National Rural Health Mission & NHM

The National Rural Health Mission (NRHM) is independent India's most ambitious public-health reform, launched on 12 April 2005 to provide accessible, affordable, accountable, effective and reliable healthcare to the rural population, especially vulnerable groups. In 2013 it was subsumed (along with the new urban arm) under the umbrella National Health Mission (NHM). This topic is a perennial Community Medicine favourite — ASHA, IPHS, JSSK, RKS and the architecture of decentralised health planning are repeatedly tested.

Orientation & timeline

NRHM was the government's response to a poorly performing rural health system: crumbling sub-centres, absentee staff, fragmented vertical programmes and abysmal health indicators in the Empowered Action Group (EAG) states. The mission adopted a "sector-wide" approach — integrating all disease-control and family-welfare programmes, decentralising funds and decisions to the community, and creating a village-level health activist (ASHA).

Year	Milestone
2005 (12 Apr)	NRHM launched; initial mission period 2005–2012
2005	ASHA scheme & Janani Suraksha Yojana (JSY) introduced
2011	Janani Shishu Suraksha Karyakram (JSSK) launched
2013 (1 May)	NHM created = NRHM + NUHM (National Urban Health Mission)
2014	Home-Based Newborn Care (HBNC) scaled nationally
2018	Ayushman Bharat – HWCs build on NHM sub-centre network

High-yield: NRHM launched 12 April 2005; NUHM approved 1 May 2013; together they form the National Health Mission (NHM). NRHM and NUHM are the two Sub-Missions under NHM.

Goals & special focus states

The original 18 high-focus states included the 8 EAG states (Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Uttar Pradesh, Uttarakhand, Odisha, Rajasthan), plus the 8 North-Eastern states, Himachal Pradesh and Jammu & Kashmir. These received enhanced resources because they lagged on the demographic and health indicators.

Core measurable goals (revised under NHM):

• Reduce IMR to 25/1000 live births.
• Reduce MMR to 1/1000 live births (i.e. 100/lakh).
• Reduce TFR to 2.1 (replacement level).
• Reduce prevalence/mortality from communicable & non-communicable diseases.
• Provide universal access to public health services.

High-yield: The unit of action for NRHM planning is the village through the Village Health Sanitation & Nutrition Committee (VHSNC), and the district through decentralised District Health Action Plans.

The architecture — what NRHM created

NRHM's strength lies in its institutional scaffolding, built from the village up.

Flow of the new system: Village (ASHA + VHSNC) → Sub-Centre → PHC (with RKS) → CHC/FRU (with RKS) → District Health Society → State Health Society → National (NHM) Mission.

1. ASHA — Accredited Social Health Activist

ASHA is the human face of NRHM, the first port of call for any health demand in the village. She is a volunteer, not a salaried government employee, and works on a performance-based incentive model.

Selection criteria (must-know exam table):

Parameter	Norm
Coverage	One ASHA per 1000 population (relaxed in tribal/hilly/desert areas)
Residence	Must be a resident of the village she serves
Sex	Woman only
Age	25–45 years
Marital status	Preferably married / widowed / divorced (so she stays in the village)
Education	Formal education up to class 8 (10th preferred; relaxed where literate women unavailable)
Selection	By the village (Gram Sabha / VHSNC) through a community process

High-yield: ASHA = one per 1000 population, woman, resident, married/widowed/divorced preferred, age 25–45, literate up to class 8. She is a volunteer with performance-linked incentives, NOT a salaried worker.

ASHA's roles: create awareness on health & determinants; mobilise the community for antenatal care, immunisation, institutional delivery; act as a depot-holder for ORS, IFA tablets, chloroquine, condoms, oral pills, disposable delivery kits (DDK); accompany women for delivery (escort under JSY); provide DOTS under RNTCP; and deliver Home-Based Newborn Care (HBNC).

HBNC visit schedule (extremely high-yield):

For an institutional delivery, ASHA makes 6 visits on days 3, 7, 14, 21, 28, 42. For a home delivery, an additional visit on day 1 is added, totalling 7 visits (days 1, 3, 7, 14, 21, 28, 42).

High-yield: HBNC = 6 home visits (days 3, 7, 14, 21, 28, 42) after institutional delivery; 7 visits (add day 1) after home delivery. HBNC incentive is paid only if the newborn is weighed, immunised (BCG), and both mother & baby are safe at the end of 42 days.

ASHA also conducts Home-Based Care of Young Child (HBYC) — visits in the 3rd, 6th, 9th, 12th and 15th month of life — to address the high mortality and undernutrition in the post-neonatal period.

2. ASHA incentives — selected, commonly asked

ASHA earns task-based incentives. Frequently quoted examples include incentives for institutional delivery facilitation (under JSY), full immunisation of a child, DOTS completion, family-planning referrals, and HBNC. Many states now provide a routine/fixed monthly incentive (often ₹2000) for a defined set of recurring tasks in addition to performance-based payments.

3. AWW–ANM–ASHA triad

A classic comparison the exam loves:

Worker	Population covered	Employment	Key role
ASHA	1000	Volunteer (incentive)	Activist, link worker, HBNC, mobilisation
AWW (Anganwadi worker, ICDS)	1000 (400–800 in tribal)	Honorary worker	Supplementary nutrition, pre-school, growth monitoring
ANM (at sub-centre)	5000 (3000 hilly/tribal)	Salaried (MPW-Female)	ANC, immunisation, deliveries, FP
Male MPW	5000 (3000)	Salaried	Communicable disease control, vital stats

High-yield: Sub-centre serves 5000 population (3000 in hilly/tribal/desert); PHC serves 30,000 (20,000 hilly/tribal); CHC serves 1,20,000 (80,000 hilly/tribal).

Rogi Kalyan Samiti (RKS) — governance & financing

The Rogi Kalyan Samiti / Hospital Management Society is a registered society that acts as a management group for a government health facility (PHC, CHC, sub-divisional & district hospitals). It is a NRHM innovation to grant financial and managerial autonomy to facilities.

• Registered under the Societies Registration Act, 1860.
• Empowered to use hospital revenue, user charges, donations and untied funds for upkeep, minor procurement, sanitation and patient amenities.
• Membership draws from local PRI (Panchayati Raj Institution) representatives, NGOs, local elected members and officials — embodying community ownership.

High-yield: RKS is registered under the Societies Registration Act 1860; it gives the facility autonomy over locally generated funds and is not meant for staff salaries. Untied funds: Sub-centre ₹10,000/year, VHSNC ₹10,000/year, PHC ₹25,000/year, CHC ₹50,000/year (figures commonly quoted).

VHSNC (Village Health Sanitation & Nutrition Committee) is the parallel community body at village/panchayat level, holding an untied fund (~₹10,000) to be spent on local public-health needs (sanitation, nutrition, household water). ASHA is often the member-secretary.

Indian Public Health Standards (IPHS)

IPHS are the benchmark standards introduced under NRHM (first issued 2007, revised 2012) to define the minimum assured services, infrastructure, manpower, drugs and equipment at each level of the rural health system. They convert vague "facility upgradation" into measurable norms.

Facility	Population	IPHS bed/service highlights
Sub-Centre	5000 (3000)	Most peripheral; ANM-run; ANC, immunisation, ORS, basic curative
PHC	30,000 (20,000)	4–6 beds; MO-led; OPD, basic lab, referral, 24×7 PHC for delivery
CHC	1,20,000 (80,000)	30 beds; 4 specialists (Medicine, Surgery, O&G, Paediatrics); designated FRU with OT, blood storage, newborn care
Sub-District/Sub-Divisional Hospital	—	31–100 beds
District Hospital	—	101–500 beds; apex of the rural referral chain

High-yield: A First Referral Unit (FRU) must provide three critical services — (1) emergency obstetric care including caesarean section, (2) newborn care, and (3) blood storage facility 24×7. A CHC qualifies as an FRU only when all three are functional.

JSY and JSSK — the maternal-health engines

NRHM's flagship demand-side and supply-side interventions to push institutional delivery and cut MMR/IMR.

Janani Suraksha Yojana (JSY) — 2005

A conditional cash transfer (demand-side incentive) to promote institutional delivery, modelled on a 100% centrally sponsored scheme.

• High-Performing States (HPS) vs Low-Performing States (LPS) distinction.
• In LPS, all pregnant women delivering in a government/accredited institution are eligible (cash benefit higher: typically ₹1400 rural / ₹1000 urban for the mother).
• In HPS, benefit restricted to BPL/SC/ST women aged ≥19, up to 2 live births (typically ₹700 rural / ₹600 urban).
• ASHA receives a transport/facilitation incentive.

High-yield: In JSY, the 8 EAG states + Assam + J&K are classified as Low-Performing States, where every woman delivering in an institution is eligible irrespective of caste/income/age/birth order.

Janani Shishu Suraksha Karyakram (JSSK) — 2011

Launched 1 June 2011 to eliminate out-of-pocket expenditure for pregnant women and sick newborns in public facilities. It supplements JSY by guaranteeing free services.

Entitlements for the pregnant woman (free):

1. Free delivery (including caesarean section).
2. Free drugs and consumables.
3. Free diagnostics (lab/USG).
4. Free diet — up to 3 days for normal delivery, 7 days for caesarean.
5. Free blood.
6. Free transport — home→facility, inter-facility referral, and drop back home (3 transports).
7. Exemption from all user charges.

Entitlements for the sick newborn (initially up to 30 days, later extended to 1 year): free treatment, drugs, diagnostics, blood and transport.

High-yield: JSSK = free everything (delivery incl. LSCS, drugs, diagnostics, diet, blood, transport both ways, no user charges) for pregnant women in public facilities and sick newborns. Launch date 1 June 2011. Originally newborns covered up to 30 days, later extended to 1 year.

Mnemonic for JSSK free entitlements — "D-DDD-BT": Delivery, Drugs, Diagnostics, Diet, Blood, Transport (free + no user charges).

NUHM and the merger into NHM (2013)

The National Urban Health Mission (NUHM) was approved on 1 May 2013 as the urban counterpart, targeting the urban poor, especially slum dwellers. On the same day NHM was constituted to house both NRHM and NUHM.

NUHM key norms:

• Targets cities/towns with population >50,000 (and district/state HQs).
• Primary urban health structure: Urban PHC (U-PHC) for every 50,000–60,000 population.
• Urban CHC for clusters of U-PHCs (≈ 2.5–5 lakh population).
• Urban ASHA — one per 1000–2500 urban poor population.
• Mahila Arogya Samiti (MAS) — the urban equivalent of the VHSNC, a women's collective for ~50–100 households, with an untied fund.

High-yield: NUHM = urban arm of NHM; targets towns >50,000; one U-PHC per ~50,000 population; community body is the Mahila Arogya Samiti (MAS).

Programme management & financing structure

NHM funds flow through integrated Health Societies at state and district level, enabling flexible pooling rather than rigid vertical budgets.

• Untied funds + Annual Maintenance Grant + RKS funds give facilities financial flexibility.
• Funding pattern (Centre:State) is generally 60:40 for most states and 90:10 for North-Eastern & Himalayan states.
• States prepare a Programme Implementation Plan (PIP) annually, approved by the central National Programme Coordination Committee.
• Workforce additions: contractual ANMs, staff nurses, AYUSH doctors (mainstreaming of AYUSH), and multi-skilling of MBBS doctors in anaesthesia (LSAS) and emergency obstetric care (EmOC) to staff FRUs.

High-yield: NHM mainstreamed AYUSH by co-locating AYUSH doctors at PHCs/CHCs, and addressed the specialist shortage at FRUs via multi-skilling (EmOC & LSAS) training of MBBS doctors.

Common complications / criticisms (exam-relevant)

• ASHA burnout & demands for salaried status — volunteer-incentive model contested.
• Delayed/irregular incentive payments undermining motivation.
• Inter-state variation — EAG states still lag despite targeted funds.
• Human-resource shortfalls — specialist vacancies at CHC/FRU level persist.
• Quality vs coverage — institutional-delivery rates rose sharply, but quality of intrapartum care lagged.

Key differentials / "don't confuse"

Confused pair	Distinction
JSY vs JSSK	JSY = cash incentive to mother (demand-side); JSSK = free services in kind, zero OOP (supply-side)
VHSNC vs MAS	VHSNC = rural village committee; MAS = urban women's collective
RKS vs VHSNC	RKS = facility-level (PHC/CHC/hospital) management society; VHSNC = village-level committee
NRHM vs NUHM	NRHM = rural sub-mission; NUHM = urban sub-mission; both under NHM
ASHA vs ANM vs AWW	ASHA = volunteer activist; ANM = salaried sub-centre worker; AWW = ICDS honorary worker
HBNC vs HBYC	HBNC = neonatal (days 3–42); HBYC = young child (months 3, 6, 9, 12, 15)

Recently asked / exam angle

• ASHA selection criteria — age, residence, education, one-per-population norm (recurrent single-best-answer).
• HBNC visit schedule — number of visits (6 vs 7) and the exact days (3, 7, 14, 21, 28, 42).
• JSSK components — "which is NOT free under JSSK?" style questions; remember diet & drop-back transport ARE free.
• IPHS norms — population covered by sub-centre/PHC/CHC; bed strength of CHC (30 beds).
• FRU definition — the three mandatory services (EmOC incl. LSCS, newborn care, blood storage).
• NUHM launch / MAS — urban arm matching, community structure.
• Dates — NRHM 2005, JSSK 2011, NHM/NUHM 2013.
• RKS — registered under Societies Registration Act 1860; purpose of untied funds.
• Image/assertion-reason items linking EAG states to high-focus status.

Rapid revision

1. NRHM launched 12 April 2005; merged with NUHM (1 May 2013) to form NHM — two sub-missions.
2. ASHA = 1 per 1000 population, woman, village resident, age 25–45, literate to class 8, married/widowed/divorced preferred, volunteer on incentives.
3. HBNC = 6 visits (days 3,7,14,21,28,42) after institutional delivery; 7 visits (add day 1) after home delivery.
4. HBYC = 5 visits in months 3, 6, 9, 12, 15 of infancy.
5. Sub-centre 5000 / PHC 30,000 / CHC 1,20,000 population (3000 / 20,000 / 80,000 in hilly-tribal).
6. CHC = 30 beds + 4 specialists; an FRU needs EmOC (incl. LSCS), newborn care, and 24×7 blood storage.
7. RKS registered under Societies Registration Act 1860; gives facilities financial autonomy over local funds.
8. JSY = conditional cash transfer for institutional delivery; in LPS (8 EAG + Assam + J&K) all women eligible.
9. JSSK (1 June 2011) = free delivery, drugs, diagnostics, diet, blood, transport (both ways), no user charges — for mothers & sick newborns.
10. NUHM: towns >50,000; U-PHC per ~50,000; community body = Mahila Arogya Samiti (MAS).
11. NHM funding pattern 60:40 (90:10 for NE/Himalayan states); states submit an annual PIP.
12. NHM mainstreamed AYUSH and used multi-skilling (EmOC/LSAS) to staff FRUs; 8 EAG states are the core high-focus group.