National Health Mission
The National Health Mission (NHM) encompasses its two Sub-Missions, the National Rural Health Mission (NRHM) and the National Urban Health Mission (NUHM). The main programmatic components include Health System Strengthening, Reproductive-Maternal- Neonatal-Child and Adolescent Health (RMNCH+A), and Communicable and Non-Communicable Diseases. The NHM envisages achievement of universal access to equitable, affordable & quality health care services that are accountable and responsive to people’s needs.
Continuation of the National Health Mission - with effect from 1st April 2017 to 31st March 2020 has been approved by Cabinet in its meeting dated 21.03.2018.
NHM has six financing components:
(i) NRHM-RCH Flexipool,
(ii) NUHM Flexipool,
(iii) Flexible pool for Communicable disease,
(iv) Flexible pool for Non communicable disease including Injury and Trauma,
(v) Infrastructure Maintenance and
(vi) Family Welfare Central Sector component.
Within the broad national parameters and priorities, states would have the flexibility to plan and implement state specific action plans. The state PIP would spell out the key strategies, activities undertaken, budgetary requirements and key health outputs and outcomes.
The State PIPs would be an aggregate of the district/city health action plans, and include activities to be carried out at the state level. The state PIP will also include all the individual district/city plans. This has several advantages: one, it will strengthen local planning at the district/city level, two, it would ensure approval of adequate resources for high priority district action plans, and three, enable communication of approvals to the districts at the same time as to the state.
The fund flow from the Central Government to the states/UTs would be as per the procedure prescribed by the Government of India.
The State PIP is approved by the Union Secretary of Health & Family Welfare as Chairman of the EPC, based on appraisal by the National Programme Coordination Committee (NPCC), which is chaired by the Mission Director and includes representatives of the state, technical and programme divisions of the MoHFW, national technical assistance agencies providing support to the respective states, other departments of the MoHFW and other Ministries as appropriate.
Outcomes for NHM in the 12th Plan are synonymous with those of the 12th Plan, and are part of the overall vision. The endeavor would be to ensure achievement of indicators mentioned below(1 to 12 ). Specific goals for the states will be based on existing levels, capacity and context. State specific innovations would be encouraged. Process and outcome indicators will be developed to reflect equity, quality, efficiency and responsiveness. Targets for communicable and non-communicable disease will be set at state level based on local epidemiological patterns and taking into account the financing available for each of these conditions.
1. Reduce MMR to 1/1000 live births
2. Reduce IMR to 25/1000 live births
3. Reduce TFR to 2.1
4. Prevention and reduction of anemia in women aged 15–49 years
5. Prevent and reduce mortality & morbidity from communicable, non- communicable; injuries and emerging diseases
6. Reduce household out-of-pocket expenditure on total health care expenditure
7. Reduce annual incidence and mortality from Tuberculosis by half
8. Reduce prevalence of Leprosy to <1/10000 population and incidence to zero in all districts
9. Annual Malaria Incidence to be <1/1000
10. Less than 1% Microfilariae prevalence in all districts
11. Kala-azar Elimination by 2015, <1 case per 10000 population in all blocks
- The institutional structures have been approved by the Cabinet for NHM wide its decision dated May 1, 2013.
- At the National level, the Mission Steering Group (MSG) and the Empowered Program Committee (EPC) are in place. The MSG provides policy direction to the Mission. The Union Minister of Health & Family Welfare chairs the MSG. The convener is the Secretary, Department of Health & Family Welfare and the co-convenor is the Additional Secretary & Mission Director. Financial proposals brought before the MSG are first placed before and examined by the EPC, which is headed by the Union Secretary of Health and Family Welfare. The composition, role and powers of the MSG and EPC are in accordance with the Cabinet approval of May 1, 2013.
- The Mission is headed by a Mission Director, of the rank of Additional Secretary, supported by a team of Joint Secretaries. The Mission handles not just the day-to-day administrative affairs of the Mission but is responsible for planning, implementing and monitoring Mission activities.
- Upto 0.5% of NHM Outlay is earmarked for program management and activities for policy support at the national level through a National Programme Management Unit (NPMU). 3.5 The National Health Systems Resource Centre (NHSRC) would continue to serve as the apex body for technical support to the Centre and states. Technical support focuses on problem identification, analysis and problem solving in the process of implementation. It also includes capacity building for district/city planning, organization of community processes and over all dimensions of institutional capacity, of which skills is only a part. NHSRC would also undertake implementation research and evaluation and support the development of State Health Systems Resource Centres (SHSRC) and knowledge networks and partnerships in the states. NHSRC would further provide support for policy and strategy development, through collating evidence and knowledge from published work, from experiences in implementation and serve as institutional memory.
- The National Institute of Health and Family Welfare (NIHFW) is the country’s apex body for training. Its main focus is on public health education, development of skills in public health management and all training needs of the health care providers. Training is focused on skill based training of service providers and includes selected aspects of health management training. Its primary accountability is to see that along with its state counterparts, necessary skills for public health management and service provision are in place. One of the major roles of the NIHFW would be to revitalize and strengthen the State Institutes of Health and Family Welfare (SIHFW). Another role would be to develop into a centre of e-learning. The NIHFW would also play a leading role in public health research and support to health and family welfare program.
- The huge need of institutional capacity development across the nation can be met only by coordinated efforts between networks of a large number of public health institutions. Knowledge resources for the National Disease Control Program are supported by the National Centre for Communicable Diseases. Additional knowledge resources can be harnessed from a number of emerging public health institutions, such as the public health divisions of centrally sponsored institutes namely, All India Institutes of Medical Sciences, (AIIMS) and Post Graduate Medical.
- Education and Research, (PGIMER) others, such as, the Public Health Foundation of India, (PHFI) the Indian Institute of Health Management and Research (IIHMR) and other institutes and schools of public health in states.
- At the state level, the Mission functions under the overall guidance of the State Health Mission (SHM) headed by the State Chief Minister. The State Health Society (SHS) would carry the functions under the Mission and would be headed by the Chief Secretary.
- The District Health Mission (DHM)/City Health Mission (CHM) would be headed by the head of the local self-government i.e. Chair Person Zila Parishad/Mayor as decided by the state depending upon whether the district is predominantly rural or urban. Every district will have a District Health Society (DHS), which will be headed by the District Collector. At the city level, the Mission or Society may be established based on local context. Existing vertical societies for various national and state health program will be merged in the DHS.
- The management of NUHM activities may be coordinated by a city level Urban Health Committee headed by the Municipal Commissioner/District Magistrate/Deputy Commissioner/District Collector/ Sub-Divisional Magistrate/Assistant Commissioner based on whether the city is the district headquarter or a sub-divisional headquarter as may be decided by the state. This would facilitate coordination with other related departments like Women & Child Development, Water Supply and Sanitation especially in times of response to disease outbreaks/ epidemics in the cities.
- For the seven mega cities of Delhi, Mumbai, Chennai, Kolkata, Bengaluru, Hyderabad and Ahmedabad, NHM will be implemented by the City Health Mission.
- The State Program Management Unit (SPMU), State Health System Resource Centres (SHSRC) and the State Institutes of Health and Family Welfare (SIHFW) will continue to play similar roles for the State as do their national counterparts for the Centre. The SPMU acts as the main secretariat of the SHS. The constitution and functioning of the SPMU and Executive Committee of the SHS shall be such that there is no hiatus between the Directorate of Health and Family Welfare services and the SPMU. The exact detail of how this would be achieved is left to the State.
- SIHFWs and SHSRCs will be strengthened with the necessary infrastructure and human resources to enable provision of quality training and skill development programs. Linkages with research institutes, schools of public health and medical colleges at State and National level would be supported.
- The District Programme Management Unit (DPMU) would be linked to a District Health Knowledge Centre (DHKC) and its partners for the requisite technical assistance. The District Training Centre (DTC) would be the nodal agency for training requirements of the District Health Society (DHS).
Strengthening State Health Systems
The NHM shall be a major instrument of financing and support to the states to strengthen public health systems and health care delivery. This financing to the state will be based on the state’s Programme Implementation Plan (PIP).
- Within the broad national parameters and priorities, States would have the flexibility to plan and implement state specific action plans. The state PIP would spell out the key strategies, activities undertaken, budgetary requirements and key health outputs and outcomes.
- The state PIPs would be an aggregate of the district/city health action plans, and include activities to be carried out at the state level. They would be expected to include the individual district plans particularly of High Priority Districts and City Plans. This has several advantages: one, it will strengthen local planning at the district/city level, two, it would ensure approval of adequate resources for high priority district action plans, and three, enable communication of approvals to the districts at the same time as to the state.
- The existing Memorandum of Understanding (MOU) signed with the states under NRHM will operate as the MOU under the NHM with modifications as required. The MOU spells out the responsibilities and commitments of the Centre and the state, the outcomes expected from the financial investments and the institutional reforms to strengthen accountability and regulatory frameworks in the state health system. States would be Incentivise to undertake governance and institutional reforms for improved health outcomes. The incentive fund approved by the MSG would be used for this purpose. Further, failure to execute fundamental reforms or comply with key Conditionality would attract disincentives. Trust in the state’s ability to adhere to rules, norms and procedures in program implementation and the delivery of results is the cornerstone of the relationship between the centre and the state. A road map for priority action in states is given in Annexure A.
- The fund flow from the Central Government to the states would be as per the procedure prescribed by the Government of India. 4.6 The State PIP is approved by the Union Secretary of Health & Family Welfare as Chairman of the EPC, based on appraisal by the National Program Coordination Committee (NPCC), which is chaired by the Mission Director and includes representatives of the state, Technical and Program divisions of the MoHFW, National Technical Assistance agencies providing support to the respective states, other departments of the MoHFW and other Ministries as appropriate.
- All existing vertical program, shall be horizontally integrated at state, district and block levels. This will mean incorporation into an integrated state, district/city program implementation plan, sharing data and information across these structures. It shall also mean rationalization of use of infrastructure and human resources across these vertical program.
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