NRHM is a very important programme, it requires the multisectoral approach. Implementation level must be strengthened.

1. 104/22/1504/22/15 11
National Rural Health Mission:National Rural Health Mission:
A Ground RealityA Ground Reality
Presented by:Presented by:
Dr. Y.L. TekhreDr. Y.L. Tekhre
Director (Research)Director (Research)
National Human Rights CommissionNational Human Rights Commission
Email:Email: yade_lal@yahoo.co.in & dirres-nhrc@nic.inyade_lal@yahoo.co.in & dirres-nhrc@nic.in
Ph. [Resi.]Ph. [Resi.] 011-26161708011-26161708
(Office)(Office) 011- 23386581 (Mobile) 9868182696011- 23386581 (Mobile) 9868182696

2. 2
Some of the features
• Allocation for human resources in health
from Rs. 62 crore in 2009-10 to Rs. 323
crore in 2010-11
• India is short by 6 lakh doctors, 10 lakh
nurses and 2 lakh dental surgeons
• The overall allocation for the health ministry
increased by 14% from Rs. 19,534 crore to
Rs. 22,300 crore for 2010-11

3. 3
• Cancer, diabetes, mental health and
cardiovascular disease received a major
push
• Cancer kills 50 people in India every
hour while 7% of the country’s adult
population is estimated to be suffering
from mental health problems
• Annual health survey to prepare the
health profile of all districts (626
districts) will be conducted in 2010-11 to
benefit the NRHM

4. 4
• Shift in National Health Policy - From
Hospital based services to
• Community based services duly backed by
Strong Referral Services
• Challenges to Health & Healthy Living
– Rural India (Majority of population living in
villages)
– High density of rural population
– Varied Linguistic & Ethnic background
– Illiteracy
– Low per capita income

5. 5
CHC
PHC
Sub Centres

6. 6
The Structure of the Public Health System
• Health is a state subject. Family Welfare is a
concurrent subject, Primary health care is a PRI
devolved area – Mandated role of local governments
• Most institutions and manpower in state
sector.
• Most programmes are in the central
sector
National Programmes address only about 25% of all
morbidities. States have to address the major part of
this.
• National Programmes cannot succeed without basic
health systems being functional

7. 7
Rejuvenate the Health delivery System
Universal Health Care
Access
Affordability
Equity
Quality
Reduce IMR, MMR,TFR
Improve Disease control
National Rural Health Mission
Launched in April, 2005

8. 8
EXPECTED OUTCOMES 2005 -
2012
•Universal Health care, well functioning health delivery
system.
•IMR reduced to 30/1000 live births by 2012
•MMR reduced to 100/100,000 live births by 2012
•TFR reduced to 2.1 by 2012
•Malaria Mortality Reduction Rate – 60% upto 2012
•Kala Azar eliminated by 2010, Filaria reduced by 80 % by 2010
•Dengue Mortality reduced by 50% by 2012
•TB DOTS series – maintain 85% cure rate

9. 9
Strategies
•Improve Infrastructure
•Augment manpower
•Improve management
•Flexibility to states to deploy funds
•Decentralisation
•Communitization

10. 10
• An audit of maternal deaths will be
conducted soon in all states, said
the Health Minister Mr. Azad…
• "This year, we have taken another
new initiative on a national level
and that is the introduction of
maternal death audits at the
community as well as the facility
level,"

11. 11
The Paradigm Shift
• Decentralised planning:
• 2005 : normative funding
• 2006 : state PIPs
• 2007 : district Plans & state PIPs
• 2008 : block desegregation in IDHAP, state PIPs.
• 2009 : villages should make village health plans
• Need to
• create capacity.
• create quality and appraisal mechanisms
• address uneven development

12. 12
Planning at the user end
• Resource Mapping – service providers, communication
facilities , drinking water sources, sanitation, nutritional status,
levels of poverty.
• Understanding main health problems of women and
children, providers used, perception of public health services
and providers
• Main illnesses in the community, Health care related
expenditure, problems faced in referral and transport,
perceptions about family planning and gender, Role of PRI in
health related areas ( water, sanitation)
• Understanding process of Pregnancy, labour and post natal
care, beliefs and practices – Key informant interview with
elderly women, TBA.

13. 13
Planning at the user end
Understanding Community Participation
and Ownership
Meeting PRI members to understand perception of health needs
Additional information
– Any special health related studies in the district by any
agency
– Any Health NGO active in the district
– Other Community Based Organizations in the district

14. 14
• Outputs and Outcome based
• Not only
• how many buildings were built
• how many training were conducted
• but also
• how it impacted on behavior change
• service delivery
• health status.
The Paradigm Shift

15. 15
BASIC FEATURES
of community monitoring
• PRIs, community based organizations and NGOs, along with
health department functionaries should be involved in the
preparation and mobilization phase
• The committees that are formed at various levels must have
concomitant authority i.e. they must have the power to
initiate action.
• Capacities of the members of a village level committee have
to be built
• Involvement of the general public by means of regular ‘Public
dialogue’ or Public hearing (Jan Samvad / Jan Sunwai)

16. 16
TOOLS OF MONITORING
Village Level
• Village Health Register - Records of ANM - Public dialogue (Jan Sa)
• Village Health Calendar- Infant and maternal death audit
PHC level
• Charter of Citizens Rights – IPHS - PHC Health Plan
Block level
• IPHS - Charter of Citizens Rights - Block Health Plan
District level
• Report from the PHC / District Mission Health committees
• Public Dialogue (Jan Samvad)
State level
• Reports of the District Health committees
• Periodic assessment reports by various taskforces / State level
committees about the progress made in formulating policies
according to IPH Standards, NHRC recommendations and its

17. 17
• Community Participation
• Bringing the public back into public
health
• At hamlet level : ASHA, VHSC, SHGs,
Panchayats.
• At the facility level: RKS
• At the management level : health societies
The Paradigm Shift

18. 18
Likely capacity needs
Developing and supporting more than
• 6000 Block Mission Team and Block Resource Groups
• 600 District level Mission Teams and Resource Groups
• 35 State/UT level Mission Teams and Resource Centres
• 1.75 lakh ANMs, 26000 LHVs, 26000 Staff Nurses
• 26000 Medical Officers into Skilled Birth Attendants.

19. 19
Likely capacity needs
Developing and supporting more than
• 7 lakh Village Health and Sanitation Committees
• 1.75 lakh Sub Centre level Panchayat Committees
• 25000 PHC level PRI/HDC/RKS Committees
• 6500 CHC level PRI/ HDC/RKS Committees
• 1200 Taluka/ Sub Divisional level Hospital Committees.
• 600 District Hospital level Committees.

20. 20
Reproductive Health
•Abortion
•Infertility
•Contraception
•Sexually Transmitted
Diseases

21. 21
Adolescence
WHO defines adolescence both
in terms of age (spanning the
ages between 10 and 19
years) and in terms of a
phase of life marked by
special attributes.
These attributes include:

22. 22
1. Rapid physical growth and
development
2. Physical, social and psychological
maturity but not all at the same time
3. Sexual maturity and the sexual activity
4. Development of adult mental
processes and adult identity
5. Transition from total socio-economic
dependence to relative independence

23. 23
Pregnancy Health
• Ensuring safe motherhood
• Complications of Pregnancy

24. 24
Important aspects of NHRM
• Ensuring effective
healthcare, especially to the
poor and vulnerable sections
• Ayurveda, Yoga & Naturopathy,
Unani, Siddha and
Homoeopathy (AYUSH)

25. 25
Contd.
• Under AYUSH, there is a network of
3,360 hospitals and 21,769 dispensaries
across the country
• The NRHM covers all the villages through
village-based "Accredited Social Health
Activists" (ASHA) who would act as a
link between the health centers and the
villagers

26. 26
• The ASHA would be trained to advise villagers
about:
• Sanitation, Hygiene, Contraception, and
Immunization to provide Primary Medical Care
for Diarrhoea, Minor Injuries, and Fevers; and
to escort patients to Medical Centers
• They would also deliver Directly Observed
Treatment Short (DOTS) course for
tuberculosis and oral rehydration; distribute
folic acid tablets and chloroquine to patients
and alert authorities to unusual outbreaks.

27. 27
ASHAs would be honorary volunteers, there
is a provision to provide them with
performance-based compensation for
undertaking specific health or other social
sector programmes with measurable outputs,
thus promoting employment for these
volunteers
•‘One ASHA per 1000 population’. In tribal,
hilly, desert areas the norm could be relaxed
to one ASHA per habitation, dependant on
workload etc.

28. 28
Criteria for selection as ASHA
• 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 literate woman with formal
education up to Eighth Class. This may be
relaxed only if no suitable person with this
qualification is available.

29. 29
Maternal Mortality
Maternal Mortality Ratio
“ number of women who die in a year due to causes related to
pregnancy and child birth for every 100, 000 live births ”
Wide Variations:
India 301/ 100,000 live births
Tamil Nadu 134/ 100,000 live births
U.P. 517/ 100,000 live births
Sweden/ USA 8- 12/ 100,000 live births
Sri Lanka 24/ 100,000 live births
Malaysia 20/ 100,000 live births

30. 30
Population
Agriculture
Health
Education
Economy
Urbanisation
Environment

31. 31 1
WHERE WE STAND
NPP 2000 and the present scenario:
1. 2010 Population replacement (put back
now to 2021)
2. 2045 Population Stabilization (put back
now to 2060 (1.53 billion in 2060).
3. EAG states constitute 42% of the
population (TFR between 3.4 and 4.3)

32. 32
 Low male participation
 Low age at marriage for girls
 Low age at bearing Children
 Low spacing between pregnancies
 Too many pregnancies
 Strong preference for son
 Low female literacy
 Low women’s empowerment
AREAS OF CONCERN IN FP
( Socio cultural factors)

33. 33

34. 34
57
Areas of concern in FP
(Programmatic factors)
 Large unmet needs for contraception
 Poor quality of family planning services
 Inadequate attention to spacing methods
 Low proportion of safe deliveries

35. 35
India’s Challenge
 26 million births every year
 1.1 million die before 4 weeks of age
 1.7 million die before completing 1 year
 2.2 million die before completing 5 years
 77,000 mothers die in this process

36. 36
What to do?
• Increasing public expenditure on health
• Reducing regional imbalance in health
infrastructure
• Pooling resources
• Integration of organizational structures
• Optimization of health manpower
• Decentralization and district
management of health programmes

37. 37
• Community participation and
ownership of assets
• Induction of management and
financial personnel into district
health system
• Operationalizing community health
centers into functional hospitals
meeting Indian Public Health
Standards in each Block of the
Country

38. 38
• India needs over 6,800 more
hospitals in rural areas to provide
basic health facilities to people
"There is still a shortage of 4,477
primary healthcare centres and
2,337 community healthcare centres
as per the 2001 population norms,"
the survey said. (Annual Survey)

39. 39
• Almost 29% of the existing health
infrastructure is in rented buildings.
Poor upkeep and maintenance, and
high absenteeism of manpower in the
rural areas are the main problems in the
health delivery system."
• The latest audit report of the Controller
and Auditor General (CAG) on National
Rural Health Mission (NRHM) has found
that hundreds of crores are lying
unspent

40. 40 55

41. 41

42. 42
THANK
YOU
THANK
YOU

43. 43 4343