The National Rural Health Mission: A Critique

SOCIOLOGICAL BULLETIN 63 (2), May – August 2014, pp. 287–301

© Indian Sociological Society

The National Rural Health Mission:

A Critique

A.K. Sharma

The National Rural Health Mission (NRHM 2005–07) has been

viewed as a holistic and democratic mission-mode state intervention

in the field of health. It is based on innovative and comprehensive

strategies for provisioning funds, creating new institutions, decentra-

lisation of services, and providing new ideas and resources for

health. Assuming the importance of NRHM in improving general

health conditions and, in particular, improving infant mortality rate

(IMR) and maternal mortality rate (MMR), the state has extended it

till 2017. The Twelfth Five-Year Plan has also extended NRHM to

urban poor, calling it a National Health Mission (NHM). This paper

examines the goals and strategies of NRHM and discusses its

strengths and weaknesses. It suggests that, to make health inter-

ventions effective, there is a need to strengthen the primary health

care system in both rural and urban areas.

[Keywords: ASHA (Accredited Social Health Activist); AYUSH

(Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy;

health; NRHM (National Rural Health Mission (NRHM); sociology

of health/illness]

The National Rural Health Mission (NRHM) has been a noble experi-

ment in the direction of improving the status of health in the country.

According to the Constitution of India, health is a state subject. But, from

the beginning, the central government recognised the need to support

state health action to provide equitable and effective services to people

belonging to different regions and social groups. This paper critiques the

ideas and practices of NRHM and related health policy matters. Using

secondary data and literature, it argues that although the aims of NRHM

are holistic and laudable, the field practices leave much to be desired. In

its present form NRHM has not achieved the stated goals in time and is

288 A.K. Sharma

suffering from many bottlenecks. Concerned with multiple macro and

micro issues, NRHM lacks a focus. The paper argues that although

action is required on several fronts, the most vital need of the project is

to strengthen the primary health care system. Due to an overambitious

approach on the part of Ministry of Health and Family Welfare, many

initiatives have been taken, but few of them are implemented effectively.

The 21st century is marked by a paradigm shift in health in India with

a more aggressive, mission mode, approach to health being adopted. In

the field of health, two important things happened in India in year 2000.

For the first time, the Government of India announced the National

Population Policy (known as NPP 2000; see Planning Commission

2000), and India became a signatory among the 191 UN Member States

to commit to Millennium Development Goals. Two years later, India also

announced the National Health Policy (NHP) 2002. This policy reflects

the concerns of NPP-2000 and Millennium Development Goals, and may

be called the forerunner of NRHM, which was to start from 2005. The

Eleventh Five-Year Plan (2007–12) and the Twelfth Five-Year Plan

(2012–17) show similar concerns with fast and inclusive growth,

focusing on the sectors and populations lagging behind in development.

The Approach of NRHM

The National Rural Health Mission 2005–07 was launched by the Prime

Minister of India on 12th April 2005 to improve the status of health

services in the country. It has since been extended till 2017. It is based on

the understanding that under the prevailing circumstances states required

additional funding and technical and institutional support from the

central government to improve the health status of their population. The

stated aim of NRHM is to provide accessible, affordable, and

accountable quality services to rural population with concentration on

eighteen ‘Special Focus States’ and the poor. These states include the

Empowered Action Group States, States of the North-East, Jammu and

Kashmir, and Himachal Pradesh (Ministry of Health and Family Welfare

(MoHFW nda). Sociologically speaking, apart from providing financial

support, NRHM intended to bring out several new institutional changes:

communitisation of funds, flexible financing, improved management

through capacity building, improved monitoring against standards, and

innovations in human resource management. Provision of untied funds,

involvement of Panchayati Raj Institutions (PRIs), public–private

partnership, convergence of health sector, and a wide range of other

determinants of health (for example, water, sanitation, education,

nutrition, and social and gender equality) were created to develop ‘a fully

The National Rural Health Mission 289

functional health system at all levels, from the village to the district’

(MoHFW ndb). Some of the major planks of NRHM were the

appointment of Accredited Social Health Activist (ASHA) in each

village (one each for 1,000 population), health insurance for the poor,

and the involvement of non-profit sector, especially in underserved

regions. It also aims at ‘fostering PPPs [public–private partnerships];

improving equity and reducing out of pocket expenses; introducing

effective risk-pooling mechanisms and social health insurance; and

taking advantage of local health traditions’ (Planning Commission 2008:

71). Quoting the Independence Day Speech, 2012 of the Prime Minister

of India, the Twelfth Five-Year Plan document noted that the success of

NRHM shows the way for converting it into a National Health Mission

(NHM) covering both rural and urban areas.

Thus, the Five-Year Plan creates the impression that NRHM has

been quite successful in achieving its goals among the rural population

and, therefore, the strategies adopted under it can be implemented to

improve the health condition in urban areas also. Supposedly, NRHM

has several new things which could be extended to urban areas. Accord-

ing to Kaveri Gill (2009), these new things are: creation and upgradation

of human and financial resources of health facilities at all levels;

revitalising and mainstreaming traditional medical practices; flexible

funding; converging health, nutrition, water, sanitation, and hygiene

activities through District Health Plans; integration of vertical health and

family welfare programmes; fostering public-private partnerships with

better regulation of the private sector; instituting Indian Public Health

Standards; and creation of Janani Suraksha Yojana, ASHAs, Hospital

Development Societies or Rogi Kalyan Samitis, and Village Health and

Sanitation Committees.

Evaluation of NRHM: Achievements and Failures

In a statement of achievements, called ‘NRHM: The Progress So Far’,

MoHFW reports that NRHM has reduced infant mortality rate (IMR,

defined as number of deaths of children aged 0–1 year per 1,000 child-

births) at a higher rate than earlier (during 2003–06), increased institu-

tional deliveries, raised the figures of full immunisation, constituted Rogi

Kalyan Samitis, appointed and trained ASHAs, constituted Village

Health Committees, created village health and nutrition days, provided

mobile medical units, and co-located Ayurveda, Yoga and Naturopathy,

Unani, Siddha and Homoeopathy (AYUSH) in a number of health

facilities. These are not mean achievements. Yet this is not the full story

and a thorough examination of cost-benefit analysis of the project is

290 A.K. Sharma

required. This has not been done so far, perhaps because problems

abound.

It is impossible to evaluate the cost-effectiveness of a national

project like NRHM. Firstly, NRHM has multiple goals, all of which have

not been achieved to the same extent. Secondly, health depends on a

number of factors, such as living and working conditions of people,

education, degree of social integration, awareness, belief systems, quality

of environment, and access to health facilities, among others. Thirdly,

even if outcome variables such as infant mortality rate (IMR) have not

reached the respective targets, they have shown an appreciable drop, and

NHRM has contributed to strengthen the mechanism of their further

reduction. There are three ways of assessing the role of NRHM: (i) by

conducting longitudinal studies in different states, (ii) by using

multivariate regression and logistic models to analyse district-level data

on health and socio-economic variables, and (iii) case studies. During the

last eight years, after implementation of NRHM, changes have occurred

in all the socio-economic parameters which present significant exter-

nalities. There is no clear, quantitative assessment of NRHM. Some data

are, however, available from both government sources and researchers

which are worth observing.

The International Institute for Population Sciences (IIPS), Mumbai

has produced a voluminous fact sheet of concurrent evaluation of

National Rural Health Mission 2009 (see IIPS 2010). This document

establishes that there are pronounced inequalities between states, and the

achievements are far from being satisfactory. Special Bulletin on

Maternal Mortality in India 2007–09 of Sample Registration Scheme

(SRS 2011) showed that maternal mortality ratio varies from 81 in

Kerala to 390 in Assam, and maternal mortality rate varies from 4.1 in

Kerala to 40.0 in Uttar Pradesh/Uttarakhand. The former indicates the

ratio of maternal deaths to 100,000 childbirths and the later, maternal

deaths to per lakh of women in age group 15–49. Various SRS bulletins

also show the continuing differences in IMR and death rates across states

and union territories. The SRS Bulletin of 2009 (SRS 2009) showed that

IMR in the country is 53; it is 58 for urban areas and 36 for rural areas.

While Goa has a very low IMR (10), Madhya Pradesh has a high IMR

(70). According to October 2012 Bulletin of SRS (2012), while for the

country as a whole IMR has declined to 44, the differences between

urban and rural localities and across different states have persisted.

While the urban IMR has declined to 29, the rural IMR is still at 48. The

states of Odisha, Rajasthan, Madhya Pradesh, and Uttar Pradesh have

IMR above 50.


The concurrent evaluation by IIPS (2010) has gathered a lot of data

at Primary Health Centre (PHC) and District Hospitals levels. It finds

Uttar Pradesh, which is one of the High Focus States, is characterised by

the following:

a) only 4.5 per cent PHCs have piped water supply;

b) only 3.0 per cent PHCs were upgraded as per Indian Public Health

Standards (IPHS) norm;

c) at only 17.9 per cent PHCs Rogi Kalyan Samitis generated resources;

d) out of thirty-one District Hospitals covered by the study, only eight had

Neo-natal Intensive Care Unit/specialised Sick New Born Care unit;

e) only 6.2 per cent ASHAs received incentive for Village Health and

Nutrition Days;

f) only 13.2 per cent Auxiliary Nurse Midwives stayed in official resi-

dence;

g) only 66.5 per cent children received full immunisation; and

h) only 28.7 per cent of the currently married women (15–49) reported to

have exclusively breastfed youngest surviving child for the first six

months.

Yet it may be noted that patients at most of the inpatient and outpatient

departments were satisfied with the services at District Hospitals,

Community Health Centres (CHC), and PHCs. What is true about Uttar

Pradesh is more or less true about Bihar and other High Focus States.

Thus, it appears that although the status of health facilities is deplorable,

for those who come to avail services in government health facilities they

are of great value, perhaps for one reason that they have no other

alternative.

Among the latest sources of data, Annual Health Surveys have

shown: (a) full ante-natal care, that is, three or more ante-natal care, one

tetanus toxoid injection and iron-folic acid drops for 100 days or more,

varies from 3.9 per cent in Uttar Pradesh to 19.5 per cent in Chhattisgarh;

(b) during 2007–09, one in four marriages of girls in Bihar and one in

five in Rajasthan and Jharkhand occurred below the age of 18; (c) in

Chhattisgarh, only 34.9 per cent deliveries are institutional; and (d) Bihar

and Uttar Pradesh continue to have high total fertility rate. On the

positive side, there has been no polio case in India after 13 January 2011

(NRHM Newsletter 2012).

Observations from the Fifth Common Review Mission reports

(NRHM nd) are also insightful. The Uttar Pradesh report shows that the

newly constructed PHCs are lying locked due to non-availability of staff;

equipment needing minor repairs are lying dysfunctional; district

priorities for infrastructure are not reflected in State Programme

Implementation Plan; there is a severe shortage of specialists, medical

292 A.K. Sharma

officers, nurses, and multi-purpose workers; the conventional methods of

recruitments/outsourcing are not producing the desired results; there is

less concern about training; there is a shortage of training institutions; the

quality of training is poor and affects delivery of health services; bio-

medical waste management is grossly inadequate; and quality assurance

mechanisms are not established.

The Eleventh Five-Year Plan document (Planning Commission

2008) itself recognises that there are several drawbacks of the public

health systems in India:

a) centralised planning instead of decentralised planning relying more on

locally relevant strategies;

b) institutions based on population norms rather than habitation norms;

c) fragmented disease-specific approach rather than comprehensive health

care approach;

d) inflexible financing and limited scope for innovations;

e) partly utilised or dysfunctional health infrastructure;

f) inadequate provision of human resources;

g) absence of prescribed standards of quality;

h) inability of the system to mobilise action in areas of safe water, sanita-

tion, hygiene, and nutrition (key determinants of health in the context of

our country), that is, lack of convergence; and

i) inability to mobilise AYUSH and Registered Medical Practitioners and

other locally available human resources.

The same document mentions about the review of NRHM leading to

following conclusions:

a) 17,318 Village Health and Sanitation Committees have been constituted

against the target of 1.80 lakh by 2007;

b) no untied grants have been released to Village Health and Sanitation

Committees pending opening of bank accounts by them;

c) against the target of three lakh fully trained ASHAs by 2007, the initial

phase of training (first module) has been imparted to 2.55 lakh, and

ASHAs in position with drug-kits are 5,030 in number;

d) out of the 52,500 sub-centres expected to be functional with two auxi-

liary nurse midwives by 2007, only 7,877 had the same;

e) 9,000 PHCs are expected to be functional with three staff nurses by

2007; this has been achieved at 2,297 PHCs;

f) there has been a shortfall of 9,413 (60.19%) specialists at the CHCs. As

against the 1950 CHCs expected to be functional with seven specialists

and nine staff nurses by 2007, none has reached that level;


g) CHCs have not been released untied or annual maintenance grants

envisaged under the NRHM, as they have not reached up to the expected

level; and

h) The number of districts where annual integrated action plan under

NRHM has been prepared for 2006–07 are 211.

While discussing the strategies of NRHM, the Eleventh Five-Year

Plan admits that there are formidable problems. For example, the central

government has focused on reducing the maternal mortality rate (MMR)

the most. Efforts are made to minimise maternal deaths in the country,

which still has an unusually high MMR. Janani Suraksha Yojana is

precisely about this. At the same time the Plan recognises that en-

couraging women to go to health facilities for delivery alone cannot

reduce maternal mortality to zero. It accepts that the country does not

have adequate institutional capacity to receive all women giving birth

each year and that half of the maternal deaths occur outside delivery, that

is, during pregnancy, abortions and postpartum complications. The

problem is mixed up with several issues such as lack of concern for

women’s health, malnutrition, lack of proper transport facilities, lack of

awareness of danger signs, lack of full ante-natal care, and lack of stress

management. In fieldwork conducted in different States, I have observed

that although women are taken to PHCs and CHCs for delivery in the

expectation of getting money, the attention they receive there is far from

adequate.

The Report of the Planning Commission’s Working Group on

NRHM for the Twelfth Five-Year Plan (2012–17) presents the policy

framework of NRHM for the Plan period (Planning Commission 2012a).

Among the new provisions under NRHM, the role of ASHA workers is

considered to be very significant. Therefore, it is revealing to quote from

Which Way Forward?: An Evaluation of the ASHA Programme in Eight

States, a study conducted by National Health Systems Resource Centre

in 2010:

In terms of work ASHAs reported as having done in last six months

different states showed different patterns. We describe this below.

1. In all states two activities – counselling women on all aspects of preg-

nancy and promotion and coordination for immunisation programmes

were consistently reported by over 85 per cent of ASHAs, with only

Jharkhand having a 77 per cent average for both and Bihar having 71

per cent for counselling women.

2. Surprisingly the third highest activity was visiting the new-born which

was higher than 80 per cent in all but six of sixteen districts. Of these

294 A.K. Sharma

four two were from Jharkhand where only 20.8 per cent reported this

activity, while the other four – two from Bihar; Karimganj and

Banswara were over 60 per cent.

3. Accompanying women for delivery, the most publicly known activity

of the ASHA was above 85 per cent in all districts except Kerala and

West Bengal. Even here, in Wayanad it was as high as 74 per cent

though in Trivandrum it was a low, but still a surprising 40 per cent.

Intuitively one would have not expected pregnant women in Kerala to

be requiring this support.

4. Another activity reported was household visits. All but eight districts

reported above 80 per cent and another seven were in the 60 to 80 per

cent range while it was lowest in West Singhbum with 46 per cent.

5. Nutrition counselling was reported as an activity by over 70 per cent

from all districts of Kerala, Andhra Pradesh and West Bengal, and from

Nayagarhand less than 50 per cent in the remainder.

6. Village meetings or any collective meeting for health promotion, an

indicator of the mobilisation role was varied, with six districts- Andhra

Pradesh and Kerala and Orissa reporting a higher than 70 per cent

activity level, while it was less than 50 per cent in all the rest. The

lowest figures were reported from Bihar – 12 per cent in Khagaria and

20 per cent in Purnia.

7. In community level care for illness and use of drug kit, only Kerala,

Khammam and Nayagarh showed an adequate over 70 per cent

response. In Bihar it was as low as 8.5 per cent of ASHAs with 2 per

cent from Purnia.

8. In malaria only four districts including two from Orissa and in

tuberculosis only the two districts of Kerala and Khammam showed

over 60 per cent activity level.

9. In Kerala 81 per cent of ASHA reported mobilisation for Non

Communicable Diseases (NCD) camps and 76 per cent responded

positively for supporting patients in palliative care- activities that are

currently exclusive to Kerala alone (NHSRC 2011).]]]

In a balanced article, K.S. Jacob (2011) said that NRHM needs to

deal with a number of challenges to deliver effectively. Two of them are

of special interest. First, the proposed system of health insurance may

take away a huge amount of funding from the health care delivery in the

rural areas and weaken the government system. Second, it is difficult to

place the trained doctors in remote rural areas which lack in basic

amenities and services at a health centre as well as the locality. This may

suggest the need for higher rewards to health staff – doctors to health

workers – who work at remote places and in difficult situations.

My experience of working among rural and tribal populations shows

that, for the rural poor, the first place to be considered for health needs is

the government hospital (in rural areas PHCs and CHCs are also called


hospitals). As long as the rural poor can work, they work; only when a

disease or illness affects their roles and they perceive a threat to their

functionality, they look for treatment (the most convenient thing is to

approach a quack at the nearest point). Failure of quack’s treatment

makes them go to ‘hospital’, which is a costlier choice. Hospital doctors

are considered to be certainly more competent. If there is a functioning

health facility in the vicinity and the treatment is accessible and

affordable, there is no reason why people go to quacks. Magical practices

of very remote areas are only an exception and adherence to them in our

age shows more of a lack of modern facilities rather than people’s

preferences. It is also a fact that the local government doctors, who are

known for their concern about people, are the most trustworthy elite of

the area, and people will approach them for making health and lifestyle

choices, immunisation, nutrition, and behaviour change.

In the neo-liberal regime, the primary health care system seems to be

weakening despite the creation of aanganwadi workers, ASHAs, and the

emergence of health insurance for the poor. There are many reasons

behind this which are well documented in the Plan drafts. They cannot be

tackled simply by prevailing models of democratisation, transfer of

responsibility to private sector, and multiple actions to involve AYUSH,

community based organisations, NGOs, and PRIs in health delivery.

Indeed, the new approach is likely to do damage to the health system for

the poor.

Major Challenges of NRHM

The chapter on health in the third volume of Twelfth Five-Year Plan is a

well-written document. It takes a holistic view of health, includes all

conceivable ways of improving health of people, and identifies twelve

issues – ranging from maternal and child health to ethical issues in

research – to ponder. Yet it lacks the field-view of health. Literature

shows that there are several determinants of people’s health: structure of

society; conditions of living and working; values and beliefs; lifestyles

and choices; and availability of health facilities. Commenting on the

higher mortality of working class in the 19th century Frederick Engels

(1845) attributed it to unhygienic living conditions, unhealthy working

conditions, poverty, lack of proper diet, non-availability of proper

medical facilities due to inability to pay high fees of doctors, and cheap

charlatans and quack remedies, which do more harm than good. His

findings are quite relevant in the prevailing context of India, too. To

improve health at the national level, it is imperative that the poor are

provided clean water, sanitation, quality employment, education, housing

296 A.K. Sharma

and nutritious diet. Research has also shown that equality in both

economic and social senses is vital to improvement of life expectancy

(Wilkinson 2005). Presenting the sociology of health perspective, Kevin

White (2011) argues that diseases are socially produced and distributed,

and class, gender, and ethnicity are three major factors which shape

them. Without going into the issues of social structure, although they are

very important in the case of public health, I wish to discuss nine

questions.

(i) What should be the targets? I am most perplexed by the target-

setting under NRHM. In the field of health, why targets for IMR, MMR,

anaemia, etc. should differ from state to state? Why should they not be

zero? Why should we be happy if Bihar has MMR of 177 or Uttar

Pradesh and Uttarakhand, 163, and Kerala, 37? Regionally differentiated

approaches to health certainly make sense from programme point of

view, but why should targets also differ? Should the goal not be to

reduce them to the lowest possible levels (say around 3–5, the levels

already attained in the developed countries) for all states and social

groups? We know that given the differences of socio-economic and

demographic conditions, all the states cannot achieve the same targets

immediately. This can be kept in mind in programme evaluations and

fixing responsibilities, but fixing targets at levels much above what is

technically and medically possible at the moment (and have already been

achieved in countries at similar levels of income) leads to lethargy in the

system and is against the constitutional guarantee of equal opportunities

for all.

(ii) How can health governance be improved? Are mechanisms to

regulate food items in place? Are rules regarding private medical practice

in place and effective? Are there negative and positive sanctions in place

for performance of staff? Can health governance be dissociated from

general governance? Uttar Pradesh reportedly has a fraud of Rs 3,000

crores under NRHM (Bhalla 2012). What does it mean in terms of

governance of the state? In the new paradigm, transfer of power to PRIs

is believed to be of great significance in running the programmes

effectively. However, investigations have shown that PRIs are not

always the epitome of democracy and decentralisation. They do not exist

in vacuum and are part of the larger socio-economic and cultural milieu

(Raghunandan 2012). They, too, have similar problems.

(iii) What are feedback mechanisms and how does programme

respond to feedback from ASHAs and aanganawadi workers? There

are serious issues not only with background, training, motivation, and

overburdening of grassroots workers, but also with the feedback from

them and response of the system to their feedback. There is very little


thinking about motivational and reward strategies among grassroots

workers and volunteers. No model of decentralisation will materialise if

there is no mechanism to listen to the problems of the grassroots workers

and change it locally to deliver better. There is also a need to have a

greater clarity on the role of ASHAs. On the one hand, they are seen as

social activists and, on the other, they are expected to behave like

government functionaries. Both state and central governments develop

guidelines for them, and assign work to them, as for other government

functionaries.

(iv) If the staff position and facilities cannot be improved, should

they not be concentrated in certain regions and for some sections of

society only, specially the poor? This issue has to be given a careful

thought. As long as limited services are thrown open to all, there is a

higher chance that they will be expropriated by the local elite and not

reach the neediest people. On the other hand, it would be unethical to

deny public health services to some local people because they do not

meet the economic or social eligibility criteria. There is a real dilemma.

(v) How does AYUSH help in strengthening health services, in

improving the quality of services at the local level, and in changing

belief systems of the people? For a long time, in the country modern

medical science has been presented as having the monopoly over truth

and all traditional practices for which there is no scientific evidence have

been rejected. This is equally true of discourses among experts and lay

persons. Now what do we achieve by including AYUSH in government

health facilities? Are we to take an official stand that both science and

non-science are on equal footing as long as they prove to be of any

personal utility? How do we select some traditional practices and not

others? Although the presence of AYUSH in the health facilities is only

tokenism (the Twelfth Five-Year Plan outlay on AYUSH is just 3.3 per

cent of the total MoHFW outlay!), this has serious implications for the

perspectives on health. The Twelfth Five-Year Plan also says that, for

involving AYUSH graduates in the primary health system, the legal

framework has to be amended. The new provisions have to authorise the

practice of modern medicine by practitioners of Indian medical systems.

Does it mean that, while the elite classes go for allopathic medicine, the

rural poor are provided AYUSH because they cannot be given allopathic

medicine? To quote from the Twelfth Five-Year Plan’s chapter on

health:

Associations of allopathic practitioners are generally opposed to AYUSH

practitioners being allowed to prescribe allopathic medicines; they will

have to be persuaded to yield in the national interest of serving the masses,

particularly the rural population and the urban poor. Suitably trained,

298 A.K. Sharma

AYUSH graduates can provide primary health care and help fill in the

human resource gaps in rural areas (Planning Commission 2012b: 38).

Then cannot we think of providing the same training to jholachhap

doctors (untrained allopathic practitioners) and involve them in the

programme? Evolved on the pattern of training of traditional birth-

attendants, training of existing village practitioners could be of immense

value in primary care.

(vi) What optimum strategies are developed for health education

and behavioural change and communication? In other words, what

needs to be done to improve the use of safe water, advantages of early

breastfeeding, compliance in cases of tuberculosis and other diseases,

and health diet? For this, we need involvement of education department,

media, administrative action, community leaders and political parties (in

Kerala political parties and religious organisations have made a great

contribution in this direction). Who can do it best, if not the local, trusted

doctor? The quickest and most effective method for spreading health

education and behavioural change is to involve the local doctor at the

PHC/CHC.

(vii) Is there any stigma against certain communities/minorities

which discourages them from availing services? Our experience in the

field shows several instances of minorities not going to health facilities

for delivery, family planning, and other services due to a perceived

stigma against them among the health providers. Something has to be

done about this and about building trust relationship with the minorities

and excluded groups. This cannot be done through legislations, legal

provisions, or mass media. Again, we have to involve the local health

providers in changing concepts of perceived and enacted stigmas.

(viii) Why are mental health and palliative care not given adequate

attention? With the aging of population and epidemiologic transition

(Omran 1971), non-communicable, degenerative diseases are going to

have a greater disease burden. Already there is evidence that prevalence

of mental illness may be higher than assumed and suicide deaths are

more than the total maternal deaths, tuberculosis, deaths due to cardio-

vascular diseases, and deaths due to accidents (Patel et al. 2012). In the

present milieu, community has to play an important role in diagnosis,

treatment, and management of mental health. Same thing can be said

about palliative care. Kerala has shown the way by involving the

community in palliative care and linking it to NRHM. World Health

Organisation (WHO) calls it the ‘Kerala Model’ of palliative care. PHCs

can play a role in palliative care through community participation in

other states, too.


(ix) Where should the priority lie? From our point of view, a

multipronged approach is required to improve health. Yet, within the

constraints of logistics and limited funds and resources we cannot

achieve everything. An important concern is to strengthen the primary

health system. India is among the countries that spend the lowest

percentage of national income on health. The planners have to realise

that, instead of expanding in all possible directions, we must prioritise

our activities and the highest priority must be assigned to strengthen the

primary health system. If the primary health services are strong, it helps

in many ways: (a) it raises trust of people in services at block, panchayat,

and hamlet (sub-centre) levels; (b) those, for example, rural poor, who do

not have any other alternative, can also have preventive, curative, and

palliative services there; (c) it makes health services more efficient and

effective; (d) it reduces the load on specialists, and on the secondary and

tertiary services (in both public and private sectors); (e) it leads to

inclusive development; and (f) it can make strategies of behaviour

change communication more effective. Empowered and independent

medical officers at these facilities can also play an important role in

regulation of food and drugs, and control of pollution. It is heartening to

learn from the Secretary, MoHFW that ‘The District Hospitals would be

strengthened to provide advanced level secondary and tertiary care to

help reduce the private out-of-pocket expenditure on health. However,

the focus on primary care would continue and not be diluted’ (Pradhan

2012).

Summary

This paper has examined the approach of NRHM in the country. Based

on available data and findings, it has discussed the achievements and

limitations of the Mission. It has raised nine questions about the

approaches and strategies of NRHM and suggests that the most effective

way to attain goals of NRHM is to strengthen the primary health care

system rather than taking up a large number of programmes simul-

taneously without any focus. This is not to denigrate the importance of

other measures or of a multipronged approach to health, but is only to

stress that, to improve public health standards in the population, a fully

functioning primary health care system is a necessary condition for other

goals to be achieved. In no case should other policies be allowed to

weaken the already weak system of primary health in India which seems

to be happening.

300 A.K. Sharma

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A.K. Sharma, Professor, Department of Humanities and Social Sciences, Indian Institute

of Technology Kanpur, Kanpur – 208016

Email: [email protected]

[The final revised version of this paper was received on 9 December 2013

– Managing Editor]

mailto:[email protected]

The National Rural Health Mission: A Critique

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