National Rural Health Mission

Dr. RAJESHWAR RAO A

MD
Preamble 2

Recognizing the importance of Health in the

process of economic and social development
and improving the quality of life of our
citizens,
the Government of India resolved to launch
the National Rural Health Mission to carry out
necessary architectural correction in the
basic health care delivery system.
Preamble 3

The Mission adopts a synergistic approach

by relating health to determinants of good
health viz. segments of nutrition, sanitation,
hygiene and safe drinking water.

It also aims at mainstreaming the Indian

systems of medicine to facilitate health care.
Preamble 4

The Goal of the Mission is to improve the

availability of and access to quality health care
by people, especially for those residing in rural
areas, the poor, women and children.
Genesis 5

To improve the quality of life of citizens in the

rural area & for social and economic
development GOI has started National Rural
Health Mission on 5th April, 2005
NRHM is for a period of 7 years (2005-2012)
Mission seeks to improve rural health care
delivery system
There is little expenditure on preventive and
promotive health and more on curative
services
Genesis 6

Rural population comprises 70% of total

Indians and has direct impact on health
indicators
Because of inequality of distribution of health
in the country and various challenges, the
union government on April 12, 2005 launched
a National Rural Health Mission
Genesis 7

The National Rural Health Mission seeks to

provide effective health care to the entire rural
population in the country with special focus on
18 states which have weak public health
indicators
Integration of vertical health and family health
programs and funds, for optimal utilization of
funds & infrastructure and strengthening
delivery of primary health care.
Principles 8

1) Promote Equity, Efficiency, Quality,

Accountability in public health systems
2) Enhance People orientation and community
based approaches
3) Ensure public health focus
4) Recognize value of traditional knowledge
base of communities
5) Promote new innovations, method and
process development
6) Decentralize and involve local bodies
Goals of NRHM 9

 Reduction by 50% from existing levels in next 7 years

• Infant mortality rate
• Maternal mortality ratio
 Universalize access to public health services such as
• Women’s health
• Child health
• Water
• Sanitation
• Immunization
• Nutrition
Goals of NRHM 10

Prevention and control of communicable

diseases including locally endemic diseases
Access to integrated comprehensive primary
health care
Revitalize local health traditions & mainstream
AYUSH
Assuring Population stabilization, Gender &
Demographic balance
Promotion of healthy life styles
Objectives 11

 Provision of trained and supported Village Health

Activist in under served areas as per need (ASHA-
Accredited Social Health Activist)

 Preparation of health action plans by panchayat as

mechanism for involving community in health

 Strengthening SC/PHC/CHC by developing Indian

Public Health Standards (IPHS)
Objectives 12

 Institutionalizing and substantially strengthening

district level management of health

 Increase utilization of first referral units from less than

20% (2002) to >75% by 2010.

 Strengthening sound local health traditions and local

resource based health practices related to PHC and
public health.
Targets 13

 IMR reduced to 30/1000 live births by 2012 (67.6)

 MMR reduced to 100/100,000 live births by 2012

(540/100,000)

 Total Fertility Rate reduced to 2.1 by 2012 (2.85)

 Malaria mortality reduction rate – 50% by 2010,

additional 10% by 2012
Targets 14

 Kala-azar mortality reduction rate – 100% by 2010

and sustaining elimination thereafter (2012)

 Filaria reduction rate – 70% by 2010, 80% by 2012

and elimination by 2015

 Dengue mortality reduction rate – 50% by 2010 and

sustaining it at that level till 2012
Targets 15

 Cataract operations increasing to 46 lakhs/annum

 Leprosy prevalence rate-reduce from 1.8/10,000 in

2005 to less than 1/10,000 thereafter

 TB DOTS series – maintain 85% cure through mission

period

 Japanese Encephalitis mortality reduction rate: 50%

by 2010 and sustaining at that level until 2012
Targets 16

 Upgrading Community Health Centers to Indian Public

Health Standards

 Increase utilization of First Referral Units from less

than 20% to 75%

 Engaging 250,000 female Accredited Social Health

Activists (ASHAs) in 10 States.
NRHM – Plan of Action 17

Creation of a cadre of Accredited Social Health

Activist (ASHA)
Strengthening sub-centres by:
Supply of essential drugs both allopathic and
AYUSH to the sub-centre
In case of additional outlay, provision of
multipurpose worker (male)/additional ANMs
wherever needed, sanction of new sub-centres
as per 2001 population norm and upgrading
existing sub-centres and
Strengthening sub-centres with untied funds of
`10,000 per annum in all 18 states
NRHM – Plan of Action 18

Strengthening Primary Health Centres:

Mission aims at strengthening PHCs for quality
preventive, promotive, curative, supervisory
and outreach services through
 Adequate and regular supply of essential drugs
and equipment
 Provision of 24 hours service in at least 50 per
cent PHCs by including an AYUSH practitioner
 Following standard treatment guidelines
 Up-gradation of all the PHCs for 24 hours
referral service and provision of second doctor
NRHM – Plan of Action 19

Strengthening Community Health Centres for

First Referral care by
 Operating all 3222 existing CHCs (30-50 beds)
as 24 hours first referral units, Including posting
of an anaesthetist
 Codification of new "Indian Public Health
Standards“
 Promotion of “Rogi Kalyan Samiti” for hospital
management
 Developing standards of services and costs in
hospital care
NRHM – Plan of Action 20

DISTRICT HEALTH PLAN

 Health Plans would form the core unit of action
proposed in areas like water supply, sanitation,
hygiene and nutrition.

Converging Sanitation and Hygiene under

NRHM
 Total Sanitation Campaign (TSC) – Components
of TSC include IEC activities, rural sanitary marts,
individual household toilets, women sanitary
complex, and School Sanitation Programme.
NRHM – Plan of Action 21

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

Reorienting health/medical education to

support rural health issues
NRHM – ORGANOGRAM
National steering group

Mission steering group

Empowered program committee

Mission Directorate

State Health Mission

District Health Mission – Rogi Kalyan Samitis

Panchayat (Village Health Committees)

22
 23

Proposed
structure of
NRHM
 ASHA 24

 Female community health

activist-chosen by and
accountable to the
Panchayat.

 Generally one ASHA is

present for every 1000
population
Selection of ASHA:- 25

 resident of village.
 preferably in the age group of 25-45 yrs.
 formal education upto 8th class,
 having community skills & leadership
qualities
ROLES & RESPONSIBILITIES OF 26

ASHA
Create awareness & provide information to the
community on determinants of health such as
• counsel women on birth preparedness,
importance of safe delivery,
• breast feeding complementary feeding,
• immunization,
• contraception
• mobilise the community & facilitate them in
accessing health & health related services
ROLES & RESPONSIBILITIES OF 27

ASHA
• arrange escort / accompany pregnant women &
children requiring Rx / admission to the nearest
available health facility
• provide primary medical care for minor ailments
such as diarrhoea, fevers & first aid for minor
injuries & also provider of DOTS under RNTCP
• work with the village health & sanitation
committee of gram Panchayat to develop
comprehensive village health plan
ROLES & RESPONSIBILITIES OF 28

ASHA
• act as depot holder & carries drug kit containing
ORS packets, Iron & folic acid tablets,
chloroquine, disposable delivery kits
• inform about the births, deaths, & any unusual
disease outbreaks in the community to SC or
PHC
• promote construction of house hold sanitary
latrines
Integrated Role of ASHA
• Organizing Health Day at AWC
• IEC activity on these days
• Replacement of the consumed drugs
AWW act as a updating the list of eligible couples
Resource person • Mobilizing pregnant and lactating
women and infants for nutrition
supplement
Carries
out
Training ASHA Organization of the Health Days at AWC

• Motivate people to attend outreach

ANM act as a session
• Motivates the pregnant women for
Resource person
coming to sub-centre
• Distribute oral pills
• Look for danger signs of pregnancy
29
INCENTIVES TO ASHA 30

She will receive performance based incentives

for each health activity
• early registration of pregnancies before 12 wks – `
25
• min of 3 ANC’s by ANM
• 100 Fe & folic acid tablets – ` 50
• institutional delivery – ` 150
• post natal follow up for a period of 1month – ` 100
INCENTIVES TO ASHA 31

She will receive performance based incentives

for each health activity
• completion of BCG, OPV-3, DPT-3, HEPATITIS-B
3doses before infant completes 5 months – ` 50
• measles & vit-A between 9 months & 1yr of age –
` 50
• motivation of tubectomy – ` 150
• motivation of vasectomy – ` 200
MONITORING OF ASHA’s WORK 32

1. PROCESS INDICATORS
• no. of ASHA’s selected by due process &
trained
• % of ASHA’s attending review meeting after 1
yr
MONITORING OF ASHA’s WORK 33

2. OUTCOME INDICATORS
• % of institutional deliveries
• % of new-borns weighed & families counselled

• % of children with diarrhoea who received ORS

• % of deliveries with skilled assistance

• % of institutional deliveries
MONITORING OF ASHA’s WORK 34

2. OUTCOME INDICATORS
• % of unmet need for spacing contraception
• % of fever cases who received chloroquine
within 1st week in malaria endemic area
• % of completely immunised in 12-23 months
age group
MONITORING OF ASHA’s WORK 35

3. IMPACT INDICATORS
• IMR
• Child malnutrition rates

• no. of cases of T.B /leprosy detected as

compared to previous year
 Monitoring and Evaluation 36

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

incorporating facility survey well as survey of the
households.
 There would be community monitoring at 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
 37

Thank you