| Beyond the Clinic
Uncertain Start To National Rural Health Mission
By Anant Phadke
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.)