Health Sector in India: Challenges and Government Initiatives
July 19, 20269 min read
[TOPIC CLASSIFICATION]
Topic type: Health and Social Welfare
PYQ frequency: High - regular in Prelims (schemes, indices) and Mains (GS 2)
Exam stage: Prelims + Mains
Primary GS paper: GS 2 (Governance - Health)
[EXAMINER REASONING]
Trap: Confusing the components of Ayushman Bharat - PM-JAY (health insurance for 40% bottom population) and Health and Wellness Centres (HWCs - primary care upgrade). They are two pillars of the same mission but serve different functions.
Most confused: The difference between 'infant mortality rate' (IMR - deaths under 1 year per 1,000 live births) and 'under-5 mortality rate' (U5MR). UPSC asks for precise definitions in Prelims.
Key anchor: India's health spending remains low at 1.8-2.1% of GDP (including states), far below the recommended 2.5-3% of GDP. Low public spending drives high out-of-pocket expenditure (about 50% of total health spending) which pushes 6 crore Indians into poverty annually.
Current affairs hook: The 2026 National Health Policy mid-term review; the Ayushman Bharat expansion to cover all citizens aged 70+; the global pandemic treaty negotiations; and the debate on 'health as a fundamental right'.
Mains hinge: Frame health sector answers around the 'universal health coverage' (UHC) goal. Every challenge (low public spending, workforce shortages, regulatory gaps) should be linked to its impact on UHC.
Core Concept
India's health sector is a story of impressive achievements alongside persistent structural failures. Life expectancy has risen from 58 years (1990) to 70.8 years (2023). Maternal mortality ratio (MMR) has declined from 556 per 100,000 live births (1990) to 97 (2018-20). Infant mortality rate (IMR) has dropped from 80 (1990) to 28 (2022). Yet, these aggregate numbers hide deep inter-state and rural-urban disparities, and the health system remains fragmented and underfunded.
The Triple Burden of Disease
India faces a triple disease burden that few countries in history have faced simultaneously:
First, communicable diseases (tuberculosis, malaria, dengue, COVID-19) continue to cause significant morbidity. India has the highest TB burden in the world (2.6 million cases annually). The National TB Elimination Programme (NTEP) targets elimination by 2025. Leprosy was declared 'eliminated' in 2005 but new cases still emerge. Vector-borne diseases (dengue, malaria, chikungunya) show seasonal spikes. COVID-19 demonstrated both India's capacity (fast vaccine production, digital surveillance via CoWIN/Aarogya Setu) and its failures (oxygen crisis during the second wave, vaccine inequity in rural areas).
Second, non-communicable diseases (NCDs) are the leading cause of death, accounting for 66% of all deaths in India (WHO 2022). Cardiovascular diseases, diabetes, cancer, and respiratory diseases dominate. The National Programme for Prevention and Control of NCDs (NP-NCD) screens for hypertension, diabetes, and three common cancers. The Indian Council of Medical Research (ICMR) estimates that 1 in 4 Indians has hypertension, and 1 in 10 has diabetes. Air pollution (5th leading risk factor for death in India), sedentary lifestyles, and dietary changes are driving the NCD epidemic.
Third, a neglected burden of maternal, neonatal, and nutritional disorders persists. India still accounts for 12% of global maternal deaths and 17% of global neonatal deaths. Anaemia affects 57% of women and 31% of men (NFHS-5). Stunting (low height-for-age) affects 35.5% of children under 5. The Prime Minister's Overarching Scheme for Holistic Nutrition (POSHAN Abhiyaan) targets reduction in stunting, undernutrition, and anaemia but has only partially achieved its 2022 targets.
Public Spending and Out-of-Pocket Expenditure
India's government health expenditure is about 1.8% of GDP (including state spending), among the lowest in the world. The National Health Policy 2017 recommended raising it to 2.5% of GDP by 2025 - a target missed. The 15th Finance Commission's health sector recommendations included a ₹1.4 lakh crore grant for health, but state-level absorption capacity remains a constraint.
The consequence of low public spending is high out-of-pocket expenditure (OOPE), which accounts for about 47% of total health expenditure. Each year, approximately 6 crore Indians are pushed into poverty due to medical expenses - a phenomenon known as 'catastrophic health expenditure'. The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PM-JAY), launched in 2018, aims to address this by providing ₹5 lakh per family per year for secondary and tertiary care hospitalisation to the bottom 40% of the population (about 55 crore beneficiaries). The scheme has covered over 6 crore hospital admissions as of 2025.
India's public health infrastructure is designed as a three-tier system: primary (Sub-Centres, Primary Health Centres), secondary (Community Health Centres, District Hospitals), and tertiary (Medical Colleges, Super-specialty Hospitals). The Indian Public Health Standards (IPHS) 2022 have revised norms for each level. Yet, gaps persist: shortfall of 30% of PHCs in rural areas as per IPHS norms; 85% of specialist positions vacant at CHCs; and the rural-urban doctor ratio is 1:10.
The Ayushman Bharat Health and Wellness Centres (HWCs) programme aims to upgrade 1.5 lakh sub-centres and PHCs into HWCs providing comprehensive primary care (12 packages including NCD screening, mental health, dental care). Over 1.6 lakh HWCs have been operationalised. However, the shortage of Community Health Officers (CHOs) and the high workload per HWC (expected to cover 5,000-6,000 population) remain bottlenecks.
Human Resources for Health
India has one of the lowest doctor-to-population ratios: 1:834 (including AYUSH doctors; allopathic-only ratio is about 1:1,400), against the WHO norm of 1:1,000. The nurse-to-population ratio (1:670) is better but unevenly distributed. The National Medical Commission Act 2019 replaced the Medical Council of India (MCI) with a four-tier regulatory framework - NMC (policy), National Board of Examinations (assessment), Ethics and Medical Registration Board, and the Advisory Council. The NMC introduced a common final-year MBBS exam (National Exit Test or NEXT) for licensing and PG admission. AYUSH (Ayurveda, Yoga, Unani, Siddha, Homeopathy) plays a significant role with over 8 lakh practitioners, and its integration into the public health system through the National AYUSH Mission continues.
Key Facts
Government health expenditure: ~1.8% of GDP (target 2.5% by 2025 - missed)
Out-of-pocket expenditure: ~47% of total health expenditure
Life expectancy: 70.8 years (2023), up from 58 (1990)
IMR: 28 per 1,000 live births (2022); MMR: 97 per 100,000 (2018-20)
NCDs cause: 66% of deaths in India
TB burden: Highest globally - 2.6 million cases annually
National Health Mission budget: ~₹38,000 crore (2025-26)
POSHAN Abhiyaan: Targets reduction in stunting from 35.5% to 25% by 2027
UPSC Question Themes (Illustrative)
Treat these as original practice prompts unless a linked official UPSC paper is provided; they are not represented as verbatim PYQs.
| Type | Stage | What was tested |
|------|-------|-----------------|
| Practice | Prelims | 'Pradhan Mantri Jan Arogya Yojana' is a scheme for: Health insurance for secondary and tertiary care. |
| Practice | Mains | Discuss the challenges in providing universal health coverage in India. How has Ayushman Bharat addressed them? |
| Practice | Prelims | NEET-PG replaced: the previous PG medical entrance exam system (now part of NEXT). |
| Practice | Mains | How has the COVID-19 pandemic revealed the strengths and weaknesses of India's health system? |
| Practice | Prelims | Which of the following is NOT covered under the 12 packages of Ayushman Bharat HWCs? |
| Practice | Mains | Critically examine the role of the National Medical Commission in regulating medical education in India. |
| Practice | Prelims | POSHAN Abhiyaan is related to: Nutritional status of children, pregnant women, and lactating mothers. |
Statement Elimination Guide
Correct: "Ayushman Bharat has two pillars: Pradhan Mantri Jan Arogya Yojana (health insurance for hospitalisation) and Health and Wellness Centres (primary care upgrade)."
False: "India has achieved the WHO-recommended doctor-population ratio of 1:1,000." (The allopathic doctor ratio is about 1:1,400, though the combined ratio including AYUSH is 1:834.)
Trap: "The National Health Policy 2017 target of 2.5% GDP health expenditure was achieved by 2020." (False. The target was missed - expenditure remains at ~1.8%.)
Correct: "The National Medical Commission Act 2019 replaced the Medical Council of India as the apex regulator of medical education."
False: "Ayushman Bharat covers all Indian citizens for healthcare." (Only the bottom 40% of the population is covered under PM-JAY.)
Current Affairs Hook
In 2026, the Ayushman Bharat scheme completed its eighth year and has been expanded to cover all citizens aged 70 and above (January 2026). The National Health Policy 2017 mid-term review was conducted in 2025-26, with recommendations for a 5-year action plan. The COVID-19 pandemic's lesson on health system resilience has driven investment in pandemic preparedness under the National Centre for Disease Control (NCDC) expansion. The WHO's 'Pandemic Treaty' negotiations remain ongoing, with India advocating for equitable vaccine distribution. The 2026-27 Budget has increased allocation for health by 11% with emphasis on mental health (following the 2025-26 National Mental Health Survey which showed 10.6% prevalence of mental disorders) and digital health under the Ayushman Bharat Digital Mission (ABDM), which has crossed 50 crore unique health IDs.
Interlinkages
Science & Tech (GS 3): Vaccine development (Covaxin, ZyCoV-D), digital health (CoWIN, Aarogya Setu), telemedicine (eSanjeevani).
Economy (GS 3): OOPE and poverty; health expenditure as fiscal policy; health insurance sector.
Society (GS 1): Social determinants of health (caste, class, gender); health and nutrition interlinkage.
Environment (GS 3): Air pollution and NCDs; climate change and vector-borne diseases.
Polity (GS 2): Right to health debate; health as a state subject under the Seventh Schedule; National Health Mission as a centrally sponsored scheme.
Governance (GS 2): Regulatory reforms (NMC Act); corruption in medical regulation; accountability in public health.
Common Mistakes
"India has universal health coverage": No. India has not achieved UHC. Out-of-pocket expenditure is still 47% of total spending, and only 40% of the population is covered by Ayushman Bharat.
"Maternal mortality is no longer a concern": India's MMR (97) has improved but is still above the SDG target (70 by 2030) and 4 times higher than countries like Sri Lanka (36).
"The National Health Mission covers all health programmes": NHM specifically covers reproductive and child health, communicable diseases, and NCD programme support. Tertiary care and medical education are managed separately.
"AIIMS is the only apex medical institution": AIIMS (New Delhi) is one of several premier institutes, but there are now 22 AIIMS under the Pradhan Mantri Swasthya Suraksha Yojana (PMSSY). The Department of Health Research and ICMR are the apex research bodies.
Revision Snapshot
India's health sector faces a triple disease burden (communicable, NCDs, and maternal-neonatal-nutritional disorders) with government expenditure stuck at ~1.8% of GDP. Out-of-pocket expenditure (47%) pushes 6 crore Indians into poverty annually. Key initiatives: Ayushman Bharat (PM-JAY covering 55 crore beneficiaries for ₹5 lakh/year + 1.6 lakh HWCs for primary care upgrade), National Health Mission (primary care backbone), POSHAN Abhiyaan (nutrition), PMSSY (22 AIIMS), National Medical Commission (regulatory reform). Achievements: Life expectancy 70.8 years, MMR 97, IMR 28. Persistent gaps: doctor shortage (1:834 including AYUSH), specialist vacancies (85% at CHCs), inter-state health disparities (Kerala IMR 7 vs Madhya Pradesh 43). The path to UHC requires raising health spending to 2.5% of GDP, strengthening primary care, and reducing OOPE through expanded insurance coverage. The Ayushman Bharat Digital Mission and the expansion of insurance to all citizens 70+ are the 2026 headlines.
Source Notes
Constitution of India (Fundamental Rights, DPSP, Special Provisions)
Acts: SC/ST PoA Act, PWDV Act, POSH Act, FRA 2006, NFSA 2013, Maternity Benefit Act, Child Labour Act, Bonded Labour Act
Census of India, NFHS, NSSO, PLFS, SECC, Periodic Labour Force Survey