Recently I visited Turimerla village in Sri potti sriramulu district (Andhrapradesh) along with Auxiliary Nurse Midwife(ANM) named Rajeswari, to observe National Rural Health Mission(NRHM) implementation at the field level. Before dwelling into some interesting observations, lets briefly discuss about mandate of NRHM and ASHA.
National Rural Health Mission (NRHM) is an Indian health program for improving health care delivery across rural hinterland. One of the key components of the NRHM is to provide every village in the country with a trained female community health activist ASHA or Accredited Social Health Activist. Selected from the village itself and accountable to it, the ASHA will be trained to work as an interface between the community and the public health system.
Selection of ASHA worker is from the most backward communities. Order of the preference would be first ST, then SC and OBC, etc. In the Turimerla village, selection of ASHA worker, itself is very democratic process of involving various community groups, self-help groups, Anganwadi Institutions, the village Health Committee and the Gram Sabha, etc. The reason behind this sort of inclusive selection is that, ASHA workers can effectively mobilize community people and build sense of attachment with the disadvantaged communities. Although caste barriers are persist in this village but in a broader manner, entire village is working for the common cause.
In the Turimerla village, ASHA workers are able to work actively with other communities, providing information to the community on basic sanitation & hygienic practices, health & nutrition education, council women on birth preparedness, importance of safe delivery, breast-feeding and complementary feeding, immunization, and contraception techniques, etc. Thus ASHA workers are fountainhead of community participation in public health delivery system. No system is false-proof across the universe, so let me put few things which needs to be improved:
ASHAs will receive performance-based incentives for promoting universal immunization, referral services and other healthcare program's, and construction of household toilets,etc. Due to lack of fixed salary, their wages are not guaranteed if they do not find any mentioned services in that particular month. They are overburdened in terms of responsibilities but lacking minimum economic security! So need of the hour is fixed salary plus performance based variable incentives to motivate and boost morale of ASHAs.
In Primary Health Centres(PHC's) found only one doctor, who has to visit field level and looking-after patience's. It is very daunting task for doctors to address the above within time bound manner. Some people stated that, at times doctors are lacking service motto and unwillingly working at the village level. Hence need to inculcate service motto's and increase doctors strengths at the PHC level.
ASHAs would be a promoter and facilitator of good health practices, providing a minimum package of curative care as appropriate and feasible for that level and make timely referrals. To achieve the above, Capacity building of ASHA is being seen as a continuous process.
Lets discuss, how Turimerla village people making NRHM more transparent, accountable and efficient way of implementing.
I really wondered regarding the community accountability because people are questioning ASHA's workers, about their basic health needs! E.g. people are asking about usage levels of bleaching powder, etc services which they are statutorily entitled to!
One more interesting point would be how collective social action of Anganwadi workers, ASHA, ANM's and gramasabha empowering the backward populace and curbing corrupt practices which is rampant in the other villages. The entire social vision of Turimerla people, brought down the MMR, IMR and various health indicators.
Recently, there was a path breaking program of 'Ravamma Mahalakshmi', where ASHAs responsibility is that every woman has to access of BP, sugar, TB, etc tests, so that collect disease info and then proper medication could be delivered in time bound manner.
After, speaking with SC community, found that, their economic well being has been improved and they are happy with primary health care needs.
To sum up, Monitoring, reviewing mechanism of ASHAs by nodal officers, motivation of district apparatus, time bound wage delivery system through bank accounts, community accountability, vibrant functioning of gross root institutions and active participation of SHG's, village sanitation committees etc are attributed for the successful implementation of NRHM and efficient public health delivery system.
I think above system is testimony for collective vision, sound gross root participation and collective social action. The same needs to be adopted in other villages to check spreading of Dengue fever, reducing IMR, MMR, and contain various endemic diseases, etc to realize success of NRHM and achieve Millennium Development Goals.
Suneel Anchipaka
anchipaka.suneel@gmail.com
