Sub Centre is the first point of contact between the primary healthcare system and community. Due to the scattered /wide dispersal of population and hilly/difficult terrain, a new norm ‘Time to care’ was adopted for establishing subcentre for hilly and Desert areas. Accordingly irrespective of population size, a Sub Centre can be established within 30 minutes by walk from habitation.
Subcentres are to be staffed by at least one Multi-Purpose Worker (Female) commonly known as ANM and one Male Health Worker. Subcentres are provided with basic drugs for minor ailments to take care of the essential health needs of the population. The Indian Public Health Standards (IPHS) 2012 categorizes subcentres into 2 Types. The difference between Type A and Type B Sub-centres is that the latter is envisaged to have facilities for conducting deliveries. Wherever two ANMs are provided, one ANMs is required to be available at Sub-centre which is to remain open for OPD services on all working days while second ANM provides outreach services. ANMs posted at Type B centres must be trained in Skilled Birth Attendance.
key Essential services to be provided by SC as per IPHS include:
Maternal Health services: Early registration of pregnancies, within first trimester before 12th week of Pregnancy, Minimum 4 Ante Natal Checks including Registration, general examination such as height, weight, B.P., anaemia, abdominal examination, breast examination, Folic Acid Supplementation (in first trimester), Iron & Folic Acid Supplementation from 12 weeks, injection tetanus toxoid, treatment of anaemia etc, post-natal home visits on 0,3,7 and 42nd day
Child Health services: l Newborn Care -maintain the airway and breathing, initiate breastfeeding within one hour, infection protection, cord care, care of the eyes, full Immunization;
Family Planning Services: Provision of contraceptives such as condoms, oral pills, emergency contraceptives, Intra Uterine Contraceptive Devices (IUCD) insertions wherever ANM is trained in IUCD insertion.
Curative Services: Treatment for minor ailments including fever, diarrhoea, ARI, first Aid and prompt referral
Home Visits: Post-natal and newborn visits – as per protocol, check out on disease incidences, notify M.O. PHC immediately about any abnormal increase in cases of diarrhoea/dysentery, fever with rigours, fever with rash, etc
Primary Health Centre
The PHC with 6 indoor beds is the first contact point between the community and the Medical Officer. A PHC should have one MBBS doctor, three Staff Nurses, One pharmacist and a Lab Technician among others. It acts as a referral unit for 6 Sub-Centres and refers out cases to CHC and higher level facilities. Essential medical care services required to be provided by a PHC s as per IPHS include:
OPD services: Total 6 hours of OPD services – 4 hours in the morning and 2 hours in the afternoon for six days/week as per time schedule set by the state. Minimum OPD attendance expected is 40 patients per doctor/ day.
24 hours emergency services: appropriate management of injuries and accident, First Aid, stitching of wounds, incision and drainage of abscess, stabilisation of patient before referral, Dog bite/snake bite/scorpion bite cases, and other emergency conditions to be provided primarily by the nursing staff. However, MO may be available to attend to emergencies on a call basis.
Referral services.
In-patient.
Community Health Centre
CHCs constitute first secondary level healthcare and provides referral as well as specialist services. A CHC is a 30 bedded facility with one OT, X-ray, Labour Room and Laboratory facilities and is required to be staffed by four Medical Specialists i.e. Surgeon, Physician, Gynecologist and Pediatrician supported by paramedical and other staff. It serves as a referral centre for 4 PHCs and also provides facilities for obstetric care and specialist consultations. Essential services include routine and emergency care in Surgery, Medicine, Obstetrics and Gynaecology, Paediatrics, Dental and AYUSH.
Detailed information is at http://www.nhm.gov.in/images/pdf/guidelines/iphs/iphs-revised-guidlines-2012.
United Grant (UG)
One of the critical components of NHM is the provision of United Funds to public health facilities for local planning and action.
Sub Centres are provided with UG of Rs 20,000/ annum. PHCs receive Rs.1.75 lakh/ annum while CHCs receive Rs 5 lakh/ annum. Untied grants are topped up based on fund utilization. United Grants can be used for minor repair and maintenance work, purchase/maintenance of light bulbs, inverter, office stationeries, purchase and repair of minor medical equipment, patients welfare etc.
Infrastructure approvals in the last five years are as follows:
(Rs in lakhs)
Major Upgradation
New Construction
(Rs in lakhs)
State Plans (PIPs) & approvals (RoPs) are at http://nhm.gov.in/nrhm-in-state/state-program-implementation-plans-pips.html
FORWARD LINKAGES TO NRHM SCHEME
NHM funds only primary & secondary care to District Hospital (DH) level. As a special dispensation for NE states, 100% of funding was provided for strengthening Tertiary / Secondary level health infrastructure. Six projects approved are:
KNOW YOUR ENTITLEMENTS UNDER NHM
NHM FREE DRUGS SERVICES INITIATIVE (FDSI)
Funding is provided for this Initiative to improve access to and provision of essential drugs/medicines free of cost in all public health facilities to reduce high out of the pocket expenditure. There is no prescribed list and free essential drugs/medicines are to be provided to all who visit public health facilities as per State Essential Drug List. The indicative numbers as per NHM Guidelines and Nagaland are:
Guidelines are at:
http://nhm.gov.in/nhm_components/Health_Systems_Strengthening/Drugs_HYPERLINK “http://nhm.gov.in/nhm_components/Health_Systems_Strengthening/Drugs_&_Logistics/Operational_Guidelines_Free_Drugs_Service_Initiative.pdf”&HYPERLINK “http://nhm.gov.in/nhm_components/Health_Systems_Strengthening/Drugs_&_Logistics/Operational_Guidelines_Free_Drugs_Service_Initiative.pdf”_Logistics/Operational_Guidelines_Free_Drugs_Service_Initiative.pdf
Approvals given are as follows:
(Rs in lakhs)
FREE DIAGNOSTIC SERVICES INITIATIVE
The objective is to reduce out-of-pocket expenditure on diagnostics as well as improve quality of care by providing an accurate diagnosis. Funding is given to provide free essential diagnostics in public health facilities. There is no prescribed list of essential diagnostics. Facility wise indicative number of essential diagnostics as per guidelines is as below:
Approvals given are as follows:
While approval has been given, the State is yet to implement this initiative. The guidelines are at:
http://nhm.gov.in/nhm_components/Health_Systems_Strengthening/Diagnostics/Free_Diagnostics_Service_Initiative.pdf
Approvals given are as follows:
(Rs in lakhs)
Pradhan Mantri National Dialysis Programme (PMNDP)
Under this Programme’, funding is provided to States for provision of free dialysis services to the poor. Approvals given are as follows:
(Rs in lakhs)
Nagaland is also one of the 10 States selected for free dialysis machines donated by M/s Fairfax India Charitable Foundation but has been able to receive only 9 of 25 machines.
NATIONAL AMBULANCE SERVICES
One of the most visible components of NHM is the free patient transport ambulances operating under Dial 108/102 Dial 108 is emergency response system, primarily designed to attend to patients of critical care, trauma and accident victims etc. Dial 102 services are essentially aimed at catering to the needs of pregnant women, children through other categories are not excluded. Funding is given for both Basic Life Support(BLS) and Advance Life Support (ALS) vehicles. BLS unit should have two Emergency medical Technicians while ALS unit should have a paramedic apart from the Emergency medical Technician apart from being equipped with airway equipment, cardiac life support, cardiac monitors and glucose testing device. Approvals given in last five years are as follows:
(Rs in lakhs)
NATIONAL MOBILE MEDICAL UNIT SERVICES (MMU)
Funds are given for MMUs with the objective of taking healthcare to the doorstep of the public and to provide a whole range of health care services – free treatment of minor ailments, communicable & non-communicable diseases, Reproductive & Child Health, Family Planning and diagnostics services.
Deployment of MMUs is 1 MMU/ 10 lakh population subject to a cap of 5 MMUs/district. Additional MMU can be supported where one MMU exceeds 60 patients/day in plain areas and 30 patients/day in hilly areas. Support includes both capital cost and operational cost (Human resource, drugs, consumables etc). Approvals given are as follows:
(Rs in lakhs)
JANANI SURAKSHA YOJANA (JSY)
JSY is a safe motherhood programme to reduce maternal and neonatal mortality by promoting delivery in public health facilities. ASHAs and pregnant women are provided Cash Assistance for Institutional Delivery and post-delivery care as under:
In Rupees
*ASHA package in rural areas includes Rs. 300 for ANC component + Rs. 300 for facilitating institutional delivery.
**ASHA package of Rs. 400 in urban areas include Rs. 200 for ANC component + Rs. 200 for facilitating institutional delivery.
(Rs in lakhs)
JANANI SHISHU SURAKSHA KARYAKRAM (JSSK)
The scheme entitles all pregnant women delivering in public health facilities to absolutely free and no expense delivery including Caesarean section for which funds are provided :
(Rs in lakhs)
RASHTRIYA BAL SWASTHYA KARYAKRAM
Funds are provided for free Screening and Early Intervention of children for early detection and management of 4 Ds i.e Defects at birth, Diseases, Deficiencies, Development delays including disability and free treatment of 30 identified health conditions including free surgery at tertiary health facilities (eg conditions like congenital heart disease, cleft lip and correction of club foot etc. The details are at http://nhm.gov.in/images/pdf/programmes/RBSK/For_more_information.pdf
NATIONAL VECTOR-BORNE DISEASE CONTROL PROGRAMME
This is an umbrella programme with an integrated approach for elimination of Malaria, Lymphatic Filariasis, Kala-azar and control of Dengue, Chikungunya and Japanese Encephalitis)
MALARIA
Following services are provided free by the Government:
Prevention of mosquitogenic conditions by source reduction activities, Larvivorous fish, antimalarials, Indoor Residual Spray (IRS) and distribution of Long Lasting Insecticidal Nets (LLIN) in a high-risk population
Early detection of malaria cases by Microscopy or Bivalent Rapid Diagnostic Tests (RDT)
Complete treatment of malaria cases-both Plasmodium vivax and Plasmodium falciparum cases
REVISED NATIONAL TB CONTROL PROGRAMME (RNTCP)
Funds are provided for free diagnosis and treatment of Tuberculosis including Drug-Resistant TB including high-quality drugs free of cost through community providers closest to the residence of the patient.
NATIONAL PROGRAMME FOR CONTROL OF BLINDNESS
Funds are provided for the following :
AYUSHMAN BHARAT -HEALTH AND WELLNESS CENTRES (HWC)
The government launched Ayushman Bharat in 2018-19 with two components, namely, the Pradhan Mantri Jan Arogya Yojana and Health and Wellness Centres to provide comprehensive primary care services.
Existing Sub Centre and PHC / Urban PHC are to be strengthened as HWCs. Sub-centre level HWC should have a Mid-level healthcare Provider, who can be BSc in Community Health/Ayurveda practitioner or Nurse trained in a six-month certificate course in Community Health through IGNOU. HWCs are to provide Preventive, promotive, rehabilitative and curative care for RMNCH+A, Communicable diseases, non-communicable diseases, Ophthalmology, ENT, Dental, Mental, Geriatric care, Palliative care, treatment for acute simple medical conditions and basic emergency & trauma services. To begin with, HWCs have to initiate free Universal Screening and treatment including a monthly refill of drugs for five common Non Communicable Diseases – Hypertension, Diabetes, and Cancer of the Breast, Cervix & Oral. i.e all population (men and women) above 30 years are to be screened and treated free of cost for these common NCDs. The PHCs upgraded as HWC should provide services as per IPHS.
Approvals given are as follows:
COMMUNITY PROCESS AND SOCIAL ACCOUNTABILITY
NHM places a strong focus on community engagement for people’s participation in health and social determinants of health as well as improve governance through social accountability. Some key players include :
1. ASHAs
Roles and responsibilities of an ASHA include that of a healthcare facilitator, a service provider and a voluntary health activist. She is expected to fulfil her role through five tasks:
Home Visits: For two to three hours every day, for at least four or five days a week, ASHAs should visit families living in her allotted area. Where there is a newborn in the house, six visits or more becomes essential.
Village Health and Nutrition Day (VHND): To attend & promote attendance at the monthly VHNDs
Visits to health facility: This usually involves accompanying the pregnant woman, sick child, or some member of the community needing facility-based care besides attending monthly PHC review meeting.
Holding village level meeting: As a member of the Village Health, Sanitation and Nutrition Committee, she is expected to call its monthly meeting.
Records: Maintain records to make her more organised
ASHA is to provide community-level care for minor ailments such as diarrhoea, fevers, care for the normal and sick newborn, childhood illnesses and first aid. She is also a provider of DOTS under RNTCP, doorstep delivery of contraceptive services (OCP, Condoms and EC). She is to inform about births and deaths in her village and any unusual health problems/disease outbreaks in the community to the Sub Centres/PHC.
VILLAGE HEALTH SANITATION AND NUTRITION COMMITTEES (VHSNC)
VHSNC is a key communication Platform for Collective Community Action, on issues related to health and its social determinants. The VHSNC should have a minimum of about 15 members and its composition are as under:
Elected Gram panchayat members
ASHAs (Member-Secretary and Convenor of VHSNC.)
ANM, AWW, School teacher provided they are resident in the village. Otherwise, they qualify as special invitees.
Community-based organizations
Service users
VHSNCs are provided with an annual untied grant of Rs 10000 to be credited to a bank account and operated by Chairperson, VHSNC and Member Secretary as joint signatories. Untied grants are topped up based on utilization. VHSNCs can undertake activities like cleanliness drives, sanitation drives, chlorination of water, repair of water facilities and drainage system, Information, Education and Communication activities. VHSNCs are required to inform about their activities and expenditures and regarding creation of facilities, infrastructure, available benefits and names of beneficiaries under the scheme to the villagers in their bi-annual meetings and the Gram Panchayat in their quarterly meetings besides monitoring public services viz, health services, MNREGA, Mid-day meals, PDS, access to drinking water, toilets etc
ROGI KALYAN SAMITI (RKS)
RKS/Patient welfare Committees are constituted at the level of PHC and above. They are required to be registered under the Societies Registration Act and with an account in a local bank. It consists of members from local Panchayati Raj Institutions, local MP/District Magistrate, NGOs, local elected representatives and state Government officials. The RKSs is to act as a forum to improve the functioning and service provision in public health facilities, increase participation and enhance accountability for the provision of better facilities to the patients. Untied grants to public health facilities are administered by RKS. Guidelines are at http://nhm.gov.in/publications/nhm-guidelines.html.
Limatula Yaden 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.
