Nrhm a critical review after its completion of

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Nrhm a critical review after its completion of

  1. 1. Dr. Ranadip Chowdhury2nd year PGTDept. of Community MedicineR.G.Kar Medical College
  2. 2.  Launched in 12th April, 2005 Key objective is “architectural correction” of healthsector Seeks to improve access of rural people to affordable,effective, accountable and RELIABLE health care Address the issue of gross intra-state and inter-districtdisparities in demographic indicators Integration of key determinants of health likesanitation, safe water, hygiene, nutrition Focus on 18 high focus states including 8 EAG states
  3. 3.  Reduction in IMR and MMR. Universal access to public health services such as women’shealth, child health, water, sanitation andhygiene, immunization and nutrition. 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 and mainstream AYUSH. Promotion of healthy life styles.
  4. 4.  IMR reduced to 30 per 1000 live births by 2012. Maternal Mortality reduced to 100/100,000 live births by 2012. TFR reduced to 2.1 by 2012. Reduction in mortality due to malaria, dengue, Kalazar,JE; Filariaelimination 2015. 85% cure rate under TB DOTs. 46 lakh cataract operations by 2012. Leprosy prevalence rate- reduction from 1.8 per 10000 in 2005 to<1/10000 thereafter. Upgrading CHCs to IPHS. Increase utilization of FRUs from 20% to 75%;
  5. 5.  Availability of trained community level worker at village level, with a drugkit for generic ailments. Health Day at Aanganwadi level on a fixed day/month for provision ofimmunization, ante/post natal check ups and services related to mother andchild care, including nutrition. Availability of generic drugs for common ailments at sub centre/hospitallevel. Good hospital care through assured availability of doctors, drugs andquality services at PHC/CHC level. Improved access to universal immunization. Improved facilities for institutional deliveries. Availability of assured health care at reduced financial risk through pilotsof Community Health Insurance. Provision of household toilets. Improve outreach services through mobile medical unit at district level.
  6. 6.  Trust communities and forge partnerships. Innovation and autonomy. Role for community organizations /PRIs. Habitation level health workers in referral chains. Service delivery and outcome focus. Service guarantees-a rights based approach. Recognition of need for management skills. Public health through convergent action. Giving authority to those with the motivation…
  7. 7. NRHM – 5 MAIN APPROACHESCOMMUNITIZEIMPROVEDMANAGEMENTTHROUGHCAPACITYBUILDINGFLEXIBLEFINANCINGMONITOR, PROGRESS AGAINSTSTANDARDSINNOVATION INHUMANRESOURCEMANAGEMENT
  8. 8.  Decline in MMR estimates in 2007-09 over 2004-06:– For India: 212 from 254 (a fall of about 17%)• States realizing MDG target of 109 have gone up to 3with TamilNadu & Maharashtra (new entrants)joining Kerala• Andhra Pradesh, West Bengal, Gujarat and Haryanaare in closer proximity to achieving the MDG target.
  9. 9. 1391401411421431441452004-06 2007-09MMR 141 145AxisTitleMMR
  10. 10.  Every 6th death in the country pertains to an infant. IMR in India has registered a 3 points decline to 50from 53 in 2008 Maximum IMR in Madhya Pradesh (67) andminimum IMR in Kerala (12) Kerala (12) & Tamil Nadu (28) have achieved theMDG target (28 by 2015) Delhi (33), Maharashtra (31) and West Bengal (33)are in close proximity
  11. 11. 0102030405060702005 2009Chart Titletotal male female
  12. 12.  TFR for the country remained stationery at 2.6during 2008 to 2009 Bihar reported the highest TFR (3.9) while Keralaand Tamil Nadu, the lowest (1.7) Replacement level TFR, viz 2.1, has been attained byAndhra Pradesh (1.9), Delhi (1.9), Himachal Pradesh(1.9), Karnataka (2.0), Kerala (1.7), Maharashtra(1.9), Punjab (1.9), Tamil Nadu (1.7) & West Bengal(1.9).
  13. 13. 2007 2008 2009 2010 2011(oct)mortality 0.46% 0.45% 0.38% 0.36% 0.24%0.00%0.05%0.10%0.15%0.20%0.25%0.30%0.35%0.40%0.45%0.50%AxisTitlemortality
  14. 14. 2007 2008 2009 2010 2011(oct)mortality 0.49% 0.24% 0.00% 0.27% 0.00%0.00%0.10%0.20%0.30%0.40%0.50%0.60%AxisTitlemortality
  15. 15.  Kala-azar fatality rate reduction in 2010 was 21.74%from 2007 in India. Till Oct’11 Kala-azar fatality rate reduction was33.33% compare to 2010 in India. Kala-azar fatality rate reduction in 2010 was 44.9%from 2007 in West Bengal. In 2011 till October no death due to kala-azar in WestBengal.
  16. 16. 1 2 3 4 5 6microfilaria rate% 1.02 0.98 0.64 0.53 0.65 0.3700.20.40.60.811.2AxisTitlemicrofilaria rate%
  17. 17. 1 2 3 4 5 6microfilaria rate% 4.1 2.72 2.83 0.89 0.48 0.4400.511.522.533.544.5AxisTitlemicrofilaria rate%
  18. 18.  Microfilaria reduction rate was 63.73%. In West Bengal microfilaria reduction rate was89.27%.
  19. 19. 2007 2008 2009 2010 2011(Nov)dengue fatality rate 1.24% 0.64% 0.62% 0.39% 0.66%0.00%0.20%0.40%0.60%0.80%1.00%1.20%1.40%AxisTitledengue fatality rate
  20. 20. 2007 2008 2009 2010 2011(Nov)dengue fatality rate 4.20% 0.67% 0% 0.12% 0.00%0.00%0.50%1.00%1.50%2.00%2.50%3.00%3.50%4.00%4.50%AxisTitledengue fatality rate
  21. 21.  Dengue case fatality rate reduction was 68.55% from2007 (1.24%) to 2010 (.39%). But rate of dengue case fatality rate has beenincreased by 69.23% in Nov’11 from 2010. In west Bengal Dengue case fatality rate reductionwas 97.15%. There is no death due to dengue in West Bengal tillNov’2011.
  22. 22. 2005 2006 2007 2008 2009 2010 2011(oct)malaria mortality 0.05% 0.10% 0.09% 0.07% 0.07% 0.06% 0.03%0.00%0.01%0.02%0.03%0.04%0.05%0.06%0.07%0.08%0.09%0.10%AxisTitlemalaria mortality
  23. 23. 2007 2008 2009 2010 2011(oct)malaria mortality 0.11% 0.12% 0.05% 0.04% 0.02%0.00%0.02%0.04%0.06%0.08%0.10%0.12%0.14%AxisTitlemalaria mortality
  24. 24.  Malaria case fatality rate had been increased by 20%from 2005 (.05%) to 2010 (.06%) in India. But in 2011 till October (.03%) malaria case fatalityrate had been decreased by 50% compared to 2010 inIndia. Malaria case fatality rate had been decreased 63.63%from 2007 (.11%) to 2010 (.04%) in West Bengal. Till Oct’11 malaria case fatality rate reduction ratewas 50% compared to 2010.
  25. 25. 2007 2008 2009 2010 2011(Dec)case fatality 24.21% 17.82% 17.27% 13.14% 14.51%0.00%5.00%10.00%15.00%20.00%25.00%30.00%AxisTitlecase fatality
  26. 26. 2007 2008 2009 2010 2011(Dec)case fatality 12.50% 0 0 0 5.60%0.00%2.00%4.00%6.00%8.00%10.00%12.00%14.00%AxisTitlecase fatality
  27. 27.  Japanese Encephalitis case fatality reduction by 40%from 2007 to2011 in India. Japanese Encephalitis case fatality reduction by55.2% from 2007 to2011 in West Bengal.
  28. 28.  Kala-azar mortality reduction by 21.93% in2006-08. Malaria mortality reduction by 45.23% in2006-08. Microfilaria reduction rate from 2006-2008was 26.74%. Dengue mortality reduction rate in 2006-2008was 56.52%.
  29. 29.  Goal: Cataract operations-increasing to 46 lakhs until 2012.570000057500005800000585000059000005950000600000060500002008-09 2009-10 2010-11cataract surgery 5810336 5906016 6023173AxisTitlecataract surgery
  30. 30.  The year 2010-11 started with 0.87 lakhleprosy cases on hand as on 1st April2010, with PR 0.72/10,000. Till then 32 States/ UTs had attained the levelof leprosy elimination. A total of 510 districts(80.6%) out of total 633 districts also achievedelimination by March 2010.
  31. 31. 2005 2006 2007 2008 2009 20102011(31stmarch)leprosy PR 2.3 0.84 0.72 0.74 0.72 0.72 0.6900.511.522.5AxisTitleleprosy PR
  32. 32.  87% cure rate of TB has been maintained over thelast 5 years. Case detection rate has moved from 70% to 71%.
  33. 33. 020406080100120Bihar ChhattisgarhHP J & K JharkhandMP Orissa RajasthanUP UttarakhandWBSeries1 47 61 102 76 77 65 74 85 83 75 72AxisTitleChart Title
  34. 34. 82838485868788899091Bihar ChhattisgarhHP J & K JharkhandMP Orissa RajasthanUP UttarakhandWBSeries1 89 87 89 91 90 88 87 89 89 85 85AxisTitleChart Title
  35. 35. 1 2 3 4 5 6 7 8 9 10 11Total sputum-positive casenotification54% 61% 65% 66% 69% 65% 67% 70% 71% 71% 71%0%10%20%30%40%50%60%70%80%AxisTitleTotal sputum-positive case notification
  36. 36. 82.58383.58484.58585.58686.58787.52000 2001 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010success rate of new smear positive patients(%)success rate of new smear positivepatients(%)
  37. 37.  Physical infrastructure up-gradation, human resourceaugmentation, equipment provision taken up innearly all community health Centres. DLHS-III found 90.1% CHCs with normal deliveryservice. Since the IPHS provides for a higher Standard, it willtake some time before augmentation is as per IPHS.
  38. 38. INFRASTRUCTURE/HUMANRESOURCE2005 2010 CommentNo. of HealthSub-centres(SC)146026 147069 .7% increaseHealth SCs inGovt. Buildings63901 84957 32.95% increaseANMs at HealthSC139798 200010 43.07% increasePHCs in Govt.Buildings23236 23673 1.88% increaseNo. of CHCs 3346 4535 35.53% increaseSpecialist atCHCs3550 6781 91% increaseGDMOs otherdoctors at CHCsNA 9432Nurse midwife atPHC/CHC28930 93935 3.25 times moreParamedical staff 12284 21740 1.75 times more
  39. 39.  461 Districts Equipped with Medical Mobile unit underNRHM 1787 Mobile Medical Units Operational in the State/UTUnder NRHM 4764 ERS Vehicles Operational in the State/UT UnderNRHM 8826 Ambulances functioning in the State/UTs (AtPHC/CHC/SDH/DH)
  40. 40.  No separate data on utilizationss levels in FRUs. The CRM reported much higher utilization of in-patients facilities due to increased institutionaldeliveries. Total 2891 First Referral Unit is operationing (31stMarch 2011). 883 FRUs in 10 high focus non NE states. 120 FRUs in 8 high focus NE states. 1842 FRUs in Non high focus states-large. 46 FRUs in Non high focus states –small & UTs.
  41. 41.  Total 128 FRUs operationing till 31st March 2011. In Last 5 years of NRHM no more District Hospital hadbeen upgraded to FRUs. 27 more sub divisional hospitals have been up graded toFRUs. In 2005 in WB there was no CHCs was functioning asFRUs, but as per 2010 SEVEN CHCs are functioning asFRUs.
  42. 42.  8.25 lakh ASHAs selected.(2010) with 690221 having drugkits. 46,690 ANMs appointed on contract. 8624 MBBS doctors appointed on contract. 2460 specialists appointed on contract. 7692 AYUSH doctors appointed on contract. 14490 paramedic staff appointed on contract.
  43. 43.  42003 ASHA selected & 32123 ASHA with drugs kit. 51 paramedical staff appointed. Specialists appointed 1253. No data on appointment on staff nurse. 19 AYUSH doctors & paramedical staffs.
  44. 44.  NRHM has brought the thrust on human resources atcentre stage. Performance based payment system. Failure of The World Bank funded Health Systemsprojects on account of lack of attention to humanresource.
  45. 45.  Boat Clinics in Assam to partnerships with tea-gardens. Partnerships for diagnostics in Bihar & West Bengal. Emergency transport system in Haryana, AP, Gujarat,Rajasthan. Rural medical assistants in Chhattisgarh. Rural Health Practitioners in Assam. Orissa recruited AYUSH doctors to provide services at PHCwhere no MBBS doctor.
  46. 46.  By end 2010, the total number of ASHAs had risen to825,000. Except for Himachal Pradesh all other 17 high focus state optfor the ASHA programme. In January 2009, responding favourably to a very positivepolitical and administrative feedback from the states, adecision was taken to extend the programme within even thenon high focus states to cover the entire state. Except inTamilnadu, which kept the programme limited to tribal areas,all other states opted for this expansion.
  47. 47. At the national level, the guidelines lay out three rolesfor ASHA: facilitator of health services service provider activist.
  48. 48.  At the time of the study only Assam had set up the full support structure asper national guidelines. Orissa had a structure in state and district and block level, but not yet at thesub-block level. Orissa had the most functional review process in place, with a clearschedule of meetings and some mechanisms of recording and measuringprogress. Rajasthan had all structures in place, but these require more content, depthand skills to be effective. At the time of the evaluation Bihar had no support structures inplace, although plans were underway to establish these. Jharkhand only state and district structures were in place. In contrast Andhra, Kerala and West Bengal had no full time supportstructures in place at any level and were managed by ad hoc appointmentsof nodal officers who oversaw this work in addition to many other tasks
  49. 49.  Andhra had a more motivated District Public Health andNutrition officer, though despite this, it was perhaps the mostweakly monitored and supported ASHA of the eight statesstudied. Kerala had a regular schedule of meetings and the ANM(called JPHN) was much more available for playing this role-as her work had either shifted up to the PHC or been shifteddown to the ASHA- making her a supervisor of an ASHA withlittle work outputs of her own. In West Bengal, panchayat and field functionaries formed aviable administrative support team, though this is of little usein providing clinical support. All states except Kerala have involved NGOs in theprogramme.
  50. 50.  In Assam and Orissa stable leadership at state leveland a dedicated technical agency have served theprogramme well. In West Bengal, Kerala, and Andhra Pradesh whilethere is commitment to the ASHA programme this isnot reflected in the management or support orrealised in terms of outcomes. In Rajasthan Bihar and Jharkhand, frequentleadership changes have hampered programmeprogress.
  51. 51.  In most states, minimum levels of training have been achieved, but the pace oftraining fell far short of what was required. In West Bengal, 90% had received 23 days of training. In Orissa about 86% received more than 16 days training of which nearly 54% hadreceived more than the targeted 23 days of training. In Assam 77% received more than 16 days, of which 26% had received more than23 days. In Kerala, 52% had received over 16 days- all had completed module 4. The poorest performance was Bihar, where about 97% of ASHA had received lessthan 16 days, and 87% had received less than ten days of training over a four yearperiod! In effect for 87% of the ASHAs in Bihar only Module 1 had been covered. In Jharkhand 46% had received between 11 and15 days of training and 50%received less than ten days. In Rajasthan 31% of ASHA had received less than 16 days of training, with theremaining 69% getting more than 16 days.
  52. 52.  Except in Orissa and Assam, states adapted the modules forlocal context and need. Jharkhand and West Bengal substantially strengthened themessage content. Jharkhand even revised the modules entirely,made it more pictorial and richer in key information. Rajasthan, Uttar Pradesh and Angul in Orissa supplementedthese modules with child and newborn health modules of theirown and Kerala included messages on non communicabledisease. Andhra Pradesh did not use these modules at all.
  53. 53.  Across the states, most ASHAs are receiving Rs. 500 to Rs.1000 per month with the highest being in Orissa followed byAssam. In West Bengal ASHA’s receive a fixed sum of Rs. 800 permonth. West Bengal has a fixed amount system which is wellimplemented. Rajasthan, a fixed sum of Rs. 950 of which at least Rs. 500 isdelivered in an assured manner. Rajasthan has a fixed plusperformance based payment system but with weakimplementation In Angul (Orissa) newborn visits are also incentivised andaccounts for the ASHA receiving the highest amounts.
  54. 54.  Assam, Orissa and Kerala have robust mechanisms ofaccounting and timely payment, but net receipts in Keralaare lower since payment is linked to RCH activities. Andhra, Bihar and Jharkhand have performance basedpayments which are poorly implemented - clearly co-relatingwith the lack of a management-support structure in these threestates. In Andhra Pradesh and Kerala, the problem is compounded byJSY being a poor yield opportunity as only BPL women getthe JSY package and anyway fertility rates are much lower. Mode of payment in Orissa, was the bank transfer, inAssam and Rajasthan a mix of all three- bank transfer,cheque and cash; in Jharkhand and AP it was a mix ofcash and cheque and it was cash predominantly in WestBengal, Kerala, Bihar.
  55. 55.  The highest expenditure of all eight states is in Assam amounting to Rs. 12,546. Orissa reports the second highest expenditures with about Rs. 10,689 per ASHA Kerala expanded its programme late, but still reports an expenditure of Rs. 10,689per ASHA. Rajasthan’s estimate of Rs. 7529 over three years may be a serious under-estimate-as the state government spends almost Rs. 500 per month per ASHA on fixedhonorarium. West Bengal’s Rs. 8300 represents the slower pace of training and the lack ofinvestment in support structures. Jharkhand has expenditure at Rs. 7348 per ASHA. Bihar’s expenditures of Rs. 3373 per ASHA is the lowest amongst the 8 statesexamined and it correlates with the weakest programme- where training is still totake off beyond the first round, and where there is no support structure in place.
  56. 56. All states have spent much less than allocated, reasonsare…. Inability or unwillingness to invest in managementand support structures at state, district and blocklevels. Poor pace of training and no doubt impacts thequality of training. Quality of political and administrative support theprogramme.
  57. 57.  VHSC have been formed in Rajasthan, Jharkhand, Assam, Andhra Pradeshand Orissa (referred to as Gaon Kalyan Samiti). In West Bengal, Kerala and Bihar the existing health and sanitationcommittees of the Gram Panchayats have been designated as the VHSCwith differing nomenclature and modifications in membership. Except in Kerala, Assam and Orissa, and to a limited extent in West Bengalthere is little systematic training of the VHSC members. The ASHA is a member of this committee and is expected to attend themeetings, mobilise community and raise issues relating to health in thevillage. Where established it is generally supportive of the ASHA andusually the ASHA has an important role in this. But in West Bengal such a relationship is established only in 48% of casesand in Jharkhand this is about 66%. The process has taken place in only about one fifth of the villages of WestBengal and half the villages of Andhra Pradesh.
  58. 58.  ASHA’s activities Optimising outcomes for time spent Areas for skill building Reaching the unreached Advocacy for health outcomes Advocacy for activism Role of ASHA Mentoring Groups Support to ASHAs Drug Kits Incentives Monitoring the ASHA programme Support, training and on the job monitoring Role, clarity and synergy Involvement of NGOs VHSC Building convergence and co-operation
  59. 59.  Till 2005 central funding to states was on normativebasis. During financial year 2005-06 basic PROGRAMMEIMPLEMENTATION PLANS (PIPs) prepared. Financial management group operationalised To oversee the release of funds. Monitoring of utilisation certificates & audit reports.
  60. 60.  Latest version of Tally ERP.9 for NRHMaccounting. Implemented concurrent audit system throughC.A firms. Open tender system. Ensuring timely submission of all FMRs onquarterly basis. Implementation of e-Banking.
  61. 61. 2005-06 2006-07 2007-08 2008-09% incraese in central transfers underNRHM26.24% 19.50% 26.05% 19.12%0.00%5.00%10.00%15.00%20.00%25.00%30.00%AxisTitle% incraese in central transfers under NRHM
  62. 62. 2005-06 2006-07 2007-08 2008-09% increase under state expenditure 23.41% 19.12% 13.37% 19.94%0.00%5.00%10.00%15.00%20.00%25.00%AxisTitle% increase under state expenditure
  63. 63. 2004-2005 2005-2006 2006-2007 2007-2008 2008-2009 2009-2010public expenditure on health aspercentage of GDP1.16% 1.23% 1.22% 1.23% 1.37% 1.45%0.00%0.20%0.40%0.60%0.80%1.00%1.20%1.40%1.60%AxisTitlepublic expenditure on health as percentage of GDP
  64. 64. 2005-2006 2006-2007 2007-2008 2008-20092009-2010(till31st Janexpenditure % 84.74% 83.18% 94.67% 94.38% 71.27%0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%90.00%100.00%AxisTitleexpenditure %
  65. 65. 0200000004000000060000000800000001E+091.2E+091.4E+091.6E+092005-06 2006-07 2007-08 2008-09PUBLIC EXPENDITURE 344461722 406788591 486852110 586813788PRIVATE EXPENDITURE 1150005214 1278405733 1426902392 1573935382EXTERNAL FLOW 21488597 22402612 26538964 37015853AxisTitleChart Title
  66. 66. 2005-2006 2006-2007 2007-2008 2008-2009PUBLIC EXPENDITURE IN TOTALHEALTH EXPENDITURE22.72% 23.82% 25.09% 26.70%20.00%21.00%22.00%23.00%24.00%25.00%26.00%27.00%AxisTitle PUBLIC EXPENDITURE IN TOTAL HEALTH EXPENDITURE
  67. 67.  619 Integrated District Health Action Plans in 2009-10. Achievements of District Health Action Plans:◦ Institutional structures.◦ Provision of untied resources for local action.◦ Identified areas for focused attention through facility andhousehold surveys.◦ Convergence with wide determinants.BASIS FOR DECENTRALIZED PLANNING…………
  68. 68.  Initial journey of NRHM-underfunded, underperforming, public health system. Positive programmatic approach-◦ Provision of resources◦ Expansion of public health infrastucture◦ Additional human resources◦ Creation of community structures◦ Decentralized◦ Non-verticalized framework
  69. 69.  State to send resource envelope to Districts-October 2009 District plans based on village/gram panchayats/ blockpanchayat samiti plans-December2009 First Draft PIP before State Health Mission- First weekJan 2010 Pre-appraisal meetings in Jan up to 15th 2010 Final NPCC meetings between Feb and 15th March 2010
  70. 70.  Clear action plan for backward districts as part of thePIP. Clear action plan for streamlining of procurement andlogistics. Clear action plan for operationalising HMIS up tofacility level. Capacity development of all institutions crafted underNRHM. Higher utilisation of financial resourses under NRHM Clear plan for human resources for health Clear action plan on training and skill developement
  71. 71.  Neo-natal Mortality Population stabilisation Malaria MDR-TB Making facilities family friendly-water, electricity, cleantoilets, lights ,security Vibrant VHSCs and RKSs NABH/ISO certification of government facilities
  72. 72.  Total 147069 SCs.• 84957 in SCs in Govt. Buildings.• 140942 SCs with one ANMs.• 6127 without ANMs.• 59068 SCs with 2nd ANMs. 18348 APHCs, PHCs, CHCs & other Sub Districtfacilities functional as 24X7 basis Total 23673 PHCs Total 4535 CHCs
  73. 73. 0100020003000400050006000700080009000100002005 2010 2011(31st march)No. of PHCs 24*7 hrs service 1263 8409 9107AxisTitleNo. of PHCs 24*7 hrs service
  74. 74. 05001000150020002500300035004000450050002005 2010 2011(31st march)No. of CHCs 24*7 hrs service 980 3829 4531AxisTitleNo. of CHCs 24*7 hrs service
  75. 75. 0100020003000400050006000PHYSICAL INFRASTRUCTURETAKEN UNDER COMPLETED
  76. 76.  Total 10356 SCs.• 4684 in SCs in Govt. Buildings.• 10205 SCs with one ANMs.• 151 without ANMs.• 7715 SCs with 2nd ANMs. 622 APHCs, PHCs, CHCs & other Sub District facilities functional as24X7 basis Total 909 PHCs Total 348 CHCs 348 CHCs functional as 24X7 basis compared to ZERO at the start ofNRHM. Of the 93 CHCs just 8 CHCs completed physical up-gradation according toIPHS.
  77. 77. 0204060801001201401601802005 2011(31st March)PHCs functioning as 24*7 hrs basis 86 179AxisTitlePHCs functioning as 24*7 hrs basis
  78. 78.  4.51 lakh village health and sanitation committees constituted. 1.87 cr village health and nutrition days organised. 8,25,000 ASHAs selected. 4.43 lakh joint account operationalised. 16687 PHCs have Rogi Kalyan Samiti out of total 23673 PHCs. Nearly all CHC, Sub Divisional and District hospitals have the RogiKalyan Samiti facility. District Health Mission under the Chairman Zila parishad/ District TribalCouncil and District Health Society under the District magistrate have beenconstituted nearly all the states/UTs. State health Mission under the Chief Minister and the state Health Societyunder the Chief Secretary have been constituted and meet regularly innearly all the states. Mission Steering Group under the Minister Health and Family Welfare atthe national level has been meeting regularly to take all decisions regardingNRHM.
  79. 79.  SRS DLHS-III IAP study (Rajasthan, UP,MP) Kaveri Gill’s study (AP, UP, Rajasthan, Bihar) PRC study (31districts) Citizen’s report Community Monitoring reports External Evaluation of JSY in 7 states. Performance audit of NRHM by CAG
  80. 80.  90.7% of villages have beneficiary under JananiSurakhsa Yojana (JSY). 72.6% of villages have sub-centres within 3 kms. 90.6% sub-centres with ANM. 57.8% of ANM living in quarter where available. 53.1% PHCs functioning on 24 hrs basis. 19.2% PHCs having AYUSH medical officer. 52% CHCs designated as FRU. 90.1% CHCs having 24hrs normal delivery service. 9.2% FRUs having blood storage facility.
  81. 81.  45.6% of ANM living in quarter whereavailable. 25.9% PHCs functioning on 24 hrs basis. 17.9% CHCs designated as FRU. 10% FRUs having blood storage facility.
  82. 82.  Positive contribution of ASHA but more training isnecessary. Facility improvement on an unprecedented scale. Slow pace of utilization of untied fund. Management structure needs further strengthening. HR challenges. Pleads for higher financial allocation.
  83. 83.  Decentralized management to be faster. JSY putting pressure on public system. System preparedness in adequate. Question ability of PRI to hold system accountable. More effforts at building capacity. Invest in ability and confidence.
  84. 84. INITIATIVES UNDER NRHM
  85. 85.  Popularity of the scheme. Increase in institutional deliveries. Quality issue at facilities. Low 48 hrs stay. Large case loads. Changing health seeking behaviuor. Timeliness of payments. Role of ASHA.
  86. 86. 0204060801001201401601802006-07 2007-08 2008-09 2009-10 2010-11Institutional deliveries(lakh) 119 143 148 162 168AxisTitleInstitutional deliveries(lakh)
  87. 87. 0.001.002.003.004.005.006.007.008.009.0010.002005-06 2006-07 2007-08 2008-09 2009-10 2010-11Institutional deliveries(lakh) 7.31 8.33 8.85 9.40 9.80 9.51AxisTitleInstitutional deliveries(lakh)
  88. 88.  Institutional deliveries increased from 47% (DLHS-III, 2007-08) to 72.9% (CES, 2009). Number of Pvt. institutions accredited under JSY12645 in India, 6691in High Focus- Non NE (10) , 53in High Focus- NE (8), 5841 in Non High Focus-Large (10) , 60 in Non High Focus- Small & UT(7). 66 Pvt. institute in WB accredited under JSY.
  89. 89. 0.0020.0040.0060.0080.00100.00120.0005-06 06-07 07- 08 08- 09 09-10 10-11No. of beneficiaries of JSY (in lakh) 7.03 28.49 67.36 83.32 93.42 108.04AxisTitleNo. of beneficiaries of JSY (in lakh)
  90. 90. 0.001.002.003.004.005.006.007.008.0005-06 06-07 07- 08 08- 09 09-10 10-11No. of beneficiaries of JSY (in lakh) 0.31 2.25 5.73 7.48 7.24 5.35AxisTitleNo. of beneficiaries of JSY (in lakh)
  91. 91.  263 Sick New Born Care unit (SNCU) establishedunder NRHM till 31ST March 2011. 1120 New Born Stabilisation Unit. 6403 New Born Care Corner (NBCC) .In West Bengal 6 Sick New Born Care unit (SNCU) establishedunder NRHM till 31ST March 2011. 100 New Born Stabilisation Unit. 105 New Born Care Corner (NBCC) .
  92. 92.  No. of districts implementing IMNCI–current(10) and planned(remaining eight).–No. of districts where training is saturated-One district(Purulia) Plan for HBNC, including incentives to ASHAs Visit of Newborn (during PNC ) incorporated in revised ASHAcomprehensive incentive package. 6th& 7thmodule training initiated in 2 districts.
  93. 93.  The new initiative of JSSK would provide completelyfree and cashless services to pregnant womenincluding normal deliveries and caesarean operationsand sick new born (up to 30 days after birth) inGovernment health institutions in both rural andurban areas. The new JSSK initiative is estimated tobenefit more than one crore pregnant women &newborns who access public health institutions everyyear in both urban & rural areas.
  94. 94.  Free and Cashless Delivery. Free C-Section. Free treatment of sick-new-born up to 30 days. Exemption from User Charges. Free Drugs and Consumables. Free Diagnostics. Free Diet during stay in the health institutions – 3days in caseof normal delivery and 7 days in case of caesarean section. Free Provision of Blood. Free Transport from Home to Health Institutions. Free Transport between facilities in case of referral as alsoDrop Back from Institutions to home after 48hrs stay.
  95. 95.  Financial management Programme management Data management Development of standards IPHS ISO 9001 NABH Capacity development for public health Accountability system
  96. 96.  Universal HIV screening included as an integrated component of ANCcheck up. VHNDs may be utilized for rapid blood test. Counselors at ICTCs also counsel the non-HIV pregnant women onnutrition, STI & birth spacing. Link workers & out reach workers to under take line listing of all pregnantwomen and prepare birth plan for non HIV women as well. ASHAs to be trained on the module “ Shaping our lives” by NACO. ASHAs to provide ANC & STI counselling, referral, pre and post natalcare for mother and new born, All 24*7 health facilities to be strengthened by ICTC service & PPTCTservice. Appropriate incentives to the service providers conducting deliveries in24*7 facilities.
  97. 97.  FP counselors may be trained on STI, PPTCT, ANC andnutrition. Infrastructure up-gradation . All HIV patients to be screened for TB and vice versa. SACS to take care of condom promotion in the highprevalence states. PD SACS & MD NRHM should meet quarterly.
  98. 98.  Macro Health Indicators-30 marks IMR-15 MARKS CBR-5 MARKS CDR-5 MARKS TFR-5 MARKS Physical capacity and delivery outcomes of rural servicescentre-40 marks 24*7 PHCs as a % of total no of PHCs-5 marks FRUs as % all CHCs, SDHs and DHs-5 marks Institutional deliveries-10 marks OPD/IPD-4 marks ABER-2 marks % of new smear positive patients registered-2 marks Sterilization performance-2 marks Physical infrastructure development-10 marks
  99. 99.  Outcomes in enhancements of human resources inthe health systems-20 marks ASHA programme-8 marks ANM, Nurses-4 marks Doctors,Specialists, AYUSH doctors-3 marks % utilisation of untied funds under the NRHM Mission flexiblepool-5 marks Outcomes in the area of Goverence-10 marks Institutional framework and decentralisation-4 marks Financial performance and state contribution-3 marks Innovation-3 marks
  100. 100.  Home based care component in the training programme ofASHA training. Basic provision for neo-natal at all facilities. Strengthening VHSC. Public Health specialist at all level; every state must have apublic health cadre. Indian Public Health Service. Universalization of basic protocols of care at all levels. NRHM needs further deepen decentralized management andaccountability by engaging NGOs for community monitoring.
  101. 101.  Every facility to develop its detailed institutional plan. Establishment of medical & nursing institutions indeficient states. Urban Health Mission. National Health Bill. Supervisory structures and job descriptions of everyworkers should well be established. Speed up the Village Health Registers. RSBY Malaria, TB & IDSP further intergraded into the NRHM. Speed up the accreditation process.
  102. 102. 1. Kishore J. National Health Programs Of India2. WHO. Meeting people’s health needs in rural areas- The progress so far the wayahead3. Maternal & Child Mortality and Total Fertility Rates Sample Registration System(SRS). Office of Registrar General, India 7th July 20114. National Vector Borne Disease Control programme5. National Programme For Control Of Blindness6. National Leprosy Elimination Programme7. RNTCP-2011 report8. National Rural Health Mission. Meeting people’s health needs in partnershipwith states, The journey so far (2005-2010).MOHFW.Govt. of India9. National Rural Health Mission State Wise Progress10. Programme Implementation Plan 2011-12. West Bengal State Health and FamilyWelfare samiti.11. ASHA –Which way forward…? Excecutive Summary-Evaluation of ASHAProgramme. NHSRC12. National Health Account13. Guidelines for Janani-Shishu Suraksha Karyakram. MOHFW. Govt. of India14. NRHM & NACP convergence. MOHFW. Govt. of India

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