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NATIONAL RURAL HEALTH MISSION
Pooja Kumari
Dr. Vinod CV
INTRODUCTION
National Rural Health Mission (NRHM- 2005-07) has been viewed as the holistic and democratic
mission mode intervention by the state in the field of health. It is based on innovative and
comprehensive strategies for providing funds, creating new institutions, decentralization and
providing new ideas and resources for health. Assuming the importance of NRHM in improving
general health conditions and in particular improvement in (IMR) Infant Mortality Rate and (MMR)
Maternal Mortality Rate the state has extended it further till 2017. The Twelfth Five Year Plan has
also extended NRHM to urban poor, calling it a National Health Mission (NHM) rather than National
Rural Health Mission (NRHM). This paper examines the goals and strategies of NRHM and discusses
its strengths and weaknesses. At the end it suggests that to make health interventions effective there
is a need to strengthen the primary health care system in both rural and urban areas. Weakening of
the primary health care system due to multiple priorities and transfer of responsibility to private
sector in the new-liberal regime may do a severe damage to the health system. The strategic options
before the Mission included integration of Reproductive Child Health (RCH) , family welfare, and
national programs of disease control under NRHM to achieve desired population stabilization goals
within reasonable period. The National Disease Control Program (NDCP) comprise of preventive and
curative measure for control of Malaria, Filarisis, Encephalitis, Dengue, Kalazar, Leprosy,
Tuberculosis, Blindness, Iodine Deficiency disorders, and Polio. However, the National AIDS and
Cancer programs were not integrated to the NRHM scheme. A funnel type approach was adopted to
ensure the integration of funds for all the national level schemes and thereby the flow of funds to
the District Health Mission through the State Health Society. Thus, under the decentralization scheme
the district was supposed to be the hub around which all health and family welfare services were
supposed to be planned and managed. . According to the Constitution of India, wellbeing has been a
State Subject yet the Centre constantly perceived the need to help State wellbeing activity to give
Impartial and successful administrations to individuals having a place with various areas and Social
gatherings. This paper goes for evaluating the thoughts and practices of NRHM and Related wellbeing
strategy matters. Utilizing auxiliary information and writing it contends that in Spite of the fact that
the points of targets of NRHM are all encompassing and praiseworthy the Field hones fail to i0mpress
anyone. In its present shape NRHM has not accomplished the Expressed objectives in time and is
experiencing numerous bottlenecks. Worried about different Full scale and smaller scale issues,
Lovely Professional University, Punjab, India
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NRHM does not have a core interest. The paper contends that Despite the fact that activity is required
on a few fronts, the most crucial need of the undertaking Is to fortify the essential social insurance
framework. Because of an overambitious approach with Respect to Ministry of Health and Family
Welfare an expansive number of activities have been taken yet few of them are viably executed. The
socio- economic progress of the country was also never uniform, as some states had developed
tremendously whereas some states had lagged far behind. In the year 2001 the then National
Democratic Alliance NDA government led by the Honourable Prime Minister Sri Atal Bihari Bajpayee
in order to bring backward states at par with developed states had constituted Empowered Action
Group (EAG) to specifically recognize and address the problems of those backward states
Review of literature
Johnson (2011) in his examination on country wellbeing mission in rustic Odisha distinguished that
the arrangement was executed not brought a positive outcome. This examination additionally tosses
light upon the positioning of various state as far as these parameters. The outcome demonstrate that
there are irregularities in all zones particularly in the foundation, pharmaceuticals and subsidizing yet
these can be dealt with effectively inside a given time period. The significant issue lies in the
accessibility, duty of staff and the use of administrations.
Gill (2009) has completed an examination paper for the arranging commission of India to think about
the nature of administration conveyance of NRHM in rustic India. It was directed in four
Conditions of North India. The investigation centres around the general effect of NRHM in these
States especially estimating the solid angles (accessibility of staff, nature of prescription,
participation, subsidizing, accessibility and usage of administrations) and indefinable (fulfilment
of patients) perspectives through irregular visits and post-employment surveys. This investigation
additionally tosses light upon the positioning of various states and state of each state regarding
these parameters.
Objectives
The following are the objectives of this study:
1. To examine the goals and strategies of NRHM.
2. To examine the qualities and shortcoming of NRAM.
3. To examine the effects of NHRM.
4. To make suggestions for developing effective Health intervention.
Goals of NRHM
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The National Rural Health Mission, 2005-07 (NRHM) was launched on 12th April 2005 by the Prime
Minister of India to improve the status of health services in India. It has now been extended till 2017.It
is based on innovative and comprehensive strategies for providing funds, creating new institutions,
decentralization and providing new ideas and resources for health. The stated aim of the NRHM was
to provide accessible, affordable and accountable quality services to rural population with
concentration on 18 ‘Special Focus States’ and the poor. Sociologically, it is notable that apart from
providing financial support several new institutional changes were envisaged. They include
communalization of funds, flexible financing, improved management through capacity building,
improved monitoring against standards, and innovations in human resource management. Provisions
of untied funds, involvement of Panchayati Raj Institutions (PRIs), public-private partnership and
convergence of health sector and a wide range of other determinants of health (e.g. water,
sanitation, education, nutrition, social and gender equality) were created to develop ‘a fully
functional health system at all levels, from the village to the district’. Some of the major planks of the
NRHM were appointment of Accredited Social Health Activist (ASHA) in each village (one on the
population of 1000), health insurance for the poor, and involvement of non-profit sector, especially
in underserved regions. The Mission aims at “fostering PPPs; improving equity and reducing out of
pocket expenses; introducing effective risk-pooling mechanisms and social health insurance; and
taking advantage of local health traditions” (Eleventh Five Year Plan, 2008). Quoting Independence
Day speech, 2012, of the Prime Minister of India, the Twelfth Five Plan document notes that the
success of the National 5 Rural Health Mission shows the way for converting NRHM into National
Health Mission (NHM) which would cover both rural and urban areas. Thus an impression is created
that NRHM has been quite successful in achieving its goals.
Strategies
1. Decentralization of the process of health planning and management from village to District level.
2. Involvement of PRIs and village Health and sanitation committees.
3. Up-gradation of existing health institution from sub centres to District Hospitals as per Indian Public
Health Standards (IPHS).
4. Flexible financing – united funds for filling up the gaps in infrastructure and other related activities.
5. Manpower requirement- recruitment of doctors, and paramedical staff in relation to woman and
child health.
6. Improved management through capacity building-provision of computers, computer operators,
establishment of state, district and block Programme Management Units (PMUs).
7. Integration of AYUSH Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy with the
mainstream health institution including recruitment of
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Ayurvedic/homeopathic doctors’ at Part of Health Care and Community health of center level.
8. Promotion of public private partnership for achieving public health goals.
Achievements and Failures
In statement of achievements, ‘NRHM – the Progress So Far’, Ministry of Health and Family Welfare
reports that NRHM has reduced IMR at higher rate than earlier (during 2003-2006), increased
institutional deliveries, raised the figures of full immunization, constituted Rogi Kalyan Samitis,
appointed and trained ASHAs, constituted Village Health Committees, created village health and
nutrition days, provided mobile medical units and co-located AYUSH in a number of health facilities.
These are not the mean achievements. Yet, this is not the full story and a thorough examination of
cost-benefit analysis of the project is required. This has not been done so far, perhaps because
problems abound. It is practically impossible to evaluate the cost-effectiveness of a national project
like NRHM. Health depends on a number of factors such as living and working conditions of people,
education, degree of social integration, awareness, belief systems, quality of environment, and
access to health facilities, among others. During the last eight years after implementation of NRHM
changes have occurred in all the parameters which present significant externalities. Some data are,
however, available from both government sources and researchers which are worth observing.
International Institute for Population Sciences (IIPS), Mumbai, has produced a voluminous Fact Sheet
of Concurrent Evaluation of National Rural Health Mission 2009. This document (IIPS, 6 2010)
establishes that there are pronounced inequalities between States and the achievements are far
from being satisfactory. Sample Registration Scheme’ Special Bulletin on Maternal Mortality in India
2007-09 (SRS, 2011) showed that MMR varies from 81 in Kerala to 390 in Assam, and maternal
mortality rate varies from 4.1 in Kerala to 40.0 in Uttar Pradesh/ Uttarakhand. SRS Bulletins also show
the continuing differences in IMR and DRs between States and different Union Territories of India.
SRS Bulletin of 2009 showed that IMR of India is 53. It is 58 for urban areas and 36 for rural areas.
While Goa has a very low IMR which is 10, IMR of Madhya Pradesh is 70. According to October 2012
Bulletin of SRS the IMR of India has come down to 44 but the differences between urban and rural
localities and different States have continued. Odisha, Rajasthan, Madhya Pradesh and Uttar Pradesh
have IMR above 50.
As per the concurrent evaluation mentioned above (IIPS. International Institute for Population
Sciences, 2010), Uttar Pradesh which is one of the High Focus States is characterized by the following:
1. Only 4.5 percent Primary Health Cares have piped water supply.
2. Only 3.0 percent Primary Health Cares were upgraded as per IPHS norm.
3. 17.9 percent Primary Health Cares Rogi Kalyan Samitis (RKS) generated resources.
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4. Out of 31 Department of Homeland Security covered in the study only 8 had Neo Natal ICU/
specialized Sick New Born Care unit.
5. Only 6.2 percent (ASHAs) Accredited Social Health Activist received incentive for Village Health and
Nutrition Days (VHND).
6. Only 13.2 percent (ANMs) Auxiliary Nurse Midwifery stayed in official residence.
7. 66.5 percent children received full immunization.
8. 28.7 percent of the currently married women (15-49) reported to have exclusively breastfed
youngest surviving child for the first six months.
Yet, it may be noted that most of the IPD inpatient department and OPD Out Patient Department
patients were satisfied with the services at DH department of health, Community Health Centre, and
Primary Health Care. More or less similar is the situation in Bihar and other High Focus States. To me
this means that for those who come to avail services in government health facilities these facilities
are of great value, if for one reason that they have no other alternative.
7 Among the latest sources of data, Annual Health Surveys have shown:
I. full ANC (i.e. three or more ANC Absolute neutrophil count, one Tetanus toxoid injection and Immuno
fluorescent assay IFA for 100 days or more) varies from 3.9 percent in Uttar Pradesh to 19.5 percent
in Chhattisgarh;
II. during 2007-09 one in four marriages of girls in Bihar and one in five in Rajasthan and Jharkhand
occurred below the age of 18;
III. In Chhattisgarh only 34.9 percent deliveries are institutional; and Bihar and Uttar Pradesh continue
to have high TFR. On the positive side there has been no polio case in India after 13 Jan. 2011 (NRHM
Newsletter, 2012). Observations from the Fifth Common Review Mission reports are also useful and
insightful. The Uttar Pradesh report shows that the newly constructed PHCs are lying locked due to
non-availability of Staff; equipments needing minor repairs are lying dysfunctional; district priorities
for infrastructure are not reflected in State PIP; there is a severe shortage of
Specialist/MOs/Nurses/MPWs; the conventional methods of recruitments/outsourcing are not
producing the desired results; there is a serious lack of priority to training; there is a shortage of
training institutions; the quality of training is not good which affects delivery of health services;
biomedical waste management is grossly inadequate; and quality assurance mechanisms are not
established. Eleventh Five Year Plan document itself recognizes that there are several drawbacks of
the public health systems.
IV. They are:
(a) Centralized planning instead of decentralized planning and using locally relevant strategies;
(b) Institutions based on population norms rather than habitations;
(c) Fragmented disease specific approach rather than comprehensive health care;
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(d) Inflexible financing and limited scope for innovations;
(e) Semi-used or dysfunctional health infrastructure;
(f) Inadequate provision of human resources;
(g) No prescribed standards of quality;
(h) Inability of system to mobilize action in areas of safe water, sanitation, hygiene, and nutrition (key
determinants of health in the context of our country)—lack of convergence; and
(i) Inability to mobilize AYUSH and RMPs and other locally available human resources.
The same document mentions about the review of NRHM leading to following conclusions:
• 17318 Village Health and Sanitation Committees (VHSCs) have been constituted against the target
of 1.80 lakh by 2007.
• No untied grants have been released to VHSCs pending opening of bank accounts by the
Committees. 8 • Against the target of 3 lakh fully trained Accredited Social Health Activists (ASHAs)
by 2007, the initial phase of training (first module) has been imparted to 2.55 lakh. ASHAs in position
with drug kits are 5030 in number.
• Out of the 52500 Sub-centres (SCs) expected to be functional with 2 Auxiliary Nurse Midwives
(ANMs) by 2007, only 7877 had the same.
• 9000 Primary Health Centres (PHCs) are expected to be functional with three staff nurses by 2007.
This has been achieved at 2297 PHCs.
• There has been a shortfall of 9413 (60.19%) specialists at the CHCs. As against the 1950 CHCs
expected to be functional with 7 specialists and 9 staff nurses by 2007, none have reached that level.
• CHCs have not been released untied or annual maintenance grant envisaged under the NRHM as
they have not reached up to the expected level.
• Number of districts where annual integrated action plan under NRHM have been prepared for
2006–07 are 211.
Effects
The National Health Mission (NHM) is an effort to increase public spending for strengthening health
system. Their are some effects mentioned below:-
Two major components of NHM are ‘Reproductive and Child Health (RCH) flexipool’ and ‘Mission
flexipool’. It has been observed that institutional deliveries have increased from 50% in 2008–2009
to 65.08 % during 2014–2015.
The objective of this study is to evaluate whether the increase in government expenditure under
NHM has benefited all classes of the society equally. The present study was conducted in Jalandhar
district to analyze the role of National Rural Health Mission (NRHM) on women health.
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Based on 120 respondents of two blocks of the district, study led to the conclusion that most of the
beneficiaries of NRHM scheme were from Schedule Caste category (55.83%).
Most of the women respondents (84.17%) were not aware about NRHM programme however they
availed the benefits due to efforts of Paramedical staff attached to NRHM.
All the respondents under study availed facilities under Janani Suraksha Yojana as well as Universal
Immunization Programme. Though half of the respondents said that basic facilities for medical
treatment were available in the sub-centres yet hardly any ambulance was available at the time of
emergency.
57.50 per cent respondents held that they did not receive cash incentive being provided by
government under the scheme.
A large number of (88.24%) respondents reported that they did not get the free provision of blood
during surgery under Janani Shishu Suraksha Karyakram (JSSK).
66.67 per cent of the respondents revealed that doctors were not available at government health
centres while majority (93.33%) of the respondents reported that ANM’s were not available at sub-
centre and (78.33%) of the respondents felt lack of attention given by Para-medical staff during
treatment.
Nearly half (49.17%) of the respondents under the study do not use any family planning methods.
The National Rural Health Mission (NRHM) has been a watershed in the history of India's health
sector. As a previously unattempted investment, governance, and mobilization effort, the NRHM
succeeded in injecting new energy into India's public health system. A huge expansion of
infrastructure and human resources is the hallmark of the NRHM action.
Demand-side initiatives led to enhanced utilization of public health facilities, especially for facility
births. The impact is visible. The Mission has brought Millennium Development Goals 4 and 5 within
India's grasp. Acceleration in infant and neonatal mortality reduction is especially notable. The NRHM
has created conditions for the country to move toward universal health coverage.
The main aim of the present study to find out the impact of National Rural Health Mission (NRHM)
on the health sector in Haryana. The National Rural Mission (NHRM) was launched by the Hon’ble
Prime Minister Dr. Man Mohan Singh on 12th April 2005, to provide accessible, affordable, equitable
and quality health services to the poorest households in the rural region of the country. The NRHM
covers the entire country with special focus on 18 states where the challenges if strengthening poor
public health system. National Rural Health Mission (NRHM) is not a first programme on rural health
in independent India, even than the enthusiasm and attention of the heath personnel and people
towards the programme is phenomenal. The attempts to improve rural health through various
programmes were started as early as in 1940, when the British government in India set up ‘Bhore
Committee’ to find out the way to improve the health of people. This was followed by a number of
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other committees and programme i.e. Balwant Rai Mahta Committee, community Development
programme and Basic need programme.
Status of Health Infrastructure in States
As per the given graph represents population of
the UP is much higher than the other states,
because in UP fertility rate, atmospheric condition
and much other factors like literacy rate are
affecting for surviving. If we compare with other
states like the lowest population is in Jammu and
Kashmir, then we found that the atmospheric
condition of J and K is not suitable for surviving. If
we take any other state like Orissa then we found
that their atmospheric condition is good but
fertility rate is low that’s why.
Same as the above graph the fertility rate of
the state UP is higher than the other states it
seems to be that the reasons of population
rate and the fertility rate is same. Here
fertility rate of Tamil Nadu is lowest due to
their warm Atmospheric condition, and if we
see other states like Orissa and Jammu &
Kashmir their fertility rate is almost same.
Their states is also to warm and cool but not
so much warm as Tamil Nadu.
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Reasons:
Education is less reduces poverty, boosts economic growth, deaths, and combats diseases such as
HIV and AIDS. .it is the rights of people to gain knowledge from their.
UP has more than 50% population below the age of 25 and more than 65% the age is 35. UP has
many number of ethics group, religious group and many number of family languages. So everyone
wants to grow their family, grow their religion and group that’s why we the population of UP is
highest and still on increase. But the main factor of their growth is their atmospheric condition and
greatest income sources.
Now if we will take the death rate then we found that the age of population is between 25-35. and
according to our top studies we found that this age can survive in the atmospheric condition.
Orissa is highest in Neo - Natal Mortality
because these deaths are due to conditions
that could be prevented or treated with
access to simple affordable interventions.
The leading causes of death of children
under five include:
1-Pneumonia
2-Preterm(premature) birth
3-Diarrhoea
4-Malaria
5-malnutrition
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Be aware to people about the populations increases is harm for environments. Overpopulation is an
undesirable condition where the number of existing human population exceeds the carrying capacity
of Earth. It caused by number of factors. Reduced mortality rate, better medical facilities, depletion
of precious resources are few of the causes which results in overpopulation. This rapid
growth increase was mainly caused by a decreasing death.
Health facilities are places that provide healthcare and its includes hospitals, clinics, outpatient care
centers. Food access is important to health because unhealthy eating habits are linked to numerous
acute and chronic health problems such as diabetes, cancer, malaria, heart disease, and etc…stroke
as well as higher mortality rates.
Enrich resources to support life
Cultural /religious belief
Conclusion
This paper examines the prehistory and the approaches of National Rural Health Mission (NRHM).
Based on available material, achievements and limitations are also discussed. The paper contains
strategies of NRHM and suggests that the most effective way to attain goals of NRHM is to strengthen
the primary health care system.
Rather than taking up a large number of things simultaneously without any focus. This is not to
denigrate the importance of other measures and we recognize that to improve public health
standards in the population a multipronged approach is indeed required but a fully functioning
primary health care system is a necessary condition for other goals to be achieved.
National Rural Health Mission had performed excellently well across the country. However
achievements as described by various governmental and non-governmental sources could not said
to be exclusively the achievement of National Rural Health Mission and research scholar would term
those as achievements of the country as a whole through both public and private health sector
combined. The public health data in the country was largely based upon sample survey and research
scholar could say that despite high rates of confidence declared by those agencies such data could
not be actual but only factual. District Level Household Survey data, Sample Registration System Data,
United Nations International Children's Emergency Fund (UNICEF) multi health indicator survey data
and even Indian Council of Medical Research data could fall in this category. It would be highly
beneficial to plan based upon actual data which could be ensured through vital or mandatory
registration of deaths, births and ailments with causes of death and ailments of each and every case
in the country. Per capita fund release and utilization was calculated to examine the respective
performances by states in terms of financial management. Such analysis was repeated for
beneficiaries under Janani Suraksha Yojna and Institutional delivery. Some great contrast was found
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in terms of Janani Suraksha Yojna and Institutional delivery as they were expected to correspond with
each other therefore this contrast was a matter of further study. It was also found that high focus
states were not provided enough per capita funds and in fact in most cases per capita funds release
to EAG states were even below other states, which were not high focused. Therefore the very idea
of grouping of states in categories such as high focus and non high focus had appeared meaningless.
However EAG or high focus states had definitely outperformed non high focus states. Without more
funds how those states performed better could be a matter of great relief. Although it was mainly
due the fact that more crowd turned to public health facilities in those states.
It was further found that each and every public health facilities across the country had become
eventful due to implementation of National Rural Health Mission. Transformation in the rural health
sector might say panoramic and easily perceived by people in comparison to pre National Rural
Health Mission period i.e. before April 2005. There were marked increase in Immunization coverage,
OPD/IPD Cases, Ambulatory services, and Institutional deliveries what was defined as perceptible
transformation under this research. Different provisions were implemented under the aegis of Rogi
Kalyan Samiti, Janani Suraksha Yojna, and Indian Public Health Standards had benefitted the rural
public health system largely. The execution of National Rural Health Mission was exclusive. The
Framework of implementation, Mission statements, and targets formulated were appeared logical,
realistic, and achievable and reflected the developmental requirements of the country.
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National Rural Health Mission:-
http://162.144.90.128/IEGIndia/upload/uploadfiles/Delhi%20South%20District%201.pdf
National rural health mission: time to take stock:-
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800893/
A primary evaluation of service delivery under the National Rural Health Mission (NRHM): findings
from a study in Andhra Pradesh, Uttar Pradesh, Bihar :-
http://environmentportal.in/files/wrkp_1_09.pdf
National Rural Health Mission–Hope or disappointment?:-
http://www.academia.edu/download/3244984/National_Rural_Health_MissionHopes_and_Fears.p
df#page=23