Saturday, June 22, 2013

Making the Health Sector Healthy: Interrogating the role of Panchayats in Assam


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.

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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.