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NRHM: addressing the challenges K.S. Jacob NRHM needs to revitalise systems, monitor their functional performance and investigate their impact on the indices of health. The National Rural Health Mission (NRHM) was launched in 2005 to bring about a dramatic improvement in the health system and health status of people in rural India. It seeks to provide universal access to health care, which is affordable, equitable, and of good quality. It aims at making architectural corrections to basic health care systems, reduce regional imbalances, pool resources, integrate organisational structures, optimise human resource, decentralise the management of district health programmes and integrate many vertical health programmes. It also aims at facilitating community participation, partnership and ownership of health and health care delivery. Ambitious programme The NRHM has been described as one of the largest and most ambitious programmes to revive health care and has many achievements to its credit. It has reiterated the focus on health and re-prioritised rural health and health care. It has increased health finance, and improved infrastructure for health delivery. It has
established standards and trained health care staff. It has also set benchmarks for health institutions and improved and streamlined health care delivery structures. It has coordinated technical support from health resource institutions and non-governmental organisations. It has improved health care delivery in many regions. It has facilitated financial management, assisted in computerisation of health data, suggested centralised procurement of drugs, hospital equipment and supplies, and mandated the formation of village health and hospital committees and community monitoring of services. It has revived and revitalised a neglected public health care delivery system. The NRHM has injected new hope in the health care delivery system. However, it continues to face diverse challenges, which need to be addressed if its goals are to be achieved in the near future. Regional variation: A comparison of data between States and within regions and social groups suggests marked variations in the NRHM process indicators, utilisation of funds, improvement in health care delivery, health indices and in community participation. Regions with good health indices have shown marked improvements, while those with prior poor indices have recorded a much lesser change. This is true, despite a greater NRHM focus on and inputs to poor-performing States. Improving governance and stewardship within the NRHM programmes mandates general improvement in the overall governance of States and regions. It calls for redoubling of efforts to improve the governance of
States and regions in general and NRHM programmes in particular. Convergence of different programmes: Many programmes of the government, the Integrated Child Development Services (ICDS), the Mahatma Gandhi National Rural Employment Guarantee Scheme (MGNREGS) and the NRHM focus on the rural poor. In principle, these programmes are meant to be complementary and synergistic. However, many issues need to be resolved. For example, the NRHM's Village Health and Nutrition Days compete with the ICDS's well-established Anganwadi programme. This results in a lack of synergy between the workers employed by the two programmes. Similarly, coordination between the MGNREGS and the NRHM, which could help the most vulnerable sections, is non-existent. The goal of health for all requires cooperative teamwork among the many schemes and departments of the government. Parallel health systems: The NRHM is intended to strengthen and support the existing State health systems and services. However, its status as a project makes its complete integration problematic. The idea that the States will take over its financing after 2012 does not generate enthusiasm for long-term commitment from staff at the State and district levels. In addition, the administrative machinery of the NRHM and health services at the national, State and district levels remains separate without complete integration, making the programme less effective and the services less than optimal. Independent and vertical disease control programmes also continue to operate with separate societies and line management. Despite calls for
integration, many States do not have active plans for a horizontal integration with the NRHM systems. In some States, the health system itself is divided into independent and poorly coordinated subsystems with medical colleges, district hospitals and community and primary health services under separate and autonomous administrative control. These divisions run deep, resulting in irrational distribution of human resource and infrastructure. Old ethos and new inputs: The NRHM brought fresh ideas and new monies to a neglected and disillusioned health care system. However, the inertia of the old system and the low morale and discipline of its staff continue to be major challenges. The NRHM has been able to add new infrastructure and personnel; however, its impact on reinventing and reinvigorating systems seems to be limited, and much more effort is required. While there is some evidence of improved health care delivery, the ambitious targets of the NRHM require systems to function like well-oiled machines, in order to be effective and efficient enough to reach these goals. New platforms competing with old programmes: Some States have introduced new programmes, which seem to rival and undermine old and established platforms. For example, they have introduced mobile medical units. These compete with older village sub-centres resulting in the undermining of previously established systems. Divisive approaches: Many States have introduced health insurance to cover life-saving medical
conditions. While such cover has helped many people, there is evidence in some States that the majority of recipients are urban-based, with the poorest and the most marginalised unable to access such services. The unregulated private sector and its high cost may not pass a cost-benefit test. In addition, the provision for the care of low-frequency diseases in tertiary care, without a gate-keeping role for primary care, adds to the complexity of the issues. The absence of cover for common conditions makes the impact of such scheme marginal for the majority. The neglect of public hospitals, the need to allow the public sector to utilise its spare capacity to meet such needs and increase their incomes, the impact of having private insurance companies at the heart of the scheme, and the role for public sector insurance also need consideration. Process and outcome indicators: The NRHM currently employs process indicators to measure its implementation. The measures used are mainly related to infrastructure and personnel. There is need to shift to indicators of efficient functioning. In the final analysis, the NRHM's impact will have to be assessed against hard data on health outcomes. The initial high rates of mortality tend to reduce rapidly with early inputs but require fully functional, efficient and effective systems for sustained results. The NRHM needs to correlate its inputs with health outputs in order to assess their effectiveness and to fine-tune its processes. There should be a much greater attempt at analysing the complex process data currently being generated and systematically collect outcome data in order to direct and modify systems.
Social determinants of health: The NRHM's goals clearly state the need to impact on the social determinants of health by coordinating efforts to provide clean water, sanitation, and nutrition. It should be in conjunction with MGNREGS work towards the reduction of poverty. Social exclusion and gender discrimination are two major areas of concern as they have a significant impact on health. The NRHM should not only focus on treating diseases in these subpopulations but also work towards implementing policies, which will bring about health and social justice for all. The NRHM has made a significant impact on health care delivery. However, the need for constant monitoring of its impact for course corrections should be built into the system for optimal results and for achieving the goal of ³Health for all.´ (K.S. Jacob is on the faculty of the Christian Medical College, Vellore, and is also a member of the Mission Steering Group of the NRHM. This article is based on his lecture at a recent conference on ³Bringing Evidence into Public Health Policy´ in Bangalore. The opinions expressed are personal and do not reflect those of any organisation.) © Copyright 2000 - 2009 The Hindu
One people, many aspirations S. Nagesh Kumar
The Telangana region has had a chequered history of popular movements. The Justice B.N. Srikrishna Committee report submitted to the Central government on December 30 marks a milestone in the history of Andhra Pradesh, which has had a turbulent existence. The Committee's recommendations will assist the Central government in determining whether the Teluguspeaking people will continue to live together in one State, or in separate states. In the 54 years since Andhra Pradesh was formed, two rounds of violent region-based agitations rocked the State earlier ² one in 1969 and the other in 1972. These threatened to tear apart the social and political fabric of Telugu society. But firm handling of the situation by Prime Minister Indira Gandhi prevented permanent damage being caused. The United Progressive Alliance (UPA) leadership in New Delhi will now be called upon to show a high degree of statesmanship in implementing the recommendations of the Committee. The future of the Telugu people, who number eight crore in Andhra Pradesh, will now depend on the UPA government's ability to take the right decisions without being swayed by emotion or letting narrow political considerations to come into play.
In a context of frayed tempers, the Centre did well in constituting in February 2010 the five-member committee headed by Justice Srikrishna. The former Supreme Court Judge has been known for his integrity and ability. He earned laurels for the inquiry into the Mumbai riots of 1992-93. Looking back The Telangana region has had a chequered history of popular movements. The peasant revolt led by the (united) Communist Party of India from 1946 against feudal forces, and later against the Nizam of Hyderabad, is part of the region's lore. It was only after the Indian Army entered the then Hyderabad state in September 1948 that the rebellion subsided. The Razakars, who were a part of the Nizam's army, had earned notoriety for their bid to suppress the movement. Hyderabad state (the Nizam's Dominions) was distributed in Telangana, and parts of what are now Karnataka and Maharashtra. Around the same time, people in the Andhra region began a struggle for an Andhra Province. They pressed their case before Prime Minister Jawaharlal Nehru and Sardar Vallabhbhai Patel. The Congress constituted a committee comprising Nehru, Patel and Pattabhi Sitaramaiah, which favoured the postponement of the creation of linguistic provinces. However, it suggested the formation of an Andhra Province, provided the people of the region gave up their claim to Madras city. Neither this body nor the Partition Committee, headed by Madras Chief Minister Kumaraswami Raja, could mollify the people of Andhra. They expressed their resentment towards the Congress leaders by defeating them in the 1952 general elections. Of the 140 seats from
Andhra in the Madras Legislative Assembly, the Congress got only 42. The CPI bagged 40. At this juncture, Potti Sriramulu, a self-effacing Gandhian, began a fast-unto-death on October 19, 1952. New Delhi did not pay heed ² until Sriramulu died on December 15, setting off a violent agitation. Four days later, Nehru announced in the Lok Sabha the formation of Andhra State, but excluding Madras city. Andhra came into being on October 1, 1953 with Kurnool as the capital. Tanguturi Prakasam was the Chief Minister. After Nehru inaugurated the State, the Telugu people looked forward to the formation of µVishalandhra' with Hyderabad as its capital. As similar demands for the creation of States on linguistic lines were being voiced in different parts, the Government of India set up the States Reorganisation Commission (SRC). Justice Fazal Ali was its Chairman. In its report submitted in 1955, the SRC observed that ³the creation of Vishalandhra is an ideal to which numerous individuals and public bodies, both in Andhra and Telangana, have been passionately attached over a long period of time, and unless there are strong reasons to the contrary, this sentiment is entitled to consideration.´ Yet, it noted that ³while opinion in Andhra is overwhelmingly in favour of the larger unit, public opinion in Telangana has still to crystallise itself. Important leaders of public opinion in Andhra themselves seem to appreciate that the unification of Telangana with Andhra, though desirable, should be based on a voluntary and willing association of the people«´ As differences over unification persisted, the Centre prevailed upon leaders of Andhra and Telangana to sort them out.
Consequently, a 10-point µGentlemen's Agreement' was reached. It was signed by political stalwarts from the two regions, including the Chief Ministers of Andhra (Bezawada Gopal Reddy) and Hyderabad (Burugula Ramakrishna Rao). A key provision was the creation of a Regional Committee for Telangana, whose recommendations would ³normally be accepted by the Government and the State Legislature.´ It went into the critical issue of reserving posts in subordinate services of the government in Telangana to µMulkis'. The µMulki' issue had a history. A Mulki was defined as one who was born in Hyderabad or had resided there continuously for at least 15 years. The Nizam of Hyderabad issued a firman in 1919 laying down that only µMulkis' were eligible for appointment to government service in the State. The Agreement prescribed improvements in educational facilities in Telangana and set down that 40 per cent of the State Ministers should be from the region. Neelam Sanjeeva Reddy became Chief Minister of the integrated Andhra Pradesh in 1956. Unrest Some 12 to 13 years later, discontent began brewing among Telangana officials and youth. This was fuelled by fears that the safeguards laid down in the Gentlemen's Agreement were not being implemented, the Mulki Rules might vanish, and people from Andhra region who were migrating to Hyderabad would corner the jobs. The unrest provided the foundation for the Telangana movement in 1969. A movement started by students received support from Congress MLAs from the region. Marri Channa
Reddy joined the fray and formed the Telangana Praja Samithi (TPS). The TPS split when the MLAs realised that Indira Gandhi did not favour Telangana. The TPS won 10 out of 14 Lok Sabha seats in Telangana in the 1971 general elections, but the party was dissolved and its members joined the Congress. The agitation, which took the lives of several students, petered out in September 1971. Kasu Brahmananda Reddy resigned from his position to make way for P.V. Narasimha Rao, who hailed from Telangana. In 1972, the Supreme Court upheld the Mulki Rules. This triggered the Jai Andhra movement in the Coastal Andhra and Rayalaseema regions. A political settlement was finally reached on Indira Gandhi's initiative. It was called the Six-Point Formula. Leaders of the two regions agreed to prevent anymore agitations, ensure development of backward areas and give preference to local candidates in admissions to educational institutions and in direct recruitment to non-gazetted posts in government. A long period of Telugu unity followed. N.T. Rama Rao strengthened this further when he fought and won the 1983 Assembly elections on the plank of µTelugu pride.' That slogan was targeted at the Congress high command that was given to changing Chief Ministers frequently. In August 2000, led by Y.S. Rajasekhara Reddy, 41 Congress MLAs signed a memorandum addressed to the high command demanding a Telangana state. This coincided with the birth of the Telangana Rashtra Samithi (TRS) floated by K. Chandrasekhar Rao. He did this after severing ties with the Telugu Desam Party led by N. Chandrababu Naidu.
The Telangana issue came to the boil again from November 29, 2009 when KCR began a fast alleging disparity in the economic development of the two regions of the State and failure by successive governments to implement agreements. He ended his protest 11 days later after the Centre decided to initiate the process of creating a Telangana state. History has turned full circle. Violent agitations shook the Telangana and Andhra regions towards the end of 2009, threatened to derail the economy of the rapidly growing Hyderabad city and forced New Delhi to constitute the committee headed by Justice Srikrishna ² which has just submitted its report.