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

Components of National Rural Health Mission

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


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