Context

• “Public Health and Hospitals” being a State subject, the primary responsibility of strengthening the public healthcare system, including for provision of quality healthcare and advanced treatment and diagnostic facilities, lies with the respective State Governments.
• However, under National Health Mission (NHM), technical and financial support is provided to the States/UTs to strengthen the public healthcare delivery at public healthcare facilities.

 

Background

• To address the healthcare challenges, particularly in rural areas, the National Rural Health Mission (NRHM) was launched in 2005 to supplement the efforts of the State/UT governments to provide accessible, affordable and quality healthcare to all those who access public health facilities. 
  • Currently, NRHM is a sub-mission of National Health Mission (NHM). 
  • National Urban Health Mission (NUHM) was also launched in 2013 as a sub-mission of NHM.

 

More in News

• As part of Ayushman Bharat, the States are supported for establishment of 1.5 lakh Health and Wellness Centres across the country by December, 2022 for provision of comprehensive primary care that includes preventive healthcare and health promotion at the community level with continuum of care approach. 
• Further Ayushman Bharat, Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) provides health coverage up to Rs 5 Lakh per family per year to around 1074 crore poor and vulnerable families as per Socio Economic Caste Census (SECC).

 

Rural Healthcare

• Rural Health Care services in India are mainly based on Primary health care, which envisages attainment of healthy status for all. Also being holistic in nature it aims to provide preventive, promote curative and rehabilitative care services.
• The health care infrastructure in rural areas has been developed as a three tier system as follows.

• Sub Centre: Most peripheral contact point between Primary Health Care System & Community manned with one Health Worker (Female)/ Auxiliary Nurse Midwife (ANM) & one Health Worker (M). The Sub Centre is the most peripheral and first contact point between the primary health care system and the community
• Primary Health Centre (PHC): A Referral Unit for 6 Sub Centres 4-6 bedded manned with a Medical Officer Incharge and 14 subordinate paramedical staff.
• Community Health Centre (CHC): A 30 bedded Hospital/Referral Unit for 4 PHCs with Specialized services

 

Shortcomings

Most people in rural India opt for government healthcare facilities because of monetary issues and as transport options to the urban centres are not very affordable. Despite that

• Only 11% sub-centres, 13% Primary Health Centres (PHCs) and 16% Community Health Centres (CHCs) in rural India meet the Indian Public Health Standards (IPHS).
• Only one allopathic doctor is available for every 10,000 people and one state run hospital is available for 90,000 people.
• Innocent and illiterate patients or their relatives are exploited and they are allowed to know their rights.
• Most of the centres are run by unskilled or semi-skilled paramedics and doctor in the rural setup is rarely available.
• Patients when in emergency sent to the tertiary care hospital where they get more confused and get easily cheated by a group of health workers and middlemen.
• Non-availability of basic drugs is a persistent problem of India’s rural healthcare.
• In many rural hospitals, the number of nurses is much less than required.

 

Other Constraints

Infrastructure

• The biggest concern for the rural healthcare system is the lack adequate infrastructure.
• The existing healthcare centres in rural areas are under-financed, uses below quality equipment, are low in supply of medicines and lacks qualified and dedicated human resources.
• Underdeveloped roads, railway systems, poor power supply are some of the major disadvantages that make it difficult to set up a rural healthcare facility.

 

Doctor

• Patient and Nurse-Doctor Ratio - Both these ratios contribute collectively to the inadequacy of the rural healthcare system.
• Every doctor needs a nurse to cater to their patients.
• The rural healthcare infrastructure is three-tiered and includes a sub-centre, a PHC and a CHC. PHCs are short of more than 3,000 doctors, with the shortage up by 200% over the last 10 years to 27,421 as per a report by India Spend.
• A patient is not always treated on time in rural India since the doctors are less in number.

 

Insurance

• Insurance is something that is severely lacking in rural healthcare.
• India has one of the lowest per capita healthcare expenditures in the world.
• The government has only contributed to about 32% for the insurance in healthcare sector in India which is sufficient.

 

Affordability

• People cannot afford the upmarket health services when they need to visit private hospitals.
• Advance technological advancements have also made healthcare costly.
• The cost of diagnostic facilities is also going up.
• Along with that, there are commissioned charges that most people don’t understand.

 

Lack of Awareness

• Awareness about proper healthcare is insufficient in India.
• Proper education on basic issues like the importance of sanitation, health, nutrition, hygiene and on healthcare policies, importance of medical services, their rights, financial support options, the need for proper waste disposal facilities.
• It is very important to inculcate a health seeking behaviour in them.
  
   

Lack of Medical Stores

• Medicines are often unavailable in rural areas.
• Supply of basic medicine is irregular in rural areas.
• The fair price shops (PPP model) are located in tertiary care and secondary care hospitals. These fair price shops charge differently in different locations.
• Discounts vary from 50% to 70% by the same provider on the same medicine.

 

Central Government Interventions

• Public health being a State subject, the primary responsibility to provide improved access to healthcare services is that of the State Governments.
• However, Central government provides financial and technical support to States and UTs to supplement their efforts for improving the healthcare services, particularly in rural areas via following initiatives –

• Under the National Health Mission (NHM), financial support is provided in the following areas: ASHAs workers, ambulances, mobile medical units (MMUs), drugs and equipments, support for Reproductive, Maternal, New-born, Child & Adolescent Health (RMNCH+A).
• As per the budget announcement 2017-18, 1,50,000 Health Sub Centres and Primary Health Centres are to be transformed into Health and Wellness Centres (AB-HWCs) by December, 2022 to provide Comprehensive Primary Health Care (CPHC) to ensure health for all.
• Operational Guidelines for NHM Free Drugs Service Initiative and Free Diagnostics Service Initiative have been shared with states. The objective is to ensure availability of essential drugs and necessary diagnostic services free of cost in public health facilities.
• Bridge Programme in Community Health - for Nurses and for Ayurveda Practitioners have been finalized. The trained personnel will provide comprehensive promotive and preventive and curative healthcare services.
• Kayakalp awards have been launched to promote cleanliness, hygiene and infection control practices in public health facilities. Additionally, NQAS quality certification of public hospitals is being undertaken.
• Pradhan Mantri Shurakshit Matritva Abhiyan (to improve access to specialist maternal care through voluntary participation of private providers).
• Ayushman Bharat

 

About National Health Mission (NHM)

• National Health Mission (NHM) was launched by the government of India in 2013 subsuming the National Rural Health Mission and the National Urban Health Mission.
• NHM support is provided to States/ UTs for setting up of new facilities as per norms and upgradation of existing facilities for bridging the infrastructure gaps based on the requirement posed by them.
• NHM support is also provided for provision of a range of free services related to maternal health, child health, adolescent health, family planning, universal immunisation programme, and for major diseases such as Tuberculosis, vector borne diseases like Malaria, Dengue and Kala Azar, Leprosy etc.

 

Other major initiatives supported under NHM include-

• Janani Shishu Suraksha Karyakram (JSSK)- under which free drugs, free diagnostics, free blood and diet, free transport from home to institution, between facilities in case of a referral and drop back home is provided, 
• Rashtriya Bal Swasthya Karyakram (RBSK)- which provides newborn and child health screening and early interventions services free of cost for birth defects, diseases, deficiencies and developmental delays to improve the quality of survival,
• Implementation of Free Drugs and Free Diagnostics Service Initiatives, PM National Dialysis Programme and implementation of National Quality Assurance Framework in all public health facilities including in rural areas.
• Mobile Medical Units (MMUs) & Tele-consultation services are also being implemented to improve access to healthcare particularly in rural areas.
• In the 15 years of implementation, the NHM has enabled achievement of the Millennium Development Goals (MDGs) for health. 
  • It has also led to significant improvements in maternal, new-born, and child health indicators, particularly for maternal mortality ratio, infant and under five mortality rates, wherein the rates of decline in India are much higher than the global averages and these declines have accelerated during the period of implementation of NHM. 

 

Achievements of National Health Mission

• Improvements in Core Health Outcomes:
  • Reduction in OOPE: The average medical expenditure per hospitalization and childbirth also declined in this period, from Rs. 5636 to Rs. 4290 in rural areas, and Rs. 7670 to Rs. 4837 in urban areas for hospitalization and from Rs. 1587 to Rs. 1324 in rural areas and Rs. 2117 to Rs. 1919 in urban areas for institutional delivery, indicating the impact of NHM in reduction of Out of Pocket Expenditures for health care. 
  • Maternal Mortality Rate (MMR) has declined from 556/lakh live births in 1990 to 113/lakh live births in 2016-2017. Rate of decline of MMR in India at 77% is much higher than the global average decline of 44% over the same period.
  • Infant Mortality Rate (IMR), declined from 80 in 1990 to 32 in the year 20181. 
  • Under 5 Mortality Rate (U5MR), declined from 52 in 2012 to 36 in 2018,
  • Total Fertility Rate (TFR) declined from 2.3 in 2013 to 2.2 in the year 20181.
  • The incidence of Tuberculosis per 1,00,000 population reduced from 234 in 2012 to 193 in 2019. The mortality due to TB per 1,00,000 population also reduced from 42 in 2012 to 33 in 2019.
  • The number of districts that achieved the target of leprosy elimination increased from 543 districts in 2011-2012 to 554 by March 2017 and to 571 districts by March 2018. 
  • For Malaria, Annual Parasitic Index (API) was sustained at levels of less than 1 and declined from 0.89 in 2014 to 0.32 in 2018, and 0.25, in 2019. Malaria cases and deaths declined from 21.27% and 20% respectively in 2019 from 2018.  
• Increased Access to Health Services:
  • As a result of the health systems strengthening efforts of NHM, the proportion of those seeking care from public health facilities, increased from 28.3% to 32.5% in rural areas and 21.2% to 26.2% in urban areas between 2014 to 2017.; and utilization of public health facilities for institutional deliveries increased from 56% to 69.2% in rural areas and from 42% to 48.3% in urban areas.  
• Growth in Public Health Facilities:
  • NHM adopts a health system approach and targets to build a network for public health facilities with Health & Wellness Centres at the grassroot level and District Hospitals, with robust referral linkage, to offer Comprehensive primary and secondary care services to citizens. 
• Equitable development: There was also a sustained focus on the health of tribal populations, those in Left Wing Extremism areas, and the urban poor. 
• National Ambulance Services: At the time of launch of NRHM (2005), ambulance networks were non-existent. So far, 20,990 Emergency Response Service Vehicles are operational under NRHM. Besides 5,499 patient transport vehicles are also deployed, particularly for providing “free pickup and drop back” facilities to pregnant women and sick infants.
• Human Resource Augmentation: NHM supports states for engaging service delivery HR such as doctors, nurses and health workers and also implements the world’s largest community health volunteer programme through the ASHAs. 
• Health Sector Reforms: The National Health Mission (NHM) enabled the design and implementation of reforms specifically related to Governance (Decentralized Management Units, and creation of flexibility in administrative and fund management decisions, creation of Rogi Kalyan Samitis, establishment of community collectives for accountability, such as the Village Health, Sanitation and Nutrition Committees.