Ensuring the health and well-being of all is essential to poverty eradication efforts and achieving sustainable development, contributing to economic growth and prosperous communities. Health is a fundamental human right and it is the responsibility of the governments to provide health care to all the people in equal proportions.Ever since India’s independence in 1947, various national health schemes and programs have been launched with the view to improve health status of people living in rural areas.
It is an established fact that India, as a growing economy is dependent on the health status of its population for its economic growth. The public health expenditure in India had declined from 1.3% of GDP in 1990 to 0.9% of GDP in 1999. The contribution of union government and state government to public health expenditure was 15% and 85% respectively.
The national health accounts 2004-2005 data shows that at the state level, 38% of health expenditure is spend on primary health care (They are the basic first level of contact between individuals and families with the health system), 18.7% on secondary health care (Health care services at such centers are provided by medical facilities) and 21.84 on tertiary health care (This is a specialized consultative health care for inpatients. The patients are admitted into these centers on a referral from primary or secondary health professionals) and rest on direction, administration and other services.
India’s public healthcare situation, particularly in rural regions and villages, had been a major concern since independence. Hunger, malnutrition, and high mortality had plagued the nation for decades. In 2005, India’s Infant Mortality Rate (IMR) stood at 58, well above the global average. In 2001-03, the Maternal Mortality Ratio (MMR) estimates were pegged at 301 maternal deaths per 100,000 live births and 2004 ; 2006 saw 254 maternal deaths per 100,000 live births. In 2006, when the first Global Hunger Index report was released, India was ranked 96 among 119 hungriest countries in the world. In 2005, about 43.5 percent children in the country were considered underweight. The need for a focused initiative to tackle the health scenario led to the launch of NRHM by the Indian government to improve the widespread malnutrition scenario, to collect and study data relating to public health, and to manage the outbreak of endemics and curb the spread of diseases.
Through the evolution of health care system in India, several surveys had put forth the importance of community participation in uplifting the health of the people, especially in rural areas. This led to the implementation of NRHM as an important component of eleventh five year plan “between” 2005 to 2012. After that in 2013 NHM (national health mission) was introduced.
The National Health Mission (NHM) encompasses its two Sub-Missions, the National Rural Health Mission (NRHM) and the newly launched National Urban Health Mission (NUHM). The main programmatic components include Health System Strengthening in rural and urban areas- Reproductive-Maternal- Neonatal-Child and Adolescent Health (RMNCH+A), and Communicable and Non-Communicable Diseases. The NHM envisages achievement of universal access to equitable, affordable ; quality health care services that are accountable and responsive to people’s needs. The vision 2 of the NHM is the “Attainment of Universal Access to Equitable, Affordable and Quality health care services, accountable and responsive to people’s needs, with effective inter-sectoral convergent action to address the wider social determinants of health”
The main aim is to create a fully functional, decentralized and community owned system with greater inter- sectoral coordination so that wider social determinant factors affecting health of people like water, sanitation, nutrition, gender and education are also equally addressed.
Reduction in Infant Mortality Rate (IMR) and Maternal Mortality Rate (MMR)
Population stabilization, gender and demographic balance
Achieve Universal access to public health services like women’s health, child health, water, sanitation & hygiene, immunization, and nutrition.
Prevention and control of communicable and non communicable diseases, including locally endemic diseases
Access to integrated comprehensive primary healthcare
Revitalization of local health traditions and mainstream AYUSH
Village Health Sanitation & Nutrition Committee (VHSNC):-
1) Formed at each village level within the framework of Gram Sabha.
2) Subcommittee or a standing committee of the Gram Panchayat.
3) Representation of disadvantaged sections including women.
4) Acts as a platform for convergence of all departments at village level. It also functions as a Planning and monitoring committee at the village level.
1) Interface between the community and the public health system.
2) They are female health activists at household level.
3) Involved in educating and mobilizing communities particularly marginalized communities.
4)Functions include home visits, attending the Village Health and Nutrition Day (VHND), visits to the health facility, holding village level meetings and maintaining records.
5) In rural areas, one ASHA worker per village and in urban areas, one ASHA per 1000-2500 population.
Anganwadi Nurse Midwife:-
1) They are resource person for ASHA
The NHM funding between the Centre and States is in the ratio of 60:40 (for all states except NE and 3 Himalayan States), 60 from Central government and 40 from State.
Financial outlay of NHM
The NHM funds have been released to states through the state health societies as four components- RCH flexi pool, mission flexi-pool, Immunization (including Pulse Polio) and the national disease control programs. Most of NRHM funds released (31%) went to finance the health system strengthening taken up under mission flexi pool, despite comptroller and auditor general allegations that the funds had been diverted for other schemes in various States. This is followed by funding the maternal and child health interventions under RCH-II ( 28%), immunization and disease control programs (14%) and on sub health centre expenses (27% under the head “infrastructure maintenance – which flows through the treasury route and not under society route). The per capita expenditure on national rural health mission was Rs. 80.44 in 2005-06, which increased to Rs. 129.77 in 2007-08 and then to Rs. 163.62 in 2009-10 (Source: Public Accounts Committee 32 Report, 2010-11). The proportion of releases between primary, secondary and tertiary level for the health sector is one area of concern. If all of NRHM is considered as primary and secondary- this accounts for approximately 70% of the health budget. The rest has gone to medical research, medical and nursing education and to tertiary care hospitals.
The central Grants released, Expenditure reported under NHM (2014-18) RS.in crore
YEAR ALLOCATION RELEASE EXPENDITURE
2014-15 18373.07 15778.67 22600.99
2015-16 16685.06 16645.07 25376.86
2016-17 17652.96 17144.30 27209.46
2017-18 19579.44 17062.66 10701.97
The important goal of NHM was to reduce the maternal mortality ratio(MMR) in the country from 407 to 100 per 1 lakh live births, infant mortality rate(IMR) from 60 to 30 and total fertility rate from 3.0 to 2.1 within 7 years of NHRM.
As we know NHM was launched in 2013 subsuming the NRHM and NUHM. NRHM was initially tasked with addressing health needs of 11 states that had been identified as having weak public indicators. They are 8 North-Eastern states added with 8 empowered action groups states(Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttaranchal and Uttar Pradesh) with 2 hill states(Himanchal Pradesh and Jammu ; Kashmir). Here I will be doing case study of two states Bihar and Madhya Pradesh.
The status of Health, infrastructure and services in Bihar and Madhya Pradesh:-
Heath structure in MP comprises of 50 districts, 270 community health center in around, 585 blocks and 1149 Primary Health Centers. All the 50 hospitals in 50 districts are operational as first referral unit whereas 21 SDM’S and 16 CHC’S are functioning as FRU’S. If we talk about a particular district of MP named Barwari, the infrastructural status of Barwari analysed in terms of development, they conclude CHC, 24*7 PHC, SHC, civil hospitals ANM training center. If we compare both the states in different ways to understand the development of NHM and the benefits. The total APHC, CHC and other sub-districts facilities functional as 24*7 basis under NHM 24*7 services under HNM in Bihar is 1222 and in MP this is 1523 in number i.e. 37 and 8 respectively the number of total USHC’S and maternity functional as 24*7 hour basis under NUHM.
There are total 9949 and 9192 sub-centers in Bihar and MP respectively. This is quite good in number but they all need to be managed very well by the government to sustain that development and change. PHC is an integral part of the health sector which is working through NHM so the number of district and the number of Primary Health Centers of MP is less than number the number of PHC in Bihar but the population is also low as compared to Bihar of MP these are not too much far from the others it show the development of UHS under the NHM and its implementation. If we will talk about the health indicators like UBR, CDR alike etc, then we can see the difference but these health indicators of each states shows the work has been done and the plan and strategies have been implemented very well apart from some flaws, it also did a very good demonstration of development and doing so.
As we can see, the CBR of Bihar is 26.8 as on March 2018 and 25.1 of MP. Here the difference shows the ineffectiveness of people utilization because MP has lower CBR than Bihar. There are many DHS and CHS etc such as Rogi Kalyan Samiti (RKS) registered. MP has got 1137 number of PHC’S under Rogi Kalyan Samiti and Bihar has only 454 PHC’S operating under Rogi Kalyan Smiti. It shows the involvement of Rogi Kalyan Samiti in MP with NHM facilitates more efficient service and development.
It shows the involvement of RKS in MP with NHM and facilitates more efficient service and development.
If we talk about the objectives and goals of the NHM one can find the clear determination towards the progression of Health sector of India. The government has also taken a good initiatives and it working well and even the estimated year of working also has been extended to 2020 of NHM. Once at a time it was only focused on the rural health but after that need calls for urban area, NUHM has been launched and after merging both NUHM and NRHM in April 2013.
We can see the progression in both the states in wellness of health and betterness of health sector. As you can see in 2010-11 the number of ASHA’s selected for rural area of MP was 831 and in 2015-16 it goes to 7448 in number of ASHA’s and same thing happened in case of Bihar.
But if we talk about overall selection of ASHA in both the states shows some comparative statement. The total number of ASHA has been selected for Bihar is 85,555 either working or selected till 2016 and till the same same year MP has 59001 ASHA in terms of number.
Here if we ask question on this data that why the number of ASHA of Bihar is more than the MP? Because of the difference between the rural population of both the states. These are a margin of more than 6.5 crores of population i.e. Bihar rural population is 6.5 crores more than the population of MP Rural area.
Bihar need more power for effective working cause of rural population. When things come to basics and basics and basic implementations of better plan and massive results always come out in positives.
These both states have the same results in terms of basic development. It can be shown on practical and on paper as well.
The ethics and objectives of NHM giving progression and achieved that fact of success towards Health in Bihar and MP.
, In recent survey it is shown that everything which was the objective of NHM and also on a comparative note both the states have done well all the plans and strategies have been implemented and worked out. The main reasons behind Bihar’s slow progress are its population (rural) and the economy of Bihar. But it has been 13 year of NRHM and 5 years of NUHM and how the efforts and vision can be deeply seen through the results.
The analysis has been done on the basis of NRHM and NUHM data and statistics and it is shown that the two developing states has been doing a good job to overcome their Health sector and shown problems.
The NHM has achieved a considerable degree of success in achieving the goals for which it was established. In 2014, India was ranked 55 in the Global Hunger Index ahead of both Pakistan (rank 57) and Bangladesh (57). Our country still trails behind Nepal (44) and Sri Lanka (39). Infant Mortality Rate (IMR) has declined to 40 in 2013 and Maternal Mortality Ratio (MMR) has declined to 178 maternal deaths per 100,000 live births. While there is much more to be done to rid India of the scourge of hunger, malnutrition, and spread of diseases, the achievements must be weighed against India’s burgeoning population that stands at 1.2 billion (2013 estimates). Lack of education, awareness, and women’s emancipation, particularly in rural regions have been the biggest challenges faced by the mission. India is currently at the threshold of a new phase of growth and development and this can only be achieved when public health is accorded a high level of importance. The NHM’s role in realizing this aim cannot be undermined.