Not In The Best of Health

The National Rural Health Mission (NRHM) was launched in India in 2005 to improve health care delivery across rural areas in the country. This flagship scheme proposed a number of innovative mechanisms for improving the healthcare delivery system in rural areas, such as training local residents as voluntary workers, Accredited Social Health Activists (ASHAs) and the Janani Suraksha Yojana. While the general aim of the NRHM was to improve the healthcare infrastructure in rural areas, specific objectives included :

  •  Reducing the Infant Mortality Rate (IMR) and the Maternal Mortality Ratio (MMR).
  •  Providing full and universal access to public health services including child health, water, sanitation, immunisation, nutrition and women’s health.
  •  Creating a healthy life style and promoting the standard of living.
  •  Maintaining a proper demographic balance and stabilising the population.
  •  Uplifting and improving local health traditions.
  •  Easy availability of comprehensive primary healthcare to all people.
  •  It also aims at mainstreaming the Indian systems of medicine to facilitate health care.
  •  Prevention and control of communicable and non-communicable diseases, including locally endemic diseases.

There were several challenges for the NRHM such as :

  •  Variations according to region.
  •  Irrational distribution of human resources and infrastructure in many of the states.
  •  Inadequate cooperation between different government schemes related to health care.
  •  Taking up ‘re-invention’ of systems of the scheme by the staff.
  •  Creating enthusiasm among the State and District staff, as the States were to take over the financing of the scheme as per plan.
  •  Focusing on social justice as well as on health and diseases.

However, from its inception up till now, although the NRHM has achieved much, it has also left much to be desired. In addition to other problem areas, the shortfall in infrastructural health care facilities in rural India — even though the NRHM is in its seventh year of operation, speaks for itself (see box). Worse, there has been bungling of funds, both by way of corruption and during implementation. Take, for instance, the scam in Uttar Pradesh (UP) in which top bureaucrats and politicians are alleged to have siphoned off an estimated Rs. 10,000 crores from the NRHM. Utilisation of funds for the
programme is another issue hampering the proper implementation of the plan and has resulted in lack of confidence and fatigue in implementing the plan and taking it to a more improved level.
Significantly, the programme was implemented properly in a few states like Odisha and Assam. This raises the question : why did states like Uttar Pradesh and Jharkhand perform so poorly in implementing the NRHM ? The fact is that transparency and accountability are given very low priority. The responsiveness of the State Governments is also a major area of concern as it is the State Governments that are vested with the responsibility of overseeing financing of the plan. Reports suggest that by and large the State Governments are not too pleased on this count. A combination of factors has thus resulted in lack of proper implementation of the plan in many states including Jharkhand and Rajasthan.
There are other issues too, such as those related to the working of ASHAs – the foot soldiers of the scheme. One of the most important issues is that of dwindling support : what will happen to the NRHM if ASHAs, who are the main stakeholders in the plan, leave the health system remains a grey area of concern. Moreover, the process of selecting ASHAs is a lengthy and time consuming one and to find a suitable functionary to replace a single ASHA would take at least a year. Absentee doctors and availability of medicines are problems faced by the plan.
It is essential to post doctors in adequate numbers as the absence of doctors for days on end defeats the purpose of providing good health care to people as and when they need it.

NRHM, Rampant Corruption & Murders

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The NRHM scam in UP came into the open after Chief Medical Officer, Family Welfare, Vinod Kumar Arya, was killed in broad daylight on October 2010. This was soon followed by the killing of CMO BP Singh outside his home on April 2, 2011. In its bid to cover up the scam, the police, allegedly under pressure from higher ups framed Deputy CMO Y.S. Sachan for getting the two doctors killed and he was sent to prison. But on June 22, 2011, Dr. Sachan was also found dead inside the jail premises, with the police trying to dismiss it as a suicide first. Later it was alleged that he too was killed to cover up the scam and despite the official final version, may still believe he was killed. All these murders were related to the rampant corruption in the implementation of the NRHM scheme in UP.

Right  to Health

It is a settled law that right to health is included in the right to life guaranteed by Article 21 of our Constitution. It is indisputable that availability of essential drugs to combat serious diseases is a component of the right to health. If a person on account of poverty or economic disability cannot have access to essential medicines, the cruel reality is that the person is likely to succumb to the fatal disease and the right to life would be violated.
A bench of the Supreme Court comprising Justices G. S. Singhvi and S. J. Mukhopadhaya recently directed the Central Government to give details of steps taken by the Centre to check the prices of 348 drugs on the National List of Essential Medicines (NLEM). The contention of the PIL petitioner before the Court was that though the NLEM had 348 drugs, prices of only 37 medicines were controlled by the National Pharmaceutical Pricing Authority. In the last two years, the Court had repeatedly asked the government to spell out a mechanism to bring under price control regime, essential medicines which are used by poor patients to fight ailments, but that was of no avail. In this context, the Bench asked the secretaries of Ministry of Health and Ministry of Chemicals and Fertilisers to file affidavits stating whether the Union Government wanted to bring essential medicines under the ambit of price control. To some, the Court’s directions are tantamount to the judiciary governing the country. Justice Singhvi speaking for the Bench dispelled this misconception and rightly pointed out that government gets going only when the court steps in and that the court does that when it is essential and unavoidable. When the issue before the court concerns the health and life of citizens, the judiciary cannot prevaricate nor procrastinate. It must respond and the Bench did respond commendably in the interests of numerous poor patients.
-Soli J Sorabjee in the Indian Express

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