Swasth Hind

Education & Capacity Building Of The Community For

Self- Management of Primary Health And Medical Care
With
Focus on Older Population Age Group – 45 Years -70 Years

THE PROPOSAL FOR PILOT PROJECT TO TEST

FEASIBILITY OF TRAINING OF
Honorary Health Animators HHA –
at village level

[To provide the building bloc of developing curriculum and training module
for Community Health Providers- Middle level Health providers envisaged
under National health policy 2017 and NMC act 2019.]

Dr. Onkar Mittal

E Mail: onkarmittal@swasthhind.in
Web: blog.swasthhind.in
Tel - +919818110784 (mobile)
Address: E-43 South Extension Part (1)
1

New Delhi 110049

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CONTENTS
1. Summary –page 3-7
2. Detailed Project Concept for Pilot page 8-28
2.1. Background – Community health provider/ Asha – page 8-11
2.2. Concepts related to Pilot Project -9-27
 Selection and Role and responsibility of HHA
 Ward level committees
 Activities of the Pilot in Support of the Training of HHAs
 MIS and health card
 List of Medicines
2.3. Training Content
2.4. Proposed Budget for the Pilot project- - 28
3. Annexure – page 29 -52
3.1. Challenge of health financing gap and high OOP expenditure
3.2. Prevalence of NCD
3.3. Vision of a comprehensive health system – compare this to
National Health Policy 2017
3.4. Health Card –prototype
3.5. Survey of Prevalence of NCD ( in Punjab)
3.6. The New incentives for ASHA
3.7. Hindi Excerpts

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 SUMMARY
DEVELOPMENT OF CURRICULUM AND TRAINING MODULE
FOR COMMUNITY HEALTH PROVIDERS –

Background

We need to congratulate the Health Ministry of GOI, for taking this bold
initiative to make an enabling provision in the NMC act for licensing the mid-
level Community Health Providers to strengthen the health systems and
primary health care in the remote areas in the country. This is a national need
which was waiting for emphatic action of Government of India for the last forty
years. We do hope that if this measure is implemented in its letter and spirit, it
will provide very solid foundation to the primary health care system on the
grass-root, enabling the more qualified health workforce to focus their
attention in provision of effective secondary and tertiary health care services.
There is need for community health experts to offer their services to assist the
Ministry and complement its efforts in this national endeavour.

We understand that the ambitious Ayushman Bharat initiative announced by

GoI in this year’s Budget Speech needs 1,50,000 mid-level providers within the
next 3-5 years to provide comprehensive primary and preventive care.

In this context there is an urgent need to undertake the following:

i. Develop selection criteria and regulatory framework for the Community
Health Provider
ii. Develop curriculum;
iii. Develop comprehensive training manuals;
iv. Training programs for the trainers;
v. pilots on the ground to validate the methodology and content of the
educational curriculum and training modules.
.
A very brief synopsis of our approach to selection and training of
community health provider –

Role –
 The Community Health Provider will provide leadership to available community
health resources in the designated area – ASHA, ANMs and pharmacies,
supervisors, ICDS workers and informal health providers, VHSNC- PRI
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representatives.
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 The focus of his/her action will be on health and wellness and prevention and
primary medical care of the chronic diseases ( Hypertension, diabetes, joint pain,
acidity and indigestion, anaemia, skin diseases, and others ). For the communicable
disease control and for Maternal and Child health services he will coordinate with
the district CMO and CHC and will provide the requisite support on the ground.
 In all aspects of his work, he will activate the village residents and their local
committees to take lead in promoting positive health attitude and other life style
changes for primary and secondary preventive health action.
Responsibility
 He/she will work under the overall supervision of the district CMO/ Medical
officer of CHC and will provide essential supervision for the health workforce in
the designated area. Qualitative surveys, prioritization in consultation with
community and a data based functional monitoring system will support this
supervision and results based accountable approach.
Selection
 Preference will be given in the selection to young and middle aged educated
persons having hands on experience of health promotion at the village and
Grampanchayat level.
 To enable motivated persons to gain right exposure and experience at the village
level health promotion work – provision will be made to run short certificate
courses of, say, 15 days duration, giving them the title of honorary health
animators ( purely voluntary). The incentive for them will be their probable
selection as mid- level provider licentiate course to enable them to practice as
community health providers.
Training
 The formal training of Community Health Providers will be district based – for
one year with with hands on practical experience. There will be refresher trainings
of 15 days each year for the next three years. In addition this will be supported by
an element of distance education.
 The training modules will be developed focusing on acquisition of functional
knowledge and skills. There will be provision for testing these within the class and
in the field.
 A series of pilots will be run to validate the training content and methodologies.
 A suitable program for training of trainers of community health providers will be
developed to enable to take the initiative to scale to meet the urgency of demand
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of training of large workforce.

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 IT IS THE CORE COMPONENT OF OUR SUGGESTED
METHODOLOGY THAT SELECTION OF COMMUNITY HEALTH
PROVIDER SHOULD BE LIMITED TO PERSONS LIVING IN VILLAGE
AND HAVING PRIOR EXPERIENCE IN HEALTH PROMOTION
ACTIVITIES AT VILLAGE LEVEL.

 HENCE WE ARE PROVIDING THE SUGGESTED APPROACH OF

TRAINING WHICH IS A KIND OF INITIAL MIX OF HONORARY
HEALTH VOUNTEER AND COMMUNITY HEALTH PROVIDER FOR
UNDERTAKING A FEW PILOTS.

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 Data based
MIS and
Supervision of
ASHA and
ANMs and

others

provider of Leader of health

primary workforce & VHSNC
medical care
for NCD at the PHC level coordinate with CHC and
CMO for supporting the
communicable disease
control programs and
maternal and child health
activties

Promote formation of ward

level health commitees &
health education through
Honorary Health Animators
( voluntary )
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 Trained Community Health
Provider

3
1 4
Self –
Health check up and Management Village&
Primary Health & 2 of Chronic Ward
Medical care Access to diseases –By level HMIS
Essential drugs / community
1. Positive health Community groups Patient
2. Family counselling Chest of Drugs Diabetes card and
3. Life style and /Anaemia register
At ward level
nutrition Old age care
and Gram Computeri
4. Treatment of Palliative care
panchayat level zed at
routine illnesses
PHC
5. Referral

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 DETAILED PROJECT INFORMATION
1. Background
NATIONAL HEALTH POLICY 2017
11.4 Mid-Level Service Providers: For expansion of primary care from
selective care to comprehensive care, complementary human resource
strategy is the development of a cadre of mid-level care providers. This can be
done through appropriate courses like a B.Sc. in community health and/or
through competency-based bridge courses and short courses. These bridge
courses could admit graduates from different clinical and paramedical
backgrounds like AYUSH doctors, B.Sc. Nurses, Pharmacists, GNMs, etc and
equip them with skills to provide services at the sub-centre and other
peripheral levels. Locale based selection, a special curriculum of training close
to the place where they live and work, conditional licensing, enabling legal
framework and a positive practice environment will ensure that this new cadre
is preferentially available where they are needed most, i.e. in the under-served
areas.

1.1. NMC Act 2019 :

This act was passed by the Parliament of India last month – which
supersedes the old MCI act. This act has made a provision for new
cadre of health workers at the middle level to be called Community
Health Workers. While this has been opposed by the IMA and other
association of doctors of modern, medical system, it has been
defended by the Health Minister in Parliament.

Objectives of introducing the middle level health provider - Shri

Harshwardhan – The Union Minister for Health
• “We are looking at universal health coverage and more importantly,
universal screening of our population for non-communicable diseases in
the years to come. This requires a large number of health professionals.
• Doctors are a scarce resource in our country and need to be optimally
utilized. They are indispensable for secondary and tertiary care;
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 • the only area where other health professionals can supplement them is
preventive and primary healthcare”.
• Dr Harsh Vardhan stated that “In the above background, a provision has
been made in the NMC Act to register some Community Health
Providers (CHPs)who shall be modern medicine professionals; they shall
not be dealing with any alternative system of medicine.
• Also, they will have limited powers for providing primary and preventive
healthcare at the mid-level”.
• He further stated that the eminent doctors in NMC shall decide their
qualifications through regulations which shall be finalized after extensive
public consultation and debate.
• The Union Health Minister explained that as part of a pragmatic and
forward looking measure in the NMC Act, in remote areas where
doctors are not available,
There will now be a health professional who can
• counsel the population,
• provide early warnings,
• treat elementary ailments, and
• provide early referral to a higher facility.
The utility of such midlevel health providers has been confirmed by the WHO
after studying their impact on healthcare in developed and developing
countries. Even developed countries like USCanada and UK have mid-level
providers like nurse practitioners, he added. Dismssing the fears of promoting
quackery, he stated that - Dispelling rumors, fears and apprehensions about
this provision giving a fillip to quackery in the country, he stated that: “A false
impression is being created that the provision for CHPs has been made to
legalize quacks. Nothing can be farther from the truth. On the contrary, the
punishment for quackery has been enhanced to uptoone year imprisonment
and upto Rs 5 lakhs fine. Most of the so-called quacks in the country do not
possess any qualifications and would not be able to meet the conditions that
will be set by NMC for becoming a CHP”,

While further consultations are going to take place to operationalize the new
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mechanism – following context needs to be kept in mind.

PRESS INFORMATION BURAEU RELEASE OF 6 AUGUST 2019

1. Clause 32: Limited License to practice at Mid-level as

Community Health Provider:

India has a doctor-population ratio of 1:1456 as compared with the WHO

standards of 1:1000. In addition, there is a huge skew in the distribution of
doctors working in the Urban and Rural areas with the urban to rural doctor
density ratio being 3.8:1. Consequently, most of our rural and poor population
is denied good quality care leaving them in the clutches of quacks. It is worth
noting that at present 57.3% of personnel currently practicing allopathic
medicine does not have a medical qualification.

The ambitious Ayushman Bharat initiative announced by GoI in this year’s Budget
Speech needs 1,50,000mid-level providers within the next 3-5 years to provide
comprehensive primary and preventive care.It will take 7-8 years to ramp up the
supply of doctors, therefore, in the interim we have no option but to rely upon
a cadre of specially trained mid-level providers who can lead the Health and
Wellness Centres.

There are international examples of Health Systems permitting such Community

Health workers. Countries such as Thailand, United Kingdom, China, and even
New York have permitted Community Health Workers/Nurse Practitioners
into mainstream health services, with improved health outcomes. Since we have
shortage of doctors and specialists, the task shifting to Mid- level Provider will
relieve the overburdened specialists. This is merely an enabling provision to
grant limited licence only in primary and preventive healthcare to practice
medicine at mid-level to such persons, who qualify such criteria as may be
specified by regulations which will have an overwhelming representation of
Doctors. Chhattisgarh and Assam have experimented with the Community
Health Workers. As per independent evaluations (carried out by Harvard School
of Public Health), they have performed very well and there is no ground of
concern if the quality of personnel is regulated tightly.

In the above overall context, it will be useful to have in perspective the

progress made since 2004 ( NRHM) in providing for another cadre of rural
community health worker- ASHA – ( ICDS worker not discussed here)
1.2. ASHA – Introduced by the Union Government in the year
2004 under the National Rural Health Mission
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The mechanism to strengthen village level service delivery, will be a local
resident and selected by the Gram Panchayat or the Village Health Committee.
• She will be supported in her work by the AWW, school teacher,
community based organizations, such as SHGs, and the VHC.
• Her role would be to facilitate care seeking and serve as a depot holder
for a package of basic medicines.
• She will be reimbursed by the panchayat on a performance based
remuneration plan.
• The Village Health Committee (VHC) will form the link between the
Gram Panchayat and the community, and will ensure that the health plan
is in harmony with the overall local plan.

Cabinet Committee on Economic Affairs (CCEA)

19-September-2018 13:25 IST Cabinet approves ASHA Benefit Package
• ASHAs and ASHA facilitators meeting the eligibility criteria to be
enrolled in social security schemes implemented by Government of India
namely, the Pradhan MantriJeevanJyotiBimaYojana and Pradhan Mantri
Suraksha BimaYojana.
• ii. An increase in the amount of routine and recurring incentives
under National Health Mission for ASHAs under NHM from Rs. 1000/-
per month to Rs. 2000/-per month.
No of beneficiaries: • Estimated 10,63,670(Ten lakh Sixty Three Thousand
Six Hundred Seventy) ASHAS and ASHA facilitators to be covered under
Pradhan MantriJeevanJyotiBimaYojana. ASHAs and ASHA Facilitators meeting
the age criteria of 18-50 years to be covered under Pradhan
MantriJeevanJyotiBimaYojana (Accident insurance). The annual premium of Rs.
330 (average) will be paid by the Central Government. Cover is for one-year
period stretching from 1st June to 31st May and benefit is Rs 2 Lakh in case of
death due to any cause. • ASHAs will get a minimum of Rs.2000/- per month
from current Rs 1000/- per month as incentives for routine activities. This is in
addition to other task based incentives approved at Central/State level.
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2. DETAILS OF THE PILOT
PROJECT AND TRAINING
2.1. CONCEPT – VISION FROM THE GROUND FROM RURAL
HEALTH WORK:

1. Every person has a right of basic medical examination by a

competent medical doctor of modern medicine and certain selective
lab tests - my list includes BP, Hb for anemia and blood sugar.

2. People should be taught basics of stretching and breathing

exercises and rationale for that and encouraged to do at least 20
minutes of exercise every day, regularly, with option of doing it in
different parts of day, depending on preference and convenience. In
addition back muscle strengthening exercises, knee joint exercises
and neck muscle exercises for so called cervical pain are equally
important.

3. There is a kind of ubiquitous complaint of mental tension - this

needs to be explored further.

4. Early diagnoses and simple affordable primary

medical treatment goes with above. Health Education related to
disease condition, its causation and rationale for treatment goes along
with that. Treatment adherence for chronic conditions like BP,
hyperglycaemia, anemia and joint pain is must.

4. Community chest of drug in each habitation with regular supply of

essential medicines for primary medical care.

5. People are open to advise on these lines and change behaviour

related to sedentary life style and treatment adherence.

6. It should be possible to identify and training community based

health educators to give effect to the above as a complimentary arm
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of a medical doctor.
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 7. Arrangent of referral for conditions like - skin problems, uterus
prolapse,psychiatric illness , congenital heart disease, correction of
refraction errors and dental problems.

MAIN COMPONENTS OF PRIMARY HEALTH AND MEDICAL

CARE
1. Promotion of attitude and value of positive health
2. Counselling for personal and family issues
3. Nutrition and life style – including exercise
4. Identification and early detection of priority diseases - Primary
Treatment of routine ailments in the community

VISION in LFA
NS OVI MOV RISKS
/ASSU
MPTIO
NS

SUPER GOAL
To develop a replicable model of
affordable rural primary health care (
including primary medical care)
focusing on prevention ( and early
detection and treatment) of
NCD/Chronic diseases of older age
group of population in Punjab

GOAL 1. The residents of the villages

Improvement in well- being and
health status of the Target
population group in 18 villages
develop an attitude of positive
health
2. Reduction in family discord
through family therapy
3. Enhancement of happiness index

PURPOSE 1. Improvement from baseline in

KAPs related to overall health and
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management of priority diseases (

prevention and early detection
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and treatment
To provide primary health ( and
primary medical ) care to residents 2. X% of residents doing regular
of villages in district of exercise and

Behavioural change in nutrition and 3. y % improved nutrition (

life style (and drug adherence etc. ) including iron and vit D
supplementation )

4. x percent of patients of
Hypertension and y percent of
diabetes patients practice drug
adherence – reflected in the
stable levels
OUTPUT 1.1. Formation of ward level health
animation groups in x villages and
1. Community action for self- y wards
management of primary health 1.2. Community chest of drugs
and medical care established for x villages and y
2. Capacity building including wards
training and communication 2. Counselling and family therapy????
support for self- management 1.3. The formation of community
3. Provision of expert advise for health funds at ward and village
primary medical care at door step level
through mobile clinic 2.1. Induction and follow up training
/telemedicine programs organized for the 90
4. Special component on ward level groups and 18 village
community Action for health committees- including
Deaddiction VHNSCs)
2.2. Community groups enabled to
maintain their own records and
use these for focused action for
health improvement (Community
HMIS)

3. Minimum 12 visit by medical

doctor to each village in a year –
total visits – 12X
3.2. Baseline health and disease data
obtained and followed up (
Project HMIS)

ACTIVITIES & Tasks INPUTS & FINANCIAL

SUMMARY
1. Survey for collecting information
on existing KAPs on key health 1. Program team and mobility
behaviours support
2. Identification and Formation of
ward level health groups with 2. Communication and training
Community Health Providers - programs and HMIS
HHAs as facilitators
3. Training and awareness programs 3. Provision of mobile clinic and
for Ward level health groups and telemedicine
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Community Health Providers-

HHAs / in future for VHNSC
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4. Provision of information, 4. Procurement and supply of
awareness and push for essential medicines including
behaviour change on nutrition community chest of drugs
and lifestyle
5. Supply of essential medicines 5. Community self-management
 Community chest of drugs at including incentive to community
ward level and village level health provider/ HHA
6. Mobile medical van to village at
fortnightly/ monthly interval – 6. Other management cost to
supplemented by contact implementing organization
through Community Health
Provider - HHA/telemedicine
 Maintenance of facilities for clinic
and training
7. Community health fund and
subsidy for the poor

Outcome Indicators

Goal
1. The residents of the villages develop an attitude of positive health
2. Reduction in family discord through family therapy
3. Enhancement of happiness index
Purpose
1. Improvement from baseline in KAPs related to overall health and
management of priority diseases ( prevention and early detection and
treatment
2. X% of residents doing regular exercise and
3. y % improved nutrition ( including iron and vit D supplementation )
4. x percent of patients of Hypertension and y percent of diabetes patients
practice drug adherence – reflected in the stable levels
Output
1. Formation of ward level health animation groups in x villages and y wards
2. Community chest of drugs established for x villages and y wards
3. Counselling and family therapy????
4. The formation of community health funds at ward and village level
5. Induction and follow up training programs organized for the y ward level
groups and x village health committees- including VHNSCs)
6. Community groups enabled to maintain their own records and use these for
focused action for health improvement (Community HMIS)
7. Minimum 12 visit by medical doctor to each village in a year – total visits –
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12X x
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8. Baseline health and disease data obtained and followed up ( Project HMIS)
 2.2. PROPOSED INSTITUTIONAL MECHAMISM

2.2.1. ROLES AND RESPONSIBILITIES OF HHA

It is suggested that the initial entry should be through the honorary
health animator and later some percentage of these can graduate to
Community Health Provider

VILLAGE HONORARY HEALTH ANIMATOR [HHA]

[ LATER COMMUNITY HEALTH PROVIDER ]
 All arrangements for the weekly clinic
 House to House contact
 Health education – during weekly clinic and house to house/school
/other community events
 To maintain a list of chronically sick families in search of treatments
 To maintain a list of BP, sugar and Anemia patients
 To ensure less usage of medicine
 To ensure treatment adherence
 To maintain community contribution collected in village health clinic

OTHERS – IN FUTURE
 To discuss the idea of community health fund in the SHGs meeting
 To visit and inform the contiguous villages – identify at least three
villages for this purpose.
 To consider playing the role of a community health provider including
health manager and leader

Table: A comparative view of the PILOT PROJECT CONCEPT OF

ward and village level committee VS VHSNC
SN Proposed Government mechanism
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1 HHA ASHA
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Asha facilitator
 Anganwadi worker

2 The work of HHA will be focused on Work of ASHA and

NCD anaganwadi is primarily
focused on MCH
3 Ward Health group and village health VHNSC -
committee
Ward and village health committee
will complement the work of VHNSC
in the area of NCD
4 Village Health Fund at ward level There is no community fund
managed by HHA and collected by as yet
community contribution and users
charges
5 NGO doctor / later Community No such mechanism as yet
Health Provider to make weekly visit
for clinic, training and health
education
6 Training in health education for No such awareness programs
prevention and early detection and available at village level
treatment of chronic diseases
7 Community Health Office at ward No office of ASHA as such /
level office may be anaganwadi – but no
provision for ward level office

2.2.2. VILLAGE HEALTH COMMITTEE AND HEALTH FUND

1. Each ward member will identify a health volunteer in consultation with
the local residents. All the health volunteers – ASHA worker, Anganwadi
worker and school teacher will form a village committee – led by one of
the ward member or sarpanch.
2. Health fund will be maintained at the ward level by community
contribution and grant for panchayat. It will be managed by the HHA
3. Training to the health committee members will be provided by the
project
4. The ward level health committee will maintain the health data and a
community chest of drugs. The village health committee to be
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coordinated by member in charge / lead HHA. It will also maintain to

stock of essential drugs replenish the community chest of drugs
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 5. The member in charge – sarpanch will coordinate with SMO –CHC for
other issues
6. Special project for deaddiction

2.2.3 ACTIVITIES AT WARD LEVEL

1. Formation of groups and group meeting – family/ old people/ etc.
2. Family survey
3. List of services to be offered at ward level
4. Maintenance of records
5. Maintaining the community chest of drugs
6. Get the services of a qualified doctor for medical examination of all
families
7. Counselling, health education and teaching of basic exercises – stretching
/ prolonged breathing / back muscle and quadriceps exercise

UPWARD LINKAGES
Ward level – HHA and community groups
Pind –village – village health committee/ VHNSC
Weekly mobile clinic
Collection and collation data
Training and mutual learning
Arranging referrals
Planning community campaigns
PHC- CHC – SMO / Block Extension Educator
Referral
Training support
Grant of funds and medicines for panchayat health activities
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 1. Affordable primary medical care : The focus remains on the NCD and
old age care ( to include (i) wellness promotion, (ii) individual and family
counselling, (iii) nutrition and behaviour change and (iv) primary medical
care ( plus referral )
2. Provide clinical services for primary medical care – Twice and month in
each village -
3. Establish village heath committee and village health fund (with ward
based structure –having one health volunteer per ward )
4. Establish village level community pharmacy – with community chest of
drugs –in each ward
5. Training of HHAs and village health committee – technical , management
and governance
6. Link the project to Block level for referral CHC,
7. Sharing lessons with District MO, Punjab health mission and NHM

2.2.4 PROPOSED MIS STRUCTURE

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#
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 1. Patient card
2. WARD BASED INFORMATION- ward HHA /
3. Information collected at weekly village clinic – Health committee-
VHSNC – patient attendance
4. Information from school / VDC meeting /MNREGA committee meeting
5. Cluster health manager
6. Information delivered to central office –
7. Key messages
8. Training programs
9. Posters and banners
10. Supply of drugs

Ward based information

Important morbidity /mortality

Survey of medical providers

Date awareness meeting Training program topic

Community chest of drug

Record of BP, sugar, Hb

Community health fund

Health expenditure and willingness to pay

2.2.5 LIST OF MEDICINES

Antihypertensive
Anti – diabetic
Analgesic –anti-inflammatory
Iron
Calcium and vit D
Eye /ear drop
Antibiotic
Bronchodilator
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Anxiety and deperession

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Skin
Antacid
Constipation
Pain abdomen
Ant-amoebic

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 2.3. TRAINING
2.3.1. COMPOSTION OF THE TEAM TO RUND THE PILOT
ROLE AND RESPONSIBILITY OF PILOT PROJECT
MANAGEMENT TEAM

TEAM
1. Health manager & Admin and Finance officer –
2. Weekly clinic doctor -1 –or More
3. Project health and Training coordinator -1 ––
4. MIS Manager and computer
5. pharmacy
6. identified Community health providers / Village Honorary health
animator- HHA
TRAINING CO-ORDINATOR at block level :
1. To work with Community Health Provider and HHAs to establish
Ward level health committees in villages and bring these together to
form a village health committee
2. To coordinate and participate in health education and training for the
honorary health animators / To ensure training of village level health
animators /To coordinate with village health animators
3. To maintain record of village health clinic / project health records –
village wise and project wise ( excel sheet to be developed)
4. To plan the maintenance of the village clinics
5. To take blood pressure and glucose reading – to ask health worker
to do the same – under his guidance
6. To make strategy and plan for community health fund
7. To establish contact with other health initiatives in payal block.

PROJECT HEALTH MANAGER

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Overall Coordination of project under the guidance of Village Clinic Doctor

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 1. To ensure weekly clinic in the pilot project villages
2. To coordinate with ASHAs, ANMs and ICDS workers and supervisors
for health activities in project villages
3. Maintain the supply of medicine -1. Office 2. In vehicle for village health
clinic 3. In the community chest of drugs
4. To provide medicine during village health clinic and educate the patient
for its proper usage.
5. To prepare a plan for community chest of drugs and its maintenance and
replenishment., - educate the community health worker regarding its
usage

VILLAGE CLINIC DOCTOR – /LATER COMMUNITY HEALTH

PROVIDER
1. To provide leadership to health project
2. Conduct village health clinic
3. Take health education sessions during village health clinic
4. To conduct training for village health animators and other project staff
on health
5. To help health coordinator, pharmacist, Training Coordinator and MIS
coordinator to collect collate and analyse village health data / clinic
health data and results

SELECTION OF AREA OF OPERATION

One district in State – One block within district and x number of
Grampanchayat -villages in a block – of household each – total …. households.
Families BPL . Elements of vulnerability – distance lack of skills and business
opportunities – caste ? Women ? Old people not cared for ?

It will be essential for The project to begin with recruiting a qualified medical
practitioner. He should be on the seat almost regularly and provide primary
medical care and health education through regular village clinics in x villages
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 2.3.2. SELECTION OF HONORARY HEALTH ANIMATORS FOR
TRAINING

WARD MEMBER AND WARD HEALTH ANIMATOR टिपण्णी

PHONE AND PHONE
VILLAGE SARPANCH

WARD MEMBER -1 HHA -1

WARD MEMBER -2 HHA-2

WARD MEMBER -3 WARD MEMBER

WARD MEMBER -4 HHA-4

WARD MEMBER-5 HHA-5

WARD MEMBER -6 HHA -6

WARD MEMBER -7 HHA -7

2.3.3. Initial Participatory Need assessment:

 Chronic ailments which require health education and non medical
interventions – joint pain – diabetes hypertension-skin disease – lack of
proper exercise / physiotherapy services – No clarity about addiction –
alcohol and drugs Diet ?
 Lack of access to services – distance / cost / poor quality of services
/lack of accountability . No Health financing /insurance / demand side
financing
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WILLINGNESS TO PAY
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1. What was your health expenditure in this month
2. What was your health expenditure in last three months ?
3. Did you borrow money to pay for the expenditure – how much
4. How much you are ready to contribute per month for primary medical care in
the community – none – 100 per month – 500 per month
5. Will you be ready to contribute to health fund for the poor and needy who
have no capacity to pay – how much

Proposed SURVEY OF DRUG ADDICTION

1. Do you have a member in the house who is suffering from addiction
• Yes –no – details type of addiction – number of years
2. What is the severity of problem – not much – troublesome –destroying the
family
3. Is there anyone else in the neighbourhood who is suffering from similar
problems – how many such families do you know

2.3.4. पाठ्यक्रम
i.प्रशिक्षण का करिचय क
ii.कशिलिशििाक–क(करर्ू वकमेंकशियशिात्स काे कअिभु र्क)क
iii. कचीचकचयि क(कएि टोमीकऔचककचीचका कसञ्य ििक(कशििशिि ोकिोिीक)क
iv. मख्ु कशििम िच ोंका कशििद िकऔचककइि िका कप्रिंधकऔचकव् र्स्थ क
v. ग ाँर्ककाीकदर् ईकरेटीक–क
vi. ग ाँर्क/ग्र मकरंय तकका कअरि कहेल्थकिण्डक
vii. ग ाँर्क/ग्र मकरंय तकका कस्र् स्् कऔचकिीम चीका कसर्ेक/किीम चीकऔचकइि िका क
िचाॉडवक
25

viii. चोिमच वकाे कइि िकाे कशििएकदर् इ ोंकाीकि िा चीक/किस्टवकऐडक

Page
 ix. ाौिकसीकदर् इ ंक–कस्र् कं मचीिकिेकसातेकहैंक/काौिकसीकदर् इ ंकडॉलटचकाे क
सरु चशिर्ििकमेंकदेिीकहैं
x. रचम्रच गतकशियशिात्स कक
xi. ाम्रटु चकशिस्ाल्सक
xii. ासचतक–कआसिक/कप्र मक/कामचकाोकमिितू काचि क/घटु िेका कददवक/कक्रेम्रककआि क
(कखशिि िकरडि क)क
xiii. शिििीकव् र्ह िचाकाौकिकाीकसयू ीकऔचकस्र् ंकाीक्षणमत का कशिर्ा सक
xiv. सततकसीखि कऔचकप्रशिक्षण क
xv. िचाॉडवकाीशिरंगका कअभ् सक
xvi. चे िचिकाीकव् र्स्थ क
xvii. शिििकमचीिोंकिेकशिि शिमतकइि िकाचर् ाचकअरिीकिीम चीकाोकठीाकशिा कहैकऔचक
सेहतकमेंकसधु चकशिि कहैकउिा कसम्म िक
xviii. ग्र मकस्र् स्् का वक ोिि का कशििध वच क–ल काचि कहैक/ाौिकाचे ग क/ाै सेकाचे ग क
xix. सरु चशिर्ििकाै सेक–कVHSNC ाीक/PHC ाे कडॉलटचक/ANM ाीकभशिू मा क
xx. मोडकऑफ़करेमेंटक

बीमारियों के बािे में जानकािी

जानकािी
1 खिू काीकामीक एिीशिम क
2 ब्िडकिढ़द कहैक ह ईकब्िडकप्रेकचक
3 कगु चक ड ईशिितीिक
4 िोड़ोंकमेंकददवक–कशिर्केषाचकघटु िोंकऔचकिीयेक ओस्टेओआथवच ईशिटसककक
ामचकमेंक
5 रचु े ककचीचकाीकम ंसरेशिक ोंकमेंकददवकिै ि कहुआक ि ईब्रोम शिल्ि क/कशिडप्रेकिक
6 तेि िक–कअरय एशिसशिडटीक/करेशिटटाकअिसचकशिडिीि/क
अन् क
26
Page

7 ख िक स्ाे िीिक
8 िचंगकर्मवक िंगिकइन्िे लकिकऑफ़कशिस्ािक
9 खगं क-सख ू ीकख ंसीक ड्र ईकाफ़क
10 खगं कऔचकचे क क एा टू कब्रोन्ा ईटीसक
11 दम क/कस ंसकिूिि क अस्थम कक
12 ाब्िक ाोन्स्टीरेकिक
13 िख्मक र्ंडु क
इन्वेस्िीगेशन – जाांच
1 ब्िडकप्रेकचक BP
2 ब्िडकसगु चक Blood sugar
3 त रम िकटेम्रचे यच temperature
4 खिू काीकम त्र -कहीमोग्िोशिििक HB

परं परागत स्वास््य पद्धतत

• vH;ax] ysiu] ukM+h 'kks/ku] _rq ladze.k] x`gxzkeokfVdk] iapxO;] miokl] fojspu] dYi]
iztuu ,oa izlo] rhFkZ] nku] gkse] lqxfa /k&nqxafZ /k] /kkj.kk] /;ku] lkewfgd mRlo esa Luku]
ysiu] enZu] olar ,oa o"kkZ esa u`R;] vkx ,oa ?kwi lsd a us dh fof/k] pkrqekZl dk [k;ky
vkfnA
• izd`friwtk nok&nk#
• euksfpfdRlk mUekn fuokj.k
• ;K] ri vkSj LokLF;
• ekfy'k jk[k ] rsy ;k ikmMj ls\ nareatu dk [ksy
• xq# ,oa fpfdRld dk varj
• ,dhd`r uke ,oa xq.k /keZ dk ,dh d`r Kku fdlds gd esa\
• ;ksx thou 'kSyh ;k fpfdRlk i)fr\
• vk;qosZn ,dek= vf/kdkjh ugha- ;g dkykrhr osn ugha] ns'k dky l;kis{k ra=

परं परागत स्वास््य तकनीक

 vkgkj&'kkd&lfCt;ksa ds jl] lwi] Qy ,oa Qyksa ds jl rFkk
27

 'kks/ku fØ;k;s&
a dq¡ty] usfr;k¡] feêh&iêh] xje& B.Mh lsd] ,fuek] dfVLuku] jh<+
Page

Luku] xeZ iSj Luku] lsd] ifê;k¡] yisV]

  ekfy'k] lw;ZLuku] Hkki Luku vkfn fØ;kvksa ds lkFk
 vklu&çk.kk;ke]
 ,D;wçs'kj vkfn dk ç;ksx

टनजी कौशल
नजरिया कौशल कौशल टवकास
ह ाँकमैंकाचकसातीकहाँ िेत्रत्र्क अरि कि ोकड ट कशििखिक

आत्मकसम्म िकऔचक ि तयीतकाचि क शिििीका ंसशििंगकऔचकइि िक

आत्मकगौचर्  टेिेिोिकऔचकएसकएमक् र िचर् िचाका शिन्स्िंगकऔचक
एसक इि ि
 आमिेकस मिेकाीक
ि तयीतक
 समहू कमेंकयय वक
सह िभु शिू त शिि व किेि कक िलक किि ि क–शिरंडका क/कसम िक
ा /शिदम गकाे कशिर्य चोंका कक
आत्मशिर्श्व सक टीमकर्ाव क शििज्ञ स कऔचकसीखिेकाे कशििएक
खोिकाचि क
ह ाँकमेंकह ाँकिहींकशिमि ि क–क सिु ि ड ट अ/िचाॉडवककचखि कऔचक
आिोयि त्माकदृशििक उसाीकव् र्स्थ किि ि कक
सम का कप्रिंधि
शििम्मेद चीकाीकभ र्ि कस म शििाकउत्तचद शि त्र्काुदचतकऔचकधचतीकहम च कघचकहैंकअच्छीक
सेहतकाोकमहत्त कदेि
MORAL AND ETHICS
28
Page
 2.4. PROPOSED BUDGET FOR PILOT PROJECT
SN CATEGORY COST Remarks
1 Weekly clinic –Total per month lac Project

1.1. Medical doctor –xxxxx per village

per month X
1.2. MIS ( Including pharmacy) –yyyyper
month –
1.3. Vehicle –zzzzper day including
driver –
2. Community Health
2.1. Project coordinator including
Training coordinator–yyyyper
month –
2.2 Associate coordinator –

2.3. Health Manager – 1

2.4. Training and others
3. Local resource mobilisation
3.1. Medicine –xxxxper month poor to be
Community contribution (???) / part subsidized
contribution –
3.2. HHAs –zzzzper month Panchayat

4 Management cost & MIS and

Research and documentation
lakh for
one year
Minus community and panchayat lakh in one
contribution year
5. SPECIAL PROGRAM FOR LAKH
CONTROL OF DRUG
ADDICTION
29
Page
 3. ANNEX –
3.1. CHALLENGE OF HEALTH FINANCING
India's public spending on health of 1.15 percent of its gross domestic product
(GDP) one of the lowest in the world.
• Much lower than the global average of 5.4% (US – 20 %)
• 1. Failure of market – catastrophic shocks due to purchase of medical care
• Health-related debt has pushed many low and middle-income households into
poverty. It has been estimated that OOP expenses are directly responsible for
the deepening of poverty in both rural and urban areas, pushing between 32
million and 39 million Indians into poverty every year
• 2. Households with elderly and chronically ill members are especially
susceptible to impoverishment due to health expenditure. In Kerala, for
example, the loss of household income per illness episode has been estimated
to be over four times greater for the poor elderly in comparison with the rich
elderly households
• 3. Hospitalization is often presumed to be the most important cause of
health related impoverishment in India, but research has revealed that drug
expenditure is actually the largest component of OOP payments, accounting
for 61% to 88% of the total OOP spending. Contributing to this expenditure is
liberal prescription of drugs by practitioners and widespread over-the-counter
medication use by both the poor and middle class It has been argued that
universal health coverage (UHC) implementers should focus explicitly on
medicines as one of the most important drivers of quality, safety, equity and
cost of care
Implications of high OOP spending
• The high OOP spending on health puts a financial burden on poor and
vulnerable families by presenting
• A barrier to utilization (first-time and continuity of treatment and care);
• It can affect the health-seeking behavior of those who cannot afford to pay.
• Those poor families who do seek care may have to forgo spending on other
basic necessities such as food, clothing, housing, and education; in many cases,
the family is pushed into poverty.
30
Page
 • Over 70% of ailing population in rural areas and almost 80% in urban areas
utilize private facilities.
• India has one of the world's highest rates of out-of-pocket (OOP) spending on
health. OOP spending in India accounts for 67.1 percent of total health
spending, whereas the global average is 29 percent.
• In contrast to this high level of private financing of health, Data from the recent
National Sample Survey Office (NSSO) household expenditure survey (round
71) and National Health Accounts support concern about the ongoing high
OOP spending, the bulk of which (63.5 percent) is on outpatient services.
• The growing incidence of non-communicable diseases (NCDs) and
introduction of new medical technologies may exacerbate the OOP spending
problem
3.2. SURVEY OF NON COMMUNICABLE DISEASE ( One of the states
in India )
• Tobacco and alcohol consumption were observed in 11.3% and 15% of the
population, respectively.
• Low levels of physical activity were recorded among 31% of the participants.
The prevalence of overweight and obesity was 28.6% and 12.8% respectively.
Central obesity was higher among women than men
• Prevalence of hypertension in population was 40.1%
• The mean sodium intake in grams per day for the population was 7.4 gms
• The prevalence of diabetes (hyperglycemia), hypertriglyceridemia and
hypercholesterolemia was 14.3%
• In addition, 7% of the population aged 40–69 years had a cardiovascular risk of
≥ 30% over a period of next 10 years.
Conclusion
• We report high prevalence of risk factors of chronic non-communicable
diseases among adults in Punjab. There is an urgent need to implement
population, individual and programme wide prevention and control
interventions to lower the serious consequences of NCDs.
31

3.3. OVERALL HEALTH SYSTEMS VISION

Page
 COMPARE THIS WITH NATIONAL HEALHT POLICY 2017
Proposals
1. One National autonomous health authority will be established for the whole
country. It will be responsible for coordination with different services providers
and for ensuring their public accountability.
2. For Each district in the country – a community health fund shall be established
by community financial contribution. The community health centres and the
district hopsitals will be suitably strengthened.

3. For each village panchayat – one or more community health animators –and /or
ASHA worker, anaganawadi worker and ANM will be fully train fro delivery of
primary health and medical care
4. At the level of each electoral ward in a gram panchayat – a community health
committee will be set up and a community chest of drug shall be provided, This
will enable the self-management of routine ailments by the community close to
their habitation and settlement.
5. The currently extant artificial division and boundaries between different systems
of medicines will be done away with – e,g, allopathy – ayurved –unani –
homeopathy and yoga and naturopathy. At each level of care, emphasis will be
on coordinates action amongst the practitioners of different systems of
medicine on the ground level.
6. The current tendencies of medical sciences, technology and knowledge systems
to become instruments of the corporate medical industrial complex /pharma
industry will be effectively controlled and prevented. The programs of
vaccination, treatment of HIV/AIDS and that of Hepatitis B and C etc. will be
suitably reviewed and amended. Similarly the Ayushman -2 scheme will be
totally overhauled.
7. For the promotion of health, emphasis will be made on public education for
health. This will be based on the proper coorination and integration of attiude
of positive health on the one hand and – including individual counselling, family
therapy, nutrition, life style and primary medical treatment on the other hand.
All decisions regarding the medical treatment of the patient shall be taken with
his participation in decision making and giving due space to his choice and
preferences.
32
Page
 3.4. INFORMATION TO BE INCLUDED IN PATIENT CARD

MAKE ADDITIONAL SEPARATE CARDS FOR PAGE 3 AND PAGE

4)

FRONT PAGE – 1

तांदुरुस्ती जागरूकता
अच्छी सेहत औि प्राथटमक इलाज के टलए सीखना औि टसखाना

 अच्छीकसेहतक–करहि कसख
ु कशििचोगीका क–कदिू कशििचकिेिकमेंकम क
 स्र् स्् काीकच्षण क–किीम चीकसेकिय र्क–किीम चीका कतचु ं तकशििद िकऔचक
इि िक
Key health messages सबके टलए सन्देश
 ब्लड प्रेशि की टनयटमत जाांच किवाएां औि टनयटमत दवाई लें
 शूगि की टनयटमत जाांच किवाएां औि टनयटमत दवाई लें
 िोज, टबना नागा एक्सिसाइज किें / उजाा सच ां ाि व्यायाम किें
 िें शन को कम किें
 अच्छी सेहत कायम किने के टलए औि बीमािी के इलाज के टलए एक दूसिे की मदद किें
इस कें द्र का मकसद आपकी अच्छी सेहत को कायम िखने में आपकी मदद किना है. साथ में बड़ी उम्र की कुछ
टबमारियों से कै से बचा जाये औि उनका प्रभावी इलाज कै से टकया जाए – इसकी व्यवस्था में आपकी मदद किना
है .अपनी देखभाल की टजम्मेदािी अपने ऊपि लेकि आप अच्छी सेहत कायम िख सकते हैं औि बहुत सािी
भयानक बीमारियों से बच सकते हैं. हमािे साप्ताटहक टवलेज टक्लटनक में डॉक्िि से टमलकि आप

Main complaints –

FINAL DIAGNOSIS –

Check list – CAN BE IN TWO OR THREE COLUMNS TO

33

ACCOMMODATE ON ONE PAGE

Page
SN Name of disease
1 Anemia
2 Anxiety
3 Major Depression
4 Elder maltreatment
5 Alcoholism
6 Drug Addiction
7 Sleep Disorder
8 Tension headache /migraine
9 Cardiac Arrhythmia
10 Hypertension ( high Blood
pressure )
11 Hyperglycemia ( diabetes )
12 Asthma
13 Acute Bronchitis
14 Dyspepsia
15 Constipation
16 Dysentery
17 Osteoarthiritis of knee
joint
18 Back Pain
19 Fibromayalgia
20 Myofascial pain syndrome –
MPS
21 Urinary Tract Infection –
UTI
22 Incontinence of Urine
23 Skin -Scabies
24 Skin -Fungal Infection
25 Skin -Eczema
26 Skin ailments –MISC
27 Skin - Wound
28 Fall
29 Pain in Ear/ Discharge
30 Irritation in Eyes
31 Dental pain
32 Gynae Disorder
33 Children with different
ailments
34 Misc
34
Page
35 Conditions requiring
referral
A Emergency visit made by
the patient to the
public/private health facility

B Regular use of village based

PMPs

C Regular use of
public/private health facility

35
Page
 PAGE -2

Gram Panchayat / Village Ward number

NAME OF COMMUNITY HEALTH PROVIDER / HHA

NAME OF MEDICAL DOCTOR

________________________________________________________________

PATIENT NAME ________ Age Sex

Registration number Date of registration

Father /husband’s name

Residential address

IDENTITY – VOTER ID CARD

________________________________________________________________

PAST MEDICAL HISTORY

Brief statement of beginning of sickness / health problems – main

morbidity & comorbidity ( and mortality ?)

Name of doctor / medical faculty consulted in past

Investigation reports

PROVISIONAL DIAGNOSIS

Names of regular medication already taking

36

PERSONAL AND FAMILY ISSUES AND STRESS FACTORS

Page
( History of fall or accident / bereavement in family/ family discord /
alcohol/ addiction/ personal issues / any other)

PAGE -3
1. TESTS RECOMMENDED AND FOLLOW UP

SN Essential Test Date And Reading

1 HB

2 Blood Sugar –
Random

3 Blood Sugar –
HbA1C

4 Blood Pressure

5 Ultra sound
report / anyother

1. FINAL DIAGNOSIS

PROGRESS

SN DATE REMARKS
37
Page
Page 4-
1. TREATMENT RECOMMENDED
Sn DATE Treatment Number Special
recommended of days instructions

38
Page
Page
39
Annex-3.5. : NCD survey in Punjab
Background
Efforts to assess the burden of non-communicable diseases risk factors has improved in low and
middle-income countries after political declarationof UN High Level Meeting on NCDs. However,
lack of reliable estimates of risk factors distribution are leading to delay in implementation of evidence
based interventions in states of India.

Methods
A STEPS Survey, comprising all the three steps for assessment of risk factors of NCDs, was
conducted in Punjab state during 2014–15. A statewide multistage sample of 5,127 residents, aged
18–69 years, was taken. STEPS questionnaire version 3.1 was used to collect information on
behavioral risk factors, followed by physical measurements and blood and urine sampling for
biochemical profile.

Results
Tobacco and alcohol consumption were observed in 11.3% (20% men and 0.9% women) and 15%
(27% men and 0.3% women) of the population, respectively. Low levels of physical activity were
recorded among 31% (95% CI: 26.7–35.5) of the participants. The prevalence of overweight and
obesity was 28.6% (95% CI: 26.3–30.9) and 12.8% (95% CI: 11.2–14.4) respectively. Central obesity
was higher among women (69.3%, 95% CI: 66.5–72.0) than men (49.5%, 95% CI: 45.3–53.7).
Prevalence of hypertension in population was 40.1% (95% CI: 37.3–43.0). The mean sodium intake in
grams per day for the population was 7.4 gms (95% CI: 7.2–7.7). The prevalence of diabetes
(hyperglycemia), hypertriglyceridemia and hypercholesterolemia was 14.3% (95% CI: 11.7–16.8),
21.6% (95% CI: 18.5–25.1) and 16.1% (95% CI: 13.1–19.2), respectively. In addition, 7% of the
population aged 40–69 years had a cardiovascular risk of ≥ 30% over a period of next 10 years.

Conclusion
We report high prevalence of risk factors of chronic non-communicable diseases among adults in
Punjab. There is an urgent need to implement population, individual and programme wide prevention
and control interventions to lower the serious consequences of NCDs.

Citation: Thakur JS, Jeet G, Pal A, Singh S, Singh A, Deepti SS, et al. (2016) Profile of Risk Factors
for Non-Communicable Diseases in Punjab, Northern India: Results of a State-Wide STEPS Survey.
PLoS ONE 11(7): e0157705. doi:10.1371/journal.pone.0157705

Editor: Hamid Reza Baradaran, Iran University of Medical Sciences, ISLAMIC REPUBLIC OF IRAN

Received: November 19, 2015; Accepted: May 8, 2016; Published: July 7, 2016

Copyright: © 2016 Thakur et al. This is an open access article distributed under the terms of
the Creative Commons Attribution License, which permits unrestricted use, distribution, and
reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting Information files.

Funding: National Health Mission, Punjab, India, JST. The funders had no role in study design, data
collection and analysis, decision to publish, or preparation of the manuscript.
40

Competing interests: The authors have declared that no competing interests exist.
Page
ANNEX 3.6. EXECUTIVE SUMMARY OF PRI AND HFW PROGRAMMES

Panchayati Raj Institutions & Health & Family Welfare Programmes an

Executive Summary

1. Background

1.1 Panchayats in India are an age-old institution for governance at village level.
Through the 73rd Constitutional Amendment, Panchayati Raj Institutions (PRI) were
strengthened with clear areas of jurisdiction, authority and funds. PRIs have been
assigned several development activities including health and population stabilization.
The Gram Sabha acts as a community level accountability mechanism to ensure that
the functions of the PRI respond to peoples needs.

1.2 Progress in engaging PRI has been uneven across states. While fiscal devolution
is a significant issue, lack of institutional modalities and clear guidelines on
PRI participation and variable capacity among PRI are key lacunae.

2. Articulation of Pri Engagement in Policy Documents

3. Experiences So Far
4. Issues and Recommendations

4.1 Critical Role of Panchayati Raj Institutions in the success of the National Rural
Health Mission

4.1.1 The National Rural Health Mission (NHM) is seen as a vehicle to ensure that
preventive and promotive interventions reach the vulnerable and marginalized
through expanding outreach and linking with local governance
institutions. PRIs are seen as critical to the planning, implementation, and
monitoring of the NHM. Implementation of the NHM in achieving its
outcomes is significantly dependent on well functioning gram, block and
district level panchayats. At the District level a District Health Mission will
coordinate NHM functions. Key to NHM success are: intersectoral
convergence, community ownership steered through village level health
committees at the level of the Gram Panchayat, and a well functioning
public sector health system with support from the private sector.

4.1.2 ASHA, (Accredited Social Health Activist), the mechanism to strengthen

village level service delivery, will be a local resident and selected by the Gram
Panchayat or the Village Health Committee. She will be supported in her work
by the AWW, school teacher, community based organizations, such as SHGs,
and the VHC. Her role would be to facilitate care seeking and serve as a
depot holder for a package of basic medicines. She will be reimbursed by the
41

panchayat on a performance based remuneration plan. The Village Health

Page

Committee (VHC) will form the link between the Gram Panchayat and the
 community, and will ensure that the health plan is in harmony with the overall
local plan.

4.2 Empowerment of Panchayats through and the assured availability of

adequate funds , clear articulation of functions, and transfer of
requisite functionaries to carry out such functions

4.2.1 State legislatures have been behindhand in framing laws that endow
Panchayats with power and authority to enable their functioning. It has largely
been a matter of political will in each state and is governed by different
legislations, despite the central mandate. While PRI are mandated to carry
out health activities, they are not backed by the necessary policy/legal
framework, authority or fiscal commitments. Many centrally sponsored
schemes and others are implemented outside the purview of the panchayats,
thus keeping them out of the loop and undermining their credibility. Issues of
political patronage hamper functioning.

4.2.1.1 Funds transfer to PRI for effective functioning of health

services. Transfer of funds to PRI is a critical must before they can
be expected to play a meaningful role in HFW activities. While
several states have taken steps complete financial devolution
commensurate with functions still has a long way to go. With
financial devolution other processes such as fiscal management,
systems training and appropriate checks and balances will need to
be introduced.

4.2.1.2 Clear articulation of functions of PRI at various levels: In areas

where little devolution of power or funds has taken place, PRI
representatives and particularly women lack clarity on their roles in
development functions, including health. Line department staff have
to recognize that PRI carry the mandate of the people.

4.2.2 Transfer of functionaries with commensurate authority and accountability

guidelines. PRIs are expected to undertake monitoring of functionaries,
particularly of line departments such as health and family welfare for
increased accountability and improved functioning, without any authority over
them. Transfer of functionaries is critical to ensure adequate functioning,
monitoring, and accountability. Safeguards must be in place to protect against
intimidation, wrongful harassment, and corruption.

4.3 Enlisting NGO support in building capacity among PRI members to effectively
handle development related functions.

4.3.1 Capacity building of PRI is required in thematic areas and leadership skills,
negotiating, monitoring, ability to withstand patronage and political
interference. Capacity building processes need to be tailored to literacy levels,
sex and circumstances of PRI members.
42
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 4.3.2 Joint orientation and sensitization meetings between PRI and health and
medical professionals could help to bridge the gap in education and social
strata. Developing Citizen Charter of Rights and Codes of conduct also lay
down guidelines for boundaries of operation and accountability.

4.3.3 NGOs could be involved in PRI strengthening in a variety of ways, including:

consciousness raising, provision of technical advice, support in participatory
planning, capacity building and facilitating monitoring processes, such as
community and social audits to improve accountability.

4.4 Repealing penalties and disincentives such as the two child norm, which
violate individual rights and discriminate against womens participation in
panchayats.

4.4.1 Several states include disincentives in their population policies. The most
draconian is that which bars people who have more than two children
from holding office. Such policies are anti- women, threaten to undo the
good of a decades work in enabling women to participate in political
processes and violate womens freedom and individual rights. They feed son
preference actions such as sex selective abortions, pushing down an already
unfavorable sex ratio. There are cases of women being abandoned, the third
child given away or disowned, and consequent denial of the childs rights.

4.4.2 Policies and laws such as this need to be repealed or they might have serious
negative consequences for women and society at large. Population
stabilization is a function of womens empowerment, access to high quality RH
services and equal participation of men. PRIs should be encouraged to
support these interventions to further promote improved health.

Conclusion

There are enough portents to suggest that PRI engagement in improving key health
indicators will become a reality. However in order to expedite the process and to
make it more effective, consideration of key issues related to empowerment of
panchayats through funds, human resources and capacity are critical. PRI
engagement is perhaps the only existing mechanism to achieve large-scale
community participation and reach the marginalized and vulnerable, particularly
women, children, and the poor. Locating NHM functions within the gram panchayat
and implementing it through a village health committee/gram Sabha will f
43

Press Information Bureau

Page

Government of India
 Cabinet Committee on Economic Affairs (CCEA)
19-September-2018 13:25 IST
Cabinet approves ASHA Benefit Package

The Cabinet Committee on Economic Affairs, chaired by the Prime Minister Shri
Narendra Modi has given its ex-post facto approval to ASHA Benefit Package w.e.f.
October, 2018 (to be paid in November, 2018) with two components as under: -

i. ASHAs and ASHA facilitators meeting the eligibility criteria to be enrolled in

social security schemes implemented by Government of India namely, the
Pradhan MantriJeevanJyotiBimaYojana and Pradhan Mantri Suraksha
BimaYojana.
ii. An increase in the amount of routine and recurring incentives under National
Health Mission for ASHAs under NHM from Rs. 1000/- per month to Rs.
2000/-per month.

The package entails an expenditure (Central funding) to Rs.1224.97 crore for two
years 2018-19 and 2019-20.

No of beneficiaries:

 Estimated 10,63,670(Ten lakh Sixty Three Thousand Six Hundred Seventy)

ASHAS and ASHA facilitators to be covered under Pradhan
MantriJeevanJyotiBimaYojana.
 Estimated 9,57,303 (Nine lakh fifty seven thousand three hundred three)
ASHAS and ASHA facilitators to be covered under Pradhan Mantri Suraksha
BimaYojana.
 Estimated 10,22,265 (Ten lakh twenty two thousand two hundred sixty five)
ASHAs will get at least minimum of Rs 2000/- per month from current
Rs1000/- for routine activities.

Details:

 ASHAs and ASHA Facilitators to be covered under Pradhan Mantri Suraksha

BimaYojana (Life Insurance). The eligibility criteria are 18-70 years.Cover is
for one-year period stretching from 1st June to 31st May and benefit is as
under:–
44

i. Rs. 2 Lakh in case of death due to accident

Page
 ii. Rs. 2 Lakh in case of total and irrecoverable loss of both eyes or loss of use of
both hands or feet or loss of sight of one eye and loss of use of one hand or
one foot
iii. Rs. 1 Lakh in case of total and irrecoverable loss of sight of one eye or loss of
use of one hand or one foot

The annual Premium of Rs 12 per beneficiary will be paid by Central

Government.

ASHAs and ASHA Facilitators meeting the age criteria of 18-50 years to be
covered under Pradhan MantriJeevanJyotiBimaYojana (Accident
insurance). The annual premium of Rs. 330 (average) will be paid by the
Central Government. Cover is for one-year period stretching from 1st June
to 31st May and benefit is Rs 2 Lakh in case of death due to any cause.

 ASHAs will get a minimum of Rs.2000/- per month from current Rs 1000/- per
month as incentives for routine activities. This is in addition to other task
based incentives approved at Central/State level.

Implementation Strategy and Targets:

 The existing institutional mechanisms for the National Health Mission would be
utilised to implement the proposed ASHA Benefit package.

 Targets:

o By 31st March 2019- 65 % of ASHAs and ASHA facilitators to be enrolled in

social security schemes implemented by Government of India namely, the
Pradhan MantriJeevanJyotiBimaYojana and Pradhan Mantri Suraksha
BimaYojana
o By 30th October, 2019-100 % of ASHAs and ASHA facilitators to be enrolled
in social security schemes implemented by Government of India namely, the
Pradhan MantriJeevanJyotiBima and Pradhan Mantri Suraksha BimaYojana
o The increase in the amount of routine and recurring incentives for ASHAs from
Rs. 1000 per month to Rs. 2000 per month would be with effect from October
2018 (to be paid in November, 2018).
45
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 3.8. Hindi excerpts

तांदुरुस्ती जागरूकता
अच्छी सेहत औि प्राथटमक इलाज के टलए सीखना औि टसखाना
o अच्छीकसेहतक–करहि कसख ु कशििचोगीका क–कदिू कशििचकिेिकमेंकम क
o स्र् स्् काीकच्षण क–किीम चीकसेकिय र्क–किीम चीका कतचु ं तकशििद िकऔचक
इि िक
o

साि –सक्ष
ां ेप कम्युटनिी हेल्थ प्रोवाइडि -
 रहिेकNMCकएलटकमेंकसचा चकआ र्ु ेशिदाकऔचकआ षु कशिडग्रीकध चाोंकाोकMBBSकाे क
समा्षणकिि िेकाे कशििएकएाकशिब्रिकाोसवकि ि कय हकचहीकथी.कइसकआईशिड काोकअिक
ड्र रकाचकशिद कग कहैक(कआईकएमक् एकाे कदि र्कमेंक?क).क
 ाम् शिु िटीकहेल्थकप्रोर् इडचका कआ षु कसेकाोईकशििंाकिहींकहै.कइसा कर ठ् क्रमक
सशिटवशििाे टकऔचका मकआधशिु िाकशियशिात्स करद्धशितकाे कअंतगवतकहीकहोग .क
 क दकइसाोकआक कर्ाव चका किड़ करूरकाहकसातेकहैंकिेशिािकअभीकइसकि चे कमेंकाोईक
भीकशिि म र्िीकसचा चकिेकिहींकिि ईकहैक....कक दक ेकच ज् कसचा चोंकाे कऊरचकछोड़क
शिद कि गे क–क क ेकभीकआक कऔचकआगं िर् डीकाीकतचहकसेकएाकसेंट्रिकस्ाीमकहोक
सातीकहै.कल कइसाोकग्र मकरंय तकाे कस्तचकरचकचख कि एग क–क कसिक–कसेंटचक क
PHCक के भीकस्रिकिहींक–कर्ैतशििाकहोग क कअर्ैतशििाक–क के भीकस्रिकिहीं.क
 मेच कशिर्य चकसिसेकरहिेकहैकशिाकहमाोकग ाँर्क/र् डवकस्तचकरचकएाकहेल्थकएशििमेटचकय शिहएक
–कअभीकआक कमेचीकि िा चीकमेंकग्र मककरंय तकस्तचकरचकहैक–कशििसाीकआि दीकऔचक
्षणेत्रििकअिगकअिगकच ज् ोंकमेंकअिगकअिगकहोकसात कहै.कइसशििएकएाकआक क
46
Page
 अप्र वप्तकहै.कहेल्थकएशििमेटचकाोकअर्ैतशििाकिि कि कसात कहैकऔचकउसाोकइसं ेंशिटर्क
ाीकव् र्स्थ कहोकसातीकहैक–कसम िकाे कद्व च क.
 इिाे कसप्रु ेशिर्सिकऔचकम गवदकविकाे कशििएकPHCककस्तचकरचकएाकडॉलटचक/क काम् शिु िटीक
हेल्थकिसवक/क काम् शिु िटीकहेल्थकप्रोर् इडचकहोकसात कहैक–क के एाकसंभ शिर्तकतचीा कहोक
सात कहै.क के व् र्स्थ क–कर् डवकस्तचकरचकहेल्थकएशििमेटचकाीकअिरु शिस्तशिथकमेंकसििकिहींक
होगी.किकहीकहेल्थकएशििमेटचकाीकव् र्स्थ क–कPHCकसप्रु ेशिर्ििकाे कअभ र्कमेंकसििक
होगी.क
 मेचीकप्रस्तशिु तकमेंकमेंकिोचकइिाीकचोिकएंडकचे स्रोशिन्सशििशिितीिकरिचभ शिषतकाचिेका कहै.क
 इसाे कअि र् कप्रशिक्षण काीकशिर्शिधका कहैक–कशििसमेंकरसवििकशिस्ाल्सकाीकिहुतकिड़ीक
भशिू मा कहै,कशििसा कआक कर्ाव सवकाीकट्रेशििंगकमेंकरू वकअभ र्कचह कहै.क

हेल्थ एटनमेिसा /कम्युटनिी हेल्थ प्रोवाइडि की पहचान

पांचायत मेम्बि औि वाडा हेल्थ वका ि – नाम टिपण्णी

फ़ोन नबां ि औि फ़ोन नबां ि
प्रधान

र् डवकमेम्िचक-1 HHA -1

र् डवकमेम्िचक -2 HHA-2

र् डवकमेम्िचक -3 HHA-3

र् डवकमेम्िचक-4 HHA-4
47
Page
 र् डवकमेम्िचक-5 HHA-5

र् डवकमेम्िचक-6 HHA -6

र् डवकमेम्िचक -7 HHA -7

सीखने के मुद्दे
LokLF; dk vk/kkj
gj balku LoLFk jguk pkgrk gSA lexz LokLF; dk rkRi;Z 'kkjhfjd] ekufld] oSpkfjd
,oa HkkoukRed LoLFkrk ls gSA FkksM+k /;ku nsus ij ;g le> esa vkrk gS fd jksx ds
eq[;r% nks dkj.k gSa
 igyk&ekufld ruko] thus esa my>usa] fj'rkas esa erHksn] eueqVko] bZ";kZ&}s"k vkfnA
 nwljk&gekjs [kku&iku] jgu&lgu esa dfe;k¡] fnup;kZ esa 'kkjhfjd Je&O;k;ke
,oa lkQ gok&ikuh dk vHkko] [kkuk&ihuk ,oa lksuk bR;kfn lgh le; ij u
gksuk A
LoLFk jgus ds ewy esa lq[kiwoZd thus dh lgh le> vkSj volj vko';d gSA lHkh ds
fy, ;g tkuuk vko';d gS fd euq"; ds thou dk D;k iz;kstu gS vFkkZr ge D;ksa ft;sa
vkSj dSls ft;sa\ vius lHkh fj'rksa ¼lac/a kks½a esa ,d nwljs ls gekjh D;k vis{kk,¡ gaS vkSj mUgsa
iwjh djus dh ;ksX;rk geesa dSls fodflr gks\ 'ks"k izÑfr ds lkFk gekjk D;k laca/k gS
vkSj izkÑfrd fu;eksa ,oa pØh;& vkorZu'khy O;oLFkk dks igpku dj ge viuh 'kkjhfjd
vko';drkvkas dh iwfrZ dSls djsa\ bUgha lokyksa ds loZekU; mÙkjkas dk feyuk gh lq[k dh
igpku gSA 'kjhj dh lnqi;ksfxrk ds fcuk LokLF; ifjHkkf"kr gh ugha gksrk gSA ru
LoLFk gks blds fy, eu%LoLFkrk Hkh vko';d gSA fujksxh 'kjhj dk lq[k rHkh fey ikrk
gS tc eu LoLFk gksA vHkh ekuo HkkSfrd lk/kuksa vkSj laosnukvksa esa lq[k [kkst jgk gS] bl
çfØ;k esa eu o 'kjhj nksuksa dk LokLF; xM+cM+k tkrk gSA LokLF; ds fy, tks la;e
48

vko';d gS og lq[k dh lgh igpku ls gh le> esa vkrk gSA

Page
 LokLF;&,d çk—frd O;oLFkk
LoLFk jgus dh ,d lqUnj izkÑfrd O;oLFkk gSA ekuo 'kjhj esa thouh 'kfDr iks"k.k ,oa
fu"dklu dk larqyu cuk;s j[krh gSA ekuo tks dqN Hkh [kkrk&ihrk gSa] 'kjhj mlesa ls
vius dke dh pht ysdj] 'ks"k vuqi;ksxh inkFkZ dks eyew=] ilhus bR;kfn ds ek/;e ls
ckgj fudky nsrk gSA xUnxh fudkyus dk ;g dke pkSchlksa ?kUVs pyrk jgrk gSA
QsQM+ksa ds ek/;e ls lkal] vk¡rksa ls 'kkSp] xqnkaZs ls ew=] Ropk ls ilhus vkfn ds }kjk ;g
lHkh vuko';d inkFkksZa ds fudyus dh izfØ;k gSaA ijUrq ekufld ruko] vlarqfyr
[kku&iku o jgu&lgu ds dkj.k ;g xanxh ¼ey@vuko';d inkFkZ½ Bhd le; ij
vFkok mfpr ek=k esa 'kjhj ls ckgj ugha fudy ikrh gSA ;gh xanxh jksx dk dkj.k
curh gSA [kk¡lh&tqdke] mYVh&nLr] vke cq[kkj tSls lkekU; jksx ,d izdkj ls thouh
'kfDr }kjk 'kjhj esa ,df=r xanxh dks ckgj fudkyus dk gh ,d iz;kl gSA ysfdu
vDlj xyr bykt ls ;g xanxh 'kjhj esa gh nc tkrh gS vkSj dqN lkyksa ckn ;g
xanxh tgjhys rRoksa esa cnydj xaHkhj jksxksa dks tUe nsrh gSA

'kjhj&'kks/kd o ey fu"dkld

 vkgkj&'kkd&lfCt;ksa ds jl] lwi] Qy ,oa Qyksa ds jl rFkk

 'kks/ku fØ;k;s&
a dq¡ty] usfr;k¡] feêh&iêh] xje& B.Mh lsd] ,fuek] dfVLuku]
jh<+ Luku] xeZ iSj Luku] lsd] ifê;k¡] yisV]
 ekfy'k] lw;ZLuku] Hkki Luku vkfn fØ;kvksa ds lkFk
 vklu&çk.kk;ke]
 ,D;wçs'kj vkfn dk ç;ksx

1. गााँव में िहने वाले प्रत्येक व्यटि का अटधकाि है टक एक टडग्री प्राप्त योग्य टचटकत्सक के द्वािा
उसका मेटडकल जाांच हो औि उसका मेटडकल काडा में उस जाांच को रिकॉडा टकया जाए
49

टजससे उसको अपनी सेहत औि बीमािी के बािे में सही जानकािी हो. टवशेषकि मटहलाओ ां
Page
 औि बुजुगों के टलए –हिेक के टलए – ये जाांच होना जरूिी है – ब्लड प्रेशि; ब्लड सुगि ; औि
खून में हीमोग्लोटबन

2. हि व्यटि को टनयमटत कसित किने के टलए - जीवन शेली के रूप में इसे अपनाने के टलए –
टशटक्षत औि प्रेरित किने की जरूित है. प्रत्येक व्यटि को कम से कम २० टमनि कसित किने
का टनयम बनाना चाटहए. कसित का तिीका उसकी व्यटिगत रूटच के अनुरूप हो सकता है.
इसमें प्राणायाम औि आसन का उटचत समावेश उपयोगी है. इसको टदन के अलग अलग
समय में िुकड़ों में भी टकया जा सकता है.

3. इसके साथ कुछ टवशेस टबमारियों के टलए – कमि की माांसपेटशयों को मजबतू किने के टलए
– एक्स्तेंसि मसल एक्स्सटसासे – औि घुिनों के ददा के टलए पिे ल्ला स्रे टचांग एक्सिसाइज; औि
गदान के ददा या तथा कटथत सवााइकल पैन के टलए – गदान की माांसपेटशयों के टलए प्रेशि
एक्सिसाइज - सीखना औि किना आवश्यक है.
4. इलाज के टलए आने वाले लगभग सभी परिवािों औि व्यटियों द्वािा िें शन की समस्या का
टजक्र टकया जाता है – इसको आगे औि समझने की जरूित है.
5. इसके साथ ही – कुछ क्रोटनक टबमारियों के टनयटमत इलाज की व्यवस्था भी जरूिी है –
इसके साथ इन टबमारियों के कािण औि इलाज की दवाइयों के बािे में जरूिी जानकािी औि
टशक्षण भी मिीज को देना जरूिी है. इसके आधाि पि ही ये सटु नटित टकया जा सकता है टक
मिीज अपनी दवाई को टनयटमत लेगा औि अपनी जीवन शेली में आवश्यक् परिवतान स्थाई
तौि से किे गा – इसमें – खून की कमी, ब्लड शुगि औि ब्लड प्रेशि तथा जोड़ों औि शिीि की
माांसपेटशयों में ददा प्रमुख है
6. प्रत्येक टपांड में एक दवाई की पेिी िखी जानी चाटहए टजसमें कुछ आवशयक दवाइयों को
टनयटमत तौि से िखा जाए औि जो दवाइयाां समाप्त हो जाएाँ उनको तुिांत सप्लाई की जाय
7. अगि गााँव के लोगों को सेहत् में सुधाि औि बीमािी के इलाज के टलए सही जानकािी दी जाए
तो वे इसको अपनाने के टलए तैयाि हैं – जैसे अपनी जाांच किवाना – दवाई टनयम से लेना –
योग इत्यटद कसित किना. इसके टलए वे अपनी जानकािी बढाने, नया सीखने औि जीवन में
बदलाव लाने के टलए तैयाि हैं
8. गााँव में डॉक्िि के सापताटहक टवटजि के पूिक के रूप में एक टशटक्षत मटहला की पहचान
किके उसको हेल्थ एटनमेिि के रूप में रे टनांग किना – ये एक आवश्यक कदम है
9. कुछ टवशेष टबमारियों के टलए िे फिल की व्यवस्था बनाना - टस्कन की बीमारियााँ; बच्चेदानी
का बाहि आना; मानटसक िोग; टदल में बचपन से छे द; आाँखों में चश्मा लगवाना; दाांतों की
बीमािी
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स्वस्थ टहन्द के टलए िाटररय दृटि
1. रचू े कदेककाे कशििए,ककएाकअशिधा चकप्र प्तकस्र् त्तकस्र् स्् कसेर् कशििगमकस्थ शिरतकशिा कि एग .कक
इसाीकमख्ु कशििम्मेद चीक–कसमन्र् काचिेकऔचकशिर्शिभन्िकस्र् श्थ् कऔचकशियशिात्स कसस्ं थ शििंकाीक
िर् िकदेशिहकाीकहोगी.क
2. प्रत् ाे कशिििेकमेंकसम िकाे कशिर्त्ती ककसह ोगकऔचक ोगद िकसेकएाकहेल्थकिण्डकाीकस्थ रि क
होगी.कस मदु शि ाकस्र् स्् काें द्रककऔचकशििि कअस्रत िकाीकव् र्स्थ काोकरू वकसदृु ढ़कशिा क
ि ग .कक
3. प्रत् ेाकग्र मकरंय तककमेंकएाकसेकअशिधाकस्र् स्् का ा व त वक–कआक ,कआगं िं कर् ड़ी, एएिक
एमक् ाोकप्र थशिमाकस्र् स्् कऔचकइि िककाे क्षणेत्रकमेंकरू कव प्रशिकशि्षणतकशिा कि एग क–काम् शिु िटीक
हेल्थकप्रोर् इडचक/कआिचे चीकहेल्थकएशििमेटचक
4. प्रत् ेाकर् डवकाे कस्तचकरचकएाकर् डवककस्र् स्् -कसगं तककऔचकएाकाम् शिु िटीकयेस्टकऑफ़कड्रग्सकाीक
स्थ रि काीकि ेगीक–कशििससेक८०कप्रशितकतकशििम िच ोंका कइि िकग ाँर्कमेंकिस र्टकाे कइदवकशिगदवक
हीकसंभर्कहोकसाे क
5. र्तवम िकमेंकशिर्शिभन्िकशियशिात्स ककरद्धशित ोंकाे काृशित्रमकशिर्भ ििकाोकसम प्तकाचकशिद कि ग .क–क
एिॉरथीक–कआ र्ु ेद/क िू िीकक–कहोशिम ोरैथी-कप्र ाृशिताकशियशिात्स कऔचक ोग.कप्रत् ेाकस्तचक
रचकशिर्शिभन्िककशियशिात्स ककरध्हशित ोंकऔचकउिाे कशियशिात्साोकाे कआरसीकसमन्र् करचकिोचकशिद क
ि एग .कक
6. मेशिडािकस इसं , तािीाकऔचकज्ञ िकतंत्रकाे काॉरोचे टकि म वक-कउद्योगकाे कअिगु मीकिििेकरचक
चोाकिग ीकि गी.ककटीा ाच , हेरेट इशिटसकिक–कसक, औचककएयकआईकर्ीककसंक्रम कऔचक
इि िकाे कशिर्ष ोंकरचकआध चभतू करिु शिर्वय चकशिा कि ग .कइसीकप्रा चक–कआ ष्ु म िक-२क
ा ेक्रमकाीकरचू ीकतचहकसेकरिु चव यि काीकि ेगी.कक
7. स्र् स्् काे कसर्धविकाे कशििएकिोाकशिक्षण ककरचकिोचकहोग कऔचकइसमेंक–करॉशििशिटर्कहेल्थक–क
ा उंसशििंगकएर्ंकिॅ शिमिीकथेचेरी, रोष , िीर्िकैिीकऔचकप्र थशिमाकइि िका कउशियतक
समिव् कहोग .ककइि िकसम्िन्धीकसभीकशिि व ोंकमेंकमचीिकाीकच कऔचकउिाीकप्र थशिमात ओकं
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ा कउशियतकसम र्ेककाचिेकरचकििकशिद कि एग .क
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