Policy analysis: National Health Mission (NHM)

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A country’s capacity to protect its citizens is amply demonstrated by how it manages its healthcare system. Relying solely on medical breakthroughs would not only setback the pace of beneficial measures, but also jeopardise the lives of millions who could neither afford nor access the breakthrough treatments. Consequently, the need of the hour lies in a consistent and comprehensive approach that encompasses every area of concern and protects every stakeholder. 

In India, with the prevalence of COVID-19 and an extended lockdown, the National Health Mission (NHM) has been in the limelight while aiding the states in combating the virus. On March 24, Prime Minister Modi and on April 9, the Centre announced an entirely centrally funded emergency package of ₹15000 crore rupees, with half of it sanctioned under the NHM.

Announced as the “India COVID-19 Emergency Response and Health System Preparedness Package”, the sanctioned funds are to be allocated to two plans of action – for an immediate response to COVID-19 (₹7774 Crores) under the NHM, and the rest towards providing medium-term support as per the ‘mission mode’ approach, which is to ensure that projects have well-defined objectives, measurable outcomes and clear implementation deadlines. The entire response is to be executed in three phases between January 2020 and March 2024. It was also explained that the majority of the allocated funds would be utilised for boosting emergency responses amongst states as well as supporting research and greater community engagement.

Significance of this development

The sanction came at the heels of persistent requests by the stakeholders to devise and finance a long-term exit strategy for the lockdown and at a time when COVID-19 hospitals and provisioning of medical equipment was being increasingly funded by private parties and. The funds have the potential to improve the country’s preparedness towards biosecurity and risk communication programs as well as bolster the measures undertaken by states to scale their testing and treatment facilities up which were otherwise facing financial issues. Coupled with the Ministry of Health and Family Welfare’s authority to re-appropriate resources within the package, directing part of the package to a longer-term investment on capacity building may ensure that any future sudden or drastic changes in the current scenario can be sufficiently accommodated.

What is the NHM?

The Mission was originally launched by the Central Government in 2013 as a decentralised health delivery system by merging the National Rural Health Mission and the National Urban Health Mission. Its major programmes include strengthening the healthcare system, improving maternal, reproductive and child health as well as protecting the public from communicable and non-communicable diseases. Guided by the broad national parameters, the states have to implement the Program Implementation Plans (PIPs) through local planning to ensure that resources are approved as per the local epidemiological patterns. The funds allocated to states would be as is prescribed the Central Government. A significant development under the NHM has been the engagement of ASHAs (Accredited Social Health Activists), who have been crucial to the public health system at the grassroot level, as well as the option to secure free medicines and medical treatment for the underprivileged.

In 2018, the Union Cabinet approved the extension of NHM till March 31, 2020 with the objective of NHM being the principal tool for ensuring universal health coverage, with a special focus on reducing out-of-pocket expenditures and access to vaccines in states. Its approach was further shifted from selective care to a more comprehensive healthcare plan including improvements in diagnostic services.

Its legal basis

Public Health and hospitals/dispensaries (Entry 6) are in the State List of the Indian Constitution’s Seventh Schedule. This means that healthcare is exclusively in the domain of individual states and the Union cannot override the state legislations subject to certain narrow exceptions (State of Andhra Pradesh v McDowell & Co. and Others). It, thus, is easier to understand the decentralised system of most healthcare-related schemes and legislations such as the Essential Services Maintenance Act (ESMA) and the NHM.

The problems associated with such an allocation of authority become apparent in times of widespread crises such as COVID-19. For instance, the Centre has urged states to invoke Section 2 of the Epidemic Diseases Act, 1897. The section (amended in 1937) leaves it to the satisfaction of the States the power to take the necessary measures to prevent the outbreak of any “dangerous epidemic disease”. Consequently, the Central Government occupies only an advisory role in such matters and has no authority to impose the regulations made under this Act. Implementation under this Act is further clouded by the fact that neither there is no clarification of the definition of scope of ‘dangerous’ nor are there no minimum requirements for a disease to be declared as an epidemic.

While the Ministry of Home Affairs has declared COVID-19 as a notified disaster under the Disaster Management Act, 2005 the definition of a ‘disaster’ in the Act can support this only through a loose interpretation. As a result of the lack of the Centre’s authority under the primary health-related legislations, the Central Government has to rely heavily on states to ensure that the entire country is combating the present pandemic in a well-coordinated manner.

The above issues highlight the obstacles that the NHM may face in uniformly implementing its schemes throughout the country. While the states have the prerogative to use the allocated funds to expand their human and additional resources, the Centre also has a responsibility to protect the country as a whole, which the decentralised system of the health legislations complicates.

Progress made under it

Given the wide coverage the NHM has been allowed for fulfilling its objectives, it has been able to target multiple areas of problems in collaboration with the State authorities and other organisation. In Kerala, the NHM (Arogya Keralam mission) has collaborated with the Centre for Migration and Inclusive Development to set up a mobile clinic for COVID-19 screening, primarily targeting the migrant labourers. The Tamil Nadu NHM team has been monitoring the pregnant ladies in the state and ensuring that their needs are met even while following the social distancing norms. In the meantime, the respective NHM teams have been distributing three-layered protective masks to ASHAs and labourers, such as those in Assam, though the health workers continue to face a dearth of sufficient personal protective equipment (PPE).

In addition, Facebook is reportedly working with eight independent third-party fact-checking entities, including the NHM, to curb the spread of falsities. The company also appears to have trained staff from the Union Health Ministry and the state units of NHM to impart accurate information to the masses at the earliest and use the platform through advertising credits and marketing support to respond to the pandemic efficiently.

The funds presently allocated, if judiciously utilised, would help in establishing and maintaining the hospitals made exclusively for treating COVID-19 patients as well as securing the essential medical equipment and personnel. The NHM has also been expanding its recruitment drives in order to meet the rising demand of health personnel albeit with some difficulties, as many doctors in Bihar (where leaves of health personnel have been cancelled till April 30) have been issued show-cause notices for absenteeism. some of the absentee doctors were appointed on contract under the NHM. This may become a setback to the large recruitment drives as medical staff are mandated to work without a leave or a right to strike (suspended in many states under the respective ESMAs).

Critical analysis

The International Health Regulations of 2005 (IHR), of which India is a member State, aims to prevent the international spread of a disease and undertake steps to set a nuanced public health response that are proportionate to the health risks faced and protect international traffic from undue interference. The NHM in India appears to be working in furtherance of this international obligation, though the individual states within the country have a far greater authority, over the management of public health and medical institutions. The Central government can cite the necessity to oblige the IHR when imposing overarching rules for controlling the pandemic, but it is foreseeable that it has to accommodate the states’ interests as well.

It is in these times that the need of a uniformly implemented national legislation on public health is required. This can be legally permitted if two-thirds of the Rajya Sabha members vote that it is “necessary and expedient in national interest” for the Parliament to legislate on an entry of the State List (Article 249 of the Indian Constitution). However, such cooperation should not become the sole determining factor for setting up a national legislation, especially in the present times, where taking prompt and adaptive measures is integral to protecting citizens. What is undoubtedly required would be greater communication, coordination and cooperation amongst the states as well as between the Centre and the states.

It is also to be observed if the Union Cabinet will decide to extend the operation of the NHM to the time of the loosening of the lockdown, given that it was previously approved to be extended till March 31, 2020 only. It may seem prudent to do so due to the responsibilities the NHM teams have been assigned for addressing the public needs during the COVID-19 pandemic.

Conclusion

The NHM has been largely diligent in its efforts to secure greater health coverage despite the hurdles it is facing. Due to each state having its own NHM unit and implementing state-specific plans, the resources may be utilised more judiciously, but the Mission’s efforts may be hampered if neither the states can collaborate with each other on time nor can the Central Government secure compliance with the regulations due to the matters of public matter being exclusively in the domain of states.

The Emergency Package, if utilised properly, would give a much-needed boost to the health infrastructure of the country for both the short-term (to combat COVID-19) and the long-term. it may also ensure that governments can secure the essential medications and drugs without there being a shortage in their regular supply. It remains imperative to acknowledge that NHM cannot fulfil its aims in isolation and needs the support of all the stakeholders to provide a holistic public health response.

Author: Rituparna Padhy from National Law University, Odisha.

Editor: Tamanna Gupta from RGNUL, Patiala.

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