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Rural healthcare revitalised
Is the National Rural Health Mission (NRHM), 2005-2020 the
prescription for rural healthcare maladies? Rita Dutta analyses a few
aspects of the Mission
The deplorable rural healthcare, suffering in the throes of poor governance,
insufficient infrastructure, financial crunch and bureaucratic hassles, may
get a much-hankered for boost from the sops announced in the National Rural
Health Mission (NRHM), 2005-2020.
In the first phase, to be implemented overt the next seven years, the Mission
has its special focus on 18 states lagging in terms of weak healthcare infrastructure.
NRHM pegs the increase of government's healthcare spending from 0.9 per cent
to 2 per cent in the GDP, re-introduces community health workers, promises to
upgrade more than 2000 community health centres as the new Indian Primary Health
Standards, encourages decentralisation in governance and traditional systems
of medicine. The Mission adopts a synergistic approach, relating health to determinants
of good health: segments of nutrition, sanitation, hygiene and safe drinking
water.
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The NRHM aims to provide basic health and medical care
to the 73 per cent of our
population, which lives in 6.5 lakh villages
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Acknowledging the debilitating healthcare system, during its
inaugural speech Prime Minister Manmohan Singh, lamented, "The slow improvement
in the health status of our people has been a matter of great concern. We have
grievously erred in many of our health programmes. We have paid inadequate attention
to public health. We have created a delivery model that fragments resources
and dissipates energies. "
Will the sops in NRHM overhaul rural healthcare delivery? Experts are optimistic.
Says Pune-based Dr N H Antia, member of NRHM's steering group, speaking to this
reporter, "The NRHM aims to provide basic health and medical care to the
73 per cent of our population, which lives in 6.5 lakh villages. This is an
earnest attempt by the government with the public healthcare sector, not providing
even 20 per cent of such care and the private sector having raised the cost
of healthcare to such a level that it has become the commonest cause of rural
indebtedness and even suicide."
According to the National Health Policy 2002, the aggregate expenditure in the
health sector is 5.2 per cent of the GDP. Out of this, about 17 per cent of
the aggregate expenditure is public health spending, the balance being out-of-pocket
expenditure. The current annual per capita public health expenditure in the
country is no more than Rs 200.
The similarity of NRHM with the ICSSR/ICMR Report of 1981
for whom Foundation for Research in Community Health (FRCH) provided the secretariat,
cannot be overlooked, says Dr Antia, who is the chairman of FRCH. Minimising
the dependency on tertiary care at the district hospital, the Report advocated
that even semi-literate village workers using knowledge and technology derived
from all available systems of health and medicine, can cater to 1,00,000 taluka
population, if supported by a community health centre with a basic hospital
and training centre. This Report also stated there must be a people’s health
movement based in the panchayat system and a bottom-up rather than a top-down
service.
According to P Gopinath, economist, Tata Institute of Social
Sciences (TISS), Mumbai, "Health and education form the foundation of a
nation's development. When poor people's health is accorded importance, their
potential to work is enhanced, thus giving a boost to the economy. That is exactly
what the NRHM attempts to do."
But this is not the first of such dream projects. Some believe
NRHM is a re-packaged product. Says Ravi Duggal, co-ordinator, Centre for Enquiry
into Health and Allied Themes (CEHAT), Mumbai, "The NRHM is primarily a
re-packaging of existing health programmes with an effort to coordinate it with
a mission approach. The programmes remain the same - RCH, including family planning
and selected disease control programmes. The proposed allocation of Rs 6,713
crore for the year 2005-06 would also come from the same programmes."
One of the earliest attempts to devise a comprehensive health programme was
the National Health Policy 1983, which paved the way for 'Health for All' by
2000 through the universal provision of comprehensive primary health care services.
After receiving much flak for not meeting its target of Health for All by 2000,
the government came up with more realistic goals in National Health Policy 2001.
The State has its commitment to improve overall quality of life, which is an
integral part of the Common Minimum Programme announced last year. The NRHM
also coincides broadly with the commitments undertaken to achieve the Millennium
Development Goals (2001).
Analysis of sops Decentralisation
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Tais administer first-aid to a village boy in Parinche
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Cutting across swathes of bureaucracy, the NRHM attempts a
major shift in governance by handing over leadership to the Panchayati Raj Institutions
(PRI) at the district and sub-district levels. The keyword here is decentralisation.
Decentralisation is welcome, but is NRHM referring to only political decentralisation?
Decentralisation, without its fiscal and administrative power would be futile.
If the PRIs are expected to oversee an array of programmes and services, then
the budget along with the freedom to use resources for the programme should
be allocated to the PRI within a broad framework.
Quips Alok Mukhopadhaya, Voluntary Health Association of India
(VHAI), New Delhi, "Currently, the panchayats are quite often like daughter-in-laws,
who have been asked to cook a nice meal, but the keys of the kitchen and store
are still with the mother-in-laws."
According to Dr Sandhya V Iyer, Unit for Rural Studies, TISS, Mumbai, "Since
the time of economic reforms, several social sector initiatives have been predominated
by centrally-sponsored schemes that are extremely target oriented. It has also
reduced the powers of the state governments in the decision making process,
while the decision making powers of the zilla parishad is confined to provisioning
of personnel and materials and supplies."
However, a community-controlled accountability mechanisms may be required to
monitor the panchayats for these programmes.
Accredited Social Health Activists
Undeterred by its initial debacle which led to community health activists programme
being scrapped, NRHM has re-introduced community health activists called Accredited
Social Health Activists (ASHAs). Around 2.5 lakh ASHAs would be recruited in
the 18 states in the first phase.
ASHAs have been introduced to fill the void created by overburdening of work
of anganwadi workers, who employed under the Integrated Child Development Scheme
(ICDS) are engaged in organising supplementary programmes. According to the
guidelines, the purview of ASHAs’s work includes creating awareness about
basic nutrition, sanitation, counselling women on birth preparedness, importance
of safe delivery, escorting pregnant women and children requiring treatment,
providing primary medical care for minor ailments, among others.
Will ASHAs be able to bolster the outreach of the health system to village and
household levels? Says Dr Shyam Ashtekar, member secretary of Nashik-based NGO,
Bharat Vaidyaka Sanstha, “With proper care and management, ASHAs can increase
access to healthcare, ensure early relief and less damage, boost preventive
health, reduce the burden of hospitals, decrease unit costs of healthcare, reduce
transport costs on healthcare and drug-expenses.”
But what measures would ensure that ASHAs don’t meet the same fate as
that of community health workers? Started during the Janata regime in 1977-78,
the community health worker scheme faltered due to political neglect and apathy.
To sustain ASHAs, Dr Ashtekar who is also director, school of health sciences,
Yashwantrao Chavan Maharashtra Open University (YCMOU), recommends, firstly,
the accreditation of such health workers must be conducted by well known educational
systems. Secondly, ASHA shall be paid based on programme performance assessment.
“The economics of such programmes is often neglected. If the programme
fails to provide day to day survival for ASHAs, it runs the risk of dying out,”
cautions Dr Ashtekar. ASHAs will not be paid any monthly fees, but a token amount
as per their service. “If fees are not charged, then medicines stock will
not last for more than a week. It also creates a total and fatal dependency
on government funds,” says Dr Ashtekar.
Debate continues to rage about ASHA’s right to prescribe medicine. Some
uphold that with appropriate training and demystification of medicine, semi-literate
women can prescribe medicine. FRCH, which has tried and tested this model in
Parinche village, 50 kms from Pune, with success, vociferously propagates this
model. Dr Ashtekar corroborates, “If ASHAs are not armed with medicines,
villagers would be disappointed and this will spurt the trend of them visiting
rural hospitals. This defeats the purpose of having health workers.”
Another school of thought counters that ASHAs should not be promoted as the
first contact provider or the soul provider for healthcare services. “They
may provide some curative services like coughs, diarrohea and unspecific fevers
etc, but they should not be viewed as an alternative for medical professionals
like nurses and doctors. ASHAs are basically link workers, connecting people
to the healthcare system and conducting some promotional, preventive and educational
activities for the public health system,” avers Duggal.
Convergence of vertical programmes
Reeling under pressure of work from various programmes, ranging from family
welfare services to reproductive health services to immunisation and nutrition
programmes, has been the eternal complaint of health workers. The Mission attempts
to correct this by consolidate different vertical programmes at the district
level.
Previously, dragged apart by various programmes and funding partners in different
directions, the convergence would ensure better planning and monitoring of the
programmes. “A separate family welfare programme has damaged the cause
of healthcare in India without serving that well. We need to integrate schemes
and create ‘single window approach’, at least at the primary level,
giving a boost to the public utilisation of services, reducing costs and making
schemes viable,” says Dr Ashtekar.
According to Raghu Nandan, secretary, Delhi Health Forum of People’s Health
Movement (PHM), “The policy needs to clearly define the ways the government
would adopt to merge the programmes, as some are controlled by the state, some
by the centre and some has multiple controls.” The Jan Swasthya Abhiyan
of PHM under its “Health for All”, has been clamouring for integration
of national health programmes with the primary healthcare system. It is also
demanding active participation of the community and that PHCs be placed under
direct control of PRIs.
Even as NRHM aims to build synergies across nutrition, sanitation, hygiene and
safe drinking water, there is a scarce mention of the measures to improve the
quality of nutrition facilities, water supply and sanitation programme. “To
a large extent, the morbidity patterns of the rural economy are determined by
the poor living conditions, imbalances in nutritional intake and dominance of
social structures in family planning norms. There is a need to take cognisance
of the mismatch between the programmes presently implemented in the district
and the proposed consolidation of the programmes under the NRHM,” avers
Dr Iyer. Given the varying structures and patterns of implementation of these
programmes, it is better to consider rationalisation of implementation framework
rather than reduce the number of programmes.
Strengthening of primary centres
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The merger of department of Health and Family Welfare
at the centre would imply that public health services become selective
and targeted towards the “below poverty line” population
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| Ravi Duggal |
The Mission’s promise of a sum of Rs 10,000 to every
sub-centre to cater to unmet needs would prevent delays in carrying out incidental
expenditures, say experts. However, the NRHM is silent about the utilisation
of these resources. “The inhibition in this regard emerges from the fact
that often untied funds tend to be misallocated to channels that would not necessary
contribute to the welfare of the patients,” says Dr Iyer.
Besides, strengthening of network of primary health centres implies that the
contingency fund would have to be allocated to these centres as well, thus enhancing
the overall expenditures of the programme. “What are the sources of financial
resource mobilisation? Would the district level authorities provide the option
of raising resources to finance these expenditures?” asks Dr Iyer.
Traditional System of Medicine
Though opinions swing about the extent to which traditional system of medicine
should be promoted, most experts believe that it’s time India emerge out
of the shadows of colonial past and encourage its very own traditional system
of medicine. “Even the health tourism industry in India rests on these
forms of treatments. In the patent regime, post January 2005, promotion of alternate
forms of treatment would also help contain the cost of treatment,” avers
Dr Iyer. If China can do well with alternate medicine, why not India, ask experts.
Standardised range of service
An important aspect of the proposed Mission is that rural hospitals will provide
a standardised range of services. With the mission document stating that utilisation
of FRUS would be hiked from 20 per cent to 75 per cent, the availability of
various specialists and provisions to support rural hospitals can prove to be
hurdle. “However, the resource commitments needed for this have not been
indicated, except for stating that a maintenance fund of Rs one lakh would be
given to FRUs which form the Rogi Kalyan Samitis,” says Duggal.
A well-run first referral hospital would need at least Rs 2,50,000 per bed per
annum. “Thus a 50 bed rural hospital would need Rs 125 lakh per year and
this would translate at the national level to Rs 8750 crores, assuming one rural
hospital per lakh population,” adds Duggal.
Concerns
Experts are concerned that the merging of the departments of Health and Family
Welfare at the Centre may lead to the hijacking of the MoHFW’s broad agenda
to a limited RCH-2 agenda. “The merger would imply that public health services
become very selective as well as targeted towards the “below poverty line”
population. The NRHM should instead focus its efforts on universal access to
a comprehensive primary healthcare package with good referral services and make
them available to all citizens,” says Duggal.
Questions also arise about ways of resource mobilisation. A major part of resource
mobilisation comes from consolidation of resources from various National Disease
Control Programmes and supplementing of additional resources from the National
Common Minimum Programme. Additionally, the States are expected to raise their
contribution to public health budget by a minimum of 10 per cent per annum to
support the Mission activities.
“Both tiers of governance are facing crucial fiscal constraints
(more so in the case of State governments). In the post-reform years, select
states have introduced user charges in the public health system, thus increasing
out-of-the pocket expenditures of the households,” says Dr Iyer.
The Task group set up to examine the new health financing mechanism along with
the IRDA would have to deliberate on this issue to explore financing mechanisms
while promoting Community Base Health Insurance Schemes (CBHIs), since this
would help promote both efficiency and equity of healthcare facilities, adds
Dr Iyer.
Others lament the neglect of the traditional birth attendants by NRHM. “Though
NRHM promotes skilled birth attendants in the form of better trained nurses
in rural areas, Auxiliary Nurse Midwives (ANMs) are hamstrung by the 5000 community
in a nurse situation. She can not attend births in 5-10 villages and still attend
other chores,” says Dr Ashtekar.
Conclusion
The government’s effort in providing a panacea for rural healthcare is
lauded, but healthcare experts are apprehensive about the implementation of
such a dream project. The NRHM is no magic wand that would waive off all problems.
The ways to active the goals need to be clearly defined,” says Nandan.
Firstly, bureaucracy can pose a hurdle, especially when handing over financial
resources to the panchayats. NGOs recount bitter experience of societies for
various programmes, with funds controlled by bureaucrats at the regional or
state levels, thus preventing local initiative and rendering a centralised character
to the programme. Decentralisation and formation of local committees of elected
representatives and various stakeholders to control the use of resources for
programmes and services are recommended.
Ashtekar has the last word. “This is the first time the
Indian Government is looking at rural health through a looking glass and providing
basic directions and some support. It is for the states to take it further.”
(With inputs from Sapna Dogra, New Delhi)
rita_dutta@rediffmail.com
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