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© 2019 IJRAR January 2019, Volume 6, Issue 1 www.ijrar.org (E-ISSN 2348-1269, P- ISSN 2349-5138)

IJRAR1BLP198 International Journal of Research and Analytical Reviews (IJRAR) www.ijrar.org 1382

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




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




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.




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;




(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.




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




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.




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




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




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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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




https://link.springer.com/content/pdf/10.1007/BF02825478.pdf

https://link.springer.com/article/10.1007/s12098-011-0536-4

https://www.sciencedirect.com/science/article/pii/B9780857090041500438

http://162.144.90.128/IEGIndia/upload/uploadfiles/Delhi%20South%20District%201.pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800893/

http://environmentportal.in/files/wrkp_1_09.pdf

http://www.academia.edu/download/3244984/National_Rural_Health_MissionHopes_and_Fears.pdf#page=23

http://www.academia.edu/download/3244984/National_Rural_Health_MissionHopes_and_Fears.pdf#page=23

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