All That You Should Know About The National Rural Health Mission: Challenges And The Path Ahead

Posted on February 26, 2014 in Health and Life, Specials

By Saem Hashmi:

“The state of health care is dismal…relying on private medical care, without the availability of public health services, allows extensive exploitation of vulnerable and under-informed patients and their families, because of the asymmetric nature of healthcare knowledge. We are not against private health care, but it shouldn’t take the place of public health care services.”

– Amartya Sen (11th Kolkata Group workshop)


India is said to have a universal health care system which takes direct reference form the constitution itself which holds the state accountable of raising the level of nutrition, the standard of living and providing enhancement in public health as one of its primary onuses. Even in spite of the referendum from the backbone book of India, 72% of the rural population has access only to 1/3rd of the total hospitals bed and 3/5th of the rural population still has to travel beyond 5 kms to reach a health care center. 8% of the Primary Health Care centers have no doctors, 39% have no lab technicians and 18% PHC’s don’t even have a pharmacist. All these gaping loop holes are there even after the passing of National Rural Health Mission (NRHM).

In 2012, on April 25th, the National Rural Health Mission (NRHM) saw its initiation under the United Progressive Alliance government as one of its commitments to the common minimal program and to the Millennium Development goals of United Nations (which shares 8 similar points with the National Population Policy), of which India is a signatory along with 195 other countries, to reach out to the regressive and the ignored section of the society which was failing to have access to the basic amenities of health. Through NRHM, the state has tried to make an attempt to implement successfully the National Health Policy (NHP-1983) of 2002 to improve the health care system in rural India and make medication an easily accessible realm to the rural poor. The positive feature of the guidelines of outreach to the poor is that the NRHM makes an inclusive approach to the rural masses and local by adopting the features of the NHP such as equity, decentralization, involving Panchayati Raj Institutions (PRIs) and local bodies in owning primary health care management, strengthening primary health care institutions and suggestions for generating alternate source of financing.

The NRHM seeks to provide efficient health care to the disadvantage groups including women, children, improving access, enabling community ownership and demand for service, strengthening public health systems, enhancing equity and accountability and promoting decentralization. The plan of action includes nutrition, sanitation, hygiene and safe drinking water, increasing public expenditure on health, mainstreaming the Indian system of medicine, reducing regional imbalance in health infrastructure, pooling resources, integration of organizational structures, optimization of health manpower, decentralization and district management of health programs, community participation and ownership of assets, induction of management and financial personnel into district health system, and upgrading community health centers into functional hospitals meeting Indian Public Health Standards (IPHS) in each Block of the Country

NRHM is a two tier strategy based scheme comprising of the core strategy 1 and the supplementary strategy 2 which encompasses reduction in Infant Mortality Rate (IMR) and Maternal Mortality Rate (MMR), universal access of public health services such as women health, child health, water, sanitation and hygiene, immunization and nutrition, prevention and control of communicable and non-communicable diseases; access to integrated comprehensive primary health care, population stabilization, revitalization of local health tradition and mainstreaming Ayurveda, Yoga and Naturopathy, Unani and Homeopathy (AYUSH); and promotion of healthy lifestyles.

India, in the last few decades, has seen that the health care system has expanded. The Indian Public Health Standards are being introduced in order to improve quality of health care delivery. At present, these standards are applied only to Community Health Centers (CHC) but subsequently standards for Sub-Centre (SC) and Primary Health Centre (PHC) shall also be developed. These set of standards are lesser resource intensive as compared to already existing Bureau of Indian Standards for 30 bedded hospitals.

Moreover, the institutional mechanisms created under the NRHM such as Village Health and Sanitation Committee (VHSC), Accredited Social Health Activist (ASHA), Rogi Kalyan Smitees (RKS) and the Panchayati Raj Institutions (PRI’s) have made the program adapt to an inclusive approach by taking in the masses and educating and empowering them over the health issues. This approach matches the essential features of a good governance that a state needs to adapt to and has a bottom to top approach in spite of being formulated with a top to bottom approach. As a result of the passing of the NRHM, rural India relatively has seen a decline in the IMR numbers as well.

Another positive aspect of the scheme is that for its monitoring and evaluation, it has formulated the ‘People’s Rural health watch’ via which monitoring of the mission activities will be done in several states and national level. It shall also include the civil society organization in order to assess and analyze the implementation of the mission.

There are few concerns that emerge from reading of mission documents. The first concern is that there is no systematic analysis of previous policies and no major lessons seem to have been learnt from the past. It does not appear to analyze why Primary Health Care approach was never implemented effectively and the goals for ‘Health for All by 2000′ has not been met. There seems to be no analysis for the fact why Community Health Volunteer scheme failed before launching ASHA.

The second concern relates to influence of globalization-privatization framework on the mission. The mission seems to be privatization friendly and there is a very strong influence of RCH program (with major funding from World Bank and other international agencies). While RCH forms one of the key components of mission, the disproportionate influence may not be healthy for integrated strengthening of rural health systems.

The third concern is related to appointment of Accredited Social Health Activist (ASHA) in a village. The selection criteria include educational level up to class eight which may impose a bias against women from disadvantaged groups which despite forming majority in her village is denied the post because of less formal education. Moreover, unless the other levels of health system such as PHCs and CHCs are substantially improved, their services upgraded and staff made responsive, ASHA would not be able to make much headway in her task as an activist i.e. mobilizing people and facilitating their access to health services as a right. Further, the amount of work expected from ASHA, with maximum compensation of Rs. 83 per month, cannot be very significant.

The fourth concern is regarding adoption and operationalization of Indian Public Health Standards for CHCs and that all the National Health Program should be delivered through CHCs. Although a step in the forward direction, these changes may weaken the institution of PHC and focus on specialized medical care services at CHC level. With CHC being further away for most people (than a PHC), communities will be increasingly pushed to access local practitioners (largely unqualified) or reach CHC with complications.

The NRHM claims to integrate various national health programs. But these integrative strategies are limited to RCH and family welfare programs with no intention of touching three major disease control programs (Malaria, AIDS, TB), that has been prioritized as a part of Millennium Development Goals (MDG) linked to market needs of large pharmaceutical industries.

Urban population constitutes nearly a third of national population and growing urban population needs to be included in the scope at three times the national population growth rate. Health status and access of RCH services of slum dwellers are poor. Lack of sensitization among service providers, weak coordination among various stakeholders, unorganized public sector infrastructure and poor living environment further compound the problems of the urban poor. Existing policies need to be improved to make them more urban poor friendly, practicable and measurable.

The setting up of NRHM is seen as yet another political move by the UPA government to make another promise to the long suffering rural population to improve their health status. It adopts a very simple approach to a highly complex problem. Nevertheless, the strategies of NRHM are based on sound management principals and an attempt has been made to overcome shortcomings of similar previous schemes. In addition, there is a prerequisite to allocation of funds to states requiring signing of Memorandum of Understanding with Government of India, stating the agreement to the policy framework of NRHM and timeliness and performance benchmarks against identified activities. The state shall also commit to devaluate powers to PRIs and decentralization of program to district levels.

One will hope and wish that increased awareness and collective power of the people along with detailed guidelines and standards provided in the mission, NRHM will be implemented in letter and spirit to bring sea change in our primary health care system and benefits the disadvantaged segments of population.

It is a well-known fact that most sub centers are in operation without any available buildings, the priority should be given to find a building for sub centers and allocation of Rs 10,000 would be useful only when infrastructure is available to carry out activities. The strengthening of sub centers is of paramount importance and allocation of this money is good but it does not solve the most important issue of the building for the sub centers as SC are the point of first contact between the community and the health system and it should be presentable enough.

More focus should be given to the continuous on job training for most functionaries as this would keep the workers motivated. Posting of another doctor from AYUSH at Primary Health Centers (PHCs) would improve the functioning there but we still need some mechanism in place to deal with the absentee doctors at this level.

Thus the NRHM makes an inclusive broad approach to reach out to the urban as well as to the rural poor and has magnificently excelled in many of its realms and areas of impacts, but there are certain aspects that the policy still needs to be tuned and refined in order to have an efficient and effective impact so that the beneficiaries of the program can avail to top class facilities without any hindrance and problems. The Indian state needs to accelerate this process of accountability, monitoring and evaluation in order to surpass its Asian counterparts in the field of health and allied sectors and also in order to achieve and fulfill its MDG and show the world that it is truly a sustainable developing 21st century nation.