NRHM needs to revitalise systems, monitor their functional performance and investigate their impact on the indices of health.
The National Rural Health Mission (NRHM) was launched in 2005 to bring about a dramatic improvement in the health system and health status of people in rural India. It seeks to provide universal access to health care, which is affordable, equitable, and of good quality. It aims at making architectural corrections to basic health care systems, reduce regional imbalances, pool resources, integrate organisational structures, optimise human resource, decentralise the management of district health programmes and integrate many vertical health programmes. It also aims at facilitating community participation, partnership and ownership of health and health care delivery.
The NRHM has been described as one of the largest and most ambitious programmes to revive health care and has many achievements to its credit. It has reiterated the focus on health and re-prioritised rural health and health care. It has increased health finance, and improved infrastructure for health delivery. It has established standards and trained health care staff. It has also set benchmarks for health institutions and improved and streamlined health care delivery structures. It has coordinated technical support from health resource institutions and non-governmental organisations. It has improved health care delivery in many regions. It has facilitated financial management, assisted in computerisation of health data, suggested centralised procurement of drugs, hospital equipment and supplies, and mandated the formation of village health and hospital committees and community monitoring of services. It has revived and revitalised a neglected public health care delivery system.
The NRHM has injected new hope in the health care delivery system. However, it continues to face diverse challenges, which need to be addressed if its goals are to be achieved in the near future.
Regional variation: A comparison of data between States and within regions and social groups suggests marked variations in the NRHM process indicators, utilisation of funds, improvement in health care delivery, health indices and in community participation. Regions with good health indices have shown marked improvements, while those with prior poor indices have recorded a much lesser change.
This is true, despite a greater NRHM focus on and inputs to poor-performing States. Improving governance and stewardship within the NRHM programmes mandates general improvement in the overall governance of States and regions. It calls for redoubling of efforts to improve the governance of States and regions in general and NRHM programmes in particular.
Convergence of different programmes: Many programmes of the government, the Integrated Child Development Services (ICDS), the Mahatma Gandhi National Rural Employment Guarantee Scheme (MGNREGS) and the NRHM focus on the rural poor. In principle, these programmes are meant to be complementary and synergistic. However, many issues need to be resolved. For example, the NRHM's Village Health and Nutrition Days compete with the ICDS's well-established Anganwadi programme. This results in a lack of synergy between the workers employed by the two programmes. Similarly, coordination between the MGNREGS and the NRHM, which could help the most vulnerable sections, is non-existent. The goal of health for all requires cooperative teamwork among the many schemes and departments of the government.
Parallel health systems: The NRHM is intended to strengthen and support the existing State health systems and services. However, its status as a project makes its complete integration problematic. The idea that the States will take over its financing after 2012 does not generate enthusiasm for long-term commitment from staff at the State and district levels. In addition, the administrative machinery of the NRHM and health services at the national, State and district levels remains separate without complete integration, making the programme less effective and the services less than optimal. Independent and vertical disease control programmes also continue to operate with separate societies and line management. Despite calls for integration, many States do not have active plans for a horizontal integration with the NRHM systems. In some States, the health system itself is divided into independent and poorly coordinated subsystems with medical colleges, district hospitals and community and primary health services under separate and autonomous administrative control. These divisions run deep, resulting in irrational distribution of human resource and infrastructure.
Old ethos and new inputs: The NRHM brought fresh ideas and new monies to a neglected and disillusioned health care system. However, the inertia of the old system and the low morale and discipline of its staff continue to be major challenges. The NRHM has been able to add new infrastructure and personnel; however, its impact on reinventing and reinvigorating systems seems to be limited, and much more effort is required. While there is some evidence of improved health care delivery, the ambitious targets of the NRHM require systems to function like well-oiled machines, in order to be effective and efficient enough to reach these goals.
New platforms competing with old programmes: Some States have introduced new programmes, which seem to rival and undermine old and established platforms. For example, they have introduced mobile medical units. These compete with older village sub-centres resulting in the undermining of previously established systems.
Divisive approaches: Many States have introduced health insurance to cover life-saving medical conditions. While such cover has helped many people, there is evidence in some States that the majority of recipients are urban-based, with the poorest and the most marginalised unable to access such services. The unregulated private sector and its high cost may not pass a cost-benefit test. In addition, the provision for the care of low-frequency diseases in tertiary care, without a gate-keeping role for primary care, adds to the complexity of the issues. The absence of cover for common conditions makes the impact of such scheme marginal for the majority. The neglect of public hospitals, the need to allow the public sector to utilise its spare capacity to meet such needs and increase their incomes, the impact of having private insurance companies at the heart of the scheme, and the role for public sector insurance also need consideration.
Process and outcome indicators: The NRHM currently employs process indicators to measure its implementation. The measures used are mainly related to infrastructure and personnel. There is need to shift to indicators of efficient functioning. In the final analysis, the NRHM's impact will have to be assessed against hard data on health outcomes. The initial high rates of mortality tend to reduce rapidly with early inputs but require fully functional, efficient and effective systems for sustained results. The NRHM needs to correlate its inputs with health outputs in order to assess their effectiveness and to fine-tune its processes. There should be a much greater attempt at analysing the complex process data currently being generated and systematically collect outcome data in order to direct and modify systems.
Social determinants of health: The NRHM's goals clearly state the need to impact on the social determinants of health by coordinating efforts to provide clean water, sanitation, and nutrition. It should be in conjunction with MGNREGS work towards the reduction of poverty. Social exclusion and gender discrimination are two major areas of concern as they have a significant impact on health. The NRHM should not only focus on treating diseases in these sub-populations but also work towards implementing policies, which will bring about health and social justice for all.
The NRHM has made a significant impact on health care delivery. However, the need for constant monitoring of its impact for course corrections should be built into the system for optimal results and for achieving the goal of “Health for all.”
(K.S. Jacob is on the faculty of the Christian Medical College, Vellore, and is also a member of the Mission Steering Group of the NRHM. This article is based on his lecture at a recent conference on “Bringing Evidence into Public Health Policy” in Bangalore. The opinions expressed are personal and do not reflect those of any organisation.)