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 the 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.

India achieved remarkable success on many fronts. 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.

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 the last case of Wild Polio Virus.

·         2012: Intensive discourses on the 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.

Key health sector related developments and proposals in India (2017-19)

National level initiatives

·         National Health Policy 2017

·         Mental Healthcare Act 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)

(b)  Pradhan Mantri Jan Arogya Yojana (PMJAY)

(c)  Mid-Level Healthcare Providers under HWCs

(d)  Aspirational District programme for prioritisation of social sector interventions

(e)  POSHAN Abhiyaan /National Nutrition Mission

(f)   First State Health Index for India released.

·         2019- NITI Aayog Strategic plan for New India

·         2018-22 Report of Taskforce 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.

         Key State-specific initiatives:

·         Universal Health Coverage (UHC) pilot in Tamil Nadu 

·         Family Health Centres (FHC) in Kerala

·         Karnataka Public Health Policy.

·         Uttar Pradesh State Health policy (Draft)

·         Launch of Basti Dawakhana, Community Clinics in Telangana

·         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 the committee in Andhra Pradesh.

Key features in recent policy and strategy documents

National Health Policy 2017

·         Proposed: Government to be the sole provider of Primary health care services.

·         Attention on special populations such as Tribal health.

·         Increasing government spending on health to 2.5 percent of Gross Domestic Product (up 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 the health sector. There are a few recent examples such as in Andhra Pradesh, the provision of kidney services at PHC level resulted in a three-fold increase in the utilisation of services for renal diseases at the 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 the 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 a 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 the 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 overtime.

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

·         Make rural health facilities ready for a disaster and emergency situations

·         Start many small non-health initiatives for big health impact

·         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.