Can India pull off its ambitious National Health Mission?

BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f2134 (Published 05 April 2013) Cite this as: BMJ 2013;346:f2134

Re: Can India pull off its ambitious National Health Mission?

The Government of India must be commended for introduction of the National Rural Health Mission (NRHM) in 2005, which was a landmark initiative and was a result of a much needed paradigm shift in health policy and thinking. It brought definite improvement of rural healthcare delivery infrastructure, increase in health manpower like “contractual medical officers”, peripheral health workers at village level called ASHA (Accredited Social Health Activist), and reaching of central government health funds at the sub district peripheral level.

However, in spite of the above mentioned gains from NRHM, it did not bring about the expected change in the quantity or quality of healthcare services in rural areas or the poor health indicators in the states, especially the acronym “BIMARU” states (Bihar, M.P, Assam, Rajasthan and Uttar Pradesh) in the country.

The one state which was an exception in the country and excelled in public health indicators like fully immunized children was the state of Tamil Nadu which established a separate “public health cadre”. The public health cadre had a separate career pathway which was different from clinicians. It did not force doctors with a clinical mindset with no training or interest in public health activities to manage or implement public health programmes. It also innovated by establishing an exemplary organization with authority for regulating procurement of drugs, medications and equipments using an accountable and transparent mechanism. The accountability and commitment of public health personnel in Tamil Nadu is well known.

Most government funded health programs and public health interventions continued to falter in spite of NRHM. The only exception was the Polio eradication program which was spearheaded by a collaboration project between Govt of India (MOHFW) and WHO country office for India. The project recruited independent, trained, accountable medical officers called surveillance medical officers (SMO) who were specifically trained and provided support to the government counterparts at the sub district, district, state and central government levels for planning and monitoring the quality of all polio eradication activities. This accountable, trained public health manpower was largely responsible for the success of polio eradication across the country in spite of disparities in resources, culture, and infrastructure among various states in the country.

Therefore, it would be very unpragmatic to believe that the National Health Mission will succeed in its objectives without the government health services at the centre and states establishing a separate “public health cadre” with distinct career pathways of the personnel involved and their accountability. As long as we have surgeons and clinicians being forced to manage public health programmes in the government sector and without any systemic accountability mechanism, the outputs are going to be sub optimal. The government health sector will not be able to deliver what is expected of it. Similarly, unless a potent, independent authority is established for regulating the private health sector involvement for delivery of public funded health care services, their involvement would not lead to attainment of the objectives of the National Health Mission and might end up opening another opportunity for favouritism and rampant corruption.
To conclude, India must learn from the demonstrated success of human resource management in the state of Tamil Nadu and the polio eradication programme for ensuring success of the National health Mission.

Competing interests: No competing interests

13 April 2013
WT Research Scholar
University College London
Department of Epidemiology and Public health,, 19 Torrington Place, UCL,, London WC 1E 6BT, U.K