2. Characteristic Urban Rural
Infant mortality rate 39 62
Government beds 68.1% 31.9%
Beds per 1000 population 1.1beds 0.2beds
Graduate doctor diustribution 74% 28%
Shortfall of
•8% doctors at PHC’s
•65% specialist at community health centers
•55.3% male health workers
•12.6% female health workers

3.  Because of this inequality of distribution of
health in the country the union government
launched,

4.  Inaugurated on April 12, 2005
 Mission:-Increase spending on health from 0.9% of
GDP to 2-3% of GDP
 Correct the deficiencies of the health system
 Focus on 18 states – Northern and Eastern
 The Mission adopts a synergistic approach by relating
health to determinants of good health viz. segments of
nutrition, sanitation, hygiene and safe drinking water.
 Intended for 2005 - 2012

5.  To provide accessible, affordable, accountable,
effective and reliable primary health care and
bridging the gap in rural health care through
creation of ASHA.

6.  SPECIAL FOCUS ON 18 STATES.
 Arunachal Pradesh, Assam, Bihar,
Chhattisgarh, Himachal Pradesh, Jharkhand,
J&K, Manipur, Mizoram, Meghalaya, MP,
Nagaland, Orissa, Rajasthan, Sikkim,
Tripura, Uttaranchal, UP.

7.  Reduction in Infant Mortality Rate (IMR) and Maternal
Mortality Ratio (MMR)
 Universal access to public health services such as
Women’s health, child health, water, sanitation &
hygiene, immunization, and Nutrition.
 Prevention and control of communicable and non-
communicable diseases, including locally endemic
diseases

8.  Access to integrated comprehensive primary healthcare
 Population stabilization, gender and demographic
balance.
 Revitalize local health traditions and mainstream
AYUSH
 Promotion of healthy life styles

9.  ASHA: Provision of trained and supported village
health activist
 Health action plan: To involve community in
preparing health action plans by Panchayath
 IPHS: Strengthening SC/PHC/CHC by developing
IPHS
 FRU: Increase utilization of first referral units
from less than 20% to 75%
 Strengthening district level management of health
 AYUSH

10.  Train and enhance capacity of Panchayat Raj
institutions to own, control and manage public
health services.
 Promote access to improved health care at
household level through the female health
activist.
 Health plan for each village through village
health committee of the Panchayat.
 Strengthening sub center through an united fund
to enable local planning and action.

11.  Strengthening existing PHC’s and CHC’c.
 Preparation and implementation of an intersect
district health plan prepared by the district health
mission .
 Strengthening capacities for data collection,
assessment and review for evidence based
planning, monitoring and supervision.
 Developing capacities for preventive health care
at all levels by promoting healthy life styles,
reduction in tobacco consumption, alcohol etc.

12. 1. Regulation of private sector to ensure
availability of quality service to citizens at
reasonable cost.
2. Mainstreaming AYUSH – revitalizing local
health traditions.
3. Reorienting medical education to support rural
health issues including regulation of Medical
care and Medical Ethics.
4. Effective and viable risk pooling and social
health insurance to provide health security to the
poor by ensuring accessible, affordable,
accountable and good quality hospital care.

13. 1. Accredited social health activists
2. Strengthening sub-centers
3. Strengthening primary health centers
4. Strengthening CHCs for first referral c
5. District health plan under NRHM
6. Strengthening disease control program
7. Public-private partnership for public health goals,
including regulation of private sector
8. New health financing mechanisms
9. Reorienting health/medical education to support rural
health issues

14. Component 1:-ASHA
- Resident of the village, a woman (M/W/D)
between 25-45 years, with formal education up
to 8th class, having communication skills and
leadership qualities.
- One ASHA per 1000 population.
- Trained for period of 23 days(induction) over
one year and periodic re-training.

15. - Chosen by the panchayat to act as the interface
between the community and the public health
system.
- Bridge between the ANM and the village.
- Honorary volunteer, receiving performance based
compensation.

16. - To create awareness among the community
regarding nutrition, basic sanitation, hygienic
practices, healthy living.
- Counsel women on birth preparedness, imp of safe
delivery, breast feeding, complementary feeding,
immunization, contraception, STDs
- Encourage the community to get involved in health
related services.

17. - Escort/ accompany pregnant women, children
requiring treatment and admissions to the nearest
PHC’s.
- Drug depot: depot holder like ORS, iron and folic
acid, oral pills, condoms etc..
- Primary medical care for minor ailment such as
diarrhea, fevers
- Provider of DOTS.

18. Component 2:-STRENGTHENING SUB-CENTRES
 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-centers.
 In case of additional Outlays, Multipurpose Workers
(Male)/Additional ANMs wherever needed, sanction
of new Sub-centers as per 2001 population norm, and
upgrading existing Sub-centers, including buildings
for Sub-centers functioning in rented premises will be
considered

19. 3: STRENGTHENING PRIMARY HEALTH CENTRES
 Mission aims at Strengthening PHC 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 immunization) to PHCs
 Provision of 24 hour service in 50% PHCs by addressing
shortage of doctors, especially in high focus States
 Observance of Standard treatment guidelines &
protocols.

20.  Intensification of ongoing communicable disease
control programs, new programs 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.

21. STRENGTHENING CHCs FOR FIRST REFERRAL
CARE
 Operationalizing existing Community Health Centers (30-50
beds) as 24 Hour First Referral Units, including posting of
anesthetists.
 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.

22.  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 Centers (30-50 beds) to meet the
population norm as per Census 2001, and bearing
their recurring costs for the Mission period could be
considered

23. 5: DISTRICT HEALTH PLAN
It would be an amalgamation through:
 Village Health Plans, State and National priorities for
Health, Water Supply, Sanitation and Nutrition.
 Health Plans would form the core unit of action
proposed in areas like water supply, sanitation,
hygiene and nutrition. Implementing. Departments
would integrate into District Health Mission for
monitoring.
 District becomes core unit of planning, budgeting and
implementation.
 Centrally Sponsored Schemes could be
rationalized/modified accordingly in consultation with
States.

24.  Concept of “funneling” funds to district for effective
integration of programs
 All vertical Health and Family Welfare Programmes at
District and state level merge into one common
“District Health Mission” at the District level and the
“State Health Mission” at the state level
 Provision of Project Management Unit for all districts,
through contractual engagement of MBA, Inter
Chartered accountants and Data Entry Operator, for
improved program management

25. 6:CONVERGING SANITATION AND HYGIENE
UNDER NRHM
 Total Sanitation Campaign (TSC) is presently implemented
in 350 districts, and is proposed to cover all districts in
10th Plan.
 Components of TSC include IEC activities, rural sanitary
marts, individual household toilets, women sanitary
complex, and School Sanitation Program.
 The TSC is also implemented through Panchayati Raj
Institutions (PRIs).
 The District Health Mission would guide activities of
sanitation at district level, and promote joint IEC for public
health, sanitation and hygiene, through Village Health &
Sanitation Committee, and promote household toilets and
School Sanitation Program ASHA would be incentivized
for promoting household toilets by the Mission.

26. 7: STRENGTHENING DISEASE CONTROL
PROGRAMMES
 National Disease Control Program for Malaria, TB,
Kala Azar, Filaria, Blindness & Iodine Deficiency and
Integrated Disease Surveillance Program shall be
integrated under the Mission, for improved program
delivery.
 New Initiatives would be launched for control of Non
Communicable Diseases.
 Disease surveillance system at village level would be
strengthened.
 Supply of generic drugs (both AYUSH & Allopathic) for
common ailment at village, SC, PHC/CHC level.
 Provision of a mobile medical unit at District level for
improved Outreach services.

27. 8: PUBLIC-PRIVATE PARTNERSHIP FOR PUBLIC
HEALTH GOALS, INCLUDING REGULATION OF
PRIVATE SECTOR
Since almost 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

28. District Institutional Mechanism for Mission
must have representation of private sector
Need to develop guidelines for Public-Private
Partnership (PPP) in 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 and National levels

29. 9: NEW HEALTH FINANCING MECHANISMS
 A Task Group to examine new health financing mechanisms,
including Risk Pooling for Hospital Care as follows:
 Progressively the District Health Missions to move towards
paying hospitals for services by way of reimbursement, on
the principle of “money follows the patient.”
 Standardization of services – outpatient, in-patient,
laboratory, surgical interventions- and costs will be done
periodically by a committee of experts in each state.
 A National Expert Group to monitor these standards and
give suitable advice 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 rendered from District Health Fund. Over the
Mission period, the CHC may move towards all costs,
including wages reimbursed for services rendered.

30.  A district health accounting system, and an ombudsman to
be created to monitor the District Health Fund
Management , and take corrective action.
 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, and monitor the schemes.
 The IRDA will be approached to promote such CBHIs,
which will be periodically evaluated for effective delivery

31. 10: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.
 Task Group to improve guidelines/details

32.  Accredited Social Health Activist (ASHA)
 Auxiliary Nurse Midwife and Anganwadi worker
 Panchayati Raj Institutions and NGOs
 District Administration
 State Governments

33.  ASHA
 Accredited social health activist
 Female activist given accreditation after 4 phase
training
 Ownership of health program given to villagers
 Village Health Committee prepares village health
Plan

34.  District health plan generated by combining
village health plans
 Elements are drinking water, sanitation, hygiene
and nutrition
 Strengthen PHC (Primary Health Centers) and
CHC (Community Health Centers)

35.  Integrate vertical health and family welfare at district,
block, state and national levels
 Integration of vertical health programs (leprosy, TB,
malarial programs, etc.)
 All health facilities and infrastructure built based on
Indian Public Health Standards (IPHS) standards
 Rectify manpower shortage, equipment and other
furnishings in health facilities
 Strengthen capacities for data collection, processing,
evaluation and supervision

36.  NGOs and ASHAs work together
 AYUSH (Ayurvedic, Yogic, Unani, Siddha and
Homoeopathy) - Local health traditions made
mainstream
 Pass regulations requiring private practitioners to give
service at reasonable cost
 Public-private partnerships
 Re-orient medical education (MBBS 6th yr in rural
service?)
 Social health insurance
 Health Information System

37.  The Mission covers the entire country (18 state). GoI
would provide funding for key components in these 18
high focus States.
 Other States would fund interventions like ASHA,
Programme Management Unit (PMU), and up gradation
of SC/PHC/CHC through Integrated Financial Envelope.
 NRHM provides broad conceptual framework. States
would project operational modalities in their State Action
Plans, to be decided in consultation with the Mission
Steering Group.

38. The Mission envisages the following roles for PRIs:
• States to indicate in their MoUs the commitment
for devolution of funds, functionaries and
programmes for health, to PRIs.
• The District Health Mission to be led by the Zila
Parishad. The DHM will control, guide and
manage all public health institutions in the district,
Sub-centers, PHCs and CHCs.
• ASHAs would be selected by and be accountable
to the Village Panchayat.

39.  The Village Health Committee of the Panchayat would
prepare the Village Health Plan, and promote inter
sectoral integration
 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.
 PRI involvement in Rogi Kalyan Samitis for good
hospital management.
 Provision of training to members of PRIs.

40. · Health MIS to be developed upto CHC level, and web-
enabled for citizen scrutiny
· Sub-centres to report on performance to Panchayats,
Hospitals to Rogi Kalyan Samitis and District Health
Mission to Zila Parishad
· The District Health Mission to monitor compliance to
Citizen’s Charter at CHC level
· Annual District Reports on People’s Health (to be prepared
by Govt/NGO collaboration)
· State and National Reports on People’s Health to be tabled
in Assemblies, Parliament
· External evaluation/social audit through professional
bodies/NGOs
· Mid Course reviews and appropriate correction

42.  Strong political commitment
 Division into high focus and non high focus
states
 Flexible financing and scope for innovation
 The active involvement of PRI’s , community
NGO’s and private practitioners
 Maximum expansion of human resource by
adding 1 lakh service providers and more
than 8lakh ASHA workers

43.  Mainstreaming of AYUSH
 Integration of various health programs
 Evidence based planning
 Transparency and accountability in the
system
 Strengthened infrastructure

44.  The selection of ASHA is rigorous and time
consuming
 ASHA’s are overburdened with work and payment is
delayed. Work to them will be delegated by ANM
 Acute shortage of skilled manpower including
specialists persists
 Program far from reaching any of its key expected
outcomes
 Much of the funds are still underutilized. Release of
funds still problematic

45.  Data collected through HMIS has not been utilized
for local action.
 Lack of drugs and regular logistics supply
 Weak supervision

46.  Utilization of AYUSH doctors at PHC/CHC/DH
 Involvement of private sectors
 Program management support through
recruitment of managers (MBA’s, CA’s) using
IT based system
 Proper utilization of ANM and MPW
 Regular monitoring which helps in correcting
deviation
 Availability of funds

47.  Lack of motivation of contractual staff
 Improper facilities to doctors and paramedics
working in rural sector
 Sustainability of political wills
 No clear agenda after 2012
 Weak quality assurance system
 Frequent change of bureaucrats

48. National Urban Health Mission
(NUHM)

49. Introduction :
As per Census 2011, population of India has crossed 121
crores with the urban population at 37.7 crores which is
31.16% of total population. Urban growth has led to rapid
increase in no.of urban poor population, many of whom live
in slums and other squatter settlements. In order to
effectively address the health concerns of the urban poor
population, the Union Cabinet gave its approval to launch
NUHM as a new sub-mission under the over arching National
Health Mission (NHM) on 1st May, 2013.

50.  Urban Health Mission is implemented through the
Health Department in the urban local bodies
except metropolitan cities as these cities forms
a registered society and is funded by State
Health Society (SHS).
 SHS and the society formed will enter into a
bipatite MOU regarding the implementation of
NUHM and periodical reporting and review of the
progress.

51. GOAL : Aim to improve the health status of the
urban population in general, but particularly of the
poor and other disadvantaged sections, by
facilitating equitable access to quality health care
through a revamped public health system,
partnerships, community based mechanism with
the active involvement of the urban local bodies

52.  Improvising the efficiency of Public Health System in
the cities by strengthening, revamping and
rationalizing existing Government Primary Urban
Health structure and designated referral facilities
 Promotion of access to improved health care at
household level through community-based groups :
Mahila Arogya Samitis
 Strengthening Public Health through innovative
preventive and promotive action

53.  Increased access to health care through creation of
revolving fund
 IT enabled services (ITES) and e-governance for
improving access improved surveillance and
monitoring
 Capacity building of stakeholders
 Prioritizing the most vulnerable amongst the poor
 Ensuring quality health care services

54. The NHUM proposes to measure results at different
levels with a long term as well as intermediate term
view :
1. Process/Thoughtput level indicator:
 Number cities/population where Mission has been
initiated
 Number of City specific urban health plans developed
and operationalised
 Number of U-PHCs with outreach made operational
 Number of Cities/population with all slums and
facilities mapped

55.  Number of Slum/Cluster level Health and Sanitation Day
 Number of Mahila Arogya Samiti (MAS) formed
 Number of U-PHCs with programme Managers
 Number of ASHAs trained and functioning
2. Output Level Indicators :
 Increase in OPD attendance
 Increase in BPL referrals from U-PHCs/referral availed
 Increase in institutional deliveries as percentage of total
deliveries
 Strengthened civil registration system to achieve 100%
registration of births and deaths

56.  Increase in complete immunization among children <
12 months
 Increase in case detection for malaria through blood
examination
 Increase in case detection of TB through
identification of Chest symptomatic
 Increase in referral for sputum microscopy
examination for TB
 Increase in number of cases screened and treated for
dental ailments
 Increase in ANC check-ups of pregnant women

57. 3. Impact Level Focus on Urban Poor :
 Reduce IMR by 40% - down to 20 per 1000 live
births by 2017
 Reduce MMR by 50%
 Achieve Universal access to reproductive health
including 100% institutional delivery
 Achieve replacement level fertility
 Achieve all targets of Disease Control
Programmes

58. 1. Slum Level Innovations :
 Community monitoring
 Creating mentoring groups/support structures for MAS/ASHA through
NGO/CBOs
 “Healthy Mother”, “Healthy Infant Competitions
2. U-PHCs Level Innovations :
 Involving private practitioners for special drives on immunization.
Diabetes etc
 Involving schools for public health action like “slum cleaning” , health
promotion etc
 Special programs for adolescent health

59. 3. City Level Innovations :
 Innovations with ICT like ‘sms’ based health promotion,
PDA s for outreach workers
 “Help-lines” for general health advise/medical
emergencies
 Review/monitoring of quality, regularity of services
through NGOs
 Identification and management/rehabilitation of
malnourished children & Nutrition Resources Centres
 Special Strategies for addressing anemia among women
and girls

60.  Improving Sanitation and Water Services
 Addressing Community behaviors pertinent to
the causation of childhood illness in Urban Slums
 Community Participation in Prevention and
Treatment on Childhood illnesses
 Focus on All Aspects of Public Health
 Inter and Intra Sectorial Co-Ordination

61.  For effective implementation and monitoring of NUHM, a
National Programme Management Unit (NPMU) is set up to
provide technical assistance to the Urban Health Division
of the Ministry
 The NUHM promotes participation of the urban local
bodies in the planning and management of the urban
health programmes
 City Health and Sanitation Planning Committee in the
urban areas work under the umbrella of the District Health
Mission and the District Health Society to integrate health
service delivery to the urban poor in the urban areas

62.  The Quality Assurance teams are responsible for
recommending accreditation of
clinics/hospitals/nursing homes/diagnostic centers
and pharmacies for empanelment for outreach
services/U-PHCs/ referral centers
 NUHM aims to provide a system for convergence of all
communicable and non-communicable disease
programmes including HIV/AIDS through integrated
planning in the City level