(The Gist of Kurukshetra) RURAL HEALTH: EVOLUTION AND WAY FORWARD

 [SEPTEMBER-2019]

RURAL HEALTH: EVOLUTION AND WAY FORWARD

Introduction

• Healthcare system in India has a long history with man reference points starting with Ayurveda, around 2500-3000 BC, to the Sir Joseph Bhore Committee Report of 1946 AD. Since independence in 1947, India has made major strides on many fronts in health sector. A major emphasis on strengthening rural health infrastructure started with setting up the first few Primary Health Centres in Najafgarh (Delhi), Poonamallee (Tamil Nadu) and Singur (West Bengal), under Community Development programme (CDP) in mid 1950s.
• Over these years, the clear focus remained on rural India. The NRHM was clearly a programme to operationalise some proposals of NHP 2002. Building on the policy and programmatic initiatives, in the years which followed, India achieved remarkable success on many fronts (See Table 1). While these initiatives need to be commended and celebrated, India needs to be equally aware of existing challenges and explore solutions to make the country a healthy nation. This article summarizes the key features and success in health sector from 2002-17, including more recent developments (2017-2019) and proposes a few actionable approaches to accelerate India's journey towards universal health coverage by 2030 (as also envisaged in NHP 2017 and most recently reiterated in the Government of India's Union Budget 2019-20 as one of the 10 components of 'Vision for India' in the decade ahead as "Healthy India: Ayushman Bharat, well-nourished women and children".

Table 1- Key health sector related developments and achievements in India (2002-17)

• 2002: National Health Policy (NHP-2002) 2002-03 Universal Health Insurance Scheme (UHIS).
• 2005: National Rural Health Mission (NRHM).
• 2008 Rashtriya Swasthya Bima Yojana (RSBY);
• 2008 Jan Aushadhi Yojana (relaunched as Pradhan Mantri Bhartiya Janaushadhi Pariyojana (PMBJP) in 2016.
• 2008-17 State specific social health insurance schemes for specific target populations.
• 2010 Report of High Level Expert Group (HLEG) on Universal Health Coverage (UHC).
• 2011 India reported last case of Wild Polio Virus.
• 2012 Intensive discourses on operationalisation of Universal Health Coverage (UHC) in India started.
• 2013 India is declared polio non-endemic country; National Urban Health Mission (NUHM), with this NRHM renamed as National Health Mission (NHM).
• 2014 South East Asia region of WHO is declared polio free; Mission Indradhanush to increase routine immunisation coverage launched; National Mental Health Policy (NMHP) released; High Priority districts (HPDs) for interventions under NRHM in India started.
• 2015 India validated maternal and neonatal tetanus elimination; Country becomes Yaws free as well 2015-16 Task force on comprehensive primary health care (PHC) in India.
• 2017 National Health Policy (NHP-2017); National Mental Healthcare Act; Report on state specific burden of disease in India.

Table 2: Key health sector related developments and proposals in India (2017-19)
A. National level initiatives

• 2017- National Health Policy; Mental Healthcare Act (of 2017); HIV/AIDS Act (2017); National Nutrition Strategy Sustainable Actions for Transforming Human capital (SATH) initiative for Health and Education sector by NITI Aayog.
• 2018- Ayushman Bharat programme (ABP) with components of (a) Health and Wellness Centres (HWC) and (b) Pradhan Mantri Jan Arogya Yojana (PMJAY); Mid-Level Healthcare Providers (MLHP) under HWCs; Aspirational District programme (ADP) for prioritisation of social sector interventions POSHAN Abhiyan/National Nutrition Mission; First State Health Index for India released.
• 2019- NITI Aayog Strategic plan for New India (2018-22) Report of Task force on Tribal health in India National Medical Commission (NMC) Act; Community Health providers (CHP) with prescription rights under NMC Act; Second State Health Index of India released.

B. Key State specific initiatives:

• 2017- Universal Health Coverage (UHC) pilot in Tamil Nadu; Family Health Centres (FHC) in Kerala; Karnataka Public Health Policy.
• 2018- Uttar Pradesh State Health policy (Draft); Launch of Basthi Dawakhana, Community Clinics in Telangana 2019 Kerala State Health policy Discourse on the Right to health in Indian states i.e. Rajasthan, Chhattisgarh and Madhya Pradesh
• Formulation of health systems reform/transition committee in Andhra Pradesh.

C. Key features in recent policy and strategy documents with potential impact on rural health National Health Policy 2017

• Proposal that Govt, would be the sole provider of Primary health care services.
• Provision and attention on special populations such as Tribal health.
• Increasing government spending on health to 2.5 percent of Gross Domestic Product (from 1.15 per cent in 2014-15) by 2025.
• Two-thirds or more government spending on health for primary health care State governments to increase spending from 5 percent to 8 percent of state budget.
  NITI Aayog strategic plan for new India (2018-22) four key thematic areas for health sector:
• Universal health coverage,
• comprehensive primary health care,
• human resources for health; and
• public health care and management. Specific initiatives for nutrition, Gender, social determinants of health.

Way Forward

• A lot of progress in rural health in India has been achieved, yet there is a long way to go. There is a felt need for building on the ongoing initiatives, starting a few new and bringing convergence.
• India clearly needs 'more, better, faster and sustained initiatives for improving health. This should, inter alia, be supplemented by innovation for health sector. There are a few recent examples such as in Andhra Pradesh, the provision of kidney services at PHC level resulted in three-fold increase in utilisation of services for renal diseases at district hospital.
• In Family Health Centres (FHC) of Kerala, elected bodies and representatives in rural settings are taking larger responsibility for health services. These are a few examples of innovation emerging from across the country, which need to be scaled up.
• There is immense potential of digital health technology in ensuring access to health services in rural areas. Here are a few suggestions for accelerated transformational changes in rural health in India.

Conclusion:

• Rural health in India has made progress in terms of services and infrastructure in the last seven decades. The situation has rapidly improved in the last two decades, with period of 2002-2017, arguably being the period of first major health systems reforms since India's Independence.
• The period of 2017-19 has many similarities with the period of 2002-05 and has potential to become the second wave of health reforms in India. This is only possible with 'more, better, faster and sustained' approach to rural health, which means more initiatives are implemented; activities and policies are executed in better ways than earlier, initiatives are added and accelerated, with innovations and all these efforts are sustained over time. A lot more is needed for rural health agenda in India. It is proposed;
• to rapidly recruit and post Community Health Providers (CHPs);
• establish toll-free call number for both curative and diagnostic services;
• omake rural health facilities ready for disaster and emergency situations;
• start many small non-health initiatives for big health impact; and
• Grand convergence' of public service delivery in rural India.
• This is what would make rural health outcomes better and contribute in achieving commitments of Universal Health Coverage and Sustainable Development Goals in India.

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