Background Note: Health
Future of India Campaign
From AIPSN Health Desk
Health and well-being is the centre of human life. In addition to healthcare, it encompasses all the dimensions of life that have a bearing on our physical, mental, social and spiritual well-being (livelihoods; conditions of work; income security; access to food; living conditions; environmental conditions; citizenship and rights; social hierarchies; developmental paradigm etc.). Although there have been significant improvements in some of the health metrics in India, like increase in overall life expectancy or decline in infant and maternal mortality, it is too late and too little in comparison to even our ‘poorer’ neighbours like Bangladesh or Nepal. Widespread social and economic disparity have denied the most marginalized the necessities required to ensure a quality life. The Adivasis, Dalits, religious minorities continue to suffer from social disparities and discrimination, which reflect on their poor health indicators. Growing economic disparities and social rift among various communities has led to a spike in violence and injury in recent years, causing death and disability. At the policy level healthcare is being seen more as a source of lucrative business and profit which contradicts with the goal of health being a right.
Given the current situation and the challenges, old and new, there needs to be a perspective shift from ‘cure’ dominated by a medical industry to ‘care’ that is holistic and rooted in the history and health culture of the country. This would mean expanding the public resources for health and optimising the potential of available knowledge, practices and infrastructure. The approach for the same has to ensure people’s participation with desired support from the public sector for ensuring primary to tertiary care with equitable access, rationality, accountability and affordability. To ensure health for all now, a change in perspective is necessary.
Such a transformation is possible if the right to healthcare a justiciable right. It needs legislations, both at the National and State levels. Such legislations should ensure universal access to good quality and comprehensive health care including the entire range of primary, secondary and tertiary services for the entire population. This must be accompanied by a public health legislation which ensures people’s access to a range of health determinants and protection from health harming influences. These should contribute to the process of making health and healthcare as fundamental rights in the Indian Constitution. Every person’s Right to free essential medicines and diagnostics in all public health facilities should be ensured. Right to health would involve, apart from guarantees related to healthcare, right to various underlying social determinants of health and domain specific laws.
The crises facing health in India: Some key concerns and demands
Poor Public spending on Health: Globally, governments bear the responsibility to provide health care. In many countries tax money is used to provide services directly. In others, health care is organized through social insurance. In India, the government bears less than a fourth of health spending- among the lowest in the world; while households spend two third. Governments in BRICS countries like Brazil, South Africa, and China, which have made significant efforts in recent times towards provisioning of universal access to health and spend higher proportions of GDP on health. Governments in nearby countries like Sri Lanka, Thailand, Malaysia, and Nepal mobilise more resources towards health than India. While the health of the people suffers, so does the healthcare system that is supposed to be the recourse to suffering. India’s public health expenditure currently stands at around 1.2 % of GDP, among the lowest in the world. The Centre’s share in this expenditure is a mere 0.3% while the states cover 0.9%.
It needs to be noted that neo-liberal reforms, extensively promoted by the multilateral bodies and wholeheartedly supported by the ruling elites, advocated for cuts in public spending on health (Indranil 2024; Duggal 1995). This led to decline in quality of care in public systems, and pushed the middle class out of the public system, creating further grounds for the private sector to grow. As a result, cost increased and inequalities in access to care grew. Until 1980s, for an overwhelming majority the tax funded and publicly provided system remained the only alternative and there was a gradual expansion of primary and secondary care in rural areas through public investments. On the other hand, the private sector was typically characterised by unskilled or semiskilled informal providers and practitioners of Indian traditional systems of medicine. But with neoliberal reforms, healthcare increasingly became a commodity and a portion of the private sector consolidated through increased investment in the health sector by big business and corporate chains. Consequences of neo-liberal reforms were clear - growing inequities in access, rising Out of pocket expenses (OOP), depleting public provisioning, growing organised market for healthcare (Indranil 2024, op cit.).
High burden on Peoples’ Pocket for health spending: Every family in India dreads a medical emergency. When a family member falls ill, we pay from our pocket- we either draw from our savings, sell assets or borrow. If one is poor, the option is to either forego care and die or get pushed to further destitution due to the costs. Children are taken out of school, women work longer hours to earn a little more, and make do with meagre meal(s). As families cope with health shocks, the vicious cycle of poverty and ill-health continues.
OOP should be minimised so that no one is pushed below poverty or faces catastrophic health spending or face indebtedness or loss of assets! OOP on chronic care and medicines remain major drivers of OOP! Current decline in OOP is accompanied by decline in utilisation of services! This should be reversed to ensure that no one forgo care due to costs!
Weakened publicly provided healthcare: Introduction of neo-liberal reforms have led to continuous decline in publicly provided systems. The public system is also beset with a massive shortfall in infrastructure by its own stated norms. Compared to the Indian Public Health Standards set by the Government, there is a shortfall of about 20% in sub-centres, about 23 % in PHCs and about 31% in CHCs. Most of the healthcare professionals and institutions are also concentrated in urban areas, although 70% of the Indian population lives in rural areas. The public system, mired in such problems, effectively forces people to seek care from the private sector.
Unregulated growth of the private sector and over medicalization have created a health system that is iniquitous, iatrogenic and unsustainable. Strengthening publicly funded and publicly provided system needs to be the fulcrum of health rights. Strengthen and enable public health systems at all levels in rural and urban areas to provide free comprehensive services, essential drugs and diagnostics, expanding both quantity and quality based on health services standards. This would require upgradation of public health facilities, with matching human resource policy and improved governance and management.
Combined with this, it is important to ensure nationwide access to essential medicines and diagnostics in all public facilities, based on the models of successful state level schemes such as those operating in Tamil Nadu, Kerala and Rajasthan. Along with ensuring genuinely autonomous corporations with adequate and competent staff and various measures for transparency and responsiveness, public budget on medicines must be majorly upscaled in most states to meet requirements. Ensure regular, adequate availability of essential vaccines and revive public sector drug and vaccine production units. Expand the primary level institutional services (outreach activities, sub-centre, PHC) depending on the epidemiological need of the specific areas, along with provision of adequate trained human resources. Strengthen CHCs and District Hospitals to provide adequate and free secondary and tertiary care.
Strengthening human resources in the public sector: Health rights cannot be ensured without ensuring dignified working conditions for health workers and fulfilling vacancies of skilled health workers at every level. Regularise all scheme based health workers, including ASHA, Anganwadi workers and helpers involved in delivery of public health services, ensuring fair wages and provisions of social security and decent working conditions. Provide adequate and continuing skill training to all the workers. Create permanent posts to guarantee a well-staffed public health system. Allocation for states to strengthen public health leadership, skills and capacities through creating a multi-capability (addressing gaps in technical, administrative and social dimensions in public health) Public Health Cadre similar to the IAS and modernising education in community medicine/preventive and social medicine in medical and nursing colleges.
Government Funded Insurance Schemes: In effective and wasteful: It has been clearly seen during the COVID-19 pandemic Pradhan Mantri Jan Arogya Yojana (PMJAY) abysmally failed in providing access to healthcare services to the poor and deprived sections during COVID-19. Moreover, during COVID-19, a significant drop in insurance claims was seen. One of the arguments given in favour of PMJAY or generally any insurance-based strategy is that people will have access to a larger number of health facilities as they have the option to go to private hospitals as well, especially in the context of poor access to public facilities in remote parts of the country. And as a result, GFHI coverage has increased considerably over the last few years, particularly since COVID-19. Around 30% people in rural areas and 16% in urban areas do possess cards. However, these schemes exclude a large proportion of the most marginalised sections of the society, even though they claim to cover at least the bottom 40% of the population. The NSS consumer expenditure survey (CES) 2023 shows that among the bottom 40% of the population in rural areas almost 2/3rd of them are not covered by the scheme (NSS 2024). In urban areas 75-80% of people belonging to the bottom two consumption quintiles are not covered by GFHIs.
Majority with card do not receive benefits
Despite being covered under GFHIs, at the time of hospitalization only a miniscule section is able to get benefits. Among the rural and urban poor, a very low percentage benefits from the scheme . For instance, out of 100 people covered and needing hospitalization, only around 40 benefit in urban areas and 34 in rural areas. Moreover, a higher proportion of people from better off quintiles benefit from the scheme, compared to their poorer counterparts
It is a well-documented reality in India that private hospitals have either grown where there are already public hospitals in place or in metro cities, state capitals and other big cities where there is greater purchasing power. Almost half of the private hospitals and two thirds of the corporate hospitals are in the few five million plus cities, where bigger government hospitals and medical colleges are also available. Even though there is equitable enrolment in health insurance schemes, this does not automatically translate into equitable access to healthcare. Access to healthcare depends on availability as well.
Around 55% of deliveries under these schemes happen through C-section under these schemes in private facilities (NFHS V)
Only 4% of total private sector admissions under PMJAY are dalits, 1.6% STs. (RTI)
Large part of the PMJAY budget remains underutilised yet Union Government keeps on allocating around INR 6400crores on the scheme.
CAG report finds huge corruption under PMJAY, with duplicate beneficiaries, multiple cards against the same name, inappropriate procedures etc.
In the case of PMJAY, the private sector is predominantly handling surgical packages (such as cataract, single stent angioplasty, and hip fracture). A bulk of lifesaving, critical and cost intensive care, is being taken care of by the public hospitals. Nearly 75% of the claim value under PMJAY has gone to the private sector (Dong 2020). In the long run, such a tendency gradually works towards pushing the public health system into non-profitable, cost intensive care, thus weakening it further.
The Union government’s priority on Ayushman Bharat PMJAY is visible in its spending priorities Between 2014-15 and 2019-20, expenditure in real terms have almost doubled, growing at an average of 18% per annum, much of this increased expenditure being borne by the states. The Union Government continues to promote the GFHIS at the cost of programmes such as the National Health Mission which have strengthened the health system, especially at the primary level of care. In contrast to the increasing expenditure on GFHIs, the spending on NHM since 2019 has declined in real terms by 5.5% on average (JSA 2025).
Despite massive failures, the government is continuing large and wasteful allocations for this scheme. Coverage is now being expanded to the non-poor by states. As a result, such schemes are also squeezing a lot of public resources.
Proliferation of unregulated for-profit private sector: The consequences of private sector led model of provisioning are well known distortions, induced consumptions, drive towards more technology intensive care and above all high cost of care. There is an effort to deliberately underestimate problems of private sector and hush up the real issues under the garb of regulation. Global experience suggests that most of the developing countries do not have the capacity to regulate private health sector and especially corporate hospitals. In India, there is very limited experience in terms of regulating private sector. Until recently, there were no efforts to enumerate total private health enterprises at the national level.
Though Clinical Establishment Act 2010 was passed in the Parliament and rules have been framed, very few states have ratified the Act. Though these legislations are there on paper there is hardly any initiative from the state governments to even register private clinical establishments, not to speak about regulating them. As a result these institutions remain highly unregulated.
We have seen the disastrous consequences, particularly during the time of COVID. Patients have been given irrational treatment, huge fees have been charged from them. There have been instances where hospitals have refused to handover dead bodies of patients.
Despite all the experiences, public resources (land and funds) that should have gone into building infrastructure in the public sector, are brazenly being given to the private sector. Government is paying private sector to set up hospitals and do any amount of profiteering. Business groups are being paid by government to become healthcare entrepreneurs and businesspersons, instead of investing the money and human resources going into strengthening the public system.
Rise in medicine prices and pharma profiteering: While price of essential medicines are rising at a very high rate, we see a strong nexus between governments and pharma companies. There have been several cases where quality of medicines have come under scrutiny and pharma companies have evaded punishment by donating in electoral bonds or bribing. Some key facts regarding pharma industry are here:
The topmost category of super-rich (more than Rs1000 crore income) come from the pharmaceuticals industry, which has 133 such capitalists (In the Hurun India Rich list of 2023)
Only 18% of medicines sold under price control
Medicine Prices are increasing at a very high rate!
30 pharma and healthcare firms together bought electoral bonds worth over Rs 900 crore!
Seven firms that failed drug quality tests gave money to political parties through electoral bonds.
In 2022, the Indian pharmaceutical sector spent a whopping 53 percent of its digital advertising budget on paid search advertising.
2 billion people have no access to essential medicines, effectively shutting them off from the benefits of advances in modern science and medicine
Lack of Social Health Protection for workers: There exists a long standing scheme for formal sector workers which provides comprehensive health protection- the Employees State Insurance Scheme (ESIS). However, the scheme coverage remains limited to formal sector workers with a limited income cap of INR22000 per month. The scheme is riddled with multiple governance and supply side challenges and need pro-people reforms to improve accountability and service delivery. The scheme needs to also include emerging forms of workers including gig and platform workers as well as traditional sectors like plantation and bidi workers. The current trajectory of privatisation of the scheme needs to be thoroughly rejected and existing system needs to be strengthened.
Environment, Climate and Health: Human health is intimately linked to the environmental conditions, and a healthy environment is integral to our survival on the planet. Environmental regulatory, thus, need to be integrated with health policy. This means the environmental regulations must be driven by the ‘Right to Life’ enshrined in the constitution and executed along the priorities of public health. The precautionary principle needs to be applied to choice of new technologies, e.g. in agriculture and systems designs as in urban development, to effectively address the interlinked issues.
Rising environmental pollution and rapid and unpredictable extreme weather events are killing thousands of people every year in India. Climate change has not only eroded the quality of life in general but also created newer complications like rise of non-communicable diseases and return of older infectious diseases in virulent forms. Non communicable diseases now account for over 61 per cent of all the deaths in India, while old diseases like diarrhoeal diseases and respiratory infections, tuberculosis and vector borne diseases continue to thrive in poverty ridden, resource poor settings. Diarrhoeal diseases, lower respiratory tract infections, Tuberculosis featured among the top ten killer diseases of 2017. Air pollution, claiming 1.5 million lives a year, is the fifth largest killer in India.
Health governance and the community
While the broad policy contours and some issues need national attention, such as Professional education and Health technology regulation mechanisms, control of communicable diseases, financing of health care, major planning and implementation has to be at state levels and below. People-centred, decentralised governance is essential in the health sphere due to diverse ecological and morbidity profiles, social and cultural contexts, health care systems and health related behaviours, as well as knowledge systems such as Unani, Ayurveda, Siddha and Sowa Rigpa that may have similar principles but vary in preventive, diagnostic and treatment regimens, and in their human resource base.
It is essential to ensure transparency and social accountability while eradicating corruption in the Public health system, with processes for democratisation. Ensure empowered participation of people through generalisation of community-based planning and monitoring, with involvement of public representatives, people’s organizations, women's groups and health sector NGOs at all levels from village to state. Develop a community-driven health system with active, diversified participation and strong grievance redressal mechanisms.
Gender and health—The health services need to be made more sensitive towards every gender and their specific needs, especially the gender minorities. Beyond maternal care, women’s specific health needs in relation to their work, within home or outside, need to be addressed. Sexual Harassment of Women at Workplace Act, 2013 needs to be strictly implemented in all workplaces with speedy mechanisms for redressal. Gender based violence as a public health issue needs urgent action for prevention, provision of better care to those who have experienced violence, and instituting referral system for related services and sensitization of healthcare workers for sensitive treatment of survivors. Maternity benefits need to be universally extended to unorganized sector and agricultural workers. Self-help groups need to be facilitated for production of low-cost, safe sanitary napkins which then should be made freely available to adolescent girls and young women across public schools and colleges.
Nutrition and Food security—Malnutrition, is a significant determinant of health in our country that requires attention. The country is also home to about 50 per cent of the undernourished children of the world. 37 per cent of under five children in India are underweight while 39 per cent are stunted, more so in the rural areas. Paradoxically, after US and China, India is also the third most obese nation in the world, afflicted with a double burden of malnutrition. Malnutrition and air pollution are thus the top risk factors causing death and disability in India.
Budgetary cuts and privatization of services like ICDS and Mid-Day Meal scheme need to stop immediately. Adequate funds must to be allocated to these schemes for ensuring a mix of food grains, pulses and oil, based on assessment of nutritional needs, for all.
The Public Distribution System (PDS) needs to be universalized to ensure that no one gets left behind. Locally produced items must be prioritised for local distribution through the PDS system. The 75 identified PVTGs in the country should be provided with a free doorstep delivery of special free nutritional package of food grain, dal and oil along with social pensions. Moratorium on GM cropping and import of GM foods need to be conducted till health concerns are satisfied and regulatory frameworks are in place
Increasing challenge of mental health: In the recent history of public health in India, nothing has drawn the country’s attention to mental health issues like the Covid-19 pandemic. Many studies and news articles have highlighted the increasing stress, anxiety, depression, insomnia, denial, anger, and fear among Indian people. Especially vulnerable are the children, elderly, women, socially vulnerable groups, frontline healthcare workers and people with existing mental illnesses. In some cases, increase in suicides have also been reported.
The Covid-19 pandemic has renewed the discussion around mental health and further propelled an enthusiasm among governments and nongovernmental organizations alike to provide accessible, affordable, and effective mental health services, especially through helplines and online counselling portals. Mental health programmes in India, however, has typically received much less attention as a public health priority. With the adoption of the National Mental Health Policy, 2014 the Mental Healthcare Act 2017, and the national tele-mental health programme, this needs to change.
Our Demands:
1. Recognise Health and Healthcare as Fundamental Rights
Enact legislation to recognise health and healthcare as fundamental public rights. Right to healthcare Should be addressed through public health laws to ensure its constitutional guarantee. Right to health would involve, apart from guarantees related to healthcare, right to various underlying social determinants of health and domain specific laws.
Strengthen publicly funded and publicly run healthcare systems at all levels, with a substantial increase in well-staffed and well-equipped Sub-Centres (SCs), Primary Health Centres (PHCs) and Community Health Centres (CHCs). Ensure full staffing, infrastructure and services in all PHCs, supported by decentralized, community-based governance systems. Increase public health expenditure to at least 5% of GDP by the Union Government.
2. Oppose Privatization and Commercialization of Healthcare
Oppose privatization and commercialization of health services. Roll back Public–Private Partnership (PPP) models in healthcare and strictly regulate charges in corporate and private hospitals. Use insurance-based programmes only as a supplementary measure, while prioritizing and strengthening public provisioning of healthcare.
3. Strengthen Anganwadi, ICDS, Mid-Day Meal and ASHA Schemes
Strengthen Anganwadi (ICDS), Mid-Day Meal and ASHA schemes. Campaign for adequate recruitment, regularization of employment, fair remuneration and proper training for ASHA workers, Anganwadi workers, ICDS staff and all other health workers.
4. Revitalize Public Sector Production of Medicines and Vaccines
Revitalize public sector production of vaccines, essential medicines and intermediates. Enforce compulsory licensing wherever required to ensure self-reliance and equitable access to essential medicines.
5. Ensure Affordable Medicines for All
Struggle for lower medicine prices through stronger regulation and price controls. Campaign for universal free-medicine schemes, as implemented successfully in some States.
6. Strengthen Food Security and Nutrition
Campaign for a universal Public Distribution System (PDS) that includes pulses and edible oils, highlighting progressive models such as Kerala. Struggle for improved quality and coverage of Mid-Day Meals and ICDS nutrition services.
7. Oppose Pseudo-Science and Unscientific Health Narratives
Expose and oppose pseudo-science and irrational “remedies,” the promotion of unscientific health information or practices, and Hindutva-driven narratives on health.
8. Oppose Privatization of Medical Education
Struggle against privatization and commercialization of medical education. Oppose centralized NEET-type entrance examinations that undermine equity, social justice and State-level health priorities, while promoting an expensive and exclusionary coaching ecosystem.
9. Defend Federalism in Health Systems
Oppose excessive centralization in health systems. Campaign for States’ autonomy in designing and implementing State-specific health systems and programmes, with adequate and timely funding from the Union Government.
10. Strengthen the Employees State Insurance Corporation
ESI system should be strengthened, reformed and expanded to include all the districts of the country, all informal workers in the formal sector as well as gig and platform workers. The income cap should be increased to INR35000.00 per month and benefits should be extended to retired workers as well.
11. Ensure Environmental and Public Health Safeguards
Campaign for effective provision of clean drinking water meeting strict potable standards; safe sewage and sanitation systems with dignified working conditions and safety protections for sanitation workers; pollution-free clean air meeting appropriate standards; and robust measures to protect people, especially vulnerable groups, from extreme heat and other climate-change-related impacts.
12. Ensure Inclusive Health Care
Campaign for comprehensive healthcare programmes for special categories, including persons with disabilities, the elderly, those with chronic illnesses, and workers facing occupational health hazards. Demand full integration of mental health services into primary healthcare systems.
13. Ensure Health and Public Services for Marginalized Communities
Ensure adequate essential public services, including healthcare, in Dalit and Adivasi hamlets and urban slums.
14. Promote Physical Activity and Well-Being
Increase playgrounds and facilities for sports and extracurricular activities in public educational institutions and in economically disadvantaged localities.
15. Ensure Accountability for Occupational and Environmental Health
Make managements legally accountable for occupational diseases and environmental health hazards.
