India's national rural health mission and reduction of neonatal mortality rate

Only one trained healthcare provider is available for every 16 villages. Although, more than 70% of India's population lives in rural areas, only 20% of the total hospital beds are located in rural area.

Journal of Neonatology
Year : 2005, Volume : 19, Issue : 3
Online ISSN : 0973-2187. Print ISSN : 0973-2179.

National rural health mission and reduction of neonatal mortality rate

Mathur NB*, Professor of Pediatrics, Incharge Referral Unit
Maulana Azad Medical College and Lok Nayak Hospital, New Delhi
*Corresponding author. E-mail: [email protected]

India has a vast public health infrastructure of Sub-centres, Primary Health Centres (PHCs) Community Health Centres (CHCs) and District Hospitals. There is also a large cadre of health care providers (Medical Officer, Auxiliary Nurse Midwives, Male Health workers, Lady Health Visitors and Male Health Assistants) besides Anganwadi Workers. For a population of 106.44 Crores (out of which rural population is 72%), there are 22842 PHCs, 137311 sub-centres spread over 602 Districts (1). Yet, this vast infrastructure is able to cater to only 20% of healthcare needs, while 80% of healthcare needs are still being provided by the private sector. Only one trained healthcare provider is available for every 16 villages. Although, more than 70% of India's population lives in rural areas, only 20% of the total hospital beds are located in rural area. Most of the health problems that people suffer in the rural community are preventable and easily treatable. Each year, 20 percent of world's infants are born in this country and 30% of the 3.9 million neonatal deaths occur in India. Neonatal mortality rate (NMR) which is 44/1000 live births is nearly two thirds of infant mortality and half of under five mortality. Nearly three-fourths of neonatal deaths occur in the first week after birth and about 50% of them within first three days. Almost 80% of the deliveries still occur at home, attended by untrained birth attendants. India thus faces a huge challenge of health care of the newborn. In view of the above situation, the National Rural Health Mission (NRHM) (2005–12) was launched in April 2005 by the Government of India (GOI).

Reduction of Infant Mortality Rate (IMR) to 30/1000 live births has been stated as the first goal and outcome of the NRHM. It seeks to provide effective healthcare to rural population throughout the country with special focus on 18 states, which have weak public health indicators and/or weak infrastructure. These states are Arunachal Pradesh, Assam, Bihar, Chhattisgarh, Himachal Pradesh, Jharkhand, Jammu and Kashmir, Manipur, Mizoram, Meghalaya, Madhya Pradesh, Nagaland, Orissa, Rajasthan, Sikkim, Tripura, Uttaranchal and Uttar Pradesh. GOI would provide funding for key components in these 18 high focus States (2). The Mission articulates commitment of the Government to raise public spending on health from 0.9% of GDP to 2–3% of GDP. The NRHM and Integrated Management of Neonatal and Childhood Illnesses (IMNCI) in RCH program envisages 24 hour deliveries at Primary Health Centers (PHC) and strengthening of newborn care in CHCs and District Hospitals.

The NRHM will cover all the villages in these 18 weak states through approximately 2.5 lakh village-based female worker named “Accredited Social Health Activists” (ASHA) who would act as a link between the ANM and the village and be accountable to the Panchayat. The ASHA would be trained to advise village populations about sanitation, hygiene, contraception, and immunization and to escort patients to medical centers. She would also be expected to give folic acid tablets to patients and will receive performance-based compensation for promoting universal immunization, referral and escort services for RCH, and other health care delivery programs (2,3).

Important steps in reduction of NMR
Policy planning in newborn care and NHRM: think tank

NMR which constitutes 60% of IMR is a difficult area to impact on in public health. Formation of a think tank for reduction of NMR under the NRHM is of paramount importance due to the complexity and technicalities involved in neonatal health care. This think tank is required for developing a long – term vision focusing on strengthening management systems, developing manpower systems and helping in improved governance. Professional organizations like NNF should be actively included in this think tank. This think tank may also be involved in external evaluations, evolving community based feedback mechanisms and developing pro poor innovations related to neonatal care. It may help in mid course reviews and providing appropriate corrections.

Provision of comprehensive newborn health care delivery

Comprehensive Newborn Care (CNC) for neonates should include an optimum mix of preventive curative and promotional services which are adequate, accessible and affordable. The primary, secondary and tertiary neonatal health care should be linked and not function in disjointed manner.

* Home based newborn care (HBNC) including Identification of sick neonates and resuscitation at birth. This could be provided through ANM, AWW and ASHA.
* Pre-transport stabilization and safe transport of sick neonates to health facility. ASHA could be trained to escort these neonates.
* Strengthening of health facilities including PHC, CHC, First Referral Units, District Hospitals and Medical Colleges for provision of neonatal care.This should include provision of essential Newborn care equipments.

Training of medical officers, ANMs, Anganwadi workers and the new cadre of ASHA in newborn care is a mammoth task for which all possible resources need to be tapped. A national committee for training in neonatal care is essential to explore innovations in training and maintaining quality control. The NNF has the experience of Operationalization of Newborn care and training in CSSM and RCH-I programs. The NNF has accredited 60 Neonatal Care Units across the country for special newborn care. These Units are run by NNF members. The infrastructure of these units and services of NNF Trainers can be utilized in training in RCH-II program.

Reducing Delays in care of sick Newborns
This is a difficult area in the RCH-II program, but is crucial for the survival of the newborn. It includes steps to identify sick neonates at home, stabilize them at home, and maintain stabilization during transferal from home to the First Referral Unit. Sri Lanka and Bangladesh have been able to reduce IMR significantly and rapidly by focusing on the Neonatal health. It is high time we take concrete steps to reduce our unacceptably high NMR.

Published: 13 Nov 2005

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Journal of Neonatology