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Rural Health Care System in India

Rural Health Care System the structure and current scenario

The health care infrastructure in rural areas has been developed as a three tier system (see
Chart 1) and is based on the following population norms:

Table 1.

Population Norms
Centre
Plain Area Hilly/Tribal/Difficult Area
Sub-Centre 5000 3000
Primary Health Centre 30,000 20,000
Community Health Centre 1,20,000 80,000

Sub-Centres (SCs)

1.2. The Sub-Centre is the most peripheral and first contact point between the primary health
care system and the community. Each Sub-Centre is manned by one Auxiliary Nurse Midwife
(ANM) and one Male Health Worker MPW(M) (for details of staffing pattern, see Box 1). One
Lady Health Worker (LHV) is entrusted with the task of supervision of six Sub-Centres. Sub-
Centres are assigned tasks relating to interpersonal communication in order to bring about
behavioral change and provide services in relation to maternal and child health, family welfare,
nutrition, immunization, diarrhea control and control of communicable diseases
programmes. The Sub-Centres are provided with basic drugs for minor ailments needed for
taking care of essential health needs of men, women and children. The Department of Family
Welfare is providing 100% Central assistance to all the Sub-Centres in the country since April
2002 in the form of salary of ANMs and LHVs, rent at the rate of Rs. 3000/- per annum and
contingency at the rate of Rs. 3200/- per annum, in addition to drugs and equipment kits. The
salary of the Male Worker is borne by the State Governments. Under the Swap Scheme, the
Government of India has taken over an additional 39554 Sub Centres from State Governments /
Union Territories since April, 2002 in lieu of 5434 number of Rural Family Welfare Centres
transferred to the State Governments / Union Territories. There are 146026 Sub Centres
functioning in the country as on September, 2005 as compared to 142655 in September, 2004.

Primary Health Centres (PHCs)

1.3. PHC is the first contact point between village community and the Medical Officer. The
PHCs were envisaged to provide an integrated curative and preventive health care to the rural
population with emphasis on preventive and promotive aspects of health care. The PHCs are
established and maintained by the State Governments under the Minimum Needs Programme
(MNP)/ Basic Minimum Services Programme (BMS). At present, a PHC is manned by a Medical
Officer supported by 14 paramedical and other staff. It acts as a referral unit for 6 Sub
Centres. It has 4 - 6 beds for patients. The activities of PHC involve curative, preventive,
primitive and Family Welfare Services. There are 23236 PHCs functioning as on September,
2005 in the country as compared to 23109 in September, 2004.

Chart 1.

Sub Centre (SC)

Most peripheral contact point between Primary Health Care System


& Community manned with one MPW(F)/ANM & one MPW(M)

Primary Health Centre (PHC)

A Referal Unit for 6 Sub Centres 4-6 beded manned with a Medical
Officer Incharge and 14 subordinate paramedifcal staff

Community Health Centre (CHC)

A 30 beded Hospital/Referal Unit for 4 PHCs with Specialised


services

RURAL HEALTH CARE SYSTEM


IN INDIA
Box 1.
STAFFING PATTERN

A. STAFF FOR SUB - CENTRE: Number of Posts

1. Health Worker (Female)/ANM............................................................................................. 1

2. Health Worker (Male)......................................................................................................... 1

3. Voluntary Worker (Paid @ Rs.100/- p.m. as honorarium)....................................................... 1

Total:.................................................................................................................... 3

B. STAFF FOR NEW PRIMARY HEALTH CENTRE

1. Medical Officer.................................................................................................................. 1

2. Pharmacist....................................................................................................................... 1

3. Nurse Mid-wife (Staff Nurse)................................................................................................ 1

4. Health Worker (Female)/ANM............................................................................................. 1

5. Health Educator................................................................................................................. 1

6. Health Assistant (Male)...................................................................................................... 1

7. Health Assistant (Female)/LHV........................................................................................... 1

8. Upper Division Clerk........................................................................................................... 1

9. Lower Division Clerk........................................................................................................... 1

10. Laboratory Technician........................................................................................................ 1

11. Driver (Subject to availability of Vehicle)............................................................................... 1

12. Class IV............................................................................................................................ 4

Total:.................................................................................................................. 15

C. STAFF FOR COMMUNITY HEALTH CENTRE:

1. Medical Officer #................................................................................................................ 4

2. Nurse Mid Wife(staff Nurse).............................................................................................. 7

3. Dresser............................................................................................................................. 1

4. Pharmacist/Compounder.................................................................................................... 1
5. Laboratory Technician........................................................................................................ 1

6. Radiographer..................................................................................................................... 1

7. Ward Boys........................................................................................................................ 2

8. Dhobi................................................................................................................................ 1

9. Sweepers.......................................................................................................................... 3

10. Mali.................................................................................................................................. 1

11. Chowkidar ........................................................................................................................ 1

12. Aya.................................................................................................................................. 1

13. Peon................................................................................................................................ 1

Total:.................................................................................................................. 25

# :Either qualified or specially trained to work as Surgeon, Obstetrician, Physician


and Pediatrician. One of the existing Medical Officers similarly should be either
qualified or specially trained in Public Health).

Box 2.

RURAL HEALTH INFRASTRUCTURE - NORMS AND LEVEL OF ACHIEVEMENTS (ALL


INDIA)
Indicator National Norms Achievements
S.No.
1 Rural Population (2001) covered by a: General Tribal/Hilly/Desert
Sub Centre 5000 3000 5085
Primary Health Centre (PHC) 30000 20000 31954
Community Health Centre (CHC) 120000 80000 2.21 lakhs

2 Number of Sub Centres per PHC 6 6

3 Number of PHCs per CHC 4 7

4 Rural Population (2001) covered by a:


MPW (F) 5000 3000 5574
MPW (M) 5000 3000 11994

5 Ratio of HA (M) to MPW (M) 1:6.0 1:3


6 Ratio of HA (F) to MPW (F) 1:6.0 1:8

7 Average Rural Area (Sq. Km) covered by a:


Sub Centre -- 21.35
PHC -- 134.20
CHC -- 931.95

Average Radial Distance (Kms) covered by


8
a:
Sub Centre -- 2.61
PHC -- 6.53
CHC -- 17.22

9 Average Number of Villages covered by a:


Sub Centre -- 4
PHC -- 27
CHC -- 191

Community Health Centres (CHCs)

1.4. CHCs are being 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 September, 2005, there
are 3346 CHCs functioning in the country.

1.5. The details of the norms for each level of rural health infrastructure and current status
against these norms are given in Box 2.

2. Strengthening of Rural Health Infrastructure

2.1. With a view of improving facilities in the existing rural health infrastructure under
Reproductive and Child Health Programme, the Government of India is assisting all the States in
improving/ constructing labour room, operation theatre and providing water/ electricity supply in
CHCs/ PHCs etc. so that essential and emergency obstetric services are improved.

Minor Civil Works


2.2. An amount of Rs.10 lakh per district has been released to the States for minor repair and
maintenance of buildings, especially for operation theatres, labour rooms and for carrying out
improvements in water and electric supply.

Major Civil Works

2.3. An amount of Rs. 10 lakh per CHC/ district hospital is available for release to all the
States to improve facilities for essential and emergency obstetric services through providing
water supply and electricity, construction/repair of operation theatre, labour room/ or to
provide/improve facilities for hospitals.

3. Training and Development

Basic Training of Auxiliary Nurse Midwife (ANM) / Lady Health Visitor( LHV)

3.1. ANM/Multipurpose Health Worker (Female) and LHV/Health Assistant (Female) play
vital role in Maternal & Child Health as well as in Family Welfare Service in the rural areas. It
is therefore, essential that the proper training to be given to them so that quality services be
provided to the rural population.

3.2. For this purpose 336 ANM/Multipurpose Health Worker (Female) schools with an
admission capacity of approximately 13,000 & 42 promotional training schools for LHV/ Health
Assistant (Female) with an admission capacity of 2600 established by the Department of Family
Welfare, Government of India. These training institutions are imparting training to prepare
required number of ANMs and LHVs to man the Subcentres, Primary Health Centres, Rural
Family Welfare Centres and other Health centres in the country. The duration of training
programme of ANM is one and half years and minimum qualification for admission to this
course is 10th pass. Senior ANM with five years of experience is given six months promotional
training to become LHV/ Health Assistant (Female). Health Assistant (Female)/LHV provides
supportive supervision and technical guidance to the ANMs in sub-centres.

3.3. The staffing pattern of the school varies according to the no. of annual admission
capacity of the trainees. However, the school with 40 admission capacity is manned by one
nursing officer, two sister tutors, 4 PHN and other supportive staff. Other approved costs besides
salary to staff are stipend to trainee, contingency and rent. The detail of financial norm which is
effected since 7.2.2001 is as follows:

Item Norm

(In Rupees)
1. Salary & allowances of staff As per State Government
2. Stipend for trainees 500/- per month/trainee
3. Contingency 10,000/- per annum / school
4. Rent* 60,000/- per annum /school
* Rent payable in respect of such schools, which are functioning in rented buildings.

Basic Training of Multipurpose Health Worker (Male)

3.4. The Basic Training of Multi Purpose Health Worker (Male) scheme was approved during
th
6 Five-Year Plan and taken up since 1984, as a 100% Centrally Sponsored Scheme. This
training is provided through 56 training centres through Health & Family Welfare Training
Centres and through basic training schools of Multipurpose Health Workers (Male). Initially, the
schools were sanctioned at the existing Health & Family Welfare Training Centres and later on
expanded to other new basic schools. The training is of one-year duration and on successful
completion of the training, the Male Health Worker is posted at the sub-centre along with an
ANM/Health Worker (Female). The main functions of Male Multi Purpose Health Worker are in
the areas of National Health Programmes like Malaria, Leprosy, T.B. & limited involvement in
U.I.P, Diarrhoea Control Program and in family welfare services.

3.5. The financial norms for this scheme have been revised w.e.f. 7.2.2001. Under the
scheme the salary of the staff, rent for school and hostel, stipend, educational aids and training
material, hiring for bus and contingency are supported. The financial norms has been revised as
follows:

(in Rupees)

Item Norm
1. Salary & allowances As per State Government
2. Rent(for new schools) 10,000/ month
3. Rent for hostel (for new schools) 250 / month / trainee
4. Stipend 300 / month / trainee
5. Educational Aids and Training Material 15,000 / annum
6. Transportation (for hiring bus) 30,000 / annum
7. Contingency 50,000 / annum

Maintenance and Strengthening of Health and Family Welfare Training Centres (HFWTC)

3.6. The HFWTCs are the training centres of DoFW, GOI which provide primarily short-term
in-service training programmes to the doctors, nurses and para-medical personnel in the rural
areas in a defined region. At present these training centres are imparting various in-service
training for RCH programme. Apart from in-service education, 19 centres also responsible for
conducting the basic training of Male Health Workers course of one year.

3.7. The training centres have multi-disciplinary staff from biomedicine, social services,
health education, public health and nursing and statistics. Apart from the salary of the staff of the
training centres, other assistance under the scheme includes contingency, rent for training centres
and payment to guest faculty. The financial pattern of assistance for this scheme has been
revised since 7.2.2001. The detail of the financial norms are as follows:
( in Rupees)

Item Revised norms


1. Salary & allowances of the staff As per State Government
2. Contingency 15,000 / annum
3. Rent* 40,000 / annum
4. Payment to Guest Faculty 50,000 / annum
*Rent payable in respect of such centres that are functioning from rented buildings.

Strengthening of Basic Training Schools

3.8. This is a new scheme, which is introduced during the 10th Plan period. This scheme
envisages strengthening basic training schools of ANM/LHV. The main objective of the scheme
is physical strengthening of the training schools for making these schools workable/ suitable,
which have gone into dilapidated condition.

3.9. The provision under the scheme is maximum of Rs.21.5 lakhs per ANM/LHV school for
following activities.

Activities Rs. in lakhs (maximum)


1. Repair*/up-gradation** for the buildings - 20.00
Trg. Centre, hostel & the field practice area
2. Furniture & Equipment 1.00
3. Books/A.V. Aids 0.50

*Will include replacement/repair of floor/roof, plastering, electric cable, water storage


tanks, wall-cupboard, doors, windows, sanitary fixtures, internal water supply (piping),
septic tank, leakage, painting etc.

** will include minor extension

3.10. The releases are however depend on the actual requirement based on the estimates of the
repair/up-gradation work for the buildings as well as other teaching material. The respective
State Government based on requirement is expected to identify the schools that are required to be
strengthened and send a proposal with following essential information:

1. Physical and financial performance of ANM/LHV training schools functioning in the


State

2. Name and address of the training school proposed to strengthen under the scheme
Strengthening of Basic Training School with reason/justification for selecting the
particular training school.

3. Details of items proposed to procure/renovate with reason/justification for selecting the


proposed items
4. Supporting documents from authorized agencies for cost estimation of each item
proposed to procure/renovate e.g. estimates for repair/up-gradation from State Building
Corporation or Hospital Services Consultancy Corporation (HSCC) etc.

5. Expected effect on performance of training school after the completion

6. Any other information in support of the proposal.

Rural Health Training Centre, Najafgarh

3.11. Rural Health Training Centre, Najafgarh was established as a Najafgarh Health Unit with
the assistance of Rockfeller Foundation in 1937 and merged in Rural Health Training Centre
(RHTC) in 1969. There are three Primary Health Centres (PHCs) under RHTC,
Najafgarh. These are Najafgarh, Palam and Ujwa. The Centre has been rendering various
services to the rural community.

3.12. Basically RHTC, Najafgarh is a training centre for the Community Health /Rural Health
Training. This Centre is imparting training to nearly 2,500 trainees every year which includes:

Medical interns (3-6 months internship of rural health course) under Rural Orientation of
Medical Education (ROME) from Dr. Ram Manohar Lohia Hospital, Safdarjung Hospital
and those sponsored from DGHS. Roughly 300 Medical Interns are being trained each
year.
Nursing students of 1st and 3rd year of GNM Course from different Nursing Training
School of Delhi are being trained. Approximately, 1200 such students are trained every
year.
ANM 10+2 (Voc) Training School under CBSE affiliated with Indian Nursing Council is
also being run and every year 20 students are being admitted for two years certificate
course.
Trainings related to Rural Health is also provided in the form of different courses like
PGDHE, TBA, LHV, PHN, Food and Nutrition, Health Economics and Anganwadi
Worker etc.
Health Education is an integral part of training component and service component for
demand generation and behavioural change.

3.13. Health Care Services in the form of OPD, Emergency, MCH, Mobile Team, PP Unit,
Malaria, TB are being provided to roughly 10.5 lakhs population through 3 PHCs and 16 sub-
centres of Rural Health Training Centre, Najafgarh. This centre covers 73 villages and JJ
Colonies (nearby these villages) out of 209 villages of Delhi, which is 1/3 of total villages of
Delhi.

3.14. This institute conducts survey in different areas pertaining to family welfare and
community health under the sponsorship of some of the pioneer institutions such as AIIMS,
NIHFW, UNICEF & NIPCCD etc. Few important projects of research are as follows:-
Micro Nutrition deficiency among pregnant women
National Health Family Survey-II
Health seeking behaviour among rural community of Najafgarh
Development of MCH card
Effect of mustard oil on normal healthy individual (funded by MRPC & NDDB)
RHTC also extends assistance to different postgraduate students for their data collection.

3.15. This centre is also responsible for providing services to the community in the form of
health camps and other specialist services with the association of Safdarjung Hospital, Richmond
Fellowship etc.

Gandhigram Institute of Rural Health and Family Welfare Trust (GIRHFWT),


Gandhigram, Tamil Nadu.

3.16. Gandhigram Institute of Rural Health and Family Welfare Trust established in 1964 with
financial support from Ford Foundation, Government of India and Government of Tamilnadu.
The Health and Family Welfare Training Centre at GIRHFWT is one of 47 training centres in the
country. It trains Health and Health related functionaries working in Primary Health Centres,
Corporations / Municipalities, Tamil Nadu Integrated Nutrition Projects. The type of training
programmes includes Diploma of Health Education of one year and short courses on
orientation training, skill training on different Health & Family Welfare issues for various
categories of health personnel etc. Gandhigram Institute is also engaged in upgrading the
capabilities of ANMs, staff nurses and students of nursing colleges through the Regional Health
Teachers Training Institute (RHTTI). The RHTTI also conducts Diploma in Nursing Education
& Administration course.

4. Rural Health Infrastructure - a statistical overview

The Centres Functioning

4.1. The entire family welfare programme is being implemented through Primary Health Care
system. The Primary Health Care Infrastructure has been developed as a three tier system with
Sub Centre, Primary Health Centre (PHC) and Community Health Centre (CHC) being the three
pillars of Primary Health Care System. Progress of Sub Centres, which is the most peripheral
contact point between the Primary Health Care System and the community, is a prerequisite for
the overall progress of the entire system. A look at the number of Sub Centres functioning over
the years reveal that at the end of the Sixth Plan (1981-85) there were 84,376 Sub Centres. The
figure rose to 1,30,165 at the end of Seventh Plan (1985-90) and to 1,36,258 at the end of Eighth
Plan (1992-97). At present, as on September, 2005, 1,46,026 Sub Centres are functioning in the
country.
Similar progress can be seen in the number of PHCs which was 9115 at the end of sixth plan
(1981-85) and the figure almost doubled to 18671 at the end of Seventh Plan (1985-90) and rose
to 22149 at the end of Eighth Plan (1992-97). As on September, 2005, there are 23236 PHCs
functioning in the country. In accordance with the progress in the number of SCs and PHCs, the
number of CHCs has also increased from 761 at the end of Sixth Plan (1981-85) to 1910 at the
end of Seventh Plan (1985-90) and 2633 at the end of Eighth Plan (1992-97). As on September,
2005, 3346 CHCs are functioning. According to the figures of population based on 2001
Population Census, the shortfall in the rural health infrastructure comes out to be of 19636 Sub
Centres, 4337 PHCs and 3206 CHCs.
Building Status
4.2. About 49.7% of Sub Centres, 78.0% of PHCs and 91.5% of CHCs are located in the
Government buildings. The rest are located either in rented building or rent free Panchayat/
Voluntary Society buildings. As on September, 2005, in case of Sub Centres, overall 60762
buildings are required to be constructed. Similarly, for PHCs 2948 and for CHCs 205 buildings
are required to be constructed.

Manpower
4.3. The existing manpower is an important prerequisite for the efficient functioning of the
Rural Health Infrastructure. As on September, 2005 the overall total shortfall (which excludes
the existing surplus in some of the states) in the posts of MPW(F) / ANM was 19311. Similarly,
in case of MPW(M), there was a shortfall of 64211. In case of Health Assistant (Female)/LHV,
the shortfall was of 4214 and that of Health Assistant (Male) was 5290.

Even out of the sanctioned posts, a significant percentage of posts are vacant at all the levels. For
instance, about 4.7% of the sanctioned posts of MPW(Female)/ ANM were vacant as compared
to about 24% of the sanctioned posts of MPW(Male)/Male Health Worker. At PHC, about 13.1%
of the sanctioned posts of Female Health Assistant/ LHV, 25.4% of Male Health Assistant and
17.4% of the sanctioned posts of doctors were vacant.

4.4. At the Sub Centre level the extent of existing manpower can be assessed from the fact
that about 4.77% of the Sub Centres were without a Female Health Worker / ANM, about 39.2%
Sub Centres were without a Male Health Worker and about 2.78% Sub Centres were without
both Female Health Worker / ANM as well as Male Health Worker. This indicates a large
shortfall in Male Health Workers, resulting in poor male participation in Family Welfare and
other health programmes and overburdening of the ANMs.

4.5. PHC is the first contact point between village community and the Medical Officer.
Manpower in PHC include a Medical Officer supported by paramedical and other staff.
As on September, 2005, about 6.5% of the PHCs were without a doctor, about 39.2% were
without a Lab technician and about 13.7% were without a Pharmacist
4.6. The Community Health Centres provide specialized medical care in the form of facilities
of Surgeons, Obstetricians & Gynaecologists, Physicians and Paediatricians.

The current position of specialists manpower at CHCs reveal that out of the sanctioned posts,
about 51.8% of Surgeons, 43.6% of Obstetricians & Gynaecologists, 56.5% of Physicians and
about 56% of Paediatricians were vacant. Overall about 49.9% of the sanctioned posts of
specialists at CHCs were vacant. Moreover, there was a shortfall of 6110 specialists at the CHCs
as compared to the requirement for existing infrastructure on the basis of existing norms.

5. National Rural Health Mission

Under the mandate of National Common Minimum Programme (NCMP) of UPA Government,
health care is one of the seven thrust areas of NCMP, wherein it is proposed to increase the
expenditure in health sector from current 0.9 % of GDP to 2-3% of GDP over the next five years,
with main focus on Primary Health Care. The National Rural Health Mission (NRHM) has been
conceptualized and the same is being operationalised from April, 2005 throughout the country,
with special focus on 18 states which includes 8 Empowered Action Group States (Bihar,
Jharkhand, Madhya Pradesh, Chhattisgarh, Uttar Pradesh, Uttaranchal, Orissa and Rajasthan), 8
North East States (Assam, Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland,
Sikkim and Tripura) Himachal Pradesh and Jammu & Kashmir.

5.2. The main aim of NRHM is to provide accessible, affordable, accountable, effective and
reliable primary health care, especially to poor and vulnerable sections of the population. It also
aims at bridging the gap in Rural Health Care through creation of a cadre of Accredited Social
Health Activists (ASHA) and improve hospital care, decentralization of programme to district
level to improve intra and inter-sectoral convergence and effective utilization of resources. The
NRHM further aims to provide overarching umbrella to the existing programmes of Health and
Family Welfare including RCH-II, Malaria, Blindness, Iodine Deficiency, Filaria, Kala Azar
T.B., Leprosy and Integrated Disease Surveillance. Further, it addresses the issue of health in the
context of sector-wise approach addressing sanitation and hygiene, nutrition and safe drinking
water as basic determinants of good health in order to have greater convergence among the
related social sector Departments i.e. AYUSH, Women & Child Development, Sanitation,
Elementary Education, Panchayati Raj and Rural Development.

5.3. The Mission further seeks to build greater ownership of the programme among the
community through involvement of Panchayati Raj Institutions, NGOs and other stakeholders at
National, State, District and Sub District levels to achieve the goals of National Population
Policy 2000 and National Health Policy.

5.4. Under the strategy of NRHM, in order to fill the gaps in the existing rural health care
infrastructure available in the country, the key components, inter-alia, of the Mission are as given
below:

(i) Creation of a cadre of Accredited Social Health Activists (ASHA) in 2.5


lakh villages in four years 8 EAG States, J&K and Assam.

(ii) Creation of village health scheme and preparation of village health plan
18+ states.

(iii) Strengthening sub centres with untied funds of Rs. 10,000/- per annum
10+8+States.
(iv) Raising 2000+CHCs to the level of IPHS.

(v) Codification of Indian Public health Standards (IPHS) 18+states.

(vi) Integrating vertical health and family welfare programmes under NRHM at
National, State and District level all states.

(vii) Strengthening Programme Management Capacities at National State and


District level 10+8+states.

(viii) Institutionalising district level management of health all districts.

(ix) Supply of generic drugs (both Allopathic and AYUSH) 18+States.

(x) School health check up programme 18+States

(xi) Promotion of multiple health insurance model all states.

(xii) Supplementing Vitamin A and Iron Folic Acid to deficient children at


Anganwadi level 18+states.

(xiii) Promotion of private sector for achieving public health goals all states.

(xiv) Setting up of comprehensive Health and Family Welfare clinics 5


States+select districts.

(xv) Services of ANM and medical officers, PHCs to be ensured at fixed days at
Anganwadi levels.

(xvi) Mainstreaming ISM. Exploring new Health Financing Mechanism, Policy


reforms in Medical Education and Public Health Management.

(xvii) The mission shall focus on rural areas since bulk of the strategic
interventions are aimed at improvement of primary health care in rural areas.

5.5. Overview of NRHM


(i) The National Rural Health Mission is being launched for a period of seven
years (2005-2012) i.e. 2 years of Tenth Plan and full Eleventh Plan.

(ii) The Mission shall cover entire country, with focus attention on 18 states
having weak demographic indicators/ infrastructure.

(iii) NRHM is an omni-bus broad band programme, and all other programmes
would be sub-components, retaining the sub-budget heads wherever required
for vertical programmes.

(iv) The emphasis under NRHM is to improve primary health care,


decentralization, intra and inter-sectoral convergence and community
ownership.

(v) NRHM provides broad policy guidelines states have flexibility to draw
their action plans to attain the goals of NRHM

(vi) RCH-II, including National Family Welfare Programme (NFWP) and


Empowered Action Group (EAG) are subsumed into NRHM.

(vii) Operational phase of the Mission is from April, 2005.

(viii) MOUs being entered into, with the State Governments for RCH-II, will be
broad based for NRHM, to ensure their commitments to the systemic reform
and new financial pattern of performance based funding under NRHM.

5.6. Funding

The budget outlay for National Rural Health Mission for 2005-06 is Rs. 6731.16 Crores.

5.7. Mission Outcome

The following are anticipated Mission outcomes likely to be achieved after its implementation:
Provision of village level health provider (ASHA) in under served villages

Strengthening Sub- centers /PHCs

Raising CHCs to the level of IPHS

Institutionalizing District level Management of Health (all districts)

Prevention and control of communicable and non communicable diseases including locally
endemic diseases

Increase utilization of First Referral Units from less than 20% (2002) to more than 75 % by 2010

Reduction in communicable diseases, MMR, IMR and would help in attaining population
stabilization.

5.8. NRHM Plan of Action for Infrastructure Strengthening

Component (A): Accredited Social Health Activists

Every village/large habitat will have a female Accredited Social Health Activist (ASHA)
-chosen by and accountable to the panchayat- to act as the interface between the
community and the public health system. States to choose State specific models.

ASHA would act as a bridge between the ANM and the village and be accountable to the
Panchayat.

She will be an honorary volunteer, receiving performance-based compensation for


promoting universal immunisation, referral and escort services for RCH, construction of
household toilets, and other healthcare delivery programmes.

She will be trained on a pedagogy of public health developed and mentored through a
Standing Mentoring Group at National level incorporating best practices and
implemented through active involvement of community health resource organisations.

She will facilitate preparation and implementation of the Village Health Plan along with
Anganwadi worker, ANM, functionaries of other Departments, and Self-Help Group
members, under the leadership of the Village Health Committee of the Panchayat.

She will be promoted all over the country, with special emphasis on the 18 high focus
States. The Government of India will bear the cost of training, incentives and medical
kits. The remaining components will be funded under Financial Envelope given to the
States under the programme.

She will be given a Drug Kit containing generic AYUSH and allopathic formulations for
common ailments. The drug kit would be replenished from time to 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 National level subject to State level


modifications.

Cascade model of training proposed through Training of Trainers including contract plus
distance learning model.

Training would require partnership with NGOs/ICDS Training Centres and State Health
Institutes.

Component (B): Strengthening Sub-Centres (SC)

Each sub-centre will have an Untied Fund for local action @ Rs. 10,000 per annum. This
Fund will be deposited in a joint Bank Account of the ANM & Sarpanch and operated by
the ANM, in consultation with the Village Health Committee.

Supply of essential drugs, both allopathic and AYUSH, to the Sub-centres.

In case of additional Outlays, Multipurpose Workers (Male)/ Additional ANMs wherever


needed, sanction of new Sub-centres as per 2001 population norm, and upgrading
existing Sub-centres, including buildings for Sub-centres functioning in rented premises
will be considered.

Component (C): Strengthening Primary Health Centres (PHCs)

Mission aims at strengthening PHCs for quality preventive, promotive, curative, supervisory
and outreach services, through:

Adequate and regular supply of essential quality drugs and equipment (including Supply
of Auto Disabled Syringes for immunisation) to PHCs

Provision of 24 hour service in at least 50% PHCs by addressing shortage of doctors,


especially in high focus States, through mainstreaming AYUSH manpower.

Observance of Standard treatment guidelines & protocols.

In case of additional Outlays, intensification of ongoing communicable disease control


programmes, new programmes for control of non-communicable diseases, upgradation of
100% PHCs for 24 hours referral service, and provision of 2nd doctor at PHC level (1
male, 1 female) would be undertaken on the basis of felt need.

Component (D): Strengthening Community Health Centres (CHCs) for First Referral
Care

A key strategy of the Mission is:

Operationalising 3,222 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. for CHCs.

Promotion of Stakeholder Committees (Rogi Kalyan Samitis) for hospital management.

Developing standards of services and costs in hospital care.

Develop, display and ensure compliance to Citizen's 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.

Another important intervention under NRHM is the provision of a Mobile Medical Unit at
District level for improved outreach services.

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