In the history of Public Health in India, a significant mile stone was, the introduction of Target Free Approach in 1996 by the visionary Secretary of Health Shri J.C. Pant. A shift from centrally set targets to the felt and expressed needs of the community in Programming. This was a liberation from the age-old yoke of targets upon the Health Staff, from the lowest cadre ANM to District Medical Officer and State Health department Supervisors. Ever since the first two National Health Programmes of Family Planning and Malaria Control started, it was always a target driven monitoring and performance assessment. Targets and number games have no human face, consideration for patient rights, quality of services, or client satisfaction. This paradigm shift led to the local adaptation in need assessment, approach to community for their involvement and support in programme planning and implementation.
Almost a decade later National Rural Health Mission was launched in 2005 while Secretary of Health Shri P.K.Hota and Joint Secretary Shri Amarjeet Sinha were in command. It had a vision of Improving access of rural people, and marginalized communities, especially poor women and children, to equitable, affordable, accountable and effective primary healthcare. This was to be achieved through participatory bottom-up planning and decentralization to district level management. One of the five main approaches in NRHM was the Communitization agenda. The components of this community oriented and community involved process was the selection and capacity building training of ASHAs, formation of a grass root level team of ASHA, ANM, Anganwadi Worker triad, formation of Village level Health, Nutrition, Water and Sanitation committees, Rogi Kalyan Samitis for PHC/CHC and District Hospitals. Ensuring accountability and quality in health service delivery for best Client Satisfaction was the aim.
Those were not a prescription from the standard text books in public health, but an evolved process especially in the newly formed State of Chhattisgarh since 2000 through the stewardship of another pioneering model of technical capacity building for Public Health Service delivery called State Health Resource Centre.
SHRC Chhattisgarh was formed after a Civil society-government partnership consultation and it had quickly initiated the selection and training of Mitanins (friend of women) in every habitation of 1000 population, the prototype of ASHAs later under NRHM. Over 15-18 rounds of cascade model of training using very innovatively adapted modules, the not so educated Mitanins acquired an amazing level of knowledge and skills over two decades. Apart from house visits and gathering of data, they provided basic symptomatic medicines for temporary relief from their Dawa Peti, and gathered children and mothers for immunization, and medical check-ups. They diagnosed pregnancy using kits, also collected sputum for tuberculosis and blood smears for malaria diagnosis. Provision of directly observed treatment for TB and supply of blister packs for Leprosy treatment were undertaken by Mitanins.
Their constant onsite mentoring and supportive supervision was provided by Mitanin Trainers, Block and District level Resource persons. Before NRHM was launched these 25000 Mitanins provided free service for nearly three years. Respect and recognition in their villages and hamlets were the only remuneration they got. After 2005 they started getting performance linked honorarium like ASHAs elsewhere in the country.
SHRC was providing technical support to the State Health Sector in annual Project planning and budgeting, identifying crucial human resource gaps and their recruitment, operationalizing First Referral Units for Emergency Obstetrics and Newborn Care, operationalizing 108 Ambulance system for Emergency transportation, etc. It organized policy workshops on Malaria and TB control, Leprosy eradication, Sickle Cell anaemia etc. It got a Corporation formed for Drugs and Equipment procurement and supply similar to that of Tamil Nadu model. Urban Health Mission piloting and recruitment of staff for NRHM and NACO were undertaken by SHRC.
Seeing the vibrancy and innovations undertaken by SHRC Chhattisgarh for NHM, at the National level authorities decided to replicate similar SHRCs in other states. 12 States launched SHRCs emulating the Chhattisgarh model till 2019 and now it is 18 States. At national level an NHSRC was formed with similar objectives and functions for providing Technical Support to Government of India under the leadership of Dr Sundararaman who was the first Director of SHRC Chhattisgarh. In 2022 the NHM raised the budget allocation for running cost of major State SHRCs to Rs 2.5 Crores annually.
Union Health Ministry has come out with a Framework on SHRC operationalization in June 2024.It recognizes it as an apex body for providing technical assistance to States having so many diverse challenges and unique features, undertaking implementation research, monitoring and evaluation, health system development and act as a “think tank” to provide innovations, document good practices and launch pilot projects. SHRC Chhattisgarh has been pioneering all these ideas even before NRHM started and continued playing that role model for the last two decades.
The last MOU is now expired and fate of the employed professionals are undecided. Already the State Programme Unit of NHM has taken over the Mitanin program and ASHA Resource centre at SHRC.
While the Union Government is actively promoting more of States to follow the example of Chhattisgarh, the irony is that the current government is closing down its own well acclaimed model. Instead of encouraging “out of the box” thinking by a think-tank to resolve their problems, the State is pruning the autonomy of Public Health experts to purely confine to their regimented dictates. This is quite a retrograde move, not beneficial to the marginalized communities in Chhattisgarh. An urgent course correction is highly warranted.
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*Independent Monitor, National Health Mission, Govt of India; Former Director, State Health Resource Centre, Chhattisgarh; Former Health & Nutrition Specialist, UNICEF, India; Life Member of Indian Academy of Paediatrics, Indian Public Health Association, Public Health Resource Network
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