CH A P T E R 35

National Rural Health

Mission—2005-2012

Health of the citizens is fundamental to the economic and

social development of any country. The cause of low state of
health in India are many including lack of sanitation, poor
standard of living, poor nutritional status, lack of safe water
supply and lack of appropriate health care. These are serious
impediments to the progress of our country.
Recognizing the importance of health in the process of
the development of the country, and improving the quality
of life of our citizens, Government of India has resolved to
launch National Rural Health Mission (NRHM) to carry out
necessary architectural correction in the basic health care Fig. 35.1 National Rural Health Mission
delivery system, as a strategic framework to implement
National Health Policy, 2002.
The plan of action includes:
• Increasing public expenditure on health
• Reducing regional imbalance in health infrastructure
OBJECTIVES • Pooling resources
• Integration of organizational structures
National Rural Health Mission (NRHM) seeks to provide • Optimization of health manpower
effective efficient and affordable health care, mainly with • Decentralization and district management of health pro-
reference to nutrition, sanitation, hygiene, safe drinking grams
water and also to mainstream the Indian systems of medicine • Community participation and ownership of assets
[Ayurveda, yoga, unani, siddha, and homeopathy (AYUSH)] • Induction of management and financial personnel into
to facilitate health care, mainly to those residing in the rural district health system
areas, especially the disadvantaged group including, women • Operationalizing community health centers into func-
and children with special focus on 18 states which have weak tional hospitals meeting Indian Public Health Standards
public health indicators and/or weak infrastructure. The (IPHS) in each Block of the country.
NRHM was launched by honorable Prime Minister of India, The National Rural Health Mission subsumes key

Dr Manmohan Singh on 12th April 2005, with the emblem national programs, namely
(Fig. 35.1), with a budget out lay of Rs. 6500 crores for 2005-06 • Reproductive and Child Health II project (RCH II)
to realize the dream of ‘Health For All and All For Health’. The • National Disease Control Programs (NDCP)
mission is for the period from 2005 to 2012 and now extended • Integrated Disease Surveillance Project (IDSP)
from 01.04.2012 to 31.03.2017. • Mainstreaming of AYUSH.

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 Chapter 35 National Rural Health Mission—2005-2012 777
National rural health mission seeks to provide effective • To strengthen the rural hospitals to meet public health
health care to rural population throughout the country with standards
special initial focus on 18 states which have poor public • To integrate national health programs
health indicators and/or weak infrastructure. • To mainstream AYUSH
These 18 states are Uttar Pradesh, Uttaranchal, Madhya • To decentralize village and district level health planning
Pradesh, Chattisgarh, Bihar, Jharkand, Orissa, Rajasthan, and management
Himachal Pradesh, Jammu and Kashmir, Assam, Arunachal • To define time bound goals
Pradesh, Manipur, Meghalaya, Nagaland, Mizoram, Sikkim • To seek access of rural people (especially poor mothers
and Tripura. and children) to equitable, affordable, accountable and
effective primary health care
• To provide improved health care services under Janani
STATE OF PUBLIC HEALTH IN INDIA Suraksha Yojana (JSY) for the Below Poverty Line families.

• Public health expenditure has declined from 1.3 percent

of GDP in 1990 to 0.9 percent of GDP in 1999 (GDP = Gross GOALS
Domestic Product. It is the market value of all final goods
and services produced within a country in a given period • Reduction of Infant Mortality Rate (IMR) and Maternal
of time) Mortality Ratio (MMR)
• The contribution of Union Government to public health • Universal access to public health services such as women’s
expenditure is 15 percent while state contribution is 85 health, child health, safe drinking water, sanitation and
percent hygiene, immunization and nutrition
• National health programs have limited synergization at • Prevention and control of communicable and non-
operational levels communicable diseases including locally endemic
• Lack of community ownership of public health pro- diseases
grams impacts level of efficiency, accountability and • Access to integrated comprehensive primary health care
effectiveness • Population stabilization, gender and demographic
• Lack of integration of sanitation, hygiene, nutrition and balance
drinking water issues • Revitalize local health traditions and mainstream AYUSH
• There are striking regional inequalities • Promotion of healthy life-styles.
• Population stabilization is still a challenge
• Curative services favor the rich
• Only 10 percent Indians have some form of health STRATEGIES
insurance
• Hospitalized Indians spend on an average 58 percent of
their total annual expenditure Core Strategies
• Over 40 percent of hospitalized Indians borrow heavily to
cover expenses • To enhance the capacity of Panchayati Raj Institutions
• Over 25 percent of hospitalized Indians fall below poverty (PRIs) to manage public health services
line because of hospital expenses. • To promote access of improved health care at household
level through female Accredited Social Health Activist
(ASHA)
NATIONAL RURAL HEALTH • To make health plan for each village through Village
Health Committee of the Panchayat
MISSION—A VISION • To strengthen subcenter by more multipurpose workers
• To strengthen existing PHCs and CHCs
• To provide effective health care services to rural • To provide one Community Health Center of 30 to 50 bed
population, especially to mothers and children with strength per lakh population
initial focus on 18 states • To prepare and implement an Intersectoral District Health
• To raise the public health expenditure from 0.9 percent of Plan, prepared by District Health Mission
GDP in 1999 to 2.3 percent of GDP • To integrate Vertical Health Programs and Family Welfare
• To undertake architectural correction in health care Programs
delivery system • To provide technical support to Health Missions at
• To provide services through the appointment of Accred- National, State and District levels for public health
ited Social Health Activist (ASHA) in each village management

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778 Section 7 Health Administration and Organization

• To formulate transparent policies for deployment and • She provides treatment for minor ailments and first aid for
career development of Human Resources for health minor injuries.
• To promote healthy life-styles such as reduction in • She acts as a depot holder for essential provisions like
consumption of tobacco, alcohol, etc. ORS packs, IFA tablets, disposable delivery kits, oral pills,
condoms, etc.
• She works with village health committee to develop
Supplementary Strategies comprehensive village health plan
Thus, ASHA provides basic nutritional, immunization,
• To regulate private sector, including the rural practi-
family planning and educational services
tioners, to ensure availability of quality service to the
Accredited Social Health Activist (ASHA) is not entitled to
people at reasonable cost
any pay. She is a honourary volunteer receiving performance
• To promote public-private partnership to achieve public
based compensation for escorting services under Janani
health goals
Suraksha Yojana (JSY), for promoting universal immunization
• To mainstream AYUSH
and also TA/DA for attending training. She is accountable
• To Reorient Medical Education (ROME) to support rural
to Gram Panchayat. She is trained by Anganwadi Worker
health issues
and Female Health Worker of the area and attends monthly
• To introduce effective risk pooling mechanisms and social
meeting.
insurance to provide health security of the poor.
Currently, ASHA is envisaged in 18 focus states. After the
orientation training, ASHA is positioned with kits containing
both AYUSH and Allopathic formulations.
PLAN OF ACTION
Strengthening Subcenters
Accredited Social Health Activist • Increase in fund to ` 10,000 per anum
Accredited Social Health Activist (ASHA) is primarily a • Supply of both allopathic and AYUSH drugs
woman resident of the village, preferably in the age of 25-45 • Increasing the number of subcenters and multipurpose
years, married/widow/divorced; educated upto minimum of workers
8th standard. She is being selected by the Village Health and • Upgrading of subcenters including buildings.
Sanitation Committee, at the rate of one per 1000 population
and is accountable to village Panchayat. Strengthening Primary Health Centers
She acts as an interface/link worker between the
For improving the quality of services through:
community (family level) and the public health system
• Adequate and regular supply of drugs
(Female Health Worker), by providing primary health care,
• Provision of 24 hours service in 50 percent PHCs
on the following health issues:
• Observation of standard treatment guidelines.
• She motivates the pregnant mother of her area to get at
least three antenatal visits
• She escorts for institutional delivery Strengthening Community Health
• She ensures postnatal check-ups in case of home
deliveries
Centers (30-50 beds)
• She promotes the couples to adopt suitable contraceptive • Operationalizing the CHCs, (First Referral Units) as
(temporary or permanent) method and to have a small 24 hour FRUs
family norm • Setting of new Indian Public Health Standards to improve
• She promotes adolescent reproductive and sexual health the quality of services
(ARSH) among adolescent girls • Promotion of Stakeholder Committees (Rogi Kalyan
• She advices the mothers on correct breastfeeding Samitis) for hospital management
practices and immunization of the child • Creation of new Community Health Centers to meet the
• She creates awareness among the people about the population norm.
importance of cleanliness in and around the houses,
drinking safe water, using sanitary latrines, personal
hygiene, etc.
District Health Plan
• She also acts as a DOTS agent under RNTCP • This would be an amalgamation of field responses
• She will inform about the births and deaths to the sub- through village health plans, state and National priorities
center or Primary Health Center. for Health, Water supply, Sanitation and Nutrition

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 Chapter 35 National Rural Health Mission—2005-2012 779
• These related departments would integrate into District • District Health Mission—at district level
Health Mission, headed by District Health Officer for • State Health Mission—at state level
monitoring • National Mission—at national level
• District becomes the core unit of planning, budgeting and • Task groups—for selected tasks (Time-bound).
implementation
• ‘Funneling’ of funds for integration of programs
• All national programs merge into District Health Mission.
TARGETS OF THE NRHM (BY THE
YEAR 2012)
Implementation of Total
Sanitation Campaign • Reduction of Infant Mortality Rate (IMR) to 30/1000
livebirths
Implementation of Total Sanitation Campaign (TSC) includes
• Reduction of Maternal Mortality Rate (MMR) to 01/1000
IEC activities, rural sanitary marts, promotion of individual
livebirths
household toilets and school sanitation program.
• Reduction of Total Fertility Rate (TFR) to 2.1
• Reduction of malaria mortality rate: 50 percent up to 2010,
Strengthening Disease Control Programs additional 10 percent by 2012
• All national programs shall be integrated under the • Reduction of kala-azar mortality rate: 100 percent by 2010
mission and sustaining elimination until 2012
• Covering both communicable and non-communicable • Reduction of filaria/microfilaria rate: 70 percent by 2010,
disease 80 percent by 2012 and elimination by the year 2015
• Strengthening Integrated Disease Surveillance Project at • Reduction of Japanese encephalitis mortality rate: 50
village level percent by 2010 and sustaining at that level until 2012
• Provision of mobile medical unit at District level for • Cataract operation: Increasing to 46 lakhs per year until
improved outreach activities. 2012
• Reduction of Leprosy prevalence rate from 1.8/10,000 in
Public-Private Partnership 2005 to less than 1/10,000 thereafter
• Tuberculosis DOTS services: Maintain 85 percent cure rate
• Mission should have representation of private sector
through entire mission period
because 75 percent of health services are being currently
• Upgrading Community Health Centers to Indian public
provided by the private sector
health standards
• To develop guidelines for Public-Private Partnership
• Increase utilization of First Referral Units from less than
(PPP) in health sector
20 percent to 75 percent
• NGOs should be included as members of various Task
• Engaging 2,50,000 female ASHAs in 18 states.
Groups.

New Health Financing Mechanisms JSY and JSSY Schemes

• By organization of various Task Groups Described under National Health Program RCH II.
• By standardization of services
• By monitoring these services
• By reimbursement of costs for services to CHCs from
District Health Fund PROGRESS UNDER NRHM
• By creation of District Health Fund Management (AS ON DECEMBER 2011)
• By encouraging Community Based Health Insurance
Schemes, as part of the mission.
• 8.52 lakh ASHA workers are selected
• 6.90 lakh ASHAs are trained and positioned with kits
Reorientation of Medical Education • Janani Suraksha Yojana (JSY) scheme is operatinoalized
in all the states, benefiting 19.43 lakh mothers during
Administrative Set-up of NRHM 2011-12
• Village Health and Sanitation samiti—at village level • Janani Shishu Suraksha Yojana (JSSY) scheme is launched
• Rogi Kalyan Samiti—for community management of in June 2011, extending the benefits for unhealthy new
hospitals borns

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780 Section 7 Health Administration and Organization

• 69.25 lakh monthly Health and Nutrition Days have been Instructions
organized at Anganwadi centres in various states during
2010-11 • Since the plunger can go back and forward only once,
• Integrated Management of Neonatal and Childhood air should not be drawn in, to inject it into the vial before
Illness (IMNCI) started in 499 districts drawing vaccine. Moreover, injecting air into the vial will
• Accelerated immunization program been taken up lock the syringe
• Intense monitoring of poliomyelitis progress • Select the correct syringe for the vaccine to be adminis

­
• Japanese encephalitis vaccination completed in 11 district tered
in four states • Don’t use the syringe, if the package is damaged, opened
• Neonatal tetanus declared eliminated from 7 states in the or expired
country • After opening the package and the needle cover, do not
• 4.9 lakh Village Health and Sanitation Committees have insert the needle in the inverted vial, beyond the level of
been constituted the vaccine, because it may draw air bubble. Do not draw
• A total of 30,818 Rogi Kalyan Samitis have been set up air into the syringe
in various health centers and hospitals and have been • In case air enters the syringe accidentally, follow these
registered steps to remove the air bubbles:
• 1.47 lakh subcenters are provided with united funds of – Remove the syringe, hold upright, tap the barrel so
`10,000 each that bubbles will come towards the tip of syringe
• Out of 4535 Community Health Centers, 2499 have – Pull the plunger back, so that air will enter in and
been selected for upgradation to Indian Public Health comes in contact with the air bubble in the syringe
Standards – Then carefully push the plunger to the dose mark (0.5
• 1797 Mobile Medical Units are operating or 0.1ml) thus expelling air bubble.
• Mainstreaming of AYUSH has been taken up
• 11205 doctors, 1572 specialists, 53552 ANMs, 26734 Staff Disposal of AD Syringes
Nurses, 18272 paramedics have been appointed
• During the financial year 2009-10, out of `14,050 crores • Remove the needle from AD syringe immediately after
allocated for the Ministry, an amount of `11,613.39 crores using it by using Hub cutter, which cuts the plastic hub of
was released as a part of NRHM. syringe and not the metal part of the needle
• The needles are collected in white translucent container
• The broken syringes and vaccine vials are collected in red
container
AUTO-DISABLE SYRINGES • The red and white bags are then sent to Biomedical Waste
Treatment Facilities (BWTF)
It has been observed recently that the glass syringes used • If BWTF does not exist, the collected materials are
in immunization are often unsafe. Therefore, the glass autoclaved. If not, the waste is boiled in water for at least
syringes and needles are replaced by auto disable syringes 10 minutes or treated with disinfectant
(ADS). • From the autoclaved/disinfected waste, the needles and
This AD syringe will have a fixed needle. It is presterilized broken vials are disposed by burying in a pit and the
in proper pack. They are available in two sizes, of 0.1 ml syringes and the unbroken vials are disposed by sending
and 0.5 ml for immunization purposes. In addition to this, them for recycling
5 ml disposable syringes and needles will be supplied for • The containers are washed properly for reuse.
reconstitution of BCG and measles vaccine separately.

BIBLIOGRAPHY
Advantages of AD Syringes 1. GOI. MOHFW. National Rural Health Mission 2005-2012.
• It is designed to prevent the reuse of nonsterile syringes Mission Document.
2. Indian Public Health Association. National Rural Health
• The fixed needle design reduces the dead space in the
Mission. Ind Jr. of Pub Health. Special Issue 2005;49(3).
syringe that wastes vaccine and eliminates the chances of 3. National Rural Health Mission. Immunization is Priceless for a
air bubble entry into the syringe due to loose fitting of the healthy young India. News Letter 2006;1(3).
needle 4. New Letter. NRHM, Ministry of Health and Family Welfare, New
• They are made, dose specific (0.1 ml and 0.5 ml) and Delhi 2006.
hence withdrawing the plunger to the full length ensures 5. NRHM Bulletin. Vol. 7(1) Nov-Dec 2011.
correct dose. No adjustment is required 6. NRHM Bulletin Vol. 6(3) Jan-Feb 2011.
• Since they are presterilized, it saves time of sterilization. 7. NRHM Bulletin Vol. 7(4) July-Aug 2012.

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CH A P T E R 36
National Urban Health Mission

National Urban Health Mission (NUHM) has been taken up • Environmental pollution (air, water and soil)
during the 11th five year plan (2008–2012) to meet the health • Outbreak of communicable diseases
needs of the urban poor, particularly the slum dwellers, • Increased incidence of STIs, RTIs, HIV/AIDS.
through primary health care services by investing high caliber
health professionals, appropriate technology through public
private partnership and health insurance. GOAL
This covers all cities with a population of more than
1,00,000. It covers slum dwellers, other marginalized urban
dwellers like rickshaw pullers, street vendors, railway and bus It is to improve the health status of the poor by:
station coolies, homeless people, street children, construction • Facilitating equitable access to quality health care
site workers, who may be in slums or sites. • Revising public health system
(NRHM covers rural areas and restricts to reproductive • Building public private partnership
and child health services). • Community based risk pooling and insurance mechanism
• Active involvement of the urban local bodies.

RATIONALE
STRATEGIES
1. Urban population is estimated to increase from 35.7
crores in 2011 to 43.2 crores in 2021. 1. Strengthening urban primary health structure:
2. Rapid increase in the urban population can lead to a. By creating new urban health centers, each covering a
increase in the number of slums. slum population of 20,000 to 30,000.
3. Slum population is growing at the rate of 7 percent b. Provision of evening OPD.
annually. c. Provision of comprehensive health care (preventive,
4. Poor health status of the urban slums. promotive and curative care).
5. Inadequacy of the health care delivery to the slum d. Provision of need based equipment, drugs and human
population. resources.
6. Unfriendly treatment at governmental hospitals. e. Provision of Rogi Kalyan Samiti.
7. Slum people are at greater health hazards because of the f. Provision of outreach health sessions in the slums.
following reasons: g. Using GIS map, for easy access of patients.
• Overcrowding 2. Strengthening community participation, improving
• Poor living conditions health awareness and capacity building, through partner-
• Poor sanitary conditions ship with nongovernment providers.
• Lack of safe water supply 3. Establishment of Mahila Arogya Samiti (MAS).

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782 Section 7 Health Administration and Organization

4. Appointment of Urban Social Health Activist (USHA). water facilities in these towns irrespective of the fact as to
5. Capacity building of stake holders. whether such slums have been notified or not as ‘Slum’
6. Prioritizing the most vulnerable amongst the poor like by State/Local government and Union Territory (UT)
destitute, beggars, street children, construction workers, administration under any Act, recognized or not, are legal or
coolies, rickshaw pullers, sex workers, street vendors and not, is be covered under NUHM’.
such others.
7. Ensuring quality health care services by defining Indian
Public Health Standards suitably modified for urban areas, INSTITUTIONAL FRAMEWORK
defining parameters for accreditation of nongovernment UNDER NATIONAL URBAN HEALTH
providers, developing capacity of both public and private
providers, encouraging the acceptance and enforcement MISSION
of local public health Acts and encouraging development
of standard treatment protocols. At the National and State level, National Rural Health Mission
(NRHM) is utilized for NUHM activities. At each city level,
separate City NUHM Health Society is framed, which moni­
TARGETS UNDER NATIONAL URBAN tors Mahila Arogya Samiti (MAS), USHA (Urban Social Health
Activist) and other activities of NUHM (Fig. 36.1).
HEALTH MISSION
• IMR—30/1000 live births by 2012. Urban Social Health Activist (USHA)
• MMR—01/1000 live births by 2012.
She is a resident woman of the same slum, studied at least
• TFR—2.1 by 2012 (Total fertility rate)
upto 8th standard, preferably in the age group of 25–45 years,
• Malaria—50 percent reduction in mortality by 2015.
married/widowed/divorced, chosen by Urban Local Body
• Kala azar—100 percent reduction in mortality by 2010 and
(ULB) counselors.
sustaining elimination by 2015.
• Filariasis—>80 percent coverage of population by Mass
Drug Administration (MDA) with DiEthyl Carbamazepine
(DEC).
70 percent reduction by 2010, 80 percent by 2012 and

elimination by 2015.
• Dengue fever—50 percent reduction in mortality by 2010
and sustaining at that level.
• Chickungunya—Control of outbreaks and morbidity.
• Tuberculosis—85 percent cure rate through DOTS.
• Leprosy—Reduction in the prevalence rate to less than 1
per 10,000 population.

Coverage and Duration of National

Urban Health Mission
Duration: Period of Eleventh Five Year Plan (2008–2012).
Coverage: Entire urban poor population of 430 cities.
Phase I: All cities with population of more than 1 lakh.
Phase II: All towns with population of less than 1 lakh.

Definition of Slum
Any compact habitation of at least 300 people or about 60
to 70 households of poorly built, congested tenements,
in unhygienic environments, usually without adequate
infrastructure and lacking in proper sanitary and drinking Fig. 36.1 Institutional framework under NUHM

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 Chapter 36 National Urban Health Mission 783

Functions of USHA URBAN HEALTH INSURANCE MODEL

• To promote good health practices in her area
This includes all the urban population (slum and nonslum).
• To facilitate awareness on RCH services
All members are issued photo identity card (Family health
• To motivate all types of family planning methods
suraksha card). Premium—annual amount is fixed per person
• To register all pregnant mothers and to motivate them for
and subsidized premium is offered for the poor.
antenatal care
• To act as a Depot holder for essential provisions like
ORS packets, IFA tablets, chloroquine tablets, oral pills, Benefits
condoms, etc.
• To support ANM/MAS (Mahila Arogya Samiti) in • It includes hospitalization, in patient services for more
conducting monthly outreach session regularly than 24 hours.
• To form and promote Mahila Arogya Samiti • It includes consultation, investigation and room charges
• To escort the patients requiring health services and medicines and surgical/medical procedures.
• To encourage the community participation in health • Maternal and childhood conditions and illnesses.
activities • Monetary coverage is up to a maximum of `50,000/year/
• To maintain the records of vital events in her area enrolled household.
• To treat minor ailments with the drug kit provided. • Amount is directly paid to the empanelled.
Activities of USHA are monitored by ANMs of Primary Public and private health care provider (Fig. 36.3).
Urban Health Center (PUHC) and Urban Local Body (ULB)
counselors.
PRIMARY URBAN HEALTH CENTER
Functions of Mahila Arogya Samiti
This is located preferably near the slum to be served which will
• To focus on preventive and promotive care be accessed by slum dwellers. It covers approximately 50,000
• To act as peer education group population, including 25 to 30 thousand slum population. It
• To facilitate access to identified facilities mainly provides curative health care. Annual fund of `1 per
• Community monitoring and referral head is provided to each PUHC.
• Risk pooling fund and health insurance.

Staff Pattern of
Functions of Auxillary Nurse Midwife Primary Urban Health Center
of Primary Urban Health Center
Medical officer –1
• To provide preventive and promotive health care services Pharmacist/Lab. technician –2
at the household level Program health manager –1
• To monitor the activities of USHA Multi-skilled nurse –2
• To arrange outreach medical camps. ANMs –4
Account keeper –1
Support staff –3
COMMUNITY RISK POOLING
Functions of
This consists of women from Mahila Arogya Samiti. One
time seed money (`25 per household) will be given by the Primary Urban Health Center
Government at the initial time and again annual performance • Medical care—OPD services. 4 hours in the morning and
grant (`25 per household) is given. From this pool, money is 2 hours in the evening
utilized for other purposes, as shown in Figure 36.2. • RCH—II services
• National Health Progam
Uses of this Pooling • Collection and reporting of vital events
• IDSP (Integrated disease surveillance project)
The fund is utilized for unforeseen health expenditure of • Referral services
the member or family, other activities like group meetings, • Basic laboratory services
mobilization for health camps etc. • Counseling services

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784 Section 7 Health Administration and Organization

Fig. 36.2 Community risk pooling under NUHM

Fig. 36.3 Public and private healthcare provider

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 Chapter 36 National Urban Health Mission 785
• Services for noncommunicable diseases • Convergence with Jawaharlal Nehur National Urban
• Social mobilization and community level activities. Renewal Mission (JNNURM).

Referral Units MONITORING AND EVALUATION

Existing hospitals including urban local body maternity
homes, state Government hospitals and medical colleges will State/District/City Urban Health Mission will regularly
be accredited as referral points for health care services. monitor the progress and provide feedback.
Monitoring will be done in three stages:
• Community based monitoring
INTRASECTORAL COORDINATION • Health management information system (HMIS) for
reporting and feedback
• External evaluations.
• Housing and slum development society to establish new
PUHCs
• Colocation of RNTCP, ICTC, AYUSH, IDSP, NVBDCP etc.
at UHCs BIBLIOGRAPHY
• Convergence of all National Health Programs
• Convergence with Swarn Jayanthi Shahri Rozgar Yojana 1. http://www.urban.health.resource.centre.in/module.
(SJSRY) 2. Planning Commission, GOI; Tenth Plan Document, 2002 07, Vol.II.

-
• Convergence with ICDs and education department 3. www.mohfw.nic.in

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