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   Home >> Library index >> Rural Health >> Beyond the Clinic 
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.)