Rural Health Mission-Undesirable Features

[dahiyars]

RURAL HEALTH MISSION: UNDESIRABLE FEATURES
The government’s commitment to primary health care is now being sought to be implemented through the proposed Rural Health Mission. However, a reading of the initial drafts of the proposed Mission raise many disturbing concerns. The scheme proposes to hand over large parts of the public health system to private providers and NGOs. It lays emphasis on the need to levy user fees in order to maintain the infrastructure. It is not committed to strengthening the public health infrastructure, but instead proposes to fill the gaps in the infrastructure through private sector participation. An impression is being created that the non-functioning of the public health system is a legitimate reason for resorting to privatisation of the structure. The move towards casualisation and privatisation is evident from the fact that the central government has recently advertised for district level posts of district managers and other personnel in six states of India to manage activities of SCOVA (autonomous organisations or societies registered by the state governments. under the direction of the central government). These personnel are to ensure increasing participation of NGOs and other private institutions in health care. In essence, thus, there appears to be a trend towards moving further away from any commitment in providing comprehensivehealthservicesbythegovernment.

The Rural Health Mission is being tomtommed as evidence of the government’s commitment to providing primary health care. While any initiative to promote larger coverage in rural areas is welcome, the scheme as it stands now is by no means adequate. Even the finances that are sought to be committed to the Mission falls far short of what would be required to put in place a comprehensive health infrastructure. We understand that the government proposes to spend something like Rs 8,000 crores on the Mission over the next five years. This works out to about 0.3 per cent of the GDP per year – in other words just one-tenth of the committed 3 per cent of GDP expenditure on health that the CMP promises. If the Rural Health Mission is to be the only matching action to the CMP’s commitment, it is obviously too little.

The lynchpin of the Mission is going to be the Accredited Social Health Assistant (ASHA), who would be at the centre of the Mission. She is to be paid on the basis of the “cases” she brings in whether for immunisation, institutional deliveries or sterilisations. Any such proposal, which does not make provision for adequate and regular remuneration for the health worker at the village level is clearly unacceptable—it is tantamount to providing poor health care for poor people. The proposed linkage to population control targets is worrying and raises the suspicion that the primary target of the Mission would be to further the government’s stated agenda of a targeted population control programme.

As discussed earlier, the other problematic feature of the proposed Mission is its attempt to privatise health care delivery by soliciting the participation of the private sector. India already has the most privatised health sector in the world with 84 per cent of health expenditure being paid for by the people. Any initiative that seeks to further skew this balance between public and private expenditure needs to be reconsidered. The proposal to set up autonomous State Health Societies at the state level will only open the floodgates for privatisation as these societies would start seeking private funding to keep them going. In essence this would mean the government withdrawing from its role as a health care provider and becoming a mere regulator. We are seeing this happening in areas like the power and telecommunications sectors already.

The Rural Health Mission, thus, needs to consider the above and locate itself in a framework that reaffirms the government’s commitment to providing comprehensive health care to all those who require it. This would require adequate resources, and strengthening of all tiers of the Primary Health Care infrastructure through government funding. Unless the Mission is designed to address the concerns stated above, it will amount to mere tokenism and would further pave the way for privatisation of the health care system. We hope the government will not act in haste to put in place a sloppy mechanism in the name of providing health care to rural areas.
Writter is Dr Amit Sen Gupta from Delhi Science Forum

[devdahiya]

My dear Ranbir singh ji,


I do appreciate the concerns of Dr Amit and public at large,but tell me how best can we deliver the health care in the villages,when there are no electricity,no clean drinking water,no drainage system,no toilets,no infra-structure and so on....

No doctor wants to venture into the rural area,there is no accountability,no monitoring,no supervision and no fear.On the top of it,our people care a damn about their welfare.The streets of my village are the same stinking resorviars as i left them 30 years back[may be worst than that]. Biggest problem is the attitude of our people.they just don' t react to the govt apathy.Maximum approach roads to our villages are in bad state and generally remain so but our people won't react[it is govt job..koe fayda na kahan ka...ke koe suunne se bhai].

Whether it is govt agency or NGOS,till such time our people don't decide and press for WHAT THEY WANT sitution,i am affraid is not going to improve.lip service and cosmatic approach will only harm the broader interest of village community....How many crores get allotted and what % of it gets rightfully spent is another million-dollar question. However,not withstanding what has been said above,Dr AMIT'S & your concerns are not misplaced.


Regards




DEV

[amitdahiya]

Bhai Ranvir/Dev,
When the writer of the post has stated that the present state of health is far from suitable why should he construct such an articulate case for its continuity. It is exactly this kind of contradiction that exposes the weakness of our well intentioned agents of change.

The fact of the matter is that in our state the public health service is riddled with corruption, incompetence and arrogance. Visit any vilage in the affluent districts of Sonepat and Rohtak and what do you find? Dozens of quacks, compounders and even school teachers posing as full fledged doctors and getting away with it. You can imagine what the situation is in the remote districts.

When my Uncle Mukhtiara suffered a stroke recently an incompetent untrained idiot posing as a physician responded to my cousins visit to the hospital at night to catheter him and caused a severe sepsis that killed an extraordinary jat in the most painful way posible. How long do you want this state of affairs to continue? Of course privatisation will bring quality medicare at a price. But the people are already paying that price and receiving nothing, why not try the private route after 50 years of failure and malpractice.

The Mission Task force is openly pro privatisation in this regard and we have been lobbying the government and influence groups actively in this regard and shall continue to do so.
Yours Sincerely
Amit Dahiya

[dahiyars]

Dear Amit

I do agree with you about the ailments of health system.
But question is what should be done?
My views on this point.
Answer is at least NOT PRIVATISATION OF HEALTH . WHERE THE POOR WILL GO?



Socialization of Health in Haryana


In a period of inhuman globalisation the public health is under severe attack. Many countries are engaged in systemic privatization of health services. Public expenditure on health is on decline whereas social causes of diseases are on the rise. All these steps are being taken with a strong publicity campaign that such steps are necessary for improvement of health scenario in Govt. institutions specially its quality. Multifarious problems of the govt. hospitals are being listed and publicized. It is being propagated that the only way to solve them is to dismantle the govt. health delivery system and replace it by a market determined private health system more so of a corporate nature. Even the individual doctor based nursing homes are not able to stand before them. Doctors in general and influential doctors in particular are supporting these changes. Only paramedical staff associations are opposing the privatization of health services in Haryana not because they are concerned about the health of people but because of the fact that their own services are at stake. HCMS doctors association also appears to be least concerned about these changes except their NPA. The health has not been on the people’s agenda. A very small awakened section in Haryana is opposing this corporate privatization and is doing a campaign against exploitation of masses by corporate privatization but this is not having the desired results. It looks like a loosing battle. Even many well intentioned doctors and paramedical staff leaders are getting reconciled to the inevitability of this change i.e. corporate privatization in health system. Because of lack of regulatory system for private doctors and CPA , the credibility of these is also declining.
The main reason behind this defeatism is that there is truth in many points of criticism of the Govt. health delivery system. People in general are far from happy with it. They are compelled to go to private practitioners through their nose. It is another matter that corporate private health sector at least for poorer section of people is not doing much or cannot do much. Overall situation is that already 82% of expenditure is born by the patient himself. In other words 22% being spent by Govt. is also under attack .But there is one question that why the people are not feeling enthused to oppose privatization of health care system? The reason is very clear that why will the people feel enthused to defend a structure which is clearly inefficient and provides only poor quality of health services? Besides the people find the campaign of various organizations in defense of public health delivery system to be motivated by their self interests. It is substantially true that the public health system as it exists today is not paying required attention to the people’s health issues. It is therefore not surprising that the movement of multipurpose health workers association, nurses association, pharmacist association, HCMS doctors association, dental surgeons association and many more associations in support of their demands and against privatization of public health care system is suspect in the eyes of people. Moreover we are functioning in an open society where public health care system do not enjoy monopoly status and given an alternative many patients who can afford would like to shift themselves or their relatives to private sector health institutions. It becomes a question of life and death so even poor people sell their properties or take loans to get the costly treatment.
There are many reasons like anti people policies, rampant corruption, dearth of preventive measures, nepotism, adohcism etc. which result in poor quality of public health care system. All of these need to be addressed for improvement of quality of public health care system.

Public health care institutions are in general alienated from the local community where they are situated and from where they have their patients. The doctors and paramedical staff are selected and appointed by the authorities which are functioning from long distances. Their emoluments are paid by the government the seat of which is not located in the vicinity. The local authorities usually do not control their promotion or punishment. Besides the doctors in public health care system themselves do not often admit and treat their relations in the hospitals where they are in service. Doctors themselves hold a poor opinion of their own hospitals. They may also consider themselves superior to the patients who may belong to socially and economically deprived sections of the population. All these result in a sense of alienation on the part of the staff. They hardly harbor any sense of loyalty or belongingness to the institutions. This sense of alienation is further strengthened by transferability of service.
Local people and patients too suffer from a sense of alienation. When they have any grievance against the hospital or any particular doctor or paramedical staff, they do not dare to articulate them fearing often justifiably, that not only will their grievance not be looked in to but their patients will not be treated properly. On the other hand even if they want to contribute something for the hospital, it is not very easy to do so. In the absence of a healthy exchange between the hospitals and society, the local populace feels alienated.
In the open society where there are many types of hospitals both private and public and of differing quality, the elite usually do not take their own patients in public hospitals. They invariably succeed in getting treatment in better and costlier private nursing homes. In such a society it is rare to find patients from families of ministers, legislatures, businessmen or rich peasants getting treatment in these public hospitals. Thus when decisions are taken for allocation of funds for improvement of quality of health care in public hospitals, the decision makers are personally unconcerned. They may have sympathy but have no stakes in the improvement of public health care system. This too is alienation at another level.
What can be done?
If Public health care system is to be saved it is necessary to fight against this multiform alienation of public health care system. This process can be given the name socialization of public health care system. It is necessary to create an atmosphere where the hospital and society enjoy the healthy rapport and exchange between each other. The society must have a sense of ownership over a public health care institutions. When this becomes possible, the health care infrastructure can freely draw on resources of the society. It is necessary to always keep in mind that the state is only one form of societal organization may be the most famous one. The state will always suffer from paucity of resources. There are always many competing claims on it from different ends. An hospital integrated with, instead of alienated from society, can receive valuable supplementary resources both material and human.( Jeevansala Experience of Samalkha is one example of Socialisation in Education). Apart from the volume of support thus received from nongovernmental sources both individual and organizational, this process can revitalize our public health care institutions. The health care institutions will be answerable to the society where these are situated. The society will take pride in the success of running of the hospital/ health care institution (CHC, PHC or Sub center) and feel vitally concerned when it faces problems and come forward with suggestions and resources for their solution. It had been a healthy tradition in Haryana society. ( most of the school buildings were built by people’s contributions.)
In such a situation hospital/ health care institution will no more be an alien institution dropped if not imposed from outside but actually will belong to the society. Living in the present imperfect situation prospect of achieving socialization of this nature may seem utopian, yet , it can be said that realization of such a level of social interaction is both possible and desirable.
But the real question is how do we break alienation and achieve socialization? Socialisation involves dilution of the control of the state and this can not be done by a fiat of the state. It requires multiform social initiatives—may be initiatives are to be taken by doctors organisations, Indian Medical association, nurses association, multipurpose health worker’s association, pharmacist association, social movements, Gyan Vigyan movement , non governmental organizations, may be community based organizations or by senior citizens. What is commonly termed civil society must play an important role in this process. We know how difficult it is to define or structure civil society organizations. Yet with their variety civil society organizations have an important and positive role to play in it to save public health care system.

Dr.R.S.Dahiya

[amitdahiya]

Dear Ranbir and Dev,

I do believe we get only what we deserve from public utilities and services. Is there a home in our villages where the women do not draw water from the earthen water pot by holding the glass with one finger inside the glass? This simple measure costs us nothing and yet a simple lack of culture change is resonsible for around 50 percent of the Gastro Intestinal disease profile in our state. If we dont address such simple hygeine and preventive issues at our own level in the family and the community what right do we have to expect better from any health service provider whether private or the government.

[devdahiya]

MY DEAR aMIT,


Thats the point i was making, HAR SAAKH PE ULLU BAITHHA HE TO HALE GULISTAAN KYA HOGA.Bhai Amit meri aatma gaawon ki halat dekh ke rotti hei because i am in touch with our village life. I agree that our people in the villages are responsible[partly] for their plight but bhai huum padhe-likhe issi-tissi karawan saan ke.I keep on doing something positive for our people, in whatever smaller way i can do and i will keep doing it till the end of my life.


REGARDS



DEV