Components of National Rural Health Mission: Civil Services Mentor Magazine September 2012

Rural Health Care forms an integral part of the National Health Care System. Provision of Primary Health Care is the foundation of all rural health care Programmes. For developing vast public health infrastructure and human resources of the country, accelerating the socio-economic development and attaining improved quality of life, the Primary health care is accepted as one of the main instruments of action. Thus, recognizing the importance of Health in the process of economic and social development and improving the quality of life of our citizens, the Government of India has launched the National Rural Health Mission to carry out necessary architectural correction in the basic health care delivery system. The Mission adopts a synergistic approach by relating health to determinants of good health viz. segments of nutrition, sanitation, hygiene and safe drinking water. It also aims at mainstreaming the Indian systems of medicine to facilitate health care. The National Rural Health Mission (NRHM), a National effort at ensuring effective healthcare, especially to the poor and vulnerable sections of the society was launched (on 12th April, 2005 for a period of seven years (2005- 2012)) throughout the Country with special focus on 18 states viz. 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. The major objectives or National Rural Health Mission was to ensure the following issues: ¨ Development of Infrastructure of state governments

• Availability of critical manpower
• Reach of mobile medical vans
• Mainstreaming AYUSH (the Homeopathic and Ayurvedic doctors)

• Coordination with community by ASHA (trained female community health activist – ‘ASHA’ or Accredited Social Health Activist. Selected from the village itself and accountable to it, the ASHA will be trained to work as an interface between the community and the public health system).

• Implementation of MIS
• Implementation of public – private partnership
• Inter-sectoral coordination
• Appropriateness of expenditure planning
• Penetration of health insurance

THE PURPOSE

The purpose of NRHM among other things was to strengthen the primary health centres (PHCs) and subcentres and creates a network of rural hospitals. However it was felt that several developments since the launch of the NRHM in April 2005 point to increased privatization of health care services. For instance in several states the NRHM under the garb of better health management opened up space to outsourcing and privatization of PHCs and subcentres.

THE CRITICISM

The NRHM is criticized for adopting a system of Indian Public Health Standards which was seen as having severe limitations. While it defined the minimum manpower requirement and the equipment and infrastructure needed to attain a set of well defined health outcomes the attempts to achieve these were not comprehensive in scope and were biased largely towards reproductive and child health. The IPHS was adopted for CHCs, PHCs and district hospitals as well. However the emphasis was still on purchasing equipment and attaining standards of infrastructure development rather than raising the level of overall service provision.

IMPLEMENTATION

The policy in some states of allowing public participation in the monitoring and administration of health care services also backfired. The Rogi Kalyan samities that were started with the intent of greater public participation in the health care system degenerated into a system of cost recovery with the introduction of user fee for many services in government hospitals. Donor agencies pushed for the user -fee system and this resulted in a reduction of state investment in the maintenance of health care facilities. The public participation has been trivialized: it translated into better access for the privileged  and the politically powerful. Urban health statistics revealed that in many states the key indicators such as urban infant mortality rate had remained stagnant or their trend had even reversed. The specific vulnerability of urban slum dwellers the lack of basic amenities and health services for them was an area yet to be addressed. The NRHM was formally empowered to cover urban slums but in reality the coverage was negligible.  Whatever urban component was there in health care ,it was in the RCH plans in a limited manner.There was no equivalent plan to set up PHCs,CHCs or sub centres in urban areas.

COMPONENTS

Accredited Social Health Activists (ASHA)

The NRHM covers all the villages through villagebased ”Accredited Social Health Activists” (ASHA) who would act as a link between the health centers and the villagers. One ASHA will be raised from every village or cluster of villages. The ASHA would be trained to advise villagers about Sanitation, Hygiene, Contraception, and Immunization to provide Primary Medical Care for Diarrhea, Minor Injuries, and Fevers; and to escort patients to Medical Centers. They would also deliver Directly Observed Treatment Short (DOTS) course for tuberculosis and oral rehydration; distribute folic acid tablets and chloroquine to patients and alert authorities to unusual outbreaks. Although these ASHAs would be honorary volunteers, there is a provision to provide them with performance-based compensation for undertaking specific health or other social sector programmes with measurable outputs, thus promoting employment for these volunteers. If rural women want counseling on important issues such as birth preparedness, importance of safe delivery, breastfeeding and complementary feeding, immunization, contraception and prevention of common infections including Reproductive Tract Infection/ Sexually Transmitted Infection (RTIs/STIs) and care of the young child, they may contact the concerned ASHA who shall be happy to provide them with all relevant guidance and assistance. The general norm as decided under the Programme is ‘One ASHA per 1000 population’. In tribal, hilly, desert areas the norm could be relaxed to one ASHA per habitation, dependant on workload etc.

JANANI SURAKSHA YOJANA (JSY)

Janani Surakha Yojana is another important component under NRHM. JSY is a centrally sponsored scheme to benefit pregnant women & certified poor families.

The Government has introduced the Janani Suraksha Yojana to provide comprehensive medical care during pregnancy, child birth and postnatal care and thereby endeavour to improve the level of institutional deliveries in low performing states to reduce maternal mortality. The NRHM provides broad operational framework for the Health Sector. Suggestive guidelines have been issued on key interventions like institutional deliveries, immunization, preparation of District Action Plan as well as schemes including ASHA, JSY etc. The States have the flexibility to project operational modalities in their State Action Plans. It is envisaged that National Rural Health Mission shall be able to effectively improve the availability of and access to quality health care by people, especially for those residing in rural areas, the poor, women and children.

OTHER STEPS

One of the remarkable steps taken under of NRHM is mainstreaming of AYUSH into the rural health system, and thereby, integration of practitioners of Indian System of Medicine with the existing Modern System of Medicine. Though, conceptually these sounds in rhythm, nonetheless, it is not free from threats. The mission is posting of one AYUSH doctor at each PHC in addition to an existing allopathic doctor. This raises concerns about the possibility that instead of practicing with their own skills, AYUSH doctors are complained to be over prescribing allopathic medicines, even antibiotics for early recovery of patients, without having the requisite knowledge or training which may result in calamity. Hence, it would be essential to make sure that the AYUSH physicians in PHCs are provided with the appropriate facilities, infrastructure and medications support , so that they can carry out with the system of  medicine they have been trained in with complete efficacy. Additionally, if AYUSH physicians are really need to prescribe some basic or emergency allopathic care in exigencies, then this should be an unambiguous pronouncement to be taken after appropriate consultation with concerned authorities and experts in the field, keeping all pros and cons into consideration. If AYUSH doctors are allowed to prescribe basic or life saving allopathic medicines, it would be crucial to train them properly in this direction. Thought should also be given on the motivational factors of an AYUSH doctor likely to work in a primarily allopathic set-up.

ASHA is working in a fantastic manner in terms of Janani Suraksha Yojana, sanitation and other responsibilities. However, in terms of promoting communitybased health insurance ASHA is yet to go a long way. Participation in community financing schemes requires resources, i.e. time and money, which the most disadvantaged group in societies often does not possess. Donors and policy makers should hence be aware that it might be very difficult, even impossible, to reach the poorest part of the population when promoting participation in these kind of local organizations. In order to both promote these initiatives and lower the barriers of participation, well-targeted subsidies and a linkage to social funds is a possible solution. As one major objective of social funds is to finance investments benefiting the poor and, since in most parts it is the public sector, which administers social funds, such a support would also strengthen the linkage to more formalized health care systems.

This suggests that, further research is needed, how these schemes can be scaled up and replicated as well as how to link them to social risk management instruments, e.g. social funds to broaden the risk pool and increasing coverage rates. Future research should also address the question of how subsidies for the poorest in a community can be designed in order to preserve the incentives for a viable management of the schemes and to achieve optimal targeting. In addition, more research is needed on other promising measures to fight social exclusion in access to social protection in low income environments. Finally, we can say that there is an immense need for massive propaganda to develop consciousness among the people regarding the need for financing health care in context of high outof- pocket expenses on health. If we can successfully use insurance in  covering our health hazards, we might create headway in front of the entire Southeast Asia to come up with a solution to this formidable challenge to the society.

It is beyond any doubt that, the wealth of a country is judged by the health of its people. Worldwide, nations are seeking viable answers to the question of how to offer a health care system, which leads to universal access to health care for their citizens. Admittance of healthy living conditions and good quality health is not only fundamental rights for each and every Indian, but also crucial factor for socio-economic maturity of the nation. The country’s policy towards health has been traditionally identified by the provision of primary healthcare as the states responsibility. The policy also encouraged the establishment of a countrywide, state-run primary care infrastructure. The role of the central government has been mainly limited to family welfare programmes and design of disease control programmes. The policy has remained silent on the role of the private sector in provision of medical care. Notwithstanding to this, the private medical care sectors have developed to meet the increasing demand for medical care services. Some isolated evidences of the community-based health care and its financing options have been reported, like Self Employed Women’s Association in Gujarat, Yeswashini Trust in Karnataka, and ACCORD in Nilgiri district in Maharashtra.

However, in absence of nationwide consensus, huge literacy or existence of extensive high quality health care network as Japan their success is limited only in the boundaries of the pioneering districts. Even the highly subsidized Universal Health Insurance Scheme announced by Government of India and administered by the Governmentowned Insurance Companies has resulted in a serious market failure. From the Indian Health care system it can be concluded that the state uses a collaborative approach, which involves financial support, strategic planning, and health prioritizing legislation that involves the government, community leaders, and private and public health care professionals. It is to be mentioned that the State Governments largely comply with the Indian structure of rural health care system consisting of primary health centres, sub-centres, and community health centres for rural health care. NGOs working in health care front are hardly found. Nonetheless, the total physical infrastructure available for rural health care in the state is still inadequate relative to its requirement. Moreover, there exists a large disparity in the availability of health care infrastructure and work force between the urban and the rural areas. 84 % percent of hospitals in India are sited in urban areas, which only account for roughly 35% of the population (Ravi Duggal, 1995).

Nearly, 75 % of allopathic doctors are positioned in urban areas. In the State of India, the availability of the recognized medical practitioners in rural areas is only 27 per lakh population whereas is the urban area it is 155 per lakh population. The kind of lopsided distribution of medical professionals in India, with a trifling proportion of medical practitioners ready to work in rural areas, is at the heart of the poor health care system of rural areas. In fact, the lacunae of the India rural medical system have become apparent within the last decade as economics forced hospitals to run with inadequate infrastructural facilities in the hospital care system and reducing staff, thereby reducing clients’ admittance to timely services. In fact, this kind of economical or political and social disparity across the population groups in a given society will naturally have a direct comportment on the health indicators. Nonetheless, if the infant and maternal mortality rates (IMR and MMR) can be considered as the most sensitive indicators of health of the society, then the Indian statistics in this front is really alarming. Around 2.2 million infants die every year. Keeping this into consideration, the National Health Policy 1983 had set target to restrict the Infant Mortality Rate to less than 60 per 1000 live births. Nonetheless, this target is yet to be achieved. In the year 2000, the National Health Policy further targeted to reduce Maternal Mortality Rate to less than 200 per 100,000 live births. But, this target also has also not been achieved yet. Till date, according to the UNDP reports, on an average 407 mothers in India die due to pregnancy related causes, for every 100,000 live births. On the contrary, as per the three rounds of National Family Health Surveys, in the last decade Maternal Mortality Rate has further reached to 540 maternal deaths per 100,000 live births.

ASHA plan conceived as an important component of NRHM was a let down due to deemphasizing of the workers’ curative and symptomatic roles and the piece rate system of payment .While the strategy of deploying ASHAs was plausible what had not been anticipated was the inability of the existing departmental structures to implement such a large scale mobilization and the absence of support structures. The implementation of the ASHA plan was poor. The NRHM was a compulsion to show the pro-poor face of the new government. It has been found during a study conducted by Jan Swasthya Abhiyan that most of the ASHAs had yet to start work; the Anganwadi worker or the Auxiliary Nurse Midwife allocated them work. Under the NRHM the ASHA was required to be accountable to the community and not subservient to the ANM or AWW.Dalit health workers were discriminated against. In MP nearly 50% of the PHCs surveyed were being managed by non medical staff, in Bihar 30%, in Rajasthan 25% and in Jharkhand 12%.The main problems plaguing  PHCs related to improper drug supply and shortage of staff. In many of the states the PHCs and even some of the CHCs had been contracted out to NGOs under the managed care approach. This system which is in vogue in Bihar, Karnataka and Arunchal Pradesh  entailed the offering of a specified package of services. There is no notion of decentralization and community management. In Gujarat under the Chiranjeevi Programme private clinics are reimbursed at fixed rates for institutional deliveries and emergency obstetric care services. The government has also contracted out peripheral health facilities and has a proposal to contract out district hospitals to  corporates. Some of the private health insurance schemes supported by state governments had failed. However in some states such as Tamil Nadu and West Bengal the partnership is working well. The core of the public health system stayed within the public domain and only some of the ancillary services were contracted out.

According to Jan Kalyan Abhiyan a vast network of government run health subcentres and PHCs supported by CHCs and district hospitals is required along with a large community -healthworker force, the expansion of nursing staff and the upgrading of their skills. The notion of primary health care continues to be limited in that it is applied to RCH and a few disease control programmes.There is still reluctance to move towards the goal of comprehensive primary health care. The health policy is silent on is the need to set up a rational drug policy. All policies including NRHM had glossed over this aspect despite the fact that nearly 2/3 of all health costs go into drugs. There is no regulation of the prices of essential drugs whose list had been brought down to 30 in 2002 from 347 in 1977.

There has been lot of importance given to two vaccination initiatives-pulse polio and universal Hepatitis B vaccination. More than Rs 1000 crore is spent annually on the pulse polio programme while the budget for other vaccines in the National Immunization Programme in 2005- 06 was only Rs 327 crore. The objectives of any health policy have to be seen in the light of the Alma Ata declaration where health was not just a desired goal but one of the main harbingers of equity in society. The government’s intent in bringing changes to the health care system may be good but their implementation seems to be directed by donor directed priorities.

CONCLUSION

It needs hardly any mention that health care in the rural India is the responsibility of the community as a whole. A collaborative approach, which involves financial support, strategic planning, and health prioritizing legislation involves the government, community leaders, and private and public health care professionals is highly essential, as mentioned in the introduction part. Faults of the Indian rural health care system, these days have become so much apparent within the last decade as economics forced hospitals to run with inadequate infrastructure facilities in the hospital care system and reducing staff, thereby reducing patients’ access to timely services.

Sudhakar Pradhan