Making the Health Sector Healthy:
Interrogating the role of
Panchayats in Assam
Pankaj Bora,
Assistant
Professor, Bahona College
Merrychaya Patiri,
Research
Scholar, Gauhati University
Bitapi Bora,
MA in Political
Science, GU
Introduction:
Panchayats,
though not like the Panchayati Raj Institutions of these days, but are the
age-old institutions working at the village level. These Panchayats work as
decentralised institutions to bring socio-economic and political development to
the people. These developmental activities include health security, sanitation
and population stabilisation etc. When we talk about health and panchayats, we
must look at the policies like National Health Policy, 2000 and National Health
Policy, 2001 etc. which indicate and ensure the role of PRIs as a responsible
agency to provide decentralised health services. The 73rd
Constitutional Amendment, which has strengthened the PRIs and drawn clear areas
of their jurisdiction, authority and funds also indicates Panchayats’ role in
providing health services.
The UPA government, to improve and
uplift the condition of health services in rural India started a comprehensive
national campaigning and launched a programme called National Rural Health
Mission (NRHM) on 12th April, 2005. NRHM has taken up myriad of
action plans and goals those include increasing public expenditure to health,
reducing regional imbalance in health infrastructure, pooling resources,
integration of organizational structures, optimization of health manpower,
decentralization and district management of health programmes, community
participation etc. These goals also reflect the Millennium Developmental Goals
(MDGs).
This research starts on the above
narrated ground and basically tries to focus on the roles and responsibilities
of the PRIs in implementing National Rural Health Mission in Assam. Empirical
data collection and scientific observation methods are used while articulating
the research findings.
Objectives of
the research:
The
research starts with few empirical objectives and a theoretical objective.
Theoretically it wants to link up the notion of health security and social
security with decentralised administration and empirically it aims to find out
how far good governance and decetralised administration has contributed towards
making the health service healthy. To be more precise we can point out the
objectives of the research like:
1. Theoretical
Objective: To see the relationship between social security and decentralised
governance.
2. Empirical
objectives:
a. To
know how far PRIs are responsible towards implementing NRHM and improving
health security
b. To
trace the progress in NRHM in Assam
c.
To find out whether the PRIs are actually
working towards making the health sector healthy.
Methodology:
In
this research paper, both primary and secondary sources for data collection
have been used. Secondary data are mainly official reports, articles from journals,
book etc. The research paper extensively depends on policy documents and
statistical input drawn from these government official reports and articles.
To collect primary data collected, the research
has followed the non-participatory observation method. The primary data
collected from the field study conducted as a part of the field survey for the ICSSR
sponsored major research project titled “Implementing NRHM in Assam: A study on
the convergence among Institutions, Infrastructure and Practices” under the
guidance of project director Dr. Akhil Ranjan Dutta.
Theoretical support:
The
focal point of this research moves round the concepts like decentralised
administration, role of state, social security, and health security etc. The
objectives reflect that all these areas are the core areas of this research.
Based on the concepts and research questions, the research has concentrated in
two metanarratives and tried to find out a clubbed approach to interrogate the
objectives and justify the findings. The research looks the notion of Health
Security as a part of Social Security and hence used the perspective of Social Security
to support the research. As it is a research investigating the role played by
PRIs, we are justifying our articulations on the basis of theory of
decentralised administration. Clubbing both the approaches in one approach, we
have experimented the finding on the basis of the presumption that providing
Social security and health security is basic responsibility of a welfare state
and they must ensure it in collaboration with decentralised institution like
PRIs. So, let us start with the theoretical understanding of Panchayati Raj
Institutions
.
Conceptual
background of Panchayati Raj in India:
Democratic
decentralization is a procedure to provide opportunity to strengthen the
democratic governance. The notion, democratic decentralization has dominated the
development discourses in contemporary period. It emerged as a popular policy
in many Asian, African and Latin American countries since the 1960s. The idea
behind democratic decentralization is that people will become the end as well
as the means of development. It rejects the idea of a highly centralized State
and replaces it with the concept of distribution of power to people at large.
Here, people occupy the centre-stage of the development process. India has also
adopted the policy of democratic decentralization and introduced the Panchayati
Raj System and other decentralized mechanisms. They act as an institution of
self governance and people’s participation in rural areas of India (Bhattacharya(Mukhopadhyay), 2011, p. 344).
The
Constitution of India, in Part IX, deals with Panchayat System and
Municipalities (Sarmah,
Gogoi, & Bora, 2011, p. 13). The Constitution envisages
a three-tiered system of Panchayats. These are: The Village Panchayats at
village level, The District Panchayats at the district level, and The
Intermediate Panchayat which stands between the Village Panchayats and District
Panchayats. The constitution says that all the seats in a Panchayats shall be
filled by persons chosen by direct election from territorial constituencies in
the Panchayat areas (Basu, 2011,
p. 283).
The 73rd Amendment Act, 1992 of the Constitution came into force in
1993 introduced the Part IX from Article 243-243-O and Eleventh Schedule to the
Constitution. This amendment empowered the Panchayats with power in 29 subjects (Bhattacharya(Mukhopadhyay), 2011, p. 249). Among the 29
subjects, health and sanitation is also a significant one. This includes
providing health services, regulation of hospitals, primary health centers and
dispensaries. Based on this amendment several policy initiatives were taken,
making the Panchayats core and National
Rural Health Mission (NRHM) is such a step.
Conceptual
background of Health Security and NRHM in India:
National Rural Health Mission (NRHM) 2005-12 is
one of the ambitious projects of the United Progressive Alliance Government
pursued at a very crucial juncture in India’s development trajectory. National Rural Health Mission (2005-2012) MISSION DOCUMENT, the
Government of India's document on NRHM, in its preamble highlights the vision
of the mission. To quote the document “Recognizing the importance of Health in
the process of economic and social development and improving the quality of
life of our citizens, the Government of India has resolved to launch the
National Rural Health Mission to carry out necessary architectural correction
in the basic health care delivery system. The Mission adopts a synergistic
approach by relating health to determinants of good health viz. segments of
nutrition, sanitation, hygiene and safe drinking water. It also aims at
mainstreaming the Indian systems of medicine to facilitate health care. The
Plan of Action includes increasing public expenditure on health, reducing
regional imbalance in health infrastructure, pooling resources, integration of
organizational structures, optimization of health manpower, decentralization
and district management of health programmes, community participation and
ownership of assets, induction of management and financial personnel into district
health system, and operationalizing community health centers into functional
hospitals meeting Indian Public Health Standards in each Block of the Country.
The goals of NRHM are reflection of Millennium Development Goals (MDGs)
especially reduction of child mortality, improve Maternal Health and combat
HIV/AIDS, Malaria and TB. (Development Goals, States of India Report, 2010)
The
Goal of the Mission is to improve the availability of and access to quality
health care by people, especially for those residing in rural areas, the poor,
women and children. The document, with 16 sub-headings, expresses the present
condition of health, vision of the mission, strategies, plan of action,
institutional mechanism, technical support, role of state government, PRI and
NGOs, focus on NE states, importance of AYUSH, fundings, targets, outcome and
monitoring and evolution of the action taken to meet the target. Here, the
document says that status of current public health is not satisfactory. In
Government annual budget, Public health expenditure has declined from 1.3% of
GDP in 1990 to 0.9% of GDP in 1999. There are many other evidences of poor
health standard in India which is explained by the document. The document also
states the vision of the mission where it categories 18 states, including
states from NE, as high focus states with special attention. It expresses the
above mentioned goal as prime objective with definite time programmes which
will be aquired with some well designed strategies and plan of action where the
state governments, Panchyats and NGOs will play a positive role. The document
has included the financial matters, institutional mechanism and technical
support and it gives emphasis to AYUSH. It has also pointed out some statistical
targets to be achieved by the mission on time. The Mission has some monitoring
and evaluation committees in three tier level- Block, Panchayat and District,
for well functioning of the mission and to bring health security. It basically
stresses on role of the Panchayats.
Panchayats in
Health security in Assam:
The
Panchayat in Assam has a long history back from the reign of the Ahoms where
this system of Panchayat is noticed among the tribal and non- tribal
communities with their own traditional institutions.
Status of the PRI framework in
Assam
The Government of Assam enacted
the Assam Panchayat Raj Act, 1994 incorporating almost all the features of the
73rd Constitutional Amendment Act, 1992. The terms of Panchayat in the state
expired in October 1997. The state government had put off the Panchayat
elections several times citing different reasons. The elections of the
Panchayat bodies were held in December 2007 and since then the PRI bodies are
active in the State.
The PRIs have been actively
involved with developmental process at all the levels are involved in the
planning, implementation and monitoring of the activities envisaged under
National Rural Health Mission, Sarbha Siksha Abhiyan, Public Health
Engineering, Total Sanitation Campaign and Women & Social Welfare
department in the state.
Role of
Panchayati Raj Institutions as per the Mission document of NRHM:
· The respective
states will indicate their MoUs the commitment for devolution of funds,
functionaries and programmes for health to their PRIs.
· In the
institutional set up, at the district level, a District Health Mission (DHM)
will be set up that to be led by Zila Parishad. The DHM will control, guide and
manage all public health institutions in the district level like Sub-Centres,
PHCs and CHCs.
· ASHA is the one
of the main stakeholders of NRHM. ASHA would be selected by and be accountable
to the village Panchayat.
· In the village
level, in the Panchayat a Village Health Committee would be organised and this
committee would be liable to prepare the Village Health Plan and promote
intersectoral integration.
· For well
functioning of the sub-centres there will be an Untied Fund for local action
@Rs. 10,000 per annum. This Fund will be deposited in a joint account of the
ANM and Head of the Panchayat i.e. Sarpanch and operated by the ANM, in
consultation with the Village Health Committee.
· In hospital
management, Rogi Kalyan Samitis are held up and in such committee’s involvement
in PRI is the key factor.
· Training will be
provided to the members of PRIs.
· Making available
health related databases to all stakeholders including Panchayats at all
levels.
As the mission describes the PRI plays a major role in
implementing NRHM. It is through PRIs the community participation is possible.
So PRI as an institution for NRHM has a significant role. The major PRI
institutions are as follows.
|
Institution
|
Regulatory Board
|
Persons involved
|
Post
|
|
District Health
Mission(PHCs, CHCs, SCS)
|
Zila Parishad
|
District
Health Head
District Health Head, NGOs, Private
professionals
|
Convener
|
|
Block level
Panchayat(PHCs)
|
Panchayat Samiti
|
PRI representatives
|
|
|
Sub Centre
|
Gram Panchayat
|
PRI representative,
Representative of VHSC
|
|
The
PRIs are the decentralized level policy makers to render the services to the
village level. Village health Plan is counted as the policy framework for the
implementation of NRHM. Having a village health plan in each level is regarded
as one of the activity of PRI in implementing NRHM. To prepare the village
health plan, Village Health and Sanitation Committee (VHSC) will be appointed.
So, VHSC is responsible to set up the health plan taking into account all the
villagers and their need. The village health plan includes some of the action
plans to implement like to orient and train the PRI members on basic health
needs in the village. The structure of VHSC is formed under the chairmanship of
Gram Panchayat members and representative from the community such as gaon
budha, women's group, and SC/ST/OBC/ minority communities etc. Hence, for the
development of the village in each village where ever there is an ASHA Village
Health and Sanitation Committee has been formed by providing untied grant for
village level activities. The basic health needs are to be fulfilled by
different health schemes, the VHSC members have to aware the people about the
various schemes and the benefits of the schemes implemented by the government
so that people can demand the benefits of the schemes. Moreover, the VHSC is
accountable to the overall village health plan. The VHSC will try to mitigate
the health and nutrition related problems of the community by organizing
Village Health and Nutrition Day (VHND) twice in a week.Training of the VHSC of
a village is usually conducted and supported by nongovernmental organistions
(NGOs).
Findings from
secondary reports:
As
far as the implementation of NRHM is concerned, certain reports are there to
review the institutionalisation, infrastructure and convergence of the
different institutions. According to the Assam report, 2009; 26,816
VHSCs has been constituted & 24,085 Joint Accounts have been
operationalised. Rogi Kalyan Samities are operational at 22 DH, 103 CHCs & 844
PHCs. All districts have started developing their own IDHAP.
Common
Review Mission (CRM) was conducted by the State wise Review Team for Assam
undertook the visit to Assam during a scheduled time frame from the year of
2007 onwards. These CRM reports had examined the institutions, infrastructures
of NRHM for the period from 2007 to 2011.
The first Common Review Mission
conducted in 2007 revealed that Village
Health and Sanitaion Committee had not been set up at the village level as the
panchayat election was not held.
In
the findings of second Common Review Mission, regarding the PRI involvement,
State has reported that 20, 309 number of VHSC are constituted and fund
released to them. But in the report, it is mentioned though VHSs have been
constituted, but the members have lack of capacity building. In many cases, these
members were not properly guided about their responsibilities.
The
fourth Common Review Mission also revealed the disappointment in practising of
implementation of NRHM, though the Panchayati Raj Institutions have been
constituted, the actual capacity building of these institutions have not been
up to the mark.
But the fifth Common Review
Mission has portrayed an another picture of involvement of PRI in NRHM. Under
the NRHM, in each village a Village Health Sanitation (& Nutrition)
Committee (VHSNC) has been formed where the elected PRI members are the
Chairman of the committee and the ASHAs are the Member Secretary. 26,312 VHSNC
have been formed in Assam. The ASHAs are working in close co-ordination with
the VHSNC members for improving the health scenario of the village. Every year
under NRHM, each VHSNC receives Rs. 10,000/- which is used for providing safe
drinking water, construction of sanitary toilets, arranging emergency referral
transport and organizing Village Health & Nutrition Day. Source: (5th
Common Review Mission, 8th-15th November, 2011, Assam).
All
the VHSNC members have been trained under NRHM regarding their roles and
responsibilities in the years 2009-10 and 2010-11. In 2010-11 and 2011-12, on
sample basis Model Village Plans havebeen prepared in each Block PHC.
Observation from
the field survey:
The
structured interview schedule was mainly targeted for the stakeholders of NRHM
like, the ASHAs, the ANMs, the BPMs and the health care seekers. As stated
earlier, the stakeholders like ASHAs and ANMs have to work with PRI officials.
Their cooperation is in workings of policy developments and implementation of
these policies and then to see how far these stakeholders are able to make the
convergence among institutions, infrastructures and practices. The observation
with the field experience reveals that some of the ASHAs we interviewed are not
satisfied working with the PRI members as they are not really cooperative. As
per their knowledge, the Panchayat members are corrupted and are not regular
and honest in using the untied fund. Some of the BPMs who have been interviewed
are also said that PRI members and the officials from department are not so
much cooperative. PRI have to lead the Mission in three ways- planning, control
and monitoring health institutions and funds. But, the people in general are
not aware of the involvement of the PRI members in the implementation of NRHM.
The patients from Sualkuchi PHCs are not aware of Village Health and Sanitation
Committee and Village Health and Nutrition Day. This is also seen during the
field survey in Silchar Medical College where very few people know about
Village Health and Sanitation Committee and Rogi Kalyan Samiti.
Conclusion:
Though
the PRI in Assam as a particular and in India as a general has a large
potentiality to improving the health indicators in reality and create awareness
among people about the health schemes and other necessary concerns. But there
are some constraints to the workings of the PRIs like lack of accountability,
dominated by political party, no periodic elections, not applicable to the BTAD
or 6th schedule areas etc.
…………………..
References:
Basu, D. D. (2011). Introduction to the
Constitution of India. New Delhi: LexisNexis Butterworths Wadhwa Nagpur.
Bhattacharya(Mukhopadhyay),
M. (2011). Democratic Decentralisation and Panchayati Raj. In N. Chandhoke,
& P. Priyadarshi, Contemporary India: Economy, Society, Politics
(pp. 344-357). New Delhi: Pearson.
Sarmah, P.,
Gogoi, C. F., & Bora, P. (2011). Brief Understanding of Indian
Constitution. In P. Bora, & C. F. Gogoi, An Introduction To Indian
Government and Politics (pp. 1-18). Guwahati: K.M. Publishing.
5th
Common Review Mission, 8th-15th November 2011, Assam;
National Rural Health Mission, Ministry of Health and Family Welfare,
Government of India.
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