1. National Rural Health Mission
Dr. Bhuwan Sharma
Asst. Professor (Grant Medical College, Mumbai)

2. The Challenges in Rural health sector
 Under funded public health system (0.9% GDP)
 High and prohibitive out of pocket expenditure
 Inequitable distribution of skilled manpower in rural
areas with 70% of total population(R-28%, U-74%).
 Poor quality services in public health system
 Poor community participation
 People’s needs different from what system offers
 Large unregulated private sector
 Minimal Insurance coverage (10%)
 Unregulated population growth.

3. Introduction
 National Rural Health Mission was launched by our
Hon’ble Prime Minister launched in 12 th April, 2005
with an objective to provide effective health care to
the rural population, by
 Improving access to health care
 Enhancing equity and accountability
 Promoting decentralization

4. Preamble of NRHM
 Provide effective health care to entire rural
population with special focus on 18 states.
 Raise public spending on health to 2-3% of GDP
 Health activist in each village, preparation of health
plans in collaboration with PRIs.
 Integration of vertical health and family welfare
programme.
 Integration of other determinants of health like
sanitation, hygiene, nutrition and safe drinking
water through a district health plan.

5.  Decentralization of health programmes at district
level and involvement of local bodies.
 Defined time bound goals
 To provide equitable, accessible, affordable,
accountable, effective and reliable primary health
care especially to poor women and children.

6. Scope of NRHM
 SPECIAL FOCUS ON 18 STATES.
 Arunachal Pradesh, Assam, Bihar,
Chhattisgarh, Himachal Pradesh, Jharkhand,
J&K, Manipur, Mizoram, Meghalaya, MP,
Nagaland, Orissa, Rajasthan, Sikkim,
Tripura, Uttaranchal, UP.

7. 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

8. Contd.
 Access to integrated comprehensive primary healthcare
 Population stabilization, gender and demographic
balance.
 Revitalize local health traditions and mainstream
AYUSH
 Promotion of healthy life styles

9. Objectives
 ASHA
 Health Action Plan
 IPHS
 FRU
 District health plans
 AYUSH

10. EXPECTED OUTCOMES
•Universal Health care, well functioning health care delivery system.
•IMR to be reduced to 30/1000 live births by 2012
•MMR to be reduced to 100/100,000 live births by 2012
•TFR to be reduced to 2.1 by 2012
•Malaria Mortality Reduction Rate – 60% upto 2012
•Kala Azar to be eliminated by 2010, Filaria reduced by 80 % by 2010
•Dengue Mortality reduced by 50%, JE mortality reduction by 50% 2012
•RNTCP-2 – maintain 85% cure rate, leprosy prevalence rate to reduce from 1.8/10,000 to less
than 1/ 10,000.
•Upgrading all SCs, PHCs and CHCs to IPHS levels,
•Increase utilization of FRUs from below 20% to over 75%.

11. Plan of action/Components
 Accredited social health activists
 Strengthening sub-centers
 Strengthening primary health centers
 Strengthening CHCs for first referral centres
 District health plan under NRHM
 Strengthening disease control program
 Public-private partnership for public health goals, including
regulation of private sector
 New health financing mechanisms
 Reorienting health/medical education to support rural
health issues

12. 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 one 100,000 ASHA’s are already selected.

13. ASHA
- 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 .

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

15. Contd.
- 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.

16. Janani Suraksha Yojana and ASHA
NRHM JSY
↓↓ all MMR
Antenatal Check up
& IMR
Institutional Care during delivery
Immediate post-partum
(coordinated care)
↑↑Institutional
Deliveries
in BPL families
Cash assistance

17. Components of NRHM contd.
2. STRENGTHENING SUB-CENTRES
 Each sub-centre will have an Untied Fund for local action
@ Rs. 10,000 per annum. This Fund will be deposited in a
joint Bank Account of the ANM & Sarpanch and operated
by the ANM, in consultation with the Village Health
Committee.
 Supply of essential drugs, both allopathic and AYUSH, to
the Sub-centers.
 In case of additional Outlays, Multipurpose Workers
(Male)/Additional ANMs wherever needed, sanction of
new Sub-centers as per 2001 population norm, and
upgrading existing Sub-centers, including buildings for Sub-
centers functioning in rented premises will be considered

18. Components of NRHM contd.
3. STRENGTHENING PRIMARY HEALTH CENTRES
 Mission aims at Strengthening PHC for quality preventive,
promotive, curative, supervisory and outreach services, through:
 Adequate and regular supply of essential quality drugs and
equipment including Supply of Auto Disabled Syringes for
immunization) to PHCs
 Provision of 24 hour service in 50% PHCs by addressing
shortage of doctors, especially in high focus States Observance
of Standard treatment guidelines & protocols.
 Intensification of ongoing communicable disease control
programs, new programs for control of non communicable
diseases, up gradation of 100% PHCs for 24 hours referral
service, and provision of 2nd doctor at PHC level (I male, 1
female) would be undertaken on the basis of felt need.

19. Components contd.
4. STRENGTHENING CHCs FOR FIRST REFERRAL
CARE
 Operationalizing 3222 existing Community Health Centers (30-50
beds) as 24 Hour First Referral Units, including posting of
anesthetists.
 Codification of new Indian Public Health Standards, setting norms
for infrastructure, staff, equipment, management etc. for CHCs.
 Promotion of Stakeholder Committees (Rogi Kalyan Samitis) for
hospital management.
 Developing standards of services and costs in hospital care
 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

20. Components contd.
5. DISTRICT HEALTH PLAN
It would be an amalgamation through:
 Village Health Plans, State and National priorities for
Health, Water Supply, Sanitation and Nutrition.
 Health Plans would form the core unit of action proposed
in areas like water supply, sanitation, hygiene and nutrition.
Implementing. Departments would integrate into District
Health Mission for monitoring.
 District becomes core unit of planning, budgeting and
implementation.
 Centrally Sponsored Schemes could be
rationalized/modified accordingly in consultation with
States.

21. Contd.
 Concept of “funneling” funds to district for
effective integration of programs
 All vertical Health and Family Welfare Programmes
at District and state level merge into one common
“District Health Mission” at the District level and
the “State Health Mission” at the state level
 Provision of Project Management Unit for all
districts, through contractual engagement of MBA,
Inter Charter/Inter Cost and Data Entry Operator,
for improved program management

22. Components contd.
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 Program.
 Similar to the DHM, the TSC is also implemented through
Panchayati Raj Institutions (PRIs).
 The District Health Mission would guide activities of sanitation
at district level, and promote joint IEC for public health,
sanitation and hygiene, through Village Health & Sanitation
Committee, and promote household toilets and School
Sanitation Program. ASHA would be incentivized for promoting
household toilets by the Mission.

23. Components contd.
7. STRENGTHENING DISEASE CONTROL
PROGRAMMES
 National Disease Control Program for Malaria, TB, Kala
Azar, Filaria, Blindness & Iodine Deficiency and Integrated
Disease Surveillance Program shall be integrated under the
Mission, for improved program delivery.
 New Initiatives would be launched for control of Non
Communicable Diseases.
 Disease surveillance system at village level would be
strengthened.
 Supply of generic drugs (both AYUSH & Allopathic) for
common ailment at village, SC, PHC/CHC level.
 Provision of a mobile medical unit at District level for
improved Outreach services.

24. Components contd.
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
 Regulation to be transparent and accountable
 Reform of regulatory bodies/creation where necessary

25. Contd.
 District Institutional Mechanism for Mission must
have representation of private sector
 Need to develop guidelines for Public-Private
Partnership (PPP) in health sector. Identifying areas
of partnership, which are need based, thematic and
geographic.
 Public sector to play the lead role in defining the
framework and sustaining the partnership
 Management plan for PPP initiatives: at
District/State and National levels

26. Components contd.
9. NEW HEALTH FINANCING MECHANISMS
 A Task Group to examine new health financing mechanisms, including Risk
Pooling for Hospital Care as follows:
 Progressively the 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 – outpatient, in-patient, laboratory,
surgical interventions- and costs will be done periodically by a
committee of experts in each state.
 A National Expert Group to monitor these standards and give
suitable advice and guidance.
 Where credible Community Based Health Insurance Schemes
(CBHI)exist/are launched, they will be encouraged as part of the
Mission. 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

27. Components contd.
10. REORIENTING HEALTH/MEDICAL EDUCATION
TO SUPPORT RURAL HEALTH ISSUES
 While district and tertiary hospitals are necessarily located in
urban centres, they form an integral part of the referral care
chain serving the needs of the rural people.
 Medical and para-medical education facilities need to be
created in states, based on need assessment.
 Mainstreaming AYUSH.
 Task Group to improve guidelines/details

28. NRHM
Main Approaches
Communitization
•Village Health &
Sanitation Committee
• ASHA
Flexible Financing • Panchayati Raj
Institutions Monitor progress
• Untied grants • Rogi Kalyan Samiti against standard
• NGOs as
implementers •IPHS Standard
• Risk Pooling • Facility Surveys
• Money follows patient • Independent
• More resources for Monitoring
more reforms Committee
Innovations in Health
Management
• Additional manpower
• Emergency services
• Multi-skilling

30. NRHM- The progress so far (2012)
 IMR – 47/ 1000 live births (58 in 2005)
 MMR- 212/ 100,000 live births (301 in 2003)
 TFR- 2.2 (2.7 in 2005)
 Leprosy eliminated
 Malaria and Dengue mortality reduced to below
50% as apposed to 2005.
 DOTS progress maintained
 SC/PHC/CHC up-gradation according to IPHS is
increasing.
 Institutional deliveries increased manifold (2.7 crore
beneficiary under JSY ).

31. MCQs
 Q1. The year of launching of NRHM ?
a) 2003
b) 2005
c) 2001
d) 2007

32.  Q2. The goal of NRHM to reduce TFR by 2012
upto ?
a) 2.7
b) 2.5
c) 2.3
d) 2.1

33.  Q3. IMR of India as per the 2012 census ?
a) 58/ 1000 live births
b) 52/ 1000 live births
c) 47/ 1000 live births
d) 45/ 1000 live births

34.  Q4. Monetary incentive to ASHA under Janani
Suraksha Yojana in Mumbai district ?
a) 1000/- Rs
b) 600 /- Rs
c) 200 /- Rs
d) Nil

35.  Q5. Benefits of JSY are extended to females of
SC/ST category in high performance states upto ?
a) Two live births
b) Three live births
c) Four live births
d) All births

36.  Q6. Under NRHM, there should be provision of
one Accredited Social Health Activist for
__________ population.
a) 500
b) 1000
c) 1500
d) 5000

37.  Q7. ASHA is selected by ?
a. ANM under Sub Centre
b. Medical Officer of PHC
c. Gram Panchayat
d. CBOs/ NGOs

38. Thank
you