National Health Mission

PRABHA KRISHNAN
 The major milestones so far include…..

a. 1992- Child survival and safe motherhood programme

(CSSM)
b. 1997-RCH-I
c. 2005- RCH-II
d. 2005- National Rural Health Mission
e. 2013- RMNCH+A strategy
f. 2013- National Health mission
g. 2014-India Newborn Action Plan
 NATIONAL HEALTH MISSION

Approved in May 2013

Two Sub-Missions :
 National Rural Health Mission
 National Urban Health Missions
 Vision Of The NHM

“Attainment of Universal Access to Equitable, Affordable

and Quality health care services, accountable and
responsive to people’s needs, with effective intersectoral
convergent action to address the wider social determinants
of health”
National Rural Health Mission (NRHM) was launched in
April 12, 2005 to address the health needs of the
underserved rural population especially women, children
and vulnerable sections of the society and to provide
affordable, accessible and quality healthcare
National Urban Health Mission, (NUHM) was launched in
May 2013 and was subsumed with NRHM as a sub-Mission
of the overarching National Health Mission(NHM). Many
unique practices were encouraged like innovations in
healthcare delivery practices, flexible financing to the states
with strengthened monitoring and evaluation component for
better health outcomes and health indicators of the states.
 Components of NHM

Public Health Planning and Financing

Human Resource Strengthening

Health Systems Strengthening

Reproductive, Maternal, New Born, Child Health and

Adolescent (RMNCH+A) Services

Preventing Communicable and Non-Communicable Diseases

Community Processes
 1. Public Health Planning and Financing

Mapping of facilities and differential planning for

districts/cities/blocks as per their health indicators
Planning for full spectrum of health services

Emphasis on quality assurance in delivery points

Strengthening of Management with full time Mission Director,

Director Finance and Programme Management support at all levels.

Developing a separate and trained Public health cadre of
professionals including doctors and nurses
2. Human Resource Strengthening in Health; Deployment and
Development

HR gaps met based on case load. Engagement of medical specialists,

medical professionals and nurses on contract based on need.

HR accountability: Performance-based incentives and for working in

difficult areas.
Additional incentives to health professionals to serve in rural and remote

areas
Speedy recruitment to fill up vacancy, preferable decentralized.

Amendments in medical college norms to increase availability of doctors

Capacity building and training of staff at all levels.

 3. Health Systems Strengthening

Construction of new buildings and renovation of existing

ones
Improving Sanitation & Hygiene in Public facilities:

Kayakalp
Social Protection: Drugs, Diet, Diagnostics and Transport

Outreach Services: Mobile Medical Units.

 4. RMNCH+A Services
A. Reducing Maternal Mortality Rate: Maternal Health
1. Incentivization: Janani Suraksha Yojana (JSY)

2. Free Patient Entitlements: Janani Sishu Suraksha

Karyakram (JSSK)
3. Strengthening infrastructure: Maternal and Child Health
(MCH) Services
4. Reorienting Medical Education: Skill Labs
5. Capacity Building: Dakshata Programme
6. Promotive Health : Mothers Absolute Affection (MAA)
7. Improves access and Coverage
8.Improving access by PPP mode: Pradhan Mantri Surakshit
Matritva Abhiyan(PMSMA)
9. NGO’s Involvement
10.Monitoring and accountability of services
B. Reducing Infant Mortality and Child Mortality Rate: New Born
and Child Health
1. New born Care Services Programme
2. Universal Immunization Programme (UIP) & Mission Indradhanush
3. Rashtriya Bal Swasthya Karyakram (RBSK)
4. Integrated Management of Common Childhood Illnesses(IMNCI)

5. Nutritional Rehabilitation Centers (NRCs)

6. Monitoring: Child Death Review
C. Adolescent Health Programme
1. Rashtriya Kishor Swasthya Karyakram (RKSK)
D. Reducing Fertility Rate: Family Planning Services
E. Declining Sex Ratio
 5. Preventing Communicable and Non
Communicable Diseases
Non Communicable Diseases Programmes

1.National Program for Prevention and Control of Diabetes, CVD and Stroke (NPCDCS)

2.National program for Prevention and Control of Blindness (NPCB)

3.National Program for Prevention and Control of Deafness (NPPCD)

4. National Mental Health Program (NMHP)

5. National Oral Health Program (NOHP)

6. National Program for Health Care of the Elderly (NPHCE)

7. National Iodine Deficiency Disease Control Program (NIDDCP)

8. National Tobacco Control Program (NTCP)

 Communicable Disease Programmes

1. National Vector Borne Disease ControlProgramme (NVBDCP)

2. Revised National Tuberculosis Control Program (RNTCP)

3. National Leprosy Eradication Program (NLEP)
4. Integrated Disease Surveillance Program (IDSP)
 6. Community Processes

Village Health Sanitation &Nutrition Committee

(VHSNC)
ASHA

Anganwadi Workers

Jan Sunwai or Jan Samvad

INSTITUTIONAL FRAMEWORK
National Level Implementation
District Level Implementation
Block Level Implementation
 NATIONAL URBAN HEALTH MISSION

NUHM seeks to improve the health status of the urban

population particularly slum dwellers and other

vulnerable section by facilitating their access to quality
health care.
 NUHM would cover all state capitals, district
headquarters and about 779 other cities/towns with a
population of 50,000 and above.
 The NUHM will focus on :

1. Urban poor population living in listed and unlisted slums;

2.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;
3.Public health thrust on sanitation, clean drinking water,vector
control etc.; and
4.Strengthening public health capacity of urban local bodies
 CORE STRATEGIES
 Improving the efficiency of public health system in the cities by strengthening and

improving existing government primary urban health structure and referral facilities.
 Promotion of access to improved health care at household level through community

based groups : Mahila Arogya Samitis.

 Strengthening public health through innovative action.

 Increased access to health care.

 IT enabled services (ITES) and e- governance for improving access improved

surveillance.
 Prioritizing the most vulnerable amongst the poor.

 Ensuring quality health care services.

 The urban health care facilities are :

Urban Community Health Centre

Urban Primary Health Centre

Community Level

Referral linkages
 1. URBAN- COMMUNITY HEALTH
CENTRE (U-CHC)

Population Norms:
One U-CHC for 4-5 U-PHCs in big cities.

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.

 2. URBAN PRIMARY HEALTH CENTRE
(U-PHC)

Population Norms:
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 kilometre radius catering to a slum population of

approximately 25,000-30,000.
The cities based upon the local situation may establish a U-PHC

for 75,000 for areas with very high density.

Services:
OPD (consultation); Basic lab diagnosis, drug
/contraceptive dispensing, Distribution of health
education, Material and counselling for all communicable
and non communicable diseases.
It will not include in-patient care.
 3. COMMUNITY LEVEL

A. Urban Social Health Activist (USHA):

A Frontline community worker for each slum/community

The USHA would be a woman resident of the slum, preferably

in the age group of 25 to 45 years married / widowed/ divorced.

She would be covering about 1000 – 2500 community level

beneficiaries.
She would be covering between 200-500 households functional

at the slum level the door steps.

She would serve as an effective link between the Urban

Primary Health Centre and the urban slum populations.

She would maintain interpersonal communication with the

beneficiary families and individuals.

She would help the ANM in delivering outreach services

in the doorsteps of the beneficiaries.

 Functions

To promote good health services in her area.

To facilitate awareness on RCH services.

To motivate all types of family planning methods.

To register all pregnant mothers and to motivate them for antenatal care.

To act as a depot for essential provisions like ORS packets, IFA tablets,

Chloroquine tablets, oral pills, condoms etc.

To support ANM in conducting monthly outreach session regularly.

To escort the patients requiring health services.

To encourage the community participation in health

activities.
To maintain the records of vital events in her area.

To treat minor ailments with the drug kit provided.

Reinforcement of community action for immunization

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 250-500

population) with an elected Chairperson and a Treasurer

supported by an USHA Link worker.
This group would focus on preventive and promotive health care.
Functions of MAS:
To focus on preventive and promotive care.

To act as peer education group.

To facilitate access to identified facilities.

Community monitoring and referral.

Risk pooling fund and health insurance.

C. AUXILIARY NURSE MID-WIFE:

Each ANM will organize a minimum of one outreach session 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.

Outreach sessions will be planned to focus special attention for slum

population, rag pickers, sex workers, street children and rickshaw pullers
 4. REFERRAL LINKAGES

Existing hospitals, including maternity homes, state

government hospitals and medical colleges, apart from
private hospitals will be accredited to act as referral
points.
Health care services like maternal health, child health,
diabetes, trauma care, orthopaedic complications, dental
surgeries, mental health, critical illness, deafness control,
cancer management, tobacco counselling / cessation,
critical illness, surgical cases etc.
 THE INTERVENTIONS UNDER THE SUB-MISSION WILL RESULT
IN

Reduce IMR & MMR by 40% (in urban areas).

Achieve universal immunization in all urban areas.
Reduce MMR by 50%.
100% of ANC coverage.
Achieve universal access to reproductive health including
100% institutional delivery.
Achieve all targets of disease control programmes
 National Rural Health Mission

The National Rural Health Mission was launched since April 2005

throughout the country for providing better rural health services.

National rural health mission has special focus on following 18 states:
Empowered action group (EAG) states: Bihar, Jharkhand, MP,

Chattisgarh, UP, Uttaranchal, Orissa and Rajasthan.

North east states: Assam, Arunachal Pradesh, Manipur, Meghalaya,

Mizoram, Nagaland, Sikkim and Tripura.

Other states: Himachal Pradesh, Jammu and Kashmir
 AIMS

The main aim of NRHM is to provide accessible,

affordable, accountable,effective and reliable primary
health care and bridging the gap in rural health care
through the creation of a cadre of Accredited Social
Health Activist.
Provision of a female health activist in each village.
Health & Sanitation Committee of the Panchayat.
It seeks to improve access of rural people, especially poor
women and children,to equitable, affordable, accountable
and effective primary healthcare.
 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 comprehensive primary healthcare.
Population stabilization, gender and demographic balance.
Mainstreaming AYUSH.
Promotion of healthy life styles.
 CORE STRATEGIES

1. Train and enhance capacity of Panchayat Raj institutions.

2. Promote access to improved health care at household level
through the female health activist.
3. Health plan for each village through village health
committee of the panchayat.

4. Strengthening sub center and more MPW’s.

5. Strengthening existing PHC’s and CHC’c.
6. Strengthening capacities for data collection, assessment
and evidence based planning, monitoring and supervision.
7. Developing capacities for preventive health care at all
levels by promoting healthy life styles, reduction in
tobacco consumption, alcohol etc.
8. Preparation and implementation of an district health plan
prepared by the district health mission.
 Plan Of Action To Strengthen Infrastructure

1. Creation of a cadre of Accredited Social Health Activist (ASHA)

2. Strengthening sub-centres by :-
a. Supply of essential drugs both allopathic and AYUSH to the sub-
centre
b. In case of additional outlay provision of multipurpose worker
(male)additional ANMs wherever needed, sanction of new sub-
centres and upgrading existing sub-centres, and
c. Strengthening sub-centres with untied funds of Rs 10,000 per
annum in all 18 states
3. Strengthening Primary Health Centres: Mission aims at strengthening PHCs for quality

preventive, promote, curative, supervisory and outreach services through

a. Adequate and regular supply of essential drugs and equipment to PHCs (including supply of

auto-disabled syringes for immunization);

b. Provision of 24 hours service in at least 50 per cent PHCs by including an AYUSH practitioner,

c. Following standard treatment guidelines

d. Upgradation of all the PHCs for 24 hours referral service and provision of second doctor at PHC

level (one male and one female) on the basis of felt need; strengthening the ongoing

communicable disease control programmes and new programmes for control of non

communicable diseases
4. Strengthening Community Health Centres for First Referral care by-

a. Operating all existing CHCs (30-50 beds) as 24 hours first referral

units, including posting of an anesthetist;

b. Codification of new “Indian Public health standards” by setting up

norms for infrastructure staff, equipment, management etc. for CHCs;

c. Promotion of “Rogi Kalyan Samiti” for hospital management etc. for

CHCs;

d. Developing standards of services and costs in hospital care.

5. District health plan under NRHM :District is the core unit of
planning , budgeting and implementation of the programme.
All vertical health and family welfare programmes at district

level have merged into one common “District Health

Mission” and at state level into “State Health Mission”.
There is provision of a "mobile medical unit at district level

for improved outreach services.

6. CONVERGING SANITATION AND HYGIENE UNDER NRHM
Total Sanitation Campaign (TSC) is implemented and is proposed to cover all
districts in 10th Plan.
Components of TSC include IEC activities, individual household toilets, women

sanitary complex, and School Sanitation Program.

The District Health Mission would guide activities of sanitation at district level, and

promote joint IEC for 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.
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.

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.

Need to develop guidelines for Public-Private Partnership (PPP) in

health sector. Identifying areas of partnership, which are need based.

Management plan for PPP initiatives: at District/State and National

levels.
9. NEW HEALTH FINANCING MECHANISMS

 The District Health Missions to move towards paying hospitals for services by

way of reimbursement.

 Standardization of services – outpatient, in-patient, laboratory, surgical

interventions.

 A National Expert Group to monitor these standards and give suitable advice and

guidance on protocols and cost comparisons.

 All existing CHCs to have wage component paid on monthly basis.

 Over the Mission period, the CHC may move towards all costs, including wages

reimbursed for services rendered.

10. REORIENTING HEALTH/MEDICAL EDUCATION TO
SUPPORT RURAL HEALTH ISSUES
 While district and tertiary hospitals are necessarily located in urban

centres, they form a 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.

 Major initiatives under NRHM

Selection of ASHA

Rogi Kalyan Samiti (Patient Welfare Committee / Hospital Management Society)

The untied grants to sub centres (SCs)

The Village Health Sanitation and Nutrition Committee (VHSNC)

Janani Suraksha Yojana (JSY)

Janani Shishu Suraksha Karyakarm (JSSK)

National Mobile Medical Units (NMMUs)

National Ambulance Services

Web enabled Mother and Child Tracking System (MCTS)

 1. Selection of ASHA

ASHA must be the resident of the village- a woman

preferably in the age group of 25 to 45 vears with formal

education up to eighth class, having communication skills
and leadership qualities.
One ASHA for 1000 population. In tribal, hilly and desert

areas the norm could be relaxed to one ASHA per

habitation
 Role and responsibilities of ASHA

create awareness and provide information to the community on

determinants of health
Counselling
mobilize the community and facilitate them in accessing health
and health related service available at the
anganwadi/subcentre/primary health centres,
work with the village health and sanitation committee of the
gram panchayat
arrange escort/accompany pregnant women and children
requiring treatment/admission to nearest pre-identified health
facility
provide primary medical care for minor ailments
depot holder for essential provisions being made available
to every habitation
inform about the births and deaths in her village and any
unusual health problems/disease outbreaks in the
community to the sub-centre/primary health centre
promote construction of household toilets
 Role and integration with Anganwadi

Organizing Health Day once/twice month

act as resource persons for the training of ASHA
Anganwadi worker will be depot holder for drug kits and
will be issuing it to ASHA.
AWW will update the list of eligible couples and also the
children less than one year of age in the village with the
help of ASHA
ASHA will support the AWW in mobilizing pregnant and
lactating women and infants for nutrition supplement
 Role and integration with ANM

hold weekly fortnightly meeting with ASHA and discuss

the activities undertaken
resource persons for the training of ASHA
inform ASHA regarding date and time of the outreach
session and will also guide her
participate and guide in organizing the Health Days at
anganwadi centre.
updating eligible couple register of the village
Motivate the pregnant women
 2. Rogi Kalyan Samiti (Patient Welfare Committee/ Hospital Management Society )

This committee is a registered society whose members act

as trustees to manage the affairs of the hospital and is

responsible for upkeep of the facilities and ensure
provision of better facilities to the patients in the hospital.
 3. The untied grants to sub centres (SCs)

The SCs are far better equipped now with blood pressure

measuring equipment. haemoglobin (Hb) measuring

equipment. stethoscope, weighing machine etc This has
facilitated provision of quality antenatal care and other
health care services
4 The Village Health Sanitation and Nutrition Committee (VHSNC)

It is an important tool of community empowerment and

participation at the grassroots level, The VHSNC reflects

the aspirations of the local community,especially the poor
households and children. Upto 31st March 2014, 5.12
lakh VHSNCs have been set up across the country.
 5 Janani Suraksha Yojana (JSY)

It aims to reduce maternal mortality among pregnant

women by encouraging them to deliver in government

health facilities. Under the scheme, cash assistance is
provided to eligible pregnant women for giving birth in a
government health facility
 Janani Shishu Suraksha Karyakarm (JSSK

Launched on 1st June, 2011, JSSR entitles all pregnant

women delivering in public health institutions to

absolutely free and no expense delivery, including
caesarean section. This marks a shift an entitlement based
approach.
 7. National Mobile Medical Units (NMMUs)

Support has been provided in 418 out of 640 districts for

2127 MMUs under NRHM in the country. To increase

visibility, awareness and accountability, all Mobile
Medical Units have been repositioned as “National
Mobile Medical Unit Service” with universal colour and
design.
 8. National Ambulance Services

NRHM has supported free ambulance services to provide patients

transport in every nook and corner of the country connected with

a toll free number. Over 16000 basic and emergency patient
transport vehicles have been provided under NRHM. Besides
these, over 4769 vehicles have been empanelled to transport
patients, particularly pregnant women and sick infants from home
to public health facilities and back.28 states have set up a call
centre for effective patient transport system
 9. Web enabled Mother and Child Tracking System (MCTS)

The name-based tracking of pregnant women and children has been initiated under

NRHM with an intention to track every pregnant woman, infant and child up to the
age of three years by name, for ensuring delivery of services like timely antenatal care,
institutional delivery and postnatal care for the mother and immunization and other
related services tor the child. The MCTs is to be fully updated for regular and effective
monitoring of service delivery including tracking and monitoring of severely anaemic
women, low birth weight babies and sick neonates In the long run. it could be used for
tracking the health status of the girl child and school health services A more recent
initiative is to link MCTS with AADHAR in order to track subsidies to eligible
women
 Monitoring and evaluation under NRHM

A baseline survey is to be taken up at the district level

incorporating facility survey as well as survey of the
households.
There would be community monitoring at the village level.
The panchayat raj institutions, rogi kalyan samitis, quality
assurance committees at the state level and district level, state
and district health missions, mission steering group at the
central level.
Planning commission is to be the eventual monitor of the
outcomes. External evaluation is also to be taken up at
frequent intervals.
 Approach For Monitoring

1. Periodic Population Health Surveys and Demographic

information
2. Evaluation studies or research on implementation
3. Strengthening Data Capturing: Health Management
Information systems (HMIS)
4. Access of services to disadvantaged communities of various
geographical areas is monitored by surveys and MCTS
reporting system
5. Field Visits/Appraisal Visits
6. Training Information Management System( TMIS)
7. Quality Monitoring
 DIFFERENCE BETWEEN NRHM AND NUHM
NRHM NUHM

National rural health mission National urban health mission

Improves rural health delivery Separate mission for urban areas and
system focus on slums & other urban poor
families

Launched on 12th April, 2005 Approved on 1st May 2013

Creation of ASHA (Accredited Creation of USHA (Urban Social Health

Social Health Activist) Activist)

1 ASHA = 1000 population 1 USHA= 1000- 2,500 beneficiaries,

200-500 households

PHC / CHC are present to provide PUHC/ CUHC is there to provide health
health services. services.
 BIBLIOGRAPHY

1. http://nhm.gov.in/images/pdf/guidelines/nrhm-
guidelines/mission_document.pdf
2. k park “park’s textbook of preventive an social medicine”
bhanot publishers 23rd edition page no:445-452