The National Rural Health Mission was launched on April 12, 2005. It sought to provide accessible, affordable and quality healthcare to the rural population, especially the vulnerable sections. NRHM recognised the leadership role of States. It proposed flexibility to States to take care of local needs. States in turn were expected to decentralise planning and implementation arrangements to ensure that need based and community owned District Health Action Plans become the basis for interventions in the health sector.

NRHM aspired to reach 2 per cent of GDP public spending by 2012, in partnership with States. ‘Communitisation’, flexible financing, monitoring progress against Indian Public Health Standards, improved management through capacity, and innovations in human resource management, were the five key approaches adopted by NRHM. The National Health Systems Resource Centre (NHSRC) was set up to drive reforms by building human resource capacity at all levels. Strengthening the public system of primary healthcare delivery with some partnerships as per need, was its avowed thrust. NRHM recognised the need for crafting a credible public system, whose need is felt even more strongly post-Covid.

NRHM has reached all the three quantifiable targets of IMR (Infant Mortality Rate), MMR (Maternal Mortality Ratio) and TFR (Total Fertility Rate), much after 2012, with public spending barely a little above one per cent of GDP. Primary healthcare has many wider determinants that make attribution very difficult. The ability to do vaccination during Covid (2021) in the remotest locations with the active community connect role played by the Accredited Social Health Activists (ASHAs), with adequate cold chain and vaccinators at the cutting edge, is a tribute to the investments 2005 onwards in strengthening the public system. What lessons in public policy does NRHM provide? How can our pandemic preparedness be better?

The foremost NRHM lesson is that crafting a credible public system of primary healthcare delivery must remain the central thrust. Health as a sector needs the countervailing presence of a functional public system, even if private sector is to provide additional capacity for secondary and tertiary care. Tamil Nadu and Kerala have a vibrant and functional public system of healthcare alongside an equally strong private sector. This has consequences for cost and quality of care, and prevents market failures.

Second, health is a sector where human resources are critical for quality service delivery. From hospital managers to nurses, para medics, doctors, specialists, there is a need for a range of human skill-sets, for quality outcomes in public systems. Innovative human resource interventions like the 24-week Life Saving Anaesthetic Skills Course for MBBS doctors, 24-week Emergency Obstetric Care Course, Family Medicine Distance Education Programme for PHC (primary health centre) doctors, One-year Public Health Masters Programme, building capacity among community volunteers like ASHAs and providing for their HR continuum, recruiting resident ANMs, skilling PHC nurses in medical colleges, setting up nursing skill labs, are all geared to improving the quality of care.

Third, while NRHM’s approach was to provide a horizontal platform at PHCs for all forms of health needs (communicable, non- communicable, reproductive and child health, preventive, promotive care) many externally funded, vertically stand-alone programmes like TB, malaria, filaria, kala-azar, etc., only superficially integrated into the platform. Fragmentation of MISs interfered with a comprehensive public health approach.

Fourth, community connect demanded the setting up of village health, sanitation, nutrition committees at community level, and Rogi Kalyan Samitis in health institutions. Their effectiveness would have been manifold higher if we had institutionalised a role for local governments in such community formations. Institutionalising decentralisation and devolution of funds, functions and functionaries would have given even better and faster results in primary healthcare.

More financial resources

Fifth, quality public health preparedness needs more financial and human resources and we must step up investments in primary healthcare. Institutions like the Tamil Nadu Medical Services Corporation with complete digitisation and decentralised warehousing with batch-wise testing of rigorous pre-qualification based procurement of generic drugs and medical equipment, are mandatory. While over 25 States have set up Corporations the last mile digitisation and random batch-wise testing with Drug Passbooks in health institutions has not become a reality in many. Doctors, drugs and diagnostics still account for over two-thirds of the out-of-pocket expenditure.

Sixth, better decentralised management capacity requires a range of new skills in hospital and health management. Many of these skill sets were brought in by NRHM but did not get institutionalised in many States. Decentralisation without professionals and capacity is always fraught with dangers. We really need to heed this need for social audit, local government role, and a role for the social capital of women’s collectives, to drive decentralisation. Connecting households to health facilities will only be possible through such an approach. Local governments also help the convergence to make a difference in wider determinants like clean water, sanitation, housing, etc.

Seventh, the excess private sector capacity for secondary and tertiary care must be used for public health purposes at reasonable rates and that is what Pradhan Mantri Jan Arogya Yojana (PMJAY) is trying to do. The Chhattisgarh study recently points out the challenge of dual payments. Given the unequal social and power relations, many a time misadventures happen in such partnerships. The community connect and real time accountability framework for social audit is our only guarantee for effectiveness of partnerships. The biggest lesson is the need to engage with States in a dialogue of equals as they alone can drive reforms with resources. The District Health Plans, the Appraisal and Approval process, the NHSRC capacity building thrust, a robust and independent accountability framework, the Common Review Missions, the Good Practices across States’ presentations, community monitoring with civil society engagement, is the way forward for quality healthcare for all.

The writer is a retired civil servant. Views are personal