Developments under the National Rural Health Mission:
The National Rural Health Mission (NRHM) led to a significant strengthening of public health
systems. It brought in a workforce of close to 900,000 community health volunteers, the
ASHAs, who brought the community closer to public services, improving utilization of services
and health behaviors. The NRHM deployed over 18,000 ambulances for free emergency
response and patient transport services to over a million patients monthly, added over 178,000
health workers to a public system that had depleted its workforce to sub-critical levels over a
long period of neglect, provided cash transfers to over one crore pregnant women annually,
empowering and facilitating them to seek free care in the institutions and began to address
infrastructure gaps. Across States, there were major increases in outpatient attendance, bed
occupancy and institutional delivery. However these developments were uneven and more
than 80% of the increase in services is likely to have been contributed by less than 20% of the
public health facilities. Further, States with better capacity at baseline were able to take
advantage of NRHM financing sooner, while high focus States had first to revive or expand
their nursing and medical schools and revitalize their management systems. Larger gaps in
baselines and more time taken to develop capacity to absorb the funds meant that gaps
between the desired norms and actual levels of achievement were worse in high focus states.
Inefficiencies in fund utilization, poor governance and leakages have been a greater problem in
some of the weaker states. Much of the increase in service delivery was related to select
reproductive and child health services and to the national disease control programmes, and not
to the wider range of health care services that were needed. Action on social determinants of
health was even weaker.
The almost exclusive focus of policy and implementation often masks the fact that all the
disease conditions for which national programmes provide universal coverage account for less
than 10% of all mortalities and only for about 15% of all morbidities. Over 75% of
communicable diseases are not part of existing national programmes. Overall, communicable
diseases contribute to 24. 4% of the entire disease burden while maternal and neonatal ailments
contribute to 13.8%. Non-communicable diseases (39.1%) and injuries (11.8%) now constitute
the bulk of the country‟s disease burden. National Health Programmes for non-communicable
diseases are very limited in coverage and scope, except perhaps in the case of the Blindness
control programme.
2.8. NRHM as an instrument for strengthening state health systems:
The National Rural Health Mission was intended to strengthen State health systems to cover all
health needs, not just those of the national health programme. In practice, however, it
remained confined largely to national programme priorities. While such a limited scope
enabled progress in a few indicators, this was a poor strategy. Beyond a point, such selective
facility development is neither sustainable nor efficient. For example female sterilization
operations or surgery for Emergency Obstetrics Care is safest if performed in an operation
theatre, that is functional throughout the year, and undertaken by professional teams with
support systems that are in constant use. But if such operations are undertaken on a few days
per year, in a camp mode or during an occasional emergency sustaining the quality of care for
such sporadic events is much more difficult. Strengthening health systems for providing
comprehensive care required higher levels of investment and human resources than were made
available. The budget received and the expenditure thereunder was only about 40% of what
was envisaged for a full re-vitalization in the NRHM Framework.
Urban Health:
Rapid and unplanned urbanization has led to massive growth in the number of the urban poor
population, especially those living in slums. This section of the population has poorer health
outcomes due to adverse social determinants and poor access to health care facilities, despite
living in close proximity to many hospitals - public and private. There is almost no
arrangement for primary care in many cities and towns. The National Urban Health Mission,
sanctioned in 2013 has a strong focus on strengthening primary health care- through additional
ANMs, urban ASHAs, women‟s health committees and a network of primary health centers. A
technical resource group has examined the urban health situation at length and suggested
measures needed to address the most vulnerable and marginalized sections of the urban poor
and the way forward in convergence. NUHM needs substantial expansion of funding on a
sustained basis in order to establish and operationalize a well functional primary health care
system in the urban areas.
The National Rural Health Mission (NRHM) led to a significant strengthening of public health
systems. It brought in a workforce of close to 900,000 community health volunteers, the
ASHAs, who brought the community closer to public services, improving utilization of services
and health behaviors. The NRHM deployed over 18,000 ambulances for free emergency
response and patient transport services to over a million patients monthly, added over 178,000
health workers to a public system that had depleted its workforce to sub-critical levels over a
long period of neglect, provided cash transfers to over one crore pregnant women annually,
empowering and facilitating them to seek free care in the institutions and began to address
infrastructure gaps. Across States, there were major increases in outpatient attendance, bed
occupancy and institutional delivery. However these developments were uneven and more
than 80% of the increase in services is likely to have been contributed by less than 20% of the
public health facilities. Further, States with better capacity at baseline were able to take
advantage of NRHM financing sooner, while high focus States had first to revive or expand
their nursing and medical schools and revitalize their management systems. Larger gaps in
baselines and more time taken to develop capacity to absorb the funds meant that gaps
between the desired norms and actual levels of achievement were worse in high focus states.
Inefficiencies in fund utilization, poor governance and leakages have been a greater problem in
some of the weaker states. Much of the increase in service delivery was related to select
reproductive and child health services and to the national disease control programmes, and not
to the wider range of health care services that were needed. Action on social determinants of
health was even weaker.
The almost exclusive focus of policy and implementation often masks the fact that all the
disease conditions for which national programmes provide universal coverage account for less
than 10% of all mortalities and only for about 15% of all morbidities. Over 75% of
communicable diseases are not part of existing national programmes. Overall, communicable
diseases contribute to 24. 4% of the entire disease burden while maternal and neonatal ailments
contribute to 13.8%. Non-communicable diseases (39.1%) and injuries (11.8%) now constitute
the bulk of the country‟s disease burden. National Health Programmes for non-communicable
diseases are very limited in coverage and scope, except perhaps in the case of the Blindness
control programme.
2.8. NRHM as an instrument for strengthening state health systems:
The National Rural Health Mission was intended to strengthen State health systems to cover all
health needs, not just those of the national health programme. In practice, however, it
remained confined largely to national programme priorities. While such a limited scope
enabled progress in a few indicators, this was a poor strategy. Beyond a point, such selective
facility development is neither sustainable nor efficient. For example female sterilization
operations or surgery for Emergency Obstetrics Care is safest if performed in an operation
theatre, that is functional throughout the year, and undertaken by professional teams with
support systems that are in constant use. But if such operations are undertaken on a few days
per year, in a camp mode or during an occasional emergency sustaining the quality of care for
such sporadic events is much more difficult. Strengthening health systems for providing
comprehensive care required higher levels of investment and human resources than were made
available. The budget received and the expenditure thereunder was only about 40% of what
was envisaged for a full re-vitalization in the NRHM Framework.
Urban Health:
Rapid and unplanned urbanization has led to massive growth in the number of the urban poor
population, especially those living in slums. This section of the population has poorer health
outcomes due to adverse social determinants and poor access to health care facilities, despite
living in close proximity to many hospitals - public and private. There is almost no
arrangement for primary care in many cities and towns. The National Urban Health Mission,
sanctioned in 2013 has a strong focus on strengthening primary health care- through additional
ANMs, urban ASHAs, women‟s health committees and a network of primary health centers. A
technical resource group has examined the urban health situation at length and suggested
measures needed to address the most vulnerable and marginalized sections of the urban poor
and the way forward in convergence. NUHM needs substantial expansion of funding on a
sustained basis in order to establish and operationalize a well functional primary health care
system in the urban areas.
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