While the National Rural Health Mission appears to be based on a lofty concept note, women's organisations and health workers are concerned that it is a disguised attempt at population control.
THE worst fears of women's organisations and health groups may have just come true. Their persistent efforts to convey to the government that any attempt at inducing population control in a situation where there is an imbalance in the child sex ratio have failed. Instead of heeding the counsel of people who work among the poor, the Ministry of Health and Family Welfare is seriously contemplating a National Rural Health Mission with its focus on population control. On January 4, the Union Cabinet approved the launch of the Mission, which would become operational in April, with the objective of strengthening infrastructure and providing comprehensive integrated primary health care.
While the Ministry had earlier clarified that the Mission would be a "National Rural Health Mission", it is now clear that it will be confined to the high-fertility States, including the eight Empowered Action Group (EAG) States (Bihar, Jharkhand, Uttar Pradesh, Uttaranchal, Madhya Pradesh, Chhattisgarh, Orissa and Rajasthan) and the eight northeastern States, besides Jammu and Kashmir. And therein lies the ambiguity. It has not been clarified that these States have been selected in view of their weak social indices and not just their fertility patterns. The child sex ratio is expected to worsen (a term used to describe this crisis is the masculinisation of the sex ratio at birth). Also the rationale of selecting States where the social indicators of development are abysmally low is incomprehensible. In fact, neonatal mortality in the majority of the EAG States is higher (save for Bihar) than the national average of 40 deaths per 1,000 births and any decline recorded between 1999 and 2001 - the years for which the latest figures are available - has been negligible.
On December 17, when Union Minister of State for Health P. Lakshmi was asked in the Rajya Sabha to provide details on the government's programme for population control, which is included in the United Progressive Alliance government's National Common Minimum Programme, she said that the CMP aimed at promoting population stabilisation, focussing on the high-fertility States by strengthening primary health care. She said the Ministry had conceptualised the strategy of the Health Mission to cover the entire country with specific focus on 17 States for comprehensive integrated primary health services. She informed the House that the proposal was "under the consideration of the government". As for population stabilisation, the Minister replied that the government was already implementing the Reproductive and Child Health (RCH) Programme, by simultaneously addressing the issues of contraception and the Maternal and Child Health (MCH) Programme. The stress was on sustained behavioural change, communication and improved access to quality family planning services, especially in the high-fertility States.
Evidently, the only thing that was clear in the Minister's reply was access to family planning services. In fact, all the replies of the Minister with regard to the promotion of the small family norm referred to the Health Mission. She clarified that the government did not advocate incentives/disincentives for the promotion of the small family norm. The Mission envisages the strengthening of the Community Health Centre/Primary Health Centre (CHC/PHC) as a full-fledged first referral unit for assured quality health care for a population of one lakh and above, by upgrading the existing facilities. But the central figure in the Mission is the accredited social health activist, or ASHA. Each village would have one such activist and in the next four years four lakh such workers, preferably women with a pass in Class X, would be trained. The health activist would be "permitted to practise and realise fees for services provided like any social entrepreneur".
THE Mission will involve the merger of funds and personnel of the Departments of Health and Family Welfare and the rationalisation of the two departments into a single integrated unit that will implement the health and family welfare programmes. The Mission was conceptualised by the Department of Family Welfare and not the Department of Health (until recently both departments had different Secretaries, but now P.K. Hota, Secretary, Department of Family Welfare, heads both Departments). Therefore, the suspicion that infrastructure creation and access to services will be primarily for family planning is not unfounded.
On December 22, the Minister once again informed the House that the Mission was being proposed with special focus on 17 States, which included the northeastern States and Jammu and Kashmir. The criterion for selection was their weak socio-demographic indices and/or weak health infrastructure. The word high fertility was missing. And the Mission was now supposed to have been conceptualised by the Ministry of Health and Family Welfare and not the Department of Family Welfare as stated on December 17.
These concerns were highlighted by a delegation of women's organisations and health professionals before the Prime Minister on December 23. The delegation, which included representatives of the All India Democratic Women's Association, the Centre for Women's Development Studies, the Action India, the Delhi Science Forum, the Jan Swasthya Abhiyan (JSA), the National Federation of Indian Women, the Joint Women's Programme, the India Alliance for Child Rights, Jagori, and the Medico Friends Circle, submitted a memorandum to the Prime Minister requesting a public debate on the proposed Mission, which it stated was a disguised attempt at population control.
The memorandum pointed out that planners ought to be more worried about the sharp deceleration in the rate of decline of the Infant Mortality Rate and Under 5 Mortality rate in the 1990s, as compared to the 1980s. The latest National Family Health Survey (NFHS) reports too showed that the Maternal Mortality Rate had increased from 424 to 540 maternal deaths per one lakh live births. The memorandum stated: "Women's organisations and their expert allies in various professions - demographers, doctors who still uphold their ethics, bio-scientists and social scientists, plus a small but committed group of civil servants with field experiences - have opposed every move to push through a top down hard line, population control policy/programme - under whatever disguised names they are touted - population stabilisation or Rural Health Mission or Tribal Health Project."
While there has been no public denial of the main features of the Mission as stated by the Minister in the House, it became evident that the public outcry had some impact. What is most insidious is that while the Mission is based on a lofty concept note - under the grandiose title "Context" - where homilies like "comprehensive restructuring of the current strategy", or banalities like "additionality of external resources inadvertently leading to further fragmentation by choosing specific areas or diseases for targeting in the absence of a comprehensive national health plan" abound, it seeks to make the ASHA central. A convoluted description of this professional goes like this: "Trained by the government but acting as a community health professional, she could be incentivised by the government and accredited but would be accountable to the community."
One of the features that the Mission envisages is the creation of a Village Health Committee headed by the local panchayat representative and consisting of the ASHA, the anganwadi worker, the auxiliary nurse and midwife, the local schoolteacher and volunteers. It is surprising that anganwadi workers and schoolteachers, who are already burdened with other government-related responsibility without any additional remuneration, have been roped into the scheme.
C.P. Sujaya, who was the first Secretary of the Women and Child Department, pointed out that while the intentions, centred around the spirit of decentralisation, appeared to be noble, the panchayati raj institutions were excluded from the local planning process. She felt that the Village Level Health Plan should be prepared by the gram panchayat and the health sub-committee of the panchayat if real decentralisation was being aimed at. Sujaya said that the "accountability" of the health activist ought to be spelt out.
The PHC, envisaged as the backbone of a comprehensive health care system, has been given the short shrift - the concept note observes that as upgrading a sector PHC is likely to be costlier, upgradation of the CHCs has been suggested as the preferred option. Secondly, public hospitals are supposed to be evaluated by the Indian Public Health Standard, a set of norms that will be drawn up by a task force.
Although the concept note mentions the weaknesses of centralised planning, it is the District Health Plan that is supposed to be the key instrument to achieve the objectives of the Mission. The Mission would create a comprehensive budget head by integrating all vertical health programmes of the Departments of Health and Family Welfare, which includes the Reproductive and Child Health Programme-II, the National Malaria Eradication Programme, the National Leprosy Eradication Programme, the National Kala-Azar Programme, the National Iodine Deficiency Disorder Programme, the National Filaria Programme, the Revised National Tuberculosis Programme and the National Blindness Control Programme. The AIDS Control Programme and the National Cancer Control Programme will not be included. The idea is to have an "omnibus National Rural Health Mission as a broadband programme and all other programmes would only be sub-components of it". The Mission will "wind up" in 2009 after reporting on some indicators such as the provision of ASHAs; raising CHCs to the level of the IPHS norms; institutionalising district-level management of health; reduction in communicable diseases, the rates of maternal and infant mortality and population stabilisation.
The tentative budget outlay for the Mission for 2005-06 is interesting. The bulk of the budget is with the Department of Family Welfare. The Department of Health accounts for only 10 per cent of the total outlay. With a major part of the outlay allocated for family welfare services, the government must clarify what kind of services need to be provided.
There are other concerns as well. The JSA has cautioned that the ASHA should not be seen as a substitute to the ANM and the sub-centre but as a supplement Ill-trained practitioners often contributed to rising health costs by the poor, a JSA note on the Mission stated. The JSA has also expressed concern over the dilution of the PHC. While welcoming the setting up of secondary care centres - 7,000 of them in all; one per 100,000 population - the JSA cautioned the "hasty switch to public-private partnerships as the main means of closing the gap in secondary sectors". The gap refers to the deadlock in the creation of such centres in the public health system, which the JSA feels is owing to problems of governance and workforce management policies. The bulk of secondary care provision would have to remain as public-provided and public-funded facilities, the JSA stresses.
On December 17, in reply to a question whether the government was planning to include private doctors in the population control programme, Minister Lakshmi said the government was "exploring the option of improving access to comprehensive health and family welfare services, especially in the demographically weaker States through increased public-private partnership for health and population stabilisation. It is proposed to involve accredited private/NGO [non-governmental organisation] health facilities in social marketing and social franchise of services and products for health and family welfare programmes."
The JSA argues that in the context of a large Community Health Worker Programme, a strengthened sub-centre and a PHC and CHC structure made functional, there would be no need to invest in this largely unregulated informal structure - the private sector.
The continuing preoccupation of the government with population stabilisation - it is lamentable that nowhere does the document even mention the adverse child sex ratio - is a worrying trend, especially as the two-child norm continues to be implemented in several States.
What is clear from the rudimentary document, a copy of which is available with Frontline, is that the Mission is yet to be given final shape.