2. Milestones
1992 – Child Survival and Safe Motherhood
(CSSM)
1997- RCH I phase
2005 – RCH II phase
(2005-2012) - National Rural Health Mission
Feb 2013 – RMNCH+ A Strategy
May 2013 – National Health Mission
June 2014 – India Newborn Action Plan (INAP)
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4. NRHM
National Rural Health Mission (NRHM) was
launched at the National Level in April
2005 for a period of seven years (2005-
2012) .
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5. Plan of Action-Components
1)ASHA
2)Strengthening of Sub-Centers
3)Strengthening of PHCs
4)Strengthening of CHCs for First referral
5)District Health Plan
6)Converging Sanitation & Hygiene under NRHM
7)Strengthening Disease control program
8)Public-private partnership for public Health goals,
including regulation of private sector
9)New health financing mechanisms
10)Reorienting health/medical education to support rural
health issues
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6. Component A: ASHA
• Accredited social
health activists
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7. Component A: ASHA
Accredited social health activists
Every village will have a female ASHA
Chosen by and accountable to the panchayat
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8. 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.
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9. Training
Prototype training material for ASHA to
be developed at National level subject to
State level modifications.
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10. 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.
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11. Role of ASHA
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.
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12. Role of ASHA
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.
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13. Role of 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.
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14. Role of ASHA 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.
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15. Role of ASHA and integration with
Anganwadi
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.
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16. 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.
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17. Role and integration with ANM
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
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18. Role and integration with ANM
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
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23. STRENGTHENING
PRIMARY HEALTH CENTRES
Adequate and regular supply of essential
quality drugs and equipment to PHCs
Provision of 24 hour service in PHCs
Intensification of ongoing communicable
disease control programmes, new
programmes for control of non-
communicable diseases and provision of
2nd doctor at PHC level (1 male, 1
female)
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25. STRENGTHENING CHCs FOR
FIRST REFERRAL UNITS
Existing CHC (30-50 beds) as 24 Hour FRU,
including posting of anaesthetists
Codification of new Indian Public Health
Standards, setting norms for
Infrastructure
Staff
Equipment
Management
Promotion of Rogi Kalyan Samitis for
hospital management.
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26. Plan of Action-Components
1)ASHA
2)Strengthening of Sub-Centers
3)Strengthening of PHCs
4)Strengthening of CHCs for First referral
5)District Health Plan
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27. DISTRICT HEALTH PLAN
• District becomes core unit of
planning, budgeting and
implementation
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29. Plan of Action-Components
1)ASHA
2)Strengthening of Sub-Centers
3)Strengthening of PHCs
4)Strengthening of CHCs for First referral
5)District Health Plan
6)Converging Sanitation &
Hygiene under NRHM
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30. CONVERGING SANITATION AND
HYGIENE UNDER NRHM
Total Sanitation Campaign (TSC) in all
districts
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31. Sanitary toilet
ASHA would be incentivized for promoting
household toilets by the Mission.
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32. Plan of Action-Components
1)ASHA
2)Strengthening of Sub-Centers
3)Strengthening of PHCs
4)Strengthening of CHCs for First referral
5)District Health Plan
6)Converging Sanitation & Hygiene under NRHM
7)Strengthening Disease control
program
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34. Contd..
Disease surveillance system at village
level would be strengthened.
Supply of generic drugs (both AYUSH &
Allopathic).
Provision of a mobile medical unit at District
level for improved Outreach services.
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35. Plan of Action-Components
1)ASHA
2)Strengthening of Sub-Centers
3)Strengthening of PHCs
4)Strengthening of CHCs for First referral
5)District Health Plan
6)Converging Sanitation & Hygiene under
NRHM
7)Strengthening Disease control program
8)Public-private partnership for public
Health goals, including regulation of
private sector
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36. 9. NEW HEALTH FINANCING
MECHANISMS
Village - VHWSC- Rs.10,000 per year.
HSC - Untied funds – Rs.10,000 per year.
AMG – Rs.10,000 per year.
PHC - Untied funds – Rs.25,000 per year.
- AMG – Rs.50,000 per year
- PWS – Rs.1,00,000 per year
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37. FLEXIBLE FINANCING LE
FINANCING
CHC - Untied funds Rs.50,000 per year.
AMG – Rs.50,000 per year.
RKS (PWS) – Rs.1,00,000 per year.
Districts - DH&SDH – RKS – Rs.5,00,000 per year.
Medical College – Rs.10,00,000 per year.
Health Melas – Rs.8,00,000 per year. per
constituency
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38. Plan of Action-Components
1)ASHA
2)Strengthening of Sub-Centers
3)Strengthening of PHCs
4)Strengthening of CHCs for First referral
5)District Health Plan
6)Converging Sanitation & Hygiene under NRHM
7)Strengthening Disease control program
8)Public-private partnership for public Health goals,
including regulation of private sector
9)New health financing mechanisms
10)Reorienting health/medical education to support
rural health issues4/29/2018 38Chengalpattu Medical College
39. REORIENTING HEALTH/MEDICAL EDUCATION
TO SUPPORT RURAL HEALTH ISSUES
While district and tertiary
hospitals they form an integral 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.
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40. 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
PROGRAMME
MANAGEMENT
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
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41. NRHM ACHIEVEMENTS IN TAMIL NADU
EMRI
Emergency Referral Services (Toll free no 108) introduced in all the
districts.
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44. INFRASTRUCTURE UPGRADATION
• 148 First Referral Units and CEmONC centers provided with
essential equipments for maternal and child care including central
oxygen supply .
• 513 PHCs taken up for Infrastructure upgradation, extensions,
renovations and repair works in 2009-10 to cope up with
additional service demands.
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45. Facelift of PHC
Omandur PHC, Villupuram Dist.
Before After
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55. New Born Corner – Radiant warmer, other necessary
equipment and trained staff.
Thirupoondi PHC,
Nagappattinam Dist.
New Born Corner
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66. 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
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67. MONITORING AND EVALUATION
(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.
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69. 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
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70. Challenges of urban health care
Poor households not knowing where to go to meet
health need
Weak and dysfunctional public system of outreach
Contaminated water, poor sanitation
Poor environmental health, poor housing
Unregistered practitioners first point of contact – use of
irrational and unethical medical practice
Community organizations helpless in health matters
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71. Challenges of urban health care
Weak public health planning capacity in urban local
bodies
Large private sector but poor cannot access them
Problems of targeting the poor on the basis of BPL card
No convergence among wider determinants of health
No system of counselling and care for adolescents
No concerted campaigns for behaviour change
Problems of unauthorized settlements
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72. Challenges of urban health care
Over congested secondary and tertiary facilities and
underutilized primary care facilities.
Problem of drug abuse and alcoholism
Many slums not having primary health care facility
High incidence of domestic violence
Multiplicity of urban local bodies, State government, etc.
management of health needs of urban people
No norms for urban health facilities
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73. Access to health care
Inadequate public health care delivery system
Severely restricted health care access (for urban poor)
lack of standards for urban health delivery system
makes the urban poor more vulnerable
Poor environmental conditions – overcrowding, poor
housing, poor water and electricity availability result in
high incidence of communicable diseases, asthma etc.
Higher rates of traffic accidents, domestic violence,
mental health cases, drugs, tobacco and alcohol abuse
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74. National Urban Health Mission
The NUHM would focus on:
– Urban Poor living in listed and unlisted slums
– Vulnerable population such as homeless, rag-pickers,
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, etc.
– Strengthening public health capacity of urban local
bodies.
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76. Urban Health Care Facilities
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77. Urban Health Care Delivery
Health services delivered under the urban health
delivery system through the Urban-PHCs and Urban-
CHCs will be universal in nature
Outreach services will be targeted to specific groups
(slum dwellers and other vulnerable groups)
1 FHW (ANM) for 10,000 population; Outreach sessions
in area of every ANM on weekly basis
FHW to be stationed at PHC; Mobility support for
outreach activities
School Health Programmes
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78. Urban CHC
For 2,50,000 population (5,00,000 for metros)
Inpatient facility, 30 -50 bedded
(100 bedded in metros)
Only for cities with a population of above 5 lakhs
Renovation of existing referral facility or up-gradation of
facility shall essentially be the first choice
Support for local contractual arrangements for part time
Specialist/ Medical Officer.
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79. Urban Health Care Delivery
Promote role of urban local bodies in the planning and
management of urban health care
One USHA for 1000-2500 population
States to have flexibility of motivating Mahila Arogya
Samiti (MAS) for getting the work done
One MAS for 50-100 households
Annual grant of Rs. 5000 to the MAS
NGOs may also be given this responsibility
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80. Urban Health Care Delivery
IPHS/ Revised IPHS for Urban areas etc
Quality of the services provided will be constantly
monitored for improvement
Strengthen IDSP
Convergence with AYUSH practitioners
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81. Roles & responsibilities of ASHA
Identify target beneficiaries and support ANM in
conducting outreach sessions
Promote formation of Women’s Health Groups
Provide information to the community
Facilitate access to health and related services
Accompany pregnant women and children requiring
treatment/ admission
Facilitate development of a comprehensive health plan
Facilitate construction of community/ household toilets
Act as depot holder
Maintain necessary information and records.
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82. Women’s Health Committee
• Process of promotion of Women’s Health
Committee
Women’s Health
Committee
15 members
for about
250-350
families
encouraged
to work
collectively
on
community
issues
potential
community
leaders and
target
women
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83. Roles of the Mahila Arogya Samiti
Support ASHA in tracking and monitoring coverage of
key interventions
Facilitate group counseling sessions
Support outreach camps by ensuring presence of target
group
The conveners or other designated representatives of
the group along with the respective Link Volunteer will
attend meetings held at the UHC and provide feedback
on service delivery.
Collect, manage and utilize a Community Health Fund for
meeting health emergencies in the slum and for
sustaining health promotion efforts.
Maintain BCC and IEC materials at a safe and easily
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84. 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
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85. Services provided under NUHM
Community / outreach services
Services at UPHC
Services at UCHC
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86. 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
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87. Main services
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
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88. Main services
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.
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89. Essential Health Care Services under NUHM
Community Level Primary Health Care Level Referral Centre
(U-CHC)
Maternal Health • Registration
• Ante-natal Care
• Identification of danger signs
• Referral for institutional delivery
• Follow-up
• Counseling and Behavior
• Ante-natal and Post-natal
care
• Management of
complicated delivery
cases and referral
• Management of regular
maternal conditions
• Referral of complicated
cases
• Delivery (normal and
complicated)
• Management of
complicated
Gynae/maternal health
condition
• Hospitalization and surgical
interventions including
blood transfusion
Child Health and
Nutrition
• Immunization
• Identification of danger signs
• Referral services
• Follow-up
• Distribution of ORS
• Post-natal visits/counseling for
new-born care
• Diagnosis and treatment
of childhood illnesses
• Referral of acute
cases/chronic illness
• Identification and referral
of neo-natal sickness
• Management of
complicated
pediatric/neonatal cases
• Hospitalization
• Surgical interventions
• Blood transfusion
Nutrition
Deficiency
Disorders
• Height/weight measurement
• Distribution of IFA tablet
• Promotion of iodized salt
• Nutrition supplements to identified
children and pregnant/lactating
mothers
• Promotion of breastfeeding
• Complementary feeding prevention
of under-nutrition
• Diagnosis and referral of
acute deficiency cases
• Management of acute
deficiency cases
• Hospitalization
• Treatment and
rehabilitation of sever
under-nutrition
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90. 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
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91. 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.
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92. 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”.
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93. 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
SNCU(Special Newborn are Units),NBSU(Newborn stabilization
Units),NBCC(NewBorn Care Corners),FBNC(Facility Based
Newborn Care),IYCF(Infant and Young Child Feeding
practices),HBNC(Home Based Newborn Care)
NSSK(Navjaat Sishu Suraksha Karyakram)
NRCs(Nutritional Rehabilitation Centres)
IDCF (Intencified Diarrhoea Control Fortnight)
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94. SERVICE DELIVERY STRATEGIES
MCTS (Maternal and Child Tracking System)-PICME
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
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95. SERVICE DELIVERY STRATEGIES
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.
Universal use of iodized salt
Family Planning
Intra-Uterine Contraceptive Devices (IUCD).
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96. Control of Communicable Diseases
1. 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.
2. Revised National Tuberculosis Control Programme
(RNTCP)
3. National Leprosy Control Programme (NLEP)
4. Integrated Disease Surveillance Programme (IDSP)
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97. Non Communicable Diseases (NCD)
1. National Programme for Prevention and Control of Cancer,
Diabetes, Cardiovascular Diseases and Stroke (NPCDCS)
2. National Programme for the Control of Blindness (NPCB)
3. National Mental Health Programme (NMHP)
4. National Programme for the Healthcare of the Elderly (NPHCE)
5. National Programme for the Prevention and Control of Deafness
(NPPCD
6. National Tobacco Control Programme (NTCP)
7. National Oral Health Programme (NOHP)
8. National Programme for Palliative Care (NPPC)
9. National Programme for the Prevention and Management of
Burn Injuries (NPPMBI)
10. National Programme for Prevention and Control of Fluorosis
(NPPCF)
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98. 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.
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100. What does RMNCH+A stands for
1. Reproductive,
2. Maternal,
3. New-born,
4. Child health
5. Adolescent care
Plus denotes
• Inclusion of adolescence as a distinct ‘life
stage’ in the overall strategy
• Links maternal and child survival to other
components (family planning , adolescent
health, gender & PC & PNDT)
• Links home and community based services
to facility based care
• Ensuring linkages , referrals and counter
referrals between various levels of health
care system
Adolescent
Health Package
Reproductive
Health package
Antenatal &
Intrapartum care
package
Newborn care
package
Post partum
family
planning,spacin
g methods
Under five
child health
pacakge
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104. RKSK (Rashtriya Kishor
Swasthiya Karyakram) Jan 2014
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Beyond ARSH - focuses on
Life skills
Nutrition
Gender based injuries and violence
Non-communicable diseases
Mental health
Substance misuse
105. WIFS –Weekly Iron Folic acid
Supplementation
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106. WIFS - Advantages
Improved concentration in school, and school
performance
Feeling stronger and less tired,
Increased energy levels and output in day to day work,
Increased appetite,
Improved overall capacity to work and earn
Better sleep
Improved skin appearance,
Regularization of menstruation
Building pre-pregnancy health
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107. Key activities
Both boys and girls to be given IFA and Albendazole
Tablets
6th to 12th class students to be covered
Weekly Fixed day approach
Supervised consumption of weekly IFA tablet to be
ensured
IFA tablet to be given after meals ( Mid-Day Meal or
Lunch)
Screen students for pallor and refer
Bi-annual ( six months apart) distribution of Albendazole
tablets
HE sessions to be conducted regularly
Filling of Individual compliance cards
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113. PUDHU YUGAM SCHEME
The programme will be focused in rural areas with
the following objectives:
To increase awareness among adolescent girls on
menstrual hygiene,
build self-esteem, and
empower girls for greater socialisation
To increase access to and use of high quality
sanitary napkins by adolescent girls in rural areas
To ensure safe disposal of sanitary napkins in an
environment friendly manner
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.
117. CONCLUSION
The NHM envisages achievement of
universal access to equitable, affordable &
quality health care services that are
accountable and responsive to people's
needs.
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