NRHM, National HIV Programme



NRHM, National HIV Programme

NATIONAL RURAL HEALTH MISSION – THE VISION

• The National Rural Health Mission (2005-12) seeks to provide effective healthcare to rural population throughout the country with special focus on 18 states, which have weak public health indicators and/or weak infrastructure.
•  These 18 States are Arunachal Pradesh, Assam, Bihar, Chhattisgarh, Himachal Pradesh, Jharkhand, Jammu & Kashmir, Manipur, Mizoram, Meghalaya, Madhya Pradesh, Nagaland, Orissa, Rajasthan, Sikkim, Tripura, Uttaranchal and Uttar Pradesh.
• The Mission is an articulation of the commitment of the Government to raise public spending on Health from 0.9% of GDP to 2-3% of GDP.
• It aims to undertake architectural correction of the health system to enable it to effectively handle increased allocations as promised under the National Common Minimum Programme and promote policies that strengthen public health management and service delivery in the country.
• It has as its key components provision of a female health activist in each village; a village health plan prepared through a local team headed by the Health & Sanitation Committee of the Panchayat; strengthening of the rural hospital for effective curative care and made measurable and accountable to the community through Indian Public Health Standards (IPHS); and integration of vertical Health & Family Welfare Programmes and Funds for optimal utilization of funds and infrastructure and strengthening delivery of primary healthcare.
• It seeks to revitalize local health traditions and mainstream AYUSH into the public health system.
• It aims at effective integration of health concerns with determinants of health like sanitation & hygiene, nutrition, and safe drinking water through a District Plan for Health.
•  It seeks decentralization of programmes for district management of health.
• It seeks to address the inter-State and inter-district disparities, especially among the 18 high focus States, including unmet needs for public health infrastructure.
• It shall define time-bound goals and report publicly on their progress.
• It seeks to improve access of rural people, especially poor women and children, to equitable, affordable, accountable and effective primary healthcare.

GOALS ·

• Reduction in Infant Mortality Rate (IMR) and Maternal Mortality Ratio (MMR)
• Universal access to public health services such as Women’s health, child health, water, sanitation & hygiene, immunization, and Nutrition
• Prevention and control of communicable and non-communicable diseases, including locally endemic diseases
• Access to integrated comprehensive primary healthcare
• Population stabilization, gender and demographic balance.
• Revitalize local health traditions and mainstream AYUSH
• Promotion of healthy life styles

STRATEGIES

• Train and enhance capacity of Panchayati Raj Institutions (PRIs) to own, control and manage public health services.
• Promote access to improved healthcare at household level through the female health activist (ASHA).
•  Health Plan for each village through Village Health Committee of the Panchayat.
• Strengthening sub-centre through an untied fund to enable local planning and action and more Multi Purpose Workers (MPWs).
• Strengthening existing PHCs and CHCs, and provision of 30-50 bedded CHC per lakh population for improved curative care to a normative standard (Indian Public Health Standards defining personnel, equipment and management standards).
• Preparation and Implementation of an inter-sectoral District Health Plan prepared by the District Health Mission, including drinking water, sanitation & hygiene and nutrition.
• Integrating vertical Health and Family Welfare programmes at National, State, Block, and District levels. Technical Support to National, State and District Health Missions, for Public Health Management.
• Strengthening capacities for data collection, assessment and review for evidence based planning, monitoring and supervision.
• Formulation of transparent policies for deployment and career development of Human Resources for health.
• Developing capacities for preventive health care at all levels for promoting healthy life styles, reduction in consumption of tobacco and alcohol etc.
• Promoting non-profit sector particularly in under served areas.

PLAN OF ACTION

1. COMPONENT (A): ACCREDITED SOCIAL HEALTH ACTIVISTS
2. COMPONENT (B): STRENGTHENING SUB-CENTRES
3. COMPONENT (C): STRENGTHENING PRIMARY HEALTH CENTRES
4. COMPONENT (D): STRENGTHENING CHCs FOR FIRST REFERRAL CARE
5. COMPONENT (E): DISTRICT HEALTH PLAN
6. COMPONENT (F): CONVERGING SANITATION AND HYGIENE UNDER NRHM
7. COMPONENT (G): STRENGTHENING DISEASE CONTROL PROGRAMMES
8. COMPONENT (H): PUBLIC-PRIVATE PARTNERSHIP FOR PUBLIC HEALTH GOALS, INCLUDING REGULATION OF PRIVATE SECTOR
9. COMPONENT (I): NEW HEALTH FINANCING MECHANISMS
10. COMPONENT (J): REORIENTING HEALTH/MEDICAL EDUCATION TO SUPPORT RURAL HEALTH ISSUES

INSTITUTIONAL MECHANISMS

• Village Health & Sanitation Samiti (at village level consisting of Panchayat Representative/s, ANM/MPW, Anganwadi worker, teacher, ASHA, community health volunteers
• Rogi Kalyan Samiti (or equivalent) for community management of public hospitals
• District Health Mission, under the leadership of Zila Parishad with District Health Head as Convener and all relevant departments, NGOs, private professionals etc represented on it
• State Health Mission, Chaired by Chief Minister and co-chaired by Health Minister and with the State Health Secretary as Convener- representation of related departments, NGOs, private professionals etc
• Integration of Departments of Health and Family Welfare, at National and State level
• National Mission Steering Group chaired by Union Minister for Health & Family Welfare with Deputy Chairman Planning Commission, Ministers of Panchayat Raj, Rural Development and Human Resource Development and public health professionals as members, to provide policy support and guidance to the Mission
• Empowered Programme Committee chaired by Secretary HFW, to be the Executive Body of the Mission
• Standing Mentoring Group shall guide and oversee the implementation of ASHA initiative  
• Task Groups for Selected Tasks (time-bound)

National HIV Programme

• India, the second most populated country in the world, is home to an estimated 2.1 million people living with HIV (PLHIV), the third highest population globally after South Africa and Nigeria.
• The HIV epidemic in India is highly heterogeneous.
• It is concentrated in specific regions of the country and in high-risk groups (HRGs) such as people who inject drugs (PWID), female sex workers (FSW), men who have sex with men (MSM) and transgender people.
• HIV prevalence among all adults (15–49 years) has been declining steadily from 0.38% in 2001 to 0.26% in 2015, while among FSW, MSM and PWID it remains at 2.2%, 4.3%, and 9.9%, respectively.
• Over the period 2000–2015, the annual estimated number of new HIV infections has decreased by 66%, while the number of annual AIDS-related deaths has decreased by 54% since 2007

The National AIDS Control Programme (NACP)

• The National AIDS Control Programme (NACP) has been implemented by Government of India as 100% centrally sponsored scheme through State AIDS Control Societies in the states for prevention and control of HIV/AIDS.
• The first National AIDS Control Programme was launched in 1992, which focused on the national HIV surveillance system, prevention activities among High Risk Groups (HRGs) including information on HIV and the blood safety programme.
• NACP-II launched in 1999 focused on the scale-up of targeted interventions for HRGs, especially prevention, out-reach, HIV testing & counselling and fostered greater involvement of People Living with HIV (PLHIV) and community networks.
• The treatment programme was also launched under NACP II. Institutionalization of decentralized programme management through State AIDS Control Society was a key thrust in phase II.
• NACP-III launched in 2007, showed a rapid expansion of prevention, care, support and treatment efforts across the country with a focus on increasing service access points through institutional scale-up and out-reach.
• Currently, the NACP-IV (2012-2017) is mid-way through implementation. It focuses on consolidating the gains made during NACP-III and aims to accelerate the process of reversal of the HIV epidemic.
• The key strategies under NACP-IV includes intensifying and consolidating prevention services with a focus on HRG and vulnerable population, increasing access and promoting comprehensive care, support and treatment, expanding IEC services for general population and high risk groups with a focus on behaviour change and demand generation, building capacities at national, state and district levels and strengthening the Strategic Information Management System.
• Prevention and Care, Support & Treatment (CST) form the two key pillars of all HIV/AIDS control efforts in India.

The package of services provided under NACP-IV includes:

Prevention Services:

• Targeted Interventions (TI) for High Risk Groups and Bridge Population, Female Sex Workers (FSW), Men who have Sex with Men (MSM), Transgenders/Hijras, Injecting Drug Users (IDU), Truckers & Migrants;
• Needle-Syringe Exchange Programme (NSEP) and Opioid Substitution Therapy (OST) for IDUs;
• Prevention Interventions for Migrant population at source, transit and destinations;
• Link Worker Scheme (LWS) for High Risk Groups and vulnerable population in rural areas;
• Prevention & Control of Sexually Transmitted Infections/Reproductive Tract Infections (STI/RTI);
• Blood Transfusion Services;  
• HIV Counselling & Testing Services;
• Prevention of Parent to Child Transmission;
• Condom promotion;
• Information, Education & Communication (IEC) and Behaviour Change Communication (BCC)–Mass Media Campaigns through Radio & TV, Mid-media campaigns through Folk Media, display panels, banners, wall writings etc., special campaigns through music and sports, flagship programmes, such as Red Ribbon Express;
•  Social Mobilization, Youth Interventions and Adolescence Education Programme;
• Mainstreaming HIV/AIDS response and Work Place Interventions.

Care, Support & Treatment Services:

• Laboratory services for CD4 Testing, Viral Load testing, Early Infant Diagnosis of HIV in infants and children up to 18 months age and confirmatory diagnosis of HIV-2;
• Free first line & second line Anti-Retroviral Treatment (ART) through ART Centres and link ART Centres, Centres of Excellence & ART plus centres;
• Pediatric ART for children;
• Nutritional and psycho-social support through community and support centres;
• HIV-TB coordination (Cross-referral, detection and treatment of co-infections) and
• Treatment of Opportunistic Infections.

State AIDS Prevention and Control Societies (SACS)

• National AIDS Control Organisation provides leadership to HIV/AIDS Control Programme in India, implementing one National Plan within one monitoring system. State AIDS Prevention and Control Societies (SACS) implement NACO programme at state level, but have functional independence to upscale and innovate.

SACS Structure

• SACS are autonomous and decentralised. Each State AIDS Prevention and Control Society has a governing body, its highest policy-making structure, headed either by the minister in charge of health or the chief secretary.
•  It has on board representatives from key government departments, the civil society, trade and industry, private health sector and PLHA networks, who meet twice a year. It approves new policy initiatives, annual plan and budget, appoints statutory auditors and accepts the annual audit report.
• For better financial and operational efficiency, administrative and financial powers are vested in the Executive Committee and the Programme Director.

Functions of SACS are:

• Medical and public health services;
• Communication and social sector services; and
• Administration, planning, coordination, monitoring and evaluation, finance and procurement.

• With the setting up of District AIDS Prevention and Control Unit under NACP-III, there will be increased emphasis on improving coordination functions at state level in supporting the programme implementation at the district level.

DAPCU (District AIDS Prevention and Control Unit)

• As a major structural reform, the management of HIV prevention and control programme was decentralised to district level during the third phase (2007-12) of National AIDS Control Programme-III in the years 2008-09.
• Using the HIV Sentinel Surveillance data (2004-2006), all the districts in the country were divided into four categories (Category A, B, C and D) based on the disease burden. As per this, there were 156 Category A and 39 Category B districts (total 195 districts) across the country (22 states) that required priority attention.
• National AIDS Control organization (NACO) established DAPCUs in 188 of the 195 districts to provide programmatic oversight through decentralized facilitation, monitoring and coordination of HIV/AIDS programme activities in the district.
• DAPCU structure and roles: DAPCU is the eye and ears of NACO and State AIDS Control Societies (SACS) with a cross cutting management structure that coordinates with all the HIV facilities in the district.
• The DAPCU is headed by a public health officer of the rank of Deputy Chief Medical & Health Officer known as District AIDS Control Officer.
• S/he is supported by a team of five people hired on a contractual basis. The major responsibility of DAPCU is facilitation, monitoring and coordination of NACP activities at the district and sub- district level by integrating it with the health system to the extent possible for better synergy and optimal results

The key functions of DAPCUS are:

• DAPCUs, through active engagement of the district administration mobilise response from allied line departments and private sector in mainstreaming the programme.
• Initiates evidence based district-specific initiatives by leveraging local resources.
• Facilitates in linking vulnerable population with various social entitlement and welfare schemes under the mechanism of DAPCU led single window approach.
• DAPCUs mentors facility staff in efficient delivery of services, conducts impact monitoring through regular supervisory visits to HIV facilities, monthly review meetings and management and use of multiple databases (SIMS/MCTS/PCTS).
• Based on these regular monitoring mechanisms, DAPCUs coordinate among NACP as well as NHM facilities and functionaries in strengthening referrals and linkages.
• Apart from these, DAPCUs address supply chain management issues through inter and intra-district transfers and liquidation of advance.
• Other activities entrusted by SACS such as setting up of FICTCs in both Government and PPP mode, facilitating Migrant Health Camps, Mid-media campaigns under IEC program, preparation of district epidemiological profile are also part of their functions