What is the National Health Mission?

The NATIONAL HEALTH MISSION (NHM) is India's overarching public health programme launched in 2013 as the umbrella merging two flagship sub-missions: (1) the NATIONAL RURAL HEALTH MISSION (NRHM), launched 12 APRIL 2005 by PM Manmohan Singh; and (2) the NATIONAL URBAN HEALTH MISSION (NUHM), launched 2013. NHM is implemented by the Ministry of Health & Family Welfare with state-level Programme Management Units. It is the largest Centrally Sponsored Scheme in health and is governed by 60:40 (general states) or 90:10 (NE/Himalayan) cost sharing. KEY THRUST AREAS: strengthening rural and urban public health systems; reducing maternal and child mortality; controlling communicable and non-communicable diseases; ensuring availability of skilled human resources; promoting institutional deliveries; community participation through Village Health Sanitation and Nutrition Committees (VHSNCs) and Mahila Arogya Samitis (MAS); and integrating AYUSH with mainstream healthcare. NHM operates the THREE-TIER RURAL HEALTH INFRASTRUCTURE — Sub-Centre (SC), Primary Health Centre (PHC), Community Health Centre (CHC) — to be later upgraded under Ayushman Bharat into Health & Wellness Centres (Ayushman Arogya Mandir). NHM is the platform on which Ayushman Bharat, COVID response, and most national health programmes (RNTCP/NTEP for TB, NACO for HIV, NPCDCS for NCDs, IDSP surveillance) are anchored. The mission has been extended multiple times; latest extension covers FY 2021-22 to FY 2025-26 with an outlay of ~₹37,000 crore annually.

What is ASHA and how does the programme work?

ASHA — ACCREDITED SOCIAL HEALTH ACTIVIST — is a community health worker scheme launched in 2005 under NRHM. Each ASHA is a TRAINED FEMALE COMMUNITY HEALTH VOLUNTEER serving an average village of 1,000 population. As of 2024, there are ~10.4 LAKH ASHAs across India — the world's largest community health worker force. SELECTION: locally selected by Gram Sabha; preferably a married/widowed/divorced woman aged 25-45 with formal education up to Class VIII (relaxed for tribal/desert areas); resident of the village. ROLES: (1) FIRST POINT OF CONTACT for any health-related need in the village; (2) Promote IMMUNISATION, antenatal/postnatal care, institutional deliveries; (3) Counsel on family planning, sanitation, nutrition; (4) Provide BASIC CURATIVE CARE (ORS, paracetamol, iron-folate, anti-malarials); (5) Mobilise community for VHSNCs, public health camps; (6) Carry an ASHA KIT with essential medicines; (7) Maintain a register of births, deaths, illnesses. INCENTIVES: ASHAs are PERFORMANCE-LINKED VOLUNTEERS, not full-time employees. They earn task-based incentives — e.g., ₹600 per institutional delivery facilitated under JSY, ₹150 per fully immunised child, incentives for TB DOTS, family planning, sterilisation referral. Average ASHA earning ~₹6,000-12,000 per month; states like Kerala pay higher fixed honorarium. RECOGNITION: ASHAs received WHO GLOBAL HEALTH LEADERS AWARD 2022 from Director-General Dr Tedros, alongside frontline workers of other nations. JANUARY 2024: ASHAs and Anganwadi workers brought into PMJAY (Ayushman Bharat) coverage. PROTESTS: ASHAs have repeatedly demanded regularisation, minimum wages, social security — they remain technically 'volunteers' under Indian labour law. RECENT POLICY DIRECTION (2024-26): increase fixed honorarium, formalise some posts, integrate with Ayushman Arogya Mandirs.

What is the Indian three-tier public health system?

India's RURAL PUBLIC HEALTH SYSTEM is organised as a three-tier referral structure based on population-based norms (revised under Indian Public Health Standards / IPHS): TIER 1 — SUB-CENTRE (SC): most peripheral; one SC per 5,000 population in plains / 3,000 in hill/tribal areas; staffed by 1 Auxiliary Nurse Midwife (ANM) and 1 Male Health Worker; provides immunisation, antenatal care, family planning. ~1.6 lakh SCs nationwide; most being upgraded to Ayushman Arogya Mandirs. TIER 2 — PRIMARY HEALTH CENTRE (PHC): one PHC per 30,000 population (20,000 in hills); staffed by 1 Medical Officer (MBBS), nurses, pharmacist; OPD, basic surgery, deliveries, referral. ~31,000 PHCs nationwide. TIER 3 — COMMUNITY HEALTH CENTRE (CHC): one CHC per 1.2 lakh population (80,000 hills); 30 beds; FOUR SPECIALISTS (surgeon, physician, obstetrician-gynaecologist, paediatrician); acts as First Referral Unit (FRU); ~5,500 CHCs. ABOVE CHC: SUB-DISTRICT HOSPITAL, DISTRICT HOSPITAL, MEDICAL COLLEGE (tertiary). URBAN parallel: NUHM operates Urban PHCs (U-PHCs) for ~50,000 population; targets slum dwellers. INDIAN PUBLIC HEALTH STANDARDS (IPHS) were first issued by MOHFW in 2007, revised 2012 and 2022. They prescribe staffing, infrastructure, equipment, drugs, and services at each level. CHALLENGES: (1) ~10% PHC vacancies; ~25% nurse vacancies; ~70% specialist vacancies at CHCs (Rural Health Statistics 2022); (2) ~25% rural population still has no PHC within 3 km; (3) Quality varies dramatically by state — Tamil Nadu, Kerala, Maharashtra strong; UP, Bihar, MP, Jharkhand weak; (4) Private sector dominates ~70% of outpatient and ~58% of inpatient care nationally; in many states private share is 80%+.

What is India's public health spending and how does NHM finance work?

India's PUBLIC HEALTH EXPENDITURE is among the lowest in the world relative to GDP. KEY NUMBERS: (1) Total Health Expenditure: ~3.3% of GDP (NHA 2019-20); (2) Government Health Expenditure: ~2.1% of GDP combined (Centre + States) — the National Health Policy 2017 target is 2.5% by 2025; (3) Out-of-Pocket Expenditure: 47% of total (down from 62% in 2014); (4) Per-capita government health spend: ~₹3,170 (~$40); compare to OECD ~$5,000+; (5) Centre's share of public health spending ~33%, states' share ~67% — health is a state subject; (6) Union Budget FY24-25: Health Ministry ~₹91,000 crore; NHM ~₹37,000 crore; PMJAY ~₹7,300 crore; AIIMS expansion + medical colleges ~₹14,000 crore. NHM FINANCING: (1) Centrally Sponsored Scheme; (2) Cost sharing 60:40 (general); 90:10 (NE + Himalayan); 100% (UTs without legislature); (3) State PIPs (Programme Implementation Plans) approved annually by NHM Mission Steering Group; (4) Funds flow via Treasury route post the move away from Society mode in 2014. KEY POLICY CONSIDERATIONS: (1) Health is Entry 6 of State List, but ~50% of total public health spending comes from Centre-driven schemes; (2) NITI Aayog and 15th Finance Commission recommended raising public health spend to 2.5% of GDP by 2025 — not yet met; (3) Post-COVID, NHM included PM Ayushman Bharat Health Infrastructure Mission (PM-ABHIM, 2021) — ₹64,180 crore over 5 years for surveillance and critical care; (4) State performance varies — Kerala, Tamil Nadu spend ~6-7% of state budget on health; UP, Bihar 4-5%. FUTURE: 15th FC + PM-ABHIM + Ayushman Bharat expansion together aim to push public health expenditure toward 2.5% target.

National Health Mission — NRHM, NUHM, ASHA, Janani Suraksha | UPSC Notes

Q: What is Janani Suraksha Yojana and Janani Shishu Suraksha Karyakram?

JANANI SURAKSHA YOJANA (JSY) is a CASH TRANSFER scheme launched in 2005 under NRHM to promote INSTITUTIONAL DELIVERY among poor pregnant women. STRUCTURE: (1) 100% Centrally sponsored; (2) Universal in 10 low-performing states (LPS) — UP, Bihar, MP, Rajasthan, Odisha, Jharkhand, Chhattisgarh, Assam, Uttarakhand, J&K; in remaining states, BPL/SC/ST women eligible; (3) RURAL benefit ~₹1,400 (LPS) / ₹700 (other); URBAN benefit ~₹1,000 (LPS) / ₹600 (other); (4) ASHA receives ~₹600 (rural LPS) / ₹400 (rural other) per delivery facilitated. IMPACT: Institutional deliveries rose from ~38% (NFHS-3, 2005-06) to ~89% (NFHS-5, 2019-21). Maternal Mortality Ratio (MMR) fell from 254 per 100,000 live births (2004-06) to 97 per 100,000 (2018-20, SRS) — meeting MDG-5 and approaching SDG-3 target (70 by 2030). JANANI SHISHU SURAKSHA KARYAKRAM (JSSK) launched 2011 complements JSY by entitling pregnant women to FREE: (1) delivery (including caesarean); (2) drugs and consumables; (3) diagnostics; (4) diet during stay; (5) blood transfusion; (6) transport (home to facility and back). Sick newborns (up to 1 year) get free treatment. JSY + JSSK + the Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA, monthly antenatal check-ups on 9th of every month) form the maternal health package. CHALLENGES: (1) Skilled birth attendants shortage; (2) Disparity — Kerala MMR 19, Assam 195; (3) Quality of care at institutions variable; (4) Stillbirth and neonatal deaths not adequately addressed.

Why this matters now

If Ayushman Bharat is India's health insurance system, the National Health Mission is its health delivery system. The two are inseparable — every PMJAY beneficiary uses an NHM-strengthened district hospital; every Ayushman Arogya Mandir is a converted NHM Sub-Centre or PHC; every COVID vaccination was given by an NHM-trained nurse, ANM, or ASHA. NHM is also the constitutional answer to a hard federal question: how does the Union government deliver public health when health is a state subject? The answer has been a Centrally Sponsored Scheme architecture with cost sharing, programme implementation plans (PIPs), and India Public Health Standards. UPSC examines NHM under GS-2 (government schemes), GS-2 (health) and increasingly GS-3 (post-COVID infrastructure, surveillance, antimicrobial resistance).

10.4 L

ASHA workers

MMR per 1L (2018-20)

89%

Institutional deliveries

~₹37K cr

NHM annual budget

NRHM 2005 — origins and design

Launched on 12 April 2005 by PM Manmohan Singh, the National Rural Health Mission was a response to a stark crisis: India's rural health infrastructure had collapsed under decades of neglect, maternal and infant mortality were among the worst in the developing world, and ~70% of healthcare expenditure was out-of-pocket. The mission was originally designed for the 18 high-focus states (states with weak health indicators — UP, Bihar, MP, Rajasthan, Odisha, Jharkhand, Chhattisgarh, the 8 NE states, J&K, Himachal, Uttarakhand) but applied across India.

Core design principles

Decentralised planning — district-level Programme Implementation Plans (DHAP) rolled up to state PIPs;
Community participation — Village Health Sanitation and Nutrition Committees (VHSNCs) under Panchayats; Rogi Kalyan Samitis (RKS) for facility management;
Flexible financing — untied grants to Sub-Centres, PHCs, CHCs for local needs;
Skilled human resources at community level — the ASHA programme;
Convergence — with AYUSH, water/sanitation (now Jal Jeevan Mission), nutrition (POSHAN Abhiyaan);
Indian Public Health Standards (IPHS) — for the first time, codified what a Sub-Centre, PHC, CHC must have.

National Health Mission (2013) — the umbrella

In 2013, the UPA government launched the National Urban Health Mission (NUHM) to extend NRHM's logic to urban slums. NRHM + NUHM together became the National Health Mission, with two sub-missions sharing a common Mission Steering Group and financing architecture. The current NHM tenure runs FY 2021-22 to FY 2025-26 with the central allocation around ₹37,000 crore per year.

Component	Detail
Cost sharing	60:40 general / 90:10 NE+Himalayan / 100% UTs w/o legislature
Implementing body	State Health Society + State Programme Management Unit
Planning	Annual State PIP approved by Mission Steering Group, MOHFW
Sub-missions	NRHM (rural), NUHM (urban)
Programmes integrated	RNTCP/NTEP (TB), NACO (HIV), NPCDCS (NCDs), IDSP, NMHP (mental health)

ASHA — the world's largest community health worker programme

Accredited Social Health Activist. Launched in 2005 under NRHM. ~10.4 lakh ASHAs as of 2024 — the world's largest community health worker force.

Who is an ASHA

A trained female community health volunteer for every village of ~1,000 population (smaller in tribal/hilly areas). Locally selected by the Gram Sabha; preferably married/widowed/divorced, aged 25-45, Class VIII pass (relaxed for tribal areas), resident of the village.

Roles

First point of contact for health needs;
Promote immunisation, antenatal/postnatal care, institutional deliveries;
Counsel on family planning, sanitation, nutrition;
Provide basic curative care — ORS, paracetamol, iron-folate, anti-malarials (ASHA kit);
Mobilise community for VHSNCs and health camps;
Maintain village health register.

Incentives — not salary

ASHAs are performance-linked volunteers, not full-time employees. Earnings come task-by-task — ~₹600 per institutional delivery facilitated under JSY (rural LPS), ₹150 per fully-immunised child, payments for TB DOTS, family planning referrals. Average ASHA earning ₹6,000-12,000 per month; Kerala pays higher fixed honorarium. Most ASHAs perform paid work effectively full-time but lack labour-law recognition.

Recognition and policy direction

ASHAs received the WHO Global Health Leaders Award 2022 from Director-General Dr Tedros, alongside frontline workers of other nations. In January 2024 ASHAs and Anganwadi workers were brought into Ayushman Bharat PMJAY. ASHAs have campaigned for regularisation, minimum wages, and social security; some states have raised fixed honorarium. Recent policy direction (2024-26) integrates ASHAs more closely with Ayushman Arogya Mandirs.

Janani Suraksha Yojana and Janani Shishu Suraksha Karyakram

JSY (2005)

A cash transfer scheme to promote institutional delivery among poor pregnant women. 100% centrally sponsored. Universal in 10 low-performing states (LPS) — UP, Bihar, MP, Rajasthan, Odisha, Jharkhand, Chhattisgarh, Assam, Uttarakhand, J&K; in other states, BPL/SC/ST women eligible.

Benefit	LPS (rural)	LPS (urban)	Other (rural)	Other (urban)
Mother (cash)	₹1,400	₹1,000	₹700	₹600
ASHA incentive	₹600	₹400	₹400	₹200

JSSK (2011)

Janani Shishu Suraksha Karyakram complements JSY by making delivery and sick-newborn care completely free at government facilities:

Free delivery (including caesarean);
Free drugs and consumables;
Free diagnostics;
Free diet during stay;
Free blood transfusion;
Free transport (home → facility → home);
Sick newborns up to 1 year — free treatment.

Impact

Institutional deliveries rose from 38% (NFHS-3, 2005-06) to 89% (NFHS-5, 2019-21). Maternal Mortality Ratio fell from 254 per 100,000 live births (2004-06) to 97 per 100,000 (2018-20, SRS) — meeting MDG-5 and approaching the SDG-3 target (70 by 2030). India ranks among the largest contributors to global MMR decline this century.

Maternal health is rounded out by PMSMA (Pradhan Mantri Surakshit Matritva Abhiyan), started 2016 — every 9th of the month, government doctors provide free antenatal check-ups; SUMAN (2019) — Surakshit Matritva Aashwasan — assured free quality care.

The three-tier rural public health system

Tier	Population norm	Staffing	~Number
Sub-Centre (SC)	5,000 (3,000 hill/tribal)	1 ANM + 1 Male Health Worker	~1.6 lakh
Primary Health Centre (PHC)	30,000 (20,000 hill)	1 MBBS Medical Officer + nurses + pharmacist	~31,000
Community Health Centre (CHC)	1.2 lakh (80,000 hill)	4 specialists + 30 beds; First Referral Unit	~5,500
Sub-District / District Hospital	Block / district	Multi-specialty	~770 districts

The four specialists at every CHC should be a Surgeon, Physician, Obstetrician-Gynaecologist, and Paediatrician. Reality: ~70% specialist vacancy at CHCs nationally per Rural Health Statistics 2022. Above CHC: Sub-District Hospital → District Hospital → Medical College (tertiary). Most Sub-Centres are being upgraded to Ayushman Arogya Mandirs under the AB-HWC pillar.

Indian Public Health Standards

First issued by MOHFW in 2007, revised in 2012 and 2022. IPHS codifies — for each level of facility — the required staffing, infrastructure, equipment, drugs, services, and quality indicators. It is the first time India had standardised norms for public health facilities. The 2022 revision aligned IPHS with Ayushman Arogya Mandir service packages, IT-enabled HMIS, NCD screening, and digital health integration.

NUHM — Urban Health Mission

Launched 2013 to extend NRHM principles to urban areas, with special focus on slum dwellers and the urban poor. Key components: Urban-PHCs (one per 50,000 population), Urban-CHCs (one per 2.5-5 lakh), Mahila Arogya Samitis (urban analogue of VHSNCs, 50-100 households each), and outreach via ANMs and ASHAs in slums. NUHM has been weaker than NRHM in execution — urban political economy, fragmented municipal administration, and a stronger private sector all dilute the public health footprint in cities.

India's public health spending

Indicator	Latest figure	Comparator
Total Health Expenditure / GDP	~3.3% (NHA 2019-20)	OECD ~9%
Government Health Expenditure / GDP	~2.1%	NHP 2017 target 2.5% by 2025
Out-of-Pocket Expenditure	~47% of THE	WHO recommends <15%
Per-capita gov't health spend	~₹3,170 (~$40)	OECD ~$5,000+
Centre's share of public health	~33%	States ~67%
Health Ministry budget FY25	~₹91,000 crore	NHM ~₹37,000 cr; PMJAY ~₹7,300 cr

State performance varies sharply — Kerala and Tamil Nadu spend ~6-7% of state budget on health; Bihar and UP closer to 4-5%. The 15th Finance Commission, NITI Aayog, and several policy committees have all called for raising public health expenditure to 2.5% of GDP by 2025 — the target has been formally repeated and not yet met.

PM-ABHIM (2021) — post-COVID health infrastructure

The Pradhan Mantri Ayushman Bharat Health Infrastructure Mission, announced October 2021, is the largest pan-India scheme for public health infrastructure ever launched. Outlay ₹64,180 crore over 5 years. Components:

Critical care hospital blocks in 600+ districts;
Strengthening district public health labs;
National Centre for Disease Control (NCDC) expansion + 5 regional NCDCs;
Integrated Health Information Platform (IHIP);
17,788 building-level Block Public Health Units;
BSL-III labs in every state; Bio-Safety Level 4 lab at NCDC.

PM-ABHIM is essentially the post-COVID lesson translated into infrastructure: surveillance, critical care, and digital integration at the district and block level.

"The success of India's health system in 2047 will depend less on insurance schemes and more on whether we finally build a public health system worthy of the name. NHM is the foundation; Ayushman Bharat the apex; PM-ABHIM the connecting infrastructure." — paraphrasing 15th Finance Commission report on health sector, 2020

UPSC PYQs and likely future questions

UPSC angle

Public health and welfare schemes are recurring GS-2 themes. Strong answers cite specific scheme components, name flagship sub-programmes (ASHA, JSY, IPHS, PM-ABHIM), quote outcome numbers (MMR, IMR, institutional delivery), and discuss federal/financial dimensions.

2017 GS-2: "The Public Health System in India has limitations in providing universal health coverage. Do you think that the private health sector could help in bridging the gap? What other viable alternatives would you suggest?"
2018 GS-2: "Appropriate local community-level health care intervention is a prerequisite to achieve Health for All in India. Explain."
2022 GS-2: "'Besides being a moral imperative of a Welfare State, primary health structure is a necessary precondition for sustainable development.' Analyse."
Likely 2026: "Examine the role of ASHA workers in India's primary health architecture. What reforms are needed to formalise this workforce?"
Likely 2026: "Discuss the post-COVID transformation of India's public health system through PM-ABHIM and the Ayushman Bharat Digital Mission."

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Health & Welfare cluster — 2/4

Two more deep-dives upcoming: Mental Health Policy (NMHP, MHCA 2017); and Nutrition (POSHAN Abhiyaan + NFSA). Read these together with Ayushman Bharat for full UPSC GS-2 coverage of health and welfare.

All deep-dives →