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Ayushman Bharat National Health Mission AYUSH healthcare India 2024 2025

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Health Care Delivery System in India

India's health care delivery system is one of the most complex in the world, shaped by its vast geography, diversity of population, constitutional structure, and a mixed public-private model. The system serves over 1.4 billion people across 28 states and 8 union territories, ranging from advanced metropolitan hospitals to remote tribal sub-centres.

1. Constitutional Framework and Governance

Under the Constitution of India, health is primarily a State subject. This means each state is largely independent in matters relating to the delivery of health care to its people, and each state has developed its own system accordingly. The Central Government's role is mainly one of policy-making, planning, guiding, assisting, evaluating, and coordinating the work of State Health Ministries, so that no region is left behind.
The health system in India has three main links: Central, State, and Local/Peripheral.

At the Centre

The official organs at the national level are:
  1. Ministry of Health and Family Welfare (MoHFW) - Headed by a Cabinet Minister, this ministry has two departments: the Department of Health and the Department of Family Welfare. It frames national policy but is not directly involved in health care delivery. It controls institutions of national importance like AIIMS, PGI Chandigarh, and JIPMER.
  2. Directorate General of Health Services (DGHS) - The principal technical adviser to the Government on all medical and public health matters. The DGHS advises the Government, undertakes research, and administers health programmes.
  3. Central Council of Health and Family Welfare - A high-level advisory body that recommends broad policy for health development across the country.

At the State Level

Each state has its own State Ministry of Health and Family Welfare, a State Directorate of Health Services, and a State Council of Health. The state governments are responsible for running hospitals, sub-divisional and district hospitals, dispensaries, and PHCs. The District Health Officer (DHO) or Chief Medical Officer (CMO) is the key administrative figure at the district level.

At the Local/Peripheral Level

Local self-government under Panchayati Raj plays a significant role:
  • Village level: Gram Panchayat (covers 5,000-15,000 population), responsible for sanitation, public health and social development.
  • Block level: Panchayat Samiti / Janpada Panchayat covering about 100 villages (~80,000 to 1,20,000 population).
  • District level: Zilla Parishad / Zilla Panchayat, a supervisory and coordinating body.

2. Levels of Health Care

It is standard to describe health care delivery at three levels in India:

Primary Care Level

This is the first level of contact of individuals, families, and communities with the national health system. It is where "essential health care" is provided - close to where people live and work. In the Indian context, primary care is delivered through:
  • Sub-Centres (SCs)
  • Primary Health Centres (PHCs)
  • Community Health Centres (CHCs)
  • ASHA workers, ANMs, Anganwadi workers
Since India signed the Alma-Ata Declaration (1978), the primary health care system has been continuously reorganized and strengthened.

Secondary Care Level

The secondary (intermediate) level handles cases that cannot be managed at primary level. It includes:
  • Sub-district/Tehsil hospitals
  • District hospitals
  • These provide specialist consultations, surgical care, inpatient management, and diagnostics.

Tertiary Care Level

The highest level of care for highly complex conditions, involving:
  • Medical college hospitals
  • Specialty hospitals
  • Apex institutions like AIIMS, PGI, JIPMER
  • They serve as referral centres and also provide medical education and research.

3. The Rural Health Infrastructure (Three-Tier System)

In 1977, the Government of India launched a Rural Health Scheme based on the Shrivastava Committee (1975) recommendation. The three-tier rural health system comprises:

Sub-Centre (SC)

  • The most peripheral contact point between the health system and the community
  • Covers a population of 3,000 - 5,000 (in hilly/tribal areas: 1,000 - 3,000)
  • Staffed by one female Auxiliary Nurse Midwife (ANM) and one male Multi-Purpose Worker (MPW)
  • Two types: Type A (outreach only) and Type B (with delivery facility, conducting ~20 deliveries/month)
  • Services: antenatal care, immunization, maternal and child health, family planning, disease surveillance, NCD screening, health counseling

Primary Health Centre (PHC)

  • First contact facility with a medical officer (MBBS doctor)
  • Covers a population of 20,000 - 30,000 (in hilly/tribal areas: 10,000 - 20,000)
  • Typically supervises 6 sub-centres
  • Services: OPD, inpatient (6 beds), emergency obstetric care, basic lab, immunization, disease control programs, referral to CHC
  • Staffed by 1 Medical Officer, 1 Pharmacist, 1 Lab Technician, 14 MPWs/ANMs, and other staff

Community Health Centre (CHC)

  • A 30-bed hospital providing referral services to PHCs
  • Covers approximately 1,20,000 population (in hilly/tribal areas: 80,000)
  • Typically supervises 4 PHCs
  • Staffed by specialists: General Surgeon, Physician, Obstetrician & Gynaecologist, Paediatrician, plus Anaesthesia and other support
  • Services: emergency surgical care, specialist OPD, specialist inpatient care, blood storage, ECG, X-ray, referral transport, maternal death review

District Hospital (DH)

  • The apex facility at the district level
  • Provides all secondary care services
  • Acts as the first referral unit for CHCs
  • Usually attached to a medical college in larger districts

4. Urban Health Infrastructure

Urban health is delivered through:
  • Urban Health Centres (UHCs) - one per 50,000 urban population (under National Urban Health Mission)
  • Urban Community Health Centres (UCHCs)
  • Municipal dispensaries and maternity homes
  • Government medical college hospitals - for tertiary care
The National Urban Health Mission (NUHM), launched in 2013, specifically targets the urban poor, slum dwellers, and unregistered migrant populations. It plans for one Urban PHC per 50,000 population, with an emphasis on maternal and child health, reduction of out-of-pocket expenses, and improving sanitation.

5. Community Health Workers

Community health workers are the backbone of primary health delivery in India:

ASHA (Accredited Social Health Activist)

  • A trained female community health activist
  • One ASHA per 1,000 population (relaxed to one per habitation in tribal/hilly/desert areas)
  • Must be a resident of the village, preferably aged 25-45 years with at least Class 8 education
  • Responsibilities: creating health awareness, mobilizing for immunization and institutional delivery, facilitating access to health services, reporting births/deaths/disease outbreaks, promoting sanitation
  • India has approximately 9.15 lakh ASHA workers nationally

ANM (Auxiliary Nurse Midwife)

  • Based at the sub-centre level
  • Provides maternal and child health services, immunization, family planning

Anganwadi Worker

  • Part of the Integrated Child Development Services (ICDS) scheme
  • Focuses on nutrition, early childhood care, and pre-school education

6. The Private Sector

The private sector is the dominant provider of health care in India, particularly for secondary, tertiary, and quaternary care. It ranges from single-room clinics to 1,000+ bed specialty hospitals.
Key features:
  • Concentrated in metros, Tier-I and Tier-II cities
  • Provides most surgical, specialist, and diagnostic services
  • Includes for-profit hospitals, nursing homes, polyclinics, diagnostic chains, and non-profit/charitable trusts
  • Major hospital chains: Apollo, Fortis, Manipal, Max, Narayana Health
  • Out-of-pocket (OOP) payments account for 44% of total health expenditure (2023), making financial protection a major concern
  • Largely unregulated and fragmented, making enforcement of standards difficult

7. AYUSH (Alternative Systems of Medicine)

India has a unique pluralistic health care system that officially recognizes traditional medicine systems under the acronym AYUSH:
  • A - Ayurveda
  • Y - Yoga and Naturopathy
  • U - Unani
  • S - Siddha
  • H - Homeopathy
The Ministry of AYUSH (formed in November 2014) established traditional medicine as an active part of India's health system. Key facts:
  • AYUSH facilities are co-located at PHCs and district hospitals under the National AYUSH Mission (NAM)
  • AYUSH care has been mainstreamed across 13,093 NHM co-located facilities (as of December 2025)
  • 942 AYUSH institutions were opened as of 2025
  • The AYUSH Grid digitally connects all AYUSH hospitals and laboratories nationwide
  • A dedicated AYUSH Visa was introduced in July 2023 for medical tourists seeking traditional treatments

8. Major National Health Programs and Schemes

National Health Mission (NHM)

The NHM has two sub-missions:
  • National Rural Health Mission (NRHM) - launched 2005, focuses on rural health, maternal and child health, infrastructure strengthening
  • National Urban Health Mission (NUHM) - launched 2013, addresses urban health inequities
NHM adopts a synergistic approach linking health to determinants like nutrition, sanitation, and hygiene. It introduced IPHS (Indian Public Health Standards) as benchmarks for facility quality.

Ayushman Bharat

India's flagship scheme launched in 2018 under the National Health Policy 2017, comprising two pillars:
  1. Ayushman Arogya Mandirs (AAMs) (formerly Health and Wellness Centres): 1,50,000 existing Sub-Centres and PHCs transformed into HWCs to deliver Comprehensive Primary Health Care (CPHC), including free essential drugs, diagnostics, maternal care, and NCD management. "Time to care" should not exceed 30 minutes.
  2. Pradhan Mantri Jan Arogya Yojana (PM-JAY): Provides annual health coverage of Rs. 5 lakh per family for secondary and tertiary care to 12 crore vulnerable families. As of September 2024, the scheme was extended to all individuals aged 70 years and above regardless of income, reaching 6 crore senior citizens through the Vay Vandana Card. The Union Budget 2026-27 allocated Rs. 9,500 crore (US$ 1.06 billion) to PM-JAY.

PM-ABHIM (Pradhan Mantri Ayushman Bharat Health Infrastructure Mission)

Launched October 25, 2021 with a total financial outlay of Rs. 64,180 crore (FY 2021-22 to 2025-26). It is building capacity at every tier of the health system, including:
  • Support for 23,224 rural Health and Wellness Centres
  • Block-level public health units
  • Critical care hospital blocks at district level
  • Integrated public health labs
  • National Centre for Disease Control (NCDC) strengthening

Ayushman Bharat Digital Mission (ABDM)

Builds India's digital health infrastructure - unique health IDs, Health Facility Registry, Healthcare Professionals Registry, and digital health records. By early 2025, hundreds of millions of health IDs had been registered, and AYUSH providers were integrated into the system.

eSanjeevani

India's national telemedicine platform has delivered over 276 million teleconsultations to date, dramatically expanding access in rural and remote areas.

9. Health Financing

India's health financing is a mixed model:
SourceShare
Out-of-pocket payments44% of total health expenditure (2023)
Government (public) spending~1.9% of GDP (FY26 estimate)
Private insurance7.4% of total health expenditure (2022)
Social/employer-based insuranceCovered ~20% of population (2023)
  • As of 2023, 50% of the population was covered by public health insurance programs (including PM-JAY)
  • 30% remained uninsured
  • Public hospitals are essentially free for all Indian residents (with nominal co-payments for some services)
  • Out-of-pocket spending has been declining - between 2021 and 2022, it dropped due to increased government spending and COVID-era health system strengthening

10. Key Challenges

Despite progress, India's health care delivery system faces several significant challenges:
  1. Infrastructure gap: India has approximately 1.3 hospital beds per 1,000 population (~13 beds per 10,000), far below the global median of 29 per 10,000.
  2. Urban-rural disparity: Private sector services are concentrated in cities while rural areas are underserved.
  3. Healthcare workforce shortage: Shortage of doctors, nurses, and specialists, especially in rural/tribal areas.
  4. High out-of-pocket spending: Despite declining, OOP at 44% pushes millions into poverty annually.
  5. Double burden of disease: India faces both unfinished communicable disease burdens (TB, malaria, dengue) and a rapidly rising NCD burden (cardiovascular disease, diabetes, cancer).
  6. Fragmented regulation: The private sector is highly fragmented and difficult to regulate; many providers operate informally.
  7. Inter-state variation: Health outcomes vary dramatically between states - Kerala and Tamil Nadu perform far better than Bihar and Uttar Pradesh on most indicators.
  8. Public expenditure: At ~1.9% of GDP, India's public health spending remains well below the WHO recommended level of 5% of GDP.

11. Recent Developments (2024-2026)

  • 10-Bed ICU Project: Establishing small ICUs in rural areas connected to urban medical experts via telemedicine.
  • U-WIN Platform: Digital platform for vaccination tracking and immunization program management.
  • Ayushman Bharat extension to seniors (September 2024): All citizens aged 70+ now covered under PM-JAY irrespective of income.
  • Digital health ecosystem growth: Integration of AYUSH records with national health IDs, private health sector integration into ABDM.
  • Private investment surge: Private equity investment in Indian healthcare surged to Rs. 4,900 crore (US$ 572 million) in Q2 CY25 across 33 deals.

Summary

India's health care delivery system is a three-tiered, mixed public-private model governed through a federal structure. The public system delivers care from the village sub-centre to the national apex hospital. ASHA workers and ANMs form the community foundation; PHCs, CHCs, and district hospitals form the backbone; and medical college hospitals anchor the tertiary level. Government programs like Ayushman Bharat, NHM, and PM-ABHIM are driving expansion toward Universal Health Coverage (UHC) by 2030. The private sector - dominant in secondary and tertiary care - provides scale and technology but requires stronger regulation. Bridging urban-rural divides, reducing out-of-pocket spending, and expanding the trained health workforce remain the most pressing priorities.
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