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Modi govt moves to rectify lacunae in rural health architecture

( By Neeraj Bajpai)

Ten years down the line since the National Rural Health Mission (NRHM) was put in place, challenges to ensure quality and affordable health services in large swathes of the country’s rural belts are being tackled with renewed vigour. Latest rural health statistics reveal that gaps are to be bridged and much has been accomplished despite a plethora of challenges on the road in the wake of increasing expectations in rural regions.

Manpower has been increased and infrastructure refurbished for the rural health set up to match ever increasing aspirations of people who are becoming more aware of quality health services available in urban stretches and government endeavours to improve health care delivery in rural regions. At some places ,more facilities and manpower are required lest it cast an adverse impact on the services.The NRHM common review commission has undertaken a close look on the set up to improve services .

The National Democratic Alliance (NDA) government, led by Prime Minister Narendra Modi, is exploring ways and means to ensure proper utilisation of public spending on the system, confronted with multiple challenges. Several state governments are also intensifying efforts to ensure sound healthcare in rural belts.

The NRHM seeks to provide effective healthcare to rural population throughout the country with special focus on 18 States, which have weak public health indicators and infrastructure. The States are Arunachal Pradesh, Assam, Bihar, Chhattisgarh, Himachal Pradesh, Jharkhand, Jammu & Kashmir, Manipur, Mizoram, Meghalaya, Madhya Pradesh, Nagaland, Odisha, Rajasthan, Sikkim, Tripura, Uttarakhand and Uttar Pradesh.

NRHM aims to undertake architectural correction of the health system to enable it to effectively handle increased allocations and promote policies that strengthen public health management and service delivery in the country. It seeks decentralisation of programmes for district management of health and to address the inter-State and inter-district disparities, with emphasis on the 18 high focus States, including unmet needs for public health infrastructure. It also seeks to improve access of rural people, especially poor women and children, to equitable, affordable, accountable and effective primary healthcare.

The last common review commission which had met late last year found some “encouraging facts” like adequate number of health facilities as per population norms in most states except Uttar Pradesh, Uttarakhand, and Bihar, the investment in infrastructure responsive to caseloads and increasing trends in OPD load at every level.

The findings also revealed availability of secondary care at district hospitals in most states, except districts in Uttarakhand (Tehri), Chhattisgarh (Jashpur), and Uttar Pradesh (Shravasti);Tamil Nadu and Kerala demonstrate relatively better availability of services at SDH/Taluka level as compared to other states.

Other features include laboratory services at sub-district level are available but not comprehensive; Tamil Nadu has a robust system of diagnostics, Odisha has taken efforts towards integration of laboratory services across various programs and optimise HR utilisation; co-location of AYUSH services in most states;and increased utilisation of 108 ambulances.

The review commission had also highlighted some concerns which inter alia include availability of radiological investigations only at district level in most contexts; Range of diagnostic services is limited at Sub-District level hospital and below and assured OPD care at sub-district level is still a challenge in most states.

It also found that time to care approach is yet to set in across the States; Non-Integration of various models of ambulances leading ineffective utilisation;Under utilisation of Mobile Medical Units; Grievance redressal mechanisms yet to be established & where available, their effectiveness is limited. Informatively, the NRHM is an articulation of the commitment of the government to raise to 2-3% public spending on health from 0.9% of GDP.

After the review commission meeting, another survey was conducted mainly to collect statistics. The latest rural health figures has highlighted that as on March 31, this year, 8.1% of the PHCs (primary health centres) were without a doctor, 38.1% a lab technician and 21.9% a pharmacist. The Community Health Centres (CHC) provide specialised medical care of surgeons, obstetricians & gynaecologists, physicians and paediatricians.

The latest survey, which compiled data on various parameters, found that progress has been made on various fronts but experts feel the limited public spending is one of the key reasons which hobbled development of the sound rural health network, and medical crisis spell doom for families running on shoestring or zero budget as they have no means to afford timely and quality healthcare.

The survey noted that in India, 1,022 Sub Divisional/ Sub District Hospitals were functioning till March. At Sub Divisional/Sub District Hospitals, there are 10,018 doctors available. In addition to the doctors, about 26,717 paramedical staffs are also available at Sub Divisional/ Sub District Hospitals.

As many as 763 District Hospitals are functioning with 18,437 doctors available. In addition, about 55,642 para medical staff were also available at District Hospitals as on March 31, 2015. Diarrhoea, typhoid, infectious hepatitis, worm infestations, measles, tuberculosis, whooping cough, respiratory infections, pneumonia and reproductive tract infections were also very common in rural pockets. Maternity and child mortality were high. Almost 50 percent of the rural mothers were said to experience post partum illnesses six weeks after delivery.

The current position of specialist manpower at CHCs reveals that as on March, 2015, out of the sanctioned posts, 74.6% of surgeons, 65.4% of obstetricians & gynaecologists, 68.1% of physicians and 62.8% of paediatricians were vacant. Overall, 67.6% of the sanctioned posts of specialists at CHCs were vacant.

Moreover, as compared to requirement for existing infrastructure, there was a shortfall of 83.4% of surgeons, 76.3% of obstetricians & gynaecologists, 83.0% of physicians and 82.1% of paediatricians. Overall, there was a shortfall of 81.2% specialists at the CHCs.

The shortfall of specialists is significantly high in most of the States. As on March 31, 2015, there were 153,655 Sub Centres (SCs), 25,308 Primary Health Centres (PHCs) and 5,396 Community Health Centres (CHCs) functioning in the country.

While the Sub Centres, PHCs and CHCs have increased in number in 2014-15, they are not sufficient to meet their population norm, the government survey had pointed out. Experts say unless public spending was increased on health, the infrastructure despite having bare minimum staff and facilities, it would not be able meet needs of patients in remote and inhospitable terrain. Locals do not have adequate funds to meet expenditure on medical treatment and the government has to ensure free distribution of generic drugs. Many of them say that corruption and middle level players had to be bridled to ensure that every penny spent on health services reaches the needy in time.

Surveillance must be mounted to control the existing staff too and frequents raids on rural health centres of all types were the need of the hour. Number of existing Sub Centres increased from 146,026 in 2005 to 153,655 by March 2015. There is significant increase in the number of Sub Centres in the States of Chhattisgarh, Gujarat, Jammu & Kashmir, Karnataka, Odisha, Rajasthan, Tripura and Uttarakhand.

There has been an addition of 1,329 Sub Centres, during the year 2014-15. Significant increases in the number of Sub Centres have been reported in the States of Gujarat (789) and Madhya Pradesh (428). Percentage of Sub Centres functioning in Government buildings has increased from 50% in 2005 to 67.5% in 2015.
The increase is mainly due to addition in the number of government buildings in the States of Assam, Chhattisgarh, Karnataka, Madhya Pradesh, Maharashtra, Odisha, Punjab, Rajasthan, Tripura, Uttarakhand, Uttar Pradesh and West Bengal. As on March 31, the overall shortfall in the posts of HW(F)/ ANM( Auxiliary Nurse Midwife ) at SCs & PHCs was 5.21% of the total requirement, mainly due to shortfall in the states of Arunachal Pradesh, Chhattisgarh, Gujarat, Himachal Pradesh, Karnataka, Rajasthan, Tamil Nadu, Tripura, Uttarakhand and Uttar Pradesh.

Number of PHCs has risen by 2072 during the period 2005-2015.Significant increase is observed in the number of PHCs in the States of Assam, Bihar, Chhattisgarh, Jammu & Kashmir, Karnataka and Rajasthan.
The number of PHCs has increased by 288 during the year 2014-15. Significant increases in the number of PHCs have been observed in the States of Karnataka (120) and Gujarat (89). Number of ANMs at Sub Centres and PHCs has increased from 133,194 in 2005 to 212,185 in 2015.

Percentage of PHCs functioning in government buildings has increased significantly from 78% in 2005 to 89.5% in 2015. This is mainly due to increase in the government buildings in the States of Assam, Chhattisgarh, Gujarat, Karnataka, Madhya Pradesh, Maharashtra, and Uttar Pradesh. The number of allopathic doctors at PHCs has increased from 20,308 in 2005 to 27,421 in 2015, which is about 35.0% increase.
The statistics say shortfall of allopathic doctors in PHCs was 11.9% of the total requirement for existing infrastructure. Number of Community Health Centres (CHC ) has increased by 2050 during the period 2005-2015.
Significant increase is observed in the number of CHCs in the States of Gujarat, Jharkhand, Kerala, Madhya Pradesh, Odisha, Rajasthan, Tamil Nadu, Uttar Pradesh and West Bengal. There has been an augmentation of 33 CHCs from the number reported upto March, 2014. Significant increase in the number of CHCs was observed in the State of Gujarat (20). Number of CHCs functioning in government buildings has also increased during the period 2005-2015.
The percentage of CHCs in Govt. buildings has increased from 91.6% in 2005 to 95.1% in 2015. Significant increase in the number of paramedical staff is also observed in 2015 when compared with the position of 2005. In addition to 4,078 Specialists, 11,822 General Duty Medical Officers (GDMOs) are also available at CHCs. There was huge shortfall of surgeons (83.4%), obstetricians & gynaecologists (76.3%), physicians (83.0%) and paediatricians (82.1%).

Overall, there was a shortfall of 81.2% specialists at the CHCs vis-a-vis the requirement for existing CHCs. While the number of Sub Centres, PHCs and CHCs have increased during the year 2014-15, the number of ANMs, Specialists & Radiographers declined, though marginally from the position in 2013.

The number of ANMs at Sub Centres and PHCs has declined from 2,13,400 in 2014 to 2,12,185 in 2015 (decrease of 1,215). Major reductions are observed in the States of Maharashtra (466), Tamil Nadu (619), Jammu & Kashmir (292), Rajasthan (259), Tripura (185) and Madhya Pradesh (168). Similarly, the number of allopathic doctors at PHCs increased from 27,355 in 2014 to 27,421 in 2015.

There are significant increases in the States of Maharashtra (431), Rajasthan (301), Tamil Nadu (236) and Haryana (94). Major reduction is observed in the State of Jammu & Kashmir (390). Regarding the specialist doctors at CHCs, the number has declined from 4,091 in 2014 to 4,078 in 2015. Major decreases have been noticed in the States of Rajasthan and Punjab .

{*Neeraj Bajpai is joint Editor with United New of India(UNI)}

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