Evolution of Healthcare Policy Framework in India
The evolution of the healthcare policy framework in India from the Bhore Committee Report emphasizing Universal Health Coverage to the positive impact of health on economic growth and the challenges faced in the early years of independence in managing epidemics and ensuring immunization.
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Working Paper 78 August 2024 Evolution of the Healthcare Policy Framework in India Janak Raj, Janak Raj, Shauryavir Shauryavir Dalal, and Aashi Gupta Dalal, and Aashi Gupta
Bhore Committee Report Emphasis on UHC provision by the state of as complete health service as possible and the inclusion, within its scope, of the largest possible proportion of the community. The need for assuring the distribution of medical benefits to all, irrespective of their ability to pay, has also received recognition. a National Health System for delivery of comprehensive preventive and curative allopathic services through a rural focused multi-level public system financed by the government, which all patients would be able to reap, irrespective of their ability to pay. 2
Bhore Committee Report Positive Impact of Health on Economic Growth Apart from the intrinsic importance of maintaining individual and community health at its highest level, we strongly hold the view that the carrying out of the health measures we propose is one of the most effective ways of ensuring the economic prosperity of the country and of materially raising the level of the national income. It is obviously impossible to assess accurately, in terms of money the effects of ill health on the community 3
Mindset Towards Health [P]roductive items such as electrification, industrial development, irrigation projects and agricultural improvement should come before unproductive items such as health and education. -Lord Mountbatten, Viceroy (1944) 4
Bhore Committee Report (1946) - Emphasised on the positive impact growth growth - Integration of curative and preventive healthcare curative and preventive healthcare - Setting up National Health System (NHS) National Health System (NHS) - Setting up primary and secondary healthcare infrastructure primary and secondary healthcare infrastructure - Health Education and Medical Research Health Education and Medical Research positive impact of good health on economic on economic 5
Early Years of IndependenceManaging Epidemics and Ensuring Immunisation Diseases Diseases Status around Independence Status around Independence Tuberculosis Tuberculosis Active cases: 4/1000 population (1955-58) Smallpox Smallpox Cases: 410,819 (1950) Deaths: 105,781 (1950) Status Status 1.13/1000 (1981) Cases: 188,000 (1974) Deaths: 31,000 (1950) Malaria Malaria Cases: 75million (21.8% of the population in 1947) 2,00,000-4,00,000 annual cases during the 1950s Cases: 2.9 million (1980) Polio Polio 1,50,000 cases in 1980 (43% of worldwide cases) 6
National Health Policy- 1983, 2002, 2017 and NHM Based on Alma Alma- -Ata Declaration of Health for All by 2000 , Ata Declaration of Health for All by 2000 , later popularised as Universal Health Coverage Universal Health Coverage Common Thread prevalent- Increasing public health spending public health spending R Reducing educing out out- -of of- -pocket health spending pocket health spending Developing primary healthcare primary healthcare Addressing rural rural- -urban inequalities urban inequalities in healthcare Achieving universal health coverage universal health coverage 7
Evolution of Health Spending Health expenditure (as a percentage of GDP) Health expenditure (as a percentage of GDP) 1.2 1.2 14th FC NRHM 1.03 1.03 1 1 0.90 0.90 0.8 0.8 0.70 0.70 0.70 0.70 0.6 0.6 0.4 0.4 0.32 0.32 0.20 0.20 0.2 0.2 0 0 Total health expenditure to GDP Total health expenditure to GDP Centre health expenditure to GDP Centre health expenditure to GDP State health expenditure to GDP State health expenditure to GDP Source: RBI State Finances, A Study of Budget; Union budgets. 8
India Spends the Lowest on Health Domestic general government health expenditure (% of GDP) Domestic general government health expenditure (% of GDP) - - 2021 2021 14 14 12.6 12.6 12 12 10 10 Percentage of GDP Percentage of GDP 8 8 6.5 6.5 6 6 5.3 5.3 5.3 5.3 5.2 5.2 5.0 5.0 4.5 4.5 3.6 3.6 4 4 2.9 2.9 2.5 2.5 2.2 2.2 1.9 1.9 1.8 1.8 2 2 1.1 1.1 0 0 Cuba Cuba Colombia Colombia Costa Rica Costa Rica Russian Russian Federation Federation Chile Chile South South Africa Africa Brazil Brazil Thailand Thailand China China Malaysia Malaysia Indonesia Indonesia Sri Lanka Sri Lanka Nepal Nepal India India Source: Government Finance Statistics, IMF; Global Health Expenditure Database, WHO 9
India vs Economies with Similar Tax-GDP Ratio Tax GDP Ratio and Government Health Expenditure in 2021 Tax GDP Ratio and Government Health Expenditure in 2021 16.0 14.1 14.1 13.4 14.0 11.6 11.5 11.5 11.2 12.0 10.0 9.1 8.0 6.1 5.3 6.0 4.5 4.0 3.0 2.5 2.3 2.2 2.0 1.1 0.0 India India Argentina Argentina Russian Federation Russian Federation Brazil Brazil Mexico Mexico Malaysia Malaysia Philippines Philippines Indonesia Indonesia Health Expenditure (% of GDP) Health Expenditure (% of GDP) Tax GDP Ratio Tax GDP Ratio Source: Government Finance Statistics, IMF; Global Health Expenditure Database, WHO 10
Not a Matter of Financial Capacity but Intent 4600 4600 (B)High (B)High- -Income High High- - Health Health Spending states Spending states Income (A)High (A)High- - Income Low Income Low- - Health Health Spending Spending Goa Goa Sik Sik 4100 4100 3600 3600 ND ND 3100 3100 Per capita NSDP (in Rs. 00') Per capita NSDP (in Rs. 00') Kar Kar 2600 2600 Har Har Mah Mah ker ker Guj Guj 2100 2100 TN TN HP HP ArP ArP Pun Pun AP AP 1600 1600 Miz Miz WB WB Nag Nag Tri Tri MP MP Raj Raj 1100 1100 (D)Low (D)Low- -Income High High- - Health Spending Health Spending states states Income JK JK UP UP Ori Ori Man Man As As 600 600 Meg Meg Bih Bih 100 100 400 400 1400 1400 2400 2400 3400 3400 4400 4400 5400 5400 6400 6400 Per capita State health expenditure (in Rs.) Per capita State health expenditure (in Rs.) Source: RBI State Finances, A Study of Budget. 11
Most States Spend Less Than 8 Per Cent of Total Expenditure on Health Source: State Budget Documents, 2023-24 12
Indicators of Health India vis--vis its Peer Economies OOPE (% of Current Health OOPE (% of Current Health Exp) Exp) Life Expectancy Life Expectancy MMR (per 100,000 live births) MMR (per 100,000 live births) IMR (per 1,000 live births) IMR (per 1,000 live births) Country Country 1991 1991 2021 2021 1991 1991 2021 2021 1991 1991 2021 2021 2000 2000 2021 2021 Nepal Nepal 54.8 68.4 924 186 96.4 22.8 55.8 51.3 Bangladesh Bangladesh 54.2 72.4 589 173 101 22.9 61.8 73 India India 59.1 59.1 67.2 67.2 487 487 133 133 88.8 88.8 25.5 25.5 71.7 71.7 49.8 49.8 Indonesia Indonesia 63.2 67.6 348 177 61.8 18.9 45.2 45.9 Philippines Philippines 65.9 69.3 198 121 39.9 20.5 41.2 45 South Africa South Africa 63.3 62.3 162 119 47.8 26.4 14.5 5.5 Brazil Brazil 66.3 72.8 112 60 52.7 12.9 36.6 22.7 China China 68 78.2 90 29 42.7 5.1 60.1 34.4 Sri Lanka Sri Lanka 71.9 76.4 79 36 19.4 5.8 40 43.6 Source: World Health Organisation 13
Primary Healthcare System- Deficiencies in Infrastructure 14
Primary Healthcare System- Deficiencies in Human Resources Rural Areas 80 Shortfall in Rural SCs and PHCs Shortfall of Specialists in Rural CHCs 66 88 87 86 85 60 84 82 81 82 80 Percentage 40 78 76 74 74 20 72 12.4 70 5.2 68 0 66 Health Worker (F)/ANM Health Worker (M) Doctors at PHCs Surgeons O&G Physicians Paediatricians Total Specialists 15
Primary Healthcare System- Deficiencies in Human Resources Urban Areas Shortfall of Human Resources - Urban PHCs 60 Shortfall of Specialists - Urban CHCs 40 49 36 50 35 29 30 40 25 Percentage 25 Percentage 30 20 15 20 15 10 10 7 5 5 5 4 1 0 0 ANMs Doctors Pharmacists Lab Staff Nurses GDMOs Radiographers Pharmacists Lab Technicians Staff Nurses Technicians 16
India Lags Behind its Peers in UHC Index UHC Index UHC Index 90 90 81 81 80 80 76 76 76 76 80 80 75 75 69 69 68 68 66 66 66 66 70 70 63 63 56 56 60 60 55 55 52 52 49 49 47 47 50 50 42 42 40 40 30 30 29 29 30 30 20 20 10 10 0 0 Brazil Brazil China China India India Indonesia Indonesia Malaysia Malaysia Mexico Mexico 2000 2000 2010 2010 2021 2021 17
Key Takeaways Health - a low priority all along. OOPE in India - one of the highest in the world. Primary Healthcare- not receiving adequate attention. Inadequate health infrastructure, shortage of human resources. Significant rural- urban disparities persist. UHC goal remains elusive. 18
Thank you 19
