This article deals with ‘ Issues relating to development and management of Social Sector/Services relating to Health .’ This is part of our series on ‘Governance’ which is important pillar of GS-2 syllabus . For more articles , you can click here

Primary , Secondary and Tertiary Sector

1 . Primary Healthcare

  • Denotes first level of contact between individuals &  with health system
  • Includes  family planning , immunization,  treatment of common diseases ,  health education etc
  • In India , Provided through network of
    • Primary Health Centres in Rural Areas
    • Family Welfare Centres in Urban Areas

2. Secondary Healthcare

  • Second Tier of Health System
  • Include
    • District Hospitals
    • Community Health Centre (CHC) at Block Level.

3. Tertiary Healthcare

  • Third Level of Health Care
  • Provide specialised consultative care 
  • Provided by Medical Colleges &  Medical Research Institutes


  • India spends a total of 4 per cent of its GDP on health, which in itself is a significant amount. However, it is high  out-of pocket expenditure that cause problem 
    • Total Spending on Health = 4% of GDP
    • Public Sector = 1.15% of GDP
    • Rest : Out of Pocket
  • Global Burden of Disease Report (2018) by LANCET  Rank =  145 
  • Research suggests that $1 spent on nutritional interventions in India could generate $34 in public economic returns.

State of Health Services in India

  • (Economic Survey) Prominence of Private Sector : Out of 4% expenditure on healthcare in India, Public Sector accounts for just 1.15%
  • (Economic Survey) High Out of Pocket Expenditure (OoPE) : OoPE is as high as 62% (2014-15) 
  • Number of hospital beds per 1000 peopleWHO average = 3.5  || India = 0.7.
  • Planning commission => health problem pushes 39 million people every year under poverty line. 
  • Doctors unwilling to serve in Rural Areas .
  • Dominance of Medical Council of India hindered development of nurses and other health cadres

Political & Constitutional Angle

  • Health is under State list
    • Debate going on – Should it be moved to Concurrent List given that even after 70 years of independence, state of health in India is still poor
    • Centre can only make model laws to which states can voluntarily subscribe
  • Article 47 of Indian Constitution (Directive Principle of State Policy) : State shall regard the raising of the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties
  • Article 21 – Right to Life

Health and SDG

  • SDG 3 : Ensure Healthy Lives & Promote well being for all at all ages
SDG 3 and Health

Health Schemes

1 . National Health Mission (NHM)

  • It is Core Scheme (60:40 Division)
  • It has two Components
National Rural Health Mission (NRHM) In areas having population below 50,000
National Urban Health Mission (NUHM) In areas having population above 50,000

2. Pradhan Mantri  Bhartiya Jan Aushadhi Pariyojana (PMBJP)

  • Inexpensive,  quality  unbranded  generic  medicines  will  be  made available  through  Jan Aushadi Stores 

3. Mohalla Clinics

  • Started by Delhi Government
  • Primary Healthcare service near the house and has potential to solve ills like Out of Pocket Expenditure .

4. Rogi Kalyan Samiti

  • Registered Society consisting of citizens of the area.  Members act as trustees to manage the affairs of hospital.
  • Act as check and increases accountability of doctors.

5. Mother and Child Health Schemes

Under Health Ministry 1. Pradhan Mantri Surakshit Matritva Yojana
2. Janani Suraksha Yojana  
Under Ministry of Women 1. Pradhan Mantri Matru Vandana Yojana
2. Integrated Child Development Program

6. Immunization Programs

  • Universal Immunization Program (UIP) against 12 diseases
  • Mission Indradhanush

More about UIP and Mission Indradhanush explained below.

7. Menstruation Health

  • Menstrual Hygiene for Adolescent Girls Scheme: To address the need of menstrual hygiene among adolescent girls residing  in rural areas.
  • Project Stree Swabhiman  (by Ministry of Electronics and Information Technology)
  • Menstrual Hygiene Scheme  ( by Health Ministry as part of Rashtriya Kishor Swasthya Karyakram. )
  • Rashtriya Madhyamik Shiksha Abhiyan (by Ministry of Human Resource Development)

8. Drug Price Control Order 

  • Drug Price Control Order (DPCO) is issued under the provisions of Essential Commodities Act .
  • Schedule 1 of DPCO contains List of Essential Medicine (376) . Their price can’t be more than the fixed ceiling price .
  • Mechanism to fix price
    • Average of price of all brands having 1% market share
    • Annual revision according to Wholesale Price Index


1 . Universal Immunization Program (UIP)

  • Universal Immunization Program started by India in 1985
  • Under Indian Immunisation Program, Vaccine is given for 12 life threatening diseases
Original (7) 1. Diphtheria
2. Whooping Cough
3. Tetanus (DPT)
4. Polio
5. TB
6. Measles
7. Hepatitis B
2016 4 more added
8. Rotavirus (for Diarrhoea)
9. Inactivated Polio Vaccine Bivalent
10. Japanese Encephalitis for Adults
11. Measles and Rubella
 2017 1 more added
12. Pneumonia

Side Note : Pentavalent

Protects against 5 infections — diphtheria, tetanus, pertussis, hepatitis B, and Haemophilus influenzae Type B (Hib) in one shot.

2. Mission Indradhanush

Time Frame Christmas 2014 to 2020
Target Full and Free Vaccination to all Children and Pregnant Women
7 Diseases 1. Diphtheria
2. Whooping Cough (Pertussis)
3. Hepatitis B
4. Tetanus
5. Polio
6. TB
7. Measles – Rubella    

In selected states , following diseases will also be covered
– Japanese Encephalitis
– Influenza Type B

Side Topic : Why People resist Vaccination ?

  • Herd Immunity : When a critical number of children are vaccinated, it protects the “herd”, so that even non-vaccinated children are safe. Some parents  begin to think that vaccinations are not needed. 
  • Misleading Comments : misleading comments on social media derail  vaccine programme.  Statements like the vaccine is introduced to induce impotence in children belonging to certain communities .
    • Muslim Community is very much vulnerable to this.
    • 2018 Punjab : Similar rumours regarding Measles – Rubella

Public Health Policy , 2017

Previous Policy was given in 2002. There was need for new policy because

  • 15 years have passed => new challenges have come up in health sector.
    1. At that time, Polio was major Problem. Now , WHO has declared India to be Polio Free
    2. That policy was keeping in view of Millennium Development Goals (MDG) . Now, we are in era of Sustainable Development Goals (SDG) . 
    3. At that time , Communicable Diseases were major problem. Now Non Communicable Diseases have come into scene.

Main provisions of Public Health Policy, 2017

Finance – Present Government  spending =  1.15 % of GDP
– New Target under Public Health Policy = increase it to 2.5% of GDP by 2025 .   
Targets Policy intends to
1. Increase life expectancy at birth from 67.5 to 70 by 2025 .
2. Reduce premature mortality from Non Communicable Diseases (NCDs) by 25 per cent by 2025.
3. Achieve the global 2020 HIV target (also termed 90:90:90)
Preventive and curative Care This policy will rely on Preventive as well as Curative Health Care (2002 Policy = just Curative )
Focus on Primary Care Policy advocates allocating two-thirds (or more) of resources to primary care.   
AYUSH AYUSH  to be promoted
Make in India Promote Promote drugs and devices manufactured in the country.  
Promote Male Sterilisation Pushing up male sterilisation (Vasectomy) atleast by  30%.  

Criticism of the policy

  • Abandoned idea to make  health a right proposed under Draft Health Policy. NHP speaks of “assurance-based approach”.
  • Raising Government Expenditure to 2.5% of GDP till 2025 is too far fetched given problem India facing is serious. Along with that no yearwise plan of yearly incrementation is given . There is lesser hope that even this will be attained given the past experience that health policy of 2002 had promised health expenditure of 2% of its GDP on health by 2010
  • Governance issues are ignored : Silent on whether Health should be moved to Concurrent list
  • Professional issues are ignored eg MCI issue , Private practice by Government doctors.

Issue : Out of pocket expenditure 

  • This topic has been frequently discussed in previous Economic Surveys. Hence, it is important topic.
  • Data
    • 5.5 Crore Indians fell into serious poverty-trap  per year due to high health expenditure
    • India’s  out-of-pocket expenditure for health is one of the highest in the world, at 62 percent.(Global Average = 18%)
    • Current expenditure on health is 4% of GDP out of which government spending is 1.15% and rest is private spending.

Why Out of Pocket Expenditure is high ?

  • Low Public Health Expenditure by Government : Government spends just 1.15% of GDP on health
  • No Insurance Cover (80% of  population not covered under any insurance) 
  • Underfunded Drug Provisions :  India allocates  0.1 % of GDP on publicly funded drugs 
  • Provider Induced Demand 
  • Changing Nature of Diseases  to non-communicable diseases  which isn’t covered by any public health system 

Impact of high Out of Pocket Expenditure

  • Large number of people are pushed into poverty because of this
  • Increasing Inequalities in the society (according to Economic Survey of 2018)
  • Causing feeling of relative deprivation in poor sections of society which can cause social unrest.
  • Sizable amount of population doesn’t  go for any treatment because of financial constraints
  • Creates vicious cycle of poverty (Poverty Trap)
Poverty Trap

Steps Already Taken

  • National Health Policy : Increase Health expenditure to 2.5% of GDP
  • Ayushman Bharat
  • Jan-Aushadi Stores
  • National Free Diagnostic  Initiative : to provide essential diagnostic services
  • National Free Drug Initiative :   expanding the availability of free drug in all public health facilities
  • All the registered Medical practitioners directed by MCI to prescribe generic drugs & write name of salt instead of brand name

Way forward / How to control

  • Pass Clinical Establishment Registration Act : To stop Provider Induced demands by doctors
  • Increase health expenditures from their current level to at least 3 percent of the GDP
  • Improve working of Jan Aushadhi stores  
  • Ensure a standard pricing system to bring parity on service cost

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