HEALTH CARE SERVICES IN INDIA

Dr. Amar Jesani

Coordinator, Centre for studies in Ethics and Rights, Mumbai

Introduction:
India’s health care service system is very complex. This is compounded by inadequacy of
reliable and consistent data on services, particularly on the services provided by the private
sector. Indeed, till mid-1980s, there had been scanty attention paid to documenting
information on the private sector. While the work done in creating databases in the last one
decade has been commendable, it is still not sufficient to give a full picture of the volume of
the formal and the informal private sector in health care. This deficiency in turn makes it
difficult to get a full picture of the total health care services, their sectoral distribution,
problems therein and the kind of inter-sectoral cooperation and reforms needed to serve the
second largest population of the world.

Public and Private Sectors:

The health care sector in India primarily comprises of public and private sectors. The public
sector comprises of service provided by the Union Ministry of Health and Family Welfare
(MOH-FW); the State Ministries of Health and Family Welfare, local government bodies
(district panchayats, municipalities, municipal corporations), the public sector undertakings,
the armed forces, the Employees State Insurance Scheme and so on. The services provided by
the MOH-FW of the union and state governments are normally integrated in the sense that
curative, preventive and promotive health care are combined, although the urban curative
public health care still account for a big proportion of services.

The services in the private health sector are provided by individual private general
practitioners, consultants and their consulting rooms and polyclinics, small hospitals called
nursing homes, big hospitals and so on. The individual private health care institutions are
owned by individuals, partnerships, trusts and societies, religious institutions, private and
public limited companies and corporate sector. The NGOs (trusts and societies) have a strong
presence in the institutional health care, but most of them run services on fee for service basis,
and although they are technically non-profit (under Indian laws, trusts and societies are not
allowed to have private appropriation of profit or surplus), the services are run like any other
normal for-profit private establishments. However, there are exceptions, some of the NGO
private services are purely for philanthropy while others are modern classical NGOs run with
external funding support. The health care in private sector is almost exclusively curative,
except for those NGOs that are involved in community health care and other such activities.

The data on public sector are better organised, reliable and accessible than on the private
sector. However, the available data point to the dominance of private sector in health care
services. As more reliable information on private sector is generated, the present trends
suggest that the degree of private sector dominance would become more visible.

Policy and Legal Framework of the System:

Amar Jesani, Health services in India 2
The serious national effort at building health care system for the country started only after
independence. Two documents, the Bhore Committee Report (1946) and Planning Committee
Report (1948) prepared by two separate committees provided inputs into the policy on health
care inaugurated in the First Five Year Plan (1952) period. The Bhore Committee in particular
had recommended a long-term plan for provision of comprehensive health care for all, with
universal access as the guiding principle. It indeed suggested that basic comprehensive care
should be made accessible to all irrespective of their capacity to pay. It also recommended
creation of a comprehensive legal framework for health care delivery, medical practice and
public health.

51 years after independence India has a huge and expanding health care sector, but it lacks a
comprehensive policy and legal framework, thus making it difficult to call it a national system
of health care services.

The First Five-Year Plan provided the first policy statement on health care. The direct state
intervention in order to provide comprehensive health care to all people was accepted as the
basic policy. For the rural areas, the government started establishing Primary Health Centre
infrastructure with referral hospitals at the district level. In the urban areas, chains of
dispensaries and hospitals were established by the state governments and by local government
bodies. However, this provision of health care has not been codified in a comprehensive
law(s). As a consequence, over the years, the priority health areas, method of provision of care
and the organisational structures for health care delivery in the public sector have undergone
frequent changes. Besides, while the creation of service is accepted as a responsibility by the
state; in the absence of translating the policies into law, the adequacy or quantum of services,
and the quality and the universality of coverage have remained out of reach of people’s
action..

Part II and Part IV of the Indian Constitution contain the Fundamental Rights and the
Directive Principles of State Policies respectively. Article 13 in Part III of the Constitution
establishes the paramount authority of the constitution with regard to fundamental rights. The
fundamental rights are not only justiciable rights but are also non-violable by any law ever
made in the country by any authority. The right to health or to basic health care is not
included as a part of fundamental rights. Part IV of the constitution- the Directive Principles-
on the other hand, are not enforceable by any court of law. Health and public health are part
of the directive principles. However, they are stipulated, as fundamental to the governance of
the country and it shall be the duty of the state to apply these principles in making laws. Thus,
they do not have the character of being justiciable, though they do provide certain positive
features. Any legislation made to implement the directive principles would in all probability be
upheld by the courts. Not only that, the parliament can, if it wishes, and without altering the
basic structure of the constitution, legislate any of the provisions in the directive principles to
make it a fundamental right by amending the constitution. Legal experts even argue that when
necessary, even constitutional provisions related to the fundamental rights should be adjusted
in their ambit so as to give effect to the directive principles. There have been some efforts
made by the judiciary to read directive principles along with the fundamental right to life, to
make provision of certain health care mandatory by the state. However, this activism is still
limited and it appears that only a separate legislation can make right to basic minimum health
care a right for people.
Amar Jesani, Health services in India 3
Only limited legislation are enacted in the field of health. Even basic regulatory provisions
such as registration and licensing are not in place. For instance, while there are three
legislations for registration and licensing of medical practitioners (one each for modern, Indian
system and homeopathic medical practitioners), no such national legislation exists for
hospitals. Though hospitals are considered part of the constitutional list for state governments
to legislate, only a few state governments have passed even simple hospital registration laws.
As a consequence, there is hardly any regulation over hospitals in many states.

Traditional and Modern Sectors:

India has a very old traditional system of medical science called Ayurveda. In addition, the
Unani and Homeopathy systems have also been indigenised. However, for over a decade now,
there have been efforts to modernise the indigenous or traditional systems of medicine. During
the independence movement, some nationalist leaders also took keen interest in establishing
formal institutions for training of doctors in these systems. In 1940 the Chopra Committee
was established to examine the indigenous systems and to make recommendations for
integrating various systems of medicine. It submitted its report in 1948. The Chopra
Committee saw an urgent necessity for evolving one unified system. It also drew up a plan for
health services where the primary levels would mostly use the indigenous system and the
secondary and tertiary levels would offer “synthesised” medicine. These recommendations
however, were not paid serious consideration, and were not implemented.

The modernisation of traditional system began with the attempts to establish medical training
colleges for these systems and by enacting separate registration laws for doctors qualified in
these systems. Thus, at present India has three medical councils, one each for Modern
medicine, Indian systems of medicine (ayurveda, unani and siddha) and Homeopathy. Of all
formally qualified and registered doctors in India, nearly three fifth are from the non-modern
systems of medicine

However, as is well known, a large number of practitioners of non-modern systems of

medicine practice modern medicine. Our estimates suggest that about one third of doctors
employed at the government’s Primary Health Centres (PHCs) in India are from the non-
modern systems. But apparently they do not have adequate scope to practice their systems due
to demand for modern medicine by patients or due to inadequate supply of their drugs. The
Supreme Court has recently ruled that such cross medical practice is in violation of medical
council laws and that it amounts to medical negligence. This ruling has already created ripples
in the medical profession because it has a potential to prevent non-modern system doctors who
are better located in rural areas from practicing modern medicine, a service demanded by the
mass of people in India.

The data on non-modern system clinics, dispensaries, hospitals and hospital beds are not
available. As a result, it is difficult to draw an overall picture of availability and access to non-
modern system institutional services in India.

Some village level micro studies-a majority of them are qualitative studies- show that due to
difficult access to modern and institutional services, a vast majority of rural population uses
non-modern health care. However, the household level health surveys conducted at the
national and district levels do not show such high utilisation of the non-modern health care.
Amar Jesani, Health services in India 4
What is better documented, though, is the fact that there is a plethora of non-qualified village
level traditional healers. In a recent survey in Surat District of Gujarat state by the Centre for
Social Studies (1998), 59 traditional healers in 27 villages were found practicing traditional
medicine that included herbal medication as well as faith healing. This appears to be true in
most parts of rural India. In most of villages in India, it is usual to find non-qualified, mostly
non-full-time traditional health practitioners. These are primarily folk healers who do not
practice classical ayurveda and therefore are not counted in the Census as well as other
surveys. Another set of such practitioners is traditional birth attendants known as dais. The
Government of India has a systematic dai training programme, started in mid-1970s. The basic
idea behind the training is that since they attend to a large proportion of childbirths in the
country, their training for observing basic hygienic practices at the childbirth would help in the
safe motherhood programmes. By March 31, 1993, the government had trained 6,09,506 dais
practicing in rural India. Five states, which have trained highest number of dais, are Uttar
Pradesh (1,45,271), Bihar (56,029), Karnataka (44,941), Andhra Pradesh (44,825) and
Madhya Pradesh (43,395). However, the dais are not integrated into the public health human
resource pool. A provision has been made to supply delivery kits to trained dais and the PHCs
are supposed to make a token payment for each delivery conducted by dais. Thus, the support
provided to trained dais is dependent on the efficiency of the PHC infrastructure in different
areas. Since most of the data on maternal mortality are based on estimates, the effect produced
by the training of dais is still not properly evaluated.

Health care human power - Doctors:

Training of Doctors:
The growth in the numbers of physicians has been reasonably high in India. There are about
368 colleges giving medical training in different systems of medicine. Only 146 or 40% of
them are for training of the doctors of modern medicine.65% of the non-modern and 30 % of
the modern system medical colleges are in the private sector. Although there has been
extensive debate on the quality of medical education and the adverse effects of high-cost and
capitation fees in the private sector modern medicine colleges, the private sector non-modern
medicine colleges have not yet been evaluated or discussed. By 1994, 23000 medical
graduates were qualifying as medical practitioners every year, 35% of them being non-
modern. We feel that these data are under estimations for the simple reason that there are more
colleges in the non-modern sector.

Gender in training of doctors:

The data on women undergoing medical training are available only for the modern system. At
the undergraduate level, there has been a steady increase in the proportion of women taking
medical graduation. Between 1971 and 1993, the proportion of women medical graduates
increased from 27% to 39.6%, thus giving an impression that a gradual feminisation of
medical profession is in progress. However, this statement needs to be qualified. There are
studies on women in science showing that many of those who obtain qualification, do not
participate in work, and indeed, many of the women doctors do not practice or practice as
junior partner of their doctor husbands. Unfortunately no good study of women doctors in
India has ever been done, and so this observation cannot be supported by hard data. However,
the trend in the choice of post-graduation medical specialisation by women suggest that
women medical graduate seem to be choosing subordinate specialties, the only exception
being the basic specialty of Obstetrics and Gynaecology.
Amar Jesani, Health services in India 5
Doctors- Number and Distribution
India has made great progress in training doctors. In 1992, 9,49,722 doctors
registered with the three licensing bodies or medical councils. While modern
medicine doctors constitute the single largest category (43.3%), their proportion
in total number of medical practioners has remained almost unchanged for over
a decade. Amongst non-modern doctors, the ayurvedic doctors constitute 35.7%
and homeopathic 16%. If we add to this the 22,838 doctors trained every year
for the subsequent five years (total 1,14,190), we come to a rough estimate of
10,63,912 doctors in 1997.

At 1991 population, India had one doctor of all systems of medicine for 889 persons. As
expected, this ratio is the best for the modern system doctors (per 2,054 persons), followed by
ayurvedic (per 2,488 persons) and homeopathic (per 5,544 persons) doctors. It is interesting to
note that most of the official international and national documents normally mention doctor-
population ratio for the modern system doctors, thus ignoring the presence of non-modern
system doctors. This is not acceptable as qualified and registered non-modern system doctors
account for the majority of practicing doctors in the country.

Lastly, it must also be recognised that despite medical council laws for registration and
licensing, India has a sizeable number of non-qualified and non-licensed medical practitioners.
These non-qualified doctors are not same as the traditional and folk practitioners. For they
have opened their clinics or dispensaries like any regular doctor and they practice
predominantly modern medicine. They are either ex-compounders or para-medical health
workers, or individuals who have just learnt medicine from others or by obtaining some
certificate from an unrecognised institution. It is estimated that their number is anything from
10% to 50% of all doctors in India.

Distribution of Doctors:
The only good data on urban/rural sectoral distribution of doctors are available from the
Census. Hard data on private and public sector are not available, thus necessitating compilation
from various sources and estimations.

Rural-Urban: Data show that the modern system doctors are located more in urban areas,
while homeopathic and ayurvedic doctors are more in rural areas. This is yet another reason
why one needs to take cognisance of non-modern doctors both in the data system and in
understanding the kind of services available to the rural population in India. Overall, the trend
across three Censuses (1961, 1971 and 1981) show that, doctors are generally locating their
practices more in urban areas than in rural areas. The proportion of rurally located doctors in
India has come down from 49.6% in 1961 Census to 41.2% of all doctors counted by 1981
Census.

The hard data on population per doctor at present are not available. However, a rough
estimation is possible by assuming that the 1991 Census would find the similar rural urban
distribution of doctors as was found in 1981 Census. With that, we find that at 1991
population, we had one doctor for 889 persons in the country, the ratio for urban areas was
387 persons while for rural areas it was 1,611 persons. While this ratio is for all doctors, it is
abysmally low when we take only PHC doctors for the rural population. At 21,854 PHCs in
Amar Jesani, Health services in India 6
rural India, there were 23,490 doctors appointed in 1996. This defines a ratio of 1.12 doctors
for one PHC, and one PHC doctor for 24,938 rural persons.

Clearly, while India has a fairly good number of doctors, their skewed distribution make them
physically inaccessible to the rural masses while the urban people enjoy physical access as
good as in any developed country (the ratio of one urban doctor for 387 urban persons).
Besides, when all rural doctors are considered, we have a ratio of 1,611, but for the PHC
doctors it is 24,938. This testifies to the extent of underdevelopment of government rural
health care in India.

Public-Private: The data on public and private sector distribution are primarily based on
various estimates. It appears that only one fourth of all modern medicine doctors are employed
in public sector in India. If we take their number in comparison to all doctors, it appears that
not more than 15% of all doctors are working in the public sector. This indeed gets reflected in
the doctor population ratios. According to our estimates, there is one private doctor for 1,048
persons while the ratio for government doctor is as low as one per 5.924 persons.

Health care human power- Nurses

Numbers of nurses:
The poor status of nursing in India is reflected in their numbers. India has the distinction of
having less nurses than medical practitioners! In 1993, there were only 6,74,946 nurses of
various categories as compared to 9,49,722 doctors of various systems. This defines a nurse
doctor ratio of 1:1.4.

Of all registered nurses in 1993, two third (66.6%) were General Nurse/Midwife, 30.1% were
Auxiliary Nurse Midwife (ANM) and 3.3% were health visitors. However, the Institute of
Applied Manpower Research (IAMR) seems to consider the registration figures of General
Nurse/midwife, an over-estimation. According to the IAMR, in 1996 India had 5,06,900
Nurses, and of them, only 2,31,800 were General Nurse/Midwife. For 1993, the IAMR
estimate was at 4,32,800 for all nurses and only 2,02,600 for General Nurse/Midwife. Thus, on
taking 1993 figures for comparison, the IAMR estimate for all nurses is low by 35.% of the
CBHI data on the registered nurses! It is difficult to make a comment on this because we do
not know the basis on which the IAMR has made low estimate of nurses. However, we suspect
that it is perhaps based on the data they might have on out-migration of nurses and on the
nurses not in practice. Given the wide difference between the CBHI and IAMR (both being
government agencies) data, it is obvious that the shortfall in number of nurses is much higher
than what the CBHI data reveal.

How does the burgeoning private hospital sector in India cope with the serious shortfall in the
total number of nurses? Clearly, this is done by employing a large mass of non-qualified
women as nurses in hospitals and nursing homes. Does the shortage of nurses increase market
demand for nurses and therefore, their status? Clearly, the market for women’s work does not
seem to confirm the predictions and assumptions made by neo-classical economics. Despite
shortfall in their number, the price of their labour has not increased. As a result of this a
significant number of them are out-migrating. Besides, the non-qualified, non-registered
women used as substitute for the nurses have kept the wages of nurses very low in private
sector. The impunity with which the private hospitals are allowed to employ non-qualified
nurses has only lowered the importance of nursing training and the economic status of nurses
Amar Jesani, Health services in India 7
in general. This economics of nursing has only helped in reinforcing the negative social
stereotype of nursing India, and made nursing a less important health profession.

Also, nursing is almost exclusively a women’s profession in India. While only 4.2% of all
General nurse/midwife are males, as a policy the government does not allow males to train as
Auxiliary Nurse Midwife. Besides, in the government primary health centres, the ANM or
Women Health Worker are at the same level as Male Health Workers and their job description
match except that the Male Health Workers do not have responsibility to undertake work of
childbirth. Yet, the ANMs are registered with the nursing council, but the male workers work
without registration with any professional of para-professional body.

The status of nursing vis-à-vis medical profession in India also demand attention. The
autonomy of the nursing profession is still not fully established. Present structure of the
nursing councils suggests that there is still heavy dominance of doctors. Besides, the nursing
council has done very little, either as a campaign or as advocacy for policy change to bring the
vast number non-registered nurses under any regulatory umbrella or provide them protection
from exploitation.

Distribution of Nurses
Unlike doctors who could do independent private general practice, most of the nurses are
dependent on the existence of health care institutions for locating their work. The data from
1961, 1971 and 1981 Census show that nurses are also progressively locating their work more
in urban areas than rural areas - 43.1% in 1981, compared to 47.5% in 1961 and 39.3% in
1971

The rural urban distribution of nurses is more pronounced when General nurse/midwife
category is examined. In 1981 only 31.3% of them were located in rural areas as compared to
38.2% of them in 1961. Only in case of ANMs and health visitors, the rural location is found
to be better, though declining. In 1961, 66.4% and in 1981 only 59.9% of them were in rural
areas. All other health workers, though showing better rural location, the trend observed in
these three Censuses is the same - that fewer of them are being absorbed in rural health care
sector.

Since the location of these health workers is determined by the location of health care
institutions, the chief reason for the trend observed among them could be slow expansion of
government rural health care infrastructure and fast expansion of private sector.

Unfortunately no hard data on public and private sector distribution of nurses are available.
However, general observation is that the government health care services invariably employ
registered nurses, and given the acute shortfall of nurses in India, a very sizeable number of
them are employed in government sector. As mentioned earlier, in the private sector a
significant number of nurses employed are unqualified or inadequately qualified and non-
registered. There are not many studies of qualification of nurses in the private hospital sector.
However, a district level sample survey of hospitals in Maharashtra found that in 49 private
hospitals and nursing homes surveyed, there were 88 nurses employed, and of them only 3
were qualified and registered.

Structure of health care services :

Amar Jesani, Health services in India 8

Primary Health Centres, Sub-centres and Community Health Centres

The health care services are provided by a network of Primary Health Centres (PHCs) of the
government in rural areas, by hospitals and dispensaries in government as well as private
health sectors. The population coverage norm for PHCs is 30,000 rural population (20,000 for
tribal and hilly areas), and each PHC has sub-centres covering 5,000 population. Normally, the
PHCs are supposed to have at least two generalist doctors. Sub-centres are run by the ANMs
(Female Health Workers) and Male Health Workers. Referral support to the PHCs is provided
by the 30 bedded Community Health Centres (CHC) and the district level civil hospitals.

Numbers
The establishment of PHCs, started with the beginning of the First Five Year plan period
(1952), has been slow, and thus, does not guarantee adequate physical access to the rural
people. Between 1952 and 1983, 5,954 PHCs were established (about 200 PHCs per year).
Thus, in 1983, there was only 1 PHC for 88,000 rural population. However, thereafter the
population coverage norm for the PHC was revised to 30,000, and so mid-1980s witnessed
some expansion of the PHC network.

In 1996 there were 21,854 PHCs established in rural India, covering on an average 28,768
rural population per PHC. However, in 1993, only 23,490 doctors were employed at the PHCs.
Thus, there was, on an average only 1.12 doctors available per PHC and the rural population
per PHC doctor was 24,838. This ratio is very poor as compared to the availability of one
doctor for 889 people at national level and one rural doctor for 1,611 rural population. Thus,
even in terms of numbers, the public health care infrastructure created by the government is
still highly underdeveloped.

The averages also hide some skewed distribution of the PHCs. In at least eight major states the
PHCs still cover more than 30,000 population/centre. These states include bigger states like
Uttar Pradesh, Bihar, Madhya Pradesh, Andhra Pradesh and West Bengal.

In 1996 there were 1,32,730 sub-centres, or one sub-centre for 4,737 rural population. While
the national average shows that the sub-centre is covering the population as per the
government norms, the very fact that some major states like Uttar Pradesh, Bihar, Andhra
Pradesh and West Bengal are still having less number of sub-centres than required.

As per government norms, there should be one CHC for three PHCs, or one CHC for 90,000
to 100,000 people. However, in 1996, there were only 2,424 CHCs, defining an average
population coverage of about 2,60,000 people. Thus, the rural referral support institutions are
developed inadequately. In this case, too, some major states like Uttar Pradesh, Bihar, Madhya
Pradesh, Tamil Nadu, Andhra Pradesh, West Bengal etc. are lagging far behind the national
norms.

Clearly, in terms of establishing the public rural health care institutions, the smaller states like
Mizoram, Meghalaya, Sikkim, Arunachal Pradesh, Manipur, Kerala etc have performed better
than the bigger states. While rich and developed states like Gujarat and Maharashtra have
performed only average.

Condition and resources for the PHCs, sub-centres and CHCs

Amar Jesani, Health services in India 9
An evaluation of the quality of family welfare services provided by 298 PHCs in 199 districts in
18 states and one union territory, by the Indian Council of Medical Research (ICMR, 1991)
revealed that only 12% of the PHCs (mostly in Maharashtra), fulfilled the required population
coverage norm of 30,000. The study observed a substantial shortage of Auxiliary Nurse
Midwives (ANMs), unavailability of oxygen (in approximately 40% of the PHCs) and
supportive drugs in emergencies (in 30% of PHCs), inadequate stocks of antibiotics (in 60% of
the PHCs), a total absence of records (in one-third of the PHCs) and an absence of a labour room
and an operation theatre (in one-fourth to one-fifth of the PHCs). Wherever they existed, they
were poorly equipped and managed. What is interesting is that a majority of the PHCs were
lacking in functional equipment and/or trained manpower to carry out pregnancy termination
even after two decades of the Act.

It is now widely accepted that for medical care, the PHCs cater to only few villages covered by
them, the rest are required to be served by the sub-centres which do not have doctors. Many of
the doctors appointed at the PHCs do not stay there. The PHCs are also starved of basic
resources. In a study of drug supply to nine PHCs and 3 CHCs in a district in Maharashtra, a
high level of inadequacy in drugs was found. Out of 149 drugs used by the PHCs, there was not
a single drug available on all days, 4 were available on 76 to 99% of days in a year, 10 on 51 to
75% of days, 45 on 25 to 49% of days, 81 on 1 to 24% of days and 9 were unavailable
throughout the year. Similarly, of the 159 drugs used by the CHCs, only 2 were available
throughout the year, 18 on 76 to 99% of days in a year, 26 on 51 to 75% of days, 60 on 25 to
49% of days, 51 on 1 to 24% of days and 2 were unavailable throughout the year. (Phadke et el,
1995)

The sub-centres are in worse shape than the PHCs. It is well known that most of them do not
have buildings to house them. In a study conducted in four districts of Maharashtra, covering
149 sub-centres under 27 PHCs, it was found that only 23.6% of sub-centres had specially
constructed buildings, 46.4% were run from rented room or from other government premises,
14.3% were run from the ANMs residence and 15.7% had no space for the sub-centres (Iyer and
Jesani, 1995) Indeed, the situation is even worse in underdeveloped states.

Hospitals and hospital beds

As explained earlier, since the basic hospital registration laws are not in place in most of the
states, the data on private hospital and hospital beds are gross under-estimations. Since private
sector has experienced very high growth, its under-estimation brings down substantially the
overall data on hospitals and hospital beds in the country. We have therefore analysed the
official data, and then tried to make our own estimation to understand the situation.

As per official data, in 1993 there were 13,692 hospitals and 5,96,203 hospital beds in the
country. These defined a ratio of one hospital for 61,637 persons and one hospital bed for
1,416 persons. Of them only 31.5% of hospitals and 20.5% of hospital beds were located in
rural areas. Thus, for 1,45,510 persons in rural area, there was one rural hospital while one
hospital was available for 23,106 persons in urban area. A similar situation existed for hospital
beds too - as one hospital bed was available for 5,136 rural persons and for 457 urban persons.
Indeed, the rural urban disparity for hospital and hospital beds has been the sharpest. The
official data still show dominance of public sector in hospitals and particularly in hospital
beds. In 1993, 33.4% of hospitals and 64.6% of hospital beds were in public sector. The
proportion in number of public hospitals is smaller because the average size of the public
Amar Jesani, Health services in India 10
hospitals is much bigger than the private hospitals. Thus, despite less number of hospitals
being in the public sector, the proportion of beds in them is much higher.

In the official data, the distribution of hospitals and hospital beds across states in India show
almost similar pattern as PHCs. Most of the bigger and underdeveloped states have very large
populations per hospital and per hospital bed. Interestingly, only 11 states have a better
population per hospital and hospital beds ratio for rural areas than the national average. On the
other hand, 17 states have better population per hospital bed ratio for urban areas than the
national average. The rural-urban gap in the bed population ratio is uneven across the states.
The least rural urban gap in bed population ratio is in Kerala (twice), Punjab (thrice), among
major states and in Goa (four times), Manipur (twice), and Mizoram (five time) among smaller
states. The largest gap is in Bihar (76 times), Jammu and Kashmir (73 times), Haryana (40
times), Rajasthan (37 times), Himachal Pradesh (55 times) and Meghalaya (115 times)
(Duggal, Nandraj, Vadair, 1995)

There is an interesting pattern emerging when one examines the distribution of public and
private hospitals and hospital beds across states. 15 states of India have a better population per
public hospital ratio than the national average. Most of such states are smaller states and
developed states like Maharashtra, Gujarat, Punjab etc. However, Only five states (Goa,
Kerala, Gujarat, Maharashtra and Andhra Pradesh) show better population per hospital ratio
than the national average. Of these states, Goa and Kerala are smaller states, while Gujarat and
Maharashtra are bigger and developed states. Andhra Pradesh, a bigger but underdeveloped
state, appears here due to better reporting (about that later) of data on private hospital sector.
Same pattern is observed with hospital beds. 19 states have better ratio than national average
for public hospital beds while only 7 show such better ratio for private hospital beds. In the
latter, in addition to the above five states, two other smaller states, Mizoram and Meghalaya
are listed.

Growth of Hospitals and Hospital beds

The growth of public and private hospitals and beds from 1973 to 1993 was compiled and
calculated. The data used for calculation are official figures obtained from the Central Bureau
of Health Intelligence documents for various years.

Clearly, there has been comparatively very high annual growth of private hospitals and beds in
the two decades. In fact, the growth in public hospital is very poor since 1979, and declining.
Interestingly, while public hospital beds increased by 3.3% per year in the period 1984-88,
there has been a negative growth of 1.2% per year for the period 1988-93. This negative
growth is the most perplexing, for in the five year period of 1988-93, 1.2% of beds have
disappeared from the public sector. This negative growth only gives credence to the claim that
the privatisation of hospital and beds is in fact on.

Estimates
As stated earlier, the estimates are required for the simple reason that there is no proper
registration of private hospitals and therefore, the data on private hospitals and beds are gross
under-estimations..

Accordingly, there were an estimated 71,860 hospitals and 12,17,427 beds in the country. 93%
of hospitals and 64% of beds were in private sector, thus showing an overwhelming
dominance of private sector. The population per bed thus was 693 and per hospital 11,744.
Amar Jesani, Health services in India 11
Whatever may be the problem in numbers estimated, these estimates are more in conformity
with the trends in private sector development observed in the two decades.

Health finance and expenditure:

Per Capita Health Expenditure:
Health is a state subject and the primary responsibility of providing health care is with state
governments. The expenditure by state governments accounts for the 90% of total health
expenditure by the government under the Ministry and Family Welfare in India. The Central
government funds for the states are in the form of grants to particular programmes or as
sponsored schemes.

The per capita revenue expenditure has increased from Rs. 0.61 in 1950-1 to Rs. 85.10 in
1994-5. However, in 1994-5, the revenue expenditure on health as a percentage of total
government revenue expenditure was 2.63% and it is declining. In fact, it was 2.69% in 1950-
51, increased to 3.84 in 1965-66, and since then it has been steadily declining. The decline has
been sharper since 1985-86. The state governments’ share in total public health expenditure
has increased from 71.6% in 1974-82 to 86.7% in 1992-3. The share of grants from the centre
has declined from 19.9% to 3.3% in the same period.

The per capita revenue expenditure of Rs. 85.1 in 1994-5 is unevenly distributed across the
states. Usually, the better developed states like Goa, Haryana, Karnataka, Maharashtra,
Gujarat, Punjab have a higher per capita expenditure as compared to states of Bihar, Rajasthan,
Orissa, and Madhya Pradesh. Kerala, despite being at a lower level of socio-economic
development scale has a higher government spending on health.

Expenditure on hospitals and dispensaries is nearly one fourth of health expenditure by most
of the states. Goa, Kerala and Tamil Nadu spend 40 to 50% on hospitals and dispensaries. The
expenditure across states shows declining trend, especially after 1980s.

Household health expenditure

The household health expenditure data provide information on the private financing of health
care. The household expenditure is the biggest component in the total health care expenditure
in India.

The household health expenditure data are available only from surveys. The problem with
survey data is that they show wide variation, and are affected by the specific methodology
used and the coverage. Only one survey was done at the national level; the rest are district and
state level surveys. The 1993 national level survey by NCAER estimated the household
expenditure on health at Rs. 204 per capita per annum. The expenditure by rural household
was Rs 184 and by urban household Rs. 258 per capita per annum. If we compare this figure
with the total per capita government revenue expenditure on health in 1992-3 (Rs.70.15), we
find that government expenditure constituted only one third of total health expenditure in the
country. As compared to this national level survey, the district level surveys have come out
with higher estimates of household health expenditure. For instance, the latest findings from a
district level survey from Maharashtra show that the per capita household expenditure in 1997
was Rs.626, which is seven times higher than the government health expenditure in 1994-5.
Amar Jesani, Health services in India 12
Thus, there is overwhelming dominance of private sector in all aspects of India’s health care
sector.

(Acknowledgement: This paper is based on a section of a report prepared by the author in

1998 at the CEHAT, Mumbai, for the World Health Organisation and Voluntary Health
Association of India for the preparation of country profile of health care in India, titled,
“National Profile on Women, Health and Development”)