Sunday Reading

New Delhi, 16 March 2010

Natl Rural Health Mission

MUCH-TOUTED BUT UNDER SCANNER

By Suraj Saraf

Acknowledging the difference the National Rural Health Mission has made to the healthcare system, the Third Common Review Mission (CRM) highlights that many States had come up with innovations for retaining professionals in public service in rural and remote areas. While most States focused on financial incentives, some others had created a special cadre for whom financial and non-financial incentives were offered. It had been impressive, highlighted the review.

The review added that regulatory mechanisms of rural service bonds for medical students and the pre-post-graduate mandatory qualification had helped in a big way. “For the first time vacancies among professionals in rural India had been addressed. It further said that the local-based selection and a special short term expansion of nursing school capacity under the private-public partnership has led to a strategy of filling 10,000 auxiliary nurse midwife (ANM) vacancies within four years in West Bengal.

The Union Health and Family Welfare Ministry had recommended an in-depth study of 20 innovative schemes in this regard.  The term innovative had been used flexibly under NRHM and encompassed pilot projects, creative use of public-private partnerships across a range of services, use of cash transfers and a demand side to the financial mechanism to give better outcomes and also to address equity issues.

The NRHM which focused on decentralized planning implementation and flexibility to States and the implementation agencies, had resulted in a number of innovations “with impressive results,” as underscored by the Mission Director Amarjeet Sinha.

The ministry had documented 227 such innovations brought about by various States and Union territories across a range of activities. The documentation had been carried out to provide an assessment of the effectiveness of these innovative schemes and how the benefits are impacting the poor and vulnerable sections, promote cross-learning among States to address challenges in the health sector and enable them to explore the possibility of replicating innovations best suited to their local contexts and needs.

The innovations identified for in-depth review include Chiran Jeevi Yojana in Gujarat, delivery huts in Haryana, Rural Emergency Health Transportation Scheme in Andhra Pradesh, Mobile Health Clinic in West Bengal Mobile Boat Clinic in Riverine area in Assam, sub-contracting of diagnostic service in rural area, security scavenging and waste management and mechanized laundry service as in West Bengal, management of primary health centres by NGOs in Arunachal, communitarian private-public partnership for management of health centres as in Nagaland,

Rapid diffusion of IUCD training programme using alternate training methodology in 12 States, practitional franchising for injectibles through private sector as in UP, Jharkhand and Uttarakhand, Shishu Samrakshak Manch as in Chhattisgarh, Dular Se Muskan Abhiyan in Bihar, Alternative health service delivery in Punjab, Family counseling centres as in MP, Rajasthan, Orissa, Maharashtra and Kerala, Swasthya Panchayat and Jeevan Deep Samitis as in Chhattisgarh, Community monitoring as in Orissa and Medical Services Corporation as in Tamil Nadu. MP and several other States provide transport to carry pregnant women to the primary health centres that has helped to increase the number of institutionalized deliveries.

As against the official review committee’s assessment highlighting the achievement of the NRHM, the Comptroller and Auditor General of India had come down heavily on the health ministry in regard to the implementation of this flagship scheme. Substandard procurement of drugs and irregularities worth crores of rupees have been detected by the CAG. It added the NRHM was making slow progress in initiating decentralized bottom up planning “primarily due to non-completion of works”.

“While the Mission succeeded in setting up the health societies at the district and State levels, it did not succeed in mainstreaming them. Since capacity building appeared to be taking time, some States outsourcers planning, resulting in lack of participation by the community which was one of the primary objectives of the Mission.

The CAG further said that initial years of the Mission period (2005-2012) had elapsed without annual plans being prepared for all districts, diluting the very concept of decentralized planning. Citing irregular payments being made without receipt of medicines, it said there was no uniformity in the procedures followed by various procurement wings. The irregularities included absence of standard tender process, ignoring lowest rates, procurement from black listed suppliers etc involving an amount of over Rs. 36 crores.

In eight States avoidable expenditure of Rs. 8.09 crore was incurred for purchase of drugs that was not required. In seven States medical equipment worth Rs. 24.69 crores were found lying unutilized resulting in non-achievement of the scheme objective and blocking of funds, said the CAG report.

It further pointed out that as one of the underlining conditions of the scheme, the States were required to contribute 15 per cent of the funds required for the Mission, but during 2007-208 only four States and during 2008-2009 only nine States and Union Territories contributed full or more than the required share.

One of the most shocking disclosures of a big ticket health programme, had been that some of the poor States that were the focus of the NRHM had actually ended up being discriminated against in the Central allocation as compared to funds released to some of the rich and efficient States that were already high on the basic health parameters. The performance audit conducted by the CAG had found that some of the poor States in fact had got 10% to 30% less.

Bihar and Assam, where the health service was believed to be in shambles, got least of the funds at the cost of their rich and efficient counterparts, who spent most of the allocated money within the stipulated timeframe and managed to get more funds from the share of the poor States. According to the CAG audit, while Andhra got Rs. 154 crores more than its share, Gujarat got an additional Rs. 237 crores, TN and Kerala also got more funds than their share.

While implementing the NRHM, grants were to be allocated to States, according to norms developed on the basis of a composite index incorporating population, disease burden, health indicators, state of public health infrastructure etc etc. One of the biggest problems facing the policy makers is shortage of medical personnel. Recently released data by the Ministry of Health and Family welfare has highlighted that there was a shocking shortage of doctors, nurses, health assistants, radiographers, pharmacists and other personnel in the rural health delivery system. This is despite 82,000 new personnel being appointed during the past four years under the NRHM and many villages seeing a doctor for the first time.

The situation is worse for qualified doctors: only about 20% of the pediatricians and only about 26% of the surgeons, obstetricians, gynecologists and general physicians are in place. There is a shortfall of about 25% of the pharmacists and 16% of staff nurses. Nearly a quarter of 46,000 male and female health assistants are missing while 60% of health workers are not yet in place.

The situation is somewhat better for the auxiliary nurse and midwife (ANM) with about 90% appointments having been made but even then there is a gap of 16,000 ANMS. Just about one third of the primary health centres are functioning with the required two ANMs.

Expenditure data shows that the problem is not one of money. Out of Rs. 42000 crores released by the Central government during the past four years, nearly Rs.1000 crores are lying unspent with State governments. In addition, all State governments had allocated Rs. 106388 crore for health and family welfare. But money can not buy everything. ---INFA

(Copyright, India News and Feature Alliance)