With the eradication of infectious diseases like small pox and yaws, as a nation we have won many battles in the war towards achieving the goal, “ Health for All”. The biggest leap can happen only when the disparity in the health care options and services is alleviated. The National Rural Health Mission (NRHM) emphasizes on primary health through decentralization. This can be regarded as the hallmark of our welfare society and the Central government’s attempt to improve the quality and accessibility to the basic tenets of healthcare.
As a part of the study on the utilization pattern of the Untied funds of NRHM, in collaboration with SHSRC (State Health System Resource Centre), my colleague Prakhya and I headed to visit the health facilities in rural Bangalore. While our colleagues were collecting formal data through questionnaires and surveys, our aim was to explore, observe and experience first hand the functioning of the various tiers of healthcare infrastructure in the state.
Our first quest took us to the Public Health Unit (PHU) in Chikajala, off the Devanahalli Highway. This PHU is newly established and runs in a building donated by ITC which has a factory setting close by. Though funds are allocated as per the NRHM guidelines, the officers faced several hindrances in its efficient utilization. We understood that due to a delay in release, the funds are not ready at hand at all times of the year. Though the national guidelines clearly state that the centers are not required to take approval prior to the expenditure, the officials here were mandated to quote a statement for any expense exceeding Rs 500 at advance notice. The PRI President who is a co-signatory for the allotted untied funds and a secretary of the ARS (Arogya Raksha Samiti/Hospital management committee) often does not understand the technical nuances that deem monetary backing. This reflects on a deficit in training and orientation causing hiccups in fund disembursement.
We visited two other PHCs (Primary Health Centre) in Bettahalsur and Sarjapura, which offer an array of services to the population. Overall the patients appear to be satisfied, especially with the MCH (Maternal and Child Health) program. We happened to visit the centre on a Thursday, which is allotted for immunization and ANC (Ante Natal Care). Some of the patients were of the opinion that the ambience could be more hygienic. Also, the doctors at the PHC were often absent from duty due to ARS/State meetings that hampered access to care.
Interaction with the ASHA (Accredited Social Health Activist) workers indicated that they were motivated and upheld their social responsibilities. However, since these women come from financially strapped households, they requested for a fixed salary to be awarded in addition to incentive based remuneration. The month long ASHA training renders them competent to advise and guide women through pregnancy and infant care. However, they need to be trained on HIV& AIDS, Hep-B infections, DOTS, POA in case of disease outbreak and fund utilization guidelines.
The ASHAs are caught up in a labyrinthine of social, economic and political issues that affect their efficiency. Being a woman, it is frowned upon for her to communicate with a male resident of the village on sensitive topics like contraception, HIV& AIDS etc. The villagers are often impertinent and disregard the ASHA’s recommendations. She is strapped into political controversies with the PRI President, who demands commission to release the VHSC (Village Health and Sanitation Committee) funds.
The ASHA is the bond between the people and primary care. In my opinion this is one of the strong aspects of the NRHM that helps to reach out to each and every individual. Offering her a stipulated fixed salary, making her technically competent through training, could empower the ASHA.
A bumpy auto ride took us through the gravel roads and lush greenery away from Bangalore to the CHC (Community Health Centre) at Annekal Taluk. What baffled us most was when we were told that this institution did not have a radiologist and scanning equipment, despite NRHM regulations. The radiologist had private clinic in the town, which left the pregnant women with the choice to either pay the practitioner (out of pocket expense for a service which has to be free) or travel all the way to Bangalore (The bad roads make it impossible for a pregnant woman to travel). Lack of a PNC (Post Natal Care/ Delivery Room) ward and the general lack of hygiene were some other issues observed. As stated by one medical officer at the CHC, there is lack of awareness about facilities like MCH Food Program, which results in misuse of funds by the officers.
Pausing here, I would like to risk a few analogies that I have drawn from these experiences and having read the article by Pritchell. The NRHM, being a central initiative can be compared to the “ Head”, which independently is so strong that it has remained sound despite teetering opinions and conflicts. But, this head is not connected by a network of nerves and sinews to its limbs, rendering our healthcare system “Quadriplegic”*. Though excellent policies and programs have been formulated in nearly every domain, there is lack of coordination and flail in implementation. As a research organization we at the Centre for Budget and Policy Studies believe that healthcare is a right and not a privilege and hope that our study on the untied funds of the NRHM will render us as a more useful tool in addressing the issues of public health services in our state.