India's health system: architecture, spending and equity

Health is where the welfare state meets the body, which is why GS-II places it among the core social sector services. India has cut its fertility rate to 2.0, reduced child mortality sharply and raised household health-insurance coverage from 41% to 60.2% in a few years, yet it spends less on public health than almost any comparable economy: about 1.9% of GDP, against its own National Health Policy 2017 target of 2.5%.

The result is a system of contrasts. World-class tertiary hospitals and AIIMS on one side; on the other, community health centres with roughly four-fifths of specialist posts vacant, a doctor map tilted heavily toward cities, and families paying nearly 40% of the country's health bill out of pocket. This article maps the architecture, the money, and the equity gaps that examiners keep probing.

The three-tier architecture

The public system is organised on the Bhore Committee (1946) model of three levels of care. Primary care is the first point of contact: Sub-Centres, Primary Health Centres and the newer Ayushman Arogya Mandirs, covering populations of roughly 3,000 to 30,000. It handles preventive care, immunisation, antenatal care, family welfare and minor ailments. Secondary care, the Community Health Centres and sub-district and district hospitals serving roughly 80,000 to 1.5 lakh people, provides specialist consultation and basic surgery. Tertiary care, the medical colleges, AIIMS-like institutes and specialty hospitals, delivers super-specialty treatment and research.

• PHCs exist in numbers but face severe staff shortages, including of doctors.
• CHCs face roughly an 80% shortfall of specialists, and district hospitals are overburdened because referral systems barely function.
• Tertiary care is urban-heavy: about 67% of doctors serve the roughly 34% of Indians who live in cities, while about 73% of public hospital beds are in urban areas though some 70% of the population is rural.

The mixed model: private dominance, public backbone

India runs a mixed healthcare model in which the private sector provides roughly 70% of outpatient and 60% of inpatient care; most patients who can pay choose private facilities. But the public sector remains the backbone for maternal health, immunisation and basic preventive care, and informal rural practitioners (RMPs) are still the first contact for many rural households. The price of marketisation, which UPSC has asked about repeatedly, shows up as profit-driven overcharging and unnecessary procedures, cherry-picking of paying patients, an urban bias where paying capacity concentrates, the drain of doctors from public to private facilities, and catastrophic out-of-pocket spending that pushes an estimated 39 million Indians into poverty every year.

The constitutional case for state intervention is settled. The Supreme Court, in Paschim Banga Khet Mazdoor Samity, read the right to health into Article 21, and the Directive Principles (39(e) on workers' health, 41 on assistance for the sick and disabled, 42 on maternity benefits, 47 on nutrition and public health, 48A on a pollution-free environment) direct the state to intervene. But health sits in the State List of the Seventh Schedule, so delivery is overwhelmingly a state responsibility, with the Centre bridging gaps through centrally sponsored schemes like the National Health Mission and Finance Commission health grants.

The money question: spending near 1.9% against a 2.5% target

The National Health Accounts for 2021-22 show total health expenditure of about 3.8% of GDP, of which government health expenditure is roughly 1.84%, or about 1.9%. The National Health Policy 2017 had set a target of 2.5% of GDP by 2025. The gap has fiscal and federal roots: the Centre's own share is only about 0.29% of GDP against an intended 1%, while states, which do most of the spending, allocate between 4% and 9% of their budgets to health. Kerala, Tamil Nadu and Delhi spend more and show better outcomes; Bihar, Uttar Pradesh, Jharkhand and Madhya Pradesh spend the least per capita and record the worst indicators. The 15th Finance Commission recommended Rs 70,051 crore in health grants to states, but fund utilisation in the weakest states remains low.

The clear win is the fall in out-of-pocket spending: from 62.6% of total health expenditure in 2014-15 to 39.4% in 2021-22, driven by the expansion of PM-JAY and state insurance schemes (household insurance coverage rose from 41% in NFHS-5 to 60.2% in NFHS-6). But the share is still more than double the global average of about 18%, and the biggest gaps are in outpatient care, diagnostics and medicines, which most insurance products do not cover. Beyond the insured poor lies the missing middle: roughly 40 crore Indians, mostly informal and self-employed workers, who sit above the PM-JAY eligibility line but cannot afford private insurance (NITI Aayog, 2021).

National Health Policy 2017: targets and the unfinished business

NHP 2017 replaced the 2002 policy and gave the health sector its first strategic vision in fifteen years. Its headline targets: lift public health spending to 2.5% of GDP by 2025; raise life expectancy from 67.5 to 70 years; cut the total fertility rate to 2.1; bring under-five mortality to 23 per 1,000 live births; reduce MMR to 100 by 2020; cut neonatal mortality to 16 and the stillbirth rate to single digits; meet the 90:90:90 HIV/AIDS target; and reduce out-of-pocket spending as a share of health expenditure. Its strategic shifts moved policy from selective to comprehensive primary care, from sectoral to integrated care, from input-based to outcome-based financing, mainstreamed AYUSH, and put NCDs and mental health on the agenda.

The scorecard is mixed. Life expectancy crossed 70, the fertility rate fell to 2.0 (below replacement level), and MMR fell to 97 per lakh live births (SRS 2018-20). But the single biggest unmet target is public health spending, still around 1.9% of GDP, and under-five mortality remains well above the target of 23.

Primary healthcare: the first line of defence

From the Alma Ata Declaration (1978) to Astana (2018), the global consensus is that primary care is the cheapest route to universal health coverage: it prevents expensive tertiary interventions, reaches the rural and urban poor, reduces out-of-pocket spending by catching disease early, and was the layer that held the line during COVID-19. India's own Srinath Reddy Committee (2011) recommended at least 70% of the health budget for primary care, against the WHO's 50% norm; NHP 2017 asked for two-thirds of public funds to go to primary and preventive care. The reality is about 40% by some estimates, one of the system's defining skews.

The delivery footprint has expanded. Health and Wellness Centres, launched in 2018 as the first pillar of Ayushman Bharat and renamed Ayushman Arogya Mandirs in 2023, offer 12 comprehensive primary-care services (maternal and child health, NCDs, eye care, elderly and mental-health care) with free essential drugs and diagnostics, staffed by mid-level Community Health Officers (1.25 lakh deployed) and linked to telemedicine through eSanjeevani. Operational centres are reported at over 1.7 lakh against the 1.5-lakh target, though some surveys report patchy supply of essential NCD drugs. The human backbone is the ASHA: 10.4 lakh workers, launched in 2005 under the NRHM, one per 1,000 population, paid performance-based incentives rather than a salary, and honoured with the WHO Global Health Leaders Award in 2022, alongside ANMs and Anganwadi workers. Their long-standing demands for regular wages, employee status and manageable workloads are a policy issue in their own right.

Health equity: the postcode lottery

The WHO defines health equity as every individual having a fair opportunity to attain their highest level of health, regardless of social, economic or political circumstances. India falls short on every dimension. Geographically, roughly 75% of healthcare professionals are in urban areas, where only about 34% of Indians live. Socially, Scheduled Castes and Tribes face higher child mortality and lower immunisation, and tribal communities carry a disproportionate burden of sickle-cell disease. Economically, out-of-pocket spending pushes tens of millions into poverty each year. On gender, women face restricted access, especially in marginalised groups. And the digital divide gives urban, connected patients better access to new digital-health tools.

The regional skews are the starkest exam facts. Kerala, Maharashtra and Tamil Nadu have maternal mortality ratios below 50 per lakh; Assam, Madhya Pradesh, Uttar Pradesh and Rajasthan sit above 150. NFHS-6 shows a widening urban-rural gap in lifestyle diseases: 42.8% of urban women are overweight or obese against 25.5% in rural areas, the sign of a dual disease burden, with infectious diseases retreating and NCDs rising to about two-thirds of deaths. Proven state models show equity is a design choice: Kerala's Family Health Centres, Delhi's Mohalla Clinics, Telangana's Basthi Dawakhanas for the urban poor, and the Tamil Nadu Medical Services Corporation's procurement system.

The health report card: what the data says

The latest National Family Health Survey (NFHS-6, 2023-24, released in 2025, covering 6.79 lakh households) tells a two-track story. On one track, clear progress: full immunisation coverage rose, antenatal visits reached 95.9%, and stunting in children fell from 35.5% to 29.3%. On the other, a new emergency: 30.7% of women and 27.3% of men are overweight or obese, and blood sugar and blood pressure levels keep climbing. India is on track for several SDG-3 targets, with MMR down 86% since 1990, IMR falling from 40 (2013) to 25 (2023), and TB incidence down 21% between 2015 and 2024, but nutrition and NCDs remain the lagging frontiers.

The digital-health backbone: ABDM and ABHA

ABDM is the Ayushman Bharat Digital Mission (2021), the national digital-health architecture run through the National Health Authority under the Ministry of Health and Family Welfare. Its building blocks are ABHA, the Ayushman Bharat Health Account, a 14-digit ID that lets a patient hold and share health records digitally; the Health Facility Registry and Healthcare Professionals Registry, which give every hospital and practitioner a verifiable digital identity; and a consent-based framework for sharing records between providers. It matters because portable records are what let a patient move between the primary, secondary and tertiary tiers this article describes without starting every diagnosis from zero. The caution, developed in the equity section above, is the digital divide: a digital backbone only helps those with connectivity and digital literacy. (sj-15 covers the programme layer built on this architecture.)

Who trains the doctors: the NMC Act, 2019

The National Medical Commission Act, 2019 replaced the Medical Council of India with the National Medical Commission as the regulator of medical education and the profession. It created a four-board structure for undergraduate, postgraduate, ethics and assessment functions; introduced NEXT, a single national exit-cum-licensing examination; and gave the Commission powers to regulate fees in private medical colleges. It matters to the health system because the doctor pipeline, its numbers, quality and distribution, is what every tier of the system runs on; governance of medical education is therefore health-system governance, not just education policy.

Where this article stops

Three items get only a passing mention here because they have their own articles. Ayushman Bharat PM-JAY (launched 2018, Rs 5 lakh per family per year for secondary and tertiary care for the poorest 40% of families) and the National Health Mission are covered in sj-15 on health interventions. Mental health, including the treatment gap and the policy response, belongs to sj-16.

Euthanasia: the right to die with dignity

Euthanasia, also known as mercy killing, refers to the intentional termination of life to relieve suffering in terminally ill patients.

Indian law draws a sharp line between its two forms. Active euthanasia means a direct intervention, such as a lethal injection, to end life, and it is not legal in India. Passive euthanasia means withholding or withdrawing life-sustaining treatment so that the patient dies naturally, and it is permitted under strict conditions.

The jurisprudence is judge-made, built case by case under Article 21. In Aruna Shanbaug (2011) the Supreme Court first recognised passive euthanasia. In Common Cause (2018) a Constitution Bench held that the right to die with dignity is part of the right to life, and validated living wills (advance medical directives). In 2023 the Court eased the procedure: attestation by a notary or gazetted officer instead of a judicial magistrate, with decisions overseen by a Primary Medical Board and a Secondary Medical Board, each of at least three physicians.

The framework got its first real-world application in 2026. In Harish Rana v. Union of India, decided on March 11, 2026, the Supreme Court permitted the withdrawal of life-sustaining treatment, including clinically assisted nutrition and hydration through a feeding tube, for a man who had spent over thirteen years in a permanent vegetative state after a 2013 accident. He passed away on March 24, 2026. The judgment is the first time the Court has directly authorised passive euthanasia in an individual case, and it has reopened the national conversation on end-of-life care. States are catching up: on January 30, 2025, Karnataka became the second state after Kerala to issue a formal order implementing the Supreme Court's directive on dignified death for the terminally ill.

The Health Ministry's draft guidelines now seek to define terminal illness, standardise withdrawal protocols and mandate hospital ethics committees, so that autonomy at the end of life is protected without opening the door to misuse.

Health financing at a glance: the National Health Accounts

The National Health Accounts (NHA) estimates, released annually by the Ministry of Health and Family Welfare since 2013-14 and prepared by the National Health Accounts Technical Secretariat, track where health money comes from and where it goes. Built on the System of Health Accounts 2011, the global standard of the OECD, WHO and Eurostat, the NHA is the single authoritative picture of health financing in India.

The headline is the fall in out-of-pocket expenditure: from nearly half of all health spending in 2017-18 to 39.4 percent in 2021-22, as the government's share rose to 48 percent. The gap to the NHP 2017 target of 2.5 percent of GDP in public spending, however, remains wide.

The last-mile workforce: ASHAs

At the bottom of the pyramid stand the ASHAs (Accredited Social Health Activists): female community health volunteers introduced under the National Rural Health Mission in 2005. Usually women aged 25-45 drawn from the same community, they number around 10.4 lakh, and the WHO recognised them as Global Health Leaders for their grassroots role during the COVID-19 pandemic.

• Acting as the link between the community and primary health services.
• Motivating families toward institutional deliveries, immunisation and family planning.
• Conducting home visits, assisting maternal and child care, and promoting hygiene.
• Facilitating access to nutrition, TB treatment and non-communicable disease care.

Their working conditions are the weak link. ASHAs depend on incentive-based payments rather than a fixed salary, face community stigma and infection risk, and enjoy limited legal and institutional protection. Reform proposals converge on four fixes: formal recognition with timely financial and non-financial incentives, clear service guidelines and digital-health training, institutional safeguards against gender, caste and class vulnerabilities, and protection from harassment.

Patient safety: the first global charter

Patient safety is the prevention of avoidable errors and harm during healthcare; it is essential for quality and public trust.

In April 2024 the WHO launched the first-ever Patient Safety Rights Charter at the Global Ministerial Summit on Patient Safety: the first international framework to define patients' rights in the specific context of safety. The trigger was scale: roughly one in ten patients is affected by unsafe care, with about three million preventable deaths a year (WHO, 2023). The Charter helps governments and institutions write laws, policies and protocols that make harm visible and dignity non-negotiable, and it feeds directly into SDG 3 on good health and well-being.

Global rules: the 2024 amendments to the International Health Regulations

The International Health Regulations (2005), successor to the International Sanitary Regulations of 1951, are a legally binding instrument setting out the rights and obligations of all 194 WHO Member States in managing public-health events that can cross borders. At the 77th World Health Assembly, member states adopted amendments to strengthen pandemic preparedness.

• Pandemic emergency defined: a communicable disease with wide geographical spread, or with high potential to overwhelm national health systems.
• Coordinating financial mechanism: a dedicated fund for the health priorities of developing countries, pushing equity into crisis response.
• States Parties Committee: a new committee to oversee implementation, assess compliance, and facilitate collaboration and dispute resolution.
• National IHR Authority: each member state must designate a real-time focal point for coordination with WHO during health emergencies.

India's digital health stack at a glance

The Ayushman Bharat Digital Mission builds the rails: a unique ABHA health ID for every citizen, longitudinal digital records and interoperability across providers. Around it sits a wider stack of public platforms.

The constraints are familiar: the digital divide can exclude the unconnected, data-protection and cybersecurity frameworks are still catching up, the system needs skilled digital manpower, and state and central systems must be made interoperable.

Key Terms

• replaced the Medical Council of India with the National Medical Commission: The National Medical Commission (NMC) is India's apex medical-education regulator, created by the NMC Act, 2019 to replace the Medical Council of India. It sets standards for medical education, recognizes institutions, maintains the national register of doctors, and regulates professional conduct, with state medical councils working under its framework. UPSC GS-2: governance and regulation of health education. The NMC Act received Presidential assent in August 2019.
• Health Facility Registry and Healthcare Professionals Registry: The Health Facility Registry and Healthcare Professionals Registry are two foundational registries of the Ayushman Bharat Digital Mission. The HFR is a verified national repository of hospitals, clinics, laboratories, and pharmacies, while the HPR registers doctors, nurses, and paramedics with unique IDs. Together they enable trusted discovery of providers for digital health records and insurance claims. For UPSC they illustrate digital health governance. A hospital must be HFR-registered to raise ABDM-linked insurance claims.
• Ministry of Health and Family Welfare: The Ministry of Health and Family Welfare is the Union ministry responsible for public health policy, disease control, and family welfare programmes. It runs flagship schemes on immunization, maternal health, and health insurance. For UPSC, it is the nodal ministry for health-related current affairs. It implements Ayushman Bharat PM-JAY, the world's largest health insurance scheme.
• National Medical Commission Act, 2019: The National Medical Commission Act, 2019 is the law that replaced the Medical Council of India with the National Medical Commission. It provides for a 33-member commission, four autonomous boards, a common final-year MBBS examination as a licentiate test, and limited-license community health providers. For UPSC, it is cited in debates on centralisation, since medical education was earlier overseen by an elected council with strong state representation. The Act's provision for community health providers drew sustained protests from the Indian Medical Association.
• WHO Global Health Leaders Award: The WHO Director-General's Global Health Leaders Award recognises outstanding contributions to advancing global health, leadership and commitment to regional health issues. Announced at the World Health Assembly, it honours individuals and groups rather than member states. For UPSC, it signals global recognition of public health work. India's one million ASHA workers received the 2022 award for linking rural communities to primary healthcare during COVID-19.
• National Rural Health Mission: The National Rural Health Mission was launched in 2005 to provide accessible and affordable health care to rural India, and was subsumed in 2013 as the rural arm of the National Health Mission. Its architecture rests on ASHA community health workers, Rogi Kalyan Samitis for hospital accountability, and Janani Suraksha Yojana for institutional deliveries. For UPSC, it is the standard case study of flagship scheme design and federal implementation through state health missions. Over ten lakh ASHA workers remain the Mission's most visible grassroots legacy.
• Health and Wellness Centres: Health and Wellness Centres are the primary-care arm of Ayushman Bharat, upgrading sub-centres and primary health centres to deliver comprehensive care including NCD screening, maternal and child health, and free diagnostics. The 2018 target was 1,50,000 centres, renamed Ayushman Arogya Mandirs in 2023. For UPSC they illustrate the shift from selective to comprehensive primary healthcare. Mains answers cite them as the backbone of preventive care. HWCs conduct population-wide screening for diabetes and hypertension under the national NCD programme.
• Scheduled Castes and Tribes: Scheduled Castes and Tribes is the collective shorthand for the two constitutionally protected groups notified under Articles 341 and 342: castes historically facing untouchability, and tribes with distinct culture and habitat. Together they anchor India's affirmative action architecture, reservation in legislatures and public employment, and safeguards like the SC/ST (Prevention of Atrocities) Act. The National Commissions for SCs and STs monitor constitutional safeguards for both groups.
• International Health Regulations: A legally binding instrument for all 194 WHO Member States on managing cross-border public-health events; amended at the 77th World Health Assembly (2024) with a pandemic-emergency definition, a coordinating financial mechanism, a States Parties Committee and National IHR Authorities.
• Community Health Officers: Community Health Officers are mid-level health providers who lead Ayushman Arogya Mandirs, the upgraded Health and Wellness Centres. Drawn from BSc Community Health graduates or nurses and AYUSH practitioners given a bridge course, they deliver expanded primary care including screening for non-communicable diseases, maternal care, and teleconsultation. They embody the shift from selective to comprehensive primary health care. A CHO screens adults over 30 for hypertension and diabetes during village outreach.
• National Medical Register: Centralised electronic database of all allopathic (MBBS) doctors, developed by the National Medical Commission under Section 31 of the NMC Act, 2019.
• Universal Health Coverage: Universal Health Coverage refers to ensuring that all individuals receive essential health services, ranging from health promotion to palliative care, without facing financial hardship. As per the WHO, it rests on equity, access and financial protection, and is a core goal under SDG 3.8. In India the right to health is read into Article 21, while Article 47 directs the state to improve public health.

Practice questions