National Rural Health Mission (NRHM) 2005-2012

The National Rural Health Mission (NRHM), launched in April 2005, was a flagship programme of the Government of India aimed at strengthening public health systems in rural areas. It was designed to provide accessible, affordable, and quality healthcare services to the rural population, especially the vulnerable groups such as women, children, and the poor. The mission represented a major reform in India’s health sector, integrating various health and family welfare programmes under a single umbrella and promoting community participation through decentralised planning.

Background and Context

Prior to 2005, India’s rural health system faced numerous challenges, including inadequate infrastructure, shortage of medical personnel, poor service delivery, and limited access to essential healthcare, particularly in remote and backward regions. Programmes like the Reproductive and Child Health (RCH) initiative and the National Disease Control Programmes operated in silos, leading to fragmented service delivery.
In response to these systemic gaps, the National Common Minimum Programme (2004) of the United Progressive Alliance (UPA) government proposed a comprehensive health initiative to strengthen the rural health system. Consequently, the National Rural Health Mission was launched by the Ministry of Health and Family Welfare (MoHFW) to address the inequities in healthcare delivery and to achieve key national health goals outlined in the National Health Policy (2002) and the Tenth Five-Year Plan (2002–2007).

Objectives and Vision

The vision of the NRHM was to provide universal access to equitable, affordable, and quality healthcare services that are accountable and responsive to people’s needs. Its objectives included:

• Reduction of infant and maternal mortality rates (IMR and MMR).
• Universal access to public health services, including women’s health, child health, sanitation, immunisation, and disease control.
• Prevention and control of communicable and non-communicable diseases.
• Access to integrated primary healthcare through strengthened institutions.
• Promotion of healthy lifestyles and community participation.
• Improved nutrition and sanitation through inter-sectoral convergence.

The NRHM’s time frame was from 2005 to 2012, covering 18 states with weak health indicators, primarily in northern and northeastern India, including Uttar Pradesh, Bihar, Madhya Pradesh, Rajasthan, Jharkhand, Chhattisgarh, and Assam.

Institutional Framework and Implementation

The NRHM was implemented through a mission-based approach, allowing flexibility and decentralisation. Its institutional framework was multi-tiered:

• National Level: The mission was steered by the Mission Steering Group (MSG) and the Empowered Programme Committee (EPC) under the Ministry of Health and Family Welfare.
• State Level: Each state established a State Health Mission headed by the Chief Minister, and a State Health Society to oversee implementation.
• District Level: District Health Missions and District Health Societies were formed, with the District Collector as Chairperson, ensuring local accountability and community participation.

At the community level, the Panchayati Raj Institutions (PRIs) were empowered to play a central role in health planning, monitoring, and implementation.

Key Components and Strategies

The NRHM introduced a series of innovative mechanisms and community-based interventions to revitalise the rural health infrastructure. Its major components included:

1. Accredited Social Health Activist (ASHA) Programme

A key innovation under NRHM was the introduction of ASHA workers, trained female community health volunteers appointed in every village. Their role was to act as an interface between the community and the public health system by promoting institutional deliveries, immunisation, and hygiene awareness. By 2012, over 9 lakh ASHAs were deployed across India.

2. Strengthening Health Infrastructure

NRHM focused on upgrading existing facilities and creating new ones:

• Sub-Centres (SCs) were enhanced to deliver preventive and promotive healthcare.
• Primary Health Centres (PHCs) and Community Health Centres (CHCs) were upgraded to meet Indian Public Health Standards (IPHS).
• The Rogi Kalyan Samitis (RKS) were established to manage funds and monitor hospital services.
• Mobile Medical Units (MMUs) were introduced to extend outreach services in remote areas.

3. Reproductive and Child Health (RCH-II)

The mission integrated RCH-II for improving maternal and child health outcomes. Initiatives such as Janani Suraksha Yojana (JSY) encouraged institutional deliveries through conditional cash transfers to pregnant women, resulting in a significant rise in institutional births during the mission period.

4. National Disease Control and Health Programmes

The NRHM integrated several vertical health programmes, including those for malaria, tuberculosis (RNTCP), leprosy, blindness, and HIV/AIDS, promoting better coordination and efficiency.

5. Health Financing and Decentralisation

The mission introduced flexible financing mechanisms, allowing districts and states to allocate funds according to local needs. Untied funds were provided to Sub-Centres and Village Health Committees to address immediate healthcare needs without bureaucratic delays.

6. Community Participation and Village Health Plans

Village-level institutions such as Village Health, Sanitation and Nutrition Committees (VHSNCs) were established to prepare local health plans, monitor service delivery, and promote awareness campaigns. Annual Village Health and Nutrition Days (VHNDs) were organised to deliver integrated health services.

7. Capacity Building and Human Resources

Large-scale recruitment and training of healthcare professionals were undertaken. Training modules for ANMs, nurses, and doctors were upgraded, while multi-skilling initiatives improved service availability in remote areas.

Achievements and Impact

The NRHM achieved substantial improvements in several key health indicators between 2005 and 2012:

• Infant Mortality Rate (IMR) declined from 58 (2005) to 44 (2011) per 1,000 live births.
• Maternal Mortality Ratio (MMR) reduced from 254 (2004–06) to 178 (2010–12) per 100,000 live births.
• Institutional deliveries increased from 39% in 2005 to 73% by 2012, primarily due to JSY.
• Immunisation coverage improved significantly, with over 70% full immunisation in many states.
• Outpatient attendance in public health facilities more than doubled, indicating increased utilisation of government services.

Additionally, the mission improved infrastructure availability: thousands of new Sub-Centres, PHCs, and CHCs were established, and existing ones were upgraded.

Challenges and Criticisms

Despite notable successes, the NRHM faced several challenges:

• Persistent shortage of skilled manpower, especially specialists in rural CHCs.
• Inter-state disparities in implementation, with southern and western states performing better than those in the north and east.
• Issues of fund utilisation and administrative delays at state and district levels.
• Quality of care remained uneven, with limited adherence to IPHS standards.
• Weak monitoring mechanisms and inadequate evaluation of outcomes.
• Limited focus on non-communicable diseases (NCDs), which were emerging as major health concerns.

Moreover, while the ASHA programme expanded community outreach, the workers often faced delays in incentive payments and inadequate training in complex health areas.

Transition to the National Health Mission (NHM)

In 2013, the NRHM was subsumed under the broader National Health Mission (NHM), which also included the National Urban Health Mission (NUHM). This transition aimed to extend the successful framework of NRHM to urban areas and to address new health challenges, including NCDs and universal health coverage.
The NRHM (2005–2012) laid the foundation for this integrated approach, having already transformed the landscape of rural health delivery in India through its focus on decentralisation, community participation, and inclusive healthcare planning.