This presentation deals with advent of NRHM, backdrop of public health scenario prior to NRHM & discusses in details vision & core strategy of NRHM. It focuses on different schemes related to maternal & child health under NRHM with special reference to Maharashtra.

1. NRHM IN CONTEXT WITH
MATERNAL & CHILD
HEALTH
DR PRADIP AWATE,
ASSISTANT DIRECTOR OF HEALTH SERVICES,
MAHARASHTRA

2. National Health
Mission (NHM)
NRHM
NUHM
From 1 May 2013

3. Scheme of Presentation
• Backdrop of NRHM
• Advent of NRHM – Why & What for ?
• Vision of NRHM
• Core Strategies
• Plan of Action
• MCH Services
• Achievements
• Way ahead …!

4. Public Health Status
1. Poor Public health expenditure in India - Public
health expenditure has declined from 1.3% of GDP in
1990 to 0.9% of GDP in 1999.
2. Vertical Health and Family Welfare Programmes
have limited synergisation at operational levels.
3. Lack of community ownership of public health
programmes impacts levels of efficiency,
accountability and effectiveness.
4. Lack of integration of sanitation, hygiene, nutrition
and drinking water issues.

5. 5. There are striking regional inequalities.
6. Population Stabilization
7. Curative services favor the non-poor: for every Re.1
spent on the poorest 20% population, Rs.3 is spent on
the richest quintile.
8. Only 10% Indians have some form of health insurance,
mostly inadequate
9. Out of Pocket Expenses -Hospitalized Indians spend on
an average 58% of their total annual expenditure Over
40% of hospitalized Indians borrow heavily or sell assets
to cover expenses. Over 25% of hospitalized Indians fall
below poverty line because of hospital expenses

6. Vision Of NRHM 1
1. To provide effective health care to rural
health population. (Special focus on 18
states)
2. To raise public spending on Health from 0.9%
of GDP to 2-3% of GDP.
3. To undertake architectural correction of the
health system to strengthen public health
management and service delivery in the
country.

7. Vision Of NRHM 2
4. Female health activist (ASHA)in every village.
5. A village health plan prepared through a local
team headed by the Health & Sanitation
Committee of the Panchayat.
6. Strengthening of the rural hospital for
effective curative care and made measurable
and accountable to the community through
Indian Public Health Standards(IPHS)

8. Vision Of NRHM 3
7. Integration of vertical Health & Family
Welfare Programmes.
8. It seeks to revitalize local health traditions
and mainstream AYUSH into the public health
system.
9. effective integration of health concerns with
determinants of health like sanitation &
hygiene, nutrition, and safe drinking water
through a District Plan for Health.

9. Vision Of NRHM 4
10. Address inter state , inter district disparities.
11.Define time-bound goals and report publicly
on their progress.
12.To improve access of rural people, especially
poor women and children, to equitable,
affordable, accountable and effective primary
healthcare.

10. NRHM - GOALS
1. Reduction in Infant Mortality Rate (IMR) and Maternal
Mortality Ratio (MMR)
2. Universal access to public health services such as
Women’s health, child health, water, sanitation & hygiene,
immunization, and Nutrition.
3. Prevention and control of communicable and non-
communicable diseases, including locally endemic
diseases.
4. Access to integrated comprehensive primary healthcare
5. Population stabilization, gender and demographic
balance.
6. Revitalize local health traditions and mainstream AYUSH
7. Promotion of healthy life styles

11. Core Strategies
1. Train and enhance capacity of Panchayati Raj Institutions
(PRIs) to own, control and manage public health services.
2. Promote access to improved healthcare at household level
through the female health activist (ASHA).
3. Health Plan for each village through Village Health
Committee
4. Strengthening sub-centre through an untied fund to enable
local planning and action and more Multi Purpose Workers .
5. Strengthening existing PHCs and CHCs, and provision of 30-
50 bedded CHC per lakh population for improved curative
care to a normative standard (Indian Public Health Standards
defining personnel, equipment and management standards).

12. Core Strategies
6. Preparation and Implementation of an inter-sectoral District
Health Plan prepared by the District Health Mission, including
drinking water, sanitation & hygiene and nutrition.
7. Integrating vertical Health and Family Welfare programmes at
National, State, Block, and District levels.
8. Technical Support to National, State and District Health Missions,
for Public Health Management.
9. Strengthening capacities for data collection, assessment and
review for evidence based planning, monitoring and supervision.
10. Formulation of transparent policies for deployment and career
development of Human Resources for health.
11. Developing capacities for preventive health care at all levels for
promoting healthy life styles, reduction in consumption of tobacco
and alcohol etc.
12. Promoting non-profit sector particularly in under served areas.

13. Supplementary Strategies
1. Regulation of Private Sector including the informal rural
practitioners to ensure availability of quality service to
citizens at reasonable cost.
2. Promotion of Public Private Partnerships for achieving
public health goals.
3. Mainstreaming AYUSH – revitalizing local health traditions.
4. Reorienting medical education to support rural health issues
including regulation of Medical care and Medical Ethics.
5. Effective and viable risk pooling and social health insurance
to provide health security to the poor by ensuring
accessible, affordable, accountable and good quality hospital
care.

14. Plan Of Action
A] ASHA –
• Honorary volunteer
• Chosen by & accountable
to Panchayat.
• Bridge between ANM &
Village.
• Will be imparted necessary
training.
• Provision of Medicine kit
• Will facilitate preparation
of Village Health Plan

15. B] Sub center Strengthening
• 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-centres.
• In case of additional Outlays, Multipurpose Workers
(Male)/Additional ANMs wherever needed, sanction of new
Sub-centres as per 2001 population norm, and
• Upgrading existing Sub-centres, including buildings for Sub-
centres functioning in rented premises will be considered.

16. C] STRENGTHENING PRIMARY HEALTH
CENTRES
• 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, through
mainstreaming AYUSH manpower.
• Observance of Standard treatment guidelines & protocols.
• In case of additional Outlays, intensification of ongoing
communicable disease control programmes, new
programmes 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.

17. D] STRENGTHENING CHCs
FOR FIRST REFERRAL
CARE
• Operationalizing 3222 existing Community Health
Centres (30-50 beds) as 24 Hour First Referral Units, including
posting of anaesthetists.
• 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.
• Creation of new Community Health Centres (30-50 beds) to
meet the population norm.

18. Other Aspects
• District Health Plan• District Health Plan
• Converging
sanitation & hygiene
• Strengthening of
Disease Control
Programmes
• PPP & Pvt Sector
Regulation
• New Health Financing• New Health Financing
 Flexibility
 Money follows the patient
 Standardization of services
• Program Management
Support
 Non lapsable health Pool (
Management System )
 Developing Manpower
 Improved Governance –
o E banking
o Social audit

19. Communitize
Flexible Financing
Monitor Progress against standards
Improved Management Through
Capacity
Innovations in HR Management

20. •Reproductive
• Maternal
•Newborn
• Child Health
And
•Adolescent
RMNCH+A Services

21. Maternal Health Services
• Janani Suraksha Yojana
• Janani Shishu Suraksha Karyakram - In this programme
following free entitlements are provided to pregnant
mothers and sick infants.
I. Free transport services from home to institute, institute to other
institute & institute to home.
II. Free diet services to mothers (3 days for normal deliveries and 7
days for C section)
III. Zero user fees.
IV. Free deliveries and C section.
V. Free diagnostics, medicines, Blood Transfusion.
• Maternal Death Review
• Performance based incentive to LSCS & EmOC trained
Medical Officers

22. Janani Suraksha Yojana (JSY)
To reduce Maternal and Neonatal Mortality by
promoting institutional delivery among
beneficiaries from BPL, SC and ST family in
rural and urban area.
Incentives for Institutional Delivery
Area
Beneficiary
ASHA
Rural Rs 700/- Rs 600/-
Urban Rs.600/- Rs 400/-
The eligible beneficiary
is from Below Poverty
Line and if she delivered
at home in this case Rs.
500/- is paid .
In case of L.S.C.S, Rs
1500/- is to be given to
beneficiary.

23. Janani Shishu Suraksha Karyakaram
(JSSK)
Janani Shishu Suraksha Karyakaram
(JSSK)
Under this scheme services are provided to
pregnant and deliverd mothers and infants up to
1 year are getting benefitted in all government
health facilities by all free health services
irrespective of poverty level, caste and parity.
1. Free drugs & Consumables
2. Free Referral Transport
3. Free Diagnostics
4. Free Diet To Delivered Mothers
5. Provision of Free Blood
6. Exemption from User Charges

24. Fully Protected Mother &
Maternal Death Review
Fully Protected Mother &
Maternal Death Review
1. These include mapping of all health facilities.1. These include mapping of all health facilities.
2. Strengthening Sub-Centres, Primary Health Centres as per IPHS
norms, strengthening of First Referral Units.
3. Providing blood transfusion facilities, Caesarean Section services
at Government facilities.
4. For enhancing quality and access of services through public health
sector, regular provision of services is planned and implemented.
Strategy of fully protected mother which include 3 ANC check up,
IFA tablet consumption, injection TT second/booster are ensured.
Free referral transport services, free diagnostics and medicines,
free diet during stay, and adequate PNC care is being
implemented across the state.
5. Facility Based MDR and Community Based MDR is taken and
reviewed by a committee under the chairmanship of Civil
Surgeon/ MOH of Corporations.

25. Navsanjivani Yojana (Tribal )
• Matrutva Anudan Yojana
• Mobile Medical Squad
• Dai Meetings
• Water Quality Monitoring
• Pre Monsoon Activities
• Provision of food and loss of wages to
relatives accompanying SAM/MAM children.

26. Child Health Services
• Special New Born Care Unit.
• Village Child Development Center in Anganwadi for
SAM & MAM Children.
• Child Treatment Center at PHC/RH for SAM & MAM
Children.
• Nutritional Rehabilitation Centre in tribal districts.
• Organization of Bi Annual Rounds of De-worming and
Vitamin A supplementation.
• Routine Immunization Programme
• Infant Death Audit in one High IMR Block in all districts.

27. Rashtriya Bal Swasthya Karykram
(RBSK)
Rashtriya Bal Swasthya Karykram
(RBSK)
• RBSK aims at early detection and
management of the '4Ds'
1. Defects at birth,
2. Diseases in children,
3. Deficiency conditions and
4. Developmental delays including
disabilities) prevalent in children.

28. Implementation Strategy
RBSK aims to cover children of 0-18 years of age in• RBSK aims to cover children of 0-18 years of age in
Maharashtra.
• Biannual Regular health screening of pre-school
children up to 6 years of age using Aganwadis as a
platform is a essential component.
• Moreover, children from 6 to 18 years of age studying
in Government and Government aided schools would
also receive regular health check-ups.
• follow-up referral support and treatment including
surgical interventions at tertiary level free of cost

29. Special Newborn Care Unit (SNCU)
• In SNCUs severely sick children born in hospital are admitted and
also children referred from outside.
• These are specialized new born and sick child care units at district
hospitals with specialised equipments, which include
1. phototherapy unit,
2. oxygen hoods, infusion pumps,
3. radiant warmer,
4. Laryngoscope and ET tubes,nasal cannulas etc.
• These units have a minimum of 12 to 16 beds with a staff of 3
physicians, 10 nurses, and 4 support staff to provide round the clock
services for a new born or child requiring special care such as
managing newborn with neonatal sepsis and child with pneumonia,
dehydration etc, prevention of hypothermia, prevention of
infection, early initiation and exclusive breast feeding, post natal
care, immunization and referral services.

30. Village Child Development Center
(VCDC)
• The SAM/MAM Children who do not have
medical problem are admitted in Village child
development Center for 30 days.
• The treatment is given by Medical Officer of
Primary Health Center and
• Nutritious diet is provided by Anganwadi.
• For each Child the budget of Rs. 1000/- is
allocated for 30 days.

31. Child Treatment Center (CTC)
• Moderately Malnourished children (MAM) and
Severely Malnourished children (SAM) having medical
complications are admitted in selected Primary Health
Centers, Rural Hospitals and Sub District Hospitals for
21 days.
• Admitted Malnourished children are examined and
treated by Medical officer.
• Nutritious diet is given to the children and
mother/caretaker.
• Loss of Daily wages is given to the mother.
• Budget allocatted is Rs. 5,250/- for each child for 21
days.

32. Nutrition Rehabilitation Center (NRC)
• NRCs are established in 15 tribal districts at
district hospital/sub district hospital level.
• Severely sick malourished children (SAM) are
admitted in Nutrition Rehabilitation Centers.
• At NRC treatment and nutritious diet for 14
days is given to the children.
• Also the mother of the child is given nutritious
diet and is taught recipes for preparation of
Nutritious diet at home.

33. De worming & Vitamin A Drive
• Bi-annual drive is implemented in Rural and
Urban areas of district in Maharashtra.
• In this round Vitamin A is given to all children
between 9 months to 5 years and
• de worming medicine is given to children of
age group 1-6 yrs .

34. Infant & Young Child Feeding (IYCF)
• Infant and young child feeding (IYCF) activities
are important to reduce malnutrition.
• In this activity the mother is educated
regarding
1. early breast feeding,
2. exclusive breast feeding for first six months and
3. initiation of complementary feeding.

35. Integrated Management of New Born
& Childhood Illnesses (IMNCI)
• In this activity, IMNCI training is given to the
staff working in health and ICDS department.
• IMNCI training regarding home visit is given to
ANM, AWW and MPW.
• The programme is implemented in all districts.
IMNCI kits are provided to all IMNCI trained
Anganwadi workers.
• The medicines are provided to AWW for their
home visit with IMNCI kit.

36. MCTS
• Mother & Child Tracking System (MCTS), web based• Mother & Child Tracking System (MCTS), web based
reporting software, under RCH-II programme for tracking of
health services delivered to pregnant mothers and children.
• Objectives:-
• Name Based Tracking of:
1. Pregnant women - for ANC, Delivery & PNC health services
2. Children - for immunization
• To Facilitate:
1. Close monitoring of regular Checkups & service delivery to pregnant
mothers with minimum essentials services
2. Full Immunization of Mother & Children
3. To follow up dropouts and track service delivery
4. To promote complete immunization and safe institutional deliveries

37. Tracking System
• New registration – 18 digit UNIQUE ID
• Service delivery record update
• Allotment of health provider –
• Overdue services for same beneficiary for every month
are generated in health provider’s work plan.
• In rural area two health providers (one ANM & one
ASHA) are allotted to each beneficiary.
• SMS alerts to beneficiary & health provider –
For the information of registration status and services
falling due on the mobile number registered in MCTS.

38. Adolescents’ Health Services
• ARSH Clinics along with support for outreach
activities
• Appointment of counselors at DH.
• Weekly Iorn Folic Acid supplementation
Scheme
• Promotion of Menstrual Hygiene in
Adolescents Girls . Under this Programme
sanitary napkins are provided at Low cost.
• Mobility Support for AH/ICTC counselors

39. Vulnerable Group
Vulnerable Group means vulnerable communities
such as SC/ST and BPL populations living in
targeted Rural areas and not covered by Urban
RCH programmes and Tribal RCH Programmes.
Mainly these are Migratory populations of
Labours, not living in slums.
1. RCH outreach camps for migratory sugarcane cutters in 25
districts having Co-Operative Sugar Factories.
2. Creation of Health Post for MIHAN SEZ, Wadi, Narsala
Industrial zone in peri Urban area of Nagpur having huge
population of labours working in Industries, Construction
sites.
3. Health Check up of Migrant brick workers

40. Achievements

41. IMR
66 64
60 58 58 57 55 53
50
47
44 42
45 45
42
36 36 35 34 33 31
28
25 25
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
India Maharashtra

42. MMR
301
254
212
178
149
130
104
87
0
50
100
150
200
250
300
350
2001-03 2004-06 2007-09 2010-12
India Maharashtra

43. Sr. Year India Maharashtra
1 1992-93 3.39 2.86
2 1998-99 2.85 2.52
3 2005-06 2.68 2.11
4 2008-09 2.60 1.90
5 2012 2.40 1.80
Total Fertility Rate

44. Thanks