National Rural Health Mission was launched by our Honble Prime Minister launched on 12th April, 2005 with

an objective to provide effective health care to the rural population, the disadvantaged groups including women and children by improving access, enabling community ownership strengthening public health systems for efficient service delivery Enhancing equity and accountability Promoting decentralization The NRHM 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, i.e., 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. NRHM envisages a significant role for communities in the delivery and monitoring of primary healthcare. One of the schemes core strategies is to build the capacity of Panchayati Raj Institutions (PRIs) to control and manage public health services. The NRHM funding is from the Centre while the implementation is by the State governments. Health care delivery cannot be improved to provide a seamless service without the removal of these barriers. The NRHM is currently functioning as a project of the Government of India and is due to end in 2012. Its significant contribution to improving health care infrastructure and service delivery across the country will be frittered away if its funding ceases with the 11th Five Year Plan (FYP). The scheme was initiated in 2005-6 with an initial budget outlay of approximately `6,700 crore. Planned central government allocations have steadily increased over the past five years to more than `67,000 crore. The Primary Health Centres (PHCs) provide curative, preventive, and promotive health and family welfare services in rural areas for a population of about 30,000. Physical Health-infrastructure in terms of district and sub-district hospitals (DHs and SDHs), Community Health Centre, Block and Additional primary health centres and PHCs, Sub centres (SCs) is existing in all the 642 districts of India. A study for the evaluation of NRHM in the states of Uttar Pradesh, Madhya Pradesh, Jharkhand, Orissa, Assam, Jammu & Kashmir and Tamilnadu revealed the following: 1) We have 578 District-hospitals, which are supposed to have all health care facilities like specialists, doctors, nurses, operation theatres, diagnostic services, drugs, etc. Nevertheless, we find only 517 out of 578 hospitals are functioning as first referral units (FRUs) and only 438 DHs have been taken up for upgradation under NRHM. 2) Facility-upgradation work at Community Health Centre (CHC) level has almost been completed in five states viz. Jharkhand, Orissa, Assam, Jammu and Kashmir and Tamil Nadu. 3) PHC functioning on 24x7 basis seems to be proportionately quite low in almost all the

states. The upgradation of PHCs into 24x7 basis health facility need to be taken up on priority basis to enhance the outreach of public health care services in the rural areas.

4) Village Health and Sanitation Committees (VHSCs) have been constituted and

functioning in most of the villages in India.

5) Village Health and Nutrition Days (VHNDs) are being organized by all the VHSCs. All

India average of monthly VHND turns out to be around 11 per year per VHSC or per village.
6) Referral and Emergency Transport system seems to working quite efficiently in some of

the states like Madhya Pradesh, Jharkhand, Assam and Tamil Nadu.

Human resource shortage in public health institutions seem to quite acute. We find shortfalls of even Specialists/post-graduate doctors, Gynaecologists, Staff Nurses and Anaesthetists in almost all the states. ASHAs recruited, trained and in position were more than the number of villages reported in India in August 2009. We find around 7.7 lakhs ASHAs were in position for around 6.8 lakhs villages in August 2009. Accredited Social Health Activist (ASHA) is a woman selected by the community, who is trained and supported to function in her village and to improve the health status of the community through securing peoples access to health care services and through improved health care practices and behaviour. Children immunization scheme seems to have been working fine and possibly majority of the new born children have been immunized in all the states of India.
The National Disease Control Programme (NDCP), though still under separate budget head than NRHM, seems to be working well in all the districts in the sense that both the incidence as well as deaths reported under different diseases depict declining trend. Under Malaria we find around 19.3 lakhs cases were reported in 2008 with only 935 deaths due to Malaria. Dengue cases were reported to be around 12.5 thousand with only 80 deaths at all India level.

SUB-CENTERS :
In the Indian health scenario, Sub-Centre (SC) is a bridge between rural community and public primary health care system. A sub centre is responsible for providing all primary health care and makes the services more responsive and sensitive for the rural community. 71 local subcenters were monitored & it was found that 1) when it comes to basic infrastructure facilities in the sub-centers, it is encouraging that most of the sub-centers seem to have some sort of basic physical structure present with 40 out of 71 sub-centers having more than one room. 2) However it is a matter of concern that nearly half the sub-centers did not have electricity or sanitation, and 15 out of 71 of the subcenters had buildings in poor dilapidated conditions. Medicine for fever was available in 37 out of 71 sub-centers. 3) Only 27 out of 71 (roughly one-third) sub-centers were reported providing ante-natal check-ups. 4) Basic instruments like weighing machine and blood pressure measuring instruments are needed for pre-natal check-ups: more than half (39 out of 71) sub-centers did not have weighing machines and 49 out of 71 sub centers did not have instrument for measuring blood pressure.

A major challenge : NRHM is designed to coordinate efforts between related schemes such as Total Sanitation Campaign, Integrated Child Development Services, Mid Day Meal, and National Disease Control Programmes for Malaria, TB, Kala Azar, Filaria, Blindness & Iodine Deficiency and Integrated Disease Surveillance Programme. However, coordination between different ministries and integration between various intersectoral programmes remains the biggest challenge for NRHM.
It can be broadly concluded that the scheme has made poor progress in national health indicators, such as life expectancy, infant mortality, and maternal mortality, and that this can be attributed to inadequate expenditure and interventions. The first phase of District Level Household and facility Survey (DLHS-3) registered an improvement in maternal and child health programmes. Infant Mortality Rate was 55% in 2008, having reduced by 2 percentage points over the previous year.8 Percentage of children receiving full immunisation9 varies from 30% in Uttar Pradesh to 90% in Goa, with Kerala, Tamil Nadu and Pondicherry achieving more than 80% coverage (Figure 1). Full immunization increased from 20.7% to 41.4% in Bihar, 25.7% to 54.1% in Jharkhand, from 30.1% to 36.1% in Madhya Pradesh, from 53.5% to 62.4% in Orissa, and from 23.9% to 48.8% in Rajasthan. Infrastructure: The performance of NRHM can be seen in the improved health infrastructure and organisational set-up and the transparency and timeliness of data on the Ministry of Health and Family Welfare (MoHFW) website as of November 2009.11 Rogi Kalyan Samitis with untied funds have been created in 566 district hospitals (DH) and 4.59 lakh ASHAs have been trained, provided with drug kits and placed in their respective villages.