V. Jwala Narasimha Rao
Consultant HMRI
(Up-Dated on 20th November)Continuation of “104 Mobile” (Fixed Date Health Service) - a scheme sanctioned by Andhra Pradesh Government, benefiting lakhs of rural poor, commenced under Public (not for Profit) Private Partnership on 10th February 2009, the way it was conceived and visualized by late Dr YS Rajasekhara Reddy, former Chief Minister is now in Jeopardy. With the entire 3000+ field staff of the Health Management and Research Institute (HMRI) which entered into MOU with State Government to operate and deliver the stipulated services on release of funds by government, going on strike demanding an assurance from the government for their job security, FDHS future is certainly in stake. In fact the very concept of Public (not for profit) Private Partnership is in question. The statewide intensity of this strike could probably be better described in terms of large number of poor and deserved patients touching as high as four lakhs in Ten days, who include pregnant women, children and those suffering from chronic diseases denied of basic healthcare delivery.
When former chairman of Satyam Computers Ramalinga Raju, founder of HMRI and his team comprising CEO Dr Balaji Utla and Medical Advisor Dr AP Ranga Rao explained to DR YS Rajasekhara Reddy three years ago about the scheme and the possible benefits to rural and tribal poor, his spontaneous response was “I am sold” and immediately sanctioned the scheme. As a result, HMRI has been operating the Fixed Date Health Service with 475 Mobile Health Units (MHU). Each MHU renders two four-hour service each day in two habitations of 1500 population each covering 39 million people living beyond 3 kilometers of any health facility. This service is regularly providing primary screening of pregnant women, growing children and patients with chronic diseases through appropriate laboratory investigations and providing medicines that are prescribed by competent medical officers. The service aims to create equity in health care by providing access to affordable and quality health services at the door steps of the poor and vulnerable sections of the state.
So far, 2.73 lakhs of Van days were provided and 22,500 villages were visited on an average 12 times and so far 116 lakhs people have been screened. More than 3.5 lakhs diabetics, 7 lakhs Hypertension cases have been diagnosed, referred to the doctors and drugs issued each time they visited the Service Points. On an average, these people have visited 6 to 7 times since their diagnosis. Nearly 13 lakhs pregnant women have been registered and on an average all pregnant women have made minimum three compulsory visits. In addition, 20 lakhs children below 5 years, and 20 lakhs school children have been provided services. The FDHS is providing healthcare services to about 4 Crore rural population.
The services that were regular so far and reached the villages on the appointed date and time have come to a halt denying rural population access to health services and medicines including free diagnosis. The Field Staff until they struck work deserve all praise and appreciation for the services rendered and for their adherence to punctuality and sincerity in spite of heavy odds. Only less than 100 times, the service could not be provided which is less than 0.001% of total Van days and reason for such non delivery is floods. Against this background there have been indications from the Government that the program is planned to be revamped and would be brought under the new scheme of Cluster Health and Nutrition Centers. Various deadlines have been fixed at District levels asking to draw new time tables and to report to District Medical and Health Officers.
In an effort to focus on improving maternal and child health and also to address nutritional deficiencies mainly in rural Andhra Pradesh the state government initiated Health Sector Reforms emphasizing among others, the need to establish Community Health and Nutrition Clusters (CHNCs) across the rural areas. In the opinion of Principal Secretary to Government Health Department Dr PV Ramesh, the Chief Architect of the scheme, with the Primary Health Centers becoming almost non-functional, the new model would establish a direct link between the Primary Health Centers, sub-centre and the village.
According to Dr PV Ramesh, the reform initiative would revitalize the primary health system by carving out 360 CHNCs. Each CHNC would provide integrated primary health services covering a population of one to two lakhs people. At the centre of the CHNC would be the first referral unit-a Community Health Centre (CHC) or an Area Hospital-that would support four to 10 Primary Health Centers. Each cluster hospital would also house a Cluster Health Officer (CHO) who would coordinate and monitor the functioning of all PHCs and sub-centers within the cluster. it was planned to make every PHC function round-the-clock by the end of 2011 and would also be mobile with the medical officer visiting all sub-centers on a fixed day twice a month.
The management of HMRI though has never objected to any such move, however cautioned against a premature revamping without providing an alternate structure. Incidentally this proposed scheme is the main objection of the striking employees. The Media and Press often brought out news items quoting officials and elected representatives, questioning the very continuation of the scheme. This has caused considerable anxiety, uncertainty and insecurity among the members of Field Staff.
However, Principal Secretary Health Dr Ramesh says that, “As the person responsible for HMRI services in the government, I would like to categorically deny any move by the government either to halt or dilute these services. I have not seen the media reports except for a couple of random news items in this regard. Propriety demands that such reports should have been validated with someone responsible in the government, before being published or telecast. Anyway, I would like to reiterate that the government has no intention of diluting such vital services. However, the government would like these services to be aligned with a slew of reforms that the government is putting in place to strengthen the health services in the state. Any probable changes will contribute to strengthening of these services and to serve the public interest with greater effectiveness.”
Against this background, a notice of strike was given by 104 Contract Employees Union affiliated to CITU on 09th November 2010 indicating that they would go on strike from the very next day submitting six demands to be addressed overnight failing which they decided to strike. The state-wide strike by the field staff paralyzed the health services in remote villages since 10th November. Interestingly one of their demands pertains to the shortage of medicines for over two months. Folic Acid tablets which are to be provided to pregnant women, medicines for diabetic and hypertension patients that are not made available by government has been questioned by the striking employees. After all they are the interface people with public and have to face the music when not able to meet the demand.
The six demands of the striking employees are, outsourcing of employees to other agencies should be stopped and the Government should directly run 104 Services; improve 104 Services by providing Medicines in time; 104 Staff should be continued under the new scheme of CHNCs; security of job should be ensured and salaries should be paid as per the norms of Pay Revision Commission; PF and ESI should be regularized; Women employees of 104 Services should be given 180 days maternity leave with salaries and Food Allowance to be increased to Rs 100.
HMRI not being in a position to take decision, on these demands independently, as they involve MOU provisions, policy matters and financial support brought to the notice of concerned Principal Secretary Health Department, Minster and also the Chief Minister. The HMRI management is also sympathetic to their demands and feel that the above demands including that of providing medicines be favorably considered for resolving the issue and smooth functioning of peripheral services providing access to the unreached population of the state. HMRI reiterates that it is interested only in providing easy, certain and low cost access to the rural population at their door step. Government also expresses the same view.
Over a period the “104 Mobile” together with the “104 Advice” serve one beneficiary every two seconds, every day round the clock throughout the year. “104 Mobile” predominantly serves beneficiaries below 15 years (31-32%) and above 60 years (23-24%) age group. Of them 42% are female and 58% are male. Preliminary analysis indicates a clear download trend in mortality across the FDHS area. Out of an estimated 4275 van days expected to be covered by the 475 MHUs during the first nine days of strike, only 523 (12%) could be achieved resulting in missing of 3752 missing days. The overall adverse impact in nine days is missing of health care delivery services to about 78.20 lakhs population. Going by the experience and data that HMRI has so far, it is estimated that about 3.37 lakhs population out of the total 78.20 lakhs missed availing the services. Among them are 46, 364 antenatal care pregnant women, 5243 postnatal care pregnant women, 1067 neonate children, 12241 infants, 114578 chronic disease affected people, 48853 student checkups and 75719 other minor diseases. This works out roughly an estimated ten lakhs of rural poor would be affected if the strike is allowed to continue in a month. In other words on an average each field staff member would be serving around 350 beneficiaries in a month’s time or even more.
“104 Mobile” services, in the long run, would substantially contribute for lowering the IMR and MMR and improving the quality of life among the vulnerable sections of the society. The technology-leveraged services that HMRI has scaled up in AP would be of immense value to those citizens who live in small habitations and are highly dispersed and make it economically challenging to deliver health services through the traditional channels of public health architecture. HMRI has demonstrated that it is possible to provide meaningful services at a fraction of a state's health budget.
Will the Chief Minister Dr. K. Rosaiah who assured a delegation of HMRI Management that he would soon call for a meeting with all the authorities concerned to resolve the issues pertaining to the functioning of HMRI keep-up his commitment and ensure the continuation of “104 Mobile”- Fixed Date Health Service?
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