NATIONAL HEALTH MISSION

 
Convergence
 
 
Intrasectoral and Intersectoral

Intersectoral co-ordination is a crucial component of the National Rural Health Mission (NRHM) and promotion of intersectoral linkages is imperative for its effective implementation. These linkages can be within the public health system such as RCH, National Disease Control programme and AIDS control programmes or with other departments like the Department of Women and Child Development and the Department of Education for health, nutrition and education programmes. These linkages could also be with the NGOs, the private health sector and the corporate sector with the overall objective of reducing duplication and fragmentation of efforts.

The pulse polio drives have demonstrated that effective mobilization of civil society can achieve remarkable results hence forging of partnerships with the government departments, NGOs, the corporate sector, trade unions, human rights commission, police, legal bodies, political parties, media and academic institutions will be promoted aggressively.

COMMON ISSUES:

  • Decentralized Community Management

Decentralization enables local people to initiate sustain and support action for children and women. The focus will be on capacity building of the panchayats in the rural areas and nagar palikas in the urban areas so that they are able to plan, implement and monitor local programmes for children. Participation of local NGOs, women’s groups, parents, families and the community will be encouraged to complement the efforts of the government. At the same time efforts will also be made to link up with the decentralization processes within sectors already underway at both the centre and the state levels. The Village Health and Water and Sanitation Committee is the point of convergence for all the stakeholders and decentralized planning.

  • Enhancing Women’s Capabilities

This will constitute a major strategic thrust of the programme and is particularly important due to the persistence of gender inequalities that exist. Besides promoting economic opportunities for women there will be a special emphasis on improving the position of women in society and the effectiveness of women’s participation in community level decision making. This requires major changes to be brought about in perceptions so that women become socially, politically and culturally more effective in influencing public decision-making. This is the mandate in all the development programmes

  • Ensuring Equity

Equity is a major cause of concern because the benefits of all the programmes should reach the unreached - the deprived communities, Poor, inaccessible areas, Schedule tribes, Schedule castes and females. NRHM proposes to ensure convergence of basic social services in order to bring government service providers into closer and more responsive working relationships with the community for convergent community action. This will enable better equity and wider coverage. This approach offers an opportunity to ensure contextuality of programme interventions and will form the basis of developing detailed programmes at district and local levels in cooperation with the state governments.

  • National Disease Control Programmes

The NDCS encompasses: National Vector Borne Disease Control Programme, the National Leprosy Eradication Programme, the Revised National Tuberculosis Control Programme, and the National Blindness Control Programme.

  • The National Vector Borne Disease Control Programme (NVBDCP)

NVBDCP includes major vector borne diseases of public health importance, such as: Malaria, Filariasis, Japanese Encephalitis, Dengue fever/Dengue Haemorrhagic fever, and Kala-Azar. At the National level the Directorate of NVBDCP provides policy and supervisory oversight. At the state level the state directorates are administering the programme. Fund flows are a mix of cash and commodity assistance for all five strategies encompass actions at household, community and system levels. They include early diagnosis and prompt specific treatment/case management, integrated vector control mechanisms, community based health education, training and capacity building of various cadres of medical and paramedical staff for prevention, management and control, and effective monitoring, supervision and surveillance. NRHM will focus on all diseases of NVBDCP. Actions to be taken under the NRHM are:

  • ASHA and Village Health Team to be oriented to community based vector control strategies. Convergence with Water and Sanitation Mission will facilitate this process.
  • ASHA to be able to give presumptive treatment for malaria.
  • Enhanced surveillance capacity (human resources and infrastructure) at PHC and CHC levels
  • Enhancing laboratory capacity at CHC and PHC.
The National Leprosy Eradication Programme (NLEP)

Leprosy is a disease of public health concern in India. Current prevalence is 1.8/10,000. One of the key outcomes in NRHM is to eliminate Leprosy. Under NRHM, the strategies drawn up under the second National Leprosy Elimination Project are to be continued. The five key components include: Decentralization and Institutional Development, Strengthening and Integration of Service Delivery, Disability Care and Prevention Information, Education, and Communication, and Training. Services will continue to be provided at PHC, CHC, Additional PHC, and Hospitals with support from the district nucleus. The subcenters will be involved in delivery of second and subsequent doses of MDT. Village and District Health Plans will enable identification and ensure referral of cases requiring disability treatment to the appropriate facility. CMOs and medical officers will continue to be trained on leprosy programme management.

Revised National TB Control Programme (RNTCP)

The Revised National TB Control Programme (RNTCP) is the vehicle through which the WHO recommended DOTS (Directly Observed Therapy, Short Course) strategy is implemented in India. Currently Phase 2 of the RNTCP is underway and all districts in are being covered. As part of the programme, Microscopy centers are established at PHC, CHC, or district hospitals. RNTCP supports the salary of laboratory technicians, laboratory supplies and consumables. All medical officers are trained under RNTCP for diagnosis, management, and referral. All SCs, PHCs, CHCs, and District Hospitals function as DOTS centers. Community level DOTS providers are also trained in delivery of the drugs. Para medical staff re trained in monitoring consumption of anti TB drugs. The RNTCP also involves civil society organizations in its outreach and communication efforts. Under NRHM, the ASHA will be the facilitator for early access to diagnosis, referral and follow up as a community provider of DOTS.

National Blindness Control Programme (NBCP)

The National Blindness Control Programme aims at reducing the prevalence of blindness form the current level of 1.1% to 0.5% by 2010. Apart form providing surgical treatment (Intra Ocular lens-IOL) for cataract, which is the leading cause of blindness, the programme seeks to tackle other causes of blindness such as childhood blindness, glaucoma, and retinal disorders. School health check up is also one of the major components of the programme. ASHA would play an important role in creating awareness of the programme and motivate people to seek treatment. NRHM would also seek to create synergy between the NBCP and the Vitamin A programme.

Integrated Disease Surveillance Programme (IDSP)

The IDSP (2004-2009) is a decentralized Information Technology based surveillance system, which monitors the incidence of a set of high priority communicable diseases and risk factors associated with non-communicable diseases. The project also provides for a rapid response to any outbreak, should the number of cases exceed pre-defined threshold levels. Through effective surveillance of such conditions, IDSP would provide a strong foundation to the disease control programmes under NRHM. ASHA, being the link between the community and the public health system would be a very important component of the programme.

NATIONAL AIDS CONTROL ORGANISATION (NACO):

The Department of Family Welfare has been actively collaborating with the NACO and Department of Women and Child Development for co-ordination between the RCH, AIDS and ICDS programmes in order to ensure optimal utilisation of resources. Co-ordination between these would also assist in delivering HIV/AIDS awareness messages at the grass root level through the field workers of these programmes who have established credibility with the community. At present there is no evidence about the effectiveness of this strategy mainly because this is a relatively recent initiative and mechanisms need to be developed to monitor co-ordination between the three programmes.

The Department of Family Welfare will benefit from those NACO activities which are aimed at blood safety and safe sexual practices, while NACO will benefit from the RTI/STI control activities which have been introduced in the RCH programme. A co-ordinated approach for setting up of RTI/STI clinics needs to be adopted by both departments wherein NACO will establish these clinics in district hospitals, while the RCH programme will establish these facilities at FRU/CHC levels.

 
Convergence with Water and Sanitation
All major infectious agents that cause diarrhea are transmitted by the faecal oral route. Availability of good quality water and sound hygienic practices are crucial to interrupt faecal-oral transmission. Several studies show a median reduction between 27% - 30% in diarrhea morbidity and mortality. Sanitation facilities are available in very few dwelling units. The Department of Drinking Water Supply, (DDWS) Ministry of Rural Development (MoRD) implements two Mission mode initiatives for improving access, coverage, quality of safe water and sanitation in a sustainable manner - Swajaldhara Scheme and the Total Sanitation Campaign (TSC). Activities under TSC are: Construction of individual household Latrines, Community Sanitary Complexes, Anganwadi Toilets, IEC, School Sanitation and Hygiene Education, and Rural Sanitary Marts and Production Centers,

Swajaldhara, TSC and NRHM rely on community led approaches and are expected to be managed by panchayats. Strong intersectoral convergence is necessary at the district and state levels for improved synergy among these three initiatives. The institutional arrangement for the Total Sanitation Campaign (to be universalized) will be the same at District and Village levels. However budgeting for the programmes will remain separate.

Integrated Child Development Services (ICDS)
Co-ordination between the ICDS and the RCH programmes is by far the most significant attempt by the Government for promoting inter sectoral co-ordination in the RCH programme. This is crucial for the successful implementation of the RCH programme, as it would result in increasing service coverage for women and children, reducing the unmet need and ensuring better quality of services. It is therefore important that both the Departments of Women and Child Development (DWCD) and Family Welfare (DOFW) should make concerted efforts to co-ordinate their activities at the grass root, district, state and central levels.

The Community Needs Assessment Approach (CNAA) was evolved to ensure the involvement of the Panchayati Raj Institutions (PRIs) in planning and implementation of the RCH programme. It was envisaged that the ANM, AWW, and members of the Panchayat and the Mahila Swasthya Sangh (MSS) would consult with each other and the community in order to prepare the Sub Centre Action Plan as a first step towards the process of decentralized planning in the RCH programme. However reports indicate that this consultative process has been sporadic and disjointed and has not resulted in contributing meaningfully to the preparation. Still both the functionaries are doing independent yearly Household surveys and the data differs.

The AWWs are providing support to the child survival components of immunisation, diarrhoea management and vitamin A deficiency control, in addition to the identification and treatment of common childhood diseases at an early stage through growth monitoring. Moreover, they also support safe motherhood components like prophylaxis for nutritional anemia, TT immunisation for pregnant women and nutritional supplementation for pregnant and lactating mothers in the project areas.

They are already trained for detecting common childhood illnesses including diarrhoea and pneumonia and commonly refer ill children to the ANMs at the sub centres or to the Primary Health Centres. The ANM is responsible for providing primary health care, ante natal care, post natal care, child care, immunization, and counseling and promotion of family planning. These services are provided by the ANM at the sub centre as well as during her field visits to the villages.

Although there is evidence of co-ordination between the DWCD and the DOFW at the field level, particularly in the immunization programme, there is a need for more effective co-ordination between both the departments at district, state and central levels for implementing the other components of the RCH programme more effectively. There is considerable overlap in the duties being performed by the AWWs and the ANMs and there is a need to rationalize their roles and responsibilities by DWCD and DOFW .

The AWC will continue to serve as the focal point for all health and nutrition services. As part of the NRHM, a Maternal, Child Health Nutrition Day (MCHN) has been fixed every month at the AWC to provide antenatal, postnatal, family planning and child health services. An ANM and preferably a Medical officer from the PHC will be in attendance. With active support from Community Groups such as Self Help Groups (SHG) to motivate the AWW and ASHA could mobilize women and children and motivate to access services.

Services to be provided on the MCHN Day include:

  • ANC
  • Newborn check up
  • Postnatal care
  • Immunization of mothers and children
  • IFA and Vitamin A administration,
  • Growth monitoring,
  • Treatment for minor ailments
  • Health education.

ANM, AWW and ASHA would provide counseling to the community regarding the importance of institutional deliveries and facilitate referral. AWW and ASHA will also counsel communities on the importance of balanced diets and promote the use of locally available foodstuffs, particularly for micronutrient supplementation.

Training programme content for effective service delivery by ANM, AWW, Sahyogini and ASHA
The following services, some of which are already being provided, can be delivered through the joint efforts of the ANM, AWW, Sahyogini and ASHA after appropriate training, for more effective co-ordination between the ICDS and the RCH programme:

  • Prevention and management of unwanted pregnancy
    1. Ante-natal Care
    2. Delivery Services
    3. Post-natal Care
    4. Child Surviva
    5. Management of RTIs/ STIs

Ayush
Integration of Ayush

The integration of Ayush is to be carried out at the State and district level :

Membership of the State and District Mission and the Integrated State and District Health Societies of a person from Ayush so that they are part of all the decision making processes. Wherever there are CMHO complexes the Ayurveda district personnel will be housed in this complex.

Mainstreaming will begin in two CHCs selected for the IPHS. The infrastructure will be used for providing a greater availability of services. All the National Programmes will also be implemented by Ayush with regular reporting. The CMHO will ensure all the supplies to the Ayush. The Ayush personnel will also be involved in wider publicity of all the schemes and messages. All the IEC material will be given by the IEC department to the Ayush personnel. Trainings also will be jointly carried out so that the skills of the Ayush personnel can carry out the National programmes effectively.

Outreach services also will be carried out through RCH camps and Sanjeevni camps, wherein the Ayush personnel will be provided with Ayurvedic medicines.

Monitoring and Evaluation

NRHM will build on the M and E arrangements established as part of RCH II and the IDSP to strengthen capacity for M and E as well as establish systems to enable collection of data and disaggregate by age, gender and other categories as required. Management Information Systems under the NRHM will be web enabled for citizen scrutiny. Civil society organizations will collaborate with the health system in preparing a People’ Health Report at the district level. . State and National reports anon People’s health to be tabled in assemblies and parliament. Each health facility will report to their respective Panchayats- sub centers to the Gram Panchayat, Hospitals to the Rogi Kalyan Samiti, and District Heath Mission to the Zila Parishad. External evaluations of the NRHM will be conducted through professional organizations with involvement of civil society. The M and E will serve to inform mid course reviews and enable corrective action in a timely manner.

 
Role of NGO's
NGOs in NRHM

NGOs can play a very important role in the success of NRHM.their role is to compliment the efforts of government.The activities envisaged for NGOs are as follows:

  1. Provide support in the selection training and post training follow up of ASHAs.
  2. Responsible for providing support and/preparation of annual plan of the district .
  3. Providing support in proper data collection especially at the time of CNAA and the yearly survey conducted by the AWW.
  4. Provide support in registration/ identification of private practitioner / Hospitals
  5. Ensure sanctioning of fund for each block/PHC/CHC.
  6. Oversee overall monitoring and evaluation of the Schemes and matters concerned therewith.
  7. Make necessary report to the State and the SHM/State’s Implementation Committee.
  8. 8. Ensure wide and continuous publicity of the benefits under all the schemes JSY and the procedures for claiming the benefit through posters, brochures, media, display of information at all Sub-centres, PHCs, CHCs and District Hospitals, Urban Health Centres, Health posts and those private hospitals, nursing homes/ clinics recognized/accredited for implementation of the Scheme.
  9. Awareness regarding the good health practices to the community e.g; Safe motherhood, Family planning, Child health, gender issues, age of marriage, Sanitation, including water, prevention of Malaria, good hygiene, safe sexual health.
  10. Ensuring the wide participation of the community in the fixed MCHN days.
  11. Counselling of the Community on various issues.
  12. Early detection of Tuberculosis, Promotion of DOTS and also in the direct implementation of DOTS.
  13. Leprosy: NGOs will continue to be involved in reconstructive surgery, disability care and prevention, and IEC. Village and District Health Plans will enable identification and ensure referral of cases requiring disability treatment to the appropriate facility.
  14. Capacity building of the PRIs.
  15. Developing the capacities of the Village health and Water Sanitation Committees to function effectively.
  16. Effective Gram Sabhas especially for development issues.
PRI's and NRHM
Panchayati Raj Institutions and NRHM

Panchayats in India are an age-old institution for governance at village level. In 1992, through the enactment of the 73rd Constitutional Amendment, Panchayati Raj Institutions (PRI) were strengthened as local government organizations with clear areas of jurisdiction, adequate power, authority and funds commensurate with responsibilities.

Panchayats have been assigned 29 rural development activities, including several, which are related to health and population stabilization. The XI schedule includes Family Welfare, Health and Sanitation, (including hospitals, primary health centers, and dispensaries,) and the XII schedule includes Public Health. Thus the possible realm of influence of the Panchayats extends over a significant proportion of public health issues. The Gram Sabha, where empowered has the potential to act as a community level accountability mechanism to ensure that the functions of the village Panchayat in the area of public health and family welfare, actually respond to people’s needs.

Increasingly it is being realized that strategies for achieving low infant, under five and maternal mortality depend on a functioning continuum of high quality services from community to secondary and sometimes higher levels of care. In addition community support for such services comes through behavior change to increase utilization as well as demand high quality services. In the RCH 2 implementation document, specific mention is made of plans to support PRI (and urban counterparts) in design, implementation, monitoring of RCH related interventions. This is also seen as a potential to address the social determinants of health through engagement with communities and PRI rather than a biomedical approach. It is also expected that PRI involvement will increase community understanding of issues of accountability for quality and reliability of health care services.

Critical Role of Panchayati Raj Institutions in NRHM

The National Rural Healthcare Mission, designed to integrate health and family welfare related interventions and address health from a holistic preventive, promotive and curative viewpoint takes a much more significant view of PRI engagement. The fulcrum of the NRHM programme is a social activist(ASHA) at the village level, who will work with the village level resource team in providing preventive and promotive health care services. It is expected that she will be supervised and supported by the panchayats.

Thus there is opportunity for PRI involvement to address the non technical components of health care seeking, provided all PRI representatives are exposed to a perspective building exercise on health within the framework of gender and equity.

Linkage from the village to Gram Panchayat to Block and District

At the village and Gram Panchayat level: The Village Health Committee (VHC) will form the link between the Gram Panchayat and the community. The VHC would be responsible for working with the Gram Panchayat to ensure that the health plan is in harmony with the overall local plan. It is anticipated that this committee will prepare a Village Health Plan and maintain village level data, supervised by the Gram Panchayat. Engaging the Gram Sabha and other groups in planning and monitoring the Village Health Plan will presumably enforce transparency and accountability.

Under the NRHM, untied funds of Rs. 10,000 are placed with the ANM to meet unanticipated expenditures and to ensure that lack of drugs and other consumables is not an issue. An account has been opened with the Sarpanch for operationlization of the activities planned. At the subcentre level planning and use of these funds will be supported by the appropriate tier of the panchayat.

Block Level: At the block level a Block Co-ordination Committee with the Block Nodal Officer /Block Panchayat President as Chairperson and the involvement of PRIs and civil society will be formed for effective functioning and convergence. This will be linked to the Meeting of the Block level Committeess under the Pradhan.

District level: At the District level the District Health Mission will coordinate NRHM functions and are under the Zila Pramukh.

ASHA and the PRIs

The selection of ASHA is the responsibility of the Gram Panchayat where it will be finalized in a meeting of the Gram Sabha.
The success of ASHA scheme will depend on how well the scheme is implemented and monitored. It will also depend crucially on the motivational level of various functionaries and the quality of all the processes involved in implementing the scheme.

  • At the village level ASHA will receive support from the women’s committees (like self help groups or women’s health committees), Village Health & Sanitation Committee of the Gram Panchayat, peripheral health workers especially ANMs and Anganwadi workers, the trainers of ASHA and mainly the Panchayat members.
  • At the block level, ASHA scheme will have a Block Co-ordination Committee with the Block Nodal Officer /Block Panchayat President as Chairperson and the involvement of PRIs and civil society.
  • The Gram Panchayat would lead the ASHA initiative in selection of ASHA, providing regular support in undertaking many health related tasks through its statutory health committee, developing the village health plan and in the compensation incentive. All ASHAs will be in this Village Heath & Sanitation Committee of the Panchayat either as members or as special invitees
  • The state level NRHM committee will monitor and support the District Health Society and District Nodal Officer.