Sawa Ram, a resident of Uplagarh under Abu Road block of Sirohi district, still recalls with chill the day a woman from the neigbouring Mathara fali, or a hamlet, had to be carried on bamboo sticks all the way to the community health centre (CHC) at Abu Road, 25 kilometres away, when she had labour pain in the dead of the night. With no health centre in the region, and no means of transport available, four men carried the woman on two bamboo sticks.  
“Such incidents were normal for the entire Bhakhar region (the hilly region of Abu Road block) in those days,” he says. While that woman was lucky and did not deliver on the way, there have been cases where either the woman or the child died due to the lack of medical facilities, he says.
But that was some 10 years ago.

Today, seven years after the national rural health mission (NRHM) was rolled out in the district in 2005, such cases are rare. Every panchayat in the hilly region now has a health sub-centre equipped with the basic minimum facility. And an ambulance service (108) is quickly pressed into action in case of any emergency.  

Along with several health sub-centres (a sub-centre caters to a panchayat), the region boasts of a primary health centre (or PHC, catering to a cluster of panchayats) in Deldar and a community health centre (CHC) at the block level in Abu Road.
With 191 health sub-centres at the village level, 22 PHCs and six CHCs at the block and tehsil levels and a district hospital to boot, Sirohi has made considerable progress after NRHM kicked in.  

The most visible effect of NRHM in the district has been the exponential increase in institutional deliveries, or deliveries at government hospitals. “Earlier (in 2004-05) we had barely 20 percent deliveries in our institutions. Last year this jumped to 85 percent. For the next year we have set our eyes on 90 percent institutional deliveries,” Dr Sanjeev Tak, chief medical and health officer (CMHO) of the district, says.
The infant mortality rate (IMR) and maternal mortality rate (MMR), two of the most important health indicators, have also shown considerable decline. While the district’s IMR dropped from 68 (sample registration survey, 2006) to 62 (the 2009 survey), MMR declined from 445 in 2006 to 322 (sample registration survey, 2009).

The district fares much better on both indicators compared to others in south Rajasthan such as Udaipur (MMR at 364), Rajsamand (IMR 65 and MMR 364) and Jalore (IMR 79).    
 
“The district has seen considerable progress under NRHM,” confirms Dharmendra Gautam, district facilitator of a convergence programme run jointly by the union government and the UN.

The benefits of NRHM, Gautam says, have accrued at three different levels: it created an institutional framework under which all health programmes operate, it added a big chunk of manpower and facilitated their trainings, and thirdly it made a huge difference to infrastructure.
 
Institutional framework
“There was no institutional framework for the health sector before NRHM,” Gautam says. “Various state and central health programmes ran independently of each other —there was no planning at any level.”

The NRHM saw formation of the district health mission and integration of multiple societies for health and family welfare programmes at state and district levels. The district health mission, led by the zila parishad chairman, is now responsible for managing all public health intuitions at the district, block and panchayat levels. It also made and implemented integrated district action plan, taking into account requirements at each level.
Medical relief societies formed at each level — district hospital, CHCs and PHCs — were made responsible for making annual plans and overseeing their execution.

At the village level, village health and sanitation committees (VHSCs) with members from panchayati raj institutions (PRIs) were formed to ensure implementation of health plan at the lowest ladder.

Decentralisation of power at panchayat level is the best achievement of NRHM, says Brijmohan Sharma of the Society for All Round Development (SARD), a Sirohi-based NGO working in the health sector.
“The approach was top-down earlier, with the target fixed at Jaipur, the state capital. It was forced on the district, which in turn forced it downed the order. Planning is now done at the panchayat level by the village health and sanitation committees,” says Sharma, whose NGO helps panchayats prepare health plans according to their needs.

The NRHM has also brought large amounts of untied and corpus funds.  
At the sub-centre level, NRHM provides for an annual sum of '10,000 as untied fund (which can be spent on anything, including maintenance of the health facility) and another '10,000 as corpus fund (which can be spent under specified heads). These can be spent under supervision of the sarpanch and the ANM. At the block level PHCs get untied fund of '25,000 and '50,000 as corpus fund and CHCs receive '50,000 as untied fund and '100,000 as corpus fund.

At both these levels, medical relief societies with members of PRIs and block decide on spending the funds.
“Availability of these funds has made a huge difference to the functioning of health centres at each level,” says Ranjit Kumar Koli, sarpanch of Datani in Reodar block.
 
The infrastructure
In pre-NRHM days, the sub-centre at Marol panchayat under Reodar block was a deserted, dilapidated building. Although an auxiliary nurse midwife (ANM) sat there, the sub-centre existed only on paper. There were no facilities to tackle any medical emergency.  Today, the sub-centre sees four or five deliveries every month, besides catering to patients with minor ailments. The building was rebuilt with NRHM funds, says Savita Chaudhary, additional ANM at the centre. “Another untied fund of '10,000, received annually, takes care of the sub-centre’s maintenance.”
In adjoining Datani village, the panchayat utilised NRHM funds to build a big labour room to ensure pregnant women from the village do not have to travel the 15 km to the community health centre during emergency.

At the block level in Reodar, the CHC is a state-of-the-art hospital with an operation theatre, a blood storage unit, a deep freezer and a neonatal care unit. “Not long ago, this hospital ran in two small rooms with hardly any equipment, and no patients. But it sees hordes of patients at the out-patient department (OPD) today,” said Dr SS Bhatti, a physician at the hospital.     

Manpower
There has been large influx of manpower under NRHM with the creation of a new cadre of ASHA workers, additional ANMs, block health managers and district health managers. “There is a huge gap between the village community and the ANM sitting in sub-centres. (But) this gap has been filled with the appointment of 6,000 trained health workers (ASHAs),” says Dharmendra Gautam.

The appointment of additional ANMs has taken the load off ANMs, who earlier found it difficult to cater to a population of 10,000. Appointment of health managers at the block level to coordinate with different departments and look after health schemes at the block level has also eased the situation to an extent.

At the district level there is a district programme manager who helps the chief medical officer in drawing up the health plan and its execution. This new manpower of health managers and programme officers is crucial in implementing the programme at each level.  

The gaps
While NRHM has helped the district meet its health needs, the problem areas remain. From the PHC level upwards, there is a huge staff crunch of specialists. Most CHCs are running with two to four specialists against a prescribed quota of 15.

Accepting that staff crunch at the CHC level affects their operations, district CMHO Dr Tak says, “We have a huge problem in availability of specialists in the district. We need a pediatrician, a gynecologist and an anesthetic specialist at CHCs but we do not have thse specialists at most centres.”
Even offering lucrative salaries have failed to attract doctors, he says. “We offer as much as '80,000 to doctors but are unable to hire them. No one wants to take a posting in Sirohi,” Dr Tak says.  

With OPD patients increasing every day at CHCs, handling them with the few doctors available is an onerous task.       
According to Gautam, another problem is the gap in communication between district officials and PRIs. “Lack of awareness among PRIs about fund entitlements of village health and sanitation committees (VHSCs) is a big problem in effective implementation of the programme,” he says.
Every panchayat has a VHSC, and receives '10,000 annually through NRHM to keep them clean and sanitised — the district has received '1.5 crore in untied fund for this over the last three years.  But, Gautam says, 50 percent of this fund remains unutilised since most panchayats are not aware of the fund. “In fact, several panchayts do not even have such committees,” he says.

Lakma Ram, president of the sarpanch association in Abu Road block, acknowledges that several sarpanches are not aware of VHSCs and the fund it is entitled to.  “ANMs keep sarpanches in the dark about several schemes and funds available,” he says.
According to Lakma Ram, the “real problem” is the huge communication gap between district officials and PRIs. “District officials do not bother to come below the block offices. How will panchayats get involved?” he asks.

CMHO Sanjeev Tak agrees on to the communication gap and says efforts are on to address the situation. “Since so much fund is available at every level it is important that PRIs who know the area’s priority are involved,” he says. “Recently we held awareness camps at the block and district levels, where PRI members were invited and told about the different schemes running under the NRHM, and the important role they could play.”