India's Healthcare Delivery System & Nursing Services

Introduction

Welcome to this comprehensive guide on India’s healthcare delivery system and nursing services! This resource is designed to help nursing students understand the complex healthcare framework in India, the evolution of nursing education, and the current trends and challenges facing the nursing profession.

Throughout this guide, you’ll find visual aids, mnemonics, flowcharts, and other memory tools to help you retain this important information. Let’s dive in!

Learning Objectives

Understand the structure and components of India’s current healthcare delivery system
Trace the planning and development of nursing services and education at global and national levels
Identify recent trends and issues in nursing service and management
Analyze the challenges and opportunities in the nursing profession in India

Current Healthcare Delivery System of India

Overview

India has a mixed healthcare delivery system with both public and private components. The healthcare infrastructure in India is organized in a three-tier system based on population norms as recommended in the landmark Bhore Committee Report of 1946.

Three-Tier Structure of India’s Public Healthcare System

Three-tier structure of India's healthcare system

Source: ResearchGate, Three-tier rural Healthcare system in India

Mnemonic: “PST” for India’s Healthcare Tiers

Primary Care: Sub-centers & Primary Health Centers (First contact point)
Secondary Care: Community Health Centers (Specialist care)
Tertiary Care: District/Specialized Hospitals (Advanced medical care)

Primary Level

1. Sub-centers (SCs)

Population coverage: 5000 people (plain areas) or 3000 people (hilly/difficult/tribal areas)
Staff: At least one Auxiliary Nurse Midwife (ANM)/female health worker and one male health worker
Under NRHM: Provision for one additional ANM on contract basis
Services: Maternal and child health, family welfare, nutrition, immunization, diarrhea control, and communicable disease control programs

2. Primary Health Centers (PHCs)

Population coverage: 30,000 people (plain areas) or 20,000 people (hilly/difficult/tribal areas)
Staff: Medical officer supported by 14 paramedical and other staff
Under NRHM: Two additional staff nurses on contract basis
Capacity: 4-6 beds for in-patients
Acts as referral unit for 5-6 SCs
Services: Health promotion and curative services

Secondary Level

Community Health Centers (CHCs)

Population coverage: 120,000 people (plain areas) or 80,000 people (hilly/difficult/tribal areas)
Staff: Four medical specialists (surgeon, physician, gynecologist/obstetrician, pediatrician) supported by 21 paramedical and other staff
Capacity: 30 beds with operating theater, X-ray, labor room, and laboratory facilities
Serves as referral center for PHCs within the block
Provides facilities for obstetric care and specialist consultations

Tertiary Level

District Hospitals and Specialized Care Centers

Highest level of public healthcare
Provides specialized healthcare services
Advanced diagnostic and treatment facilities
Teaching hospitals and medical college hospitals

First Referral Units (FRUs)

An existing facility (district hospital, sub-divisional hospital, CHC) can be declared a fully operational FRU only if it meets specific criteria:

Three Critical Determinants of a FRU:

Emergency obstetric care including surgical interventions such as caesarean sections
Care for small and sick newborns
Blood storage facility on a 24-hour basis

National Rural Health Mission (NRHM)

Launched in 2005, NRHM was a watershed moment for India’s health sector, aiming to provide effective healthcare to the rural population with a special focus on 18 states having weak public health indicators and/or weak infrastructure.

Key Achievements of NRHM (2005-2013)

Human resources: 931,239 Accredited Social Health Activists (ASHAs), 27,421 doctors, 4,078 specialists, 40,119 staff nurses, 72,984 ANMs
Management: 618 District Program Managers and 633 District Accounts Managers deployed
Infrastructure: More than 30,000 ambulances deployed nationwide
Community participation: 499,210 Village level Health Sanitation and Nutrition Committees created
Finances: Total investment of 21 billion USD by the central government (2005-2015)
Education: Graduate medical capacity increased by 54% and post-graduate medical seats by 74% (2009-2013)

Recent Initiatives and Developments

1. Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) Approach

Launched in 2013, this approach recognized that newborn health and survival is inextricably linked to women’s health across all life stages.

Specific interventions include:

Delivery of antenatal care package and tracking of high-risk pregnancies
Skilled care at birth, emergency obstetric care, and postpartum care
Home-based newborn care and prompt referral
Facility-based care of the sick newborn
Integrated management of common childhood illnesses

2. Ayushman Bharat

Launched in 2018, it consists of two major initiatives:

Health and Wellness Centers: Upgrading SCs and PHCs to provide comprehensive primary healthcare
Pradhan Mantri Jan Arogya Yojana (PM-JAY): World’s largest health insurance scheme, providing coverage up to ₹5 lakhs per family per year for secondary and tertiary care hospitalization

3. Digital Health Initiatives

Ayushman Bharat Digital Mission: Creating digital health IDs for all citizens
Telemedicine: Expansion during COVID-19 through eSanjeevani platform
Electronic Health Records: Standardization and implementation

Current Challenges in India’s Healthcare System

Critical Challenges

Inadequate Infrastructure: Shortage of healthcare facilities, especially in rural areas
Workforce Shortages: Insufficient doctors, nurses, and other healthcare professionals
Urban-Rural Divide: Concentration of healthcare facilities in urban areas
Financial Barriers: High out-of-pocket expenditure leading to catastrophic health spending
Quality of Care: Variation in standards of care across facilities
Governance Issues: Weak regulatory mechanisms and accountability systems

Planning and Development of Nursing Services and Education

Historical Evolution of Nursing in India

Pre-Independence Era (Before 1947)

• 1871: First School of Nursing established in Madras

• 1908: Formation of Trained Nurses Association of India (TNAI)

• 1926: Indian Nursing Council Act passed but not implemented

Post-Independence (1947-1970)

• 1947: Indian Nursing Council (INC) established

• 1950s: Bachelor of Nursing programs started

• 1959: First Master’s program in nursing at RAK College of Nursing, Delhi

• 1960s: Nursing recognized as professional service

Expansion Period (1970-2000)

• 1972: Nursing included in 5th Five Year Plan

• 1988: First PhD in Nursing at SNDT Women’s University, Mumbai

• 1992: Introduction of specialized nursing courses

• 1998: Major curriculum revisions by INC

Modern Era (2000-Present)

• 2005: NRHM launched with focus on rural health workforce

• 2013: RMNCH+A strategy with emphasis on maternal and child health

• 2017: National Health Policy emphasized specialized nursing training

• 2023: National Nursing and Midwifery Commission Act passed

Structure of Nursing Education in India

Source: International Journal for Equity in Health – BioMed Central

Current Nursing Education Structure

Program	Duration	Eligibility	Annual Output (Approx.)
Auxiliary Nurse Midwifery (ANM)	2 years	10+2 in any stream	Not specified
General Nursing and Midwifery (GNM)	3.5 years	10+2 with 40% marks	134,949
B.Sc. Nursing (Basic)	4 years	10+2 with PCB and 45% marks	107,814
Post Basic B.Sc. Nursing	2 years	GNM with 2 years experience	25,485
M.Sc. Nursing	2 years	B.Sc. Nursing with 1 year experience	13,971
M.Phil./Ph.D. in Nursing	2-5 years	M.Sc. Nursing	Limited

Mnemonic: “CAREER” in Nursing Education Governance

Council (Indian Nursing Council) – National regulatory body
Approval of nursing institutions and programs
Regulation of curriculum and standards
Examination and certification standards
Enrollment of qualified nurses in the register
Reciprocity with nursing councils of other countries

Recent Developments in Nursing Curriculum

Key Reforms in Nursing Education

Competency-Based Education: Shift from knowledge-based to competency-based curriculum
CGPA System: Implementation of Cumulative Grade Point Average for academic evaluation
Semester System: Division of academic year into semesters for better assessment
Self-Directed Learning: Emphasis on providing environment for self-directed learning
Technology Integration: Use of simulation, e-learning, and digital tools
Specialization Options: Introduction of various specializations in nursing education

Global Scenario of Nursing Education

Aspect	Global Trends	India’s Status
Minimum Educational Requirement	Bachelor’s degree increasingly becoming standard	Diploma (GNM) still widely accepted for practice
Advanced Practice Roles	Nurse Practitioners, Clinical Nurse Specialists recognized and autonomous	Limited recognition of advanced practice roles
Technology Integration	Advanced simulation labs, VR/AR, digital health records training	Growing but limited to certain institutions
Research Focus	Strong emphasis on evidence-based practice and nursing research	Emerging focus, limited resources and opportunities
Continuing Education	Mandatory for license renewal in many countries	Not consistently required or enforced
Nurse-Patient Ratio Standards	Legally mandated in many developed countries	No legally enforced standards

International Mobility of Indian Nurses

Indian nurses are highly valued internationally, with significant migration to countries like:

United States
United Kingdom
Australia
Canada
Gulf Countries (UAE, Saudi Arabia, Kuwait, etc.)

Impact of Nurse Migration

Positive Effects

Remittances to home country
Knowledge and skill transfer upon return
International recognition of Indian nursing
Better professional opportunities

Negative Effects

Brain drain from Indian healthcare system
Shortage of experienced nurses
Loss on investment in education
Quality of care impacts in domestic settings

Recent Trends and Issues in Nursing Service and Management

Current Challenges in Nursing Profession

Nursing Workforce Challenges in India

Source: HealthLeaders Media – Top 5 Challenges in Nursing

Nursing Shortage

India has nurse-to-population ratio of 1:670, compared to WHO standard of 1:300
Estimated shortage of 4.3 million nurses to meet WHO norms
Uneven distribution across urban and rural areas
High turnover rates due to working conditions

Working Conditions

Poor staffing ratios, especially in government hospitals
Long working hours leading to burnout
Lack of adequate facilities and support systems
Safety concerns and workplace violence
Psychological stress, especially highlighted during COVID-19

Economic Concerns

Low pay scales compared to other professionals with similar qualifications
Discrepancies between private and public sector compensation
Lack of standardized minimum wages based on qualifications
Limited financial incentives for specialization or higher education
Economic factors driving international migration

Theory-Practice Gap

Disconnect between nursing education and clinical practice
Limited clinical exposure during training
Inadequate clinical facilities for practice
Limited simulation and skill labs
Need for mentorship and clinical support systems

Regulatory Issues

Weak regulatory bodies and enforcement
Insufficient representation of nurses in policy-making
Lack of amendment of nursing acts
Undermined leadership positions
Proliferation of nursing institutions without quality control

Technological Adaptation

Need for training in new healthcare technologies
Limited digital literacy among nursing workforce
Inadequate infrastructure for technology integration
Gaps in telenursing and digital health competencies
Limited research on technology application in nursing

Emerging Trends in Nursing Services

Mnemonic: “DIGITAL” Nursing Trends

Digital Health Records & Informatics
Integrated Care Models
Global Nursing Mobility
Innovative Teaching Methodologies
Telehealth & Remote Care
Advanced Practice Roles
Leadership Development

Technological Advancements in Nursing

Telenursing: Remote patient monitoring and consultation
Mobile Health: Use of apps for patient education and monitoring
Simulation-Based Training: High-fidelity mannequins and virtual reality
Electronic Health Records: Digital documentation and data management
AI and Predictive Analytics: For patient risk assessment
Wearable Technology: For patient monitoring and health promotion

Expansion of Nursing Research

Evidence-Based Practice: Integration of research into care
Clinical Trials: More nurses leading and participating
Systematic Reviews: Critical analysis of existing literature
Meta-analyses: Statistical combining of results from multiple studies
Collaborative Research: Interdisciplinary and international partnerships
Implementation Science: Translating research into practice

Faculty Development Challenges

Qualification requirements: Many institutions struggle to recruit faculty with required qualifications
Continuing education: Limited opportunities for faculty development and continuing education
Research capacity: Insufficient training and resources for conducting research
Teaching methodologies: Need for training in modern pedagogical approaches
Technology competence: Gaps in digital literacy and technology use in teaching
Clinical expertise: Faculty often lack recent clinical experience

Cultural Diversity in Nursing

Cultural Competence in Nursing

India’s diverse population requires nurses to develop cultural competence to provide effective care across different communities.

Challenges

Diverse languages and communication barriers
Varied health beliefs and practices
Different dietary customs and restrictions
Religious practices impacting healthcare decisions
Traditional medicine use alongside modern healthcare

Opportunities

Learning from diverse perspectives
Developing versatile communication skills
Building cultural competence applicable globally
Enhanced patient satisfaction through cultural sensitivity
Integration of beneficial traditional practices

Future Opportunities and Solutions

Policy Level

Strengthening nursing regulatory bodies
Standardizing nurse-patient ratios
Implementing qualification-based pay scales
Developing career advancement pathways
Including nurses in policy-making committees
Ensuring quality control in nursing education

Institutional Level

Creating better working environments
Implementing mentorship programs
Investing in continuing education
Enhancing clinical simulation facilities
Developing research infrastructure
Promoting leadership development
Supporting work-life balance initiatives

Individual Level

Pursuing continuous professional development
Developing specialized clinical skills
Engaging in research activities
Building technological competence
Participating in professional organizations
Advocating for the nursing profession
Mentoring junior nurses

Conclusion

India’s healthcare delivery system has undergone significant transformation since independence, with the development of a three-tier structure and various national programs and initiatives. The nursing profession has evolved alongside this system, facing both challenges and opportunities in education, service, and management.

The future of nursing in India depends on addressing persistent systemic challenges such as workforce shortages, economic concerns, and regulatory issues. At the same time, embracing emerging trends in technology, research, and specialized care will help advance the profession and improve healthcare outcomes.

By strengthening nursing education, improving working conditions, enhancing career pathways, and ensuring greater representation in policy decisions, nurses can play a pivotal role in achieving India’s healthcare goals and providing quality care to its diverse population.

Key Takeaways

India’s healthcare system operates on a three-tier structure with primary, secondary, and tertiary levels of care.
National initiatives like NRHM and RMNCH+A have significantly impacted healthcare delivery and nursing services.
Nursing education in India has evolved from basic training to specialized education at graduate and post-graduate levels.
Major challenges include nursing shortages, poor working conditions, economic concerns, and regulatory issues.
Emerging trends include technological integration, expanded research scope, and cultural competence development.
Multi-level solutions involving policy changes, institutional improvements, and individual development are needed.
The future of nursing in India requires balancing global standards with local healthcare needs and contexts.

References

Health systems in India – PMC – PubMed Central. https://pmc.ncbi.nlm.nih.gov/articles/PMC5144115/
Transformation in nursing education in India: Current issues – IJMPO. https://www.ijmpo.com/html-article/14978
State of nursing in India: Persistent systemic challenges – PMC. https://pmc.ncbi.nlm.nih.gov/articles/PMC9547647/
India | International Health Care System Profiles. https://www.commonwealthfund.org/international-health-policy-center/countries/india
Healthcare Industry in India – IBEF. https://www.ibef.org/industry/healthcare-india
Nursing Services in India. https://www.tnaijournal-nji.com/admin/assets/article/pdf/10860_pdf.pdf
Development of nursing education in India: past, present and future. https://www.ijcmph.com/index.php/ijcmph/article/download/13361/8053/64460
Nursing Shortage in India: Are There Solutions for Policymakers? https://journals.lww.com/ijcn/fulltext/2024/07000/nursing_shortage_in_india__are_there_solutions_for.3.aspx
Top 10 Nursing Trends for 2025 | Purdue Global. https://www.purdueglobal.edu/blog/nursing/top-10-nursing-trends/
7 Growing Trends in Nursing Education | University of Cincinnati. https://online.uc.edu/blog/seven-growing-trends-in-nursing-education/

India’s Healthcare Delivery System & Nursing Services