Rural Healthcare System in India: Structure and Current Scenario Post-Ayushman Bharat

Rural India is home to nearly 65% of the country’s population, yet accessing quality healthcare remains a challenge for millions. The rural healthcare system operates through a three-tier structure designed to bring medical services closer to communities. Since the launch of initiatives like the Ayushman Bharat program in 2018, there has been renewed focus on strengthening this infrastructure. However, significant gaps in manpower and resources continue to affect service delivery across the nation.

Understanding the three-tier rural health structure 🔗

India’s rural healthcare delivery follows a structured three-tier system consisting of Sub-Centres at the grassroots level, Primary Health Centres at the intermediate level, and Community Health Centres that serve as referral hubs. This hierarchy is designed to ensure that even remote populations have access to essential health services without traveling long distances.

Sub-centres: The first point of contact 🔗

Sub-centres represent the most peripheral contact point between communities and the primary healthcare system. As of March 2023, India has 1,69,615 sub-centres functioning across rural and urban areas, serving as the foundation of healthcare delivery.

Population coverage and norms 🔗

Each sub-centre is established to serve a specific population base. In plain areas, one sub-centre covers approximately 5,000 people, while in hilly and tribal regions, this number reduces to 3,000 people. Rural Health Statistics 2021-22 indicates that the average rural population covered by one sub-centre was 5,691 individuals.

Core responsibilities and staffing 🔗

Sub-centres are typically staffed by one Auxiliary Nurse Midwife and one Male Health Worker. Their primary focus includes maternal and child health services, immunization programs, disease control initiatives, and basic health education. These facilities are equipped with essential medicines for minor ailments and work closely with Accredited Social Health Activists to reach every household in their catchment area.

Primary health centres: Comprehensive care providers 🔗

Primary Health Centres serve as the first contact point between village communities and medical officers. As of March 2023, there are 31,882 PHCs operating across the country, providing an integrated approach to healthcare that combines curative, preventive, and promotive services.

Infrastructure and service scope 🔗

According to established norms, one PHC should serve 30,000 people in plains and 20,000 in hilly and tribal areas. Data shows that on average, one PHC covers 36,049 individuals in rural areas. Each PHC acts as a referral unit for approximately six sub-centres and typically has 4-6 beds for patient care.

Notable growth in specific states 🔗

The expansion of PHCs has been particularly significant in states like Rajasthan and Gujarat, which have witnessed substantial increases in their healthcare infrastructure. This growth reflects targeted efforts under national health missions to bridge the gap between healthcare demand and supply in underserved regions.

Evolution through Ayushman Bharat 🔗

The Ayushman Bharat program, launched in February 2018, aims to transform 150,000 existing sub-centres and PHCs into Health and Wellness Centres by providing comprehensive primary healthcare services. These upgraded facilities now offer an expanded range of services, including non-communicable disease management, geriatric care, palliative care, and mental health services alongside traditional maternal and child health programs.

Community health centres: Referral hubs for specialized care 🔗

Community Health Centres function as the first referral units in the rural healthcare system. As of March 2023, India has 6,359 CHCs serving both rural and urban populations. These facilities are designed to provide specialized medical care that goes beyond the scope of PHCs.

Population norms and infrastructure 🔗

Each CHC is meant to serve 1,20,000 people in plains and 80,000 in hilly and tribal areas. Statistics indicate that one CHC covers an average of 164,027 individuals in rural areas. CHCs typically have 30 beds and are equipped with operation theaters, X-ray facilities, and laboratory services.

Critical specialist shortages 🔗

Despite their importance as referral centers, CHCs face severe shortages in specialist positions. The 2021-22 data reveals alarming gaps: 83.2% shortage of surgeons, 74.2% shortage of obstetricians and gynecologists, 79.1% shortage of physicians, and 81.6% shortage of pediatricians. Overall, nearly 80% of specialist positions at CHCs remain vacant compared to requirements.

Current manpower: Progress and persistent gaps 🔗

The healthcare workforce is the backbone of service delivery, and India has made considerable progress in expanding human resources over the years.

Growth in health workers 🔗

The number of Auxiliary Nurse Midwives at sub-centres and PHCs increased from 133,194 in 2005 to 207,587 in 2022, representing a 56% increase. Similarly, allopathic doctors at rural PHCs grew from 20,308 to 30,640 during the same period.

Continuing workforce challenges 🔗

Despite this growth, shortages persist. There is a 3.1% deficit in allopathic doctors at rural PHCs, with states like Odisha, Chhattisgarh, and Karnataka facing the most significant shortfalls. The specialist shortage at CHCs remains the most critical concern, directly impacting the quality of referral services.

Addressing gaps through innovative approaches 🔗

The Ayushman Bharat program introduced Community Health Officers and mid-level healthcare providers to address workforce shortages. These providers, trained through certificate programs, help bridge the gap between doctors and basic health workers, enabling team-based service delivery rather than relying solely on physicians.

Infrastructure investments and policy support 🔗

Recent policy initiatives demonstrate the government’s commitment to strengthening rural healthcare. The Pradhan Mantri Ayushman Bharat Health Infrastructure Mission with an outlay of Rs. 64,180 crores supports infrastructure development for sub-health centres, wellness centres, and critical care blocks. Additionally, the XV Finance Commission recommended grants totaling Rs. 70,051 crores over five years to strengthen state healthcare systems.

Challenges and the path forward 🔗

While infrastructure numbers show improvement, utilization remains a concern. Many facilities struggle with inadequate supplies, irregular staffing, and poor maintenance. The shift from disease-focused care to comprehensive wellness requires not just upgraded facilities but also continuous training, community engagement, and effective referral linkages between different tiers of the healthcare system.

The success of rural healthcare transformation depends on addressing both supply-side gaps-infrastructure, equipment, medicines, and personnel-and demand-side factors such as awareness, accessibility, and quality of care. States that have innovated with models like Kerala’s Family Health Centres or Delhi’s Mohalla Clinics demonstrate that functional, well-staffed facilities can dramatically improve healthcare utilization.

What do you think? How can rural healthcare systems balance the need for specialized care at CHCs while ensuring basic services remain strong at sub-centres and PHCs? What role should community participation play in making these health facilities more effective and accountable?

References

1. https://www.pib.gov.in/PressReleasePage.aspx?PRID=1896950
2. https://www.pib.gov.in/PressReleasePage.aspx?PRID=2053070
3. https://ruralindiaonline.org/en/library/resource/rural-health-statistics-2021-22/
4. https://pmc.ncbi.nlm.nih.gov/articles/PMC7340764/