Enhancing Services of Panchayat Raj in Public Health
* Ramaiah Bheenaveni
Panchayats in India are an age old institution for governance at village level. In 1992, through the enactment of the 73rd Constitutional Amendment, Panchayati Raj Institutions (PRI) were strengthened as local government organizations with clear areas of jurisdiction, adequate power, authority and funds commensurate with responsibilities.
Panchayats have been assigned 29 rural development activities, including several, which are related to health and population stabilization. The XI schedule includes Family Welfare, Health and Sanitation, (including hospitals, primary health centers, and dispensaries,) and the XII schedule includes Public Health.
“Thus the possible realm of influence of the Panchayats extends over a significant proportion of public health issues. The Gram Sabha, where empowered has the potential to act as a community level accountability mechanism to ensure that the functions of the village Panchayat in the area of public health and family welfare, actually respond to people’s needs”.
The 73rd Constitutional Amendment makes it mandatory that functions related to the provision of primary health care – maternal health and family welfare are the responsibility of the PRIs. Besides the various development sector departments come under the functional jurisdiction of the district panchayat. Creating a health system with the panchayats being made responsible for supervising and monitoring health services seems an ideal model.
The National Health Policy, 2001, also emphasizes implementation of public health programmes through local self-government institutions, especially relating to the national disease control programmes. The Planning Commission set up a Task Force to review PRI involvement in various sectors and to make recommendations on engagement of PRIs specific to each sector. A Task Force Report pertaining to five major programmes within HFW and the particular functions of PRI. The Task Force Report summarizes key functions for each of the tiers of the PRI in respect of five major programmes- Reproductive and Child Health (RCH), and programmes for Vector Borne Diseases, Blindness TB Control Programmes, and STI/AIDS. Many of the activities proposed are related to identification of people in need of services, in collaboration with the health system and monitoring of village level health workers, and Primary and secondary health care facilities. Currently the PRI are not equipped to take on such planning and monitoring functions, nor is there a cognizance in the health system of the role of PRI.
Critical Role of Panchayati Raj Institutions in the success of the National Rural Health Mission
PRIs are seen as critical to the planning, implementation, and monitoring of the NRHM. The NRHM is seen as a vehicle to ensure that preventive and promotive interventions reach the vulnerable and marginalized through expanding outreach and linking with local governance institutions. Key to the success of the NRHM are: intersectoral convergence, community ownership steered through village level health committees at the level of the Gram Panchayat, and a strong public sector health system with support from the private sector. Underlying this is a commitment to systemic reform within the health sector for better regulation of medical establishments, public health oriented medical education, strengthened management capacity, and effective and rational human resource policies. Success of the NRHM in achieving its outcomes is significantly dependent on well functioning gram, block and district level Panchayats. It is anticipated that in the NRHM, a Task Force will be set up to specifically recommend and study the centrality of PRIs to the NRHM.
ASHA, the mechanism to strengthen village level service delivery, will be a local resident and selected by the Gram Panchayat or the Village Health Committee (VHC). She will be supported in her work by the AWW, school teacher, members of local community based organizations, such as SHGs, and the Village Health committee. ASHA’s role would be to facilitate care seeking and serve as a depot holder for a package of basic medicines. She will be reimbursed on a performance based remuneration plan.
The Village Health Committee (VHC) will form the link between the Gram Panchayat and the community. The VHC would be responsible for working with the Gram Panchayat to ensure that the health plan is in harmony with the overall local plan. It is anticipated that this committee will prepare a Village Health Plan and maintain village level data, supervised by the Gram Panchayat. Engaging the Gram Sabha and other groups in planning and monitoring the Village Health Plan will presumably enforce transparency and accountability.
Under the NRHM, untied funds of about Rs.5000-Rs. 10,000 are to be placed with the ANM to meet unanticipated expenditures and to ensure that lack of drugs and other consumables is not an issue. At the sub center level planning and use of these funds will be supported by the appropriate tier of the panchayat.
Effective health care is not within the realm of the health department alone. At the village level convergence is required with agencies providing nutrition, sanitation, education, livelihood/poverty alleviation and empowerment schemes at the very least. Beyond the functionaries of each of the line departments, the only institution at the village level which can coordinate all these functions is the PRI. In reality however there is little convergence at the village level in many states, much less an active role
for the PRI in facilitating convergence. At the District level a District Health Mission will coordinate NRHM functions. Sanitation will be aligned with the NRHM.
Several Health Programmes Monitoring by PRI:
ACCELERATED RURAL WATER SUPPLY PROGRAMME (ARWSP)
Under ARWSP, the Central Government is to supplement the efforts of the State Governments in providing access to safe drinking water to all rural habitations of the country.
The role of PRIs in implementation of this scheme are :
Panchayati Raj Institutions should be involved in the implementation of schemes particularly in selecting the location of standpost, spot sources, operation and maintenance, fixing of cess/water tariff, etc.
The implementation of the Sector Reform Projects in the identified pilot districts, are also to be carried out either by the District Panchayats or through the District Water and Sanitation Missions (DWSM), which are to be registered societies under the supervision, control and guidance of District Panchayat.
Wherever PRIs are themselves firmly in place and willing to take up the responsibility and are strong enough to do so, they implement the projects themselves instead of DWSM.
At the village level, the individual Rural Water Supply Schemes are to be implemented through Village Water and Sanitation Committees which should be committees of Gram Panchayats.
Drinking water supply assets are transferred to the appropriate level of Panchayats and such Panchayats are to be empowered to undertake operation and maintenance of drinking water systems.
CENTRAL RURAL SANITATION PROGRAMME (CRSP)
This programme aims at improving the general quality of life in rural areas; accelerating coverage in rural areas; generating demand through awareness creation and health education; and controlling incidence of water sanitation related diseases.
The role of PRIs in implementation if this scheme are :-
Total Sanitation Campain (TSC) is a community based programme where Panchayati Raj Institutons are in the forefront.
As per TSC Guidelines, the implementation at the district level is to be done by the District Panchayats. Panchayats at block and village level are to be fully involved for implementation of the programme.
Where District Panchayat is not in a position to implement the programme, it is being implemented by District Water & Sanitation Mission which is chaired by Chairperson of District Panchayat and the Village Committees are chaired by the Chairpersons of Gram Panchayats. In the later case, the Village Water & Sanitation Mission are part of the Gram Panchayat.
SWAJALDHARA
This programme aims at providing Community-based Rural Drinking Water Supply. The key elements of this programmes are namely, (i) demand-driven and community participation approach, (ii) panchayats / communities to plan, implement, operate, maintain and manage all drinking water schemes, (iii) partial capital cost sharing by the communities upfront in cash, (iv) full ownership of drinking water assets with Gram Panchayats and (v) full Operation and Maintenance by the users/ Panchayats.
The role of PRIs in implementation of this scheme are :-
Gram Panchayat shall convene a Gram Sabha Meeting where the Drinking Water Supply Scheme of People’s choice including design and cost etc. must be finalized. Gram Panchayats are to undertake procurement of materials/services for execution of schemes and supervise the scheme execution.
A resolution must be passed in the Gram Panchayat meeting calling for users/beneficiaries to contribute 10% of the capital expenditure. However, GP can remit towards community contribution from its tax revinue (Not from Government Grants) with the approval of Gram Sabha.
Gram Panchayat will decide whether the Panchayat wants to execute Scheme on its own or wants the State Government Agency to undertake the execution.
After completion of such schemes, the Gram Panchayat will take over the Schemes for Operation & Maintenance(O&M).
Panchayat must decide on the user charges from the community so that adequate funds available with Panchayat to undertake O&M.
Conclusions:
However, the extent to which reproductive health care is enhanced by the panchayats depends on the funds and functions devolved to them for carrying out these responsibilities. Clarity in the separation of powers between the elected representatives and the bureaucracy at the local government are important in this context. While the development targets include reducing the incidence of maternal mortality and morbidity, the question still remains whether the institutional interventions and resources allocated are adequate to address these problems. Gram Panchayat has a supervisory role in ensuring proper delivery of services. Many of them were not aware of what comprised the role and responsibility of panchayats in healthcare service delivery.
References:
1. Manual on Target Free Approach, Department of Family Welfare, Ministry of Health and Family Welfare, Govt. of India
2. Panchayat Raj Institutions In India An Appraisal- National Institute Of Rural Development, 1995.
3. Vijayanand, S.M, Decentralization and Health, Paper presented at Role of Local Government Institutions in Population Stabilization, Institute of Social Sciences, New Delhi, February 2003.
4. Dash, Dhanlaxmi (2006) – Women Environment and Health, Manga Deep Publications, Delhi.
5. The Constitution ( Seventy-third Amendment) Act, 1992,
6. Rosenstock IM. What research in motivation suggests for public health. Am J. Public Health. 1960; 50:295-301.