Training Module for DPMU Staff

315 Pages·2012·20.35 MB·English

Training Module
for
DPMU Staff

Compiled & developed by:
State Institute of Health and Family Welfare, Jaipur
(An ISO 9001:2008 Certified Institution)
Supported by:
NRHM, Rajasthan
Mission

State Institute of Health & Family Welfare, Rajasthan is committed
to improvement in health care through HRD, Health Service
Research, Consultancy and networking in aiming at enhancement
in the quality of life.
HEALTH SCENARIO:
India Rajasthan

Population 2001 [Million] 1028.61 56.501
Projected Population 2010 [Million] 1176.71 66.751
Health Care Infrastructure

Community Health Centers 42762 3683
Primary Health Centers 234582 15033
Sub Centers 1460362 114883
Total FRUs 18132 2373
Manpower Status

Total Allopathic Doctors 7251904 265924
Total Allopathic Doctors in Govt. 848524 62854
Total Dentist 730574 3644
Total Ayurvedic Doctors 4584184 238614
Total Registered ANMs 5492924 222394
Total ANMs in Govt. 1535682 121503
Total Registered GNMs 9715744 376674
Total Registered LHVs 514974 8504
Total Specialist at CHCs 42792 8113
MBBS Doctors at PHCs 243752 13793
Mortality Indicators

Infant Mortality Rate 535 635
Maternal Mortality Ratio 2545 3885
Total Fertility Rate 2.75 3.45
Crude Birth Rate 22.85 27.55
Crude Death Rate 7.45 6.85
Life Expectancy 66.94 67.64
Under 5 Mortality Rate 74.36 85.46
Health Care Indicators

Doctor Population Ratio [per 1000] 0.634 0.414
Nurse Population Ratio [per 1000] 1.374 0.944
Bed Population Ratio 0.877 0.678
Population per Sub centre Ratio 78382 57143
Population per PHC 487992 436793
Population per CHC 2677112 1783963
Couple Protection Rate 54.19 579
Proportion of fully immunized children [12-24 months] 54.19 48.89
Proportion of Pregnant receiving ANC [Full ANC] 19.19 6.69
Proportion of Safe Deliveries 52.69 52.79
Institutional Deliveries 479 45.59
3. Census of India, 2. RHS-08, 3.DM & HS, Raj. 4. NHP-08, 5.SRS-09, 6.NFHS-3, 7.CBHI, 8.Pragati
Partivedan, 2009, 9.DLHS-3

SIHFW: ISO 9001:2008 Certified institution

NRHM Trainings. Feb. 2010

Index

S.No. Content Page No.

1. Overview of National Rural Health Mission 001
2. Health care delivery System 012
3. National Health Programs 027
4. PIPs and District Health Action Plan 089
5. Inter Sectoral Convergence 100
6. JSY 105
7. ASHA 118
8. SBA 130
9. VHND (MCHN day) 142
10. Interpersonal Communication / BCC 150
11. IDSP 157
12. Epidemic Preparedness & 162
Outbreak Investigation
13. IMNCI 171
14. ICDS 180
15. VHSC, Role of PRIs & Community Monitoring 189
16. HMIS 198
17. Immunization 205
18. IPHS 213
19. PPP 229
20. Rashtriya Swasthya Bima Yojana 235
21. Policies and Legislation 241
22. Financial Management under NRHM 266
23. Procurement & Logistic Management 278
24. Office Procedures 291
25. NFHS III, DLHS III, SRS 305

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NRHM Trainings. Feb. 2010

National Rural Health Mission (2005-2012)

Conceived on: April, 2005 (May 2005 in Rajasthan)
Need:
1. Declining Public Health expenditure (1.3 % of GDP in 1990 to 0.9% in
1999)
2. Limited synergism in Vertical and Horizontal Health Programs
3. Lack of community ownership
4. Lack of integration of issues
5. Regional inequalities
6. Population stabilization still not met
7. Curative services favor rich
8. Poor coverage by Health insurance (only 10%)
9. Hospitalization eats 58% of annual income, 25% pop. falls below poverty line following
hospitalization expenses.

Objectives:
1. To provide effective health care to rural population with focus on 18 States those have poor
health indicators
2. To raise public health expenditure from 0.9% of GDP to 2-3% of GDP

Goals:
1. Reduction in IMR & MMR (Rajasthan)
a. Infant Mortality Rate to be reduced to 56/1000 live births by 2011
b. Maternal Mortality Ratio to be reduced to 285/100,000 by 2011
2. Universal access to public health services
3. Prevention & Control of Communicable diseases.
4. Access to integrated comprehensive primary health care
5. Population stabilization, gender and demographic balance.
6. Revitalize local health traditions and mainstream of AYUSH.
7. Promote healthy life styles.

National Goals in context of MDGs

Current 10th FY NPP MDG 2015
Plan 2010
Total Fertility Rate 3 (2003) 2.3 2.1 --
Infant Mortality Rate 53 (SRS-2009) 45 <30 <27
Neonatal Mortality rate 37 (NFHS III) 26 <20 <20
Maternal Mortality Rate 254 (SRS 2006) 200 <100 <100
Institutional deliveries 45.5 % (DLHS-3) 80% 80% -

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SIHFW: ISO 9001:2008 Certified institution

NRHM Trainings. Feb. 2010

The NRHM carries a paradigm shift with-
• Decentralised planning
• Outputs and Outcome based
• Pro-Poor Focus: Equitable systems
• Quality of Care and the IPHS norms
• Rights based service delivery
• Pre stated entitlements at all levels
• Inputs computed as function of the entitlements and estimated patient load
• Judicious mix of dedicated budget lines - untied funds
• Monitor quality
• Community Participation
• Bringing the public back into public health
• At hamlet level: ASHA, VHSC, SHGs, Panchayats.
• At the facility level: RKS
• At the management level : health societies
• Governance reform
• Manpower, Logistics & Procurement processes.
• Decision making processes
• Institutional design, Accountability framework
• Convergence
• Water and sanitation
• Nutrition
• Education

The Mission outcomes are expected to follow a phased approach and are at two levels:
1. National Level
a. Infant Mortality Rate to be reduced to 30/1000 live births
b. Maternal Mortality Ratio to be reduced to 100/100,000
c. Total Fertility Rate to be brought to 2.1
d. Malaria mortality reduction rate – 50% up to 2010, additional 10% by 2012
e. Kala Azar to be eliminated by 2010.
f. Filaria/Microfilaria reduction rate: 70% by 2010, 80% by 2012 and elimination by 2015
g. Dengue mortality reduction rate: 50% by 2010 and sustaining at that level until 2012
h. Japanese Encephalitis mortality reduction rate: 50% by 2010 and sustaining at that level
until 2012
i. Cataract Operation: increasing to 46 lacs per year until 2012.
j. Leprosy prevalence rate: to be brought to less than 1/10,000.
k. Tuberculosis DOTS services: from the current rate of 1.8/10,00, 85% cure rate to be
maintained through the entire Mission period.
l. 2000 Community Health Centers to be upgraded to Indian Public Health Standards
m. Utilization of First Referral Units to be increased from less than 20% to 75%
n. 250,000 women to be engaged in 18 states as Accredited Social Health Activists (ASHA).
2. Community Level
a. Availability of trained community level worker at village level, with a drug kit for generic
ailments
b. Health Day at Anganwadi level on a fixed day/month for immunization, ante/post natal
checkups mother & child healthcare, including nutrition
c. Availability of generic drugs for common ailments at Sub-centre and hospital level
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d. Good hospital care through assured availability of doctors, drugs and quality services at
PHC/CHC level
e. Improved access to Universal Immunization through induction of Auto Disabled Syringes,
alternate vaccine delivery and improved mobilization services under the program
f. Improved facilities for institutional delivery through provision of referral, transport, escort
and improved hospital care subsidized under the Janani Suraksha Yojana (JSY) for the
Below Poverty Line families
g. Availability of assured healthcare at reduced financial risk through pilots of Community
Health Insurance under the Mission
h. Provision of household toilets
i. Improved Outreach services through mobile medical unit at district-level.

Areas addressed:
1. AYUSH
2. Maternal & Reproductive health
3. Population stabilization
4. HMIS
5. Micro planning
6. Integration of programs and services
7. Health expenditure pattern and quantum
8. Indian Public Health Standards (IPHS)
9. Interstate and inter district disparities
10. Access, Availability, Affordability and equity

Components of NRHM:
1. RCH-II
2. All activities of NRHM
a. ASHA
b. JSY (Janani Suraksha Yojana)
c. Institutional deliveries and cash assistance
d. United fund of Rs. 10000/- for each Sub Centre
e. Dai Training
f. RCH camps
g. On-Contract staff deployment
h. Immunization
i. National Health Programs
j. Inter-sectoral and inter-departmental coordination
3. Vector Borne Disease Control Program
4. TB control program
5. Blindness control
6. Leprosy Eradication
7. Iodine Deficiency Disorders
8. Disease Surveillance project
9. HMIS

Reach:
18 High focus statesStates (UP, Uttaranchal, MP, Chhattisgarh, Bihar, Jharkhand, Orissa,
Rajasthan, HP, J&K, Assam, Arunachal Pradesh, Manipur, Meghalaya,
Nagaland, Mizoram, Sikkim and Tripura)
Now extended to entire country
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NRHM Trainings. Feb. 2010

Approach:
The 5 main approaches under NRHM are-
1. Communitize
a. Hospital Mgt. Committees/ PRIs at all levels
b. Untied grants to communities / PRI bodies
c. Funds, functions and functionaries to local community
d. Decentralized planning
e. Intersectoral convergence
2. Flexible Financing
a. Untied grants
b. NGOs for public health goals
c. NGOs as implementers
d. Risk pooling
e. More resources for more reforms
3. Improved management through capacity building
a. Block and District health offices through mgt.
b. NGOs in capacity building
c. NHSRC/ SHSRC/ DRG/BRG
d. Continuous skill development support
4. Monitor progress against standards
a. Setting IPHS standards
b. Facility surveys
c. Independent monitoring committees at Block, District & State
5. Innovation in human resource management
a. More nurses-Local resident criteria
b. 24 x 7 emergencies by Nurses at PHC. AYUSH
c. 24 x 7 emergencies by Nurses at CHC
d. Multi skilling.

Strategy:
1. Capacity building of PRIs to own and manage public health services.
2. Promote access to improved health care at house hold level through ASHA (Accredited
Social Health Activists).
3. Health plan for each village (micro-planning) through village Panchayat health committees.
4. Strengthening sub-centre through a united fund to enable local planning and action.
5. Strengthening existing CHCs with provision of 30-50 beds per lac population for improved
curative care to a normative standard (IPHS) regarding personnel, equipment, and
management standards.
6. Preparation and implementation of an inter-sectoral district Health plan prepared by District
Health Mission including Water, Sanitation & Hygiene and Nutrition.
7. Integration of Vertical Health & Family Welfare Programs at National, State, District and Block
levels.
8. Technical support to National, State and District Health Missions.
9. Strengthening capacity for information management and evidence based planning,
monitoring and supervision.
10. Developing capacity for preventive health care.
11. Promoting Non-profit sector particularly in under served areas.
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12. Supplementary strategy-
a. Regulation of private sector
b. Promotion of Private Public Partnership
c. Mainstreaming AYUSH
d. Re-orienting Medical Education towards rural health issues
e. Effective and viable risk pooling and social health insurance

Situation at the time of rolling out of NRHM

Indicator source National situation Current value
IMR SRS 25, RGIs Office 58 (Kerala:14, MP: 76) 53 (SRS, Oct.2009)
Rajasthan-63
Maternal 301 (Kerala:4,UP: 517) 254 (Special bulletin on
Mortality Ratio MMR-SRS 2004-06,
Rajasthan-388
Non hospitalized NSS 60 th round 2004 22% (Bihar 5%, HP-68%)
treatment on
Govt. facilities
In patient treated NSS 60 th round 2004 41.7% (Bihar-14.4%, J&K-
in Public 91.3)
Hospitals
Average medical NSS 60 th round 2004 Rs. 3238 in Govt. Hospitals to
expenditure per Rs.7408 in pvt. Hospitals in
Hospitalisation rural areas
State of Health DLHS and facility Adequacy cut off- 60%
facilities survey coordinated by Infrastructure- 76% FRU’s,
IIPS 2003 63% of CHC’s,
Equipment: 61% FRU’s, 46%
CHC’s
Manpower: 37% FRU’s and
14% CHC’s
Anemia among NFHS-III (2005-06) 79.1%-6-35 months 56.1%
children and women
women
Immunization UNICEF’s coverage 54.5% children Rajasthan-FI-48.8%
evaluation survey (DLHS-3)
2005
Institutional NFHS-III (2005-06) 40.7% institutional births , Rajasthan-ID-46%
births, 3 50.7% 3antinatal care visits, (DLHS III, 2008), ANC-
antenatal care 36.4% post natal 56%, PNC-38.2%
visits, post natal
care
Child morbidity FOCUS survey 2004 Fever-32%, Dioarrrohea-
(Jean Dreaz et al) in 21%,persistant cough-17%,
Tamil Nadu, HP, extreme weakness- 11%, skin
Maharashtra, Raj, rashes-5%, eye infections -
Chattisgarh, and UP 2%, 50% children had one of
the above problems

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