National Rural Health Mission (NRHM)

The National Rural Health Mission (NRHM) was launched by the Government of India on 12 April 2005 by the Ministry of Health and Family Welfare to address the inequities and deficiencies in healthcare delivery across rural India. Its mandate flowed from the constitutional placement of public health and sanitation under the State List (Entry 6, List II of the Seventh Schedule), which historically left health financing fragmented and underfunded at the state level. The Mission drew its policy lineage from the National Health Policy 2002 and the commitments of the Common Minimum Programme of the United Progressive Alliance government, which pledged to raise public health expenditure to 2–3 percent of GDP. NRHM initially covered 18 high-focus states with weak public health indicators, including the Empowered Action Group states (Bihar, Uttar Pradesh, Madhya Pradesh, Rajasthan, Odisha, Jharkhand, Chhattisgarh, Uttarakhand), the eight North-Eastern states, plus Jammu and Kashmir and Himachal Pradesh, while extending a lighter framework to the remainder of the country.

The operational architecture of NRHM rested on a small number of structural interventions executed in sequence. The first was the creation of the Accredited Social Health Activist (ASHA), a trained female community health worker selected by and accountable to the village, deployed at roughly one per thousand population to act as the interface between the community and the public health system. The second was the institution of decentralised planning through Village Health and Sanitation Committees and District Health Action Plans, allowing felt needs to inform resource allocation rather than top-down disbursement. The third mechanism was untied funds released directly to facilities and committees—typically a small annual grant to each sub-centre, Primary Health Centre, and Village Health and Sanitation Committee—to permit flexible local spending without prior sanction. Financing was routed through state and district health societies registered under the Societies Registration Act, bypassing the slower treasury route to accelerate fund flow.

A further set of mechanisms addressed infrastructure and human resources. The Mission mandated the Indian Public Health Standards (IPHS), a set of benchmarks specifying staffing, equipment, drugs, and physical infrastructure for sub-centres, PHCs, Community Health Centres, and district hospitals, against which facilities were to be upgraded and audited. Health facilities were progressively converted into 24x7 service points, and the Janani Suraksha Yojana—a conditional cash transfer—was integrated to incentivise institutional delivery and reduce maternal mortality. The Mission also promoted the integration of vertical disease-control programmes (malaria, tuberculosis, blindness, leprosy) into a single district health framework, and mainstreamed AYUSH practitioners into the public system to expand the available workforce.

In practice, NRHM produced measurable shifts. The Maternal Mortality Ratio and Infant Mortality Rate declined steadily over the Mission period, and institutional deliveries rose sharply, particularly in the high-focus states, as documented in the National Family Health Survey rounds and successive Common Review Mission reports compiled by the Ministry of Health and Family Welfare in New Delhi. By 2012 the ASHA cadre numbered over 850,000. The Mission was also scrutinised: the National Rural Health Mission scam in Uttar Pradesh, investigated by the Central Bureau of Investigation from 2011, exposed large-scale embezzlement and several deaths of officials, illustrating the governance risks of the society-routed financing model.

NRHM should be distinguished from the broader National Health Mission (NHM), under which it was subsumed in 2013 alongside the newly created National Urban Health Mission; NRHM thereafter became the rural sub-mission rather than a standalone programme. It is also distinct from Ayushman Bharat, launched in 2018, which couples Health and Wellness Centres with the PM-JAY insurance scheme—a demand-side financing approach that contrasts with NRHM's supply-side strengthening of public facilities. Practitioners should not conflate NRHM with the Reproductive and Child Health programme, which it absorbed, nor with the National Health Policy documents that set its objectives but carried no operational machinery.

Persistent controversies surround the Mission's reliance on contractual and honorarium-based workers, most acutely the ASHAs, who are classified as volunteers receiving performance-linked incentives rather than salaried employees—a status that triggered repeated agitations and demands for regularisation through the 2010s and 2020s. Recurring Comptroller and Auditor General audits flagged underutilisation of funds, parking of money in society accounts, and incomplete IPHS compliance. The Fifteenth Finance Commission and the National Health Policy 2017 revisited the unmet target of raising public health spending, which remained near 1.3 percent of GDP, and the COVID-19 pandemic exposed the residual fragility of rural health infrastructure that NRHM had sought to remedy.

For the working civil servant, policy researcher, or UPSC aspirant addressing General Studies Paper II, NRHM remains a canonical case study in centrally sponsored schemes operating within a federal health architecture, in community health worker models since emulated elsewhere, and in the tension between flexible financing and accountability. Understanding its instruments—ASHA, IPHS, untied funds, decentralised district planning—and its evolution into the NHM equips the practitioner to analyse contemporary debates over Ayushman Bharat, health federalism, and the unfinished agenda of universal health coverage in India.