National Rural Health Mission
Beyond the Clinic
Uncertain Start To National Rural Health Mission
By Anant Phadke
14 Apr 05
The National Rural Health Mission (NRHM) is a response to the verdict of the May
2004 general elections which led to the conceptualisation of a set of pro-poor
policies under the Common Minimum Programme (CMP). This mission, launched by the
Union government on April 12, could help correct the gross neglect of the
healthcare needs of the rural people. It has, however, begun on a rather
tentative note. The NRHM would have to address the three major problems of rural
healthcare.
First, rural health is starved of funds. Various studies corroborate the
perception of grass-root activists that the facilities at primary health centres
(PHCs) and rural hospitals fall short of people’s needs both in quantitative
and qualitative terms. Even the National Health Policy 2002 concedes this.
During the last 10-15 years, the situation has worsened due to reduction in
public investment in social sectors, including healthcare. Hence we find that
posts of various categories of staff from medical officers to auxiliary nurse
midwives to ambulance drivers lie vacant for years. Drug supplies are deficient
and unrepaired instruments gather dust.
In response to the widespread criticism of under-budgeting for healthcare, the
CMP promised an increase of Central healthcare expenditure from 0.9% to 2-3% of
GDP. In the 2005-06 Budget, the healthcare budget has increased by 25% or Rs
1,860 crore. But this increased budget is still 0.9% of GDP! Moreover, increased
allocation for four ongoing programmes (AIDS control, reproductive and child
health, medical education, Indian systems of medicine) account for Rs 1,540
crore, leaving only about Rs 320 crore for the NRHM per se. Will the government
only make lofty pronouncements and fall short of implementing election promises?
Rural health requires much more budgetary support. The
proposal that the additional 10% levy on cigarettes, gutka, chewing tobacco,
would be used to part-finance the NRHM is problematic. While these noxious
products should be taxed more, the proceeds should be spent on deaddiction
propaganda, rehabilitation of the families of the alcoholics and alternative
employment opportunities for those in these noxious industries. NRHM needs other
forms of fiscal support.
Second, the NRHM needs to tackle wastage, poor accountability
and inefficient use for resources. NGOs have given specific suggestions to
overcome these problems. These include, to avoid wastage, a rigorous scientific
debate among public health experts before launching low-priority or unrealistic
programmes like universal hepatitis-B immunisation and polio eradication.
Developing six AIIMS at a cost of hundreds of crores of rupees is more grandiose
than useful. Instead, we need to focus on better capacity-building of paramedics
and convert some of the unipurpose PHC staff into multipurpose staff through
reorientation and training. For better utilisation of public health services, we
need to create awareness through a rights-based approach, or one that looks at
health as a fundamental right.
Third, the NRHM should address the absence of a residential
healthcare provider in every village. Patients have to travel to a nearby PHC
for even minor problems like a small wound, ordinary diarrhoea or fever. People
tend to stay at home and seek help only when the situation deteriorates.
Community Health Workers (CHWs), if properly trained and supported, can
considerably reduce the suffering and loss of human days due to absence of
timely first contact care. Though the official CHW scheme launched in 1978 has
failed, the NRHM has done well to reconceptualise the CHW as ASHA, or Accredited
Social Health Activist.
In order to avoid the same fate as of the 1978 CHW scheme,
NGOs under the Jan Swasthya Abhiyan have given suggestions to ensure the success
of the ASHA component of NRHM. On the recruitment, they have suggested that ASHA
should be a woman, a permanent resident of the village with basic education. She
should have functional literacy if situated in remote, tribal areas or have
passed eighth standard if working in well-developed areas. Unfortunately, the
government appears to be rigid about educational qualification, which could end
up discriminating against lower caste women in many regions. The selection
process should be assisted by a facilitator to assess the capacity and
commitment of the candidates, with the final selection being done at the gram
sabha and not merely by panchayat samiti members and sarpanch.
As for her training, all three functions — awareness
building about health rights, provision of first contact care and implementation
in the village of national health programmes — are equally important.
Strangely, the government has not adequately emphasised the first contact
aspect. For ASHA’s sustenance, the gram panchayat should receive an untied
grant to compensate her suitably. Performance-linked remuneration should also be
paid for implementation of national health programmes in the villages. The
government may jeopardise the programme by ruling out the honorarium and
restricting her remuneration only to performance. Annual assessment in gram
sabhas based on well-defined parameters would make her accountable to the
community. The implementation of her tasks should be phased out and experienced
NGOs involved wherever possible, as facilitators in the selection and monitoring
processes.
If NRHM is not properly designed and implemented, it will be
just one more failed government scheme, something the ruling coalition and the
rural people can ill afford.
(The author is an expert on community health.)
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