NATIONAL HEALTH MISSION
Public Health and Hospitals is a State subject. Hence the main responsibility for provison of quality healthcare and ensure its availability lies with the State Government. However, under the erstwhile National Rural Health Mission (NRHM) now subsumed as a Sub Mission of the overarching National Health Mission (NHM), the Central governments supplements the efforts of the States through both financial and technical support to strengthen their healthcare systems for provision of accessible, affordable, accountable, and effective healthcare. The National Urban Health Mission (NUHM) is the other sub Mission of NHM.
NHM envisages architectural correction of the public health system throughsector wide health reforms including integration of vertical programmes, decentralization and Communitisation as a pillar of accountability. The NUHM covers cities and towns with more than 50,000 population as well as District Headquarters having population between 30,000 – 50,000, while smaller cities/ towns continue to be covered under sub mission of NRHM.
Funding is provided through five pools: (1) NRHM RCH Flexipool (2) NUHM Flexipool, (3) Flexible Pool for Communicable Diseases, (4) Flexible Pool for Non Communicable Diseases, Injury and Trauma and (5) Infrastructure Maintenance. The support (financial and technical) to States is provided as under:
1.1 NRHM Flexipool Health– Under this pool funding is provided for healthssstem Strengthening Component such as support for augmentation of infrastructure, both upgradation and new construction of Sub Centre,,PHC, CHC, Sub District Hospital, District Hospital, strengthening Sub Centre/PHC to Health and Wellness Centres, Mother and Child Wings (MCH Wings), Sick Newborn Care Units(SNCUs) Newborn Care Corners (NBCCS) etc;Human resources including programme management; patient transport services, that is, ambulances, ( Dial 108 for critical care and Dial 102 for predominantly transporting pregnant women and sick infants), Mobile Medical Units (MMUs), engagement of ASHAs, Rogi Kalyan Samitis, mainstreaming of AYUSH, drugs and drug warehouse, Consumables, equipment including for Bio Medical Equipment Maintence for ensuring functionality of medical equipement, diagnostics ,Untied Grants etc
1.2 RCH Flexipool– Under this pool all interventions/programmes for Reproductive, Maternal, Newborn, Child and Adolescent health (RMNCH+A), such as JSY, JSSK, RBSK, Rashtriya Kishor Swasthya Karyakram,for Adoloscents etc is provided to ensure a continuum of care approach.
2 Flexible Pool for Communicable Diseases– Under this pool funds are provided for control of Communicable Diseases such as National Vector Borne Disease Control Programme (Malaria, Filaria, Kala-azar, Dengue, Chikungunya and Japanese Encephalitis), National Leprosy Eradication Programme, Revised National Tuberculosis Control Programme, and Integrated Disease Surveillance Project.
3 Flexible Pool for Non Communicable Diseases– Under this pool funds are provided for control of Non-Communicable Diseases.This includes all interventions up to District Hospital level for non-communicable disease programmes such as National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS), National Mental Health Programme (NMHP), National Programme for Health Care of the Elderly (NPHCE), and National Tobacco Control Programme (NTCP). The NPCDCS programme also includes programmatic interventions to control and manage chronic kidney diseases and Chronic Pulmonary Obstructive Disorder (COPD).
4 Infrastructure Maintenance– Funds under this component is provided to states to meet salary of regular ANMs, ANM/LHV Training Schools, Health & Family Welfare Training Centres, and Training of Multi-Purpose Workers (Male). These are funded based on reimbursement basis. This is in addition to remuneration of contractual ANMs under Mission Flexipool.
5 NUHM Flexipool– Under this funds are provided for interventions for primary healthcare of the urban poor for Urban PHCs in the state.
NHM – STATE PLANS AND APPROVAL PROCESS
NHM provides unprecedented flexibility to States to prepare plans based on their felt needs and requirements within the resource envelope allocated to them. The State Plans prepared by States which is the Programme Implementation Plan (PIPs) every financial year are submitted to Ministry of Health and Family Welfare. Based on appraisal of the plan and discussion of the PIP in National Programme Coordination Committee Meeting attended by both State and Ministry officials, approval is given to states in the form of Record of Proceedings (RoPs). Both the PIPs and RoPs of all states are available in public domain at //www.nhm.gov.in/index4.php?lang=1&level=0&linkid=449&lid=53.
The NHM is guided by Framework for Implementation of NHM, 2012-2017 which has been approved by the Union Cabinet.
Technical Support and Capacity Building
One key mandate of NHM is training and capacity building of health human resource across States to ensure effective, appropriate and quality health services. The National Health Systems Resource Centre (NHSRC) registered as a Society is an autonomous body and serves as apex technical arm of the NHM in the Ministry of Health and Family Welfare. In addition to technical support, NHSRC provides capacity building through training and also handholds States in rolling out programmes under NHM.
As a special dispensation, for NE States, NHSRC has a dedicated regional Resource Centre known as Regional Resource Centre-NE (RRC-NE) . The mandate of RRC-NE is to assist the NE states to plan, implements and monitor the health activities under NHM. Information about RRC-NE is available at http://www.rrcnes.gov.in/index.html
Currently, the funding pattern under NHM between the Centre-State is 60:40 for all States except for the North East (NE) and three Himalayan States (Uttarakhand, Himachal Pradesh and J&K), where it is 90:10. This means practically NHM funding is mostly borne by the central government for NE states and Himalayan States. Allocation of funds to the states under NRHM- RCH Flexible Pool is done on the basis of population with some additional weightage to states on account of socio-economic backwardness and health lag. The weightage to the states are as under:
For RCH flexible pool allocation is done on the basis of total population of the state and rural area. For Mission Flexible Pool, allocation is done on the basis of rural population and rural area.In these broad categories of states, excluding small UTs category, inter-se allocation of funds to States based on rural population and rural areas in the ratio 75:25. Allocation for National Urban Health Mission is done on the basis of 50% weightage to urban population & 50% to slum population.
The Allocation, Release & Expenditure from 2013-14 to 2017-18 is given at Table below:
- Allocation is as per original outlay/B.E. after revising the allocation under Infrastructure Maintenance to the extent of releases made.
- During the F.Y. 2017-18, as additional funds have been provided at Revised Estimate (RE) stage therefore the allocation has been considered as per the RE.
- Expenditure includes Central Releases, State Releses and unspent balance of previous years. Expenditure is as per FMR , hence Provisional.
- The above releases relate to Central Govt. Grants& do not include State share contribution.
HUMAN RESOURCE UNDER NHM
One of the critical components of healthcare service delivery is the health human resource that are skilled, trained to provide appropriate care to the population. Public Health and hospitals being a state subject, it is the primary responsibility of the State Government to ensure adequate and trained health human resource in public health facilities. To assist States to ensure delivery of health care services, NHM has been augmenting health human resource on contractual basis. If all the positions are filled, it will not only ensure good health service coverage but also provideemployment opportunity.
More pertinently, NHM has been supporting provision of incentives to ensure service of Specialists, doctors, nurses in hard to reach areas. Incentives include funding for hard area allowances, approval for staff quarters and negotiable salaries particularly for doctors and Specialists. NHM has supported initiatives such as “You quote, We pay” for Specialists in backward areas of most States. The approval and status of engagement of HR approved under NHM is as below:
In addition to the above service delivery Staff, there are substantial numbers of Programme Management staff and also support staff which are to be utilized on outsouring basis such as DEOs, Drivers etc.
Limatula Yaden, the writer is Commissioner, Indirect Taxes and Customs and served as Director NHM Policy, Ministry of Health and Family Welfare, Government of India for over 6 years . The views expressed are personal.