Health Care Delivery in India — ASHA, ANM, Sub-Centre, PHC and CHC Norms

India's rural public health system is built as a pyramid. The sub-centre is the most peripheral institution and the first contact point between the primary health care system and the community. The primary health centre (PHC) sits between the sub-centre and the block-level community health centre (CHC). Population norms come from the Indian Public Health Standards (IPHS), first released in 2007 under the National Rural Health Mission and revised in 2012; a further IPHS 2022 revision has since been issued by the National Health Systems Resource Centre.

ASHA (Accredited Social Health Activist) was introduced as a key component of the National Rural Health Mission: a trained female community health activist for every village, selected from the village itself and accountable to it. She acts as an interface between the community and the public health system. The National Health Mission (NHM) describes the norm as one ASHA per village of 1,000 population, with states allowed to relax the population and educational norms case by case.

NHM data from the programme's support-mechanism page reported over 8.9 lakh ASHAs selected by 31 March 2014 (figure as of 2014), with the scheme in place in 33 states and Union Territories at that time. Her training is a continuing process of repeated training episodes rather than a single course.

The NHM describes ASHA as the first port of call for health-related demands, especially of women and children from deprived sections. Her tasks fall into three groups: creating awareness and mobilising the community, counselling, and providing a minimum package of care with timely referral.

• Awareness and mobilisation — information on nutrition, basic sanitation and hygiene, healthy living and working conditions, and existing health services; helps local health planning and the Village Health and Sanitation Committee.
• Counselling — birth preparedness, safe delivery, breastfeeding and complementary feeding, immunisation, contraception, and prevention of common infections including RTI/STI, and care of the young child.
• Facilitating access — accompanies and mobilises people to the Anganwadi, sub-centre and PHC for immunisation, antenatal and postnatal check-ups, supplementary nutrition and sanitation.
• Depot holder — provides ORS, iron–folic acid tablets, chloroquine, disposable delivery kits, oral pills and condoms.
• Incentives — performance-based incentives for promoting universal immunisation, referral and escort services for reproductive and child health and other programmes, and construction of household toilets.

The NHM states that the home-based newborn care kit is provided for growth assessment and newborn care after training in modules 6 and 7. The drug kit mainly contains drugs for minor ailments; its purpose is to give ASHA first-contact credibility in the community.

The Auxiliary Nurse Midwife (ANM), officially the Health Worker (Female), is the multipurpose worker of the sub-centre. She carries out maternal and child health work, family planning, immunisation, treatment of minor ailments and the supervision of ASHAs in her area. IPHS recommends that a sub-centre have one ANM (essential) and one male health worker (essential), with a second ANM desirable; a delivery-conducting (MCH) sub-centre has two ANMs and a male health worker, and a staff nurse is desirable if there are 20 or more deliveries a month.

Other ANM functions in the IPHS job description include providing IFA tablets and tetanus immunisation, urine tests for albumin and sugar, haemoglobin estimation, conducting deliveries where a labour room is available, referring difficult labour and abnormal newborns, tracking all pregnancies by name, and identifying beneficiaries under Janani Suraksha Yojana. She prepares a monthly work schedule at the meeting of all accredited workers held on the third Friday of every month and holds weekly or fortnightly meetings with all ASHAs in her area to guide and monitor them.

The IPHS describe the PHC as the first port of call to a qualified doctor in the rural public health sector, providing curative, promotive and preventive care. A PHC covers 30,000 people in plains and 20,000 in hilly, tribal or difficult areas, has about 6 indoor or observation beds, acts as a referral unit for 6 sub-centres and refers cases to the CHC. A PHC offering 24-hour services with appropriate linkages helps raise institutional deliveries and reduce maternal and infant mortality.

• Services — curative, preventive and promotive care, including 24-hour emergency care for injuries, first aid, stitching of wounds, snake and dog bite cases and stabilisation before referral, together with maternal and child health, immunisation, family planning and national programme services.
• Field duty — the medical officer should spend at least two hours a day, twice a week, on field visits and monitoring.
• Monthly review meeting — chaired by the MO and attended by health workers and health assistants (male and female); ASHAs and Anganwadi workers should also attend, and the MO orients ASHAs on selected topics.
• Supervision — the medical officer, lady health visitor and male health assistant monitor the sub-centres, while the lady health visitor and ANM monitor the ASHAs.
• Management — Rogi Kalyan Samiti / PHC management committee with Panchayati Raj Institution involvement.

The NHM stresses that ASHA cannot function without institutional support at the village level: women's committees or self-help groups, the Village Health and Sanitation Committee of the Gram Panchayat, peripheral workers (the ANM and Anganwadi worker), trainers, and in-service periodic training.