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In Defence of the National Rural Health Mission

The National Rural Health Mission provides a large canvas and platform for health action, but Shyam Ashtekar (EPW, 13 September 2008) misses many issues and does not make his critique from the right perspective. During the short period of its existence there is ample evidence to show that the mission has been moving in the right direction, crafting a credible public system of health delivery starting from the village and going up to the district level.

DISCUSSIONapril 4, 2009 vol xliv no 14 EPW Economic & Political Weekly72In Defence of the National Rural Health MissionAmarjeet SinhaThe National Rural Health Mission provides a large canvas and platform for health action, but Shyam Ashtekar (EPW, 13 September 2008) misses many issues and does not make his critique from the right perspective. During the short period of its existence there is ample evidence to show that the mission has been moving in the right direction, crafting a credible public system of health delivery starting from the village and going up to the district level.Ihave carefully read Shyam Ashtekar’s article titled “The National Rural Health Mission: A Stocktaking” (EPW, 13 September 2008) and would like to sub-mit that the article misses many issues and does not seem to place them in the right perspective. This response is not meant so much to challenge the wisdom of Shyam Ashtekar. He has been guiding the National Rural Health Mission’s (NRHM) Accredited Social Health Activist (ASHA) mentoring group and the mission would like to place on record the learning from his insights. We value his views. As someone associated with the design and implementation of NRHM, I thought a few clarifications on some of the “perceptions” would be in or-der. The NRHM has deemed it fit to re-quest the most independent minded non-governmental organisations (NGOs) to create a framework for community moni-toring by organising public hearings and to help the mission in making public sys-tems accountable. The mission has noth-ing to hide and would like transparency and accountability to community organi-sations to be a part of all its activities.Home-grown IdeaThe assumption in the article is that the NRHM is driven by external funding agen-cies. He does not seem to be aware that theNRHM is entirely a home-grown idea which has developed with contributions from the best of public health and public administration experts. The prime minister launched the mission in April 2005 and a number of task forces went into develop-ing clear focus on a range of healthcare issues. These task forces had representa-tion of public health experts, civil society organisations, academics, etc. One of these task forces worked on developing the Framework for Implementation of the NRHM which was approved by the union cabinet in July 2006. The detailed framework is a very strong commitment towards crafting credible public systems byfollowing five key approaches, namely: (a) communitisation; (b) adequate and flexible financing; (c) monitoring against Indian Public Health Standards; (d) inno-vations in human resource management; and (e) building capacity at all levels for decentralised health action. The thrust of NRHM is public systems and its accessibili-ty, affordability and accountability. Unlike many other programmes in the health sec-tor in the past, the NRHM is about crafting a credible public system of health delivery at all levels starting from the village and going right up to the district level. All pro-grammes (except HIV/AIDS, cancer and mental health) were brought under the umbrella of the NRHM. Very categoricallyNRHM committed it-self to communitisation under the umbre-lla of panchayati raj institutions (PRIs). Ac-cordingly, Village Health and Sanitation Committees were to be set up, joint ac-counts of auxiliary nurse-midwife (ANM) and sarpanch were to be opened at the health sub-centre and block levels and dis-trict level health missions had to be consti-tuted involvingPRIs. Facility specificRogi Kalyan Samitis (patient welfare commit-tees) had to be established in primary health centres (PHCs), community health centres (CHCs), sub-district and district hospitals. The Village Health and Sanita-tion Committees and the thrust on organi-sing the Village Health and Nutrition Day every month at the village Integrated Child Development Services (ICDS) centre are intended to promote greater conver-gence among sectors that determine health outcomes like water, sanitation, education, health and nutrition. Initiatives in nutrition have been funded in West Bengal, Andhra Pradesh, Gujarat, Madhya Pradesh, Orissa, Bihar, etc. TheNRHM pro-vided the flexibility to the states to design their own interventions for outreach of services. From the gram panchayat head-quarter level clinics at sub-centres in West Bengal to the Muskaan programme at the ICDS centre in Bihar, the Mamta Abhiyaan in Gujarat, the boat clinics and mobile medical units in Assam, are an affirmation of flexibility available to the states. Amarjeet Sinha ( is a civil servant and is currently with the Min-istry of Health and Family Welfare, New Delhi.
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DISCUSSIONEconomic & Political Weekly EPW april 4, 2009 vol xliv no 1475after adequate training. States like Gujarat and now Orissa have recruited a large number of ayurveda doctors and propose to use them for the management of na-tional health programmes as well. It is only on account of the thrust to add resi-dent human resources that the number of 24 × 7 healthcare institutions has risen many times. The names of all such insti-tutions are being placed on the web site of the Ministry of Health and Family Welfare for anyone to visit the field and hold us responsible. The issue of salaries of doctors has been rightly raised in Ashtekar’s article. We would like to inform him thatNRHM pro-cesses have led to a demand for better service conditions in many states. New agreements have been concluded in Ker-ala and Orissa which provide better ser-vice condition for doctors. This has been on account of the pressure put byNRHM’s higher contractual salaries for doctors and specialists. TheNRHM has also encour-aged large-scale provision for difficult area allowances, tribal area allowances, PG allowances, etc. Evening out patient departments (OPDs) have been started in states like Assam and Kerala and doctors are compensated for this additional duty. Performance based payments have also been introduced in many states to ensure that the take home package of doctors and specialists are satisfactory. Many states have devised new ways of attracting doc-tors to rural areas by providing them an enabling environment to work in. There are still large governance issues which need to be resolved. TheNRHM, in part-nership with the states, is providing a plat-form which allows for it.Funds and AccountingIt is strange that Ashtekar identifies trans-fer of funds to the State Health Societies as not a very accountable system and largely driven by external agencies. He does not seem to realise that this has been resorted to as the transfer through treas-uries have in the past led to delayed and inadequate funds for activities. As some-body associated with the design of Sarva Shiksha Abhiyan (SSA) as well, the govern-ment first went in for the treasury route for the fund transfer to the states for the programme. It had to be given up within a year on account of delayed releases for the activities in the field. The State Health Societies are subject to the same set of audit and NRHM in fact provides for Comptroller and Auditor General’s (CAG) audit as well. Currently, the CAGs per-formance audit ofNRHM is also going on in all the states. The State Health Society route of funding has nothing to do with external agencies. Both theSSA and NRHM are completely home-grown and not influenced by external agencies, whose fear and apprehension seems to inform Ashtekar’s article. If the treasury system could ensure transfer of funds to each and every level of decentralised programme implementation in time, all state governments will be very happy to move to that account. The NRHM will be very happy to make that shift if it works effectively.Faulty AssumptionsAshtekar laments the decline of the dai system or its inadequate involvement under the NRHM. We would like to clarify thatNRHM allows for training and skill de-velopment of registered medical practi-tioners/traditional medical attendants/dais as well, wherever they have basic lit-eracy and are willing to do long-term pro-grammes that help them to improve their skills. This has been provided for in the framework for implementation and states are being encouraged to undertake this as well. The role conflicts of anganwadi workers, ASHAs and dais needs to be viewed differently as any change always leads to resistance. Ashtekar’s lament is that the male multi purpose worker (MPW) is not a part of NRHM. I would like to clarify that the male worker is very much a part ofNRHM. The states have to provide for a male worker and currently not even 50% of health sub-centres have a male worker. The govern-ment of India under NRHM has been putting pressure on state governments to fill up the existing vacancies of MPW(male) before they are entitled to the secondANM. This pressure is being put to ensure the availability of three persons at the sub-centre, namely, two ANMs and one male MPW. The intent of the mission is not to substitute and that is why existing posts of MPW (male) had to be filled up by state governments. If we wish to reach 2% to 3% gross domestic product public ex-penditure on health it cannot come by substitution; it will only come by supple-mentation. I am amazed how lack of facts and figures can at times lead to faulty conclusions.As has been mentioned earlier, the framework for implementation of the NRHM was approved only in July 2006. It provided a large canvas and platform for health action. It is not even two years since the framework for implementation of the NRHM was approved and during this period there is evidence from a large number of states of improved outpatient cases, insti-tutional deliveries, immunisation, drug availability, diagnostic service, ambulance services, etc. Public health is a marathon and not a sprint and Ashtekar will agree with us that it will take a little time. We are seeking partnerships with the NGO sector wherever required to build on the public sector health resources. These part-nerships are for a range of services from diagnostics to human resources to institu-tional deliveries, etc. We haveNGOs who have taken the responsibility of running PHCs in very remote tribal areas. We have a large number of innovations going around in the states, the details of which are all available on the web site of the Ministry of Health and Family Welfare. The thrust on human resources and the flexible financing is providing the rare opportunity to seek service deliveries at alllevels of the health system. We are confident that the health indicators of our country will not be the same if we contin-ue to relentlessly pursue the strategies that we have adopted in the NRHM in partnership with the states. The NRHM respects health as a state subject and pro-vides the states the opportunity to deter-mine their course of action. The large number of innovations reflects the con-fidence of the states in doing what is a priority. I only wish Ashtekar’s piece was better informed with facts and figures and had been based on a wider travel across the country to see what is happening in the field. We accept all his criticism in humility. We would like to assure readers that three years later he will realise that his assessments were far from the real picture.

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