Out of focus

An appraisal of the health care promised by the National Rural Health Mission launched in April 2005.

T.K. RAJALAKSHMI in New Delhi

ONE of the primary aims of the National Rural Health Mission (NRHM), which was launched with much fanfare in April 2005 in order to make "architectural corrections" in the rural health infrastructure, was to provide universal access to equitable, affordable and quality health care. Its other goals include responding to the needs of the people, reducing infant and maternal mortality, preventing and controlling diseases, providing access to integrated and comprehensive primary health care and achieving population stabilisation and gender and demographic balance.

Its vision, unveiled in the "Framework for Implementation 2005-2012" - a plan of action document of the Ministry of Health and Family Welfare - is to provide effective health care to the rural population with special focus on 18 States known to have weak public health indicators and or weak infrastructure.

Several members of the Jan Swasthya Abhiyan (JSA), a people's movement comprising progressive organisations dealing with public health and women, who had participated in the discussions preceding the drafting of the document, are disappointed that the concerns raised by them have not been reflected adequately in it. The budget for all family welfare activities have been clubbed together as the budget for the NRHM, they argue. There appears to be a distinct lack of conceptual clarity, apart from the fact that the budgetary allocation appeared to be skewed in favour of family welfare activities.

Moreover, preliminary feedback from some of the States where the scheme was launched indicates that there is much confusion about what it is intended to achieve. The NRHM had proposed to create an all-woman "band of community-based functionaries", called ASHA (Accredited Social Health Activist), who would play a key role in mobilising the community in local health planning and facilitate the utilisation and accountability of existing health care services. During the discussions, the JSA highlighted the impracticality of insisting on a minimum educational qualification for an ASHA. (These women are supposed to have studied up to Class VIII.) According to the 1991 Census, 91 per cent of the women did not have middle-level education. The situation has not changed substantially since then. The JSA feared that the educational barrier would exclude from the programme women with strong social motivation and representatives of deprived groups.

Moreover, there is a deep mismatch between the work expected of an ASHA and the compensation she is to receive. Apart from being compensated for specific tasks relating to national programmes, she is to undertake routine activities that include immunisation, weighing newborns, treating patients, facilitating ante-natal care, educating mothers and mobilising the community. For all these, the maximum compensation she is to receive from the Village Untied Fund is Rs.1,000 annually or Rs.83 a month.

One of the key challenges in the area of rural health care is meeting the needs of basic curative care or First Contact Care. The ASHA is tasked to provide this need using a monthly allocation of Rs.50 for drug purchase. Apparently, this was the norm in 1978 when Community Health Volunteers were employed. Given her limited effectiveness in the light of the overall budgetary constraints, it is felt the ASHA's credibility as a health facilitator would come under question.

Yet another aspect is that of assessment. The indicators used for monitoring an ASHA's performance show that out of the eight outcome indicators, seven are related to the Reproductive and Child Health programme (RCH). Public health activists fear that given the strong influence of the RCH programme on the NRHM in general, the family planning component may influence the ASHA's functioning in a disproportionate manner. It has been found that any emphasis on family planning has often distorted the priorities of primary health functionaries and reduced their overall effectiveness.

Public health experts had insisted during discussions that primary health centres should be strengthened. But the Mission document has stressed that all National Health Programmes should be delivered through community health centres (CHCs).

A new concern raised by experts is about the levy of user fees by hospital management societies. A "Generic Model for Hospital Management Societies" has been circulated as a kind of guide for managing CHCs and other hospitals. These societies are to generate resources locally through donations, user fees and other means. The scope of the functions of the societies include entering into partnership arrangement with the private sector (including individuals) for the improvement of support services and developing/leasing out vacant land in the premises for commercial purposes.

The JSA has objected to this provision, saying that if any improvement in services needs to be done, it should be done through enhanced public funds and not by levying user fees. It is felt that this could not only result in part-privatisation of public hospitals but also act as a barrier to the use of services by the poor for whom the Mission was conceived.

The problems do not end here. A representative of the JSA from Assam opined that one other basic flaw in the scheme was that it had a uniform approach to all the States in the country, without taking into account the cultural and geographical dissimilarities.

"There should have been a bottoms-up approach rather than a top-down one. How can a scheme applicable in Chhattisgarh be replicated for the northeastern region?" asked Satyashree Goswami from Shakti Collective, an organisation representing the northeastern region and which is part of the JSA network. She told Frontline that institutional deliveries were rare in most part of the region. Most women were delivered of the baby at their homes. "For institutional delivery, the woman would have to walk long distances and would most probably end up in a critical state in the process," she said.

The Assam government had organised "baby-shows" to promote the NRHM. "This means nothing to a village woman," she said. There were also reports from Arunachal Pradesh that non-governmental organisations were told to run the PHCs and when tenders were floated for this, several nursing home owners applied for NGO status in order to grab the opportunity.

The JSA has found a new set of problems. Even before the formal selection of ASHAs several NGOs started offering training services for the job. In Chhattisgarh, voluntary workers called Mitanins were converted to ASHAs and Collectors and government medical officers took decisions regarding the untied funds instead of elected village representatives. In Jharkhand, the procedures regarding the selection of the Sahiya (as the ASHA is called here) were not followed despite clear orders.

Said Narendra Gupta, who heads Prayas, an NGO in Chittorgarh, Rajasthan: "On the face of it, the NRHM appears to be decentralised, but actually it is a top-down scheme." One of the first things that should have been done was to have an assessment of the disease burden at the ground level, he said.