Evaluating India's Public Health Landscape: Challenges and Opportunities • Law Notes by TheLaw.Institute

India has made remarkable strides in healthcare over the past few decades – life expectancy has risen, infant mortality has fallen, and large-scale insurance schemes now cover millions of previously unprotected families. Yet beneath these headline improvements lies a public health system under deep strain. Hospitals are concentrated in cities, rural areas are served by unqualified practitioners, and households are pushed into debt by medical bills they cannot afford. Understanding these fault lines is essential – not just for policymakers, but for every citizen whose access to healthcare depends on how well these problems are addressed.

The public vs. private healthcare divide
The burden of out-of-pocket expenditure
The crisis of healthcare infrastructure in rural India
The prevalence of unqualified practitioners
The regulatory gap: private sector and quackery
Government initiatives and the path forward

The public vs. private healthcare divide

India’s healthcare system is split between a publicly funded tier meant to serve everyone and a sprawling private sector that has grown to fill the gaps left by underinvestment. The result is a lopsided landscape. Approximately 75% of health infrastructure and resources are concentrated in urban areas, where only 27% of the population resides. For the roughly 65% of Indians who live in rural areas, this concentration is not just a statistic – it determines whether they can access a doctor at all.

On the financing side, India’s public health spending has historically been one of the lowest among comparable economies. Healthcare spending has recently ranged from just 1.2% to 1.6% of GDP, well below the global average of around 6%. The Union Budget 2024-25 allocated ₹90,958 crore for healthcare – a 12.96% increase over the previous year – but even this remains insufficient given the scale of unmet need. The government has set a target to raise public health expenditure to 2.5% of GDP by 2025 under the National Health Policy 2017, but progress toward that target has been slow.

The private sector, meanwhile, dominates actual service delivery. By 2014, private providers had become the dominant point of contact for both outpatient and inpatient care, particularly in urban areas. While this reflects the private sector’s responsiveness to demand, it has also created a system where quality care is largely available only to those who can pay for it.

The burden of out-of-pocket expenditure

When public systems are weak and insurance coverage is low, patients end up paying from their own pockets – often at the worst possible time. Out-of-pocket expenditure (OOPE) constitutes 47.1% of total health expenditure in India, according to the National Health Accounts Estimates for 2019-20. This means that nearly half of every rupee spent on healthcare in the country comes directly from patients and their families, not from government programs or insurance.

The consequences are severe. Rural households heavily rely on distress financing mechanisms like borrowing and selling assets to meet healthcare costs, a pattern that disproportionately affects poorer households and traps them in a cycle of poverty. In Odisha alone, 40% of households that experienced a hospitalisation had to take out loans or sell assets to cover costs.

Insurance coverage, which could reduce this burden, remains inadequate. As per the National Sample Survey of 2017-18, 86% of persons in rural areas were not covered by any form of health insurance. While the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) has expanded coverage significantly, nearly 400 million Indians remain uninsured and financially vulnerable to medical emergencies, according to NITI Aayog.

The crisis of healthcare infrastructure in rural India

India organises its rural healthcare delivery through a three-tier system: Sub-Centres, Primary Health Centres (PHCs), and Community Health Centres (CHCs). Each is meant to serve a defined population and provide progressively more specialised services. In practice, this system is chronically understaffed and under-resourced.

Between 2005 and 2022, the shortfall of specialists such as surgeons in rural areas increased from 46% to 79%. Community Health Centres, which are supposed to provide specialist-level care, have reported vacancy rates of 83% for surgeons, 76% for gynaecologists and obstetricians, 83% for physicians, and 82% for paediatricians. The situation is further illustrated in state-level data: Chhattisgarh has a doctor vacancy rate of 71% in PHCs, followed by West Bengal at 44%, Maharashtra at 37%, and Uttar Pradesh at 36%.

Physical infrastructure lags as well. India has only 0.6 hospital beds per 1,000 persons, against the National Health Policy 2017 recommendation of two beds per 1,000. Access to diagnostics is equally poor: only 39% of rural respondents in a 2024 survey reported having a diagnostic facility within commutable distance, and only 12.2% of households could access subsidised medicines from government-run Jan Aushadhi Kendras.

The prevalence of unqualified practitioners

Where the public system is absent and private qualified care is unaffordable, a third option fills the gap: the unqualified or informal health practitioner – colloquially called a “quack” or, in official parlance, a Rural Medical Practitioner (RMP). These individuals practice without any formal medical registration or legal authorisation, yet they are often the first – and only – point of healthcare contact for millions of rural Indians.

The Indian Medical Association estimates that India has around one million quacks practising medicine, of whom 600,000 offer allopathic treatments. A 2019 study cited by the Indian Journal of Medical Ethics found that approximately 60% of rural households rely on unqualified and unlicensed practitioners for healthcare.

The reason quacks persist is structural, not merely a matter of patient ignorance. India has just 0.7 doctors for every 1,000 people against the WHO recommendation of at least 1:1,000, and poor public hospitals combined with high private costs leave rural patients with little practical choice. As a World Bank economist has pointedly observed, shutting down informal providers would effectively eliminate 80% of the rural medical workforce.

The quality implications, however, are serious. Studies have found that correct diagnoses were rare and incorrect treatments were widely prescribed by informal providers, with one study finding 67% of healthcare providers in rural areas reported no medical qualifications whatsoever. Inappropriate prescriptions, including the misuse of antibiotics and injections, contribute to drug resistance and patient harm. A 2018 case in Uttar Pradesh, where an unqualified practitioner infected nearly 40 patients with HIV by reusing contaminated needles, illustrates the very real dangers involved.

The regulatory gap: private sector and quackery

India has a legal framework meant to regulate both qualified private providers and prevent unqualified practice. The Clinical Establishments (Registration and Regulation) Act, 2010 requires all clinical establishments to register and meet minimum standards. However, the Act has been adopted by only 11 of India’s 36 states and territories, and even in states where it applies, enforcement is widely acknowledged to be weak.

The National Health Policy 2017 identifies regulation of clinical establishments as a priority and calls for patient rights protections – including rights to information, informed consent, and access to medical records – as key standards. It also advocates for a separate empowered medical tribunal to resolve disputes. Yet these remain largely aspirational. As one analysis put it, the private healthcare sector today lacks effective mechanisms for regulation, and the consequences are visible in negligence, malpractice, and patient exploitation.

On quackery specifically, the Indian Medical Council Act, 1956 prohibits any person not enrolled on a State Medical Register from practising modern scientific medicine. The IMA and the National Medical Commission have submitted draft anti-quackery legislation, but no such bill has yet been placed before Parliament. Courts have reinforced legal clarity: the Calcutta High Court, in cases such as Dhritarastra Dutta vs. State of West Bengal (2023), affirmed that only individuals with recognised qualifications under the Indian Medical Council Act, 1956 may use the “Dr.” prefix, re-emphasising that unqualified practitioners cannot legitimise their practice through self-styling.

Government initiatives and the path forward

Despite the systemic challenges, there are meaningful policy interventions underway. The Ayushman Bharat scheme – which encompasses both Ayushman Arogya Mandirs (formerly Health and Wellness Centres) and the AB-PMJAY insurance programme – represents the most comprehensive reform attempt in recent decades. The share of government health expenditure in total health expenditure increased from 29% in 2014-15 to 41.4% in 2019-20, and the proportion of rural patients using public facilities also rose during this period.

The Ayushman Bharat Digital Mission (ABDM) aims to create a unified digital health ecosystem, including a National Health Professional Registry that would allow patients to verify a doctor’s credentials – a step that could directly address the quackery problem by making it easier to distinguish qualified practitioners from fraudulent ones. Telemedicine, scaled through platforms like eSanjeevni, is also bridging geographic gaps, connecting rural patients with specialists in larger cities.

The Pradhan Mantri Swasthya Suraksha Yojana (PMSSY) is expanding AIIMS institutions and upgrading government medical colleges across states to address the specialist shortage. On medicines, the Jan Aushadhi scheme provides generic drugs at subsidised prices through government-run stores, though access remains patchy, with only 12.2% of rural households currently benefiting.

What these initiatives have yet to fully address is the structural inequity at the core of the problem: public investment remains inadequate, private sector regulation remains fragmented, and the rural health workforce gap persists. Research shows that increased per capita public health expenditure has not consistently translated into improved healthcare infrastructure and manpower in Indian states – pointing to a governance and delivery challenge as much as a funding one. Targeted reform of how money flows to rural and tribal healthcare, combined with stricter enforcement of existing regulations, is essential to close the gap.

What do you think? Given that unqualified practitioners fill a genuine healthcare vacuum in rural India, should the law focus more on training and regulating them within a defined scope of practice, or should enforcement of outright prohibition be strengthened – and what would each approach mean for the millions of rural patients who currently have no other option? And with the Clinical Establishments Act adopted by fewer than half of India’s states, what accountability mechanisms should be introduced to ensure the private healthcare sector serves public health goals rather than working against them?

How useful was this post?

Click on a star to rate it!

Average rating 0 / 5. Vote count: 0

No votes so far! Be the first to rate this post.

References

PDF 📄

Evaluating India’s Public Health Landscape: Challenges and Opportunities

Share on Mastodon

Evaluating India’s Public Health Landscape: Challenges and Opportunities

Table of Contents

The public vs. private healthcare divide 🔗

The burden of out-of-pocket expenditure 🔗

The crisis of healthcare infrastructure in rural India 🔗

The prevalence of unqualified practitioners 🔗

The regulatory gap: private sector and quackery 🔗

Government initiatives and the path forward 🔗