The (National Rural Health Mission) NRHM make a faulty start. The mission begins with the statement, "The NRHM seeks to provide effective healthcare to the poor, the vulnerable and to marginalized sections of society throughout the country" (Chapter 1, section 2, page 3). Further, in rest of the document it keeps referring to 18 states as the focus area. One acknowledges that these groups need special support form the public health system but the goal of the program cannot be selective because in doing so it distorts the design.It is well established today that anything designed specifically for the poor or marginalized does not work in practice. If universal access is not at the core of the mission then it will never be able to achieve its goals.
Since universal access to comprehensive primary healthcare and referral services, which the 1982 National Health Policy committed, is not stated clearly as a goal, the financing strategy for NRHM also falls into the trap of selective for targeted populations. Hence separate schemes like Rs. 10,000 for untied funds for the subcentres, Rs. 100,000 for rural hospital maintenance if Rogi Kalyan Samitis are formed, Rs. 750,000 per block for training ASHA's etc.. have been worked out, instead of determining what resources would the proposed package of services require in order to implement it.
For 2005-06, the mission document states that Rs. 6713 crore have been allocated for NRHM. If we look at the 2005-06 Central government budget we do not see NRHM figuring as a separate budget item. Infact, NRHM is going to use funds of existing programs like RCH-2, NDCP, Integrated Disease Surveillance Project and the AYUSH program (Annex 5, page 3). NRHM is being seen as an omnibus for the above programs (Chapter 3, page 12).
Thus in effect NRHM is only a label for selected activities from amongst existing programs. The only "new" component is the ASHA scheme, which is actually a revival of the erstwhile CHV scheme of 1978, which became defunct in the nineties in most states.
At the national level today the Central and State governments spend about Rs.25,000 crore annually on healthcare (excluding water supply and sanitation), which is just about one percent of GDP. If these resources were to be distributed on a per capita basis equitably, then rural healthcare should get Rs. 17,500 crore in contrast to about Rs. 10,000 crore it receives today. Of course, this does not happen because the more expensive hospital services and the elaborate health bureaucracy are located in urban areas.
There was great expectation that the Budget 2005-06 will make a marked deviation using the NRHM as the peg for at least launching a process for changing the political economy of healthcare in India. Unfortunately the only mention of the NRHM within the budget is in the Finance Minister's speech, "The National Rural Health Mission (NRHM) will be launched in the next fiscal. Its focus will be strengthening primary health care through grass root level public health interventions based on community ownership. The total allocation for the Department of Health and the Department of Family Welfare will increase from Rs.8,420 crore in the current year to Rs.10,280 crore in the next year. The increase will finance the NRHM and its components like training of health volunteers, providing more medicines and strengthening the primary and community health centre system."
When we look at the expenditure budgets and demand for grants of Budget 2005-06 we find that there is no mention of NRHM as an item of expenditure. The Finance Minister says that the increase (Rs. 1860 crore) over the previous budget will finance the NRHM component. This overall increase of 24% in the budget appears substantial and if it were to be divided equally among all PHCs then each PHC would get additionally about Rs. 8 lakhs. However the budgetary allocations belie this fact when we see that the increase for the HIV/AIDS program is 105% from Rs. 232 crore in 2004-05 to Rs. 476.5 crore in 2005-6. Similarly for the RCH program the increase is a whopping 94% from Rs. 710.51 crore to Rs. 1380.68 crore, for medical education also a high of 50% from Rs. 912.82 crore to Rs. 1360.78 crore and as much as 80% for Indian Systems of Medicine and Homoeopathy (AYUSH) from Rs. 225.73 crore to Rs. 405.98 crore. Just these four programs account for Rs. 1543 crore (or 83%) of the increased amount of Rs. 1860 crore.
Thus the FMs statement in the budget speech is clearly a populist pronouncement and like all such pronouncements of past budgets similar to the various versions of health insurance packages of different finance ministers, sickness assistance funds etc.. is pure gas and will disappear as soon as the budget euphoria dies down. The overall budget of the Ministry of Health and Family Welfare is outlined below:
Those in decision making positions at the Centre and State levels feel that increased resources in the rural areas will not help because there is limited "absorption capacity". Hence, unwillingness on behalf of these decision makers for fiscal devolution to the district and panchayat levels. This business of absorption capacity is a façade.
While governments have created the infrastructure, like hospitals, primary health centres, subcentres etc., they have not endeavored to assure that the complete inputs for the efficient functioning of these are provided. The government's own RCH Facility surveys highlights the pathetic conditions of public healthcare facilities, which is largely due to inadequate resources being allocated, but very little has been done to use this most valuable information to improve the public healthcare facilities.
Thus this absorption capacity pretense has no meaning; it is sheer indolence that drives this belief leading to curtailment and/or non-allocation of resources for peripheral health institutions. If autonomy is given to districts and panchayats to use resources as per their local needs and demands within a defined framework that is open to social audit then one will see a wide range of innovations in setting up local healthcare delivery systems and provision of healthcare for the people.
Thus the overall NRHM strategy needs a drastic makeover and reoriented into a universal access framework for which financial resources need to be determined on the basis of needs and demands of people, and this would be best met if resource allocations are based on an assessments of such needs and demands and given to local governments to plan their use autonomously.
To conclude the NRHM should be used as an opportunity to work out a new health financing strategy, which devolves financial resources to local governments and uses a social audit framework to monitor its implementation.
(The author iswith Centre for Enquiry into Health and Allied Themes, Courtesy: Jan Swasthya Abhiyan, a Health NGO)