Health check

The second National Health Assembly, in Bhopal, criticises the NRHM and the government's health care priorities.

T.K. RAJALAKSHMI in Bhopal

SEVEN years after people's health organisations in India met in Kolkata to constitute formally the first National Health Assembly (NHA) and the subsequent meeting in Savar, Bangladesh, launched the global People's Health Movement (PHM), the increasing realisation is that health care has become more iniquitous than ever.

From March 23 to 25, health activists from India and several other countries congregated in Bhopal to assess and defend people's right to health in an era of globalisation. The Second National Health Assembly (NHA 2) deliberated on, among other issues, primary health care, rural and urban health care, violence against women and children, and the effects of military conflict on health facilities in Iraq and Palestine. The National Rural Health Mission (NRHM) came in for particular scrutiny, as did the limited impact of vertical programmes such as the polio eradication programme.

The meeting, which devised an alternative health plan, assumed more relevance in the context of the transition, at least conceptually, from vertical health programmes to a more horizontal approach under the United Progressive Alliance (UPA) government at the Centre. Even this conceptual shift, as the Bhopal meet discovered, was superficial at best; things on the ground were far worse.

Shakuntala, a health activist with Healthwatch Forum, Uttar Pradesh, and one of the participants at the NHA 2, said: "On March 10, Susheela, wife of Achelal, a Dalit, gave birth to a child at the Atrolia Community Health Centre [CHC] in Azamgarh, Uttar Pradesh. She paid Rs.500 for the service rendered despite being entitled to the Janani Suraksha Yojana." In Azamgarh district, Accredited Social Health Activists (ASHAs) were geared towards meeting sterilisation targets, she added.

The Jan Swasthya Abhiyan (JSA), a coalition of more than 20 networks which included some 1,000 organisations and a number of health activists, spearheads the PHM in India. It critiques health policies, raises these issues with the government and even influences policy directly to an extent. One of its main demands is the strengthening and expansion of the public health system. In fact, the collective effect of the JSA is evident in the formulation of the NRHM's policy document.

The People's Health Charter adopted in Savar had, in the spirit of the Alma Ata Declaration of 1978, declared that health was a justiciable right. "The existing gross inequality in the health status of the people, particularly between developed and developing countries as well as within countries, is politically, socially and economically unacceptable and is, therefore, of common concern to all countries," the Alma Ata Declaration had stated. In contrast, the United Nations' Millennium Development Goals talk about the halving of the proportion of people earning less than $1 a day between 1990 and 2015; the eradication of iniquities was no longer a priority.

In the changed context, globalisation with a human face was the new mantra for the PHM. Between 1978 and now, despite the rhetoric, little had changed and it was time for some stocktaking and the NRHM was quickly in focus.

The purpose of the NRHM was to, among other things, strengthen the primary health centres (PHCs) and sub-centres and create a network of rural hospitals. However, it was felt that several developments since the launch of the NRHM in April 2005 (for a period of seven years) point to increased privatisation of health care services. For instance, in several States the NRHM, under the garb of better health management, opened up space to outsourcing and privatisation of PHCs and sub-centres. The JSA believes that a serious engagement with the private sector in delivering health care services is needed, but not by compromising the public provisioning for health care.

The NRHM was criticised for adopting a system of Indian Public Health Standards, which was seen as having severe limitations. While it defined the minimum manpower requirement and the equipment and infrastructure needed to attain a set of well-defined health outcomes, the attempts to achieve these were not comprehensive in scope and were biased largely towards reproductive and child health (RCH). The IPHS was adopted for CHCs, PHCs and district hospitals as well. However, the emphasis was still on purchasing equipment and attaining standards of infrastructure development rather than raising the level of overall service provision.

The policy, in some States, of allowing public participation in the monitoring and administration of health care services also backfired. The Rogi Kalyan Samitis that were started with the intent of greater public participation in the health care system degenerated into a system of cost recovery with the introduction of user fees for many services in government hospitals. Donor agencies pushed for the user-fee system and this resulted in a reduction of state investment in the maintenance of health care facilities.

Public participation, said the JSA's alternative plan document, had been trivialised: it translated into better access for the privileged and the politically powerful. In Andhra Pradesh the system was given up following public pressure and electoral compulsions.

The NHA 2 drew the attention of policy-makers to urban health care, which, it said, showed worrisome trends. Urban health statistics revealed that in many States the key indicators, such as urban infant mortality rate (IMR), had remained stagnant or their trend had even reversed. The specific vulnerability of urban slumdwellers - the lack of basic amenities and health services for them - was an area yet to be addressed.

The NRHM, said the JSA plan document, was formally empowered to cover urban slums, but in reality the coverage was negligible. Interestingly, whatever urban component was there in health care, it was in the RCH plans, albeit in a limited manner. There was no equivalent plan to set up PHCs, CHCs or sub-centres in urban areas.

But the greatest disappointment was with the ASHA plan, conceived as the linchpin of the NRHM. While the concept of a community health worker for every village was a welcome one, the de-emphasising of the worker's curative and symptomatic roles, and the piece-rate system of payment were controversial elements.

The JSA's experience was that while the strategy of deploying ASHAs was plausible, what had not been anticipated was the inability of the existing departmental structures to implement such a large-scale mobilisation and the absence of support structures. Early reports suggested that the implementation of the ASHA plan was poor and the threat of this approach being discredited was real.

"We have one of the most privatised health systems in the world. Nearly 40 per cent of Indians who get hospitalised are forced to borrow money or sell assets to cover health expenses," said Joe Verghese of the Christian Medical Association of India. He said the failure of "India Shining" perhaps forced those who believed in the inevitability of privatisation and globalisation to design pro-poor policies. The NRHM, then, was a compulsion to show the pro-poor face of the new government. Even so, the shift in the approach was welcome.

Last year, the JSA initiated a people's rural health watch survey, which included interviews with 250 ASHAs, in around 80 districts. The preliminary findings revealed that most of the ASHAs had yet to start work; the Anganwadi worker (AWW) or the Auxilliary Nurse Midwife (ANM) allocated them work. Under the NRHM, the ASHA was required to be accountable to the community and not subservient to the ANM or the AWW.

Besides, Dalit health activists were discriminated against. In Madhya Pradesh, nearly 50 per cent of the PHCs surveyed were being managed by non-medical staff, in Bihar 30 per cent, in Rajasthan 25 per cent and in Jharkhand 12 per cent. The main problems plaguing PHCs related to improper drug supply and shortage of staff.

In Chhattisgarh, Sulakshana, a health worker, and her team conducted the survey in 12 of the 16 districts. The Salwa Judum operations in the naxalite-affected parts had forced people into camps, where high child malnutrition was prevalent. She said the situation was worse in some 500 villages that had refused to join the Salwa Judum. The government had withdrawn all health facilities from these villages, she said. There was gross underestimation of the degree of child malnutrition in the State, she added.

Another area that the JSA was concerned about was the much-touted notion of private-public partnership in health care. In many of the States, the PHCs and even some of the CHCs had been contracted out to non-governmental organisations under the "managed care approach". This system, which is in vogue in Bihar, Karnataka and Arunachal Pradesh, entailed the offering of a specified package of services. There is no notion of decentralisation and community management.

In Gujarat, under the Chiranjeevi Programme private clinics are reimbursed at fixed rates for institutional deliveries and emergency obstetric care services. The government has also contracted out peripheral health facilities and has a proposal to contract out district hospitals to corporate players. Some of the private health insurance schemes supported by State governments had failed.

However, in some States, such as Tamil Nadu and West Bengal, the partnership was working well. The core of the public health system stayed within the public domain and only some of the ancillary services were contracted out.

According to the JSA plan document, what was needed urgently was a vast network of government-run health sub-centres and PHCs supported by CHCs and district hospitals, a large community-health-worker force, the expansion of nursing staff and the upgrading of their skills.

However, the notion of primary health care continues to be limited in that it is applied to RCH and a few disease control programmes. There is still a great reluctance to move towards the goal of "comprehensive" primary health care, says T. Sundararaman, one of the key drafters of the alternative plan. Even urban health services, apart from being inadequate, were, by and large, confined to providing selective and/or RCH services only.

Another area that the present health policy is silent on is the need to set up a rational drug policy, according to the JSA document. All national health policy documents, including the NRHM, had glossed over this aspect despite the fact that nearly two-thirds of all health costs go into drugs. The document laments that while there were regulatory controls for telecom, electricity rates, insurance premiums and even trading of shares, there was no regulation of the prices of essential drugs, whose list had been brought down to 30 in 2002 from 347 in 1977.

Deep concern was also expressed over the skewed priorities given to two vaccination initiatives - pulse polio and universal Hepatitis B vaccination. The JSA argued that more than Rs.1,000 crore was spent annually on the pulse polio programme alone for the eradication of polio, while the budget for other vaccines in the National Immunisation Programme in 2005-06 was only Rs.327 crore.

There was a need, said Anant Phadke of Sathi-Cehat, a Pune-based NGO, to revert to the polio control strategy, because of the neglect of other health programmes, including routine immunisation, and a huge rise in the number of cases of Acute Flaccid Paralysis, including Vaccine Associated Paralytic Polio. Similarly, the proposed universal vaccination programme for Hepatitis B lacked scientific evidence, as the carrier rate in India was less than 2 per cent. Therefore, as in the United Kingdom, Japan and the Netherlands, only a "selective" programme of vaccinating newborns was justified, the JSA said.

The objectives of any health policy have to be seen in the light of the Alma Ata declaration, where health was not just a desired goal but one of the main harbingers of equity in society. The UPA government's intent in bringing changes to the health care system may be good but their implementation seems to be directed by donor-dictated priorities.

In such a scenario, the NHA and its constituents can be expected to play a major role in making the goal of `health for all' an attainable reality.