Director of Mumbai Center Speaks on the Challenges of the Public Health in India

March 04, 2014

Nirupam Bajpai, Director, Columbia Global Centers | South Asia delivered a guest lecture on 15 Feburary, 2014 at the Giri Institute of Development Studies (GIDS) on the challenges of service delivery in the public health sector in India. Addressing the GIDS faculty and students from the G L Gupta Institute of Public Health, Bajpai said India’s achievements in the field of public health leave much to be desired and the burden of disease among the Indian population remains high. Infant and child mortality and morbidity and maternal mortality and morbidity affect millions of children and women despite the recent gains of the last 3-5 years as part of the National Rural Health Mission (NRHM) initiatives.

While the NRHM, launched in April 2005, had laid emphasis on strategies for improved governance, district-level planning, demand-side financing and public-private partnerships focusing on core reproductive, maternal, newborn and child health issues, Bajpai said, implementation on the ground, despite an eight year run of the Mission, was far from satisfactory. Similarly, for substantially improved health outcomes, strengthening intersectoral linkages in the areas of nutrition, sanitation and safe drinking water and implementation of new training in public health with a view to train and enhance capacity of the Panchayati Raj Institutions (PRIs) to own, control and manage public health services had made little, if any progress. In these specific areas, NRHM had not made any significant gains, though these had been outlined as core strategies of the Mission.

Bajpai said the average figures for India hide a great deal of variation in the performance of different states, which are on different points along the health transition path. While Kerala, Karnataka, Maharashtra and Tamil Nadu are much further along in the health transition trajectory, the densely populated states of Orissa, West Bengal, Bihar, Rajasthan, Madhya Pradesh and Uttar Pradesh are still in the early part, with the other states falling in between. For instance, he said, while in Kerala, life expectancy at birth is 76; in Madhya Pradesh it was merely 58. Apart from variations due to income and education, health status in India varies systematically between rural-urban location, membership of scheduled caste and tribe, and by age and gender. All health indicators for rural areas compare unfavorably with those for urban areas; people belonging to scheduled castes and tribes have much poorer health compared to those who belong to the upper castes; and children and women in India suffer grossly from the burden of disease and ill-health, he said.

Commenting on NRHM, Bajpai said he believed that NRHM is a fairly well designed program to address the healthcare needs of rural India. On a positive note he said, since the launch of the NRHM, undoubtedly, the Mission has achieved a great deal, especially in the areas of putting in place an ASHA for every 1000 population; creating greater awareness about ante-natal care, institutional delivery, post-natal care and child immunization; raising institutional deliveries; raising the numbers of out-patients being provided with healthcare services in the health facilities (HFs); provision of un-tied funds for all HFs and in the process witnessing a clear decline in the IMR and MMR rates over the last few years and so on. However, the scale of the challenge that still remains is immense. It is important, said Bajpai to recognize that the following issues were critical if NRHM has to succeed on scale and deliver what it promises to deliver: 1) much higher level of public health spending is needed, say from the current level of 1.5% of GDP to upwards of 3%; 2) comprehensive training, effective control and oversight and timely and adequate payments for the community health workers; 3) a realistic and implementable plan for intersectoral convergence especially to integrate nutrition into health programming; 4) careful and detailed needs assessment, region specific innovations and adequate financing of the district health action plans of the bottom 200 districts of India; 5) commensurate infrastructure and human resources in the sub-Centers (SCs) and the Primary Health Centers (PHCs) with the needs of the regions; 5) making access available to specialist services, especially using ICT; and 5) increased supply of doctors, specialists, pharmacists, technicians, trained nurses and midwives, etc. offering them much higher levels of compensation has to be ensured for the success of the scaling up effort.