NATIONAL

HEALTH
MISSION
Submitted By: Submitted To:

Prabha Krishnan Mrs. Sheena P

2nd M.Sc Nursing Asst. Professor

GCN, Kozhikode GCN, Kozhikode

 NATIONAL HEALTH MISSION
INTRODUCTION

The Ministry of health and Family Welfare is implementing various schemes and programmes
and national initiatives to provide universal access to the quality health care. The approach is to
increase access to the decentralized health system by establishing new infrastructure in deficient
areas and by upgrading the infrastructure in existing institutions. The Government of India has
introduced a series of programmes over the past two decades to address maternal and newborn
health. The major milestones so far include:

a. 1992- Chld survival and safe motherhood programme (CSSM)

b. 1997-RCH-I
c. 2005- RCH-II
d. 2005- National Rural Health Mission
e. 2013- RMNCH+A strategy
f. 2013- Natonal Health mission
g. 2014-India Newborn Action Plan

The National health Mission was approved in May 2013. As part of the plan process, many
different programmes have been brought together under the overarching umbrella of National
Health Mission (NHM), with National rural Health Mission and National Urban Health Missions
as its two Sub-Missions. The main programmatic components include health system
strengthening in rural and urban areas; Reproductive- Maternal- Newborn- Child and adolescent
health (RMNCH+A); and control of communicable and non communicable diseases. An
important achievement of NHM has been considerable reduction in out of pocket expenses from
72 per cent to 60 percent.

The vision of the NHM is the “Attainment of Universal Access to Equitable, Affordable
and Quality health care services, accountable and responsive to people’s needs, with effective
inter sectoral convergent action to address the wider social determinants of health”
National Rural Health Mission (NRHM) was launched in April 12, 2005 to address the health
needs of the underserved rural population especially women, children and vulnerable sections of
the society and to provide affordable, accessible and quality healthcare.
The National Urban Health Mission, (NUHM) was launched in May 2013 and was subsumed
with NRHM as a sub-Mission of the overarching National Health Mission(NHM). Many unique
practices were encouraged like innovations in healthcare delivery practices, flexible financing to
the states with strengthened monitoring and evaluation component for better health outcomes and
health indicators of the states.
 Components of NHM:

Components

Public Health Human Health Systems Reproductive, Preventing Community

Planning and Resource Strengthening Maternal, New Communicable Processes
Financing Strengthening Born, Child Health and Non
and Adolescent
(RMNCH+ Communicable
A) Services Diseases

1. Public Health Planning and Financing:

 Mapping of facilities and differential planning for districts/cities/blocks as per their
health indicators
 Planning for full spectrum of health services
 Emphasis on quality assurance in delivery points
 Strengthening of Management with full time Mission Director, Director Finance and
Programme Management support at all levels.
 Developing a separate and trained Public health cadre of professionals including
doctors and nurses

2. Human Resource Strengthening in Health; Deployment and Development

 HR gaps met based on case load. Engagement of medical specialists, Medical
professionals and nurses on contract based on need.
 HR accountability: Performance- based incentives and for working in difficult areas.
 Additional incentives to health professionals to serve in rural and remote areas
 Speedy recruitment to fill up vacancy, preferable decentralized.
 Amendments in medical college norms to increase availability of doctors
 Capacity building and training of staff at all levels.

3. Health Systems Strengthening

Funds are provided for up gradation of existing and construction of new infrastructure.
High focus States spend up to 33 per cent and other States up to 25 per cent of their funds
on infrastructure.The various sub- components of Health Systems Strengthening are as follows:
i. Construction of new buildings and renovation of existing ones-Budget provisions
available for construction, maintenance, carpentry, electrical, plumbing, sanitation, water
 provision etc. to fulfill the infrastructural gaps based of IPHS (Indian Public Health
Standards) and existing structure.
ii. Improving Sanitation & Hygiene in Public facilities: Kayakalp
Kayakalp initiative is a new initiative launched in 2015 under NHM, to inculcate the
practice of hygiene, sanitation, effective waste management and infection control in
public health facilities. It also includes recognition with Certificate of Commendation
and Cash Awards of such public healthcare facilities that show extraordinary
performance and compliance to protocols.
iii. Social Protection: Reducing Out of pocket expense:

A. Drugs: Free Drugs Service Initiatives

 Provisions for supply of essential drugs as per the defined Essential Drugs List (EDL),
free of cost, to lower the out
 Centrally procurement of drugs for various programmes as per the EDL and Standard
Treatment Guidel
 Provision of local purchase of drugs and supplies at lower levels, if need arises.
Drugs & Logistic Support: Procurement and Supply Chain Management Systems Drug
Procurement System for public health facilities and E- Procurement are very crucial for supply of
essential drugs for JSSK and other programmes.

B. Diagnostics: Free Diagnostics Service Initiative

Under this programme, free diagnostics services (radiological & laboratory) are provided to
patients free of charge, as per Guidelines on Free Diagnostics Service Initiative.

C. Diet: Free good quality Diet

It is available to all inpatients including pregnant women.

D. Transport: Emergency Response System (ERS)/ Patient Transport Service/National

Ambulance Services (NAS)
These services are offered on cashless basis and are the pillars for providing free assured
transport services to the patients as entitled by Janani Suraksha Yojana (JSY) and Janani Sishu
Suraksha Karyakram (JSSK)

Equipments: Biomedical Equipment Management and Maintenance Programme. The

comprehensive program includes detailed guidelines on the comprehensive medical equipment
management and maintenance in a Public Private Partnership mode, its components, structure for
partnerships and inventory mapping.

Blood Services: NHM supports activities to meet annual requirements of blood through district
government by supplementing Human Resources, equipment and other requirements like e-
blood banking, voluntary blood donation and functional linkages of blood storage centres with
blood banks Transport

iv. Outreach Services: Mobile Medical Units.

Vehicles are used to improve outreach services and bring healthcare to the doorstep of especially
in difficult terrain and remote areas. It may carry medical and paramedical personnel, drugs,
supplies and laboratory and diagnostics equipment. The number of vehicles varies from State to
State.

4. Reproductive, Maternal, New Born, Child Health and Adolescent (RMNCH+A) Services
This programme was launched in 2013 to address increasing maternal and child health mortality,
associated causes and to bring in improvement in access and utilisation of health care services by
the vulnerable population. The subcomponents of this Scheme are as follows:
A. Reducing Maternal Mortality Rate: Maternal Health
1. Incentivization: Janani Suraksha Yojana (JSY) This scheme is for strengthening Maternal and
Child Health Services wherein incentives are paid to all the pregnant women of both urban and
rural areas for deliveries in public institutions. Incentives are given to all patients irrespective of
their BPL status, so as to facilitate public institutional deliveries.

2. Free Patient Entitlements: Janani Sishu Suraksha Karyakram (JSSK) JSSK scheme ensures
cashless delivery and C- section for pregnant women and management of sick neonates up to one
year to prevent incurring high out- of pocket expenses and exploitation by unwarranted people.

3. Strengthening infrastructure: Maternal and Child Health (MCH) Services Under NHM,
100/50/30 bedded MCH wings are established to improve quality of care if the bed occupancy is
more than 70 per cent. Such wings can be established in District Hospitals/ District Women's
Hospitals/ Sub- District Hospitals/CHC- First Referral Units (FRUs) to overcome the constraints
of increasing caseloads and institutional deliveries at these facilities.

4. Reorienting Medical Education: Skill Labs,Skills Labs are established for competency based
training and skill enhancement of healthcare providers for RMNCH+A services, both in- service
and pre- service training. Thus reorient existing personnel and train students of ANM, GNM and
midwifery courses.

5. Capacity Building: Dakshata Programme.It is the capacity building programme for service
providers in labor room best practices during labor, delivery and post- partum.

6. Promotive Health : Mothers Absolute Affection (MAA).It is a new initiative Programme for
Promotion of Breast Feeding.
7. Improves access and Coverage: Safe Abortion Services,Medical Termination of Pregnancy
(MTP) services are provided in FRUs, functional 24x7.

8. Improving access by PPP mode: Pradhan Mantri Surakshit Matritva Abhiyan(PMSMA).Under

the PMSMA, on the 9th of every month, pregnant ladies are given free health check- up
including blood pressure, sugar level, Hemoglobin test, Blood test etc. and the required treatment
in all government medical facilities. Private sector gynecologists are encouraged to voluntarily
participate and provide antenatal checkup (ANC) services in these public health facilities.

9. NGOs Involvement: Gender Based Violence,ASHAs and clinical service providers are
sensitized and trained to identify, counsel and refer such cases to higher centres, with the support
of Non- Governmental Organisations (NGOs) and women support groups.

10. Monitoring and accountability of services: Maternal Death Review.The purpose of both
Facility- Based Maternal Death Review (FBMDR) and Community- Based Maternal Death
Review (CBMDR) is to identify the causes of maternal deaths and the gaps in service delivery in
order to take corrective action.

B. Reducing Infant Mortality and Child Mortality Rate: New Born and Child Health

1. New born Care Services Programme

2. Universal Immunization Programme (UIP) & Mission Indradhanush
Under the routine immunization, children are given vaccines for the prevention of seven life-
threatening diseases (Tetanus, Tuberculosis, Diphtheria, Pertussis, Measles, Polio and Hepatitis-
B).Vitamin A dosages are also given with Measles. Tetanus Toxoid is provided to the pregnant
women. These vaccinations are being organized by immunization sessions in all the hospitals,
health centers, sub centers and anganwadi centers, during special vaccination weeks. Cold chain
logistics are provided at all facilities. Surveillance of vaccine preventable diseases is integrated
with Integrated Disease Surveillance Programme (IDSP). Name- based monitoring of both
mother and children for vaccination are done through Mother and Child Tracking System
(MCTS)
Mission Indradhanush: To strengthen and invigorate the Universal Immunization
Programme (UIP) and achieve full immunization coverage for all children at a rapid pace, the
Government of India (GoI) launched Mission Indradhanush in December 2014. Mission
Indradhanush ensures that all children under the age of two years and pregnant women are fully
immunized with all available vaccines.

3. Rashtriya Bal Swasthya Karyakram (RBSK)

The Purpose of RBSK is to improve the overall quality of life of children, 0- 18 years, through
early detection & intervention of 4Ds i.e. Defect at birth, Diseases,Deficiencies, Developmental
delays and disabilities. These will cover 38 identified health conditions through dedicated mobile
health teams in every block in schools and Anganwadi centers. District Early Intervention Center
(DEIC) is the setup for further screening, management support and referral to higher center.

4. Integrated Management of Common Childhood Illnesses(IMNCI)

Facilities for prevention, early detection and management of diarrhea, Pneumonia and Malaria

5. Nutritional Rehabilitation Centers (NRCs)

NRCs are set up in the health facilities, especially at DHs and FRUs for inpatient management of
severely malnourished children, with counseling of mothers for proper feeding and regular
follow up on discharge.

6. Monitoring: Child Death Review

Reporting and reviewing of child death under 5 years is a priority area.

C. Adolescent Health Programme

1. Rashtriya Kishor Swasthya Karyakram (RKSK):Adolescent Friendly Health Services (AFHS)
are present in district health facilities to provide counseling on sexual and reproductive health
including menstrual hygiene, substance abuse, violence including domestic violence, mental
health, injuries, non- communicable diseases and provide iron and folic acid tablets,condoms,
pregnancy kits and Oral Contraceptive Pills (OCPs) through dedicated trained counselors.

D. Reducing Fertility Rate: Family Planning Services

For the purpose of encouraging family planning in the district, all PHCs, CHCs and DH services
provide temporary and permanent family planning methods including male and female
sterilization surgeries, Intrauterine Contraceptive Device (IUCD), Post- Partum Intrauterine
Contraceptive Device (PPIUCD), Oral Contraceptive Pills (OCPs), Emergency Contraceptive
Pills (ECPs), condoms and counseling services. In addition, outreach sterilization services are
conducted in remote areas. A month long (in two phases June 27- July 10 and July 11- July 24)
national campaign on World Population Day per year, is done in all the states/ Districts. AYUSH
Doctors are also trained in IUCD insertions. NSV Day (Non Scalpel Vasectomy Day) is
conducted on the 21st of each month.
National family planning indemnity scheme (NFPIS) insures and indemnifies institutions
against litigations in case of deaths, complications and sterilization failures.

E. Declining Sex Ratio:

Under this program, Government has been implementing the Pre- Conception and Pre-
Natal Diagnostic Techniques (PCPNDT) Act 1994, to control the falling child sex ratio and to
prevent female foeticide. Registered ultrasound centres have to ensure that sex determination of
foetus is not done under any circumstances. There is a provision of punitive action during the
execution or after receiving the complaint of foetal testing.
5. Preventing Communicable and Non Communicable Diseases: National Disease Control
Programmes

Non Communicable Diseases Programmes

1. National Program for Prevention and Control of Diabetes, CVD and Stroke (NPCDCS)
Specialized management of Diabetes, CVD, Stroke and Cancer.
2. National program for Prevention and Control of Blindness (NPCB):Providing screening for
detection and management of diabetic retinopathy, refractory defects and glaucoma.
3. National Program for Prevention and Control of Deafness (NPPCD): Prevention of avoidable
hearing loss and early detection & treatment of ear problems.
4. National Mental Health Program (NMHP): Providing services for early detection & treatment
of mental illness in the community
5. National Oral Health Program (NOHP) Promotive and preventive oral health care at Primary
and secondary level.
6. National Program for Health Care of the Elderly (NPHCE):Specialized accessible healthcare
for elderly.
7. National Iodine Deficiency Disease Control Program (NIDDCP):To check iodine deficiency
related health Problems.
8. National Tobacco Control Program (NTCP):To spread awareness and better implementation
of tobacco control.

Communicable Disease Programmes

1. National Vector Borne Disease Control Programme (NVBDCP):Prevention and control of
vector borne diseases like malaria, Japanese encephalitis, dengue, chicken guinea, Kala-azar,
Lymphatic filariasis.
2. Revised National Tuberculosis Control Program (RNTCP):Prevention, Control & Treatment
of Tuberculosis.
3. National Leprosy Eradication Program (NLEP):Diagnosis and treatment (Multi-Drug
Treatment- MDT) of leprosy patients.
4. Integrated Disease Surveillance Program (IDSP):Prevention and Control of outbreaks

6. Community Processes

1. Village Health Sanitation &Nutrition Committee (VHSNC)

 Formed at each village level within the framework of Gram Sabha.
 Subcommittee or a standing committee of the Gram Panchayat.
 Representation of disadvantaged sections including women.
 Acts as a platform for convergence of all departments at village level.It is also functions
as a Planning and monitoring committee at the village level.
2. ASHA
 Interface between the community and the public health system.
 They are female health activists at household level.
 Involved in educating and mobilizing communities particularly marginalized
communities.
 Functions include home visits, attending the Village Health and Nutrition Day (VHND),
visits to the health facility, holding village level meetings and maintaining records.
 In rural areas, one ASHA worker per village and in urban areas, one ASHA per 1000-
2500 population.

3. Anganwadi Workers
 Under the ICDS programme Involved with ASHAs and ANM( Triple A team) in
convening the Village Health & Nutrition Days and VHSNCs.

4. Jan Sunwai or Jan Samvad

 Public Dialogues/Public Hearings - taking direct feedback taken from the Community
members
 Grievance Redressal mechanism
IEC Activities: Comprehensive communication strategy adopted with a strong behavior
change communication (BCC) component in the IEC strategy; dissemination in villages and
lowest levels. There is participation of non government agencies and professional and
specialized agencies, visible mass media efforts in massive health communication efforts. There
is a substantial portion of the interpersonal BCC effort is through local ground level workers
including ASHA and ANMs, and community level structures equipped with communication kits,
interacting on a one to one basis with families.

INSTITUTIONAL FRAMEWORK
A. National Level Implementation
At National Level, there is a Mission Steering Group (MSG) under the chairmanship of Union
Minister of Health & Family Welfare and Convener as Secretary ,Department of Health &
Family Welfare. MSG provides policy direction to NHM. There is an Empowered Programme
Committee (EPC) headed by Secretary, Department of Health & Family Welfare, which
scrutinizes all before approval by MSG.
B. State Level Implementation
There is a State Health Mission with the State level Health Society (SHS), headed by the Mission
Director. It is further supported by State Programme Management Unit, State Health Resource
Centre and State Institute of Health and Family Welfare.

C. District Level Implementation

At District Level, the mission operates under the District Health Mission (DHM)/City Health
Mission (CHM) with District Health Society (DHS) headed by District Collector. Societies for
various National in DHS.

District Health Society (DHS):Like State Health Mission, there is a District Health
Mission in every District and under it functions a District Health Society to support its activities.
It has a Governing Body with District Collector/District Magistrate as the Chairperson (CEO). It
also has an Executive Committee with Deputy District Collector (DDC)/CMO (if no DDC) as
the Chairperson and District Programme Manager (DPM) as the CEO and Convener. DHS is
responsible for planning and managing all NHM programmes in the district.

District Programme Management Unit (DPMU), District Public Health Resource District
Education and Training Centre perform similar functions as their state and national counterparts.
Each District Hospital’s role is strengthened to create District Hospital and Knowledge Centre
(DHKC). This includes secondary care provision, considerable tertiary care provision, referral
support, centre for skill based in service training, clinical site training for nursing, paramedical
and public health professionals, data management and analysis for district planning, knowledge
support for clinical centres below it via telemedicine etc.

D. Block and Below Level Implementation

Implementation of programme and utilization of funds starts at Block level. Block Accounts
Officer disburses the funds to Block Level PHCs, CHCs, Sub-centres and VHCs under his
jurisdiction and monitors its utilization.

At Village level, there is PHC Medical Officer in Charge and ASHA Facilitators (1 per
20 ASHAs) supported by ANM; AWW and Village Health Sanitation and Nutrition Committee
(VHSNC). VHSNC acts as a platform for convergence of all departments at village level.
NATIONAL URBAN HEALTH MISSION

NUHM seeks to improve the health status of the urban population particularly slum
dwellers and other vulnerable section by facilitating their acces to quality health care. NUHM
would cover all state capitals, district headquarters and about 779 other cities/towns with a
population of 50,000 and above (as per census 2011) in a phased manner, Cities and towns below
50,000 population will be covered by NRHM.

The NUHM will focus on :

1. Urban poor population living in listed and unlisted slums;

2. All other vulnerable population such as homeless, rag-pickers, street children, rickshaw
pullers, construction and brick and lime-kiln workers, sex workers and other temporary
migrants;

3. Public health thrust on sanitation, clean drinking water,vector control etc.; and

4. Strengthening public health capacity of urban local bodies

The treatment of seven meteropolitan cities, viz., Mumbai, New Delhi, Chennai, Kolkata,
Hyderabad, Bengaluru and Ahmedabad will be different. These cities are expected to manage
NUHM through their Municipal Corporation directly.

Core Strategies:

 Improving the efficiency of public health system in the cities by strengthening and
improving existing government primary urban health structure and referral facilities.

 Promotion of access to improved health care at household level through community

based groups : Mahila Arogya Samitis.

 Strengthening public health through innovative action.

 Increased access to health care.

 IT enabled services (ITES) and e- governance for improving access improved

surveillance.

 Prioritizing the most vulnerable amongst the poor.

 Ensuring quality health care services.

Essential services to be rendered by the ASHA may be as follows :

i. Active promoter of good health practices and enjoying community support

 ii. Facilitate awareness on essential RCH services,Sexuality, gender equality, age at
marriage/pregnancy, motivation on contraception adoption, medical termination of
pregnancy, sterilization, spacing methods. Early registration of pregnancies, pregnancy
care, clean and sale delivery, nutritional care during pregnancy, identification of danger
signs during pregnancy, counselling on immunization. ANC, PNC act as a depot holder
for essential provisions like oral rehydration therapy TORS). Iron Folic Acid Tablet
(IFA), chloroquine, oral pills and condoms, etc. Identification of target beneticsaries and
support the ANM in conducting regular monthly outreach session and tracking service
coverage
iii. Facilitate access to health related services available at the Anganwadi/ Primary Urban
Health Centres /Urban Local Body (ULBs) and other services being provided by the ULB
State Central Government.
iv. Formation and promotion of Mahila Arogya Samitis in her community
v. Arrange escort/accompany pregnant women and children requiring treatment to the
nearest Urban Primary Health Centre, secondary tertiary level health care facility
vi. Reinforcement of community action for immunization, prevention of water borne and
other communicable diseases like TB (DOTS). Malaria Chilungunya and Japanese
Encephalitis
vii. Carrying out preventive and promotive health activities with AWW/ Mahila Arogya
Samiti
viii. Maintenance of necessary information and records about births and deaths.
immunization, antenatal services in het assigned locality as also about any unusual health
problem or disease outbreak in the slum and share it with the ANM in charge of the area
In return for the services rendered, she would receive a performance based
incentive For this purpose a revolving fund would be kept with the ANM at the U PHC
(in the PHC account), which would be replenished from time to time

The urban health care facilities are :

 Urban Primary Health Centre

Functional for a population of around approximately 50.000- 60 000, the U-PHC may be
located preferably within a slum or near a slum within half a kilometer radius, catering to a slum
population of approximately 25,000-30,000, with provision for OPD The cities based upon the
local situation may establish a U-PHC for 75,000 for areas with very high density and can also
establish one for around 5,000-10.000, slum population for isolated slum clusters

At the UPHC level services provided will include OPD (consultation) basic laboratory
diagnosis drug /contraceptive dispensing apart from distribution of health education material and
counselling for all communicable and non-communicable diseases. In order to ensure access to
the urban slum population at convenient timings the U-PHC may provide services from 12 noon
fo 8 pm. It will not include In-patient care. The staff pattern will be as
 Referral unit

Urban Community Health Centre (U CHC) may be set up as a satellite hospital for every 4-5
U-PHC. The U-CHC would cater to a population of 2.50.000 It would provide in-patient services
and would be a 30-50 bedded facility.UCHCs would be set up in cities with a population of
above 5 lakhs, whenever required. These facilities would be in addition to the existing facilities
SDH /DH) to cater to the urban population in the locality,

For the metro cities, the U-CHCs may be established for every 5 lakh population with
100 beds.

For setting up the U-CHCs the Central Government would provide only a one time
capital cost, and the recurrent costs including the salary of the staff would be borne by the
respective state governments.

The U-CHC would provide medical care, minor surgical facilities and facilities for institutional
delivery.

 Community Level

A. Urban Social Health Activist (USHA):

 A Frontline community worker for each slum/community

 The USHA would be a woman resident of the slum, preferably in the age group of 25 to
45 years married / widowed/ divorced.

 She would be covering about 1000 – 2500 community level beneficiaries.

 She would be covering between 200-500 households functional at the slum level the door
steps.
 She would serve as an effective link between the Urban Primary Health Centre and the
urban slum populations.

 She would maintain interpersonal communication with the beneficiary families and
individuals.

 She would help the ANM in delivering outreach services in the doorsteps of the
beneficiaries.

FUNCTIONS:

 To promote good health services in her area.

 To facilitate awareness on RCH services.

 To motivate all types of family planning methods.

 To register all pregnant mothers and to motivate them for antenatal care.

 To act as a depot for essential provisions like ORS packets, IFA tablets, Chloroquine
tablets, oral pills, condoms etc.

 To support ANM in conducting monthly outreach session regularly.

 To escort the patients requiring health services.

 To encourage the community participation in health activities.

 To maintain the records of vital events in her area.

 To treat minor ailments with the drug kit provided.

 Reinforcement of community action for immunization

B. MAHILA AROGYA SAMITI (MAS):

 It acts as community group involved in community awareness, interpersonal

communication, community based monitoring and linkages with the services and referral.

 The MAS may cover around 50- 100 households (HHs 250-500 population) with an
elected Chairperson and a Treasurer supported by an USHA Link worker.

 This group would focus on preventive and promotive health care.

Functions of MAS:

 To focus on preventive and promotive care.

  To act as peer education group.

 To facilitate access to identified facilities.

 Community monitoring and referral.

 Risk pooling fund and health insurance.

C. AUXILIARY NURSE MID-WIFE:

 Each ANM will organize a minimum of one outreach session every month.

 Outreach Medical Camps – Once in a week the ANMs would organize one Outreach
Medical Camp in partnership with other health professionals (doctors
/pharmacist/technicians /nurses – government or private.

Outreach sessions will be planned to focus special attention for slum population, rag pickers, sex
workers, street children and rickshaw pullers

 Referral linkages

Existing hospitals, including ULB maternity homes, state government hospitals and
medical colleges, apart from private hospitals will be empanelled/accredited to act as referral
points for different types of healthcare services like maternal health. child health, diabetes,
trauma care, orthopaedic complications, dental surgeries, mental health, critical illness, deafness
control, cancer management, tobacco counselling /cessation, critical illness, surgical cases etc.

NATIONAL RURAL HEALTH MISSION (NRHM)

Objectives, Goals & Strategies of NRHM

Objectives Goals Strategies

1. Reduction in Infant Mortality 1. Reduce IMR to 25/ 1000 1. Strengthening infrastructure at

Rate (IMR) and Maternal live births all levels
Mortality Rate (MMR 2.Prevention and reduction of 2. Quality Monitoring of
2. Population stabilization, anaemia facilities as per Indian Public
gender and demographic in women aged 15- 49 years Health
balance 3. Reduce Total Fertility Rate Standards ( IPHS) Standard
(TFR) to 2.1 3. Decentralised planning with
4. Reduce MMR to 1/ 1000 autonomy for local action
live births 4. Institutional Mechanisms at all
levels with autonomy
5. Induction of management
 specialist into Programme
management Units
6. Centralized technical support
unit- National Health
Resource Centre and State Health
ResourceCentre(NHSRC
and SHSRC)
3. Achieve Universal access to 1. Reduce household out –of- 1. Decentralised planning with
public health services like pocket autonomy for local action
women’s health, child health, expenditure on total health 2. Inter sector District Health
water, sanitation & hygiene, care Plan includes drinking water,
immunization, and nutrition. expenditure sanitation, hygiene, nutrition
4. Promotion of healthy life Capacity- Building of Panchayati
styles Raj institutions
3. Developing capacities for
preventive health care at all
levels
5. Prevention and control of 1. Prevent and reduce mortality 1. Integrating vertical Health and
communicable and and Family Welfare programmes
noncommunicable morbidity from communicable, 2. Developing capacities for
diseases, noncommunicable, preventive health care at all
including locally endemic injuries and emergency levels
diseases diseases 3. Reorienting Medical
2. Reduce annual incidence Education to Rural Health Issues
and mortality
from Tuberculosis by half
3. Reduce prevalence of
Leprosy to
<1/10000 population and
incidence to
zero in all districts
4. Annual Malaria incidence to
be <1/1000
Less than 1 per cent
microfilaria
prevalence in all districts
5. Kala- Azar Elimination by
2015, <1case
per 10000 population in all
blocks
6. Access to integrated 1. Reduce household out –of- 1. Promote ASHA healthcare
 comprehensive primary pocket service delivery
healthcare expenditure on total health 2. Health Plan for each village
7. Revitalization of local health care through VHNSC
traditions and mainstream expenditure 3. Untied funds with flexi pools
AYUSH of funds
4. Effective and visible risk
pooling and social health
insurance
5. Promoting non-profit sector
and PPP for achieving goals in
underserved areas
6. Mainstreaming AYUSH and
local health traditions

Plan Of Action To Strengthen Infrastructure:

1. Creation of a cadre of Accredited Social Health Activist (ASHA)

2. Strengthening sub-centres by :-
a. Supply of essential drugs both allopathic and AYUSH to the sub-centre
b. In case of additional outlay provision of multipurpose worker (male)additional ANMs
wherever needed, sanction of new sub-centres and upgrading existing sub-centres, and
c. Strengthering sub-centres with untied funds of Rs 10,000 per annum in all 18 states

3. Strengthening Primary Health Centres: Mission aims at strengthening PHCs for quality
preventive, promote, curative, supervisory and outreach services through
a. Adequate and regular supply of essential drugs and equipment to PHCs (including supply
of auto-disabled syringes for immunization);
b. Provision of 24 hours service in at least 50 per cent PHCs by including an AYUSH
practitioner,
c. Following standard treatment guidelines
d. Upgradation of all the PHCs for 24 hours referral service and provision of second doctor
at PHC level (one male and one female) on the basis of felt need; strengthening the
ongoing communicable disease control programmes and new programmes for control of
non communicable diseases

4. Strengthening Community Health Centres for First Referral care by-

a. Operating all existing CHCs (30-50 beds) as 24 hours first referral units, including
posting of an anesthetist;
b. Codification of new “Indian Public health standards” by setting up norms for
infrastructure staff, equipment, management etc. for CHCs;
c. Promotion of “Rogi Kalyan Samiti” for hospital management etc. for CHCs;
d. Developing standards of services and costs in hospital care.

5. District health plan under NRHM :District is the core unit of planning , budgeting and
implementation of the programme.

 —All vertical health and family welfare programmes at district level have merged into
one common “District Health Mission” and at state level into “State Health Mission”.
 —There is provision of a "mobile medical unit at district level for improved outreach
services.
6. CONVERGING SANITATION AND HYGIENE UNDER NRHM

 —Total Sanitation Campaign (TSC) is implemented and  is proposed to cover all districts
in 10th Plan.
 —Components of TSC include IEC activities, individual household toilets, women
sanitary complex, and School Sanitation Program.
 —The District Health Mission would guide activities of sanitation at district level, and
promote joint IEC for 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.
7. STRENGTHENING DISEASE CONTROL PROGRAMMES

 —National Disease Control Program for Malaria, TB, Kala Azar, Filaria, Blindness &
Iodine Deficiency and Integrated Disease Surveillance Program shall be integrated under
the Mission, for improved program delivery.
 —New Initiatives would be launched for control of Non Communicable Diseases.
 —Disease surveillance system at village level would be strengthened.
 —Supply of generic drugs (both AYUSH & Allopathic) for common ailment at village,
SC, PHC/CHC level.
8. PUBLIC-PRIVATE PARTNERSHIP FOR PUBLIC HEALTH GOALS, INCLUDING
REGULATION OF PRIVATE SECTOR

 —Since almost 75% of health services are being currently provided by the private sector,
there is a need to refine regulation.
 —Need to develop guidelines for Public-Private Partnership (PPP) in health sector.
Identifying areas of partnership, which are need based.
 —Management plan for PPP initiatives: at District/State and National levels.
9. NEW HEALTH FINANCING MECHANISMS

 —The District Health Missions to move towards paying hospitals for services by way of
reimbursement.
 —Standardization of services – outpatient, in-patient, laboratory, surgical interventions.
 —A National Expert Group to monitor these standards and give suitable advice and
guidance on protocols and cost comparisons.
  —All existing CHCs to have wage component paid on monthly basis.
 Over the Mission period, the CHC may move towards all costs, including wages
reimbursed for services
10. REORIENTING HEALTH/MEDICAL EDUCATION TO SUPPORT RURAL
HEALTH ISSUES

 —While district and tertiary hospitals are necessarily located in urban centres, they form
a 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.
Major initiatives under NRHM

1. Selection of ASHA:
ASHA must be the resident of the village- a woman (married/ widow / divorced) preferably
in the age group of 25 to 45 vears with formal education up to eighth class, having
communication skills and leadership qualities. Adequate representation from the
disadvantaged population group will ensure to serve such groups better.
The general norm of selection is one ASHA for 1000 population. In tribal, hilly and
desert areas the norm could be relaxed to one ASHA per habitation

Role and responsibilities of ASHA

ASHA will be a health activist in the community who will create awareness on health.
Her responsibilities will be as follows:

1. ASHA will take steps to create awareness and provide information to the community on
determinants of health such as nutrition, basic sanitation and hygienic practices, healthy living
and working conditions, information on existing health services, and the need for timely
utilization of health and family welfare services.

2. She will counsel women on birth preparedness, importance of safe delivery, breast-feeding
and complementary feeding, immunization, contraception and prevention of common infections
including reproductive tract infection/sexually transmitted infection and care of the young child.

3.ASHA will mobilize the community and facilitate them in accessing health and health related
service available at the anganwadi/subcentre/primary health centres, such as immunization,
antenatal check up,postnatal check-up supplementary nutrition,sanitation and other services
being provided by the government

4 She will work with the village health and sanitation committee of the gram panchayat to
develop comprehensive village health plan
5.She will arrange escort/accompany pregnant women and children requiring
treatment/admission to nearest pre-identified health facility i.e. primary heath centre/community
health centre/First Referral Unit.

6. ASHA will provide primary medical care for minor ailments such as diarrhoea, fevers, and
first-aid for minor injuries. She will be a provider of directly observed treatment short-course
(DOTS) under revised national tuberculosis control programme.

7. She will also act as a depot holder for essential provisions being made available to every
habitation like oral rehydration therapy, iron folic acid tablet, chloroquine, disposable delivery
kits, oral pills and condoms etc. A drug kit will be provided to each ASHA Contents of the kit
will be based on the recommendations of the expert technical advisory group set up by the
government of lndia, and include both AYUSH and allopathic formulations.

8. Her role as a provider can be enhanced subsequently. States can explore the possibility of
graded training to her tor providing newborn care and management of a range of common
ailments, particularly childhood illnesses

9. She will inform about the births and deaths in her village and any unusual health
problems/disease outbreaks in the community to the sub-centre/primary health centre

10. She will promote construction of household toilets under total sanitation campaign.

Role and integration with Anganwadi

Anganwadi worker will guide ASHA in performing following activities

a. Organizing Health Day once/twice month. On health day, the women, adolescent girls
and children from the village will be mobilized for orientation on health related issues
such as importance of nutritious food personal hygiene, care during pregnancy,
importance of antenatal check-up and institutional delivery, home remedies for minor
ailment and importance of immunization etc. AWWs will inform ANM to participate and
guide organizing the Health Days at anganwadi centre;
b. AWWs and ANMs will act as 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;
c. Anganwadi worker will be depot holder for drug kits and will be issuing it to ASHA. The
replacement of the consumed drugs can also be done through AWW;
d. 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; and
e. 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 check-ups/health days etc. to
anganwadi centres.

Role and integration with ANM

Auxiliary Nurse Midwife (ANM) will guide ASHA in performing following activities

a. She will hold weekly fortnightly meeting with ASHA and discuss the activities
undertaken during the week / fortnight. She will guide her incase ASHA had encountered
any problem during the performance of her activity,
b. AWWs and ANMs will act as resource persons for the training of ASHA.
c. 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.
d. ANM will participate and guide in organizing the Health Days at anganwadi centre.
e. She will take help of ASHA in updating eligible couple register of the village concerned;
f. She will utilize ASHA In motivating the pregnant women for coming to sub-centre for
initial check ups. She will also help ANMs in bringing married couples to sub centres for
adopting family planning:
g. ANM will guide ASHA in motivating pregnant women for taking full course of iron and
folic acid tablets and tetanus toxoid injections etc.
h. ANMs will orient ASHA on the dose schedule and side effects of oral pills,
i. ANMs will educate ASHA on danger signs of pregnancy and labour so that she can
timely identify and help beneficiary in getting further treatment, and
j. ANMs will inform ASHA on date, time and place for initial and periodic training
schedule She will also ensure that during the training ASHA gets the compensation for
performance and also TA/DA for attending the training.

2. Rogi Kalyan Samiti (Patient Welfare Committee/ Hospital Management Society):

It is a simple yet effective management structure This committee is a registered society whose
members act as trustees to manage the affairs of the hospital and is responsible for upkeep of the
facilities and ensure provision of better facilities to the patients in the hospital. Financial
assistance is provided to these committees through untied fund to undertake activities for patient
welfare. 31,109 Rogi Kalyan Samitis (RKS) have been set up involving the community members
in almost all District Hospitals (DHs), Sub-District Hospitals (SDHs),Community Health Centres
(CHCS) and Primary Health Centres (PHCS) till March 2014

3. The untied grants to sub centres (SCs):

The SCs are far better equipped now 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

4 The Village Health Sanitation and Nutrition Committee (VHSNC):

It is an important tool of community empowerment and participation at the grassroots level, The
VHSNC reflects the aspirations of the local community,especially the poor households and
children. Upto 31st March 2014, 5.12 lakh VHSNCs have been set up across the country.

5 Janani Suraksha Yojana (JSY):

It aims to reduce maternal mortality among pregnant women by encouraging them to deliver in
government health facilities. Under the scheme, cash assistance is provided to eligible pregnant
women for giving birth in a government health facility Since the inception of NRHM, 7.04 crore
women have benefited under this scheme.

6. Janani Shishu Suraksha Karyakarm (JSSK):

Launched on 1st June, 2011, JSSR entitles all pregnant women delivering in public health
institutions to absolutely free and no expense delivery, including caesarean section. This marks a
shift an entitlement based approach.

1. National Mobile Medical Units (NMMUs):

Support has been provided in 418 out of 640 districts for 2127 MMUs under NRHM in the
country.To increase visibility, awareness and accountability, all Mobile Medical Units have been
repositioned as “National Mobile Medical Unit Service” with universal colour and design.

2. National Ambulance Services:

NRHM has supported free ambulance services to provide patients transport in every nook and
corner of the country connected with a toll free number. Over 16000 basic and emergency patient
transport vehicles have been provided under NRHM. Besides these, over 4769 vehicles have
been empanelled to transport patients, particularly pregnant women and sick infants from home
to public health facilities and back.28 states have set up a call centre for effective patient
transport system

3. Web enabled Mother and Child Tracking System (MCTS):

The name-based tracking of pregnant women and children has been initiated under NRHM with
an intention to track every pregnant woman, infant and child up to the age of three years by
name, for ensuring delivery of services like timely antenatal care, institutional delivery and
postnatal care for 1he mother and immunization and other related services tor the child. The
MCTs is to be fully updated for regular and effective monitoring of service delivery including
tracking and monitoring of severely anaemic women, low birth weight babies and sick neonates
In the long run. it could be used for tracking the health status of the girl child and school health
services A more recent initiative is to link MCTS with AADHAR in order to track subsidies to
eligible women
New Initiatives

The following are the major decisions of Mission Steering Group: taken since 2011:

1. Home delivery of contraceptives (condoms oral contaceptive pills, emergency contraceptive

pills) by ASHA:

2. Conducting District Level Household Survey (DLHS)-4 in 26 States/UTs where the Annual
Health Survey (AHS) is not being done;

3. Modifications in the scheme for promotion of menstrual hygiene covering 152 districts and
nearly 1.5 crores of adolescent girls in 20 states;

4. Differential financial approach for comprehensive health care by which allocation of Untied
Funds and Rogi Kalyan Samiti grants will be made based on the case load and services provided
by the health facility;

5. Involving ASHA in Home Based Newborn Care;

6. Revision in the criterion of allocation of funds to the states under NRHM based on the
performance of the states against the monitorable targets implementation of specific reform
agenda in the health sector;

7. Expansion of Village Health and Sanitation committee include nutrition in its mandate and
renaming it as Village Health, Sanitation and Nutrition Committee (VHSNC);and 

8 Partial modification of the centrally sponsored scheme for development of AYUSH hospitals
and dispensaries for mainstreaming of AYUSH under NRHM,

9. Rashtriya Bal Swasthya Karyakram (RBSK): This initiative was launched in February 2013
and provides for Child Health Screening and Early Intervention Services through early detection
and management of 4 Ds i.e; Defects at birth, Diseases, Deficiencies, Development delays
including disability.

10 Rashtriya Kishor Swasthya Karyakram (RKSK): This is a new initiative, launched in January
2014 to reach out to 253 million adolescents in the country in their own spaces and introduces
peer-led interventions at the community level, supported by augmentation of facility based
services This initiative broadens the focus of the adolescent health programme beyond
reproductive and sexual health and brings in focus on life skills. Nutrition injuries and violence
(including gender based violence), non-communicable diseases, mental health and substance
misuse

11. Mother and Child Health Wings (MCH Wings): 100/50/ 30 bedded Maternal and Child
Health (MCH) Wings have been sanctioned in public health facilities with high bed occupancy to
cater to the increased demand for services. More than 28000 additional beds have been
sanctioned across 470 health facilities across 18 states.

12. Free drugs and free diagnostic service

13 National Iron+ Initiative is another new initiative launched in 2013, to prevent and control
iron deficiency anaemia, a grave public health challenge in India. Besides pregnant women and
lactating mothers, it aims to provide IFA supplementation for children, adolescents and women
in reproductive age group. Weekly Iron and Folic Acid Supplementation (WIFS) for adolescents
is an important strategy under this initiative WIFS (for 10-19 years age) has already been rolled
out in 32 states and UTs under the National Iron Plus Initiative WIFS covered around 3 crore
beneficiaries in December 2013

14. Reproductive, Maternal Newborn. Child and Adolescent Health Services (RMNCH+A) A
continuum of care approach has now been adopted under NRHM with the articulation of
strategic approach to Reproductive Maternal Newborn Child and Adolescent Health (RMNCH+
A) in India his approach brings focus on adolescents as a critical life stage and linkages between
child survival, maternal health and family planning efforts lt aims to strengthen the referral
linkages between community and facility based health services and between the various levels ot
health system itself.

15. Delivery Points (DPs): Health facilities that have demand for services and performance
above a certain benchmark have been identified as “Delivery Points” with the objective of
providing comprehensive reproductive. maternal, newborn, child and adolescent health services
(RMNCH+A) at these facilities. Funds have been allocated to strengthen these DPs in terms of
infrastructure, human resource. drugs, equipments etc. Around 17000 health facilities have been
identified as Delivery Points for focussed support under NRHM.

16. Universal Health Coverage tUHC): Moving towards Universal Health Coverage (UHC) is a
key goal of the 12th Five Year Plan. The National Health Mission is the primary vehicle to move
towards this goal.

Achievements: The achievements of NRHM as on 30th June 2013 are as follows

(1) 8.89 lakh ASHAs have been selected in the entire country of which 8.06 lakh ASHAS have
been trained and provided with drug kits

(2) 147 lakh sub-centres in the country are provided with untied funds of Rs 10.000 each. 40426
sub-centres are functional with second ANM

(3) 31.109 Rogi Kalyan Samitis have been registered at different level of facilities.

(4) 8,129 doctors and specialists, 70,608 ANMs, 34.605 staff nurses, 13.725 paramedics have
been appointed on contract to fill-in critical gaps in services.
(5) 1.691 professionals (CA/MBA/MCA) have been appointed to support NRHM.

(6) 2.127 Mobile Medical Units are operational under NRHM in states

(7) Emergency transport system operational in 12 states

(8) Accelerated immunization programme taken up tor North-East states and EAG (Empowered
Action Group) states. Progress made in pulse polio immunization (India declared polio free
country): neonatal tetanus declared eliminated in 7 states in the country; JE vaccination
completed in 11 districts in 4 states

(9) Janani Suraksha Yojana is operational in all the states. 106.57 lakh women were benefitted in
the year 2012-13.

(10) Integrated Management of Neonatal and Childhood Ilness (IMNCI) started in 310 districts.

(11) Monthly Health and Nutrition Days being organized at the village level in various states.

(12) The states have constituted 5.12 lakh Village Health Sanitation and Nutrition Committees.

(13) School health programme have been initiated in over 26 states

Monitoring and evaluation under NRHM

A baseline survey is to be taken up at the district level incorporating facility survey

(including private facilities) as well as survey of the households. The baseline survey is to help
the mission in fixing decentralized monitorable goals and indicators. There would be community
monitoring at the village level. The panchayat raj institutions, rogi kalyan samitis, quality
assurance committees at the state level and district level, state and district health missions,
mission steering group at the central level. Planning commission is to be the eventual monitor of
the outcomes. External evaluation is also to be taken up at frequent intervals.

There is a multi fold approach for monitoring. This includes

i. Large scale population surveys
ii. Evaluation studies or research on implementation
iii. HMIS data
iv. Field visits by officials.

1. Periodic Population Health Surveys and Demographic information

Periodic Sample Registration Surveys (SRS), Death statistics, National Sample Survey
Organization (NSSO) data on cost of care and morbidity, District Level Household survey
(DLHS) and National Family Health Survey (NFHS) is done to give insights into the functioning
of NRHM.

2. Evaluation studies or research on implementation

Expert groups from multiple organizations are involved for conducting independent evaluation
of all components of NRHM. Evaluation of the programme implementation in districts is done
by Regional Evaluation Teams and reports are available in public domain.

3. Strengthening Data Capturing: Health Management Information systems (HMIS):

Data is regularly uploaded from all levels, facility wise and programme wise and is monitored by
the District Teams. Health Management Information System (HMIS) Reports: HMIS is a web
based monitoring system to capture information from the primary levels and is consolidated at
State Level on a monthly basis. This is used to monitor performance of health programmes at
facility and district level and thus helps in timely corrective action.

The information from HMIS and other sources like National Family Health Survey (NFHS),
District Level Household Survey (DLHS), Census, SRS and performance statistics, is compiled
into the NHM Health Statistics Information Portal.
Data Analysis is done based on the data uploaded and further used for development of
Scorecards/Grading of CHC/Dashboards of performance based on key performance indicators
for Grading of Districts all over the country. Process and Outcome (Mortality and Morbidity
rates) indicators for diseases and Output indicators for programmes, are measured and monitored
regularly. Suitable corrective actions are taken for facilities with low scores and
reward/recognition for high performing
facilities. Achievement of goals of Universal health care i.e. out of pocket expenditure by
patients, percentage of access/coverage of people for specific services, assured services access
and availability on a cashless basis is also monitored. This is an important monitoring tool used
by District level Programme Managers.
State and District wise analysis reports are published and are available in the public
domain.

4. Access of services to disadvantaged communities of various geographical areas is monitored

by surveys and MCTS reporting system. Mother and Child Tracking System (MCTS) is a web-
based application to monitor Maternal and Infant Mortality, by facilitating tracking of Case
specific pregnant women (both ANC and PNC), child births and immunization of children up to
five years of age. It is a tool which sends regular alerts to the service providers as well as
beneficiaries about the services, to ensure the continuity of services.

5. Field Visits/Appraisal Visits: by public health experts. Reports of Common Review Mission
(CRM) annually, integrated monitoring teams of the Ministry, the Regional Directors, and the
Population Resource Centers (PRC) are some of the important ones. There are regular
monitoring visits from the Programme Management Units from States, Districts and Block to
respective lower levels under their jurisdiction.
6. Training Information Management System( TMIS) : It is an online database from district level
and above, which captures details of trainings( Guidelines, manuals, course content, real time
trainings, nominations, registrations, post training evaluations, deployment of staff etc). This is
used for monitoring of in-service trainings of health professionals in India on a single mouse
click.

7. Quality Monitoring
a. Quality Assurance in Public Health Facilities :- GoI has rolled out the “National Quality
Assurance Standards (NQAS) Guidelines” in 2013. These guidelines define a ‘road map’ for
implementing and improving quality standards of Public Health Facilities. Each healthcare
facility has in- house Quality Management System and Ranking of the facilities is done based on
performance against predefined standards. There is a State Level and District Level Quality
Assurance Cell (State Quality Assurance Committee (SQAC) & District Quality Assurance
Committee (DQAC)) coordinating these activities.
b. Mera Aspataal :- GOI recently initiated an ICT- based Patient Satisfaction System (PSS) i.e.
“Mera Aspataal/ My Hospital”. This to empower the patients to express their views on the
health services delivered in a public facility and empanelled private hospitals.

BIBLIOGRAPHY
1. http://nhm.gov.in/images/pdf/guidelines/nrhm-guidelines/mission_document.pdf
2. k park “park’s textbook of preventive an social medicine” bhanot publishers 23rd edition
page no:445-452