Dear Friends,

While we attempt to understand what is going on with the NUHM, here is
some food for thought with regard to the NRHM. Some more from Srinath
Reddy!

Regards,
Anil


http://www.moneycontrol.com/india/news/economy/what-ailsnational-rural-health-mission/404645
 
What
ails the National
Rural Health Mission?
Published
on Sat, Jul 04, 2009 at 17:28 , Updated at Sat, Jul 04, 2009 at 18:41
Source : CNBC-TV18
The National Rural Health Mission (NRHM) is effectively
into its fourth
year. India’s
healthcare
system is one of the most privatised in the world and health shocks are
one of
the main reasons why poor people slip into poverty. As a flagship
programme,
the rural health mission did not get single-minded ministerial
attention that
the National Rural Employment Guarantee (NREG) scheme got under Former
Minister
Raghuvansh Prasad Singh. But this government wants
to make
amends. Last week, there was a review meeting in Jammu,
but Health Minister Ghulam Nabi Azad and Health Secretary Naresh Dayal
did not
fill us in on the details despite repeated request.
Dr Srinath Reddy combines passion of
public healthcare with close association with the rural health mission.
Incidentally, he was personal physician to Prime Minister Narsimha Rao
and heads
Prime Minister Manmohan Singh’s medical team.
Commenting on what ails the National Rural Health
Mission, Reddy said it
needs far greater strengthening in terms of several of its components
in order
to yield the expected outcomes. “We require greater strengthening in
terms of
the human resources for health. We need more doctors, nurses, and
auxiliary
nurse midwives.”
Here is a verbatim tran_script_ of the exclusive interview
with Dr Srinath
Reddy on CNBC-TV18. Also see the accompanying video.
Q: As a cardiologist to Prime Minister, Manmohan
Singh, you controversially advised him to undergo bypass surgery
earlier
this year. As Public Health specialist, would you advise something as
radical
for the National Rural Health Mission
as well?
A: As you have noted, whatever advice was given to the
Prime Minister
turned out quite well. We are very delighted that he is absolutely fit
to head
the nation but we are also equally eager that every Indian citizen
enjoy good
health as well. In order to make sure that health is available,
affordable, and
is of an appropriate nature to everybody including in those who are
living in
the rural areas, we need much greater strengthening of our health
services. We
would like to see that happen during this term of the PM.
Q: What kind of radical measures or changes do you think
that the NRHM
requires?
A: The National Rural Health Mission has been well
conceived and it has
been set already into motion in a substantial way. However, it needs
far
greater strengthening in terms of several of its components in order to
yield
the expected outcomes. First, we require greater strengthening in terms
of the
human resources for health. We need more doctors, nurses, and auxiliary
nurse
midwives.
Though even rich countries have to grapple with it, the
shortage of the
medical staff in the public hospitals is a painful affliction for poor
countries. Planning Commission’s sample study of Andhra Pradesh,
Rajasthan, Bihar,
and Uttar Pradesh done as recently as May by Kaveri Gill found that the
lowest
sub-centre level for all four states had the mandatory one auxiliary
nurse midwife
but not the desirable tool.
UP leads with the most number of technicians at Primary
Health Centres
(PHC), Rajasthan with paramedics, and Andhra Pradesh with doctors. But
at that
level, there were no anesthetists in any of the four states, no
gynaecologists
either. Rajasthan makes Bachelor of Medicine and Bachelor of Surgery
(MBBS)
doctors undergo four months gynaecology training so they can stand in
during
emergencies. In Bihar, nearly all
doctors
have been diverted to upgraded PHCs which serve the district. In all
states
except Bihar, auxiliary nurse
midwives were
found to be the most diligent perhaps because of community pressure.
Absenteeism was a norm among doctors and specialists which aggravates
the
scarcity of skills. Scarcity and non-accountability is one reason why Gujarat
is trying out a partnership with private gynaecologist.
Q: Would you agree with the public private partnership
(PPP) model
because the government has now enlisted private gynaecologist as in
Gujarat in
the Chiranjeevi
Yojana Programme and the state government there was telling me that
this is
because there is only a limited amount of a medical skill available so
we must
make use of that skill. There are those who say that in this process,
we are
going to neglect the public health system and we are already going to
make a
highly privatized healthcare system, still more privatized.
A: If you look at Tamil Nadu for example, it has achieved
excellent gains
in maternal health and reduction in maternal and infant mortality as
well as
improvement in many other health indicators mainly through the public
health
system. It is the public system that has been very efficient in Tamil
Nadu. But
it is not necessary that we must always take recourse to a PPP model.
But where
necessary and where useful, PPP can extend the outreach of services and
enhance
the efficiency as well to some extent. In Gujarat
particularly, the Chiranjeevi model has been successful and where
you do not
have adequate facilities for immediate provision of services in the
public
facilities co-opting people from the sector through PPP would appear to
be
useful modality.
Q: The Gujarat model
would be the
short-term model whereas ultimately we must progress towards the Tamil
Nadu
model.
A: I believe ultimately the state has to be the main
provider or at
least guarantor of health services in this country. The private sector
and the
voluntary sector also have useful complementary roles to play, but
unless you
have a strong and efficient public health system, you are not going to
see
improvement in health gains, particularly you will not see reduction in
health
inequities.
Q: Would you say this is also for health insurance
because we find that
private health insurers who were licensed thinking that they would
expand the
coverage of health insurance? We find that they are very choosy and
even those
who were the minor medical histories, they are not being covered.
A: This whole problem of private insurance is not only
that not many
people can afford it, but even those who have acquired private health
insurance
find that the whole amount of risk coverage is very limited because
those who
are likely to have events fairly soon are weeded out of the insurance
schemes
and the coverage provided is not adequate for such people. While health
insurance particularly social insurance provided by the government
aided by the
employer provided health insurance. To some extent, private insurance
can
together increase the availability of healthcare. You must ensure that
universal healthcare especially of essential health services is
available and
one should not be dependent on out of pocket spending.
The rural health mission has set a target of spending
2-3% of gross
domestic product (GDP) on public healthcare. Overal,l spending now is
0.89% of
GDP with increased Central spending making up for the decline in state
spending, though health is a state subject. This raises doubts about
the
ability and willingness of states to make the required 10% of
contribution. The
Centre’s outlay has increased from Rs 7,200 crore to Rs 12,050 crore
over a
four year period but four states evaluated recently in a Planning
Commission
Sample Study were found not to have spent over a third of the money
allocated
to them.
Q: The NHRM has been able to reverse the decline in
public spending on
healthcare. We are not there yet, we have not met the target, but do
you think
that whatever money is being spent is being spent effectively?
A: Certainly things are happening but unless you improve
the
infrastructure, unless you augment the human resources, the services
will not
be delivered in the scale intended or required. All of these have to
keep a
pace. While the NRHM does provide substantial amount of revenues to
various
states to improve health services, the states too need to pitch in with
greater
contributions to primary healthcare. This possibly is something that
the 13th
Finance Commissioner should address by providing earmarked allocations
to
states for their own investments and primary healthcare. Till states
take
ownership of these programmes, you are not going to see an effective
delivery
at the state level.
Q: Does it mean more taxation as well to raise those
resources?
A: If it is more taxation on cigarettes, alcohol and
cars, I welcome it
because these are some things where taxation serves a double benefit.
Q: So you say that increase in sin taxes is the way to go?
A: I would certainly not advocate increasing of sin in
society, but sin
being taxed is certainly fine. In terms of tobacco and alcohol, the
prime
candidates which are under-taxed, should be taxed more heavily. Even
cars being
taxed can provide for lot more urban amenities and reduce the
environmental
pollution.
Q: The government has spoken of having trained six lakh
Accredited
Social Health Assistants (ASHA) who are go between the auxiliary nurse
midwives
and the expectant mother. In the process the government says that there
has
been a sevenfold increase in hospital deliveries because of which
deaths of
infants and mothers have come down?
A: ASHA are an important contribution to social
mobilization and are increasing
the referrals for institutional deliveries by both increasing awareness
plus
motivating the women to seek that kind of care. ASHA have other
functions to
deliver as well. They are involved in motivation for immunization and
now some
additional activities are also being added to their portfolio, so that
they
will actually become health motivators in the village not merely for a
few
confined functions but for several other broadband range of health
functions.
Doctors do not
like to
serve in villages. It is in cities that you see a protrusion of
clinics,
nursing homes and speciality hospitals. But you would be surprised to
know that
cities don’t even have a semblance of a public primary healthcare
system. This
government has vowed to change that.
Q: So the government has announced the National Urban
Health Mission –
how do you think it should be crafted?
Reddy: Atleast in the rural
areas there has been a design of a primary healthcare system but in
urban areas
we did not even have the design of an Urban Primary Health care
system. 
So it was left to the vagaries of whatever system existed in terms of
individual doctors and quite often people ended up even for primary
healthcare
related needs with tertiary care hospitals, overloading those hospitals
unnecessarily.
So Urban Primary healthcare in short has been anarchic.
Now we have an opportunity to redesign that, to provide
substantial
community health centres, municipal hospitals, _link_ing them with
secondary and
tertiary care hospitals, rationalizing the entire structure. We must
also
recognize whether in rural healthcare and particularly in urban
healthcare the
determinants of many other sectors which operate outside of the health
system.
Whether in water supply, sanitation, in agricultural nutrition,
environment,
urban transport, all of these have a tremendous influence on health.
So, all of those policies also must become more aligned,
sensitive to
and responsive to public health concerns. Otherwise we will always be
dealing
with the health sector as a mopping brigade, mopping up the mess
created by
policies that have gone wrong in other sectors.
Q: So you would want every minister to be health minister
in a way?
Reddy: I believe that every
minister should be a health minister, and must align their policies and
programmes within their domain in the interest of public health.
SEWA is a trade union of self employed women in the
organized sector. It
has 1.1 million members across 9 states. For the rural health mission
it has
been training ASHA, the Accredited Social Health Assistants setting up
village
health and sanitation committees and persuading women to do deliveries
in
hospitals under the Janani Suraksha Yojana.
Sapna Desai is a self coordinator for all the nine states.
Q: Decentralisation is key to the rural health mission
and many thousand
Rogi Kalyan and village health and sanitation committees have been set
up. Are
they as impressive on the ground as they appear on paper?
Desai: I think the greatest
strength of NRHM is that the Vaccine Healthcare Centers (VHC) have been
created
and the Rogi Kalyan Samiti’s. They are certainly at the beginning like
in Bihar
were we work in three districts. We have been actively involved in
created the
VHCs. So where there is an active civil society involvement you will
see strong
VHCs. They are at the inception stage now.
Q: The ASHA’S are key functionaries of the rural health
mission and they
have been able to persuade expectant mothers to do the deliveries in
hospitals.
Does their training equip them to be broadband health motivators as
well?
A: I think the key issue here is that the traditional
person doing that
in terms of working women particularly mothers has been the Dai. In a
place
like Bihar and many other places we work upwards of 80% of deliveries
are at
home. So the ASHA has in a sense replaced the Dai as the focal point
for
pregnant women. So while ASHA certainly accompany women to
institutions, it is
the Dai who is still the first point of call and who goes with them. So
the
ASHA’S training equips her to do basic public health certainly but it
is the
Dai who still is the first point of call.
Q: Now public health is not just about cure it is also
about prevention.
Has the rural health mission created enough awareness, has it enabled
people or
has it changed attitudes towards sanitation?
A: I think in terms of prevention the key issue is
investing in water
and sanitation. We have not seen the level of investment we need such
that
every family has a toilet, every family has access to clean water and
drainage.
If those three issues are addressed, in depth, then I think we’ll see
definite
public health gains. That is well established.
In terms of awareness, that is certainly an issue that
needs a lot more
work because health education and awareness can’t just be done through
mass
media. As we have learnt that it also requires a level of one on one
contact
which could be a role for ASHA’S and other community health workers
like Dai’s
if the appropriate training is given.
Q: If I understand it correctly, drug delivery and the
scarcity of
trained medical personnel those are the big gaps in rural areas. Has
the rural
health mission been able to address these intractable issues? I am not
saying
you should solve them but has it atleast made a dent in these issues?
A: In my experience over the past three years in Bihar
for instance, we
have seen a fantastic improvement in medical officers being available
in PHCs
(Primary Healthcare Centres) and in all of our work when we go to the
PHC the
doctor isn’t there. That said, drug availability is still a major
concern. So,
out of pocket expenditure essentially is still an issue.
Four years later, has the Rural Health Mission made a
difference? This
is what people have to say.
The Planning Commission study reported the highest share
of negative
experiences among patients in Bihar followed by UP, Rajasthan and
Andhra. The
highest level of satisfaction was in Andhra. The causes of
dissatisfaction were
no medicines, absent staff and long waits.
According to SEWA Bharat, public healthcare has improved
ever since Nitish
Kumar took over as Chief Minister. But a recent Planning Commission
evaluation study found that Biharis had the highest number of negative
experiences. I asked Sapna Desai how she would square her own
experience with
the findings of the study.
Desai: I think one key
issue is that we have seen the changes in Bihar over time. Governance
has
played a key role. It is not only the NRHM, it has been governance. The
Nitish
Kumar government has really achieved remarkable results. We see the
accountability
shifting in a sense that doctors are now accountable to a system.
I’d also say that looking at things over time, things
have improved and
certainly those experiences must ring true where experiences are
negative in
Bihar. But on the whole, we see positive things happening. So, I
couldn’t
reconcile what Kaveri (Gill) has found in her report, which I agree
with in
what we see except that you have to look at the change over time and
positive
things are happening.
Q: I am going to talk about accountability. The same
study finds that
ANMs for example, they are the most diligent because they are I think
more
responsive to community oversight and monitoring whereas this was not
the case
with the more specialised, medical people?
A: I think it is a question of how the system is
designed. If the system
is designed such that doctors have to be responsive to a community, it
is not a
question. That is their duty and that is what a public system is for. I
don’t
think the question should be will doctors be amenable to community
oversight
but rather how do we create a system or construct a national health
programme
in which doctors are answerable to the community by design.
Q: You have exposure to Gujarat as well as to Bihar. We
have seen a lot
of private participation in Gujarat, in deliveries for example. In
Bihar I
think the government is going in a different way, they are going the
Tamil Nadu
way. Has that worked in Bihar in terms of Janani Suraksha Yojana, in
terms of
institutional deliveries?
A: Yes, we are seeing an increase in institutional
deliveries. Amongst
women who are close to the hospital, I mean in more rural areas. And
the
numbers speak of it, 80% of deliveries as of the last NFHS (National
Family
Health Survey) were at home. We will see a steady decrease. But I think
until
we integrate Dai’s firstly into the system more than point of call, and
secondly improve quality in hospitals such that women naturally want to
go to a
hospital for a delivery as opposed to for an incentive, we will see it
work.
Q: But in your experience, you don’t think that private
hospitals are
necessarily better than public ones?
A: Not at all, not necessarily at all. In private
hospitals we have seen
over-diagnosis, you’ll see higher expenditure, you’ll see unnecessary
tests.
The expenditure pattern is very different in private. They don’t
necessarily
provide better services.
Frankly, when public systems work and work well, our
members prefer
them. We see in a place like Ahmedabad when given a choice, our members
use the
government hospitals.
Q: Finally if you had to suggest a set of correctives,
what would those
be for the NRHM?
A: First and foremost, I think it is on a good path,
decentralization
certainly is a great way to go and community participation and the fact
that
VHCs and Rogi Kalyan Samiti’s exist, I think is a really positive move.
In terms of corrections, I think one is definitely
integration of Dai’s
into the referral system and upgrading the capacity of Dai’s to also
service
health workers. Secondly, I would say drugs. I mean ensuring that their
monetary mechanism to actually ensure that drugs are available to
people and
out of pocket expenditure isn’t wasted on drugs, which shouldn’t be in
the
public system.
Probably most importantly, investment in water and
sanitation such that
every household has a toilet, has access to clean water, to prevent the
actual
illnesses before they occur rather than focusing only on treating them.
The government has declared that public healthcare is up
there in its
list of priorities in the second term. It has vowed to slash the death
rate of
infants and mothers, expand the coverage of immunisation, check
malnutrition by
bringing the nutrition delivery programme under community oversight and
expand
public health insurance to cover all extremely poor families.
But the rural health mission must subject itself much
more to public
scrutiny than the National Rural Employment Guarantee Scheme, if it is
to serve
the purpose intended. Even Kaveri Gill of the Planning Commission found
a
dearth of information. More sunlight is needed.