Perspective of the National Rural Health Mission in North East India

The National Rural Health Mission ( NRHM )  has been launched on 12th April, 2005 for a period of seven years (2005 -2012) for providing integrated comprehensive Primary Health Care Services, specially to the poor and vulnerable sections of the society. Dr. S. I.  Ahmed writes about the NHRM mission in North Esat India.

The NRHM operate as an omnibus broadband programme by integrating all vertical health programmes of the Departments of Health and Family Welfare including Reproductive & Child Health Programme -II, National Programme for Malaria , Leprosy Eradication , Kala-Azar, Iodine Deficiency Disorder, Filaria ,Tuberculosis, Blindness Control and Externally Aided Projects (EAP). Recognizing the importance of Health in the process of economic and social development and improving the quality of life of our citizens, the Government of India has resolved to launch the National Rural Health Mission to carry out necessary architectural correction in the basic health care delivery system. The Mission adopts a synergistic approach by relating health to determinants of good health viz. segments of nutrition, sanitation, hygiene and safe drinking water. It also aims at mainstreaming the Indian systems of medicine to facilitate health care. The Plan of Action includes increasing public expenditure on health, reducing regional imbalance in health infrastructure, pooling resources, integration of organizational structures, optimization of health manpower, decentralization and district management of health programmes, community participation and ownership of assets, induction of management and financial personnel into district health system, and operationalizing community health centers into functional hospitals meeting Indian Public Health Standards in each Block of the Country.  

India has registered significant progress in improving life expectancy at birth, reducing mortality due to Malaria, as well as reducing infant and material mortality over the last few decades. In spite of the progress made, a high proportion of the population, especially in rural areas, continues to suffer and die from preventable diseases, pregnancy and child birth related complications as well as malnutrition. In addition to old unresolved problems, the health system in the country is facing emerging threats and  challenges. The rural public health care system in many States and regions is in an unsatisfactory state leading to pauperization of poor households due to expensive private sector health care. India is in the midst of an epidemiological and demographic  transition – with the attendant problems of increased chronic disease burden and a decline in mortality and fertility rates leading to an ageing of the population. An estimated 2.5 million people in the country are living with HIV/AIDS, a threat which has the potential to undermine the health and developmental gains India has made since its independence. Non-communicable diseases such as cardio-vascular diseases, cancer, blindness, mental illness and tobacco use related illnesses have imposed the chronic diseases burden on the already over- stretched health care system in the country. Premature morbidity and mortality from chronic diseases can be a major economic and human resource loss for India. The large disparity across India places the burden of these conditions mostly on the poor, and on women, scheduled castes and tribes especially those who live in the rural areas of the country. The inequity is also reflected  in the skewed availability of public resources between the advanced and less developed  states. Public spending on preventive health services has a low priority over curative health in the country as a whole. Indian public spending on health is amongst the lowest  in the world, whereas its proportion of private spending on health is one of the highest. More than Rs. 100,000 crores is being spent annually as household expenditure on health, which is more than three times the public expenditure on health. The private sector health care is unregulated pushing the cost of health care up and making it unaffordable for the rural poor. It is clear that maintaining the health system in its present form will become untenable in India. Persistent malnutrition, high levels of anemia amongst children and women, low age of marriage and at first child birth, inadequate safe drinking water round the year in many villages, over-crowding of dwelling units, unsatisfactory state of sanitation and disposal of wastes constitute major challenges for the public health system in India. Most of these public health determinants are correlated to high levels of poverty and to degradation of the environment in our villages. Thus, the country has to deal with multiple health crisis, rising costs of health care and mounting expectations of the people. The challenge of quality health services in remote rural regions has to be met with a sense of urgency. Given the scope and magnitude of the problem, it is no longer enough to focus on narrowly defined projects.

It is important here to understand the Rural Health Care System in India – the structure and current scenario. The Primary Health Care Infrastructure has been developed as a three tier system with:

A. Sub Centre,

B. Primary Health Centre (PHC) and

C. Community Health Centre (CHC) being the three pillars of Primary Health Care System.

A. The Sub-Centre is the most peripheral and first contact point between the primary health care system and the community. Each Sub-Centre is required to be manned by at least one Auxiliary Nurse Midwife (ANM) / Female Health Worker and one Male Health Worker. One Lady Health Visitor (LHV) is entrusted with the task of supervision of six Sub-Centres. Sub-Centres are assigned tasks relating to interpersonal communication in order to bring about behavioral change and provide services in relation to maternal and child health, family welfare, nutrition, immunization, diaorrhea control and control of communicable diseases programmes. The Sub-Centres are provided with basic drugs for minor ailments needed for taking care of essential health needs of men, women and children. There are 1,46,036 Sub Centres functioning in the country as on March 2008.

B. Primary Health Centre (PHC): PHC is the first contact point between village community and the Medical Officer. The PHCs were envisaged to provide an integrated curative and preventive health care to the rural population with emphasis on preventive and promotive aspects of health care. The  PHCs are established and maintained by the State Governments under the Minimum Needs  Programme (MNP)/ Basic Minimum Services Programme (BMS). As per minimum requirement, a PHC is to be manned by a Medical Officer supported by 14 paramedical and other staff. It acts as a referral unit for 6 Sub Centres. It has 4 - 6 beds for patients. The  activities of PHC involve curative, preventive, promotive and Family Welfare Services. There are 23,458 PHCs functioning as on March 2008 in the country.

C. Community Health Centre (CHC): CHCs are being established and maintained by the State Government under  MNP/BMS programme . As per minimum norms, a CHC is required to be manned by four  medical specialists i.e. Surgeon, Physician, Gynecologist and Pediatrician supported by 21  paramedical and other staff. It has 30 in-door beds with one OT, X-ray, Labour Room and Laboratory facilities. It serves as a referral centre for 4 PHCs and also provides facilities for obstetric care and specialist consultations. As on March, 2008, there are 4,276 CHCs  functioning in the country.

Strengthening of Rural Health Infrastructure Under National Rural Health Mission

The National Rural Health Mission (2005-12) seeks to provide effective healthcare to rural population throughout the country with special focus on 18 states, which have weak public health indicators and/or weak infrastructure. These 18 States are Arunachal Pradesh, Assam, Bihar, Chhattisgarh, Himachal Pradesh, Jharkhand, Jammu & Kashmir, Manipur, Mizoram, Meghalaya, Madhya Pradesh, Nagaland, Orissa, Rajasthan, Sikkim, Tripura, Uttarakhand and Uttar Pradesh. The Mission is an articulation of the commitment of the Government to raise public spending on Health from 0.9% of GDP to 2-3% of GDP. It has as its key components provision of a female health activist in each village; a village health plan prepared through a local team headed by the Health & Sanitation Committee of the Panchayat; strengthening of the rural hospital for effective curative care and made measurable and accountable to the community through Indian Public Health Standards (IPHS); integration of vertical Health & Family Welfare Programmes, optimal utilization of funds & infrastructure, and strengthening delivery of primary healthcare. It seeks to revitalize local health traditions and mainstream AYUSH into the public health system. It further aims at effective integration of health concerns with determinants of health like sanitation & hygiene, nutrition, and safe drinking water through a District Plan for Health. It seeks decentralization of programmes for district management of health and to address the inter-State and inter-district disparities, especially among the 18 high focus States, including unmet needs for public health infrastructure. It also seeks to improve access of rural people, especially poor women and children, to equitable, affordable, accountable and effective primary healthcare.

The Vision of the Mission

•  To provide effective healthcare to rural population throughout the country with special focus on 18 states, which have weak public health indicators and/or  weak infrastructure. 18 special focus states are Arunachal Pradesh, Assam, Bihar, Chattisgarh, Himachal Pradesh, Jharkhand, Jammu and Kashmir, Manipur , Mizoram,  Meghalaya, Madhya Pradesh, Nagaland, Orissa , Rajasthan, Sikkim, Tripura,  Uttaranchal and Uttar Pradesh.
•  To raise public spending on health from 0.9% GDP to 2-3% of GDP, with improved arrangement for community financing and risk pooling.
• To undertake architectural correction of the health system to enable it to effectively handle increased allocations and promote policies that strengthen public health management and service delivery in the country.
• To revitalize local health traditions and mainstream AYUSH into the public health system.
• Effective integration of health concerns through decentralized management at district, with determinants of health like sanitation and hygiene, nutrition, safe  drinking water, gender and social concerns.
•  Address inter State and inter district disparities.
•  Time bound goals and report publicly on progress.
• To improve access to rural people, especially poor women and children to  equitable, affordable, accountable and effective primary health care.

The Objectives of the Mission

• Reduction in child and maternal mortality
• Universal access to public services for food and nutrition, sanitation and hygiene and universal access to public health care services with emphasis on services
• Addressing women’s and children’s health and universal immunization
• Prevention and control of communicable and non-communicable diseases, including locally endemic diseases.
• Access to integrated comprehensive primary health care.
• Population stabilization, gender and demographic balance.
• Revitalize local health traditions & mainstream AYUSH.
• Promotion of healthy life styles.

The expected outcomes from the Mission as reflected in statistical data are:

• IMR reduced to 30/1000 live births by 2012.
• Maternal Mortality reduced to 100/100,000 live births by 2012.
• TFR reduced to 2.1 by 2012.
• Malaria Mortality Reduction Rate - 50% up to 2010, additional 10% by 2012.
• Kala Azar Mortality Reduction Rate - 100% by 2010 and sustaining elimination until 2012.
• Filaria/Microfilaria Reduction Rate - 70% by 2010, 80% by 2012 and elimination by 2015.
• Dengue Mortality Reduction Rate - 50% by 2010 and sustaining at that level until 2012.
• Cataract operations-increasing to 46 lakhs until 2012.
• Leprosy Prevalence Rate –reduce from 1.8 per 10,000 in 2005 to less that 1 per 10,000 thereafter.
• Tuberculosis DOTS series - maintain 85% cure rate through entire Mission Period
• Upgrading all Community Health Centers to Indian Public Health Standards.
• Increase utilization of First Referral units from bed occupancy by referred cases of less than 20% to over 75%.
• Engaging 4,00,000 female Accredited Social Health Activists (ASHAs). The expected outcomes at Community level
• Availability of trained community level worker at village level, with a drug kit for generic ailments.
• Health Day at Aanganwadi level on a fixed day/month for provision of immunization, ante/post natal check ups and services related to mother and child health care.
• Availability of generic drugs for common ailments at sub Centre and Hospital level.
• Access to good hospital care through assured availability of doctors, drugs and quality services at PHC/CHC level and assured referral-transport-communication systems to reach these facilities in time.
• Improved access to universal immunization through induction of Auto Disabled Syringes, alternate vaccine delivery and improved mobilization services under the programme.
• Improved facilities for institutional deliveries through provision of referral transport, escort and improved hospital care subsidized under the Janani Surakshya Yojana (JSY) for the below poverty line families.
• Availability of assured health care at reduced financial risk through pilots of Community Health Insurance under the Mission.
• Provision of household toilets.
• Improved outreach services to medically under-served remote areas through mobile medical units.
• Increase awareness about preventive health including nutrition.

The core strategies of the Mission

• Train and enhance capacity of Panchayati Raj Institutions (PRIs) to own, control and
• Promote access to improved healthcare at household level through the female health
• Health Plan for each village through Village Health Committee of the Panchayat.
• Strengthening sub-centre through better human resource development, clear quality standards, better community support and an untied fund to enable local planning and action and more Multi Purpose Workers (MPWs).
• Strengthening existing (PHCs) through better staffing and human resource development policy, clear quality standards, better community support and an untied fund to enable the local management committee to achieve these standards.
• Provision of 30-50 bedded CHC per lakh population for improved curative care to a normative standard. (IPHS defining personnel, equipment and management standards, its decentralized administration by a hospital management committee and the provision of adequate funds and powers to enable these committees to reach desired levels)
• Preparation and implementation of an inter sector District Health Plan prepared by the District Health Mission, including drinking water, sanitation, hygiene and nutrition.
• Integrating vertical Health and Family Welfare programmes at National, State level.
• Technical support to National, State and District Health Mission, for public health management.
• Strengthening capacities for data collection, assessment and review for evidence based planning, monitoring and supervision.
• Formulation of transparent policies for deployment and career development of human resource for health.
• Developing capacities for preventive health care at all levels for promoting healthy life style, reduction in consumption of tobacco and alcohol, etc.
• • Promoting non-profit sector particularly in underserved areas.

The supplementary strategies of the mission

• Regulation for Private sector including the informal Rural Medical Practitioners (RMP) to ensure availability of quality service to citizens at reasonable cost.
• Promotion of public private partnerships for achieving public health goals.
• Mainstreaming AYUSH – revitalizing local health traditions.
• Reorienting medical education to support rural health issues including regulation of medical care and medical ethics.
• Effective and visible risk pooling and social health insurance to provide health security to the poor by ensuring accessible, affordable, accountable and good quality hospital care.

Health Indicators of India  vis-à-vis  eight North Esat States             

Comparative figures of major health and demographic indicators are as follows:  

Table I: Demographic, Socio-economic and Health profile of the North East State as compared to India figures 

 (Source: RHS Bulletin, March 2008, M/O Health & F.W., GOI)  

Progress of NRHM in Assam (June 2009)

NHRM gives a new thrust to the health activities in the country in general and the rural areas in particular. The State of Assam is persistently progressing towards attaining the goals and objectives shared under National Rural Health Mission (NRHM), National Population Policy (NPP) and Millennium Development Goals (MDG). The activities under National Rural Health Mission are transforming the health care delivery to rural populace with increasing accessibility to quality services and the opportunity to participate actively in managing these services as well. The state has increased coverage under JSY; improvement in infrastructure; availability of paramedical and medical personnel. Brief information on the progress is as follows:

Institutional Framework of NRHM

Rogi Kalyan Samities are operational at 22 DH, 103 CHCs & 844 PHCs. All districts have started developing their own IDHAP.

Infrastructure Improvements

A total of 149 PHC have been strengthened with three Staff Nurses each and 297 are functional for 24x7 work. State has 100 CHC functioning on 24X7 basis & facility survey completed in 93 health institutions at below district level. 22 District Hospitals are functioning as FRUs. 23 districts have functional Mobile Medical Unit (MMU)

Human Resources

A total of 26,225 ASHAs have been selected & 26,225 are trained upto 4th Module. And, 26225 ASHAs have been provided with drug kits. A total of 5029 Sub-centres are functional with an ANM and 2540 SCs are strengthened with 2nd ANM. State has appointed 232 Contractual AYUSH Doctors. As far as manpower augmentation is concerned, 117 specialists, 178 Doctors, 2112 SN, and 4334 ANM recruited on contractual basis to provide quality health services. Services Institutional deliveries have improved from 1.92 lakhs (2006-07) to 3.23 lakhs (2007-08). During the year 2008-09 there were 3.57 lakhs Institutional deliveries in the state. The JSY beneficiaries increased from 1.90 lakhs (2006-07) to 3.05 lakhs (2007-08). During the year 2008-09 the JSY beneficiaries numbers is 3.28 lakh. Female sterilizations have increased from 0.03 lakh (2006-07) to 0.20 lakh (07-08) and male sterlisation has increased from 11 (2006-07) to 19 (2007-08).

During the year 2008-09, 47916 female & 1144 male sterilization has been done so far. 5 districts are implementing IMNCI & 923 people trained so far. 401838 VHND held since the launch of NRHM.  First Phase of Community Monitoring has been operationalised in the state.

General

Overall improvement in health system since NRHM

Achievements made - • Increase in general utilization of OPD & indoor services, institutional delivery, and routine immunization. •VHSC and RKS instituted at village and facility level.

• 26,225 ASHAS have completed Module IV training and are positioned with drug kits as well.
• Weekly radio programme is popular.
• Dibrugarh boat clinic is a good initiative for island communities.
• Special efforts being made for services to tea plantation workers people living in tribal and char areas.
• Full coverage of immunization has improved.
• First phase of community monitoring pilot has been completed in the state.

Infrastructure

• Substantial improvement in infrastructure. Need for further improvement of quality and range of services. Wards are patient friendly with clean linen, sufficient lighting and clean toilets. Segregation of waste with deep burial at health institutions. • Facility surveys have been completed, need to rationalise the upgradation and construction.

Human Resources

• Contractual appointments of doctors and paramedics to rationalize the positioning at the health facilities. •Need for cadre review of doctors and paramedics to retain good human resource.
• Need for coordination between NRHM and the Directorate of Health.
• The regular cadre of health personnel still not fully involved. Cleavages between public health system and NRHM.

Service Delivery

• Institutional births gone up to 60% from 37%. Home births need attention as well.
• NGOs are involved in community monitoring programme. There could be greater involvement.

Critical Areas for Concerted Action

The launch of NRHM has provided the Central and the State Governments with a unique opportunity for carrying out necessary reforms in the Health Sector. The reforms are necessary for restructuring the health delivery system as well as for developing better health financing mechanisms. The strengthening and effectiveness of health institutions like SHCs/PHCs/CHCs/Taluk/District Hospitals have positive consequences for all health programmes [TB, Malaria, HIV/AIDS, Filaria, Family Welfare, Leprosy, Disease Surveillance etc.] as all programmes are based on the assumption that a functioning public health system actually exists. The submission of the Task Force Reports and the recently published Reports of the Commission on Macroeconomics and Health and Mid-Term Appraisal by the Planning Commission provide valuable insights on these issues. In order to improve the health outcomes, it is necessary to give close attention to critical areas like service delivery, finances (including risk pooling), resources (human, physical, knowledge technology) and leadership. The following are identified as some of the areas for concerted action:

• Well functioning health facilities;
• Quality and accountability in the delivery of health services;
• Taking care of the needs of the poor and vulnerable sections of the societyand their empowerment;
• Prepare for health transition with appropriate health financing;
• Pro-people public private partnership;
• Convergence for effectiveness and efficiency.
• Responsive health system meeting people’s health needs.

It is hoped that  States will carefully look into these recommendations to address the constraints for a meaningful  delivery of health services to the rural population of the country.

[Dr. S. I. Ahmed is a civil society activist of North East India involved in providing health care services to the most underpriviledged & marginalized population of the region since 1980. As the Founder & Chairman of  AIDS Prevention Society,  a premier Civil Society Organization of North East India  based in Guwahati  , Assam, Dr. Ahmed  implemented pioneering targeted  intervention projects in the country   for slowing down the epidemic of HIV/AIDS  and in  providing treatment ,care & support to  PLWHA (People Living With HIV/AIDS ) in North East India.  Recipient of UNAIDS Award in 2005  “Recognising his contribution in the Global fight against AIDS” , Dr Ahmed was twice invited to the UN General Assembly in New York in 2006 & 2008 to address HIV/AIDS issues.]