NRHM

1
National Rural Health Mission (NRHM) Merits and
Challenges
Dr Manoj Kr Dhingra MBBS,MD,MAHA,MISHWM,MIPHA Asso
ciate Professor ICRI
2
NRHM Merits and Challenges
3
NRHM

• National Rural Health Mission was launched by our
  Honble Prime Minister launched in 12 th April,
  2005 with an objective to provide effective
  health care to the rural population, the
  disadvantaged groups including women and children
  by
• improving access,
• enabling community ownership
• strengthening public health systems for efficient
  service delivery
• Enhancing equity and accountability
• Promoting decentralization

4
Strengthening Public Health Systems

• The NRHM covers the entire country, with special
  focus on 18 states where the challenge of
  strengthening poor public health systems and
  thereby improve key health indicators is the
  greatest.
• These are Uttar Pradesh, Uttaranchal, Madhya
  Pradesh, Chhattisgarh, Bihar, Jharkhand, Orissa,
  Rajasthan, Himachal Pradesh, Jammu and Kashmir,
  Assam, Arunachal Pradesh, Manipur, Meghalaya,
  Nagaland, Mizoram, Sikkim and Tripura.

5
EXPECTED OUTCOMES 2005 - 2012

• Universal Health care, well functioning health
  care delivery system.
• IMR to be reduced to 30/1000 live births by 2012
• MMR to be reduced to 100/100,000 live births by
  2012
• TFR to be reduced to 2.1 by 2012
• Malaria Mortality Reduction Rate 60 upto 2012
• Kala Azar to be eliminated by 2010, Filaria
  reduced by 80 by 2010
• Dengue Mortality reduced by 50 by 2012
• RNTCP-2 maintain 85 cure rate
• Responsive Functional Health System

6
Challenge Are we on course to meet the NATIONAL
GOALS MDGs?
Source SRS 2005. SRS 2002 DLHS 2002
2004 NFHS 2 LB Live Births
7
The MESH approach to reach MDGs

• Building of the necessary infrastructure with
  emphasis on MESH--management, economic, social
  and human interface has been shown to improve
  public health care delivery
• MESH is strengthening integrated infrastructure
  growth, which is built to improve the capacity of
  communities and other entities to implement
  health service programs efficiently
• Thomas S, Mooney G, Mbatsha S. The MESH
  approach strengthening public health systems for
  the MDGs. Health Policy. 2007 Oct83(2-3)180-5.
  Epub 2007 Feb 7

8
Reduce IMR and MMR Inter state variability
9
INNOVATION in HUMAN RESOURCEMANAGEMENT

• Promote access to improved healthcare at
  household level through the Accredited Female
  Health Activist (ASHA).
• ASHA would act as a bridge between the ANM and
  the village and be accountable to the Panchayat.

10
ASHA and Village Health Plan

• ASHA would facilitate in the implementation of
  the Village Health Plan along with Anganwadi
  worker, ANM, functionaries of other Departments,
  and Self Help Group members, under the leadership
  of the Village Health Committee of the Panchayat.

11
Janani Suraksha Yojana and ASHA
NRHM
JSY
?? all MMR IMR
Antenatal Check up Institutional Care during
delivery Immediate post-partum (coordinated
care)
??Institutional Deliveries in BPL families
Cash assistance
12
Community Health WorkerASHA
12
13
Enhancement of Leadership skills in ASHA

• Build leadership and personal commitments among
  ASHA who serve as Community Health Workers
• Lack of leadership competence can contribute to
  employee frustration and dissatisfaction,
• Do we need a National Public Health Leadership
  Program ?
• Farquhar SA, Michael YL, Wiggins N. Building on
  leadership and social capital to create change in
  2 urban communities. Educ Health (Abingdon). 2008
  Jul21(2)39. Epub 2008 Sep 9.
• Weston MJ, Falter B, Lamb GS, Mahon G, Malloch K,
  Provan KG, Roe S, Werbylo L. Health care
  leadership academy a statewide collaboration to
  enhance nursing leadership competencies. J Contin
  Educ Nurs. 2008 Oct39(10)468-72.

14
Strengthening Public Health Delivery in India

• New concept of Indian Public Health Standards
  introduced
• Indian Public Health Standards (IPHS) are set of
  standards envisaged to improve the quality of
  health care delivery in the country under the
  National Rural Health Mission.

15
Strengthening Sub-centres

• Each sub-centre will have an Untied Fund for
  local action _at_ Rs. 10,000 per annum.
• Maintaining Logistics Supply of essential drugs,
  both allopathic and AYUSH, to the Sub-centres.
• Postings of Additional ANMs wherever needed

16
Strengthening PHCs

• Infrastructure Strengthening as per IPHS
  guidelines
• Adequate and regular supply of essential quality
  drugs and equipment (including Supply of Auto
  Disabled Syringes for immunization) to PHCs
• Provision of 24 hour service in 50 PHCs by
  addressing shortage of doctors, especially in
  high focus States, through mainstreaming AYUSH
  manpower.

17
Strengthen CHCs

• Infrastructure strengthening by implementation of
  IPHS standards
• Promotion of Stakeholder Committees (Rogi Kalyan
  Samitis) for hospital management.
• Developing standards of services and costs in
  hospital care.

18
Adequate emphasis to Users Perceptions

• Another factor in shaping health care delivery
  may be the extent to which leaders pay attention
  to service user perceptions.
• Understanding of the perception of the rural
  community and its dynamic and changing linkages
  with this crucial National Program is vital for
  its sustenance and accelerated progress
• Schneider B, Ehrhart MW, Mayer DM et al.
  Understanding organizationcustomer links in
  service settings. Acad Manage J 200548101732.

19
Decentralized Planning

• District Health Mission at the District level
  and the State Health Mission at the state level
• District Health Plan would be a reflection of
  synergy between Village Health Plans, State and
  National priorities for Health, Water Supply,
  Sanitation and Nutrition.
• Involvement of PRIs in planning process

20
NRHM and PRI

• The NRHM envisages a major shift in the
  governance of public health by giving a
  leadership role to the Panchayati Raj
  Institutions in all matters relating to health at
  the district and sub-district levels
• Attention in recent years has crystallized on the
  role of health-care leaders (1,2)
• 1. Touati N, Roberge D, Denis JL et al. Clinical
  leaders at the forefront of change in health-care
  systems advantages and issues. Health Serv
  Manage Res 20061910522.
• 2. Silimperi DR. A framework for
  institutionalizing quality assurance. Int J Qual
  Health Care 2002146773.

21
Leadership Initiatives with the PRI

• Health-care programs across the world have to
  deal with escalating demands in the face of
  limited resources.
• Against this backdrop, particular attention has
  been paid particularly in the UK on the on the
  role and contribution of health-care leaders
• Manning K. Leadership in Commissioning. National
  Health Service Institute for Innovation and
  Improvement. 2008. http//www. Leadership
  development. nhs. uk

22
Convergence Sanitation and Hygiene under NRHM

• Total Sanitation Campaign (TSC) implemented
  through guidance of District Health Mission and
  PRIs
• Components of TSC include IEC activities, rural
  sanitary marts, individual household toilets,
  women sanitary complex, and School Sanitation
  Programme.

23
Innovative Financial Mechanisms

• Utilization of the principle of money follows
  the patient.
• Funds to all States and UTs being sent
  electronically.
• Time taken in fund transfer brought down from 1-3
  months to 1-2 days.
• Sanction letters uploaded on website along with
  e-transfer

24
Utilization of funds

• The problem of absorption and appropriate use of
  funds in disadvantaged areas has been highlighted
  as a critical bottleneck to the achievement of
  the Millennium Development Goals (MDGs).
• Thomas S, Mooney G, Mbatsha S. The MESH
  approach strengthening public health systems for
  the MDGs. Health Policy. 2007 Oct83(2-3)180-5.
  Epub 2007 Feb 7

25
Program Management Support Systems

• Delivery of health care processes are complex and
  are convoluted as well
• Program management systems should be an integral
  part of administrative structure
• Programme Management Units (PMU) for improved
  monitoring and support have been incorporated in
  NRHM

26
Relevance of Organizational Change in NRHM

• Managers need to understand forces for and
  against organization change in real Health care
  delivery settings of NRHM
• Simulation based NRHM exercises can increase
  managerial skills
• Mash BJ, Mayers P, Conradie H, Orayn A, Kuiper M,
  Marais J. How to manage organizational change and
  create practice teams experiences of a South
  African primary care health centre. Educ Health
  (Abingdon). 2008 Jul21(2)132. Epub 2008 Aug 26.

27
Administrative Reforms and NRHM

• New regulations such as Accreditation, enlarging
  role of JCI in India and emergence of high
  quality care in corporate hospitals would put
  additional strain of the delivery of NRHM
• as flux of patients towards the private sector
  would emerge as an operational reality

28
Management and Gain in efficiency

• An article in the New England Journal of Medicine
  showed that 19 to 24 of US Health care is
  devoted to administrative costs in monitoring
  health care delivery
• Health care spending in the US accounts for
  approx 14 of the GDP or 1.4 trillion dollars
• A 1 gain in the efficiency of health care would
  save 10 billion
• S Woolhandler and DU Himmelstein. The
  deteriorating administrative efficiency of the
  U.S. health care system New Eng J of Med
  3241253-1258

29
NRHM and Community based Participatory research

• It is important to teach community members about
  the causes, magnitude and effects of health
  inequalities that affect them, and
• Medical officers in NRHM to use community based
  participatory research to partner with community
  and develop, test and disseminate programs that
  they can sustain and improve health.
• Horowitz CR, Arniella A, James S, Bickell
  NA.Using community-based participatory research
  to reduce health disparities in East and Central
  Harlem. Mt Sinai J Med. 2004 Nov71(6)368-74.

30
Medical Students and NRHM

• LOCUS (Leadership Opportunities with Communities,
  the Medically Underserved, and Special
  Populations) has been used successfully as a
  pilot program in USA and has
• Shown that motivated students can develop
  leadership skills and address unmet community
  health needs while they progress through the
  medical school.
• LOCUS students, staff, and physicians provide a
  social network that includes opportunities,
  encouragement, reflection, and problem solving.
• Haq C, Grosch M, Carufel-Wert D. Leadership
  Opportunities with Communities, the Medically
  Underserved, and Special Populations (LOCUS).
  Acad Med. 2002 Jul77(7)740.

31
Medical Students and NRHM

• Student and mentor satisfaction with this program
  has been high.
• With over 200 medical colleges in India medical
  students could take up community administrative
  skills as electives during postings/Internship

32
Stress on Quality

• A significantly positive relationship was
  observed between the quality and utilization of
  antenatal care in the rural areas
• Poor quality of antenatal care is likely to
  reduce its utilization.
• The India's National Rural Health Mission (NRHM),
  launched in 2005, should lay greater emphasis on
  improving the quality of antenatal care, among
  other things, to increase utilization of
  antenatal care and achieve better maternal health
  outcomes.
• Rani M, Bonu S, Harvey S. Differentials in the
  quality of antenatal care in India. Int J Qual
  Health Care. 2008 Feb20(1)62-71. Epub 2007 Nov
  17.

33
Strengthening Disease ControlMechanisms

• National Disease Control Programmes have been
  redefined and updated
• New Initiatives launched for control of Non
  Communicable Diseases.
• Disease surveillance system have been
  decentralized with the launch of IDSP

34
Public Private Partnerships

• Need to develop guidelines for Public-Private
  Partnership (PPP) in health sector.
• Identifying areas of partnership, which are need
  based, thematic and geographic

35
Develop and Sustain partnerships

• Partnerships between academic medical centers
  (public hospitals) and Community Health Centers.
• Data driven participatory management
• Jandorf L, Fatone A, Borker PV, Levin M, Esmond
  WA, Brenner B, Butts G, Redd WH. Creating
  alliances to improve cancer prevention and
  detection among urban medically underserved
  minority groups.
• The East Harlem Partnership for Cancer Awareness.
  Cancer. 2006 Oct 15107(8 Suppl)2043-51.

36
THANKS
37
Cultural framework and public health

• Weizhen Dong. Beyond SARS ethnic community
  organization's role in public health -- a Toronto
  experience. Promot Educ. 200815(4)53-5.

38
Accredited Social Health Activist ASHA

• Escort
• Pregnant women and children to the nearest
  identified health facility
• Mobilize
• In Assessing health and health related services
  at the health centres like PHCs, CHCs, FRUs
  Curative
• Primary Medical Care for ailment like diarrhoea
  fever.

39
Roles and Responsibilities of ASHA

• Curative
• DOT provider
• Depot holder for essential provisions life IFA,
  DDK, OCs, ORS etc.
• Inform
• About birth and deaths in the village or any
  other disease out break in the centre.