National Health Mission (NHM)
The National Health Mission (NHM) seeks to provide universal access to equitable, affordable and quality health care which is accountable, at the same time responsive, to the needs of the people, reduction of child and maternal deaths as well as population stabilization, gender and demographic balance.
Sub-missions of NHM
NHM encompasses two Sub-Missions, National Rural Health Mission (NRHM) and National Urban Health Mission (NUHM).
The National Rural Health Mission (NRHM) was launched in 2005 with a view to bringing about dramatic improvement in the health system and the health status of the people, especially those who live in the rural areas of the country. More details may be seen here.
The sub-mission of National Urban Health Mission (NUHM) under the NHM strives to improve the health status of the urban poor particularly the slum dwellers and other disadvantaged sections by facilitating equitable access to quality health care. The Framework for Implementation of NUHM has been approved by the Cabinet on May 1, 2013.
The urban population of country has gone up to 37.7 crores as per the 2011 Census. Urban growth has also led to increase in the urban poor, especially those living in slums, thus putting greater strain on an already deficient urban infrastructure. Despite the supposed proximity of the urban poor to urban health facilities their access to these is severely restricted. This is on account of their being “crowded out” because of the inadequacy of the urban public health delivery system. Ineffective outreach and weak referral system also limits the access of urban poor to health care services. Rates of under-nutrition, anemia, and incidence of vector borne diseases, TB, and other respiratory infections are significantly higher than among other urban population groups. This situation is further exacerbated by the fact that a large number of urban poor are living in slums that are not part of the official list as slums. This compromises the entitlement of the slum dweller to basic services. Slum populations face greater health hazards due to overcrowding, poor sanitation, lack of access to safe drinking water and environmental pollution. Under NUHM, the most vulnerable including construction site workers, homeless persons, street children, victims of communal violence, invisible habitations such as lime and brick kiln workers would be accorded focused attention and health care through strategies appropriate to the local situation.
Focus Areas, approach and sub-programmes
The NHM essentially focuses on strengthening primary health care across the country. The emphasis is on strengthening health facilities and services up to the district level in urban and rural areas. The key approaches of NHM include augmentation of human resources, strengthening health infrastructure, flexible financing, decentralized planning through village health sanitation and nutrition committees and setting up of Rogi Kalyan Samitis, Medical Mobile Units to provide health service delivery especially in un-served and underserved areas, accredited social health activists (ASHA) who act as a link between community and health care facilities, the reproductive and child health (RCH) programme to improve the maternal and child health in the country, improved management capacity, robust monitoring and evaluation mechanisms, use of Information technology in health to improve services delivery and strengthening monitoring and mainstreaming of AYUSH.
Among the focus areas of NHM, is Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) to address the major causes of mortality among women and children as well as the delays in accessing and utilizing health care and services. The RMNCH+A strategic approach entails ‘continuum of care’ to ensure equal focus on various life stages. RCH entitles all pregnant women delivery in public health institutions to absolutely free and no expense delivery including Caesarean section. The initiative stipulates free drugs, diagnostics, blood and diet, besides free transport from home to institutions, between facilities in case of a referral and drop back home. Similar entitlements have been put up in place for all sick newborns accessing public health institutions for treatment till 30 days after birth. This approach was adopted to address the challenges of high infant mortality rate, maternal mortality ratio, and high fertility rate. Under this approach the Pradhan Mantri Surakshit Maitritva Abhiyan(PMSMA) has been launched with the intention of ensuring quality antental care to pregnant women . One of the critical components of this initiative is that every pregnant woman must be examined by a doctor. The strategies for child health intervention focuses on neonatal health, nutrition, management of common childhood diseases and immunization, besides improving skill sets of the health care workers, strengthening the health care infrastructure and involvement of the community through behaviour change communication.
The Universal Immunization Programme that covers 2.7 crore children in India each year, includes vaccines that prevent childhood pneumonia. These vaccines are DPT, Measles and BCG that protect against diphtheria, pertussis (also known as whooping cough), measles and tuberculosis. Vaccine against Haemophilus Influenzae Type B (Hib) infection has been introduced in the form of pentavalent vaccine. Second Dose of measles has also been incorporated in the Universal Immunization Programme in all the states and UTs.
Promotion of early and exclusive breastfeeding offers protection against common childhood illnesses including diarrhea and pneumonia. Infant and Young Child feeding practices are being promoted through the national health programme. Antibiotics for treatment of pneumonia and dysentery are made available through the public health system. The community health workers and facility based health service providers are trained in early detection and management of diarrhea and pneumonia through the IMNCI (Integrated Management of Neonatal and Childhood Illnesses) programme across the country. Promoting use of dispersible Zinc tablets and ORS is one of the priority activities for child survival. Oral Rehydration Salt (ORS) packets and zinc tablets are made available free of cost and mothers are taught how to use them. Vitamin A Supplementation programme covers children up to the age of 5 years and offers protection against diarrhea and pneumonia by improving the immunity and is used as a preventive measure. Awareness is being created amongst mothers on sanitation and hygiene and in the communities about the causes and treatment of diarrhea through health education during Village Health and Nutrition Days. To track every pregnant woman and child to ensure registration of all pregnant mothers and neonates, Government has introduced a Name based Mother and Child Tracking System (MCTS), to monitor the ante-natal and post-natal care of mother and immunization of children.
The National School Health Programme under NHM includes screening, health care and referral so as to comprehensively address the health needs of children. The programme entails biannual health screening and early management of disease, disability and common deficiency and linkages with secondary and tertiary health facilities as required for children of Government, Government aided and Municipal Primary, Upper Primary and Secondary schools.
One of the areas of focus of NHM is facility based delivery system. In this direction the NHM seeks to strengthen infrastructure, equipment, human resources, drugs and supplies, quality assurance systems and service provisioning. While the Indian Public Health Standards (IPHS) guide the facility strengthening plan in terms of specifications, appropriate increases in human resources, beds, drugs and supplies commensurate with caseloads are made. New construction are planned taking into account not just population norms, but also taking into consideration other factors such as utilization of existing facility, existence of other facilities (public as well as private) and disease burden. Further, strengthening district hospital capacity entails the creation of a minimum number of hospital beds in the public sector for serving the secondary care clinical needs of the district population. A critical issue in delivering health care in the outreach areas, particularly in hilly and desert areas is the “time-to-care” wherein health care delivery facilities should be within 30 minutes of walking distance from habitation. This implies that additional sub-centres where population is dispersed would need to be created. First Referral Units (FRU) have been envisaged under NHM which provides comprehensive obstetric care services including like cesarean section, newborn care, emergency care of sick children, full range of family planning services, safe abortion services, treatment of Sexually transmitted and other reproductive tract infections (STI/RTI), availability of blood storage unit and referral transport services.
The NHM’s approach towards health care delivery encompasses Community Processes, Behaviour Change Communication, and addressing social determinants. The involvement of Accredited Social Health Assistant (ASHA) for health care outreach is an essential aspect of NHM. ASHA is engaged on the principles of voluntarism, local residency and community based selection. ASHAs responsibilities involve the key roles of facilitation for health care services, community level care provision including counseling and interpersonal communication for behavior change and social mobilization, especially for the marginalized to access essential health care services. The involvement of the local government in the health care delivery and its provisioning is facilitated through the Village Health and Sanitation Committee (VHSNC) which is a sub-committee or a standing committee of the Gram Panchayat. The VHSNCs are supported to develop village health plans and also act as a platform for convergence between different departments and committees at village level for inter sectoral coordination on health related issues.
To provide out reach of health care delivery the NHM supports Mobile medical units (MMUs) for rural and remote areas. Each unit has- one doctor, one nurse, one radiologist, one lab attendant, one pharmacist and a helper and driver. There is provision of medicines in the unit. The NHM also provides for Patient Transport Service (National Ambulance Service (NAS)- 108 which is predominantly an emergency response system (ERS), primarily designed to attend to patients of critical care, trauma and accident victims etc. The capital expenditure of ambulances is supported under NHM and operational cost is supported on a diminishing scale. Further the Mission supports 102 services which essentially consist of basic patient transport aimed largely to cater the needs of pregnant women and children. Both capital and operational cost are fully supported under NHM for free transfer from home to facility, inter-facility transfer in case of referral and drop back for mother and children under the Janini Shishu Suraksha karyakram(JSSK) .
Under the Missions, Human Resources- component’s aim is to strengthen the health system. This inter-alia encompasses engagement of nurses, doctors and specialist on contractual basis based on the appraisal of requirements proposed by the States in their annual Programme Implementation Plans to address shortages in human resources. Additional incentives are also offered, to serve in remote underserved areas, so that health professionals find it attractive to join public health facilities in such areas. Further Performance based incentives are also being provided to motivate service providers to give better service delivery.
Social protection from the rising cost of health care is a desirable and critical component of an effective health system. It is essential that good quality and safe medicines, diagnostics, and therapeutic procedures are accessible, available and affordable to the beneficiaries. Towards this objective, financial support is provided to States under National Health Mission to strengthen the health system including supply of drugs based on the requirement proposed by the State in their annual Programme Implementation Plans. States are being incentivized to prepare policy and establish systems for free distribution of essential drugs including preparation of Essential Drug List (EDL), Standard Treatment Protocols, robust procurement system etc., for free distribution of essential medicines in Public Health facilities. Various programme components under NHM such as Maternal health, Child health, Family planning, Adolescent health and National disease control programmes prescribe specific drugs which are either centrally procured or funds are provided to States/ UTs for decentralized procurement. Apart from programme specific drugs, funds are also provided for general drugs and supplies.
To address the affordability aspect various measures have been taken under NHM . These include: Initiatives under the National Health Mission (NHM) for providing free of cost health care in the public health facilities through a nationwide network of Community Health Centres (CHCs), Primary Health Centres (PHCs) and Sub Centres (SCs) in both rural and urban areas. Various programs such as National AYUSH Mission, Kishor Swasthya Karyakram, Bal Swasthya Karyakram, National Deworming Day, Weekly Iron Folic Acid supplementation program, Menstrual Hygiene Program, Indradhanush, Kayakalp initiative, Free Drugs and Diagnostic Initiative, Janani Shishu Suraksha Karyakaram (JSSK), free medicines under the various national health programmes like Anti-Malaria and Anti-TB Programmes seek to strengthen various health components. The Government has already taken steps towards provision of free services for maternal health, child health, adolescent health, family planning, universal immunisation programme and for major diseases such as TB, vector borne diseases such as Malaria, dengue and kalazar and HIV/AIDS, leprosy etc. Other major initiatives for which states are being supported include Janani Shishu Suraksha Karyakram (JSSK), Rashtriya Bal Swasthya Karyakram (RBSK), Rashtriya Kishor Swasthya Karyakram (RKSK), implementation of National Health Mission Free Drugs Service Initiative and National Health Mission Free Diagnostics Service Initiative.
Implementation and financing of NHM
The programmes under NHM are essentially implemented through the State/Union Territory (UT) Governments. The Central Government supplements the finances of the state for implementation of the schemes. The financing mechanism involves determining the annual resource envelope of the State/UT based on the Government of India’s allocation under various components of NHM, State/UT’s matching share and the available uncommitted balance unutilized. Based on the resource envelope, the Annual Programme Implementation Plan (PIP) is prepared as per Government of India guidelines. This PIP is formulated based on the District Plans, which inter alia takes into account the village and block level plans. Apart from certain core activities the Mission provides flexibility in choosing interventions. Within the broad national parameters and priorities, States would have the flexibility to plan and implement state specific action plans. The PIP consists broadly of the following parts:: NRHM RCH Flexipool, NUHM Flexipool, Flexible Pool for Communicable Diseases, Flexible Pool for Non Communicable Diseases, Injury and Trauma and Infrastructure Maintenance. The NHM also funds innovations.
Monitoring of funds placement under NHM and developing accountability for its proper utilization is facilitated and implemented with formulation of Model Accounting Guidelines and Advisories, E-Banking etc. The overall physical and financial progress of the NHM implementation is also critically examined by various other forums like Joint Review Missions (JRMs) and Common Review Missions(CRMs) consisting of representatives of Central Government, State Government , Development Partners ,and other organizations in the field of health.