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Programme, Implementation and its Critical Appraisal

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  1. Rural Economic Policy & Environment Term Paper Programme, Implementation and its Critical Appraisal LG-8 _ REEP Term Paper on NRHM

  2. 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

  3. What is National Rural Health Mission (NRHM)? LG-8 _ REEP Term Paper on 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. LG-8 _ REEP Term Paper on NRHM

  5. Need for National Rural Health Mission (NRHM) LG-8 _ REEP Term Paper on NRHM

  6. Changes in Status of Health – Over the Years LG-8 _ REEP Term Paper on NRHM

  7. Changes in Status of Health – Over the Years LG-8 _ REEP Term Paper on NRHM

  8. Disparities in Status of Health – Rural & Urban LG-8 _ REEP Term Paper on NRHM

  9. Disparities in Status of Health – Inter Regional LG-8 _ REEP Term Paper on NRHM

  10. Disparities in Status of Health – Inter Caste & Countries LG-8 _ REEP Term Paper on NRHM

  11. Health Expenditure – Over the Years LG-8 _ REEP Term Paper on NRHM

  12. 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

  13. 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

  14. National Rural Health Mission (NRHM) The Programme LG-8 _ REEP Term Paper on NRHM

  15. 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

  16. NRHM – Components LG-8 _ REEP Term Paper on NRHM

  17. 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

  18. 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

  19. 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

  20. 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

  21. Progress So Far Based on Government Claims LG-8 _ REEP Term Paper on NRHM

  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 LG-8 _ REEP Term Paper on NRHM

  23. 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

  24. 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

  25. Critical Appraisal of NRHM LG-8 _ REEP Term Paper on NRHM

  26. 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

  27. 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

  28. 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

  29. 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

  30. 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

  31. 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

  32. 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

  33. 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

  34. 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