NRHM Review 2009 Ministry of Health and Family Welfare

Consolidation of gains reached a new momentum with fresh thrust in crucial areas of health sector. While management of H1N1 situation was the highlight of the year, government’s innovative push was also evident in Medical Education, National Rural health Mission, curbing the menace of spurious drugs, Indian Systems of Medicine, Medical Research and AIDS control. 

National Rural Health Mission (NRHM)
The NRHM was launched by the Government in 2005 throughout the country, with special focus on 18 states which includes 8 erstwhile Empowered Action Group States, 8 North-East States, Himachal Pradesh and Jammu & Kashmir to provide accessible, affordable, accountable, effective and reliable primary health care facilities, especially, to the poor and vulnerable sections of the population of rural India. Since, the launch of NRHM, several activities have been undertaken under NRHM like strengthening institutional mechanism at State, District and Sub-District level, financial support at Village, Sub Centre, Primary Health Centres (PHC), Community Health Centers (CHC), Sub-District, District and State level for better utilization of health services; prevention and control of communicable and non-communicable diseases; revitalizing local health traditions and mainstreaming   Ayurveda, Yoga, Unani, Siddha, Homeopathy (AYUSH) etc.  and considerable progress has been made. The Institutional Framework of the NRHM has been established and operationalised in the various States and Districts.

The progress made under NRHM  as reported by States is as follows :

  • Over 6.77 Lakhs trained Accredited Social Health Activists (ASHAs) working actively in the field to connect households with health facilities.
  • 4.28 lakh Village Health and Sanitation Committees constituted and untied funds made available to them for local public health action.
  • 1.45 lakh Health Sub Centres made more effective through utilization of untied funds, availability of drugs and addition of 44,429 Auxiliary Nurse Midwives (ANMs) on contract.
  • 7,613 PHCs made 24X7, with provision of drugs, untied grants, maintenance grants, Rogi Kalyan Samiti (RKS) grants.
  • 9,874 MBBS Doctors, 6,660 AYUSH  Doctors, 13,278 paramedic staff, 3 staff Nurses in 5,520 PHCs. 2,344 Specialists taken on contract.
  • Upgradation of physical infrastructure completed in 822 CHCs.
  • More than 28,000 RKS established in DHs, CHCs, PHCs.
  • 617 Integrated District Health Action Plans completed.
  • 354 Districts have functional Mobile Medical Units.

Identifying the unreached – most difficult, difficult and inaccessible areas
The problems in such areas, particularly in hilly states, NE States, desert areas  and tribal areas in other states are more acute due to shortage of human resources including doctors and paramedics and need special solutions. It was decided to provide additional financial support (for Human Resources, infrastructure maintenance and logistics supply chain management etc) to such areas through NRHM. The task of classifying the health facilities into most difficult, difficult and inaccessible areas was undertaken through the states governments. Besides, the existing norms like terrain, left wing extremism, tribal concentrations followed by some states, other factors like absence of proper road communication, electricity, telecommunication services, public transport and climatic factors are also taken into consideration while identifying difficult, most difficult and inaccessible areas. 

Focus on New Born Care
To reduce the neonatal mortality which constitutes 45% of under-5 mortality, the following initiatives have been taken under the NRHM framework:

(i) Navjat Shishu Suraksha Karyakram – a new programme in Basic new-born care and resuscitation (23% of neonatal death occurs due to asphyxia at birth). A two-day training module for care providers at health facilities has been developed and training programme to train master trainers at State and district levels has been rolled out with the support of Indian Academy of Paediatrics and Neonatal Forum of India. Training for all care providers shall be completed  by June 2010.

(ii) Creation of new-born care units at district level hospitals, stabilization units at CHC level and new born corners at PHC level to provide specialized care.

(iii) Skill development of ASHAs and skilled birth attendants to ensure home-based new born and child care.

The above three prong strategy is expected to make a significant reduction in infant mortality.

In order to avoid delay in data that hampers health policy making Annual Health Survey have been envisaged to obtain district level data on various health indicators. The indicators have been finalised and the field survey shall commence from January 2010. This will be undertaken through the Registrar General of India and initially taken up in 284 districts of 9 high-focus States.

H1N1 Situation
The first case of Pandemic Influenza A H1N1 (swine flu) was reported in India on 13th May, 2009. As of now 30 states/ UTs have reported Pandemic influenza A H1N1 (swine flu). Government of India took a series of action to prevent / limit the spread of pandemic influenza A H1N1 and to mitigate its impact.  Entry screening of passengers is continuing at 22 international airports and five international checkpoints. Community surveillance to detect clusters of influenza like illness is being done through Integrated Disease Surveillance Project.

Laboratory network has been strengthened. There are forty two laboratories (24 in Government Sector and 18 in Private Sector) testing the clinical samples. Government of India procured 40 million capsules of which 18 million have been given to the States/UTs which is also used for preventive chemoprophylaxis. Three Indian manufacturers of Vaccine are being supported to manufacture H1N1 vaccine. Four million doses are being imported to vaccinate the higher risk group.

Training of district level teams is supported by Ministry of Health and Family Welfare. IMA has been provided funds to train private practitioners. All States have been requested to gear up the State machinery, open large number of screening centres and strengthen isolation facilities including critical care facilities at district level.

 A task force in the I&B Ministry is implementing the media plan. Travel advisory, do’s and don’ts and other pertinent information has been widely published to create awareness among public. All such information is also available on the website: As of now Government has spent / committed about Rs 331 crores in the current financial year. 

Medical education
To improve the quality of medical education, focus has been given to upgrading the skills of medical teachers, increase in post graduate courses/seats, revision of curriculum, introduction of new medical courses and revision of the norms of infrastructure etc.  While these amendments have taken effect, the actual implementation is expected to commence from the next academic session. Some of the important amendments made in the MCI Regulations are as under:-

i) The ratio of post graduate medical teacher to the student has been relaxed from 1:1 to 1:2.

ii) Research publications in indexed/National Journals have been made compulsory for promotion to the post of Professor/Associate Professor.

iii) Permitted colleges which are not yet fully recognized are allowed to offer postgraduate courses in the subjects of preclinical and paraclincial Departments of Anatomy, Physiology, Biochemistry, Pharmacology, Microbiology, forensic Medicine & Community Medicine without waiting for full recognition.

iv) The teaching experience required for the post of Professor/Associate Professor has been reduced by one year in the respective feeder cadres.

v) Emergency Medicine has been incorporated in the medical curriculum so that the medical students are trained to tackle medical emergencies.

vi) Basic management skills in the area of human resources, materials and resource management related to health care delivery, General and hospital management, principal inventory skills and counselling have been included in the curriculum.

vii) A village attachment of at least one week to understand issues of community health along with exposure to village health centres, ASHA, Sub Centres have also been included in the curriculum.

viii) The requirement of infrastructure like institution block, library, auditorium, examination hall, lecture theatres, etc. has been rationalized for optimal use, and

ix) Laboratories in different departments have been pooled to have common laboratories which can be used by all the departments for better utilization of the equipment and space and to reduce capital expenditure.

2. In addition, to facilitate expansion of medical education to the  unserved and underserved areas of the country,  amendments have been made in the Medical Council of India (MCI) Regulations, some of which are as follows:-

(a) For opening of new medical colleges, land requirements have been rationalized across the country and they have been further liberalized in the case of notified tribal areas, underserved/unserved areas and hill areas.  In respect of these areas, land need not be unitary piece but can be in two pieces of land,

(b) In respect of North-East and Hill States, the requirement of bed strength in the teaching hospital has been liberalized, and

(c) Staff and infrastructural requirements have also been rationalized etc.

Spurious Drugs
Government has amended The Drugs and Cosmetics Act, 1940  check the manufacture, sale or marketing of spurious and sub-standard drugs in the country. Amendments have come into force since 10th Aug, 2009. Under this Act stringent penalties for manufacture of spurious and adulterated drugs have been provided. Certain offences have been made cognizable and non-bailable.

A Whistle Blower Policy has been started by Government of India to encourage vigilant public participation in the detection of movement of spurious drugs in the country. Under this policy the informers would be suitably rewarded for providing concrete information in respect of movement of spurious drugs to the regulatory authorities.

The Government is promoting Indian Systems of Medicines in the Country. Following activities are being carried out to promote Ayurveda, Yoga & naturopathy, Unani, Siddha and Homoeopathy

i. Standardization of drugs.

ii. Production and Quality control of raw material (Medicinal Plants).

iii. Production of Quality Assurance of drugs

iv. Raising the standards of Research and Education

v. Generation of awareness

  • The following steps are being taken to increase India’s share in global market of herbal medicines
  • Reimbursement of 50% of the expenditure limited to Rs. 1.00 lakh to AYUSH entrepreneurs, industry representatives etc. for participating in international exhibitions, trade fairs, road shows etc.
  • Reimbursement of 50% of the expenditure incurred on preparation of Drug Dossiers and Registration of ASU&H products by US-FDA/EMEA/UK-MHRA subject to a maximum limit of Rs.5.00 lakhs per product to AYUSH units for encouraging them to register their products for export.
  • Funding of upto Rs. 50 lakhs for market development linked activities and to organize or support international conferences, seminars, workshops, conduct of market surveys & studies, etc.
  • A Centre for Research on Indian System of Medicine (CRISM) has been set up in the National Centre for Natural Products Research (NCNPR), University of Mississippi, USA. The NCNPR has an institutional interface with US-FDA which will facilitate Ayurveda, Siddha and Unani drug manufacturing companies to get their herbal medicines/food supplements registered on the basis of Common technical dossiers to be prepared jointly by CRISM and ASU Industry partners.
  • Framework of Cooperation has been signed with International Trade Center, UNCTAD/WTO, Geneva for development of International Trade of Indian Traditional Medicinal Products and Services.
  • Collaborative project on preparation of drug dossiers for market authorization in the EU to meet the regulatory requirements under the Traditional Herbal Medicinal Products Directive (THMPD) is being taken up.

New Initiatives in AYUSH
The new initiatives taken by the Department of AYUSH during the last 100 days are as follows:

  • Upgradation of nine AYUSH institutions as All India AYUSH institutions.
  • Modified scheme for strengthening of AYUSH Hospitals & Dispensaries under National Rural Health Mission (NRHM).
  • Approval for co-location of AYUSH facilities in major allopathic hospitals in Delhi.
  • Task Force on AYUSH education set up.
  • Curriculum finalized for international level studies on Ayurveda.
  • Scheme for voluntary certification of AYUSH drugs finalized in collaboration with the Quality Council of India (QCI).
  • Scheme for accreditation of AYUSH hospitals and laboratories finalized jointly with QCI.
  • Pharmacopoeial Standards finalized upto now for 640 AYUSH single drugs & formulations.
  • Launch of –
  •  National Campaign on Mother & Child Health
  •  National Campaign on Anaemia.
  •  National Campaign on Yoga.
  •  National Campaign on Unani.
  • Acceleration of the existing campaigns on Kshar Sutra for Ano-rectal disorders, Geriatric care and Quality Assurance.
  • Campaign on Yoga and Diabetes in 31 cities in partnership with the Vivekananda Yoga University.
  • Sanction for coverage of 32,636 hectares of land for cultivation of medicinal plants under the National Mission on Medicinal Plants and 4350 hectres of  land under the Center Sector Scheme in forest areas.
  • Launch of country wide campaign on Amla.
  • Traditional Knowledge Digital Library – transcription of 2,10,000 formulations upto now in patent compatible format.
  • Signing of Access Agreement with the European Patent Offices to prevent biopiracy.
  • Rs.100 crore for clusters scheme taken up for AYUSH drug manufacturing and approval given for schemes in Punjab, Maharashtra, Karnataka, Tamil Nadu, Hyderabad and Orissa and Assam.
  • Human Resource Development of 5760 AYUSH medical practitioners.
  • A PPP Cell set up in the Department of AYUSH to promote participation of credible non-government organizations..
  • PPP Project on eye care in Ayurveda set up in Bihar.
  • Tele Homoeopathy/Ayurveda projects taken up in Tripura and Bihar.
  • Recognition of Sowa Rigpa (Amachi) system practiced in the Sub-Himalayan region.
  • North East Resource Centre set up at Guwahati for providing support to
  • North Eastern States for implementing AYUSH sector schemes.
  • An Inter-ministerial Committee on high quality research set up.
  • Performance standards set for all AYUSH National Institutes/Research Councils.
  • Collaborative Research Project on prevention and treatment of Cancer,
  • Diabetes, Kala Azar, chickungunia & other illnesses by the Research Councils with top level institutions in the country.
  • Validation of safety studies of eight herbo-mineral formulations completed under the Golden Triangle Project for validation of AYUSH systems.
  • Support/participation in International Conferences on AYUSH systems in USA, Germany, Australia, South Africa, Malaysia, Netherlands and Greece.
  • Approval for Arogya Fairs in all North East States, Bihar, Orissa, Jammu & Kashmir, Chhatisgarh, Himachal Pradesh, West Bengal and Punjab.

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