National Rural Health

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National Rural Health



About NHRM

Inaugurated on April 12, 2005

Increase spending on health from 0.9% of GDP to 2-3% of GDP

Correct the deficiencies of the health system

Focus on 18 states – northern and eastern

Goal is good decentralized healthcare

Missionary approach by government.

Intended for 2005 - 2012



To provide accessible, affordable,

accountable, effective and reliable primary health care and bridging the gap in rural

health care through creation of ASHA.




Scope of NRHM


Arunachal Pradesh, Assam,

Bihar, Chhattisgarh, Himachal Pradesh, Jharkhand, J&K,

Manipur, Mizoram, Meghalaya,

MP, Nagaland, Orissa, Rajasthan,

Sikkim, Tripura, Uttaranchal, UP




Reduction in Infant Mortality Rate (IMR) and Maternal Mortality Ratio (MMR)

Universal access to public health services such as Women’s health, child health,

water, sanitation & hygiene, immunization, and Nutrition.

Prevention and control of communicable and non-communicable diseases,

including locally endemic diseases



Access to integrated comprehensive primary healthcare

Population stabilization, gender and demographic balance.

Revitalize local health traditions and mainstream AYUSH

Promotion of healthy life styles


Plan of action/Components

Accredited social health activists

Strengthening sub-centers

Strengthening primary health centers

Strengthening CHCs for first referral unit.

District health plan under NRHM

Strengthening disease control program

Public-private partnership for public health goals, including regulation of private sector

New health financing mechanisms

Reorienting health/medical education to support rural health issues


Components of NRHM




Resident of the village, a woman (M/

W/D) between 25-45 years, with formal education up to 8


class, having communication skills and leadership qualities.


One ASHA per 1000 population.


Around one 100,000 ASHA’s are

already selected.




Chosen by the panchayat to act as the interface between the community and the public health system.


Bridge between the ANM and the village.


Honorary volunteer, receiving

performance based compensation .


Responsibility of ASHA


To create awareness among the

community regarding nutrition, basic sanitation, hygienic practices, healthy living.


Counsel women on birth preparedness, imp of safe delivery, breast feeding,

complementary feeding, immunization, contraception, STDs.


Encourage the community to get involved

in health related services.




Escort/ accompany pregnant women, children requiring treatment and

admissions to the nearest PHC’s.


Primary medical care for minor ailment such as diarrhea, fevers


Provider of DOTS.


ASHA can help AWW to complete and update Village Health Register by

maintaining a daily diary.



Promoting construction of household toilets

Facilitating preparation and implementation of village health plan through ANM, AWW, SHG members under the leadership of village health and sanitation committee.

Organizing Health Day once/twice a month at the Anganwadi with the AWW and ANM.

Depot holder of essential services like IFA,

OCP, condoms, DDK, ORS etc. issued by AWW.


Components of NRHM contd.


Each sub-centre will have an Untied Fund for local action @ Rs. 10,000 per annum. This Fund will be deposited in a joint Bank Account of the ANM & Sarpanch and operated by the ANM, in consultation with the Village Health Committee.

Supply of essential drugs, both allopathic and AYUSH, to the Sub-centers.

In case of additional Outlays, Multipurpose Workers (Male)/Additional ANMs wherever needed, sanction of new Sub-centers as per

2001 population norm, and upgrading existing Sub-centers, including buildings for Sub-centers functioning in rented premises will be



Components of NRHM contd.


Mission aims at Strengthening PHC for quality preventive, promotive, curative, supervisory and outreach services, through:

Adequate and regular supply of essential quality drugs

and equipment including Supply of Auto Disabled Syringes for immunization) to PHCs

Provision of 24 hour service in 50% PHCs by addressing shortage of doctors, especially in high focus

StatesObservance of Standard treatment guidelines &


Intensification of ongoing communicable disease control programs, new programs for control of non communicable diseases, up gradation of 100% PHCs for 24 hours referral service, and provision of 2nd doctor at PHC level (I male, 1 female) would be undertaken on the basis of felt need.


Components contd.


Operationalizing 3222 existing Community Health Centers (30-50 beds) as 24 Hour First Referral Units, including posting of


Codification of new Indian Public Health

Standards, setting norms for infrastructure, staff, equipment, management etc. for CHCs.

Promotion of Stakeholder Committees (Rogi Kalyan Samitis) for hospital management.

Developing standards of services and costs in hospital care


Components contd.


It would be an amalgamation through:

Village Health Plans, State and National priorities for Health, Water Supply, Sanitation and Nutrition.

Health Plans would form the core unit of action proposed in areas like water supply, sanitation,

hygiene and nutrition. Implementing. Departments would integrate into District Health Mission for


District becomes core unit of planning, budgeting and implementation.

Centrally Sponsored Schemes could be rationalized/

modified accordingly in consultation with States.



Concept of “funneling” funds to district for effective integration of programs

All vertical Health and Family Welfare Programmes at District and state level merge into one common “District Health

Mission” at the District level and the “State Health Mission” at the state level

Provision of Project Management Unit for all districts, through contractual engagement of MBA, Inter Charter/Inter Cost and Data

Entry Operator, for improved program management


Components contd.


Total Sanitation Campaign (TSC) is presently

implemented in 350 districts, and was proposed to cover all districts in 10th Plan.

Components of TSC include IEC activities, rural

sanitary marts, individual household toilets, women sanitary complex, and School Sanitation Program.

Similar to the DHM, the TSC is also implemented through Panchayati Raj Institutions (PRIs).

The District Health Mission would guide activities of sanitation at district level, and promote joint IEC for public health, sanitation and hygiene, through Village Health & Sanitation Committee, and promote

household toilets and School Sanitation Program.

ASHA would be incentivized for promoting household toilets by the Mission.


Components contd.


National Disease Control Program for Malari a, 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.

Provision of a mobile medical unit at District level for improved Outreach services.


Components contd.


Since almost 75% of health services are being currently provided by the private sector, there is a need to refine regulation

Regulation to be transparent and accountable

Reform of regulatory bodies/creation where




District Institutional Mechanism for Mission must have representation of private sector

Need to develop guidelines for Public-

Private Partnership (PPP) in health sector.

Identifying areas of partnership, which are need based, thematic and geographic.

Public sector to play the lead role in

defining the framework and sustaining the partnership

Management plan for PPP initiatives: at

District/State and National levels


Role of Panchayati Raj Institutions

The Mission envisages the following roles for PRIs:

States to indicate in their MoUs the commitment for devolution of funds,

functionaries and programmes for health, to PRIs.

The District Health Mission to be led by the Zila Parishad. The DHM will control, guide and manage all public health institutions in the district, Sub-centers, PHCs and CHCs.

ASHAs would be selected by and be accountable to the Village Panchayat.



· The Village Health Committee of the

Panchayat would prepare the Village Health Plan, and promote inter sectoral integration

· Each sub-centre will have an Untied Fund for local action @ Rs. 10,000 per annum.

This Fund will be deposited in a joint Bank Account of the ANM & Sarpanch and

operated by the ANM, in consultation with the Village Health Committee.

· PRI involvement in Rogi Kalyan Samitis for good hospital management.

· Provision of training to members of PRIs.


Community participation in NRHM:

Village and Health Sanitation Committee

Rogi Kalyan Samiti


Janani Suraksha Yojana (JSY)

It is a flagship scheme under NRHM which

integrates the cash assistance with antenatal care during the pregnancy period, institutional care

during delivery and immediate post-partum period in a health centre by establishing a system of

coordinated care by field level health worker.

It is a 100% centrally sponsored scheme.

Goals :

To reduce over all maternal mortality ratio and infant mortality rate,

To increase institutional deliveries in BPL families.


Target Group

All pregnant women belonging to the below poverty line (BPL) households and

Of the age of 19 years or above

Up to two live births.

The benefits would be extended to all women from BPL families of 10 low performing states namely 8 EAG

states (Uttar Pradesh, Uttaranchal, Madhya Pradesh, Chhattisgarh, Rajasthan, Bihar, Jharkhand and Orissa) and the states of Assam and J&K even after the third live birth if the mother, of her own accord chooses to undergo sterilization in the health facility where she delivered, immediately after the delivery.


In LPS: all women , including SC, ST. benefit extended to all births delivered in health

centre, govt or accredited private health institution.

In HPS: BPL women, aged 19 yrs & above, and ST, SC pregnant women. Benefit is only up to 2 live births.

In HPS & LPS, all BPL pregnant women aged 19 yrs & above, preferring to deliver at home, are entitled to cash assistance of Rs 500 per delivery, up to 2 live births.




Early registration of the beneficiaries with the help of the village level health workers like ASHA

Early identification of complicated cases;

Providing atleast three antenatal care, and post delivery visits;

Organizing appropriate referral and provide referral transport to the pregnant mother;

Convergence with Integrated Child Development

Services (ICDS) worker by way of involving Anganwadi worker (AWW) intensively;

Devising as well as ensuring transparent and timely disbursement of the cash assistance to the mother and the incentive to the Accredited Social Health Activist (ASHA) with fund available with ANM.


The strategy also involves the following -

Operationalisation of 24/7 delivery services at PHC level to provide basic obstetric care,

Operationalisation of First Referral Units (FRUs) to provide the emergency obstetric care,

Building partnerships through a process of recognition/ accreditation with doctors,

hospitals/nursing homes/clinics from the private sector specially in the rural areas to provide

obstetrics services to the JSY beneficiaries.


Catego ry of States


Assistanc e

Package to mother

Package for ASHA


Assistan ce Package

to Mother


for ASHA Total

LPS 1400 600 2000 1000 200 1200

HPS 700 200 900 600 200 800

States/UTs have been classified into two categories based on the institutional delivery rate.

The 10 states namely the eight EAG states and the states of Assam and Jammu & Kashmir would

constitute Low Performing States (LPS) and the rest High Performing States (HPS).

Cash assistance linked to Institutional Delivery.



Eliminating out-of-pocket expenses for families of pregnant women and sick newborns in government health facilities

Reaching the unreached pregnant women (nearly 75 lakh a year who still deliver at home)

Timely access to care for sick newborns


Free and cashless delivery

Free C-section

Free drugs and consumables

Free diagnostics

Free provision of blood

Free diet during stay in health institutions

Up to 3 days for normal delivery

7 days for Caesarean sections

Free transport

Home to health institution

Between health institutions in case of referral

Drop back home after delivery

Exemption from all kinds of user charges, including for seeking hospital care up to 6 weeks post delivery (for post natal complications)


Free treatment at the public health institutions

Free drugs and consumables

Free diagnostics

Free provision of blood

Free transport

Home to health institution

Between health institutions in case of referral

Drop back home after delivery

Exemption from all kinds of user charges


All the 35 States /UTs have initiated implementation of the scheme

While Rs 1437 crores was approved under NRHM for the entitlements in 2011 -12 another 2103 crores have been sanctioned in 2012-13 for provision of free entitlements




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