The purpose of NRHM among other things was to strengthen the primary health centres (PHCs) and subcentres and creates a network of rural hospitals. However it was felt that several developments since the launch of the NRHM in April 2005 point to increased privatization of health care services. For instance in several states the NRHM under the garb of better health management opened up space to outsourcing and privatization of PHCs and subcentres.
The NRHM is criticized for adopting a system of Indian Public Health Standards which was seen as having severe limitations. While it defined the minimum manpower requirement and the equipment and infrastructure needed to attain a set of well defined health outcomes the attempts to achieve these were not comprehensive in scope and were biased largely towards reproductive and child health. The IPHS was adopted for CHCs, PHCs and district hospitals as well. However the emphasis was still on purchasing equipment and attaining standards of infrastructure development rather than raising the level of overall service provision.
The policy in some states of allowing public participation in the monitoring and administration of health care services also backfired. The Rogi Kalyan samities that were started with the intent of greater public participation in the health care system degenerated into a system of cost recovery with the introduction of user fee for many services in government hospitals. Donor agencies pushed for the user -fee system and this resulted in a reduction of state investment in the maintenance of health care facilities. The public participation has been trivialized: it translated into better access for the privileged and the politically powerful.
Urban health statistics revealed that in many states the key indicators such as urban infant mortality rate had remained stagnant or their trend had even reversed. The specific vulnerability of urban slum dwellers the lack of basic amenities and health services for them was an area yet to be addressed. The NRHM was formally empowered to cover urban slums but in reality the coverage was negligible. Whatever urban component was there in health care ,it was in the RCH plans in a limited manner.There was no equivalent plan to set up PHCs,CHCs or sub centres in urban areas.
ASHA plan conceived as an important component of NRHM was a let down due to de-emphasizing of the workers' curative and symptomatic roles and the piece rate system of payment .While the strategy of deploying ASHAs was plausible what had not been anticipated was the inability of the existing departmental structures to implement such a large scale mobilization and the absence of support structures. The implementation of the ASHA plan was poor. The NRHM was a compulsion to show the pro-poor face of the new government. It has been found during a study conducted by Jan Swasthya Abhiyan that most of the ASHAs had yet to start work; the Anganwadi worker or the Auxiliary Nurse Midwife allocated them work. Under the NRHM the ASHA was required to be accountable to the community and not subservient to the ANM or AWW.Dalit health workers were discriminated against. In MP nearly 50% of the PHCs surveyed were being managed by non medical staff, in Bihar 30%, in Rajasthan 25% and in Jharkhand 12%.The main problems plaguing PHCs related to improper drug supply and shortage of staff.
In many of the states the PHCs and even some of the CHCs had been contracted out to NGOs under the managed care approach. This system which is in vogue in Bihar, Karnataka and Arunchal Pradesh entailed the offering of a specified package of services. There is no notion of decentralization and community management. In Gujarat under the Chiranjeevi Programme private clinics are reimbursed at fixed rates for institutional deliveries and emergency obstetric care services. The government has also contracted out peripheral health facilities and has a proposal to contract out district hospitals to corporates.Some of the private health insurance schemes supported by state governments had failed. However in some states such as Tamil Nadu and West Bengal the partnership is working well. The core of the public health system stayed within the public domain and only some of the ancillary services were contracted out.
According to Jan Kalyan Abhiyan a vast network of government run health subcentres and PHCs supported by CHCs and district hospitals is required along with a large community -health-worker force, the expansion of nursing staff and the upgrading of their skills. The notion of primary health care continues to be limited in that it is applied to RCH and a few disease control programmes.There is still reluctance to move towards the goal of comprehensive primary health care. The health policy is silent on is the need to set up a rational drug policy. All policies including NRHM had glossed over this aspect despite the fact that nearly 2/3 of all health costs go into drugs. There is no regulation of the prices of essential drugs whose list had been brought down to 30 in 2002 from 347 in 1977.
There has been lot of importance given to two vaccination initiatives-pulse polio and universal Hepatitis B vaccination. More than Rs 1000 crore is spent annually on the pulse polio programme while the budget for other vaccines in the National Immunization Programme in 2005-06 was only Rs 327 crore.
The objectives of any health policy have to be seen in the light of the Alma Ata declaration where health was not just a desired goal but one of the main harbingers of equity in society. The government's intent in bringing changes to the health care system may be good but their implementation seems to be directed by donor directed priorities.