For a new and improved NRHM

The National Rural Health Mission (NRHM) has been described as one of the largest and most ambitious programmes to revive health care in the world and has many achievements to its credit. It seeks to provide universal access to health care, which is affordable, equitable, and of good quality. It has increased health finance, improved infrastructure for health delivery, established institutional standards, trained health care staff and has provided technical support. It has facilitated financial management, assisted in computerisation of health data, suggested centralised procurement of drugs, equipment and supplies, mandated the formation of village health and hospital committees and community monitoring of services. It has revived and revitalised a neglected public health care delivery system.

Challenges and solutions: The NRHM has injected new hope into the health care delivery system in India. However, it continues to face diverse challenges, which need to be addressed if its goals are to be achieved in the near future.

Health as a State subject: The location of health in the State list rather than the concurrent list poses major problems for service delivery. This is also compounded by the fact that the NRHM funding is from the Centre while the implementation is by the State governments. Health care delivery cannot be improved to provide a seamless service without the removal of these barriers.

Project mode and problems: The NRHM is currently functioning as a project of the Government of India and is due to end in 2012. Its significant contribution to improving health care infrastructure and service delivery across the country will be frittered away if its funding ceases with the 11th Five Year Plan (FYP). The NRHM should be not only included in the 12th FYP but also be changed from its limited term project mode to a permanent solution to India's health problems.

Its status as a project makes the integration of the NRHM with the State health care systems problematic. The divisions run deep resulting in irrational distribution of human resource and infrastructure. The inertia of the old system and the low morale and discipline of its staff continue to be major challenges. The NRHM has been able to add new infrastructure and personnel; however, its impact on re-inventing and re-invigorating systems seems to be limited, with much more effort being required. There is a need for a more coordinated approach which optimally utilises resources.

Improving governance: A comparison of data between States and within regions and social groups suggests marked variations in the NRHM process indicators, utilisation of funds, improvements in health care delivery, health indices and in community participation. Regions with prior good health indices have shown marked improvements, while those with prior poor indices have recorded much less change. This is true, despite a greater NRHM focus on and inputs to poor-performance States. Improving governance and stewardship within the NRHM programmes mandates general improvement in the overall governance of States and regions.

Increased funding: Health care costs for the average Indian usually results in catastrophic out-of-pocket expenditure and is a well recognised cause of indebtedness in the country. The total health budget for India is about 1 per cent of the country's GDP. Most developed nations prioritise health care and provide 5-10 per cent of their GDP. The 12th FYP should increase funding for health to the tune of 2-3 per cent as promised by the United Progressive Alliance.

The diversion of funds, through private health insurance schemes for the care of rare disorders to be treated in corporate hospitals, takes away funding from the public health care system. The injection of such money into the public system would allow for the provision of universal health care, improve government health systems and provide for common health conditions benefiting larger numbers.

Urban health: The NRHM has focussed on rural health. Many parts of urban India have similar health care needs and currently have glaring deficiencies. The National Urban Health Mission should be accorded the same status as the NRHM. Both efforts should be coordinated and combined into a National Health Mission.

Expand focus: The major focus of NRHM is on maternal and child health. While this is vital, there is a need to expand the vision to other common general health problems. There is evidence to suggest that other crucial government programmes (e.g. blindness) have taken a back seat.

Cash transfers and outcome: The NRHM currently employs process indicators to measure its implementation. The measures used are mainly related to finance, infrastructure and personnel. There is need to shift over to indicators of efficient functioning and examine their impact on health outcomes. The initial high rates of mortality tend to reduce rapidly with early inputs but require fully functional, efficient and effective systems for sustained results. The Janani Suraksha Yojana, a conditional cash transfer scheme to incentivise the use of health services to reduce maternal and neo-natal mortality among poor women, has become a success by encouraging institutional deliveries. However, the evaluation of its success should be based on its impact on the health outcome of the mother and baby, rather than on financial process indicators.

Similarly, the diverse and difficult circumstances of medical practice across the country mandate a differential reinforcement for health professionals. There is need for differential payments to health care staff who work in remote situations and difficult contexts.

Health information and monitoring: The NRHM has provided for infrastructure, personnel and training for Health Management Information Systems. However, these are not optimally utilised. There is need to improve the information system as part of the process of monitoring health indices of populations and functioning of the public health care system. The NRHM already has a programme of community monitoring and social audit. This should be strengthened in order to monitor the use of funds and empower local communities.

Social determinants and public health approaches: The goals of the NRHM clearly state the need to impact on the social determinants of health by coordinating efforts to provide clean water, sanitation, nutrition, housing, education and employment. It should, in conjunction with other government programmes, work towards the reduction of poverty, social exclusion and gender discrimination, all of which have a significant impact on health. There is need to increase the synergy and coordination between government programmes (e.g. the Integrated Child Development Scheme, the Mahatma Gandhi National Rural Employment Guarantee Act, etc.) and the NRHM.

Funding priorities

Improvements in health of populations contribute to economic development and vice versa. This bidirectional relationship justifies increased investment in health. The NRHM should become an integral part of the Five Year Plans and the health budget should be increased to 2-3 per cent of GDP. The National Urban Health Mission should receive equal funding priority and be coordinated with the NRHM. Greater financial inputs to improve governance and specific funding to coordinate NRHM programmes with those of the State health services are crucial, as is cooperation with other government programmes to target social determinants of health. Strengthening of health information, community monitoring and social audits to assess its impact on health outcome indicators is necessary. Improved funding for the public health sector to treat common health conditions, rather than providing private health insurance for uncommon disorders, is mandatory. State governments also need to prioritise health and increase their share of the health budget.

The NRHM has made a significant impact on health care delivery. However, greater political, administrative and financial commitment is required for it to make a substantial impact on health outcomes. The 12th Plan should allocate ring-fenced budgets for specific operations. There is need to develop systems to monitor and audit performance and health indices; this will allow for course corrections.

The health care system has flaws, both at the conceptual and operational levels. However, there is no simple, band-aid solution to the problem. There is a need for continuous monitoring and appraisal, allowing for regular course corrections. Unfortunately, health is a prime example where good politics and good policy diverge. One cannot ignore the economic interests of the health education-hospital-pharmaceutical-insurance industries who directly profit from tertiary specialist care, indirectly when public health delivery systems are run down and when the social determinants of health are neglected. In our capitalistic world, these interest groups cannot be expected to look beyond their strategy to generate profit. Politicians and governments are also unable to see the ethical issues related to equity and lack the conviction to provide services for the poor. Health, a human right, and universal health care should not remain an aspiration but should become operational in the near future.

(Professor K.S. Jacob is on the faculty of the Christian Medical College, Vellore.)