Natl Rural Health Mission
MUCH-TOUTED BUT UNDER SCANNER
By Suraj Saraf
New Delhi, March 21, 2010
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
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 & Feature Alliance)