Ayushman Bharat HWCs: Expanding NCD Services Across India

India’s health system has long been challenged by a double burden: the persistent demands of maternal and child care alongside the rapidly rising tide of non-communicable diseases (NCDs) like diabetes, hypertension, cancer, and stroke. To address this shift, the government launched the Ayushman Bharat Health and Wellness Centre (HWC) scheme in 2018, transforming the country’s primary healthcare backbone. Now rebranded as Ayushman Arogya Mandir, these centres are designed to bring screening, treatment, and follow-up for chronic diseases closer to where people actually live.

From sub-centres to wellness hubs 🔗

For decades, sub-health centres (SHCs) across rural India operated as the smallest unit of public healthcare, mainly delivering reproductive, maternal, newborn, child, and adolescent (RMNCH+A) services. They were limited in scope, often poorly stocked, and rarely equipped to handle chronic illnesses. The HWC scheme was launched on 14 April 2018, when the first centre opened at Jangla, Bijapur, in Chhattisgarh, with the goal of converting 1,50,000 SHCs and Primary Health Centres into HWCs by December 2022.

The core principle is simple: time to care should not exceed 30 minutes. Each HWC serves a population of 3,000 to 5,000 in plains and 3,000 in tribal, hilly, or desert areas. The redesigned centres deliver Comprehensive Primary Health Care (CPHC) that is universal, free at the point of use, and spans preventive, promotive, curative, rehabilitative, and palliative care.

Scale and reach so far 🔗

As of 31 July 2024, 1,73,881 Ayushman Arogya Mandirs had been operationalised across India, with a cumulative footfall of 317.34 crore visits. The centres have recorded over 84 crore hypertension screenings, 74 crore diabetes screenings, and nearly 50 crore oral cancer screenings, alongside breast and cervical cancer screening drives. These numbers reflect a major shift from episodic care to population-based, continuous service delivery.

The 12 essential service packages 🔗

Unlike the old sub-centre model, the HWC is built around an expanded package of services. The Ministry of Health and Family Welfare has structured these into twelve thematic packages, which are being rolled out in incremental phases.

What the packages cover 🔗

The twelve packages include care in pregnancy and childbirth, neonatal and infant healthcare, childhood and adolescent care, family planning and reproductive health, management of communicable diseases, general outpatient care for acute illnesses, and screening, prevention, and management of NCDs including diabetes, hypertension, and the three common cancers – oral, breast, and cervical. The remaining packages cover basic oral healthcare, eye and ENT care, mental health services, geriatric and palliative care, and emergency medical care, along with screening and basic management of chronic communicable diseases like tuberculosis and leprosy.

This is a fundamental departure from the earlier system. By bringing NCD care into the basket of 12 CPHC services, the scheme acknowledges that chronic conditions now account for the largest share of the disease burden and cannot be managed only at tertiary hospitals.

How NCD services actually work at an HWC 🔗

The NCD module focuses on adults aged 30 years and above. Field workers, mainly ASHAs (Accredited Social Health Activists), conduct house-to-house enumeration and fill the Community-Based Assessment Checklist (CBAC) to identify people at risk. Those screened positive are referred to the HWC for confirmatory testing of blood pressure, blood glucose, and visual examination for oral, breast, and cervical cancers.

Once a diagnosis is confirmed, treatment is initiated at the HWC itself, often through teleconsultation with a medical officer at the linked PHC. Medicines are dispensed free of cost, and patients are followed up monthly. A facility assessment in Chhattisgarh found that an HWC treats an average of 358 outpatients per month, of whom 128 are NCD patients – a clear indicator that chronic disease care is now anchored at the primary level.

Mental health, elderly care, and the wider basket 🔗

The expanded package also includes screening for common mental health conditions like depression and anxiety, basic management of stress-related disorders, and referral for severe cases. Elderly and palliative care services include home-based follow-up for bedridden patients, pain management, and counselling for caregivers. However, real-world studies suggest awareness of these services is still uneven – a study in Marh block of Jammu found that only 10 per cent of community members were aware of mental health screening, while 62 per cent recognised NCD-related home visits.

The mid-level provider: the heart of the HWC 🔗

The single biggest human resource innovation of the scheme is the creation of a new cadre called the Mid-Level Health Provider (MLHP), who functions as a Community Health Officer (CHO) at each HWC. This is the first time India has formally institutionalised a non-physician clinical provider in the public system at scale.

Who becomes a CHO and how they are trained 🔗

A CHO can be a BSc in Community Health, a nurse (GNM or BSc Nursing), or an Ayurveda graduate (BAMS) who has completed a structured certificate programme. The programme is delivered through IGNOU and select state public health universities and includes a six-month Certificate in Community Health (CCH) covering primary care competencies, public health management, and use of digital tools.

The training emphasises clinical protocols for the most common conditions encountered at the primary level. Modules cover hypertension and diabetes management using standard treatment guidelines, screening protocols for the three common cancers, identification of TB and leprosy symptoms, mental health screening using validated tools, and emergency stabilisation before referral. An induction module developed by the National Health Systems Resource Centre further covers leadership, team management, and use of the Health Management Information System.

What the CHO does every day 🔗

The CHO leads a primary care team that typically includes a male and female Multi-Purpose Worker (MPW) and several ASHAs from the catchment area. A typical day at an HWC involves running the morning OPD, dispensing medicines for chronic disease patients, conducting yoga and wellness sessions, supervising ASHA-led screening drives, and entering data on the HWC portal. The CHO also conducts teleconsultations through the eSanjeevani platform, connecting patients to specialists at higher facilities without the need for travel.

Crucially, the CHO holds the prescription authority for a defined list of medicines under standing orders, which means a patient with diabetes or hypertension does not need to travel repeatedly to a PHC or district hospital for routine refills.

Performance-linked payments and continuity of care 🔗

To incentivise quality, the government introduced performance-linked payments tied to specific service indicators such as number of people screened, follow-ups completed, and teleconsultations conducted. This has helped sustain motivation, but an evaluation in Dhamtari district, Chhattisgarh noted a 41 per cent shortfall in CHO availability and gaps in equipment and medicine supply, suggesting that the cadre is still being scaled up.

Why this matters for the larger NCD response 🔗

The HWC scheme is the operational arm of the National Programme for Prevention and Control of Non-Communicable Diseases (NP-NCD), through which India aims to meet the global target of a 25 per cent relative reduction in premature NCD mortality by 2025. Without a functional first contact point that can identify, treat, and follow up patients close to home, this target is unreachable.

The model also rebalances India’s health system. Historically, secondary and tertiary hospitals have absorbed the bulk of NCD load, leading to overcrowding and high out-of-pocket expenditure. By shifting screening and stable disease management to HWCs and reserving hospitals for complications and acute episodes, the scheme is designed to decongest higher facilities and reduce costs for households.

Persistent challenges 🔗

The scheme is not without limitations. Infrastructure deficits, irregular drug supplies, weak internet connectivity hampering teleconsultation, and shortfalls in trained CHOs continue to slow progress in many states. Mental health and palliative care, while listed in the package, remain the least developed. Community awareness about the full range of services also lags, with many people still thinking of these centres as maternal-and-child facilities.

Still, with over 1.73 lakh centres operational and an integrated digital backbone connecting screenings, prescriptions, and referrals, the Ayushman Arogya Mandir programme is the most ambitious primary healthcare reform the country has attempted since the National Rural Health Mission of 2005.

What do you think? Should India invest further in expanding the role of mid-level providers like CHOs to fully manage chronic diseases, or should every HWC be staffed with a full-time medical officer? And how can community awareness of the less-utilised services like mental health and palliative care be strengthened at the village level?

References

1. https://ab-hwc.nhp.gov.in/home/aboutus
2. https://nhsrcindia.org/AB-HWCs-map-table
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4. https://pmc.ncbi.nlm.nih.gov/articles/PMC12550422/
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7. https://www.ignou.ac.in/
8. https://www.ijcmph.com/index.php/ijcmph/article/view/13558
9. https://esanjeevaniopd.in/
10. https://pmc.ncbi.nlm.nih.gov/articles/PMC12356159/