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Wednesday, April 14, 2010

The National Rural Health Mission (NRHM) completes five years

The challenge is to honour every household’s right to quality healthcare. The Mission, which has set up a community monitoring system in nine states, now needs to make it universal before the end of the Eleventh Five-Year Plan so that local communities begin to demand healthcare as a right, says a review

The National Rural Health Mission (NRHM) completed five years on April 12, 2010. Launched in 2005 as a seven-year programme, the government may extend it by three years, to 2015, as many of its goals are still to be achieved, say senior health officials in New Delhi.

The Union government’s flagship scheme to improve healthcare services in rural areas seeks to reduce infant and maternal mortality rates, prevent disease, control population, and ensure gender balance in rural India, according to the government website.

One of the visions of the NRHM was to increase public spending on healthcare, from around 0.9% of India’s gross domestic product in 2004-05 to 2-3%. This has not been achieved. The national health accounts of the health ministry says it increased from 0.84% in 2004-05 to 1.1% in 2008-09, while the Economic Survey 2009-10 put the increase from 1.19% in 2004-05 to 1.45% in 2009-10.

“There are some goals that the NRHM still has to achieve… So, the Centre is thinking of extending the NRHM by three years before beginning the next phase,” said the head of a non-government organisation that works closely with the government under the programme. He added that plans were being drawn up with the 2015 deadline in mind. When asked if the Mission would be extended to 2015, Union Health Secretary K Sujatha Rao said: “I suppose so.”

“In 2012, the Twelfth Five-Year Plan will start so it (the extension) will depend on that. But it is likely that the NRHM will be extended, even though no decision has yet been taken,” said Amarjeet Sinha, joint secretary (NRHM), Ministry of Health and Family Welfare.

Poor utilisation of allocated funds and a shortage of medical professionals and administrators seem to have slowed the initiative’s progress. An audit by the Comptroller and Auditor General of India stressed the need to build public-private partnerships under the NRHM to better utilise the money.

However, in a statement, the health ministry said that spending was poor at the local level initially due to decades of over-centralisation. It added that the situation was improving and that a number of local-level institutions were making better use of funds.

A mid-term review of the programme claims it has unleashed a lot of positive synergies and that the government should make an all-out effort to deepen the processes of community health in such a way that every household is able to seek its entitlement to healthcare.

The review says the 700,000 Accredited Social Health Activists (ASHAs) -- the first port of call -- across the country have demonstrated their ability to link households with facilities. The challenge in the coming years would be to honour the entitlement of every household to quality healthcare that is accessible, accountable and affordable. This would also call for a behaviour change in the way the public system interfaces with poor households, particularly women.

The challenge before the NRHM is to craft credible public systems. This would call for new systems of public recruitment that are institution-specific and based on service guarantees with complete local-level accountability. “The NRHM has promoted this culture of local recruitment and local accountability through contractual appointments. There is the need to develop a new paradigm of public recruitment based on the learning of the last five years,” the report says.

Quoting evidence-based studies, the mid-term review added that basic protocols of care at all levels, with wide publicity at facilities, must be universalised. There is a lot to learn from the protocols followed by the armed forces hospitals and dispensaries, in this regard.

While a lot has moved on delegation of administrative and financial powers, the NRHM needs to further deepen decentralised management and accountability by engaging non-governmental organisations for community monitoring at all levels. The NGO programme of the ministry needs to be revised in such a manner that the presence of quality NGOs for community monitoring and skill development can be crafted from block to district to state levels.

Further, the review says, while resources have reached institutions across the length and breadth of the country, under the NRHM, it is time for every facility to develop a detailed institutional plan for utilising the untied resources being made available to it.

Timely utilisation of such resources, their effectiveness and their efficiency must be periodically assessed. Governance reforms and greater supervision in this regard would help, the report concludes.


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