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I think there is need for much more innovation on the ground to truly get to a desirable end-state. The government can clearly do a lot more under the framework of the NRHM and the RSBY but so can the private sector. At Rs. 3000 per annum per household expenditure, a group of 2000 dwellings (about 5 villages on average) ends up spending Rs. 60 lacs ($150,000) per year on health care. For this much money, there is a lot more value that can be delivered by the private sector than is being done right now particularly if it collaborates with the government and complements it services and competes with the unqualified "medical" community currently operating there. In we are spending a lot of time researching various components of what is needed at the village and where it may best be provided. We have for example developed a Rs. 5 (13 cents) Population Level Screening Protocol adminstered by well trained lay health workers which we feel is an essential component of any long-term strategy. We are experimenting with a new (and hopefully improved) sub-centre design "manned" by a Graduate Nurse and a full time lay health worker (we are calling it a Rural Micro Health Centre -- RMHC), which may need the private sector and the government to collaborate since it aspires to bring many-more services and diagnostics facilities far closer to the ground. Eventually we are hoping that we will be able to evolve a design for a rural HMO which combines RSBY style hospitalisation insurance (which much larger upper limits and much larger deductibles) with a high quality RMHC and a referral chain that goes up to the PHC and the GH. Not yet sure what the end state will be but the direction feels right and we are trying hard to fall into the trap of government versus private - we feel that a new hybrid would need to emerge -- perhaps closer to the UK model where the GP is a private practioner (our Nurse + our lay health worker both paid for directly by the community could substitute for the GP) and the rest of the system is government owned.