The National Rural Health Mission(NRHM) is a major flagship programme of the Govt. of India in the health sector, which aims at inclusive health and improved access to quality health care for those residing in rural areas, particularly women, children and the poor by promoting integration, decentralization and encouraging community participation in health programmes.
- NRHM was launched in 2005.
- NRHM is a sector wide reform agenda. It is not a scheme/project/programme. It is an Oooverarching umbrella to strengthen health system and improve efficiencies of constituent initiatives.
- Centre-State funding share - 100% (C) 2005-2007; 85(C):15(S) from 2007 onwards.
- Special attention to 18 Focus States, which have weak public health and weak health infrastructure. What are focus states? Read about Focus and EAG states, in my other post, here.
Why was NRHM needed?
What was the status of health sector when NRHM was initiated in 2005?
- Centralized, verticalized and fragmented Health system – donor driven agendas
- Virtually non-existent primary health care system in many States
- High disease burden and poor health indicators – lack of public health thrust
- No thrust on human resources in health initiatives
- Unacceptably high out of pocket expenditure and Low public spending on health
- RCH-II(2005-10) (Reproductive and Child Healthcare) which aimed at reducing IMR and MMR was in progress, but the results were not encouraging. Stagnating IMR, poor implementation etc
- Central programmes used to get initiated on the assumption that there is a public system waiting to deliver
- Absence of decentralized planning and system of dialogue with States
NRHM Framework Approach: MESH
As stated in my other post (see here) that India has an obligation to meet the Millenium Development Goals(MDGs) by 2015, and the problem of absorption and appropriate use of funds in disadvantaged areas along with the critical state of health sector in India, was proving to be a bottleneck to the achievement of the MDG goals.
So, NRHM adopted MESH approach to address this issue by building necessary infrastructure with emphasis on MESH - Management, Economic, Social and Human interface. MESH approach is strengthening of integrated infrastructure growth, which is built to improve the capacity of communities and other entities to implement health service programs efficiently.
Since, healthcare sector does not fit very well as a 'free-market' solution, there was this need to change the way we formulate public policy on health sector in India. (Note: Education is another such sector which does not fit well in the free market format) Read more about free market and healthcare sector in my other post, here.
So, there was a need to bring about a 'paradigm shift' in the way we formulate public policies (including health) and change something called "a politician's logic". (Read, here).
A spirit to reform the healthcare sector, the need to achieve MDG goals using MESH approach and the commitment India had made with regards to the primary health care, in the Alma Ata Declaration (1978), led to the formulation of five NRHM with five major approaches as follows:
|Five Main Approaches of NRHM|
This NRHM framework is different, because:
- For the first time, rights based service delivery and pre-stated entitlements model was adopted at all levels
- Earlier approaches were more donor-driven i.e. citizens were at the mercy of what state provided.
- Introduction of decentralized planning and community participation – decisions at local level, based on different localized needs
- District Health Action Plan - main instrument of planning for health in NRHM
- Bringing the public back into public health
- At village level : ASHA, VHSC, SHGs, Panchayats.
- At the facility level: Rogi Kalyan Samitis
- At the management level : health societies
- Special untied funds at sub-center level
- Focus on convergence with other sectors - health determinants
- Water & Sanitation
- Women & Child development
- Focus on Governance reform
- Manpower, Logistics & Procurement processes.
- Decision making processes
- Institutional design & Accountability framework
- Increased focus on Quality Of Service(QOS) & adopting standards
- Creation of IPHS norms
- Right based services delivery
- Pre-stated entitlement at all level
- Judicious mix of dedicated budget fund
- Quality Monitoring
- A worker, an institution and an event in every village – ASHA, VH&SC, Village Health Nutrition Day
- Long term sustainable development of Human Resources
|NRHM Implementation Framework|
|NRHM Implementation Framework - Integration of all its components|
RCH - Reproductive & Child Health