India: Adjustment to Population Health Needs

The National Rural Health Mission (NRHM), now named the National Health Mission was launched in 2005 in India to improve the availability, access, and quality of high-quality health services for all. The NRHM focuses on 18 states with weak public health infrastructure and outcomes to improve care for poor women and children living in rural areas.1 The launch of the NRHM required significant collaboration among a diverse set of stakeholders from different sectors and political parties to improve various deficiencies in the health system such as a lack of community ownership and accountability, infrastructure and human resource shortages, and a lack of integration among disease control programs.2

The Government of India is actively promoting a decentralized approach to develop and maintain more participatory and accountable processes for decision-making and to provide more efficient opportunities for community involvement. The NRHM has leveraged this decentralization to increase stakeholder and public engagement in priority setting at the village, sub-center, block, district, and state levels.123 To better tailor resources and services to local community needs, there are specific guidelines for the allocation and management of funds and roles and responsibilities related to service delivery at different levels of the health system. Elected representatives are involved in the institutional structures at all levels of the health system to provide an efficient avenue for communities to express their voice. Additionally, various committees are in place at the district and village level to ensure decentralized planning, efficient allocation of funds, and the integration of community voices - including district health committees, village health sanitation and nutrition committees, and facility-based committees.4

Despite the roll-out of these institutional structures for participatory decision-making, studies have shown mixed-results.234 This is in part due to a poorly-defined planning process and low levels of awareness of the role and functions of the different communities. However, states in India that have a stronger state and local institutional capacity to support civil society organizations and mobilize partnerships between different stakeholders have had more success in implementing the NRHM initiatives, including decentralized health planning.45 These studies underscore that mandating public participation is not sufficient and success relies on the presence of support structures such as well-defined policies and guidelines and sustained capacity-building efforts at lower levels of the health system.3


  1. Bajpai N, Sachs J, Dholakia R. Improving access, service delivery and efficiency of the public health system in rural India: Mid-term evaluation of the National Rural Health Mission. Center on Globalization and Sustainable Development: The Earth Institute at Columbia University; 2009.
  2. Nandan D. National rural health mission: turning into reality. Indian J Community Med. 2010 Oct;35(4):453–4.
  3. Terwindt F. Priority-setting for national health policies, strategies and plans. Soucat A, editor. World Health Organization; 2016.
  4. Seshadri SR, Parab S, Kotte S, Latha N, Subbiah K. Decentralization and decision space in the health sector: a case study from Karnataka, India. Health Policy Plan. 2016 Mar;31(2):171–81.
  5. Shukla A, Khanna R, Jadhav N. Using community-based evidence for decentralized health planning: insights from Maharashtra, India. Health Policy Plan. 2018 Jan 1;33(1):e34–45.