National Rural Health Mission

I. Profile, Components, and Strategies
1. Why a National Rural Health Mission?

It will provide effective health care to the rural population, especially the disadvantaged groups including women and children, by improving access, enabling community ownership and demand for services, strengthening public health systems for efficient service delivery, enhancing equity and accountability and promoting decentralisation.

2. What is the coverage of the National Rural Health Mission (NRHM)?

It covers the entire country, with special focus on 18 states where the challenge of strengthening poor public health systems and thereby improve key health indicators is the greatest. These are Uttar Pradesh, Uttaranchal, Madhya Pradesh, Chhattisgarh, Bihar, Jharkhand, Orissa, Rajasthan, Himachal Pradesh, Jammu and Kashmir, Assam, Arunachal Pradesh, Manipur, Meghalaya, Nagaland, Mizoram, Sikkim and Tripura.

3. Is NRHM a new programme of the Government of India?

No NRHM is not a new programme of Govt. of India but NRHM is the combination of national programmes, namely, the Reproductive and Child Health II project, (RCH II) the National Disease Control Programmes (NDCP) and the Integrated Disease Surveillance Project (IDSP). NRHM will also enable the mainstreaming of Ayurvedic, Yoga, Unani, Siddha and Homeopathy Systems of Health (AYUSH).

4. What are the strategies of the NRHM?

While providing a broad framework for operationalisation, NRHM lists a set of core and supplementary strategies to meet its goals.

The core strategy of NRHM will include decentralisation of villages and district level Rural Planning and Management and to appoint ASHA for creation of awareness, to counsel women and for the mobilisation of community facilities for accessing health related services. ASHA is supposed to escort pregnant women for delivery to institutions as PHC/FRU.

The Ayurvedic system will improve management capacity to organise health system and Public Health Services.

Supplementary Strategies include regulation of the private sector to improve equity and reduce out of pocket expenses, foster public–private partnerships to meet national public health goals, re-orienting medical education, introduction of effective risk pooling mechanisms and social insurance to raise the health security of the poor, and taking full advantage of local health traditions.

5. Does the NRHM exclude provision of Health Care to urban populations?

A Task Group on Urban Health is being constituted to recommend strategies for urban poor.

II. Institutional Framework and Fund Flows
1. What is the institutional set up at National, State and District levels?

The Union Minister for Health & Family Welfare will provide policy guidance and operational oversight at the National level. Secretary of Planning Commission, Rural Development, HRD, H&FW, H&FW Secretary of 4 states and 10 Public Health professional nominated PM will be members of Mission steering group.

At the State level, the State Health Mission shall be led by the Chief Minister. It shall be co-chaired by the Health Minister with the State Health Secretary, as convenient, and representation from related Departments, NGOs, private professionals etc.

The District Health Mission shall be led by the Chairman, Zila Parishad, and be convened by the District Head of the Health Department. It shall have representation from all relevant Departments, NGOs and private professionals.

2. What will be the role of the State Governments under the NRHM?
  • The mission cover the entire country. The 18 high focus state are Uttar Pradesh, Uttaranchal, Madhya Pradesh, Chhattisgarh, Bihar, Jharkhand, Orissa, Rajasthan, Himachal Pradesh, Jammu and Kashmir, Assam, Arunachal Pradesh, Manipur, Meghalaya, Nagaland, Mizoram, Sikkim and Tripura.The rest of the states have to follow the pattern of high focus states for programme management units and upgradation of SC, PHC and CHC through integrated financial envelope.
  • NRHM provides board conceptual framework. States would project operational modalities in their State Action Plans, to be decided in consultation with the Mission Steering Group.
  • NRHM would prioritise funding for addressing inter-state and intra-district disparities in terms of health infrastructure and indicators.

  • States would sign Memorandum of Understanding with Government of India, indicating their commitment of increase contribution to Public Health Budget (preferably by 10% each year), increased devolution to Panchayati Raj Institutions as per 73rd Constitution (Amendment) Act. and performance benchmarks for release of funds.
3. What will be the roles of the State and District Health Missions?

The State Health Mission shall prepare the roadmap for architectural correction of the Health System, including merger/integration of vertical structures; delegation and decentralisation of administrative and financial powers; empowering the PRIs; preparation of Operational Guidelines for the implementation of the Mission; logistics arrangements; disease surveillance; IEC; and MIS, whereas, the District Health Mission shall control, guide and manage all public health institutions in the district and at sub-district levels. It will be responsible for preparation and implementation of an integrated District Action Plan in respect of funds received from all funding agencies into the District Health Fund.

4. What are the flexibilities available to the States under the NRHM?

The States shall have flexibility to project operational modalities in their State Action Plans, which would be decided in consultation with the Mission Steering Group.

The NRHM is being launched as a framework of partnership among Government of India, related Departments of the Government, especially Departments of Women & Child Development, Drinking Water Supply, Panchayati Raj, and Development of North Eastern Region State Governments, Panchayat Raj Institutions, NGOs, and private health providers. The detailing of strategies will continue during the Mission with the combined effort of all the stakeholders.

5. What is the Outlay of NRHM?

The Outlay of the NRHM for 2005-06 is Rs.6713 crore. The Outlay of the Mission in subsequent years will be dependent on the Outlay of the Ministry of Health and Family Welfare.

6. Can the States expect an increased outlay in the coming years by 50% over the last year?

The Budget Outlay of the Ministry of Health and Family Welfare has increased by 30% in 2005-06 over the previous financial year. The States would prepare comprehensive Action Plans for NRHM, indicating priorities for funding, which shall be covered under the increased Outlays expected in the coming years.

7. What shall be the State contribution in term of fund under the NRHM?

The States are required to sign MOU with the Govt. of India, committing a minimal increase of 10% for Public Health expenditure in the State Budget each year.

8. What is the fund flow mechanism?

The States will be given an advance, indication of funds to be devolved. State Action Plan would be prepared, which would be funded through a financial envelope for RCH-II and funding under NDCP. The Societies for Health and Family Welfare programmes shall merge into one integrated Society at State and District level to enable "funneling" of funds. The NRHM Budget Head would retain Sub-Budget Heads for the erstwhile Societies.

9. What is the role of Panchayati Raj Institutions (PRI) in the NRHM?

For developing the Village Health Plan with the support of the ANM, ASHA, AWW and Self Help Groups. Block level Panchayat Samitis will coordinate the work of the GP in their jurisdiction and will serve as link to the DHM. The major role of Panchayat is to select ASHA preferably from there village.

10. Why Programme management units have been formed?

To help in better management of health services in relation to monitoring and implementation of programme professionally qualified managers viz., financial personnel and data managers at state and district level.

11. What is the role of PMU at state and district H.Q.?

The states are expected to review the state level proforma in atleast 4 district on half yearly basis. Where as the role of PMU at district level is to ensure regular and continues provision of MCH services including our reach services as scheduled, to strengthen critical interventions and ensure continuous availability of supplies and equipment from the state HQ to the service provider to trained manpower with appropriate skills, to facilitates improvement in context of quality and coverage of services, to ensure adequate and efficient utilisation of funds, to monitor the performance of MCH services.

What are the infrastructure available under AYUSH under NRHM?
  • The personnel of AYUSH may work under the same roof of Health infrastructure.
  • The posting of any one Doctor of AYUSH System.
  • Provision of one specialist of any of AYUSH System as per the local need in CHC.
  • AYUSH dispensary which are not doing well may be merged with PHC/CHC.
  • Cross referral between Allopathic & AYUSH stream should be encouraged based on the need for the same.
  • AYUSH Doctors should be involved in IEC health promotion and also supervisory activities.
  • III. Operational Issues
    1. What are key activities for the Year 2005-2006?

    Broadly speaking, the common activities under NRHM, which are uniformly applicable across all States/UTs over and above those proposed under ongoing programmes like RCH and National Disease Control Programmes are as follows:

    Constitution of State and District Health Missions

    Merger of Health and Family Welfare Societies

    Preparation of State Action Plan, which identifies sectoral needs and priorities

    Finalising performance benchmarks for MOU

    Signing of MOU between State and GOI

    Preparation of District Action Plans.

    Upgrading two CHCs in every district to the level of Indian Public Health Standards, including the provision for two rooms in these CHCs for bringing AYUSH practitioners under the same roof.

    Formation of Rogi Kalyan Samitis

    Immunisation strengthening through induction of Auto Disabled Syringes and arrangement for alternate vaccine delivery at immunisation sites.

    Organising mobile medical services at district level.

    Organising Health Camp at AWW level on a fixed day in a month for assured services for women and child health care.

    Provision of household toilets.

    Strengthening institutional delivery under Janani Suraksha Yojana (JSY) through provision of escort and referral services by ASHA & subsidised hospital services for BPL women.

    Establishing systems to increase accountability of health systems to PRIs.

    Selection and training of ASHA, including provision of drug kits

    Organising Health Melas as a platform to inform and educate the public on NRHM

    Provision of generic drugs, both AYUSH and allopathic, at village, SC/PHC/CHC level, for common ailments.

    Some activities as mentioned above shall be specially funded in the 18 high focus States.

    2. What additional inputs will States receive in 1st Year?

    Rs. 20 lakh/CHC to two CHCs in every district for bringing them on par with


    Maintenance grant of Rs. 1 lakh per CHC, after constitution of Rogi Kalyan

    Samiti at that level.

    Untied fund of Rs. 10,000 per Sub-centre.

    Supply of additional drugs (allopathic and AYUSH) at Sub-centre, PHC and

    CHC level

    Mobile Medical Unit for district

    50% districts in EAG states to get Rs. 10 lakh/district for district planning

    Funds for training of ASHAs

    3. When are State, District and Village Action Plans due?

    The State and District Action Plans are expected to be formulated within the first six months.

    Village Action Plans can be formulated during the second year.

    4. What should State Action Plans include in 1st Year?

    State Action Plans in Year I should include outlays for RCH II, National Disease Control Programme and the Integrated Disease Surveillance Programme. The State Action Plan would also include funds under AYUSH, Finance Commission grants- in-aid, Rashtriya Sam Vikas Yojana, external bilateral funding, and large NGO grants. Even though budgeting would remain separate for better convergence, the outlays and programmes to improve sanitation, nutrition etc. should also be reflected in the State Action Plan. Once the District Plans are ready, the State Action Plan should be based on those Plans.

    5. What should a District Action Plan include in 1st Year?

    For 2005-2006, districts should consolidate existing resources within the HFW sector, plan for convergence with nutrition, water and sanitation, and focus on identifying areas in the district with poor indicators and greatest need of financial resources. After 2 Year detailed District Action Plans, based on Village Health Plans should be developed by the DHM.

    6. Will NRHM provide for additional project management cost?

    Project Management cost for all districts is covered under the financial envelope of RCH II. 18 high focus States shall make contractual engagement of skilled professionals

    7. How to integrate Water, Sanitation, and Nutrition in NRHM?

    The institutional arrangement for the NRHM as well as Total Sanitation Campaign will be the same at District and Village levels. However budgeting for the two programmes will remain separate. Integration with ICDS implies joint planning, us of AWC as the hub of the NRHM interventions in the village, joint reporting and monitoring on common indicators, and engagement with the AWW as a key figure in village planning and implementation.

    8. What is the budget profile of NRHM? What will separate sub budget lines look like?

    In Year 1 (2005-2006) there will be no separate Budget Head for NRHM. Creation of a new Budget Head for NRHM will be from 2006 onwards. The existing programmes would maintain sub-Budget Heads under the omnibus NRHM Budget Head.

    9. Will the States have to sign separate MOUs for RCH-II and NRHM?

    There will be only one MOU, subsuming the MOU for all programmes integrated under NRHM. Signing of this MOU shall be the precondition to release of second tranche of funds in October 2005.

    10. What are key performance benchmarks for 1st Year ?

    Performance benchmarks under NRHM would include performance indicators in respect of all integrated programmes. In addition, NRHM requires the following activities to be completed in Year 1:

    • Constitution of State and District Health Missions
    • Merger of Health and Family Welfare Societies
    • Signing of MOU for NRHM between State and GOI
    Why FAQs for different programme have been prepared by Dept. of CHA?

    The FAQs are prepared for the website of the institute so that the PG Students and students of Distance Learning Course may have knowledge about the NRHM programme launched by the Govt. of India and to be implemented by Ministry of Health & Family Welfare in 18 states of the country. We prepared these Questions & Answers keeping in view the role of the institute an apex body attached to the MOHFW to guide in technical matters. These FAQs are in simple language which even the staff at peripheral level in the states can understand easily. These are not the copy of FAQs prepared by the MOHFW but the theme is same.

    Proposed role of NIHFW

    Being the apex body of MOHFW , institute can guide the ministry by preparing teaching module for Sr. level trainers and for Refresher training of ASHA workers. The Training of Trainers can also be undertaken by NIHFW. Developing refresher training curriculum for ASHA workers and other staff associated with this programme.

    Monitoring and mid term evaluation of various scheme like JSY, ASHA workers, IPHS can be taken up as a regular activity of the institute for a period of 5 years. End term evaluation can be undertaken at the close of the programme.

    List of subprograms under National Rural Health Mission are given below:

    ASHA (Accredited Social Health Activist)

    IPHS (Indian Public Health Standards)

    JSY (Janani Suraksha Yojana)