National Rural Health Mission

43
National Rural Health Mission
Deoki Nandan

Deoki Nandan, MD, FAMS, FIPHA, FIAPSM, FISCD, is currently the

Director of the National Institute of Health & Family Welfare, New
Delhi. He has worked as Principal/Dean and Chief of hospital, S N
Medical College, Agra. He has been actively working in the field of
public health for more than 30 years and during this period has been
associated as an advisor as well as consultant with many international
organizations. He is also a member of many state-level committees
and National Technical Expert Committees, specifically for AIDS,
IMNCI and Child Health.

"!.1 Introduction
The National Rural Health Mission (NRHM) was launched on 12 th April
2005 throughout India with a commitment of the government to carry out
the necessary architectural corrections in the basic health care delivery
system. NRHM covers the entire country but has a special focus on eighteen
states (of these 8 are EAG states), identified to have weak public health
indicators and/or weak health infrastructure. These focused states are
Arunachal Pradesh, Assam, Bihar, Chhattisgarh, Himachal Pradesh,
Jharkhand, Jammu & Kashmir, Manipur, Mizoram, Meghalaya, Madhya
Pradesh, Nagaland, Orissa, Rajasthan, Sikkim, Tripura, Uttaranchal and
Uttar Pradesh. While all the Mission activities are the same for all the
states/UTs in the country, the high focus states have the following additional
support:
(i) An Accredited Social Health Worker (ASHA) in all villages with a
population of 1000.
(ii) Project Management Support at the state and district level.

"!.2 The vision of the mission

The mission seeks to provide effective health care to rural population

# Empowered Action Group (EAG) refers to the following 8 states – Bihar,

Chattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttaranchal and Uttar
Pradesh.

1195
1196 Advanced public health nutrition

throughout the country with special focus on 18 identified focused states

[1]. Further, NRHM seeks to:
● Raise public spending on health from 0.9% to 2–3% of GDP, with
improved 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
country.
● Revitalize local health traditions and mainstream Ayurveda, Yoga,
Unani, Siddha and Homeopathy (AYUSH) into the public health
system.
● Integrate the health concerns effectively through decentralized
management at the district, with determinants of health like sanitation
and hygiene, nutrition, safe drinking water, gender and social
concerns.
● Addressed inter-state and inter-district disparities, especially among
the 18 high focus states, including unmet needs for public health
infrastructure.
● Ensure achievement of time bound goals and report the progress
publicly.
● Improve access of rural people, especially poor women and children
to equitable, affordable, accountable and effective primary health
care.

43.3 The objectives of the mission

● Reduction in child and maternal mortality.
● Universal access to public health care services for food and nutrition,
sanitation and hygiene with emphasis on services addressing women’s
and children’s health and universal immunization.
● Prevention and control of communicable and non-communicable
diseases, including locally endemic diseases.
● Access to integrated comprehensive primary health care.
● Population stabilization, gender and demographic balance.
● Revitalize local health traditions and mainstream AYUSH.
● Promotion of healthy life styles.

43.4 The expected outcomes from the mission as

proposed for reflection in statistical data
● Infant Mortality Rate (IMR) reduced to 30/1000 live births by 2012.
● Maternal mortality reduced to 100/100,000 live births by 2012.
 National Rural Health Mission 1197

● Total Fertility Rate (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/Microfilaria Reduction Rate – 70% by 2010, 80% by 2012
and elimination by 2015.
● Dengue Mortality Reduction Rate – 50% by 2010 and sustaining at
that level till 2012.
● Cataract operation – increasing to 46 lakhs by 2012.
● Leprosy Prevalence Rate – reduced from 1.8 per 10,000 in 2005 to
less that 1 per 10,000 thereafter.
● Tuberculosis – DOTS services maintain 85% cure rate through entire
mission period and also sustain planned case detection rate.
● Upgrading Community Health Centres to Indian Public Health
Standards. Increase utilization of First Referral units from bed
occupancy by referred cases of less than 20% to over 75%.
● Engaging 250,000 female Accredited Social Health Activists
(ASHAs) in 18 states.

43.5 Goals, strategies and outcomes of the Mission

The mission seeks to provide universal access to equitable, affordable and
quality health care services which is responsive to the needs of the people,
reduction of child and maternal deaths, population stabilization, gender
and demographic balance. In this process, the mission would help achieve
goals set under the National Health Policy and the Millennium
Development Goals. To achieve these goals NRHM will
● Facilitate increased access and utilization of quality health services
by all.
● Forge a partnership between the Central, State and the Local
governments.
● Set up a platform for involving the Panchayati Raj institutions and
community in the management of primary health programmes and
infrastructure.
● Provide an opportunity for promoting equity and social justice.
● Establish a mechanism to provide flexibility to the states and the
community to promote local initiatives.
● Develop a framework for promoting inter-sectoral convergence for
promotive and preventive health care.
1198 Advanced public health nutrition

43.5.1 The core strategies of the mission

The following core strategies have been adopted to achieve the goals of
mission:
● Train and enhance the capacity of Panchayati Raj Institutions (PRIs)
to own, control and manage public health services.
● Promote access to improved health care at household level through
the female-health activist (ASHA).
● Health plan for each village through village-health committee of the
panchayat.
● Strengthening sub-centre through better human resource
development, clear quality standards, better community support and
an untied fund to enable local planning, action and induction of more
Multi-Purpose Workers (MPWs).
● Strengthening existing primary health care centres (PHCs) through
better staffing and human resource development policy, clear quality
standards, better community support and an untied fund to enable
the local management committee to achieve these standards.
● Provision of 30–50 bedded community health centres (CHC) per lakh
population for improved curative care to a normative standard (Indian
Public Health Standards – IPHS defining personnel, equipment and
management standards, its decentralized administration by a hospital
management committee and the provision of adequate funds and
powers to enable these committees to function at optimum levels).
● Preparation and implementation of an inter-sector District Health
Plan including drinking water, sanitation, hygiene and nutrition.
● Integrating vertical health and family welfare programmes at national,
state, district and block levels.
● Technical support to national, state and district health mission, for
public health management.
● Strengthening capacities for data collection, assessment and review
for evidence-based planning, monitoring and supervision.
● Formulation of transparent policies for deployment and career
development of human resource for health.
● Developing capacities for preventive health care at all levels for
promoting healthy life style, reduction in consumption of tobacco
and alcohol, etc.
● Promoting non-profit sector particularly in underserved areas.

43.5.2 Supplementary strategies

In addition to these core strategies, some of the supplementary strategies
of the mission include:
 National Rural Health Mission 1199

● Regulation of private sector including the informal Rural Medical

Practitioners (RMP) to ensure availability of quality service to citizens
at reasonable cost.
● Promotion of public private partnerships for achieving public health
goals.
● Mainstreaming AYUSH, revitalizing local health traditions.
● Reorienting medical education to support rural health issues including
regulation of medical care and medical ethics.
● Effective and visible risk pooling and social health insurance to
provide health security to the poor by ensuring accessible, affordable,
accountable and good quality hospital care.

43.6 Institutional mechanisms in the National Rural

Health Mission
The following institutional mechanisms have been created to strengthen
functioning at various levels:
● Village health and sanitation samiti (at village level consisting of
panchayat representative/s, ANM/MPW, anganwadi worker, teacher,
ASHA, community health volunteers),
● Hospital Management Committee/Rogi Kalyan Samiti 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 and others represented on it.
● 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
and others.
● Integration of Departments of Health and Family Welfare, at national
and state level.
● National Mission Steering Group chaired by Union Minister for
Health & Family Welfare with Deputy Chairman Planning
Commission, Ministers of Panchayat Raj, Rural Development and
Human Resource Development and public health professionals as
members, to provide policy support and guidance to the Mission.
● Empowered Programme Committee chaired by Secretary Health and
family Welfare, to be the Executive Body of the Mission.
As a part of this strategy, the state and district missions have been set
up in all the states and UTs (Figure 43.1). The Departments of Health and
Family Welfare have been merged at the level of the Government of India
1200 Advanced public health nutrition

(GoI) and similar system is being followed up at state levels. State level
NRHM activities have been designed taking into consideration the reform
commitments expected by states including enhanced public spending on
health, decentralization, promotion of district level planning, etc.

Governing body, State Health Society (SHS)

43.1 Institutional Mechanisms under NRHM.

43.7 Accredited Social Health Activists (ASHA)

The core strategies envisaged to realize the objectives include improved
access to health care at household level through local women in the age
of 25–40 years known as Accredited Social Health Activist (ASHA).
Every village/large habitat is to have an ASHA chosen by and accountable
to the Panchayat. She is to serve as a bridge between the anganwadi
workers, ANMs and community. As link between the community and
the health facility, the ASHAs are expected to be the first person to call
for any health related demand. Under the Framework of Implementation
[2], it is proposed to have ASHAs in all the 18 high focus states and to
support ASHAs in tribal districts of all the remaining states. One of the
main approaches of NRHM involves large-scale transfer of knowledge
and skills and health information to ASHAs. Each state is imparting
 National Rural Health Mission 1201

trainings to them for 23 days in five episodes as per their state specific
needs.
A set of guidelines have been developed to enable the states to
develop and put in place a proper support mechanism for ASHA. These
guidelines spell out the role of ASHA vis-à-vis Anganwadi Worker
(AWW) of ICDS and the Auxiliary Nurse Midwives (ANM) of health
sector [3]. She is to act as an interface between the community and the
public health system. Working as an honorary volunteer, she receives
performance-based compensation on specified services rendered by her.
The NRHM focuses on decentralization for planning at all levels; ASHA
would facilitate preparation and implementation of the Village Health Plans
along with anganwadi workers, ANMs, functionaries of other departments
and self-help groups (SHGs) under the leadership of Village Health Com-
mittee of the Panchayat (elected village body). ASHA is also supplied
with a drug kit containing generic AYUSH and allopathic formulations
for common ailments, which is replenished, periodically.
Some of the roles and responsibilities of ASHA are
● To create awareness and provide information to community on
determinants of health such as nutrition, basic sanitation and hygiene
practices, healthy living and working conditions.
● To provide information on existing health services and the need for
timely utilization of health and family welfare services.
● Counsel women on birth preparedness, RTIs/STDs (Reproductive
Tract Infection / Sexually Transmitted Diseases).
● Mobilize community and facilitate them in accessing available health
related services.
● Work with voluntary health and sanitation committee to develop a
comprehensive village plan.
● Maintain drug kit to provide first aid facilities.
ASHA is viewed as a key person who would provide help to
strengthen the services at the outreach level for a sub-centre, PHC or
district health centre. In addition, ASHA is expected to provide data
regarding the progress made by the village/community for the
consolidation of report at PHC by the medical officer for the bi-monthly
meetings.
The expected outcomes related to ASHAs at community level as
envisaged in the Framework for Implementation (2005–2012) are as
below:
● Availability of trained community level worker at village level, with
a drug kit for generic ailments.
● Health and Nutrition Day at anganwadi level on a fixed day/month
1202 Advanced public health nutrition

for provision of immunization; Ante/post natal check ups and services

related to mother and child health care, including nutrition.
● Availability of generic drugs for common ailments at sub-centre and
hospital level.
● Access to good hospital care through assured availability of doctors,
drugs and quality services at PHC/CHC level and assured referral–
transport–communication systems to reach these facilities in time.
● Access to Universal Immunization improved through induction of
auto disabled syringes, alternate vaccine delivery and improved
mobilization services under the programme.
● Facilities for institutional delivery improved through provision of
referral, transport, escort and improved hospital care subsidized under
the Janani Surakshya Yojana (JSY) for the below-poverty-line
families.
● Availability of assured health care at reduced financial risk through
pilots of community health insurance under the mission.
● Availability of safe drinking water.
● Provisions for household toilets.
● Outreach services to medically under-served remote areas improved
through mobile medical units.
● Awareness about preventive health including nutrition increased.

43.7.1 The integrated role of ASHA and organizing

Village Health Nutrition Days
Health Days (referred also as Village Health and Nutrition Days or VHND)
are organized every month at the anganwadi level in each village in which
immunization, ante/post-natal check ups and services related to mother
and child health care including nutrition are being provided. Space at each
anganwadi centre (AWC) of ICDS (Integrated Child Development
Services) is proposed to serve as the hub of health and nutrition activities
in the village. The AWC space is also recommended to be utilized for
dispensing out-patient services by any health provider and also serve as
depot for medicines and contraceptives. It is proposed that NRHM will
aim to establish a village level health institution co-located with AWC
with a specific physical location.
The role of ASHAs under NRHM is very critical for child survival,
child health and strengthening immune functions (Figure 43.2). A
number of state governments have introduced innovative programmes
related to various schemes under NRHM, where ASHAs play a central
role such as vitamin A programme using the biannual administration
strategy.
 National Rural Health Mission 1203

43.2 Integrated role of ASHA.

(a)
Task added by GoI in 2009 [4]

43.8 Implementation Framework and Plan of Action

for NRHM
The inherent strength of NRHM lies in its implementation of various
schemes with rigor and appropriate monitoring strategy. In order to achieve
the goals of the NRHM, some of the key features identified in the
Implementation Framework and the Plan of Action of the Mission are
● Making the public health delivery system fully functional and
accountable to the community
● Human resources management
● Community involvement
● Decentralization
● Rigorous monitoring and evaluation against standards
● Convergence of health and related programmes from village level upwards
● Innovations and flexible financing and
● Interventions for improving the health indicators

43.8.1 Decentralization
In line with the above, the Mission seeks to adopt a convergent approach for
interventions under the umbrella of the district plan which seeks to integrate
all the related initiatives at the village, block and district levels. The District
Health Action Plan is the main instrument for planning, inter-sectoral
1204 Advanced public health nutrition

convergence, implementation and monitoring of the activities under the

Mission. Based on the district plans, annual state plans are developed. The
allocation of funds is as per these annual plans. It is also proposed to conduct
periodic surveys on an annual basis to track the improvements in the facilities
as well as in the reduction in health indicators. The state plans are approved
by the Mission at the national level.

43.8.2 Convergent action on other determinants of health

One of the key components of NRHM is about effective integration of
health concerns with determinants of health like sanitation and hygiene,
nutrition and safe drinking water through a district plan for health. The
status of health and related indicators depend on many factors such as
drinking water, female literacy, nutrition, early childhood development,
sanitation, women’s empowerment along with hospitals and functional
health systems. NRHM seeks to adopt a convergent approach for these
key determinants for interventions under the umbrella of the district plan.
Anganwadi Centre under the ICDS at the village level is proposed to be
the principal hub for health action (Figure 43.3). The village committees
constituted for drinking water, sanitation, ICDS etc. is envisaged to
converge under one common village health committee to cover all these
activities. Panchayati Raj Institutions (PRIs), the community level
institutions are expected to be fully involved in this convergent approach
so that the gains of integrated action can be reflected in district plans.

43.3 Convergent action at village level.

Convergence is also envisaged at the level of the Mission Steering Group

which has representation of all the concerned Ministries, such as Department
of Women and Child Development, Department of Education and with
AYUSH. The PRIs organizations (Self-help Groups, Schools, Water, Health
 National Rural Health Mission 1205

and Sanitation Committee or Health, Nutrition and Sanitation Committees,

Mahila Samakhya Groups, Zila Saksharta Samitis) are expected to provide
an opportunity for seeking local levels accountability in the delivery of social
sector programmes. There is a provision under the NRHM to provide for
School Health Checkups and School Health Education in consultation with
the states. As presented in Figures 43.3 and 43.4 (a, b), convergence of all
programmes is at the village and facility levels.

43.4a Intersectoral Convergence.

43.4b Intersectoral convergence under NRHM.

1206 Advanced public health nutrition

"!.9 Nutrition: a determinant of health

NRHM has proposed service guarantee for health care at sub-health centre,
primary health centre and community health centre. These include
prevention and control of childhood diseases as well as malnutrition,
vitamin A prophylaxis to the children, iron–folic acid to pregnant mothers
and children and testing of iodine in salt. These nutrition services are
proposed to be coordinated with the ICDS.

43.5 NRHM – five main approaches.

"!.10 Improving the public health delivery system

The status of public health infrastructure in the country, particularly in the
EAG and north-east states is very weak and has been the cause for concern
for many years. It is pertinent that providing the desired quality services
especially in the EAG and the north-eastern states will not be possible till
 National Rural Health Mission 1207

the infrastructure is sufficiently upgraded. Realizing this, the Mission seeks

to establish functional health facilities in the public domain through
revitalization of the existing infrastructure and fresh construction or
renovation wherever required. The Mission also seeks to improve service
delivery by putting in place enabling systems at all levels. This involves
simultaneous corrections in manpower planning as well as infrastructure
strengthening. The generic public health delivery system envisioned under
NRHM from the village to the block level is presented in Fig. 43.6.

43.11 Indian Public Health Standards (IPHS)

The Indian Public Health Standards (IPHS) have been set up for all levels
to ensure that quality in services is maintained throughout the delivery of
health care services. Figure 43.7 presents the human resource requirements
at various levels of health infrastructure under NRHM and Fig. 43.8
presents the details of IPHS.

; ;

MOIC

(a)
Lady Health Visitor, Sub-centre centre, Maternal and Child health
43.6 NRHM – Public Health Delivery Systems.
1208 Advanced public health nutrition

"!.12 Public health infrastructure

Given the general observation that the health infrastructure is in poor
condition in most of the states, NRHM has allocated the budget for

43.7 Human resource requirements.

IPHS for CHCs at a Glance

43.8 Indian Public Health Standards (IPHS) at CHCs.

construction, subject to the condition that it should not be more than 33%
of the total NRHM outlay in the case of high focus states and 25% in the
case of non-high focus states.
 National Rural Health Mission 1209

In order to improve public health infrastructure, a number of initiatives

have been put forth such as:
● Providing untied grants at sub-centre, PHC/CHC and district level.
● Provision for funds for taking up innovative schemes at district/state/
central level.
● Funds for Rogi Kalyan Samitis (welfare association for sick persons)
for managing the health facilities.
The Mission seeks to ensure the availability of requisite equipment and
drugs at all the public health care facilities and it is proposed to procure
equipment and drugs progressively in a decentralized manner. It is also
proposed to improve outreach activities in un-served and underserved areas
specially inhabited by vulnerable sections through provision of Mobile
Medical Units (MMU) in every district, which would cover anganwadi
centres also.

43.13 Improving availability of critical manpower

The issues of availability of critical manpower in the rural areas is proposed
to be addressed through initiatives like: (i) introduction of a trained
voluntary community health worker (ASHA) in every village of the 18
high-focus states; (ii) an additional ANM at each sub-centre; (iii) three
staff nurses at the primary health centres (PHC) to make them operational
round the clock and additional specialists and paramedical staff at the
community health centres (CHC).
In north-east States, keeping in view the difficulty in availing services
of doctors and specialists, the emphasis is on recruitment, training and
skill up-gradation of locally recruited ANMs, nurses, midwives and
paramedics. Contractual appointment/local level engagement of medical
and paramedical manpower, upgrading and multi-skilling of the existing
medical personnel are some other options which are being planned to fill
the critical gaps of manpower. A number of innovations like public-private
partnership (PPP) for service provision, franchising of service providers,
licensing and training of rural medical practitioners (RMP), rationalization
of existing manpower are being explored. It is envisaged that stringent
monitoring at all levels, involvement of the PRIs and monitoring by the
Rogi Kalyan Samitis would ensure presence of doctors and paramedical
in the rural areas. Besides compulsory posting of doctors in the rural areas,
better cadre management and personnel policies would also help to improve
manpower availability.
1210 Advanced public health nutrition

"!.1" Capacity building

Capacity building at all levels in India has been a huge challenge and
therefore various initiatives have been made under the Mission for capacity
building of human resources. These are
(i) Programme Management Units (PMUs) at the state/district level – PMUs
at the state/district level have been set up in order to provide managerial
support for monitoring various activities under NRHM and also tracking
of funds (Over 500 professionals have already been recruited).
Additionally, the successful implementation of the Mission requires
health sector reforms and development of human resources.
(ii) National Health System Resource Centre (NHSRC) – NHSRC at the
Central and State levels (SHSRC) have been set up to provide
technical support at the central and state government levels,
respectively.
(iii) The NRHM also emphasizes the setting up of fully functional block
and district level health management systems. Under NRHM, 70%
of the resources would be utilized at block and below block levels
while only 20% at the district level. Given the large army of ASHAs,
ANMs, nurses, rural medical practitioners, the need of the hour is
continuous development of the skills of these health personnel.
(iv) Strengthening nursing institutions and linking medical colleges – In
order to provide skill development support to rural health workers,
involving the voluntary sector in skill development, it is proposed to
strengthen the nursing and medical institutions of our country.
(v) Strengthening of PRIs – It is proposed to gradually shift the central
mechanism of the health facilities like sub-centres under the control
of panchayats (elected village body) elicited community organization,
with a view to make them more accountable.

"!.15 Monitoring and review

One of the differences in the monitoring strategy of NRHM is to involve
local communities in planning, implementing and monitoring. NRHM
proposes an intensive accountability framework through a three pronged
process of community based monitoring, external surveys and stringent
internal monitoring. Role of Village Health Committees, PHC health
monitoring and planning committees have been spelt out for ensuring
monitoring at community level.
 National Rural Health Mission 1211

"!.16 Flexible financing

One of the strengths of the Mission is to increase the share of central and
state governments on health care from the current 20–80 to 40–60 sharing
in the long run. While under Xth Plan, 100% grants were planned to be
provided to states, in the XI th Plan period the states are expected to
contribute 15% to make the share of the Central Government 85%. This
relative share of the centre and state is projected to be sustained at 75:25.
One of the practical problems experienced by the states has been the
transfer of funds under different budget heads at different points of time
vertically and for many programmes. Such a system has been found to
often result in duplication of efforts, and wastage of scarce resources.
The strength of Mission is recognised to lie in providing flexible financing
options. The Mission attempts to bring all the schemes of the Ministry of
Health and Family Welfare within the overarching umbrella of NRHM.
From the XI th Plan onwards, the Framework of Implementation has
proposed to have a single budget head for the activities under the Mission.
The mechanism of flow of funds under the NRHM budget head is
proposed through the Integrated Health Society at the state and the district
levels.

43.16.1 Related financial mechanisms: provision of untied

funds
In order to strengthen the sub-centres, each sub-centre will have an Untied
Fund for local action at Rs 10,000 per annum. This fund will be deposited
in a joint Bank account of the ANM and Sarpanch (Head of village committee
or Panchayat ) and operated by the ANM, in consultation with the village
health and sanitation committees. A revolving fund is to be set up at the
village level for providing referral and transport facilities for emergency
deliveries as well as immediate financial needs for hospitalization. The fund
is to be operated by the village health and sanitation committee (VHSC).
Such fund would also be made available to VHSC for various health activities
including IEC, household survey, preparation of health register, organization
of meetings at the village level, etc.

43.16.2 Financial Provisions under Janani Suraksha Yojana

(JSY)
As per JSY, [5] cash assistance for institutional delivery is given to both
mothers and ASHAs in the low- and high-performing states, on produc-
tion of below poverty line (BPL) cards. All pregnant women delivering in
the government health centre like sub-centre, PHC/CHC/FRU (First Re-
1212 Advanced public health nutrition

ferral Unit)/general wards of district hospitals and state hospitals or ac-

credited private institutions are eligible to avail of this assistance. In the
low-performing states, the assistance is Rs. 1400/- (about US $ 30) for a
pregnant woman while in the high-performing states, the assistance is fixed
at Rs. 700/- (about $ 15). The JSY has shown significant progress since
its inception with a sharp increase in institutional deliveries.

43.17 NRHM progress made

The Mission has shown progress in many states in the past three to four
year’s time. More than 0.6 million ASHAs have been selected and are at
various stages of selection and training. A total of 13,358 (additional PHCs)
APHCs, PHCs, CHCs, and other sub-district facilities have been made
24 × 7 functional. The state of Bihar has reported that the average number
of patients visiting a PHC every month has gone up from 39 in January
2006 to 3015 in August 2006. In Punjab, with the Alternate Health Delivery
involving service providers under PRIs at 1310 subsidiary health centres,
out-patient cases have gone up by 290% between June and October 2006.
Regarding availability of medicines, states of UP and Jharkhand revised
the per capita allocation for drugs in out-patient leading to better availability
of drugs at health facilities [6].
Infant mortality rate is reduced to come to 55, down by 2 points in 2007
as compared to a point in earlier years (2003–06) [6]. Significant gains
have also been reported in the rates of institutional deliveries which have
increased by 66.4 % in MP, 50.2 % in Rajasthan, 47.3 % in Bihar, 43.8%
in Orissa, 20.9% in Andhra Pradesh and 12.4% in Uttar Pradesh between
District Level Household Survey DLHS-II (2004) and DLHS-III (2007).
The status of full immunization has increased from 20.7% to 41.4% in
Bihar, 25.7% to 54.1% in Jharkhand, 30.1% to 36.1% in MP, 53.5% to
62.4 % in Orissa, 23.9% to 48.8 % in Rajasthan and 25.8 % to 30.3 % in
UP between DLHS II and DLHS III.
The success of NRHM depends to a large extent on many factors. One of
these factors is the performance of ASHA or the link worker in the community
and her linkages with the health system [3]. For the effective implementation
of NRHM, each link worker must be fully aware of the facilities available in
the area of operation and also what types of services are available at each
facility. Support provided by the district and state nodal officers to immediately
respond to local needs is another factor responsible for the successful
functioning of NRHM, as the inputs provided by these officers include
immediately responding to referrals made by ASHA, upgrading health facilities
and infrastructure as per IPHS standards, timely provision of drugs and taking
care of logistics as well as organizing campaigns and publicity activities with
respect to availability of various services and schemes.
 National Rural Health Mission 1213

References
1. National Rural Health Mission (2005–2012) Document, Ministry of Health and
Family Welfare, Government of India.
2. Framework for Implementation (2005–2012). National Rural Health Mission-
Meeting people’s health needs in rural areas’, Ministry of Health and Family
Welfare, Government of India.
3. Guidelines for Operationalising Support Mechanism for ASHA. Department of
Family Welfare. Ministry of Health & Family Welfare. Government of India.
2006.
4. TEWARI , B .K. State Level Awareness Meeting on NIDDCP, State Government of
Chattisgarh, 31st October 2009, Raipur, Chhattisgarh.
5. JANANI SURAKSHA YOJANA (2006). Features & frequently asked questions
& answers’. Government of India. http://mohfw.nic.in/dofw/JSY
6. NRHM-The Progress so far. http://mohfw.nic.in/nrhm
7. District Level Household and Facility Survey: Reproductive and Child Health
Project. www.rchiips.org/ARCH-1.html