National health mission

About NHM (NUHM & NRHM)

1. NATIONAL HEALTH MISSION BY DR. Anup Kr Gupta MD (CHA) NIHFW

2. INTRODUCTION The National Health Mission (NHM) encompasses its two Sub-Missions, the National Rural Health Mission (NRHM) and the National Urban Health Mission (NUHM). The National Health Mission was approved in May 2013. The NHM envisages achievement of universal access to equitable, affordable & quality healthcare services that are accountable and responsive to people’s needs.

3. OBJECTIVES Brief presentation o n the n a ti ona l hea l th mi s s i on D i scus s about the N a t i ona l Ru r al Hea lth Mi ss i on & N a ti ona l Urban Hea lth Mi ss i on

4. Problem statement Multi p l e bu r de n o f c ommun i c abl e & no n – c o m mun i c abl e diseases . H igh infant and ma t ernal mortality H igh T F R in many states 5 % unde r nour i she d and anemi c w ome n and chil d r en – v ery l i t tl e i mp r o v em e n t W a t er a n d s ani t a ti o n problems are still a big challenge M a lari a, dengue , ch i k ungun i y a o n the ri se Pub l ic hea l th r egu l a ti o n – poor monitoring

5. COMPONENT OF NHM NHM Finance Health system strengthening RMNCH+A National disease & control programs

6. Goals & Achievements 1. Reduce MMR to 1/1000 live births (1.30/1000 in 2016) 2. Reduce IMR to 25/1000 live births (34/1000 as in year 2016 ) 3. Reduce TFR to 2.1( 2.3 in year 2016) 4. Prevention and reduction of anaemia in women aged 15–49 years 5. Prevent and reduce mortality & morbidity from communicable, non- communicable; injuries and emerging diseases 6. Reduce household out-of-pocket expenditure on total health care expenditure(reduction from 72% to 60% achieved)

7. GOALS Continue 7. Reduce annual incidence and mortality from Tuberculosis by half (in 2015, incidence is 167 per lakh & mortality17 per 2015.) 8. Reduce prevalence of Leprosy to <1/10000 population and incidence to zero in all districts ( achieved) 9. Annual Malaria Incidence to be <1/1000 ( achieved) 10. Less than 1 per cent microfilaria prevalence in all districts( Achieved in 222 districts out of 225) 11. Kala- azar Elimination by 2015, <1 case per 10000 population in all blocks ( 454 blocks out of 611 blocks achieved )

8. NRHM Launched in 2005 Focus of the mission is on establishing a fully functional, community owned , decentralized health delivery system with inter- sectoral convergence at all levels. Under the NRHM , special focus have been given on 18 states including the 8 Empowered Action Group(EAG ) States as well as 8 North Eastern States, Jammu & Kashmir and Himachal Pradesh. There is  a shortfall of 35110 SCs (20%), 6572 PHCs (22%) and 2220 CHCs (30%) across the country as per the Rural Health Statistics (RHS) 2016. 

9. CONTINUE.. AIMS OF NRHM Universal access to equitable, affordable and quality health care. Bridging the gap in rural health care through creation of a cadre of Accredited Social Health Activist(ASHA) Reduction of child and maternal mortality Population Stabilization including gender and demographic balance

10. Components of NRHM 1. ASHA - Resident of the village, a woman (M/W/D) between 25-45 years, with formal education up to 8th class, having communication skills and leadership qualities. - One ASHA per 1000 population. - Around 9.4 lakhs ASHA’s are already selected. ASHA is 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 .

11. Responsibility of ASHA To create awareness among the community regarding nutrition, basic sanitation, hygienic practices, healthy living. Counsel women on birth preparedness, importance of safe delivery, breast feeding, complementary feeding, immunization, 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.

12. STRENGTHENING Primary Health Centres : Mission aims at Strengthening PHC for quality preventive, promotive , curative, supervisory and outreach services, through  25,354 Primary Health Centres : – 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 States. 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 considered if required .

13. For Sub- Centres The Untied Grants of Rs. 10,000 per annum to Sub- Centres (SCs) has given a new confidence to our ANMs in the field. . This Fund will be deposited in a joint Bank Account of the ANM & Sarpanch and operated by the ANM. The SCs are far better equipped now with blood pressure measuring equipment, haemoglobin ( Hb ) measuring equipment, stethoscope, weighing machine etc. Supply of essential drugs, both allopathic and AYUSH, to the 1.5 lakhs Sub Centres ( SCs ) . In case wherever needed, sanction of new Sub-centers, and upgrading existing Sub-centers, including buildings for Sub-centers functioning in rented premises will be considered.

14. Rogi Kalyan Samiti /Hospital Management Society is a simple yet effective management structure. This committee is a registered society whose members act as trustees to manage the affairs of the hospital and is responsible for upkeep of the facilities and ensure provision of better facilities to the patients in the hospital . Healthcare service delivery requires intensive human resource inputs. NHM has attempted to fill the gaps in human resources by providing nearly 1.88 lakh additional health human resources to States including 7,263 GDMOs, 3,355 Specialists, 73,154 ANMs, 40,847 Staff Nurses on contractual basis.

15. The Village Health Sanitation and Nutrition Committee (VHSNC) is an important tool of community empowerment and participation at the grassroots level to address issues of environmental and social determinants. Untied grants of Rs. 10,000 are provided annually to each VHSNC. Till date, 5.01 lakh VHSNCs have been set up across the country. Janani Suraksha Yojana (JSY, 100% centre funded) aims to reduce maternal mortality among pregnant women by encouraging them to deliver in government health facilities. Under the scheme, cash assistance is provided to eligible pregnant women for giving birth in a government health facility/ accredited private hospital. Since the inception of NRHM, 8.55 crore women have benefited under this scheme.

16. Janani Shishu Suraksha Karyakram (JSSK): Launched on 1st June, 2011. JSSK entitles all pregnant women delivering in public health institutions to absolutely free and no expense delivery, including caesarean section. Facility Based Newborn Care: As on June 2015, a total of 14,441Newborn Care Corners (NBCCs), 2,020 Newborn Stabilization Units(NBSUs) and 575 Special Newborn Care Units (SNCUs) have been made operational across the country. National Mobile Medical Units(NMMUs ): Support has been provided in 333 out of 672 districts for 1107 Mobile Medical Units (MMUs) under NHM in the country

17. National Ambulance Services (NAS): As on date, 31 States/UTs have the facility where presently, 7358 Dial-108, 400 Dial-104 and 7836 Dial-102 Emergency Response Service Vehicles are operational under NHM, besides 6290 empaneled vehicles for transportation of patients, particularly pregnant women and sick infants from home to public health facilities and back. Mainstreaming of AYUSH: Mainstreaming of AYUSH has been taken up by allocating AYUSH facilities in 10042 PHCs, 2732 CHCs, 501 DHs, 5714 health facilities above SC but below block level and 421 health facilities other than CHC at or above block level but below district level .

18. National Quality Assurance Framework for Health facilities: To improve quality of healthcare in over 31000 public facilities and provide a clear roadmap to States, Quality Standards for District Hospitals (DHs), CHCs and PHCs under National Quality Assurance Framework were rolled out in November, 2014. Launch of Kayakalp - An initiative for Award to Public Health facilities: Kayakalpinitiative has been launched to promote cleanliness, hygiene and infection control practices in public health facilities. Free Drugs Service Initiative: Under the NHM-Free Drug Service Initiative, substantial funding is available to States for provision of free drugs subject to States/UTs meeting certain specified conditions.

19. Free Diagnostics Service Initiative: The NHM- Free Diagnostics Service Initiative was launched in 2013 to provide free essential diagnostic services at public health facilities under which substantial funding was provided to States. Bio Medical Equipment Maintenance: States have been asked to plan interventions for comprehensive equipment maintenance for all functional medical equipment/machinery.

20. Comprehensive Primary Healthcare: In December 2014, the Ministry of Health and Family Welfare constituted a Task Force to identify current challenges like rolling out comprehensive primary health care, finalizing components of service delivery, clarifying the institutional structures and service organizations, developing guidelines. Kilkari : To create proper awareness among pregnant women, parents of children and field workers about the importance of Ante-Natal Care (ANC), Institutional Delivery, Post-Natal Care (PNC) and Immunization, it was decided to implement the Kilkari and Mobile Academy services across India in phased manner.

21. Mobile Academy is an anytime, anywhere audio training course on interpersonal communication skills that the ASHA can access from her mobile phone. Launch of Nationwide Anti-TB drug resistance survey: Drug resistance survey for 13 anti TB drugs was launched to provide a better estimate on the burden of Multi-Drug Resistant Tuberculosis within the community. This is the biggest ever such survey in the world with a sample size of 5214 patients. Kala- Azar Elimination Plan: To reduce the annual incidence of Kala- azar to less than one per 10,000 population at block PHC level by the end of 2015.

22. NATIONAL URBAN HEALTH MISSION(NUHM) Launched on 1 st May 2013. for providing equitable and quality primary healthcare services to the urban population with special focus on slum and vulnerable sections of the society. The Centre-State funding pattern is 60:40 for all the States except the North-Eastern States and other hilly States viz. Jammu & Kashmir, Himachal Pradesh and Uttarakhand , for which the Centre-State funding pattern is 90:10. In the case of UTs the entire NUHM programme is fully funded by Central Government.

23. Nuhm has high focus on urban poor population living in listed & unlisted slum areas. All others vulnerable population are rikshaw pullers, homeless, street children, sex workers, beggers . Public health thrust on sanitation, clean water, vector controls. Strengthening public health capacity of urban local bodies.

24. Problem statement There has been a considerable rise of urbanization in the country over the last decade. Census 2011 data showed, for the first time since Independence, the absolute increase in population was more in urban areas that in rural areas. As per Census 2001, 28.6 crore people live in urban areas. The urban population has increased to 37.7 crore in 2011. Of the 370 million urban dwellers, over 100 million are estimated to live in slums and face multiple health challenges on the fronts of Sanitation, Communicable and Non communicable diseases.

25. Slums

26. Goal of NUHM The NUHM aims to address the health concerns of the urban poor Facilitating equitable access to available health facilities Strengthening of the existing capacity of health delivery The existing gaps to be filled up through partnership with NGOs. Planning process to undertake large scale community level i nsu r an c e mechan ism. A c ti v e i n v o l v eme n t o f the urba n l o c al bod i es

27. Service Delivery Infrastructure of NUHM Urban–Primary Health Centre (U-PHC): New U-PHCs are established as per gap analysis, as per norm of one U-PHC for approximately 50,000 urban populations. Urban-Community Health Centre (U-CHC) and Referral Hospitals: 30- 50 bedded U-CHCs are established for providing inpatient care. U-CHCs are set up in cities with a population of above 5 lakhs . Urban Community Health Centre (U-CHC) are proposed to be set up as a satellite hospital for every 4-5 U-PHCs. Outreach services: NUHM also support engagement of ANMs for conducting outreach services for targeted groups particularly slum dwellers and the vulnerable population. All the services delivered under the mission will be based on identification of the target groups through distribution of Family/ Individual Health Suraksha Cards

28. Urban Social Health Activist(USHA) An USHA will be posted for every 200-500 households Maintain IPC with the families and the Mahila Arogya Samities (MAS) for which they are earmarked. The USHA , preferably be a woman resident of the slummarried /widowed/ divorced & preferably in the age group of 25 to 45 years, should be literate with formal education up to class eight subjected to relaxation.Approx 33000 USHA has been selected. Chosen through a rigorous community driven process involving ULB Counsellors , community groups, self help groups, Anganwadis , ANMs.

29. Functio n s of USHA T o p r omo t e g oo d hea l th se r vices in he r a r ea T o f acili t a t e a w a r eness o n R C H se r vices T o mot i v a t e all typ e s o f f amily p lann ing m e thods T o r egi s t er all p r egn a n t m o the r s and t o mot i v a t e them f o r a n t en a t al c a r e T o act as a dep o t f o l de r f o r esse n tial p r ov i s i on s li k e O R S p a c k e t s , I F A t able t s, Ch l o r oqu i n e t able t s , o r al p ill s, c ond o ms. Contn …

30. T o suppor t ANM/MAS in c onduct i n g mo n thl y ou t r each se s s i o n r egu l arl y T o f or m a n d p r o m o t e M AS T o es c or t the p a ti e n ts r equ i r i n g hea l th se rvi ces T o en c ou r a g e the c o m mun i ty par tici p a ti o n in hea l th a c tiviti es T o m a i n t ain the r e c o r d s o f vi t al e v e n ts in he r a r ea T o t r e a t mi no r a ilm e n ts with the dru g k it p r ov i d e d

31. Community Process Mahila Arogya Samiti (MAS): One Mahila Arogya Samiti will covers 250-1,000 beneficiaries and between 50-100 households and act as community based peer education group in slums. So far 40132 MAS have been formed ASHA/Link Workers: ASHA serves as an effective and demand–generating link between the health facility and the urban slum population. Each link worker/ASHA will have a well-defined service area of about 1000-2,500 beneficiaries/between 200-500 households. So far 31899 ASHAs have been identified.

32. HEALTH MANAGEMENT INFORMATION SYSTEM (HMIS) It is a web-based monitoring system that has been put in place by the Ministry to monitor health programmes under National Health Mission. It was launched in October 2008 with district wise data uploading on HMIS portal. At present, 672 districts are reporting facility wise data while Brihan Mumbai and Kolkata are uploading district consolidated figure on the HMIS web portal. HMIS data is widely used by the Central/State Government officials for monitoring and supervision purposes

33. SURVEYS AND EVALUATION ACTIVITIES Periodically surveys to assess the level and impact of health interventions that include National Family Health Survey (NFHS), District Level Household Survey (DLHS), Annual Health Survey (AHS).

34. NATIONAL HEALTH SYSTEM RESOURCE CENTRE (NHSRC) The National Health System Resource Centre (NHSRC) was set up in 2007, as a technical support and knowledge management agency for the National Rural Health Mission (NRHM). SUPPORT TO NGO: the Central Government will support the NGOs only as per the proposals of States through their Programme Implementation Plans (PIPs).

35. Serial No. Parameter 1951 1981 1991 2001 2016 1 Crude Birth Rate( Per 1000 population) 40.8 33.9 29.5 25.4 20.4 2 Crude death rate ( Per 1000 population) 25.1 12.5 9.8 8.4 6.4 3 Total fertility rate 6.0 4.5 3.6 3.1 2.3 4 Maternal Mortality rate (per lakh live birth) NA NA 437 301 130 5 Infant Mortality Rate (per 1000 live birth) 146 110 80 66 34 6 Expectation of life at birth 55.4 59.4 63.4 67.9 (2010-14)