1. NRHM Meeting People’s Health Needs
16th June 2008
National Institute of Public Cooperation & Child Development
ToT of AWTCs/MLTCs
National Rural Health Mission
Ministry of Health & Family Welfare
Government of India
Notes

2. India a snapshot Total Population : 1.1 billion
Rural Population : million
Number of Administrative units
States : 35
Districts : 609
Blocks : 6345
Villages : 638,588
HR as per World Health Report World Health Organization, Geneva.
India a snapshot
Physicians per 1,000 population
0.60
2005
No. of Nurses per 1,000 population
0.80
2004
No. of Midwives per 1,000 population
0.47
No. of Pharmacists per 1,000 population
0.56

3. National goals & MDG context
Current
10th FY Plan
NPP
2010
MDG
2015
Total Fertility Rate 3
(2003)
2.3
2.1 --
Infant Mortality Rate 57
(2007) 45
<30
<27
Neonatal Mort rate 37 26
<20
Maternal Mortality Rate
301
(2005)
200
<100
100
Institutional deliveries
40.5 %
80% -

4. India’s Health Indicators
Large inter state variations
State/UT
IMR
SRS 2007 
MMR
SRS 01-03
TFR
SRS 2005
Kerala 15
110
1.7
Tamil Nadu 37
134
All India 57
301 
2.9
Madhya Pradesh 74
379
3.6
Orissa 73
358
2.6
Uttar Pradesh 71
517
4.2
NOTES
A SLIDE OF THESE INDICATORS FOR ALL THE STATERS IS ALSO AVAILABLKE TO BE SHOWN ON REQUEST

5. Large inter state variations
Key Indicators
States with most to catch up
Best performing state in India
NPP
2010
MDG
2015
IMR
High Focus States 15
(Goa, Kerala)
<30 27
NMR
8.8
(Goa)
<20*
U5MR
16.3 - 41
MMR
110
(Kerala)
<100
Reference: IMR - SRS 2006
MMR -SRS

7. India’s child survival challenge
Birth rate 24.1 (2004)
27 million neonates to take care
U5MR 95 ( )
2.5 million die before completing 5 years
Globally India accounts for 23% of all U% deaths
IMR 57 (2007)
1.6 million die before completing 1 year
64% of infant deaths occur in the first 30 days.
More than 50% occur in first 3 days
NMR 40 (2002)
1.1 million die before 4 weeks of age

8. Health delivery apparatus
Public Sector facilities
Private Practitioners
ESI, CGHS, PSU Hospitals
Railways Hospitals
Armed Forces Medical Services
Corporate Hospitals
Indian System of medicine
Informal providers
Quacks/Crooks & magico religious practitioners

10. Sub-Centres (SCs)
Most peripheral contact point with primary health system
One ANM and one Male Health Worker
One Lady Health Worker (LHV) supervises six Sub-Centres.
Tasks relating to interpersonal communication wrt maternal and child health, family welfare, nutrition, immunization, diarrhea control and control of communicable diseases programmes.
Provided with basic drugs
100% Central assistance to all the Sub-Centres since April 2002
There are 1,45,272 Sub Centre as on March, 2007

11. Primary Health Centres (PHCs)
First contact point with Medical Officer.
Envisaged to provide an integrated curative and preventive care
Established and maintained by the State Governments under the Minimum Needs Programme (MNP)
Manned by a Medical Officer supported by 14 paramedical and other staff.
It acts as a referral unit for 6 Sub Centres.
It has beds for patients.
There are 22,370 PHCs as on March, 2007 in the country

12. Community Health Centres
Established and maintained by the State Government under MNP/BMS programme .
It is manned by four medical specialists i.e. Surgeon, Physician, Gynecologist and Pediatrician supported by 21 paramedical and other staff.
It has 30 in-door beds with one OT, X-ray, Labour Room and Laboratory facilities.
It serves as a referral centre for 4 PHCs and also provides facilities for obstetric care and specialist consultations.
As on March, 2007, there are 4045 CHCs functioning.

13. The Structure of the Public Health System
Health is a State Subject Family Welfare is Concurrent.
Primary Health care is Local self Government.
Most institutions and manpower are in state sector.
Most programmes are in the central sector
National Programmes address about 25% of all morbidities.
No dedicated health functionary at village level.
1st Doctor at PHC (30,000 population),1st Specialist at CHC (80,000 popu).

14. Deep rooted structural issues
Sustainable Systems
Financing 5.2 % of GDP ( Private 4.3 %, Public 0.9%)
Infrastructure (over 2,00,000 facilities yet inadequate)
Manpower Workforce Issues: Irrational distribution; Poor work culture; absenteeism; Poor supervision
Logistics
Management
Evaluation
Responsive & Equitable to citizens

15. National Rural Health Mission launched in April, 2005
Rejuvenate the Health delivery System
Universal Health Care
Access
Affordability
Equity
Quality
Reduce IMR, MMR,TFR
Improve Disease control

16. Goals of the Mission
Universal Health care, well functioning health system.
Reduce IMR to 30/1000 live births by 2012
Reduce MMR to 100/100,000 live births by 2012
TFR reduced to 2.1 by 2012
Reduce & sustain Malaria Mortality to 60% by 2012
Kala Azar eliminated by 2010, Filaria reduced by 80 % by 2010
Dengue Mortality reduced by 50% by 2012
TB DOTS maintain over 70 % case detection & 85% cure rate
46 lakh cataract operations annually by 2012.
Upgrading all health facilities to IPHS.
Increase utilization of FRUs from 20% bed occupancy to 75%
NOTES
Under NRHM support of Rs. 50 per day of hospitalization is given to Kala Azar cases through the Rogi Kalyan samitis.

17. The formative years of NRHM
Original approval for NRHM in January 2005
Country wide Launch by Prime Minister, 12 April 2005
was formative year during which
Strategies & Guidelines firmed up
Merger of Deptt of Health & family welfare
State & District Health Missions constituted
Specific Activities funded on Normative basis
Framework for Implementation approved July 2006
Highest institutions of NRHM empowered
Mission Steering Group
Empowered Programme Committee
Financial envelopes to states, NPCC
Monitoring systems & Management structures put in place.

18. The
Paradigm
Shift

19. The Paradigm Shift Community Participation Decentralised planning
Outputs and Outcome based
Pro-Poor Focus: Equitable systems
Quality of Care and the IPHS norms
Rights based service delivery
Pre stated entitlements at all levels
Inputs computed as function of the entitlements and estimated patient load
Judicious mix of dedicated budget lines - untied funds
Monitor quality
Community Participation
Health is a State Subject Family Welfare is Concurrent.
73rd Amendment 1992 PHC is with Local self Government.
Institutions & manpower in state sector.
Programmes in the central sector
National Programmes address about 25% of all morbidities.
NDCPs depend upon a functional health system.
1.86 health worker /1000 (.59 doctors, 0.8 nurses and 0.47 Midwives per 1000 population)
No (dedicated) health functionary at the village level.
First functionary at Sub Centre level (5000 population)
First doctor only at PHC (30,000 population)
Sustainable Systems
Financing 5.2 % of GDP ( Private 4.3 %, Public 0.9%) Inadequate funding – less capacity to utilise funds
Infrastructure (over 2,00,000 facilities yet inadequate) Very large number – inadequate upkeep
Manpower Workforce Issues: Irrational distribution; Poor work culture; absenteeism; Poor supervision
Logistics, Management Inadequate capacity, Rational O & Methods
Evaluatio (Unbiased, informed evaluation, meta evaluation)

20. The Paradigm Shift Governance reform
Bringing the public back into public health
At hamlet level : ASHA, VHSC, SHGs, Panchayats.
At the facility level: RKS
At the management level : health societies
Governance reform
Manpower, Logistics & Procurement processes.
Decision making processes
Institutional design, Accountability framework
Convergence
Water and sanitation
Nutrition
Education
Local Funds under NRHM
Annual Untied funds to VHSC
Rs. 10,000
Annual Untied Grant to SC
in joint account
PHC
through RKS
Rs, 25,000
CHC
Rs. 50,000
Annual Maintainence Grant
Rs, 1 lakh
Annual Corpus Grant RKS
Rs. 1 lakh
District Hospital
Rs. 5 lakh

21. Monitoring & Mentoring
Regular review meetings
State visits – evaluation teams, SFTs, RDs
Integrated MIS (web based)
External Surveys
Immunisation - UNICEF
ASHA & JSY – UNICEF, UNFPA, GTZ
Financial protocols- Institute of Public Auditors
Concurrent External Evaluations
Concurrent Financial Audit at District level by external CAs
Financial Audit of SHS/DHS by CAG CAs
Community monitoring – AGCA/PFI
ASHA Mentoring Group
JRM & Common Review Mission

22. Community empowerment under NRHM
Not (only) Community Monitoring but Empowerment
Part of over all health sector reform agenda
Embed Community ownership within reform processes
In programme design of all strategies (PPP, Insurance etc) process monitoring by the community needs to be built in.
More than grievance redress forum or adverse impact analysis
Covers planning, designing, implementation as well as ongoing concurrent oversight.
Does not have large budgetary footprint
Not all reforms have budgetary implications.

23. Contours of Community empowerment
Notes

24. OBJECTIVES Create forums for community ownership VHSC, RKS,DHM,SHM
Collect systematic info about community needs
provide feedback according to
locally developed yardsticks
key indicators.
Do with salary based systems what seems possible only with passion based systems.
Validate sector wide data from other sources
Triangulation

25. Tools of Community Monitoring
Village Level
Village Health Register - Records of ANM - Public dialogue
Village Health Calendar- Infant and maternal death audit
PHC level
Charter of Citizens Rights – IPHS - PHC Health Plan
Block level
IPHS - Charter of Citizens Rights - Block Health Plan
District level
Report from the PHC Health committees
Report of the District Mission committee
Public Dialogue (Jan Samvad)
State level
Reports of the District Health committees
Periodic assessment reports by taskforces / State level committees about the progress made in formulating policies according to IPHS, NHSRC recommendations etc.

26. Village Health Score Card Issues to be monitored MCH,JSY,ASHA,VHSC
Untied funding
Disease Surveillance
Curative care
etc
Scores
Good Performance
Cause for Concern
Poor Performance
Village
Health
Score Card
Methods
Village Group Meeting
Interviews with beneficiaries
Interviews with ASHAs
etc

27. Facility Score Card Issues to be monitored
Service availability, Quality
Equipment, Supplies, Personnel
Charges, Corruption
RKS Functioning
etc
Scores
Good Performance
Cause for Concern
Poor Performance
Facility
Score Card
Methods
Facility Observations
Meetings with Providers
Exit Interviews
etc

28. Community Monitoring Committees
Notes

29. Village Health & Sanitation Committee
Gram Panchayat members from the village
ASHA, Anganwadi Sevika, ANM
SHG leader, the PTA/MTA Secretary, village representative of any Community based organisation working in the village, user group representative
Chairperson would be the Panchayat member
Convenor would be ASHA / Anganwadi Sevika of the village.
Formed at level of revenue village
(more than one such village may come under single Gram Panchayat).

30. PHC Level Committee
30% members : representatives of Panchayati Raj Institutions
(Panchayat Samiti member from the area; two or more sarpanchs)
20% members - non-official representatives from VHSCs with annual rotation to enable representation from all the villages
20% members representatives from NGOs / CBOs in the area
30% members representatives of providers, MO, ANM
Chairperson be one of the Panchayat representatives,
Executive chairperson be Medical officer of PHC.
Secretary be one of the NGO / CBO representatives.

31. Block level Committee
30% members representatives of the Block Panchayat Samiti
(Adhyaksha / Adhyakshika of the Block Panchayat Samiti or members of the Block Panchayat samiti, with at least one woman)
20% members be non-official representatives from the PHC committees with annual rotation to enable representation from all PHCs over time
20% members be representatives from NGOs / CBOs
20% members be officials : BMO, BDO, selected MOs from PHCs etc
10% members should be representatives of the CHC level RKS
Chairperson be one of Block Panchayat Samiti reps.
Executive chairperson be the BMO.
Secretary would be one of the NGO/CBO reps.

32. District Level Committee
30% members be representatives of the Zilla Parishad
(esp. convenor and members of its Health committee)
25% members be district health officials, including DHO/ CMO/ Civil Surgeon and representatives from DPMUs
15% members be non-official representatives of block committees, with annual rotation
20% members be representatives from NGOs / CBOs
10% members be representatives of RKSs in the district
Chairperson be one of ZP reps
preferably convenor of the Zilla Parishad Health committee.
Executive chairperson be CMO / CMHO / DHO
Secretary be one of the NGO / CBO representatives.

33. State Level Committee
30% members be elected reps in legislative body (MLAs /MLCs) or Convenors of Health committees of ZPs by rotation
15% be non-official members of District committees, by rotation
20% members be representatives from State Health NGO coalitions
25% members would belong to State Health Department incl Secretary HFW, Commissioner Health, officials from Dt. of Health Services, NRHM Mission Director) along with experts from SHRC / SPMU
10% members be officials belonging to other related departments
Chairperson be one of the elected members (MLAs).
Executive chairperson would be the Secretary HFW.
Secretary be one of the NGO representatives.

34. Role of Monitoring Committees
Notes

35. Role Of VHSC Create Public Awareness about programmes.
Discuss and develop Village Health Plan.
Maintenance of a village health register.
Ensure that ANM and MPW visit village on fixed days.
Get bi-monthly health delivery report from service providers.
Discuss every maternal & neonatal death in village.
Convener (ASHA or AWW) will sign attendance registers of the AWWs, Mid-Day meal Sanchalak, MPWs, and ANMs.
MPWs and ANMs to submit a bi-monthly village report to the committee along with the plan for next two months.
Format and contents of the bi-monthly reports would be decided village health committee.
The committee will receive funds of Rs.10,000 per year. This fund may be used as per the discretion of the VHC.

36. Role of PHC Committee Consolidation of village health plans
Charting out the annual health action plan & a PHC Health Plan
Disseminate Charter of citizen’s health rights
Monitoring of physical resources at PHC
Coordinate with local CBOs and NGOs
Review functioning of Sub-centres operating under the PHC
Initiate action on instances of denial of right to health care.
Contribute to ACRs of MO/ other functionaries at the PHC.
Take collective decision about untied funds utilisation.

37. Role of Block level Committe
Consolidation of the PHC level plans and preparing block plan.
Review of progress difficulties at PHCs and CHC.
Analysis of neonatal & maternal deaths & other indicators.
Monitoring of the physical resources at the CHC
Coordinate with local CBOs and NGOs
Review functioning of Sub-centres and PHCs
Initiate action on instances of denial of right to health care.

38. Role of District level Committee
Monitor Health committees at lower levels, Financial reporting and solving blockages in flow of resources.
Monitoring of physical resources at all District Health facilities
Progress report of Health facilities esp referral utilisation.
Charting out Integrated District Health Aaction Plan
Ensuring proper functioning of the RKS.
Discussion on Health Policy of the state level – local relevance.
Initiate action on instances of denial of right to health care.

39. Role of State level Committee
Manage programmatic and policy issues.
Review and contribute to State Health Plan & NRHM PIP.
Issues arising from District Committees relating to state action.
Institute a Health rights redressal mechanism.
Assessing progress made in actualization of the Right to health care at the state level.
Proactive dissemination of GOI guidelines.

40. Village Health Report Card
S.No
Theme
Calculation
Score 1
Maternal Health Guarantee
Number of women * X = N
> 75 % of N
% of N
< 50 % of N 2
Janani Suraksha Yojana
Number of women * X = N 3
Child Health
Total Score - 20
0 - 9 4
Disease Surveillance
Total Score - 8
7 - 8
5 - 6
0 - 4

41. Village Health Report Card
S.No
Theme
Calculation
Score 5
Curative Services
Total Score - 8
7 - 8
5 - 6
0 - 4 6
United funds 7
Quality of Care
Total Score - 24
0 - 11 8
Community Perceptions of ASHA
Total Score - 16
8 - 12
0 - 7

42. Village Health Report Card
S.No
Theme
Calculation
Score 9
ASHA functioning
Total Score - 12
6 - 9
0 - 5 10
Equity Index
(Total score general community women)/ (Total score marginalized community women)
< Favorable to marginalized group
No difference
> Unfavorable to marginalized group 11
Adverse Outcome or experience reports
Total Score

43. Cumulative Report Card - Villages
Theme
Villages
Maternal Health Guarantee
Janani Suraksha Yojana
Child Health
Disease Surveillance
Curative Services
United funds
Quality of Care
Community Perceptions of
ASHA
ASHA Functioning
Equity Index
Adverse Outcomes

44. Infrastructure and Personnel Equipment and Supplies
Facility Score Card
S.No
Theme
Calculation
Score 1
Infrastructure and Personnel
N=Maximum Score
75% of N
50-74% of N
<50% of N 2
Equipment and Supplies 3
Service Availability

45. Facility Score Card S.No Theme Calculation Score 4 Unofficial charges
Add points of all the persons interviewed (max 25)
≥ 19
≤ 12 5
Quality of Care
Add points of all the persons interview (max 35)
>28
< 18 6
Functioning of Rogi Kalyan Samiti
Total Points scored
> 7
5 - 7
< 5

46. Cumulative Facility Score Card
Theme
Facility
Infrastructure and Personnel
Equipment and Supplies
Service Availability
Unofficial charges
Quality of Care
Functioning of Rogi Kalyan Samiti
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47. Community Monitoring Phase 1
Notes

48. Scale of Phase 1 Nine States 38 districts (3-5 districts per state)
114 blocks (three in each district )
342 PHCs (three in each block.
1710 villages (five revenue villages per PHC).

49. Features of Phase I Green field activity
Work of Capital nature : Institutions, Committees, Orientation material, formats, channels of reporting to be developed
Advisory Group of Community Action is the operational partner
AGCA through Population Foundation of India is vehicle for
Start up activities in the initiative.
Preparation for basic documentation
Handholding the finalisation of G Orders/Resolutions
Handholding the formation, orientation and operationalisation of committes
Phase 1 funding by MoHFW is to PFI.
Funds passed to State Nodal NGOs by PFI.
District & Block level funds disbursed by State nodal NGO.
Sustenance of CM will be through state PIP

50. Features of Phase I MOHFW has allocated funds to PFI for :
Support for preparation of orientation material,
Travel of mentoring group members to states
State preparatory meetings, workshops, orientation material, travel and meeting expenses.
District workshops, expenses for committee formation and orientation
Village, PHC and Block levels orientation sessions, travel
Travel support to mentoring team from AGCA

51. AP Rural Emergency Health Transport
Transport to pregnant women, infants, children & emergencies.
Toll-free No x24x7.
502 ambulances in 1107 mandals.
Average time for reaching hospital 16 min. in Urban & 22 min. in Rural areas.
Total emergencies attended per day is 2,806 (97% are Medical)
In two years, REHTS has saved 20,394 lives by attending to them in the crucial Golden hour

52. Andhra Pradesh Toopran PHC
Before Intervention
Andhra Pradesh
Toopran PHC
After Intervention

53. Assam- Institutional Deliveries (approximately 6
Assam- Institutional Deliveries (approximately 6.55 lakh total deliveries annually)

54. Gujarat Institutional deliveries

55. Gujarat
Infrastructure
Upgradation
under NRHM

56. Bihar – Increase in OPD Patients

57. Bihar- Institutional Deliveries
2006
2007

58. Garlagird village, Guna
Nutrition Rehabilitation Center Guna, Madhya Pradesh
NRCs making difference for Severely malnourished children in MP (Guna dist)
Prahlad August 2005,
Garlagird village, Guna
Prahlad March 2006

59. Institutional Deliveries – Madhya Pradesh (approximately 17
Institutional Deliveries – Madhya Pradesh (approximately 17.6 lakh total deliveries annually)

60. Notes

61. YEAR WISE DISTRIBUTION OF DELIVERIES (%)

62. Jammu & Kashmir – Institutional delivery
(approximately 1.9 lakh total deliveries annually) 62

66. THANK YOU web : mohfw. nic. in\nrhm
THANK YOU web : mohfw.nic.in\nrhm.htm
Notes