Health Care Delivery System in India: Structure and Function

India’s health care delivery system is one of the most complex and multifaceted in the world, serving over 1.4 billion people across diverse geographies and socioeconomic backgrounds. This system operates through a carefully designed network of public and private providers, traditional medicine practitioners, and various national health programs-all working together to deliver preventive, promotive, curative, and rehabilitative care to citizens at every level.

Understanding India’s health care delivery system 🔗

A health care delivery system refers to the organization, delivery, staffing, regulation, and quality control of health services designed to meet a population’s health needs. India operates a mixed health care system that includes both public and private providers, with the constitutional framework dividing responsibilities between the central and state governments.

The primary objectives of India’s health care delivery system include improving the overall health status of the population, enhancing the experience of care, reducing the economic burden of illness, and promoting social justice and equity in health access.

Constitutional framework and governance 🔗

Under the Indian Constitution, health is primarily a state subject. This means that while the central government formulates policies, guidelines, and national programs, state governments are responsible for implementing health services within their territories. The Union Ministry of Health and Family Welfare handles policy-making, planning, coordination, and technical assistance, while states directly manage health service delivery.

At the central level, three key bodies govern health administration: the Ministry of Health and Family Welfare, the Directorate General of Health Services, and the Central Council of Health. Each state has its own health ministry and directorate that adapts national guidelines to local contexts.

The public health care infrastructure 🔗

India’s public health system follows a three-tier structure designed to ensure that health services reach even the most remote areas. This pyramid-like organization ensures that basic care is available at the village level, with progressively specialized services available at higher levels.

Sub-centers: the first point of contact 🔗

Sub-centers form the foundation of rural health care delivery. One sub-center is established for every 5,000 people in plain areas and 3,000 people in hilly, tribal, or difficult-to-reach regions. These facilities serve as the most peripheral contact point between the community and the health system.

Each sub-center is staffed by at least one Auxiliary Nurse Midwife (ANM) or female health worker and one male health worker. The services provided here include maternal and child health care, immunization, family planning counseling, nutrition guidance, and treatment for minor ailments like diarrhea, acute respiratory infections, fever, and worm infestations.

Primary health centers: bridging communities and medical officers 🔗

Primary Health Centers (PHCs) serve populations of 30,000 in plain areas and 20,000 in hilly or tribal regions. The concept of PHCs was recommended by the Bhore Committee in 1946, envisioning them as the first contact point between village communities and qualified medical officers.

A standard PHC is staffed by one medical officer supported by 14 paramedical and other staff members. These centers provide integrated curative and preventive health care, with emphasis on health promotion. PHCs typically have 4-6 beds for inpatients and serve as referral units for 5-6 sub-centers. Under the National Rural Health Mission, provisions were made for two additional staff nurses at PHCs on a contract basis.

Community health centers: referral and specialist care 🔗

Community Health Centers (CHCs) cater to populations of 120,000 in plain areas and 80,000 in hilly or tribal regions. As per Indian Public Health Standards (IPHS) norms, each CHC should be staffed by four medical specialists-a surgeon, physician, gynecologist/obstetrician, and pediatrician-supported by 21 paramedical and other staff.

CHCs provide 30 beds, an operation theater, X-ray facilities, a labor room, and laboratory services. They function as the first referral unit for PHCs within their block, offering obstetric care and specialist consultations.

District hospitals and tertiary care 🔗

District hospitals represent the secondary level of care, while medical colleges and super-specialty hospitals provide tertiary care. First Referral Units (FRUs) are facilities-whether district hospitals, sub-divisional hospitals, or CHCs-that can provide round-the-clock emergency obstetric and newborn care, including surgical interventions like cesarean sections, care for sick newborns, and blood storage facilities.

The private health sector 🔗

The private sector plays a significant role in India’s health care landscape, particularly in urban areas. Private providers deliver approximately 70% of all health care services in the country and control about 50% of total hospital beds. However, most private facilities are small establishments with fewer than 25 beds, primarily offering non-specialized general clinical care.

Private hospitals are largely concentrated in metropolitan cities and urban neighborhoods, creating significant disparities in health care access between urban and rural populations. The private sector mainly focuses on curative services, with secondary and tertiary care dominating their offerings.

Indigenous systems of medicine: AYUSH 🔗

India has a rich tradition of indigenous medicine systems that complement modern allopathic care. The Ministry of AYUSH oversees the development, education, and research of these traditional systems, which include Ayurveda, Yoga, Naturopathy, Unani, Siddha, Sowa-Rigpa, and Homeopathy.

The Department of Indian Systems of Medicine and Homeopathy, established in 1995, was renamed the Department of AYUSH in 2003. In November 2014, it was elevated to a full ministry. These traditional systems provide a substantial portion of medical care to rural populations and are being progressively integrated into the mainstream health system.

Under the National AYUSH Mission launched in 2014, efforts are being made to co-locate AYUSH facilities at PHCs, CHCs, and district hospitals. The World Health Organization has partnered with India’s Ministry of AYUSH to develop technical documents and integrate evidence-based traditional medicine practices into national health systems.

National health programs and initiatives 🔗

India operates numerous national health programs targeting specific diseases and population groups. These programs address communicable diseases like tuberculosis, malaria, and HIV/AIDS, as well as non-communicable diseases, maternal and child health, and nutritional deficiencies.

National Health Mission 🔗

The National Health Mission (NHM) encompasses two sub-missions: the National Rural Health Mission (NRHM), launched in 2005, and the National Urban Health Mission (NUHM), launched in 2013. NHM provides support for maternal, child, and adolescent health, family planning, universal immunization, and control of diseases like tuberculosis, malaria, dengue, and leprosy.

The mission focuses on health system strengthening through infrastructure development, human resource augmentation, program management, emergency response services, mobile medical units, and community participation. A significant achievement has been the deployment of over 900,000 Accredited Social Health Activists (ASHAs) who serve as community health workers at the village level.

Ayushman Bharat: toward universal health coverage 🔗

Ayushman Bharat, launched in 2018, represents India’s most ambitious step toward Universal Health Coverage. This flagship scheme has two components: Health and Wellness Centers (HWCs) and the Pradhan Mantri Jan Arogya Yojana (PM-JAY).

The government aims to establish 150,000 Health and Wellness Centers by transforming existing sub-centers and PHCs to deliver comprehensive primary health care closer to people’s homes. These centers expand services beyond maternal and child health to include non-communicable diseases, free essential drugs, and diagnostic services.

PM-JAY provides health insurance coverage of Rs. 5 lakhs per family per year for secondary and tertiary hospitalization to over 12 crore poor and vulnerable families. It covers approximately 1,929 medical procedures and operates on a cashless, paperless basis across empaneled public and private hospitals nationwide.

Community-level health workers 🔗

At the village level, health services are delivered through various community health workers who form the backbone of India’s primary health care system.

ASHAs (Accredited Social Health Activists) are trained female community health workers who serve as the first point of contact for health-related matters. They facilitate access to health services, promote healthy behaviors, and accompany women to health facilities for antenatal care and institutional deliveries.

Anganwadi Workers operate under the Integrated Child Development Services (ICDS) scheme, providing nutrition supplementation, health education, and early childhood care.

Auxiliary Nurse Midwives (ANMs) provide essential maternal and child health services, immunization, and family planning counseling at sub-centers and through outreach activities.

Comprehensive health services approach 🔗

India’s health care delivery system aims to provide comprehensive services across four domains:

Preventive care focuses on disease prevention through immunization programs, vector control measures, health education, and sanitation improvement. The Universal Immunization Programme protects children against vaccine-preventable diseases.

Promotive care emphasizes health promotion through nutrition programs, maternal health initiatives, adolescent health services, and lifestyle modification counseling.

Curative care addresses illness treatment through outpatient and inpatient services at various levels of the health system, from sub-centers providing basic treatment to tertiary hospitals offering specialized surgical interventions.

Rehabilitative care supports recovery and restoration of function for individuals with disabilities or chronic conditions through physiotherapy, occupational therapy, and long-term care services.

Challenges and the path forward 🔗

Despite significant progress, India’s health system faces persistent challenges. Public health expenditure remains around 1.2% of GDP, leading to high out-of-pocket expenses that push millions into poverty annually. The shortage of trained health professionals, particularly in rural areas, creates significant access gaps. Infrastructure deficiencies and quality concerns in public facilities drive patients toward often unregulated private providers.

Recent initiatives focus on strengthening primary care, expanding insurance coverage, integrating traditional medicine systems, and leveraging digital health technologies. The PM-Ayushman Bharat Health Infrastructure Mission (PM-ABHIM), launched in 2021, specifically addresses infrastructure gaps exposed by the COVID-19 pandemic and aims to enhance preparedness for future health emergencies.

What do you think? How can India better integrate its traditional medicine systems with modern health care to create a truly comprehensive delivery system? What role should community health workers play in bridging the gap between rural populations and quality health services?

References

1. https://pmc.ncbi.nlm.nih.gov/articles/PMC5144115/
2. https://en.wikipedia.org/wiki/Healthcare_in_India
3. https://en.wikipedia.org/wiki/Ministry_of_Ayush
4. https://www.who.int/news/item/17-11-2023-new-who-and-ministry-of-ayush–republic-of-india-agreement-signed-to-advance-traditional–complementary–and-integrative-medicine
5. https://www.investindia.gov.in/blogs/national-health-mission-healthcare-all
6. https://nha.gov.in/PM-JAY