Gaps in a Mission

If the National Rural Health Mission aims to be a holistic scheme, it should have more clarity on the devolution of responsibilities and power and should concentrate more on qualitative health care, including the survival of the girl child.

in New Delhi

THE much-awaited National Rural Health Mission (NRHM) was launched on April 12, fulfilling a seven-year-old commitment for rural health care, which is also envisioned in the Common Minimum Programme (CMP) of the United Progressive Alliance (UPA) government. The seven-year period is inclusive of two years of the Tenth Plan and the entire term of the Eleventh Plan. Noble in intent and participative in character, the NRHM, as stated in the Preamble, has as its goal improving "the availability of and access to quality health care by people, especially for those residing in rural areas - the poor, women and children".

But what went largely unnoticed was the logo atop the mission document, which has two adults holding the hands of a child. From "Ham do, hamare do", the previous slogan of family planning that sold the idea of a small family, it now seems as if it is "Ham do, hamare ek". The child portrayed is a girl child - perhaps a reflection of the political correctness of the times. But the symbolism aside, the popularisation of the one-child norm is not what is required. If the idea of the logo was to point to the gender-sensitive approach of the Mission and to give an impetus to the fast-vanishing girl child, the document itself is woefully silent on the falling juvenile sex ratio. And the States with the worst distortions - where girls are far fewer than boys - are not even in the list of the initial 18 beneficiary-States of the NRHM. Among the 18 are the BIMARU States, which are also the Empowered Action Group (EAG) States, Uttaranchal, Chhattisgarh and Jharkhand.

It is also strange that the document, while reflecting on the condition of public health, states that population stabilisation is still a challenge, especially in States with weak demographic indicators. Incidentally, the CMP is committed strongly to population stabilisation. The EAG States are those with high fertility rates and weak socio-demographic indicators. The EAG was created in the Ministry of Health and Family Welfare (MoHFW) especially to ensure population stabilisation and intersectoral convergence.

One of the key objectives of National Population Policy (NPP) 2000 is the attainment of a Total Fertility Rate of 2.1 by 2010. The MoHFW's annual report for 2004-2005 notes: "It is felt that although progress in some States is satisfactory, poor performance in Bihar, U.P., M.P., Rajasthan and Orissa is proving to be a drag on national achievement. Therefore, unless urgent and focussed interventions are undertaken to address the issues of reproductive and child health care in these States, the attainment of the demographic goal set in the NPP 2000 seems unlikely. The three new States of Uttaranchal, Jharkhand and Chhattisgarh have been included in the EAG, both on account of unsatisfactory socio-demographic indicators and also to provide an impetus to the strengthening of the primary health care infrastructure, a prerequisite for efficient delivery of family welfare services."

The ultimate objective of the EAG concept, then, is not overall health care but demographic stabilisation. The understanding is that issues of reproductive health and child care have to be addressed not because they are rights but because they will lead to demographic stabilisation. There is a special fund called the Jansankhya Sthirata Kosh, the objective of which is to facilitate the attainment of the goals of NPP 2000. While all these may appear to be disparate entities, the connection between the EAG concept, the EAG States and their inclusion in the NRHM cannot be wished away entirely. The EAG concept was floated by the National Democratic Alliance (NDA) government but the fact that the UPA government has retained it indicates that despite some semantic changes the basic understanding remains the same. The paradigm shift, if any, intended by the use of grandiose phrases such as "architectural correction of the health system", in the NRHM document is meaningless if the basic intent is the same.

Initially, the objectives of the NRHM were approached with great trepidation, as some of the highly populous States in the Hindi belt (which came under the EAG category) were identified as the target-States. This had fuelled fears about a hidden fertility-control agenda. These fears were strengthened by the Mission's attempt to facilitate the unregulated entry of the private sector into rural health care and by the general lack of commitment to the creation and strengthening of public health infrastructure. As a result, a debate and a controversy ensued over the purpose of the Mission. It is now felt that although a considerable shift in both conceptual and material terms has taken place, some fundamental issues remain.

Evidently, a holistic approach to health care is lacking. More so when an important vision of the Mission is "an articulation of the commitment of the government to raise public spending on health from 0.9 per cent of the gross domestic product to 2-3 per cent of the GDP". So, is the Mission merely a scheme to reflect the enhanced allocation or is it meant to deliver qualitative changes in rural health care and question practices that militate against the health and survival of the girl child?

The Mission's key features include the provision of a health activist in each village; preparation of a village health plan by involving panchayat representatives; strengthening of the rural hospital for effective curative care, which is measured by the mechanism of Indian Public Health Standards and is accountable to the community; optimal utilisation of funds and infrastructure; and strengthening of the delivery of primary health care.

There are some areas of the Mission that may need more clarity, especially the role of the accredited social health activist (ASHA), who is considered the linchpin, and the devolution of powers at the panchayat level. The MoHFW, the nodal agency coordinating the Mission at the Centre, set up eight task groups to look into various aspects including strategies, health financing, strengthening of community health care, strengthening of public institutions for health delivery, regulation of health providers, reform in the area of public health management, role of panchayati raj institutions, and community action and the promotion of private-public partnership for public health goals. The task groups consisted of health professionals, public health experts and bureaucrats and were entrusted with finalising the concept and strategies of the Mission. The groups met on February 10 in a national consultation hosted by the Ministry and their recommendations were meant to improve the draft Mission document.

However, some of the fundamental recommendations of the groups are different from those in the Mission document. One of the prime actors in the Mission is the ASHA, the woman responsible for a variety of tasks, but she does not have a fixed remuneration. The group dealing with strengthening community health care recommended that there should be one ASHA for every 1,000 population; however, in tribal, hilly and desert areas, there should be one ASHA per habitation. She must be an "ever-married" woman volunteer in the 25-45 age group and from a disadvantaged group. Literacy as an eligibility criterion should not be a limiting condition.

But the Mission document is silent on these aspects. Neither does it specify the population covered by the ASHA. The ASHA will be an honorary volunteer; she would act as a bridge between the auxiliary nurse midwife (ANM) and the village and be accountable to the panchayat.

The task group had advised against performance-based incentives and instead recommended non-monetary incentives such as annual conventions. The Mission document is silent on this but reiterates that she will receive performance-based compensation for promoting universal immunisation, referral and escort services for RCH, construction of household toilets, and other health care delivery programmes.

There appears to be some ambivalence in the role and location of the ASHA. She is to act as a bridge between the ANM and the village and, at the same time, she is to be accountable to the panchayat. When the ANM herself is not accountable to the panchayat, but is under the control of the Health Department at the block and district levels, how is the ASHA supposed to do the balancing act between the ANM and the panchayat?

As the ASHA was entrusted with awareness generation and community mobilisation, the task group had recommended the simultaneous strengthening of health care delivery systems to meet the demand created by the ASHA. The task group on strengthening public institutions for health delivery and so on cautioned against the ASHA being treated as a government servant. She, it said, should be accountable to the gram sabha. A Gram Panchayat Standing Committee on Health should monitor her work and if she should be given monetary incentives, it should be through the gram panchayat alone.

ONE of the key strategies of the Mission is to operationalise the existing 3,222 community health centres (CHCs) as 24-hour first referral units with 30-50 beds and the posting of anaesthetists. A similar emphasis is lacking for the primary health centres (PHCs), which is where most people are first likely to go for treatment. The Mission has recommended 24-hour service in only 50 per cent of the PHCs by addressing the issue of shortage of doctors, especially in the high-focus States.

One of the task groups had recommended that the NRHM should provide the "maximum support to strengthen primary health centres so that these can provide quality, preventive and curative services... ." This implies adequate supplies of drugs and enough qualified manpower. It recommended that "if doctors are not available, they may be appointed on contract basis from private practitioners if properly certified by the Chief Medical Health Officer". It also strongly recommended that primary health care should be made available in urban areas so that the poor, whether living in slums or not, have access to such services on the model of Rural Health Infrastructure.

However, the Mission document does not reflect most of these concerns and is silent on health care for the urban poor.

A District Health Mission has been entrusted with the responsibility of preparation and implementation of an inter-sectoral District Health Plan for drinking water, sanitation and hygiene, and nutrition. While a horizontal integration of programmes is welcome, the concentration of responsibilities at the district level seems to undermine the Village Health Samitis of the panchayats, which are supposed to prepare health plans.

The Mission states clearly that the "district becomes the core unit of planning, budgeting and implementation". Also, it states that the District Health Mission would control, guide and manage all public health institutions in the district, sub-centres, PHCs and CHCs. Some task group members feel that decentralisation is only a theoretical notion and that there has to be more clarity on who will prepare the health plan of the village. Will it be done through a local team headed by the panchayat representative or by the panchayats themselves through the Village Health Samiti? What is also missing is clarity about roles and responsibilities.

Some task group members felt that since the community is to be involved, the panchayat should decide on the village health plan through its health committee - involving the ASHA, the ANM and other grassroots workers - and not the Health Department.

The question of funding is also vague, say some task group members. The Mission envisages an untied fund of Rs.10,000 per annum for each sub-centre. The fund will be deposited in a joint bank account of the ANM and the sarpanch and operated by the ANM - who is a government employee - in consultation with the Village Health Samiti. The question being asked is why the untied funds should not be given to the panchayat, which will then cause it to be spent through the sub-centre. The Mission, these task group members say, only pays lip service to decentralisation; the fineprint shows that the control is still with the health establishment.

Equally important are the concerns raised in some quarters over the basis for selecting a few States. Some task group members wonder why some States have been left out of the prioritised list of the NRHM. States such as Punjab, Haryana, Maharashtra, West Bengal, Tamil Nadu, Kerala, Andhra Pradesh and Karnataka have been left out of the prioritised list. At the same time, the NRHM is to cover the whole country, but financing seems to be on a lower level for these `second category' States.

The documents say that the prioritised States have "weak public health indicators" and that is why they have got higher importance in the Mission. States like Punjab and Haryana (besides Gujarat, Tamil Nadu and so on) suffer from severe gender imbalance in the child population, which, task force members say, is the definition of a "serious weakness". The child sex ratio has come down from 976 in 1961 to 927 in 2001. During the decade 1991-2001, a more than 50-point decline was observed in Punjab, Haryana, Chandigarh and Himachal Pradesh.

One of the stated goals of the Mission is to assure population stabilisation and gender and demographic balance. Then why have the States with definitely skewed child sex ratios been left out? It has been pointed out that these States should have been specially included at least for the purpose of restoring the gender balance, since this restoration is a stated goal of the NRHM. Most of the `second priority' States have shown greater fertility reduction than States in the `first priority' list. Therefore, in the absence of a cogent explanation, the fear that fertility reduction is the real and unstated motive behind the choice is bound to rise. In fact, it has been opined that the government ought to have a rethink on this and announce special programmes under the NRHM in favour of the girl child for the States that have been left out.

On the whole, there appears to be a perceptional shift. According to Nargis Mistry, joint-director and Trustee of the Pune-based Foundation for Research in Community Health, the "position had changed considerably since October 7" when the initial concept of the NRHM was made public. Non-governmental organisations (NGOs) will now play a leading role in selecting and training the ASHAs. They will be represented in State, district and block level societies. FRCH is one such organisation that will be training the ASHAs. In Nargis Mistry's opinion, the ASHA ought to be given a reasonable sum to support herself and her family and that she should not be made subservient to the ANM and the anganwadi worker. "If that happens, she will get reduced to the lowest rung of the health system, like the community health worker," she said. She added that while some centralisation was inevitable, more decentralisation had to be built in.

The goals are laudable, especially those relating to the reduction of infant mortality and maternal mortality. But this by itself will not take care of other maladies such as the pressing issue of the juvenile sex ratio (number of females in the 0-6 age group for every 1,000 males), especially in States not covered under the "high focus" category. A skewed child sex ratio also reflects the "health" of the nation. If the NRHM aims to be a holistic scheme, it should have more clarity on the devolution of responsibilities and power and should concentrate more on qualitative health care, including the survival of the girl child. To achieve this, it has to shift focus from the EAG States to the entire country.