Poor State of Health Infrastructure

Context: The second wave of the COVID-19 pandemic has exposed the abysmally poor state of the country’s health infrastructure.

What does the data say?

  • World Bank data reveal the poor state of India’s health infrastructure. It reveals that India had 85.7 physicians per 1,00,000 people in 2017. In contrast, it is 98 in Pakistan, 58 in Bangladesh, 100 in Sri Lanka and 241 in Japan. India had 53 beds per 1,00,000 people.
  • It is 63 in Pakistan, 79.5 in Bangladesh, 415 in Sri Lanka and 1,298 in Japan. India had172.7 nurses and midwives per 1,00,000 people in contrast to 220 in Sri Lanka, 40 in Bangladesh, 70 in Pakistan, and 1,220 in Japan.

Factors responsible behind such situation:

  • Low public health expenditure- 1% of GDP 2013-14 and 1.28% in 2017-18 (including expenditure by the Centre, all States and Union Territories). Centre is the key player in public health management because the main bodies with technical expertise are under central control. The States lack corresponding expert bodies such as the National Centre for Disease Control or the Indian Council of Medical Research.
  • States also differ a great deal in terms of the fiscal space to deal with the novel coronavirus pandemic because of the wide variation in per capita health expenditure.
  • There is Inter-State variation in per capita health-care expenditure (between 2010-11 to 2019-20). Kerala and Delhi have been close to the top in all the years.
  • Bihar, Jharkhand and Uttar Pradesh have been consistently towards the bottom of the ranking in all years.
  • Odisha is noteworthy as it had the same per capita health expenditure as Uttar Pradesh in 2010, but now has more than double that of Uttar Pradesh.

Component of Out-of-pocket expenditure:

  • Due to low levels of public health provision, the World Health Organization estimates that 62% of the total health expenditure in India is OOP, among the highest in the world.
  • Some of the poorest States, Uttar Pradesh, Bihar, Madhya Pradesh, Jharkhand and Odisha, have a high ratio of OOP expenditures in total health expenditure. High ratio of OOP means that the poor in the poorest States, the most vulnerable sections, are the worst victims of a health emergency.


  • The inter-State variation in health expenditure highlights the need for a coordinated national plan at the central level to fight the pandemic. The Centre already tightly controls major decisions, including additional resources raised specifically for pandemic relief, e.g. the PM CARES Fund.
  • The need for a coordinated strategy on essential supplies of oxygen and vaccines is acute.
  • The Centre can bargain for a good price from vaccine manufacturers in its capacity as a single large buyer like the European Union did for its member states. Centre will also benefit from the economies of scale in transportation of vaccines into the country. Once the vaccines arrive in India, these could be distributed across States equitably in a needs-based and transparent manner.
  • Another benefit of central coordination is that distribution of constrained resources like medical supplies, financial resources can internalise the existing disparities in health infrastructure across States.
  • There is a need for the creation of a “Pandemic Preparedness Unit” (PPU) by the central government. PPU would streamline disease surveillance and reporting systems; coordinate public health management and policy responses across all levels of government. It will also formulate policies to mitigate economic and social costs, and communicate effectively about the health crisis.


  • As and when we emerge on the other side of the pandemic, bolstering public health-care systems has to be the topmost priority for all governments: the Centre as well as States.