PART 1. RURAL HEALTH CARE SYSTEM IN INDIA

PART 1. RURAL HEALTH CARE SYSTEM IN INDIA

Rural Health Care System the structure and current scenario The primary health care infrastructure in rural areas has been developed as a three tier system and is based on the following population norms: Table 1. Population Norms Centre Plain Area Hilly/Tribal/Difficult Area Sub-Centre 5000 3000 Primary Health Centre 30,000 20,000 Community Health Centre 1,20,000 80,000 Sub-Centres (SCs) 1.2. The Sub-Centre is the most peripheral and first contact point between the primary health care system and the community. Each Sub-Centre is manned by one Auxiliary Nurse Midwife (ANM) and one Male Health Worker MPW(M). One Lady Health Worker (LHV) is entrusted with the task of supervision of six Sub-Centres. Sub-Centres are assigned tasks relating to interpersonal communication in order to bring about behavioral change and provide services in relation to maternal and child health, family welfare, nutrition, immunization, diarrhea control and control of communicable diseases programmes. The Sub-Centres are provided with basic drugs for minor ailments needed for taking care of essential health needs of men, women and children. The Department of Family Welfare is providing 100% Central assistance to all the Sub- Centres in the country since April 2002 in the form of salary of ANMs and LHVs, rent at the rate of Rs. 3000/- per annum and contingency at the rate of Rs. 3200/- per annum, in addition to drugs and equipment kits. The salary of the Male Worker is borne by the State Governments. Under the Swap Scheme, the Government of India has taken over an additional 39554 Sub Centres from State Governments / Union Territories since April, 2002 in lieu of 5434 number of Rural Family Welfare Centres transferred to the State Governments / Union Territories. There are 142655 Sub Centres functioning in the country as on September, 2004. Primary Health Centres (PHCs) 1.3. PHC is the first contact point between village community and the Medical Officer. The PHCs were envisaged to provide an integrated curative and preventive health care to the rural population with emphasis on preventive and promotive aspects of health care. The PHCs are established and maintained by the State Governments under the Minimum Needs Programme (MNP)/ Basic Minimum Services Programme (BMS). At present, a PHC is manned by a Medical Officer supported by 14 paramedical and other staff. It acts as a referral unit for 6 Sub Centres. It has 4-6 beds for patients. The activities of PHC involve curative, preventive, primitive and Family Welfare Services. There are 23109 PHCs functioning as on September, 2004 in the country. 1

The basic structure of the three tier system can be summarized as follows in : Chart 1. RURAL HEALTH CARE SYSTEM IN INDIA Community Health Centre (CHC) A 30 beded Hospital/Referal Unit for 4 PHCs with Specialised services Primary Health Centre (PHC) A Referal Unit for 6 Sub Centres 4-6 beded manned with a Medical Officer Incharge and 14 subordinate paramedifcal staff Sub Centre (SC) Most peripheral contact point between Primary Health Care System & Community manned with one MPW(F)/ANM & one MPW(M) 2

Box 1. STAFFING PATTERN A. STAFF FOR SUB - CENTRE: Number of Posts 1. Health Worker (Female)/ANM... 1 2. Health Worker (Male)... 1 3. Voluntary Worker (Paid @ Rs.100/- p.m. as honorarium)... 1 Total:... 3 B. STAFF FOR NEW PRIMARY HEALTH CENTRE 1. Medical Officer... 1 2. Pharmacist... 1 3. Nurse Mid-wife (Staff Nurse)... 1 4. Health Worker (Female)/ANM... 1 5. Health Educator... 1 6. Health Assistant (Male)... 1 7. Health Assistant (Female)/LHV... 1 8. Upper Division Clerk... 1 9. Lower Division Clerk... 1 10. Laboratory Technician... 1 11. Driver (Subject to availability of Vehicle)... 1 12. Class IV... 4 Total:... 15 C. STAFF FOR COMMUNITY HEALTH CENTRE: 1. Medical Officer #... 4 2. Nurse Mid Wife(staff Nurse)... 7 3. Dresser... 1 4. Pharmacist/Compounder... 1 5. Laboratory Technician... 1 6. Radiographer... 1 7. Ward Boys... 2 8. Dhobi... 1 9. Sweepers... 3 10. Mali... 1 11. Chowkidar... 1 12. Aya... 1 13. Peon... 1 Total:... 25 # :Either qualified or specially trained to work as Surgeon, Obstetrician, Physician and Pediatrician. One of the existing Medical Officers similarly should be either qualified or specially trained in Public Health). 3

Box 2. S.No. RURAL HEALTH INFRASTRUCTURE - NORMS AND LEVEL OF ACHIEVEMENTS (ALL INDIA) Indicator National Norms Achievements 1 Rural Population (2001) covered by a: General Tribal/Hilly/Desert Sub Centre 5000 3000 5204 Primary Health Centre (PHC) 30000 20000 32129 Community Health Centre (CHC) 120000 80000 2.30 lakhs 2 Number of Sub Centres per PHC 6 6.19 3 Number of PHCs per CHC 4 7.14 4 Rural Population (2001) covered by a: MPW (F) 5000 3000 5345 MPW (M) 5000 3000 12221 5 Ratio of HA (M) to MPW (M) 1:6.0 1:3.02 6 Ratio of HA (F) to MPW (F) 1:6.0 1:7.03 7 Average Rural Area (Sq. Km) covered by a: Sub Centre -- 21.86 PHC -- 134.94 CHC -- 967.82 8 Average Radial Distance (Kms) covered by a: Sub Centre -- 2.64 PHC -- 6.55 CHC -- 17.55 9 Average Number of Villages covered by a: Sub Centre -- 4.48 PHC -- 27.63 CHC -- 198.20 4

Community Health Centres (CHCs) 1.4. CHCs are being established and maintained by the State Government under MNP/BMS programme. It is manned by four medical specialists i.e. Surgeon, Physician, Gynecologist and Pediatrician supported by 21 paramedical and other staff. It has 30 in-door beds with one OT, X- ray, Labour Room and Laboratory facilities. It serves as a referral centre for 4 PHCs and also provides facilities for obstetric care and specialist consultations. As on September, 2004, there are 3222 CHCs functioning in the country. 2. Strengthening of Rural Health Infrastructure 2.1. With a view of improving facilities in the existing rural health infrastructure under Reproductive and Child Health Programme, the Government of India is assisting all the States in improving/ constructing labour room, operation theatre and providing water/ electricity supply in CHCs/ PHCs etc. so that essential and emergency obstetric services are improved. Minor Civil Works 2.2. An amount of Rs.10 lakh per district has been released to the States for minor repair and maintenance of buildings, especially for operation theatres, labour rooms and for carrying out improvements in water and electric supply. Major Civil Works 2.3. An amount of Rs. 10 lakh per CHC/ district hospital is available for release to all the States to improve facilities for essential and emergency obstetric services through providing water supply and electricity, construction/repair of operation theatre, labour room/ or to provide/improve facilities for hospitals. Pradhan Mantri Gramodaya Yojana [PMGY] 2.4. The PMGY is an initiative to expand outreach and coverage in the provisioning for basic minimum services in rural areas, with a view to improving the quality of lives that people lead. 2.5. The Planning Commission of India has allocated an Additional Central Assistance, 2001-2002, of Rs.2800 crores for six sectors viz. Rural Electrification, Primary Health, Primary Education, Shelter, Drinking Water and Nutrition. The Planning Commission has conveyed that during 2001-2002, the mandatory earmarking for all components except nutrition will be limited to 10% of the ACA allocation of a state/ut as against a ceiling of 15% during the previous year, 2000-2001. While the States and UTs must allocate 65% of their total ACA towards the six sectors, the allocation of the remaining 35% of the ACA would be determined by the States/UTs on the basis of their own priorities. 2.6. Funds under the PMGY are to be utilized to further the goals and objectives of primary health care as per the following guidelines: i. 50% towards strengthening the functioning of the existing primary health care facilities by provisioning for: A. Procurement of drugs (other than those supplied under the National Disease Control, Family Welfare Programme, Externally Aided Projects 5

etc.) as well as essential consumables, including disposable delivery kits, reagents, X-ray films etc. for diagnostic and therapeutic procedures. 2% of the funds allocated to the Primary Health Sector under PMGY are to be earmarked for purchase of the ISM&H Drugs. B. Contingencies for meeting travel costs of the ANMs, maintenance of installed equipments and fixtures, inclusive of bed linen, repair of essential, repairs / replacement of furniture and movables like beds and bed-equipment, fixtures and furnishings for operation theatres, and generators. ii. 50% towards strengthening, repair and maintenance of the infrastructure in Subcentres, Primary health Centres and in Community Health Centres, inclusive of staff quarters. Priority may be accorded to ensuring potable water supply, adequate toilet facilities, and waste management at district hospitals and in facilities below district hospitals. 2.7. Paras 2.6. (i) and (ii) above refers to the entire allocation towards Primary Health Care under PMGY i.e. the 10% earmarked for this sector, plus the additional allocation made at the discretion of the state governments from the 35% unallocated funds. 2.8. PMGY funds will be released in half yearly instalments upon receipt of Statements of Expenditure from state governments. Utilization Certificates/Audited Statement will be due from ;state governments at the end of each financial year. 2.9. As a rule of thumb, about 40% of the PMGY funds provided to the States should be allocated towards strengthening the existing infrastructure so that it steadily becomes fully functional. To begin with, it is suggested that attention may be paid to the bottom 20% districts, so identified in terms of the their infant mortality rate (IMR)/crude birth rate (CBR) as per Census 2001. 2.10. Available data from facility survey conducted by the Department of Family Welfare and the facility surveys carried out by states may be utilized to identify geographical areas and specific primary health facilities that need strengthening, and therefore become eligible to be assigned the PMGY funds under the items 4.6 (i) and (ii). 2.11. Caution may be exercised to avoid duplication. Any facility being strengthened under any other ongoing project / programme should ordinarily be excluded from additional funding. 2.12. State Govts./UTs are not required to seek prior approval of Deptt. of Family Welfare /Ministry of Health and Family Welfare, GOI, before incurring expenditures under the PMGY if these expenditures are in accordance with the scheme outlined in para 4.6 above. 3. Training and Development Basic Training of Auxiliary Nurse Midwife (ANM) / Lady Health Visitor( LHV) 3.1. ANM/Multipurpose Health Worker (Female) and LHV/Health Assistant (Female) play vital role in Maternal & Child Health as well as in Family Welfare Service in the rural areas. It 6

is therefore, essential that the proper training to be given to them so that quality services be provided to the rural population. 3.2. For this purpose 336 ANM/Multipurpose Health Worker (Female) schools with an admission capacity of approximately 13,000 & 42 promotional training schools for LHV/ Health Assistant (Female) with an admission capacity of 2600 established by the Department of Family Welfare, Government of India. These training institutions are imparting training to prepare required number of ANMs and LHVs to man the Subcentres, Primary Health Centres, Rural Family Welfare Centres and other Health centres in the country. The duration of training programme of ANM is one and half years and minimum qualification for admission to this course is 10 th pass. Senior ANM with five years of experience is given six months promotional training to become LHV/ Health Assistant (Female). Health Assistant (Female)/LHV provides supportive supervision and technical guidance to the ANMs in sub-centres. 3.3. The staffing pattern of the school varies according to the no. of annual admission capacity of the trainees. However, the school with 40 admission capacity is manned by one nursing officer, two sister tutors, 4 PHN and other supportive staff. Other approved costs besides salary to staff are stipend to trainee, contingency and rent. The detail of financial norm which is effected since 7.2.2001 is as follows: Item Norm (In Rupees) 1. Salary & allowances of staff As per State Government 2. Stipend for trainees 500/- per month/trainee 3. Contingency 10,000/- per annum / school 4. Rent* 60,000/- per annum /school * Rent payable in respect of such schools, which are functioning in rented buildings. Basic Training of Multipurpose Health Worker (Male) 3.4. The Basic Training of Multi Purpose Health Worker (Male) scheme was approved during 6 th Five-Year Plan and taken up since 1984, as a 100% Centrally Sponsored Scheme. This training is provided through 56 training centres through Health & Family Welfare Training Centres and through basic training schools of Multipurpose Health Workers (Male). Initially, the schools were sanctioned at the existing Health & Family Welfare Training Centres and later on expanded to other new basic schools. The training is of one-year duration and on successful completion of the training, the Male Health Worker is posted at the sub-centre along with an ANM/Health Worker (Female). The main functions of Male Multi Purpose Health Worker are in the areas of National Health Programmes like Malaria, Leprosy, T.B. & limited involvement in U.I.P, Diarrhoea Control Program and in family welfare services. 3.5. The financial norms for this scheme have been revised w.e.f. 7.2.2001. Under the scheme the salary of the staff, rent for school and hostel, stipend, educational aids and training material, hiring for bus and contingency are supported. The financial norms has been revised as follows: 7

(in Rupees) Item Norm 1. Salary & allowances As per State Government 2. Rent(for new schools) 10,000/ month 3. Rent for hostel (for new schools) 250 / month / trainee 4. Stipend 300 / month / trainee 5. Educational Aids and Training Material 15,000 / annum 6. Transportation (for hiring bus) 30,000 / annum 7. Contingency 50,000 / annum Maintenance and Strengthening of Health and Family Welfare Training Centres (HFWTC) 3.6. The HFWTCs are the training centres of DoFW, GOI which provide primarily short-term in-service training programmes to the doctors, nurses and para-medical personnel in the rural areas in a defined region. At present these training centres are imparting various in-service training for RCH programme. Apart from in-service education, 19 centres also responsible for conducting the basic training of Male Health Worker s course of one year. 3.7. The training centres have multi-disciplinary staff from biomedicine, social services, health education, public health and nursing and statistics. Apart from the salary of the staff of the training centres, other assistance under the scheme includes contingency, rent for training centres and payment to guest faculty. The financial pattern of assistance for this scheme has been revised since 7.2.2001. The detail of the financial norms are as follows: ( in Rupees) Item Revised norms 1. Salary & allowances of the staff As per State Government 2. Contingency 15,000 / annum 3. Rent* 40,000 / annum 4. Payment to Guest Faculty 50,000 / annum *Rent payable in respect of such centres that are functioning from rented buildings. Strengthening of Basic Training Schools 3.8. This is a new scheme, which is introduced during the 10 th Plan period. This scheme envisages strengthening basic training schools of ANM/LHV. The main objective of the scheme is physical strengthening of the training schools for making these schools workable/ suitable, which have gone into dilapidated condition. 3.9. The provision under the scheme is maximum of Rs.21.5 lakhs per ANM/LHV school for following activities. 8

Activities Rs. in lakhs (maximum) 1. Repair*/up-gradation** for the buildings - 20.00 Trg. Centre, hostel & the field practice area 2. Furniture & Equipment 1.00 3. Books/A.V. Aids 0.50 *Will include replacement/repair of floor/roof, plastering, electric cable, water storage tanks, wall-cupboard, doors, windows, sanitary fixtures, internal water supply (piping), septic tank, leakage, painting etc. ** will include minor extension 3.10. The releases are however depend on the actual requirement based on the estimates of the repair/up-gradation work for the buildings as well as other teaching material. The respective State Government based on requirement is expected to identify the schools that are required to be strengthened and send a proposal with following essential information: 1. Physical and financial performance of ANM/LHV training schools functioning in the State 2. Name and address of the training school proposed to strengthen under the scheme Strengthening of Basic Training School with reason/justification for selecting the particular training school. 3. Details of items proposed to procure/renovate with reason/justification for selecting the proposed items 4. Supporting documents from authorized agencies for cost estimation of each item proposed to procure/renovate e.g. estimates for repair/up-gradation from State Building Corporation or Hospital Services Consultancy Corporation (HSCC) etc. 5. Expected effect on performance of training school after the completion 6. Any other information in support of the proposal. Rural Health Training Centre, Najafgarh 3.11. Rural Health Training Centre, Najafgarh was established as a Najafgarh Health Unit with the assistance of Rockfeller Foundation in 1937 and merged in Rural Health Training Centre (RHTC) in 1969. There are three Primary Health Centres (PHCs) under RHTC, Najafgarh. These are Najafgarh, Palam and Ujwa. The Centre has been rendering various services to the rural community. 3.12. Basically RHTC, Najafgarh is a training centre for the Community Health /Rural Health Training. This Centre is imparting training to nearly 2,500 trainees every year which includes: Medical interns (3-6 months internship of rural health course) under Rural Orientation of Medical Education (ROME) from Dr. Ram Manohar Lohia Hospital, Safdarjung Hospital and those sponsored from DGHS. Roughly 300 Medical Interns are being trained each year. Nursing students of 1 st and 3 rd year of GNM Course from different Nursing Training School of Delhi are being trained. Approximately, 1200 such students are trained every year. 9

ANM 10+2 (Voc) Training School under CBSE affiliated with Indian Nursing Council is also being run and every year 20 students are being admitted for two years certificate course. Trainings related to Rural Health is also provided in the form of different courses like PGDHE, TBA, LHV, PHN, Food and Nutrition, Health Economics and Anganwadi Worker etc. Health Education is an integral part of training component and service component for demand generation and behavioural change. 3.13. Health Care Services in the form of OPD, Emergency, MCH, Mobile Team, PP Unit, Malaria, TB are being provided to roughly 10.5 lakhs population through 3 PHCs and 16 subcentres of Rural Health Training Centre, Najafgarh. This centre covers 73 villages and JJ Colonies (nearby these villages) out of 209 villages of Delhi, which is 1/3 of total villages of Delhi. 3.14. This institute conducts survey in different areas pertaining to family welfare and community health under the sponsorship of some of the pioneer institutions such as AIIMS, NIHFW, UNICEF & NIPCCD etc. Few important projects of research are as follows:- Micro Nutrition deficiency among pregnant women National Health Family Survey-II Health seeking behaviour among rural community of Najafgarh Development of MCH card Effect of mustard oil on normal healthy individual (funded by MRPC & NDDB) RHTC also extends assistance to different postgraduate students for their data collection. 3.15. This centre is also responsible for providing services to the community in the form of health camps and other specialist services with the association of Safdarjung Hospital, Richmond Fellowship etc. Gandhigram Institute of Rural Health and Family Welfare Trust (GIRHFWT), Gandhigram, Tamil Nadu. 3.16. Gandhigram Institute of Rural Health and Family Welfare Trust established in 1964 with financial support from Ford Foundation, Government of India and Government of Tamilnadu. The Health and Family Welfare Training Centre at GIRHFWT is one of 47 training centres in the country. It trains Health and Health related functionaries working in Primary Health Centres, Corporations / Municipalities, Tamil Nadu Integrated Nutrition Projects. The type of training programmes includes Diploma of Health Education of one year and short courses on orientation training, skill training on different Health & Family Welfare issues for various categories of health personnel etc. Gandhigram Institute is also engaged in upgrading the capabilities of ANMs, staff nurses and students of nursing colleges through the Regional Health Teachers Training Institute (RHTTI). The RHTTI also conducts Diploma in Nursing Education & Administration course. 10

Number Number Number 4. Rural Health Infrastructure - a statistical overview The Centres Functioning 4.1. The entire family welfare programme is being implemented through Primary Health Care system. The Primary Health Care Infrastructure has been developed as a three tier system with Sub Centre, Primary Health Centre (PHC) and Community Health Centre (CHC) being the three pillars of Primary Health Care System. Progress of Sub Centres, which is the most peripheral contact point between the Primary Health Care System and the community, is a prerequisite for the overall progress of the entire system. A look at the number of Sub Centres functioning over the years reveal that at the end of the Sixth Plan (1981-85) there were 84,376 Sub Centres. The figure rose to 1,30,165 at the end of Seventh Plan (1985-90) and to 1,36,258 at the end of Eighth Plan (1992-97). At present, as on September, 2004, 1,42,655 Sub Centres are functioning in the country. Graph 1A. Progress of Primary Health Care System 160000 140000 120000 100000 80000 60000 40000 20000 0 Sub Centres Sixth Plan (1981-85) Seventh Plan(1985-90) Eighth Plan(1992-97) Five Year Plan / Year Ninth Plan (1997-2002) Tenth Plan (Upto Sept. 2004) Graph 1B. Progress of Primary Health Care System 25000 20000 15000 10000 5000 0 Primary Health Centres Sixth Plan (1981-85) Seventh Plan(1985-90) Eighth Plan(1992-97) Ninth Plan (1997-2002) Tenth Plan (Upto Sept. 2004) Five Year Plan / Year Graph 1C. Progress of Primary Health Care System 3500 3000 2500 2000 1500 1000 500 0 Sixth Plan (1981-85) Seventh Plan(1985-90) Eighth Plan(1992-97) Ninth Plan (1997-2002) Tenth Plan (Upto Sept. 2004) Five Year Plan / Year Community Health Centres 11

Number Percentage Similar progress can be seen in the number of PHCs which was 9115 at the end of sixth plan (1981-85) and the figure almost doubled to 18671 at the end of Seventh Plan (1985-90) and rose to 22149 at the end of Eighth Plan (1992-97). As on September, 2004, there are 23109 PHCs functioning in the country. In accordance with the progress in the number of SCs and PHCs, the number of CHCs has also increased from 761 at the end of Sixth Plan (1981-85) to 1910 at the end of Seventh Plan (1985-90) and 2633 at the end of Eighth Plan (1992-97). As on September, 2004, 3222 CHCs are functioning. According to the figures of population based on 2001 Population Census, the shortfall in the rural health infrastructure comes out to be of 21983 Sub Centres, 4436 PHCs and 3332 CHCs. Building Status 4.2. About 50.6% of Sub Centres, 84.1% of PHCs and 86.7% of CHCs are located in the Government buildings. The rest are located either in rented building or rent free Panchayat/ Voluntary Society buildings. As on September, 2004, in case of Sub Centres, overall 59226 buildings are required to be constructed. Similarly, for PHCs 1693 and for CHCs 318 buildings are required to be constructed. Graph 2. Percentage of Sub Centres, PHCs and CHCs functioning in Government buildings 100.00 90.00 80.00 70.00 60.00 50.00 40.00 30.00 20.00 10.00 0.00 50.64 84.17 86.75 Sub Centres PHCs CHCs Manpower 4.3. The existing manpower is an important prerequisite for the efficient functioning of the Rural Health Infrastructure. As on September, 2004 the overall total shortfall (which excludes the existing surplus in some of the states) in the posts of MPW(F) / ANM was 11194. Similarly, in case of MPW(M), there was a shortfall of 67261. In case of Health Assistant (Female)/LHV, the shortfall was of 3198 and that of Health Assistant (Male) was 5137. Graph 3A. Shortfall in manpower 80000 70000 60000 50000 40000 30000 20000 10000 0 11191 67261 MPW(F)/ANM MPW(M)/HW(M) LHV/Health Assistants(F) Shortfall 3198 5137 Health Assistant(M) 12

Percentage Even out of the sanctioned posts, a significant percentage of posts are vacant at all the levels. For instance, about 5.4% of the sanctioned posts of MPW(Female)/ ANM were vacant as compared to about 27.1% of the sanctioned posts of MPW(Male)/Male Health Worker. At PHC, about 12.6% of the sanctioned posts of Female Health Assistant/ LHV, 25.2% of Male Health Assistant and 10.9% of the sanctioned posts of doctors were vacant. Graph 3B. Vacancy Position - Percentage of Sanctioned Post Vacant 30.00 25.00 27.14 25.24 20.00 15.00 10.00 5.00 5.44 12.64 10.91 0.00 MPW(F)/ANM MPW(M)/HW(M) LHV/Health Assistants(F) Health Assistant(M) Doctors at PHC 4.4. At the Sub Centre level the extent of existing manpower can be assessed from the fact that about 5% of the Sub Centres were without a Female Health Worker / ANM, about 38.9% Sub Centres were without a Male Health Worker and about 1.3% Sub Centres were without both Female Health Worker / ANM as well as Male Health Worker. This indicates a large shortfall in Male Health Workers, resulting in poor male participation in Family Welfare and other health programmes and overburdening of the ANMs. Graph 4. Percentage of Sub Centres functioning without ANMs or/and HW(M) 45.00 40.00 35.00 30.00 25.00 20.00 15.00 10.00 5.00 0.00 38.93 Without HW (F)/ ANM Without HW(M) Without Both 5.03 1.32 Without HW (F)/ ANM Without HW(M) Without Both 4.5. PHC is the first contact point between village community and the Medical Officer. Manpower in PHC include a Medical Officer supported by paramedical and other staff. 13

Percentage Percentage of PHCs Graph 5. Manpower in the PHCs 45.00 40.00 35.00 30.00 25.00 20.00 15.00 10.00 5.00 0.00 38.99 11.87 4.36 Without Doctor Without Lab Technician Without Pharmacist As on September, 2004, about 4.3% of the PHCs were without a doctor, about 38.9% were without a Lab technician and about 11.8% were without a Pharmacist 4.6. The Community Health Centres provide specialized medical care in the form of facilities of Surgeons, Obstetricians & Gynaecologists, Physicians and Paediatricians. 50.00 45.00 40.00 35.00 30.00 25.00 20.00 15.00 10.00 5.00 0.00 40.99 Graph 6. Percentage of Sanctioned Posts of Specialists' Vacant 24.64 41.13 42.89 37.12 Sugeons O&G Physicians Paediatricians Total Percentage Vacant The current position of specialists manpower at CHCs reveal that out of the sanctioned posts, about 40.9% of Surgeons, 24.6% of Obstetricians & Gynaecologists, 41.1% of Physicians and about 42.8% of Paediatricians were vacant. Overall about 37.1% of the sanctioned posts of specialists at CHCs were vacant. Moreover, there was a shortfall of 5339 specialists at the CHCs as compared to the requirement on the basis of existing norms. 5. National Rural Health Mission Under the mandate of National Common Minimum Programme (NCMP) of UPA Government, health care is one of the seven thrust areas of NCMP, wherein it is proposed to increase the expenditure in health sector from current 0.9 % of GDP to 2-3% of GDP over the next five years, with main focus on Primary Health Care. The National Rural Health Mission (NRHM) has been conceptualized and the same is being operationalised from April, 2005 throughout the country, with special focus on 18 states which includes 8 Empowered Action Group States (Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Uttar Pradesh, Uttaranchal, Orissa and Rajasthan), 8 North East States (Assam, Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim and Tripura) Himachal Pradesh and Jammu & Kashmir. 14

5.2. The main aim of NRHM is to provide accessible, affordable, accountable, effective and reliable primary health care, especially to poor and vulnerable sections of the population. It also aims at bridging the gap in Rural Health Care through creation of a cadre of Accredited Social Health Activists (ASHA) and improve hospital care, decentralization of programme to district level to improve intra and inter-sectoral convergence and effective utilization of resources. The NRHM further aims to provide overarching umbrella to the existing programmes of Health and Family Welfare including RCH-II, Malaria, Blindness, Iodine Deficiency, Filaria, Kala Azar T.B., Leprosy and Integrated Disease Surveillance. Further, it addresses the issue of health in the context of sector-wise approach addressing sanitation and hygiene, nutrition and safe drinking water as basic determinants of good health in order to have greater convergence among the related social sector Departments i.e. AYUSH, Women & Child Development, Sanitation, Elementary Education, Panchayati Raj and Rural Development. 5.3. The Mission further seeks to build greater ownership of the programme among the community through involvement of Panchayati Raj Institutions, NGOs and other stakeholders at National, State, District and Sub District levels to achieve the goals of National Population Policy 2000 and National Health Policy. 5.4. Under the strategy of NRHM, in order to fill the gaps in the existing rural health care infrastructure available in the country, the key components, inter-alia, of the Mission are as given below: (i) Creation of a cadre of Accredited Social Health Activists (ASHA) in 2.5 lakh villages in four years 8 EAG States, J&K and Assam. (ii) Creation of village health scheme and preparation of village health plan 18+ states. (iii) Strengthening sub centres with untied funds of Rs. 10,000/- per annum 10+8+States. (iv) Raising 2000+CHCs to the level of IPHS. (v) Codification of Indian Public health Standards (IPHS) 18+states. (vi) Integrating vertical health and family welfare programmes under NRHM at National, State and District level all states. (vii) Strengthening Programme Management Capacities at National State and District level 10+8+states. (viii) Institutionalising district level management of health all districts. (ix) Supply of generic drugs (both Allopathic and AYUSH) 18+States. (x) School health check up programme 18+States (xi) Promotion of multiple health insurance model all states. (xii) Supplementing Vitamin A and Iron Folic Acid to deficient children at Anganwadi level 18+states. (xiii) Promotion of private sector for achieving public health goals all states. (xiv) Setting up of comprehensive Health and Family Welfare clinics 5 States+select districts. (xv) Services of ANM and medical officers, PHCs to be ensured at fixed days at Anganwadi levels. (xvi) Mainstreaming ISM. Exploring new Health Financing Mechanism, Policy reforms in Medical Education and Public Health Management. (xvii) The mission shall focus on rural areas since bulk of the strategic interventions are aimed at improvement of primary health care in rural areas. 15

5.5. Overview of NRHM (i) The National Rural Health Mission is being launched for a period of seven years (2005-2012) i.e. 2 years of Tenth Plan and full Eleventh Plan. (ii) The Mission shall cover entire country, with focus attention on 18 states having weak demographic indicators/ infrastructure. (iii) NRHM is an omni-bus broad band programme, and all other programmes would be sub-components, retaining the sub-budget heads wherever required for vertical programmes. (iv) The emphasis under NRHM is to improve primary health care, decentralization, intra and inter-sectoral convergence and community ownership. (v) NRHM provides broad policy guidelines states have flexibility to draw their action plans to attain the goals of NRHM (vi) RCH-II, including National Family Welfare Programme (NFWP) and Empowered Action Group (EAG) are subsumed into NRHM. (vii) Operational phase of the Mission is from April, 2005. (viii) MOUs being entered into, with the State Governments for RCH-II, will be broad based for NRHM, to ensure their commitments to the systemic reform and new financial pattern of performance based funding under NRHM. 5.6. Funding The budget outlay for National Rural Health Mission for 2005-06 is Rs. 6731.16 Crores. 5.7. Mission Outcome The following are anticipated Mission outcomes likely to be achieved after its implementation: Provision of village level health provider (ASHA) in under served villages Strengthening Sub- centers /PHCs Raising CHCs to the level of IPHS Institutionalizing District level Management of Health (all districts) Prevention and control of communicable and non communicable diseases including locally endemic diseases Increase utilization of First Referral Units from less than 20% (2002) to more than 75 % by 2010 Reduction in communicable diseases, MMR, IMR and would help in attaining population stabilization. 16