BY – Lt Col Prakash Singh Dasauni




  1. The growth of a nation is not just about tallying its industrial, agricultural and services balance sheets. It is equally about tallying its performance on the human development indices. The state of its healthcare is one of the critical measures of how a nation state is performing. For a country the size of India, that is even more important.
  2. The healthcare ecosystem in India is at an inflection point. While the outlook for the healthcare industry is optimistic, there is a need to move towards an integrated healthcare delivery system, which leverages technology and has the patient at its center

Challenges for Health Care System in India

  1. Dual Disease Burden. Even as the incidence of lifestyle diseases is steadily on the rise, a vast majority of rural and poor patients still suffer from infectious and acute diseases.
  2. Low Penetration of Insurance And Other Payer Mechanisms.  The overall quantum of health insurance may have increased, but it is largely limited to urban areas. In other areas, especially rural, people continue to spend from their own pockets.
  3. Inequity in Infrastructure.  While the urban India is witnessing a mushrooming of world-class medical facilities, the rural areas are bereft of even basic healthcare facilities. This has resulted in severe inequities between the urban and rural areas across all major health indicators.
  4. Low Levels of Healthcare Spend  The per capita spend on healthcare (both public and private), as well as the healthcare spend as a portion of the comparable economies, and way below global averages.
  5. Increase in Lifestyle Diseases.  Lifestyle-related diseases comprised 13 percent of total ailments in India, according to a 2008 data, and this number is expected to increase to 20 percent by 2018. This is expected to trigger an additional demand for specialised treatment.

Positives For The Health Care Industry in India

  1. Rising Affordability  In the past decade, India has witnessed a rapid increase in levels of wealth and disposable incomes. Coupled with a better standard of living and health awareness, this has led to an increase in spending on healthcare and wellness.
  2. Increase in Lifestyle Diseases. This will lead to increased margins for hospitals since these diseases lie at the high margin end of the spectrum.
  3. Health Insurance And Medical Tourism.  While out-of-pocket spending remains the mainstay of healthcare expenditure, health insurance is gaining momentum in India.The increasing penetration of health insurance is expected to significantly increase the affordability of healthcare services, driving up the demand for preventive healthcare and curative services. Medical tourism is also driving the healthcare market in India.The fact that the treatment for major surgeries in India costs approximately 20 percent of that in developed countries; coupled with the high quality of care in Indian tertiary and specialty hospitals makes medical tourism attractive for patients from developed as well as emerging economies.
  4. Patient/Consumer Centric Healthcare. Given the nature of the healthcare ecosystem in

India, several hospitals and other health facilities are waking up to the need for ‘patient-centric care’. At the core of this approach is the customer or the patient. It links multiple levels of care management, coordinates services and encourages professional collaboration across a range of care delivery.

  1. Conducive Demographics.  While the population growth rate for India has steadily gone down, it is still at over 1.3 percent and is not expected to go below one percent in the near future. Also, it is interesting to note that our population aged above 60 years is projected to grow to around 193 million, compared with over 96 million in 2010. This change in the population pyramid is expected to fuel the demand for healthcare in general, particularly lifestyle diseases.

Health Scenario in India

  1. India’s public health care system is patchy, with underfunded and overcrowded hospitals and clinics, and inadequate rural coverage. Reduced funding by the Indian Government has been attributed to historic failures on the part of the Ministry of Health and Family Welfare (MHFW) to spend its allocated budget fully. This is despite increasing demand, due, in part, to growing incidence of age- and lifestyle-related chronic diseases resulting from urbanization, sedentary lifestyles, changing diets, rising obesity levels, and widespread availability of tobacco products. India’s health care sector witnesses close to 50 percent spend on in-patient beds for lifestyle diseases, especially in urban and semi-urban pockets. India has one the world’s highest numbers of diabetes sufferers, at more than 65 million individuals.This trend has resulted in the mushrooming of super specialty hospitals to combat lifestyle diseases.
  2. Out-Of-Pocket (OOP) Spending. The government’s low spending on health care places much of the burden on patients and their families, as evidenced by the country’s out-of-pocket (OOP) spending rate, one of the world’s highest. According to the World Health Organization (WHO), just 33 percent of Indian health care expenditures in 2012 came from government sources. Of the remaining private spending, around 86 percent was OOP.
  3. Health Insurance Systems.  Several public health insurance systems exist, such as state-level employee insurance for industrial workers and the central government’s health care plan for civil servants. Several large companies also operate employee health policies. While health insurance penetration in India is increasing, it has been proposed that better accessibility to quality health care could be made possible by extending coverage to all employees in the private sector and by offering inexpensive health plans for the poor. This way, people can have full coverage for themselves, their families and elders.
  4. Health Infrastructure.   The statistics for India’s health infrastructure are below that of

other large countries. The U.S. has one bed for every 350 patients while the ratio for Japan is

1 for 85. In contrast, India has one bed for every 1,050 patients. To match bed availability to the standards of more developed nations, India needs to add 100,000 beds this decade.

  1. Health Care Information Technology (HIT).       India’s expenditure on health care information technology (HIT) is considerably low. Hospitals in India will need to increase their IT spend considerably to provide improved and patient-centric service.
  2. Qualified Medical Professionals.   The shortage of qualified medical professionals is one of the key challenges facing the Indian health care industry. India’s ratio of 0.7 doctors and 1.5 nurses per 1,000 people is dramatically lower than the WHO average of 2.5 doctors and nurses per 1,000 people. Furthermore, there is an acute shortage of paramedical and administrative professionals. The situation is aggravated by the concentration of medical professionals in urban areas, which have only 30 percent of India’s population. Many patients, especially those living in rural and semi urban areas, are still

receiving services from unqualified practitioners. The industry needs an additional 1.54 million doctors and 2.4 million nurses to match the global average.

  1. Mortality Rate.  India’s health care professional and infrastructure shortage is one of the major reasons for the country’s high mortality rate. Although there has been a consistent decline in the Infant Mortality Rate (IMR) and the Under-Five Mortality Rate (U5MR).
  2. Telemedicine.  Telemedicine is a fast-emerging sector in India. In 2012, the telemedicine market in India was valued at $7.5 million, and it is expected to rise 20 percent annually, to $18.7 million by 2017. Telemedicine can bridge the rural-urban divide by extending low-cost consultation and diagnostic facilities to the remotest areas.
  3. Mobile Health (mHealth).  India’s solid mobile technology infrastructure and the launch of 4G is expected to drive mobile health (mHealth) adoption. Currently, there are over 20 mhealth initiatives for spreading awareness of family planning and other ailments – the industry is expected to reach $0.6 billion by 2017.
  4. Health Policy.       Indian  government has announced a new health policy(draft)  to focus on reducing malnutrition, improving the use of essential medicines, expanding immunization, modernizing public hospitals, and instituting a better tobacco control program. The government wants a holistic health care system that is universally accessible, affordable, and dramatically reduces OOP expenditures.
  5. Regulatory Authority.   India still doesn’t have a central regulatory authority for its health care sector. In 2011, a high-level expert group constituted by the Planning Commission of India suggested setting up a National Health Regulatory and Development Authority to monitor both government and private-sector health care providers. The group has also proposed to establish a National Health and Medical Facilities Accreditation Authority (NHMFA) for defining health care facility standards.
  6. Public-Private Partnerships.    India’s health care sector is capital-intensive, with long gestation and payback periods for new projects. Land and infrastructure costs account for 60-70 percent of the capital expenditure for hospitals. Further, the industry also requires capital for upgrade/maintenance/replacement of medical equipment and expansion. Availability of capital at a reasonable cost remains a hurdle.  One way to increase India’s health care funding and access is through innovative public-private partnerships. While an appropriate model for partnerships at the primary, secondary, and tertiary levels still remains a distant dream, participation by the government and private sector will help create a blueprint for such partnerships to create an infrastructure for the future. One such example in India is SRL (Diagnostic), which has partnered with the Himachal Pradesh State Government to set up and operate 24 labs in the large state-run hospitals in various districts, thereby bringing superior diagnostics services to the doorstep of people in remote areas.
  7. National Rural Health Mission/National Urban Health Mission (NUHM).        These programmes are being implemented in various areas in partnership with private entities to reach to the poorest section of people, with special emphasis to women and children. Problem Areas
  8. Statistics.  Some disturbing facts about Indian health situation are the chronic issue of Infant Mortality Rate and Maternal Mortality Rate that is even lesser that many low-income countries.
  9. Low bed density,doctor-to-patient ratio in rural areas.
    29. Low budget expenditure.
  10. Below standard infrastructure for a larger population.
  11. Inadequate and under-trained staffs.
    32. Lack of public private collaboration.
  12. Insufficient incentives

Suggestions For Improvement.

34           Government must provide effective health insurance to the poor, along with payments or incentives through social welfare programmes.

  1. Resources required for the emancipation of this sector, such as number of trained doctors and medical staffs, as well as infrastructure gap must be taken seriously. Also, generic medicines availability must be made more rampant.
  2. Proper payment to AYUSH, SHG, ASHA or other medical practitioners must be made mandatory for far outreach of health awareness and prevention.
  3. Any malpractice or treatment discrepancies must be strictly punishable and monitored at any cost.
  4. Increase in the health budget allocation, to cover the entire population in need.
  5. government should focus on establishing more medical colleges and training institutes to provide the requisite doctors, dentists, nurses and paramedics.
  6. Government should leverage information technology (IT) to create patient-centric healthcare systems that can improve response times, reduce human error, save costs, and impact the quality of life.
  7. The government should invest in preventive and social medicine by promoting health education and preventive health-care concepts.


National Health Policy

  1. Health policyrefers to decisions, plans, and actions that are undertaken to achieve specific health care goals within a society. An explicit health policy can achieve several things: it defines a vision for the future which in turn helps to establish targets and points of reference for the short and medium term.

National Health Policy 2015 Draft

  1. Goal.  The attainment of the highest possible level of good health and well-being, through a preventive and promotive health care orientation in all developmental policies, and universal access to good quality health care services without anyone having to face financial hardship as a consequence.
  2. Key Policy Principles.
  3.  Equity.       Public expenditure in health care, prioritizing the needs of the most vulnerable, who suffer the largest burden of disease, would imply greater investment in access and financial protection measures for the poor. Reducing inequity would also mean affirmative action to reach the poorest and minimizing disparity on account of gender, poverty, caste, disability, other forms of social exclusion and geographical barriers. Universality: Systems and services are designed to cater to the entire population- not only a targeted sub-group. Care to be taken to prevent exclusions on social or economic grounds.
  4. Patient Centered & Quality of Care.       Health Care services would be         effective,            safe, and convenient, provided with dignity and confidentiality with all             facilities across all sectors being assessed, certified and incentivized to maintain                quality of care.
  5.  Inclusive Partnerships.       The task of providing health care for all cannot be            undertaken by Government, acting alone. It would also require the participation of communities – who view this participation as a means and a goal, as a right and as a    duty. It would also require the widest level of partnerships with academic        institutions, not for profit agencies and with the commercial private sector and        health   care industry to achieve these goals.
  6.  Pluralism.       Patients who so choose and when appropriate, would have                 access to                 AYUSH care providers based on validated local health traditions. These systems would also have 14 Government support and supervision to develop and    enrich their         contribution to meeting the national health goals and objectives.        Research,            development of models of integrative practice, efforts at documentation,               validation of traditional practices and engagement with such practitioners would                 form important elements of enabling medical pluralism.
  7.  Subsidiarity.       For ensuring responsiveness and greater participation,      increasing transfer of decision making to as decentralized a level as is consistent           with       practical considerations and institutional capacity would be promoted. (Nothing         should be done by a larger and more complex organization which can be done as           well by a              smaller and simpler organization.
  8.  Accountability.       Financial and performance accountability, transparency in            decision making, and elimination of corruption in health care systems, both in the             public systems and in the private health care industry, would be essential.               Professionalism, Integrity and Ethics: Health workers and managers shall perform       their work with the highest level of professionalism, integrity and trust and be           supported by a systems and regulatory environment that enables this.
  9.  Learning and Adaptive System.       constantly improving dynamic organization         of health care which is knowledge and evidence based, reflective and learning from    the communities they serve, the experience of implementation itself, and from national                and international knowledge partners.
  10.  Affordability.       As costs of care rise, affordability, as distinct from equity,               requires emphasis. Health care costs of a household exceeding 10% of its total    monthly               consumption expenditures or 40% of its non-food consumption           expenditure- is                 designated catastrophic health expenditures- and is declared as an          unacceptable     level of health care costs. Impoverishment due to health care costs is            of course, even                more unacceptable.


  1. Objectives.
  2. Improve population health status through concerted policy action in all sectors and expand preventive, promotive, curative, palliative and rehabilitative       services                provided by the public health sector.
  3.  Achieve a significant reduction in out of pocket expenditure due to health          care costs and reduction in proportion of households experiencing catastrophic     health   expenditures and consequent impoverishment.
  4. Assure universal availability of free, comprehensive primary health care              services, as an entitlement, for all aspects of reproductive, maternal, child and          adolescent health and for the most prevalent communicable and non-communicable             diseases in the population.
  5. Enable universal access to free essential drugs, diagnostics, emergency                ambulance services, and emergency medical and surgical care services in public        health   facilities, so as to enhance the financial protection role of public facilities for             all            sections of the population.
  6. Ensure improved access and affordability of secondary and tertiary care              services through a combination of public hospitals and strategic purchasing of     services                from the private health sector.
  7. Influence the growth of the private health care industry and medical     technologies to ensure alignment with public health goals, and enable contribution         to making health care systems more effective, efficient, rational, safe, affordable      and ethical.
  8. Policy Directions.
  9. The National Health Policy accepts and endorses the understanding that a                          full achievement of the goals and principles as defined would require an increased                                 public                 health expenditure to 4 to 5% of the GDP. However, given that the NHP,                             2002 target of 2%          was not met, and taking into account the financial capacity                          of the country to provide this                 amount and the institutional capacity to utilize the                           increased funding in an effective manner,               this policy proposes a potentially                              achievable target of raising public health expenditure to 2.5 % of the GDP. It                         also notes that 40% of this would need to come from Central                 expenditures. At                              current prices, a target of 2.5% of GDP translates to Rs. 3800 per capita,                                                   representing an almost four fold increase in five years. Thus a longer time frame                    may be                 appropriate to even reach this modest target.
  10. The major source of financing would remain general taxation. With the                                                projection of a promising economic growth, the fiscal capacity to provide this level                          of financing should become available. The Government would explore the creation                             of a health cess on the lines of the education cess for raising the necessary                                                resources. Other than general taxation, this cess could mobilise contributions from                            specific commodity taxes- such as the taxes on tobacco, and alcohol, from specific                                industries and innovative forms of resource mobilization. Extractive industries and                                development projects that result in displacement, or those that have negative                                          impacts on natural habitats or the resource base can be considered for special                                           taxation thereby allowing investment and job opportunities in education and health                    for affected communities.
  11. Since about 50% of health expenditure goes into                             human                                  resources for health, an equitous growth of health and education sectors                                            would also lead to increased employment in many areas and communities, which do                      not otherwise benefit from the economic growth rate, particularly where jobless                    growth is a phenomenon. High public investment in health care is one of the most                 efficient ways of ameliorating inequities, and for this reason, this commitment to                         higher public expenditures is essential.
  12. Corporate social responsibility has now been made mandatory- and this                              avenue should be maximally leveraged. Though actual CSR flows to health care may                       be                 modest in comparison to needs, these could be leveraged for well-focused                        programmes, communities or geographies with special levels of vulnerability which                     require special attention.


  1. Having reviewed the health scenario in India, it becomes evident that concerted efforts have                 to be made by the government and the community for improving the quality     of life of people. While one can notice a considerable progress in certain fronts; in              the field of health,          all is not so well.
  2. We will have to ensure equitable distribution of health services for ensuring equity for health. Location of health services and facilities should be such that these are easily accessible and available to people, especially the under-privileged sections of the society. Regionalization of health care services with clear-cut geographical demarcation for use of         facilities along with proper two-way referral system would go a long way to ensure equitable              distribution of health services to all.
  3. Strengthening of international partnership in health by integrated involvement of international organisations and agencies in important national health programmes and having a common platform for sharing experiences and expertise in health among various countries especially in the South East Asian countries are important requirements.