NRHM: Time to Take StockSharma AK. National rural health mission:

Time to take stock. Indian J Community Med 2009 Dec ;34:175-82.

Introduction:The poor performance of the Indian Public Health

System is widely acknowledged.By the end of 2008, NRHM has lived half of its life. It

is the right time to take stock . Core objective - To create fully functional health

facilities within the public health system.

Five principles of structural correctionSetting norms and standards and achieving

service guarantees, Innovations in the human resource

development for the health sectorIncreasing participation and ownership by the

community, Improving the management capacity and Flexible financing.

1. Infrastructure and Preparedness of Health Facilities

 

Functioning SHCS, PHCS, and CHCS

Numbers

SHCS 1,45,272

PHCS 22,370

CHCS 4045

•24 x 7 health facilities - at 12166 units (include SHCs, PHCs, CHCs): 58% of these are in the non high focus large and small states. • Last 3 years , the no. of PHCs with 24 x 7 facilities -1263 to 6397 (506%)and CHCS- 980 to 2469 (251%)and the high focus non NE states have recorded 500% growth. Mobile medical units (MMUs) - 243 of the 623 districts(39%).

Case load handling by the health system.

case load• OPD Increased- 342- 477million .• IPD increased - 23 million - gone up by

155%.

Institutional deliveries

• 108 lakhs in 2005-2006 -143 lakhs in 2007-2008 (75% increase).

• high focus non-NE states - 164% and about 200% in the NE states. JSY beneficiaries - increased -7 lakhs in 2005-2006 to 72 lakhs in 2007-2008.

Negative points

• Impossible to keep the mother and baby for 48 hours after delivery.

• Performance has been below par in Orissa and Himachal Pradesh.

Quality of services:Quantitative improvement

in services having been achieved in a majority of the states, the quality needs scrutiny.

Episiotomy is performed by AYUSH doctors who are not trained in surgical skills.

Incompetence in the early stage may lead to major aversion, which may be even more difficult to overcome for a long time.

4. Diagnostics and Drugs:Basic drugs have been made available up to the SHC and PHC

level in most places. However, AYUSH doctors are not provided with AYUSH medicines.

5. Human Resource Planning :Acute shortage of all categories of staff in health sectors across

the length and breadth of the nation. Lack of specialist doctors, laboratory technicians, and male

health workers.Multi-skilling and multitasking is being talked about, but could

not be seen.

ASHA:states No. of ASHA appointed

total 5,00,532 (4,00,000expected)

High focus non NE 4,07,957

High focus NE 48,552

The ASHA quarterly newsletter, ASHA sammelan, and annual ASHA awards are the highlights of the ASHA-related activities in Uttar Pradesh. The ASHA support system and ASHA mentoring group is being formulated.

7. Community Processes Including Community Participation:

Rogi kalyan samitis : DH-565, CHCs-3912, PHC-16628, others-1995. In large states like Uttar Pradesh the participation of the Panchayati Raj Institutions (PRIs) is not very encouraging.

Lack of political will and an attitude of indifference prevails. Meetings of VHSC are not held regularly and the RKS are also not very proactive in participating in the activities of the health institutions.

Lack of awareness and motivation has led to minimal community participation.

It appears to be an uphill task to initiate a social audit at the village level.

8. Difficult Areas and Vulnerable Groups:

• Mobile medical units and 'difficult area allowance‘ Monetary incentives and faster promotions .• In Maharashtra, an additional stipend of Rs. 1000 per month is given for working in tribal areas, and an additional payment of Rs. 1500 is given to ANMs, for working in insurgency affected areas of the Nagpur division.9. Information Systems and Record Maintenance•Integrated Disease Surveillance Project (IDSP) and Health Management Information System (HMIS) were aimed at documentation and flow of data. Tamil Nadu and Maharashtra have good computerized HMIS systems.

Safe motherhood

Ayushmati and Vande Mataram scheme (WB)

Chiranjeevi yojana (GJ)

Mamta Friendly Hospital Initiative

(DL)

Saubhagyawati scheme

(UP)

Janani Express Yojana (MP)

Birth waiting rooms (AP)

Janani Suraksha

Vahini (KA)

Innovations in Implementation

Balshakti Yojana

Kano parbo na

Panchamrit campain

Ankur Project

Immunization

10.3. Adolescent reproductive and sexual health

Saathiya Youth Friendly Project in Uttar Pradesh strengthens provider knowledge and skills on contraception and sexual health for out-of-school girls at youth information centers.

10.4 Behavior change communication

Goli ki hamjoli-7 states in

north

Bindass bol – 9 states

Saathi bachapan ke-Ors

Bodhana Nauka in Kerala

Aadarsh Dampati

Samman in UP

10.5. Gender mainstreaming

In Karnataka ,special provisions in the budget for needs of adolescent girls, pregnant, and lactating women in tribal districts.

The Bhagya Lakshmi scheme in Karnataka and Ladli scheme in Delhi gift Rs. 10000 in the form of fixed deposit.

10.6. Service delivery for RCH

Services in the difficult-to-reach areas : Mobile Health Clinics in seven states, mobile boat clinics in Assam, Mobile Helicopter services for remote inaccessible areas in Tripura, and floating dispensaries in the Narmada basin of Maharashtra.

Social franchising networks : Distribution of contraceptives in Karnataka, Uttar Pradesh, Jharkhand, and Uttarakhand.

10.7. Program management :•Decentralized clinical training and post training supervision of Integrated Management of Neonatal and Childhood Illnesses (IMNCI) trained personnel by (NGOs); community and panchayat involvement. •Improvements of procurement and finance systems e.g. Tamil Nadu and Kerala Medical Services Corporation as a drug management and supply system, e-banking for fund management in Kerala and Debit cards for ASHAs.

Conclusion:NRHM in its endeavor to improve healthcare delivery system

in rural India may be considered as a paradigm shift in the way healthcare delivery is to be executed.

In spite of the supply of computers and availability of internet links, data management and information flow to and from the peripheral levels is still very poor.

The future of the mission appears promising as a political will, hard work, and professional managerial approach will help cross the hurdles and accomplish the mission.

Innovative schemes under NRHM in Wardha District:

CUG scheme:The central server is installed at DHO office and is receiving

SMS from the field staff & the HRIS updated. Inventory control: Install an Application Software for

Inventory Control and Stock Management at District Warehouse and 27 PHCs in 8 (eight) blocks of Wardha district.

Arogya Udyan in Wardha district Human resource development: - ASHA- 967, AYUSH -10School health check up program: - out of 153026 student

and 133153 were examined (87%).

•VHNSC : -formed in the 870 villages out of 967 villages.•Janani Suraksha Yojana : - beneficiaries- 3621•CDC: In 17 PHCs CDC were established, 202 grade III ,IV & (-3) sd. malnourished children were admitted in CDC for 21 days. The change in gradation of these malnourished children were 204 (88%). While in the second term 193 (76 %) children improved in the camp taken in Nov. & Dec. 08.•ARSH: 65000 adolescent girls - sanitary Napkins provided to the adolescent girls for the period of two months totally free of cost and thereafter at minimal price through these depots.

Thanks…....