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  • National Rural Health Mission : Hope or disappointment

    The recently declared National Rural Health Mission has aroused significant interest, being both welcomed and closely scrutinized, since there is a long overdue and outstanding need to strengthen weak and dysfunctional public health systems in rural India. In this setting, Jan Swasthya Abhiyan (People’s Health Movement – India), a large national coalition of 18 national networks and several hundred organisations working in different states and concerned with the health sector, has been involved in analysing various aspects of the Mission. The concern has been that it should develop in a manner that actually strengthens public health systems in an integrated manner, and that it should empower communities to be involved in the planning and utilization of these systems in a Rights-based framework. In this article, one will draw upon and reflect on a few of the major concerns about NRHM that have emerged during the insightful discussions in JSA, although the responsibility for opinions expressed and liability for any omissions finally rests with the author.

    Some general concerns
    Before discussing certain specific components of NRHM, it will be logical to pose two general concerns that emerge from a reading of the Mission documents, and have been observed by some of us who have participated in discussions related to formulation of the Mission. The first concern is that there is no systematic analysis of previous policies, and no major lessons seem to have been learnt from the past. The NRHM documents do not appear to analyse why the Primary Health Care approach was never implemented effectively and the goals of ‘Health for All by 2000’ have not been met, a quarter of a century after they were declared; why instead of improvements in public health services we have seen stagnation and even certain deterioration since the 1990s; what are the critical issues related to the recent National Health Policy 2002 which must be reviewed – in short one does not see meaningful analysis which could lead to learning from past policy deficiencies.

    While launching a major nationwide community health worker programme in the form of ASHA, there is no systematic analysis of why the CHV scheme of 1978 failed; and while declaring ‘public-private partnerships’ as an important strategy of the Mission, there seems to be no analysis of the glaring issues related to decades of non-regulation of the private medical sector. Here we may keep in mind that ‘those who cannot learn from History are doomed to repeat it’.

    A second concern relates to the influence of the globalisation-privatisation framework on the Mission. While this is a National mission, transnationally funded programmes presently seem to have a strong presence compared to augmented national finances for the Mission; and although the aim is to strengthen public health, privatisation-friendly measures appear in various places in the Mission related documents. There appears to be a very strong influence of the RCH programme (with major funding by the World Bank and other international agencies); according to the Annexure ‘State, District and Block action plan’, the funding for NRHM appears as a consolidated repackaging of various existing national programmes, with the single largest chunk being contributed by the RCH programme. If one examines other annexures circulated with the NRHM Manual, the Annexure on ‘Statewise allocation for 2005-06’ details the funds available for NRHM, which appear to be entirely RCH activity related funds; and the only Annexure dealing with indicators deals entirely with RCH-II performance indicators. While Reproductive and Child Health undeniably should form one important component of such a Mission, the disproportionate influence of a single externally funded programme may not be healthy for the integrated strengthening of rural health systems, especially given our history of the dominating and distorting influence of vertical programmes such as the Family Planning programme. Similarly, in the Indian situation of an already debilitated public health system and an overwhelming private medical sector, the need is for urgent and substantial strengthening of the public health system and avoiding any further privatisation oriented measures; however some such measures are mentioned in Mission documents, which are discussed below. In the present year’s Union budget, we find no separate financial allocation or additional funds for NRHM; ultimately one of the key criteria to assess the strength of political will supporting the Mission is to see whether a substantial scale of additional domestic funding (not just repackaged external funds) is allocated to the Mission in the coming few years.

    ASHA – barriers to success, measures required to overcome them
    One of the most ‘visible’ and politically high-profile interventions of NRHM is the proposed ASHA programme. Based on suggestions and examples from the Health NGO sector, and recognising the need for a resident health facilitator at the village level, the idea of having a women health promoter in each village is definitely positive. However, we know that whether it is God or the Devil, both often lurk in the details. In the design of the ASHA programme we see a number of serious concerns which would need to be addressed, for the ASHA to be able to function with even a minimum level of effectiveness3:

    • Selection criteria – at present, an educational level upto eighth class (middle education) is expected for a woman to qualify as ASHA. An analysis of the 1991 census data shows that in the rural areas of the NRHM states in Northern India, over 91% women did not have middle level education – and more recent data shows that this situation has not changed significantly in the subsequent period. In the hierarchical, often caste-ridden villages of North India, if this educational criterion is rigidly imposed, it will impose a bias against women from disadvantaged groups such as poorer women with less formal education, and SC and ST women. Myriad experiences of NGO health worker programmes have shown that insisting on formal education is not necessary, provided the training of health workers is properly designed. However, with the present educational barrier, the women with strongest social motivation, women who are representative of deprived groups, are likely to get excluded from the programme.

    • Lack of adequate regular compensation – In the final programme design, ASHA is supposed to work primarily as a volunteer. She would be compensated on performance of certain specific tasks related to National programmes. However, for her major routine activities such as immunisation, weighing of newborns, facilitating ANC, treating patients, visiting households, giving education to mothers, mobilising the community etc., as per the financial norms, the maximum compensation from the Village Untied Fund that may be given is mentioned as Rs. 1000 annually, or about Rs. 83 per month. It does not require a great degree of imagination to realise that with such a paltry compensation (equivalent to less than two days of wages in a month) the amount of work that can be expected from the ASHA cannot be very significant. To sustain the motivation and activity of village women working as ASHAs, who would have many other competing work priorities and domestic responsibilities, will be a challenge given the very limited and uncertain compensation they would receive.

    • Limited provisions for First Contact Care – One of the strongest felt needs expressed by communities is the need for basic curative care being made available within their village. Many NGOs have demonstrated that well trained Health workers can give a wide range of First Contact Care effectively. However, the ability of ASHA to give basic care in simple illnesses is dependent on adequate relevant training, provision of a proper kit and regular replenishment of the range of necessary medicines. The drug list for ASHA as has been presently proposed is extremely limited, and the budgetary norm for drugs is Rs. 50 per month (the same as for CHVs way back in 1978!) which raises doubts about her being made capable to meet people’s needs for First contact care. If she is seen as a person who cannot give significant care to persons with health problems, her credibility in the village as a Health facilitator and hence her overall effectiveness may also become limited.

    • Activist or appendage? By her very name – ‘Accredited Social Health Activist’ the ASHA is supposed to be an ‘Activist’ mobilizing people and facilitating their access to health services as a right. However, given the fact that the ANM will be involved in sanctioning her compensation, and she would be reporting to the health system for implementation of various programme related activities, would she be realistically able to function as an ‘activist’ and lead people to put pressure on non-performing health services? Given the way in which the programme is presently structured, there are strong inhibiting forces to prevent her from really becoming an ‘activist’ vis-a-vis the health system. Moreover, unless the other levels of the Health system such as PHCs and CHCs are substantially improved, their services upgraded, and the staff made responsive to people claiming Health rights, ASHA would not be able to make much headway in her task of facilitating people’s access to health services. In the absence of major programmatic changes, the likely scenario is that ASHA would be placed in a peripheral ‘helper’ role related to the Health system, but the need for significant compensation to carry out this role might be brushed aside on the pretext that she is an ‘activist’!

    • Focus on RCH, possible adverse influence of Family Planning programme - While the ASHA’s role in providing primary medical care at the village level appears weak, a look at the indicators to be used for monitoring her performance shows that out of the eight outcome indicators for ASHA, seven are related to RCH. The strong influences of the RCH programme on NRHM in general have already been noted. In this context, it needs to be seen whether a key component of the RCH programme, the Family Planning component, influences ASHA’s functioning in a disproportionate manner, since it has often distorted the priorities of other Primary Health functionaries and has reduced their overall effectiveness.

    Most of these concerns stem from the national guidelines for the ASHA programme, which have already been finalized. However, the state level design of the ASHA programme in various states is presently underway; along with addressing the concerns mentioned above, certain principles and guidelines should be followed to substantially reorient the programme, otherwise it is unlikely that it would achieve its stated objectives:

    • The role of ASHA is not to substitute elements of the existing health system, but to complement it and promote its better utilisation. The ASHA should not be viewed as a replacement for any of the functions to be performed by the ANM, Anganwadi worker or other public health functionaries.

    • Training of ASHA should be substantial and adequate to equip her for her multiple and reasonably demanding roles, this would require at least about one month of initial training followed by regular (monthly or once in two months) follow up training. Training needs to be a continuous effort, provided over a period of a few years.

    • A specially developed cadre of local trainers / facilitators would be required to provide adequate training support and ongoing other types of support to ASHAs. These may be drawn from existing staff or may be newly appointed, but must devote practically full time efforts for supporting the ASHA programme. Lack of such dedicated support would fatally weaken the programme.

    • Principal amount of adequate remuneration for ASHA should be assured and delinked from specific activities, with a small performance linked component if necessary. The remuneration for regular health activities and village level processes could be routed through the Panchayat or Village health committee if required. Monitoring of ASHA should involve social monitoring by the Gram Sabha and Village health committee, and technical monitoring by the Public health system.

    • Adequate budgetary provisions must be made to support all the critical elements of the ASHA programme including training and training compensation, cadre of trainers / facilitators, regular replenishment of the drug kit, remuneration for regular tasks and additional activities done by ASHA, capacity building and support to Village health committees etc.

    Strengthening of PHCs and CHCs
    The strengthening of PHCs and CHCs is an important component of the Mission, which is central to the upgradation of Health services in rural areas. The intention to adopt and operationalise Indian Public Health Standards (IPHS) for CHCs is a definite step forward. However, while operationalising this process of strengthening, certain key issues may be kept in mind:

    • In contrast to a current trend which looks at PHCs as being expendable, it is necessary to ensure that PHCs are substantially upgraded to provide a full range of basic services including primary medical care, institutional deliveries, basic emergency care, and referral transport services. This would require renovation of infrastructure, provisioning of adequate and regular drug supply, functional ambulance facilities, adequate all-round staffing, multi-skilling of paramedicals, and adequate facilities for health professionals with time-bound postings in difficult areas with necessary incentives.

    • A ‘Generic model for Hospital Management Societies’ has been circulated as an annexure to the Mission manual, which would presumably guide societies which would manage CHCs and other hospitals being dealt with by the Mission. This document includes under the Aim and Objectives of the Society – ‘Generate resources locally through donations, user fees and other means’. Under the scope of functions of such societies, points include – ‘Entering into partnership arrangement with the private sector (including individuals) for the improvement of support services’ and ‘Developing/leasing out vacant land in the premises of the hospital for commercial purposes’. Such provisions raise an apprehension about the processes that might be followed while managing such Hospital societies, and whether these could lead to semi-privatisation of such public hospitals. Specifically, implementation of such societies and related committees (such as Rogi Kalyan Samitis) should not be accompanied by any introduction of user fees or any resort to privatisation; rather the improvement of services should be provisioned through enhanced public funds. The experience of user fees in rural public health facilities, in other developing countries as well as in India, is that such fees can form a significant barrier to utilisation of services by the poorest. Exclusion mechanisms (such as the ‘BPL’ criteria) frequently do not work, and the genuinely poor often end up paying while certain politically influential individuals may avail the benefits.

    • While the formulation of ‘Indian Public Health Standards’ for CHCs is a welcome step, such standards should also be formulated for PHCs, and should mandate Charters of Patient’s Rights applicable at various levels. Accountability committees for PHCs and CHCs should involve not only Panchayat leaders, but also representatives of local Community based organisations, Women’s groups, locally active NGOs and Village health committees.

    Public-private partnerships
    The NRHM documents specify ‘Public private partnership’ as one of the Mission components. However, given the fundamentally divergent objectives of the Public health system (to provide services to the general population based on public financing) and of the Private medical sector (to run as profitable institutions, providing care to those who can pay), a ‘partnership’ of such differing institutions needs to be very clearly specified, to prevent its abuse. The variable quality of care, frequent lack of minimum standards, prevalence of irrational practices and often unaffordable price of care in the Private medical sector has been documented by various studies. In this context, the foundation of the relationship between the Public health system and the private medical sector must be effective public regulation of the quality, rationality and costs of care in the private sector. There is no reason why Indian Public Health Standards cannot be applied to the private sector as well. The long-standing and glaring non-regulation of this proliferating sector and the need for strong, effective measures in this direction are only weakly addressed in the Mission document which does not mention any specific legislative or operational mechanisms and blandly talks of the ‘need to refine regulation’1.

    Similarly, any measures under the banner of ‘partnership’ which may lead to privatization of existing public health services should be strongly questioned and opposed, since the consequence of such privatization has often been introduction of steep user fees, barring the poor and lower middle class from accessing services. The recent episode of attempted privatization of Wadia Hospital in Mumbai, which was blocked by the High Court following widespread public protest, is a case in point. In the same vein, public funding for the private medical sector should be strongly critiqued; the Qureshi Committee which investigated major private hospitals in Delhi (who were beneficiaries of large public subsidies) found major non-compliance with stipulations to provide services to poor patients; this highlights the dangers in unquestioningly relying on profit-making agencies to provide care to the poor. However, the obligations of the Private Sector towards Public Health (in terms of support to National health programmes, surveillance, disease notification etc.) should be emphasized; the overriding role of the Public health system in defining public interest needs to be stressed while enforcing the consequent responsibilities of private medical providers.

    Conclusion – need to critically support and influence the Mission; People’s Rural Health Watch
    In India, given the dismal situation of rural health services in most states, any genuine measure to strengthen the rural public health system is welcome; hence the National Rural Health Mission has aroused many hopes and expectations. The long-overdue renewed attention to public health, and most of the overall goals of the Mission are definitely positive. However, as this article has tried to outline, in many respects the Mission falls significantly short of expectations, and the details of the actual measures do not seem equal to its objectives. There is a decision to strengthen national health services, but this is presently significantly linked to internationally funded programmes; there is a desire to improve public health but this is mixed up with some notions of privatisation; there is a recognition of the present deep health crisis, but the response is somewhat fragmented and seems to lack an integrated, health systems approach.

    Keeping this in mind, it is necessary to support and press for proper, effective and accountable implementation of the positive elements of the Mission, while critiquing and presenting alternatives regarding its negative aspects. It is with such an objective in mind that Jan Swasthya Abhiyan has decided to initiate a ‘People’s Rural Health Watch’ which would monitor the development of Mission activities in several selected states, and at the national level, in the coming few years. By means of multi-centric surveys involving civil society organisations, JSA would assess and analyse the implementation of the Mission, and would widely disseminate the survey findings along with giving policy suggestions and alternatives, with a view to support genuine strengthening of rural Public health systems. Public health professionals and academics could definitely contribute to this process, and could thereby help strengthen rural public health, in a setting of social accountability.

    Finally, History, it is said, repeats itself – the first time as tragedy, and the second time as farce. The story of ensuring health care for the rural people of India may be traced back to the Bhore Committee, which adopted the goal of Universal access to Health care for all on the eve of Indian independence. That this goal could not be achieved is obvious; and then history repeated itself for the first time a quarter of a century ago when ‘Health for All’ was adopted as a goal for Health development. This repetition of history ended in tragedy, with the subversion of the comprehensive Primary Health Care approach, which was replaced by a set of technological ‘quick-fixes’ that only scraped the surface of the problem while leaving the systemic issues unchanged. And now, History is repeating itself for the second time; again the declared goal of the Mission is “to improve the availability of and access to quality health care by people, especially for those residing in rural areas…”1

    If the first repeat of history ended in tragedy, what fate will NRHM, this second repetition of history, meet? While it is too early to pass judgment on this, already some ominous trends are visible, which have been outlined in this article. It should be our task as public health professionals and concerned citizens to strongly advocate for the NRHM to adopt a comprehensive approach to strengthening of public health systems, based on enhanced national resources, in a framework of accountability and rights; this could be our contribution to strengthening Health services for the people of rural India, whose striving for better health and better lives in the face of tremendous odds should be our primary inspiration.

    Dr. Abhay Shukla is a Public health specialist working with SATHI-CEHAT, Pune. He is associated with Jan Swasthya Abhiyan, and would like to acknowledge various JSA documents, which have been referred to while drafting this article.

    • Mission Document, National Rural Health Mission, Ministry of Health and Family Welfare, Govt. of India, April 2005
    • Manual on National Rural Health Mission circulated by Ministry of Health and Family Welfare, Govt. of India, April 2005
    • Accredited Social Health Activist Guidelines, Ministry of Health and Family Welfare, Govt. of India, April 2005
    • Annexure-5 to NRHM Manual, circulated by Ministry of Health and Family Welfare, Govt. of India, April 2005
    • Annexure-13 to NRHM Manual circulated by Ministry of Health and Family Welfare, Govt. of India, April 2005
    • Annexure-10 to NRHM Manual circulated by Ministry of Health and Family Welfare, Govt. of India, April 2005
    • Indian Public Health Standards (IPHS) for Community Health Centre, Draft Guidelines, Directorate General of Health Services, Ministry of Health and Family Welfare, Govt. of India, April 2005
    • Annexure-4 to NRHM Manual circulated by Ministry of Health and Family Welfare, Govt. of India, April 2005.