The district of Gadchiroli in Maharashtra, better known for deaths from conflict between CRPF forces and the Naxalites is also home to the Madia Gond, one of India’s oldest tribes and most vulnerable to the worst manifestation of malaria – celebral malaria. The Primary Healthcare Centres (PHC) that should to serve the hamlets is not functional.
This story seems a paradox of sorts when the National Rural Health Mission and the recent Srinath Reddy report suggesting Universal Health Care target inclusion in health facilities. Is there a need to look deeper?
Public health in its present form can be traced back to the 1943 Bhore committee, under Joseph Bhore which recommended a framework to develop a free-access network of hospitals and health centers around the country. This model failed due to a lack of funds.
Current public health commitments took shape in a 1978 WHO conference called Alma-Ata in Kazakhstan. It declared the prospect of ‘Health for All’ by 2000 and held that health was a basic human right. The declaration also relied on ‘political will’ to mobilize a country’s resources. However, as Dr. Binayak Sen points out “The authors of the declaration have worked out one mighty shotgun burst of social engineering and left one lonely cowboy called “political will” to pull the trigger.”
The Alma-Ata declaration was replaced by the Millennium Development Goals (MDGs) in 2000. In order to achieve uniform health care facilities by the year 2015, the United Progressive Alliance government began its National Rural Health Mission (NRHM) in 2005.
At its core, the NRHM focuses on the MDG of reducing infant and maternal mortality. It also aims at more power to the panchayati raj. Public-private partnerships (PPPs) in the rural health sector were encouraged to increase the flow of funds, along with a provision for health insurance. In 2010, the proportion of GDP spent on health was 4.1 per cent, according to the World Health Organisation – a considerable increase from the 2008 figure of 1.2 per cent.
However, the NRHM is plagued with as many problems as India’s villages. Shyam Ashtekar, in a 2008 article says “The utilisation of NRHM funds in states is both tardy and ineffective.”
Dr. Sen outlines the major health problems faced by India’s villages including chronic hunger (BMI of a third of Indian adults is below 18.5 per cent according to the National Nutrition Monitoring Bureau), anaemia, maternal mortality due to intra-uterine malnutrition and poor sanitation resulting in numerous infectious diseases.
The inability of the Indian health infrastructure to tackle such a wide range of problems may be attributed to an ailing NRHM, dysfunctional public-private partnership and excessive dependence on imported vaccines.
First, for the NRHM’s main function of reducing infant and maternal mortality, ASHAs or Accredited Social Health Activists programme was implemented, to encourage institutional births against traditional home delivery.
ASHAs escort expectant mothers to a public or private hospital for which both ASHAs and the mother are given incentives. However, as Ashtekar points out, the ASHAs have been reduced from a ‘committed worker’ to a ‘lackey of the system’.
The ASHA system also tries to edge out the Dais or traditional midwives. With most women still favoring the dai system, by not providing them support, infant and maternal mortality rates could rise.
PPP in public health has found support as a “practical solution for the dismal state of national health”, according to Ashtekar or criticism as Binayak Sen displays its exploitative nature in states like Chattisgarh where nearly two million dollars was spent to set up a private heart care centre at the Raipur Medical College.
A third aspect of the NRHM is the dependence on imported vaccines. Sen says that India’s capacity of manufacturing vaccines was one of the most advanced in the world; instead India has been reduced to importing vaccines for one-sixth of its population.
The structure of the NRHM makes it dependent on the people who staff it, people who are grossly underpaid. The number of doctors in rural centres is dismally low. As Ashtekar states, “The annual salary given to doctors is so low (Rs 12,000-18,000 per month) that it acts as a deterrent to the commitment of the doctors.”
The NRHM was aimed for completion this year, with a considerable improvement in levels of hygiene, nutrition, sanitation and drinking water, but this promised architectural correction in the basic health care system has not been achieved. Further, in the seven years of the NRHM, the scheme has received bleak coverage in mainstream media – a horrifying trend.