Describe the National Health Mission with its components and achievements.

Origin, Structure and the Asha

• The goals — to provide accessible, affordable, accountable and effective health care to rural populations, especially the vulnerable; to reduce infant, maternal and total fertility rates; to achieve universal access to public health services; to prevent and control communicable and non-communicable disease; and to promote healthy lifestyles and AYUSH
• The mission gave special focus to 18 high-focus states with weak public health indicators and infrastructure, which is an application of the principle that equal effort everywhere widens rather than narrows a gap
• The five approaches — communitisation; flexible financing; improved management through capacity building; monitoring against Indian Public Health Standards; and innovation in human resource management
• The ASHA is the mission’s central and most successful innovation
• Her selection and status — a female volunteer, one per about 1,000 population, aged 25 to 45, preferably married, widowed or divorced, with a formal education preferably to class 8, selected BY and from the village through the panchayat and gram sabha
• Selection from the community she serves is the crucial design feature, since it gives her local knowledge, social acceptability, physical presence at all hours, and accountability to people who know her — none of which an outsider on a salary can have
• She is paid by performance-based incentive rather than by salary
• That design choice is genuinely double-edged and should be presented as such:
• In its favour — it keeps costs low enough to permit nearly a million workers; it links payment to work actually done; and it preserves her identity as a community volunteer rather than a government employee
• Against it — incomes are low and irregular; payments are frequently delayed, sometimes by months; incentives distort effort toward incentivised tasks and away from unincentivised ones such as counselling and follow-up; and the "volunteer" designation denies her the wages, security and benefits of employment while the workload is that of a full-time job
• ASHA demands for regularisation have been a recurrent industrial dispute, and the issue is unresolved rather than settled
• Her roles — mobilising women for antenatal care and institutional delivery and accompanying them; home-based newborn and young child care visits; promoting immunisation and family planning; acting as a depot holder for ORS, contraceptives, iron tablets and chloroquine; DOTS provider; counselling on nutrition, sanitation and danger signs; convening the village health and nutrition day; and community mobilisation and acting as a link with the health system
• The other communitisation mechanisms:
• Village health sanitation and nutrition committees, with an untied fund for local health and sanitation action decided locally
• ROGI KALYAN samitis (patient welfare committees) at facilities, which can retain and spend user charges and local funds on maintenance and improvement without waiting for a sanction from above
• The importance of untied funds is worth arguing — a facility that cannot spend a small sum on repairing a tap, buying a bulb or hiring a cleaner will simply do without, because a centralised sanction takes months and is not worth requesting
• Decentralised planning through district and state health action plans, built upward from the village and block rather than issued downward

Financing, Achievements and Limitations

• Flexible financing was the mission’s most important administrative innovation — providing funds that a district could allocate according to its own plan rather than according to line items fixed centrally
• The rationale is that the problems of a coastal district and a Himalayan one are not the same, and a single national budget line cannot fit both
• The funding is shared between centre and state, in a 60:40 ratio for most states and 90:10 for the north-eastern and Himalayan states
• Funds flow through state and district health societies, which bypass the slower treasury route
• The components of the NHM — RMNCH+A; communicable disease control programmes; non-communicable disease programmes; infrastructure strengthening and IPHS; human resources, including contractual appointment to fill vacancies quickly; mobile medical units for remote areas; free referral transport (102 and 108); free drugs and free diagnostics; AYUSH mainstreaming; and quality assurance
• The achievements, fairly stated — a very large rise in institutional delivery; substantial declines in maternal, infant and under-five mortality; improved immunisation coverage; the elimination of polio and of maternal and neonatal tetanus; the creation of a community health workforce of nearly a million ASHAs; increased outpatient and inpatient utilisation of public facilities; and free ambulance services now used at very large scale
• The rise in public facility utilisation is a significant achievement in itself, since it reverses a long drift toward the private sector and indicates recovered confidence
• The limitations and criticisms, which an honest answer must give:
• Quality of care has lagged behind coverage — the recurring theme
• The rise in institutional delivery outpaced the capacity of institutions to manage complications, which is why maternal mortality fell more slowly than delivery rates rose
• Persisting specialist shortage, so that many CHCs are not functional first referral units
• Heavy reliance on contractual staff, with insecurity and turnover
• The ASHA overburdened, underpaid and paid late, with every new programme adding tasks and none removing any
• Continuing dominance of vertical programme structures despite the intention of integration
• Public health expenditure remaining low as a share of national income, so that the mission did not change the fundamental level of financing
• Out-OF-pocket expenditure remaining very high
• Wide inter-state variation, with the high-focus states improving but from a much lower base
• The urban mission (NUHM) receiving far less attention and funding than the rural one, despite the urban poor having outcomes comparable to or worse than rural populations
• The assessment that the evidence supports — the NHM demonstrated that public health services can be revived where money, flexibility and community accountability are provided together; and that the remaining constraints are human resources and total financing rather than design
• Untied funds matter more than they sound, since a facility that cannot buy a bulb simply does without one
• A central sanction takes months and is not worth requesting for a small sum, which is why local money changes behaviour
• The ASHA design is honestly double-edged, making a million-strong workforce affordable while leaving her underpaid
• Incentives distort effort toward incentivised tasks, and away from counselling and follow-up which pay nothing
• Delayed payment is a recurrent grievance, sometimes running to months, and undermines the incentive logic entirely
• Selection by and from the village is the design, giving acceptability and accountability an outsider cannot have
• Rogi Kalyan Samitis can retain and spend local funds without waiting for approval from above
• District plans are built upward, not issued downward, which is what decentralised planning actually means
• Funding is sixty-forty, or ninety-ten for the north-eastern and Himalayan states
• Health societies bypass the treasury route, which is why money actually reaches districts within the financial year
• Eighteen high-focus states received special attention, since equal effort everywhere widens rather than narrows a gap
• Institutional delivery outpaced institutional capacity, which is why maternal mortality fell more slowly than delivery rose
• Rising public facility use is itself an achievement, reversing a long drift toward private providers
• Contractual appointment filled vacancies quickly at the cost of insecurity and high turnover
• Mobile medical units reach where nothing is fixed, which is the practical answer for remote and tribal blocks
• Vertical structures persisted despite integration being the stated intention, which is a candid criticism to include
• The urban mission received less than the rural, despite the urban poor faring comparably or worse
• The mission did not change the level of financing, which remains the fundamental constraint on everything else
• It showed public services can be revived where money, flexibility and accountability arrive together
• Every new programme adds ASHA tasks and none removes any, which is how overburdening happens without anyone deciding it
• Flexible financing lets a district decide, since a coastal and a Himalayan district do not have the same problems
• Free ambulance services are used at vast scale, and address the second delay in maternal mortality directly