING SANITATION AND HYGIENE UNDER NRHM Total Sanitation Campaign (TSC) is presently implemented in 350 districts, and is proposed to cover all districts in 10th Plan. Components of TSC include IEC activities, rural sanitary marts, individual household toilets, women sanitary complex, and School Sanitation Program. Similar to the DHM, the TSC is also implemented through Panchayati Raj Institutions (PRIs). The District Health Mission would guide activities of sanitation at district level, and promote joint IEC for public health, sanitation and hygiene, through Village Health & Sanitation Committee, and promote household toilets and School Sanitation Program. ASHA would be incentivized for promoting household toilets by the Mission.
Components contd.7. STRENGTHENING DISEASE CONTROLPROGRAMMES National Disease Control Program for Malaria, TB, Kala Azar, Filaria, Blindness & Iodine Deficiency and Integrated Disease Surveillance Program shall be integrated under the Mission, for improved program delivery. New Initiatives would be launched for control of Non Communicable Diseases. Disease surveillance system at village level would be strengthened. Supply of generic drugs (both AYUSH & Allopathic) for common ailment at village, SC, PHC/CHC level. Provision of a mobile medical unit at District level for improved Outreach services.
Components contd.8. PUBLIC-PRIVATE PARTNERSHIP FOR PUBLICHEALTH GOALS, INCLUDING REGULATION OFPRIVATE SECTOR Since almost 75% of health services are being currently provided by the private sector, there is a need to refine regulation Regulation to be transparent and accountable Reform of regulatory bodies/creation where necessary
Contd. District Institutional Mechanism for Mission must have representation of private sector Need to develop guidelines for Public-Private Partnership (PPP) in health sector. Identifying areas of partnership, which are need based, thematic and geographic. Public sector to play the lead role in defining the framework and sustaining the partnership Management plan for PPP initiatives: at District/State and National levels
Components contd.9. NEW HEALTH FINANCING MECHANISMS A Task Group to examine new health financing mechanisms, including Risk Pooling for Hospital Care as follows: Progressively the District Health Missions to move towards paying hospitals for services by way of reimbursement, on the principle of “money follows the patient.” Standardization of services – outpatient, in-patient, laboratory, surgical interventions- and costs will be done periodically by a committee of experts in each state. A National Expert Group to monitor these standards and give suitable advice and guidance. Where credible Community Based Health Insurance Schemes (CBHI)exist/are launched, they will be encouraged as part of the Mission. The Central government will provide subsidies to cover a part of the premiums for the poor, and monitor the schemes. The IRDA will be approached to promote such CBHIs, which will be periodically evaluated for effective delivery
Components contd.10. REORIENTING HEALTH/MEDICAL EDUCATION TO SUPPORT RURAL HEALTH ISSUES While district and tertiary hospitals are necessarily located in urban centres, they form an integral part of the referral care chain serving the needs of the rural people. Medical and para-medical education facilities need to be created in states, based on need assessment. Mainstreaming AYUSH. Task Group to improve guidelines/details
NRHM Main Approaches Communitization •Village Health & Sanitation Committee • ASHA Flexible Financing • Panchayati Raj Institutions Monitor progress• Untied grants • Rogi Kalyan Samiti against standard• NGOs as implementers •IPHS Standard• Risk Pooling • Facility Surveys• Money follows patient • Independent• More resources for Monitoring more reforms Committee Innovations in Health Management • Additional manpower • Emergency services • Multi-skilling
NRHM- The progress so far (2012) IMR – 47/ 1000 live births (58 in 2005) MMR- 212/ 100,000 live births (301 in 2003) TFR- 2.2 (2.7 in 2005) Leprosy eliminated Malaria and Dengue mortality reduced to below 50% as apposed to 2005. DOTS progress maintained SC/PHC/CHC up-gradation according to IPHS is increasing. Institutional deliveries increased manifold (2.7 crore beneficiary under JSY ).
MCQs Q1. The year of launching of NRHM ?a) 2003b) 2005c) 2001d) 2007
Q2. The goal of NRHM to reduce TFR by 2012 upto ?a) 2.7b) 2.5c) 2.3d) 2.1
Q3. IMR of India as per the 2012 census ?a) 58/ 1000 live birthsb) 52/ 1000 live birthsc) 47/ 1000 live birthsd) 45/ 1000 live births
Q4. Monetary incentive to ASHA under Janani Suraksha Yojana in Mumbai district ?a) 1000/- Rsb) 600 /- Rsc) 200 /- Rsd) Nil
Q5. Benefits of JSY are extended to females of SC/ST category in high performance states upto ?a) Two live birthsb) Three live birthsc) Four live birthsd) All births
Q6. Under NRHM, there should be provision of one Accredited Social Health Activist for __________ population.a) 500b) 1000c) 1500d) 5000
Q7. ASHA is selected by ?a. ANM under Sub Centreb. Medical Officer of PHCc. Gram Panchayatd. CBOs/ NGOs