Thursday, March 30, 2017

Is NRHM the most successful healthcare program in the world?

In the dismal world of pervasive program failures in development, India's National Rural Health Mission (NRHM) should stand out as a heartening positive deviance. While it is undeniable that there are fundamental problems like poor quality of health care, which need systemic reforms that go beyond a single program, the NRHM has helped achieve significant improvements in a broad spectrum of health outcomes (maternal and child mortality) and outputs (immunisation, ante-natal care, institutional deliveries etc). 

The most striking indicator is the near doubling of institutional deliveries over a ten year period.
Given the importance of this single intervention of promoting safe delivery, I cannot recollect an achievement of similar scale on any similarly important indicator in any other sector. The contrast with Sarva Siksha Abhiyaan in school education cannot have been starker. Granted the nature of challenges are different. 

The Janani Suraksha Yojana, initiated in 2005, has been instrumental in the success with maternal and child health interventions. It is the world's largest conditional cash transfer program, and makes payments to mothers to undertake institutional deliveries and to community health workers for ante-natal and post-natal visits, institutional deliveries, and immunisations. 

The NRHM's success (as evident from the graphics here) can be traced back to its unique focus on implementation flexibility, untied resource allocations, local accountability, demand-side incentives, and outcomes-based payments. In fact, the NRHM may also be the only example of Payment by Results (PbR) financing that has worked in scale in social sectors anywhere in the world.

1 comment:

Karthik Dinne said...

Don't want to be a spoilsport, but just wanted to point to this research, an alternate take by Jishnu Das and Jeff Hammer.

Das and Hammer argue that the story is different if measured by outcomes (reduction in infant mortality), instead of outputs (number of institutionalised births). They seem to argue that increase in institutionalised births has had no impact on infant mortality. If anything, it has halted the slow decline of infant mortality (if my interpretation is correct).

The central argument being - institutionalised births reduce infant mortality if those institutions "work properly". If they don't work properly, it might even back fire.