Februaury 2007

E-APPLICATIONS IN NATIONAL RURAL HEALTH MISSION : Toms K. Thomas

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“The test of our progress is not whether we add more to the abundance of those who have mu ch; it is whether we provide enough for those who have too little.”-Franklin D. Roosevelt, second inaugural address, 1937

Public health is one of the important responsibilities of the state. The health of the citizens significantly affects their economic productivity, their livelihood capacity and adversely affects the local economy. Health also impacts access to labour market as it influences the capacity to work.  For the poor, a healthy body is an important asset and so ill health does have a greater impact on their livelihood. But sadly public health in many of the third world countries are not given adequate attention and this is amply reflected in the very low allocations given to their public health sector. Providing quality healthcare to the vast majority, living in very remote and rural localities, has become one of the challenges of the governments of developing countries, as majority of the people living in rural areas don’t have the capacity to pay for the healthcare services.

It is a fact that healthcare sector has undergone considerable changes with the development of technology. However the rural healthcare system in the developing countries is more or less rooted in the same traditional practices. There is a yawning gap in rural and urban healthcare in developing countries. Take the case of India, where infant mortality rate (IMR) in rural areas at 82 per 1000 live births is nearly double the number of 45 for urban areas.

Technology connectivity between various public heath tiers and actors can better the health service delivery and improve the health status of the people living in rural areas as such network would improve the capacity of accredited social health activist (ASHA), the local health care provider, as well as the other local healthcare actors like auxiliary nurses and midwives (ANM) and multipurpose health workers (MPHW)

While urban middle classes in India today have ready access to best health, the rural population is isolated from these services both because of access and cost. Most of the poor living in rural localities are isolated from the benefits of formal health care (both public and private) and most of them access untrained local ‘private practitioners’ incase of any illness.  A formal health centre is only a last alternative as they are mostly located only in the urban localities and present great logistical problem to the poor villagers to commute. In India, poverty is another common barrier to good health. Only 20 countries have a higher IMR than Orissa’s tragic figure of 110 per 1000 births, which shows that the poor localities are most vulnerable to health problems.

It can be safely said that India, to a great extent, has failed in bringing equity in healthcare, as it has not been able to effectively address the issue of access. Government though has set up various mechanisms to provide access to the people living in rural and remote areas to quality health services, but many of them are not performing as per the requirements of the rural localities.

One exception to this depressing healthcare scenario in India is the National Rural Health Mission (NRHM). National Rural Health Mission (NRHM) is an initiative of Central Government  in India to integrate various public health services. NRHM has a 10 year target to strengthen the public health system in various Indian states especially the low performing states.

Recognizing the importance of health in the process of economic and social development and in improving the quality of life of our citizens, the Government of India has resolved to launch the National Rural Health Mission to carry out necessary architectural alteration in the basic healthcare delivery system. The mission adopts a synergistic approach by relating health to determinants of good health viz. segments of nutrition, sanitation, hygiene and safe drinking water. It also aims at mainstreaming the Indian systems of medicine to make possible healthcare, especially in rural localities.

The plan of action includes escalating public expenditure on health, dropping regional discrepancy in health infrastructure, pooling resources, amalgamation of organizational structures, optimization of health manpower, decentralization and district management of health programs, community participation and title of assets, induction of management and financial personnel into district health system, and transforming community health centers into functional hospitals, thereby meeting Indian public health standards in each block of the country.

The government has approved the launch of the National Rural Health Mission (2005-12) for providing integrated comprehensive primary healthcare services, with a special focus on the poor and vulnerable sections of the society. Formulation of  Indian public health standards is one of the ground-breaking steps in NRHM as it attempts to define the quality of public health services and their standards. The mission is to be launched throughout the country with high focus on the 18 states, including 8 empowered action group states (U.P., Bihar, Madhya Pradesh, Orissa, Jharkhand, Uttaranchal, Rajasthan and Chhattisgarh), 8 North-East States (Sikkim, Assam, Arunachal Pradesh, Nagaland, Manipur, Tripura, Meghalaya and Mizoram), and Jammu & Kashmir and Himachal Pradesh.  NRHM addresses various public health issues like inadequate financial allocation, lack of trained health personnel in rural localities, emergency medical access and promotion of various other systems of medicines, along with the conventional allopathic system of medicine.

The mission aims to undertake architectural correction of the health system to enable it to effectively handle the increased allocation for public health, as promised under the National Common Minimum Programme of the United Progress Alliance government.  It also aims to bridge the gaps in rural healthcare through increased community ownership, decentralization of the programs to the district level, inter-sectoral convergence and improved primary healthcare.  The mission aims to achieve the goal of the National Population Policy and the National Health Policy through improved access to affordable, accountable and reliable primary health services.  NRHM also attempts to integrate divergent medical systems, both conventional and alternative, which are practiced in India.

The active engagement of technology at various healthcare levels through induction of ICT into NRHM components would improve its outreach as well as quality. The department of IT should take the lead in bringing the technology integration and the ongoing technology initiative should incorporate healthcare components in it.

The goal of the NRHM is to improve the availability of and access to quality healthcare by people, especially for those residing in rural areas, the poor, women and children. The main objectives are; reduction in infant mortality rate (IMR) and maternal mortality ratio (MMR), access to public health services such as women’s health, child’s health, water, sanitation & hygiene, immunization, and nutrition, prevention and control of communicable and non-communicable diseases which includes locally endemic diseases, access to integrated comprehensive primary healthcare, population stabilization, ensuring gender and demographic balance, revitalizing of local health traditions and promotion of best practices in health.

The Figure-1 shows the various components of NRHM and suggests the linkages with different healthcare facilities and its functions. However, integration to bring in improvement in quality needs to think of establishing linkages with these different functions and actors. As the local government has been given a crucial role in the implementation as well as monitoring of NRHM activities, the local governments have a great role to play in bringing in quality healthcare in their respective localities.

NRHM Components

Public health in India has a bias towards building institutions rather than strengthening the local capacities. Though NRHM is an excellent initiative, having a strong component of local capacity building, it significantly lacks the linkage between various healthcare actors and components. It is also important to integrate various technology initiatives in promotion of technology and these initiatives should integrate health component also. Some of the initiatives are;

� Knowledge Centre Initiative of the Mission 2007 by Government of India

� Common Service Centre initiative of the Ministry of Information Technology and Panchayats

� Rural business hubs as an initiative of the Ministry of Rural Development, Government of India.

What is needed is to make the technology innovation in human development services more effective is an integration of these various ICT missions under one umbrella to make it more comprehensive both in terms of its content and operations.

Succinctly, NRHM is one of the pioneering initiatives to provide quality healthcare access, through bringing in the various public health machineries under one umbrella. The local capacity building has been given central consideration through organising various grassroots training programmes. However the matter of entrance to the quality healthcare remains a concern and the NRHM does not adequately address this particular issue.  Though some engagements are made at the local level with the help of Panchayat and ASHA (Accredited Social Health Activist), it is not sufficient to address the issue of bringing in access to quality healthcare.


Though there is technical integration and inclusion of various segments of health care in to the NRHM, there is a gross inadequacy of linkages between various components of NRHM. Establishing these networks would better the efficiency of the rural health service delivery and would impact the quality of rural health care services.

Here we attempt to make a dispassionate enquiry into those lacunas, and explore how Information and Communication Technologies (ICT) could be used as a tool to improve the capacities of the local actors; through facilitating the networking with various rural healthcare actors. Technology connectivity between various public heath tiers and actors can better the health service delivery and improve the health status of the people living in rural areas.

The government has approved the launch of the National Rural Health Mission (2005-12) for providing integrated comprehensive primary healthcare services, with a special focus on the poor and vulnerable sections of the society. Formulation of  Indian public health standards is one of the ground-breaking steps in NRHM as it attempts to define the quality of public health services and their standards.

and make various actors more accountable and functional. Furthermore, a network at the district level between ASHA in various locations as well as establishing of communication network with some of the leading specialists and hospitals could improve the quality of public health services provided by the local healthcare actors like ASHA.

The active engagement of technology at various healthcare levels through induction of ICT into NRHM components would improve its outreach as well as quality. The department of IT should take the lead in bringing the technology integration and the ongoing technology initiative should incorporate healthcare components in it. The following chart shows a representatiSuch network would improve the capacity of accredited social health activist (ASHA), the local health care provider, as well as the other local healthcare actors like auxiliary nurses and midwives (ANM) and multipurpose health workers (MPHW). Such network also would give confidence in health service delivery of local actors on of technology linkage of the various components of NRHM, and linking of ASHA with various health service providers would help her to provide the best care to the rural poor.

NRHM Components and its Network with ICT

The figure-2 below depicts a technology networking between various actors involved in the National Rural Health Mission. ASHA has been shown as the key person in NRHM and the network is instrumental in building her capacity to provide the best possible healthcare to the people living in the rural areas. The various components of this network and its functions are explained below:

 

1.Telephone network with ASHA and other care providers

ASHA should be connected with a telephone as well as a computer with the rest of the facilities in the public healthcare chain. Telephones are used to transmit health information that facilitates diagnosis of the primary ailments of ill health in case the sickness is not observed as serious. The Verbal Communication System (VCS) is the first step in imparting treatment, where doctor gets only the minimal verbal communication on external symptoms (like temperature, BP, weight, etc.). Doctor could prescribe medicine based on the minimal information provided to him/her. In this case, the medications would be limited to very minimal emergency public health drugs. These drugs could be dispensed from the community pharmacy that is managed by ASHA. ASHA should be authorised to dispense certain emergency drugs that are provided through the PHC.

2.Primary Diagnostic Centre (PDC)

Primary diagnostic centre would be a centre that provides further facility for investigation as well as pharmacy service, in case the sickness is being diagnosed with mere external symptoms.  Where ASHA has doubt about the cause of the sickness she should refer the patient for further investigation to PDC. This centre would have facility for vital lab investigations apart from the pharmacy service. All PDCs would be supervised by the community doctors and the doctors would directly monitor these centres. The results shall be informed to the doctor by the pharmacist  directly and the medicines prescribed are given from the pharmacy at the PDC. What the ASHA does is the follow up of this patient and informs doctor about the progress of the patient.

3. Community Pharmacy

Community pharmacy is a crucial component of the healthcare network and this pharmacy is directly controlled by ASHA. She would be authorised to dispense drugs that are given in this pharmacy at the advice of the community doctor.

4. Casualty Ambulance Service

This is another important component of the ICT network. A telephone networked ambulance is provided at the PDC level, which would provide transport service to all the clients of ASHA. This would enable ASHA to take the patient to the hospital / the doctor as early as possible, in case of any medical causality. The delivery cases would benefit much through this facility. An appropriate health insurance package also would be worked out to minimise the cost burden of hospitalisation.

5. E-Doctors

These doctors are designated doctors for every village. Every ASHA would work under a community doctor who would be available for her to consult at times of any medical casuality. He or she would be available over telephone as well as over net, to provide necessary medical advice to ASHA. He / she would also provide electronic prescriptions and diagnosis through PDC. There could be one e-doctor for every 5000 population. The population is limited to 5000 to minimise the number of calls. At the e-doctor level, there would also be an assistant who would receive the calls /download investigation reports and process it before it goes to the doctor. Doctor then would write the prescription and the assistant will sent it to the PDC. Telephone calls from ASHA could also be directly attended by the doctor.

6. e-linkage to various healthcare units

Linkage to the primary care facilities like sub-centre, PHC and CHC also is an important element of the use of the ICT solutions for pubic health system. ASHA would be linked through telephone and with the help of village ICT hub (VIH), with these various health services agencies.  This could also be used as a means to strengthen the public health information system. The births, deaths and other registrations could be done through ASHA and through these centres, that could be further networked with the Births and Deaths Registrar office. The linkages also could help in following up of patients treated at these various healthcare facilities. The follow-up at the village level could be done through ASHA.

Conclusion

The use of Information and Communication Technology (ICT) has lots of potential in improving the overall performance of the public healthcare system. It could transform both quality and access of public health services. The network facilitates appropriate and timely provision of quality treatment at a very minimal cost, along with promoting the best practices in delivering public health services. The rural poor would be greatly benefited as they would be able to access quality health services through ASHA.

However, the success of this network will depend on various factors.
They are:

� The capacity of ASHA to operate ICT kiosks and the willingness of the community to access ICT enabled treatment provided through ASHA.

� Acceptance of ASHA in rural locality as there is no patient to doctor contact.

� Finding out a person who is acceptable to all villagers.

� Willingness of the medical practitioner to provide consultations over phone and to be available for consultations.

� The diagnostic capacity of Primary Diagnostic Centres.

� The existing healthcare practices in the rural localities and health seeking behaviour of the poor.

� The effect of the local private practitioners and their influence on the local population.

� The acceptance of ASHA as a healthcare provider.

� The commitment of the local government to promote the work
of ASHA

� The capacity of the staff at various healthcare centres, starting from the sub-centre, to maintain the linkages as active.

In spite of these riders, if planned and executed seriously, such ICT linkages in healthcare would have all the potential to improve the overall performance of the public health delivery mechanism of our country, especially that of the rural areas. To explore more avenues  further research is needed on the best and appropriate technology solution that would work better in various local contexts. Such technology solutions would definitely improve the overall performance of NRHM, through making public health interventions more accessible and poor friendly.  

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