Programme, Implementation and its Critical Appraisal

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Programme, Implementation and its Critical Appraisal

Rural Economic Policy & EnvironmentTerm Paper

LG-8 _ REEP Term Paper on NRHM

What is NRHM? Need Of NRHM NRHM - The Programme NRHM - Its Implementation Progress So Far Critical Appraisal of NRHM

Flow of Presentation

2 LG-8 _ REEP Term Paper on NRHM

What is

National Rural Health Mission

(NRHM)?


About NRHMLaunched by the UPA government in 2005In view of the promises made under National Common

Minimum Programme (NCMP)The targets to be achieved were framed keeping in mind

the Millennium Development Goals (MDGs) of United Nations.

The most comprehensive programme on health implemented till date in India both in terms of allocations and scale of operations.

The Mission is conceived as an umbrella programme subsuming the existing programmes of health and family welfare, including the RCH II, National Disease Control Programmes for Malaria, TB, Kala Azar, Filaria, Blindness & Iodine Deficiency and Integrated Disease Surveillance Programme.


Needfor

National Rural Health Mission (NRHM)


Changes in Status of Health – Over the YearsDemographicChanges

1951 1981 2004

Life Expectancy 36.7 54 64.6Crude Birth Rate 40.8 33.9 26.1Crude Death Rate 25 12.5 8.7Infant Mortality Rate

146 110 70

Health Infrastructure

1951 1981 2004

SC/PHC/CHC 725 57, 363 163, 181Dispensaries & Hospitals (all)

9209 23, 555 43, 322

Beds (Private & Public)

117, 198 569, 495 870, 161

Doctors (Allopathic)

61, 800 268, 700 503, 900

Nursing Personnel 18, 054 143, 887 737, 0006 LG-8 _ REEP Term Paper on NRHM

Epidemiological Shifts 1951 1981 2004Malaria (cases in millions)

75 2.7 2.2

Leprosy (per 10,000 population)

38.1 57.3 3.74

Small Pox (nos. of cases)

45,000 Eradicated

Guinea worm 40, 000 EradicatedPolio 29, 709 265

Changes in Status of Health – Over the Years


Disparities in Status of Health – Rural & Urban

Category Population BPL

(%)

IMR (per 1000 Live

Births)

Under 5 Mortality (per 1000)

MMR (per

Lakh)

Leprosy case

per 10, 000

Malaria +ve case (in

‘000)India 26.1 70 94.9 408 3.7 2200Rural 27.09 75 103.7 - - -Urban 23.62 44 63.1 - - -


Better Performing States

Population BPL (%)

IMR (per 1000 Live Births)

<5 Mortality (per 1000)

MMR (per Lakh)

Leprosy case per 10, 000

Malaria +ve cases (in ‘000)

Kerala 12.72 14 18.8 87 0.9 5.1Maharashtra

25.02 48 58.1 135 3.1 138

Tamil Nadu

21.12 52 63.3 79 4.1 56Worst Performing States

Population BPL (%)

IMR (per 1000 Live Births)

<5 Mortality (per 1000)

MMR (per Lakh)

Leprosy case per 10, 000

Malaria +ve case (in ‘000)

Orissa 47.15 97 104.4 498 7.05 483Bihar 42.60 63 105.1 707 11.83 132Rajasthan 15.28 81 114.9 607 0.8 53Uttar Pradesh

31.15 84 122.5 707 4.3 99

M. P. 37.43 90 137.6 498 3.83 528

Disparities in Status of Health – Inter Regional


Section Infant Mortality/10

00

Under 5 Mortality/100

0

% Children Underweig

htIndia 70 94.9 47Scheduled Caste 83 119.3 53.5Scheduled Tribe 84.2 126.6 55.9Other Disadvantaged Sections

76 103.1 47.3Country % of

Population <$1/day

Infant Mortality Rate/1000

% of Health

Expenditure to GDP

Public Expenditure(% of Total

Exp.)India 44.2 70 5.2 17.3China 18.5 31 2.7 24.9Sri Lanka 6.6 16 3 45.4UK - 6 5.8 96.9USA - 7 13.7 44.1

Disparities in Status of Health – Inter Caste & Countries


Health Expenditure – Over the Years


Daunting Challenges The morbidity and mortality levels in the country are still

unacceptably high. 35% of infants are not fully immunised (90% in Bihar, 81% in UP).

The persistent incidence of macro and micro nutrient efficiencies especially among women and children. The incidence of the more deadly P-Falciparum Malaria has risen

to about 50 percent in the country as a whole. TB – cases 85 lakhs; 2 lakhs die each year. There is a distressing

trend in the increase of drug resistance to the type of infection.The common water-borne infections – Gastroenteritis, Cholera,

and some forms of Hepatitis – continue to contribute to a high level of morbidity in the population. Diarrhoea – leading cause of child deaths; 19.2% children below the 3 years of age suffer from diarrhoea


Daunting Challenges An increase in mortality through ‘life-style’ diseases - diabetes, cancer and cardiovascular diseases. Diabetic patients – 3.3. Crores; 50,000

loose their legs. Cancer – 75 lakhs diagnosed each year Cardiovascular diseases – 3.8 crores. HIV/AIDS cases 51 lakhs (2nd highest in world) The increase in life expectancy has increased the requirement for

geriatric care. Conflict of interest of different systems of medicine Allopathy,

Ayurveda, Siddha, Unani and Homeopathy. The increasing burden of trauma cases is also a significant public

health problem.13 LG-8 _ REEP Term Paper on NRHM

National Rural Health Mission (NRHM)

The Programme


NRHM – The Programme Goal : To improve the availability of and access to quality health care by people, especially for those residing in rural areas, the poor, women and children. Objectives:

Reduction in IMR and MMR Universal access to public health services such as Women’s health,

child health, water, sanitation & hygiene, immunization, and Nutrition.

Prevention and control of communicable and non-communicable diseases, including locally endemic diseases

Access to integrated comprehensive primary healthcare Population stabilization, gender and demographic balance. Revitalize local health traditions and mainstream AYUSH Promotion of healthy life styles


NRHM – Components


Dept. of family welfare

Dept. of women and

child

National mission steering

State health mission

District health mission

Block coordination

VHCGram

ASHA

AWMANMCLIENTS

Gram panchayat

The Institutional Structure

Service provider


Stakeholders Involved

NRHM

Government of India

People

External /Funding Agencies-

UNICEF, WHO, UNDAF, UNOPS

etc

NGOs

PRIs

State Govt. and

District Administrati

on


Fund Flow Plan The Budget Head for NRHM shall be created in B.E. 2006-07 at National and State levels.

The Outlay of the NRHM for 2005-06 is in the range of Rs.6700 crores.

The Mission envisages an additionality of 30% over existing Annual Budgetary Outlays, every year, to fulfill the mandate of the National Common Minimum Programme to raise the Outlays for Public Health from 0.9% of GDP to 2-3% of GDP

The States are expected to raise their contributions to Public Health Budget by minimum 10% p.a. to support the Mission activities.

Funds shall be released to States, largely in the form of Financial Envelopes, with weightage to 18 high focus States.


Rapid FrameworkPolitical Context

•Key actors: GOI, State govt. NGOs , WHO•Political environment:Poor status of health sectorNCMP of UPA Govt.MDG of UN

Government Spending Is 0.9% of GDP

• Poor quality of services • Health status below MDGs target• HDI Rank-126

GOI , State Govt. , District administration, PRIs, NGOsWHO, UNICEF,

Evidences

Links


Progress So Far Based on

Government Claims


Progress so far Accessibility– has increased significantly in all

states more than 500% increase in some of the states like Bihar 36% improvement in Cataract operation cases 11% increase in TB detection 25% increase in students health check up in schools

Institutional deliveries NRHM practices decentralized procurement in line with

various Public and private organization for better delivery Has insured availability of essential medicines and

equipments in most of the areas For example, in Malkangiri and Koraput, institutional delivery

has improved from 88 to 149 and 97 to 169 respectively


Immunization program Serious attempts have been made to increase coverage as well

as quality of services. Providing subsidies for immunization sessions and alternate

vaccine delivery 15% improvement in immunization in terms of numbers

Monthly health days More than 10 lakhs monthly health days have been

organized Has significantly improved health as well as awareness

level of the women

Resident Community workers/functional Sub Centers More than 4.35 lakhs ASHA workers have been selected More than 2.400 PHC have been made 24X7 MMU In 314 district to reach remote areas

Progress so far


Partnerships with Non Governmental organizations More than 300 organizations are associated with NRHM NGOs are playing a very important role in facilitating ASHAs and

community wnd in their capacity building efforts

Capacity building initiatives More than 1,200 professionals have been appointed Better program management, monitoring and evaluation.

Progress so far


Critical Appraisal of NRHM


Shortcomings of the Programme – As Identified by Critics

No ‘New Deal’ for Rural Poor Problems identified with implementation of

NRHM – Based on the Survey conducted by Jan Swasthya Abhiyaan (JSA)

Critical Appraisal of NRHM


Shortcomings of the Programme

Has not taken cue out of earlier similar failed efforts

A similar effort by Janata Party government of appointment of

community health volunteer (CHV) for every 1,000 persons, along

with setting up of a trained dai in every village, which at one stage

had more than Rs.4,50,000 workers, could not be sustained because

of the nature of the power structure in villages.

No provision for training and imparting skills Developing facilities for education and training of

managerial physicians, who have the epidemiological, managerial,

social and political competence to provide leadership in the administration of the health services in the country, ought

to have found a key place in the Mission Document


No background work has been done before the implementation

The central task for the NRHM was to produce data which would enable the MOHFW to devise the mechanism(s) to make most effective use of the resources required to find ways of optimising use of resources under given conditions However, NRHM has produced little supportive data for carrying out its elaborate plan of action, which encompass a number of key components – technical support mechanisms, including conceptualisation of a programme management support centre and health trust of India, role of the central and state government machinery, panchayati raj institutions, NGOs and paying attention to special problems of the north-eastern states and mainstreaming Ayurveda, Yoga, Unani, Siddha and Homeopathy (AYUSH).

Shortcomings of the Programme


No ‘New Deal’ for Rural Poor The budget heads for the NRHM do not address the

missing link in rural healthcare – medical care. Allocations to rural health would be restricted to the

NRHM; any other source of funds for rural health may get blocked. The danger is that the NRHM may become an amalgamated vertical health programme for rural areas!

The key issue in access to healthcare that even the NRHM fails to address is the mechanism for allocating resources.

Resources are presently distributed on the basis of what is available, what can be procured and where they can be parked in terms of infrastructure, human resources, etc.


Problems identified with implementation of NRHM Working of ASHAs They are engaged solely in RCH-related work, including mobilizing for immunization and pulse polio immunization. All this goes against the very conceptualisaton of ASHA as an `activist’; and she was not meant to provide services, other than some basic ones.

Untied funds to the sub-centres At least 50 % of the sub-centers have not received the

untied grant. Of those who have received, only about 50 % have

spent it, on items like building repairs, purchase of furniture30 LG-8 _ REEP Term Paper on NRHM

The ANMs, in the survey conducted by JSA, pointed out That the untied fund is of no use as there are many

problems at sub-centre level like - Lack of building, water, electricity and toilets;

Problems in supply of medicines, syringes and vaccines – not regular, do not get on time; have to go to PHC to pick them up; Lack of doctor and other staff, especially MPW; Problems in traveling from village-to-village, especially to isolated villages; have to walk; Lack of co-operation from panchayat and problem of salary.

Problems identified with implementation of NRHM


Decentralised Planning - Non Starter With a grant of Rs. 10 lakhs, all districts expected to have completed preparation of District Health Plan by March 2007. However, the necessary groundwork for preparation of District Action Plans do not exist .

Jugglery of allocations Budget heads have been merely shifted/re-positioned and placed under NRHM. The allocations continue to follow the earlier trends – Family Welfare getting more than the Health component; RCH II component and the pulse polio programmes continue to be at the centre of all health

allocations

Problems identified with implementation of NRHM


References Mission document, National rural health mission (2005-12) National Health Policy Document (2002) Banerjee,Debabar; Politics of rural health in India, Economic and political weekly; July 23, 2005, p.p3253-3258. Shiva kumar, A.K.; Budgeting for health, Economic and political weekly; April 2 , 2005; p.p.1391-1396 Duggal, Ravi. ; Is the trend in health changing? , Economic and political weekly; April 8, 2006, p.p. 1335-1338 Framework for implementation, National Rural Health Mission, Ministry of health and family welfare, Government of India,(2005-12) Reports of the Peoples’ rural health watch-Jan Swasthya Abhiyaan; June 2000, Health services and the National Rural Health Mission-An Interim Stock taking. http://mohfw.nic.in/nrhm.htm


Thank You Presentation By LG-8 Shubha (49) Nikash Anand (22) Praful Ranjan (28) Vibhas Chandra (56) Rakesh Kumar Panda (34) Harendra Pratap Singh Raghuwanshi (17)


Programme, Implementation and its Critical Appraisal

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