Lok Sabha Question No. 3385 (UNSTARRED), answered on 2019-07-12
Subject: NRHM
Ministry: HEALTH AND FAMILY WELFARE
Asked by: Devusinh Jesingbhai Chauhan

## GOVERNMENT OF INDIA MINISTRY OF HEALTH AND FAMILY WELFARE DEPARTMENT OF HEALTH AND FAMILY WELFARE

LOK SABHA UNSTARRED QUESTION NO. 3385 TO BE ANSWERED ON 12 TH JULY, 2019

## NRHM

## 3385. SHRI DEVUSINH JESINGBHAI CHAUHAN:

Will the Minister of HEALTH AND FAMILY WELFARE be pleased to state:

- (a) the aims and objectives of the National Rural Health Mission (NRHM) and strategies worked out for its implementation;
- (b) the details of the key goals of NRHM and achievements madethereunder, State/UT - wise;
- (c) w hether few programmes are lagging behind in terms of performance under NRHM and if so, the details thereof along with the reasons therefor; and
- (d) the corrective measures taken/being taken by the Government to achieve the targets?

## ANSWER THE MINISTER OF STATE IN THE MINISTRY OF HEALTH AND FAMILY WELFARE (SHRI ASHWINI KUMAR CHOUBEY)

- (a)to  (d)  National  Rural  Health  Mission  (NRHM)  is  a  sub - Mission  under  the  overarching National Health Mission (NHM), along with National Urban Health Mission (NUHM) as the other sub - Mission. It is implemented in all the States/UTs in the country. The National He Mission  (NHM)  aims  for  attainment  of  universal  access  to  equitable,  affordable  and  qua health care services, accountable and responsive to peop le's needs, with effective inter - sectoral convergent action to address the wider social determinants of health.  The key objecti NHM are summarised as under:
- (i) Reduction in child and maternal mortality .
- (ii) Prevention  and  control  of  communicable  and  non - communicable  diseases,  including locally endemic diseases.
- (iii) Access to integrated comprehensive primary health care.
- (iv) Population stabilisation, gender equality and demographic balance.
- (v) Revitalize local health t raditions & mainstream AYUSH.
- (vi) Universal  access  to  public  services  for  food  and  nutrition,  sanitation  and  hygie universal  access  to  public  health  care  services  with  emphasis  on  services  addressing  women's and children's health and universal immunisati on.
- (vii) Promotion of healthy life styles.

The  key  goals  of  NHM  are  to  focus  on  the  survival  and  well  being of  women  and children,  reduce  existing  disease  burden  and  ensure  financial  protection  for  househol achieve these goals, strategies which are being implemented under NHM is given at Annexure- 1

.

Further, Public health and hospitals being a State subject, the primary responsibility to provide  healthcare  facilities  to  its  citizens  lies  with  the  State  Governments. However,  under National  Health  Mission  (NHM),  the  performance  of  various  health  programmes  is  bein regularly assessed, inter -ali a, through review meetings, video conferences & field visits of sen officials, setting up benchmarks for service delivery and rewarding achievements etc. Si Common Review Missions (CRMs) undertake review of NHM implementations in the States annually.

At  village  level,  Village  Health  Sanitation  &  Nutrition  Committee  (VHSNC)  i constituted which function under the ambit of the Panchayati Raj Institution (PRI) and a sub-Committee or a Standing Committee of the Gram Panchyat, to enable com munities to take collective action for the attainment of better health status in the village. A s milar mechanism in urban areas is the Mahila Arogya  Samiti (MAS). Untied funds are provided to the VHSNC a MAS on an annual basis to undertake their functi ons. Similarly, at health facility level, Rogi Kalyan  Samitis  (RKSs)  act  as  a  forum  to  improve  the  functioning  and  service  provision increase participation and enhance accountability for provision of better services to th at the level of Prim ary Health Centres and above.

Further in every district, DISHA (District Development Coordination and Monitori Committees)  are  constituted  for  monitoring  of  various  Centrally  Sponsored  Schemes.  It includes  representatives  from Panchayati  Raj  Institutions  (PRIs) and  Urban  Local  Bodies (ULBs).

Statements  showing  Key  achievements  under  NHM  is  given  at  Annexure -II.  Also, State/UTs - wise status of key health indicators under NHM are at Annexure -III and IV.

## Strategies

1. Support and  supplement  state  efforts  to  undertake  sector  wide  health  system strengthening through the provision of financial and technical assistance.
2. Build state, district and city capacity for decentralized outcome based planning and implementation, based on varying diseases burden scenarios, and using a differential financing approach. There will be a focus on results and performance based funding including linkage to case loads.
3. Enable integrated facility development planning which would include infrastructure,  human  resources,  drugs  and  supplies,  quality  assurance,  and effective Rogi Kalyan Samitis (RKS).
4. Create a District Level Knowledge Centre within each District Hospital to serve as the hub for a range of tasks including inter alia, provision of secondary care and selected  elements  of  tertiary  care,  and  the  site  for  skill  based  training  for  all cadres of health workers, collating and analyzing data and coordinating district planning.
5. Improve delivery of outreach services through a mix of static facilities and mobile medical  units  with  a  team  of  health  service  providers  with  the  skill  mix  and capacity to address primary health care needs.
6. Strengthen the sub-centre/Urban Primary Health Centre (UPHC) with additional human  resources  and  supplies  to  deliver  a much  larger  range  of  preventive, promotive and curative care services- so that it becomes the first port of call for each family to access a full range of primary care services.
7. Prioritize achievement of universal coverage for Reproductive Maternal, Newborn, Child Health + Adolescent (RMNCH+A), National Communicable Disease Control and Non Communicable Diseases programmes.
8. Expand focus from child survival to child development of all children 0-18 years through a mix of Community, Anganwadi, and School based health services. The focus of such services will be on prevention and early identification of diseases through  periodic  screening,  health  education  and  promotion  of  good  health practices  and  values  during  these  formative  years  and  timely management including assured referral for secondary and tertiary level care as appropriate.
9. Achieve the goals of safe motherhood and transition to addressing the broader reproductive health needs of women.
10. Focus on adolescents and their health needs.
11. Ensure the control of communicable disease which includes prompt response to epidemics and effective surveillance.
12. Use primary health care delivery platforms to address the rising burden of Non Communicable Diseases
13. Converge  with  Ministry  of  Women  &  Child Development  and  other  related Ministries  for  effective  prevention  and  reduction  of  under-nutrition  in  children aged 0-3 years and anaemia among children, adolescents and women.
14. Empower the ASHA to serve as a facilitator, mobilizer and provider of community level care.
15. Strengthen  people's  organizations  such  as  the  Village  Health  Sanitation  and Nutrition Committees (VHSNC) and Mahila Arogya Samitis (MAS) for convergent inter-sectoral planning to address social determinants of health and increasing utilization of health and related public services at the community level.
16. Create mechanisms to strengthen Behaviour Change Communication efforts for preventive and promotive health functions, action on social determinants and to reach the most marginalized.
17. Enable Social  Protection  Function  of  Public  Hospitals  through  the  universal provision  of  free  consultations,  free  drugs  and  diagnostics,  free  emergency response and patient transport systems.
18. Develop effective partnerships with the not-for-profit, nongovernmental organizations  and  with  the  for-profit,  private  sector  to  bring  in  additional capacity where needed to close gaps or improve quality of services.
19. Improve Public Health Management by encouraging states to create public health cadre, and strengthening/ creating effective institutions for programme management, providing incentives for improved performance and building high quality research and knowledge management structures.
20. Support  states  to  develop  a  comprehensive  strategy  for  human  resources  in health, through policies to support improved recruitment, retention  and motivation of health workers in rural, remote and underserved areas, improved workforce  management,  required  staff  to  help  achieve  IPHS  norms  of  human resource  deployment,  development  of  mid level  care  providers  and  creation  of new cadres with appropriate skill sets, and in-service training.
21. Enhance use of Information & Communication Technology to improve health care and health systems performance.
22. Strengthen Health Management Information Systems as an effective instrument for programme planning and monitoring, supplemented by regular district level surveys and a strong disease surveillance system.
23. Ensure universal registration of births and deaths with adequate information on cause of death, to assist in health outcome measurements and health planning.
24. Establish  Accountability  Frameworks  at  all  levels  for  improved  oversight  of programme implementation and achievement of goals. Mechanisms for accountability  shall  range  from  participatory community  processes  like  Jan Sunwais/Samwads, Social Audit through Gram Sabhas to professional independent concurrent evaluation.

The outcomes achieved under the NHM are:

- Decline  in  the  Maternal  Mortality  Ratio  (MMR)  to  130  during 2014-16 from 178 during 2010-12;
- Decline in the Infant Mortality Rate (IMR) to 33 in 2017 as compared to 42 in 2012.
- Decline in the Under 5 Mortality Rate (U5MR) to 39 in 2016 from 55 in 2011.
- Decline in the Total Fertility Rate (TFR) to 2.3 in 2016.

Further various diseases-related health indicators have also shown improvement, such as:

- Annual Parasite Incidence (API) of Malaria Cases has declined to 0.30 in 2018 from 1.10 in 2011.
- The  incidence  of  Tuberculosis  (TB)  per  1  lakh  population  has  been reduced to 204 in 2017, from 234 in 2012.
- The  target  of  prevalence  of  leprosy  <1/one  lakh  population  has  been achieved nationally.
- At  the  end  of  December  2018,  92%  Kala-azar  endemic  blocks  have achieved  the  elimination  target  of  <1  Kala  Aazar  case  per  10,000 population at block level.
- The prevalence of tobacco use has reduced by six percentage points from 34.6% (2009-10) to 28.6% (2016-17) as per Global Adult Tobacco Survey (GATS-2)]

## Statement showing State/UTs wise achievements made under NHM

|         |                   | SRS 2017         | SRS 2017         | SRS 2017              | SRS 2016                  | SRS 2016               | SRS 2016             |
|---------|-------------------|------------------|------------------|-----------------------|---------------------------|------------------------|----------------------|
| Sl. No. | States            | Crude Birth Rate | Crude Death Rate | Infant Mortality Rate | Neo -natal Mortality Rate | Under 5 Mortality Rate | Total Fertility Rate |
|         | ALL INDIA         | 20.2             | 6.3              | 33                    | 24                        | 39                     | 2.3                  |
| 1       | Andhra Pradesh    | 16.2             | 7.2              | 32                    | 23                        | 37                     | 1.7                  |
| 2       | Assam             | 21.2             | 6.5              | 44                    | 23                        | 52                     | 2.3                  |
| 3       | Bihar             | 26. 4            | 5.8              | 35                    | 27                        | 43                     | 3.3                  |
| 4       | Chhattisgarh      | 22. 7            | 7.5              | 38                    | 26                        | 49                     | 2.5                  |
| 5       | Gujarat           | 19.9             | 6.2              | 30                    | 21                        | 33                     | 2.2                  |
| 6       | Haryana           | 20.5             | 5.8              | 30                    | 22                        | 37                     | 2.3                  |
| 7       | Jharkhand         | 22.7             | 5.5              | 29                    | 21                        | 33                     | 2.6                  |
| 8       | Karnataka         | 17.4             | 6.5              | 25                    | 18                        | 29                     | 1.8                  |
| 9       | Kerala            | 14.2             | 6.8              | 10                    | 6                         | 11                     | 1.8                  |
| 10      | Madhya Pradesh    | 24.8             | 6.8              | 47                    | 32                        | 55                     | 2.8                  |
| 11      | Maharashtra       | 15.7             | 5.7              | 19                    | 13                        | 21                     | 1.8                  |
| 12      | Odisha            | 18.3             | 7.4              | 41                    | 32                        | 50                     | 2.0                  |
| 13      | Punjab            | 14.9             | 7.0              | 21                    | 13                        | 24                     | 1.7                  |
| 14      | Rajasthan         | 24.1             | 6.0              | 38                    | 28                        | 45                     | 2.7                  |
| 15      | Tamil Nadu        | 14.9             | 6.7              | 16                    | 12                        | 19                     | 1.6                  |
| 16      | Telangana         | 17.2             | 6.6              | 29                    | 21                        | 34                     | 1.7                  |
| 17      | Uttar Pradesh     | 25.9             | 6.7              | 41                    | 30                        | 47                     | 3.1                  |
| 18      | West Bengal       | 15.2             | 5.8              | 24                    | 17                        | 27                     | 1.6                  |
| 19      | Arunachal Pradesh | 18.3             | 6.1              | 42                    | ..                        | ..                     | ..                   |
| 20      | Delhi             | 15.2             | 3.7              | 16                    | 12                        | 22                     | 1.6                  |
| 21      | Goa               | 12.5             | 6.2              | 9                     | ..                        | ..                     | ..                   |
| 22      | Himachal Pradesh  | 15.8             | 6. 6             | 22                    | 16                        | 27                     | 1.7                  |
| 23      | Jammu & Kashmir   | 15.4             | 4.8              | 23                    | 18                        | 26                     | 1.7                  |
| 24      | Manipur           | 14.6             | 5.3              | 12                    | ..                        | ..                     | ..                   |
| 25      | Meghalaya         | 22.8             | 6.1              | 39                    | ..                        | ..                     | ..                   |
| 26      | Mizoram           | 15.0             | 4.0              | 15                    | ..                        | ..                     | ..                   |
| 27      | Nagaland          | 13.5             | 3.6              | 7                     | ..                        | ..                     | ..                   |
| 28      | Sikkim            | 16.4             | 4.5              | 12                    | ..                        | ..                     | ..                   |
| 29      | Tripura           | 13.0             | 5.2              | 29                    | ..                        | ..                     | ..                   |
| 30      | Uttarakhand       | 17.3             | 6.7              | 32                    | 30                        | 41                     | 1.9                  |
| 31      | A&N Islands       | 11.4             | 5.1              | 14                    | ..                        | ..                     | ..                   |
| 32      | Chandigarh        | 13.5             | 4.5              | 14                    | ..                        | ..                     | ..                   |
| 33      | D&N Haveli        | 23.6             | 4.4              | 13                    | ..                        | ..                     | ..                   |
| 34      | Daman & Diu       | 20.2             | 4.7              | 17                    | ..                        | ..                     | ..                   |
| 35      | Lakshadweep       | 15.0             | 6.5              | 20                    | ..                        | ..                     | ..                   |

.. Not available , Source : SRS, RGI

## ANNEXURE-III

MATERNAL MORTALITY RATIO (per 1,00,000 live births)

| India/States               |   2014-16 * |
|----------------------------|-------------|
| India                      |         130 |
| Andhra Pradesh             |          74 |
| Assam                      |         237 |
| Bihar/Jharkhand            |         165 |
| Gujarat                    |          91 |
| Haryana                    |         101 |
| Karnataka                  |         108 |
| Kerala                     |          46 |
| Madhya Pradesh/Chhatisgarh |         173 |
| Maharashtra                |          61 |
| Odisha                     |         180 |
| Punjab                     |         122 |
| Rajasthan                  |         199 |
| Tamil Nadu                 |          66 |
| Telangana                  |          81 |
| Uttar Pradesh/Uttarakhand  |         201 |
| West Bengal                |         101 |

Source: * latest available SRS