• To be aware of Institutional structure for implementation of NHM

1

Service Delivery, Monitoring and Financing under NHM Quadrant – I

Personal details:

Role Name Affiliation

Principal Investigator Dr. C.P. Mishra Professor

Department of Community Medicine Benaras Hindu University, Varanasi Uttar Pradesh, India

Paper Coordinator Dr. Davendra Kumar Taneja Director Professor

Department of Community Medicine Maulana Azad Medical College New Delhi, India

Content Writer/Author Dr. Neeti Rustagi Assistant Professor

Department of Community & Family Medicine

All India Institute of Medical Sciences Jodhpur, India

Content Reviewer Dr. Bratati Banerjee Professor

Department of Community Medicine Maulana Azad Medical College New Delhi, India

Description of Module:

Items Description of Module Subject Name Community Medicine

Paper Name National Health Policies and Programmes Module Name/Title National Health Mission - II

Module Id NHPP25

Pre-requisites Knowledge on health problems and health care delivery in India

Objectives

• To get acquainted with the targeted outcomes for NHM in the 12

plan for communicable and non- communicable diseases.

• To be aware of Institutional structure for implementation of NHM

•

To understand the critical areas for concerted action envisaged for attaining health system strengthening

Key words National Health Mission

2 Introduction

With an aim to achieve country wide universal access to health care, the National Health Mission (NHM) lay down guidelines and strategies for states to build upon the experience from National Rural Health Mission (NRHM) implementation over the past seven years.

NHM adopts the Framework for NRHM Implementation approved by the Cabinet in 2006 for first phase. The Framework for Implementation of National Urban Health Mission (NUHM) has been approved by the Cabinet on May 1, 2013. Thus National Health Mission (NHM) encompasses two Sub-Missions:

The NHM for the period 2012-2017 and beyond is based on following vision:

“Attainment of Universal Access to Equitable, Affordable and Quality health care services,

Learning outcomes

At the end of the session, the students should be able to know the:

 Service Delivery Strategies under NHM

- Reproductive, Maternal, New-born, Child Health and Adolescent (RMNCH + A) Services - Control of Communicable Diseases

- Non Communicable Diseases (NCD)

 Monitoring and Evaluation

 Financing of the National Health Mission

Main Text

1. Reproductive, Maternal, New-born, Child Health and Adolescent (RMNCH + A) Services NHM emphasises on life cycle approach and continuum of care for improving maternal and child health. Enhanced focus is now on adolescence as a distinct ‘life stage’ and the strategy is to increase adolescents’ knowledge and access to reproductive health services and to address nutritional anaemia.

Further, linking of community and facility-based care and strengthening referrals to create a continuous care pathway is considered as an essential strategy embodied in RMNCH+A services.

Coverage targets for key RMNCH+ A interventions for 2017

- Increase facilities equipped for perinatal care (designated as delivery points) by 100%

- Increase proportion of all births in government and accredited private institutions at annual rate of 5.6% from the baseline of 61% (SRS 2010)

- Increase proportion of pregnant women receiving antenatal care at annual rate of 6%

from the baseline of 53%. (CES 2009)

- Increase proportion of mothers and new-borns receiving post- natal care at annual rate of 7.5% from the baseline of 45%. (CES 2009)

- Increase proportion of deliveries conducted by skilled birth attendants at annual rate of

3

- Increase exclusive breast feeding rates at annual rate of 9.6% from the baseline of 35%

(CES 2009)

- Reduce prevalence of under five children who are underweight at annual rate of 5.5%

from the baseline of 45%. (NFHS-3)

- Increase coverage of 3 doses of combined DPT3 (12-23 months) at annual rate of 3.5%

from the baseline of 7% (CES 2009)

- Increase ORS use in under- five children with diarrhoea at annual rate of 7.2% from the baseline of 43%. (CES 2009)

- Reduce unmet need for family planning methods among eligible couples, married and unmarried, at annual rate of 8.8% from the baseline of 21% (DLHS-3)

- Increase met need for modern family planning methods among eligible couples at annual rate of 4.5% from the baseline of 47% (DLHS-3)

- Reduce anaemia in adolescent girls and boys (15-19 years) at annual rate of 6% from the baseline of 56% and 30% respectively (NFHS-3)

- Decrease the proportion of total fertility contributed by adolescents (15-19 years) at annual rate of 3.8% per year from the baseline of 16% (NFHS-3)

- Raise child sex ratio in the 0-6 year age group at annual rate of 0.6% per year from the baseline of 914 (Census 2011).

1.1. Maternal health: Universal access to all populations in a district is envisaged for:

- Improved access to skilled obstetric care through facility development - Increased coverage and quality of ante-natal and post natal care - Increased access to skilled birth attendance and institutional delivery - Basic and comprehensive emergency obstetric care

This will be achieved through

a. Mapping and identification of health facilities as “delivery points” and strengthening them for delivery of comprehensive package of RMNCH+A services.

Delivery Points :

L1 – Minimum 3 deliveries per month

L2 - Minimum 10 deliveries per month, including management of complications L3 - Minimum 20- 50 deliveries per month, including C- section

MCH wings – to be established in facilities with high case load (30/50/100 bedded) to ensure provision of emergency maternal and new-born care services along with 48 hours stay.

b. Contract- In of private providers to supplement services through public health facilities.

c. Multi-skilling medical officers with specialist skills to provide emergency obstetric care.

d. The Janani Suraksha Yojana (JSY) will be modified to synergise with the new Food Security legislation.

e. Janani Shishu Suraksha Karyakram (JSSK) launched on June 1, 2011 to provide universal health coverage through an expanding comprehensive package of free and cashless services currently covering all pregnant women and sick infants up to the age of one year in government health institutions.

f. Strengthening of emergency response and patient transport systems for improving access to institutional care including assured availability of referral and transport services with respect to inter facility transfers and out referrals.

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g. For improved monitoring of care in pregnancy, mother and child name based information systems and facility and community based Maternal Death Reviews (MDRs) to be emphasised.

h. Emphasis on comprehensive women’s health including pregnancy related morbidity, care for non-communicable diseases among women including screening and treatment of women for common cancers such as cervix and breast.

1.2. Access to safe abortion services:

The focus is on improving access to comprehensive abortion care including post abortion contraceptive counselling and services by expanding the network of facilities providing Medical Termination of Pregnancy (MTP) services. This will be achieved by enabling:

a. MTP services to be provided at least in every 24×7 facility in every block and in every facility upgraded for FRU services (also Level 3 services).

b. Multi-skilling of providers will include use of Manual Vacuum Aspiration (MVA) and medical abortion.

1.3. Prevention and Management of reproductive Tract Infections (RTI) and Sexually Transmitted Infections (STI):

Key strategies include

a. Prevention of RTI/STI to be included in BCC interventions for community health education and especially for adolescents.

b. Provision of diagnosis and treatment services at health facilities, syndromic management at 24×7 and lower levels, and laboratory and diagnostic based services at Level 3 facilities.

c. Special focus on linking up RTI/STI services with Integrated Counselling and Treatment Centres (ICTCs) and establishing appropriate referrals for HIV testing and RTI/STI management.

1.4. Gender based Violence

Gender based violence against women results in physical injuries, reproductive health and mental health problems. The steps towards enabling a system wide response to gender based violence (GBV) include:

- Sensitise and train frontline workers and clinical service providers to identify and manage (refer/counsel) GBV.

- Developing of effective referral mechanisms and creating functional referral linkages and follow up mechanisms with government departments, NGOs (for providing legal and social welfare services) and women’s support groups in the district.

1.5. New-born and Child health

India has launched, the India Newborn Action Plan (INAP) in response to the global Every Newborn Action Plan (ENAP) in June 2014.

Goal:

To attain “Single Digit Neonatal Mortality rate by 2030” &

“Single Digit Stillbirth rate by 2030”.

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Figure 1. Continuum of care from the community to facility level under INAP

All the interventions for new-born are grouped in six packages (based on life stages) and are categorised as:

a. Essential (E) – to be implemented universally

b. Situational (S) – implementation dependent on epidemiological context

c. Advanced (A) –implementation based on the health – system capacity of state / district.

1.6. Navjat Shishu Suraksha Karyakaram (NSSK):

This aims to train health personnel in basic new-born care and resuscitation at every delivery point (hypothermia, infection, breast – feeding and basic new-born resuscitation) by establishing Newborn Care Corners. This will be supplemented with provision of home based new-born and child care through ASHAs and ANMs supplemented by AWW and community level care for acute respiratory infections, diarrhoea, and fevers, including home remedies, first contact curative care, or referral as appropriate. Other important area to be emphasised is Infant and Young Child Feeding (IYCF) and nutrition counselling to support early and exclusive breastfeeding, complementary feeding and micronutrient supplementation. New-born Stabilisation Units (NBSU) and Special New-born Care Units (SNCU) need to be established by strengthening public health facilities and accrediting private providers to manage referrals. Institutional care for sick children and management of Severe Acute Malnourished (SAM) children at Nutrition Rehabilitation Centres (NRC) with linkage to community based care is also envisaged. NRCs are facility based units providing medical and nutritional care to SAM children under 5 years of age with medical complications. Also, emphasis will be made on reporting and reviewing of child deaths (under five years).

1.7. Universal Immunisation: Immunisation, an essential pillar of RMNCH+A services will be strengthened by

- Sustaining of Pulse polio campaigns and achieving over 80% routine immunisation in a ll districts.

- Introduction of new and underutilised vaccines on the basis of recommendations of the National Technical Advisory Group on Immunisation (NTAGI).

Pre- conception

Care during labour and child

birth

Immediate newborn care

- care of the healthy newborn

- care of small and sick newborn

Care beyond newborn

survival

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- Improving cold chain management with adequate densities of Ice Lined Refrigerators (ILRs) and deep freezers.

- Adequate number of vaccination sessions and sites, and logistics arrangements to reach all such sites especially in remote areas will be a key area of intervention.

- Surveillance of vaccine preventable diseases would be integrated with IDSP and name based monitoring of children done through the MCTS system.

1.8. Child health screening and early Intervention services:

- Rashtriya Bal Swasthya Karyakram (RBSK) aims to improve the overall quality of life of children 0-18 years through screening and early intervention for 4Ds-

Birth Defects, Diseases, Deficiencies, Development delays including disabilities and provide comprehensive care.

- District Early Intervention Centres (DEIC) will be set up to provide screening and management support to children detected with health conditions. Screening will be done for at least 30 identified conditions through dedicated Mobile Health Teams at the Anganwadi Centre (till 6 years of age) and in Government and Government aided school children (6-18 years)

- Public health institutions, private sector partnerships and partnerships with NGOs will be encouraged.

- Patient transport network supported under NHM will be used to transport sick children to higher facilities.

Identified health conditions for child health screening and early intervention services:

Defects at birth

- Neural Tube Defect - Down’s syndrome

- Cleft lip and palate / cleft palate alone

- Talipes (club foot)

- Developmental dysplasia of the hip

- Congenital cataract - Congenital deafness - Congenital heart diseases - Retinopathy of Prematurity

Deficiencies

- Anaemia especially severe anaemia - Vitamin A deficiency (Bitot’s spots) - Vitamin D deficiency (Rickets) - Severe acute malnutrition - Goitre

Childhood diseases

- Skin conditions (scabies, fungal infections, eczema)

- Otitis media

- Rheumatic Heart disease - Reactive Airway disease - Dental caries

- Convulsive disorders

Developmental delays and disabilities - Vision impairment

- Hearing impairment - Neuro- motor impairment - Motor delay

- Cognitive delay - Language delay

- Behaviour disorder (Autism) - Learning disorder

- Attention deficit Hyperactivity disorder - Congenital Hypothyroidism, Sickle cell

anaemia, Beta thalassemia

7 1.9. Adolescent health:

- Adolescent Health programmes include the following priority interventions both in form of Facility and Community based health promotion activities

- Information and counselling on sexual and reproductive health (including menstrual hygiene), substance abuse, mental health, non-communicable diseases, injuries and violence including domestic violence.

- Menstrual hygiene practices will be promoted in rural areas through use of sanitary napkins along with building adequate knowledge and information about the product through ASHAs.

- Provision of nutrition counselling, treatment for RTIs/STIs, appropriate referrals and commodities such as IFA tablets, condoms, Oral Contraceptive Pills (OCPs) and pregnancy kits for all adolescent girls and boys.

- National Iron Plus Initiative: Provision of Weekly Iron and Folic acid Supplementation (WIFS) for addressing nutritional anaemia among adolescent boys and girls in rural and urban areas. The scheme also includes nutrition and health education sessions, screening of target groups for moderate/severe anaemia and referring these cases to an appropriate health facility.

- Provision for biannual de-worming (Albendazole 400mg), six months apart, for control of helminthic infestation, information and counselling for improving dietary intake and preventing intestinal worm infestation.

1.10. Rashtriya Kishor Swasthya Karyakaram:

All these interventions will be operationalised through various platforms including Adolescent Friendly Health Clinics (AFHC), VHNDs, Schools, Anganwadi Centres and Nehru Yuva Kendra Sangathan (NYKS), Teen Clubs and a dedicated Adolescent Health Day. Outreach activities aimed at providing information and health promotion will be through Peer educators, mentors who will act as dedicated and trained counsellors with enhanced focus on addressing issues of adolescents from vulnerable and marginalised subgroups.

1.11. Family Planning:

Family planning services will be utilised as a key strategy to reduce maternal and child morbidities and mortalities in addition to stabilising population. Improved family planning service delivery ensures access, availability and quality of services; counselling services through dedicated counsellors; improved technical competence of the providers and increased awareness among the beneficiaries would be ensured.

- Prioritisation of Post-partum and post abortion contraception

- Focus on promotion of spacing methods, especially Intra-Uterine Contraceptive Devices (IUCDs)

- Promoting post-partum IUCD as a key spacing method - Promotion of male involvement including male sterilisation - Training of AYUSH doctors for IUCD services

- Promoting distribution of contraceptives at the doorstep through ASHAs and other channels.

- Compensation scheme for sterilisation acceptors to cover loss of wages to the beneficiary and also to the service provider (and team) for conducting sterilisations.

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Month-long national campaigns on the eve of World Population Day would be continued every year in all states/ districts across the country.

In the eventuality of deaths, complications and failures following sterilisation clients will be insured and the providers/ accredited institutions will be indemnified against litigations in those eventualities under the National Family Planning Indemnity Scheme (NFPIS). The State Quality Assurance Cell would be responsible for management of claims under the NFPIS scheme.

Differential approach for the high fertility states is being adopted to reduce fertility to replacement levels through the promotion of healthy spacing after marriage and between the births; engaging ASHAs as the motivator and counsellor for the community; intensification of skill building strategies for family planning providers; involvement of private providers ; substantial expansion in facilities and providers offering the full range of contraceptive services and BCC activities that focuses on improving access and reducing unmet need.

1.12. Addressing the declining sex ratio:

For improving the adverse child sex ratio, strategies that lie within the domain of health include:

- Stricter enforcement of the PCPNDT Act

- Improved monitoring and sensitisation of the medical community - Active role of civil society action in addressing son preference - Addressing neglect of the girl child in illness care

- Observing sex ratios in hospital admissions for illness in children

- Providing proactive support for girl children through the ASHA and Anganwadi system.

1.13. Cross cutting areas:

Focus on these areas will enable overall strengthening of health services delivery:

- Behaviour Change Communication and addressing social determinants is essential.

- Human resources and infrastructure requirements to be achieved through facility strengthening.

- Continuous training, technical support and supervision of the RMNCH+A programme.

- Management support through Programme Management Units at the national, state, district and block levels, SIHFW, SHSRC and District Knowledge Centres.

9 2. Control of Communicable Diseases

Introduction: The NHM will continue to focus on communicable disease control programmes and disease surveillance. The Flexi-pool for Communicable Diseases will facilitate the states in preparing state, district and city specific PIPs.

2.1. The National Vector Borne Disease Control Programme (NVBDCP):

This is an umbrella programme for prevention and control of vector borne diseases viz. Malaria, Japanese Encephalitis (JE), Dengue, Chikungunya, Kala-Azar and Lymphatic Filariasis.

Of these, Kala-Azar and Lymphatic Filariasis have been targeted for elimination by 2015.

2.2. Revised National Tuberculosis Control Programme (RNTCP):

The goal is to decrease mortality and morbidity due to TB and reduce transmission of infection until TB ceases to be a major public health problem in India.

Objectives of the programme are:

- To achieve and maintain cure rate of at least 85% among New Sputum Positive (NSP) patients

- To achieve and maintain case detection of at least 70% of the estimated NSP cases in the community.

The current focus of the programme is on ensuring universal access to quality TB diagnosis and treatment services to TB patients in the community in a patient-friendly environment. The programme has made special provisions to reach marginalised sections including creating demand for services through specific advocacy, communication and social mobilisation activities.

2.3. National Leprosy Control Programme (NLEP):

NVBDCP

- Policy guidance

- Technical assistance

- Support to the states in the form of funds and commodities

Government of India - Technical assistance

- Logistics support including anti-malaria drugs, DDT, larvicides, etc.

State Government

- Early case detection and prompt treatment

- Strengthening of referral services

- Integrated vector management

- Use of Long Lasting Insecticidal Nets (LLIN) and larvivorous fishes

- Behaviour change communication

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Key activities include diagnosis and treatment of leprosy and

- Services are provided by all primary health centres and government dispensaries throughout the country free of cost

- ASHAs are involved through incentive based approach for bringing leprosy cases from villages for diagnosis at PHC, following up cases for treatment completion, and are paid an incentive for this.

- In urban areas, Urban Leprosy control activities are being implemented in 422 urban areas with a population of over 100,000. These activities include MDT delivery services and follow up of patient for treatment completion, providing supportive medicines, dressing material and monitoring & supervision.

2.4. Integrated disease surveillance Programme (IDSP):

This is being implemented in all the states for surveillance of out-break of communicable diseases.

Central Surveillance Unit (CSU)

Surveillance units established in all states/districts

(SSU/DSU)

Weekly disease surveillance data on epidemic disease collected from reporting units

(RU)

•Established and integrated in the National Centre for Disease Control (NCDC), Delhi

•Weekly data analysed for disease trends

•Rising trend of illnesses is investigated to manage and control the outbreak

•RUs- Sub-centres, PHC, CHC, DH and other hospitals including government and private sector hospitals and medical colleges

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Integration of communicable disease programmes will occur at six levels:

3. Non Communicable Diseases (NCD) Burden:

NCDs account for 53% of the total deaths (10.3 million) and 44% (291 million) of disability adjusted life years (DALYs) lost in India and may contribute up to 67% of all deaths by 2030.

The rising burden of NCDs calls for concerted public health action in addition to clinical approaches.

NHM plans to strategise schemes and interventions for the non-communicable diseases to be implemented upto the district hospital financed through a Flexible Pool, tertiary level NCD care would not be supported under this flexi pool. All aspects of care for NCD will be part of the integrated district plan.

Programmes for NCDs would emphasise on

1. Continuity of care and two way referral linkage

Communicable Dseases Program

District plan and Facility strengthening

plan

Institutional mechanisms for capacity building,

knowledge management and

technical support

BCC strategy integrated with the BCC strategy for the ASHA and

VHSNC

system for each programme which

get exported to a common data

warehouse District/city plan to

specifically address prevalent communicable diseases in their area

(besides National Programme)

Progress review by the state, city

and district

health societies

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2. Building accessible health records for patients requiring long term follow up at primary levels with occasional visits to the specialist in the higher facility

3. Indicators for monitoring process and outcomes and organise the analysis of information flowing in through programme management cells located within District, City and State Programme Management Units

4. Arrange for supply of free drugs and diagnostics as assurance that anti-diabetic drugs including insulin, anti-hypertensive, essential medicines for treatment of cardiovascular diseases, chemotherapy for cancer patients through day care centres, anti-asthmatics, anti- epileptics, anti-depressants and other basic psycho-active drugs to the poor to expand the range of illnesses managed. This will be coupled with annual specialist consultation enabled through electronic medical records to improve quality of care.

5. Mainstreaming AYUSH to increase the care available for NCD by training AYUSH practitioners in preventive, promotive activities and screening for NCD, and integrating Indian systems of medicine with modern system of medicine.

NHM under 12^th plan envisages to build capacity for multiple NCD diseases and has launched specific schemes and programs in this regard.

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3.1.National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular diseases and Stroke (NPCDCS):

Primary

a) prevention of hypertension and diabetes; b) screening ; c) secondary prevention by routine follow up with medication to prevent strokes and ischemic heart disease; d)two way referral linkages with appropriate secondary and tertiary care providers.

For Cancers : prevention, promotion, and early detection,

assisted access to higher specialist care, guidance and support.

Secondary

- Cardiac Care Units for treatment of Ischemic heart disease, stroke and other cardiovascular

emergencies

- Facilities for diagnosis and treatment of chronic kidney diseases including dialysis - Facilities for screening of common cancers - Day Care Centres for chemotherapy prescribed

by Tertiary level cancer hospitals

Tertiary sector

- specialised treatment

and referral linkages

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3.2. National Programme for the Control of blindness (NPCB):

The NPCB would be part of the NCD flexi-pool under NHM and would aim to

- Consolidate gains achieved in controlling cataract blindness and increase public awareness about prevention and timely treatment of other avoidable causes of blindness - Emphasis on primary healthcare (eye care) by establishing Vision Centres in all PHCs - Active screening of population above 50 years through screening camps and transporting

of operable cases to eye care facilities

- Screening of school age children for identification and treatment of refractive errors (in synergy with the RBSK)

- Provision of assistance for other eye diseases like Diabetic Retinopathy, Glaucoma and childhood blindness through use of laser techniques, corneal transplantation, Vitreoretinal Surgery, etc.

- Construction of dedicated Eye Wards and Eye Operation Theatres (OT) in District Hospitals and in NE states and few other states

- Use of Mobile Ophthalmic Units at district level for patient screening and transportation - Strengthening of existing Eye Banks and Eye Donation Centres

- Participation of NGOs and contracting in of private sector where required.

- Special focus towards illiterate women in rural areas and under-served areas

15 3.3. National Mental health Programme (NMHP):

The existing District Mental Health Programme would be integrated into NHM, and expanded to cover all districts in a phased manner.

Components of NMHP will include 

National Mental Health Program Common mental

problems

Severe diseases and emergencies

New areas

Alcohol and substance use Rehabilitation of

the mentally ill - home and community care

Identify and manage post partum depression

(linkage through RMNCH+A )

- Suicide prevention, - Workplace stress management - Adolescent mental health

- College counselling services

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Range of mental health services envisaged under NHM (12^th plan )

a. At level of District Hospitals - Outpatient services - In patient services

- Child mental health services - Specialist and counselling services

- Referrals for day centres, medium stay centres and long stay centres - Disability certification by the psychiatrist

- Laboratory services including Therapeutic Drug Monitoring for psychotropic medications - Training, supervision and support to taluk/CHC and primary health care staff at the PHCs - Conducting periodic outreach clinics at the CHC.

b. At level of CHC

- Outpatient services for walk in patients and patients referred by the PHC - Inpatient services for emergencies and assessment

- Medical and Social Care and Support to Continuing Care services and Counselling services.

c. Outreach services

- Community mental health nurses supported by the PHC for case detection, management of common mental illness, stabilising and referral of severe illness or emergency and providing medication refills.

- 108 Ambulance services to transport patients to the District Hospital in an emergency - Setting up of Country wide mental health help line

- Day Care Centres, Residential Continuing Care Centres, and Long Term Residential Continuing Care Centres to be established in selected districts

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3.4. National Programme for Health Care of the Elderly (NPHCE):

The aim of the NPHCE is to provide comprehensive health care to senior citizens through all levels of the health care delivery system including outreach services. In addition to services in 100 identified districts, 225 additional districts will be taken up and the eight Regional Geriatric Centres will be expanded to 20.

The range of services envisaged under NHM is:

District Hospital /Medical college

- Geriatric Units to be set up in 100 selected District Hospitals - Regular geriatric clinics

- Ten bedded geriatric ward for in-patient care - Facilities for laboratory investigations,

Provision of equipment and medicines for geriatric care

- Training of MOs and allied health staff at CHCs and PHCs, and referral services for severe cases

CHC

- First medical referral unit for patients from PHCs and below

- Organise bi weekly Geriatric Clinics - Rehabilitation Services

(Physiotherapist/Rehabilitation worker) - Organise referral to District Hospital /Medical college

Sub-centre team

- IEC on healthy ageing, environmental modification, nutritional requirements,

life style and behavioural changes, - support care givers for home bound/bedridden elderly and arrange for callipers and supportive devices to

make patients ambulatory - Facilitate linkage with other support

groups and day care centres

PHC

- organise weekly Geriatric Clinics - basic clinical assessments relating to vision, joints, hearing, chest, and blood

pressure

- undertake simple investigations including blood sugar

- ensure provision of drugs to the elderly - facilitate referral for further

investigations and treatment

Community level ( ASHAs) - Mobilisation of elderly to screening camps

- Home based care

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3.5. National Programme for the Prevention and Control of Deafness (NPPCD):

The current pilot phase of the NPPCD in 192 districts, will be expanded to 200 additional districts.

Its key objectives are:

- To prevent avoidable hearing loss

- Early identification, diagnosis and treatment of ear problems responsible for hearing loss and deafness

- Rehabilitate persons of all age groups suffering with deafness

The existing inter-sectoral linkages will be strengthened and institutional capacity will be developed for ear care. Ear Nose Throat (ENT) and Audiology infrastructure, training of human resources, including an Audiometric Assistant/Instructor for the hearing impaired, management of hearing and speech impaired cases and rehabilitation at different levels of health care delivery system is envisaged.

Provision of hearing aid to hearing impaired children and conducting screening camps for early detection will be through RBSK and in convergence with the Ministry of Social Justice and Empowerment.

3.6. National Tobacco Control Programme (NTCP):

Interventions under the NTCP will be largely at the primordial and primary levels of prevention.

Key thrust areas include:

- Training of health and social workers including ASHAs, NGOs, school teachers,

enforcement officers

- Provision of pharmacological treatment facilities at district level.

- IEC activities

- School based programmes

- Reaching out to the urban poor, tribals and populations in Left Wing Extremism affected areas as well as in underserved areas

- Emphasis on tobacco cessation services - Integrating tobacco control interventions

with other health programmes

-Monitoring tobacco control laws - Co-ordination with PRI/VHSNC for village

level activities National Tobacco Control

Programme (NTCP)

19 3.7. National Oral Health Programme (NOHP):

Under NHM, a total of 200 districts would be taken up in a phased manner to strengthen the promotive and preventive oral health care by supporting through equipment, human resources and consumables for a dental unit.

States which already have a dental unit at district level would be enabled to set up such units at CHC level.

3.8. National Programme for Palliative Care (NPPC):

Palliative care improves the quality of life by alleviating pain and suffering and may influence the course of the disease in chronic illness patients.

Continuum of care approach for palliative care in NHM will be adopted. Palliative care strategies will be synergised with programmes for the care of the elderly and patients with cancer and chronic diseases (cancer, AIDS, chronic disease, and the bed ridden elderly).

At PHC :

- out-patient and home-based care - coordination of Referral

- IEC Manpower

training (medical officers,

nurses and counsellors )

DH, Medical College and Regional Cancer Centres - In-patient care through allocating specific beds

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3.9. National Programme for the Prevention and Management of burn Injuries (NPPMBI):

Key objectives are

- To reduce incidence, mortality, morbidity and disability due to burn injuries, Strategic approach

3.10. National Programme for Prevention and Control of fluorosis (NPPCF):

The programme will be expanded from the existing 100 to an additional 95 new districts.

The key strategies are:

- Community based surveillance of fluorosis

- Capacity building in the form of training and manpower support

- Management of fluorosis cases including surgery, rehabilitation and health education for prevention and control.

Burn management and rehabilitation

• Adequate infrastructural facility

• District hospitals to be provided with six beds for burn units

• Facility and

community based rehabilitation services

Improve awareness

• Among vulnerable groups (women, children, industrial and hazardous occupational workers),

• School based programmes and mass media programmes for general public

Formative research

• To assess

behavioural, social and other

determinants of

burn injuries

21 Score Card

Indicators for survey based score Card

Mortality

- Under five Mortality rate - Infant Mortality rate - Neonatal Mortality rate

- Maternal Mortality ratio ( per 100,000 live births )

Fertility - Total fertility rate

- Births to women age 15-19 out of total births

Nutrition

- children with birth weight less than 2.5 kg

- children under 3 years who are under weight

Gender child sex ratio 0-6

Cross cutting - full Immunisation

(12- 23 months children receiving BCG , 3 doses of DPT/ Hep B/ OPV and Measles) - household having access to toilet facility

- couple using spacing method for more than 6 months

Diarrhoea

- ORT or increased fluids for diarrhea (among children <2 years of age who had

diarrhea in preceding 2 weeks)

Pneumonia

- Care seeking for ARI in any health facility ( among children <2 years of age who had

ARI in preceding 2 weeks)

Service delivery

- Women who received 4 + ANC - skilled birth attendance

- Mothers receiving post natal care within 2 days of delivery for their last birth - Early initiation of breast feeding ( <1 hr)

- EBF for 6 months ( among 6 - 9 months children )

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Positive scores from 1 to 4 for those above the national average (for positive indicators) and for those below the national average (for negative indicators)

Negative scores -1 to -4 for those below national

average(for positive indicators) and for those below the national average (for negative indicators)

All India average for each indicator taken as the reference point States to be classified into four categories based on consolidated score

Positive indicators -

Green: more than 20% of national average

Yellow: 20% below and above the national average

Red: less than 20% of national average

Green - less than 20% of the national average

Yellow: 20% below and above national average

Red: morethan 20% of the national average

23

The National Health Mission is a flagship programme of the Government of India. The NHM shall be one of the main vehicles for increasing central government share of total health expenditure with the immediate objective to reduce out of pocket expenditure.

Financing of National Health Mission

Center contribution to

NHM

- 25% of share under the NHM by state government - North- East states and the

special category states (J&K, Himachal Pradesh, and Uttarakhand) share

would be 10%.

- Public expenditure on health to be at least 2.5% of the GDP.

In the 12th Plan period,the commitment is to increase it to 1.87% of the GDP.

Further, state government to maintain a minimum of 10% annual increase in budgetary outlay on health sector

24 5.1. Incentive Pool:

A part of NHM funds provided in the national budget is committed as an incentive pool. Once a state demonstrates that it is able to absorb the funds already provided and is able to show progress on key areas of institutional reforms identified in the MoU with the SHS, and those communicated in the approvals of the PIPs, it becomes eligible for further funds from the incentive pool which constitute a minimum of 10%.

NHM funding to states

NUHM Flexipool

Flexible Pool for Communicable

Diseases

Flexible Pool for Non Communicable Diseases, Injury and Trauma

Infrastructure Maintenance Family Welfare

Central Sector Component

NRHM RCH

Flexipool

25 5.2. NRHM RCH Flexipool:

For Health systems strengthening including Infrastructure, Mobile Medical Units, Patient Transport Systems (for referral and emergency), procurement of equipment and drugs, AYUSH mainstreaming and drugs, support to ASHAs and VHSNC, Maternal and Child Health interventions, Adolescent health interventions and Immunisation.

5.3. NUHM Flexipool:

To meet the health needs of urban population particularly the poor and vulnerable sections.

5.4. The Flexible Pool for Communicable Disease:

For interventions under Communicable Disease Control Programmes.

5.5. The Flexible Pool for Non-Communicables Disease including Injury and Trauma:

For interventions for non-communicable diseases including National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular diseases and Stroke, National Mental Health Programme, National Programme for Control of Blindness and National Programme for Health care of the Elderly.

6. Infrastructure Maintenance

As this component has been supported over several Plan periods, under 12^th plan support is provided to states to meet salary requirement of Schemes viz. Direction and Administration (Family Welfare Bureaus at state and district level), Sub Centres, Urban Family Welfare Centres, Urban Revamping Scheme (Health Posts), ANM/LHV Training Schools, Health and Family Welfare Training Centres, and Training of Multi-Purpose Workers (Male). Expenditure on any new SHCs or health posts under this component would be supported only with the approval of the GOI.

Family Welfare Central Sector Component: In this component, no funds are provided to states and all the funds are utilised at the central level. These include schemes/activities to support Management Information system, such as HMIS and MCTS, Population Research Centres, National Institute of Health & Family Welfare (NIHFW), International Institute of Population Sciences (IIPS), National Commission on Population, free distribution of contraceptives, National Programme Management of NHM including support to NHSRC, support for the Annual Health Survey, District Level Household Survey and National Family Health Survey (NFHS). These schemes/activities are integral to and important for NHM planning, implementation and monitoring.

Funds from central government

State Health Society

Part of the expenditure

for state level activities

Rest provided to

the District/

City Health

Society

26 Summary

NHM aims to provide universal health coverage and reducing out of pocket expenditure. It is strategised through service delivery mechanism in following manner

- Reproductive, Maternal, New-born, Child Health and Adolescent (RMNCH + A) Services: to adopt life cycle approach and continuum of care for reducing morbidities and mortalities of mother and children. Enhanced focus is now on adolescent health care and enabling health system to respond to their demand of services.

- Control of Communicable Diseases: states will be encouraged to devise their plan of action to effectively manage their endemic diseases and the diseases in National health programmes.

- Non Communicable Diseases (NCD): A range of programmes are to be included under NHM to address NCDs through enabling various assured services at all level of health care services.

References

1. 1. National Health Mission – Framework for Implementation. Ministry of Health and Family Welfare. Government of India 2012-2017

2. http://nrhm.gov.in/nhm.html

3. Government of India (2014), India New-born Action Plan (INAP), Sept. 2014. Ministry of Health & Family Welfare, New Delhi.

4. Government of India (2013), For Healthy Mother and Child, A strategic approach to Reproductive, Maternal, New-born, Child and Adolescent Health (RMNCH+A) in India, January 2013, Ministry of Health and Family Welfare, New Delhi.

27

1. Areas of Reproductive Health services to be strengthened through RMNCH + A strategies Eleven areas to be strengthened through RMNCH + A strategies

1. Maternal Health

2. Access to safe abortion services

3. Prevention and Management of Reproductive Tract Infections (RTI) and Sexually Transmitted Infections (STI):

4. Gender Based Violence 5. New-born and Child health 6. Universal Immunisation

7. Child health screening and early Intervention services 8. Adolescent health

9. Family Planning:

10. Addressing the declining sex ratio 11. Cross cutting areas

2. Strategy for communicable disease programmes under NHM

Under NHM, integration for communicable disease programmes will occur at 6 levels

• District plan and Facility strengthening plan

• Institutional mechanisms for capacity building, knowledge management and technical support

• Integration of BCC strategy with the health education strategy for the ASHA and VHSNC

• Own information system for each program which get exported to a common data warehouse to be used for decision making

• District/city plan to specifically address prevalent communicable diseases in their area other than the diseases in National Programme.

• Progress review by the state, city and district health societies

3. Components of financing under NHM NHM has six financing components

(i) NRHM/RCH Flexi-pool (ii) NUHM Flexi-pool

(iii) Flexible pool for Communicable Disease

(iv) Flexible pool for Non Communicable Disease including injury and trauma (v) Infrastructure Maintenance and

(vi) Family Welfare Central Sector Component

MCQs

1. Which of the components of financing is totally strategised by Central government?

a. Flexible pool for Communicable Disease

b. Flexible pool for Non Communicable Disease including injury and trauma c. Infrastructure Maintenance

d. Family Welfare Central Sector Component

Ans. d

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Quadrant – IV Learn more/Web Resources/Supporting Materials/Interesting Facts:

 nrhm.gov.in/nhm/nuhm.html

 www.mohfw.nic.in/WriteReadData/c08032016/56987532145632566578.pdf

 nhmmizoram.org/page?id=3

 http://palliumindia.org/cms/wp-

content/uploads/2014/01/NHM_PIP_operating_manual_29.10.2013.pdf

 http://www.ideasforindia.in/article.aspx?article_id=1432

 https://en.wikipedia.org/wiki/National_Rural_Health_Mission