Health Systems in India - A Review

-Dr. S. Vijay Kumar

              India today, is the world’s third largest economy in terms of its Gross National Income (in PPP terms) and has the potential to grow larger and more equitably, and to be emerged as one of the developed nations of the world. Yet the gaps in health outcomes continue to widen. On the face of it, much of the ill health, disease, premature death, and suffering, we see on such a large scale is needless, given the availability of effective and affordable interventions for prevention and treatment. “The reality is, the power of existing interventions is not matched by the power of health systems to deliver them to those in greatest need, in a comprehensive way, and on an adequate scale".

NATIONAL HEALTH POLICY IN INDIA

• It was not until 1983 that India adopted a formal or official National Health Policy.

• Prior to that health activities of the state were formulated through the Five year Plans and    recommendations of various Committees.

National Health Policy 2002

Objectives:

·         Achieving an acceptable standard of good health of Indian Population.

·         Decentralizing public health system by upgrading infrastructure in existing institutions.

·         Ensuring a more equitable access to health service across the social and geographical expanse of India. • Enhancing the contribution of private sector in providing health service for people who can afford to pay.

·         Giving primacy for prevention and first line curative initiative.

·         Emphasizing rational use of drugs.

·         Increasing access to tried systems of Traditional Medicine.

Facts about Indian Health Care System:

1. Rural Versus Urban Divide: While the opportunity to enter the market is very ripe, India still spends only around 4.2% of its national GDP towards healthcare goods and services (compared to 18% by the US). Additionally, there are wide gaps between the rural and urban populations in its healthcare system which worsen the problem. A staggering 70% of the population still lives in rural areas and has no or limited access to hospitals and clinics. Consequently, the rural population mostly relies on alternative medicine and government programmes in rural health clinics. One such government programme is the National Urban Health Mission which pays individuals for healthcare premiums, in partnership with various local private partners, which have proven ineffective to date. In contrast, the urban centres have numerous private hospitals and clinics which provide quality healthcare. These centres have better doctors, access to preventive medicine, and quality clinics which are a result of better profitability for investors compared to the not-so-profitable rural areas.

2. Need for Effective Payment Mechanisms: Besides the rural-urban divide, another key driver of India’s healthcare landscape is the high out-of-pocket expenditure (roughly 70%). This means that most Indian patients pay for their hospital visits and doctors’ appointments with straight up cash after care with no payment arrangements.  According to the World Bank and National Commission’s report on Macroeconomics, only 5% of Indians are covered by health insurance policies. Such a low figure has resulted in a nascent health insurance market which is only available for the urban, middle and high income populations. The good news is that the penetration of the health insurance market has been increasing over the years; it has been one of the fastest-growing segments of business in India. Coming to the regulatory side, the Indian government plays an important role in running several safety net health insurance programmes for the high-risk population and actively regulates the private insurance markets. Currently there are a handful of such programmes including the Community Health Insurance programme for the population below poverty line (like Medicaid in the US) and Life Insurance Company (LIC) policy for senior citizens (like Medicare in the US). All these plans are monitored and controlled by the government-run General Insurance Corporation, which is designed for people to pay upfront cash and then get reimbursed by filing a claim. There are additional plans offered to government employees, and a handful of private companies sell private health insurance to the public.

3. Demand for Basic Primary Healthcare and Infrastructure: India faces a growing need to fix its basic health concerns in the areas of HIV, malaria, tuberculosis, and diarrhea. Additionally, children under five are born underweight and roughly 7% (compared to 0.8% in the US) of them die before their fifth birthday. Sadly, only a small percentage of the population has access to quality sanitation, which further exacerbates some key concerns above.

For primary healthcare, the Indian government spends only about 30% of the country’s total healthcare budget. This is just a fraction of what the US and the UK spend every year. One way to solve this problem is to address the infrastructure issue by standardizing diagnostic procedures, building rural clinics, and developing streamlined health IT systems, and improving efficiency. The need for skilled medical graduates continues to grow, especially in rural areas which fail to attract new graduates because of financial reasons. A sizeable percentage of the graduates also go abroad to pursue higher studies and employment.

4. Growing Pharmaceutical Sector: According to the Indian Brand Equity Foundation (IBEF), India is the third-largest exporter of pharmaceutical products in terms of volume. Around 80% of the market is composed of generic low-cost drugs which seem to be the major driver of this industry. The increase in the ageing population, rising incomes of the middle class, and the development of primary care facilities are expected to shape the pharmaceutical industry in future. The government has already taken some liberal measures by allowing foreign direct investment in this area which has been a key driving force behind the growth of Indian Pharma.

5. Underdeveloped Medical Devices Sector: The medical devices sector is the smallest piece of India’s healthcare pie. However, it is one of the fastest-growing sectors in the country like the health insurance marketplace. Till date, the industry has faced a number of regulatory challenges which has prevented its growth and development. Recently, the government has been positive on clearing regulatory hurdles related to the import-export of medical devices, and has set a few standards around clinical trials. According to The Economic Times, the medical devices sector is seen as the most promising area for future development by foreign and regional investors; they are highly profitable and always in demand in other countries.

Goals – NHP 2002

Eradication of Polio & Yaws	2005
Elimination of Leprosy	2005
Elimination of Kala‐azar	2010
Elimination of lymphatic Filariasis	2015
Achieve of Zero level growth of HIV/AIDS	2007
Reduction of mortality by 50% on account of Tuberculosis, Malaria, Other vector and water borne Diseases	2010
Reduce prevalence of blindness to 0.5%	2010
Reduction of IMR to 30/1000 & MMR to 100/lakh	2010
Increase utilization of public health facilities from current level of < 20% to > 75%	2010
Establishment of an integrated system of surveillance, National Health Accounts and Health Statistics	2005
Increase health expenditure by government as a % of GDP from the existing 0.9% to 2.0%	2010
Increase share of Central grants to constitute at least 25% of total health spending	2010
Increase State Sector Health spending from 5.5% to 7% of the budget	2005
Further increase of State sector Health spending from 7% to 8%	2010

Achievements:

Millennium Development Goals: India is set to reach the Millennium Development Goals (MDG) with respect to maternal and child survival. The MDG target for Maternal Mortality Ratio (MMR) is 140 per 100,000 live births. From a baseline of 560 in 1990, the nation had achieved 178 by 2010-12, and at this rate of decline is estimated to reach an MMR of 141 by 2015. In the case of under-5 mortality rate (U5MR), the MDG target is 42. From a baseline of 126 in 1990, in 2012 the nation has an U5MR of 52 and an extrapolation of this rate would bring it to 42 by 2015. This is particularly creditable on a global scale where in 1990 India’s MMR and U5MR were 47% and 40% above the international average respectively. While the narrowing of these gaps and closure, demonstrate a significant effort we could have done better. Notably, the rate of decline of still-births and neonatal mortality has been lower than the child mortality on the whole. In some states there is stagnation on these two indicators.

Population Stabilization: India has also shown consistent improvement in population stabilization, with a decrease in decadal growth rates, both as a percentage and in absolute numbers. Twelve of the 21 large States for which recent Total Fertility Rates (TFR) is available, have achieved a TFR of at or below the replacement rate of 2.1 and three are likely to reach this soon. The challenge is now in the remaining six states of Bihar, Uttar Pradesh, Rajasthan, Madhya Pradesh, Jharkhand and Chhattisgarh but even here rates are declining. However these six States between them account for 42 % of the national population and 56 % of the annual population increase. In the remaining small States and Union Territories except Meghalaya, the Crude Birth Rate (CBR), is less than 21 per 1000. The national TFR has declined from 2.9 to 2.4. The persistent challenge on this front is the declining sex ratio.

Performance in Disease Control Programmes: India’s progress on communicable disease control is mixed. The most acclaimed success of this period is the complete elimination of polio. In Leprosy too there have been significant reductions, but after a reduction of an annual incidence of 120,000 cases, there is stagnation, with new infective cases and disabilities being reported. Kala-azar and Lymphatic filariasis are expected to decline below the threshold for certifying by 2015, but as in leprosy there are likely to be Blocks where the prevalence is above this threshold. In many more Blocks, which have achieved elimination, continuing attention to identifying and managing low levels of disease incidence is required for some time to come. In AIDS control, progress has been good with a decline from a 0.41 % prevalence rate in 2001 to 0.27% in 2011- but this still leaves about 21 lakh persons living with HIV, with about 1.16 lakh new cases and 1.48 deaths in 2011. In tuberculosis the challenge is a prevalence of close to 211 cases and 19 deaths per 100,000 population and rising problems of multi-drug resistant tuberculosis. Though these are significant declines from the MDG baseline, India still contributes to 24% of all global new case detection. In malaria there has been a significant decline, but there are also the challenges, of resistant strains developing and of sustaining the gains, in a disease known for its cyclical reemergence and focal outbreaks. Viral Encephalitis, Dengue and Chikungunya are on the increase, particularly in urban areas and as of now we do not have effective measures to address them. Performance in disease control programmes is largely a function and reflection of the strengths of the public health systems. Where there are sub-critical human resource deployment, weak logistics and inadequate infrastructure, all national health programmes do badly. This was one of the important reasons of the launch of the National Rural Health Mission, which was geared to strengthen health systems.

Inequities in Health Outcomes: While acknowledging these achievements we need to be mindful and confront the high degree of health inequity in health outcomes and access to health care services as evidenced by indicators disaggregated for vulnerable groups. There are urban-rural inequities and there are inequities across states. A number of districts, many in tribal areas, perform poorly even in those states where overall averages are improving. Marginalized communities and poorer economic quintiles of the population continue to fare poorly. Outreach and service delivery for the urban poor, even for immunization services has been inadequate.

Social Health Initiatives in India: It is both challenging and expensive to try to attain the goal of universal health coverage in a country where most of its people are unemployed or employed informally. From 1948 to now, the Indian government has launched a series of social health insurance schemes to ensure healthcare access to the middle and upper classes as well as the poor and other special populations. The following table is a summary of the schemes launched.

Name of Scheme	Year of Enactment	Target	Objective		Means of Financing
ESIS: Employee’s State Insurance Scheme	1948	Employees with income less than Rs 15000/month and dependents	To achieve universal health coverage		Financed by state government, employers and employees
CGHS: Central Government Health Scheme	1954	Government employees and families	To achieve universal health coverage		Financed by state government, employers and employees
ICDS: Integrated Child Development Services	1975	Malnutrition children under age 6	To improve nutrition and health status to children		The government, the United Nations Children's Fund (UNICEF) and the World Bank
RSBY: Rashtriya Swasthya Bima Yojana	2009	The poor below the poverty line	To provide affordable healthcare to the poor		Financed by Federal (75%) and State (25%) Government
NPHCE: National Programme for the Health Care of the Elderly 14	2011	Seniors	To provide the elderly an easy access to primary healthcare		Ministry of Health & Family Welfare
Aam Aadmi Bima Yojana	2013	For BPL or Marginally above Poverty line	Persons aged between 18 –59 Access to primary health		GOI
Universal Health Scheme Insurance (UHSI)	2015	Reimbursement of Hospitalization expenses	For BPL families		GOI

Source: Ministry of Health & Family Welfare, GOI

Health Planning in India:

Plans				Salient Points/Committees Recommendations
1stFive Year  Plan       2nd Five Year Plan				The basic structural framework of the public health care delivery system remained unchanged. Urban areas continued to get over three-fourth of the medical care resources, whereas rural areas received "special attention" under the Community Development Program (CDP). The CDP was failing even before the Second Five Year Plan began. The governments own evaluation reports confessed this failure. Bhore Committee (1946): Integration of preventive and curative services of all administrative levels. Major changes in medical education which includes three months training in preventive and social medicine to prepare “social physicians”. Development of PHS. Mudaliar Committee (1962): Consolidation of advances made in the first two five year plans. Strengthening of the district hospitals. Each PHC not to serve more than 40,000 population. To improve the quality of health care provided by PHC. Integration of medical and health services.
3rd Five Year Plan				Discussed the problems affecting the provision of PHCs, and directed attention to the shortage of health personnel, delays in the construction of PHCs, buildings and staff quarters and inadequate training facilities for the different categories of staff required in the rural areas. Chadah Committee (1963): Advised for the maintenance phase of National Malaria Eradication Programme. Recommended the integration of health and family planning services. Mukherjee Committee (1966): The committee worked out the details of basic Health Service at the Block level, strengthening of higher levels of administration. Jungalwalla Committee (1967): Unified Cadre; Common Seniority; Recognition of extra qualifications; Equal pay for equal work; Special pay for special work 6. Abolition of private practice by government doctors; Improvement in their service conditions.
4th Five Year Plan				Continued on the same line as the 3rd plan. It lamented on the poor progress made in the PHC programme and recognized again the need to strengthen it. It pleaded for the establishment of effective machinery for speedy construction of buildings and improvement of the performance of PHCs by providing them with staff, equipment and other facilities. Kartar Singh Committee (1973): Various categories of peripheral workers should be amalgamated into a single cadre of multipurpose workers (male and female). One PHC should cover a population of 50,000. It should be divided into 16 sub centres, each to be staffed by a male and a female health worker. Srivastchav Committee (1975): This committee was set up in 1974 as Group on Medical Education and Support Manpower.  Creation of bands of paraprofessional and semi professional health workers from within the community itself e.g. school teachers, postmasters etc.  Establishment of two cadres of health workers between the community level workers and doctors at PHC namely – multipurpose health workers and health assistants.  Development of a “Referral Services Complex” by establishing proper linkage between PHC and higher referral services. Establishment of a Medical and Health Education Commission for planning and implementing the reforms needed in health and medical education on the lines of University Grants Commission.
5th Five Year Plan				The government realized that the number of medical institutions, functionaries, beds, health facilities etc, were still inadequate in the rural areas despite advances in terms of infant mortality rate going down, life expectancy going up; The urban health structure had expanded at the cost of the rural sectors; Major innovations took place with regard to the health policy and method of delivery of health care services; Increasing the accessibility of health services to rural areas through the Minimum Needs Programme (MNP) and correcting the regional imbalances.
6th Five Year Plan				The 6th Plan was to a great extent influenced by the Alma Ata declaration of Health For All by 2000 AD (WHO, 1978) and the ICSSR ‐ ICMR report (1980). The plan conceded that "there is a serious dissatisfaction with the existing model of medical and health services with its emphasis on hospitals, specialization and super specialization and highly trained doctors which is availed of mostly by the well to do classes. It is also realized that it is this model which is depriving the rural areas and the poor people of the benefits of good health and medical services“. The National Health Policy of 1983 was announced during the Sixth plan period.
7th Five Year Plan				The 7th Five Year Plan recommended that "development of specialties and super‐specialties need to be pursued with proper attention to regional distribution” and such "development of specialized and training in super specialties would be encouraged in the public and the private sectors“. This plan also talks of improvement and further support for urban health services, biotechnology and medical electronics and non‐communicable diseases. Enhanced support for population control activities also continues. The special attention that AIDS, cancer, and coronary heart diseases are receiving and the current boom of the diagnostic industry and corporate hospitals is a clear indication of where the health sector priorities lie.
	8th Five Year Plan		On the eve of the Eighth Five Year Plan the country went through a massive economic crisis. The Plan got pushed forward by two years. But despite this no new thinking went into this plan.  In fact, keeping with the selective health care approach the eighth plan adopted a new slogan – instead of Health for All by 2000 AD it chose to emphasize Health for the Underprivileged.  Simultaneously it continued the support to privatization. During the Eighth Plan resources were provided to set up the Education Commission for Health Sciences, and a few states have even set up the University for Health Sciences as per the recommendations of the Bajaj committee report. Bajaj Committee (1986): Formulation of National Medical & Health Education Policy. Formulation of National Health Manpower Policy. Establishment of an Educational Commission for Health Sciences (ECHS) on the lines of UGC. Establishment of Health Science Universities in various states and union territories. Establishment of health manpower cells at centre and in the states. Vocationalisation of education at 10+2 levels as regards health related fields with appropriate incentives, so that good quality paramedical personnel may be available in adequate numbers. Carrying out a realistic health manpower survey. During the 8th Plan period a committee to review public health was set up. It was called the Expert Committee on Public Health Systems. This committee made a thorough appraisal of public health programs and found that we were facing a resurgence of most communicable diseases and there was need to drastically improve disease surveillance in the country.
	9th Five Year Plan		The 9th Five Year Plan by contrast provides a good review of all programs and has made an effort to strategise on achievements hitherto and learn from them in order to move forward. There are a number of innovative ideas in the ninth plan. Reference is once again being made to the Bhore Committee report. Another unique suggestion is evolving state specific strategies because states have different scenarios and are at different levels of development and have different health care needs. The Ninth Plan proposes to set up at district level a strong detection come response system for rapid containment of any outbreaks that may occur.
10th Five Year Plan		On the eve of the 10th Plan, the draft National Health Policy 2002 has been announced.
11th Five  Year  Plan		National Health Policy 2002
12th Five Year Plan		National Health Policy 2002

Comparison of India & US Health Care Systems:

To gain a better understanding of the healthcare system in India, a comparison can be drawn to a more familiar system: the United States. Like American Medicare, India also has health care plans for senior citizens, but their criteria used to determine qualification differs. In India, the minimum age to apply for health care plans is 60, five years earlier that its US counterpart.22 Indian policies are regulated by state-sponsored insurance companies while the US Federal Government regulates Medicare. In accordance to National Policy on Senior Citizens in 2011, the Indian Government also pays more attention to specialty groups including women seniors and poor seniors. India has some additional healthcare plans aimed at special populations. Central Government Health Scheme (CGHS) and Employee State Insurance Scheme (ESIS) are two plans that are regulated by Public-Sector employers to provide benefits for employees. The CGHS is available to Central Government employees and their family members as well as employees of the railways, national defense, police, mining, post, telecommunications, and education. ESIS is another low-income program that is regulated by Public-Sector employers. Although India has a wide-spread health system, the benefits these plans can provide are very limited compared to the plans of US.

Major Health Concerns & Concerns on Quality of health Care: The World Health Organization’s 2000 global healthcare profile ranked India’s healthcare system 112th out of 190 countries. This survey highlighted four major health concerns for India that still are prominent today. The first concern is the high vulnerability of young children. Among children under five, 43.5% are underweight (the highest percentage in the world) and have 6.6% dying before their fifth birthday (which is quite high compared to United States’ rate of 0.8%).The second major concern is poor sanitation. Only about 30% of the population uses improved sanitation facilities and this figure dips below 20% when focusing solely on the rural population. The final concern is disease. The top three are malaria, tuberculosis, and diarrhea. 9 Combined, these health concerns have hindered India’s life expectancy: 63 for males and 66 for females, which is considerably lower than the United States life expectancy of 69 and 75 respectively.

                      The situation in quality of care is also a matter of serious concern and this seriously compromises the effectiveness of care. For example though over 90% of pregnant women receive one antenatal check up and 87 % received full TT immunization, only about 68.7 % of women have received the mandatory three antenatal check-ups. Again whereas most women had received iron and folic acid tablets, only 31% of pregnant women had consumed more than 100 IFA tablets. For institutional delivery standard protocols are often not followed during labour and the postpartum period. Sterilization related deaths a preventable tragedy, are often a direct consequence of poor quality of care. Only 61% of children (12 -23 months) have been fully immunized. There are gaps in access to safe abortion services too, and in care for the sick neonate.

Developments under the National Rural Health Mission: The National Rural Health Mission (NRHM) led to a significant strengthening of public health systems. It brought in a workforce of close to 900,000 community health volunteers, the ASHAs, who brought the community closer to public services, improving utilization of services and health behaviors. The NRHM deployed over 18,000 ambulances for free emergency response and patient transport services to over a million patients monthly, added over 178,000 health workers to a public system that had depleted its workforce to sub-critical levels over a long period of neglect, provided cash transfers to over one crore pregnant women annually, empowering and facilitating them to seek free care in the institutions and began to address infrastructure gaps. Across States, there were major increases in outpatient attendance, bed occupancy and institutional delivery. However these developments were uneven and more than 80% of the increase in services is likely to have been contributed by less than 20% of the public health facilities. Further, States with better capacity at baseline were able to take advantage of NRHM financing sooner, while high focus States had first to revive or expand their nursing and medical schools and revitalize their management systems. Larger gaps in baselines and more time taken to develop capacity to absorb the funds meant that gaps between the desired norms and actual levels of achievement were worse in high focus states. Inefficiencies in fund utilization, poor governance and leakages have been a greater problem in some of the weaker states. Much of the increase in service delivery was related to select reproductive and child health services and to the national disease control programmes, and not to the wider range of health care services that were needed. Action on social determinants of health was even weaker.

Access to Health Care in India:

•         India has 48 doctors per 100,000 persons which is fewer than in developed nations

•         Wide urban-rural gap in the availability of medical services: Inequity

•         Poor facilities even in large Government institutions compared to corporate hospitals (Lack of funds, poor management, political and bureaucratic interference, lack of leadership in medical community).

Regulatory Role of Government: The Government’s regulatory role extends to the regulation of drugs through the CDSCO, the regulation of food safety through the office of the Food Safety and Standards Authority of India, support to the regulation of professional education through the four professional councils and the regulation of clinical establishments by the National Council for the same. Progress in each of these areas has been challenging. Some of the challenges relate to institutional strengthening and also the mechanisms of institutional governance, and some of the latter require amendments to the laws. Regulation of drug pricing is under the Department of Pharmaceuticals and this has been playing an active and effective role in monitoring prices and taking actions. Reforms in each of these areas, but especially in professional councils and clinical establishments is also facing resistance from certain stakeholders and will require considerable political leadership and public support to implement these reforms. There are also genuine concerns that it would bring back “license raj” the unnecessary and inefficient Government interference in private sector growth. But clearly as private industry grows at a massive pace, and as this is an area touching upon the lives and health of its population the Government has to find ways to move forward on these responsibilities.

The Institutional Framework: The main challenge at both Center and the States is strengthening the synergistic functioning of the directorate as the technical leadership and the civil services as the administrative leadership and coordinating both of these with the increasing number of State owned or fully state financed corporations, and registered societies and autonomous or semi-autonomous institutions. Directorates need to be strengthened by HR policies, central to which is that, those from a public health management cadre must hold senior positions in public health. In all directorates, senior personnel need to have been groomed into leadership roles by experience of policy and administrative work, before they come to occupy key positions. Civil servants too should have clear induction and orientation programmes in the domain as also general understanding of institutional processes that they need to put in place so that the directorates and various state owned institutions in a knowledge based sector are able to perform optimally.

Legal Framework for Health Care and the Right to Health: There are a large number of laws that govern health policy and implementation in a number of areas- and health policy has not only to be compliant with these laws but also contribute to strengthening implementation. There are unfortunately a number of laws that have over time developed inadequacies due to changed contexts and a number of newly emerged services and technologies where laws are needed. Laws under review include the Mental Health Bill, the Medical Termination of Pregnancy Act, the bill regulating surrogate pregnancy and assisted reproductive technologies, Food Safety Act, Drugs and Cosmetics Act and the Clinical Establishments Act. The process of aligning many of these laws to meet our needs and changed circumstances and understanding becomes one of the urgent tasks in the coming years.

                           One of the fundamental policy questions of our times is whether to pass a health rights bill making health a fundamental right- in the way that was done for education. Many industrialized nations have laws that do so. Many of the developing nations that have made significant progress towards universal health coverage like Brazil and Thailand have done so and the presence of such a law was a major contributory factor. A number of international covenants to which we are joint signatories give us such a mandate- and this could be used to make a national law. Courts have also rulings that in effect see health care as a fundamental right- and a constitutional obligation flowing out of the right to life. There has been a ten-year long discussion over this without a final resolution. The policy question is whether we have reached the level of economic and health systems development as to make this a justifiable right- implying that its denial is an offense. And whether when health care is a State subject, it is desirable or useful to make a central law? And whether such a law should mainly focus on the enforcement of public health standards on water, sanitation, food safety, air pollution etc, or on health rights- access to health care and quality of health care – i.e. on what the state enforces on citizens or on what the citizen demands of the state? Or does the health policy take the position that given the existence of a large number of laws including the clinical establishments Act, and the track record on adopting them and implementing them, a Central law is neither essential nor feasible. To break the deadlock and this vacillation and move forwards with determination- the draft national health policy proposes the following formulation- “the Center shall enact, after due discussion and on the request of three or more States (using the same legal clause as used for the Clinical Establishments Bill) a National Health Rights Act, which will ensure health as a fundamental right, whose denial will be justifiable. States would voluntarily opt to adopt this by a resolution of their Legislative Assembly. States which have achieved a per capita public health expenditure rate of over Rs 3800 per capita ( at current prices) should be in a position to deliver on this- and though many States are some distance away- there are states which are approaching or have even reached this target.” Such a policy formulation/resolution we feel would be the right signal to give a push for more public health expenditure as well as for the recognition of health as a basic human right, and its realization as goal that the nation must set itself.

Research and Challenges: The Department of Health Research was established in 2006 to strengthen Indian efforts in health research. Much of its results are delivered though the research institutions that come under the Indian Council of Medical Research. Simultaneously research support to medical colleges across the country is being strengthened to ensure their engagement in research. Currently over 90% of the research publications from medical colleges come from only nine medical colleges. There have been significant contributions made by the Department, but modest funding of less than 1 % of all public health expenditure has resulted in limited progress. The report of the Committee that examined the functioning of the ICMR in 2012, and the report of the Working Group constituted for the 12th Plan can guide policy in this area. India’s strengths in AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy) can also be leveraged for becoming a world leader in drug discovery as also in integrative medicine and this needs not only research as pure and applied science but also creating institutional structures for documentation, validation and accreditation of community health practices and practitioners.

Conclusion: “The reality is, the power of existing interventions is not matched by the power of health systems to deliver them to those in greatest need, in a comprehensive way, and on an adequate scale". Hence, the Government of India should move in this direction.