Organisation of Community Health Nursing Services in India

Community health nursing forms the backbone of India’s public healthcare delivery, particularly in rural and underserved areas. These services operate through a well-defined organizational structure that spans from the national level down to the village level, ensuring healthcare reaches even the most remote corners of the country. Understanding how these services are organized helps nursing students appreciate the administrative framework within which they will eventually work and contribute to improving public health outcomes.

The national level: nursing division and its functions 🔗

At the apex of community health nursing services in India sits the nursing division within the Directorate General of Health Services (DGHS) under the Ministry of Health and Family Welfare. This division is headed by the Nursing Adviser, who reports directly to the Secretary of Health and Family Welfare. The Nursing Adviser is assisted by the Deputy Nursing Adviser (also designated as Assistant Director General of Nursing), Deputy Assistant Director of Nursing, Nursing Officers, and support staff.

The nursing division at the national level performs several critical functions. These include formulating and implementing nursing policies aligned with overall healthcare objectives, developing standards for nursing practice, and ensuring their adherence across healthcare facilities nationwide. The division also handles nursing workforce planning, coordinates nursing education reforms, and advises various ministries and departments on matters related to nursing services.

Key responsibilities of the national nursing division 🔗

The national nursing division undertakes policy development and implementation, training and education coordination, licensing and regulation oversight, and quality assurance activities. It also manages research and innovation initiatives, facilitates collaboration with nursing associations and professional organizations, and participates in emergency preparedness planning. The division coordinates with the Indian Nursing Council and professional associations like the Trained Nurses’ Association of India to strengthen the nursing profession across the country.

Challenges at the national level 🔗

Despite having this organizational structure, the nursing profession faces significant challenges at the national level. There is inadequate representation of nurses in high-level health policy committees and boards, which limits their influence on major healthcare decisions. The nursing division operates within a hierarchical structure that can slow down innovation and responsive action. Resource limitations and insufficient budget allocation also affect the division’s ability to implement comprehensive nursing development programs. These constraints have created a situation where, even with a formal organizational framework, nursing professionals often struggle to shape policies that directly impact their practice and community health services.

State level organization of community health nursing 🔗

The organization of community health nursing services at the state level varies across different states but generally follows a structure that aligns with the national framework while adapting to local needs. Most states have nursing officers working within the State Health Directorates, though their designations and authority differ. For example, West Bengal has an elaborate setup with a Deputy Director of Nursing assisted by Assistant Directors and Deputy Assistant Directors, while Tamil Nadu has an Assistant Director of Nursing responsible to the Director of Medical Services.

State Nursing Cells, such as the one in Maharashtra, coordinate nursing education, service delivery, and professional development activities. These cells manage nursing training schools, oversee various nursing cadres, and provide technical guidance to district health officers regarding service matters of nursing personnel. State-level nursing administrators implement national policies adapted to local contexts, develop state-specific nursing initiatives, and coordinate with nursing education institutions to ensure adequate workforce supply.

District level: the operational heart of community health nursing 🔗

The district level represents where community health nursing services become operational and reach the population directly. The nursing hierarchy at this level comprises several key positions that work together to deliver primary healthcare services.

District Public Health Nurse (DPHN) 🔗

The DPHN represents the highest nursing authority at the district level and oversees all public health nursing activities across the district. This position is responsible for supervising nursing personnel at Community Health Centres (CHCs) and Primary Health Centres (PHCs), implementing public health programs, and coordinating with district health officials to ensure effective healthcare delivery.

Public Health Nurse (PHN) 🔗

Working under the DPHN, Public Health Nurses implement public health programs, conduct health education sessions, and provide technical guidance to other nursing staff. They play a significant role in strengthening preventive and promotive health services at the primary healthcare level.

Lady Health Visitor (LHV) 🔗

LHVs typically supervise the work of Auxiliary Nurse Midwives and provide maternal and child health services at PHCs and sub-centres. Once an ANM has five or more years of experience, she can pursue six months of promotional training to become a Lady Health Visitor. This career progression pathway provides opportunities for professional growth within the community health nursing framework.

Auxiliary Nurse Midwife (ANM) 🔗

ANMs form the frontline workforce of community health nursing, providing primary healthcare services at sub-centres, which are the most peripheral health facilities in rural areas. The ANM cadre was created in the 1950s to focus on maternal and child health, including midwifery and child health within the first two years of life. Today, ANMs are recognized as multipurpose health workers responsible for maternal and child health, family planning services, health and nutrition education, immunization, environmental sanitation efforts, treatment of minor injuries, and first aid in emergencies.

Under the current National Health Mission, ANMs are placed at sub-centres catering to a population of 5,000 in plain areas and 3,000 in hilly and tribal areas. They work in coordination with Accredited Social Health Activists (ASHAs) and Anganwadi Workers to ensure comprehensive community health coverage.

The Bhore Committee’s vision and its implementation gap 🔗

The organizational framework for community health nursing in India has its roots in the landmark Bhore Committee Report of 1946. Officially known as the Health Survey and Development Committee, this body was appointed in 1943 under Sir Joseph Bhore to survey health conditions and organizations in India and make recommendations for future development.

The committee made a significant recommendation regarding the deployment of Public Health Nurses at Primary Health Centres. According to the committee’s short-term plan, each PHC serving a population of 40,000 was to be staffed by two doctors, one nurse, four public health nurses, four midwives, four trained dais, two sanitary inspectors, two health assistants, one pharmacist, and fifteen other class IV employees. The committee envisioned PHNs working alongside medical officers to strengthen primary healthcare delivery, especially for maternal and child health services.

Why the recommendation remains unimplemented 🔗

However, this recommendation has not been widely implemented across India. Instead of posting qualified PHNs at PHCs as the Bhore Committee envisioned, the system has evolved with ANMs and LHVs forming the backbone of primary healthcare delivery at the grassroots level. This deviation from the original recommendation has created certain gaps in service delivery, particularly in specialized nursing care and health education at the primary level.

The evolution of the health system saw ANMs, originally temporary workers focused on midwifery, gradually take on expanded responsibilities including family planning, immunization, and infectious disease prevention. While this expanded their scope of work, it also meant that the specialized PHN cadre recommended by the Bhore Committee never fully materialized at the PHC level in most states.

Modern developments and emerging roles 🔗

Recent initiatives have attempted to strengthen community health nursing services in India. The National Health Mission has emphasized increasing healthcare delivery points and enhancing facilities available at these points. This includes increasing the number of staff nurses and ANMs while also focusing on improving their production capacity through nursing education institutions.

The introduction of Community Health Officers (CHOs), often nurses with additional training, at Ayushman Bharat Health and Wellness Centres represents a significant step toward realizing the Bhore Committee’s vision of qualified nursing professionals at the primary healthcare level. These mid-level healthcare providers are expanding the scope of services available at peripheral health facilities and bridging the gap between basic ANM services and more comprehensive nursing care.

The path forward for community health nursing organization 🔗

Strengthening the organization of community health nursing services requires addressing several systemic issues. Professional development pathways need clearer definition to allow community health nurses to advance their careers while remaining in service delivery roles. Greater representation of nursing professionals in health policy committees would ensure that policies affecting nursing practice are informed by practitioners’ insights and experiences.

Digital health initiatives are transforming record-keeping and monitoring processes, making supervision and coordination more effective. States like Maharashtra have established structured State Nursing Cells that could serve as models for other states seeking to strengthen their nursing administration. Regular capacity building, including clinical mentoring and skill-based training, remains essential for maintaining and improving the quality of services provided by community health nurses at all levels.

What do you think? How might better implementation of the Bhore Committee’s recommendations for deploying Public Health Nurses at Primary Health Centres improve healthcare delivery in rural India? What administrative changes would help community health nurses gain greater influence in shaping health policies that affect their practice?

References

1. https://dghs.mohfw.gov.in/nursing.php
2. https://phd.maharashtra.gov.in/en/scheme/state-nursing-cell/
3. https://chwcentral.org/indias-auxiliary-nurse-midwife-anganwadi-worker-accredited-social-health-activist-multipurpose-worker-and-lady-health-visitor-programs/
4. https://en.wikipedia.org/wiki/Auxiliary_nurse_midwife
5. https://pmc.ncbi.nlm.nih.gov/articles/PMC6934276/
6. https://pmc.ncbi.nlm.nih.gov/articles/PMC11414765/
7. https://en.wikipedia.org/wiki/Bhore_Committee
8. https://pmc.ncbi.nlm.nih.gov/articles/PMC5144115/