Four years ago, the National Rural Health Mission (NRHM) was launched with the aim to provide accessible, affordable and accountable quality health services to the poorest households in the remotest rural regions. With barely three years of the mission remaining, it may be worthwhile to take a look at the progress that has so far been made in achieving the objectives that had been set out. A preliminary assessment of the programme, based on health indicators, shows that the government has had very limited success in achieving its objective to establish a fully functional, community-owned, decentralised health delivery system.
The mission was launched to correct the skewed access to healthcare facilities between the urban and rural areas. While there were a plethora of schemes that catered to the healthcare needs of urban areas, there was little that had been done to set up a functioning rural healthcare system. One of the main reasons for inequalities in access to healthcare facilities between the rural and urban areas was the lack of good medicare infrastructure in rural areas of most states, particularly Arunachal Pradesh, Assam, Bihar, Chhattisgarh, Himachal Pradesh, Jharkhand, Jammu and Kashmir, Manipur, Mizoram, Meghalaya, Madhya Pradesh, Nagaland, Orissa, Rajasthan, Sikkim, Tripura, Uttarakhand and Uttar Pradesh.
Because the NRHM was specifically aimed at removing infrastructural (both physical and human) bottlenecks that resulted in unequal access, states with unsatisfactory health indicators and/or with weak infrastructure were classified as special focus states to ensure that efforts were concentrated where it was most needed.
The mission had set specific targets that were to have been met by 2012. These include a reduction in the infant mortality rate (IMR) to 30 per 1000 live births, a reduction in the maternal mortality rate (MMR) to 100 per 100,000 births, improved access to integrated comprehensive primary health care and, last but not least, upgrading community health centres.
There is little doubt that the mission has conferred some benefits on rural areas. Major health indicators in the focus states have shown some improvement. For instance, at the national level, there was a decline in the infant mortality rate from 58 per thousand live births in 2005 to 53 in 2008 (all India) after implementation of NRHM. The IMR in focus states like Bihar fell from 61 to 56, in Chhattisgarh from 63 to 57, in Madhya Pradesh from 76 to 70, in Uttar Pradesh from 73 to 67, in Rajasthan from 68 to 63 and in Assam from 68 to 64. These figures are, however, still dismal even when compared to the target IMR rate of 30 under NRHM. The NRHM has had an impact but a rather limited one. (Graph 1).
Graph 1: IMR figures in various states and all India level (recent figures)
Source- NRHM website.
The state of public health in India and gains under NRHM, as indicated by a few important health indicators, are as follows:-
Indicators and Action Points Gains under NRHM
1. IMR IMR down to 53. Down by 4 points in 2008 as compared to a point a year in earlier years (2003-06).
2. Immunisation Full immunisation increased from 20.7 per cent to 41.4 per cent in Bihar, 25.7 per cent to 54.1 per cent in Jharkhand, 30.1 per cent to 36.1 per cent in MP, 53.5 per cent to 62.4 per cent in Orissa, 23.9 per cent to 48.8 per cent in Rajasthan, 25.8 per cent to 30.3 per cent in UP between District Level Household and Facility Survey (DLHS)-II and DLHS-III.
3. Accredited Social Health Activist (ASHAs)/ Link Workers In total, 7.31 lakhs ASHAs selected under NRHM till 31st Aug, 2009 as compared to 1.30 lakh in 2005-06, 5.25 lakh trained upto the 4th module (ASHAs induction training may be completed in 23 days spread over a period of 12 months)
4. Primary Health Centre (PHC) and Community Health Centre (CHC) Total number of PHCs functioning on a 24×7 basis increased from 1263 at start of NRHM (31/3/2005) to 7613 (as on 31/8/2009). Similarly CHCs functioning on a 24 x 7 basis increased from 980 to 3606 ( as on 31/8/2009)
5. Mobile Medical Units (MMU) 354 districts have MMUs functional so far (Out of that 136 in High focus non northeast (NE), 83 high focus NE, 131 non-high focus large and 4 in non high focus small and UT)
Notwithstanding the claims of progress made by the NRHM, nothing perhaps reflects its painfully slow pace as a comparison with Kerala (Table 1).
Table-1: Comparison of major health indicators
(status as on 31st Aug, 09)
IMR (in per 1000 live births) Life expectancy rate ( in years) MMR (in per 100,000 births)
Kerala 12 73.8 95
Bihar 56 61.05 312
Uttar Pradesh(UP) 67 59.7 440
Madhya Pradesh(MP) 70 57.65 335
Rajasthan 63 61.7 388
The poor performance of these states in terms of major health indicators should perhaps come as no surprise. Data provided by the NRHM shows that there has been little progress in creating the required infrastructure. NRHM had assessed the needs of the focus states. Table 2 shows the assessed need for infrastructure and the actual achievement on this count.
Table-2: Comparison of sub-centre and health specialist under NRHM in few focus states (in no�s)
Bihar UP MP
Sub-centre required 14,959 26,344 10,402
Shortfall in target achievement 6,101 5,823 1,568
Total health specialist required at CHC 280 2,060 1,080
Shortfall in target achievement at CHC 176 1,442 860
Apart from the severe shortfall in physical infrastructure, the programme has been plagued by inadequate and irregular drug supply, poor staffing and ambulance facilities, lack of specialised medical professionals etc. Similarly, ASHA, the programme for first contact care, has not been effectively implemented because of lax selection criteria and poor compensation.
Clearly, the government will have to introduce fresh initiatives if the targets set for the mission are to be achieved. One way is to explore the possibility of public-private partnerships to accelerate the implementation of various programmes under the mission. There is also need to integrate disease control, sanitation and hygiene programmes. Linking budgetary allocations to actual achievement of targets could act as an incentive for timely completion of projects. More importantly, the government needs to persuade rural communities to take ownership of healthcare projects � this would involve community participation right from the stage of assessing its requirements for healthcare facilities that include physical and other infrastructure to involvement in project execution.