Investment in Health Care:

Despite years of strong economic growth and increased Government health spending in the
11th Five Year plan period, the total spending on healthcare in 2011 in the country is about
4.1% of GDP. Global evidence on health spending shows that unless a country spends at least
5–6% of its GDP on health and the major part of it is from Government expenditure, basic
health care needs are seldom met. The Government spending on healthcare in India is only
1.04% of GDP which is about 4 % of total Government expenditure, less than 30% of total
health spending. This translates in absolute terms to Rs. 957 per capita at current market prices.
The Central Government share of this is Rs. 325 (0.34% GDP) while State Government share
translates to about Rs. 632 on per capita basis at base line scenario. Perhaps the single most
important policy pronouncement of the National Health Policy 2002 articulated in the 10th
, 11th
and 12th Five Year Plans, and the NRHM framework was the decision to increase public health
expenditure to 2 to 3 % of the GDP. Public health expenditure rose briskly in the first years of
the NRHM, but at the peak of its performance it started stagnating at about 1.04 % of the
GDP. The pinch of such stagnation is felt in the failure to expand workforce, even to train and
retain them. This reluctance to provide for regular employment affects service delivery,
regulatory functions, management functions and research and development functions of the
Government. Though there is always space to generate some more value for the money
provided, it is unrealistic to expect to achieve key goals in a Five Year Plan on half the
estimated and sanctioned budget. The failure to attain minimum levels of public health
expenditure remains the single most important constraint. While it is important to recognize
the growth and potential of a rapidly expanding private sector, international experience (as
evidenced from the table below) shows that health outcomes and financial protection are
closely related to absolute and relative levels of public health expenditure.
Country Total Health Exp per
capita (USD) - 2011

Country Total Health Exp per
capita (USD) - 2011
Total Health Exp as %
of GDP - 2011
Govt. Health Exp as
% of Total Health Exp
- 2011
Life Expectancy at
birth (years) 2012
India $62 3.9% 30.5% 66
Thailand $214 4.1% 77.7% 75
Sri Lanka $ 93 3.3% 42.1% 75
BRIC Countries
Brazil $ 1119 8.9% 45.7% 74
China $ 274 5.1% 55.9% 75
Russia $803 6.1% 59.8% 69
South Africa $670 8.7% 47.7% 59
OECD Countries
USA $ 8,467 17.7% 47.8% 79
United Kingdom $ 3,659 9.4% 82.8% 81
Germany $ 4,996 11.3% 76.5% 81
France $ 4,968 11.6% 76.8% 82
Norway $ 9,908 9.9% 85.1% 82
Sweden $ 5,419 9.5% 81.6% 82
Denmark $ 6,521 10.9% 85.3% 80
Japan $ 4,656 10% 82.1% 84

NHP-2015IV

Developments under the National Rural Health Mission:
The National Rural Health Mission (NRHM) led to a significant strengthening of public health
systems. It brought in a workforce of close to 900,000 community health volunteers, the
ASHAs, who brought the community closer to public services, improving utilization of services
and health behaviors. The NRHM deployed over 18,000 ambulances for free emergency
response and patient transport services to over a million patients monthly, added over 178,000
health workers to a public system that had depleted its workforce to sub-critical levels over a
long period of neglect, provided cash transfers to over one crore pregnant women annually,
empowering and facilitating them to seek free care in the institutions and began to address
infrastructure gaps. Across States, there were major increases in outpatient attendance, bed
occupancy and institutional delivery. However these developments were uneven and more
than 80% of the increase in services is likely to have been contributed by less than 20% of the
public health facilities. Further, States with better capacity at baseline were able to take
advantage of NRHM financing sooner, while high focus States had first to revive or expand
their nursing and medical schools and revitalize their management systems. Larger gaps in
baselines and more time taken to develop capacity to absorb the funds meant that gaps
between the desired norms and actual levels of achievement were worse in high focus states.
Inefficiencies in fund utilization, poor governance and leakages have been a greater problem in
some of the weaker states. Much of the increase in service delivery was related to select
reproductive and child health services and to the national disease control programmes, and not
to the wider range of health care services that were needed. Action on social determinants of
health was even weaker.

The almost exclusive focus of policy and implementation often masks the fact that all the
disease conditions for which national programmes provide universal coverage account for less
than 10% of all mortalities and only for about 15% of all morbidities. Over 75% of
communicable diseases are not part of existing national programmes. Overall, communicable
diseases contribute to 24. 4% of the entire disease burden while maternal and neonatal ailments
contribute to 13.8%. Non-communicable diseases (39.1%) and injuries (11.8%) now constitute
the bulk of the country‟s disease burden. National Health Programmes for non-communicable
diseases are very limited in coverage and scope, except perhaps in the case of the Blindness
control programme.
2.8. NRHM as an instrument for strengthening state health systems:
The National Rural Health Mission was intended to strengthen State health systems to cover all
health needs, not just those of the national health programme. In practice, however, it
remained confined largely to national programme priorities. While such a limited scope
enabled progress in a few indicators, this was a poor strategy. Beyond a point, such selective
facility development is neither sustainable nor efficient. For example female sterilization
operations or surgery for Emergency Obstetrics Care is safest if performed in an operation
theatre, that is functional throughout the year, and undertaken by professional teams with
support systems that are in constant use. But if such operations are undertaken on a few days
per year, in a camp mode or during an occasional emergency sustaining the quality of care for
such sporadic events is much more difficult. Strengthening health systems for providing
comprehensive care required higher levels of investment and human resources than were made
available. The budget received and the expenditure thereunder was only about 40% of what
was envisaged for a full re-vitalization in the NRHM Framework.

Urban Health:
Rapid and unplanned urbanization has led to massive growth in the number of the urban poor
population, especially those living in slums. This section of the population has poorer health
outcomes due to adverse social determinants and poor access to health care facilities, despite
living in close proximity to many hospitals - public and private. There is almost no
arrangement for primary care in many cities and towns. The National Urban Health Mission,
sanctioned in 2013 has a strong focus on strengthening primary health care- through additional
ANMs, urban ASHAs, women‟s health committees and a network of primary health centers. A
technical resource group has examined the urban health situation at length and suggested
measures needed to address the most vulnerable and marginalized sections of the urban poor
and the way forward in convergence. NUHM needs substantial expansion of funding on a
sustained basis in order to establish and operationalize a well functional primary health care
system in the urban areas.

NHP-2015 III

Inequities in Health Outcomes:
While acknowledging these achievements we need to be mindful and confront the high degree
of health inequity in health outcomes and access to health care services as evidenced by
indicators disaggregated for vulnerable groups. There are urban-rural inequities and there are 5
inequities across states. (Table 1). A number of districts, many in tribal areas, perform poorly
even in those states where overall averages are improving. Marginalized communities and
poorer economic quintiles of the population continue to fare poorly. Outreach and service
delivery for the urban poor, even for immunization services has been inadequate.

Table 1 : Disparities in health outcomes:
Indicator India
Total Rural Urban % differential
TFR (2012) 2.4 2.6 1.8 44% difference
IMR (2012) 40 44 27 63% difference 

Concerns on Quality of Care:
The situation in quality of care is also a matter of serious concern and this seriously
compromises the effectiveness of care. For example though over 90% of pregnant women
receive one antenatal check up and 87 % received full TT immunization, only about 68.7 % of
women have received the mandatory three antenatal check-ups. Again whereas most women had
received iron and folic acid tablets, only 31% of pregnant women had consumed more than 100
IFA tablets. For institutional delivery standard protocols are often not followed during labour
and the postpartum period. Sterilization related deaths a preventable tragedy, are often a direct
consequence of poor quality of care. Only 61% of children (12 -23 months) have been fully
immunized. There are gaps in access to safe abortion services too, and in care for the sick
neonate.
2.5. Performance in Disease Control Programmes:
India‟s progress on communicable disease control is mixed. The most acclaimed success of
this period is the complete elimination of polio. In Leprosy too there have been significant
reductions, but after a reduction of an annual incidence of 120,000 cases, there is stagnation,
with new infective cases and disabilities being reported. Kala-azar and Lymphatic filariasis are
expected to decline below the threshold for certifying by 2015, but as in leprosy there are likely

to be Blocks where the prevalence is above this threshold. In many more Blocks, which have achieved elimination, continuing attention to identifying and managing low levels of disease
incidence is required for some time to come. In AIDS control, progress has been good with a
decline from a 0.41 % prevalence rate in 2001 to 0.27% in 2011- but this still leaves about 21
lakh persons living with HIV, with about 1.16 lakh new cases and 1.48 deaths in 2011. In
tuberculosis the challenge is a prevalence of close to 211 cases and 19 deaths per 100,000
population and rising problems of multi-drug resistant tuberculosis. Though these are
significant declines from the MDG baseline, India still contributes to 24% of all global new
case detection. In malaria there has been a significant decline, but there are also the challenges,
of resistant strains developing and of sustaining the gains, in a disease known for its cyclical
reemergence and focal outbreaks. Viral Encephalitis, Dengue and Chikungunya are on the
increase, particularly in urban areas and as of now we do not have effective measures to address
them. Performance in disease control programmes is largely a function and reflection of the
strengths of the public health systems. Where there are sub-critical human resource
deployment, weak logistics and inadequate infrastructure, all national health programmes do
badly. This was one of the important reasons of the launch of the National Rural Health
Mission, which was geared to strengthen health systems. 

NHP-2015-II,SAMVEG IAS

Achievement of Millennium Development Goals:
India is set to reach the Millennium Development Goals (MDG) with respect to maternal and
child survival. The MDG target for Maternal Mortality Ratio (MMR) is 140 per 100,000 live
births. From a baseline of 560 in 1990, the nation had achieved 178 by 2010-12, and at this
rate of decline is estimated to reach an MMR of 141 by 2015. In the case of under-5 mortality
rate (U5MR), the MDG target is 42. From a baseline of 126 in 1990, in 2012 the nation has an
U5MR of 52 and an extrapolation of this rate would bring it to 42 by 2015. This is particularly
creditable on a global scale where in 1990 India‟s MMR and U5MR were 47% and 40% above
the international average respectively. While the narrowing of these gaps and closure,
demonstrate a significant effort we could have done better. Notably, the rate of decline of
still-births and neonatal mortality has been lower than the child mortality on the whole. In
some states there is stagnation on these two indicators.

2.2.Achievements in Population Stabilization:
India has also shown consistent improvement in population stabilization, with a decrease in
decadal growth rates, both as a percentage and in absolute numbers. Twelve of the 21 large
States for which recent Total Fertility Rates (TFR) is available, have achieved a TFR of at or
below the replacement rate of 2.1 and three are likely to reach this soon. The challenge is now
in the remaining six states of Bihar, Uttar Pradesh, Rajasthan, Madhya Pradesh, Jharkhand and
Chhattisgarh but even here rates are declining. However these six States between them account
for 42 % of the national population and 56 % of the annual population increase. In the
remaining small States and Union Territories except Meghalaya, the Crude Birth Rate (CBR), is
less than 21 per 1000. The national TFR has declined from 2.9 to 2.4. The persistent challenge
on this front is the declining sex ratio.

National Health Policy 2015-I

India today, is the world‟s third largest economy in terms of its Gross National Income

(in PPP terms) and has the potential to grow larger and more equitably, and to emerge to be

counted as one of the developed nations of the world. India today possesses as never before, a

sophisticated arsenal of interventions, technologies and knowledge required for providing

health care to her people. Yet the gaps in health outcomes continue to widen. On the face of

it, much of the ill health, disease, premature death, and suffering we see on such a large scale is

needless, given the availability of effective and affordable interventions for prevention and

treatment. “The reality is straightforward. The power of existing interventions is not matched

by the power of health systems to deliver them to those in greatest need, in a comprehensive

way, and on an adequate scale".

1.2.This National Health Policy addresses the urgent need to improve the performance of health

systems. It is being formulated at the last year of the Millennium Declaration and its Goals, in

the global context of all nations committed to moving towards universal health coverage.

Given the two-way linkage between economic growth and health status, this National Health

Policy is a declaration of the determination of the Government to leverage economic growth to

achieve health outcomes and an explicit acknowledgement that better health contributes

immensely to improved productivity as well as to equity. 

The National Health Policy of 1983 and the National Health Policy of 2002 have served us

well, in guiding the approach for the health sector in the Five-Year Plans and for different

schemes, Now 13 years after the last health policy, the context has changed in four major ways.

Firstly- Health Priorities are changing. As a result of focused action over the last decade we are

projected to attain Millennium Development Goals with respect to maternal and child

mortality. Maternal mortality now accounts for 0.55% of all deaths and 4% of all female deaths

in the 15 to 49 year age group. This is still 46,500 maternal deaths too many, and demands that

the commitments to further reduction must not flag. However it also signifies a rising and

unfulfilled expectation of many other health needs that currently receive little public attention.

There are many infectious diseases which the system has failed to respond to – either in terms

of prevention or access to treatment. Then there is a growing burden of non-communicable

disease. The second important change in context is the emergence of a robust health care

industry growing at 15% compound annual growth rate (CAGR). This represents twice the

rate of growth in all services and thrice the national economic growth rate. Thirdly, incidence

of catastrophic expenditure due to health care costs is growing and is now being estimated to

be one of the major contributors to poverty. The drain on family incomes due to health care

costs can neutralize the gains of income increases and every Government scheme aimed to

reduce poverty. The fourth and final change in context is that economic growth has increased

the fiscal capacity available. Therefore, the country needs a new health policy that is responsive

to these contextual changes. Other than these objective factors, the political will to ensure universal access to affordable healthcare services in an assured mode – the promise of Health

Assurance – is an important catalyst for the framing of a New Health Policy.

1.4.The primary aim of the National Health Policy, 2015, is to inform, clarify, strengthen and

prioritize the role of the Government in shaping health systems in all its dimensionsinvestment

in health, organization and financing of healthcare services, prevention of diseases

and promotion of good health through cross sectoral action, access to technologies, developing

human resources, encouraging medical pluralism, building the knowledge base required for

better health, financial protection strategies and regulation and legislation for health. 

Birth of a new institution

In line with the Government of India’s approach of less government and a move away from centralised planning, the NITI Aayog with a new structure and focus on policy will replace the 64-year old Planning Commission that was seen as a vestige of the socialist era. The new body, conceived more in the nature of a think-tank that will provide strategic and technical advice, will be helmed by the Prime Minister with a Governing Council of Chief Ministers and Lt. Governors, similar to the National Development Council that set the objectives for the Planning Commission. The NITI Aayog seeks substitute centralised planning with a ‘bottom-up’ approach where the body will support formulation of plans at the village level and aggregate them at higher levels of government. In short, the new body is envisaged to follow the norm of cooperative federalism, giving room to States to tailor schemes to suit their unique needs rather than be dictated to by the Centre. This is meant to be a recognition of the country’s diversity. The needs of a State such as Kerala with its highly developed social indicators may not be the same as that of, say, Jharkhand, which scores relatively low on this count. If indeed the body does function as has been envisaged now — and the jury will be out on that — States will, for the first time, have a say in setting their own development priorities.

One significant change of note is that one of the functions of the body will be to address the needs of national security in economic strategy. Nowhere is this more relevant than in the area of energy security where India, unlike China, has failed to evolve a coherent policy over the years. Similarly, networking with other national and international think-tanks and with experts and practitioners, as has been envisaged, will add heft to the advice that the NITI Aayog will provide. To deflect criticism that this will be a free-market institution that ignores the deprived, the government has taken care to make the point that the body will pay special attention to the sections of society that may not benefit enough from economic progress. How this operates in practice will bear close watching. Interestingly, though it will not be formulating Central plans any more, the NITI Aayog will be vested with the responsibility of monitoring and evaluating the implementation of programmes. Thus, while the advisory and monitoring functions of the erstwhile Planning Commission have been retained in the new body, the executive function of framing Plans and allocating funds for Plan-assisted schemes has been taken away. But who will now be responsible for the critical function of allocating Plan funds? Hopefully, there will be greater clarity on this aspect in the days ahead.

A step in the right direction,ias mains

Yet another bold initiative was taken on the last day of 2014 when the Union government made public the draft National Health Policy 2015. The policy is a first step in achieving universal health coverage by advocating health as a fundamental right, whose “denial will be justiciable”. While it makes a strong case for moving towards universal access to affordable health-care services, there are innumerable challenges to be overcome before the objectives become a reality. The current government spending on health care is a dismal 1.04 per cent of gross domestic product (GDP), one of the lowest in the world; this translates to Rs.957 per capita in absolute terms. The draft policy has addressed this critical issue by championing an increase in government spending to 2.5 per cent of GDP (Rs.3,800 per capita) in the next five years. But even this increase in allocation falls short of the requirement to set right the dysfunctional health-care services in the country. Citing the health-care system’s low absorption capacity and inefficient utilisation of funding as an alibi for not raising the spending to 3 per cent of GDP is nothing but a specious argument. Insufficient funding over the years combined with other faulty practices have led to a dysfunctional health-care system in the country. Undivided focus is an imperative to strengthen all the elements of health-care delivery. The failure of the public health-care system to provide affordable services has been the main reason that has led to increased out-of-pocket expenditure on health care. As a result, nearly 63 million people are driven into poverty every year. The Ebola crisis in Liberia, Guinea and Sierra Leone, which underlined the repercussions of a weak public health-care system, should serve as a grim reminder of this.

The national programmes provide universal coverage only with respect to certain interventions such as maternal ailments, that account for less than 10 per cent of all mortalities. Over 75 per cent of the communicable diseases are outside their purview and only a limited number of non-communicable diseases are covered. It is, therefore, crucial for the Union government to undertake proactive measures to upgrade the health-care services of poorly performing States such as Bihar and Uttar Pradesh. As it stands, health will be recognised as a fundamental right through a National Health Rights Act only when three or more States “request” it. Since health is a State subject, adoption by the respective States will be voluntary. Though a different approach has been taken to improve adoption and implementation by States, the very objective of universal health coverage that hinges on portability will be defeated in the absence of uniform adoption across India.