Dr Sanjeev Tak, the chief medical and health officer (CMHO) of Sirohi, is a bit busy these days, holding interactions with panchayati raj institutions (PRIs), whose involvement in the implementation of health schemes, he says, is as important as those of district officials.

But even without the PRI work, Dr Tak’s day is pretty much chock-a-block. As the chief health officer of the district, he has under his supervision 191 health sub centres at the village level, 22 primary health centres and six community health centres at the block level — and a workforce running into thousands.

He is responsible not only for the implementation of the Centre’s national rural health mission (NRHM) but also several state government-run health schemes. Getting a hold of him during work hours being a near-impossible task, Governance Now reached his official residence at 8 am — for a conversation over a cup of tea and a whiff of the pleasant early-winter morning.

How do you evaluate the health scenario in your district?
There has been a perceptible, even drastic, change in the health sector in Sirohi after NRHM. The infrastructure has improved significantly. You can visit any of the 191 sub-centres, 22 primary health centres, six community health centres and three referral units in the district and check the facilities.

Major repair and renovation works have been carried out and equipment installed using NRHM funds. In terms of manpower, accredited social health activists (ASHAs) for every 1,000 people and a graduate nurse midwife (GNM), besides an additional auxiliary nurse midwife (ANM) for every sub-centre, have been appointed. These ground-level workers have changed the health situation in the district.

Twice a month, every first and third Thursdays, we hold a special day for mother and child health and nutrition (MCHN) at every anganwadi centre.

Each pregnant woman is checked by the ANM on these days and newborns are given vaccines. We have medical mobile units that reach even remote areas that do not have sub-centres. We have held 80 camps till date, taking hospital facilities to those who cannot reach hospitals.

Another significant change I must point out is the increased institutional deliveries after NRHM (kicked in). Earlier (in 2004-05) we had only 20 percent of total deliveries at our institutions. Last year this went up to 85 percent. For the next year, we have set our eyes on 90 percent institutional deliveries. 

What do you think are the challenges at present?
We have a huge problem in terms of unavailability of specialists in the district. At the community health centres (there are six CHCs in the district) we should have a pediatrician, a gynecologist and an anesthetic specialist. But we do not have them in most of these centres. We pay as much as Rs 80,000 to these doctors but unfortunately are unable to hire many. No one wants to take a posting in Sirohi.

With OPD patients increasing every day at these centres, handling them with the number of doctors on duty is extremely difficult.

Another challenge is reaching out to the tribal belt. The tribal population is scattered all over: (at many places) one family lives on one hilltop and another on a different hilltop. There is a need to make them live in a community. Their eating habits need to change, too, with most tribals being malnourished.

Speaking of the tribal belts, several sub centres, which are the only health facility available for remote corners in this region, do not open. At one sub-centre I visited, the ANM had not been seen for at least a couple of weeks. How do you plan to address this?
Keeping the staff at these locations is a problem. There are incidents of theft and intimidation and for a young woman (ANM) it is sometimes difficult to live in such far-flung (areas housing) sub centres. Having said that, we ensure most sub centres are attended to by ANMs.

A criticism one often hears is about the target-oriented, top-down approach to health planning. Instead of preparing health plans from the panchayat level upward, it is done vice versa.
I would disagree to that. The planning is done at the block level, which is then sent to the district. Ideally it should be done at the panchayats in the gram sabha and sent to the block, which should then be forwarded to the district headquarters. But the problem is lack of participation of the panchayati raj institutions. Here I would agree with you that at the panchayat and block levels only formalities are done.

We are trying to involve PRIs participation. At every level there is a provision for PRIs’ involvement. And with so much funds available if the PRIs are seriously involved in planning, the health scenario at the ground level will surely change.

Could you elaborate on involvement of PRIs at each level and the funds available?
At the sub-centre level, NRHM provides for an annual sum of Rs 10,000 as untied fund and another Rs 10,000 as corpus fund. These can be spent under the supervision of the sarpanch and the ANM. At the block level, the PHCs get an untied fund of Rs 25,000 and Rs 50,000 as corpus fund and the CHCs receive Rs 50,000 as untied fund and Rs 100,000 as corpus fund. There are medical relief societies at both these levels that have members of PRIs and blocks who can decide how these funds should be spent.

Since so much funds are available at every level it is important that health plans are made through the involvement of PRIs, who know the priority for the area. While earlier their involvement was only a formality, we are now trying hard to get them involved.

Recently we held awareness camps at the block and district level where the members of PRIs were told about the different schemes running under the NRHM and the important role they could play. This is not to say there is no involvement of PRIs at all — meetings at village health and sanitation committees (VHSCs) do take place but not as sincerely as required.

In one meeting I attended in the district recently there was much debate about the child sex ratio. Sirohi has a very low sex ratio (890) compared to 914 for the country. How are you tackling this?
Declining sex ratio is a serious concern, and to deal with this situation we have come out with an initiative in which every pregnant woman who has had one to four girl children will be monitored till the (point of) delivery. The ANMs and ASHAs have been asked to track these women constantly. If the woman undergoes abortion, the cause will be investigated and necessary action taken accordingly.