National health mission

NATIONAL HEALTH
MISSION : NRHM & NUHM
MARY JACOB CHIYEDATH
II MSc NURSING
GOVT COLLEGE OF NURSING
THRISSUR

• National Health Mission (NHM) encompassing
two Sub-Missions
• National Rural Health Mission (NRHM)
• National Urban Health Mission (NUHM).

OBJECTIVES
• Describe in detail about the National Rural
Health Mission
• Discuss the core strategies and
implementation of National Urban Health
Mission
• Explain in detail on the national health
mission

HEALTH SCENARIO
• Multiple burden of disease –communicable, non-
communicable and unattended morbidities
• High child and maternal deaths
• 50% under nourished and anemic women and
children – very little improvement
• Water and sanitation challenges remain
• Food security
• Malaria, dengue, chikunguniya on the rise
• Public health regulation – very weak
• High TFR in UP, Bihar, MP, Rajasthan, Jharkhand

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, Odisha
and Rajasthan.
• North east states: Assam, Arunachal Pradesh, Manipur,
Meghalaya, Mizoram, Nagaland, Sikkim and Tripura.
• Other states: Himachal Pradesh, Jammu and Kashmir

• National Rural Health Mission (NRHM) was
launched at the National Level in April 2005
for a period of seven years (2005-2012)
extended up to year 2017.

VISION
• The National Rural Health Mission (2005-12)
seeks to provide effective healthcare to rural
population throughout the country with
special focus on 18 states, which have weak
public health indicators and/or weak
infrastructure.

MISSION
• The Mission is an articulation of the
commitment of the Government to raise
public spending on Health from 0.9% of GDP
to 2-3% of GDP.
• The mission will be the instrument to
integrate multiple vertical programmes along
with their funds at the district level.

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
• Indian Public Health Standards (IPHS)
• Integration of vertical Health & Family Welfare
Programmes

– Mainstream AYUSH into the public health system.
– Effective integration of health concerns with
determinants of health like sanitation & hygiene,
nutrition, and safe drinking water through a District
Plan for Health.
– It shall define time-bound goals and report publicly on
their progress.
• 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 integrated comprehensive primary healthcare
• Population stabilization, gender and demographic balance.
• Revitalize local health traditions and mainstream AYUSH
• Promotion of healthy life styles

OBJECTIVES OF NATIONAL RURAL
HEALTH MISSION
• To reduce Maternal Mortality Rate (MMR)
• To reduce Infant Mortality Rate (IMR)
• To reduce Total Fertility Rate (TFR)

• To provide accessible, affordable, accountable,
effective and reliable primary health care, especially to
poor and vulnerable sections of the population
• To provide the overarching umbrella to the existing
programmes of health and family welfare including
malaria, blindness, iodine deficiency, filarial, kala-azar,
tuberculosis control and RCH II
• maximum coordination can be achieved among the
related social sector, department of AYUSH, women
and child development, elementary education,
panchayati raj and rural development.

Approaches of NRHM: 5 pillars
• Increasing participation and ownership by the
community
• Improved management capacity
• Flexible financing
• Innovations in human resources development
for the health sector
• Setting of standards and norms with
monitoring

NRHM – 5 MAIN APPROACHES
COMMUNITIZE
Hospital management
committees
United grants to community
Funds, functions to local
community organizations
Decentralized planning, village
health and sanitation
committees
FLEXIBLE FINANCING
Partnership of state and
community resources
United grants to institutions
NGO sector for public health
goals
More resources for more
reforms
MONITOR, PROGESS
AGAINST STANDARDS
Setting IPHS standards
Facility surveys
Independent monitoring
committees at block, district
and state levels
IMPROVED
MANAGEMNT THROUGH
CAPACITY
Block and district health
office with management
skills
NGOs in capacity building
Continuous skill
development support
INNOVATION IN HUMAN
RESOURCE
MANAGEMENT
Nurse managers
More nurses local resident
criteria
24X7 emergency medical
services at PHC/CHC
Multi skilling

Expected outcomes of NRHM
• IMR reduced to 30/1000 live births by 2012
• Maternal mortality reduced to 100/100000 live
births by 2012
• TFR reduced to 2.1 by 2012
• Malaria mortality reduction rate – 50% up to
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 until 2012
• Cataract operations – increasing to 46 lakhs until 2012
• Leprosy prevalence rate – reduce from 1.8 per 10000 in
2005 to less than 1 per 10000 thereafter
• Tuberculosis DOTS series – maintain 85% cure rate
through entire mission period and also sustain planned
case detection rate
• Upgrading all 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 400000 female accredited social health
activists (ASHAs)

Community level targets
• Availability of trained community level worker at village level,
with drug kit for generic ailments.
• Health day at Anganwadi level on a fixed day/ month for
provision of immunization, antenatal / postnatal 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 communications systems to reach
these facilities in time.
• Improved access to universal immunization through induction
of Auto disposable syringes, alternate vaccine delivery and
improved mobilization services under the programme.

• Janani Surakshya Yojana (YSY) 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
• Provision of household toilets
• Improved outreach services to medically
underserved remote areas through mobile
medical units
• Increase awareness about preventive health
including nutrition

STRATEGIES
• Strengthening of the health institutions providing Primary Health
Care (CHCs, PHCs and Sub Centres) so as to provide all the basic and
emergency obstetric care
• Strengthening of the routine immunization for the vaccine
preventable diseases.
• Improving the health services and the services determining the
health of the society viz sanitation and potable drinking water.
• Decentralizing the health planning and management of the health
institutions by way of Constitution of District Health Missions and
District Health Societies
• Formation of Rogi Kalyan Samitis (RKS) and Village Health Sanitation
and Nutrition Committees (VHSNC).
• Bringing all the centrally sponsored Health schemes under the
umbrella of NRHM.

ORGANIZATION STRUCTURE
• Central level
• State level

PLAN OF ACTION FOR STRENGHENING
THE INFRASTRUCTURE AND
MANPOWER
• Creation of ASHA (accredited social health
activist): every village will have female
accredited social health activist
• Strengthening sub-centres
– United fund of Rs. 10000 per annum
– Supply of drugs both allopathic and AYUSH
– Additional ANMs / Multipurpose worker (male)
– Upgrading existing sub centres
– Sanction of new sub centres

• Strengthening primary health centres
– Adequate and regular supply of essential quality drugs
and equipments including auto disabled syringes for
immunization
– Provision of 24 x 7 service in at least 50% PHCs
– Mainstreaming of AYUSH man power
– Following standard guidelines and standing protocols
– Provision of a second doctor at PHC level (one male
and one female )
– Up gradation of 100% PHCs for 24 hours referral
service

• Strengthening community health centres for first
referral services
– Operationalizing the existing CHCs (30 to 50 beds) as
24 hour FRUs including posting of anaesthetists
– New Indian public health standards (IPHS) for CHCs
– Promotion of Rogi kalian Samiti (RKS) for hospital
management
– Developing standards of services and costs in health
care
– Display of citizens charter at PHC/CHC level.

The schedule of implementation of major components of NRHM is as follows:
 Merger of multiple societies and constitution of district/ state mission : June 2005
 Provision of additional generic drugs at SC/PHC/CHC level : December 2005
 Operational programme management units : 2005-06
 Preparation of village health plans : 2006
 ASHA at village level (with drug kit) : 2005-08
 Upgrading of rural hospitals : 2005-07
 Operationalizing district planning : 2005-07
 Mobile medical unit at district level : 2005 -08

GOALS TO BE ACHIEVED BY NRHM
NATIONAL LEVEL
• Infant mortality rate reduced to 30/1000live births
• Maternal mortality ratio reduced to 100/100000
• Total fertility rate reduced to 2.1
• Malaria mortality rate reduction -50% by 2010,
additional 10% by 2012
• Kala-azar mortality rate reduction – 100% by 2010 and
sustaining elimination until 2012
• Filaria / microfilaria rate reduction – 70% by 2010, 80%
by 2012 and elimination by 2015

• Dengue mortality rate reduction – 50% by 2010 and
sustaining at that level until 2012
• Japanese encephalitis mortality rate reduction – 50% by
2010 and sustaining at that level until 2012
• Cataract operation : increasing to 46 lakhs per year by 2012
• Leprosy prevalence rate : reduce from 1.8/10000 in 2005
to less than 1/10000 thereafter
• Tuberculosis DOTS services : maintain 85% cure rate
through entire mission period
• Upgrading community health centres to Indian Public
Health Standards
• Increase utilization of first referral units from less than 20%
to 75%
• Engaging 250000 female Accredited Social Health Activist
(ASHAs) in 10 states.

COMMUNITY LEVEL
• Availability of trained community level worker at
village level, with a drug kit for general ailments
• Health day at anganwadi level on a fixed day/ month
for provision of immunization, ante/postnatal 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.
• Good hospital care through assured availability of
doctors, drugs and quality services at PHC/CHC level

• Improved access to universal immunization through
induction to auto disabled syringes, alternate vaccine
delivery and improved mobilization services under the
programme.
• Improved facilities for institutional delivery through
provision of referral, transport, escort and improved
hospital care subsidized under the Janani Suraksha
Yojana for the below poverty line families
• Availability of assured health care at reduced financial
risk through pilots of community health insurance
under the mission.
• Provision of household toilets
• Improved outreach services through mobile medical
unit at district level.

MAINSTREAMING AYUSH
• The Mission seeks to revitalize local health traditions and
mainstream AYUSH infrastructure, including manpower, and drugs,
to strengthen the public health system at all levels.
• AYUSH medications shall be included in the Drug Kit provided at
Village levels to ASHA.
• The additional supply of generic drugs for common ailments at Sub
Centre/PHC/CHC levels under the Mission shall also include AYUSH
formulations.
• At the CHC level, two rooms shall be provided for AYUSH
practitioner and pharmacist under the Indian Public Health System
(IPHS) model.
• Single doctor PHCs shall be upgraded to two doctor PHCs by
mainstreaming AYUSH practitioner at that level.

ASHA – Accredited Social Health
Activist
• ASHA must be primarily a woman resident of the
village ‘Married/ Widow/ Divorced” and
preferably in the age group of 25 to 45 yrs.
• ASHA should have effective communication skills,
leadership qualities and be able to reach out to
the community.
• She should be a woman with formal education
up to Eighth Class.
• Adequate representation from disadvantaged
population groups should be ensured to serve
such groups better.

Compensation to ASHA
• ASHA is a honorary volunteer and would not
receive any salary or honorarium.
• she could be compensated for her time in the
form of TA and DA.
• She can also be given awards, non- monetary
incentives etc. Drug kit is given free.

No. of ASHA selected
during (including in tribal
areas in Non-High Focus
States)
2005-06 130315
2006-07 30068
2007-08 17168
2008-09 105150
2009-10 102070
2010-11 0
Total 809637
No. of ASHA who have
received training
1st
module 763560
2nd
module 632022
3rd
module 625879
4th
module 61319
5th
module 254608
No. of ASHA in position
with drug kits
553061
Total No. of Monthly
Village Health & Nutrition
Days held in the state.
2006-07 3505902
2007-08 4962883
2008-09 5819410
2009-10 5620331
2010-11 844645
Total 20753171

MONITORING AND EVALUATION
Process indicators :
(a) Numbers of ASHA seleted by due process
(b) Number of ASHA trained
(c) % of ASHA attending review meeting after one
year.
Outcome indicators :
(a) % of newborn who were weighed and families
counselled
(b) % of children with diarrhoea who received ORS
(c) % of institutional deliveries

(d) % of JSY claims made to ASHA
(e) % completely immunized in 12-23 months age group
(f) % of unmet need for spacing contraception among BPL
(g) % of fever cases who received chloroquine within first
week in an malaria endemic area;
Impact indicators :
(a) IMR
(b) child malnutrition
(c) number of case of TB/ leprosy cases detected as
compared to previous year.

ROLE AND RESPONSIBILITY OF ASHA
• ASHA will be the health activist in the community
who will create awareness on health
• She will take steps to create awareness and
provide information to the community
• She will counsel women on birth preparedness,
importance of safe delivery, breast feeding and
complementary feeding, immunization,
contraception and prevention of common
infections including reproductive tract infection /
sexually transmitted infection and care of the
young child.

• She will mobilize the community and facilitate them in
accessing health and health related services available
at the anganwadi / sub centre / primary health centres
• She will work with the village health and sanitation
committee of the gram Panchayat to develop a
comprehensive village health plan
• She will arrange escort/ accompany pregnant women
and children requiring treatment/ admission to the
nearest pre-identified health facility i.e., primary health
centre / community health centre/ first referral unit.

• She will provide primary medical care for minor
ailments such as diarrhoea, fevers, and first aid
for minor injuries.
• She will be a provider of directly observed
treatment short – course (DOTS) under revised
national tuberculosis control programme.
• She will also act as a depot holder for essential
provisions being made available to every
habitation.
• A drug kit will be provided to each ASHA.

• Her role as a provider can be enhanced
subsequently.
• She will inform about the births and deaths in
her village and any unusual health
problems/disease outbreaks in the community
to the Sub-centres/ Primary Health Centre.
• She will promote construction of household
toilets under Total Sanitation Campaign.

Role and integration with anganwadi
• Organizing Health Day once/twice a month.
• On health day, the women, adolescent girls
and children from the village will be mobilized
for orientation on health related issues
• AWW to participate and guide organizing the
Health Days at Anganwadi Centre (AWC).
• AWW and ANMs will act as resource persons
for the training of ASHA.

• IEC activity through display of posters, folk dances
etc.
• 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
• She will hold weekly / fortnightly meeting with ASHA
and discuss the activities undertaken during the week/
fortnight.
• She will guide her in case ASHA had encountered any
problem during the performance of her activity.
• AWWs and ANMs will act as resource persons for the
training of ASHA
• ANMs will inform ASHA regarding date and time of the
outreach session and will also guide her for bringing
the beneficiary to the outreach session.
• ANM will participate and guide in organizing the health
days at anganwadi centres
• She will take help of ASHA in updating eligible couple
register of the village concerned.

• She will utilize ASHA in motivating the pregnant
women for coming to sub centre for initial check-ups.
• She will also help ANMs in bringing married couples to
sub centres for adopting family planning.
• ANM will guide ASHA in motivating pregnant women
for taking full course of Iron and folic acid tablets and
tetanus toxoid injections etc.
• ANMs will orient ASHA on the dose schedule and side
effects of oral pills
• ANMs will educate ASHA on danger signs of pregnancy
and labour so that she can timely identify and help
beneficiary in getting further treatment.
• ANMs will inform ASHA on date, time and place for
initial and periodic training schedule.
• She will also ensure that during the training ASHA gets
the compensation for performance and also TA/DA for
attending the training

• Rogi Kalyan Samitis (patient welfare committee
/ hospital management society)
• The united grants to sub centres (SCs)
• The village health sanitation and nutrition
committee (VHSNC)
• Janani Suraksha Yojana (JSY)
• Janani Shishu Suraksha Karyakram (JSSK)
• National mobile medical units (NMMUs)
• National ambulance services
• Web enabled mother and child tracking system
(MCTS)

NEW INITIATTIVES
• Home delivery of contraceptives (condoms, oral
contraceptive pills, emergency contraceptive pills) by ASHA
• Conducting district level household survey (DLHS) -4 in 26
states /UTs where the annual health survey (AHS) is not
being done.
• Modifications in the scheme for promotion of menstrual
hygiene covering 152 districts and nearly 1.5 crores of
adolescent girls in 20 states
• allocation of united funds and Rogi Kalyan Samiti grants will
be made based on the case load and services provided by
the health facility.
• Involving ASHA in home based new-born care

• Revision in the criterion of allocation of funds to
the states under NRHM
• Expansion of village health and sanitation
committees to include nutrition in its mandate
and renaming it as village health, sanitation and
nutrition committee (VHSNC)
• Centrally sponsored scheme for development of
AYUSH hospitals and dispensaries for
mainstreaming of AYUSH under NRHM.
• Rashtriya Bal Swasthya Karyakram (RBSK)

• Rastriya Kishor Swasthya Karyakram (RKSK):
this is a new initiative, launched in January
2014 to reach out to 253 million adolescents
in the country in their own spaces and
introduces peer- led interventions at the
community level, supported by augmentation
of facility based services.
• Mother and child health wings (MCH wings
• Free drugs and free diagnostic services

• National iron + initiative is new initiative launched in 2013,
to prevent and control iron deficiency anaemia, a grave
public health challenge in India. Besides pregnant women
and lactating mothers, it aims to provide IFA
supplementation for children, adolescents and women in
reproductive age group.
• Weekly iron and folic acid supplementation (WIFS) for
adolescents is an important strategy under this initiative.
WIFS (for 10-19 years age) has already been rolled out in 32
states and UTs under the National Iron Plus Initiative. WIFS
covered around 3 crore beneficiaries in December 2013.
• Reproductive, maternal, new-born, child and adolescent
health services (RMNCH +A)

• Delivery Points (DPs): with the objective of
providing comprehensive reproductive,
maternal, new-born, child and adolescent
health services (RMNCH+A) at these facilities.
• Universal Health Coverage (UHC): moving
towards Universal Health Coverage (UHC) is a
key goal of the 12 the five year plan

SPECIAL INITIATIVES
• GERIATRIC CARE PROJECT
• COMMUNITY BASED MENTAL HEALTH PROJECT
• POLY CLINIC SERVICES
• RADIO HEALTH
• TELE MEDICINE
• MOBILE DISPENSARY
• PALLIATIVE CARE PROJECT
• MCTS

ACHIEVEMENTS
• 8.35 lakh ASHAs have been selected in the entire
country of which 8.07 lakh ASHAs have been trained.
7.41 lakh ASHAs have been provided with drug kits
• 1.47 lakh sub centres in the country are provided with
united funds of Rs 10000 each. 40426 sub centres are
functional with second ANM
• 31109 Rogi Kalyan Samitis have been registered at
different level of facilities
• 8630 doctors and specialists, 66786 ANMs, 328604
staff nurses, 14434 paramedics have been appointed
on contract to fill in critical gaps in services

• 1691 professionals (CA/MBA/MCA) have been
appointed to support NRHM
• 1842 mobile medical units are operational under
NRHM in states
• Emergency transport system operational in 12 states
• Accelerated immunization programme
• Janani suraksha yojana is operational in all the states.
1.13 crore women were benefited in the year 2011-12
• Integrated management of neonatal and childhood
illness (IMNCI) started in 310 districts

• Monthly health and nutrition days being
organized at the village level in various states
• The states have constituted 4.96 lakh village
health sanitation and nutrition committees
• School health programme have been initiated
in over 26 states

NATIONAL URBAN HEALTH MISSION
• The NUHM will focus on:
• Urban poor population living in listed and
unlisted slums
• All other vulnerable population such as homeless,
ragpickers, street children, rickshaw pullers,
construction and brick and lime –kiln workers, sex
workers, and other temporary migrants.
• Public health thrust on sanitation, clean drinking
water, vector control
• Strengthening public health capacity of urban
local bodies

Why NUHM?
• Urban population is estimated to increase from
35.7 crores in 2011 to 43.2 crores in 2021
• Rapid increase in the urban population can lead
to increase in the number of slums
• Slum population is growing at the rate of 7%
annually
• Poor health status of the urban slums
• Inadequacy of the health care delivery to the
slum population

• Slum people are at greater health hazards due
to
– Overcrowding
– Poor living conditions
– Poor sanitary conditions
– Lack of safe water supply
– Environmental pollution
– Outbreak of communicable diseases
– Increased incidence of STIs, RTIs, HIV/AIDS

Goal of NUHM
• It is to improve the health status of the poor by:
• By facilitating equitable access to quality health
care
• Revising public health system
• Building public private partnership
• Community based risk pooling and insurance
mechanism
• Active involvement of the urban local bodies

Strategies of NUHM
• Improving the efficiency of public health system in the
cities.
• MAS (Mahila Arogya Samitis) and USHA (Urban Social
Health Activists) and Rogi kalian samitis (RKSs).
• Information Technology Enabled Services (ITES) and e-
governance by improved surveillance and monitoring.
• Enhanced role of urban local bodies and capacity
building of stakeholders.
• Prioritizing the most vulnerable amongst the poor.

• Ensuring quality health care services through
development of IPHS.
• Strengthening urban primary health structure
– By creating new UHC, each covering a slum population of
20000 to 30000
– Provision of evening OPD
– Provision of comprehensive healthcare
– Provision of need based equipment, drugs, and human
resources
– Provision of Rogi Kalyan Samiti
– Provision of outreach health sessions in the slums
• Strengthening community participation, improving
health awareness and capacity building through
partnership with non-government providers

• Establishment of mahila Arogya Samiti
• Appointment of ASHA
• Capacity building of stakeholders
• Prioritizing the most vulnerable amongst the
poor like destitute, beggars, street children,
construction workers, coolies, rickshaw pullers,
sex workers, street vendors and such others.
• Ensuring quality health care services by defining
Indian Public health standards

Targets under National Urban Health
Mission
• IMR -30/1000 live births by 2012
• MMR – 1/1000 live births by 2012
• TFR – 2.1 by 2012
• Malaria – 50% reduction in mortality by 2015
• Kala azar – 100% reduction in mortality by
2010 ans sustaining elimination by 2015

• Fliariasis - > 80% coverage of population by mass
drug administration (MDA) with diethyl
carbamazepine (DEC), 70% reduction by 2010,
80% by 2012 and elimination by 2015
• Dengue fever – 50% reduction in mortality by
2010 and sustaining at that level
• Chikunguniya – control of outbreaks and
morbidity
• Tuberculosis – 85% cure rate through DOTS
• Leprosy – reduction in prevalence rate to less
than 1 per 1000 popualtion

Coverage and duration of National
Urban Health Mission
• Duration : period of 11th five year plan (2008-
2012)
• Coverage : entire urban poor population of
430 cities
• Phase I : all cities with population of more
than 1 lakh
• Phase II: all towns with population of less than
1 lakh

Definition of slum
• Any compact habitation of at least 300 people or
about 60 to 70 households of poorly built,
congested tenements, in unhygienic
environments, usually without adequate
infrastructure and lacking in proper sanitary and
drinking water facilities in these towns
irrespective of the fact as to whether such slums
have been notified or not as ‘Slum’ by state/ local
government and union territory administration
under any act, recognized or not, are legal or not,
is be covered under NUHM

USHA (urban social health activist)
• She is a resident woman of the same slum,
studied at least up to 8th standard, preferably
in the age group of 25-45years, married /
widowed/ divorced, chosen by urban local
body counsellors

Functions of USHA
• 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 folder for essential
provisions like ORS packets, IFA tablets,
Chloroquine tablets, oral pills, condoms etc.

• To support ANM/MAS in conducting monthly
outreach session regularly
• To form and promote MAS
• 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

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

Essential services rendered by ASHA
• Active promoter of good health practices and enjoying
community support
• Facilitate awareness on essential RCH services, sexuality,
gender equality, age at marriage/pregnancy; motivation on
contraception, adoption, medical termination of pregnancy,
sterilization, spacing methods, early registration of
pregnancies. Pregnancy care, clean and safe delivery,
nutritional care during pregnancy, identification of danger
signs during pregnancy, counselling on immunization, ANC,
PNC etc., act as a depot holder for essential provisions like
oral rehydration therapy (ORS), iron folic acid tablets (IFA),
chloroquine, oral pills and condoms etc., identification of
target beneficiaries and support the ANM in conducting
regular monthly outreach sessions and tracking service
coverage.

• Facilitate access to health related services available at the
Anganwadi / primary health centres / urban local body
(ULBs) and other services being provided by the ULB
/state/central government.
• Formation and promotion of Mahila Arogya Samiti sin her
community
• Arrange escort/ accompany pregnant women and children
requiring treatment to the nearest urban primary health
care, secondary/ tertiary level health care facility
• Reinforcement of community action for immunization,
prevention of water borne and other communicable
diseases like TB(DOTS), malaria, chikunguniya, and
Japanese encephalitis.

• Carrying out preventive and promotive health
activities with AWW/ Mahila Arogya Samiti.
• Maintenance of necessary information and
records about births and deaths,
immunization, antenatal services in her
assigned locality as also about any unusual
health problem or disease outbreak in the
slum, and share it with the ANM in charge of
the area.

Urban primary health centre
• Functional for a population of around
approximately 50000 to 60000, the UPHC may
be located preferably within a slum or near a
slum within half a kilometre radius, catering to
a slum population of approximately 25000-
30000 with provision for OPD

Staffing pattern
UPHC
• For every 50000 population
• MO I/C – 1
• 2nd MO (part time) -1
• Nurse - 3
• LHV -1
• Pharmacist -1
• ANMs -3-5
• Public health manager/ mobilization officer – 1
• Support staff - 3
• M & E unit 1 -1

• One ANM for every 10000 population,
outreach services in area of every ANM on
weekly basis
• For every 200-500 HHs (1000 -2500
population) – community health volunteer
(ASHA /LW)
• Mahila Arogya Samiti for every 50-100 HHs
(250-500 population)

• Urban Community Health Centre UCHC may
be set up as a satellite hospital for every 4-5
UPHCS.
• The UCHC would cater to a population of 2,
50000. It would provide in patient services
and would be a 30-50 bedded facility.

Referral linkages
• Existing hospitals, including ULB maternity
homes, state government hospitals and medical
colleges, apart from private hospitals will be
empanelled / 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.

Functions of UPHC
• Medical care – OPD services 4 hours in the
morning and 2 hours in the evening
• RCH II services
• National health programmes
• Collection and reporting of vital events
• IDSP
• Referral services
• Basic laboratory services
• Counselling services

Services provided under NUHM
• Community / outreach services
• Services at UPHC
• Services at UCHC

Main services
• Maternal health
– Registration, ANC, identification of danger signs, referral for
institutional delivery, follow up counselling and behaviour
promotion
– ANC, PNC, initial management of complicated delivery cases and
referral, management of regular maternal health conditions,
referral of complicated cases
– Delivery, management of complicated gynae/ maternal health
conditions, hospitalization and surgical interventions including
blood transfusion.
• Family welfare
– Counselling, distribution of OCP/CC, referral for sterilization,
follow up of contraceptive related complications
– IUD insertion, management of contraceptive related
complications
– Sterilization operations, fertility treatment

• Family welfare
– Counselling, distribution of OCP/CC, referral for
sterilization, follow up of contraceptive related
complications
– IUD insertion, management of contraceptive related
complications
– Sterilization operations, fertility treatment
• child health and nutrition
– immunization, identification of danger signs, referral,
follow –up, distribution of ORS, paediatric cotrimoxazole,
post natal visits, counselling for new born care
– diagnosis and treatment of childhood illness, referral of
acute/chronic cases, identification and referral of neonatal
sickness
– management of complicated paediatric / neo-natal cases,
hospitalization, surgical intervention, blood transfusion

• RTI/STI including HIV/ AIDS
– Referral, community level follow up for ensuring
adherence to treatment regime of cases undergoing
treatment.
– Symptomatic diagnosis and primary treatment and referral
of complicated cases
– Management of complicated cases, hospitalization
• Nutrition deficiency disorders
– Height/weight measurement, Hb testing, distribution of
IFA tablets, promotion of localized salt, nutrition
supplements to children and pregnant/ lactating women,
promotion of breast feeding
– Symptomatic diagnosis and primary treatment and referral
of complicated cases
– Management of acute deficiency diseases, hospitalization,
treatment, rehabilitation of severe under nutrition

• Vector borne diseases
– Slide collection, testing using RDKs, DDT, counselling
for practices for vector control and protection
– Diagnosis and treatment, referral of terminally ill
cases
– Management of terminally ill cases, hospitalization
• Mental health
– Initial screening and referral
– Psychiatric, neurological services
• Oral health
– Diagnosis and referral
– Management of complicated cases
• Hearing impairment / deafness

• Chest infections (TB/Asthma)
– Symptomatic search and referral, ensuring adherence to
DOTS, other treatment
– Diagnosis, treatment, referral of complicated cases
• Cardiovascular diseases
– BP measurement, symptomatic search and referral, follow
up of under treatment patients
• Diabetes
– Blood / urine sugar test (using disposable kit) symptomatic
search and referral
• Management of complicated cases

• Cancer
– Symptomatic search and referral, follow up of under treatment
patients
– Identification and referral, follow up of under treatment
patients
– Diagnosis, treatment and hospitalization
• Trauma care (burns and injuries)
– First aid and referral
– First aid/ emergency resuscitation, documentation for medico-
legal case and referral
– Case management and hospitalization, physiotherapy and
rehabiltiation
• Other surgical interventions
– Identification and referral
– Hospitalization and surgical intervnetion
• Other support services like IEC, BCC, counselling and
personal and social hygiene.

Monitoring and evaluation
City level indicators (process and input indicators of NUHM)
Community process
• Number of mahila Arogya Samiti (MAS) formed
• Number of MAS members trained
• Number of ASHA selected and trained
Health systems
• Number of ANMs recruited
• Number of special outreach health camps organized in slum / HFas
• Number of UHNDs organized in the slums aand vulnerable areas
• Number of UPHCs made operational
• Number of UCHCs made operational
• Number of RKS created at UPHC and UCHC
• OPD attendance in UPHCs
• Number of deliveries conducted in public health facilities

RCH services
• ANC early registration in first trimester
• Number of women who had ANC check-up in their first trimester of
pregnancy
• TT (2nd dose ) coverage among pregnant women
• Number of children fully immunized
• Number of severely acute malnourished children identified and
referred for treatment
Communicable diseases
• Number of malaria cases detected through blood examination
• Number of TB cases identified through chest symptomatic
• Number of suspected Tb cases referred for sputum examination
• Number of MDR-TB cases put under DOTS plus
• Non-communicable diseases
• Number of diabetes cases screened in the city
• Number of cancer cases screened in the city
• Number of hypertension case screened in the city

Impact level targets of NUHM
• Reduce IMR by 40% (in urban areas) – National Urban
IMR down to 20 per 1000 live births by 2017
– 40% reduction in MMR and IMR
– Achieve universal immunization in all urban areas
• Reduce MMR by 50%
– 50% reduction in MMR
– 100% of ANC coverage
• Achieve universal access to reproductive health
including 100% institutional delivery
• Achieve replacement level fertility
• Achieve all targets of disease control programmes

Monitoring and evaluation
• State/ district/ city urban health mission will
regularly monitor the progress and provide
feedback.
• Monitoring will be done in three stages:
• Community based monitoring
• Health management information system
(HMIS) for reporting and feedback
• External evaluations

NATIONAL HEALTH MISSION
• The National health mission was approved in
May 2013. The main programmatic
components include health system
strengthening in rural and urban areas,
reproductive – maternal – new-born – child
and adolescent health (RMNCH+A) and
control of communicable and non-
communicable diseases.

• 1992 : child survival and safe motherhood
programme (CSSM)
• 1997 : RCH I
• 1997 : RCH II
• 2005 : national rural health mission (NRHM)
• 2013 : RMNCH +A strategy
• 2014 : India new-born action plan (INAP)

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 inter-sectoral convergent action
to address the wider social determinants of
health”.

Core Values
• Safeguard the health of the poor, vulnerable and
disadvantaged.
• Strengthen public health systems.
• Build environment of trust between people and
providers of health services
• Empower community to become active participants in
the process of attainment of highest possible levels of
health.
• Institutionalize transparency and accountability in all
processes and mechanisms.
• Improve efficiency to optimize use of available
resources.

Guiding Principles
• Build an integrated network of all primary,
secondary and a substantial part of tertiary
care, providing a continuum from community
level to the district hospital, with robust
referral linkages to tertiary care and a
particular focus on strengthening the Primary
Health Care System including outreach
services in both rural areas and urban slums.
• Ensure coordinated inter-sectoral action

• Ensure prioritization of services that address the health
of women and children and the prevention and control
of communicable and non-communicable diseases,
including locally endemic diseases.
• Ensure increased access and utilization of quality
health services to minimize disparity on account of
gender, poverty, caste, other forms of social exclusion
and geographical barriers.
• Incentivize good performance of both facilities and
providers.
• Address shortages of skilled workers in remote, rural
areas, and other under-served pockets through
appropriate monetary and non-monetary incentives.

• Promote partnerships with private, for profit, and not
for profit agencies including civil society organizations
to achieve health outcomes.
• Facilitate knowledge networks and create effective
public health institutions.
• Encourage and enable the involvement of Panchayati
Raj Institutions (PRIs) /Urban Local Bodies
• (ULBs) representatives in the governance and oversight
of health services
• Mainstream AYUSH, so as to enhance choice of
services for users and to learn from and revitalize local
health care traditions.
• Expand focus beyond maternal and child survival to
ensuring quality of life for women, children and
adolescents.

Goals, Outcomes and Strategies
• Reduce MMR to 1/1000 live births
• Reduce IMR to 25/1000 live births
• Reduce TFR to 2.1
• Prevention and reduction of anaemia in
women aged 15–49 years
• Prevent and reduce mortality & morbidity
from communicable, non- communicable;
injuries and emerging diseases

• Reduce household out-of-pocket expenditure on
total health care expenditure
• Reduce annual incidence and mortality from
Tuberculosis by half
• Reduce prevalence of Leprosy to <1/10000
population and incidence to zero in all districts
• Annual Malaria Incidence to be <1/1000
• Less than 1 per cent microfilaria prevalence in all
districts
• Kala-azar Elimination by 2015, <1 case per 10000
population in all blocks

• Goals of this phase of NHM will be towards
enabling and achieving the stated vision.
• Making the system responsive to the needs of
citizens, building a broad based inclusive
partnership for realizing National health goals,
focusing on the survival and well-being of
women and children, reducing existing disease
burden and ensuring financial protection for
households.

Strategies
• Support and supplement state efforts to
undertake sector wide health system
strengthening through the provision of financial
and technical assistance.
• Build state, district and city capacity for
decentralized outcome based planning and
implementation
• Enable integrated facility development planning
which would include infrastructure human
resources, drugs and supplies, quality assurance,
and effective Rogi Kalyan Samitis (RKS).

• Create a District Level Knowledge Centre within
each District Hospital
• Improve delivery of outreach services
• Strengthen the sub-centre/Urban Primary Health
Centre (UPHC) with additional human resources
and supplies
• Prioritize achievement of universal coverage for
Reproductive Maternal, Newborn, Child Health +
Adolescent (RMNCH+A), National Communicable
Disease Control and Non Communicable Diseases
programmes.

• Expand focus from child survival to child development
of all children 0-18 years through a mix of Community,
Anganwadi, and School based health services.
• Achieve the goals of safe motherhood
• Focus on adolescents and their health needs.
• Ensure the control of communicable disease
• Use primary health care delivery platforms to address
the rising burden of Non- Communicable Diseases
• Converge with Ministry of Women & Child
Development

• Empower the ASHA to serve as a facilitator, mobilizer
and provider of community level care.
• Strengthen people’s organizations such as the Village
Health Sanitation and Nutrition Committees (VHSNC)
and Mahila Arogya Samitis (MAS)
• Create mechanisms to strengthen Behaviour Change
Communication
• Develop effective partnerships with private sector
• Enhance use of Information & Communication
Technology
• Strengthen Health Management Information Systems

• Ensure universal registration of births and deaths
with adequate information on cause of death
• To ensure equitable health care and to bring
about sharper improvements in health outcomes
• The government has already taken steps towards
provision of free maternal, and child health
services, including newborn care, immunization,
adolescent health, and family planning.
• Free diagnostic and treatment services
• Focus on strengthening primary health care
across the country.

The Primary Care List of Assured
Services
Reproductive and Child Health
• Care in pregnancy- all care including identification of
complications, but excluding management of complications
requiring surgery or blood transfusion.
• All aspects of Essential New-born Care.
• Care for common illnesses of new-born and of children-
identify, stabilize and refer life threatening conditions
beyond the approved skill sets of the mid level care
provider.
• Immunization
• Universal use of iodized salt.
• All aspects of prevention and management of malnutrition,
excepting those that requiring institutional care.
• All family planning services except female sterilization

• Provision of safe abortion services - medical and surgical.
• Identification and management of anaemia, Common sexual and
urogenital problems which can be treated syndromically, or
diagnose with point of care diagnostics, and identification of those
which need referral.
• All health education and individual counselling measures needed
for promotion of desirable health behaviours and health care
practices and change from inappropriate health care practices and
behaviours, related to RCH.
• All activities under the Rashtriya Bal Suraksha Karyakram- at
Anganwadi and school level
• All laboratory support
• Patient transport systems that can bring and drop back patients for
example sick infants up to one year of age, institutional delivery, for
disability, and address problems of access due to lack of transport.

Emergency and Trauma Care
• Prevention and appropriate management for
bites and stings- snakes, scorpions, wild animals.
• Management of poisoning, including food
poisoning.
• Complete first aid including management of
minor injuries
• Stabilization care in poisoning and major injuries
and ensuring referral through emergency
response systems.

Control of Communicable Diseases
• Screening for leprosy, referral on suspicion, and follow up of cases
with confirmed diagnosis and prescribed treatment.
• Referral of suspect tuberculosis, family level screening of known
patients, and follow up of cases with confirmed diagnosis and
prescribed treatment.
• HIV testing, appropriate referral and follow up of specialist-initiated
treatment.
• All measures for the prevention of Vector Borne Diseases; early and
prompt treatment for these diseases, with referral of complicated
cases.
• Control of helminthiasis.
• Reduction in burden of waterborne disease
• Reduction of infectious hepatitis B and identification and referral for
the same.
• Primary care for other infectious diseases

Non-Communicable Diseases
• Screening for breast and cervical cancers in all women over the age
of 30.
• Screening for mental disorders, counselling, and follow up to
specialist initiated care.
• Detection of epilepsy and stroke and follow up to specialist initiated
drugs and rehabilitative measures.
• Screening for visual impairments, correction of refractive errors and
referrals for the rest.
• Screening for diabetes and hypertension in all population above 30
annually.
• Ensuring follow up on doctor initiated drugs in diabetes and
hypertension- and secondary prevention – so that no complications
develop.
• Prevention – primary, secondary and tertiary preventive care in
rheumatic heart disease.

• Primary and secondary prevention in COPD and bronchial
asthma, with provision of follow up care in patients put on
treatment by specialists.
• Counselling and support to victims of violence.
• Preventive measures against all harmful addictive
substances- tobacco in the main, but also alcohol and
addictive drugs
• Community based geriatric care support.
• Preventive and promotive measures to address musculo-
skeletal disorders- mainly osteoporosis, arthritis of different
types and referral or follow up as indicated.
• Community based rehabilitative and disability care support.

FINANCING OF THE NATIONAL
HEALTH MISSION
• NRHM/RCH Flexi-pool
• NUHM Flexi-pool
• Flexible pool for Communicable Disease
• Flexible pool for Non Communicable Disease
including injury and trauma
• Infrastructure Maintenance
• Family Welfare Central Sector Component.

MONITORING AND EVALUATION
• Use of data from large scale population surveys
• Commissioning implementation research or evaluation
studies
• use of HMIS data and field appraisals and reviews
• Health outcomes, output and process indicators
• Periodic Population Health Surveys and Demographic
Information
• The Sample Registration Surveys (SRS)
• Death statistics
• National Sample Survey Organization (NSSO) data on
cost of care and morbidity, DLHS and NFHS.

SERVICE DELIVERY STRATEGIES
• Reproductive, Maternal, Newborn, Child
Health and Adolescent (RMNCH+A) Services
• Maternal Health
– Comprehensive package of RMNCH+A services.
– Janani Suraksha Yojana (JSY)
– Janani Shishu Suraksha Karyakram (JSSK)
• Access to safe abortion services

• Prevention and Management of Reproductive
Tract Infections (RTI) and Sexually Transmitted
Infections (STI)
• Gender Based Violence
• New-born and Child Health
• Universal Immunization
• Health Screening and Early Intervention Services
• Adolescent Health
• Iron and Folic Acid (IFA) supplementation
• Facility -based adolescent health services

• Community based health promotion activities
• Information and counseling on sexual and
reproductive health (including menstrual
hygiene),
• Substance abuse
• Mental health
• Non-communicable diseases, injuries
• Adolescent Friendly Health Clinics (AFHC)
• Provision of Weekly Iron and Folic acid
Supplementation (WIFS)
• National Iron Plus Initiative.
• Family Planning
– Intra-Uterine Contraceptive Devices (IUCD).

Control of Communicable Diseases
• The National Vector Borne Diseases Control
Programme (NVBDCP) is an umbrella programme for
prevention and control of vector borne diseases viz.
Malaria, Japanese Encephalitis (JE), Dengue,
Chikungunya, Kala-Azar and Lymphatic Filariasis. Of
these, Kala-Azar and Lymphatic Filariasis have been
targeted for elimination by 2015.
• Revised National Tuberculosis Control Programme
(RNTCP)
• National Leprosy Control Programme (NLEP)
• Integrated Disease Surveillance Programme (IDSP)

Non Communicable Diseases (NCD)
• National Programme for Prevention and Control of Cancer,
Diabetes, Cardiovascular Diseases and Stroke (NPCDCS)
• National Programme for the Control of Blindness (NPCB)
• National Mental Health Programme (NMHP)
• National Programme for the Healthcare of the Elderly (NPHCE)
• National Programme for the Prevention and Control of
Deafness (NPPCD
• National Tobacco Control Programme (NTCP)
• National Oral Health Programme (NOHP)
• National Programme for Palliative Care (NPPC)
• National Programme for the Prevention and Management of
Burn Injuries (NPPMBI)
• National Programme for Prevention and Control of Fluorosis
(NPPCF)

RESEARCH EVIDENCES
• Study of Rogi Kalyan samitis in strengthening
health systems under national rural health
mission, district Pune, Maharashtra, Neha
Adsul, Manoj Kar

• The study was an attempt to define 'functional Health Systems'
with a focus on strategic issues concerning RKS operations.
• Materials and Methods: A mixed-method, multi-site, collective
case study approach was adopted. In-depth interviews of key-
stakeholders were conducted. Qualitative data were analyzed
thematically and coded inductively.
• Results: RKS is yet to bring out quality component to the health
services being provided through facilities. This can be attributed to
structural and managerial weakness in the system; however,
certainly NRHM has been consistent in creating a road-map for
benefitting local community and their participation through RKS.
• Conclusion: The progress of the RKS can further be enhanced by
giving due priority to critical areas. Furthermore, the results
emphasize an urgent need for devising strategies and actions to
overcome significant systemic constraints as highlighted in the
present study.

CONCLUSION
• The NHM envisages achievement of universal
access to equitable, affordable & quality
health care services that are accountable and
responsive to people's needs.

REFERENCES
• K.Park; Text Book of Preventive and Social Medicine;
Bhanot Banarsidas Publishers, 22nd Edition 2009
• Keshav Swarnkar, Community Health Nursing; 2nd Edition,
Nr Brothers Publications
• K.K Gulani ‘Community Health Nursing’ Kumar Publishers
1st Edition
• AH Suryakantha, Community Medicine With Recent
Advances, 2nd Edition, New Delhi: Jaypee Publishers, 2010
• www.keralahealht/gov.in
• www.who.in
• http://www.urban.health.resource.centre.in/module
• NRHMbulletin.vol7(4)july-aug2012

National health mission

Empfohlen

Empfohlen

Weitere ähnliche Inhalte

Was ist angesagt?

Was ist angesagt? (20)

Ähnlich wie National health mission

Ähnlich wie National health mission (20)

Kürzlich hochgeladen

Kürzlich hochgeladen (20)

National health mission