Mission for Creating a Healthy India

Anuradha Gupta
Additional Secretary & Mission Director, NRHM, Ministry
of Health & Family Welfare, Government of India

“The NRHM is designed in such a way that the individual states enjoy substantial flexibility in managing their healthcare needs. The intention is to encourage different states to come up with initiatives that are designed to meet the specific healthcare challenges that people in any particular state may face,” says Anuradha Gupta. In conversation with Nayana Singh and Kartik Sharma

The people in the rural areas face lot of problems in meeting their healthcare needs, at times they have to travel all the way to the cities for treatment of their ailments. Please tell us about the work that is being done under the National Rural Health Mission for improving healthcare facilities in the rural areas?
The National Rural Health Mission (NRHM) aims to improve health services in rural areas and provide accessible, affordable and accountable healthcare. Augmentation of infrastructure and human resources and increased provisioning of drugs, diagnostics, ambulances and logistics have received focus under the Mission. Mainstreaming of AYUSH to offer patients choice and broadening the range of services in public health institutions are important priorities. Over 50,000 health facilities have been newly constructed or renovated and more than 1.5 lakh human resources have been added including specialists, doctors and nurses.

What are the most significant achievements of NRHM?
One significant achievement of the Mission is introduction of dial 108/102 ambulance service. Today, more than 18000 ambulances are transporting patients in 28 states/UTs with priority accorded to mothers, children and patients requiring critical care. Over 2045 Mobile Medical Units are delivering health services in remote and far flung areas. 8.89 lakh ASHAs, a singular contribution of NRHM, act as a strong interface between the community and the health system and mobilize demand for institutional care. The huge surge in service delivery in public health institutions indicates the enhanced public confidence in public health system. It is impressive that annual OPD in government institutions has exceeded to 90 crore and nearly 1.66 crore women are delivering in government and accredited institutions in a year.

India is a geographically and socially diverse country, the government initiatives that work in one part of the country, might not see that much of success in some other part. So what are the states where NRHM has been most successful so far?
It is true that states have made variable progress in terms of Reproductive and Child health indicators, Tamil Nadu and Kerala have already achieved the national goals. Maharashtra also joined their league. Punjab, Haryana, Gujarat, Uttarakhand, Odisha are emerging as cusp states.

One significant achievement of the Mission is introduction of dial 108/102 ambulance service

In your opinion during the last few years what have been the key achievements of NRHM. Also please throw light on the road ahead.
Acceleration of rate of decline in maternal and child mortality is unmistakable. Total fertility rate has also started to decline faster than before. What is encouraging is the fact that large and populous states carrying the highest burden of maternal and child mortality and having the highest fertility rates have started to show progress. ‘Janani Suraksha Yojana’ has seen a phenomenal increase from 7 lakh beneficiaries in 2005 to more than 1 crore a year 2010 onwards. Institutional deliveries rose from 47 percent in 2007-08 to 72 percent in 2009. Building on JSY, another major initiative ‘Janani Shishu Suraksha Karyakram’ was launched in June, 2011 to eliminate out of pocket expenditure for pregnant women and sick neonates. The initiative entitles every woman delivering in a public health institution to free drugs, diagnostics, diet besides to and fro transport.

Free entitlements have now been expanded to cover ante natal and post natal complications and sick infants up to one year of age. Bringing down out of pocket expenditure, which is very substantial in India, is now a key priority. Medicines account for over 70 percent of health expenditure and therefore,ensuring universal access to free essential medicines in all public health facilities is being emphasized under NRHM. Over `1600 crore was provided to states last year for provisioning free drugs and this year, this figure is likely to reach about 2000 crore. We have also introduced an incentive of 5 percent additional allocation, over and above the normal allocation, for states that implement free drugs initiative. 28 states have already made an explicit articulation to provide free essential drugs in public health system. Another new initiative is the Rashtriya Bal Swasthya Karyakram, which is an effort to look beyond survival of children to ensuring their quality of life and holistic development. The initiative provides for comprehensive screening of children from 0 to 18 years of life against 4 Ds- Defects at birth, Diseases, Deficiencies and Developmental delays including disabilities.

The initiative provides for free treatment including surgeries at tertiary level. An estimated 27 crore children are expected to be annually screened in a phased manner. Other new initiatives include a strategy to address intra state inequities through identification of 184 high priority districts in the country suffering from the most adverse health indicators which would receive higher financial allocation, greater flexibility for need based innovations and harmonized technical assistance, including from central level. The recent launch of the National Urban Health Mission is another major step forward towards strengthening primary health care in urban areas and would help cater to the health needs of more than 10 crore urban poor. We expect it to gather pace from next year.

Dr Rakesh Kumar-Ministry of Health and Family Welfare,
Anuradha Gupta-NHRM,
Louis-Georges Arsenault, Unicef representative to India

You have been using ICT to enhance the ambulance service across the nation. Please tell us about it. Tell us about the ways by which you are leveraging IT in healthcare.

There are several ways in which we have started to use ICT under NRHM. Mother and Child Tracking System is a mission mode project and one of the largest applications with a data base of over nine crore pregnant women and children each one of whom is tracked for services. MCTS helps us ensure and monitor, in real time, delivery of services to women and children. The application is used to send regular SMS alerts to beneficiaries ahead of dates when ante natal check up or immunization services are due, to generate weekly work plans for ANMs and to monitor how many due services were actually delivered. NIKSHAY is a similar tracking system for every TB patient. Our ambulances are now GPS fitted and call centre based thus making it possible to monitor their movement. Same is the case with Mobile Medical Units which are monitored for service delivery in remote and difficult areas.

Tele medicine and tele radiology are also being promoted under NRHM. Hospital Management Information Systems are being put in place in several states, making paper work including paper prescriptions a thing of the past and paving way for electronic health records. Health Management Information System captures on line data on 240 key healthparameters and in most of the states, individual facilities are uploading data. IT is also being extensively used to manage and monitor supply, distribution, consumption and stock of medicines across health facilities. Even for financial management, CPSMS makes effective use of information technology and tracks, in real time, funds and transactions at the level of sub district health facilities. These are only some of the illustrations and there are unlimited possibilities of use of ICT in health. e-Health and m-Health are areas where we can go a long way.

What is your view of private sector participation in healthcare sector?
The private sector has both advantages and limitations. In urban areas the private sector has a large presence and thus offers opportunities for collaboration under the newly launched NUHM. But the focus of NRHM is on reaching the unreached in remote and far flung areas wherethe private sector is hardly present and thus strengthening of public health system is an imperative. There is no doubt that private sector can play a supplemental role for critical gap filling. PPP models are highly successful in the field of diagnostics, in running ambulance services and Mobile Medical Units and providing services where public sector has limited capacity bur the demand for services is very high.

What are the areas where you think maximum impact can be made by latest advances in IT?
I feel that m-Health and e-Health have vast potential and we should tap it much more than what we are doing today. For leveraging their potential to the fullest, we are trying to upgrade our own capacities at the national level. Besides strengthening IT infrastructure, our endeavor is to design holistic IT solutions. We are making efforts to increase the inter operability of applications, so that all our services become interconnected. We are working with National Institute of Smart Governance and the Department of Information Technology to take forward some of these initiatives.

In your opinion what are the major challenges that are making it difficult for India to have an efficient healthcare system?
The most prominent challenge is the lack of highly trained human resources to cater to the needs of such a large population. This shortage is exacerbated in rural and particularly remote and difficult areas. NRHM provides special financial incentives to attract service providers to difficult geographies. We are also encouraging graded incentives, depending on how remote the facility is. On top of the base incentive that health personnel receive for serving in difficult areas, we are now promoting performance linked incentives.The NRHM is designed in such a way that the individual states enjoy substantial flexibility in managing their healthcare needs. The intention is to encourage different states to come up with initiatives that are designed to meet the specific healthcare challenges that people in any particular state may face. ‘One size fits all’ is not an approach that NRHM pursues.