Public Healthcare System in India – Are the NRHM norms adequate?

Posted on May 28, 2009


The National Rural Health Mission (NRHM) 2005 is the latest government of India initiative to address the healthcare needs of the citizens especially of those in residing in rural areas, the poor, women and children. The NRHM’s zen is to ensure availability and accessibility of quality healthcare services through a four-tiered infrastructure.  The NRHM recognizes the relatively poorer health status of Indian women and children below 5 years of age and its structure, as you will see below, is skewed to address this inequality. As an interesting aside – you will notice, as you read more below, the primal urge of bureaucratic India to coin acronyms.

The basic building block of the NRHM infrastructure is the female accredited social health assistant or ASHA. Every village panchayat is provided specific funds to engage an ASHA who acts as the intelligent/ knowledgeable gateway for individuals to access public health programs and infrastructure. An ASHA is a jack-of-all-trade and is expected to promote multiple government public healthcare initiatives.

The next layer of the public healthcare system is the Sub-health Center (SC). A SC is a physical establishment and provides the first contact point between the healthcare system and individuals. NRHM norms required 1 SC for every 5000 people in plains or for every 3000 people in hilly or tribal areas. The SC has a clinic room, a labour room and an examination room. Moreover the SC stocks a specified list of drugs and diagnostic supplies. The goal for SC is to provide diagnosis and relief from common and easily curable diseases, support in-establishment births, promote sound health practices and spread awareness and education of key health programs. The SC is staffed by a female auxiliary nurse midwife (ANM) and a male health worker who are trained in administering the stocked drugs and diagnostic supplies.  It is expected that the ANM is provided accommodation in or near the SC and hence ensure 24X7 availability of trained medical resource to the community.

A group of 6 SCs is supported by a Primary Health Center (PHC). A PHC is the most immediate place for the community to access a qualified medical doctor. The NRHM norms require 1 PHC for every 30,000 people in plains or every 20,000 people in hilly and tribal areas.  In addition to an examination room, a labour room and a consultation room, the PHC provides a 4/6 bed inpatient facility, a minor operations theater and a laboratory. A PHC is staffed by 1 medical doctor, 1 pharmacist, 1 nurse, 1 female health worker, 1 health educator and 8 support staff. In addition, 1 female health assistant (referred to as a Lady Health Visitor or LHV) and 1 male health assistant are attached to each PHC bringing the total staff strength to 15. These health assistants support the ANMs of the affiliated SCs through regular field visits and consultations.

The final layer of the healthcare system is the Community Health Centers (CHC). The CHC provides referral and specialist healthcare services. A CHC usually acts as a referral service provider for about 4 PHCs. The NRHM norms require 1 CHC for every 120,000 people in plains or every 80,000 people in hilly or tribal areas. A CHC is a 30 bedded hospital with 4 specialties/departments – medicine, obstetrics & gynecology, surgery and pediatrics. A CHC is staffed by 4 doctors, 9 nurses, 3 technicians and 10 support staff bringing the total to 26.

The government of India maintains a sufficiently informative NRHM website and you can amuse yourself by reading the level of detail that the bureaucracy provides specific recommendations on.



2020 (desired)

Per NRHM norms

Health worker density (per 10,000 population)




Ratio of nurses & midwifery personnel to physicians




Hospital bed density (per 10,000 population)




In earlier two entries, I had compared the current availability of health workers and hospital beds in India and, if India is to achieve universal health coverage, the recommended number of healthcare workers and hospital beds by 2020. My recommendations were based on a comparative data analysis of 193 countries.  It would be interesting to compare my recommendations with what the NRHM norms would deliver. Per the NRHM norms, for every 120,000 people there should be 8 doctors, 70 nurses & midwifery personnel and about 50 hospital beds. The adjacent table provides an interesting comparison.

Clearly the NRHM norms come up woefully short on all counts – ensuring adequate number of health workers, doctors and hospital beds.  It is hard for me to understand why the norms set a bar well below India’s current standards. Coincidentally the numbers per the NRHM norms are comparable to the numbers seen in countries with lowest level of life expectancy. Now I am not one to deride anything and everything that the government undertakes, but in this case I do believe that the NRHM will fall well short of its goal because gross under resourcing of the program. NRHM may well be a case of good intentions marred by poor resourcing.

If this blog entry is read by those in charge of the NRHM (hey I am an optimist) then I do hope they use this data to relook at the recommended resourcing levels for the program.