Strengthening Rural Healthcare: India’s Mission for an Inclusive Health System

India is home to nearly 65% of its population in rural areas, yet for decades, a simple fever or a difficult pregnancy could mean travelling hours to the nearest doctor. The National Rural Health Mission (NRHM), launched on 12 April 2005 by Prime Minister Manmohan Singh, was the government’s most ambitious attempt to fix this. It set out to rebuild rural healthcare from the ground up – through physical infrastructure, trained human resources, and community-level health workers who would bring the system directly to the people.

What the NRHM set out to do 🔗

The NRHM was launched on 12 April 2005 throughout India with a commitment to carry out the necessary architectural corrections in the basic healthcare delivery system. It was not a single scheme but a comprehensive framework that restructured how healthcare was planned, financed, and delivered in rural India. The thrust of the mission was on establishing a fully functional, community-owned, decentralised health delivery system with inter-sectoral convergence at all levels, to ensure simultaneous action on a wide range of determinants of health such as water, sanitation, education, nutrition, social and gender equality.

The NRHM primarily targeted rural residents, especially vulnerable groups such as women, children, and the elderly. Its core objectives included reducing maternal and infant mortality rates, controlling communicable and non-communicable diseases, stabilising population growth through family planning, and ensuring universal access to quality healthcare by expanding and upgrading facilities across the country.

The Mission is an articulation of the government’s commitment to increase outlays for health from 0.9% to 2-3% of GDP over the next five years and to undertake systemic correction of the health system to effectively utilise such increased outlays for sustainable outcomes. In 2013, the NRHM was subsumed under the broader National Health Mission (NHM), which also incorporated the National Urban Health Mission (NUHM).

The three-tier infrastructure backbone 🔗

One of the NRHM’s defining contributions was its systematic approach to physical healthcare infrastructure. It established a clear, three-tier system – sub-centres, Primary Health Centres, and Community Health Centres – each with defined population norms and service standards.

Sub-centres: the first point of contact 🔗

Sub-centres are the most peripheral level of the public health system – the first formal touchpoint between the community and government healthcare. As per established norms, one sub-centre is set up per 5,000 population in general areas and one per 3,000 population in difficult, tribal, and hilly areas. These centres are staffed primarily by Auxiliary Nurse Midwives (ANMs) and are responsible for maternal and child health services, immunisation, basic medicines, and health education at the village level. Under the NRHM, each sub-centre receives untied funds of ₹10,000 per annum, deposited in a joint account of the ANM and the woman Sarpanch, for local health action.

Primary Health Centres (PHCs): the backbone of rural care 🔗

PHCs occupy the middle tier of the rural health system and serve as the first point of contact with a qualified medical doctor. A PHC covers a population of 20,000-30,000 depending on geographical location, and occupies a place between the sub-centre at the most peripheral level and the Community Health Centre at block level. Under the NRHM, significant attention was paid to making PHCs functional around the clock. The mission mandated provision of 24-hour service in 50% of PHCs by addressing the shortage of doctors, especially in high-focus states, through mainstreaming AYUSH practitioners. As on 30 June 2024, there are 12,453 PHCs operational as 24×7 facilities across the country. Each PHC also receives untied funds to allow it to respond to local needs without bureaucratic delays.

Community Health Centres (CHCs): specialist care at the block level 🔗

CHCs function as referral hubs and secondary care centres, positioned at the block or taluka level. Each CHC caters to approximately 80,000 population in tribal or hilly areas and 1,20,000 in plain areas, and is a 30-bedded hospital providing specialist care in medicine, obstetrics and gynaecology, surgery, paediatrics, dental care, and AYUSH. The NRHM envisaged upgrading all CHCs to meet the Indian Public Health Standards (IPHS) – a set of benchmarks covering infrastructure, human resources, drugs, diagnostics, and service quality. All CHCs at block headquarters level are to be developed as Block Public Health Units (BPHUs), expected to have four functional areas: clinical service delivery, public health functions, a Block Public Health Laboratory, and an HMIS unit. Additionally, selected CHCs were to be upgraded to First Referral Units (FRUs) capable of handling emergency obstetric care and surgeries.

ASHA: the human link the system was missing 🔗

Infrastructure alone cannot bridge the trust gap between a marginalised rural community and a formal healthcare system. That is precisely why the introduction of the Accredited Social Health Activist (ASHA) was arguably the most transformative innovation of the NRHM.

One of the key components of the National Rural Health Mission is to provide every village in the country with a trained female community health activist – the ASHA – who is selected from the village itself and accountable to it, trained to work as an interface between the community and the public health system. The word ASHA means “hope” in Hindi, and for millions of rural women, that is exactly what she represents.

Who is an ASHA and how is she selected? 🔗

ASHAs must primarily be female residents of the village they are selected to serve, who are likely to remain there for the foreseeable future. Married, widowed, or divorced women are preferred. They must have qualified up to the tenth grade, though this criterion may be relaxed if no suitable literate candidate is available, and they must preferably be between the ages of 25 and 45. Crucially, ASHAs are selected by and accountable to the Gram Panchayat, which gives them deep community legitimacy. As of June 2022, there are more than 10.52 lakh active ASHAs working across all states and union territories (excluding Goa), making this the largest community health worker programme in the world.

What does an ASHA actually do? 🔗

The scope of an ASHA’s work is wide. ASHA provides information to the community on determinants of health such as nutrition, basic sanitation, hygiene, healthy living, and existing health services. She counsels women on birth preparedness, safe delivery, breastfeeding, complementary feeding, immunisation, contraception, and prevention of common infections including RTIs and STIs.

Her role in maternal health is especially significant. ASHA workers encourage and facilitate institutional deliveries, help pregnant women understand the benefits of delivering in healthcare facilities rather than at home, and often accompany women to hospitals during labour. This support has directly contributed to the decline in maternal and infant mortality rates in rural areas. Under the Janani Suraksha Yojana (JSY), a safe motherhood scheme operating under NRHM, ASHA receives ₹300 for antenatal care and ₹300 for facilitating an institutional delivery in rural areas, while the mother also receives cash assistance, integrating financial incentives with delivery and post-delivery care.

On immunisation, ASHAs are expected to take steps to create awareness and mobilise the community towards increased utilisation and accountability of existing health services, empowered with knowledge and a drug-kit to deliver first-contact healthcare. They maintain records of children due for vaccination, remind families, and counter vaccine hesitancy – a role that proved critical during India’s polio eradication campaign and, more recently, during the COVID-19 response.

ASHA’s challenges and the road ahead 🔗

Despite their enormous contribution, ASHA workers face structural challenges. Heavy workload with limited support, delayed payments, lack of social security benefits, gender and caste discrimination, and inadequate access to transport and medical supplies continue to hamper their effectiveness. Research from Harvard T.H. Chan School of Public Health has noted that inadequate supervision, limited continuing education, and concerns about the financial incentive structure can reduce motivation among ASHAs. Formalising their employment status and ensuring timely, fair compensation remains an ongoing policy priority.

Decentralised planning and community ownership 🔗

A critical but often overlooked feature of the NRHM was its insistence on decentralised governance. Rather than imposing a top-down model, the mission required each village, block, and district to develop its own health plan. Block-level monitoring and planning committees – comprising the Block Pramukh, the Block Medical Officer, the Block Development Officer, and NGO/CBO representatives – are responsible for finalising block health plans, which are then consolidated into the district health plan.

Village Health, Sanitation, and Nutrition Committees (VHSNCs) were formed at the gram panchayat level, ensuring that ordinary citizens – especially women – had a say in how healthcare was planned and monitored in their locality. This community-based monitoring model placed accountability not just with government officials but with the people the system was meant to serve.

Key programmes under NRHM targeting mortality and disease 🔗

The NRHM was not just an infrastructure project. It anchored several targeted programmes to address specific health burdens in rural India.

Janani Suraksha Yojana (JSY) tackled institutional delivery rates, which were critically low in states like Bihar, Uttar Pradesh, and Rajasthan. By combining cash transfers with ASHA-facilitated escorts and referral services, the scheme incentivised pregnant women to deliver in government facilities, directly reducing neonatal and maternal mortality.

Immunisation strengthening under NRHM included the induction of auto-disabled syringes, alternate vaccine delivery arrangements at immunisation sites, and the systematic involvement of ASHAs and Anganwadi Workers (AWWs) to reach every child. The goal was universal immunisation coverage, particularly for conditions like polio, measles, and tuberculosis.

National Disease Control Programmes for tuberculosis, malaria, kala-azar, and other communicable diseases were integrated under NRHM, enabling convergence of resources rather than parallel, vertical delivery systems. The NRHM provided generic drugs – both AYUSH and allopathic – at village, sub-centre, PHC, and CHC levels , reducing out-of-pocket expenses for rural families.

The mission also integrated AYUSH (Ayurveda, Yoga, Unani, Siddha, and Homeopathy) into mainstream facilities. NHM supports the co-location of AYUSH services in health facilities such as PHCs, CHCs, and district hospitals , recognising that local health traditions are often more trusted by rural communities than purely allopathic approaches.

Impact and continuity under NHM 🔗

The NRHM achieved significant milestones in reducing maternal and infant mortality rates, improving child health indicators, and curbing the spread of infectious diseases in rural areas. It strengthened healthcare infrastructure, expanded the network of healthcare facilities, and enhanced the availability of skilled healthcare professionals in rural communities. In 2013, NRHM was expanded into the National Health Mission, extending similar principles of decentralisation, community participation, and infrastructure investment to urban areas as well.

The Ministry of Health and Family Welfare continues to publish annual Rural Health Statistics, tracking the status of sub-centres, PHCs, CHCs, and human resources across every state – a transparency mechanism that did not exist at scale before the NRHM era. Under Ayushman Bharat, sub-health centres and PHCs are now being upgraded to Health and Wellness Centres (HWCs), extending comprehensive primary healthcare to include non-communicable diseases, mental health, and palliative care – building directly on the NRHM’s foundational architecture.

What do you think? Given that ASHA workers carry some of the heaviest responsibilities in India’s rural health system but remain classified as voluntary workers rather than regular employees, should the government reconsider their formal employment status? And with persistent shortages of specialist doctors at CHCs – over 60% vacancy rates in some states – how effectively can the three-tier healthcare model deliver on its promise without addressing this human resources gap?

References

1. https://nhm.gov.in/index1.php?lang=1&level=1&sublinkid=150&lid=226
2. https://en.wikipedia.org/wiki/National_Health_Mission
3. https://nhm.gov.in/images/pdf/guidelines/iphs/iphs-revised-guidlines-2022/02-CHC_IPHS_Guidelines-2022.pdf
4. https://hsph.harvard.edu/maternal-health-task-force/news/the-role-of-ashas-in-improving-maternal-and-newborn-health-a-closer-look-at-indias-community-health-worker-program/
5. https://mohfw.gov.in