Developments in NRHM

Ten years down the line since the National Rural Health Mission (NRHM) was put in place, challenges to ensure quality and affordable health services in large swathes of the country’s rural belts are being tackled with renewed vigour

Latest rural health statistics reveal that gaps are to be bridged and much has been accomplished despite a plethora of challenges on the road in the wake of increasing expectations in rural regions.

Manpower has been increased and infrastructure refurbished for the rural health set up to match ever increasing aspirations of people who are becoming more aware of quality health services available in urban stretches and government endeavours to improve health care delivery in rural regions.

At some places, more facilities and manpower are required lest it cast an adverse impact on the services. The NRHM common review commission has undertaken a close look on the set up to improve services.

The NRHM seeks to provide effective healthcare to rural population throughout the country with special focus on 18 States, which have weak public health indicators and infrastructure.

The States are Arunachal Pradesh, Assam, Bihar, Chhattisgarh, Himachal Pradesh, Jharkhand, Jammu & Kashmir, Manipur, Mizoram, Meghalaya, Madhya Pradesh, Nagaland, Odisha, Rajasthan, Sikkim, Tripura, Uttarakhand and Uttar Pradesh.

NRHM aims 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.

It seeks decentralisation of programmes for district management of health and to address the inter-state and inter-district disparities, with emphasis on 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.

Other features include laboratory services at sub-district level are available but not comprehensive; Tamil Nadu has a robust system of diagnostics, Odisha has taken efforts towards integration of laboratory services across various programs and optimise HR utilisation; co-location of AYUSH services in most states; and increased utilisation of 108 ambulances.

The review commission had also highlighted some concerns which inter alia include availability of radiological investigations only at district level in most contexts; Range of diagnostic services is limited at Sub-District level hospital and below and assured OPD care at sub-district level is still a challenge in most states.

It also found that time to care approach is yet to set in across the states; non-integration of various models of ambulances leading in effective utilisation; under utilisation of mobile medical units; grievance redressal mechanisms yet to be established & where available, their effectiveness is limited. Informatively, the NRHM is an articulation of the commitment of the government to rise to 2-3 per cent public spending on health from 0.9 per cent of GDP.

The latest survey done after the review meeting has compiled data on various parameters, found that progress has been made on various fronts but experts feel the limited public spending is one of the key reasons which hobbled development of the sound rural health network, and medical crisis spell doom for families running on shoestring or zero budget as they have no means to afford timely and quality healthcare.

The survey noted that in India, 1,022 sub divisional/ sub district hospitals were functioning till March. At sub divisional/sub district hospitals, there are 10,018 doctors available. In addition to the doctors, about 26,717 paramedical staffs are also available at sub divisional/ sub district hospitals.

As many as 763 district hospitals are functioning with 18,437 doctors available. In addition, about 55,642 para medical staff was also available at district hospitals as on March 31, 2015. Diarrhoea, typhoid, infectious hepatitis, worm infestations, measles, tuberculosis, whooping cough, respiratory infections,

pneumonia and reproductive tract infections were also very common in rural pockets. Maternity and child mortality were high.Almost 50 per cent of the rural mothers were said to experience post partum illnesses six weeks after delivery.

The current position of specialist manpower at CHCs reveals that out of the sanctioned posts, 74.6 per cent of surgeons, 65.4 per cent of obstetricians & gynaecologists, 68.1 per cent of physicians and 62.8 per cent of paediatricians were vacant.

Overall, 67.6 per cent of the sanctioned posts of specialists at CHCs were vacant.Moreover, as compared to requirement for existing infrastructure, there was a shortfall of 83.4 per cent of surgeons, 76.3 per cent of obstetricians & gynaecologists, 83.0 per cent of physicians and 82.1 per cent of paediatricians.

Overall, there was a shortfall of 81.2 per cent specialists at the CHCs.The shortfall of specialists is significantly high in most of the states. While the sub centres, PHCs and CHCs have increased in number in 2014-15, they are not sufficient to meet their population norm, the government survey had pointed out.

Experts say unless public spending was increased on health, the infrastructure despite having bare minimum staff and facilities, it would not be able meet needs of patients in remote and inhospitable terrain. Locals do not have adequate funds to meet expenditure on medical treatment and the government has to ensure free distribution of generic drugs.

Many of them say that corruption and middle level players had to be bridled to ensure that every penny spent on health services reaches the needy in time.

Surveillance must be mounted to control the existing staff too and frequents raids on rural health centres of all types were the need of the hour. There is significant increase in the number of Sub Centres in the States of Chhattisgarh, Gujarat, Jammu & Kashmir, Karnataka, Odisha, Rajasthan, Tripura and Uttarakhand.

The increase is mainly due to addition in the number of government buildings in the States of Assam, Chhattisgarh, Karnataka, Madhya Pradesh, Maharashtra, Odisha, Punjab, Rajasthan, Tripura, Uttarakhand, Uttar Pradesh and West Bengal.

The statistics say shortfall of allopathic doctors in PHCs was 11.9 per cent of the total requirement for existing infrastructure. Number of Community Health Centres (CHC ) has increased by 2050 during the period 2005-2015.

Significant increase is observed in the number of CHCs in the States of Gujarat, Jharkhand, Kerala, Madhya Pradesh, Odisha, Rajasthan, Tamil Nadu, Uttar Pradesh and West Bengal. There has been an augmentation of 33 CHCs from the number reported upto March, 2014.

Significant increase in the number of CHCs was observed in the State of Gujarat (20). Number of CHCs functioning in government buildings has also increased during the period 2005-2015.

The percentage of CHCs in Govt. buildings has increased from 91.6 per cent in 2005 to 95.1 per cent. Significant increase in the number of paramedical staff is also observed.

Overall, there was a shortfall of 81.2 per cent specialists at the CHCs vis-a-vis the requirement for existing CHCs. While the number of sub centres, PHCs and CHCs have increased during the year 2014-15, the number of ANMs, Specialists & Radiographers declined, though marginally from the position earlier

he number of ANMs at sub centres and PHCs has declined in the States of Maharashtra, Tamil Nadu, Jammu & Kashmir, Rajasthan, Tripura and Madhya Pradesh. Similarly, the number of allopathic doctors at PHCs increased too.

There are significant increases in the States of Maharashtra, Rajasthan, Tamil Nadu and Haryana. Major reduction is observed in the State of Jammu & Kashmir. Major decreases have been noticed in the States of Rajasthan and Punjab.