Indian Journal of Medical Ethics

A National Rural Health Mission (NRHM) was officially launched by Prime Minister Manmohan Singh on April 12, 2005. The mission document and the implementation framework were developed after 10 months of strategising. The NRHM reportedly aims to fulfil one of the most important commitments of the United Progressive Alliance, to meet people's aspirations for better health and access to health care.
Civil society organisations, health activists and movements are planning to follow the government's commitments through a countrywide Rural Health Watch initiated by the Jan Swasthya Abhiyan (JSA, or People's Health Movement in India). During 2004 a series of national, regional and local public hearings on the right to health care, jointly organised by the National Human Rights Commission and the JSA, documented the apathy, corruption, callousness and poor quality of care in primary, secondary and tertiary health care centres in numerous states.
The past decade has seen growing inequalities in access to health care. On the one hand corporate hospitals with state-of-the art facilities cater to the elite and attract foreign patients, creating medical tourism as a new economic entity that gets undue policy attention in the National Health Policy 2002. On the other hand the majority are left to market forces, and medical expenditure is the second highest cause of rural indebtedness. Health indicators like the infant mortality rate have stagnated
or even worsened in some large states, despite growing national wealth. It is in this context that the NRHM has been introduced.
The NRHM undoubtedly is responding to an urgent ethical imperative. Its interpretation and implementation will show how well and effectively people's aspirations are met. For a start there is to be an annual 30% increase in the central health budget for five years. States are also expected to increase their health budgets by 10% annually. Thus public sector expenditure on health is expected to increase from the current 0.9% of Gross Domestic Product to 2-3% of GDP over five years.
The NRHM includes ambitious goals such as decentralisation, with district and village health plans; integration of vertical disease control programmes; the training of over 250,000 Accredited Social Health Activists in 18 states at the village/hamlet level; strengthening block level referral hospitals (community health centres); new Indian Public Health Standards strengthening the capacity of Panchayat Raj institutions in governing health care; improving water supply sanitation and nutrition; expanding community health insurance; and enhancing accountability of public health institutions. There are a lot of politically correct goals and strategies.
However, this is not the first time that the central government has announced such an ambitious programme for health. The Janata government's experiment, in the 1970s, to strengthen rural primary health care with trained Jana Swasthya Sevaks, ended dismally. This time, however, there has been an extensive consultative process with a broad spectrum of civil society and NGO health innovators including constituents of the JSA. The national meetings for the Mission and the eight task groups have included health activists, professionals and innovators from all over the country. The Mission document has evolved, with several modifications through these interactions.
While this consultative process must be commended many challenges must still be faced if the Mission has to move beyond populist policy rhetoric:.
The government must move from the population and contraceptive technology agenda which was a focus of the earliest version of this Mission to a truly comprehensive primary health care orientation that stresses empowerment and the rights-based approach to health care. The Mission must build systems and institutional mechanisms at the peripheral level if its community-based and community-oriented goals are to be met. Unless it addresses the realities of the lives of the poor and marginalised in the rural, adivasi and urban poor communities it will remain yet another populist exercise on paper.
Promoting decentralisation of health care and encouraging a truly inter-sectoral approach (including multi-ministry cooperation for health) is a basic requirement and a challenge, especially when there are forces of the status quo both within and outside the health system opposing these trends.
The Mission must become part of a bold paradigm shift, from providing services through 'top down planning' (an approach that has consistently failed to reach goals and targets in the past) to building capacity and empowering communities to manage their own health care needs.
The government must also come to terms with a basic contradiction in today's health policy planning. On one hand, in response to market forces the government is promoting medical tourism and providing incentives and support to the corporatisation of health care in India, catering to the needs of the local and global elite. On the other hand in response to the aspirations and needs of the large majority it promotes the components of the Rural Health Mission. The policy of 'medical tourism for the classes and health missions for the masses' will only lead to a deepening of the inequities already embedded in our health care system.
JSA and related civil society organisations in health have an equally important challenge ahead as this process which has involved them takes off. There must be cautious engagement and involvement, especially in training of health workers based on the rich micro-level experience of the alternate health sector in the country. They must also play a watchdog role to ensure that the Mission reaches those it is supposed to reach, and does not get distorted by market forces and political and other agendas.
In the ultimate analysis the success of the Mission depends entirely on the continuing openness of the government at different levels, the alertness of civil society and the 'learning from the grassroots' ethos of both.