Role of the Government

The Indian constitution charges the states with "the raising of the level of nutrition and the standard of living of its people and the improvement of public health" (see The Constitutional Framework, ch. 8). However, many critics of India's National Health Policy, endorsed by Parliament in 1983, point out that the policy lacks specific measures to achieve broad stated goals. Particular problems include the failure to integrate health services with wider economic and social development, the lack of nutritional support and sanitation, and the poor participatory involvement at the local level.

Central government efforts at influencing public health have focused on the five-year plans, on coordinated planning with the states, and on sponsoring major health programs. Government expenditures are jointly shared by the central and state governments. Goals and strategies are set through central-state government consultations of the Central Council of Health and Family Welfare. Central government efforts are administered by the Ministry of Health and Family Welfare, which provides both administrative and technical services and manages medical education. States provide public services and health education.

The 1983 National Health Policy is committed to providing health services to all by 2000 (see table 8, Appendix; The Legislature, ch. 8). In 1983 health care expenditures varied greatly among the states and union territories, from Rs13 per capita in Bihar to Rs60 per capita in Himachal Pradesh (for value of the rupee--see Glossary), and Indian per capita expenditure was low when compared with other Asian countries outside of South Asia. Although government health care spending progressively grew throughout the 1980s, such spending as a percentage of the gross national product (GNP--see Glossary) remained fairly constant. In the meantime, health care spending as a share of total government spending decreased. During the same period, private-sector spending on health care was about 1.5 times as much as government spending.

Expenditures

In the mid-1990s, health spending amounts to 6 percent of GDP, one of the highest levels among developing nations. The established per capita spending is around Rs320 per year with the major input from private households (75 percent). State governments contribute 15.2 percent, the central government 5.2 percent, third-party insurance and employers 3.3 percent, and municipal government and foreign donors about 1.3, according to a 1995 World Bank study. Of these proportions, 58.7 percent goes toward primary health care (curative, preventive, and promotive) and 38.8 percent is spent on secondary and tertiary inpatient care. The rest goes for nonservice costs.

The fifth and sixth five-year plans (FY 1974-78 and FY 1980-84, respectively) included programs to assist delivery of preventive medicine and improve the health status of the rural population. Supplemental nutrition programs and increasing the supply of safe drinking water were high priorities. The sixth plan aimed at training more community health workers and increasing efforts to control communicable diseases. There were also efforts to improve regional imbalances in the distribution of health care resources.

The Seventh Five-Year Plan (FY 1985-89) budgeted Rs33.9 billion for health, an amount roughly double the outlay of the sixth plan. Health spending as a portion of total plan outlays, however, had declined over the years since the first plan in 1951, from a high of 3.3 percent of the total plan spending in FY 1951-55 to 1.9 percent of the total for the seventh plan. Mid-way through the Eighth Five-Year Plan (FY 1992-96), however, health and family welfare was budgeted at Rs20 billion, or 4.3 percent of the total plan spending for FY 1994, with an additional Rs3.6 billion in the nonplan budget.

Primary Services

Health care facilities and personnel increased substantially between the early 1950s and early 1980s, but because of fast population growth, the number of licensed medical practitioners per 10,000 individuals had fallen by the late 1980s to three per 10,000 from the 1981 level of four per 10,000. In 1991 there were approximately ten hospital beds per 10,000 individuals.

Primary health centers are the cornerstone of the rural health care system. By 1991, India had about 22,400 primary health centers, 11,200 hospitals, and 27,400 dispensaries. These facilities are part of a tiered health care system that funnels more difficult cases into urban hospitals while attempting to provide routine medical care to the vast majority in the countryside. Primary health centers and subcenters rely on trained paramedics to meet most of their needs. The main problems affecting the success of primary health centers are the predominance of clinical and curative concerns over the intended emphasis on preventive work and the reluctance of staff to work in rural areas. In addition, the integration of health services with family planning programs often causes the local population to perceive the primary health centers as hostile to their traditional preference for large families. Therefore, primary health centers often play an adversarial role in local efforts to implement national health policies.

According to data provided in 1989 by the Ministry of Health and Family Welfare, the total number of civilian hospitals for all states and union territories combined was 10,157. In 1991 there was a total of 811,000 hospital and health care facilities beds. The geographical distribution of hospitals varied according to local socioeconomic conditions. In India's most populous state, Uttar Pradesh, with a 1991 population of more than 139 million, there were 735 hospitals as of 1990. In Kerala, with a 1991 population of 29 million occupying an area only one-seventh the size of Uttar Pradesh, there were 2,053 hospitals. In light of the central government's goal of health care for all by 2000, the uneven distribution of hospitals needs to be reexamined. Private studies of India's total number of hospitals in the early 1990s were more conservative than official Indian data, estimating that in 1992 there were 7,300 hospitals. Of this total, nearly 4,000 were owned and managed by central, state, or local governments. Another 2,000, owned and managed by charitable trusts, received partial support from the government, and the remaining 1,300 hospitals, many of which were relatively small facilities, were owned and managed by the private sector. The use of state-of-the-art medical equipment, often imported from Western countries, was primarily limited to urban centers in the early 1990s. A network of regional cancer diagnostic and treatment facilities was being established in the early 1990s in major hospitals that were part of government medical colleges. By 1992 twenty-two such centers were in operation. Most of the 1,300 private hospitals lacked sophisticated medical facilities, although in 1992 approximately 12 percent possessed state-of-the-art equipment for diagnosis and treatment of all major diseases, including cancer. The fast pace of development of the private medical sector and the burgeoning middle class in the 1990s have led to the emergence of the new concept in India of establishing hospitals and health care facilities on a for-profit basis.

By the late 1980s, there were approximately 128 medical colleges--roughly three times more than in 1950. These medical colleges in 1987 accepted a combined annual class of 14,166 students. Data for 1987 show that there were 320,000 registered medical practitioners and 219,300 registered nurses. Various studies have shown that in both urban and rural areas people preferred to pay and seek the more sophisticated services provided by private physicians rather than use free treatment at public health centers.

Indigenous or traditional medical practitioners continue to practice throughout the country. The two main forms of traditional medicine practiced are the ayurvedic (meaning science of life) system, which deals with causes, symptoms, diagnoses, and treatment based on all aspects of well-being (mental, physical, and spiritual), and the unani (so-called Galenic medicine) herbal medical practice. A vaidya is a practitioner of the ayurvedic tradition, and a hakim (Arabic for a Muslim physician) is a practitioner of the unani tradition. These professions are frequently hereditary. A variety of institutions offer training in indigenous medical practice. Only in the late 1970s did official health policy refer to any form of integration between Western-oriented medical personnel and indigenous medical practitioners. In the early 1990s, there were ninety-eight ayurvedic colleges and seventeen unani colleges operating in both the governmental and nongovernmental sectors.

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Source: U.S. Library of Congress