Alex Webb Glbl390 Memorandum: Improving Indias National Health by Targeting Rural Populations Executive Summary This policy

memo addresses the current state of rural health in India in light of the National Rural Health Mission (NRHM) reforms implemented from 20052012 and in preparation for the full rollout of the Twelfth Five Year Plan (20122017). Its purpose is to provide for the Government of Indias Planning Commission and Ministry of Health and Family Welfare (MOHFW) an assessment of the NRHMs success in meeting expected outcomes, as well as recommendations for continuing to improve rural health moving forward. By first analyzing the original impetus for the NRHM, we seek to elucidate several key factors contributing to urban-rural health disparities in hopes of more capably addressing them. Pursuant to the Millennium Development Goals as well as those set forth in Articles 42 and 47 of the Constitution of India, we will argue in support of new policies intended to promote further improvements in the health of rural communities by focusing on two essential inputs for health: human resources and infrastructure. Introduction Indias remarkable economic proliferation over the last 60 years has failed to produce commensurate improvements in the health of its citizens1. Despite boasting the third largest GDP (PPP) globally and a 10-year economic growth rate almost double that of most of the worlds top 50 economies2, according to 2012 world estimates India ranked 161st and 175th in life expectancy at birth (LEB) and infant

mortality rate (IMR) respectively3. Table 1 (see Tables and Figures) presents changes in LEB and IMR for assorted regions and countries from 1960 to 20074. According to this data, China, who has experienced comparable economic growth over recent decades2, and Bangladesh, Indias much poorer neighbor, have both managed to outpace Indias sluggish health gains. In order to ameliorate the current national health outlook, Indias rural population has been identified as a high-priority target for health improvements based on population size and relative health status. Table 2 presents the results of the most recent National Family Health Survey, published under MOHFW auspices in 20075. These results elucidate the ongoing health disparity between urban and rural populations, with all key indicators highlighting the higher overall health of the former. Given that more than 833 million Indians 69% of the nations total population6 live rurally, improving the health status of rural communities should unequivocally continue to be a top priority for the Ministry. Background Indias current health system and its patterns of distribution are built upon the Western medical practices that were introduced during British colonial rule and brought to dominate over indigenous practices7,8. During the late 18th and 19th centuries, the economic interests of the British Empire dictated the distribution of this new, Western health system. State-owned medical facilities were established to service the needs of the colonial British population that was concentrated in urban centers, plantations, factories, and mines7, and largely ignored the welfare of the Indian people, the bulk of whom lived rurally. This initial phase of Indias

modern health system served to establish a norm of health disparities, as exclusive provision of services was among its intentions. Indian independence did not bring with it extensive restructuring of the national health system. Health policy and planning became largely centralized under the Federal Five-Year plans created to guide the nations economic development8. Initially these plans did not include a comprehensive national health plan, instead pursuing targeted interventions addressing specific health issues9. As no effort was made to expand the health care delivery systems structural framework, urban centers continued to receive 75% of health resources under the first two Five-Year plans8. While subsequent plans sought to integrate specific initiatives into broader more comprehensive programs, investment in primary health centers remained low. The combined effect of centralized planning and emphasis on vertical programs over the scaling-up of basic health services was the creation of a system neither accountable to local populations nor capable of addressing their needs especially over the long run. Furthermore, both public and private health services became increasingly concentrated in the urban centers in which they were initially installed. Serving to further solidify these health patterns and exacerbate existing disparities was the international influence that came during the 1980s and 90s. Organizations such as the WHO and UNICEF helped maintain the vertical structure of the Indian health system through donor-driven programs such as immunization and those targeting TB and AIDS10. After taking a loan from the International Monetary Fund in response to the national economic crisis of the early 1990s, the Indian government was forced to relinquish control of its own budgetary allocations

due to the IMFs Structural Adjustment Program. This program, designed to ensure recuperation of IMF investment, reduced the already meager federal health budget. Between 1991 and 1999, the decrease in government health expenditure from 1.3% of GDP to a mere 0.9%11 meant that necessary investments in the expansion of the public health system could not be made. Waning public supply promoted marketdriven growth of the private health sector during this time, leading to further expansion of urban health systems while rural services remained relatively unchanged12. The National Rural Health Mission It was in this context that the NRHM was launched in 2005. The vision of this sweeping initiative centered on improving access and efficiency of the public health system throughout rural India. By and large it can be seen as a systemic overhaul aimed at creating an integrated rural health system. By subsuming all relevant existing health and family welfare initiatives the Mission sought to improve the operational synergy of these programs and streamline the necessary administrative and support resources. Its goals included: a commitment to raise public spending on health; improved structural framework of the health system to enable increased service capacity; decentralized management of district health programs to promote community involvement and ownership; and improved access to equitable primary healthcare for rural poor with emphasis on women and children. Key target outcomes to be achieved over the seven-year timeframe included an increase in public outlay on health from 0.9% to 2-3% of GDP and reductions in IMR, Maternal

Mortality Rate (MMR), and Total Fertility Rate (TFR) to 30/1000 live births, 100/100,000 live births, and 2.1 respectively11. The progress of the NRHM as gauged by these key indicators is presented below in Table 3. It can be seen that while noticeable progress has been made, all outcomes fall short of the explicitly established goals. In the following section we identify the most pertinent issues that have limited the NRHMs success and recommend policies moving forward. Core Issues & Recommendations 1. Human Resources for Health Among the most critical components of an effective health system are its human resources. Meeting social demand for health services both in terms of quantity and quality of supply is dependent upon a sufficient number of appropriately trained and effectively allocated health personnel. In 2009 India had 0.6 physicians per 1,000 people, far short of the WHO identified optimal level of one per 1,000.13 Table 4 shows the unfavorable international comparison of this number, while Figure 1 indicates the increased burden of this shortfall within rural systems. It is recommended that expansions and improvements be made along the entire supply chain of public human resources for health in an effort to optimize the functioning of existing medical centers and enable the creation of new ones. Increasing the enrollment capacity at medical colleges will produce a greater stock of national doctors. Here, we recommend this be facilitated through fiscal policies that will encourage existing medical colleges to increase enrollment. Specific recommendations include: providing tax-incentives for colleges that

commit to and produce a certain level of enrollment growth; subsidizing construction of additional academic buildings at existing colleges either through direct investment or additional tax-breaks; and reducing payroll taxes associated with hiring new professors and administrative staff (to a degree commensurate with increased enrollment). This method of increasing the training of new physicians is preferred over the creation of new colleges by the state due to the significantly fewer requisite resources and shorter outcome timeframe. Problems arise as private institutions seek to take advantage of financial incentives in an unpredicted way thereby reducing the marginal social value of these public investments. Through careful planning and deliberate wording the authors of new legislation can obviate such issues. It is also recommended that disbursal of these benefits be subject to the approval of local committees within each district to further avoid private sector abuse. The benefits of training more doctors will only be brought to rural populations if doctors are willing to work there. Impediments to attracting new physicians to rural communities include weakly structured incentives, insufficient quantity and quality of paramedical staff, and poor working conditions at existing health facilities4, 14. Improving the benefits package of rural positions will attract more physicians to these locales. This can be achieved by raising base salaries, while a moderately accelerated pay-promotion schedule can serve to incentivize longerterm commitments. Alternatively, long-term contracts with payment plans designed

to provide progressively higher incomes during later stages may reduce initial financial barriers associated with higher base salaries and additionally prevent attrition that may occur under the accelerated raise plan (ie after attaining the first raise). Other benefits may include assistance with relocation expenses and housing, as well as a travel stipend to reduce isolation. Mandatory internships or postgraduate rotations in rural centers can be used to complement these policies. As such measures do not promote long-term rural employment, they should not be viewed as stand-alone remedies. An integral paramedical component of the NRHMs human resources is the Accredited Social Health Activist (ASHA). These positions are held exclusively by local women who have received a primary education and undergo basic health training subsequent to hiring. The ASHA serves as the initial point of contact between the public health system and the local people, and her role includes provision of basic health services, first aid, and promotion of preventive care11. As the ASHA and other paramedical staff are more likely to be rural natives, increasing their recruitment and retention will not only provide physicians with necessary support personnel, but will also increase community ownership of the health system. We recommend expanding the role of health Sub-Centers (SC) (the most peripheral aspect of the three-tiered medical facility structure) to include training of these paramedical staff. Given the greater number and community integration of SCs as compared to the upper-tier facilities, such an expansion would provide rural communities with increased access to health education, which is currently concentrated in urban centers14. These services will improve staff

recruitment efforts, as many newly trained local employees may prefer to remain in their home villages. This approach will circumvent the extensive capital investment required to erect new teaching institutions by instead leveraging the existing health infrastructure. Potential challenges will be ensuring a standardized high quality of training at these often-remote centers, as well as implementing updates to training protocols. Incorporating the regulation of these training initiatives into the role of the current administrative and monitoring and evaluation staff will help alleviate these issues. The final stated obstacle to bringing human resources for health to rural communities is the substandard condition of existing facilities. It is reflective of the larger issue of health infrastructure inadequacies and is addressed below. 2. Health Infrastructure The current capacity of Indias national health system is simply insufficient to respond to the needs of its people. The 2010 India Health Report showed a national hospital bed density of 0.7 per 1,000 people, a figure they referred to as miserably behind the global average of 2.6. Hidden within this figure is the dire nature of the rural system, which at the time showed a density of 0.1 compared to the urban 1.8.4 The rural system, organized into three tiers, shows deficiency at all levels. According to the Planning Commissions 2011 review, there was a shortage of 25,981 Sub-Centers (SC), 4,252 Primary Health Centers, and 2,115 Community Health Centers.14 A 2009 study also showed that in Madhya Pradesh almost 40% of

the surveyed SCs had ongoing problems with water and electricity.4 Improvement and expansion of healthcare infrastructure is an urgent priority. Under the current NRHM guidelines, population norms are used to dictate the target number of each of the above facilities.4 These rigid norms, however, fail to differentiate between regions on the basis of their distinct needs, and therefore have the potential to underserve those most in need. We recommend a reevaluation of this practice and the establishment of new norms that account for both population and burden of disease. This practice will lead to more effective distribution of infrastructure and quicker health improvements in the most needy areas, as evidenced in mortality indicators. Potential resistance to this policy may come if it leads to reallocation of federal outlay from an identified low-need state to a highneed one. Given that approximately 70% of public health expense comes from state budgets10, such resistance will probably be low, as state outlay will also be reduced. The progress of the system as a whole is dependent upon the progress of the SCs, as it is the peoples entry point into the system. For this reason, we recommend increased focus at this level. Table 5 shows the 2011 total number of SCs in comparison to the target number for selected rural states. In previous analyses of infrastructure development, it has been noted that the lowest achieving states are those without an explicitly mapped, multiple year timeline for development that incorporates specific deadlines for certain progress indicators. Meanwhile the majority of states that have attained or nearly attained target levels have dedicated infrastructure management teams.15 We therefore recommend that the federal government require all states to establish such a team whose duty will be to draft an

infrastructure development plan and oversee its execution. Given its success in other states, we anticipate that this measure will lead to improved pace of construction and a greater rate of increase in new facilities compared to previous years. Concluding Remarks After seven years of targeted action under the National Rural Health Mission, significant gains have been made. With Infant Mortality Rate, Maternal Mortality Rate, and Total Fertility Rate lower than ever, the health and well being of over 800 million individuals living in rural communities are better than ever. The fact of the matter is, though, that even with these improvements 42 out every 100 Indian mothers are forced to bury a child of theirs before celebrating its first birthday, while 170 out of every 100,000 husbands are forced to bury their wives due to complications in labor. These figures do not compare well internationally, nor do they live up to the expectations set by NRHM organizers. Nationwide, policy makers must make a commitment to continue improving Indias health system, as is their Constitutional duty. Public health expenditures must continue to increase, but with limited resources effectiveness and efficiency are critical. Through this memo, we have shown how the health of rural populations is truly the health of India, and presented concrete recommendation to address what we believe are among the most pressing issues. Through these policies, current patterns of health disparity may be worn down and the national health of India will improve over the coming years.

Works Cited 1. Gangolli, Leena, Ravi Duggal, and Abhay Shukla. Review of Healthcare in India. Mumbai: Centre for Enquiry into Health and Allied Themes, 2005. Print. 2. "GDP (PPP) growth by country in the last ten years." n.p. 20. Lebanese Economy Forum. Web. 3. United States Government. Central Intelligence Agency. The World Factbook. 2012. Web. 4. Mahal, Ajay, Bibek Debroy, and Laveesh Bhandari. India Health Report 2010. New Delhi: Business Standard, 2010. Print. 5. International Institute for Population Sciences (IIPS) and Macro International. National Family Health Survey (NFHS-3), 200506: India: Volume I. Mumbai: IIPS. 2007. Web. 6. "Rural Population, (% of Total Population)." The World Bank Group. n.p. 2011. Web. 7. Palit, Chittabrata, and Achintya Kumar Dutta. History of Medicine in India: The Medical Encounter. Delhi: Kalpaz Publications, 2005. Print. 8. Gangolli, Leena, Ravi Duggal, and Abhay Shukla. Review of Healthcare in India. Mumbai: Centre for Enquiry into Health and Allied Themes, 2005. Web. 9. Kishore, J. National Health Programs of India: National Policies and Legislations Related to Health. 5th ed. New Delhi: Century Publications, 2005. Print. 10. Banerji, D. "Politics of Rural Health in India." Indian Journal of Public Health. 49.3 (2005): 113-122. Print. 11. Bajpai, Nirupam, Jeffrey Sachs, and Ravindra Dholakia. Improving Access and Efficiency in Public Health Services: Mid-term Evaluation of India's National Rural Health Mission. New Delhi: SAGE Publications, 2010. Print. 12. India. National Rural Health Mission. NRHM in the Eleventh Five Year Plan (2007-2012). New Delhi: National Health Systems Resource Centre, 2012. Web. 13. Physicians per 1000 population: WHO (2012b). Global Health Observatory. http://www.who.int/gho/epidemic_diseases/cholera/deaths/en/ Accessed March 21, 2012. 14. India. Government of India Planning Commission. Faster, Sustainable, and More Inclusive Growth: An Approach to the Twelfth Five Year Plan . New Delhi: India Offset Press, 2011. Web. 15. India. Ministry of Health and Family Welfare. 6th Common Review Mission Report. New Delhi: Royal Press, 2012. Web. 16. "Health Expenditure, public (%GDP)." The World Bank Group. n.p. 2011. Web. 17. United Nations. Department of Economic and Social Affairs. World Population Prospects, the 2010 Revision. 2011. Web.