Training Module for DPMU Staff Compiled & developed by: State Institute of Health and Family Welfare, Jaipur (An ISO 9001:2008 Certified Institution) Supported by: NRHM, Rajasthan Mission State Institute of Health & Family Welfare, Rajasthan is committed to improvement in health care through HRD, Health Service Research, Consultancy and networking in aiming at enhancement in the quality of life. HEALTH SCENARIO: India Rajasthan Population 2001 [Million] 1028.61 56.501 Projected Population 2010 [Million] 1176.71 66.751 Health Care Infrastructure Community Health Centers 42762 3683 Primary Health Centers 234582 15033 Sub Centers 1460362 114883 Total FRUs 18132 2373 Manpower Status Total Allopathic Doctors 7251904 265924 Total Allopathic Doctors in Govt. 848524 62854 Total Dentist 730574 3644 Total Ayurvedic Doctors 4584184 238614 Total Registered ANMs 5492924 222394 Total ANMs in Govt. 1535682 121503 Total Registered GNMs 9715744 376674 Total Registered LHVs 514974 8504 Total Specialist at CHCs 42792 8113 MBBS Doctors at PHCs 243752 13793 Mortality Indicators Infant Mortality Rate 535 635 Maternal Mortality Ratio 2545 3885 Total Fertility Rate 2.75 3.45 Crude Birth Rate 22.85 27.55 Crude Death Rate 7.45 6.85 Life Expectancy 66.94 67.64 Under 5 Mortality Rate 74.36 85.46 Health Care Indicators Doctor Population Ratio [per 1000] 0.634 0.414 Nurse Population Ratio [per 1000] 1.374 0.944 Bed Population Ratio 0.877 0.678 Population per Sub centre Ratio 78382 57143 Population per PHC 487992 436793 Population per CHC 2677112 1783963 Couple Protection Rate 54.19 579 Proportion of fully immunized children [12-24 months] 54.19 48.89 Proportion of Pregnant receiving ANC [Full ANC] 19.19 6.69 Proportion of Safe Deliveries 52.69 52.79 Institutional Deliveries 479 45.59 3. Census of India, 2. RHS-08, 3.DM & HS, Raj. 4. NHP-08, 5.SRS-09, 6.NFHS-3, 7.CBHI, 8.Pragati Partivedan, 2009, 9.DLHS-3 SIHFW: ISO 9001:2008 Certified institution NRHM Trainings. Feb. 2010 Index S.No. Content Page No. 1. Overview of National Rural Health Mission 001 2. Health care delivery System 012 3. National Health Programs 027 4. PIPs and District Health Action Plan 089 5. Inter Sectoral Convergence 100 6. JSY 105 7. ASHA 118 8. SBA 130 9. VHND (MCHN day) 142 10. Interpersonal Communication / BCC 150 11. IDSP 157 12. Epidemic Preparedness & 162 Outbreak Investigation 13. IMNCI 171 14. ICDS 180 15. VHSC, Role of PRIs & Community Monitoring 189 16. HMIS 198 17. Immunization 205 18. IPHS 213 19. PPP 229 20. Rashtriya Swasthya Bima Yojana 235 21. Policies and Legislation 241 22. Financial Management under NRHM 266 23. Procurement & Logistic Management 278 24. Office Procedures 291 25. NFHS III, DLHS III, SRS 305 0 SIHFW: ISO 9001:2008 Certified institution NRHM Trainings. Feb. 2010 National Rural Health Mission (2005-2012) Conceived on: April, 2005 (May 2005 in Rajasthan) Need: 1. Declining Public Health expenditure (1.3 % of GDP in 1990 to 0.9% in 1999) 2. Limited synergism in Vertical and Horizontal Health Programs 3. Lack of community ownership 4. Lack of integration of issues 5. Regional inequalities 6. Population stabilization still not met 7. Curative services favor rich 8. Poor coverage by Health insurance (only 10%) 9. Hospitalization eats 58% of annual income, 25% pop. falls below poverty line following hospitalization expenses. Objectives: 1. To provide effective health care to rural population with focus on 18 States those have poor health indicators 2. To raise public health expenditure from 0.9% of GDP to 2-3% of GDP Goals: 1. Reduction in IMR & MMR (Rajasthan) a. Infant Mortality Rate to be reduced to 56/1000 live births by 2011 b. Maternal Mortality Ratio to be reduced to 285/100,000 by 2011 2. Universal access to public health services 3. Prevention & Control of Communicable diseases. 4. Access to integrated comprehensive primary health care 5. Population stabilization, gender and demographic balance. 6. Revitalize local health traditions and mainstream of AYUSH. 7. Promote healthy life styles. National Goals in context of MDGs Current 10th FY NPP MDG 2015 Plan 2010 Total Fertility Rate 3 (2003) 2.3 2.1 -- Infant Mortality Rate 53 (SRS-2009) 45 <30 <27 Neonatal Mortality rate 37 (NFHS III) 26 <20 <20 Maternal Mortality Rate 254 (SRS 2006) 200 <100 <100 Institutional deliveries 45.5 % (DLHS-3) 80% 80% - 1 SIHFW: ISO 9001:2008 Certified institution NRHM Trainings. Feb. 2010 The NRHM carries a paradigm shift with- • Decentralised planning • Outputs and Outcome based • Pro-Poor Focus: Equitable systems • Quality of Care and the IPHS norms • Rights based service delivery • Pre stated entitlements at all levels • Inputs computed as function of the entitlements and estimated patient load • Judicious mix of dedicated budget lines - untied funds • Monitor quality • Community Participation • Bringing the public back into public health • At hamlet level: ASHA, VHSC, SHGs, Panchayats. • At the facility level: RKS • At the management level : health societies • Governance reform • Manpower, Logistics & Procurement processes. • Decision making processes • Institutional design, Accountability framework • Convergence • Water and sanitation • Nutrition • Education The Mission outcomes are expected to follow a phased approach and are at two levels: 1. National Level a. Infant Mortality Rate to be reduced to 30/1000 live births b. Maternal Mortality Ratio to be reduced to 100/100,000 c. Total Fertility Rate to be brought to 2.1 d. Malaria mortality reduction rate – 50% up to 2010, additional 10% by 2012 e. Kala Azar to be eliminated by 2010. f. Filaria/Microfilaria reduction rate: 70% by 2010, 80% by 2012 and elimination by 2015 g. Dengue mortality reduction rate: 50% by 2010 and sustaining at that level until 2012 h. Japanese Encephalitis mortality reduction rate: 50% by 2010 and sustaining at that level until 2012 i. Cataract Operation: increasing to 46 lacs per year until 2012. j. Leprosy prevalence rate: to be brought to less than 1/10,000. k. Tuberculosis DOTS services: from the current rate of 1.8/10,00, 85% cure rate to be maintained through the entire Mission period. l. 2000 Community Health Centers to be upgraded to Indian Public Health Standards m. Utilization of First Referral Units to be increased from less than 20% to 75% n. 250,000 women to be engaged in 18 states as Accredited Social Health Activists (ASHA). 2. Community Level a. Availability of trained community level worker at village level, with a drug kit for generic ailments b. Health Day at Anganwadi level on a fixed day/month for immunization, ante/post natal checkups mother & child healthcare, including nutrition c. Availability of generic drugs for common ailments at Sub-centre and hospital level 2 SIHFW: ISO 9001:2008 Certified institution NRHM Trainings. Feb. 2010 d. Good hospital care through assured availability of doctors, drugs and quality services at PHC/CHC level e. Improved access to Universal Immunization through induction of Auto Disabled Syringes, alternate vaccine delivery and improved mobilization services under the program f. Improved facilities for institutional delivery through provision of referral, transport, escort and improved hospital care subsidized under the Janani Suraksha Yojana (JSY) for the Below Poverty Line families g. Availability of assured healthcare at reduced financial risk through pilots of Community Health Insurance under the Mission h. Provision of household toilets i. Improved Outreach services through mobile medical unit at district-level. Areas addressed: 1. AYUSH 2. Maternal & Reproductive health 3. Population stabilization 4. HMIS 5. Micro planning 6. Integration of programs and services 7. Health expenditure pattern and quantum 8. Indian Public Health Standards (IPHS) 9. Interstate and inter district disparities 10. Access, Availability, Affordability and equity Components of NRHM: 1. RCH-II 2. All activities of NRHM a. ASHA b. JSY (Janani Suraksha Yojana) c. Institutional deliveries and cash assistance d. United fund of Rs. 10000/- for each Sub Centre e. Dai Training f. RCH camps g. On-Contract staff deployment h. Immunization i. National Health Programs j. Inter-sectoral and inter-departmental coordination 3. Vector Borne Disease Control Program 4. TB control program 5. Blindness control 6. Leprosy Eradication 7. Iodine Deficiency Disorders 8. Disease Surveillance project 9. HMIS Reach: 18 High focus statesStates (UP, Uttaranchal, MP, Chhattisgarh, Bihar, Jharkhand, Orissa, Rajasthan, HP, J&K, Assam, Arunachal Pradesh, Manipur, Meghalaya, Nagaland, Mizoram, Sikkim and Tripura) Now extended to entire country 3 SIHFW: ISO 9001:2008 Certified institution NRHM Trainings. Feb. 2010 Approach: The 5 main approaches under NRHM are- 1. Communitize a. Hospital Mgt. Committees/ PRIs at all levels b. Untied grants to communities / PRI bodies c. Funds, functions and functionaries to local community d. Decentralized planning e. Intersectoral convergence 2. Flexible Financing a. Untied grants b. NGOs for public health goals c. NGOs as implementers d. Risk pooling e. More resources for more reforms 3. Improved management through capacity building a. Block and District health offices through mgt. b. NGOs in capacity building c. NHSRC/ SHSRC/ DRG/BRG d. Continuous skill development support 4. Monitor progress against standards a. Setting IPHS standards b. Facility surveys c. Independent monitoring committees at Block, District & State 5. Innovation in human resource management a. More nurses-Local resident criteria b. 24 x 7 emergencies by Nurses at PHC. AYUSH c. 24 x 7 emergencies by Nurses at CHC d. Multi skilling. Strategy: 1. Capacity building of PRIs to own and manage public health services. 2. Promote access to improved health care at house hold level through ASHA (Accredited Social Health Activists). 3. Health plan for each village (micro-planning) through village Panchayat health committees. 4. Strengthening sub-centre through a united fund to enable local planning and action. 5. Strengthening existing CHCs with provision of 30-50 beds per lac population for improved curative care to a normative standard (IPHS) regarding personnel, equipment, and management standards. 6. Preparation and implementation of an inter-sectoral district Health plan prepared by District Health Mission including Water, Sanitation & Hygiene and Nutrition. 7. Integration of Vertical Health & Family Welfare Programs at National, State, District and Block levels. 8. Technical support to National, State and District Health Missions. 9. Strengthening capacity for information management and evidence based planning, monitoring and supervision. 10. Developing capacity for preventive health care. 11. Promoting Non-profit sector particularly in under served areas. 4 SIHFW: ISO 9001:2008 Certified institution NRHM Trainings. Feb. 2010 12. Supplementary strategy- a. Regulation of private sector b. Promotion of Private Public Partnership c. Mainstreaming AYUSH d. Re-orienting Medical Education towards rural health issues e. Effective and viable risk pooling and social health insurance Situation at the time of rolling out of NRHM Indicator source National situation Current value IMR SRS 25, RGIs Office 58 (Kerala:14, MP: 76) 53 (SRS, Oct.2009) Rajasthan-63 Maternal 301 (Kerala:4,UP: 517) 254 (Special bulletin on Mortality Ratio MMR-SRS 2004-06, Rajasthan-388 Non hospitalized NSS 60 th round 2004 22% (Bihar 5%, HP-68%) treatment on Govt. facilities In patient treated NSS 60 th round 2004 41.7% (Bihar-14.4%, J&K- in Public 91.3) Hospitals Average medical NSS 60 th round 2004 Rs. 3238 in Govt. Hospitals to expenditure per Rs.7408 in pvt. Hospitals in Hospitalisation rural areas State of Health DLHS and facility Adequacy cut off- 60% facilities survey coordinated by Infrastructure- 76% FRU’s, IIPS 2003 63% of CHC’s, Equipment: 61% FRU’s, 46% CHC’s Manpower: 37% FRU’s and 14% CHC’s Anemia among NFHS-III (2005-06) 79.1%-6-35 months 56.1% children and women women Immunization UNICEF’s coverage 54.5% children Rajasthan-FI-48.8% evaluation survey (DLHS-3) 2005 Institutional NFHS-III (2005-06) 40.7% institutional births , Rajasthan-ID-46% births, 3 50.7% 3antinatal care visits, (DLHS III, 2008), ANC- antenatal care 36.4% post natal 56%, PNC-38.2% visits, post natal care Child morbidity FOCUS survey 2004 Fever-32%, Dioarrrohea- (Jean Dreaz et al) in 21%,persistant cough-17%, Tamil Nadu, HP, extreme weakness- 11%, skin Maharashtra, Raj, rashes-5%, eye infections - Chattisgarh, and UP 2%, 50% children had one of the above problems 5