The following is the report of a survey conducted by the Institute of Social Sciences, New Delhi on the National Rural Health Mission (NRHM) and Panchayats.
Just like the Mahatma Gandhi National Rural Employment Guarantee Scheme (MGNREGS), the National Rural Health Mission (NRHM) is another rights-based and flagship programme, which was introduced from 2005 to 2012 in 18 States to improve the health delivery system in rural areas. It was introduced by the Ministry of Health and Welfare of the Government of India. The States in which it has been introduced are: Arunachal Pradesh, Assam, Bihar, Chhattis-garh, Himachal Pradesh, Jharkhand, Jammu and Kashmir, Manipur, Meghalaya, Mizoram, Madhya Pradesh, Nagaland, Odisha, Rajasthan, Sikkim, Tripura, Uttarakhand, and Uttar Pradesh. In the rest of the country, the backward districts came under the scheme. Recently the scheme has been renamed the National Health Mission (NHM), under which the towns and cities will be covered.
Objectives of NRHM
Under this scheme, the term ‘health’ has been defined in a more comprehensive manner. It is defined not only in terms of the well-being of mental and physical health, but also improving sanitation, drinking water, shelter, and assured livelihood which contribute to raising the health conditions of the population. The ultimate goal is to have healthy human resources in order to meet the Millennium Development Goals (MDGs), which are coming to an end in 2015. Further, under this scheme, equal emphasis has been given on all aspects of health care services, such as curative, preventive and rehabilitative care. The branches of treatment consist of both traditional and non-traditional aspects such as allopathic and Ayush. Keeping this in mind, about one million health personnel, out of which 0.8 million are Accredited Social Health Activists (ASHA), have been recruited locally and are trained to act as health educators and facilitators at the community level.
The introduction of the scheme became absolutely necessary because our health indicators are not satisfactory. First, our maternal mortality rate (254 per one hundred thousand population), infant mortality rate (47 per one thousand live births), and incidence of malnutrition among children (46 per cent of the total child population) are worse than the world average. According to the World Bank, India’s healthcare expenditure relative to GDP was 4.1 per cent in 2010. By contrast, Nepal spent 5.5 per cent, and even Afghanistan spent a larger proportion at 7.6 per cent. Germany spent 11.6 per cent, and the United States spent 17.9 per cent. It seems that India would do well to increase its spending in this area.
The Central Role of Panchayats
Yet another feature of the scheme is that it highlighted a bottom-up approach through participatory planning by the community and panchayats. Additionally, the formation of the Health, Nutrition and Sanitation Committee at the panchayat level has been yet another novel approach to address health issues. This is because the Committee comprises panchayat members, micro credit members, and community workers etc. The Committee is entitled to Rs 10,000 as untied funds per year to spend wherever it deems necessary. The grant can be enhanced if the Committee can show the proper utilisation certificate of funds.
In order to give a sense of ownership, it has been envisaged to set up a platform to involve Panchayati Raj Institutions (PRIs) and commu-nities to manage the primary health programme and infrastructure. In order to do that it was necessary to train and enhance the capacity of elected representatives. The aim was that the panchayat members would be able to own, control, and manage public health services. In other words, the panchayats have a very important role in heath issues. The year 2012 is the final year of the Mission. It is important to know to what extent the elected representatives in general and women representatives (EWRs) in particular know about a flagship programme such as the NRHM. In order to gauge the realities on the ground, the Institute of Social Sciences, New Delhi conducted a survey by fielding a structured questionnaire among 400 elected women representatives in 20 States. Those States are: Arunachal Pradesh, Assam, Andhra (though the panchayats are non-functional there), Bihar, Chhattisgarh, Goa, Gujarat, Haryana, Himachal Pradesh, Jammu and Kashmir, Karnataka, Madhya Pradesh, Maha-rashtra, Manipur, Odisha, Rajasthan, Sikkim, Uttar Pradesh, Uttarakhand, and West Bengal.
The overall conclusions that emerged from the survey among the predominantly gram pancha-yats are given below:
First, panchayats play a minimal role inso-far as the implementation of the NRHM is concerned. Not a single woman interviewed by us talked about the preparation of a health plan, which had been mandatory under the NRHM.
Second, the objectives of the NRHM in terms of promoting good health, rehabilitating patients in post-care situations, and preventing occurr-ences of epidemics have not been fulfilled. However, in terms of reaching out to pregnant women in order to increase institutional delivery as well as to reduce maternal and infant mortality, the NRHM’s strategy has been somewhat successful. The success may, however, be partly due to an earlier scheme called the Janani Surakshya Yojana.
The Socio-Economic Background of the EWRs
Of the respondents, 75 per cent were from the village panchayats level and happened to be predominantly ward members. Block panchayat members constituted eight per cent and that of zilla panchayats was nine per cent. The rest were civil society members. With regard to the age composition of the EWRs, it is important to note that 55 per cent of the EWRs were in the age-group of 25-49 and nine per cent were below 20 years of age. In other words, 64 per cent were in the age-group of ‘reproductive phase’, for whom the NRHM is quite important. The respondents in the age-group of above 60 constituted only two per cent. At the State level, it varied from 90 per cent in Odisha to 36 per cent in Rajasthan. As for the caste composition, it is important to note that out of the total respondents, SCs constituted 29 per cent, STs 21 per cent, OBCs 17 per cent, and general 26 per cent. On the other hand, at the disaggregated level the highest percentage of SC respondents (52 per cent) came from Bihar and lowest percentage (seven per cent) came from Madhya Pradesh. With regard to the ST category, Madhya Pradesh topped the list in sending 50 per cent of respondents, whereas Bihar had none.
In terms of the occupational break-up, 41 per cent of the women replied that they were householders, followed by agriculture with 27 per cent and labour with 14 per cent. We also enquired about the duration of their leadership: 82 per cent of them replied that they were first-timers. Second-termers constituted a poor 13 per cent. With regard to their educational qualification it is important to note that almost 80 per cent of them were educated, of which 11 per cent had a college degree. Seventeen per cent had education up to higher secondary, 29 per cent were from the middle school level, and the rest had primary level education. With regard to the major States, respondents from Odisha, Himachal Pradesh, and Karnataka were fully literate, whereas in Haryana the figure was only 50 per cent.
Nature of Heath Care Services available in the Panchayats
At the level of gram panchayat, the existence of a Primary Health Centre/Community Health Centre is absolutely necessary. Fiftyseven per cent of the EWRs reported that they have PHCs, but a whopping 43 per cent of them said ‘no’. Out of the 57 per cent of women who responded positively, 54 per cent said that the PHC/CSC has its own building. But it is encouraging to note that 90 per cent of the structures were made up of pucca houses. The State-level data on the existence of PHCs revealed that in Haryana, 88 per cent respondents replied they don’t have PHCs, leaving Rajasthan the lowest percentage, namely, 21.
In responding to the query as to whether doctors visit the health centre, 51 per cent of them said that ‘yes they do’ but 49 per cent replied in the negative. The State-level picture reflected the grim reality of different States. Bihar figured the highest since 90 per cent of the respondents said that doctors don’t visit the PHCs, while only 21 per cent from Karnataka replied in the negative. How often do the doctors visit the centre? To this 45 per cent out of 51 per cent said daily, 25 per cent said weekly, and 29 per cent said monthly. Insofar as the availability of the para-medical personnel in the centre is concerned, 53 per cent of them said ‘yes’ but 47 per cent of them replied in the negative. At the disaggregated level, Bihar again topped the list with 83 per cent of the interviewees saying that the para-medicos never visited the PHCs, leaving Karnataka in the lowest place.
Availability of Medicine
One of the important components of the NRHM is to provide basic medicines free to the villagers. Fiftyfive per cent of the total EWRs interviewed pointed out that they do get medicine free but 45 per cent said that it was not available. Do they get medicine free? Among the 45 per cent, 88 per cent confirmed that they do. But the remaining 16 per cent of the women said that they have to pay for the same.
Information about ASHA
One of the important strategies of the NRHM is to reach out to pregnant women through Accredited Social Health Activists (ASHA) to improve the health of women as well as to encourage them to go for institutional delivery in the nearby hospital. The objective is to reduce both maternal and infant mortality. ASHA acts as a community worker to bridge between the health personnel and village women. Since the majority of the interviewees were in the age group of reproductive span it was important to know what percentage of them at least knew about the ASHA karmee. It is indeed heartening to know that 89 per cent said that they were aware of the activities of ASHA. It is also interesting to know that wherever ASHA has not been appointed, Anganwadi workers do the needful. In some places, like Himachal Pradesh, both ASHA and Anganwadi workers go together to reach out to the pregnant women. The women talked about the activities of ASHA. Almost all of them said they encouraged pregnant women to get registered at the nearest CSC.
Women from the South said that ASHA also informed about family planning and measures to prevent the onslaught of HIV. Further, some replied that ASHA was involved in vaccinations and had a health kit with her. However, 12 per cent of the EWRs replied that they are unaware of the detailed activities of ASHA. Further, it should be noted that almost all the EWRs knew that both ASHA and the pregnant women were paid if women delivered in the hospital. Everybody also knew that there were provisions for transporting pregnant women when they were in labour, though it was named differently in different States. For example, in Odisha, it is known as the Janani Express but in Bihar it is known by some other name. However, it is equally important to find that transport is hardly available when it is needed. Here also corruption has made inroads quite a bit. Further, the women knew that both ASHA and the pregnant woman get some remuneration just after delivery. However, the women lamented that most of the time the pregnant woman has to pay much more than whatever she gets from the government. Finally, it is important to note that one important component of the NRHM, namely, Ayush, has been completely sidelined since no one talked about that.
Information regarding NRHM
We received a very interesting reply to our query about the information regarding the NRHM and its objectives. Half of the respondents said that they were not aware of the grand objectives of the NRHM. But the level of ignorance is the highest in Haryana (87 per cent) leaving West Bengal (24 per cent), the lowest.
Not knowing about the NRHM could be due partly to the renaming of the health scheme at the State level. For example, the Odisha government has named it as the MAMATA health scheme and in Chhattisgarh it is known as the Mitanin programme. But most of these programmes are geared towards reaching out to pregnant women only. The preventive aspect of the scheme is hardly reflected. To the question, ‘do panchayats get any NRHM related funding?’, 33 per cent said ‘yes’ whereas 56 per cent said ‘no’ and 11 per cent said ‘don’t know’. The amount received under the heading of the NRHM, varied from Rs 50,000 to Rs 10,00,000. Fifty-three per cent vouched for the first amount and the last one was supported by four per cent. However, 36 per cent replied saying that they were ignorant about the grant.
Do they have a Standing Committee on Health?
There was yet another query on the existence of the Standing Committee regarding health, nutrition and sanitation at the panchayat level. The Standing committee is important because it is the monitoring agency for the implementation of the scheme. However, the statistics has some other story to tell. Only 55 per cent of the total EWRs surveyed were aware of the Committee. But 45 per cent did not know anything about it. The State-level scene showed a dismal picture for Bihar just like other health indicators since 83 per cent of the respondents informed us that they didn’t have any Standing Committee whereas that of nine per cent of West Bengal had the same opinion. About the periodicity of Committee members’ meetings, 76 per cent out of 55 per cent said that the Committee met monthly, but nine per cent said it met weekly.
With regard to the range of activities, 35 per cent said that they were not aware of any activities of the Committee, but 24 per cent said that the Committee looked after vaccination and other health related work and 16 per cent replied that it monitored sanitation-related matters. Fourteen per cent said that the Committee looked after development issues such as the construction of roads.
Finally, we were curious to know if the siphoning off of health-related funds takes place or not. Unfortunately, many ward members felt constrained in the presence of the pradhans or other officials. So 55 per cent of them replied that no leakage had been taking place out of funds meant for healthcare. 26 per cent of them said that they were not aware of such leakage and only 19 per cent came forward to say that it ran into lakhs. According to them, Anganwadi workers, sarpanches, BDOs etc. were responsible for such leakage.
Bidyut Mohanty is the Head, Women’s Studies Unit, Institute of Social Sciences, New Delhi.