Prof.

Deoki Nandan
Doctor Honoris Causa-Odessa State Medical University, MD,
FAMS, FIAPSM, FIPHA, FISCD, DHC
DIRECTOR
National Institute of Health & Family Welfare
(director@nihfw.org, dnandan51@yahoo.com
www.nihfw.org)

1
SYSTEMIC DEFICIENCIES IN HEALTH SECTOR

•Lack of Holistic Approach

•Inadequate attention to Preventive & promotive health

care
•Absence of linkages with collateral health determinants

•Health not a priority.

•Under funded, yet not utilised.

•Shortage of infrastructure & human resources

•Lack of community ownership and accountability

•Non integration of Vertical Disease Control programmes

•Non responsiveness to Citizens’ grievances.

2
 INTRODUCTION
 Launched on 12th April
2005 by the Prime
Minister .

 Identified 18 States with

week PH Indicators/Health
Care Infrastructure

 The initial Outlay for

NRHM for 2005-06 was
over Rs.6700 Crore.

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 THE VISION
• Architectural correction in health care delivery

• Special focus on 18 states with weak indicators.

• Improve availability of quality health care in

rural areas

• Synergy between health and determinants of

good health

• Mainstream the Indian Systems of Medicine.

• Capacity Building.

• Involve the community in the planning process.

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 OBJECTIVES

 Reduction in child and maternal mortality

 Universal access to PH services for food and

nutrition, sanitation and hygiene with focus
on women and children health

 Prevention and control of communicable and

non communicable diseases including
locally and endemic diseases

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 OBJECTIVES ….contd.

 Population stabilization, attaining

gender and demographic balance

 Revitalize local health traditions and

mainstream AYUSH

 Promotion of healthy life styles

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 NRHM
INTERVENTIONS

• Significant step up in expenditure to

2– 3 % of GDP

• Inter-sectoral convergence

• Horizontal integration of existing

vertical schemes.

   

                                
• Merger of societies at State &
District level
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 NRHM
INTERVENTIONS

• Decentralized planning at
Village & District level

• Community ownership of
Health facilities

• Fully trained ASHA in

each village.

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 NRHM
INTERVENTIONS

• Under IPHS, upgradation

of CHCs into 24x7 FRUs

• Mainstreaming of AYUSH

• Public Private Partnership

• Risk Pooling

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 NRHM – 5 MAIN APPROACHES

COMMUNITIZE
MONITOR,
1. Hospital Management
PROGRESS AGAINST
Committee/ PRIs at all levels
STANDARDS
2. Untied grants to community/
PRI Bodies
1. Setting IPHS Standards
3. Funds, functions & FLEXIBLE FINANCING 2. Facility Surveys
functionaries to local
3. Independent Monitoring
community organizations 1. Untied grants to institutions Committees at
4. Decentralized planning, 2. NGO sector for public Block, District & State
Village Health & Health goals levels
Sanitation 3. NGOs as implementers
Committees 4. Risk Pooling – money
follows patient
5. More resources for
more reforms INNOVATION IN
IMPROVED
HUMAN RESOURCE
MANAGEMENT
MANAGEMENT
THROUGH CAPACITY
1. More Nurses – local
1. Block & District Health
Resident criteria
Office with management skills
2. 24 X 7 emergencies by
2. NGOs in capacity building
Nurses at PHC. AYUSH
3. NHSRC / SHSRC / DRG / BRG
3. 24 x 7 medical emergency
4. Continuous skill development
at CHC
support 10
4. Multi skilling
 GOALS

• To provide universal access to

equitable, affordable and quality health
care services, responsive to the needs
of the people

 
                

• NRHM would help achieve goals set

under NHP and MDGs

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 Accredited Social Health Activist
(ASHA)
 ASHA is expected to work with communities
for social mobilization and improve access to
services. She will be located in every
village/habitation.

 ASHA would act as a bridge between the ANM

and the village.

 ASHA’s role will be to facilitate care seeking

and serve as a depot holder for a package of
basic medicines.

 The AWW, schoolteacher, members of local

community based organizations, such as
SHGs, and the Village Health Committee are
expected to support the ASHA in her work.
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 ASHA
 ASHA will be honorary volunteer. She will
receive performance based incentives for
promoting universal immunization, referral and
escort services for RCH, construction of
household toilets, and other healthcare delivery
programs.

 She will be given a Drug Kit.

 NGOs to mentor the process.

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  Central Component of NRHM.

 A New Brand of Community based

functionary .

 1st port of call for any health

ASHA related demand.

 A resident of a village-Married/
Widow/ Divorced.

 A representative from disadvantage

group.
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 Roles of ASHA
 As an Educator.
 As a Counsellor.
 As a Facilitator.
 As a New Link.
 As an Escort .
 As a mobiliser.
 As a Provider of Primary Medical Care.
 As an Informer.
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INTEGRATED ROLE OF ASHA

1 2 3

AWWs ANMs Community

ASHA
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 Janani Suraksha Yojana

NMBS NRHM JSY

(Better Diet for BPL
pregnant females)

↓↓ all MMR
Antenatal Check up
& IMR
Institutional Care during delivery

Immediate post-partum

(coordinated care)

↑↑Institutional
Deliveries
in BPL families
Cash assistance 17
 Improving Public Health
Delivery System

IMPLEMENTATION
Decentrali- FRAMEWORK & PLAN Convergence
zation OF ACTION

Indian Public Health

Standards

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 DECENTRALIZATION
 Village health plan through village health committee

 District plan integrating village block & district level

 District health plan – main instrument for planning, inter-

sectoral convergence, implementation & monitoring

 States to prepare annual plans based on district plan

 Periodic annual service to track improvements in facilities

& reduction in negative health indicators

 District plans collated in state plan for approval by the

mission at national level

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 CONVERGENCE
 Convergence of all programs at village & facility
level

 Effective integration of health concerns with other

health determinants like sanitation and hygiene,
nutrition and safe drinking water through district
health plan

 Seeking local accountability in the delivery of

programs through Panchayati Raj Institutions, Self
help groups, Schools, water, health, nutrition &
sanitation committees

 School health check up and education in

consultation with the Sates
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 IMPROVING PUBLIC HEALTH
DELIVERY SYSTEM

 Providing desired quality services specially in EAG

and Northeasters States

 Revitalising existing infrastructure

 Fresh construction, Renovation

 Putting in place enabling systems at all levels

 Corrections in manpower planning

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 IMPROVING PUBLIC HEALTH
DELIVERY SYSTEM
Capacity building:

 PMUs at State/District level for managerial support,

monitoring and tracking of funds

 Setting up NHSRC at Central and State level to provide

technical support

 Emphasizes the need for setting up block and district

level health management system
 Strengthening nursing and medical institutions & skill
development support to rural health workers

 Strengthening of PRIs

 Proposed to shift central mechanism like sub centres

under control of Panchayat
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 NRHM – ILLUSTRATIVE STRUCTURE Health Manager
CHIEF BLOCK HEALTH OFFICER –--------------- Accountant
Store Keeper

Accredit private 100,000 BLOCK

providers for public Population LEVEL
health goals 100 Villages HOSPITAL Strengthen Ambulance/
Ambulance transport Services
Telephone Increase availability of Nurses
Obstetric/Surgical Medical Provide Telephones
Emergencies 24 X 7 Encourage fixed day clinics
Round the Clock Services;
30-40 Villages
CLUSTER OF GPs – PHC LEVEL
3 Staff Nurses; 1 LHV for 4-5 SHCs;
Ambulance/hired vehicle; Fixed Day MCH/Immunization
Clinics; Telephone; MO i/c; Ayush Doctor;
Emergencies that can be handled by Nurses – 24 X 7;
Round the Clock Services; Drugs; TB / Malaria etc. tests
5-6 Villages GRAM PANCHAYAT – SUB HEALTH CENTRE LEVEL
Skill up-gradation of educated RMPs / 2 ANMs, 1 male MPW FOR 5-6 Villages;
1000 Telephone Link; MCH/Immunization Days; Drugs; MCH Clinic
Popu
lation VILLAGE LEVEL – ASHA, AWW, VH & SC
1 ASHA, AWWs in every village; Village Health Day 23

Drug Kit, Referral chains

 FUNDING UNDER NRHM
 Selection, training, drug kit, compensation package for ASHAs.

 Total Grant at Sub – Centre Rs.20,000/- per annum

Untied Fund Rs.10,000/-
Annual Maintenance Rs.10,000/-

 Total Grant at PHC @ 1.75 lacs per annum

Annual Maintenance Rs.50,000/-
Untied fund Rs. 25,000/-
Rogi Kalyan Samities Rs.1,00,000/-

 Total grant at Community Health Centre @ Rs.2.50 Lacs

Annual Maintenance RS.1,00,000/-
Untied fund Rs. 50,000/-
Rogi Kalyan Samities Rs.1,00,000/-

 Total grant at District Hospital Rs.5.00 Lacs

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 FUNDING UNDER NRHM ….contd.

 Upgrading 2 CHCs/district to IPHS, @ Rs.20 lakhs.

 Corpus Grant for Rogi Kalyan Samiti, @ Rs.5

lakhs/District Hospital, and @ Rs.1 lakh/Sub District
Hospital and CHC.

 One Mobile Medical Unit/district, @ Rs.40 lakhs.

 Preparation of District Action Plans.

 Health Melas.

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 UNTIED FUND

 Untied fund to each sub center - Rs.10,000 to facilitate urgent

activities needing relatively small sums of money.

 Fund kept in joint bank account of ANM & Sarpanch

 Used only for common good & not for individual needs, except
in case of referral & transport in emergency situations.

 Purchase of consumables such as bandages in sub center

 Purchase of bleaching powder and disinfectants for use in

common areas of the village.

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 UNTIED FUND
 Suggested areas where Untied Funds may be used:

• Minor modifications to sub center- curtains to ensure privacy, repair

of taps, installation of bulbs, other minor repairs, which can be done
at local level.

• Ad hoc payments for cleaning up sub center, especially after

childbirth.

• Transport of emergencies to appropriate referral centers.

• Transport of samples during epidemics.

 Labour and supplies for environmental sanitation, such as clearing or
larvicidal measures for stagnant water.

 Payment/reward to ASHA for certain identified activities .

 Untied funds shall not be used for any salaries, vehicle purchase, and
recurring expenditures or to meet the expenses of the Gram
Panchayat.
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 INDIAN PUBLIC HEALTH STANDARDS

The Indian Public Health Standards (IPHS) set up at all levels to

ensure quality service

IPHS FOR CHCs AT A GLANCE

• Essential Drug list has been updated

• Laboratory facilities to be strengthened
• Capacity building ensured at all levels
• Each CHC shall display “Charter of Patient’s
Rights”
• Social audit by consumer forum &
“Rogi Kalyan Samitis”.
• Joint Review Mission (JRM)
• Common Review Mission (CRM)
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 OBJECTIVES OF IPHS

 To provide optimal expert care to the community.

 To achieve and maintain an acceptable standard

of quality of care.

 To make the services more responsive and

sensitive to the needs of the community.

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 ROGI KALYAN SAMITIS

 Rogi Kalyan Samiti (RKS) (Patient

Welfare Committee) / Hospital
Management Society (HMS) is a system for
ensuring degree of permanency
sustainability.

 RKS is free to prescribe, generate and

use funds with it as per its best
judgement for smooth functioning
&maintaining quality of services.

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 ROGI KALYAN SAMITIS
Registered society, all District Hospitals / Sub District Hospitals/
CHCs / FRUs. consisting of:

 People’s representatives – MLA / MP

 Health officials (including an Ayush doctor)
 Local district officials
 Leading members of the community
 Local CHC/ FRU in-charge
 Representatives of the Indian Medical Association
 Members of the local bodies and Panchayati Raj representative
 Leading donors

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 OBJECTIVES OF THE RKS / HMS

 Ensure compliance to minimal standard for facility and

hospital care and protocols of treatment as issued by
the Government.

 Ensure accountability of the public health providers to

the community;

 Introduce transparency with regard to management of

funds;

 Upgrade and modernize the health services provided by

the hospital and any associated outreach services;

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 OBJECTIVES OF THE RKS / HMS

 Supervise the implementation of National

Health Programs at the hospital and other
health institutions that may be placed under
its administrative jurisdiction;

 Organize outreach services / health camps at

facilities under the jurisdiction of the hospital;

 Display a Citizens’ Charter in the Health

facility and ensure its compliance through
operationalisation of a Grievance Redressal
Mechanism;
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 OBJECTIVES OF THE RKS / HMS
 Generate resources locally through donations, user
fees and other means;

 Establish affiliations with private institutions to upgrade

services;

 Undertake construction and expansion in the hospital

building;

 Ensure optimal use of hospital land as per govt.

guidelines;

 Improve participation of the Society in the running of

the hospital;

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 Inter- Sectoral Convergence

 Committee for Intersectoral Convergence under

Mission Director.

 In-principle agreement among Department of

Women & Child Development, Total Sanitation
Campaign, Panchayati Raj for NRHM.

 Common strategy for Behavioural Change

Communication and Training being worked out.

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 Inter-Sectoral Convergence
 Institutional strategy of State Health Mission/District
Health Mission reflects convergence.

 NRHM Information Kit being sent to State

counterparts of these Departments.

 Common G.O.s to be issued, stressing convergence.

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Role of Non Governmental Organizations

 NGOs are critical for the success of NRHM.

 NGO services are being utilized under the Disease

Control program RCH-II, immunization and pulse
polio program, JSY make use of partnerships of
variety of NGOs.

 Efforts are being made to involve NGOs at all levels

of the health delivery system.

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 ROLE OF NGOS
 Advocacy,

 Building capacity at all levels,

 Monitoring and evaluation of the health sector,

 Delivery of health services,

 Developing innovative approaches to health care

delivery for marginalized sections or in underserved
areas and aspects,
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 ROLE OF NGOS
 Working together with community organizations and
PRI.

 Contributing to monitoring the Right to health care

and service guarantees from the public health
institutions.

 The effort will be to support/ facilitate action by NGO

networks of NGOs in the country which would
contribute to the sustainability of innovations and
people’s participation in the NRHM.
39
 FUNCTIONS AND ACTIVITIES

 Entering into partnership arrangement with the

private sector (including individuals) for the
improvement of support services such as cleaning
services, laundry services, diagnostic facilities and
ambulatory services etc.

 Developing / leasing out vacant land in the premises

of the hospital for commercial purposes with a view
to improve financial position of the Society;

 Encouraging community participation in the

maintenance and upkeep of the hospital;

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 FUNCTIONS AND ACTIVITIES
 Promoting measures for resource
conservation through adoption of wards by
institutions or individuals; and,

 Adopting sustainable and environmental

friendly measures for the day-to-day
management of the hospital, e.g. scientific
hospital waste disposal system, solar
lighting systems, solar refrigeration systems,
water harvesting and water re­charging
systems etc

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 MONITORING
• Community Monitoring

• PHC Health Monitoring and Planning Committee

• Block Health Monitoring and Planning Committee

• District Health Monitoring and Planning

Committee

• State Health Monitoring and Planning Committee

• Concurrent Evaluation

• Rapid assessment through external agencies- 42

UNFPA for ASHA training

 NRHM

The National Rural Health Mission

(NRHM) launched by the Ministry of
Health and Family Welfare is seen as a
vehicle to ensure that preventive and
promotive interventions reach the
vulnerable and marginalized through
expanding outreach and linking with
local governance institutions.

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 SUCCESS OF NRHM

 Much depends on the quality of local

authorities and state governments and their
utilisation of funds i.e appropriate
managerial skills (Program +Financial).

 Actual implementation of NRHM at grass root

level is a big challenge .

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KEY TO THE SUCCESS OF THE NRHM

 Intersectoral convergence, community ownership

steered through Village Health Committees at the
level of the Gram Panchayat, and a strong public
sector health system with support from the private
sector.

 Intersectoral convergence in NRHM is visualized

with drinking water, sanitation, hygiene and
nutrition.

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 NRHM

 N…Newer Initiatives.
 R…Rural Poor Population
 H…Holistic Health Package.
 M…Monitoring mechanisms

To cater to the Primary health care

needs of vulnerable segment of pop. to
bring down IMR and MMR . to attain
Pop. Stabilisation.
46
 CHALLENGES & ISSUES
• Complexity of the sector
(Cross linkages with poverty, illiteracy, social customs)

• Governance issues

• Involvement of states

• Assured availability of incremental Outlays for

Mission period.

• Shortage of manpower / lack of capacity

47
 EXPECTED OUTCOMES
(2005 – 2012)
• 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

• Leprosy eliminated by December 2005

• TB DOTS series – maintain 85% cure rate 48

 YEARLY GOALS

Raising
Engaging
2000+C Malaria Mortality
Years TFR IMR MMR 2.5 lakh
HCs to Reduction Rate
ASHAs
IPHS

2005 2.6 58 300 15% 15% 5%

2006 2.5 50 250 15% 30% 10%

2007 2.4 45 200 20% 40% 20%

2008 2.3 36 150 20% 15% 10%

2009 2.2 33 112 10% 5%

2010 2.1 30 100 10% Total 50% by 2010

2011 2.1 30 100 10% 5%

2012 2.1 30 100 5% 49

 YEARLY GOALS
Japanese
Kala-Azar Filaria Micro- Encephalitis Leprosy
Dengue Mortality
Years Mortality Filaria Reduction Mortality Prevalence
Reduction Rate
Reduction Rate Rate Reduction Rate
Rate

2005 50% - 0% 5% 1.8

2006 25% 10% 10% 5% <1

2007 25% 15% 15% 15% <1

2008 20% 15% 15% <1

2009 25% 10% 10% <1

2010 Total 100% by Total 70% by 2010 Total 50% by 2010 Total 50% by <1
2010 and elimination by 2010
2015

2011 Sustenance by 5% Sustenance at 50% Sustenance at <1

elimination 50%

2012 Sustenance by 5% Sustenance at 50% Sustenance at <150

elimination 50%
Let us respond to the call of
the people

Let us respond to the call of

India

Let us Reach Out to our

people