NRHM General Presentation by 4705Kd3

VIEWS: 18 PAGES: 66

									 Meeting




                                              NRHM
 People’s
 Health Needs  16th June 2008

National Institute of Public Cooperation
         & Child Development
         ToT of AWTCs/MLTCs
       National Rural Health Mission
        Ministry of Health & Family Welfare    1
               Government of India
Total Population : 1.1 billion
  Rural Population : 742.7
                                               India
            million
 Number of Administrative
                                            a snapshot
             units
         States : 35
       Districts : 609
       Blocks : 6345
     Villages : 638,588
HR as per World Health Report 2006. World
        Health Organization, Geneva.


       Physicians per 1,000 population          0.60   2005

     No. of Nurses per 1,000 population         0.80   2004

   No. of Midwives per 1,000 population         0.47   2004

  No. of Pharmacists per 1,000 population       0.56   2004
                                                       2
         National goals & MDG context
                             10th FY   NPP    MDG
                   Current
                              Plan     2010   2015
 Total Fertility      3
                               2.3     2.1     --
     Rate          (2003)
Infant Mortality     57
                               45      <30    <27
     Rate          (2007)
Neonatal Mort        37
                               26      <20    <20
    rate           (2003)
  Maternal           301
                              200      <100   100
Mortality Rate     (2005)
 Institutional     40.5 %     80%      80%     -
  deliveries       (2003)

                                               3
    India’s Health Indicators
        Large inter state variations
                      IMR        MMR         TFR
   State/UT                     SRS 01-03   SRS 2005
                     SRS 2007

    Kerala             15         110         1.7

  Tamil Nadu           37         134         1.7

  All India            57       301          2.9
Madhya Pradesh         74         379         3.6

    Orissa             73         358         2.6

 Uttar Pradesh         71         517         4.2
                                               4
           Large inter state variations

            States            Best performing   NPP    MDG
   Key       with              state in India   2010   2015
Indicators most to
           catch up
     IMR                            15          <30     27
                               (Goa, Kerala)
     NMR        High                8.8         <20*   <20*
               Focus               (Goa)
 U5MR          States              16.3          -      41
                               (Goa, Kerala)
     MMR                           110          <100   <100
 •Reference: IMR - SRS 2006
                                 (Kerala)
 •          MMR -SRS 2001-2003
                             Maternal Mortality Ratio
600                                                                                                                              8 states have met 10th Plan target
      517              517                                                                                                   No state has met RCH II/ NRHM target
                                      490
500                                            445
                                                                                                                                                                                     10th Plan                         RCH II
                                                            379             379              371      371                                                                            Goal : '07
400                                                                                                                358                                                                                                Goal: '10

300
                                                                                                                             228
                                                                                                                                          195               194            178
200                                                                                                                                                                                  172        162        149            134
                                                                                                                                                                                                                                           110
100

 0




                                                                                                                                                                                                                          Tamil Nadu
                                                                                                       Jharkhand
                        Uttarakhand
       Uttar Pradesh




                                                                            Madhya Pradesh




                                                                                                                                                                            Punjab
                                                                                                                    Orissa




                                                                                                                                                                                                 Haryana
                                                Rajasthan




                                                                                                                              Karnataka




                                                                                                                                                                                      Gujarat




                                                                                                                                                                                                            Maharashtra
                                                             Chhattisgarh




                                                                                                                                                             West Bengal
                                       Assam




                                                                                                                                                                                                                                            Kerala
                                                                                                                                           Andhra Pradesh
                                                                                              Bihar




                                                                                                                                                                                                                                       4
India’s child survival challenge
• Birth rate 24.1          (2004)
  – 27 million neonates to take care


                                                       • U5MR 95 (1998-99)
                     – 2.5 million die before completing 5 years
                            – Globally India accounts for 23% of all U% deaths
• IMR 57      (2007)
  – 1.6 million die before completing 1 year
  – 64% of infant deaths occur in the first 30 days.
  – More than 50% occur in first 3 days
                                                         • NMR 40       (2002)
                           – 1.1 million die before 4 weeks of age
                                                             7
Health delivery
apparatus
    – Public Sector facilities
    – Private Practitioners

    – ESI, CGHS, PSU Hospitals
    – Railways Hospitals
    – Armed Forces Medical Services

    – Corporate Hospitals

    – Indian System of medicine
    – Informal providers
                                                8
    – Quacks/Crooks & magico religious practitioners
   CHC

   PHC


Sub Centres


              9
                   Sub-Centres (SCs)

•Most peripheral contact point with primary health system

•One ANM and one Male Health Worker

•One Lady Health Worker (LHV) supervises six Sub-Centres.

•Tasks relating to interpersonal communication wrt maternal and
child health, family welfare, nutrition, immunization, diarrhea
control and control of communicable diseases programmes.

•Provided with basic drugs

•100% Central assistance to all the Sub-Centres since April 2002

•There are 1,45,272 Sub Centre as on March, 2007
                                                           10
             Primary Health Centres (PHCs)

•First contact point with Medical Officer.

•Envisaged to provide an integrated curative and preventive care

•Established and maintained by the State Governments under the
Minimum Needs Programme (MNP)

•Manned by a Medical Officer supported by 14 paramedical and
other staff.

•It acts as a referral unit for 6 Sub Centres.

•It has 4 - 6 beds for patients.
                                                           11
• There are 22,370 PHCs as on March, 2007 in the country
           Community Health Centres

•Established and maintained by the State Government under
MNP/BMS programme .

•It is manned by four medical specialists i.e. Surgeon,
Physician,   Gynecologist and Pediatrician supported by 21
paramedical and other staff.

•It has 30 in-door beds with one OT, X-ray, Labour Room and
Laboratory facilities.

•It serves as a referral centre for 4 PHCs and also provides
facilities for obstetric care and specialist consultations.

•As on March, 2007, there are 4045 CHCs functioning.   12
     The Structure of the Public Health
                  System
• Health is a State Subject Family Welfare is Concurrent.

• Primary Health care is Local self Government.

• Most institutions and manpower are in state sector.

• Most programmes are in the central sector

• National Programmes address about 25% of all morbidities.

• No dedicated health functionary at village level.

• 1st Doctor at PHC (30,000 population),1st Specialist at CHC (80,000 popu).
                                                                      13
          Deep rooted structural issues
• Sustainable Systems

       • Financing 5.2 % of GDP ( Private 4.3 %, Public 0.9%)

       • Infrastructure      (over 2,00,000 facilities yet inadequate)

       • Manpower            Workforce Issues: Irrational distribution; Poor
                             work culture; absenteeism; Poor supervision

       • Logistics

       • Management

       • Evaluation

• Responsive & Equitable to citizens                                 14
   National Rural Health Mission
      launched in April, 2005
Rejuvenate the Health delivery System

Universal Health Care
                    Access
                   Affordability
                      Equity
                      Quality

              Reduce IMR, MMR,TFR
             Improve Disease control
                                        15
            Goals of the Mission
•Universal Health care, well functioning health system.

•Reduce IMR to 30/1000 live births by 2012
•Reduce MMR to 100/100,000 live births by 2012
•TFR reduced to 2.1 by 2012

•Reduce & sustain Malaria Mortality to 60% by 2012
•Kala Azar eliminated by 2010, Filaria reduced by 80 % by 2010
•Dengue Mortality reduced by 50% by 2012
•TB DOTS maintain over 70 % case detection & 85% cure rate
•46 lakh cataract operations annually by 2012.

•Upgrading all health facilities to IPHS.
•Increase utilization of FRUs from 20% bed occupancy to 75%
                                                          16
      The formative years of NRHM
• Original approval for NRHM in January 2005
• Country wide Launch by Prime Minister, 12 April 2005

• 2005-06 was formative year during which
     • Strategies & Guidelines firmed up
     • Merger of Deptt of Health & family welfare
     • State & District Health Missions constituted
     • Specific Activities funded on Normative basis

• Framework for Implementation approved July 2006
• Highest institutions of NRHM empowered
      • Mission Steering Group
      • Empowered Programme Committee

• Financial envelopes to states, NPCC
                                                         17
• Monitoring systems & Management structures put in place.
The
Paradigm
Shift
           18
               The Paradigm Shift
•   Decentralised planning
•   Outputs and Outcome based
•   Pro-Poor Focus: Equitable systems
•   Quality of Care and the IPHS norms
    • Rights based service delivery
    • Pre stated entitlements at all levels
    • Inputs computed as function of the entitlements
      and estimated patient load
    • Judicious mix of dedicated budget lines - untied
      funds
    • Monitor quality
• Community Participation                           19
              The Paradigm Shift
• Bringing the public back into public health
  • At hamlet level : ASHA, VHSC, SHGs, Panchayats.
  • At the facility level: RKS
  • At the management level : health societies
• Governance reform
  • Manpower, Logistics & Procurement processes.
  • Decision making processes
  • Institutional design, Accountability framework
• Convergence
  • Water and sanitation
  • Nutrition
                                                      20
  • Education
             Monitoring & Mentoring
•   Regular review meetings
•   State visits – evaluation teams, SFTs, RDs
•   Integrated MIS (web based)
•   External Surveys
     – Immunisation - UNICEF
     – ASHA & JSY – UNICEF, UNFPA, GTZ
     – Financial protocols- Institute of Public Auditors
     – Concurrent External Evaluations
•   Concurrent Financial Audit at District level by external CAs
•   Financial Audit of SHS/DHS by CAG CAs
•   Community monitoring – AGCA/PFI
•   ASHA Mentoring Group
•   JRM & Common Review Mission                                 21
Community empowerment under NRHM
• Not (only) Community Monitoring but Empowerment
• Part of over all health sector reform agenda



• Embed Community ownership within reform processes
   – In programme design of all strategies (PPP, Insurance etc)
     process monitoring by the community needs to be built in.


• More than grievance redress forum or adverse impact analysis
   – Covers planning, designing, implementation as well as ongoing
     concurrent oversight.


• Does not have large budgetary footprint
                                                                     22
                              Not all reforms have budgetary implications.
Contours of
Community
empowerment
              23
                  OBJECTIVES
• Create forums for community ownership
                                 VHSC, RKS,DHM,SHM

• Collect systematic info about community needs
• provide feedback according to
            »locally developed yardsticks
           »key indicators.

• Do with salary based systems what seems possible
  only with passion based systems.
• Validate sector wide data from other sources
• Triangulation                                24
     Tools of Community Monitoring
Village Level
        • Village Health Register - Records of ANM - Public dialogue
        • Village Health Calendar- Infant and maternal death audit
PHC level
        • Charter of Citizens Rights – IPHS - PHC Health Plan

Block level
       • IPHS - Charter of Citizens Rights - Block Health Plan

District level
        • Report from the PHC Health committees
        • Report of the District Mission committee
        • Public Dialogue (Jan Samvad)

State level
        • Reports of the District Health committees
        • Periodic assessment reports by taskforces / State level committees
          about the progress made in formulating policies according to IPHS,
                                                                        25
          NHSRC recommendations etc.
  Issues to be monitored
   MCH,JSY,ASHA,VHSC
       Untied funding
    Disease Surveillance
        Curative care
             etc      Scores
                      Good Performance
                                         Village
                     Cause for Concern   Health
                                         Score Card
Methods               Poor Performance
Village Group Meeting
Interviews         with
   beneficiaries
Interviews with ASHAs                          26
etc
 Issues to be monitored
Service availability, Quality
 Equipment, Supplies, Personnel
    Charges, Corruption
     RKS Functioning
            etc      Scores
                     Good Performance
                                            Facility
                        Cause for Concern   Score Card

                      Poor Performance
Methods
Facility Observations
Meetings with Providers
Exit Interviews
etc                                               27
Community
Monitoring
Committees
             28
Village Health & Sanitation Committee
• Gram Panchayat members from the village

• ASHA, Anganwadi Sevika, ANM

• SHG leader, the PTA/MTA Secretary, village representative of
  any Community based organisation working in the village, user
  group representative

   Chairperson would be the Panchayat member
   Convenor would be ASHA / Anganwadi Sevika of the village.
   Formed at level of revenue village
           (more than one such village may come under single Gram
                                                      Panchayat).
                                                          29
             PHC Level Committee
• 30% members : representatives of Panchayati Raj Institutions
        (Panchayat Samiti member from the area; two or more
                                                   sarpanchs)

• 20% members - non-official representatives from VHSCs with
  annual rotation to enable representation from all the villages

• 20% members representatives from NGOs / CBOs in the area

• 30% members representatives of providers, MO, ANM


   Chairperson be one of the Panchayat representatives,
   Executive chairperson be Medical officer of PHC.
   Secretary be one of the NGO / CBO representatives.     30
              Block level Committee
• 30% members representatives of the Block Panchayat Samiti
   (Adhyaksha / Adhyakshika of the Block Panchayat Samiti or members of the
                           Block Panchayat samiti, with at least one woman)

• 20% members be non-official representatives from the PHC committees
  with annual rotation to enable representation from all PHCs over time

• 20% members be representatives from NGOs / CBOs

• 20% members be officials : BMO, BDO, selected MOs from PHCs etc

• 10% members should be representatives of the CHC level RKS

         Chairperson be one of Block Panchayat Samiti reps.
         Executive chairperson be the BMO.
         Secretary would be one of the NGO/CBO reps.        31
          District Level Committee
• 30% members be representatives of the Zilla Parishad
        (esp. convenor and members of its Health committee)

• 25% members be district health officials, including DHO/ CMO/
  Civil Surgeon and representatives from DPMUs

• 15% members be non-official representatives of block
  committees, with annual rotation
• 20% members be representatives from NGOs / CBOs
• 10% members be representatives of RKSs in the district

Chairperson be one of ZP reps
                preferably convenor of the Zilla Parishad Health committee.
Executive chairperson be CMO / CMHO / DHO
Secretary be one of the NGO / CBO representatives.
                                                                   32
              State Level Committee
• 30% members be elected reps in legislative body (MLAs /MLCs) or
  Convenors of Health committees of ZPs by rotation

• 15% be non-official members of District committees, by rotation

• 20% members be representatives from State Health NGO coalitions

• 25% members would belong to State Health Department incl Secretary
  HFW, Commissioner Health, officials from Dt. of Health Services, NRHM
  Mission Director) along with experts from SHRC / SPMU

• 10% members be officials belonging to other related departments



Chairperson be one of the elected members (MLAs).
Executive chairperson would be the Secretary HFW.
Secretary be one of the NGO representatives.                        33
Role of
Monitoring
Committees
             34
                   Role Of VHSC
• Create Public Awareness about programmes.
• Discuss and develop Village Health Plan.
• Maintenance of a village health register.
• Ensure that ANM and MPW visit village on fixed days.
• Get bi-monthly health delivery report from service providers.
• Discuss every maternal & neonatal death in village.
• Convener (ASHA or AWW) will sign attendance registers of the
  AWWs, Mid-Day meal Sanchalak, MPWs, and ANMs.
• MPWs and ANMs to submit a bi-monthly village report to the
  committee along with the plan for next two months.
• Format and contents of the bi-monthly reports would be
  decided village health committee.

• The committee will receive funds of Rs.10,000 per year. This
                                                       35
  fund may be used as per the discretion of the VHC.
             Role of PHC Committee
• Consolidation of village health plans

• Charting out the annual health action plan & a PHC Health Plan

• Disseminate Charter of citizen’s health rights
• Monitoring of physical resources at PHC

• Coordinate with local CBOs and NGOs

•   Review functioning of Sub-centres operating under the PHC
•   Initiate action on instances of denial of right to health care.
•   Contribute to ACRs of MO/ other functionaries at the PHC.
•   Take collective decision about untied funds utilisation.     36
       Role of Block level Committe
• Consolidation of the PHC level plans and preparing block plan.

• Review of progress difficulties at PHCs and CHC.

• Analysis of neonatal & maternal deaths & other indicators.

• Monitoring of the physical resources at the CHC

• Coordinate with local CBOs and NGOs

• Review functioning of Sub-centres and PHCs

• Initiate action on instances of denial of right to health care.
                                                               37
     Role of District level Committee
• Monitor Health committees at lower levels, Financial reporting
  and solving blockages in flow of resources.

• Monitoring of physical resources at all District Health facilities

• Progress report of Health facilities esp referral utilisation.

• Charting out Integrated District Health Aaction Plan

• Ensuring proper functioning of the RKS.

• Discussion on Health Policy of the state level – local relevance.

• Initiate action on instances of denial of right to health care.
                                                                   38
      Role of State level Committee
• Manage programmatic and policy issues.

• Review and contribute to State Health Plan & NRHM PIP.

• Issues arising from District Committees relating to state action.

• Institute a Health rights redressal mechanism.

• Assessing progress made in actualization of the Right to health
  care at the state level.

• Proactive dissemination of GOI guidelines.


                                                             39
         Village Health Report Card
S.No     Theme             Calculation           Score

        Maternal                              > 75 % of N
                      Number of women * X =
 1       Health                               50 - 75% of N
                                N
       Guarantee                              < 50 % of N

         Janani                               > 75 % of N
                      Number of women * X =
 2      Suraksha                              50 - 75% of N
                                N
         Yojana                               < 50 % of N

                                                 16 - 20
 3     Child Health      Total Score - 20        10 - 15
                                                 0-9

                                                  7-8
         Disease
 4                        Total Score - 8         5-6
       Surveillance
                                                  0-4
        Village Health Report Card
S.No         Theme             Calculation      Score

                                                 7-8
 5      Curative Services    Total Score - 8     5-6
                                                 0-4
                                                 7-8
 6        United funds       Total Score - 8     5-6
                                                 0-4
                                                19 - 24
 7       Quality of Care     Total Score - 24   12 - 18
                                                0 - 11
                                                13 - 16
           Community
 8                           Total Score - 16   8 - 12
       Perceptions of ASHA
                                                0-7
         Village Health Report Card
S.No     Theme            Calculation                Score
                                                    10 - 12
          ASHA                                       6-9
 9                      Total Score - 12
       functioning
                                                     0-5

                                              <1      Favorable to
                       (Total score general   marginalized group
                      community women)/       1     No difference
10
       Equity Index        (Total score       >1      Unfavorable
                          marginalized          to marginalized
                       community women)              group

        Adverse
       Outcome or
11                        Total Score
       experience
         reports
        Cumulative Report Card - Villages
          Theme             Villages   Villages   Villages

Maternal Health Guarantee

 Janani Suraksha Yojana
       Child Health
   Disease Surveillance
    Curative Services
      United funds
     Quality of Care
Community Perceptions of
        ASHA
    ASHA Functioning
      Equity Index
   Adverse Outcomes
               Facility Score Card
S.No      Theme            Calculation       Score


                                          75% of N
       Infrastructure
 1                      N=Maximum Score   50-74% of N
       and Personnel
                                          <50% of N


                                          75% of N
       Equipment and
 2                      N=Maximum Score   50-74% of N
          Supplies
                                          <50% of N


                                          75% of N
         Service
 3                      N=Maximum Score   50-74% of N
        Availability
                                          <50% of N
                 Facility Score Card
S.No         Theme               Calculation         Score


                             Add points of all the    ≥ 19
 4     Unofficial charges    persons interviewed     13 - 18
                                  (max 25)            ≤ 12



                             Add points of all the    >28
 5       Quality of Care      persons interview      18 - 28
                                  (max 35)            < 18


                                                      >7
       Functioning of Rogi
 6                           Total Points scored      5-7
         Kalyan Samiti
                                                      <5
      Cumulative Facility Score Card
      Theme
      dz la eqn~nk                  x.kuk      fooj.k Facility
                                    Facility                     Facility
       5     fpfdRlfd; lsok;sa      3          2 ls vf/kd
Infrastructure and                             2
    Personnel                                  2 ls de
       6     fuZca/k jk’kh          3          2 ls vf/kd
  Equipment and                                2
     Supplies                                  2 ls de
       7     lsokvksa dh xq.koRrk   3          2 ls vf/kd
Service Availability                           2
                                               2 ls de
           foifjr and
Infrastructure ifj.kke
      8                             dqy vad    dqy vad
    Personnel

Unofficial charges
  Quality of Care

Functioning of Rogi
Community
Monitoring
Phase 1
             47
                 Scale of Phase 1
• Nine States

• 38 districts (3-5 districts per state)

• 114 blocks (three in each district )

• 342 PHCs (three in each block.

• 1710 villages (five revenue villages per PHC).

                                                   48
                   Features of Phase I
• Green field activity
• Work of Capital nature : Institutions, Committees, Orientation material,
    formats, channels of reporting to be developed
• Advisory Group of Community Action is the operational partner

• AGCA through Population Foundation of India is vehicle for
    –   Start up activities in the initiative.
    –   Preparation for basic documentation
    –   Handholding the finalisation of G Orders/Resolutions
    –   Handholding the formation, orientation and operationalisation of
        committes
•   Phase 1 funding by MoHFW is to PFI.
•   Funds passed to State Nodal NGOs by PFI.
•   District & Block level funds disbursed by State nodal NGO.
•   Sustenance of CM will be through state PIP               49
               Features of Phase I
• MOHFW has allocated funds to PFI for :

   – Support for preparation of orientation material,

   – Travel of mentoring group members to states

   – State preparatory meetings, workshops, orientation material,
     travel and meeting expenses.

   – District workshops, expenses for committee formation and
     orientation

   – Village, PHC and Block levels orientation sessions, travel
                                                             50
   – Travel support to mentoring team from AGCA
    AP Rural Emergency Health Transport
•   Transport to pregnant women,
    infants, children & emergencies.
•   Toll-free No.108 365x24x7.
•   502 ambulances in 1107 mandals.


•   Average time for reaching hospital
    16 min. in Urban & 22 min. in
    Rural areas.


•   Total emergencies attended per
    day is 2,806 (97% are Medical)
•   In two years, REHTS has saved
    20,394 lives by attending to them
    in the crucial Golden hour           51
     Before Intervention



Andhra Pradesh
 Toopran PHC




                           After Intervention
                                                52
  Assam- Institutional Deliveries
(approximately 6.55 lakh total deliveries annually)




                                                53
        Gujarat Institutional deliveries

                                  Trend in deliveries

80.00
                                                                                      76
70.00
                                                                          67.63
60.00                                 55.87       57.03       63.24
            51.43       53.21
50.00       48.57       46.79
                                                  42.97
40.00                                 44.13
                                                              36.76
30.00                                                                     32.37
                                                                                      24
20.00

10.00

 0.00
        2001-02     2002-03      2003-04      2004-05     2005-06     2006-07     2007-08

                              Institutional deliveries %      Home %
                                                                                      54
                 Gujarat




Infrastructure
 Upgradation
 under NRHM

                           55
Bihar – Increase in OPD Patients




                                   56
 Bihar- Institutional Deliveries



2006   2007




                                   57
Nutrition Rehabilitation Center Guna, Madhya Pradesh
    NRCs making difference for
    Severely        malnourished
    children in MP (Guna dist)




      Prahlad August 2005,
                                   Prahlad March 2006
     Garlagird village, Guna
                                                        58
             Institutional Deliveries – Madhya Pradesh
                  (approximately 17.6 lakh total deliveries annually)


             70

                                                              62 %
             60

                                         51 %
             50

                    41 %
             40
Precentage




             30



             20



             10



             0
                      2005-06              2006-07            2007-08 Dec. 07

                                                                                59
                      2000
                             4000
                                    6000
                                            8000
                                                     10000
                                                               12000
                                                                       14000
                                                                               16000




                  0
      Ap
         r   il                            6583
                                                  7465

      M
          ay                                7045
                                                   8155
      Ju
         n   e                             6508

                                                    8651
      Ju
         l   y                              6434

                                                             9898
  Au
     g    us
            t                              6291
Se
  pt                                                          10516
    em
         be
           r                                6194

                                                                  11831
  O
   ct
      o  be
           r                               6895
                                                                               15009
                                                                                       PHC Deliveries Tamil Nadu Apr 06 to Oct 07




 60
                                    2007
                                           2006
         YEAR WISE DISTRIBUTION OF DELIVERIES (%)

              100%

              90%                                                                           Pvt.

                      39.9      40.1                                     40       34.64
              80%                         40.3      40.5      41.2
              70%
Percentages




              60%
                                                                                            GH
              50%
                                                                                  40.15
              40%      38       38.5      39.6      40.6                41.8
                                                              41.8
              30%

              20%     6.3                                                                   PHC
                                 7        7.3                                     19.68
                      5.9                           7.6       7.7        9.7
              10%               6.7        7        6.9
HOME                  9.9       7.7       5.7       4.4
                                                              5.9        6.3                HSC
               0%                                             3.4      2.25        4.42
                                                                                   1.11
                     2002-03   2003-04   2004-05   2005-06   2006-07   2007-08*   2008-09



                                                                                            61
                                                                    Source : PHC Records
Jammu & Kashmir – Institutional delivery
    (approximately 1.9 lakh total deliveries annually)




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63
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65
 THANK YOU
  web : mohfw.nic.in\nrhm.htm
email : healthmission@nic.in

                                66

								
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