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NRHM launched on 12th April, 2005 to improve health care delivery across rural India.

AIMS: Improve health system and health status of poor Universal access to affordable and good quality healthcare Reduce regional imbalances Decentralize district health programme management Integrate vertical health programmes Facilitate community participation, partnership and ownership of health care delivery.

CHALLENGES: Regional variation: A comparison of data between States and within regions and social groups suggests marked variations in the NRHM process indicators, utilisation of funds, improvement in health care delivery, health indices and in community participation. Regions with good health indices have shown marked improvements, while those with prior poor indices have recorded a much lesser change. This is true, despite a greater NRHM focus on and inputs to poor-performing States. Convergence of different programmes: Many programmes of the government, the Integrated Child Development Services (ICDS), the Mahatma Gandhi National Rural Employment Guarantee Scheme (MGNREGS) and the NRHM focus on the rural poor. In principle, these programmes are meant to be complementary and synergistic. However, many issues need to be resolved. For example, the NRHM's Village Health and Nutrition Days compete with the ICDS's well-established Anganwadi programme. This results in a lack of synergy between the workers employed by the two programmes Parallel health systems: The NRHM is intended to strengthen and support the existing State health systems and services. However, its status as a project makes its complete integration problematic. The idea that the States will take over its financing after 2012 does not generate enthusiasm for long-term commitment from staff at the State and district levels. Old ethos and new inputs: The NRHM brought fresh ideas and new monies to a neglected and disillusioned health care system. However, the inertia of the old system and the low morale and discipline of its staff continue to be major challenges. The NRHM has been able to add new infrastructure and personnel; however, its impact on reinventing and reinvigorating systems seems to be limited, and much more effort is required. New platforms competing with old programmes: Some States have introduced new programmes, which seem to rival and undermine old and established platforms. For example, they have introduced mobile medical units. These compete with older village sub-centres resulting in the undermining of previously established systems. Divisive approaches: Many States have introduced health insurance to cover life-saving medical conditions. While such cover has helped many people, there is evidence in some States that the

majority of recipients are urban-based, with the poorest and the most marginalised unable to access such services. The unregulated private sector and its high cost may not pass a cost-benefit test. Social determinants of health: The NRHM's goals clearly state the need to impact on the social determinants of health by coordinating efforts to provide clean water, sanitation, and nutrition. It should be in conjunction with MGNREGS work towards the reduction of poverty. Social exclusion and gender discrimination are two major areas of concern as they have a significant impact on health. The NRHM should not only focus on treating diseases in these sub-populations but also work towards implementing policies, which will bring about health and social justice for all.

NRHM- Key Achievements Some of the key achievements under National Rural Health Mission are: 1. Accelerated improvements in key reproductive health indicators e.g. Maternal Mortality Ratio (MMR), Infant Mortality Rate (IMR), Total Fertility Rate (TFR) and Institutional Delivery Rate. 2. Upgradation and operationalization of 8250 Primary Health Centers (PHCs) as 24X7 facilities 3. Operationalization of 2312 FRUs which includes Community Health Centers (CHCs), Sub District Hospitals and District Hospitals for providing OPD and 24*7 indoor facilities especially for comprehensive emergency obstetric and newborn care. 4. 374 Special Newborn Care Units, 1638 Newborn Stabilization Units, and 11432 Newborn Care Corners have been established at different levels of health facilities. 5. Augmentation of the availability of skilled manpower by means of different skill- based trainings such as Skilled Birth Attendance for Auxiliary Nurse Midwives/Staff Nurses/Lady Health Visitors; training of MBBS Doctors in Life Saving Anaesthetic Skills and Emergency Obstetric Care including Caesarean Section. 6. Over 1.4 lakh Human Resources have been engaged across the country on contractual basis under National Rural Health Mission which includes- ANMs, Staff Nurses, Paramedics, AYUSH Doctors, Doctors, Specialists and AYUSH Paramedics. 7. Engagement of 8.61 lakhs Accredited Social Health Activists (ASHAs) to generate demand and facilitate accessing of health care services by the community. 8. More than One Crore pregnant women across India are covered in the year 2009-2010 under the Janani Suraksha Yojana or J.S.Y. under the National Rural Health Mission or N.H.R.M. as against only 7.39 Lakh pregnant women covered during 2005-2006 9. Village Health and Nutrition Day is being organised every month in every village 10. Around 5.7 Lakh ASHA workers or Accredited Social Health Activists are provided with drug kits for treatment

11. Around 2300 Specialist Doctors, 8300 M.B.B.S. Doctors, 9600 Ayush Doctors, 26700 Staff Nurses and 53550 Auxiliary Nurse Midwifes or A.N.M. were added to the Rural Health System As per the Health Management Information System (HMIS) under the National Rural Health Mission, total institutional deliveries at public and private accredited health facilities increased from 1.62 Crores in the year 2009-10 to 1.68 Crores in the year 2010-11.

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