Enhancing Rural Health through Decentralisation: The Role of NRHM

When a pregnant woman in a remote village cannot reach a hospital in time, or when a cluster of children fall ill because of contaminated water, the gap between policy written in Delhi and healthcare delivered at the doorstep becomes painfully visible. The National Rural Health Mission (NRHM), launched in 2005, was designed to close exactly that gap – not by sending more orders from the top, but by pushing planning, money, and decision-making down to the village itself. It is one of the clearest examples in contemporary governance of how decentralisation can transform a public service.

What the NRHM set out to achieve 🔗

The Prime Minister launched the NRHM on 12th April 2005 to provide accessible, affordable and quality health care to the rural population, with special focus on vulnerable groups like women and children. The mission recognised that rural India could not be served adequately by a centralised, top-down health bureaucracy. Primary health centres were understaffed, funds were tied to narrow programme lines, and communities had little say in how services were delivered.

To fix this, the NRHM was built around a core idea: architectural correction of the health system through decentralisation. According to the official NRHM framework, the mission provides effective health care to rural populations by enabling community ownership, strengthening public health systems, and promoting decentralisation. Eighteen states with weak public health indicators – including Uttar Pradesh, Bihar, Madhya Pradesh, Rajasthan, Odisha, Assam and the North Eastern states – received special focus under the scheme.

Why decentralisation was central to the design 🔗

Before 2005, rural health programmes ran largely as vertical, disease-specific missions. The NRHM merged these into a single framework and deliberately shifted responsibility downwards. One of the most noted strategies of the Mission is decentralisation of programmes for district-level management of health, with leadership given to Panchayati Raj Institutions at district and sub-district levels. Multiple disease society funds were funnelled into a unified District Health Mission, giving local managers the flexibility to plan for local priorities rather than simply execute national instructions.

The role of Panchayati Raj Institutions 🔗

The 73rd Constitutional Amendment had already given Panchayati Raj Institutions (PRIs) constitutional status in 1992, but their role in health remained weak. The NRHM made PRIs the backbone of rural health governance. As the NRHM guidelines outline, Panchayati Raj Institutions are responsible for developing the Village Health Plan with support from the ANM, ASHA, AWW and Self Help Groups, while Block Panchayat Samitis coordinate the work of Gram Panchayats and serve as the link to the District Health Mission.

This means a Gram Panchayat is no longer a passive spectator in rural health. It helps select the village-level Accredited Social Health Activist (ASHA), oversees planning, and monitors the functioning of sub-centres and primary health centres. At the district level, Zilla Parishads work alongside District Health Missions to manage public health services, while State Health Missions handle the broader architectural reforms.

Three tiers, one health system 🔗

The decentralisation model under NRHM roughly follows the three tiers of rural local government. The Gram Panchayat owns village-level planning and community mobilisation. The Panchayat Samiti at the block level coordinates primary health centres and supervises village plans. The Zilla Parishad at the district level integrates health planning with other sectors like water, sanitation, and women and child development. A study funded by the Indian Council of Medical Research in Karnataka notes that decentralisation through PRIs is meant to create greater accountability by enabling people’s participation, transparency, and grassroots-level service delivery – though the same study also cautions that the devolution is often incomplete on the ground.

Village Health, Sanitation and Nutrition Committees: the smallest but most important unit 🔗

If PRIs are the backbone, Village Health, Sanitation and Nutrition Committees (VHSNCs) are the nerve endings of the NRHM. Originally formed in 2007 as Village Health and Sanitation Committees, these bodies were renamed in 2011 to include nutrition within their mandate. The Ministry of Health and Family Welfare describes the VHSNC as one of the key elements of the NRHM, formed to take collective action on issues related to health and its social determinants at the village level.

A VHSNC is formed at the revenue village level and acts as a sub-committee of the Gram Panchayat. It typically has at least 15 members, with women accounting for half. Members include an elected panchayat representative (usually a woman panch from an SC/ST background as Chairperson), the ASHA as Member-Secretary, the Anganwadi Worker, the Auxiliary Nurse Midwife (ANM), a school teacher, and representatives from self-help groups, youth groups, and minority communities.

What a VHSNC actually does 🔗

The committee is expected to meet at least once a month. Its responsibilities fall into four broad areas:

Health awareness and community mobilisation: VHSNCs organise the monthly Village Health and Nutrition Day, support immunisation drives, promote behaviour change around hygiene, nutrition, and maternal care, and encourage families to use institutional delivery services.

Local planning and surveys: Committees prepare the Village Health Plan, which identifies local priorities – be it malnourished children needing referral, a chlorination plan for contaminated wells, or sanitation gaps during monsoon. Researchers studying VHSNCs in Jharkhand and Odisha describe them as participatory community health forums tasked with preparing village-level health and sanitation improvement plans based on local priorities.

Monitoring services and providers: VHSNCs track the functioning of ASHAs, sub-centres, drug availability, and the delivery of services under schemes like Janani Suraksha Yojana. They flag absenteeism, stock-outs, and service gaps to the block administration.

Managing the untied grant: Each VHSNC receives an annual untied fund of ₹10,000 from the National Health Mission to address local health priorities. The fund can be used for sanitation drives, emergency transport, nutrition support for destitute families, or simple village-level public health measures.

How VHSNCs build accountability 🔗

The real significance of a VHSNC lies in reversing the direction of accountability. In the older model, a village health worker answered to the block medical officer, who answered to the district administration. Under the NRHM, the ASHA and the ANM also answer to the community through the VHSNC. The Assam National Health Mission describes VHSNCs as community-led platforms for local self-governance, enabling villages to address health, nutrition, sanitation and related determinants through collective planning and action. Community-based monitoring and periodic public dialogues (Jan Samwad) allow villagers to publicly review service delivery and raise concerns.

Lessons from the ground: Karnataka and Assam 🔗

Karnataka: maturity through sustained facilitation 🔗

Karnataka has been one of the states where VHSNCs have shown the clearest shift from paper existence to real function. A longitudinal study of 13 VHSNCs around the Gumballi Primary Health Centre in Karnataka traced how these committees moved from being non-functional in 2012 to achieving basic functioning by 2015. The turning point was consistent sensitisation of members about their roles, careful enrolment of the right community representatives, and the creation of routines that made members accountable to each other for improving village health.

The Karnataka Health and Family Welfare Department’s VHSNC framework lays out detailed composition rules that give preference to women and SC/ST panchayat members as Chairpersons, requires a joint bank account operated by the President and ASHA, and specifies that the ₹10,000 untied fund must be used for community benefit – from sanitation and environmental protection to emergency care for destitute women. State-run training programmes for five lakh members between 2010 and 2012 helped push VHSNCs from being names on a register to functioning bodies.

Assam: scale, oversight, and digital monitoring 🔗

Assam shows what VHSNCs can look like when a state invests in infrastructure and monitoring at scale. According to the Assam NHM portal, the state runs 28,149 VHSNCs across 35 districts, with meetings scheduled on the 15th of every month in a public space, a mandatory two-thirds attendance rule, and the PRI president’s presence being compulsory. Block officials and Community Health Officers attend periodically for oversight, and findings are uploaded to the Swasthya Sewa Dapoon portal. A biannual Jan Samwad publicly shares progress and records, building transparency into the routine.

Assam has also linked its VHSNCs closely with other mission components – Mobile Medical Units, Boat Clinics for river islands in the Brahmaputra, Janani Suraksha Yojana, and tea-garden-specific schemes like Wage Compensation for pregnant women. The state describes VHSNCs as the platform through which identified village-level needs are fulfilled via the Village Health Plan.

Results and lingering challenges 🔗

The NRHM has delivered measurable gains: institutional deliveries have risen sharply, maternal and infant mortality have declined, and nearly nine lakh ASHAs now act as the first point of contact for rural health needs. Sub-centres, PHCs and CHCs have been upgraded to Indian Public Health Standards, and the Janani Suraksha Yojana has brought cash incentives and free delivery services to poor pregnant women.

Yet the record on decentralisation is mixed. A reflective study on VHSNC functioning notes that India’s nearly 550,000 VHSNCs are a key mechanism for community health governance, yet many have been poorly functional. Revised guidelines in 2013 attempted to fix this through institutional support packages, but integration with rigid and often unresponsive administrative structures remains a persistent challenge.

Common problems include irregular meetings, limited awareness among members about their roles, under-utilisation of the untied fund, weak supervision by block and district officials, and domination of committees by local elites. A cross-sectional study in Dehradun district found that only about half of VHSNC members were fully aware of how the committee should function, and many were unclear about fund utilisation. Studies in Himachal Pradesh’s Kangra district found that while all committee members knew about VHSNCs, community awareness was significantly lower, pointing to a gap in outreach.

What the evidence suggests 🔗

Several patterns emerge from state-level studies. Sustained capacity building – not one-off trainings – is what makes a difference. Aligning VHSNCs tightly with Gram Panchayats gives them political legitimacy. Equitable representation of women, SC/ST members, and minorities improves the quality of decisions. And ongoing facilitation by NGOs or state community mobilisers keeps committees active when routine bureaucratic supervision falters.

From NRHM to NHM: continuity of the decentralised idea 🔗

In 2013, the NRHM became a sub-mission of the broader National Health Mission (NHM), which also includes the National Urban Health Mission. The NHM continues the thrust on establishing a fully functional, community-owned, decentralised health delivery system with inter-sectoral convergence at all levels. VHSNCs, Rogi Kalyan Samitis (hospital management committees), and district and state health missions remain the scaffolding of this system.

The journey from NRHM to NHM is not just a rebranding. It reflects a maturing understanding that health is shaped by water, sanitation, nutrition, education, gender equality, and local governance – and that no centralised ministry can manage those determinants from afar. The village committee meeting on the 15th of every month, messy and imperfect as it often is, may be the most important unit of rural health administration.

What do you think? Do the Village Health, Sanitation and Nutrition Committees in your region feel like genuine community bodies, or are they mostly records on paper? If you were redesigning the untied grant system, would you increase the ₹10,000 annual fund, or would you first invest in training and monitoring before adding more money?

References

1. https://nhm.gov.in/index1.php?lang=1&level=1&lid=49&sublinkid=969
2. https://nihfw.ac.in/cms/national-rural-health-mission.php
3. https://nhm.gov.in/images/pdf/nrhm-in-state/factsheet-district-report/district-report/sonitpur.pdf
4. https://journals.sagepub.com/doi/10.1177/0019556120906587
5. https://nhm.gov.in/index1.php?lang=1&level=1&sublinkid=149&lid=225
6. https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-016-2699-4
7. https://nhm.assam.gov.in/schemes/village-health-sanitation-nutrition-committee-vhsnc
8. https://pmc.ncbi.nlm.nih.gov/articles/PMC9189612/
9. https://karunadu.karnataka.gov.in/hfw/nhm/Pages/commonitor_vhsnc.aspx
10. https://www.india.gov.in/information-village-health-sanitation-nutrition-committee-vhsnc-assam?page=1
11. https://pmc.ncbi.nlm.nih.gov/articles/PMC6195149/
12. https://pmc.ncbi.nlm.nih.gov/articles/PMC9480799/
13. https://pmc.ncbi.nlm.nih.gov/articles/PMC7652205/
14. https://en.wikipedia.org/wiki/National_Health_Mission