Since the launch of National Rural Health Mission (NRHM) in 2005 India has significantly improved its key health outcomes – notably in child survival, maternal mortality, immunisation, and population stabilisation. However we may still not be able to achieve the Millennium Development Goals (MDGs) in health by 2015. These shortfalls are due to the historical legacy of a weak public health system in rural India, reflected in low baselines and lack of infrastructure, as well as due to still continuing institutional constraints that have hampered more rapid progress.

Recent evaluations by the Planning Commission and the Sixth Common Review Mission on the quantity and quality of service delivery in rural public health facilities under NRHM showed that the human resource gap remains the singular most important challenge in strengthening the public health system and meeting the MDG goals. For instance, in Jamui district of Bihar, against sanctioned posts of 147 regular and 38 contractual Medical Officers only 35 regular and 26 contractual doctors were in position in 2012, and thus almost 70 per cent posts were vacant.

Medical professionals available in the country, especially specialists, are not joining the public services. Some specialities, such as anaesthesia and psychiatry, have very few professionals being produced in the country. Nursing colleges are far short of requirements and ANM Training Centres have been non-functional for about a decade in several states, leading to non-availability of staff nurses and ANMs for recruitment. Paramedical personnel such as Laboratory Technicians are again too few, or not trained and registered as per standards. Few of the cadres have an orientation or training in public health planning and management.

The Primary Health Centres (PHCs, supposed to cover a population of 30,000) and Sub-Centers (for 5,000 population) either don’t exist or, if they exist, find themselves severely under-staffed and undersupplied. Only 38 Per cent of PHCs have the necessary manpower and only 31 per cent have critical supplies. In-patient increases are seen in facilities at district levels and higher. As a consequence of this overcrowding, quality of care is compromised.

The physician-patient ratio is 6 times lower in rural areas and physician-bed ratio is 15 times lower compared to urban areas. There is huge inequality in healthcare distribution: although 73 per cent of Indians lives in rural areas, more that 75 per cent of Indian doctors are based in cities. A study conducted by the Indian Institute of Public Opinion found that 89 per cent of rural Indian patients have to travel about 8 kms to access basic medical treatment.

Staff addition under NRHM has almost exclusively been through the creation of contractual posts. Over 100,000 skilled health workers were added onto the public health workforce in the Eleventh Plan (2007-12) period. However, partly due to the absence of a clear long-term policy commitment and financing plan for these additional human resources, states have been unable to create the human resource management policies that would ensure the motivation and performance needed from a contractual workforce. Therefore despite these impressive advances in numerical addition, the shortage of health personnel and the poor quality of support they receive remains the single biggest impediment to optimal functioning of existing health facilities and to operationalising of new services like facility based care for sick newborns etc. There are no systems of provider incentives, financial or non-financial, which provide either social recognition or economic gain for those who are required to put in far greater efforts.

The other problems are lack of parity on work allocation and remuneration between contractual and regular staff, and the insensitivity to other needs of contractual staff. This leads to a revolving door effect, with constant, high attrition and inadequate replacement resulting in poor quality and performance.

There is huge inequality in healthcare distribution: although 73 per cent of Indians lives in rural areas, more that 75 per cent of Indian doctors are based in cities. Almost 89 per cent of rural Indian patients have to travel about 8 kms to access basic medical treatment

Early attempts at outsourcing for diagnostics and facility management attempted in many states have either not survived or demonstrated success as yet. It is difficult to determine whether the cause is poor contract design or mismatch with existing systems or whether the problem is inherent to our context. Many of the poor admitted in private Hospitals are not covered by RSBY (health insurance scheme), and those who are, report substantial out of pocket expenditures. Reimbursements by RSBY to the hospitals are not complete or timely. Denial of claims occurs on technical grounds (e.g., non-working of smart card readers) or on social patterns (family of five could exclude the younger girl child or the elderly etc).

The ASHA programme remains the component where reports from across states are uniformly positive, as regards her functionality and enthusiastic participation. Today the country has 8,48,940 ASHAs in place. However, mechanisms of payment, drug logistics, supportive supervision and performance assessment remain a challenge in states, which have failed to invest in a well-trained support structure. Most ASHA are currently able to earn only between `500-1,000 per month. This needs enhancement.

Within the unorganised sector untrained local practitioners and drug shop owners have grown into the dominant type of provider of outpatient medical care and are collectively known as rural medical practitioners, village doctors or quacks. These informally trained providers have largely been ignored by the central and state Ministries of Health.

Demographic burdens, poverty and poor infrastructure means that India faces perhaps the world’s heaviest disease burden, ranging from infectious diseases, the traditional scourge of the poor, to diseases of affluence such as diabetes and hypertension.

The public health sector has been afflicted by a number of persistent problems including the quality of services, absenteeism, malpractice and gaps in the supplies of essential medicines. Many attribute these challenges, in part, to issues of governance and regulation amongst public officials. Strong oversight and quality governance of the institutions involved in the financing, purchasing, delivery and regulation of healthcare would determine whether additional investments in the health sector will yield tangible improvements in health outcomes. At the very least all doctors must write the generic name of the medicine in their prescription, so that the patient has a choice whether to buy the branded or the cheaper generic drug.

Despite NRHM, Government expenditure on health as a share of GDP increased only marginally; from 0.9 per cent in 2004-05 to 1.04 per cent in 2011-12. Little of this spending reaches remote villages. At present nobody – whether a village level health worker, auxiliary nurse, compounder, PHC physician, or CMO, is held accountable for what he/she does or does not do.