Thursday, December 20, 2007


Reaching quality health care to every household is a daunting challenge in a country of over a billion people living in thousands of hamlets, villages, towns and cities. The National Rural Health Mission (NRHM) is a serious effort to address this challenge. Launched in April 2005 by the Hon’ble Prime Minister, the Mission has made significant progress, especially after the approval of the detailed Framework for Implementation of NRHM by the Union Cabinet in July 2006. In partnership with States and through state led innovations, NRHM is rapidly expanding accessible, affordable and accountable quality care for every household in the country.

More than 5,30,000 ASHAs and Link Workers are connecting households to health facilities. The presence of community volunteers on this unprecedented scale has resulted in people’s growing pressure on utilization of services from the public sector health system. States across the country are reporting significantly higher utilization of outpatient services, diagnostic facilities, institutional deliveries and inpatient care. Large scale demand side financing under the Janani Suraksha Yojana (JSY) has brought poor households to public sector health facilities on a scale never witnessed before. Over 50 lakh women have been covered under JSY so far since its introduction in 2005.

While in some regions government health facilities have geared up by utilizing flexible finances under NRHM to cope with the increased workload, in many other regions there is a long way to go before health facilities fully gear themselves to meet the growing need of people’s health care. Poor households have voted with their feet by coming to the public system as never before. The challenge of NRHM now is to provide quality health care to the growing number of households whose faith in the government system has been restored. NRHM cannot afford to let down poor households who have come to the public system with so much hope and aspiration. There is a sense of urgency in improving the facilities for quality health care.

NRHM – A Unique Partnership with States

The journey of NRHM has been crafted by the responses of the States. It is for the States to decide on what their priorities are. District and State Programme Implementation Plans form the basis of approvals. Never before has there been so much flexibility in a programme to suit the diverse needs of States and Regions. NRHM has set a new standard of partnership with States where it is the States that determine what is needed to resolve the crisis of the public sector health system. Human Resources, physical infrastructure, equipment, capacity building resources, skill up-gradation resources, etc. are available on an unprecedented scale. The philosophy of NRHM is to move from distrust to trust. Within the umbrella of Panchayati Raj Institutions, NRHM has tried to formulate an accountability framework that makes every health facility responsible to the people whose needs it caters to. Starting from the Village Health and Sanitation Committees, NRHM has crafted facility specific public institutions within the framework of PRI to ensure that Health Institutions have the flexibility to deliver in partnership with the community.

From the village to the district level, all requirements of the health system can be met through the NRHM and States have come up with innovative plans to suit their needs. Realizing the need for improved management of the Public Sector Health System, NRHM has extended management support to States at all levels and for all institutions. The thrust on Nursing Institutions, Nurses and Auxiliary Nurse Midwives (ANMs) has been its foremost message to the States, considering the need for public sector facilities to provide round the clock services.

A second ANM in Sub Centres, 3 Nurses in PHCs for 24X7 services along with diagnostic services, co-locating of Ayush doctor at PHC and availability of Specialist Doctors and Nurses on a much larger scale has been attempted under the NRHM to take accountability to the people. States recruit Nurses and other Para Medic Staff on contract and based on local criteria. Even Doctors and Specialists are recruited at the district level on contract and based on local criteria. Various form of performance based incentives have been attempted to make money follow the patient and to keep the motivation of public health workers in remote areas high. A lot more needs to be done in the sphere for performance based incentives in remote and difficult areas in order to ensure availability of skilled human resources where needed.

Greater Functional Flexibility

By forming registered Societies (Rogi Kalyan Samitis) at PHCs, CHCs and District Hospitals, legal entities are created that have far greater flexibility in discharge of their functions. NRHM has provided an opportunity to provide cashless hospitalized services to the poor through the Rogi Kalyan Samiti resources. It has also provided an opportunity to charge a modest fee from those who can afford to pay. The Rogi Kalyan Samitis (RKSs) have adequate resources for local health action and for ensuring a well-maintained hospital. Wherever Medical Officers, in-charge of PHCs and CHCs and their RKSs, have taken interest, the face of government hospital has been transformed with the untied funds available to every institution under NRHM. NRHM is an opportunity for States to display to the people that fully functional quality health care is possible within the public system.

The untied grants to sub-centres has given a new confidence to our ANMs in the field who are far better equipped now with Blood Pressure measuring equipment, stethoscope, the weighing machine etc. They can actually undertake a proper ante-natal care and other health care services. Sub-Centres look like sub-centres and provide services which many of them were not doing on account of lack of regular resources. The constitution of the Village Health and Sanitation Committees itself is taking a little time in many States as the effort is to set up these Committees within the umbrella of Panchayati Raj Institutions. The intention of NRHM is inter-sector convergence and the effort in all the States is to bring Health, Sanitation, Nutrition, Water and Education together on a common platform within the framework of PRIs, at the village level. The untied funds to Village Committees are a great boon for public health action as was demonstrated in Kerala in Alleppey District where large scale vector control measures could be taken up with untied funds.

Human Resources is a key issue in the health sector and, specially, resident health workers in remote areas. Some excellent innovations have been attempted in the States to train local women as ANM. West Bengal’s efforts in this direction has been path breaking where educated women from the 100 most difficult blocks of West Bengal are being trained to become ANMs on condition that they go back to the village. The efforts to provide opportunities for ASHAs and Aanganwadi Workers to become ANMs has also been emphasized as ultimately the quest for better health care must realize that a locally resident person is the best bet to secure a resident health worker. The problems of absenteeism can be tackled through emphasis on the local criteria in such recruitments.

Many un-served areas have been covered through Mobile Medical Units. The efforts in Gujarat in this direction have been commendable. Andhra Pradesh’s EMRI system enables people to access well equipped ambulances within no time anywhere in the State. Such successful models are worthy of replication and NRHM’s efforts have been to encourage emulation. Sincere efforts to promote good practices have been made by providing opportunities of all State level teams to visit such regions that have done good work. There is a lot to learn from each other and NRHM promotes the bonding of States through regular inter-State visits to see good practices.

The partnerships with the non-governmental sector has also been an important priority for NRHM. The Chiranjeevi programme in Gujarat has demonstrated how private sector gynecologists can be brought in to provide institutional delivery for below poverty line women at government costs. Many such models have been attempted in States, from diagnostic facilities, to provision of health care. NRHM is about partnerships and service provision. The focus on outcome allows experiments in NRHM by seeing every health professional as a national asset who can be involved in the public health system to meet its growing needs at agreed costs and standards.


Forget yourself for others, and others will never forget you.

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