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Rural Economic Policy & Environment Term Paper. Programme, Implementation and its Critical Appraisal. Flow of Presentation. What is NRHM? Need Of NRHM NRHM - The Programme NRHM - Its Implementation Progress So Far Critical Appraisal of NRHM. What is

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Programme implementation and its critical appraisal

Rural Economic Policy & Environment

Term Paper

Programme, Implementation and its Critical Appraisal

LG-8 _ REEP Term Paper on NRHM


Programme implementation and its critical appraisal

Flow of Presentation

  • What is NRHM?

  • Need Of NRHM

  • NRHM - The Programme

  • NRHM - Its Implementation

  • Progress So Far

  • Critical Appraisal of NRHM

LG-8 _ REEP Term Paper on NRHM


Programme implementation and its critical appraisal

What

is

National Rural Health Mission

(NRHM)?

LG-8 _ REEP Term Paper on NRHM


About nrhm

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.

LG-8 _ REEP Term Paper on NRHM


Programme implementation and its critical appraisal

Need

for

National Rural Health Mission

(NRHM)

LG-8 _ REEP Term Paper on NRHM


Changes in status of health over the years

Changes in Status of Health – Over the Years

LG-8 _ REEP Term Paper on NRHM


Programme implementation and its critical appraisal

Changes in Status of Health – Over the Years

LG-8 _ REEP Term Paper on NRHM


Disparities in status of health rural urban

Disparities in Status of Health – Rural & Urban

LG-8 _ REEP Term Paper on NRHM


Disparities in status of health inter regional

Disparities in Status of Health – Inter Regional

LG-8 _ REEP Term Paper on NRHM


Disparities in status of health inter caste countries

Disparities in Status of Health – Inter Caste & Countries

LG-8 _ REEP Term Paper on NRHM


Programme implementation and its critical appraisal

Health Expenditure – Over the Years

LG-8 _ REEP Term Paper on NRHM


Daunting challenges

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

LG-8 _ REEP Term Paper on NRHM


Daunting challenges1

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.

  • LG-8 _ REEP Term Paper on NRHM


    Programme implementation and its critical appraisal

    National Rural Health Mission

    (NRHM)

    The Programme

    LG-8 _ REEP Term Paper on NRHM


    Programme implementation and its critical appraisal

    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

    LG-8 _ REEP Term Paper on NRHM


    Programme implementation and its critical appraisal

    NRHM – Components

    LG-8 _ REEP Term Paper on NRHM


    Programme implementation and its critical appraisal

    The Institutional Structure

    National mission steering

    State health mission

    Dept. of

    family welfare

    Dept. of

    women and

    child

    District health mission

    Blockcoordination

    Gram panchayat

    Gram

    VHC

    Service provider

    ANM

    AWM

    CLIENTS

    ASHA

    LG-8 _ REEP Term Paper on NRHM


    Programme implementation and its critical appraisal

    Stakeholders Involved

    • Government of India

    • NGOs

    • State Govt.

    • and

    • District Administration

    NRHM

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

    • PRIs

    • People

    LG-8 _ REEP Term Paper on NRHM


    Programme implementation and its critical appraisal

    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.

    LG-8 _ REEP Term Paper on NRHM


    Rapid framework

    Rapid Framework

    PoliticalContext

    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,

    LG-8 _ REEP Term Paper on NRHM


    Programme implementation and its critical appraisal

    Progress So Far

    Based on

    Government Claims

    LG-8 _ REEP Term Paper on NRHM


    Progress so far

    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

    LG-8 _ REEP Term Paper on NRHM


    Programme implementation and its critical appraisal

    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

    LG-8 _ REEP Term Paper on NRHM


    Programme implementation and its critical appraisal

    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.

    LG-8 _ REEP Term Paper on NRHM


    Programme implementation and its critical appraisal

    Critical

    Appraisal

    of NRHM

    LG-8 _ REEP Term Paper on NRHM


    Programme implementation and its critical appraisal

    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)

    LG-8 _ REEP Term Paper on NRHM


    Programme implementation and its critical appraisal

    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

    LG-8 _ REEP Term Paper on NRHM


    Programme implementation and its critical appraisal

    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).

    LG-8 _ REEP Term Paper on NRHM


    No new deal for rural poor

    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.

    LG-8 _ REEP Term Paper on NRHM


    Problems identified with implementation of nrhm

    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

    LG-8 _ REEP Term Paper on NRHM


    Problems identified with implementation of nrhm1

    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.

    LG-8 _ REEP Term Paper on NRHM


    Programme implementation and its critical appraisal

    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

    LG-8 _ REEP Term Paper on NRHM


    Programme implementation and its critical appraisal

    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

    LG-8 _ REEP Term Paper on NRHM


    Programme implementation and its critical appraisal

    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)

    LG-8 _ REEP Term Paper on NRHM


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