The Model Districts project is the most recent of the Earth Institute’s long engagement with development issues in India.
Before getting into project details, we’ll start with some background – the National Rural Health Mission (NRHM). In 2005, the Government of India took a significant step in the country’s health history and created the NRHM – with some inputs from Jeffrey Sachs and Nirupam Bajpai’s research on scaling up health services in India that was conducted at the request of Prime Minister Dr. Manmohan Singh. The NRHM was designed as a cornerstone project of the Ministry of Health and Family Welfare (MOHFW), and by operating in mission mode with a preliminary end date of 2012, it can roll-out new programming in the country with a sense of urgency.
NRHM set a focus on high-impact health interventions for the rural masses, targeting maternal and child health, preventative health services, behaviour change, and a stronger, decentralized health system to increase coverage in rural areas. The NRHM sought to push a more holistic approach to health and integrate key sectors – including nutrition, clean water, hygiene, infrastructure, and education.
With the additional spending placed into NRHM, India’s total health spending went from 0.9% GDP to about 1.4% GDP. (This was a great step – but India’s health spending is still miserably low; it should be at a minimum of 3%, and for a country of India’s size, should reach 4-4.5% by 2020. As it stands, the WHO ranks India 171st out of 175 countries in public health spending.) In an effort to reinforce a health system that could reach into the villages, NRHM commissioned a female community health worker for every 1,000 people, called an Accredited Social Health Activist (ASHA). This was the first time community workers had been established at a national scale in India, and they are a really interesting case study – we’ll look more into ASHAs in future blog pieces, as they are playing an important role in the India’s health system today, and subsequently, in the Model Districts project.
The Earth Institute was asked to convene a biannual International Advisory Panel (IAP) with the Health Minister, international health experts, and other officials to review the NRHM’s operations, challenges, and opportunities to integrate best practices. The Health Minister requested Jeffrey Sachs and Nirupam Bajpai of the Earth Institute to conduct a mid-term evaluation of the NRHM in 2009. The evaluation showed that NRHM was making strides in creating critical health infrastructure, workforce, and interventions; now that the systems were in place, it was time to focus on quality improvements, management, and innovations.
India is too big, too complex, and too different in disease burden and NRHM coverage to do the same quality improvements across the entire country. The Earth Institute and the MOHFW decided to collaborate and create Model Districts across the country – think centres of excellence in health and nutrition. Five states were selected to represent the major regions of India – Northeast, North, East, West, and South – and a rural district in each state was designated a Model District. While there is incredible diversity in the public health, economic, socio-cultural, and political landscapes of each of the five regions, there is enough shared in these regions for us to think about these districts as models of regional scale-up.
So, why districts? India’s scale is just too big to focus on villages. This project wants to demonstrate that targeted innovations and spending are high-impact and scale-able. According to the 2001 Census, there are over 600,000 villages in India (we’re eagerly awaiting 2011 Census data), so even if a project does great work in a set of villages, it’s still quite difficult to prove scaleability. Alternatively, our districts are substantial – from 1.5 to 4 million people, and hundreds of villages each, but more viable models than, say, a state.
In late September, we launched our first Model District in Morigaon, Assam. Assam is one of India’s Northeast states — a fascinating, economically marginalized region of the country that we’re excited to be working in. State and district officials as well as NRHM teams have been energetically supportive of the Model Districts concept. We’ll have much more to say about what is happening in Morigaon in future blog posts.
What makes these districts ‘models’? This project is an exercise in health systems strengthening – so it is ultimately the district governments and district health units that are responsible for implementing quality improvements, best practices, and innovations. State governments and NRHM offices have a big role to play in driving innovations at district, and providing additional funding when it’s necessary. The Model Districts team provides strategic guidance, research support and technical assistance, and champions policy reform or additional funding at state and national level. The Model Districts project team is housed at the Columbia Global Center | South Asia in Mumbai (inaugurated in September 2010), the Earth Institute in NYC, and will soon have team members at the district level.
What are the ultimate goals of Model Districts? There are several levels to what we want to accomplish.
First, we want to see improved health outcomes for mothers and children – by 2015, we aim to demonstrate lower rates of maternal, peri/neonatal, infant, and child mortality. To get there, we want (among many things) more women receiving quality antenatal care and having safe deliveries, fewer low birthweight babies, better newborn care, improved nutrition for children, more timely care for children suffering from illness, and improved coverage of preventative measures like immunizations and nutritional supplementation. To get there, we need to focus on the gaps in health system management, delivery, oversight, and data-driven decision-making that impact the coverage and uptake of health services.
Second, we want to serve as a learning site for our districts, states, regions, and ultimately, all of India. As a collaboration with the MOHFW, a major focus of our project is to share what we have learned – results, challenges, impact, facilitating factors – between our sites, and with government officials so that we can advise on making NRHM an efficient, high quality public health mission. Part of sharing our lessons learned is with the public, so we look forward to further discussing the project and Indian health context on this blog – stay tuned.
The Model Districts project is generously funded by the IKEA Foundation.
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