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Health & Wellbeing

A health system that reaches every family.

Infant mortality has reached its lowest recorded level, but a child in Chhattisgarh is seven times more likely to die before age one than a child in Kerala. [2] Government health spending has risen — then retreated after the pandemic — and households are again paying a rising share of health costs directly. [1] These are not separate stories; they are the same story at different stages. This brief sets out where India stands, why, and a costed five-year plan to close the gap.

35 sources · methodology

Where India stands

The numbers, sourced.

1.43%[1]

Government health expenditure as a share of GDP

NHA 2022-23

Down from 1.84% in FY22 as COVID-era public spending normalised. [1] The National Health Policy 2017 target of 2.5% by 2025 has been missed. [4]

43.4%[1]

Out-of-pocket expenditure as a share of total health spending

NHA 2022-23

Up from 39.4% in the COVID-distorted year 2021-22. [3] The longer-term trend is an improvement from 64.2% in 2013-14, but the post-pandemic reversal is real. [1]

₹1,06,530 cr[5]

Union Budget 2026-27 allocation to the Ministry of Health and Family Welfare

Union Budget 2026-27

Includes ₹39,390 crore for the National Health Mission, ₹9,500 crore for PM-JAY, and ₹4,770 crore for PM-ABHIM. [5]

25 per 1,000[2]

Infant mortality rate (live births)

SRS 2023

Down from 32 in 2018. Kerala is at 5; Chhattisgarh, Madhya Pradesh, and Uttar Pradesh are at 37 — a seven-fold spread. [2]

88 per 100,000[6]

Maternal mortality ratio (live births)

SRS MMR Bulletin 2020-22

Down from 130 in 2014-16. [6] Assam's MMR remains several times Kerala's — the interstate gap is the central fact of Indian maternal health. [6]

19 per 1,000[7]

Neonatal mortality rate (live births), 2021

SRS / PIB 2025

Under-five mortality was 31 per 1,000 in the same year. [7] Neonatal deaths — concentrated in the first month of life — now dominate child mortality and depend on facility quality, not just outreach.

62%[8]

Share of deaths in India attributable to non-communicable diseases

GBD 2016 / PIB 2022

Up from about 38% in 1990. [8] Cardiovascular disease, diabetes, chronic respiratory disease, and cancers are now the main killers, yet the public system was built for infections and childbirth.

35.5% / 57%[9]

Children under 5 stunted / women aged 15-49 anaemic

NFHS-5 2019-21

67% of children aged 6-59 months are anaemic. Anaemia among women worsened relative to NFHS-4 (53% in 2015-16). [9] No NFHS-6 national report has been released as of June 2026.

5 + 6 per 10,000[10]

Active qualified doctors and nurses/midwives per 10,000 population

NSSO 2017-18 / Karan et al. 2021

Against the WHO threshold of 44.5 doctors-nurses-midwives combined per 10,000. [10] The nurse-to-doctor ratio is inverted relative to well-functioning systems.

79.9%[11]

Specialist shortfall at rural Community Health Centres

RHS 2022-23

4,413 specialists in place against 21,964 required. Surgeons: 83.3% short; physicians: 81.9% short; paediatricians: 80.5% short; obstetrician-gynaecologists: 74.2% short. [11]

0.79 per 1,000[12]

Government hospital beds per 1,000 population

Knight Frank-Berkadia, 2023

Against the National Health Policy 2017 norm of 2 public beds per 1,000. [12] Over 60% of all beds are private and concentrated in cities. [13]

~55 crore[14]

People covered under Ayushman Bharat PM-JAY (₹5 lakh per family per year of cashless hospitalisation)

NHA, accessed 2026

Over 42 crore Ayushman cards issued by late 2025. [14] Card issuance is an enrolment metric, not a utilisation or financial-protection metric.

1.78 lakh[15]

Ayushman Arogya Mandirs operationalised (expanded primary care with NCD screening)

MoHFW 2025

Operationalisation is an input measure — staffing, drug stocks, and footfall vary widely by state. [15]

Why it hasn't changed

The root causes.

  • Public financing is low — and what exists is not fully absorbed

    At 1.43% of GDP (NHA 2022-23), India's public health spending is among the lowest of major economies relative to income. [1] But money alone is not the binding constraint everywhere: National Health Mission fund utilisation has been chronically incomplete. Unspent NHM balances with states rose to ₹9,509 crore by 2015-16; [17] NIPFP's analysis documents low absorption concentrated in precisely the states with the weakest health outcomes, driven by missing complementary inputs. [16] CAG audits found state treasuries took 50 to 271 days to move released funds to health societies. [16] Raising spending without fixing the plumbing produces lapsed budgets, not health.

  • The workforce is too small, wrongly mixed, and badly distributed

    With roughly 5 qualified active doctors and 6 nurses/midwives per 10,000 population, India is short by an estimated 1.5-1.8 million workers against the WHO 44.5 threshold. [10] The shortage is most acute for nurses and for specialists in rural facilities — 80% specialist shortfall at rural Community Health Centres. [11] More than 20% of qualified professionals are not in the health labour market at all. [10] This is a retention and posting problem, not just a production problem.

  • Primary care is too weak to manage the non-communicable disease transition

    With roughly 62% of deaths from chronic disease, [8] the system needs continuous, protocol-based care close to home: screening, cheap generic drugs, follow-up. The India Hypertension Control Initiative had enrolled over 4 million patients by 2022 — important progress, but roughly 12.5% of the estimated hypertensive population in covered areas. [28] Untreated chronic disease surfaces later as expensive hospitalisation — the most regressive way to buy health.

  • Medicines and diagnostics drive impoverishing payments

    Medicines are the single largest component of household out-of-pocket spending in NHA estimates. [1] Where states have not built reliable free-drug systems, patients buy from private pharmacies at retail prices. Before Uttar Pradesh's supply-chain redesign, overall essential medicine availability across public warehouses was around 34% at the December 2020 baseline. [21] The combination of empty shelves and uninsured households is what drives impoverishment.

  • Governance is thin: no public health cadres and weak audit

    Tamil Nadu is the only large state with a full directorate of public health staffed by a dedicated, trained public health cadre at district level, under a Public Health Act dating to 1939. [19] Most states assign public health functions to clinicians without public health training or career tracks. On the demand side, the CAG's 2023 performance audit of PM-JAY found 9.85 lakh beneficiaries linked to a single mobile number, claims paid for patients recorded as dead (₹6.97 crore across 3,903 claims), and ₹57.53 crore of excess payments to providers in four states. [18] Fraud controls and data quality lag the scheme's scale.

  • Dual practice and an unregulated private sector

    The private sector delivers over 70% of outpatient care and holds over 60% of hospital beds. [12] Public-sector workforce expansion is partially offset by dual practice: doctors holding government posts who also run private clinics. The best multi-state household evidence finds PM-JAY associated with a shift toward private facilities, [31] meaning the scheme is financing private-sector growth rather than substituting it. Any plan that strengthens the public system without acknowledging private-sector lock-in will find out-of-pocket and NCD control targets harder to reach.

  • Federal inequality compounds everything

    Kerala's infant mortality rate is 5 per 1,000; Madhya Pradesh, Uttar Pradesh, and Chhattisgarh are at 37 per 1,000 — a seven-fold spread. [2] Assam's maternal mortality ratio remains several times Kerala's. [6] The states with the worst outcomes also have the lowest per-capita health spending, weakest absorption, and thinnest workforce. [16] A national average is a misleading target; the policy problem is disproportionately an eight-state problem.

What has worked

Benchmarks and precedents.

Around the world

International

Thailand

Out-of-pocket spending fell from 34% to 11% of total health expenditure after the Universal Coverage Scheme launched in 2002

Thailand's tax-financed Universal Coverage Scheme, built on capitation payment to primary-care networks and a strong purchaser (the National Health Security Office), covered the informal sector from 2002. Measured outcomes: the incidence of catastrophic health spending fell from about 6% in 1996 to under 3-4% within the first decade; out-of-pocket share of current health expenditure fell from 34% in 2000 to 11% by 2017. [22] Government share of health spending rose from 65% in 2002 to 78% in 2016. [22] Transferability caveat: Thailand spent decades building district hospitals and a rural health workforce before 2002, and is a unitary state of 70 million people. India must do workforce-building and coverage expansion simultaneously, state by state.

International

Brazil — Family Health Strategy

Family Health Strategy expansion associated with falling infant mortality in 73% of Brazilian municipalities

Salaried teams — a doctor, nurse, and 4-6 community health agents — each cover a defined catchment of about 3,500 people and deliver proactive primary care within the SUS universal system. A national municipal panel study found the programme's expansion was associated with falling infant mortality in 73% of Brazilian municipalities; the effect is strongest on post-neonatal deaths, which primary care can most plausibly prevent. [23] A sub-national study from Paraná's third health region illustrates the pattern: infant mortality fell from 17.1 to 10.7 per 1,000 as coverage rose from 44% to 66% between 2005 and 2016 — a regional figure, not nationally representative. [24] Transferability caveat: these are panel associations with selection issues; Brazil pays community health agents full salaries, unlike India's honorarium-based ASHAs.

International

Sri Lanka

Maternal mortality around 18 per 100,000 and infant mortality near 5 per 1,000, achieved at roughly 3% of GDP in total health spending

Sri Lanka built outcomes on free public primary care and a cadre of salaried public health midwives attending 98%+ of institutional deliveries, with no period of high health expenditure. [25] The CGD case study provides institutional detail; current statistics are from WHO/World Bank global health databases. Transferability caveat: small country, high female literacy, century-long head start on civil registration and community-based care.

Within India

India

Tamil Nadu

Infant mortality rate 18, under-5 mortality 22, maternal mortality 60 — all far below national averages of the same vintage

Two institutions underpin Tamil Nadu's performance. First, the Directorate of Public Health, staffed by a dedicated public-health-trained cadre managing districts under the Tamil Nadu Public Health Act, 1939. [19] Second, the Tamil Nadu Medical Services Corporation: centralised tendering for a stable essential drugs list, district warehouses, passbook-based facility drawing rights, and pre-dispatch quality testing. [19] Dvara Research's compilation of NFHS-5 2019-21 and SRS 2016-18 state indicators confirms the outcome advantage. [20] Transferability caveat: TN's results reflect over 80 years of institutional accumulation and high female literacy; the cadre and corporation are replicable, the head start is not.

India

Uttar Pradesh — supply-chain redesign

Essential medicine availability in public warehouses rose from 34% to 88% after redesign on the TNMSC model (December 2020 to July 2024)

When UP redesigned its medicines supply chain on the Tamil Nadu model, overall availability of essential medicines across all warehouses improved from 34% to 88%; average availability per warehouse improved from 27% to 97%, with an average of 275 of 287 listed medicines in stock per warehouse by mid-2024. [21] These are warehouse-level figures; the paper does not separately report facility-level availability after redesign, so the last-mile picture is not fully captured. Transferability caveat: supply-chain programme evaluation, not a randomised study; selection effects and parallel improvements cannot be ruled out.

India

Chhattisgarh — Mitanin community health workers

Quasi-experimental evaluation estimated annual reductions of 4-5% in underweight and 5-6% in stunting in programme areas

Nearly 70,000 women community health workers covering virtually all rural hamlets, selected by communities and supported by a dedicated technical body — the explicit prototype for the national ASHA programme. [26] [27] Qualitative evaluations document effective community action on nutrition entitlements and gender-based violence. Transferability caveat: not a randomised controlled trial; causal attribution is uncertain; effects depend on the State Health Resource Centre-style support structure that several states copying the ASHA form did not copy in substance.

India

Kerala — Aardram Family Health Centres

Family Health Centres delivered higher annual outpatient utilisation and offered services — depression and COPD screening — that ordinary PHCs did not

A 2024 facility survey found that upgraded Family Health Centres averaged 11,343 versus 9,580 outpatient visits per 10,000 population in comparable primary health centres, and offered expanded services including NCD and mental-health screening. [30] Transferability caveat: early-stage, facility-level evidence; Kerala's baseline human development is exceptional and cannot be assumed elsewhere.

“Every number here has a receipt. Every proposal names who does it, what it costs, and what could go wrong.”

Sabka Sarkar — evidence standard

What we propose

Costed interventions.

Each intervention names a problem, a causal mechanism, a measurable target, who implements it, what it costs, and the honest risks.

01

Raise public health spending to 2.5% of GDP — tied to absorption reform

The problem

Government health expenditure stands at 1.43% of GDP (NHA 2022-23). [1] The National Health Policy 2017 target of 2.5% by 2025 has been missed. [4] Simultaneously, NHM funds go unspent in weak states: treasury delays of 50-271 days have been documented by CAG. [16] The most recent documented NHM utilisation was roughly 71% across surveyed states in FY2015-16. [16] [17]

The intervention

A centre-state compact: the centre raises NHM and PM-ABHIM transfers on a published glide path; states qualify for increments by (a) transferring funds from treasury to implementing societies within 15 days, (b) filling sanctioned posts above a threshold, and (c) publishing quarterly utilisation data. Increments are front-loaded to the eight Empowered Action Group states.

Why it works

Conditional grants change state behaviour where unconditional ones lapse; the binding constraint in poor states is absorption capacity, so the money must purchase capacity — staff and systems — first. [16] Evidence from NHM evaluations shows that states with stronger complementary inputs (facility readiness, filled posts) absorb and spend at higher rates than states without them.

5-yr target

Government health expenditure from ~1.9% of GDP (centre+state budgeted, 2024-25) to 2.5% of GDP by FY2031; NHM utilisation at or above 85% in every major state.

Baseline: GHE 1.43% of GDP, NHA 2022-23 [1]; budgeted centre+state spending ~1.9% of GDP, 2024-25 [4]; NHM utilisation ~71% across surveyed states, FY2015-16 [16].

Who does it

Union Ministry of Finance and MoHFW (transfers and conditions); state finance and health departments (absorption); Fifteenth/Sixteenth Finance Commission architecture for health grants.

What it costs

This is the overall cost envelope (see Overall Cost section). Adding 0.6 percentage points of GDP per year at maturity equals approximately ₹1.9-2.0 lakh crore per year in FY2024-25 terms, against India's nominal GDP of ₹330.68 lakh crore. [35] Phased in over five years, split between centre and states along existing NHM and Finance Commission lines.

Risks & trade-offs

Conditionality can punish exactly the states whose citizens most need spending; mitigate with capacity-building grants rather than pure penalties. Nominal %-of-GDP targets slip silently if GDP grows fast and health budgets do not keep pace. Conditional financing in Indian federalism has a mixed record — Bihar and UP saw large NHM unspent balances in earlier cycles even when funds were released unconditionally.

02

Dedicated public health cadres and Public Health Acts in every major state

The problem

Only Tamil Nadu runs district health through a trained public health cadre under a Public Health Act. [19] Elsewhere, clinicians manage epidemics, sanitation, and health programmes without public health training or career incentives. Proposals for such cadres have been floated and shelved in Maharashtra, Karnataka, and Rajasthan over 20+ years.

The intervention

Each state notifies a three-tier public health management cadre (block-district-state) with MPH-qualified entry, separate from the clinical cadre, plus a model State Public Health Act. Draft model rules already exist with MoHFW and NITI Aayog. MoHFW provides model rules and NHM funds the transition; public health schools (IIPH network, medical colleges) supply training.

Why it works

Tamil Nadu's outcome edge is credibly attributed in the health-systems literature to managerial specialisation: professionals whose entire career ladder is population health, not surgery interrupted by administration. [19] [20] Trained public health cadres manage district-level surveillance, outbreak response, and programme performance in ways that visiting clinicians with split roles do not.

5-yr target

From 1 large state with a full cadre (baseline 2026) to all 20 large states notified and at least 60% of district public health officer posts filled by trained candidates by FY2031.

Baseline: 1 state (Tamil Nadu) with a functioning public health cadre under a Public Health Act, as of 2026. [19] [20]

Who does it

State governments (cadre rules are a state subject); MoHFW provides model rules and NHM funds the transition; IIPH network and public health schools for training supply.

What it costs

Modest — salary differential and training for approximately 2-3 senior officers per district plus block officers. The relevant comparator is administrative cost within the existing NHM envelope; Tamil Nadu runs its directorate within an ordinary state health budget. [20] Reliable all-India costing is unavailable; each state should build a budget line.

Risks & trade-offs

Cadre proposals have failed repeatedly across large states for over 20 years. Resistance comes from IAS and clinical-cadre lobbies who resist delegated authority. A cadre without delegated financial powers is a nameplate. Legislative backing (state Acts rather than administrative orders) reduces the risk of reversal. Phased entry through new posts rather than conversions reduces direct conflict but does not resolve budget competition.

03

Free essential medicines and diagnostics everywhere via pooled procurement

The problem

Medicines are the largest component of out-of-pocket spending. [1] Availability in weak-state public warehouses has been as low as 27-34% at the warehouse level before reform. [21] Where public facilities lack reliable stocks, patients buy from private pharmacies at retail prices — often the single financial catastrophe that drives households into debt.

The intervention

Every state operates an autonomous procurement corporation on the Tamil Nadu Medical Services Corporation design: a stable essential drugs list, e-tendered rate contracts, district warehouses, facility passbooks, NABL-tested batches, and real-time stock information systems. [19] [21] The centre co-finances through NHM Free Drugs and Diagnostics Service Initiatives and makes publication of monthly facility-level stock-out data a condition for incremental transfers. Rajasthan's Mukhyamantri Nishulk Dava Yojana covers 1,795 medicines and surgical consumables free statewide and is centrally co-financed at up to 60% under NHM. [34]

Why it works

Pooled procurement cuts unit prices and corruption simultaneously (single transparent tender versus thousands of local purchases); guaranteed supply is what moves patients from private pharmacies back to free public care. UP's redesign raised overall warehouse availability from 34% to 88% and average per-warehouse availability from 27% to 97% between 2020 and 2024. [21] TNMSC-type systems historically deliver drugs at a fraction of retail prices. [19]

5-yr target

At least 90% availability of essential-list medicines in public facilities in every state by FY2030; out-of-pocket expenditure share of total health spending below 30% by FY2031.

Baseline: 27-34% warehouse-level availability in pre-reform UP (December 2020 baseline) [21]; OOPE 43.4% of total health expenditure, NHA 2022-23 [1].

Who does it

State health departments via procurement corporations; MoHFW (NHM) co-financing; state drug controllers for quality.

What it costs

Rajasthan's experience is the best cost basis: a comprehensive state free-drug scheme is centrally co-financed at up to 60% under NHM. [34] TNMSC-type systems deliver drugs at a fraction of retail prices, [19] so the gross cost is partly offset by household savings that no longer leave the state as medicine expenditure.

Risks & trade-offs

Warehouse availability does not guarantee last-mile delivery to primary health centres — the last-mile gap is where patients are actually lost to private pharmacies. Stock-outs from poor demand forecasting occur even in Tamil Nadu. [21] Free drugs without prescribing audits can fuel irrational prescription. The OOPE target of 30% requires parallel action on diagnostics, user fees, and private-sector price regulation — drug availability alone is not sufficient.

04

Scale a primary-care chronic disease platform through 1.78 lakh Ayushman Arogya Mandirs

The problem

Non-communicable diseases cause roughly 62% of deaths in India, [8] yet the public system was built for infections and childbirth. Only a fraction of hypertensives and diabetics are diagnosed, treated, and controlled. Anaemia among women aged 15-49 is 57% (NFHS-5, 2019-21). [9] Untreated chronic disease surfaces later as expensive hospitalisation — the most regressive way to buy health.

The intervention

Universalise the India Hypertension Control Initiative package — simple drug protocols, guaranteed drug supply at the Ayushman Arogya Mandir, task-sharing with nurses and Community Health Officers, a digital treatment register with cohort-based reporting — across all districts, extended to diabetes. Link to annual population screening of adults aged 30 and above already mandated under the National Programme for Non-Communicable Diseases.

Why it works

IHCI is the rare Indian NCD intervention with measured results at scale. Rolled out with WHO support to 130+ districts, enrolling over 4 million patients by 2022. [28] Programme cohort data reported by WHO and Resolve to Save Lives show blood pressure control rising from 37% to 48% among patients enrolled in programme facilities, and the share of patients paying out of pocket for blood pressure drugs falling from 47% to 9%. [28] [29] These figures come from programme-internal cohort tracking, not an independent controlled comparison. The mechanism is coherent and proven elsewhere: protocols plus assured drugs plus follow-up registers.

5-yr target

Blood pressure control at or above 60% among patients under treatment in public facilities by FY2031; all 1.78 lakh Ayushman Arogya Mandirs reporting monthly NCD cohort data.

Baseline: 48% blood pressure control in IHCI programme cohorts [29]; 1.78 lakh AAMs operationalised as of mid-2025 [15].

Who does it

MoHFW (NP-NCD, NHM) sets protocol and finances drugs; states run through AAM staff (Community Health Officers, ANMs); WHO-India and ICMR for technical monitoring.

What it costs

WHO describes IHCI as a high-impact, low-cost intervention — its costs are dominated by generic drugs (amlodipine and telmisartan class) procured at pooled-tender prices. [28] The delivery infrastructure — Ayushman Arogya Mandirs and Community Health Officers — is already financed under NHM and PM-ABHIM. [32]

Risks & trade-offs

Screening without treatment capacity creates worried-well patients and wasted data — sequence drug availability first, screening expansion second. Digital registers can become data-entry burdens that crowd out care; keep indicators few and reporting simple. IHCI's internal cohort evidence has not been independently replicated at scale; treat the 37%-to-48% BP-control figure as promising internal evidence, not a confirmed effect size.

05

Fix the secondary tier: district hospitals, specialists, and a nursing surge

The problem

The 80% specialist shortfall at rural Community Health Centres [11] and only 0.79 government beds per 1,000 population [12] mean that referrals from primary care arrive at facilities that cannot treat them. Nurse density at approximately 6 active qualified nurses per 10,000 population is too low relative to what functional systems require. [10] Neonatal mortality at 19 per 1,000 (SRS 2021) [7] is now the hard core of child deaths and is a facility-quality problem.

The intervention

Three components: (a) Complete PM-ABHIM's 602 critical-care blocks and 730 district integrated public health labs on schedule. [32] (b) Operate the 157 new government nursing colleges (Cabinet-approved 2023, ₹1,570 crore, approximately 15,700 additional graduates per year) at full capacity and add a second tranche. [33] (c) Attack the specialist gap with bonded district-service postgraduate seats in district hospitals (DNB programmes) and team-based task-sharing — anaesthesia assistants, obstetric nurse practitioners — rather than waiting for specialists who will not come to rural areas.

Why it works

Thailand and Sri Lanka both built outcomes on functional district hospitals staffed heavily by nurses and midwives, not on specialist density. [22] [25] India's own residual neonatal and maternal mortality is concentrated where comprehensive emergency obstetric care facilities are missing. Tamil Nadu's maternal death decline tracked its build-out of comprehensive emergency obstetric care centres. [20]

5-yr target

Halve the CHC specialist shortfall to 40% or below by FY2031; government beds from 0.79 to at least 1.2 per 1,000; 75,000 or more cumulative additional nursing graduates by FY2031.

Baseline: 79.9% CHC specialist shortfall, RHS 2022-23 [11]; 0.79 government beds per 1,000 [12]; 157 nursing colleges at 15,700 graduates per year from Cabinet-approved 2023 scheme [33].

Who does it

Centre: MoHFW (PM-ABHIM, nursing colleges, DNB seats via National Board of Examinations). States: recruitment and hospital operations. District: hospital management societies.

What it costs

PM-ABHIM's existing envelope is ₹64,180 crore for 2021-26. [32] Nursing expansion cost basis is ₹10 crore per college. [33] A successor PM-ABHIM of comparable scale is the realistic vehicle for the capital and operational investment required.

Risks & trade-offs

Buildings without staff — PM-ABHIM's own documented risk — argue for tying capital releases to staffing plans. Bonded rural service has a mixed record: evasion rates in prior state schemes ranged from 30-60%, and enforcement actions have faced legal challenges. The target of halving the specialist shortfall is achievable only with simultaneous improvements in facility living conditions, spousal employment, and school access in posting areas. Without these non-financial conditions, the bottleneck shifts from training supply to placement compliance regardless of how many seats are sanctioned.

06

Measure quality and stop the leaks: death audits, facility dashboards, PM-JAY integrity

The problem

The system measures inputs, not outcomes. Facility quality against Indian Public Health Standards is largely unreported. The CAG found PM-JAY paying claims for patients recorded as dead, lakhs of beneficiaries linked to a single mobile number, and ₹57.53 crore in excess provider payments across four states. [18] Fraud money does not reach intended poor households; it either exits the system or subsidises ineligible users.

The intervention

Two sub-goals. Quality measurement: mandatory confidential maternal, neonatal, and in-hospital death audits in every district hospital, published annually in aggregate; a public IPHS-compliance dashboard for every public health centre, Community Health Centre, and district hospital. The IPHS 2022 framework and NQAS certification machinery already exist. Scheme integrity: implement the CAG's PM-JAY recommendations — Aadhaar-validated beneficiary cleanup, real-time duplicate-admission flags, recovery of irregular payments, and independent state anti-fraud units. [18]

Why it works

Tamil Nadu and Kerala's health improvements were measurement-led — Tamil Nadu's maternal death audits are central to its MMR record. [20] Transparency changes manager behaviour at near-zero marginal cost. Insurance schemes worldwide leak 3-10% to fraud without active controls; the CAG findings show India is not exempt. [18]

5-yr target

100% of district hospitals conducting and publishing death audits by FY2029; at least 50% of public facilities NQAS-assessed by FY2031; zero PM-JAY claims payable against deceased-patient IDs in audit re-tests.

Baseline: No national publication of district-hospital death audit results as of 2026; 3,903 PM-JAY claims paid against deceased-patient IDs documented by CAG 2023 [18].

Who does it

National Health Authority (PM-JAY controls); MoHFW and NHSRC (IPHS/NQAS); state quality assurance committees; CAG follow-up audits.

What it costs

Small — audit cells and dashboards are administrative costs within NHM programme management. The CAG recoveries already identified across four states exceed any plausible system cost for audit infrastructure. [18]

Risks & trade-offs

Punitive use of audit data drives under-reporting; the international norm is confidential, no-blame clinical audit with public aggregate reporting. Dashboards can be gamed; rotate independent verification. Beneficiary cleanup reduces headline enrolment counts and may generate political resistance if scheme coverage figures are used as performance metrics.

The price tag

What the full agenda would cost

Government health expenditure was 1.43% of GDP in 2022-23 (NHA 2022-23) [1] and budgeted centre-plus-state spending ran at roughly 1.9% of GDP in 2024-25 (PRS). [4] The centre's health ministry budget for FY2026-27 is ₹1,06,530 crore. [5] States together account for the larger share of public health spending.

Reaching the National Health Policy target of 2.5% of GDP by FY2031 means adding roughly 0.6 percentage points of GDP per year at maturity. At FY2024-25 nominal GDP of ₹330.68 lakh crore, [35] that increment is approximately ₹1.9-2.0 lakh crore per year in today's terms, phased in over five years and split between centre and states along existing NHM and Finance Commission lines. This envelope contains all six interventions: cadres, drug corporations, NCD platform, PM-ABHIM successor (current PM-ABHIM: ₹64,180 crore over five years [32]), and nursing expansion (₹1,570 crore for 157 colleges [33]) are claims on it, not additions to it.

The honest comparison: the increment of roughly ₹2.0 lakh crore per year at maturity is approximately twice the centre's entire current annual health budget. [5] It is achievable only if states — who hire the nurses and run the hospitals — raise their own health allocations. For the eight Empowered Action Group states, reaching 2.5% of state GDP in health would require health to grow from roughly 4-5% of state budgets to roughly 7-8%. This is comparable to what Tamil Nadu and Kerala already spend. [20]

Every percentage point shifted from out-of-pocket to public financing is regressive household spending avoided. NHA 2022-23 confirms that OOPE has risen back to 43.4% post-pandemic, [1] underscoring that public spending retreats are not costless. Thailand bought catastrophic-spending incidence below 3-4% with a government share of 78% of health spending. [22] India at 2.5% of GDP would still be financing a leaner system than that.

What we don't know

Where we could be wrong.

A credible plan names its own uncertainties. These are ours.

  • Nutrition and household-health data are stale. NFHS-5 fieldwork ended in 2021; as of June 2026 no NFHS-6 national report is available. [9] Anaemia, stunting, and service-coverage figures are five-plus years old. If post-COVID recovery — or deterioration — has been large, parts of Section 1 are wrong in unknown directions.
  • The out-of-pocket expenditure number is contested. NHA 2021-22's 39.4% [3] reflects a pandemic year with exceptional public spending. Peer-reviewed syntheses report OOPE estimates in the 47-49% range for nearby years. [31] The official NHA 2022-23 series, at 43.4%, [1] is used throughout this brief, but the true current share may be several points higher.
  • PM-JAY's impact evidence cuts both ways. A six-state household study finds 13% and 21% relative reductions in out-of-pocket and catastrophic spending respectively. [31] Other peer-reviewed work finds publicly funded insurance failing to protect the poorest and documents exclusion errors in enrolment. The plan treats demand-side insurance as necessary but insufficient; if the optimistic estimates are right, supply-side spending could show lower marginal returns than assumed — and vice versa.
  • Anaemia measurement itself is disputed. The NFHS capillary-blood method likely overstates anaemia relative to venous samples. The 57% and 67% figures [9] may be biased upward, though the adverse trend between NFHS-4 and NFHS-5 is harder to dismiss.
  • State success stories may not transfer. Tamil Nadu and Kerala built on decades of literacy, female agency, and administrative depth. [19] [20] The Mitanin estimates are quasi-experimental, not randomised. [26] Brazil's Family Health Strategy effects are strongest in municipal panel correlations. [23] Institutional designs — cadres, procurement corporations, CHW support structures — have a plausible mechanism and replication evidence, [21] but replication failure is a live risk.
  • Absorption is the plan's biggest internal tension. More money is proposed (Intervention 4.1) while evidence shows weak states cannot spend current allocations. [16] [17] The conditional-grant design is the answer, but conditional financing in Indian federalism has a mixed record. Bihar and UP saw large NHM unspent balances in earlier cycles with unconditional grants; this plan's conditional-grant architecture is different in design, but the mechanism is untested at this scale in India. Observable evidence within 24 months that should trigger a reassessment: if any two large EAG states show NHM utilisation still below 60% after conditional grants have been in place for two full fiscal years, the conditionality is not working.

Sources

Every number has a receipt.

35 sources cited on this page. See the full methodology →

  1. 1.
    National Health Accounts Estimates for India 2022-23Official

    MoHFW / NHSRC · 2026

    GHE 1.43% of GDP; OOPE 43.4% of THE; government share of THE 43.7%

    View source
  2. 2.
    Sample Registration System Statistical Report 2023Official

    Office of the Registrar General of India · 2025

    IMR 25 per 1,000; state-level spread Kerala 5 to Chhattisgarh/MP/UP 37

    View source
  3. 3.
    National Health Accounts Estimates for India 2021-22Official

    MoHFW / NHSRC · 2024

    OOPE 39.4% of THE (pandemic-year figure); GHE 1.84% of GDP

    View source
  4. 4.
    Demand for Grants 2025-26 Analysis: Health and Family WelfareResearch

    PRS Legislative Research · 2025

    Combined centre-plus-state budgeted health spending ~1.9% of GDP, 2024-25

    View source
  5. 5.
    Union Budget 2026-27: MoHFW allocationOfficial

    Press Information Bureau · 2026

    ₹1,06,530 crore total; NHM ₹39,390 crore; PM-JAY ₹9,500 crore; PM-ABHIM ₹4,770 crore

    View source
  6. 6.
    Special Bulletin on Maternal Mortality in India 2020-22Official

    Office of the Registrar General of India · 2025

    MMR 88 per 100,000 live births; down from 130 in 2014-16

    View source
  7. 7.
    India maternal and child mortality trends toward SDG 2030Official

    Press Information Bureau · 2025

    Neonatal mortality 19/1,000 and under-5 mortality 31/1,000 (SRS 2021)

    View source
  8. 8.
    Status of Non-Communicable Diseases in IndiaOfficial

    Press Information Bureau · 2022

    NCDs 62% of deaths (GBD 2016); up from 38% in 1990

    View source
  9. 9.
    National Family Health Survey (NFHS-5) 2019-21: India ReportOfficial

    IIPS & MoHFW · 2022

    Stunting 35.5%; anaemia: children 6-59 months 67%; women 15-49 57%

    View source
  10. 10.
    Size, composition and distribution of health workforce in India (Human Resources for Health 2021)Research

    Karan A. et al. · 2021

    Active qualified doctors: 5/10,000; nurses/midwives: 6/10,000; WHO threshold 44.5

    View source
  11. 11.
    Rural Health Statistics 2022-23Official

    MoHFW · 2024

    CHC specialist shortfall 79.9%; 4,413 in place against 21,964 required

    View source
  12. 12.
    India has only 0.79 beds per 1,000 population in government hospitalsOther

    The South First · 2023

    Knight Frank-Berkadia estimate; over 60% of beds private and city-concentrated

    View source
  13. 13.
    Hospital beds (per 1,000 people) — India (latest year 2021)Multilateral

    World Bank · 2021

    1.6 per 1,000 (all beds, 2021)

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  14. 14.
    About PM-JAYOfficial

    National Health Authority · 2026

    Coverage ~55 crore people; 42 crore+ Ayushman cards issued by late 2025

    View source
  15. 15.
    Update on Ayushman Arogya MandirOfficial

    MoHFW · 2025

    1.78 lakh AAMs operationalised as of mid-2025

    View source
  16. 16.
    Role of National Health Mission in Health Spending of States, Working Paper 317Research

    NIPFP · 2020

    NHM utilisation ~71% in surveyed states FY15-16; treasury delays 50-271 days documented

    View source
  17. 17.
    29% of NHM funds with states not spent in 5 yearsOther

    IndiaSpend · 2017

    Unspent NHM balances with states rose to ₹9,509 crore by 2015-16

    View source
  18. 18.
    Performance Audit of Ayushman Bharat – PM-JAY, Report No. 11 of 2023Official

    Comptroller and Auditor General of India · 2023

    3,903 claims paid for deceased patients (₹6.97 crore); ₹57.53 crore excess payments in 4 states

    View source
  19. 19.
    Towards a Better Health Care Delivery System: The Tamil Nadu Model (IJCM 2016)Research

    Parthasarathi R. & Sinha S.P. · 2016

    TNMSC design and Tamil Nadu public health cadre under PH Act 1939

    View source
  20. 20.
    Political Economy of Health: Tamil NaduResearch

    Dvara Research · not dated

    TN state indicators: IMR 18, U5MR 22, MMR 60; NFHS-5 2019-21 / SRS 2016-18

    View source
  21. 21.
    Lessons learned from redesigning public health medicines supply chain in Uttar Pradesh, IndiaResearch

    PMC / authors · 2025

    Warehouse availability: 34% to 88% overall; 27% to 97% per warehouse (Dec 2020–Jul 2024)

    View source
  22. 22.
    Financial risk protection of Thailand's universal health coverage 1996-2015 (Int J Equity Health 2020)Research

    Tangcharoensathien V. et al. · 2020

    OOP fell from 34% (2000) to 11% (2017); catastrophic spending below 3-4%

    View source
  23. 23.
    Impact of the Family Health Program on Infant Mortality in Brazilian Municipalities (AJPH 2009)Research

    Aquino R., de Oliveira N.F. & Barreto M.L. · 2009

    FHS expansion associated with falling IMR in 73% of municipalities

    View source
  24. 24.
    Infant mortality and Family Health Strategy in the 3rd Health Regional of Paraná 2005-2016Research

    Revista Paulista de Pediatria (SciELO Brazil) · 2021

    IMR fell from 17.1 to 10.7 as FHS coverage rose from 44% to 66%

    View source
  25. 25.
    Millions Saved Case 6: Saving Mothers' Lives in Sri LankaOther

    Center for Global Development · not dated

    Salaried public health midwives; 98%+ institutional delivery rate

    View source
  26. 26.
    Addressing social determinants of health: the Mitanin programme in India (Health Policy and Planning 2014)Research

    Nandi S. & Schneider H. · 2014

    70,000 Mitanin CHWs; prototype for national ASHA programme

    View source
  27. 27.
    Scale-up of community action for health: Mitanin program in ChhattisgarhResearch

    Sundararaman T. et al. · 2012

    4-5% annual reduction in underweight and 5-6% in stunting in programme areas

    View source
  28. 28.
    India Hypertension Control Initiative: a high impact and low-cost solutionMultilateral

    WHO India · 2022

    130+ districts; 4 million+ patients enrolled by 2022; BP control 37% to 48%

    View source
  29. 29.
    Evidence from India: progress in hypertension controlOther

    Resolve to Save Lives · not dated

    OOP for BP drugs fell from 47% to 9% among IHCI enrolled patients

    View source
  30. 30.
    Monitoring the Family Health Centres in Kerala: Findings from a facility surveyResearch

    PMC / authors · 2024

    FHCs: 11,343 vs 9,580 OPD visits/10,000; offered depression and COPD screening

    View source
  31. 31.
    Effects of PM-JAY on hospitalizations, OOP expenditures and catastrophic expendituresResearch

    Health Systems & Reform · 2023

    13% relative OOPE reduction; 21% relative catastrophic expenditure reduction; shift toward private facilities

    View source
  32. 32.
    PM-ABHIM scheme updateOfficial

    Press Information Bureau · 2025

    ₹64,180 crore outlay for 2021-26; 602 critical care blocks; 730 district labs

    View source
  33. 33.
    Cabinet approves 157 new nursing colleges at cost of ₹1,570 croreOfficial

    ANI · 2023

    ~15,700 additional graduates per year; ₹10 crore per college

    View source
  34. 34.
    Mukhyamantri Nishulk Dava Yojana scheme pageOfficial

    Govt of Rajasthan · not dated

    1,795 medicines and surgical consumables free statewide; 60% NHM co-financing

    View source
  35. 35.
    Provisional Estimates of Annual GDP 2024-25Official

    NSO / PIB · 2025

    Nominal GDP ₹330.68 lakh crore (FY2024-25)

    View source

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