Programme, Implementation and its Critical Appraisal

1
Rural Economic Policy Environment Term Paper
Programme, Implementation and its Critical
Appraisal
2
Flow of Presentation

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

3

• What
• is
• National Rural Health Mission
• (NRHM)?

4
About NRHM

• Launched by the UPA government in 2005
• In 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.

5

• Need
• for
• National Rural Health Mission
• (NRHM)

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Changes in Status of Health
Over the Years
Demographic Changes 1951 1981 2004
Life Expectancy 36.7 54 64.6
Crude Birth Rate 40.8 33.9 26.1
Crude Death Rate 25 12.5 8.7
Infant Mortality Rate 146 110 70
Health Infrastructure 1951 1981 2004
SC/PHC/CHC 725 57, 363 163, 181
Dispensaries 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, 000
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Changes in Status of Health
Over the Years
Epidemiological Shifts 1951 1981 2004
Malaria (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 Eradicated
Polio 29, 709 265
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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 2200
Rural 27.09 75 103.7 - - -
Urban 23.62 44 63.1 - - -
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Disparities in Status of Health Inter Regional
Better Performing States Population BPL () IMR (per 1000 Live Births) lt5 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 5.1
Maharashtra 25.02 48 58.1 135 3.1 138
Tamil Nadu 21.12 52 63.3 79 4.1 56
Worst Performing States Population BPL () IMR (per 1000 Live Births) lt5 Mortality (per 1000) MMR (per Lakh) Leprosy case per 10, 000 Malaria ve case (in 000)
Orissa 47.15 97 104.4 498 7.05 483
Bihar 42.60 63 105.1 707 11.83 132
Rajasthan 15.28 81 114.9 607 0.8 53
Uttar Pradesh 31.15 84 122.5 707 4.3 99
M. P. 37.43 90 137.6 498 3.83 528
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Disparities in Status of Health Inter Caste
Countries
Section Infant Mortality/1000 Under 5 Mortality/1000 Children Underweight
India 70 94.9 47
Scheduled Caste 83 119.3 53.5
Scheduled Tribe 84.2 126.6 55.9
Other Disadvantaged Sections 76 103.1 47.3
Country of Population lt1/day Infant Mortality Rate/1000 of Health Expenditure to GDP Public Expenditure ( of Total Exp.)
India 44.2 70 5.2 17.3
China 18.5 31 2.7 24.9
Sri Lanka 6.6 16 3 45.4
UK - 6 5.8 96.9
USA - 7 13.7 44.1
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Health Expenditure Over
the Years
Year 1996 1997 1998 1999 2000 2001 2002 2003 2004
Health Exp. 4.0 4.3 4.3 4.0 4.3 4.5 4.8 4.9 5.0
Govt. Exp. 24.6 23.5 22.0 22.7 20.9 19.2 17.8 17.1 17.3
Private Exp. 75.4 76.5 78.0 77.3 79.1 80.8 82.2 82.9 82.7
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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

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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.

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• National Rural Health Mission
• (NRHM)
• The Programme

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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 Womens 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

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NRHM Components
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The Institutional Structure
National mission steering
State health mission
Dept. of family welfare
Dept. of women and child
District health mission
Block coordination
Gram panchayat
VHC
Gram
Service provider
AWM
ANM
CLIENTS
ASHA
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Stakeholders Involved

• Government of India

• NGOs

• State Govt.
• and
• District Administration

NRHM

• External /Funding Agencies- UNICEF, WHO, UNDAF,
  UNOPS etc

• PRIs

• People

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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.

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Rapid Framework
Political Context
Evidences

• Key actors GOI, State govt. NGOs , WHO
• Political environment
• Poor status of health sector
• NCMP 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

Links
GOI , State Govt. , District administration,
PRIs, NGOs WHO, UNICEF,
21

• Progress So Far
• Based on
• Government Claims

22
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

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Progress so far

• 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

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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.

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• Critical
• Appraisal
• of NRHM

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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)

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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

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Shortcomings of the Programme

• 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).

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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.

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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 furniture

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Problems identified with implementation of 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.

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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

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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

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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)