Public Health in India: Current State, Challenges, and Pathways for Improvement

Public Health in India: Current State, Challenges, and Pathways for Improvement- Kirti Yadav. 

India's public health landscape stands at a critical juncture, marked by significant achievements alongside persistent challenges that demand urgent attention and strategic intervention. With a population exceeding 1.4 billion, India faces the complex task of ensuring equitable healthcare access while managing a dual burden of communicable and non-communicable diseases. While the country has made remarkable progress in reducing maternal and infant mortality rates and eliminating several diseases, substantial gaps remain in healthcare infrastructure, financing, and service delivery that require comprehensive reforms to achieve sustainable public health outcomes.

Healthcare Infrastructure and Access Disparities

Urban-Rural Healthcare Divide

The most pronounced challenge in India's public health system is the stark disparity between urban and rural healthcare access. Despite rural areas housing approximately 65% of India's population, nearly 75% of healthcare infrastructure remains concentrated in urban centers. This imbalance creates a critical access gap, forcing rural populations to travel distances of up to 100 kilometers to receive adequate medical care.prsindia+2

Rural healthcare infrastructure has shown improvement over recent years, with the number of Primary Health Centers increasing from 23,236 in 2005 to 31,053 in 2022, and Community Health Centers expanding from 3,346 to 6,064 during the same period. However, the doctor-to-patient ratio in rural areas remains approximately 1:25,000, significantly below the World Health Organization's recommended ratio of 1:1,000.drishtiias+1

The strengthening of rural healthcare facilities under the National Health Mission has begun to reduce the burden on urban hospitals. The proportion of beneficiaries seeking care from public health facilities has increased from 41.9% to 45.7% in rural areas between 2014 and 2017, while institutional deliveries have improved from 56% to 69.2% in rural public hospitals.bsp.bimtech+1

Healthcare Workforce Shortages

India faces a critical shortage of healthcare professionals across all levels of care. According to parliamentary data, the country is short of approximately 600,000 doctors. This shortage is compounded by the uneven distribution of healthcare workers, with most qualified professionals concentrated in urban areas, leaving rural communities underserved by an under-resourced public health sector.prsindia+2

The current ratio of one government doctor for every 1,511 people falls short of optimal healthcare delivery standards. This workforce shortage results in overburdened hospitals, delayed treatments, and compromised quality of care, particularly affecting vulnerable populations who cannot afford private healthcare services.pmc.ncbi.nlm.nih

Healthcare Financing and Expenditure Patterns

Government Health Spending Trends

India's healthcare financing has undergone significant transformation in recent years, though challenges persist. The share of government health expenditure in total health expenditure has increased substantially from 29.0% in FY15 to 48.0% in FY22. Total health expenditure reached ₹9,04,461 crore (3.8% of GDP) in FY22, with per capita health expenditure of ₹6,602.data.worldbank

India's healthcare expenditure patterns and trends showing government-private spending composition

The Ministry of Health and Family Welfare received an allocation of ₹99,859 crore in 2025-26, representing an 11% increase over the previous year's revised estimates. The National Health Mission constitutes 37% of this budget with ₹37,227 crore allocated for primary healthcare strengthening.pib

Despite these increases, India's public health expenditure of 1.9% of GDP remains below the National Health Policy 2017 target of 2.5% by 2025. This falls significantly short of the global average of 6% of GDP spent on healthcare and lags behind neighboring countries like Bangladesh and Pakistan, which allocate over 3% of their GDP to public healthcare.mohfw+1

Out-of-Pocket Expenditure Challenges

A persistent challenge in India's healthcare system is the high burden of out-of-pocket expenditure on households. While there has been improvement, with out-of-pocket expenditure decreasing from 69.4% in 2004-05 to 48.31% in 2018-19, it remains substantially high compared to global standards. This high out-of-pocket spending accounts for 2.3% of GDP and leads to significant financial stress, pushing approximately 50-60 million people into poverty annually due to medical expenses.pib+2

Nearly 400 million Indians remain uninsured and financially vulnerable to medical emergencies. The high cost of healthcare services, combined with limited insurance coverage, creates barriers to healthcare access for economically disadvantaged populations.pmc.ncbi.nlm.nih

Disease Burden and Epidemiological Transition

Communicable Disease Control

India continues to battle several communicable diseases, though significant progress has been achieved in disease control and elimination efforts. The country has successfully eliminated trachoma as a public health problem in 2024 and is close to eliminating kala-azar (visceral leishmaniasis).bajajallianz+1

Tuberculosis remains a major public health challenge, with India accounting for nearly one-fourth of global TB cases. However, the National Tuberculosis Elimination Programme has achieved remarkable success, with a 17.7% decline in TB incidence from 2015 to 2023, more than twice the global average decline of 8.3%. The program has diagnosed 63,939 cases of multidrug-resistant TB, demonstrating commitment to addressing drug resistance.plutusias+2

Malaria control efforts have shown substantial improvement, with an estimated reduction in cases from 33 million in 1990 to 5.5 million in 2019. India achieved a 69% reduction in estimated malaria cases from 6.4 million in 2017 to 2.0 million in 2023.pib+1

Vector-borne diseases like dengue continue to pose challenges, particularly during monsoon seasons when transmission intensifies due to environmental factors and lack of effective vaccines.pib

Non-Communicable Disease Epidemic

India is experiencing a significant epidemiological transition, with non-communicable diseases (NCDs) now accounting for approximately 60% of all deaths, up from 37.9% in 1990 to 61.8% in 2016. This transition reflects changing lifestyle patterns, urbanization, and demographic shifts toward an aging population.thelancet+1

Disease burden transition in India: Shift from communicable to non-communicable diseases (1990-2016)

The four leading NCDs in India are cardiovascular diseases, diabetes, chronic obstructive pulmonary disease, and cancer. Diabetes prevalence has reached epidemic proportions, with India often referred to as the "diabetes capital of the world," housing 50.8 million diabetic patients. The prevalence varies significantly across regions, with southern states showing higher rates than northern states.who

Cardiovascular diseases represent the leading cause of NCD-related mortality, with the proportion of disability-adjusted life years increasing from 2.9% in 1990 to 6.6% in 2016. Cancer incidence stands at approximately 83 per 100,000 persons, with higher prevalence in urban areas.thelancet+1

Maternal and Child Health Progress

India has achieved remarkable progress in maternal and child health outcomes, demonstrating the effectiveness of targeted interventions and policy reforms. The Maternal Mortality Ratio (MMR) has declined significantly from 130 per 100,000 live births in 2014-16 to 88 per 100,000 live births in 2020-22, surpassing the National Health Policy 2017 target of MMR below 100.nhm+1

Declining trends in India's maternal and child health indicators (2014-2022)

Child health indicators have shown equally impressive improvements. The Infant Mortality Rate decreased from 39 per 1,000 live births in 2014 to 27 in 2021, while the Under-Five Mortality Rate declined from 45 to 31 per 1,000 live births during the same period. India's progress outpaces global averages, with a 78% decline in Under-Five Mortality Rate compared to 61% globally, and a 70% decline in Neonatal Mortality Rate compared to 54% globally over the past 33 years.nhm+1

Eight states have already achieved the Sustainable Development Goal target for MMR (below 70 by 2030): Kerala (18), Maharashtra (36), Tamil Nadu (38), Andhra Pradesh (47), Telangana (50), Jharkhand (50), Gujarat (55), and Karnataka (58).tbcindia.mohfw

Digital Health Transformation

Ayushman Bharat Digital Mission

India has embarked on an ambitious digital health transformation through the Ayushman Bharat Digital Mission (ABDM), launched in 2021. This comprehensive initiative aims to create a secure, integrated digital health ecosystem emphasizing personal health records under patient control.who+1

The ABDM has achieved significant scale, with over 568 million Ayushman Bharat Health Accounts (ABHA) created as of March 2024, integrating over 350 million health records into the digital ecosystem. The program encompasses over 230,000 health facilities and 285,000 registered providers, demonstrating the scale of digital adoption.pmc.ncbi.nlm.nih

The COVID-19 pandemic accelerated digital health adoption, with the CoWIN platform facilitating registration and management of COVID-19 vaccinations, leading to 130 million new ABHA accounts. The Aarogya Setu contact tracing application was transformed into a comprehensive national health app, providing digital health services powered by ABDM.who+1

Telemedicine and Remote Care

Telemedicine services have experienced unprecedented growth, particularly during the COVID-19 pandemic. The eSanjeevani telemedicine platform facilitated over 270 million teleconsultations as of August 2024, with 57% of beneficiaries being female and 12% senior citizens.who+1

The digital health infrastructure bridges the urban-rural healthcare gap by enabling remote consultations, reducing the burden on physical healthcare facilities, and improving access to specialist care in underserved regions.who

Environmental Health Challenges

Air Pollution and Respiratory Health

Environmental health represents a critical challenge for India's public health system, with air pollution emerging as a major contributor to disease burden. A nationwide analysis of 224,214 children under-5 revealed extremely high annual PM2.5 levels throughout India (median 63.4 μg/m³), significantly above the Indian National Ambient Air Quality Standards of 40 μg/m³.dataforindia

Air pollution shows a significant association with respiratory illness in young children, affecting both rural and urban populations. The World Health Organization estimates that 900,000 Indians die annually from drinking contaminated water and breathing polluted air.tsapmumbai+1

Outdoor air pollution has become the fifth leading cause of death in India after high blood pressure, indoor air pollution, poor nutrition, and tobacco smoking, causing approximately 620,000 premature deaths in 2012. The Indo-Gangetic Plains region faces particularly severe air quality challenges, with secondary aerosols contributing up to 60% of PM1 loading.tsapmumbai

Water and Sanitation Issues

Water-related health challenges persist across India, with 70% of surface water unfit for drinking according to the World Economic Forum. Each year, 40 million liters of wastewater enter Indian rivers and other water bodies, causing an estimated 9% reduction in agricultural revenues and $80 billion in environmental losses.pib

Water-related diseases result in approximately 400,000 deaths annually in India, with children under 5 years being particularly vulnerable. The lack of adequate sanitation infrastructure compounds these challenges, with 22% of healthcare facilities lacking water services and 21% lacking sanitation services.tsapmumbai+1

Nutritional Health and Food Security

India has implemented comprehensive nutrition programs to address malnutrition and related health outcomes. The POSHAN Abhiyaan (National Nutrition Mission), launched in 2018, targets stunting, undernutrition, anemia, and low birth weight reduction.slideshare+1

The mission aims to reduce stunting by at least 2% annually, striving to decrease it from 38.4% (NFHS-4) to 25% by 2022. The program operates through a multi-ministerial convergence approach, covering 315 districts in the first year, 235 districts in the second year, and remaining districts in subsequent phases.pmc.ncbi.nlm.nih+1

Key nutritional interventions include the Integrated Child Development Services (ICDS), Mid-Day Meal Programme, iron and folic acid supplementation, and food fortification programs. These programs target vulnerable populations including children 0-6 years, adolescent girls, pregnant women, and lactating mothers.slideshare+1

Pandemic Preparedness and Emergency Response

COVID-19 Response Lessons

India's response to the COVID-19 pandemic provided valuable insights for future public health emergency preparedness. The country implemented early response measures including thermal screening, travel restrictions, and a nationwide lockdown to contain transmission.nature+1

The pandemic response leveraged existing legal frameworks through the Epidemic Disease Act of 1897 and the Disaster Management Act of 2005, providing widespread legal authority for pandemic control measures. India successfully produced and administered over 2.2 billion doses of domestically manufactured vaccines through the public health system.pubmed.ncbi.nlm.nih+1

Future Pandemic Preparedness Framework

NITI Aayog has developed a comprehensive framework for future pandemic preparedness and emergency response, emphasizing the critical importance of the first 100 days of any public health emergency. The framework proposes establishing an Empowered Group of Secretaries chaired by the Cabinet Secretary for pandemic preparedness and emergency response.pubmed.ncbi.nlm.nih+1

Key recommendations include strengthening surveillance networks connecting epidemiological, genomic, and clinical data; developing platform technologies for rapid countermeasure development; establishing Centres of Excellence for research on priority pathogens; and creating high-risk financing mechanisms for emergency response.pubmed.ncbi.nlm.nih

The One Health approach has been adopted to address future zoonotic threats, with the WHO warning that 75% of future public health threats are likely to be zoonotic.hpr.abdm+1

Areas Requiring Urgent Improvement

Healthcare Infrastructure Strengthening

Despite progress, significant gaps remain in healthcare infrastructure development. The establishment of functional district Cardiac Care Units, quality accreditation of public health facilities, and institutionalization of Human Resource Management Information Systems require immediate attention.bbau

The rural healthcare infrastructure needs substantial investment to achieve optimal doctor-to-patient ratios and reduce travel distances for healthcare access. Mobile medical units, health camps, and community-based interventions should be scaled up to bridge access gaps.drishtiias

Health Financing Reforms

India must accelerate progress toward achieving the National Health Policy 2017 target of 2.5% of GDP allocation for healthcare by 2025. This requires increased budgetary allocation, improved tax-to-GDP ratios, and enhanced efficiency in healthcare spending.pmc.ncbi.nlm.nih

Reducing out-of-pocket expenditure through expanded health insurance coverage and strengthened public healthcare systems remains critical. The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana should be expanded to cover more population segments while improving service quality and provider networks.pmc.ncbi.nlm.nih

Environmental Health Interventions

Urgent action is required to address air and water pollution challenges affecting public health outcomes. Implementing stricter emission standards, promoting clean energy alternatives, and strengthening water treatment and sanitation infrastructure are essential for reducing environment-related disease burden.dataforindia+2

Climate change adaptation measures should be integrated into public health planning, considering the increasing frequency of extreme weather events and their health impacts.tsapmumbai

Prevention and Health Promotion

Shifting focus from curative to preventive healthcare requires substantial investment in health promotion, disease prevention, and lifestyle modification programs. Currently, preventive healthcare receives only 10-15% of total health spending, which needs significant enhancement to address the growing NCD burden.pmc.ncbi.nlm.nih

Community health worker programs should be strengthened and expanded, with adequate training, compensation, and support systems to ensure effective primary healthcare delivery at the grassroots level.prsindia

Strategic Recommendations

Integrated Health System Approach

Developing an integrated health system that seamlessly connects primary, secondary, and tertiary care levels through robust referral networks and digital health platforms is essential. This integration should leverage telemedicine capabilities to extend specialist care to remote areas while maintaining care continuity.who+1

Human Resource Development

Implementing comprehensive strategies to address healthcare workforce shortages through increased medical education capacity, improved distribution incentives for rural postings, and enhanced training programs for mid-level healthcare providers is crucial.prsindia+1

Technology and Innovation

Expanding digital health initiatives beyond ABDM to include artificial intelligence-driven diagnostics, predictive analytics for disease surveillance, and personalized medicine approaches can significantly enhance healthcare delivery efficiency and outcomes.who+1

Multi-sectoral Collaboration

Strengthening partnerships between government agencies, private sector entities, civil society organizations, and international partners is essential for addressing complex public health challenges that require coordinated responses across sectors.pubmed.ncbi.nlm.nih

Conclusion

India's public health landscape demonstrates a country in transition, achieving significant milestones in maternal and child health while grappling with emerging challenges from non-communicable diseases, environmental health threats, and healthcare access disparities. The successful elimination of diseases like trachoma, substantial reductions in maternal and infant mortality, and innovative digital health initiatives showcase India's potential for transformative public health achievements.

However, persistent challenges including healthcare infrastructure gaps, financing constraints, workforce shortages, and environmental health risks require sustained commitment and strategic intervention. The COVID-19 pandemic has highlighted both the resilience and vulnerabilities of India's health system, providing valuable lessons for future preparedness.

Moving forward, India's public health strategy must prioritize equitable access to quality healthcare services, strengthen preventive care systems, address environmental determinants of health, and leverage technology for innovative service delivery models. Achieving the vision of universal health coverage and ensuring health for all requires coordinated efforts across government levels, adequate financial investment, and sustained political commitment to public health as a fundamental right and prerequisite for sustainable development.

The path forward demands balancing immediate healthcare needs with long-term systemic reforms, ensuring that India's public health system can effectively serve its diverse population while adapting to evolving health challenges in the 21st century. Success in this endeavor will not only improve health outcomes for Indians but also contribute valuable lessons and innovations for global health advancement.

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