The Doctor Is Out
- Rs 1,30,000 crore National Rural Health Mission launched in 2006
- Planning Commission says human resources a big problem for the NRHM
- Severe shortage of trained medical, managerial and administrative staff
- NRHM wants “architectural changes” in rural health system, decentralising of allocated projects in the states
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The National Rural Health Mission (NRHM), launched in 2006 as the UPA’s flagship project that would dramatically change the healthcare system in rural India, is already under review. Three years on, the general consensus within the Planning Commission and international partners is that there are several shortfalls on the supply side and that there is a need to reorient the mission.
For a project with a budget of over Rs 1,30,000 crore, it’s human resource that’s proved to be the deficiency. The NRHM was aimed at making ‘architectural changes’ in the public delivery system by increasing communitisation and decentralisation with a focus on 18 states over seven years. However, a severe shortage of trained/skilled medical staff is impacting the project’s capacity to deliver, says a recent primary evaluation done by the Planning Commission in four states. Kaveri Gill, who wrote the May ’09 working paper for the Commission, says: “Human resources is probably the project’s single largest challenge. It is most complex and requires a long-term solution in terms of education and training.”
In her paper, detailed from a study in Andhra Pradesh, UP, Bihar and Rajasthan, she highlights the problem of staff shortage, absenteeism, lack of managerial staff leading to large amounts of the allocated funds remaining unspent. “Health is a state subject. And with centrally sponsored schemes such as the NRHM, the problem of who takes ownership or credit comes up. Not all states are equally responsive,” notes Gill.
An increase in institutional delivery is one of the more celebrated achievements of the NRHM, with officials attributing the fall in Maternal Mortality Rate to it. But ground reports claim the infrastructure is inadequate to support the demand. “There has been a surge of women patients but the infrastructure to cope with them is inadequate. They are given one meal a day and post-partum care is inadequate,” says Kimberley Allen, a UNICEF health specialist. World Bank health specialist Vikram Rajan adds, “You want to move to a model that pays less for inputs but more for results. The Indian government needs to look at the centrally sponsored schemes and stimulate behaviours from the states with some intense handholding.”
With the onus on the states, NRHM projects have naturally received varying degrees of focus. Recent figures show that apart from Bihar, where a large chunk of funds are lying unspent, other states have shown an increase in capacity in the past one year. But a lot more needs to be done. “What is going to hold India back is 6-7 poorly performing states. We have to go beyond what the NRHM has done so far and start introducing more managerial capacity in these states,” says Gerard M. La Forgia, lead health specialist, South Asia Human Development Department, World Bank.
The government, of course, also wants critics to be sensitive to the difficulties. Says Amarjeet Sinha, joint secretary in the Union health ministry, “We are on the right track but it will take some time before the results show.... Every year, we produce 33,000 medical graduates but very few come into the public system so we are developing incentives for them.” Tamil Nadu has reserved 50 per cent of seats in PG courses for those who have served in rural areas. Now 18 other states are adopting the same system. “Measures are being taken now to get doctors back into the public system. There are challenges in human resources...we are trying to overcome them,” says Sinha. Overcome challenges, that’s the key if mega projects like the NRHM are to deliver optimal results.