|Photo Credit: HIFA 15|
National Rural Health Mission (NRHM) is a unique programme that has recognised capacity, knowledge and skill of the communities to plan, implement health policies and monitor public health institutions. Various institutionalised community processes of NRHM such as Accredited Social Health Activists (ASHAs), Village Health Sanitation and Nutrition Committee (VHSNCs), Rogi Kalyan Samiti (RKS) and Community Monitoring provides ownership and responsibility directly to community to actively contribute in the overall aim to seek universal access to equitable, affordable and quality health care which is accountable and at the same time responsive to the needs of the people. A radical policy change in the form of NRHM has actually pushed the idea of people centered planning and decision making or communitisation in health system. How this idea has been actually implemented at ground level in the first phase of NRHM that ended in 2012, is a matter of great concern. Government of India has extended NRHM with same principles, so it is now necessary to understand the implementation of community processes and their impact.
Various evaluations of NRHM in the last couple of years shows mixed results about implementation and impact of various community processes. ASHA program remain the back bone of the community process and works as the primary link between community and public health system. Country has recorded a substantial increase in utilisation of services such as institutional deliveries, immunisation, ANC checkups and family planning but recorded less impact on health seeking behaviour of people. However, an evaluation by Planning Commission reveals that because of inadequate emphasis on skills, training and supportive monitoring, ASHAs are less functional and effective in tasks related to community level counseling, care provisions and community mobilisation work.
As a policy, NRHM has institutionalised roles, responsibilities and power of the community in deciding community level health needs, making health system friendly to the local people and contributing in delivery of quality care by health institutions. RKS constituted in each public health institution involves active participation of community, patient and civil society in assessing need of institutions and making them responsive and accountable to public. Review of RKS reveals that members of RKS are unclear about their role, rights and overall objective. Mostly RKS discuss fund utilisation issue in their meeting. There are very few evidences where RKS are found discussing non-budgetary issues such as improving IPD/OPD cases, outreach work, absence of health personal etc. On the other hand, VHSNC ensure micro health planning, implementation and monitoring at village level. Fifth Common Review Mission (CRM) of NRHM reveals that though VHSNCs are active in spending fund allocated to them, but the village health plan is not yet institutionalised anywhere and there is no clear model or clarity in its role and utility. There is an increase in utilisation of untied funds for VHSNCs but had limited involvement of PRI in health planning process and in the function of VHSNC.
Community monitoring is another institutional mechanism introduced by NRHM to communitise function and accountability of health institutions. The community as well as the Patient Welfare Committees is expected to monitor the performance of the health facilities on various parameters using techniques such as jansunwai. But this process has given least priority during entire phase of NRHM. The idea was successfully implemented in nine states on pilot basis that resulted in increased utilisation of services and accountability. But unfortunately, no state government except Karnataka took it forward as integral part of health system.
Level of health institution communitisation varies from state to state and hence health care utilisation also differs across states. Fifth CRM conducted in 15 states found that more than 50% of expected in-patients are seen in public sector health institutions of Himachal Pradesh, Sikkim, Goa, Rajasthan, Odisha and Karnataka. It is interesting to observe that in these states communitisation process such as VHSNCs, RKS, PRI participation and institutionalisation of community monitoring are in place and functioning remarkably better. On the contrary, states like Jharkhand, Uttar Pradesh, Gujarat and Chhattisgarh have given less priority to communitisation process and resulted into less turn out in public health institutions. According to 5th CRM in these state less than 30% of expected in-patients are seeking public sector hospitalisation.
Various evaluations of NRHM reveal that it has not achieved its target and is still much behind from its targets of first phase. However, NRHM has recorded a faster improvement in health service utilisation, quality care and availability of health institutions in its first phase of implementation. Communitisation process involved in it has great role in this improvement as it is revealed through various evaluations. It raises a need of strengthen and mainstreaming such process for future success. Traditional mindset of functioning in public health institutions needs facilitation to accept and imbibe the spirit of community driven system.