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
- Jeetha D’Silva, freelance journalist, Mumbai
India’s creation of a National Health Mission seems to show that the government is finally recognising the importance of the health of its 1.2 billion citizens. The mission could substantially improve healthcare infrastructure and service delivery throughout the country, especially in urban areas, say public health doctors.
This new overarching programme will bring together the proposed National Urban Health Mission and the existing National Rural Health Mission. “The genesis of the National Health Mission goes back to the agenda of providing a potential platform for equitable, universal health coverage which is inclusive to every citizen of the country, regardless of economic status,” Priya Balasubramaniam, director of Universal Health Coverage for India Initiative at the Public Health Foundation of India, a public-private initiative based in New Delhi, told the BMJ.
India has an acute need for healthcare reform. Despite its growing economic clout and technological advances, the country lags behind much of the developing world on key health parameters. For instance, infant mortality is 48 per 1000 live births: Sri Lanka’s is 12, and Nepal’s is 41. Mortality in children under 5 years is 63 per 1000 in India: the global average is 57, in Sri Lanka it is 17, and in Nepal it is 50. India’s burden of communicable and non-communicable disease is also very high—for example, the prevalence of tuberculosis is 256 per 100 000 population, compared with a global average of 178.1
The concept of the National Health Mission is based on recommendations made by a group of public health experts that was constituted to formulate the health agenda for the 12th five year plan (from 2012 to 2017). They said that the “impressive gains” made by national health programmes such as the National Rural Health Mission, as well as by other disease control programmes, should now be channelled to deliver universal healthcare in all urban and rural areas.2
Lessons from the National Rural Health Mission
The government started its mission to improve healthcare delivery in rural India in 2005, and this is now operational in all states of the country. A progress report states that infant mortality rates declined from 58 per 1000 live births in 2005 to 53 in 2008, and maternal mortality fell from 301 per 100 000 in 2001-03 to 254 in 2004-06.3
“The good thing about the National Rural Health Mission is that it brought focus on the right things. Community needs became a priority for the first time; infrastructure was looked at; and equity, accountability, and coordination all came together to achieve health goals,” said Aparna Hegde, IUGA international fellow in urogynaecology at the Cleveland Clinic Florida, and the founder and chairperson of Armman, a Mumbai based not for profit organisation that focuses on maternal and child health.
The National Urban Health Mission
A critical component in the planning and implementation of the overarching National Health Mission is the setting up of the National Urban Health Mission. This was announced as a standalone initiative in the 2012-13 union budget but it was combined with the existing rural health mission in this year’s budget session to form the National Health Mission.4 5“The urban poor comprise a significant and rapidly growing proportion of the population,” Dr Balasubramaniam told the BMJ. “Studies have projected that by 2050 about 51.7% of the country’s population will be urban.”
“The growing recognition of the problem and commitment on the part of policy makers and the government to include the urban poor will hopefully lay the foundations for improved access to care; establishment of a functioning, decentralised, and equitable referral system; improved health education; and improved financial management,” commented Dr Hegde of Armman.
Doctors often point out the irony in urban healthcare. Despite the supposed proximity of the urban poor to health facilities, their access is severely restricted, as the draft framework for the National Urban Health Mission pointed out.6 They are “crowded out” because of the inadequacy of urban health services, and outreach is ineffective and referral systems weak. “Further, the lack of standards and norms for the urban health delivery system when contrasted with the rural network makes the urban poor vulnerable and worse off than their rural counterpart,” the document says.6
Details of the final plan for the National Health Mission are yet to be announced, and government officials did not respond to the BMJ’s queries on the programme. However, it has been reported that two cities, Bangalore and Bhubaneswar, will launch pilot projects shortly.
The media has reported that Karnataka’s health department has prepared a 2.5bn rupee (£30m; €36m; $46m) project implementation plan, which includes setting up urban primary healthcare centres and zonal hospitals throughout Bangalore.7 The National Urban Health Mission aims eventually to cover 640 cities and towns.6
Implications for doctors
In scaling up healthcare infrastructure and expanding the scope of health programmes, the National Health Mission is expected to generate employment opportunities for doctors and allied healthcare professionals. “The potential for human resources will increase at all levels, and the universal healthcare programme could be one of the largest employers in the country,” Dr Balasubramaniam told the BMJ.
There are also likely to be opportunities for doctors to partner with the government. With 80% of doctors, 26% of nurses, 49% of beds, 78% of ambulatory services, and 60% of inpatient care, the private sector has a part to play in healthcare delivery.2 The high level expert group that devised the national mission has recommended using private sector capacity, albeit within a strict regulatory framework.2
Health workers foresee numerous challenges, especially in implementing the urban mission. For one, the budgetary allocation is low, at 21 239 crore (212 390 million) rupees,8 while the allocation for the rural mission alone in 2012-13 was 20 822 crore rupees.4 The annual projected cost of the urban mission is estimated to be more than 5000 crore rupees.6
There is also the challenge of integrating programmes. Dr Hegde told the BMJ that combining two diverse behemoth systems could help to improve efficiency. “However, there is a very real danger of resources being spread too thin,” she said.
“For a healthcare system to be effective, it has to be adequate on the input side—in terms of infrastructure, funding, and staffing—as well as efficient on the output side in terms of delivery of health services,” said Dr Abhay Shukla, a co-convenor of Jan Swasthya Abhiyan, the Indian circle of the worldwide People’s Health Movement.
Procurement of drugs is one area that needs to be looked at urgently. Dr Shukla pointed out that only a few states, such as Tamil Nadu, Kerala, and Rajasthan, have managed to implement effective free drug programmes. “Staffing and placement reforms in public healthcare facilities are another critical area,” he added. And finally, there has to be accountability, transparency, and checks on corruption, he said.
Dr Shukla has been involved with community based monitoring programmes associated with the National Rural Health Mission in Maharashtra. “In areas where community-based monitoring is under way, delivery of services is definitely more accountable and effective,” he said.
Cite this as: BMJ 2013;346:f2134
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.