TASK GROUP-I
GOALS OF THE MISSION AND ITS KEY COMPONENTS/STRATEGIES
Preamble
•The National Rural Health Mission seeks to provide effective health care to the entire rural population in the country with special focus on 18 states which have weak public health indicators.
•The Mission is an articulation of the commitment of the Government to raise public spending on Health from 0.9% of GDP to 2-3% of GDP, over the next 5 years.
•It aims to undertake architectural correction of the health system to enable it to effectively handle increased allocations as promised under the National Common Minimum Programme.
•It has as its key components provision of a health activist in each village; a village health plan prepared through a local team headed by the panchayat representative; strengthening of the rural hospital for effective curative care and made measurable through Indian Public Health Standards (IPHS), and accountable to the community; and integration of vertical Health & Family Welfare Programmes and Funds for optimal utilization of funds and infrastructure and strengthening delivery of primary healthcare.
•It aims at effective integration of health concerns with determinants of health like sanitation & hygiene, nutrition, and safe drinking water through a District Plan for Health.
•It seeks decentralization of the programme for district management of health.
•It seeks to address the intra-State and inter-district disparities, especially among the 18 high focus States, including unmet needs for public health infrastructure.
•It aims to promote policies that strengthen public health management and services in the country.
•It shall define time-bound goals and report publicly on their progress.
•Above all, it seeks to improve access of rural people, especially poor women and children, to equitable, affordable, accountable and effective primary healthcare.
Guiding principles
•Promote Equity
•Enhance People orientation and community based approaches
•Ensure Public Health Focus
•Recognize value of traditional knowledge base of communities
•Decentralize and involve local bodies.
Goals
•Reduction in Infant Mortality Rate and Maternal Mortality Ratio by 50% from existing levels in next 7 years
•Universalize access to public health services : such as Women’s health, child health, water, sanitation, immunization, Nutrition….
•Prevention and control of communicable and non-communicable diseases, including locally endemic diseases
•Access to Integrated comprehensive primary healthcare
•Assuring Population stabilization, gender and demographic balance.
•Promotion of healthy life styles
Outcomes
•Provision of trained and supported Village Health Activist in under served areas as per need (ASHA) – Ensuring quality and close supervision of ASHA.
•Preparation of health action plans by panchayats as mechanism for involving community in health.
•Strengthening SC/PHC/CHC by developing Indian Public Health Standards
•Institutionalizing and substantially strengthening District level Management of Health (all districts)
•Increase utilization of First Referral Units from less than 20% (2002) to more than 75% by 2010
•Strengthening sound local health traditions and local resource based health practices related to PHC and public health
Core Strategies
•Train and enhance capacity of PRIs to own, control and manage public health services.
•Promote access to healthcare to household through the female health activist (ASHA).
•Health Plan for each village through Village Health Samiti of the Panchayat.
•Strengthening sub-centre through an untied fund to enable local planning and action and more MPWs.
•Strengthening existing PHCs and CHCs, and provision of 30-50 bedded CHC per lakh population for improved curative care to a normative standard (Indian Public Health Standards defining personnel, equipment and management standards).
•Preparation and Implementation of an inter-sectoral District Health Plan prepared by the District Health Mission, including drinking water, sanitation & hygiene and nutrition.
•Integrating relevant vertical Health and Family Welfare programmes at National, State and District levels.
•Technical Support to National, State and District Health Missions, for Public Health Management.
•Strengthening capacities for data collection assessment and review for evidence based planning – monitoring and supervision…
•Ensure formulation of transparent policies for deployment and career development of Human Resources for health.
•Developing capacities for preventive and promoting health care at all levels – such as healthy life styles, reduction in consumption of tobacco and alcohol….etc.
•Promoting non-profit sector particularly in under served areas.
Supplementary Strategies
•Regulation of Private Sector, including the informal rural practitioners, to ensure availability of quality service to citizens at reasonable cost.
•Promotion of Public Private Partnerships for achieving public health goals.
•Mainstreaming AYUSH. – revitalizing local health traditions.
•Reorienting medical education to support rural health issues including regulation of Medical care and Medical Ethics.
•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.
TASK GROUP-II
STRENGTHENING COMMUNITY HEALTH CARE THROUGH COMMUNITY LEVEL ACTIVISTS
Scope and Role of Works
•Awareness generation/information dissemination on determinants including social determinants of health.
•Facilitator for utilization of services in villages/sub centres on the basis of entitlements
•Escorting/accompanying women, children from poor sections to negotiate clinical services at CHCs, DHs,private sector
•ASHA will also work as primary medical care provider for minor ailments. Initially for treatment of ailments like diarrhea, malaria, fevers, minor painful conditions, providing dots treatment, spacing methods, act as depot holder for DDK and condoms to help implement NHPs.
•Her training should be enhanced in a graded manner to provide care for child health illnesses, new born care, as also care for maternal health, other national programmes and a larger range of common ailments. Her movement from level one to level two should occur after appropriate evaluation.
Selection of ASHAs (I)
•There should be one ASHA for 1000 population,
However in tribal, hilly, desert areas there would be one ASHA per habitation
For non tribal areas the range of norm would be one ASHA for 500-1500 population and 2 ASHA in case of population above 1500
•ASHA must be an ever married woman volunteer, preferable within age group of 25-45 yrs.
•Adequate representation from disadvantaged groups
•ASHA should be able to reach out, have effective communication skills and leadership qualities. Preferably literate woman; however this should not be a limiting condition.
Selection of ASHAs (II)
•The states may decide if they wish to have ASHA at sub centre, HQ/PHC HQ, village or villages with more than 1000 population.
•There should be phased selection process for example:
SHGs/NGOs/CBOs may suggest names
Gram Sabha may shortlist 3 names
A workshop be held for such short listed women during which assessment of aptitude and skills, final selection may take place. NGOs and PRI representatives may be involved in the workshop.
•A small core group will work out the final details in this regard.
Selection of ASHAs (III)
•Existing NGO health programmes or networks of grass roots health functionaries or groups may be considered for selection of ASHAs by the states.
•Geographic phasing of selection and programme
Phase one: 20% villages
Phase two: 40% villages
Phase three: 40% villages
•The state may have flexibility in determining population norms as per local needs and literacy requirements. However selection process, women being selected as ASHA and age criteria will be uniform.
Compensation to ASHA
•ASHA would be an honorary volunteer. She will not receive any honorarium/stipend. One option suggested was that a portion of funds from various NHPs could be considered to be given to the Panchayat as an annual grant who would in turn compensate ASHA.
•Wherever compensation is available under various schemes under programmes of GOI and state governments, these schemes should provide for payment to ASHA
•ASHA should be adequately compensated for wages lost for the days she is invited to attend trainings and other follow-up meetings
•Group recommendations/awards may be considered
•Non monetary incentives e.g. Exposure visits, annual conventions etc. can be considered
•A drug kit containing basic drugs should be given
Training
•Various models of training have been suggested by members.
•A contact plus distance learning model may be considered
•NGO/private partnership(based on training experience, quality criteria) may be considered
•ICDS training centres and state health institutes may be involved
•Comprehensive women's health and empowerment model
•Various NGO models which have proved effective should be considered
Suggestions
•A core group for training should be constituted for finalizing the details of the training strategy including its contents. The role of state training institutions and NGOs should be considered by the core group.
•Effective training will be critical for ASHA. Use of experiential training will be useful in the light of adult learning principles. While broad training guidelines can be finalized by central governments, the state should have flexibility to modify, adapt these guidelines as per their state needs.
•Duration of training; initial training followed by periodic training as a continuous process in principle.
•Monitoring the standard of training
•Accreditation by a national consortium
•State level core groups including NGOs for strategizing, training and monitoring
•Training material- primarily pictorial, local/herbal remedies to be included.
•Re-look at roles of government health functionaries vis-à-vis ASHA especially ANM/AWW
Institutional Arrangements
•Clear and defined arrangements are considered important for implementing ASHA scheme
•The task force suggested for training should also look into the details of selection processes, compensation package and arrangements for flow of funds to ASHAs
General Points
•While ASHA is tasked with awareness generation and mobilization of communities, strengthening health care delivery systems should go side by side to provide for the demand created by ASHA
•There should be mechanisms for accountability and periodic monitoring to assess if the stated objectives are being achieved. The guidance note should reflect on key impact indicators
TASK GROUP-III
STRENGTHENING PUBLIC INSTITUTIONS FOR HEALTH DELIVERY, INCLUDING UPGRADING CHCs TO IPHS, MAINSTREAMING ISM, REGULATION OF HEALTH PROVIDERS AND ALSO REFORM IN THE AREAS OF PUBLIC HEALTH MANAGEMENT THROUGH APPROPRIATE INSTITUTIONAL ARRANGEMENTS
Review Process
•The Group reviewed the existing Rural Health Care infrastructure and the issues related to their functional status
•The Group also reviewed proposed provisions under the RCH-II and the NRHM
•The Group took note of the gaps and shortcomings in the existing health care system and examined them in the context of the proposals under the NRHM.
Views/Recommendations-1
•The Group appreciated the efforts made by the MOHFW to address the gaps and shortcomings in the existing health care system and the appropriate of the strategies proposed.
•However, some suggestions/ recommendations are put for the consideration.
Village level
•It appears that the ASHA will form the link between the village community and the ANM/MPW
•The Group support for creation of this voluntary worker provided ASHA is properly selected, trained and equipped and is not considered a Govt. servant at any stage.
Sub-Centre
•Group supports the proposals for strengthening of SCs.
•No. of sub-centres established should be as per 2001 census population.
•The necessity of a male worker was strongly felt. To ensure that MPWs are available at all SCs, Centre should bear at least 50% salary of each MPW.
PHC-1
•The Group felt that NHRM should provide the maximum support to strengthen the PHC so that these can provide quality preventive, promotive and curative services and supervise and monitor the SCs, AWs and ASHA.
•Adequate and regular supply of quality essential drugs and equipment must be ensured.
•2 doctors (1 male, 1 female) should be posted at each PHC.
•If doctors are not available, they may be appointed on contract basis from private practitioners if properly certified by CMHO.
•AYUSH physicians may be posted on the felt need, but no cross prescription should be allowed between them and the Allopathic doctors. They however, should be fully used for preventive and promotive services and supervision of SCs, ASHA.
PHC-2
•Adequate referral system and support should be ensured.
•Local community should have some hold on PHC through some mechanism such as Rogi Kalyan Samiti.
•Fill up all posts of LHV and Centre should provide 50% Salary of each male supervisor.
•Standard treatment guidelines and protocols must be available at all PHCs.
CHC
•Group supports all the provisions under the NRHM for CHC
•Anaesth. should be posted in all CHCs. If not available, one of other doctors may be given 6 month training in Anaesthesis.
Urban Health Care
•The Group felt the need of availability of Primary Health Care in urban areas and recommends that all poor whether living in slums or not should have access to the Primary Health Care services on the modal of Rural Health Infrastructure.
Private Sector
•Mechanism for regulation and monitoring of Private Health Care Infrastructure.
Standards and Accreditation
•The Group appreciated the concept of having Standards and accreditation of Health care in Public and Private Sectors.
•Scheme for assessment of PHC/CHC may include (i) Organizational issues, (ii) human resources, (iii) medical equipment and their maintenance, (iv) infrastructure, utility and house keeping, (v) information for patients, (vi) Admission and referral, and (vii) clinical records
TASK GROUP-IV
ROLE OF PRIs AND COMMUNITY ACTION
Tasks for the Group
•Review NRHM strategies for PRIs/ Comm. Engagement across components
•Develop TOR for role of PRIs & Community action in NRHM
Issues
•Capacity Building
•Devolution of Financial and other powers
•Role of Gram Sabha and Village Health Team
•Support to ASHA
•Convergence
•Institutional Linkages
•Involvement of Civil Society
Capacity Building
•Health professionals to be made cognizant of the central role of PRIs in the NRHM
•PRIs at all levels to be sensitized and trained on Primary Health Care and NRHM
•MOPRI and MOHFW will work together to evolve the methodology and implement the process
•Important to build in gender and equity issues in the process
•Need to build capacity for advocacy against laws and norms unfavorable against women and the marginalized
•Orientation of G Sabha/ Ward Sabha about NHRM in order to demand accountability from the GP
•Mechanisms to include: IEC, Distance learning
•Involvement of NGOs and Community Based Organisations
•Need also to build knowledge and skills of health professionals in areas of social medicine and epidemiology
Devolution of Financial and other Powers
•Fiscal Devolution should not be conditional but should be concurrent with capacity building
•Should strongly recommend that all States carry out such devolution
•Dt. Health Mission should work in close co-ordination and under overall guidance of the Zila Parishad for financial and monitoring issues
Village Planning
•Standing Committee on Health of the GP should have overall responsibility at the Panchayat level
•Should encourage mechanisms such as formation of village health teams at the ward/village level
•Functions of above could include: articulation of community health needs, formulation of village health plan and charter
•Village Health Team to include among others ASHA, AWW, ANM, School teacher, etc.
ASHA and PRI
•ASHA is accountable to G Sabha
•Monitoring through GP Standing Committee on Health
•If ASHA gets monetary incentives, it must be through GP
Convergence
•Convergence of health and related determinants to be be reflected in village planning
•Cross cutting across capacity building, planning and implementation
•Involvement of village level functionaries of all social sector programmes
Institutional Linkages
•Establish linkages for periodic review and analysis between public health system and PRI
•Concurrent review and coordination between the Mission and other social sector departments
Civil Society Partnership
•Monitoring of Mission through bodies, with majority rep. Form a range of community based organizations, a the appropriate level
•Regular meetings (biannual) for social monitoring
•Enable provision of financial and technical progress including data to ensure transparency
Gram Sabha Empowerment
•Gram Panchayat to ensure-
Regular meetings of Gram Sabha for NRHM
Conform to Village Health Charter
Right to Information
Social Audits
TASK GROUP-V
EXPLORING NEW HEALTH FINANCING MECHANISM
GOAL
•Move towards full health security for all
District Health Fund (I)
•Primary responsibility of the DHF will be to meet all primary health needs.
•Centre: Funds for building infrastructure, meet transitional requirements and to flow directly to District Health Mission
•Exploring additional Finance Commission allocations by earmarking it to health
•State: All preventive and curative funds:
ASHA + Sub-centre + PHC
CHC + AH + DH
District Health Fund (II)
•Exploring local cess (linked to property taxes)
•4-5% maintenance - building and equipment
•10% for drugs
•A non-lapsable, local, sector specific District Health Fund
•Conditionalities/MoUs with States
•Similar efforts to be made in respect of other Schemes like Nutrition, Water Supply etc.
Infrastructure Financing
•Capital costs to be borne by the Union Government
•Recurring costs to be borne by the Centre + States
Pooling of Resources
•Fund flow to all National Programmes (Disease Control and Family Welfare Programmes) to flow into the District Health Fund.
•All Hospital Budgets – CHCs + AH + DH
•Effective health accounting
District Health Board/Unit
•Funding and control of all PHCs + SCs + ASHAs