As a nation and as a population, India shares with its South and South-East Asian neighbours the legacy of a heavy public health burden shaped by a common historical past. The basic determinants of poverty and food insecurity, compounded by very significant discrimination against women, lie at the core of the region’s public health woes.

As a newly independent country, India emerged with a fair articulation of public health policy and programmes to respond to the urgent health needs of the population. This was evidenced by road maps laid out in various committees such as the Bhore Committee of 1946 and several others subsequently, leading to the High Level Expert Group (HLEG) of the Planning Commission in 2010. These committees formulated the tiered structure of the public health system that exists to this day, laid equal stress on the prevention of illness and the promotion of well-being in addition to curative efforts, and highlighted the critical importance of the social determinants of health. The clarion call for “Health for All” raised at the Alma-Ata conference of 1978 (in present-day Kazakhstan) further reinforced health as a fundamental right, gave primacy to comprehensive primary healthcare, and established healthcare as a primary responsibility of governments. This, it was understood, required massive structural and systemic transformations and the allocation of much needed financial and human resources.

India is now nearing 78 years of Independence. This article considers some trends and vicissitudes in public health policy from the 1980s to date, and where the country stands with respect to the Sustainable Development Goal (SDG) 3 that targets “good health and well-being” by 2030.

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Within this overarching goal, there is no doubt whatsoever that gains have been made in all the areas relating to maternal and child mortality, and infectious disease control (SDG 3.1, 3.2, and 3.3). If one were to look at some summary indicators that generally reflect a complex base of determinants and interventions, maternal mortality ratios are estimated to have decreased from approximately 398 per 1,00,000 live births in the late 1970s to about 99 per 1,00,000 live births in 2020.

Similarly, trends in the undernutrition of children reveal a reduction in stunting from 51.9 per cent to 34.1 per cent while the incidence of underweight children decreased from 45.8 per cent to 29.4 per cent between National Family Health Survey 1 (1992-93) and NFHS 5 (2019-21) (wasting remained much the same). Age-standardised incidence and mortality rates of tuberculosis in India declined from about 390 to 223 and from 122 to 36 per 1,00,000 people over the 30 years from 1990 to 2019 as per the Global Burden of Disease estimates. On the whole, average life expectancy has gone up from 54 in the 1980s to about 70 in current times.

A 1939 photograph of some wards in the Tambaram TB Sanatorium hospital in Madras (now Chennai).
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The Hindu Archives

However, like the rest of the world, India is experiencing an epidemiological transition, wherein the progress made in addressing undernutrition and communicable diseases is being overshadowed by the rapid rise of weight gain and obesity and consequent non-communicable diseases such as diabetes and hypertension.

The increase in life spans is leading to newer geriatric problems as well, besides rising rates of cancers. Here, India is certainly not meeting the challenge of the related SDG goals 3.4 to 3.9 head-on. To illustrate, the prevalence of full-fledged diabetes has risen from 5.5 per cent in the 1990s to over 8-16 per cent in current times, with the increase in actual numbers being even more dramatic. India is now the country with the highest number of diabetics in the entire world, estimated at over a 100 million. Added to this are the undeniable health impacts of climate change and air pollution that disproportionately affect the poor, the marginalised, women and children, and the most vulnerable.

Malnourished children being weighed in a village in Palghar district of Maharashtra in September 2016. The incidence of underweight children decreased from 45.8 per cent to 29.4 per cent between 1992-93 and 2019-21. 
| Photo Credit:
Prashant Nakwe

Even with respect to gains, some facts are immediately evident. First, the rate of positive change has been small: too small to achieve any of the goals that have been repeatedly set over the decades by various public planning processes. Second, the differentials between the data when disaggregated by class, gender, caste, tribal and minority status, or, even more intersectionally, with respect to vulnerabilities such as Particularly Vulnerable Tribal Group status, disability, people in institutional care, and people living on the streets are so stark as to be shocking.

Data not collected

Given that we do not even collect adequate data to demonstrate the enormous and unacceptable inequity that marks the current socio-economic landscape, this can only be demonstrated broadly by some better-known differentials. For instance, a composite health index drawn up by the NITI Aayog in its 4th round (2019-20) places Kerala, Tamil Nadu, and Telangana at the top with Uttar Pradesh, Bihar, and Madhya Pradesh at the bottom, where the larger States are concerned. Notably, the difference, even in this composite indicator, is enormous, with Kerala scoring 82 against 31 for Uttar Pradesh.

The intersectional differentials for life expectancy are equally telling, with average life expectancy being lowest for men living in households from the poorest wealth quintile in rural areas (62.2 years) and highest for women living in households from the richest wealth quintile in urban areas (77.0 years): an average difference of 15 years. While the prevalence of diabetes is currently higher amongst the rich, the richest fifth were respectively 12.4, 10.5, and 2.3 percentage points more likely to be aware of the disease, get treatment, and have it under control than the poorest fifth.

Thus, there can be no doubt that India is in the midst of a massive public health crisis that needs urgent, well-planned, concerted, well-resourced, well-monitored intervention. Equally, there is no doubt that this would need a systems approach.

Narrating the history of health policy shifts is well beyond the scope of this brief article; however, it is important to note the domination of a particular viewpoint in the past few decades. This is well exhibited in a nomenclature that has come to take centre stage: “universal health coverage” (UHC). This has generally been interpreted, for instance by the HLEG in its report, to mean that the government may act as “the guarantor and enabler, although not necessarily the only provider, of health and related services”. In other words, while health may continue to be publicly funded, it may be privately provided. Increasingly, the policy has shifted further to not merely acknowledge the private health sector but to actively promote it.

Notably, India already has among the most privatised (and least regulated) healthcare systems in the world. About 75 per cent of all healthcare needs in the country are met through private players ranging from informal untrained/insufficiently trained practitioners to large, well-resourced, influential, super-specialised corporate hospitals, with the latter dominating. This highly privatised landscape has been marked infamously by high out-of-pocket expenditure (OOPE) and catastrophic health expenditure (CHE), defined as those that push households into poverty (see box).

The HLEG made a pitch against insurance being the primary strategy to achieve affordable health services for all, arguing correctly that the essential elements of primary healthcare, including prevention and promotion, would not be served. Yet, it is the route of insurance schemes that has come to represent the entirety of UHC. The government’s health insurance scheme, the Pradhan Mantri Jan Arogya Yojana (PM-JAY), is its major response to OOPE. It provides a Rs.5 lakh annual cover for households with annual incomes of less than Rs.1.5 lakh, allowing patients to access both government and select private facilities. This has recently been expanded to cover all senior citizens.

Low government spending

Meanwhile, government spending on health has remained well below the repeated promises of 2.5 per cent of the GDP and is currently below 2 per cent. A substantial part of the health budget goes towards PM-JAY while the composite architecture of public health suffers from severe underfunding and critical shortages of human resources.

It is with these challenges that government health facilities must draw patients (and PM-JAY funds) while competing with private facilities where they exist. They continue to serve the poorest and remotest communities with scarce means or motivation to improve quantity and quality. Where people have better access, private care is chosen due to perceptions of better quality, albeit at great financial burden, resulting in OOPE and CHE.

The crowded outpatient department at Victoria Hospital in Bengaluru in September 2013. Government hospitals like this one serve the poorest and remotest communities, but with the scarcest means.
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Along with funnelling public funds towards the private sector through PM-JAY, the government promotes private players in many other ways, including tax benefits and “blended financing” that seek to catalyse grants and concessional capital from public and philanthropic sources for the private sector. There are also State-level schemes and programmes to provide land at highly concessional rates for private health facilities . These include private medical colleges that charge enormous fees justified by the promise of future profits.

The move to promote the private sector as an “industry” results in extremely serious concerns for public health. Currently, about 55 crore people are enrolled in PM-JAY, which is expected to cover about 40 per cent of the population, but typically leaves out the urban poor on income grounds, even though they cannot survive on an income under Rs.1.5 lakh per annum.

Despite the coverage, OOPE and CHE remain high. A simple comparison of OOPE between those availing themselves of private versus public services expectedly reveals that about two-thirds of PM-JAY coverage happens in the private sector, where patients in general incur as much as four times higher CHEs.

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According to a study done in Chhattisgarh in 2021-22, among individuals enrolled under the PM-JAY who used private hospitals, the proportion incurring CHE was as high as 78.1 per cent and 70.9 per cent in 2021 and 2022 respectively, with the overall mean OOPE in private hospitals around 10 times larger than that in public hospitals. The overall absence of strong regulatory frameworks also leads to irrational and unethical practices such as unnecessary caesarean sections (about five times more in the private than the public sector), hysterectomies, and cardiac operations. Thus, not only is public money being routed majorly to private players who consider health a profit-making industry, it is also increasing healthcare costs per se by pushing tertiarisation, medicalisation, and irrationality. Further, the lack of quality services for the most vulnerable perpetuates a situation where those with the poorest health and greatest needs remain the most underserved.

Clearly, this is not a win-win game but a zero-sum game for the struggling, underfunded, and short-staffed public sector that cannot compete in demand-side funding. If the public health sector fails, not only will the most vulnerable remain underserved, India will also continue to lose the battle of substantially reducing ill-health due to a lack of emphasis on prevention. At the same time, it will continue to shovel money into the bottomless pit of the private health industry. As citizens, we end up paying the private sector, first as taxpayers through the government, then again directly as patients.

Health is not a business. India should establish the “Right to Health” in law, claim full state responsibility, invest sufficiently in the public health system, and once and for all release health from the stranglehold of the “industry” logic. 

Vandana Prasad is a public health professional who has been engaged in community policy-level interventions for three decades.