Author: Dr. Chilshu Chandran
Human resources in the healthcare sector are nothing less than heroes. The recent pandemic is a testimony to this fact. When the whole world was under the wrath of a raging pandemic, it is the health workforce that fought the battle and is still battling it out.
So often, the reason behind systemic failures is the systems itself and not so much the individuals. Science has travelled so far, yet it is undeniable that with each stride towards advancement, human intervention is a constant necessity. To achieve the sustainable development goals in healthcare, we need more skilled and better enabled human resources in the public health system. In a developing country like ours, human resources are scarce and unevenly distributed. Therefore, poor human resource management can hinder the effective functioning of the system.
The National Rural Health Mission (NRHM) was launched as a flagship program of the Government of India in the year 2005-06 aimed at architectural correction of health systems in general and rural health systems in particular. It came up with various core and general strategies to provide healthcare to the vastly under-served rural population. The National Health Mission was launched by the Government of India in 2005 that comprised of the NRHM and the National Urban Health Mission was further added to it. NRHM was launched to provide accessible, affordable, and quality health care to rural population, especially the vulnerable groups. 
NRHM is broadly categorized into preventive care and curative care. Under the preventive care, all primary health units are clustered together and it works under the supervision of various health officials at various levels. The other broad domain is the curative field that is also by headed by various experts on the field. Hence the whole system is driven by the human force at all levels. The study aimed at identifying the major challenges faced by this army and tried to explore the major issues existing in the present model of the NRHM.
The study followed a qualitative methodology and the major tools adopted were in depth interviews and Focus group discussions with the various health officials at all levels from one of the districts of Maharashtra.
FINDINGS AND DISCUSSION:
Every job role comes with some set of challenges which motivates or demotivates the employee to march ahead.in this study, the major challenges identified were:
- Twin burden of roles: Since all the remedial work that includes OPD, operative services, and administrative work is handled by the medical officers, it becomes challenging for them to give time for administrative aspects like making action plans, attending meetings, etc. When interacted with the medical officer, he quoted, “I have studied 5.5 years for clinical practice; managing administrative job is a huge burden.”
- Lack of motivation and inadequate resources among existing resources: Most of the staff under NRHM are contractual. Despite sharing the same workload, they receive a meagre salary compared to other staff. Many posts are vacant, so there is an increased delay in the work process. The medical officer is held accountable for any delay found. “Most of the posts here are vacant, so delay happens sometimes. We get stressed when there is a delay, and I am answerable to everyone if anything happens” said one of the Medical officers.
- Infrastructural inadequacy and supplies shortages: The infrastructure of the PHC in most of the remote areas is not in its optimal condition. The medical officer said, “Even after being such a high performing PHC, we do not have a proper vehicle, the government is not providing vehicles and expecting me to do visits. It’s challenging to perform operations with 6.5 sized gloves, but I am not getting 7 sized gloves.” Shortages of drugs are also another challenges encountered, especially pediatric drugs. One PHC staff member complained about the online updating of data as a network issue was present in her area. She mentioned, “there is a network issue here; even BSNL does not work here. Sometimes for an entire day, there is no network, and I have to go to Block to do the online filling of data.” These types of infrastructural shortcomings hamper the activities and affect the resources that are working on ground
- Problems with intersectoral coordination: “We have no authority over the Anganwadi workers, so it becomes difficult for us to manage the needed coordination. They respect me but are not answerable to me.” Conveyed one of the Medical Officers.
- Community level challenges: The people who come to PHC prefer injections over medicines; hence sometimes, they do not follow the prescription given by medical officers and go to private doctors. There are instances where certain the community opposed the Vaccination campaign. The medical officer said, “When I first came here, I started writing medicines and people told me to give them injections.” One of the ANMs further explained that convincing community members is a big task sometimes “People sometimes close the door and say why we always go and ask for the same thing“. Many people want a male child, so they do not believe in FPP.
- Disruption to the personal life: Accommodation facility is provided to staff like nurses and doctors but the condition of those spaces are not very good. When probed about this, one of the MO replied, “A doctor expects a certain living condition, and the quarters here are so ill-maintained that nobody wants to stay here.” Also the MO is supposed to be present at the PHC for 24 hours, and that affects the personal life of medical officers to a large extent. He expressed by saying, “The supreme court has assigned only 8 hours of work; how am I supposed to work for 24 hours with a normal salary? If I am working on this, then I expect a payment accordingly.”
- The other significant issues frontline workers face are low incentives or loss of stimuli. They also complained about not taking maternity leave for an extended period and the discomfort they have when they have to travel a lot, especially on the days of menstruation. One of them complained about costume; she said, “it’s very difficult to drape saree every time especially during emergencies“. Few of them complained of prolonged travel, especially when the area is inaccessible.
MAJOR ISSUES IN THE PRESENT NRHM MODEL:
The contractual model of staff appointment brings demotivation among staff as they do not have any job security. Despite sharing the same workload, they are paid significantly less than the permanent staff. So, this factor is making them irresponsible towards their work. Lack of adequate human resources is affecting their work and is causing a delay in functioning and ultimately to stress among the working staff.
There is a lot of paper works to be maintained for producing proofs signed by various people, and approval of budget needs the signature of many officers. The target is set according to population count and not factors like education, financial conditions etc.
Most of the posts are filled by staff not qualified for that post. The primary focus is on RMNCH+A, RNTCP etc., whereas program like palliative care or mental health programs are not focused on much. The IEC is functioning at every level but only the information is conveyed. The education and communication aspect is under-utilized.
NRHM focus on intersectoral coordination with the village panchayat, education department etc. and tries to combat issues like malnutrition. And yet it has not focused on other determinants which can affect health like “gender discrimination” that is affecting FPP methods. Coordinated activity with anganwadis becomes a problem when the medical officer has no authority over AWW. NRHM focuses on a vertical approach with multiple vertical programmes with changing guidelines. No feedback has been taken from ASHA or ANM even after knowing that they interact closely with the community, and input from them could really help in performing better. NRHM focuses on promoting public private partnerships, but the private sector is flourishing independently and does not have enough incentives to partner with the public sector. There is no strict regulation over the doctors’ private practice that prevents people from coming to the public sector.
Multiple issues affect the NRHM presently, and each of them needs attention. The contractual model of employment can be continued either by providing job security for at least a few years or by increasing their salary. A horizontal approach could be adopted for most of the programmes.
Maintaining a hard copy and soft copy for the same thing will be difficult for the staff like ANM or ASHA, so either of them should be made compulsory depending on the program.
There should be activities like social audits to keep a check on progress.
PPP should be encouraged where authority should be in the hands of the public sector.
AYUSH doctors should prescribe their medicines, and those medicines should be made available by the state at each PHC and SC.
Proper regulation of private practice should be ensured.
Before setting a target, a qualitative analysis of the area should be undertaken.
Author: Dr. Chilshu Chandran
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