The public health system

The first principle

Illness is one of the commonest reasons a household slips into poverty, because it stops earning and starts spending at the same moment. A public health system exists to break that link: it prevents what can be prevented, treats what cannot, and spreads the cost across society so that no family pays for a hospital stay by selling its land. The design question is always the same, namely how much of this the State should provide itself, how much it should buy from others, and how close to the household the first point of care should sit.

The core

Constitutional and legal base

• A state subject with a national duty. "Public health and sanitation; hospitals and dispensaries" is Entry 6 of the State List, so states run most hospitals and employ most health workers, while the Union funds national programmes and regulates medicines and medical education through the Concurrent List. Article 47 directs the State to treat raising the level of nutrition and improving public health as among its primary duties.
• Health as part of the right to life. In Paschim Banga Khet Mazdoor Samity v State of West Bengal (1996), a man with head injuries was turned away by several government hospitals, and the Supreme Court held that failure to provide timely medical treatment violates Article 21. Lack of funds, the Court said, cannot excuse this duty.

The three tier structure

• Where it came from. The Health Survey and Development Committee, chaired by Sir Joseph Bhore (1946), recommended integrated preventive and curative care through a primary health centre serving a defined population, with referral upwards. The rural network India built after 1950 follows that plan.
• How it works today. In plain areas, a Sub Health Centre serves about 5,000 people, a Primary Health Centre (PHC) about 30,000, and a Community Health Centre (CHC) about 1,20,000, with smaller norms of 3,000, 20,000 and 80,000 in hilly and tribal areas. A CHC is meant to be a 30 bed hospital with a surgeon, physician, obstetrician and paediatrician, and above it the district hospital handles referral care.
• Ayushman Arogya Mandir. Since 2018 Sub Health Centres and PHCs are being upgraded into Health and Wellness Centres, renamed Ayushman Arogya Mandir in 2023, which add screening for hypertension, diabetes and common cancers, mental health and elderly care to maternal and child care.

Missions and policies

• National Rural Health Mission (NRHM), 2005. It brought flexible funds, untied grants and community structures to rural health, and created the Accredited Social Health Activist (ASHA), a woman from the village chosen to link households with the system, roughly one for every 1,000 people. Janani Suraksha Yojana (JSY, 2005) paid a cash incentive for delivery in a health facility, and ASHAs were paid for escorting mothers.
• National Health Mission (NHM), 2013. The National Urban Health Mission was added in 2013 and both were brought under the NHM, which today is the main channel of central funding to states for primary care.
• National Health Policy (NHP), 2017. It set the goal of raising public health spending to 2.5 per cent of gross domestic product (GDP) by 2025, asked that two thirds or more of it go to primary care, and moved the State from selective care towards assured comprehensive primary care with strategic purchasing of secondary and tertiary care.
• Ayushman Bharat, 2018. It has two pillars: the Health and Wellness Centres for comprehensive primary care, and the Pradhan Mantri Jan Arogya Yojana (PM JAY), which gives ₹5 lakh per family per year for secondary and tertiary hospitalisation in empanelled public and private hospitals. In 2024 PM JAY was extended to every citizen aged 70 and above, regardless of income.

Dimensions

• Moral. A welfare state that lets a citizen die for want of a doctor fails its first test, which is why the Supreme Court read health into Article 21.
• Economic. A healthy, well nourished workforce is the condition for a demographic dividend, and spending on prevention costs far less than treating late disease. Out of pocket expenditure (OOPE) fell from about 64 per cent of total health expenditure in 2013 to 14 to below 40 per cent in 2021 to 22, according to the National Health Accounts, yet medical costs still push many families into debt.
• Sustainable development. Sustainable Development Goal (SDG) 3 asks for universal health coverage by 2030, and health links to the other goals: clean water and sanitation cut diarrhoea, nutrition cuts stunting, and educated mothers raise healthier children. A strong primary structure is therefore a precondition for development that lasts, not a cost to be met after growth.
• Federal. States carry most of the burden but depend on centrally sponsored funds, and the Fifteenth Finance Commission recommended health grants of about ₹70,000 crore routed through local bodies for diagnostics and primary care buildings.
• Demographic. India now carries a double burden: unfinished work on maternal, child and infectious disease, and a rising load of non communicable disease and ageing, which a system built around childbirth was not designed for.

Health for All from the community up

• The Alma Ata idea. The Declaration of Alma Ata (1978) called for "Health for All by 2000" through primary health care that is close to where people live, uses local workers and involves the community, and NHP 2017 returned to the same idea.
• Community health workers. The Mitanin programme of Chhattisgarh (2002), which trained a woman health volunteer in each hamlet, became the model for the ASHA.
• Community institutions. Village Health Sanitation and Nutrition Committees, under the panchayat, hold untied funds and plan local action on water, sanitation and nutrition, while Rogi Kalyan Samitis manage hospital funds. Community based monitoring, in which villagers audit services and report in public hearings, makes facilities answerable to users.

In practice

Maternal and geriatric care

• Maternal health. The maternal mortality ratio fell from 254 per lakh live births in 2004 to 06 to 97 in 2018 to 20, according to the Sample Registration System (SRS), and institutional deliveries reached about 89 per cent in the National Family Health Survey 5 (NFHS 5, 2019 to 21). Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA, 2016) offers a free antenatal check by a doctor on the ninth of every month, LaQshya (2017) improves the quality of labour rooms, and Pradhan Mantri Matru Vandana Yojana (PMMVY, 2017) pays ₹5,000 to compensate for wage loss for the first child.
• Geriatric health. People aged 60 and above were about 8.6 per cent of the population in Census 2011, and their share is rising fast. The National Programme for Health Care of the Elderly (NPHCE, 2010) provides geriatric wards in district hospitals, regional geriatric centres and National Centres for Ageing, while the Maintenance and Welfare of Parents and Senior Citizens Act, 2007 adds a legal duty on children. The elderly mostly need chronic disease, mental health and palliative care close to home.

Source: Office of the Registrar General of India, SRS special bulletins on maternal mortality.

The State and a marketised system

Most outpatient care and much hospital care in India is bought from private providers, which brings capacity but also unregulated prices and catastrophic bills. The State has several tools to contain this.

• Regulator. The Clinical Establishments (Registration and Regulation) Act, 2010 requires registration, minimum standards and display of rates, but applies only in states that adopt it. The National Pharmaceutical Pricing Authority capped the price of coronary stents in 2017 and knee implants soon after, under the Drugs (Prices Control) Order, 2013.
• Purchaser. Through PM JAY, the National Health Authority buys care at fixed package rates, which uses the State's buying power to discipline private prices, an approach called strategic purchasing.
• Provider. Free medicines and diagnostics in public facilities, as in the Tamil Nadu Medical Services Corporation model of pooled drug procurement, and generic medicines through Jan Aushadhi Kendras, reduce the largest part of OOPE, which is drugs.
• Digital enabler. The eSanjeevani telemedicine service links Ayushman Arogya Mandirs to doctors at hub hospitals, and the Ayushman Bharat Digital Mission (ABDM, 2021) gives each citizen an Ayushman Bharat Health Account (ABHA) number and registries of facilities and professionals so records can follow the patient.

Issues and way forward

• Low public spending. Government health spending is still below 2 per cent of GDP in the National Health Accounts, short of the NHP target, so the system relies on households. States need to raise health to at least 8 per cent of their budgets, as NHP 2017 suggested, with central grants tied to primary care.
• Human resources. Rural Health Statistics show that most of the specialist posts needed at CHCs are vacant or never sanctioned, and PHCs often run without a doctor. Remedies include a public health management cadre, as NHP 2017 recommended, incentives and housing for rural postings, wider use of nurse practitioners and community health officers, and district hospitals turned into teaching hospitals.
• Insurance without primary care. PM JAY pays for hospital stays but not outpatient care and drugs, which make up most OOPE, and empanelled private hospitals cluster in cities. Insurance must sit on a strong primary layer, otherwise it pays to treat diseases that cheap screening would have caught.
• Weak regulation. Since many states have not adopted the Clinical Establishments Act, a model law with grievance redressal and standard treatment protocols, adopted by all states, is needed.

Common confusions

• Health and Wellness Centre and PM JAY. The first provides primary care free at the village level; the second is an insurance cover for hospital stays. Both are under Ayushman Bharat, but they solve different problems.
• NRHM and NHM. NRHM (2005) covered rural areas; NHM (2013) is the umbrella over NRHM and the National Urban Health Mission.
• Maternal mortality ratio and maternal mortality rate. The ratio counts maternal deaths per lakh live births and measures the risk of each pregnancy; the rate counts them per lakh women of reproductive age and also reflects how often women give birth.
• OOPE and catastrophic expenditure. OOPE is the share of health spending paid by households at the point of care; catastrophic expenditure is when such spending crosses a set share of a household's income or consumption.

For the exam

• Keyword bank: Entry 6 State List, Article 47, Paschim Banga Khet Mazdoor Samity, Bhore Committee, three tier structure, Ayushman Arogya Mandir, ASHA, National Health Mission, National Health Policy 2017, PM JAY, strategic purchasing, out of pocket expenditure, Alma Ata, community based monitoring, maternal mortality ratio.
• Practise the previous year questions on this topic →
• Use in an answer:
  • Introduction with data: "Out of pocket spending fell from about 64 per cent of total health expenditure in 2013 to 14 to below 40 per cent in 2021 to 22, yet it remains the main way Indian families pay for illness."
  • Introduction with a judgement: "In Paschim Banga Khet Mazdoor Samity (1996) the Supreme Court held that denial of timely treatment in a government hospital violates the right to life under Article 21."
  • Conclusion: "Insurance can pay a hospital bill, but only a strong primary layer, run by trained workers close to the household, can keep the bill from arising."
  • Conclusion: "The Bhore Committee's vision of care that is integrated, preventive and near the people remains the right foundation; what India must now supply is the money and the staff to make it real."