Q: The Gujarat model would be the short-term model whereas ultimately we must progress towards the Tamil Nadu model.

A: I believe ultimately the state has to be the main provider or at least guarantor of health services in this country. The private sector and the voluntary sector also have useful complementary roles to play, but unless you have a strong and efficient public health system, you are not going to see improvement in health gains, particularly you will not see reduction in health inequities.

Q: Would you say this is also for health insurance because we find that private health insurers who were licensed thinking that they would expand the coverage of health insurance? We find that they are very choosy and even those who were the minor medical histories, they are not being covered.

A: This whole problem of private insurance is not only that not many people can afford it, but even those who have acquired private health insurance find that the whole amount of risk coverage is very limited because those who are likely to have events fairly soon are weeded out of the insurance schemes and the coverage provided is not adequate for such people. While health insurance particularly social insurance provided by the government aided by the employer provided health insurance. To some extent, private insurance can together increase the availability of healthcare. You must ensure that universal healthcare especially of essential health services is available and one should not be dependent on out of pocket spending.

The rural health mission has set a target of spending 2-3% of gross domestic product (GDP) on public healthcare. Overal,l spending now is 0.89% of GDP with increased Central spending making up for the decline in state spending, though health is a state subject. This raises doubts about the ability and willingness of states to make the required 10% of contribution. The Centre’s outlay has increased from Rs 7,200 crore to Rs 12,050 crore over a four year period but four states evaluated recently in a Planning Commission Sample Study were found not to have spent over a third of the money allocated to them.

Q: The NHRM has been able to reverse the decline in public spending on healthcare. We are not there yet, we have not met the target, but do you think that whatever money is being spent is being spent effectively?

A: Certainly things are happening but unless you improve the infrastructure, unless you augment the human resources, the services will not be delivered in the scale intended or required. All of these have to keep a pace. While the NRHM does provide substantial amount of revenues to various states to improve health services, the states too need to pitch in with greater contributions to primary healthcare. This possibly is something that the 13th Finance Commissioner should address by providing earmarked allocations to states for their own investments and primary healthcare. Till states take ownership of these programmes, you are not going to see an effective delivery at the state level.

Q: Does it mean more taxation as well to raise those resources?

A: If it is more taxation on cigarettes, alcohol and cars, I welcome it because these are some things where taxation serves a double benefit.

Q: So you say that increase in sin taxes is the way to go?

A: I would certainly not advocate increasing of sin in society, but sin being taxed is certainly fine. In terms of tobacco and alcohol, the prime candidates which are under-taxed, should be taxed more heavily. Even cars being taxed can provide for lot more urban amenities and reduce the environmental pollution.

Q: The government has spoken of having trained six lakh Accredited Social Health Assistants (ASHA) who are go between the auxiliary nurse midwives and the expectant mother. In the process the government says that there has been a sevenfold increase in hospital deliveries because of which deaths of infants and mothers have come down?

A: ASHA are an important contribution to social mobilization and are increasing the referrals for institutional deliveries by both increasing awareness plus motivating the women to seek that kind of care. ASHA have other functions to deliver as well. They are involved in motivation for immunization and now some additional activities are also being added to their portfolio, so that they will actually become health motivators in the village not merely for a few confined functions but for several other broadband range of health functions.
Doctors do not like to serve in villages. It is in cities that you see a protrusion of clinics, nursing homes and speciality hospitals. But you would be surprised to know that cities don’t even have a semblance of a public primary healthcare system. This government has vowed to change that.

Q: So the government has announced the National Urban Health Mission – how do you think it should be crafted?

Reddy: Atleast in the rural areas there has been a design of a primary healthcare system but in urban areas we did not even have the design of an Urban Primary Health care system.  So it was left to the vagaries of whatever system existed in terms of individual doctors and quite often people ended up even for primary healthcare related needs with tertiary care hospitals, overloading those hospitals unnecessarily. So Urban Primary healthcare in short has been anarchic.

Now we have an opportunity to redesign that, to provide substantial community health centres, municipal hospitals, linking them with secondary and tertiary care hospitals, rationalizing the entire structure. We must also recognize whether in rural healthcare and particularly in urban healthcare the determinants of many other sectors which operate outside of the health system. Whether in water supply, sanitation, in agricultural nutrition, environment, urban transport, all of these have a tremendous influence on health.

So, all of those policies also must become more aligned, sensitive to and responsive to public health concerns. Otherwise we will always be dealing with the health sector as a mopping brigade, mopping up the mess created by policies that have gone wrong in other sectors.

Q: So you would want every minister to be health minister in a way?

Reddy: I believe that every minister should be a health minister, and must align their policies and programmes within their domain in the interest of public health.

SEWA is a trade union of self employed women in the organized sector. It has 1.1 million members across 9 states. For the rural health mission it has been training ASHA, the Accredited Social Health Assistants setting up village health and sanitation committees and persuading women to do deliveries in hospitals under the Janani Suraksha Yojana.

Sapna Desai is a self coordinator for all the nine states.

Q: Decentralisation is key to the rural health mission and many thousand Rogi Kalyan and village health and sanitation committees have been set up. Are they as impressive on the ground as they appear on paper?

Desai: I think the greatest strength of NRHM is that the Vaccine Healthcare Centers (VHC) have been created and the Rogi Kalyan Samiti’s. They are certainly at the beginning like in Bihar were we work in three districts. We have been actively involved in created the VHCs. So where there is an active civil society involvement you will see strong VHCs. They are at the inception stage now.

Q: The ASHA’S are key functionaries of the rural health mission and they have been able to persuade expectant mothers to do the deliveries in hospitals. Does their training equip them to be broadband health motivators as well?

A: I think the key issue here is that the traditional person doing that in terms of working women particularly mothers has been the Dai. In a place like Bihar and many other places we work upwards of 80% of deliveries are at home. So the ASHA has in a sense replaced the Dai as the focal point for pregnant women. So while ASHA certainly accompany women to institutions, it is the Dai who is still the first point of call and who goes with them. So the ASHA’S training equips her to do basic public health certainly but it is the Dai who still is the first point of call.

Q: Now public health is not just about cure it is also about prevention. Has the rural health mission created enough awareness, has it enabled people or has it changed attitudes towards sanitation?

A: I think in terms of prevention the key issue is investing in water and sanitation. We have not seen the level of investment we need such that every family has a toilet, every family has access to clean water and drainage. If those three issues are addressed, in depth, then I think we’ll see definite public health gains. That is well established.

In terms of awareness, that is certainly an issue that needs a lot more work because health education and awareness can’t just be done through mass media. As we have learnt that it also requires a level of one on one contact which could be a role for ASHA’S and other community health workers like Dai’s if the appropriate training is given.

Q: If I understand it correctly, drug delivery and the scarcity of trained medical personnel those are the big gaps in rural areas. Has the rural health mission been able to address these intractable issues? I am not saying you should solve them but has it atleast made a dent in these issues?

A: In my experience over the past three years in Bihar for instance, we have seen a fantastic improvement in medical officers being available in PHCs (Primary Healthcare Centres) and in all of our work when we go to the PHC the doctor isn’t there. That said, drug availability is still a major concern. So, out of pocket expenditure essentially is still an issue.

Four years later, has the Rural Health Mission made a difference? This is what people have to say.

The Planning Commission study reported the highest share of negative experiences among patients in Bihar followed by UP, Rajasthan and Andhra. The highest level of satisfaction was in Andhra. The causes of dissatisfaction were no medicines, absent staff and long waits.

According to SEWA Bharat, public healthcare has improved ever since Nitish Kumar took over as Chief Minister. But a recent Planning Commission evaluation study found that Biharis had the highest number of negative experiences. I asked Sapna Desai how she would square her own experience with the findings of the study.

Desai: I think one key issue is that we have seen the changes in Bihar over time. Governance has played a key role. It is not only the NRHM, it has been governance. The Nitish Kumar government has really achieved remarkable results. We see the accountability shifting in a sense that doctors are now accountable to a system.

I’d also say that looking at things over time, things have improved and certainly those experiences must ring true where experiences are negative in Bihar. But on the whole, we see positive things happening. So, I couldn’t reconcile what Kaveri (Gill) has found in her report, which I agree with in what we see except that you have to look at the change over time and positive things are happening.

Q: I am going to talk about accountability. The same study finds that ANMs for example, they are the most diligent because they are I think more responsive to community oversight and monitoring whereas this was not the case with the more specialised, medical people?

A: I think it is a question of how the system is designed. If the system is designed such that doctors have to be responsive to a community, it is not a question. That is their duty and that is what a public system is for. I don’t think the question should be will doctors be amenable to community oversight but rather how do we create a system or construct a national health programme in which doctors are answerable to the community by design.

Q: You have exposure to Gujarat as well as to Bihar. We have seen a lot of private participation in Gujarat, in deliveries for example. In Bihar I think the government is going in a different way, they are going the Tamil Nadu way. Has that worked in Bihar in terms of Janani Suraksha Yojana, in terms of institutional deliveries?

A: Yes, we are seeing an increase in institutional deliveries. Amongst women who are close to the hospital, I mean in more rural areas. And the numbers speak of it, 80% of deliveries as of the last NFHS (National Family Health Survey) were at home. We will see a steady decrease. But I think until we integrate Dai’s firstly into the system more than point of call, and secondly improve quality in hospitals such that women naturally want to go to a hospital for a delivery as opposed to for an incentive, we will see it work.

Q: But in your experience, you don’t think that private hospitals are necessarily better than public ones?

A: Not at all, not necessarily at all. In private hospitals we have seen over-diagnosis, you’ll see higher expenditure, you’ll see unnecessary tests. The expenditure pattern is very different in private. They don’t necessarily provide better services.

Frankly, when public systems work and work well, our members prefer them. We see in a place like Ahmedabad when given a choice, our members use the government hospitals.

Q: Finally if you had to suggest a set of correctives, what would those be for the NRHM?

A: First and foremost, I think it is on a good path, decentralization certainly is a great way to go and community participation and the fact that VHCs and Rogi Kalyan Samiti’s exist, I think is a really positive move.

In terms of corrections, I think one is definitely integration of Dai’s into the referral system and upgrading the capacity of Dai’s to also service health workers. Secondly, I would say drugs. I mean ensuring that their monetary mechanism to actually ensure that drugs are available to people and out of pocket expenditure isn’t wasted on drugs, which shouldn’t be in the public system.

Probably most importantly, investment in water and sanitation such that every household has a toilet, has access to clean water, to prevent the actual illnesses before they occur rather than focusing only on treating them.

The government has declared that public healthcare is up there in its list of priorities in the second term. It has vowed to slash the death rate of infants and mothers, expand the coverage of immunisation, check malnutrition by bringing the nutrition delivery programme under community oversight and expand public health insurance to cover all extremely poor families.

But the rural health mission must subject itself much more to public scrutiny than the National Rural Employment Guarantee Scheme, if it is to serve the purpose intended. Even Kaveri Gill of the Planning Commission found a dearth of information. More sunlight is needed.