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NATIONAL RURAL HEALTH
MISSION
1
Presented by-
Dr.Payal Dash
Post Graduate Trainee
CONTENTS
• Background and History
• Terminologies
• NRHM- Why NRHM?
• Illustrative Structure
Goals and Objectives
Strategies- Core and Supplimentary
Approaches
Outcomes
Critical Areas for Concerted Action
Finances
• Health Monitoring and Planning Committee under NRHM
PHC level
Block level
State level
District level
• Concrete Service Guarantees
• Coverage
2
CONTENTS
• Communisation-
VILLAGE HEALTH SANITATION & NUTRITION COMMITTEE
ACCREDITED SOCIAL HEALTH ACTIVIST (ASHA)
VILLAGE HEALTH NUTRITION DAY
ROGI KALYAN SAMITIES
• Components Of NHM-
RMNCH+A
Health Systems Strengthening
Non-Communicable Disease Control Programmes
Communicable Disease Control Programme
Infrastructure Maintenance
• NHUM
• Summary
• Conclusion
• References
3
PART 2
BACKGROUND
4
Adopted in 2000 3 out of 8 related
to Health
• MDG 4-: Reduce child
mortality
• MDG 5-Improve maternal
health
• MDG 6- Combat HIV/AIDS,
malaria and other diseases
MILLENIUM DEVELOPMENT GOALS
NRHM (NHM) Goals are largely aligned to the acheivement of MDGs.
BACKGROUND-
NATIONAL HEALTH MISSION
• The Union Cabinet vide its decision dated
1st May 2013 has approved the launch of
National Urban Health Mission
(NUHM) as a Sub-mission of an over-
arching National Health Mission (NHM),
with National Rural Health Mission
(NRHM) being the other Sub-mission of
National Health Mission.
National
Health Mission
NUHM NRHM
5
• The National Rural Health Mission (NRHM),
now under National Health Mission Launched -
12 April 2005 by Manmohan Singh
• To address the health needs of 18 states -
Empowered Action Group (EAG) States as well
as North Eastern States, Jammu and Kashmir and
Himachal Pradesh
• Bihar, Chhattisgarh, Jharkhand, Madhya
Pradesh, Orissa, Rajasthan, Uttaranchal and
Uttar Pradesh, referred to as the Empowered
Action Group (EAG) states
6
HISTORY
• As per the 12th Plan (2012-2017) document of the Planning Commission, the flagship programme of NRHM
will be strengthened under the umbrella of National Health Mission.
• The focus to include non-communicable diseases and expanding health coverage to urban areas.
• Launched by the government of India in 2013 subsuming the NRHM and NHUM
• Further extended in March 2018, to continue until March 2020.
7
TERMINOLOGIES
• Infant mortality rate : Infant mortality rate is the ratio of deaths under 1 year of age in a given
year to the total number of live births in the same year
• usually expressed as a rate per 1000 live births.
• universally accepted indicators of health status for whole population
• Maternal (puerperal) mortality rate : greatest proportion of deaths among women of
reproductive age in most of the developing world.
• number of maternal deaths during a given time period per 100,000 live births during the same time
period
8
NATIONAL RURAL HEALTH MISSION
• LAUNCHED-5th April, 2005 for a period of 7
years (2005-2012) and recently extended upto year
2017.
• adopts a synergic approach by relating health to
determinants of good health viz.of nutrition,
sanitation , hygiene and safe drinking water.
• It also brings the Indian system of medicine
(AYUSH) to mainstream.
9
NRHM-Illustrative Structure
10
Block
Level-
Hospital
Clusters of
GP-PHC
level
Gram Panchayat-
Sub Health centre
level
Vilage Level-ASHA
Institutional Setup
National
Mission Steering
Group-Union Minister
Empowered
Programme
committee-U.Secretary
State
State Health Mission-
CM
State Health Society
District
District Health Mission
District Health Society
11
12
STATE HEALTH MISSION STATE HEALTH SOCIETY
Chairperson Chief Minister Chief Secretary/Development Commissioner
Co-
Chairperson
Minister of Health and Family Welfare, State
Government
Development Commissioner
Convener Principal Secretary/Secretary (Family Welfare) Officer designated as Mission Director of State
Health Mission
Frequency of
Meetings
At least once in every six months At least once in every six month
Ordinary
Business
Providing health system oversight, consideration of
policy matters related with health sector (including
determinants of good health), review of progress in
implementation of NHM; inter-sectoral
coordination, advocacy measures required to
promote NHM visibility.
Approval / endorsement of Annual State Action Plan
for the NHM.
Consideration of proposals for institutional reforms
in the H&FW sector.
Review of implementation of the Annual Action
Plan.
Inter-sectoral co-ordination: all NHM related sectors
and beyond (e.g. administrative reforms across the
State).
Status of follow up action on decisions of the State
Health Mission.
Co-ordination with NGOs/Donors/other
agencies/organisations.
13
DISTICT HEALTH MISSION DISTRICT HEALTH SOCIETY
Chairperson Chairman, Zilla Parishad District Collector/DM/CEO Zilla Parishad
Co-
Chairperson
District Collector/DM CEO, Zilla Parishad
Convener Chief Medical Officer/CDMO/CMHO/Civil Surgeon Chief Medical Officer/CDMO/Civil Surgeon
Members MPs, MLAs, MLCs from the district, Chair-persons of
the Standing Committees of the Zilla Parishad,
Project Officer (DRDA), Chair-persons of the
Panchayat Samitis and Hospital Management
Societies, District Programme Managers for health,
PHED, ICDS, AYUSH, education, social welfare,
Panchayati Raj, State representative, representatives
of MNGO/SNGO, etc.
Project Officer (DRDA), District Programme
Managers for Health, AYUSH, Water and Sanitation
[under Total Sanitation Campaign (TSC)], DPMSU,
PHED, ICDS, education, social welfare, Panchayati
Raj, a State representative, Sub-Divisional Officer,
CHC In-charge; representatives of Medical
Association/MNGO/SNGO and Development
Partners
AIMS & OBJECTIVES
• Reduction in child and maternal mortality
• Universal access to food and nutrition, sanitation ,hygiene and public health care services
• Prevention and control of communicable and non-communicable diseases,endemic disease
• Access to integrated comprehensive primary health care.
• Population stabilization, gender and demographic balance.
• Revitalize local health traditions & mainstream AYUSH.
• Promotion of healthy life styles.
to provide accessible, affordable, accountable, effective and reliable primary health care, and bridging the gap in rural
health care through creation of a cadre of Accredited Social Health Activist (ASHA).
14
APPROACHES OF NRHM
Communitize
Innovation in
Human Resource
Management
Improved
management through
capacity
Flexible
Financing
Monitor,Progress
against
standards
15
Core
Strategies
Train and
Enhance
Panchaya
ti Raj
Promote
healthcare
through
ASHA
Health
Plan
Strengthe-
ning sub
centre
Strengthe
ning
existing
PHCs
16
17
Regulation for
Private sector
including the
informal Rural
Medical
Practitioners (RMP)
Mainstreaming
AYUSH
Promotion of
public private
partnerships for
achieving public
health goals.
Reorienting
medical education
to support rural
health issues
Effective and
visible risk pooling
and social health
insurance
SUPPLIMENTARY STRATEGIES
INITIATIVES UNDER NRHM
SELECTION OF ASHA
• resident of village
• woman(married/divorced/widow)
• 8th class
• Leadership qualities
• 1 ASHA for 1000 population
Rogi Kalyan Samiti
• members act as trustees
• 31,763 Rogi Kalyan Samities
(RKS) have been set up
untied grants to sub-centres
• equipped with blood pressure
measuring equipment,
haemoglobin (Hb) measuring
equipment,stethoscope, weighing
machine etc.
• This has facilitated provision of
quality antenatal care and other
health care services
18
Village Health Sanitation and
Nutrition Committee
• reflects the aspirations of the
local community
• especially the poor
households and children.
• 2015-5.01 lakh VHSNCs
have been set up
Janani Suraksha Yojana
• to reduce maternal mortality
among pregnant women
• cash assistance is provided
• 8.55 crore women have
benefited
Janani Shishu Suraksha
Karyakarm
• Launched on 1st June, 2011 ,
• JSSK entitles all pregnant
women delivering in public
health institutions to
absolutely free and no
expense delivery, including
caesarean section.
National Mobile Medical
Units
• 333 out of 672 districts -
2127 MMU
National Ambulance
Services
• 16,000 basic and
emergency patient
transport vehicles
• 6.290 vehicles have been
empanelled to transport
patients
Web Enabled Mother and
Child Tracking System
• track every pregnant
woman, infant and child
upto the age of three years
by name
• ensuring delivery of
services
19
New Initiatives under NRHM
• 1. Home delivery of contraceptives (condoms, oral contraceptive pills, emergency contraceptive pills) by ASHA
• SCHEME:-
• Implemented across all districts of the country.
• ASHA would do home delivery of the contraceptives at the doorstep
• The free supply of contraceptives at PHC and Sub-Centre level would stand withdrawn
• The free supply of contraceptives at CHCs, Sub-Divisional and District level hospitals shall continue as before.
• State- 25% and District -10% of the total stock of contraceptives as buffer
• ASHA shall collect the consignment/ replenish her stock every month
• No transport cost
“Government of India supply,”
“For home delivery by ASHA,”
“Re 1/- for a pack of 3 condoms”
“Re 1/- for a cycle of OCP”
“Re 2/- for a pack of one tablet of ECP”
20
• STATE:
• Designate a nodal person to manage and monitor the scheme.
• Orient the CMOs of the districts
• CMOs of the pilot districts would further orient MOs
• Develop communication material (banners, posters and leaflets etc.)
• PHC I/C /ANM : MO I/C of PHC :
• Certify ANMs, list of eligible couples and make corrections, if necessary.
• Ensure all ASHAs collect supply from designated place. Verify ASHAs’ performance on a monthly basis.
• Screen the couples for eligibility for OCPs
• ASHA would:
• Inform / counsel all the eligible couples in her area regarding availability of various contraceptive choices.
• Get the clients screened by the MO/ ANM before selling OCPs to them.
• Prepare and update list of eligible couples in her village and deliver contraceptives at door step of the beneficiaries.
• Regularly collect stock from Block/ CHC/ PHC and charge the beneficiary at the approved rate, as an incentive for her
efforts. 21
22
• 2. Conducting District Level Household Survey SCHEME:-
• initiated in 1997
• DLHS-1 -1998-99 and DLHS-2 in 2002-04.
23
24
Health Monitoring and Planning Committee under NRHM
PHC level
Block level
State level
District level
PHC Health Monitoring and Planning Committee
• Role and Responsibilities of the Committee
• Consolidation of the village health plans and charting out the annual
health action plan in order of priority.
• Presentation of the progress made at the village level, achievements,
actions taken and difficulties faced followed by discussion
25
• access to health facilities in the area of that particular PHC. The
discussion could include:
o Sharing of reports of Village Health Committees
o Reports from ANM about the coverage of health facilities
o Any efforts done at the village level to improve the access to health
care services
o Record and analysis of neonatal and maternal deaths.
o Any epidemic occurring in the area and preventive actions taken.
26
Block Health Monitoring and Planning Committee
• Role and Responsibilities:
• Consolidation of the PHC level health plans and charting out of the annual health action plan for the
block.
• Review of the progress made at the PHC levels, difficulties faced, actions taken and achievements
made, followed by discussion
• Analysis of records on neonatal and maternal deaths; and the status of other indicators.
• Monitoring of the physical resources
• Coordinate with local CBOs and NGOs to improve the health services in the block
27
District Health Monitoring and Planning Committee
• Role and Responsibility
• Discussion on the reports of the PHC health committees
• Financial reporting and solving blockages in flow of resources if any
• Infrastructure, medicine and health personnel related information and necessary steps required to correct the
discrepancies.
• Progress report of the PHCs emphasising the information on referrals utilisation of the services, quality of
care etc.
• Contribute to development of the District Health Plan
• Ensuring proper functioning of the Hospital Management Committees.
28
State Health Monitoring and Planning Committee
• Role and Responsibilities
• To discuss the programmatic and policy issues related to access to health care and to suggest
necessary changes.
• This committee will review and contribute to the development of the State health plan.
• Key issues arising from various District health committees.
• Institute a health rights redressal mechanism
• Operationalising and assessing the progress made in implementing the recommendations of the
NHRC.
29
Concrete Service Guarantees that NRHM will
provide:
• Skilled attendance at all Births
• Emergency Obstetric care
• Basic neonatal care for new born
• Full coverage of services related to childhood diseases / health conditions
• Full coverage of services related to maternal diseases / health conditions
• Full coverage of services related to low vision and blindness due to refractive errors and
cataract.
• Full coverage for curative and restorative services related to leprosy
• Full coverage of diagnostic and treatment services for tuberculosis
• Full coverage of preventive, diagnostic and treatment services for vector borne diseases
30
Coverage
• The Mission has the following coverage:
• Population coverage - 740 million
• Households - 148 million (approx.)
• Birth Rate in Rural Areas - 26.6, nearly 20 million births
• Sub Health Centres - 1,75,000 ( on population, distance and work load norm)
• P H Cs - 27,000 (single MO, 2 MO, 1 AYUSH)
• C H Cs - 7,000 (every Block)
• Sub Divisional/Taluk Hospitals - 1,800
• District Hospital - 600
• ANMs - 3.50 lakhs
• Staff Nurses at PHC - 81,000
31
FINANCE
• Public health expenditure -1% of the GDP
• The above target however cannot be achieved unless the states also step up
• major burden of the additional expenditure- Central Government
• It would be the aim of the NRHM to increase the share of central and State Governments on health care
from the current 20 – 80 to 40 – 60 sharing in the long run.
• X Plan-100 % to states
• XI Plan- Central-85% States -15%
• XII Plan-Central -75% States -25%
32
• Financial Resource
Assessment -by National
Commission on Macro
Economics and Health
• Non-recurring investment of
Rs. 33811 crores
• Recurring investment of Rs.
41006 crores
• 5-7 Years
33
COMPONENTS OF NHM
1.Reproductive, Maternal, Newborn, Child and Adolescent Health
Ministry of Health & Family Welfare launched (RMNCH+A) to influence the key interventions for reducing maternal and child
morbidity and mortality.
34
RMNCH+A
RMNCH
PLUS
Inclusion of adolescence
Linking maternal and child
health to reproductive
health
Linking home and
community-based
services to facility-based
services
Ensuring linkages,
referrals, and counter-
referrals
35
RMNCH+A
Adolescent
Health
Rashtriya
Kishor
Swasthya
Karyakram
ADOLESCENT
FRIENDLY HEALTH
CLINICS
WEEKLY IRON
FOLIC ACID
SUPPLEMENTATION
MENSTRUAL
HYGIENE
SCHEME(MHS)
Child
Health
Maternal
Health
Family
Planning
Immunizatio
n
Aspirational
District Program
CHILD HEALTH
National Deworming Day RBSK
INTENSIFIED DIARRHOEA
CONTROL FORTNIGHT
MAA (MOTHERS'
ABSOLUTE AFFECTION)
PROGRAMME
PROMOTION OF
BREASTFEEDING
SOCIAL AWARENESS AND
ACTIONS TO NEUTRALIZE
PNEUMONIA
SUCCESSFULLY (SAANS)
36
MATERNAL HEALTH
JANANI-SHISHU
SURAKSHA
KARYAKRAM
JANANI SURAKSHA
YOJANA
DAKSHATA
IMPLEMENTATION
PACKAGE
PRADHAN MANTRI
SURAKSHIT
MATRITVA ABHIYAN
LABOUR ROOM &
QUALITY
IMPROVEMENT
INITIATIVE
Rashtriya Kishor Swasthya Karyakram (RKSK)
In order to ensure holistic development of adolescent population, the
Ministry of Health and Family Welfare launched Rashtriya Kishor
Swasthya Karyakram (RKSK) on 7th January 2014
• to reach out to 253 million adolescents - male and female, rural and
urban, married and unmarried, in and out-of-school adolescents with
special focus on marginalized and undeserved groups .
37
38
39
ADOLESCENT FRIENDLY HEALTH CLINICS (AFHCS)
• This approach was initiated in 2006
• The key ‘friendly’ component of AFHC mandates facility-based clinical and counselling services for
adolescents, which are:
• Equitable—services are provided to all adolescents who need them.
• Accessible—ready accessibility to AFHCs by adolescents
• Acceptable—health providers meet the expectation of adolescents who use the services.
• Appropriate—the required care is provided and any unnecessary and harmful practices are avoided.
• Effective—healthcare produces positive change in the status of the adolescents; services are efficient and
have high quality.
40
WEEKLY IRON FOLIC ACID SUPPLEMENTATION (WIFS)
• i. Objective To reduce the prevalence and severity of anaemia in adolescent population (10-19 years).
• ii. Target groups
• School going adolescent girls and boys in 6th to 12th class enrolled in government/government aided/municipal
schools.
• Out of school adolescent girls.
• iii. Intervention
• Administration of supervised Weekly Iron-folic Acid Supplements of 100mg elemental iron and 500ug Folic acid
using a fixed day approach.
• Screening of target groups for moderate/severe anaemia and referring these cases to an appropriate health facility.
• Biannual de-worming (Albendazole 400mg), six months apart, for control of helminthic infestation.
• Information and counselling for improving dietary intake and for taking actions for prevention of intestinal worm
infestation.
• iv. Current Status:
• The programme has been rolled out in all States/UTs. The programme covers 11.2 crore beneficiaries including 8.4
crore in-school and 2.8 crore out of school beneficiaries.
41
• MENSTRUAL HYGIENE SCHEME
• The major objectives of the scheme are:
• To increase awareness among adolescent girls on Menstrual Hygiene
• To increase access to and use of high quality sanitary napkins to adolescent girls in rural areas.
• To ensure safe disposal of Sanitary Napkins in an environmentally friendly manner.
• 2011- 107 selected districts in 17 States wherein a pack of six sanitary napkins called “Freedays” was provided to rural adolescent girls
for Rs. 6.
• 2014 onwards, funds are now being provided to States/UTs under National Health Mission for decentralized procurement of sanitary
napkins packs for provision to rural adolescent girls at a subsidized rate of Rs 6 for a pack of 6 napkins.
• The ASHA will continue to be responsible for distribution, receiving an incentive @ Rs 1 per pack sold and a free pack of napkins every
month for her own personal use.
• IEC material has been developed around MHS, using a 360 degree approach
42
CHILD HEALTH:-
1.NATIONAL DEWORMING DAY
43
2.RASHTRIYA BAL SWASTHYA KARYAKRAM(RBSK)
• According to March of Dimes (2006), out of every 100 babies born in this country
annually, 6 to 7 have a birth defect. This would translate to around 17 lakhs birth
defects annually in the country and accounts for 9.6% of all the newborn deaths
• cover 4 ‘D’s viz. Defects at birth, Deficiencies, Diseases, Development delays
including disability.
44
45
46
47
48
49
50
51
JANANI SURAKSHA YOJANA
• Janani Suraksha Yojana (JSY) is a safe
motherhood intervention
• objective - reducing maternal and neo-
natal mortality by promoting institutional
delivery among the poor pregnant
women.
• Launched on 12th April 2005,
• JSY is a 100 % centrally sponsored
scheme and it integrates cash
assistancewith delivery and post-delivery
care.
52
53
DAKSHATA IMPLEMENTATION PROGRAM
54
PRADHAN MANTRI SURAKSHIT MATRITVA
ABHIYAN
• Pradhan Mantri Surakshit Matritva
Abhiyan (PMSMA) was launched to
provide fixed-day assured,
comprehensive and quality antenatal
care universally to all pregnant
women (in 2nd and 3rd trimester) on
the 9th of every month.
55
1. Outline the implementation approach for operationalizing PMSMA.
2. Outline the contours for private sector engagement for PMSMA
56
LABOUR ROOM & QUALITY IMPROVEMENT
INITIATIVE
• LaQshyaon 11th December 2017 with following
objectives:
• Reduce maternal and newborn morbidity and
mortality
• Improve quality of care during delivery and
immediate post-partum period
• Enhance satisfaction of beneficiaries, positive birthing
experience and provide Respectful Maternity Care
(RMC) to all pregnant women attending public health
facilities.
• Following facilities are being taken under LaQshya
initiative on priority:
• All Government Medical College hospitals.
• All District Hospitals & equivalent healthy facilities.
• All designated high case load CHCs with over 100
deliveries/60 (per month) in hills and desert areas.
57
2. HEALTH SYSTEMS STRENGTHENING
A. Adoption of the Indian Public Health Standards
• minimum inputs required to ensure quality of care, in terms of infrastructure,
equipment, skilled human resources, and supplies.
• Assurance to the states of financing the gaps between available levels of these
inputs and the levels needed to achieve the IPHS norms.
B.Quality standards
clinical protocols, administrative and management processes and for support
services.
58
C.Skill gaps and Standard Treatment Protocols-
• Skilled Birth Attendance (SBA)
"an accredited health professional - such as midwife, doctor or nurse - who has been
educated and trained to achieve proficiency in the skills needed to manage normal
(uncomplicated) pregnancies, childbirth and immediate postnatal period and in the
identification, management and referral of complications in women and newborns."
• Navjat Shishu Suraksha Karyakram (NSSK)
• Training Program
• To reduce perinatal asphyxia (1/5th of all neonatal deaths)
59
• IMNCI packages for ANMs-Implementation of Integrated Management of Neonatal and
Childhood Illness
60
Keeping the child warm.
o Initiation of breastfeeding immediately after birth and counseling for exclusive
breastfeeding and non-use
of pre lacteal feeds.
o Cord, skin and eye care.
o Recognition of illness in newborn and management and/or referral).
o Immunization
o Home visits in the postnatal period
Care of
Newborns and
Young Infants
(infants under
2 months)
Care of Infants
(2 months to 5
years)
Management of diarrhoea, acute respiratory infections (pneumonia) malaria,
measles, acute ear infection,
malnutrition and anemia.
o Recognition of illness and at risk conditions and management/referral)
o Prevention and management of Iron and Vitamin A deficiency.
o Counseling on feeding for all children below 2 years
o Counseling on feeding for malnourished children between 2 to 5 years.
o Immunization
Home Based Newborn Care (HBNC) for ASHAs
61
• D. Hospital Management Societies (RKS) and untied funds
• The mandatory creation of a hospital management society (Rogi Kalyan
Samiti) and empowering this body with untied funds has allowed public
participation also contributed to improved quality of care.
• E.Quality Improvement Programmes
• Supports initiatives for building quality management systems.
• Till date, 82 facilities have been certified by ISO, nine facilities have been
certified by NABH and 446 facilities are under process of certification.
62
63
Health Systems
Strengthening
FREE DRUGS &
DIAGNOSTICS
SERVICE INITIATIVE
Free Drug Service
Free Diagnosis
Service
ERS/PATIENT
TRANSPORT
SERVICE
National
Ambulance Service
(NAS)
HUMAN RESOURCE
MOBILE MEDICAL
UNIT
COMPREHENSIVE
PRIMARY HEALTH
CARE
TRIBAL HEALTH
BLOOD SERVICES
AND BLOOD
DISORDERS
DISTRICT HOSPITAL
STRENGTHENING
National Ambulance Service (NAS)
• One of the achievement of NHM is the patient transport ambulances operating under Dial 108/102 ambulance
services.
• Now 35 States/UTs have the facility
• Dial 108 is predominantly an emergency response system, primarily designed to attend to patients of critical
care, trauma and accident victims etc.
• Dial 102 services essentially consist of basic patient transport aimed to cater the needs of pregnant women
and children though other categories are also taking benefit and are not excluded.
64
• Implementation of National Ambulance Service (NAS) guidelines has been made
mandatory for all the ambulances whose Operational Cost is supported under NHM.
• 10993 ambulances are being supported under 108 emergency transport systems
including new.
• 9955 ambulances are operating as 102 patient transport including new ambulances.
• 5126 empanelled vehicles are also being used in some States to provide transport to
pregnant women and children e.g. Janani express in MP, Odisha, Mamta Vahan in
Jharkhand, Nishchay Yan Prakalpa in West Bengal and Khushiyo ki Sawari in
Uttarakhand.
65
NON COMMUNICABLE DISEASE CONRTROLPROGRAMME
66
NATIONAL ORAL HEALTH PROGRAM
• Objectives:-
• To improve the determinants of oral health
• To reduce morbidity from oral diseases
• To integrate oral health promotion and preventive services with general
health care system
• To encourage Promotion of Public Private Partnerships (PPP) model for
achieving better oral health.
67
National Tobacco Control Programme
• launched 2007-08 during the 11th Five-Year-Plan, with the aim to
• (i) create awareness about the harmful effects of tobacco consumption,
• (ii) reduce the production and supply of tobacco products,
• (iii) ensure effective implementation of the provisions under “The
Cigarettes and Other Tobacco Products (Prohibition of Advertisement and
Regulation of Trade and Commerce, Production, Supply and Distribution)
Act, 2003” (COTPA)
• (iv) help the people quit tobacco use
• (v) facilitate implementation of strategies for prevention and control of
tobacco advocated by WHO Framework Convention of Tobacco Control .
68
COMMUNICABLE DISEASE CONTROL PROGRAMME
69
70
COMMUNISATION
VILLAGE HEALTH
SANITATION &
NUTRITION
ASHA
VILLAGE HEALTH
NUTRITION DAY
ROGI KALYAN
SAMITI
71
Components Of Village Health Sanitation and Nutrition
Committee
72
2. ASHA
• Anganwadi Workers (AWWs) under the Integrated Child Development Scheme (ICDS) are
engaged in organizing supplementary nutrition programmes and other supportive activities.
• The very nature of her job responsibilities (with emphasis on supplementary feeding and pre
school education) does not allow her to take up the responsibility of a change agent on
health in a village.
• Thus a new band of community based functionaries, named as Accredited Social Health
Activist (ASHA) is proposed to fill this void.
• first port of call for any health related demands of deprived sections
73
• Roles and Responsibilties
• Create Awareness
• Counsel women
• mobilize the community and facilitate them in accessing health
• work with the Village Health & Sanitation Committee of the Gram Panchayat
• escort/accompany pregnant women
• provide primary medical care for minor ailments such as diarrhoea, fevers,and first
aid for minor injuries.
• inform about the births and deaths
• She will promote construction of household toilets under Total Sanitation
Campaign.
74
• SELECTION OF ASHA
• The general norm will be ‘One ASHA per 1000 population’.
• In tribal, hilly, desert areas the norm could be relaxed to one ASHA per
habitation, dependant on workload etc.
• The States will also need to work out the district and block-wise
coverage/phasing for selection of ASHAs.
• Criteria for Selection
• ASHA must be primarily a woman resident of the village -
• ‘Married/Widow/Divorced’ and preferably in the age group of 25 to 45 yrs.
• ASHA should have effective communication skills, leadership qualities and be
able to reach out to the community.
• She should be a literate woman with formal education upto Eighth Class.
75
• ROLE AND INTEGRATION WITH ANGANWADI
• Anganwadi Worker (AWW) will Guide ASHA in performing following activities:
• Organizing Health Day once/twice a month.
• AWWs and ANMs will act as a resource persons for the training of ASHA.
• IEC activity through display of posters, folk dances etc. on these days can be undertaken to sensitize the beneficiaries on
health related issues.
• Anganwadi worker will be depot holder for drug kits and will be issuing it to ASHA.
• AWW will update the list of eligible couples and also the children less than one year of age in the village with the help of
ASHA.
• ASHA will support the AWW in mobilizing pregnant and lactating women and infants for nutrition supplement.
• She would also take initiative for bringing the beneficiaries from the village on specific days of immunization, health
checkups / health days etc. to Anganwadi Centres.
76
• ROLE AND INTEGRATION WITH ANM
• Auxiliary Nurse Midwife (ANM) will Guide ASHA in performing following activities:
• She will hold weekly / fortnightly meeting with ASHA and discuss the activities undertaken during the week /
fortnight.
• AWWs and ANMs will act as a resource person for the training of ASHA.
• ANMs will inform ASHA regarding date and time of the outreach session and will also guide her for bringing the
beneficiary to the outreach session.
• ANM will participate & guide in organizing the Health Days at AWC.
ANMs will orient ASHA on the dose schedule and side affects of oral pills.
• ANMs will educate ASHA on danger signs of pregnancy and labour
• ANMs will inform ASHA on date, time and place for initial and periodic training schedule.
77
• FUND-FLOW MECHANISM FOR ASHA
• It is proposed that funds for making the payments to ASHA may flow from Centre to
States through SCOVA mechanism and from State SCOVAs to District Health Societies.
Standing Committee of Voluntary Agencies (SCOVA) in 1986.
• SCOVA functions to promote the following objectives:-
• To provide a feedback on implementation of process/programmes of the Department of
Pension & Pensioners’ Welfare
• To discuss and critically examine the policy initiatives and
• To mobilize voluntary efforts to supplement the Government action
78
(a) The compensation to ASHA based on measurable outputs would be given under the
overall supervision and control by Panchayat. For this purpose a revolving fund would be
kept at Panchayat. The guidelines for such compensation would be provided by the District
Health Mission, led by the Zila Parishad.
(b) For the compensation money under the various national programmes / Schemes, the
programmes have in-built provisions for the payment of compensation. These
compensations will be made in accordance with the programme guidelines.
(c) ASHA would be entitled for DA for attending training programmes. She would
be given the amount at the venue itself.
79
BUDGET & FINANCIAL MECHANISMS FOR TRAINING ASHAs
80
81
82
4.ROGI KALYAN SAMITTI
• Rogi Kalyan Samities (RKSs) / Hospital Management Committees
• 2005 under the National Rural Health Mission (NRHM) as a forum
• to improve the functioning and service provision in public health
facilities, increase participation and enhance accountability.
• 31,763 Rogi Kalyan Samities (RKS) have been set up
83
OBJECTIVES OF RKS
84
Serve as a consultative
body to enable active
citizen participation
Ensure that essentially
no user fees or charges
are levied for treatment
Decide on the user fee
structure for outpatient
and inpatient treatment
Ensure that those
patients who are Below
Poverty Line, vulnerable
and marginalized groups
do not incur any
financial hardship for
their treatment
85
Ensure provision of all
non-clinical services
and processes such as
provisioning of safe
drinking water, diet,
litter free premises,
clean toilets,
Ensure availability of
essential drugs and
diagnostics
Promote a culture of
user-friendly
behaviour amongst
service providers
Operationalize a
Grievance Redressal
Mechanism
• Source of RKS Funds
• 1. Each RKS will be provided with Untied funds under NHM by State Health
Society/District Health Society based on the level of facility, its case load, fund
utilization capacity and availability of previous year funds.
• 2. User fees as determined by RKS for hospital services E.g. X-ray, Ultrasound scanning,
laboratory services, private wards etc.Levying of user charges will depend on
localcircumstances and decided by the GB, and implemented by the EC.
• 3. Funds can also be raised from donations, grants from government and loans
fromfinancial institutions (with permission of State Government).
86
MAINSTREAMING AYUSH-Ayurveda Yoga
& Naturopathy, Unani, Siddha and
Homoeopathy
• STRATEGIES
• Integrate in health care delivery system including National Programmes.
• Encourage and facilitate in setting up of specialty centres and ISM
clinics.
• Facilitate and Strengthen Quality Control Laboratory.
• Strengthening the Drug Standardization and Research activities on
AYUSH.
• Develop Advocacy for AYUSH.
• Establish Sectoral linkages for AYUSH activities
87
Activities
Improving the
availability of
AYUSH
treatment
Integration of
AYUSH with
ASHA.
Drug
Management
Strengthening
the Quality
Control
Laboratory
Development
of Herbariums
and crude
drug
museums:
Strengthening
of the State
and District
Management
• AYUSH services in 314 CHC / Block PHC - contractual
AYUSH Doctors.
• Appointment of 200 paramedics and Data assistant
• Strengthening of AYUSH Dispensaries
• Making provision for AYUSH Drugs at all levels.
• Establishment of specialized therapy centers in District
Head Quarter Hospitals & 3 Medical Colleges.
• AYUSH doctors to be involved in all National Health Care
programmes,
• Training of AYUSH doctors in Primary Health Care and
NDCP.
• Yoga Therapy Centre will be opened in district
• Headquarters Hospitals to provide Yogic therapy
• Block level School Health Programmes to be conducted
twice in a year 88
• Integration of AYUSH with ASHA.
• Update Training module for ASHA and ANMs
• Training & capacity building - Director, SIHFW, Bhubaneswar
• Drug kit - one AYUSH preparation in the form of iron supplement.
• Other drugs - treatment of common diseases,communicable diseases ,maternal and child
health as well as improving quality of life could be included subsequently.
• Drug Management:
• Priority will be given to manufacture drugs in Govt. Sector Pharmacies as per their capacity. In
case of any surplus funds, drugs will be procured from the market observing all financial
formalities of the Govt.
• Provision of Rs. 25,000/- to supply drugs per AYUSH dispensary has been projected as per
NRHM norm.
• Provisions of medicines for District AYUSH wings and Specialty Therapy Centres proposed to be
operated in the State. 89
• Strengthening the Quality Control Laboratory
• Drug regulation and enforcement unit has to be established in the state.
• The drug regulatory mechanism to be strengthened at the state level
• The existing State DrugTesting and Research Laboratory (ISM) at Bhubaneswar shall also be modernised and
strengthened for the purpose.
• Strengthening the Drug Standardisation and Research Activities on AYUSH:
• Tto evaluate the chemical, pharmacological and clinical efficacy of the plant drugs.
• The pharmacologically viable drugs will be screened clinically under WHO guideline to
establish the therapeutic activity
90
• Development of Herbariums and crude drug museums:
• Herbarium will be developed in collaboration with the Forest Dept. in 15 selected Districts of the State.
• The existing Herbal gardens strengthened with necessary infrastructure.
• One State Herbarium at DTL, Bhubaneswar shall be developed.
• Strengthening of the State and District Management System of AYUSH:
• It is proposed to create necessary Managerial post in the State and District level for
effective supervision and implementation of different activities.
• Necessary vehicles with supporting manpower has also been proposed to strengthen the
supervisory
91
92
• Kilkari:
• Interactive Voice Response (IVR) based mobile service that delivers time- sensitive audio
• messages (voice call) about pregnancy and child health directly to the mobile phones of
pregnant women, mothers of young children and their families.
• The service covers the critical time period- where the most maternal/ infant deaths occur from
the 4th month of pregnancy until the child is one year old. Families which subscribe to the
service receive one pre-recorded system generated call per week.
• Launch of Nationwide anti-TB drug resistance survey:
• Drug resistance survey for 13 anti- tuberculosis drugs was launched to estimate the burden of MOR-TB
within the community.
93
Kala- azar elimination plan
• The National Health Policy-2002 set the goal of Kala-azar elimination in India by the year
2010 which was revised to 2015.
• Objective-To reduce the annual incidence of Kala-azar to less than one per 10 000
population at block PHC level by the end of 2015 by:
• reducing Kala-azar in the vulnerable, poor and unreached populations in endemic areas;
• reducing case-fatality rates from Kala-azar to negligible level;
• reducing cases of PKDL to interrupt transmission of Kala-azar; and
• preventing the emergence of Kala-azar and HIV/TB co-infections in endemic areas.
94
S.no Targets
1 Reduce IMR to 30/1000 live births by 2012
2 Reduce MMR to 100/1,00,000 live births by 2012
3 Reduce TFR to 2.1
4 Reduce annual prevalence and mortality from Tuberculosis by half
5 Reduce prevalence rate of Leprosy to <1/10000 population in all districts.
6 Annual Malaria Incidence to be <1/1000
7 Less than 1 per cent microfilaria prevalence in all districts
8 Kala-Azar Elimination by 2015, <1 case per 10000 population in all blocks
95
TARGETS OF NRHM
96
https://timesofindia.indiatimes.com/india/india-improves-infant-mortality-rate-but-gains-slowing-
down/articleshow/87266537.cms
• Maternal Mortality Ratio (MMR) of India has reduced from 130 per 100,000 live births in SRS 2014-16 to 122 in SRS 2015-17 and to
113 per 100,000 live births in SRS 2016-18.
97
98
West Bengal, Maharashtra were
found to have the lowest Total
Fertility Rate in India
https://www.indiatoday.in/india/story/india-fertilitaty-rate-declines-replacement-level-meaning-nfhs-survey-
99
• The countries that contributed most
to the global drop between 2019
and 2020 were India (41%),
Indonesia(14%), the Philippines
(12%) and China (8%); these and 12
other countries accounted for 93%
of the total global drop of 1.3 million
100
https://www.who.int/publications/i/item/9789240037
021
https://www.nhp.gov.in/wo
rld-leprosy-day-2021_pg
101
102
• The eastern state of Odisha, which carried more than 40% of the country’s malaria burden,
reported a 90% decline in malaria cases and 89% decline in malaria deaths in 2020 as
compared to 2015.
• The malaria-endemic North-Eastern region and the states of Jharkhand, Chhattisgarh, and
Madhya Pradesh also registered similar reductions in cases and deaths.
• The WHO’s World Malaria Report 2020 highlighted India’s gains in the path to elimination.
India recorded impressive 60% reduction in reported cases compared with 2017, and a 46%
reduction in cases compared with 2018, which built momentum to reach the goal of zero
indigenous malaria cases by 2027.
https://theprint.in/health/poor-campaign-aversion-to-medicines-why-india-is-unlikely-to-eradicate-filariasis-by-2021/542340/
103
104
The disease incidence has been declining steadily, from 13869 in 2013 to 3145 in 2019.
Of the cases reported in 2019, nearly 60 per cent cases were from four States alone.
These included Bihar with maximum number (2416 cases), followed by Jharkhand (541),
Uttar Pradesh (97) and West Bengal (87)7.
In addition, 821 cases of post-kala-azar dermal leishmaniasis (PKDL) were reported and
these were considered as the main cause of transmission in the community
Thakur CP, Thakur M. Accelerating kala-azar elimination in India. Indian J Med Res. 2020;152(6):538-540.
REFERENCES
• https://www.nhm.gov.in/WriteReadData/l892s/nrhm-framework-
latest.pdf
• https://nhm.gov.in/images/pdf/communitisation/task-group-
reports/guidelines-on-asha.pdf
• https://www.nhm.gov.in/New_Updates_2018/communization/RKS/G
uidelines_for_Rogi_Kalyan_Samities_in_Public_Health_Facilities.pdf
• http://nhm.gov.in/images/pdf/programmes/RKSK/RKSK_Implementat
ion_Guideline_05.03.2015.pdf
• http://www.nhm.gov.in/MAA/Operational_Guidelines.pdf
• https://www.ayush.gov.in/docs/ayurved-guidlines.pdf
105
106

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NRHM Overview and Initiatives

  • 1. NATIONAL RURAL HEALTH MISSION 1 Presented by- Dr.Payal Dash Post Graduate Trainee
  • 2. CONTENTS • Background and History • Terminologies • NRHM- Why NRHM? • Illustrative Structure Goals and Objectives Strategies- Core and Supplimentary Approaches Outcomes Critical Areas for Concerted Action Finances • Health Monitoring and Planning Committee under NRHM PHC level Block level State level District level • Concrete Service Guarantees • Coverage 2
  • 3. CONTENTS • Communisation- VILLAGE HEALTH SANITATION & NUTRITION COMMITTEE ACCREDITED SOCIAL HEALTH ACTIVIST (ASHA) VILLAGE HEALTH NUTRITION DAY ROGI KALYAN SAMITIES • Components Of NHM- RMNCH+A Health Systems Strengthening Non-Communicable Disease Control Programmes Communicable Disease Control Programme Infrastructure Maintenance • NHUM • Summary • Conclusion • References 3 PART 2
  • 4. BACKGROUND 4 Adopted in 2000 3 out of 8 related to Health • MDG 4-: Reduce child mortality • MDG 5-Improve maternal health • MDG 6- Combat HIV/AIDS, malaria and other diseases MILLENIUM DEVELOPMENT GOALS NRHM (NHM) Goals are largely aligned to the acheivement of MDGs.
  • 5. BACKGROUND- NATIONAL HEALTH MISSION • The Union Cabinet vide its decision dated 1st May 2013 has approved the launch of National Urban Health Mission (NUHM) as a Sub-mission of an over- arching National Health Mission (NHM), with National Rural Health Mission (NRHM) being the other Sub-mission of National Health Mission. National Health Mission NUHM NRHM 5
  • 6. • The National Rural Health Mission (NRHM), now under National Health Mission Launched - 12 April 2005 by Manmohan Singh • To address the health needs of 18 states - Empowered Action Group (EAG) States as well as North Eastern States, Jammu and Kashmir and Himachal Pradesh • Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttaranchal and Uttar Pradesh, referred to as the Empowered Action Group (EAG) states 6 HISTORY
  • 7. • As per the 12th Plan (2012-2017) document of the Planning Commission, the flagship programme of NRHM will be strengthened under the umbrella of National Health Mission. • The focus to include non-communicable diseases and expanding health coverage to urban areas. • Launched by the government of India in 2013 subsuming the NRHM and NHUM • Further extended in March 2018, to continue until March 2020. 7
  • 8. TERMINOLOGIES • Infant mortality rate : Infant mortality rate is the ratio of deaths under 1 year of age in a given year to the total number of live births in the same year • usually expressed as a rate per 1000 live births. • universally accepted indicators of health status for whole population • Maternal (puerperal) mortality rate : greatest proportion of deaths among women of reproductive age in most of the developing world. • number of maternal deaths during a given time period per 100,000 live births during the same time period 8
  • 9. NATIONAL RURAL HEALTH MISSION • LAUNCHED-5th April, 2005 for a period of 7 years (2005-2012) and recently extended upto year 2017. • adopts a synergic approach by relating health to determinants of good health viz.of nutrition, sanitation , hygiene and safe drinking water. • It also brings the Indian system of medicine (AYUSH) to mainstream. 9
  • 10. NRHM-Illustrative Structure 10 Block Level- Hospital Clusters of GP-PHC level Gram Panchayat- Sub Health centre level Vilage Level-ASHA
  • 11. Institutional Setup National Mission Steering Group-Union Minister Empowered Programme committee-U.Secretary State State Health Mission- CM State Health Society District District Health Mission District Health Society 11
  • 12. 12 STATE HEALTH MISSION STATE HEALTH SOCIETY Chairperson Chief Minister Chief Secretary/Development Commissioner Co- Chairperson Minister of Health and Family Welfare, State Government Development Commissioner Convener Principal Secretary/Secretary (Family Welfare) Officer designated as Mission Director of State Health Mission Frequency of Meetings At least once in every six months At least once in every six month Ordinary Business Providing health system oversight, consideration of policy matters related with health sector (including determinants of good health), review of progress in implementation of NHM; inter-sectoral coordination, advocacy measures required to promote NHM visibility. Approval / endorsement of Annual State Action Plan for the NHM. Consideration of proposals for institutional reforms in the H&FW sector. Review of implementation of the Annual Action Plan. Inter-sectoral co-ordination: all NHM related sectors and beyond (e.g. administrative reforms across the State). Status of follow up action on decisions of the State Health Mission. Co-ordination with NGOs/Donors/other agencies/organisations.
  • 13. 13 DISTICT HEALTH MISSION DISTRICT HEALTH SOCIETY Chairperson Chairman, Zilla Parishad District Collector/DM/CEO Zilla Parishad Co- Chairperson District Collector/DM CEO, Zilla Parishad Convener Chief Medical Officer/CDMO/CMHO/Civil Surgeon Chief Medical Officer/CDMO/Civil Surgeon Members MPs, MLAs, MLCs from the district, Chair-persons of the Standing Committees of the Zilla Parishad, Project Officer (DRDA), Chair-persons of the Panchayat Samitis and Hospital Management Societies, District Programme Managers for health, PHED, ICDS, AYUSH, education, social welfare, Panchayati Raj, State representative, representatives of MNGO/SNGO, etc. Project Officer (DRDA), District Programme Managers for Health, AYUSH, Water and Sanitation [under Total Sanitation Campaign (TSC)], DPMSU, PHED, ICDS, education, social welfare, Panchayati Raj, a State representative, Sub-Divisional Officer, CHC In-charge; representatives of Medical Association/MNGO/SNGO and Development Partners
  • 14. AIMS & OBJECTIVES • Reduction in child and maternal mortality • Universal access to food and nutrition, sanitation ,hygiene and public health care services • Prevention and control of communicable and non-communicable diseases,endemic disease • Access to integrated comprehensive primary health care. • Population stabilization, gender and demographic balance. • Revitalize local health traditions & mainstream AYUSH. • Promotion of healthy life styles. to provide accessible, affordable, accountable, effective and reliable primary health care, and bridging the gap in rural health care through creation of a cadre of Accredited Social Health Activist (ASHA). 14
  • 15. APPROACHES OF NRHM Communitize Innovation in Human Resource Management Improved management through capacity Flexible Financing Monitor,Progress against standards 15
  • 17. 17 Regulation for Private sector including the informal Rural Medical Practitioners (RMP) Mainstreaming AYUSH Promotion of public private partnerships for achieving public health goals. Reorienting medical education to support rural health issues Effective and visible risk pooling and social health insurance SUPPLIMENTARY STRATEGIES
  • 18. INITIATIVES UNDER NRHM SELECTION OF ASHA • resident of village • woman(married/divorced/widow) • 8th class • Leadership qualities • 1 ASHA for 1000 population Rogi Kalyan Samiti • members act as trustees • 31,763 Rogi Kalyan Samities (RKS) have been set up untied grants to sub-centres • equipped with blood pressure measuring equipment, haemoglobin (Hb) measuring equipment,stethoscope, weighing machine etc. • This has facilitated provision of quality antenatal care and other health care services 18
  • 19. Village Health Sanitation and Nutrition Committee • reflects the aspirations of the local community • especially the poor households and children. • 2015-5.01 lakh VHSNCs have been set up Janani Suraksha Yojana • to reduce maternal mortality among pregnant women • cash assistance is provided • 8.55 crore women have benefited Janani Shishu Suraksha Karyakarm • Launched on 1st June, 2011 , • JSSK entitles all pregnant women delivering in public health institutions to absolutely free and no expense delivery, including caesarean section. National Mobile Medical Units • 333 out of 672 districts - 2127 MMU National Ambulance Services • 16,000 basic and emergency patient transport vehicles • 6.290 vehicles have been empanelled to transport patients Web Enabled Mother and Child Tracking System • track every pregnant woman, infant and child upto the age of three years by name • ensuring delivery of services 19
  • 20. New Initiatives under NRHM • 1. Home delivery of contraceptives (condoms, oral contraceptive pills, emergency contraceptive pills) by ASHA • SCHEME:- • Implemented across all districts of the country. • ASHA would do home delivery of the contraceptives at the doorstep • The free supply of contraceptives at PHC and Sub-Centre level would stand withdrawn • The free supply of contraceptives at CHCs, Sub-Divisional and District level hospitals shall continue as before. • State- 25% and District -10% of the total stock of contraceptives as buffer • ASHA shall collect the consignment/ replenish her stock every month • No transport cost “Government of India supply,” “For home delivery by ASHA,” “Re 1/- for a pack of 3 condoms” “Re 1/- for a cycle of OCP” “Re 2/- for a pack of one tablet of ECP” 20
  • 21. • STATE: • Designate a nodal person to manage and monitor the scheme. • Orient the CMOs of the districts • CMOs of the pilot districts would further orient MOs • Develop communication material (banners, posters and leaflets etc.) • PHC I/C /ANM : MO I/C of PHC : • Certify ANMs, list of eligible couples and make corrections, if necessary. • Ensure all ASHAs collect supply from designated place. Verify ASHAs’ performance on a monthly basis. • Screen the couples for eligibility for OCPs • ASHA would: • Inform / counsel all the eligible couples in her area regarding availability of various contraceptive choices. • Get the clients screened by the MO/ ANM before selling OCPs to them. • Prepare and update list of eligible couples in her village and deliver contraceptives at door step of the beneficiaries. • Regularly collect stock from Block/ CHC/ PHC and charge the beneficiary at the approved rate, as an incentive for her efforts. 21
  • 22. 22
  • 23. • 2. Conducting District Level Household Survey SCHEME:- • initiated in 1997 • DLHS-1 -1998-99 and DLHS-2 in 2002-04. 23
  • 24. 24 Health Monitoring and Planning Committee under NRHM PHC level Block level State level District level
  • 25. PHC Health Monitoring and Planning Committee • Role and Responsibilities of the Committee • Consolidation of the village health plans and charting out the annual health action plan in order of priority. • Presentation of the progress made at the village level, achievements, actions taken and difficulties faced followed by discussion 25
  • 26. • access to health facilities in the area of that particular PHC. The discussion could include: o Sharing of reports of Village Health Committees o Reports from ANM about the coverage of health facilities o Any efforts done at the village level to improve the access to health care services o Record and analysis of neonatal and maternal deaths. o Any epidemic occurring in the area and preventive actions taken. 26
  • 27. Block Health Monitoring and Planning Committee • Role and Responsibilities: • Consolidation of the PHC level health plans and charting out of the annual health action plan for the block. • Review of the progress made at the PHC levels, difficulties faced, actions taken and achievements made, followed by discussion • Analysis of records on neonatal and maternal deaths; and the status of other indicators. • Monitoring of the physical resources • Coordinate with local CBOs and NGOs to improve the health services in the block 27
  • 28. District Health Monitoring and Planning Committee • Role and Responsibility • Discussion on the reports of the PHC health committees • Financial reporting and solving blockages in flow of resources if any • Infrastructure, medicine and health personnel related information and necessary steps required to correct the discrepancies. • Progress report of the PHCs emphasising the information on referrals utilisation of the services, quality of care etc. • Contribute to development of the District Health Plan • Ensuring proper functioning of the Hospital Management Committees. 28
  • 29. State Health Monitoring and Planning Committee • Role and Responsibilities • To discuss the programmatic and policy issues related to access to health care and to suggest necessary changes. • This committee will review and contribute to the development of the State health plan. • Key issues arising from various District health committees. • Institute a health rights redressal mechanism • Operationalising and assessing the progress made in implementing the recommendations of the NHRC. 29
  • 30. Concrete Service Guarantees that NRHM will provide: • Skilled attendance at all Births • Emergency Obstetric care • Basic neonatal care for new born • Full coverage of services related to childhood diseases / health conditions • Full coverage of services related to maternal diseases / health conditions • Full coverage of services related to low vision and blindness due to refractive errors and cataract. • Full coverage for curative and restorative services related to leprosy • Full coverage of diagnostic and treatment services for tuberculosis • Full coverage of preventive, diagnostic and treatment services for vector borne diseases 30
  • 31. Coverage • The Mission has the following coverage: • Population coverage - 740 million • Households - 148 million (approx.) • Birth Rate in Rural Areas - 26.6, nearly 20 million births • Sub Health Centres - 1,75,000 ( on population, distance and work load norm) • P H Cs - 27,000 (single MO, 2 MO, 1 AYUSH) • C H Cs - 7,000 (every Block) • Sub Divisional/Taluk Hospitals - 1,800 • District Hospital - 600 • ANMs - 3.50 lakhs • Staff Nurses at PHC - 81,000 31
  • 32. FINANCE • Public health expenditure -1% of the GDP • The above target however cannot be achieved unless the states also step up • major burden of the additional expenditure- Central Government • It would be the aim of the NRHM to increase the share of central and State Governments on health care from the current 20 – 80 to 40 – 60 sharing in the long run. • X Plan-100 % to states • XI Plan- Central-85% States -15% • XII Plan-Central -75% States -25% 32
  • 33. • Financial Resource Assessment -by National Commission on Macro Economics and Health • Non-recurring investment of Rs. 33811 crores • Recurring investment of Rs. 41006 crores • 5-7 Years 33
  • 34. COMPONENTS OF NHM 1.Reproductive, Maternal, Newborn, Child and Adolescent Health Ministry of Health & Family Welfare launched (RMNCH+A) to influence the key interventions for reducing maternal and child morbidity and mortality. 34 RMNCH+A RMNCH PLUS Inclusion of adolescence Linking maternal and child health to reproductive health Linking home and community-based services to facility-based services Ensuring linkages, referrals, and counter- referrals
  • 35. 35 RMNCH+A Adolescent Health Rashtriya Kishor Swasthya Karyakram ADOLESCENT FRIENDLY HEALTH CLINICS WEEKLY IRON FOLIC ACID SUPPLEMENTATION MENSTRUAL HYGIENE SCHEME(MHS) Child Health Maternal Health Family Planning Immunizatio n Aspirational District Program CHILD HEALTH National Deworming Day RBSK INTENSIFIED DIARRHOEA CONTROL FORTNIGHT MAA (MOTHERS' ABSOLUTE AFFECTION) PROGRAMME PROMOTION OF BREASTFEEDING SOCIAL AWARENESS AND ACTIONS TO NEUTRALIZE PNEUMONIA SUCCESSFULLY (SAANS)
  • 36. 36 MATERNAL HEALTH JANANI-SHISHU SURAKSHA KARYAKRAM JANANI SURAKSHA YOJANA DAKSHATA IMPLEMENTATION PACKAGE PRADHAN MANTRI SURAKSHIT MATRITVA ABHIYAN LABOUR ROOM & QUALITY IMPROVEMENT INITIATIVE
  • 37. Rashtriya Kishor Swasthya Karyakram (RKSK) In order to ensure holistic development of adolescent population, the Ministry of Health and Family Welfare launched Rashtriya Kishor Swasthya Karyakram (RKSK) on 7th January 2014 • to reach out to 253 million adolescents - male and female, rural and urban, married and unmarried, in and out-of-school adolescents with special focus on marginalized and undeserved groups . 37
  • 38. 38
  • 39. 39
  • 40. ADOLESCENT FRIENDLY HEALTH CLINICS (AFHCS) • This approach was initiated in 2006 • The key ‘friendly’ component of AFHC mandates facility-based clinical and counselling services for adolescents, which are: • Equitable—services are provided to all adolescents who need them. • Accessible—ready accessibility to AFHCs by adolescents • Acceptable—health providers meet the expectation of adolescents who use the services. • Appropriate—the required care is provided and any unnecessary and harmful practices are avoided. • Effective—healthcare produces positive change in the status of the adolescents; services are efficient and have high quality. 40
  • 41. WEEKLY IRON FOLIC ACID SUPPLEMENTATION (WIFS) • i. Objective To reduce the prevalence and severity of anaemia in adolescent population (10-19 years). • ii. Target groups • School going adolescent girls and boys in 6th to 12th class enrolled in government/government aided/municipal schools. • Out of school adolescent girls. • iii. Intervention • Administration of supervised Weekly Iron-folic Acid Supplements of 100mg elemental iron and 500ug Folic acid using a fixed day approach. • Screening of target groups for moderate/severe anaemia and referring these cases to an appropriate health facility. • Biannual de-worming (Albendazole 400mg), six months apart, for control of helminthic infestation. • Information and counselling for improving dietary intake and for taking actions for prevention of intestinal worm infestation. • iv. Current Status: • The programme has been rolled out in all States/UTs. The programme covers 11.2 crore beneficiaries including 8.4 crore in-school and 2.8 crore out of school beneficiaries. 41
  • 42. • MENSTRUAL HYGIENE SCHEME • The major objectives of the scheme are: • To increase awareness among adolescent girls on Menstrual Hygiene • To increase access to and use of high quality sanitary napkins to adolescent girls in rural areas. • To ensure safe disposal of Sanitary Napkins in an environmentally friendly manner. • 2011- 107 selected districts in 17 States wherein a pack of six sanitary napkins called “Freedays” was provided to rural adolescent girls for Rs. 6. • 2014 onwards, funds are now being provided to States/UTs under National Health Mission for decentralized procurement of sanitary napkins packs for provision to rural adolescent girls at a subsidized rate of Rs 6 for a pack of 6 napkins. • The ASHA will continue to be responsible for distribution, receiving an incentive @ Rs 1 per pack sold and a free pack of napkins every month for her own personal use. • IEC material has been developed around MHS, using a 360 degree approach 42
  • 44. 2.RASHTRIYA BAL SWASTHYA KARYAKRAM(RBSK) • According to March of Dimes (2006), out of every 100 babies born in this country annually, 6 to 7 have a birth defect. This would translate to around 17 lakhs birth defects annually in the country and accounts for 9.6% of all the newborn deaths • cover 4 ‘D’s viz. Defects at birth, Deficiencies, Diseases, Development delays including disability. 44
  • 45. 45
  • 46. 46
  • 47. 47
  • 48. 48
  • 49. 49
  • 50. 50
  • 51. 51
  • 52. JANANI SURAKSHA YOJANA • Janani Suraksha Yojana (JSY) is a safe motherhood intervention • objective - reducing maternal and neo- natal mortality by promoting institutional delivery among the poor pregnant women. • Launched on 12th April 2005, • JSY is a 100 % centrally sponsored scheme and it integrates cash assistancewith delivery and post-delivery care. 52
  • 53. 53
  • 55. PRADHAN MANTRI SURAKSHIT MATRITVA ABHIYAN • Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) was launched to provide fixed-day assured, comprehensive and quality antenatal care universally to all pregnant women (in 2nd and 3rd trimester) on the 9th of every month. 55
  • 56. 1. Outline the implementation approach for operationalizing PMSMA. 2. Outline the contours for private sector engagement for PMSMA 56
  • 57. LABOUR ROOM & QUALITY IMPROVEMENT INITIATIVE • LaQshyaon 11th December 2017 with following objectives: • Reduce maternal and newborn morbidity and mortality • Improve quality of care during delivery and immediate post-partum period • Enhance satisfaction of beneficiaries, positive birthing experience and provide Respectful Maternity Care (RMC) to all pregnant women attending public health facilities. • Following facilities are being taken under LaQshya initiative on priority: • All Government Medical College hospitals. • All District Hospitals & equivalent healthy facilities. • All designated high case load CHCs with over 100 deliveries/60 (per month) in hills and desert areas. 57
  • 58. 2. HEALTH SYSTEMS STRENGTHENING A. Adoption of the Indian Public Health Standards • minimum inputs required to ensure quality of care, in terms of infrastructure, equipment, skilled human resources, and supplies. • Assurance to the states of financing the gaps between available levels of these inputs and the levels needed to achieve the IPHS norms. B.Quality standards clinical protocols, administrative and management processes and for support services. 58
  • 59. C.Skill gaps and Standard Treatment Protocols- • Skilled Birth Attendance (SBA) "an accredited health professional - such as midwife, doctor or nurse - who has been educated and trained to achieve proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and immediate postnatal period and in the identification, management and referral of complications in women and newborns." • Navjat Shishu Suraksha Karyakram (NSSK) • Training Program • To reduce perinatal asphyxia (1/5th of all neonatal deaths) 59
  • 60. • IMNCI packages for ANMs-Implementation of Integrated Management of Neonatal and Childhood Illness 60 Keeping the child warm. o Initiation of breastfeeding immediately after birth and counseling for exclusive breastfeeding and non-use of pre lacteal feeds. o Cord, skin and eye care. o Recognition of illness in newborn and management and/or referral). o Immunization o Home visits in the postnatal period Care of Newborns and Young Infants (infants under 2 months) Care of Infants (2 months to 5 years) Management of diarrhoea, acute respiratory infections (pneumonia) malaria, measles, acute ear infection, malnutrition and anemia. o Recognition of illness and at risk conditions and management/referral) o Prevention and management of Iron and Vitamin A deficiency. o Counseling on feeding for all children below 2 years o Counseling on feeding for malnourished children between 2 to 5 years. o Immunization
  • 61. Home Based Newborn Care (HBNC) for ASHAs 61
  • 62. • D. Hospital Management Societies (RKS) and untied funds • The mandatory creation of a hospital management society (Rogi Kalyan Samiti) and empowering this body with untied funds has allowed public participation also contributed to improved quality of care. • E.Quality Improvement Programmes • Supports initiatives for building quality management systems. • Till date, 82 facilities have been certified by ISO, nine facilities have been certified by NABH and 446 facilities are under process of certification. 62
  • 63. 63 Health Systems Strengthening FREE DRUGS & DIAGNOSTICS SERVICE INITIATIVE Free Drug Service Free Diagnosis Service ERS/PATIENT TRANSPORT SERVICE National Ambulance Service (NAS) HUMAN RESOURCE MOBILE MEDICAL UNIT COMPREHENSIVE PRIMARY HEALTH CARE TRIBAL HEALTH BLOOD SERVICES AND BLOOD DISORDERS DISTRICT HOSPITAL STRENGTHENING
  • 64. National Ambulance Service (NAS) • One of the achievement of NHM is the patient transport ambulances operating under Dial 108/102 ambulance services. • Now 35 States/UTs have the facility • Dial 108 is predominantly an emergency response system, primarily designed to attend to patients of critical care, trauma and accident victims etc. • Dial 102 services essentially consist of basic patient transport aimed to cater the needs of pregnant women and children though other categories are also taking benefit and are not excluded. 64
  • 65. • Implementation of National Ambulance Service (NAS) guidelines has been made mandatory for all the ambulances whose Operational Cost is supported under NHM. • 10993 ambulances are being supported under 108 emergency transport systems including new. • 9955 ambulances are operating as 102 patient transport including new ambulances. • 5126 empanelled vehicles are also being used in some States to provide transport to pregnant women and children e.g. Janani express in MP, Odisha, Mamta Vahan in Jharkhand, Nishchay Yan Prakalpa in West Bengal and Khushiyo ki Sawari in Uttarakhand. 65
  • 66. NON COMMUNICABLE DISEASE CONRTROLPROGRAMME 66
  • 67. NATIONAL ORAL HEALTH PROGRAM • Objectives:- • To improve the determinants of oral health • To reduce morbidity from oral diseases • To integrate oral health promotion and preventive services with general health care system • To encourage Promotion of Public Private Partnerships (PPP) model for achieving better oral health. 67
  • 68. National Tobacco Control Programme • launched 2007-08 during the 11th Five-Year-Plan, with the aim to • (i) create awareness about the harmful effects of tobacco consumption, • (ii) reduce the production and supply of tobacco products, • (iii) ensure effective implementation of the provisions under “The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003” (COTPA) • (iv) help the people quit tobacco use • (v) facilitate implementation of strategies for prevention and control of tobacco advocated by WHO Framework Convention of Tobacco Control . 68
  • 71. 71 Components Of Village Health Sanitation and Nutrition Committee
  • 72. 72
  • 73. 2. ASHA • Anganwadi Workers (AWWs) under the Integrated Child Development Scheme (ICDS) are engaged in organizing supplementary nutrition programmes and other supportive activities. • The very nature of her job responsibilities (with emphasis on supplementary feeding and pre school education) does not allow her to take up the responsibility of a change agent on health in a village. • Thus a new band of community based functionaries, named as Accredited Social Health Activist (ASHA) is proposed to fill this void. • first port of call for any health related demands of deprived sections 73
  • 74. • Roles and Responsibilties • Create Awareness • Counsel women • mobilize the community and facilitate them in accessing health • work with the Village Health & Sanitation Committee of the Gram Panchayat • escort/accompany pregnant women • provide primary medical care for minor ailments such as diarrhoea, fevers,and first aid for minor injuries. • inform about the births and deaths • She will promote construction of household toilets under Total Sanitation Campaign. 74
  • 75. • SELECTION OF ASHA • The general norm will be ‘One ASHA per 1000 population’. • In tribal, hilly, desert areas the norm could be relaxed to one ASHA per habitation, dependant on workload etc. • The States will also need to work out the district and block-wise coverage/phasing for selection of ASHAs. • Criteria for Selection • ASHA must be primarily a woman resident of the village - • ‘Married/Widow/Divorced’ and preferably in the age group of 25 to 45 yrs. • ASHA should have effective communication skills, leadership qualities and be able to reach out to the community. • She should be a literate woman with formal education upto Eighth Class. 75
  • 76. • ROLE AND INTEGRATION WITH ANGANWADI • Anganwadi Worker (AWW) will Guide ASHA in performing following activities: • Organizing Health Day once/twice a month. • AWWs and ANMs will act as a resource persons for the training of ASHA. • IEC activity through display of posters, folk dances etc. on these days can be undertaken to sensitize the beneficiaries on health related issues. • Anganwadi worker will be depot holder for drug kits and will be issuing it to ASHA. • AWW will update the list of eligible couples and also the children less than one year of age in the village with the help of ASHA. • ASHA will support the AWW in mobilizing pregnant and lactating women and infants for nutrition supplement. • She would also take initiative for bringing the beneficiaries from the village on specific days of immunization, health checkups / health days etc. to Anganwadi Centres. 76
  • 77. • ROLE AND INTEGRATION WITH ANM • Auxiliary Nurse Midwife (ANM) will Guide ASHA in performing following activities: • She will hold weekly / fortnightly meeting with ASHA and discuss the activities undertaken during the week / fortnight. • AWWs and ANMs will act as a resource person for the training of ASHA. • ANMs will inform ASHA regarding date and time of the outreach session and will also guide her for bringing the beneficiary to the outreach session. • ANM will participate & guide in organizing the Health Days at AWC. ANMs will orient ASHA on the dose schedule and side affects of oral pills. • ANMs will educate ASHA on danger signs of pregnancy and labour • ANMs will inform ASHA on date, time and place for initial and periodic training schedule. 77
  • 78. • FUND-FLOW MECHANISM FOR ASHA • It is proposed that funds for making the payments to ASHA may flow from Centre to States through SCOVA mechanism and from State SCOVAs to District Health Societies. Standing Committee of Voluntary Agencies (SCOVA) in 1986. • SCOVA functions to promote the following objectives:- • To provide a feedback on implementation of process/programmes of the Department of Pension & Pensioners’ Welfare • To discuss and critically examine the policy initiatives and • To mobilize voluntary efforts to supplement the Government action 78
  • 79. (a) The compensation to ASHA based on measurable outputs would be given under the overall supervision and control by Panchayat. For this purpose a revolving fund would be kept at Panchayat. The guidelines for such compensation would be provided by the District Health Mission, led by the Zila Parishad. (b) For the compensation money under the various national programmes / Schemes, the programmes have in-built provisions for the payment of compensation. These compensations will be made in accordance with the programme guidelines. (c) ASHA would be entitled for DA for attending training programmes. She would be given the amount at the venue itself. 79
  • 80. BUDGET & FINANCIAL MECHANISMS FOR TRAINING ASHAs 80
  • 81. 81
  • 82. 82
  • 83. 4.ROGI KALYAN SAMITTI • Rogi Kalyan Samities (RKSs) / Hospital Management Committees • 2005 under the National Rural Health Mission (NRHM) as a forum • to improve the functioning and service provision in public health facilities, increase participation and enhance accountability. • 31,763 Rogi Kalyan Samities (RKS) have been set up 83
  • 84. OBJECTIVES OF RKS 84 Serve as a consultative body to enable active citizen participation Ensure that essentially no user fees or charges are levied for treatment Decide on the user fee structure for outpatient and inpatient treatment Ensure that those patients who are Below Poverty Line, vulnerable and marginalized groups do not incur any financial hardship for their treatment
  • 85. 85 Ensure provision of all non-clinical services and processes such as provisioning of safe drinking water, diet, litter free premises, clean toilets, Ensure availability of essential drugs and diagnostics Promote a culture of user-friendly behaviour amongst service providers Operationalize a Grievance Redressal Mechanism
  • 86. • Source of RKS Funds • 1. Each RKS will be provided with Untied funds under NHM by State Health Society/District Health Society based on the level of facility, its case load, fund utilization capacity and availability of previous year funds. • 2. User fees as determined by RKS for hospital services E.g. X-ray, Ultrasound scanning, laboratory services, private wards etc.Levying of user charges will depend on localcircumstances and decided by the GB, and implemented by the EC. • 3. Funds can also be raised from donations, grants from government and loans fromfinancial institutions (with permission of State Government). 86
  • 87. MAINSTREAMING AYUSH-Ayurveda Yoga & Naturopathy, Unani, Siddha and Homoeopathy • STRATEGIES • Integrate in health care delivery system including National Programmes. • Encourage and facilitate in setting up of specialty centres and ISM clinics. • Facilitate and Strengthen Quality Control Laboratory. • Strengthening the Drug Standardization and Research activities on AYUSH. • Develop Advocacy for AYUSH. • Establish Sectoral linkages for AYUSH activities 87
  • 88. Activities Improving the availability of AYUSH treatment Integration of AYUSH with ASHA. Drug Management Strengthening the Quality Control Laboratory Development of Herbariums and crude drug museums: Strengthening of the State and District Management • AYUSH services in 314 CHC / Block PHC - contractual AYUSH Doctors. • Appointment of 200 paramedics and Data assistant • Strengthening of AYUSH Dispensaries • Making provision for AYUSH Drugs at all levels. • Establishment of specialized therapy centers in District Head Quarter Hospitals & 3 Medical Colleges. • AYUSH doctors to be involved in all National Health Care programmes, • Training of AYUSH doctors in Primary Health Care and NDCP. • Yoga Therapy Centre will be opened in district • Headquarters Hospitals to provide Yogic therapy • Block level School Health Programmes to be conducted twice in a year 88
  • 89. • Integration of AYUSH with ASHA. • Update Training module for ASHA and ANMs • Training & capacity building - Director, SIHFW, Bhubaneswar • Drug kit - one AYUSH preparation in the form of iron supplement. • Other drugs - treatment of common diseases,communicable diseases ,maternal and child health as well as improving quality of life could be included subsequently. • Drug Management: • Priority will be given to manufacture drugs in Govt. Sector Pharmacies as per their capacity. In case of any surplus funds, drugs will be procured from the market observing all financial formalities of the Govt. • Provision of Rs. 25,000/- to supply drugs per AYUSH dispensary has been projected as per NRHM norm. • Provisions of medicines for District AYUSH wings and Specialty Therapy Centres proposed to be operated in the State. 89
  • 90. • Strengthening the Quality Control Laboratory • Drug regulation and enforcement unit has to be established in the state. • The drug regulatory mechanism to be strengthened at the state level • The existing State DrugTesting and Research Laboratory (ISM) at Bhubaneswar shall also be modernised and strengthened for the purpose. • Strengthening the Drug Standardisation and Research Activities on AYUSH: • Tto evaluate the chemical, pharmacological and clinical efficacy of the plant drugs. • The pharmacologically viable drugs will be screened clinically under WHO guideline to establish the therapeutic activity 90
  • 91. • Development of Herbariums and crude drug museums: • Herbarium will be developed in collaboration with the Forest Dept. in 15 selected Districts of the State. • The existing Herbal gardens strengthened with necessary infrastructure. • One State Herbarium at DTL, Bhubaneswar shall be developed. • Strengthening of the State and District Management System of AYUSH: • It is proposed to create necessary Managerial post in the State and District level for effective supervision and implementation of different activities. • Necessary vehicles with supporting manpower has also been proposed to strengthen the supervisory 91
  • 92. 92
  • 93. • Kilkari: • Interactive Voice Response (IVR) based mobile service that delivers time- sensitive audio • messages (voice call) about pregnancy and child health directly to the mobile phones of pregnant women, mothers of young children and their families. • The service covers the critical time period- where the most maternal/ infant deaths occur from the 4th month of pregnancy until the child is one year old. Families which subscribe to the service receive one pre-recorded system generated call per week. • Launch of Nationwide anti-TB drug resistance survey: • Drug resistance survey for 13 anti- tuberculosis drugs was launched to estimate the burden of MOR-TB within the community. 93
  • 94. Kala- azar elimination plan • The National Health Policy-2002 set the goal of Kala-azar elimination in India by the year 2010 which was revised to 2015. • Objective-To reduce the annual incidence of Kala-azar to less than one per 10 000 population at block PHC level by the end of 2015 by: • reducing Kala-azar in the vulnerable, poor and unreached populations in endemic areas; • reducing case-fatality rates from Kala-azar to negligible level; • reducing cases of PKDL to interrupt transmission of Kala-azar; and • preventing the emergence of Kala-azar and HIV/TB co-infections in endemic areas. 94
  • 95. S.no Targets 1 Reduce IMR to 30/1000 live births by 2012 2 Reduce MMR to 100/1,00,000 live births by 2012 3 Reduce TFR to 2.1 4 Reduce annual prevalence and mortality from Tuberculosis by half 5 Reduce prevalence rate of Leprosy to <1/10000 population in all districts. 6 Annual Malaria Incidence to be <1/1000 7 Less than 1 per cent microfilaria prevalence in all districts 8 Kala-Azar Elimination by 2015, <1 case per 10000 population in all blocks 95 TARGETS OF NRHM
  • 97. • Maternal Mortality Ratio (MMR) of India has reduced from 130 per 100,000 live births in SRS 2014-16 to 122 in SRS 2015-17 and to 113 per 100,000 live births in SRS 2016-18. 97
  • 98. 98 West Bengal, Maharashtra were found to have the lowest Total Fertility Rate in India https://www.indiatoday.in/india/story/india-fertilitaty-rate-declines-replacement-level-meaning-nfhs-survey-
  • 99. 99
  • 100. • The countries that contributed most to the global drop between 2019 and 2020 were India (41%), Indonesia(14%), the Philippines (12%) and China (8%); these and 12 other countries accounted for 93% of the total global drop of 1.3 million 100 https://www.who.int/publications/i/item/9789240037 021
  • 102. 102 • The eastern state of Odisha, which carried more than 40% of the country’s malaria burden, reported a 90% decline in malaria cases and 89% decline in malaria deaths in 2020 as compared to 2015. • The malaria-endemic North-Eastern region and the states of Jharkhand, Chhattisgarh, and Madhya Pradesh also registered similar reductions in cases and deaths. • The WHO’s World Malaria Report 2020 highlighted India’s gains in the path to elimination. India recorded impressive 60% reduction in reported cases compared with 2017, and a 46% reduction in cases compared with 2018, which built momentum to reach the goal of zero indigenous malaria cases by 2027.
  • 104. 104 The disease incidence has been declining steadily, from 13869 in 2013 to 3145 in 2019. Of the cases reported in 2019, nearly 60 per cent cases were from four States alone. These included Bihar with maximum number (2416 cases), followed by Jharkhand (541), Uttar Pradesh (97) and West Bengal (87)7. In addition, 821 cases of post-kala-azar dermal leishmaniasis (PKDL) were reported and these were considered as the main cause of transmission in the community Thakur CP, Thakur M. Accelerating kala-azar elimination in India. Indian J Med Res. 2020;152(6):538-540.
  • 105. REFERENCES • https://www.nhm.gov.in/WriteReadData/l892s/nrhm-framework- latest.pdf • https://nhm.gov.in/images/pdf/communitisation/task-group- reports/guidelines-on-asha.pdf • https://www.nhm.gov.in/New_Updates_2018/communization/RKS/G uidelines_for_Rogi_Kalyan_Samities_in_Public_Health_Facilities.pdf • http://nhm.gov.in/images/pdf/programmes/RKSK/RKSK_Implementat ion_Guideline_05.03.2015.pdf • http://www.nhm.gov.in/MAA/Operational_Guidelines.pdf • https://www.ayush.gov.in/docs/ayurved-guidlines.pdf 105
  • 106. 106