Building a Healthier India

Exploring the landscape of public health, welfare, and justice in the nation, focusing on progress, challenges, and policy interventions.

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Introduction & Summary

Health is a fundamental human right and a critical determinant of human development and societal well-being. India's vast population presents unique challenges and opportunities in delivering equitable and quality healthcare.

Despite significant improvements in various health indicators, the country continues to grapple with issues of access, affordability, quality, and infrastructure deficiencies, exacerbated by rising non-communicable diseases and the persistent threat of pandemics. This module provides a comprehensive overview of India's health status, analyzes the multifaceted challenges plaguing its health sector, critically evaluates key government health programs and policies, and explores the role of traditional medicine systems in achieving universal health coverage.

Health Status in India

India's health status is characterized by a mixed picture of progress and persistent challenges, marked by significant disparities.

Key Health Indicators

Infant Mortality Rate (IMR), Maternal Mortality Ratio (MMR), Life Expectancy, Disease Burden.

  • Infant Mortality Rate (IMR): 28 per 1000 live births (SRS 2020). Steadily declining, reflecting improvements in MCH, immunization, nutrition. Disparities persist.
  • Maternal Mortality Ratio (MMR): 97 per 100,000 live births (SRS 2018-20). Significant decline due to increased institutional deliveries & skilled attendance. India is making strong progress towards the SDG target of <70.
  • Life Expectancy: 69.7 years (2015-19). Increasing, indicates overall improvements in health, sanitation, and living conditions.

Disease Burden & Malnutrition

India faces a dual burden of diseases.

Communicable Diseases (CDs):

  • Still a significant challenge (Tuberculosis (TB), Malaria, HIV/AIDS, Dengue, Chikungunya, water-borne diseases). TB remains a major public health concern.

Non-Communicable Diseases (NCDs):

  • Rapidly rising and becoming the leading cause of mortality and morbidity (heart disease, stroke, diabetes, cancer, chronic respiratory diseases, hypertension).

Malnutrition:

  • High prevalence of stunting (35.5%), wasting (19.3%), and underweight (32.1%) among children (<5 years, NFHS-5).
  • High rates of anaemia among women (57%) and children (67%).

Urban-Rural & Interstate Disparities

Urban-Rural Divide:

  • Urban Advantages: Better access to tertiary care, specialized doctors, diagnostic facilities, and private hospitals.
  • Rural Disadvantages: Limited access to primary healthcare (PHCs/CHCs), shortage of doctors, poor infrastructure, higher burden of CDs.

Interstate & Socio-economic Disparities:

  • Better Performing States: Southern states (Kerala, Tamil Nadu) and some Northern states (Himachal Pradesh) due to strong public health systems and social development.
  • Lagging States (EAG States): Empowered Action Group states (Bihar, Chhattisgarh, Jharkhand, MP, Odisha, Rajasthan, UP, Uttarakhand) lag in most health indicators.
  • Socio-economic Disparities: Health outcomes vary significantly based on income, caste, gender, and education levels. Vulnerable groups (SC/ST, poor, women, PwDs) have poorer indicators.

Challenges in Health Sector

Despite policy reforms and progress, India's health sector faces systemic challenges.

Access, Affordability, Quality

  • Access: Geographical barriers (remote areas), lack of infrastructure, human resource shortage.
  • Affordability: High Out-of-Pocket Expenditure (OOPE) globally, limited insurance coverage, high cost of medicines.
  • Quality of Care: Substandard services in public facilities, unregulated private sector (over-prescription, unethical practices), misdiagnosis.

Infrastructure Deficiencies

  • PHCs & CHCs: Significant shortage, especially in rural areas; many existing facilities lack adequate staff, equipment, and drugs.
  • Hospitals: Shortage of beds, specialized departments, and advanced diagnostic equipment, particularly in public hospitals.
  • Urban Primary Health Centres (UPHCs): Inadequate to cater to growing urban population.

Human Resources

  • Overall Shortage: Significant shortage of doctors, nurses, and paramedical staff compared to WHO norms.
  • Maldistribution: Severe rural-urban disparity, with doctors preferring urban areas.
  • Specialist Shortage: Acute shortage of specialists in rural PHCs/CHCs.
  • Quality Concerns: Issues with quality of medical education and ongoing training. Brain drain.

Funding Gaps & OOPE

  • Low Public Health Spending: India's public expenditure on health as % of GDP remains low (~2.1% in 2022-23), far below National Health Policy targets (2.5% by 2025) and global averages.
  • High OOPE: Due to low public spending, individuals bear a large proportion of healthcare costs directly, pushing millions into poverty annually.
  • Impact: Perpetuates inequalities, limits access, and hinders investment in public health infrastructure.

Antimicrobial Resistance (AMR) & New Pandemics

Antimicrobial Resistance (AMR):

  • Microorganisms developing resistance to drugs, making infections harder to treat.
  • Causes: Over-prescription/misuse of antibiotics, poor sanitation, lack of awareness.
  • Impact: Threatens effective treatment, making routine procedures risky. A major global health threat.

New Pandemics (e.g., COVID-19) & Lessons Learned:

  • Impact: Exposed fragilities (infrastructure deficit, oxygen shortage, HR strain), high OOPE, digital divide.
  • Lessons: Strengthening Primary Healthcare, Public Health Surveillance, Increased Investment, Digital Health (telemedicine, CoWIN), Vaccine Development/Manufacturing, Social Safety Nets.

Government Health Programs & Policies

India's health policy has evolved towards achieving Universal Health Coverage (UHC).

National Health Mission (NHM) - 2013

Launch: 2013 (combined NRHM 2005 & NUHM 2013).

Objectives: Universal access to equitable, affordable & quality healthcare services; reduce MMR, IMR, TFR; prevent/control communicable/non-communicable diseases.

Components: NRHM (strengthening PHCs/CHCs, ASHA workers, JSSK); NUHM (urban poor's health needs, strengthening urban primary health centers).

Significance: Contributed significantly to improvements in IMR, MMR, and access to primary care.

Ayushman Bharat - 2018

Launch: 2018. India's flagship program for Universal Health Coverage.

1. Pradhan Mantri Jan Arogya Yojana (PMJAY):

  • Objective: Health insurance cover of Rs. 5 lakh per family per year for secondary and tertiary care hospitalization.
  • Coverage: Over 10.74 crore poor and vulnerable families (around 50 crore beneficiaries).
  • Significance: Largest government-funded health insurance scheme globally, aims to reduce catastrophic health expenditure.

2. Health and Wellness Centres (HWCs):

  • Objective: Transform existing PHCs and Sub-Centres into HWCs, providing comprehensive primary healthcare services (preventive, promotive, curative, rehabilitative, palliative care).
  • Services: Covers reproductive & child health, NCDs, elderly care, mental health, free essential drugs & diagnostics.
  • Significance: Shifts focus to comprehensive primary care, bringing services closer to the community.

JSSK & RMNCH+A

Janani Shishu Suraksha Karyakram (JSSK) - 2011:

  • Objective: Eliminate out-of-pocket expenses for pregnant women and sick neonates accessing public health institutions for delivery and treatment.
  • Benefits: Free services for pregnant women (delivery, C-section, drugs, diagnostics, transport, blood, diet), and for sick infants (treatment up to 1 year).

Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A):

  • Approach: Comprehensive strategy under NHM to address health needs across the life cycle.
  • Focus: Continuum of care, ensuring services from pregnancy through delivery, postpartum, infancy, childhood, and adolescence.

National Nutrition Mission (POSHAN Abhiyaan) - 2018

Aim: Reduce stunting, under-nutrition, anaemia, and low birth weight among children and women in a mission-mode approach.

Strategy: Multi-ministerial convergence, technology-enabled monitoring, behavioral change communication, community mobilization.

Significance: Flagship program to address India's persistent malnutrition problem.

Public Health System vs. Private Healthcare

Public Health System:

  • Structure: Three-tier - Sub-Centres, PHCs, CHCs (primary & secondary), District Hospitals, Tertiary care.
  • Role: Provides accessible and affordable healthcare, crucial for public health functions (immunization, disease surveillance).
  • Challenges: Underfunding, infrastructure gaps, human resource shortages, quality concerns.

Private Healthcare Sector:

  • Dominance: Dominant provider, especially secondary/tertiary care & diagnostics.
  • Role: Fills gaps, offers specialized/high-quality care (often at high cost).
  • Challenges: Lack of regulation, high costs, high out-of-pocket expenditure, ethical concerns, lack of transparency.

Regulation:

  • Clinical Establishments Act, 2010 (aims to regulate standards, registration).
  • National Medical Commission (NMC) Act, 2019 (reforms medical education/practice).
  • Way Forward: Stronger regulation, strategic PPPs ensuring equity, increased public investment.

AYUSH & Traditional Medicine

India's rich heritage of traditional medicine systems offers a complementary approach to modern healthcare.

Role of AYUSH in Healthcare

Ayurveda, Yoga & Naturopathy, Unani, Siddha, Homoeopathy.

  • Preventive & Promotive: Strong emphasis on lifestyle, diet, preventive care (e.g., Yoga for well-being).
  • Chronic Diseases: Often used for managing chronic conditions where modern medicine may have limitations.
  • Accessibility & Affordability: Often more accessible and affordable, particularly in rural areas.
  • Holistic Approach: Focus on treating the individual as a whole, addressing root causes rather than just symptoms.

Integration with Modern Medicine

Policy push for pluralism and integration.

  • Policy Push: National Health Policy 2017 advocates for pluralism in healthcare and integration of AYUSH systems into mainstream.
  • Initiatives: Establishment of AYUSH dispensaries/hospitals, co-location of AYUSH practitioners in PHCs/CHCs, promotion of AYUSH education/research, Yoga as Public Health Initiative, PMJAY covers certain AYUSH treatments.
  • Challenges: Lack of scientific validation for some practices, quality control issues, integration challenges with allopathic system (data sharing, referral mechanisms).

Prelims-ready Notes

Key Facts at a Glance

  • Health Indicators: IMR: 28 (SRS 2020) - Declining. MMR: 97 (SRS 2018-20) - Declining, strong progress towards SDG target. Life Expectancy: 69.7 years (2015-19). Dual Disease Burden (CDs like TB, NCDs like heart disease, diabetes). High malnutrition (NFHS-5: 35.5% stunted, 57% women anaemic).
  • Disparities: Urban-Rural, Interstate (EAG states lag), Socio-economic.
  • Challenges: Access, Affordability (High OOPE ~2.1% public spending of GDP), Quality. Infrastructure deficiencies (PHCs/CHCs, hospitals). HR shortage & maldistribution. AMR, Pandemics (COVID-19 lessons).
  • Govt Health Programs: National Health Mission (NHM) (2013): Combined NRHM (2005) & NUHM (2013). Universal access, reduce MMR/IMR. Ayushman Bharat (2018): PMJAY (Rs 5 lakh health insurance), Health & Wellness Centres (HWCs) (comprehensive primary care). JSSK (2011): Free services for pregnant women/sick neonates. RMNCH+A: Continuum of care. POSHAN Abhiyaan (2018): National Nutrition Mission. Public vs. Private: Public sector challenges (funding, HR), Private sector dominance (cost, regulation - Clinical Establishments Act 2010).
  • AYUSH: Ayurveda, Yoga & Naturopathy, Unani, Siddha, Homoeopathy. Role: Preventive, chronic disease management, affordable, holistic. Integration: Co-location in PHCs, PMJAY covers AYUSH.

Key Health Indicators & Trends Table

Indicator Latest Value (Source) Trend/Significance
Infant Mortality Rate (IMR) 28/1000 live births (SRS 2020) Continues to decline, reflecting improved child health.
Maternal Mortality Ratio (MMR) 97/100,000 live births (SRS 2018-20) Significantly declined, strong progress towards SDG target (though not all states have achieved <70).
Total Fertility Rate (TFR) 2.0 (NFHS-5, 2019-21) Below replacement level (2.1), indicating population stabilization.
Stunting (<5 years) 35.5% (NFHS-5) Decreasing but still high, indicating chronic undernutrition.
Anaemia (Women 15-49) 57% (NFHS-5) High prevalence, critical public health challenge.
Public Health Spending (as % of GDP) ~2.1% (2022-23) Historically low, needs to increase to meet National Health Policy targets.

Mains-ready Analytical Notes

Major Debates/Discussions

1. Universal Health Coverage (UHC): How to achieve it?

  • Debate: Should India primarily focus on strengthening its public health system or rely more on health insurance models (PMJAY)?
  • Conclusion: A mixed approach combining robust primary healthcare (HWCs) with a strong health insurance safety net (PMJAY) is essential, coupled with increased public spending.

2. Private Sector in Healthcare: Partner or Predatory?

  • Debate: Does the private sector complement the public sector or exploit patients due to inadequate regulation?
  • Way Forward: Effective regulation, transparent pricing, and strategic PPPs that serve public interest are needed.

3. AMR: A Silent Pandemic:

  • Debate: The growing threat of Antimicrobial Resistance. How to balance access to essential medicines with prudent use of antibiotics.
  • Solutions: One Health approach (human, animal, environmental health), strict regulation of antibiotic sales, awareness, research for new drugs.

Historical/Long-term Trends, Continuity & Changes

  • Shift from Curative to Comprehensive Care: Evolution from disease-specific focus to holistic, comprehensive primary care (HWCs).
  • Improved Health Indicators: Consistent long-term decline in IMR and MMR.
  • Epidemiological Transition: Shift from dominant communicable diseases to rising non-communicable diseases.
  • Digitalization of Health: Increasing adoption of technology (CoWIN, Telemedicine, Ayushman Bharat Digital Mission), accelerated by COVID-19.

Contemporary Relevance/Significance/Impact

  • Lessons from COVID-19: Exposed critical vulnerabilities, importance of primary care, surveillance, and social safety nets. Led to renewed calls for increased public health spending.
  • Ayushman Bharat Digital Mission (ABDM) / Ayushman Bharat Health Account (ABHA): Major ongoing initiative to create a digital health ecosystem for efficiency and evidence-based policy.
  • One Health Approach: Growing recognition of the interconnectedness of human, animal, and environmental health, relevant for preventing future pandemics and combating AMR.
  • National Medical Commission (NMC): Continually bringing reforms to improve quality and address HR shortages in medical education and practice.
  • Focus on Mental Health: Increased policy attention (National Mental Health Programme), recognizing its growing burden, especially post-pandemic.

Real-world/Data-backed Recent Examples (Last 1 Year)

  • Latest NFHS-5 (2019-21) data: Primary source for most health indicators, providing comprehensive insights into MMR, IMR, TFR, malnutrition, and access.
  • Union Budget 2023-24 Health Allocations: Analysis of budget for health, particularly on schemes like PMJAY and setting up new medical/nursing facilities.
  • Progress of Health & Wellness Centres (HWCs): Reports show increasing reach and services provided in comprehensive primary healthcare.
  • National Health Accounts (NHA) Estimates: Provide data on public and private health expenditure, OOPE, highlighting trends and progress towards UHC.
  • Indian Council of Medical Research (ICMR) initiatives: Ongoing research on AMR, new diagnostics, and public health advisories related to emerging diseases.

UPSC Previous Year Questions (PYQs)

Prelims MCQs

UPSC 2023: In the context of "Vaccine Maitri", which of the following statements is/are correct?

  1. It is a humanitarian initiative of the Government of India to provide COVID-19 vaccines to other countries.
  2. It was launched in January 2021.
  3. Under this initiative, India provided vaccines to both developed and developing countries.

Answer: (d) All statements are correct.

Hint: Directly tests a recent Indian health diplomacy initiative, relevant to India's health sector capabilities.

UPSC 2021: Which of the following is/are the likely consequence/consequences of implementing the 'National Health Policy, 2017'?

  1. Health expenditure will be a major component of GDP in India.
  2. Private sector's role in health care will decline.
  3. Emphasis on preventive and promotive healthcare.

Answer: (b) 3 only

Hint: Directly tests objectives of a major health policy. NHP 2017 aims to increase public health spending, but not necessarily make it a *major* component of GDP compared to other sectors. It also doesn't aim to *decline* private sector role but to regulate it and work alongside.

Mains Questions

UPSC 2023: "Urbanization is a boon as well as a bane. Discuss with examples." (15 marks)

Direction: Connects to health. Unplanned urbanization leads to problems like inadequate water, sanitation, pollution, and overcrowding, directly impacting public health in cities, leading to disease burden.

UPSC 2022: "Discuss the various types of challenges faced by tribal communities in India in terms of their cultural identity, land rights, and development." (15 marks)

Direction: Health is a major challenge for tribal communities, who often lack access to healthcare, suffer from specific diseases, and face malnutrition. Government schemes like NHM components target these issues.

UPSC 2019: "What are the challenges for the working women in India?" (10 marks)

Direction: Women's health (MMR, anaemia, reproductive health) is crucial for their workforce participation and overall well-being. Lack of proper healthcare services contributes to their challenges.

Trend Analysis

  • Prelims: Questions on Health are consistently high-priority, focusing on key health indicators and their latest trends. Major government health programs are frequently tested for their objectives and components. Attention to emerging challenges (AMR, pandemics) and the role of AYUSH.
  • Mains: Very high-priority topic for Mains (GS Paper 1 & 2). Questions are analytical, problem-solution oriented. Demand deep understanding of challenges (access, affordability, quality, infrastructure, HR, funding, OOPE) and critical evaluation of policy responses. Lessons from COVID-19, digital health, and public vs. private healthcare are recurring themes. Expect questions requiring linking health to broader developmental goals, concrete examples, data, and comprehensive policy recommendations.

Original MCQs for Prelims

1. Which of the following best represents the objective of Ayushman Bharat - Health and Wellness Centres (HWCs)?

  • (a) Providing a health insurance cover of Rs. 5 lakh per family for secondary and tertiary care.
  • (b) Transforming existing primary healthcare facilities into comprehensive primary healthcare providers.
  • (c) Offering free essential drugs and diagnostics exclusively at tertiary care hospitals.
  • (d) Focusing solely on curative care for non-communicable diseases.

Answer: (b)

Explanation: (a) describes PMJAY. (b) correctly describes the core objective of HWCs. (c) is incorrect as HWCs focus on primary care. (d) is incorrect as HWCs provide comprehensive care, including preventive and promotive.

2. Which of the following is/are the key feature/s of India's National Health Mission (NHM)?

  1. It subsumed the National Rural Health Mission (NRHM) and National Urban Health Mission (NUHM).
  2. It primarily focuses on providing tertiary care services through specialized hospitals.
  3. It aims to reduce Infant Mortality Rate (IMR) and Maternal Mortality Ratio (MMR).

Select the correct answer using the code given below:

  • (a) 1 only
  • (b) 1 and 3 only
  • (c) 2 and 3 only
  • (d) 1, 2 and 3

Answer: (b)

Explanation: Statement 1 is correct: NHM was formed by merging NRHM and NUHM. Statement 2 is incorrect: NHM primarily focuses on strengthening primary and secondary care. Statement 3 is correct: Reduction of IMR and MMR are core objectives of NHM.

Original Descriptive Questions for Mains

1. "India's health sector faces a complex interplay of challenges related to access, affordability, and quality of care, leading to persistent disparities. Critically analyze these challenges and evaluate the effectiveness of the Ayushman Bharat scheme in addressing these issues, highlighting its potential and limitations." (15 marks)

Key points/structure:

  • Introduction: Acknowledge India's health progress but highlight deep-seated challenges in access, affordability, and quality.
  • Challenges in Health Sector: Access (geographical barriers, inadequate infrastructure, HR shortages), Affordability (High OOPE, high medicine costs), Quality (substandard public facilities, unregulated private sector), Funding Gaps, Dual Disease Burden.
  • Effectiveness of Ayushman Bharat (PMJAY + HWCs):
    • Potential/Achievements: PMJAY (reduced catastrophic expenditure, expanded insurance), HWCs (transformed primary care, expanded services, reduced OOPE at primary level).
    • Limitations/Challenges: PMJAY (focus on tertiary care, profiteering, fraud), HWCs (capacity building, HR shortage, ensuring quality). Overall (not standalone solution, requires increased public funding, better regulation).
  • Conclusion: Ayushman Bharat is transformative, but full potential requires increased public health spending, strengthening the entire health continuum, robust regulation, and equitable access.

2. "India faces a growing burden of non-communicable diseases (NCDs) alongside persistent challenges from communicable diseases. Discuss the socio-economic implications of this dual disease burden and suggest comprehensive public health strategies to address it." (10 marks)

Key points/structure:

  • Introduction: Highlight India's epidemiological transition and dual disease burden.
  • Socio-economic Implications of Dual Disease Burden: Economic Impact (loss of productivity, increased healthcare expenditure, financial strain, reduced national output), Social Impact (reduced quality of life, increased dependency, mental health issues, poverty), Disparities (disproportionate impact on vulnerable), Strain on Health System.
  • Comprehensive Public Health Strategies: Strengthening Primary Healthcare (HWCs, screening NCDs, CD efforts), Preventive & Promotive Health (lifestyle changes, awareness, AYUSH), Universal Health Coverage (PMJAY), Integrated Disease Surveillance, Human Resource Development, Affordable Medicines & Diagnostics, Multi-sectoral Approach, Research & Innovation.
  • Conclusion: Addressing dual disease burden requires holistic, multi-pronged public health approach prioritizing prevention, strong primary care, equitable access, and integration of traditional medicine, focusing on overall well-being.