Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Healthcare - the Indian Paradox
- Susheel Oommen John (22 April 2005)
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Revival of the Fittest: ASHA for Indian Rural Health
- DHRUV L MANKAD, NASIK, ROAD INDIA 422006 (22 April 2005)
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National Rural Health Mission : What can be achieved
- Umesh Kapil, Nil (23 April 2005)
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Role of Volunteers
- TAPASVI PUWAR (24 April 2005)
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Better Indian health: need for a fresh outlook
- Sandeepa Chauhan, Shruti Chauhan, Shivendra Pratap Singh Chauhan (25 April 2005)
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Need for change
- Dr. Dr. Akhilesh Kumar Singh.MBBS, MD, Dr. Parul Kushwah.MBBS, MISCD., Dr. Rajesh Chauhan. MBBS (AFMC), DFM, FCGP, ADHA, FISCD (26 April 2005)
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Allopathic Holistic Health Care for India's National (Rural )Health Mission For All. .
- Dr.Hanamaraddi.T Gangal (2 May 2005)
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It is time to learn to ask; Are the target communities being asked what they want?
- Dr. Beena Nayak, IIM, Ahmedabad. India (8 May 2007)
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Susheel Oommen John, Consultant The Leprosy Mission, New Delhi 110 001
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The National Rural Health Mission is an ambitious yet sincere effort of India's Health Ministry. It is reassuring to note that the commitment to raise the annual spending on healthcare to more than 2% of the GDP, which had fallen to 0.9% in the past few years. India is a land of striking inequalities, more than 70% of its population lives in rural areas, where only 20% of the total hospital beds are located. Yet India is proudly announcing that it is ready to cater to "health tourists" from the developed world. The advances in health care are accessible to only a very small percentage of Indians, with the influx of medical tourists the healthcare inequality is bound to widen. The corporate hospitals are well known for their "poaching" doctors from government and teaching institutions, luring them with huge sums of money, this often paralizes the government healthcare infrastructure. How can a country allow its doctors who were educated at the Governments expenses, to cater the affluent patients of the developed nations when more than 1300 people die every single day of a completely curable disease like Tuberculosis. Most of the medical education in India is government sponsored, however there are no mechanisms in place to ensure that the beneficiaries of this subsidized education pay back the people who have contributed to their education. India is probably the worlds leading exporter of trained medical professionals (doctors, nurses, Para medical workers). In other words some of the worlds poorest people living in rural India actually subsidize the medical care provided to people from developed nations, either in the form of health tourism or "export" of medical skills. Only when these issues are addressed can the Rural Health Mission become successful, after all quality healthcare delivery requires that trained professionals are made available where they are most needed. Competing interests: None declared |
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DHRUV L MANKAD, Jt Programme Organizor MITTRA , Bodhalenagar,, NASIK, ROAD INDIA 422006
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Rural India is suffering from a long-standing healthcare problem. To say that inadequate, inaccessible and unaffordable healthcare facilities, public or private is a common symptom in India, is almost a cliché’. Studies have shown that only one trained healthcare provider including a doctor with any degree is available per every 16 villages. Even in urban areas, medical graduate is a rare species. Most graduates have the ambition to go for specialities and superspeciality trainings. Therefore, producing more doctors who would not go abroad does not ensure adequately armed primary health care service. Most of the health problems the rural community suffer are preventable and easily treatable e.g. anemia, diarrhea, malaria, pneumonia and tuberculosis, malnutrition, injuries and bites etc. They are often main killers of the children, women and men. Adequate and safe water supply, ample nutritious food, wastewater disposal and adequate safe housing along with special care to children and mother and availability of someone providing primary medical care Where There is No Doctor is a recognized approach to tackle this problem. National Rural Health Mission’s declaration of raising a cadre of Accredited Social Health Activist (ASHA, which in Indian national language means Hope!) in India is a Revival of this Fittest approach to provide such basic healthcare services. Earlier, the Government of India had implemented such an approach in 1978 through a Community Health Worker Scheme (CHW), but it failed to fulfill the purpose for which it was initiated. Similar programs like the Jan Swasthya Rakshak (JSR meaning Peoples’ Health Guard) Scheme had several hitches both in its implementation and in its impact. Therefore, cautions are essential while designing and implementing such a program to ensure its success. First, the ASHA cadre should be representing the community's interest, which has ‘accredited’ it. It cannot be the last chain of existing primary health care infrastructure but an interface between the community and the public health care system. Secondly, the ASHA would need to have a sustained motivation through adequate and frequent, learner centered training, social support by the peer group and financial reimbursement of the wage-time lost. Finally, the most important caution would be to integrate healthcare with other development services like availability of safe drinking water, public system for food grain distribution and for guaranteed employment, adequate transportation for timely referral etc. Only then, the Survival of this Fittest approach of ASHA for community based primary health care could be ensured. mankad_nsk@sancharnet.in Competing interests: None declared |
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Umesh Kapil, Professor All India Institute of Medical; Sciences,New delhi, India, Nil
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The Launching of National Rural Health Mission (NRHM) by the Government of India to provide Primary Health Care (PHC) Services through cadre of Accredited Social Health Activist (ASHA, which in Hindi the Indian National Language means Hope) is an explicit attempt of the commitment of the present government of India to provide PHC care to the underserved and poor rural communities. The main emphasis of NRHM is to have an integrated approach in providing Health Care Services. The funds allocated to stats under different National Health Programmes will be pooled and services would be delivered in an integrated manner. Under NRHM ,it planned to improve the infrastructure and staffing pattern at different levels i.e. village, block, district, division and state level. The annual spending on healthcare will also be increased to more than 2% of the GDP, against present 0.9%. Under NRHM a cadre of women volunteers designated as ASHA will be raised at the village level. These women would be local and likely to stay for their life time in the village itself like the Anganwadi worker of Integrated Child Development services scheme.They would be available which is the most important asset. Presently ,the village level health functionary who is regular staff and provided a salary of Rs. 8-10 thousand (250 USD) per month is infrequently available and hence ASHA is being introduced who being the local resident would be available in the village and act as link person to provide primary health care services to the communities. The creation of ASHA is similar to the Village Health Guide Scheme (VHGs)launched by the then Government in 1978, however, the experience was not successful. The VHGs were provided a monthly honorarium, however, no payment would be made to ASHA.We should learn from the history and should not repeat the same mistakes which we committed during implementation of VHG scheme. The initiation of NRHM would now start an era of training of different levels of functionaries about the NRHM objectives and it's componenets for next 3-5 years and the entire health care staff will be busy in either giving training or receiving training due to large size of the country. During 1997-99, when "Target Free Approach" project was initiated similar exercise was conducted. No report of the evaluation of benefits of massive training exercise undertaken is available . The training is always very convenient as the trainer and the trainee both get per diem and they don’t have to perform their routine responsibilities. The funding agency can also show objectively how many workers have been trained . The earlier National initiatives like Child Survival and Safe Motherhood Programme (CSSM) and Reproductive and Child Health (RCH) Programme started with training which continued for a period of 3-5 years .No evaluation is available on the improvement of services after receiving of trainingCSSM programme and RCH programme. In India, presently the pulse polio immunization is causing major disruptions in the routine primary health care services delivered by the peripheral health functionaries. Each year, 4-6 rounds of polio immunization are being undertaken in each state leading to health functionaries fully occupied with only one disease. Another two months are being devoted for Vitamin A monthly campaigns. The remaining 3-4 months are needed for family welfare programme activities. Country is observing the re-emergence of diphtheria which has been earlier reported from a tertiary care hospital in Delhi (1,2 ).However ,the hard data on incidence of diphtheria, measles, neonatal tetanus is not available from large scale systematic research studies. The national scenario of decline in infant mortality rate (IMR) also reflect that the PPI rounds have adversely affected the child health services.Prior to 1995 there was a reduction of infant mortality rate by 3.3% per year. However, after 1995 the decline in IMR was only 1.8% per year (3). In several states, apart from the participation of the health functionaries even schools are closed as government teachers are asked to assist with PPI rounds. As a result, in states with already poor development indicators, total immunization coverage for all other diseases is at an all time low. For example, immunization coverage in Bihar is only 13%, followed by Rajasthan with 19.7% and UP at 26.7%. What is presently needed is developing a comprehensive strategy and deciding what are our priorities .Increaseing numbers may not be the answer.There is a urgent need of motivating and tightening of the health functionaries of the existing system. ASHA would be of great help to the remote villages but can not be a replacement of the regular trained health functionaries of the health sysytem. If the health functionaruies are busy for 8 month for one disease and one micronutrient the other component of primary health care would definetely neglected. The NRHM should have at least one coordinator, preferably senior public health specialist, for 4-5 districts to monitor the implementation of the NRHM. There should be a system of concurrent evaluation of the Mission activities and for undertaking immediate remedial measures . The NRHM should have flexible guidelines and not the central monolithic norms issued by government of India . The benefits of the masses should be kept in mind rather then procedural formalities while implementing the mission. Dr. Umesh Kapil Professor, Department of Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110 029. kapilumesh@hotmail.com References 1. Singhal T, Lodha R, Kapil A, Jain Y, Kabra SK. Diphtheria-down but not out. Indian Pediatr. 2000 ;37:728-38. 2.Lodha R, Dash NR, Kapil A, Kabra SK. Diphtheria in urban slums in north India. Lancet. 2000 :15;355:204. 3.Diphtheria, measles on a killing spree. The Times of India, New Delhi,November 8, 2004; pp 12. Competing interests: None declared |
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TAPASVI PUWAR, Assistant Professor, Dept. of Community Medicine Department of Community Medicine, Smt. NHL Municipal Medical College, Ahmedabad, Gujarat, India
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Realizing the role and importance of Community Health Volunteers, the schemes of Community Health workers was implemented from 2nd October 1977. The fate of the scheme is well known. It is non functional in many states. This mission also banks upon voluntary health workers. Experience suggest these workers are not owned by communities and they simply donot rely on them. So the question of faith, credibility comes in. The Non Governmental Organizations (NGOs) successful experience with voluntary health workers in country is because of lot of hard put in there by these organizations with commitment. So for the successful implementation of scheme, commitment from Government side and volunteers’ side should be there. Otherwise the mission will also meet the same fate. On the other hand even after more than fifty years of independence the Indian doctors in rural areas is a dream which remains a dream even today and it is realized that they are not willing to go in the villages. For that now Government must think on line of Chinese experience of rural doctors and start some short duration courses for rural health. This may play a role in realizing the dream of rural health in country. Competing interests: None declared |
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Sandeepa Chauhan, Housewife 6B/154, AV Colony Sikandra, AGRA -282007, Shruti Chauhan, Shivendra Pratap Singh Chauhan
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Dear Editor, Having read the article published on the health reforms in India, and having come from a rural background, we would like to suggest the following since we know what it means for the rural folk: 1. Privatise or perish: Already vast human resources are deployed for implementation and provision of better health resources at an exorbitant price that is paid out of taxpayer’s hard earned money. What has been the achievement so far? In certain pockets, the health care is virtually non-existent or probably exists in papers only. Daily we see and hear tales of various Government Health Functionaries being: • absent from duty
The need of the day is to privatise. A strong and comprehensive agenda and governing rules within the same budget allocation can be handed over to competent private agency. The outcome measures have to be clearly spelt out, including quality of service to be rendered and desired satisfaction levels, with strict monitoring in place and a clause to terminate the services when found unsuitable. 2. If privatization is not possible: The Government should foresee that such bad hats are immediately thrown out of the job, setting an example for the others. There should be an assessment system, both by the caregiver and care seeker. Two warnings for improvement may be issued and in cases of failure to improve, the services should be terminated without recall. Just suspension would not work, as the same person would be back on duty after say 10 years of a protracted court battle. The irony remains, and is, that the person was sacked for being constantly absent for duty for say 5 years, and for the next 10 years he continues being absent as the battle was on in the court, and then the person gets reinstated with full honours and arrears of pay for the complete duration of absence, which now is 15 years. To add to further misery, this person would thereafter be more unrestrained having been reinstated by the court. 3. Do we want a parallel set up: The voluntary agencies have their own agenda and charter. Many a times the paths intertwine with the established Government agencies. The outlook and perceptions may be different and this would lead to complexities. Is there a system in place for better understanding and mutual cooperation and for urgent clearing of doubts, acrimony, dislike, and distaste? Efficiency and effectiveness of different agencies ought to be segregated so as not to overlap. Perhaps more need to be done in this aspect for ensuring mutual cooperation and coexistence and working together towards attaining the ultimate goal of providing better health care. 4. A better vigil with inbuilt mechanism for prompt disciplinary action, including termination of job of the offender is urgently required, which should not be mixed up with politics and personal vendetta. Local populace and the care seekers have stopped airing their views and problems as more often that not, these are not heard and remedial action is not instituted. Hence if a system of seeking their views on the performance of health providers is also implemented, it would lead to a better overall assessment. Next, only the qualified are given the job and considerations of vote bank driven governance should cease. Those not qualified must be given a fair chance for attaining requisite qualifications and if meeting the grade that should be equal for everyone, the job is given. Once the house is set in order, we are sure there would be no looking back and no further need of such strong force of NGOs to do what the existing trained manpower, duly paid, is supposed to be doing. Regards. 1. Sandeepa Chauhan 2. Shruti Chauhan 3. Shivendra Pratap Singh Chauhan Competing interests: None declared |
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Dr. Dr. Akhilesh Kumar Singh.MBBS, MD, Senior Resident Neurology 309/9 AV Colony Sikandra, AGRA 282007. INDIA, Dr. Parul Kushwah.MBBS, MISCD., Dr. Rajesh Chauhan. MBBS (AFMC), DFM, FCGP, ADHA, FISCD
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Dear Editor, The health of the rural folk in India requires urgent attention and a revamp of the existing system. We agree to Sandeepa Chauhan et al; maybe the methods used for change may not be that harsh. Perhaps the authors were not intending to be that harsh. However a strict enforcement mechanism of the Government's policies and directives should be in place. There is absolutely no need of duplicating the efforts and the salaried staff ought to produce tangible results. Regards. 1. Dr. Akhilesh Kumar Singh
2. Dr. Parul Kushwah
3. Dr. Rajesh Chauhan
Competing interests: None declared |
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Dr.Hanamaraddi.T Gangal, Practicing Surgeon P.B.Rd Hosur Hubli 580021
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Utilisation of regenerative medicine in the form of Allopathic Holistic Health Rejuvenation to all, as implied in the concept of evolving National Rural Health Mission by Govt of India. The Authors concept can fit to the need of the nation, as well as the world, on the lines of ENHR(Essential National Health Research) of a country to others through COHRED (Council On Health Research For Development) affiliated to WHO. 1. Holistic approach in allopathic medical science, in the field of regenerative medicine. 2. Concept and the Formulations to achieve the above objectives. 3. Clinical results and the conditions used. 4. Their utility in industrial application, and later large scale clinical utility. I was associated with research and development of newer technology in medical science One of outcomes of such association is, Rejuvenation of organs and suppression of degenerative process of the body on any account including - aging?. in regenerative medicine. I beleive, under stress, every individual behaves like diabetic and responds so to the treatment. The conditions treated on this bases include, a. Most of the cardiovascular diseases, except congenital and a very
few of the acquired ones.
Clinical results on these works are published. This concept promotes regenerative medicine, in gaining holistic benifits to the patient, at reduced cost to the patient, risk to life, loss of working and earning time, converts the sick to a working and productive individual. There is every possibility this treatment could promote the stem cell rejuvenation, change internal environment to suppress aging as it enhances the level of insulin receptors in terms of number and quality on the cell membane. This concept may avoid many major operative procedures as means to treat such condititons, and can be utilised at primary health care centers, thus serve to avoid large scale movement of the patients to the tertiary referel hospitals. It could be the one needed world over in the present situation. It is already evaluated by
Dr.H.T.Gangal Competing interests: None declared |
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Dr. Beena Nayak, Project Associate CMHS, IIM, Ahmedabad. India
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NRHM is a great example of reinventing the wheel. The history of development of Indian Medical Services after Independence begin with quotes from Mahatma Gandhi asserting the Village Panchayat Raj to be at the heart of all Indian developments. Indian medicine is geared to rural health as it was reported from the times of the First Five year Plan introduced by the Planning Commission of India. So the Great Indian Health Mission has always been the Great Indian Rural Health Mission. Urbanisation is a very new trend barely recognised in the policy making for health. But, with all the ASHA, hope, for the future,is India asking the village population 1) what do they perceive as health?
Is it time to begin with the right questions to the right people at the right time? Indian culture has a rich archetypal treasure of the ability which includes homegrown wisdom for coping with illnesses of all kinds. Is it pertinent to take this vast repository of knowledge into account to fulfil the noble goals of the National Rural Health Mission of India? Competing interests: None declared |
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