The document summarizes the National Rural Health Mission (NRHM) in India, which aimed to provide accessible, affordable and quality healthcare, especially to rural and vulnerable populations, from 2005-2012. Key aspects included decentralizing healthcare and increasing public health expenditure to 2-3% of GDP. Goals were to reduce infant and maternal mortality, and ensure access to primary healthcare through community health workers like ASHAs, improved infrastructure like 24/7 facilities, and intersectoral coordination between health, water, sanitation and nutrition initiatives. The document outlines the organizational structure, strategies and interventions of the NRHM at national, state, district and community levels.

2. Dr Sumanth M M
MBBS, MD (Community Medicine), DNB
(SPM)
Assistant Professor
Department of Community Medicine
MMCRI, Mysore

3. Time-bound 2005 – 2012
High political commitment:
“We have grievously erred in the design of many of our health programs. We
have created a model that fragments resources and dissipates energies.
Most importantly we have paid inadequate attention to the Public Health
issues”
(Prime Minister of India- Inauguration speech)
Goal: Good decentralized healthcare
Where ? Focus on 18 states:
8 NE states, 8 EAG states, Hilly states of Himachal Pradesh and Jammu
Kashmir

4. To bring all round improvement in public health services by
1.Improving the capacity of the health system
Architectural Correction of health sector-Decentralization, Integration of vertical
programs, Involvement of PRI, AYUSH.
2.Increasing the public expenditure on health to 2-3% of GDP
3.bring effective health care to rural population/women/children

5. 1. Reduction in Infant Mortality Rate (IMR) and Maternal
Mortality Ratio (MMR)
2. Universal access to public health services such as Women’s
health, child health, water, sanitation & hygiene,
immunization, and Nutrition.
3. Prevention and control of communicable and non-
communicable diseases, including locally endemic diseases
4. Access to integrated comprehensive primary healthcare
5. Population stabilization, gender and demographic balance.
6. Revitalize local health traditions and mainstream AYUSH
7. Promotion of healthy life styles

7. Increase in OPD/IPD case load
Institutional deliveries have increased from 60% in
2005 and 63% in 2006 to 68% in 2007 and 79% in
the current year
Electronic transfer of funds from state to district,
software development in process for e transfer to
sub-district levels
Program Management structure in place & are
supportive to SHS & DHS.

8. 6 ‘C’ Category
Districts
3 Tribal
Districts

9. Crude Birth Rate 2003 - 2012
21.8
20.9 20.6 20.2 19.76 19.3218.88 18.44 18 17.56
24.8 24.1 23.8
0
5
10
15
20
25
30
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Year
Rate
Karnataka
India
Situational analysis
Source SRS up to 2005, Estimates 2006 onwards

10. Kar. India
58 66
55 64
52 60
49 58
50 58
48 57
IMR
58 55 52 49 50 48
66 64 60 58 58 57
0
20
40
60
80
2001 2002 2003 2004 2005 2006
Year
Nos.
Kar.
India
I.M.R
Source SRS
2001 2002 2003 2004 2005

11. MMR
245 266
228
398
327 301
0
100
200
300
400
500
1 2 3
Year
No.
Karnataka
India
Source SRS
1997-98 1999-2000 2001-2003
M.M.R

12. Source CNAA
Trend in Institutional Delivery Rate (in %)
45.7 47.2
50.6 52.3
56.1
60
63
68
72
0
10
20
30
40
50
60
70
80
2000 2001 2002 2003 2004 2005 2006 2007 2007
Dec
year
%ofInstitutionaldeliveries
%

13. 39
51
67
0
20
40
60
80
NFHS-1 NFHS-2 NFHS-3
Series1
Institutional Deliveries
1992-93 1998-99 2005-06

14. Fig. in lakhs
FullyImmunized - Source UNICEF
74 67.8
59.9
73.5
86.9
0
20
40
60
80
100
1998-99 1999-00 2000-01 2001-02 2004-05
Year
%
%
Source CNAA

15. NRHM
State Health Mission State Health Society
State Project
Management
Unit
District Health Mission District Health Society
Block Health & Sanitation
committee
CHC
District Project
Management
Unit
PHC
Village Health & Sanitation
committee
Sub Centre
Untied
Fund
ASHA PW

16. 16
National Steering Group
Mission Steering
Group
Empowered Program Committee
State Health Mission
District Health Mission
Village Health Committee
Mission Directorate
ORGANOGRAM
Panchayat samiti

17. 17
BLOCK
LEVEL
HOSPITAL
30-40 Villages
Strengthen Ambulance/
transport Services
Increase availability of Nurses
Provide Telephones
Encourage fixed day clinics
Ambulance
Telephone
Obstetric/Surgical Medical
Emergencies 24 X 7
Round the Clock Services;
CHIEF BLOCK MEDICAL OFFICER / BLOCK LEVEL HEALTH OFFICE –--------------- Accountant
CLUSTER OF GPs – PHC LEVEL
3 Staff Nurses; 1 LHV for 4-5 SHCs;
Ambulance/hired vehicle; Fixed Day MCH/Immunization
Clinics; Telephone; MO i/c; Ayush Doctor;
Emergencies that can be handled by Nurses – 24 X 7;
Round the Clock Services; Drugs; TB / Malaria etc. tests
GRAM PANCHAYAT – SUB HEALTH CENTRE LEVEL
Skill up-gradation of educated RMPs / 2 ANMs, 1 male MPW FOR 5-6 Villages;
Telephone Link; MCH/Immunization Days; Drugs; MCH Clinic1000
Popu lation
VILLAGE LEVEL – ASHA, AWW, VH & SC
1 ASHA, AWWs in every village; Village Health Day
Drug Kit, Referral chains
100,000
Population
100 Villages
5-6 Villages
Accredit private
providers for public
health goals
Health Manager
Store Keeper
NRHM – ILLUSTRATIVE STRUCTURE

18. Communitisation
Decentralized Planning
Committee for Health
Facilities Mgt.
Health Mission Goals & Approaches
Financing
Untied grants
MNGO/FNGO
Money follows patient-JSY
Capacity Building
District/ Block Mgt. skills
Indian PH Standards
HR Management
PHC 24x7 by Nurses
CHC 24x7 Emergency services
Multi Skills - Training
Monitoring
Facility Surveys
Monitoring Committees

19. 19
Involvement of PRIs
ASHA
Untied fund
IPHS standards
Inter-sectoral District Health Plan prepared by the District
Health Mission, including drinking water, sanitation &
hygiene and nutrition
Integrating relevant vertical Health and Family Welfare
programs at National, State and District levels
Technical Support all levels for Public Health Management

20. 20
Promotion of Public Private Partnerships for achieving
public health goals
Mainstreaming AYUSH
Reorienting medical education to support rural health
issues including regulation of Medical care and Ethics
Effective and viable risk pooling to provide health
security to the poor by ensuring accessible, accountable
and good quality hospital care

21. 21
Every village will have a female community health activist
chosen by and accountable to the panchayat- to act as the
interface between the community and the public healthcare
system. States to choose State specific models
ASHAs will be trained on a pedagogy of public health
mentored through a National Experts Group
ASHA would act as a bridge between the ANM and the
village and be accountable to the Panchayat

22. 22
Each sub-centre will have an untied fund for local action @
Rs. 10,000 per annum. This fund will be held in joint
account of ANM and Panchayat Sarpanch
Supply of essential drugs (allopathic and AYUSH) to the
Sub-centres
MPWs (Male)/Additional ANMs wherever needed, sanction
of new Sub-centres as per 2001 population norm, and
upgrading existing Sub-centres, including buildings for
Sub-centres functioning in rented premises will be
considered.

23. 23
Supply of essential drugs to PHCs
Provision of 24 hour services in 50% PHCs by addressing
shortage of doctors, especially in high focus states,
through mainstreaming AYUSH manpower
Supply of Auto Disabled Syringes for immunization
Intensification of ongoing communicable disease control
programmes, new programmes for control of non-
communicable diseases

24. 24
Operationalizing 3215 existing Community Health Centres
(30-50 beds) as 24 Hour First Referral Units
Codification of new Indian Public Health Standards, setting
norms for infrastructure, staff, equipment, management etc
Promotion of Stake-holders’ Committees (Rogi Kalyan
Samitis) for hospital management
In case of additional Outlays, creation of new Community
Health Centres (30-50 beds) to meet the norm of one per
100,000 population

25. 25
District Health Plan would be an amalgamation of field
responses through Village Health Plans, State and National
priorities for Health, Water Supply, Sanitation and Nutrition
Health Plans would form the core unit of action proposed
in areas like water supply, sanitation, hygiene and
nutrition.
Implementing Departments would integrate into District
Health Mission for monitoring
District becomes core unit of planning, budgeting and
implementation

26. 26
Components of TSC include IEC activities, rural sanitary
marts, individual household toilets, women sanitary
complex, and School Sanitation Program
The TSC is implemented through PRIs. additional Rs.4000
crores over next 5 years for TSC advocated by the NRHM
The DHM will promote joint IEC for public health, sanitation
and hygiene, through Village Health & Sanitation Committee,
and promote household toilets and School Sanitation
Program. ASHA would be incentivized for promoting
household toilets by the Mission.

27. 27
Strengthening ongoing National Disease Control Programs
for Malaria, TB, Kala Azar, Filaria, Blindness & Iodine
Deficiency shall be horizontally integrated under the Mission
New Initiatives for control of Non Communicable Diseases
Strengthening disease surveillance system at village level
Supply of generic drugs (both AYUSH & Allopathic) for
common ailments at village, SC, PHC/CHC level

28. 28
Since 75% of health services are being currently provided
by the private sector, there is a need to refine regulation
Regulation to be transparent and accountable
District Institutional Mechanism for Mission must have
representation of private sector
Need to develop guidelines for PPP for health sector
Task Force to improve details/guidelines

29. 29
Task Force to examine new health financing mechanisms, including
Risk Pooling for Hospital Care as follows:
Standardization of services – outpatient, in-patient, laboratory,
surgical interventions- and costs will be done periodically by a
committee of experts in each state.
A National Expert Group to monitor these standards and give
suitable advise and guidance on protocols and cost comparisons.
A district health accounting system to be created to monitor the
District Health Fund Management and take corrective action
Where credible Community Based Health Insurance Schemes (CBHI)
exist/are launched, they will be encouraged as part of the Mission

30. 30
While district and tertiary hospitals are necessarily located in
urban centres, they form an integral part of the referral care
chain serving the needs of the rural people
Medical and para-medical education facilities need to be
created in states, based on need assessment
Suggestion for Commission for Excellence in Health Care
(Medical Grants Commission), National Institution for Public
Health Management etc
Task Force to improve guidelines/details.

31. Accredited Social Health Activist (ASHA)
Auxiliary Nurse Midwife and Anganwadi worker
Panchayati Raj Institutions and NGOs
District Administration
State Governments

32. Selection of ASHA
Prepare the Village Health Plan and promote
intersectoral integration.
Untied fund at Sub-centres to be deposited in a
joint Bank Account operated by ANM & Sarpanch
District Health Mission to be led by the ZP. The
DHM would also guide activities of sanitation.

33. VHND
JSY
IMNCI