National health mission

NHM: NRHM and NUHm

1. NATIONAL HEALTH MISSION : NRHM & NUHM MARY JACOB CHIYEDATH II MSc NURSING GOVT COLLEGE OF NURSING THRISSUR

2. National Health Mission (NHM) encompassing two Sub-Missions National Rural Health Mission ( NRHM) National Urban Health Mission (NUHM).

3. OBJECTIVES Describe in detail about the National Rural Health Mission Discuss the core strategies and implementation of National Urban Health Mission Explain in detail on the national health mission

4. HEALTH SCENARIO Multiple burden of disease –communicable, non-communicable and unattended morbidities High child and maternal deaths 50% under nourished and anemic women and children – very little improvement Water and sanitation challenges remain Food security Malaria, dengue, chikunguniya on the rise Public health regulation – very weak High TFR in UP, Bihar, MP, Rajasthan, Jharkhand

5. National Rural Health Mission The National Rural Health Mission was launched since April 2005 throughout the country for providing better rural health services. National rural health mission has special focus on following 18 states: Empowered action group (EAG) states: Bihar, Jharkhand, MP, Chattisgarh , Up, Uttaranchal, Odisha and Rajasthan. North east states: Assam, Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim and Tripura. Other states: Himachal Pradesh, Jammu and Kashmir

6. National Rural Health Mission (NRHM) was launched at the National Level in April 2005 for a period of seven years (2005-2012) extended up to year 2017.

7. VISION The National Rural Health Mission (2005-12) seeks to provide effective healthcare to rural population throughout the country with special focus on 18 states, which have weak public health indicators and/or weak infrastructure.

8. MISSION The Mission is an articulation of the commitment of the Government to raise public spending on Health from 0.9% of GDP to 2-3% of GDP. The mission will be the instrument to integrate multiple vertical programmes along with their funds at the district level.

9. AIMS The main aim of NRHM is to provide accessible, affordable, accountable, effective and reliable primary health care and bridging the gap in rural health care through the creation of a cadre of Accredited Social Health Activist. provision of a female health activist in each village Health & Sanitation Committee of the Panchayat Indian Public Health Standards ( IPHS) Integration of vertical Health & Family Welfare Programmes

10. Mainstream AYUSH into the public health system. Effective integration of health concerns with determinants of health like sanitation & hygiene, nutrition, and safe drinking water through a District Plan for Health. It shall define time-bound goals and report publicly on their progress. It seeks to improve access of rural people, especially poor women and children, to equitable, affordable, accountable and effective primary healthcare

11. GOALS 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

12. OBJECTIVES OF NATIONAL RURAL HEALTH MISSION To reduce Maternal Mortality Rate (MMR) To reduce Infant Mortality Rate (IMR) To reduce Total Fertility Rate (TFR)

13. To provide accessible, affordable, accountable, effective and reliable primary health care, especially to poor and vulnerable sections of the population To provide the overarching umbrella to the existing programmes of health and family welfare including malaria, blindness, iodine deficiency, filarial, kala-azar , tuberculosis control and RCH II maximum coordination can be achieved among the related social sector, department of AYUSH, women and child development, elementary education, panchayati raj and rural development .

14. Approaches of NRHM: 5 pillars Increasing participation and ownership by the community Improved management capacity Flexible financing Innovations in human resources development for the health sector Setting of standards and norms with monitoring

15. Expected outcomes of NRHM IMR reduced to 30/1000 live births by 2012 Maternal mortality reduced to 100/100000 live births by 2012 TFR reduced to 2.1 by 2012 Malaria mortality reduction rate – 50% up to 2010, additional 10% by 2012. Kala Azar mortality reduction rate -100% by 2010 and sustaining elimination until 2012 Filarial/ microfilaria reduction rate – 70% by 2010, 80% by 2012 and elimination by 2015

16. Dengue mortality reduction rate – 50% by 2010 and sustaining at that level until 2012 Cataract operations – increasing to 46 lakhs until 2012 Leprosy prevalence rate – reduce from 1.8 per 10000 in 2005 to less than 1 per 10000 thereafter Tuberculosis DOTS series – maintain 85% cure rate through entire mission period and also sustain planned case detection rate Upgrading all community health centres to Indian public health standards Increase utilization of first referral units from bed occupancy by referred cases of less than 20% to over 75% Engaging 400000 female accredited social health activists (ASHAs)

17. Community level targets Availability of trained community level worker at village level, with drug kit for generic ailments. Health day at Anganwadi level on a fixed day/ month for provision of immunization, antenatal / postnatal check-ups and services related to mother and child health care, including nutrition Availability of generic drugs for common ailments at sub centre and hospital level. Access to good hospital care through assured availability of doctors, drugs and quality services at PHC/CHC level and assured referral transport communications systems to reach these facilities in time. Improved access to universal immunization through induction of Auto disposable syringes, alternate vaccine delivery and improved mobilization services under the programme.

18. Janani Surakshya Yojana (YSY) for the below poverty line families Availability of assured health care at reduced financial risk through pilots of community health insurance under the mission Availability of safe drinking water Provision of household toilets Improved outreach services to medically underserved remote areas through mobile medical units Increase awareness about preventive health including nutrition

19. STRATEGIES Strengthening of the health institutions providing Primary Health Care (CHCs, PHCs and Sub Centres) so as to provide all the basic and emergency obstetric care Strengthening of the routine immunization for the vaccine preventable diseases. Improving the health services and the services determining the health of the society viz sanitation and potable drinking water. Decentralizing the health planning and management of the health institutions by way of Constitution of District Health Missions and District Health Societies Formation of Rogi Kalyan Samitis (RKS) and Village Health Sanitation and Nutrition Committees (VHSNC). Bringing all the centrally sponsored Health schemes under the umbrella of NRHM.

20. ORGANIZATION STRUCTURE Central level State level

21. NRHM INFRASTRUCTURE

22. PLAN OF ACTION FOR STRENGHENING THE INFRASTRUCTURE AND MANPOWER Creation of ASHA (accredited social health activist): every village will have female accredited social health activist Strengthening sub-centres United fund of Rs. 10000 per annum Supply of drugs both allopathic and AYUSH Additional ANMs / Multipurpose worker (male) Upgrading existing sub centres Sanction of new sub centres

23. Strengthening primary health centres Adequate and regular supply of essential quality drugs and equipments including auto disabled syringes for immunization Provision of 24 x 7 service in at least 50% PHCs Mainstreaming of AYUSH man power Following standard guidelines and standing protocols Provision of a second doctor at PHC level (one male and one female ) Up gradation of 100% PHCs for 24 hours referral service

24. Strengthening community health centres for first referral services Operationalizing the existing CHCs (30 to 50 beds) as 24 hour FRUs including posting of anaesthetists New Indian public health standards (IPHS) for CHCs Promotion of Rogi kalian Samiti (RKS) for hospital management Developing standards of services and costs in health care Display of citizens charter at PHC/CHC level.

25. GOALS TO BE ACHIEVED BY NRHM NATIONAL LEVEL Infant mortality rate reduced to 30/1000live births Maternal mortality ratio reduced to 100/100000 Total fertility rate reduced to 2.1 Malaria mortality rate reduction -50% by 2010, additional 10% by 2012 Kala- azar mortality rate reduction – 100% by 2010 and sustaining elimination until 2012 Filaria / microfilaria rate reduction – 70% by 2010, 80% by 2012 and elimination by 2015

26. Dengue mortality rate reduction – 50% by 2010 and sustaining at that level until 2012 Japanese encephalitis mortality rate reduction – 50% by 2010 and sustaining at that level until 2012 Cataract operation : increasing to 46 lakhs per year by 2012 Leprosy prevalence rate : reduce from 1.8/10000 in 2005 to less than 1/10000 thereafter Tuberculosis DOTS services : maintain 85% cure rate through entire mission period Upgrading community health centres to Indian Public Health Standards Increase utilization of first referral units from less than 20% to 75% Engaging 250000 female Accredited Social Health Activist (ASHAs) in 10 states.

27. COMMUNITY LEVEL Availability of trained community level worker at village level, with a drug kit for general ailments Health day at anganwadi level on a fixed day/ month for provision of immunization, ante/postnatal check-ups and services related to mother and child health care including nutrition. Availability of generic drugs for common ailments at sub centre and hospital level. Good hospital care through assured availability of doctors, drugs and quality services at PHC/CHC level

28. Improved access to universal immunization through induction to auto disabled syringes, alternate vaccine delivery and improved mobilization services under the programme. Improved facilities for institutional delivery through provision of referral, transport, escort and improved hospital care subsidized under the Janani Suraksha Yojana for the below poverty line families Availability of assured health care at reduced financial risk through pilots of community health insurance under the mission. Provision of household toilets Improved outreach services through mobile medical unit at district level.

29. MAINSTREAMING AYUSH The Mission seeks to revitalize local health traditions and mainstream AYUSH infrastructure, including manpower, and drugs, to strengthen the public health system at all levels. AYUSH medications shall be included in the Drug Kit provided at Village levels to ASHA. The additional supply of generic drugs for common ailments at Sub Centre/PHC/CHC levels under the Mission shall also include AYUSH formulations. At the CHC level, two rooms shall be provided for AYUSH practitioner and pharmacist under the Indian Public Health System (IPHS) model. Single doctor PHCs shall be upgraded to two doctor PHCs by mainstreaming AYUSH practitioner at that level.

30. ASHA – Accredited Social Health Activist ASHA must be primarily a woman resident of the village ‘Married/ Widow/ Divorced” and preferably in the age group of 25 to 45 yrs. ASHA should have effective communication skills, leadership qualities and be able to reach out to the community. She should be a woman with formal education up to Eighth Class. Adequate representation from disadvantaged population groups should be ensured to serve such groups better.

31. Compensation to ASHA ASHA is a honorary volunteer and would not receive any salary or honorarium. she could be compensated for her time in the form of TA and DA. She can also be given awards, non- monetary incentives etc. Drug kit is given free.

32. Support mechanism for ASHA

33. MONITORING AND EVALUATION Process indicators : ( a) Numbers of ASHA seleted by due process (b ) Number of ASHA trained (c ) % of ASHA attending review meeting after one year. Outcome indicators : ( a) % of newborn who were weighed and families counselled (b ) % of children with diarrhoea who received ORS (c ) % of institutional deliveries

34. (d) % of JSY claims made to ASHA (e) % completely immunized in 12-23 months age group (f) % of unmet need for spacing contraception among BPL (g) % of fever cases who received chloroquine within first week in an malaria endemic area; Impact indicators : (a) IMR (b) child malnutrition (c) number of case of TB/ leprosy cases detected as compared to previous year.

35. ROLE AND RESPONSIBILITY OF ASHA ASHA will be the health activist in the community who will create awareness on health She will take steps to create awareness and provide information to the community 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.

36. She will mobilize the community and facilitate them in accessing health and health related services available at the anganwadi / sub centre / primary health centres She will work with the village health and sanitation committee of the gram Panchayat to develop a comprehensive village health plan She will arrange escort/ accompany pregnant women and children requiring treatment/ admission to the nearest pre-identified health facility i.e., primary health centre / community health centre/ first referral unit.

37. She 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. She will also act as a depot holder for essential provisions being made available to every habitation. A drug kit will be provided to each ASHA.

38. Her role as a provider can be enhanced subsequently. She will inform about the births and deaths in her village and any unusual health problems/disease outbreaks in the community to the Sub-centres/ Primary Health Centre. She will promote construction of household toilets under Total Sanitation Campaign.

39. Role and integration with anganwadi Organizing Health Day once/twice a month. On health day, the women, adolescent girls and children from the village will be mobilized for orientation on health related issues AWW to participate and guide organizing the Health Days at Anganwadi Centre (AWC). AWW and ANMs will act as resource persons for the training of ASHA.

40. IEC activity through display of posters, folk dances etc. Anganwadi worker will be depot holder for drug kits and will be issuing it to ASHA. 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. ASHA will support the AWW in mobilizing pregnant and lactating women and infants for nutrition supplement.

41. Role and integration with ANM She will hold weekly / fortnightly meeting with ASHA and discuss the activities undertaken during the week/ fortnight. She will guide her in case ASHA had encountered any problem during the performance of her activity. AWWs and ANMs will act as resource persons for the training of ASHA 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. ANM will participate and guide in organizing the health days at anganwadi centres She will take help of ASHA in updating eligible couple register of the village concerned.

42. 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. ANM will guide ASHA in motivating pregnant women for taking full course of Iron and folic acid tablets and tetanus toxoid injections etc. ANMs will orient ASHA on the dose schedule and side effects of oral pills ANMs will educate ASHA on danger signs of pregnancy and labour so that she can timely identify and help beneficiary in getting further treatment. 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

43. Rogi Kalyan Samitis (patient welfare committee / hospital management society) The united grants to sub centres ( SCs) The village health sanitation and nutrition committee (VHSNC ) Janani Suraksha Yojana (JSY) Janani Shishu Suraksha Karyakram (JSSK) National mobile medical units (NMMUs ) National ambulance services Web enabled mother and child tracking system (MCTS )

44. NEW INITIATTIVES Home delivery of contraceptives (condoms, oral contraceptive pills, emergency contraceptive pills) by ASHA Conducting district level household survey (DLHS) -4 in 26 states /UTs where the annual health survey (AHS) is not being done. Modifications in the scheme for promotion of menstrual hygiene covering 152 districts and nearly 1.5 crores of adolescent girls in 20 states allocation of united funds and Rogi Kalyan Samiti grants will be made based on the case load and services provided by the health facility. Involving ASHA in home based new-born care

45. Revision in the criterion of allocation of funds to the states under NRHM Expansion of village health and sanitation committees to include nutrition in its mandate and renaming it as village health, sanitation and nutrition committee (VHSNC) Centrally sponsored scheme for development of AYUSH hospitals and dispensaries for mainstreaming of AYUSH under NRHM. Rashtriya Bal Swasthya Karyakram ( RBSK)

46. Rastriya 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. Mother and child health wings (MCH wings Free drugs and free diagnostic services

47. National iron + initiative is 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. Reproductive, maternal, new-born, child and adolescent health services (RMNCH + A)

48. Delivery Points ( DPs): with the objective of providing comprehensive reproductive, maternal, new-born, child and adolescent health services (RMNCH+A) at these facilities. Universal Health Coverage (UHC): moving towards Universal Health Coverage (UHC) is a key goal of the 12 the five year plan

49. SPECIAL INITIATIVES GERIATRIC CARE PROJECT COMMUNITY BASED MENTAL HEALTH PROJECT POLY CLINIC SERVICES RADIO HEALTH TELE MEDICINE MOBILE DISPENSARY PALLIATIVE CARE PROJECT MCTS

50. ACHIEVEMENTS 8.35 lakh ASHAs have been selected in the entire country of which 8.07 lakh ASHAs have been trained. 7.41 lakh ASHAs have been provided with drug kits 1.47 lakh sub centres in the country are provided with united funds of Rs 10000 each. 40426 sub centres are functional with second ANM 31109 Rogi Kalyan Samitis have been registered at different level of facilities 8630 doctors and specialists, 66786 ANMs, 328604 staff nurses, 14434 paramedics have been appointed on contract to fill in critical gaps in services

51. 1691 professionals (CA/MBA/MCA) have been appointed to support NRHM 1842 mobile medical units are operational under NRHM in states Emergency transport system operational in 12 states Accelerated immunization programme Janani suraksha yojana is operational in all the states. 1.13 crore women were benefited in the year 2011-12 Integrated management of neonatal and childhood illness (IMNCI) started in 310 districts

52. Monthly health and nutrition days being organized at the village level in various states The states have constituted 4.96 lakh village health sanitation and nutrition committees School health programme have been initiated in over 26 states

53. NATIONAL URBAN HEALTH MISSION The NUHM will focus on: Urban poor population living in listed and unlisted slums All other vulnerable population such as homeless, ragpickers , street children, rickshaw pullers, construction and brick and lime –kiln workers, sex workers, and other temporary migrants. Public health thrust on sanitation, clean drinking water, vector control Strengthening public health capacity of urban local bodies

54. Why NUHM ? Urban population is estimated to increase from 35.7 crores in 2011 to 43.2 crores in 2021 Rapid increase in the urban population can lead to increase in the number of slums Slum population is growing at the rate of 7% annually Poor health status of the urban slums Inadequacy of the health care delivery to the slum population

55. Slum people are at greater health hazards due to Overcrowding Poor living conditions Poor sanitary conditions Lack of safe water supply Environmental pollution Outbreak of communicable diseases Increased incidence of STIs, RTIs, HIV/AIDS

56. Goal of NUHM It is to improve the health status of the poor by: By facilitating equitable access to quality health care Revising public health system Building public private partnership Community based risk pooling and insurance mechanism Active involvement of the urban local bodies

57. Strategies of NUHM Improving the efficiency of public health system in the cities. MAS (Mahila Arogya Samitis) and USHA (Urban Social Health Activists) and Rogi kalian samitis (RKSs). Information Technology Enabled Services (ITES) and e-governance by improved surveillance and monitoring. Enhanced role of urban local bodies and capacity building of stakeholders. Prioritizing the most vulnerable amongst the poor.

58. Ensuring quality health care services through development of IPHS. Strengthening urban primary health structure By creating new UHC, each covering a slum population of 20000 to 30000 Provision of evening OPD Provision of comprehensive healthcare Provision of need based equipment, drugs, and human resources Provision of Rogi Kalyan Samiti Provision of outreach health sessions in the slums Strengthening community participation, improving health awareness and capacity building through partnership with non-government providers

59. Establishment of mahila Arogya Samiti Appointment of ASHA Capacity building of stakeholders Prioritizing the most vulnerable amongst the poor like destitute, beggars, street children, construction workers, coolies, rickshaw pullers, sex workers, street vendors and such others. Ensuring quality health care services by defining Indian Public health standards

60. Targets under National Urban Health Mission IMR -30/1000 live births by 2012 MMR – 1/1000 live births by 2012 TFR – 2.1 by 2012 Malaria – 50% reduction in mortality by 2015 Kala azar – 100% reduction in mortality by 2010 ans sustaining elimination by 2015

61. Fliariasis - > 80% coverage of population by mass drug administration (MDA) with diethyl carbamazepine (DEC), 70% reduction by 2010, 80% by 2012 and elimination by 2015 Dengue fever – 50% reduction in mortality by 2010 and sustaining at that level Chikunguniya – control of outbreaks and morbidity Tuberculosis – 85% cure rate through DOTS Leprosy – reduction in prevalence rate to less than 1 per 1000 popualtion

62. Coverage and duration of National Urban Health Mission Duration : period of 11 th five year plan (2008-2012) Coverage : entire urban poor population of 430 cities Phase I : all cities with population of more than 1 lakh Phase II: all towns with population of less than 1 lakh

63. Definition of slum Any compact habitation of at least 300 people or about 60 to 70 households of poorly built, congested tenements, in unhygienic environments, usually without adequate infrastructure and lacking in proper sanitary and drinking water facilities in these towns irrespective of the fact as to whether such slums have been notified or not as ‘Slum’ by state/ local government and union territory administration under any act, recognized or not, are legal or not, is be covered under NUHM

64. NUHM INFRASTRUCTURE

65. USHA (urban social health activist ) She is a resident woman of the same slum, studied at least up to 8 th standard, preferably in the age group of 25-45years, married / widowed/ divorced, chosen by urban local body counsellors

66. Functions of USHA 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 folder for essential provisions like ORS packets, IFA tablets, Chloroquine tablets, oral pills, condoms etc.

67. To support ANM/MAS in conducting monthly outreach session regularly To form and promote MAS 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

68. 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

69. Essential services rendered by ASHA Active promoter of good health practices and enjoying community support 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 safe delivery, nutritional care during pregnancy, identification of danger signs during pregnancy, counselling on immunization, ANC, PNC etc., act as a depot holder for essential provisions like oral rehydration therapy (ORS), iron folic acid tablets (IFA), chloroquine, oral pills and condoms etc., identification of target beneficiaries and support the ANM in conducting regular monthly outreach sessions and tracking service coverage.

70. Facilitate access to health related services available at the Anganwadi / primary health centres / urban local body (ULBs) and other services being provided by the ULB /state/central government. Formation and promotion of Mahila Arogya Samiti sin her community Arrange escort/ accompany pregnant women and children requiring treatment to the nearest urban primary health care, secondary/ tertiary level health care facility Reinforcement of community action for immunization, prevention of water borne and other communicable diseases like TB(DOTS), malaria, chikunguniya, and Japanese encephalitis.

71. Carrying out preventive and promotive health activities with AWW/ Mahila Arogya Samiti. Maintenance of necessary information and records about births and deaths, immunization, antenatal services in her 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.

72. Urban primary health centre Functional for a population of around approximately 50000 to 60000, the UPHC may be located preferably within a slum or near a slum within half a kilometre radius, catering to a slum population of approximately 25000- 30000 with provision for OPD

73. Staffing pattern UPHC For every 50000 population MO I/C – 1 2 nd MO (part time) -1 Nurse - 3 LHV -1 Pharmacist -1 ANMs - 3-5 Public health manager/ mobilization officer – 1 Support staff - 3 M & E unit 1 -1

74. One ANM for every 10000 population, outreach services in area of every ANM on weekly basis For every 200-500 HHs (1000 -2500 population) – community health volunteer (ASHA /LW) Mahila Arogya Samiti for every 50-100 HHs (250-500 population)

75. Urban Community Health Centre UCHC may be set up as a satellite hospital for every 4-5 UPHCS. The UCHC would cater to a population of 2, 50000. It would provide in patient services and would be a 30-50 bedded facility.

76. 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 Health care 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.

77. Functions of UPHC Medical care – OPD services 4 hours in the morning and 2 hours in the evening RCH II services National health programmes Collection and reporting of vital events IDSP Referral services Basic laboratory services Counselling services

78. Services provided under NUHM Community / outreach services Services at UPHC Services at UCHC

79. Main services Maternal health Registration, ANC, identification of danger signs, referral for institutional delivery, follow up counselling and behaviour promotion ANC, PNC, initial management of complicated delivery cases and referral, management of regular maternal health conditions, referral of complicated cases Delivery, management of complicated gynae / maternal health conditions, hospitalization and surgical interventions including blood transfusion. Family welfare Counselling, distribution of OCP/CC, referral for sterilization, follow up of contraceptive related complications IUD insertion, management of contraceptive related complications Sterilization operations, fertility treatment

80. Family welfare Counselling, distribution of OCP/CC, referral for sterilization, follow up of contraceptive related complications IUD insertion, management of contraceptive related complications Sterilization operations, fertility treatment child health and nutrition immunization, identification of danger signs, referral, follow –up, distribution of ORS, paediatric cotrimoxazole , post natal visits, counselling for new born care diagnosis and treatment of childhood illness, referral of acute/chronic cases, identification and referral of neonatal sickness management of complicated paediatric / neo-natal cases, hospitalization, surgical intervention, blood transfusion

81. RTI/STI including HIV/ AIDS Referral, community level follow up for ensuring adherence to treatment regime of cases undergoing treatment. Symptomatic diagnosis and primary treatment and referral of complicated cases Management of complicated cases, hospitalization Nutrition deficiency disorders Height/weight measurement, Hb testing, distribution of IFA tablets, promotion of localized salt, nutrition supplements to children and pregnant/ lactating women, promotion of breast feeding Symptomatic diagnosis and primary treatment and referral of complicated cases Management of acute deficiency diseases, hospitalization, treatment, rehabilitation of severe under nutrition

82. Vector borne diseases Slide collection, testing using RDKs, DDT, counselling for practices for vector control and protection Diagnosis and treatment, referral of terminally ill cases Management of terminally ill cases, hospitalization Mental health Initial screening and referral Psychiatric, neurological services Oral health Diagnosis and referral Management of complicated cases Hearing impairment / deafness Management of complicated cases

83. Chest infections (TB/Asthma) Symptomatic search and referral, ensuring adherence to DOTS, other treatment Diagnosis, treatment, referral of complicated cases Management of complicated cases Cardiovascular diseases BP measurement, symptomatic search and referral, follow up of under treatment patients Diagnosis, treatment, referral of complicated cases Management of complicated cases Diabetes Blood / urine sugar test (using disposable kit) symptomatic search and referral Diagnosis, treatment, referral of complicated cases Management of complicated cases

84. Cancer Symptomatic search and referral, follow up of under treatment patients Identification and referral, follow up of under treatment patients Diagnosis, treatment and hospitalization Trauma care (burns and injuries) First aid and referral First aid/ emergency resuscitation, documentation for medico-legal case and referral Case management and hospitalization, physiotherapy and rehabiltiation Other surgical interventions Identification and referral Hospitalization and surgical intervnetion Other support services like IEC, BCC, counselling and personal and social hygiene.

85. Monitoring and evaluation City level indicators (process and input indicators of NUHM) Community process Number of mahila Arogya Samiti (MAS) formed Number of MAS members trained Number of ASHA selected and trained Health systems Number of ANMs recruited Number of special outreach health camps organized in slum / HFas Number of UHNDs organized in the slums aand vulnerable areas Number of UPHCs made operational Number of UCHCs made operational Number of RKS created at UPHC and UCHC OPD attendance in UPHCs Number of deliveries conducted in public health facilities

86. RCH services ANC early registration in first trimester Number of women who had ANC check-up in their first trimester of pregnancy TT (2 nd dose ) coverage among pregnant women Number of children fully immunized Number of severely acute malnourished children identified and referred for treatment Communicable diseases Number of malaria cases detected through blood examination Number of TB cases identified through chest symptomatic Number of suspected Tb cases referred for sputum examination Number of MDR-TB cases put under DOTS plus Non-communicable diseases Number of diabetes cases screened in the city Number of cancer cases screened in the city Number of hypertension case screened in the city

87. Impact level targets of NUHM Reduce IMR by 40% (in urban areas) – National Urban IMR down to 20 per 1000 live births by 2017 40% reduction in MMR and IMR Achieve universal immunization in all urban areas Reduce MMR by 50% 50% reduction in MMR 100% of ANC coverage Achieve universal access to reproductive health including 100% institutional delivery Achieve replacement level fertility Achieve all targets of disease control programmes

88. Monitoring and evaluation State / district/ city urban health mission will regularly monitor the progress and provide feedback. Monitoring will be done in three stages: Community based monitoring Health management information system (HMIS) for reporting and feedback External evaluations

89. NATIONAL HEALTH MISSION The National health mission was approved in May 2013. The main programmatic components include health system strengthening in rural and urban areas, reproductive – maternal – new-born – child and adolescent health (RMNCH+A) and control of communicable and non-communicable diseases.

90. 1992 : child survival and safe motherhood programme (CSSM) 1997 : RCH I 1997 : RCH II 2005 : national rural health mission (NRHM) 2013 : RMNCH +A strategy 2014 : India new-born action plan (INAP)

91. Vision of the NHM “ 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”.

92. Core Values Safeguard the health of the poor, vulnerable and disadvantaged. Strengthen public health systems. Build environment of trust between people and providers of health services Empower community to become active participants in the process of attainment of highest possible levels of health. Institutionalize transparency and accountability in all processes and mechanisms. Improve efficiency to optimize use of available resources.

93. Guiding Principles Build an integrated network of all primary, secondary and a substantial part of tertiary care, providing a continuum from community level to the district hospital, with robust referral linkages to tertiary care and a particular focus on strengthening the Primary Health Care System including outreach services in both rural areas and urban slums. Ensure coordinated inter- sectoral action

94. Ensure prioritization of services that address the health of women and children and the prevention and control of communicable and non-communicable diseases, including locally endemic diseases. Ensure increased access and utilization of quality health services to minimize disparity on account of gender, poverty, caste, other forms of social exclusion and geographical barriers. Incentivize good performance of both facilities and providers. Address shortages of skilled workers in remote, rural areas, and other under-served pockets through appropriate monetary and non-monetary incentives.

95. Promote partnerships with private, for profit, and not for profit agencies including civil society organizations to achieve health outcomes. Facilitate knowledge networks and create effective public health institutions. Encourage and enable the involvement of Panchayati Raj Institutions (PRIs) /Urban Local Bodies (ULBs) representatives in the governance and oversight of health services Mainstream AYUSH, so as to enhance choice of services for users and to learn from and revitalize local health care traditions. Expand focus beyond maternal and child survival to ensuring quality of life for women, children and adolescents.

96. Goals, Outcomes and Strategies Reduce MMR to 1/1000 live births Reduce IMR to 25/1000 live births Reduce TFR to 2.1 Prevention and reduction of anaemia in women aged 15–49 years Prevent and reduce mortality & morbidity from communicable, non- communicable; injuries and emerging diseases

97. Reduce household out-of-pocket expenditure on total health care expenditure Reduce annual incidence and mortality from Tuberculosis by half Reduce prevalence of Leprosy to <1/10000 population and incidence to zero in all districts Annual Malaria Incidence to be <1/1000 Less than 1 per cent microfilaria prevalence in all districts Kala- azar Elimination by 2015, <1 case per 10000 population in all blocks

98. G oals of this phase of NHM will be towards enabling and achieving the stated vision. Making the system responsive to the needs of citizens, building a broad based inclusive partnership for realizing National health goals, focusing on the survival and well-being of women and children, reducing existing disease burden and ensuring financial protection for households.

99. Strategies Support and supplement state efforts to undertake sector wide health system strengthening through the provision of financial and technical assistance. Build state, district and city capacity for decentralized outcome based planning and implementation Enable integrated facility development planning which would include infrastructure human resources, drugs and supplies, quality assurance, and effective Rogi Kalyan Samitis (RKS).

100. Create a District Level Knowledge Centre within each District Hospital Improve delivery of outreach services Strengthen the sub-centre/Urban Primary Health Centre (UPHC) with additional human resources and supplies Prioritize achievement of universal coverage for Reproductive Maternal, Newborn , Child Health + Adolescent (RMNCH+A), National Communicable Disease Control and Non Communicable Diseases programmes.

101. Expand focus from child survival to child development of all children 0-18 years through a mix of Community, Anganwadi, and School based health services. Achieve the goals of safe motherhood Focus on adolescents and their health needs. Ensure the control of communicable disease Use primary health care delivery platforms to address the rising burden of Non- Communicable Diseases Converge with Ministry of Women & Child Development

102. Empower the ASHA to serve as a facilitator, mobilizer and provider of community level care. Strengthen people’s organizations such as the Village Health Sanitation and Nutrition Committees (VHSNC) and Mahila Arogya Samitis (MAS) Create mechanisms to strengthen Behaviour Change Communication Develop effective partnerships with private sector Enhance use of Information & Communication Technology Strengthen Health Management Information Systems

103. Ensure universal registration of births and deaths with adequate information on cause of death To ensure equitable health care and to bring about sharper improvements in health outcomes The government has already taken steps towards provision of free maternal, and child health services, including newborn care, immunization, adolescent health, and family planning. Free diagnostic and treatment services Focus on strengthening primary health care across the country.

104. The Primary Care List of Assured Services Reproductive and Child Health Care in pregnancy- all care including identification of complications, but excluding management of complications requiring surgery or blood transfusion. All aspects of Essential New-born Care. Care for common illnesses of new-born and of children- identify, stabilize and refer life threatening conditions beyond the approved skill sets of the mid level care provider. Immunization Universal use of iodized salt. All aspects of prevention and management of malnutrition, excepting those that requiring institutional care. All family planning services except female sterilization

105. Provision of safe abortion services - medical and surgical. Identification and management of anaemia, Common sexual and urogenital problems which can be treated syndromically , or diagnose with point of care diagnostics, and identification of those which need referral. All health education and individual counselling measures needed for promotion of desirable health behaviours and health care practices and change from inappropriate health care practices and behaviours, related to RCH. All activities under the Rashtriya Bal Suraksha Karyakram - at Anganwadi and school level All laboratory support Patient transport systems that can bring and drop back patients for example sick infants up to one year of age, institutional delivery, for disability, and address problems of access due to lack of transport.

106. Emergency and Trauma Care Prevention and appropriate management for bites and stings- snakes, scorpions, wild animals. Management of poisoning, including food poisoning. Complete first aid including management of minor injuries Stabilization care in poisoning and major injuries and ensuring referral through emergency response systems.

107. Control of Communicable Diseases Screening for leprosy, referral on suspicion, and follow up of cases with confirmed diagnosis and prescribed treatment. Referral of suspect tuberculosis, family level screening of known patients, and follow up of cases with confirmed diagnosis and prescribed treatment. HIV testing, appropriate referral and follow up of specialist-initiated treatment. All measures for the prevention of Vector Borne Diseases; early and prompt treatment for these diseases, with referral of complicated cases. Control of helminthiasis . Reduction in burden of waterborne disease Reduction of infectious hepatitis B and identification and referral for the same. Primary care for other infectious diseases

108. Non-Communicable Diseases Screening for breast and cervical cancers in all women over the age of 30. Screening for mental disorders, counselling, and follow up to specialist initiated care. Detection of epilepsy and stroke and follow up to specialist initiated drugs and rehabilitative measures. Screening for visual impairments, correction of refractive errors and referrals for the rest. Screening for diabetes and hypertension in all population above 30 annually. Ensuring follow up on doctor initiated drugs in diabetes and hypertension- and secondary prevention – so that no complications develop. Prevention – primary, secondary and tertiary preventive care in rheumatic heart disease.

109. Primary and secondary prevention in COPD and bronchial asthma, with provision of follow up care in patients put on treatment by specialists. Counselling and support to victims of violence. Preventive measures against all harmful addictive substances- tobacco in the main, but also alcohol and addictive drugs Community based geriatric care support. Preventive and promotive measures to address musculo -skeletal disorders- mainly osteoporosis, arthritis of different types and referral or follow up as indicated. Community based rehabilitative and disability care support.

110. FINANCING OF THE NATIONAL HEALTH MISSION NRHM/RCH Flexi-pool NUHM Flexi-pool Flexible pool for Communicable Disease Flexible pool for Non Communicable Disease including injury and trauma Infrastructure Maintenance Family Welfare Central Sector Component.

111. MONITORING AND EVALUATION Use of data from large scale population surveys Commissioning implementation research or evaluation studies use of HMIS data and field appraisals and reviews Health outcomes, output and process indicators Periodic Population Health Surveys and Demographic Information The Sample Registration Surveys (SRS ) Death statistics National Sample Survey Organization (NSSO) data on cost of care and morbidity, DLHS and NFHS.

112. SERVICE DELIVERY STRATEGIES Reproductive , Maternal, Newborn , Child Health and Adolescent (RMNCH+A) Services Maternal Health Comprehensive package of RMNCH+A services. Janani Suraksha Yojana (JSY) Janani Shishu Suraksha Karyakram (JSSK) Access to safe abortion services

113. Prevention and Management of Reproductive Tract Infections (RTI) and Sexually Transmitted Infections (STI) Gender Based Violence New-born and Child Health Universal Immunization Health Screening and Early Intervention Services Adolescent Health Iron and Folic Acid (IFA) supplementation Facility -based adolescent health services

114. Community based health promotion activities Information and counseling on sexual and reproductive health (including menstrual hygiene), Substance abuse Mental health Non-communicable diseases, injuries Adolescent Friendly Health Clinics (AFHC) Provision of Weekly Iron and Folic acid Supplementation (WIFS) National Iron Plus Initiative. Family Planning Intra-Uterine Contraceptive Devices (IUCD).

115. Control of Communicable Diseases The National Vector Borne Diseases Control Programme (NVBDCP) 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. Revised National Tuberculosis Control Programme (RNTCP) National Leprosy Control Programme (NLEP) Integrated Disease Surveillance Programme (IDSP)

116. Non Communicable Diseases (NCD ) National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) National Programme for the Control of Blindness (NPCB) National Mental Health Programme (NMHP) National Programme for the Healthcare of the Elderly (NPHCE) National Programme for the Prevention and Control of Deafness (NPPCD National Tobacco Control Programme (NTCP) National Oral Health Programme (NOHP) National Programme for Palliative Care (NPPC) National Programme for the Prevention and Management of Burn Injuries (NPPMBI) National Programme for Prevention and Control of Fluorosis (NPPCF)

117. RESEARCH EVIDENCES Study of Rogi Kalyan samitis in strengthening health systems under national rural health mission, district Pune, Maharashtra , Neha Adsul ,  Manoj Kar

118. The study was an attempt to define 'functional Health Systems' with a focus on strategic issues concerning RKS operations .   Materials   and Methods:  A mixed-method, multi-site, collective case study approach was adopted. In-depth interviews of key-stakeholders were conducted. Qualitative data were analyzed thematically and coded inductively.  Results :  RKS is yet to bring out quality component to the health services being provided through facilities. This can be attributed to structural and managerial weakness in the system; however, certainly NRHM has been consistent in creating a road-map for benefitting local community and their participation through RKS.  Conclusion :  The progress of the RKS can further be enhanced by giving due priority to critical areas. Furthermore, the results emphasize an urgent need for devising strategies and actions to overcome significant systemic constraints as highlighted in the present study.

119. CONCLUSION The NHM envisages achievement of universal access to equitable, affordable & quality health care services that are accountable and responsive to people's needs.

120. REFERENCES K.Park ; Text Book of Preventive and Social Medicine; Bhanot Banarsidas Publishers, 22nd Edition 2009 Keshav Swarnkar , Community Health Nursing; 2nd Edition, Nr Brothers Publications K.K Gulani ‘Community Health Nursing’ Kumar Publishers 1st Edition AH Suryakantha , Community Medicine With Recent Advances, 2nd Edition, New Delhi: Jaypee Publishers, 2010 www.keralahealht/gov.in www.who.in http://www.urban.health.resource.centre.in/module NRHMbulletin.vol7(4)july-aug2012

121. THANK YOU