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Chapter 3
Various Health Schemes under
National Rural Health Mission (NRHM)
―National Rural Health Mission (NRHM) is a national health program for
improving health care delivery across rural India. The mission, initially mooted for 7
years (2005-2012) has been extended to 12th five year plan period by the Ministry of
Health GoI. The scheme proposes a number of new mechanism for healthcare
delivery including training local residents as Accredited Social Health Activists
(ASHA), and the Janani Surakshay Yojana (motherhood protection program). It also
aims at improving hygiene and sanitation infrastructure. The mission has a special
focus on 18 states Arunachal Pradesh, Assam, Bihar, Chhattisgarh, Himachal Pradesh,
Jharkhand, Jammu and Kashmir, Manipur, Mizoram, Meghalaya, Madhya Pradesh,
Nagaland, Orissa, Rajasthan, Sikkim, Tripura, Uttarakhand and Uttar Pradesh. In the
12th Five Year Plan period, efforts will be made to consolidate the gains and build on
the successes of NRHM to provide accessible, affordable and quality universal health
care, both preventive and curative, which would include all aspects of a clearly
defined set of healthcare entitlements including preventive, primary and secondary
health services. The main targets for mother and child health care at the national level
for 12th five year plan period which are also in consonance with Millenium
development Goals(MDGs)have been set as follows‖1:
Reduction of Maternal Mortality Ratio (MMR) to < 109 per 100000 live
births, by 2015
Reducing Infant Mortality Rate(IMR) to < 27 per 1000 live births, by 2015
Reduction in Neo-Natal Mortality Rate(NMR) to < 18 per 1000 live births, by
2015
Reducing Total Fertility Rate(TFR) to 2.1 by 2017
Raising child sex ratio in the 0-6 year age group from 914 to 935
Prevention and reduction of anemia among women aged 15-49 years-
Reducing anemia to 28%,by the end of the 12th Plan(2017)
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Prevention and reduction of underweight children under 3 years- Reducing
undernourished children under 3 years to 26% by 2015
There are many programmes under NRHM, but for the purpose of present
study only programmes directly related to rural women‘s health in three important
stages of her life as a mother, as a wife and as a daughter are focussed upon. The brief
details of these programmes has been given below:
3.01 Maternal Health
―About 56,000 women in India die every year due to pregnancy related
complications. Similarly, every year more than 13 lacs infants die within 1year of the
birth and out of these approximately 9 lacs i.e. 2/3rd of the infant deaths take place
within the first four weeks of life. Out of these, approximately 7 lacs i.e. 75% of the
deaths take place within a week of the birth and a majority of these occur in the first
two days afterbirth. In order to reduce the maternal and infant mortality,
Reproductive and Child Health (RCH) Programme under the National Rural health
Mission (NRHM) is being implemented to promote institutional deliveries so that
skilled attendance at birth is available and women and new born can be saved from
pregnancy related deaths. Several initiatives have been launched by the Ministry of
health and Family Welfare (MoHFW) including Janani Suraksha Yojana (JSY) a key
intervention that has resulted in phenomenal growth in institutional deliveries. More
than one crore women are benefitting from the scheme annually and the outlay for
JSY has exceeded 1600 crores per year.
3.02 Janani Suraksha Yojana (JSY)
JSY is a scheme supported and funded by the Government of India. It was launched
on 12 April 2005 by the Prime Minister of India. Its aim is to decrease the neo-natal
and maternal deaths happening in the country by promoting institutional delivery of
babies. It is a 100% centrally sponsored scheme it integrates cash assistance with
delivery and post-delivery care. The success of the scheme would be determined by
the increase in institutional delivery among the poor families. Under the scheme
ASHA activists have been assigned the responsibility to encourage the people in the
rural areas for institutional delivery, with particular focus on poor women. Under the
scheme, the states with low rate of Institutional deliveries are classified as 'Low
Performing States(LPS)' which include Uttar Pradesh, Uttaranchal, Bihar, Jharkhand,
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Madhya Pradesh, Chhattisgarh, Assam, Rajasthan, Orissa and Jammu and Kashmir,
whereas the remainingstates are termed as High Performing States(HPS). The details
of Cashbenefits under this scheme are as under‖2:
Rural Areas:
Table3.1 JSY Package for rural areas.
Category Mother’s
Package
ASHA’s
Package
Total Package
(in Rs.)
LPS 1477 677 2777
HPS 777 - 777
Urban Areas:
Table3.2 JSY Package for urban areas
Category Mother’s
Package
ASHA’s
Package
Total
Package
(in Rs.) LPS 1000 200 1200
HPS 600 - 600
The sheme has been operational in Uttarakhand and the status of implementation in
Uttarakhand and district Almora is given below:
Table3.3 Implementation status of JSY in Uttarakhand and Almora
State/District Mothers who
availed financial
assistance for
Delivery under
JSY(%)
Mothers who
availed financial
assistance for
institutional
Delivery
underJSY(%)
Mothers who
availed financial
assistance for
Government
institutional
Delivery under
JSY(%)
Total Rural Urban Total Rural Urban Total Rural Urban
Uttarakhand 30.1 30 30.2 54.3 61.4 41.2 84.7 86.5 80.4
Almora 35.4 34.8 46.8 76.5 78.5 56.4 85.3 86.7 69.9
Source (Annual Health Survey Fact Sheet, Uttarakhand (2011-12)
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According to 42 Point report for March 2013of Almora District out of 6761
expected beneficiaries of JSY Scheme 5485 beneficiaries have availed the benefits
under the scheme during the year 2012-13. In view of the difficulty being faced by the
pregnant women and parents of sick new- born along-with high out of pocket
expenses incurred by them on delivery and treatment of sick- new-born, Ministry of
health and Family Welfare (MoHFW) has taken a major initiative to evolve a
consensus on the part of all States to provide completely free and cashless services to
pregnant women including normal deliveries and caesarean operations and sick new
born(up to 30 days after birth) in Government health institutions in both rural and
urban areas.
3.03 Janani Shishu Suraksha Karyakaram (JSSK)
Government of India , after reviewing the implementation and impact of JSY
has launched JSSK on 1st June, 2011 with free entitlements to pregnant women and
new born. The main features of the scheme includes free and cashless delivery, free
caesarian-Section, free drugs and consumables, free diagnostics, free diet during stay
in the govt. health institutions. Other benefits under the scheme are free provision of
blood, exemption from user charges, free transport from home to govt. health
institutions, free transport between facilities in case of referral, free drop back from
institutions to home after 48hrs of institutional delivery by Khusiyon Ki Sawari (104
service). If the need arises, the scheme also has provision for above mentioned free
entitlements for Sick newborns till 30 days after birth‖3. According to Uttarakhand
Health And Family Welfare Society‘s (UKHFWS‘s ) report for 2011-12 pertaining to
District Almora 4654 women and 4654 children had availed different entitlements
under Janani Shishu Suraksha Karyakaram (JSSK). As per the report of CMO Almora
1836 women were given drop back home facility during 2011-12 under the scheme.
3.04 Village Health and Nutrition Day (VHND)
The basic objective of organizing Village Health and Nutrition Day in Agan
Wari Centres (AWCs) is to create awareness among the pregnant women, lactating
mothers and children and to encourage them for early registration, ANC checkups,
counseling on institutional deliveries, counseling on breastfeeding, family planning,
immunization, menstrual hygiene etc. with an objective to achieve better maternal
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and child health. Weight Monitoring of underweight children usually 3 years of age is
done and efforts are made to improve their weight to healthy category through
counseling of parents and providing fortified food to such children. Village Health
and Nutrition Days are also a platform for creating awareness among the community
about importance of girl child,various health and social security schemes launched
especially targeting the girls as well as disseminating information about The Pre-natal
Diagnostic Techniques (Regulation and Prevention of Misuse) Act, 1994, and
provisions of punishment under the act so that sex ratio between 0-6 years of age
group can be increased. Village Health and Nutrition Days are organized once in a
months at each Anganwadi Centre. ANM, Anganwadi Worker and ASHA workers
have been given the responsibility to ensure the presence of target group on Saturday
(as per Schedule) to make this activity at village level an effective intervention.
During the VHN Day, CHC/PHC wise supervisor/ HealthVisitor(HV)/Block
Programme Management Unit(BPMU)will be responsible for Supervision/monitoring
of VHND activities in their respective area4.
According to report of CMO Almora(
March 2013) District out of 7000 VHNDs 6674 VHNDs has been organized.
3.05 Reproductive and Child Health (RCH) Camps
Reproductive and Child Health (RCH) camps, which are popular as Parivar
Swasthya Sewa Divas (Family Health Day) organized at CHCs and PHCs, provide an
opportunity to integrate the efforts of providers and increase access to reproductive
health services. Each camp includes a gynecological check-up, child examination and
immunization, family planning counseling and services and transportation for
sterilization clients.
Though sterilization camps have been part of the family planning programme
for many years, these RCH camps are different in that they:
Provide assured services as per a pre-determined calendar.
Combine benefits of rural outreach and high quality services.
Provide an array of maternal, child health and family planning services under
one roof.
The organization of camps involves detailed planning relating to publicity,
manpower deployment, camp arrangements, and post-camp services including
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transportation, availability of consumables and medical equipment. Each camp is
scheduled in advance and publicized. Specially designed banners and handbills
promote them as Pariwar Swasthya Sewa Divas. In rural areas, playing attractive
jingles on audio cassettes carried around in hired rickshaws or vehicles spreads the
word. Since most of these camps are in remote rural areas, the availability of a team
of surgeons, anesthetist and female gynecologist has to be ensured from the district
level. Enhanced budget for maintenance and fuel for vehicles is provided so that an
adequate number of vehicles can be deployed to transport doctors to RCH camp sites
and sterilization clients to their homes.5
3.06 Family planning
In 1952, India launched the world first national program emphasizing family
planning to the extent necessary for reducing birth rates and to stabilize the
population at a level consistent with the requirement of national economy. Since then,
the family planning program has evolved and the program is currently being
repositioned to not only achieve population stabilization but also to
promote reproductive health and reduce maternal, infant and child mortality and
morbidity.
The objectives, strategies and goals of the Family Planning have been stated
in various policy documents like National Population Policy (NPP) 2000, National
Health Policy (NHP)2002, National Rural Health Mission (NRHM) and Millennium
Development Goals (MDG). Crucial factors influencing population growth can be
grouped into following 3 categories-
1. Unmet need of Family Planning : This includes the currently married
women, who wish to stop child bearing or wait for next two or more years for the next
child birth, but not using any contraceptive method. Total unmet need of Family
Planning is 21.3% (DLHS-III) in our country.The findings of AHS 2011-12 for
Uttarakhand and district Almora are given below:
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Table 3.4Unmet need of Family Planning for Uttarakhand and District Almora
Unmet need for Family Planning(2011-12)
State/District Unmet Need For
Spacing(%)
Unmet Need For
Limiting(%)
Total Unmet
Need(%)
Total Rural Urban Total Rural Urban Total Rural Urban
Uttarakhand 8.4 8.9 7.2 9.7 9.4 10.3 18.1 18.2 17.6
Almora 12.3 12.8 6.0 15.0 14.9 17.1 27.4 27.7 23.1
Source {Annual Health Survey Fact Sheet, Uttarakhand (2011-12)}
2. Age at Marriage and first childbirth: Age at marriage and first child
birth are important indicators of the status of family planning and health of women.
This has gradually increased over the years. According to SRS 2012 and census 2011,
the earlier custom of teen marriage and teen motherhood has declined by over 32% in
a decade.
3. Spacing between Births : Healthy spacing of 3 years improves the
chances of survival of infants and also helps in reducing the impact of population
momentum on population growth. NFHS III data shows that in India, spacing between
two childbirths is less than the recommended period of 3 years in 61% of births.
According to SRS 2012, only 40.3% rural women maintained the gap of 36 months
between the current birth and previous ones
3.07 Total Fertility Rate (TFR)
The Total Fertility Rate (TFR), is the average number of births a women would have
by the time they reach 50 years of age.The TFR is expressed as the average number of
births per woman.Total Fertility Rate (TFR) in the country has recorded a steady
decline to the current levels of 2.4 (SRS 2011).Table below shows the declining TFR
over that years.
Table No.3.5 Total Fertility Rate (TFR) in the country
2775 2776 2777 2778 2779 2717 2711
2.9 2.8 2.7 2.6 2.6 2.5 2.4
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Nationwide, the small family norm is widely accepted (the wanted fertility rate
for India as a whole is 1.9: NFHS-3) and the general awareness of contraception is
almost universal (98% among women and 98.6% among men: NFHS-3).
Both NFHS and DLHS surveys showed that contraceptive use is generally
rising. Contraceptive use among married women (aged 15-49 years) was 56.3% in
NFHS-3 (an increase of 8.1 percentage points from NFHS-2) while corresponding
increase between DLHS-2 and 3 is relatively lesser (from52.5% to 54.0%).Strategies
under family planning programme is given below:
Policy Level Service Level
Target free approach Equal emphasis on both spacing and limiting
methods
Voluntary adoption of Family Planning
Methods
Assuring Quality of services
Based on felt need of the community Expanding Contraceptive choices
Children by choice and not chance
The public sector provides the following contraceptive methods at various levels of
health system6:
Spacing Methods Limiting Methods
IUCD 380 A and Cu IUCD 375 Female Sterilization:
Oral Contraceptive Pills Laparoscopy
Condoms Minilap
Emergency Contraceptive Pills Male Sterilization (No Scalpel Vasectomy)
The TFR for Uttarakhand and district Almora as studied during 2011-12 are given
below:
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Table No.3.6 TFR for Uttarakhand and District Almora
State/District Total Fertility Rate
Total Rural Urban
Uttarakhand 2.1 2.3 1.6
Almora 1.9 - -
Source(Annual Health Survey Fact Sheet,Uttarakhand( 2011-12)
Current Family Planning Practices used by currently married Women in the
age group of 15-49 years in the state of Uttarakhand and district Almora have been
given below:
Table No.3.7 Current Family Planning Practices and Female sterlization
Current Family Planning Practices(Currently married Women)aged 15-49
years(2011-12)
State/District Any method% Any modern method
%
Female Sterlization %
Total Rural Ur1ban Total Rural Urban Total Rural Urban
Uttarakhand 61.7 60.3 65.1 54.1 53.6 55.3 28.1 32.4 17.2
Almora 70.5 70.9 66.4 67.5 67.9 62.8 46.1 47.7 27.0
Source(Annual Health Survey Fact Sheet,Uttarakhand( 2011-12)
Current Family Planning Practices like male sterilization, copper-T and pills
used by currently married Women in the age group of 15-49 years in the state of
Uttarakhand and district Almora are given below:
Table No.3.8 Current Family Planning Practices and Male sterlization
Current Family Planning Practices(Currently married Women)aged 15-49
years(2011-12)
State/District Male sterilization% Copper-T/IUD% Pills %
Total Rural Urban Total Rural Urban Total Rural Urban
Uttarakhand 1.6 1.9 1.1 1.0 0.7 1.7 4.6 4.2 5.5
Almora 5.1 5.4 1.9 0.5 0.4 1.2 2.9 2.6 5.5
Source {Annual Health Survey Fact Sheet,Uttarakhand( 2011-12)}
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Current Family Planning Practices like male condom, emergency
contraceptive pills and any other traditional methods used by currently married
Women in the age group of 15-49 years in the state of Uttarakhand and district
Almora are given below:
Table No.3.9Current Family Planning Practices through Temporary Methods
Current Family Planning Practices(Currently married Women)aged 15-49 years (2011-12)
State/District
Male
Condom/Nirodh%
Emergency
Contraceptive Pills%
Any Traditional
Method%
Total Rural Urban Total Rural Urban Total Rural Urban
Uttarakhand 18.0 13.8 28.7 0.6 0.5 0.6 7.6 6.8 9.9
Almora 12.8 11.6 27.1 0.1 0.1 00 3.0 3.0 3.5
Source {Annual Health Survey Fact Sheet,Uttarakhand( 2011-12)}
3.08 Adolescent Health
Persons in age group of 10-19 years are known as adolescents which
comprises of individuals in a transient phase of life requiring nutrition, education,
counseling and guidance to ensure their development into healthy adults.
Government of India has recognized the importance of influencing health-seeking
behaviour of adolescents. The health situation of this age group is a key determinant
of India's overall health, mortality, morbidity and population growth scenario.
Therefore, investments in adolescent reproductive and sexual health will yield
dividends in terms of delaying age at marriage, reducing incidence of teenage
pregnancy, meeting unmet contraception need, reducing the maternal mortality,
reducing STI incidence and reducing HIV prevalence in. It will also help India realize
its demographic bonus, as healthy adolescents are an important resource for the
economy. In keeping with the spirit of convergence under NRHM, the RCH-II ARSH
strategy emphasizes the need for inter-sectoral linkage with other Departments at the
policy and programme levels to create a supportive environment for adolescent
interventions and to improve awareness levels among adolescents. Relevant schemes
under different departments of the government are mentioned below:
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Women and Child Development:- Kishori Shakti Yojna, Balika Samridhi
Yojana, Rajiv Gandhi Scheme for Empowerment of Adolescent Girls
(SABLA);
Human Resource Development:- Sarva Shiksha Abhiyan; National Population
Education Project , (NPEP); Adolescence Education Program (AEP)
Youth Affairs and Sports:- Adolescent Empowerment Scheme; National Service
Scheme; Nehru Yuva Kendra Sangathan (NYKS) Programs, National Program
for Youth and Adolescent Development (NPYAD).
3.09 Adolescent Reproductive and Sexual Health (ARSH)
The goals of the Government of India RCH-II programme are reduction in
IMR, MMR and TFR. In order to achieve these goals, RCH-II has four technical
strategies. One of these four is Adolescent and reproductive Health. Adolescents are
nation's future and investment in their development is critical. The government of
India has a comprehensive package for meeting the multiple health needs of the
adolescents and offers a roadmap for programmes and priorities that aim to address
adolescent health.The National Adolescent Reproductive and Sexual Health strategy
provides a framework for a range of sexual and reproductive health services to be
provided to the adolescents. The strategy incorporates a core package of services
including preventive, promotive, curative and counseling services. Effective
implementation of policies and programmes has progressed from the past few years
and has lead to strengthening of Adolescent Friendly Counselling centers
(AFCCs)and subsequently the outreach programmes7.
3.10 School Health Programme
The School Health Programme was launched to address the health needs of school
going children and adolescents in the 6-18 year age groups in the Government and
Government aided schools. The programme entails biannual health screening and
early management of disease, disability and common deficiency and linkages with
secondary and tertiary health facilities as required. The School health programme is
the only public sector programmespecifically focused on school age children. Its main
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focus is to address the health needs of children, both physical and mental, and in
addition, it provides for nutrition interventions, yoga facilities and counseling. It
responds to an increased need, increases the efficacy of other investments in child
development, ensures good current and future health, better educational outcomes and
improves social equity and all the services are provided for in a costeffective manner.
The decentralized framework of implementation under NRHM has enabled
various states to devise and implement their own version of School Health
Programme. Components of School Health Program include Health service provisions
like , Micronutrient (Vitamin A andIron Folic
Acid(IFA) management, De-worming, Counseling services, Regular practice of Yoga
and Physical education.Health Management Structure has been provided for in the
guidelines at national, State and District levels.
The NRHM convergence mechanism will apply to this programme as well.
The involvement of MSG, State Health Mission and District Health Mission has been
ensured by placing the school health programme management committees under the
overall supervision/guidance of these overarching structures.
has been placed at making these management committees multi-departmental
involving the functionaries of various related departments/organisations such as
Committees recommended at State, District, Block and School levels is detailed in the
enclosed write-up of the programme. School Health Coordinator on contract basis at
the State and District levels has been provided to support the programme in the areas
of coordination and monitoring and evaluation.
These management committees have been proposed in a manner that they
bring in convergence between related departments/organizations. The main
convergence required in the programme is between the Ministry of Health and Family
Welfare, Ministry of Human Resources Development (MHRD) and Ministry of Rural
Development (MRD). MHRD will be partner in capacity building, IEC, Monitoring
and Evaluation. MRD needs to take care of water, safety education, Sanitation
Education and Garbage disposal waste management. The MoHFW will take care of
screening, health care services, immunization, referral, micronutrient management,
health education, capacity building, monitoring and evaluation, etc.8
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3.11 Rastriya Bal Swasthya Karyakram (RBSK)
RBSKhas been launched in 2013 for child health screening with an objective of
early intervention services to provide comprehensive care to all children in the
community. The purpose of these services is to improve the overall quality of life of
children through early detection of birth defects, diseases, deficiencies, development
delays including disability. Health screening of children is a known intervention is
now being expanded to cover all children from birth to 18 years of age. The
Programme has been initiated as significant progress has already been made in
reducing child mortality under the National Rural Health Mission. However, further
gains can be achieved by early detection and management of conditions in all age
groups. There are also groups of diseases which are very common in children e.g.,
dental caries, otitis media, rheumatic heart disease and reactive airways diseases
which can be cured if detected early. It is understood that early intervention and
management can prevent these conditions to progress into more severe and
debilitating forms, thereby reducing hospitalisation and resulting in improved school
attendance. The ‗Child Health Screening and Early Intervention Services‘ will also
translate into economic benefits in the long run. Timely intervention would not only
halt the condition to deteriorate but would also reduce the out-of-pocket (OOP)
expenditure of the poor and the marginalized population in the country. Additionally,
the Child Health Screening and Early Intervention Services will also provide country-
wide epidemiological data on the 4 Ds (i.e., Defects at birth, Diseases, Deficiencies
and Developmental Delays including Disabilities). Such a data is expected to hold
relevance for future planning of area specific services.9
3.12 Weekly Iron Folic acid Supplementation (WIFS)
Adolescent Anemia is a long standing public health problem in India. Anemia
is caused by Iron deficiency and adolescents are at high risk of Iron deficiency and
thereby anemia due to accelerated growth and body mass building, poor dietary intake
of iron and high rate of worm infestation In girls deficiency of iron is further
aggravated with higher demands with onset of menstruation and also due to the
problem of adolescent pregnancy and conception. The Programme envisages
administration of supervised weekly IFA Supplementation and biannual deworming
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tablets to approximately 13 crore rural and urban adolescents through the platform of
Govt./Govt. aided and municipal school and Anganwadi Kendra and combat the
intergenerational cycle of anemia10
. WIFS Programme has been Started at District
Almora since 2012-13.
3.13Immunization:
Intensification of Routine Immunization, eliminating measles and Japanese
encephalitis related deaths and Polio eradication are the key area to be covered under
universal immunization programme. The strategies for child health intervention
focuses on improving skills of the health care workers, strengthening the health care
infrastructure and involvement of the community through behaviour change
communication.11
During the current study attempts have been made to assess the
implementation and impact of some schemes directly related to the rural women‘s
health in three important stages of her life as a mother, as a wife and as a daughter in
selected villages of district Almora in three development blocks namely Hawalbagh,
Tarikhet and Sult. The details of the findings have been mentioned in the relevant
chapters.
* * * * *
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References :
1. National Health Mission(NHM),Ministry of Health and Family
welfare(MoHFW), Govt of India. Website: nrhm.gov.in
2. Janani Suraksha Yojana (JSY),NHM, MoHFW, Govt of India. Website:
nrhm.gov.in
3. Janani Shishu Suraksha Karyakaram (JSSK),NHM,(MoHFW),Govt of India.
Website: nrhm.gov.in
4. Village Health and Nutrition Day(VHND),NHM,(MoHFW),Govt of India.
Website: nrhm.gov.in
5. Reproductive and Child Health (RCH) camps,NHM,(MoHFW),Govt of India.
Website: nrhm.gov.in
6. Family planning,NHM,(MoHFW),Govt of India. Website: nrhm.gov.in
7. Adolescent Reproductive and Sexual Health (ARSH),NHM,(MoHFW),Govt
of India. Website: nrhm.gov.in
8. The School Health Programme,NHM,(MoHFW),Govt of India. Website:
nrhm.gov.in
9. Rastriya Bal Swasthya Karyakram (RBSK),NHM,(MoHFW),Govt of
India.Website: nrhm.gov.in
10. Weekly Iron Folic acid Supplementation(WIFS),NHM,(MoHFW),Govt of
India.Website: nrhm.gov.in
11. Immunization,NHM,(MoHFW),Govt of India.Website: nrhm.gov.in
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