Performance Audit of Reproductive and Child Health under National Rural Health Mission
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Abstract
The National Rural Health Mission (NRHM) was launched in April 2005 to provide accessible, affordable and quality health care to the rural population. The aim of NRHM is to bridge gaps in healthcare facilities, facilitate decentralised planning in the health sector, and provide an overarching umbrella to the existing disease control programmes run by the Ministry of Health and Family Welfare. The yearly expenditure on the programme increased from INR 15,961 crore during 2011-12 to INR 26,397 crore during 2015-16.
Under the umbrella of NRHM, the Government has been implementing Reproductive and Child Health (RCH) programme with the main components being Maternal Health, Child Health, Immunisation and Family Planning. Considering the strong correlation between health facilities and RCH outcomes and given that RCH indices are pursued under the Millennium Development Goals, this performance audit concentrated on assessing the impact of NRHM on improving RCH. The performance audit, which covers the period from 2011- 12 to 2015-16, attempts to touch upon the various facets of the programme such as financial management, infrastructural facility and quality of health care and suggests ways to bring about improvement in programme delivery.
The specific objectives for this performance audit have been finalised on the basis of detailed examination of all available dataset, such as District Level Health Survey-3 (2007-08), Health Management Information System (HMIS) 2013-15, Annual Health Survey (2012-13) and National Sample Survey Round 71 (2014) with regard to prevailing health conditions. We have availed the assistance of Evidence for Policy Design (EPoD), operating through the Institute for Financial Management and Research, Chennai for finalising the audit objectives, determining the sampling strategy and designing the surveys.
Surveys of the selected facilities, Accredited Social Health Activists (ASHAs) and beneficiaries were carried out to assess the status of infrastructural facilities, the equipment available with field level functionaries and its utilization and also for assessing the level of awareness among the population about the programme and the difficulties faced by them in utilising the facilities available. 1 National Rural Health Mission (NRHM) and National Urban Health Mission (NUHM) are sub-mission.
We also analysed the Health Management Information System (HMIS) using Computer Assisted Audit Techniques (CAATs) for checking the accuracy, completeness and timeliness of data which is used by the Ministry to evaluate the pan-India performance of NRHM. We also compared the data in HMIS with the data in the basic records available at the health facilities.
Shortfalls in the availability of required health facilities in the States coupled with deficient infrastructural facilities and unhygienic surroundings in some existing facilities are areas of concern. Significant shortfalls of doctors, health care support staff, technicians, etc., across Community Health Centres (CHCs), Primary Health Centres (PHCs) and Sub-Centres (SCs) countrywide compromised the administration of health care.
The primary objective of the RCH programme, of increasing institutional deliveries, had not been fulfilled in most of the States. Poor record management across all States rendered the quality of some of the data reported in the Health Management Information System (HMIS) erroneous. The objectives of the National Quality Assurance Programme (NQAP) launched by Government of India in 2013 for improving the quality of care in District Hospitals, CHCs and PHCs remained largely unfulfilled.