India's Public Health System

Levels of Care:

Public vs. Private Healthcare:

Traditional Medicine (AYUSH):

Evolution of Health Policies & Committees:

Summary Table of Policies:

Challenges of Public System:

Despite its vast network, the public health system is plagued by chronic underfunding, dilapidated infrastructure, shortage of qualified personnel (especially specialists in rural areas), lack of equipment, and often low quality of care. This forces a large population, particularly the poor, to rely on expensive private care.

Implications of Private Sector Dominance:

• High OOP Expenditure: Most prominent implication. Drives families into poverty or debt, hindering access to necessary care.
• Equity Concerns: Private sector is market-driven; it prioritizes profit, leading to concentration in urban areas and neglect of rural, underserved regions and vulnerable populations.
• Quality & Ethical Concerns: Lack of stringent regulation can lead to over-prescription, unnecessary procedures, and unethical practices.
• Regulation: Need for robust regulatory frameworks to ensure affordability, quality, and ethical practices in the private sector.

Integration of AYUSH:

• Potential: Offers culturally acceptable, often affordable, and holistic approaches to health. Can expand reach of healthcare, especially for chronic diseases and preventive care.
• Challenges: Lack of standardization, scientific validation of all practices, quality control issues, and resistance from mainstream medical practitioners. Need for evidence-based integration.

Evolutionary Trends:

India's health policies show an evolution from a focus on specific disease control to a more comprehensive, holistic primary healthcare approach (post-Alma Ata) and now towards Universal Health Coverage, recognizing health as a fundamental right and a key driver of human development. The emphasis has shifted from "vertical" (disease-specific) programs to "horizontal" (system-strengthening) interventions.

Demographic & Epidemiological Indicators:

• Infant Mortality Rate (IMR): Deaths of infants under 1 year per 1,000 live births. Trend: Decreasing. (SRS 2021: 28).
• Maternal Mortality Rate (MMR): Maternal deaths per 100,000 live births. Trend: Decreasing. (SRS 2018-20: 97).
• Total Fertility Rate (TFR): Average children born to a woman. Trend: Decreasing, below replacement level. (NFHS-5: 2.0).
• Life Expectancy at Birth: Trend: Increasing. (Economic Survey 2022-23: approx. 69.4 years).
• Disease Burden:
  • Communicable Diseases (CDs): Significant but declining (TB, HIV/AIDS, Malaria).
  • Non-Communicable Diseases (NCDs): Rising rapidly (Diabetes, Hypertension, Cancer, CVDs). Leading cause of morbidity and mortality. This represents the epidemiological transition.
  • Mental Health: Significant and growing burden (depression, anxiety, suicide).

Disparities:

Access & Quality Concerns:

• Availability of facilities: Uneven distribution; rural areas lack adequate facilities.
• Human Resources: Severe shortage of doctors (especially specialists), nurses, paramedics, particularly in public sector and rural areas. Low doctor-patient ratio.
• Quality of Care: Concerns regarding diagnostic accuracy, treatment protocols, patient safety, medical negligence.
• Drug Availability: Issues of stock-outs in public facilities, affordability of essential medicines in private sector.
• Affordability (Out-of-Pocket Expenditure - OOP): Over 60% of total health expenditure is OOP, one of the highest globally, pushing millions into poverty annually.

Summary Table of Key Health Indicators:

Analysis of Disparities:

Health disparities are not random but systematically linked to socio-economic status, geography, gender, and caste. These are often the result of historical injustices, unequal distribution of resources, and institutional biases. For example, tribal communities in remote areas not only lack access to health facilities but also face cultural barriers to seeking care from mainstream providers.

Reasons for Disparities:

• Socio-economic: Poverty, illiteracy, lack of awareness, and malnutrition reinforce poor health outcomes.
• Geographical: Lack of infrastructure, human resources, and connectivity in rural/remote areas.
• Gender/Caste: Discrimination, lower decision-making power, limited mobility.
• Political Will & Governance: Uneven prioritization of health by state governments, implementation gaps.

Impact on Development:

• Reduced Human Capital: Impaired cognitive and physical development, lower productivity.
• Increased Poverty: Catastrophic health expenditures push families into debt.
• Hindered Economic Growth: Lost productivity and increased burden on social security.
• Inequality: Health disparities exacerbate existing social and economic inequalities.

Epidemiological Transition:

India is experiencing a dual disease burden: still grappling with communicable diseases (TB, malaria) while simultaneously facing a rapid rise in NCDs. This poses a unique challenge requiring integrated health strategies. Mental health is an emerging crisis, demanding greater attention and resource allocation due to its stigma and lack of awareness.

National Health Mission (NHM), 2005:

• Components: National Rural Health Mission (NRHM) and National Urban Health Mission (NUHM).
• Objectives: Achieve universal access to equitable, affordable, quality healthcare. Targets reduction of IMR, MMR, TFR, and disease burden.
• ASHA (Accredited Social Health Activist) workers: Village-level female health activists under NHM, crucial for community mobilization, MCH services.
• Janani Shishu Suraksha Karyakram (JSSK), 2011: Free entitlements for pregnant women and sick neonates in public health institutions.
• Rashtriya Bal Swasthya Karyakram (RBSK), 2013: Child Health Screening and Early Intervention Services, covering 4Ds: Defects at birth, Deficiencies, Diseases, Developmental delays.

Ayushman Bharat (AB), 2018:

Disease-Specific Programs:

• National Tuberculosis Elimination Programme (NTEP): Aims for TB elimination by 2025. Provides free diagnosis, treatment (DOTS), and financial incentives.
• National AIDS Control Organisation (NACO): Manages India's HIV/AIDS prevention and control programs.
• National Programme for Prevention and Control of Cancer, Diabetes, CVD & Stroke (NPCDCS): Focuses on prevention, early diagnosis, treatment for NCDs.
• National Mental Health Programme (NMHP): Aims to provide mental health services at all levels, promote mental health, and prevent mental illness.

Vaccination & Immunization:

• Universal Immunization Programme (UIP), 1985: Provides free vaccines against 12 vaccine-preventable diseases.
• Mission Indradhanush, 2014: Aims to rapidly increase full immunization coverage in areas with low rates, targets unvaccinated/partially vaccinated children and pregnant women.

Summary Table of Major Government Health Schemes:

Evaluation of Impact:

• Successes: Significant improvements in IMR, MMR, TFR, and institutional deliveries due to NHM and JSSK. PMJAY has provided financial protection to millions. HWCs are shifting focus to comprehensive primary care. Immunization coverage has improved.
• Limitations:
  • Quality of Care: While access has increased, quality remains a major concern.
  • Financing Issues: Continued reliance on low public spending.
  • Human Resource Shortages: Schemes cannot fully compensate for systemic HR gaps.
  • Implementation Gaps: Regional disparities, bureaucratic hurdles, lack of awareness.
  • PMJAY Debates: Concerns about reliance on private sector, impact on public system, potential for fraud.

Challenges in Implementation:

• Federal Structure: Health is a state subject; success depends on state governments' commitment.
• Capacity Building: Training and retaining sufficient skilled personnel.
• IT Infrastructure: For digital health initiatives like ABDM and PMJAY.
• Community Participation: Sustained engagement beyond initial mobilization.
• Addressing NCDs: Requires behavioral change, harder than infectious disease control.
• Fragmented Approach: Health programs often still operate in silos despite convergence attempts.

Role of ASHA workers:

They are the backbone of primary healthcare delivery, especially in rural areas. Their contribution to maternal and child health, immunization, and community health needs is immense. However, they face challenges of low remuneration, heavy workload, and lack of adequate support.

Major Challenges:

Reforms & Way Forward: