Improving access, service delivery and efficiency of the public health system in rural India Mid-term evaluation of the National Rural Health Mission CGSD Working Paper No. 37 October 2009 Nirupam Bajpai Jeffrey D. Sachs and Ravindra H. Dholakia Working Papers Series Center on Globalization and Sustainable Development The Earth Institute at Columbia University www.earth.columbia.edu Table of Contents ACKNOWLEDGEMENTS……………………………………………………………………... 3 LIST OF INTERNTIONAL ADVISORY PANEL MEMBERS……………………………… 5 INTRODUCTION………………………………………………………………………............... 6 HEALTH SECTOR IN RURAL INDIA……………………………………………..…………. 9 PROGRESS OF NRHM SO FAR…………………………………………………………..…. 21 HEALTH INDICATORS – REGRESSION RESULTS………………………………........... 41 EVALUATION OF NRHM: SAMPLE SURVEY OF ANMS, ASHAS AND PEOPLE’S PARTICIPATION…………………………………………………………………………….... 48 KEY CHALLENGES OBSERVED FROM THE FIELD – UTTAR PRADESH, MADHYA PRADESH AND RAJASTHAN……………………………………………………………..… 64 REDUCING UNDER-5 MORTALITY……………………………………………………..… 81 NON-COMMUNICABLE DISESASES……………………………………………………... 113 CONCLUDING REMARKS AND RECOMMENDATIONS FOR IMPROVEMENT….. 116 REFERENCES………………………………………………………………………………… 128 APPENDIX I: REGRESSION TECHNIQUE – EXPLANATORY NOTE……………….. 133 APPENDIX II: FIVE QUESTIONNAIRES FOR THE SAMPLE SURVEY……………... 135 2 Acknowledgements This book is the product of a request made by the Ministry of Health and Family Welfare, Government of India to an International Advisory Panel (IAP) on the National Rural Health Mission (NRHM) to undertake a mid-term evaluation of the functioning of the NRHM. The work leading up to this book was undertaken with the generous support of the Government of Norway and we gratefully acknowledge the Norwegian Government‘s support and the support we received from the Bill and Melinda Gates Foundation for convening seven IAP meetings in Delhi over three years. We would like to record our sincere thanks to the Honorable Dr. Manmohan Singh, Prime Minister of India for having given us the opportunity to work with him and his cabinet members over the last several years. It has been our profound privilege to collaborate with Dr. Singh and senior policy makers in the Government of India. We presented this Report to Prime Minister Singh in New Delhi on August 5, 2009. We are grateful to Ghulam Nabi Azad, Health and Family Welfare Minister of India, Sujatha Rao, Secretary, Ministry of Health and Family Welfare, P. K. Pradhan, Additional Secretary and Mission Director, NRHM, Amarjeet Sinha, Joint Secretary and Archana Varma, Director, NRHM for useful discussions and for extending their support and cooperation in our work. We presented this Report to Health Minister Azad and the ministry officials on August 7, 2009. We owe a special debt of gratitude to all IAP members for providing valuable insights during the IAP meetings: Dr. Tore Godal: Special Advisor to the Prime Minister of Norway; former Special Advisor & Consultant, Bill and Melinda Gates Foundation; Dr. Kiyoshi Kurokawa: President, Science Council of Japan; Commissioner, WHO Commission for Social Determinants of Health; Special Advisor to the Cabinet, Government of Japan; Dr. Stephen R. Leeder: Director, the Australian Health Policy Institute; Co-Director, the Menzies Centre for Health Policy; Dr. Joanna Rubinstein: Chief of Staff to Jeffrey Sachs, Director of Strategic Programs, Director of the Center for Global Health and Economic Development, the Earth Institute at Columbia University; Dr. Sonia Ehrlich Sachs: Health Coordinator of the Millennium Villages Project, the Earth Institute at Columbia University; Dr. Mathuram Santosham: Professor of International Health and Pediatrics, Director of the Health Systems Program, Director of the Center for American Indian Health, Johns Hopkins University; Dr. Awash Teklehaimanot: Director, Center for National Health Development in Ethiopia, the Earth Institute at Columbia University and Dr. Walter Willett: Chair of the Department of Nutrition, Frederick John Stare Professor of Epidemiology and Nutrition, Departments of Nutrition and Epidemiology, Harvard School of Public Health, Harvard University. Of the above IAP members, special thanks are due to Stephen Leeder, Mathuram Santosham, Awash Teklehaimanot and Walter Willett for their contributions in this Report. 3 The field data collection was undertaken by a team at the Indian Institute of Management at Ahmedabad. We are grateful to Surbhi Grover from the Harvard Medical School for fieldwork and reporting and Shreekant Iyengar, Prabal Singh and Prakash Parmar for their help in primary data collection, collation and tabulation. We thank all the respondents of our primary survey among the major stakeholders in the NRHM for sharing their views and information so kindly and generously. We also thank the district health functionaries of the selected districts who supported and cooperated with our survey team to enable us to complete the survey work in time. Over the years, we have benefitted immensely from our discussions with and thank Ashok Alexander, Shobha and Raj Arole, Abhay Bang, Larry Brilliant, Gary Darmstadt, Rajan Dubey, Roger Glass, Sangeeta Goyal, Geeta Rao Gupta, Rajat Gupta, Prabhat Jha, Usha Kiran, Vishwajeet Kumar, Vinod Paul, Rajiv Misra, Pavitra Mohan, Rachel Moresky, Rohini Nilekani, Srinath Reddy, Devi Shetty, Digvijaya Singh, and Puja Thakker. October 2009 Nirupam Bajpai New York Jeffrey Sachs Ravindra Dholakia 4 MEMBERS OF THE INTERNATIONAL ADVISORY PANEL Dr. Jeffrey D. Sachs: Chairman, International Advisory Panel; Director, the Earth Institute at Columbia University & Special Advisor to the United Nations Secretary General Ban Ki-moon. Dr. Nirupam Bajpai: Senior Development Advisor and Director of South Asian Programs, Center on Globalization & Sustainable Development, the Earth Institute at Columbia University. Dr. Tore Godal: Special Advisor to the Prime Minister of Norway; former Special Advisor & Consultant, Bill and Melinda Gates Foundation. Dr. Kiyoshi Kurokawa: President, Science Council of Japan; Commissioner, WHO Commission for Social Determinants of Health; Special Advisor to the Cabinet, Government of Japan. Dr. Stephen R. Leeder: Director, the Australian Health Policy Institute; Co- Director, the Menzies Centre for Health Policy. Dr. Joanna Rubinstein: Chief of Staff to Jeffrey Sachs, Director of Strategic Programs, Director of the Center for Global Health and Economic Development, the Earth Institute at Columbia University. Dr. Sonia Ehrlich Sachs: Health Coordinator of the Millennium Villages Project, the Earth Institute at Columbia University. Dr. Mathuram Santoshman: Professor of International Health and Pediatrics, Director of the Health Systems Program, Director of the Center for American Indian Health, Johns Hopkins University. Dr. Awash Teklehaimanot: Director, Center for National Health Development in Ethiopia, the Earth Institute at Columbia University. Dr. Walter Willett: Chair of the Department of Nutrition, Frederick John Stare Professor of Epidemiology and Nutrition, Departments of Nutrition and Epidemiology, Harvard School of Public Health, Harvard University. 5 The National Rural Health Mission Mid-term evaluation Introduction: This book presents the findings of a project to evaluate the functioning of the National Rural Health Mission (NRHM) which was put together at the request of the Minister of Health and Family Welfare, Government of India to an International Advisory Panel (IAP) for the NRHM. The IAP was constituted to provide broad policy advice to the Ministry of Health on how best to achieve the key objectives of the NRHM. The principal activity under this project was to conduct a systematic evaluation of the performance of the NRHM in selected states of India relying on a mix of inputs: extensive data sets already collected by the Ministry of Health since the launch of the NRHM; new survey data which was collected; empirical analysis of the primary and secondary data; detailed interviews of health functionaries at the village, block and the district levels; documentation of key innovations, challenges and successes that have arisen in particular regions, and inputs from some of the members of the IAP, such as our experts on core reproductive, maternal, newborn and child health issues, nutrition, chronic diseases, and malaria among others. The project was undertaken in collaboration with the Indian Institute of Management (IIM) at Ahmedabad. It was decided to focus on three of NRHM‘s high-focus states, i.e. Madhya Pradesh (henceforth MP), Rajasthan (henceforth RJ) and Uttar Pradesh (henceforth UP). The project undertook field work in selected districts of MP, RJ and UP. We selected five districts from these states and surveyed health facilities and functionaries. These were Sagar district in MP; Jalore and Chittorgarh districts in RJ; and Sitapur and Azamgarh districts in UP. In RJ, we selected two districts because we needed to have both the desert conditions (Jalore) and tribal population (Chittorgarh) represented in our sample survey. Similarly, we selected two districts in UP too because we needed populations of both central UP (Sitapur) and eastern UP (Azamgarh) represented in our survey to make the sample representative of the state-wide conditions. We sought to determine perception of public health services in light of decentralization changes put in place by the NRHM to better understand the utilization of these facilities; the availability of manpower, especially Accredited Social Health Activists (ASHAs); availability