Need for dedicated focus on urban health within National Rural Health Mission

National Rural Health Mission represents an important public health initiative to address essential health needs of the country's underserved population. For the Mission to achieve its goals, urban population needs to be included in its scope. Urban poor population constitutes nearly a third of India's urban population and is growing at three times the national population growth rate. Health status and access of reproductive and child health services of slum dwellers are poor and comparable to the rural population. Efforts to improve the conditions of urban poor necessitate strengthening national policy and fiscal mandate, augmenting and strengthening the urban health delivery system, coordinating among multiple stakeholders, involving private sector, strengthening municipal functioning and building community capacities. National Rural Health Mission should be broadened to National Public Health Mission. This paper discusses issues pertaining to health conditions of the urban poor, present status of services, challenges and suggests options for NRHM to bridge the large gap.     

An innovative National Rural Health Mission capacity development initiative for improving public health practice in India

National Rural Health Mission (NRHM) foresaw improved health management in India through sustained capacity development of in-service health personnel and their post-training duties in the public health system. Acknowledging the urgency of addressing this issue, the Indian Government, under the NRHM, launched a 1-year Post Graduate Diploma in Public Health Management (PGDPHM) to impart public health management knowledge and skills to these professionals in the state health services. Four institutes partnered this program in 2008, its first year. Between 2008 and 2011, this expanded to 10 institutes and 386 students have graduated the program. The program offered across all these institutes is uniquely identified as against other Health Management courses being offered across the country. The NRHM context in its content and pedagogy is its prime feature. The program offers multiple opportunities to encourage states and the central government to clearly delineate a much needed specialized public health cadre in India. The efforts of this program emphasize on improved public health practice and are a unique pathway to a better health system. Its multidisciplinary facets are aimed at addressing the mismatch of demand and supply of health professionals who could contribute effectively to strengthening the public health system in India through proficient public health practice.     

National rural health mission--hope or disappointment?

The recently declared National Rural Health Mission has aroused significant interest, being both welcomed and closely scrutinized, since there is a long overdue and outstanding need to strengthen weak and dysfunctional public health systems in rural India. In this setting, Jan Swasthya Abhiyan (JSA) has been involved in analysing various aspects of the Mission. The concern has been that it should develop in a manner that actually strengthens public health systems in an integrated manner, and that it should empower communities to be involved in the planning and utilization of these systems in a Rights-based framework. In this article, one will draw upon and reflect on a few of the major concerns about NRHM that have emerged during the insightful discussions in JSA.     

The National Rural Health Mission (NRHM): a critical overview

This paper explores the forces that led to the conceptualisation of the National Rural Health Mission (NRHM) including the role of the Common Minimum Programme and the Structural Adjustment Programme. The paper analyses the key components of the NRHM in terms of the theoretical frameworks of decentralisation, integration of programmes, primary health care, community health workers and standards.     

Indian approaches to retaining skilled health workers in rural areas

Problem

The lack of skilled service providers in rural areas of India has emerged as the most important constraint in achieving universal health care. India has about 1.4 million medical practitioners, 74% of whom live in urban areas where they serve only 28% of the population, while the rural population remains largely underserved.

Approach

The National Rural Health Mission, launched by the Government of India in 2005, promoted various state and national initiatives to address this issue. Under India’s federal constitution, the states are responsible for implementing the health system with financial support from the national government.

Local setting

The availability of doctors and nurses is limited by a lack of training colleges in states with the greatest need as well as the reluctance of professionals from urban areas to work in rural areas. Before 2005, the most common strategy was compulsory rural service bonds and mandatory rural service for preferential admission into post-graduate programmes.

Relevant changes

Initiatives under the National Rural Health Mission include an increase in sanctioned posts for public health facilities, incentives, workforce management policies, locality-specific recruitment and the creation of a new service cadre specifically for public sector employment. As a result, the National Rural Health Mission has added more than 82 343 skilled health workers to the public health workforce.

Lessons learnt

The problem of uneven distribution of skilled health workers can be solved. Educational strategies and community health worker programmes have shown promising results. Most of these strategies are too recent for outcome evaluation, although this would help optimize and develop an ideal mix of strategies for different contexts.     

National rural health mission--opportunity for Indian Public Health Association

Indian Public Health Association (IPHA) welcomes the release of National Rural Health Mission (NRHM) documents. It suggests that manpower requirements of the Community Health Centre (CHC) should be rationally determined on the basis of work and patient load of the CHC. Importance should be given on availability of simple & life saving equipment, female staff when male staff is not available. Safe drinking water, an adequate sanitation and excreta disposal facility through Panchayet Raj Institution (PRI) or privatization was proposed. Accredited Social Health Activist (ASHA) has been accepted more streamlining based on the community was suggested. Capacity building or training should be CHC based for grass-root level functionaries with incentive to Medical officer (MO). IPHA proposes to extend support in capacity building, development of manual for ASHA & other categories of health professional as well as Program Implementation Plan (PIP).     

National Rural Health Mission--"rhetoric or reality"

National Rural Health Mission (NRHM) launched by Government of India holds great hopes and promises to serve the deprived and underserved communities of rural areas. The backbone of the programme is Accredited Social Health Activist (ASHA), which will play major role in the implementation of the programme. The invariable existence of socio-cultural clusters in the community has always been a major challenge to the health care efforts made by the government. Though ASHA is a novel concept to melt the ice in the culture of silence among the various cluster community groups, it is important to emphasize that inter-cluster communication may still pose a problem, which ASHA may be unable to address. Considering the constraints of ASHA and success of cluster community approach in Unicef supported community based Maternal Child Health & Nutrition (MCHN) Project, it is quite reasonable to state that inclusion of community mobilisers (Bal Parivar Mitra) from within the cluster community group might well be an asset to the programme, who may actually bring about the task of spreading the spirit of NRHM. These set of functionaries may work in coordination to bring about the desired behaviour changes and decrease the social delays responsible for maternal and childhood mortality. It will also bring about the feeling of community participation and ownership. The programme is in its initial phase but has years ahead of it to bring visible changes at community level to make it a reality.     

Morbidity profile of paediatric inpatents at a community health centre and a nearby [correction of near by] district hospital in northern India

The study was conducted to ascertain the morbidity profile among children by retrospective review of inpatient data of children admitted to Comprehensive Rural Health Services Project (CRHSP), Ballabgarh, a model CHC and Badshah Khan (B.K.) hospital, Faridabad, a district hospital over a period of one year. Diarrhea and pneumonia comprised 64% of all admissions at the model CHC and 30% at the district hospital. Thalassemics requiring blood transfusion formed 21% of inpatients at the district hospital. Common paediatric ailments can be managed appropriately at CHC level, provided the infrastructure as recommended by Indian Public Health sandards for CHC under National Rural Health Mission (NRHM) is available. The blood bank or blood storage facility at a CHC is desirable.     

Challenges of maternal mortality reduction and opportunities under National Rural Health Mission--a critical appraisal

Maternal Mortality Ratio (MMR) continues to remain high in our country without showing any declining trend over a period of two decades. The proportions of maternal deaths contributed by direct obstetric causes have also remained more or less the same in rural areas. There is a strong need to improve coverage of antenatal care, promote institutional deliveries and provide emergency obstetric care. Delays occur in seeking care for obstetric complications and levels of 'met obstetric need' continue to be low in many parts of the country. Most of the First Referral Units (FRUs) and CHCs function at sub-optimal level in the country. National Rural Health Mission (NRHM) offers institutional mechanism and strategic options to reduce high MMR. 'Janani Suraksha Yojna', strengthening of CHCs (as per Indian Public Health standards) to offer 24 hours quality services including that of anesthetists and Accredited Social Health Activist (ASHA) are important proposals in this regard. District Health Mission can play an important role in monitoring maternal deaths occurring in hospitals or in community and thus create a social momentum to prevent and reduce maternal deaths. NRHM, however, depends largely on Panchayati Raj Institutions for effective implementation of proposed interventions and utilization of resources. In most parts of our country, State Governments have not empowered PRIs with real devolution of power. Therefore, much needs to be done locally to build the capacity of PRIs and develop state-specific guidelines in operational terms to implement interventions under NRHM for reducing maternal mortality ratio.     

National Rural Health Mission--a critical review

National Rural Health Mission is strategic framework to implement the National Health Policy 2002. The scheme of Accredited Social Health Activist is an improvement over the earlier Community Health Guide Scheme. Integration of various health and family welfare programmes will result in economy and allocation of resources as per needs of the districts. Decentralised planning with the involvement of Panchayati Raj Institutions is likely to make health as people's programme. Converging water supply, sanitation, hygiene and nutrition with health planning is a logical step. The proposal to strenthen institutions of primary health care and Community Health Centres as functional Rural Hospitals alongwith introduction of Indian Public Health Standards and accountability of public health institutions to the public is likely to revolutionise the status of health care in rural India.     

Improving health services in India: a different perspective

Two papers in this volume focus on public finance and decentralization as central to resolving India's systemic public health crisis. However, some states and districts have achieved success despite serious financial and administrative deficits; this suggests that factors such as political commitment, community participation, human resource management, women's empowerment, and governance may be as or more important. The success of the National Rural Health Mission will depend on state and local institutional capacity, including strong partnerships with civil society organizations and private-sector actors. Increased resources and decentralization will not be sufficient by themselves.     

Human Rights Implications of the Digital Revolution in Health Care in India

The COVID-19 pandemic has ushered in rapidly evolving developments in digital health, and governments around the world are experimenting with different ways of introducing technological tools in the management and delivery of health care services. India, among the countries that faced one of the most serious outbreaks in the second wave of the pandemic, recently rolled out the National Digital Health Mission, which promises an integrated but federated digital architecture and a digital health ecosystem that will solve the information asymmetries of the health care sector in India. While the promises of the National Digital Health Mission are many, India’s experience with using another digital tool during the pandemic—the CoWIN portal for vaccine management—alerts us to the human rights concerns of rapid introductions of digital tools to address infrastructural and governance challenges in health care. This paper attempts to take a closer look at these two digital tools and the potential human rights implications of the National Digital Health Mission, particularly for the right to health.     

RURAL HEALTH POLICY: THE THIRD NATIONAL RURAL HEALTH CONFERENCE

ABSTRACT: The Third National Rural Health Conference was convened at Mt Beauty in February 1995, by the National Rural Health Alliance, to promote the continuing improvement of the health and well-being of people in rural and remote Australia. The agenda reflected the initiatives of the National Rural Health Strategy, developed as the result of earlier National Conferences. The conference aimed to share information and direct it to relevant institutions, to strengthen bonds and communication within the rural health field and to encourage the advocacy role of delegates within their own organisations. By drawing the themes together, the conference program highlighted the principle of equity, the plight of Aboriginal health, the right of the community to self determination and participation, and the needs, entitlements and roles of consumers. The conference further emphasised the need for an integrated or holistic approach to service planning and the need for service delivery to reflect the specific needs of rural communities. Delegates, led by the Federal Minister for Health, identified specific strategies for reinforcing and implementing programs that promote dialogue between community, workforce and government and contribute to a cohesive national and state agenda in rural health. Delegates recognised that the rural health community is now much better organised, but considerable inequities remain and must be addressed urgently.     

Changing the public-private mix: An assessment of the health reforms in greece

The 1983 health reform in Greece was a major political event in the social policy agenda. The main objective of the reform was the institution of a National Health System and the expansion of the health sector, improved equity, and the assumption of full responsibility for health services delivery by the state. An assessment of the results 10 years after full implementation of the reform shows that despite the expansion of the public sector, the public-private mix in financing and delivery has changed in favour of the private sector, making the Greek health system the most ‘privatised’ among the EU countries. The main reasons why the health reform failed to meet its objectives was the restrictive enforcement of full-time and exclusive hospital employment for doctors, the virtual ban on private hospital expansion, the much faster introduction and diffusion of new health technology by the private sector, and poor management, planning and control in the public sector. A new health reform voted into law in the summer of 1997 shows promise of redressing some of the shortcomings of the 1983 reform.     

Evidence-informed evidence-making

The extent to which clinical and public health guidance developed by the National Institute for Health and Clinical Excellence (NICE) can effectively serve the public by improving quality and efficiency across the National Health Service (NHS) and the broader public sector depends largely on the quality and relevance of the available evidence which informs its decisions. There are well-established organizational and procedural links between NICE and academic and professional organizations that undertake evidence synthesis. However, there are fewer means for evidence gaps identified during the development of NICE guidance to lead to the commissioning of new prospective studies. In this paper, we discuss the importance of a publicly funded clinical and public health research agenda that includes new prospective studies aimed at addressing knowledge gaps identified by NICE. We describe the early experience of NICE and the National Institute for Health Research (NIHR) working together to articulate and commission research to inform best practice recommendations. We propose ways in which NICE can collaborate more effectively with research funders to improve the evidence base upon which it bases its recommendations.     

Differentials in the quality of antenatal care in India.

OBJECTIVE: To investigate the socio-economic differentials in the quality (clinical and interpersonal) of antenatal care and also the correlation between differentials in the quality and utilization of antenatal care. DESIGN: The study uses cross-sectional, nationally representative data from National Family Health Survey (1998-99). SETTING: Four south Indian states (Andhra Pradesh, Karnataka, Kerala and Tamil Nadu) and four north Indian states (Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh). MAIN OUTCOMES MEASURED: More than four antenatal care visits for utilization, and index of clinical, information and interpersonal quality of care. RESULTS: Lower than desired quality of antenatal care was observed in both north and south Indian states, though the quality was significantly better in south India compared with north India, especially among the disadvantaged women. Significant socio-economic differentials in the quality of care were evident in both north and south India, but were more glaring in north India. A significantly positive relationship was observed between the quality and utilization of antenatal care in the rural areas from village-level multivariate analysis. DISCUSSION: Poor quality of antenatal care is likely to reduce its utilization. Policy and program interventions to improve the quality of care of antenatal care, especially for the poor and other disadvantaged population groups, more so in north India, are essential to improve maternal health outcomes. 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.     

Study of Rogi Kalyan Samitis in Strengthening Health Systems Under National Rural Health Mission,District Pune,Maharashtra

Background:

With objective of health systems strengthening, as visualized under National Rural Health Mission (NRHM); one key strategic intervention is up-gradation of health service delivery facilities so as to provide sustainable quality care with accountability and people''s participation, which required the development of a proper management structure called Rogi Kalyan Samitis (RKS). It is the State''s attempt to make health everyone''s business by de-mystifying health-care delivery at district and sub-district levels with reference to facility based health-care delivery by encouraging citizen''s participation in management bodies.

Objective:

The study was an attempt to define ‘functional Health Systems’ with a focus on strategic issues concerning RKS operations.

Materials and Methods:

A mixed-method, multi-site, collective case study approach was adopted. In-depth interviews of key-stakeholders were conducted. Qualitative data were analyzed thematically and coded inductively.

Results:

RKS is yet to bring out quality component to the health services being provided through facilities. This can be attributed to structural and managerial weakness in the system; however, certainly NRHM has been consistent in creating a road-map for benefitting local community and their participation through RKS.

Conclusion:

The progress of the RKS can further be enhanced by giving due priority to critical areas. Furthermore, the results emphasize an urgent need for devising strategies and actions to overcome significant systemic constraints as highlighted in the present study.     

Public health in India: issues and challenges

Health is determined not only by medical care but also by determinants outside the medical sector. Public health approach is to deal with all these determinants of health which requires multi sectoral collaboration and inter-disciplinary coordination. Although there have been major improvements in public health since 1950s, India is passing through demographic and environmental transition which is adding to burden of diseases. There is triple burden of diseases, viz. communicable, non-communicable and emerging infectious diseases. This high burden of disease, disability and death can only be addressed through an effective public health system. However, the growth of public health in India has been very slow due to low public expenditure on health, very few public health institutes in India and inadequate national standards for public health education. Recent years have seen efforts towards strengthening public health in India in the form of launch of NRHM, upgradation of health care infrastructure as per IPHS, initiation of more public health courses in some medical colleges and public health institutions and strengthening of public health functional capacity of states and districts under IDSP.     

Indian public health standards (IPHS) for community health centres

The health care system in India has expanded considerably over the last few decades but the quality of the services is not up to the mark due to various reasons. Hence standards are being introduced in order to improve the quality of services. A task group under the chairmanship of Director General of Health Services, Government of India was constituted to recommend the standards to be called as Indian Public Health Standards. IPHS are a set of standards envisaged to improve the quality of health care delivery in the country under the National Rural Health Mission.