Strengths and Weaknesses of the National Health Mission

India’s public health system has long struggled with a basic problem: how to deliver care to over 65% of the population living in rural areas, where doctors are scarce and hospitals are far away. The National Health Mission (NHM), launched in 2005 as the National Rural Health Mission, was designed to fix exactly this. Two decades later, the verdict is mixed. The Mission has genuinely transformed maternal and child health, yet it continues to stumble on fund utilisation, frontline coordination, and rural infrastructure. Understanding both sides of this ledger is essential for anyone studying public policy or health administration.

What the National Health Mission set out to do
The strengths: where the Mission delivered
The ASHA: a community health revolution
Free drugs and free diagnostics
Mobile medical units and emergency transport
Sharp gains in maternal and child health
The weaknesses: where the Mission falls short
Funds released but not spent
ASHAs need better training and mentoring
Coordination among frontline workers
Inadequate rural infrastructure
What the evidence adds up to

What the National Health Mission set out to do

The NHM aims to provide universal, accessible, affordable, and quality healthcare, with a special focus on the underserved. It operates through two sub-missions: the National Rural Health Mission and the National Urban Health Mission. Its strategy rests on strengthening health systems, building human resources at the grassroots, and reducing the heavy out-of-pocket expenditure that pushes Indian families into poverty when illness strikes.

To do this, the Mission introduced a cluster of flagship initiatives, from community health workers to free drugs and emergency transport. Evaluating the NHM means asking a simple question: have these initiatives actually moved the needle on health outcomes, and where are they falling short?

The strengths: where the Mission delivered

The ASHA: a community health revolution

The single most celebrated innovation of the NHM is the Accredited Social Health Activist (ASHA). An ASHA is a woman selected from her own village, trained to act as the first point of contact between the community and the public health system. There is roughly one ASHA for every 1,000 people, and the workforce now numbers over nine lakh across the country.

Evaluations consistently confirm the ASHA’s value. A study across eight states by the National Health Systems Resource Centre found that ASHAs grew into the most important facet of the Mission, while a Karnataka evaluation noted that through home visits, ASHAs improved basic antenatal care and increased institutional deliveries and immunisation. By bringing people back into the public health system, ASHAs raised the use of outpatient services, diagnostics, and hospital deliveries.

Free drugs and free diagnostics

One of the biggest reasons Indians avoid public hospitals is cost. The Free Drugs Service Initiative and Free Diagnostics Service Initiative were introduced to tackle the high out-of-pocket expenditure (OOPE) on medicines and tests. The impact has been substantial. According to the Health Ministry, OOPE as a percentage of total health expenditure fell from 64.2% in 2013-14 to 39.4% in 2021-22. That is a remarkable decline that directly protects poor families from medical debt.

Mobile medical units and emergency transport

For villages with no nearby clinic, the NHM rolled out Mobile Medical Units (MMUs) to carry diagnostics and basic care directly to remote areas. Alongside these, free ambulance services under the 108 (emergency) and 102 (patient transport) numbers were introduced. The 102 service specifically caters to pregnant women and children, offering free transport from home to facility and back, which removes a major barrier to institutional delivery.

Sharp gains in maternal and child health

The clearest measure of success is in maternal and child survival. The Janani Suraksha Yojana (JSY), a conditional cash transfer scheme, and the Janani Shishu Suraksha Karyakram (JSSK), which guarantees free delivery, drugs, diet, and transport, together pushed institutional deliveries upward. One observational study in Madhya Pradesh found that institutional deliveries rose by 42.6% after JSY was implemented, particularly among rural and lower-income women.

The headline indicator tells the story. India’s Maternal Mortality Ratio (MMR) has fallen steadily, reaching 88 maternal deaths per 100,000 live births for the period 2020-22. The Health Ministry notes that the rate of decline in maternal and child mortality in India has been faster than the global average during the NHM period.

The weaknesses: where the Mission falls short

Funds released but not spent

A persistent paradox haunts the NHM: money is allocated, yet large amounts go unspent. A 2017 audit by the Comptroller and Auditor General (CAG) found that NHM funds left unutilised by states over a five-year period rose by 29%, with unspent amounts climbing from around ₹73.75 billion in 2011-12 to ₹95.09 billion in 2015-16. Some funds were even diverted to unrelated state schemes.

Part of the problem is the funding pipeline itself. Funds flow from the Centre to state health societies through complex “flexipools,” and the system is rigid. The same CAG audit reported that transfers meant to take 15 days instead took between 50 and 271 days. When money arrives late and the rules for spending it are complicated, programmes stall regardless of how much was budgeted.

ASHAs need better training and mentoring

The ASHA programme’s success is undercut by gaps in support. ASHAs receive 23 days of training in their first year and are meant to receive 12 days annually thereafter, but the quality is inconsistent. A review of frontline health worker programmes found the early training manuals to be broadly simplistic and insufficient, with trainers often simply reading through the manual rather than building practical skills.

The consequences show up in field studies. A district-level evaluation in Bihar found that ASHAs’ knowledge was strong on antenatal and postnatal care but weaker on family planning, child health, and general health, with most workers asking for periodic retraining and skill upgradation. Systematic reviews echo this, noting a positive correlation between the frequency of training and the knowledge level of ASHAs. Put simply, where mentoring is weak, performance suffers.

Coordination among frontline workers

Rural health depends on three women working together: the ASHA, the Auxiliary Nurse Midwife (ANM), and the Anganwadi Worker (AWW). In theory their roles complement each other; in practice, overlap and friction are common. The NHM and the Integrated Child Development Services run parallel programmes, and one analysis noted a lack of synergy where the NRHM’s Village Health and Nutrition Days compete with the well-established Anganwadi programme.

To address this, the Mission promotes regular “AAA meetings” (ASHA, ANM, and Anganwadi Worker) held twice a month at the sub-centre level, designed to improve coordination between the three cadres of frontline workers. Where these meetings function well, coordination improves; where they are skipped, the system fragments.

Inadequate rural infrastructure

Even the best-trained worker cannot deliver care without functioning facilities, and here the gaps are stark. The CAG analysis found that rural sub-centres were 20% short of human resources, 29% lacked a regular water supply, 26% had no electricity, and 11% were not connected by all-weather roads. A medical review described the public system as already over-stretched and grappling with a gross shortage and non-utilisation of infrastructure and human resources.

This creates a structural weakness: the NHM has added new buildings and posts, but its impact on genuinely strengthening systems has been limited. A federal tension lies underneath it all, as funding comes from the Centre while implementation rests with the states, which vary widely in their administrative capacity.

What the evidence adds up to

The honest assessment is that the NHM is a programme of real achievement held back by execution problems. It has demonstrably saved lives, cut out-of-pocket costs, and built a community health workforce admired worldwide. Yet the gap between funds released and funds spent, the uneven training of ASHAs, the friction between frontline cadres, and the crumbling state of rural facilities all limit how far it can go.

The path forward is not a new scheme but better delivery of the existing one: simpler fund-flow rules, structured and continuous mentoring for ASHAs, genuine integration of frontline workers, and serious investment in the physical backbone of rural health centres. The Mission’s goals of universal, affordable, and quality care remain achievable, but only if administration catches up with ambition.

What do you think? Should the central government tie NHM funding more tightly to how efficiently states actually spend it, even if that risks penalising the poorest states that need it most? And given how much rides on the ASHA, is it time to formally recognise her as a salaried health worker rather than a volunteer paid through incentives?

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Table of Contents

What the National Health Mission set out to do 🔗

The strengths: where the Mission delivered 🔗

The ASHA: a community health revolution 🔗

Free drugs and free diagnostics 🔗

Mobile medical units and emergency transport 🔗

Sharp gains in maternal and child health 🔗

The weaknesses: where the Mission falls short 🔗

Funds released but not spent 🔗

ASHAs need better training and mentoring 🔗

Coordination among frontline workers 🔗

Inadequate rural infrastructure 🔗

What the evidence adds up to 🔗