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NRHM: New hope for the rural poor

By Abhijit Das

The mission provides for a health activist in each village, a village health plan prepared by a local team headed by a panchayat representative, strengthening of rural hospitals for effective curative care and accountability to the community

There are stark disparities in the healthcare services available to rural and urban Indians. While world-class five-star hospitals have sprung up in various cities across the country, encouraging the new growth industry of medical tourism, facilities in rural India languish. A countrywide study conducted a few years ago (RCH Facility Survey 1st round) found that less than 50% of primary health centres (PHCs) had a labour room or a laboratory, and less than 20% had a telephone. Less than a third of these centres stocked iron and folic acid, a very cheap but essential drug.

Rural healthcare service delivery is thus severely compromised. Despite major advances in medical science, people continue to die in large numbers from preventable illnesses like tuberculosis, gastroenteritis and malaria. Five lakh succumb to tuberculosis alone. Emergency services for delivery complications are unavailable outside cities, and, as a result, maternal death rates in the northern states rival those of sub-Saharan African countries. India accounts for a fourth of all maternal deaths worldwide, and the numbers are increasing. Uttar Pradesh, with its huge population base and very poor health system, contributes a large proportion to the overall preventable mortality and morbidity in the country. But its healthcare delivery system is preoccupied with the pulse polio campaign and with chasing family planning targets (see box).

If it delivers on its promises, the planned National Rural Health Mission (NRHM) could change the face of rural healthcare in India . On January 4, 2005 , cabinet approved the formation of this mission which aims to improve the access of rural people, especially poor women and children, to equitable, affordable, accountable and effective primary healthcare.

The mission seeks to integrate different vertical health programmes, decentralise healthcare service delivery at the village level and improve intersectoral action. It 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, over the next five years.

The NRHM is expected to substantially reduce maternal and infant mortality and communicable diseases within the next four years. It is focussed on 18 states that have weak public health indicators, including the seven northeastern states, and 11 states in north and eastern India .

Key components of the mission include the provision of a health activist in each village; a village health plan prepared through a local team headed by the panchayat representative; strengthening of rural hospitals for effective curative care and accountability to the community; and integration of vertical health and family welfare programmes.

The mission proposes a village health plan, to be drawn up by members of the community in partnership with the auxiliary nurse midwife (ANM) and anganwadi worker. It also makes provision for employing nearly 300,000 rural women health workers who will provide frontline healthcare to the community. These health workers will not only offer simple remedies such as the oral rehydration mix but will also motivate families to adopt clean drinking water practices, sanitation and safe pregnancy and delivery.

The provision of curative services at the peripheral level is an area of weakness in present government healthcare service delivery. There is an acute shortage of medical officers. The NRHM proposes to strengthen curative services from the village up. There will be two people at each sub-centre (auxiliary nurse midwives or health workers) and PHC (medical officers), so that one person is available for curative services. Community health centres (CHCs) are to be strengthened as rural hospitals so that emergency surgery and hospitalisation are possible round the clock. This requires operationalising 3,215 existing CHCs (30-50 beds) as 24-hour first referral units.

Protocol and standards for curative services will be codified into the Indian public health standards to ensure quality of care. Stakeholders' committees (Rogi Kalyan Samitis) will be promoted for hospital management so that the health facilities are accountable to the community.

The National Rural Health Mission is a bold proposition aimed at changing the way healthcare services are prioritised and delivered in India . But, while it is true that the moribund government healthcare services need bold measures to revitalise them, there is also a sense of déjà vu. Many new health-related programmes have been initiated over the years, and others re-organised, but the results have always lagged far behind the projections. And, the more things change the more they tend to remain the same. Take, for example, the family welfare programme -- the most active health-related initiative in the country. In the last decade, this programme has seen a whole slew of new initiatives, but it seems to be delivered the same way it was a long time ago. Not so long ago, family planning targets were given to ANMs and anganwadi workers and even the district magistrate's work was judged by the number of cases obtained from his/her district. Then, the target-free approach was announced and there was a general sigh of relief. However, the situation now seems to have reverted to the earlier state. Reports from Uttar Pradesh, Madhya Pradesh and Rajasthan indicate that not only are targets in place once again, but there are inducements like gun licences for getting sterilisation cases.

Hopefully the National Rural Health Mission will be different and will deliver on a significant number of its promises. However there are still many unanswered questions and unresolved issues. The idea of a village health worker is not new. There was an earlier scheme of a village health worker (VHW), who was paid Rs 50, in the late-'70s. The ASHA (the reincarnated VHW) will not be paid a fixed honorarium and is expected instead to earn a living from performance-linked incentives. A similar experiment of the Jan Swasthya Rakshak, currently operating in Madhya Pradesh, has not brought about much improvement in the healthcare indices. Some authorities note that it has, instead, led to the creation of a new rural political cadre as well as a new class of informal private practitioners. There is also concern that instead of becoming a community activist, this person may end up as an auxiliary to the ANM.

Improving the access of the poor to affordable healthcare services has to be seen in the context of the health systems development projects that are being implemented in many Indian states. These World Bank-supported projects have a set of simplistic prescriptions for improving health service delivery. There is a fee for service and public-private partnerships which include a range of options from contracting out hospital services to promoting private practitioners. There are examples from African countries where fees for services have further reduced the access of the poor to essential healthcare services like safe delivery services. Getting formally trained private healthcare providers to serve rural India , especially in some states, is not a feasible option because if it were they would already have been there. Thus the challenge of providing quality and affordable healthcare services remains, particularly because many earlier experiments need to be reversed.

The most important hurdle will be getting different states to take ownership of the entire process. Health is a state subject in India and most of the financial outlay (upto 85% of government spending) is made by the state governments. Appointing personnel, filling vacancies, ensuring district-level coordination, and enabling community and panchayat institutions to have a role in planning and monitoring services are all functions that require the active participation of the state government.

The poor in India have always lived in hope; the National Rural Health Mission has become a new hope for them. It will take a concerted effort between the state and central governments, a partnership between the government and the non-government sector, a common commitment to standards by providers and managers, and faith in the people's ability to make plans and monitor them for this hope not to be betrayed.

40,000 women die in childbirth every year in UP

Uttar Pradesh's shocking statistics on maternal and child health bring the state of public healthcare in rural India into sharp focus

Healthwatch UP/Bihar and KRITI Resource Centre, Lucknow , report some shocking statistics on maternal and infant health in the state of Uttar Pradesh:

  • Total population of Uttar Pradesh:  16.6 crore (2001 census)
  • Crude birth rate in Uttar Pradesh:  32.9 per 1,000 population (e-Census India , Issue 13, August 2002)
  • Infant mortality rate in Uttar Pradesh: 85.1 per 1,000 live births (e-Census India , Issue 13, August 2002)
  • Neonatal mortality rate in Uttar Pradesh: 51.4 per 1,000 live births (NFHS 2-1998 99)
  • Maternal mortality rate: 707 per 100,000 live births (Sample Registration System 1998)
  • All recommended types of antenatal care: 4.4% (NFHS 2-1998- 99)
  • Birth attended by skilled attendant: 22.4% (NFHS 2-1998-99)
  • Delivery at a medical institution: 15.5% (NFHS 2-1998-99)
  • Post-natal care: 7.2% (NFHS 2-1998-99)

These statistics reveal that around 54,00,000 children are born in Uttar Pradesh each year. Of these, 450,000 infants die before they are one year old, and 275,000 infants die before the age of one month. The rate of infant mortality in Uttar Pradesh is among the highest in the country.

Nearly 40,000 women lose their lives giving birth, each year. The rate of maternal mortality in Uttar Pradesh is the highest in the country and roughly one out of every 15 maternal deaths worldwide takes place in Uttar Pradesh.

Of the more than 54,00,000 pregnant women, only 225,000 receive the full check-up and care that they require during pregnancy. Over 40,00,000 women deliver without any skilled attendant present, and over 45,00,000 deliver at home. Of the women who deliver at home, 42,00,000 are not visited by a health worker even two months after childbirth.

Conditions at government health centres and hospitals
The Government of India conducted a survey to understand the status of government healthcare facilities in 2000. The report on Uttar Pradesh mentions:

Total number of PHCs surveyed: 486. Of these 486 PHCs only 10 had a working telephone, 418 did not have a working vehicle. A medical officer was not present at 107 PHCs. Female health staff was not complete in 442 PHCs; male staff was incomplete in 403 places. As far as equipment is concerned, 342 PHCs did not have labour room equipment; 418 places did not have normal delivery kits; and 467 places did not have emergency delivery kits/drugs.

Of a total number of 34 first referral units surveyed (FRUs are hospitals like community health centres and district hospitals where facilities for Caesarean operations should be available), 16 FRUs did not have a working vehicle, 24 FRUs did not have a telephone. Eighteen FRUs had an obstetrician posted, but only two places had an anaesthetist. Anaesthesia equipment was available in 16 places, but emergency labour drugs were only available in six places. Oxygen cylinders were available in 19 places.

Source: http://mohfw.nic.in

(Abhijit Das works on public health and human rights issues, and is associated with various organisations, networks, grassroots groups and related campaigns. He is currently adviser to SAHAYOG, an NGO based in India, and clinical assistant professor at the School of Public Health and Community Medicine, University of Washington , Seattle , USA . Email: This email address is being protected from spambots. You need JavaScript enabled to view it.This email address is being protected from spambots. You need JavaScript enabled to view it.">)

InfoChange News & Features, June 2005