Healthcare Delivery System in Rural Hinterland

Dr Manish Ranjan
Mission Director, NRHM, Department of Health
and Family Welfare, Government of Jharkhand

NRHM Jharkhand has the motto of “Healthy Jharkhand, Happy Jharkhand. My vision is to realize this motto,” says Dr Manish Ranjan. In conversation with Souvik Goswami

Health care to the last village, the last household and the last person.” This has been the endeavour of the NRHM, Jharkhand. How much progress has been made in this context in the state of Jharkhand?
The health care delivery mechanism in any country, state or for that matter at districts or blocks can be divided into two broad categories of Access and Utilization. Access defines the reach of services and utilization defines the uptake of the services by the beneficiaries. Both these were major challenges faced by the state at the time of creation. Access of services was compromised due to the lack of adequate infrastructure and Human Resources (HR). Over the past decade, the state has tried to improve the scenario and strengthen the health facilities at all levels. At present, 3,958 Health Sub Centers (HSCs), 330 Primary Health Centers (PHCs), 188 Community Health Centers (CHCs) and 24 District Hospitals are operational in the State. Similarly, HR is also another aspect on which the State has worked upon, and now has a strong and committed cadre of field workers and doctors functioning in all the districts of the State. Jharkhand has 7,734 Auxiliary Nurse Midwives (ANMs), 976 Nursing staff and around 1,800 medical officers providing health services in every nook and corner of the State.

A similar emphasis and impetus has been put on outreach services as well. Jharkhand conducts around 38,000 Village Health, Sanitation and Nutrition days annually which provide basic health care services at the village level. 40,964 Sahiyas (ASHAs Accredited Social Health Activists) have been appointed to act as a fulcrum between NRHM and the beneficiaries. They are working towards improving the community processes in the state. All these efforts have gone into optimizing the access of health care services in the state. The result has been improved utilization of services which is reflected by comparing the existing and earlier process and outcome indicators, for example Infant Mortality Rate has shown considerable decline and has reduced from 62 in 2001 to 38 in 2011-122.

Please tell us about the various projects which have been undertaken by the government under the “Nation Rural Health Mission.”
Here, I would like to state that NRHM is Government of India’s flagship programme and activities and strategies enlisted or rolled out in the country under NRHM have been implemented to the core in the state. Also, the recent launch of the National Health Mission (NHM), has again categorically shifted the outlook and structure of the public health care scenario in the country. NRHM is now a part of NHM which also includes the National Urban Health Mission (NUHM), the Communicable and Non-Communicable National disease control programmes.

While NRHM is related to health-care delivery system in rural hinterland, NUHM does the same in urban areas. Services provided include programs and projects aimed at all age groups though specifically at the women and children. This coupled with the communicable disease control programme, preventing morbidity and mortality due to malaria, dengue, filaria among others, and non-communicable disease control programmes aimed at controlling diabetes, hypertension, cancer etc., provide an extremely component and potent mix of services aimed at providing quality services provided to beneficiaries.

In addition to the strategies and activities enlisted by Government of India, the State has initiated quite a few state-specific interventions which have been acclaimed at the National level. The Mamta Vahan free referral transport initiative for mothers and infants was conferred the Skoch order of merit award, the Healthcare Innovation and Entrepreneurship award by AIIMS, and was also shortlisted for jury presentation at the National e-Governance awards in 2013. Similarly, the RAPID supportive supervision model for Routine Immunization initiated in the State has been implemented by other States in the country. For strengthening community processes, various initiatives as community-based monitoring, and Saas Bahu Pati Sammelans have been undertaken resulting in extremely favourable results.

Reproductive and Child Health (RCH) condition of the state, especially for the disadvantage population living in the remote areas, are discussed often in public domain. What steps have been taken by your department to do more on RCH issues?
This is an extremely pertinent question. The care of the mother and the child occupies the central position within the framework of any health-care delivery system. Under the overall gamut of NRHM, the RCH component is perhaps the most important aspect and the performance of the Government health care programs is adequately and comprehensively reflected upon by the status of the mother and the child. Again, very recently, the RCH program has also been revamped into the Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) strategy by Government of India. Through this strategy, the National Government has tried to link all relevant interventions through the life-cycle approach with the continuum of care concept.

Special emphasis has been laid out on specifically identified High Priority Districts (HPDs), which have been weak performing and in a similar way interventions have also been prioritized across each of the 5 thematic areas. Jharkhand has 11 such HPDs and the State is working towards improving the health care services in these districts. Coming back to the question, the State has been consistently working towards improving the RMNCH+A scenario. Maternal health is a prime focus area and the State has consistently tried to improve Antenatal Care (ANC) services through VHSNDs and improve institutional delivery rates by progressively increasing health facilities providing delivery services and also implementing key GOI schemes like Janani Suraksha Yojna (JSY) and Janani Shishu Suraksha Karyakram (JSSK).

Interventions have also been undertaken for new-born health by providing both facility-based newborn care through New Born Care Corners (NBCCs), Newborn Stabilization Units (NBSUs) and Special Newborn Care Units (SNCUs) and community-based care through Home Based Newborn Care (HBNC) programme. Key services aimed at child health include Routine Immunization where Full Immunization Coverage (FIC) has improved from 8.8% in 1998-99 , to 69.1% in 2011-12 . Malnutrition among children is being tackled through in service treatment at Malnutrition Treatment Centers (MTCs). The State is also looking into family planning as not just a population control measure but as an important strategy for improving maternal and child health. Documented data states that birth spacing reduces around 25% maternal deaths and increasing use of contraception by 30% could result in 50% reduction in infant deaths. Finally, adolescent health is one important aspect which has been traditionally neglected. The RMNCH+A strategy provides focus on adolescent health in a big way and the State is equally concerned about it. Adolescent Friendly Health Clinics (AFHCs) have been established in all the districts.

“The major challenge faced by the State included lack of basic infrastructure in the rural areas”

What are the main challenges for providing health care services in the rural areas?
Being a relatively new state, the major challenge faced by the State included lack of basic infrastructure in the rural areas for providing quality services. Though a lot has been done to improve the picture, still this is the major limiting factor for e.g., though the State has 3,958 functioning HSCs, there remains a shortfall of 3,130 HSCs, similarly there is 67% shortfall of PHCs. Adequate HR is another major challenge, and there is huge deficiency of nursing staff and medical specialists in rural health facilities. Also, the State has right now only 3 medical colleges which again hamper providing quality tertiary health-care services to beneficiaries from rural areas.

Please tell us about the various ICT initiatives taken by your department; Mother and Child Tracking System, Health Management Information System (HMIS), etc.
The face of the Public Health Care System has undergone a sea change with the advent and use of Information Communication Technology (ICT) applications to potentiate and propel various Government Health interventions and initiatives across the country. Use of effective ICT-methods not only enhances the overall outlook and quality but also help in better and effective monitoring of the services. Under the overall purview of NRHM, Government of India has rolled out effective programs using ICT initiatives as MCTS and HMIS. Both the initiatives are being implemented in the State.

The RMNCH+A strategy also provides for effective use of HMIS for concurrent monitoring of programme performance through development of quarterly dashboards based on the life-cycle approach. Government of India had developed state dashboards and similarly the State Government is developing district and block-based dashboards. Very recently, NRHM has entered into partnerships with various organizations on piloting m-Health interventions in the state. These include developing mobile applications for Sahiyas, strengthening logistics management through mobiles and online transfer of government incentives. The state is extremely optimistic that such initiatives would definitely further strengthen the health care services in Jharkhand.

Please share your vision for NRHM in the state of Jharkhand
NRHM Jharkhand has the motto of “Healthy Jharkhand, Happy Jharkhand”. My vision is to realize this motto. The entire NRHM staff has been consistently striving towards providing optimal care to the beneficiaries and the team is committed towards striving for and achieving the best results. The state has been well supported in this endeavor by Development partners, Non-Government Organizations (NGOs) and Civil Society Organizations (CSOs) and would very well like to keep up the endeavor in moving forward towards realizing the set goals and targets.