NRHM & NUHM

NATIONAL RURAL HEALTH MISSION AND NATIONAL URBAN HEALTH MISSION

1. NATIONAL RURAL HEALTH MISSION & NATIONAL URBAN HEALTH MISSION PRAMOD KUMAR

2. HEALTH Health is defined as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." 

3. NATIONAL RURAL HEALTH MISSION- The National Rural Health Mission (NRHM) was launched on 12th April 2005, to provide accessible, affordable and accountable quality health services to the poorest households in the remotest rural regions. Under the NRHM, difficult areas with unsatisfactory health indicators were classified as special focus States to ensure greatest attention where needed.

4. CHALLENGES OF PUBLIC HEALTH IN RURAL AREA Integration of sanitation, hygiene, nutrition and drinking water issues needed in the overall sectoral approach for health. Striking regional inequalities. The challenge of population stabilization especially in States with weak demographic indicators. Undue importance of curative services that favor non-poor. For every Rs.1 spent on poorest 20% population, Rs.3 spent on the richest quintile. About 10% Indians had some form of health insurance, mostly inadequate.

5. PRINCIPLES Promote equity, efficiency, quality and accountability in Public Health Systems. Enhance people orientation band community- based approaches. Ensure Public health focus. Recognize value of traditional knowledge base of communities. Promote new innovations, methods and process development. Decentralize and involve local bodies.

6. 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.

7. VISION Provide effective healthcare to rural population throughout the state. Increase public spending on health with increased arrangement for community financing and risk pooling. Undertake architectural correction of the health system to enable it to effectively handle increased allocations and promote policies that strengthen public health management and service delivery in the state. Revitalise local health traditions and mainstream AYUSH into the public health system.

8. cont.. Effectively integrate of health concerns, through decentralized management at district level, with determinants of health like sanitation and hygiene, nutrition, safe drinking water, gender and social concerns. Set time bound goals and report publicly of progress. Improve access of rural people, especially poor women and children to equitable, affordable, accountable and effective primary health care.

9. OBJECTIVES ASHA : Provision of trained and supported Village Health Activist in underserved areas as per need (Accredited Social Health Activists, ASHA)-Ensuring quality and close supervision of ASHA . Health Action Plan: Preparation of health action plans by panchayat as mechanism for involving community in health . IPHS: Strengthening SC/PHC/CHC by developing Indian Public Health Standards.

10. cont.. FRU: Increase utilization of First Referral Units from less than 20% (2002) to more than 75% by 2010. District: Institutionalizing and substantially strengthening District level Management of Health (all districts). AYUSH: Strengthening sound local health traditions and local resource based practices related to PHC and public health.

11. EXPECTED OUTCOMES FROM THE MISSION IMR reduced to 30/1000 live births by 2010. MMR reduced to 100/100.000 live births by 2012. TFR reduced to 2.1 by 2012. Malaria mortality reduction rate-50% by 2010, additional 10% by 2012. Kala- Azar mortality reduction rate-100% by 2010 and sustaining elimination until 2012. Filarial reduction rate-70% by 2010, 80% by 2012 and elimination by 2015 .

12. cont.. Dengue mortality reduction rate-50% by 2010 and sustaining it at that level till 2012. Japanese encephalitis mortality reduction rate-50% by 2010 and sustaining it at that the level till 2012. Cataract operations increasing to 46 lakh per annum until 2012. Leprosy prevalence rate- reduce from 1.8 per 10,000 in 2005 to less than one per 10000 thereafter. TB DOTS series- maintain 85% cure rate through entire mission period. Upgrading all CHCs to Indian Public Health Standards.

13. PLAN OF ACTION Consists of 10 components COMPONENT-1: ASHA (ACCREDITED SOCIAL HEALTH ACTIVISTS) Selection: every village/large habitat (1000 population) will have a female community health activist-chosen by and accountable to the panchayat -to act as the interface between the community and the public healthcare system. ASHA must be primarily a woman resident of the village-married/widow/ divorced and preferably in the age group of 25-45 yrs. She should be a literate woman with formal education upto the 8 th class with communication and leadership qualities. ASHA would act as a bridge between the ANM and the village and be accountable to the panchayat . ASHA will be honorary volunteer.

14. cont.. Responsibilities Awareness : Regarding nutrition, basic sanitation and hygienic practices, healthy living and working conditions, information on existing health services and need for utilization of health & family welfare services . Counseling: On birth preparedness, importance of safe delivery, breast feeding, and complementary feeding, immunization, contraception and prevention of common infections including RTIs/STIs and care of the young child . Mobilization: to mobilize the community and facilitate them in accessing health and health related services available at the Anganwadi / subcentres /PHCs . Escort : to arrange escort/accompany pregnant women and children requiring treatment/ admission to the nearest pre-identified health facility .

15. cont.. Medical care: to provide primary medical care for minor ailments such as diarrhea, fever, and first aid. She will be a provider of DOTS also. Drug Depot: to act as depot holder for essential provisions being made available to every habitation like ORS, iron & folic acid tablets, Disposable Delivery Kit, Oral pills, condoms etc. Birth & death registration: to inform sub- centre /PHC about birth and death and

16. cont.. COMPONENT 2: STRENGTHENING SUB-CENTRES Each sub- centre will have an untied fund for local action @ Rs . 10,000 per annum. This fund will be held in joint account of ANM and Panchayat Sarpanch . Supply of essential drugs (allopathic and AYUSH) to the sub- centres . In case of additional outlays, MPWs (Male)/additional ANMs wherever needed, sanction of new sub-centers as per 2001 population norm, and upgrading existing subcentres , including buildings for subcentres functioning in rented premises will be considered.

17. cont .. COMPONENT 3: STRENGTHENING PRIMARY HEALTH CENTRES Strengthening of PHC for quality preventive, promotive , curative, supervisory and outreach services. Adequate and regular supply of essential quality drugs and equipment to PHCs. Provision of 24 hours services in 50% PHCs by addressing shortage of doctors, especially in high focus states, through mainstreaming AYUSH manpower. Standard treatment guidelines & protocols.

18. cont.. Supply of Auto Disabled (AD) Syringes for immunization. In case of additional outlays, intensification of ongoing communicable disease control programmes , new progress for control of non-communicable diseases, upgradation of 100% PHCs, and provision of 2 nd doctor at PHC level (1 male, 1 female) would be undertaken on the basis of felt need.

19. cont.. COMPONENT 4: STRENGTHENING OF CHCS FOR FIRST REFERRAL CARE Operationalsing existing community Health centres (30-50 beds) as 24 hours First Referral Units, including posting of anesthetists . Codification of new Indian Public Health Standards (IPHS), setting norms for infrastructures, staff, equipment, management etc. for SC/PHC/CHC . Promotion of stakeholders’ committees ( Rogi Kalyan Samities ) for hospital management .

20. cont.. Developing standards of services and costs in hospital care. Develop, display and ensure compliance to Citizen’s Charter at CHC/PHC level. In case of additional Outlays, creation of new Community Health Centres (30-50 beds) to meet the population norm as per Census 2001, and bearing their recurring costs for the Mission period could be considered.

21. cont.. COMPONENT 5: DISTRICT HEALTH PLAN District Health Plan would be an amalgamation of field responses 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 monitoring .

22. cont.. 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 programmes

23. cont.. 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.

24. cont.. COMPONENT 6: CONVERGING SANITATION AND HYGIENE UNDER NRHM Total Sanitation Campaign (TSC) is presently implemented in 350 districts, and is 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 Programme . 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 ASHA would be incentivized for promoting household toilets by the Mission.

25. cont.. COMPONENT 7: STRENGTHENING DISEASE CONTROL PROGRAMMES National Disease Control Programmes for Malaria a, TB, Kala Azar , Filaria , Blindness & Iodine Deficiency and Integrated Disease Surveillance Programme shall be integrated under the Mission, for improved programme delivery . New Initiatives would be launched for control of Non Communicable Diseases.

26. cont.. Disease surveillance system at village level would be strengthened. Supply of generic drugs (both AYUSH & Allopathic) for common ailments at village, SC, PHC/CHC level . Provision of a mobile medical unit at District level for improved Outreach  services.

27. cont.. COMPONENT 8: PUBLIC-PRIVATE PARTNERSHIP FOR PUBLIC HEALTH GOALS, INCLUDING REGULATION OF PRIVATE SECTOR Since almost 75% of health services are being currently provided by the private sector, there is a need to refine regulation District Institutional Mechanism for Mission must have representation of private sector

28. cont.. Need to develop guidelines for Public-Private Partnership (PPP) in health sector. 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

29. cont.. COMPONENT 9: NEW HEALTH FINANCING MECHANISMS A Task Group to examine new health financing mechanisms, including Risk Pooling for Hospital Care as follows : District Health Missions to move towards paying hospitals for services by way of reimbursement, on the principle of “money follows the patient .” Standardization of services and National Expert Group to monitor these standards and give suitable advice and guidance on protocols and cost comparisons.

30. cont.. COMPONENT 10: REORIENTING HEALTH/MEDICAL EDUCATION TO SUPPORT RURAL HEALTH ISSUES Medical and Para-medical education facilities need to be created in states, based on need assessment . Suggestion for Commission for Excellence in Health Care (Medical Grants Commission), National Institution for Public Health Management etc . Task Group to improve guidelines/details.

31. NATIONAL RURAL HEALTH MISSION - INSTITUTIONAL MECHANISM Village Health & Sanitation Samiti . Rogi Kalyan Samiti (or equivalent) for community management of public hospitals . District Health Mission, under the leadership of Zila Parishad with District Health Head as Convener and all relevant departments, NGOs, private professionals etc represented on it

32. cont.. State Health Mission, Chaired by Chief Minister and co-chaired by Health Minister and with the State Health Secretary as Convener- representation of related departments, NGOs, private professionals etc. Integration of Departments of Health and Family Welfare, at National and State level. National Mission Steering Group to provide policy support and guidance to the Mission.

33. cont.. Empowered Programme Committee Standing Mentoring Group shall guide and oversee the implementation of ASHA initiative.

34. ROLE OF STATE GOVERNMENTS UNDER NRHM   The Mission covers the entire country. The 18 high focus States are Uttar Pradesh, Bihar, Rajasthan, Madhya Pradesh, Orissa, Uttaranchal, Jharkhand, Chhattisgarh, Assam, Sikkim, Arunachal Pradesh, Manipur, Meghalaya, Tripura, Nagaland, Mizoram Himachal Pradesh and Jammu & Kashmir. Govt would provide funding for key components in these 18 high focus States. NRHM provides broad conceptual framework. States would project operational modalities in their State Action Plans, to be decided in consultation with the Mission Steering Group .

35. cont.. NRHM would prioritize funding for addressing inter-state and intra district disparities in terms of health infrastructure and indicators. States would sign Memorandum of Understanding with Government of India, indicating their commitment to increase contribution to Public Health Budget (preferably by 10% each year), increased devolution to Panchayati Raj Institutions.

36. NATIONAL URBAN HEALTH MISSION GOAL To improve the health status of the urban population but particularly of the poor and other disadvantaged sections, by facilitating equitable access to quality health care through a revamped public health system. capacity of urban local bodies.

37. Mission’s High Focus •Urban Poor Population living in listed and unlisted slums •All other vulnerable population such as homeless, rag-pickers, 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, etc. • Strengthening public health

38. cont.. All existing CHCs to have wage component paid on monthly basis. Other recurrent costs may be reimbursed for services rendered from District Health Fund. Over the Mission period, the CHC may move towards all costs, including wages reimbursed for services rendered . A district health accounting system, and an ombudsman to be created to monitor the District Health Fund Management, and take corrective action .

39. cont.. Adequate technical managerial and accounting support to be provided to DHM in managing risk-pooling and health security. The Central government will provide subsidies to cover a part of the premiums for the poor, and monitor the schemes. The IRDA will be approached to promote such CBHIs, which will be periodically evaluated for effective delivery.

40. CORE STRATEGIES Improving the efficiency of public health system in the cities by strengthening, revamping and rationalizing existing government primary urban health structure and designated referral facilities Promotion of access to improved health care at household level through community based groups : Mahila Arogya Samitis

41. cont.. Strengthening public health through innovative preventive and promotive action Increased access to health care through creation of revolving fund IT enabled services (ITES) and e- governance for improving access improved surveillance.

42. cont.. Capacity building of stakeholders Prioritizing the most vulnerable amongst the poor Ensuring quality health care services

43. OUTCOMES- IMPACT LEVEL Reduce IMR by 40 % (in urban areas) – National Urban IMR down to 20 per 1000 live births by 2017 Mternal mortality reduced to 100/10,000 live births by 2012. TFR reduced to 2.1 by 2012 Malaria Mortality reduction rate- 50% by 2010, assitional 10% by 2012. Kala- Azar mortality reduction rate 100% by 2010 and sustaining elimination thereafter.

44. cont.. Filarial reduction rate 70% by 2010, 80 % by 2012 and elimination by 2015. Dengue mortality reduction rate 50% by 2010 and sustaining it at that level till 2012 Japanese encephalitis mortality reduction rates 50% by 2010 and sustaining it at the level till 2012. Chikungunya : reduction in number of outbreaks and morbidity due to chikungunya by prevention and control strategy.

45. cont.. Leprosy prevalence rate reduced from 1.8 per 10,000 in 2005 to less than 1 per 10,000 thereafter. Tuberculosis DOTS series- maintain 85% cure rate through the entire mission period and also sustain planned case detection rate. Reduce the prevalence of deafness by the 25% by 2012.

46. Measurable indicators of improved health of the urban poor at the city level are also proposed to be assessed annually through e-enabled HIMS and surveys. Some of the measurable indicators are given below: Cities/population where mission has been mapped Number cities/population where mission has been initiated. Increase in OPD attendance Increase in BPL referrals from UHCs. Increase in BPL referral availed at referral units. Number of slum/cluster level health and sanitation day. Number of USHA receiving full honorarium. Number of MAS formed. Number of UHCs with program manager. Increase in ANC check-up of pregnant. Women .

47. cont.. Increased tetanus toxoid coverage among pregnant women. Increase in institutional deliveries as percentage of total deliveries. Increase in complete immunization among children <12 months. Increase in case detection for malaria through blood examination. Increase in case detection of TB through identification of chest symptomatic. Increase in referral for sputum microscopy examination for TB. Increase in number of cases screened and treated for dental ailments.

48. cont.. Increase in number of cases screened for diabetes. Increase in number of cases referred and operated for heart related ailments. Increased in first aid and referral of burns and injury cases. Increase in number of mental health services at primary health care level in urban health setting. Increase in the awareness of community about tobacco products/alcohol and substance abuse.

49. URBAN HEALTH CARE DELIVERY MODEL The urban health delivery model would basically comprise of an Urban Primary Health Centre for provision of primary health care with outreach and referral linkages.

50. 1. URBAN- COMMUNITY HEALTH CENTRE (U-CHC) Population Norms and Location May act as a satellite hospital for every 4-5 U-PHCs The U-CHC would cater to a population of 2,50,000 Services It would provide in patient services and would be a 30-50 bedded facility It would provide medical care, minor surgical facilities and facilities for institutional delivery.

51. cont.. Support Staff Two doctors (one regular and one on a part time basis) There will be 2 multi skilled paramedics (lab technician and pharmacist) 2 multi-skilled nurse, 1 LHV, 4-5 ANMs (depending upon the population covered) Clerical and support staff and one Programme Manager for supporting community mobilization, behavior change communication, capacity building efforts and strengthening referrals

52. 2. URBAN PRIMARY HEALTH CENTRE (U-PHC) Population Norms and Location Functional for a population of around approximately 50,000-60,000 It may be located preferably within a slum or near a slum within half a kilometer radius catering to a slum population of approximately 25,000-30,000, with provision for OPD from 12 noon to 8 pm in the evening The cities based upon the local situation may establish a U-PHC for 75,000 for areas with very high density

53. cont.. Services OPD (consultation); Basic lab diagnosis, drug /contraceptive dispensing; Distribution of health education; Material and counseling for all communicable and non communicable diseases It will not include in-patient care

54. cont.. Support Staff Two doctors (one regular and one on a part time basis) There will be 2 multi skilled paramedics (lab technician and pharmacist) 2 multi-skilled nurse, 1 LHV, 4-5 ANMs (depending upon the population covered) Clerical and support staff and one Programme Manager for supporting community mobilization, behavior change communication, capacity building efforts and strengthening referrals

55. 3. COMMUNITY LEVEL A . Urban Social Health Activist (USHA) A Frontline community worker for each slum/community similar to USHA under NRHM The USHA would be a woman resident of the slum, preferably in the age group of 25 to 45 years She would be covering about 1000 - 2500 community level beneficiaries. She would be covering between 200-500 households based on spatial consideration preferably co-located at the Anganwadi Centre functional at the slum level the door steps

56. cont.. She would serve as an effective demand–generating link between the health facility (Urban Primary Health Centre) and the urban slum populations She would maintain interpersonal communication with the beneficiary families and individuals to promote the desired health seeking behavior She would help the ANM in delivering outreach services in the vicinity of the doorsteps of the beneficiaries She will be responsible to the Mahila Arogya Samitis (community groups) for which they are designated

57. cont.. Selection Process The USHA will be selected through a community driven process led by the Urban Local Body To facilitate the selection process the District/ City level Mission would constitute a City Level USHA Selection Committee headed by the member of the urban local body. The CMO/CDMO; DPOICDS; and PO of JnNURM ; DUDA; SJSRY would be the members The District/ City level health mission can also decide to induct more members from the NGO/ Civil society based on the local need.

58. cont.. Mentoring System Involving dedicated community level volunteers/professionals preferably through the local NGO at the U-PHC level for supporting and coordinating the activities of the USHA The states may also consider the option of 1 Community Organizer for 10 USHAs for more effective coordination and mentoring.

59. cont.. Essential services to be rendered by the USHA 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; counseling on immunization, ANC, PNC etc. act as a depot holder for essential provisions like Oral Re-hydration Therapy (ORS), Iron Folic Acid Tablet (IFA), chloroquine , Oral Pills & Condoms, etc .

60. cont.. Facilitate access to health related services available at the Anganwadi /Primary Urban Health Centres /ULBs, and other services being provided by the ULB/State/ Central Government Formation and promotion of Mahila Arogya Samitis in her community Arrange escort/accompany pregnant women and children requiring treatment to the nearest Urban Primary Health Centre, secondary/tertiary level health care facility

61. cont.. Reinforcement of community action for immunization, prevention of water borne and other communicable diseases like TB (DOTS), Malaria, Chikungunya and Japanese Encephalitis Carrying out preventive and promotive health activities with AWW/ Mahila Arogya Samiti . Maintenance of necessary information and records about births & 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.

62. B. MAHILA AROGYA SAMITI (MAS) It acts as community group involved in community awareness, interpersonal communication, community based monitoring and linkages with the services and referral The MAS may cover around 50- 100 households (HHs) with an elected Chairperson and a Treasurer supported by an USHA Link worker

63. cont.. Activity Preventive and promotive health care Facilitating access to identified facilities Management of revolving fund \ Constitution of Mahila Arogya Samiti ASHA Group of socially committed females from the community itself Women’s/ SHG groups

64. C. AUXILIARY NURSE MID-WIFE: OUTREACH SESSION Each ANM will organize a minimum of one outreach session in the area of the MAS every month Outreach Medical Camps – Once in a week the ANMs would organize one Outreach Medical Camp in partnership with other health professionals (doctors/pharmacist/technicians/nurses – government or private.

65. cont.. 4-5 ANMs will be posted in each U-PHC depending upon the population Outreach sessions will be planned to focus special attention for reaching out to the vulnerable sections like slum population, rag pickers, sex workers, brick kiln workers, street children and rickshaw pullers  

66. REFERRAL LINKAGES: Existing hospitals including maternity homes, state government hospitals and medical colleges.

67. COORDINATION AND CONVERGENCE FOR EFFECTIVE IMPLEMENTATION 1. JAWAHARLAL NEHRU URBAN RENEWAL MISSION (JNNURM) Sub- Mission 1- Basic Services to the Urban Poor (BSUP )\ City will be the unit of planning for health and allied activities The City Health plan would also be shared for prioritization of actions at the City level

68. cont.. GIS based physical mapping of the slums is being undertaken The community level institutions such as MAS may also be utilized by the implementation mechanism of JnNURM Sub- Mission 2- Integrated Housing and Slum Development The community centers being created under IHSDP will be used as sites for conducting fixed outreach session

69. cont.. 2. RAJIV AWAS YOJANA The City Health Plans under NUHM can be incorporated into the slum free city and state plans of action under RAY GIS based physical mapping of the slums and the spatial representation of the socio-economic profile of slums (Slum MIS) is being undertaken under RAY. This will also be useful for development of city health plans

70. cont.. 3. SWARN-JAYANTI SHEHRI ROJGAR YOJNA The community level structures being proposed under NUHM can be strengthened by effectively aligning them with the SJSRY structures . Community organizer for about 2000 identified families under SJSRY can be co-opted as ASHA

71. cont.. Neighborhood Groups which are informal associations of woman living in mohalla or slum or neighborhood representing 10 to 40 urban poor or slum families and Development of Women and Children in Urban Areas (DWCUA) Groups under SJSRY may be federated into Mahila Arogya Samitis (MAS) Neighborhood Committee (NHC) is a more formal association of women from slum or mohalla . Representatives from other sectoral programmes in the community like ICDS supervisor, school teacher, ANM etc. are also its members

72. cont.. 4. MINISTRY OF WOMEN AND CHILD DEVELOPMENT MAS/ASHA in coordination with the ANM to organize Community Health and Nutrition day in close coordination with the Anganwadi worker (AWW) on lines of NRHM MAS/ ASHA to support AWW/ANM in updating the cluster/ slum level health register

73. cont.. Outreach session also to be organized in the Anganwadi centers located in slums or nearby Organization level health education activities at the AW Centre AWW and MAS to work as a team for promoting health and nutrition related activities.

74. cont.. 5. SCHOOL HEALTH PROGRAMME (MINISTRY OF HUMAN RESOURCE DEVELOPMENT ) It cover Government or private schools located in slums (U-PHC catchment) or government schools near slums which slum children attend It would focus on school health services, school environment and health education

75. cont.. 6. ADOLESCENT REPRODUCTIVE AND SEXUAL HEALTH Once a week adolescent clinic will be organized at the Urban PHC During this teen clinic health education and counseling will be provided to the adolescent girls for promoting menstrual hygiene, prevention of anemia, prevention of RTIs/STIs, counseling for sexual problems etc.

76. cont.. 7. Member of Parliament/Legislative Assembly/ Municipal Local Area Development Fund   8. Corporate Social Responsibility (CSR )   9. North Eastern Region Urban Development Programme   10. Multi Sectoral Development Programme ( MsDP )- in 90 minority districts in the country

77. ESSENTIAL HEALTH CARE SERVICES UNDER NUHM   Community Level Primary Health Care Level   Referral Centre (U-CHC)   Maternal Health   - Registration Ante-natal Care Identification of danger signs Referral for institutional delivery Follow-up Counseling and Behavior   Ante-natal and Post-natal care Management of complicated delivery cases and referral Management of regular maternal conditions Referral of complicated cases   Delivery (normal and complicated) Management of complicated Gynae /maternal health condition Hospitalization and surgical interventions including blood transfusion  

78. Difference between NRHM and NUHM NRHM NUHM National rural health mission National urban health mission Improves rural health delivery system Separate mission for urban areas and focus on slums & other urban poor families. Launched on 12 th April, 2005 Approved on 1st May 2013 Creation of ASHA (Accredited Social Health Activist) Creation of USHA (Urban Social Health Activist)

79. RESEARCH ARTICLE Impact of National Rural Health Mission on Perinatal Mortality in Rural India The aim of present study was to find whether increase in hospital deliveries is associated with decline in perinatal mortality in rural areas of India after the launch of NRHM.

80. METHODS Institutional deliveries (in government and private hospitals ) and perinatal mortality rate reported by the sample registration system (SRS) operated by the Registrar General of India on a representative sample from 2005-2008 was used for this study . The relative change in PNMR and hospital deliveries was calculated for rural areas in each of the major states of India from year 2005 to 2008, and correlation between relative change in PNMR and hospital deliveries was examined using SPSS version 17. The study had 80% power at 5% significance level for finding a correction co-efficient of 0.54 or higher.

81. RESULTS In most of the Indian states, hospital deliveries in rural areas have increased during 2005 to 2008. However, PNMR has declined only marginally during this period; it has even increased in few states . At the national level , relative increase in hospital deliveries was 57% and elative decline in PNMR was only 2.5% in the rural areas of Indian states.

82. DISCUSSION NRHM is a novel initiative by the Government of India to provide health care to people living in the rural areas of relatively poorer states of India. It is evident from the present study that post NRHM there have been a significant rise in hospital deliveries in rural areas. It was expected that the rise in the institutional delivery will lead to decline in PNMR.