NRHM- Hope or Disappointment..??

The recently declared National Rural Health Mission has aroused significant interest, being both welcomed and closely scrutinized, since there is a long overdue and outstanding need to strengthen weak and dysfunctional public health systems in rural India. In this setting, Jan Swasthya Abhiyan (People’s Health Movement – India), a large national coalition of 18 national networks and several hundred organisations working in different states and concerned with the health sector, has been involved in analysing various aspects of the Mission. The concern has been that it should develop in a manner that actually strengthens public health systems in an integrated manner, and that it should empower communities to be involved in the planning and utilization of these systems in a Rights-based framework. In this article, one will draw upon and reflect on a few of the major concerns about NRHM that have emerged during the insightful discussions in JSA, although the responsibility for opinions expressed and liability for any omissions finally rests with the author.



Some general concerns
The first concern is that there is no systematic analysis of previous policies, and no major lessons seem to have been learnt from the past.

A second concern relates to the influence of the globalisation-privatisation framework on the Mission.

ASHA – barriers to success, measures required to overcome them

•Selection criteria – at present, an educational level upto eighth class (middle education) is expected for a woman to qualify as ASHA. An analysis of the 1991 census data shows that in the rural areas of the NRHM states in Northern India, over 91% women did not have middle level education – and more recent data shows that this situation has not changed significantly in the subsequent period.

•Lack of adequate regular compensation – In the final programme design, ASHA is supposed to work primarily as a volunteer. She would be compensated on performance of certain specific tasks related to National programmes. However, for her major routine activities such as immunisation, weighing of newborns, facilitating ANC, treating patients, visiting households, giving education to mothers, mobilising the community etc., as per the financial norms, the maximum compensation from the Village Untied Fund that may be given is mentioned as Rs. 1000 annually, or about Rs. 83 per month

•Limited provisions for First Contact Care – One of the strongest felt needs expressed by communities is the need for basic curative care being made available within their village. Many NGOs have demonstrated that well trained Health workers can give a wide range of First Contact Care effectively. However, the ability of ASHA to give basic care in simple illnesses is dependent on adequate relevant training, provision of a proper kit and regular replenishment of the range of necessary medicines. The drug list for ASHA as has been presently proposed is extremely limited, and the budgetary norm for drugs is Rs. 50 per month

•Activist or appendage? By her very name – ‘Accredited Social Health Activist’ the ASHA is supposed to be an ‘Activist’ mobilizing people and facilitating their access to health services as a right. However, given the fact that the ANM will be involved in sanctioning her compensation, and she would be reporting to the health system for implementation of various programme related activities, would she be realistically able to function as an ‘activist’ and lead people to put pressure on non-performing health services?

•Focus on RCH, possible adverse influence of Family Planning programme - While the ASHA’s role in providing primary medical care at the village level appears weak, a look at the indicators to be used for monitoring her performance shows that out of the eight outcome indicators for ASHA, seven are related to RCH.

• Principal amount of adequate remuneration for ASHA should be assured and delinked from specific activities, with a small performance linked component if necessary. The remuneration for regular health activities and village level processes could be routed through the Panchayat or Village health committee if required. Monitoring of ASHA should involve social monitoring by the Gram Sabha and Village health committee, and technical monitoring by the Public health system

Public-private partnerships
The NRHM documents specify ‘Public private partnership’ as one of the Mission components. However, given the fundamentally divergent objectives of the Public health system (to provide services to the general population based on public financing) and of the Private medical sector (to run as profitable institutions, providing care to those who can pay), a ‘partnership’ of such differing institutions needs to be very clearly specified, to prevent its abuse. The variable quality of care, frequent lack of minimum standards, prevalence of irrational practices and often unaffordable price of care in the Private medical sector has been documented by various studies. In this context, the foundation of the relationship between the Public health system and the private medical sector must be effective public regulation of the quality, rationality and costs of care in the private sector. There is no reason why Indian Public Health Standards cannot be applied to the private sector as well. The long-standing and glaring non-regulation of this proliferating sector and the need for strong, effective measures in this direction are only weakly addressed in the Mission document which does not mention any specific legislative or operational mechanisms and blandly talks of the ‘need to refine regulation’

Conclusion – need to critically support and influence the Mission; People’s Rural Health Watch
In India, given the dismal situation of rural health services in most states, any genuine measure to strengthen the rural public health system is welcome; hence the National Rural Health Mission has aroused many hopes and expectations. The long-overdue renewed attention to public health, and most of the overall goals of the Mission are definitely positive. However, as this article has tried to outline, in many respects the Mission falls significantly short of expectations, and the details of the actual measures do not seem equal to its objectives. There is a decision to strengthen national health services, but this is presently significantly linked to internationally funded programmes; there is a desire to improve public health but this is mixed up with some notions of privatisation; there is a recognition of the present deep health crisis, but the response is somewhat fragmented and seems to lack an integrated, health systems approach.

Finally, History, it is said, repeats itself – the first time as tragedy, and the second time as farce. The story of ensuring health care for the rural people of India may be traced back to the Bhore Committee, which adopted the goal of Universal access to Health care for all on the eve of Indian independence. That this goal could not be achieved is obvious; and then history repeated itself for the first time a quarter of a century ago when ‘Health for All’ was adopted as a goal for Health development. This repetition of history ended in tragedy, with the subversion of the comprehensive Primary Health Care approach, which was replaced by a set of technological ‘quick-fixes’ that only scraped the surface of the problem while leaving the systemic issues unchanged. And now, History is repeating itself for the second time; again the declared goal of the Mission is “to improve the availability of and access to quality health care by people, especially for those residing in rural areas…”