Discuss about the Health Care Delivery and Reform for NRHM.
National Rural Health Mission (NRHM) was initiated in 2005 by Government of India. Main objective of the NRHM was to provide affordable and quality healthcare services to the people in rural India. Strategy of this healthcare delivery system is to involve different sectors and to achieve collaboration among these sectors and organisations to provide uniform health and family welfare services through single window. This system aimed at providing sustainable healthcare delivery to the rural Indians; however, this system didn’t imagine potential hurdles and challenges in its implementation. However, foundation laid down by NRHM can be taken forward to improve healthcare delivery system in India to the next level. It can be considered as the road map to achieve varied goals of health and welfare in India. It is an appreciable effort by the Government of India to build the necessary infrastructure to provide uniform health services to all classes of people in the rural India. NRHM should be given full credit for initiating efforts for empowering healthcare system in rural India specifically in the poor states. NRHM gave importance to the community participation and involvement of different sectors to achieve health indicators in most of the sates. NRHM can be taken forward by not only to give more attention for capacity building in terms of infrastructure and technical aspects but also to build skilled healthcare professionals which are one of the important components for providing sustained healthcare services.
NRHM was aimed to improve the accessibility of the people in the rural region like poor, children and women for quality healthcare services and utilization of these healthcare services in the sustained manner (Garg and Laskar, 2011). NRHM performs its functions through different important national healthcare delivery programmes like Reproductive and Child Health II project (RCH II), the National Disease Control Programs (NDCP) and the Integrated Disease Surveillance Project (IDSP). Aim of the NDCP is to provide preventive and curative efforts for control of diseases like filarisis, encephalitis, dengue, kalazar, leprosy, tuberculosis, blindness, iodine deficiency disorders, and polio. Healthcare delivery was planned through different centres like village health sub centres (VHSCs), recruitment and functioning of ASHAs, constitution of registered Rogi Kalyan Samities at district hospitals (DHs), Sub-Divisional Hospitals (SDHs), community health centres (CHCs) and primary health centres (PHCs) (NRHM, 2011).
NRHM put future picture of involvement of communities in providing quality healthcare services to the people of rural India. One of the most significant strategy of NRHM to improve capacity and capability of Panchayati Raj Institutions to participate and contribute in public health services. NRHM involves both Government professional bodies and nongovernmental organizations (NGOs) to monitor and evaluate implementation of the NRHM scheme. It also depends on the community stakeholders for monitoring delivery of healthcare services and provision of healthcare services (Doke et al., 2015). District level annual report preparation is the responsibility of Government departments and NGOs. State and national reports are being presented in the State Legislative Assemblies and the Parliament. At national level activities are being controlled by joint Mission Steering Group, headed by the Union Minister of Health and Family Welfare and at state level activities are being controlled by Health Mission headed by the Chief Minister. At district level activities are being controlled by Chairman of the Zilla Parishad, and District Head of the Health Department (NRHM, 2005).
NRHM is also aimed at mainstreaming traditional system of medicine which is called AYUSH which comprises of different systems of medicine like Ayurvedic, Yoga, Unani, Siddha and Homeopathy systems of health. Main focus was given to the maternal and child health and family welfare by improving participation from the different community members and improving coordinated efforts by professional from different sectors like medicine, pharmacy, social, physiotherapy, nutrition and psychology. Healthcare services enabled by the NRHM can be availed at primary, secondary and tertiary health care levels. Though, objective of the NRHM is provide affordable and accountable healthcare services to the people across the country main attention was given to the 18 states with low socioeconomic status. These states include 8 North Eastern states, 8 empowered action group (EAG) states and 2 hilly states. Empowered action group (EAG) states include Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttaranchal and Uttar Pradesh. Two hilly states include Himachal Pradesh and Jammu & Kashmir.
Public health expenditure in India reduced from 1.3 % of GDP in 1990 to 0.9 % in 1999. However, in NRHM it was aimed at improving public health expenditure from 0.9 % of GDP to 2-3 % of GDP. Aim of the improvement of the budget to improve health system and health status of the rural people (NHA, 2005). There was major implementation issue while implementing NRHM. It was not uniformly implemented in different states of India. Different states had their healthcare delivery strategy. Hence, it was difficult to implement NRHM uniformly throughout the India. For example, Tamil Nadu has Tamil Nadu health systems project (TNHSP) as a health delivery system. Though TNHSP and NRHM together brought improved results in improving health status and well being of the rural people; there were few basic variabilities in NRHM implementation owing to existence of schemes and strategies in the form of TNHSP. ASHA one of the components of the NRHM was not implemented in the Tamil Nadu because presence of grass root workers namely village health nurses (VHN). Primary health centres (PHCs) are one of the major components of the design of NRHM for providing healthcare services. PHCs are the primary resource centre for the accessibility of healthcare services by rural people. In Tamil Nadu, it was evident that PHC load was augmented from 0.87 lakhs in 2005-2006 to 3.87 lakhs in 2008-2009. It indicates that NRHM played significant role in improving PHC load. From this it can be concluded that incorporation of PHC in the design and strategy of NRHM proved to be beneficial. Children being immunized gone down from 11.2 lakhs in 2007-08 to 10.1 lakhs in 2008-09. However, analysis of the data indicated that this decline in immunization was not due to implementation of NRHM; however, this decline was due to reduced fertility rate. Prior to implementation of NRHM also, there was improved quality of health services in Tamil Nadu. However, due to implementation of NRHM proved to be significantly improved accessibility and quality of care. This improvement was observed mainly due to design and functioning of the NRHM. Functioning of NRHM was implemented at three different levels like primary, secondary and tertiary healthcare centres. It helped in improving accessibility of healthcare services by all classes of people. In NRHM multiple aspects were being incorporated; however, budget was not segregated effectively for different aspects. AYUSH system was incorporated in NRHM; however sufficient budget was not allocated for AYUSH. Hence, it was difficult to make proper plan for implementing AYUSH in rural areas. However, in lately in 2008-09 budget was allocate for improvement of infrastructure and manpower in AYUSH sector (Samal, 2015). Proper design and functioning of the NRHM helped in effective utilization of budget allocated under NRHM scheme for Tamil Nadu. Supply chain functioning of the NRHM system in Tamil Nadu seems to be worked efficiently. It has been observed that drugs and other requirements were effectively supplied to PHCs after implementation of the NRHM (Gopalakrishnan and Immanuel, 2018; NRHM, 2011).
NRHM proved to be effective in bringing face-lift in rural health in India. It enabled effective healthcare with uniform access to healthcare services to the rural population. Different aspects of the healthcare were assigned to the different healthcare schemes and missions. Hence, specific attention was given to each healthcare sector. For example, improvement in the indicators related to maternal and child health and fertility were achieved due to implementation of specific schemes and mission like ASHA and welfare scheme Janani Suraksha Yojana (JSY) (Nagarajan et al., 2015). Improvement in the health and wellbeing can be effectively achieved by improving accessibility to both health and social services. Structure of ASHA was designed in such a way that that there is provision for providing both health and social intervention for the people in the rural India. Social intervention can be effectively implemented by improving community participation. Community participation is one of the important components for the success of any programme. NRHM could not implement uniform functioning in all the schemes and healthcare centres. Successful implementation of the integrated health and social services in the ASHA was not effectively implemented in PHCs and panchayats. It indicates, there is scope for the improvement in the design of NRHM. All the centres which come under NRHM need to be provided with basis infrastructure, facilities and workforce to provide health and social services. Any mission and scheme can be effectively implemented and completed by giving authority and freedom (Shukla, 2005; Nandan, 2010). NRHM healthcare delivery system was designed in such a way that at each level of healthcare service decentralisation of the activities were implemented. This decentralised functioning of the NRHM proved to be successful because at each level task were performed with more responsibility and ownership. It helped to improve the accountability of panchayat raj and reduce the burden of State and Union Government. This decentralised functioning proved successful because workforce at the panchayat level knows the community well and healthcare services were provided in more effective manner due to intersectoral collaboration at the panchayat level. NRHM strengthened CHC as the first referral units (FRU). It helped in the improving capacity of the secondary healthcare systems and improving quality of care. However, it doesn’t proved to be true for all the FRUs because in few of the districts due to long distance and less number of FRUs proved to be limiting factors for availing services at FRUs. Hence, number of FRUs need to be increased with availability of all resources and workforce (Shukla et al., 2012).
In NRHM, PHC proved to be most widely healthcare centre for availing healthcare services under this scheme. However, in few of the rural areas PHCs proved to limiting factors for availing healthcare services. Main reason for availing insufficient healthcare services at the PHCs is scarcity of basic infrastructure and resources for availing healthcare services. Hence, PHCs need to be upgraded with all the modern facilities and resources. PHCs can be effectively improved through public private partnership based on the leasing model. It can be helpful in improving standards of PHCs without losing its identity. It is very important to reserve identity of the PHCs because in rural India, PHCs are the most accessible healthcare centres and rural people give more preferences to the PHCs in comparison to the private health centres. Healthcare services are workforce driven services. Hence, efficient workforce need to produce for the improving the functioning of the NRHM. It is evident that medical professionals are not willing to work in the rural area. It can adversely affect outcome of NRHM. Hence, for these medical professionals’ compulsion need to be made for working at the PHCs. This practice is being already implemented; however increased duration of stay of medical professionals at PHCs can be helpful in improving outcome of the PHCs and NRHM (Sundararaman and Gupta, 2011). Increasing incentives of medical professionals and providing them with improved facilities can also be helpful in improving outcome of NRHM. This manpower need to be trained not only in medical services but also in administrative services; hence PHCs in the remote areas can be effectively managed by these people. In remote areas people seeking healthcare services can be less; hence posting people for each department can put burden on the national economy. Hence, these medical professionals with training in both medical and administrative departments can prove to be more cost-effective manner (Nayar, 2013). Hence, NRHM budget can be effectively shifted to the most desirable section. Alternative healthcare professionals need to be produced for occupying positions in the rural PHCs. Healthcare professionals from the alternative system of medicine need to be upgraded both in knowledge, skills and technological advances to the level of medical professionals. It can be achieved by implementing bridge course for these alternative medicine professionals. Hence, scarcity problem of healthcare professionals at the PHCs can be effectively resolved.
After Alma Ata Declaration in 1978, India is competing at the global level for providing ‘’Health for All’’. It can be effectively achieved through Millennium Development Goals (MDG). Goals 4 and 5 of MDG are being already covered in the NRHM. One of the major discrepancy for achieving this goal is regional variations in India. Hence, to eliminate these regional discrepancies, NRHM gave special attention to the states which were lagging behind in implementing NRHM schemes. Beyond MDG, in current scenario India need to meet the goals of Sustainable Development Goals (SDG). According to goal 3 of the SDG, people of the age should live healthy life and with well-being. Hence, NRHM initiated efforts to achieve this goal. Policy makers and programme implementers of NRHM need to ensure credible, accountable and quality in health services through this health delivery service. Policy makers and programme implementers should amend the NRHM strategies and activities keeping in mind SDG and should work in with commitment and political will. In current scenario to meet the global standards with respect to MDG and SDG, NRHM should address the following recommendations : percentage GDP expenditure on the public health, increase in budget allocation to each state, increase in resource allocation at panchayat and district levels, resources need to be allocated based on public health studies and needs of the local people, improved utilization of the allocated funds obligation and insuring social protection of public health sector. NRHM should work towards availing health services in timely and easy manner which are nearer to each people. Hence, NRHM need to give attention to provide healthcare services at the village levels. Hence, healthcare sub-centre need to be set-up at each village. Access mapping need to be used to improve accessibility of the healthcare centres and outreach centres. Modification of the healthcare facilities infrastructure need to be modified based on the requirements of the population and standards of access. It can be helpful in the availing healthcare services at the village level without moving to urban healthcare facilities to access emergency healthcare services. It can surely reduce mortality rate to the standards of MDG and SDG goals (Roy, 2015). Hence, India can compete effectively with the other countries in providing quality healthcare services to all the people. NRHM strategies and activities are designed for all the population of the rural India. However, in the current scenario, strategies and activities need to be amended based on the requirements and number of population. Primary and secondary care beds need to be increased based on the population in each district and epidemiological background of each district. Optimum utilization of the provided resources is very important in designing any type of scheme and mission for public health. Initially, 500 beds for every 10 lakh population can be fixed. Utilization of these beds in each district can be evaluated by establishing occupancy rate of these beds. Based on the data obtained in the occupancy rate, number of beds for each district level hospital can be amended. Maximum size of district hospital also need to be fixed and those districts with overburdened district hospitals, another hospital need to be opened. 30 beds in CHC and 200 beds in the district hospitals need to be fixed per 10 lakh population to avail quality healthcare services (D'Silva, 2013).
Poor coordination and the integration with other healthcare institutes is the major hurdle for implementing effective NRHM policies. Integration of different sectors like nutrition, water, sanitation and hygiene need to be achieved for implementing effective NRHM policies. NRHM was designed in such as way that there should be coordination among different related schemes like Total Sanitation Campaign, Integrated Child Development Services, Mid Day Meal, and National Disease Control Programmes for Malaria, TB, Kala Azar, Filaria, Blindness & Iodine Deficiency and Integrated Disease Surveillance Programme. However, due to lack of coordination among different ministers and departments, effective implementation of NRHM scheme is questionable. Frame work of NRHM is designed to implement effective healthcare services at each level; however, there is no effective mechanism to assess or judge success of scheme at each level. Hence, evaluation and outcome strategies of the NRHM scheme need to be improved. Targets for each state need to be framed which can be helpful in the evaluation of each state in implementing NRHM scheme. Baseline surveys for health status of each state need to be carried out for evaluating outcome of NRHM. However, baselines surveys are not being completed for most of the states. Design and functioning of NRHM is being initiated as package of schemes. Hence, participatory activities need to be achieved from different stakeholders like Community, PRIs, government and non-governmental organizations. However, integration and collaboration of these different stakeholders is not evident in implementing NRHM scheme. Corruption in the utilization of the allocated budget can lead to the ineffective implementation of the scheme. Hence, authorities need to engage both civil societies and local people in the effective utilization of the allocated budget. However, it is evident that civil society engagement is not evident at the state level. Most of the times funds are not being released at the proper time; hence not utilized in the proper way. Funds received after the completion of the priority tasks can result in the utilization of funds in the low priority tasks. Panchayat Raj Institutions are not adequately trained for the proper utilization of the funds (Dhingra and Dutta, 2011; Bahadur, 2010).
NRHM contributed significantly for upgradation of the public health infrastructure of India. This scheme should be given its credit for empowering rural India to improve access to the required healthcare facilities and services. NRHM brings community participation and intersectoral collaboration in the healthcare services (Prasad et al., 2013). It helped in achieving healthcare indicators in most of the states. This foundation should be carried forward in capacity building not only in terms of infrastructure and technical improvement but also in training healthcare workforce. These improvements can be helpful in the providing sustainable healthcare services in rural India. Public private partnership need to be effectively implemented to improve quality of delivery of healthcare services. NRHM need to meet global standards of health through improved implementation of NRHM.
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