National Rural Health Mission (NRHM)€¦ · Central University of South Bihar Lecture Notes Note: This is for teaching purpose at CUSB 1 . Key points •Key components of NRHM •Status

National Rural Health Mission (NRHM)

MADVS3003E04:Public Health Systems and

Management

Dr. Anju Helen Bara Department of Development Studies

Central University of South Bihar Lecture Notes

Note: This is for teaching purpose at CUSB 1

Key points

• Key components of NRHM

• Status of Rural Health Services

• Detailed discussion on three major components:

– Decentralisation,

– Community Mobilisation,

– Rogi Kalyan Samitis

– ASHAs workers

– Note: Various journals, books, websites has been used to prepare this lecture note


Introduction

• The Alma-Ata Declaration in 1978 called on all

governments to “formulate national policies, strategies and plans of action to launch and sustain primary health care as part of a comprehensive national health system”. Indian public health owes its framework to the Bhore Committee's (headed by Joseph Bhore in 1943)

• The Bhore committee suggested an elaborate health centre netw;ork with free health care delivery system;

• This top-down western model could not fully penetrate the entire country due to lack of funds (Ashtekar, 2008);


• The Indian National Health Policy 2002 recognised the sorry health situation and suggested a basket of reforms from co-opting rural doctors to medical tourism. – The policy recognizes that there is wide inter-State disparity

which implies that for vulnerable sections of society access to public health services is minimal and health standards are totally inadequate.

– The policy envisages a key role for the Central Government in designing national programmes with the active participation of the State Governments. It calls for a greater participation of civil society organisations and community.

– The approach would be to increase access to the decentralized public health system by establishing new infrastructure in deficient areas, and by upgrading the infrastructure in the existing institutions.

– (refer: National Health Policy, 2020)


• The Millennium Development Goals (MDGs) replaced the Health for All 2000 plan with a selective health agenda.

• MDGs aim for universal health (MDG report, 2005) – Goal 4: Reduce Child Mortality – Goal 5: Improve Maternal Health – Goal 6: Combat HIV/AIDs, malaria and other diseases

• National Rural Health Mission (NRHM) launched in 2005 by the United Progressive Alliance government set out to out to attain the MDGs with "architectural corrections" in the health system .

• NRHM aims to provide accessible, affordable and quality health care to all. It aims to bring effective healthcare through a range of interventions at individual, household, community.


Objectives of NRHM

• To improve the availability of and access to quality health

care by people • Strengthening Rural Public Health Facilities • To reduce infant mortality and maternal mortality rates

following the MDGs. – Expected to be achieved through promoting

institutional births and thereby protecting both the mother and the new born. Accredited Social Health Activist (ASHA) workers; Janani Suraksha Yojana (JSY).

– Improvement of Health centres – Community Participation


Provisions of NRHM

• Effective healthcare and universal access to rural population with special focus on 18 states,

• Architectural correction of the health system

• Decentralisation of programmes and population stabilisation.

• Appointment of Accredited Social Health Activist (ASHA) to facilitate access to health services (Ashtekar, 2008; Dagupta and Qadeer, 2005)


• NRHM has a three-pronged strategy of (a) community involvement, (b) decentralisation to panchayati raj institutions-zilla parishads, and (c) programme management units in each district.

• Public-Private Partnerships

• Village Health and Sanitation Committees (VHSC)-Community Participation


Status of Rural Health Facilities

• Deficiencies in physical infrastructure

• Shortage of equipment and medicine

• Deficiencies in manpower

• Problem of access and availability • (for more details refer to the lecture notes on rural health

systems)


Deficiencies in Physical Infrastructure

• Lack of infrastructures in most of the states;

• Absence of toilet facilities and medical waste disposal system in many SCs, PHCs, CHCs;

• General cleanliness is poor

• (refer: Husain, 2011)


Mainstreaming Indigenous Health Systems

• In order to meet the manpower and drug shortage in rural areas, the NRHM seeks to revitalise local health traditions and mainstream AYUSH infrastructure.

– AYUSH medicine/ drug kit provided to ASHAs, PHCs, CHCs etc

– AYUSH practitioners/pharmacist being available in SCs, PHCs, CHCs


• The health management information system (HMIS) data reveals that AYUSH staff has been integrated in only 49% of the district hospitals, 37% of the CHCs and 29% of the PHCs (Hussain, 2011).

• Although AYUSH can provide effective remedies in the case of minor ailments, but they do not jave the skill in cases of surgery and extreme life threatening conditions.

• Hussain (2011) argues that AYUSH cannot substitute allopathic staff.


Decentralising Health Sector

• NRHM recognizes the importance of grassroots involvement of health care system.

• NRHM focuses on the involvement of gram panchayats.

• Gram Panchayats-decentralisation facilitates the integrated delivery of health services through the convergence of services like drinking water, sanitation, nutrition, empowerment etc that are of crucial importance in ensuring a healthy population (Gulati et al, 2009).


How it works • Under NRHM, a district has been recognized as the most

important operational level for ensuring provision of primary health care.

• One of the key strategies is the preparation of need-based district health plans through intensive participation and consultation among the key stakeholders, which includes the PRI, civil society and the concerned government departments.

• The PRIs from the village to the district level are engaged in the preparation of Integrated health action plan.

• The district level plans are made in consultations from block level and village level. Thus, it follows a bottom up approach.

• The CHC and PHC will involve the elected members of the panchayati raj in their management through the Rogi Kalyan Samitis, the SC will be accountable to the gram panchayat (GP) through the local committee under the village health and sanitation committee (VHSC) (Dwivedi and Mukherjee, 2011)


• District health action plan integrates the various interrelated components of health to ensure quality of care and access to service . They work on the following issues:

• Resources – health manpower, logistics and supplies, community resources and financial resources, voluntary sector health resources

• Access to services – public and private services as well as informal health care services; levels of integration of services within public health system

• Utilization of services – continuity of care, factors responsible for possible low utilization of public health system

• Quality of care – technical competence, interpersonal communication, and client satisfaction, client participation in management, accountability and redress mechanisms

• Community – needs, perceptions and economic capacities, PRI involvement in health, existing community organizations and nature of involvement in health

• Socio-epidemiological situation – local morbidity profile, major communicable diseases and transmission patterns, health needs of special social groups (e.g. tribals or Adivasis, migrants, very remote hamlets) (Dwivedi and Mukherjee, 2011)


Accountability: Community Monitoring

• Community-based monitoring (CBM) a key strategy of the

NRHM ensures that the services reach the targeted beneficiaries.

• The CBM implementation framework involves five steps: – 1) orientation of stakeholders and the strengthening of

district and block (subdistrict) nongovernmental organizations (NGOs);

– 2) community mobilization resulting in the production of a village health services profile;

– 3) formation and strengthening of Village Health and Sanitation Committees (VHSCs), primary health centers (PHCs), and district and block committees;

– 4) community level investigation and monitoring involving village health report cards and facility score cards; and

– 5) sharing of reports (through public hearings) and planning at the PHC, village, and block levels.


• Within CBM, there is Community based Monitoring and Planning Committees (MPCs).

• It has formed at the PHC, block, district and state levels.

• The members of MPCs consist of representatives of elected members, health care providers and officials, civil society organizations and members of the community.

• They have the power to monitor and provide community inputs to resolve issues related to functioning of health care services.


Village Health & Sanitation Committee

• VHSC-The objective of this committee is to help the ANM in preparing the SC action plan and help her in planning and implementing various programmes related to health, hygiene, nutrition, sanitation and drinking water.

• It has been formed in each revenue village and its members comprise of village level elected representatives, health functionaries and community members.

• This committee is engaged in planning process regarding health action at village level. They receive fund from the government to carry on such action plan. They also monitor village level health services.

• The NRHM guidelines state that the VHSC should comprise the ANM, ASHA, representatives of the village panchayat, women non-governmental organisations and self-help groups. Backward social classes should also be represented.


Rogi Kalyan Samiti (RKS)

• RKS is a health facility management committee consisting mainly of health officials and elected representatives.

• RKS have mandate to plan for utilization of these funds, to ensure the welfare of patients and proper functioning of the health institution (Shukla et al, 2014).

• It has been established in rural areas. • The major strengths of RKS as commonly perceived by

stakeholders were community participation and availability of funds at the level of devolution.

• Establishment of the Rogi Kalyan Samiti (RKS) would improve service quality and management by increasing accountability.


• The actual progress has again fallen short of expectations (Hussain, 2011).

• While almost all district hospitals and CHCs have registered RKS, the coverage of PHCs is much less.

• The role of the RKS is limited by the tendency to view them as an alternative financing device and the consequent emphasis on user fees as cost recovery.

• Further, the composition of these bodies and processes of functioning are also not always conducive to community participation (NRHM 2007).


• The functioning of CBM and RKS in strengthening heath care system. – Community needs and priorities are identified

through CBM process through report cards and jan sunwais (public hearing). PIP development process through visits to facilities, interviews and FDGs.

– Once the information has been collected, community based planning is done through local heath action plan, dialogues, communication and funding. There is community participation and discussion of community representatives at Project implementation plans (PIPs) at block and district level (Shukla et. Al, 2014).


ASHA

• They are female health activist in the community; • They have to create awareness and do community

mobilization towards local health planning; • They are also engaged in monitoring the utilization and

accountability of the existing health services (Dasgupta and Qadeer);

• She acts as a promoter of good health practices; • They are responsible for mobilisation of the

community to access public health services (NIHFW, 2005)

• ASHA workers are essentially females in the age group of 25-45 years;


• They need to have formal education till class eighth. • They may be married/ widow/ divorced. • The norms states that in every 1000 population there has

to be 1 ASHA, but for deserts and hilly areas, these norms are relaxed.

• ASHA are not entitled to any pay or honorarium, but are eligible for compensation for services provided under various schemes and programs of Government of India and State Governments;

• For instance they get honorarium from institutional delivery under Janani Suraksha Yojana (JSY), Directly Observed Treatment Short Course chemotherapy (DOTS) treatment under Revised National Tuberculosis Control Program (RNTCP), etc. under the overall guidance of the District Health Mission (DHM) (Dasgupta and Qadeer, 2005) .



Agarwal et al, 2019

Fig 1: Percentage of women reporting getting services from ASHA *Agarwal et al (2019) found

that ASHA workers play a significant role in building connectivity between marginalized communities and health services. *The study found that ASHA have a vital role in maternity health services. *ASHA workers have a wide presence in all the states in India (see Fig 1)

• Sundararaman et al, (2012) in their study on the effectiveness of community health workers found that apart from cash incentives, a greater support should be given competency based training, the health rights dimension, an adequate supply of medicines, and mentoring and motivation to ASHAs.

• Karol and Pattanaik (2014), in their study done in Rajasthan concluded that ASHAs do not have more knowlegde on HIV/ AIDs and other ailments.

• According to them, ASHAs need motivational and leadership training in family planning services and chronic disases such as STDs, HIV/AIDS.


References • Agarwal et al, 2019, The impact of India’s accredited social

health activist program on the utilization of maternity services, Human Resources for Health, 17, 68

• Ashtekar, S, 2008, The National Rural Health Mission: A Stocktaking, EPW, Vol. 43, No. 37

• Dasgupta, R and I. Qadeer, 2005, The National Rural Health Mission (NRHM): A Critical Overview, India Journal of Public Health, Vol. XXXXIX, No. 3, pg.138-140

• Dwivedi, S and A. Mukherjee, 2011, District and village planning- a decentralized implementation approach in public health in India in Public Health Nutrition in Developing Countries, Sheila C Vir (ed), Woodhead Publishing India

• Husain, Z, 2011, Health of the National Rural health Mission, EPW, Vol. XLVI, No. 4


• Karol G S and B K Pattanaik, 2014, Community health workers and reproductive and child health care: A evaluative study on knowledge and motivatio of ASHA workers in Rajasthan, India, Internal Journal of Humanities and Social Science, Vol. 4, No. 9

• NRHM, 2007, https://nhm.gov.in/WriteReadData/l892s/nrhm-framework-latest.pdf

• National Health Policy, 2002, https://nhm.gov.in/images/pdf/guidelines/nrhmguidelines/national_nealth_policy_2002.pdf

• National Institute of Health and Family Welfare (NIHFW), GOI, 2005 • Shukla et al, 2014, Using community based evidence for decentralized

health planning: insights, Health Policy and Planning Advance, 1-12 • Sundararaman et al, 2012, Determinants of functionality and effectiveness

of community health workers: results from evaluation of ASHA program in eight Indian states, BMC Proceedings, 6, 030


https://nhm.gov.in/WriteReadData/l892s/nrhm-framework-latest.pdf















https://nhm.gov.in/images/pdf/guidelines/nrhm-guidelines/national_nealth_policy_2002.pdf












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National Rural Health Mission (NRHM)€¦ · Central University of South Bihar Lecture Notes Note: This is for teaching purpose at CUSB 1 . Key points •Key components of NRHM •Status