New Delhi:A government-funded review of its flagship National Rural Health Mission, or NRHM, has criticized the slow pace in rolling out the health care programme, with a manpower crunch impeding its progress further, and substantial variation across states on project milestones.
The review of the signature programme of the Union ministry of health and family welfare—it has got the largest sum of money ever in a public health project—traced the slow pace of progress to administrative constraints, governance issues, inadequacies in human resources as well as the poor investment in public health services in the recent past.
Seeking treatment : A file picture of a patient at a hospital in Tikiri village, Orissa. To make a qualitative assessment of the government’s rural health mission programme, a 52-member team surveyed 13 states, including Assam, Bihar, Orissa and Rajasthan, in November last year. (Photo: Manpreet Romana/AFP)
“People at the lowest level have begun receiving money under NRHM but are not used to spending it. Up to 70% of the untied funds (not specific to any purpose) are not used,” said a ministry official, preferring not to be identified.
The official identified Uttar Pradesh, Jharkhand and Chhattisgarh as among the laggards in the programme.
The NRHM initiatives, though funded by the Centre, have to be executed by the state machinery, and that leaves a lot of room for coo-rdination and governancefailures.
“Over the last four years, the health budget had increased, but the capacity of all the states in implementing the health programmes has not kept pace,” said Denis Broun, country coordinator for international aid agency UNAIDS.
On the positive side, the funds under NRHM have led to innovations such as boat clinics in Assam, helicopter service health camps in Tripura and emergency ambulance services in Andhra Pradesh, while a few states such as Uttar Pradesh are suffering gaps in quality of care at all levels, says the review report, which was finished in February.
The ministry is planning a second survey in the next six months that would match outcomes to inputs quantitatively. The first survey was qualitative in content as it was felt that initiatives under NRHM had not had time to show a tangible impact on health statistics such as mortality rates of infants and mothers as also other health indicators.
The report, forwarded to states and Union territories for follow-up action, has recommended timely release of funds, cross-learning for states from those that have done better, setting up of training institutes down to the district levels and “multi-skilling of doctors and nurses...for reaching service guarantees” given the human resource constraints.
The review was carried out by a 52-member team that surveyed 13 states which included Assam, Bihar, Orissa and Rajasthan in November last year and put together a report assessing the progress of NRHM. The team included 20 non-official members drawn from public health organizations and independent consultants; the rest were from Central and state government health departments. In the next review, the health ministry plans to increase the participation of non-governmental representatives to half the team.
Some experts pointed out the need for a more independent valuation to give a clear and unbiased overview. In the Union budget for 2008-09, the health sector was allocated Rs16,534 crore, an increase of 15% over the preceding year. Of this, Rs12,050 crore, roughly three quarters was earmarked for NRHM, making it the largest fund infusion by the government into the sector. Mandated with bringing “architectural correction” of the public health systems, NRHM was approved by the cabinet in July 2006.
The health ministry official, calling the review a dipstick survey, said “the next one in October-November will be far stricter and will look at service guarantees as well”.
Service guarantees imply that health centres at various levels—primary, community and the district—are actually giving out all the services they are supposed to, at an acceptable level of quality.
NRHM envisages an army of Accredited Social Health Activists (ASHAs)—600,000 women have been recruited so far—as one of the pillars of community health. While the review report calls the recruitment record of ASHAs “numerically impressive”, it has commented on the “considerable lack of role clarity and thus monitoring and direction” for these health workers by the state governments, beyond promoting immunization and child births in medical institutions. The report also found that most non-governmental organizations felt rebuffed, with their services not utilized adequately although they were keen to coordinate for the ASHA programme among other community processes.
One trend the review spotted was that there has been an increase in out-patients, or those not requiring hospitalization, and child deliveries in government-run institutions across states. For example, child deliveries in government facilities of Bihar were 425,253 between April and September 2007—a jump of 62% over the corresponding period in 2006. This increase was credited to what is called the Janani Suraksha Yojna, an initiative that provides cash assistance with delivery and post-delivery care.
Such programmes have created so much traffic in states such as Madhya Pradesh and Orissa that the public health system and its trained personnel have been stretched in servicing them.
The report also pointed to an endemic shortage of nurses and specialists, ensuring that wherever the programme took off driven by demand, it ran into people or infrastructure shortage.