Download - NRHM - NATIONAL RURAL HEALTH MISSION
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National Rural Health Mission
(2005-2012)
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Public Health: Background
Progress of the primary Health care system
84376
130165136258 137311
142655
9115
1867122149 22875 23109
0
20000
40000
60000
80000
100000
120000
140000
160000
Sixth plan (1981-85) Seventh plan (1985-90)
Eighth plan (1992-97) Ninth plan (1997-2002)
Tenth plan (upto Sept2004)
SubcentresPrimary Health centers
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Public Health: Background
(contd..)Progress of the primary Health care system
761
1910
26332900
3222
0500
1000
1500
2000
2500
3000
3500
Sixth plan
(1981-85)
Seventh
plan
(1985-90)
Eighth
plan
(1992-97)
Ninth plan
(1997-
2002)
Tenth plan
(upto Sept
2004)
CHCs
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Public Health: Background
(contd..)
Percentage of Health centers functioning inGovt buildings
50.84
84.17 86.75
0
10
20
30
40
50
60
70
80
90
P
ercentage
Sub centers PHCs CHCs
Sub centers
PHCs
CHCs
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Public Health: Background
(contd..)
Public health expenditure has declined from 1.3%of GDP in 1990 to 0.9% of GDP in 1999. The Union
Budgetary allocation for health is 1.3% while the
StatesBudgetary allocation is 5.5%.
1.30%
0.90%
3%
0.00%
1.00%
2.00%
3.00%
1990
1999
NRHM
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Public Health: Background
(contd..)
Union Government contribution in public healthexpenditure is 15% while States contribution is 85%
85%
15% NationalStates
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Public Health: Background
(contd..) Vertical Health and Family Welfare Programmes
have limited synergisation at operational levels.
Lack of community ownership of public health
programmes impacts levels of efficiency,
accountability and effectiveness. Integration of sanitation, hygiene, nutrition and
drinking water issues is needed in the overall sectoral
approach for Health.
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Public Health: Background
(contd..) Striking regional inequalities
The challenge of Population Stabilization especially in
States with weak demographic indicators.
Curative services favour the non-poor.
For every Re.1 spent on poorest 20% population, Rs.3
spent on the richest quintile.
About 10% Indians have some form of health insurance,
mostly inadequate
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Public Health: Background
(contd..)
Hospitalized Indians spend on an average 58% of theirtotal annual expenditure
Over 40% of hospitalized Indians borrow heavily orsell assets to cover expenses
Over 25% of hospitalized Indians fall below povertyline because of hospital expenses
58%
40%
25%
0%
10%
20%
30%
40%
50%
60%
Total Annual
Expediture
Borrow
heavily or sellAssets
BPL because
hospitalexpenses
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National Rural Health Mission
The Vision NRHM was launched on 12thApril 2005
The National Rural Health Mission seeks to provide effectivehealth care to the entire rural population in the country withspecial focus on 18 states which have weak public healthindicators, and/or weak infrastructure.
These 18 States are Arunachal Pradesh, Assam, Bihar,Chhattisgarh, Himachal Pradesh, Jharkhand, Jammu &Kashmir, Manipur, Mizoram, Meghalaya, Madhya Pradesh,Nagaland, Orissa, Rajasthan, Sikkim, Tripura, Uttaranchaland Uttar Pradesh.
The Mission is an articulation of the commitment of the
Government to raise public spending on Health from 0.9% ofGDP to 2-3% of GDP, over the next 5 years.
It aims to undertake architectural correction of the healthsystem to enable it to effectively handle increased allocationsas promised under the National Common Minimum
Programme.
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National Rural Health Mission
The Vision (contd..)
It has as its key components provision of a health activist ineach village; a village health plan prepared through a local
team headed by the panchayat representative; strengthening of
the rural hospital for effective curative care and made
measurable through Indian Public Health Standards (IPHS),
and accountable to the community; and integration of vertical
Health & Family Welfare Programmes and Funds for optimal
utilization of funds and infrastructure and strengthening
delivery of primary healthcare.
It seeks to revitalize local health traditions and mainstreamAYUSH into the public health system.
It aims at effective integration of health concerns with
determinants of health like sanitation & hygiene, nutrition, and
safe drinking water through a District Plan for Health.
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National Rural Health Mission
The Vision (contd..)
It seeks decentralization of the programme for districtmanagement of health.
It seeks to address the intra-State and inter-districtdisparities, especially among the 18 high focus States,including unmet needs for public health infrastructure.
It shall define time-bound goals and report publicly ontheir progress.
It aims to promote policies that strengthen publichealth management and services in the country.
It shall define time-bound goals and report publicly ontheir progress.
Above all, it seeks to improve access of rural people,especially poor women and children, to equitable,affordable, accountable and effective primaryhealthcare.
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Goals Reduction in Infant Mortality Rate and Maternal Mortality
Rate by 50% from existing levels in next 7 years
Universalize access to public health services : such asWomens health, child health, water, sanitation,immunization, Nutrition.
Prevention and control of communicable and non-communicable diseases, including locally endemic diseases
Access to Integrated comprehensive primary healthcare
Assuring Population stabilization, gender and demographic
balance. Revitalize local health traditions and mainstream AYUSH
Promotion of healthy life styles
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NRHMThe Concept (II)
Health Health Determinants
RCH-II NDCP
AYUSH GeneralCurative
Care
Nutrition Sanitation
& HygieneDrinking
Water
Supply
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Strategies
a) Core Strategies1. Train and enhance capacity of PRIs to own, control and
manage public health services.
2. Promote access to healthcare to household through the
female health activist (ASHA).
3. Health Plan for each village through Village Health Samiti
of the Panchayat.
4. Strengthening sub-centre through an untied fund to enable
local planning and action and more MPWs.
5. Strengthening existing PHCs and CHCs, and provision of30-50 bedded CHC per lakh population for improved
curative care to a normative standard (Indian Public
Health Standards defining personnel, equipment and
management standards).
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Core Strategies (contd..)6. Preparation and Implementation of an inter-sectoral District
Health Plan prepared by the District Health Mission,including drinking water, sanitation & hygiene and nutrition.
7. Integrating vertical Health and Family Welfare programmesat National, State and District levels.
8. Technical Support to National, State and District Health
Missions, for Public Health Management.9. Strengthening capacities for data collection assessment and
review for evidence based planning monitoring andsupervision
10. Formulation of transparent policies for deployment and
career development of Human Resources for health.11. Developing capacities for preventive and promoting health
care at all levels such as healthy life styles, reduction inconsumption of tobacco and alcohol.etc.
12. Promoting non-profit sector particularly in under served
areas.
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b) Supplementary Strategies
1. Regulation of Private Sector, including the informalrural practitioners, to ensure availability of qualityservice to citizens at reasonable cost.
2. Promotion of Public Private Partnerships forachieving public health goals.
3. Mainstreaming AYUSH. revitalizing local healthtraditions.
4. Reorienting medical education to support ruralhealth issues including regulation of Medical care
and Medical Ethics.5. Effective and viable risk pooling and social healthinsurance to provide health security to the poor byensuring accessible, affordable, accountable and goodquality hospital care.
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Plan of Action (Components A-J)
A:Accredited Social Health Activists
B: Strengthening Sub-Centres
C: Strengthening PHCs
D: Strengthening CHCs for First ReferralCare
E: District Health PlanF: Converging Sanitation and Hygiene under
NRHM (I)
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Plan of Action (Components A-J)
G:Strengthening Disease ControlProgramme
H:Public-Private Partnership for publichealth goals, including Regulation ofPrivate Sector
I : New Health Financing MechanismsJ: Reorienting Health/Medical Education to
support Rural Health Issues
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Component A:
Accredited Social Health Activists She will be trained on a pedagogy of public health
developed and mentored through a National ExpertsGroup incorporating best practices and implementedthrough active involvement of community healthresource organisations.
She will facilitate preparation and implementation ofVillage Health Plan alongwith Anganwadi worker,community workers and ANM under the leadership ofthe Panchayat Health Samiti.
She will be promoted all over the country, with special
emphasis on the 18 high focus States. GoI will bear thecost of training, incentives and medical kits. Rest to befunded under Financial Envelope.
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Component A:
Accredited Social Health Activists
She will be given a Drug Kit containing genericAYUSH and allopathic formulations for commonailments. The drug kit would be replenished from timeto time
Induction training of ASHA to be of 23 days in all,
spread over 12 months. On the job training would continue throughout the
year.
Prototype training material to be developed at Nationallevel subject to State level modifications.
Cascade model of training proposed through Trainingof Trainers including contract plus distance learningmodel
Training would require partnership with NGOs/ICDSTraining Centres and State Health Institutes.
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Component B: Strengthening Sub-Centres
Each sub-centre will have an untied fund for
local action @ Rs. 10,000 per annum. This fundwill be held in joint account of ANM andPanchayat Sarpanch.
Supply of essential drugs (allopathic and
AYUSH) to the Sub-centres. In case of additional Outlays, MPWs
(Male)/Additional ANMs wherever needed,sanction of new Sub-centres as per 2001
population norm, and upgrading existing Sub-centres, including buildings for Sub-centresfunctioning in rented premises will beconsidered.
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Component C: Strengthening PHCs
Mission aims at Strengthening PHC for quality preventive,
promotive, curative, supervisory and Outreach services, Adequate and regular supply of essential quality drugs and
equipment (including Supply of Auto Disabled Syringes for
immunization) to PHCs
Provision of 24 hour service in 50% PHCs by addressingshortage of doctors, especially in high focus States, through
mainstreaming AYUSH manpower.
Observance of Standard treatment guidelines & protocols.
In case of additional Outlays, intensification of ongoingcommunicable disease control programmes, new programmes
for control of non communicable diseases, up gradation of
100% PHCs for 24 hours referral service, and provision of 2nd
doctor at PHC level (I male, 1 female) would be undertaken on
the basis of felt need.
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Component D: Strengthening CHCs for
First Referral Care
Operationalizing 3222 existing Community Health Centres (30-50
beds) as 24 Hour First Referral Units, including posting of
anaesthetists
Codification of new Indian Public Health Standards, setting
norms for infrastructure, staff, equipment, management etc. CHC
Promotion of Stake-holders Committees (Rogi Kalyan Samitis)
for hospital management
Developing standards of services and costs in hospital care
Develop, display and ensure compliance to Citizens Charter at
CHC/PHC level.
In case of additional Outlays, creation of new Community Health
Centres (30-50 beds) to meet the population norm as per Census
2001, and bearing their recurring costs for the Mission period
could be considered.
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Component E : District Health Plan
District Health Plan would be an amalgamation of field
responses through Village Health Plans, State and Nationalpriorities for Health, Water Supply, Sanitation and Nutrition.
Health Plans would form the core unit of action proposed inareas like water supply, sanitation, hygiene and nutrition.Implementing Departments would integrate into DistrictHealth Mission for monitoring.
District becomes core unit of planning, budgeting andimplementation.
Centrally Sponsored Schemes could be rationalized/modified
accordingly in consultation with states.
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Component E : District Health Plan
Concept of funneling to district for effectiveintegration of programmes.
All parallel bodies in Health at District and statelevel merge into one common District Health
Mission at the District level and the StateHealth Missionat the state level
Provision of Project Management Unit for alldistricts, through contractual engagement of
MBA, Inter Charter/Inter Cost and Data EntryOperator, for improved programme management
A i P i Di i L l
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Action Points at District Level
District Health Mission
District, Block and
Village Plan
Integration with
ICDS, TSC
Quality AssuranceCommittee
Rogi Kalyan
Samiti
Strengthening
Immunization
Janani SurakshaYojana
PPP for Health
C t F C i S it ti d
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Component F: Converging Sanitation and
Hygiene under NRHM (I)
The Total Sanitation Campaign (TSC) is presently implemented in
350 districts, and is proposed to cover all 578 districts in 10thPlan.
Components of TSC include IEC activities, rural sanitary marts,
individual household toilets, women sanitary complex, and School
Sanitation Programme.
Similar to the DHM, the TSC is implemented through PRIs. NRHM proposes district and sub-district arrangements for Rural
Sanitation Programme similar to the DHM. The DHM would
guide activities of sanitation at district level.
The District Health Mission would therefore guide activities of
sanitation at district level, and promote joint IEC for publichealth, sanitation and hygiene, through Village Health &
Sanitation Committee, and promote household toilets and School
Sanitation Programme. ASHA would be incentivized for
promoting household toilets by the Mission.
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Component G: Strengthening Disease
Control Programme
National Disease Control Programmes for Malaria, TB,
Kala Azar, Filaria, Blindness & Iodine Deficiency shall
be integrated under the Mission, for improved
programme delivery.
New Initiatives would be launched for control of Non
Communicable Diseases.
Disease surveillance system at village level would be
Strenghthened
Supply of generic drugs (both AYUSH & Allopathic)
for common ailments at village, SC, PHC/CHC level.
Provision of a mobile medical unit at District level for
improved Outreach services.
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Component H: Public-Private Partnershipfor public health goals, including
Regulation of Private Sector Since 75% of health services are being currently provided
by the private sector, there is a need to refine regulation
Regulation to be transparent and accountable
Reform of regulatory bodies/creation where necessary
District Institutional Mechanism for Mission must haverepresentation of private sector
Need to develop guidelines for PPP for health sector.Identifying areas of partnership, which are need based,
thematic and geographic. Public sector to play the lead role in defining the framework
and sustaining the partnership
Management plan for PPP initiatives: at District/State andNational levels
Component I: New Health Financing
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Component I: New Health Financing
MechanismsTask Force to examine new health financing mechanisms,including
Risk Pooling for Hospital Care as follows:
Progressively the District Health Missions to move towards payinghospitals for services by way of reimbursement, on the principle ofmoneyfollows the patient.
Standardization of services outpatient, in-patient, laboratory,surgical interventions- and costs will be done periodically by acommittee of experts in each state.
A National Expert Group to monitor these standards and givesuitable advise and guidance on protocols and cost comparisons.
All existing CHCs to have wage component paid on monthly basis.Other recurrent costs may be reimbursed for services renderedfrom District Health Fund. Over the Mission period, the CHC
may move towards all costs, including wages reimbursed forservices rendered.
A district health accounting system, and an ombudsman to becreated to monitor the District Health Fund Management , andtake corrective action.
Adequate technical managerial and accounting support to beprovided to DHM in managing risk-pooling and health security.
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Component I: New Health FinancingMechanisms (contd..)
Where credible Community Based Health
Insurance Schemes (CBHI) exist/are launched,
they will be encouraged as part of the Mission.
The Central government will provide subsidies to
cover a part of the premiums for the poor, andmonitor the schemes.
The IRDA will be approached to promote such
CBHIs which will be periodically evaluated for
effective delivery.
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Funding Arrangements
The Mission is conceived as an umbrella programmesubsuming the existing programmes of health and family
welfare, including the RCHII, National Disease Control
Programmes for Malaria, TB, Kala Azar, Filaria, Blindness
& Iodine Deficiency and Integrated Disease SurveillanceProgramme.
The Budget Head For NRHM shall be created in B.E. 2006-
07 at National and State levels. Initially, the vertical health
and family welfare programmes shall retain their Sub-
Budget Head under the NRHM.
The Outlay of the NRHM for 2005-06 is in the range of
Rs.6700 crores.
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Component J: Reorienting Health/Medical
Education to support Rural Health Issues
While district and tertiary hospitals are necessarily
located in urban centres, 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.
Suggestion for Commission for Excellence in Health
Care (Medical Grants Commission), National
Institution for Public Health Management etc
Need for mainstreaming AYUSH
Task Force to improve guidelines/details.
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Mainstreaming AYUSH The Mission seeks to revitalize local health traditions and
mainstream AYUSH infrastructure, including manpower, anddrugs, 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 atSubcentre/ 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 HealthSystem (IPHS) model.
Single doctor PHCs shall be upgraded to two doctor PHCs by
mainstreaming AYUSH practitioner at that level.
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National Steering Group
Mission Steering Group
Empowered Programme Committee
State Health Mission
District Health Mission ------------Rogi Kalyan Samitis
Village Health
Committee
Village Health
Committee
Village Health
Committee
Mission Directorate
ORGANOGRAM
Panchayat Raj Institutuions (PRIs)
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Institutional Mechanism (I)
Village Health & Sanitation Samiti (at village levelconsisting of Panchayat Representative/s, ANM/MPW,Anganwadi worker, teacher, ASHA, community healthvolunteers
Rogi Kalyan Samiti (or equivalent) for communitymanagement of public hospitals
District Health Mission under the leadership of ZilaParishad with District
Health Head as Convener and all relevant departments,
NGOs, private professionals etc represented on it. State Health Mission (Chaired by Chief Minister and
co-chaired by Health Minister and with the StateHealth Secretary as Convener- representation ofrelated departments, NGOs, private professionals etc)
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Technical Support
To be effective the Mission needs a strong component
of Technical Support This would include reorientation into public health
management
Reposition existing health resource institutions, likePopulation Research Centre (PRC), Regional Resource
Centre (RRC), State Institute of Health & FamilyWelfare (SIHFW)
Involve NGOs as resource organizations
Improved Health Information System
Support required at all levels: National, State, Districtand Sub district level.
Mission would require two distinct supportmechanisms Program Management Support Centreand Health Trust of India.
Program Management Support
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Program Management Support
centre
For Strengthening Management Systems-basic programmanagement, financial systems, infrastructure
maintenance, procurement systems, MIS, non-lapsable
health pool etc.
For Developing Manpower Systems recruitment(induction of MBAs/CAs /MCAs), training & curr iculum
development (r evitalization of existing insti tuti ons &
partnerships with NGO & pvt. Sector insti tutions),
motivation & performance appraisal etc.
For Improved Governance decentralization &empowerment of communities, induction of I T based
systems like e-banking, social audit and right to
information.
Of
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Health Trust Of I ndia
Proposed as a knowledge insti tution, to be the repository of
innovation research & documentation, health informationsystem, planning, monitoring & evaluation etc.
For establ ishing Public Accountabil i ty Systemsexternalevaluations, community based feedback mechanisms,
participation of PRIs /NGOs etc. For developing a Framework for pro-poor I nnovations
For reviewing Health Legislations.
A base for encouraging exper imentation and action research.
For inter & intra Sector Networking with National andI nternational Organizations.
Think Tank for developing a long-term vision of the Sector &for building planning capaciti es of PRI s, Distr icts etc.
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Role of State Government
State Government
State & District Health Missions
MoU with GoI Integrated HFW Societies
NRHM State Action PlanDecentralization to District level
Merger of Departments of H&FWInvolve PRIs
Programme Management Unit ASHA Model
Role of State Governments under
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Role of State Governments under
NRHM The Mission covers the entire country. The 18 high focus States GoI
would provide funding for key components in these 18 high focusStates. Other States would fund some interventions like ASHA,PMU, upgradation of SC/PHC/CHC through Integrated FinanceEnvelope.
NRHM provides broad conceptual framework. States wouldproject operational modalities in their State Action Plans, to bedecided in consultation with the National Mission Steering Group.
NRHM would prioritize funding for addressing inter-state andintra-district disparities in terms of health infrastructure andindicators.
States would sign Memorandum of Understanding with Government ofIndia, indicating their commitment to increase contribution to PublicHealth Budget (preferably by 10% each year), increased devolution toPanchayati Raj Institutions as per 73rd Constitution (Amendment) Act,and performance benchmarks for release of funds.
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Strategy for North East States
All 8 North East States, including Assam, Arunachal Pradesh,Manipur, Meghalaya, Mizoram, Nagaland, Sikkim andTripura, are among the States selected under the Mission, forspecial focus.
Empowerment to the Mission would mean greater flexibilitiesfor the 10% committed Outlay of the Ministry of Health &
Family Welfare, for North East States. States shall be supported for creation/upgradation of health
infrastructure, increased mobility, contractual engagement,and technical support under the Mission.
Regional Resource Centre is being supported under NRHM
for the North Eastern States. Funding would be available to address local health issues in a
comprehensive manner, through State specific schemes andinitiatives.
R l f PRI
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Role of PRIs The Mission envisages the following roles for PRIs:
States to indicate in their MoUs the commitment fordevolution of funds, functionaries and programmes forhealth, to PRIs.
The District Health Mission to be led by the ZilaParishad. The DHM will control, guide and manage all
public health institutions in the district, Sub-centres,PHCs and CHCs.
ASHAs would be selected by and be accountable to theVillage Panchayat.
The Village Health Committee of the Panchayat would
prepare the Village Health Plan, and promoteintersectoral integration
R l f PRI ( d )
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Role of PRIs (contd..)
Each sub-centre will have an Untied Fund for localaction @ Rs. 10,000 per annum. This Fund will bedeposited in a joint Bank Account of the ANM &Sarpanch and operated by the ANM, in consultationwith the Village Health Committee.
PRI involvement in Rogi Kalyan Samitis for good
hospital management. Provision of training to members of PRIs.
Making available health related databases to allstakeholders, including Panchayats at all levels
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Role of NGOs for the Mission Role of the NGOs for the Mission is as envisaged
as follows: Included in institutional arrangement at National, State
and District levels, including Standing MentoringGroup for ASHA
Member of Task Groups
Provision of Training, BCC and Technical Support forASHAs/DHM
Health Resource Organizations
Service delivery for identified population groups onselect themes
For monitoring, evaluation and social audit
i A
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Funding Arrangements
The Mission envisages an additionality of 30% over existing
Annual Budgetary Outlays, every year, to fulfill the mandateof the National Common Minimum Programme to raise the
Outlays for Public Health from 0.9% of GDP to 2-3% of
GDP
The Outlay for NRHM shall accordingly be determined inthe Annual Budgetary exercise.
The States are expected to raise their contributions to Public
Health Budget by minimum 10% p.a. to support the Mission
activities. Funds shall be released to States through SCOVA, largely in
the form of Financial Envelopes, with weightage to 18 high
focus States.
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Outcomes Contd.
Cataract Operation: increasing to 46 lakhs per yearuntil 2012.
Leprosy prevalence rate: reduce from 1.8/10,000 in2005 to less than 1/10,000 thereafter
Tuberculosis DOTS services: Maintain 85% cure ratethrough entire Mission period.
Upgrading Community Health Centers to IndianPublic Health Standards
Increase utilization of First Referral Units from lessthan 20% to 75%
Engaging 250,000 female Accredited Social Health
Activists (ASHAs) in 10 States.
Outcomes Contd
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Outcomes Contd.b) Community level Provision of trained and supported Village Health Activist in under served
areas as per need (ASHA) Ensuring quality and close supervision ofASHA.
Preparation of health action plans by panchayats as mechanism forinvolving community in health.
Strengthening SC/PHC/CHC by developing Indian Public Health Standards
Institutionalizing and substantially strengthening District level
Management of Health (all districts) Increase utilization of First Referral Units from less than 20% (2002) to
more than 75% by 2010
Strengthening sound local health traditions and local resource based healthpractices related to PHC and public health
Improved facilities for institutional delivery through provision of referral,
transport, escort and improved hospital care subsidized under the JananiSuraksha Yojana (JSY) for the Below Poverty Line families
Availability of assured healthcare at reduced financial risk through pilots ofCommunity Health Insurance under the Mission
Provision of household toilets Improved Outreach services through mobilemedical unit at district level
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Monitoring and Evaluation
Health MIS to be developed and web-enabled for
citizen scrutiny
Annual District Reports on Peoples Health (to be
prepared by Govt/NGO collaboration)
State and National Reports on Peoples Health to be
tabled in Assemblies, Parliament
Sub Centres to Report on performance to Panchayats,
Hospitals to Rogi Kalyan Samitis and District HealthMission to Zila Parishad
External evaluation through professional bodies/NGOs
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