“The test of our progress is not whether we add more to the abundance of those who have mu ch; it is whether we provide enough for those who have too little.”-Franklin D. Roosevelt, second inaugural address, 1937
Public health is one of the important responsibilities of the state. The health of the citizens significantly affects their economic productivity, their livelihood capacity and adversely affects the local economy. Health also impacts access to labour market as it influences the capacity to work. For the poor, a healthy body is an important asset and so ill health does have a greater impact on their livelihood. But sadly public health in many of the third world countries are not given adequate attention and this is amply reflected in the very low allocations given to their public health sector. Providing quality healthcare to the vast majority, living in very remote and rural localities, has become one of the challenges of the governments of developing countries, as majority of the people living in rural areas don’t have the capacity to pay for the healthcare services.
It is a fact that healthcare sector has undergone considerable changes with the development of technology. However the rural healthcare system in the developing countries is more or less rooted in the same traditional practices. There is a yawning gap in rural and urban healthcare in developing countries. Take the case of India, where infant mortality rate (IMR) in rural areas at 82 per 1000 live births is nearly double the number of 45 for urban areas.
Technology connectivity between various public heath tiers and actors can better the health service delivery and improve the health status of the people living in rural areas as such network would improve the capacity of accredited social health activist (ASHA), the local health care provider, as well as the other local healthcare actors like auxiliary nurses and midwives (ANM) and multipurpose health workers (MPHW)
While urban middle classes in India today have ready access to best health, the rural population is isolated from these services both because of access and cost. Most of the poor living in rural localities are isolated from the benefits of formal health care (both public and private) and most of them access untrained local ‘private practitioners’ incase of any illness. A formal health centre is only a last alternative as they are mostly located only in the urban localities and present great logistical problem to the poor villagers to commute. In India, poverty is another common barrier to good health. Only 20 countries have a higher IMR than Orissa’s tragic figure of 110 per 1000 births, which shows that the poor localities are most vulnerable to health problems.
It can be safely said that India, to a great extent, has failed in bringing equity in healthcare, as it has not been able to effectively address the issue of access. Government though has set up various mechanisms to provide access to the people living in rural and remote areas to quality health services, but many of them are not performing as per the requirements of the rural localities.
One exception to this depressing healthcare scenario in India is the National Rural Health Mission (NRHM). National Rural Health Mission (NRHM) is an initiative of Central Government in India to integrate various public health services. NRHM has a 10 year target to strengthen the public health system in various Indian states especially the low performing states.
Recognizing the importance of health in the process of economic and social development and in improving the quality of life of our citizens, the Government of India has resolved to launch the National Rural Health Mission to carry out necessary architectural alteration in the basic healthcare delivery system. The mission adopts a synergistic approach by relating health to determinants of good health viz. segments of nutrition, sanitation, hygiene and safe drinking water. It also aims at mainstreaming the Indian systems of medicine to make possible healthcare, especially in rural localities.
The plan of action includes escalating public expenditure on health, dropping regional discrepancy in health infrastructure, pooling resources, amalgamation of organizational structures, optimization of health manpower, decentralization and district management of health programs, community participation and title of assets, induction of management and financial personnel into district health system, and transforming community health centers into functional hospitals, thereby meeting Indian public health standards in each block of the country.
The government has approved the launch of the National Rural Health Mission (2005-12) for providing integrated comprehensive primary healthcare services, with a special focus on the poor and vulnerable sections of the society. Formulation of Indian public health standards is one of the ground-breaking steps in NRHM as it attempts to define the quality of public health services and their standards. The mission is to be launched throughout the country with high focus on the 18 states, including 8 empowered action group states (U.P., Bihar, Madhya Pradesh, Orissa, Jharkhand, Uttaranchal, Rajasthan and Chhattisgarh), 8 North-East States (Sikkim, Assam, Arunachal Pradesh, Nagaland, Manipur, Tripura, Meghalaya and Mizoram), and Jammu & Kashmir and Himachal Pradesh. NRHM addresses various public health issues like inadequate financial allocation, lack of trained health personnel in rural localities, emergency medical access and promotion of various other systems of medicines, along with the conventional allopathic system of medicine.
The mission aims to undertake architectural correction of the health system to enable it to effectively handle the increased allocation for public health, as promised under the National Common Minimum Programme of the United Progress Alliance government. It also aims to bridge the gaps in rural healthcare through increased community ownership, decentralization of the programs to the district level, inter-sectoral convergence and improved primary healthcare. The mission aims to achieve the goal of the National Population Policy and the National Health Policy through improved access to affordable, accountable and reliable primary health services. NRHM also attempts to integrate divergent medical systems, both conventional and alternative, which are practiced in India.
The active engagement of technology at various healthcare levels through induction of ICT into NRHM components would improve its outreach as well as quality. The department of IT should take the lead in bringing the technology integration and the ongoing technology initiative should incorporate healthcare components in it.
The goal of the NRHM is to improve the availability of and access to quality healthcare by people, especially for those residing in rural areas, the poor, women and children. The main objectives are; reduction in infant mortality rate (IMR) and maternal mortality ratio (MMR), access to public health services such as women’s health, child’s health, water, sanitation & hygiene, immunization, and nutrition, prevention and control of communicable and non-communicable diseases which includes locally endemic diseases, access to integrated comprehensive primary healthcare, population stabilization, ensuring gender and demographic balance, revitalizing of local health traditions and promotion of best practices in health.
The Figure-1 shows the various components of NRHM and suggests the linkages with different healthcare facilities and its functions. However, integration to bring in improvement in quality needs to think of establishing linkages with these different functions and actors. As the local government has been given a crucial role in the implementation as well as monitoring of NRHM activities, the local governments have a great role to play in bringing in quality healthcare in their respective localities.
Public health in India has a bias towards building institutions rather than strengthening the local capacities. Though NRHM is an excellent initiative, having a strong component of local capacity building, it significantly lacks the linkage between various healthcare actors and components. It is also important to integrate various technology initiatives in promotion of technology and these initiatives should integrate health component also. Some of the initiatives are;