28-Sep-2022: Union Cabinet informed about progress under National Health Mission (NHM) - 2020-21

The Union Cabinet, chaired by Prime Minister, Shri Narendra Modi, was apprised about the progress under NHM during FY 2020-21 including accelerated decline in MMR, IMR, U5MR and TFR. It also noted the progress in respect of various diseases programmes like TB, Malaria, Kala-Azar, Dengue, Tuberculosis, Leprosy, Viral Hepatitis etc.

Expenditure involved: Rs. 27,989.00 Cr (Central Share)

No. of beneficiaries: NHM is implemented for universal benefit – i.e. entire population; services are offered to everyone visiting the public healthcare facilities with a special focus to vulnerable section of the society.

Point-wise details: The Cabinet noted the role of NHM as implementing agency for the Emergency Response and Health Systems Preparedness Package (ECRP) Phase-I to accelerate health system preparedness for immediate responsiveness for early prevention, detection and management of COVID-19. ECRP-I is a 100% centrally supported intervention and an amount of Rs. 8,147.28 crores were allocated to States/UTs for the period upto 31.03.2021.

The interventions in this package were implemented using National Health Mission framework, supplementing the available resources for health systems strengthening. The objective of the package was to slow down the spread of COVID-19 and to support & strengthen National and State Health System for prevention and preparedness for future.

Implementation strategy and targets:

Implementation strategy: The implementation strategy of Ministry of Health and Family Welfare under NHM is to provide financial and technical support to States / Union Territories (UTs) enabling them to provide accessible, affordable, accountable, and effective healthcare upto District Hospitals (DHs), especially to the poor and vulnerable sections of the population. It has also aimed to bridge the gap in rural healthcare services through improved health infrastructure, augmentation of human resource and improved service delivery in rural areas and has envisaged decentralization of programme to district level to facilitate need-based interventions, improve intra and inter-sectoral convergence and effective utilization of resources.

Targets under NHM by 2025:

• Reduce MMR to 90 from 113
• Reduce IMR to 23 from 32
• Reduce U5MR to 23 from 36
• Sustain TFR to 2.1
• Reduce prevalence of Leprosy to <1/10000 population and incidence to zero in all districts
• Annual Malaria Incidence to be <1/1000
• Prevent and reduce mortality & morbidity from communicable, non- communicable; injuries and emerging diseases
• Reduce household out-of-pocket expenditure on total health care expenditure
• Ending the TB epidemic by 2025 from the country.

Major impact, including Employment Generation Potential:

• The implementation of NHM in 2020-21 lead to engagement of 2.71 lakh additional Human Resources which includes GDMOs, Specialists, ANMs, Staff Nurses, AYUSH Doctors, Paramedics, AYUSH Paramedics, Programme Management Staff and Public Health Mangers on contractual basis.
• The implementation of NHM during 2020-21 has led to further strengthening of Public Health system which also enabled effective and coordinated COVID-19 response by way of introducing India COVID 19 Emergency Response and Health Systems Preparedness Package (ECRP).
• U5MR in India has declined from 49 in 2013 to 36 in 2018 and the percentage annual rate of decline in U5MR during 2013-2018 has accelerated to 6.0 % from 3.9 % observed during 1990-2012.  As per SRS 2020, U5MR has further reduced to 32.
• Maternal Mortality Ratio (MMR) of India has declined by 443 points from 556 per one lakh live births in 1990 to 113 in 2016-18. A decline of 80% has been achieved in MMR since 1990, which is higher than the global decline of 45%. In last five years, Maternal Mortality Ratio (MMR) has declined from 167 in 2011-13 (SRS) to 113 in 2016-18 (SRS). As per SRS 2017-19, MMR has further reduced to 103.
• IMR has declined from 80 in 1990 to 32 in the year 2018. Percentage annual compound rate of decline in IMR during past five years, i.e. during 2013 to 2018, has accelerated to 4.4% from 2.9% observed during 1990-2012. As per SRS 2020, IMR has further reduced to 28.
• As per Sample Registration System (SRS), TFR in India declined from 2.3 in 2013 to 2.2 in the year 2018. The National Family Health Survey-4 (NFHS-4, 2015-16) also recorded a TFR of 2.2. The percentage annual compound rate of decline in TFR during 2013 -2018 has been observed as 0.89%. Currently 28 States/ UTs out of 36 have achieved desired replacement level of fertility (2.1). As per SRS 2020, SRS has further reduced to 2.0.
• In the year 2020, malaria cases and deaths have declined by 46.28% and 18.18%, respectively.
• The incidence of TB per 1,00,000 population has been reduced from 234 in 2012 to 193 in 2019. The mortality due to TB per 1,00,000 populations for India reduced from 42 in 2012 to 33 in 2019.
• The percentage of Kala Azar (KA) endemic blocks, achieving the elimination target of < 1 KA case per 10000 population, increased from 74.2% in 2014 to 97.5% in 2020-21.
• The National target of sustaining Case Fatality Rate (CFR) to less than 1 percent was achieved. In 2020, the case fatality rate on account of Dengue has been sustained at 0.01% as it was in 2019.

Details & progress of scheme:

Progress under NHM during 2020-21 is as under:

• The approvals of 1,05,147 Ayushman Bharat-Health & Wellness Centres were accorded till 31st March 2021. As reported by the States/UTs on the Ayushman Bharat - Health & Wellness Centres Portal, 1,17,440 Health & Wellness Centres were operationalized against the cumulative target of 1,10,000 till 31st March, 2022.
• A total of 5,34,771 ASHAs, 1,24,732 Multi-Purpose Workers (MPWs-F) / Auxiliary Nurse Midwife (ANMs), 26,033 Staff Nurses and 26,633 Primary Health Center (PHC) Medical Officers were trained on Non-Communicable Diseases (NCDs) by the end of 31st March, 2021.
• There has been acceleration in decline of Maternal Mortality Ratio (MMR), Under Five Mortality Rate (U5MR) and the IMR since the launch of the NRHM/NHM. At the current rate of decline, India should able to reach its SDG target (MMR-70, U5MR-25) much before the due year i.e. 2030.
• Intensified Mission Indradhanush 3.0 was conducted from February 2021 to March 2021, a total of 250 districts were identified across 29 states/UTs.
• Around 6.58 crore doses of Rotavirus vaccine were administered in all States/UTs.
• Around 204.06 lakh doses of Pneumococcal Conjugated Vaccine (PCV) were administered in 6 states Bihar, Himachal Pradesh, Madhya Pradesh, Rajasthan, Uttar Pradesh & Haryana. As per Budget Announcement 2021-22, PCV has been scaled up nationwide under Universal Immunization Programme (UIP).
• Around 3.5 crore adults have been vaccinated with adult Japanese Encephalitis Vaccine which has been carried out in 35 endemic Districts of 3 States viz. Assam, Uttar Pradesh and West Bengal.
• 31.49 Lakh ANC check-ups had been conducted at over 18,400 health facilities across all State/UTs under Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA).
• LaQshya: 202 Labour Rooms & 141 Maternity Operation Theatres are State LaQshya certified and 64 Labour Rooms & 47 Maternity Operation Theatres are National LaQshya certified.
• To strengthen the Cold Chain system in the country, Cold Chain equipment i.e. ILR (large)- 1041, ILR (small)- 5185, DF (large)- 1532, Cold Box (large)- 2674, Cold Box (Small) - 3700, Vaccine Carrier – 66,584 and Ice packs – 31,003 had been supplied to the States/UTs.
• A total of 13,066 ASHAs were selected during 2020-21 making the total pool ASHAs 10.69 lakhs across the country upto 31st March, 2021.
• National Ambulance Services (NAS): As on March 2021, 35 States / UTs have the facility where people can Dial 108 or 102 for calling an ambulance. 735 additional Emergency Response Service vehicles were added in 2020-21.
• During 2020-21, 30 additional Mobile Medical Units (MMUs) were added.
• 24x7 Services and First Referral facilities: During 2020-21, 1140 facilities were added as FRUs operationalization.
• Kayakalp: 10,717 public health facilities received Kayakalp awards under this scheme in 2020-21.
• Malaria: The total number of malaria cases and deaths reported in 2020 were 1,81,831 and 63 respectively in comparison to 11,02,205 cases and 561 deaths reported in 2014, indicating a decline of 83.50% malaria cases and 88.77% deaths in comparison to the corresponding period of 2014.
• Kala-Azar: The percentage of Kala Azar (KA) endemic blocks, achieving the elimination target of < 1 KA case per 10,000 population, increased from 74.2% in 2014 to 97.5% in 2020-21.
• Lymphatic Filariasis: In 2020-21, among 272 LF endemic districts, 98 districts have successfully cleared 1 Transmission Assessment Survey (TAS-1) and stopped MDA and these districts are under Post MDA surveillance.
• In relation to Dengue, the National target was to sustain case fatality rate (CFR)<1 percent. The target was achieved as case fatality rate in 2014 was 0.3% and during 2015 to 2018, CFR has been sustained at 0.2%. Further in 2020, it has been sustained at 0.1% as it was in 2019.
• National Tuberculosis Elimination Programme (NTEP): A total of 1,285 Cartridge Based Nucleic Acid Amplification Test (CBNAAT) machines and 2,206 Truenat machines are operational at district level across the country. In 2020, 29.85 lakh molecular tests have been performed. This is 4 times increase as compared to 7.48 lakh during 2017. Shorter MDR-TB regimen and Bedaquiline/Delamanid (newer drugs) based regimen rolled out in all State/UTs. In 2020, 30,605 MDR/RR-TB patients have been initiated on shorter MDR-TB regimen, 10,489 DR-TB patients have been initiated on newer drug containing regimen (Bedaquiline-10,140 and Delamanid-349) throughout country.
• Pradhan Mantri National Dialysis Programme (PMNDP) was launched in 2016 to support dialysis facilities in all district hospitals in the PPP mode under NHM. During FY 2020-21, PMNDP has been implemented in 35 States/UT in 505 Districts in 910 Dialysis Centres by deploying 5781 machines. During 2020-21, total 3.59 lakh patient availed dialysis services and 35.82 Lakhs Hemo-dialysis Sessions held.

Background:

The National Rural Health Mission was launched in 2005 with the objective of building public health systems to provide accessible, affordable and quality health care to the rural population, especially the vulnerable groups, up to the District Hospitals (DH) level. In 2012, the National Urban Health Mission (NUHM) was conceptualized and the NRHM was rechristened as the National Health Mission (NHM) with the two Sub Missions viz. the NRHM and the NUHM.

Continuation of the National Health Mission-with effect from 1st April 2017 to 31st March 2020 was approved by Cabinet in its meeting held on 21st March 2018.

The Ministry of Finance, Department of Expenditure vide its Office Memorandum No. 42(02/PF-II.2014) dated 10th January 2020 has also accorded interim extension of National Health Mission for a period up to 31st March 2021 or till the date the recommendation of 15th Finance Commissions come into effect, whichever is earlier.

The Ministry of Finance, Department of Expenditure vide its OM No. 01(01)/PFC-I/2022 dated 01st February, 2022 has further accorded the approval for continuation of National Health Mission from 01.04.2021 to 31.03.2026 or till further review, whichever is earlier, subject to the adherence to Expenditure Finance Committee’s (EFC) recommendations and the financial ceilings etc.

The Cabinet approval for NHM Framework further stipulates that exercise of these delegated powers would be subject to the condition that a progress report regarding N(R)HM, along with deviation in financial norms, modifications in ongoing schemes and details of new schemes be placed before the Cabinet for information on an annual basis.

21-Sep-2022: India wins UN awards for Large-scale Initiative against Hypertension under NHM

In a significant achievement and recognition to country’s efforts against hypertension, India has won an UN award for its “India Hypertension Control Initiative (IHCI)”, a large-scale hypertension intervention under National Health Mission. IHCI has been recognized for its exceptional work within India’s existing primary healthcare system.

Complimenting the healthcare initiative, Dr. Mansukh Mandaviya, Union Minister of Health & Family Welfare stated in a tweet: “IHCI has strengthened PM @NarendraModi  Ji's mission to ensure health & wellness for all”. We are committed to building a healthy & fit India, he further noted.

A collaborative initiative of Ministry of Health and Family Welfare, Indian Council of Medical Research (ICMR), State Governments and World Health Organization-India, IHCI has won the ‘2022 UN Interagency Task Force, and WHO Special Programme on Primary Health Care Award’ at the UN General Assembly side event held on 21st September 2022 at New York, USA. The award recognizes outstanding commitment and action of India to: (i) prevent and control Non-Communicable Diseases (NCDs) and (ii) deliver integrated people-centric primary care. The UN Task Force has identified organisation which has multisectoral approach in prevention and control of NCDs and multisectoral action with demonstrated results at primary care for prevention and control of NCDs and related Sustainable Development Goals (SDGs).

Significance of the initiative can be adjudged from the fact that one in four adults in India has high blood pressure. The control of hypertension at primary care system level will contribute  to reducing deaths due to heart attacks, stroke and kidney failures.

IHCI has been able to leverage and strengthen the existing healthcare delivery system, hypertension control interventions under National Health Mission and improve the linkages between populations-based screening initiative with health care.  The initiative was launched in 2017 and expanded in a phased manner to cover more than 130 districts across 23 states. Under the initiative, more than 34 lakh people with hypertension are taking treatment in government health facilities, including Ayushman Bharat Health Wellness Centres (HWCs).  The project strategies are easily scalable within the health system. The strategies include a simple drug-dose-specific standard treatment protocol, ensuring adequate quantity of protocol medications, decentralization of care with follow-up and refills of medicines at Health Wellness Centres, task sharing involving all health staff and a powerful real-time information system which can track every patient for follow-up and blood pressure control. Under IHCI, nearly half of those who were treated had blood pressure under control.  

The IHCI complements the National Programme for Prevention and Control of Diabetes, Cardiovascular Disease and Stroke (NPCDCS) of the Ministry of Health & Family Welfare, Government of India. IHCI accelerates the achievement of targets of the Government of India by ensuring a continuum of care and giving a boost to the ongoing “Ayushman Bharat” programme.

22-Mar-2022: Assessment of working of NRHM

The National Health Mission (NHM) envisages achievement of universal access to equitable, affordable & quality health care services that are accountable and responsive to people’s needs.

“Public Health and Hospitals” is a State subject and the primary responsibility of strengthening public healthcare system including up gradation and strengthening of existing health facilities lies with the respective State/ UT. However, under NHM, Ministry of Health and Family Welfare (MoHFW) provides the technical and financial support to States/UTs based on the proposals received from States within their overall resource envelope.

Under NHM, the performance of various health programmes is regularly assessed, through review meetings, video conferences & field visits of senior officials, promoting performance by setting up benchmarks for service delivery & rewarding achievements etc. The working of National Health Mission (NHM) has been regularly assessed through external surveys such as, National Family Health Survey (NFHS) and Sample Registration System (SRS). Further, under NHM, Common Review Missions (CRM) are conducted annually to assess and monitor the progress and implementation status of various schemes. The key strategies and priority areas of CRM is to analyze challenges with respect to strengthening health systems, identify trends in progress of key indicators, evaluate the readiness of the state to undertake implementation of new initiatives, and review the progress and coordination mechanisms with various partners.. The details of various reports of CRM are available in public domain at https://nhm.gov.in/index1.php?lang=1&level=1&sublinkid=795&lid=195

As per the report of NITI Aayog (March 2021), collated the three Studies done on the aspects of Governance, Human Resources, Financing and Health outcomes and the key findings of the Report are as follows:

• There has been significant improvement in the infrastructure facilities during NHM period with an increase in number of beds in the government hospitals as well in the community health centers (CHCs) from 0.44 in 2005 to 0.7 in 2019 per 1000 population. The focus on infrastructure improvement resulted in construction of more than 46,000 health facilities, with a significant increase in the total number of first referral units (FRUs) (940 in 2005 to 3057 in 2019).
• The number of doctors, nurses in PHCs and CHCs also increased during the NHM periods. An additional 200,000 healthcare providers (from auxiliary nurse-midwives (ANMs) to specialists‟ doctors) and 850,000 village level ASHA in rural areas were recruited during the NHM period.
• There is strong evidence to show that increased infrastructure and increased human resources has had a positive effect on improving the availability, affordability and accessibility of maternal and child services, leading to improved antenatal and postnatal care and improved maternal and child outcomes.
• Maternal and child indicators such as the IMR, NMR and MMR have shown a marked improvement in the NHM period. There has been a remarkable decline in under five mortality rate (U5MR) from 78 to 37 per thousand live births from 2005 to 2019. The infant mortality rate (IMR) declined from 58 per 1000 live births to 32 per 1000 live births during 2013-18. The neonatal mortality reduced from 38 per thousand live births to 22 per thousand live births, with a percentage decline of 42.1% from 2005 to 2019. Maternal mortality ratio (MMR) declined by 52%, from 257 per lakh live births in 2004- 06 to 122 per lakh live births, in 2015-17.
• Improvements in maternal and child indicators can be attributed to better implementation of facility based newborn care including sick newborn care units (SNCUs), evidenced from systematic review.
• Various studies showed that Janani Suraksha Yojana (JSY) strategy had a strong evidence in promoting institutional delivery and reducing perinatal mortality. JSSK had a role in providing free diagnostics by improving the affordability.
• There is strong evidence that shows that child health strategies such as Facility Based Newborn Care (FBNC), Home Based Post Natal Care (HBPNC), Integrated Management of Neonatal and Childhood Illness (IMNCI) and immunization improved the availability, affordability and accessibility of child health services especially for the rural and poor community.
• There has been steady decline in out-of-pocket expenditure for under five child hospitalization, institutional deliveries and catastrophic hospitalizations as per consecutive rounds of NSS surveys. Multiple schemes launched by the government like free transport, free diagnostics, free dialysis, and free drug / Jan Aushadhi Kendras are initiatives that have contributed to reducing OOPE.

The framework for implementation of National Health Mission is available over public domain of NHM website and the URL are https://nhm.gov.in/WriteReadData/l892s/nrhm-framework-latest.pdf

The recommendations of 15th Finance Commission (FC-XV) w.r.t Health Grants through Local Governments announced in Union Budget 2021-22, addresses the gaps in Primary Healthcare facilities. Out of the total grants for health through Local Governments of Rs 70,051 crore, Rs 43,928 Crore has been allocated as tied grants for the 28 states through Rural Local Bodies (RLBs) and Rs. 26,123 Cr has been allocated as tied grants for Urban local bodies (ULBs).

The Grants recommends support for diagnostic infrastructure in Sub Health Centres (SHCs), Primary Health Centres (PHCs) and Urban Health and Wellness Centres, support for converting Sub Health Centre and Primary Health Centre to HWCs in rural areas, construction of building-less Sub Health Centres (SHCs), Primary Health Centres (PHCs) and Community Health Centres (CHCs), Urban Health and Wellness Centres (urban-HWCs) and polyclinics.

17-Dec-2021: Funds Allocated and Key Achievements made under National Health Mission

Under the National Health Mission (NHM), Government of India provides financial and technical support to States/UTs to strengthen their healthcare systems. The Government has continued to allocate more funds to strengthen the National Health Mission (NHM). Allocation under NHM has increased from Rs.27,989crore in 2020-21 to Rs.31,100 crore in 2021-22 Budget Estimate. Further, the National Health Policy, 2017, also envisages the States to increase their health spending to at least 8% of their health budget and the policy advocates allocating major proportion (up to two thirds or more) of resources to primary care followed by secondary and tertiary care.

The 'India COVID-19 Emergency Response and Health System Preparedness Package-I' (ECRP-I) of Rs.15,000crore has been approved with an objective to prevent, detect and respond to the threat posed by COVID-19. Further, the Cabinet has also approved the scheme, "India Covid-19 Emergency Response and Health Systems Preparedness Package -II" (ECRP-II) for an amount of Rs.23,123crore. This is a Centrally Sponsored Scheme (CSS) with some Central Sector (CS) components. The Scheme is aimed further to prevent, detect and respond to the continuing threat posed by COVID-19 and strengthen national health system for preparedness in India. In order to ensure implementation of critical activities at the State/District levels to prepare the public healthcare system in response to the evolving pandemic, 50% of Central Share of Resource Envelope of the State/UT, has been released in advance to the States/UTs.

The PM-Ayushman Bharat Health Infrastructure Mission (PM-ABHIM) was launched by Hon'ble Prime Minister of India for an amount of Rs.64,180crore. The measures under the scheme focus on developing capacities of health systems and institutions across the continuum of care at all levels viz. tertiary and primary, secondary preparing health systems effectively pandemics/disasters.

Further, Government of India continues to keep a close watch over COVID-19 situation in the country and globally. Government is supporting states in their endeavor to manage COVID-19 since the beginning of pandemic. Requisite support is provided to States/UTs to enhance preparedness and response capacities against COVID-19 and other public health emergencies. Some of the major areas of intervention include:

• Ministry of Health & Family Welfare continues to provide technical guidance for managing various aspects of COVID-19. So far more than 150 guidelines/advisories/SoPs/plans have been provided to States/UTs.
• Guidelines on Clinical management of COVID-19 continue to be updated with emerging scientific evidence. The treatment protocol for adults was last updated on 24th May 2021 and has been widely circulated.
• Guidelines for management of COVID-19 in children were issued on 18th June 2021. The guideline covers guidance on management of acute presentation of COVID-19 as well as Multisystem Inflammatory Syndrome (MIS-C) in children and adolescents found temporally related to COVID-19.
• A Comprehensive Guidelines for Management of Post-COVID Sequelae was issued by MoHFW on 21stOctober 2021 after expert consultations to guide doctors on post-COVID-19 complications and their management.
• Travel advisories for international travelers have been revised from time to time based on the epidemiological situation of COVID-19 including circulation of Variants of Concern (including Omicron) of SARS-CoV-2. In view of declaration of Omicron variant as a Variant of Concern by the World Health Organization, guidelines for international arrivals were updated on 28th November 2021. As per the current guidelines, all travelers (irrespective of COVID-19 vaccination status) coming from countries deemed ‘at-risk’ are required to mandatorily undergo post-arrival COVID-19 testing at the arrival. Such travelers will also need to undergo a mandatory home quarantine for 7 days followed by repeat testing on 8th day of arrival in India to be monitored by State Health Authorities. Additionally, 2% of travelers from countries not deemed ‘at-risk’ shall also be subjected to post-arrival COVID-19 testing in India.
• Union Ministry of Health & FW has advised all States to (i) ensure rigorous follow up and testing of travelers from ‘at-risk’ countries, (ii) send positive samples for genome sequencing to INSACOG labs in a prompt manner, (iii) ramp up testing for COVID-19, (iv) ensure preparedness of health infrastructure (availability of ICU, O2 beds, ventilators, etc.), (v) ramp up COVID-19 vaccination rates and (vi) ensure adherence to COVID appropriate behavior etc.
• To further provide on-field assistance to the States/UTs, a total of 172 Central multi-disciplinary teams comprising of epidemiologists, clinicians, microbiologists and senior officials from the Ministry has been deployed to States/Districts reporting increased trajectory of cases.

10-Dec-2021: Health Programmes under National Health Mission

“Public Health and Hospital” is a state subject, the primary responsibility of ensuring availability of healthcare facilities lies with respective State/UT Governments.

Under the National Health Mission (NHM), Government of India provides financial and technical support to States/UTs to strengthen their health care systems for provision of equitable, affordable healthcare to all its citizens based on requirements posed by the States in their Programme Implementation Plans (PIPs).

NHM support is provided for provision of a range of free services related to maternal health, child health, adolescent health, family planning, universal immunization programme, and for major diseases such as Tuberculosis, vector borne diseases like Malaria, Dengue and Kala Azar, Leprosy etc.

Other major initiatives supported under NHM include Janani Shishu Suraksha Karyakaram (JSSK), Rashtriya Bal Swasthya Karyakaram (RBSK), implementation of Free Drugs and Free Diagnostics Service Initiatives, Mobile Medical Units (MMUs), Tele-consultation services, Ambulance services, PM National Dialysis Programme and implementation of National Quality Assurance Framework in all public health facilities of all states/UTs including Maharashtra.

As part of Ayushman Bharat-Health & Wellness Centres (AB-HWCs), more than 80000 Health and Wellness Centres across the country have been established for provision of comprehensive primary care that includes preventive healthcare and health promotion at the community level with continuum of care approach.

Public health and hospitals are a state subject, the primary responsibility to ensure payment of salary of human healthcare professionals including contractual employees lies with the respective State/UT Governments including Maharashtra. Under the National Health Mission (NHM), support is provided to States/UTs to augment health human resource on contractual basis including support for in-sourcing or engagement of doctors, specialist doctors and other health professionals for provision of equitable, affordable healthcare based on requirements posed by the States in their Programme Implementation Plans (PIPs) and within their overall resource envelope.

In Record of Proceeding (ROP), 8% of the total HR budget is approved as per State proposal, as increment and for rationalization and experience bonus (as per eligibility and principles of rationalization). Only those who have completed minimum one year of engagement under NHM and whose contract (in case of annual contract) gets renewed are eligible for annual increment. Principles of increments are approved by State Health Society Governing Body.

10-Aug-2021: Steps taken for Betterment of Local Public Health System

To address the health care challenges, in urban/rural areas, National Health Mission (NHM) and its two sub missions namely National Rural Health Mission (NRHM) and National Urban Health Mission (NUHM) provide technical and financial support to supplement the efforts of the States/UT Governments in order to meet the objective of equitable, accessible and affordable health care services to all. Such support includes, free medicines/ drugs, free diagnostics and patient transport, in order to lessen the burden of the out-of-pocket expenditure on health care.

Under Ayushman Bharat-Health and Wellness Centres (AB-HWC) initiative, launched by Government of India in the year 2018, 1.5 lakh Sub-Health Centres (SHCs) / Primary Health Centres, both in rural/urban areas, are being upgraded into HWCs for the betterment of local public health care. Accordingly, more than 77,406 HWCs have become functional (73,391 in rural areas & 4,015 in urban areas) and are delivering comprehensive primary health care closer to the homes of the people. Details of packages provided under AB-HWCs in rural/urban HWCs is at Annexure.

Also, the Fifteenth Finance Commission has recommended grants aggregating to Rs.70,051 Crores, over the period of five years (2021-2026) through local governments, for strengthening healthcare system at the primary health care level.

Packages provided under AB-HWC in rural/urban HWCs.

1. Care in Pregnancy and Child Birth.
2. Neonatal and Infant health care services.
3. Childhood and Adolescent health care services.
4. Family planning, contraceptive services and other reproductive health care services.
5. Management of communicable diseases: National Health programmes.
6. General out-patient care for acute simple illnesses and minor ailments.
7. Screening, prevention, control and management of non-communicable diseases and chronic communicable diseases like tuberculosis and leprosy.
8. Basic oral health care.
9. Screening and basic management of mental Health ailments.
10. Care for common ophthalmic and ENT problem.
11. Elderly and palliative health care services.
12. Emergency medical services including burns and trauma.

The upgradation of existing SHC and PHC into AB-HWC includes the following key components:

• Expanded Service Delivery- At the AB-HWCs, the package of Comprehensive Primary Health Care services is being expanded to go beyond Reproductive and Child Health to include care for non-communicable diseases, Palliative and Rehabilitative care, Oral, Eye and Ear, Nose and Throat (ENT) care, Elderly care, Mental health and first level care for Emergencies and Trauma as mentioned in the list above.
• Continuum of care/Telehealth –The AB-HWCs provide teleconsultation services, whereby every level of service provider from community health officer (CHO) to medical officer can access a higher level of consultation, including with specialists in secondary and tertiary centres, so that physical travel by patients can be minimized, reducing costs and any potential hardship. Currently, 67% of the AB-HWCs have teleconsultation facilities.
• Expanding HR-MLHP & multiskilling- To improve the delivery mechanism, a new cadre of healthcare providers are introduced at the mid-level with educational backgrounds such as B.Sc. in Community Health or a Nurse (GNM or B.SC) or an Ayurveda Practitioners with due certification in public health  are added as Community Health Officer (CHO) or Mid-Level Health Care Provider. The CHO at SHC-HWC carry out public health functions, ambulatory care, and management and provide leadership at the Health and Wellness Centres.
• Medicines & expanding diagnostics- The AB-HWCs serve as the hub for diagnostic tests and dispensing medicines based on treatment plans initiated by the medical officer at the PHC. Number of essential medicines at PHC –AB-HWCs have been increased to 172 and number of essential diagnostic services to 63. While at the SHC-AB-HWCs, these have been increased to 105 essential medicines and 14 essential diagnostic services. This ensures the uninterrupted availability of medicines to ensure adherence and continuation of care, but also reduces any patient hardship by providing medicines closer to their homes.

Community mobilisation and health promotion-

• The AB-HWC team works closely with communities enables empowerment of individuals, families and communities with knowledge and skills to take responsibility for their own health. The AB-HWCs also focus on improving health literacy through interpersonal communication, and media including social media, for promotion of healthy lifestyles – diet, yoga, exercise, tobacco cessation, and self-care for those with chronic disease conditions. Institutional structures such as Jan Arogya Samitis (JAS), with representation from the local bodies and Panchayats, Self Help Groups and patients, have also been envisaged to enable community ownership and accountability of AB-HWC teams.
• A Fit Health Worker Campaign was also launched at these centres to enable the screening and early detection of non-communicable diseases in the Frontline-Health Care Workers. Frontline Workers (FLWs) are not only involved in ensuring essential services at these centres but also played a crucial role in community-based surveillance and pandemic outbreak management related activities in the community.
• GOI initiated training of ‘Eat Right’ and ‘Eat Safe’ module to the primary healthcare team at these functional AB-HWCs.
• Thirty-nine health calendar days are celebrated by each AB-HWCs . These centres also conduct various wellness related activities like Yoga, Zumba, Meditation etc. which not only enable improved physical health but also mental wellbeing of the community. It is envisaged that these centres will not only be the point of delivery for healthcare services, but at the same time enable the community to take health in their own hands.
• Community Ownership: Jan Arogya Samiti (JAS), a facility based multi-stakeholder committee, led by the PRI member of the area, has been established at AB-HWCs to enhance ownership of the community on AB-HWCs. JAS is responsible for overall functioning of the AB-HWCs. The amount of untied funds to the SHC-HWC has also been increased from Rs.20,000 to Rs.50,000 per annum.
• Infrastructure Augmentation - All HWCs are provided with sufficient space for outpatient care, for dispensing medicines, diagnostic services, adequate spaces for display of communication material of health messages, including audio visual aids and appropriate community spaces for wellness activities, including the practice of Yoga and physical exercises.
• Financing /provider payment reforms- All HWCs have system for population empanelment and record of services, team-based incentives are provided. This facilitates accountability to outputs/outcomes and provide individual centred care.
• Government of India has launched Health and Wellness Ambassadors initiative under AB-HWCs to promote a healthy lifestyle among students. It includes school health activities; teachers are trained to serve as Health and Wellness Ambassadors and students as messengers. It is a joint initiative of the Ministry of Health and Family Welfare and the Department of School Education &Literacy, Ministry of Education enables creating healthy habits leading to early action and encouragement to adopt healthy behaviours at young age and prevent chronic diseases later in life.
• IT enabled Reporting and Data management- An online portal- AB-HWC portal was developed in 2018 to capture progress on AB-HWC operationalization and is being used in all the States. An App version of the AB-HWC portal has also been developed to enable geo-tagging of the AB-HWCs and entering the daily service delivery parameters by the frontline healthcare workers. The AB-HWC team are equipped with IT equipment- Tablets at SHCs and Laptop/ Desktop at PHC/UPHC level to create electronic health record of the population covered by AB-HWCs.

10-Aug-2021: Setting up New Hospitals in Rural and Urban Areas

The Ministry of Health and Family Welfare provides technical and financial support to the States/UTs, for their health system strengthening, including that of Primary Health Centres (PHCs), Community Health Centres (CHCs) and District Hospitals (DHs) through the National Health Mission (NHM). The States/UT Governments are also encouraged to meet the objective of making Health Care services equitable, accessible and affordable by increasing their health budgets each year.

In order to provide comprehensive primary health care, Government of India has launched Ayushman Bharat Scheme in 2018. As part of this scheme, 1.5 lakh Ayushman Bharat-Health and Wellness Centres (AB-HWCs), are being set up across the country by upgrading Sub-Health Centres (SHCs), Primary Health Centres (PHCs) and Urban Primary Health Centres (UPHCs) which provide preventive healthcare and health promotion at the community level, with continuum of care approach.

In addition to the above, through other schemes like Pradhan Mantri Swasthya Suraksha Yojana (PMSSY) and Human Resources for Health and Medical Education (HRH&ME), efforts are being taken to improve the overall health sector of the country. PMSSY aims at setting up of new AIIMS like institutions and the upgradation of existing Government Medical colleges while through HRH-ME, improves access to tertiary care in underserved areas as well as aims at increasing the availability of health professionals.

For the containment and management of the pandemic, which includes support for augmentation of infrastructure, oxygen supported beds, isolation beds, ICUs & Human Resources, supply of drugs, etc. States/UTs are being supported under the “India COVID-19 Emergency Response & Health System Preparedness Package”. During the financial year 2020-21, Rs. 8147.28 crores has been released to States under this package. In addition, Rs.110.60 crores has been made available for insurance of Health Care workers. Thus, a total amount of Rs.8257.88 crores has been provisioned for the States/ UTs.

The Cabinet has also approved the scheme, “India Covid-19 Emergency Response and Health Systems Preparedness Package - Phase-II” (ECRP-Phase-II) on 8.07.2021 for an amount of Rs.23,123 crores. This Scheme is aimed at preventing, detecting and responding to the continuing threat posed by COVID-19 as well as for strengthening national health systems for preparedness in similar health emergencies in India.

Also, the Fifteenth Finance Commission has recommended grants aggregating to Rs.70, 051 Crores, over the period of five years (2021-2026) through local governments, for strengthening healthcare system at the primary health care level.

For better monitoring and improved quality of services, Government is implementing National Quality Assurance Programme (NQAS), Kayakalp award scheme and LaQshya initiatives.

3-Aug-2021: Proposal to implement New Family Planning Policy

The Government has been implementing the Family Planning programme in line with the policy framework of population stabilization as envisaged in the National Population Policy (NPP-2000), by creating a robust service delivery and demand side mechanism to address the unmet needs for family planning.

The programme received a further boost through holistic and comprehensive planning with the advent of the National Health Mission (NHM) in 2005.

The National Health Policy (NHP) 2017 also provides policy guidance and sets out indicative, quantitative goals and objectives for population stabilization.

Moreover, the Government has also launched Mission Parivar Vikas in 146 high fertility districts of seven high focus states (Uttar Pradesh, Bihar, Rajasthan, Madhya Pradesh, Chhattisgarh, Jharkhand and Assam) to focus on improving access to contraceptives through promotional schemes, awareness generation activities, capacity building and intensive monitoring.

As a result of the Government’s initiatives for controlling the Population;

• The TFR of the country has declined from 2.9 in 2005 to 2.2 in 2018 (SRS)
• 28 out of 36 States/UTs have already achieved the replacement level fertility of 2.1 or less
• The Crude Birth Rate (CBR) has declined from 23.8 in 2005 to 20.0 in 2018 (SRS)
• The Decadal growth rate has declined from 21.54% in 1990-2000 to 17.64% during 2001-11
• India’s Wanted Fertility Rate has declined from 1.9 in NFHS III to 1.8 in NFHS IV.

23-Mar-2021: Cabinet apprised on progress under National Health Mission (NHM) 2019-20

The Union Cabinet chaired by the Prime Minister, Shri Narendra Modi was apprised on the progress under National Health Mission (NHM)during FY 2019-20 including accelerated decline in Maternal Mortality Ratio (MMR), Infant Mortality Rate (IMR), Under Five Mortality Rate (U5MR)  and Total Fertility Rate (TFR). It also noted the progress in respect of various diseases programmes like TB, Malaria, Kala-Azar, Dengue, Tuberculosis, Leprosy, Viral Hepatitis etc.

Details:

The Cabinet noted that NHM has envisaged new Initiatives in 2019-20 as:

• Social Awareness and Actions to Neutralize Pneumonia Successfully (SAANS) initiative was launched to accelerate action to reduce deaths due to childhood pneumonia.
• Surakshit Matritva Aashwasan (SUMAN) initiative was launched to provide assured, dignified, respectful and quality healthcare at no cost and zero tolerance for denial of services and all existing Schemes for maternal and neonatal health have been brought under one umbrella.
• Midwifery Services Initiative aims to create a cadre of Nurse Practitioners in Midwifery who are skilled in accordance to competencies prescribed by the International Confederation of Midwives (ICM) and are knowledgeable and capable of providing compassionate women-centered, reproductive, maternal and newborn health care services.
• School Health and Wellness Ambassadors Initiative has been launched under the AB-HWCs Programme in partnership with Ministry of Education to promote health and well-being through an active lifestyle amongst school children.

Implementation strategy and targets:

Implementation strategy: The implementation strategy of Ministry of Health and Family Welfare under NHM is to provide financial and technical support to States / Union Territories (UTs) enabling them to provide accessible, affordable, accountable, and effective healthcare upto District Hospitals (DHs), especially to the poor and vulnerable sections of the population. It has also aimed to bridge the gap in rural healthcare services through improved health infrastructure, augmentation of human resource and improved service delivery in rural areas and has envisaged decentralization of programme to district level to facilitate need-based interventions, improve intra and inter-sectoral convergence and effective utilization of resources.

Targets:

• Reduce MMR to 1/1000 live births
• Reduce IMR to 25/1000 live births
• Reduce TFR to 2.1
• Reduce prevalence of Leprosy to < 1 /10000 population and incidence to zero in all districts
• Annual Malaria Incidence to be <I/1000
• Prevent and reduce mortality &morbidity from communicable, non-communicable; injuries and emerging diseases
• Reduce household out-of-pocket expenditure on total health care expenditure
• Ending the TB epidemic by 2025 from the country.

Impact including Employment Generation Potential:

• The implementation of NHM in 2019-20 lead to engagement of 18,779 additional Human Resources which includes GDMOs, Specialists, ANMs, Staff Nurses, AYUSH Doctors, Paramedics, AYUSH Paramedics, Programme Management Staff and Public Health Mangers on contractual basis.
• The implementation of NHM during 2019-20 has led to further strengthening of Public Health system which also enabled effective and coordinated Covid-19 response.
• U5MR in India has declined from 52 in 2012 to 36 in 2018 and the percentage annual rate of decline in U5MR during 2013-2018 has accelerated to 6.0 % from 3.9 % observed during 1990-2012.
• Maternal Mortality Ratio (MMR) of India has declined by 443 points from 556 per one lakh live births in 1990 to 113 in 2016-18. A decline of 80% has been achieved in MMR since 1990, which is higher than the global decline of 45%. In last five years, Maternal Mortality Ratio (MMR) has declined from 167 in 2011-13 Sample Registration System (SRS) to 113 in 2016-18 (SRS).
• MR has declined from 80 in 1990 to 32 in the year 2018. Percentage annual compound rate of decline in IMR during past five years, i.e. during 2013 to 2018, has accelerated to 4.4% from 2.9% observed during 1990-2012.
• As per Sample Registration System (SRS), TFR in India declined from 2.3 in 2013 to 2.2 in the year 2018. The National Family Health Survey-4 (NFHS-4, 2015-16) also recorded a TFR of 2.2. The percentage annual compound rate of decline in TFR during 2013-2018has been observed as 0.89%.
• In the year 2019, malaria cases and deaths declined by 21.27% and 20% respectively as compared to 2018.
• The incidence of TB per 1,00,000 population has been reduced from 234 in 2012 to 193 in 2019. The mortality due to TB per 1,00,000 populations for India reduced from 42 in 2012 to 33 in 2019.
• The percentage of Kala-Azar endemic blocks, achieving the elimination target of < 1 KA case per 10000 population, increased from 74.2% in 2014 to 94% in 2019-20.
• The National target of sustaining case fatality rate (CFR) to less than 1 percent was achieved. The case fatality rate on account of Dengue in 2019 was 0.1%.

Expenditure: Rs 27,989.00 Cr (Central Share)

Beneficiaries: NHM is implemented for universal benefit - i.e. entire population; services are offered to everyone visiting the public healthcare facilities with a special focus to vulnerable section of the society.

Details & progress under NHM during 2019-20 is as under:

• Approvals of 63,761 Ayushman Bharat-Health & Wellness Centres were accorded till 31st March 2020, 38,595 Health & Wellness Centres were operationalized against the target of 40,000 till 31st March, 2020. A total of 3,08,410 health workers which includes ASHAs, Multi-Purpose Workers (MPWs-F) / Auxiliary Nurse Midwife (ANMs), Staff Nurses and Primary Health Center (PHC) Medical Officers by the end of 31st March 2020.
• There has been acceleration in decline of Maternal Mortality Ratio (MMR), Under Five Mortality Rate (U5MR) and the IMR since the launch of the NRHM/NHM. At the current rate of decline, India should able to reach its SDG target (MMR-70, U5MR-25) much before the due year i.e. 2030.
• In 2019-20, Intensified Mission Indradhanush2.0 was conducted to reach the unreached and partially vaccinated children in 381 Districts across 29 States/UTs.
• During 2019-20, around 529.98 lakh doses of Rota virus vaccine and 463.88 lakh doses of Measles-Rubella vaccine were administered in all states/UTs.
• During 2019-20, around 164.18 lakh doses of Pneumococcal Conjugated Vaccine were administered in 6 states Bihar, Himachal Pradesh, Madhya Pradesh, Rajasthan, Uttar Pradesh & Haryana.
• During 2019-20, 25.27 lakhs adults were administered with adult Japanese Encephalitis Vaccine (25 JE endemic Blocks of 9 Districts of West Bengal).
• During 2019-20, 45.45 Lakh ANC check-ups had been conducted at over 16,900 health facilities across all State/UTs under Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) program.
• LaQshya: Till 31st March 2020, 543 Labour Rooms and 491 Maternity Operation Theatres are State LaQshya certified and 220 Labour Rooms &190 Maternity Operation Theatres are National LaQshya certified.
• In 2019-20, to strengthen the cold chain system in the country, cold chain equipment i.e., ILR- 283, DF- 187, Cold Box(large)- 13,609, Cold Box (Small)-11,010, Vaccine Carrier - 270,230 and Ice packs - 10,94,650 had been supplied to the States/UTs.
• Approvals of 63,761 Ayushman Bharat-Health & Wellness Centres were accorded till 31st March 2020, 38,595 Health & Wellness Centres were operationalized against the target of 40,000 till 31st March, 2020. A total of 3,08,410 health workers which includes ASHAs, Multi-Purpose Workers (MPWs-F) / Auxiliary Nurse Midwife (ANMs), Staff Nurses and Primary Health Center (PHC) Medical Officers by the end of 31st March 2020.
• During 2019-20, a total of 16,795 ASHAs were selected making the total pool ASHAs 10.56 lakhs across the country by March, 2020.
• National Ambulance Services (NAS): As on March 2020, 33 States / UTs have the facility where people can Dial 108 or 102 for calling an ambulance. 1096, additional Emergency Response Service vehicles were added in 2019-20.
• During 2019-20, 187 additional Mobile Medical Units (MMUs) were added.
• 24x7 Services and First Referral facilities: During 2019-20, additional 53 facilities were operationalized as FRUs.
• Kayakalp: 25 States & UTs, 293 DHs, 1,201 CHCs/SDHs, 2,802 PHCs, 668 UHCs, and 305 HWCs have scored more than 70% in 2019-20. 5,269 public health facilities have been awarded under this scheme in 2019-20.
• Malaria: The total number of malaria cases and deaths reported in 2018 were 4,29,928 and 96 in comparison to 11,02,205 cases and 561 deaths reported in 2014, indicating a decline of 61% malaria cases and 83% deaths in comparison to the corresponding period of 2014.
• Kala-Azar: At the end of December 2019, 94% Kala-azar endemic blocks have achieved the elimination target of <1 KA case per 10,000 population at block level.
• Lymphatic Filariasis: In 2019, among 257 LF endemic districts, 98 districts have achieved microfilaria rate <1% and verified by Transmission Assessment Survey (TAS-1) and stopped Mass Drug Administration (MDA).
• In relation to Dengue, the National target was to sustain case fatality rate (CFR)< 1 percent. The target was achieved as case fatality rate in 2014 was 0.3% and during 2015 to 2018, CFR has been sustained at 0.2%. Further in 2019, it has been reduced to 0.1%.
• National Tuberculosis Elimination Programme (NTEP): A total of 1,264 Cartridge Based Nucleic Acid Amplification Test (CBNAAT) machines and 2,206 Truenat machines are operational at district level across the country. In 2019, 35.30 lakh molecular tests have been performed. This is 5 times increase as compared to 7.48 lakh during 2017. In 2019, 22,03,895 TB patients received Daily Regimen for treatment of Drug Sensitive TB compared to 19,71,685 in 2018. Introduction of newer anti-TB drugs: Shorter drug regimen and Bedaquiline based regimen rolled out in all State/UTs. In 2019, 40,397 MDR/RR-TB patients have been initiated on shorter regimen.
• Pradhan Mantri National Dialysis Programme(PMNDP) was Launched in 2016 to support dialysis facilities in all district hospitals in the PPP mode under NHM. During FY 2019-20 PMNDP has been implemented in 3 States/UT in 52 Districts in 105 Centres deploying 885 machines.

Background: The National Rural Health Mission (NRHM) was launched by the Hon'ble Prime Minister on 12th April 2005, for accessible, affordable and quality health care to the rural population, especially the vulnerable groups. The Union Cabinet vide in its meeting held on 1st May 2013, approved the National Urban Health Mission (NUHM) as a Sub-mission of an over-arching National Health Mission (NHM), with National Rural Health Mission (NRHM) being the other Sub-mission of National Health Mission.

Continuation of the National Health Mission-with effect from 1st April 2017 to 31st March 2020 was approved by Cabinet in its meeting held on 21st March 2018.

The Ministry of Finance, Department of Expenditure vide its Office Memorandum No. 42(02/PF-II.2014) dated 10th January 2020 has also accorded interim extension of National Health Mission for a period up to 31st March 2021 or till the date the recommendation of 15th Finance Commissions come into effect, whichever is earlier.

The Cabinet approval for NHM Framework further stipulates that exercise of these delegated powers would be subject to the condition that a progress report regarding N(R)HM, along with deviation in financial norms, modifications in ongoing schemes and details of new schemes be placed before the Cabinet for information on an annual basis.