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Chapter 3

Various Health Schemes under

National Rural Health Mission (NRHM)

―National Rural Health Mission (NRHM) is a national health program for

improving health care delivery across rural India. The mission, initially mooted for 7

years (2005-2012) has been extended to 12th five year plan period by the Ministry of

Health GoI. The scheme proposes a number of new mechanism for healthcare

delivery including training local residents as Accredited Social Health Activists

(ASHA), and the Janani Surakshay Yojana (motherhood protection program). It also

aims at improving hygiene and sanitation infrastructure. The mission has a special

focus on 18 states Arunachal Pradesh, Assam, Bihar, Chhattisgarh, Himachal Pradesh,

Jharkhand, Jammu and Kashmir, Manipur, Mizoram, Meghalaya, Madhya Pradesh,

Nagaland, Orissa, Rajasthan, Sikkim, Tripura, Uttarakhand and Uttar Pradesh. In the

12th Five Year Plan period, efforts will be made to consolidate the gains and build on

the successes of NRHM to provide accessible, affordable and quality universal health

care, both preventive and curative, which would include all aspects of a clearly

defined set of healthcare entitlements including preventive, primary and secondary

health services. The main targets for mother and child health care at the national level

for 12th five year plan period which are also in consonance with Millenium

development Goals(MDGs)have been set as follows‖1:

Reduction of Maternal Mortality Ratio (MMR) to < 109 per 100000 live

births, by 2015

Reducing Infant Mortality Rate(IMR) to < 27 per 1000 live births, by 2015

Reduction in Neo-Natal Mortality Rate(NMR) to < 18 per 1000 live births, by

2015

Reducing Total Fertility Rate(TFR) to 2.1 by 2017

Raising child sex ratio in the 0-6 year age group from 914 to 935

Prevention and reduction of anemia among women aged 15-49 years-

Reducing anemia to 28%,by the end of the 12th Plan(2017)

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Prevention and reduction of underweight children under 3 years- Reducing

undernourished children under 3 years to 26% by 2015

There are many programmes under NRHM, but for the purpose of present

study only programmes directly related to rural women‘s health in three important

stages of her life as a mother, as a wife and as a daughter are focussed upon. The brief

details of these programmes has been given below:

3.01 Maternal Health

―About 56,000 women in India die every year due to pregnancy related

complications. Similarly, every year more than 13 lacs infants die within 1year of the

birth and out of these approximately 9 lacs i.e. 2/3rd of the infant deaths take place

within the first four weeks of life. Out of these, approximately 7 lacs i.e. 75% of the

deaths take place within a week of the birth and a majority of these occur in the first

two days afterbirth. In order to reduce the maternal and infant mortality,

Reproductive and Child Health (RCH) Programme under the National Rural health

Mission (NRHM) is being implemented to promote institutional deliveries so that

skilled attendance at birth is available and women and new born can be saved from

pregnancy related deaths. Several initiatives have been launched by the Ministry of

health and Family Welfare (MoHFW) including Janani Suraksha Yojana (JSY) a key

intervention that has resulted in phenomenal growth in institutional deliveries. More

than one crore women are benefitting from the scheme annually and the outlay for

JSY has exceeded 1600 crores per year.

3.02 Janani Suraksha Yojana (JSY)

JSY is a scheme supported and funded by the Government of India. It was launched

on 12 April 2005 by the Prime Minister of India. Its aim is to decrease the neo-natal

and maternal deaths happening in the country by promoting institutional delivery of

babies. It is a 100% centrally sponsored scheme it integrates cash assistance with

delivery and post-delivery care. The success of the scheme would be determined by

the increase in institutional delivery among the poor families. Under the scheme

ASHA activists have been assigned the responsibility to encourage the people in the

rural areas for institutional delivery, with particular focus on poor women. Under the

scheme, the states with low rate of Institutional deliveries are classified as 'Low

Performing States(LPS)' which include Uttar Pradesh, Uttaranchal, Bihar, Jharkhand,

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Madhya Pradesh, Chhattisgarh, Assam, Rajasthan, Orissa and Jammu and Kashmir,

whereas the remainingstates are termed as High Performing States(HPS). The details

of Cashbenefits under this scheme are as under‖2:

Rural Areas:

Table3.1 JSY Package for rural areas.

Category Mother’s

Package

ASHA’s

Package

Total Package

(in Rs.)

LPS 1477 677 2777

HPS 777 - 777

Urban Areas:

Table3.2 JSY Package for urban areas

Category Mother’s

Package

ASHA’s

Package

Total

Package

(in Rs.) LPS 1000 200 1200

HPS 600 - 600

The sheme has been operational in Uttarakhand and the status of implementation in

Uttarakhand and district Almora is given below:

Table3.3 Implementation status of JSY in Uttarakhand and Almora

State/District Mothers who

availed financial

assistance for

Delivery under

JSY(%)

Mothers who

availed financial

assistance for

institutional

Delivery

underJSY(%)

Mothers who

availed financial

assistance for

Government

institutional

Delivery under

JSY(%)

Total Rural Urban Total Rural Urban Total Rural Urban

Uttarakhand 30.1 30 30.2 54.3 61.4 41.2 84.7 86.5 80.4

Almora 35.4 34.8 46.8 76.5 78.5 56.4 85.3 86.7 69.9

Source (Annual Health Survey Fact Sheet, Uttarakhand (2011-12)

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According to 42 Point report for March 2013of Almora District out of 6761

expected beneficiaries of JSY Scheme 5485 beneficiaries have availed the benefits

under the scheme during the year 2012-13. In view of the difficulty being faced by the

pregnant women and parents of sick new- born along-with high out of pocket

expenses incurred by them on delivery and treatment of sick- new-born, Ministry of

health and Family Welfare (MoHFW) has taken a major initiative to evolve a

consensus on the part of all States to provide completely free and cashless services to

pregnant women including normal deliveries and caesarean operations and sick new

born(up to 30 days after birth) in Government health institutions in both rural and

urban areas.

3.03 Janani Shishu Suraksha Karyakaram (JSSK)

Government of India , after reviewing the implementation and impact of JSY

has launched JSSK on 1st June, 2011 with free entitlements to pregnant women and

new born. The main features of the scheme includes free and cashless delivery, free

caesarian-Section, free drugs and consumables, free diagnostics, free diet during stay

in the govt. health institutions. Other benefits under the scheme are free provision of

blood, exemption from user charges, free transport from home to govt. health

institutions, free transport between facilities in case of referral, free drop back from

institutions to home after 48hrs of institutional delivery by Khusiyon Ki Sawari (104

service). If the need arises, the scheme also has provision for above mentioned free

entitlements for Sick newborns till 30 days after birth‖3. According to Uttarakhand

Health And Family Welfare Society‘s (UKHFWS‘s ) report for 2011-12 pertaining to

District Almora 4654 women and 4654 children had availed different entitlements

under Janani Shishu Suraksha Karyakaram (JSSK). As per the report of CMO Almora

1836 women were given drop back home facility during 2011-12 under the scheme.

3.04 Village Health and Nutrition Day (VHND)

The basic objective of organizing Village Health and Nutrition Day in Agan

Wari Centres (AWCs) is to create awareness among the pregnant women, lactating

mothers and children and to encourage them for early registration, ANC checkups,

counseling on institutional deliveries, counseling on breastfeeding, family planning,

immunization, menstrual hygiene etc. with an objective to achieve better maternal

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and child health. Weight Monitoring of underweight children usually 3 years of age is

done and efforts are made to improve their weight to healthy category through

counseling of parents and providing fortified food to such children. Village Health

and Nutrition Days are also a platform for creating awareness among the community

about importance of girl child,various health and social security schemes launched

especially targeting the girls as well as disseminating information about The Pre-natal

Diagnostic Techniques (Regulation and Prevention of Misuse) Act, 1994, and

provisions of punishment under the act so that sex ratio between 0-6 years of age

group can be increased. Village Health and Nutrition Days are organized once in a

months at each Anganwadi Centre. ANM, Anganwadi Worker and ASHA workers

have been given the responsibility to ensure the presence of target group on Saturday

(as per Schedule) to make this activity at village level an effective intervention.

During the VHN Day, CHC/PHC wise supervisor/ HealthVisitor(HV)/Block

Programme Management Unit(BPMU)will be responsible for Supervision/monitoring

of VHND activities in their respective area4.

According to report of CMO Almora(

March 2013) District out of 7000 VHNDs 6674 VHNDs has been organized.

3.05 Reproductive and Child Health (RCH) Camps

Reproductive and Child Health (RCH) camps, which are popular as Parivar

Swasthya Sewa Divas (Family Health Day) organized at CHCs and PHCs, provide an

opportunity to integrate the efforts of providers and increase access to reproductive

health services. Each camp includes a gynecological check-up, child examination and

immunization, family planning counseling and services and transportation for

sterilization clients.

Though sterilization camps have been part of the family planning programme

for many years, these RCH camps are different in that they:

Provide assured services as per a pre-determined calendar.

Combine benefits of rural outreach and high quality services.

Provide an array of maternal, child health and family planning services under

one roof.

The organization of camps involves detailed planning relating to publicity,

manpower deployment, camp arrangements, and post-camp services including

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transportation, availability of consumables and medical equipment. Each camp is

scheduled in advance and publicized. Specially designed banners and handbills

promote them as Pariwar Swasthya Sewa Divas. In rural areas, playing attractive

jingles on audio cassettes carried around in hired rickshaws or vehicles spreads the

word. Since most of these camps are in remote rural areas, the availability of a team

of surgeons, anesthetist and female gynecologist has to be ensured from the district

level. Enhanced budget for maintenance and fuel for vehicles is provided so that an

adequate number of vehicles can be deployed to transport doctors to RCH camp sites

and sterilization clients to their homes.5

3.06 Family planning

In 1952, India launched the world first national program emphasizing family

planning to the extent necessary for reducing birth rates and to stabilize the

population at a level consistent with the requirement of national economy. Since then,

the family planning program has evolved and the program is currently being

repositioned to not only achieve population stabilization but also to

promote reproductive health and reduce maternal, infant and child mortality and

morbidity.

The objectives, strategies and goals of the Family Planning have been stated

in various policy documents like National Population Policy (NPP) 2000, National

Health Policy (NHP)2002, National Rural Health Mission (NRHM) and Millennium

Development Goals (MDG). Crucial factors influencing population growth can be

grouped into following 3 categories-

1. Unmet need of Family Planning : This includes the currently married

women, who wish to stop child bearing or wait for next two or more years for the next

child birth, but not using any contraceptive method. Total unmet need of Family

Planning is 21.3% (DLHS-III) in our country.The findings of AHS 2011-12 for

Uttarakhand and district Almora are given below:

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Table 3.4Unmet need of Family Planning for Uttarakhand and District Almora

Unmet need for Family Planning(2011-12)

State/District Unmet Need For

Spacing(%)

Unmet Need For

Limiting(%)

Total Unmet

Need(%)

Total Rural Urban Total Rural Urban Total Rural Urban

Uttarakhand 8.4 8.9 7.2 9.7 9.4 10.3 18.1 18.2 17.6

Almora 12.3 12.8 6.0 15.0 14.9 17.1 27.4 27.7 23.1

Source {Annual Health Survey Fact Sheet, Uttarakhand (2011-12)}

2. Age at Marriage and first childbirth: Age at marriage and first child

birth are important indicators of the status of family planning and health of women.

This has gradually increased over the years. According to SRS 2012 and census 2011,

the earlier custom of teen marriage and teen motherhood has declined by over 32% in

a decade.

3. Spacing between Births : Healthy spacing of 3 years improves the

chances of survival of infants and also helps in reducing the impact of population

momentum on population growth. NFHS III data shows that in India, spacing between

two childbirths is less than the recommended period of 3 years in 61% of births.

According to SRS 2012, only 40.3% rural women maintained the gap of 36 months

between the current birth and previous ones

3.07 Total Fertility Rate (TFR)

The Total Fertility Rate (TFR), is the average number of births a women would have

by the time they reach 50 years of age.The TFR is expressed as the average number of

births per woman.Total Fertility Rate (TFR) in the country has recorded a steady

decline to the current levels of 2.4 (SRS 2011).Table below shows the declining TFR

over that years.

Table No.3.5 Total Fertility Rate (TFR) in the country

2775 2776 2777 2778 2779 2717 2711

2.9 2.8 2.7 2.6 2.6 2.5 2.4

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Nationwide, the small family norm is widely accepted (the wanted fertility rate

for India as a whole is 1.9: NFHS-3) and the general awareness of contraception is

almost universal (98% among women and 98.6% among men: NFHS-3).

Both NFHS and DLHS surveys showed that contraceptive use is generally

rising. Contraceptive use among married women (aged 15-49 years) was 56.3% in

NFHS-3 (an increase of 8.1 percentage points from NFHS-2) while corresponding

increase between DLHS-2 and 3 is relatively lesser (from52.5% to 54.0%).Strategies

under family planning programme is given below:

Policy Level Service Level

Target free approach Equal emphasis on both spacing and limiting

methods

Voluntary adoption of Family Planning

Methods

Assuring Quality of services

Based on felt need of the community Expanding Contraceptive choices

Children by choice and not chance

The public sector provides the following contraceptive methods at various levels of

health system6:

Spacing Methods Limiting Methods

IUCD 380 A and Cu IUCD 375 Female Sterilization:

Oral Contraceptive Pills Laparoscopy

Condoms Minilap

Emergency Contraceptive Pills Male Sterilization (No Scalpel Vasectomy)

The TFR for Uttarakhand and district Almora as studied during 2011-12 are given

below:

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Table No.3.6 TFR for Uttarakhand and District Almora

State/District Total Fertility Rate

Total Rural Urban

Uttarakhand 2.1 2.3 1.6

Almora 1.9 - -

Source(Annual Health Survey Fact Sheet,Uttarakhand( 2011-12)

Current Family Planning Practices used by currently married Women in the

age group of 15-49 years in the state of Uttarakhand and district Almora have been

given below:

Table No.3.7 Current Family Planning Practices and Female sterlization

Current Family Planning Practices(Currently married Women)aged 15-49

years(2011-12)

State/District Any method% Any modern method

%

Female Sterlization %

Total Rural Ur1ban Total Rural Urban Total Rural Urban

Uttarakhand 61.7 60.3 65.1 54.1 53.6 55.3 28.1 32.4 17.2

Almora 70.5 70.9 66.4 67.5 67.9 62.8 46.1 47.7 27.0

Source(Annual Health Survey Fact Sheet,Uttarakhand( 2011-12)

Current Family Planning Practices like male sterilization, copper-T and pills

used by currently married Women in the age group of 15-49 years in the state of

Uttarakhand and district Almora are given below:

Table No.3.8 Current Family Planning Practices and Male sterlization

Current Family Planning Practices(Currently married Women)aged 15-49

years(2011-12)

State/District Male sterilization% Copper-T/IUD% Pills %

Total Rural Urban Total Rural Urban Total Rural Urban

Uttarakhand 1.6 1.9 1.1 1.0 0.7 1.7 4.6 4.2 5.5

Almora 5.1 5.4 1.9 0.5 0.4 1.2 2.9 2.6 5.5

Source {Annual Health Survey Fact Sheet,Uttarakhand( 2011-12)}

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Current Family Planning Practices like male condom, emergency

contraceptive pills and any other traditional methods used by currently married

Women in the age group of 15-49 years in the state of Uttarakhand and district

Almora are given below:

Table No.3.9Current Family Planning Practices through Temporary Methods

Current Family Planning Practices(Currently married Women)aged 15-49 years (2011-12)

State/District

Male

Condom/Nirodh%

Emergency

Contraceptive Pills%

Any Traditional

Method%

Total Rural Urban Total Rural Urban Total Rural Urban

Uttarakhand 18.0 13.8 28.7 0.6 0.5 0.6 7.6 6.8 9.9

Almora 12.8 11.6 27.1 0.1 0.1 00 3.0 3.0 3.5

Source {Annual Health Survey Fact Sheet,Uttarakhand( 2011-12)}

3.08 Adolescent Health

Persons in age group of 10-19 years are known as adolescents which

comprises of individuals in a transient phase of life requiring nutrition, education,

counseling and guidance to ensure their development into healthy adults.

Government of India has recognized the importance of influencing health-seeking

behaviour of adolescents. The health situation of this age group is a key determinant

of India's overall health, mortality, morbidity and population growth scenario.

Therefore, investments in adolescent reproductive and sexual health will yield

dividends in terms of delaying age at marriage, reducing incidence of teenage

pregnancy, meeting unmet contraception need, reducing the maternal mortality,

reducing STI incidence and reducing HIV prevalence in. It will also help India realize

its demographic bonus, as healthy adolescents are an important resource for the

economy. In keeping with the spirit of convergence under NRHM, the RCH-II ARSH

strategy emphasizes the need for inter-sectoral linkage with other Departments at the

policy and programme levels to create a supportive environment for adolescent

interventions and to improve awareness levels among adolescents. Relevant schemes

under different departments of the government are mentioned below:

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Women and Child Development:- Kishori Shakti Yojna, Balika Samridhi

Yojana, Rajiv Gandhi Scheme for Empowerment of Adolescent Girls

(SABLA);

Human Resource Development:- Sarva Shiksha Abhiyan; National Population

Education Project , (NPEP); Adolescence Education Program (AEP)

Youth Affairs and Sports:- Adolescent Empowerment Scheme; National Service

Scheme; Nehru Yuva Kendra Sangathan (NYKS) Programs, National Program

for Youth and Adolescent Development (NPYAD).

3.09 Adolescent Reproductive and Sexual Health (ARSH)

The goals of the Government of India RCH-II programme are reduction in

IMR, MMR and TFR. In order to achieve these goals, RCH-II has four technical

strategies. One of these four is Adolescent and reproductive Health. Adolescents are

nation's future and investment in their development is critical. The government of

India has a comprehensive package for meeting the multiple health needs of the

adolescents and offers a roadmap for programmes and priorities that aim to address

adolescent health.The National Adolescent Reproductive and Sexual Health strategy

provides a framework for a range of sexual and reproductive health services to be

provided to the adolescents. The strategy incorporates a core package of services

including preventive, promotive, curative and counseling services. Effective

implementation of policies and programmes has progressed from the past few years

and has lead to strengthening of Adolescent Friendly Counselling centers

(AFCCs)and subsequently the outreach programmes7.

3.10 School Health Programme

The School Health Programme was launched to address the health needs of school

going children and adolescents in the 6-18 year age groups in the Government and

Government aided schools. The programme entails biannual health screening and

early management of disease, disability and common deficiency and linkages with

secondary and tertiary health facilities as required. The School health programme is

the only public sector programmespecifically focused on school age children. Its main

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focus is to address the health needs of children, both physical and mental, and in

addition, it provides for nutrition interventions, yoga facilities and counseling. It

responds to an increased need, increases the efficacy of other investments in child

development, ensures good current and future health, better educational outcomes and

improves social equity and all the services are provided for in a costeffective manner.

The decentralized framework of implementation under NRHM has enabled

various states to devise and implement their own version of School Health

Programme. Components of School Health Program include Health service provisions

like , Micronutrient (Vitamin A andIron Folic

Acid(IFA) management, De-worming, Counseling services, Regular practice of Yoga

and Physical education.Health Management Structure has been provided for in the

guidelines at national, State and District levels.

The NRHM convergence mechanism will apply to this programme as well.

The involvement of MSG, State Health Mission and District Health Mission has been

ensured by placing the school health programme management committees under the

overall supervision/guidance of these overarching structures.

has been placed at making these management committees multi-departmental

involving the functionaries of various related departments/organisations such as

Committees recommended at State, District, Block and School levels is detailed in the

enclosed write-up of the programme. School Health Coordinator on contract basis at

the State and District levels has been provided to support the programme in the areas

of coordination and monitoring and evaluation.

These management committees have been proposed in a manner that they

bring in convergence between related departments/organizations. The main

convergence required in the programme is between the Ministry of Health and Family

Welfare, Ministry of Human Resources Development (MHRD) and Ministry of Rural

Development (MRD). MHRD will be partner in capacity building, IEC, Monitoring

and Evaluation. MRD needs to take care of water, safety education, Sanitation

Education and Garbage disposal waste management. The MoHFW will take care of

screening, health care services, immunization, referral, micronutrient management,

health education, capacity building, monitoring and evaluation, etc.8

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3.11 Rastriya Bal Swasthya Karyakram (RBSK)

RBSKhas been launched in 2013 for child health screening with an objective of

early intervention services to provide comprehensive care to all children in the

community. The purpose of these services is to improve the overall quality of life of

children through early detection of birth defects, diseases, deficiencies, development

delays including disability. Health screening of children is a known intervention is

now being expanded to cover all children from birth to 18 years of age. The

Programme has been initiated as significant progress has already been made in

reducing child mortality under the National Rural Health Mission. However, further

gains can be achieved by early detection and management of conditions in all age

groups. There are also groups of diseases which are very common in children e.g.,

dental caries, otitis media, rheumatic heart disease and reactive airways diseases

which can be cured if detected early. It is understood that early intervention and

management can prevent these conditions to progress into more severe and

debilitating forms, thereby reducing hospitalisation and resulting in improved school

attendance. The ‗Child Health Screening and Early Intervention Services‘ will also

translate into economic benefits in the long run. Timely intervention would not only

halt the condition to deteriorate but would also reduce the out-of-pocket (OOP)

expenditure of the poor and the marginalized population in the country. Additionally,

the Child Health Screening and Early Intervention Services will also provide country-

wide epidemiological data on the 4 Ds (i.e., Defects at birth, Diseases, Deficiencies

and Developmental Delays including Disabilities). Such a data is expected to hold

relevance for future planning of area specific services.9

3.12 Weekly Iron Folic acid Supplementation (WIFS)

Adolescent Anemia is a long standing public health problem in India. Anemia

is caused by Iron deficiency and adolescents are at high risk of Iron deficiency and

thereby anemia due to accelerated growth and body mass building, poor dietary intake

of iron and high rate of worm infestation In girls deficiency of iron is further

aggravated with higher demands with onset of menstruation and also due to the

problem of adolescent pregnancy and conception. The Programme envisages

administration of supervised weekly IFA Supplementation and biannual deworming

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tablets to approximately 13 crore rural and urban adolescents through the platform of

Govt./Govt. aided and municipal school and Anganwadi Kendra and combat the

intergenerational cycle of anemia10

. WIFS Programme has been Started at District

Almora since 2012-13.

3.13Immunization:

Intensification of Routine Immunization, eliminating measles and Japanese

encephalitis related deaths and Polio eradication are the key area to be covered under

universal immunization programme. The strategies for child health intervention

focuses on improving skills of the health care workers, strengthening the health care

infrastructure and involvement of the community through behaviour change

communication.11

During the current study attempts have been made to assess the

implementation and impact of some schemes directly related to the rural women‘s

health in three important stages of her life as a mother, as a wife and as a daughter in

selected villages of district Almora in three development blocks namely Hawalbagh,

Tarikhet and Sult. The details of the findings have been mentioned in the relevant

chapters.

* * * * *

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References :

1. National Health Mission(NHM),Ministry of Health and Family

welfare(MoHFW), Govt of India. Website: nrhm.gov.in

2. Janani Suraksha Yojana (JSY),NHM, MoHFW, Govt of India. Website:

nrhm.gov.in

3. Janani Shishu Suraksha Karyakaram (JSSK),NHM,(MoHFW),Govt of India.

Website: nrhm.gov.in

4. Village Health and Nutrition Day(VHND),NHM,(MoHFW),Govt of India.

Website: nrhm.gov.in

5. Reproductive and Child Health (RCH) camps,NHM,(MoHFW),Govt of India.

Website: nrhm.gov.in

6. Family planning,NHM,(MoHFW),Govt of India. Website: nrhm.gov.in

7. Adolescent Reproductive and Sexual Health (ARSH),NHM,(MoHFW),Govt

of India. Website: nrhm.gov.in

8. The School Health Programme,NHM,(MoHFW),Govt of India. Website:

nrhm.gov.in

9. Rastriya Bal Swasthya Karyakram (RBSK),NHM,(MoHFW),Govt of

India.Website: nrhm.gov.in

10. Weekly Iron Folic acid Supplementation(WIFS),NHM,(MoHFW),Govt of

India.Website: nrhm.gov.in

11. Immunization,NHM,(MoHFW),Govt of India.Website: nrhm.gov.in

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