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Lack of health administrators impact scope, scale of NRHM by Radhieka Pandeya

In the remote Raghopur block of Vaishali district in Bihar, the primary health centre (PHC) is supposed to be operational 24X7, with the medical officer in charge (MOIC) running the out-patient department between 8am and 12.30pm. On 8 May, the MOIC reached the PHC at 10.30am and left after an hour. According to patients, this was not a random event.

Most of the 20-strong crowd awaiting medical attention is turned away. Similarly, outside the tuberculosis ward, four men wait all morning outside a locked door and finally leave unattended.

The PHC in Mokhada block of Thane district in Maharashtra is a study in contrast. Tidy consultation rooms with clean mattresses covered with clean, white sheets. Two doctors have computers with Internet connectivity. The MOIC of this facility has been given a laptop. One of the two doctors is always available for incoming patients.

The basis of this stark difference is what doctors in the two states are expected to do. An MOIC in Bihar is expected to provide medical care and double up as an administrator at the PHC. The two doctors in Mokhada focus on patient care while a medical superintendent handles administration.

As the National Rural Health Mission (NRHM), the United Progressive Alliance’s flagship public health scheme launched in 2005, sought to scale up the scope of public healthcare in the last five years to reach out to 742 million people in 35 states, across 642 districts and 638,000 villages, the importance of health administration is being acutely felt, all the more since state governments have loaded their own specific health initiatives onto NRHM. Also, given that the programme’s guidelines require regular monitoring, it has led to heavy documentation, performance assessment and critical examination by state governments.

Growing public health programmes need to be coordinated by people who understand them. It also means that for each programme, medicines need to be made available on time while the PHC has to ensure its ambulance is working properly, the clinic is not facing any absenteeism, and that patient’s monetary compensation under NRHM for availing its services, and those of health volunteers, is disbursed on time.

The lack of efficient public health administration at the local level has restricted the ability of governments to spend money. In 2008-09, about 12% of the total budget allocation of Rs11,930 crore was unspent.

Some states such as Assam have been quick to recognize this and now employ an accounts manager and a programme manager at every PHC. “A doctor may be a very good surgeon but won’t be a good logistics manager. We have huge funds available, but doctors have no training in accounts so they don’t want to utilize these funds. This is where the managers step in. The accounts manager, for instance, helps in efficiently utilizing the untied and tied funds,” says J.B. Ekka, mission director for NRHM in Assam.

K. Srinath Reddy, director of the Public Health Foundation of India, agrees: “There is a competency mismatch in many states. People who are not trained in public health and not oriented to public health are asked to manage public health functions. For instance, an orthopedic surgeon or an ophthalmologist becomes a district health officer.”

While Tamil Nadu was the first to make investments in public health administration, some of the more recent states are already beginning to see the benefits. “We now are able to generate and make available monthly data on every programme from every facility and this puts us in a much better position to find and fill the gaps in the system,” says Ekka.

Tamil Nadu’s headstart of 15 years is being linked to its success in healthcare metrics. “That had brought in a much greater impact and helped Tamil Nadu significantly reduce the disease burden, maternal mortality and infant mortality rates, among others.” said P.V. Ramesh, health secretary, Andhra Pradesh.

Tamil Nadu is now in the process of evolving a method by which, at the time of entry itself, doctors are able to choose their cadre—clinical or administrative. “Doctors are available but doctors trained in administrative field are a big shortage. We’ve encountered such people. They’re good doctors but when it comes to administration, they find it difficult,” says V.K. Subburaj, principal secretary, health and family welfare, government of Tamil Nadu.

An independent review of NRHM conducted in 2009 confirmed that in the absence of a health manager, the medical officer is unable to provide adequate medical attention. “One of the things we found during our assessment was the idea that management of health services is grossly lacking at all levels right from village to block to district,” says Nirupam Bajpai, senior development adviser and director, South Asian programme, Earth Institute, Columbia University, who along with two others had undertaken the mid-term evaluation.

“The doctors are actually losing out on their clinical skills and doing paperwork. So there is need for introducing health managers at every level to make sure that the facility is functional,” he adds.