National Health Mission (NHM) and ASHA Workers
The National Health Mission (NHM) is the Indian government's flagship health sector programme aimed at providing accessible, affordable, and quality healthcare to rural and urban populations, particularly to marginalised communities. Launched in 2005 as the National Rural Health Mission (NRHM), it was expanded in 2013 to include the National Urban Health Mission (NUHM) and renamed NHM. ASHA (Accredited Social Health Activist) workers are the frontline community health workers who form the human backbone of the NHM's last-mile health delivery.
NHM addresses the structural weaknesses of India's public health system — inadequate infrastructure, shortage of healthcare professionals, and poor health outcomes in rural areas — through institutional strengthening, community engagement, and demand-side financing. The ASHA worker, one per 1,000 population (approximately 10.4 lakh ASHAs nationwide), acts as the interface between the community and the formal health system, facilitating institutional deliveries, immunisation, and disease surveillance. NHM has contributed to significant improvements in maternal mortality, infant mortality, and immunisation coverage, though urban health and quality of care remain persistent challenges.
📌 Revision Pointers
NRHM launched: 5 April 2005 under PM Manmohan Singh; restructured as NHM in 2013
Implementing Ministry: Ministry of Health and Family Welfare (MoHFW)
NHM has two sub-missions: NRHM (rural) and NUHM (urban)
ASHA: Accredited Social Health Activist; one per 1,000 population in rural areas; approximately 10.4 lakh ASHAs (2023)
ASHA eligibility: Woman, resident of village, at least Class 8 educated, preferably married/widowed/divorced
ASHA incentive-based (not salaried): Paid per task — e.g., Rs. 600 for institutional delivery facilitation, immunisation incentives
MMR progress: India's MMR declined from 254 (2004-06) to 97 (2018-20) — NHM a key driver
IMR progress: Infant Mortality Rate fell from 58 (2005) to 28 per 1,000 live births (2020)
JSY (Janani Suraksha Yojana): Conditional cash transfer under NHM for institutional deliveries
JSSK (Janani Shishu Suraksha Karyakram): Free entitlements for pregnant women and sick newborns
Ayushman Bharat Health and Wellness Centres (HWCs): Under NHM — 1.5 lakh Sub-Health Centres upgraded for comprehensive primary care
4.1 Historical Context
India's public health system was characterised by acute underfunding (0.9% of GDP on health vs. WHO-recommended 5%), workforce shortages (especially in rural areas), and weak infrastructure. The 10th Five Year Plan and the Task Force on Health (2003) highlighted critical gaps. NRHM was designed as a systemic reform programme — not just a disease programme — to strengthen health system architecture from the ground up.
4.2 NHM Architecture and Key Components
Institutional Strengthening:
Strengthening primary health centres (PHCs), community health centres (CHCs), and district hospitals
Operationalisation of 24/7 delivery services at PHCs and CHCs
Facility-based newborn care (FBNC) units at district hospitals
Human Resources for Health:
Appointment of contractual specialists, MBBS doctors, nurses, and ANMs (Auxiliary Nurse Midwives) under NHM
Incentive packages for doctors serving in rural/difficult areas
Community Processes:
ASHA workers (see below)
Village Health Sanitation and Nutrition Committees (VHSNCs) — local accountability structures
Mahila Arogya Samitis (MAS) in urban areas
Demand-Side Financing:
JSY: Cash transfer of Rs. 1,400 (rural) to mothers for institutional delivery
JSSK: Free drugs, diagnostics, diet, blood transfusion, and transport for pregnant women and sick newborns
Disease Control Programmes:
National Vector Borne Disease Control Programme (NVBDCP): Malaria, dengue, kala-azar
Revised National TB Control Programme (RNTCP): Now rebranded as National TB Elimination Programme (NTEP)
National AIDS Control Organisation (NACO) integrated under NHM
4.3 ASHA: System Design and Role
ASHA is a community health activist, selected by and accountable to the Gram Panchayat. Her primary role is demand generation and facilitation:
Motivate women to seek institutional delivery at government facilities
Accompany pregnant women to health facilities for ANC and delivery
Mobilise children for immunisation under the Universal Immunisation Programme (UIP)
Provide basic curative care: ORS for diarrhoea, iron-folic acid tablets, contraceptives
First contact for disease surveillance: report fever cases for malaria/dengue testing
Maintain village-level health registers
ASHA carries a 'drug kit' with essential medicines. She works as a social mobiliser rather than a healthcare provider, serving as a bridge between community and PHC/ANM.
4.4 Challenges
Incentive vs. Salary: ASHA workers are incentive-based volunteers — not employees. This creates income insecurity; demands for regularisation have grown into a major labour rights issue (ASHA strikes, 2023)
Workload Burden: ASHAs are increasingly burdened with administrative tasks, data entry, and non-health duties
Low Incentives: Many ASHA incentives remain unpaid or delayed; effective monthly income often below minimum wage
Urban Health Gap: NHM's urban component (NUHM) significantly weaker than NRHM; urban slum health remains neglected
Infrastructure Deficit: Many PHCs lack doctors, medicines, and equipment despite NHM investment
Quality of Care: Focus on quantity indicators (deliveries, immunisation) over quality of care (respectful maternity, infection control)
AYUSH Integration: Integration of AYUSH practitioners as stop-gap for specialist shortage raises concerns about quality
Important Concepts
Health and Wellness Centres (HWCs):
Sub-Health Centres upgraded under Ayushman Bharat to provide comprehensive primary healthcare — NCD management, mental health, oral health — beyond maternal-child health. 1.5 lakh HWCs targeted by 2022.
MMR (Maternal Mortality Ratio):
Deaths per 1,00,000 live births. India's MMR decline from 254 to 97 is a public health achievement; NHM's JSY and institutional delivery push is a key driver. Target: SDG goal of less than 70 by 2030.
IMR (Infant Mortality Rate):
Deaths per 1,000 live births in the first year. Declined from 58 (2005) to 28 (2020) — but inter-state disparities persist (UP, MP, Rajasthan still high).
Village Health Sanitation and Nutrition Committee (VHSNC):
Gram Panchayat-level committee that oversees health activities, manages an untied fund of Rs. 10,000 annually, and ensures community accountability.
Current Relevance
ASHA workers' demand for regularisation and minimum wage: Major policy debate in 2022-23; WHO Director General's Special Recognition Award given to ASHA workers (2022)
Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (PM-JAY): Hospital insurance component complementary to NHM's primary care push
National Health Policy 2017: Targets raising public health expenditure to 2.5% of GDP; NHM is the primary vehicle
COVID-19 pandemic exposed the limitations of primary health infrastructure — NHM's HWCs and ASHAs were frontline responders
National TB Elimination Programme (NTEP) 2025 target: India's ambition to eliminate TB by 2025 (vs. global target 2030) relies on ASHA-led case detection and DOTS compliance
National Digital Health Mission (ABDM): Integrating NHM health records with Ayushman Bharat Digital Mission — ASHA workers to use digital tools for health data
💭 Conclusion
The National Health Mission represents India's most sustained attempt at building a universal public health system from the grassroots upward. The ASHA worker is its most innovative feature — a community embedded health facilitator who bridges the demand-supply gap in rural healthcare. Two decades of NHM have produced measurable gains in MMR, IMR, and immunisation. However, the mission's full potential is constrained by persistent underfunding, the precarisation of ASHA labour, urban health neglect, and quality deficits. A rededication to universal health coverage — treating health as a right and not a market commodity — demands that NHM be backed by adequate financing, regularised frontline workers, and strengthened district health systems.