The architects of the Indian Constitution had wisely left healthcare as a state subject.
This is because considering the geographical spread of the nation, huge variances in demographic profiles, the vagaries of nature, social disparities, cultural and traditional differences, food habits, education levels and standard of living among other markers, health had to be micro managed. There cannot be a one-size fits all. That task was rightly left to the States. But that does not mean that the Centre has no role. The Central Government did enter the field of healthcare in a limited and in specific domains.
But these were only to specific and well-defined groups. On a larger canvass, the Health Ministry was mandated to set up over all national policies like eradication of polio, cancer, leprosy, tuberculosis, malaria, AIDS control, mother and child protection, mental health etc. (See Box). Apart from this, the Union Health Ministry was also tasked with formulating national campaigns like anti-smoking, sanitation, need for hygiene, hand wash etc. Formulating policies concerning medical education, setting a uniform syllabus for medical education, guidelines for setting up hospitals etc are also under the central purview. Of late, medical entrance examinations too is under the central rules following the intervention of the Supreme Court to provide level playing field and to rationalise medical education standards. One major task that came directly under the Union Health Ministry is research. Research concerning health issues that are relevant to India are carried out by the Indian Council of Medical Research (ICMR), one of the oldest and largest medical research bodies in the world that was set up in 1911 (it
was then known as the Indian Research Fund Association and re-designated as ICMR in 1949). The ICMR is funded by the Government of India through the Department of Health Research, Ministry of Health and Family Welfare. ICMR has 26 national institutes under its umbrella to do research on specific health issues like tuberculosis, leprosy, cholera and diarrhoeal diseases, viral diseases including AIDS, malaria, kala- azar, vector control, nutrition, food & drug toxicology, reproduction, immuno-haematology, oncology, medical statistics, etc. ICMR also has six regional medical research centres mandated to look specifically into regional health issues and strengthen or generate research capabilities in different geographic areas of the country. From post-Independence government under Pandit Jawaharlal Nehru to economic liberalisation in 1991 under PV Narasimha Rai, healthcare was predominantly under the government at the centre and the states. But before getting into the post liberalisation stage, it would be worthwhile to look into the brief history on how healthcare policies were shaped.
The Ministry of Health was established following Independence in 1947. Subsequent to that, the
government under Jawaharlal Nehru made health a priority in its series of five-year plans. These
plans determined the state's spending priorities for the coming five years.
In 1948, the Employees' State Insurance was set up as a self-financing social security and health
insurance scheme for workers. The fund is managed by the Employees' State Insurance Corporation
according to rules and regulations stipulated in the ESI Act 1948.
In 1954, the Central Government Health Scheme (CGHS) was set up to provide comprehensive
medical care to the Central Government employees and pensioners enrolled under the scheme.
CGHS is considered to be a model Health care facility provider for Central Government employees
and pensioners and handles a large volume of beneficiary base.
A major milestone was in 1983 when the National Health Policy was endorsed by Parliament.
Subsequently it was updated in 2002 and 2017. Notable updates came when the Narendra Modi
government in 2017 brought healthcare back to mainstream budget proposals. The government
focus was on growing burden of non-communicable diseases, on the emergence of the robust
healthcare industry, on growing incidences of unsustainable expenditure due to health care costs
and on rising economic growth enabling enhanced fiscal capacity.
Subsequent to the 2002 update, in 2005 it was realised that the lack of medical coverage in rural
areas has to be addressed. Hence, the Union national Government launched the National Rural
Health Mission in 2005 to focus resources on rural areas and poor states, which have weak health
services, in the hope of improving health care in India's poorest regions.
Though health care system in India is universal, on the ground there are great discrepancies in the
quality and coverage of medical treatment. This resulted in the setting up of Primary Health Centre
(PHCs), sometimes referred to as public health centres. PHCs are state-owned rural health care
facilities and are single-physician clinics usually with facilities for minor surgeries, too. They are part
of the government-funded public health system and are the most basic units of this system.
Presently there are 28,863 PHCs in India and most of the treatments are either free or subsidised to
that they are affordable to the people at the bottom of the pyramid. The system of PHCs became a
role model for many developing nations.
Apart from the regular medical treatments, PHCs in India also focus mainly on the following
programmes: immunization, anti-epidemic, birth control programmes, pregnancy and related care
with special focus on neonatal care, and emergencies: All the PHCs store drugs for medical
emergencies which could be expected in rural areas. For example antivenoms for snake bites, rabies
Of late, under the present Narendra Modi government, these PHCs would be converted into
wellness centres. This was announced in the 2018 Union Budget proposals under the ambitious
Ayushman Bharat plan.
Cases that could not be dealt with by the PHCs were referred to district hospital and cases that
needed specialised treatment and complex surgeries were referred by district hospitals to super-
specialty hospitals like the AIIMS.
The first AIIMS was set up in 1956 in New Delhi primarily with the objective to developing certain
patterns of teaching in undergraduate and post-graduate medical levels. Today, there are 12 AIIMS
where teaching and treatment go hand in hand. Today, the AIMMS set-ups handle some of the most
Post liberalisation marked the entry of private players in setting up super-speciality and multi-
speciality hospitals. While the State government gave land at subsidised rates to major players, the
centre slashed import and excise duties on high-end medical equipment so that the cost of
treatment would be affordable.
Moreover, hospitals that enjoyed subsidies had to reserve a percentage of beds for the poor and
underprivileged and provide treatment at a lower cost.
With this, the foundations of Public-Private Partnerships were laid. But there was a worry. Since
2005, most of the healthcare capacity added has been in the private sector, or in partnership with
the private sector. The private sector consists of 58% of the hospitals in the country, 29% of beds in
hospitals, and 81% of doctors. So, is the government slowly withdrawing from healthcare segment?
Not necessarily if the larger picture is taken into consideration.
From post liberalisation era, healthcare policies either continued on existing lines or started losing
focus. Moreover, some of the schemes were being misused and had become breeding grounds for
corruption and scandals.
Then came the epoch moment in 2014 when healthcare regained importance under the Narendra
Modi government. As India started gaining steam to become one of the world’s largest economies,
the Modi government rightfully planned to create a healthy workforce as drivers of the wheels of
Experts say that one extra year of life expectancy adds 4 per cent to GDP; and with every dollar /
rupee spent on health, return on investment will be 9 to 10 times.
It is with this idea of having a healthy skilled workforce that Prime Minister Narendra Modi launched
Ayushman Bharat, or, healthy India. In 2018 Union Budget came the National Health Protection
Scheme (NHPS) for over 10 crore poor and vulnerable families. In real numbers, an estimated 50
crore individual beneficiaries would get coverage of up to Rs 5 lakh per family per year.
This is undoubtedly the world’s largest government-funded healthcare programme. NHPS will be
part of an umbrella Ayushman Bharat scheme, along with a preventive healthcare component worth
Rs 1,200 crore. “These two far-reaching initiatives (the other being the Pradhan Mantri Jeevan Jyoti
Bima Yojana or PMJJBY) under the Ayushman Bharat will build a New India 2022 and ensure
enhanced productivity, well-being and avert wage loss and impoverishment,” according to the then
Finance Minister Arun Jaitley.
The NHPS has been rightly described as the mother of all insurance schemes in the country with sum
assured estimated to touch a whopping Rs 50 lakh crore! That would be almost one-third of India’s
stock market value, or market capitalisation.
Despite all this, India has miles to go to achieve a threshold of wellness and healthcare. According to
the World Bank, the total expenditure on health care as a proportion of GDP in 2015 was just 3.89%
out of which governmental health expenditure as a proportion of GDP was a measly 1%. But though
there are many schemes, the out-of-pocket expenditure as a proportion of the current health
expenditure was a whopping 65.06% in 2015.
But with schemes like Ayushman Bharat and the new resolve of the Narendra Modi government to
re-focus on healthcare and remove bottleneck like access to healthcare services, provision of
essential medicines and scarcity of doctors, India can look at a bright future.