Change is inevitable and is health any exception to that? The nature of public health has changed globally in conjunction with the ever-expanding economy and modern lifestyles. A few modern public health challenges include – antimicrobial resistance, chronic non-communicable diseases (NCDs), zoonotic diseases, and mental health illnesses. NCDs continue to account for more than 60% of global deaths and are estimated to increase by 17% in the next decade. These challenges are complex, multifaceted and require a new public health system that comprehensively understands health, one that extends beyond the absence of diseases. This new system needs to see public health as a product of ongoing interactions between the environment, socioeconomic determinants, and people’s health-seeking behavior.
India’s recent achievements
The government of India introduced the ‘Ayushman Bharat’ scheme in its 2018 budget (approx. US $ 8.4 billion) as an ambitious project to transform and strengthen India’s public health system., including through public funding for healthcare of disadvantage groups. This nationally-funded scheme incorporates three major components: Pradhan Mantri – Jan Arogya Yojana (PM-JAY), Ayushman Arogya Mandir (AAM) and Pradhan Mantri Ayushman Bharat Health Infrastructure Mission (PM-ABHIM).
PM-JAY, being the largest publicly funded health insurance, provides financial coverage of ₹5 lakh to BPL cardholders and senior citizens. On the other hand, Ayushman Arogya Mandir aims to transform and strengthen primary health care through its Health and Wellness Centres (HWCs) holistically. The delivery of public health services through these centers is anchored around the concept of continuous comprehensive (preventive, promotive, curative, rehabilitative and palliative) care. This brings services related to non-communicable diseases (hypertension, diabetes and high priority cancers), ENT, mental health, oral health, geriatric and palliative care, health promotion and wellness activities closer to the general community. The PM-ABHIM component (with an outlay of ₹64,180 crore), was launched in October 2021 to equip India’s comprehensive care system with required health infrastructure to deliver and maintain high quality services within the country.
Public-funded programmes like these are designed to improve survival and well-being, while safeguarding the community from catastrophic healthcare expenditure (CHO). The World Health Organization defines CHO as ‘out-of-pocket payments greater than 40% of the capacity to pay for health care.’
Absolute numbers provide a different narrative
As per the latest report from the Union Ministry of Health and Family Welfare, as of November 2024, a total of 1,75,338 AAMs have been established and operationalised with a footfall of 350 crore consultations. If we closely examine the National Health Accounts report 2021–2022, we can see how the Health Ministry has marginally increased healthcare expenditure in recent years. The report also shows a decreasing trend of per capita out-of-pocket health expenditure (OOPHE) (2013-14: 64.2%; 2014-15: 62.6%; 2015-16: 60.6%; 2016-17: 58.7%; 2017-18: 48.8%; 2018-19: 48.2%; 2019-20: 47.1%; 2020-21: 44.4%; 2021-22: 39.4%) in the country. Along with dedicated budgets from respective States, the Central government additionally complements a State’s public health infrastructure through schemes like the National Health Mission and Ayushman Bharat. With the help of this substantial funding, India was able to improve the average lifespan of its population and improve health outcomes. The true question is, however, to what extent is our public health system VISIBLE to our people?
How visible is our public health system?
In India, there exist a few blind spots in the public health system such as user experience, and people’s trust and confidence in the system. People’s ‘trust’ in public health or healthcare has always been ambiguous; however, this has been linked with many health outcomes such as health-seeking behavior, healthcare utilisation and continuity of care and self-satisfaction. ‘Trust in healthcare’ is defined as ‘an optimistic acceptance of a helpless situation where the trustee (patients) believes that the trustor (doctors) will care for their concern or interest’. Many lower- and middle-income nations, including India, still struggle to foster people’s trust in their public health systems.
Every country’s public health system plays a crucial role in health service delivery and trust brings people closer to the publicly-funded system and safeguards the community against catastrophic health expenditure from the private sector. The private healthcare sector in India still holds a lion’s share of health spending, the OOPHE percentages mentioned earlier highlights how the government has managed to reduce the per capita OOPHE over the years. However, when we look at absolute numbers rather than percentages, it tells a different story all together. As per the same report, the OOPHE in India has been steadily increasing (2017-18: ₹2,097; 2018-19: ₹2,155; 2019-20: ₹2,289; 2020-21: ₹2,415; 2021-22: ₹2,600) annually.
People often turn to the private sector for consistent care, timely access, and clean infrastructure. India has a respectable public health system that has gradually improved over time, especially at the primary level. Publicly funded sub-centers, primary health centers, and community health centers have been established at the primary level to address the public health needs of the populace, both in urban and rural areas. Each of these institutions provides healthcare services in accordance with their designated catchment areas.
While Ayushman Bharat and the National Health Mission (Urban and Rural) aim to strengthen public health accessibility and infrastructure, the Indian government also introduced the National Quality Assurance Standards (NQAS) to raise public health facilities to global standards. These standards are based on The International Society for Quality in Healthcare (ISQua), and have been developed to improve quality in eight areas of concern: service, patient rights, inputs, support services, clinical care, infection control, quality management and outcomes.As per the latest report, 17,017 public health facilities were NQAS certified as of November 2024. Lack of knowledge about these programmes and figures prevents people from utilising India’s public health facilities. Due to the private health sector’s increased visibility, a large proportion of the populace has still not seen, or does not know of the existence of,g their designated public health institution in their vicinity.
Way forward
India’s SDG (sustainable development goals) 2030 commitments call for a high-quality public health system. According to The Lancet Global Health Commission on High Quality Health Systems, a high-performing health system is not always indicated by the mere existence of basic infrastructure (such as human resources, medications, running water, power, etc.). The commission further defines a high-quality health system as “one that optimises health care in a given context by consistently delivering care that improves or maintains health outcomes, by being valued and trusted by all people, and by responding to changing population needs”.
The Indian Public Health Standards (IPHS) were released in 2007, prescribing only the most basic standards for our publicly-funded healthcare facilities, but it’s time to assign top priority to NQAS, which guarantees healthcare that meets international standards. These should be made mandatory for newly-constructed institutions because they are less difficult to implement across newly-established institutions.
Even though the system produces measurable data about service management and utilisation, it misses a few parameters that people care about the most. By capturing user experience and making the findings publicly available, we can potentially increase people’s trust and confidence in our public health system. This kind of rethinking can help in the better management of modern public health issues, such as chronic and complex diseases which require several visits and comprehensive care.
Local governments should prioritise and locate public health facilities in convenient locations that are accessible with public transportation to increase their visibility. File photograph of a PHC in Anantapur district, Andhra Pradesh.
Local governments should prioritise and locate public health facilities in convenient locations that are accessible with public transportation to increase their visibility. In an urban setting, this kind of prioritisation is typically challenging, but it has both epidemiological and economic benefits. Plans can also be made under the National Digital Health Mission to assist individuals to locate (via GPS), different types of public health facilities in and around their locality. In summary, only providing access to care is insufficient to address today’s public health issues; instead, a high-quality public health system should be the goal in order to foster trust in government health services to protect citizens from catastrophic health expenditures.
(Irfan Shakeer is an epidemiologistbased in Bengaluru. [email protected] Dr. Janane S is an epidemiologistbased in Hyderabad. [email protected])
Published – April 18, 2025 06:00 am IST