Abstract
A multi-strategy community intervention, known as National Rural Health Mission (NRHM), was implemented in India from 2005 to 2012. By improving the availability of and access to better-quality healthcare, the aim was to reduce maternal and child health (MCH) inequalities. This study was planned to explore the perceptions and beliefs of stakeholders about extent of implementation and effectiveness of NRHM’s health sector plans in improving MCH status and reducing inequalities. A total of 33 in-depth interviews (n = 33) with program managers, community representatives, mothers and 8 focus group discussions (n = 42) with health service providers were conducted from September to December 2013, in Haryana, post NRHM. Using NVivo software (version 9), an inductive applied thematic analysis was done based upon grounded theory, program theory of change and a framework approach. Almost all the participants reported that there was an improvement in overall health infrastructure through an increased availability of accredited social health activists, free ambulance services, and free treatment facilities in rural areas. This had increased the demand and utilization of MCH services, especially for those related to institutional delivery, even by the poor families. Service providers felt that acute shortage of human resources was a major health system level barrier. District-specific individual, community, and socio-political level barriers were also observed. Overall program managers, service providers and community representatives believed that NRHM had a role in improving MCH outcomes and in reduction of geographical and socioeconomic inequalities, through improvement in accessibility, availability and affordability of the MCH services in the rural areas and for the poor. Any reduction in gender-based inequalities, however, was linked to the adoption of small family sizes and an increase in educational levels.
Highlights
Large geographical and socioeconomic inequalities in maternal and child health (MCH) continue to persist in India and have even widened across states, between rural and urban areas and within communities [1]
To deal with MCH inequalities and improve MCH, the government of India implemented a multi-strategy community intervention known as the National Rural Health Mission (NRHM) from 2005–06 to 2012–13
This study aimed to explore the perceptions and beliefs of stakeholders regarding extent of implementation of these four major NRHM’s health sector plans; and effectiveness of these plans in improving MCH status and reducing geographical, socioeconomic and gender based MCH inequalities in two districts of Haryana in India with extreme situations, so as to have in-depth understanding of the contextual issues, barriers, facilitating factors, and the pathways of change for improving the MCH outcomes or reducing the MCH inequalities
Summary
Large geographical and socioeconomic inequalities in maternal and child health (MCH) continue to persist in India and have even widened across states, between rural and urban areas and within communities [1]. IMR is higher in rural (44 per thousand live births) as compared to urban areas (27 per thousand live births) [3]. NRHM’s aim was to improve the availability of and access to better-quality healthcare, especially for people residing in rural areas (to reduce geographical inequality), for the poor (to reduce socioeconomic inequality), and for women and children (to reduce gender inequality) [8]. NRHM aimed to reduce the IMR to 30 infant deaths /1000 live births, MMR to 1 maternal death /1000 live births
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