NATIONAL RURAL HEALTH MISSION (NRHM) AND NATIONAL URBAN HEALTH MISSION (NUHM)

NATIONAL RURAL HEALTH MISSION (NRHM)

Background and Launch

• 8 Empowered Action Group (EAG) states: Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Uttar Pradesh, Uttarakhand, Orissa, Rajasthan
• 8 North East states: Assam, Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim, Tripura
• Himachal Pradesh and Jammu & Kashmir

Aims

• RCH II
• National Vector Borne Disease Control Programmes (malaria, filaria, kala-azar, dengue/DHF, Japanese encephalitis)
• National Leprosy Eradication Programme
• Revised National Tuberculosis Control Programme
• National Programme for Control of Blindness
• Iodine Deficiency Disorder Control Programme
• Integrated Disease Surveillance Project

PLAN OF ACTION TO STRENGTHEN INFRASTRUCTURE

1. Creation of a cadre of ASHA (Accredited Social Health Activist)
2. Strengthening sub-centres by:
   • Supply of essential drugs (allopathic and AYUSH)
   • Provision of multipurpose workers / additional ANMs
   • Sanction of new sub-centres
3. Strengthening PHCs for 24×7 services
4. Strengthening CHCs to Indian Public Health Standards (IPHS)
5. Decentralized district and village level health planning
6. Prioritizing the unserved/underserved areas and the poor/vulnerable population groups
7. Mainstreaming AYUSH

NON-NEGOTIABLE GOALS (NTG) - NRHM

(All NTGs consolidated in one place as requested)

1. Every village to have a trained ASHA with a drug kit within 2 years (by 2007)
2. Every sub-centre to have two ANMs (one regular + one contractual) within 2 years (by 2007)
3. Every PHC to have 7 staff (1 doctor + 1 staff nurse + 1 pharmacist + 1 lab technician + 1 AN worker + 1 accountant + 1 peon/chowkidar) within 3 years (by 2008)
4. Every PHC to have essential drugs, diagnostics and equipment within 2 years (by 2007)
5. Every sub-centre to have essential drugs, diagnostics and equipment within 2 years (by 2007)
6. Every PHC to provide 24-hour services for deliveries (within 5 years, i.e., by 2010)
7. All existing PHCs and CHCs to be made functional as per IPHS within 5 years (by 2010)
8. All vacant positions of specialists at CHCs to be filled within 5 years (by 2010)
9. District hospitals to be strengthened to provide quality secondary care within 5 years (by 2010)
10. Panchayati Raj Institutions (PRIs) to manage VHSCs and lead the village health planning within 1 year (by 2006)

MAJOR INITIATIVES UNDER NRHM

• Must be a resident of the village
• Woman (married/widow/divorced), preferably aged 25-45 years
• Formal education up to 8th class
• Should have communication skills and leadership qualities
• Norm: 1 ASHA per 1000 population (relaxed to 1 per habitation in tribal, hilly, desert areas)

• Registered society; members act as trustees to manage hospital affairs
• Responsible for upkeep of facilities and provision of better patient care
• Financial assistance through untied funds
• As of March 2015: 32,005 RKS set up in DHs, SDHs, CHCs, and PHCs

• SCs are now equipped with BP measuring equipment, Hb measuring equipment, stethoscope, weighing machine, etc.
• Facilitates quality antenatal care and other health services

• Important tool of community empowerment and participation at grassroots level
• Reflects aspirations of local community, especially poor households and children
• By 2015: 5.01 lakh VHSNCs set up across the country
• Renamed to include Nutrition in mandate (earlier Village Health and Sanitation Committee)

• Aims to reduce maternal mortality by encouraging institutional delivery
• Cash assistance to eligible pregnant women delivering in government health facilities
• Since inception: 8.55 crore women benefited

• Launched on 1st June, 2011
• Entitlements for pregnant women and sick newborns in public health institutions
• Key focus: free transport (home to facility, inter-facility, drop back for mother and child)

• To provide healthcare services to people in remote and difficult areas
• As of 2015: 2,156 MMUs operational

• Free ambulance services via toll-free numbers 108 and 102
• Currently: 32 states/UTs have the facility
• Dial 108: Emergency response (critical care, trauma, accident victims)
• Dial 102: Basic patient transport, mainly for pregnant women and children (JSSK-linked)
• Operational: 8,680 Dial-108; 603 Dial-104; 8,718 Dial-102 emergency vehicles + 5,859 empaneled vehicles

• Name-based tracking of every pregnant woman, infant and child up to age 3 years
• Ensures timely ANC, institutional delivery, PNC, and immunization
• Can track severely anaemic women, low birth weight babies, sick neonates
• Future use: tracking health status of girl child and school health services
• Being linked with AADHAAR to track subsidies

NEW INITIATIVES (Major decisions of Mission Steering Group since 2011)

1. Home delivery of contraceptives (condoms, OCPs, emergency contraceptive pills) by ASHA
2. District Level Household Survey (DLHS)-4 in 26 States/UTs
3. Modifications in menstrual hygiene scheme - 152 districts, ~1.5 crore adolescent girls in 20 states
4. Differential financial approach for comprehensive health care (untied funds and RKS grants based on case load)
5. Involving ASHA in Home Based Newborn Care
6. Revision in fund allocation based on state performance
7. Expansion of VHSCs to include Nutrition - renamed VHSNC
8. Mainstreaming of AYUSH under NRHM
9. Rashtriya Bal Swasthya Karyakram (RBSK) - child health screening and early intervention
10. Health and Wellness Centres (HWCs) - expansion of primary care
11. Sub-Health Centre (SHC) as Health and Wellness Centre - to deliver comprehensive primary health care
12. Plans for Health and Wellness Centres:
    • Expand services beyond RCH and IDD to include Non-communicable diseases (NCDs), oral health, mental health, ENT, etc.
    • Each HWC to have mid-level health provider (Community Health Officer - CHO)
    • Goals: a. Expand primary health care to be more inclusive; b. Ensure universal access; c. Emphasize first contact care; d. Provide care in an integrated manner; e. Ensure continuity of care; f. Focus on promotion and prevention; g. Emphasize community participation and address equity; h. Develop human resource policy; i. Strengthen governance
13. Kilkari - Interactive Voice Response (IVR)-based mobile service:
    • Delivers audio messages about pregnancy and child health directly to families' mobile phones
    • Covers 4th month of pregnancy until child is 1 year old
    • One pre-recorded call per week (2 minutes); available in regional dialects
14. Nationwide anti-TB drug resistance survey - estimates MDR-TB burden; largest such survey in the world
15. Kala-azar elimination plan for UP, Bihar, West Bengal, Jharkhand - active search, new drug regimen, coordinated indoor residual spray, non-invasive diagnostic kit

NATIONAL URBAN HEALTH MISSION (NUHM)

Background

Coverage

• All state capitals
• District headquarters
• About 779 other cities/towns with population 50,000 and above (as per Census 2011), in a phased manner
• Cities and towns below 50,000 population will be covered by NRHM

Focus Areas

1. Urban poor population living in listed and unlisted slums
2. All other vulnerable populations: homeless, rag-pickers, street children, rickshaw pullers, construction and brick/lime-kiln workers, sex workers, and other temporary migrants
3. Public health thrust on sanitation, clean drinking water, vector control
4. Strengthening public health capacity of urban local bodies

Delivery System under NUHM

• Urban PHCs (U-PHCs) and Urban CHCs (U-CHCs) provide universal services
• Outreach services are targeted to slum dwellers and other vulnerable groups
• Outreach services delivered by Female Health Workers (FHWs) - essentially ANMs with induction training of 3-6 months
  • ANMs report at U-PHC and move to their respective areas for outreach services on designated days
  • On other days, conduct immunization and ANC clinics at U-PHC

Community Participation under NUHM

1. ASHA / Link Worker (LW):
   • One ASHA for 1000-2500 urban poor population (200-500 households)
   • States have flexibility to engage ASHA or transfer responsibilities to MAS
2. Mahila Arogya Samiti (MAS):
   • Community-based institution (50-100 households)
   • Annual grant of Rs. 5000/- per year from NUHM
   • States can transfer ASHA incentives to MAS
3. Rogi Kalyan Samiti (RKS) - hospital management committees

Essential Services of ASHA under NUHM

Service Delivery Levels under NUHM

Goals of NUHM

1. Reduce MMR to 60/1,00,000 live births
2. Achieve 100% ANC coverage in urban areas
3. Achieve universal access to reproductive health including 100% institutional delivery
4. Achieve replacement level fertility (TFR 2.1)
5. Achieve all targets of disease control programmes