TATA INSTITUTE OF SOCIAL SCIENCES,

SCHOOL OF RURAL DEVELOPMENT, TULJAPUR

Livelihood Development Policies[LDP] Assignment

Semester-VI

Submitted To: Dr.Sridhar Samant

Submitted By:Subhasish Sahoo
Gnanasabaapati R G
Deepali Mehra
Manoj Meghwal
Kim Nei Chong

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 CONTENTS

1. About National Health Mission [Subhasish Sahoo]

1.1. National Health Mission………………………………………………………………02
1.2. National Rural Health Mission (NRHM)………………………………………….….03
1.3. National Urban Health Mission (NUHM)…………………………………………03-04

2. Vision and Objectives of National Rural Health Mission [Kim Nei Chong]
2.1. The Vision of the Mission………………………………………………………..……04
2.2. Objectives of the Mission………………………………………………………..……05
2.3. The Core Strategies of the Mission……………………………………………….…..05

3. Implementation and Broader Framework [Gnanasabaapati R G]……………….06

4. Institutional Setup of National Rural Health Mission [Manoj Meghwal]

4.1.National Level……………………………………………………………………..……08
4.2.State Level……………………………………………….……………………….……..09
4.3.District Level……………………………………………….……………………..……09
4.4. Block Level……………………………………………….………………………….09
4.5 Village Level……………………………………………….……………………..…….09

5. Scheme Evaluation [ Deepali Mehra]

5.1. Stakeholder Analysis…………..……………………………………………………09-10
5.2.Recommendation………………………………………………………………………11

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1. About National Health Mission [NHM] By: Subhasish Sahoo

1.1 National Health Mission

National Health Mission was launched by the Government of India with the objective of addressing
India’s malnutrition crisis by providing flexible finances to State Governments.
This mission subsumed 2 other malnutrition missions that already existed with the aim of targeting
rural population and urban population i.e. National Rural Health Mission (NRHM) and the National
Urban Health Mission (NUHM). This mission was launched in the year 2013. This mission is
implemented by the Ministry of Health and Family Welfare.

The main programmatic components of NHM are Health System Strengthening, Reproductive-
Maternal- Neonatal-Child and Adolescent Health (RMNCH+A), and Communicable and Non-
Communicable Diseases.

National Health Mission has six financing components:

(i) NRHM-RCH Flexipool: Provide RMNCH+A Services to the rural deprived people. Covers all
towns and villages below population of 50,000.
(ii) NUHM Flexipool: NUHM covers all state capitals, district headquarters and other cities/towns
with a population of 50,000 and above (as per census 2011) in a phased manner. Seeks to
improve the health status of the urban population particularly urban poor and other vulnerable
sections by facilitating their access to qual
(iii) Flexible pool for Communicable disease:To combine and integrate all the ongoing schemes
related to communicable diseases.These include National Vector Borne Diseases Control
Programme (NVBDCP), Revised National Tuberculosis Control Programme (RNTCP),
National Leprosy Control Programme (NLEP) and Integrated Disease Surveillance Programme
(IDSP)
(iv) Flexible pool for Non communicable disease including Injury and Trauma: The Flexible
Pool for Control of Non-communicable Diseases has been created to combine and integrate all
the ongoing schemes related to non communicable.These include NPCDCS,
NPCB,NMHP,NPHCE,NPPCD,NTCP,NOHP,NPPC,NPPMBI and NPPCF.
(v) Infrastructure Maintenance
(vi) Family Welfare Central Sector component.
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1.2. National Rural Health Mission (NRHM)
The National Rural Health Mission (NRHM) was launched on 12th April 2005 throughout India to
provide equitable, affordable and quality health care to the rural population, especially the
vulnerable groups. The thrust of the mission is on establishing a fully functional, community
owned, decentralized health delivery system with inter-sectoral convergence at all levels, to ensure
simultaneous action on a wide range of determinants of health such as water, sanitation, education,
nutrition, social and gender equality. Institutional integration within the fragmented health sector
was expected to provide a focus on outcomes, measured against Indian Public Health Standards for
all health facilities.

NRHM covers the entire country but has a special focus on eighteen states (of these 8 are EAG
states), identified to have weak public health indicators and/or weak health infrastructure. These
focused states are Arunachal Pradesh, Assam, Bihar, Chhattisgarh, Himachal Pradesh,
Jharkhand, Jammu & Kashmir, Manipur, Mizoram, Meghalaya, Madhya Pradesh, Nagaland, Orissa,
Rajasthan, Sikkim, Tripura, Uttaranchal and Uttar Pradesh. While all the Mission activities are
the same for all the states/UT’s in the country, the high focus states have the following additional
support:
(i) An Accredited Social Health Worker (ASHA) in all villages with a population of 1000
(ii) Project Management Support at the state and district level.
# Empowered Action Group (EAG) refers to the following 8 states – Bihar,
Chattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttarakhand and Uttar Pradesh.

1.3. National Urban Health Mission (NUHM)

The Union Cabinet gave its approval to launch a National Urban Health Mission (NUHM) as a new
sub-mission under the over-arching National Health Mission (NHM) on 1st May 2013.
NUHM aims to improve the health status of the urban population in general, particularly the poor
and other disadvantaged sections by facilitating equitable access to quality health care, through a
revamped primary public health care system, targeted outreach services and involvement of the
community and urban local bodies.
Under the Scheme the following steps have been taken:
• One Urban Primary Health Centre (U-PHC) for every fifty to sixty thousand population
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• One Urban Community Health Centre (U-CHC) for five to six U-PHCs in big cities.
• One Auxiliary Nursing Midwives (ANM) for 10,000 population.
• One Accredited Social Health Activist ASHA (community link worker) for 200 to 500
households.

The scheme focusses on primary health care needs of the urban poor. This Mission is being
implemented in 779 cities and towns with more than 50,000 population and cover about 7.75 crore
people.
The interventions under the sub-mission results in
• Reduction in Infant Mortality Rate (IMR)
• Reduction in Maternal Mortality Ratio (MMR)
• Universal access to reproductive health care
• Convergence of all health related interventions.

The expenses of NUHM for last 5 years period is Rs 22,507 crore with the Central Government
share of Rs 16,955 crore. Centre-state funding pattern is 75:25 except for North Eastern states and
other special category states of Jammu and Kashmir, Himachal Pradesh and Uttarakhand for whom
funding pattern is 90:10.

2. Vision and Objectives of National Rural Health Mission By:Kim Nei Chong

2.1. The Vision of the Mission

• To provide effective healthcare to rural population throughout the country with special focus on
18 states which have weak public health indicators and weak infrastructure. They are Assam,
Nagaland, Arunachal Pradesh, Madhya Pradesh, Bihar, Mizoram, Manipur, Meghalaya,
Chhattisgarh, Jharkhand, Himachal Pradesh, Jammu and Kashmir, Nagaland, Tripura, Rajasthan,
Odisha, Uttar Pradesh, Sikkim and Uttaranchal.
• To raise spending of public on health from 0.9% GDP to 2-3% of GDP, with improved
arrangement for community financing and risk pooling.
• To undertake architectural correction of the health system to enable it to effectively handle
increased allocations and to promote policies that will strengthen public health management and
service delivery in the country.

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• To mainstream AYUSH into the public health system and to revitalize local health traditions.
• To have a successful integration of health issues through decentralized management at every
district with health determinants like nutrition, sanitation and hygiene, safe drinking water, gender
and social concerns.

• To address the disparities between inter State and inter districts.

• To improve access to rural people, especially children and poor women to equitable, affordable,
accountable and effective primary health care.

2.2. Objectives of the Mission

• Reduce the rate of infant and maternal mortality

• Universal access to public health care services with emphasis on services that addresses children’s
and women’s health, public services for food and nutrition, hygiene and sanitation and also
universal immunization.
• To prevent and control communicable and non-communicable diseases, including locally endemic
diseases.

• Access to integrated comprehensive primary health care.

• Population stabilization, gender and demographic balance.
• Revitalize local health traditions & mainstream AYUSH.
• Promotion of healthy life styles.

2.3. The Core Strategies of the Mission

• To train and enhance capacity of Panchayati Raj Institutions (PRIs) to own, control and manage
public health services.
• To promote access to improved healthcare at household level through the female health activist
(ASHA).
• To organize Health Plan for each village through Village Health Committee of the Panchayat.
• To strengthen sub-center through clear quality standards, better human resource development,
better community support and an untied fund to enable local planning and action and more Multi-
Purpose Workers (MPWs).
• Strengthening existing (PHCs) through better staffing and human resource development policy
and also clear quality standard local management committee to achieve these standards.
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• Provision of 30-50 bedded CHC per lakh population for improved curative care to a normative
standard.
• The District Health Mission prepare and implements an inter sector District Health Plan including
sanitation, drinking water, nutrition and hygiene.

• Integrating vertical Health and Family Welfare programmes at National, State, District and Block
levels.

3. Implementation and Broader Framework By Gnanasabaapati R G

The main concerned areas were

• Well-functioning health facilities
• Quality and accountability in the delivery of health services;
• Taking care of the needs of the poor and vulnerable sections of the society and their
empowerment;
• Prepare for health transition with appropriate health financing;
• Pro-people public private partnership;
• Convergence for effectiveness and efficiency.
• Responsive health system meeting people’s health needs.

Action at Central Level

The centre has the role of reviewing current health system and should develop appropriate policies.
They should create regulations, create tools for measuring the performance of public/private sector
in health. They should issue guidelines, develop partnership with non-governmental stakeholders,
decentralisation of financing of the program are some of the key things central government’s action
should be based on.

Role of States
To make community owned and need based district health action plans for interventions in the
health sector. States have the freedom and flexibility to innovate according to their socio-cultural
and local needs when it comes to intervening and designing policies. The states are required to give
sufficient powers to PRIs.
Giving power to communities

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For this health missions to get succeed it should touch each and every village of India and to that we
should empower community to take charge of health issues. The panchayat raj institutions should be
given ownership of public health delivery system. Other community organisation and women’s
groups should also be associated with the communitization of health care.

• They should be empowered to manage health infrastructure at each level such as district and sub
district.
• The village health and sanitation committee (VHSC) should be formed in each village within
gram Sabha framework and adequate representation of women and other minority communities
will be there.
• The sub health centre will be accountable to the gram panchayat and can have a local committee
for its management with members from VHSCs.
• The primary health centre will be responsible for the elected representative of the gram
panchayat where it is located.
• The block level PHC and CHC will involve panchayati raj elected leaders in its management
with the Rogi Kalyan Samiti would also be there for day to day management
• Zilla parishad at the district level will be responsible for the budgets and planning for people’s
health needs
• The entire district public health management will come under district health society which would
be controlled by district panchayat with participation of the block panchayats.
• Monitoring committee will be formed at all level with PRI representatives and to enable the
community in a broad based review and suggestions in the process of planning.
• Jan sunwai at various levels will facilitate community members to engage in giving direct
feedback and suggestions for improving the public health system.

Promoting Equity
This one of the main aims of this mission. To empower vulnerable through health education and
giving priority to the areas they live and involving them in the planning process and recruiting
volunteers among them is one of the main strategies of the mission to address the poor health
indicators of the socially and economically deprived groups.

Promoting preventive health

The health sector in the country is more focussed on the curative side rather than on being on the
side of preventive. Mission will ensure that the focus is more on preventive side by working with
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department of education for promotion of preventive health measures and will also work with
ministry of labour for workers health conditions. Also will work with ministry of women and child
for preventive health measures for women and children.

Dealing with Chronic Diseases

India has one of the highest disease burden in the world and death toll from chronic health diseases
are expected to rise to 7.6 million which is more than 60% of total deaths. Preventive and curative
strategies along with additional resources will be integrated in the plan at all levels.

Reducing child and maternal mortality rates and reducing fertility rates
The mission aims to provide a push for reduction of child and maternal mortality and reduce
fertility rates. There will be efforts to provide quality reproductive health services. It also aims to
increase the male participation in the family planning. Reduction of IMR requires greater
convergent action to influence the wider determinants of health care like female literacy, safe
drinking water, sanitation, gender and social empowerment, early child hood development,
nutrition, marriage after18, spacing of children, and behavioural changes etc.

4. Institutional Setup of National Rural Health Mission

National Level:

• At the National level, the NHM features a Mission Steering Group (MSG) headed by the
Union Minister for Health & Family Welfare and an Empowered Programme Committee
(EPC) headed by the Union Secretary for Health & FW. The EPC will implement the Mission
under the general guidance of the MSG.

• National Mission Steering Group chaired by Union Minister for Health & Family Welfare
with Deputy Chairman committee, Ministers of Panchayat Raj, Rural Development and
Human Resource Development and public health professionals as members, to supply policy
support and guidance to the Mission.

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State Level:

• At the State level, the Mission would function under the general guidance of the State Health
Mission headed by the Chief Minister of the State. The functions under the Mission would be
administered through the State Health & Family Welfare Society.

• Empowered Programme Committee chaired by Secretary HFW, to be the chief Body of the
Mission

• State Health Mission, Chaired by Chief Minister and co-chaired by Health Minister and with
the State Health Secretary as Convener- representation of related departments, NGOs, private
professionals, etc.

District Level:

• District Health Mission, under the leadership of Zila Parishad with District Health Head as
Convener and everyone relevant departments, NGOs, private professionals, etc represented
thereon.

• The District Programme Management Unit (DPMU) would be linked to a neighbourhood

Health Knowledge Centre (DHKC) and its partners for the requisite technical assistance. The
District Training Centre (DTC) would be the nodal agency for training requirements of the
District Health Society (DHS).

Block Level:

Village Level: Village Health & Sanitation Samiti (at village level consisting of Panchayat
Representative/s, ANM/MPW, Anganwadi worker, teacher, ASHA, community health volunteers.
Rogi Kalyan Samiti (or equivalent) for community management of public hospitals

5. Scheme Evaluation

It attempts to evaluate schemes, how effective, adequate, efficient and reached the people. The
utilization of health, the roles played by the ASHA workers, in creating awareness of health, and
nutrition among the rural population. It is done to identify the problems and barriere in the
implementation of the NRHM programmes. Along with the basic health facilities of ASHAs and

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AYUSH, the study will focus on different factors like planning, availability and effective
decentralization, drugs facilities, communication, referral services and empowerment etc.

5.1. Stakeholders Analysis

The stakeholders of the Mission were:-

A] District Health Societies

It is performing well in maintaining some responsibilities such as PHCs health reports are being
listened to in 35 out of 37 district health societies(DHSs). It has not been discussed in Assam and
Jammu and Kashmir. In all the parts of UP, MP, Jharkhand and Tamil Nadu, vertical integration
of the health societies has been created under DHS. National Disease Control Program has a
separate budget but it comes under NRHM budget also. And the data of the incidences of
diseases are quite insufficient.

B] Community Health Centres

The CHCs are mainly present in every districts but when we come to avaialabilty of emergency
care for sick children, emergency obseteric care, abortion services etc. the situation are not so
fine. Availability of specialists and doctors, gynaecologists, surgeons, physicians and
pediatricians are quite poor in most of the CHCs.

C]Village Health and Sanitation Committee

The VHSC inspects the mechanism of decentralised health care at the ground level. There is a
huge importance of involvement of panchayat raj. The main slogan “people health in their hands''
as the elected GP member in VHSC for monitoring the schemes carefully. Most of the villages
dad the sub centre facility provided by the SC. The provision of giving common facilities like
drinking water was very good. But the condition of sanitation and cleanliness are still very poor
in all the states excepting Tamil Nadu.

D] Accredited Social Health Activists (ASHA)

ASHA is a link between the community and the rural health system. It was to help and motivate
the poorer section of the society like women, childrens, and poors. The selection of the ASHAs
are done on the basis of proper criteria and focused group discussions to know their knowledge
and understanding about their roles and responsibilities under the program. The counseling for
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them is also a part of the program and it is very essential. The medicines and frequent home
visits are also there. The coordination between the ASHA workers and other grass root level
health workers are strong. However they have minimum interaction with the self help groups.
Overall functioning of ASHA seems to be satisfactory in every state.

6. Recommendations to make Better Public Health Facilities

• Firstly, need to recruit more doctors, specialists, and staff nurses in the vacant positions under
NRHM to utilize the scheme effectively.There is a need to give proper training to ASHA
workers to upgrade their skills and facilitate more health services. The training of vaccination
would be really helpful.
• AYUSH needs to be more innovative and effective according to the current situation as hardly
anybody opt for indian medical system.
• The medicine facilities need a strong and strict committee and supervision to make it more
available to the BPL categories of people. The availability of drugs and medicines need a strict
action as it is lacking to reach people.
• The coordination between village level programmes and VHSC can change the poor condition
in terms of nutrition, sanitation, etc.
• FRUs mainly focuses on delivery care and chronic diseases with proper resources and
equipment. It can provide emergency obstetric also.

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