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).     

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--hopes and fears. Concerns about targeted sterilisation, retreat of the state and privatisation

The National Rural Health Mission (NRHM), launched by the present government as part of its honouring the Common Minimum Programme (CMP) commitment, had its content shaped by an active process of dialogue between many stakeholders. This article traces the contours of the discussions on three key concerns of civil society that influenced their contributions to the shaping of the National Rural Health Mission agenda. These three concerns were promotion of targeted sterilisation, a retreat of the state from its commitments to the health sector and that the NRHM agenda would lead to privatisation of public health facilities. Whereas fears on targeted sterilisation and retreat of the state may be unrealistic, there is a thrust to increased involvement of the private sector, which needs to be understood in its entirety. There is need for continued engagement byequity concerned public health professionals and health activists at all levels of implementation and not merely community monitoring to influence and shape the National Rural Health Mission in a pro-poor direction.     

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.     

Factors Influencing Utilization of ASHA Services under NRHM in Relation to Maternal Health in Rural Lucknow

Background:

Under National Rural Health Mission (NRHM), ASHA (accredited social health activist) has been identified as an effective link to address the poor utilization of maternal and child health (MCH) services by rural pregnant women.

Objective:

To study the factors influencing utilization of ASHA services in relation to maternal health.

Study Design:

Cross-sectional.

Setting

Primary Health Centre (PHC), Sarojininagar, Lucknow and its rural field area.

Study Period:

September 2007 to August 2008.

Study Unit:

RDW (recently delivered women) were considered as those who delivered a live newborn at PHC Sarojininagar, within a week of interview and belonged to villages within the confines of the PHC being served by ASHA.

Materials and Methods:

350 RDW were interviewed at their bedside, by a preformed and pretested schedule and then were followed-up after six weeks.

Results:

Utilization of ASHA services for early registration was significantly associated with age and religion of RDW. Young, educated and socio-economic class III RDW utilized ASHA services the maximum for early registration. Utilization of ASHA services for adequate ANC or antenatal care (100 iron and folic acid tablets, 2 tetanus toxoid injection and ≥3 antenatal visits) was also inversely associated with age of RDW. Young, Hindu, scheduled caste, middle school pass, Class III RDW and those with birth order one had high odds for utilization of ASHA services for adequate ANC. With regard to postnatal check-up, again young RDW with birth order one, Hindu RDW in reference to Muslim and RDW in socio-economic class III had higher likelihood for utilization of ASHA services. Caste-wise scheduled caste (SC) and other backward caste (OBC) RDW had higher odds for utilization of ASHA services. Educated RDW and those with educated husband had higher odds for utilization of ASHA services for postnatal check-up.

Conclusion:

Young, educated RDW with low parity, educated husband and belonging to higher socio-economic class had higher odds of utilization of ASHA services.     

Urban poverty: delivering babies in the slum

Government of India statistics indicate that about 3 million of New Delhi's 11 million people live in slums, while another 3 million people, most fleeing rural poverty, are expected to migrate to the capital by 2000. ASHA Community Health and Development Society is a nongovernmental organization currently working in 23 of India's slums, serving a population of about 150,000 people. The group has pioneered the use of community-based networks in New Delhi to improve health in the poorest communities. While ASHA has a small, full-time staff, most of the daily health care work is conducted by slum volunteers. Ekta Vihar is a slum community of 1800 residents. Community members' primary source of health care are Vimla Rana and Sobha, two illiterate women who reside in the community and are part of a team of community health workers trained by ASHA. Rana and Sobha deliver almost all of the babies born annually in the slum and care for community members when they become ill.     

Determinants of utilization of services under MMJSSA scheme in Jharkhand 'Client Perspective': a qualitative study in a low performing state of India

Preventing maternal death associated with pregnancy and child birth is one of the greatest challenges for India. Approximately 55,000 women die in India due to pregnancy- and childbirth- related conditions each year. Increasing the coverage of maternal and newborn interventions is essential if Millennium Development Goals (MDG) 4 and 5 are to be reached. With a view to accelerate the reduction in maternal and neonatal mortality through institutional deliveries, Government of India initiated a scheme in 2005 called Janani Suraksha Yojna (JSY) under its National Rural Health Mission (NRHM). In Jharkhand the scheme is called the Mukhya Mantri Janani Shishu Swasthya Abhiyan (MMJSSA). This paper focuses on community perspectives, for indentifying key areas that require improvement for proper implementation of the MMJSSA in Jharkhand. Qualitative research method was used to collect data through in-depth interviews (IDIs) and focus group discussions (FGDs) in six districts of Jharkhand- Gumla, West Singhbhum, Koderma, Deoghar, Garhwa, and Ranchi. Total 300 IDIs (24 IDIs each from mother given birth at home and institution respectively; two IDIs each with members of Village Health and Sanitation Committees (VHSC) / Rogi Kalyan Samitis (RKS) from each district) and 24 FGDs (four FGDs were conducted from pools of husbands, mothers-in-law and fathers-in-law in each district) were conducted. Although people indicated willingness for institutional deliveries (generally perceived to be safe deliveries), several barriers emerged as critical obstacles. These included poor infrastructure, lack of quality of care, difficulties while availing incentives, corruption in disbursement of incentives, behavior of the healthcare personnel and lack of information about MMJSSA. Poor (and expensive) transport facilities and difficult terrain made geographical access difficult. The level of utilization of maternal healthcare among women in Jharkhand is low. There was an overwhelming demand for energizing sub-centers (including for deliveries) in order to increase access to maternal and child health services. Having second ANMs will go a long way in achieving this end. The MMJSSA scheme will thus have to re-invent itself within the overall framework of the NRHM.     

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.     

Developing health services management in South Africa: The question of transformation

The end of the Apartheid system in South Africa will have a major impact on its public sector, and the health service in particular. The key player in the process of transformation, the African National Congress, has put forward proposals for a National Health Service. The need for a management cadre to bring about and maintain these major changes is slowly being recognized. This article considers the impact of the proposed changes for health service management, and argues that management education has to produce people who possess both strategic and operational competencies to effect the transformation of an unequal and divisive health service into one that offers an equitable and high quality service to all South Africans.     

Are community health workers cost-effective for childhood vaccination in India?

IntroductionAccredited Social Health Activists (ASHAs) are female community health workers whose primary role is to promote utilization of primary healthcare services and improve sanitation in rural areas and are financially incentivized for services provided. Prior studies evaluating ASHAs have been largely qualitative, and assess their knowledge, skills, and practice. Globally, there have been very few studies that have quantitatively assessed community health workers. We analyzed the cost effectiveness of ASHAs in facilitating measles vaccination among children under 5 years during 2012–2013.MethodsWe utilized Markov modeling simulating a cohort of children in villages with and without ASHAs. We extrapolated the health states to a lifetime of 68 years to estimate the effects of ASHA intervention. Measles vaccination rates were obtained from 2013 District Level Household and Facilities Survey 4. Other parameter estimates were obtained from a review of relevant literature.ResultsASHA intervention was highly cost effective at $162 per DALY averted compared to no ASHA and remained cost effective with the ASHA incentive increased from $2 to $15, across the range of probabilities and cost parameters. Analyses were sensitive to probability of death due to childhood pneumonia, susceptibility to measles after one dose measles vaccine, and probability of pneumonia after measles infection.ConclusionASHAs were cost-effective under a wide range of scenarios even when a single health outcome such as measles vaccination was considered. The Government of India and individual state governments of India should consider increasing the incentives provided to ASHAs.     

Global eradication of polio: the case for "finishing the job"

While seven years have passed since 2000, the target set for the eradication of polio, success remains elusive. In 2006, despite coordinated international efforts, there was no major breakthrough in containing the polio virus, which persists in a few pockets in the four countries in which it is endemic. The polio eradication programme faces new hurdles such as importation, re-emergence and failure of political and community mobilization. The decreasing morale of health workers and volunteers, doubts about the efficacy of oral polio vaccine and ever-increasing programme costs and funding challenges are other issues to be addressed. This paper describes the ongoing conventional strategy adopted for polio eradication, then analyses existing challenges and some possible solutions. The author suggests that major modifications and additions to the ongoing conventional strategy are required in order to create a multi-pronged, area-specific strategy that can finish the job of polio eradication. This should include an area-specific approach, community dialogue, enhanced political advocacy and compulsory vaccination, as well as the use of inactivated polio vaccine in endemic countries even before the transmission of wild polio virus has been halted. This appears to be the best way to achieve eradication at the earliest opportunity.     

Cluster randomized trial of a parent-based intervention to support early development of children in a low-income country

Background   Programmes that promote early psychological development of children in the developed world have been found to be beneficial. However, such programmes are rare in underprivileged parts of the developing world. We adapted one such parent-based programme (Learning Through Play) for a rural Pakistani population and aimed to study if: (1) it was acceptable to community health workers; (2) the programme led to an improvement, after a period of 6 months, in mothers' knowledge and attitudes about early infant development; (3) it led to a reduction in the levels of maternal mental distress in the post-natal period.
Methods   Using a cluster randomized design with villages as unit of randomization, 163 mothers from 24 villages in a rural sub-district of Rawalpindi, Pakistan, received the 'Learning Through Play' programme, whereas 146 mothers from 24 villages acted as controls. Twenty-four community health workers were trained to carry out the programme. Assessments were conducted using a specially developed 15-item Infant Development Questionnaire and the 20-item Self-Reporting Questionnaire (SRQ).
Results   Over 80% of the community health workers trained found the programme to be relevant and were able to integrate it into their routine work. There was a significant increase in mothers' knowledge and positive attitudes about infant development in the intervention group, compared with the control group. Women in the intervention group answered correctly 4.3 (95% CI 3.7–14.9, P  < 0.001) more questions than the control group. There was no difference in levels of mental distress measured by the SRQ.
Conclusions   The 'Learning Through Play' programme was successfully integrated into the existing health system and accepted by community health workers. The programme succeeded in improving the knowledge and attitudes of mothers about infant development.     

Who should run worksite health programmes in hospitals?

The authors discuss the pros and cons of having each of the following occupational groups heading a worksite health promotion in a hospital: health educators/promoters, nurses, managers, external consultants. The authors draw on recently completed research in New Zealand organisations to suggest that: 1) Health educators have the necessary diagnosing and programme planning skills, but may not have a good grasp of workplace issues and hazards; 2) Nurses have an extensive medical background, but may lack the skills of consultation and/or the ability to see worker-clients in the context of the total environment; they may be biased towards changing the individual worker rather than an unhealthy environment; 3) Managers may understand the client population at the workplace, and have the power to make comprehensive, system-wide changes, but may not have an extensive medical or health background, requiring ongoing liaison with resources that do; 4) External consultants are probably able to bring in fresh ideas borrowed from similar organisations and may have excellent initiative and coordination for recreational events. They may be expensive, and may not be familiar or powerful enough with an organisation to be able to make organisation-wide changes for health. Multiple factors must be considered when a health programme leader is chosen. The situation in each organisation will require a unique blending of the roles and skills for the smoothest implementation of the programme. An example is offered of how these could come together in a hypothetical hospital situation.     

Training and retaining Shasthyo Shebika: reasons for turnover of community health workers in Bangladesh

Shasthyo Shebikas (SS) are community health workers forming the core of BRAC's Essential Health Care (EHC) programme. The SS dropout was 44 percent for study area and 32 percent for EHC programme. The SS discontinued their work due to lack of time, lack of "profit", and family's disapproval. The effects of the dropouts were decreased achievement of targets, and a loss of money in the amount of $24 (U.S.) per dropout SS for their training and supervision. The SS retention may increase if EHC strictly adheres to its existing guidelines when selecting trainees, and if it highlights during SS training that SS; s first and foremost role will be as that of a volunteer and then of a salesperson.     

"The walls were so damp and cold" fuel poverty and ill health in Northern Ireland: results from a housing intervention

This article reports the findings from an evaluation of a fuel poverty programme in the Armagh and Dungannon Health Action Zone in Northern Ireland. Focusing on a rural community, it adds to the debate surrounding the hidden nature of rural fuel poverty. As part of the programme, energy efficiency measures, including some central heating systems, were installed in 54 homes. Surveys were conducted both pre and post intervention and analysed to assess any changes. The programme demonstrated that energy efficiency intervention can lead to improvements in health and well being, increased comfort levels in the home and a reduction in the use of health services, therefore having potential cost savings for the NHS. Some households, however, remain in fuel poverty after having full central heating installed, reflecting the significant contribution of low income on the production of fuel poverty. The article concludes by suggesting that interventions in this area require commitment from multiple sectors of society, including health professionals and local communities.     

Subregional resource allocations in the National Health Service.

The Resource Allocation Working Party in its report Sharing Resources for Health in England proposes a formula for the identification of both regional and district financial targets (Department of Health and Social Security, 1976). In this paper it is argued that the national formula is not a valid instrument for the latter purpose. Furthermore, research into medical needs and outcomes will not be adequate to bring about real changes in resource distribution at local levels unless it is recognised that the health authorities can meet needs in different ways and that a change in resource management from institutional to service budgeting is required.     

Systematic curriculum development in an Indonesian post-graduate Faculty of Public Health

This paper describes a programme of curriculum development in an Indonesian post-graduate Faculty of Public Health. This faculty redefined all its curricula within a 2-year period, and these curricula are now stated in terms of sets of instructional objectives which are skill-based and learner-centred. These curricula are now being implemented in ways which are consistent with contemporary educational thinking. It is contended that the rapidity with which these changes occurred can be accounted for in terms of: (a) the strong support of the faculty's leadership; (b) the methods used to bring about these changes; and (c) the sustained efforts made by many of the teaching staff.     

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.