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The provision of curative services at the peripheral level is an area of weakness in present government healthcare service delivery. There is an acute shortage of medical officers. The NRHM proposes to strengthen curative services from the village up. There will be two people
at each sub-centre (auxiliary nurse midwives or health workers) and PHC (Primary Health Centres), so that one person is available for curative services. Community Health Centres (CHCs) are to be strengthened as rural hospitals so that emergency surgery and hospitalization are possible round the clock. This requires operationalizing 3,215 existing CHCs (30-50 beds) as 24-hour first referral units. Protocol and standards for curative services will be codified into the Indian public health standards to ensure quality of care. Stakeholders' committees (Rogi Kalyan Samitis) will be promoted for hospital management so that the health facilities are accountable to the community.

Strategies

One of the key strategies under the NRHM is a community health worker, i.e., Accredited Social Health Activist (ASHA), for every village at a norm of 1,000 populations. The role of ASHA vis-à-vis that of Aganwadi Worker (AWW) and Auxiliary Nurse Mid-wife (ANM) is also clearly laid down. Under the implementation framework for the NRHM, the scheme of ASHA has now been extended to all the 18 high-focus states. Besides, the scheme would also be implemented in the tribal districts of the other states. In the new implementation framework, a provision has been made for an expenditure of Rs. 10,000 per ASHA during a financial year. This ceiling does not include the performance-based compensation, which the different programme divisions would disburse from their own funds. The earlier ASHA guidelines had visualized an expenditure of Rs. 7,415 per ASHA. The increased outlay gives a valuable opportunity to further strengthen the support mechanism.

However, we know that whether it is God or the Devil, both often lurk in the details. In the design of the ASHA programme, there are a number of serious concerns which would need to be addressed, for the ASHA to be able to function with even a minimum level of effectiveness. At present, an educational level up to eighth class (middle education) is expected for a woman to qualify as ASHA. The 1991 census data shows that in the rural areas of the NRHM states in Northern India, over 91per cent women did not have middle level education - and more recent data shows that this situation has not changed significantly in the subsequent period. In the hierarchical, often caste-ridden villages of North India, if this educational criterion is rigidly imposed, it will impose a bias against women from disadvantaged groups such as poorer women with less formal education, and SC and ST women.

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Dr. Gursharan Singh Kainth started his career as Lecturer at Post Graduate Dept. of Economics, Government College, Gurdaspur, and later at Khalsa College; Amritsar, specializes in Quantitative & Development Economics. Has the distinction of serving Punjab Agricultural Univ, Ludhiana, for more than 2 decades and remained Director-Principal of Saint Soldier Management & Technical Institute, Jalandhar. Currently, heading GAD Institute of Development Studies, Amritsar, a self-financed research institute. Has been honoured with various awards, including Guru Draunacharya Samman, Vijay Rattan Award, etc.
Article posted on December 14, 2008.