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Convergence |
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Intrasectoral
and Intersectoral |
Intersectoral co-ordination
is a crucial component of the National Rural Health Mission
(NRHM) and promotion of intersectoral linkages is imperative
for its effective implementation. These linkages can be within
the public health system such as RCH, National Disease Control
programme and AIDS control programmes or with other departments
like the Department of Women and Child Development and the Department
of Education for health, nutrition and education programmes.
These linkages could also be with the NGOs, the private health
sector and the corporate sector with the overall objective of
reducing duplication and fragmentation of efforts.
The pulse
polio drives have demonstrated that effective mobilization of
civil society can achieve remarkable results hence forging of
partnerships with the government departments, NGOs, the corporate
sector, trade unions, human rights commission, police, legal
bodies, political parties, media and academic institutions will
be promoted aggressively.
COMMON ISSUES:
Decentralization
enables local people to initiate sustain and support action
for children and women. The focus will be on capacity building
of the panchayats in the rural areas and nagar palikas in the
urban areas so that they are able to plan, implement and monitor
local programmes for children. Participation of local NGOs,
women’s groups, parents, families and the community will
be encouraged to complement the efforts of the government. At
the same time efforts will also be made to link up with the
decentralization processes within sectors already underway at
both the centre and the state levels. The Village Health and
Water and Sanitation Committee is the point of convergence for
all the stakeholders and decentralized planning.
This will constitute
a major strategic thrust of the programme and is particularly
important due to the persistence of gender inequalities that
exist. Besides promoting economic opportunities for women there
will be a special emphasis on improving the position of women
in society and the effectiveness of women’s participation
in community level decision making. This requires major changes
to be brought about in perceptions so that women become socially,
politically and culturally more effective in influencing public
decision-making. This is the mandate in all the development
programmes
Equity is a major
cause of concern because the benefits of all the programmes
should reach the unreached - the deprived communities, Poor,
inaccessible areas, Schedule tribes, Schedule castes and females.
NRHM proposes to ensure convergence of basic social services
in order to bring government service providers into closer and
more responsive working relationships with the community for
convergent community action. This will enable better equity
and wider coverage. This approach offers an opportunity to ensure
contextuality of programme interventions and will form the basis
of developing detailed programmes at district and local levels
in cooperation with the state governments.
The NDCS encompasses:
National Vector Borne Disease Control Programme, the National
Leprosy Eradication Programme, the Revised National Tuberculosis
Control Programme, and the National Blindness Control Programme.
NVBDCP includes
major vector borne diseases of public health importance, such
as: Malaria, Filariasis, Japanese Encephalitis, Dengue fever/Dengue
Haemorrhagic fever, and Kala-Azar. At the National level the
Directorate of NVBDCP provides policy and supervisory oversight.
At the state level the state directorates are administering
the programme. Fund flows are a mix of cash and commodity assistance
for all five strategies encompass actions at household, community
and system levels. They include early diagnosis and prompt specific
treatment/case management, integrated vector control mechanisms,
community based health education, training and capacity building
of various cadres of medical and paramedical staff for prevention,
management and control, and effective monitoring, supervision
and surveillance. NRHM will focus on all diseases of NVBDCP.
Actions to be taken under the NRHM are:
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ASHA
and Village Health Team to be oriented to community based
vector control strategies. Convergence with Water and Sanitation
Mission will facilitate this process.
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ASHA to be able to give presumptive treatment for malaria.
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Enhanced surveillance capacity (human resources and infrastructure)
at PHC and CHC levels
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Enhancing
laboratory capacity at CHC and PHC.
The National Leprosy Eradication Programme (NLEP)
Leprosy is a disease
of public health concern in India. Current prevalence is 1.8/10,000.
One of the key outcomes in NRHM is to eliminate Leprosy. Under
NRHM, the strategies drawn up under the second National Leprosy
Elimination Project are to be continued. The five key components
include: Decentralization and Institutional Development, Strengthening
and Integration of Service Delivery, Disability Care and Prevention
Information, Education, and Communication, and Training. Services
will continue to be provided at PHC, CHC, Additional PHC, and
Hospitals with support from the district nucleus. The subcenters
will be involved in delivery of second and subsequent doses
of MDT. Village and District Health Plans will enable identification
and ensure referral of cases requiring disability treatment
to the appropriate facility. CMOs and medical officers will
continue to be trained on leprosy programme management.
Revised
National TB Control Programme (RNTCP)
The Revised National
TB Control Programme (RNTCP) is the vehicle through which the
WHO recommended DOTS (Directly Observed Therapy, Short Course)
strategy is implemented in India. Currently Phase 2 of the RNTCP
is underway and all districts in are being covered. As part
of the programme, Microscopy centers are established at PHC,
CHC, or district hospitals. RNTCP supports the salary of laboratory
technicians, laboratory supplies and consumables. All medical
officers are trained under RNTCP for diagnosis, management,
and referral. All SCs, PHCs, CHCs, and District Hospitals function
as DOTS centers. Community level DOTS providers are also trained
in delivery of the drugs. Para medical staff re trained in monitoring
consumption of anti TB drugs. The RNTCP also involves civil
society organizations in its outreach and communication efforts.
Under NRHM, the ASHA will be the facilitator for early access
to diagnosis, referral and follow up as a community provider
of DOTS.
National
Blindness Control Programme (NBCP)
The National Blindness
Control Programme aims at reducing the prevalence of blindness
form the current level of 1.1% to 0.5% by 2010. Apart form providing
surgical treatment (Intra Ocular lens-IOL) for cataract, which
is the leading cause of blindness, the programme seeks to tackle
other causes of blindness such as childhood blindness, glaucoma,
and retinal disorders. School health check up is also one of
the major components of the programme. ASHA would play an important
role in creating awareness of the programme and motivate people
to seek treatment. NRHM would also seek to create synergy between
the NBCP and the Vitamin A programme.
Integrated
Disease Surveillance Programme (IDSP)
The IDSP (2004-2009)
is a decentralized Information Technology based surveillance
system, which monitors the incidence of a set of high priority
communicable diseases and risk factors associated with non-communicable
diseases. The project also provides for a rapid response to
any outbreak, should the number of cases exceed pre-defined
threshold levels. Through effective surveillance of such conditions,
IDSP would provide a strong foundation to the disease control
programmes under NRHM. ASHA, being the link between the community
and the public health system would be a very important component
of the programme.
NATIONAL
AIDS CONTROL ORGANISATION (NACO):
The Department of
Family Welfare has been actively collaborating with the NACO
and Department of Women and Child Development for co-ordination
between the RCH, AIDS and ICDS programmes in order to ensure
optimal utilisation of resources. Co-ordination between these
would also assist in delivering HIV/AIDS awareness messages
at the grass root level through the field workers of these programmes
who have established credibility with the community. At present
there is no evidence about the effectiveness of this strategy
mainly because this is a relatively recent initiative and mechanisms
need to be developed to monitor co-ordination between the three
programmes.
The Department of
Family Welfare will benefit from those NACO activities which
are aimed at blood safety and safe sexual practices, while NACO
will benefit from the RTI/STI control activities which have
been introduced in the RCH programme. A co-ordinated approach
for setting up of RTI/STI clinics needs to be adopted by both
departments wherein NACO will establish these clinics in district
hospitals, while the RCH programme will establish these facilities
at FRU/CHC levels.
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| Convergence
with Water and Sanitation |
All
major infectious agents that cause diarrhea are transmitted by
the faecal oral route. Availability of good quality water and
sound hygienic practices are crucial to interrupt faecal-oral
transmission. Several studies show a median reduction between
27% - 30% in diarrhea morbidity and mortality. Sanitation facilities
are available in very few dwelling units. The Department of Drinking
Water Supply, (DDWS) Ministry of Rural Development (MoRD) implements
two Mission mode initiatives for improving access, coverage, quality
of safe water and sanitation in a sustainable manner - Swajaldhara
Scheme and the Total Sanitation Campaign (TSC). Activities under
TSC are: Construction of individual household Latrines, Community
Sanitary Complexes, Anganwadi Toilets, IEC, School Sanitation
and Hygiene Education, and Rural Sanitary Marts and Production
Centers,
Swajaldhara, TSC and NRHM rely on community led approaches
and are expected to be managed by panchayats. Strong intersectoral
convergence is necessary at the district and state levels for
improved synergy among these three initiatives. The institutional
arrangement for the Total Sanitation Campaign (to be universalized)
will be the same at District and Village levels. However budgeting
for the programmes will remain separate.
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| Integrated
Child Development Services (ICDS) |
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Co-ordination between the ICDS and the RCH
programmes is by far the most significant attempt by the Government
for promoting inter sectoral co-ordination in the RCH programme.
This is crucial for the successful implementation of the RCH programme,
as it would result in increasing service coverage for women and
children, reducing the unmet need and ensuring better quality
of services. It is therefore important that both the Departments
of Women and Child Development (DWCD) and Family Welfare (DOFW)
should make concerted efforts to co-ordinate their activities
at the grass root, district, state and central levels.
The Community Needs Assessment Approach (CNAA)
was evolved to ensure the involvement of the Panchayati Raj Institutions
(PRIs) in planning and implementation of the RCH programme. It
was envisaged that the ANM, AWW, and members of the Panchayat
and the Mahila Swasthya Sangh (MSS) would consult with each other
and the community in order to prepare the Sub Centre Action Plan
as a first step towards the process of decentralized planning
in the RCH programme. However reports indicate that this consultative
process has been sporadic and disjointed and has not resulted
in contributing meaningfully to the preparation. Still both the
functionaries are doing independent yearly Household surveys and
the data differs.
The AWWs are providing support to the child
survival components of immunisation, diarrhoea management and
vitamin A deficiency control, in addition to the identification
and treatment of common childhood diseases at an early stage through
growth monitoring. Moreover, they also support safe motherhood
components like prophylaxis for nutritional anemia, TT immunisation
for pregnant women and nutritional supplementation for pregnant
and lactating mothers in the project areas.
They are already trained for detecting common
childhood illnesses including diarrhoea and pneumonia and commonly
refer ill children to the ANMs at the sub centres or to the Primary
Health Centres. The ANM is responsible for providing primary health
care, ante natal care, post natal care, child care, immunization,
and counseling and promotion of family planning. These services
are provided by the ANM at the sub centre as well as during her
field visits to the villages.
Although there is evidence of co-ordination between
the DWCD and the DOFW at the field level, particularly in the
immunization programme, there is a need for more effective co-ordination
between both the departments at district, state and central levels
for implementing the other components of the RCH programme more
effectively. There is considerable overlap in the duties being
performed by the AWWs and the ANMs and there is a need to rationalize
their roles and responsibilities by DWCD and DOFW .
The AWC will continue to serve as the focal point
for all health and nutrition services. As part of the NRHM, a
Maternal, Child Health Nutrition Day (MCHN) has been fixed every
month at the AWC to provide antenatal, postnatal, family planning
and child health services. An ANM and preferably a Medical officer
from the PHC will be in attendance. With active support from Community
Groups such as Self Help Groups (SHG) to motivate the AWW and
ASHA could mobilize women and children and motivate to access
services.
Services to be provided on the MCHN Day
include:
- ANC
- Newborn check
up
- Postnatal care
- Immunization of
mothers and children
- IFA and Vitamin
A administration,
- Growth monitoring,
- Treatment for
minor ailments
- Health education.
ANM,
AWW and ASHA would provide counseling to the community regarding
the importance of institutional deliveries and facilitate referral.
AWW and ASHA will also counsel communities on the importance of
balanced diets and promote the use of locally available foodstuffs,
particularly for micronutrient supplementation.
Training
programme content for effective service delivery by ANM, AWW,
Sahyogini and ASHA
The following services, some of which are already being provided,
can be delivered through the joint efforts of the ANM, AWW, Sahyogini
and ASHA after appropriate training, for more effective co-ordination
between the ICDS and the RCH programme:
- Prevention and
management of unwanted pregnancy
- Ante-natal
Care
- Delivery
Services
- Post-natal
Care
- Child Surviva
- Management
of RTIs/ STIs
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| Ayush
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| Integration
of Ayush
The
integration of Ayush is to be carried out at the State and district
level :
Membership
of the State and District Mission and the Integrated State and
District Health Societies of a person from Ayush so that they
are part of all the decision making processes. Wherever there
are CMHO complexes the Ayurveda district personnel will be housed
in this complex.
Mainstreaming
will begin in two CHCs selected for the IPHS. The infrastructure
will be used for providing a greater availability of services.
All the National Programmes will also be implemented by Ayush
with regular reporting. The CMHO will ensure all the supplies
to the Ayush. The Ayush personnel will also be involved in wider
publicity of all the schemes and messages. All the IEC material
will be given by the IEC department to the Ayush personnel. Trainings
also will be jointly carried out so that the skills of the Ayush
personnel can carry out the National programmes effectively.
Outreach
services also will be carried out through RCH camps and Sanjeevni
camps, wherein the Ayush personnel will be provided with Ayurvedic
medicines.
Monitoring
and Evaluation
NRHM
will build on the M and E arrangements established as part of
RCH II and the IDSP to strengthen capacity for M and E as well
as establish systems to enable collection of data and disaggregate
by age, gender and other categories as required. Management Information
Systems under the NRHM will be web enabled for citizen scrutiny.
Civil society organizations will collaborate with the health system
in preparing a People’ Health Report at the district level.
. State and National reports anon People’s health to be
tabled in assemblies and parliament. Each health facility will
report to their respective Panchayats- sub centers to the Gram
Panchayat, Hospitals to the Rogi Kalyan Samiti, and District Heath
Mission to the Zila Parishad. External evaluations of the NRHM
will be conducted through professional organizations with involvement
of civil society. The M and E will serve to inform mid course
reviews and enable corrective action in a timely manner. |
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Role of NGO's |
| NGOs
in NRHM NGOs
can play a very important role in the success of NRHM.their role
is to compliment the efforts of government.The activities envisaged
for NGOs are as follows:
- Provide support
in the selection training and post training follow up of ASHAs.
- Responsible for
providing support and/preparation of annual plan of the district
.
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Providing support in proper data collection especially at
the time of CNAA and the yearly survey conducted by the AWW.
- Provide support
in registration/ identification of private practitioner / Hospitals
- Ensure sanctioning
of fund for each block/PHC/CHC.
- Oversee overall
monitoring and evaluation of the Schemes and matters concerned
therewith.
- Make necessary
report to the State and the SHM/State’s Implementation
Committee.
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8.
Ensure wide and continuous publicity of the benefits under
all the schemes JSY and the procedures for claiming the benefit
through posters, brochures, media, display of information
at all Sub-centres, PHCs, CHCs and District Hospitals, Urban
Health Centres, Health posts and those private hospitals,
nursing homes/ clinics recognized/accredited for implementation
of the Scheme.
- Awareness regarding
the good health practices to the community e.g; Safe motherhood,
Family planning, Child health, gender issues, age of marriage,
Sanitation, including water, prevention of Malaria, good hygiene,
safe sexual health.
- Ensuring the wide
participation of the community in the fixed MCHN days.
- Counselling of
the Community on various issues.
- Early detection
of Tuberculosis, Promotion of DOTS and also in the direct implementation
of DOTS.
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Leprosy: NGOs will continue to be involved in reconstructive
surgery, disability care and prevention, and IEC. Village
and District Health Plans will enable identification and ensure
referral of cases requiring disability treatment to the appropriate
facility.
- Capacity building
of the PRIs.
- Developing the
capacities of the Village health and Water Sanitation Committees
to function effectively.
- Effective Gram
Sabhas especially for development issues.
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| PRI's
and NRHM |
| Panchayati
Raj Institutions and NRHM
Panchayats
in India are an age-old institution for governance at village
level. In 1992, through the enactment of the 73rd Constitutional
Amendment, Panchayati Raj Institutions (PRI) were strengthened
as local government organizations with clear areas of jurisdiction,
adequate power, authority and funds commensurate with responsibilities.
Panchayats
have been assigned 29 rural development activities, including
several, which are related to health and population stabilization.
The XI schedule includes Family Welfare, Health and Sanitation,
(including hospitals, primary health centers, and dispensaries,)
and the XII schedule includes Public Health. Thus the possible
realm of influence of the Panchayats extends over a significant
proportion of public health issues. The Gram Sabha, where empowered
has the potential to act as a community level accountability mechanism
to ensure that the functions of the village Panchayat in the area
of public health and family welfare, actually respond to people’s
needs.
Increasingly
it is being realized that strategies for achieving low infant,
under five and maternal mortality depend on a functioning continuum
of high quality services from community to secondary and sometimes
higher levels of care. In addition community support for such
services comes through behavior change to increase utilization
as well as demand high quality services. In the RCH 2 implementation
document, specific mention is made of plans to support PRI (and
urban counterparts) in design, implementation, monitoring of RCH
related interventions. This is also seen as a potential to address
the social determinants of health through engagement with communities
and PRI rather than a biomedical approach. It is also expected
that PRI involvement will increase community understanding of
issues of accountability for quality and reliability of health
care services.
Critical Role
of Panchayati Raj Institutions in NRHM
The
National Rural Healthcare Mission, designed to integrate health
and family welfare related interventions and address health from
a holistic preventive, promotive and curative viewpoint takes
a much more significant view of PRI engagement. The fulcrum of
the NRHM programme is a social activist(ASHA) at the village level,
who will work with the village level resource team in providing
preventive and promotive health care services. It is expected
that she will be supervised and supported by the panchayats.
Thus
there is opportunity for PRI involvement to address the non technical
components of health care seeking, provided all PRI representatives
are exposed to a perspective building exercise on health within
the framework of gender and equity.
Linkage
from the village to Gram Panchayat to Block and District
At
the village and Gram Panchayat level: The Village Health
Committee (VHC) will form the link between the Gram Panchayat
and the community. The VHC would be responsible for working with
the Gram Panchayat to ensure that the health plan is in harmony
with the overall local plan. It is anticipated that this committee
will prepare a Village Health Plan and maintain village level
data, supervised by the Gram Panchayat. Engaging the Gram Sabha
and other groups in planning and monitoring the Village Health
Plan will presumably enforce transparency and accountability.
Under
the NRHM, untied funds of Rs. 10,000 are placed with the ANM to
meet unanticipated expenditures and to ensure that lack of drugs
and other consumables is not an issue. An account has been opened
with the Sarpanch for operationlization of the activities planned.
At the subcentre level planning and use of these funds will be
supported by the appropriate tier of the panchayat.
Block
Level: At the block level a Block Co-ordination Committee
with the Block Nodal Officer /Block Panchayat President as Chairperson
and the involvement of PRIs and civil society will be formed for
effective functioning and convergence. This will be linked to
the Meeting of the Block level Committeess under the Pradhan.
District
level: At the District level the District Health Mission
will coordinate NRHM functions and are under the Zila Pramukh.
ASHA and the
PRIs
The
selection of ASHA is the responsibility of the Gram Panchayat
where it will be finalized in a meeting of the Gram Sabha.
The success of ASHA scheme will depend on how well the scheme
is implemented and monitored. It will also depend crucially on
the motivational level of various functionaries and the quality
of all the processes involved in implementing the scheme.
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At the village level ASHA will receive support from the women’s
committees (like self help groups or women’s health
committees), Village Health & Sanitation Committee of
the Gram Panchayat, peripheral health workers especially ANMs
and Anganwadi workers, the trainers of ASHA and mainly the
Panchayat members.
- At the block level,
ASHA scheme will have a Block Co-ordination Committee with the
Block Nodal Officer /Block Panchayat President as Chairperson
and the involvement of PRIs and civil society.
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The Gram Panchayat would lead the ASHA initiative in selection
of ASHA, providing regular support in undertaking many health
related tasks through its statutory health committee, developing
the village health plan and in the compensation incentive.
All ASHAs will be in this Village Heath & Sanitation Committee
of the Panchayat either as members or as special invitees
- The state level
NRHM committee will monitor and support the District Health
Society and District Nodal Officer.
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