Unit 1: Introduction to healthcare delivery system | Indian Medicine and Telemedicine | 3rd Semester of Bachelor of Optometry

Healthcare Delivery System in India at Primary, Secondary, and Tertiary Care

Healthcare delivery is the process through which health services are provided to the population. In India, this system is a combination of public and private sectors, modern medicine, and traditional systems. It is organized in a three-tier structure – primary, secondary, and tertiary care, designed to address the needs of a large and diverse population. Each tier has specific roles, responsibilities, and infrastructure that contribute to the overall health of the community.

1. Overview of Healthcare Delivery System in India

India’s healthcare system has evolved through centuries, influenced by ancient systems like Ayurveda and modern allopathic medicine introduced during colonial rule. Today, the system is a mixed structure, with government-funded services operating parallel to a large private sector.

The Indian Constitution places health under the State List, making states responsible for planning and delivery of healthcare. However, the central government provides policy frameworks, financial support, and national health programs.

The system aims to:

• Provide universal, affordable, and accessible care.
• Reduce health inequalities between rural and urban populations.
• Deliver preventive, promotive, curative, and rehabilitative services.

2. Primary Healthcare

Definition

Primary healthcare is the first level of contact between individuals and the healthcare system. It emphasizes prevention, health promotion, and basic curative care.

Infrastructure

India’s primary healthcare system is structured as follows:

Sub-Centres (SCs):

• The most peripheral unit, covering 5,000 population in plains and 3,000 in hilly/tribal areas.
• Staffed by Auxiliary Nurse Midwives (ANMs) and multipurpose health workers.
• Focus on maternal and child health, immunization, family planning, health education, and basic treatments.

Primary Health Centres (PHCs):

• Cover around 30,000 population in plains and 20,000 in hilly/tribal areas.
• Staffed by one Medical Officer, nurses, and health workers.
• Provide outpatient care, minor surgeries, disease control, maternal-child healthcare, and referral services to higher centers.

Community Health Centres (CHCs):

• Serve as referral centers for PHCs.
• Cover around 120,000 people in plains and 80,000 in hilly/tribal regions.
• Staffed with four specialists: physician, surgeon, gynecologist, and pediatrician.
• Equipped with 30 beds, operation theatre, X-ray, and laboratory facilities.

Role of Primary Healthcare

• Acts as the foundation of India’s healthcare system.
• Provides preventive services like immunization, health education, sanitation programs.
• Promotes safe deliveries, family planning, and nutrition.
• Offers treatment of common diseases and injuries.
• Reduces pressure on higher centers by handling minor ailments locally.

3. Secondary Healthcare

Definition

Secondary care is the second level of healthcare, provided by specialists to patients referred from primary care facilities. It bridges the gap between basic services and advanced treatment.

Infrastructure

Secondary healthcare is delivered mainly through:

District Hospitals:

• Located in every district (approximately 700+ across India).
• Equipped with multiple specialties – medicine, surgery, obstetrics and gynecology, pediatrics, orthopedics, ophthalmology, ENT, and psychiatry.
• Provide both inpatient and outpatient services.
• Have diagnostic laboratories, radiology units, blood banks, and emergency care.

Sub-District/Taluk Hospitals:

• Located between CHCs and district hospitals.
• Provide emergency obstetric care, inpatient services, and specialist consultations.

Role of Secondary Healthcare

• Provide specialized care that PHCs and CHCs cannot handle.
• Offer surgical and advanced diagnostic services.
• Manage complicated deliveries, trauma, infectious diseases, and non-communicable diseases.
• Serve as training centers for healthcare workers.
• Act as a referral hub for multiple PHCs/CHCs.

4. Tertiary Healthcare

Definition

Tertiary care is the highest level of healthcare, involving advanced diagnostic, therapeutic, and surgical procedures. It caters to patients referred from secondary care for conditions requiring super-specialist expertise.

Infrastructure

Tertiary healthcare is provided by:

• Medical Colleges & Teaching Hospitals:
• Offer specialized services in cardiology, neurology, oncology, nephrology, plastic surgery, etc.
• Function as training and research institutions for doctors, nurses, and allied health professionals.

Super-Specialty Hospitals/Institutes:

Examples: All India Institute of Medical Sciences (AIIMS), Postgraduate Institute of Medical Education and Research (PGIMER), National Institute of Mental Health and Neurosciences (NIMHANS), LV Prasad Eye Institute.

Equipped with cutting-edge technology, research facilities, and advanced surgical units.

Role of Tertiary Healthcare

• Handle complex diseases requiring advanced interventions (cancer, organ transplants, cardiac surgeries).
• Provide rehabilitation and palliative care.
• Act as centers for innovation, research, and training of specialists.
• Support national health programs through expertise and outreach.

5. Challenges in the Three-Tier System

Despite this well-planned structure, several challenges affect India’s healthcare delivery:

• Urban-Rural Gap: Majority of tertiary care hospitals are urban, leaving rural populations underserved.
• Human Resource Shortage: Lack of doctors, nurses, and specialists at PHCs and CHCs.
• Infrastructure Gaps: Many centers lack adequate beds, medicines, and diagnostic tools.
• High Out-of-Pocket Expenditure: Nearly 65% of healthcare costs are paid directly by households, leading to financial burden.
• Unequal Distribution: Southern states often have better healthcare indicators than northern and eastern states.
• Coordination Issues: Poor referral linkages between primary, secondary, and tertiary care.

6. Recent Reforms and Initiatives

• National Health Mission (NHM): Strengthened sub-centers, PHCs, and CHCs with more staff and funds.
• Ayushman Bharat – Health and Wellness Centres (HWCs): Upgrading 150,000 sub-centres/PHCs to provide comprehensive primary care.
• Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (PM-JAY): Provides health insurance coverage of ₹5 lakh per family per year for secondary and tertiary hospitalization.
• Telemedicine Initiatives: Bridging rural-urban gap using digital technology and e-health platforms.
• Public-Private Partnerships (PPPs): Collaborations to expand diagnostic and treatment services.

Community Participation in the Healthcare Delivery System

Community participation is the active involvement of local people — individuals, families, groups, and community institutions — in planning, implementing, monitoring, and evaluating health services that affect them. It shifts health from being a top-down provision to a shared responsibility, aligning services with local needs, culture, and priorities. In India, community participation has been recognized as a cornerstone for achieving equitable and sustainable health outcomes, especially in rural and underserved urban areas.

Why community participation matters

• Improves relevance and uptake: When communities are involved, health programs better reflect local beliefs, barriers, and preferences, increasing utilization.
• Enhances accountability: Communities can hold providers and systems accountable for quality, timeliness, and respectful care.
• Builds trust: Collaboration between health workers and community members reduces mistrust and improves adherence to public health measures.
• Strengthens prevention: Community-driven health promotion and disease prevention (sanitation, immunization drives, maternal care) are more effective and sustainable.
• Cost-effective: Community volunteers and local resources often reduce program costs while increasing reach.

Forms and levels of participation

Participation occurs across a spectrum—from passive receipt of services to full partnership or community-led initiatives. Key levels include:

1. Consultation: Communities are consulted for needs assessment or feedback (surveys, focus groups).
2. Collaboration: Shared planning and implementation (community health committees, joint campaigns).
3. Delegated power: Communities are given real decision-making authority (local management of funds, autonomy in program design).
4. Community control: Communities design, manage, and evaluate programs independently or with minimal external inputs.

Institutional mechanisms in India

India has several formal structures that institutionalize community participation at different levels of the health system:

• ASHA (Accredited Social Health Activist): Community health volunteers under the National Health Mission who mobilize households for maternal-child health, immunization, and basic services. ASHAs bridge the community–facility gap and are pivotal for outreach services.
• Gram Panchayats & Panchayati Raj Institutions: Local self-government bodies that can plan and allocate funds for local health priorities and sanitation.
• Village Health Sanitation & Nutrition Committee (VHSNC): A village-level platform for community members, ANMs, ASHAs, and local leaders to review health issues, use untied funds, and coordinate community-level actions.
• Patient Welfare Committees / Rogi Kalyan Samiti: Committees in district and facility-level hospitals that include community representatives to improve facility-level governance and patient services.
• Self-Help Groups (SHGs) and NGOs: Often engage in health promotion, microinsurance, and community financing schemes.

Community participation in public health programs

Examples show how participation strengthens large-scale programs:

• Immunization drives: Local volunteers map households, counter vaccine hesitancy, and organize camps—leading to higher coverage.
• Maternal and newborn care: Home visits by ASHAs and community mobilization for institutional deliveries reduce maternal and neonatal mortality.
• TB and leprosy control: Community treatment supporters ensure adherence to long-term therapy.
• Vector control and sanitation: Community-led total sanitation (CLTS) mobilizes behavior change for open-defecation-free communities.

Role in eye care and optometry

Community participation is especially relevant to eye care services where screening, early detection, and follow-up are essential:

• Community screening camps: Trained volunteers and ASHAs mobilize and help screen for visual impairment and common ocular diseases, increasing community reach.
• Referral and follow-up: Community workers ensure referred patients reach secondary/tertiary centers and adhere to spectacle use, treatment, or surgical appointments.
• Awareness and behavior change: Local campaigns reduce myths about cataract surgery, glaucoma, and childhood blindness, improving care-seeking behavior.
• School eye health: Teachers and parent-teacher associations help in screening and spectacle compliance among children.

Enablers of effective community participation

To make participation meaningful rather than tokenistic, several enablers are necessary:

• Capacity building: Training community volunteers, ASHAs, and committee members in basic health knowledge, communication, and data collection.
• Structured platforms: Regular meetings (VHSNC, facility committees) with clear agendas, minutes, and follow-ups.
• Resource support: Small untied funds, logistical support for outreach, and incentives for volunteers to sustain engagement.
• Information systems: Simple community-led monitoring tools, checklists, and feedback channels to track service quality.
• Legal & policy backing: Laws and policies that recognize community roles, protect volunteers, and decentralize authority and funds.
• Respectful partnerships: Healthcare providers must value community inputs and act on feedback — transforming relationships from paternalistic to participatory.

Challenges and barriers

Despite the promise, community participation faces real-world obstacles:

• Tokenism: Communities may be invited to meetings but lack real decision-making power or resources.
• Unequal representation: Women, marginalized castes, and tribal groups are often underrepresented in committees.
• Volunteer fatigue: ASHAs and volunteers can be overburdened, underpaid, or unpaid, causing dropout and reduced motivation.
• Power imbalances: Health professionals or local elites may dominate decision-making, sidelining community voices.
• Capacity gaps: Low literacy and limited training can restrict meaningful engagement in technical planning or monitoring.

Strategies to strengthen community participation

Practical strategies to deepen and scale participation include:

1. Participatory planning: Use community diagnosis, participatory rural appraisal, and joint priority setting during program design.
2. Decentralized budgeting: Allocate untied funds to village committees with transparent processes and public audits.
3. Gender and equity focus: Ensure women and marginalized groups have seats and voice in committees and leadership roles.
4. Incentives and recognition: Provide non-monetary recognition, certificates, and conditional incentives for volunteers to sustain morale.
5. Digital inclusion: Use mobile tools for community reporting, appointment reminders, and teleconsultation links to specialists.
6. Community scorecards: Regular local scorecards and social audits help track performance and trigger corrective actions.

Measuring impact

Impact of community participation can be assessed using indicators such as:

• Service uptake (immunization, antenatal visits, cataract surgeries)
• Health outcomes (reduced neonatal mortality, improved visual outcomes)
• Process indicators (meeting frequency, fund utilization, referral completion rates)
• Equity measures (service access across gender, caste, and geographic divides)
• Community satisfaction and perceived quality of care

Health System in Developed Countries

Comparing the health system in developed countries with that of developing nations such as India provides valuable insights into organization, financing, quality, and efficiency of healthcare delivery. Developed countries generally have stronger infrastructures, higher investments in health, advanced technology, and comprehensive insurance coverage. Their systems emphasize equity, efficiency, and quality while balancing public and private roles. Studying these models is crucial for shaping reforms in India, especially in terms of universal health coverage and integration of telemedicine.

Defining characteristics of developed country health systems

• Universal access: Most developed nations ensure all citizens have access to essential healthcare, often funded through taxes or mandatory insurance.
• Strong primary care: Primary care physicians (family doctors, general practitioners) act as gatekeepers, reducing unnecessary hospital visits and ensuring coordinated care.
• Robust financing: High percentage of GDP (8–12% or more) invested in healthcare compared to India’s ~2%.
• Advanced technology: Widespread use of diagnostic imaging, electronic health records, telehealth, and AI-driven decision support.
• Quality assurance: Accreditation systems, standard treatment protocols, and continuous monitoring of outcomes.
• Emphasis on prevention: Strong public health programs in immunization, screening, and lifestyle interventions.

Models of healthcare delivery in developed countries

Developed nations use different models to organize healthcare. The most studied ones are:

1. Beveridge Model (e.g., United Kingdom, Spain, New Zealand)
   • Healthcare funded primarily through taxation.
   • Hospitals and providers often owned by the government.
   • Services are provided free or nearly free at the point of delivery.
   • Example: The UK’s National Health Service (NHS) provides comprehensive coverage to all residents with minimal out-of-pocket cost.
2. Bismarck Model (e.g., Germany, France, Japan)
   • Based on mandatory social health insurance funded by employers and employees.
   • Providers are private, but the system is tightly regulated by the government.
   • Ensures universal coverage while allowing competition among insurers.
   • Example: Germany’s statutory health insurance covers over 85% of the population, with high satisfaction levels.
3. National Health Insurance Model (e.g., Canada, South Korea, Taiwan)
   • Hybrid between Beveridge and Bismarck models.
   • Funded by national insurance run by the government.
   • Providers are private, but the payer is public, reducing administrative costs.
   • Example: Canada’s Medicare ensures equal access across provinces, funded through taxes.
4. Private Insurance Model (e.g., United States)
   • Dominated by private insurance companies with employer-based coverage.
   • Government programs like Medicare (for elderly) and Medicaid (for low-income) provide partial safety nets.
   • High-quality care but very high costs and unequal access remain challenges.

Strengths of developed country health systems

• Universal or near-universal coverage: Minimizes catastrophic health expenditure.
• High doctor-patient ratios: Better availability of specialists and general physicians.
• Technological advancement: Cutting-edge diagnostic and therapeutic facilities.
• Strong health workforce training: Continuous medical education and advanced research institutions.
• Better outcomes: Lower maternal mortality, infant mortality, and higher life expectancy.
• Robust surveillance: Early detection of epidemics and efficient response mechanisms.

Weaknesses and challenges

Even advanced systems face certain limitations:

• Cost escalation: High healthcare costs (especially in the USA) lead to unsustainable expenditure.
• Aging populations: Developed nations face increasing burden of geriatric care and chronic diseases.
• Over-medicalization: Overuse of diagnostics and procedures can raise costs without proportional benefits.
• Equity issues: Even with universal coverage, marginalized groups may face access barriers due to geography, language, or discrimination.
• Dependence on technology: Technology-driven care can reduce human touch and lead to inequalities if rural areas lack infrastructure.

Lessons for India from developed countries

1. Strengthening primary care: Family physicians as gatekeepers can reduce unnecessary burden on tertiary hospitals.
2. Universal coverage: Expansion of insurance schemes like PM-JAY can mirror models of Canada and Germany.
3. Regulation of private sector: Transparent pricing and accountability as in Europe can reduce exploitation.
4. Integrated electronic records: Digital health records improve continuity of care and reduce duplication of tests.
5. Focus on prevention: Regular screening programs for hypertension, diabetes, cancers, and vision impairment can reduce long-term costs.
6. Investment in research: Developed nations allocate significant funds for medical research, which India can emulate for innovation.

Application to eye care and optometry

• Universal screening: Developed countries often have organized screening for glaucoma, diabetic retinopathy, and refractive errors.
• Integration of optometrists: Optometrists are an essential part of the healthcare team, reducing specialist workload.
• Advanced technology: Use of teleophthalmology, AI-based retinal scans, and mobile vision testing is common.
• Insurance coverage: Eye surgeries, spectacles, and preventive eye care are usually included in national insurance packages.

Private Sector in Healthcare Delivery System

The private sector plays a dominant role in the healthcare delivery system of India and other developing nations. It refers to health services provided by individuals, corporate hospitals, charitable trusts, and non-governmental organizations outside the direct control of the government. While public facilities are intended to ensure universal access, the reality is that more than 70% of outpatient care and about 60% of inpatient care in India is delivered by the private sector. Understanding the scope, strengths, and weaknesses of private health services is essential to design policies that balance accessibility, affordability, and quality.

Nature and scope of private healthcare sector

The private sector is highly diverse, ranging from informal providers to world-class corporate hospitals:

• Informal practitioners: Local healers, unqualified practitioners, and chemists providing basic treatments, especially in rural areas.
• Individual clinics: Registered doctors running small outpatient clinics, often the first point of contact for urban and semi-urban populations.
• Nursing homes and small hospitals: 10–50 bedded facilities managed by medical practitioners providing maternity, surgical, and general care.
• Corporate hospitals: Large multispecialty or super-specialty hospitals offering advanced diagnostics, surgeries, and critical care.
• Charitable and trust hospitals: Non-profit facilities providing subsidized or free care alongside paid services.
• Diagnostic and pharmacy chains: Imaging centers, laboratories, and pharmacies that support the care ecosystem.
• Insurance and telemedicine providers: Emerging private enterprises delivering financial protection and digital health services.

Growth of the private sector in India

The private sector expanded significantly after the 1980s due to liberalization, rising income levels, and perceived inadequacies in public healthcare. Key drivers include:

• Public sector limitations: Overburdened government facilities with staff shortages and poor infrastructure pushed people to private providers.
• Economic liberalization: Investment-friendly policies encouraged private hospitals and medical tourism.
• Urbanization: Growth of middle-class populations demanding high-quality and specialized care.
• Medical technology: Corporate hospitals rapidly adopted advanced diagnostics, telemedicine, and robotic surgeries.
• Insurance penetration: Health insurance schemes widened access to costly private care.

Contributions of private healthcare sector

1. Accessibility: In many areas, especially urban centers, private facilities are more accessible and have shorter waiting times compared to government hospitals.
2. Quality and innovation: Corporate hospitals often offer world-class care, advanced technology, and specialized expertise.
3. Employment: The sector employs millions of doctors, nurses, pharmacists, and allied health workers, contributing to the economy.
4. Medical tourism: India has become a hub for affordable, high-quality treatments (cardiac surgery, organ transplants, eye surgeries) attracting international patients.
5. Complementing public services: Private players often fill gaps left by public facilities, particularly in diagnostics, maternity care, and elective surgeries.

Limitations and criticisms

Despite its strengths, the private sector also has significant drawbacks:

• High cost: Treatment in private hospitals is often unaffordable for poor and middle-income groups.
• Over-commercialization: Profit motives sometimes lead to unnecessary diagnostic tests, procedures, and prolonged hospitalization.
• Unequal distribution: Private hospitals are concentrated in cities, while rural areas depend on unqualified practitioners.
• Lack of regulation: Many small facilities operate without proper licensing, quality checks, or standard treatment protocols.
• Ethical concerns: Issues like denial of care for non-paying patients, lack of transparency in billing, and conflict of interest arise.
• Limited preventive care: Focus is primarily on curative, revenue-generating services rather than prevention and health promotion.

Role in public-private partnerships (PPPs)

Recognizing its dominance, governments are increasingly engaging private providers in structured partnerships:

• National Health Mission: Contracting private doctors for maternal and child healthcare in underserved areas.
• Ayushman Bharat (PM-JAY): Empaneling private hospitals to provide cashless secondary and tertiary care to insured families.
• Diagnostic services: Outsourcing advanced imaging and lab services to private firms under government schemes.
• Telemedicine collaborations: Private digital health companies supporting outreach in remote areas.

Private sector in eye care and optometry

• Specialty eye hospitals: Organizations like Aravind Eye Care, LV Prasad Eye Institute, and Sankara Nethralaya are leaders in affordable, quality eye care.
• Vision centers: Private clinics and optical outlets provide refractive services, spectacles, and low vision aids.
• Medical technology adoption: Use of advanced imaging (OCT, fundus photography) and surgical tools for cataract and refractive surgeries.
• Research and innovation: Private eye care institutions contribute to research in teleophthalmology, community screening, and low-cost surgical techniques.

Regulation and future directions

To maximize benefits while addressing challenges, stronger governance is required:

• Standard treatment protocols: Implementing evidence-based guidelines across private facilities.
• Transparent pricing: Regulating costs of procedures, drugs, and devices.
• Quality accreditation: Encouraging NABH (National Accreditation Board for Hospitals) certification for uniform quality.
• Integration with public health: Strengthening PPPs for preventive, promotive, and rehabilitative services.
• Equitable distribution: Incentives for private providers to operate in rural and underserved regions.

National Health Mission (NHM)

The National Health Mission (NHM) is one of the most significant health sector initiatives launched by the Government of India to strengthen healthcare delivery, particularly for vulnerable populations. Originally launched in 2005 as the National Rural Health Mission (NRHM), it was later expanded in 2013 to include the National Urban Health Mission (NUHM), together forming the NHM. Its overarching goal is to provide accessible, affordable, and quality healthcare, especially for rural, poor, and marginalized communities, by strengthening health systems at the primary, secondary, and community levels.

Objectives of NHM

• Reduce maternal, infant, and child mortality rates.
• Control communicable and non-communicable diseases through integrated programs.
• Provide universal access to equitable, affordable, and quality healthcare services.
• Strengthen rural and urban health systems with special focus on infrastructure, human resources, and community participation.
• Promote preventive, promotive, and rehabilitative healthcare.
• Reduce out-of-pocket expenditure by expanding free drugs, diagnostics, and insurance schemes.

Structure of NHM

The NHM consists of two major sub-missions:

1. National Rural Health Mission (NRHM) (2005)
   • Focus on strengthening healthcare in rural areas, especially underserved states and districts.
   • Improvement of sub-centres, PHCs, and CHCs.
   • Introduction of ASHA (Accredited Social Health Activist) workers as community-level volunteers.
2. National Urban Health Mission (NUHM) (2013)
   • Targets urban poor populations living in slums and marginalized settlements.
   • Establishment of Urban Primary Health Centres (UPHCs) and outreach through Urban Social Health Activists (USHAs).

Key components of NHM

• Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCH+A): Comprehensive approach to reduce maternal and child mortality.
• Communicable Disease Control: Programs for malaria, TB, leprosy, and HIV/AIDS.
• Non-Communicable Disease Control: Screening and management of diabetes, hypertension, cancer, and mental health conditions.
• Health Systems Strengthening: Upgrading infrastructure, human resources, essential drugs, and diagnostic services.
• Community Participation: Village Health Sanitation & Nutrition Committees (VHSNCs), Rogi Kalyan Samitis (RKS), and ASHA involvement.
• Health and Wellness Centres (HWCs): Converting sub-centres and PHCs into comprehensive primary healthcare facilities.

Achievements of NHM

• Maternal and child health: Institutional deliveries increased significantly due to Janani Suraksha Yojana (JSY) and Janani Shishu Suraksha Karyakram (JSSK).
• Immunization: Improved coverage with Mission Indradhanush and intensified immunization drives.
• ASHA workers: Over 1 million ASHAs mobilized to provide community-level care and promote health awareness.
• Infrastructure: Thousands of new PHCs, CHCs, and district hospitals upgraded with beds, specialists, and diagnostic facilities.
• Health financing: Free drugs, diagnostics, and diet under NHM schemes reduced out-of-pocket costs.
• Urban outreach: NUHM established thousands of UPHCs to reach urban slum populations.
• Telemedicine and digital health: E-health and teleconsultation models piloted under NHM frameworks.

Challenges faced by NHM

• Unequal progress: Some states (Kerala, Tamil Nadu) show high success, while others lag due to governance and resource gaps.
• Human resource shortages: Inadequate doctors, nurses, and specialists at PHCs and CHCs.
• Quality of care: Variable quality across facilities; many still lack essential drugs and equipment.
• Urban healthcare: Despite NUHM, urban poor often lack effective outreach and follow-up care.
• Monitoring and accountability: Challenges in ensuring transparency, reducing corruption, and effective fund utilization.

Role in eye care and optometry

NHM has played a role in strengthening eye care services through integration with national programs:

• National Programme for Control of Blindness & Visual Impairment (NPCBVI): Supported by NHM funds to expand cataract surgeries, refractive error correction, and school eye screening.
• Community outreach: ASHAs mobilize patients for cataract surgeries and spectacle compliance among children.
• School health programs: Screening of school children for visual problems and referral to optometrists or ophthalmologists.
• Integration with HWCs: Vision screening and management of common eye conditions included in primary care packages.

Future directions

• Expansion of Health and Wellness Centres for comprehensive primary care including vision, dental, and mental health.
• Greater emphasis on digital health and telemedicine to reach rural and remote populations.
• Improved training and deployment of optometrists and allied health professionals at primary care level.
• Strengthening public-private partnerships to expand coverage of diagnostics and super-specialty care.
• Focus on non-communicable diseases and lifestyle conditions including diabetes-related eye complications.

National Health Policy (NHP)

The National Health Policy (NHP) is the guiding framework for India’s healthcare sector, shaping strategies, programs, and priorities to achieve better health outcomes. It outlines the government’s vision for providing accessible, affordable, and quality health services to all citizens. India has had three major health policies—NHP 1983, NHP 2002, and the most recent NHP 2017. Each policy was formulated in response to the changing health needs, challenges, and socio-economic conditions of the country. Understanding the evolution and objectives of these policies provides clarity on India’s approach to universal health coverage.

Evolution of National Health Policy

1. NHP 1983
   • First official health policy after independence.
   • Focused on universal, comprehensive primary healthcare as part of the Alma Ata Declaration (1978).
   • Emphasized rural health infrastructure—sub-centres, PHCs, CHCs—and training of health workers.
   • Prioritized control of communicable diseases, maternal and child health, and family planning.
   • Target: Achieve “Health for All by 2000.”
2. NHP 2002
   • Focused on emerging non-communicable diseases, privatization, and use of advanced technology.
   • Emphasized increased public health expenditure (aim: 2% of GDP by 2010).
   • Encouraged public-private partnerships and health insurance expansion.
   • Strengthened decentralization through Panchayati Raj institutions.
   • Prioritized the growing burden of HIV/AIDS, tobacco use, and lifestyle-related illnesses.
3. NHP 2017
   • Latest health policy aligned with Sustainable Development Goals (SDGs).
   • Focus: Universal Health Coverage (UHC) and reduction of out-of-pocket expenditure.
   • Promoted use of digital health, telemedicine, and e-health systems.
   • Introduced the concept of Health and Wellness Centres (HWCs) for comprehensive primary care.
   • Recognized the rising burden of non-communicable diseases, mental health, and geriatric care.

Key goals of NHP 2017

• Increase public health spending: Raise it to 2.5% of GDP by 2025.
• Reduce out-of-pocket expenditure: Expand insurance coverage and provide free essential drugs and diagnostics.
• Strengthen primary care: Upgrade sub-centres and PHCs into Health and Wellness Centres.
• Preventive and promotive health: Greater investment in vaccination, screening, and lifestyle modification.
• Improve quality of care: Standard treatment protocols, accreditation, and patient safety initiatives.
• Human resources: Train and deploy more doctors, nurses, optometrists, and allied health workers, especially in rural areas.
• Digital health: Expand electronic health records, telemedicine, and mobile health applications.
• Equity: Reduce health disparities among states, regions, gender, and socio-economic groups.

Strategies under NHP 2017

1. Comprehensive primary healthcare: Expansion of services beyond maternal-child health to include NCDs, mental health, and palliative care.
2. Assurance-based approach: Government ensures essential health services rather than only infrastructure expansion.
3. Multi-sectoral action: Collaboration across water, sanitation, nutrition, and environment to improve health determinants.
4. Public-private partnerships: Leverage private sector to expand reach while ensuring affordability.
5. Community participation: Strengthening Village Health Committees, ASHAs, and patient feedback systems.

Achievements and progress

• Launch of Ayushman Bharat (2018) with two components: HWCs and PM-JAY insurance scheme.
• Improved immunization coverage through Mission Indradhanush.
• Expansion of digital health platforms like eSanjeevani teleconsultation service.
• Focus on mental health with the National Mental Health Policy (2014) integrated into NHP goals.
• Reduction in MMR and IMR due to strengthened maternal-child health services.

Challenges in implementation

• Funding gap: Despite targets, public health expenditure still hovers around 1.2–1.5% of GDP.
• State variations: Kerala, Tamil Nadu, and Himachal show strong progress, while poorer states lag behind.
• Infrastructure gaps: Many PHCs and CHCs lack doctors, nurses, or essential equipment.
• Human resource shortages: Vacancies for specialists, especially in rural areas, hinder universal coverage.
• Monitoring issues: Weak accountability mechanisms reduce effectiveness of schemes.

Implications for eye care and optometry

The NHP 2017 recognized eye health as a critical component of primary care. Its integration with the National Programme for Control of Blindness and Visual Impairment (NPCBVI) has strengthened:

• School eye screening programs for refractive errors.
• Provision of free spectacles to children with uncorrected vision problems.
• Cataract surgical programs in rural and underserved areas.
• Inclusion of optometrists in primary healthcare teams.
• Use of teleophthalmology for diabetic retinopathy screening.

Issues in Healthcare Delivery System in India

India’s healthcare delivery system is vast, diverse, and structured into primary, secondary, and tertiary care. Despite significant progress over the past decades, the system faces multiple challenges that limit its effectiveness in ensuring equitable, affordable, and quality health services for all citizens. These issues arise from structural gaps, resource shortages, socio-economic inequalities, and governance challenges. Understanding these limitations is crucial for framing policies and reforms to strengthen the health system and move closer to universal health coverage.

1. Urban–rural disparities

A major issue is the unequal distribution of health facilities and professionals. Nearly 65–70% of India’s population resides in rural areas, yet most tertiary hospitals, specialists, and advanced diagnostic facilities are concentrated in urban regions. Rural populations depend heavily on sub-centres, PHCs, and informal providers, many of which lack infrastructure and trained staff. This leads to delayed treatment, under-diagnosis, and higher disease burden in rural communities.

2. Inadequate public health expenditure

India spends around 1.2–1.5% of GDP on public healthcare, one of the lowest among major economies. Limited funding results in poor infrastructure, stock-outs of essential medicines, and inadequate salaries for healthcare workers. This underfunding forces citizens to seek private care, leading to higher out-of-pocket expenditure and financial hardship.

3. Human resource shortages

India faces a shortage of doctors, nurses, and allied health professionals. According to WHO recommendations, the doctor–population ratio should be 1:1000, but India’s ratio remains around 1:1500, with severe rural-urban imbalances. Specialists such as anesthetists, ophthalmologists, and pediatricians are scarce at the CHC and district hospital levels. Many PHCs operate without a single doctor, reducing confidence in public services.

4. Fragmented infrastructure

Infrastructure is often inadequate or poorly maintained. Many facilities lack basic amenities such as clean water, electricity, and functional toilets. Sub-centres and PHCs are under-equipped, and CHCs often lack specialists. Overcrowding in district hospitals and tertiary centers reflects the weak referral linkages between different levels of care.

5. High out-of-pocket expenditure

Around 65% of health expenditure in India is borne directly by households. Costs of medicines, diagnostics, and hospitalization often push families into poverty. Private sector dominance in secondary and tertiary care, combined with weak insurance coverage, worsens financial vulnerability. Even Ayushman Bharat’s PM-JAY covers hospitalization but not many outpatient or diagnostic costs, leaving gaps in protection.

6. Disease burden transition

India is experiencing a double burden of disease. While infectious diseases like TB, malaria, and diarrheal diseases persist, non-communicable diseases (NCDs) such as diabetes, hypertension, cancer, and cardiovascular conditions are rising sharply. The healthcare system struggles to balance resources for both communicable and lifestyle-related diseases, leading to fragmented responses.

7. Quality of care

Quality in healthcare is inconsistent across facilities. Many small private clinics and rural hospitals lack accreditation and follow non-standardized treatment protocols. Over-prescription of antibiotics, unnecessary diagnostic tests, and variable surgical outcomes undermine patient trust and waste resources. Patient safety mechanisms are weak in most facilities.

8. Lack of effective referral system

Ideally, primary centers should manage minor illnesses and refer complicated cases to higher centers. In India, weak referral linkages and lack of trust in PHCs drive patients directly to tertiary hospitals, causing overcrowding. This results in inefficient use of resources, longer waiting times, and reduced quality of care in urban hospitals.

9. Governance and accountability issues

Weak regulatory mechanisms allow unlicensed practitioners, poor quality standards, and corruption in procurement and service delivery. Many state governments struggle with monitoring fund utilization, maintaining supply chains, and ensuring transparency in public health programs. Decentralization efforts under Panchayati Raj institutions are often unevenly implemented.

10. Inequities in access

Marginalized groups such as women, children, elderly, tribal communities, and the urban poor often face barriers in accessing healthcare. Social and cultural factors, lack of awareness, and discrimination further worsen health inequities. Gender biases often delay women’s care-seeking for eye conditions, maternal health, and chronic illnesses.

11. Rising cost of private care

Private hospitals offer advanced care but at high costs, making them inaccessible to lower-income groups. Profit motives sometimes lead to over-medicalization—unnecessary surgeries, diagnostic tests, or extended hospital stays. Lack of transparent pricing and inadequate regulation exacerbate financial strain on patients.

12. Limited preventive and promotive healthcare

The system remains heavily curative-focused. Preventive strategies like screening for hypertension, diabetes, cancers, and eye diseases are still inadequately integrated at the primary level. Health promotion through lifestyle education, nutrition awareness, and community engagement receives insufficient emphasis.

13. Technology and digital divide

Although telemedicine and digital health initiatives are growing, rural populations often face barriers due to poor internet connectivity, lack of digital literacy, and limited access to smartphones. This restricts the scaling of digital health innovations.

14. Eye care challenges within the system

India faces a significant burden of preventable blindness and visual impairment. Issues include:

• Insufficient integration of optometrists at primary care levels.
• Unequal access to cataract surgeries, especially in rural and tribal areas.
• Low compliance with spectacle use in children due to affordability and social stigma.
• Inadequate screening for diabetic retinopathy and glaucoma at PHCs.

Strategies to address challenges

• Increase public health spending to at least 2.5% of GDP.
• Strengthen PHCs and CHCs with better staffing, infrastructure, and medicines.
• Expand insurance coverage beyond hospitalization to outpatient and diagnostics.
• Improve regulation of private sector with transparent pricing and treatment standards.
• Train and deploy more doctors, nurses, optometrists, and allied health professionals in underserved areas.
• Adopt technology and telemedicine to bridge rural–urban healthcare divide.
• Integrate preventive eye care and vision screening into school and community health programs.

National Health Programmes – Objectives, Action Plan, Targets, Operations, Achievements, and Constraints

India implements a wide range of National Health Programmes (NHPs) to address priority health challenges in a systematic and targeted manner. These programs are designed to control communicable and non-communicable diseases, improve maternal and child health, reduce nutritional deficiencies, and prevent blindness and disabilities. Each programme has well-defined objectives, action plans, targets, and operational strategies, but also faces implementation challenges. Understanding their structure provides insight into India’s public health response.

1. Objectives of National Health Programmes

• Control and eliminate communicable diseases such as malaria, TB, leprosy, and HIV/AIDS.
• Prevent and manage non-communicable diseases like cancer, diabetes, hypertension, and blindness.
• Reduce maternal and child mortality through reproductive and child health initiatives.
• Strengthen nutrition and address micronutrient deficiencies (iodine, iron, vitamin A).
• Enhance access to essential drugs, vaccines, and diagnostics.
• Provide rehabilitation and support for disabilities and chronic diseases.
• Promote equity by prioritizing rural, tribal, and underserved populations.

2. Action Plan and Strategies

National health programmes adopt a multi-tiered strategy integrating prevention, diagnosis, treatment, and community participation. Key action plans include:

• Preventive measures: Immunization, health education, sanitation, vector control, and lifestyle interventions.
• Early detection: Screening at sub-centres, PHCs, and schools for diseases like TB, diabetes, hypertension, and refractive errors.
• Treatment and rehabilitation: Free treatment services, referral linkages, and rehabilitation for chronic conditions.
• Capacity building: Training ASHAs, ANMs, and doctors to deliver program-specific services.
• Community participation: Involvement of Village Health Committees and NGOs in mobilization and awareness campaigns.
• Integration with NHM: Convergence of disease control and health promotion with the primary healthcare system.

3. Major National Health Programmes

a. Reproductive and Child Health (RCH) Programme

• Focus on maternal care, institutional deliveries, child immunization, and adolescent health.
• Key schemes: Janani Suraksha Yojana (JSY), Janani Shishu Suraksha Karyakram (JSSK).
• Achievements: Decline in maternal mortality ratio (MMR) and infant mortality rate (IMR).
• Constraints: Regional disparities, poor quality of maternal services in some states.

b. National Tuberculosis Elimination Programme (NTEP)

• Goal: Eliminate TB by 2025 (ahead of WHO’s 2030 target).
• Action plan: Free diagnostics, Directly Observed Therapy (DOT), nutritional support, and private sector engagement.
• Achievements: Expansion of molecular diagnostics, increased case notifications.
• Constraints: Rising multidrug-resistant TB, treatment adherence challenges.

c. National Vector-Borne Disease Control Programme (NVBDCP)

• Targets malaria, dengue, chikungunya, Japanese encephalitis, and filariasis.
• Strategies: Bed nets, insecticide spraying, rapid diagnostics, and treatment kits.
• Achievements: Significant reduction in malaria incidence and mortality.
• Constraints: Insecticide resistance, climate-related disease spread.

d. National AIDS Control Programme (NACP)

• Objective: Prevent and control HIV/AIDS spread and provide ART (antiretroviral therapy).
• Strategies: Condom promotion, awareness, screening centers, ART distribution.
• Achievements: Decline in HIV prevalence and improved life expectancy of PLHIV.
• Constraints: Stigma, discrimination, and funding gaps.

e. National Programme for Control of Blindness and Visual Impairment (NPCBVI)

• Launched in 1976, renamed as NPCBVI in 2017.
• Objective: Reduce the prevalence of blindness to 0.25% by 2025.
• Action plan: Cataract surgery camps, refractive error correction, free spectacles for children, school screenings.
• Achievements: Millions of cataract surgeries performed annually, improved spectacle distribution.
• Constraints: Unequal access in rural/tribal areas, low compliance with spectacle use in children.

f. National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke (NPCDCS)

• Objective: Early detection and management of NCDs at primary health centers.
• Action plan: Screening at HWCs, training of ASHAs and ANMs, NCD clinics at district hospitals.
• Achievements: Widespread screening for diabetes and hypertension under Ayushman Bharat.
• Constraints: Shortage of medicines, lack of specialists in rural areas.

g. National Mental Health Programme (NMHP)

• Objective: Ensure availability and accessibility of mental health care.
• Action plan: District Mental Health Programme, training general physicians in psychiatry.
• Achievements: Increased awareness and service availability in urban areas.
• Constraints: Severe shortage of psychiatrists and counselors, stigma associated with mental illness.

h. Universal Immunization Programme (UIP)

• Objective: Immunize children against vaccine-preventable diseases.
• Action plan: Mission Indradhanush to achieve full immunization coverage.
• Achievements: Increased coverage, introduction of new vaccines (rotavirus, pneumococcal).
• Constraints: Dropouts in remote areas, vaccine hesitancy.

4. Achievements of National Health Programmes

• Improved life expectancy from ~63 years (2000) to 70+ years (2022).
• Significant decline in maternal and infant mortality.
• Control of leprosy and near-elimination of polio.
• Increased institutional deliveries and immunization coverage.
• Expansion of cataract surgeries, refractive error correction, and blindness prevention.

5. Constraints and Challenges

• Unequal performance across states due to socio-economic and governance gaps.
• Human resource shortages at PHCs, CHCs, and district hospitals.
• Funding constraints and delays in program implementation.
• Weak monitoring, data collection, and accountability systems.
• Community participation still limited in some programs.
• Stigma, myths, and cultural barriers affecting program uptake (HIV, mental health, spectacles use).

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