The Union Cabinet vide its decision dated 1st May 2013 has approved the launch of National Urban Health Mission (NUHM) as a Sub-mission of an over-arching National Health Mission (NHM), with National Rural Health Mission (NRHM) being the other Sub-mission of National Health Mission.
NHM has six financing components:
NRHM-RCH Flexi pool
NUHM Flexi pool
Flexible pool for Communicable disease
Flexible pool for Non communicable disease including Injury and Trauma
Family Welfare Central Sector component
Within the broad national parameters and priorities, states would have the flexibility to plan and implement state specific action plans. The state PIP would spell out the key strategies, activities undertaken, budgetary requirements and key health outputs and outcomes.
Even though the state of Kerala has advanced as compared to the other states of India in terms of critical health indicators are concerned, the state is facing challenges that are unique and specific. The people are now facing the problem of high morbidity both from re-emergence of communicable diseases and the second generation problems like the ageing population and non communicable diseases. Moreover, there remains the challenge of sustaining the privileged health indicators.
Further, improving the quality of health care where the health seeking behavior is very high is of utmost importance. The resources of National Rural Health Mission came in an opportune time when the state was finding it difficult to find resources matching the demand.
During the last three years the State has been able to initiate many programmes suiting to its specific requirements and considering its health issues that need immediate intervention. These initiatives correspond to the Key Performance areas outlined by NRHM like a) Institutional Strengthening b)Improving access to better health care and quality services and c) Accessibility of health care to the under privileged and marginalized
Infrastructure development under NRHM mainly consists of undertaking up-gradation of all the Community Health Centres and select General/ District /Taluk / Block PHCs / PHCs and other medical institutions. In the initial phase the work of the115 CHCs were taken up as per the guideline of Indian Public Health Standards. Agencies with experience in Health Construction like Hindustan Latex Ltd, Hindustan Prefab Ltd and Kerala Health Research and Welfare Society have been hired as implementing agencies for the civil works on turnkey basis. Of the 115 CHCs taken up for upgrading through HLL, Work has been fully completed in more than 100 CHCs. The entire CHC upgrading work is expected to be completed by December 2010.
Other works include the upgrading of the General hospitals, District hospitals, Taluk hospitals, and other institutions in the State. Work has been fully completed in 9 institutions and the other works at various stages shall be completed by March 2010. One of the major works is the construction of a new block and renovation of the old building at IMCH Kozhikode which alone is estimated around 33 crore. A modern sewage treatment plant was constructed for the Kozhikode medical college campus and the construction was completed in record time.
The State is implementing a robust Health Management Information System (HMIS) as reporting and analyzing a variety of data is of vital importance in Health care. Accurate and timely information, in a web based platform, is required both by the Government of India and the State.
The HMIS, developed by HISP India, a not-for-profit NGO, on Free & Open Source Software (FOSS) in accordance with the State IT Policy, now links 1,200 plus health facilities in the State including all PHCs, CHCs, District Hospitals, Government Hospitals, General Hospitals, W & C Hospitals, Medical Colleges, Taluk Hospitals and Specialty hospitals to collect and process data from all institutions up to peripheral Sub Centres and even Private health facilities. Approximately 10,000 Health staff belonging to Health department was given initial training under the programme to switch over to online reporting. From April '09 onwards, the State started generating data in the new system.
The seed for renovating the School Health programme in the State was sown with the starting of a School Health Clinic in 2007 December in the largest girl's school in India, the Cotton Hill Girls Higher Secondary School in the capital city Thiruvananthapuram. A full time Doctor, a staff Nurse and an attendant was appointed. The clinic proved to be a great success with 30-40 out patients (students), who were given appropriate treatment either with medicines or proper advice.
Health education was approached in a multi pronged manner. Along with the conventional class room method, an year long standing exhibition, quiz competitions, demonstration on preparation of easy to prepare nutritious food etc were conducted. In 2008, realizing a need for extending health activities in all schools of the state planning was undertaken which culminated in implementation of the Special School Health programme.
Thus a renovated School Health Program was launched in 2009 in 10% of Govt and Govt Aided schools in Kerala. The programme was envisaged cover all Government & Aided schools of the state in a phased manner.
The Vision of the programme is to develop healthy and informed adult human capital by promoting physical and mental health through childhood and adolescent.
The main objective of the programme is to identify incipient diseases, disorders and disability by adequate and timely action and to become the anchor of promotive and preventive health.
Tribals form more than 1% of the State's total population and they belong to 35 communities. 22% of them are still living in the forest areas. Wayanad district with 1,36,062 Tribal population, Idukki district with 50,973 and Palakkad district with 39,665 account for the majority of the tribal population of Kerala.
In order to provide primary Health care services for the tribals living in the remote and hard to reach tribal settlements, 13 tribal Mobile Medical units are functioning in the state. Five of these units are functioning in the Wayanad district, two each in Idukki and Palakkad districts and one each in Kasaragod, Malappuram, Kannur and Trivandrum districts. These units are conducting on an average 20 medical camps per month in the remote tribal settlements under the leadership of a medical officer with the supporting para-medical staff like pharmacists, staff nurse etc. The field workers and the supervisors of the respective areas do the mobilization of the community to the camps. In these camps the essential primary health care needs of the community namely the treatment of the basic illnesses, antenatal and postnatal care, immunization services, prevention and control of the communicable diseases etc. are provided. Also necessary health education programmes including the prevention of waterborne diseases are imparted through these medical camps.
Accredited Social Health Activists (ASHAs) are being deployed for every 1000 population in the state. ASHAs are voluntary workers who are paid incentives based on performance.
ASHAs will act as a link between the community and health care services and ensure that the primary health care services are accessed by the rural poor. Considering the peculiar Health scenario in Kerala the role of ASHAs has been extended to other fields like Prevention & Control of Communicable diseases, Identification & Control of NCD's, Palliative care and Community based Mental Health Programme.
Though started late when compared to other states, the implementation of ASHA scheme in the state has gained significant momentum in the last two years which is reflected on indicators like ANC and Immunization etc. Till July 2009, 30909 ASHAs have been selected and 27904 ASHAs who were given the induction training have been deployed in the field. Drug kits are being provided to ASHAs as per GoI norms. 22750 drug kits have already been procured and distributed. Debit card system has also been implemented in one of the districts to avoid delay in payment of incentives.
Investment in Adolescent Reproductive and Sexual Health will positively influence MMR, IMR, reducing incidence of teenage pregnancy, meeting unmet contraceptive needs, reducing the incidence of Sexually Transmitted Infections (STIs) and reducing the proportion of HIV positive cases. Issues of adolescents range from undernourishment, sexual harassments, substance abuse, suicides and a lot of unhappy situations in the life. It is in this context that a programme for the adolescents is envisaged by NRHM namely Adolescent Friendly Health Services (AFHS). In order to reduce risky sexual behavior and empowering adolescents to make informed decisions for facing the challenges of life, they need to develop the necessary life skills. Thus, the focus of interventions with adolescents has to shift from information given, to building life skills. While life skills are built through experimental learning, these skills can be enhanced in the context of ARSH.
ARSH was initiated in Kerala during 2008-09. The pilot study was conducted at Thiruvananthapuram. The trainings for the staff implementing the project were given by the Child Development Center (CDC). It is now being implemented in 5 Taluk hospitals directly under CDC and in 1 Taluk hospital the ARSH clinic is being supervised by CDC. Besides, ARSH clinics are conducted in 62 PHCs and 24 CHCs on weekly basis.
Non communicable life style diseases pose a huge threat to the nation's public health system both in terms of morbidity, mortality and economic burden it imposes. In order to address one of the greatest public health challenges, the state NRHM has designed a non communicable diseases prevention and control programme in the state – which is the first of its kind in the country- and successfully pilot tested in a taluk of Trivandrum district and whole of Wayanad district. The essential component of this programme is ASHA service and from there on the NRHM machinery working together with state health service system at various levels.
This programme has been pilot tested in 2008-09 in a Neyyattinkara Taluk in Trivandrum district and in Wayanad district and was proved successful in improving the efficiency, accessibility and equity in non communicable diseases care in the pilot Taluk and Wayanad district.
During 2010-2011 year we have planned to expand the project to the whole of Trivandrum district. The NCD programme has been operational in Wayanad district in 2008-09 and we would like to continue the programme in the coming year as well.
Despite, better health outcomes on certain indicators, the much-proclaimed Kerala model of health has been showing a number of disturbing trends. Although mortality is low, the morbidity (those suffering from chronic/non-communicable diseases) levels in urban and rural Kerala is high in Kerala compared to other Indian States. Thus the paradox is that on the one side Kerala stands as the State with all indicators of better health care development in terms of IMR, MMR, birth rate, death rate etc. on the other it outstrips all other Indian States in terms of morbidity especially the chronic illness. Kerala may have the best health indicators but necessarily not have the best public health care institutions. The success of Kerala health indicators is more due to the investment in the social capital rather than only in the public health care, resulting in a more accountable and integrated primary health care system
Increasingly, the public sector is unable to meet the demands for health care and people have responded to these inadequacies by increasing using the emerging private sector. This has led to the impetus growth of the private medical care set up in the State and the dependence on private health care is quite high even among the lower expenditure classes and rural areas. The unregulated private sector raises household health care expenditures, making health a commodity purchased by 'ability to pay.'
Many public facilities remain underutilized especially in the institution at the level of CHC and below. In the changing scenario, the private sector reigns supremacy in the infrastructure and health manpower development than public sector in the State. The public health centers are currently being utilized mostly for maternal and child health care programmes especially for immunization schemes.
It is in this context, the government of Kerala has taken up the Rashtriya Swasthya Bima Yojana scheme of Government of India announced by Prime Minister, along with Comprehensive Health Insurance Scheme for (CHIS) in October 2008. The objective of RSBY/CHIS is to protect below poverty line (BPL) households from major health shocks that involve hospitalization. Specifically, BPL families are entitled to more than 700 in-patient procedures with a cost of up to 30,000 rupees per annum for a nominal registration fee of 30 rupees. The Scheme is jointly implemented by departments of Labour& Rehabilitation, Health & Family Welfare, Rural Development, and Local Self Govt. The Labour Department is the Nodal dept. for implementation of CHIS. A separate agency "Comprehensive Health Insurance Agency of Kerala" (CHIAK) is created for implementation of the scheme. "United India Insurance Company Limited" is the insurance provider for all 14 districts. 140 government hospitals and 165 private hospitals have been empanelled towards implementing the scheme.
Janani Suraksha Yojana (JSY) is a safe motherhood intervention under the National Rural Health Mission (NRHM). This scheme is in operation in Kerala from 2005-06 and is implemented with the objective of reducing maternal and infant mortality by promoting institutional delivery. The beneficiaries are pregnant women falling in the BPL category, aged 19 years and above and also SC&ST categories opting deliveries in public or accredited private health institutions.
Cash Assistance under JSY
BPL or SC/ST mothers from Rural area who are delivering in Government Hospitals/ Accredited Private Hospitals- ` 700/-
BPL or SC/ST mothers from Municipal/Corporation area who are delivering in Government Hospital/Accredited private Hospitals -`600/-
Home delivery- ` 500/-
As the scheme targets the poor women who would generally be short of cash, it is ensured that the cash assistance provided under the scheme is made available to her in shortest possible time. Implementation of Janani Suraksha Yojana has shown phenomenal progress in the last three years in the State, with number of women benefiting out of it increasing considerably over the year This has been attributed to an increase in mass awareness and also by making the procedures simple. The State government has ordered to make all payments in one installment before discharge from the health care institutions after delivery. This facility can be availed on on producing any document that proves the income status or caste in case of SC/ST
Ward Health Nutrition days with focus on Reproductive Child Health care services are being held in all the Wards in the state every month. ASHAs play a key role in conducting the nutrition day by mobilizing the people to attend the program. Agenda for WHNDs are decided in advance based on the need of the area during the monthly conference at the PHCs. Junior Public Health Nurses keep the record of all the activities in the register and the consolidated reports of the block is prepared by the Block Coordinator
In Kerala wards are the lowest unit in Panchayat Raj Institutions and sub centre in the basic health unit in Health Delivery system. Grass root level health workers like Junior Public Health Nurse (JPHN) and Junior Health Inspector (JHI) are attached to the sub centre. In such case the lowest level of health plan, in Kerala shall be Ward Health Plan. The ward level planning is an important unit for NRHM plan preparation. Hence Ward Health and Sanitation Committees are constituted in every ward with the following composition.
The state recorded the lowest population growth rate, 9.42, in the country during the decade 1991-2001 as per 2001 census. The decadal growth rate has recorded substantial decline over the previous census, from 14.32 (1981-91) to 9.42 (1991-2001). As per the result of sample registration survey 2007, state of Kerala has recorded the lowest birth rate (14.7) and Infant Mortality Rate (13) far below the National average of 23.1and 55 respectively. Death rate in the State is 6.8 against National rate of 7.4 during the year. As per the results of NFHS-3 Kerala has achieved the target of hundred percent institutional deliveries there by reducing Maternal Mortality to considerable levels. Sex ratio as per census 2001 is 1058 female per thousand men. Child Sex ratio (age 0-6) is 960 females per thousand male children. Female literacy rate is (86.87%) is also the highest in the country. National Family Health Survey 2005-06 has recorded the total fertility rate as 1.9, which is below the replacement level of fertility. SRS 2007 has recorded a further reduction in TFR to 1.7 which is the lowest in the country
However the results of NFHS 3 show that the state has gone down in vaccination coverage due to many reasons. Various action plans have been mooted to sustain the achievements already recorded and improve performance wherever required. As a result the latest Coverage Evaluation Survey shows that 87.9 % of children are fully immunized though the percentage of full immunization by age 12 months is 82.9. Further the recently concluded DLHS III shows 79.5% coverage for full immunization.
Many initiatives have been taken to improve the immunization status in the state. Outreach immunization camps have been identified as a means to extend immunization to floating and migrant population. Service of ASHA is utilized in a big way to achieve maximum coverage of these groups. Immunization sessions are organized in the remote areas giving special attention to tribal, coastal and urban slums. In the low coverage areas, immunization activities are strengthened with the help of NGOs and private institutions.
As envisaged in the Programme Implementation Plan (PIP) of NRHM Behaviour Change Communication Strategies implemented are a mix of media, message and interpersonal communication with emphasis on counseling of families and community. The BCC interventions under NRHM focused on a) Mass Media, b) Mid Media (use of folk groups) and c) Interpersonal Communication.While Mass media campaign focuses on making use of electronic, print and other possible media of mass communication towards creating awareness and publicity for demand generation/behaviour change Mid media campaign focuses on communication through art/folk media for which NRHM has identified groups who can perform street plays and other folk arts and Equipped them to perform plays that communicate health messages.
Mainstreaming of AYUSH (Ayurveda, Yoga & Naturopathy, Unani, Siddha & Homoeopathy) systems of Medicine and revitalization of LHT (Local Health Traditions) is a major vision of NRHM. The AYUSH systems, especially Ayurveda and Homeopathy play an important role in the Health Care Delivery System in Kerala. There are over 1300 institutions in these systems of medicine. In the Health sector, there are separate directorates for Allopathy, Ayurveda, Homeopathy etc.
Deploying Medical Officers to AYUSH dispensaries under LSGIs
Strengthening of existing AYUSH infrastructure in the state