Health out of reach

The book highlights the challenges faced by users of the NRHM as well as those offering the delivery systems under the mission.

IN 2005, the United Progressive Alliance (UPA) launched its flagship programme for health for the rural poor promising, among other things, a complete architectural overhaul of the system. This was the National Rural Health Mission (NRHM). Seven years later, the government, in a different coalition avatar, UPA-II, has declared its intention to provide universal health care.

There are several studies, including the government's own Common Review Missions, that have reviewed the functioning and efficacy of the NRHM. The collection under review, brought out by the Centre for Health and Social Justice, though a little dated, is still relevant. For instance, female sterilisation, the book says, remains the most common form of birth control in India. The current situation is no different.

There are 12 studies in this collection, each involving districtwise studies in different States. They reflect the micro realities and throw up stories from villages, blocks and health facilities across nine States. The report looks at services and initiatives under the NRHM, bringing to the fore issues of access and delivery and the challenges faced by the users as well as those offering the delivery systems.

As the NRHM itself was tilted heavily towards maternal and child health, six of the 12 papers focus on maternal health. Three papers look at the readiness of the health services.

Health experts have often debated the obsession with institutional deliveries and whether this fetish has endangered women's lives in the process. The first chapter of the book under review evaluates the Janani Suraksha Yojana's (JSY) role in encouraging institutional delivery. It looks at Una district in Himachal Pradesh. The district overall has a high degree of literacy, but apparently this has not translated into entitlements and change. The survey, based on the experiences of 291 women, revealed that the majority of those belonging to labourer families preferred delivery at home as they expected higher costs at institutions. Now under the JSY a woman is entitled to a monetary incentive for delivery at an institution. However, not only were the women treated with disdain at government health institutions, but they also felt they were spending more. These negative experiences made many women prefer private health institutions. At the time of the study, there was confusion about the role of accredited social health activists (ASHAs).

Chapter 2 deals with the quality of women's sterilisation in five States and analyses the findings in the light of the Supreme Court guidelines regarding sterilisation operations ( Ramakant Rai & Anr vs Union of India & Ors). The survey did not find evidence of coercion or physical abuse but found gaps in the implementation of quality standards, in the monitoring mechanism, and in infrastructure and supplies, too. Crucial areas of quality care, such as counselling, pre-operative screening and post-operative procedures, continued to be ignored. There were reportedly many cases of complications. More than half of the women interviewed revealed that they had had some adverse outcome and a quarter of them had had to seek medical help for complications.

The third chapter deals with the issue of children identified with acute flaccid paralysis caused by poliomyelitis. At the time of compiling the papers, the government had not made the claim that it had eradicated polio. Now it claims that India has been polio-free for the past one year. The last polio case was detected in Howrah district in West Bengal on January 13, 2011, and the World Health Organisation has removed India from the list of countries with active endemic wild polio transmission. The paper argues that while the pulse polio programme is the largest public health programme in India, issues of aftercare are not addressed adequately. The importance of physiotherapy as a key part of the treatment for polio is not adequately stressed. There is a general need to improve people's living conditions, including the availability of nutritional supplements for the patient as long as paralysis persists. Even now, the emphasis in the government's response is more to do with the idea of eradicating the virus and less with the post-prophylactic aspects of the disease.

The next four chapters concentrate on the capacities of service delivery systems such as the community health centres (CHC) and the ASHAs, the adequacy of private-public partnerships (PPPs), staffing and service guarantees, and the preparedness levels of CHCs as first referral units. What these chapters seem to suggest is that the workforce of specialists needs to be increased manifold and that PPP cannot be a substitute for building the capacity of government staff and recruitment of full-time specialists.

The provision of free emergency and obstetric care services in public facilities is crucial, and the guidelines for implementing the PPP initiative in the JSY should be inclusive, allowing access to the maximum number of women who face the risk of maternal death. Although slightly wary of the PPP model, the authors seem to suggest that this may be a necessary evil given the lack of public health facilities. Therefore, in one of the chapters, they suggest that the government needs to ensure that the partnership brings private investment into the public health system. Further research, advocate the authors, is needed to assess the effect of PPPs in reducing the risk of maternal death.

Staffing shortage

A micro-level study of Ganjam district in Odisha showed that the overall health staffing for ensuring service guarantees for maternal and child health according to the NRHM framework was inadequate. In fact, the study says that in India the staffing requirements vary widely from one health facility to another. For various reasons, doctors and other health personnel live in the district headquarters or cities, while more than 70 per cent of the population lives in rural areas. The shortfall of specialists and other staff continues to be a festering problem, and one manifestation of this is the overcrowding of public hospitals in the metros and other cities. The study is also critical of the ASHAs, the implementing channel of the NRHM. The ASHAs were found to be struggling to establish their identity both within the community where they lived and among the formal service providers whom they assisted in providing statutory health services. The situation of the ASHAs has not changed much, with the government refusing to give them the status and recognition of regular workers. In fact, the conflict between them and the other regular staff continues in various forms. The study observes that joint training and collaborative planning of all the front-line workers are essential. Compensation issues and the reimbursement-driven system also need looking into, it says.

Reducing child and maternal mortality by two-thirds and three-quarters respectively is among the eight international Millennium Development Goals to be achieved by India by 2015. As per the latest figures given in the form of a reply in Parliament on March 13, 2012, the under-five mortality rate in India was 64 per 1,000 live births in 2009 and the maternal mortality rate for the same period stood at 212 per one lakh live births. The study under review was published in 2009 and a micro study of five districts in Uttar Pradesh on the preparedness of the health system to tackle maternal mortality showed that the health system lagged at all the essential levels of infrastructure, supply, performance and human resources. The responsiveness of the health system (through its providers), say the authors, to poor women users is a determinant in addressing the readiness of the system to improve maternal care. The public health system, despite the NRHM's focus on improving maternal health through the promotion of institutional delivery and strengthening infrastructure since 2005, needs far more strengthening to deal with maternal mortality. The study found it difficult to identify health facility staff who were motivated, knowledgeable and capable of bringing about improvements.

The last three chapters look at the efficacy of community monitoring in the delivery of maternal health services, the efficacy of the Sahiyya, the counterpart of the ASHA in Jharkhand, and the role of the JSY in institutional delivery in one district of Manipur. The 12 papers and the micro studies give some insight into the problems of the NRHM. The questionnaires developed by the researchers in the studies throw light on a wide range of aspects, including the supply-and-demand issues of basic health services.

The studies seem to emphasise that there is no substitute for a robust public health delivery system and that the lack of well-trained professional maternal and child health delivery personnel willing to work in the poorest communities remains at the root of the slow rate of decline of both infant and maternal mortality rates. It was found that strong village health and sanitation committees were associated with better health delivery mechanisms, and while institutional deliveries were a welcome idea, it needed to be matched with a lot at the supply level in terms of health services. The government itself admits that the factors that are behind neonatal deaths include home delivery by unskilled persons, lack of essential newborn care for asphyxia and hypothermia, poor childcare practices, lack of early detection of sick newborns, inadequate and delayed referral mechanisms and, last but not the least, inadequate infrastructure at health care facilities for specialised care of sick newborns.

According to the Sample Registration System (2010) of the Registrar General of India's office, nearly 47 children for every 1,000 born die before their first birthday. This translates into 12.5 lakh children dying before their first birthday. The unreached continue to remain out of reach.