India - A mission that's possible

Community-based monitoring has laid bare the inadequacies of the primary health care system in Maharashtra.
Sayvan primary health centre (PHC), a little over 100 km from Mumbai, is a study in neglect. Far removed from the city’s snazzy private hospitals, its dilapidated buildings, non-functional operation theatre and lack of water and sanitation are an accepted reality. As in other Adivasi areas, patients here have to contend with insensitivity apart from the severe shortage of personnel and medicines.
The National Rural Health Mission (NRHM) was introduced in 2005 to improve health care in poor areas with an enhanced funding mechanism.
More than the mission itself, it is the community-based monitoring component introduced in Maharashtra in April 2007, which has emerged as a means of correcting institutionalised deficiencies. Community-based monitoring in 225 villages of five districts of Maharashtra — Thane, Pune, Amravati, Nandurbar and Osmanabad has laid bare the inadequacies of the system. Dr. Nitin Jadhav of Sathi, State coordinator of the Pune-based nodal non-governmental organisation (NGO) for monitoring, says for the first time in the history of health care in Independent India, the government has allowed such a process in nine States in the country. This has resulted in problem solving at the community level itself and it has introduced some accountability in terms of increased visits by medical personnel and more availability of medicines and services.
Data analysed by Sathi from 128 villages in Thane, Pune and Amravati districts shows that while immunisation and anti-natal care were satisfactory, services and the range of services at the PHC were quite bad as also post natal care. Disease surveillance, a service provided by the multipurpose health workers (MPW) was also poor. This reflects on the pathetic quality of health care especially in the Adivasi areas where the data was gathered from. In the Adivasi blocks of Dahanu, Jawhar and Murbad in Thane district infant deaths were reported from more than 33 per cent of the villages.
Structured jansunwais or public hearings have allowed people to speak up before government health officials and NGOs, and the difference is their voices are being heard. Corruption in PHCs, poor health care, lack of services and medicines, unsafe practices have all come to light. These experiences have formed the basis of corrective action in many places. The monitoring looks at how people are treated at PHCs and there are different indicators to assess feedback.
Shortage of doctors
One of the key issues that has emerged is the shortage of doctors and the government openly admits the shortage is acute in Adivasi and rural areas. For instance in Gadchiroli district, there are only ten permanent MBBS doctors, the rest are ad hoc appointments. The need in the district is for 100 MBBS doctors but the rest of the vacancies have been filled by Bachelor of Ayurvedic Medicine and Surgery (BAMS) graduates. According to official statistics, of the 439 sanctioned posts for class 1 medical officers in rural areas, 290 are vacant. In urban areas too, the sanctioned class 1 posts are 965 with only 469 filled. Overall in the State, of the sanctioned posts for doctors at a senior level (as of June 2008), of the 1440 posts, 781 are vacant. At the PHC level of 7,281 posts, 667 are vacant. The official position is that 30 to 40 per cent of the vacancies are taken care of by ad hoc appointments with an 11-month tenure which is renewable. About 50 per cent of the posts are permanently filled while 10 per cent almost always remain vacant. Absenteeism is another problem and the existing doctors have poor outreach. Some PHCs are located more than 25 km away from villages. A reorganisation of PHCs, which have sometimes been built for political convenience rather than people’s needs is worth thinking about.
Medical graduates are expected to serve a two -year tenure in government service or pay Rs. 2 lakhs in default. Next year this will be increased to Rs. 5 lakhs but going by past experience, it is doubtful if that will make a dent in the availability of doctors. Of the 3,000-odd medical students who graduate every year in the state, hardly 100 join government service, a senior health official pointed out. Poor pay, pathetic living conditions and lack of basic facilities like housing or schooling for children are a severe deterrent.
It is not only MBBS doctors who are in short supply, there is also a shortage of health assistants, multipurpose health workers (MPWs) and auxiliary nurse midwives (ANMs) in the State. Since the MPWs and ANMs work closely with the local people it is here that a serious lacuna is felt. The National Family Health Survey (NFHS-3) 2005-06 says that more than one in ten rural women did not receive any ante-natal care and Scheduled Tribe women were less likely than women belonging to any other caste/tribe to have received ante-natal care. One in three births in Maharashtra still takes place at home.
The NRHM has changed the articulation of health care by pumping in money as a senior health official put it. How this money is being used is debatable, though in some places, buildings are being repaired, equipment is being bought and health experts are being hired. The mission provides Rs. 60 crores to each taluka for expenses and at the public hearings the health officials often spoke with great glee about the “untied funds.” With Rs. 1,000 crores as the annual budget for Maharashtra, NRHM seeks to correct many imbalances.
Community-based monitoring is being taken very seriously by the authorities and there are plans to extend it to seven more districts in the State. However, the government has to realise that while funds are crucial, it cannot make up for the lack of doctors in areas where they are most needed.
The NFHS-3 report does not give a favourable picture of the State’s health. Forty-six per cent children under age five are stunted, and only half the adults in the State are at a healthy weight for their height. Anaemia, chronic malnutrition, a high perinatal mortality are persistent issues and these cannot be solved by enhanced funding alone. Facts in the NFHS report should at least spur the government to immediately tackle shortage in health service personnel. Merely signing bonds and fining people is not going to serve the purpose as has been proved. The government has to display political will and ensure that maximum benefits are realised under NRHM by using people’s participation as a basis for increased accountability and services.