51

CHAPTER-3

HEALTH SCENARIO IN INDIA

Health and socio-economic developments are so closely intertwined

that it is impossible to achieve one without the other. Health is a priority

goal in its own right, as well as central input into economic development and

poverty reduction. Improving the health of individuals, particularly those

belonging to socially and economically disadvantaged groups, is a key

objective of the Indian government and a major consequence of a

Constitution that repeatedly directs the state to this end. Moreover, the

Indian government has, at various points in time, embraced the objective of

promoting the health of the poor and the disadvantaged in its policy

statements and actions, one being its signing of the Alma Ata Declaration of

1978, emphasizing „Health for All‟. Although the National Health Policy

(NHP) in India was not framed until 1983, India initiated several national

health programmes over last five decades in government, voluntary and

private sectors under the guidance and direction of various committees

(Bhore, Mudaliar, Kartar Singh, Srivastava), the Constitution, the Planning

Commission, the Central Council of Health and Family Welfare, and

Consultative Committees attached to the Ministry of Health and Family

Welfare. The period after 1983 witnessed several major developments in the

policies impacting the health sector-adoption of National Health Policy in

1983, National Health Policy 2002, National Policy on Indian System of

Medicine and Homeopathy in 2002, Drug Policy in 2002, introduction of

Universal Health Insurance schemes for the poor in 2003 and inclusion of

health in Common Minimum Programme of the United Progressive Alliance

(UPA) government in 2004.

52

The concern for health improvements, especially among the poor and

the disadvantaged, whether espoused in government policies or elsewhere,

stems from several considerations. One is the increasing recognition that

improvements in health translate into substantial gains in economic

performance and overall well-being of society. Second, good health may be

considered an end in itself, irrespective of any contribution it can potentially

make to enhance economic growth. Third, poor health has significant

adverse implications for the economic well-being of affected households and

individuals, particularly for poor households (Sundar Ramamani and

Abhilasha Sharma, 2002). Recognising „health‟ as an important contributory

factor in the utilization of manpower and the uplifting of the economic

condition of the country, the Planning Commission gave considerable

importance to health programmes in five year plans. From the First Five

Year Plan efforts were made to build up primary, secondary and tertiary care

centres and to link through appropriate referral system. National

programmes for combating major public health problems were evolved and

implemented. India‟s achievement in the health front is significant

particularly in attainment of development indicators, viz., reduction in birth

rate, death rate, infant mortality rate and increase in life expectancy

(Ambedkar S. Nagendra and Shilaja Nagendra, 2006). But still the health

indicators vary widely across states reflecting the differing levels of

resources available to state governments, but one trend that is totally

consistent is that these indicators are much worse in rural areas than in urban

areas (Economist Intelligence Unit, 2009). A comparison of the health

indicators of India with other developing countries of Asia reveals the real

position and condition of the health of the Indian population. The countries

like China, Sri Lanka and Bangladesh have better health indices than that of

53

India (Rawat Deepa, Kalpna Aggarwal and Manish Dev, 2006).

The ailing public health services in the country are manifested in the

poor health infrastructure besides the health indicators. The public sector

health infrastructure consists of a three-tier structure with around 4000

community health centres, 22000 primary health centres and 145000

sub-centres spread in semi-urban and rural areas. Tertiary medical care is

provided at multi and super-speciality hospitals and medical colleges. There

are around 750000 doctors, 1000000 nurses, 7500 hospitals and 493000 beds

(National Health Profile, 2009). But still, the health infrastructure in India

has a long way to go towards achieving 100 per cent quality, technology and

superior health care delivery system, as the private sector provides

80 per cent of the health care services and only 20 per cent are provided by

the government (www.buyusa.gov/india).

The condition of expenditure on health services in India is no less

dismal. India is estimated to be spending around 5 per cent of Gross

Domestic Product (GDP) on health, and much of the expenditure is incurred

on the private account. The public expenditure incurred on health is only

0.9 per cent of GDP (Sathayamala, C. and N.J. Kurian, 2008). The high

private expenditure on health points more to the failure of the public sector

to provide health care services and is a reflection of the relatively high

disease burden and the high cost of health care in the country rather than

choice on the part of the people. The cost of health care has been rising over

the years. It is estimated that 7-9 per cent of annual household consumption

expenditure is spent on health care needs. The burden of treatment is the

highest for the poorest sections of society in rural areas. It is estimated that

the poor spend 12 per cent of their incomes on health care as opposed to

2 per cent spent by the rich (Misra et al., 2003). The state governments in

54

India bear the major responsibility for health care as in the constitutional

division of responsibilities across the union government and the states;

health has been identified as a state subject. The union government plays an

important role in influencing health outcomes of states through its

expenditure on centrally sponsored programmes, loans, transfers and grants.

The role of the central allocations in health spending varies across states

(Prabhu, K. Seeta and V. Selvaraju, 2006).

In the present chapter an attempt has been made to provide a broad

overview of the health scenario in India, in terms of vital health indicators,

public health infrastructure and public health expenditure.

Health Indicators

Health is a basic component of human development, and hence,

determines society‟s well being. It is a means to empower the deprived

sections of society and thus, an important element in the strategy for poverty

alleviation. Access to preventive and protective health care enhances

entitlements of the poor by enabling steady employment, improving

productivity and facilitating demographic transition. India‟s performance in

ensuring basic health care facilities has left much to be desired. To assess the

overall health conditions of each country, a new index known as Health

Index (HI) for 177 countries of the world were presented in the report-

Human Development in South Asia, 2004 of UNDP. In this report India was

ranked 140th out of 177 countries (with health index value of 0.476) which

was quite lower than those of other countries of the world like Japan (21),

United States (10), Australia (9), Canada (5), Germany (2) and

Sweden (1).Table 3.1 displays information regarding some health indicators

like life expectancy, infant mortality rate, under-five mortality rate, maternal

55

Table 3.1: Selected Health Indicators: South Asian Countries

Countries Life

Expectancy

at

birth(years)

(2000-05)

Infant

Mortality

Rate

(per 1000

live births)

2003

Under-five

Mortality

Rate

(per 1000

live births)

2003

Maternal

Mortality

Rate

(per 100000

live births)

Adjusted

2000

Probability at

birth of surviving

to age 65

(%of cohort)

(2000-05)

Females Males

India 63.1 63 87 540 67.4 59.2

Pakistan 62.9 81 103 500 65.6 62.7

Bangladesh 62.6 46 69 380 63.7 59.3

Nepal 61.4 61 82 740 61.0 57.9

Sri Lanka 73.9 13 15 92 85.6 76.1

Bhutan 62.7 70 85 420 65.3 60.2

All developing countries 64.9 60 88 NA 69.6 62.3

All countries 67.0 54 80 NA 73.1 64.5

Source: Human Development Report, 2005.

mortality rate and probability at birth of surviving to age 65 of India

vis-à-vis world as well as other developing countries of the world. It shows

that the average life expectancy at birth for India i.e. 63.1 years was lower

than that of the world i.e. 67 years and of developing countries i.e. 64.9

years during 2000-05. The Infant Mortality Rate (IMR) in India at 63 years

(per 1000 live births) was higher than that of the world (54) as well as

developing countries (60) in 2003. Mortality of children under 5 years at 87

(per 1000 live births) in India too was higher than the world average at 80.

The Maternal Mortality Rate (MMR) in India at 540 (per 100000 live births)

in 2000 was higher than that of other South Asian countries such as Pakistan

(500), Bangladesh (380) and Sri Lanka (92).The probability at birth of

surviving to age 65 in India was more for females i.e. 67.4 than that of males

i.e. 59.2, but lesser than the world average of 73.1 and 64.5 respectively.

Thus the performance of India‟s health status vis-à-vis other countries of the

world in terms of the most frequently used health indicators does not present

56

an encouraging picture. The poor health infrastructure combined with low-

income level and poverty has been a major cause of the poor health

achievements of the country.

The vital statistics like Crude Birth Rate (CBR), Crude Death Rate

(CDR), Infant Mortality Rate (IMR) and life expectancy at birth provide the

base for information on the health status and human development of any

region or country. These health parameters affect the prioritization of health

issues, allocation of public resources for health, formulation of effective

strategies and implementation of health programmes. To examine the

progress in health status of the people in India, various health indicators

have been analyzed over the period 1981-2008. To view the inter-period

changes and trends this period has been disaggregated into three time

periods as follows:(i) First period-1981-90 ; (ii) Second period-1991-2000;

(iii) Third period-2001-08.

Table 3.2 gives data pertaining to crude birth rate, crude death rate

and natural growth rate in India during the period 1981-2008. Crude Birth

Rate (CBR) which is the number of live births in a year per 1000 population

of the mid-year population declined continuously from 33.9 births per 1000

population in 1981 to 22.8 births per 1000 population in 2008 i.e. a decline

of 32.74 per cent. It declined from 33.9 to 30.2 during 1981-90 (10.91per

cent), slid down from 29.5 to 25.8 (12.54 per cent) during 1991-2000 and it

further reduced from 25.4 to 22.8 (10.24 per cent) during 2001-08. This

decline was observed to be the highest during the second period. Similarly, a

declining trend has been observed in both rural and urban areas during the

period 1981-2008, but still a large gap persists between them (Figure 3.1).

During the first period, the percentage decline in crude birth rate was higher

in rural areas than that of urban areas while during the second period the rate

57

Table 3.2: Area-wise Crude Birth Rate, Crude Death Rate and Natural Growth Rate in India

(per thousand population per annum)

Year Crude Birth Rate Crude Death Rate Natural Growth Rate

Rural Urban Combined Rural Urban Combined Rural Urban Combined

1981 35.6 27.0 33.9 13.7 7.8 12.5 21.9 19.2 21.4

1982 35.5 27.6 33.8 13.1 7.4 11.9 22.4 20.2 21.9

1983 35.3 28.3 33.7 13.1 7.9 11.9 22.2 20.4 21.8

1984 35.3 29.4 33.9 13.8 8.6 12.6 21.5 20.8 21.3

1985 34.3 28.1 32.9 13.0 7.8 11.8 21.3 20.3 21.1

1986 34.2 27.1 32.6 12.2 7.6 11.1 22.0 19.5 21.5

1987 33.7 27.4 32.2 12.0 7.4 10.9 21.7 20.0 21.3

1988 33.1 26.3 31.5 12.0 7.7 11.0 21.1 18.6 20.5

1989 32.2 25.2 30.6 11.1 7.2 10.3 21.1 18.0 20.3

1990 31.7 24.7 30.2 10.5 6.8 9.7 21.2 17.9 20.5

1991 30.9 24.3 29.5 10.6 7.1 9.8 20.3 17.2 19.7

1992 30.9 23.1 29.2 10.9 7.0 10.1 20.0 16.1 19.1

1993 30.4 23.7 28.7 10.6 5.8 9.3 19.8 17.9 19.4

1994 30.5 23.1 28.7 10.1 6.7 9.3 20.4 16.4 19.4

1995 30.0 22.7 28.3 9.8 6.6 9.0 20.2 16.1 19.3

1996 29.3 21.6 27.5 9.7 6.5 9.0 19.6 15.1 18.5

1997 28.9 21.5 27.2 9.6 6.5 8.9 19.3 15.0 18.3

1998 28.0 21.1 26.5 9.7 6.6 9.0 18.3 14.5 17.5

1999 27.6 20.8 26.1 9.4 6.3 8.7 18.2 14.5 17.4

2000 27.6 20.7 25.8 9.3 6.3 8.5 18.3 14.4 17.3

2001 27.1 20.3 25.4 9.1 6.3 8.4 18.0 14.0 17.0

2002 26.6 20.0 25.0 8.7 6.1 8.1 17.9 13.9 16.9

2003 26.4 19.8 24.8 8.7 6.0 8.0 17.8 13.8 16.8

2004 25.9 19.0 24.1 8.2 5.8 7.5 17.8 13.3 16.6

2005 25.6 19.1 23.8 8.1 6.0 7.6 17.5 13.1 16.3

2006 25.2 18.8 23.5 8.1 6.0 7.5 17.2 12.8 16.0

2007 24.7 18.6 23.1 8.0 6.0 7.4 16.8 12.7 15.7

2008 24.4 18.5 22.8 8.0 5.9 7.4 16.5 12.6 15.4

Source: Statistical Abstract of India, Various Issues.

of decline was higher in urban areas than that of the rural areas. During the

third period again, the percentage decline in CBR was slightly higher in rural

areas as compared to the urban areas. Thus, a large number of factors such

as increasing incomes, increasing literacy rate especially of women,

reduction in child mortality rates, increasing awareness and use of birth

control have led to reductions in crude birth rate in the country as a whole

and in both rural and urban areas over a period of time.

58

Figure 3.1: Area-wise Crude Birth Rate in India.

Source: Statistical Abstract of India, Various Issues.

0

5

10

15

20

25

30

35

401

98

1

19

82

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07

20

08

Ra

te

(per

th

ou

san

d p

op

ula

rio

n p

er a

nn

um

)

Years

Crude Birth Rate Rural

Crude Birth Rate Urban

Crude Birth Rate Combined

59

Figure 3.2: Area-wise Crude Death Rate in India.

Source: Statistical Abstract of India, Various Issues.

0

2

4

6

8

10

12

14

16

19

81

19

82

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83

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84

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03

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05

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07

20

08

Ra

te

(per

th

ou

san

d p

op

ula

tio

n p

er a

nn

um

)

Years

Crude Death Rate Rural

Crude Death Rate Urban

Crude Death Rate Combined

60

Crude Death Rate (CDR) is another important measure as it, in

combination with the crude birth rate determines population growth rate. It

is the number of deaths in a year per 1000 population of the mid-year

population. It registered a decline from 12.5 deaths per 1000 population in

1981 to 7.4 deaths per 1000 population in 2008 i.e. a decline of 40.8 per

cent. It went down from 12.5 to 9.7 during 1981-90 (22.40 per cent),

declined from 9.8 to 8.5 (13.27 per cent) during 1991-2000 and it further

dropped from 8.4 to 7.4 (11.90 per cent) during 2001-08. Thus, the

maximum decline in CDR was observed during the first period. On

comparing the CDR in rural and urban areas, it has been found that though

the CDR declined in both rural and urban areas but still a big difference

exists between them (Figure 3.2). During the first period, the percentage

decline in CDR was quite high for rural areas than the urban areas; during

1991-2000 though the rate of decline was higher in rural areas than that of

the urban areas, but the gap between both the areas narrowed down than

before, while during the third period this gap widened as the decline was

higher in rural areas as compared to the urban areas. Better control of

famines, better management of natural disasters, better medical facilities,

improvement in public health and sanitation, decline of major killer diseases

like cholera, tuberculosis etc, better control of epidemics, spread of

education and immunization programmes have helped to bring down the

crude death rate in India.

The Natural Growth Rate (NGR) of population is computed simply by

subtracting the crude death rate from the crude birth rate. The figures in the

table exhibit that natural growth rate declined from 21.4 in 1981 to 15.4 in

2008, registering a decline of 28.04 per cent. It declined moderately from

21.4 to 20.5 (4.21 per cent) during 1981-90, slid down from 19.7 to 17.3

61

(12.18 per cent) during 1991-2000 and it further reduced from 17 to 15.4

(9.41 per cent) during 2001-08. The maximum decline in NGR was observed

during the second period. On comparing the rate of decline in NGR in rural

and urban areas, it has been found that the rate of decline in NGR of

population during all the three periods i.e. first, second and third was lower

in rural areas as compared to those of the urban areas.

Table 3.3 depicts data regarding Infant Mortality Rate (IMR) by

locality in India during the period 1981-2008. It is the number of infant

deaths per 1000 live births. Infant mortality rate is one of the most telling

indicators on the health services, health awareness and satisfactory health

practices. It dropped significantly from 110 per 1000 live births in 1981 to

53 per 1000 live births in 2008, registering a decline of more than

50 per cent. It dwindled from 110 to 80 (27.27 per cent) during 1981-90,

reduced from 80 to 68 (15 per cent) during 1991-2000 and went down from

66 to 53 (19.70 per cent) during 2001-08. The maximum decline in IMR was

recorded during the first period. The rate at which the decline of IMR has

occurred has slowed down over the period of time. The important causes of

infant deaths in India in the recent years have been, pneumonia, diarrhoea

and neonatal sepsis, mainly because of lack of timely attention and treatment

of infants and low rates of routine immunization. Further, IMR has shown a

falling trend in both rural and urban areas during the period 1981-2008

(Figure 3.3). During the first period, the percentage decline in IMR was

remarkable in rural areas as compared to that of the urban areas while during

the second period, the rate of decline was greater in urban areas than that of

rural areas. During the third period, the rate of decline in IMR was recorded

to be higher in rural areas than that of the urban areas. The IMR in rural

areas accounted to be higher than that of urban areas throughout the study

62

Table 3.3: Area-wise Infant Mortality Rate in India

(per thousand live births)

Year Infant Mortality Rate

Rural Urban Combined

1981 119 62 110

1982 114 65 105

1983 114 66 105

1984 113 66 104

1985 107 59 97

1986 105 62 96

1987 104 61 95

1988 102 62 94

1989 98 58 91

1990 86 50 80

1991 87 53 80

1992 85 53 79

1993 82 45 74

1994 80 52 74

1995 80 48 74

1996 77 46 72

1997 77 45 71

1998 77 45 72

1999 75 44 70

2000 74 44 68

2001 72 42 66

2002 69 40 63

2003 66 38 60

2004 64 40 58

2005 64 40 58

2006 62 39 57

2007 61 37 55

2008 58 36 53

Source: National Health Profile, Various Issues.

period depicting marked rural-urban differences. This may be due to

inadequate health facilities, illiteracy and poverty etc. in rural areas. Thus, it

may be stated that despite policy commitments to provide equal access to

health care provision in rural as well as urban areas, marked rural-urban

differences remain unchanged due to lack of efficient implementation of

these policies.

63

Figure 3.3: Area-wise Infant Mortality Rate in India

Source: National Health Profile, Various Issues.

0

20

40

60

80

100

120

1401

98

1

19

82

19

83

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08

Ra

te

(per t

ho

usa

nd

liv

e b

irth

s)

Years

Infant Mortality Rate Rural

Infant Mortality Rate Urban

Infant Mortality Rate Combined

64

Table 3.4 manifests data regarding life expectancy at birth by sex in

India during the period 1981-85 and 2002-06. Life expectancy of an

individual is the number of years a person is expected to live given the

prevailing age-specific mortality rates of the population to which he/she

belongs. It is a general measure of mortality that captures prevailing

mortality rates of a population at different age groups. Moreover, life

expectancy provides more than sufficient material to assess the quality of

life. Besides there is a conceptual appeal in having a summary measure that

provides some indication on the longevity that a person is likely to enjoy in

any society. The data in the table show that the life expectancy at birth

underwent a significant change from 55.4 years during 1981-85 to 63.4 years

during 2002-06, registering an increase of 8 years. The life expectancy at

birth for females was 55.7 years during 1981-85 which increased to 64.2

years during 2002-06. For males, the life expectancy was 55.4 years during

1981-85 which moved up to 62.6 years during 2002-06 (Figure 3.4). The life

expectancy increased by 8.5 years for females and 7.2 years for males.

Besides, it has been observed that female life expectancy remained higher

than male life expectancy throughout the study period. The discovery of

wonder medicines to control epidemics like plague, cholera, influenza or

small pox, the general improvement in medical assistance, increase in

number of hospitals, doctors, nurses, medicines and better control of

diseases and decline in mortality have helped to raise life expectancy in

India.

Within India there exists wide inter-state variation in health indicators,

as can be seen from Table 3.5. This table presents the health indicators like

birth rate, death rate, infant mortality rate and life expectancy at birth for

fifteen major states. The table reveals that average birth rate of India was

65

Table 3.4: Life Expectancy at Birth by Sex, India

(in years)

Period Life Expectancy

Male Female Total

1981-85 55.4 55.7 55.4

1986-90 57.7 58.1 57.7

1987-91 58.1 58.6 58.3

1988-92 58.6 59.0 58.7

1989-93 59.0 59.7 59.4

1990-94 59.4 60.4 60.0

1991-95 59.7 60.9 60.3

1992-96 60.1 61.4 60.7

1993-97 60.4 61.8 61.1

1994-98 60.6 62.2 61.4

1995-99 60.8 62.5 61.7

1996-00 61.0 62.7 61.9

1997-01 61.3 63.0 62.2

1998-02 61.6 63.3 62.5

1999-03 61.8 63.5 62.7

2000-04 62.1 63.7 63.0

2001-05 62.3 63.9 63.2

2002-06 62.6 64.2 63.4

Source : SRS Abridged Life Tables, 2002-06

Figure: 3.4: Life Expectancy at Birth by Sex, India

Source : SRS Abridged Life Tables, 2002-06

50

52

54

56

58

60

62

64

66

19

81-

85

19

86-

90

19

87-

91

19

88-

92

19

89-

93

19

90-

94

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91-

95

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92-

96

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00

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01

19

98-

02

19

99-

03

20

00-

04

20

01-

05

20

02-

06

(in

yea

rs)

Years

Life Expectancy Male

Life Expectancy Female

66

22.8 per 1000 population in 2008. Out of the fifteen states, six states had

birth rate at more than this level. Uttar Pradesh (29.1) had the highest birth

rate followed by Bihar (28.9), Madhya Pradesh (28.0), Rajasthan (27.5) and

Assam (23.9). Remaining nine states including Punjab (17.3) had birth rate

lower than the national average. The lowest birth rate was found in Kerala

(14.6). The average death rate of India was 7.4 per 1000 population in 2008.

There also exist wide inter-state variations in death rate. Out of the fifteen

states, five states had death rate more than the national average. The highest

death rate was observed for Orissa (9.0) followed by Madhya Pradesh (8.6),

Assam (8.6), Uttar Pradesh (8.4) and Andhra Pradesh (7.5).Tamil Nadu and

Karnataka recorded death rate same as the national average. Remaining eight

states had death rate lower than the national average. The lowest death rate

was observed in West Bengal (6.2) followed by Kerala (6.6) and

Maharashtra (6.6). Punjab state had death rate slightly lower than the

national average. The average Infant Mortality Rate (IMR) of India was 53

in 2008 and there were seven Indian states that had IMR at more than this

level, with Madhya Pradesh (70) at the top followed by Orissa (69), Uttar

Pradesh (67), Assam (64), Rajasthan (63), Bihar (56) and Haryana (54).

Remaining eight states including Punjab had IMR lower than the national

average. The lowest IMR was found in Kerala at 12. The diversity in the

states regarding IMR is visible from the fact that on the one hand there is

state like Kerala and on the other, there are states like Madhya Pradesh,

Orissa and Uttar Pradesh. Life expectancy at birth for India was 62.6 and

64.2 years for male and female respectively in 2008. Kerala had the highest

life expectancy for male and female followed by that of Punjab and

Maharashtra, while Madhya Pradesh had the lowest life expectancy for both

male (58.1) and female (57.9) as compared to other states. Except Madhya

67

Pradesh, Uttar Pradesh and Bihar, all the states have been observed to have

higher life expectancy for female than that of male. It has been found that

the state of Punjab fares a better position than that of India in all these health

indicators.

Table 3.5 Health Indicators for Major States, 2008

State

Birth Rate

(per 1000

population)

Death Rate

(per 1000

population)

Infant

Mortality

Rate

(per 1000

population)

Life Expectancy (in years)

Male

Female

Andhra

Pradesh 18.4 7.5 52 62.9 65.5

Assam 23.9 8.6 64 58.6 59.3

Bihar 28.9 7.3 56 62.2 60.4

Gujarat 22.6 6.9 50 62.9 65.2

Haryana 23.0 6.9 54 65.9 66.3

Karnataka 19.8 7.4 45 63.6 67.1

Kerala 14.6 6.6 12 71.4 76.3

Madhya

Pradesh 28.0 8.6 70 58.1 57.9

Maharashtra 17.9 6.6 33 66.0 68.4

Orissa 21.4 9.0 69 59.5 59.6

Punjab 17.3 7.2 41 68.4 70.4

Rajasthan 27.5 6.8 63 61.5 62.3

Tamil Nadu 16.0 7.4 31 65.0 67.4

Uttar Pradesh 29.1 8.4 67 60.3 59.5

West Bengal 17.5 6.2 35 64.1 65.8

India 22.8 7.4 53 62.6 64.2

Source: National Health Profile, 2009

While considerable progress has been achieved by India in these

health indicators over a period of time, but the situation is far from

satisfactory. India continues to lag behind several other countries of the

world. Inter-state diversities in the health indicators are quite remarkable.

Moreover, within the country urban areas are faring better than rural areas.

Health Infrastructure

India‟s performance in health can be judged from the performance of

the healthcare system. Table 3.6 presents data regarding the number of

68

Table 3.6: Hospitals, Dispensaries and Beds in India

Year

Number

of

Hospitals

Number of

hospitals per 1

million

population

Number

of

Dispensaries

Number of

dispensaries

per 1 million

population

Number of

Beds

( ’000)

Number

of beds per

1 lakh

population

1981 6804 10 16751 25 569 83

1982 6897 10 17409 25 584 83

1983 7189 10 21777 30 599 84

1984 7369 10 21872 30 625 86

1985 7474 10 25584 34 657 88

1986 9843 13 25193 33 694 91

1987 N.A. - N.A. - N.A. -

1988 10156 13 28841 36 741 94

1989 10172 13 28304 35 795 99

1990 11571 14 28321 34 806 98

1991 11571 14 27994 33 806 95

1992 13692 16 27431 32 835 98

1993 14867 17 28279 33 860 99

1994 15033 17 28200 32 864 98

1995 15097 17 28225 31 870 97

1996 15097 16 28225 30 870 93

1997 15170 16 25653 27 893 94

1998 15188 16 25670 26 897 92

1999 15501 16 22967 23 908 92

2000 18218 18 23065 23 909 90

2001 17952 17 22306 22 904 88

2002 15393A - 22291 22 915 92

2003 5479B - - - 381C -

2004 7029B - - - 470 -

2005 7008B - - - 470 -

2006 7663B - - - 493 -

Note: A- Total hospitals reduced from 2001 due to exclusion of CHCs and non-reporting.

B- Relates to government allopathic hospitals only.

C- Estimated at 30 beds per one CHC.

#- Year 2003 onwards, CBHI did not compile the information on number of dispensaries.

Source: Directorate General of Health Services (CBHI)

hospitals, dispensaries and beds in India. The number of hospitals increased

nearly 2.5 times during 1981-2001, but then reduced in 2002 due to

exclusion of CHCs and non-reporting. The figures showed a further decline

in 2006 because these included only allopathic hospitals. The number of

hospitals showed an increase of 1.70 times during 1981-90 and it further

increased by 1.57 times during 1991-2000. The number of hospitals per 1

million population increased from 10 to 17 during 1981-2001. The number

69

of dispensaries went up 1.33 times during 1981-2002. The number of

dispensaries showed a significant rise during 1981-90, while it declined

during 1991-2000. The number of dispensaries per 1 million population

rather declined from 25 to 22 during 1981-2002. The number of beds

increased 1.61 times during 1981-2002, but later reduced in 2006. The

number of beds increased by 1.42 times during 1981-90, while it rose by

1.13 times during 1991-2000. The number of beds per 1 lakh population

increased from 83 to 92 during 1981-2002.

Table 3.7: Share of Public and Private Sector Hospitals and Beds

(in percentage)

Year Hospitals Hospital Beds

Public Private Total Public Private Total

1974 81.4 18.6 100 78.5 21.5 100

1979 64.7 35.3 100 74.2 25.8 100

1984 54.6 45.4 100 72.5 27.5 100

1988 44.1 55.9 100 70.1 29.9 100

1996 31.9 68.1 100 63.4 36.6 100

2002 26 74 100 61.6 38.4 100

Source: Health Information of India, CBHI, Government of India, Various Issues.

Table 3.7 provides information regarding share of public and private

sector hospitals in India during 1974-2002. The data in the table show that in

1974, out of total hospitals the proportionate share of public and private

hospitals were 81.4 per cent and 18.6 per cent respectively. In 2002, the

corresponding shares were 26 per cent and 74 per cent. Thus, private

hospitals have grown sharply (Figure 3.5). On observing the share of public

and private sector hospital beds, it has been found that in 1974, out of total

hospital beds the proportionate share of public and private hospital beds

were 78.5 per cent and 21.5 per cent respectively. In 2002, the

corresponding shares were 61.6 per cent and 38.4 per cent. Thus, the share

of private sector hospital beds has also shown an upward trend although not

as significant as the number of hospitals (Figure 3.6).

70

Figure 3.5: Share of Public and Private Sector Hospitals

Source: Health Information of India, CBHI, Government of India, Various Issues.

Figure 3.6: Share of Public and Private Sector Beds

Source: Health Information of India, CBHI, Government of India, Various Issues.

The data relating to public and private hospitals and beds according to

area have been shown in Table 3.8. It reveals that during the nineties,

75 per cent of government hospitals were located in urban areas and only

0

10

20

30

40

50

60

70

80

90

1974 1979 1984 1988 1996 2002

Ho

spit

als

(in

percen

tag

e)

Years

Hospitals Public

Hospitals Private

0

10

20

30

40

50

60

70

80

90

1974 1979 1984 1988 1996 2002

Bed

s

(in

per

cen

tag

e)

Years

Hospital Beds Public

Hospital Beds Private

71

25 per cent were located in rural areas. Even the proportion of private

hospitals was found to be more in urban areas (69 per cent) than that of the

rural areas (31 per cent). Further it revealed that both government and

private hospital beds were located more in urban areas as compared to the

rural areas. It indicates acute rural-urban disparities. Thus, the health care

facilities were available more in the private sector and in the urban areas

during nineties.

Table 3.8: Rural-Urban Distribution of Hospitals/Hospital Beds: Public and Private Sectors,

1990s

(in percentage)

Area Hospitals Hospital Beds

Government Private Government Private

Rural 25 31 10 29

Urban 75 69 90 71

Total 100 100 100 100

Source: Nandraj 2000 and Directory of Hospitals in India, Various Issues

In India, most people belonging to different strata of society, primarily

in rural areas, resort to Indian systems of medicine for health care. India has

perhaps the world‟s largest community-based tradition of indigenous

systems of medicine. Due to its countrywide presence, easy availability,

affordability and safety, it has been institutionalized in modern India as far

as education and service delivery are concerned. It has been integrated with

government health services at the central and state level and is currently

being given a further impetus by the government. Since the creation of a

separate department of AYUSH, a positive impact has been observed in

growth of almost all AYUSH infrastructural facilities due to departmental

investment and focus on overall development of these systems. Though the

government is making an effort to expand these facilities by adopting

various measures, growth has been rather slow over the years. The data

relating to the ayurvedic, unani, siddha and homeopathic institutions in India

72

during the period 1981-2009 have been presented in Table 3.9. The data in

the table revealed that the number of AYUSH institutions spiralled up from

15823 to 25074 during 1981-2009, indicating a growth rate of 1.60 per cent

per annum. During the first period, the number of these institutions increased

from 15823 in 1981 to 22155 in 1990 depicting growth rate of 4.59 per cent

per annum. During the second period, their number went up from 26049 in

1991 to 27267 in 2000, showing growth rate of 0.12 per cent per annum,

whereas during the third period, their number rather shrank from 27254 in

2001 to 25074 in 2009, exhibiting a negative growth rate i.e. -0.96 per cent

per annum. Thus, these institutions registered maximum growth during the

eighties.

Further, it has been found that during the period 1981-2009,

maximum growth has been observed in the number of homeopathic

institutions (3.35 per cent) followed by siddha (2.66 per cent), ayurvedic

(1.20 per cent) and unani (0.97 per cent) institutions. During the first period,

the homeopathic institutions registered maximum growth rate

(17.03 per cent per annum) followed by ayurvedic (1.90 per cent per annum)

and unani institutions (0.44 per cent per annum), while the siddha

institutions exhibited a negative growth rate i.e. -2.19 per cent per annum.

During the second period, the situation reversed where maximum growth

was noticed for the siddha institutions (4.28 per cent per annum) followed by

ayurvedic institutions (1.34 per cent per annum) and unani institutions (0.88

per cent per annum), while the homeopathic institutions depicted a negative

growth rate i.e. -2.70 per cent per annum. This scenario changed a little

73

Table 3.9: Number of Ayurvedic, Unani, Siddha and Homeopathic (AYUSH) Institutions in India

Year Ayurvedic Unani Siddha Homeopathic Total

1981 12394 1009 503 1917 15823

1982 12502 1070 536 2260 16368

1983 12777 1070 349 2307 16503

1984 12552 958 416 2284 16210

1985 13571 967 421 2423 17382

1986 13578 972 334 6765 21649

1987 13840 1066 342 7267 22515

1988 14013 1055 409 5364 20841

1989 14366 1067 413 5875 21721

1990 14510 1073 413 6159 22155

1991 15239 1117 418 9275 26049

1992 15393 1131 426 9299 26249

1993 15726 1135 438 9585 26884

1994 15779 1145 443 6824 24191

1995 15840 1144 448 6891 24323

1996 15872 1152 452 6933 24409

1997 16173 1141 495 7184 24993

1998 16441 1155 561 7280 25437

1999 16633 1169 587 7452 25841

2000 17724 1275 592 7676 27267

2001 17677 1270 589 7718 27254

2002 17457 1245 583 7478 26763

2003 16179 1136 675 5688 23678

2004 N.A. N.A. 700 N.A. N.A.

2005 15946 1227 720 5857 23750

2006 16281 1271 743 6031 24326

2007 16312 1278 745 6066 24401

2008 16976 1292 765 6277 25310

2009 16407 1273 805 6589 25074

Compound Annual Growth Rate (per cent)

1981-2009 1.20 0.97 2.66 3.35 1.60

1981-1990 1.90 0.44 -2.19 17.03 4.59

1991-2000 1.34 0.88 4.28 -2.70 0.12

2001-2009 -0.74 0.67 4.59 -2.01 -0.96

Source: (1) AYUSH in India (2005), Planning and Evaluation Cell, Department of Ayurveda,

Yoga and Naturopathy, Unani, Siddha and Homeopathy (AYUSH), MOHFW, GOI.

(2) National Health Profile,Various Issues.

during the third period as the siddha institutions again showed maximum

growth rate (4.59 per cent per annum) this time followed by unani

institutions (0.67 per cent per annum), while the homeopathic and ayurvedic

institutions showed negative growth rates i.e. -2.01 per cent per annum and

74

-0.74 per cent per annum. Thus, it can be concluded that during the first

period, maximum growth rate was recorded for homeopathic institutions

whereas during the second and third period siddha institutions registered

maximum growth rate.

The health infrastructure in rural areas has been developed as a three

tier system. The sub-centre (SC) is the most peripheral and the first contact

point between the primary health care system and the community.

Sub-centres are assigned tasks relating to interpersonal communication in

order to bring about behavioural change and provide services in relation to

maternal and child health, family welfare, nutrition , immunization,

diarrhoea control and control of communicable diseases programmes. The

sub-centres are provided with basic drugs for minor ailments needed for

taking care of essential health needs of men, women and children. The

Ministry of Health and Family Welfare has been providing 100 per cent

central assistance to all the sub-centres in the country since April 2002 in the

form of salary of auxiliary nurse midwives (ANMs) and lady health visitors

(LHVs), rent at the rate of Rs. 3000 per annum and contingency at the rate of

Rs. 3200 per annum, in addition to drugs and equipment kits. Primary Health

Centre (PHC) is the first contact point between village community and the

medical officer. The primary health centres (PHCs) are envisaged to provide

an integrated curative and preventive health care to the rural population with

emphasis on preventive and promotive aspects of health care. These are

established and maintained by the state governments under the Minimum

Needs Programme (MNP)/Basic Minimum Services (BMS) Programme. A

PHC acts as a referral unit for six sub-centres. It has 4-6 beds for patients.

The activities of PHC involve curative, promotive and family welfare

services. The community health centres (CHCs) are being established and

75

maintained by the state government under the MNP/ BMS programme. It

serves as a referral centre for four PHCs and also provides facilities for

obstetric care and specialist consultations.

Table 3.10: Number of Primary Health Centres, Sub-centres and Community Health Centres in

India

Period Community Health

Centres

Primary Health

Centres Sub-centres

1st Five Year Plan - 725 -

2nd

Five Year Plan - 2565 -

3rd

Five Year Plan - 4631 -

Inter Plan Period - -

As on 31.3.67 - 4793 17521

As on 31.3.68 - 4946 21539

As on 31.3.69 - 4919 22826

4th Five Year Plan - 5283 33509

5th Five Year Plan 214 5484 47112

6th Five Year Plan 761 9115 84376

7th Five Year Plan 1910 18671 130165

Inter-Plan Period - - -

As on 31.3.91 2070 20139 130984

As on 31.3.92 2188 20407 131369

8th Five Year Plan 2633 22149 136258

9th Five Year Plan 3054 22875 137311

10th Five Year Plan 4045 22370 145272

Source: National Health Profile, Various Issues.

Plan-wise total number of sub-centres, primary health centres and

community health centres, in India have been shown in Table 3.10.A look at

the number of sub-centres over the years reveals that during the fourth plan

there were 33509 sub-centres which increased to 47112 and then to 84376

during the Fifth and Sixth Five Year Plan respectively. Their number further

rose to 130165 and 136258 during the Seventh and Eighth Five Year Plan

respectively. The number of sub-centres further climbed up from 137311

during the Ninth Five Year Plan to 145272 during the Tenth Five Year Plan.

Thus, the number of sub-centres increased by 4.34 times from Fourth Plan to

Tenth Plan. During the First Plan the number of PHCs was 725 which

increased to 2565 and 4631 during Second and Third plan respectively. The

76

number of PHCs registered increase from 5283 during Fourth Plan to 5484

during the Fifth Plan. During Sixth Plan number of PHCs was 9115 and it

almost doubled as 18671 during the Seventh Plan. Their number further rose

to 22149 and 22875 during the Eighth and Ninth Five Year Plan

respectively, but during the Tenth Plan their number reduced slightly to

22370. Thus, the number of PHCs increased by 30.85 times since the First

Five Year Plan. In accordance with the progress in the number of SCs and

PHCs, the number of CHCs have also shown an upward trend. The number

of community health centres increased from 214 during Fifth Five Year Plan

to 761 and then to 1910 during Sixth and Seventh Five Year Plan

respectively. Their number rose to 2633 during Eighth Plan and to 3054 and

4045 during Ninth and Tenth Plan respectively. Thus, the number of CHCs

increased by 18.90 times since the Fifth Five Year Plan. Although public

health care facilities in terms of SCs, PHCs and CHCs have been expanding

fairly and rapidly across India, still they are in shortage. The figures of

population based on 2001 population census revealed that there is still a

shortfall of 20903 (13.16 per cent) sub-centres, 4803 (18.46 per cent)

primary health centres and 2653 (40.87 per cent) community health centres

in the rural health infrastructure. Maximum shortage at the community

health centres (CHCs) level is adversely affecting the secondary health care.

Table 3.11 incorporates data on the number of allopathic medical

practitioners and the ratio of population served by them. The number of

medical practitioners zoomed up from 268700 to 757400 during 1981-2009,

showing a growth rate of 3.87 per cent per annum. The growth rate of

allopathic medical practitioners was 4.11 per cent per annum during the first

period, 3.97 per cent per annum during the second period and 3.35 per cent

per annum during the third period. Thus, the maximum growth rate in the

77

Table 3.11: Number of Allopathic Medical Practitioners Registered with Medical Council of

India

Year Medical Practitioners Registered

with Medical Council of India (00)

Medical Practitioners per 100000

population

1981 2687 39.32

1982 2715 38.77

1983 2842 39.73

1984 2965 40.59

1985 3082 41.32

1986 3254 42.75

1987 3378 43.51

1988 3503 44.25

1989 3643 45.15

1990 3787 46.07

1991 3936 46.51

1992 4097 48.06

1993 4265 49.15

1994 4426 50.12

1995 4597 51.18

1996 4776 51.05

1997 4969 52.11

1998 5152 53.01

1999 5360 54.13

2000 5556 55.09

2001 5771 56.11

2002 6071 58.10

2003 6254 58.87

2004 6440 59.24

2005 6609 60.24

2006 6821 61.22

2007 7080 62.60

2008 7367 64.18

2009 7574 65.06

Compound Annual Growth Rate (per cent)

1981-2009 3.87 1.88

1981-1990 4.11 2.00

1991-2000 3.97 1.75

2001-2009 3.35 1.77

Source: 1) Health Information of India, Various Issues

2) National Health Profile, Various Issues

number of medical practitioners was witnessed during the eighties. The

medical practitioners per 100000 population climbed up from 39.32 to 65.06

during 1981-2009, depicting a growth rate of 1.88 per cent per annum. The

growth rate of medical practitioners per 100000 population was 2 per cent

78

per annum during the first period, 1.75 per cent per annum during the second

period and 1.77 per cent per annum during the third period. Thus, the

maximum growth rate in the number of medical practitioners per 100000

population was observed during the eighties.

The growth in the number of registered nursing personnel in India has

been presented in Table 3.12. It shows that during 1981-2008, the number of

nurses and midwives increased from 295218 to 1043363, depicting a growth

rate of 5.32 per cent per annum; health visitors rose from 9486 to 51776

indicating a growth rate of 6.83 per cent per annum and the number of

auxiliary nurses/midwives (ANMs) shot up from 73161 to 557022,

exhibiting a growth rate of 8.69 per cent per annum. It shows that there has

been a significant increase in the number of registered nursing personnel.

The number of auxiliary nurses/ midwives witnessed maximum growth rate

followed by that of health visitors and nurses and midwives. On observing

the growth of registered nursing personnel period-wise, it has been revealed

that during the first period, the auxiliary nurses/midwives registered

maximum growth i.e. 8.57 per cent per annum followed by health visitors

(7.15 per cent per annum), while the number of nurses and midwives

depicted a negative growth rate of -1.08 per cent per annum. During the

second period also the maximum growth was recorded for the ANMs

(11.69 per cent per annum), this time followed by the nurses and midwives

(9.19 per cent per annum) and health visitors (7.94 per cent per annum).

During the third period, the maximum growth was witnessed in case of

health visitors (6.22 per cent per annum) followed by ANMs (3.85 per cent

per annum) and nurses and midwives (3.71 per cent per annum). Thus it can

be concluded that there has been a consistent increase in the number of

79

Table 3.12: Number of Registered Nursing Personnel in India

Year Nurses and Midwives Health Visitors Auxiliary

Nurses/Midwives

1981 295218 9486 73161

1982 319745 10912 80012

1983 321790 10918 86520

1984 339359 11556 89952

1985 369325 12411 98543

1986 392670 13248 108511

1987 400622 14273 118230

1988 245405 15817 132923

1989 261504 16635 141191

1990 311235 17892 150431

1991 340208 17302 150658

1992 385410 17910 165143

1993 449351 22144 203451

1994 512495 24411 229304

1995 562966 26046 278172

1996 565696 26578 283195

1997 607396 24824 301691

1998 671341 32249 335485

1999 737280 32249 380593

2000 776355 35890 419077

2001 805827 35904 428568

2002 805827 35904 428568

2003 839862 40536 502503

2004 865135 50393 506924

2005 908962 50715 521593

2006 930528 51186 527482

2007 971574 51497 549292

2008 1043363 51776 557022

Compound Annual Growth Rate (per cent)

1981-2008 5.32 6.83 8.69

1981-1990 -1.08 7.15 8.57

1991-2000 9.19 7.94 11.69

2001-2008 3.71 6.22 3.85

Source: 1) Statistical Abstract of India, Various Issues.

2) National Health Profile, Various Issues.

registered nursing personnel except during the first period for the number of

nurses and midwives where their number registered a decline. Besides it has

been observed that the growth has been slower in case of nurses and

midwives and health visitors as compared to the growth of ANMs during the

study period.

80

The data pertaining to registered practitioners under AYUSH in India

have been presented in Table 3.13. The total number of registered

practitioners under AYUSH increased from 387910 to 760900 during

1981-2009, depicting a growth rate of 2.64 per cent per annum. The growth

rate of registered practitioners under AYUSH was 3.84 per cent per annum

during the first period, 1.84 per cent per annum during the second period and

1.51 per cent per annum during the third period. Thus, the registered

practitioners witnessed maximum increase during the eighties. Further it has

been noticed that during the study period, maximum growth was recorded

for the homeopathic practitioners (2.83 per cent per annum) followed by

ayurvedic (2.73 per cent per annum) and unani practitioners (2.21 per cent

per annum), while the siddha practitioners exhibited a negative growth rate

of -0.67 per cent per annum.

On analyzing the growth of registered practitioners under AYUSH

period-wise, it has been revealed that during the first period maximum

growth was witnessed in ayurvedic practitioners (4.47 per cent per annum),

followed by homeopathic practitioners (3.84 per cent per annum) and unani

practitioners (2.47 per cent per annum), while the number of siddha

practitioners showed a negative growth rate (-4.08 per cent per annum).

During the second period maximum growth was noticed in homeopathic

practitioners (2.70 per cent per annum), followed by siddha practitioners

(2.59 per cent per annum), ayurvedic practitioners (1.51 per cent per annum)

and unani practitioners (1.11 per cent per annum). During the third period

maximum growth was observed in homeopathic practitioners (3.16 per cent

per annum), followed by unani practitioners (1.93 per cent per annum) and

ayurvedic practitioners (1.11 per cent per annum) while the siddha

practitioners registered a negative growth rate (-15.65 per cent per annum).

81

Table 3.13: Number of Registered Practitioners under AYUSH in India

Year Ayurveda Unani Siddha Homeopathy Total

1981 232227 28000 18190 109493 387910

1982 233824 28737 18357 112638 393556

1983 232190 27736 11476 115710 387112

1984 243153 28021 11509 122173 404856

1985 251071 28382 11532 123852 414837

1986 264800 28715 11581 131091 436187

1987 271696 29097 11632 137507 449932

1988 306740 29701 11644 143380 491465

1989 315719 34886 11717 148866 511188

1990 337966 35350 11801 148707 533824

1991 339200 35633 11615 152521 538969

1992 354423 39469 11990 156134 562016

1993 353924 39802 11994 162766 568486

1994 354684 39550 11895 167097 573226

1995 355816 40827 12437 172623 581703

1996 358564 41420 12450 174564 586998

1997 360290 39497 12780 178943 591510

1998 363885 39958 12911 184894 601648

1999 366812 40748 12915 188527 609002

2000 427504 42445 16599 194147 680695

2001 430890 43108 17097 197252 688347

2002 430263 43330 17392 200003 690988

2003 432625 42833 17550 201484 694492

2004 N.A. N.A. N.A. N.A. N.A.

2005 438721 43578 17560 217460 717319

2006 443634 46230 17560 216858 724282

2007 453661 46558 6381 217850 724450

2008 458418 47456 6601 238627 751102

2009 463485 48679 6877 241859 760900

Compound Annual Growth Rate (per cent)

1981-2009 2.73 2.21 -0.67 2.83 2.64

1981-1990 4.47 2.47 -4.08 3.84 3.84

1991-2000 1.51 1.11 2.59 2.70 1.84

2001-2009 1.11 1.93 -15.65 3.16 1.51

Source: AYUSH in India (2005), Planning and Evaluation Cell, Department of Ayurveda, Yoga

and Naturopathy, Unani, Siddha and Homeopathy (AYUSH), MOHFW,GOI.

There has been a large scale expansion of medical facilities in India so

that the health requirements of the population could be met. A vast health

care infrastructure in government and private sector has been created which

has helped to improve the health of the people. But still, the governmental

measures are quite disheartening in terms of infrastructure. The inadequate

82

health infrastructure of the government has resulted in mushrooming growth

of private hospitals and clinics throughout the country. Thus, there is an

urgent need to expand and improve public health services.

Health Expenditure

Health expenditure in India is dominated by private spending which is

a clear reflection of the inadequate public spending. India‟s performance is

not very impressive in terms of commitment to improve the health services.

One of the indicators of the inadequacy of public health spending in India is

the very small amount of such spending relative to GDP. Table 3.14 shows

India‟s performance vis-à-vis other South Asian countries regarding health

expenditure. During 2002, India‟s public expenditure on health care

(including spending on water supply and sanitation) was 1.3 per cent of

GDP, while it was 1.4 per cent in Nepal, 1.8 per cent in Sri Lanka and

4.1 per cent in Bhutan. Of 174 countries for which information was

presented in the Human Development Report (UNDP, 2005), India‟s rank in

proportion of health expenditures to GDP was 159 and only 15 countries

incurred lower expenditure than India. Infact, private health expenditure in

India was highest amongst all the South Asian countries i.e. 4.8 per cent, as

against 0.4 per cent in Bhutan, 1.9 per cent in Sri Lanka, 2.1 per cent in

Pakistan, 2.3 per cent in Bangladesh and 3.8 per cent in Nepal. The low level

of public expenditures is not the only concern; an overwhelming proportion

of health spending is on curative rather than preventive healthcare. Spending

on preventive health care has a pro-poor impact. This is because, affluent

sections of population already have access to facilities like protected water

supply and immunization and additional spending enhances the coverage of

the facilities to hitherto uncovered areas and provides greater access to the

83

Table 3.14: Commitment to Health in India and other South Asian Countries

Country

Health Expenditure (2002)

One year olds fully

immunized (2003)

(per cent)

Contraceptive

Prevalence

Rate

(1995-2003)

(per cent)

Births attended by

skilled Health

Personnel (1995-2003)

(per cent)

Physicians per

one population

(1990-2004) Public

(Per cent of

GDP)

Private

(Per cent

of GDP)

Per Capita

(PPPUS$)

Against

Tuberculosis

Against

Measles

India 1.3 4.8 96 81 67 48 43 51

Pakistan 1.1 2.1 62 82 61 28 23 66

Bangladesh 0.8 2.3 54 95 77 58 14 23

Nepal 1.4 3.8 64 91 75 39 11 5

Sri Lanka 1.8 1.9 131 99 99 70 97 43

Bhutan 4.1 0.4 76 93 88 19 24 5

Developing

Countries NA NA NA 85 75 NA 59 NA

All

Countries NA NA NA 85 77 NA 62 NA

Source: Human Development Report, 2005

84

poor. Preventive health care also has greater impact in enhancing

“capabilities” of the poor. The coverage of immunization for both

tuberculosis and measles is lower than the world average as well as

developing countries average. Infact, the coverage in India is lower than all

South Asian countries except Pakistan. The percentage of births attended by

skilled health personnel in India is lower than the developing countries

average though it is higher than other South Asian countries except

Sri Lanka. India has the second highest physician-population ratio- next only

to Pakistan among the South Asian countries, but this does not ensure easy

access to the poor as predominant proportion of the physicians could be in

the private sector and in urban areas and poor can not afford to pay for their

services.

It is very important to understand how resources are invested over the

period of time in India. The role of the government is to make available

more infrastructure and health professionals. It is mainly done through the

five year plans and annual budgets of central and state governments. The

data regarding the pattern of central government investment on health and

family welfare and AYUSH during different plan periods have been

presented in Table 3.15. During the First Plan period total investment was

Rs. 1960 Cr which increased to Rs. 2156571 Cr during the Eleventh Plan.

On analyzing the investment on health, family welfare and AYUSH

separately it has been observed that investment on health in absolute terms

increased from Rs. 65.2 Cr during the First Plan to Rs. 31020.3 Cr during

the Tenth Plan. Investment on health during the First Plan was 3.3 per cent

of total plan investment. It came down to 3.0 per cent in Second Plan,

2.6 per cent in Third Plan and showed a consistent decline thereafter till the

Tenth Plan where it settled at 2.09 per cent. On the contrary, investment on

85

Table 3.15: Pattern of Central Allocation on Health Sector, Plan-wise

(Rs. in crore)

Plan

Total Plan

Investment

Outlay(All

Heads of

Dev)of

country

Health Sector Total

(1+2+3)

Health

(1)

Family

Welfare

(2)

AYUSH

(3)

First Plan (1951-56) 1960.0

65.2

(3.3)

0.1

(0.01) -

65.3

(3.4)

Second Plan (1956-61) 4672.0

140.8

(3.0)

5.0

(0.1) -

145.8

(3.1)

Third Plan (1961-66) 8576.5

225.9

(2.6)

24.9

(0.3) -

250.8

(2.9)

Annual Plans (1966-69) 6625.4

140.2

(2.1)

70.4

(1.1) -

210.6

(3.2)

Fourth Plan (1969-74) 15578.8

335.5

(2.1)

278.0

(1.8) -

613.5

(3.9)

Fifth Plan (1974-79) 39426.2

760.8

(1.9)

491.8

(1.2) -

1252.6

(3.1)

Annual Plan (1979-80) 12176.5

223.1

(1.8)

118.5

(1.0) -

341.6

(2.8)

Sixth Plan (1980-85) 109291.7 2025.2

(1.8)

1387.0

(1.3) -

3412.2

(3.1)

Seventh Plan (1985-90) 218729.6 3686.6

(1.7)

3120.8

(1.4) -

6809.4

(3.1)

Annual Plan (1990-91) 61518.1 960.9

(1.6)

784.9

(1.3) -

1745.8

(2.9)

Annual Plan (1991-92) 65855.8 1042.2

(1.6)

856.6

(1.3) -

1898.8

(2.9)

Eighth Plan (1992-97) 434100.0 7494.2

(1.7)

6500.0

(1.5)

108.0

(0.02)

14102.2

(3.2)

Ninth Plan (1997-02) 859200.0 19818.4

(2.31)

15120.2

(1.76)

266.35

(0.03)

35204.95

(4.09)

Tenth Plan (2002-07) 1484131.3 31020.3

(2.09)

27125.0

(1.83)

775.0

(0.05)

58920.3

(3.97)

Eleventh Plan(2007-12) 2156571.0 136147.0#

(6.31) -

3988.0

(0.18)

140135.0

(6.5)

Note: 1) Dept. of ISM and H (now AYUSH) was created during 8th Plan

2) Figures in parentheses indicate percentages to total plan investment outlay.

# Dept. of Health and Family Welfare merged from 2005 and 136147.0 crore includes

Rs.4496.08 crore for newly created Health Research Dept. created during 2008-09.

Source: Planning Commission of India, MOHFW, GOI

86

family welfare increased considerably in absolute terms from a meagre sum

of Rs. 0.10 Cr during First Plan to Rs. 27125 Cr during Tenth Plan. The

investment on family welfare as a percentage of total plan investment also

increased from .01 per cent during the First Plan to 1.83 per cent during the

Tenth Plan. An amount of Rs. 136147.0 (6.31 per cent) during Eleventh Plan

indicates investment on both health and family welfare, as department of

health and family welfare merged together from 2005 onwards. This amount

also included Rs. 4496.08 Cr for newly created health research department

created during 2008-09. Investment on AYUSH increased in absolute terms

from Rs. 108 Cr during Eighth Plan to Rs. 3988 Cr during Eleventh Plan and

in relative terms rose from 0.02 per cent to 0.18 per cent. Central

government allocation on health sector (i.e. health and family welfare and

AYUSH) taken as a whole jumped from 65.3 Cr during the First Plan to

Rs. 58920.3 Cr during the Tenth Plan. Thus, total health investment as a

percentage of total plan investment showed gradual and steady increase from

3.4 per cent to 3.97 per cent during the corresponding period. During the

eleventh plan, this percentage grew to 6.5 per cent.

The level of public expenditure by the centre and state health

departments as a share of Gross Domestic Product (GDP) has not

significantly risen between 1950-51 and 2003-04. This has primarily been

due to the austerity measures introduced in the late 1980s, which negatively

affected sectors such as health. Table 3.16 depicts the trends in health

expenditure in India. It reveals that public spending on health in India

gradually accelerated from 0.22 per cent in 1950-51 to 1.05 per cent during

the mid-1980s, and stagnated at around 0.9 per cent of the GDP during the

later years. Moreover, health sector suffered more during post-liberalization

period. In the pre-liberalization period of independent India, the health

87

Table 3.16: Trends in Public Health Expenditure in India

Year Public Health Expenditure as per cent of GDP

Per Capita

Public

Expenditure on

Health (Rs.) Revenue Capital Total

1950-51 0.22 N.A. 0.22 0.61

1955-56 0.49 N.A. 0.49 1.36

1960-61 0.63 N.A. 0.63 2.48

1965-66 0.61 N.A. 0.61 3.47

1970-71 0.74 N.A. 0.74 6.22

1975-76 0.73 0.08 0.81 11.15

1980-81 0.83 0.09 0.91 19.37

1985-86 0.96 0.09 1.05 38.63

1990-91 0.89 0.06 0.96 64.83

1995-96 0.82 0.06 0.88 112.21

2000-01 0.86 0.04 0.90 184.56

2001-02 0.79 0.04 0.83 183.56

2002-03 0.82 0.04 0.86 202.22

2003-04 0.86 0.06 0.91 214.62

Note: GDP is at market price, with base year 1993-94

N.A- Not Available

Source:1. Report on Currency and Finance, RBI, Various Issues

2. Statistical Abstract of India, Govt. of India, Various Issues

3. Handbook of Statistics of India, RBI, Various Issues quoted in Financing and Delivery

of Health Care in India, NCMH, 2005.

expenditure as percentage of the GDP increased as a whole from

0.22 per cent in 1950-51 to 0.96 per cent in 1990-91. However, it has seen a

steady decline ever since in the post-liberalization period from 0.96 per cent

in 1990-91 to 0.91 per cent in 2003-04. Of this, recurring expenditures like,

salaries and wages, drugs, consumables, etc., accounted for more than 90 per

cent and has been on the rise in the recent years. In terms of per capita

expenditure, it increased significantly from less than Re. 1 in 1950-51 to

about Rs. 215 in 2003-04, but the per capita spending by the government

was far below the international aspiration of US$ 12 recommended for an

essential health package by the World Development Report 1993 and again

by the Commission on Macroeconomics and Health (World Health

Organisation, 2002) for low-income countries. As a result of stagnant

88

budgetary allocations, the quality of care suffered substantially and

adversely impacted the utilization of government services by households.

The salient feature of health spending in India has been noted to be

just 0.9 per cent of GDP, which is really inadequate. Besides, its distribution

is not proper. Much of the allocation of health expenditure is on curative

health leaving very little resources for preventive healthcare. Even more

important is the inter-state differences in per capita health expenditures.

Generally, in the states with low per capita incomes and with high

concentration of poverty, per capita public expenditure on health and family

welfare is very low. Low per capita expenditure on health services in states

with larger concentration of poverty results in high out-of-pocket

expenditure. The out-of-pocket expenditure being highly regressive in nature

leads to low access to health care services to the poor.

Table 3.17 presents per capita public expenditure on health and family

welfare incurred by the state governments. The expenditures are shown in

both per capita terms and as a percentage of Gross State Domestic Product

(GSDP). The table reveals that the aggregate spending on health services as

a ratio of GSDP has been extremely low and has been declining over the

time. The aggregate spending on health services relative to GSDP showed a

marginal increase from 1.23 per cent in 1995-96 to 1.37 per cent in 2000-01

mainly due to the pay revision in the states in 1998-99 and declined

thereafter to 1.18 per cent in 2004-05. The inter-state inequalities in per

capita spending on health services has been observed, which has steadily

increased over the years. During 1995-96 the per capita health expenditure

89

Table 3.17: State-wise Public Health Expenditure in India

State

Per capita Health Expenditure (Rs.) Per cent of GSDP

1995-96 2000-01 2004-05 1995-96 2001-01 2004-05

Andhra Pradesh 117.33 229.03 282.09 1.06 1.24 1.10

Assam 128.58 208.09 259.29 1.63 1.74 1.69

Bihar 91.59 108.18 100.12 2.69 1.89 1.55

Gujarat 135.24 397.88 345.69 0.85 1.84 1.04

Haryana 171.42 297.16 418.42 1.06 1.13 1.14

Karnataka 149.13 263.70 284.10 1.30 1.32 1.06

Kerala 166.57 270.65 354.31 1.31 1.23 1.17

Madhya Pradesh 146.72 222.49 210.05 1.65 1.81 1.33

Maharashtra 141.78 252.50 316.33 0.78 1.02 0.87

Orissa 115.01 183.64 238.61 1.45 1.73 1.55

Punjab 159.22 324.32 344.68 0.91 1.19 1.00

Rajasthan 250.01 353.14 408.91 2.60 2.50 2.25

Tamil Nadu 166.07 299.00 447.51 1.25 1.31 1.53

Uttar Pradesh 87.88 99.59 156.58 1.21 0.95 1.19

West Bengal 101.38 236.36 206.90 1.02 1.35 0.84

Mean 131.37 224.29 262.24 1.23 1.37 1.18

Standard

Deviation 40.33 81.74 98.98 0.57 0.42 0.37

Co-efficient of

Variation 0.31 0.36 0.38 0.467 0.31 0.315

Source: Finance Accounts of State Governments.

was lowest in Uttar Pradesh (Rs. 87.88) and highest in Rajasthan

(Rs. 250.01), showing a difference of about three times. During 2000-01,

again the lowest per capita health expenditure was observed in Uttar Pradesh

(Rs. 99.59) while it was highest in Gujarat (Rs. 397.88) showing a difference

of about four times, and during 2004-05, per capita health expenditure varied

from Rs. 100.12 in Bihar to Rs. 447.51 in Tamil Nadu, thus showing the

difference of four and a half times between the lowest and highest

expenditure. The co-efficient of variation in per capita health expenditure

increased steadily from 0.31 in 1995-96 to 0.38 in 2004-05, which indicates

a steady increase in inter- state inequalities.

India is one among the developing countries where households spend

a disproportionate share of their consumption expenditure on health care,

90

Table 3.18: Household Health Expenditure by Different Source of Care in India

(Rs. in crore)

Type of Service 1995-96 2001-02 2003-04 Growth Rate

Outpatient-rural 16692.96 34290.99 43590.87 12.75

Outpatient-urban 7251.45 16904.82 22415.01 15.15

Inpatient-rural 3030.04 8536.86 12057.25 18.84

Inpatient-urban 2092.90 5150.72 6954.1 16.19

Child birth 1654.22 2258.14 2504.97 5.32

Ante-natal Care(ANC) 1053.90 2383.27 3128.22 14.57

Post-natal Care(PNC) 390.85 1028.1 1419.21 17.49

Immunization 241.02 535.61 698.95 14.23

Contraceptives 207.14 422.74 536.22 12.62

Self-care 638.83 1247.47 1559.23 11.8

Total 33253.31 72758.72 94864.03 13.94

Source: Estimated from the 52nd

round of the NSS, using 2001 population census and applying

growth rates worked out from the 50th and 55

th rounds of the NSS quoted in Financing and

Delivery of the Health Care Services in India, NCMH, 2005.

with the government‟s contribution being minimal. Households consumer

expenditure data of various rounds of National Sample Survey Organisation

( NSSO) shows that households spend about 5-6 per cent of their total

consumption expenditure on health and nearly 11 per cent of all non-food

consumption expenditure. Table 3.18 depicts the household health

expenditure by different source of care in India. It shows that since 1995-96,

household expenditure on health has been growing at the rate of

approximately 14 per cent overall. In 1995-96, households in India spent an

estimated Rs.33253 Cr at nominal prices which is then estimated to have

increased to Rs. 72759 Cr in 2001-02. With an overall growth rate of about

14 per cent, household spending has been found to be close to Rs. 100000 Cr

during 2003-04. The maximum expenditure has been found to be incurred

on outpatient care, while the minimum expenditure has been incurred on

contraceptives. It has been noticed that except the category of child birth, all

other categories registered a growth rate in double digits indicating a fairly

good growth rate. The growth in inpatient expenditure was highest, in the

range of 16-19 per cent during 1995-96 to 2003-04.

91

Table 3.19: Health Care Expenditure in Major States, 2004-05

State Per Capita Health

Expenditure (Rs.)

Percent Spent By

Households Public Other

Andhra Pradesh 1118 73.4 19.4 7.2

Assam 4365 86.5 13.5 0

Bihar 1497 90.2 8.3 1.5

Gujarat 1187 77.5 15.8 6.7

Haryana 1786 85 10.6 4.4

Karnataka 997 70.4 23.2 6.4

Kerala 2952 86.3 10.8 2.9

Madhya Pradesh 1200 83.4 13.6 3

Maharashtra 1576 73.3 22.1 4.6

Orissa 995 79.1 18 2.9

Punjab 1813 76.1 18 5.9

Rajasthan 808 70 24.5 5.5

Tamil Nadu 933 60.7 26.6 12.7

Uttar Pradesh 1152 84.3 13 2.7

West Bengal 1188 78.4 17.3 4.3

India 1377 73.5 22 4.5

Source: Report of National Commission on Macroeconomics and Health, Government of India,

2005

The role of the households in health care spending has increased

substantially. According to the Report of National Commission on

Macroeconomics and Health, 2005, households undertook nearly

three-fourths of all the health spending in the country. The data pertaining to

the health care spending in major states for the year 2004-05 have been

depicted in Table 3.19. Public spending was only 22 per cent and all other

sources accounted for less than 5 per cent. It has also been revealed that both

the per capita spending and the share of households varied across states. Per

capita spending was highest in Assam (Rs. 4365) which was nearly five

times the per capita spending of Rajasthan (Rs. 808), which was the state

with lowest per capita spending. The share of public spending was observed

to be highest in Tamil Nadu (26.6 per cent) while it was lowest in Bihar

(8.3 per cent). Further it showed that the share of household spending was

lowest in Tamil Nadu (60.7 per cent) while it was highest in Bihar

92

Figure 3.7: Health Care Expenditure in Major States, 2004-05

Source: Report of National Commission on Macroeconomics and Health, Government of India, 2005

(90.2 per cent). Many of the states undertook more than 75 per cent of all

health spending indicating an exceptionally high burden upon them

(Figure 3.7).

Thus the health sector in India has been accorded very low priority in

terms of allocation of resources. Public expenditure on health is less than

one per cent of GDP in India. It has further witnessed decline during the post

economic liberalization period because of which households account for the

bulk of health expenditure.

There has been an improvement in health facilities and as a

consequence there has been appreciable improvement in birth rate, death

rate, infant mortality rate and life expectancy, but within India, wide

inter-sector and inter-state disparities exist in the health status. India has

invested substantially in developing the health infrastructure but still there

are gaps and inadequacies in health infrastructure. The public expenditure on

health has not been an issue of high priority. The states have been allocating

0102030405060708090

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93

very low levels of expenditure on health sector because of which a

disproportionately large share of the burden of health care has to be borne by

the households. Health security in India needs to become an urgent national

priority. Rapid improvements in health are needed not only to accelerate and

sustain India‟s economic growth; they are also fundamental to India‟s

gaining recognition as a distinguished country with improved standards of

living and reduced levels of human deprivation. Focusing on health equity

and increasing the allocation on health will be critical to enhance human

capabilities and advancing the progress of Indian society over the next

decade.