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LG 8 REEP Term Paper NRHM

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					Rural Economic Policy & Environment Term Paper

Programme, Implementation and its Critical Appraisal
1 LG-8 _ REEP Term Paper on NRHM

Flow of Presentation
 What is NRHM?

 Need Of NRHM  NRHM - The Programme  NRHM - Its Implementation  Progress So Far
 Critical Appraisal of NRHM
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What is National Rural Health Mission (NRHM)?
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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.
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Need for National Rural Health Mission (NRHM)
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Changes in Status of Health – Over the Years
Demographic Changes
Life Expectancy

1951
36.7

1981
54

2004
64.6

Crude Birth Rate
Crude Death Rate

40.8
25

33.9
12.5

26.1
8.7

Infant Mortality Rate
Health Infrastructure

146
1951

110
1981

70
2004

SC/PHC/CHC Dispensaries & Hospitals (all)
Beds (Private & Public)

725 9209
117, 198

57, 363 23, 555
569, 495

163, 181 43, 322
870, 161

Doctors (Allopathic) Nursing Personnel
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61, 800 18, 054

268, 700 143, 887

503, 900 737, 000

Changes in Status of Health – Over the Years
Epidemiological Shifts Malaria (cases in millions) Leprosy (per 10,000 population)
Small Pox (nos. of cases) Guinea worm

1951 75 38.1
45,000

1981 2.7 57.3
Eradicated 40, 000

2004 2.2 3.74

Eradicated

Polio

29, 709

265

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LG-8 _ REEP Term Paper on NRHM

Disparities in Status of Health – Rural & Urban
Category Populatio n BPL (%) 26.1
27.09

IMR (per 1000 Live Births) 70
75

Under 5 Mortality (per 1000) 94.9
103.7

MMR (per Lakh) 408
-

Leprosy case per 10, 000 3.7
-

Malaria +ve case (in ‘000) 2200
-

India
Rural

Urban

23.62

44

63.1

-

-

-

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LG-8 _ REEP Term Paper on NRHM

Disparities in Status of Health – Inter Regional
Better Performing States Kerala
Maharashtra

Populatio n BPL (%) 12.72
25.02

IMR (per 1000 Live Births) 14
48

<5 Mortality (per 1000) 18.8
58.1

MMR (per Lakh) 87
135

Leprosy case per 10, 000 0.9
3.1

Malaria +ve cases (in ‘000) 5.1
138

Tamil Nadu
Worst Performing States Orissa Bihar

21.12
Populatio n BPL (%) 47.15 42.60

52
IMR (per 1000 Live Births) 97 63

63.3
<5 Mortality (per 1000) 104.4 105.1

79
MMR (per Lakh) 498 707

4.1
Leprosy case per 10, 000 7.05 11.83

56
Malaria +ve case (in ‘000) 483 132

Rajasthan Uttar Pradesh
M. P.
9

15.28 31.15
37.43

81 84
90

114.9 122.5
137.6

607 707
498

0.8 4.3
3.83

53 99
528

LG-8 _ REEP Term Paper on NRHM

Disparities in Status of Health – Inter Caste & Countries
Section
India

Infant Mortality/1000
70

Under 5 Mortality/1000
94.9

% Children Underweight
47

Scheduled Caste Scheduled Tribe Other Disadvantaged Sections Country % of Population <$1/day 44.2 18.5 6.6
LG-8 _ REEP Term Paper on NRHM

83 84.2 76 Infant Mortality Rate/1000 70 31 16
6 7

119.3 126.6 103.1 % of Health Expenditure to GDP 5.2 2.7 3
5.8 13.7

53.5 55.9 47.3 Public Expenditure (% of Total Exp.) 17.3 24.9 45.4
96.9 44.1

India China Sri Lanka
UK USA
10

-

Health Expenditure – Over the Years
Year
% Health Exp. Govt. Exp. Private Exp.
90.0 80.0 70.0

1996
4.0 24.6 75.4

1997
4.3 23.5 76.5

1998
4.3 22.0 78.0

1999
4.0 22.7 77.3

2000
4.3 20.9 79.1

2001
4.5 19.2 80.8

2002
4.8 17.8 82.2

2003
4.9 17.1 82.9

2004
5.0 17.3 82.7

60.0 50.0 40.0 30.0 20.0
10.0 0.0

% Share of Private Expenditure (of total Health Exp.)

% share of govt. expenditure (of total health Exp.)

Health Exp.(as % of GDP) LG-8 _ REEP Term Paper on NRHM

11

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 LG-8 _ REEP 12 diarrhoea Term Paper on NRHM

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
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problem.

LG-8 _ REEP Term Paper on NRHM

National Rural Health Mission (NRHM) The Programme

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LG-8 _ REEP Term Paper on NRHM

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   
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Access to integrated comprehensive primary healthcare Population stabilization, gender and demographic balance. Revitalize local health traditions and mainstream AYUSH
LG-8 _ REEP Term Paper on NRHM



Promotion of healthy life styles

NRHM – Components

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LG-8 _ REEP Term Paper on NRHM

The Institutional Structure
National mission steering State health mission

District health mission Block coordination Gram panchayat
Gram VHC

Dept. of family welfare

Dept. of women and child

Service provider ANM CLIENTS
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AWM

ASHA

Stakeholders Involved
Government of India
State Govt.
and District Administration

NGOs

NRHM

External
/Funding AgenciesUNICEF, WHO, UNDAF, UNOPS etc

PRIs

People

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LG-8 _ REEP Term Paper on NRHM

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.
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Rapid Framework
•Key actors: GOI, State govt. NGOs , WHO •Political environment: Poor status of health sector NCMP of UPA Govt. MDG of UN

Political Context

Evidences
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,

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LG-8 _ REEP Term Paper on NRHM

Progress So Far Based on Government Claims

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LG-8 _ REEP Term Paper on NRHM

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
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improved from 88 NRHM and 97 to 169 respectively LG-8 _ REEP Term Paper on to 149

Progress so far
 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

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 More than 4.35 lakhs ASHA workers have been selected  More than 2.400 PHC have been made 24X7  LG-8 _ REEP Term Paper on NRHM reach remote areas MMU In 314 district to

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.

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LG-8 _ REEP Term Paper on NRHM

Critical Appraisal of NRHM

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LG-8 _ REEP Term Paper on NRHM

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)

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LG-8 _ REEP Term Paper on NRHM

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

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LG-8 _ REEP Term Paper on NRHM

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

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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.
29 LG-8 _ REEP Term Paper on 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
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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.
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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
32 LG-8 _ REEP Term Paper on NRHM

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
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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)
34 LG-8 _ REEP Term Paper on NRHM


				
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