DPMU Module PDF

Training Module
for
DPMU Staff
Compiled & developed by:

State Institute of Health and Family Welfare, Jaipur
(An ISO 9001:2008 Certified Institution)
Supported by:
NRHM, Rajasthan
Mission
State Institute of Health & Family Welfare, Rajasthan is committed
to improvement in health care through HRD, Health Service
Research, Consultancy and networking in aiming at enhancement
in the quality of life.
HEALTH SCENARIO:
India
Rajasthan
56.50
66.75
Population 2001 [Million]
1028.6
Projected Population 2010 [Million]
1176.7
Health Care Infrastruc ture

Community Health Centers
Primary Health Cent ers
4276
2
23458
Sub Centers
146036
Total FRUs
1813
1
1
368
3
1503
2
11488
3
237
Manpow er Status
4
Total Allopat hic Doctors
725190
Total Allopat hic Doctors in Govt.

Total Dentist
Total Ayurvedic Doctors
Total Registered ANMs
Total ANMs in Govt.
Total Registered GNMs
Total Registered LHVs
Total Specialist at CHCs
MBBS Doctors at PHCs
84852
4
73057
4
458418
4
549292
2
153568
4
971574
4
51497
2
4279
2
24375
26592
4
6285
4
364
4
23861
4
22239
3
12150
4
37667
4
850
3
811
3
1379
Mortality Indicator s
5
Infant Mortality Rate
53
63
Maternal Mortality Ratio
254
Total Fertility Rate
2.7
388
3.4
5
Crude Birth Rate

Crude Death Rat e
Life Expectancy
Under 5 Mortality Rate
Health Care Indicators
Doctor Population Ratio [per 1000]
Nurs e Population Ratio [per 1000]
22.8
5
7.4
4
66.9
6
74.3
27.5
5
6.8
4
67.6
6
85.4
0.41
4
0.94
Bed Population Ratio
0.87
0.67
0.63
4
1.37
Population per Sub centre Ratio
7838
5714
Population per PHC
48799
Population per CHC
267711
Couple Protection Rate
54.1
Proportion of fully immunized children [12-24 months]
54.1
Proportion of Pregnant receiving A NC [Full ANC]
19.1
43679
2
57
48.8
6.6
52.7
Proportion of Safe Deliveries
52.6
Institutional Deliveries
47
178396
9
9
9
9
9
45.5
3. Census of India, 2. RHS-08, 3.DM & HS, Raj. 4. NHP-08, 5.SRS-09, 6.NFHS-3, 7.CBHI, 8.Pragati
Partivedan, 2009, 9.DLHS-3
SIHFW: ISO 9001:2008 Certified institution

NRHM Trainings. Feb. 2010
Index
S.No.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
Content
Overview of National Rural Health Mission
Health care delivery System
National Health Programs
PIPs and District Health Action Plan
Inter Sectoral Convergence
JSY
ASHA
SBA
VHND (MCHN day)
Interpersonal Communication / BCC
IDSP
Epidemic Preparedness &
Outbreak Investigation
IMNCI
ICDS
VHSC, Role of PRIs & Community Monitoring
HMIS
Immunization
IPHS
PPP
Rashtriya Swasthya Bima Yojana
Policies and Legislation
Financial Management under NRHM
Procurement & Logistic Management
Office Procedures
NFHS III, DLHS III, SRS
Page No.
001
012
027
089
100
105
118
130
142
150
157
162
171
180
189
198
205
213
229
235
241
266
278
291
305

National Rural Health Mission (2005-2012)

Conceived on: April, 2005 (May 2005 in Rajasthan)
Need:
1. Declining Public Health expenditure (1.3 % of GDP in 1990 to 0.9% in
1999)
2. Limited synergism in Vertical and Horizont al Health Programs
3. Lack of community ownership
4. Lack of integration of issues
5. Regional inequalities
6. Population stabilization still not met
7. Curative services favor rich
8. Poor coverage by Health insurance (only 10%)
9. Hospitalization eats 58% of annual income, 25% pop. falls below poverty line following
hospitalization expenses.
Objectives:
1. To provide effective health care to rural population with focus on 18 States those have poor
health indicators
2. To raise public health expenditure from 0.9% of GDP to 2-3% of GDP
Goals:
1. Reduction in IMR & MMR (Rajasthan)
a. Infant Mortality Rate to be reduced to 56/1000 live births by 2011
b. Maternal Mortality Ratio to be reduced to 285/100,000 by 2011
2. Universal access to public health services
3. Prevention & Control of Communicable diseases.
4. Access to integrated comprehensive primary health care
5. Population stabilization, gender and demographic balance.
6. Revitalize local health traditions and mainstream of AYUS H.
7. Promote healthy life styles.
National Goals in contex t of MDGs
Current
10th
Plan
3 (2003)
FY
NPP
2010
MDG 2015
2.3
2.1
--
53 (S RS-2009)
45
<30
<27
Neonatal Mortality rate
37 (NFHS III)
26
<20
<20
Maternal Mortality Rate
254 (S RS 2006)
200
<100
<100
Institutional deliveries
45.5 % (DLHS -3)
80%
80%

The NRHM carries a paradigm shift with Decentralised planning

Outpu t s and Out come based
Pro-Poor Foc u s: Equi table sy stems
Quality of Care and the IPHS norms
Rights based service delivery
Pre stated entitlements at all levels
Inputs computed as function of the entitlements and estimated patient load
Judicious mix of dedicated budget lines - untied funds
Monitor quality
Community Participation
Bringing the public back into public health
At hamlet level: ASHA, VHSC, SHGs, Panchayats.
At the facility level: RKS
At the management level : health societies
Governance reform
Manpower, Logistics & Procurement processes.
Decision making processes
Institutional design, Account ability framework
Convergence
Water and sanitation
Nutrition
Education
The Mission outcomes are expected to follow a phased approach and are at two levels:
1. National Level
a. Infant Mortality Rate to be reduced to 30/1000 live births
b. Maternal Mortality Ratio to be reduced to 100/100,000
c. Total Fertility Rate to be brought to 2.1
d. Malaria mort ality reduction rate 50% up to 2010, additional 10% by 2012
e. Kala Azar to be eliminated by 2010.
f. Filaria/Microfilaria reduction rate: 70% by 2010, 80% by 2012 and elimination by 2015
g. Dengue mort ality reduction rate: 50% by 2010 and sustaining at that level until 2012
h. Japanese E ncephalitis mortality reduction rate: 50% by 2010 and sustaining at that level
until 2012
i. Cataract Operation: increasing to 46 lacs per year until 2012.
j. Leprosy prevalence rate: to be brought to less than 1/10,000.
k. Tuberculosis DOTS services: from the current rat e of 1.8/10,00, 85% cure rate to be
maintained through the entire Mission period.
l. 2000 Community Health Centers to be upgraded to Indian Public Health Standards
m. Utilization of First Referral Units to be increased from less than 20% to 75%
n. 250,000 women to be engaged in 18 states as Accredited Social Health Activists (ASHA).
2. Community Level
a. A vailability of trained community level worker at village level, with a drug kit for generic
ailments
b. Healt h Day at Anganwadi level on a fixed day/month for immunization, ante/post natal
checkups mother & child healthcare, including nutrition
c. A vailability of generic drugs for common ailments at Sub-centre and hospital level
2

d.
e.
f.
g.
h.
i.
Good hospital care through assured availability of doctors, drugs and quality services at
PHC/ CHC level
Improved access to Universal Immunization t hrough induction of A uto Disabled Syringes,
alternate vaccine delivery and improved mobilization services under the program
Improved facilities for institutional delivery through provision of referral, transport, escort
and improved hospital care subsidized under the Janani Suraksha Yojana (JSY ) for the
Below Poverty Line families
A vailability of assured healthc are at reduced financial risk through pilots of Community
Healt h Insurance under the Mission
Provision of household toilets
Improved Outreach services through mobile medical unit at district-level.
Areas addre ssed:

1. AYUSH
2. Maternal & Reproductive health
3. Population stabilization
4. HMIS
5. Micro planning
6. Integration of programs and services
7. Healt h expenditure pattern and quantum
8. Indian Public Health Standards (IP HS)
9. Interstate and inter district disparities
10. Access, Availability, Affordability and equity
Component s o f NRHM:
1. RCH-II
2. All activities of NRHM
a. ASHA
b. JSY (Janani Suraksha Yojana)
c. Institutional deliveries and cash assistance
d. United fund of Rs. 10000/- for each Sub Centre
e. Dai Training
f. RCH camps
g. On-Contract staff deployment
h. Immunization
i. National Health Programs
j. Inter-sectoral and inter-departmental coordination
3. Vector Borne Disease Control Program
4. TB control program
5. Blindness control
6. Leprosy Eradication
7. Iodine Deficiency Disorders
8. Disease Surveillanc e project
9. HMIS
Reach:
18 High foc us statesStates (UP, Uttaranchal, MP, Chhattisgarh, Bihar, Jharkhand, Orissa,
Rajasthan, HP, J&K, Assam, Arunachal Pradesh, Manipur, Meghalaya,
Nagaland, Mizoram, Sikkim and Tripura)
Now extended to entire country
3

Approach :
The 5 main approaches under NRHM are1. Communitize
a. Hospital Mgt. Committees/ PRIs at all levels
b. Untied grants to communities / PRI bodies
c. Funds, functions and functionaries to local community
d. Decentralized planning
e. Intersectoral convergence
2. Flexible Financing
a. Untied grants
b. NGOs for public health goals
c. NGOs as implement ers
d. Risk pooling
e. More resources for more reforms
3. Improved management through capacity building
a. Block and District health offices through mgt.
b. NGOs in capacity building
c. NHS RC/ SHS RC/ DRG/BRG
d. Continuous skill development support
4. Monitor progre ss again st standard s
a. Setting IPHS standards
b. Facility surveys
c. Independent monitoring committees at Block, District & State
5. Innovation in human resource management
a. More nurses -Loc al resident criteria
b. 24 x 7 emergencies by Nurs es at PHC. AYUSH
c. 24 x 7 emergencies by Nurs es at CHC
d. Multi skilling.
Strategy:
1. Capacity building of P RIs to own and manage public healt h services.
2. Promote access to improved health care at house hold level through ASHA (Accredited
Social Health Activists).
3. Healt h plan for each village (micro-planning) through village Panchay at health committees.
4. Strengthening sub-centre through a unit ed fund to enable local planning and action.
5. Strengthening existing CHCs with provision of 30-50 beds per lac population for improved
curative care t o a normative standard (IP HS) regarding pers onnel, equipment, and
management standards.
6. Preparation and implement ation of an inter-sectoral district Health plan prepared by District
Healt h Mission including Water, Sanitation & Hygiene and Nutrition.
7. Integration of Vertical Healt h & Family Welfare Programs at National, State, District and Block
levels.
8. Technical support to National, State and District Health Missions.
9. Strengthening capacity for information management and evidence based planning,
monitoring and supervision.
10. Developing capacity for preventive health care.
11. Promoting Non-profit sector particularly in under served areas.
4

12. Supplement ary strategya. Regulation of private sector

b. Promotion of P rivate Public Partnership
c. Mainstreaming AYUSH
d. Re-orienting Medical Education towards rural health issues
e. Effective and viable risk pooling and social healt h insurance
Situation at the time of rolling out of NRHM
Indicator
IMR
source
SRS 25, RGIs Office
Maternal
Mortality Ratio
National situation
58 (Kerala:14, MP: 76)
Current value
53 (SRS, Oct.2009)
Rajasthan-63
254 (Special bulletin on
MMR-S RS
2004-06,
Rajasthan-388
301 (K erala:4,UP: 517)
Non hospitalized
treatment
on
Govt. facilities
In patient treated
in
Public
Hospitals
A verage medical
expenditure per
Hospitalisation
State of Health
facilities
NSS 60
th
round 2004
22% (Bihar 5%, HP-68% )
NSS 60
th
round 2004
41.7%
91.3)
NSS 60
th
round 2004
Anemia among
children
and
women
Immunization
NFHS -III (2005-06)
Rs. 3238 in Govt. Hospitals to

Rs.7408 in pvt. Hospitals in
rural areas
Adequacy cut off- 60%
Infrastructure- 76% FRUs,
63% of CHCs,
Equipment: 61% FRUs, 46%
CHCs
Manpower: 37% FRUs and
14% CHCs
79.1%-6-35 mont hs 56.1%
women
Institutional
births,
3
antenatal
care
visits, post natal
care
Child morbidity
DLHS
and
facility
survey coordinated by
IIPS 2003
(Bihar-14. 4%,
J&K-
UNICEFs
coverage
evaluation
survey
2005
NFHS -III (2005-06)
54.5% children
Rajasthan-FI-48.8%
(DLHS-3)
40.7% institutional births ,

50.7% 3antinatal care visits,
36.4% post natal
Rajasthan-ID-46%
(DLHS III, 2008), ANC56%, PNC-38.2%
FOCUS survey 2004

(Jean Dreaz et al) in
Tamil
Nadu,
HP,
Maharashtra,
Raj,
Chattisgarh, and UP
Fever-32%,
Dioarrrohea21%,persistant cough-17%,
extreme weakness- 11%, skin
rashes-5%, eye infections 2%, 50% children had one of
the above problems

Institutional mechanism:
Under the NRHM, institutional mechanisms have been created at each level to support National
Healt h Programs & improve delivery of health care services. These are1. Village Health & Sanitation Committee (V HSC)
2. Accredited Social Health Activist (ASHA)
3. Rogi Kaly an Samities (RKS/RMRS in Rajasthan)
4. Panchayati Raj Institutions (PRIs)
5. Finance Management Group (FMG)
Ex ecution & Monit oring:
Institutional Set-upMissi on Steering Group:
1. National LevelChairman
Members
2.
- Union Minister H & FW

- Rep. of Planning Commission
- Secretaries of 4 States from Rural Development Panchayati Raj
HRD H & FW
- 10 Public Health Representatives
State LevelChief Secretary, GOR, Chairperson.

Addl. Chief Secretary (Development), GOR, Co-Chairperson.
Principal Secretary, Health & Family Welfare, GOR, Vice-Chairperson.
Principal Secretary-Finance, Member.
Principal Secretary-P anchyati Raj and Rural Development, GOR, Member
Principal Secretary-Women & Child Development, GOR, Member.
Secretary FW & Mission Director-NRHM, GOR, Executive Secretary.
State Health Mission :

State Health Missions role includes the following:
1. Actively undertake Policy and Institutional Reforms to enable effective implementation of
NRHM
2. State level planning, implementation and monitoring.
3. Support District level planning, implementation and monitoring.
4. Provide Training support to districts.
5. Coordination across relevant departments.
6. Sharing of experiences across districts.
7. Management of cash flows.
8. Financial accounting/ administration.
The state has registered a single State Health S ociety through merger of all state level societies in
the Health and Family Welfare sector, except the State Aids Control Society.
These Societies will maintain separate Bank Accounts even under the unified structure. Funds for
separate programs would continue to flow under Sub-Budget Heads of t he NRHM B udget Head. The
Integrated State Health and Family Welfare Society has a full-time secretariat to act as the State
Program Management S upport Unit (SPMSU), headed by a full time Executive Director. The SPMSU
will
(a) Assist the Directorate of Health & FW in implementation,
(b) Act as the coordinating agency with other Departments for the Mission and
(c) Perform the role of the secretariat of the State Health Mission
6

State Health Society:

Objectives
The Society shall serve in an additional managerial and technical capacity to the Department of
Healt h & Family Welfare, Government of Rajasthan for the implementation of National Rural Health
Mission (NRHM) in the State.
Scope of func tion s
To achieve the above objectives, the S ociety shall direct its resources towards performance of the
following key tasks:
1. Receive, manage (including disbursement to implementing agencies e.g. Directorate, District
Societies, NGOs etc.) and account for the funds received from the Ministry of Health & Family
Welfare, Government of India and other sources.
2. Manage the NGO / PPP (publicprivate partnership) components of the NRHM in the State,
including execution of contracts, disbursement of funds and monitoring of performance.
3. Function as a Res ourc e Centre for the Department of Health & Family Welfare in
policy/situational analysis and policy development (including development of operational
guidelines and preparation of policy change proposals for the consideration of State
Government).
4. Strengthen the technical / management capacity of the State Directorat e as well as of the
Districts Societies by various means including through recruitment of individual / institutional
experts from the open mark et (with tot al program management costs for the State as a whole
not exceeding 6% of the total program costs).
5. Mobilize financial / non-financial resources for complementing/supplementing the NRHM
activities in the State.
6. Organize t raining, meetings, conferences, policy review studies / surveys, workshops and
inter-Stat e exchange visits etc. for deriving inputs for improving the implementation of NRHM
in the State.
7. Undertak e such other activities for strengthening NRHM in the State as may be identified
from time to time, including mechanisms for intra and int er-sectoral convergence of inputs
and structures.
Di stri ct Health Mission & Society :
At the district level all existing societies have been merged into the District Health Society with its
apex body performing the functions of the District Health Mission (DHM). It is envisaged that the
Secretariat of the District Health Society should have a small but dedicated unit for inter-sectoral coordination, which may directly report to the CEO, Zilla Parishad.
Roles and Re spon si bility of Di stric t Health Mission include:
1.
2.
3.
4.
District health planning, implementation and monit oring

Coordination across relevant Departments
Management of cash flows
Financial accounting/ administration
Members of Di stric t Health Society:

1.
2.
3.
4.
District Collector Chairperson

CEO-Zila Parishad Co-Chair person
CM &HO Chief Executive officer
Project Director DRDA Member
7

5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Dy. Director ICDS Member

Officer in charge-Total Sanitation Campaign. Member
Executive Engineer-P HED Member
District Education Officer-P rimary & Secondary Member
CHC incharges Member
Three Represent ative of Medical Associations/MNGOs/SNGOs to be dominated by collector.
Member
Additional CMHO- Member
RCHO- Member
District Ayurved Officer- Member
District Program Officer - Convener
Program Management Units:

State Program Management Unit (SPMU)
The main objective of establishing this unit is to strengthen t he existing management
structures/functions at the state and district levels respectively as RCH-II is characterized by
allocation of flexible funds t o states, preparation of program implementation plans by States and
districts and performance linked dis bursement based on MOU.
The SPMU con si st s of follow ing four po si tion s:
State Program Manager
State Finance Manager
State Accounts Manager
State Data Officer
Role of SPMU
The SPMU is responsible for the overall state level planning and monitoring for NRHM, management
of flexi-pool funds, initiation of healt h sector reforms, continuous process improvement and for
secretarial functions to the State Health Mission and State Health Society.
Di stri ct Program Management Unit (DPMU)
While the Collector would continue to be the Chairperson of District RCH Society, suitable manpower
resources for program management and finance/accounts functions has been provided. The district
level functions include planning, implementation and monitoring of all EAPs including RCH II, finance
and accounting, training and capacity building, MIES and district plans etc.
The district PMU is composed of three skilled personnel i.e. Program Manager, Accounts Manager
and Data Assistant;
Di stri ct A ction Plan
District Health Action Plan is to be prepared by each District. The Key strategies suggested for DAP
are as follows:
Block w ill be the key level for development of decentralized plans so each block will be covered
under the DAP and a block level plan will be prepared for each block in each district.
Technical resource agency/ groups will be identified for each block to assist in planning.
A technical resource agency would be identified for the District to support the implementation of the
DAP.

Four broad categories of prog rams have been indicated under NRHM.
1. RCH-II activities and programs
2. NRHM activities such as IPHS, Untied funds, JSY, and integration, AYUS H, nut rition and
child development
3. National Disease Control Program
4. Immunization
5. A number of inputs have been suggested under NRHM implementation framework. A detailed
plan for additional ties will be incorporated in the DAP.
Facility survey of the PHCs, CHCs and S ub Centre is a c ritical part of the DAP. As State has taken
the decision t o conduct the Facility Survey of health institutions (CHC/P HC) separat ely, from the DAP
but in the frame work of DAP there should be clearly indicat ed the provision of facility survey under
NRHM. Cost for the facility survey will not be the part of DAP.
Under NRHM there is provision of untied fund for the different levels Village, Block and District. GoI is
yet to indicate the amount of untied funds. So under plan there should be the action points for utilizing
the untied funds.
Under NRHM & RCH-II, a list of propos ed activities have been worked out and a templates of the
activities have been developed t his template will be used as worksheet for t he action plan for each
year activities.
Under NRHM DAP will be prepared with involvement of different sectoral departments such as
DWCD, P HED and Rural Development, Panchayati Raj and AY USH etc. All the activities of NRHM
related to other departments will be spelt out clearly with budget provisions.
Village Health Sanitation Committee (VHSC)
The NRHM framework support decent ralized planning & monit oring up to the grass root level.
Therefore it was decided to entrust village level committees of the users group, community based
organization for the planning monitoring & implementation of NRHM activities into the 41000 revenue
villages of the State.
The VHS C will be the key agency for developing Village Health Plan & the entire planning of village
Panchayat for NRHM. This committee compris es of Panchayat representatives, ANM, MTW,
Aganwari workers, Teac hers, Community health volunteers, ASHA.
NRHM Funding :
Amount : 6713 crores for 2005-06, Rs. 20300 crores (2008-09), Rs. 55800 (2011-12)
Rajasthan-1010 crores for 2009-10
State contribution minimum 10% increase per year in State Health Budget for Public
Health Expenditure under signed MoU with GOI
More than 70% going to block level and below
Fund flow : Advance to States
State plans to be funded through RCH-II and NDCP
Societies for H & FW to be merged into one Society at District and State level for
funneling of funds
Addl. Input s: Rs. 20 lacs per district for 2 CHCs for up gradation up to IP HS
Maintenance grant of Rs 1 lac per CHC after constitution of RKS
United fund of Rs. 10000 per Sub Centre
Supply of Additional drugs
Mobile Medical units at District

Key Ac tivities (2005-06):

1. Constitution of State & District Health Missions
2. Merger of Health & Family Welfare Societies
3. Preparation of State Action Plans-identifying sectoral needs and priorities
4. Finalizing performance bench marks for MoU
5. Signing of MoU between State & GOI
6. Preparation of District Plans
7. Upgrading 2 CHCs in each District as per IP HS with provision of 2 rooms for AY USH
8. Formation of Rogi Kalyan Samitis (RMRS in Rajasthan)
9. Strengthening Immunization
a. Induction of Auto-disabled Syringes
b. Arrangement for alternate vaccine delivery at immunization sites
10. Organizing mobile medical services at District level
11. Organizing healt h camps at AWW level on fixed day each month
12. Provision of House hold toilets
13. Strengthening institutional delivery under JSY
14. Establishing systems to increase accountability of Health System to PRIs
a. Selection & Training of ASHA, including provision of drug kits
b. Organizing Health Melas to inform & educate people about NRHM
c. Provision of generic drugs (for AYUS H & Allopathic) at village/ SC/ PHC/ CHC level
for common ailments
Key activities planned under PIP (2009-10)
A. Strengthen the su b centre s
1. United fund for local action @ Rs.10, 000 per annum.
2. Supply of essential drugs, both allopathic and AY USH ,
3. Sanction of new Sub centres as per 2001 population norm.
4. Upgrading existing Sub centres,
B. Strengthen the Primary Health Centres
1. Adequate and regular supply of essential quality drugs and equipment to PHCs,
2. Provision of 24 hour services in 50%
3. Mainstreaming AY USH manpower,
4. Standard treatment guideline & protocols,
5. Supply of Auto Disabled Syringes, for immunization, intensification of ongoing
communicable Disease control programs, new programs for control of non
communicable diseases,
6. Up gradation of 100% PHCs as FRUs , and provision of 2nd doctor at P HC level( 1male,
1 female)
C. Strengthening CHCs for fir st referral care
This includes, operationalizing CHC (30-50 beds) as 24 Hour FRUs, including posting of
anesthetists, - 2 CHCs per district initially, SC/PHC/ CHC to be upgraded to IP HS, promotion
of Rogi Kaly an Samitis for hospital management, developing standards of services and
costs in hospital care, creation of new CHCs (30-50 beds) to meet the population norm as
per Cens us 2001.
D. Di stri ct Health Plan as per Village Health Plans, State and National priorities for Health,
Water Supply, Sanitation and Nutrition
10

E. Convergence of sanitation and hygiene under NRHM

F. Strengthening disea se control prog ram
G. Public Private Partnership for public health goals, including regulation of private
sec tor
H. New health financing mechanism s
I.
Measure s to re-orient health/medical education to sup port ru ral health issue s

The Mission envisages the following roles for P RIs;
1. ASHAs would be selected by and be accountable to the Village Panchayat.
2. The Village Health Committee of the P anchayat would prepare the Village Health Plan,
and promote intersect oral integration.
3. The united fund at Sub-centres to be deposited in a Bank Account, jointly operated by the
ANM and Sarpanch.
4. District health Mission to be led by the Zila Parishad.
5. The DHM would also guide activities of sanitation.
6. States are to indicate in their MOUs devolution of funds and programs to PRIs.
7. The DHM will cont rol, guide and manage all public Health institutions in the district, Subcentres, PHCs and CHCs.
8. PRI involvement in Rogi Kalyan Samitis is to ensure good hospital management.
9. Training to members of PRIs and making available health related databases to all
stakeholders, including Panchayats at all levels are planned under NRHM.
Integrated
Service
delivery
under
NRHM:
PRI to plan & Monitor

program
Community Access, Awareness,&
Participation
Nutrition, Education,
Sanitation, Water
supply, WCD
NACP, RNTCP, NVB
DCP, RCH, IDD, IDS
P, NCCP, School
Health, Blindness
People
11

Health care delivery system in India

Milestone s in
1. 1947
a.
b.
c.
d.
e.
2.
3.
4.
5.
1.
2.
f.
g.
h.
1948
a.
b.
c.
d.
Health service s development in India

Bhore committee appointed.
India bec ame independent country
Establishment of Ministries Of Health And Director General Of Health Services
Became the member of WHO
Development of P rimary Health Centers as the nodal cent ers for providing health
services
Integrated approach with referral system
Healt h as a state subject
Launching of national programs on malaria, small fox, Filaria, TB etc.
Establishment of dental council of India

Healt h subcommittee of the National Planning Committee
Committee suggested preventive approach to Primary health care
Preservation and maintenance of the health of the people should be the responsibility
of the state
1949: Establishment of Pharmacy council of India, Family Planning Association of India.
1952: A ppointed population policy committee Creation of Family Planning Cell in the Director
General of Healt h Services.
1951-56: Fir st five year plan launched
a. Million rupees allocat ed to family planning and only 1 million was spend, voluntary
effort.
b. Launching of Malaria Eradication Program in 1953,
c. Leprosy control program in 1954
d. Filaria control program in 1955,
e. National TB sample survey 1955
f. Establishment of institutions like AIMS, CPHEO
g. Still low priority to health sector
h. Only 725 P HC are opened with limited staff
1956-61: Second Five year plan was launched 143 Crores for health sector out of 4672
a. Establishment of Indian medical council and Central Healt h educ ation Bureau
b. Mudaliar committee was appointed to review t he first and second five year health
plans.
c. Malaria Control program was renamed as National Malaria eradication program
d. National TB survey complet ed and national TB institute was established
e. Total 1840 new PHC were opened
1961-66: Third Five-year plan was launched.
a. Mudaliar committee report published. Allocated 342 Crores for health sector.
b. UN Healt h mission visit and suggestion of Population control.
c. Cent ral Bureau of health intelligence was established
d. Small pox eradication program,
e. Goiter control program,
f. District TB program were launc hed.
g. National institute of communicable diseases,
h. National institute of healt h administration and education were created.
i. Family welfare given priority.
j. Malaria program became successful and other progress with the other programs.
k. Family welfare became an independent department.
12

3.
4.
5.
6.
7.
8.
l. Target approach to Family Planning evolved. Sterilization approach.

m. Promotion of nutrition education.
1966-69
a. Jungalwala committee (small family committee) submitted report.
b. National Nutrition Monitoring Bureau was started.
c. Progress on many indicators like death and birth rate.
d. 315 new P HCs were established.
e. Sample registration system was launched to generate health data.
1969-74
a. Emphasis on training facilities for different cadres of pers onnel.
b. Medical termination of pregnancy bill passed.
c. Post Partum scheme started.
d. 364 new P HC were opened.
e. Marginal improvements in indicators.
f. Integration of Family Planning services with MCH services and increased acceptance
of contraceptive met hods.
g. Proposed increased nutrition plan.
h. Midday meals program to cover 14 million children.
1974-79 : Fif th Five year plan was launched
a. National minimum needs program was launc hed and health services, drinking water
supply, environment improvement of slums were included as components.
b. Srivastava committee recommendation and Community Health worker scheme was
launched. Part time and honorarium to be paid to them. Principle thrust was to
accelerat e the Family planning targets in birth rate.
c. Compulsive approach in national emergency 1977 through c amps, and increased
fundings.
d. Government change and new policy on Immunization, womans education, and
emphasis on family welfare.
e. National rural health scheme was launched and also NIHFW.
f. WHO adopted Health for All by 2000 A D (Alma-Ata Declaration, 1978)
g. Improved attention on nutrition status of woman.
h. Integrated Child Development Services (ICDS) was launc hed.
i. National population policy was introduced. (Raising of age of marriage for men and
woman from 15 to 18 years for females and 18 to 21 for males, Freezing of P eoples
representation in legislatures and parliament on the basis of 1971 census till 2001.
more central assistance to state on family planning.
1980-85: National Health Policy formulated, 1983
1985-90
a. National AIDS Control Program, 1987
b. Emphasis on consolidation and operationalization of PHCs and CHCs.
1992-97: V III Five year plan launched
a. Convergence of various schemes provided by different sectors, decent ralized
planning, urban health centers development.
b. Draft population policy- suggestion of social development committees at different
levels.
c. Adoption of National Nutrition Policy.
d. Launching of major projects by states to develop sec ondary level health
infrastructure. Andhra Pradesh, Maharasht ra, Orissa, Punjab and West Bengal.
e. ICDS renamed Integrat ed Mother and Child Development (IMCD)
f. IX Five year plan launched (1997-2002)
13

g.
h.
i.
j.
k.
RCH phase- I, 1997 October

NSPCD-1997
2000 National population Policy
2002 National Health Policy (revised)
2004 RCH- Phase-II, integration of Japanese Encephalitis, Kalazar, Dengue, Filaria
and Malaria into National Vector Borne Dis ease Control Program
l. 2005 National Rural Health Mission launched.
9. 1997-2002: IX Five year plan launched
10. 2002-2007: X Five year plan launched
11. 2007-2012: XI Five year plan launched
The rave review clearly establishes a few factsa. There was NO Health Policy for the country for 36 years
b. The Health was left to the wisdom of Committees and Commissions
c. Each Committee addressed to a single specific issue.
d. Comprehension was missing
e. Majority of recommendations of every committee were reiterations of Bhore
Committee.
f. Individual Health Programs were developed in isolation based on situational exigency.
g. Uni-purpose workers were created later baptized as Multi-purpose.
h. Some Programs worked in complete isolation till 1980 (e.g. NTCP).
Healt h per se had a fragmented approach till 1978 when Global conc ern dictated in favor of HFA2000 and, with a little longer latent period at last, a National Health Policy (1983) was formulat ed.
It is not that nothing was done till 1983 or that the Programs could not achieve any thing. We have
seen Small pox eradicated through the same infrastructure, and Human resource. Somehow, the
frequent P aradigm shifts (e.g. Age at which BCG vaccine is to be administered) have made the
system cluttered and indifferent.
Achievements throug h the Years - 1951-2000 :
Indicator
Demographic Changes
Life Expectancy
Crude Birth Rate
IMR
1951
1981
2000
36.7
40.8
146
54
33.9(SRS)
110
64.6(RGI)
26.1(99 SRS)
70 (99 SRS)
The progress was not restricted to a few demographic indicators wherein substantial improvements
were made over last 50 years, and remarkable progress was made in reducing morbidity/ mortality on
account of Communicable disease.
A large health care service delivery infrastructure today complements the efforts and inputs provided
to accomplish the policy objectives and goals. A quick review of the Epidemiological shifts in
communicable diseases and the Infrastructure gives us the following picture
Epidemiological Shifts
1951
1981
2000
Malaria (cases in million)
75
2.7
2.2
Leprosy cases per 10,000 population
38.1
57.3
3.74
Small Pox (no of cases)
>44,887
Eradicated
Guinea worm (no. Of cases)
>39,792
Eradicated
Polio
29709
265
Infrastructure
SC/PHC/CHC
725
57,363
1,63,181 (99-RHS)
Beds (Pvt & Public)
117,198
569,495
8,70,161 (95-96-CBHI)
Doctors(Allopathy)
Nursing Personnel
61,800
18,054
2,68,700
1,43,887
5,03,900 (98-99-MCI)
7,37,000 (99-INC)
14

Encouraged by the said achievements, threshold levels were raised and new goals were set as
followsGoals to be achieved by 2000-2015:
Eradicate Polio and Yaws
Eliminate Leprosy
Eliminate Kala Azar
Eliminate Lymphatic Filariasis
Achieve Zero level growth of HIV/AIDS
Reduce Mortality b y 50% on account of TB, Malaria and Other Vector
and Water Borne diseases
Reduce Prevalence of Blindness to 0.5%
Reduce IMR to 30/1000 And MMR to 100/Lakh
Increase utilization of public health facilities from current Level of <20
to >75%
Establish an integrated system of surveillance, National Health
Accounts and Health Statistics.
2005
2005
2010
2015
2007
2010
2010
2010
2010
2005
Health Care System s in India

1. Public Sector
a. Rural Health Scheme
i.
Primary Health Cent ers
ii.
Sub-Health Centers
b. Hospitals/Health Centers
i.
Community Health Centers
ii.
District Hospitals
iii.
Apex Hospitals
iv.
Teaching Hospitals
c. Healt h Insurance Schemes
i.
Employees State Insurance
ii.
Cent ral Government Health Scheme
d. Other Agencies
i.
Defense Medical and Healt h Services
ii.
Railways Medical and Health Services
2. Private Sector
a. Hospitals and Nursing Homes
b. General P ractitioners
c. Medical Insurance
Health sy stem operating in India
The systems in operation in India are classified based on Nature/ Philosophy or Services as followsPhilosoph y of Service s:
1. Official / Allopathic
2. Indigenous/Traditional
a. Ayurvedic
b. Unani
c. Homeopathy
d. Naturopathy
e. Siddha
f. Chinese
g. Tibetan
h. Yoga & Medit ation
i. Hypnosis
15

j. Divination & Exorcism

k. Individual therapies like
Nature of service
1. Indigenous- in rural areas
2. General care- for poor
3. Speciality
4. Corporate- for elite class
Modern medicine (concepts: Hippocrates, Gelen, Lind, J. Graunt, J. Snow, L. Pasteur, William Bud,
Robert Koch,)
Strength s
1. Systematic approac h
2. Search for cause & causal association
3. Data base
4. Powerful pharmacopeia
5. Diagnostic technology
6. Quick
7. interventional procedures
8. Epidemiological developments
Weaknesse s
1. Cost
2. Isolated-anat omical approach
3. Dependence on technology
4. Human touch
5. Iatrogenic diseases.
6. Irrational drug us e
7. Voracious resource eat er
8. Western
Health sy stem classi fied in relation to traditional medicineEx clu sive (tolerant): UK, Germany
Inclu sive:
India, Pakistan, Burma, Sri lank a, Bangladesh, Thailand
Integrated:
China, Nepal
Health sy stem s in India (Inclusive)
Official/ Allopathic
-Cost
-Coverage
-Coordination
-Cult ure
Traditional (ethno / alternative/ indigenous/ unofficial)
-Roots
-Res pect
-Reach
-Rural
-Renaissanc e
-Role
16

The fragmented approach t o health continued for quite s ome time till the stubborn c omplac ency was
dropped at Alma Ata in 1978 where a global concern by all member countries converged to a goal of
Healt h for All by2000 (HFA-2000).
The basic strategy adopted was primary health care in order to make t he health care services
Acceptable, A vailable, Accessible, Affordable, Appropriate through Equitable distribution and
Community Participation. It was further appreciat ed, during the process of evolution of National
Healt h Policy (1983) that in order to reach masses with primary health care approach, a large number
of manpower shall be required for which practitioners of Traditional medicine, with roots and respect
in community, can be of great help.
Over period of last 62 years, some of the laudable achievements area. Decrease in Crude Deat h Rate
b. Decline in Crude birth rate
c. Increase in Life expectancy
d. S.pox & G. worm eradicated
e. Leprosy eliminated
f. Reduction in IMR
g. Infrastructure expanded
Public Health Governance in India:
National Development Council
Highest constitutional Policy making body to approve Policies and strategies for development
Composition:
ChairmanPM
MembersCentral Ministers
Chief Ministers
Lt. Governors & Administrators of UTs
Dy. Chairman & members of Planning Commission
Planning Commission Composition: ChairmanPM
Dy. Chairman
Members
5-7 (Full time)
2-3 (Part time)
Function s:
1. Assess & augment resources-mat erial, capital & human
2. Formulate Plan for utilization of res ources
3. Decision on priority based phas ed implement ation
4. Decide on nature of executing mac hinery
5. Periodic progress review
6. Make appropriate interim recommendations
Role of Central Govt. in Health:
1. Policy formulation
2. Maintaining International health relations
3. Administration of central health institutions
4. Regulating Medical educ ation through statutory bodies-MCI/DCI/ Councils
5. Medical & Public health research-funding
6. Standards (Drugs/Education)
7. Coordination-Ministries/States/Statutory bodies
17

8.
9.
Cent ral Health Acts

Negotiation with International agencies
Population Grow th in India-
Total Population in Lacs

Year
Male
Female
Total
Sex Ratio
1901
1207.9
1173.6
2384
972
1911
1283.9
1237.1
2520.9
964
1921
1285.5
1227.7
2513.2
955
1931
1429.3
1357.9
2789.8
950
1941
1636.9
1546.9
3186.6
945
1951
1855.3
1755.6
3610.9
946
1961
2262.9
2129.4
4392.3
941
1971
2840.5
2641.1
5481.6
930
1981
3533.7
3299.5
6833.3
934
1991
4393.6
4070.6
8464.2
926
2001
5321.6
4965.5
10286.1
933
12000
Population: India
10286.1
10000
8464.2
8000
6833.3
5481.6
6000
4000
2384 2520.92513.22789.8
3186.63610.9
4392.3
Male
Female
Total
Poly. (Total)
2000
0
1901 1911 1921 1931 1941 1951 1961 1971 1981 1991 2001
Health and Vital stati stic s:

India
CBR
22.8
CDR
7.4
Growth Rate
15.4
IMR
53
MMR
254*
Source: SRS bulletin October 2009.
*Special bulletin on MMR SRS -2004-06
Rajasthan
27.5
6.8
20.7
63
388*
18

Health Infrastr uct ure:

The recommendations of Health
survey and Development Committee
(Bhore
Committee)
asked
for
expansion of the Health care delivery
system in phases with Primary Health
Cent ers as the nodal points of service
delivery.
Subsequently a 3 tier structure (SCPHC-CHC) was adopted for Health
care in the Country.
Somehow, the initial response on this
account had been very sluggish and
for first 3 five year plans we did not
have a single Sub-cent re, PHCs were
not functional till 1961 and there was
not a single CHC till 1971
By the end of March 2008 (under XIFYP) there were 146036 SCs, 23458
PHCs, and 4276 CHCs.
Out of these, 54% of SCs, 84% of
PHCs and 91% of CHCs were housed
in Govt. buildings by March 2008
Sub-centers over FYPs

137311
145272
136258
160000
140000
120000
100000
80000
60000
40000
20000
0
130165
84376
33509
0
II
III
IV
47112
VI
VII
VIII
IX
Five Year Plans
PHCs over FYPs

25000
22149
20000
22875 22370
18671
15000
9115
10000
5283 5484
5000
2565
0
I
Rajasthan (Jan,.2010) has 11448 SC,

1503 PHCs and 368 CHCs along with
33 District Hos pitals, 6 satellit e
hospitals,12 Sub divisional hospitals
and 199 city dispensaries
II
III
IV V VI VII VIII
Five Year Plans
IX
CHCs over FYPs

5000
Health Manpower:
The targeted doctor population norm
of 1:1000 (WHO) means at least
600,000 more doctors are required for
the country based on population
projections of 2008.
4045
4000
2633
3000
3054
1910
2000
1000
761
0
214
I
II
III IV
V VI VII VIII IX
X
Likewise the total no. of Dentists
registered stands at 72497 against the
Five Year Plans
required number of 282130 as on
December 2007.(WHO norm 1:7500 pop.)
While the ideal population of nurses should have been 2, 188,890 in 2007, only 1,156,372 nurses
were available.
There were 550958 ANM, 993256 GNM and 51498 LHV as on March 31, 2008(INC)
19

The Bulletin of Rural Health Statistics

No. of Doctors registered with State Medical
in India shows that while there has
800000
Councils
been a 66% rise in reported ailments
Source: CBHI NHP, 2007
between 1995-96 and 2004-05, the
bed density has actually gone down to
600000
0.86 from 0.93 during the same period
as the population growth was not
India
400000
matched with bed compliment. This
doesnt augur well for the country,
Rajasth
considering t hat the growth of in200000
an
patient numbers (6%) will be higher
than the growth of out-patient numbers
(2.7%) between 2007 and 2017,
0
according to a projection by Crisil
2000 2001 2002 2003 2004 2005 2006 2007
research.
The ideal recommended Bed: Population ratio of 5:1000 (W HO) is a distant dream for majority of
countries and the current world average rests at 2.6 beds per 1000 population.
Physicians per 1,000 population
0.60
2005
No. of Nurses per 1,000 population
0.80
2004
No. of Midwives per 1,000 population
0.47
2004
No. of Pharmacists per 1,000 population
0.56
2004
Source: World Health Report 2006
Health Expenditure as % of total Plan Outlay

Source: CBHI, NHP, 2006
6.5
2007-12
2002-07
1997-02
1992-97
1991-92
1990-91
1985-90
1980-85
1979-80
1974-79
1969-74
1969-74
1961-66
3.4 3.1 2.9 3.2 3.9 3.1 2.8 3.1 3.1 2.9 2.9 3.2 4.093.97
1956-61
8
6
4
2
0
1951-56
Health Ex penditure:
From 3. 4% of the total plan
expenditure under First Five Year
Plan, the Health expenditure has
shown just a marginal increase in XFYP where it was 3.97% (CB HI,
2006).However,
the
total
Govt.
expenditure on Health as % of GDP
had an increase from 0.22% in 195156(First FYP) t o 0.9% in 2002-2007(XFYP).
National Commission on Macroeconomics & Health reported per

capita Health expenditure as INR 1377 and 808 for India and Rajasthan respectively for year 200405.
India spends 5% of GDP on health but the total pulic spending on health is just 0.95% and WHO
(2007-08) ranked India at no. 171 out of 175 countries in this regard. With 80% of health care
spending in private sector which is largely unorganized and unregulated
20

1377
Health Care Spending (2004-05)

Source: NCMHGI, 2005
1400
1200
808
1000
India
Rajasthan
800
600
400
22
73.5 70
200
24.5
4.5
5.5
0
Per capita
expenditure
Household
Public
Other
Burden of Di sea se
Diseases
ARI
2005
Cases
/lac
2349
Deat hs
/lac
0.375
2006
Cases
/lac
2351
Deat hs
/lac
0.336
2007
Cases
/lac
2319
Deat hs
/lac
0.616
Diarrhea
1002
0.196
918
0.286
974
0.319
Pneumonia
71
0.321
61
0.300
66
TB
Malaria
118
166
5154
0.088
126
161
5803
0.153
Viral
Hepatitis
Polio
17
0.066
14
0.062
Diabetes
31039
932
35886
789
11.2/1
000
CHD
Blindness
2008
Cases
Deat hs
25541645
4681
11231039
2841
0.306
720454
3765
131
134
5744
0.116
911739
1366517
878
10
0.048
90440
510
874
35
559
(568,Nov.09)
30
Source: CB HI
21

Organization stru ctu re of Health care System: Rajasthan
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3-Tier health Structure of Health Care Delivery Sy stem:

CHC
(30 bedded unit, Pop. 80000-120000, covering 4 PHCs, with specialized care)
Staff streng th
MOStaff NurseDresserPharmacistLTRadiographerWard BoyDhobiSweepersMaliChowkidarAyaPeon-
(25)
4
7
1
1
1
1
2
1
3
1
1
1
1
Under IPHS propo sed Staff strength (64)

Specialist s
Block Health officer1
Ob. & Gy.*
1
Surgeon*
1
Phy sician*
1
Pediatrician-*
1
Anesthetist
1
Ophthalmologist
1 (1 for 5CHC)
Dentist
1
Public Health Manager
1
GDMO
6 (2 LMO)
AYUSH
1
AYUSH-GDMO
1
Staff Nurse19
PHN1
Ophth.Asstt.1
ANM1
Support staff
Facilities:
Entrance Zone and OPDs
Emergency Room/Casualty
Treatment room (minor OT, Injection / dressing room )
Wards- male and female
Labor Room and Operation theatre
Blood Storage unit.
Laboratory
X-ray and ECG
Other Servic es
Electricity with Back-up
Water:
Separate toilets for male & female
Telephones
Maintenance and sanitation facility
Computerization for record and
surveillance.
*Minimum required
25

PHC
(Referral unit for 4-5 SC, pop.-20000-30000, 4-6 beds)
Staff streng th
MOStaff NurseHW (ANM)HA (M)HA (F)HEUDCLDCLTClass IVPeonDriver-
SC
(15)
1
1
1
1
1
1
1
1
1
4
1
1
Under IPHS propo sed Staff strength (24/

25)
MO
AYUSH
PharmacistsStaff NurseAccounts MangerHW (ANM)HEHA (M)HA (F)LTClass IVPeonDriver-
3 (1 LMO)
1
2
5
1
1
1
1
1
2
4
1
1-2
(Most peripheral unit covering 4-5 villages, Pop.-3000-5000)
Staff streng th (2)

HW (ANM) 1
HW (M) 1
Propo sed Staff st rength

(3)
HW (ANM) 1
HW (M) 1
Additional ANM-1
Voluntary w orkers
AWW- 1
ASHA- 1
JMC-1
26

National Health Programs

Major:
National
National
National
National
National
National
National
National
National
National
National
National
AIDS Control Program

Cancer Control Program
Diarrheal Disease Control Program
Filaria Control Program*
Family Welfare Program
Iodine Deficiency Disorders Control Program
Leprosy Eradication Program
Malaria Eradication Program*
Program for Control of Blindness & Visual Impairment
Reproductive and Child Healt h Program
Program for surveillance of Communicable diseases
Tuberc ulosis Cont rol Program (Revised)
Minor:
National
National
National
National
National
Mental Health Program

Japanes e Encephalitis control Program*
Diabetes Cont rol Program
Kala-azar Control Program*
Water Supply and Sanitation Program
Prologue:
A Program is a strategy w ith defined Objectives; where as the Policy i s a w ritten statement of
objectives and ex pected outcomes.
In the process of planning (a pr ocess o f choo si ng between alt ern ativ es to acc omplish the
desired ) using the input of data/ information the Program is an output with intentions, implementation
and introspection as inherent elements.
In context to Health, basically all Programs are addressing to either
1.
A Disease
2.
A Behavior, or
3.
A Development issue
Environmen t
NGCP
NWSSP
A gent
Host
RNTCP
MAP
NL EP
UIP
HIV/AIDS
NFWP
NPCB
27

Disease
Behavior
Developm
ent
NMCP1953
NFCP1955
NLCP1955
NTCP1962
NPIDD
NFPP1953
NWSSP
5-Yr. Plan
Pd.
I
1951-56
II
195661
III
196166
% of total
plan outlay
3.3
3.06
2.63
IV
196974
(66-69
annual
plans)
NPCBI1976
(Trachoma1968)
NCCP-1976
NGEP1983
NLEP83
NDDCP-
EPI-1978
UIP1985
AIHPPP1970
MNP
20-Point
Program
V
1974-79
2.45
NACP1987
NMHP-
ARI1992
RNTCP1993
NSPCD1997
CSSM1992
RCH1997
VI
1980-85
(79-80
Plan
Outlay)
VII
198590
(9091&
91-92
Annual
Plans
VIII
1992-97
IX
19972002
1.87
3.69
(0.98%
of
GDP)
1.76
0.9%
Majority of programs address to either Agent or Host and hardly any attention has been paid to
environment despite the realization that manipulation of environment helps in identifying and breaking
the weakest shackle in the transmission chain that too in a cost effective manner.
Those addressed to environment yielded results (e.g. NGCP ), those addressing to agent are still
caught up in vortex of paradigm shifts (NMCP to NMEP to MOP to MAP and, NTCP to RNTCP with
changing strategies from DOTS t o DOTS-plus. Addressing to behavior (NFWP and HIV/A IDS ) is a
slow process but once successfully modified the dents made shall be permanent.
Program processMajority of these Health programs are basically Disease programs; addressed as National Health
Programs, But, then that is how it is; after all the working definition of Health is also based on
deducing inferences.
The second largest Program (RNTCP) and the First (NFPP/ NFWP) address to agent and human
behavior respectively; unfortunately the first one has started defying (emergenc e of MDR-TB ) and the
seconds growth has been stagnant (measured in terms of TFR over last two decades).
The fact here to be appreciated is that despite the provisions existing to address a public health
problem, a strong Political commitment is an equally strong catalyst to start and sustain a program
at National level.
The evolution of National Health Policy (1983), subsequent t o Alma-Ata Declaration (1978) is an
empirical example of the earlier statement and absence of National Rabies Control Program, hitherto,
is a point in case.
28

Healt h per se had a fragmented approach till 1978 when Global conc ern dictated in favor of HFA2000 and, with a little longer latent period at last, a National Health Policy (1983) was formulat ed.
It is not that nothing was done till 1983 or that the Programs could not achieve any thing. The table
below clearly shows what was ac hieved despite the constrained approach. We have seen Small pox
eradicated through the same infrastructure, and Human resource. Somehow, the frequent Paradigm
shifts (e. g. Age at which BCG vaccine is to be administered) have made the system cluttered and
indifferent.
After formulating the national family welfare program, India has:
1. Reduced crude birth rate (CBR) from 40.8 (1951) to 22.8 (2009, SRS );
2. Halved the infant mortality rate (IMR) from 146 per 1000 live births (1951) to 53 per 1000 live
births (2009, SRS );
3. Quadrupled the couple protection rate (CP R) from 10.4 percent (1971) to 56 percent (NFHS
III);
4. Reduced crude deat h rate (CDR) from 25 (1951) to 7.4 (2009, SRS);
5. Added 27 years to life expectancy from 37 years to 64 years;
6. Achieved nearly universal awareness of the need for and methods of family Planning, and
7. Reduced total fertility rate from 6.0 (1951) to 2.7 (NFHS III).
Incidentally, by any scale, these are no mean achievements yet they do not offer any room for
complacency if NHP -2002 and NPP-2000 goals are kept in mind.
Program Component s:
Each of the programs here shall be dealt under following heads
1.
2.
3.
4.
5.
6.
7.
8.
Need
Goals & Objectives
Strategy
Approach
Activity
Indicators
Monitoring & E valuation
Financing
29

Reproduc tive and Child Health Program

What is RCH?
Reproduc tive health refers to a state w here people can1. Reproduce and regulate their fertility,
2. Women go through pregnancy and childbirt h safely,
3. Outcome of pregnancy is successful in terms of maternal and
infant survival and well-being, and
4. Couples are able to have sexual relations free of the fear of
pregnancy and disease.
Chronolog y of event s that led to RCHNFPP-1951
NFWP-1977
Alma Ata-1978
EPI-1978
NHP -1983
UIP-1985 (the success story of unified approach and micro planning)
CSSM-1992 (the first program officially launched by President of India- an example of national
commitment)
ICPD-1994 (international concern for women, gender equity and social justice) at Cairo
Beijing conference-1995
RCH-1997, Oc tober
RCH-II (2005-06 -2009-10)
Reproductive & Child Healt h program is a model developed through experiments in paradigm shifts,
as shown belowClinic approach
Extension & Education
Cafeteria/ Targets
Comprehensive service delivery approach
Primary health care (1983)
Targeted int erventions-Target couples and Eligible couples
th
Target free approac h (1996) adopted in 4 meeting of Cent ral Council of Health & Family Welfare
Quality services & Policy reforms
Community Needs Assessment Approach (1997-98)
Capacity enhancement,
30

Instead of Targets passed from National epicent er to periphery the shift was towards setting goals
through a participatory proc ess involving all stak e holders and the approach was bottom up with
concern towards quality of care.
April 1996
National
State
District
PHC
Sub-Center
Targets
Goals
Participatory planning, Community
Involvement & Quality of Care
The Need:
The RCH Program was conceived in view of the need fora. Unified approach
b. Convergence for integration
c. Performance in relation to Goals & Timeframe
d. Shuffling priorities-P aradigm shift
e. Fertility regulation & Replac ement goals
f. High Unmet needs
g. High Morbidity/Mortality in women & children
Objectives:
1. Reduction in Birth Rate to stabilize population- Empowering women through informed
decisions
2. Integrating efforts of related programs to bring in meaningful convergenc e
3. Meeting unmet needs through institutional strengt hening & Quality of Care througha. Choic e of methods
b. Information provided to clients
c. Technical competence of providers
d. Interpersonal relationship bet ween Clients & service providers
e. Mechanism to ensure continuity of Care
f. Constellation of service appropriate to need of users
Program component s and activities:
1.
CSSM intervention s-Child / Mother

a)
Child Survival activities
i)
ii)
iii)
iv)
v)
Care of New borne

(1)
Eye, Cord, Bath & Feed
(2)
Special care & Referral conditions
Immunization
Vitamin-A (9 dose prophylaxis)
Diarrhea-ORT & A RI
(1)
Standard case definition & management
Support Activities (1)
Cold chain
31

(2)
(3)
b)
i)
ii)
iii)
iv)
2.
3.
4.
5.
6.
7.
8.
Supplies
Surveillance
Safe Motherhood interventions

Essen tial Obstetric care(1)
Early registration of pregnancy (12-16 weeks)
(2)
ANC (3 visits)
(3)
TT (2 or Booster)
(4)
IFA (100 Tab.)
(5)
Delivery by Trained Birth attendants (TB A) observing 5Cs
(Term TBA, now stands replac ed by SBA- (Skilled Birth Attendant)).
(6)
Institutional, if complicated
(7)
Referral for emergencies-conditions, time-frame& place
(8)
PNC (3 visits)
(9)
Spacing 3 yrs.
(10)
STI/RTI-Mgt. As per S TD control component under NA CP
(11)
Adolescent Reprodu ctive health(12)
Counseling/IE C based on Life cycle approach
Emergency Obstetric care
Strengthening Referrals
Training of TBA
RTI/S TDs (including HIV/A IDS )

Adolescent Reproductive Healt h
FP Services
Modified Mgt. Information Sub-System
IEC & Couns eling
Referral
Community Needs Assessment Approach (CNNA)
Approach :
The strategic approach in RCH program is based on1. Integration of all related components/ interventions/ programs
2. Differential strategy bas ed on
a. Crude Birth Rate
b. Female Literacy rate, based on which the districts have been put under
i.Category -A (low CB R, high Literacy) (58)
ii.Category -B (moderate CB R, moderat e literacy)(184)
iii.Category -C (High CB R, Low literacy)(265)
The approach has two components1. Policy reforms package in relation toa. Monitoring & E valuation
b. Institutional strengthening
c. Service delivery
2. Capacity enhancement througha. Infrastructure
b. NGO support
c. Village workers
d. Women Health committees
32

Acti vities under RCH:

1. Univer sal intervention s w ithout any differentiationa. CS & SM interventions
b. Operationalization of CNAA
c. Institutional development
d. Modified Management Information sub-system
e. IEC & Couns eling on Health, Sexuality & Gender
f. Urban & Tribal area RCH package
g. District sub-projects for capacity enhancement
2. Additional service s in selected States & Di stric t sa. Improving Institutional Delivery & Emergency care Equipment / IUD / Drug kits
b. Screening & Treatment of RTI/S TI ini. 3 FRUs - A, (FRU=First Referral Unit)
ii. 2 FRUs - B,
iii. 1 FRU of C
c. Emergency Obstetric Care
i. 2 FRUs of B ,
ii. 3 FRUs of C
d. Essential Obstetric. Carei. Drugs & PHCs in B & C and
ii. Cont ractual PHN/Staff nurse in C
e. Additional HWF in 30% S/C of C of 8 States
f. Rent al to Contractual P HNs/Staff Nurse
g. Referral Transport facility-25%S/C of C Districts of all States
h. Service strengthening-inputs fori. Mobility,
ii. Supervision,
iii. Micro-planning (50 Districts in 8 States)
i. Dai training-142 Districts with < 30% safe delivery
j. RCH Camps in remote/under-utilized PHCs
k. Border Cluster project-46 Districts in 16 States to have addl. Inputs
CNA A (Communi ty Need s A sse ssment A pproach ) & RCH:
The difference bet ween perception and Feeling of a need made a huge difference to Maternal &
Child Health in general and Family Welfare Program in particular. This was realized during ICPD
(1994) that people should be left to freely and responsibly decide, based on informed choices, about
the number of children and spacing between two births.
Earlier to the international initiative, The Committee on Population in National Development Council
(NDC) in 1993 recommended that there is a need for
1. Decent ralized area specific planning based on Local Needs
2. Creation of a District level Data base on:
a. Quality,
b. Coverage,
c. Impact indicators; for monit oring & E valuation.
33

The rational of the CNAA approach can be summarized asFamily Planning / Welfare ObjectiveStabilize population
Targets a s an end
Reduction in Births
Administrative &, Performance pressure
Informed decision
Client driven
Resentment, Disownment
Quality?
Some how the TFA (Target Free Approach) was sending a wrong message among field functionaries
and that led to baptizing it as CNAA with key words like Quality & Client Satisfaction.
The purpo se of CNAA1. Setting Priorities
2. Identify Target and High Risk groups
3. Estimation of Service needs and matching it with Resources
4. Develop a realistic action Plan
Key issue s in CNAA1. Micro-planning
2. Community involvement
3. Clients perspective
4. Quality of Care
Process of CNAAThe process focuses on Participatory Planning based on:
1. Felt Needs
2. Actual workload assessment
3. Assess Capacity of Providers
4. Involve people for better Utilization
The process stresses on Speak to People, Get through Records and Take up surveys to make a
Community diagnosis.
The process steps are1.
Develop teams involving local people- (support team & consultative team)
2.
Organize meetings for decision on service delivery
3.
E valuate need for each Health & Family Welfare service
4.
Share it with people
5.
Develop an Action Plan
6.
Sub-Center Action plan: Steps
i. Interview people- house to hous e
ii. Involve AWW/MSS/Link persons
iii. Validate information-cross check
iv. Up-date E CR (Eligible Couple Register)
v. Compare vital information
vi. Develop Action Plan
34

7.
PHC Action plan: Steps

i. Cons olidate S/C plans
ii. MO/IC Calculate requirementsa. Routine
b. Additional relevant items
8.
CHC Action plan: Steps
i. Check list of services provided
ii. Assess / calculate matching requirements
9.
District Action plan: Steps-Consolidation
10.
State Action plan: Steps -Compilation
Problems
Focused around peoples participation to empower them in decision-making, process of CNAA is slow
for the following reas ons1. Medical fraternity had been too assertive,
2. Program carries a vertical structure,
3. Inter sectoral coordination is missing,
4. The stress is on infrastructure rather than on functions,
5. Information requirements meet with the indifferent attitude of providers,
6. States with their own reservation have been slow in reacting and matching with the pac e that GOI
7. Regular monitoring at State level is missing
8. Medical Offic ers are reluctant to discuss with field staff and PRIs (Panc hayat Raj Institutions)
9. Providers still decide the best for clients (Informed choices v/s Client segmentation)
10. Performance measurement tools are missing
11. Multiple entries in 3 different records
13. Unnecessary dat a collection
RCH-II (2005-06 to 2009-10)
Goals and Objective s
Indicator
IMR
U-5 MR
Tenth Plan Goals

(2002-07)
<45/1000
-
RCH Phase ii
Goals(2005-10)
<30/1000
-
NPP
2000
(By 2010)
<30/1000
-
MMR
TFR
200/100000
2.3
<100/100000
2.1
<100/100000
2.1
MDG
Reduce by 2/3 from
1990 levels
Reduce by by 2015
-
The overall goal of RCH program is to reduce infant and maternal morbidity and mortality in the state.
These goals will be achieved through improvement in quality, enhancing accessibility and availability,
and coverage with the reproductive and child health services, including family welfare. The program
emphasizes empowerment of women and communities for enhancing health service utilization to
achieve reproductive goals and population stabilization.
Indicators
Infant Mortality Rate (IMR)
Goal of Rajasthan up t o 2011-12

32
Maternal Mortality Ratio (MMR)
148
Total Fertility Rate (TFR)
2.1
Crude Birth Rate (CBR)
21
Crude Death Rate (CDR)
35

Issue s raised during RCH I

a. One size fits all approach
b. state/district level requirements not accounted
c. adequate program management skills missing amongst professionals
d. Planning, monitoring, budgeting and resource allocation did not match program objectives
e. Frequent turnover (trans fer and retirement )
f. result/outcome orientation missing
g. Human Resource planning neglected
h. Financial/ accounting/disbursement and utilization bottlenecks
i. generic BCC
j. focused and thematic approach missing
k. Low utilization of public health facilities
l. Complaints against insensitive providers
m. Hidden cost incurred by users
n. Limited choices for clients
o. No convergence between related sectors
p. Fragment ed approach
q. Duplication
r. Loss of opportunities to achieve effectiveness
Key issue s and strategies for RCH II
1.
Flexibility: States needs and capacities
a. Planning will be based on the analysis of state level requirements as assessed from
district level requirements
b. Different approach based on state specific scenarios
c. Encourage and gather evidence for decent ralized planning at the state level
d. Plans to be prepared by states based on the overall guidelines provided by the
national framework
e. Special attention to states facing the biggest socio demographic challenges
2.
Strengthening management capacity
a. Program management structures with provision for on contract professionals
b. Capacity building in program management
c. Monitoring systems to be introduced
d. Structures to provide for functional specification in planning etc.
e. Review and adoption of HR planning, transfer, promotion policy
f. Infusion of qualified finance professionals and overhauling of the traditional
accounting system to make it faster yet easier to monitor
3.
Integrated Behavior Change Communication (BCC) st rategies
a. Emphasis placed on development of a BCC strategy
b. Overall national priorities and desired behavior change to guide the framing of the
strategy
c. Based on the national BCC strategy states to adapt/adopt it to develop state specific
objectives and strategies
d. Emphasis on viewing BCC as a driver to change and adopting this to impact the
drivers impacting on the outcomes
e. Trained human resources and partnerships with NGO/ CBO needed
f. Linkages of the present IEC structures would be reckoned
g. Tracking IEC input and output linkages for optimal utilization of the IE C resources
h. Emphasis on increasing the health/life skill issues in the syllabus of elementary and
secondary education
36

i.
4.
Accessing all available channels for dissemination of Health Values, Hygiene,

HIV/AIDS, No to Early Marriage, No to Gender Violence, No to Female Feticide
Improved client respon sivene ss to pu blic health facilities
a.
b.
c.
d.
e.
f.
g.
h.
5.
Reviews of responsiveness and service quality

Taking into account both the users and providers perspective
Strategies for responsiveness
Option for demand generated interventions
Monitoring service quality
Systematic efforts to improve quality through training, BCC, evaluation and feedback
Working on a private partnership protocol
Convergence and converting single doctor sub-optimal PHCs to at least two doctor
FRUs.
Convergence w ith other critical sector s
a. Inter-relations between sectors have been considered

b. Build in co-ordination at state levels and below
c. Coordination with National AIDS Control Program (NACP)
d. Coordination with Integrated Child Development Services (ICDS)
Result Framew ork:
Outcome
indicators
Desegregated
by
Baseline
2003-04
(%)
% of eligible
couples using
modern
contraceptive
method
% of eligible
couples using
any modern
contraceptive
method
%
of
deliveries
conducted by
skilled
providers
% of 12-23
months
children fully
immunized
Permanent
Methods
Spacing
Methods
34
35
36
11
12
16
Overall
SC/ST
45
41
47
52
45
EAG States
33
35
40
Overall
SC/ST
48
35
55
40
60
45
EAG States
32
35
45
Female
44
60
75
Male
45
60
75
Overall
SC/ST
45
39
60
50
75
75
EAG States
overall
28
<10
45
20
60
40
10
states
have
polio
Over
30
states
polio
free
All
states
polio
free
% of mothers
& newborns
visited w ithin
2 w eeks of
delivery by a
trained
worker
Polio
free
status
achieved
Objectives set to be achieved

2005 2006
2007 2008
(%)
(%)
Data collection and reporting

Frequency Data tools
of
reporting
Annual
MIS
HH
Annual
Surveys
Independen
t Evaluation
Annual
Mid ter m &
end line
Annual
Responsibility
for
data
collection
M&E Division,
MOHFW;
IIPS
RCHOs
Annual
Mid ter m &
end line
Annual
Mid ter m &
end line
Mid ter m &
end line
Annual
Mid ter m &
end line
Annual
Annual
Annual
NPSP
37

Other focu s areas

a. Targeting of services
Define essential services for the poor and the vulnerable
Review physical and financial performance against such priorities
Resources to be used mainly to finance essential servic es that address the needs of
the poor
Need-based/performance-based financing
b.
Strengthening service delivery

Provide quality, accessible and client sensitive servic es
Enabling contracting of staff, mobility support and contingency
Support to servic e providers and clear mandates on supervision
Focus on essential services and improve utilization
c. Infrastructure and maintenance
The assessment of potential utilization is the key determinant for creation of
infrastructure
Complementary factors such as power, water, approach roads and communication to
be strengthened through convergence and networking with other sectors
Strategy for infrastructure developed.
d. Supply of drugs and equipment
In consonance with essential drugs policy
Estimation bases developed to assess requirements
Logistics management strategy developed
e. Healt h care providers
Appraisal of options of the role, scope and potential for part nership with the private
sector and NGOs
Enhance the privat e-public partnership mechanism through win-win situations
These strategies outlined above would lead to the achievement of the vision in the
long-term
f. Improved transparency and efficiency in procurement of goods and services
Strengthening the implementation of good manufacturing practices to ensure supply
of quality pharmaceuticals
Ensuring better competition and price by undertaking periodic surveys to get more
reliable information about the market
Strengthening logistic systems to deliver quality goods and services in a timely
manner to the end users
Promoting transparency in procurement and disclosing information on procurement
actions
Acti vities under RCH II in Rajasthan
1. Strengthening Project Management Structure at state and district levels
a. Re-organizing of Medical Directorate.
b. Renovation of Medical Directorate and NRHM/RCH-II cell.
c. Setting up, of the PMU at state & district levels.
d. Induction of newly appointed professionals done on program management and
interventions.
e. Support for communication, equipments and mobility to DPMUs.
38

2. Strengthening Infrastructure at various levels of health service delivery

a. Upgrading of P HCs as BEmOcs.
b. Provision of blood storage at 26 identified CEmOcs of IP D districts to make them fully
functional.
c. Support for equipment and labor tables at 25% PHCs.(10000.00 Rs. Per Institution)
d. Support for minor repair and renovation of public facilities at 50% PHCs. (25000.00 Rs.
Per Institution)
e. Facility survey of all P HC and CHCs.
3. Human resource development and capacity building
a. Development of annual training calendar.
b. Strengthening of ANMTCs.
c. Support medical colleges for Anesthesia trainings.
d. Library at SIHFW & Medical Directorat e.
e. Orientation of AYUS H Doctors on National Programs.
4. Improving quality of care and Strengthening Referral System
a. Study on referral system by RHSDP
b. 7 days Mobility support to PHC MOs
c. Installation of new telephone connection at all PHC/CHCs.
d. Work shops for developing standards and protocols for quality of care.
5. Strengthening and improvement of logistics and supply systems
a. Feasibility study to s etting up of the drugs and logistics warehousing has been done
under E uropean Commission S IP program. A c ommittee to finalize the modalities behind
the setting up of Drug Corporation has been set up at the state level.
b. Support for the repair of workshop for cold chain equipment has been provided for Jaipur.
c. Support for hiring 12 new refrigerator mec hanics has been provided to district where such
positions are vac ant.
6. Strengthening Health Management information system (HMIS), monitoring and evaluation
a. Support for CNNA format, ECS has been provided from state level.
b. Integration of RCH-II/ NRHM reporting format in existing HMIS software.
c. Baseline and concurrent evaluation.
7. Behavior Change Communication for increasing demand for RCH and contraceptive services
a. Intensive IEC for RCH-II and NRHM interventions.
b. Provision for hiring of IEC van in all districts.
c. Implementation of Integrated Media Plan.
d. IEC for Panchamrit program done by printing of booklet, Banners, cards.
8. Specific Interventions
a. Maternal Health:
i.
RCH camps target:
ii.
Dai training target:
iii.
Night delivery facility at all PHCs and CHCs.
iv.
Hiring of contractual staff (PHN & LT) at CEmOcs.
v.
Provision of 1321 additional ANMS at 10 desert and tribal districts.
vi.
STD/RTI drugs for PHCs.
vii.
Jannani Suraksha Yojna
b. Child Health:
i.
IMNCI launched in 9 districts.
ii.
Mal nutrition corner at all 237 blocks.
iii.
Purchase of ORS packets.
c. Adolescent Health
i.
AFHS training at 25% P HCs
39

d.
Family
i.
ii.
iii.
iv.
Planning
Improving quality of fix camps.
Compens ation scheme for sterilization.
Blood donation camps.
NSV mega camps
9. Strengthening Networking and Partnership wit h the civil society

a. Collaboration with IMA & FOGSI to build partnership to improve access and quality of
health care service in services.
b. Accreditation of Private nursing home for JSY.
c. MNGO scheme in all districts.
d. Annual consultation with stakeholders on NRHM.
e. Social marketing of contraceptives and other health services.
10. Innovative schemes and pilot projects
a. Pilot Project on Population stabilization initiated at Jhalawar & Tonk.
b. PARINCHE project for five districts.
c. A help line proposed at medical directorate for improving communication between field
level functionaries, districts and state level officers.
d. Campaign on Age at Marriage.
e. Medical Mobile unit for all districts.
f. VCTC at 16 CHCs.
11. Improving and strengthening RCH Services in Tribal population
a. Six districts, namely, Baran, Banswara, Chittorgarh Dungarpur, Sirohi and Udaipur will be
included as non-primitive tribal group districts under the project in addition to the tribal
population in the adjoining blocks of Jhalawar and Kot a district.
b. Process for developing PIP for six urban districts is under process.
12. Establishing and strengthening RCH services in Urban Area
The Program will address the urban slum population in Jaipur, Jodhpur, Kota, Bikaner, Pali,
Udaipur, Ganganagar, Hanumangarh, Bhilwara and Tonk cities.PIP for 8 urban slums is
under process.
40

National Family Welfare Program (NFWP):

India is the second most populous country in the world. India has 17 % of worlds
population and has less than 3% of eart hs land area. While the global population
has increased 3 times, India has increased its population 5 times during the last
century. Indias population is expected to exceed that of China before 2030 to
become the most populous country in the world.
1952, India was the first country to launch a national program emphasizing Family planning, wit h the
objective of reducing t he birth rat e to the extent necessary to stabilize the population at a level
consistent with the requirement of National economy and it was put in the concurrent list. Health
Policy, 1983 stated that replacement levels of tot al fertility rate (TFR) should be ac hieved by the year
2000.
On 11 May, 2000 Indian population crossed 1 billion (100 crores) mark which meant 16 percent of the
Worlds population on 2. 4 percent of the globe's land area.
Under this back drop for the first time a National Population Policy was formulat ed in year 2000 (The
earlier one of 1976 (April, 16) and 1977(June) were simply the statements on population policy put
before the Parliament).
The Program during first two 5-year plan periods (1951-56 & 1956-61) maintained a clinic approach
under which facilities for providing services were created. The second 5-year Plan period saw Target
approach to Family Planning that focused on Sterilization approach
The figures of 1961 census, however asked for a change in approach which was replaced by
rd
Extension and E ducation approach in t he 3 5-year plan (1961-66) period. During the same period
a separate department of Family Welfare was created.
th
The 4 plan (1969-74) accorded a high priority to program in terms of integration of Family Planning
services with MCH services and increased accept ance of contraceptive met hods and proposed to
reduce CB R from 35/ 1000 to 32/ 1000 by end of plan period. 16.5 million couples (16.5% ) were
protected from conceiving at the end of plan period. Also during this period Medical termination of
pregnancy bill was passed, Post Partum scheme started and 364 new PHC were opened with
marginal improvements in indicators.
The 5th Five year plan (1974-79) aimed to reduce CBR to 30/ 1000 by 1978-79. The record
performance in sterilization area under cover of targets and coercion during 1975-77, proved
detrimental. The NFPP was replaced by NFWP. Statement on National population policy was made
with salient feat ure like raise of age of marriage for men and woman from 15 t o 18 years for females
and 18 to 21 for males., Freezing of Peoples represent ation in legislatures and parliament on the
basis of 1971 census till 2001 and more central assistance to States on family planning.
The V I five- year plan (1980-85) stressed on long term goal of Net Reproduction Rate (NRR) of 1 by
achieving a reduction in average family size from 4. 4 to 2.3, reduction in CB R from 33 (in 1978) to
21/1000, reducing death rate from 14 to 9 and IMR from 127 to below 60 and increasing Couple
Protection Rate (CPR) from 22% to 60%.
th
All the goals remained elusive and what was envisaged for 5 plan could partly be achieved by end of
year 1990.
41

During the 7th five-year plan (1985-90) Family Welfare continued on voluntary basis and stressed on
promotion of spacing methods, community participation and promotion of MCH care.
th
The achievements were a little closer to what was thought of in 5 plan.

1. CBR reduced from 41.7 (1951-61) to 30.2 (1990-S RS),
2. TFR (Total Fertility Rate) dropped from 5.97(1950-55) to 3.8 (1990-SRS ),
3. IMR reduced from146 (1970-71) to 80(1990-S RS),
4. CPR increased from 10.4% (1970-71) to 43.3% (March,1990)
The 8th five-year plan (1992-97) int roduced many new schemes and revamped the ongoing ones in
Family Welfare. Some of the new schemes were1. Area Development Projects to upgrade infrastructure and develop trained manpower were
continued
2. India Population Project-VIII & IX start ed (IPP-V III to improve Health &FW services in urban
areas of Delhi, Kolkata, Hyderabad and Bangalore; while IPP-IX t o operat e in States of
Rajasthan, Assam and Karnataka)
3. Project on Innovations in Family Planning services was taken up in UP with assistance from
USAID with a specific objective to reduce TFR from 5.4 t o 4.0 and increasing CP R from 35%
to 50% over 10 years.
4. Differential planning scheme-90 districts with CBR over 39/1000(1991 census ) were identified
for enhanced financial allocation amounting to 50 lacs per district per year for upgrading
infrastructure (OT, Labor Room, Six bedded observation ward and Residential quarters for
Paramedical workers in 5 PHCs of each district per year) over 1992-93 to 1995-96.
5. Increasing involvement of NGOs in Family Welfare promotion for which 4 new schemes were
started.
6. UIP strengthened and extended as CSSM Project since 1992-93
7. Target Free Approach(TFA ) adopted in Family Welfare in 1996-97
The targets of VIII plan of National CB R of 26/1000 were achieved by all States except Assam, Bihar,
Hary ana, MP, Orissa, Rajasthan, and UP.
th
Under the 8 Five year plan greater stress has been laid on the involvement of NGOs to supplement
and complement the Government efforts.
9th five-y ear plan period (1997-2002) stressed on reduction in population growth.
The priority objectives laid were1. To meet all felt needs for contraception
2. To reduce IMR and Mat ernal Morbidity & Mortality for reducing fertility top desired levels
The Strategies identified were1. To assess the needs for RCH at PHC level and undertake area specific micro planning
2. To provide need based demand driven high quality integrated Reproductive and Child Health
services.
The expected levels of achievement by the terminal year of Ninth Plan (2002) are given below
Indicator
If current trend continues
CBR
IMR
TFR
CPR
NNMR
MMR
24/1000
56/1000
2.9
51%
35/1000
3/1000
If acceleration envisaged in Approach Paper to the Ninth Five

Year Plan is achieved.
23/1000
50/1000
2.6
60%
42

The efforts towards Family welfare have resulted in a decrease in CB R from 36.8 in 1970 to 25.8 in
year 2000 though the death rate decline has been relatively steeper.
Projected population as on 1st March 2001-2026 (in million)
Rajasthan
India
2001
57
1029
2006
62
1112
2011
68
1193
2016
73
1269
2021
78
1340
2026
82
1400
Empow ered Action Grou p sIn order to facilitate the preparation of area-s pecific programs, with special emphasis on eight states
that have been lagging behind in containing population growth(contributes 45% of the population of
the country) to manageable limits, the Government of India has constituted an Empowered Action
th
Group in the Ministry of Health and Family Welfare w.e. f. 20 March, 2001. The members of the
group consist of
Chairman -Minister for Health and Family Welfare,

Vice Chairman- Minister of State for H&FW, and are
Members- Secretaries of these 8 states,
Secretaries of different Cent ral Govt. Depts.
Advisor (Health) Planning Commission,
Other Central Govt. officials
Convener- Joint Secretary (P) D/O Family Welfare
Role of the EA G
The EAG will seek to facilitate the change process by:
1. Ensuring appropriate policy development at the Centre,
2. Provisioning for technical assistance to the member States,
3. Addressing issues of coordination between member states and departments, and
4. Deploying financial resourc es, as appropriate and feasible.
5. The Empowered Action Group will meet during the inter-session period at least twice a year,
first after the budget session of Parliament, during May-June, and then after the monsoon
session during October-November
Objectives1. Universal access to quality family Planning services so that the small-family norm becomes
a reality
2. Total coverage of registration of births, deaths and marriages
3. Full access to information on birth limitation methods and freedom of choice, especially to
women, for planning their families
4. Reduction of Infant Mort ality Rate to below 30 per thousand live births, incidence of low birth
weight and maternal mortality rate
5. Immunization against vaccine prevent able diseases
6. Elimination of incidence of girls being married below the age of 18
7. Increase in the perc entage of deliveries conducted by trained persons to 100 per cent
8. Cont ain Sexually Transmitted diseases, especially AIDS
9. Universalization of primary education and reduction in the dropout rates at primary and
secondary levels to below 20 per cent for boys and girls
43

10. To introduce information technologies and management information systems, at district and
sub-district levels, to monitor availability and access to contraceptives, drugs and vaccines as
well as to servic es, in the near and far flung areas
11. To improve the existing systems for logistics
12. To implement the paradigm shift in the management of programs for population stabilization
by incorporating diverse health care providers.
13. Accrediting private medical practitioners and assigning to them defined satellite populations
for whom they will provide basic health services;
14. Reviving t he system of licens ed medical practitioner; who can provide specific clinical
services, aft er appropriate certification;
15. Involving the non-medical fraternity;
16. Creating a network in thes e states of all manner of health facilities, identified by a common
logo, to provide reproductive and child health services free to any client;
17. Forming a consortium of t he voluntary sector, t he non-government sector and private
corporate s ector to aid government in the provision and outreach of basic reproductive and
child health care and basic education;
18. Mainstreaming Indian Systems of Medicine;
19. To position appropriate healt h care providers at every CHC/PHC/Sub-Centers in these states,
to target 24 hour service delivery at the primary health centers in these states;
20. To pilot convergence of service delivery at village levels, through self help groups, with the
help of the voluntary sector and the non-government organizations;
21. To finalize a t argeted campaign for information, education and communication in these states
that will involve the community, civil society, opinion leaders and political representatives,
from village levels upwards, for dissemination of advocacy, information and communication;
22. To energize the existing system of referral trans port ation, training of dais, and quality of
reproductive health care through a public private part ners hip;
23. To put in place intensive monitoring systems, inclusive of concurrent evaluation and reliable,
detailed household and facility surveys, through professional agencies;
24. To ensure implementation of district planning through the community needs assessment
reporting from each of the districts;
25. To align program and project delivery with advances in c urrent technologies in reproductive
research;
26. To pioneer projects for extending wider coverage and outreach of basic health care services
through the active participation of non-government organizations, the voluntary sector and the
private corporate sector, particularly in the area of referral transportation and improving
quality of care;
27. To explore t he possibility of expanding the scope of s ocial marketing of c ontraceptives in a
manner that mak es them easily accessible even while raising awareness level.
The efforts towards Family welfare have resulted in a decrease in CB R from 36.8 in 1970 to 25.8 in
year 2000 though the death rate decline has been relatively steeper.
Some of the steps imitated during X five year plan1. IEC in Family Welfare
2. Red Triangle
3. New Initiativesa. Professional agencies for creating audio-visual and advertising campaigns.
b.
Separate IEC Bureaus for better planning and evolve local specific media strategies.
44

c.
Decentralized strategyi. IEC at State level

ii. IEC at District Level
iii. Non Government IE C efforts
d.
Population education
i. Project on School education (implemented with the help of t he National
Council of Education Research and Training (NCE RT) in 30 out of a total of
32 States/ U.T.)
ii. Project on post-literacy & continuing Education is being implement ed by
Directorate Of Adult E ducation (National Literacy Mission) through
State/Regional Resource Cent ers in 430 districts of 26 States/UTs.
iii. Project on Higher E ducation is being implemented since 1986 through 17
Population Educ ation Research Centers (PERCs),
iv. Project on Vocational Training is being implemented through Directorate
General of Employment and Training (DGE T), M/o Labor in 600 Industrial
Technical Institutes (ITI) all over the country in its second phase. The first
phase covered about 1000 ITIs.
e.
Training and development in Family Welfarei. Village Health Guides (VHG) scheme:
ii. Basic training of ANM / MPHFW (F):
iii. Training of Multipurpose Health Worker (Male)/MPHW (M)
iv. Healt h and Family Welfare Training Centers
A big achievement was made in Family Welfare when the first Population Policy was announced in
2000 with specific objectives and Goals to be achieved in a set timeframe. The Policy focuses on
reduction in TFR for Population stabilization.
th
The 10 Plan (2002-2007) focus was on reaching a TFR of 2.1 by 2016 from the current levels (2003)
of 3.2
The estimates of population requiring various family welfare services as on 2001 were:
Total eligible couples (wife in the reproductive age group of 15-44) 177 millions
Total no. of pregnant women
29.5 millions
Total no. of new borne
26.8 millions
Total no. of children 0-6 Years as per Census 2001
158 millions
45

Family Planning Insurance scheme:

Compen sation: (w .e.f-07.09.07)
In Govt. facilitiesCateg Intervention
ory
High
focus
states
Non
high
focus
states
Acc
epto
r
Motiva
tor
Dru
gs
Surge
on
Vasectomy
(all)
110
0
200
50
100
Tubectomy
(all)
Vasectomy
(all)
600
150
100
75
110
0
200
50
Tubectomy
(BPL, SC/S T
only)
600
150
Tubectomy
(APL only)
250
150
Anest
hetist
Staf
f
nur
se
15
OT
Ass
tt.
Refresh
ment
Camp
mgt.
15
10
10
25
15
15
10
10
100
15
15
10
10
100
75
25
15
15
10
10
100
75
25
15
15
10
10
In Private facilitiesCategory
High Focus States
Type of operation
Vasectomy (All)
Tubectomy (All)
Facility
1300
1350
Motivator
200
150
Total
1500
1500
Non
High
states
Vasectomy (All)
Tubectomy (BPL+S C/ST)
1300
1350
200
150
1500
1500
focus
st
Compen sation in case of adver se event (w .e.f. January 1 , 2009)

Section
I
Coverage
IA
Limits
Lakhs)
2
(Rs.
in
To be paid to
whom
Spouse
and/or
dependant children
Deat h following sterilization in

hospital or within 7 days from the
date of discharge from the hospital
IB
Deat h following sterilization within 8- 0.5
Spouse
and/or
30 days from the date of discharge
dependant children
from the hos pital
IC
Failure of sterilization
0.3
Beneficiary
ID
Cost of treatment upto 60 days Actual
not Beneficiary
arising of complication from the date exceeding 0.25
of discharge
II
Indemnity
Insurance
per Upto 2 per claim
Doctor/ facility but not more than 4
cases in a year
Total liability of the insurance Company shall not exceed Rs. 9 crores in a year under each section
46

Jansank hya Sthirata Ko sh

The " Jansank hya Sthirata Ko sh" (JSK) (National Population Stabilisation Fund) has been
registered as an autonomous Society established under the Societies Registration Act of 1860. JSK
has to promote and undertak e activities aimed at achieving population stabilisation at a level
consistent with the needs of sustainable economic growth, social development and environment
protection, by 2045. The Union Health Minister heads the General Body of JSK and the Ministries of
Healt h and Family Welfare, Women and Child Development, Department of School Education &
Literacy, Rural Development, Planning Commission are represented by their S ecretaries on the
General Body of JSK. All State Governments are members of JSK. Besides this the General Body
has demographers, representatives of Industry & Trade, NGOs, medical and para-medic al
associations, general citizens as its members. This enables JSK run as a civil society movement
drawing on the strength of its partners. JSK has started a Call Centre service to give information on
reproductive health and family planning in English and Hindi.
Innovative Strategy under JSK
a. Prern a provides an opportunity for couples who have fulfilled specific re spon sible
parenthood criteria to bec ome entitled to receive a reward. The ingredients to qualify are :1.
Girls marriage after 19 years of age (Rew ard of Rs.5000/) and giving birth to the first
child after the mother was 21 years old (Rew ard of Rs. 7000/ if it s a girl child & Rs
5000/ if its a boy).
2.
Keeping a 36 month gap between first and second child and one parent getting
sterilized after the second child is born(Rew ard of Rs. 7000/ if it s a girl child & Rs
5000/ if its a boy)
Couple must belong t o any of t he 46 districts identified for 2008-09 P rerna
awards by JSK.
Must belong to BPL category.
Preference will be given to younger couples (age of wife not exceeding 30
years).
Only those couples who have completed registration of marriage and
registration of the birth of each child wit h the competent authority (Registrar
of Marriages / A ppropriate Govt. Officer registering births) would qualify for
the Award.
The award s hall be given in form of Kisan Vikas Patra in the name of Couple
and will be given at a public function
b. Santu sh ti strategy private gynecologists are being encouraged to perform 100 tubectomy
(laparoscopic sterilization operation) / NSV for which the doctors will be paid according to
compens ation rates already notified by the Government with an additionality for fast track
quality service. A n MOU is signed bet ween the district CMHO and private facilities. Funding
is provided by JSK through the Collector and CHMO to save time and paperwork and
encourage the private sector to join hands. To date 25 MOUs have been signed in Satna
and Jabalpur district of Madhya Pradesh
JSK v s. Family Welfare
JSK is a unique organization. Its goal is to promote initiatives which leverage the strength of different
economic and social sectors and reach out to needy population groups through innovative strategies.
It is a combination of government and civil society working hand in hand to promote innovations by
drawing on the strength of joint part nerships.
All the events that JSK has organized are evidence of partnership forged already which indicates
JSKs uniqueness.
Observation of World Population Day
Prerna Awards at Dhaulpur and Jodhpur in Rajasthan and Nabarangpur in Orissa- Direct
contact with village people who have now become JSKs Role Models for responsible
Parenthood practices.
47

Working wit h the Private Sector Medical Specialists (Gyneacologists and NSV Surgeons) to
enhance services for contraception.
Induction of professional people, NGOs, CII, FICCI, IASP, IP HA, IAP & SM, FOGSI, TNA I,
IMA and ASSOCHAM in the Governing Board of JSK.
JSKs initiatives like GIS Maps, Call Centre, Virtual Resou rce Center , Prerna, Santu shti , large
scale sensitisation workshops for adolescents from remot e villages.
JSK Strategies
a. Prerna
b. Santhushti
c. Call Center
d. Virtual Resource Center
e. Involvement of Gynaecologists in IUD(380A ) and Material Development and display for
IEC/BCC
48

National AIDS Contr ol Program:

HIV/ AIDS
A Acquired must do something to ac quire
I
Immune ability to fight diseas e
D Deficiency
S Syndrome cluster of symptoms characteristic of
disease
Transmission modes
First ca se: 1986

National AIDS control prog ram: 1987
NA C0: 1992
HIV/ AIDS prevalence criteria
1. High> 1% in Ante-natal women
2. Moderate< 1% in Ante-natal,
>5% in S TD/other high
behavior
risk
Avoiding Transmission
3.
Some
1.
2.
3.
4.
5.
Avoid
1.
2.
3.
4.
5.
Low-
< 1% in Ante-natal &

< 5% in STD/ot her high risk
behavior
facts:
One disease
Tw o Viruse s
Three transmi ssion mode sa. Sexual
b. Vertical
c. IV Drug/Blood
Four intervention s
a. Communication
b. Counseling
c. Condoms
d. Care of PLWA
Five owe respon sibility
a. Individual
b. Family
c. Community
d. Care providers
e. Media
tran smi ssi on
Condom use
Sterile needle use
Blood safety
Single partner
Universal Precautions
Signs:
Major:
1. Weight loss:
2. Chronic diarrhea
No transmission
> 10% of body weight

> I month
49

3.
Minor:
1.
2.
3.
4.
5.
6.
7.
Fever > 1 mont h (intermittent or constant)

Persistent cough > 1 month
General pruritic dermatitis
Recurrent herpes zoster
Oropharyngeal candidiasis
Chronic progressive and disseminated
herpes simplex infection
Generalis ed lymphadenopathy
Symptom s:
Swollen glands
Mouth ulcers
Sore throat, cough
Symptoms of opportunistic infections
Skin rashes, pruritus, and recurrent herpes
Prolonged unexplained fatigue
Joint pains, muscle atrophy,
Impaired cognitive functions, vision problems
NA CP-III (2006-2111)
Current epidemiological situation in India:
The HIV/AIDS situation is monitored through sentinel
surveillance sinc e 1992. Sentinel surveillance started
with 192 sites and by end of 2007 there were 1134
sites (646 A nte-natal clinics and 488 high risk
sites).There were 2.31 million people living with HIV/
AIDS by Dec. 2007, wit h adult prevalence of 0.34% .
Diagno si s
1. ELISA/Rapid Simple Tests
2. Western Blot
Criteria for confirmation:
A +ve E LISA antibody test
A +ve Western Blot Test
Absolute CD4 cell count <200
Abnormal p24 antigen
T(thymus derived) Lymphocyte count
is abnormal
HIV/ AIDS cont rol strategy
Program management
Surveillance & Research
IEC & S ocial mobilization
through NGOs.
Cont rol of S TDs.
Condom programming
Blood safety
Impact reduction
NA CO policie s
National
AIDS
contr ol
Policy
Policy on HIV testing
National Blood policy
ART guidelines
The first phase of National A IDS Control Programme was initially from 1992 to 1997 and was
extended to 1999.
3
Estimated Adult prevalence & No. of
PLHA
2.5
NACP -II commenced from A pril
1999 with the twin objectives of
2
A.
Reducing the s pread of HIV
infection and strengthening
1.5
PLHA
the capacity of Central and
Prevalence%
State
Governments
to
1
respond to HIV/A IDS on a
0.5
long term basis.
B.
Targeted interventions for
0
high
risk
groups
and
2002 2003 2004 2005 2006 2007
measures to prevent HIV
transmission
among
the
general population. Anti-Retro Viral Therapy was provided to AIDS patients at selected centres.
The programme implementation has been completely dec entralized to states and UTs. Each state
and UT has registered a State AIDS Control Society (SA CS) res ponsible for implementing the
programme at the State/ UT level. Mumbai, Chennai and A hmedabad have formed Municipal A IDS
Cont rol Societies to effectively implement the programme.
50

Important policy initiatives taken during NA CP-II include

a. Adoption of National AIDS Prevention and Control Policy (2002);
b. National Blood Policy; Greater Involvement of People with HIV/AIDS (GIPA);
c. Launch of the National Adolescent Education Programme;
d. Provision of anti-retroviral treatment (ART);
e. Formation of an inter-ministerial group for mainstreaming; and
f. Setting up of the National Council on AIDS, chaired by the Prime Minister.
National AIDS Contr ol Programme Phase III
The overall goal of NA CP-III launched in June 2007 is t o halt and reverse the epidemic in India over
the next 5 years. Considering that more than 99% of the population in the count ry is free from
infection, NACP -III will place the highest priority on preventive efforts while, at the same time, seeking
to integrate prevention with care, support and t reatment. This will be achieved through a fourpronged strategy:
1.
2.
3.
4.
Prevention of new infections in high risk groups and general population

through:
a. Saturation of coverage of high risk groups with targeted interventions
(TIs)
b. Scaled up int erventions in the general population
Providing greater care, support and treatment to larger number of PLHA.
Strengthening the infrastructure, systems and human resources in
prevention, care, support and treatment programmes at the district, state
and national level.
Strengthening the nationwide Strategic Information Management
System.
The specific objective is to reduce new infection as estimated in the first year of the programme by:
a.
Sixty per cent (60%) in high prevalence states so as to obtain the reversal of the epidemic;
b.
Forty per cent (40% ) in the vulnerable states so as to stabilize the epidemic.
S.No.
Activity/Component
Baseline
Sept 1999
June 2007
1
2
Establishment of Sentinel sites for HIV trends

Knowledge of HIV/AIDS and at least 2 methods
of prevention
50-80%
Urban,
13-64%
Rural
50.3%
43-83% (U)
25-86% (R)
3
4
Consistent condom use among female sex

work ers
Coverage of schools & colleges for awareness
112000
schools
11025
231.07
crores (200607)
1086
59.1%
4312
5
6
Condom vending machines installed by NA CO

Condoms distributed
7
8
9
Modernization of blood banks

Voluntary blood donation (%of requirement)
Establishhment of ICTC
960
20%
0
March 2009
73.4%
97279
schools
19525
221.31
crores (200809)
1092
61.7%
4987
51

10
11
12
HIV test conducted

Cent ers providing PPTCT services
Cent ers
providing
HIV-TB
collaborative
services
Government STI clinics
Anti retrovial theraphy ccentrres
Patient on ART
Children on ART
Community care centres
PLHA net works
Drop-in centres
Coverage of high-risk population across the
country through targeted int ervention projects
13
14
15
16
17
18
19
20
0
0
0
10 million
2418
2684
10.02million
3452
4987
504
0
0
0
0
0
0
300
845
127
85915
6300
101
90
84
764
886
211
217781
13961
254
259
204
1271
Strategy:
1. Prevent infections through saturation of coverage high-risk groups with targeted interventions
(TIs) and scaled up interventions in the general population.
2. Provide greater care, support and treatment to larger number of PLHA.
3. Strengthen the infrastructure, systems and human resources in prevention, care, support and
treatment Programs at district, state and national levels.
4. Strengthen the nationwide Strategic Information Management System.
5. The specific objective is to reduce the rat e of incidence by 60 per cent in t he first year of the
Program in high prevalence states to obtain the reversal of the epidemic, and by 40 percent
in the vulnerable states to stabilise the epidemic.
A. Targeted Interventions
Currently, 1,271 Targeted Intervention projects are operational in the e c ount ry under various
State AIDS Cont rol S ocieties and around 200 TIs are managed by other partners. These TIs
cover 55 5% of FSW, 73% of IDU and 77% of MSM & Transgender populations. Saturation of
all high risk groups through 2,100 TI projects and development of ownership by community to
ensure the services accessibility to all is the target aimed at during NACP -III.
NACO has institutionalized the training and capacity building process with the establishment
of the State Training and Resource Centres (S TRC). S TRCs function with the objectives of:
a.
Ensuring need based training of TIs as per NACP IIIs technical and operational guidelines;
b.
Enhancing the capacity of NGOs and civil society organiz ations in proposal development for
NACP funded targeted intervention projects; and
c.
Undertaking operational res earch and evaluation of TIs. S TRCs have been established in 14
states and 6 more are being established
A new intervention that has been taken up in NA CP-III for addressing the HIV risk
among Injecting Drug Users is provision of Oral Substitution Therapy (OS T), which has
been seen to be an effective strategy worldwide.
As per NA CP III, truckers interventions are to be focused on high priority locations i.e. major
trans-shipment locations (TS Ls) with 5,000 or more long distance truckers halt on a monthly
52

basis. At present, there are 52 truckers interventions, of which 17 are in high-priority locations,
being implemented by NGOs.
B. The Link Worker Scheme (LWS):
Under NA CP-III has been designed specifically to address population with high-risk behaviors
(including High Risk Groups and Bridge P opulations). LWS is a medium term, meso-level
strategy, whose scope is limited to five years. The services established through LWS will be
linked to local healt h governanc e system at three levels. This will again ensure mainstreaming of
the HIV response project and, therefore, the project sustainability can be assured beyond five
years. They work in each cluster of villages around a 5,000+ population. They are supported in
their work by village-level volunteers selected from the available groups in the community. In
every district, the LWS is being implemented through one or two District Resource Persons, one
Monitoring & E valuation Offic er, four Supervisors and 40 Link Workers. The scheme is supported
by UNDP, UNICEF, USG and GFA TM.
C. Preventive interventions for the general population
Prevention has always been the main stay of addressing the HIV/AIDS epidemic. Under NACPIII, it is proposed to integrat e and scale-up service delivery to sub-district and community levels
through existing infrastructure in the public and private sectors. The following is the package of
preventive servic es provided under NA CP-III:
i.
ii.
iii.
iv.
v.
vi.
Creating awareness about symptoms, spread, prevention and services available through a
strong IE C campaign
Condom promotion
Promotion of voluntary blood donation and access to safe blood
Integrated Counseling and Testing (ICT)
Prevention of Parent To Child Transmission
Management of STI and RTI
vii.
viii.
ix.
Post Exposure Prophylaxis (PEP)

Promotion of safe practices and infection control
Intersectoral coordination and mainstreaming
Under NA CP-III, Voluntary Cou n seling and Testing Cent res (VCTC) & Prevention of Parent to
Child Transmission Centres (PP TCT) have been remodeled together as ICTC (Integrated
Coun seling and Testing Centre). The number of integrated couns eling and testing centres
increased from 982 (2004), 1,476 (2005), 4,027 (2006), 4, 567 (2007), 4,987 (March 2009). The
number of persons tested in these centres increased from 17.5 lakhs in 2004 to 27.8 lakhs in 2005,
40.3 lakhs in 2006, 73.7 lakhs in 2007 and 102 lakhs in 2008-09.
ICTCs als o provide PP TCT services to pregnant women. The number of pregnant women counseled
and tested was 1.8 lakhs in 2004, 13.7 lakhs in 2005, 21 lakhs in 2006, 32.3 lakhs in 2007 and 46.31
lakhs in 2008. In 2008, 21,483 pregnant women were found to be HIV positive. Women who are HIV
positive are given a single dose of Nevirapine prophylaxis at the time of labor and newborn is also
given a single dose of Nevirapine within 72 hours of birt h. In 2008, a total of 10,494 mother-baby
pairs were given prophylaxis dose of Nevirapine.
NACP -III aims to accomplish the following targets to expand the outreach of ICTC services:
a. All Community Health Cent res to have HIV counseling and testing services
b. 24hr Primary Health Centres and Private hospitals are also being involved
53

c.
d.
e.
Mobile ICTCs in hard to access areas in collaboration with NRHM

Internal and External Quality assuranc e mechanisms
Target of 10-15 tests per day per cent re
D. Sex ually Transmitted Infection s (STI) Service s

As STI inc reas e the risk of HIV transmission signific antly, their care has been given high
importance in NA CP-III. NA CP-III envisages that about 15 million episodes with S TI/RTI will be
treated through the programme. The S TI / RTI services are being delivered through designated
STI/RTI clinics, TI S TI clinics, and a net work of S TI/ RTI private preferred providers and NRHM at
sub-district facility. The Regional S TI Reference Research and Training Centres are providing
high quality laboratory support to generate scientific evidence for providing good quality S TI/ RTI
services through monit oring drug resistance to gonococci and implementing Syphilis EQAS so
as to review the syndromic protocol on a periodic basis.
STI Services provided under NA CP-III
S.No. Name of Centre
No.
of
Center s
1.
Designated S TI clinics
886
2.
Targeted Intervention Clinics
1271
3.
Community based STI/RTI

services delivery through
network of P rivate Preferred
Providers Janani Scheme
in Bihar
NRHM facilities
8515
4.
5.
S.No.
Regional
research
centers
S TI Referenc e,
and
training
26,415
PHC/ CHC
7
Location
Medical Colleges, District hospitals, selected
area hospitals and large CHCs under
SACS/NACO.
In the each district to cater the high risk
population
STI/RTI services to be provided to the HRG and
the clients of HRG through the network of Private
providers (Allopath and non allopath) in 100 high
priority districts.
STI/RTI services delivered at sub district level
through NRHM facilities.
In medical colleges -S afdarjung & Maulana Azad
Medical College in Delhi, Osmania Medical
College in Hyderabad, B.J. Medical College in
Ahmedabad, Institute of Serology and Calcutta
Medical College in Kolkata, Institute of
Venereology in Chennai & Government Medical
College in Nagpur.
STI/RTI episodes managed under NACP III (2008-2009)

Name of the health care facility
Number of ca se s (in lakhs)
1.
Designated S TI/RTI Clinics
25.7
2.
TI S TI clinics
9.1
3.
PPP Scheme
1.0
4.
NRHM facilities
Total
31.0
66.7
During 2008-09, a P ublic Privat e Partnership scheme was launched in 91 priority districts in 14 zones
in 16 states involving 7 agencies. This scheme was implemented as a pilot wherein t he agencies
identified 8,515 private practitioners (including 2,233 allopaths and 6,282 non-allopaths) who were
54

high volume S TI/RTI service providers in and around hot zones in the selected districts. These
networked providers were trained and provided with colour-coded S TD drugs to administer the
syndromic treatment and provided on-site supervision. Demand generation activities were als o carried
out alongside. As of 31st March, 2009, 1,975 (88%) allopaths and 5, 528 (88%) nonallopaths had been
trained; 1,06,684 S TI/RTI cases treated; 1,49,880 clients counseled; and 15,226 clients referred.
E. Mainstreaming HIV for multi-secto ral respon se:
1. Con stitu tion of the State Council s on AI DS (SCA):
2. Mainstreaming w ith civil society organizations:
3. Greater Involvement of People Living w ith HIV (GIPA) under NA CP-III:
NACP III has outlined steps in establishing systems, structures and various activities to
meaningfully involve people living with HIV (PLHIV) in programme design and implementation
to reduce stigma and discrimination associated with the infected and affected persons. This
will also enhance their access to prevention and quality treatment, care, insurance and legal
services. Support from NACO has enabled the Indian Net work of P ositive People to establish
and strengthen up to 22 state level networks and 221 district level networks of people living
with HIV. These net works aim to mobilize t he communities t o ensure community access to
various services, like ART Centres, Community Care Centres, and Drop-in centers (DIC). At
present, a total of 204 DICs are operational across the country out of which 127 are in the A
category districts and 27 in the B category districts. NACO is working t owards establishing
DIC in all A and B category districts
F.
Condom Promotion
The NACP -III envisages significant expansion in the condom use through social marketing for
which partnerships with private sector and social marketing organizations were planned.
a. Scaling up condom so cial marketing:

NACO supported the social marketing programmes in various states during 2008-09. These
programmes were initially extended for a six month period during which a total of 856 lakh
condoms, against the target of 750 lakh condoms, were marketed and over 2.7 lakh outlets,
against the target of 2.4 lakh outlets, were covered with socially marketed condoms. With the
focus on expanding the retail outlet and coverage of non-traditional outlets, 71% of the outlets
were the non-traditional outlets.
Retail Condom off take (In lakh pieces)
2006-07
2007-08
2008-09
Social market
6395
6393
8353
Commercial
Free
3837
12875
4386
7750
6313
7465
Total
23107
18529
22131
During 2008-09, socially marketed condom off-t ake of 83.53 Crore pieces (Table 6) and outlet reach
of 12 lakhs were achieved.
b. Scaling up Female Condom Programme:

Based on the pre-programme assessment of the Female Condom Programme, NACO
scaled up the Female Condom Programme in Andhra Pradesh, Tamil Nadu, Maharashtra
and West Bengal to saturate all female sex worker Targeted Interventions. The peer-led
55

programme aims to build capacity of two lakh female sex workers. During 2008-09, 15 lakh
female condoms were proc ured for the programme.
c. Installation of Condom Vending Machines:

During the year 2008-09, four metro cities and two large towns in Uttar Pradesh were
target ed for t he installation of condom vending machines. Against 10,025 targeted number
of CVMs, 8,500 CVMs have already been installed. During 2008-09, 7,50,000 condoms
were sold through these CVMs.
G.
Blood Safety:
The Blood Safety Programme under NA CP-III aims to ensure provision of safe and quality blood
to far-flung remote areas of the country in the shortest possible time through a well-coordinated
National Blood Transfusion Service. The specific objective is to ensure reduction in the
transfusion associated.HIV transmission to 0.5 per cent. This is sought to be ac hieved by:
1.
Ensuring that regular (repeat) voluntary non-remunerated blood donors constitute the
main source of blood supply through phased increase in donor rec ruitment and
retention;
2.
Establishing blood storage cent res in the primary healt h care system for availability of
blood in far-flung remot e areas;
3.
Vigorously promoting appropriate us e of blood, blood components and blood products
among the clinicians; and
4.
Developing long-term policy for capacity building to achieve efficient and self sufficient
blood trans fusion servic es.
a.
Blood collection:
Access to safe blood is ensured by a net work of 1,092 blood banks including 104 Blood
Component Separation Units (BCSU) and 10 Model Blood Banks. NACO supported the
installation of blood component separation units and also funded modernization of all major
blood banks at state and district levels, besides the procurement of equipments, test kits and
reagents as well as the recurring expenditure of government blood banks and those run by
charitable organizations that were modernized.
Based on population standards, the requirement of blood for the country is estimated to be
100 lakh units annually, whereas the available supply was 74 lak h units in 2008-09. During
this period, 61.7% of blood was collected through Voluntary Blood Donation programme.
b.
Strengthening of Blood bank facilities th rough :

i.
District level Blood Banks
ii.
Blood Component Separation Units
iii.
Blood Storage Centres
iv.
Blood Refrigerated Vans
H. Other activities for Blood safet y initiated under NACP-III area.

Blood Safety Training Programme:
b.
Monitoring of blood banks
c.
Newer initiatives
i.
Cent re of Excellence in Trans fusion Medicine:
ii.
Plasma Fractionation Cent re:
iii.
National Blood Transfusion Authority:
56

I.
Care, Support and Treatment for People Living w ith HIV/AIDS (PLHA )The Care, support and treatment programme under NA CP III includes comprehensive
management of PLHA with respect to treatment and prevention of Opportunistic infections,
antiret roviral therapy (ART), psychosocial support, home based care, positive prevention and
impact mitigation.
Any person who has a confirmed HIV infection is subjected to further evaluation for determining
whet her he requires ART or not by performing CD4 count and ot her baseline investigations. All
those eligible as per technical guidelines are started on ART.
The target for National ART program is to:
1.
Free A RT to 300000 adult, and 40000 pediatric PLHA by 2012 through 250 ART and 650
Link ART centers.
2.
Achieve and maintain high levels of adherence and minimize numbers lost to follow up
3.
Involve intersectoral partners, NGOs and Private partners
4.
Provide comprehensive care, support and treatment through 350 Community Care Centers
by 2012.
During 2008-09, the following activities were undert aken to improve the quality of care offered to
PLHAs:
i)
ii)
iii)
iv)
v)
vi)
vii)
viii)
ix)
Revision of technical and operational guidelines on A RT, Opportunistic Infections, Community

Care Centres and Pediatrics
Preparation of training modules for doctors, couns elors and nurses.
Appointment of Regional coordinators for care, support and treatment t o monitor quality of
services
Revi sion of Manpow er at ART Centres. The human resources at ART centres have been
linked to the number of patients at the centre so that all patients get proper time for counseling
and patients satisfaction is increas ed.
Strengthening the capacity o f laboratories for CD4 te sting. At the end of March 2009, 145
CD4 machines were installed in t he country to take care of 197 cent res, by way of a sample
transport mechanism for centres without CD4 machines. The sample is transported by the lab
technician who also brings back the report after testing at the Nodal Cent re.
Technical Resou rce Grou p s have been constituted on ART, P ediat ric issues, Lab. services
and CCCs for discussion and recommendations on various technical and operational issues
relating to the programme.
Supply Chain Management for A RV Drug s. All efforts are made to ensure continuity of drug
supply to ART centres and in case of unex pected in number of patients at any particular centre,
re-location of drugs is done in order to ensure that there are no stock outs.
Concept ualization and operationalization of the Link ART Centre s. The concept of Link
ART centres was developed considering the large distances PHLAs had to cover to reach A RT
centres. These Link ART Centres are
being developed at ICTC or CCC, whereby stabilized patients will get their drugs within easy
reach and need to travel to the main ART cent re only once in six months. A total of 300 Link
ART Centres have been sanctioned so far.
Collaboration w ith intersectoral partners, NGOs & CII. NACO is strengthening the public
private partnership by involving corporat e sector, intersectoral partners and NGOs in ART roll
out. Presently, eight ART centres are running in collaboration with different NGOs/Industries.
57

x)
Community Care Centres. In order to improve the quality of counseling and also reduce the
inconvenience caus ed to PLHAs while being investigat ed at ART centres, all ART centres will
be linked t o a Community Care Centre, where patients can be admitted during the period of
investigation and adherence counseling can be reinforced. At the end of March 2009, a total of
254 CCCs were operational. It is planned to have a tot al of 350 CCC across the country by
2012. Each CCC will be linked to the closest ART Centre.
J.
Institutional Strengthening and Capacity Building throug h

a. strategic planning skills,
b. disseminating best practices for TIs,
c. establishing and managing a net work of t echnical ex pertise through Technical Res ource
Groups (TRGs) in S TI/HIV/AIDS,
d. conducting OR and
e. R&D activities
K.
Strategic Information Management

Key activities being undertaken are a. Establishing a Research Wing/ Division at NA CO with strong linkages developed with
research/academic institutions at regional/ state level;
b. Strengthening operations research and evaluation studies on the design, strategies,
implementation and testing of HIV intervention programmes and measure their impact related
to risk/vulnerability reduction, behavior change, stigma reduction, HIV prevalence rate,
c. Building c apacity for monitoring and evaluating community based interventions, school based
adolescent educ ation programmes and support groups of positive people;
d. Conducting t wo types of Behavioral Surveillance S urvey, namely,
i. annual risk assessment at the district level and
ii. Methodologically rigorous Integrated Biological and Behavioral Surveillance
(IBSS) at district level, once in three years.
L.
M.
Monitoring and Evaluation

Following activities were undertaken:
a. Development of an integrat ed M&E Plan for NACP -III
b. Strengthening systems for better M&E
c. Improving Component Specific M&E
i. ART Centers
ii. Integrated Counseling and Testing Centres
iii. STI/RTI Reporting
iv. Community Care Centers
Improving CMIS and overall Reporting
Through a comprehensive soft ware for S IMS with advanced features like on and off-line
reporting, client tracking, GIS features and basic statistical analysis. A process
development of smart card is re-initiated for tracking of patients on ART.
for
N. HIV Sentinel Surveillance

Scale-up of S entinel Sites: HIV Surveillance in India was started from 1985. Subsequently,
NACO established in 1992, sentinel s urveillance for HIV/A IDS in India. The number of sentinel
sites were increased from 176 in 1998 to 1,215 in 2008 The population groups monitored under
HSS include pregnant women attending antenatal clinics (A NC), patients attending Sexually
Transmitted Diseases Clinics (STD), Female Sex Workers (FSW), Men who have Sex with Men
(MSM), Injecting Drug Users (IDU), High Risk Migrants/ Single Male Migrants and Long distance
Truckers.
The objectives of HIV Sentinel Surveillance are to:
58

a.
determine the level of HIV infection among general population as well as high risk groups in
different states;
b.
understand the trends of HIV epidemic among general population as well as high risk groups
in different states;
c.
understand the geographical spread of HIV infection and to identify emerging pockets of HIV
epidemic;
d.
provide information for planning the programme in different states and districts, for
prioritization of programme resources and evaluation of programme impact; and
e.
estimate HIV Prevalence and HIV burden in the country besides HIV incidenc e, Mortality
due to AIDS and ART needs.
Methodology of HIV Sentinel Surveillance

S Item
Surveillance
Surveillance among High Risk
S.
among
General Groups (HRG)
No
Population
1Population
Pregnant women Female S ex Workers, Men who have
1
Group
attending
ANC Sex with Men, Injecting Drug Users,
Clinics of 15 49 Eunuchs, Migrants, Truckers of 15
years age group.
49 years age group.
2
4
5
2Sample
size
3Method of
sample
collection
4Testing
Strategy
5Testing
Protocol
400
through
consecutive
sampling
Routine method of
blood collection at
ANC Clinics (IntraVenous Samples)
Unlinked
Anonymous
2-test protoc ol
250 through consecutive sampling at

service points or satellite points.
Dried Blood Spot (DBS) method at
HRG sites (Drops of blood collected
through finger prick)
Unlinked Anonymous with Informed
Cons ent
2-test protoc ol
Surveillance among
Special Groups
Patients attending
STD Clinics of 15
49 years age group.
250
through
consecutive
sampling
Routine method of
blood collection at
STD Clinics (IntraVenous Samples)
Unlinked
Anonymous
2-test protoc ol
59

National Anti Malaria Program:

(Now merged into National Vector Borne Diseas e Control P rogram, since
Dec. 2, 2004)
Chronology of developments in MalariaApril 1953: Case load- 75 million
National Malaria Control Program (NMCP) launched
Focus on twice an year indoor residual spray (1 Gm. per Sq. meter) in areas
with annual spleen rate of >10%
1958: Case load- reduced to 2 Million cases
National Malaria Eradication Program (NMEP) launched
NMEP had phas ed approach1. Preparat ory
2. Attack
3. Cons olidation
4. Maintenance
1971: Urban Malaria Scheme (UMS )
1. To reduce/ control transmission
2. Extensive use of Anti-larval measures
3. Operational in 131 large cities
1976: Resurgence with peak in 1976 (1961-50000 cases, 1976-6.47 million cases)
Reas ons:
1. Priority shifts
2. Sole reliance on DDT-Insecticide resistance
3. Rising costs of Insecticides
4. Chloroquine resistance in falciparum
1977: Modified Plan of Operation (MP O) and Plasmodium falciparum containment P rogram
(PfCP )
1. Objectivea. Prevent Malaria deat hs
b. Reduce Malaria morbidity
c. Cons olidate gains
d. Maintain production-agricultural and industrial
2. Activitiesa. Reclassification of area bas ed on API
i. Area with API >2
a) Spraying- DDT 2 rounds (1.0 Gms./Sq.meter)
- Malathion 3 rounds (2.0 Gms./Sq.meter)
- Synthetic pyrethroids 2 rounds (0.25 Gms./
Sq.meter
b) Entomological assessment
c) Surveillance-Active &Passive
d) Treatment of Cases
ii. Areas with API <2
a) Spraying-Focal around Pf cases
b) Surveillance
c) Treatment
d) Monthly Follow-up of all smear positive4 cases for one
year
b. Drug Distribution Centers (DDC) and Fever Treatment Depots (FTD)
60

3.
i. DDC only for dis pensing anti-malarial drugs

ii. FTD for collecting slides and dispensing drugs (1/ 1000 pop. or part
thereof with a stock of 200 Chloroquine tablets)
c. Pf containment (Oct. 1997) (SIDA assisted)
d. Research & Re-organization
e. IEC
Records to be maintained and forwardeda. MF-1 (Family Health Register)
b. MF-2 (Reporting of Blood smears by MPW/HA/Surveillance workers)
c. MF-3 (Tour record of HA ) & MF-3A (MPW)
d. MF-4 & MF-5 (Monthly report of PHC)
e. MF-6 (Monthly report-progress & assessment of spraying)
f. MF-7 (Details of positives & remedial actions)
g. MF-8 (blood smears received and examined Sub center wise)
h. MF-9 (E pidemiological evaluation master register-S ub center, village & month wise)
i. MF-10 (Passive agencies including FTDs report)
j. MF-11
k. MF-12 (Tour report of District Medical Officer)
l. MF-13-(Mont hly report of work by CMHO)
m. MF-14 (Particulars of PHCs visited)
n. Mf-15 (Zonal officers activity report for the month)
o. MF-16 (For reporting by DDC/FTD and Malaria clinics)
1979:
Centrally sp on sored category -II scheme on 50:50 ba si s

(Poor States who do not spend their 50% do not get central assistance of 50% - tho se w ho
need most get the least )
1985: 2 million cases
1991: Peak in Pf cases
1994: Epidemic proportions in Eastern India and Western Rajasthan
1994: 100% centrally spon sored program for N-E States, covers1. Operational cost
2. Equipments cost
3. Cash assistance
1995: Malaria Action Plan
Sep. 1997:
Enhanced Malaria Control Project (EMCP )- 8 States (AP, Chattisgarh, Gujarat,
MP, Jharkhand, Maharasht ra, Orissa, and Rajasthan).
Program is in operation in 1045 PHCs o f 100 di stric t s of these States with rural population
of 62.2 million along wit h 19 citie s/ tow n s in these States and in States of Karnataka, WB
and Tamil Nadu. (Cost-891 Crores for 1997-2002)
Criteria for selection of P HCs in EMCP area1. API > 2 in last 3 years (>5- High risk)
2. SFR > 30% of total cases (0. 9% -High Risk)
3. PHCs with 25% or more tribal population
4. PHCs reporting mortality because of malaria
The main foc us areas under EMCP area. Early diagnosis and prompt presumptive treatment (E DP T)
i. Active & passive surveillance, slide examination and rendering radical
treatment within 48 hours.
a) One microscopic Center/30000 pop.
61

b.
c.
d.
e.
f.
g.
h.
April 1999:
2004:
b) RDK for emergency and difficult areas.

c) DDC per village/MLV on 2000 High Risk area
ii. Selective/ Int egrated vector control and personal protection (IVM)
Graded reduction in IRS, Village as a unit for IRS, Selective use of
Synthetic Pyrethroids.
Integrated Vector Managementi. Anti adult measures
a) Indoor Residual Spray(IRS)
b) Space Spray
c) Genetic Control
ii. Anti-larval Measures
a) Environmental cont rol
b) Chemical and Biological Control
iii. Personal Prophylaxis
a) Mosquito-net
b) Screening and repellent
IEC
Capacity building, and
Epidemic containment plan and Rapid action
Surveillance
Rapid diagnostic kits
Inclusion of alternative insecticides like synthetic pyrethroids & biological control
methods
National Anti Malaria Program (NAMP)

NVB DCP
1869403
2000000
Malaria situation:
1780777
1600000
Data for the year 2006 reveals the

largest numbers of cases in the country
were reported by Orissa, followed by
Jharkhand, West Bengal, Assam,
Chhattisgarh, Rajasthan, Gujarat &
Uttar Pradesh and the largest numbers
of deaths were reported by Assam
followed by Orissa, West Bengal,
Arunachal
P radesh,
Meghalaya,
Maharashtra, Mizoram, Gujarat &
Karnataka.
1.79 million Cases of malaria (including
0.84 million P.falciparum cases) and
1707 deaths were reported from the
country in 2006.
In 2008, 1524939 cases were detected
out of which 755582 were Pf cases and
595 deaths (Source: NVB DCP).
In 2009 till May 319581 cases, 184591
Pf cases and 178 deaths were reported
across the country.
Malaria: India
1915363
1816569
1800000
1508927
1400000
1366517
1200000
1000000
800000
Cases
Deaths
600000
400000
200000
1006
949
2003 2004
57482
963
2005
1704
2006
1331
2007
8878
2008*
Malaria: Cases Rajasthan

142738
2003
55043
2004
2005
2006
99529
2007
2008*
52286
105022
62

Rajasthan had reported 6020 positive cases, 258 Pf cases and zero Death for 2009(till May 2009)
Main factor s for Malaria spread:
1. Irrigation practices IG canal in Raj.-P f cases on rise
2. Wet cultivation rice
3. Labor migrationasymptomatic carriers
4. Dams -----Pf int roduction
5. DeforestationVivax introduction, epidemics of P f
6. Plantation--- Pf introduction
Measuring Malaria:
1. Human indicesa. Annual Parasite Index (API) Annual Blood Examination Rate (ABER)
b. Annual Falciparum Index (AFI)
c. Slide positivity rate (SP R)
d. Slide Falciparum Rate (SFR)
API =
Confirmed case in one year

------------------------------------------x 1000
Population under surveillance
No. of slides examined

ABER =------------------------------------x 1000
Population
2.
Vector Indicesa. Human Blood Index (HB I)-proportion of freshly fed female anopheles with human blood in
stomach.
b. Sporozoite rate-percentage of female anopheles with Sporozoites in salivary glands
c. Mosquito densityno. Of mosquitoes per man hour catch
d. Man-biting rate-average anopheline bites per pers on per day
High-ri sk area Identification -Criteria:

Rural area1. Recorded Malaria deaths due to P.falciparum in last 3 yrs.
2. Slide Positivity Rate (SPR)
nd
rd
a. Doubling of SP R during last 3 years, provided the SPR in 2 & 3 year is 4% or more
b. NO doubling trend of SPR but average SP R is 5% or more in last 3 years.
3. P.falciparum proportion is 30% or more and SPR is 3% or more in any of the last 3 years.
4. Areas with focus of Chloroquine resistant P.falciparum-more than 25% cases in a sample of
30 are of R-II & R-III level
5. Tropical aggregation of labor population in project areas
6. New settlements in endemic areas
Urban area1. SPR > 5% or
2. Ratio of clinical Malaria cases to t otal fever cases being more t han 1/3 , during a calendar
year in a population of 50000
63

Malaria control st rategies:

1.
Early ca se Detection and Prompt Treatment (EDPT)

a. EDP T is the main strategy of malaria control radical treatment is necessary for all the
cases of malaria to prevent transmission of malaria.
b. Chloroquine is the main anti-malaria drug for uncomplicat ed malaria.
c. Drug Distribution Centres (DDCs) and Fever Treatment Depots (FTDs) have been
established in the rural areas for providing easy access to anti-malarial drugs to the
community.
d. Alternative drugs for chloroquine resistant malaria are recommended as per the drug
policy of malaria.
2.
Vector Con trol

a.
3.
4.
Chemical Control
i.
Use of Indoor Residual S pray (IRS) with insecticides recommended under the
programnme
ii.
Use of chemical larvicides like Abate in potable water
iii.
Aerosol spac e spray during day time
iv.
Malathion fogging during outbreaks
b. Biological Control
i.
Use of larvivorous fish in pond, ornamental tanks, fountains etc.
ii.
Use of biocides.
c. Personal Prophylatic Measure s that individuals/ communities can take up
i.
Use of mosquito repellent creams, liquids, coils, mats etc.
ii.
Screening of the houses with wire mesh
iii.
Use of bednets treat ed with ins ecticide
iv.
Wearing clothes that cover maximum surface area of the body
Community Participation
a. Sensitizing and involving the community for det ection of Anopheles breeding places and
their elimination
b. Involving NGOs in Program strategies
Envir onmental Management & Source Reduction Method s
a. Source reduction i.e. filling of the breeding places
b. Proper covering of stored water
The basic premise of Malaria control is1. Management of case s

2. Interrupting tran smi ssio n
The management issues that punctuate control area. All kind of irrational prescriptions from General practitioners who attend to 60-70% of
fever cases
b. Competence of Laboratory technicians, work load, Delay in slide reporting and
offering radic al Treatment
c. Drug resistance
Management of cases:
a. Diagnosis- Blood slide (Thick & Thin)
b. Treatment
1. Presumptive
2. Radic al
64

National Drug Policy on Malaria (2008)

Drug schedule for treatment of malaria under NVBDCP.
1. Chloroquine
Chloroquine bas e
Chloroquine bas e
Chloroquine bas e
Day 1
Day 2
Day 3
10 mg/kg
10 mg/kg
5 mg/kg
(600 mg adult dose)

(600 mg adult dose)
(300 mg adult dose)
Do sage as per age groups

Day 1
Age in years
Tab. chloroquine
<1
3
Day 2
Tab. Chloroquine
3
Day -3
Tab. Chloroquine
4
1-4
5-8
9-14
15 & above
1
2
3
4
1
2
3
4
3
1
13
2
2.
Primaquine
(contr aindicated
Do sage as per age groups
in
and
pregnan t
w omen)
Primaquine On Day 1
(a) P. falcip arum

Age in years
mg base
<1
1-4
5-8
9-14
15 & above
Nil
7.5
15
30
45
(b) P. vivax
Age in year
<1
1-4
5-8
9-14
15 & Above
infant s
mg base
Nil
2.5
5.0
10.0
15.0
No. of Tablet s (2.5 mg

base)
Nil
3
6
12
18
No. of Tablets (7.5 mg base)

Nil
1
2
4
6
Primaquine Daily dose for 14 days*

Nil
Nil
1
2
4
1
6
2
*Primaquin e for 14 day s should be giv en as p er prescrib ed guidelines o nly

3. Arte sunate + Sulpha-pyrimethamine (ACT) combination Age w ise Do se Schedule for AS+SP
Age
1st Day (number of 2nd Day (number 3rd Day (numbers of
tabs)*
of tabs)
tabs)
<1 Year
AS SP
34
3 Nil
3 Nil
1-4 Years
AS SP
11
1 Nil
1 Nil
5-8 Years
AS SP
213
2 Nil
2 Nil
9-14 Years
AS SP
32
3 Nil
3 Nil
15 +
AS SP
43
4 Nil
4 Nil
65

ACT should be given only to confirmed P. falciparum cases, found positive by microscopy or Rapid
Diagnostic Test (RDT). ACT tablets are not to be used in pregnant women.
Primaquine is contra indicated in pregnant woman and infants.
Strength of each A rtesunate tablet: contains 50 mg & each Sulpha Pyrimethamine (SP) tablet contain
500mg sulphadoxine/sulphalene and 25mg pyrimethamine
*A rtemi sinin group of dr ug s i s not r ecommended in preg nan cy
ACT: consists of an artemisinin derivative combined with a long acting antimalarial (amodiaquine,
lumefant rine, mefloquine or sulfadoxine-pyrimethamine). Tha A CT used in the national program in
India is artesunate+sulfadoxine-pyrimethamine (SP ). Presently, Artemether+Lumefantrine fixed dose
combination and blister pack of art esunate+mefloquine are also available in the country.
Chemoprophylax is
Chemoprophylaxis should be administered only in selective groups in high P.falciparum endemic
areas.
Flow chart for the treatment of an uncomplicated malaria case (2008)
Suspected (Cli nicall y) Malaria Cases
Microscopy result
Avai lable
Falci parum
Treatment-1
Vivax
Not Available
Rapid diag nostic Kit
Negative
Not Available
Avai lable
Treatment-2
Falci parum
Negative
Take slide
Treatment 3
Treatment-1
Slide
Falci parum
Primaquine 0.75 mg/kg sin gle d ose or ACT +

Primaquine in qual ified areas
Vivax
Negative
Primaquine 0.25mg/kg for 14 days
66

Treatment 1
Chloroquine + Primaquine (25mg/kg over 3 days + 0.75mg/kg single dose) or

Arte sunate + Sulpha Pyrimethamine + Primaquine (in areas qualified for ACT)
4 mg/kg for 3 days + 25/1.25mg/kg single dose + 0.75mg/kg single dose
Treatment 2
Chloroquine + Primaquine (25mg/kg over 3 days + 0.25mg/kg for 14 days)
Treatment 3
Chloroquine (25mg/kg over 3 days)
Not e: Primaq uine i s contr aindicated in preg nan t women, G6PD deficien cy, an d infan t s; A CT i s
contr aindicated in pregnan t women
* For clinically suspected malaria cases, signs and symptoms may be referred
Di stri ct s identified for u se o f ACT Combination (AS+SP) for treatment of Pf malaria in
Rajasthan:
4 Di st rict s and 11 P HCs
Dungarpur (4 PHCs): Bicchiwara, Damri, Simalwara, Dungarpur
Ban sw ara (4 PHCs): Kushalgarh, Chota Dungra, Bans wara, Talwara
Baran (2 PHCs):
Kishanganj, Shahbad
Udaipur (1 PHC):
Kotra
67

Revi sed National Tuberculosi s Contr ol Program (RNTCP)

Issue s in Tuberculo si s:
1. Case finding-Access to/ Availability of, sputum microscopy
2. Treatment-continuity, regularity & compliance
3. Drug resistance-MDR-TB (E very one who breathes should be
concerned)
4. Dual Epidemic-HIV/AIDS & Tuberculosis.
Chronolog y of development s in Tuberculo si s
1955-58:
ICMR conducted survey to assess burden of disease in India
1956-61:
Tuberculosis Research Center at Chennai (1956)
National Tuberc ulosis Institute established at Bangalore (1959)
District Tuberculosis Program (1961)
1962:
1973-74:
National Tuberculosis Control Program (NTCP) established

NTI initiated longitudinal surveys at Bangalore, Delhi, and
Chingelput (not represent ative of the country scenario).
1975:
Tuberculosis included in 20-point Program
1991:
Surajkund Conclave for review of NTCP; recommended
1. Strengthening of Laboratory services
2. Ensure regular drug supply-create a Drug Bank
3. Create a task force to monitor program implementation
1992:
Situational review by Government of India and World Bank
1. Achievements not as desired
2. Suggested a revised approach as RNTCP.
1993:
Pilot phase of Revised National Tuberculo si s Con trol Program
(RNTCP ) started with DOTS (Directly Observed Treatment wit h Short course Chemotherapy) as the
main interventional stay. By 1998 coverage was only 2% of population
1998:
Stop TB initiative
1999:
RNTCP becomes the second largest program in the World
2000:
Stop TB movement (Amsterdam Declaration)- Targets
By 2005, 70% people with TB will be diagnosed and 85% cured.
By 2010, Global burden will be 50%
By 2050, global TB incidence will be <1/ million populations
2001:
of the countrys population covered
2002:
50% population under RNTCP
2003:
More than 900,000 cases were placed on treatment- largest cohort
of cases, more than any ot her country in the world
2004, Feb.:
819 Million (76%) population (16 States /Union territories under RNTCP )
National Tuberculosi s Cont rol Program (NTCP) comprised:

1. Domiciliary treatment
2. Use of a standard drug regimen of 12-18 months duration
3. Treatment free of cost
4. Priority to newly diagnosed patients, over previously treated patients
5. Treatment organization fully decentralized
6. Efficient defaulter system/mostly self-administered regimen
7. Timely follow up
68

In India BCG vaccination policy was revised and it was recommended to be given at an early age
preferably before the end of the first year after birth by integrating under UIP.
NTCP was not measuring up to the expectations. The NTP was evaluated by t hree agencies, ICMR,
Institute of Communication, Operations Research and Community Involvement (ICORCI) and WHO.
Started in 1962, National Tuberc ulosis Control P rogram had certain short term and a few long-term
objectives.
The long-term objectives were addresses to reducing t he t ransmission to a level where Tuberculosis
ceases to be a public health problem (Control), measured through prevalence which was to drop to
1% in population below 14 years from the then existing level of 30%.
In 1992, review of national program concluded that it suffered from1. Managerial weakness,
2. Inadequate funding,
3. Over-reliance on x-ray,
4. Non-standard treatment regimen,
5. Low rates of treatment completion, And
6. Lack of systematic information on treatment outcomes.
NTP, however, created an extensive infrastructure for tuberc ulosis control, with a network of 632
District (March 2006) TB Cent ers, 330 TB Clinics and more than 47,600 TB beds; wherein 1.29million
patients were treated in 2005.
In 2006, 1.39 milllion and in 2007, 1.48 million patients have been enrolled for treatment. In 2008,
1.51 million were placed on treatment.
Treatment success rates have ttripled from 25% to 86% and TB death rates have been cut 7 folds
from 29% to 4% in comparison to the pre RNTCP era.
Evolu tion of RNTCP
As a result, a Revised National Tuberculosis Control Program (RNTCP) was designed in 1993 using
the infrastructure created under NTP and the achievements it made. RNTCP furthered the cause by
creating a management unit (TB unit), for 5-lac population, manned by-A Senior Treatment
Supervisor (S TS), A Senior TB Laboratory Supervisor (S TLS ) and a Medical Officer.
The other areas attended by program are1. State of art binocular microscope (78000 Laborat ory Microscopy centers
2. Good quality reagents
3. New recording reporting formats
4. Vehicle/ POL
5. Intensive modular training
6. Supervision
7. Cross checking the work of Lab. Technician
RNTCP-Goals
1. To cure at least 85% of new smear positive cases of Tuberculosis
2. To detect at least 70% of sputum positive cases after reaching 85% cure rat e
Strength s o f RNTCP 1.
Phased expansion
a. Does not dilute efforts
69

2.
3.
4.
b. Helps capacity building towards sustainability

c. Allows evaluation & correction
d. Ensures smooth service delivery within resources
Systems Accountability (Direct observation of drug administration)
New Reporting/ Recording system
Rec ruitment effect-cured patient are best motivators for case detection
StrategyThe main stay of RNTCP is based on Directly Observed Treatment with Short course Chemotherapy
(DOTS )
DOTS is a comprehensive, systematic strategy for effective Tuberc ulosis control on a mass scale
The strategy c omponent s are1.
2.
3.
4.
5.
Political & Administrative commitment.

Good Quality diagnosis
Good Quality drugs
Right treatment administered rightly
Systematic Monitoring and Account ability
The DOTS was developed in India only by TRC, Chennai in and now is being practiced by 60% of
Countries (127 out of 211 by year 1999) and makes RNTCP the second largest program in the world
(after China)
The DOTS Strategy intervention s are1. Case detection primarily by microscopic examination of sputum of patients presenting to a
health facility (Note the paradigm shift- Active case finding, the forte of NTCP, is no more
pursued in RNTCP)
2. Adequate Drug supply- Patient wise boxes to ensure regular availability.
3. Short Course chemotherapy given under direct supervision.
4. Systematic Monitoring and Account ability for every patient diagnosed &registered for DOTS
5. Political will & Advocacy
6. System is made Accountable rather than Patient for Drug complianc e
DOTS Operational sc heme under RNTCPUnder the DOTS regimen of chemotherapy in India, follow ing schedule is u sed
The figures outside the bracket refer to number of mont hs while t hose after t he bracket indicate
number of doses per week.
The Normal dose for each of the drug isIsoniazid (H) - 600 mg.
Rifampicin (R) -450 mg. (additional 150 mg if patient weighs more than 60 Kg)
Pyrazinamide (Z) -1500 mg.
Ethambut ol (E) -1200 mg.
Streptomycin (S) -750 mg. (reduced to 500 mg. if age is more than 50 years
70

Treatment Regimen
Category
Type of Patient
Category-I
New
sputum
smear positive
Regimen
Intensive
phase
2 (HRZE)3
Seriously
ill
sputum -ve
Seriously ill extra
pulmonary
Category-II
Category-III
Sputum
smear
+ve relapse
Sputum
smear
+ve failure
Sputum
smear
+ve
treatment
after default
Sputum smear
ve not seriously
ill,
Extra pulmonary
not seriously ill
2 (HRZES)3
Sputum examination for Pulmonary Tuberculosis

PreTest
If Result is
Then
treatm
at
ent
mont
sputum hs
+ve
2
-ve
Start Continuation phase,
test again at 4 & 6 months
+ve
Continue intensive phase
for one more month
-ve
2
-ve
test again at 6 months
+ve
for one more month, test
again at3, 4 & 7 months
-ve
test again at 5 & 6 months
+ve
+ve

for one more month, test
again at4, 6 & 9 months
-ve

test again at 6 months
+ve
Re-register
and
category-II treatment
1 (HRZE)3
5 (HRE)3
2 (HRZ)3
-ve
4 (HR)3
start
To simplify for remembranceCategory

I
Intensive pha se
2 (HRZE) 3
Continuation pha se
4 (HR) 3
II
2 (HRZES) 3
+
1 (HRZE) 3
5 (HRE) 3
III
2 (HRZ) 3
4 (HR) 3
Year
1998 1999 2000
Population Covered
18
130
287
*
* cumulative, in millions; ** Entire country
2001
2002
2003
2004
2005
March 2006
450
530
775
947
1080
1114**
Second Phase of RNTCP

In the first phase of RNTCP (1998-2005), the Programs focus was on ensuring expansion of quality
DOTS services to the entire count ry.
The RNTCP has now entered its second phas e in which the Program aims to firstly consolidate the
gains made to date, to widen services bot h in terms of activities and access, and to s ustain the
achievements for decades to come in order to achieve ultimate objective of TB control in the count ry.
71

All components of new Stop TB Strategy are incorporated in the second phase of RNTCP. These are:
a. Pursue quality DOTS expansion and enhancement, by improving the case finding and cure
through an effective patient-centred approach to reach all patients, especially the poor.
b. Address TB-HIV, MDR-TB and other challenges, by scaling up TB-HIV joint activities, DOTS
Plus, and other relevant approaches.
c. Cont ribut e to health system strengthening, by collaborating with other health P rograms and
general services
d. Involve all health care providers, public, nongovernment al and privat e, by scaling up
approaches based on a public-private mix (PPM),
e. Engage people with TB, and affected communities to demand, and cont ribut e to effective
care.
f. Enable and promote research for the development of new drugs, diagnostic and vaccines.
Operational Research will also be needed to improve Program performance.
RNTCP performance (Oc t. Dec. 2008)
Suspects examined:
Sputum + ve :
Registered for Treatment:
New smear positive case detection rate:
1.65 million
207144
351593
67%
Multi Drug Re si stant Tuberculo si s:

As per the estimates from the State repres entative drug resistance surveillance (DRS ) survey in
Gujarat and various district level DRS studies, the prevalence of MDR-TB in new smear positive
pulmonary TB (P TB) cases is 3% and 12 to 17% amongst smear positive previously treated P TB
cases. Review of studies wit h repres entative samples do not indicate any increase in India of the
prevalence of drug resistance over the years.
Although isolated reports, both published and unpublished, indicate the existence of XDR-TB in the
country, it is not possible as yet to estimate its magnitude and distribution from the available data.
Definition s
MDR-TB is defined as resistance to isoniazid and rifampicin, with or wit hout resistance to other antiTB drugs.
XDR-TB is defined as resistance to at least Is oniazid and Rifampicin (i.e. MDR-TB) plus resistance to
any of the fluoroquinolones and any one of the second-line injectable drugs (amikacin, kanamycin, or
capreomycin).
Prevention of MDR-TB and XDR-TB
The use of inadequate regimens and the absence, or inappropriate application, of directly observed
treatment can lead t o the development of drug resistance and pot entially to an inc rease in drug
resistance levels amongst the community. The implementation of a good quality DOTS programme
will prevent the emergence of MDR and XDR-TB in the community. Therefore the highest priority is to
further improve the quality and reac h of DOTS services in the country. For this, all health care
providers managing TB patients need to be linked to RNTCP and operational challenges in
implementing DOTS needs to be addressed. The proportion of TB patients being treated outside the
DOTS strategy needs to be minimized. The International Standards of TB Care need to be used by
RNTCP and professional medic al associations as a tool to improve TB care in the country. The
fluoroquinolone group of drugs are not as yet recognized, nor recommended, as first line anti-TB
drugs, and their use should be restricted only to the treatment of confirmed MDR-TB cases.
72

Management of MDR-TB
National guidelines and plans for scaling up management of MDR-TB have been developed under
RNTCP. In the interim, while RNTCP DOTS -Plus services are being expanded across the country, all
health care providers in the public and private sector managing MDR TB cases, need to adhere to the
following:
a. MDR-TB management to be preferably undert aken only at selected health institutions with
experience, expertise and availability of required diagnostic and treatment facilities
b. Diagnosis of MDR-TB
i. Drug resistance may be suspected based on history of prior t reatment (e.g.
smear positive case aft er repeated treatment courses, Cat II failure etc.)
and/or close exposure to a possible source case confirmed to have drugresistant TB
ii. For patients in whom drug resistance is suspected, diagnosis of MDR-TB
should be done t hrough culture and drug susceptibility testing from a qualityassured laboratory.
iii. Interpretation of DS T Results
st
iv. Drug susceptibility test results of the 1 line anti-TB drugs pyrazinamide,
streptomycin, and et hambutol should be interpreted wit h caution due to the
poor reproducibility of these res ults even under optimal laboratory conditions.
nd
*
v. Drug Susceptibility Test (DS T) results of 2 line anti-TB drugs should be
interpreted with great caution due to limited capacity of laboratories, absence
of quality-assurance, and lack of standardized methodology.
c. Treatment regimen
i. All relevant investigations to be performed prior to treatment initiation
ii. Preferably the standardized regimen as recommended in the national DOTS
Plus guidelines should be us ed [6(9) Km Ofx Eto Cs Z E / 18 Ofx Eto Cs E]
nd
iii. If results of 2 line DS T from an accredited laborat ory are available, an
individualized regimen may be used in such patients after obtaining a
detailed history of previous anti-TB treatment
d. Duration of treatment
i. At least six months of Intensive Phase (IP ) should be given, extended up to 9
th
months in patients who have a positive culture result taken at 4 month of
treatment
ii. Minimum 18 months of Continuation Phase (CP ) should be given following
the Int ensive Phase
e. Follow-up schedule
i. Smear examination should be conducted monthly during IP and at least
quarterly during CP
ii. Culture examination should be done at least at 4, 6, 12, 18 and 24 months of
treatment
iii. Relevant additional investigations should be performed as indicat ed
f. Treatment adherenc e and support
i. All patients initiated on treatment and their family members should be
intensively counseled prior to t reatment initiation and during all follow-up
visits
ii. To reduc e the risk of development of resistance to second-line anti-TB drugs
and promote optimal treatment outcomes, all efforts should be made to
administer treatment under direct observation (DOT) over the entire course
of treatment
73

g.
h.
i.
j.
iii. If DOT is not possible, attempts to ensure treatment adherence should be

made by
1. Checking empty blister packs; and
2. Follow up visits at least every month
Documentation of treatment
i. Healt h care facilities/practitioners managing MDR-TB patients should
maintain a systematic record of treatment regimen, doses, duration, sideeffects, investigation results and treatment outcome for all patients initiated
on second-line treatment.
Public health responsibilities of health care providers
i. Healt h care facilities/practitioners managing confirmed MDR-TB patients
should inform their respective District TB Officer regarding treatment initiation
and outcome of all MDR-TB cases
ii. Prior to treatment initiation and on all follow up visits the patient and family
members should be counseled on all aspects of MDR-TB
iii. All house hold contacts of t he MDR-TB patients should be screened for
active TB disease
Infection control measures
i. All large health care facilities need to have an infection cont rol (including
airborne infection) plan and a team for implement ation of meas ures to
prevent nosocomial transmission of TB and other air-borne infections
Statements to the press/media on MDR-TB and XDR-TB should be made with extreme
caution and after requisite verification and aut hentication
Fluoroquinolones (Ciprofloxacin, Ofloxacin, Levofloxacin, Moxifloxacin, Gatifloxacin, Sparfloxacin,

Pefloxacin); Kanamycin, Amikacin, Capreomycin, Ethionamide, Prothionamide, Cycloserine and PAS
Km = Kanamycin; Ofx=Ofloxacin; Eto=Ethinamide; Cs=Cycloserine; Z=Pyrazinamide; E=Etambutol

Impact of the program:
TB mortality in the country has reduced from over 42/100,000 population in 1990 to
28/100,000 population in 2006 as per the WHO global TB report 2008.
Ther prevalence of TB in the country has reduced from 568/100,000 population in 1990 to
299/100,000 by the year 2006 as per the WHO global TB report 2008.
Repeat population surveys conducted by TRC indicate an annual decline and prevelane of
disease by 12%
The program is currently undertaking repeat zonal ARTI survey (2008-10) and disease
prevelance survey at 7 sites (2007-09) to assess the impact of the program and TB control and
additional monitor the progress towards MDGs
Advo cacy, Communo cation and Social Mobilisation (A CSM):
An effective ACSM strategy is in place, in order to maintain hifgh visibility of TB and RNTCP
amongst policy makers, opinion leaders and community.
Four National level ACSM capacity building training workshops held with the support of
National Institute of Health and Family Welfare for the key functionaries in the field (State TB
officers, IE C officers and Communication facilitators).
Mass Media A gency developed new TV and radio spot and also conducted Capacity Building
in the few selectewd States.
74

National Leprosy Eradication Program:

In India first records of Leprosy Like disease appear in the
sixth century B.C. First described in S usruth Samhita and
treatment with Choulmoogra oil was known at that time.
Leprosy was referred to as Kusht in the Vedic writing.
In India The Lepers Ac t 1898 w as enacted, w hich
discriminated against the Lepro sy patient s and segregated
them socially. Union Government & all the States & UTs have
since repealed this act.
In 1991, WHO and its member States committed themselves to
eliminate Leprosy as a public health problem by the y ear 2000, whic h means to bring down the
Leprosy cases below one case per 10,000 population.
Leprosy is a major public health problem in 24 countries and 90% of t he global leprosy pro blem
is in 11 count ries. Namely India, Brazil (b) Indonesia, Myanmar, Nepal. Ethiopia, Mozambique, D. R.
Congo, Niger, Gunea.
Globally
At the beginning of 2001, the total number of leprosy patients in the world was less than
600000. About 720 000 new cases were detected during 2000. (S ource: WHO Weekly
Epidemiological Record 4 January 2002 No77). The proportion of single skin lesions among new
cases was 9% and the proportion of new cases with grade 2 disabilities was 4%.
Magnitude of leprosy in India
60% of globally recorded patients are in India.
Total patient load in 1981 was 4 Million. (Prevalence Rate (PR) -51/ 10,000)
Total recorded patient load by March 1999 -0.5 Million, {MB-56%} (P revalence Rate 5.2/10,000)
Prevalence rate decreased to 4. 1/10000 by March 2002
Prevalence rate decreased to .74/10000 by April 2008
5 States / UTs viz. Bihar, Chhattisgarh, Jharkhand, West Bengal and Chandigarh have P R between 1
and 2 per 10,000 populations.
Dadra & Nagar Haveli has PR of 2.34/10,000.
These 6 states/UTs contribute 33% of countrys recorded caseload and 35% of the countrys new
case detected during the year 2007-08
29 states and UT has achieved PR less than 1 per 10000 population
This load decreased to .87 lakh in 2007- 2008 (PR-0.74) of which
1. MB cases-47.2%
2. Female- 34. 5%
3. Child- 9.4%
4. Visible Deformity- 2.5%
5. ST cases -13%
6. SC Cases -18.9%
Till Marc h 2002, 10.8 million cases ere discharged through MDT (MDTs geographic coverage has
already reached 100% since 1999)
75

60
50
40
30
20
10
0
1981
cases in million Prevalence/ 10000

4
51
1999
0.5
5.2
2002
0.62
4.2
2008
0.87
0.74
Trend of leprosy Prevalence (PR) and Annual New Case Detection Rate (ANCDR) in India:
The statu s on Ap ril 2008 is that there are 6 States/UT viz. Bihar, Chhattisgarh, Jharkhand, West
Bengal, Chandigarh and Dadra & Nagar Haveli w ith PR betw een 1 and 3 per 10,000 population.
These 6 States w ith 20.8% o f coun try s population now contribu te 33% of the coun try s
recorded case load.
Statu s of PR and NCDR in 6 States/ UTs
S. No. State
Population %
of No. of %
of PR/ 10,000 No.
of %
of ANCDR/
countrys
cases countrys
new
countrys 100,000
population on
case load
cases
new case
record
detected
3
4
5
6
7
8
9
10
D& N Haveli
303029
2
3
4
Chhattisgarh 23336171
Jharkhand
31101898
Bihar
98516843
5
6
1.88
150
0.11
49.50
5465 6.27
3460 3.97
10262 11.76
2.34
1.11
1.04
7808
6799
19041
5.67
4.94
13.83
33.46
21.86
19.33
Chandigarh 1137712
0.14
West Bengal 89899615 7.64
Total
244295268
140
0.16
9358 10.73
28742 -
1.23
1.04
1.18
190
13551
47539
0.14
9.84
-
16.70
15.07
19.46
Percentage
34.53
0.03
57
1.98
2.64
8.37
20.77
0.07
32.95
Leprosy Co ntrol in IndiaThe Government of India started National Lepro sy Contr ol Program in 1955 with objective of
controlling Leprosy with help of Dapsone.
Main features of NLCP were1.
Input orienteda. No primary prevention

b. Non-availability of potent drugs
c. Lack of Community co-operation
76

2.
Performance oriented (since 1976)

a. Targets
i. New cases
ii. Discharged cases
3.
Operational limitations
a. Self administered mono-drug
b. Rural focus
c. Decline in Incidence
The program was re-designated as National Lepro sy Eradication Program (NL EP) in 1983 as a
100% centrally spon sored scheme, after MDT became available for effective treatment of Leprosy.
The NLEP had a Goal of eradicating Leprosy by year 2000 and mid term Goal of bring down the case
load to < 1/ 10000
The i ssue s o f concern before NL EP were1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Multi Drug therapy

Case detection
Disease classification
Clinical examination
Bacteriological examination
Diagnosis and D/D
Disease activity status
Surveillance
Case holding
Defaulter retrieval action
Discharge criteria
Relapse
Reports
Objectives1.
2.
3.
4.
5.
Render all case non-infectious in shortest time by

a. Early detection & treatment
b. Interrupting transmission
Prevent deformities
Eradicate Leprosy
MDT throughout
Prevalence-<1/ 10000 by 2002
Strategy1.
2.
3.
Interruption of transmission by early detection and treatment using MDT

Case holding & Surveillance
Social & Economic rehabilitation
77

Organizational str uct ure for NL EP implementationNational Leprosy Eradication Commission

National Leprosy Eradication Board
MOHFW
DGHS
Leprosy Division
State Leprosy Officer
LCU
Leprosy Trg.
778
49
Each LCU has
SSAUs
39
DLUs LPRU/RSU
285
13/75
ULC THW
907 290
SET centers MLT

6097 350
MO-1/4. 5 lac population besides Physiotherapists (1), Lab. Tech. (2), Non-med. Supervisors (4),
PMWs (20), Health educator (1)
(LCU-Leprosy Control Unit; SSAU-Sample Survey cum Assessment Unit; DLU-District Leprosy Unit;
LPRU-Leprosy Rehabilitation Unit; RS U-Reconstructive Surgery Unit; ULC-Urban Leprosy Centers;
THW-Temporary Hospit alization Wards; SET-Survey E ducation and Treatment centers; MLT-Mobile
Leprosy Treatment Units.)
Approach 1. Prevalence based categorization
a. Endemic-> 5/1000
b. Moderate endemic-3-5/1000
c. Low endemic-<2/1000
2. Plan of Actiona. Preparat ory phase
b. Intensive phase
c. Maintenance phase
Program implementationPrimar y preven tion (Not possible in Leprosy)
Second ary pr ev ention
Case finding
Diagnostic services
Clinical Exam.
Bacteriological exam
Tertiary preven tion
Disability limitation
Constructive/ corrective surgery
Rehabilitation
Social
Vocational
78

Case finding in Lepro sy

1. Acti vea. Sample surveys (in areas with PR >1/1000)
b. Mass Surveys (>10/1000)
c. Cont act surveys (<1/1000)
d. Rapid surveys
2. Passivea. Voluntary reporting
b. Referral & Notification
Organizing case finding-some con sideration s
1. Prevalence
2. Pop. Density
3. Geography
4. Communication net work
5. Healt h care delivery system
Case holding-Facilitator s
1. Regularity of drug intake
a. Location & timing of clinic
b. Clinical
&
Bacteriological
reviews
c. Physiotherapy
d. Care of plantar ulcers
e. Provision of suitable foot
wears
f. Timely & appropriate referral
g. Comprehensive care
h. Timely
termination
of
treatment
i. Rehabilitation
j. Supervision of workers
2. Promoting Compliancea. Home Visits, Family pressure
b. Urine sample monitoring
c. Drug dispensing
30
25.9
25
Leprosy trend PR & ANCDR

Source : MoHFW
20
PR
ANCDR
15
10
5.9
8.4
4.9
5.3
5.5
3.7
5.9
4.2
4.4
3.2
0
1991
1995
2000
2001
2002
2003
2004
3.3
2.4
2.3 1.43
1.3
0.95
2005 2006
Issue s in treatment with Multi Drug Therapy (MDT)

1. Prioritize (based on resources)
a. Multibaciliary
b. Paucibacilliary resistant to Dapsone
c. Other Paucibacilliary
2. Delivery
a. Adequate, Efficient, Flexible
b. Referral
c. Integration with primary care
Treatment in Multibaciliary (12 months course)
1. All skin smear +ve
2. All clinically active BB, BL, LL cases
79

3.
All active B T cases with 10 0r >lesions

a. Supervised once a month
i. Clofazamine 300 mg
ii. Rifampicin 600 mg
b. Unsupervised daily i. Clofazamine 50 mg
ii. Daps one 100 mg
Treatment in Paucibacilliary
1. Single skin lesion, no nerve thickening
a. Single dose-Rifampicin 600 mg +
i. Oflox acin 400 mg +
ii. Minocyclin 100 mg
2. Single nerve lesion or 2-9 lesion-(6 mont h s)
a. Supervised once a month
i. Rifampicin 600 mg
ii. Daps one plus
b. Unsupervised dailyi. Daps one 100mg
Treatment Failure reason s1. Ignorance
2. Toxicity
3. Skin discoloration
4. Attitude of Health staff
5. Social prejudice
6. Symptoms do not subside as quickly as expected
7. Distance
8. Clinic hours
The elimination strategy based on MDT has proved to be effective and is working well. However,
several challenges need t o be overcome to ensure that leprosy services are fully integrated and
sustained. These include to:
a. Further simplify and shorten the current MDT regimen;
b. Abolish classification for treatment purposes;
c. Identify areas and communities not yet covered by leprosy services;
d. Actively change the negative image of leprosy to be more positive;
e. Focus more on analysis of detection trends than on prevalenc e; and
f. Develop an integrated community-based strategy for rehabilitation.
New er approachesModified Leprosy Eradication Program (1997)Realizing that though the National average performance has been satisfactory, there were States with
poor performance which was revealed during a mid term appraisal in April 1997
In order to address these challenges mentioned above and referring to the appraisal report, a few
areas were identified for int ensive efforts. These are1. Training
2. Intensified IE C
3. Detection and immediat e MDT
80

These three activities have been merged in the Modified Lepro sy Eradication Program wherein
States and Districts according to endemicity levels have been categorized and accordingly action
plan developed for1. 8 States with prevalence rate less than 5/ 10000 with
a. Active case finding
b. Promoting self reporting (Voluntary reporting by cases-VRC)
c. IEC & Training
2. 14 States with prevalence rate 1-5/ 10000
a. VRC
b. Staff training &IE C
c. Detection of paucibacilliary cases
3. 13 States with prevalence rate less than 1/ 10000
a. Intensified IE C
b. Detection of paucibacilliary cases
81

National Program for prevention of Visual Impairment and Control of Blindness (1976):
Started as National Trachoma Control P rogram in 1963 as the first
organized attempt to control blindness, the program was renamed as
National P rogram for prevention of Visual Impairment and Control of
Blindness in 1976.
The National surveys (1973-75) have estimated 12.5 million people to
be suffering form economic blindness with a visual acuity of < 6/60. (2.2
million became ec onomically blind each y ear). Children almost makeup
for 25% of total blind in the country
Ex tent of the problem:
As per WHO criteria 40-45 million people are blind worldwide. Where as a further 135 million people
have low vision. In India nearly 12 million people are blind, the major proportion of which remain in
rural, remote and underserved areas. According t o WHO estimation, by the year 2020 the number of
people who are blind and vis ually impaired will be t wice the current level unless aggressive and
innovative approac hes are taken. India is committed to reduce this burden of blindness by adopting
the strategies advocated for vision 2020-' THE RIGHT TO SIGHT."
Prevalence Rate
As per survey conducted by Indian Council of Medical Research during 1974 the prevalence rate of
blindness in India was 1.38%. During 1986-89 conducted by GOI/WHO, the prevalence rat e was
1.49%. During 1999-01 survey in 15 districts of the country indicated that 8.5% of 50+ population are
blind.
Rapid survey oon avoidable Blindness conducted under NP CP during 2006-07 showed reduction in
the prevalenc e rate of blindness from 1.1% (2001-02) to 1%(2006-07).
With a Goal of reducing the Blindness prevalence from 1.4% to 0.3% by 2020; a centr ally
spon so red program was started with following objectivesMajor cause s for Blindne ssOf the total,
Cataract:
80.1 %
Refractive errors:
7.35%,
aphakia:
4.6%
Glaucoma:
1.7%,
Corneal opacities:
1.55%
Trachoma:
3.9%
Other causes:
4.25%
Objectives:
1. To bring down the prevalence rat e of cataract blindness from 1.49% to 0.8% by the year
2007.
2. To provide high quality of eye care to the affected population.
3. To expand coverage of eye care to the affected population.
4. To expand coverage of eye care services to the under-served areas.
5. To reduce the backlog of blindness by identifying and providing services to the affected
population.
6. To develop institutional capacity for eye care services by providing support for equipment and
material and training personnel
82

th
11 Plan Objectives (2007-12)
To reduce the backlog of blindness through identification and ttratment of blindness.

To develop Comprehensive Eye care facilities in every District.
To develop Human Res ourc es for providing ey e care services.
To improve quality of service delivery.
To secure participation of Voluntary Organisations/Private Practitioners in eye care.
To enhance Community awareness on eye care.
th
11 Plan Strategies (2007-12)
Decentalise implementation of the scheme through District Healtrh S ocieties (NP CB)
Reduction in the backlog of the blind persons by active screening of the population above
50years, organizing screening eye camps and transporting operable cases to eye care
facilities.
Involvement of voluntary organisations in various eye care activities.
Participation of community and Panchayati Raj Institutions in organizing services in rural
areas.
Development of eye care services and improvement in quality of eye care by training of
personnel, supply of hightech opthalmic equipments, strengthening follow up services and
regular monitoring of services.
Screening of school age group children for identification of treatment of refractive errors with
special attention in under served ares.
Public awareness about prevention and timely treatment of eye ailments.
Special focus on illetrate women ofn rural areas. Foer this purpose there should be
convergence with various ongoing schemes for development of women and children.
To make eye care comprehensive, besides cataract surgery, provision of assistance for ot her
eye diaseases like diabetic retinopathy, glaucoma management , laser techniques, corneal
transplantation, vitreoretinal surgery, treatment of childhood blindness ect.
Program Strategy1. Strengthening Service delivery

a. Improving physical, technical and managerial capabilities of all Health institutions and
selected NGOs
b. Setting norms for servic e delivery
c. Emphasis on vision restoration through quality surgery, after care, follow up,
provision of IOL
d. Camp approach to cover Rural and tribal areas on priority
2. Developing Human resource for ey e care
a. Training of Ophthalmic personnel, besides teachers, volunteers and functionaries of
Primary health care system
3. Promoting outreach activities
4. Increasing Public awareness
5. Developing institutional capacity
a. Management training
b. Developing collaborative mechanism
c. Introducing monitoring and feedback mechanisms
83

Strategies:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Decentralized implementation of the scheme through District Blindness Cont rol Societies.
Reduction in backlog of blind persons by active screening of population above 50 years of
age. Organizing screening eye camps and transporting operable cases to eye care facilities.
Involvement of voluntary Organization in various eye care activities.
Participation of community and panchayat Raj institutions in organizing services in rural
areas.
Development of eye care services and improvement in quality of eye care by training of
personnel, supply of high-tech equipments, strengthening follow up and monitoring services.
Screening of school going children for identification and treatment of refractive errors with
special attention in underserved areas.
Public awareness about prevention and timely treatment of eye ailments.
Specific focus on illiterate women in rural areas. For this purpose there should be
convergence with various ongoing schemes for development of women and children.
To make eye care comprehensive, besides cataract surgery other interlobular surgic al
operations for treatment of Glaucoma. Diabetic Retinopathy may also be provided free of cost
to poor patients through Govt. and NGOs.
Acti vities:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Strengthening of eye care infrastructures in the state.

Improvement of quality of eye care services by training of ey e care personnel.
Provision of modern equipments instruments and other commodity assistance by GOI.
Provision of vehicle.
Increased no of cataract surgery.
Abolition of reach out camps.
Introduction of cataract surgery with IOL implantation.
Involvement of NGOs. Component activities under NPCB:
Cataract surgery.
School eye screening.
Eye donation and Eye Banking.
Training and capacity building of ASHAs to orient them towards Blindness control program as
well as create a core group of field functionaries who will initiat e and c reat e awareness on
blindness control program at the village level.
a. IEC and EYE health education at all levels to be undertaken. and referral for eye care
Implementing agenciesDi stri ct Blindn ess Cont rol Societ y (DB CS) Compo sition o f DBCS Chairman
: District Collector
Vice chairman
: Chief Medical & Health Officer
Members
: Medical Superintendent. Of District hospital
District Education Officer
Representatives of NGOs
President of IMA
Ophthalmic surgeon of Mobile surgical unit
An eminent practicing Ophthalmologist
Member secretary
: District Blindness Control Coordinator
84

Function s of DB CS
1. Plan, Implement and Monitor activities related to Blindness control
2. Draw list of voluntary agencies/ private hospitals/ NGOs & involve in Blindness control
3. Coordination with Health & other departments
4. Raise funds and monitor use of funds
Indicator s:
1. Cataract operation in bi-lateral Blind
2. Cataract surgery in Female.
3. Cataract surgery in SC S T population.
4. Cataract surgery in different facilities
5. Cataract surgery in different age groups.
6. Initiatives that will be int egrated int o the Blindness Control Program:
7. Free surgery for cataract cases in rural areas.
8. Free transportation for patients of unreached areas.
9. Free medicine for all types of eye ailments.
10. Free spectacles for post operative care.
11. Free spectacles for poor school students.
12. All backlog cataract cases would be treated.
13. All schools would be covered for SES.
14. All children would be given Vitamin-A supplement ation and immunization coverage.
15. Modern and advanced t reatment would be available in all Medical College Hospitals and
DHHs,
16. Two Eye Banks to be established.
17. Establishment of one RIO (Regional Institute of Ophthalmology) in one of the medic al
colleges.
Achievements:
Performance of Cataract Surgery:
Year
Target
2002-03
4000000
2003-04
4000000
2004-05
4200000
2005-06
4513000
2006-07
4500000
2007-08
5000000
2008-09**
6000000
International partners: World Bank and DANIDA
Achievement
3857133
4200138
4513667
4905619
5040089
5404406
192805
% Surgery w ith IOL

77
83
88
90
93
94
--
All this requires is enforcement; education and strengthening iodized salt supply through Public
Distribution System and incentive to salt manufacturers. The Sun logo on iodized s alt packs has
already helped in distinguishing it from plain salt.
85

National Iodine Deficiency Di sorder s Control Program:

Launched as National Goiter Control Program in 1962, the program
simply focused on iodized salt.
The operational and logistics punctuations prevailed. Prevalence of
goiter did not change. The problem was reasse ssed b y ICMR and
findings indic ated that i.
Goiter is just not restricted to Goiter- belt in Sub-Himalayan
region but is prevalent in other areas also (Gujarat,
Maharashtra, Punjab, MP, Kerala, Assam and AP).
ii.
Iodine deficiency is not restricted to endemic Goiter and/ or Cretinism but has wider
implications in form of deaf mutism, mental retardation and impaired cognitive functions.
iii.
200 million are exposed t o risk of IDD (61 M with Goiter, 2.2 M have cretinism, 6. 6 M mild
neurological disorder)
The program was re-baptized as National Iodine Deficiency Diso rder s Con trol Program, in 1992.
Problem StatementWorlds single most signific ant cause of preventable brain damage and mental retardation.
261 million suffering from brain damage (10 million cretins)
130 countries, 13% of worlds population.9 million persons affected. 2.2 billion people live in ID areas
167 million at risk of IDD Goiter- 54.4 million, IDD mental/motor handicaps - 8.8 million
1984-86: ICMR multi centric study(14 districts in 9 States, Goiter prevalence 21.1%, Endemic
cretinism : 0.7%)
India : 241 of 617 Districts are Goit er endemic
140 million people are estimated to be living in goiter endemic regions
In 1983 Mrs. Indira Gandhi asked-What is Iodine Deficiency?, Why should I be interested in National
Goitre Control Programme ( NGCP)? and how is it going to contribute towards Prime Ministers 20
point programme?
51% HH consuming iodized salt (State of Worlds Children, 2009-UNICEF)
Surveys in 310 districts of 28 States and 5 Union territories by DGHS, ICMR and State Health
departments has revealed that out of 324 districts surveyed, 263 districts have IDD prevalence of >
10%, 200 million people are at a risk of IDD and 71 million people are suffering from Goiter and other
iodine deficiency related disorders
Chronolog y of development s in Iodine deficiency:
1962: NGCP launched
1984: Policy of Universal salt Iodization (US I)
: Private sector to produce iodized salt
1992: NGCP renamed as NIDDCP
1995: Independent survey evaluation of US I in
MP, New Delhi and Sikkim
1997: sale and storage of common salt banned
1998-99: NFHS II (71% using iodized salt)
13th Sept 2000: ban on sale of common salt lifted by the GoI, States continued the ban
Spectrum of IDD
Fetu s:
Abortion, Still Birth, Congenital Anomalies, Prenatal mortality, Infant

mortality, Neurological cretinism (mental deficiency, deaf mutism, squint)
Neonate:
Neonatal Goiter, Neonat Hypothyroidism
Child and adolescent : Juvenile Hypothyroidism, Impaired Mental function, Growth retardation
Adult :
Goiter, Hypothyroidism, Impaired mental function
86

Classi fication
Grade 0:
Grade 1:
Grade 2:
of goiter
No palpable or visible goiter
A mass in the neck with enlarged thyroid, palpable but not visible
Swelling in the neck that is palpable as well as visible
Program goalBring down IDD prevalence to < 10% by 2000

To decrease overall IDD prevalence (goiter) to <5% in the school children 6-12 years.
Program Objective
1.
Surveys to assess the magnitude of the Iodine Deficiency Disorders
2.
Supply of iodated salt in place of common salt
3.
Resurvey after every 5 years to assess the extent of IDD and the impact of iodated salt
4.
Laboratory monit oring of iodated salt and urinary iodine excretion
5.
Healt h education and publicity
Program component s1.
Survey to identify Goiter endemic areas
th
2.
Fortify all edible salt with iodine in a phased manner by end of 8 5-year plan
3.
Production and supply of Iodized salt to all endemic areas
4.
IEC
5.
Re survey of endemic areas after 5 years of iodized salt supply to ascertain impact
6.
Laboratory monit oring of iodized salt and urinary excretion of iodine
Implementation plan:
Creating Demand for iodized salt in Community
Improving Monitoring of quality of iodized salt
Increasing outlets and access to low cost adequately iodized salt
Improving iodized salt production
Advocacy with Policy Makers and Programme Managers

Implementing partnersa. Ministry of Railw ays (subsidized trans port of Iodized salt)
b. Ministry of Indu stry (controlling production of iodized salt through S alt Commissioners
office)
c. Ministry of Health (Supervision, monitoring & evaluation besides implementation of PFA
Act)
d. Civil supplies department in States (Procurement, transportation and s upply of iodized
salt to population in endemic areas )
Support fr om International agenciesUNICEF is the main partner in IDD control program, in 13 States for monitoring and extensive IE C
Achievements:
a. Salt manufacturing license issued to 930 units, 550 of them are producing iodized salt
with a capacity of 13 million MT
b. Production of iodized salt recorded at 49.83 million MT in 2005-06
c. 26 States have totally banned non-iodized salt, and 2 have banned it partially
d. 29 States and UTs have established IDD cells
e. Intensive IEC campaigns using all kind of media has started in all States
87

f.
Standards for iodized salt have been laid down as 30 ppm at production and 15 ppm at
consumption level
g. A National reference laborat ory set up at Bio-Chemistry division of NICD for training
h. Ban on sale of non iodised salt w.e. f May 2006, under PFA Act 1954
Of the 11091 samples of salt examined in 2002-03, 87.3% samples were not satisfactory. The
reasons offered arePoor supervision and control over salt manufacturers
Poor PFA Act enforcement by States
Industrial salt being sold to domestic consumers for economic reasons
Plain salt is economical
88

PIP & District Ac tion Plan (DAP) under NRHM

Planning terse can be put as an act or proc ess of choosing between alternatives to accomplish
preset goals.
Plan denotes a blue print of action.
The planning process involves a number of steps which are essential to identify, look into
alternatives, and decide priorities and evaluation of impact.
The entire planning process is punctuated and complimented by constraints & considerations related
to Finances, Manpower, Legal issues and expectations of people, whic h put together forms the
Planning Environment.
Planning helps in assessing and forecasting demands and requirements, assessing resources
available and matching resources with requirements in view of competing priorities
The planning prerequisites are1. Base line of standards and performanc e
2. Additional resources
3. Reallocation of resources.
Planning step s1.
2.
3.
4.
5.
6.
Situational analysis
Deciding objectives
Defining strategies
Laying an Operational Plan
Implementation
E valuationa. criteria,
b. frequency and
c. process
Further, specific to Health care, the planning process is cyclical & repetitive involving the following
steps1. Measurement or assessment of burden of illness
2. Identification of cause of illness
3. Measurement of effectiveness of different community interventions
4. Assessment of efficiency of interventions in terms of resourc es used
5. Implementation of interventions
6. Monitoring of activities
7. Reassessment of burden of Dis ease to see if there is any change
Planning as such need to be tailor made in view of the varied geo geographical situation , burden of
diseases, the infrastructure and manpower available and the resources based on these. Under this
context it was envisaged under NRHM to develop District specific plans taking a cognizanc e of
morbidity, mortality, resources, infrastructure and objectives in consonance to t he overall goals of
NRHM and National Health Policy.
89

Why district action plan s?

1. Mechanism to partner with community
2. Planning bas ed on local evidence and needs
3. Area specific strategies to achieve NRHM goals
4. Cost effective and practical solutions
5. Move from budget based plans to outcome oriented plans
6. Requirement of GOI no funds if no plans
Why emphasis on participator y planning?
The very basis of District Action Plan is to have all t he stake holders involved into the planning
process so that everyone in rank and file feels involved and has a feel of ownership. The participatory
planning shall help in:
1. Promote community ownership
2. Greater ownership of health functionaries
3. Harness benefits of community action
4. Bring accountability of healt h functionaries to community members
5. Draw together elements that are determinants of health
6. Share resources and opportunities with partnering departments convergent action
Di stri ct Plan Component s
1. Introduction: - The Setting:
2. Situational Analysis
3. Goals and Objectives
4. Strategies
5. Activities
6. Work Plan/Schedule
7. Monitoring and E valuation
8. Budget
What a distric t plan ought to have
1. Background
2. Planning Process
3. Priorities as per the background and planning proc ess
4. Annual Plan for each of the Health Institutions based on facility surveys
5. Community Action Plan
6. Financing of Health Care Management
7. Structure to deliver the program
8. Partnerships for convergent action
9. Capacity Building Plan
10. Human Resource Plan
11. Procurement and Logistics Plan
12. Non-governmental Partnerships
13. Community Monitoring and evaluation Framework
14. Action Plan for Demand generation
15. Sector specific plan for maternal health, child health, adolescent health, disease control,
Geriatric care disease, Surveillance, family welfare
16. Program Management Structure
17. Budget
90

The entire planning process has to be dealt under different heads wherein the activities will go
simultaneously. For a better understanding the levels of planning have been identified asThe Levels of Planning1. Goals
2. Objectives
3. Strategies
4. Activities/ Processes
5. Inputs indicators
6. Impact indicators
7. Outcome indicators
8. Output indicators
9. Process indicators
Steps f or planning
1. Objectives (what is being planned?)
2. Approach or strategies for reac hing the objectives (how shall the objectives be achieved?)
3. Activities required to achieve the objectives (which? enlistment)
4. The obstacles that may hamper the activities (why?)
5. Resources to be used (who?)
6. Cost of activities (money?)
7. Detailed scheduling
What is being planned?
1. Looking at the situation
a. Information from the community
b. Information from records
i. Morbidity and mortality profile
ii. Healt h care institutions (PPP)
iii. ICDS
iv. Social and cultural background
v. PRI structure
vi. Geographical area
Di stri ct planning-situation analysi s
1. Identify the problems
2. Identify the caus es
3. Do resource analysis to handle the causes---man, money, material &time
4. Map the problem geographically, groups& vulnerability and the resources
5. Identify the strategies to improve.
Di stri ct planning
a. Preparatory Activitie s -Orient District Collectors and CMO & train District Planning teams.
b. Desk Review
1. Compare District with State average and NRHM objectives
2. Mapping- facilities / services /staffing, infrastructure, population served /Patient load
& utilization (PHCs &CHCs)
3. Review performance of National Programs in the last year
4. Map performanc e of A NM/ MPW
5. Mapping of TBA- AWW-ANM- LHV
91

6. Listing of NGOs reach and foc us of work

7. CBOs in the district block and activity- wise
8. Last years budget and expendit ure analysis
c. Community A sse ssment
1. Resource Mapping
2. Understanding health problems
3. Assess BOD
4. Healt h expenditure
5. Problems- referral/ transport/FP
6. Role of P RI
7. Understanding health seeking behavior and practices Pregnancy/illnesses
8. Understanding Community Participation and Ownership: Meeting VHS C
9. Perception and the role of PRI
10. Additional Information
11. Studies
12. NGOs- activities/achievement and willingness
13. Other CBOs / SHGs federation
d. Recognizing important problems
1. Healt h problems
a. Malaria
b. Malnutrition
2. Healt h servic e problems
a. Insufficient drugs
b. Lack of qualified person
c. Difficult terrain
3. Community problems
a. Inadequate water supply
b. No primary education
c. Inaccessibility of health care-socio cultural barriers
e. Setting objective
1. Expected outcomes
2. Relevance(related to the problem or policy)
3. Feasibility (it can be achieved)
4. Observable (its achievement can be clearly seen)
5. Measurable (outcome can be stated in number)
f. Review ing punctuations
1. Types
a. Manpower
b. Materials
c. Money
d. Minutes
e. Environment
f. Technical
g. Social
2. Analyzing punctuations
a. Removable
b. Modifiable
c. Stubborn
g. Defining strategies
How do we aim to achieve objectives?
92

h. Choo sin g Alternative s

a. Technically sound
b. Feasible
i.
Manpower
ii.
Finances
iii.
Manageability of constraints
i. Scheduling the activities
1. Consider the alternative strategies
2. List out the resources
3. Select the best strategy
4. Mobilize the community resources
5. Detail activities
6. Log frame approach
j. Monitoring E fficiency tells you that the input into the work is appropriate in terms of the
output. This could be put in terms of money, time, staff, equipment and so on.
k. Evaluation
1. Measure of the extent of achievement of specific objectives.
2. Whether or not the specific objectives made any difference to the main goals
The PIP is
1. Essentially a statement of intent
2. A description of implement ation wit h estimation of cost
3. Implementation likely to lead to desired results
4. The MOU bet ween C&S should include plans, budget and log frames
Planning Process
The entire DAP should have a bottom up approach where village is the key focus and all
Village plans get converged to Block plans which subsequently are dovetailed into one District Plan.
These DAPs then are consolidated into a State Plan.
State Planning &
Appraisal Committee
District Health
Committees
Block Health
Committees
Village
Healt h
Committees
Additional provi sion s and norm s under NRHM

Village Health Water & Sanitation Committee
10,000
Gram Panchayat Health Committee
10,000
PHC Level Rogi Kalyan Samiti
50,000
Block Untied Fund
50,000
ASHA Workers per 1000 population Gram Panchay at level revolving advance
5,000
CHC Rogi Kalyan Samiti
1,00,000
DH/S DH Rogi Kalyan Samiti
5,00,000
93

Additional provi sion s and norm s under NRHM

1 ASHA Sahyogini /1000 population
2 ANMs/Sub Centre
2 Medical Officers/ PHC (1 AYUS H) Mainstreaming AYUSH
3 Staff Nurses/PHC
7 Specialists/CHC
9 Staff Nurses/CHC
Rs. 20 lakhs for Staff Quarters as per IPHS standards
1 Mobile Medical Unit in each district
Source s of data
1. DLHS
2. NFHS
3. SRS
4. NSSO
5. UNICEF
6. Special surveys by Medical colleges
7. CBHI
8. District data
9. Hous ehold surveys
10. Facility surveys
11. Eligible couple register
12. State annual reports
13. Disease surveillance system
14. Routine reports
Institutional Framew ork for Convergent A ction
1. State Health Mission/Society
2. District Health Mission/Society
3. Block Water & Health Sanitation Committee
4. Village Water & Health Sanitation Committee
Partners and Members in above mentioned Societies and Committees are DWCD; PRI/RD;
Education; PHE D and AYUSH
NRHM
1.
2.
3.
4.
Suppor t to Convergence
Planning process and Joint Action Plan
Sharing of Information
Regular Joint Reviews
Funds for Gap filling - Untied Funds at various levels
Key Enabling Ac tion s

Constitution of State Health Mission
Constitution of State Planning & Appraisal Committee
Constitution of District Planning Teams & their training
Constitution of Block Planning Teams & their training
Forming of Village Health, Water and Sanitation Committees
Nominating selected functionaries to the State, District and Block Planning Committees/Teams for leading
the planning process
Preparing clear guidelines on core NRHM strategies for planning teams at District and Block
Communicating fund availability, allocations and the flow of funds to the Districts and other levels as per
NRHM guidelines
94

Level of planning and the key functionaries:

1.
2.
3.
Village Level
a. ASHA
b. Anganwadi
c. Panchayat Representative
d. SHG Leader
e. PTA/ MTA Secretary
f. Local CB O Representative
g. Data Source-Village Health Register
Gram Panchayat Level
a. The Gram Panc hayat Pradhan
b. ANM
c. MPW
d. Village Health & Sanitation Committee
e. Village Health Plan
Di stri ct Level
a. NGO Repres entatives
b. Few professionals recruited to meet planning and implementation needs.
c. Zila P arishad Chairman
d. District Medical Officer
e. District Magistrate
Condu cting sit uational analysi s

1. Di stri ct Profile
a. Public Health Infrastructure in the District e.g. at Government/rented
b. Human Resources in the District
Functionality of Di stri ct Ho spital s, CHCs, PHCs &SC
1. District: - Availability of Staff needed for service Guarantees.
2. CHC: - Ob & Gy. Specialists, Pediatrician Anesthetist at identified FRUs. Indicate blocks
where more than 20 % posts are vacant.
3. PHC: - A vailability of an ANM at SC. Indic ate PHCs with more than 10 % vacant.
4. Sub-Centre:- A vailability of an A NM at sub-centre.
Statu s of Logi stic s
1. A vailability of a dedicated District warehouse for health department.
2. Stock outs of any vital supplies in last year.
3. Indenting Systems (from peripheral facilities of districts).
Ex istence of a functional sy stem for asse ssin g Quality of Vaccine
1. Status of Logistics
a. Physical Infrastructures
b. Indicate the trainings conducted for all categories of health personnel's.
c. Training load.
d. Personnel's trained each training or topic wise
2. Locally Endemic Dis eases in the District.
3. New Interventions under NRHM
95

Importance of Facility sur vey s

1. No routine allocation of resources under NRHM.
2. E very health facility will have to develop a baseline and an annual plan.
3. Funds will be released only after outcomes are guaranteed by additional funds
4. E very health facility need will be specifi cally asked for in the annual district action plan and
budget.
5. Facility survey should focus on:
a. Main building
b. Staff quarters
c. Equipment
d. Furnit ure and fixtures
e. Cleanliness and sanitation
f. Human resources
g. Needs for medicines and supplies
Indicator s- Some of the variables which should be measured in the District Action Plan
S.
No.
1
2
3
4
5
6
7
8
9
10
Objectives to be achieved b y the district
Current
year
Next
year
Universal coverage of all pregnant women with package of quality ANC services as
per national guidelines
Increase in deliveries with skilled attendance at birth including institutional deliveries
FRUs (including DHs, CHCs/PHCs) made functional as defined in the National RCH
2 PIP
Universal coverage of all eligible pregnant women under JSY scheme
Increase in percentage of new born babies given colostrums
Increase in prevalence of exclusive breast feeding
Increase in percentage of fully protected children in 12-23 months as per national
immunization schedule
Universal coverage with Vitamin A prophylaxis in 9-36 months children
Percentage of severely malnourished children below 6 yrs referred to medical
institutions
Unmet demand for contraception
-Spacing
-Limiting
A. Number of Govt. Health Institutions providing:
i) Female sterilization services DH/ SDH / CHC / PHC
ii) Male sterilization services
iii) IUD insertion services --------- CHC / PHC / SC
B. Number of accredited private institutions providing:
i) Female sterilization services
ii) Male sterilization services
iii) IUD insertion services
11
Number of health institutions in PHCs/CHCs offering ARSH services
12
Number of health institutions providing services for management of STIs and RTIs
13
Percentage (as planned) of ASHAs functional in the district (received induction

training )
14
Number of RKS registered /established
15
Number of Health care delivery institutions upgraded

SHCs
PHCs
CHCs to FRUs fulfilling the 4 basic criteria in FRU guidelines Upgrading to
IPHS will come later ( these institutions should be in conformity with IPHS)
96

16
Performance indicator for NVBDCP

-API for MP
-Annual blood examination rate for MP increased (over 10 % of all OPD cases)
-Slide Postivity Rate
-Number of deaths due to malaria
17
Performance indicator for RNTCP

-Percentage of TB suspects examined out of the total outpatients
-Annualized New Smear Positive (NSP) case detection rate per 100,000 populations
-Annualized Total Case detection rate per 100,000 populations
-Treatment success rate
18
Village health and sanitation committeesConstituted

- Grants given
19
Number of SCs strengthened

- Additional ANMs hired
- Annual maintenance grants given
20
No. of PHCs strengthened to provide 24x7

- 3 staff Nurses hired
- Annual maintenance grants given
21
National Blindness Control Program

- Cataract surgery rate (450/100,000 population)
-% surgery with IOL
- School Eye Screening in the age group of 10-14 years should be screened for
refractive errors
- Oral Health Screening for:
Community
School Children
22
National Leprosy Eradication Program

- PR Leprosy cases per 10,000 population
- ANCDR New leprosy cases per 1,00,000 population
- Proportion of MB, Female, Child, ST, SC cases among the new cases detected
- Proportion of Patients completed treatment (RFT)
23
Integrated Disease Surveillance Program

- Number of labs to be upgraded ( L1 and L2)
- Number of staff to be trained in surveillance activities
24
25
26
27
28
29
30
31
Staff for mobile medical units in place

Number of facilities to be covered for facility survey
- SHCs
- PHCs
- CHCs
No. of villages to be covered for HH survey
No. of Community hearings planned
District training plan developed and implemented
District BCCC plan developed and implemented
District procurement and Logistics plan developed
No. of PHC/CHCs where AYUSH physicians posted
97

Role of DPM
1. Review of sec ondary data, consultations with Department officials to prepare common
guidelines and resource material
2. Facilitate the planning exercise and support the State Planning cell
3. Orientation of Dist. Officials
4. Development and management of Monitoring System for Dist. Planning
5. Field level support to staff
6. Monitoring and review of the field level activities
7. District & Block Level Plan Appraisal
8. Orientation of District Health Missions and Societies
9. Training of District Planning and Appraisal Core Groups (DCGs)
10. Training of Block Planning and Appraisal Core Groups
11. Training of NGOs in the Districts allocated to them
12. Support to multi-stakeholder consultation workshops at block level
13. Support to NGOs for conducting village level participatory planning
14. Assist health facility surveys
15. Assist consolidation of Block Action Plans (BAPs)
16. Assist appraisal and approval of block action plans by the DCGs
17. Assist in preparation of District Action Plan based on BAPs
18. Assist in approval and state level appraisal of DAPs
Role of Block f unc tionaries
1. Review RCH-I lessons & existing program strategies.
2. Compiling t he information, data, reports and evidence from existing rec ords at various levels,
as the basis for planning
3. Reviewing the existing management systems and identifying gaps
4. Development of locally relevant strategies and suggesting changes
5. Provide lead to the cons ultation and participatory planning processes
6. Carry out assessment of strengthening needs of health facilities as per prescribed GoI norms
7. Cons olidate Block Action Plans (BAPs)
8. Prepare District Action Plans based on Block level plans
Role of NGOs
1. Orientation of Village Health Water and Sanitation Committees
2. Involvement of womens groups and community based organizations
3. Support to multi-stakeholder consultation workshops at block level
4. Assist health facility surveys
5. Assist consolidation of Block Action Plans (BAPs)
6. Participate in the functioning of Block Core Group/ Health Committee for planning, program
implementation and monitoring support to the Block Health Plan
Role of PRIs
1. Village Level
a. Select Panchayats for participatory planning.
b. All Gram Panchayats to be included.
2. Block Level
a. PS and Pradhans to lead planning proc ess in Block core groups.
3. Di stri ct Level
a. Healt h and Nutrition Committees of District Panchayats lead the planning process as part
of the District Core Groups.
98

b.
c.
d.
e.
Support implementation of Village Health Plans.

Organize monthly review meetings.
Report progress to Block Health Planning and Appraisal Committees.
Draw attention of emerging needs and call for support from the Health, W CD, IPH, RD
Departments.
99

Inter sectoral convergence

In view of the various determinants, Healt h, terse, requires concerted approach and interaction
between various sectors and calls for strong interaction bet ween all related s ectors. E ven the guiding
principles of the healt h strategy adopted at Alma-Ata, 1978, identified Inter sectoral coordination as
key to achieving HFA recognizing the multilateral linkages bet ween Health, Socio-cultural, Political
and Economic spheres. The departments and areas involved are WCD, PHE D, transport,
communication, Education, PRI member, Local groups, Youth clubs, Mahila mandals, SHGs, and
NGOs
The National Rural Health Mission seeks to adopt a sector wide approach and subsumes key
National Programmes such as: The Reproductive & Child Health P rogramme (RCH-II), the National
Disease control programmes (NDCP) and the Integrat ed Disease Surveillance Programme (IDSP).
NRHM will also enable the mainstreaming of Ayurvedic, Yoga, Unani, Siddha and homeopathy
system of Health (AY USH). Given that health is so critically linked with nut rition, water and sanitation,
NRHM includes strategies for operational convergence to ensure that there is demonstrable synergy
between these sectors.. One of the c riteria for appraisal of District Health Plan was ensuring that the
entire range of wider determinants of health have been taken care of in the approach to convergent
action.
The Anganwadi Worker, ASHA and ANM are proposed to form the core of the Village Healt h Team
and all three will work together to draw the village healt h plan in consultation with dais, other
stakeholders and local opinion leaders. The Anganwadi will be the core institution for activities
relating to delivery of health, family welfare and nutrition services at the village level. It will also serve
as the institutional set up for ASHA at village level.
What is convergence:
A proc ess - that facilitates different functionaries and community to work together for efficient service
delivery
Convergence 1. Saves time
2. Helps in building rapport
3. Increases efficiency
4. Reduces workload
5. Sharing of ideas
6. Trustworthy
Why convergence:
1. Vertical nature of programs
2. loosing focus on primary health care
3. Need to ensure unity of purpose
4. Provide directionality
5. Promote team work
How ISC helps:
1. More participative
2. Implies commitment
3. Economizes efforts
4. Improves quality of work
5. A void duplication and wastage
6. Optimizes output
100

Type s of con vergence:

1. Within the department Int ra-s ectoral
2. Between the department
3. Inter-sectoral coordination
4. Intra-sectoral coordination:
Con straint s in inter-sect oral coordination:
1. At the Knowledge level (program goals and implementation in isolation)
2. At the Attitudinal level(power conflicts and egos related to programs)
3. At the Practice level(unaware about mechanism of operations)
Pre-requisite s of effec tive coordination:
1. leadership style and willingness
2. Healt h policies and priorities
3. Sharing of a common vision and perspective
4. Defining role & responsibilities of participatory agencies
5. Participatory decision making
6. Developing informal contacts with involved groups
7. Learning more about quality of services
8. Spelling out strategies and procedures
9. Conducting joint monitoring and evaluation
10. Taking remedial measures in solving problems related to coordination
Some of the activities of health department providing scope for inter-sectoral coordination are:
a. Supply of safe water,
b. Excreta disposal and refuse disposal,
c. Waste water disposal,
d. Maternal and child health,
e. Family welfare, immunization against major infectious diseas es,
f. Prevention and control of locally endemic diseases, and
g. Healt h education on prevailing healt h problems.
Coordination Mechanism
a. Listing out the programmes which need joint efforts
b. Identifying the areas where coordination is required
c. Know ing the categories of health personnel whose activities should be integrated
d. Locating the level of health systems where joint efforts are needed
e. Forming coordination committee of members of district health team which includes all the
middle level supervisors and specialized functionaries
f. Forming of operation teams at field level
Interdepartmental convergence 1.
Convergence w ith WCD:
The Department of Women and Children (DWCD) is t he repository of national programmes for the
holistic development of women and children. It includes: the Integrat ed Child Development Services
(ICDS ), to provide supplementary nutrition for pregnant and lactating mothers and children under six,
and non-formal preschool education; programmes to ensure social and ec onomic empowerment of
101

women through collectivization, welfare and support services, training for employment and income
generation, and gender sensitization. DWCD and Health Dept.have overlapping goals, and thus
complementary programming is essential. Such programming needs to extend to other stakeholders,
such as NGOs, academic, researc h, and t raining institutions, involved in health, nutrition, and
womens
empowerment.
Success of convergence in health, nut rition, and empowerment requires convergence of approaches
in DW CD and Health Dept.in: behaviour change communication strategies, planning modalities,
monitoring and information systems, capacity building and training inputs. Additionally theHealth
Dept. must ensure that convergence efforts are backed by a strong service delivery system,
responsive to community needs.
The following areas of convergence between Health Dept. and DWCD could be considered:
a.
b.
Women and Childrens Healt h: Mobilization of women, adolescents, and children and
provision of a package of quality health education and services at the village level
Womens empowerment, gender and equity: Involvement of community based womens
groups to ensure that social and related determinants of health including gender and equity
are addressed. These include prevention of early child marriages, implementation of the
PNDT Act, including awareness and action against girl child elimination, leading to distorted
sex ratios, domestic violence, and mobilization of resources through collective action for
health and ot her emergencies.
Convergence between the following functions of bot h departments for nutrition, health and womens
empowerment is also necessary. They include:
a.
b.
c.
d.
Joint formulation of BCC strategies, materials, and messages,

Operational strategies for joint planning at village, block and district levels,
Development of joint MIS including common indicators,
Identification of functional areas for training of staff including joint training
Issue s for con vergence betw een WCD and Health

1.
Low birth weight how to reduce it? cope with it ?
2.
How to reduce IMR, high morbidity and undernutrition during infancy
3.
How to reduce under five mortality rates& high undernutrition rat es in preschool children
4.
What can we do to reduce anaemia in Indians
5.
Is it possible to ensure universal access to iodised salt by 2010
6.
How do we tackle over- nutrition and disease risks
Synergy betw een ANM, ASHA and AWW
A. Safe Abortion Services
i.
AWW, and ASHA may help in early identification of women who need safe abortion
services
ii.
ANM can refer them to the appropriate facility for MTP and cont raception
B. Antenatal Care
i.
ANM provides ANC
ii.
AWW provides Food supplements to pregnant women
C. Convergence: on the health & nutrition days
i.
AWW& ASHA can bring all pregnant women to AW to record weight.
102

ii.
ANM can provide ANC (check BP,Hb?& obst exam) to 15-20 pregnant women in the
anganwadi.
iii.
Synergy in delivery care
iv.
Decision regarding place of delivery (domiciliary & health facilities).
v.
ANM will identify low risk women who can deliver at home;
vi.
AWW and ASHA can monitor for clean delivery
vii.
If there are complications during delivery ASHA can help the woman to access
emergency care at the right place
viii.
PRI can facilitate emergency transport
ix.
AWW can weigh all neonates in home deliveries,
x.
identify those weighing less than 2 kg and refer them to CHC for care
xi.
ASHA and P RI can facilitate emergency referral for neonate
D. Declining sex ratio
i.
Women who have two or more girls can be counseled about the fact that fetal sex
determination by ultrasound is possible only in second trimester and s econd trimester
abortions are dangerous to the mother
ii.
The village women / AWW /ASHA can readily identify women in the village who
have two or more girl children these women can be pers uaded during ant enatal
check up to have hospital deliveries; hospital delivery may
reduce the female
infanticide at birt h
E. Low Birt h Weight
i.
anganwadi workers to report all births in village,
ii.
weigh all neonates delivered at home soon after birth and
iii.
refer those weighing less than 2.2 kg to a hospital with a pediatrician.
2. Convergence w ith water and sanitation
The department of public health engineering(P HED) & department of panc hayat & rural development
implements two mission mode initiatives for improving access, coverage, quality of s afe water and
sanitation in a sustainable manner through the total sanitation campaign (TS C). Activities under TSC
are: construction of individual household latrines, latrines, community sanitary complex es, anganwadi
toilets,IEC , school sanitation and hygiene education, and rural sanitary marts and production centers.
TS C and NRHM rely on community led approaches and are expected to be managed by panchayats.
Strong intersectoral convergence is necessary at the district and state levels for improved synergy
among these three initiatives. The institutional arrangement for the total s anitation campaign (to be
universalized) will be the same at district and village levels.
The village health & sanitation committee (V HSC) will be formed in every villages of state as per
guidelines of govt. of India. The VHS C will be responsible for planning, monitoring and
implementation of NRHM activities at the village and creating a demand for the services.
Involvement of PRI s: Monitoring and supervising the services of healt h (and related) functionaries
providing services to the masses are important and hence involvement of elected representatives is
imperative. Under t he programme, the P RIs will be involved. PRIs will be sensitized and oriented
towards issued relating to women and reproductive health issues, child health issues, family planning
and gender.
Panchayati Raj Institutions will be responsible for the selection of AS HA and AS HA will be
responsible t o the Gram Panchayat. At the village level, the Gram Panchayat will guide the Village
103

Healt h and Sanitation Committee. Funds for activities for involvement of PRIs have already been
budgeted under the head Behaviour Change Communication.
3. Convergence w ith Education Department:
Various agencies working on adolescent issues will be converged for improving the knowledge of
adolescents in sexual and reproductive health issues. Secondary, Higher and Technical Education
dept would be involved in implementing the School Health P rogramme like formation. They will be
involved in ASRH issues. A system of counseling young married adolescents and adults will be
work ed out through the peer educator and other grass root NGOs, by the health department
Extension workers of educ ation, rural development, agriculture departments in propagating IEC
messages pertaining to health and RCH programs Coordination among village-level functionaries anganwadi workers,
TBAs, Mahila Swasthaya S angh, Krishi Vigyan Kendra volunteers and school teac hers can help in
the population to optimally utilise available services reproductive and child healt h care to the
population with whom they work.
ANM, MMPW and AWW can also talk to the families they look after and give them messages
pertaining to agriculture, education, water supply, sanitation, how to improve the status of the girl
child and women, how to improve female literacy and employment, raise age at marriage, and how to
improve nutritional status of women and children.
Potential areas of convergence of services between healt h and educ ation include:
a.
b.
c.
inclusion of educ ational material relating to health, nutrition and population in the curriculum
for formal and non-formal education;
involvement of all zilla saksharata samitis in IE C activities pertaining to the RCH programme;
involving school teachers and c hildren in Class V and above in school health programmes,
growth monitoring , immunisation and related activities in the anganwadi at least once a
month as a part of socially useful productive work.
4. Con vergence w ith National Blindness Con trol Programme:,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,

The National Blindness Control Programme and NRHM will develop a strategic plan to address the
refractory errors and eye related problems of children & adolescents under the School Health
Programme.
104

Janani Suraksha Yojana (JSY)

Janani Suraksha Y ojana (JS Y) is a s afe motherhood intervention,
replacing the Maternity Benefit Scheme, under the National
Rural Health Mission (NRHM) being implemented with the
objective of reducing maternal and neo-natal mortality by
promoting institutional delivery among the poor pregnant women.
JSY is a 100 % centrally sponsored scheme and it integrat es cash
assistance with delivery and post-delivery care.
The scheme has identified ASHA, the accredited social healt h activist as an effective link between the
Government and the poor pregnant women in l0 low performing states, namely the 8 EA G states and
Assam and J&K and the remaining NE States. In other eligible states and UTs, wherever, AWW and
TBAs or AS HA like activist has been engaged in this purpose, she can be associated wit h this Yojana
for providing the services.
Vision Goal s
:
a. To reduce MMR & IMR
b. Increas e in stitu tional deliveries in BPL families
Target group
:
a.
b.
Strategy
Features
All pregnant women of the age 19 yrs and above from BPL families up to 2 live
births
All women from BPL families of 10 LPS (8 EA G plus Assam and J&K ) even after
third live birth
: Link cash incentive to Institutional Delivery by promoting1. Early registration

2. Identification of complicated cases
3. providing 3, ante-natal & post-natal visits
4. Organizing referral services and trans port
5. Convergence with IMCD (ICDS) by involving Anganwadi workers
6. Transparent & Timely disbu r sement of cash assistance and incentive to AS HA
from funds available with Female Health Work er
7. 24 X 7 delivery services at PHC
8. Making FRUs functional to provide Emergency Obstetric services
9. Building partner ship through a proc ess of recognition/ accreditation of
Professional, Institutions in private sector specially in rural areas
:
1. Number of States covered- 10
2. 8 EAG (Economic Action Group) States
3. Assam
4. J& K
5. Categories under which 10 States are put6. High Performanc e States (HPS)
7. Low performance States (LPS)
8. Cash assistance linked to Institutional delivery
9. Cash assistance in Graded scale-
105

Eligibility for Ca sh A ssi stance:

LPS States
All pregnant w omen delivering in Government health centres like Sub-centre,

PHC/CHC/ FRU / general wards of District and state Hospitals or accredited private
institutions
BPL pregnant w omen, aged 19 years and above
All SC and ST w omen delivering in a government health centre like Sub-centre,
PHC/CHC/ FRU / general ward of District and state Hospitals or accredited private
institutions
HPS States
LPS & HPS
Note: BPL Certification Thi s i s required in all HPS states. However, where BP L cards have not
yet been issued or have not been updated, States/UTs would formulate a simple criterion for
certification of poor and needy status of the expectant mothers family by empowering the gram
pradhan or ward member.
Scale of Cash A ssi stance for In stitutional Delivery:
Category
LPS
HPS
Rural Area
Mothers
Package
1400
700
ASH As
Package
600
Total
Rs.
2000
700
Urban Area
Mothers
Package
1000
600
ASH As
Package
200
Total
Rs.
1200
600
Note 1: Importantly, such woman in both LPS and HPS states, choosing to deliver in an accredited
private health institution will have to produc e a proper BPL or a SC/ST certificate in order to
access JSY benefits. In addition she should carry a referral slip from the ASHA/A NM/MO and the
MCH - Janani Suraksha Yojana (JSY) card.
Note 2: A NM / ASHA / MO should mak e it clear to the beneficiary that Government is not responsible
for the cost of her delivery. She has to bear cost, while choosing to go to an accredited private
institution for delivery. She only gets her entitled cash.
While mother will receive her entitled cash, the scheme doe s n ot provide f or ASHA pac kage for
such pregnant women choosing to deliver in an accredited private instit ution.
Limitations of Ca sh A ssi stance for Institu tional Delivery:
In LPS States
In HPS States
All b irths, delivered in a health centre Government or Accredited Private

institutions.
Up t o 2 l ive births.
health
Di sbur sement of Ca sh A ssi stance: As the cash assistance to the mother is mainly to meet the cost
of delivery, it should be disburs ed effectively at the institution it self.
For pregnant women going to a public health institution for delivery, entire cash entitlement should be
disbursed to her in one go, at the health institution. Considering that some women would access
accrediting privat e institution for antenatal care, they would require some financial support to get at
least 3 A NCs including the TT injections. In suc h cases, at least three-four th (3/4) o f the cash
assi stance under JSY should be paid to the beneficiary in one go, importantly, at the time of
delivery.
To Beneficiary:
1. The mother and the ASHA (wherever applicable) should get their entitled money at the heath
centre immediately on arrival and registration for delivery.
106

2.
Generally the A NM/ ASHA should carry out the entire disbursement process. However, till
ASHA joins, AWW or any identified link worker, under t he guidance of the A NM may also do
the disbursement.
At accredited private institution : Disbursement of cash to the mother should be done through the
ANM/ASHA/ Link worker c hannel and the money available under JSY should be paid to the
beneficiary only and not to any ot her person or relative.
Sy stem should en sure that:
1. Such accredited private institution would also be responsible for any postnat al complication
arising out of the cases handled by them.
2. They should not deny their services to any referred target ed expectant mother.
Note: E very month, accredited private health centers would prepare a statement of JSY delivery / ANC/ obstetric complication cases handled by them and send it to the Medical officer,
along with the referral slips for sample verification by the concerned ANM / ASHA.
If there is no ASHA the total amount shall be paid to women, same if woman opts not to take
assistance of ASHA
1. Assistance for Caesarean section- 1500/- per case for hiring s ervices of private expert in
cases of Facility for C/S not available at FRU/ CHC
2. Compens ation payment for Tubectomies/ Laparoscopy
3. Disbursement of cash assistance at the earliest
a. Impress of 5000/- with Female Health worker
b. Cash advance of 1500/ - with ANM at any point in time
4. Partnership with Private Sector - Empanel at least 2 private institutions
5. Provision to meet administrative expenses
(7% (4% district, 2% for state & 1% nodal ministry) of the fund released to State is to be used
for administrative expenses towards monit oring and IE C monitoring and IE C)
Payment of cash:
1. To expectant mother
a. all payments in one installment
b. Responsibility of disbursement-A NM / ASHA
2. To ASHA or equivalent worker
a. In 2 installments
i. Advance
ii. Balance in 2 installments
-50% on discharge of JSY beneficiary
-50% after one month - (PNC, BCG, New born
registration
3. Cause of delay to be dealt seriously
4. Display of names of JSY beneficiaries (mandatory) at SC, PHC and local
Panchayat office
BPL Certification :
a.
b.
c.
BPL card verification

Criteria to be laid down by State/ Municipalities
ASHA to facilitate obtaining of certificate
107

Micro-birth plan for JS Y beneficiaries:

Ste
p
1
Acti vity
To be undertaken by
Identification
and
Registration of beneficiary
AN M/ASH A/AWW or any link worker
Filling up of Maternal and

Child card ( In duplicate
one each for mother and
ASH A/Link worker)
Inform dates of 3 ANC &
TT Injection (s)
AN M/ASH A/AWW or an equivalent link worker
Identify the health center

for all referral
ASH A to follow up the ANCs at the Anganwadi Centres/

Sub-center (SC) and ensure that the beneficiary attends the
SC/Anganwadi centre /PHC for ANC on the indicated dates
Identify the
Delivery
Place
AN M/ASH A/AWW or an equivalent link worker

Provide the 1st ANC immediately on Registration.
of
Inform expected date of

delivery
Collecting
BPL
or
necessary
proofs
/certificates
Wherever necessary from
Panchayat / local bodies /
Municipalities
Submission
of
the
completed JSY card in the
Health
center
for
verification
by
the
authorized/Medical officer.
Proposed
Time Line
At least 2024
weeks
before the
expected
date
of
delivery.
Immediately
on
registration
Immediately
on
registration
Moti vation: ANM should call the beneficiary to the

Anganwadi/SC to participate in the Monthly meeting and
explain enhanced cash and Transport assistance benefits
for Institutional delivery.
AN M/ASH A/AWW or an link worker
MO, PHC
AN M/ASH A/AWW/link worker
Within 2-4
weeks from
Registration
Atleast 2-4
weeks
before the
expected
date
of
delivery
II. Take necessary steps

toward arranging transport
or making available cash to
the beneficiary to come to
the Health Centre
AN M/ MO, PHC
6.
III. Ensure availability of

fund
to
ANM/Health
worker/ASHA
Payment of cash benefit /
incentive to the mother and
ASH A
AN M/ MO, PHC
At
the
institution.
108

For complicated case s or tho se requiring ce sarean section etc:

Ac 1
Ac 2
Ac 3
Ac 4
Pre-determine a Referral health center and

intimate the pregnant women
Familiarize the woman with the referral centre, if
necessary carry a letter of referral from MO PHC
Pre-organize the transport facility in consultation
with family members/community leader
Arrange for the medical experts if the same is not
available in the referred heath center
By AN M/ASH A/link worker

AN M/ASH A/link worker
AN M/ASH A/Community
MO, PHC
Role of ASHA or ot her link health worker associated with JSY would be to:
1. Identify pregnant woman as a beneficiary of the scheme and report or facilitate registration for
ANC,
2. Assist the pregnant woman to obtain necessary certifications wherever necessary,
3. Provide and / or help the women in receiving at least three ANC checkups including TT
injections, IFA tablets,
4. Identify a functional Government health cent re or an accredited private health institution for
referral and delivery,
5. Counsel for institutional delivery,
6. Escort the beneficiary women to t he pre-determined health center and stay with her till the
woman is discharged,
7. Arrange to immunize the newborn till the age of 14 weeks,
8. Inform about the birth or death of the child or mot her to the ANM/MO,
9. Post natal visit wit hin 7 days of delivery to track mothers health after delivery and facilitate in
obtaining care, wherever necessary,
10. Counsel for initiation of breastfeeding to the newborn within one-hour of delivery and its
continuance till 3-6 months and promote family planning.
Note: Work of the ASHA or any link worker associated with Yojana would be assessed based on the
number of pregnant women she has been able to motivate to deliver in a health institution and the
number of women she has escorted to the health institutions.
Important Features of JS Y:
The scheme focuses on the poor pregnant woman with special dispensation for states having low
institutional delivery rat es namely the states of Uttar Pradesh, Uttaranchal, Bihar, Jharkhand, Madhya
Pradesh, Chhattisgarh, Assam, Rajasthan, Orissa and Jammu and Kashmir. While these states have
been named as Low P erforming States (LPS), the remaining states have been named as High
performing States (HPS).
Tracking Each Pregnancy : Each beneficiary registered under this Yojana should have a JSY card
along wit h a MCH card. ASHA/AWW/ any other identified link work er under t he overall supervision of
the ANM and the MO, PHC should mandatorily prepare a micro-birth plan. This will effectively help
in monitoring Ant enatal Check-up, and the post delivery care.
In the Dist rict / Womens Ho spital / State Ho spital:

1. State / District should allocat e sufficient amount of money (based on the load of deliveries in
these institutions) for each of these institution. This money should be kept in a separate
account under the supervi sion of the Rogi Kalyan Samity.
109

2.
The residency of t he beneficiary would det ermine entitlement of c ash benefit in such
institutions, to be verified based on the referral slip from the ANM, carried by the beneficiary.
Format of Referral Slip: State should prepare a format of t he referral slip, which should mainly
indicate, identification det ails of the beneficiary, JSY registration number in the register of the A NM,
reason for referral (including medical complications), name of ASHA, amount already disbursed,
amount due, including referral trans port money (if applicable), amount due to ASHA and to be paid,
signature of MO/ANM.
It is therefore, essential that all targeted expectant mother should carry a referral slip from the
ANM/MO where she generally resides. This will, in fact, help all such pregnant woman who go to her
mothers place for delivery.
Disbursement of money t o expectant mother going to her mothers place for delivery should be done
at the place she delivers. The entitlement of ca sh sho uld be determined by her referral slip
carried by her and her usual place of residence.
A voucher scheme may be int roduced in such a way that along with admission slip for delivery, a
voucher amounting t o mothers package plus the transport assistance money is given to the
expectant mother and that she should be able to en cash the same at the Hospitals cash counter, at
the time of discharge.
Flow of Fund:
State/ District authorities would advance Rs. 5000/- and Rs. Rs.10,000/- to each ANM in HPS /LPS
States respectively as a rec oupable impressed money from the JSY fund.
This money could be kept in the joint account of A NM and Gram Pradhan, as in case of untied fund
placed with sub-c enters so that the ANM could roll the entire amount by advancing Rs.1500 to Rs.
2,500/ - to AS HA / AWW per delivery and later s he could recoup it from the P HC or CHC, where JSY
fund is parked by the aut horities.
Ex penditure Monitoring: AS HA / AWW should provide an expenditure statement of money
advanced to her in previous month to the ANM in the monthly meeting held by ANM.
There should be a clear aut hority for A NM to wit hdraw cash from this account for advancing it t o the
ASHA or AWW / any other health link worker, needed for ready use towards disbursement to the
pregnant and also for arranging the referral transport for escorting t he pregnant women to the
institution.
Note: Where an elected body of the P anchayati Raj Institution (PRIs) exists, the State
Governments/Health society may keep t he money in a joint account of the Gram Pradhan and the
ANM (like that of the untied fund). The proc ess of recoupment of fund should be so simple to be able
to disburse the cash to the pregnant women in time.
ASHA Package: This package, as of now, is available in all LPS, NE State s and in the t ribal
district s of all state s and UTs. In rural areas it includes the following three components:
1. Cash a ssi stance for Referral tran spor t (State to decide, not less than Rs. 250/- per
delivery) depending on the topography and the infrastructure available in their state. ASHA
and the ANM to organize or facilitate in organizing referral the transport, in conjunction with
gram pradhan, Gram Sabha etc.
Note: This assistance is over and above the Mothers package.
110

2.
3.
Cash incentive to ASHA : Thi s should not be less than Rs.200/- per delivery. Generally,
ASHA should get this money aft er her postnatal visit to the beneficiary and that t he child has
been immunized for BCG.
Transac tional co st (B alance out of Rs.600/-) is to be paid to ASHA in lieu of her stay with
the pregnant woman in the health centre for delivery to meet her cost of boarding and lodging
etc.. Therefore, this payment should be made at the hospital/ heath institution itself.
Note 1: In Urban areas, ASHA package consists of only the incentive for ASHA, for providing the
services,
Note 2: In case ASHA fails to organize t rans port for the pregnant woman to go to the health
institution, transport assistance money available wit hin the ASHAs package should be paid to the
pregnant woman at the institution, immediately on arrival and registration for delivery.
Note 3: In case ASHA is yet to join, transport assistance money may be kept with the institution and a
voucher scheme may be int roduced for disbursement.
Payment to ASHA :
ASHA should get herFirst payment is to be made, for the transactional cost at the health centre aft er reaching the
institution along with the expectant mother.
The second payment should be paid after she has made postnatal visit and the c hild has been
immunized for BCG.
All payments to AS HA w ould be done by the ANM only. In this case too, a voucher scheme be
introduced in such a manner that for every pregnant woman she registers under JSY, ANM would
give t wo vouchers to ASHA, which she would be able to en cash on certification by ANM.
Important: It must be ensured that ASHA gets her second payment within 7 days of t he delivery, as
that would be essential to keep her sustained in the system.
Special Dispen sation fo r LPS state s:
1. Age restriction removed
2. Restricting benefits of JSY up to 2 births removed. In other words, the benefits of the scheme
are extended to all pregnant women in LPS states irrespective of birt h orders.
3. No need for any marriage or BPL certification provided woman delivers in Government or
accredited private health institution.
Important: The state / UTs would be res ponsible for instituting an appropriate monitoring mechanism
and ensure that a proper accounting procedure is put in place for all transactions.
Sub sidizing co st of Caesarean Section or management of Ob stetric c omplication s: Generally
PHCs/ FRUs / CHCs etc. would provide emergency obstetric services free of cost. Where
Government specialists are not available in the Govt. health institution to manage complications or for
Caesarean Section, assistance up to Rs. 1500/- per delivery could be utilized by the health
institution for hiring service s o f specialist s from the private sector. If a specialist i s not
available or that the list of empanelled specialist is very few, specialist doctors working in the other
Government set -up s may even be empanelled, provided his/her services are s pare and he/she is
willing. In such a situation, the cash s ubsidy can be utilized t o pay honorarium or for meeting
transport cost to bring the specialist to the health centre. It may however be remembered that a panel
of su ch doc tor s from private or Go vernment in stitu tion s need to be prepared beforehand in all
111

such health institution s where such facility would be provided and the pregnant women are
informed of this facility, at time of micro-birth planning.
Import an t: State Governments would ensure that this assistance is not miss utilized and would
exercise adequate control and monitor expenditure under this component.
A ssi stance f or Home Delivery: In LPS and HPS States, BPL pregnant women, aged 19 years and
above, preferring to deliver at home is entitled to cash assistance of Rs. 500/- per delivery. Such cash
assistance would be available only up to 2 live births and the disbursement would be done at the
time of delivery or around 7 days before the delivery by ANM/ ASHA/ any other link w orker. The
rationale is that beneficiary would be able to use the cash assistance for her care during delivery or to
meet incidental expenses of delivery. It should be the responsibility of A NM/ASHA, MO PHC to
ensure disbursement. It is very important that the cash is disbursed in time. Importantly, such woman
choosing to deliver at home should have a BPL certific ate to access JSY benefits.
Compen sation Money: If the mother or her husband, of their own will, undergoes sterilization,
immediately after the delivery of the child, compensation money available under t he existing Family
welfare scheme should also be disbursed to the mother at the hospital itself.
JSY Benefit s in Ac credited Private Health In stit ution: In order to increase choice of delivery care
institutions, at least tw o w illing private instit ution s per block should be accredited to provide
delivery servic es. State and the di stri ct auth orities sho uld draw up a list o f c riterion / pro tocol s
for such ac creditation. (Please see a model criterion at Annex ure-2) Such beneficiaries
delivering in thes e institutions would get the cash benefits admissible under the JSY.
Equip Sub-center s for Normal delivery: For women living in tribal and hilly districts, it becomes
difficult to access PHC/CHCs for maternal care or delivery. A well-equipped sub-c enter is a better
option for normal delivery. Deliveries conducted in sub-centers, which are accredited by the state/
district authorities will be considered as institutional delivery and therefore, women delivering in these
centers would be eligible for all cash assistance under JSY.
Import an t: All States and UTs to undertak e a process of accreditation of all such sub-centre located
in Govt. buildings and having proper f acility of light, electricity, wat er, and other medical requirements
of basic obstetric services including drugs, equipments and services of trained mid-wife for the
purpose of conducting normal deliveries in these institutions.
Provi sion o f Admini strative Ex pense s: Up t o 4 % and 1% of the fund released could be utilized
towards administrative expenses like monitoring, IE C and office ex penses for implement ation of JSY
by the district and state authorities respectively.
Essen tial Strategy: While the scheme would create demand for institutional delivery, it would be
necessary to have adequate number of 24X7 delivery services centre, doctors, mid-wives, drugs etc.
at appropriate places. Mainly, this will entail
1. Linking each habitation to a functional health centre- public or accredited privat e institution
where 24X7 delivery service would be available,
2. Associate an ASHA or a health link worker to each of these functional health centre,
3. It should be ensured that ASHA keeps track of all expectant mothers and newborn. All
expectant mother and newborn should avail ANC and immunization services, if not in health
centres, at least on the monthl y health and nutrition day, t o be organized in the
Anganw adi or sub-cent re:
112

a.
b.
c.
d.
e.
f.
g.
Each pregnant women is registered and a micro-birth plan is prepared

Each pregnant woman is tracked for ANC,
For each of the expectant mother, a place of delivery is pre-det ermined at the time of
registration and the expectant mother is informed,
A referral centre is identified and expectant mother is informed,
ASHA and ANM to ensure that adequate fund is available for disbursement to
expectant mother,
ASHA takes adequate steps to organize transport for taking the women to the predetermined health institution for delivery.
ASHA assures availability of cash for disbursement at the health centre and she
escorts pregnant women to the pre-det ermined health centre.
10. Po ssible IEC strategy:

1. To a sso ciate NGO and Self Help Grou p s for popularizing the scheme among womens
group and also for monitoring of the implementation.
2.
To provide wide publicity to the scheme by:
a. Promoting JS Y as a component of t otal package of service s under RCH along
with Programs like Pulse polio Program, Monthly Village Health Day, Health Melas.
b. Printing and distributing JSY guidelines, pamphlets, notices in local languages at
SC/PHCs/CHCs/ District Hospitals/ DMs and Divisional Commissioners office and
even in at the accredited P vt. Nursing Homes, in abundance,
c. Supporting printing of states stationery, specially for States Health Secretary, DMs /
SDMs/ Block/ PHC/ CHC/ District Hos pital, advocating on Institutional Delivery and
cash benefits of JSY,
d. Facilitate organizing workshops and meetings in villages / blocks - by womens
group, local leaders (P RIs ), Opinion Maker, at functional health institutions on
promoting maternal health in general, Institutional Delivery and JSY,
e. Undertaking wall painting in all sub-centers, PHCs and CHCs, District & State
Hospitals and the accredited private institutions,
f. Supporting women self help Groups and NGOs for promoting the scheme,
g. Facilitating woman Panchayat member to take review of Janani Suraksha Yojana
(JSY)
Establish a grievance redressal cell in each district, under the Distric t Project Management Unit,
mainly to facilitate meeting peoples genuine grievances on 1. Eligibility for the scheme,
2. Quantum of cash assistance,
3. Delays in disbursement of the cash assistance,
If necessary, fund available under administrative expenses could be utilized for this purpose.
Di splay of names of JSY beneficiaries: The list of JSY beneficiaries along with the date of
disbursement of cash to her should mandatorily be di splayed on the display board at the subcenter, PHC/CHC/ District Hospitals (from where beneficiaries have got the benefit), being updated
regularly on month-to-mont h basis. Wherever necessary, display board s may be procured.
Guidelines For urban areas: The state shall prepare detailed guidelines by stating a simple
procedure of implementing the Janani Suraksha Y ojana (JSY) in the urban areas through the
Municipalities/local bodies ((where an elected body exits) and quickly obtain approval of the state
Government/SHS. The guidelines should bring out clearly, the chain of fund flow as well as
113

disbursement of the benefits to the ultimate beneficiaries. The quantum of grants to be placed at the
disposal of the Municipalities shall be in proportion to the BPL families in the Municipal area. The
district annual plan w ill also include the plan of the municipalities in the distric t s w herever
applicable. The Chief medical Officer of such an authority should be the implementing authority. It
must be ensured that basic objectives and the scale of disbursements are not altered. A copy such
plan along with necessary Governments order should be sent to the GOI.
Monitoring:
Monthly Meeting at Sub-cent re Level: For assessing the effectiveness of t he implementation of
JSY, mont hly meeting of all AS HAs / related health link workers working under an A NM should be
held by the A NM, possibly on a fixed day (may be on the third Friday) of every mont h, at the subcenter or at any of Anganwadi Cent res falling under the A NMs area of jurisdiction.
Prepare Monthly Work Sc hedule: In the monthly meeting, the A NM, besides reviewing the current
months work vis--vis envisaged activities, should prepare a Mont hly Work Schedule for each AS HA
/ village level health worker of following aspects of the coming month:
1.
Feed back on previou s month s schedule a. Number of pregnant women missing A NCs,
b. No. of cases, ASHA/link worker did not accompany the pregnant women for
Delivery,
c. Out of the identified beneficiary, number of Home deliveries,
d. No. of post natal visits missed by ASHA,
e. Cases referred to Referral Unit (FRU) and review their current health status,
f. No. of children missing immunization.
2.
Fix ing Nex t Month s Work Schedule (NMWS): To include a. Names of t he identified pregnant women to be registered and to be taken t o the health
center/Anganwadi for ANC,
b. Names of the pregnant women to be taken to the health center for delivery (wherever
applicable),
c. Names of the pregnant women with possible complications to be taken to the health
center for check-up and/or delivery,
d. Names of women to be visited (wit hin 7 days ) after their delivery,
e. List of infants / newborn children for routine immunization,
f. To ensure availability of imprest cash,
g. Check whether referral transport has been organized.
Note 1: While no target needs to be fixed, but for the purpose of monitoring, some monthly goal of
institutional delivery for the village may be kept.
Note 2: A format of monthly work schedule to be filled by the ANM /ASHA incorporating t he physical
and financial aspect may be printed.
Reporting: For the purpose of reviewing the progress of implementation and also for allocating fund
to the state, under the RCH-flexi Pool, all States would provide:
1. Annual District-wise report as per An nex ure IV, reaching MoHFW in the month of April of
the follow ing financial year
2. Quarterly Report reaching MoHFW in the month follow ing the end of the Quarter.
114

Criteria
for
accreditation
of
24
hour s
c omprehensive
emergency
obstetric
care:
Casualty service s
1.
2.
3.
4.
5.
A pregnant woman in labor or distress on entering the hospital at any time during the day
or night is directly taken to the obstetric casualty and immediately examined by a
professional with midwifery skills and decision taken within fifteen minut es.
a. If there are signs or bleeding, convulsions or shock, she should be immediat ely
attended by the Obstetrician on duty and necessary treatment to be initiated.
b. Send the mot her to the labor room, ward or operation theatre, depending on the
signs and symptoms.
No pregnant woman in labor or distress should be turned away from the hospital for any
reason at any time of the day or night.
Casualty should be located close to the labor room and theatre.
Casualty to receive advance intimation about the arrival of the mother and keep the
specialist team ready with blood, if needed.
Casualty should have the following round the clock:
a. An obstetrician
b. Life saving drugs and IV fluids
c. Facility for examining the patient (including pv)
d. Emergency prot ocols
e. Telephone connection in the casualty, labor room and blood bank
f. Patient transport system within the institution
Emergency Ob stetric Procedure s

1.
2.
Procedures
a. Vacuum extraction
b. Forceps delivery
c. LSCS
d. Emergency Hysterectomy
e. Manual removal of placenta
f. Dilation and Curettage
g. Laparotomy
h. Blood transfusion
Facilities
a. Separate theatre for above obstetric procedures.
b. The Government shall provide at least 4 obstetricians, 4 pediatricians, 2 general
Surgeons and 2 anesthetists to each CEmONC centre.
Emergency New born Care

1. E very delivery to be attended by a staff nurse trained in newborn resuscitation.
2. Pediatricians to be available in the institution round the clock for emergency interventions
3. Emergency Protocol should be available
Laboratory Services
1. 24 hours laboratory services including
a. Blood grouping, typing and cross matching
b. All routine examinations such as hemoglobin, blood glucose, urine sugar,
albumin.
115

Post Natal Care

All normally delivered mothers should be observed in the labour room for at least two hours after
delivery. B efore transferring the mothers to the postnatal ward, pulse, BP, firmness of the uterus
and amount of vaginal bleeding should be checked.
In the postnatal ward vital signs and height of the ut erus should be monitored once in two hours
for the first six hours and onc e in six hours till 24 hours. Twice a day monitoring until discharge
should follow this.
Those mothers who had instrumental vaginal delivery should be observed in the labour ward for
six hours after delivery before transferring the mother to the postnatal ward pulse, BP, firmness of
the uterus, urine output and amount of vaginal bleeding should be checked. Postnatal care in the
ward is similar to the care provided for normal vaginal delivery.
Post Operative Care
1. Staff
a. For the first two hours after surgery, staff nurse remains at the bedside to monitor
patient continuously.
b. Hourly checkups of vital signs (temperature, pulse, BP, and urine output), for t he next
six hours.
c. Forth hourly check up of vital signs by staff nurs e for next two days and thereafter
twice daily till discharge.
d. Check up by doctor at least once during t he first two hours and every sixth hourly for
three days and then twice daily till discharge.
Record s and Regi ster s
1. Parturition Register
2. Case Records
3. Reporting Formats
4. Referral register
Ambulance Services
1. For referral
a. Ambulance with driver and fuel available 24 hours.
b. Linkages with other ambulance providers.
c. Casualty to have telephone attendant who will organize the transportation.
Adherence to standard emergency treatment protocol
1. Standard emergency treatment protocol should in the casualty, in labor ward and in
theatre.
2. The obstetrician and staff nurse posted in t he labor ward and theatre should be thorough
with emergency prot ocol.
Quality of provider- Patient interaction
1.
2.
3.
4.
5.
6.
Patient treated with respect and dignity.

Privacy and confidentiality assured.
Informal payment from patients strictly banned.
Informed consent obtained from the family for major proc edure.
Procedures clearly explained to family members.
A female attendant to be permitted in labor room while ensuring asepsis.
116

Performance under JSY

% of Institutional Deliveries as per NFHS-III
(as per NFHS data)
Number of Institutional Deliveries (in Lakhs)
Number of beneficiaries of JSY (in Lakhs)
India
Rajat han
40.70
32.20
05-06
108.41
5.37
06-07
119.59
7.23
07-08
143.71
10.19
08-09
144.85
11.36
09-10
80.71
6.79
05-06
7.04
0.05
06-07
29.31
3.88
07-08
71.19
7.75
08-09
85.30
9.17
09-10
49.92
242.77
5.84
732
138
Year
Total
Number of pvt institutions accredited under JSY
26.68
117

ASHA
One of the key components of the National Rural Health Mission is to provide every village in the
country with a trained female community health activist AS HA or Ac credited Social Health
Acti vi st. Selected from the village itself and accountable to it, the ASHA will be trained to work as
an interface bet ween the community and the public health system.
Eligibility for AS HA :
1.
2.
3.
ASHA must primarily be a w oman resident of the village married/ widowed/ divorced,
preferably in the age group of 21 to 45 years.
She should be a literate w oman with formal education up to class eight. This may be
relaxed only if no suitable person with this qualification is available.
ASHA will be chosen through a rigorous process of selection involving various community
groups, self-help groups, Anganwadi Institutions, the Block Nodal officer, District Nodal
officer, the village Health Committee and the Gram Sabha.
Capacity building
Capacity building of AS HA is being seen as a continuous process. ASHA will have to undergo
series of training episodes to acquire the nec essary knowledge, skills and confidence for
performing her spelled out roles.
Performance-based incentive s
The AS HAs will receive performance-based incentives for promoting universal immunization,
referral and escort services for Reproductive & Child Health (RCH) and other healthcare
Programs, and construction of household toilets.
Compen sation applicable for ASHA (Rajasthan) as on date
One time honorarium
Amount
Monthly meeting
100
Social mobilization for MCHN day
150
Organizing monthly VHS C meeting
100
Bi-monthly conduction of meeting for adolescent girls
100
Total to be paid by NRHM
450
Amount to be paid by WCD aft er attending monthly meeting at PHC
500
TOTAL
950
118

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dk vkWijs'ku
fd;k
x;k
gSA
250 @& :- izfr Vh- bykt iw.kZ gksus ij ,- lEcfU/kr
ch- ejht
,u-,e- ds izek.khdj.k izkFkfed
bykt iw.kZ gksus ds ds i'pkr~
LokLF; dsUnz
Ikpkr~
ij vk;ksftr
ekfld
@f}ekfld
cSBd esaA
fpfdRlk
vf/kdkjh izHkkjh
}kjk ,e- vkj,l- ls ns; gS A
izfk{k.k
esa 100 @& :- iz fr
lfEEkfyr
gksu s fnu
gsrq izfr fnu izk Ir
gksus okyh izfriw frZ
jfkA
?kjsyw 'kksSpky;
: 30 @&
cukus ds fy,
:- xjhch js[ kk ds
ds
fpfdRlk vf/kdkjh
laLFkk ij
fpfdRlk
vf/kdkjh izHkkjh
}kjk rFkk f}rh;
fd'r ,-,u-,e}kjk tgk ykHkkFkhZ
izlwrk dk iath;u
fd;k x;k gSA
fpfdRlk
vf/kdkjh izHkkjh
}kjk ns; gS A
izf'k{k.k ds vfUre izf'k{k.k LFky vk;kst d

laLFkk
fnu] ?kj tkus ls iwoZ ij
}kjk@fpfdRlk
vf/kdkjh
izHkkjh
izkFkfed fpfdRlk
dsUnz }kjk
Tkc 'kksSpky; cukus lEiw.kZ
eq[ ; fpfdRlk ,oa
dk dk;Z iw.kZ gks tk, LoPNrk
LokLF; vf/kdkjh
119

izsjd jkfk A
10
ij ds ifjokjksa ds rFkk mi;ksx 'kq: gks

fy, izfr 'kkSpky;
tk,
: 20@&
:- xjhch js[ kk ds
uhps ds ifjokjksa ds
fy, izfr 'kkSpky;
: 10@&
:- izfr ekg ;fn
ifjokj 6 ekg rd
'kkSpky; dk iz;ks x
djrk gSA
leqnk;
ls 5@& :- izfr O;fDr nokbZ nsus ds i'pkr~
izkFkfed bykt ds
fy;s
dk;Zdze Vh- vius ftys esa

,l- lh- en lEiw.kZ
LoPNrk
ls
dk;Zdze ds izHkkjh
vf/kdkjh ls lEidZ
dj izsjd jkf'k
vkkk&lg;ks fxuh
dks nsuk lqqfuf'pr
djssA
ifjokj }kjk
ns;
Role of ASHA:
Empowered with knowledge and a drug-kit to deliver first-contact healthcare, every ASHA is
expected to be a fountainhead of community participation in public health programs in her village.
ASHA will be the first port of call for any health related demands of deprived sections of the
population, especially women and children, who find it difficult to access health services.
ASHA will be a health activist in the community who will create awareness on health and its social
determinants and mobilize the community towards local health planning and increased utilization
and accountability of the existing health services.
1. She would be a promoter of good health practices and will also provide a minimum
package of curative care as appropriate and feasible for that level and make timely
referrals.
2. ASHA will provide information to the community on determinants of health s uch as
nutrition, basic sanitation & hygienic practices, healthy living and working c onditions,
information on existing health services and the need for timely utilization of health &
family welfare servic es.
3. She will counsel women on birth preparedness, importance of safe delivery, breastfeeding and complementary feeding, immunization, contraception and prevention of
common infections including Reproductive Tract Infection/Sexually Transmitted Infections
(RTIs/STIs) and care of the young child.
4. ASHA will mobilize the community and facilitate t hem in accessing health and health
related services available at the Anganwadi/sub-centre/primary health centers, such as
immunization, Ante Natal Check-up (A NC), Post Natal Check-up supplementary nutrition,
sanitation and other services being provided by the government.
5. She will act as a depot older for essential provisions being made available to all
habitations like Oral Rehydration Therapy (ORS), Iron Folic Acid Tablet(IFA), chloroquine,
Disposable Delivery Kits (DDK ), Oral Pills & Condoms, etc.
6. At the village level it is recognized that ASHA cannot function without adequate
institutional support. Womens committees (lik e self-help groups or womens health
committees), village Health & Sanitation Committee of the Gram Panchayat, peripheral
health workers especially ANMs and Anganwadi workers, and the t rainers of ASHA and
in-service periodic training would be a major source of support to ASHA.
7. Knowing the beneficiaries:
120

For every 1000 population ASHA shall get following number of Beneficiaries in the villageBeneficiary category
Expected number i n an Year
Pregnant w omen
30-31
Out of w hich 4-5 may ha ve complicatio ns
50% shal l ha ve anemia
New Borne
27-28
Chi ldren i n 0-1 Year
30 ( 3 % of the p opu lation)
Chi ldren 1-5 years
130, (13 % of Po pulati on
El igi ble cou ples
16-17% (15-45 years of Age gro up)
El igi ble for Vasectomy/ Tubectomy
5-7% of El igi ble cou ples
El igi ble for spacin g Metho ds
11-12% of Elig ible co uples
Support Mechani sm for AS HA

The following set of guidelines is issued to enable the States to develop and put in place a proper
support mechanism for ASHA.
1.
ASHA Mentoring Gro up:

The Government of India has set up an ASHA Mentoring Group comprising of leading
NGOs and well known experts on community health. Similar mentoring groups at the
State/District/Block levels could be set up by the States to provide guidance and advise
on matter relating to s election, training and support for AS HA. At the District level,
MNGOs and at Block level, FNGOs could be involved in the mentoring of ASHA. The
State Govt. may utilize the services of Regional Resource Centre (RRC) and include
them in the Mentoring Group at the State level.
2.
Selection of ASHA
As ASHA will be in the village on a permanent basis, she should be selected carefully
through the process laid down in the first set of ASHA guidelines. It is possible that the
selected ASHA drops out of the program. It is, therefore, necessary to keep a rec ord of
such cases at SUb-Centre/ P HC level. In the above circumstance, a new AS HA could be
selected from the panel of three names previously prepared on the recommendation of
the Gram Sabha.
3.
Training of ASHA
a. The guidelines envisage a total period of 23 day s training in five epi sode s. (15
days comprehensi ve training to new ASHA s)
b. ASHA training is a continuous one and that she will develop the necessary skills
& expertise through continuous on the job training.
c. After a period of 6 months of her functioning in the village it is proposed that she
be sensitized on HIV / AIDS issues including S TI, RTI, prevention and referrals
and also trained on new born care.
4.
Familiarizing ASHA w ith the village

a. Visit every household and make a sample survey of the residents of village to
understand their health status.
121

b.
c.
d.
Know the villagers, the common diseases which are prevalent amongst the
villagers, the number of pregnant women, the number of newborn, educational
and socio economic status of different categories of people, the health status of
weak er sections especially scheduled castes/scheduled tribes etc.
Simple format for conducting the surveys. In this she should be supported by the
AWW and the Village Health & Sanitation Committee.
The SHGs, Womans Health Committees, Village Health and Sanitation
Committees of the Gram Panc hayat will be major sources of support to AS HA.
The Panchayat members will ensure sec ure and congenial environment for
enabling AS HAs to function effectively to achieve the desired goal.
5.
Maintenance of Village Health Register:

A village healt h register is maintained by the AWW whic h is not always complete. ASHA
can help AWW to complete and update this register by maintaining a daily diary. The
diaries, registers, health cards, immunization cards may be provided to her from the
untied funds made available to the Sub-Centres.
6.
Organization of the Village Health and Nutrition Day:

a. Mobilize women, children and vulnerable population for the monthly health day
activities.
b. Ensure a list of beneficiaries is maintained
c. Facilitate immunization, assessment of nutritional status of pregnant/lactating
women, newborn & children, ANC/PNC and other health check-ups of women and
children, taking weight of babies and pregnant women etc. and all range of other
health activities
7.
Co-o rdination w ith SHG Group s:

a. Interact with SHG Groups, if available in the villages, along with AWW,
b. Jointly organize check up of pregnant women, t heir transportation for safe
institutional delivery to a pre-identified functional health facility.
8.
Meeting w ith ANM:

ANM should have a monthly meeting with the ASHAs stationed (5-6 ASHAs) in the
villages of her work area at the Anganwadi Centre during the mont hly Health and
Nutrition Day to assess the quality of their work and provide them guidance
9.
Monthly meetings at PHC level:

The Medical Officer In-charge of the PHC will hold a monthly meeting which would be
attended by ANM and ASHAs, LHVs and Block Facilitator. On meeting day, following are
to be ensureda. Review health status of the villages.
b. Payment of incentive to ASHAs under various schemes.
c. Assess support received from the Village Health and Sanitation Committee.
d. Replenish ASHA kits
10. Monthly meetings o f AS HA s:

A meeting of ASHA could be organiz ed on the day monthly meetings are organized at
the PHC level to avoid unnecessary travel expenditure and wastage of time. In addition to
monthly meetings at P HC, periodic retraining of ASHAs may be held for two days once in
122

every alternate month where interactive sessions will be held to help then to refresh and
upgrade their knowledge and skills, as provided for in the original guidelines for AS HA.
11. Block level management:
At the block level, the BMO will be in overall charge of ASHA related activities. However,
an officer will be designated as Block level organizer for the AS HA to be assisted by
Block Facilitators (one for every 10 ASHAs). Block Facilitators could be appointed as
provided for under the first set of guidelines on ASHA already issued to the States. The
Block Facilitator may be necessarily women. However, male members if any, who may
have
already been appointed earlier as Block Facilitator may continue. The Block
Facilitators would provide feedback on the functioning of ASHAs to the BMO & Block level
organizers. They shall also visit the ASHAS in villages.
12. Management Support for AS HA:
a. Involve ICDS Officials.
b. Creating a network for support to ASHA including timely disbursement of
incentives, at various levels.
c. Information system that has full information on the number of ASHAs, quality of
their out put, outcomes of the Village Health and Nutrition Day, periodic health
surveys of the villages to assess her impact on community.
13. Community monit oring:
a. Periodic survey s are envisaged under NRHM in every village to assess the
improvement brought about by ASHA and other interventions.
b. The funding for t he survey will be provided o ut of the untied f und s provided to
the Sub-Centre.
c. The first survey would provide the base line for monit oring the impact of health
activities in the village.
14. Role of Di stric t Health Missi on s:
a. Assess the progress of selection of ASHAs, their training and orientation,
usefulness to the villages etc.
b. They should also have a Cell in the DP U to collect all information related to ASHA
and the community which should be available on the computer net work. This
information should be accessible by the State Health Missions as well as the
Mission at the national level.
15. Linkage w ith Health Facility, in terms of:
a. Prompt action on the referrals made by her; otherwise t he system cannot be
sustained.
b. E very ASHA must be familiar with the identified functional health facility in the
respective area where she can refer or escort the patients for specific servic es.
c. The persons manning these health facilities should be sensitized to effectively
respond to the instant needs of the local people.
d. Funds available under IEC-program may be used for education and publicity in
respect of above services. The role of the State & District level Missions would
be to provide support to AS HA from village to the district level without any
blockage on the way.
123

Support
Support mechanism f or AS HA :
State level ASHA
mentoring group
Di stri ct Health Mission

DPMU
CDP O-ICDS
Site
State
District
Activity
Monthly Review Meeting
Periodic surveys by DHS to assess

performance of ASHA
District Mission meeting to assess
progress of ASHA scheme
Medical Offic er
BPM
CHC
Block Facilitator
Monthly Meeting & Feed back

from Block facility
ICDS officials
Payment of Incentives to ASHA
Medical Offic er
ASHA facilities
HW-Female
under different
PHC
SC
SHG
HW-Female
Gram P anchayat
Periodic training
Monthly Meeting
Replenishment of kits
Monthly Meeting ( Not applicable to
Rajasthan)
As Members of VHSC
Developing Village Health Plan
AWW
Village
Help A NM in Maint aining Village

Healt h Register
Organizing MCHN day with help

of ANM & AWW
Services available at different levels:
Lrj
xzke
Lrj
laL Fkku
vkaxuckM+h
dsUnz
midsUnz
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lso k,
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iwoZ izkjaf Hkd fk{kk] Vhdkdj.k] iks"k.k ,oa LokLF; fk{kk] LokLF; tkWap]
lanHkZ lsok] vkfkad Ms&ds;j fkkq x`g
ekr` LokLF;&izloiwoZ ns[ kHkky] izlo ds nkSjku] izl okskj ns[ kHkky] vko;d uotkr
ns[ kHkky] tuuh lqj{kk ;kstuk] iks"k.k ijkekZ o jsQjy
cky LokLF;&Vhdkdj.k] foVkfeu ,
ifjokj dY;k.k&xHkZfujks/kdksa dks izks Rlkgu o vkiwfrZ] vkbZ-;w-Mh- dkWij Vh yxkuk]
LFkkbZ i)fr;ks a ds fy, vuqorhZ ls ok, ] ijke'kZA
fdkksj LokLF;&fdkksj&vuqdwy LokLF; lgk;rk o jsQjy] xHkZ fujks /kd o fdkksj
LokLF; ls ok,
iztuu o cky LokLF; lac a/kh lso k,
124

Lrj
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lkekU; o lgk;rk iz kIr nksu ksa rjg dh izlw fr;ksa ds fy, 24 ?kaVs lsok, A
tfVy izlwfr dh vkikr fLFkfr;ksa ds fy, iz kFkfed fpfdRlk ,oa jsQjy A
uotkr ns[ kHkky
chekj cPpksa dh vkikr ns[ kHkky
izlokskj ,oa cPpksa dh chekfj;ksa dk lesfdr izaca /k
ifjokj fu;kstu ds fy, varjky o LFkkbZ i)fr;k o mudk QkWyks&vi
xHkZi kr lso k,
jk"Vh ; LokLF; dk;Ze
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Msaxw rFkk ,p-vkbZ-oh- dh tkpA
[kwu] dQ] iskkc] ey dh lkekU; ySc tkp
vlkekU; LokLF; ifjfLFfr;ksa o izd ksi dh fLFkfr esa igys Lrj dh dk;Z okghA
LFkkbZ ifjokj fu;ks tu] ,e-Vh-ih-] gkbMksf ly o eksfr;kfcan ds fy, foks"k
vkWijsku fkfojA
vk;qosZn] ;ks x] izk d`frd fpfdRlk] ;wu kuh] fln~/ k o gksE;ksisF kh vk;q"k mipkjA
'kkyk LokLF; dk;Ze esa fu;fer tkp o LokLF; dk;Ze dh lgk;rk A
'kkjhfjd detks fj;ksa @dfe;ksa dk Bhd le; ij irk djuk ]kq:vkrh bykt o
jsQjyA
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iztuu o cky LokLF; laca /kh fkfojA
Lkkeqnkf;d izkFkfed LokLF; dsUnz }kjk iznku dh tkus okyh mijksDr leLr lso k, ,oa muds
LokLF;
vfrfjr &
dsUnz lh vkikr fLFkfr;ksa ls fuiVus ds fy, midj.kksa ls lqlfTtr e/;e vkdkj dk
,p-lh-
vLirkyA
LFkkfud chekfj;ksa dk foks"kKksa }kjk byktA
lkekU; 'kY; iz fdz;k, o vklku vkijskuA
vko;d o vkikr izlw fr ns[ kHkky o lkekU; ,oa lgk;rk izkIr iz lwfr;ksa ds
fy, 24 ?kaVs lsok,A
ySizksLdksi h] L=h jksx o lqjf{kr xHkZi kr lso k,A
vkj-Vh-vkbZ-@,l-Vh-vkbZ- ds fy, ijkekZ o byktA
jDr cSad dh lq fo/kk,]
is;ty L=ksrksa dh tkp o lQkbZA
egkekfj;ksa o izdks iksa dks jks dus ds fy, izca /kA
ftyk
mijksDr leLr lsok,
fpfdRlky;
vk/kqfud lk/ku o foks"kK }kjk lsok,
vkikrdkyhu lso k,
Factor s Critical to the Succe ss of ASHA

1. Selection of ASHA by prescribed process as per the ASHA guidelines.
2. Linkage with nearest functional health facility for referral services.
3. Identified transport for referral of cases from village to facility
4. Priority and recognition of cases referred by ASHA to MO / ANM.
5. Successful organiz ation of monthly Health and Nutrition Day (in every village with the
ANM / AWW).
6. Monthly meeting of ASHA at PHC.
125

7.
8.
Timely payment of incentives to ASHA.

Timely replenishment of ASHA kit.
How to know that ASHA i s effective

1.
Devising indicators for each state:
a. % of newborns who were visited thrice in first week including once in first day
b. % of ASHAs who received more than 20 visits for common illnesses per month
c. % of ASHAs who have referred all (or at least half ) their pregnant women for
institutional delivery. Etc etc.
2.
Deciding who will collect information and validate it while collecting it by group
processes and by village visits.
3.
Decide on frequency and heirarchy of participatory review meetings where the dat a flows
up as well as gets acted upon
Reflection s of ASHA performance:
1.
Increase in ANC registration in first trimester
2.
Institutional Deliveries 80. 7% in Govt. hospitals (31. 12.09)
3.
Immunization full immunization (Source: rajmedical)
a. OPV3: 67.73;
b. DP T3:68.08;
c. BCG:71. 15;
d. Measles:69.02
4.
No. of Sterilization
5.
Practices
a. Breast feeding practices
b. Healt h seeking behavior
6.
Referral
7.
Community involvement VHC/MCHN
ASHA and Expectations from DPMU:
Role of DPM
1. Develop annual plan for selection and training for ASHA
2. Drafting of annual targets for CHC-P HC wise ASHA to achieve the health targets of
District like; sterilization, institutional deliveries and immunization etc.
3. Ensure adoption and implementation of plan and fund flow at local level.
4. Support District ASHA Coordinator in developing localised implementation plans.
5. Monitor physical and financial progress of the component.
Role of DA C
1. Create database of AS HA.
2. Liaise with district level stakeholders for mobilizing support
3. Supervision and monitoring of the AS HAs, NGOs involved in asha training and Block
ASHA facilitators and PHC ASHA Supervisors.
4. Attend ASHA meetings at block and PHC.
5. Prepare annual training plan of AS HA for different rounds.
6. Compilation of monthly report with the help of Dat a Assistant of DPMU.
7. Dissemination of guidelines related to ASHA to all functionaries at different levels.
8. Follow up wit h Block ASHA facilitators/ BPMs on the progress of assigned job.
126

9. Monitor timely payments of AS HAs

10. Monitor physical and financial progress of the component.
11. Field visits
Monitoring indicator s for AS HA s
Role of Block ASHA Facilitator
1. More stress on field supervision
2. Compile P HC-CHC wis e data base of AS HA wit h the details of their name, joining,
training and performance etc.
3. Attend block meetings of medical officers and P HC monthly meetings of AS HAs.
4. Draft training plan of ASHAs in consultation with DAC.
5. Monitoring and supervision of ASHAs and PHC ASHA Supervisors.
6. Monitor t he availability of funds at PHC level for the payment of incentives and organising
monthly meetings of AS HAs.
7. Collect and compile the mont hly progress report of selected, trained, drop out and
functional ASHAs.
8. Hand holding support to ASHAs during field visits.
Institutional
deliveries
5 Deliveries per year ( 80% of total deliveries should be escorted by

ASHAs)
Social Mobilization
80% beneficiaries (A NC & c hildren) of the due list should be mobilized

for MCHN day.
Sterilization
1 case per month.
Role of PHC AS HA Facilitator

1. Intensive field visits.
2. On the job hand holding support to ASHAs (during field visits)
3. Organise PHC monthly meetings of ASHAs at PHC.
4. Collection and compilation of reports of ASHA with support of ANM.
5. Support MO/IC in reviewing the performance of ASHAs.
What can help ASHA to be more effective
1.
2.
3.
4.
5.
6.
7.
8.
A clear role definition.- state specific

A proper process of selection- are guidelines adequate?
A high quality and minimum duration of training- is training schedule and in place?
A Continued high quality on-the- job support- is the support structure in place
The spirit of a peoples movement
a. Healt h are as an entitlement, a basic right
b. Collective action by local communities cause change to occur.
c. Behaviour change needs both inter-personal int eraction and an enabling
atmosphere
Is there an understanding of ASHA as social mobilisation.
Are the drug kits in place? Where is the hold-up
Is incentive payments streamlined and adequate? personal incentive scheme to get
sanction and support of the family and compensate for wage loss.
127

List of Cir cular s issued by NRHM, Rajasthan

dze
la0
1
2
3
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
6
7
8
fo"k; lwp h
ASHA Selection
F21/NRHM/ASHA/Convergence/2009/4387 date 5/10/09
p;u ifji= fpfdRlk foHkkx o vkbZ-lh-Mh-,l dk l;qDr i=
F21/NRHM/ASHA/ASHA-4/09-10/ 4494 date 9/10/09
uohu vkkk p;u ,oa 15 fnolh; izfk{k.k ds laca/ k esa
F21/NRHM/ASHA/ASHA-4/09-10/ 3863 date 2/09/09
vkkk lg;ksfxuh ds dk;Z dh leh{kk ,oa mudks ns; jkfk ds Hkqxrku ds dze esa
ASHA Mont hly Meetings
F21/NRHM/ASHA/ASHA mont hely meeting/09-10/2435 date 22/06/ 09
vkkk lg;ksfxfu;ks ds ekfld cS Bd vk;kstu ds laca/ k esa
F21/NRHM/ASHA/2009/2902 date 14/ 07/09
vkkk lg;ksfxuhs ih-,p-lh ekfld cS Bd
F21(1)/ NRHM/ASHA/ASHA meeting/2008/4135 date 18/09/09
'kgjh vkacuckM+h ds Unksa dh vkkk &lg;ksfxuh ds dz e esa
F21(1)/ NRHM/ASHA/ASHA Sah./2008/1881 date 15/11/06
vkkk &lg;ksfxuh ds ekfld csB dks ds dze esa ,u-vkj-,p-,e ,oa vkbZ -lh-Mh-,l }kjk l;qD r i=
ftyk@Cykd@ih-,p-lh F21/NRHM/2008/3136 Date 22-9-08
ASHA Training s
vkkk & lg;ksfxuh ds r`rh; pj.k izfk{k.k ds fy, Cykd Lrjh; izfk{kd &izfk{k.k ,oa vkkk izfk{k.k ds l naH kZ esa A
F21/ NRHM/ASHA/III round trg./2009/1659 Date 21-4-09
F21(1)/ NRHM/ASHA/SARC/2009/3673 date 25/ 08/09
uop;fur ,oa vizfkf{kr vkkk &lg;ksfxuh ds 15 fnolh; izfk{k.k gsrq ftyk Lrjh; izfk{k.k ny ds ukekad u ,oa vkkk izfk{k.k
ds lanHkZ esa
NGO s Selection
Review of performance of NGOs involved in ASHA training ( F21/NRHM/ASHA/NGOs/20809/817 Date 17-2-09)
F21(2)/ NRHM/2005/ 942 date 08/12/05
Expression of interest for selection of NGOs for training of ASHA at Block Levels
ASHA Incentive s
vkkk & lg;ksfxuh dks ,dhd` r ekfld ekuns; gs rqAF21/ NRHM/ASHA/2008/SPL-1 Date 13-10-2008
F26/NRHM/ARSH/ adol cou./2009/ 2594 date 30/06/09 fdkksjh ckfydk gsrq uohu fnkk funsZk
F21/NRHM/VHC/2009/4224 date 24/09/09
Strengthening of VHCs streamlining the VHC meetings
F()/malaria/ direc./2009/450 date 21/05/09
Eysfj;k dk vkj-Vh vkkk }kjk fd;k tkus ij : 50 @& bUlsU Vho fn;s tkus dh Lohd`fr ds laca/ k esa
F21/ASHA/ASHA-4./09-10/ 3896 date 07/09/09
vkkk lg;ksfxuh ds nok is Vh ds la nHkZ esa
F21/ASHA/ASHA-4./09-10/ 1693 date 23/0/09
vkkk lg;ksfxuh }kjk laLFkkxr izlo ,oa ulcanh o`f} gs rq y{; vkoaV u
F21/NRHM/VHC/2009/2078 date 21/05/09
Xzke LokLF; lfefr dh ekflsd cSB d gsrq fnkk funsZk
lh-,p/fu-Vh-lq@ 2009-10@1355 fnukad 13-04-09
fu;fer Vhsdkj.k gsrq lksky eksfcykbts ku ds fy, vkkk lg;ksfxuh dks ns; jkfk ds dz e esa
128

lh-,p/,elh,p,u@268 fnuka d 2-12-08

Vhdkdj.k ,oa ,elh,p,u fnol ds vk;ksftr ds laca/ k esa
10
tuuh lqj{kk ;kstuk ds fdz; kUo;u gsrq fnkk funsZk NRHM/RCH-II/ JSY/08/536 Date 24-11-08
11
tuuh lqj{kk ;kstuk ds vUrxZr vkkk & lg;ksfxuh dks izloksijkUr nwljh fdr ds Hkqxrku ds dze esaA NRHM/RCHII/ JSY/661 Date 23-4-09
tuuh lqj{kk ;kstuk ds vUrxZ r 25 izfrkr midsU nzksa ,oa 'kr~ & izf rkr izkFkfed LokLF; dsU nzksa ij izlo djk;s tkus gsrq A
NRHM/ RCH-II.JSY/09/ 662
12
MIS
Monthly reporting format
ASHA report up to Sept-09
129

Skilled Birth Attendant (SBA)

With an estimated 28 million pregnancies per year and 26 million deliveries, almost 15% of the
expectant mothers land up with one or the other life threatening obstetric complication during or
immediat ely after delivery as a consequence of which there are 67,000 maternal deaths every
year (254/100,000 live births, SRS B ulletin Oct. 2009). It becomes imperative t hat all expectant
mothers have access to birth attendant with requisite midwifery skills for ensuring safe delivery
and timely recognition of complications.
Government of India t ook policy initiatives to empower ANM/LHVs/Staff Nurses to mak e them
competent for undert aking life s aving measures like use of Uterotonic drugs for prevention of
PPH, drugs in emergency situations prior to referral and perform basic procedures at community
level in emergency.
Skilled Birth Attendant
A SBA is an accredited health professional such as midwife, doctor or nurse who has been
educated and trained to achieve proficiency in the skills needed to manage normal pregnancies,
child birth and immediat e post natal period and in the identification, management and referral of
complications in women and the new born.
Training Objectives
This training is meant to upgrade the skills of practicing birt h attendants. It aims to achieve the
mandatory minimum standard for a skilled birth attendant at all levels. Given that more facilities
and s upervis ory capacity is available at institutional level (PHCs/CHCs) additional skills may be
practiced by ANMs, LHVs and Staff Nurses.
Know ledge based objectives
At the end of the training the participants are expected to have improved understanding of:
1. Steps in the care and importance of health of the woman and the baby during antenatal, labour,
delivery and postnatal period.
2. Steps of essential newborn care and their importance for the healt h of the baby.
3. The clinical features and management of common obstetric complications during pregnancy,
labour, delivery and postpartum period.
4. The importance of quality of care for midwifery services through client-c entered approac h,
using infection prevention practices, community involvement and supportive environment to the
mother and family.
Skills ba sed objectives

At the end of the training the participants are expected to perform the following skills
1. Measure the blood pressure, height and weight, fundal height, foetal lie, presentation and foetal
heart sounds accurately.
2. Measure haemoglobin and examine urine for protein and sugar.
3. Provide care and counseling to the woman during antenatal, labour and postpartum period.
4. Monitor labour and identify prolonged labour using part ograph.
5. Conduct delivery with active management of third stage of labour {use of uterotonic drug,
controlled cord traction (CCT) and uterine massage} using infection prevention practices.
6. Provide essential newborn care, and newborn resuscitation, weigh the newborn.
130

7. Identify danger signs during pregnancy, labour, delivery and postpartum period and danger
signs in newborns; provide supportive care prior to referral at home/in community.
8. Insert Intravenous (IV ) line and give IV fluids.
9. Give deep intramuscular injections (magnesium sulphate) and IM/IV antibiotics.
10. Perform uterine massage to expel clots in case of PP H and digital removal of clots and P OC
for bleeding after an abortion.
11. Prepare High Level Disinfected (HLD) gloves and instruments.
Training methodology
The following training techniques and met hods are used to conduct the SBA training:
interactive presentation and discussion
demonstration and simulated practice of skills on models and clients/patients
intensive hands-on guided practical training on clients/patients under supervision of the
trainers/facilitators of the training site
Training Plan
A. State Level
Identify State Nodal Officer
Prioritize the districts,

eventually all to be
involved
Identify state level

training institute SIHFW
Nominate Nodal
person in charge for
training at district
Strengthen the
Training Institute
Develop state training

plan, budget in
consultation with District
Nodal Officer, to be
reflected in State PIP
Identify state level

Master trainers to be
oriented at NIHFW
Conduct training of District level trainers
Constitute State core

group/QA Cell for
monitoring
Monitoring at district
level
131

B. Di stri ct Level
Identify Nodal Officer/District Nodal Officer/RCHO
Orient MOs in
basic skills
MOs in PHCs will

orient ANMs in basic
skills
Identify district level

trainers
Identify DTC
Training Institute
Strengthening of
training centers
SIHFW
conducts
training
MOs will give the names of

the AN Ms skilled in Basic
Skills to Nodal Person
Monitoring at district
level through QA
Cell or monitoring
team
Identify DTC
Formation
of State
Calendar
Formulation of District
Training Plan: Training Load,
Calendar
Inclusion of Training Plan

into District PIP
Formulation of
State PIP
training
Nominate & Release

Trainees for the
Training
Ensure practicing
of essential skills
at training center
DH/Training center
is ready to conduct
the training
Logistics
for training
Initiation of training
at Training Center
Trainees posted &

practice skills learnt
Batch size for SBA Training

No. of deliveries per month
150
150-250
>250
Recommended batch size

2
3
4-8
132

Training Duration
Staff Nurses
ANMs & LHVs
2-3 weeks
3-6 weeks
Monitoring of Training by QA Cell/Core Group at State/District in coordination with S IHFW/SPMU/DPMU

SBA Di stric t Training Monitoring Format
Name of the Observer
------------------------------------------------------------------------------------------------
Designation
------------------------------------------------------------------------------------------------
District Posted
------------------------------------------------------------------------------------------
District Observed
------------------------------------------------------------------------------------------
Training Site :
Dates Theory
Start
End
Date of Observation
Start
End
Total no. of participants attending the training:
Total no. of participants joined on first day of the training:
Total no. of participants who were supposed to attend the training:
No of Participant s :
1. From Model Sub Centres :
4. From CHCs
:
2. From Sub Centres :
5. District Hospital :
3. From PHCs
:
6. Others :
Training Residential :
Yes / No Residential Facilities Safe or not :
Yes / No
Arrangements:
Di stance of Training Site from Residence
Toilets A vailable
3-5 : Good
< 1 Kms : Good
Toilets A vailable
2-3 : Available
1-2 Kms : Average
Toilets A vailable
1 : Poor
>-2 Kms : Poor
No of Participants Residing at the Residential Location :
Residing Facilities: Good /Satisfactory /Poor
Welcome & Briefing Session held
Yes / No
Name Training Coordinator :
MRC / ARTH Trained
:
Yes / No
No of Person who Underwent Training At MRC/ARTH
:
No of Team Members Who Underwent Training At MRC/ARTH A vailable During the Training :
Details of Trainers Appoin ted for the Training
Does the training include an Ob/Gyn and Paed. Specialist?
Yes / No
Name :
Designation :
MRC/ARTH Trained: Yes / No Ph.No:
Name :
Designation :
Name :
Designation :
Name :
Designation :
Name :
Designation :
Name :
Designation :
Checkli st f or monitoring
S.no
Supply
1. Training Modules for every Participant (Individual Copy)
2. Guidelines for Ante-Natal Care & Skilled Attendance at Birth by ANM and LHVs
(Individual Copy
3. Facilitators Guide
Yes/No
133

4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Partograph Booklet (Individual Copy)

Operational Guidelines with the Facilitators
Training Schedule
Hemoglobinometer
B P instrument & Stethoscope
Neonatal size Ambu Bags & Makes
Midwifery mannequin
Baby mennequin
Training Schedule
Diary and bag
A sse ssment of Theory :

Feedback from the trainers
Number of participants not showing interest in learning? ________________________
Difficulties experienced by trainers in transcending the knowledge / teaching and why?
_______________________________________________________________________
Which are the topics which most of the participants find difficulty to understand?
_______________________________________________________________________
What are their suggestions ?

_______________________________________________________________________
Interaction w ith the participants:
What new learning they have learnt during this period?
_______________________________________________________________________
Which topics were difficult to understand?
_______________________________________________________________________
What they would like to do after reaching their Health facility and in their area?
_______________________________________________________________________
What kind of support is required to practice the learning at their facility level?
_______________________________________________________________________
Class Room Ob ser vation s:

Gaps in teaching content
Yes / No
Interaction level between facilitators & Trainees
Good / average / satisfactor y
Level of interest and learning by the participants.
Good / Average / Poor
Attitude and confidence level of the trainer :
Ex cellent/ Good / Average / Poor
Appropriateness of Teaching Methodology during
the session observed
Yes / No
Use checklist for monitoring
Ye s / No
Mention
what
Methodology
could
have
been
better:
________________________________________________________________________
See 3-4 sample of Daily Dairy and note your observations on Quality & Content of training:
_______________________________________________________________________
To be asse ssed on the basi s of w hat ha s been taught till the day of vi si t, by interaction
w ith the participants and the facilitators.
1. Probable Question for a sse ssing learning :
1. List four Major Causes of Maternal Mortality?
2. What are important things to observe during ANC check-up?
3. How do you diagnose pre Eclampsia?
4. Assess counseling skills through a role pay.
134

5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Name and describe four fundal grips?

Knowledge on fundal height at different gestational period?
List 10 danger signs during pregnancy?
Describe stage of labour?
What is to be seen while conducting during P. V in labour?
What is partograph?
What components are mark ed in partograph? (Give a sample exercise and let the
participants mark on it and check it for correction.)
How do you differentiate bet ween true and fals e labour pains?
Define PPH? What tablet and does is given whether the patient needs referral or not?
How is PPH managed?
What symptoms will support you to decide whether the patient needs referral or not ?
What are the import ant symptoms to be observed for post partum care?
What is APGAR score?
What is new learning during the program?
What learning you have found most useful?
What learning do you think will be difficult to use in daily practice?
Comment s (can be given in Hindi):

----------------------------------------------------------------------------------------------------------------------Name
--------------------------------------------Place
of
po sting-----------------------------Designation --------Signature--------------------------------------------------------------- Date-------------------------------2.
Practical Training
Ob servation during practical Training
Make A sse ssment indi vidually by practi cally asking them to Perfo rm. (A s far as
po ssible 2-3 Ca se each for given Point s) Select the Participant your self for
A sse ssment.
1. Observe for hand washing steps.
2. Ask practically to take BP and assess for correct reading for Measuring BP.
3. Practically make the participants do hemoglobin estimation and urine test and assess
for correct estimation.
4. Let the participants/take ANC history and do all the procedures for conducting quality
ANC care. (Practically or through role play )
5. Assess for the abdominal grips and FHS.
6. Assess for conducting PV examination
7. Birth preparedness.
8. Observe for plotting of pantograph, if supporting a delivery. (or through an ex ercise)
9. Correct assess mental for dilation.
10. Observe for practice during conducting labour (behavior & counseling skill also)
11. Ask for when are the Tab Misoprostral/Injection Oxytocin should be administered
12. Whether knows about Cont rolled Cord Traction? Has she done it?
13. Whether knows about Uterine massage? Has she done it?
14. Assess skill for putting IV line and canula.
15. Assess for resuscitation skill (Use of Ambu bag)
16. Let the participant assess for APGA R score
17. Counseling skills
A sse ssment Sheet for Practical Know ledge

Name of the Observer-------------------------------------------------------------------------------------------------Designation ---------------------------------------------------------------------------------------------------------------Di stri ct Po sted------------------------------------------------------------------------------------------------------------
135

Ob serving Di stric t-------------------------------------------------------------------------------------------------------Venue of Training-------------------------------------------------------------------------------------------------------Date of Practical ( First Batch)

Start
Date of Observation
Start
No. Of Participants Attending The Training:
End
End
No. Of P articipants Residing at the Residential

Location on:
Are the trainees provided duty schedules
Are the trainees given duty at
Yes / No
Labour
room
Laboratory
OPD/ANC
clinic
PP ward
Yes / No
Yes / No
Yes / No
Yes / No
Details about the trainers available

Name :
Designation :
Name :
Designation :
Name :
Designation :
Name :
Designation :
S.No
Topic
A sse ssment
1.
Observe for hand

washing
step
(participant)
Mea
sure
BP
(Assess
for
correctly)
Correctly
/
Satisfied/poor
2.
3.
4.
5.
6.
Hemoglobin
Estimation
Urine Examination
ANC
History Taking
Recording ANC
JSY Card filed
B P Measurement
Urine Examination
Weight Taking
PV Assessment
Counseling
skill
(Expectant Mother )
Abdominal grip
(Expectant Mother
Mannequins
Diastolic :
No
Systolic:
No
Correct :
/ No
Correct :
/ No
A sse ssment
Done
Yes /
Correctly / Done / Satisfied/ poor
Diastolic :
Systolic:
Yes / No
Yes / No
Yes /
Yes
Yes
Correct :
No
Correct :
Yes /
Yes / No
Good/Satisfactory /Poor
Done / Not Done
Yes / No
Correct / in Correct/ Not Done
Done / Not Done
Done / Not Done
Yes / No
Done / Not Done
Fundal grip
/ No
Lateral grip
/ No
Pelvic grip I
No
Fundal grip
No
Lateral grip
No
Pelvic grip I
No
Yes
Yes
Yes /
Yes /
Yes /
Yes /
136

7.
Birth preparedness
8.
Partograph
(Expectant Mother/
Exercise)
9.
Dilation
Assessment
Delivering
&
Assessing
Placenta
Foetal Heart Rate
Taken (child)
Use of Ambu Bag
10.
11.
12.
13.
14.
15.
APGAR
Score
(child)
Individual Diary
Pelvic grip II
Yes /
No
Excellent/ good/ Satisfactory/
Poor
Plots
Correctly
Yes/No
Understands
when to refer
Yes / No Understanding on
Usage
Good/A verage/Poor
Correct
Yes
/No
Correctly Done/ S atisfactory
/Poor
Pelvic grip II
Yes /
No
Excellent/ good/ Satisfactory/
Poor
Plots
Correctly
Yes/No
Understands when to refer Yes /
No Understanding on Usage
Good/A verage/Poor
Correct
/ No
Understanding on us e
Good/A verage/poor
Correct
Yes
Maintained: Daily /incomplete

Quality of Contents:
Correct
Correctly
/Poor
Yes / No
Done/
Satisfactory
Yes / No
Understanding on us e
Good/A verage/poor
Maintained: Daily /incomplete
Quality of Contents:
No. of deliveries
assisted
No. of deliveries
independently
conducted
For point 7 please mention whether actually carried out during delivering a patient
through an exercise.
The following are mandatory for assessment of all 5 participants:
1. Hand washing Step
2. ANC
History Taking
Measuring BP
Hemoglobin Estimation
PV Assessment
Counseling Skills
3. Dilation Assessment
4. Foetal Heart Rate
5. Plotting Partograph
6. APGAR Score
or
Observations for Training site:

1. A vailability of drugs - Inj oxytocin / Diazepam/ Tab. Nifedifine/ Inj. MgSO4/ Inj. Lignocaine
Hydrochloride/ Ta. Misoprostral/ Inj. Gentamycin/ Inj. Ampicillin/ oral metranidaz ole /
sterilized cotton and gauze/ gloves/ sterile syringes and needles/ sterile I/V sets
2. A vailability of equipments- delivery kits normal and assisted/ Cheattle forceps ina dry
bottle/ foetal stethoscope/ baby weighing scale/ radiant warmer/ table lamp with 200 watt
bulb/ phototherapy unit/ self inflating bag and mask/ oxygen hood/ laryngoscope and
endotracheal tubes/ mucus extractor with s uction tube and foot operated suction
137

3.
4.
5.
6.
7.
8.
machine/ feeding tubes/ blankets/ clean towels/ baby feeding cup/ BP apparatus and
stethoscope/ sterile clean pads/ bleaching powder/ Providine Iodine solution/ Spirit/
micropore tape/ antenatal card/ partograph
Is the partograph being maintained in every delivery?
Is the staff (other than trainers) involved in conducting of delivery/LR following the SBA
training protocol?
Is the staff in LR aware of any training being conducted for SBA?
Is the teaching schedule posted at LR/ wards/OPDs?
Is the duty roster for the trainees posted at the LR/wards/OP Ds?
Is a functional New born corner with at least ambu bag, baby warmer, suction etc.
available in the LR?
Feedback from Clinical Trainers:

__________________________________________________________________________
Comment s Ob ser ver
---------------------------------------------------------------------------------------------------------------------------Name -----------------------------------Place of posting----------------------De signation-----------------Signature-------------------------------Date---------------------------------Model Sub Centre:
The Model S ub Center scheme represents a c ritical policy intervention to provide essential
obstetric care at sub centers. Model sub centers are intended to provide services included
antenatal care, intra natal care, (institutional deliveries), post natal care, new born care services,
family planning and immunization services.
Under this program, NRHM has sanctioned Rs. 61. 12 c rores till 2008-09 and money has been
transferred to District Health Societies from the State Health Society. The physical progress
envis ages the construction of 3000 model sub centers in Rajasthan.
Check-li st
1. District Observed
2. Name of the Model sub center
3. Population covered
4. Name of the PHC
5. Name of the Block
6. Location of Sub centre
.
.
.
Within Village
7.
Building
8.
Construction of Labor room
9.
Whether labor room is being constructed in the same building
Rent ed
Govt .
Complete
Outside Village
No building
Under construction
Not started
10. Labour room functional

11. Electricity
12. Water availability
None
Own tap
Yes
.
No
.
Yes
.
Yes
.
No
.
No
.
Boring
Community Tap
.
138

13. No. of Health Workers-Female( ANM)

a. Sanctioned
b.
14.
15.
16.
17.
18.
19.
Posted
c. Vacant
Name: (ANM 1)
Cont act no
SBA trained
Name: (ANM 2)
Cont act no.
SBA trained
.
.......
Yes
.
.
.........
Yes
.
No
.
No
.
20. Other service provider available

a. If Yes, Category
...
b. Number
.
21. Number of pregnant women registered with
Sub centers (Since April 08-Check from register)
22. Number of pregnant women offered ANC in last one month
23. Number of deliveries at the sub-center in last one month
24. Number of deliveries conducted at home in last one mont h
25. Referral institution identified for emergency referral
26. Distance of referral institution from
Less
5-10
the sub-center
than 5 K.m.
K.m.
27. Number of pregnant women referred to the
None
1-3
Institutions in last month
28. Number live births and Still Births
i. at Sub center delivery
Live Births.
ii. home delivery
Live Births..
31. Funds utilized

32. Whether accredited for Institutional Deliveries
33. Are the records of ANC/ Int ra natal/ PNC records maintained
4-5
5+
Still Births...
Still Births..
29. Number of neonates referred to higher centers in the last month.

30. A vailability of fund
. No
Yes
a. Nature of fund
.
.
i. Untied fund
Less than 1000
1000
1. Amount
ii. Model sub center development fund
1. Amount
More than
10 K.m.
More than 1000
Yes
.
Less than 5000
No
.
5000
Yes
.
Yes
.
Yes
.
No
.
No
.
No
.
139

34. Equipments available (Check and tick):

S.no.
Basi c Equipment s
i.
Weighing Machine (Adult)
ii.
Weighing Machine (Baby)
iii.
BP Instrument
iv.
Stethoscope
v.
Hemoglobinometer
vi.
Urostix
vii.
Thermomet er (dual Cel/Fah scale)
viii.
Instrument sterilizer
ix.
Table
x.
Chairs
xi.
Wooden benches
xii.
Patient stool (revolving)
xiii.
Dressing forceps (stainless steel)
xiv.
Kidney basins (stainless steel) large
xv.
Kidney basins (stainless steel) small
xvi.
Sponge bowls small (stainless steel)
xvii.
Sponge bowls large (stainless steel)
xviii.
Urinary catheters
xix.
Mouth gag
xx.
Scissors
xxi.
Mackintosh
xxii.
Labor table: stainless steel
xxiii.
Chittle forceps
xxiv.
Foot step
xxv.
Emergency Light
xxvi.
Dressing drum
xxvii.
Dressing trolley
xxviii.
Infant tray
xxix.
Gallies Pads
xxx.
Movable curtains
xxxi.
IV stand
xxxii.
Foetoscope
xxxiii.
Inj. MgSO4
xxxiv.
Tab. Mesoprostral
xxxv.
Ambu bag & masks (neonatal size)
xxxvi.
Pedal Suction
xxxvii.
Mucus Sucker
xxxviii.
New born corner
Number available
Functionality Ye s/No
140

35. Skill Assessment

S.no. Topic
1. Hand Washing steps
Measuring BP
2.
Systolic
Diastolic
3. Weight Taking
4. Hb Estimation
Urine Examination
5.
Sugar
Albumin
6. Counselling Skills
Abdominal grips
Fundal
7.
Lateral
Pelvic
Pawlic
8. PV Assessment
9. Plotting Partograph
10. Fetal Heart Rate
11. Conducting Deliveries
12. ANC visits per pregnant woman
rd
13. Active mgmt of 3 stage of labour
Know ledge
Correct/ Incorrect
Performing
Yes/ No
Correct/ Incorrect
Correct/ Incorrect
Yes/ No
Yes/ No
Correct/ Incorrect
Correct/ Incorrect
Yes/ No
Yes/ No
Correct/ Incorrect
Correct/ Incorrect
Yes/ No
Yes/ No
Correct/ Incorrect
Yes/ No
Correct/
Correct/
Correct/
Correct/
Incorrect
Incorrect
Incorrect
Incorrect
Yes/
Yes/
Yes/
Yes/
Correct/
Correct/
Correct/
Correct/
1/2/3/4
Correct/
Incorrect
Incorrect
Incorrect
Incorrect
Yes/ No
Yes/ No
Yes/ No
Yes/ No
1/2/3/4
Yes/ No
Incorrect
No
No
No
No
Observations
and
Comments
(can
also
give
in
Hindi)
Name of observer
DesignationDistrict ..
Mobile Number
Email id.
Observation in the month of
Date of observation..
Distance from city (observers head-quarter)kms.
Signatures
141

Village Health and Nutr ition Day (MCHN day):

The V HND is to be organiz ed once every month
(preferably on Wednesdays and for t hose villages that
have been left out, on any other day of the same month)
at the AWC in the village
On the appointed day, ASHAs, AWWs, and others will
mobilize the villagers, especially women and children, to
assemble at the nearest AWC
Services to be provided:
1. All pregnant women are to be registered.
2. Registered pregnant women are to be given ANC.
3. Dropout pregnant women eligible for ANC are to be tracked and services are to be
provided to them.
4. All eligible children below one year are to be given vaccines against six Vaccinepreventable diseases.
5. All dropout children who do not receive vaccines as per the scheduled doses are to be
vaccinated.
6. Vitamin A solution is to be administered, to children.
7. All children are to be weighed, with the weight being plotted on a card and managed
appropriately in order to combat malnut rition.
8. Anti-TB drugs are to be given to patients of TB.
9. All eligible couples are to be given condoms and OCPs as per their choice and referrals
are to be made for other contraceptive services.
10. Supplement ary nutrition is to be provided to underweight children.
Issue s to be discu ssed w ith the community:
1. Danger signs during pregnancy
2. Importance of institutional delivery and where to go for delivery
3. Importance of seeking post-nat al care
4. Counseling on E NBC
5. Registration for the JSY
6. Counseling for better nut rition
7. Exclusive Breastfeeding
8. Weaning and complementary feeding
9. Care during diarrhea and home management
10. Care during acute respiratory infections
11. Prevention of malaria, TB, and other communicable diseases
12. Prevention of HIV/AIDS
13. Prevention of STIs
14. Importance of safe drinking water
15. Personal hygiene
16. Hous ehold sanitation
17. Education of children
18. Dangers of sex selection
19. Age at marriage
20. Information on RTIs, S TIs, HIV and AIDS
21. Disease outbreak
22. Disaster management
142

Identification of case s that need special attention:

1. Identify children with disabilities.
2. Identify children with Grade III and Grade IV malnutrition for referral
3. Identify severe cases of anemia.
4. Identify pregnant women who need hospitalization.
5. Identify cases of Malaria, TB, leprosy, and Kala Azar.
6. Identify problems of the old and the destitute.
7. Pay special attention to the SC, S T, the minorities, and the weaker sections
8. Reproductive & Child Healt h Program(RCH)
Collection of data:
1. Compile dat a on the number of children with special needs, particularly girl children with
disabilities.
2. Report outbreaks of disease.
3. Report/audit deaths of children and women.
4. Compile data pertaining to the SCs, the S Ts, the minorities, and weaker sections of
society that need services.
Check Li st :
1.
2.
ASHA
Action s to be taken before the Village Health and Nutrition Day:
a. Visit all households and get to know all the families. Make it a point to visit all
poor households, especially SC/S T families.
b. Make a list of pregnant women.
c. Make a list of women who need to come for A NC for first time or for repeat visits.
d. Make a list of infants who need immunization, were left out or dropped-out.
e. Make a list of children who need care for malnutrition.
f. Make a list of children who were missed during the pulse polio round.
g. Make a list of children with special needs, particularly girl children.
h. Make a list of TB patients who need anti-TB drugs.
i. Coordinate with the AWW and the ANM.
On the
a.
b.
c.
d.
e.
f.
day:
Ensure that all listed women come for services.
Ensure that all listed children come for services.
Ensure that malnourished children come for consultation with the ANM.
Ensure supplementary nutrition to children with special needs.
Ensure that all listed TB patients collect their drugs.
Assist the ANM and the AWW.
AWW
a.
b.
c.
d.
e.
Ensure that the AWC is clean.

Ensure availability of clean drinking water during the VHND.
Ensure a place with privacy at the AWC for ANC.
Keep an adequate number of MCH cards.
Coordinate activities wit h the ASHA and the ANM.
143

3.
ANM
a.
b.
c.
d.
e.
f.
g.
4.
PRI s
a.
b.
c.
Ensure that the V HND is held without fail. Make alternative arrangements in case
the ANM is on leave.
Ensure that the supply of vaccines reaches the site well before the day 's activities
begin.
Ensure that all instruments, drugs, and other materials as listed in the annexure
are in place.
Carry communic ation materials.
Ensure that adequat e money is available for disbursement to the ASHA.
Ensure reporting of the VHND to the MO in charge of the PHC.
Coordinate with the ASHA and the AWW.
Ensure that the members of the VHS C are available to support the sessions.
Ensure participation of schoolteachers and PRI members.
Ensure availability of clean drinking water, proper sanitation, and convenient
approach to the AWC for participating in the VHND by all.
Service Package:
1. Maternal Health
2. Early registration of pregnancies.
3. Focused ANC.
4. Referral for women with signs of complications during pregnancy and those needing
emergency care.
5. Referral for safe abortion to approved MTP centres.
6. Counseling on:
7. Education of girls.
8. Age at marriage.
9. Care during pregnancy.
10. Danger signs during pregnancy.
11. Birth preparedness.
12. Importance of nutrition.
13. Institutional delivery.
14. Identification of referral transport.
15. A vailability of funds under the JSY for referral transport.
16. Post-natal care.
17. Breastfeeding and complementary feeding.
18. Care of a newborn.
19. Cont raception.
20. Organizing group discussions on maternal deaths, if any; that have occurred during
the previous mont h in order to identify and analyze the possible causes.
Child Health:
Infant s up to 1 year:
1. Registration of new births.
2. Counseling for care of newborns and feeding.
3. Complete routine immunization.
4. Immunization for dropout children.
5. First dose of Vitamin A along with measles vaccine.
6. Weighing.
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Children aged 1-3 years:

1. Booster dose of DP T/OPV.
2. Second to fifth dose of Vitamin A.
3. Tablet IFA - (small) to children with clinical anemia.
4. Weighing.
5. Provision of supplementary food for grades of mild malnutrition and referral for cases of
severe malnutrition.
All children below 5 years:
1. Tracking and vaccination of missed children by ASHA and AWW.
2. Case management of those suffering from diarrhea and Acute Respiratory Infections.
3. Counseling to all mothers on home management and where to go in even of
complications.
4. Organizing ORS depots at the session site.
5. Counseling on nutrition supplement ation and balanced diet.
6. Counseling on and management of w orm infestation s.
Family Planning
1. Information on use of contraceptives.
2. Distribution - provision of contraceptive counseling and provision of non-clinic
contraceptives such as condoms and OCPs.
3. Information on compensation for loss of wages resulting from sterilization and insurance
scheme for family planning.
Reproduc tive Tract Infection s and Sex ually Transmitted Infection s
1. Counseling on prevention of RTIs and S TIs, including HIV/AIDS, and referral of cases for
diagnosis and treatment.
2. Counseling for premenopausal and post-menopausal problems
3. Communication on causation, t ransmission, and prevention of HIV/ AIDS and distribution
of condoms for dual protection.
4. Referral for VCTC and PPTCT services to the appropriate institutions.
Sanitation
1. Identification of households for the construction of sanitary latrines
2. Guidance on where to go and who to approach for availing of subsidy for those eligible to
get the same under the Tot al Sanitation Campaign.
3. A voidance of breeding sites for mosquitoes.
4. Mobilization of community action for safe disposal of household refuse and garbage.
Communicable Disease s
1. Group c ommunication activities for raising awareness about signs and symptoms of
leprosy, suspected cases, and referrals.
2. Group communication activities for elimination of breeding sites for mosquitoes,
management of fever cases, i.e. importance of collection of blood film for MP and
presumptive treatment.
3. Awareness generation about symptoms of TB (coughing for more than three weeks),
importance of continued treatment, referral of symptomatics for sputum examination at
the nearest health centre.
4. Provision of anti-TB drugs to patients.
5. Reporting of unusual numbers of cases of any disease or disease outbreak in village.
145

Gender
1. Communication activities for prevention of pre-natal sex selection, illegality of pre-natal
sex selection, and special alert for one-daught er families.
2. Communication on the Prevention of Violence against Women, Domestic Violence Act,
2006.
3. Age at marriage, especially the importance of raising the age at marriage for girls.
A YUS H
1. Home remedies for common ailments based on cert ain common herbs and medicinal
plants like tulsi found in the locality.
2. Information related to other AY USH components, including drugs for t reating conditions
like anemia.
Health
1.
2.
3.
4.
5.
Promotion
Chronic diseases can be prevented by providing information and counseling on:
Tobacco chewing
Healt hy lifestyle
Proper diet
Proper exercise
Nutri tion
Diseases due to nutritional deficiencies can be prevented by information and couns eling on:
1. Healt hy food habits.
2. Hygienic and correct cooking practices.
3. Checking for anemia, especially in adolescent girls and pregnant women; checking,
advising, and referring.
4. Weighing of infants and children.
5. Importance of iron supplements, vitamins, and micronutrients
6. Food that can be grown locally.
7. Focus on adolescent pregnant women and infants aged 6 months to 2 years.
Who Are Needed
1. ASHA
2. AWW
3. PRI member
4. Helper of AWW
5. Staff to come from outside the village
6. ANMs
7. Male MPW (if available)
8. ASHA facilitators (if available)
Instrument s and Equipment s:
1. Weighing scale-adult, child
2. Examination table
3. Bed screen/curtain
4. Hemoglobin met ers, kits for urine examination
5. Gloves
6. Slides
7. Stethoscope and blood pressure instrument
146

8. Measuring tape
9. Foetoscope
10. Vaccine carrier with ice packs
If these items are not available, their provision could be arranged by using the untied fund of Rs
10,000/- available with the ANM or with the VHSC.
These items should be kept under the safe custody of the ANM/ AWW/ASHA
Supplies:
1.
2.
3.
4.
5.
6.
Vaccines,
Medicinesa. IFA tablets,
b. Vitamin A,
c. Cotrimox azole
d. Anti-helminthic drug
e. Chloroquin
f. Anti-TB drugs
g. Paracetamol
Stains for fixing BF
condoms, OCPs, (ECPs), ORS,
AD syringes in sufficient quantity
IEC mat erial for communication and counseling
Superviso ry Checkli st :
(To be used by the different cadres of supervis ors during visits to the VHND sites)
1. General information: Session site, availability of staff, timings display ed
2. Cold chain: Vaccine carrier with ice packs, VVM's status on vaccine vials
3. A vailability of essential supplies in adequate quantities
4. Procedure of vaccination, especially injection safety
5. A vailability of communication and counseling materials
6. Record review for
i. Women and children from vulnerable communities
ii. Immunization for children scheduled to arrive
iii. Follow-up activities for ANC
iv. Blood films collected for MP
7. Disposal of AD syringes
8. Client satisfaction: Exit interviews with some clients about t he dates of repeat visits for
immunization, birth preparedness, and the institution identified for delivery
9. Disbursement of incentives to ASHA for mobilizing clients to get immunization.
MCHN Week- Guidelines
1. Urban strategy:
Focus will be on recognized urban slums. RCH officer will be t he nodal officer for urban slums in
the district. Deputy CMHOs will be the nodal officers for urban slums in their own areas.
147

a.
Sites for vac cination:

Anganwadi centers, schools and urban dispens aries will be the sites for vaccination. In
addition, private clinics identified under PPI will also be used as session sites. For scattered
slums, mobile vans could be used to cover all families.
b. Team:
Each team should have on vaccinator (staff skilled in immunization and authorized to provide
immunization) and 2-3- social mobilizers (to mobilize children and women, control crowd and
support recording)
Vaccinator can be drawn from the following:
ANMs of the revamping scheme.
Nursing staff of the dispensaries.
Nursing staff/ ANMs posted at the district headquarters.
ANMs/ LHVs of the nearest CHC
Trained MPWs
Social mobilizers: Social mobilizers will be drawn from the following:
AWWs, workers of local NGOs, other women residing in that area.
c. Timing:
Sessions will begin at 10: 00 am not more than two sessions should be conducted per day.
Timings of each session should be clearly identified and communicated to the community.
2. Rural Strategy:
Each PHC will be the planning unit. Medical officer will be the overall in Charge.
a. Team:
Vaccinators:All the ANMs and LHVs will form the PHC team. When required, additional
vaccinators could be deployed from neighboring PHCs where activities are not planned.
Social mobilizers: In each village, A NM/LHV will identify 1 mobillizer (AWW, Sahyogini,
ASHA: if none of these are available, identify another local woman)
b. Sites:
Sub- cent er, Anganwadi, school, panchayat ghar. For remote hamlets, a site as close to the
hamlets as possible should be identified. For scattered hamlets, mobile teams should cover
the populations.
Remember: Conduct the MCHN session as scheduled on Thursdays
3. Conduc ting a Session
a. Timing:
10:00 am to 05:00 pm. If two sessions are planned, conduct sessions from 10-1 pm and 2:00
to 05:00.
b. Informing families and mobilizing children:,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
One day prior to the session, social mobilizer should be requested to conduct house-to
house canvassing ans community line-listing to identify all eligible children and pregnant
women.
c. Preparing the vaccine and logistic s:,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Cold chain handler at the PHC will be vaccine- carrier as per the requirements specified in
the PHC plan, and label eac h vaccine- carrier.
d. Transp orting vac cines, logi stic s and staff :
One vehicle will be hired at the vaccine depot for transporting vaccines, logistics and
manpower to the session- site. Vehicle will leave the vaccine depot at 07:00 am so as to
148

e.
cover all the session sites by 10: 00 am. If all session- sites cannot be reac hed in three hours
due to large distance/ inaccessibility, another vehicle may be hired.
Supervising :
Supervisor (LHV and or MO) will monitor the sessions using the monitoring Checklist using
the same vehicle after dropping the vaccines and logistics. In the evening, same vehicle will
return to the vaccine depot, collecting all the vaccine carriers and dropping back the staff.
Outc omes:
The organization of the Village Health and Nutrition Day on a regular basis as per the guidelines
will result in the achievement of the following outcomes:
1. Hundred per c ent coverage with preventive and promotive interventions, especially for
pregnant women, children, and adolescents
2. Preventive and promotive coverage for the National Disease Control Programs
3. Increased awareness about the determinants of health such as nutrition, sanitation, timely
care.
4. Improved knowledge about the services offered under the various Nutritional Health
Programs.
5. Greater emphasis on the community's role in making the health system responsive t o the
health needs of the community and in demanding and ensuring accountability.
149

Interpersonal Communication & BCC

The National Rural Health Mission accords priority to BCC (Behavior Change Communication)
interventions as a mechanism for achieving its goals .
The State PIP for Rajasthan has identified the lack of a state specific integrated B CC strategy
and implementation plan as a key area for strategic input. It is also required to undertake the
regular research and evaluation studies for BCC interventions.
Uttar Pradesh is one of the first states in India to initiate t he process of development of a state
level comprehensive BCC strategy for NRHM. Similar efforts need to be initiated in Rajasthan
also where the past experiences of IEC Bureau need to be revived
The BCC strategy seeks to address the following gaps in BCC services in the state
1. lack of a coordinated BCC effort across and within national programs;
2. lack of decentralized BCC planning at the district, block and village levels
3. lack of behaviorally focused, socio-culturally driven BCC approaches and
4. an excessive focus on electronic mass media without large scale community based
Activities
5. Rajasthan is largely rural, with a high level of non-literacy in women.
6. Strategy foc uses on community based approaches while using mass media to create an
enabling environment. Community based approaches to BCC include home visits, group
meetings and working with existing local structures and community groups.
Communication i s a process o f convergence
Communication is a process in which participants create and share information with one another
in order to reach a mutual understanding Mutual understanding builds the foundation for mutual
agreement, which in turn makes collective action possible. Effective communication begins with
the audience and continues over time as a process of mutual understanding and convergence.
The main difference bet ween IE C (information education and communication) and BCC is that
while IEC is more one-way and foc used on messages, BCC is more outcome oriented and
also includes the role of participatory methods and motivation in the behavior change process.
IEC is based on the implicit assumption that awareness creation will automatically lead to
behavior change. Hence the emphasis of IE C is on creating messages, entertainment and
media.
Behavior Change Communication
BCC is a research-based, consultative process of addressing k nowledge, attitudes, and practices
through identifying, analyzing, and segmenting audiences and participants in programs and by
providing them wit h relevant information and motivation through well-defined strategies, using an
appropriate mix of interpersonal, group and mass media channels, including participatory
methods.
What is Behavior Change Communication
BCC is about changing specific behaviors well defined actions at the household, community
and health service levels . BCC approaches recognize that behavior change is more about
identifying the causes and barriers to behavior change and overcoming the barriers.
150

It is about understanding the communities, contexts and environments in which behavior occur.
BCC is also about using persuasive techniques to demand health rights and to mak e public sector
health services available and accessible to the neediest. BCC is about integrating new practices
into long standing social, cultural and communication systems.
Communication proce ss:
In the process of communic ation the message has to have the following attribut es1. Command Attention
2. Cater to the Heart and Head
3. Clarify the Message
4. Communicate a Benefit
5. Create Trust
6. Convey a Consistent Message
7. Call for Action
For example- Small family is happy family, Buy one, get one free, Small is beautiful, No
substitute for hard work, Team works, Together everyone achieves more.
Difference betw een IPC and Mass communication:
S.No.
1
2
3
4
5
6
7
8
9
Characteristic s
Nature
Reac h
Audience
Message
Purpose
Cost Effectiveness
Feed Back
Support of Other
Media
Retention of
Message
IPC
Personal
Very Slow
Specific
Focused
Help Take Decisions
Very Expensive
Instant
It Becomes More Effective
Mass communication
Impersonal
Very Fast
General
Generaliz ed
Create Awareness/Sensitize
Cheap
Delay ed
Supplements Each Other
For a Long Time/till Adoption of an

Idea
for a Short Time
How to Initiate Inter-Personal Communication

1. Proper introduction of yourself/revealing your identity and explaining the purpose of your
visit.
2. Establish mutual understanding of each other
3. Allow the audience to speak more and facilitate
4. Win the confidence of the audience.
5. Understand his/her problems in proper perspectives
6. Analyze whether your interest and his/her problems are the same or different.
7. If same, your t ask becomes simpler, otherwise, you need to take up your interest in the
second phase
8. Do not make falls promises/pos e yourself
How to
1.
2.
3.
4.
5.
terminate IPC
Leave good impression of yours elf
Have issues for next meeting
Identify contact people/influencers
Should become one among the audiences/sense of belongingness
Give an opportunity for the audiences to come with their real problems
151

Skills required for IPC

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Keep your mind open

Be flexible
Find area of interest
Listen to ideas
Judge content, not delivery
Resist distractions
Hold your fire
Work at listening
Capit alize on thought speed
Face the audience
Maintain eye contact
Use appropriate aids, if you can
Use appropriate language
Focus on the needs of the audience
Be brief and to the point w ithout having any ambiguity
Understand the audiences profile first their need, interest, culture, socio-economic
status, religious beliefs etc.
17. Put questions in such a way the audience understand and reply favorably
18. Start questions from simpler to complex
19. Do not put questions in such a way which may embarrass you t he way you ask
questions is important
Developing BCC strategy
First need to understand the BCC Gap sTo develop the B CC strategy and action plan first need is to identify the Gaps and resourc es
available to address thes e BCC gaps through different interventions. Following areas may be
consulted to identify the BCC gaps
1. Status of BCC supervision at the state, district, block & village levels
2. Status of capacity for planning and Implementing B CC programs at different level
3. Status of community based BCC inputs
4. Status of mass media campaigns
5. Capacity in the state to implement BCC programs at scale
6. Understanding of health personnel in the state on BCC
The situational analysis can help to indicate the health scenario in Rajasthan: Fo r ex ample
1. Infant and child mortality rates.
2. Infant mortality rat es are higher in young mothers (< 20 years) compared to women 2029yrs.
3. maternal mortality ratio
4. Maternal coverage in terms of antenatal care, institutional deliveries and postnatal care
5. contraceptive us e by eligible couples ( Current CPR)
6. Unmet need of contraceptives
7. New born care practices are another area where there is scope for improvement
8. Anemia levels in women and in children ages 6- 36 months.
9. TB rates in state
152

Selection of Priority Behavior s & B CC Barriers A nalysi s

There are about 10 National Health P rograms under the NRHM umbrella ranging from maternal
health to blindness control. This BCC strategy proposes a t wo-pronged approach t o circumvent
the dilemma of addressing too many care seeking and household behaviors at one time. The
approach includes:
1. The selection of priority behaviors for mass promotion and
2. Addressing specific behaviors through interpersonal communication (IPC) and community
based B CC approac hes.
Priority Areas for B CC Strategy
The priority areas for BCC focus within NRHM based on the situational analysis of Rajasthan are:
1. Antenatal Care
2. Institutional Deliveries
3. Post Natal & New Born Care
4. Married Adolescents
5. Gender discrimination (female feticide, infant girl, under 5 girl, son preference and
6. therefore large family size)
7. Unmet need for family planning
8. Nutrition through the life cycle (infant, under three, adolescent, woman)
9. Routine immunization
10. Hygiene and safe water practices
11. Marginalized groups and households including urban poor
12. Need for supportive supervision of AS HAs
13. Capacity building of B CC skills for service providers across NRHM
14. Workload definition and structuring of workload for the ASHAs
BCC Barrier s Analy si s:
The behavioral analysis for health care can indicat e at common t hemes related to behavioral
barriers. Behaviors in the household and/or community are not dependent on healt h services.
These include hygiene, nutrition, new born care related behaviors.
Barriers related to health providers and health services are anot her common theme. These
barriers range from lack of regular outreach and other health services to low motivational levels
and low community accountability of the service provider.
Priority Behavior for B CC Campaigns
Core Trigger Behavior
1
Age at marriage > 18 yrs; Delay first pregnancy till 21 years for girls
2.
3.
Eat three times a day (women and adolescent girls); eat 3-4 times a day (pregnant women)
Early registration <12 weeks; 3 ANC check ups
4.
Institutional Delivery; Stay in the hospital for 24 hrs aft er delivery
5.
Immediate health seeking behavior on recognition of danger signs in mother and newborn
6.
Immediate and exclusive breast feeding within one hour of birt h and continue exclusive
breast feeding up to six months
7.
Keep the newborn warm with skin to skin care
8.
Complete Immunization/ Booster / Vit A
9.
Complementary feeding from six months 4-5 times a day in addition to breast feeding
153

10.
Wash hands wit h soap after defecation and prior to feeding child under three years
11.
Increase birth interval to three years
12.
Adopt any limiting method after two children even if both are girls
13.
Early detection of TB
14.
Empty and dry water containers once a week
Barriers to Behavior Change:

Socio-Cultural Barriers
Gender discrimination; son preferenc e
Norm of early child bearing/early marriage
Colostrum feeding & other new born care practices
Dietary pattern of eating t wo meals a day, women eat last
Healt h Services
Lack of regular outreach services at the village level
Health provider attitude and low motivation levels
Lack of trust in public sector services
Socio-Economic and Infrastructure
Transport constraints
Households with food insecurity
BCC
Too much focus on awareness creation
Limited reach of mass media in rural areas
Weak systems for BCC supervision
Community based BCC (IP C, group meetings, community events) is limited
Uncoordinated mass media campaigns
BCC Strategy for NRHM in Rajast han
The core strategic input for the NRHM BCC strat egy should be focused around int erpersonal
communication (IP C) and community level BCC activities. This in turn will be supported by mass
media and community mobilization interventions.
BCC Intervention s
The NRHM BCC interventions required to be initiated at various levels such as:
1. State
2. Facility/institution
3. Local/ village-slum
4. Hous ehold/family
These int erventions are link ed together by a common strategic plan. However interventions at the
household and facility levels will provide need based BCC that will include a much larger set of
behavior.
State Level
1. Airing TV, radio spots, health related serials etc.,
2. Celebration of health days,
154

3.
4.
5.
Implementing mass campaigns, ranging from 3-4 months to 1 week, (initiating use of
alternate media such as cell phones using SMS campaigns and cont ests)
Political & Media Advocacy
Use of outdoor media such as bus and auto-rickshaw panels, hoardings etc.
Facility/Insti tution
BCC interventions at health facilities and schools can be implemented through c ounseling
sessions organized by a trained professional health worker patient c ouns elor, teacher, A NM or
Male Health worker. He /she should be equipped with audio visual t ools for c ounseling. B CC
areas to be prioritized such as1. Maternal & Child Health,
2. Family Planning and
3. National Programs TB Malaria, or any other focused program
4. Postnatal care of mother,
5. new born care and family planning to JSY beneficiaries at the PHC
Community Ba sed BCC Intervention s
1. Community level BCC interventions include2. Group meetings, VHND,
3. community notice boards,
4. use of short films, CD Spots etc.
Hou sehold/Family Level (Interpersonal Communication)
1. Home visits by ASHA to eligible women and pregnant women.
2. An IP C (interpersonal communication) tool for maternal and newborn health c an be
suggested to enable ASHAs to do need specific BCC at the household level.
3. Other household level BCC interventions include child to community approaches and
promoting couple and family communication
Interpersonal Communication (IPC) & Community Level BCC Ac tivitie s
Healt h related behavior c an be divided into t wo broad sets. One within the microenvironment of
the home e.g. hygiene and dietary behavior; condom use, oral pill use etc.; the other which
requires contact with the health delivery system e.g. antenatal checkups, routine immunization,
sputum testing.
Behavior occurring within the micro-environment of t he hous ehold can be c hanged irrespective of
the availability or accessibility of health services 26. In the case of healt h seeking behavior,
government health services have to be made accessible, available and of good quality, for people
to use them consistently and BCC needs to address health service barriers.
Why IPC & Communit y Level BCC Ap proache s?
A total of 18 contacts with mot her and c hild over five years (3 contacts per year) can deliver
effective child survi val interventions, almo st entirely thro ugh communi ty ba sed and
outreach delivery effort s .
This BCC strategy propos es changing household level behavior t hrough focused community
based interventions at the community, group and hous ehold levels in addition to mass media
inputs.
155

The proposed community based BCC activities are:

1. MCHN Day
2. Home visits by ASHA to offer need specific BCC.
3. Group meetings by ASHA and ANM on specific topics
4. Swasthya Camps at the block level with video vans (Pilot basis)
5. Child to community BCC for hygiene behavior, routine immunization and prevention of
6. Mosquito breeding sites
7. Folk performances and Nukkad Nataks
156

Integrated Disease Surveillance Project

The Government of India is initiating a dec entraliz ed, state based Integrated Disease Surveillance
Project (IDSP) in the country in response to a long felt need expressed by various expert
committees. The project would be able to detect early warning signals of impending out breaks
and help initiat e an effective response in a timely manner. It is als o expected to provide essential
data to monitor progress of on going disease control programs and help allocate health resourc es
more optimally.
Objectives
The project development objective is to improve the information available to the government
health servic es and private health care providers on a set of high-priorit y diseases and risk
factors, with a view to improving the on-the-ground responses to such diseases and risk factors.
Specifically, the project aims at:
1. To establish a dec entralized state based system of surveillance for communicable and
non-communicable diseases, so that timely and effective public health actions can be
initiated in response to healt h challenges in the country at the state and national level.
2. To improve the efficiency of t he existing surveillance activities of disease control
programs and facilitate sharing of relevant information with the healt h administration,
community and other stakeholders so as to det ect disease t rends over time and evaluate
control strategies.
The project will assist the Government of India and the states and territories to:
1. Surveil a limited number of health conditions and risk factors;
2. Strengthen data quality, analysis and links to action;
3. Improve laboratory support;
4. Train stakeholders in diseas e surveillance and action;
5. Coordinate and decentralize surveillance activities;
6. Integrate disease surveillanc e at the state and district levels, and involve communities
and ot her stakeholders, particularly the privat e sector.
Component s
Component 1. Establi sh and Operate a Central-level Disease Surveillance Unit.
Under this component, Ministry of Health and Family Welfare (MOHFW) will establish a new
Disease S urveillance Unit at the cent ral level to help coordinate and decentralize disease
surveillance activities. The new unit will support and complement the states' disease surveillance
efforts. The unit will be staffed by existing permanent staff reassigned from wit hin the MOHFW.
This component will address the constraints of lack of coordination despite cent ral control of
surveillance activities and the need for changing the diseases included in the system. Effective
coordination (as compared to control) of disease s urveillance activities depends on establishing
the appropriate processes and institutional arrangements at t he c entral level. This will be done
through the creation of a small disease surveillance unit to support the states disease surveillance
efforts.
Component 2. Integrate and strengthen di sease sur veillance at the state and district levels.
This component addresses the constraints imposed by lack of coordination at the sub-national
levels, the limited use of modern technology and data management techniques, the inability of the
system to act on information and t he need for inclusion of other stakeholders. It will integrate and
strengthen disease surveillance at the state and district levels, and involve communities and other
stakeholders, in particular, the private sector.
157

Component 3. Improve laboratory suppor t. This component will consist of:

(i) upgrading laboratories at the state level, in order to improve laboratory support for surveillance
activities. A dequate laboratory support is essential for providing on-time and reliable confirmation
of suspected cases; monitoring drug resistance; and monitoring changes in disease agents;
(ii) introducing a quality assurance system for assessing and improving t he quality of laboratory
data.
Component 4. Training for disea se sur veillance and action. The changes envisaged under
the first three components will require a large and coordinated training effort to reorient health
staff to an int egrated surveillance system and provide the new skills needed. Training programs
will include representatives from the private sector, NGOs and community groups.
Project Highlight s
1. It will monitor a limited number of conditions based on state perceptions including 13
core and 5 state priority conditions for which pubic health res ponse is available.
2. District, State & Central Surveillance units will be set up so that the program is able to
respond in a timely manner to surveillance challenges in the country including
emerging epidemics.
3. It will integrate surveillance activities in the count ry under various programs and use
existing infrastructure for its function.
4. Privat e practitioners / Private hospitals / Private laboratories will be inducted into the
program as sentinel units.
5. Active participation of medic al colleges in the surveillance activities.
6. The project will ensure uniform high quality surveillance activities at all levels by
a. Limiting the tot al number of diseases under surveillance and reducing overload at
the periphery
b. Developing standard case definitions
c. Developing formats for reporting
d. Developing user friendly manuals
e. Providing training to all essential personnel, and
f. Setting a system of regular feed back to the participants on the quality of
surveillance activity.
7. District Public Health Laboratory will be strengthened to enhance capacity for
diagnosis and investigations of epidemics and confirmation of disease conditions.
8. Use of information technology for communication, data entry, analysis, reporting,
feedback and actions. A national level surveillance network will be established up to
the district level.
Di sease s condi tion s under the surveillance program
(i) Regular Sur veillanc e:
Vector Borne Disease
Water Borne Disease
Respiratory Diseases
Vaccine Prevent able Diseases
Diseases under eradication
Other Conditions
:
:
:
:
:
:
:
1. Malaria
2. Acute Diarrhoeal Diseas e (Cholera)
3. Typhoid
4. Tuberculosis
5. Measles
6. Polio
7. Road Traffic Accidents
(Linkup with police computers )
158

Other International commitments

Unus ual clinical syndromes
(ii) Sentin el Surveillanc e

Sexually transmitted diseases/Blood borne
Other Conditions
(iii) Regular periodic sur vey s:

NCD Risk Factors
: 8. Plague
: 9. Menigo-encephalitis/Respiratory
(Causing death / hos pitalization)
Dengue Hemorrhagic fevers,
undiagnosed conditions
other
: 10 HIV/ HBV, HCV

: 11 Water Quality
: 12 Outdoor Air Quality
(Large Urban centers)
: 13 Anthropometry, Physical activity,
Blood Pressure, Tobacco, Nutrition,
Blindness
(iv) A dditional St at e Priorities: E ach state may identify up to five additional conditions for
surveillance.
Note : GOI may include in a public health emergency any other unusual health condition.
Project funds could be used for such emergencies and reimbursed by IDA subject to agreement
at the next joint project review mission.
Phasing
Phase I (commencing from FY 2004-05)
Andhra Pradesh, Himachal P radesh, Karnat aka, Madhya Pradesh, Maharashtra, Uttaranchal,
Tamil Nadu, Mizoram & Kerala
Phase II (commencing from FY 2005-06)
Chhatisgarh, Goa, Gujarat, Haryana, Rajasthan, West Bengal, Manipur, Meghalay a, Orissa,
Tripura, Chandigarh, Pondicherry, Delhi
Phase III (commencing from FY 2006-07)
Uttar Pradesh, Bihar, Jammu & Kashmir, Jharkhand, Punjab, Arunachal Pradesh, Assam,
Nagaland, Sikkim, A & N Nicobar, D & N Haveli, Daman & Diu, Lakshdweep.
Key performance indicators:
Key aspects of overall performance of the surveillance system will be assessed using the
following indicat ors:
1. Number and perc entage of districts providing mont hly surveillance reports on time by
state and overall;
2. Number and percentage of responses to disease-specific triggers on time - by state and
overall;
3. Number and percentage of responses to disease-specific triggers assessed to be
adequate - by state and overall;
4. Number and percent age of laboratories providing adequate quality of information by
state and center;
5. Number of districts in which private providers are contributing to diseas e information;
6. Number of reports derived from private health care providers;
159

7.
8.
Number of reports derived from private laboratories;

# and % of states in which surveillanc e information relating to various vertical disease
control programs have been integrated
9. # and % of project districts and states publishing annual surveillance reports within three
months of the end of the fiscal year;
10. Publication by CSU of consolidated annual surveillance report (print, electronic, including
posting on the websites) within three mont hs of the end of fiscal year.
IDSP Reporting
1.
Form S (Suspect Cases) by Health Workers (Sub Centres)
2.
Form P (Probable Cases) by Doctors (PHC, CHC, Hospitals)
3.
Form L (Lab Confirmed Cases) from Laborat ories
Frequency of reporting weekly (Monday to Sunday)
Data c ompilation/analysis and response should be at all levels. Presently at State/ District/Block
level 12- 15 Out breaks reported every week.
Ex pectation s
By setting up a decentralized, action orient ed, integrated and responsive program, it is expected
that IDSP will avert a sufficient number of disease out breaks and epidemics and reduce human
suffering and improve the efficiency of all existing health programs. Such a program will also allow
monitoring of resource allocation and form a tool to enhance equity in health delivery.
Year w ise project cost s:
Year
2004-05
2005-06
Total
700.0
880.0
2006-07
1020.0
Sub Total (X Plan)
2600.0
2007-08
840.0
2008-09
643.6
Sub Total (XI Plan)

Grand Total
1483.6
4083.6
Component s-w ise Project Co st s

Non-Recurring :
Renovation & Furnishing
Laboratory Equipments
Computer Hardware & Accessories
Office Equipments
Application Software
Furnit ure & Fixtures
IEC Activities
Training of Pers onnel
Cons ultancy (Procurement, Soft ware, E valuation Studies etc)
Sub-to tal Non Recurring Co st s
Rs. in Millions
243.6
641.9
432.6
102.5
220.0
142.5
360.1
204.3
158.6
2506.2
160

Recurring (for 5 year s):

Laboratory consumables
Personnel Costs
Networking Costs
Operational & Maintenance Costs
Sub-to tal Recurring Co st s
310.5
561.2
125.2
580.6
1577.5
Grand total
4083.6
New initiatives under IDSP

1. Alert s throu gh IDSP call center
Call Centre operational with 1075 toll free number since February 2008
Call received as on 8th October 2008 : 18,872
No. of Health Alerts : 60
Led to detection of 5 out breaks (Cholera, Acute Diarrhoeal Disease and Chickenpox )
2. e-learning
The objective of e-learning is to enhance the skills to a wide arena of health personnel.
Proposed components:
o Discussion Forums
o Online Survey & Assessment
o Feedback
o FAQs
Currently e-learning modules are being prepared.
3. Media Scanning Cell
Objective:
o To provide the supplemental information about outbreaks
Method:
o National and local newspapers, Internet surfing, TV channel screening for news
item on disease occurrence.
Benefits of Media Scanning:
o Increases the sensitivity & strengthen the surveillance system
o Provide early warning of occurrence of clusters of diseases
161

Epidemic Preparedness and Outbreak Investigation

By and large the term outbreak and epidemics have been used interchangeably in public health
for the thin line that differentiates the two. By definition epidemics refer to a situation which is
clearly in excess to the normal expectation, often measured as endemic level. The outbreaks also
could be defined based on the same, the only difference being that outbreaks hav a sudden ons et
meaning thereby t hat the dis eases which qualify for out breaks hav a relatively short incubation
period.
The epidemic somehow, based on the epidemiological forecasting (we need data on endemic
levels on a regular basis for such forecast) can often be managed with advanced preparedness
but then the effective s urveillance system has to be in place. Since t he system needs to be
prepared in advance it is imperative to understand the procedural det ails.
Why do outbreak s occu r?
Single lapse in infection cont rol in hosp.
Lapse in surveillanc e
A hidden pocket of infection
Smuggled animals
Single volume of international air traffic
Rapid mutation & Adoptation in microbial world
Emergence of New risk groups
Modes of transmission can change
Drug resistance effect on treatment and prophylaxis
Outbreak management.involves
Anticipating, preventing, preparing for, det ecting, responding and controlling disease out breaks
with the whole purpose of preventing or minimizing health and economic impacts of possible
outbreaks
Why preparedness in advance?
Emergencies caused by epidemics are
frequent
Epidemics require urgent action and
Epidemics may oft en lead to panic if
preparedness is not adequat e
Response can be delayed, with possibility of
fast spread, and avoidable loss to human
lives, and ec onomy
Why Investigate?
Cont rol and prevention measures
Knowledge of an agent
Training
Public concerns
Concept s in Outbreak Investigation
Quantifying the epidemic (Descriptive epidemiology)
Getting at the source (Analytic epidemiology)
Basi c step s fo r communicable disease outbreak investigation
1. Preparation
a. Healt h coordination meetings
b. Use data from surveillance system
162

c.
d.
2.
3.
Review local directives or plans for each disease

Assemble your team
Epidemiologist
Laboratory workers
Environmental health specialists
Local health department
e. Identify and contact Key community contacts
f. Arrange supplies, equipment
g. Sample questionnaires
h. Plans for isolation wards
i. Laboratory support
Detection
a. Surveillance system with early warning system (EWS) for epidemic prone
diseases.
Clustering of cases or deaths in time and/or space
Unus ual increase in cases or deaths
Acute haemorrhagic fever
Severe dehydration following diarrohoea (usually with vomiting) in
patients >5 years of age
Acute fever with altered sensorium
Acute fever with renal involvement
Acute flaccid paralysis in a child
Acute fever with painful lymphnodes
Acute febrile severe illness of unknown aetiology
Occurrence of two or more epidemiologically linked cases of meningitis
E ven a single cas e of measles or any other epidemic prone diseases
from a tribal or other poorly accessible area
Unus ual isolates
Shifting in age distribution of cases
High vector density
Natural disasters
b. Notify ministry of health and WHO in case of outbreaks of specific diseases.
c. Take appropriate specimens (stool, CSF or serum) for laboratory confirmation.
d. Include case in the weekly report.
Response
a. Confirm the out break
i.
Determine if disease incidence is higher than background level
ii.
How do you determine background level? -surveillance
iii.
Reas ons for Obs erved >Expected
Change in case definition
Change in reporting procedures
Increased awareness or int erest
Improved diagnostics
New clinician
Change in Population
True increas e
Activate the outbreak control team
Investigat e the outbreak
163

b.
c.
d.
4.
Cont rol the outbreak

Define and identify cases in terms of time, place and person distribution
Establish Case Definition and classify as confirmed, propable, suspect
Identify Population At Risk (that would serve as denominator to calculat e attack
rate)
E valuation
a. Assess appropriateness and effectiveness of containment measures.
b. Assess timeliness of out break detection and response.
c. Change public health policy if indicated.
d. Write and disseminate outbreak report.
Epidemic Curve s: Time

Plot number of cases by onset date
Index case: first case of out break
Determine time course and future course,
exposure period
Point Source Outbreak s
1. All exposed at one time
2. Cases occur suddenly after minimum
incubation time
3. All cases occur within one incubation period
4. Outbreak stops unless secondary spread
5. Curves have steep upslope, more gradual
down slope
Continu ou s Common Source
1. May begin suddenly or gradually
2. Does not have an early peak (v/s Point source)
3. Cases do not disappear bec ause of secondary exposure
4. Curves have gradual or steep upslope, plateau trickling down slope, and may repeat
Propagated Outbreaks
Typical of person-to-person outbreaks
Secondary cases appear, at intervals corresponding to average incubation period after
peak of first wave
Taller successive waves of cases
Evaluate Hypot hesi s via Analytical Epidemiology
Determine exposure variables. Compare ill to not ill.
Construct a 2 X 2 table
Perform Cohort or Case Control Study
Use Cohort study when:
o Population at risk is known
o (you have a denominator)
o Interview ill and not ill
o Calculat e attack rates - ate v/s didnt eat
o Put on food-specific attack rate table
164

Calculation of Attac k Rate for Food X

Ate the food
Did not eat the food
Ill
Well
Total
Attack
Rate
Ill
Well
Total
Attack Rate
10
13
76%
11
64%
Attack Rate = Ill / (Ill + Well) x 100 during a time period

Attack rate = (10/13) x 100 = 76%
(4/11) x 100 = 36%
Calculating Risk Ratio s
Attack rate of ill and exposed a/ (a+ b)
---------------------------------------------------Attack rate of ill, not exposed c/ (c+ d)
A risk ratio of >1.0 means increased risk whereas RR 1. 0 indicat es no correlation, on the other
hand if the RR is less than 1. 0, it can be safely interpreted that the risk gets dec reased on
account of the factor present.
Additional Studies
Clinical Specimens
Clinical Specimens
Identifies agent and confirms cases
Obtain results if already collected
Collect specimens if necessary
Type of specimen depends on suspected agent, nature of outbreak
Collect
Clinical Specimens
Specimens must be labeled with patients name and collection date
Indicate on form that specimen is related to investigation
Submission form (s ) must be complet ed and enclosed wit h specimen
Local health department should collect and transport specimens to lab
Envir onmental Investigation

Help explain why out break occurred
Begins when suspected mode of transmission identified
Identifies vehicle of transmission
Samples: food, wat er, air
Implement Control Measure s
Cont rol Measures: (Aim at weakest link in infection cycle of agent host - environment)
Post-exposure prophylaxis/treatment
Recalling/destroying food
165

Providing educational information

Closing an establishment
Exclusion (work, daycare, school)
Making public announcements
Possible control measure s for dif ferent communicable disease s:

1.
ARI
a. Early recognition and treatment
b. All children with cough carefully assessed
c. Assess signs of malnutrition
d. Refer severely malnourished to hospital
e. Manage pneumonia with antibiotics
f. Follow national treatment protocols
g. Supportive meas ures
h. Vaccination against measles, diphtheria and whooping cough
2.
Cholera
a. Prompt diagnosis and management
b. Establish treatment cent ers with barrier nursing.
c. Fecal material and vomit properly disinfected and disposed.
d. Healt h Education on hygiene, safe water, safe food and hand washing.
e. Funerals to be held quickly and near the place of death.Meticulous hand washing
for those who handle the body.
f. Promote washing hands wit h soap and water when food is being handled.
3.
Typhoid
a. Healt h education, clean water, food inspection, proper food handling and proper
sewage disposal.
b. Early detection and cont rol are important in prevention of spread.
c. Laboratory services are essential to know the out break strain and the anti
microbial sensitivity pattern.
4.
Viral Hepatitis
a. Enforcement of water and food sanitation.
b. For Hepatitis B and C, all blood products should be screened for the two (and for
HIV ).
c. Vaccination of target population groups for Hepatitis A recommended.
5.
Diarrhea
a. Provision of safe water supply
b. Supply of adequat e quantities of reasonably clean water is more important than
supply of small quantities of microbiologically clean water
c. Food safety
6.
Conjunc tiviti s
a. personal hygiene and hand washing.
b. Vector control measures to reduce fly population.
c. Disinfect articles contaminated by nasal and conjunctival discharges.
d. In health facilities vigorous hand washing to avoid cross contamination and
proper disposal of infected material.
7.
Dengue
a. Eliminate habitats of Aedes mosquitoes.
b. Personal protection against mosquito bites during day time (clothes, repellants).
c. In an outbreak use larvicide on all potential habitats of Aedes aegypti.
166

8.
9.
10.
11.
12.
13.
d. Insecticides to reduce vector population.

e. Social mobilization to eliminate breeding sites.
Japanese Encephalitis (J E)
a. Personal protection against mosquito bites.
b. Screen the sleeping and living areas.
c. Hous e pigs away from the living quarters.
d. Vaccines are available for travelers.
e. Vaccination of pigs and fogging with insecticide although effective are expensive.
Malaria
a. Rapid diagnosis and effective case management.
b. Use of insecticide treated nets.
c. Indoor Residual Spraying.
d. Chemo prophylaxis to non-immune expatriat es and Intermittent Presumptive
Therapy for pregnant women.
Measles
a. Routine vaccination
b. Measles outbreak response.
c. Mass vaccination wit h measles vaccine is priority in emergency situations. The
ideal target population being 6 month to 14 years old although age groups from 6
months to four years is still acceptable.
d. Measles vaccine should be accompanied with vitamin A administration in children
9 months to 5 years of age.
Meningococcal Meningitis
a. Early detection and cont rol of the outbreak.
b. Diagnosis and management of cases.
c. Mass vaccination
d. Highest risk group for meningococcal meningitis is children aged 2-10 years and
this should be the priority group during vaccination campaigns.
Tuberculo si s
a. Need for integration with the national TB control Program and involve loc al TB
coordinators.
b. Use the national TB treatment protocols.
c. Cover the local population also.
d. Refer seriously ill patients to local hospitals.
e. Laboratory services for sputum smears.
f. Procedures in place for follow up of cases.
g. Program evaluation.
HIV/AIDS
a. Reduce sexual and mot her to child transmission.
b. Ensure blood safety
c. Universal precautions to be used.
d. Physical protection especially of women and children.
e. Protect health care workers.
f. Counseling and voluntary testing programs.
g. Vaccination of asymptomatic HIV infected children with EPI vaccines.
h. Symptomatic HIV infected children should not be given BCG or y ellow fever
vaccine.
167

14.
H1NI (Sw ine Flu)

a. Entry screening, aircraft disinsection, isolation of suspects, sample
collection/transportation, contact tracing, quarantine, prophylaxis and case
management
b. Active search for contacts and cases
c. PPEs use
d. Public health mass prophylaxis
e. Social distancing, PPEs etc.
f. SOPs
i. Self reporting on Sign and Symptoms of Swine Flu
ii. Details for Contact Tracing
iii. Examination of Suspect
iv. Referral system for suspects
v. Flight Disinsection
g. SOPs for confirmed cases
i. Guidelines for the case and relatives
ii. Movement & Visiting restrictions
iii. Use of PPEs when required
iv. Personal protective measures to be followed
v. Food and ot her arrangements at the facility
vi. Watch for symptoms and complications
vii. Treatment with Tamiflu
viii. Prophylaxis for immediate contacts
ix. MOHFW guidelines to be followed for treatment and discharge
x. Fumigation of the room and belongings
h. IEC for Communication
i. Signs and symptoms
ii. Risk groups
iii. Transmission of outbreak
iv. Risks of Late detection & late reporting
v. Where to report, what to report
vi. Healt h facilities available
vii. Co-morbid conditions
viii. Preventive health practices
Coordination and Communication during ou tbreak betw een

a. State/National and international
MOHFW
DGHS/DM& HS
National IHR foc al point
JMG
b. Healt h Functionaries
c. National IHR foc al points
d. Interdepartment al and intra-department al
e. Mass Media
f. Public
168

Communicate Findings
Investigation Report
Outlines investigation
Write report
Purpose of Report
1. Prevent similar outbreaks
2. Identify trends/causal factors
3. Justify resources used
4. Serves as public rec ord
Report Format
Cover page in memo format
Background
Epidemiologic investigation
Environmental assessment
Laboratory results
Conclusions
Media
Calls
Confirm investigation underway
Provide only confirmed or statistically proven information
Be careful mentioning businesses
Never speculate or provide identifiers
Remain calm and do not be rushed
Real-Life Ex amples
On June 30 2009, the local health officer of Jaipur, reported the occurrence of an out break of
acute gastrointestinal illness to the District Health Officer. Dr. X, epidemiologist-in-training, was
assigned to conduct an investigation. When Dr. X arrived in the field, he learned from the health
officer that all persons known to be ill had attended a dinner at Hotel on June 30 2009. Family
members who had not attended the Dinner had not become ill. Accordingly, the investigation was
focused on the circ umstances related to the supper. Interviews regarding the pres ence of
symptoms, including the day and hour of onset, and the food consumed at the Dinner, were
completed on 75 of the 80 persons known to have been present. A total of 46 persons who had
experienced gastrointestinal illness were identified. The epidemiologist started questioning
himself
1.
Is this an Outbreak?
2.
What might be the agent?
3.
How is this agent transmitted?
4.
What am I looking for?
Select the correct ca se definition and find the error in the others:
1. All Invitees in Dinner held in Hotel on June 30 2009between 8:00 PM and 11:00 PM;
whet her they attended Dinner or not; whether they participat ed in food preparation,
transport, or distribution or not; whether they ate or not. . Missing definition of sic kne ss
2. Persons who developed acute gastrointestinal symptoms within 72 hours of eating supper
and who were among Invitees in Dinner held in Hotel on June 30 2009. Correct
definition
3. Invit ees who developed acute gastrointestinal symptoms within 24 hours of the Dinner
held in Hotel on June 30 2009 between 8:00 PM and 11:00 PM Doe s no t specify
w hether the invitees w ent to the dinner
169

The Dinner was held at Hotel. Food was prepared by Chefs of the Hotel. The Dinner began at
8:00 PM and continued until 11:00 PM. Food was spread out upon a table and consumed over a
period of several hours. The food items served were: B aked Vegetable, Malai paneer , Dum
Aaloo, Cabbage salad, Paneer Khumb, Raita, Raj bhog, Cream salad, Ice cream (van), Ice
cream (choc) and Fruit salad
Which menu item (s ) is the potential culprit? In order to find that, we need to calculate attack
rates.
The foods that have the greatest differenc e in attack rates may be the foods that were responsible
for the illness.
Number of persons who ate
Number of persons who did not eat
specified item
specified item
Ill
Well
Total Attack
rate
Ill
Well
Total
Attack rate
(%)
%
Baked Veg.
29
17
46
63
17
12
29
59
Malai paneer
26
17
43
60
20
12
32
62
Dum Aaloo
23
14
37
62
23
14
37
62
Cabbage salad
18
10
28
64
28
19
47
60
Paneer Khumb
16
23
70
30
22
52
58
Raita
21
16
37
57
25
13
38
66
Raj bhog
50
44
27
71
62
Cream salad
27
13
40
67
19
16
35
54
Ice cream (van)
43
11
54
80
18
21
14
Ice cream (choc)
25
22
47
53
20
27
74
Fruit salad
67
42
27
69
61
And that brings the epidemiologist to the conclusion that vanilla ice cream (attack rate 80%) was
the food that cont ributed to the illness.
This emphatically proves that for an outbreak investigation, following steps is a must
Collect good descriptive data
Be observant -- Be objective
Keep Authority informed
Be sure to collect data on both the ill and the not ill
Ask for help
Disease prevention
Only work in the field can unc over t he way in which an agent links to a host in the real world
(Environment) outside of the laboratory.
Jhon Snow discovered t he wat erbo rne route as a major mode of communication of diseas e,
which turned out to apply not only to cholera, but also to typhoid fever and other infections.
170

Integrated Management of Neonatal and Childhood Illnesses (IMNCI)

Child health programs/ schemes in India:
1978- Expanded Programme of immunization (EPI)
1984- Universal Immunization Programme (UIP ) For prevention of
deaths due to 6 VPDs
1985- Oral Rehydration Therapy P rogramme for prevention of
deaths due to diarrhoea
1990- UIP and ORT universalized in all districts
1990- ARI Programme taken up as a pilot in 26 districts
1992- CSSM
1997- RCH-1
2005- NRHM and RCH II
Under RCH-II, various strategic approache s have been put in place to address child health,
likeIntegrated Management of Neonat al and Childhood Illnesses (IMNCI)
Home Based Newborn and Childhood Care
Facility Based Care SNCUs
Infant & Young Child Feeding & Nutrition Rehabilitation Centres
Micronut rient supplementation Vitamin A & Iron folic acid
Concept ual frame w ork of Maternal and New born health under NRHM:
Implementation of IMNCI in the districts has to be seen as part of the Child Health Strategy under
the National rural health mission/Reproductive and Child Health Program- Phase II.
Maternal Health
New Born Health
ANC
Institutional Delivery
Safe Home Delivery
Referral Transport
Emergency Obstetric Care
Post Partum Care
Home based care of

new born and mother
strengthening of
existingChild Health
Programs
Facility
based
care of sick
new born &
child
IMNCI
IMNCI
Bringing down Infant and Child Mortality Rates and improving Child Health & Survival has been
an important goal of the Family Welfare Programs in India. During the period 1977 to 1992
171

programs like universal immunization program; oral rehydration therapy (ORT) program and
program for prevention of deat hs due to acute respiratory infections (A RI) were implemented as
vertical programs. These programs were integrated in 1992 under the Child Survival and Safe
Motherhood P rograms and have continued to be a part of the Reproductive & Child Health
Program implemented since 1997.
As a result of these efforts, the Infant Mort ality Rate (IMR) has come down significantly over the
years from 114 in 1980 to 53 in 2008(S RS bulletin, Oct. 2009)though the decline has not been
uniform across all States over the years. 20 states have achieved the IMR goal of 2007, 10 have
already achieved the goals laid for 2012 while 8 states including Rajasthan are below the national
average.
It has to be remembered that malnutrition and low birth weight (LBW) are contributors to the about
50% deaths among infants and children under 5 years of age and post natal care has not
received adequat e attention until recently. According to NFHS-II Survey only 6% of recently
delivered women were visited by a health worker during the first week of life. Efforts have
therefore to be made during the coming years to ensure that the numbers of home visits during
the post natal care are increased significantly.
WHO/UNICEF have developed a new approac h to tackling the major diseases of early childhood
called the Integrated Management of Childhood Illnesses (IMCI).
The IMNCI Package
Generic IMCI
India IMNCI
0-6 days coverage
No
Yes (except care at birt h)
Training days for newborn & YI care
2/11 (18%)
4/8 (50%)
Training sequence
Child Newborn
NB/YI Child
Home visits for newborn & YI
No
Yes
Home-based training
No
Yes
The package includes the following interventions:Care of New borns and You ng Infant s (in fant s under 2 month s)
1. Keeping the child warm.
2. Initiation of breastfeeding immediately after birt h and counseling for exclusive
breastfeeding and non-use of pre lacteal feeds.
3. Cord, skin and eye care.
4. Recognition of illness in newborn and management and/or referral).
5. Immunization
6. Home visits in the postnatal period.
Home visi t s are an integral part of this intervention. Home visits by health workers (A NMs,
AWWs, ASHAs and link volunteers) help mothers and families to understand and provide
essential newborn care at home and detect and manage newborns with special needs due to low
birth weight or sickness.
172

Three home visits are to be provided to every newborn starting with first visit on the day of birth
(day 1) followed by visits on day 3 and day 7. For low birth weight babies, 3 more visits (total of
six visits) are to be undertaken before the baby is one month of age. The details of these visits
are given in the training package.
In addition the opportunity of home visit is to be used for the care of mothers during the postpartum period. This will help mothers and families on how to recognize and manage minor
conditions and will ensure timely referral of severe cases.
Care of Infants (2 month s to 5 year s)
1. Management of diarrhoea, acute respiratory infections (pneumonia) malaria, measles,
acute ear infection, malnutrition and anemia.
2. Recognition of illness and at risk conditions and management/referral)
3. Prevention and management of Iron and Vitamin A deficiency.
4. Counseling on feeding for all children below 2 years
5. Counseling on feeding for malnourished children between 2 to 5 years.
6. Immunization
After neonatal period, IMNCI package is accessed by the family for their newborns/children from
the health workers in the community (ANM, AWW, ASHA or link volunteer) or providers at the
facility (PHC/ CHC/FRU).
IMNCI Component s and Intervention areas
Improve health w orker skills Improve health sy stem s
Case management standards
& guidelines
Training
of
facility-based
public health care providers
IMNCI roles
for
private
providers
Maintenance of c ompet ence
among trained health
District & Block planning and

management
A vailability of IMNCI drugs
Quality
improvement
and
supervision at health facilities
public & private
Referral pathways & services
Improve family & community

prectice s
Appropriate Care seeking
Nutrition
Home case management &
adherence to recommended
treatment
Community services planning
& monitoring
Healt h Information System
Component s o f IMNCI
1. Training
IMNCI i s a skill based training in both facility and community settings.
Broadly, two categories of t raining are included, one for medical officers and a second for
front-line functionaries including ANMs and Anganwadi Work ers (AWWs).
For AS HA and link volunteers if any, a separat e package consistent with IMNCI focusing
on the home care of newborn and children is in preparation keeping in mind their
educational status.
While training i s an impo rtant inpu t for implement ation o f IMNCI, thi s i s not the
only one. Ef fectiv e implement ation o f IMNCI in a di strict al so inv olves th e following
componen t s.
a. Improvements to the health sy stem. The essential elements include:
173

i.
ii.
iii.
iv.
v.
vi.
b.
2.
Ensuring availability of the essential drugs with workers and at facilities covered
under IMNCI.
Improve referral to identified referral facility.
Referral mechanism to ensure that an identified sick infant or child can be
swiftly trans ferred to a higher level of care when needed. E very health worker
must be aware of where to refer a sick child and the staff at appropriate health
facilities must be in position to identify and acknowledge the referral slips and
give priority care to the sick children.
Functioning referral centres, especially where healthcare systems are weak,
referral
institutions need to be reinforced or privat e/public partnerships
established
Ensuring availability of health workers / providers at all levels
Ensuring supervision and monitoring through follow up visits by trained
supervisors as well as on-t he-job supportive supervision
Improvement of Family and Community Practice s
Counseling of families and creating awareness among communities on their role
is an important component of IMNCI. This includesi.
Promoting healthy behaviors, such as breastfeeding, illness recognition,
early case seeking etc.
ii.
IEC campaigns for awareness generation.
iii.
Counseling of care givers and families as part of management of the sick
child, when they are brought to the health worker/ healt h facility.
iv.
During Home Visits- Home Visits provide an opport unity for identification
of sickness and focused B CC for improving newborn and child care
practices.
Collaboration/coordination w ith other Departments, PRI s, Self Help Group s, MSS

Implementation of IMNCI in an effective way in any district would be possible only with the
total involvement of A NM and Anganwadi workers of ICDS, and grass-root functionaries
of ot her sectors. Community owners hips and participation is of paramount importance.
Therefore active involvement of PRI, self help groups and womens groups is a must.
Special effort will thus be required on the part of the district CMOs to involve the
concerned departments.
For training of health staff and follow-up and supervision of IMNCI activities in the district,
the involvement of pediatrics units/departments of District Hospitals will be necessary.
The involvement of the Departments of P ediat rics and Preventive and Social Medicine of
the local or regional medical colleges should be sought.
The referral care for sick children and newborns is to be provided at the upgraded P HCs
and FRUs which are being developed as a part of the RCH program phase-II .The
guidelines for services at these facilities have been developed.
F-IMNCI
From November 2009 IMNCI has been re-baptized as F-IMNCI, wherein F stands for Facility
based management; with added component of
a. Asphyxia Management and
b. Care of Sick new born at facility level, besides all other components included under IMNCI
174

Institutional Arrangement sIMNCI is a Child Health Intervention to be implemented as part of NRHM/RCH-II. Training for
IMNCI will therefore be part of the overall training plan under RCH-Phas e II.
A. State Level
1. Appoint a nodal officer for IMNCI. The State RCH Program Director could
take up the
responsibility himself. The nodal officer will be responsible for the
institutional arrangements
listed below.
2. Set up a co-or dination Grou p, including the donor agencies, other
Departments like ICDS, Panchayati Raj, department of medical educ ation are
important as medical colleges will be involved not only in IMNCI implementation
but also educ ation of medical and nursing students. The coordination committee
should be linked to the State Health Mission of the NRHM.
Meeting quarterly, the role of the coordination group would be to
a. Provide any technical support needed for state and district level
implementation,
b. Coordinate financial inputs,
c. Review logistics and dugs supply and
d. Review progress in the implementation of imnci training and
implementation activities. Involvement of departments like icds,
panchayati Raj, Medical E ducation will all have essential and specific
contributions to make in scaling up IMNCI.
3. Arrange translation, printing and supply o f training material. Requirement
of funding for these activities may be reflected as part of State PIPs.
4. Create pool of State level trainers. These trainers are required for t raining of
trainers (TOT) of district trainers as defined earlier and also to monit or quality of
training in the districts. These trainers will be trained at the National Institutes at
Delhi.
,
5. Select priority di strict s for IMNCI implementation First phase may therefore
be restricted to 3-4 districts along with regional training centers (preferably
medical colleges) in the first
phase. Eac h state should however; strive to
complete implementation of IMNCI in at least 25-30% of the districts over the
next 2-3 years.
6. Monitoring, follow -up and review of implementation of IMNCI
7. Identify the state nodal institute for IMNCI training.
8. Improvement in family and community practices
B. Di stri ct Level
Many of the institutional arrangements at the State level need to be developed at district
level, though emphasis is less on overall direction and quality control and more on the
day-to-day activities to make IMNCI successful.
1. Appoint District Coordinator for IMNCI.
2. Set up an IMNCI Coordination Group.
3. Train District Trainers.
4. Develop a detailed plan for IMNCI Implement ation in the District.
5. Ensure timely supplies & logistics, supervision and follow-up
6. IEC activities for improvement in family and community practices
175

Training in IMNCIFocu s on Skill Development

The training under IMNCI is focused on applied skill development. Around 50% of training time is
spent building skills by han d s-on training involving actual cas e management and counselling,
the remaining 50% is spent in classroom sessions, building theoretical understanding of essential
health interventions. The hands-on training is undertak en through clinical training sessions in
hospitals and in the community. Physicians spend 6 days in hospital and 1 day in community;
work ers spend 3 days in hospit al and 4 days in community settings.
The hands on practice are to be undertaken through:
1. Visits to hospitals and
2. In the case of Health workers in addition to hospital based practice, the participants are to
be trained through field visits and visits to the homes of sick children.
Sk ill development i s c ritical to t he implement ation o f IMNCI.
Training at tw o levels:
In-service training for the existing staff The existing staff in the districts will have to be
provided in-service training in a phased manner. The objective of the training effort would be to
ensure that all medic al officers and health worker are trained in IMNCI.
Pre-Service Training for including IMNCI in the pre-servi ce teaching of doct or s, nur se s,
ANM s, L HV s and others. Th e Stat e Gov ernment s will need t o issue in struc tion s in thi s
regar d.
Personnel to be Trained
There are 2 types of trainings under IMNCI*
Type of Personnel to be trained
Training
Clinical
Medical Offic er and Pediatricians
skills
training
Healt h Workers, ANMs, LHVs,
Mukhya
Sevikas, CDPOs and
AWWs
Supervis
Medical Officers, Pediatricians,
ory Skills CDP Os LHVs and
Mukhiya
Training
Sevikas)
Duration
8 days
8 days
2days#
Package to be
used
Physicians
Package
Healt h
Workers
Package
Supervisory
Skills package
Place of Training
Medical
college
/District Hospital
District Hospital
Medical
college
/District Hospital
# To be clubbed P referably with clinical skills training. Where this is not possible the two days
training should be conducted within 4-6 weeks of the clinical skills training. Experience has shown
that it is difficult to call back people within 6 weeks again for anot her training.
* An orientation meeting of 1 to 2 days may be organized in some districts for planners and key
personnel such as people from P RI, CDPOs and ot her senior health functionaries and other
stake
holders
to
orient
them
about
IMNCI
and
its
implement ation
plan.
176

Training of Trainers
For training of the district staff it w ould be essential to have adequate number of trainers
w ithin the dist rict s. The trainers at di stric t level includes all pediatricians in the district,
selected medical officers from CHCs and block PHCs, selected staff nurses and LHVs and
CDP Os and Mukhiya Sevikas from ICDS. Ex perience has show n that abou t 40-50 trainers
are required for undertaking training of the health staf f on a con tinuou s ba si s. Thi s i s
because in every di stric t around 200 do cto r s and 200 supervi sor s along w ith 1200- 1600
w orkers need to be trained. Total training time is 10 days: 8 days (Clinical skills training ) + 2
days for supportive supervision. The TOT for Physicians is facilitated by National IMNCI
facilitators; the TOT for Health/ ICDS workers is facilitated by State IMNCI facilitators ideally with
participation of national IMNCI facilitators. Candidates for the all TOTs and ultimately the district
training pool would ideally include all pediatricians in the district, plus selected CHC/Block PHC
medical officers, staff nurses, LHVs, CDP Os, and ICDS supervisors. Additional TOT candidat es
might include faculty of HFW TC, A NMTC, GNMTC, MPW (M) TC, junior faculty of medical
colleges, and NGOs. All candidates should have good c ommunication sk ills. Districts with limited
manpower might also consider including freelance facilitators.
Number to be trained
1. It is estimated that in a district of average size about 1800 health staff will need to be
trained. The exact numbers will however have to be calculated for each district will be
taken up for implementation of IMNCI.
2. Since the staff of ot her departments like ICDS etc is also to be trained, their numbers
should be carefully included in consultation with the concerned district officers.
3. Since meaningful implementation of IMNCI will need adequate numbers of trained staff, it
will be better if the staff belonging t o a PHC areas may be taken up fully before moving to
another PHC area.
Training Institu tion s:
1. State Level
a. Identify a Regional Training Centre.
b. The Departments of P ediatrics and Preventive & Social Medicine in eac h college
will have to take up this responsibility. Another benefit of selecting the medical
colleges as regional t raining c entre would be in the pre-s ervice training of
undergraduate students. In addition to medical colleges, other centres including
private centres can als o be used for training provided they have the requisite
clinical material and facilities for training available.
2.
Di stri ct Level
The following issues need consideration before selecting the institutions for training of
district staff:
a. The selected institution for training should have sufficient load of inpatient
newborns to provide case material for hands on training.
b. Healt h work ers have to be given the opportunity for practice on cases in home
situations. Therefore at -least 4 visits have to be organized to nearby field areas
during their training.
c. Ensure adequat e number of class rooms (P referably two) with sitting capacity of
12-15 participants each.
d. Batch size not more than 25 participants with 6-7 facilitators.
177

e.
HFW TCs/ANM schools can perform this task only jointly with a hospital/health
institutions. District hospital will thus be an obvious choice for training of medical
officers. For training of healt h work ers CHCs/operational FRUs etc can be
considered. Where institutions with enough case load are not available in public
sector involvement of hospitals/health cent res of local bodies/public sector
enterprises or even private sector. In rare cases even facilities of adjoining
districts should be considered
Follow -up Training (FUT)

The Follow-up Training is designed to improve supportive supervision skills such as methods for
skill reinforcement, records review, and assessment of facility functioning for 2 days which may
either be clubbed with Clinical skills training or conducted within 6-8 weeks of the initial Clinical
skills training.
Pre-servi ce Training
Following the initial experiences in implement ation IMNCI in several districts, States should plan
early for the expansion to remaining districts. Pre-service training in medical colleges will need to
include training on IMNCI in the training schedules of undergraduate students and interns, during
their postings in the Departments of Paediatrics and Preventive & Social Medicine. ANM, AWW,
and Staff Nurses training schools will need to include training on IMNCI in their t raining
schedules. State Governments will need to issue instructions in this regard to be implemented by
teaching institutions by respective directorates.
Funding arrangements for IMNCI Trainings
National Level training:
For the national level training of the faculty of Medical Colleges of different States at Kalawati
Saran Children Hospital and Safdarjung Hospital at Delhi, the States need not provide for budget
in their NRHM/RCH-II-Program Implementation Plans (PIPs) as the funding for this training will be
entirely provided by the Government of India. This will include all costs such as TA/DA, stay and
other training expenses.
State Level training (at the Medical Colleges identified as training centres):
The States need t o project their funding requirements for the following in their NRHM/ RCH-IIPIPs:
1. Equipments for imparting training such as:
a. One Computer with in-built CD RW/ROM
b. One LCD Projector with display screen
c. Other miscellaneous training/ teaching accessories.
2. TA/DA and honorarium to the trainees and trainers as per RCH norms.
3. Vehicle hiring for field visits for trainees as per State Government norms.
Di stri ct Level training:
1. At Di stric t Training Cell (in the Distric t Ho spital):
The States need to project their funding requirements for the following in their
NRHM/RCH-II-P IPs:
a. Equipments for imparting training such as:
i.
One Computer with in-built CD RW/ROM
ii.
One LCD Projector with display screen
178

b.
c.
iii.
Other miscellaneous training/ teaching accessories.
TA/DA and honorarium to the trainees and trainers as per RCH norms.
Vehicle hiring for field visits for trainees as per State Government norms.
2.
At other Training Centres w ithin the Di stric t (Max imum tw o in identified

CHCs/P HCs):
The States need to project their funding requirements for the following in their
NRHM/RCH-II- PIPs:
a. Equipments for imparting training such as:
i. One television (which is CD player compatible)
ii. One CD player
iii. Other miscellaneous training/ teaching accessories.
b. TA/DA and honorarium to the trainees and trainers as per RCH norms.
c. Vehicle hiring for field visits for trainees as per State Government norms.
3.
Translation, printing and supply of training material
4.
Field-level Monitoring Support, Follow up and Coordination
Navjat Shishu Surak sha Karykram(NSS K):

The trainings under IMNCI shall take a long time to deliver the desired to all, for which GoI has
come out with anot her program Navjat Shishu Suraksha Karykram(NSSK) ON September 15,
2009;which focuses ona.
b.
c.
d.
Prevention of Hypo thermia

Prevention of Infection
Early initiation of Breast feeding and
Basi c New born Re su scitation.
The objective is to have one trained person at institutional facility, where deliveries take plac e.
The NSSK will train healthcare providers at the district hospitals, community health centres and
primary health cent res in the interventions at birth with the application of the latest available
scientific methods aimed at significantly reducing the infant mortality ratio.
Limitations of IMNCI
Outpatient Facility Based
Community activities not given adequat e focus
Training cent re of attention
Vertical initiatives in Non IMNCI districts sorely lacking
179

Integrated Child Development Services (ICDS) Scheme

Introduc tion
India is the home to the largest child population in the world. As per 2001 census, India has
around 157. 86 million children, constituting 15.42% of India's population, who are below the age
of 6 years. Of these 157.86 million children, 75.95 million children are girls and remaining 81.91
million children are boys. The sex ratio among children (0-6 years) as per Census 2001 is 927. A
significant proportion of these children live in economic and social environment which impedes
the child's physical and mental development. These conditions include poverty, poor
environmental sanitation, disease, infection, inadequate access to primary health care,
inappropriate child caring and feeding practices etc.
National Policy on Children in August 1974 provided the required framework for assigning
priority to different needs of the child. The program of the Integrated Child Development
Services (I CDS ) was launched in 1975 seeking to provide an integrated package of servic es in a
convergent manner for the holistic development of the child.
Integrated Child Development Scheme
nd
Launched on 2 October 1975 in 33 Communit y Dev elopmen t Block s, ICDS today represents
one of the worlds largest program for early childhood development providing pre-school
education on one hand and breaking the vicious cycle of malnutrition, morbidity, reduced learning
capacity and mortality, on the other.
It is an inter-sectoral program which seeks to directly reach out to children, below six years,
especially from vulnerable and remot e areas and give them a head-start by providing an
integrated program of early childhood education, health and nutrition.
Objectives:
1. Lay the foundation for proper psychological development of the child
2. Improve nutritional & health status of children 0-6 years
3. Reduce incidence of mortality, morbidity, malnutrition and school drop-outs
4. Enhance the capability of the mot her and family to look after the health, nutritional and
development needs of the child
5. Achieve effective coordination of policy and implementation among various departments
to promote child development
ServicesThe Scheme provides an integrated approach for converging basic services through communitybased workers and helpers. The services are provided at a centre called the Anganwadi. The
Anganwadi, literally a courtyard play centre, is a c hildcare centre, located within the village itself.
A package of following six services is provided under the ICDS Scheme:
1. Supplement ary nutrition
2. Growth Monitoring and nut rition surveillance
3. Non-formal pre-school education
4. Immunization
5. Healt h Check-up
6. Referral services
7. Nutrition and Health Education
The three services namely immunization, health check-up and referral are delivered through
public health infrastructure viz. Health Sub Centres, Primary and Community Health Centers
under the Ministry of Health & Family Welfare.
180

Target Group s & Service Provider

Services
Target Group
Services Provid ed By
Supplement ary Children below 6 years; pregnant and lactating Anganwadi Workers (AWW)
Nutrition
mothers
Anganwadi Helper (AWH)
&
Immunization* Children below 6 years; pregnant and lactating ANM/MO

mothers
Healt h Check- Children below 6 years; pregnant and lactating ANM/MO/AWW
ups*
mothers
Referral
Children below 6 years; pregnant and lactating AWW/ANM/MO
mothers
Pre-School
Children 3-6 years
AWW
Education
Nutrition
& Women (15-45 years)
AWW/ANM/MO
Healt h
Education
Population Norm s
The revised Population norms for setting up a Project, Anganwadi Centre and Mini-AWC are as
under:
Project s:
(i) Community Development Block in a State should be t he unit for sanction of an ICDS P roject in
rural/tribal areas, irrespective of number of villages/population in it.
(ii) The existing norm of 1 lakh population for sanction of urban project may continue.
Further to this, for blocks with more than two lac population, States could opt for more than one
Project (@ one per one lac population) or could opt for one project only. In the latter case, staff
could be suitably strengthened based on population or number of AWCs in the block. Similarly, for
blocks with population of less than 1 lac or so, staffing pattern of CDPO offic e could be less than
that of a normal block.
Anganw adi Centres
For Rural/Urban Project s
400-800 1 AWC
800-1600 - 2 AWCs
1600-2400 - 3 AWCs
Thereafter in multiples of 800 1 AWC
For Mini-AWC
150-400 1 Mini-AWC
181

For Tribal /Riverine/Desert, Hilly and other difficult areas/ Projects

300-800 - 1 AWC
For Mini- AWC
150-300 1 Mini AWC
Supplementary Nutrition Norm s:
Financial norms:- The Government of India has recently, revised the cost of supplementary
nutrition for different category of beneficiaries vide this Ministrys letter No. F.No. 4-2/2008-CD. II
dated 07.11. 2008, the details of which are as under:Sl.No.
Category
Pre-revised
rates
Revi sed
rates
beneficiary per day)
1.
Children (6-72 months)
Rs.2.00
Rs.4.00
2.
Severely malnouris hed children (672 mont hs)
Rs.2.70
Rs.6.00
3.
Pregnant
mothers
Rs.2.30
Rs.5.00
women
and
Nursing
(per
Nutri tional Norm s: - Revi sed vide letter No. 5-9/2005-ND-Tech Vol. II dated 24.2.2009
[Pr-revi sed]
[Revi sed]
Calories
(K Cal)
300
Protein
(g)
8-10
(per beneficiary per day)

Calories
Protein (g)
(K Cal)
500
12-15
20
800
20-25
15-20
600
18-20
Sl. No. Category
1.
2.
3.
Children (6-72 months)

Severely malnourished children
600
(6-72 months)
Pregnant women and Nursing
500
mothers
Budgetary Allocation : Alongside gradual expansion of the Scheme, there has also been a
th
significant increase in the Budgetary allocation for ICDS Scheme from Rs.10391.75 crore in 10
Five Year Plan to Rs.44,400 crore in XI Plan Period.
The ICDS Team
The ICDS team comprises the A nganwadi Workers, Anganwadi Helpers, S upervis ors, Child
Development Project Officers (CDPOs) and District Programme Officers (DPOs). A nganwadi
Worker, a lady selected from the local community, is a community based frontline honorary
work er of the ICDS Programme. She is also an agent of social change, mobilizing community
support for better care of young children, girls and women. Besides, the medical officers, Auxiliary
Nurs e Midwife (ANM) and Accredited Social Health Activist (AS HA) form a team with the ICDS
functionaries to achieve convergence of different services .
182

ICDS Training Programme

Training and capacity building is the most crucial element in the ICDS Scheme, as the
achievement of the programme goals largely depends upon the effectiveness of frontline workers
in improving service delivery under the programme. Since inception of t he ICDS scheme, the
Government of India has formulated a comprehensive training strat egy for the ICDS functionaries.
Training under ICDS scheme is a continuous programme and is implemented through 35
States/UTs and National Institute of Public Cooperation and Child Development (NIP CCD) and its
four regional cent res.
th
During the 11 Five Year Plan, the Government of India has laid much emphasis on
strengthening the training component of ICDS in order to improve t he service delivery mechanism
and accelerate better programme outcomes. An allocation of Rs. 500 crore has been k ept for the
th
ICDS Training Programme during the 11 Five Year Plan.
Financial norms relating to training of various ICDS functionaries and trainers have been revised
upwardly with effect from 1 April 2009.
Type s of Training Cour se s: Three types of regular training are imparted to AWWs,
AWHs, Supervis ors, CDP Os/ACDPOs and Instructors of AWTCs and MLTCs, viz.:
1.
o
o
o
Induction Training (on initial engagement/appointment ) mainly to AWWs

Job/Orientation Training (once during service period)
Refresher Training (in-s ervice, once in every t wo years)
Also, specific need based training programmes are organized under the Other Training
component, whereby the States/UTs are given flexibility to identify state specific problems that
need specialized issue based training and take up such training activities.
Training Infrastruc ture: There is a country wide infrastructure for the training of ICDS
functionaries, viz.
1.
o
o
o
Anganw adi Workers Training Cent re s (AWTCs) for the training of Anganwadi
Workers and Helpers.
Middle Level Training Centres (ML TCs) for the training of Supervisors and Trainers
of AWTCs;
National Instit ute of Public Cooperation and Child Development (NIPCCD) and its
Regional Centres for training of CDPOs/ACDP Os and Trainers of MLTCs. NIP CCD
also conducts several skill development training programmes.
[Govt. of Tamil Nadu has established a State Training Institute (S TI) at the State level for the
training of Trainers of MLTCs and CDPOs/ACDP Os]
Based on the needs, State Governments identify and open up AW TCs and MLTCs after due
approval by the Government of India. As on 31.3.2009, 490 AWTCs and 31 MLTCs were
operational across the country. About 80% of the AW TCs and 70% MLTCs are run by
State/District based NGOs.
Monitoring & Supervi sion of Training Programme: A separate ICDS Training Unit within the
Ministry of Women and Child Development headed by a Director/ Dy. Secretary level officer is
responsible for overall monitoring, supervision and evaluation of the training programme. The
following measures are undertaken for monitoring and supervision:
183

o
o
o
o
o
Physical and financial progress are captured through Quarterly Progress Reports (QPRs)
in a standardized format, that are submitted by the States/UTs to GoI at the end of every
quarter;
A detailed analysis of the QP Rs is carried out by the ICDS Training Unit and based on the
same, quarterly review meetings are organized with the States at the central level;
Monthly/quarterly review meeting with the Training Cent res at the state level;
Necessary feedback and guidelines are issued to the States after each of the review
meetings;
Field visits to AWTCs/MLTCs by Nodal Officer or the District Programme Officers
(DPOs)/ CDP Os; and also by the officials from the Ministry of WCD and NIP CCD.
Annual meeting of State Training Task Force (S TTF) for the approval of S TRAP and
review of past performance and chalking out future actions.
Ex isting Monitoring S y stem under ICDS Scheme:

Central Level
Ministry of Women and Child Development (MWCD) has the overall responsibility of monitoring
the ICDS scheme. There exists a Central Level ICDS Monitoring Unit in the Ministry which is
responsible for collection and analysis of the periodic work reports received from the St ates in the
th
prescribed formats. States have been asked to send the State level consolidated reports by 17
day of the following month.
The existing status of monitoring of these six services is as under :
(i) Supplementary Nut rition : No. of Beneficiaries (Children 6 months to 6 y ears and pregnant &
lactating mothers) for supplementary nutrition;
(ii) Pre-School Edu cation: No. of Beneficiaries (Children 3-6 years ) attending pre-school
education;
(iii) Immunization, Health Check-up and Referral services : Ministry of Healt h and Family
Welfare is responsible for monitoring on healt h indicators relating to immunization, health checkup and referrals services under the Scheme.
(iv) Nu trition and Health Education: This service is not monitored at the Central Level. State
Governments are required to monitor up to State level in the existing MIS System.
(v) No. of ICDS Project s and Anganw adi Centres (AWCs) w.r.t. targeted no. of ICDS Projects
and AWCs are taken into account for review purpose.
Analy si s & Action
The information received in the prescribed formats is compiled, processed and analysed at the
Cent ral level on quarterly basis. The progress and short falls indicated in the reports on ICDS are
reviewed by the Ministry with the State Governments regularly by review meetings/ letters.
184

State Level
Various quantitative inputs captured through CDPOs MPR/ HP R are compiled at the State level
for all Projects in the State. No technical staff has been sanctioned for the state for programme
monitoring. CDPOs MP R capture information on number of beneficiaries for supplementary
nutrition, pre-school education, field visit to AWCs by ICDS functionaries like Supervisors, CDP O/
ACDPO etc., information on number of meeting on nutrition and healt h educ ation (NHE D) and
vacancy position of ICDS functionaries etc.
Block Level
At block level, Child Development Project Officer (CDPO) is the in-charge of an ICDS Project.
CDP Os MPR and HPR have been prescribed at block level,. These CDP Os MPR/ HPR formats
have one-to-one correspondence with AWWs MPR/ HP R. CDPOs MP R consists vacancy
position of ICDS functionaries at block and AWC levels. At block level, no technical post of
officials have been sanctioned under the scheme for monitoring. However, one post of statistical
Assistant./ Assistant is sanctioned at block level to consolidate the MPR/ HP R dat a.
In bet ween CDPO and AWW, there exists a supervisor who is required to supervise 25 AWC on
an average.
th
CDP O is required to send the Monthly Progress Report (MP R) by 7 day of the following month to
State Government. Similarly, CDPO is required to send Half-yearly Progress Report (HP R) to
th
th
State by 7 April and 7 October every year.
Village Level (Anganwadi Level)
At the grass-root level, delivery of various services to target groups is given at the Anganwadi
Cent re (AWC). An AWC is managed by an honorary Anganwadi Worker (AWW) and an honorary
Anganwadi Helper (AWH).
In the existing Management Information System, records and registers are prescribed at the
Anganwadi level i.e. at village level. The Monthly and Half-yearly Progress Reports of A nganwadi
Worker have also been prescribed. The monthly progress report of AWW capture information on
population details, births and deaths of children, maternal deaths, no. of children attended AWC
for supplementary nutrition and pre-school education, nutritional status of children by weight for
age, information on nut rition and health education and home visits by AWW. Similarly, AWWs
Half yearly Progress Report capture data on literacy standard of AWW, training details of AWW,
increase/ decrease in weight of children, details on space for storing ration at AWC, availability of
health cards, availability of registers, availability of growth charts etc.
th
AWW is required to send these Monthly Progress Report (MPR) by 5 day of following mont h to
CDP O In-charge of an ICDS Project. Similarly, AWW is required to send Half-yearly Progress
th
th
Report (HPR) to CDPO by 5 April and 5 October every year.
International partners
Government of India part ners with the following international agencies to supplement
interventions under the ICDS:
i.
ii.
iii.
United Nations International Children Emergency Fund (UNICEF)

Cooperative for Assistance and Relief E very where (CA RE)
World Food Programme (WFP )
185

UNI CEF supports the ICDS by providing technical support for the development of training plans,
organizing of regional workshops and dissemination of best practices of ICDS. It also assists in
service delivery and accreditation system where the capacity of ICDS functionary is strengthened.
Impact assessment in selected States on early childhood nutrition and development, micronutrient and anemia control through Vit. A supplementations and deworming int erventions for
children in the age group of 9-59 months is also conducted by UNICEF from time to time.
CA RE is primarily implementing some non-food projects in areas of maternal and child health, girl
primary education, micro-credit etc. Integrated Nut rition and Health P roject (INHP)-III, whic h is a
phaseout programme of INHP series would come to an end on 31.12.2009.
WFP has been extending assistance to enhance the effectiveness and outreach of t he ICDS
Scheme in s elected districts (Tikamgarh & Chhattarpur in Madhya P radesh, Koraput, Malkangir &
Nabrangpur in Orissa, Banswara in Rajasthan and Dantewada in Chhattisgarh), notably, by
assisting the State Governments to start and expand production of low c ost micronutrient fortified
food known as Indiamix. Under this the concerned State Government are required to contribute
to the cost of Indiamix by matching the WFP wheat contribution at a 1:1 cost sharing ratio.
Special Focu s on Nor th East : Keeping in view the special needs of North Eastern States, the
Cent ral Government sanctioned construction of 4800 Anganwadi Cent res at a cost of Rs.60 crore
in 2001-02, 7600 Anganwadi Centres at a cost of Rs.95.00 crore in 2002-03 and 7600 AWCs at a
cost of Rs.95.00 crore in 2004-05. In the wake of ex pansion of ICDS Scheme in 2005-06, it was
provided in the Scheme itself that GOI will support construction of AWCs in NE States. The cost
of construction was also revised from Rs.1.25 lakh per c entre to Rs.1.75 lakh per center. In 200607, 50% of funds have been released to all the NE States except the State of Manipur.
Recent Initiatives
o
Revision in Population norm s for setting up of AWCs/Mini-AWCs
Universalisation and 3 phase of expansion of the Scheme of ICDS for 792 additional
Projects, 2.13 lakh additional Anganwadi Centres (AWCs) and 77102 Mini-AW Cs, as per
the revised population norms, with s pecial focus on coverage of SC/S T and Minority
population.
Introduction of cost sharing bet ween Centre & States, with effect from the financial year
2009-10, in the following ratio:
rd
a. 90:10 for all components including S NP for North East;

b. 50:50 for S NP and 90:10 for all other components for all States other than North East.
o
o
o
o
o
th
Budgetary alloc ation for ICDS Scheme increased from Rs.10391.75 crore in 10 Five Year
th
Plan to Rs.44,400 crore in the 11 Plan Period
Revision in financial norms of supplementary nutrition enhancing t he unit cost per ben per
day
Revision of feeding and nutrition norms as under (vide letter No. 5-9/2005-ND-Tech Vol. II
dated 24.2.2009)
Revision in financial norms of other existing interventions to improve the service delivery.
Enhancement of honoraria w.e. f. 1.04. 2008 by Rs.500 of AWWs and by Rs.250 of Helpers
of AWCs and Workers of Mini-AWCs. Prior to enhancement, AWWs were being paid a
monthly honoraria ranging from Rs. 938/ to Rs. 1063/- per month depending on their
educational qualifications and experience. Similarly, AWHs were being paid mont hly
honoraria of Rs. 500/-
186

Qualification/Year
197576
1.4.78 1.7.86 2.10.92
16.5.97
1.04.02
1.04.08
Non-Mat riculate
100
125
225
350
438
938
1438
Matriculate
150
175
275
400
500
1000
1500
Non-Mat riculate
250
375
469
969
1469
300
425
531
1031
1531
275
400
500
1000
1500
325
450
563
1063
1563
500 (w. ef.

1.1.2007)
750
50
110
200
260
With 5 year exp

Matriculate
With 5 year exp
Non-Mat riculate
With 10 year exp
Matriculate
With 10 year exp
Mini-Anganwadi Workers
Honorarium of Helper:
Helper
o
o
o
o
o
o
o
o
35
500
750
Introduction of World Health Organis ations (WHO) Growth Standards for monitoring the
growth of children.
The GoI introduc ed Ànganwadi Karyak artri Bima Yojana to AWW & AWH w.e.f.1.4.2004
under Life Insurance Corporations Social Security Scheme. The amount of premium of
Rs. 80/- payable by AWWs and AWHs has also been waived of w.e. f. 1.4.2007 for a period
of two years.
A scheme of award for AWWs has been introduced, both at the National and State Level.
The A ward comprises Rs.25,000/- cash and a Cit ation at Central level and Rs.5000/- cash
and a Citation at State level.
Provision of flexi funds at Anganwadi level.
They have been allowed paid absence of 135 days of mat ernity leave.
Provision for a Uniform (saree/suit @ Rs. 200/- per saree per annum) and a name badge
to Anganwadi Workers and HelpersProvision of Uniform for AWWs and Helpers.
Strengthening of Management Information System (MIS)
Revision in cost norms of Training component of ICDS Scheme.
BPL no longer a criteria
187

Achievements: There has been significant progress in the implementation of ICDS Scheme
during X Plan both and during XI Plan (up to 2008-09), in terms of increase in number of
operational projects and Anganwadi Centres (AWCs ) and coverage of beneficiaries as indicated
below:Year ending
No.
of
operational
projects
No. of operational
AWCs
No. of Supplementary
nutrition beneficiaries
No. of pre-school
education
beneficiaries
31.03. 2002
4608
545714
375.10 lakh
166.56 lakh
31.03. 2003
4903
600391
387.84 lakh
188.02 lakh
31.03. 2004
5267
649307
415.08 lakh
204.38 lakh
31.03. 2005
5422
706872
484.42 lakh
218.41 lakh
31.03. 2006
5659
748229
562.18 lakh
244.92 lakh
31.03. 2007
5829
844743
705.43 lakh
300.81 lakh
31.03. 2008
6070
1013337
843.26 lakh
339.11 lakh
31.03. 2009
6120
1044269
873.43 lakh
340.60 lakh
188

VHSC, Role of PRIs and Community Monitor ing

Village Health Sanitation Committee (VHSC):
The NRHM framework support decentralized planning &
monitoring up t o the grass root level. Therefore it was decided
to entrust village level committees of the users group,
community based organization for the planning monitoring &
implementation of NRHM activities into t he 41000 revenue
villages of the State.
Village Health & Sanitation c ommittee (VHS C) feed suc h groups, which is the fift h committee
(Development Committee) of the Gram P anchayat. The V HSC will be the key agency for
developing Village Health Plan & the entire planning of village Panchayat for NRHM. This
committee comprises of Panchayat representatives, ANM, MTW, Aganwari workers, Teachers,
Community healt h volunteers, ASHA.
Village Health Committees are the first step towards communitization of health c are services and
for making health as a people's movement. The Village Health Committees are constituted in all
the 40479 habitat villages with elected member of Panchayti Raj Institution of the village as
Chairperson. The other members of the committee are ASHA S ahyogini, Anganwadi Worker,
ANM, Represent ative from S HG, NGO, MSS etc. ASHA Sahyogini is the Convener for t his
Committee. Village Healt h Committee will facilitate in addressing the health needs of the entire
village wit h the help of health providers and health institutions. VHCs will play an important role in
planning and monitoring of the healt h care services through community monitoring mechanisam.
Compo si tion of the Village Health & Sanitation Committee
To enable the Village Health & Sanitation Committee to reflect the aspirations of the local
community especially of the poor households and women, it has been suggested that:
a. At least 50% member s on the Village Health & Sanitation Committee should be w omen.
b. E very hamlet within a revenue village must be given due representation on the Village
Healt h and Sanitation Committee to ensure that the needs of the weaker sections
especially Scheduled Castes, Scheduled Tribes, Other Backward Classes are fully
reflected in the activities of the committee.
c. A provision of at least 30% representation from t he Non-go vernmental sector.
d. Representation to womens self-help group etc. on these committees etc. will enable the
Committee to undertake womens health activities more effectively.
e. Notwithstanding t he above, the overall composition and nomenclature of the Village
Healt h & Sanitation Committees is left to the State Governments as long as these
committees were within the umbrella of PRIs.
Compo si tion:
Gram Panchayat members from the village.
ASHA, Anganwadi Sevika, ANM
SHG leader, the P TA/MTA Secret ary, village representative of any community based organization
working in the village, user group representative.
189

Role of Village Health Committee

Acti vities
a. Create Public Awareness about the essentials of health programs.
b. Discuss and develop a Village Health Plan based on an assessment of the village
situation and priorities identified by the village community.
c. Analyze key issues and problems related to village level health and nutrition activities,
give feedback on t hese to relevant functionaries and officials. Present annual health
report of the village in the Gram Sabha.
d. Participatory Rapid Assessment: to ascertain the major health problems and health
related issues in the village. Estimation of the annual expendit ure incurred for
management of all the morbidities may also be done. The mapping will also take into
account the health resources and the unhealthy influences within village boundaries.
e. Maintenance of a village health register and health information board/calendar: The
health register and board put up at the most frequent ed section of the village will have
information about mandated services, along with services actually rendered to all
pregnant women, new born and infants, people suffering from chronic diseases etc.
f. Ensure t hat the A NM and MPW visit the village on the fixed days and perform the
stipulated activity; oversee the work of village health and nutrition functionaries like ANM,
MPW and AWW.
g. Get a bi-monthly health delivery report from health service providers during their visit to
the village.
h. Take into consideration of the problems of the community and the health and nutrition
care providers and suggest mechanisms to solve it.
i. Discuss every maternal death or neonatal deat h that occurs in their village, analyze it and
suggest necessary action t o prevent such deaths. Get these deaths registered in the
Panchayat.
j. Managing the Village health fund.
Village Health Fund
Untied funds for V HCs- There is a provision of Rs.10,000/- as untied funds for each V HC per
year. This untied fund is to be deposited in concerned Subc enters Account which is jointly
operated by ANM and Sarpanch. The untied funds are utilized for demand generation for health
care s ervices, sanitation drives, emergency health care needs, rewards for exceptional work in
health sector, publicity of MCHN days, RCH camps etc.
The untied funds are to be used for the community actions for improvement of health status of the
community,for any of the following activities: a. As a revolving fund from which households could draw in times of need to be returned in
installments thereafter.
b. For any village level public health activity like cleanliness drive, sanitation drive, school
health activities, ICDS, Anganwadi level activities, household surveys etc.
c. In extraordinary case of a destitute women or very poor household, the Village Healt h &
Sanitation Committee untied grants could even be used for health care need of the poor
household.
d. The untied grant is a resource for community action at the local level and shall only be
used for community activities that involve and benefit more than one household. Nutrition,
Education & Sanitation, E nvironment al Protection, Public Health Measures s hall be k ey
areas where these funds could be utilized.
e. E very village is free to contribute additional grant t owards t he Village Health & Sanitation
Committee. In villages where the community contributes financial resources to the Village
190

Healt h & Sanitation Committee untied grant of Rs.10, 000/ -, additional incentive and
financial assistance to the village could be explored. The intention of this untied grant is to
enable local action and to ensure that Public Healt h activities at the village level receive
priority attention.
TrainingAs per the NRHM framework for implementation, all the members of VHCs are to be trained. The
objective of training
To develop VHS C as strong Vibrant Group which will be responsible for improving the
health status of fellow villagers
To develop understanding on Health Issues, Health Problems, Health Servic es, Health
Programmes
To empower the V HSC members to plan, demand and monit or the health services
To strengthen the group to work as active participants of society for the cause of Health.
The content of the training is developed with focus on the following issues1. Conc ept of Health and determinants of health.
2. Healt h institutions and health programmes
3. Social aspects impacting health status like child marriages, son preference etc.
4. Demand generation for health care services
5. Planning and monitoring of health care services
6. Team Building and networking
7. Operational issues - Constitution, monthly meetings, funds management, reporting
8. Roles and responsibility of VHC in improvement of health status of the community
The expected training load is of about 250,000 members. The training will be imparted at
PHC/Block level and all t he committee members of the cluster of villages will be trained in one
batch. State Institute of Health and Family Welfare is the A pex body for the task of trainings. The
support will be taken from the NGOs which have an experienc e in implementing the community
level interventions in the health sector. The trainings will be completed in two years time span.
The pool of trainers will be developed at State, District and Block level. The cascade model will be
used for these trainings. The trainers team will include identified and experienced trainers from
DMHS, DWCD, P R and RD, NGOs and some free lancing trainers. SIHFW will carry out the state
and district level t rainings and will provide supportive supervision for block/ PHC level trainings.
NGOs will be involved in the trainings of members of the c ommittee and provision of the logistics
support for the trainings.
Training of trainers
a. State level- 20 selected trainers at state level will be identified who are involved in the
development of training module and reading material. The support of the NGOs who are
involved in Community Monitoring Programme will be sought for development of reference
material and state trainers group.
b. District Level- 6 selected trainers - 2 DMHS, 1 Panchayati Raj, 1 DWCD and 4 NGO and free
lancer trainers- Total 10 per District will be trained at state level by SIHFW.
c. Block Level - 6 trainers per block- Constitution same as District Level Trainers- 6* 237 =
1422 trainers. These t rainings will be conducted at District level, simultaneously in all the
districts
191

Training of Village Health Committee Members- The training will be impart ed to all the members
of Village Health Committee. The total training load is of approximate 2,50, 000 members. The
trainings at grass root level will be contracted out to t he NGOs which will be selected at district
level to carry out the t rainings. State level SIHFW will monitor and provide supportive supervision
for the trainings.
IECThe component of V HSC is to be widely publicized, so that it could be robustly rooted in the
institutional framework. The IEC can be done through posters, pamphlet and radio jingles. The
issues like health rights, citizens charter of subcenter, PHC, CHC, roles and responsibilities of
committees will be addressed through posters, radio jingles etc. The awareness campaign can be
organized for all Sarpanchs at district or block level.
Monthly Meeting sThe monthly meetings of Village Health Committees are planned on each MCHN days whic h are
facilitated by ASHA Sahyogini and ANM. As a convener AS HA Sahyogini will be res ponsible for
conducting the monthly meetings, documenting the minutes, approval of the resolutions. ASHA
Sahyogini will facilitate for the compliance on t he decisions taken during the meeting. ASHA
Sahyogini will support the ANM to c ollect all t he members of the Committee and will ensure
maximum attendance. An incentive of Rs. 100/- for ASHA Sahyogini is provided for convening the
meeting from the budget head of AS HA Sahyogini- S election and training. Format for the
proceeding of the meeting are developed, printed and disseminat ed for facilitating the meetings.
The key for the success of Village Health Committees intervention is monthly meetings. The
committees will become vibrant and active through the planned monthly meetings. For
conducting the meetings, month wise agenda is developed and provided in the districts.
MISThe physical and financial reports are incorporat ed in the monthly progress report of the Stat e.
The MIS is developed on the basis of four measurable indicators. They are Constitution of
Committees, Monthly Meetings held, mont hly meeting through ASHA Sahyoginis and utilization of
funds. The information on the trainings will also be included after initiation of the trainings.
Monitoring
The constitution of Village Health Committees, making it vibrant and utilization of untied funds for
VHCs will be incorporated as the permanent Agenda Point in the monthly review meetings at all
levels i.e Executive Committee at State level, District Health Society at District Level and review
meetings at block and PHC level.
Support Sy stemF.
State level
State Institute of Health and Family Welfare will provide technical backstopping to the
programme at state level. The training modules, development of resource pool, state level
trainings, supportive supervision for district and block level trainings will be provided by
SIHFW. The support will also be provided in monitoring of the programme from State level.
192

G.
Di stri ct levelThe CMHO, DPM, District ASHA Coordinator are responsible for implementation of V HC
programme in the district. The DPM, ASHA Coordinator in t he district will facilitate the
following components of Village Health Committees
1. Constitution of V HCs in all the revenue villages
2. Making data base and profile of VHCs.
3. Facilitation of monthly meetings of VHC on each MCHN day at village level
4. Facilitation in Development of village healt h plans
5. Facilitation in incorporation of VHPs in to Block Health plans and Block Health Plans in to
District Health Plans.
6. Addressing the issues identified by Village Health Committees and work for the emicable
solutions.
The DPM and District ASHA Coordinator will facilitate the proc ess of constitution and functioning
of Village Health Committees.
H. Block Level- Block Chief Medical and Health Officer and Block Programme Manager will be
responsible for the intervention related to Village Health Committees. They will provide
support to PHC level factionaries. Block ASHA Coordinator will also be res ponsible for V HC
intervention.
I.
PHC Level -PHC Level Facilitator - The ASHA facilitator who will be coterminous with P HC
will be responsible with the P HC medical Officer and LHV for following activities1. Constitution of Village Health Committees
2. Organizing Monthly Meetings
3. Providing support in trainings
4. Facilitation in development of Village Health Plans
5. Facilitation in conflict redressal
6. Other issues related to VHCs
J.
Village Health Plans- The Village Health Plans have been developed with ten meas urable
indicators. The indicators are ANC, Institutional Delivery, PNC, Immunization, Control of TB
and Malaria, Registration of Adolescent Girls in Anganwadis, Sterilization, IUCD and
Prevention of Child Marriages.
The challenge is to strengthen the Village Health Committees to take the ownership of Health
Status of the villagers. This could only be done through fruit ful mont hly meetings and intensive
training programmes.
Ex pected Fund s Inflow :
E very VHS C will receive an untied amount of Rs 10,000 every year which is to be used as per the
guidelines issued in this regard.
Banking Sy stem: V HSC may open a joint bank account of (1) Gram P radhan or Panchay at
Secretary and (2) ASHA or A NGA NWARI Worker in any scheduled bank/Grameen B ank/Post
Offices.
Joint Signatories: ASHA/Health Link Worker/Anganwadi Worker along with the P resident of the
VHSC/Pradhan of the Gram Panchayat.
193

Record s: VHS C may maintain a simple register for Untied Grants to VHS C. This register may
be maintained by ASHA/MPW. This register can be verified by the Panchayat representative at
the close of each month.
Submissio n of S tatement of Ex penditure (So E): SoE may be submitted on half yearly basis by
5th October and 5t h April respectively to the concerned A NM. It would be desirable if, at the time
of submission of S oE, ASHA reconciles the expenditure with the bank statement. SoE can be
submitted on a plain paper stating as below:
Certified that an amount of Rs. . has been utilized during the half year
ending 30th September. / 31st March .. from out of untied funds
released to the Village Health and Sanitation Committee for the village
The t wo joint signatories of the V HSC account should jointly certify this SoE.
Administrative Approval & Financial Sanction: The funds under Untied Grant should be spent after
the approval of majority members of t he Committee provided the expenditure is made for the
activities approved by State Government.
Acc ountability of VHS C
1. E very Village Health & Sanitation Committee needs to maintain updat ed Household
Survey data to enable need based interventions.
2. Maintain a register where complete details of activities undertak en, expenditure incurred
etc. will be maintained for public scrutiny. This should be periodically reviewed by the
ANM/Sarpanch.
3. The Block level Panchayat Samiti will review the functioning and progress of activities
undertaken by the VHS C.
4. The District Mission in its meeting also through its members/block facilitators supporting
ASHA [wherever ASHAs are in position] elicit information on the functioning of the VHS C.
5. A data base may be maintained on VHCSs by the DPMUs.
Community ba sed Monitoring o f Health service s under NRHM
Community-based Monitoring of health services is a key strategy of National Rural Health Mission
(NRHM) to ensure that the services reach those for whom they are meant, especially for those
residing in rural areas, the poor, women and children. Community Monitoring is also seen as an
important aspect of promoting community led action in the field of health.
Objectives of Community based Monitoring:
1.
Create forums for community ownership

a.
VHSC, RKS,DHM,SHM
2.
Collect systematic info about community needs
3.
Provide feedback according to

a.
locally developed yardsticks
b.
key indicators.
4.
Do with salary based systems what seems possible only with passion based systems.
5.
Validate sector wide data from other sources
6.
Triangulation
194

Organogram:
MOHFW
AGCA (Advisory Group on Community Action)
National secretariat
State Planning and Monitoring Committee
State Mentoring Group
State Nodal NGO
District Mentoring Group
District Nodal NGO
District Planning and Monitoring Committee
Block Nodal NGO
Block Planning and Monitoring Committee
PHC Planning and Monitoring Committee
Village Planning and Monitoring Committee
The NRHM proposes a monitoring and planning committee at the village, PHC, block, district and
state level. The main functions of the committee are:
1. To create public awareness about t he essentials of health programs, with focus on
peoples knowledge of entitlements to enable their involvement in the monitoring.
2. Conduct Participat ory Rapid Assessment to ascertain the major health problems and
health related issues
3. Discuss and develop a Health Plan based on an assessment of the situation and priorities
identified by the community.
4. Presentation of the progress made at the village level, achievements, actions taken and
difficulties faced followed by discussion on the progress of the achievements of the health
facilities.
5. Taking cognizance of the reported cases of the denial of health care and ensuring proper
redressal.
6. Report to the monitoring committee at the next level and collate information collected from
the lower level committee.
Issue s to be monitored:
1.
MCH, JSY,ASHA,VHSC
2.
Untied funding
3.
Disease Surveillanc e
4.
Curative care
5.
Service availability, Quality
6.
Equipment, Supplies, Personnel
7.
Charges, Corruption
8.
RKS Functioning
Tool s for communi ty monitoring :
1.
Village Level
i. Village Health Register - Records of ANM - Public dialogue
ii. Village Health Calendar- Infant and maternal death audit
2.
PHC level
i. Charter of Citizens Rights IPHS - PHC Health Plan
3.
Block level
i. IPHS - Charter of Citizens Rights - Block Health Plan
195

4.
Di stri ct level
i.
ii.
iii.
State level
i.
ii.
5.
Report from the PHC Health committees

Report of the District Mission committee
Public Dialogue (Jan Samvad)
Reports of the District Healt h committees
Periodic assessment reports by taskforces / State level committees about
the progress made in formulating policies according to IP HS, NHS RC
recommendations etc.
Flow of Report/Feedback & Necessary Action amongst the Monitoring and Planning Committees
is shown below:
State Planning and Monitoring Committee
Appropriate
Action &
Intervention
District Planning and Monitoring Committee

Block Planning and Monitoring Committee
Feedback &
Reports
PHC Planning and Monitoring Committee

Village P lanning and Monitoring Committe
People Involved in Community Monitoring

1. State, District & Block Nodal NGOs
2. State Mentoring Group Members
3. State Resource Group
4. District Mentoring Group Members
Processe s:
The implementation framework includes:
1. Orientation of stakeholders & Strengthening of Di stric t /Bloc k NGO s
2. Strengthening of Di strict/ Block NGO s
3. Mobilization of community
Objective of community mobilization:
a. To make the communities aware of their health related entitlement within NRHM.
b. To have a shared understanding of the health issues of the community.
c. To facilitate the formation or expansion of the Village Healt h and Sanitation
Committee.
d. Building ownership about public health service.
e. Developing awareness about determinants of health.
4.
Village Health Services Pro file

It is an outcome of the mobilization process. It should be used by the block facilitators and
the VHSC members to familiarise thems elves before they start wit h the monitoring
process. It will help in comparing the changes that will be brought about aft er the
community monitoring proc ess.
196

5.
Formation & Streng thening of VHS C/PHC/Bloc k/Di strict Commit tees
There is formation or expansion of committees at village, PHC, block and district levels
Strengthening of Committees Once the committees are formed there are trainings at
each level for the monitoring exercise that the members will undertake.
6.
Community Level Enquir y

The monitoring committee members conduct the first round of monitoring by conducting
beneficiary interviews, provider interviews, exit interviews, focus group discussions and
observations. At the end of the first round of community monitoring a report card and a
cumulative report card is generat ed at each level. The village report card consists of the
issue and their status by means of traffic lights. Green suggests good performing village,
yellow suggests there is a cause for concern and Red suggests that the village is
performing badly. After the village report cards have been formed for each village, they
are collated by the PHC, block, district and state level monitoring and planning
committees. So according to the color code for eac h issue in each of the village health
report card, the greens, yellows and reds are added at each level. The facility score card
is a snapshot of the status of the health facility in the village/block/district. The color codes
display the facilitys level of performanc e. Green stands for good performance, Yellow
stands for Cause for concern. A fter the facility score cards have been formed for each
facility, they are collated by the PHC, block, district and state level monitoring and
planning committees. So according to the color code for each issue in eac h of the facility
score card, the greens, yellows and reds are added at each level.
7.
Sharing of Report s & Planning

a. Village Sharing Meeting
i.
Village Score Card and key findings of the Community Monitoring exercise
ii.
Adverse experiences and adverse outcome
iii.
To improve service delivery & not fault finding with health care service
providers
iv.
To discuss key problems & suggest action points
b. Jan Samvad (Public Dialogue)
i.
Conducted at Block and PHC level
ii.
Presentation of Cumulative Village Report Card & Facility Report Card
iii.
Presentation of Denial of Care / Adverse Outcomes
iv.
Discussion on implementation of outreach services, improving Facility level
service utilization & support to denial of care/adverse outcome cases.
197

Health Management Information System

Information in Health care Planning:
The amount of information available to health policy-mak ers and planners at the time of the
Declaration of Alma-Ata on primary health care was limited. The main sources of populationbased health information were vital registration, censuses, national surveys, and research
studies. Information was generated through routine reporting at facility level. However, data were
rarely collated and used at national level, and feedback mechanisms from cent ral to local levels
were missing.
Substantial progress has been made since then in t he field of health information. An increasing
volume of data has become available on health status, health services utilization, and
determinants of health through population-based health interview surveys.
Information, a vital input to planning and programming that is not available in tine and is not valid
can put off the best of planning or policy processes. The amount of information and data available
to policy makers and planners is always limited and w hatever is made available is o ften the
result o f ad hoc attempt s in form of sur vey s out o f compliance .
Which ever way we look at, it has gradually become evident that Information i s cri tical input to
the entire planning process in Healt h care.
Survey s, the most fashionable tool for secondary data, continue to rule the information base
for the simple reason that they are relatively more accurate for the extra inputs but are ba sed
purely on self-reporting, whic h puts a question mark to their reliability, validity and
comparability. Also the su rv ey ef fort s in rou tine cant be su st ained by the system.
Population-based household surveys have become the major source of health information. Much
of the information generated by surveys is based on self-reporting, raising issues of reliability,
validity and cross-population comparability.
We need to develop an Information culture in Health to measure Health Systems performance
Slow at pace, but this dimension has started getting attention particularly since late nineties. A
good volume of data is now available on health status, service utilization, and determinants of
health, still morbidity is not measured over a standard scale and only child mortality is
documented on a limited level. Further, we do not have empirical evidence for coverage and cost
of health care interventions.
Major issues that remain to be addressed are:
1. How to dovet ail health information with operational management and strat egic planning in
the health care delivery system;
2. How to enhance the information management capacity in countries especially in area of
human resources development; and
3. How to improve use of information technology to improve dat a collection and
dissemination of information.
The need:
Primarily, Information in Healt h care delivery is required for the four distinct but still related
purposes like1. E vidence bas ed policy and strategic decision-making
2. Program management
3. Monitoring the process and outcomes
4. E valuation of achievements
198

Issue s in HMIS:
1. Is there a policy existing for Health Information system?
2. Does an organizational structure exist at the National level for HMIS ?
3. Functional linkages between sub-systems for feedback, utilization, responsibility
4. Capacity building-potential, activities and resources
5. Is there a Fixed- frequency review of reports and records ?
6. How are reports made and who makes them?
7. Is there a built in system for checking reliability of dat a generated at the lowest level
Terms u sed in Information Sy stem:
Data: Messages not evaluated for their worth in specific situations. Data could be-P rimary or
Secondary
Data QualityQuality is defined as ability to achieve desirable objectives using legitimat e means
The data quality refers to what was initially intended and is objective, unbiased and complies with
standards.
The attributes of data quality are1. Accuracy & Validity
2. Reliability
3. Completeness
4. Legibility
5. Timeliness
6. Accessibility
7. Usefulness
8. Confidentiality
Factor s deciding Quality in Data collection:
1. Who collected for whom?
2. For what service
3. When and where
4. Why was it provided?
5. How effective the service was
6. What was the outcome?
Source s of DataThe data for the above said purpose are us ually available from different sources like1. Diaries
2. Family registers
3. Hospital registers / Records
4. Periodic reports
5. Rapid surveys
6. Exit interviews
7. National sample survey
8. Cens us
9. Special studies
Data may be defined as a repre sentation of fact s o r con cept s o r in st ruc tion s in a formalized
manner, suitable for communication, interpretation or processing by manual or electronic
199

means. Data need to be A ccurate and Valid at each point (Point of Entry, Point of Service
delivery and Point of Decision making), besides being Reliable, Timely, Complete, and
Retrievable.
Information: E valuated data
A resource with cost & benefit, P otential knowledge, An essential input for decision making
Record: A document of transaction bet ween a client and service provider of who did what to
whom, when and where, e.g. A bill, A prescription, A discharge ticket, A laborat ory report, A
register.
Information Sy stem: Comprehensive, coherent arrangement organized on an organizational or
major program basis to collect, process and provide coordinated information to serve multiple
needs of management system.
Health Information System: an integrated effort to collect, process, report and use healt h
Information & knowledge for influencing policy-making, program action, and res earc h.
Objectives o f HMIS:
1. To support the development of strategic plan for national health information systems
2. To encourage the establis hment of communicable and non communicable disease
surveillance systems
3. To promote the use of ICD-10 (International Classification of Diseases, Injuries and
Caus es of Death) and to improve data quality
4. To establish a National health database with indicators to monitor and assess health
outcomes
5. To provide technical s upport to strengt hen dat a analysis and use of information at all
levels of health care delivery
6. To promote research related to health, such as research into human behavior, biomedical
interventions and health systems
7. To facilitate the use of scientific evidence based on research
The other set of objectives could be1. Medical carea. Quality assurance &
b. Assessment of outcome
2. Cost control & productivity enhancement
3. Utilization analysis and demand estimation
4. Program planning & evaluation
5. Simplification of Records
6. Education
7. Clinical research
Component s o f the basic mg t. proce ss in health care are1. Establishing goal s & Objecti ve for which information is required regardinga. Problem indicators
i.
Mortality
ii.
morbidity
iii.
Social indicators
iv.
Economic data
v.
Healt h seeking behavior
200

b.
c.
Data on services delivered by other community organizations

Resources available
2.
Estimate demand for service s based on

a. Data on utilization
b. Demographic data
c. Community projections
3.
Allocate resour ces to meet demands, based on

a. Data on work force
b. Financial information
c. Capit al requirements
d. Short term demand forecasts
4.
Cont rol quality, based on data on

a. Output measure
b. Quality control data
c. Work sampling & meas urement
d. Medical audit
5.
Evaluate performance through

a. Changes in problem indicators
b. Cost benefit analysis
c. Changes in communitys capability to provide services
The major component s of HMIS are1. Identification

2. Collection
3. Classification
4. Processing
5. Communication
6. Interpretation
7. Storage and Ret rieval
Use of
1.
2.
3.
4.
Information in Health care planning:

Information for assessing need
Information for controlling utilization and standards (quality of servic es)
Information for controlling deployment of resources
Information for increasing effectiveness of services
Prerequisite s of HMISThe following review activities may be cont emplat ed in order to assess the current status of
HMIS 1. Existing formats, transmission system & channels, capacity of data handlers and
analyzers and the resources (hard and soft) available.
2. Exploring possibilities of additions and deletion of parameters
3. Compliment ary or cont radictory nature of sub-systems of the System
201

" How do w e determine ideal number of indicators and co st?" Collection of information is
expensive and one really needs to prioritize the indicat ors.
The number of indicators on which information is to be collected depends on1. National Health policy & priorities
2. Relevance in view of Epidemiologic al transition
3. Resources at command
4. Capacity of Dat a generators and data handlers
5. Systems overall responsiveness to data being us ed in planning
Levels at w hich we need information
1. Point of entry of client into the System
2. Point of Service
3. Point of decision-making
Who use s the information and for w hat1. National & State Ministries for
a. Assessing impact
b. Policy development
c. Financial allocations
2. Healt h care professionals for
a. Treatment in Hospitals/ CHC/ PHC
b. Choosing alt ernatives between care lines
3. Legal bodies
a. As documentary evidence of care
b. Protect interests of Health care professionals and patients
4. Insuranc e companies for reimbursement of claims
Designing HMIS
1. Design Requirements:
a. Clarity of Objectives
b. Awareness of information need
c. Flexibility to change
2. Con sideration s in information sy stem design
a. Identifying & listing of objectives and norms in hierarc hy
b. Identification of all decision points to be served by the system
c. Determination of relative importance & priority of identified decisions
d. Identifying information need for decision
e. Identification of relationship among decision sets
f.
Specification of information system
g. Installation
h. Establishing a review mechanism
3. Information requirements, is governed by
a.
Decision structure of Program
b.
Levels of decision making
c.
Questions to be answered
d.
Economics of information management, based on these requirements decision
shall be taken regarding type of information, which could bei.
Scientific& Technical (Related to problem & solution
202

ii.
iii.
Situational (P rogram environment)

Programmatic (Intervention system)
An answer to questions like1. What data is needed?

2. Who generates, in what form
3. Quality
4. Processing requirement
5. Types of formats for reporting
6. Frequency of reporting
7. Data storage system,
8. Devices for storage
9. What should be the channel for information flow;
shall determine the basi c step s in designing HMIS, which are1. Determine organizational need for information
2. Identify sources of information
3. Decide on amount, form and frequency
4. Select means of information communication & processing
Application of HMISA good HMIS that is Reliable, Timely, Complete, and Retrievable should facilitate decision
making at different levels
HMIS should provide suppo rt to 1. Health Workers, in
a. Understand health needs (based on approaches like CNAA)
b. Prioritizing clients
c. Estimate requirements (based on Demographic profile, morbidity profile, coverage
and /or Expectations)
2. Program Mangers, for
a. Assessing quality & Coverage
b. Allocating resources
c. Reducing wastage and duplication
3. Policy makers, to
a. Assess cost-effectiveness
b. Decide content & mode of service delivery
c. Develop norms
i.
Financial
ii.
Infrastructure
iii.
Staffing
iv.
Logistics
Problem areas in HMIS:
1. Unrealistic expectation of Managers
2. Addressing to Report to higher levels rather t han convincing work ers about the
benefits
3. Too much information asked
4. Poorly trained, Over worked staff, (30-40 % time in reporting)
5. Information collected is selective is directed to handle out of pressure ad hoc exigent
requirements of Managers or System
203

6.
7.
Many reporting levels- Data lost in transmission

Performance indicators keep changing witha. Shifting priorities within program
b. New additions- NO deletions of irrelevant
8. Indicators-simply output oriented
9. Program priorities & timeliness of information flow do not match
10. Retrieval
11. Duplication
12. NO periodic review
204

Immunization
46% of total children in India are malnouris hed.
Pneumonia kills 2 million children every year followed by Diarrhea.
th
Rate of improvement 1% in the last decade. For child mortality, India ranks at 49 place in the
World
Why immunization:
1. Immunization is a key strategy to child survival.
2. By protecting infants from VPDs, immunization significantly lowers morbidity and mortality
rates in children. The security provided to families can lead to lower birth rates.
3. Immunization is an indicator of a strong primary health care system
Full immunization:
Means child has received one dose of B CG, three doses of DP T and OPV each and one dose of
Measles before one year of age
1. 43.5% of children in India received all vaccinations as per NFHS-III 2005-06.
2. Very little improvement in full vaccination coverage between NHFS-2 & NFHS -3.
Reason s for low coverage in immunization:
1. Failure to provide immunization at planned outreach, sub centre or PHC sites.
2. Dropouts: children who receive one or more vaccination, but do not return for subsequent
doses.
3. Unreached populations
a. Children whos e parents do not know about immunization or face s ocio-ec onomic
barriers to utilize services.
b. Lack of geographic access: children who live too far away from a health centre or
outreach site to realistically complete a full immunization schedule.
4. Resistant populations: Children whos e parents do not believe in immunization services,
even though a health centre is within reach.
5. Missed Opportunities: Children who visit the health cent re for some other reason, but are
not immunized by health workers.
6. Improper logistics management
Immunization Micro Plan
1.
At SC level:
a. Estimation of benefictiories
b. Estimation of vaccine and logistics
c. Work plan
i. Who will provide services
ii. Who wil assist (AWW, ASHA, PRI, NGO)
iii. Where wil the services be provided (Site)
iv. When will the services be provided (Session plan)
2.
At SC/PHC level
a. Area map at SC level
b. Alternative vaccine delivery routes
3.
At PHC/District level
a. Supervision plan
b. Budget plan (t ransport, social mobilization, meetings)
c. IEC and training plan
205

Simple way to keep injections safe:

1.
Keep hand s clean b efor e giving injection s

a. Wash or disinfect hands prior to preparing injection material.
b. A void giving injections if the skin of the recipient is infected or compromis ed by
local infection (such as a skin lesion, cut, or weeping dermatitis).
c. Cover any small cuts on the servic e providers skin.
2.
Use sterile injection equipm ent, ev ery time
3.
Pr even t th e con tamination of vaccine and injection equipmen t

a.
b.
c.
d.
e.
f.
4.
A ssume all u sed equipment i s c ont aminat ed

a.
b.
c.
d.
5.
Cut the used syringe at the hub immediately after use.

Wash or disinfect hands prior to preparing injection material.
A void giving injections if the skin of the recipient is infected or compromis ed by
local infection (such as a skin lesion, cut, or weeping dermatitis).
Cover any small cuts on the servic e providers skin.
Pr actic e safe di sp o sal of all medical sharp s wast e

a.
6.
Prepare each injection in a designat ed clean area where contamination from

blood or body fluid is unlikely.
If the injection site is dirty, wash with clan water
Always pierce the rubber cap of the vial with a sterile needle.
Do not leave the needle in the stopper of the vial.
Follow product-specific recommendations for use, storage, and handling of a
vaccine.
Discard any needle that has touched any non-sterile surface.
Used sharps (needles ) must be deposited in a hub cutter and then carried to the
PHC for safe dis posal.
Pr even t needle-stick injuries

a.
b.
c.
Do not recap.
Collect sharps in a puncture proof container (Hub cutter).
Anticipate sudden movement of the child.
206

Adver se Event s follow ing Immunization

Programmatic Errors
Possible Adverse event that ma y occur
Non-Sterile injectio n:
1. Improperly sterilizing syringe
2. Contaminated vaccine or diluents
3. Re-use of reconstituted vaccine
subsequent sessions
4. Wiping the needle with a swab
5. Administering injection over clothes
1.
Infection such as local abscess at site of

injection sepsis, toxic shock syndrome or
death.
Re-use of disposable syringe and needle
1.
Transmission of blood-borne infections such

as Heb B, HIV, Hep C
Reconstitution Error/ Wrong vaccine preparation

1. Reconstitution with incorrect diluents
2. Drug substituted for vaccine diluents
3. Inadequate shaking for T-series vaccines
Injection at incorrect site
1. BCG given sub-cutaneously
2. DPT/DT/TT given superficially
3. Injection into buttocks
Vaccine transportation/storage
1.
2.
3.
1.
2.
3.
Vaccine ineffective
Negative effect of drug, e.g. insulin causing
death
Local abscess
Local reaction or abscess
Local reaction or abscess
Sciatic nerve damage
1.
2.
Local reaction from frozen vaccine

Vaccine ineffective
Contraindications ign ored
1.
Avoidable serious reaction
at
When a severe adverse event occurs, the healt h worker should immediately contact the Medical
Officer and if needed should accompany the patient.
All vaccines can cause minor vaccine reactions in some patients. Thes e mild reactions are normal
and do not need to be reported.
Mild vaccine reactions
Local reaction
redness)
(pain,
Treatment
selling,
1.
Irritability, malaise and systemic

symptoms
2.
1.
2.
3.
4.
1.
2.
Fever > 38.5C
Cold cloth at injection

site
Give Paracetamol
Give e xtra fluids
Wear cool clothing
Give tepid sponging
Give Paracetamol
Give e xtra fluids
Give Paracetamol
When to report
1.
In case of an abscess
1.
When accompanied by
other symptoms
1.
When severe or unusual
Why children drop out:

1.
2.
3.
4.
5.
Anaphylaxis or a severe allergic reaction is an absolute contraindic ation to subsequent

doses of a vaccine. Persons with a known allergy to a vaccine component should not be
vaccinated. Parents are not told or forget when to return.
Parents are not aware of the reason of following an immunization schedule.
Parents do not know that immunization is important.
Parents develop misconceptions about immunization.
Families move to a new village.
207

Action s to be taken to reach the un-reached (instru ct you r health w orkers):
1. Develop a list of children who have never accessed immunization servic es in the area.
2. Look for migrant populations travelling through your service delivery area and reach out to
them. Tell them about immunization and give them the date, time and place of the nearest
session.
3. Visit several of these households to find out the reasons why they have never accessed
immunization servic es. Use the opportunity to clear up any doubts expressed by the
families and help them find ways to overcome any barriers that prevent t hem from
bringing their child to the next session.
4. Take the help of t he c ommunity workers such as ASHA, AWW and NGOs to talk to
parents about the import ance of full immunization and give them the date and time of the
next session.
Action s to be taken for dealing w ith resistant population s
1. Find out the reasons by taking directly to them and address their misconceptions, doubts,
and fears by listening to them, and offering support and care.
2. Request community leaders and ot her staff working to educate them about vaccination.
3. Spend more time talking with community leaders, religious leaders, and other k ey
persons in the village about the benefits of immunization.
4. Always provide prompt and quality services.
5. Arrange for an interaction between resistant groups and satisfied beneficiaries in the area
to promote immunization.
6. Community meetings
7. Discussion sessions at farmers meetings, in the market place and other places
8. Loudspeaker messages for the community, use Radio and TV spots Newspaper and
drama
National Immunization schedule:
Vaccine
When to give
Dose
Route
Site
For Pregnant Women

TT-1
Early in pregnancy
0.5 ml
IM
Upper Arm
TT-2
TT- Booster
4 weeks after TT-1*

0.5 ml
If pregnancy occur within three yrs of last 0.5 ml
TT vaccination*
IM
IM
Upper Arm
Upper Arm
For infants
BCG
At birth (for institutional deliveries) or along 0.1 ml (0.05ml ID

with DPT-1
for infant up to 1
month)
Left Upper Arm
OPV-0
At birth if delivery is in institution
2 drops
Oral
Oral
OPV- 1,2 & 3 At 6 weeks, 10 weeks & 14 weeks
2 drops
Oral
Oral
DPT- 1,2 & 3 At 6 weeks, 10 weeks & 14 weeks
0.5 ml
IM
Hep B 1,2 & At 6 weeks, 10 weeks & 14 weeks**

3
0.5 ml
IM
Outer
Mid-thigh
(Antero-lateral side of
mid-thigh)
Outer
Mid-thigh
mid-thigh)
208

Measles
9-12 months
0.5 ml
SC
Right upper Arm
Vitamin-A
st
(1 Dose)
At 9 months with measles
1 ml (1 lakh IU)
Oral
Oral
0.5 ml
IM
For chil dren

DPT Booster 16-24 months
OPV Booster 16-24 months

2 drops
Vitamin-A
16
months
with 2 ml
nd
th
(2
to 9
(2 lakh IU)
DPT/OPV booster
Dose)
Then, one dose every 6

months up to the age of 5 years.
Oral
Oral
Outer
Mid-thigh
mid-thigh)
Oral
Oral
DT Booster
5 years
0.5 ml
IM
Upper Arm
TT
10 years & 16 years
0.5 ml
IM
Upper Arm
Cold Chain:
Cold Chain is a system of transporting and storing vaccines at recommended temperat ure from
the point of manufacture to the point of use. All V accines tend to lose potency on exposure to
heat above +80 C
Some Vaccines lose pot ency when exposed to freezing temperatures. The damage is irreversible
Essen tials of c old chain1.
2.
3.
4.
5.
6.
Personnel to organize and manage vaccine distribution

Equipment for storage and transport of vaccines.
Trans port facilities
Maintenance of equipment
Monitoring
It is the responsibility of district block managers to ensure the cold chain equipment are
installed operated and maint ained properly so as to keep it continuously functioning
equipment.
How to be sure that the vaccine is still Potent?

VVM for Heat Damage-
A Vaccine Vial Monitor (VVM) is a label that changes colour when the vaccine vial has been
exposed to heat over a period of time. Before opening a vial, the status of the VVM must be
checked to see whether the vaccine has been damaged by heat. The VVM is printed on the vial
label or cap. It looks like a square inside a circle. As the vaccine vial is ex posed to more heat, the
square becomes darker.
1. Use only vial with inner squares that are lighter in colour than the outside circle.
2. Vials with VVMs in which the inner square has begun to darken but is still lighter than the
outer circle should be used before the vials with a lighter inner square.
3. VVMs do not measure exposure to freezing temperatures (for freeze- sensitive vaccines).
209

Shake test for Cold Damage

Shake test is designed to determine whether adsorbed vaccines (DP T, DT, TT or Hepatitis B)
have been frozen. After freezing, the vaccine is no longer a uniform cloudy liquid, but tends to
form flakes which gradually settle to the bottom after the vial has been shaken. Sedimentation
occurs faster in a vaccine vial which has been frozen that in a vaccine from the same
manufacturer which has never been frozen.
Step1 Prepare a frozen control sample: Take a vial of vaccine of the same type and batch
number as the vaccine you want to test, and from the same manufacturer. Freeze the vial until the
contents are solid (at least 10 hours at -10C) and t hen let it thaw. This vial is the control sample.
Mark the vial clearly so that it is easily identifiable and will not be used by mistake.
Step2 Choose a test sample: Take a vial (s) of vaccine from the batch (es) that you suspect has
been frozen. This is the test sample.
Step3 Shake the control and test samples: Hold the control s ample and the test sample
together in one hand and shake vigorously for 10-15 seconds.
Step4 Allow to rest: Leave both vials to rest by placing the vials on a table and not moving them
further.
Step5 Compare the vials: View bot h vials against the light to compare t he sediment ation rate. If
the test sample shows a much slower sedimentation rate than the control sample, the test sample
has most probably not been frozen and can be used. If the sedimentation rat e is similar, the vial
has probably been damaged by freezing and should not be used.
What are Vaccine Carriers?
Vaccine carriers are used by health workers for carrying vaccines (16-20 vials) to sub-centres or
to villages. They maintain t he cold c hain for one days use in the field. Vaccine carriers have thick
walls and lids and are made of a special material that prevents heat from passing t hrough and
reducing the potency of vaccines. The inside temperature of a vaccine carrier is maintained
between +2 to +8 degrees centigrade with 4 frozen ice packs for one day (if not opened
frequently).
1. Only vaccine carriers with 4 ice packs should be used. Day carriers with 2 ice packs
should not be used.
2. Do not leave vaccine carriers in the sunlight; this spoils vaccines that are sensitive to heat
and light.
3. Do not open the lid unnecessarily as this can allow heat and light into the carrier, which
can spoil vaccines
Ice lined Refrigerators (ILRs)
1. Capacity: 140 litres at PHC level(1200 vials)
2. Ideal Temperature: +2C to 8C (Effective with electricity supply of 8/24 hrs)
3. Safe Storage: Always in the basket section
a. (Always T series, Hepatitis-B and Diluents)
b. (OPV/Measles/BCG may be kept below basket in case space is not available)
4. Thermomet er: Place in the ILR-basket
Deep Freezers:
1. Capacity: 140 litres at PHC level
2. Ideal Temperature: -18C to -20C (In case of power failure - maintain temperature for 1820 hrs )
210

3.
Ice Pack Freezing Capacity: freez es 20 ice packs every 24 hours
Cold Box es:

1. Type: Insulated boxes of 5 litre capacity
2. Usage: Stores & transports vaccine. Also stores frozen Ice Packs
3. Capacity: 1500 doses (mixed antigen) or 5000 dos es (only OPV) wit h 24 ice packs.
4. Holdover Time:3 days (Keep thermometer inside)
5. Vaccine Layout: Direct contact of frozen ice packs spoils the vaccine. Give carton
spacers/surround vaccine by OPV vials.
6. Label Protection: Place vaccine in cart ons or polythene bags.
Vaccine carrier:
1. Type: Insulated boxes used for carrying small quantities of vaccine.
2. Capacity: 16-20 vials
0
3. Holdover Time: Maintain +2 to+8 C for about 24 hours (one day)
4. Ice packs: A maximum of 4 frozen packs
5. Vaccine Layout: Keep vaccines in a plastic bag (not in direct touch with the ice packs)
Do not 1. Leave vaccine carrier in sunlight; this spoils vaccines that are sensitive to heat and light.
2. Leave the lid open; this can allow heat and light into the carrier, which can spoil vaccines.
3. Drop or sit on the vaccine carrier: this can damage the carrier.
4. Carry vaccines in handbag as this can spoil vaccines that are sensitive to heat.
5. Keep the DP T, DT, TT and Hep. B vaccines on the Ice pack during the session
Ice packs:
1. Do not fill 100%.
2. Leave 10 mm room for expansion as water freezes.
3. Close the cap tightly
4. Clean the outer surface dry before freezing
5. Ice Packs to be froz en ROCK Solid
6. Freezing is faster & uniform if gap /breathing space is left bet ween ice packs
7. Ice Packs are best frozen in Deep Freezers
8. Condition before use
Vaccine distribution :
1. Follow first-in-first - out rule (FIFO)
2. Also: first to expire - first out. (FEFO)
3. Vaccines are not stored at the sub-cent re level and must be supplied on the day of use
4. Note manufacturer, batch no, VVM status
5. Use VVM stage-II vaccine near the cold chain point (do not distribut e to remote areas)
Micro planning in Immunization
Micro-planning helps to ans wer1. What needs to be provided
2. Who will provide
3. Where to provide (including hard to reach)
4. When to provide
5. How to provide
6. How many to provide for (beneficiaries)
7. How much to provide (vaccines & logistics)
211

Steps f or Suppor tive Supervision

Step 1: Set up a Supportive Supervision System
Right Supervisors
Right Tools
Right Resources
Step 2: Plan regular Supervisory Visits

Where to conduct visits
When to conduct visits
What to do during visit
Step 3: Conduuct supportive Supervision Visits

Collect information
Problem-solve and
provide feedback
Record results
of superrvision
Step 4 : Follow up
Follow up on
agreed actions
Analyze data regularly
Provide on the
job training
Provide feedback
to all stakeholders
Conduct follow
up visits
212

Indian Public Health Standards (IPHS)

Why Standards:
1. Standards describe a level of quality that health care facilities are expected to meet.
2. Setting standards is a dynamic process
3. Revision of standards will occur as and when the facilities achieve a minimum functional
grade.
4. Standards are also flexible, to be applied keeping in view the needs of the States.
Genesi s of IPHS:
NRHM- launched on 12 April 2005 aimed at universal access to equitable, affordable and quality
health care that is accountable and responsive to the peoples needs. NRHM aims to reduce child
and maternal Deaths, stabilize population and ens ure gender and demographic balance. This
requires a restructuring of delivery mechanism for health services for which it is proposed to up
grade public health institutions from their present level to achieve a level of set standards called
Indian Public Health Standards (IP HS).
The IPHS have been prepared, keeping in mind the minimum resour ces available at the
facilities. It mentions the minimum functional level of insti tution s in terms of space, building,
manpower, instruments, equipments, drugs and health care services to be made available .The
IPHS w ill help the State and Central Government s, and P RI s (where applicable), to monitor
periodically how many of their health facilities are conforming to IPHS standards.
Need for Standards?
1.
2.
Functioning of Rural Health Care Institutions not satisfactory

Lack of comprehensive and realistic mandatory standards for P ublic Healt h Institutions in
Indian context
Needed to ensure
1. Quality management
2. Quality Assurance
3. Effective, economical and accountable health care delivery system
4. Optimal level of services
Objectives for IPHS:
1. Describe benchmarks for quality expected from various components of health care
organizations
2. Standards for quality of services, facilities, infrastructure, manpower, machines &
equipment, drugs etc.
3. Main driver for continuous improvements in quality
4. Standards for assessing performance of healt h care delivery system
Process
1. Setting standards a dynamic proc ess
2. Current standards prepared keeping in view available resources
3. Minimum standards for functional requirements of buildings, manpower, instruments &
equipments, drugs and other facilities
213

Ex isting Standard s
1. Hospital Standards by Bureau of Indian Standards (BIS )
2. BIS Standards considered very res ource intensive in current scenario
3. No such standards for primary health care institutions
4. National Rural Health Mission (NRHM) opportunity to prescribe Indian P ublic Health
Standards for rural healt h care
Process of Formulating IPHS
1. Constitution of Expert Committee under DGHS
2. Discussion with members comprised of ministry officials, State Governments
representatives, academicians, management experts, economists, donor agencies, public
health professionals, and ot her organizations such as NGOs etc.
3. Circulation of draft IPHS for public health institutions in rural areas
4. Putting drafts standard on website
5. Finalization of draft IP HS for public health institutions
Implementation and Monitoring
1. Under National Rural Health Mission (NRHM) States / UTs to upgrade CHCs, PHCs and
Sub Centres up to IPHS levels
2. Govt. of India also provided funds @ Rs. 20 Lacs per CHCs for all CHCs to various
States / UTs
3. Strengthening health infrastructure in terms of t rained staff, infrastructure, equipment and
supplies required
4. Prerequisite to obtain knowledge of existing situation at different levels of health facilities
Main objectives of IPHS Facility Survey
1. To assess existing facilities as per the norms under IPHS and identify gaps
2. To assess utilization of facilities provided
3. To assess quality of services using appropriate outcome indicators
4. Proforma designed and circulated among all States / UTs which could be used for
conducting
IPHS facility surveys
5. States / UTs in the process of conducting facility surveys
6. Reports of IPHS facility survey for identified CHCs received from 15 States / UTs
7. Monitoring Perform for Identifying Gaps for IP HS bas ed on Facility Survey
a. To properly analyze and monitor process of up gradation of CHCs to IPHS
b. Proforma designed to highlight gaps
c. To judge situation at a particular centre just by giving a look at proforma
d. Monitoring Proforma to be kept as benchmark record for each centre
e. Monitoring process for ensuring proper and effective implementation
8. Other requirements for IPHS
a. Capacity Building at all levels
b. Optimal Use of available infrastructure
c. Quality Assurance & Accountability
d. Standard Treatment protocols/ Standard Operating Guidelines
e. Rogi Kaly an Samiti
f. Charter of Patients Rights (Citizens Charter)
9. Monitoring mechanism
a. Internal & External monitoring by PRIs and RKS/ HMS
214

b. Audits Social, Economic, Medical & Tec hnical

10. Checklist
a. Checklist for minimum requirement for following components
b. Services, Manpower, Physical infrastructure, Equipment, Drugs
IPHS for Sub Center s:
In t he public sector, the Sub-Centre is the mo st peripheral and fir st contac t poin t between the
primary health care system and the community. Therefore, the success of any health program will
depend on well functioning Sub-centres, providing service s of acceptable standard s to the
people, through c ertain available guidelines. Thus, the necessary fir st step i s to lay dow n
norm s and standard s for Sub Cent res.
Choo sin g location1. it is not too close to an existing sub centre/PHC
2. as far as possible, no person has to travel more than 3 km to reach the Sub-centre
Manpow erOne more ANM is pro po sed in addition to the ex isting one A NM and one Male Health Worker.
Drug s:
Elementary drugs for minor ailments such as ARI, diarrhea, fever, w orm infestation etc
Services:
1. All Assured Services including routine, preventive, promotive, few curative and referral
services and national health programs as applicable.
2. The assured package of services at SC level include
3. Full immunization and Vitamin A prophylaxis
4. Essential newborn care
5. Antenatal, natal and postnat al care
6. Prevention of malnutrition and common childhood diseases
7. Family planning services
8. Counseling.
9. community needs assessment
10. Minimum laboratory service s to be made available are
a. hemoglobin estimation,
b. urine for albumin and sugar and
c. Referral to P HC for blood grouping.
11. Others
a. Malaria prophylax is as per guidelines of` NVBDCP
b. Provision of facilities under Janani Suraksha Yojana (JSY)
c. Adolescent health care and assi stance to school health service s
d. Organizing VHND in each village A nganwadi centre, at least once in a month,
with the help of MO-P HC, ASHA, AWW, PRI, self help groups , PMU etc.
e. Appropriate and prompt referral service s
f. Providing treatment as per AYUS H according to local need.
g. Training of Traditional Birt h Attendants and ASHA/Community Health V olunteers
h. Recording and reporting of vital events
i. Syndromic sur veillance to be done and reported to PHC every week
j. Water Quality Monitoring
215

k.
l.
Di sinfection o f w ater sources

Promotion of sanitation including use of toilets and appropriate garbage
disposal.
m. Field visit s for disease surveillance, community need assessment, family welfare
services, including RTI/S TI awareness
12. Norms for facilitya. Residential Accommodation should be available for the Health workers,
especially the ANMs
b. Maintenance of equipment is advised through preventive maintenance or
prompt repair of non-functional equipment to ensure uninterrupted delivery of
services, by making use of the untied funds
c. Potable w ater for patients and staff and water for other use should be made
available in adequate quantity.
d. Wherever possible, uninterru pted pow er supply has to be ensured
13. Fund, Monitoring & E valuation
a. assistance from MOHFW to all Sub-c entres in the country since April 2002
b. Untied fund s are provided (currently Rs. 10,000 per Subcentre under NRHM)
c. One Health Assistant (Female) / Lady Health Visitor (LHV) and one Health
Assistant (Male) located at the PHC are entrusted with the task of supervision of
all the Sub-c entres (generally six sub centres) under a PHC.
IPHS for PHC:
The 6th Five year Plan (1983-88) proposed reorganization of PHCs on the basis of one PHC for
every 30, 000 rural population in the plains and one PHC for every 20,000 population in hilly, tribal
and backward areas for more effective coverage.A PHC ser ve s a s a fir st por t o f call to a
qualified doctor in rural areas. On one hand it serve s a s a referral unit for 6 Sub -centre s
and on the other hand, c ases are referred from PHCs to CHCs/other higher secondary level
institutions. It provides a range of curative, promotive and preventive health care services.
Besides minimum resource s available and minimum func tional standard s Constitution of
RMRS (Rogi Kalyan Samiti) / Management Committee w ith involvement of PRI and Citizen s
Charter are some of the innovative approaches incorporated under IP HS for PHC.
24 x 7 PHC sho uld:
1. Provide 24-hour delivery servic es, both normal and assisted
2. Provide Obstetric First Aid and Referrals to First Referral Units (FRUs)/ other hospitals, for
high risk pregnancy cases beyond the capability of Medical Officer, PHC.
3. Provide 24 hours emergency servic es for management of injuries and accidents.
4. Provide emergency care of sick children
Genesi s of IPHS
Minimum requirement for assured service s at PHC under IPHS:
The requirements are projected based on an average case load of 40 patients per doctor per day,
expected number of beneficiaries for maternal health ,child health and family planning servic es
and 60% utilization of the available indoor/observation beds (6 beds).
It is a dynamic process - if utilization goes up, the standards are to be further upgraded.
Regarding manpower, one more Medical Officer (AYUSH or lady doctor) and two more staff
nurses are to be added to the existing total staff strengt h of 15 in the P HC, if it is to be made into
a 24x7 services delivery centre.
Minimum laboratory investigations should be provided as listed in the IP HS doc ument on PHC
216

A ssured service s co ver all the essen tial elements o f preventive, promotive, cu rative and
rehabilitative primary health care. This implies a w ide range of service s that include:
Medical care:
OPD services: 4 hours in the morning and 2 hours in the aft ernoon / evening. Time Minimum OPD
attendance should be 40 patients per doctor per day.
24 hours emergency services: appropriate management of injuries and accident, First Aid,
Stabilization of the condition of the patient before referral, Dog bite/snake bit e/scorpion bite cases,
and ot her emergency conditions
Referral services
In-patient servic es (6 beds)
Maternal and Child Health Care including family planning:
1. Antenatal care:
2. Intra-natal care: (24-hour delivery services bot h normal and assisted)
3. Postnatal Care:
4. New Born care:
5. Care of the child:
6. Family Planning:
7. Medical Termination of Pregnancies using Manual Vacuum Aspiration (MVA ) technique.
(wherever trained personnel and facility exists)
8. Management of Reproductive Tract Infections / Sexually Transmitted Infections:
9. Nutrition Services (coordinated with ICDS):
10. School Health:
11. Adolescent Health Care:
12. Promotion of Safe Drinking Water and Basic Sanitation
13. Prevention and control of locally endemic diseases like malaria, Kalaazar, Japanese
Encephalitis, etc.
14. Disease Surveillanc e and Control of Epidemics:
15. Collection and reporting of vital events
16. Education about health/Behavior Change Communication (BCC)
17. National Health Programs including Reproductive and Child Health Program (RCH),
HIV/A IDS control program, Non communicable disease control Program - as relevant:
18. Revised National Tuberculosis Control Program (RNTCP ): All PHCs to function as DOTS
Cent res to deliver treatment as per RNTCP treatment guidelines through DOTS providers
and treatment of common complications of TB and side effects of drugs, record and
report on RNTCP activities as per guidelines.
19. Integrated Disease Surveillance Project (IDSP):
20. National Program for Control of Blindness (NPCB ):
21. National Vector Borne Disease Control Program (NVBDCP):
22. National AIDS Control Program:
23. Referral Services:
24. Appropriate and prompt referral of cases needing specialist care including:
25. Training:
26. Basic Laboratory Services: Essential Laboratory services including:
27. Monitoring and Supervision:
28. AYUSH services as per loc al peoples preference (Mainstreaming of AYUS H)
29. Rehabilitation:
217

30. 24 hour delivery services and new born care, all seven days a week in order to increase
the institutional deliveries which would help in reducing maternal mortality
31. Selected Surgical Procedures:
32. Record of Vital E vents and Reporting:
Essen tial Infrastru ctu re:
The PHC should have a building of its own. The surroundings should be clean. The details are
as follows:
PHC Building
Location:
1. Easily accessible area.
2. Prominent board displaying the name of the Centre in the local language.
3. Facility for electricity, all weather road communication, adequate water supply, telephone.
Well lit and ventilated with as much use of natural light and ventilation as possible.
4. The plinth area would vary from 375 t o 450 sq. meters depending on whether an OT
facility is opted for.
5. Entrance- well-lit and ventilated with space for Registration and record room,
6. Drug dispensing room, and waiting area for patients.
7. The doorway leading to the ent ranc e should also have a ramp facilitating easy access
for handicapped patients, wheel chairs, stretchers etc.
Waiting area:
1. This should have adequate space and seating arrangements for
2. waiting clients / patients
3. The walls should carry posters imparting health education.
4. Booklets / leaflets may be provided in the waiting area for the same purpose.
5. Toilets with adequate water supply separate for males and females should be available.
6. Drinking water should be available in the patients waiting area.
7. Signage-displaying wings of the centre, available services, and names of the doctors,
users fee det ails and list of members of the RMRS/ Hospital Mgt Committee.
8. A locked complaint / suggestion box and complaints at regular int ervals are addressed.
9. The surroundings should be kept clean wit h no water-logging in and around the centre
and vector breeding plac es.
Outpatient Department:
1. The outpatient room should have separate areas for consultation and examination.
2. The area for examination should have sufficient privacy.
3. In P HCs with AYUSH doctors, necessary infrastructure such as consultation room for
AYUSH Doctor and AYUS H Drug dispensing should be made available.
Wards 5.5x 3.5 m each:
1. There should be 4-6 beds in a primary healt h centre. Separat e wards/areas should be
earmarked for males and females with the necessary furniture.
2. There should be facilities for drinking water and separat e and clean toilets for men and
women.
3. The ward s hould be easily accessible from the OP D so as to obviate the need for a
separate nursing staff in the ward and OP D during OPD hours.
218

Nur sing station:

Location should be easily accessible to
OT and labour room after regular clinic timings.
1. Clean linen should be provided and cleanliness should be ensured at all times.
2. Cooking should not be allowed inside t he wards for admitted patients suitable
arrangement with a local agency like a local womens group for provision of nutritious and
hygienic food at reas onable rates may be made wherever feasible and possible.
3. Cleaning of the wards, etc. should be carried out at such times so as not to interfere with
the work during peak hours and also during times of eating.
Operation Theatre: (Optional) to facilitate conducting selected surgical procedures (e. g.
vasectomy, tubectomy, hydroc electomy, Cataract surgery camps)
1. It should have a changing room, sterilization area operating area and washing area.
2. Separate facilities for storing of sterile and unsterile equipments /instruments should be
available in the OT.
3. patient preparation area and Post-OP area. However, in view of the existing situation, the
OT should be well connected to the wards.
4. The OT should be well-equipped with all the necessary accessories and equipment
5. Surgeries like laparoscopy / cataract / Tubectomy / Vasectomy should be able to be
carried out in these OTs.
Labour Room (3800x 4200mm):
1. There should be separate areas for septic and aseptic deliveries.
2. The LR should be well-lit and ventilated with an attached toilet and drinking water
facilities.Plan has been annexed.
3. Dirty linen, baby wash, toilet, Sterilization
Minor OT/Dre ssing Room/Injection Room/Emergenc y:
1. This should be loc ated close to the OP D to cater to patients for minor surgeries and
emergencies after OPD hours.
2. It should be well equipped with all the emergency drugs and instruments.
Laboratory (3800x 2700mm):
1. Sufficient space wit h workbenches and separate area for collection and screening should
be available.
2. Should have marble/stone table top for platform and wash basins.
General sto re:
1. Separate area for storage of sterile and common linen and other materials/ drugs/
consumable etc. should be provided with adequate storage space.
2. The area should be well-lit and ventilated and should be rodent/ pest- free.
Di spen sing cum store area: 3000x 3000mm
Infrastru cture fo r A YUSH d oct or: Bas ed on the specialty being practiced, appropriate
arrangements should be made for the provision of a doctors room and a dispensing room cum
drug storage.
219

Immunization/FP/coun seling area: 3000x 4000mm

Office room 3500x 3000mm
Dirty utility ro om for dirt y linen and used items
Boundary w all w ith gate
Residential Ac commodation: Decent accommodation with all the amenities likes 24-hrs.
Water supply, electricity, etc. should be available for medic al officers and nursing staff,
pharmacist and laboratory technician and other staff.
Other amenities:
1.
2.
3.
4.
Electricity with generator back-up

Adequate water supply
Telephone: at least one direct line
Wherever possible garden should be developed preferably with the involvement of
community.
Equipment and Furniture:

1.
2.
3.
The necessary equipment to deliver the assured services of the PHC should be available
in adequate quantity and also be functional.
Equipment maint enance should be given special attention.
Periodic stock taking of equipment and preventive/ round the year maintenance will
ensure proper functioning equipment. Back up should be made available wherever
possible.
Manpow er: The manpower that should be available in the PHC s a s follow s:
Existing
Recommended
Medical Officer
Pharmacist
Nurse-midwife (Staff
3 (for 24-hour PHCs)
(Nurse)
2(one may be from AYUSH or Lady Medical Officer)
(2 may be contractual)
Health workers (F)
Health Educator
Health Astt. (Male &
Clerks
Laboratory Technician
Driver
Optional/vehicles may be out-sourced.
Class IV
Total
15
17/18
Female)
220

Drug s:
1. All the drugs available in the Sub-centre should also be available in the PHC.
2. In addition, all the drugs required for the National health P rograms and emergency
management should be available in adequate quantities so as to ensure completion of
treatment by all patients.
3. Adequate quantities of all drugs s hould be maintained through periodic stock-checking,
appropriate record maint enance and invent ory methods. Facilities for local purchase of
drugs in times of epidemics / outbreaks / emergencies should be made available
4. Drugs required for the AYUSH doctor should be available in addition to all other facilities.
The Transpor t Facilities: The PHC should have an ambulance, which can be outsourced.
Referral Transport Facility: The PHC should have an ambulance for transportation of
emergency patients, can be outsourced.
Transp ort fo r Supervi sory and other outreach activities: The vehicle can also be outsourced
for this purpose.
Laundry and Dietary facilities for indoor patient s: These facilities can be outsourced.
Waste Management at PHC level: GOI guidelines to be followed.
Quality A ssurance: Periodic skill development training of the staff of the PHC in the various jobs/
responsibilities assigned to them can ensure quality. Standard Treatment Protocol for all national
Programs and locally common disease should be made available at all P HCs, regular monitoring
is another important means.
A few aspect s that need definite attention are:
1. Interaction and Information Exchange with the client/ patient:
a. Courtesy should be extended to patients / clients by all the health providers including
the support staff
b. All relevant information should be provided as regards the condition / illness of the
client/ patient.
2. Attitude of the health care providers needs to undergo a radical change so as to
incorporat e the feeling that client is important and needs to be treated with respect.
3. Cleanliness should be maintained at all points
Monitoring: This is import ant to ensure t hat quality is maintained and also to mak e changes if
necessary.
Internal Mechanism: Record maintenance, checking and supportive supervision
Ex ternal Mechanism: Monitoring through the PRI / Village Health Committee / RMRS (as per
guidelines of State Government). A format for conducting facility survey for t he P HCs on Indian
Public Health Standards t o have baseline information on the gaps and subsequently to monitor
the availability of facilities is to be developed.
Acc ountability: To ensure accountability, the Charter of Patients Rights should be made
available in each P HC.E very PHC should have a RMRS / Primary Health Cent res Management
Committee for improvement of the management and s ervice provision of t he P HC. This
committee will have the authority to generate its own funds (through users charges, donation
etc.) and utilize the same for service improvement of the PHC. The PRI/Village Health Committee
/ RMRS will also monitor the functioning of the PHCs.
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Indian Public Health Standard for CHC

Objectives o f Indian Public Health Standards (IPHS ) for CHCs:
1. To provide optimal expert care to the community
2. To achieve and maintain an acceptable standard of quality of care
3. To make the services more res ponsive and sensitive to the needs of the community.
Service delivery in CHCs: Assured Services:
1. Care of routine and emergency cases in surgery: This includes Incision and drainage, and
surgery for Hernia, hydrocele, Appendicitis, hemorrhoids, fistula, etc.
2. Handling of emergencies like intestinal obstruction, hemorrhage, etc.
3. Care of routine and emergency cases in medicine:
4. Specific mention is being made of handling of all emergencies in relation to the National
Healt h Programs as per guidelines like Dengue Hemorrhagic fever, cerebral malaria, etc.
Appropriate guidelines are already available under each P rogram, which should be
compiled in a single manual.
5. 24-hour delivery services including normal and assisted deliveries
6. Essential and Emergency Obstetric Care including surgical interventions like Caesarean
Sections and other medical interventions
7. Full range of family planning services including Laparoscopic Services
8. Safe Abortion Services
9. New-born Care
10. Routine and Emergency Care of sick children
11. Other management including nasal packing, tracheostomy, foreign body removal etc.
All the National Health Programs (NHP) should be delivered through the CHCs
Other facilities:
1. Blood Storage Facility
2. Essential Laboratory Services
3. Referral (transport) Services
Minimum requirement for delivery of the above-mentioned service s: The following

requirements are being projected based on the assumption that there will be average bed
occupancy of 60%. The strength may be further increased if the occupancy inc reases with
subsequent up gradation.
Clinical Manpower:
Personnel
General Surgeon
Minm.
require
ment
1
Pro
pos
ed
1
Desirable qualifications
Physician
Obstetrician/
Gynecologist
Pediatrics
MD/DNB,
(General
Medicine)
MD/DNB/DGO (OBG)
MD/DNB/D.Ch (Pediatrics)
Anesthetist
MD/DNB/DA(Anesthesia)/
Certificate
course
in
Anesthesia for one year
Justification
MS/DNB, (General Surgery)
Essential if there is to be utilization of the

surgical specialties. They may be on
contractual appointment or hiring of
services from private sectors on case-to
case basis.
222

Public Health
Program Manager.
He/she will be also
designated as Block
Surveillance Officer.
Eye surgeon
MD/DNB/
DPH/
Social
science with public health
background/
any
other
recognized course
Will be responsible for surveillance,

coordination of NHPs, management of
ASH As, Training, etc. The appointment
will be on contractual basis.
MD/MS/DOMS/DNB/(Ophth
al)
For every 5 lakh population as per Vision

2020 approved Plan of Action.
Total
6/7
Cert ain suggestions for offsetting the deficiencies in the availability of required manpower:
1.
Ane stheti st s:
a. Diploma and MD seats for post graduation in Anesthesia to be increased across the
country. However care should be taken to only include institutions with assured
quality and able to provide adequate clinical training.
b. Certificate course for one year in Anesthesia by the National Board of Examinations
2.
Public Health Program Manager:

a. Diploma and MD seats for post graduation in P ublic Health to be increased across
the country. However care s hould be taken to only include institutions with assured
quality and able to provide adequate field and community-based training.
b. Persons with DNB degrees in Family Medicine, Hospital Administration, Public
Healt h, Maternal and Child health are to be recognized for the post.
c. Persons who have completed the Professional Development Course of 3 months with
a 9-month field training in recognized training institute may also be eligible for the
same. This may also be seen as a career advancement avenue for Medical Officers
serving in P HCs who may be eligible for the post after a stint of 3-4 years in PHC and
completion of this cours e.
Support manpow er:

Personnel
Existin g
*Nurse-midwife
7+2
Dresser (certified by Red Cross/ St.Johns Ambulance)
Pharmacist/compounder
Lab. Technician
Radiographer
**Ophthalmic Assistant
0-1
Ward boys/ nursing orderly
Sweepers
Chowkidar
OPD attendant
Statistical Assistant/Data entry operator
5***
OT attendant
Registration clerk
Total Essential
21/22+2
*1 ANM and 1 PHN for family welfare will be appointed under the ASHA scheme
** Ophthalmic assistant may be placed wherever it does not exist through redeployment or contract basis.
*** Flexibility may rest with the state for recruitment of personnel as per needs.
223

Equipment:
The list of equipment provided under the CSSM may be referred to.
10-15% of the annual budget to be kept for Maintenance
Refrigerators - one for the ward and one for OT. Sharing of Refrigerator with the lab should be
possible.
Appropriate standards for equipments are already available in the Bureau of Indian Standards.
Drug s:
The essential & emergency drugs to be maintained as per list. Program specific drugs
are detailed in the Guidelines under each Program.
Investigative facilities at the CHC:
Routine along with ECG.
Phy sical Infrastruc ture:
The CHC should have
1. 30 indoor beds
2. one Operation theatre,
3. labor room,
4. X-ray facility and
5. Laboratory facility.
Location of the centre: at the centre of the block head quarter in order to improve access to the
patients. This may be applicable only to centres that are to be newly established.
How ever, priority i s to be giv en to op erationalize the exi sting CHCs.
The building should have areas/ space marked for the follow ing:
1. Entrance zone:
a. Prominent display boards in local language providing information regarding the servic es
available and the timings of the institute.
b. Registration counters.
c. Pharmacy for drug dispensing and storage
d. Clean Public utilities separate for males and females
e. Suggestion/ complaint boxes for the patients/ visitors and also information regarding the
person responsible for redressal of complaints.
2. Outpatient department:
a. Clinics for Various Medical Disciplines
i.
general medicine,
ii.
general surgery,
iii.
dental (optional),
iv.
obstetric and gynecology,
v.
pediatrics and
vi.
Family welfare.
vii.
Separate cubicles for general medicine and surgery with separat e area for
internal examination (privacy) can be provided
viii.
Family Welfare Clinic
ix.
Waiting room for patients
x.
Drug Dispensary
3. Emergency Room/ Casualty:
a. The emergency cases may be attended by OPD during OP D hours and in inpatient units
afterwards.
224

4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Treatment Room:
a. Minor OT
b. Injection Room and Dressing Room
Wards: Separate for males and females
a. Nursing Station Centralized location, spacious, work counters, trash cans.
b. It should have provision for:
i.
Injections,
ii.
Dressings,
iii.
Examination and dressing table,
iv.
Bins for waste material,
v.
Wash basins,
vi.
Syringe destroyer
vii.
Needle cutter.
Patient Area:
a. Enough space between beds.
b. Toilets; separat e for males and females.
c. Separate space/ room for patients needing isolation
Ancillary rooms:
a. Nurs es rest room
b. There should be an area separating OP D and Indoor facility.
Operation theatre/ Labour room:
a. Patient area
b. Pre-operative and Post-operative(recovery)room
Staff area:
a. Changing room separate for males and females
Storage area for sterile supplies
a. OT/ Labor room area:
b. Operating room/ labor room
c. Scrub area
d. Instrument sterilization area
e. Disposal area
Public utilities: Separate for males and females
a. Physical infrastructure for S upport services:
b. CSSD:
c. Sterilization and Sterile storage
Laundry:
a. Storage: separate for Dirty linen and clean linen
b. Outsourcing is recommended after appropriate training of was her man regarding
separate treatment for infected and non-infected linen.
Services:
a. Electricity/ telephones/ water/ civil engineering: May be outsourced.
b. Maintenance of proper sanit ation in Toilets and other Public utilities should be given
utmost attention.
c. Sufficient funding for this purpose must be kept and the services may be outsourced.
Water Supply:
a. 10,000 liters of potable water per day
b. Storage capacity for 2 days requirements
c. Round the clock water supply
d. Separate reserve emergency overhead tank for operation theatre.
225

15.
16.
17.
18.
e. Necessary water storage overhead tanks with pumping/boosting arrangement shall be

made. The laying and distribution of the water supply system shall be according to the
provisions of IS: 2065-1983*.
Geyser in O. T. / L.R. and one in ward also should be provided.
Emergency lighting:
a. Emergency port able/ fixed light units in the wards and departments
b. Generat or backup
c. Use of solar energy wherever feasible.
Telephone: minimum two direct lines with intercom facility should be available.
Administrative zone:
a. Separate rooms should be available for Office
b. Stores
Capacity building:
Training of all cadres of worker at periodic intervals is an essential component. Multi-skill training
for paramedical workers.
Quality A ssurance in Service delivery:
Quality of service should be maintained at all levels. Standard treatment protocol for all national
Programs and locally common diseases should be made available at all CHCs.
Standard Treatment protocol:
Diet: Diet may either be outsourced or adequate space for cooking should be provided in a
separate space.
CSSD:
Adequate space and standard procedures for sterilization and sterile storage should be available.
Laundry:
Storage: separate for Dirty linen and clean linen
Outsourcing is recommended after appropriate training of washerman regarding separate
treatment for infected and non-infected linen.
Services: Electricity/ telephones/ water/ civil engineering: may be outsourced.
Blood Storage Unit s: as per GOI guidelines
Waste dispo sal: As per National guidelines on hospital waste management as applicable to 30
bed CHCs or may be outsourced to agencies trained in this.
Charter of Patient Right s: It is mandatory for every CHC to have the Charter of Patient Rights
prominently displayed at the entrance.
Quality Contr ol:
1. Internal monitoring:
a. Social Audit: through Ro gi Kalyan Samitis (RMRS in Rajasthan)/ Panchayati
Raj Institu tion, etc
b. Medical audit
226

c.
d.
2.
3.
Others like technical audit, economic audit, disaster preparedness audit, etc.
Patient care:
i. Access to patients
ii. Registration and admission procedures
iii. Examination
iv. Information exchange
v. Treatment
vi. Other facilities: waiting, toilets, drinking water
vii. Indoor patients:
Linen/ beds
Staying facilities for relatives
Diet and drinking water
Toilets
External Monitoring: Gradation by PRI(Zilla Parishad)/ Rogi Kalyan Samitis
Monitoring of laboratory
Record maintenance
Computers are to be used for accurate record maintenance.
Suggested innovation s:
1.
2.
3.
Water harvesting should be int roduced in all new buildings

Computerization is a must and would be essential for record maint enance and
surveillance.
To maint ain the hospit al landscaping, a room to store garden implements; seeds, etc,
should be provided.
Checkli st f or minimum requirement of CHCs

Services
Population covered
Specialist services available
Medicine
Surgery
OBG
Pediatrics
NHPs
Existing
Remarks
Existing
Remarks
Emergency services
Laboratory
Blood Storage
Check li st fo r Infra stru ctu re

Infrastructure (As per specifications)
Area of the Building
OPD rooms/cubicles
Waiting room for patients
No. of beds: Male
No. of beds: Female
Operation theatre
Labour room
227

Laboratory
X-ra y Room
Blood Storage
Pharmacy
Water supply
Electricity
Garden
Transport facilities
Checkli st f or Equipment
Equipment (As per list)
Available
Functional
Remarks
Available
Remarks
Available
Whether functional as per

norms
Checkli st f or Dru g s:
Drugs (As per Essential Drug list)
Checkli st f or Audi t:
Particulars
Patients charter
Rogi Kalyan Samiti
Internal monitoring
External Monitoring
Availability of SOPs/STPs*
228

Public Private Partnership

It is widely accepted that the deficiencies in public sector health system can only be overcome by
significant reforms. The need for reforms in Indias health sector has been emphasized by
successive plan documents since t he Eighth Five-Year Plan in 1992, by the 2002 national health
policy and by international donor agencies. The proposed reforms are not cheap, but the cost of
not reforming is even greater.
Healt h Sector Reform (HS R) is defined as a sustained, purposeful change to improve the
efficiency, equity and effectiveness of the health sector (B erman 1995). The World Health
Organization (1997) defined health sector reform as a sustained process of fundamental change
in policy and institutional arrangements of the health sector, usually guided by the government.
Reform strategies include:
1. alternative financing (user-fees, health insurance, community financing, private sector
investment);
2. institutional management (autonomy to hospit als, monitoring and management by local
government agencies, contracting);
3. Public sector reforms (civil service reforms, capacity building, productivity improvement);
and
4. Collaboration with the private sector (public/private partnerships, joint ventures)
In an effort to bring in desired reforms into Health Care Delivery System, particularly so in wake
of1. Rising costs,
2. Changing political situations, and
3. Social contexts (expectations of people from System);
The Public sector Health services are finding it difficult to sustain the services without extra inputs
that need to be pumped in. Many of t he functions of health care systems depend on adequate
financing. If sustainable financing mechanisms are not put in place, innovative ideas for
strengthening the primary health care bas e of health c are systems will not yield results. But then
where are those extra resources. One needs to look into the alternatives and explore the
possibility of applying economics for financing Health sector.
Hitherto, governments were responsible for providing and financing health care, but rapid
increase of health care expenditure requires more resourc es than those at the command of the
governments. As a result, government participation in health care financing has been declining
which affects the poor and marginalized sections of society, the most.
The ex penditure pattern:
The public health investment a s a percentage of GDP ha s declined from 1.3 percent in 1990
to 0.9 percent in 1999. The aggregate ex penditure (2000) in the Indian Health sec tor w as 5.2
percent of the GDP, of which only 17% w a s public health ex penditure, rest being Out of
Pocket Expenditure.
Different recommendations at different times were made with regard to the percent age of GDP/
plan allocations that should be spent on health sector, like Alma-Ata-5%, CSSR-ICMR-6%,
CCHFW (1989)-7% of Plan; actual for 1990 was only 1.3% of GDP
CCHFW (2001) suggested 2% of GDP from the then current level of 0.9%.
229

If we look into per capita health expenditure it was Rs.320/- per annum in 1990-91 with the
following break up
Primary care-58.7%
Secondary/ Tertiary-38.8%
Non-service expenditure-2. 5%
The option s available for Health care financing are1. Healt h insurance
2. Regulation and Legislation.
3. National Health Accounts (NHA )
4. Resource allocation
5. Cost - effectiveness and benefits
6. Partnership collaboration
Given their respective strengths and weaknesses, neither the public sector nor t he private sector
alone can operate in the best interest of the health system.
Recent estimates indicate that 93% of all hospitals, 64% of beds, 85% of doctors, 80% of
outpatients and 57% of inpatients are in the private sector (World Bank 2001) and private
hospitals are relatively less urban-biased than the public hospitals. The presence of the private
sector in healt h has prompted various state governments in India to explore the option of involving
the private sector and creating part ners hips to meet the growing health care needs.
The private sector is not only Indias most unregulated sector but als o its most potent unt apped
sector. Besides punctuations like inequit able, expensive, over-indulgent in clinical procedures and
without quality standards or public disclosure of practices, the private sector is perceived to be
easily accessible, better managed and more efficient collaboration in the form of Public/Private
Partnership would improve equity, efficiency, accountability, quality and accessibility of the entire
health system. Partners hips are expected to ameliorate the resource constraints of the public
sector by reducing investments in expensive tertiary care services.
What is Public/Private Partnership?
The definition adopted by GOI defines PPP as collaborative efforts, between private and public
sectors, with clearly identified partnership structures, shared objectives, and specified
performance indicat ors for delivery of a set of health services (MOHFW,GOI).
Advantage s:
The advantages with public sector are1. Improvement in Health is the primary objective
2. Economies of Scale
3. More Equitable
The private sector offers a different set of advantages1. Market/Choice and Access
2. Efficiency
3. Flexibility
230

The overall objective of PPP are1. Improving access to essential services

2. Improving the quality of services available
3. Exchange of expertise
4. Mobilize additional resources for activities
5. Improve efficiency
6. Better Management of Health services
7. Increasing scope and scale of services
8. Increasing community ownership of programs.
9. Ensuring optimal utilization of govt. investment and infrastructure
The basic s of PPP are1. Problem
2. Profile of Partners
3. Process of Building a partnership
4. Profit Mut ual Benefit
5. Phase start small & build
6. Proliferate Grow, Expand, & Sustain
7. Priorities & Preferred group
8. PolicingMechanism of Monitoring & Transparency
9. PoliticsGovernance, Administration, Peoples audit
10. Protection/proof: A security
system
11. Price: A cost share in terms of money/kind
12. Professional Net work
13. Platform
14. Prize: Acknowledgement/recognition
Factor s influencing PPP1. Clarity of Purpose
2. Creation of value
3. Congruency of Mission, Strategy and Values
4. Connection with purpose and people
5. Communication bet ween partners
6. Continual learning
7. Commitment to the partnership
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Models of PPP
Social Franc hising
Branded Clinics
Cont racting
Social Marketing
Build, Operate and Trans fer
Joint Venture Companies
Voucher System
Donations from individuals
Involvement of Corporate sector
Partnership with Professional Associations
Capacity Building of Private Providers
Autonomous Institutions
231

13. Mobile Healt h Vans

14. Healt h Insurance
15. Partnerships with Social Clubs and Groups (e.g. Rotary Club)
The STRAIGHT approach to PPP1. Identifying the Scope of partnership
2. Identifying the appropriate Target Population
3. Selecting the Righ t Part ners and Model of PPP
4. Ensuring Ac coun tability of private providers
5. Ensure active Involvement of the government
6. Generate Support of all the key stakeholders through IEC, advoc acy and rapport building
7. Highlight achievements of the partnerships
8. Build Tru st of all the partners and clients
Some PPP models in India:
Conventional
Contracting in
SMS Hospital, Jaipur

Bhagajatin Hospital Kolkata
Radiology &
Drug store
Diet,
Cleaning,
security
Laundry,
Private
Compan y/
Indi vi dual
Entrepreneurs
Contracting out
Karuna Trust, Karnataka

Shamlaji Hospital Gujarat
Rajiv Gandhi Hospital, Raichur
PHC Mgt.
CHC Mgt.
Tertiary care hospital
Charitable NGO
Charitable NGO
Private company
Performance
Management
Contracts
APUHS Project, Adilabad, AP

Chiranjeevi Yojana, Gujarat
RCH Services
RCH/MH services
Charitable NGO
Private clinics
Charitable NGO
Community/
Health
Insurance
Yeshashvini Scheme,Karnataka
Surgical Care
Private Hospita ls
consortium
Voucher
Scheme
Arogya Raksha Scheme, AP

SIFPSA, Agra UP
SCOVA, Haridwar, UK
Hospitalization
Maternity Care/ Institutional
Delivery
Private
Hospitals/
PSU
insurance
Private Hosp itals
Hospital
Autonomy
RKS, Bhopal / & Other Places
Patient welfare committee
Public Hosp ital
Franchising
Merri Tarang; Merri Silver; Merri

Gold; Life Spring- HLFPPT/
SIFPSA Janani, Bihar
M CH
services
Franchised
private
entrepreneurs
Other
curative
Rajasthan Medic-care Relief Society (RMRS):

First started (1996) in a tertiary level hospital, SMS hospital, Jaipur and replicat ed in other
medical colleges, district hospital and sub-divisional hos pitals. The s uccess of this initiative has
led the Rajasthan State government to support the setting up of suc h societies Rajasthan Medical
Relief Societies (RMRS) at all hospitals having 30 beds or more, including Community Health
Cent res (CHC) and recently it has also been introduced in all model Primary Health Care Centres
(PHCs).
232

Action:
Seed money: INR. 12 lacs was given to t he medical college hospit als; 2 lacs to district hospitals.
Guidelines and orders were issued to ensure effective functioning of thes e societies.
Allowed to collect the revenue of user fees from patients hospit alized and out -patient department
and laboratory, as well as from donations, and contracting out of space.
Purchase of hospit al equipment was permitted and t he government contributed half the cost if the
other half was obtained through public contributions.
In 1998 guidelines were issued for utilization of revenue generated by the societies; 50% could be
used for purc hase of equipment, while the other half had to be spent on provision of facilities to
patients, cleanliness, and purchas e of instruments. Detailed guidelines for purchase, maintenance
and repair works were also issued.
In 1996, the RMRS was scaled up to cover all hos pitals with 100 beds.
All equipment used under the aut o finance scheme was trans ferred to a society which would be
responsible for its maintenance.
Amendments were also made to the Rajasthan civil service (Medical Attendance) Rules, 1970, so
as to allow re-imbursement of the charges paid by government employees to the RMRS for
diagnostic tests and investigations.
A regular audit of accounts was also ordered, along with the ex emption of donations received
from income tax.
The management structure of the societies is autonomous and consists of 9 to 11 officials and
non-officials at State, Regional and district levels. The Society functions outside the purview of the
State, the General Financial Rules (GFR) do not apply and it can purchase equipment according
to its own requirements.
Funds used - maintenance and renovation of buildings, maintenanc e and repair of equipment,
purchase of new equipment, improving sanitation and cleanliness, improving other facilities for
patients and attendants, computerization of various systems and provision of free medicines for
below poverty line (BPL) families.
The source of funds for the S ociety includes seed money from the State Government and transfer
of operational control of diagnostic machines.
Free services provided to families living below the poverty line, widows, freedom fighters,
destitute people, and citizens over 70 years and retired government servants.
Charges are as follows i) A verage OPD charge INR 2. ii) Inpatient charges INR 5 . iii) In-patient
referral by private practitioner INR 10. iv) B ed c harges for private rooms, cubicles or c ottage
wards from INR 50 to 600 depending upon the type of facility.
Management training has been organized for RMRS senior managers on guidelines, stock
keeping and accounting. The training program was coordinated by State Institute of Health Family
Welfare.
233

Results: In 2003 CHC S adri, P ali constituted an RMRS with seed money from t he E uropean
commission.
Place:
All public health facilities above Sub-centre level in Rajasthan.
Time Frame - One year.
Advantages- Revenue generation: Increased availability of financial resources to hospit als from
renting of parking areas, auditoriums, contracting out the administration of canteens. Financial
Autonomy: Each society is aut horized to purchas e items ranging from INR 1000 to10,000 t hough
the States guidelines suggest that institutional heads have authority to make decisions regarding
expenses less than INR 5000. Improved efficiency in the system: The society can follow the
States established government financial and accounting rules or their own purchasing
procedures. Cost recovery: Multiple sources of supplementary financing are available and user
charges are levied for a full range of services. Exemptions are judicious.
Challenges- Management skills: Continuous enhanc ement of t he management capabilities of
hospital administrators, systems and procedures of procurement, maintenance of equipment and
hospital buildings as well as contracting and outsourcing is necessary for smooth functioning of
RMRS. Maintenance: A lack of clear policy regarding with whom rests the decision-making
authority for repair and maintenance. A study found 53% societies report difficulty in repairing and
maintaining equipment. User charges: Procedures for exemption of user charges to vulnerable
groups are usually informal and discretionary. Increase in proportion of patients visiting the health
facility will make it difficult for RMRS to spend money on upgrading s ervices. Utilization of RMRS
funds: Hospital managers fail to spend the generated revenue efficiently, as most of spending is
on equipment in absence of t rained personnel to operate the machines. So there is underutilization of machines.
Subsidy: The government subsidies to hospitals have not declined because of the transfer of
matching grants to participating hospit als. So, it has not relieved the states burden. Monitoring:
Regular systemic monitoring of the RMRS has to be undertaken at all levels.
Prerequisites Training of society officials regarding objectives of the society, guidelines governing
the societies, budgeting, accounting, management information systems, pricing and needs
assessment. Managerial guidelines should be in place. Facilitation of purchase of equipment,
rationalizing pricing schemes. Expert committee to resolve issues and problems. Continuous
monitoring of the functioning of RMRS.
Ri sk s:
Sustainability- The program is sustainable. Under NRHM, each year now INR 1 lakhs will be
transferred to these societies as untied funds.
Chances of ReplicationThe innovative scheme was started in Rajasthan in one government hospital and later replicated
in other facilities up to CHC level. (By March 2003, the number of RMRS in Rajasthan has
reached to 301 which includes 16 RMRS in t he Medical College Hospitals, 58 in t he District
Hospitals and 217 at the level of CHCs). Now government is going t o start such societies in Model
PHC across Rajasthan as on March 31, 2009 1500 PHCs are having functional RMRS
234

Rashtriya Swasthya Bima Yojana

Backgro und
The work ers in the unorganiz ed sector constitute about 93% of t he total work force in the country.
The Government has been implementing some social security measures for certain occupational
groups but the coverage is miniscule. Majority of the workers are still without any social security
coverage. Recognizing the need for providing social security to these workers, the Central
Government has introduced a Bill in the Parliament.
One of the major insecurities for work ers in the unorganized sector is the frequent incidences of
illness and need for medical care and hospitalization of such workers and their family members.
Despite t he expansion in the health facilities, illness remains one of the most prevalent causes of
human deprivation in India. It has been clearly recognized that healt h insuranc e is one way of
providing protection to poor households against the risk of health spending leading to poverty.
However, most efforts to provide healt h insurance in the past have faced difficulties in both design
and implement ation. The poor are unable or unwilling to take up health insurance bec ause of its
cost, or lack of perceived benefits. Organizing and administering health insurance, especially in
rural areas, is also diffic ult.
In the past Government have tried to provide a health insurance cover t o selected beneficiaries
either at the St ate level or National level. However, most of these schemes were not able to
achieve t heir intended objectives. Often there were issues with either the design and/ or
implementation of these schemes.
Keeping t his background in mind, Government of India decided t o design a health insurance
scheme which not only avoids the pit falls of the earlier schemes but goes a step beyond and
provides a world class model. A critical review of the existing and earlier health insurance
schemes was done with the objective of learning from their good practices as well as seeks
lessons from the mistakes. After taking all this into account and also reviewing other successful
models of health ins urance in the world in similar settings, Rasht riya Swasthya Bima Yojna was
designed.
Objective
Recognizing the diversity with regard to public healt h infrastructure, socioeconomic conditions
and the administrative network, the healt h insurance scheme aims to facilitate launching of health
insurance projects in all the districts of the States in a phased manner for BP L workers. The
definition of BPL is the one prescribed by the Planning Commission.
The main is to provide protection to BPL hous eholds from financial liabilities arising out of health
shocks that involve hospitalization.
Salient Features of t he Scheme
Funding Pattern
1.
GoI Contribution: 75% of the estimated annual premium of Rs.750, subject to a maximum
of Rs. 565 per family per annum. The cost of smart c ard will be borne by the Central
Government.
2.
State Contribution: 25% of the annual premium, as well as any additional premium.
3.
Beneficiary Contribution: Rs. 30 per annum as registration/renewal fee.
4.
The administrative and other related cost of administering the scheme would be borne by
235

the respective State Governments

Implementing Agency & Formulation of Project s
The Stat e Government while formulating the pilot project will determine the implementing agency
on behalf of the State Government.
Eligibility
Unorganized sector work ers belonging to BPL category and t heir family members (a family unit of
five) shall be the beneficiaries under the scheme.
It will be the responsibility of the implementing agencies t o verify the eligibility of the unorganized
sector workers and his family members who are proposed to be benefited under the scheme.
The beneficiaries will be issued smart cards for the purpose of identification.
Benefit s
The beneficiary shall be eligible for such in-patient health care insuranc e benefits as would be
designed by the respective State Governments based on the requirement of the people/
geographical area. However, the State Governments are advised t o incorporate at least the
following minimum benefits in the package / scheme:
a. Family unit of 5
b. Total sum insured - Rs. 30,000/ - per family per annum on a family floater basis.
c. Cashless attendanc e to all covered ailments
d. Hospitalization ex penses, taking care of most common illnesses with as few exclusions
as possible
e. All pre-existing diseases to be covered
f. Trans port ation costs (actual with maximum limit of Rs. 100 per visit) within an overall limit
of Rs.1000.
Formulation of the Projects
The State Government shall formulate project/projects for providing health insuranc e benefits,
taking into account the aforementioned points, for the workers and their families in the
unorganized sectors for a defined geographical area, preferably a district. While formulating the
project/projects, the following aspects may be considered:
1. Clearly defined institution (autonomous body, State Government Department, a
Cooperative S ociety or even an NGO) capable of organizing a health insurance
programme.
2. The organization should have
a. the technical skills
b. should be able to design a programme that is technically sound,
c. should have skills to be able to discuss with the community and
d. should have the administrative capacity to organiz e the programme.
3. There must be a network of health care providers (public and private). The Project should
incorporate use of privat e and all public healthcare providers, including ESI hos pitals.
4. There should be some basic data available regarding the demographic profile of the District.
5. The cost of the scheme, i.e., total premium per year, along with the procedure adopted to
arrive at the premium.
6. The procedure for collecting the registration/renewal fee from the beneficiary should be
outlined in the proposal.
236

Setting up of Technical Cell

A Cell would be constituted in the Ministry, administering the scheme, to assist the State
Governments in formulating projects. The Cell would be headed by a Sr. Advisor who would be
assisted by two Advisors. The expert would be hired on cont ract basis or on deputation. The Cell
would perform following functions:
1.
Plan the insurance scheme bas ed on the requirements of State;
2.
Workout financial implication and other details;
3.
Assist the State Governments in the preparation of pilot projects d) Assist in the effective
implementation of the Scheme.
4.
Monitor and evaluat e the implementation of the project.
The propos al for launching healt h insurance project would be submitted to the A dministrative
Ministry for approval along with all the financial implications and details.
Selection of in surance provider:
The s election of the health insurance provider shall be done by the state/implementing agency
through tendering proc ess inviting both Public and Private Insurers for better terms of referenc e.
The State Government would formulate the projects and determine the implementing agency
such as Insurance Trust/ Insurance Cell/ Mother NGO etc. to monitor/supervise the scheme and
integrate with ins urance company. This would be further monitored at State and Central level.
Appro val and Monitoring Committee:
i) Joint Secretary/Director General Labour Welfare,
Ministry of Labour & Employment
ii) Representatives of Ministry of Finance
Convener
iii) Representatives of Ministry of Health and Family Welfare
Member
iv) Representatives of Planning Commission
Member
Member
The Committee will also periodically monitor and review the progress of the projects.
Release of fund s:
On the approval of the project, the State Government will, from time to time, intimate the Central
Government about the payment of the premium to the Insurance Company. The Central
Government, on receipt of this information, shall release its share of premium.
Operationalizing the scheme
Signing of MOU between the Central and the State Government.

Cont ract between the State Government and the Insurance Provider.
Delivery of Smart Card to commence
Setting up of a Central Key Management system (KMS) for a secure system
Development of a Uniform application
A vailability of a Robust Backend system for data transmission & MIS
Defining a process for system conformonc e of Smart Card product
Designate a Cent ral Nodal officer to deal with complet e smart Card system
E valuate the various Smart Card vendors & their capabilities
237

Ensure Tight contracts with Smart Card vendor for Seamless & Unint errupted Operation
& Maintenance of the system
Set up systems of checks & balances of the smart card product to ensure conformance to
Government guidelines.
Smart card
Basic purpos e for induction of Smart Cards as RSBY card is to provide
Capability to store data on-board into the chip for field usage
Capability to perform authentic field transactions
Providing correct entitlement details for servic e delivery
Ease of handling
Inbuilt mechanism to verify the authenticity of card after issuance, thereby checking the
fake duplication
Smart cards to be provided by the selected Ins urance Company. The Insurance Company
can outsource this task.
BPL family details will be provided in a predefined electronic format by the respective
State Governments to the Insurance Company for the Districts selected for health
insurance coverage.
A detailed village-wise schedule will be worked out by the State Government in
consultation with the selected Insuranc e Provider.
Representatives of the respective State Governments and the Insurance P rovider to visit
each village jointly in the selected District(s).
Advance publicity of these visits by the State Governments
Photograph of t he head of the family and thumb impressions of all the family members to
be taken during the visit to the village.
Collection of Rs.30 from the beneficiary as registration fee by the Ins urance Service
Provider. (This would be adjusted against the amount of premium to be paid to the
Insuranc e Company.)
Handing over the smart card and insurance related pamphlet, in local language, by the
Insuranc e Provider to the beneficiary.
The smart card would entitle the beneficiary at the time of the delivery of the card.
Features of Smart Card
Unique Identification
o Fool proof Authentication of Beneficiary
o Instant Validation of Mediclaim Balance available
o Multiple levels of Security
Claims Processing
o Least inconvenience to Beneficiary
o Reduction in administrative costs for Hospitals & Insurance agencies
Enable product innovation
o Fast availability of MIS for analysis & fraud control
o Possible to Store customers health history
o Other Government Schemes for the same set of beneficiaries can make use of
available Card real estate.
238

Stores
o Data
o Images
o Codes
o Security Keys
o Algorithms
Supports
o Authentication
o Validation
o Verification
o Encryption
o Business Logic
o Non Repudiation
Enrollment Process
Customer
Data - Deduping
An application to capture
beneficiary data, Personalise
Cards, Conduct transactions ,
Transmit Data & provide MIS
Various methodologies used

like demographic, Biomet ric
(finger, face, etc.) - Fingerprint
most effective from technical &
cost perspective
Uniform Application Across

states & Insurance P roviders
Possible state of the

technology for de-duping
art
UID ( Unique Identification ) 17

digit number
Sr no(5) + Birth Yr (2)+
Gender(1) +
State(2) +
Location(6) + Checksum(1)
This number can be and

should be shared across
several entities
Key Management System

KMS is the basic requirement for implementing Smart Card Sec urity. It provides following:
Establishing Authenticity of Card that verifies the authenticity of card at field.
Protection against un-authorized tampering of data whic h means provide a mechanism
for card modification only by authorized agencies or persons.
Issuance of RSB Y card
Rashtriya Swasthya Bima Yojna Cards are generated wit h the help of Master Issuance
cards (MIC).
Is the ultimate point of usage of Master Issuance card for issuance.
Field Key Officer (FKO) is the entity which is responsible for safe keeping and safe usage
of these cards, while they are in use.
Responsibility is to ensure and see to it t hat all the defined sec urity guidelines are strictly
being followed at the field by various trusted authorities which are using authority cards
for various functionalities.
239

Key
Derivation
URN
Healt h Card
Master Key
FKMA
Derived Key
Beneficiary
FKMA: Field Key Management Authority, URN: Universal Registration Number
Monitoring and evaluation:

The State Government will put in place a well defined mechanism for monitoring and evaluation of
the pilot project at the time of its implementation. At the Central Government level, the Cell
constituted for examining project proposals shall also periodically monitor and evaluate the
performance of each pilot project with a view to evolving workable models which can be up-scaled
for wider application.
240

Policies & Legislations

National Health Policy-2002
Healt h per se had a fragmented approach till 1978 when Global concern dictated in favor of HFA2000 and, wit h a little longer latent period at last, a National Health P olicy (1983) was formulated.
It took us 36 years to formulate a Healt h Policy for the first time in 1983.
The basic issue s involved in NHP-1983 formulation were1. Re-orientation of Medical education
2. Re-structuring and Re-organizing the then existing health care services
3. Population stabilization
4. Re-orientation of existing health personnel
5. Role of practitioners of ISM in Health care delivery
These issues were addressed through incorporation of certain key areas for action, in the policy.
The ba sic elements identified were1. Nutrition
2. Preventing food adulteration and maint aining drug quality
3. Water supply and sanitation
4. Environmental protection
5. Immunization
6. Mother and Child health services
7. School health
8. Occupational health
9. Healt h education
10. Management information System
11. Medical industry
12. Healt h insurance
13. Healt h legislations, and
14. Medical researc h.
The NHP-1983 gave a general exposition of the policies, which required recommendation in the
circumstances then prevailing in the health sector.
The noteworthy initiatives under that policy w ere: 1. A phas ed, time bound program comprehensive for setting up a well-dispersed network of
primary health c are services, linked wit h extension and health education, designed in the
context of the ground reality that element ary health problems can be res olved by the
people thems elves;
2. Intermediation through Health volunteers having appropriat e knowledge, simple skills
and requisite technologies;
3. Establishment of a well-worked out referral system to ensure that patient load at the
higher levels of the hierarchy is not needlessly burdened by those who can be treated at
the decentralized level;
4. An integrated net-work of evenly spread specialty and super-specialty services;
encouragement of such facilities through private investments for patients who can pay, so
that the draw on the Governments facilities is limited to those entitled to free use.
241

The National Health Policy of 1983 laid down certain Goal s and Indicator s which were
expected to be achieved in a prescribed time frame. These wereIndicator
Infant mortality rate
Perinatal mortality rate
Crude death rate
Maternal mortality rate/1000
Child mortality rate
Life expectancy at birth
Babies with birth weight
<2500 gms.
Crude birth rate
Couple protection rate
Net reproduction rate
Annual growth rate
Family size
Percentage of pregnant
women receiving ANC
Percentage of deliveries by
TBA
%
of TT (PW)
Immunizatio
TT (10yrs.)
n coverage
TT (16 yrs.)
DPT
(<3
yrs.)
OPV
(Infants)
BCG
DT
Typhoid
Leprosy-%
of
disease
arrested cases
TB--% of disease arrested
cases
%
Of
Blindness
(Incidence/100000)
Current level
(year)
122 (1978)
76 (1976)
14
4-5
24 (1976-77)
52.6 Male
51.6 Female
30%
1985
106
Goals
1990
87
12
3-4
20-24
55.1
54.3
25%
10.4
2-3
15-20
57.6
57.1
18%
2000
< 60
30-35
9.0
<2
10
64
64
10%
35
23.6
(March,
1982)
1.48(1981)
2.24 (1971-81)
4.4 (1975)
40-50
31
37
27
42
21
60
1.34
1.90
3.8
50-60
1.17
1.66
60-75
1.0
1.20
2.8
100
30-35
50
80
100
20
20
25
60
40
60
70
100
100
100
85
100
100
100
85
50
70
85
65
20
2
20
70
80
70
40
80
85
85
60
85
85
85
80
50
60
75
90
1.4
1.0
0.7
0.3
Government initiatives in the pubic health sector have recorded some remarkable su cce sse s
over time. Smallpox and Guinea Worm Disease have been eradicated from the country; Polio
is on t he verge of being eradicated; Leprosy, Kala Azar, and Filariasis are w aiting for
elimination, in the foreseeable future. There has been a sub stantial drop in the Total Fertility
Rate and Infant Mortality Rate. The success of the initiatives taken in the public health field is
reflected in the progressive improvement of many demographic / epidemiological / infrastructural
indicators over time.
Somehow odds kept challenging the system. Malaria staged resurgence in the1980s before
stabilizing at a fairly high prevalence level during the 1990s.
242

TB, continue s to be a problem, and there has been a distressing trend in the increase of drug
resistance to t he type of infection prevailing in the country; HIV/AI DS - has emerged on the
health scene since the declaration of the NHP-1983.
The common water-borne infections Ga stroenteriti s, Cholera, and some form s of Hepatiti s
continue to cont ribute to a high level of morbidity in t he population, even though the mortality
rate may have been somewhat moderated.
Increase in mort ality through life-st yle disease s- diabetes, cancer and cardiovascular diseases.
Increase in life expectancy has increased the requirement for geriatric care. Similarly, the
increasing burden of trauma cases is also a significant public health problem.
The policy, under the spirit of HFA -2000, stressed on universal provision of comprehensive
primary health care services but t he financial resources and public health administrative capacity
was far short of that necessary to achieve such an ambitious and holistic goal.
Against this backdrop, it was felt to pitch NHP -2002 at a level consistent with our realistic
expectations about financial resources, and about the likely increase in Public Health
administrative capacity.
Some how what was envisaged could not be ac hieved and a revisit to the policy resulted in
another revision in Health Policy in 2002
The Con sideration s that w ere accounted for in NHP -2002:
The public health investment a s a percentage of GDP ha s declined from 1.3 percent in 1990
to 0.9 percent in 1999.
The aggregate ex penditure in the Health sect or i s 5.2 percent of the GDP, of which o nly 17%
w as public health ex penditure, rest being Out of Pocket Expenditure.
The cent ral budgetary allocation for health over this period, as a percentage of the total Central
Budget, has been stagnant at 1.3 percent, while t hat in the States has declined from 7.0 percent
to 5.5 percent. The current annual per capita public health ex penditure in the country is no
more than Rs. 200.
The c ontribu tion of Central resource s to the overall public health funding has been limited to
about 15 per cent. The fiscal resources of the Stat e Governments are known to be very inelastic.
This is reflected in the declining percentage of State resources allocated to the health sector out
of the State Budget.
If the decentralized pubic health services in the country are to improve significantly, there is a
need for t he injection of s ubstantial resources int o the health sector from the Central Government
Budget.
With wide differences between the attainments of health goals in the better performing States as
compared to the low-performing States. It is clear that national averages of health indices hide
w ide disparities in public health facilities and health standard s in dif ferent part s of the
countr y.
243

The infrastructure facilities as envisaged in the 1983 policy also fell short. Applying current norms
to the population for the year 2000, it is estimated that the short fall in the number of
SCs/PHCs/ CHCs i s o f the order of 16 percent. However, this short age is as high as 58 percent
w hen disaggregated for CHCs onl y.
It is a principal objective of NHP-2002 to evolve a policy st ruc ture, w hich reduces the se
inequities and allows the disadvantaged sections of society a fairer access to public health
services.
NHP -2002 attempts to define the role of the Central Government and the State Governments in
the public health sector of the country.
Over a period it has been realized that vertical implementational stru cture i s no t going to
w ork as for the major disease control program it has created a situation where if there is no
separate vertical structure, there is no identifiable service delivery system at all.
With general shor tage of medical personnel in the country and t he dis proportionate shortage in
rural and less developed areas and the efforts to deploy Doctors on contractual appointment has
proved to be fighting a losing battle, NHP -2002 also takes cognizance of formally trained
manpow er in Indigenous Medical System and their possible role in health care delivery.
NHP -2002 is based on an objective assessment of the quality and efficiency of the existing public
health machinery which is far from satisfactory. It has been estimated that less t han 20 percent
of the population, w hich seek OPD service s, and less than 45 percent of that w hich seek
indoor treatment, avail of such ser vice s in public ho spitals, at the cost of other essential
expenditure for items such as basic nutrition.
The other areas which were under consideration of NHP -2002 formulation exercise are1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Need bas ed alloc ation and implementation through Panchayat Raj Institutions (P RIs ).
Norms for manpower in relation to services
Medical education to be more meaningful for delivery of primary health care
Development of relevant specialties under changing epidemiological profile and National
Goals
Need for Public health specialists and Family Medicine
Use of Generic drugs.
Urban health infrastructure
Mental Health
IEC
Healt h research
Privat e sector participation
Disease surveillance
Women health
Medical ethics
Quality standards for food and drugs
Regulation of Standards in Paramedical disciplines
Environment and Occupational health
244

18. Medical facility to overseas users on package basis

19. Synchronized implementation of NHP-2002 and NPP-2000
The NHP-2002 Objective:
1. To achieve an acceptable standard of good health amongst the general population of
the country.
2. To ensure a more equitable access to health services across the social and
geographical expans e of the country
3. To increase t he aggregate public health investment through a substantially increased
contribution by the Central Government.
The approach would be to increase access to the decentralized public health system by establishing
new infrastructure in deficient areas, and by upgrading the infrastructure in the existing institutions.
Goals that NHP-2002 laid are Eradicate Polio and Yaws
2005
Eliminate Leprosy
2005
Eliminate Kala Azar
2010
Eliminate Lymphatic Filariasis
2015
Achieve Zero level growth of HIV/AIDS
2007
Reduce Mortality b y 50% on account of TB, Malaria and Other Vector and Water Borne diseases
2010
Reduce Prevalence of Blindness to 0.5%
2010
Reduce IMR to 30/1000 And MMR to 100/Lakh
2010
Increase utilization of public health facilities from current Level of <20 to >75%
2010
Establish an integrated system of surveillance, National Health Accounts and Health Statistics.
2005
Policy Presc ription s-NHP-2002:

1. To increa se health sect or ex penditure to 6 percent of GDP, wit h 2 percent of GDP being
contribut ed as public healt h investment, by the year 2010 ( The State Governments would also
need to increase, in the first phase, by 2005, to 7 percent of the Budget and by 2010, to
increase it to 8 percent).
2. Increased allocation of 55 percent of the total public health investment for the primary
health secto r; the secondary and tertiary health sectors being targeted for 35 percent and 10
percent respectively.
3. Gradual convergence of all health programs under a single field administration.(Vertical
programs for control of major diseases like TB, Malaria, HIV/AIDS, as also the RCH and
Universal Immunization Programs, would need to be continued till moderate levels of
prevalence are reached.
4. Program implementation to be effected through auton omou s bodie s at State and district
levels.( presence of State Government officials, social activists, private health professionals
and MLAs/MPs on the management boards of the autonomous bodies will facilitate well245

5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
informed decision-making.
Developing the capacity within the St ate Public Health administration for scientific designing
of public health projects, suited to the local situation.
All rural health staf f should be available for the entire gamut of public health at the
decentralized level, irrespective of whether these activities relate to national programs or other
public health initiatives.
Some essen tial drugs under Central Government funding through the decent ralized health
system
Frequent in-service training of public health medical personnel, at the level of medical
officers as well as paramedics.
Strengthening of the primary health str uct ure for the attaining of improved public health
outcomes on an equitable basis. besides committing additional aggregate financial resources.
Levying reasonable u ser-charge s for certain secondary and tertiary public health care
services, for those who can afford to pay.
Cont ract employment in order to provide trained medical manpower in under-served areas.
All State Governments to consider decentralizing the implementation of the programs to
Local Self Government, by 2005
Minimal statutory norm s fo r the deployment of doc tor s and nur se s in medical institutions
need to be introduced urgently under the provisions of the Indian Medical Council Act and
Indian Nursing Council Act, respectively.
Setting up of a Medical Grant s Commission for funding new Government Medical and
Dent al Colleges in different parts of the country, besides funding up gradation of existing Govt.
colleges.
Need to modify the ex isting cur riculum- A need-based, skill-oriented syllabus, with a more
significant component of practical training.
The Policy envisages the progressive implementation of mandatory norms to raise the
proportion of po stgraduate seats in di scipline of Public Health & Family Medicine in
medical training institutions, to reach a stage wherein th of the seat s are earmarked for
these disciplines.
Improvement in the ratio of nur se s vis--vis doctors/beds besides improving t he skill -level
of nur se s, and on increasing the ratio of degree- holding nurses vis--vis diploma-holding
nurses.
Basing treatment regimens, in bot h the public and private domain, on a limited number of
essential drug s of a generic nature, for cost-effective public health care, to be enforced by
prohibiting the u se of proprietary drug s, except in special circumstanc es.
Not less than 50% o f the requirement of vaccine s/ sera be sour ced from public sec tor
institution s
Organized urban primary health care stru ctu re- a tw o-tiered one, the first-tier covering a
population of one lakh, and a second-tier at the level of the Government general hos pital,
where reference is made from the primary centre. Funding from local self-government
institutions and State and Central Governments.
Decentralized mental health services for diagnosis of common disorders, and the
prescription of common therapeutic drugs, by general duty medical staff and Upgrading of the
physical infrastructure so as to secure the human rights of this vulnerable segment of society.
IEC with targets for association with NGOs/PRIs for bringing change in behavior
Government-f unded health research to a level of 1 percent of the total health spending by
2005; and thereafter, up to 2 percent by 2010.
Enactment of suitable legi slation fo r regulating minimum infra struc ture and q uality
246

25.
26.
27.
28.
29.
30.
31.
32.
standard s in clinical establishment s/medical insti tution s by 2003. Also, statutory

guidelines for the conduct of clinical practice and delivery of medical services are targeted to
be developed over the same period.
Di sease co ntrol program s should earmark not less than 10% o f t he budget in respect of
identified program components, to be exclusively implemented through NGOs.
Full operationalization of an integrated disease control netw ork (including installation of
data-base handling hardware, IT inter-connectivity between different tiers of the network, and
in-house training for data collection and interpretation for undertaking timely and effective
response) from the lowest rung of public health administration to the Central Government, by
2005.
Completion of ba seline estimate s for the incidence of the common diseases TB, Malaria,
Blindness by 2005 and als o for no n-communicable disease s, like CV D, Cancer, Diabetes;
and accidental injuries, and communicable diseases, like Hepatitis and JE.
Establish national health account s, conforming to the `source-to-users matrix structure.
Highest priorit y of the Central Government to the funding of the identified programs relating
to w omans health. Also, the policy recognizes the need to review the staffing norms of the
public health administration to meet the specific requirements of women in a more
comprehensive manner.
Cont emporary code of ethics be notified and rigorously implemented by the Medical Council
of India.
Food and dru g administration will be pro gre ssively strengthened, in terms of both
laboratory facilities and technical expertise so that ultimately fo od standard s w ill be close, if
not equivalent, to Codex specification s; and that drug standards will be at par with the most
rigorous ones adopted elsewhere.
Independently -stated policies and programs of the environment -related sector s be
smo othly interfaced w ith the policie s and the program s of the health secto r. Also,
periodic screening of the health conditions of the work ers, particularly for high- risk health
disorders associated with their occupation.
Despite the best of int entions that the policy has, the basic financial input levels stay stagnant and all
claims and declarations have made mockery of intents. Besides finances, Public health and
Epidemiology continue to be neglected though we keep airing our concern towards the role of Public
health in achieving the desired.
247

National Population Policy-2000

Some developm ent sMileston es in the evolution o f the pop ulation policy o f India
1946-Bhore Committee Report
1952-Launching of Family Planning Program
1976-Statement of National Population Policy
1977-Policy Statement on Family Welfare Program
Both statements were laid on the Table of the House in Parliament, but never discussed or adopted.
1983-The National Health Policy of 1983 emphasized the need for "securing t he small family norm,
through voluntary efforts and moving towards the goal of population stabilization". While adopting the
Healt h Policy, Parliament emphasized the need for a separate National Population Policy.
1991-The National Development Council appointed a Committee on Population with Shri Karunakaran
as Chairman. The Karunakaran Report (Report of the National Development Council (NDC)
Committee on Population) endorsed by NDC in 1993 proposed the formulation of a National
Population Policy (Planning Commission, 1992).
1993- An Expert Group headed by Dr. M.S. Swaminathan was asked to prepare a draft of a national
population policy that would be discussed by the Cabinet and then by Parliament.
1994- Report on a National Population Policy by the Expert Group headed by Dr. Swaminat han.
1997- During Nov. 97 Cabinet approved t he draft National Population Policy with the direction that this
be placed before Parliament, but was not done.
1999- during 1998, and another draft National P opulation P olicy was finalized and placed before the
Cabinet in Marc h 1999. Cabinet appointed a Group of Ministers to examine the draft Policy. The GOM
finalized a draft population policy, and placed the same before Cabinet. Several suggestions were
made during the deliberations. On that basis, a fresh draft was submitted to Cabinet.
2000-National Population Policy came in ex istence
1952, India w as the first coun try in the w orld to launch a national program, emphasizing
Family planning to the extent is necessary for reducing birth rates "to stabilize the population at a level
consistent with the requirement of national economy".
Subsequently, sharp declines in death rates were not accompanied by a similar drop in birth rates.
Health Policy, 1983 stated that replacement levels of total fertility rate (TFR) sh ould be achieved by
the year 2000.
On 11 May, 2000 Indian population cro ssed 1 billion (100 crore s) mark which meant 16 percent of
the Worlds population on 2.4 percent of the globe's land area.
While global Population has increased threefold during thi s centur y, from 2 billion to 6 billion, the
population of India ha s increa sed nearly five times from 238 million (23 crore s) t o 1 billion in the
same period. India's current annual increase in population of 15.5 million is large enough to neutralize
248

efforts to conserve the resource endowment and environment.

Stabilizing population is an essential requirement for promoting sustainable development with
more equitable distribution. Under this back drop for the first time a National Population Policy was
formulat ed in y ear 2000 (The earlier one of 1976 (A pril, 16) and 1977(June) were simply the
statements on population policy put before the Parliament).
The salient features of statement on Population Policy made on April, 16, 1976 are1. Implementation of minimum needs program
2. Education and Economic development are crucial but waiting for the change on this account is
not practical for time constraint.
3. Family planning has not made desired progress
4. Raising age of marriage has demonstrable demographic impact
5. Adoption of small family norm is vital
6. Voluntary organizations can contribute effectively
7. Research in Reproductive health and contraceptive tec hnology can strengthen cafeteria
approach
8. Multi-media motivational strategy can work.
Based on these features, a few sugge stion s fo r the approach were made1. Freezing the repres entation of States in Parliament till 2001 based on population of 1971
census
2. Year 1971 becomes the basis for Central assistance, Devolution of taxes and Grant in aid till
2001
3. 8% of Central assistance to be linked to States performance in Family Planning
4. Monetary compensation to couples adopting terminal methods to be linked to no. of children
5. Compulsory sterilization after 3 children if State feels it has sufficient legislative power and
infrastructure for enforcement
6. Rising the marriage age (Girls-18 yrs. and Boys-21 yrs.)
7. Research in reproductive biology and cont raception
8. Introduction of group incentives in a bold and innovative manner to make Family Planning a
peoples movement.
9. Promotion of multi media, rural oriented communication strategy
10. Inclusion of population education in education system
11. Increasing level of female education through formal & non-formal education.
12. Involvement & support of voluntary organizations.
The later statement of June 1977, with the c hange in Political governance, in conformance t o the
earlier statement but doing away with compulsion factor, stressed on the following1. Voluntary nature of program
2. Re-naming the program to Family Welfare
3. Political commitment
4. Amending constitution for freezing States representation at 1971 levels
5. Continuing 8% central assistance linked to Performance in Family Welfare.
Subsequently, realizing the need for SFN and, NRR-1 for population stabilization, a committee on
Population was appointed by National Development Council in 1991, which recommended having a
population policy formulated and approved.
July, 1993 and this task was assigned to an expert group chaired by MS Swami Nathan. Group
249

submitted draft policy on May 23, 1994 t o MOHFW the contents of which were said to be pro-poor,
pro-women, pro-nature and emphasized on1. Setting up of a Population and Social Development Commission (PS DC)
2. Freezing to continue till 2001 at 1971 levels
3. 1/3 Representation of women and poor section in Panchayat and Nagar Palika to increase
community participation
The basic premise of the draft was over all social development placing greater demands on statistical
system by Planners and P olicy makers fore which it was suggested to upgrade the Office of Registrar
General to Dept. of Census, SRS and CRS under ministry of Home.
Better late than never, and the policy makers and Political system woke up t o the need and
incorporating the basic feat ures approved of the National Population Policy in the year 2000.
The National Population Policy, 2000 (NPP-2000) affirms the commitment of government towards1. voluntary and informed choice and consent of citizens while availing of reproductive health
care services
2. Continuation of the target free approach in administering family planning services.
Policy Objec tives1. Immediate
a. To address the unmet needs for
i. Cont raception,
ii. Healt h care infrastructure, and
iii. Healt h personnel, and
b. To provide integrated service delivery for basic reproductive and child health care
2. Medium
a. To bring the TFR to replacement levels by 2010
3. Long term
a. To achieve a stable population by 2045
National Socio-Demographic Goals fo r 2010:
1. Address the unmet needs for basic reproductive and child health services, supplies and
infrastructure.
2. Make school education up to age 14 free and c ompuls ory, and reduce drop outs at primary
and secondary school levels to below 20 percent for both boys and girls.
3. Reduce infant mortality rate to below 30 per 1000 live births.
4. Reduce maternal mortality ratio to below 100 per 100,000 live births.
5. Achieve univers al immunization of children against all vaccine preventable diseases.
6. Promote delayed marriage for girls, not earlier than age 18 and preferably after 20 years of
age.
7. Achieve 80 percent institutional deliveries and 100 percent deliveries by trained persons.
8. Achieve universal access to information/counseling, and services for fertility regulation and
contraception wit h a wide basket of choices.
9. Achieve 100 per cent registration of birt hs, deaths, marriage and pregnancy.
10. Cont ain the spread of Acquired Immunodeficiency Syndrome (A IDS), and promote greater
integration bet ween the management of reproductive tract infections (RTI) and sexually
transmitted infections (S TI) and the National A IDS Control Organization.
250

11. Prevent and control communicable diseases.

12. Integrate Indian Systems of Medicine (ISM) in the provision of reproductive and child health
services, and in reaching out to households.
13. Promote vigorously the small family norm to achieve replacement levels of TFR.
14. Bring about convergence in implementation of relat ed social sector programs so that family
welfare becomes a people centered program
Some Projection s made-.
If the NPP 2000 is fully implemented, anticipated population will be1107 million (110 crores) in 2010,
instead of 1162 million (116 crores) projected by the Technical Group on Population Projections:
Anticipated Grow th in Population (million)
Year
If current trend s c ontinue

Total Population
If TFR 2.1 i s achieved by 2010
Increase in Population
Total Population
Increase in Population
1991
846.3
846.3
1996
934.2
17.6
934.2
17.6
1997
949.9
15.7
949.0
14.8
2000
996.9
15.7
991.0
14.0
2002
1027.6
15.4
1013.0
11.0
2010
1162.3
16.8
1107.0
11.75
Similarly, the anticipated reductions in the birth, infant mortality and total fertility rates are:
Projection s of Cr ude Birth Rate, Infant Mortality Rate, and TFR,
If the NPP 2000 i s f ully implemented.
Year
Crude Birth Rate
1997
27.2
71
3.3
1998
26.4
72
3.3
2002
23.0
50
2.6
2010
21.0
30
2.1
(Source: Ministry of Health and Family Welfare)
Population grow th in India continues to be high on account o f:

1. The large size of the population in the reproductive age-group (Estimated contribution- 58
percent). An addition of 417.2 million bet ween 1991 and 2016 is anticipat ed despite
substantial reductions in family size in several states, including thos e, which
have already
achieved replacement levels of TFR.
2. Higher fertility due to unmet need for con traception (estimated contribution 20 percent ).
India has 168 million eligible couples, of which just 44 percent are currently effectively
protected. Urgent steps are currently required to mak e contraception more widely available,
accessible, and affordable. Around 74 percent of the population lives in rural areas, in about
5.5 lakh villages, many with poor communications and transport. Reproductive health and
basic health infrastructure and services often do not reach t he villages, and, accordingly, vast
numbers of people cannot avail of thes e servic es.
251

3.
High w anted fertility due to the high infant mor tality rate (IMR) (estimated contribution
about 20 percent). Repeated childbirths are seen as an insurance against multiple infant (and
child) deaths and accordingly, high infant mort ality stymies all efforts at reducing TFR.
Under this background, a National Population P olicy-2000 identified 12 basic strategic themes and
operational strategy to accomplish each one of them.
Strategic themes of NPP-2000:
The NPP-2000 ha s 12 ba sic themes1. Decentralized Planning and Program Implementation
2. Convergence of Service Delivery at Village Levels
3. Empowering Women for Improved Health and Nut rition
4. Child Health and Survival
5. Meeting the Unmet Needs for Family Welfare Services
6. Under-Served Population Groups
7. Diverse Health Care Providers
8. Collaboration With and Commitments from Non-Government Organizations and the Private
Sector
9. Cont raceptive Technology and Research on Reproductive and Child Health
10. Mainstreaming Indian Systems of Medicine and Homeopathy
11. Providing for the Older Population
12. Information, Education, and Communication
1) Decentralized Planning and Program Implementation
The 73rd and 74th Constitutional Amendments Act, 1992, entrusted the responsibility of health, family
welfare, and education to village Panchayats which need strengthening by furt her delegation of
administrative and financial powers, including powers of resource mobilization.
The other approaches suggested area. 33 percent of elected Panchayat seats are reserved for w omen
b. Promotion of a gender sensi tive, multi-sec toral agenda for population stabilization
c. Identify area-specific unmet needs for reproductive health services
d. Prepare need-based, demand-driven, socio-demographic plan s at the village level
e. Panchayats w ith exemplary performance be nationally recognized and honored.
(for compulsory registration of births, deaths, marriages, and pregnancies, universalizing the small
family norm, increasing safe deliveries, bringing about reductions in infant and maternal mortality, and
promoting compulsory education up to age 14 )
2) Con vergence of Service Delivery at Village Levels
Efforts at population stabilization will be effective only if an integrated package of
essential service s at village and household levels can be delivered. Meaningful decentralization will
result only if the convergence of the national family welfare program with the ICDS program is
strengthened.
Somehow, hitherto this was punctuated witha. Poor and inadequate infrastructure below district levels. Current health Infrastructure
(MOHFW-1998) includesa. 2,500 community health centers,
b. 25,000 primary healt h centers (eac h covering a population of 30,000), and 1.36 lakh
252

b.
c.
d.
e.
f.
g.
h.
sub centers (each covering a population of 5,000 in the plains and 3,000 in hilly
regions); which is far from adequate
An unmet need of 28 percent for contraception services,
Gaps in coverage and outreach.
Over-burdened Health care centers
Limited personnel and equipment.
Absence of supportive supervision,
Lack of training in inter-personal communication, and
Lack of motivation to work in rural areas
Taking cognizance of these constraints, NPP-2000 propo se s t oa. Promote a more flexible approach, by extending basic reproductive and child health care
through mobile clinics and counseling services.
b. Involvement of the voluntary sector and the non-government sector in part ners hip with the
government is essential.
c. A one-stop, integrated and coordinated service delivery should be provided at village levels,
for basic reproductive and child health services.
d. At least two trained birth attendants, per village to universalize coverage and outreach of
antenatal, natal and post-nat al healt h care.
e. Have a equipped mat ernity hut in each village should be set up to serve as a delivery room,
with functioning midwifery kits, basic medication for essential obstetric aid, and indigenous
medicines and supplies for maternal and new born care.
f. Registration at village levels, of birt hs, deaths, marriage, and pregnancies.
g. Each village s hould maintain a list of community midwives and t rained birth attendants, village
health guides, Panchayat sewa sahayaks, primary school teachers and aanganwadi workers
who may be entrusted with various responsibilities in the implementation of integrated service
delivery.
h. Involving community opinion leaders toI) Communicate the benefits of smaller, healthier families, the significance of educating girls,
II) Promoting female participation in paid employment
III) Monitoring the availability, accessibility and affordability of services and supplies
To operationalize the said propositions, operational strategies have been identified as followsa. Utilize village self help groups
b. Organize neighborhood acceptor group s, and provide them with a revolving fund that may
be accessed for income generation activities.
Train and motivate the village s elf-help acceptor groups to become t he primary cont act at
household levels. Once every fort night, these acceptor g roup s w ill meet, and provide at
one place 6 different service s for i) Registration of births, deaths, marriage and pregnancy;
ii) Weighing of children under 5 years, and recording the weight on a standard growth chart;
iii) Counseling and advocacy for contraception, plus free supply of contraceptives;
iv) Preventive care, with availability of basic medicines for common ailments: antipyretics for
fevers, antibiotic ointments for infections, ORT /ORS 1 for childhood
diarrheas, together
with standardized indigenous medication and homeopathic cures;
v) Nutrition supplements; and
vi) Advocacy and enc ouragement for the continued enrolment of children in school up to age
of 14 yrs.
253

c.
d.
e.
f.
Wherever these village self-help groups have not developed for any reason community
midwives, practitioners of ISMH, retired school teac hers and ex -defense personnel may be
organized into neighborhood groups to perform similar functions
At village levels, the aanganwadi center may become the pivot of basic health care activities,
contraceptive counseling and supply, nut rition education and supplementation, as well as preschool activities. The aanganwadi centers can also function as depots for ORS/basic
medicines and contraceptives
A maternity hut to serve as the village delivery room, with storage space for supplies and
medicines. The P anchayat may appoint a competent and mature mid-wife, to look after this
village maternity hut. Volunteers may assist her.
Trained birth attendant s as well as the vast pool of traditional dais should be made
familiar with emergency and referral procedures.
Each village may maintain a list of community midw ives, village health guides, Panchayat
sew a sahayak s, t rained birth attendant s, p ractitioner s of indigenous systems of medicine,
primary sch ool teachers and other relevant persons, as well as the nearest in sti tutional
health care facilities that may be accessed for integrated service delivery
3) Emp ow ering Women for Improved Health and Nutrition

The NPP -2000 stays fully informed of
a. The complex socio-cultural determinants of women's health and nutrition that has cumulative
effects over a lifetime.
b. Discriminatory childcare leading to malnutrition and impaired physical development of the girl
child.
c. Under nutrition and micronutrient deficiency in early adolescence are crucial to a woman's well
being, and through her, to the well being of children.
d. Malnutrition, frequent pregnancies, unsafe abortions, RTI and S TI, all combine to keep the
maternal mortality ratio in India among the highest globally. The extent of maternal mortality is
an indicat or of disparity and inequity in access to appropriate health care.
e. Early childbearing compounds impaired health and nutrition, and consequent risk of serious
pregnancy related complications.
f. Role of Integrat ed Reproductive and Child Health Program, which also includes promoting
management of STIs and RTIs.
g. The role and reach of volunt ary non-government sector and the private corporat e sector ;
h. in view of which the following operational strategies have been framed under NPP-2000
The operational strategiesa. Create an enabling environment for women and children
b. Clu ster service s for women and children at the same place and time.
c. Open more child care centers in rural areas and in urban slums, where a woman worker
may leave her children
d. Improve district, sub-district and Panchayat-level health management with coordination and
Collaboration between district health officer, sub-district health officer and the P anchayat for
Planning and implement ation activities
e. Strengthen the referral netw ork bet ween t he district health office, district hospit al and the
community healt h centers, the primary health centers and the sub cent ers in management of
obstetric and neo-natal complications.
f. Strengthen communit y health center s to provide comprehensive emergency obstetric and
neo-natal care.
254

g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
r.
s.
t.
u.
v.
w.
x.
y.
z.
aa.
bb.
Strengthen primary health centers to provide essential obstetric and neo-natal care.
Strengthen sub center s to provide a comprehensive range of servic es, with delivery rooms,
counseling for contraception, supplies of free cont raceptives, ORS and basic medicines,
together with facilities for immunization.
Establish rigor ou s problem identification mechanism s through maternal and peri-natal
audit, from village level upwards.
En sure adequate transpor tation at village level, sub center levels, zila parishads, and
primary healt h centers and at community health centers.
Improve supervi sion by developing guidance and supervision checklists
To empower women, pursue programs of
i. Social afforestation to facilitate access to fuel wood and fodder.
ii. Similarly, purs ue drinking water schemes for increasing access to pot able water. (This will
reduce long absences from home, and the need for large numbers of children to perform
such tasks.)
Monitor performance of maternal and child health services at each level by using the
maternal and child health local area monitoring system, which includes monitoring the
incidence and coverage of ante-natal visits, deliveries assisted by trained health care
personnel and post-natal visits, among other indicators.
Improve technical skill s of maternal and child health care providers
Program development w ith Partnership in family health and nutrition
Convergence, strengthening, and universalisation of the nutritional programs of the
Department of Family Welfare and the ICDS run by the Department of Women and Child
Development,
Provide quality care in family planning, including information
Develop a health package for adolescents
Ensure availability of safe and legal abortion service s byi.
Increasing geographic spread;
ii.
Enhancing affordability;
iii.
Ensuring confidentiality and
iv.
Providing compassionate abortion care, including post-abortion Counseling.
Adopt updated and simple technologies that are safe and easy, e.g. manual vacuum
extraction not necessarily dependant upon anesthesia, or non-surgical techniques which are
non-invasive
Promote collaborative arrangements with private sector health professionals, NGOs and the
public sector
Formulate and notify standard s for abortion ser vice s. Strengthen enforcement
mechanisms at district and sub-district levels to ensure that these norms are followed.
Eliminate the current cumber some procedure s fo r registration o f abortion clinic s &
Formulate and notify standards for abortion services
Follow norm s-based regi stration of ser vice provision cent ers
Ensure services for termination of p regnancy at primary health center s and at community
health centers.
Develop mat ernity hospitals at sub-district levels and at communit y health center s to
func tion as FRUs for complicated and life-threat ening deliveries
Formulate and enfo rce standard s f or clinical service s in t he public, private, and NGO
sec tor s, and Focus on distribution of con ventional contraceptive through free supply, social
marketing as well as commercial sales.
Create a national netw ork consisting of public, p rivate and NGO center s, identified by a
255

common logo, for delivering reproductive and child health services free to any client
(Provider shall be compensated for service through a coupon signed by beneficiary,
Compens ation same for all sectors, beneficiary to choose provider, review mechanism to
avoid misu se)
4) Child Health and Survival
The NPP-200 als o takes a note of the following factsa. Infant mortality is a sen sitive indicator of human development.
b. High mortality and morbidity among infants and children below 5 years occurs on account ofi.
Inadequate care,
ii.
Asphyxia during birt h,
iii.
Premature birth,
iv.
Low birth weight,
v.
Acute respiratory infections,
vi.
Diarrhea,
vii.
Vaccine preventable diseas es,
viii.
Malnutrition and deficiencies of nutrients, including Vitamin A., and
c. That Infant mortality rates have not significantly declined in recent years
d. Need to intensify neo-natal care on priority
And proposes a few action areasa. The Baby Friendly Hospital Initiative (BFHI) should be extended t o all hospitals and clinics, up
to sub center levels
b. Promoting breast-feeding and complement ary feeds
c. Updating of skills of trained birth attendants to improve new born care practices to reduce the
risks of hypothermia and infection.
d. Child survival int erventions
Operational strategies for Child health & survivala. Support communit y activi ties, from village level upwards to monitor early and adequate
antenatal, natal and post-nat al care. Focus attention on neo-natal health care and nutrition.
b. Set up a National Technical Committee on neo-natal care, to align program and project
interventions with newly emerging technologies in neo-natal and peri-nat al care.
c. Pursue compulsory registration o f birth s in coordination with the ICDS Program.
d. After the birth of a child, provide cou n seling and advocacy about contraception, to
encourage adoption of a reversible or a terminal method.
e. Improve capacities at health centers in basic midwifery services, essential neo-natal care,
including the management of sick neonates outside the hospital.
f. Sensitize and train health personnel in the integrated management of childhood illnesses.
g. Standard case management of diarrhea and acute respiratory infections must be provided at
sub cent ers and primary health centers, with appropriate training, and adequate equipment.
Besides, training in this s ector may be imparted to health care providers at village levels,
especially in indigenous systems.
h. Strengthen critical intervention s aimed at bringing about reductions in maternal
malnutrition, morbidity and mortality, by ensuring availability of supplies and equipment at
village levels, and at sub centers.
i. Pursue rigorously the pul se polio campaign to eradicate polio.
j. Ensure 100 percent ro utine immunization for all vaccine prevent able diseases, in particular
tetanus and measles.
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k.
As a child survival initiative, explore promotional and motivational measures for couples below
the poverty line who marry after the legal age of marriage, to have t he fir st child after the
mother reaches the age of 21, and adopt a terminal method of contraception after the birth
of the seco nd child.
l. Children form a vulnerable group and certain sub-groups merit focu sed at tention and
intervention, such as street children and child laborers.
m. Encourage voluntary groups as well as NGOs to formulate and implement special schemes for
these groups of children.
n. Ex plore the feasibility of a national health insurance covering hospit alization costs for
children below 5 years, whose parents have adopted the small family norm, and opted for a
terminal method of contraception after the birt h of the second child.
o. Expand the ICDS t o include children betw een 6-9 years of age, specifically to promote and
ensure 100 percent school enrolment, particularly for girls.
p. Promote p rimary education with the help of aanganwadi workers, and encourage retention
in school till age 14. Provide voc ational t raining for girls, and g radually raise the average
age of marriage.
q. Involve NGOs, the voluntary sector and the private sector to target employment opportunities.
5) Meeting the Unmet Needs for Family Welfare Services
The needed support for meeting un-met needs includesa. Supplies and equipment for int egrated service delivery,
b. Mobility of health providers and patients,
c. Comprehensive information.
d. Improvement in facilities for referral transportation,
e. Encouragement and strengthening local initiatives for ambulance services at village and block
levels,
f. Increasing innovative social marketing schemes for affordable products and services and
g. Improving advocacy in locally relevant and acceptable dialects.
Operational strategy for meeting un-met needsa. Strengthen, energize and make publicly accountable the cutting edge of healt h infrastructure
at the village, sub center and primary health center levels.
b. Address on priority the different unmet needs
c. Formulate and implement innovative social marketing schemes
d. Improve facilities for referral transportation at P anchayat, zilla parishad and primary health
center levels
e. Encourage local entrepreneurs at village and block levels to start ambulance services through
special loan schemes
f. Provide special Strengthen, energize and mak e publicly accountable the cutting edge of health
infrastructure at the village, sub center and primary health center levels.
g. Address on priority the different unmet needs
h. Formulate and implement innovative social marketing schemes
i. Improve facilities for referral transportation at P anchayat, zilla parishad and primary health
center levels
j. Encourage local entrepreneurs at village and block levels to start ambulance services through
special loan schemes and make site allotments for chemist shops for basic medicines and
provision for medical first aid.
257

6) Under -Served Population Group s

a. Urban Slums
Operational strategiesi.
Finalize a comp rehensive urban health care strategy and facilitate service delivery
ii.
Reproduc tive and child health service s b y NGOs and private sector organizations,
including corporate houses.
iii.
Promote netw ork s of retired government do ctor s and Para-medical and non-medical
personnel who may function as health care providers on remunerative terms.
iv.
Strengthen social marketing programs for non-clinical family planning products and
services in urban slums.
v.
Initiate specially targeted information, educ ation and communication (I EC) campaigns
for urban slums on family planning, immunization, ant e-natal, natal and post-natal checkups and other reproductive health care services.
vi.
Integrate health education w ith health & medical care programs, with emphasis on
environmental health, personal hygiene and healthy habits, nutrition education and
population education.
vii.
Promote inter-sectoral coor dination bet ween departments/municipal bodies dealing
with water and sanitation, industry and pollution, housing, transport, educ ation and
nutrition and women and child development, to deal with unplanned and uncoordinated
settlements.
viii.
Streamline the referral sy stem s and link ages between the primary, secondary and
tertiary levels of health care in the urban areas.
ix.
Link the provi sion of continued facilities to urban slum dwellers with their ob ser vance
of the small family norm.
b. Tribal Communities, Hill Area Populations and Di splaced and Migrant Populations
Provide information and counseling in respect of infertility, including fertility regulation
ii.
Provide Mobile clinics for regular coverage and outreach for the nomadic nature and
frequent
iii.
Promote indigenous sy stem s of medicine which is more trusted by these communities
iv.
Adop t a " burden of di sea se" approach to meet the special needs of tribal and hill area
communities.
c.
Adolescent s
Ensure adolescent s acce ss to information, coun seling and ser vice s, including
affordable and accessible reproductive health services for which primary health centers
and sub centers need to be strengt hened, to provide counseling, both to adolescents
and also to newly weds (who may also be adolescents).
ii.
Emphasize proper spacing of children.
iii.
Provide for adole scent s the package of n utritional service s available under the
ICDS program.
iv.
Enf orce the Child Marriage Restraint Ac t, 1976, to reduce the incidence of teenage
pregnancies.
v.
Preventing the marriage of girls below the legally permissible age of 18 should
become a national concern.
258

vi.
Provide integrated intervention in pocket s w ith unmet needs in the urban slums,
remot e rural areas, border districts and among tribal populations.
d. Increased Participation of Men in Planned Parenthood

Focus IEC effo rt s on men to sensitize them towards their family responsibility
ii.
Re-popularize vasectomies, in particular the no-scalpel vasectomy
iii.
In the continuing education and t raining at all levels f or no -scalpel vasect omy, and all
such emerging techniques and skills are included in the syllabi, together with abundant
practical training.
7) Diver se Health Care Providers
Ways of doing this includea. Acc rediting private medical practitioners and assigning them t o defined beneficiary groups
to provide these services;
b. Revival of the sy stem of licensed medical practitioner who, after appropriate certification
from the Indian Medical Association (IMA), could provide specified clinical services.
Operational strategiesa. At district and sub-district levels, maint ain block-wise data base of private medical practitioners
who after verification from IMA are accredited and assigned a population (not > 5000) for
compens ation based service for one year with renewal subject to client satisfaction
b. Revive the earlier system of the licensed medical practitioners who, after appropriate
certification from the IMA, may participate in the provision of clinical services.
c. Involve the non-medical fraternity (retired defense personnel, school teachers ) in c ouns eling
and advocacy so as to demystify the national family welfare effort,
d. Modify the under/post-graduate medical, nursing, and paramedical professional course syllabi
and curricula, in consultation with t he Medical Council of India, the Councils of ISMH, and the
Indian Nursing Council, in order to reflect the concepts and implementation strategies of the
reproductive and child healt h program and the national population policy.
e. Ensure the efficient functioning of the First Referral Units i.e. 30 bed hospitals at block levels
f. Augment the availability of specialists in three disciplines (gynecology & obstetrics,
anesthesiology and pediatrics), byi. Increasing seats in medical institutions,
ii. Facilitate the acquisition of in-service post-graduate qualifications through the National
Board of Medical Examination and open universities like IGNOU in larger numbers.
iii. As an incentive, seats will be reserved for those in-service medical graduates who are
willing to abide by a bond to serve for 5 years at First Referral Units after completion of the
course.
iv. States would need to sanction posts of Specialists at the FRUs.
v. These specialists should be provided with clear promotion channels.
8) Collaboration With and Commitment s f rom Non-Government Organization s and the Private
Sector
Operational strategiesa. Collaboration w ith and Commitments from the Non -Go vernment Sector
i. A forum of represent atives from government, the non-government organizations and the
259

ii.
iii.
iv.
v.
b.
private sector may identify hurdles that inhibit genuine long-term collaboration bet ween the
government and non-government sectors and prepare guidelines that will facilitate and
promote collaborative arrangements.
Collaboration with and commitments from NGOs to augment advocacy, counseling and
clinical services, while accessing village levels. This will require increased clinic outlets as
well as mobile clinics.
Collaboration between the voluntary sector and the NGOs will facilitate dissemination of
efficient service delivery to village levels. The guidelines could articulate the role and
responsibility of eac h sector.
Encourage the voluntary sector to motivate village-level self-help groups to participate in
community activities.
Specific collaboration with the non-government s ector in the social marketing of
contraceptives to reach village levels will be encouraged.
Collaboration w ith and Commitments from Indu st ry

i. The corporate sector and industry could, for instance, take on the challenge of
strengthening the management information systems in the seven most deficient states, at
primary healt h center and sub center levels.
ii. Introduce electronic data entry machines to lighten the tedious workload while enabling
wider coverage and outreach.
iii. Collaborate with non-government sectors in running professionally sound advertisement
and marketing campaigns for products and services, strengthen advocacy and IE C,
including social marketing of contraceptives.
iv. Provide markets to sustain the income-generating activities from village levels upwards. In
v. Help promote transportation to remote and inaccessible areas up to village levels.
vi. The social responsibility of the corporate sector in industry must, at the very minimum,
extend to providing preventive reproductive and child health care for its own employees (if
>100 workers are engaged).
vii. Create a national network consisting of volunt ary, public, private and non-government
health centers, identified by a common logo, for delivering reproductive and child health
services, free to any client. The provider will be compens ated for the servic e provided
viii. Form a consortium of the voluntary sector, the non-government sector and the private
corporate sector to aid government in the provision and outreach of basic reproductive
and child health care and basic education
ix. set up privately run/managed primary schools for children up to age 14-15. Alternately, if
the schools are set up/managed by t he P anchayat, the privat e corporate sector could
provide the mid-day meals, the text -books and/or the uniforms.
9) Mainstreaming Indian Systems o f Medicine and Homeopathy

Operational strategiesa.
b.
Provide appropriate training and orientation in respect of the RCH program for the
institutionally qualified ISMH medical practitioners (already educated in midwifery, obstetrics
and gynecology over 5-1/2 years), and utilize their services to fill in gaps in manpower at
appropriate levels in the health infrastructure
Utilize the ISMH institutions, dispensaries and hospitals for health and population related
programs.
260

c.
Disseminate the t ried and tested concepts and practices of the indigenous systems of
medicine, t oget her wit h ISMH medication at village maternity huts and at household levels for
antenatal and post-natal care, besides nurture of the newborn.
d. Utilize the servic es of ISMH 'barefoot doctors' after training and orient ation for
i. Advocacy and couns eling
ii. Disseminating supplies and equipment, and as
iii. Depot holders at village levels
10) Cont raceptive Technology and Research on Reprodu ctive and Child Health
The National Health and Family Welfare Survey provide data on key health and family welfare
indicators every five years. Data from the first National Family Health Survey (NFHS-1) 1992-93 has
been updated by NFHS-2, 1998-99 and now by NFHS-III (2005-06).
Annual data is generated by the Sample Registration Survey, which, inter alia, maps at state levels
the birt h, death and infant mortality rates. Absence of regular feedback has been a weak ness in the
family welfare program.
For t his reason, t he Department of Family Welfare is strengthening its management information
systems (MIS) and has commenced during 1998, a system of ascertaining impacts and outcomes
through district surveys and facility surveys. The district surveys cover 50% districts every year, so that
every 2 years there is an updat e on every district in the country.
Operational strategiesa. Government will encourage, support and advance t he pursuit of medical and social science
research on reproductive and child health, in cons ultation with ICMR and the net work of
academic and research institutions.
b. The International Institute of Population Sciences and the Population Research Centers will
continue to review program and monitoring indicators to ensure their continued relevance to
strategic goals.
c. Government will restructure the Population Research Centers, if necessary.
d. Standards for clinical and non-clinical interventions will be issued and regularly reviewed.
e. A constant review and evaluation of t he community needs assessment approach will be
pursued to align program delivery with good management practices and with newly emerging
technologies.
f. A committee of international and Indian experts, voluntary and non-government organizations
and government may be set up to regularly review and recommend specific incorporation of
the advances in contraceptive technology and, in particular, the newly emerging techniques,
into program development.
11) Pro viding for the Older Population
Operational strategiesa. Sensitize, train and equip rural and urban health cent ers and hospitals towards providing
geriatric health care.
b. Encourage NGOs and voluntary organizations to formulate and strengthen a series of formal
and informal avenues that make the elderly economically self-reliant.
c. Tax benefits could be explored as an enc ouragement for children to look after their aged
parents.
261

12) Info rmation, Education, and Communication

Operational strategiesa. Converge IEC effor t s acro ss t he social sect or s making op timal use of media- Involve all
related departments
b. Health and population education must be inculcated from the school levels.
c. Fund the nagar palikas, Panchayat, NGOs and community organizations for interactive and
participat ory IE C activities.
d. Demonstration of sup port b y elected leaders, opinion makers, Public leaders, film star s
and religious leaders with close involvement in the reproductive and child health program
greatly influences the behavior and res ponse patterns of individuals and communities.
e. Utilize radio and television as the most powerful media for disseminating relevant sociodemographic messages. Government could explore the feasibility of appropriate regulations,
and even legislation, if necessary, to mandate the broadcast of social messages during
prime time.
f. Utilize dairy cooperatives, the public distribution systems, other established net works like the
LIC at district and s ub-district levels for IEC and for distribution of cont raceptives and basic
medicines to target infant/childhood diarrheas, anemia and malnutrition among adolescent
girls and pregnant mothers.
g. Sensitize the field level functionaries across diverse sectors (education, rural development,
forest and environment, women and child development, drinking water mission, and
cooperatives) to the strategies, goals and objective s of the population stabilization
program s.
h. Involve civil society for disseminating information, counseling about the small family norm,
higher female literacy and late marriages for women. Civil society could also monitor
availability of contraceptives, vaccines and drugs.
Legislation for NPP-2000:
It is recommended that the 42nd Con stitu tional Amendment that freezes, till 2001, the number of
seat s to the Lok Sabha and the Rajya Sabha based on the 1971 Cen su s be ex tended up to 2026
New stru ctu re:
The NPP 2000 i s t o be largely implemented and managed through PRI s in coordination with the
concerned state/Union Territory administrations.
This will require comprehensive and multi-sec toral coordination of planning and implementation
between health and family welfare on the one hand, along with schemes for education, nutrition,
women and child development, safe drinking water, sanitation, rural roads, communications,
transportation, housing, forestry development, environmental protection, and urban development.
Accordingly, the following structures are recommended:
1. National Commission on Population
2. State / UT Commission s on Population
3. Coordination Cell in the Planning Commission
4. Technology Mi ssion in the Department of Family Welfare
Funding
The programs, projects and schemes premised on the goals and objectives of the NPP 2000, and
indeed all efforts at population stabilization, will be adequately funded in view of their c ritical
importance to national development.
262

E ven though the annual budget for population stabilization activities assigned to the Department of
Family Welfare has increased over the years, at least 50 percent of the budgetary outlay is deployed
towards non-plan activities (recurring expenditures for maintenance of health care infrastructure in the
states and UTs, and towards salaries). To illustrate, of the annual budget of Rs. 2920 Crores for 19992000, nearly Rs 1500 Crores is allocated towards non-plan activities. Only the remaining 50 percent
becomes available for genuine plan activities, including procurement of supplies and equipment. For
these reasons, since 1980 the Department of Family Welfare has been unable to revise norms of
operational costs of health infrastructure, which in turn has impacted directly the quality of care and
outreach of services provided.
Promotional and motivational measure s for Ad option o f the small family norm:
1. Panchayats and Zila Parishads will be rewarded for exemplary performance in universalizing
the small family norm, achieving reductions in infant mortality and birth rates, and promoting
literacy with completion of primary schooling.
2. The Balika Samridhi Yojana run by the Department of Women and Child Development,
to promote survival and care of the girl child, will continue. A cash incentive of Rs. 500 is
awarded at the birth of the girl child of birth order 1 or 2.
3. Maternity Benefit Scheme run by the Department of Rural Development will continue. (Thi s
Has been replaced by JSY since 2005)
4. A Family Welfare-linked Health Insurance Plan will be established.
5. Couples below the poverty line, who marry after the legal age of marriage, register the
marriage, have their first child after the mot her reaches the age of 21, accept the small family
norm, and adopt a terminal method aft er the birth of the second child, will be rewarded.
6. A revolving fund will be set up for income-generating activities by village-level self help groups,
who provide community-level health care services.
7. Crc hes and c hild care centers will be opened in rural areas and urban slums.A wider,
affordable choice of contraceptives will be made accessible at divers e delivery points,
8. Facilities for safe abortion will be strengthened and ex panded.
9. Products and servic es will be made affordable through innovative social marketing schemes.
10. Local ent repreneurs at village levels will be provided soft loans and encouraged to run
11. ambulance services.
12. Increased vocational training schemes for girls, leading to self-employment will be
encouraged.
13. Strict enforc ement of Child Marriage Restraint A ct, 1976.
14. Strict enforc ement of the Pre-Natal Diagnostic Technique s Ac t, 1994.
15. Soft loans to ensure mobility of the ANMs will be increas ed.
16. The 42nd Constitutional Amendment has frozen the number of representatives in the Lok
Sabha (on the basis of population) at 1971 Census levels. The freeze is currently valid until
2001, and has served as an incentive for Stat e Governments to fearlessly pursue the agenda
for population stabilization
263

Health Legislations in India:

1.
Legislation s related to Health in general

a. The Epidemic Diseases Act, 1897
b. Indian Air Craft (Public Health) Rules, 1954
c. The Registration of Births and Deaths Act, 1969
d. The Persons with Disabilities (Equal Opportunity, Protection Of Rights And Full
Participation) Act, 1995
e. The Biomedical Waste (Management And Handling Rules 1998) Act
2.
Legislation related to Mother/ w omens Health

a. Hindu Marriage Act, 1955
b. The Special Marriage Act, 1954
c. Hindu Succession Act, 1956
d. The Maternity Benefits Act, 1961
e. The Dowry Prohibition Act, 1961
f. Hindu Adoption and Maintenance Act, 1956
g. The Immoral Traffic (Prevention) Act, 1956; amended in 1986
h. The Medical Termination Of Pregnancy Act 1971(The MTP Rules, 1975)
i. The P re-nat al Diagnostic Techniques (Regulation & P revention of misuse) Act, 1994
Rules, November 26, 1996
3.
Legislation s related to Child Health

a. The Child Marriage Restraint Act, 1929
b. Children Act, 1960
c. The Juvenile Justice Act, 1986
d. The Child Labor (Prohibition and Regulation) Act, 1986
e. Infant Milk substitute Act, 1992
4.
Legislation s related to Environment

a. Factory Act, 1947
b. The Atomic energy Act, 1962
c. The Insecticides Act, 1968
d. The Wild Life (Protection) Act 1972
e. The Indian Forest Act, 1972
f. The Water (P revention and Control of Pollution) Act, 1974
g. The Forest (Conservation) Act, 1980
h. The Air (Prevention and Control of Pollution) Act, 1981
i. The Environmental (Protection) Act, 1986
j. The Motor Vehicle Act, 1988
k. The Natural Environment Tribunal Act, 1995
Legislation s related to Occupation
a. The Workmens Compensation Act, 1923 (Amended In 1984)
b. The Trade Union Act 1926
c. The Factories Act, 1948,
d. The Employees States Insurance Act, 1948
e. The Plant ation Labor Act, 1951
f. Mines Act, 1952
5.
264

g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
6.
Plantation Labor Act, 1951

The Employee State Insurance Act, 1948
The Factories (Amendment) Act, 1976
The Dangerous Machine (Regulation) Act, 1983
Legislations relat ed o Human rights
The Equal Remuneration Act, 1976
The Contract Labor (Regulation and Abortion) Act ,1976
Indecent Representation of Women (Prohibition) Act, 1986
The Commission on Sati (Prevention) Act, 1987
The Minimum Wages Act, 1948
The Consumer Protection Act (CPA) 1986
Legislation s related to Medical Profession

a. The Indian Nursing Council Act 1947
b. The Dentists Act 1948
c. The Pharmacy Act 1948
d. The Indian Medical Council Act, 1956 (Amended in 1964, 1993)
265

Financial Management under NRHM in Rajasthan

Financial Management of NRHM in Rajasthan involves coordination with multiple levels of Central and
State government, liquidity management for ens uring adequate moneys are available at field
institutions, establishment of new procedures of accounting at nearly 2000 public health institutions,
and ensuring that all these institutions function in accordance with FMG guidelines
It is going to take more time for the systems of financial governance to settle down as the current
system is vastly different from the conventional treasury system and is not entirely works accounting
system either.
Outc omes
1. Understanding of Financial & Accounting aspects in NRHM
2. Uniformity of Accounting at different level under NRHM
3. Accuracy & Timely reporting system
4. Synchronization of Tally Soft ware
5. Improving in fund flow from various level
6. Aging of Advanc es & Cut down long period advances
Acc ounting pr ocedure s:
Accounting is process of recording the financial transaction of a business in a systematic manner and
preparing summarized financial statement.
Acc ounting pr oce ss1. Identification of Transaction
2. Recording the Transaction
3. Classifying the trans action
4. Summarizing
5. Analyzing and Interpret ation
6. Presentation or reporting
Fundamentals of Ac coun ting1. Personal Accounts
a. Debit -Receiver
b. Credit-Giver
2. Real Accounts
a. Debit - What comes in
b. Credit-What goes out
3. Nominal Account
a. Debit -All Expenses and Losses
b. Credit-All Income and Gains
Acc ounting tool s1. Ledger is defined as summarized statement of all the transaction relating to Persons, Assets,
Income, expenditure etc.
2. Cash Bo ok-Cash book rec ord all the t rans action in cash or cheque; Receipt of Debit Side and
Payment on Credit side
Types o f Ca sh Bo ok
a. Simple Cash book
b. Cash book with discount
266

c. Cash book with Discount and Bank

d. Bank Cash Book
e. Petty Cash Book
Purcha se Book /Purchase ret urn Book
Sales Boo k/Sales return books
Bills receivable
Bills Payable
Trial Balance- is statement of total of all ledger accounts. Prepared at given time. Method
checking arithmetical accuracy
3.
4.
5.
6.
7.
Importance of financial managementTwo Way Process: Top-down, Bottom-up

1. Flow of funds at each level (Top-down)
Clear purpose, adequacy, timely and sufficient guidance to spend
Cent re>States>Districts>Blocks (BMOs)>Other CHCs/PHCs>SHCs>VHSCs
2. Reporting of Expenditure through reports & returns
Timely (discipline is important), accuracy
VHSCs>SHCs>PHCs/CHCs>Blocks (BMOs)>Districts>State>Centre
Fund flow under NRHM:
Fund Flow to States under 2 routes:
1. Treas ury Route: primarily salary component.
a. Salaries of the posts of Auxiliary Nurse Midwife (A NMs) & LHVs
b. Training of ANMs.
c. Support to Family Welfare Bureau at state and district levels.
2. Society Route:
a. for programme implementation
b. salaries for the contractual employees hired for strengthening of programme implementation
under the Mission
Financial Guidelines under NRHM:
1.
Funds available for various interventions under NRHM

a. RCH Phase-II Program
b. Additionalities under NRHM
i. Village Level
1) Funds for Village Health & Sanitation Committees @Rs.10000 per VHSC
p.a.(E very village upto 1500 pop.-H/h surveys, health camps, sanitation
drives, & sanitation committees)
2) Community monitoring
ii.
Sub Health Centre Level
1) Untied funds @ Rs.10000 per subcenter per year
2) Annual Maintenance Grant @Rs.10000 p.a.
3) Construction of Sub-centres
4) Additional ANM
iii.
PHC Level
1) Funds for Selection & Training of ASHAs
2) Untied funds @ Rs.25000 per PHC per year
267

2.
3.
4.
5.
6.
3) Annual Maintenance Grant @Rs.50000 p.a

4) Rogi Kaly an Samiti @ Rs.1 lakh
5) Funds for JSY
6) Staff Nurses, Up-gradations to IPHS
iv.
CHC Level
1) Untied funds @ Rs.50000 per CHC per year
2) Annual Maintenance Grant @Rs.50000 p.a
3) Funds for up-gradation of CHCs to IP H
4) Rogi Kaly an Samiti @ Rs.1 lakh-Corpus Grants
5) Funds for Selection & Training of ASHAs
6) Mobile Medical Units
v.
District Level
1) Funds for construction of buildings of existing sub-c enters, PHCs, CHCs
etc.
2) District Health Action Plans (upto Rs.20 lakhs)
3) Rogi Kaly an Samiti (Rs.5 lakhs )
4) Funds for up-grading Dist. Hospitals/Other hospit als
5) Healt h Melas
c. Routine Immuniz ation
i.
Funds for routine immunization activities BCG, DP T, Measles, Polio, Hepatitis
B, etc.
ii.
Introduction of newer vaccine like JE etc.
iii.
Funds are for improving service delivery to achieve accelerated coverage Alternate V accine Delivery, incentive to ASHAs for Mobilization, underserved
areas and campaign approach.
iv.
Injection safety through introduction of A D syringes.
v.
Cold chain equipments Deep freezers, ILR, , vaccine carriers, WIF & W IC
(replacement of CFC with non-CFC equipment)
d. National Disease Control Programs
i.
National Vector Borne Disease Control Program Malaria, Filaria, JE, etc.
ii.
Revised National Tuberculosis Control Program ( RNTCP)
iii.
National Leprosy Elimination Program
iv.
National Iodine Deficiency Disorder Control Program
v.
National Program for Control of Blindness
vi.
Integrated Disease Surveillance Project
vii.
National Drug De-addiction Program
e. Inter-sectoral convergence with drinking water, sanitation, AYUSH, WCD, PRI
Issues related to untied funds at Sub-cent res, PHCs, Block CHCs, FRUs & District Levels
Problems relating to Funds release, disbursement, SoEs, UCs at Facility Level
Mechanism for optimal utilization of funds under NRHM
Importance of monitoring of Financial Mgt.
Format for monitoring the fund flow
Financial Accounting & Reporting at NRHM:

NRHM State Level
1. Cash Balance Certificate
2. Treatment of Int erest Earned in the Bank Account
268

3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Preparation of Cheques
Cash Book with Cas h & Bank Columns
Petty Cash Book
Serial Numbering of Vouchers
Ledger
District Program Management Support Unit-wise ledgers
Journal
Register of investments
Registers for temporary advanc es as below:
a.
Advance to staff
b.
Advances to Contractors / NGOs
c.
TA/DA Advance
Stock Register for:
a. Machinery & Equipment
b. Furniture & Other Non-consumable articles
c. Register for drugs & medicines
d. Register for consumable articles
Dead Stock Register (Machinery & Equipments, Other non-cons umable articles)
Receipts & Payments Statement
Reporting:
a.
b.
c.
d.
e.
f.
g.
Certificate by State that funds have been transferred to Districts within 15 days
Monthly FMR from District Society to State Health Society
Quarterly FMR from State Society to GOI
Statement of fund positions
Monthly statement of bank balances
Annual UCs in form GFR-19A along with audit ed statements
Annual audited accounts to GOI
Monitoring:
a.
b.
c.
d.
e.
f.
At District Societies based on SoEs/Bills/ Vouchers from Block PHCs on monthly basis
At State - Based on monthly FMR from Districts
At Centre Bas ed on Quarterly FMR from States
With specialized FMG in place with state-specific consultants, constant monitoring will be a
success
Finance & Accounts Manual clearly indicates dates of all monthly, Quarterly & Annual reports
with responsibility matrix
E-Banking:
i.
Which can be used to evaluate the program implementation status independently
without waiting for Quarterly FMR
ii.
Will show red-alert districts
iii.
Will allow mid-term corrections
iv.
In conjunction wit h the physical delivery evaluation will become a potent monitoring
tool
269

Fund flow and reporting mechanism:

MOHFW
Dept. of FW
NRHM-State level
Fund Flow
Reporting
PWD or other agency

for civil works
NRHM
District level
NRHM
Block level
MNGO
NGOs
CHC
PHC
SC
VHSC
Managed
Centrally by FMG
PAO issued cheques
and passing them to
on to FMG for etransfer for entire

NRHM
Managed
Centrally by FMG, state
PMSU
Issuing cheques on sectioned
issued by different program
divisions
Managed Centrally By
FMG, Distt. PMSU.
Issuing cheques on
sectioned is sued by
different program
divisions
Parts of the state PIP

A- RCH
GOI Funds
B- Additional Under NRHM

C- Immunization
Fund Flow
Part A, B, C
Main Bank
Account
For Parts A, B, C
Fund Flow
State Health
Society
NDCP
NDCP
Joint Signatories:
MD/ED
State Account Manager/ State
Finance Manager/State Program
Manager
State Program Officer
Main Bank
Account
For Parts A, B, C
Block CHC/PHC
Distt. Health
Society
NDCP
NDCP
Joint Signatories:
CMO
Distt. Account Manager/ Distt.
Program Manager
Programme Officer
270

B. NRHM
A. RCH
C. IMMU
D. NDCP
Index
Funds
FMG/NRHM- Finance
FMR
UC
Audit
Report
SMPU-S HS
District Health Society
DPMU
RCH
NRHM
IMMU
TB
Malaria
Blindnes s
Financial Management Report

RCH Flexi Pool
14 Main Heads
NRHM Flexi Pool

28 Activities
SRI
3 Heads
Total Accoun t s un der NRHM-Rajasthan

12889 Bank Accounts
2 Bank A/c SHS, Rajasthan
34 Bank A/c DHS
237 Bank A/c Block
365 Bank A/c CHC
1509 Bank A/c PHC
10742 Bank A/c SC
All Bank Accounts operational. E -transfer is functional at all districts and out of 237 Block A/c 200 are
covered through E -transfer. Negotiations are under process with Bankers to facilitate E-transfer/ RTGS
at Block & CHC level.
GOI
E-Transfer (State Healt h Society, Rajasthan)
E-Transfer (District Health Societies)
E-Transfer in 200 Blocks
DD/ Cheque in 37 Blocks

271
DD Cheque in all CHC/P HC/S HS

Key Features of NRHM Finance & Acc ount s Manual:

Tranche Release Arrangements
Extent of Releases possible
Dead
line
Conditions Precedent
1st
Tra
nc
he
Up to 75% of approved PIP

after taking in to account the
Unspent balance available
with the State/U Ts at the
beginning of the financial
year (i.e. 1st April 200)
by
30th
Ma y
1. Approval of PIP by NPCC.

2. Submission of Utilization Certificates on provisional basis for the
grants released in preceding year.
3. Submission of Financial Monitoring Reports for the last quarter of
the preceding financial year (quarter ending 31st March 200)
4. Submission of Statement of Fund Position (SFP) showing the bank
balance and advance position of SHS (including DHS) for the last
quarter of the preceding financial year (quarter ending 31st
March200)
5. Submission of Statement showing Interest earned at the State
level and District level during the preceding financial year.
6. Achievement of at least half the institutional process targets
specified in Annex III all of the MoU (for RCH releases).
2nd
Tra
nc
he
Up to 75% of approved PIP

after taking in to account the
Unspent balance available
with the State/U Ts at the
beginning of the financial
year (i.e. 1st April 200)
By
30th
Octo
ber
1. Provided Annual Audited Accounts along with UCs (duly tallied

with the Audited Statements) are submitted for the preceding
financial year.
Bank Ac coun t s:
1. Number of Bank Accounts: 1 (Main B ank Account) for Part A, B, C & separate accounts for each of
6 NDCPs.
Flow of funds from GOISHS-RNTCP A/c DHS RNTCP A/C.
2. Nomenclature of Bank Accounts SHS- ..
3. Any fund under any other intervention (Cardio-vascular, telemedicine etc) would be credited in Main
Bank Account.
4. Only Saving Banks. No FDs, No Investments
Acc ounting Policies & Repor ting requirements:
1. Acc ounting Center s
a. SHS
b. DHS
c. Block CHC/PHC (provided the Block Accountant has been posted). Else, DHS should be the
Accounting Centre.
d. RKS of PHC/CHC/Rural Hospitals/Sub-district Hospitals
2.
Movement of Record s
a. SHS Level
b. DHS Level & Block CHC/P HC level:
i. Records for all the transactions taking place at DHS & Block CHC/PHC would be kept at
these institutions itself.
272

ii. Records will not be moved from these institutions to any other plac e so that they can be
made available to the audit whenever necessary.
iii. Will only furnish Statement of Expenditures (SoE)/Financial Monit oring Reports (FMRs) to
next higher institution (i.e. Block CHC/PHC to DHS and DHS to S HS). S HS may prescribe
other reporting formats for their satisfaction.
3.
Treatment of G-I-A
a. Funds transferred from GoI but not received shall be entered on the income side of the income
and expenditure account under the heading "Grants- in-Aids and taken in the balanc e sheet on
the assets side under the heading Fund s in Tran sit" below Current Assets (Cash and Bank
Balance).
b. G-i-A is reflected in the Inc ome & Expenditure accounts as income to the extent of fund utilization
against it.
c. The Grant-in-Aid to t he extent of remaining unutilized at the end of the financial year is shown as
liability in the Balance Sheet.
4.
Recognition of Ex penditure
a. Releases to Public Health Institutions: shall not be treated as expenditure unless they are
reported back as expenditure (either by voucher or SoE, whichever is applicable)
b. Advance to NGOs: NO
c. Advances for Civil Works: treated as advance at the time of release. On receipt of certificat e of
stage of completion and part bill from PWD or Contractor, it is booked as expense to the extent it
is certified by the PWD as per the terms of the agreement.
d. Releases to V HSCs: Untied Fund to VHSCs @ of Rs 10,000/ per annum shall be deemed to be
treated as expenditure provided the Untied Funds have been credited in the Bank Account of
VHSC.
e. Commodity Grant s: not reflected in the financial statements of the Society. However, they
f. Should be appearing in the Notes on Accounts and Disclosure of the Audit Report.
5. Ex penditure Reporting Ba si s
a. Expenditure reporting from various institutions would be considered as expenditure based on
following reports or documents:
i.
From DHS: Based on FMR/SoE. However, FMR or SoE must carry a c ertification by the
expenditure has been made for the approved items and vouchers have been ret ained at
the District level.
ii.
From Block CHC/PHC: Based on FMR/SoE. However, FMR or SoE must carry a
certification by the expendit ure has been made for the approved items and vouchers have
been retained at the Block CHC/PHC level.
iii.
From PHC, SHC: Based on actual receipt of vouc hers and supporting documents.
iv.
From Rajasthan Medical Relief Societies at various levels: Based on Monthly and Quarterly
Statement of Expenditure (SoEs).
6.
Reporting from RMRS

a. Reporting from RMRS:
i.
For Monthly/Quart erly FMRs: would furnish a monthly Statement of Expendit ure (SoE ) to
the controlling Block CHC/PHC or DHS.
ii.
For Annual Audit of DHS/SHS:
SHS and DHS should endeavour to make sure that Audit of all the RKS is complete
within 2 months of the closure of financial year as prescribed in this Manual.
273

However, if for c ertain reasons, the Audit of some of the RKS can not be completed
then, Audit Report of the DHS s hould be finalized (without delay ) based on mont hly
SoEs for the last month (i. e. March) showing monthly and cumulative expenditure for
the whole financial year.
Differences can be adjusted during next year audit corres pondingly.
7. Treatment of Fixed Asset s

a.
Assets that are to be capitalized: to B/S while s ending Utilization Certificates (UCs), the
expenditure shown in UCs should include t he expenditure as per Income & Expenditure
Account plus the amount of such Capitalized Assets.
b.
Assets not to be capitalized: in Income & Exp Statement.
Guidelines for u se of Sub-cent re (SC) fu nd s under NRHM
1. As part of the National Rural Health Mission, it is proposed to provide each sub center with Rs.10,
000 as an untied fund to facilitate meeting urgent yet discrete activities that need relatively small
sums of money.
2. The fund shall be kept in a joint bank account of the ANM and the Sarpanch
3. Decisions on activities for which the funds are to be spent will be approved by the Village Health
Committee (V HC) and be administered by the ANM. In areas where t he sub center is not coterminus with the Gram Panc hayat (GP) and the sub center covers more than one GP, the VHC of
the Gram Panchayat where the S C is located will approve the Action Plan. The funds can be used
for any of the villages, which are covered by the sub center.
4. Untied Funds will be used only for the common good and not for individual needs, except the case
of referral and transport in emergency situations.
5. Suggested areas where Un tied Fund s may be used include:
a. Minor modifications to sub center- curtains to ensure privacy, repair of taps, installation bulbs,
other minor repairs, which can be done at the local level
b. Ad hoc payments for cleaning up sub center, especially after childbirth.
c. Trans port of emergencies to appropriate referral centers
d. Trans port of samples during epidemics.
e. Purchase of consumables such as bandages in sub center
f. Purchase of bleaching powder and disinfectants for use in common areas of the village.
g. Labour and supplies for environmental sanit ation, such as clearing or larvicidal measures for
stagnant water.
h. Payment/reward to ASHA for cert ain identified activities
6. Untied funds shall not be us ed for any salaries, vehicle purchase, and recurring expenditures to
meet the expenses of the Gram Panchayat.
Management of fund s at the Sub-Health Centre level
Ex pected Fund s Inflow : Sub-Centres shall receive NRHM funds under the following heads:
1.
Permanent Advance for performance related incentive to ASHA
2.
Annual Maintenance Grant of Rs 10,000/3.
Untied grant of Rs 10,000/- every year.
4.
Janani Suraksha Yojana.
Banking Sy stem: A bank account has already been prescribed,, to be opened and operat ed under
joint signatures of the A NM and Sarpanch at the sub-cent re level. The same may be utilized for all
274

funds received by the Sub-Centre. The Account can be opened in any scheduled commercial bank/
Grameen Bank/Post Office.
Joint Signatories: Sarpanch and A NM
Record s: ANM may maintain a separate register for each of the activities for which funds have been
received, such as JSY, Untied Grant, Maintenance Grant, etc., showing t he total funds received and
expenditure made date-wise. These registers should be verified by Sarpanch at the close of every
month.
Submissio n of Statement of Ex penditure (So E): The SoE may be submitted by the ANM on a
quarterly basis wit hin 5 days of the end of the quarter to t he controlling MO in charge. It would be
desirable if, at the time of s ubmission of S oE, ANM reconciles the expenditure with the bank
statement. SoE can be submitted on the simple format for Untied Grant, Annual Maintenance Grant,
JSY, etc. separately on plain paper stating as below:
Certified that follow ing amount s w ere utilized during the quarter ending, 200..
Activity
Amount utilized
Payment to beneficiaries of Janani Suraksha Yojana
--------------------Payments to ASHAs
--------------------Maintenance of Sub-centre
--------------------Activities funded from the untied grants
--------------------Others
--------------------Total
Signature . (ANM)
Guidelines for Utilization of Untied Fund and An nual Maintenance Grant for P rimary Health
Centre s (PHCS)
1.
PHC will get Rs. 25,000/- p.a. as untied grant and Annual Maintenance Grant of Rs.50,000/-.
2.
A separat e register be maintained in the PHC giving sources of funds clearly for various
activities.
3.
PHC untied fund shall be kept in the bank account of the concerned Rogi
4.
Kalyan Samitti (RKS)/ Hospital Management Committee (HMC).
5.
PHC level Panchayat Committee/Rogi Kalyan Samiti will have the mandate to undertake and
supervise t he work to be undertak en from A nnual Maintenance Grant. Bot h the funds will be
spent and monitored by RKS.
Fund allocation:
Type of Grant
Annual untied grant
Ent ity to w hich due

i. VHSC
ii. SC
iii. PHC
iv. CHC
Amount
10000
10000
25000
50000
Annual Maintenance Grant
i. SC
ii. PHC
iii. CHC
i. PHC
ii. CHC
iii. Rural Hospitals
10000
50000
100000
100000
100000
500000
Annual group grants to RMRS
275

Suggested areas w here Untied Fund may be used include:

1.
Minor modifications to the Center- curtains to ensure privacy, repair of taps, installation of
bulbs, other minor repairs, which can be done at the local level
2.
Patient examination table, delivery table, DP apparatus, hemoglobin meter, copper-T insertion
kit, instruments tray, baby tray, weighing scales for mothers and for newborn babies,
plastic/rubber sheets, dressing scissors, stethoscopes, buckets, attendanc e stool, mackintosh
sheet
3.
Provision of running water supply
4.
Provision of electricity
5.
Ad hoc payments for cleaning up the Center, especially after childbirth.
6.
Trans port of emergencies to appropriate referral centers
7.
Trans port of samples during epidemics.
8.
Purchase of consumables such as bandages in the Center
9.
Purchase of bleaching powder and disinfectants for us e in common areas Under the jurisdiction
of the Centre.
10. Labor and supplies for environmental sanitation, such as clearing or Larvicidal meas ures for
stagnant water.
11. Payment/reward to ASHA for cert ain identified activities
12. Repair/operationalising soak pits
Management of fund s by Blo ck Medical Officer s and Medical Officers in charge of
CHC/PHC in relation to regular program funds under NRHM
Besides the untied / maintenance grants which shall go to t he Rogi Kalyan Samitis, the Block Medical
Officer (BMO) and Medical Officers in-charge of CHC / PHC will receive funds either for carrying out
regular activities under various programs or for further disbursement / distribution to lower institutions.
These include funds, among others, for the following activities:
1.
Janani Suraksha Yojana.
2.
Untied Grants/annual maintenance grants to Sub-Centres and Village Health and
Sanitation Committees
3.
Workshops for Block Level Mission team
4.
Constitution & Orientation of all community leaders on PHC and CHC committees
5.
Training of community health work ers (ASHAs, AWW etc)
6.
ASHA support/mentoring mechanism
7.
Training of ANM, PHN, Staff Nurses etc
8.
Support for School Health Programs.
9.
Improving physical infrastructure
10.
Ambulances for PHC/CHC
11.
National Disease control Programs,
12.
Healt h melas, RCH Camp,
13.
Program Management, etc.
Banking arrangement: The BMO and MO-in-Charge of CHC/PHC should have a separate bank
account for all funds received for regular activities under various programs. This Bank Account may be
in the name of t he institution itself or in the name of the BMO or the Medical Officer in-charge of
CHC/PHC. This bank account may be operated by two joint signatories (e. g. BMO / Medical Officer incharge and Accountant of the block PHC / CHC/ P HC). If this is not possible, operation by a single
signature of the BMO / MO-in- Charge can also be permitted. State Governments may issue a specific
Government Order (GO) to put this system in place.
276

Record s: A separate cash book should be maint ained for the Bank Account in the name of the
institution or the BMO /Officer in-charge of CHC/PHC, as the cas e may be. The Accountant posted at
the BMO Offic e / CHC / P HC should maintain a separate ledger for each of the activities for which
funds are being received.
Submissio n of Statement of Ex penditure (SoE)
SoE should be submitted on a mon thly basis within 5 days of the end of the month to the Block
Medical Officer by the Medical Officer in-charge of the CHCs/PHCs within the jurisdiction of the BMO
277

Procurement & Logistics management:

The proper management of equipment and supplies is essential to the efficiency and effectiveness of
RCH clinical and support services. Quality care depends upon the availability of appropriate equipment,
materials and services. To ensure efficiency, and to reap benefits of scale, a supplies strategy is
needed to:
1.
2.
3.
Address supply management arrangements to decide appropriate levels of purchasing

activities at state, district and local level.
Establish a modern, integrat ed, cost-effective logistics and supply chain for states.
Set key performance measures and indicators.
In designing an RCH Phase II supply strategy the following areas need to be addressed:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
The scope of the strategy

What is handled in-hous e or outsourced?
Non-pay expenditure on items such as pathology, IT, drugs
Non-pay expenditure on services such as outsourced contract management
Information needs and reporting levels
Physical distribution and storage
Payment systems
The need for the supply strategy to integrate with ot her activities such as environment al, human
resources and healt h and safety arrangements
The ways in which the strategy will support other objectives such as estates management and
cost improvement programs
Decision-making delegations with respect to outsourcing, acquisition, procurement, tendering,
contracting and expenditure limits
The level and balanc e of collaboration nationwide, state-wide and loc ally.
Expectations of staff and suppliers behavior in terms of public accountability and adherenc e to
statutory and mandat ory regulations (e.g. standing orders, financial instructions and
procurement regulations).
Policy or intentions for e-commerce
Strengthening Systems and Partnerships
Procurement in RCH Pha se II

In the initial two years of RCH Phase II the MoH&FW will be responsible for procurement of drugs,
vaccines, equipment, kits and contraceptives as done in RCH Phase I. P rocurement plans for year 1
and year 2 have been shared with the development partners. The states will be gradually encouraged
to undertake proc urement at their level for which t he MoH&FW has framed the following guideline
document:
Guidelines for Procurement issued by GoI briefly provide the essential information and step-by-step
procurement procedures to achieve objectives. However, the states may be required to customize the
procedure described herein to meet the requirements of existing system preferably by way of
development of a state specific operation manual.
For additional guidance on this subject, DGS& D manual can be referred to. DGS& D booklets governing
the contract and standard tender forms e.g Bank Guarant ee for EMD, bank guarantee for performance
security, performance statement etc. are available on www.dgsnd.gov.in or www.dgsnd.nic.in. The
choice of procurement procedures may be decided by the ex ecutive c ommittee of the state for the
entire procurement or for each proc urement on a case-to-case basis.
278

This document is intended for the procurement officer t o use a uniform system of procurement in all the
states. It is also intended to guide the Procurement Service Agents (PSAs), wherever hired, to
understand the procurement procedure. The rights and obligations of the purc haser and the contractor
of goods and works are governed by the tender documents and by the contracts signed by the
purchaser with the contractor and not by these guidelines.
The aim of the procurement process should be to ensure that necessary supplies of the right quality are
obtained at reasonable cost through a fair and transparent system.
1. Procurement plan and procedures
When making procurements, specific budget provision should be available for meeting the expenditures
in the financial year in which it is to be incurred.
a. Procurement plan
Preparation of a procurement plan is essential. A procurement plan covering civil works,

equipment,goods, consultancy services and resource support shall be prepared on a firm basis
for the first year of the program and on a tentative basis for the subs equent years.
Procurement plans shall be prepared every year for proper monitoring and exec ution.
Procurement plans shall be prepared contract-wise.
Method of purchase shall be based on the value of the contract, urgency of the demand, type
ofgoods/services, and availability of different sourc es of supply etc.
Limit of value per contract applicable to the particular procurement procedure shall be
strictlyadhered to.
It shall be ensured that the procurement is based strictly on actual need.
The Principles and E vidence Base for State RCH Phase II Program Implementation Plans
(PIPs)
b. Procurement procedure
The procurement procedure broadly consists of the following steps:

Assessment of requirement
Deciding procurement strategy including technical specifications
Mode of procurement
Preparation of tender document
Advertisement of the tender
Issue of tender documents
Opening of the tender
E valuation of the tender
Clearance of World Bank/DFID, whenever required
Award of contract
Notification of delivery to consignee
Inspection and testing notification of delivery to consignee
Receipt of consignment
Acceptance and storage of the consignment
Resolution of disput es, if any
2. Forecasting/a sse ssment of the requirement

Bulk requirement of the stores for state level/district level should be assessed prior to t he beginning of
the financial year to get competitive prices. Action for procurement should be initiated in accordance
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with the purchase procedures. While forecasting the requirement the following factors should be
considered:
A verage time period required in complete procurement cycle. In some cases; it can take 8 to 12
months to complete the procurement cycle.
The trends in usage at the time of requirement.

Current stock, where the stock is located, when the product is due to reach t he expiry dat e and
what the projected time scale is for distribution.
Storage capacity for receiving the bulk consignment. In case the storage capacity is limited, the
procurement/supply of commodities should be phased over time rather than arriving as one
consignment.
List of consignees and their storage capacity.
The problems, if any, encountered with procurement and distribution over the last few years.
Cons olidating several program procurement requirements can result in savings through price
discounts as well as reduc e the administrative costs associated with having to process multiple
orders.
3. Deciding on procurement strategy

It is important to agree on the procurement strategy before initiating the tendering. For example,
purchase of drugs having limited shelf life shall require a different procurement strategy than purchase
Strengthening Systems and Partnerships of hospital beds, for example. Issues like pre-qualification of
suppliers to reduce the procurement cycle time in the case of life-saving drugs and having multiple
supply lines for essential items should also be c onsidered. Similarly for civil works, options like work
contract on lump-sum basis or based on bill of quantities can be explored. The procurement strategy
should cover:
Key objectives of the procurement for the project

Chos en procurement option
Chos en procurement route (Open, Negotiated, Restricted)
Key milestones (check that enough time will be allowed for negotiations, if relevant.)
Key documents (e.g. requirements specification)
Key factors influencing the proc urement strategy relate to the degree of complexity, innovating and
uncertainty about the requirement, together with the time needed to achieve a successful outcome.
4. Mode of procurement
The methods of procurement normally followed are:
Global tender/international competitive bidding (ICB)

Open advertised tender/ national competitive bidding (NCB )
Limited tender (National /International)
Shopping (National/International)
Single tender/direct contracting
Procurement of civil works through PRIs
A. Global tender/International Competitive Bidding (ICB )

This method is generally adopted where the supplies need to be import ed and foreign firms are
expected to participate, irrespective of the value. In the case of RCH procurement, this method is
adopted when the estimated cost of t he procurement is more than the equivalent of US $ 1,000,000 for
goods and US $ 10,000,000 for works.
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Requirement
Apart from wide publicity nationally, invitation to bid shall also be forwarded to embassy and
trade repres entatives of the countries of likely suppliers/contractor of the goods and
works and
also to those who have expressed interest in response to t he general
procurement notice.
Invitation to bid will also be published in UNDB and DgMarket in cases where estimated value
of the contract is more than the equivalent of US $ 200, 000. This publication will be arranged
by the World Bank/DFID.
Use of standard tender document.
Sale of bidding documents should start only after publication of invitation to bid.
Bidding period 45 to 90 days from the date of start of sale of bidding document.
Other procedures for global tender will broadly be same as that of open advertised tender.
The Principles and E vidence Base for State RCH Phase II Program Implementation Plans
(PIPs)
B. Open advertised tender/National Competitive Bidding (NCB)
Open tender is the competitive bidding procedure normally used for public procurement in the
country and by their nat ure or scope may be the most efficient and economical way of
procuring goods or works. The procedures shall provide for adequate competition in order to
ensure reasonable prices.
The method to be used in the evaluation of tenders and the award of contracts shall be made
known to all bidders and not be applied arbitrarily.
In the case of RCH procurement open tender is normally adopted where the contract value is
less than US $ 1,000,000
Civil works, and also goods, could be procured under contracts awarded in accordance with the
procedures prescribed under open tenders.
Various steps involved in procurement under open tender procedure have been enumerated in
clause I (b).
Notification/Advertising: Timely notification of bidding opportunities is essential in competitive
bidding:
Invitation to bid shall be published in daily newspapers with wide circulation all over India, in at
least one national English and one regional language daily. If the advertisement is for more
than one it em, it should also be indicated whether the evaluation would be item-wise or as a
package.
The advertisement should also be placed on the website of the department.
If a condition in the invitation for tender is that earnest money is to be deposited by the supplier/
contractor, the bid of a supplier / contractor not complying with this requirement, shall be
rejected.
In the case of deposit of earnest money, the states existing proc edure may be followed.
However, it is desirable that a level playing field be creat ed in this regard.
In a package, the earnest money is indicated taking into account all the items. This cannot be
changed lat er on. Once it is decided that the contract is for a package the earnest money for
that package is to be indicated and the same cannot be changed according to each item.
The last date for receipt of tender shall be the day following the date for clos e of sale of tender
documents.
Tendering period shall not be less than 30 days from the date of start of sale of tender
documents.
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Tenders can be sold from different places but the tenders may be received at one place to
avoid problems arising out of late/delayed t enders. Tenders should normally be opened half an
hour after the deadline for receipt.
Tender documents:
The state governments standard tender documents should be used. Sale of tender documents should
begin only after the publication of notification for tender in the newspapers. The t ender documents shall
furnish all information necessary for a prospective bidder to prepare a tender for the goods and works
to be provided. Tender documents should be made available to all who seek them after paying the
requisite fees, if any, regardless of registration status and they should be allowed to bid.
Clarity of tender documents: Tender documents shall furnish clearly and precisely the work to be
carried out, the location of the work, the goods to be supplied, the place of delivery or installation, the
schedule for delivery or completion, specification/technical specification, minimum performanc e
Strengthening Systems and Partnerships requirements, warranty and maintenance requirements, if
any, and the method of evaluation. The basis for tender evaluation and selection of the lowest
technically suitable and evaluated t ender shall be clearly outlined in the instructions to tenders and / or
the specifications.
Tender documents should state clearly whether the bid prices will be fixed or whether price adjustments
will be made to reflect any change in major cost components of the contract.
Standards and technical specifi cation s:
The implementing agency shall specify the generally accepted standards of technical specifications.
Unbiased technical specification s hall be prepared with no mention of brand names and catalogue
numbers. In case the item to be procured is not covered under B IS or I.P. and specifications are t o be
framed, these may be prepared by a committee of experts associated with the t rade, if required. The
functional performance, design, quality, packaging and additional requirements should be clearly spelt
out in the s pecifications. The specifications should be generic and should not appear to favor a
particular brand or supplier.
Technical specifications, bill of quantities and civil drawings should be prepared before tendering. Clear
specifications for the articles to be procured should be drawn up in every case. No deviation from the
specifications should be allowed aft er opening of tender.
Validity of tender:
Bidders shall be required t o submit tenders valid for t he period specified in the tender documents.
Normally, the bid validity period shall not exceed 90 days.
Earnest money:
Earnest money of normally 2% of the estimated cost of the item or works shall be the appropriate
amount, which should be indicated, as a specific amount. The earnest money shall be in the form of a
demand draft / bankers cheque/bank guarant ee from a scheduled bank, which should be valid up to 45
days beyond the validity period of the tender. The earnest money of uns uccessful bidders shall be
refunded soon after the final acceptance of tenders. The earnest money shall be forfeited in the event
of withdrawal of the tender within the original validity once submitted or in case a successful bidder fails
to execute necessary agreement within the period specified.
Pre-bid conference:
A pre-bid conference (date/ venue to be indicated in the bid document) may be arranged wherein
potential bidders may meet the representatives of the implementing authority to seek clarifications on
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the tender documents. Copy of minut es of the pre-bid conference s hould be furnished to the bidders
who have already purchas ed the bid documents and also sold along with the bid document to the
parties purchasing the document subsequent to the pre-bid conference.
Terms and method s of payment:
Payment terms shall be in accordance with the practices applicable to the specific goods and works.
Tender documents should specify the payment method and terms offered.
Conditions of contract: The contract documents shall clearly define the scope of work to be performed,
the goods to be supplied, the rights and obligations of the implementing agency and of the supplier or
contractor, and the functions and authority of the engineer, architect, or construction manager, (if one
is employed by the implementing agency) in the supervision and administration of the contract. Special
conditions related to specific items should also be clearly specified in the tender document.
Performance security depo si t:
Tender documents for works and goods shall require security in an amount sufficient to protect the
implementing agency in case of breach of contract by the contractor. This shall be in the form The
Principles and E vidence Base for State RCH Phase II Program Implementation Plans (PIPs)
of a bank guarant ee or any other instrument and the amount should be specified in the tender
document. The amount of performance guarantee shall normally be 5% of contract price (valid till 28
days from t he date of expiry of defect liability period or the guarantee/ warranty period as the case may
be).
The performance security deposit shall be refunded within one month of the completion of
supply of goods/works. It will, however, be refunded after the expiry of guarant ee/warranty
period (as mentioned above) where there is condition of guarant ee/warrantee.
The performance security deposit shall be forfeited in case any terms and conditions of the
contract are infringed upon or the bidder fails to make complete supply satisfactorily or
complete the work within the delivery/completion period agreed in the contract.
Retention money:
In contracts for works, normally 5-10% of contract pric e shall be recovered for retention money. 50% of
such money shall be retained till completion of the whole work and 50% shall be retained till the end of
defects liability period.
Liquidated damages:
Provisions for liquidated damages shall be included in the conditions of contract when delays in the
delivery of goods, completion of works, failure of the goods or works to meet performance requirements
would res ult in extra cost, or loss of revenue or loss of other benefits to the implementing agency.
Tender opening:
The time for the tender opening should be at least half an hour after the deadline for rec eipt as
discussed above.
Tenders shall be opened in public. The bidders or their represent atives shall be allowed to be
present at the time of opening of bids.
All tenders received should be opened. No bid should be rejected at bid opening except for late
tenders. Late tenders shall be returned to the bidders unopened.
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The name of the bidder and total amount of each bid along with important conditions like excise
duty, sales tax, delivery terms, delivery period, special conditions, if any, shall be read out at
the time of bid opening.
Spot comparative statement (minutes of bid opening) must be prepared by the bid opening
official and should be signed.
Confidentiality:
After t he public opening of tenders, information relating to the ex amination, clarification, and evaluation
of tenders and recommendations concerning awards shall not be disclosed t o bidders or other persons
not officially concerned with t his process until t he successful bidder is notified of the award of the
contract.
Ex amination of tenders.
a.
b.
The implementing agency shall ascertain whether the tenders

Meet the eligibility requirements specified
Have been properly signed
Are accompanied by the required earnest money and valid for the period specified in the tender
document Strengthening Systems and Partnerships
Are substantially res ponsive to the tender document
Have t he tec hnical and financial capability to successfully execut e the contract. For ens uring
financial capacity a minimum t urnover requirement should be indicated in the bid document are
otherwise generally in order.
is not substantially responsive, that is, it contains material deviations from or reservationsto the
terms, conditions, and specifications in the tender documents, it shall not be consideredfurther. The
bidder shall not be permitted to correct or withdraw material deviations or reservationsonce tenders
have been opened.
Tender evaluation and comparison

The purpose of tender evaluation is to determine the cost to the implementing agency of each tender in
a manner that permits a comparison based on its evaluated cost. The tender with the lowest evaluated
cost and substantially res ponsive, but not necessarily the lowest submitted price, should be selected for
award.
The bid price read out at the bid opening shall be adjusted t o correct any arithmetical errors for
the purpose of evaluation.
E valuation of tenders should be made strictly in terms of the provision in the tender documents
to ensure compliance with the commercial and technical aspects.
The conditional discounts offered by the bidder shall not be taken into account for evaluation.
The past performance of the suppliers/ contractor should also be taken into account while
evaluating the tenders. (this should also be indicated in the bid document)
The implementing agency shall prepare a det ailed report on the evaluation and comparison of
tenders setting forth the specific reasons on which the recommendation is based for the award
of the contract.
Negotiation
Negotiation aft er tenders are opened should ordinarily be discouraged. However, in exceptional cases it
may be undertaken only with the lowest evaluated responsive bidder (L-1) as per the states
procurement procedure. In cas e the rat es even after negotiation are very high, fres h tenders should be
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invited. While fixing the date for negotiation, it should be ensured that sufficient time is allowed to the
bidders to attend the same.
Ex ten sion of validity of tender s
As far as possible, the contract should be finalized within the original validity of t he offers mentioned in
the tender. An extension of bid validity, if justified by exceptional circumstances with the approval of
next higher authority, shall be requested in writing from all bidders (of valid tenders only ) before the
expiry date. Bidders shall have the right to refuse to grant such an extension without forfeiting their
earnest money, but those who are willing to extend the validity of their bid shall also be required to
provide a suitable extension of earnest money.
The Principles and E vidence Base for State RCH Phase II Program Implementation Plans (PIPs)
Post-q ualification of bidders
If bidders have not been pre-qualified, the implementing agency shall determine whether the bidder
whos e bid has been determined t o offer the lowest evaluated cost has the technical capability and
financial resources to effectively carry out the cont ract as offered in the bid. The criteria to be met shall
be set out in the tender doc uments, and if the bidder does not meet them, the bid shall be rejected. In
such an event, the implementing agency shall make a similar determination for the next lowest
evaluated bidder and so on.
Repeat orders
Purchases under open tender method may be increased as per the prevailing state procedure up to
15% of the quantity originally ordered through repeat orders after rec ording reasons provided that such
orders shall be given before the date of the expiry of last supply made and also s ubject to the c ondition
that prices have since not reduced and purchases were required urgently.
Rejection of all tenders
Tender documents usually provide that the implementing agency may reject all tenders. Rejection of all
tenders is justified when none of the tenders are substantially responsive or when negotiations with the
L1 bidder has failed. However, lack of competition shall not be determined solely on the basis of the
number of bidders. If all tenders are rejected, the implementing agency shall review the causes
justifying the rejection and consider making revisions to t he conditions of contract, design and
specifications, scope of the cont ract, or a combination of thes e, before inviting new tenders.
If the rejection of all tenders is due to lack of competition, wider advertising shall be considered.
If the rejection is due to most or all of the tenders being non-responsive, new tenders may be
invited.
Rejection of all tenders and re-inviting new tenders, irrespective of value shall be referred to the
competent authority for approval after examining whether t echnical specifications need any
change.
C. Limited tender (National/International)

Limited tendering is nothing but NCB done by direct invit ation to selected potential suppliers of proven
capacity-cum-capability (from at least two different countries in case of international limited tender)
without open advertisement but enough to ensure receipt of competitive bids.
This procedure could be adopt ed where:
There are only a limited number of suppliers of the particular goods or services
Demand is urgent in nature
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Exceptional reas ons exist justifying departure from full Advertised Open Tender. Other
procedures under limited tender will be s ame as that of open advertised tender. Rat e contracts
of Directorate General of Suppliers and Disposals (DGS&D) and rat e contracts of
state
governments shall also be an appropriate method under limited tender system. The purchaser
shall, however, check that the rate contracts are representative of market price and
are
not obsolete. In all such cases, approval of the competent authority to dispense with open
advertised tender should be taken. Strengthening Systems and Partnerships
D. Shopping
Shopping is a procurement method based on comparing price quotations obtained from several
suppliers/contractors, usually at least three, to ensure competitive prices.
Goods including drugs and equipment, and civil works estimated to cost below the financial
ceiling prevailing in states or less per contract may be procured under the shopping.
It is an appropriate method for procuring readily available off-the-shelf goods or standard
specifications commodities of small value or simple civil works of small value.
Approval of competent authority may be obtained for items of goods to be purchased or civil
works to be constructed/renovat ed/repaired along with s pecifications, estimated costs and
agencies from whom quotations should be invited.
The requests for quotations shall indicate the description, specification and quantity of the
goods and terms of delivery or specification of works, as well as desired delivery or completion
time and place. If the quotations are called for more than one item/ works, it should also be
indicated whether the evaluation would be for each item or for each civil work or as a package.
Quotations could also be obtained by telex or facsimile. The terms of accepted offer s hall be
incorporated in a purchase order or brief contract.
Rate contracts entered into by DGS& D and by state governments will be acceptable for any
procurement under shopping.
E. Single tender/Direct contrac ting
The single tender system may be adopted in cas e of articles including drugs and equipment,
which are specifically certified as propriety in nature, or where only a particular firm
manufactures the articles demanded or in case of extreme emergency.
The single tender system without competition shall be an appropriate method under the
following circumstances:
Extension of existing contracts for works or goods awarded with the prescribed procedures,
justifiable on economic grounds
Standardization of equipment or spare parts to be compatible with existing equipment may
justify additional purchases from the original supplier
The required item is proprietary and obtainable only from one source
Need for early delivery to avoid costly delays
Works are small and scattered or in remote locations where mobilization costs for contractors
would be unreasonably high; and
In exceptional cases, such as in response to natural disasters.
F. Procurement of civil w orks th rough Panchayati Raj Institu tion s (P RI s)

For small works of value up to Rs. 6 lakh, the states may decide to get these execut ed through PRIs
wherever considered appropriate. In the RCH Phase II, construction/repair of sub-c enters would fall
within this threshold limit. Wherever works are entrusted to PRIs, it should be ensured that these
institutions do manage to obtain contributions from the community. The extent of s uch contribution may
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be decided by the states. It should als o be ensured that adequate arrangements for supply of The
Principles and E vidence Bas e for State RCH Phase II Program Implementation Plans (P IPs)
standardized designs and preparation of estimates, supervision of construction, maintenanc e of quality
control, and rendering appropriate accounts are in place.
G. Aw ard of contract
The implementing agency shall award the contract, within the period of the validity of t enders, to the
bidder who meets the tender conditions in all aspects, has the necessary technical capability and
financial resources and whose bid is substantially responsive to the tender documents and has the
lowest evaluated cost. The purchaser can, if so desired, depute a team of 3-4 officers to the premises
of the manufacturer to whom the contract is proposed to be awarded to satisfy itself that the
manufacturer has capability to produce the required quantity and also the necessary quality testing and
assuranc e facilities to meet the required standards. Based on the report of this committee, the
purchaser may decide to award the contract to the successful bidder offering the lowest or reasonable
price after approval of the appropriate authority.
Single tenders should also be considered for award, if it is determined that publicity was adequate, bid
specification/conditions were not restrictive or unclear, and bid prices are considered reasonable.
H. Inspec tion, sampling and testing procedure
The inspection authority and procedure for sampling and t esting should be clearly specified in the
tender document. A purchaser must select a set of accredited testing laborat ories for testing the
samples accordance with IS O requirements. The purchaser should request a written confirmation from
the supplier t hat the results of the testing laboratory chosen for qualification and compliance testing will
be accepted by the supplier. The name of the testing lab should be incorporated in the tender
document.
The authority that will collect random samples should also be specified.
The purchas er will decide whether 100% pre-dispatch inspection is required at the manufacturers
premises, depending on the items to be purchased. Sometimes it is important to verify that each
manufactured batch complies with the specifications before it is finally dispatched to the consignee.
When a consignment is ready for dispatch, the supplier will inform the purchaser t hat the consignment
is ready for the testing. The purchaser then instructs the inspection agency to carry out the inspection
viz. visit the suppliers factory and draw samples from the batches offered for inspection, in accordance
with sampling guidelines. The inspection agency will send the samples directly to the designated testing
laboratory chosen by the purchaser for quality testing. Based on the results of the test, the batch may
be cleared for dispatch. To avoid later dispute on the testing results, a representative of the supplier
may be invit ed to witness the testing of the sample at the laboratory, if feasible.
In case of procurement of kits, where the kits are assembled by another party before supplying the final
kits to the purchaser, the inspection and quality control procedures should be clearly mentioned in the
tender document.
The above procedure applies mainly for procurement of drugs. In case of procurement of other goods,
they may be inspected on arrival at purchas ers premises for any possible damage/defect either in
manufacturing or in transit. In case of complex capital goods, the inspection at manufacturers premises
may also be required.
If the stores do not meet the performance requirement, they should not be accepted. If there are any
disputes or doubts about the quality of the products, a procedure of resolution of dispute may be
followed as per the terms of the contract.
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Strengthening Sy stem s and Partnership s

I. Notification of delivery to con signee
Notification of delivery or dispatch in regard to each and every installment shall be made by the supplier
to the consignee through a packing account quoting the number of the s upply order and t he date of
dispatch of the stores. All packages, containers, bundles and loos e materials part of each and every
installment shall be fully described in the packing account and full det ails of the contents of the
packages and quantity of materials shall be given to enable the consignee to check the stores on arrival
at destination. The railway receipt, consignment note or the bill of t he lading, if any, should be drawn in
the name of t he consignee and should be sent to him by registered post acknowledgement due
immediat ely on dispatch of stores, quoting the No. (s) and date (s) of the corresponding Inspection
Note(s) in relation to the stores covered by the said Railway Receipt, the consignment note or the Bill of
Lading, as the case may be. The contractor shall bear and reimburse to the purchaser, demurrage
charge, if any paid by t he reasons of delay on the part of the supplier in forwarding t he railway receipt,
consignment note or bill of lading.
J. Receipt of con signment
In case of imported stores, the purc haser should be aware of the custom clearance requirement prior to
issuing the contract. A clear procedure (i.e. who will clear the goods and pay the duties, loading and
unloading of the consignment, transport of the consignment to the premises of the consignee etc.) for
custom clearanc e should be specified in the contract.
At the time of the delivery of the stores, the consignee should accept the stores on said to contain
basis and should issue the provisional receipt certificate in the standard format (sample attached). After
opening the package and making a detailed examination of the stores the consignee will issue the final
acceptance certificate if he is satisfied with t he quality of the goods. Notwithstanding the prequalification or the inspection of the goods/services by the inspection agency, the c onsignee has the
right to furt her inspect and test the goods but within a reasonable time (say up to 60 days) and if the
goods fail to meet the specifications given in the contract, he should reject the goods and ask the
supplier to replace the goods or rectify the defects.
K. Storage
Experience has demonstrated that properly packed, good quality goods (except some drugs and
vaccines or specific items) do not det eriorate when stored at average temperature found in tropical
climates.
Air-conditioning is generally not necessary if the goods are properly packaged and stored in a clean,
dry and well-ventilated environment.
If quality assurance measures have been strictly followed during the manufacturing process; the
conditions of warehousing and storage play a major role in ensuring that quality goods received reach
final users in good condition. They should be left in their original packaging while in storage. The batch
number and marking on the cartons should be recorded to ensure that all batches are traceable and
distributed on a first in first expiry basis. The drugs, which require special storage such as maintaining
proper temperature, should be stored in appropriat e condition.
L. Resolution o f di spute s
The dispute resolution met hodology should be very clearly indicated in the contract document. As far as
possible, disputes may be resolved with mutual agreement between purchaser and buyer through
alternate dispute resolution met hods to avoid going through arbitration and litigation stage.
The Principles and E vidence Base for State RCH Phase II Program Implementation Plans (PIPs)
There a number of possible causes of disputes during the execution of cont ract. These may involve:
Interpretation of the terms and conditions of the contract

288

Delay in delivery/completion of the works

Delay in release of payment
Independent laboratory test results
Condition of the items on arrival at consignee and after delivery
Rate of the items, variation in quantity in civil works contract etc.
Design/specification issue
Di spute s o ver laboratory result s

Disputes over product acceptance usually arise when independent testing determines that the product
is not in compliance with the required specification or standard. It is also possible for a manufacturer to
dispute a decision made by the inspection agency regarding product packaging or appearance.
In most cases, manufacturers accept the results of independent laboratories and replace batches that
have been rejected. When manufacturers do not accept the test results, they usually present test
results or other evidenc e to suggest that the independent laboratory test are incorrect and do not
accurately represent the quality of the product tested. Procedures for dealing with such disputes should
be covered in the contract.
Deci sion on re-te sting
Re-t esting should only be undertak en when there is reasonable evidence that the laboratory has made
a mistake. Before considering a re-test all the available data should be reviewed. If a manufacturer
disputes a test result, the following issues should be considered in deciding whether to allow a re-test:
What is the margin by which the product has failed to comply?

Is the manufacturers history of production for the client a good one?
What is the nature of the difference between the manufacturers and the laboratorys test
results?
Where appropriate, the laboratory should keep the failed s amples of goods so that the
manufacturer can examine them.
Samples of the failed batch could be sent to the designat ed appellate testing laborat ory as
specified in the contract.
The amount of information available for review depends on the type of test.
In all cases, the manufacturer should bear the cost of a retest, unless it can be demonstrated that it is
likely that the laboratory res ults; it is always desirable to invite the representative of the supplier to
witness the testing of samples.
M. Law s governing the con tract
The contract shall be governed by the laws of India in forc e.

The courts of the place from where the acceptance of tender has been issued shall alone have
jurisdiction to decide any dispute arising out of or in res pect of the contract irrespective of the
place of delivery, the place of performance or place of payment under the contract
Strengthening Systems and Partnerships or the place of issue of advance intimation of
acceptance of tender, the contract shall be deemed to have been made at the place from
where the acceptanc e of the tenders have been issued
N. Arbitration (NCB/Shopping )
In the event of any question, dispute or difference arising under the contract conditions or any special
conditions of cont ract, or in connection with the contract (except as to any matters the decision of which
is specially provided for by these or the special conditions) the same shall be referred to the sole
arbitration of an officer, from the department other than the department who has decided the contract
289

having sufficient knowledge of Law, appointed to be the arbitrator by the purchaser. The award of the
arbitrator shall be final and binding on the parties to this contract.
In the event of t he arbit rator dying, neglecting or refusing to act or resigning or being unable to
act for any reason, or his award being set aside by the court for any reason, it shall be
lawful for the purchas er to appoint another arbitrator in place of the outgoing arbit rator in the
manner aforementioned.
It is further a term of the contract that no person other than the person appoint ed by the
purchaser as aforementioned should act as arbitrator and that, if for any reason t hat is not
possible, the matter is not to be referred to arbitration at all.
The arbitrator may from time to time with the consent of all parties to the contract, enlarge the
time for making the award.
Upon every and any such reference, t he assessment of the costs incidental to the reference
and award respectively shall be in the discretion of the arbitrator.
Subject as aforesaid, the Arbitration Act, amended up to date and the rules there under and
any statutory modification t hereof for the time being in force s hall be deemed to apply to the
Arbitration proceedings under this clause.
If the value of the claim in a reference exceeds Rs.1 lakh the arbitrator shall give reas oned
award.
The venue of arbitration shall be the place from which formal Acceptanc e of Tender is issued or
such other place as the purchaser at his discretion may determine. Suitable cause may be
incorporated in the tender enquiry to obtain the consent of the bidder to accept the arbitration
clause.
O. Ex ten sion of con tract

Normally, the contract onc e awarded should not be extended. Under exceptional circumstances,
extension of existing c ontracts up to 50% of the original contract value may be considered, if it is
justifiable on economic grounds.
P. Complaint redressal mechanism (also applicable to service procurement)
In order to deal with t he complaints received from the contractors/suppliers effectively, a compliant
handling mechanism should be available at the national level as well as at state level, and immediate
action should be initiat ed on receipt of complaints to redress the grievances. All complaints should be
handled at a level higher than that of the level at which the procurement process is being undertaken
and the allegations made in the complaints should be thoroughly enquired into. If found correct,
appropriate remedial measures should be taken by the appropriate aut horities. The Principles and
E vidence Base for State RCH Phase II Program Implementation Plans (PIPs)
In case any individual staff is found res ponsible, suitable disciplinary proceedings should be initiated
against such staff under the applicable government conduct rules. The existing provisions under the
Indian law including the instructions of central vigilance commission should be followed in this regard.
Q. Procurement audit (also applicable to service procurement)
All the procurements made by the central and state governments are subject to post-audit either by
Comptroller and A uditor General (CAG)/State A udit Departments and by the Development Partners
(DPs).
Henc e, all the documents relat ed to the procurement should be filed and kept systematically and safely.
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Office procedures:
Introduction:
Office is a room or set of rooms in which business, professional duties, clerical work, etc., are carried
out. It is a back bone of an organization, it controls all activities of administration.
The efficiency of an organization, to a large extent, depends on evolution of adequate processes and
procedures of its office (administration) and the ability of its employees to follow t hem. Accordingly, the
efficiency of persons handling secretarial work in an organization can be judged by their ability to
dispose of receipts with speed, following the procedures prescribed for the purpose. The ultimate object
of all Government business is to meet the citizens needs and to furt her their welfare without undue
delay. At the same time, those who are account able for the conduct of that business have to ensure
that public funds are managed with utmost care and prudence. It is, therefore, necessary, in each
case, to keep appropriat e record not only of what has been done but also of why it was so done.
Departments
Finance & Accounts
Human Resource &

Personnel
Administration &
Establishment
Store & Purchase
A department is responsible for formulation of policies of the government in relation to business

allocated to it and also for the exec ution and review of those policies.
Receipts
Perusal and marking of receipts
The diarist will submit all receipts to the concerned officer who will:
(1) Go through the receipts;
(2) Forward misdirected receipts to the sections concerned;
(3) Separate those which, either under the departmental instructions or in his discretion, should be
seen by higher officers before they are processed and mark them to such officers;
(4) Keep a note in his diary of important receipts requiring prompt action or disposal by a specified
date.
Ent ry of receipt s in diary
(1) Each section will maintain a section diary

(2) The diarist will diaries in the section diary all receipts except the following before they are
submitted to the offic ers concerned or distributed among the dealing hands:
a. Receipts which, as a class, are adequately taken care of by a register specially devised for
the purpose (e.g. telephone bills which are entered in telephone bill register);
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b.
c.
(3)
(4)
(5)
(6)
(7)
Receipts which have already been diarized in comput er;

Unsigned communications (except e-mail) on which no instructions have been recorded by
officers and on which no action is to be taken;
d. Identical copies of representations, save the one received first;
e. Post copies of telegrams unless the endorsement contains a message in addition to that
contained in the telegrams;
f. Petty contingent vouchers such as those relating to night duty or overtime claims of the
staff, claims for coolie hire or conveyance hire, chits asking for articles of furniture,
stationery etc.
g. Routine acknowledgements;
h. Casual leave applications;
i. Copies of miscellaneous circulars, office memoranda, extracts, etc; circulated by any
section for general information, e.g., orders of general application, telephone lists, notices
of holidays, tour program, etc; and
j. Any other types of receipts which under departmental instructions are not required t o be
diarized.
Inter-departmental notes, telegrams, or any other category of receipts sought to be
distinguished from the rest, may be entered in the section diary in red ink.
Receipts redirected to other sections will also be diarized.
Papers referred to another department will be diarized each time they are received back.
For those referred under diary numbers, however, previous and later entries in the
diary will be linked by giving the earlier and the later diary numbers against each entry.
If a receipt is diarized after a lapse of more than 15 days from the date it bears, the entry
regarding date in column 3 of the section diary will be circled in red ink.
The concerned officers will scrutinize the section diaries once a week to see that these are
being properly maintained and append his dated initials in token of scrutiny.
Action b y higher officer s

Officers to whom receipts are submitted will:
(1) Go through the receipts and initial them;
(2) Remove receipts which they may like to dispose of without assistance from section or to submit
to higher offic ers;
(3) Enter the diary numbers of the receipts removed on the movement slip
(4) Where necessary, give directions regarding line of action to be taken on other receipts; and
(5) Return the receipts together with movement slip, if any, to the Officer for action
Allocation of di sputed receipt s
If a section feels that it is not concerned with a misdirected receipt forwarded to it the same should
be brought to the notice of the officer designated by the department for deciding allocation of
disputed receipts.
Dispatch
Despatch of po stal communication s
(1)
The despatcher will hand over communications to be sent by post to the peon/daftry, who will:
(a) Separate those to be sent by foreign post from the rest;
(b) Paste the telegrams, if typed on plain paper, over the printed form of telegram
supplied by the Department of Posts and affix service postage stamps of the
appropriate value thereon;
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(c) If a c redit deposit account is maintained for issuing telegrams, affix rubber-stamp
indicating the credit deposit account number assigned to the department in the
space provided for affixing postage stamps;
(d) Affix postage stamps of the appropriate value on covers, packets, etc. where
necessary after weighing them, using ordinary postage stamps for foreign post and
service postage stamps for inland post;
(e) Stamp the covers with a rubber-stamp bearing the name of the department; and
(f) Return the communications to the dispatcher.
(2)
The despatcher will enter the particulars of the communications and the value of stamps
affixed thereon in the dis patch register.
This can be generat ed automatically in a
computer environment.
Despatch of non -po stal communication s

(1)
(2)
(3)
(4)
Non-postal communications will be sorted out according to the location of the addressees,
entered in messenger books and handed over to messenger for delivery to the addressees.
Messenger books will be numbered serially and an adequat e number of such books
allotted t o each department/office or several departments/offices grouped conveniently
according to their loc ation.
Urgent communications will be des patched promptly. The time of despatch will invariably be
noted in the messenger book. The receipts will similarly be required to indicate the time of their
receipt. Ordinary communic ations will be despatched at least twice a day at suitable intervals.
Only urgent communications will be despatched outside office hours.
Ret urn of p aper s - A fter issue of fair communications the des patcher will make over office
copies, toget her with drafts and relevant files, if any, to the clerk maintaining the issue diary.
The latter will return t he papers to the diarists of the sections concerned after making entries in
column 3 of the issue diary.
Reference list s
(1)
To facilitate quick despatch of papers the central issue section will maintain the following lists
and directories:
(a) Residential addresses and telephone numbers
department;
of officers
and staff of the
(b) Departments which have arrangements within the central registry for receipt of dak
outside office hours (wit h name and telephone number of the official incharge);
(c) Residential addresses and telephone numbers of officers of other departments
designated to receive urgent dak outside office hours;
(d) Residential addresses and telephone numbers of officers of other departments
designated to receive parliamentary papers;
(e) Postal addresses of all offices under the department, attached offices, subordinate
offices, autonomous bodies, etc; which deal directly with it;
(f) Telegraphic and e-mail addresses, and telephone and fax numbers of State
Governments and other outstation offices frequently addressed;
(g) Schedule of postal rates.
(h) Postal PIN code directory
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(2)
These lists will be kept up to date and displayed prominently for easy consultation by the
despatcher, the resident clerk and other officials on duty.
Note Sheet
The aim of a note is to present the facts in the most intelligible, condensed and convenient form so
that the decision taking authority may take a quick and correct decision.
Guidelines for noting
(1)
(2)
(3)
(4)
(5)
All notes will be concise and to the point. Lengthy notes are to be avoided.
When passing orders or making suggestions, an officer will confine his note to the actual points
he proposes to make without reit erating the ground already covered in t he previous notes. If he
agrees to the line of action suggested in the preceding note, he will merely append his
signature.
The dealing hand will append his full signature wit h date on the left below his note. An officer
will append his full signature on the right hand side of the note with name, designation and
date.
A note will be divided into serially numbered paragraphs of easy size, say ten lines each.
Paragraphs may preferably have brief titles. The first paragraph will give an indication of the
evidence and the conclusions reached. The final paragraph should weigh the arguments and
make recommendations for action.
A small margin of about one inch will be left on all sides (left, right, top and bottom) of each
page of the note sheet to ensure better preservation of notes recorded on the files as at times
the paper gets torn from the edges making reading of the document difficult. However, notes
should be typed/ written on both sides of the note sheet.
Noting on file s received from other departments

(1)
If t he reference seeks the opinion, ruling or concurrence of the receiving department and
requires detailed examination, s uch examination will normally be done separately through
routine notes and only the final result will be recorded on the file by the officer responsible for
commenting upon the reference.
(2)
Where the reference requires information of a factual nature or other action based on a clear
precedent or practice, the dealing hand in the receiving department may note on the file
straightway.
(3)
Where a note on a file is recorded by an officer after obtaining the orders of a higher officer, the
fact that t he views expressed therein have the approval of t he latter s hould be specifically
mentioned.
Oral discu ssion s

All points emerging from discussions (including t elephonic discussions) bet ween two or more
officers of the same department or from discussions bet ween officers of different departments, and
the conclusions reached will be recorded on the relevant file by the officer authorizing action.
Oral instru ction s by higher officer s
(1)
Where an officer is giving direction (including telephonic direction) for taking action in any case
in respect of matters on which he or his subordinate has powers to decide, he shall ordinarily
do so in writing. If, however, the circ umstances of the case are such that there is no time for
giving the instructions in writing, he should follow it up by a written confirmation at his earliest.
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File Management
Filing of papers
(1)
Papers required to be filed will be punc hed on the left hand top corner and tagged onto the
appropriate part of the file viz. notes, correspondence, appendix to notes and appendix to
correspondence, in chronological order, from left to right.
(2)
Earlier communications referred to in the receipt or issue, will be indic ated by pencil by giving
their position on the file.
(3)
Routine receipts and issues (e.g., reminders, acknowledgments) and routine not es will not be
allowed to clutter up the file. They will be placed below t he file in a separate cover and
destroyed when they have served their purpose.
(4)
On top of the first page of the note portion in eac h volume of the file, file number, name of the
Department, name of branch/section and subject of the file will be mentioned.
File numbering sy stem - A proper file numbering system is essential for convenient identification,
sorting, storage and ret rieval of papers.
E very file will be assigned a file number which will consist of: Serial No.Year under a standard head
and Subject of the file and An abbreviated symbol identifying the Dept./Section
Note: In a c omput er environment file numbering will be done electronically in either of t he systems.
A unique file number will be automatically generated whenever a fres h file is opened.
Records Management
Record s Section: Records Section is a very important section as far as an office is
concerned,. The old records, containing important orders and decisions and valuable
registers have to be arranged and kept in a section for future reference. A systematic
arrangement is necessary to keep the old records, to make them available for immediate reference
and also for weeding out of the old records.
Acti vities invol ved in records management

(1)
(2)
(3)
(4)
Records management covers the activities concerning recording, retention, ret rieval and
weeding out.
Stage of recording - Files should be recorded after action on the issues considered thereon
has been completed. However, files of a purely ephemeral nature (such as casual leave
records or circulars of temporary nature) containing papers of little reference or research value
may be destroyed after one year without being formally recorded.
Cu stody of reco rd s - Recorded files will be k ept serially arranged in the sections/desks
concerned for not more than one year, aft er which they will be trans ferred to the departmental
record room.
Record s maintained by officer s and their personal staff - Each department may issue
departmental instructions to regulate the review and weeding out of records maintained by
officers and their personal staff.
Forms and Procedure of Communication

Form s of w ritten communication s and method s of delivery The different forms of written c ommunication and their methods of delivery generally used by a
department are described below. Each form has a use and, in some cases, a phraseology of its
295

own. Only black or blue ink will be used in communic ations. A small margin of about one and half
inch will be left side and one inc h on right side of each page of communications to ensure better
preservations of records as at times the paper gets torn from the edges, making reading of the
documents difficult.
(1)
Letter - This form is used for corresponding with Foreign Governments, State Governments, the
Union Public Service Commission and other constitutional bodies, heads of attached and
subordinate offices, public enterprises, statutory authorities, public bodies and members of the
public generally. A letter begins with the salutation Sir/Madam as may be appropriat e.
C..omponents of a letter:
(2)
Number of communication along with no. of file

Letter head -showing details of office
Place & Date of Communication
Name & Address of sender
Name & Address of Addressee
Subject
Salutation
Subscription
Signature, Name & Designation of Sender
Copy to, as endorsement, if needed ;and signed again at the bottom
Demi-official letter (a) This form is generally used in correspondence bet ween Government officers for an interchange or communication of opinion or information without the formality of the prescribed
procedures. It may also be used when it is desired that the matter should receive personal
attention of the individual addressed. Since demi-official letter is written in the first person in
a pers onal and friendly tone, it should be addressed by an officer in a Department who is
ordinarily not more than one or t wo levels below the officer to whom such communication is
addressed.
(b) Communications to non-officials can also take the form of a demi-official letter.
(3)
When to writ e a DO:

Correspondence bet ween officers without formality of prescribed procedures
In matters seeking personal attention
In cases of delayed action and reminders going un-noticed, for inviting
personal attention
Features of DO:
Addressed personally to officer
Written in First person
Starts with Salutation-My Dear or Dear.
Ends with subscription-yours sincerely
Signed without mentioning designation
Office Memorandum - This form is generally used for c orresponding with other departments or
in calling for information from or conveying information to its employees. It may also be used in
corresponding with attached and subordinate offices. It is written in the third person and bears
no salutation or supersession except the name and designation of the officer signing it.
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(4)
Inter-departmental note (a) This form is generally employed for obtaining the advice, views, concurrence or comments
of other departments on a proposal or in seeking clarification of the existing rules,
instructions etc. It may also be used by a department when consulting its attached and
subordinate offices and vice versa.
(b) The int er-departmental note may either be recorded on a file referred to anot her department
or may take the form of an independent self-contained note. The subject need not be
mentioned when rec orded on the file.
(5)
Telegram
This form is used for communicating with out-station parties in matters demanding prompt
attention. The text of the telegram should be as brief as possible.
(6)
Fax facility In urgent and import ant matters (including legal and financial messages),
departments may use fax facilities to send messages, wherever available.
Offices not connected through fax but having telex facilities, may send urgent and important
messages through telex instead of a telegram in communicating with out -station offices.
(7) Registered Post/ Registered AD This method of delivery is used in communicating with offices
to ensure receipt of the communication and in the case of Registered AD an
acknowledgement of the delivery is also received by the issuing office.
(8)
Speed Post This method of delivery is used to ensure quick receipt of messages warranting
urgent attention at the receiving end and an acknowledgement of the delivery is also r
eceived by the issuing office.
(9)
Office order - This form is normally used for issuing instructions meant for int ernal
administration, e.g., grant of regular leave, distribution of work among officers and sections,
appointments and transfers, etc.
(10) Order - This form is generally used for issuing certain types of financial sanctions and for
communicating government orders in disciplinary cases, etc., to the officials concerned.
(11) Notification - This form is mostly used in notifying the promulgation of statutory rules and
orders, appointments and promotions of gazetted officers, etc. through publications in the
Gazette of India.
(12) Resolution - This form of communication is used for making public announcement of decisions
of government in important matters of policy, e.g., the policy of industrial licensing, appointment
of committees or commissions of enquiry. Resolutions are also published in the Gazette of
India.
(13) Press communiqu/ note - This form is used when it is proposed to give wide publicity to a
decision of government. A press communiqu is more formal in character t han a press note
and is expected to be reproduced intact by the press. A press note, on the ot her hand, is
intended to serve as a hand-out to the press which may edit, compress or enlarge it, as
deemed fit.
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(12) Endorsement - This form is used when a paper has to be returned in original to the sender, or
the paper in original or its copy is sent to another department or office, for information or action.
It is also used when a copy of a communication is proposed to be forwarded to parties other
than the one to which it is addressed. Normally this form will not be used in communicating
copies to state governments. The appropriate form for such communication should be a letter.
(13) Circular This form is used when important and urgent external communications received or
important and urgent decisions taken internally have to be circulated within a department for
information and compliance by a large number of employees.
(14) Advertisement This form is used for communicating with the general public to create
awareness and may take the form of audio-visual or written communication.
(15) E-mail This is a paperless form of communication to be used by department having
computer facilities supported by internet or intranet connectivity and can be widely used for
subjects where legal or financial implications are not involved.
Telephonic communications
(1)
Appropriate use of the medium of telephone may be made by departments for intra and interdepartmental consultation and for communication of information bet ween parties situated
locally.
(2)
In matters of urgency, departments may communicate with out-station offices also over
telephone.
(3)
Telephonic communications, wherever

communications by way of confirmation.
(4)
Resort to ISD/ S TD and trunk calls will be regulat ed by departmental instructions.
necessary,
may
be
followed
by
the
written
Target date for replies - In all important matters in which State Governments, departments of the
Cent ral Government, or other offic es, public bodies or individuals are cons ulted, time limit for replies
may ordinarily be specified. On the expiry of the specified dat e, orders of the appropriate aut hority
may be obtained on whether t he offices, whose replies have not been received, may be allowed an
extension of time or whether the matter may be processed, without waiting for their replies.
Drafting of Communications
General instructions for drafting
o
o
o
o
o
o
o
o
A draft should carry the message sought to be convey ed in a language that is clear, concise
and incapable of misconstruction.
Lengthy sentences, abrupt ness, redundancy, circumlocution, superlatives and repetition,
whet her of words, observations or ideas, should be avoided.
Communications of some lengt h or complexity should generally conclude with a summary.
Depending upon the form of communic ation the subject should be mentioned in it (including
reminders).
A draft should clearly specify the enclosures which are to accompany the fair copy.
The name, designation, telephone number, fax number, and e-mail address of the officer, over
whos e signature the communication is to issue, should invariably be indicated on the draft.
In writing or typing a draft, sufficient space should be left for the margin and bet ween
successive lines to admit additions or interpolation of words, if necessary.
A slip bearing the words `Draft for approval' should be attached to the draft. If two or more
drafts are put up on a file, the drafts as well as the slips attached thereto will be marked `DFA I',
`DFA II', `DFA III' and so on.
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Drafts which are to issue as Ìmmediate' or `Priority' will be so marked under the orders of an
officer not lower in rank than a Section Officer.
Marking of draft s f or i ssue

After a draft has been approved, the concerned officer will:
(1)
Examine the draft to see that all corrections of spelling and grammar, etc., have been properly
carried out and that there are no typographical errors;
(2)
Photocopy of signed communication will be preferably kept as office copy;
(3)
ensure that copies of enclosures are attached to the draft where these are available in the
section;
(4)
Give clear indication on the draft, where a communication is to be despatched by a special

messenger/fax/speed post/registered post on account of its special nature, importance or
urgency;
(5)
Mark the draft for ìssue' (if there are more than one draft for issue from the same file, indicate
the total number of drafts, e.g., ìssue 3 drafts'); and
(6)
Mark the file for rec ording it in a case where the issue of said communication constitutes final
disposal of the case under consideration.
The sam e proc edure may be follow ed for i ssue o f draf t s g ener at ed thro ugh compu ter.
Meetings and Consultation

Departmental meetings may be held where it is necessary t o elicit the opinion of other departments
on important cases and arrive at a decision within a limited time. No such meeting will normally be
convened except under the orders of an officer not below the level of Joint Secretary. In respect of
such meetings, it will be ens ured that:
a.
b.
c.
d.
e.
The representatives attending the meeting are officers who c an take decisions on behalf of
their departments;
An agenda/minutes setting up clearly the points for discussion is prepared and sent along with
the proposal for holding the meeting, allowing adequate time for t he repres entatives of other
departments to prepare themselves for the meeting; and
A record of discussions is prepared immediately aft er the meeting and circulated to the other
departments concerned, setting out the conclusions reached and indicating the department or
departments responsible for taking further action on each conclusion.
On occasions it may be necessary to have oral discussions (including teleconferencing or video
conferencing) with officers of other departments.
The result of such oral consultation should be recorded in a single note on the file by the officer
of the department to which t he case belongs. The note will state clearly the conclusions
reached and the reasons thereof. A copy of the note will also be sent to the departments
consulted in order that they have a record of the conclusions reached.
Condu cting Meeting

What is a meeting?
Two or more people coming together, for t he purpose of discussing/ debating on a (usually)
predetermined topic /agenda.
Purpo se of meeting in health sect or Sharing information,

299

Receiving instructions,
Planning,
Crisis management
Process:
Pre-plan
o who will be invited to the meeting (Enlist),
o convey the purpose of the assembly(communication),
o the topics to be covered (identify & enumerate)and
o The information to be gathered and disseminated (formats and procedure).
Call/Send -circular/ notices minimum 15 days in advance to confirm the timing and location.
o Participants will be better prepared
o The desired dossier can be prepared by the participants for bringing to the meeting.
Get all the requisite /report s/record s in advance, analyze them and prepare brief to facilitate
interaction.
Make a specific goal for themeeting. The end goal could be a brainstorming session, a decision
making on new strategies / review of performance /planning for a new service.
Write a precise agenda. Detail the important facts.
Di stribu te the explicitly detailed agenda along with the meeting notices.
Set up the Meeting Place Cleanliness ,Comfortable,
Sitting space,
Proper AV aids,
Food/snacks.
Note pad & Pen to scribble
Keep extra copies of notices and agenda.
Keep a attendance sheet ready and have it signed by those attending
Keep handy the supplement ary papers/ reports/ references.
Welcome the participants to the meeting and make sure everyone has their agenda in front of
them. State the purpose of the meeting and the preset ending time.
Ex plain the purpose, proce ss and ex pected outcomes.
Listen to the participants fir st before offering comment s.
Stay on track and quickly hit the highlights and address questions.
If the meeting is a presentation that you are doing, keep check of your own timing. At the
beginning you can request that questions be kept to the end of the presentation.
A ssign a repertoire ( to record proceedings)
1. Who attended?
2. What problems were discussed?
3. Key decisions reached.
Meeting needs to be focu sed & mo ving.
Summarize the key point s as the meeting ends.
Break the meeting on time and thank everyone for their contribu tion
Follow up:
After 7-15 days ensure Communication is sent on the desired action points
Feed back obtained
Responses acknowledged
Corrective meas ures taken and communicated
Actions appreciated in writing
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Security of Of ficial Information and Document s

Unless aut horiz ed by general or specific orders, no official will communicat e to another official or a nonofficial, any information or doc ument(s) (including electronic document(s)) which has come into his
possession in the course of his official duties.
Confidential character of notes/ file s

The notes portion of a file referred by a department to another will be treat ed as confidential and will not
be referred to any aut hority outside the secretariat and attached offic es without the general or specific
consent of the department to which the file belongs. If the information is in the electronic form it will be
handled by the authorized official only.
Communication of information to the press
1.
Official information to the press and other news media, i.e. radio and television, will normally be
communicated through the Press Information Bureau.
2.
Whenever it is proposed to release an official information to the press, or to hold a press

conference or press briefing, or to give publicity to an official report, resolution or any other
publication, the department concerned will consult the accredited information offic er in
advance. The accredited information officer will meet the authorized officials from time to time
and collect information worthy of publicity.
Office Au tomation and their Safety

Purpo se of o ffice automation - Use of modern office equipment in of business in the disposal
Government departments is intended to facilitate faster processing and delivery of information,
accurate analysis of facts and figures, higher efficiency and productivity, and elimination of fatigue
arising from performing repetitive jobs manually. So taking care of these is not only the responsibility
of a single person but of every employee who is working on them.
Computer and peripherals such as printer, scanner, server, CD writer, ISDN server, etc
Electronic typewriter, Photocopier, Dictaphone, Microfilming of records
a.
b.
Internal Communication Aids -Electronic Private Aut omatic Exchange (EPA X), Local Area
Network (LA N),
External Communication Aids - Electronic Mail(E-Mail) and FA X, Paper Binding E quipment,
Document shredder, Risograph, Overhead projector, Slide projector, LCD projector, Video
projection system, Video Conferencing Equipment .
Handling of Public/Staff Grievances

1.
2.
All officers will redress public grievanc es pert aining to the divisions under their charge. They
will view public grievances with sympathy and mak e special efforts to decide on such cases
expeditiously.
The name, designation, room number, telephone number, etc., of the Officer of Grievances
should be displayed prominently at the Reception and some other convenient place in the
office building of Department/ Public Sector Undertaking/ Autonomous Body so that the
public are made fully aware of it.
a. Each grievance petition will be acknowledged within 15 days. E ven if no action is
warranted on a petition, a reply intimating the stand of the organization must be sent
to the petitioner.
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b.
3.
4.
Time limits will be fix ed for disposal of various types of public/Staff grievances which
are handled in the department with due regard to the minimum time needed for each
type, through departmental instructions.
c. While sending replies communicating final decision rejecting a grievance petition,
the reason or the rule(s) under which it has been rejected will be communicated to
the petitioner along with det ails of the appellate authority wherever applicable.
The feedback mechanism and the monitoring system for grievance redress will be
strengthened, in view of the time limits fixed
The record of grievances will be retained in the c omput er for one year after the date of final
disposal of the grievanc es.
Call Book
The section officer will scrutinize t he call book in the last week of every mont h to see that the cases
which become ripe for further action during the following month are brought forward and action
initiated on due dates. The call book will be submitted to the branch officer/ Divisional Head once a
quarter, i.e. during the mont hs of January, April, July and October. He will satisfy himself that no
case on which action could have been taken suffers by its inclusion in the call book and, in suitable
cases, give directions for the action to be taken.
Miscellaneous
Monthly prog ress report s o f recording and review of files
On the first working day of each month, the record clerk will prepare, in duplicate, progress reports
on the recording and review of files for the preceding month and submit them, together with the
following rec ords, to the concerned officer:
(a)
Register for watching the progress of recording; and
(b)
Lists of files received for review.
Monitoring of Court/ CA T ca ses and implementation of Court/CAT Or der s

The Personal section of eac h Joint Secretary/Director (if the Director s ubmit cases direct to
Secretary/Additional Sec retary) will maintain a separate register of Court/CA T Cases from the date
of filing the petition/ application in Court/CA T. The s erial number at which a petition is entered in the
register will be prominently marked on the petition/application together with its date of registration.
Check-li st of periodical reports
1.
2.
3.
To ensure timely receipt, preparation and des patch of periodical reports, each section will
maintain two check-lists, one for incoming reports and the other for outgoing reports, in the
forms.
The check-lists will be prepared at the commencement of each year, approved by the
section officer, shown to the branch officer and displayed prominently on the wall.
The section officer will go through the check-lists once a week to plan action on items
requiring attention during the next week or so.
Review of periodical report s/return s

All periodical reports and returns relating to each section will be reviewed every three years with the
following objectives;
-
To eliminate those are unnecessary;
To redesign those do not provide information/data in usable form;
To rationalize/simplify the essential ones by combining two or more of them when possible; and
302

To revise the frequency in relation to t he need with due regard to constraint of time required for
collection of information/data from field levels.
Respon sibilities o f Admini st rative Officer A.
General Duties
(i)
Distribution of work among the staff as evenly as possible;
(ii)
Training, helping and advising the staff;
(iii) Management and co-ordination of the work;

(iv) Maintenance of order and discipline in the section;
(v)
Maintenance of a list of residential addresses of the Staff.
B.
Respon sibilities relating to Dak
(i)
to go through the rec eipts;
(ii)
to submit receipts which should be seen by the concerning Officer or higher offic ers at t he dak
stage;
(iii) to keep a watch on any hold-up in the movement of dak; and

(iv) to scrutinize the section diary once a week to know that it is being properly maintained.
C.
Respon sibilities relating to issue of draft
(i)
to see that all corrections have been made in the draft before it is marked for issue;
(ii)
to indicate whether a clean copy of the draft is necessary;
(iii) to indicate the number of spare copies required;

(iv) to check whether all enclos ures are attached;
(v)
to indicate priority marking;
(vi) to indicate mode of despatch.

D.
Respon sibility of effi cient and ex peditious di spo sal of w ork and check s on delays
(i)
to keep a not e of import ant receipts with a view to watching the progress of action;
(ii)
to ensure timely submission of arrear and other returns;
(iii) to undertake inspection of Assistants table to ensure that no paper of file has been overlooked;
(iv) to ensure that cases are not held up at any stage;
(v) to go t hrough the list of periodical returns every week and t ake suitable action on items
requiring attention during next week.
E.
Independent dispo sal of case s
He should take independently action of the following types

(i)
issuing reminders;
(ii)
obtaining or supplying factual information of a non-classified nature;
(iii) any other action which a Officer is authorized to take independently.

303

F.
Dutie s in respect o f recording and index ing
(i)
to approve the recording of files and their classification;
(ii)
to review the recorded file before destruction;
(iii) to order and supervise periodic weeding of unwant ed spare copies;

(iv) ensuring proper maintenanc e of registers required to be maintained in the section;
(v)
Ensuring proper maintenance of reference books, Office Orders etc. and keep them up-to-dat e;
(vi) Ensuring neatness and tidiness in the Section;
(vii) Dealing with important and complicated cases himself;

(viii) Ensuring strict compliance with Departmental Security Instructions.
304

NFHS -III, Rajasthan

Indicators
Marriage & Fertility
Women age 20-24 married by age 18 (%)
Men age 25-29 married by age 21 (%)
Total fertility rate (children per woman)
Women age 15-19 who were already mothers or pregnant at
the time of the survey (%)
Median age at first birth for women age 25-49
Married women with two living children wanting no more
children (%)
a. Two sons
b. One son, one daughter
c. Two daughters
Family Planning (currently married w omen, age 15-49)
Any method (% )
Any modern method (% )
a. Female sterilization
b. Male sterilization
c. IUD
d. Pill
e. Condom
Unmet need for family planning
Total unmet need
a. For spacing
b. For limiting
Maternal and Child Health
Mothers who had at least 3 antenatal care visits for their last
birth (%)
Mothers who consumed IFA for 90 days or more when they
were pregnant with their last child (%)
Births assisted by a doctor/nurs e/LHV/ANM/other health
personnel (%)
Institutional births (%)
Mothers who received P NC from a
doctor/nurse/LHV/ANM/other health personnel within 2 days
of delivery for their birth (%)
Child immunization and Vitamin A supplemantation
Children 12-23 months fully immunized (BCG, measles, 3
doses each of polio/DP T) (%)
Children 12-23 months who have received BCG (%)
Children 12-23 months who have received 3 doses of polio
vaccine (% )
Children 12-23 months who have received 3 doses of DP T
vaccine (% )
Children 12-23 months who have received measles vaccine
(%)
NFHS III
(2005-06)
NFHS
II
(1998-99)
NFHS I
(1992-93)
57.1
56.7
3.21
16.0
68.3
N.A.
3.78
N.A.
69.5
N.A.
3.63
N.A.
19.6
72.8
19.4
58.3
19.7
44.2
83.9
77.7
33.1
74.8
63.1
12.5
57.4
53.0
6.7
47.2
44.4
34.2
0.8
1.6
2.0
5.8
40.3
38.1
30.8
1.5
1.2
1.5
3.1
31.9
31.0
25.4
2.4
1.2
0.5
1.5
14.7
7.3
7.4
17.6
8.7
8.9
19.8
10.8
9.0
41.2
23.6
18.1
12.8
N.A.
N.A.
43.2
35.8
19.3
32.2
28.9
21.5
N.A.
12.0
N.A.
26.5
17.3
21.1
68.5
65.2
53.9
44.6
45.6
33.9
38.7
26.1
29.6
42.7
27.1
31.3
305

Children 12-35 months who received a vitamin A dos e in the 13.2

last 6 months (%)
Treatment of childhood disease s (children under 3 years)
Children with diarrhea in the last 2 weeks who received ORS 16.0
(%)
Children with diarrhea in the last 2 weeks taken to a healt h
56.6
facility (%)
Children with ARI or fever in the last 2 weeks taken to a
68.9
health facility (%)
Child Feeding Practices and Nu tritional Statu s of Children
Children under 3 years breastfed within one hour of birth (%) 13.3
Children age 0-5 months exclusively breastfed (%)
33.2
Children age 6-9 months receiving solid or semi-solid food
38.7
and breastmilk (%)
Children under 3 years who are stunted (%)
33.7
Children under 3 years who are wasted (% )
19.7
Children under 3 years who are underweight (%)
44.0
Nutri tional Status of Ever -Married Adult s (age 15-49)
Women whose Body Mass Index is below normal (%)
33.6
Men whose Body Mass Index is below normal (%)
33.8
Women who are overweight or obese (%)
10.2
Men who are overweight or obese (%)
8.4
Anaemia among Children and Adults
Children age 6-35 months who are anaemic (%)
79.6
E ver-married women age 15-49 who are anaemic (%)
53.1
Pregnant women age 15-49 who are anaemic (%)
61.2
E ver-married men age 15-49 who are anaemic (%)
20.5
Know ledge of HIV/AIDS among Ever-Married Adult s (age 15-49)
Women who have heard of A IDS (% )
33.8
Men who have heard of A IDS (% )
74.2
Women who know that consistent condom use reduc e the
27.3
changes of getting HIV/AIDS (%)
Men who know that consistent condom use reduc e the
63.2
changes of getting HIV/AIDS (%)
Womens Empow erment
Currently married women who usually participate in
40.2
household decisions (%)
E ver-married women who have ver experienced spousal
46.3
violence (%)
N.A.
N.A.
20.3
12.1
58.2
50.0
N.A.
N.A.
4.8
N.A.
N.A.
8.1
N.A.
N.A.
52.0
11.7
50.6
41.8
21.2
44.3
36.1
N.A.
7.1
N.A.
N.A.
N.A.
N.A.
N.A.
82.3
48.5
51.4
N.A.
N.A.
N.A.
N.A.
N.A.
20.8
N.A.
N.A.
N.A.
N.A.
N.A.
N.A.
N.A.
N.A.
N.A.
N.A.
N.A.
306

DLHS -3, Rajasthan

Indicator s
DLHS -3
(2007-08)
Sample Size
Hous eholds
40052
E ver-married women (15-49)
41448
Currently married women (15-44)
35366
Unmarried women (15-24)
8418
Population and household profile
Population literate age 7+ (%)
61
Population below 15 years (%)
36.2
Mean HH size
5.4
Percentage of HH that
Have electricity
61.7
Have access to toilet facility
25.1
Live in kachcha house
34.5
Live in pucca house
37.7
Use piped drinking water
34.6
Low standard of living
50.6
High standard of living
22.5
Aw areness about Government health programs (ba sed on respon se of HH)
DOTS (% )
79.5
Leprosy eradication (%)
53.8
Malaria/dengue/chikunguinea
90.6
Prevention of sex selection (%)
64.3
Marriage
Mean age at marriage for boys
20.7
Mean age at marriage for girls
17.7
Boys married below age of 21
48.4
Girls married below age of 18
41
Currently married wome 20-24, married before 18 years (%)
57.6
Indicator s based on cur rently married w omen (age 15-44)
Characteristics of women
Currently married non literate women (%)
66.3
Currently married women with 10 or more years of schooling (%)
9.2
Fertility
Births to women during age 15-19 out of total births (%)
4.7
Women 20-24 reporting birth order of 2 and above (%)
45.9
Women with 2 children wanting no more child
56.0
Mean children ever born to women (40-44 years)
4.4
Current u se of family planning methods
Any method (% )
57
Any modern method (% )
54.0
Female sterilization (%)
40.5
Male sterilization (% )
0.5
Pill (%)
3.2
IUD (%)
1.4
Condom (%)
8.3
DLHS -2
(2002-04)
33833
N.A.
32911
N.A.
57.2
39.2
5.7
61.9
29.4
31.3
53.3
42.2
49.3
22.6
N.A.
N.A.
N.A.
N.A.
20.3
17.2
53.4
50.8
N.A.
68.4
9.6
N.A.
60.3
40.8
4.8
45.9
41.4
31.2
0.6
2.6
1.3
5.5
307

Any traditional method (%)

Rhythm/Safe period (%)
Couple using spacing method for more than 6 months (%)
E ver used Emergency Cont raceptive Pills (%)
Unmet need for family planning
Total unmet need (%)
For spacing (Definition I) (% )
For limiting (Definition I) (%)
Total unmet need (%)
For spacing (Definition II) (%)
For limiting (Definition II) (%)
Antenatal care (based on w omen w hose last pregnancy ou tcome w as
reference period)
Mothers who received any antenatal check-up (% )
Mothers who had antenatal check-up in first trimester (%)
Mothers who had 3 or more ANC (%)
Mothers who had at least one tetanus toxoid injection (%)
Mothers whose Blood Pressure (BP) taken (% )
Mothers who consumed 100 IFA Tablets (%)
Mothers who had full antenatal check-up (%)
Delivery care (based on w omen w hose last pregnancy ou tcome w as
reference period)
Institutional delivery (% )
Delivery at home (% )
Delivery at home conducted by skilled health personnel (% )
Safe delivery (% )
Mothers who received P NC within two weeks of delivery (%)
Mothers who received financial assistance for delivery under JSY
(%)
Child immunization
Number of children age 12-23 months
Children 12-23 months fully immunized (%)
Children 12-23 months not received any vaccination (%)
Children 12-23 months who have received BCG vaccine (%)
Children 12-23 months who have received 3 doses of DP T vaccine
(%)
Children 12-23 months who have received 3 doses of polio
vaccine (% )
Children 12-23 months who have received measles vaccine (% )
Children (age 9 months and above) received at least one dos e of
vitamin A supplement (%)
Child feeding practices (ba se on last born c hild) (%)
Children under 3 years breastfed within one hour of birth
Children age 0-5 months exclusively breastfed
Children age 6-35 months exclusively breastfed for at least 6
months
Children age 6-9 months receiving solid/semi-solid food and breast
milk
2.8
1.7
9.6
0.5
4.5
3.2
N.A.
N.A.
17.9
22.1
7.7
8.3
10.2
13.8
11.4
N.A.
4.4
N.A.
7.0
N.A.
live/still birth during
56.6
67.3
32.7
29.3
27.7
28.8
55.0
61.4
29.5
32.3
15.6
7.4
5.7
4.5
live/still birth during
45.5
53.7
13.4
52.7
38.2
31.9
30.3
69.2
20.0
43.4
N.A.
N.A.
3411
48.8
14.3
82.8
55.6
4183
23.9
29.6
60.0
35.0
63.9
35.2
67.5
50.8
35.1
21.6
41.9
65.5
25.4
14.3
N.A.
5.3
43.7
N.A.
308

Aw areness about Diarrhea and ARI

Women aware about danger signs of ARI (%)
98.6
71.7
Treatment of childhood disea ses (ba sed on last tw o survi ving children born during the
reference period)
Children with diarrhea in the last 2 weeks who received ORS (% )
30.6
28.9
Children with diarrhea in the last 2 weeks who were given
59.7
61.7
treatment (%)
Children with ARI or fever in the last 2 weeks who were given
69.8
70.1
advis e or treatment (% )
Aw areness o f RTI/STI and HIV/AIDS
Women who have heard of RTI/STI (% )
47.3
63.8
Women who have heard of HIV/A IDS (% )
52.3
30.0
Women who have any symptoms of RTI/S TI (%)
16.2
47.9
Women who know the place to go for testing of HIV/A IDS (% )
64.9
N.A.
Women underwent test for detecting HIV/A IDS (% )
0.8
N.A.
Other reproduc tive health problems
Women had primary or secondary infertility (%)
4.8
N.A.
Women had problem of obstetric fistula (% )
0.4
N.A.
Quality of family planning services
Currently married non-users who ever rec eived counseling by
21.8
9.6
health personnel to adopt family planning (% )
Current users ever told about side effects of family planning
21.1
32.5
methods (% )
Users who received follow-up services for IUD/sterilization within
62.3
N.A.
48 hours (%)
Indicator s based on unmarried w omen (age 15-24)
Characteristics of women
Unmarried non-literate women (%)
16.3
N.A.
Unmarried women with 10 or more years of schooling (%)
26.6
N.A.
Family life education
Unmarried women who opined family life education/sex education
71.1
N.A.
important (%)
Unmarried women who ever received family life education/sex
38.1
N.A.
education (%)
Unmarried women who are aware of legal minimum age at
94.9
N.A.
marriage for girls in India (%)
Aw areness o f con traceptive methods
Unmarried women who know about condom (% )
73.7
N.A.
Unmarried women who know about pills (%)
82.3
N.A.
Unmarried women who know about Emergency Cont raceptive Pills (%)
32.3
N.A.
Unmarried women who ever discussed about contraception with
any one (%)
Aw areness o f RTI/STI and HIV/AIDS
Unmarried women who have heard of RTI/STI (% )
Unmarried women who have heard of HIV/A IDS (% )
Unmarried women who know the place to go for testing of
HIV/A IDS (% )
Unmarried women underwent test for detecting HIV/A IDS (% )
25.0
N.A.
41.6
72.9
68.3
N.A.
N.A.
N.A.
0.2
N.A.
309

Indicator s
DLHS -3
(2007-08)
Villages covered
Number of villages
Health Facilities covered
Sub centers (SC)
Primary Health Cent ers (PHC)
Community Health Center (CHC)
District Hospitals (DH)
Health programmes at village level
Number of villages having AS HA
Villages having beneficiary under JSY (%)
Villages where Health and Sanit ation Committee formed (%)
Villages where Pradhan/Panchayat member aware of untied fund (%)
Acce ssi bility of Health Facility
Villages with Sub Center within 3 kms (%)
Villages with PHC within 10 kms (%)
Infrastru cture, staff and service s at Sub Center (SC)
Sub Center located in government building (% )
Sub Center with ANM (% )
Sub Center with male healt h worker (% )
Sub Center with additional ANM (% )
ANM living in Sub Cent er quart er where facility is available (%)
Infrastru cture, staff and service s at Primary Health Centers (PHC)
PHCs having Lady Medical Officer (% )
PHCs having AYUS H Medical Officer (% )
PHCs with at least 4 beds (%)
PHCs having residential quarter for Medical Officer (% )
PHCs functioning on 24 hours basis (%)
PHCs having new born care services (%)
PHCs having referral services for pregnancies/delivery (%)
PHCs conducted at least 10 deliveries during last one month (%)
Infrastru cture, staff and service s at Community Health Centers (CHC)
CHCs having Obstetrician/ Gynaec ologist (%)
CHCs having 24 hours normal delivery services (%)
CHCs having functional Operation Theatre (%)
CHCs designated as FRUs (% )
CHCs designated as FRUs offering caesarean section (% )
FRUs having new born care services on 24 hour basis (%)
FRUs having blood storage facility (%)
SRS Oct ober 2009 (Reference Year 2008)
Indicator
Birth Rate
Deat h Rate
Natural Growth Rat e
Rajasthan
27.5
6.8
20.7
63
1265
1004
692
355
32
927
95.7
10.0
29.3
72.4
66.2
76.2
86.5
9.5
21.8
55.1
6.2
19.9
89.9
63.3
56.9
23.9
31.5
42.1
31.5
98.9
60.3
52.7
18.2
88.2
15.0
India
22.8
7.4
15.4
53
310

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What are the main health indicators mentioned for Rajasthan and India?

What are the main health indicators mentioned for Rajasthan and India?

What are the main objectives of NRHM?

What are the main objectives of NRHM?

Training Module

Compiled & developed by:

Population 2001 [Million]

Projected Population 2010 [Million]

Health Care Infrastruc ture

Total Allopat hic Doctors

Total Allopat hic Doctors in Govt.

Infant Mortality Rate

Maternal Mortality Ratio

Total Fertility Rate

Crude Birth Rate

Bed Population Ratio

Population per Sub centre Ratio

Population per PHC

Population per CHC

Couple Protection Rate

Proportion of fully immunized children [12-24 months]

Proportion of Pregnant receiving A NC [Full ANC]

Proportion of Safe Deliveries

SIHFW: ISO 9001:2008 Certified institution

SIHFW: ISO 9001:2008 Certified institution

National Rural Health Mission (2005-2012)

Total Fertility Rate

Infant Mortality Rate

Neonatal Mortality rate

Maternal Mortality Rate

45.5 % (DLHS -3)

SIHFW: ISO 9001:2008 Certified institution

The NRHM carries a paradigm shift with Decentralised planning

SIHFW: ISO 9001:2008 Certified institution

Areas addre ssed:

SIHFW: ISO 9001:2008 Certified institution

SIHFW: ISO 9001:2008 Certified institution

12. Supplement ary strategya. Regulation of private sector

301 (K erala:4,UP: 517)

22% (Bihar 5%, HP-68% )

NFHS -III (2005-06)

Rs. 3238 in Govt. Hospitals to

40.7% institutional births ,

FOCUS survey 2004

SIHFW: ISO 9001:2008 Certified institution

- Union Minister H & FW

State LevelChief Secretary, GOR, Chairperson.

State Health Mission :

SIHFW: ISO 9001:2008 Certified institution

State Health Society:

District health planning, implementation and monit oring

Members of Di stric t Health Society:

District Collector Chairperson

SIHFW: ISO 9001:2008 Certified institution

Dy. Director ICDS Member

Program Management Units:

SIHFW: ISO 9001:2008 Certified institution

SIHFW: ISO 9001:2008 Certified institution

Key Ac tivities (2005-06):