It began in 2005 with the promise of being the answer to rural India’s health worries but 10 years on, the National Rural Health Mission is plagued by a massive shortage of manpower and lack of infrastructure. This is due largely to an inadequacy in public spending on health, experts say, pointing out that this has never crossed 1 per cent of the GDP.
With the allocation in health stagnant around the Rs 22,000-24,500 crore range (revised estimates) for some years now, few new rural health centres have come up, particularly during the 12th Plan period.
Former Union health secretary Sujatha Rao links the problem to poor spending. “In all these years we have spent Rs 6,000-7,000 crore on physical infrastructure in NRHM while the gap is of Rs 70,000 crore. Our total health spending has never been more than 1% of the GDP; the US spends 18-20% and the UK 9-12%,” she says. “Seventy per cent of the disease burden and bad health indicators are in 250 districts. The central government has to fund healthcare there.”
Inevitably, the shortfall puts severe pressure also on existing infrastructure. A rural sub-centre is supposed to cater to a population of 3,000-5,000. In India the 1,52,326 such centres would be responsible for 5,473 people each, going by the 2011 population census. A PHC is supposed to cover 20,000-30,000 but the average coverage of the 25,020 PHCs in 2014 stood at 33,323. A CHC is supposed to cover 80,000-1,20,000; India’s 5,363 provide services to an average 1,55,463.
During the entire 12th Plan, 3,960 new SCs, 971 PHCs and 530 CHCs came up. The current shortfall is 36,346, 6,700 and 2,350. The CHCs are 70-80% short of trained physicians and surgeons.
Since it was launched in April 2005 with the purpose of improving rural health infrastructure and services, NRHM has been renamed National Health Mission in the hope of extending the model to urban areas. It has, however, not been able to start even one of the basic requirements of a universal healthcare model — a free generic drugs programme. Some states are worse off than others. Bihar, for example of 91% short of CHCs and 48% short of sub-centres while UP is 40%, 33% and 34% short respectively, according to Rural Health Statistics 2014. Tamil Nadu, Uttarakhand, Himachal Pradesh and Kerala, on the other hand, have a surplus of rural health infrastructure.
The data, according to Dr Mohan Rao, professor at the Centre for Social Medicine and Community Health at Jawaharlal Nehru University, shows how health has been a victim of “policy-led collapse of public health -a way of giving public subsidy to private healthcare”. “As for people in rural areas – we do not really care about people who are not potential patients for the private sector. It is the measly healthcare spend that is the real problem. We spend vast amounts on defence but not on health. Whenever it is about health we start talking insurance,” Rao says.
The total health spend in the first three years of the 12th Plan has been Rs 70,000 crore, way below the Rs 2,68,000 crore allocation given in the Plan document.