Some thoughts on the National Rural Health Mission and on public

health policyK. S. Jacob

Christian Medical College, Vellore

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NRHM

• Refocus on health• Prioritizing rural India• Major inputs• Revitalized health infrastructure• A success

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Background and bias

• Academic• Recent convert to public health

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Basis of my perspectives

• NRHM Common review missions– Kerala– Andhra Pradesh

• NRHM Mission Steering Group• Central Council of Health and Family Welfare

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Regional variation, inputs and governance

• High focus states• Health, utilization and governance• Unutilized funds, technology and training• NRHM governance and governance of the

state/region

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Convergence of diverse efforts

• State health service• NRHM• ICDS• MNREGA

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Assessment of the NRHM

• Process and outcome assessment and audit– NRHM data process data– Systemic lack of outcome data• Janani Suraksha Yojana and maternal and neonatal

outcome• Hospital deliveries and duration of stay, monitoring,

facilities• ? Correlation to National Sample Survey and National

Family Health Survey data– Lack of mechanism for correction/targeting

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Parallel health systems and integration

• Project mode • Parallel health systems and integration

- Medical colleges, district hospitals, PHC

• Systems or building and infrastructure

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New platforms and old programs

• VHND and ICDS• Anganwadis and ANMs• Mobile clinics and sub-centers

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Divided approach

• Health insurance and out sourcing– Aarogyasri– KKT

• Impact on state health systems

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Old ethos and new inputs

• Inertia of system, discipline and morale of health staff

• Myths to cover up problems• Internal correction and external assessments

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Social group variation and targeted input

• Scheduled caste and tribes• Specific district programs

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Theory and practice

• Planning and implementation• Successful vertical programs and integration

with horizontal infrastructure

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Determinants of health

• Curative medicine• Social determinants– Poverty– Caste– Gender

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Errors of the public health- 1

• Urgency-driven curative medical interventions instead of long-term public health solutions– Antibiotics instead of clean water for cholera– DOTS only instead of nutrition and housing

• Mistaking primary care for public health– Extension clinics in villages/towns

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Errors of the public health-2

• Reducing health to a biomedical perspective– Social determinants of health

• Biased use of evidence

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Public health

• Convergence of politics, finance, social science, cultural studies, engineering, science, education, religions, legal studies, medical

• Different frameworks, language• Shared objectives, divergent agenda• Ownership and delivery

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The way forward

• Population health and national interest• Social and population interventions rather

than medical approaches• General health infrastructure rather than

vertical programs• Capitalism and regulation

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