A Rural Housing Policy that is missing!!

A roof over the head is a basic right of every human being. For those who do not have one, it is a

dream. Home does not only provide protection, it also has symbolic significance in a person’s life. In addition to security, owning a house adds to the status, dignity and affects the social, physical and psychological well being of a person.

India, with its predominantly rural populace, faces a unique challenge in addressing adequate housing for all. The XII^th five year plan has estimated the current rural housing shortage at 44 million houses, out of which 90 per cent of the rural housing shortage are in the BPL categories. Yet India does not have a Rural Housing Policy!

Mismatch between the availability of housing stock and number of households is one aspect of housing inadequacy. The other aspect relates to the mismatch between the desired and actual quality. Kuchcha or semi –pucca house with thatched roofs, mud walls, no cooking space and poor ventilation describe the living conditions of a poor man. According to the National Family Health Survey (2000), only 19% of the rural population lives in pucca houses, while the remaining live in kaccha and semi-pucca houses. Poor living conditions have direct bearing on the health of the rural poor.

The Housing Policy of 1998 which is supposed to address the housing needs of both the rural and the urban population has shown considerable bias towards the urban needs.  It is futile to challenge the fact that the needs, aspirations and demography of the urban and the rural are dissimilar.  To ensure parity in development, the housing needs of the rural areas have to be addressed separately which is possible only when India has an exclusive Rural Housing Policy.

Government initiative in rural housing has been through the subsidy based Indira Awas Yojna Scheme (IAY) and similar other schemes. There are also state wise housing schemes targeted to different target groups like the SCs, STs and BPL families, such as, Jharkhand Government’s Birsa Awaas Yojana and Siddho-Kanu Awas Yojna, Rajasthan’s Mukhya Mantri Gramin BPL Awaas Yojana, Tamil Nadu’s Kaliagnar Housing Scheme and two schemes in Karnataka namely Basava Vasathi Yojana and Ambedkar Housing Scheme, to name a few.

All these housing schemes vary in terms of the target audience, implementing agencies, funding opportunities and unit cost of the house. However the participation of all the States has not been equal. In some cases, States do not have separate State level agencies for taking up the Rural Housing Programmes, in other cases, funds taken from HUDCO are passed on as loans to beneficiaries but the cost is ultimately borne on the budget as the recovery rate is very poor.   Similarly the IAY scheme which has been beneficial in several ways, have many shortcomings like inadequacy of space, unit cost, selection of beneficiaries, ownership issues, lack of people’s and other stakeholders participation. Building the capacity of beneficiaries to build their house and enabling them to construct disaster resistant houses have been ignored under the IAY.  The housing programmes have loopholes and have not been able to achieve its targets to reduce the gap between the demand and supply of housing units.

 

Apart from the physical structure of a house, what people also require are – electricity, sewage system, toilets and safe drinking water. Thus there is a need to have a comprehensive Rural Housing Policy that would address the shortage of dwelling units along with the bleak habitat conditions of rural India by providing decent and affordable housing to the rural poor, linking Housing Finance Institutions and Micro Finance Institutions with the housing programmes, reorganising delivery mechanisms and bringing legal reforms to facilitate access to land titles for the poor. The Policy should focus on strengthening the capacities of the people living in rural areas and ensure that the Panchayats are successfully engaged in implementing the housing schemes. In addition, the housing policy should promote the development of micro enterprises that would open employment opportunities for villagers. The Rural Housing Policy should not only meet the demand of dwelling units but also make sure that these dwelling units are of live-able quality and resistant to nature’s susceptibility. Promotion of locally available environment friendly construction materials and technology should also be an integral part of the Policy.

Investment in rural housing will have a high multiplier effect on income and employment of the rural people, therefore reinforce Government’s strategy towards inclusive economic growth. It is estimated that overall employment generation in the economy due to additional investment in the housing/construction is eight times the direct employment. (IIM-Ahmedabad Study, 2000)

 

As rightly said by Mahatma Gandhi “India lives in her villages” and “If the village perishes India will perish too”, therefore only an integrated Rural Housing Policy can achieve desired results in building India of our dreams.

Abhishikta Roy

SEZ Policy in India and Issues with Labour Law

Source: Bangla Mail

To achieve an instant and overall sense of the content of Indian labour law, the Industrial Disputes Act 1947 (IDA) can be read as a metaphor for Indian labour law in general. The IDA is the essential legislation associated with ‘industrial relations’ in India, covering labour disputes, strikes, lock-outs, lay-offs and retrenchments. Clause 2(n) (vi) of IDA gives the government the right to notify in public interest, any industry specified in the First Schedule of the IDA as a ‘public utility service’. A ‘public utility service’ is associated with railways, ports, post, telegraph, telephones, power, light, water and sanitation etc. Since labour is a concurrent issue in the Indian Constitution, individual states have by amendment put in a host of industries such as polyester, resin, flour and rice mills in the First Schedule and dubiously labelled them as a ‘Public Utility Service’. Special Economic Zones (SEZs) fall in this category as well.

Even before the SEZ movement had reached the levels of current enthusiasm, ‘Hundred percent Export Units’, particularly those located in Export Processing Zones (the smaller precursors of the SEZs) were listed in the First Schedule by a number of Indian states. With the initiation of an explicit SEZ policy in 2005, one of the key devices sought to be used to circumscribe labour rights was to have the establishments located in a SEZ to fall in the First Schedule.

There are three significant features regarding the regime governing labour in SEZs. Firstly, labour laws in SEZs are not covered under formal sector labour laws but under labour laws meant for ‘public utility service’. By classifying employment in SEZs as formal sector employment, labour costs would rise, thus dampening national and international investment. This would go against the overall desire of the SEZ endeavour to push for labour intensive export oriented consumer goods. Secondly, the law is implemented by the office of the Development Commissioner rather than the Labour Commissioner unlike in other industries. Thirdly, the ability of the workers to organise strikes is curtailed in SEZs on account of being labelled as a ‘public utility service.’

Concentration of power in the hands of the Development Commissioner and not the Labour Commissioner has been criticised even by supporters of SEZs. Firstly, it leads to conflict of interest. Indian labour legislation is structured to give the Labour Commissioner enormous voice in determining labour market outcomes, whether it is in relation to work conditions or firing decisions – all this power now comes to vest with the Development Commissioner, whose job, unlike that of the Labour Commissioner is not primarily to look into labour matters but to ensure that the SEZ is able to attract sufficient investment and generate earnings. This clearly generates a conflict of interests and there is no in-built guarantee that labour interests will be privileged efficiently in relation to those of employers.

Secondly, will the office of the Development Commissioner be able to learn about the implementation of the plethora of labour laws in place, if so, it is essential to acknowledge that this will be costly in resources and to the extent such learning is not invested in, it will be costly to the degree the units slackens in the implementation.

The circumscription of labour rights has been reaffirmed by a survey of The International Trade Union Confederation (ITUC). According to its findings, trade unionists are not able to enter the SEZs in India because entry in to the zones is restricted to the workers who are transported in by their employers, making it very hard to organise workers and rendering union activity virtually non- existent. It also notes that that the bulk of the employment in these zones is confined to young women who are too frightened to form unions. These women are subjected to bad working conditions and compulsory overtime. Also, workers face the constant threat of immediate sacking if they make demands to implement labour laws.

Section 49 of the SEZ Act empowers individual states to modify the SEZ Act and other related laws and regulations that enable the delivery of fiscal benefits envisioned by the SEZ policy, however, it excludes labour laws from its purview. It states that such powers of modification are not applicable to “matters relating to trade unions, industrial and labour disputes, welfare of labour including conditions of work, provident funds, employers’ liability, workmen’s compensation, invalidity and old age pensions and maternity benefits applicable in any Special Economic Zones.” In other words unlike fiscal laws, rules and regulations, the set of labour laws, rules, regulations and orders relating to labour matters cannot be modified by invoking the provisions of the SEZ Act. Needless to say, there is a definite case to reform the laws in a manner such that both labour and producer interests are adequately balanced.

In the end it may be noted that India has signed some of the Conventions associated with the International Labour Organisation (ILO) Declaration on Fundamental Principles and Rights at Work, but it has not ratified the critical Conventions regarding Freedom of Association, Right to Organise and Collective Bargaining*.

Note
* India has ratified a total of 39 Conventions adopted at different sessions of the International Labour Organisation. These include conventions on hours of work, unemployment, night work, minimum wages, weekly rest, workers’ compensation, forced labour, labour inspection, child labour, underground work and equal remuneration for men and women for work of a similar nature.

By Karishma Mutreja

Realistically Defining Tribal Identity for Effective Policy Interventions

Photo Source: IndiaNetzone

In India’s struggle to safeguard tribal rights, the deliberations on tribal identities are still coloured by stereotypes. The discourses pertaining to tribal populations and tribal identities invariably fall upon the civilised-uncivilised, primitive-modern dichotomies.

Political representatives in the country have not been able to effectively lobby for tribal rights and tribal voice in policy decisions. The National Tribal Policy, which was formulated in 2008 and is still in the draft phase, bears testimony to this fact. The country has not yet formulated a comprehensive national policy guaranteeing tribal rights. Apart from the lack of a strong political will; the policy formulation mechanism is also based on the model of assimilation of a ‘primitive’ culture to a ‘mainstream’ culture, the root cause of which, perhaps, is that the discourse governing policy decisions is a bureaucratic discourse prescribing modes of modernisation of the primitive instead of being driven by the tribal voice and demands, the Draft National Tribal Policy is a case in point.

Need for Tribal Welfare

The need to safeguard tribal rights arises because; “as per the 2001 Census, the tribal population was 8.43 crore or eight per cent of the total population, with over 90 per cent living in rural areas with poor social indicators...Infant mortality, maternal mortality and neo-natal death figures are unacceptably high among the STs because of lack of healthcare infrastructure [and] low literacy rates.” Moreover almost 40% of those who have been   permanently displaced from their native habitats due to development projects are tribals.

As a result of these displacements a large number of tribals have migrated to metropolises where while some work as domestic and shop servants, rickshaw-pullers, even sex-workers, some get pushed into petty, deviant and criminal activities. But the draft notices that tribes are scattered “over all the States/Union Territories, except Punjab, Haryana, Delhi, and the Union Territories of Pondicherry and Chandigarh.” These three states and two union territories do not have the native communities scheduled as tribes; however, they have a considerable population of migrant tribals. While the draft acknowledges this phenomenon, it does not provide for acknowledging this section of the tribal community, which has moved out of the conventional markers of tribal identity.

Locating Stereotypes

Clause 20 of the draft, which deals with the Scheduling and De-scheduling of Tribes, refers to criteria evolved by the Lokur Committee for determining which communities could be classified as Scheduled Tribes which include: (i) an ensemble of primitive traits, (ii) distinctive culture, (iii) geographical isolation, (iv) shyness of contact with the community outside, and (v) backwardness. It follows by noting that the criteria laid down by the Lokur Committee are hardly relevant today. The draft notes that “for instance, very few tribes can today be said to possess ‘primitive traits’. Other more accurate criteria need to be fixed.”

Again, while the draft acknowledges the need for more accurate criteria, it does not provide for reformulating the tribal identity as one that is dynamic and not static. Vinay Kumar Srivastava in his analyses of the draft policy, by way of an analogy notes, that many “of the traits that are found in the so-called primitive societies, may also be found among the contemporary affluent and patriarchal societies.” Moreover he notes that in “the context of definition, we need to use concepts that have an operational value, i.e., they are given an empirical content, and with their help, we are able to classify societies as objectively as possible.”

Conclusion

Policy interventions cannot be effective unless the policy making decision is guided by the needs of the stakeholders. For this Srivastava notes, realistic understanding of tribal society lies in refraining from using value-loaded assumptions, such as the ones the draft notes: tribal way of life is “woven around harmony with and preservation of nature.”

Preserving a culture to contribute to the ethnic diversity of the country traps the tribal community in a frozen image. The dynamic reality of tribal living is missing in the draft, the policy needs to incorporate tribal voice and more comprehensively acknowledge the dynamism of tribal identity.

Ashwin Varghese 

Building a safe India for mothers

Photo Credit: UNICEF

The report by the Registrar General of India on maternal mortality which was released in December 2013 came as a respite in the face of India’s failure to achieve the targets under the Millennium Development Goals. Maternal mortality has significantly decreased in India over the past few years. India’s maternal mortality rate (MMR), or the rate of deaths among women during or after pregnancy, declined by 16 percent in 2011-12 from 2007-09, according to the Census data.

Although, the MMR dropped from 212 deaths per 100,000 live births in 2007-09 to 178 in 2010-12, India is lagging behind the target of 103 deaths per 100,000live births to be achieved by 2015 under the United Nations-mandated Millennium Development Goals (MDGs).

Moreover, international comparisons reveal a grim picture. According to the 2010 figures from the "World Development Indicators", South Korea has a maternal mortality count of 16, followed by Sri Lanka (35) and China (37). India is way below at 200, lagging behind even Nepal (170). The three regional countries that are behind India are Indonesia (220), Bangladesh (240) and Pakistan (260).

So what is preventing India from not even matching countries like Nepal in ensuring better health care facilities to expecting and new mothers? Lack of institutional delivery or delivery by skilled professionals, poor health budgetary allocation to health, discrimination against women and cultural attitudes that do not consider professional prenatal and delivery care are the major contributors to this sorry picture.

The NFHS data released by the Ministry of Health and Family Welfare in 2012 also revealed that with the existing rate of increase in deliveries by skilled personnel, the achievement for 2015 is likely to be only 62 percent which is still considerably short of the targeted universal coverage. High out of pocket expenses by pregnant women and their families on institutional deliveries like drugs, user charges, diagnostic tests, diet and C –sections prevented the poor from accessing health care centres leading to high mortality rates.

Janani Suraksha Yojana by the National Rural Health Mission was launched in 2005 as a response to this poor health infrastructure.  It provides for graded scale of cash assistance based on the categorisation of States as well as whether beneficiary was from rural/urban area. However, is merely doling out money to BPL families enough to reduce maternal deaths? Is this an effective policy approach to a complex issue like maternal mortality?

In the “high focus” states (Bihar, Madhya Pradesh, Rajasthan, Uttar Pradesh), according to the NRHM document, the MMR is high because there are not enough rural hospitals and road connectivity is poor. If the objective is to reduce MMR in these states, an all-out effort has to be made in both these fronts: creating the health infrastructure in rural areas which is truly functional and ensuring road connectivity. There is a lack of a policy framework which can move beyond the idea of financial incentive and respond to the underlying hindrances to improved maternal health. There is a need to pilot solutions which address the intertwined factors which lead to high number of deaths among pregnant women or new mothers. It is the need of the hour that we have policies which are born from a better understanding of the ground reality rather than mere financial assistance.

There are quite a few successful approaches we can learn from. Unicef’s work in Madhya Pradesh is worth a mention. Along with the State Government, Unicef has upgraded maternal and neonatal health centres in several remote districts of MP.  A call centre was also established in the district hospital two hours away to make sure that the ambulance reaches women on time and takes them home again, once they’ve given birth. If there are problems with a birth, the ambulance can take the mother to a newborn care unit in the district hospital. The unit is equipped with incubators and can accommodate children born underweight and unwell.

Maternal and Prenatal Death Inquiry and Response (MAPEDIR) is yet another innovative tool which is being used by health experts, policy makers and communities. This innovation extends across select districts in Rajasthan, Madhya Pradesh (MP), West Bengal, Jharkhand, Orissa and Bihar. It seeks to kindle the community’s participation in probing why women died in pregnancy, delivery or soon after, with an emphasis on developing feasible solutions to the identified problems. The entire process includes identifying and investigating maternal deaths, sensitising the community, galvanising communities and health systems into action, and monitoring and adjusting interventions through continuing inquiries. The accumulated evidence can help communities understand the root causes behind these deaths so they can take effective local action and advocate for improved services to prevent future deaths.

The role of private sector and public-private partnerships in increasing availability and physical access to services for women in rural areas is another solution which can be considered.

Whatever be the approach, reproductive freedom lies at the heart of the promise of human dignity, self-determination, and equality. Every woman in India should have the right to access to best reproductive health care available. Only then can they participate with full dignity as equal members of the society.

 

Simi Sunny

 

 

 

Deconstructing Domestic Spending & International Assistance to End Poverty

1.2 billion people in the world today live beneath the international poverty line on less than US$1.25 a day. Out of the 507 million people living in this extreme poverty in South Asia, 400 million are Indians.

Development Initiatives is think tank that believes that we can end this extreme poverty by 2030. To do that we have to:

·Target aid at the poorest,

·Mobilise all available resources and

·Get the maximum value out of every dollar.

Their report entitled Investments to End Poverty maps all resources coming in and going out of developing economies. If we can better understand what resources, domestic and international are available to us, then we can better decide when and how to deploy them in order for it to have the greatest impact.

Judith Randel, Executive Director Development Initiatives says, “If we are serious about ending poverty we have to move from a vision to a time-tabled reality.” On the domestic front, economic growth will play a critical role in reducing poverty but, according to Randel, the data shows that even current patterns of growth will not be enough.

Despite recent slowdowns, since 1991 the Indian economy has grown exponentially. The World Bank even moved India to a “lower middle income” country from a “low income” one in 2007.  But, no matter where the poverty line is placed, this continues to be a country of rampant poverty and vast inequities. And this dichotomy is in accordance with global trends in poverty.

A 2010 study by economist Andy Sumner at the Institute of Development Studies titled “The New Bottom Billion” found that where two decades ago, 93 percent of the world’s poorest lived in low-income countries, today nearly 75% of them (1 billion people), live in middle-income economies.

It would therefore be imprudent to depend on economic growth alone and we need to have a deeper understanding of all the resources at our disposal if we are to make the most effective use of them.

Domestic government spending per poor person is the most important indicator as to whether enough is being done to lift people out of extreme poverty. Most poor people live in countries with very low government spending per capita that is nowhere near enough to end poverty.

Government spending in India per capita, at purchasing power parity was US$864.1 in 2011. On the other hand, China spent nearly US$2000 and Brazil spent over US$2500 during that same year.

 

India still spends only 0.9 percent of gross domestic product on health care, among the lowest in the world, and only 3 percent on education.

Not only does this imply that not enough domestic resources are being spent on lifting people out of poverty in India, it also dictates the kind of international aid India has access to. It is only where government expenditure is higher, that international aid flows are also larger and more diverse.

The report deconstructs the kinds of financial aid being provided so that a country can see what funds are available to it, for what purposes and who controls how they will be used. This is crucial for 2 reasons: First, each donor offers a different package. For e.g., 2/3rds of Italy’s aid stays in Italy while most of Denmark’s aid, goes to the recipient country. Secondly, the bundle that each country receives is also different. Togo and Afghanistan for example appear equally aid dependent but while most of what Togo receives is in the form of debt relief that stays in the donor country, the bulk of Afghanistan’s aid actually reaches Afghanistan as cash, projects and technical help.

Governments that spend more see a greater diversity of funds flow into the country—not just aid, but also lending, remittances and foreign direct investment, because better-run countries are able to spend more and have the capacity to attract other sources of funds.

More mature economies like Brazil and China, where resource use is more effective and efficient, rely on direct investment and lending. Africa, where government spending per person is less than $500, per year depends most on aid which accounts for nearly 70% of the financial resources from abroad.

According to the report, remittances remain the largest resource flow into India; followed at some distance by long terms loan and then FDI.

59% of Overseas Donor Aid (ODA) to India goes to just 3 sectors – infrastructure, health and education. Three –quarters of all aid is in the form of loans and equity investments which is much higher percentage than that of the average recipient. Health is the only sector where other types of aid, cash in grants, in particular prevail. Funding to these sectors is also highly concentrated. International Donor Aid, Japan, the UK and Germany account for most of it.

Though ODA volumes to India have increased over 2000-2011 from US$3.6 billion to US$5.4 billion making India the 3^rd largest recipient of aid in 2011, ODA per poor person has actually decreased.

A slew of recent pro poor legislation have been passed by the Government of India but unless they translate into increased per poor person spending in the country we will be unable to see a sharp decline in poverty. A simultaneous challenge is how to attract greater diversity and flexibility in the kind of aid packages being offered to us.

By Gayatri Verma

 

 

 

 

Infrastructure Bonanza: Policy Initiatives for India’s Northeast

Photo Credit: The Economic Times

Infrastructure and connectivity deficit have always remained a perpetual challenge for India’s Northeast. Due to harsh geographical terrain, it almost remained isolated and only a stress of 28 km long road through Siliguri corridor, popularly known as chicken neck connected this entire mass of land with rest of India. The railway link was established during colonial period for interest and expansion of colonial economy in this remote region. Though Northeast shares 98 percent of its boundary with international neighbours, but for geo-strategic reasons, many of its organic cross-border routes were closed in post-Independent period. Intra-regional accessibility also has been difficult, making NER cut-off from all sides. Attempts to connect the region has gained momentum in post 1990s with Look East Policy and was reiterated in 2008 in 2020 NER Vision document. In the recent past, the 12^th plan once again ensures UPA government initiatives on infrastructure and connectivity in Northeast as a key development strategy, which focuses on following areas.

Railways

Major expansion in railways is charted out with 20 projects of which 10 are national projects. Additional financial resources of Rs 314 crore in the current year expects to complete railway routes like Rangiya-Rangpura (Tezpur), Rangpura- North-Lakhimpur and North-Lakhimpur- Murkongselek. Lumding – Silchar gauge conversion for main and branch lines also are suppose to be completed between March 2015and June 2016. Two most remote states like Meghalaya and Arunachal Pradesh are going to be connected through rails with new broad gauge lines Dudhnoi - Mendipathar and Harmuti-Naharlagun by March 2014. The seven national projects to be completed in the Twelfth Plan period are Rangiya-Murkongselek (Assam), Lumding- Silchar including branch lines (Assam, Manipur, Mizoram, Tripura), Tetelia- Byrnihat (Meghalaya), Jiribam-Tupul-Imphal (Manipur), Bogibeel bridge (Assam), Kumarghat-Agartala (Tripura), Agartala-Subroom (Tripura).

Roadways

500 km East -West Corridor of the National Highways in Northeast is expected to be completed in December 2014. Another mega project on Special Accelerated Road Development is targeted to be completed by June 2015, which involves development of 4099 km of roads. Trans Arunachal Highway programme involving a length of 2319 km is likely to be over by June 2016 and March 2018.

Airways 

Air connectivity has increased considerably in the region and average departures per week have more than doubled from 226 in 2001 to 497 in 2012. However more initiatives like creating new airport at Pakyong, Sikkim are taken. For completion by 2014, the issue of land acquisition needs to be resolved and State Government has to construct the approach road from Gangtok to Pakyong. Similarly the new airport at Itanagar also needs to resolve land acquisition issues, approach road, electricity and water issues. Several existing airports are being expanded/modernized like in Guwahati, Dibrugarh, Jorhat, Shillong, Imphal, and Agartala.
Guwahati will be a regional hub to improve connectivity.

Waterways 

National Waterway 2 on Brahmaputra stressing 891 km can provide scope for eco-friendly and cheap transport for both commodities and people. It is planned to ensure 2 to 2.5 metre depth with navigation aids and ten floating terminals maintained by IWAI.
16 floating terminals for passengers being set up by Ministry of Shipping are expected to be operational by March 2014, four are already operational. IWAI is developing a Roll on Roll off facility at Dubri and Hatsingimari to reduce travel time of vehicles between Meghalaya and Dhubri in Assam which now have to go over Jogigopa bridge adding 220 km.

Power-Telecom 

Northeast currently has 4080 MW of generation capacity and another 6810 MW are under development. Untapped hydro potential is 55,561 MW can generate surplus power, meeting the energy needs of the nation and also generating resources for the region. There is need for expeditious clearance on environmental, forest and land acquisition. The Cabinet Committee on Investment cleared the Dibang project in AP though its Lower Subansiri project is facing some implementation problems. Intra-state Transmission line network for Arunachal Pradesh and Sikkim is being taken up under NLCPR (Central). For states other than Arunachal Pradesh and Sikkim Power grid has prepared a project for evacuation of power being funded by World Bank and GOI. 

Teledensity in the Northeast has improved but still remains below national average. Twelfth Plan envisages a Comprehensive Telecom Development Plan for the Northeast which includes mobile coverage in uncovered sub-divisional district headquarters and villages. This is undertaken by Northeast Space Application Centre and DoT. Mobile coverage would extend to uncovered portions like National Highways and all District Headquarters with optical fibre cable (OFC) connectivity or satellite media. Such OFC aims to connect District to Block to Panchayat/Village Council by 2015.

Appropriate cooperation from region can make such significant step a reality and helps Northeast to break its barrier of isolation.  

For more see, http://pib.nic.in/newsite/PrintRelease.aspx
 

Rakhee Bhattacharya

 

Communitisation of Health Institutions and its Impact

Photo Credit: HIFA 15

National Rural Health Mission (NRHM) is a unique programme that has recognised capacity, knowledge and skill of the communities to plan, implement health policies and monitor public health institutions. Various institutionalised community processes of NRHM such as Accredited Social Health Activists (ASHAs), Village Health Sanitation and Nutrition Committee (VHSNCs), Rogi Kalyan Samiti (RKS) and Community Monitoring provides ownership and responsibility directly to community to actively contribute in the overall aim to seek universal access to equitable, affordable and quality health care which is accountable and at the same time responsive to the needs of the people. A radical policy change in the form of NRHM has actually pushed the idea of people centered planning and decision making or communitisation in health system. How this idea has been actually implemented at ground level in the first phase of NRHM that ended in 2012, is a matter of great concern. Government of India has extended NRHM with same principles, so it is now necessary to understand the implementation of community processes and their impact.

Various evaluations of NRHM in the last couple of years shows mixed results about implementation and impact of various community processes. ASHA program remain the back bone of the community process and works as the primary link between community and public health system. Country has recorded a substantial increase in utilisation of services such as institutional deliveries, immunisation, ANC checkups and family planning but recorded less impact on health seeking behaviour of people. However, an evaluation by Planning Commission reveals that because of inadequate emphasis on skills, training and supportive monitoring, ASHAs are less functional and effective in tasks related to community level counseling, care provisions and community mobilisation work.

As a policy, NRHM has institutionalised roles, responsibilities and power of the community in deciding community level health needs, making health system friendly to the local people and contributing in delivery of quality care by health institutions. RKS constituted in each public health institution involves active participation of community, patient and civil society in assessing need of institutions and making them responsive and accountable to public. Review of RKS reveals that members of RKS are unclear about their role, rights and overall objective. Mostly RKS discuss fund utilisation issue in their meeting. There are very few evidences where RKS are found discussing non-budgetary issues such as improving IPD/OPD cases, outreach work, absence of health personal etc. On the other hand, VHSNC ensure micro health planning, implementation and monitoring at village level. Fifth Common Review Mission (CRM) of NRHM reveals that though VHSNCs are active in spending fund allocated to them, but the village health plan is not yet institutionalised anywhere and there is no clear model or clarity in its role and utility. There is an increase in utilisation of untied funds for VHSNCs but had limited involvement of PRI in health planning process and in the function of VHSNC.

Community monitoring is another institutional mechanism introduced by NRHM to communitise function and accountability of health institutions. The community as well as the Patient Welfare Committees is expected to monitor the performance of the health facilities on various parameters using techniques such as jansunwai.   But this process has given least priority during entire phase of NRHM. The idea was successfully implemented in nine states on pilot basis that resulted in increased utilisation of services and accountability. But unfortunately, no state government except Karnataka took it forward as integral part of health system.

Level of health institution communitisation varies from state to state and hence health care utilisation also differs across states. Fifth CRM conducted in 15 states found that more than 50% of expected in-patients are seen in public sector health institutions of Himachal Pradesh, Sikkim, Goa, Rajasthan, Odisha and Karnataka. It is interesting to observe that in these states communitisation process such as VHSNCs, RKS, PRI participation and institutionalisation of community monitoring are in place and functioning remarkably better. On the contrary, states like Jharkhand, Uttar Pradesh, Gujarat and Chhattisgarh have given less priority to communitisation process and resulted into less turn out in public health institutions. According to 5^th CRM in these state less than 30% of expected in-patients are seeking public sector hospitalisation.

Various evaluations of NRHM reveal that it has not achieved its target and is still much behind from its targets of first phase. However, NRHM has recorded a faster improvement in health service utilisation, quality care and availability of health institutions in its first phase of implementation. Communitisation process involved in it has great role in this improvement as it is revealed through various evaluations. It raises a need of strengthen and mainstreaming such process for future success. Traditional mindset of functioning in public health institutions needs facilitation to accept and imbibe the spirit of community driven system.
 

-Jeet Singh