30 March 2014

health of NRHM

SPECIAL ARTICLE
Economic & Political Weekly EPW january 22, 2011 vol xlvi no 4 53
Zakir Husain (dzhusain@gmail.com) is at the Population Research
C entre, Institute of Economic Growth, Delhi.
Health of the National Rural Health Mission
Zakir Husain
The National Rural Health Mission was introduced as a
flagship scheme of the United Progressive Alliance
government in 2005-06 to address the needs of the rural
population through an architectural correction of the
health system. With the completion period drawing to a
close in 2012, this paper critically evaluates the success of
the intervention strategies under this scheme. Based on
rapid appraisal surveys in selected districts, three
common review missions by the Ministry of Health and
Family Welfare, and data reported on the NRHM website,
this paper attempts a desk review of the progress of the
mission with respect to its core strategies – provisioning
of health services to households through accredited
social health activists, strengthening rural public health
facilities, enhancing capacity of panchayats to control
and manage provisioning of health services and
positioning of an effective health management
information system.
1 Introduction The Alma-Ata Declaration in 1978 called on all governments
to “formulate national policies, strategies and plans
of action to launch and sustain primary health care as part
of a comprehensive national health system”. In India, however,
health has traditionally received low priority in the central and
state budgets. Expenditure on the health sector comprised, for
instance, less than 1% of the gross domestic product (GDP) in
1999 – one of the lowest in the world. Further, there was a considerable
urban bias characterising health policies and investment
strategies – about 75% of the resources and infrastructure were
concentrated in urban India (Patil et al 2002). The resultant increase
in the incidence of both communicable and non-communicable
diseases, coupled with poor health facilities in rural areas
r esulted in high infant, child and maternal mortality rates.
While the United Progressive Alliance government integrated
public health as a critical component into its common minimum
programme, this objective could not be attained without providing
efficient and affordable healthcare services to the rural
p opulation, which constitute three-fourths of India’s population.
However, the sheer enormity involved in servicing a population
of over 74 crore calls for integrated macroeconomic and grassroot
level efforts to improve the rural health infrastructure,
e nsuring adequate presence of healthcare manpower and addressing
local needs and concerns.
The need for a concerted targeting of rural India led the government
to introduce the National Rural Health Mission (NRHM)
as its health flagship scheme in 2005. The objective of this scheme
was to “carry out necessary architectural correction in the basic
health care delivery system … 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” (GOI 2005: 1).
This objective is sought to be attained through strategies aimed
at improving household health status through the introduction of
female health activists, strengthening the three-tiered public
health system, increasing community participation through the
involvement of panchayati raj institutions (PRIs) and strengthening
capacities for data collection to facilitate evidence-based
planning, monitoring and supervision.
With the deadline of this scheme drawing to a close in 2012, it
is an appropriate time to undertake an evaluation of the success
of the NRHM. Three common review missions (CRMs) have been
completed. The population research centres (PRCs) have undertaken
a first round evaluation of the mission based on rapid
a ppraisal methods in select districts on behalf of the Ministry of
Health and Family Welfare.1 These reports and the data available
from the NRHM website provide a useful source of secondary
SPECIAL ARTICLE
january 22, 2011 vol xlvi no 4 EPW Economic 54 & Political Weekly
Figure 1: Infrastructural Deficiency under NRHM (2008)
􀀃
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􀀘􀀓􀀓􀀓􀀓􀀃
􀀔􀀓􀀓􀀓􀀓􀀓􀀃
􀀔􀀘􀀓􀀓􀀓􀀓􀀃
􀀕􀀓􀀓􀀓􀀓􀀓􀀃
􀀶􀀦􀀃 􀀳􀀫􀀦􀀃 􀀦􀀫􀀦􀀃
􀀓􀀃
􀀔􀀓􀀃
􀀕􀀓􀀃
􀀖􀀓􀀃
2,00,000 􀀗􀀓􀀃
1,50,000
1,00,000
50,000
0
40
30
20
10
0
SC PHC CHC
Number required under NRHM
Number available
16 Deficit (%)
13
37
Source: Estimated from http://www.mohfw.nic.in/NRHM/Documents/Executive_summery_
January10.pdf
Table 1: Facilities and Personnel Available in Public Health Facilities in High Focus States (2009, in %)
Indicators Uttar Madhya Assam Jammu and Chhattisgarh Himachal Rajasthan
Pradesh Pradesh Kashmir Pradesh
Sub-centres surveyed (number) 60 36 24 24 12 12 24
Functioning in own government building 61.7 53.4 91.7 75.0 8.3 91.7 100
IPHS facility survey done 25.0 0 29.2 100 100 33.3 29.2
Sub-centres with ANM quarter 41.7 37.5 41.7 4.2 16.7 83.3 58.3
Labour room available 36.7 22.4 16.7 4.2 8.3 0 37.5
Labour room currently in use 25.0 0 0 4.2 8.3 0 37.5
Primary health centres surveyed (number) 20 12 8.0 8 4 4 8
With 4-6 beds 45.0 58.3 37.5 62.5 50 25.0 50
Labour room available 40 91.7 87.5 75.0 50 75.0 100
New born care corner 0 16.7 25.0 12.5 0 0 0
Names of JSY beneficiaries maintained in record 50 75.0 100 75.0 0 50 100
IPHS facility survey done 10 25.0 37.5 100 100 50 25.0
Functioning 24x7 20 33.3 62.5 25.0 0 25.0 37.5
Provide basic obstetric services 45.0 41.7 62.5 62.5 0 0 62.5
Labour room currently in use 25.0 83.3 87.5 62.5 0 25.0 100
Community health centres surveyed (number) 10 6 4 4 2 2 4
CHCs with 30 or more beds 40 16.7 50 25.0 100 50 75.0
Operation theatre available 100 100 75.0 75.0 100 100 50
Operation theatre used for gynaecological purposes 20 33.3 25.0 25.0 0 50 50
Labour room available 100 100 100 100 100 100 100
Functioning on 24x7 basis 90 100 100 100 100 50 100
IPHS facility survey done 30 66.7 50 100 100 50 0
Surgery facilities available 50 16.7 50 50 50 0 50
Blood storage facility available 0 0 25.0 0 0 0 0
Emergency care for sick children available 60 0 25.0 25.0 0 0 25.0
Mobile medical unit available 20 33.3 25.0 0 0 0 50
ANM – auxiliary nurse midwife, JSY – Janani Suraksha Yojana.
Source: Estimated from State Fact Sheets, NRHM site /www.mohfw.nic.in/NRHM/PRC_Reports.htm
i nformation to undertake a desk review of the progress made so
far.2 This paper attempts such an evaluation, with a focus on
some key components: provisioning of healthcare at the household
level through the accredited social health activist (ASHA),
strengthening the rural public health facilities, decentralising
the health sector by enhancing the capacity of panchayats to control
and manage the provisioning of health services, and positioning
of a health management information system.
2 Strengthening Rural Public Health Facilities
One of the core strategies for providing accessible healthcare to
the population is to strengthen the sub-centres (SCs), primary
health centres (PHCs) and community health centres (CHCs) –
units where healthcare is actually delivered. Accordingly, the
NRHM envisages sanctioning of new SCs as per 2001 population
norms, upgrading existing SCs, provisioning 24-hour service
in half of the PHCs, upgrading all the PHCs and 3,222 CHCs as
24-hour First Referral Units (FRUs), etc.
2.1 Deficiencies in Physical Infrastructure
Using data from the NRHM portal, we have estimated the number
of units required, the number available and the deficit (as a proportion
of available units) in Figure 1. It can be seen that a substantial
deficit persists, particularly at the CHC level.
The extent to which attainments have fallen short of targets is
also indicated through the estimates of PHCs that are functional
for 24 hours. Despite an increase of 44% (between 2005 and
2010) in their numbers, such PHCs comprise only 36% at the
all-India level and 27% in high focus states. The corresponding
fi gures for CHCs are 93% and 88%, respectively. The progress
with respect to upgradation is also a matter of concern. About
71% of the CHCs have been selected for upgradation. While facility
surveys have been undertaken in 95% of these CHCs, the process
of physical ugradation has been started in only 65% of the
CHCs and completed in only a third of the CHCs. Another disturbing
feature is that about 46% of the SCs are not operating out of
government buildings. This figure is slightly higher in high focus
states (49%). The evaluation surveys undertaken by the PRCs also
reveal that the availability of functional labour rooms is very low
and that the Indian Public Health Standards (IPHS) facility survey
remains to be undertaken in the majority of SCs (Table 1). Gill’s
study (2009) also notes the lack of regular electricity supply to
SCs in some states like Uttar Pradesh (UP).
The situation in PHCs and CHCs is equally distressing. In majority
of the states surveyed, PHCs did not have 4-6 beds, or care corner
for newborn babies. Few PHCs are performing
on a 24-hour basis. Except for
Assam, Jammu and Kashmir (J&K)
and Rajasthan, provisioning of obstetric
facilities is poor. Although the situation
with respect to infrastructural
facilities in CHCs is reported to be satisfactory,
the non-availability of facilities
like mobile medical units,3 blood
storage, emergency care facilities for
children and surgery needs to be addressed
by the concerned states.
Gill (2009) found an absence of
toilet facilities and medical waste disposal
system in many SCs, PHCs and
CHCs. The general cleanliness of
PHCs and CHCs is also lamentably
poor, despite the presence of a sufficient
number of cleaning staff. Gill
suggests that this laxity could be explained
by the fact that awarding
regular or contractual cleaning jobs
was one of the few patronage tools
used by small-time decentralised
functionaries, such as the Hospital
Development Society mem bers, to
get known people employed and on
the pay roll (ibid: 23).
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Economic & Political Weekly EPW january 22, 2011 vol xlvi no 4 55
Table 2: Manpower Availability in Rural Public Health Facilities (as on 31 January 2010, in %)
Indicators Uttar Madhya Assam Jammu and Chhattisgarh Himachal Rajasthan
Pradesh Pradesh Kashmir Pradesh
Sub-centres surveyed (number) 60 36 24 24 12 12 24
ANM staying in sub-centre 18.3 15.1 20.9 0 8.3 8.3 54.2
Health worker male in position 20 44.1 0 58.4 33.3 91.7 0
Health worker female in position 91.7 61.8 70.8 70.9 83.3 50 62.5
Additional ANM contractual 60 42.9 83.4 29.2 0 0 37.5
No ANM 5.0 0 4.2 20.9 16.7 50 0
Arrangement for deliveries and referral between
8 PM and 8 AM 6.7 0 0 4.2 8.3 0 37.5
ANM been trained on the insertion/removal of
IUD A380 68.3 46.0 50 8.4 25.0 25.0 95.9
IUCD insertions being carried out using IUD A380 48.3 42.2 25.0 0 25.0 25.0 83.3
Primary health centres surveyed (number) 20 12 8 8 4 4 8
At least one medical officer 65.0 100 100 100 75.0 50 100
MO AYSUH available 20 33.3 37.5 100 0 0 25.0
Community health centres surveyed (number) 10 6 4 4 2 2 4
General surgeon available 70 33.3 25.0 50 0 0 25.0
Physician available 50 33.3 0 50 0 0 25.0
Obstetrician and gynaecologists available 70 16.7 75.0 50 0 0 0
Paediatrician available 70 50 25.0 25.0 0 0 0
MO trained in sbstetrics available 50 0 0 50 50 0 0
MO trained in anaesthesia available 20 0 0 0 0 0 0
Anaesthetist available 30 33.3 75.0 0 0 0 0
MO – Medical officer.
Source: Estimated from State Fact Sheets, NRHM site www.mohfw.nic.in/NRHM/PRC_Reports.htm
2.2 Shortage of Equipment and Medicine
The shortage of medical equipment also needs to be addressed by
the states. The rapid appraisal survey undertaken by the PRCs
o bserved shortages in basic equipment. Some evidence in this regard:
(i) None of the surveyed community centres in Kanpur-Dehat in
UP had any electrocardiogram (ECG) machines, operation theatre
(OT) care fumigation apparatus, and cardiac monitors for OTs.
(ii) Shortage of baby cradles, laryngoscope, wheelchairs were
observed in surveyed PHCs in the Sidhi district of Madhya
Pradesh.
(iii) None of the PHCs surveyed in Shrawasti (UP) had oxygen cylinders,
infant warmers, baby cradles, laryngoscope or wheelchairs,
while 75% of the PHCs did not have delivery tables.
(iv) Around 42% of the SCs surveyed in Anuppur (Madhya
Pradesh) did not have thermometers and fetoscopes; 83% lacked
sterilisers; and 92% did not have regent strips for urine tests.
(v) Around 42% of the SCs surveyed in Siddharth Nagar (UP)
were found to lack blood pressure apparatus and 75% did not
have fetoscopes.
It is necessary to identify common shortages at each level and
attempt to cover such deficits on a priority basis.
A similar shortage was also observed with respect to the medicine
stock. Surveys undertaken by the PRCs found a significant
gap in the supply of essential drugs to the PHCs. Gulati et al
(2009a) found that iron folic acid tablets, oral pills, vitamin A,
measles vaccine, oral rehydration salts and intrauterine device
(IUDs) were not regularly available in every three out of four PHCs
surveyed by them in UP. Even basic medicines like albendazole/
mabendazole tablets, bandages, cotrimoxazole syrup, etc, were
found to be out of stock or in irregular supply (ibid). The nonavailability
of medicine and material at the health facilities is
forcing patients to purchase them from private sources, where
the cost of medicine is substantially
higher (because of the large profit
margins maintained by intermediaries).
This is leading to high out of
pocket expenditures, defeating the
objective of providing accessible
healthcare services to vulnerable sections
of the population, and pushing
households below the poverty line.
Realising the need to provide
a utonomy and flexibility to meet
l ocal needs, the NRHM had stated that
SCs, PHCs and CHCs would receive
respectively Rs 10,000, Rs 25,000
and Rs 50,000 annually as untied
grants. Based on figures relating to
the disbursement of untied grants
to SCs in 2008-09, an attempt was
made to estimate the proportion of
SCs covered under this component.4
It appears that only 49% of SCs
r eceived such funds; the figure is
even lower in high focus states outside
the north eastern region (40%).
The corresponding figures for CHCs and PHCs are 36% and 42%,
respectively. Moreover, evaluation reports suggest that this
money was generally spent on meeting telephone and power
bills, maintenance, purchasing drugs and facilities for patients.
During the evaluation surveys, most local officials were found to
be unaware of the guidelines for utilising untied funds; the latter
also r eported that changes in the guidelines created confusion.
This indicates the need to further simplify procedures for spending
the untied funds. It is also necessary to monitor the proportion
of expenditure of such funds under different heads.
3 Deficiencies in Manpower
The quality of the health workforce is crucial in delivering good
health outcomes. Evaluation reports have highlighted a shortage
of manpower – of doctors at the PHC level and specialists at the
CHC level (Table 2). Data from the health ministry reveals that
11% of the PHCs do not have a doctor (this is 17% in high focus
states). At the CHC level, only 49% of the required specialist posts
have been sanctioned so far, and 25% positioned. Less than a
third of the required number of staff nurses has been positioned.
The proportion of auxiliary nurse midwives (ANMs) staying at
the SCs has reduced in several states, owing to the non-availability
of quarters for them. ANMs also attribute reluctance to reside in
staff quarters to the poor conditions of the quarters, lack of
i nfrastructural facilities and safety concerns. This has resulted in
a low proportion of SCs with arrangements for night delivery, and
is responsible for the continued dependence of the rural population
on district hospitals and private providers. In particular, the
lack of availability of delivery arrangements has affected the JSY
in many regions, thereby limiting the role of the ASHAs.
Manpower shortage in rural areas has emerged as a major
problem in other developing countries also. An examination of
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january 22, 2011 vol xlvi no 4 EPW Economic 56 & Political Weekly
the policies undertaken in other countries provides valuable insights
into how this problem can be tackled in the long run. A
cross-country study of the success of compulsory service shows
that such a strategy can work only when supported by economic
incentives (Frehywot et al 2010), though the type of incentives
that are likely to be attractive varies among countries (Blaaw et
al 2010). Some states like Rajasthan and Chhattisgarh have been
successful in designing an attractive combination of financial
and non-financial incentives (NRHM 2009a). Persons from rural
backgrounds may also be relatively willing to accept rural postings
(Serneels et al 2010); location-specific selection of ANMs in
West Bengal, for instance, has been successful in this regard.
Apart from lack of manpower, another factor that affects the
delivery of health services is absenteeism. Evaluation reports
identified the absence of social facilities like educational infrastructure
for children, irregular supply of electricity and potable
water, and safety of women in some of the rural tracts in UP, and
unhygienic and insanitation in villages and health facilities as
reasons underlying absenteeism and reluctance to accept rural postings.
This led to suggestions that such handicaps be compensated by
enhanced financial incentives in the form of non-practising and
transport allowances (Gulati et al 2009b).
This view has been criticised by Gill (2009), who points out
that given the lower cost of living in rural areas, paramedical and
medical staff in rural India fare quite well in real terms (particularly
after implementation of the Sixth Pay Commission recommendations).
Moreover, the disparity in the public/private pay
packages applies to all spheres and in all countries irrespective of
their levels of development. Rather, according to her, the main
reason for absenteeism and other manpower-related issues is the
complacency arising from the assured nature of regular lifetime
employment in the government sector, along with a complete
lack of monitoring by the state health hierarchy. This has eliminated
fear of reprisals (in the form of firing or transfers) for underperformance.
As a result, medical staff are scarcely accountable
to the rural community they supposedly serve. This affects the
ability to access health services, particularly by the poorer and
often illiterate category of patients. The principal-agent problem
characterising patient-provider relations inhibits any kind of protest
– “key informants actually articulated that the doctor might
give them the wrong medicines if they complained too much!”
(Gill 2009: 34-35).
States have relied on contractual employment to solve the
shortage of manpower. Under the NRHM, contractual appointments
to the extent of 14% have somewhat reduced this deficit.
This, however, may not be sustainable beyond the sanctioned
NRHM period, especially where states have not planned for such
expansion in their budgets (NRHM 2008).
Apart from the genuine shortage in manpower, health departments
in many states fail to utilise even the available resources
optimally, leading to misalignment of services demanded and
supplied. The third CRM has observed irrational deployment of
doctors in many areas. For instance, several specialists were not
performing procedures in which they were trained.5 It is therefore
necessary to improve the fit between posting of specialists
and the patient load.
3.1 Accredited Social Health Activist
Global experience shows that women, even when briefly trained,
can successfully increase the coverage of healthcare, particularly
if they are locally recruited and made accountable to the local
clients (Global Equity Initiative 2004). The introduction of the
ASHA is thus an important and welcome step. The NRHM envisages
that every village will have an ASHA, chosen by and accountable
to the panchayat, who will “act as the interface between the
community and the public health system”. ASHAs will be given
induction training and provided with a drug kit containing
g eneric AYUSH (Ayurvedic, Yogic, Unani, Siddhi and Homeopathic)
and allopathic formulations for common ailments. While
ASHAs will be volunteers, they will be given a performance-based
incentive for promoting immunisation, referral and escort services
for reproductive child health (RCH) and other health delivery
programmes. In addition, they are also to be involved in the preparation
of village health plans.
The ASHA website reveals that 7.49 lakh ASHAs have been
s elected from 2005-06 to 2009-10. While this is a large number,
implying that about 90% of all villages have been covered (Table 1);
the selection process has to be made more transparent. Although
norms for recruiting ASHAs state that they should be selected on
the basis of recommendations of ANMs, anganwadi workers and
the panchayat head, in many cases they are recruited from influential
families. In Madhya Pradesh, evaluation reports observed
that the majority of ASHAs belonged to influential families of the
villages and selection criteria such as education, willingness to
serve community and her background were not considered (Basu
2009: 148). Further, in some cases, wives of community health
workers were appointed, with most of their duties undertaken by
their husbands.
The position with regard to training and availability of kits is
also not satisfactory (Table 3). Though 94% of ASHAs have received
the first module training, only 26.6% have received the
fifth level of training. While this can be explained partly in terms
of the newness of the scheme – ASHAs inducted in the last two or
three years can hardly be expected to have received fourth or fifth
level training – it is also true that training is very discontinuous
Table 3: ASHAs Selected, Trained and Provided with Drug Kits
Indicators Years India HFS non-NE HFS NE NHFS (Large) NHFS
(Small)
and UTs
Number of 2005-06 1,30,315 1,19,642 10,673 0 0
ASHAs 2006-07 3,00,699 2,52,454 29,639 18,606 0
selected in
2007-08 1,71,931 58,270 5,718 1,07,702 241
2008-09 1,22,048 19,383 4,238 95,838 2589
2009-10 24,447 11401 2,733 10,313 0
Total 7,49,440 461150 53,001 2,32,459 2830
No of ASHAs per village 0.9 0.9 0.8 0.9 0.3
% of ASHAs First module 94.1 95.7 94.4 91.2 83.1
who have Second module 80.8 81.2 91.3 77.6 83.1
received
Third module 78.5 80.9 90.7 70.7 83.1
training
Fourth module 75.5 78.5 89.4 66.2 83.1
Fifth module 26.6 18.3 69.5 33.8 3.1
No of ASHAs with drug kits 69.4 75.8 90.8 51.6 84.9
HFS – High focus states; NE – North-eastern states; NHFS – Non-high focus states.
Source: Estimated from http://www.mohfw.nic.in/NRHM/Documents/Executive_summery_
January10.pdf.
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Economic & Political Weekly EPW january 22, 2011 vol xlvi no 4 57
and infrequent, and most states do not even reach a minimum of
12 days training per year (against the desirable period of 28 days).
The quality of training has also been observed to vary between
states due to a weak support structure. The experience of Andhra
Pradesh shows that making such training residential improves
quality. Fieldwork and visits should also be made an important
part of the training to ensure on the job training of ASHAs.
The provisioning of drug kits also needs to be improved. In
2008-09, only 56% of ASHAs had received kits. While the situation
did improve in 2009-10, the current figure (69%) is still low.
It has also been claimed that the kit often contains just four medicines
(iron tablets, chloroquine, paracetamol and oral hydration
therapy packets); ayurvedic and homeopathic medicines have
not been supplied to most of the ASHAs (Ashtekar 2008: 25). Evaluation
reports also list complaints by ASHAs that their kits are not
adequate and contain drugs close to the expiry date. Timely refilling
of drugs is not undertaken in many states.6 This has
r estricted the role of ASHAs to essentially providing directly
o bserved treatment, short course (DOTS), immunisation, institutional
deliveries, and antenatal checkups. Even with respect to
increasing coverage of women under the JSY, as revealed by the
evaluation reports, delays in the release of funds have eroded the
faith of the community in ASHAs.7 In several states like J&K and
Madhya Pradesh, delays in receiving
incentives have resulted in dropouts
of ASHAs (Bajpai et al 2009; Bhat
et al 2009).8 Ashtekar (2008) also
r eports unhealthy competition between
ASHAs and anganwadi, with the
latter viewing ASHAs as encroaching
upon their jurisdiction and reducing
their income.
At the same time, it would be hasty
to dismiss the ASHA scheme as a failure.
A study by Bajpai et al (2009)
found that the introduction of ASHAs
has had a positive impact in increasing the proportion of women
taking at least three antenatal checkups and immunisation institutional
deliveries. It should also be kept in mind that the scheme
requires the volunteers to play an activist role in communities
which are often characterised by religion and caste politics, conservative
attitudes and where women are still looked down upon.
Expecting partially trained local volunteers to adapt to the complex
dynamics of Indian rural communities and effect an immediate
radical change in the situation is expecting too much. It is
necessary to persist with the scheme and strengthen it by providing
ASHAs with improved support structure, regular financial incentives
and better quality of ser vices through training. This will
ensure that their activism is gradually accepted so that they can
become “social workers”, rather than merely “health workers”.
3.2 Mainstreaming Indigenous Health Systems
In order to meet the manpower and drug shortage in rural areas,
the NRHM seeks to revitalise local health traditions and mainstream
AYUSH infrastructure. This is sought to be attained
through two means: (i) AYUSH medicine shall be included in the
drug kit provided to ASHAs, and additional supply of generic drugs
for common ailments at SCs, PHCs and CHCs under the mission
shall also include AYUSH formulations, and (ii) AYUSH practitioners
will be mainstreamed at the PHC and CHC level – single doctor
PHCs will be upgraded to two doctor PHCs by incorporating an
AYUSH practitioner, and at the CHC level, two rooms will be provided
for an AYUSH practitioner and a pharmacist.
AYUSH is an innovative strategy with important implications for
the provisioning of healthcare services and increasing choice
available to households (Sinha 2009). Duggal (2009) reports that
expenditure under this head has increased fourfold between 2005-
06 and 2009-10. There has also been a concerted attempt to incorporate
AYUSH components in the state programme implementation
plans (PIPs) and in different organisations like health societies,
state health missions, rogi kalyan samitis (RKS) and ASHA
training. The record has been mixed. While AYUSH has been incorporated
in the PIPs of most states, its record in ASHA training is
quite poor – it has been introduced in only 56% of the states.
In particular, the record with respect to integrating AYUSH
components into the health delivery system at the grass-root
level leaves much to be desired (Figure 2). The health management
information system (HMIS) data reveals that AYUSH staff
has been integrated in only 49% of the district hospitals, 37% of
the CHCs and 29% of the PHCs. The record of such integration is
also low in priority states outside the north-eastern region. The
concurrent evaluation undertaken in 2009 by the PRCs on behalf
of the health ministry also presents a disappointing picture. Except
in J&K, less than a third of the PHCs surveyed in UP, Uttarakhand,
Madhya Pradesh and Rajasthan have AYUSH practitioners.
In J&K, where the record of mainstreaming is relatively better,
A YUSH practitioners complain that the lack of AYUSH drugs
and pharmacists trained to deal with such drugs, and preference
of patients for allopathic drugs have limited their role in offering
alternative healthcare services. In fact, a study of Rajouri, a district
in J&K, observes that in such circumstances many AYUSH
doctors are forced to offer allopathic drugs to their patients (Bhat
et al 2009).
The availability of AYUSH practitioners has, in many cases,
managed to sustain demand for public health facilities. A study
by the Planning Commission, however, questions the limits to
which alternative AYUSH practitioners can substitute for allopathic
medical staff. Although the former can provide effective
remedies in the case of minor and certain kinds of chronic
Figure 2: Integration of AYUSH Staff in Healthcare Institutions (2010, in %)
100
80
60
40
20
0
India High focus High focus Non-focus Non-focus
non-NE states NE large states small states/UTs
DH
CHC
PHC
Source: Estimated from http://www.mohfw.nic.in/NRHM/Documents/Executive_summery_
January10.pdf
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a ilments, such as skin and digestion-related illnesses, their remedial
skills are inadequate in the cases of surgery and extreme lifethreatening
conditions (Gill 2009). Thus, AYUSH practitioners
should be conceived as a supplement to allopathic staff, and not
their substitute. Further, their deployment should be keeping in
mind the load of facilities and the observed preference of the
public for AYUSH doctors only in the case of chronic ailments.
4 Decentralising Health Sector
Recognising the importance of involving grass-root level organisations
in the healthcare delivery system, the NRHM has sought to
encourage decentralisation as part of its core strategy.
4.1 Role of Gram Panchayats
As pointed out by Gulati et al (2009b), decentralisation facilitates
the integrated delivery of health services through the convergence
of services like drinking water, sanitation, nutrition, empowerment,
etc, that are of crucial importance in ensuring a
healthy population, while simultaneously ensuring that local
healthcare needs are addressed.
The Integrated Health Action Plan is a major instrument in
leading to the inter-sectoral convergence. At the initial stages,
this plan would be prepared only at the district level – by the district
health mission under the zila parishad. Given that this is a
pioneering exercise in large-scale decentralisation, the initial experience
has been quite encouraging though diverse (Sinha
2009). Some states have been able to involve panchayats in the
planning process, resulting in the identification of important
m icro-level issues and problems. In other parts of the country,
consultants with technical planning skills formed the core of the
planning process. While this somewhat reduced the participative
element in these plans, at least it has initiated the process in
states where conditions were not conducive for decentralised
planning (ibid). In 2006-07, about 48% of the districts had prepared
district plans, and by 2008-09 this figure rose to 85%.
However, 2009-10 witnessed a decline (74%) – which might indicate
that the process of decentralisation is running out of steam.
Some of the State CRMs also support the observation that these
district plans have not been repeated after the initial year in
some villages.
The PRIs from the village to the district level are expected to
get the ownership of the public health system in their respective
jurisdictions. While the CHC and PHC will involve the elected
members of the panchayati raj in their management through the
RKS, the SC will be accountable to the gram panchayat (GP)
through the local committee under the village health and sanitation
committee (VHSC). So far, VHSCs have been established in
nearly 75% of the villages, and have received cumulative financial
assistance of Rs 970 crore as untied funds. The objective of
this committee is to help the ANM in preparing the SC action plan
and help her in planning and implementing various programmes
related to health, hygiene, nutrition, sanitation and drinking
w ater. The NRHM guidelines state that the VHSC should comprise
the ANM, ASHA, representatives of the village panchayat, women
non-governmental organisations and self-help groups. Backward
social classes should also be represented. Some evaluation
s tudies have noted that the constitution of the VHSC does not
a lways follow these norms – for instance, in J&K, representatives
of the village, socially backward classes or women representatives
are not present in many of the VHSCs formed (Bhat et al
2009). The failure of the state health departments to provide
training through orientation programmes to the VHSC members
has limited their role to helping the ANMs utilise the untied funds.
Meetings are not regularly held in many states, and the role of
the VHSCs in preparing the district plans has remained limited.
Bajpai et al (2009) report that 95% of ANMs had joint bank accounts
with the sarpanch of the panchayat. Further, analysis of
expenditure patterns9 reveals that in general, funds were used
for overcoming the infrastructural shortcomings wherever they
were used. However, expenditure of the untied funds in some
cases is planned by the ANM in consultation with the block medical
officers, bypassing the panchayat members (Bhat et al 2009).
4.2 Increasing Accountability: Community Monitoring
It was expected that the establishment of the RKS would improve
service quality and management by increasing accountability,
but the actual progress has again fallen short of expectations.
While almost all district hospitals and CHCs have registered RKS,
the coverage of PHCs is much less. At the all-India level, only 71%
of the PHCs have registered RKS; this figure is slightly better in
the high focus states covered in the rapid appraisal survey
(77%). Despite expectations from the RKS, their actual performance
has been below par. The first CRM observes that the role of
the RKS is limited by the tendency to view them as an alternative
financing device and the consequent emphasis on user fees as
cost recovery. Further, the composition of these bodies and processes
of functioning are also not always conducive to community
participation (NRHM 2007).
Evaluation surveys observed that display boards stating members
and decisions about meetings are often not in order. There is
no adequate system of grievance redressal. The RKS need to be
strengthened as they can monitor the local health delivery system
and also solve some of its deficiencies through its untied
funds.10 The third CRM report for Bihar observes that though RKS
have been formed up to the PHC level in most places, meetings
are irregular and do not undertake the specific activities outlined
in the NRHM documents (NRHM 2009b).
5 Health Management Information System
The mission statement acknowledges that a strong component of
technical support is essential for the success of the NRHM. This
requires, inter alia, the positioning of programme management
units and an improved health information system.
The overall situation with respect to the positioning of district
programme management units (DPMUs) is quite satisfactory.
While the coverage of blocks is still inadequate, the situation is
slightly better in the high focus states. The problem lies at the
PHC level (Table 4, p 59).
In their survey, Bajpai et al (2009) found lack of coordination
and cooperation between the health facilities and the DPMUs.
A nother important issue is that the role of the DPMus has been so
defined that they lack the required authority to take crucial
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Economic & Political Weekly EPW january 22, 2011 vol xlvi no 4 59
a dministrative decisions. For instance, in case of non-performance
of paramedic staff (ASHA or ANM) at the village level, the
DPMus cannot take any corrective action directly; nor is the feedback
given by these units to the paramedic staff always accepted
by the latter.
Further, in order to complete unfinished tasks, it is necessary to
identify weaknesses in the implementation procedures of the
NRHM. A crucial component in this context is the health management
information system (HMIS). The HMIS should be so designed
that it can serve as a mechanism for effective monitoring and
s upervision of the Mission activities and evidence based planning.
Unfortunately, despite the elaborate structure created and data
validation checks, the quality of the HMIS reportedly remains poor.
At the PHC and SC level, all registers are not maintained; those
maintained are not updated regularly or in accordance with the
RCH formats.11 Part of this may be attributed to the unrealistic
expectations of “health managers” regarding the information
that the health facilities are able to furnish, and seeking too
much information – even if it is not used subsequently. Often the
same data has to be repeatedly supplied. Further, the second CRM
found that multiple reporting existed, with earlier forms still
b eing used (NRHM 2008). It also identified the existence of various
constraints to data collection and flow. This creates pressure
on the PHC and SC personnel, often making it difficult for them to
both undertake their health-related duties and keep detailed
records of their activities.12 The CRMs have also noted that copies
of reports sent to higher authorities (like office of the chief district
MO) are not maintained by the facilities.
Overall, as CRMs have observed, the HMIS is not used adequately
to inform planning and responsive corrective action. It is
therefore necessary to revamp this system by identifying essential
informational requirements, eliminating r edundant formats,
revising formats for primary data capture by taking into account
operational constraints, increasing quality of data input at the
grass-root level through proper training and c apacity building,
greater convergence between staff supplying data and providing
a loop for feedback to the SC and PHC level. The PRCs may be
involved in the process of capacity building with respect to
the HMIS.
6 Conclusions
To sum up, the actual delivery of the NRHM has fallen far short
of its targets. Evaluation studies undertaken by the Planning
C ommission, the Ministry of Health and independent authorities
indicate that the situation in terms of quantitative goals and quality
of service in many states leaves much to be desired. With the
mission nearing its deadline in 2012, it is unlikely that unfinished
tasks can be completed within the remaining period.
However, within this limited period, the NRHM
has succeeded in putting back the issue of public
health at the top of the government agenda. This has
put pressure on the state governments to divert resources
to the health sector, thereby substantially
strengthening the public health system, including its
workforce (GoI 2010). Although these achievements
have fallen short of what was originally conceptualised,
the investment has had a positive impact on
several health indicators like immunisation, institutional
deliveries and antenatal care (Duggal 2009).13
A study of UP found that the service delivery capacity of the public
health system had increased at each level (Kumar 2010). Outdoor
patient visits had increased at all three levels (SC, PHC and
CHC). The maximum improvement was found at the PHC level
(129%) followed by an almost similar increase at the district and
CHC level (86%). The main beneficiaries of indoor services at
each level were invariably women followed by c hildren and men,
respectively.
Given the condition of the health infrastructure and manpower
shortage in 2005, and the size of the country, the NRHM had an immense
task before it. The fiscal crisis of the states, d iversity in administrative
ability and political will to administer the architectural
modifications envisaged under the NRHM, and constraints in
creating the workforce essential to provide the quality health services
promised to a rural population of 74.4 crore perhaps made the
targets and goals of the NRHM overambitious – particularly in a
period of less than a decade.14 Above all, the NRHM did not adequately
take into account the complexities of Indian rural societies,
characterised by gender disparities, and divided on the lines
of caste, micro-politics and economic class. In its focus on architectural
modification of the health system and introducing modern
managerial concepts, the NRHM did not pay sufficient attention to
the sociocultural context in which the health system is situated
and which ultimately determines the success of policies and measures,
including decentralisation. This is perhaps the most important
factor limiting the success of the NRHM.
Table 4: Snapshot of Programme Management Units (2010, in %)
Indicators India High Focus High Focus
Non-NE States NE States
Number of District programme manager (managerial) is in position 90.5 92.6 87.5
districts District accounts manager (accounts) is in position 90.2 84.2 98.9
where
District data manager (MIS) is in position 82.7 86.8 98.9
DPMU established 99.5 102.3 98.9
Number of Block manager is in position 48.5 72.5 64.2
blocks where Accountant is in position 59.2 79.4 54.9
Number of PHCs where accountant is in position 12.5 3.0 57.3
Source: Estimated from http://www.mohfw.nic.in/NRHM/Documents/Executive_summery_January10.pdf
Notes
1 Available at http://www.mohfw.nic.in/NRHM/
PRC_Reports.htm.
2 Most of the data has been extracted on 22 April
2010 from the link available on the NRHM
website: http://www.mohfw.nic.in/NRHM/Documents/
Executive_summery_January10.pdf (which
provides data up to 31 January 2010) and http://
www.mohfw.nic.in/NRHM/PRC_Reports.htm.
In addition, http://mohfw.nic.in/dmu_report.
htm also provides some useful data up to 28 February
2010.
3 The Health Ministry data shows that mobile medical
units are available in only 56% of the districts.
The evaluation studies report that most of
these units do not have life support systems (so
that they are basically for transporting patients);
in some districts they are reportedly unavailable
in the evenings. The common review mission
notes that in some cases, they are used for purposes
other than transporting patients. Fees are
also being charged in some places, leading to dependence
on private sources of transportation.
4 No of SCs covered = Total amount disbursed/
10,000 (i e, the annual amount to be disbursed to
each SC annually).
5 It was reported that an orthopaedic surgeon in
SPECIAL ARTICLE
january 22, 2011 vol xlvi no 4 EPW Economic 60 & Political Weekly
the Tamnar PHC, Chhattisgarh, had not performed
any surgery in the last 18 months. Similarly, an
ophthalmic surgeon in Basthar, Chhattisgarh,
was undertaking general surgeries on a regular
basis, while another in the same region was a
non-operating surgeon (NRHM 2009a).
6 Minutes of ASHA Mentoring Group Meeting,
11 February and 6 August 2009, accessed on
15 March 2010 at http://www.mohfw.nic.in/
NRHM/asha.htm#AMG.
7 As an ASHA worker complains, “Since no money
is presently available under JSY, we are rebuked
and abused by women whom we had registered
for JSY. This has demoralised ASHAs to perform
their duties. Now even our family members criticise
us and discourage us to work as ASHAs”
( cited in Bhat et al 2009: 140).
8 In Rajouri district of J&K, though ASHAs were
s elected in almost every village, information
from the selected VHSC members indicate that in
55% of the panchayats, ASHAs had stopped working
(Bhat et al 2009: 150).
9 Sixty per cent ANMs used the fund for repairs
and renovations, 50% for purchasing equipment,
31% for buying medicines, 24% for electricity
supply and 19% for running water supply (Bajpai
et al 2009).
10 For instance, RKSs are empowered to make purchases
to meet shortages in drugs.
11 “MOs expressed that printed registers as per RCH
format have not been provided to them. The
workers maintain information on blank registers
and each PHC has devised its own format for
r ecording information” (Bhat et al 2009: 90).
12 The Third CRM comments that it takes about two
working days every week for the ANM to fill in
formats (NRHM 2009c).
13 The incidence of institutional deliveries has
i ncreased by 23% between 2005 and 2010, while
the number of JSY beneficiaries has increased
11 times in this period (NRHM website).
14 In some states the spread of Maoist insurgency
may have created obstacles as medical staff are
reluctant to be posted to “red” areas (Gill 2009;
also, personal communication from local political
leaders in West Bengal).
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