National Health Mission (NHM)

About National Health Mission (NHM):

The Union Cabinet vide its decision dated 1st May 2013 has approved the launch of National
Urban Health Mission (NUHM) as a Sub-mission of an over-arching National Health Mission
(NHM), with National Rural Health Mission (NRHM) being the other Sub-mission of National
Health Mission.

Outcomes for NHM in the 12th Plan are synonymous with those of the 12th Plan, and are part
of the overall vision. The endeavor would be to ensure achievement of those indicators in Box
1. Specific goals for the states will be based on existing levels, capacity and context. State
specific innovations would be encouraged. Process and outcome indicators will be developed
to reflect equity, quality, efficiency and responsiveness. Targets for communicable and non-
communicable disease will be set at state level based on local epidemiological patterns and
taking into account the financing available for each of these conditions.

Box 1

1. Reduce MMR to 1/1000 live births 2. Reduce IMR to 25/1000 live births 3. Reduce TFR to 2.1
4. Prevention and reduction of anaemia in women aged 15–49 years 5. Prevent and reduce
mortality & morbidity from communicable, non- communicable; injuries and emerging diseases
6. Reduce household out-of-pocket expenditure on total health care expenditure 7. Reduce
annual incidence and mortality from Tuberculosis by half 8. Reduce prevalence of Leprosy to
<1/10000 population and incidence to zero in all districts 9. Annual Malaria Incidence to be
<1/1000 10. Less than 1 per cent microfilaria prevalence in all districts 11. Kala-azar Elimination
by 2015, <1 case per 10000 population in all blocks

Institutional Mechanisms

oNational level o At the National level, the Mission Steering Group (MSG) and the Empowered
Programme Committee (EPC) are in place. The MSG provides policy direction to the Mission.
The Union Minister of Health & Family Welfare chairs the MSG. The convener is the Secretary,
Department of Health & Family Welfare and the co-convener is the Additional Secretary &
Mission Director. Financial proposals brought before the MSG are first placed before and
examined by the EPC, which is headed by the Union Secretary of Health and Family Welfare.
The composition, role and powers of the MSG and EPC are in accordance with the Cabinet
approval of May 1, 2013. o The Mission is headed by a Mission Director, of the rank of
Additional Secretary, supported by a team of Joint Secretaries. The Mission handles not just
the day-to-day administrative affairs of the Mission but is responsible for planning,
implementing and monitoring Mission activities.

o Upto 0.5% of NHM Outlay is earmarked for programme management and activities for policy
support at the national level through a National Programme Management Unit (NPMU). o The
National Health Systems Resource Center (NHSRC) serve as the apex body for technical support
to the center and states. Technical support focuses on problem identification, analysis and
problem solving in the process of implementation. It also includes capacity building for
district/city planning, and organization of community processes and over all dimensions of
institutional capacity, of which skills is only a part. NHSRC also undertake implementation
research and evaluation and support the development of State Health Systems Resource
Centers (SHSRC) and knowledge networks and partnerships in the states. NHSRC also provide
support for policy and strategy development, through collating evidence and knowledge from
published work, from experiences in implementation and serve as institutional memory.

o The National Institute of Health and Family Welfare (NIHFW) is the country‟s apex body for
training. Its main focus is on public health education, development of skills in public health
management and all training needs of the health care providers. Training is focused on skill
based training of service providers and includes selected aspects of health management
training. Its primary accountability is to see that along with its state counterparts, necessary
skills for public health management and service provision are in place. One of the major roles of
the NIHFW is to revitalize and strengthen the State Institutes of Health and Family Welfare
(SIHFW). Another role is to develop into a center of e-learning. The NIHFW also play a leading
role in public health research and support to health and family welfare programmes.

o The huge need of institutional capacity development across the nation can be met only by
coordinated efforts between planned networks of a large number of public health institutions.
Knowledge resources for the National Disease Control Programmes are supported by the
National Center for Communicable Diseases. Additional knowledge resources can be
harnessed from a number of emerging public health institutions, such as the public health
divisions of centrally sponsored institutes namely, All India Institutes of Medical Sciences,
(AIIMS) and Post Graduate Medical Education and Research, (PGIMER) others, such as, the
Public Health Foundation of India, (PHFI) the Indian Institutes of Health Management and
Research (IIHMR) and institutes and schools of public health in states.

o State level At the State level, the Mission functions under the overall guidance of the State
Health Mission (SHM) headed by the State Chief Minister. The State Health Society (SHS) would
carry the functions under the Mission and would be headed by the Chief Secretary. The
District Health Mission (DHM)/City Health Mission (CHM) would be headed by the head of the
local self-government i.e. Chair Person Zila Parishad / Mayor as decided by the state depending
upon whether the district is predominantly rural or urban. Every district will have a District
Health Society (DHS), which will be headed by the District Collector. At the city level, the
Mission or Society may be established based on local context. Existing vertical societies for
various national and state health programmes will be merged in the DHS. The management
of NUHM activities may be coordinated by a city level Urban Health Committee headed by the
Municipal Commissioner/ District Magistrate/ Deputy Commissioner/ District Collector/ Sub-
Divisional Magistrate/ Assistant Commissioner based on whether the city is the district
headquarter or a sub-divisional headquarter as may be decided by the state. This would
facilitate coordination with other related departments like Women & Child Development,
Water Supply and Sanitation especially in times of response to disease outbreaks/ epidemics in
the cities. For the seven mega cities of Delhi, Mumbai, Chennai, Kolkata, Bengaluru,
Hyderabad and Ahmedabad, NHM will be implemented by the City Health Mission. The State
Program Management Unit (SPMU), State Health System Resource Centers (SHSRC) and the
State Institutes of Health and Family Welfare (SIHFW) will continue to play similar roles for the
state as do their national counterparts for the Centre. The SPMU acts as the main secretariat of
the SHS. The constitution and functioning of the SPMU and Executive Committee of the SHS
shall be such that there is no hiatus between the Directorate of Health and Family Welfare
services and the SPMU. The exact detail of how this would be achieved is left to the state.
SIHFWs and SHSRCs will be strengthened with the necessary infrastructure and human
resources to enable provision of quality trainings and skill development programs. Linkages
with research institutes, schools of public health and medical colleges at state and national
level would be supported. The District Programme Management Unit (DPMU) would be linked
to a District Health Knowledge Center (DHKC) and its partners for the requisite technical
assistance. The District Training Center (DTC) would be the nodal agency for training
requirements of the District Health Society (DHS).

NHM has six financing components: (i) NRHM-RCH Flexipool, (ii) NUHM Flexipool, (iii) Flexible
pool for Communicable disease, (iv) Flexible pool for Non communicable disease including
Injury and Trauma, (v) Infrastructure Maintenance and (vi) Family Welfare Central Sector
component.

Within the broad national parameters and priorities, states would have the flexibility to plan
and implement state specific action plans. The state PIP would spell out the key strategies,
activities undertaken, budgetary requirements and key health outputs and outcomes.

The State PIPs would be an aggregate of the district/city health action plans, and include
activities to be carried out at the state level. The state PIP will also include all the individual
district/city plans. This has several advantages: one, it will strengthen local planning at the
district/city level, two, it would ensure approval of adequate resources for high priority district
action plans, and three, enable communication of approvals to the districts at the same time as
to the state.

The fund flow from the Central Government to the states/UTs would be as per the procedure
prescribed by the Government of India.

The State PIP is approved by the Union Secretary of Health & Family Welfare as Chairman of the
EPC, based on appraisal by the National Programme Coordination Committee (NPCC), which is
chaired by the Mission Director and includes representatives of the state, technical and
programme divisions of the MoHFW, national technical assistance agencies providing support
to the respective states, other departments of the MoHFW and other Ministries as appropriate.

All existing vertical programmes, shall be horizontally integrated at state, district and block
levels. This will mean incorporation into an integrated state, district/city programme
implementation plan, sharing data and information across these structures. It shall also mean
rationalization of use of infrastructure and human resources across these vertical disease
programmes.

National Rural Health Mission (NRHM): NRHM seeks to provide equitable, affordable and
quality health care to the rural population, especially the vulnerable

groups. Under the NRHM, the Empowered Action Group (EAG) States as well as North Eastern
States, Jammu and Kashmir and Himachal Pradesh have been given special focus. The thrust of
the mission is on establishing a fully functional, community owned, decentralized health
delivery system with inter-sectoral convergence at all levels, to ensure simultaneous action on a
wide range of determinants of health such as water, sanitation, education, nutrition, social and
gender equality. Institutional integration within the fragmented health sector was expected to
provide a focus on outcomes, measured against Indian Public Health Standards for all health
facilities.

NRHM- Health Systems Strengthening:

Reproductive, Maternal, Newborn, Child Health and Adolescent (RMNCH+A) Services All
schemes and programmes that constituted RCH-II would be absorbed into the NHM. The NHM
provides an opportunity to build on past work and renew the emphasis on strategies for
improving maternal and child health through a continuum of care and the life cycle approach.
The inextricable linkages between adolescent health, family planning, maternal health and child
survival have been recognized. There is additional focus on adolescence as a distinct „life stage‟
and the strategy is to increase knowledge and access to reproductive health services and
information for adolescents and to address nutritional anaemia. Another dimension of the
continuum of care which will receive attention is the linking of community and facility-based
care and strengthening referrals between various levels of health care system to create a
continuous care pathway. All these aspects are embodied in the „Strategic Approach to
Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) in India‟. The
main strategies for RMNCH+A include services for mothers, newborns, children, adolescents
and women and men in the reproductive age group. Maternal Health: Key strategies include
improved access to skilled obstetric care through facility development, increased coverage and

quality of ante-natal and post natal care, increased access to skilled birth attendance,
institutional delivery; basic and comprehensive emergency obstetric care through
strengthening of carefully prioritized health care facilities. This will be done through mapping
and identifying health facilities as “delivery points” and strengthening them for delivery of
comprehensive package of RMNCH+A services. The purpose is to ensure universal access to all
populations in a district. Wherever required, private providers would also be contracted-in to
supplement services through public health facilities. Multi-skilling medical officers with
specialist skills will be needed to provide emergency obstetric care. The Janani Suraksha Yojana
(JSY) which enables institutional delivery will be modified in the NHM period to synergize with
the new Food Security legislation. Another key goal is to move towards UHC through an
expanding comprehensive package of free and cashless services currently covering all pregnant
women, and sick infants up to the age of one year, in government health institutions through
Janani Shishu Suraksha Karyakram (JSSK), thereby reducing financial barriers to care and
improving access to health services by eliminating OOP expenditure in all government facilities.
In addition strengthened emergency response and patient transport systems for improving
access to institutional care, including assured availability of referral and transport services with
respect to inter facility transfers and out referrals will be supported. Improved monitoring of
care in pregnancy will be enabled by mother and child name based information systems, and
facility and community based MDRs will be emphasized. Comprehensive women‟s health
including pregnancy related morbidity, care for non-communicable diseases among women
including screening and treatment of women for common cancers such as cervix and breast
would be emphasized. Access to safe abortion services: The focus would be to improve access
to comprehensive abortion care, including post abortion contraceptive counseling and services,
by expanding the network of facilities providing MTP services. MTP services would be provided
at

least in every 24*7 facility in every block and in every facility upgraded for FRU services (also
Level 3 services). Multi-skilling of providers will include use of Manual Vacuum Aspiration
(MVA) and medical abortion. Prevention and Management of Reproductive Tract Infections
(RTI) and Sexually Transmitted Infections (STI): Key strategies include: prevention of RTI/STI to
be included in BCC interventions for community health education and as part of adolescent
health education, provision of diagnosis and treatment services at health facilities, syndromic
management at 24*7 and lower levels, and laboratory and diagnostic based services at Level 3
facilities. Special focus would be given on linking up with Integrated Counseling and Treatment
Centers (ICTCs) and establishing appropriate referrals for HIV testing and RTI/STI management.
Gender Based Violence: The consequences of gender based violence against women include
physical injuries, reproductive health problems, and mental health. Because women are most
often seen for the provision of reproductive and child health services, this is a starting point to
identify women who are at risk for or who are subject to domestic violence. The steps towards
enabling a system wide response to gender based violence (GBV) include: sensitize and train
frontline workers and clinical service providers to identify and manage GBV, train ASHAs to
identify and refer/counsel cases of GBV in the community, develop effective referral
mechanisms from primary care to secondary and tertiary centers, with assured services, build
functional referral linkages and create follow up mechanisms with government departments
and NGOs providing legal and social welfare services and women‟s support groups in the
district. Newborn and Child Health: This will be through a continuum of care from the
community to facility level and include the provision of home based newborn and child care
through ASHAs and ANMs, supplemented by AWW, and community level care for acute
respiratory infections, diarrhea, and fevers, including home remedies, first contact curative
care,

or referral as appropriate. Essential newborn care and resuscitation at all delivery points
through establishment of Newborn Care Corners and skilled personnel will be ensured. Facility
Based Care for sick newborns will be provided through the establishment of Newborn
Stabilization Units and Special Newborn Care Units. This includes strengthening public health
facilities and accrediting private providers to manage referrals. Institutional care for sick
children and provision for management of children with Severe Acute Malnourished (SAM) at
Nutrition Rehabilitation Centers (NRC) will be linked to community based care for SAM. Infant
and Young Child Feeding (IYCF) and nutrition counseling to support early and exclusive
breastfeeding, complementary feeding, micronutrient supplementation and convergent action
will be also encouraged through platforms like VHSNC, VHNDs etc. Reporting and reviewing of
child deaths (under five years) is another area of attention. Universal Immunization:
Sustaining Pulse polio campaigns and achieving over 80% routine immunization in all districts
will be emphasized. Introduction of new and underutilized vaccines will be considered on the
basis of recommendations of the National Technical Advisory Group on Immunization (NTAGI).
Improved cold chain management would be ensured with adequate densities of Ice Lined
Refrigerators (ILRs) and deep freezers. Adequate number of vaccination sessions and sites, and
logistics arrangements to reach all such sites especially in remote areas will be a key area of
intervention. Surveillance of vaccine preventable diseases would be integrated with IDSP and
name based monitoring of children done through the MCTS system. Child Health Screening
and Early Intervention Services: The purpose is to improve the overall quality of life of children
0-18 years through early detection of birth defects, diseases, deficiencies, development delays
including disability and provide comprehensive care at appropriate levels of health facilities.
These services will be delivered through the Rashtriya Bal Swasthya Karyakram (RBSK). RBSK
will cover at least 30 identified

health conditions for early detection, free treatment and management through dedicated
mobile health teams placed in every block in the country. District Early Intervention Centers
(DEIC) will be set up to provide further screening and management support to children
detected with health conditions and make appropriate referrals. The mechanism to reach all
the target groups of children for health screening will be through enabling facility based
newborn screening at public health facilities, by existing health manpower, and community
based newborn screening at home through ASHAs during home visits. Children six weeks to six
years would be screened periodically by dedicated Mobile Health Teams at the Anganwadi
Center. Further, in Government and Government aided schools children six years to 18 years
will be screened. This intervention will not only halt deterioration of the condition but also
reduce the OOP expenditure among the poor and the marginalized. Additionally, the Child
Health Screening and Early Intervention Services will also provide country-wide epidemiological
data on the 4 Ds (i.e., Defects at birth, Diseases, Deficiencies, Developmental Delays and
Disabilities). This is important to inform planning in the future, for area specific services. Public
health institutions, private sector partnerships and partnerships with NGOs will be encouraged
to provide specialized diagnostics/tests and services and to fill gaps in services. Such institutions
would be reimbursed for services as per agreed costs of tests or treatment. In addition to the
direct provision of such services, the state will enable convergence with ongoing schemes of
other relevant ministries. Patient transport network supported under NHM will be used to
transport sick children to higher facilities. Adolescent Health: Adolescent Health
programmes include the following priority interventions: Iron and Folic Acid (IFA)
supplementation, facility-based adolescent health services, community based health promotion
activities, information and counseling on sexual and reproductive health (including menstrual
hygiene), substance abuse, mental health, non-communicable diseases, injuries and violence

including domestic violence. These interventions will be operationalized through various

platforms including Adolescent Friendly Health Clinics (AFHC), VHNDs, Schools, Anganwadi
Centers and Nehru Yuva Kendra Sangathan (NYKS), Teen Clubs and a dedicated Adolescent
Health Day. Outreach activities aimed at information provision and health promotion will be
through Peer educators and mentors. Provision of nutrition counseling, treatment for RTIs/STIs,
appropriate referrals and commodities such as IFA tablets, condoms, Oral Contraceptive Pills
(OCPs) and pregnancy kits for all adolescent girls and boys at the AFHCs. Information and
counseling will be provided by dedicated and trained counselors. There will be enhanced focus
on vulnerable and marginalized sub-groups. Menstrual hygiene practices will be promoted in
rural areas through use of sanitary napkins. This is to be combined with building adequate
knowledge and information about the product through ASHAs. Provision of Weekly Iron and
Folic acid Supplementation (WIFS) for addressing nutritional anemia among adolescent boys
and girls in rural and urban areas would be part of the National Iron Plus Initiative. The scheme
also includes nutrition and health education sessions, screening of target groups for
moderate/severe anaemia and referring these cases to an appropriate health facility. There
would be provision for biannual de-worming (Albendazole 400mg), six months apart, for control
of helminth infestation, information and counseling for improving dietary intake and preventing
intestinal worm infestation. Family Planning: Meeting unmet needs for contraception through
provisioning of a range of family planning methods will be prioritized. A differential approach
between the high fertility states and the rest will be followed. In high fertility states the aim is
to reduce fertility to replacement levels and states which have achieved replacement levels will
sustain it. Family planning services would be utilized as a key strategy to reduce maternal and
child morbidities and mortalities in addition to stabilizing population. Post-partum and post
abortion contraception would be a priority. All states would be encouraged to focus on
promotion of spacing

methods, especially Intra-Uterine Contraceptive Devices (IUCDs). Postpartum IUCD will be

emphasized as a key spacing method to leverage the increase in institutional deliveries while
ensuring appropriate counseling and quality of services. In addition to existing providers,
AYUSH doctors will also be trained for IUCD services. Male involvement including male
sterilization would be promoted. Distribution of contraceptives at the doorstep through ASHAs
and other channels will be actively promoted. Improved family planning service delivery
including access, availability and quality of services; counseling services through dedicated
counselors; improved technical competence of the providers and increased awareness among
the beneficiaries would be ensured. Month-long national campaigns on the eve of World
Population Day would be continued every year in all states/ districts across the country. The
compensation scheme for sterilization acceptors to cover loss of wages to the beneficiary and
also to the service provider (and team) for conducting sterilizations would be continued. The
clients will be insured in the eventuality of deaths, complications and failures following
sterilization and the providers/ accredited institutions will be indemnified against litigations in
those eventualities under the National Family Planning Indemnity Scheme (NFPIS). The State
Quality Assurance Cell would be responsible for management of claims under the NFPIS
scheme. Additional strategies to be adopted in the high fertility states are: the promotion of
healthy spacing after marriage and between the births by engaging ASHAs as the motivator and
counselor for the community; intensification of skill building strategies for family planning
providers; involvement of private providers as appropriate to increase the use of spacing and
limiting methods; substantial expansion in facilities and providers offering the full range of
contraceptive services; and BCC activities that focuses on improving access and reducing unmet
need. Addressing the Declining Sex Ratio : Improving the adverse child sex ratio will be crucial
and strategies that lie within the domain of health include: Stricter enforcement of the PCPNDT
Act, improved monitoring and

sensitization of the medical community, and a greater role for civil society action in addressing
son preference, addressing neglect of the girl child in illness care, observing sex ratios in
hospital admissions for illness in children, and providing proactive support for girl children
through the ASHA and Anganwadi system. Cross cutting areas: BCC and addressing social
determinants is complementary to all the above strategies. Human resources and infrastructure
requirements for RMNCH +A services would be integrated with the facility strengthening
component. Continuous training, technical support and supervision of the RMNCH+A
programme and management support through Programme Management Units at the national,
state, district and block levels, SIHFW, SHSRC and District Knowledge Centres will be critical.

National Urban Health Mission (NUHM): NUHM seeks to improve the health status of the urban
population particularly slum dwellers and other vulnerable sections by facilitating their access
to quality primary health care. NUHM would cover all state capitals, district headquarters and
other cities/towns with a population of 50,000 and above (as per census 2011) in a phased
manner. Cities and towns with population below 50,000 will be covered under NRHM.

Flexible Pool for Control of Communicable Diseases: The NHM will continue to focus on
communicable disease control programmes and disease surveillance. The strategies,
interventions and activities under each programme as also the resource envelopes have been
approved already for the years 2013-17. The strategies, interventions and activities will be
appropriately adapted and fine-tuned to meet the distinct challenges of urban settings. The
Flexipool for Communicable Diseases will facilitate the states in preparing state, district and city
specific PIPs.

National Vector Borne Diseases Control Programme (NVBDCP): The NVBDCP is an umbrella
programme for prevention and control of vector borne diseases viz. Malaria, Japanese
Encephalitis (JE), Dengue, Chikungunya, Kalaazar and Lymphatic Filariasis. Of these, Kala-azar
and Lymphatic Filariasis have been targeted for elimination by 2015. The States are responsible
for programme implementation and the Directorate of NVBDCP provides policy guidance and
technical assistance, and support to the states in the form of funds and commodities. The
Government of India provides technical assistance and logistics support including anti-malaria
drugs, DDT, larvicides, etc. under the Programme. State Governments have to meet other
requirements of the programme and to ensure effective programme implementation. There
would also be a thrust on identified geographic areas where the problems are most severe.
Strategies employed would include early case detection and prompt treatment, strengthening
of referral services, integrated vector management, use of Long Lasting Insecticidal Nets (LLIN)
and larvivorous fishes. Other interventions including behaviour change communication will also
be undertaken. Revised National Tuberculosis Control Programme (RNTCP):The goal is to
decrease mortality and morbidity due to TB and reduce transmission of infection until TB
ceases to be a major public health problem in India. Objectives of the programme are to
achieve and maintain cure rate of at least 85% among New Sputum Positive (NSP) patients and
achieve and maintain case detection of at least 70% of the estimated NSP cases in the
community. The current focus of the programme is on ensuring universal access to quality TB
diagnosis and treatment services to TB patients in the community and now aims to widen the
scope for providing standardized, good quality treatment and diagnostic services to all TB
patients in a patient-friendly environment, in which ever health care facility they seek
treatment from. The programme has made special provisions to reach marginalized sections
including

creating demand for services through specific advocacy, communication and social mobilization
activities. National Leprosy Control Programme (NLEP): Key activities include diagnosis and
treatment of leprosy. Services for diagnosis and treatment (Multi Drug Therapy, MDT) are
provided by all primary health centres and govt. dispensaries throughout the country free of
cost. ASHAs are involved in bringing leprosy cases from villages for diagnosis at PHC, following
up cases for treatment completion, and are paid an incentive for this. To address the problem
in urban areas, Urban Leprosy control activities are being implemented in 422 urban areas with
a population of over 100,000. These activities include MDT delivery services and follow up of
patient for treatment completion, providing supportive medicines, dressing material and
monitoring & supervision. Integrated Disease Surveillance Programme (IDSP): IDSP is being
implemented in all the States for surveillance of out-break of communicable diseases.
Surveillance units have been established in all states/districts (SSU/DSU), with a Central
Surveillance Unit (CSU) established and integrated in the National Centre for Disease Control
(NCDC), Delhi. Weekly disease surveillance data on epidemic disease are being collected from
reporting units such as sub centers, PHC, CHC, DH and other hospitals including government
and private sector hospitals and medical colleges. The data are being collected on „S‟
syndromic; „P‟ probable; & „L‟ laboratory formats using standard case definitions. Over 90%
districts report such weekly data through a dedicated e-mail/portal. The weekly data are
analyzed by SSU/DSU for disease trends. Whenever there is rising trend of illnesses, it is
investigated to manage and control the outbreak. Communicable diseases need a special
focus in urban areas, where disease transmission is facilitated by high population density. Poor
urban management, lack of implementation of construction/ building laws, issues relating to
water supply, poor waste disposal practices etc have a
direct bearing on vector breeding. Diseases like TB which are transmitted through droplets
have a higher incidence in crowded habitats. The NUHM, with a focus on urban areas, will
enable heightened attention on prevention and control activities of communicable diseases
Integration of communicable disease programmes will occur at six levels: o The district plan and
facility strengthening plan for disease control programmes will be integrated with the overall
strategy. For each of these programmes, there is a facility development requirement and a
community action component. A strategic district plan would be able to ensure that both
components are put in place. o The BCC strategy will be integrated with the BCC strategy for
the ASHA and VHSNC. o Each programme could manage and maintain its own information
system with the condition that the data from each system shall be exported to a common data
warehouse. The current web-portal would be modified to allow data entry through multiple
formats and routes of entry, and serve as a portal of access to information in different systems.
The IDSP data, the data from the Disease Control programmes, from the health care facilities
and the mortality data will be taken together to build an information base of all diseases in the
district. o The district/city plan will specifically address prevention and control of those
communicable diseases with a significant prevalence specific to a district or city, other than the
national disease control programmes. o Progress review of the communicable disease
programmes will be undertaken by the state, city and district health societies. o Institutional
mechanisms for capacity building, knowledge management and technical support at state and
national levels will be developed, but at the district/city level activities would be integrated into
the broad heads indicated earlier.

Flexible Pool for Non Communicable Diseases (NCD)

NCDs account for 53% of the total deaths (10.3 million) and 44% (291 million) of disability
adjusted life years (DALYs) lost in India. By 2030, NCDs are projected to cause up to 67% of all
deaths in India. Most NCDs have common risk factors such as tobacco use, unhealthy diet,
physical inactivity, alcohol use and require integrated interventions targeting these risk factors.
The rising burden of NCDs calls for concerted public health action. In addition to clinical
approaches, preventive action and policy responses involving multiple stakeholders are
required, and the NHM will need to address the growing burden of non-communicable
diseases. The schemes and interventions under the non-communicable diseases that would
be implemented upto the district hospital would be financed through a Flexible Pool for non-
communicable diseases under NHM. o National Programme for Prevention and Control of
Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS): Primary care includes primary
prevention of hypertension and diabetes, screening for these diseases and secondary
prevention by routine follow up with medication to prevent strokes and ischemic heart disease.
This needs to be linked through two way referral linkages with appropriate secondary and
tertiary care providers. Cardiac Care Units for treatment of Ischemic heart disease, stroke and
other cardiovascular emergencies, and facilities for diagnosis and treatment of chronic kidney
diseases including dialysis will be made available at district hospital level. For cancer control,
one dimension is care at the primary level, i.e. prevention, promotion, and early detection,
assisted access to higher specialist care, guidance and support. Another dimension is to create a
network of hospitals that could provide free care for cancer patients. Most of the latter is in the
tertiary sector, but a number of district hospitals should also be able to provide cancer
treatment. Facilities for screening of common cancers (Cervical Cancer, Breast Cancer and Oral
cancer) and Day care centres for chemotherapy prescribed by Tertiary level cancer hospitals
would be provided.

o National Programme for the Control of Blindness (NPCB): The NPCB would be part of the NCD
flexi-pool under the overarching umbrella of the NHM. The focus in the 12th Plan period would
be to consolidate gains in controlling cataract blindness and also initiate activities to prevent
and control blindness due to other causes. Key strategies are to increase public awareness
about prevention and timely treatment of eye ailments; with a special focus on illiterate
women in rural areas; continuing emphasis on primary healthcare (eye care) by establishing
Vision Centers in all PHCs; active screening of population above 50 years through screening
camps; transporting operable cases to eye care facilities; screening of school age children for
identification and treatment of refractive errors (in synergy with the RBSK); with special
attention in under-served areas; provision of assistance for other eye diseases like Diabetic
Retinopathy, Glaucoma and childhood blindness through use of laser techniques, corneal
transplantation, Vitreoretinal Surgery, construction of dedicated Eye Wards and Eye Operation
Theatres (OT) in District Hospitals in NE States and few other States as needed, use of Mobile
Ophthalmic Units, at district level for patient screening & transportation; and strengthening of
existing Eye Banks and Eye Donation Centres. NGOs will be involved and the private sector will
be contracted-in where required. o National Mental Health Programme (NMHP): The existing
District Mental Health Programme would be integrated into NHM, and expanded to cover all
districts in a phased manner. In addition to managing common mental problems, severe
mental diseases, and mental emergencies, new components like suicide prevention, workplace
stress management, adolescent mental health and college counseling services will be included.
Services for alcohol and substance use, rehabilitation of the mentally ill and community and
home care for chronic and enduring mental illness will be provided and synergies will be built
with RMNCH+A to identify and manage post partum depression. 108 Ambulance services will
be made available to transport patients to the District Hospital in an emergency and a country
wide mental health help line will be set up. Day Care Centres, Residential

Continuing Care Centres, and Long Term Residential Continuing Care Centre will be provided in
selected districts in this plan period. The provision of mental health in NHM will entail the
provision of an integrated package of care to be delivered at various levels. Outreach services
will be provided by community mental health nurses supported by the PHC which will also
undertake case detection, management of common mental illness, stabilizing and referral of
severe illness or emergency and providing medication refills. The CHC will provide outpatient
services for walk in patients and patients referred by the PHC, Inpatient services for
emergencies and assessment, Medical & Social Care & Support to Continuing Care services and
Counselling services. The DH will offer outpatient services, Inpatient services, Child Mental
Health Service, specialist and counseling services, referrals for day centres, medium stay
centers and long stay centers, disability certification by the psychiatrist, laboratory services
including Therapeutic Drug Monitoring for psychotropic medications, Training, supervision and
support to taluk/CHC and primary health care staff at the PHCs, and conducting periodic
outreach clinics at the CHC. Additional human resources include psychiatrists, clinical
psychologists, trained psychiatric nurses, and counselors. Existing staff, charged with
supporting the programme will be trained appropriately. NGOs and CBOs will be involved in the
provision of services such as counseling and managing selected interventions. o National
Programme for the Healthcare of the Elderly (NPHCE): The aim of the NPHCE is to provide
comprehensive health care to senior citizens through all levels of the health care delivery
system including outreach services. In addition to services in 100 identified districts, 225
additional districts will be taken up, and the eight Regional Geriatric centres will be expanded to
20. At the community level, ASHA will enable mobilization of elderly to screening camps and be
trained to provide home based care. The sub-center team will support home visits, IEC, related
to healthy ageing, environmental modification, nutritional requirements, life style and
behavioural changes, and support care givers in care for home

bound / bedridden elderly persons, arrange for callipers and supportive devices from PHC to
make patients ambulatory, and facilitate linkage with other support groups and day care
centres etc. operational in the area. PHC/CHC will undertake periodic check-up of the elderly,
and the information updated in a Health Card for the Elderly. Training will be integrated with
the NPCDCS. The PHC will organize weekly geriatric clinics, conduct basic clinical assessments
of the elderly relating to vision, joints, hearing, chest, and blood pressure, undertake simple
investigations including blood sugar, etc, ensure provision of drugs to the elderly, and facilitate
referral for further investigations and treatment to the CHC or DH. The CHC will be the first
medical referral unit for patients from PHCs and below, organize bi weekly geriatric Clinics,
provide Rehabilitation Services and requisite equipment through a
Physiotherapist/Rehabilitation worker, and organize referral to DH/Medical college. Geriatric
Units are to be set up in 100 selected District Hospitals to conduct geriatric clinics through
regular dedicated OPD. Other interventions at the DH include a ten bedded geriatric ward (10-
bedded) for in-patient care, facilities for laboratory investigations, provision of equipment and
medicines for geriatric care, training of MOs and allied health staff at CHCs and PHCs, and
Referral services for severe cases to tertiary level hospitals/Regional Geriatric Centers. Given
the scarcity of specialists in geriatric field, existing specialists in various fields who are either
trained in geriatric or interested in the field will be utilized for managing Geriatric Clinic and
Geriatric Wards. At all levels, there would be synergy with other NCD programmes and
interventions for the provision of diagnostics, equipments, consumables, medicines and
services for geriatric care. o National programme for the Prevention and Control of Deafness
(NPPCD): The current pilot phase of the NPPCD in 192 districts, will be expanded to 200
additional districts. Its key objectives are to prevent avoidable hearing loss, early identification,
diagnosis and treatment of ear problems responsible for hearing loss and deafness, rehabilitate
persons of all age groups, suffering with deafness, and strengthen the existing inter

sectoral linkages for continuity of the rehabilitation programme, and develop institutional
capacity for ear care services by providing support for equipment and material and training
personnel. This will be done through strengthening capacity of DH, CHC and PHC for ENT and
Audiology infrastructure; training of human resources, including an Audiometric
Assistant/Instructor for the hearing impaired, management of hearing and speech impaired
cases and rehabilitation at different levels of health care delivery system. Provision of Hearing
Aid to hearing impaired children and conducting screening camps for early detection of hearing
impairment, will be through RBSK and in convergence with the Ministry for Social Justice and
Empowerment. o National Tobacco Control Programme (NTCP): Interventions under the NTCP
will be largely at the primordial and primary levels of prevention. Key thrust areas include
training of health and social workers including ASHAs, NGOs, school teachers, enforcement
officers; IEC activities; School based programmes; monitoring tobacco control laws; co-
ordination with PRI/VHSNC for village level activities and strengthening/establishment of
cessation facilities including provision of pharmacological treatment facilities at district level.
The NTCP would emphasize tobacco cessation services at all levels of the healthcare delivery
system. The NTCP would tap all possible opportunities to integrate tobacco control
interventions with other health programmes to ensure most effective and efficient use of
available resources. Through the NHM, the NTCP would specially strive to reach out to the
urban poor, tribals and populations in (Left Wing Extremism infested areas as well as in
underserved areas, who are prone to the menace of tobacco products including smokeless
forms of tobacco. o National Oral Health Programme (NOHP): A total of 200 districts in a
phased manner would be taken up to strengthen the existing healthcare delivery system at
primary and secondary level in order to provide promotive and preventive oral health care The
district will be supported with equipment, human resources and consumables for a dental unit.

States which already have a dental unit at district level would be enabled to set up such units at
CHC level. o National Programme for Palliative Care (NPPC): Palliative care improves the quality
of life by alleviating pain and suffering, and may influence the course of the disease in patients
with cancer, AIDS, chronic disease, and the bed ridden elderly. Palliative care strategies will be
synergized with programmes for the care of the elderly, cancer and chronic diseases. Strategies
for palliative care in NHM will use the continuum of care approach, through IEC, outreach and
coordination of referral at the level of the PHC, out-patient and home-based care at the PHC
and inpatient care through allocating specific beds at the DH, Medical College and Regional
Cancer Centers. Additional human resources (medical officers, nurses and counselors) would
be provided for and appropriately trained in palliative care. o National Programme for the
Prevention and Management of Burn Injuries (NPPMBI): Key objectives are to reduce incidence,
mortality, morbidity and disability due to burn injuries, improve awareness among the general
masses and vulnerable groups (women, children, industrial and hazardous occupational
workers), establish adequate infrastructural facility and network for BCC, enable burn
management and rehabilitation, and carry out formative research to assess behavioral, social
and other determinants of burn injuries to facilitate need based program planning. Prevention
would be through school based programmes, mass media programmes for general public and
appropriate advocacy. District hospitals would be provided with six beds for burn units.
Rehabilitation services would be provided through facility and community based rehabilitation
services, and HR would be trained appropriately. o National Programme for Prevention and
Control of Fluorosis (NPPCF): The programme will be expanded from the existing 100 to an
additional 95 new districts. The key strategies are surveillance of fluorosis in the community,
capacity building in the form of training and manpower

support as required, management of fluorosis cases including surgery, rehabilitation and health
education for prevention and control of fluorosis.

NRHM-RCH Flexipool: This flexipool would address the needs of health systems strengthening
and Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) of the States.

Critical Areas for Concerted Action towards Health Systems Strengthening

Decentralized Health Planning The District/City Health Action Plan is an important

institutional structure for enabling decentralization, convergence, and integration, and is also
the vehicle for promoting equity and prioritizing the needs of the most socially and
economically vulnerable groups in a district. The District/City Health Action Plan will be
developed as an instrument of progress towards the provision of universal health care in a
phased manner. The District/City Health Action Plan would outline the facility strengthening
plan- essentially listing the facilities and defining the assured services each would provide and
ensure that all essential health services are provided within the district. These plans would
specify the current (baseline) package of services available in each facility, the inputs, activities
and budget required to expand this package, improve the quality of care, expand access, and
enable positive outcomes in service delivery for the following areas of service coverage: (1)
Reproductive, Maternal, Newborn, Child Health and Adolescents (RMNCH+A), (2)
Communicable Diseases, (3) Non Communicable diseases, and (4) Emergency Care Services.
Districts with poor health indicators would be prioritized and be the focus of concerted action
by all stakeholders including the centre, state, and technical agencies at national and state
levels and other partners. In urban areas cities with large slums with poor service access would
be prioritized. To address issues of access and continuum of care, the plan would prioritize the
creation/up gradation of a set of inter-connected facilities based on “time to care” and
caseloads. The endeavour would be to ensure that primary services are available within 30
minutes of any habitation and secondary services including C

section and blood transfusion are available within two hours of any habitation, with an assured
referral transport system connecting the two. Further a continuum of care from the level of the
community to the primary care and secondary care facility and back again to the community
shall be established. The district/city health action plans will be prepared on the basis of a
socioepidemiological profile with a focus on the health needs of vulnerable groups (i.e. people
living in difficult and remote hamlets, migrants, SC/ST and Primitive Tribal Groups, and other
such populations including the poor, homeless, street children, construction and migrant
workers, rag pickers, vendors, beggars, sex workers, etc.). Implicit in this is the use of a
decentralized health information system which has robust data quality and is largely consistent
with external surveys. Once the district/city health action plan has specified the facilities where
assured services would be available (including through contracted-in private facilities where
necessary), a comprehensive plan for improving and prioritizing services for drugs and supplies,
equipment, diagnostic services, human resources and infrastructure will be prepared. The
district/city health action plan will be the platform for convergent local action and will integrate
the common goals of related departments like Women and Child Development, School
Education, Water and Sanitation, Housing and Urban Poverty Alleviation, Rural Development,
Urban Development, and Environment for addressing the wider social determinants of health.
As part of the planning process, the draft plan would be shared with these departments for
their inputs. Similarly the district/city plans of these departments would also be shared with the
DHS. The district/city health action plan will clearly prioritize intra district areas which are more
difficult to reach, or have lower baseline indicators and devise plans to improve access to
services. The plans should demonstrate through measurable indicators and increased financial
allocation rules, that equity considerations are paramount in planning. Additional resources
would be allowed for incentive packages for ensuring availability of human resources in remote
and difficult areas.

The process of making the district and city health action plans would include consultations with
key stakeholders including people‟s representatives, community organizations such as
SHG/MAS and other CBOs, specifically representing marginalized communities, and local NGOs.
The plan process would require approval of District and City Health Society and Zila
Panchayat/District Planning Committee. A district plan should include block wise activities and
budget. Village health plans are within the ambit of the VHSNC and inform the block health
plan.

Facility Based Service Delivery A Facility Development Plan has the following components:
Infrastructure, equipment, human resources, drugs and supplies, quality assurance systems and
service provisioning. While the Indian Public Health Standards (IPHS) guides the facility
strengthening plan in terms of specifications, appropriate increases in Human Resources, beds,
drugs and supplies commensurate with caseloads will be made. Facilities prioritized for
development on account of high caseloads, would receive additional inputs. Excess staff would
be redeployed from facilities with low caseloads. New construction would be planned not just
on the basis of population norms, but also consider other factors such as utilization of existing
facility, existence of other facilities (public as well as private) and disease burden. State
investments in technical support agencies or capacity building programmes to ensure building
designs that conform to health care requirements would be needed. In the plan for developing
health care facilities, efforts would be to review the entire set of facilities as an integrated care
network in rural and urban areas. The facility development plan would normally include the
provision of AYUSH services. The important principle of co-location of AYUSH services in health
facilities would continue to be supported. Provision for supply of AYUSH drugs to support the
human resource deployed would be made. Rogi Kalyan Samiti (RKS) would be strengthened to
oversee governance and serve as an effective Grievance Redressal mechanism at the facility
level, with

active engagement of PRIs/ULBs. Regularity in functioning of RKS would be ensured by

improved supervision and support. Every facility would have a quality management system in
place to ensure quality assurance of all services. This would lead to improvements in health
outcomes, support and ancillary systems, including diagnostic services, diet, laundry, security,
sanitation, biomedical-waste disposal, better patient amenities and patient flow, record
maintenance, for the safety, security, comfort and satisfaction of the patient. The quality
standards would follow national guidelines and allow for scoring quality achievements of each
facility. States would be provided with technical support to build capacity to ensure that quality
standards are reached and independently certified. For facilities that meet standards of quality
certification, suitable recognition and rewards would be provided to the RKS, and a part (not
exceeding 25%) could be distributed among the service providers. Every facility shall display
prominently not only the citizen‟s charter but the assured list of services available. The District
Hospital (DH) would meet most of the secondary health requirements of the community at
district level. These could be modified / adapted to the needs of each specific district and
include outpatient, indoor and emergency services. The minimum assured secondary level
health care services will be General Medicine, General Surgery, Obstetrics and Gynaecology,
Paediatrics including Neonatology, Anaesthesia, ENT, Ophthalmology, Dermatology and
Venereology, Dental Care, Orthopaedics, Physiotherapy, Psychiatry and De-Addiction services.
In addition, states which have achieved these could also provide the services for Cardiology and
Cardio thoracic surgery, Urology and Nephrology, Neurosurgery, Gastro-enterology, Oncology,
Palliative care and Geriatric care, particularly in such district head quarters where there is no
medical college. These services as well as those for diagnostic and laboratory services have
been elaborated in the IPHS. The district hospital would be supported by telemedicine centres,
established in centres of excellence for tertiary care. They would also serve as channels to
provide continuing education for doctors and nurses. Most district hospitals are located in
urban areas. Though they are meant to act mainly as sites of referral care, in practice however,
since primary care in urban

areas is weak, the district hospitals also serve as a primary care centre for the urban poor. With
the launch of NUHM, primary health care in urban areas would be strengthened, and district
hospitals would be enabled to provide multi specialty referral care. All district hospitals would
have a quality management system that would be certified against set standards. A full time
qualified hospital manager would be desirable. An approach to quality certification would be
developed, based on learning from the pilots in quality management systems undertaken in the
XI plan period. Outreach Services

Sub Centers are the hub for delivering effective outreach services in rural areas. Most outreach
activities will take place at the village level, with the Anganwadi Center being the usual platform
for service delivery. For the sub centres to become the first port of call, an assured set of
services would need to be provided at the sub center level. For facilitating access to the
community and for the safety of the providers, new construction of sub-centers must be
located in well-populated and frequented parts of the village.

The set of services that the sub-center will provide is laid down under the IPHS. Where the
population to be covered is high, and the numbers of women and children are large, the
priority will remain RCH services. But this plan period will see a transition of the sub center to
becoming the first point of access for a comprehensive range of primary care services. This may
entail strengthening the staffing at sub center level, through additional ANM, a multipurpose
worker, a lab technician and a community health officer and further augmentation based on
case loads.

During the 12th Plan period, the infrastructure gaps in the sub-center would reduce but may
not close. However within the first three years, all sub-centers providing regular midwifery
services should function out of government owned buildings. Sub centers providing only
ambulatory care require an examination room to ensure privacy for women patients, and space
for basic stores and records. This requirement could also be met through a rented building.
A critical issue in delivering health care in the outreach areas, particularly in hilly and desert
areas is the “time-to-care”. Health care delivery facilities should be within 30

minutes of walking distance, from habitation, implying that additional sub centers where
population is dispersed would need to be created. Though there is the assured sub center team
per population of 5000 (3000 in hilly, desert and tribal areas), where the population is dense,
the gap can be met by positioning multiple service provider teams at existing sub
centers/UPHCs.

The drugs and supplies provided to the sub-center/UPHC would be integrated with the state
drug procurement and logistics system. The provision of a bag or container for the drug kit is a
one time or occasional event. It is the regular refill of the drug stocks at the sub-center that is
critical. All equipment in the sub-center may also follow the district warehouse route. The
immediate stores from which the health workers get their stock would be the block, and
wherever possible, the PHC. The diagnostic and equipment kit with the sub-center/UPHC is
proposed to be modernized through a specific technology innovation board for the sub-center
kit.

The sub-center would continue to receive its untied fund, with additional allocation of untied
funds to sub-centers providing midwifery services, and/or handling larger caseloads and those
that have special difficulties to overcome.

Mobile Medical Units (MMUs) to take health services to remote, far flung, difficult to reach
areas and urban slums shall be supported. The pattern of MMUs will depend on the geography
and could provide a package of services equivalent to a primary health center, and have the
necessary HR, equipment and supplies.

Community Processes, Behaviour Change Communication, and Addressing Social Determinants

ASHA The ASHA component would continue to be strengthened, while preserving the principles
of voluntarism, local residency, community based selection, and the three key roles of
facilitation for health care services, community level care provision including counseling and
interpersonal communication for behaviour change, and social mobilization, especially for the
marginalized to access essential health care services. Each of these roles reinforces the other.
Community

mobilization will also include action in convergent areas such as importance of sanitation
facilities and health and hygiene education programs, in schools and Anganwadi centers. While
there is substantial experience with the ASHA programme in rural areas, ASHAs in urban areas
would be a new feature. Broadly selection processes and roles would be similar but would be
tailored to the urban context as appropriate. They would be selected at the level of 200-500
households, using community based selection mechanisms. The tasks expected of the ASHA
define the skills she needs. A dedicated training structure at district, state and national levels
would ensure that she gets these skills that would support her in her functioning. Training is not
seen as a onetime event, but a continuous process of renewal, reinforcement and motivation as
is essential for a voluntary force. Support to the ASHA rests on the following:

(i) A prompt payment of performance based incentives which are adequate to enable an ASHA
working in a population, of 1000, (1000-2500 in urban areas) to earn at least Rs. 3000 per
month, (in difficult areas where she serves populations of less than a 1000, additional
incentives may be provided by states after notification). Incentives at national and state levels
may be appropriately designed for a range of activities, based on the complexity of tasks
undertaken by the ASHAs and the principle of fair remuneration. States would have the
flexibility to deign appropriate incentives for ASHAs. To ensure timely payment and monitor
fund flows, ASHA payments would be linked to the MCTS-Central Plan Scheme Monitoring
System (CPSMS). (ii) A clear structure of facilitators and coordinators (from state to sub block
levels) - who provide in-service support. In urban areas, ANMs would be trained to perform the
role of a facilitator to provide on the job support to the ASHAs. . (iii) Adequate response to
referrals made by her and treatment with dignity when she escorts patients. (iv) A basic set of
drugs in her drug kit that enables her to provide

lifesaving but basic first contact community level care. (v) A well functioning Grievance
Redressal System Given the enormity of the tasks of supporting such a work-force for ASHAs in
rural and urban areas, the internal capacity of the department, must be enhanced by recruiting
additional capacity from civil society and NGOs. Such support can also be garnered through
creating organizational structures, such as ASHA mentoring groups, ASHA Resource Centers and
contracting out some of the training and support functions at different levels to NGO partners.
Additional technical capacity from such sources is necessary because the capacity available
within government is better prioritized for skill training and support to service providers. The
nature of training and support for ASHAs could be assigned to NGOs, with experience in training
community health workers. This must be done without in any way reducing government
participation and ownership over the programme- for it is neither feasible nor desirable for
NGOs to manage the entire programme. This is a dynamic and evolving programme. As the
programme evolves it will face new challenges. There is a need to plan for an annual turnover
and fresh recruitment of about 5% of ASHAs at least. There would also be turnover in trainers.
The programme in many states would take on new priorities- depending on local needs and
there would be a need to pilot these new tasks and approaches. For example, some states
require a greater role of ASHA in community mobilization for prevention, behaviour change and
screening of non– communicable diseases, or palliative care, or disability. All this calls for a
systematic approach and states need to develop a number of sites for community health
innovation, learning and training. Most sites would focus only on training but some would have
the capacity for innovation as well. These sites would be built through a consortia or
partnership between a state department agency like SIHFW, and NGO and a medical college
department- so that the wide range of skills requires is in place. Sustaining the ASHA
programme also requires increasing the avenues for career opportunity of those ASHA with
such aspirations, e.g. by giving eligible ASHAs, preference in admission to ANM/GNM schools.
This will also expand the human resource pool at the local level. Suitably qualified ASHAs
should also be seen as

preferential candidates for posts of AWW and in other relevant departments. A system for
certification for all ASHAs, who have achieved a minimum set of competencies required of
community health workers (CHWs) is being put up in place with the help of National Institute of
Open Schooling (NIOS). The certification will help improve the quality of training and provide
assurance to the community on the quality of services being provided by ASHA. The process
will require accreditation of the trainers, the training sites and the training syllabi/curriculum
for the ASHA program Sensitization and advocacy on the role and scope of this programme for
senior and mid level managers is important in implementation of the programme.

The Village, Health, Sanitation and Nutrition Committee (VHSNC) The VHSNC will be a sub-
committee or a standing committee of the Gram Panchayat. The VHSNCs shall be supported to
develop village health plans to - a) ensure convergent action on social determinants of health,
b) ensure access to health services, especially of the more marginalized sections in the village,
and c) support the organization of the Village Health and Nutrition Day. The VHSNC will also
monitor the services provided by the Anganwadi Worker, the ASHA, and the sub-center. The
system‟s capacity for energizing, supporting and monitoring the VHSNC needs to be expanded
through partnerships as described in Para [Link] above. States shall work with NGOs to build
capacities of VHSNC members for making village health plans and increasing community
participation. Particular emphasis will be on strengthening the capacity of members in
understanding their roles in relation to development, implementation and monitoring of
convergent action plans. VHSNC training will include skill building for development of
convergent action plans including provision of safe drinking water, sanitation, and health and
hygiene education. The VHSNC will act as a platform for convergence between different
departments and committees at village level. All committees can jointly organize a monthly
review to monitor scheme convergence in terms of pooling of funds and human resources,
which can also become an integral part of organizing VHND. Greater involvement of PRIs, Self
Help groups and community based organizations

through representation and active engagement in the VHSNC and supporting the ASHAs should
be encouraged.
Behaviour Change Communication (BCC) BCC will be an important adjunct to every programme
and on a number of themes would also be a standalone programme of its own. There is
considerable space for participation of non government agencies and professional and
specialized agencies in such a massive health communication effort. BCC programmes will be
based on systematic identification of key behaviours and health care related practices and
attitudes, which are detrimental to good health and those which promote good health, as well
as analysis to understand the determinants of such behavior. This shall be the basis of
determining the mix of media, message and communicators through which a measurable
change in behaviours and health care practices shall be secured. A substantial portion of the
interpersonal BCC effort will be through peripheral service providers including ASHA and ANMs,
and community level structures equipped with communication kits, interacting on a one to one
basis with families. But to be effective, such inter-personal and local efforts need to be
supported by other visible mass media, acting as constant reminders, or by creating a favorable
cultural environment for change.

Addressing Social Determinants Action on social determinants will occur at many levels. One is
the integration into respective district/city plans as described earlier. Another level is shaping
the VHSNC as a forum of convergent grass roots level action to address social determinants. A
third level is inter-sectoral coordination at the state and central levels for policy reforms
needed including “health in all policies” that would address social determinants. At the
district/city level, the level of malnutrition, outbreaks of water borne diseases, and the health
of preschool and school children and out of school adolescents, are seen as important areas
where convergent action is necessary

and will be supported to achieve desired outcomes. Other than monitoring outcome indicators
there must be a planned effort to gather sectoral process indicators and relate them to health
outcomes. Joint monitoring and review of Anganwadi worker and ASHA should be undertaken
by the CDPO and Block Medical Officers, and ANM and Anganwadi supervisor. ASHAs, ANMs,
and other frontline health workers will be trained in the critical importance of sanitation, health
and hygiene. This will also be an important component of the training curriculum for the
Rashtriya Bal Swasthya Karyakram (RBSK) teams. Another area for convergence is addressing
the prevention, identification, and management of malnutrition in children. In line with the
ICDS restructuring, ASHA and the VHSNC/MAS will work with the AWW, in enabling the Sneha
Shivirs, community forums to address malnutrition, and ensuring referral for examination by
the Medical Officer. In addition mobile health teams under RBSK will screen children in AWC,
government and government-aided schools for nutrition related deficiencies. The health
hazards of poor access to safe water and poor sanitary practices including open defecation are
well known. The Ministry of Drinking Water and Sanitation (MWDS) has developed a
framework for advocacy and communication to strengthen four critical behaviours to improve
sanitation and hygiene: Building and use of toilets, the safe disposal of child faeces, hand
washing with soap after defecation, before food and after handling child faeces, and safe
storage and handling of drinking water. This involves enabling the ASHA to function as
Swachata Doot, and the use of Village Water and Sanitation Committees (whose role has now
been merged with that of the VHNSC). NHM supported community level interventions such as
the ASHA and the VHSNC/MAS offer a viable platform to address health issues related to safe
water and improved sanitation in urban and rural areas. In urban areas, convergent action with
the Urban Local Bodies responsible for improved sanitation will be undertaken. There are
numerous physical and mental health consequences associated with early age at marriage for
girls. Girls aged 15-19 years are twice as likely to die in pregnancy or childbirth in comparison
to women aged 20-24. Good antenatal care reduces the risk of childbirth complications, but in
many instances, due to limited autonomy or freedom of

movement, young wives are not able to negotiate access to health care. Another advantage of
delaying age at marriage among girls is that the total fertility rate declines. Evidence shows that
the more education a girl receives, and the longer the years she spends in school, her chances
of early marriage reduce. Therefore improving access to education for girls and eliminating
gender gaps in education are important strategies in addressing early marriage. It is also
important to capitalize on the window of opportunity created by the increasing gap in time
between the onset of puberty and the time of marriage by providing substantive skill
enhancement opportunities. Thus convergence with the Education department and
programmes such as SABLA which are directly concerned with these strategies would be
required. One major social determinant of health is gender. Mainstreaming gender concerns
shall be done by sensitizing providers and mid level managers to gender issues, and making
facility level care women friendly, both as patients or care givers. Other women‟s health
related interventions and interventions on gender issues are in sub section 6.

Social Protection Function of Public Health Services Social protection from the rising cost of
health care is a desirable and critical component of an effective health system. In order to
achieve the NHM objectives, it is essential that good quality and safe medicines, diagnostics,
and therapeutic procedures should be accessible, available and affordable to the beneficiaries.
The public provisioning of services is expected to provide social protection and ensure equity of
access. However high Out of pocket (OOP) expenditure is a barrier to accessing health care.
The provision of free drugs and diagnostics, free transport, and the removal of user fees under
JSSK, has brought down OOPs. The most cost effective way of providing social protection
against the rising costs of health care is by making the major part of health services available
through public health facilities on cash-less basis. In effect, it means the reduction and where
possible elimination not only of explicit user fees but all out-of-pocket expenditures related to
health care. Studies show that the major part of expenditure is on drugs and diagnostics. This
would be the focus of NHM efforts to reduce OOPs.

In addition, the free provision of diet for in-patients, cashless patient transport systems and
emergency response systems are areas where public intervention is immediately possible. The
strategies for these are known and tested, and would increase access and use of the public
health sector In the first phase of NRHM, more than 13,000 ambulances with Dial 108/102 have
been operationalised and are a key success of the Mission. In the 12th Plan, focus would be to
ensure universal access to patient transport services with response time of not more than 30
minutes. Access to free drugs is an important initiative under NHM in the 12th Plan. The route
to ensuring free drug supply is to strengthen the capacity of the states in procurement, supply
chain management and quality assurance, preferably through the establishment of a state level
autonomous corporation/body which is in charge not only of transparent and efficient
procurement of drugs, but also of quality assurance and the logistics, including efficient
distribution systems down to the facility level. The Tamil Nadu Medical Services Corporation
(TNMSC) has established benchmarks for this, recently followed by other states, e.g. Kerala and
Rajasthan. NHM or separate schemes for that purpose need to provide funds for drugs, and
related systems. To ensure the effectiveness of such an initiative, other measures including
development and use of state and national level essential drug lists, preparation and use of
standard treatment guidelines, building the capacity of the doctors and sensitizing them on
rational prescription, use of rational and generic drugs and public education measures would be
necessary. Making diagnostics free in the hospital is also essential for eliminating OOP
expenditure since it is another major cost centre and therefore an NHM priority. Minor
equipment, diagnostic reagents and consumables, would have to be made available though
funding on case load and utilization basis. The district untied fund pool can also be used to
cover the cost of most diagnostics. Provision of free diet for all in-patients in the public
hospital, including pregnant women is an essential part of the package of assured services
offered by the public facility. Nutritious food of good quality should be aimed at and could be
prepared in the facility, but in many situations it may be more efficient and effective to
outsource it.

Assured free transport in the form of Emergency Response System (ERS) and Patient Transport
Systems (PTS) is an essential requirement of the public hospital and one which would reduce
the cost barriers to institutional care. The ERS will cater to all medical emergencies and delivery
cases while the PTS will primarily be used to ensure entitlements for mothers and sick infants
under JSSK, and shifting of patients (non-critical) to higher health facilities. Other patients
however will not be denied PTS facility. The ERS/PTS would respond within a time interval of 30
minutes of the call. This system requires a referral matrix as a basis for the coordination
between ambulances and the hospitals, a well-established predefined process at the call-center
guiding the ambulance staff to the right hospital, victim arrival information to the hospital by
EMT, and a supporting institutional framework. Systems for Monitoring and Evaluation, HR
strategy and Technical Training for EMTs and paramedics should be put in place. There is also a
section of the population who is not only poor, but also suffers from additional cause of
vulnerability and marginalization. This includes the migrant worker, the homeless, the street
children, occupational groups like rag-pickers, sanitation workers, trans-gender population,
commercial sex workers and so on. For these groups to access essential health care services
affirmative action is needed. Efforts will be made to ensure that these populations are
adequately covered by NHM‟s social protection initiatives.

Partnerships with the NGOs, Civil Society, and the For Profit private sector The private sector
has immense potential to contribute to the achievement of public health goals, and will form a
significant source of additional capacity for a range of functions where there are critical gaps,
through clearly articulated deliverables and well designed monitoring mechanisms. IPHS norms
shall be adhered to while contracting for services with the private not for profit or for profit
sector. NHM will encourage the public sector to contract-in or outsource those services which
improve efficiency and quality of care in the public hospital. These services include the
provision of diet, of emergency transport services, of housekeeping services, and diagnostic
services. In cases where the skill sets required are non-clinical but specialized, and high quality
cannot be assured

because the public health workforce is largely clinical; outsourcing has significant advantages.
There are also instances where specialized clinical services can be outsourced. For example
common blood tests may be provided locally at the public health institutions but biopsies or
more technically demanding blood tests can be best done where there is specific expertise and
specialization. Similarly the provision of ambulance services based on a call center which meet
standards of immediacy and quality are a specialized skill, and could be outsourced. Purchase
of specific secondary or tertiary care services should be limited to such services which are part
of the “assured services” for that level of care, and ought to be available in the district / public
health facility, but are not for a range of reasons. This decision to purchase care can be taken
based on local needs by the RKS/DHS. Thus for example, a district hospital that is unable to
provide C-section services may refer the patients to a nearby non-governmental or private
sector institution and undertake to pay for those services on a pre fixed rate. The government
institution will monitor the service to ensure quality. The private sector engagement is clearly
supplemental to the public sector, and can be from within and outside the district. The cost of
transport would be included, provided that the said service was included on the assured
services list. Purchase of those services which are needed in large numbers and where the
demand exceeds public provider capacity could also be considered. For example, cataract
surgery, or sterilization services in a district could be purchased. It could also apply where the
load of a particular service is high and where quality cannot be assured beyond a certain
number of cases, viz: the load exceeds the quantity ceiling required for quality care e.g. where
number of C-sections exceeds the capacity of a single gynecologist in a district hospital. Where
services are contracted in, these will be governed by well designed contracts, which should
include a set of measurable outcomes, quality control measures, careful monitoring, and
appropriate budgets. Preference would be given to competent not for profit agencies.
Contracting out of services which require specialists or medical doctors would be considered in
case they are not available or adequate within the public health

system. Contracting in of a private care facility in case there is no public health facility, can also
be considered. For e.g., in urban agglomerations with large low income populations seeking
publicly financed care. Contracting out of those tasks where internal capacity is already
saturated, or which are not prioritized, such as training of VHSNC/MAS members or even
ASHAs, to NGOs could be considered. A key function of NGO support would not only be to
involve them as additional technical capacity to supplement government efforts in capacity
building and support for community processes – mainly for the VHSNC/MAS and the ASHA
programme, but also to encourage public participation in Rogi Kalyan Samiti and district/city
planning. NGOs would be supported to mobilize additional technical capacity from a national
canvas, where intra-district management capacity and training capacity is overwhelmed by
existing requirements in districts with limited capacity. Community based monitoring would be
continued into the Twelfth Plan and scaled up. However this must be closely linked to local
health planning and facilitation of service delivery and efforts must be made to bring
community and service providers closer to develop mutual trust and support. Community
monitoring could be further expanded into areas such as improving data quality in HMIS and
MCTS, measuring availability of drugs, monitoring support to JSSK and RBSK, and cashless
Public-Private Partnership (PPP) arrangements. NGO involvement in NHM will be through the
states, with the center playing a facilitatory role through a resource cell at the national level in
NHSRC. NGO involvement would inter alia include areas such as community monitoring, the
monitoring of Pre-Conception Prenatal Diagnostic Techniques (PCPNDT) Act implementation,
assessing health impact of development programmes, monitoring of Food and Drug
adulteration (consumer education and assistance to inspection roles), ensuring implementation
of the Infant Milk Substitutes Act, Promotion of Rational Drug Use, amongst the public and
professionals, where they have the necessary expertise.

Human Resource Development The component of the Human Resources (HR) strategy that
relates to increasing numbers of key staff in consonance with IPHS and assured services has
already been presented as a sub-component of facility strengthening. Many areas of skill
development are presented as part of specific RCH, and communicable and noncommunicable
disease control programmes. This section focuses on the overall strategy for HR development.
NHM shall have a substantial programme of creating/strengthening institutions for building
capacity at state and sub-state and regional levels. States will be supported to develop strong
HR Management systems with improved practices for decentralized recruitment, fair and
transparent systems of postings, timely promotions, financial and non financial incentives for
performance and service in underserved areas, measures to reduce professional isolation by
provisioning access to continuing medical education and skill up gradation programs, provide
career opportunities for frontline workers, and utilize the enormous flexibility available under
the Mission. NHM will support in-service programmes, both residential and through distance
education mode on family medicine, epidemiology, public health management skills and such
other skills and specialisations as are needed. In service training will also emphasize building
leadership skills among key functionaries. Special emphasis is needed for family medicine
programmes to ameliorate the specialist gaps at secondary care levels and provide a better
quality and range of services at both primary and secondary levels. NHM would encourage
development of bridge courses for ASHAs to become ANMs/GNMs and for ANMs to become
nurses and nurses to become nurse practitioners. NHM will support development of a three-
year course for [Link] in Community Health for mid-level clinical care provider. Graduates from
different clinical and paramedical backgrounds, like pharmacists, BSc Nurses, etc, would also be
able to obtain this qualification through appropriate bridge courses. The design and duration of
the bridge course would depend upon an assessment of the gap between current and desired
competencies. Locale based selection, a special

curriculum of training close to the place where they live and work, conditional licensing and a
positive practice environment will ensure that this new cadre is preferentially available where
they are needed most, i.e. in the under-served areas. Nurses will serve as the backbone of
clinical facilities and NHM will support the expansion of their role as clinical care providers.
NHM will support advanced training of nurses, including multi skilling and task shifting in order
to enable and empower them to take on newer service areas. They will also be supported to
obtain educational advancement through bridge courses and other training. NHM envisages
the use of telemedicine to support continuing medical and nursing education and on the job
support to providers working in professional isolation in rural areas. NHM would also support
strategies to recruit, and deploy skilled health workers in rural and remote areas. These
strategies would include financial and non-financial incentives, regulatory measures, workforce
management and measures to reduce professional and social isolation. For the staff of
programme management units, improved performance will be enabled through setting clear
deliverables, undertaking regular performance monitoring and instituting a proper appraisal
system. In addition, training based on gaps identified through skill assessment and supportive
supervision will enable service providers to achieve their performance goals. One related issue
is the conflict of interest situations that arise when government doctors are also involved in
private practice. This should be discouraged and suitable incentives made available to such
providers to spend extra time in public service in the public hospital. However many states
would need to start by focusing on conflict of interest situations such as, private practice on
public time, cross referral to their own clinics, and other unscrupulous practices. The RKS
should also be enabled to address such situations.

Public Health Management Managerial expertise is needed for public health services and
clinical services, to enhance their outreach and effectiveness. While public health professionals
should be provided training in managerial skills apart from public health related

knowledge, a specialized Public Health Cadre would be needed to infuse managerial expertise
into health services. The NHM shall strive to increase the quality of public health management
through the following measures: (i) Support the establishment and strengthening of State,
District, City and Block Programme Management Units with suitably qualified and supported
human resources and requisite infrastructure. (ii) Support public health management training
of programme officers and city, district and state level officers with management functions. (iii)
Incentivize the development of a Public Health Cadre by the states, at block, city, district and
state level and ensure that they are non practising positions. (iii) Improve the coordinated and
synergistic functioning of the Directorate of Health Services with the SPMU. The SPMU enables
the induction of multi-disciplinary skills and of deputing younger officers from within the
government cadre to form viable leadership teams at the state level. The conventional
administrative structure of the Directorate does not allow this, but by placing Joint Directors
with the Programme Management Committees for each major programme component and
giving them charge of districts, their leadership and experience can be utilized. (iv) Promote
synergy at leadership level between the Directorate and State Health Society. Past experience
shows coordination is facilitated where the Mission Director is also a Secretary or
Commissioner of Health Services, and the Director of Health and Family Welfare serves as the
Additional or Joint Mission Director or equivalent. This arrangement would be encouraged
under NHM. (v) Incentivize the creation of the necessary organizational structures at state level
required for effective management of the finances and implementation of the programmes.
These shall include the following: o Strengthen the Directorate(s) of Health Services to provide
leadership to public health programmes and interventions. o Strengthen the programme
management units under the State Health

Society o Establish a Corporation/body for procurement and logistics of equipment and supplies
o Establish a Cell, Division or Corporation for infrastructure development. o Strengthen/Create
an SIHFW which provides or coordinates all skill building and continuing medical education and
related operational research efforts. It should preferably be registered as a society. o
Create/Strengthen an SHSRC to be in charge of knowledge management support for district
planning, quality improvement systems, data analysis, building information systems and
evidence based support to decision making. Results have been seen to be most effective where
such an organization is registered as a society. o Establish a Community Processes Resource
support team. This function could be outsourced to an NGO, or provided through a separate
cell in the programme management unit or through the SHSRC. o Create a full time
management unit for managing the Emergency Response and Transport Systems. Outsourcing
has worked well for this. Effective implementation of the complex interventions under NHM
necessitates technical support and handholding which requires a multiplicity of skills and
competencies. Such resource support needs to be organized through distinct entities/agencies
with the ability to convert knowledge gained from the field through practice, research, and
training into implementation processes, constant internal learning and renewal, ability to draw
on skilled human resources and build institutional memory. This is essential to not just ensure
the pace and quality of implementation, but for the absorption of funds and delivery of
outcomes. However for small states these functions could be integrated into fewer institutions.
Given the huge requirement for technical support, other national institutions to meet the
technical needs of states and districts in programme planning and implementation need to be
involved. This would also strengthen the quality and relevance of work done in

these institutions. Examples of such institutions are NIHFW, All India Institute of Public Health
and Hygiene, (AIIPH&H), the National Institute of Nutrition (NIN), other Indian Council of
Medical research (ICMR) funded research institutions, Schools of Public Health and Health
Administration and NGOs. Enabling these institutions would require grant-in-aid to expand
human resources and skills and ensure policies by which they can respond to such requests.
Incentives for experts in such institutions who invest their efforts in providing technical support
without detriment to their core research work could also be considered. In addition to this,
states would need to invest in building capacity in public health education and research
institutions for research support and for partnering with the organizations that is directly
involved in day to day in programme support and implementation. States would also need to
develop strong financial management teams and expand their capacity in terms of institutional
structures and systems so as to be able to handle the increased amounts efficiently and
reliably.

Pilots for Universal Health Coverage

One of the key objectives of the 12th Plan is to design and run pilots which move towards
Universal Health Coverage (UHC). Each state would be encouraged to undertake two to three
pilot districts, if they are performing well against the existing programme and fulfilling the
mandatory conditionalities and preparatory activities for the UHC.

Three key preparatory activities are

(i) A good baseline measurement of the effective coverage/access to different services and the
current out of pocket expenditure on health care. (ii) A good quality district action plan (iii) A
health management information system linked to family health cards, which is able to support
population-based health services for both RCH and NCDs as well as support continuity of care
across different levels of care.

The pilots would demonstrate how access to care and social protection against the costs of care
can be meaningfully expanded in the most cost effective manner, while at the same time
reducing health inequity. Innovations would be required in financing, institutional
arrangements, capacity development and the organization of service delivery and in the
building of partnerships. Care would be taken to ensure that the models so proposed are
scalable in terms of costs, efficiencies and the boundary conditions needed for such scaling up.

Health Management Information Systems (HMIS) NHM envisages a fully functional health
information system facilitating smooth flow of information for effective decision-making. A
robust health management information system is essential for decentralized health planning.
Lack of indicators and local health needs assessment have been identified as constraints to
effective decentralization. The health management information systems would be designed to
support regular decentralized analysis of data and for decision making at state, district, city and
subdistrict levels. The information systems will enable local users in management of health
service delivery as well as help them in their routine activities. Problems of data quality would
be systematically studied by comparing data from routine reporting systems with external
surveys. Independent assessment of data quality by accredited agencies will also help in
identifying issues and providing feedback through proper sampling and comparison of recorded
and reported figures at each level. Another measure would be the dissemination of the
analysis of key data elements like maternal or child mortality to community monitoring groups,
PRI/ULB representatives, VHSNCs, etc, and obtain their assistance to correct information gaps.
These inputs for identifying and correcting data quality gaps should be provided on a continuing
basis. An important step to improve data quality and utility is to actually use the data on a
regular basis for planning and monitoring implementation of various programmes at all levels.
This would be emphasized. There would be an integrated National Family Health Survey (NFHS)
which will provide district level data on key programme outcome indicators with a periodicity of
three years. Efforts would also be made to obtain district wise data on vital indicators like CBR,
CDR, IMR, Neo-natal Mortality (NMR), U5MR, MMR, TFR etc. with fixed periodicity through a

dedicated survey by Registrar General of India (RGI). The HMIS would be further strengthened
and enlarged to provide data on a wide range of new and emerging programme components.
NHM will work with RGI office to strengthen the contribution of sub-centers/U-PHC and public
health facilities as registration sites and ensure universal registration of births and deaths. A
major component of this would be to improve reporting on cause of death data. This would
serve as an important data source for planning action on communicable and non communicable
diseases. Periodic measurement on governance related parameters for the states would also
be developed and used for incentivizing the states to achieve institutional reform.

Governance and Accountability Framework The NHM would have the following framework for
ensuring accountability: - At the national level, the Mission Steering Group would continue to
exercise the main programme and governance oversight. - At the state level, the State Health
Mission and the Governing Body (GB) of the State Health Society and the District/City Health
Society would serve as the primary mechanism of holding programme executives accountable.
- The GB would meet annually, while the Executive Committee (EC) would meet at least thrice a
year. Regular meetings of the GB and EC with adequate preparation, reports, transparency and
multi-stakeholder participation are essential. The Society is also answerable through its
Chairperson and Member Secretary to the Legislature and Parliament. - The Statutory Audit
report would mandatorily be placed before the GB of the SHS every year and shall report
compliance on observations of statutory auditor. At the facility level, the RKS would play a
similar role. Intensive capacity building for improving the currently low effectiveness of the RKS
as an accountability mechanism would be undertaken. Score cards would capture the
performance of all facilities and these would be used for monitoring and redressing areas of
low performance and rewarding those who are doing well. Community monitoring structures
may be involved in making these scorecards. Scoring would be based on key performance
indicators.

All districts will have a system of periodic concurrent audit and an annual audit. The national
programme on the whole is subject to the Comptroller and Audit General (CAG) audit. All
accounts down to the district level, and increasingly to the block level have been computerized,
and with insistence on the CPSMS the entire flow of funds would be visible and monitored from
higher levels. This will be strengthened further. Levels of service delivery on key parameters
would be visible through the HMIS, and can be triangulated with data of high quality and
reliability which is available at a lower frequency from external surveys. The most important of
these external surveys are the Sample Registration Survey (SRS), the District Level Household
Survey (DLHS) and NFHS. A concurrent evaluation is conducted under the leadership of the
International Institute of Population Studies (IIPS) which also leads the NFHS and DLHS. The
Common Review Mission (CRM) also provides programme related information on an annual
basis. Community monitoring of facilities supported by NGOs, would also contribute to holding
the system accountable. Other innovative systems of community oversight such as social audit
should be encouraged. Another major accountability mechanism is District Level Vigilance and
Monitoring Committees (DLVMC) that function under the chairpersonship of the Member of
Parliament (MP).