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The National Rural Health Mission: A Stocktaking

The failure of decentralisation, the lack of inter-sectoral coordination, and the undermining of traditional health support are the reasons why the National Rural Health Mission has not delivered what it had set out to achieve.

COMMENTARYEconomic & Political Weekly EPW september 13, 200823The National Rural Health Mission: A Stocktaking Shyam AshtekarShyam Ashtekar (shyamashtekar@yahoo.com) is with the School of Health Sciences, Yashwantrao Chavan Maharashtra Open University, Gangapur, Nashik.The failure of decentralisation, the lack of inter-sectoral coordination, and the undermining of traditional health support are the reasons why the National Rural Health Mission has not delivered what it had set out to achieve. The Alma Ata United National con-ference’s mission statement, Health for All by 2000, has come and gone, but we continue to suffer from poor health status and a weak public healthcare sys-tem. Indian public health owes its frame-work to the Bhore Committee’s (headed by Joseph Bhore in 1943) lofty recommen-dations made in the pre-independence years. The committee suggested an elabo-rate hospital and health centre network and free care for all. This top-down west-ern model could not fully penetrate the entire country due to paucity of funds. In the 1970s the family planning obsession nearly wrested all other initiatives from the health department. This started the era of overseas agencies deciding our health plans and priorities. This weakened public health system withered and finally gave way to a competing private medical sector. Meanwhile in the same period, China was busy making its very own widely based pyramidal healthcare system – from a million barefoot doctors to pro-vincial hospitals. The Chinese healthcare system has inspired the paradigm shift from the western model to the primary healthcare approach delineated at Alma Ata. India is still struggling to establish its healthcare system. The Alma Ata driven change of direction in India was short-lived. The Indian National Health Policy 2002 recognised the sorry health situation and suggested a basket of reforms from co-opting rural doctors to medical tour-ism. However, the Millennium Develop-ment Goals (MDGs) had finally replaced the Health for All 2000 plan with a selec-tive health agenda. The consequent National Rural Health Mission (NRHM) launched in 2005 by the United Progres-sive Alliance government set out to attain theMDGs with “architectural corrections” in the health system. It would be useful to take a mid-course review of this yet another ambitious programme to know if we are on the right path. The main objectives of NRHM are to reduce infant mortality and maternal mortality rates following the MDGs. This is expected to be achieved through promot-ing institutional births and thereby pro-tecting both the mother and the newborn. TheNRHM has woven everything around this core programme. The new Accredited Social Health Activist (ASHA) escorts the expectant mother to a public or private hospital. For this she is paid Rs 700 per case (as incentives plus costs), and the mother also gets cash maternity benefits. This is termed as the Janani Suraksha Yojna (JSY). Other expectations are that the health centres and hospitals will be improved; and the health sub-centre gets an additional nurse. To manage all this better, theNRHM has a three-pronged strategy of (a) commu-nity involvement, (b) decentralisation to panchayati raj institutions-zilla parishads, and (c) programme management units in each district. The centre has increased funds for NRHM by repackaging ongoing schemes. Public-private partnerships (PPPs) are supposed to take the agenda to the private sector. All vertical (centre to state) programmes are now brought under a parallel system of societies – at state and district levels with separate fund flow. The village will have a Health and Sanitation Committee (VHSC) and a fund of Rs 10,000. The NRHM also mentions private sector regulation and health insurance in its guidelines. The entire mission has a provi-sion of Rs 12,000 crore in the 2008-09 national budget and more is expected each year till 2012, presumably to a level of about 2 per cent of the gross domestic product from the current level of 1.2 per cent. The NRHM has another 46 months to go and a lot of ground to cover. Decentralisation and FinancingHealth is a state subject. The central gov-ernment mainly provides the overall framework; plan funds and support for all national health programmes. Though flexibility is its keyword, the NRHM’s design and budgeting leaves little creative freedom for states. The states have their own problems of rural health services and need special political will and strategies. The utilisation of NRHM funds in states is both tardy and ineffective. Many schemes
COMMENTARY

are not understood properly even in the third year of NRHM. Vernacular versions of state/district plans are still non-existent. Bureaucrats have bypassed technical heads as mission directors, ostensibly in order to hasten the mission implementation. NRHM is also yet to catch the attention of the political community.

The NrHM provides for fund allocations and powers to states and district societies. The VHSCs get Rs 10,000 as untied funds, and this account is jointly operated by the sarpanch and ASHA or anganwadi w orkers. The district health action plans were often “a fill in the blanks” for some local officer or consultant. There was and is no scope for innovation, local resource use or l ateral thinking. The district elected representatives have very little knowledge of the NRHM. Hence there is little scope for imagination and creativity for the stakeholders. In the light of the 73rd amendment, NRHM could have encouraged gram panchayats to create their own health stations with these funds, with a well-trained ASHA to help. After all, what most village people need and want is medical aid. “Communitisation” mainly implies control of health centres by the panchayats and other stakeholders through the Rogi Kalyan Samitis (RKS) and VHSCs. But the RKS rarely meet as revenue officials have little time for it. The VHSC exists more often as a bank account. Involvement of the panchayati raj institutions is essential, but only a few states have ensured that they have been given orientation on the NrHM (perhaps television c ampaigns would have served well).

The NRHM’s financing model – fund flow from the centre to the state and then to district societies – was to provide flexibi lity to the mission. But since the mission is treated as being outside the treasury system and therefore not subject to internal audit by the respective departments of the state, has only resulted in a situation where corruption and financial scandals rule the roost. This red-tapism is a legacy of other programmes on reproductive child health (the old family planning programme), national AIDS control programme and health system development projects which were possible due to donors and organisations such as the World Bank. In essence, such unaccountability has resulted in the spawning of g overnment authorised non-governmental organisations (NGOs), myriad NGOs, contractors, subcontractors, etc. The financial model of NrHM owes an explanation, for it has to be accountable to the public who finance it through the tax system. Such unaccountability in the NrHM is a threat to the already dilapidated state of the overall health s ystem and its financing.

Improving Human Resources

The insitution of the Indian Public Health Standard (IPHS) is a good idea (akin to the International Organisation for Standardisation). IPHS lists physical and human resources requirements. However even after three years very few hospitals fall under the purview of IPHS. The causes are macro and water

economic (powerscarcity) and systemic – paucity of d octors and nurses and ubiquitous g overnance problems.

Doctors abhor rural centres because of poor infrastructure and working conditions; apart from the universal attraction of the cities. The salaries are poor (Rs 12,000-18,000 per month) and the lack of work-satisfaction is a genuine problem. In most states, appointments are mostly contractual and money is demanded at all levels. The annual salary given to doctors is so low that this acts as a deterrent to the commitment of the doctors. The idea of compulsory postings before postgraduation is not likely to improve matters. Many doctors attend rural offices only for a few hours and commute back to cities. Not ensuring a right skill mix of doctors (for example, the presence of anesthetists along with surgeons, etc) at every rural hospital is another reason for the mismanagement of rural health centres. The lack of a good and transparent human resources policy encourages corruption and discourages good work. The shortage of nurses is due to a thoughtless human resources management policy of the Nursing Council, and hence only 30 per cent nurses’ positions are filled and that too with great difficulty. On the other hand, the idea of posting another auxiliary nurse-midwife (ANM) at sub-centres (a cluster of 5-10 villages) does not address the basic gaps in provisions at the village level facilities. The resources (Rs 5,000 per month for the ANMs) could have been b etter used for improving the ASHA programme in the cluster of 6-10 villages.

The institutional obsession of NRHM will discourage the ASHA, ANM and the multipurpose health workers (MPhWs) from extending any primary medical care to locals. The dai system is a major casualty of NRHM, depriving people from

september 13, 2008 EPW Economic & Political Weekly

COMMENTARYEconomic & Political Weekly EPW september 13, 200825remote villages, the only help in times of difficulty. Instead the NRHM could have offered graded care involving dais for perinatal care, occasional home delivery and as a JSY escort. This would have won community acceptance. TheASHA is any-way only escorting the expectant mother to a hospital. A major folly of NRHM is to completely bypass the MPhW system, which has fought major public health bat-tles against diseases such as small pox, cholera, malaria, leprosy and now tuber-culosis. TheNRHM could have encouraged MPhW to combat the new infections and chronic diseases like hypertension and diabetes. This deliberate neglect of the base of the human resources pyramid questions the very wisdom of the struc-ture and objectives of the NRHM. The NRHM is targeting only women as workers part of the mission and bypasses men MPhW, in a way eliminating the role of men in health work actions.The ASHA SchemeThe ASHA scheme, after the deplorable withdrawal of the 1978 community health worker (CHW) programme, could have been better planned. The programme (a male and female community health worker in each village) was hacked to death by uncaring bureaucrats and the apathetic Congress regime in the mid-1980s. The eight tasks of the health activist in theASHA scheme are only for namesake, the main being taking “delivery cases” to the rural hospitals and gathering children for pulse polio and other immunisations. This is ostensibly to raise the “demand” of health services among “clients” who otherwise either prefer home delivery or go to any nearby private doctor. To waste a potent pro-gramme like ASHA for merely escorting women to unwilling hospitals is a ques-tionable strategy. The average ASHA is hardly getting the promised Rs 1,400 per month. I found in my recent visit to Uttar Pradesh that the average monthly earning of ASHAs is just Rs 250. They are going through untold hassles at every level, more so in the north- eastern states. Training is poor, barely halfway and accreditation is yet to even begin. Drug kits are either not supplied or not refilled. The drug kit consists of just four medicines (iron tablets, chloroquine, paracetamol and oral rehydration therapy (ORT) packet for diarrhoea). Ayurveda and homeopathy remedies have not arrived. Thus the small kit is only to prevent the criticism thatASHAs are mere lackeys in the system. Denying ASHA a meaningful curative role ignores the fact that there exists a basic gap in our public health sys-tem. ASHAs are supposed to be activists but in reality,ASHAs are not equipped to undertake their complex social roles in rural areas. The NRHM has cleverly used this angle for making the ASHA a dispen-sable item. Inter-sectoral CoordinationCoordination and cooperation with the water and sanitation sections of the rural development department and with the Integrated Child Development Services (ICDS) (department of women and child) are much needed for the NRHM’s success-ful implementation. Yet, sanitation work is still in the “pits” in most states, as sto-ries of coercion for installation of toilets abound rather than persuasion and education, to quote one example. Anganwadi workers look at the ASHA as some kind of an adversary in the same field of work. This is because of the fact that such workers get a salary of Rs 1,400 per month while ASHAs have the opportu-nity to earn Rs 700 in one instance of work done. The anganwadi worker also has the herculean task of combating malnutrition and other socio-economic adversities. Lots of potential exist in the prospect of integrating the ayurveda, yoga, unani, siddha and homeopathy sector (the AYUSH sector) in some spaces of the NrHM, but such a presence is quite lacking. The AYUSH medicine, equipment and know-ledge base is inadequate in the ASHAs’ kit and capabilities. As regards, coordination with the pri-vate sector, a proper form of it is not pos-sible unless there is a concrete PPP policy and strategy for providing a guarantee for universal health coverage. The NrHM is relying upon the private medical sector only for JSY maternity services. Gujarat, for example, has used this scheme fully through the Chiranjeevi Yojna, albeit at the cost of public hospitals. Public hospi-tals have started losing clients and government doctors have resented their counterparts in the private business of health. Also, the business of clandestine referrals from public to private sector was already on, the JSY has only formalised it. On the whole, good inter-sectoral business is still missing inNRHM.ConclusionsThe three years of NRHM have made only marginal impact on the health system; apart from some rise in institutional deliv-eries. TheASHA can be a positive feature of NRHM but it remains weak in training, accreditation, drug kit/refill, payment. This reduces the activist (envisaged to be a committed worker) into a lackey of the system.NRHM is using the system of pro-viding incentives for institutional births (and family planning). This is neither sus-tainable nor wholesome. Home births will still be around for some time, and not sup-porting dais is bound to hurt those home births seriously.The IPHS may be confined to some repair and equipment, but with non- participation of doctors and paucity of nurses these tangentialIPHS decorations will erode. We need better working and service conditions for doctors and nurses rather than coercive laws. TheNRHM-ICDS integration is in jeopardy, due to the very JSY wedge. The private sector has a 70 per cent share in healthcare but is largely bypassed inNRHM, leading to no great progress in the integration of the health sector. Involvement of the private sector with a well thought-out long-term plan for integration of the two sectors through reg-ulation is necessary.PPPs are a pragmatic need but this has happened only in the “creamy” layers and not much in delivery of services save perhaps the Marigold ini-tiative inUP. The RKs are also functioning poorly. Community monitoring of NRHM is limited to some NGOs. Monitoring itself is weak. Transparency and public report-ing are scant, especially in the vernacular press. However, the advertisements on TVhave certainly helped spread the word on NRHM.States (and hence panchayati raj insti-tutions) deserved more creative freedom for their perceived needs. IsNRHM’s dimin-ishing the role of states in healthcare by
COMMENTARYseptember 13, 2008 EPW Economic & Political Weekly26pushing centrally fabricated schemes? There is a serious mismatch between the local needs andNRHM prescriptions. States have however not graduated to raise such a question even in the sixth dec-ade of independence. Use of funds at state and district levels is either tardy in many states or hasty in some states like Madhya Pradesh. Audit reports are not made public, as is expected of NRHM. The untied fund is verily a prob-lem rather than a solution. The donor dominance has damaged the cause of the National Mission. Unfortunately now more donors are at play, like the case of the Norway-India project (for the Home-Based Neonatal Care) worth $80 million in a nearly opposite direction of the JSY driven institutionalisation. Thus issues concerning the infant mortality rate and maternal mortality rate will now be dis-creetly pursued by donors. The donors can redesign our programmes upside down. This sad legacy continues from the days when the family planning department started dominating the health ministry. India’s health performance is rather low because of weak fundamentals like nutri-tion, sanitation, hygiene, gender inequal-ity, and helpless urban migration. The widening India-Bharat divide has wors-ened these factors. In addition we have severe mal-distribution of health services – both public and private. The Indian healthcare system has become an inverse pyramid with very little primary care as foundation and ever-ballooning “medical” sector through a hospital-doctor-centric and urban model which is largely privatised, unregulated and western- oriented. The rights approach of NRHM may unwittingly come in handy for pro-moting the health institutional sector. But canNRHM help? The NRHM has however turned out to be an antithesis of primary healthcare – which was supposed to be essential, acceptable, accessible, afforda-ble, participatory and appropriate health-care for all. NRHM may prove to be a costly and irrational donor tonic for the sick health system of India. We can ill-afford theNRHM in its present structure and as it is implemented today. There is need to pause and rethink.Neetha N (neetha@cwds.ac.in) is with the Centre for Women’s Development Studies, New Delhi.Regulating Domestic WorkNeetha NDomestic work is next only to education in its share of total female employment in the service sector. Except for piecemeal measures in a few states, there is no legislation to protect this vulnerable workforce or monitor the increasing number of agencies supplying domestic workers who are mostly recruited from the tribal pockets of underdeveloped states. The number of female domestic workers in cities across India has been increasing rapidly since 1999. Yet, domestic workers occupy little or no place in most of the contemporary dis-course on economic development. Domes-tic workers do not have the required collectivities or associations or popular spokespersons to voice their concerns. Thisisnotto claim that domestic workers asacategory is completely ignored in public discourse. It does figure in academic circles sporadically as a growing category of female employment, and their refer-ence in intervention programmes is largely limited to their status as migrant workers.1 However, they are largely absent from state policy – be it labour laws or social policy. Thanks to collective struggles, some interventions have come through in a few states. In Karnataka, Maharashtra and Rajasthan domestic work is now included under the minimum wages notification. In Tamil Nadu, domestic work is added to the scheduled list under the Manual Workers Act (Regulation and Employment and Conditions of Work Act), 1982. However, even in Karnataka, which is the first state to fix minimum wages for domestic workers and has a strong organisational backing of domestic workers, the legisla-tive benefits are yet to reach a large chunk of workers. The politics at work is evident in its removal from the scheduled list in 1993 (after a year of its inclusion) till 2004, when it finally reappeared in the schedule. Apart from these sporadic interventions, national level interventions are yet to begin in this sector. Size, Growth and CharacteristicsThe importance of the sector in our economy can be gauged from a careful analysis of its size and growth. Private households with employed persons who are largely domestic workers are next to only educa-tion in terms of the share in female employ-ment in the service sector. The percentage of domestic workers in total female employment in the service sector increased from 11.8 per cent in 1999-2000 to 27.1 per cent in 2004-05, with a phenomenal increase in the number of workers by about 2.25 million in a short span of five years.The data shows a feminisation of the service with the share of female workers increasing sharply over the period [Neetha 2007].Domestic work in itself has undergone tremendous changes. Domestic workers used to be attached to one single house-hold and undertook one or more work such as cleaning or cooking. In the modern system of domestic work, this has changed and a large number of workers undertake

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