Health Sector: Policy, Institutions, Ayushman Bharat and Challenges

Health in the Constitution and the federal scheme

"Public health and sanitation; hospitals and dispensaries" is a State List subject (Entry 6). "Population control and family planning" and "medical education" are on the Concurrent List. The Centre influences health through funding (the National Health Mission), regulation (drugs and medical education) and national programmes. Article 47 directs the State to raise nutrition and the standard of living and to improve public health. The Supreme Court has read the right to health into Article 21, for example in *Paschim Banga Khet Mazdoor Samity* (1996), where it held that denial of emergency treatment by government hospitals violates Article 21.

Health outcomes: progress and gaps

India has made large gains:

• Life expectancy has risen to around 70 years.
• Polio: the WHO certified India polio-free in 2014.
• Maternal and neonatal tetanus was eliminated in 2015.
• Infant and maternal mortality have fallen steadily. According to the Sample Registration System, the IMR was 28 per 1,000 live births in 2020 and the MMR 97 per 100,000 live births in 2018–20.

Gaps remain:

• Malnutrition and anaemia are high.
• Non-communicable diseases (diabetes, hypertension, cancer) now account for a majority of deaths.
• TB remains a large burden: India aims to eliminate TB ahead of the SDG 2030 target, and the Ni-kshay Poshan Yojana gives nutrition support to TB patients.
• Outcomes vary sharply between states (Kerala and Tamil Nadu do far better than Uttar Pradesh or Bihar on most indicators).

Health system structure

India's public health system has three tiers.

• Primary: Sub-centre or Health and Wellness Centre (population of about 5,000 in plains, 3,000 in hilly and tribal areas) → Primary Health Centre (30,000 / 20,000) → Community Health Centre (1,20,000 / 80,000), which acts as a first referral unit with specialists.
• Secondary: district and sub-district hospitals.
• Tertiary: medical colleges, AIIMS and super-speciality institutes.

The ASHA (Accredited Social Health Activist) is the community health volunteer, roughly one per 1,000 population, introduced under the NRHM in 2005. ASHAs were recognised by the WHO with a Global Health Leaders Award in 2022.

Key policies

• National Health Policy 1983 and 2002.
• National Health Policy 2017: aims for universal health coverage, with public health expenditure of 2.5% of GDP by 2025 and two-thirds of resources for primary care. It favours "strategic purchasing" from the private sector.
• National Health Mission: NRHM (2005) plus NUHM (2013), merged as NHM. It funds states for reproductive, maternal, newborn, child and adolescent health (RMNCH+A), communicable and non-communicable disease programmes, and health systems. It also introduced Janani Suraksha Yojana (cash for institutional deliveries) and Janani Shishu Suraksha Karyakram (free care for pregnant women and sick infants).

Ayushman Bharat (2018)

1. Ayushman Arogya Mandirs (formerly Health and Wellness Centres): upgrading sub-centres and PHCs to provide comprehensive primary health care. This includes NCD screening, mental health, eye, ENT and dental care, palliative care and free medicines and diagnostics.

2. Pradhan Mantri Jan Arogya Yojana (PM-JAY): health cover of ₹5 lakh per family per year for secondary and tertiary hospitalisation. It is cashless and portable, with no cap on family size, and is based on SECC deprivation criteria (expanded later). It is administered by the National Health Authority. In 2024 it was extended to all senior citizens aged 70 and above, irrespective of income.

Related initiatives:

• Ayushman Bharat Digital Mission (2021): ABHA health IDs, health facility and professional registries, interoperable health records.
• PM-ABHIM (2021): building critical care and labs at district level.
• Jan Aushadhi Kendras: low-cost generic medicines.
• eSanjeevani: telemedicine.

Regulation and human resources

• The National Medical Commission Act 2019 replaced the Medical Council of India. It introduced NEXT (a common final-year exam) and regulation of fees for 50% of seats in private colleges.
• The National Commission for Allied and Healthcare Professions Act 2021.
• The Drugs and Cosmetics Act 1940 governs drug regulation (CDSCO is the regulator). The Clinical Trials Rules date from 2019.
• Human resources: the number of doctors has grown with more medical seats, but distribution is skewed towards cities. Shortages of specialists at CHCs are documented in the Rural Health Statistics.

Financing: the core challenge

• Government health spending is still below 2% of GDP, short of the NHP target.
• Out-of-pocket expenditure (OOPE) has fallen but remains high: National Health Accounts estimates show it below half of total health expenditure in recent years, down from over 60% in the mid-2010s. Medicines are the largest component.
• Health shocks push millions into poverty every year.
• The 15th Finance Commission recommended raising state health spending to over 8% of their budgets. It also gave health grants to local bodies.

Challenges and way forward

Challenges:

• Weak primary care, which leads to crowding at tertiary hospitals.
• Shortage of doctors and nurses in rural areas.
• An unregulated private sector, with problems such as overcharging.
• Low insurance coverage of outpatient costs, even though they drive OOPE.
• Data gaps.
• The dual burden of disease.
• Antimicrobial resistance.
• Preparedness for pandemics (lessons from COVID-19).

Way forward:

• Raise public spending to 2.5% of GDP and beyond.
• Strengthen primary care through Ayushman Arogya Mandirs.
• Create a public health cadre (as in Tamil Nadu).
• Implement the Clinical Establishments Act 2010 in more states.
• Expand outpatient coverage.
• Invest in the One Health approach linking human, animal and environmental health.
• Use digital health while protecting privacy.

Practice: Mains question

*"Ayushman Bharat represents a paradigm shift in health care delivery but its success depends on strengthening primary care." Discuss. (250 words)*

Communicable disease programmes and recent milestones

• Universal Immunisation Programme (1985): one of the world's largest. Mission Indradhanush (2014) targets unvaccinated and partially vaccinated children, and the U-WIN portal digitises records.
• National TB Elimination Programme: uses the Ni-kshay portal and molecular diagnostics such as TrueNat, an indigenous technology.
• National Vector Borne Disease Control Programme: covers malaria, dengue, kala-azar, filariasis and others. India aims to eliminate malaria by 2030.
• Leprosy: eliminated as a public health problem at national level in 2005 (prevalence below 1 per 10,000), though new cases continue.
• COVID-19: India's vaccination drive used domestically produced vaccines (Covaxin, Covishield) and CoWIN, and administered more than 200 crore doses. Under Vaccine Maitri, India supplied vaccines to other countries.

Mental health and NCDs

The Mental Healthcare Act 2017 guarantees a right to access mental health care. Tele-MANAS (2022) provides a 24×7 helpline. For non-communicable diseases, the NP-NCD programme (formerly NPCDCS) screens people aged 30 and above for hypertension, diabetes and common cancers at Ayushman Arogya Mandirs.

Traditional medicine

The Ministry of AYUSH (2014) covers Ayurveda, Yoga & Naturopathy, Unani, Siddha, Sowa-Rigpa and Homoeopathy. The WHO Global Centre for Traditional Medicine is being established in Jamnagar, Gujarat (agreement in 2022). The National Commission for Indian System of Medicine Act 2020 regulates education in this field.

Private sector role

The private sector provides most outpatient care and a large share of hospital care. Regulation is weak in many states. The Clinical Establishments Act has been adopted by only some states, and price transparency is limited. Public–private partnerships in diagnostics and dialysis (the PM National Dialysis Programme) show the potential of strategic purchasing. Critics, however, warn of insurance-led privatisation.