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> Every village/large habitat will have a female Accredited Social Health Activist (ASHA) - chosen by and accountable to the panchayat- to act as the interface between the community and the public health system. States to choose State specific models.
> ASHA would act as a bridge between the ANM and the village and be accountable to the Panchayat.
> She will be an honorary volunteer, receiving performance-based compensation for promoting universal immunization, referral and escort services for RCH, construction of household toilets, and other healthcare delivery programmes.
> She will be trained on a pedagogy of public health developed and mentored through a Standing Mentoring Group at National level incorporating best practices and implemented through active involvement of community health resource organizations.
> She will facilitate preparation and implementation of the Village Health Plan along with Anganwadi worker, ANM, functionaries of other Departments, and Self Help Group members, under the leadership of the Village Health Committee of the Panchayat.
> She will be promoted all over the country, with special emphasis on the 18 high focus States. The Government of India will bear the cost of training,
incentives and medical kits. The remaining components will be funded under Financial Envelope given to the States under the programme.
> She will be given a Drug Kit containing generic AYUSH and allopathic formulations for common ailments. The drug kit would be replenished from time to time.
> Induction training of ASHA to be of 23 days in all, spread over 12 months. On the job training would continue throughout the year.
> Prototype training material to be developed at National level subject to State level modifications.
> Cascade model of training proposed through Training of Trainers including contract plus distance learning model Training would require partnership with NGOs/ICDS Training Centres and State Health Institutes.


>  Each sub-centre will have an Untied Fund for local action @ Rs. 10,000 per annum. This Fund will be deposited in a joint Bank Account of the ANM & Sarpanch and operated by the ANM, in consultation with the Village Health Committee.
> Supply of essential drugs, both allopathic and AYUSH, to the Sub-centres.
> In case of additional Outlays, Multipurpose Workers (Male)/Additional ANMs wherever needed, sanction of new Sub-centres as per 2001 population norm, and upgrading existing Sub-centres, including buildings for Sub-centres functioning in rented premises will be considered.


Mission aims at Strengthening PHC for quality preventive, promotive, curative, supervisory and Outreach services, through:

> Adequate and regular supply of essential quality drugs and equipment (including Supply of Auto Disabled Syringes for immunization) to PHCs
> Provision of 24 hour service in 50% PHCs by addressing shortage of doctors, especially in high focus States, through mainstreaming AYUSH manpower.
> Observance of Standard treatment guidelines & protocols.
> In case of additional Outlays, intensification of ongoing communicable disease control programmes, new programmes for control of noncommunicable diseases, upgradation of 100% PHCs for 24 hours referral service, and provision of 2nd doctor at PHC level (I male, 1 female) would be undertaken on the basis of felt need.


A key strategy of the Mission is:

> Operationalizing 3222 existing Community Health Centres (30-50 beds) as 24 Hour First Referral Units, including posting of anaesthetists.
> Codification of new Indian Public Health Standards, setting norms for infrastructure, staff, equipment, management etc. for CHCs.
> Promotion of Stakeholder Committees (Rogi Kalyan Samitis) for hospital management.
> Developing standards of services and costs in hospital care.
> Develop, display and ensure compliance to Citizen’s Charter at CHC/PHC level.
> In case of additional Outlays, creation of new Community Health Centres (30-50 beds) to meet the population norm as per Census 2001, and bearing their recurring costs for the Mission period could be considered.


> District Health Plan would be an amalgamation of field responses through Village Health Plans, State and National priorities for Health, Water Supply, Sanitation and Nutrition.
> Health Plans would form the core unit of action proposed in areas like water supply, sanitation, hygiene and nutrition. Implementing Departments would integrate into District Health Mission for monitoring.
> District becomes core unit of planning, budgeting and implementation.
> Centrally Sponsored Schemes could be rationalized/modified accordingly in consultation with States.
> Concept of “funneling” funds to district for effective integration of programmes
> All vertical Health and Family Welfare Programmes at District and state level merge into one common “District Health Mission” at the District level and the “State Health Mission” at the state level
> Provision of Project Management Unit for all districts, through contractual engagement of MBA, Inter Charter/Inter Cost and Data Entry Operator,


> Total Sanitation Campaign (TSC) is presently implemented in 350 districts, and is proposed to cover all districts in 10th Plan.
> Components of TSC include IEC activities, rural sanitary marts, individual household toilets, women sanitary complex, and School Sanitation Programme.
> Similar to the DHM, the TSC is also implemented through Panchayati Raj Institutions (PRIs).
> The District Health Mission would therefore guide activities of sanitation at district level, and promote joint IEC for public health, sanitation and hygiene, through Village Health & Sanitation Committee, and promote household toilets and School Sanitation Programme. ASHA would be incentivized for promoting household toilets by the Mission.


> National Disease Control Programmes for Malari a, TB, Kala Azar, Filaria, Blindness & Iodine Deficiency and Integrated Disease Surveillance Programme shall be integrated under the Mission, for improved programme delivery.
> New Initiatives would be launched for control of Non Communicable Diseases.
> Disease surveillance system at village level would be strengthened.
> Supply of generic drugs (both AYUSH & Allopathic) for common ailments at village, SC, PHC/CHC level.
> Provision of a mobile medical unit at District level for improved Outreach services.


> Since almost 75% of health services are being currently provided by the private sector, there is a need to refine regulation
> Regulation to be transparent and accountable
> Reform of regulatory bodies/creation where necessary
> District Institutional Mechanism for Mission must have representation of private sector
> Need to develop guidelines for Public-Private Partnership (PPP) in health sector. Identifying areas of partnership, which are need based, thematic and geographic.
> Public sector to play the lead role in defining the framework and sustaining the partnership
> Management plan for PPP initiatives: at District/State and National levels


A Task Group to examine new health financing mechanisms, including Risk Pooling for Hospital Care as follows:

> Progressively the District Health Missions to move towards paying hospitals for services by way of reimbursement, on the principle of “money follows the patient.”
> Standardization of services – outpatient, in-patient, laboratory, surgical interventions- and costs will be done periodically by a committee of experts in each state.
> A National Expert Group to monitor these standards and give suitable advice and guidance on protocols and cost comparisons.
> All existing CHCs to have wage component paid on monthly basis. Other recurrent costs may be reimbursed for services rendered from District Health Fund. Over the Mission period, the CHC may move towards all costs, including wages reimbursed for services rendered.
> A district health accounting system, and an ombudsman to be created to monitor the District Health Fund Management , and take corrective action.
> Adequate technical managerial and accounting support to be provided to DHM in managing risk-pooling and health security.
> Where credible Community Based Health Insurance Schemes (CBHI) exist/are launched, they will be encouraged as part of the Mission.
> The Central government will provide subsidies to cover a part of the premiums for the poor, and monitor the schemes.
> The IRDA will be approached to promote such CBHIs, which will be periodically evaluated for effective delivery.


> While district and tertiary hospitals are necessarily located in urban centres, they form an integral part of the referral care chain serving the needs of the rural people.
> Medical and para-medical education facilities need to be created in states, based on need assessment.
> Suggestion for Commission for Excellence in Health Care (Medical Grants Commission), National Institution for Public Health Management etc.
> Task Group to improve guidelines/details.

District-wise Report

Udhamsingh Nagar

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