
## Demand For Grants 2018-19 Analysis Health And Family Welfare

The Ministry of Health and Family Welfare (MoHFW) has two departments: (i) the Department of Health and Family Welfare, and (ii) the Department of Health Research. The Department of Health and Family Welfare is responsible for functions including (i) implementing health schemes, and (ii) regulating medical education and training.  The Department of Health Research is broadly responsible for conducting medical research. This note analyses the financial allocation trends and key issues concerning the health sector. 

## Overview Of Finances

In 2018-19, the MoHFW received an allocation of Rs 54,600 crore. This allocation is an increase of 2% over the revised estimates of 2017-18 (Rs 53,294 crore).1 Under the Ministry, the Department of Health and Family Welfare accounts for 97% of the allocation, at Rs 52,800 crore.  This is followed by the Department of Health Research (3%) at Rs 1,800 crore.  Table 1 provides details on the two departments under the MoHFW. 

| RE         | BE      |
|------------|---------|
| Item       |         |
| Actuals    |         |
| 2016-17    | 2017-18 |
| % Change   |         |
| (RE to BE) |         |
| 37,671     |         |
| 51,551     | 52,800  |
| Health &   |         |
| Family     |         |
| Welfare    |         |
| 1,324      | 1,743   |
| Health     |         |
| Research   |         |
| Total      | 38,995  |

Note: BE - Budget Estimate; RE - Revised Estimates. Source: Demand Nos. 42 & 43, Ministry of Health and Family Welfare, Union Budget 2018-19, PRS. 

The revised estimate in 2017-18 for the Department of Health and Family Welfare overshot the budget estimate of that year by Rs 4,198 crore.  Similarly, the Department of Health Research also overshot the budget estimate by Rs 243 crore. Table 2 contains the split in the allocation under the MoHFW for the year 2018-19. 

MoHFW (2018-19) (in %) 
| Expenditure head              | Allocation (%)                |
|-------------------------------|-------------------------------|
| National Health Mission       | 55%                           |
| Autonomous Bodies             | 13%                           |
| 7%                            | Pradhan Mantri Swasthya       |
| Suraksha Yojana               |                               |
| 4%                            | National AIDS and STD Control |
| Programme                     |                               |
| Rashtriya Swasthya Bima Yojna | 4%                            |
| Family Welfare Schemes        | 1%                            |
| Others                        | 16%                           |
| Total                         | 100%                          |

Source:  Demand Nos. 42 & 43, Ministry of Health and Family 
Welfare, Union Budget 2018-19, PRS. 
Note: Autonomous Bodies include the All India Institute of 
Medical Science and Post Graduate Institute of Medical 
Education and Research, Chandigarh. 

Key allocation trends are as follows (see Table 3): 

 
The National Health Mission (NHM) received the highest allocation at Rs 30,130 crore and constitutes 55% of the total ministry allocation. The allocation is a 2% decrease over the revised estimates of 2017-18.  Under the NHM, the rural component, i.e., the National Rural Health Mission (NRHM) has been allocated Rs 24,280 crore, a 5% decrease over the revised estimates of 2017-18.  The allocation for National Urban Health Mission (NUHM) has increased by 34% at Rs 875 crore.  Note that the NUHM under NHM 
constitutes 2.9% of its allocation for 2018-19. 
 
Rashtriya Swasthya Bima Yojna has seen the biggest increase at 325% (Rs 2,000 crore) over the revised estimates of 2017-18.   
 
Higher allocation has been made for Pradhan Mantri Swasthya Suraksha Yojana (PMSSY) at Rs 3,825 crore (20% increase).  It focusses on correcting regional imbalances in the availability of affordable and reliable tertiary healthcare services. 
 
Family Welfare Schemes and the National AIDS and STD Control Programme have seen a decrease of 2% and 3% respectively from the revised estimates of 2017-18.  Note that both these schemes spent more than their budget estimates in 2017-18.   
 
Allocation to autonomous institutes (13%) like the AIIMS saw a decrease of 1% at Rs 6,900 crore from the revised estimates of 2017-18.   

| RE          | BE      |
|-------------|---------|
| Major Heads |         |
| Actuals     |         |
| 2016-17     | 2017-18 |
| % Change    |         |
| (RE to BE)  |         |
| NHM (total) | 22,454  |
| -NRHM       | 19,826  |
| -NUHM       | 491     |
| -Others     | 2,137   |
| 5,467       | 6,971   |
| Autonomous  |         |
| Bodies      |         |
| (AIIMS,     |         |
| PGIMER,     |         |
| etc.)       |         |
| PMSSY       | 1,953   |
| 1,749       | 2,163   |
| National    |         |
| AIDS & STD  |         |
| Control     |         |
| Programme   |         |
| 466         | 471     |
| Rashtriya   |         |
| Swasthya    |         |
| Bima Yojna  |         |
| 575         | 788     |
| Family      |         |
| Welfare     |         |
| Schemes     |         |
| Others      | 6,331   |
| Total       | 38,995  |

Note: BE - Budget Estimate; RE - Revised Estimates; NHM- National Health Mission; NRHM- National Rural Health Mission; NUHM- National Urban Health Mission; PMSSY- Pradhan Mantri Swasthya Suraksha Yojana. Source: Demand No. 42 & 43, Ministry of Health and Family Welfare, Union Budget 2018-19, PRS. 

## Proposals For The Health Sector In The Union Budget 2018-19


 
The National Health Protection Scheme will be launched to cover approximately 50 crore beneficiaries (poor and vulnerable families) for secondary and tertiary care hospitalisation (part of Ayushman Bharat programme). 

 

 
 
1.5 lakh Health and Wellness centres to provide comprehensive health care (including non-communicable diseases, and maternal and child health services).  These centres will also provide free essential drugs and diagnostic services (part of Ayushman Bharat programme). 
 
Additional Rs 600 crore to provide nutritional support to all Tuberculosis patients at the rate of Rs 500 per month for the duration of their treatment. 
 
 
Setting up 24 new government medical colleges and 
hospitals by upgrading existing district hospitals. 

## Trends In Allocation And Expenditure

As indicated in Figure 1, the allocation to the Department of Health and Family Welfare has increased from Rs 11,366 crore in 2006-07 to Rs 52,800 crore in 2018-19.  Over the period 2006-18, the Compound Annual Growth Rate (CAGR) has been 13%.  CAGR is the annual growth rate over a certain period of time.   
18) for 2018-19. Source: Union Budgets, 2006-07 to 2018-19; PRS. 

Table 4 indicates the actual expenditure of the 
Department of Health and Family Welfare 
compared with the budget estimates of that year 
(2010-17).  The utilisation has been over 100% in 
the last three years. 

Table 4: Comparison of budget estimates and the actual expenditure (2010-17) (in Rs crore) 
Year 
BE 
Actuals 
Actuals/BE 
2010-11 
23,530 
22,765 
82% 
2011-12 
26,897 
24,355 
82% 
2012-13 
30,702 
25,133 
82% 
2013-14 
33,278 
27,145 
82% 
2014-15 
35,163 
30,626 
87% 
2015-16 
29,653 
30,626 
103% 
2016-17 
37,066 
37,671 
102% 
2017-18 
48,853 
53,294* 
109% 

Note: BE - Budget Estimates; *Revised Estimates. Sources: Union Budgets, 2010-18; PRS. 

## Public Health Spending

The public health expenditure (sum of central and 
state spending) has remained constant at 
approximately 1.3% of the GDP between 2008-09 
and 2015-16, and increased marginally to 1.4% in 
2016-17.2,3  Note that the National Health Policy, 
2017 has proposed to increase the public health 
expenditure to 2.5% of the GDP by 2025.4   

Including the private sector, the total health 
expenditure as a percentage of GDP is estimated at 
4.0%.5  If 1.3% is attributed to public spending in 
India, then effectively, 2.7% is spent by the private 
sector.  This means that out of the total 
expenditure, about one-third is contributed by the 
public sector.  As per World Health Statistics 
(2014), this contribution by the public sector to the 
total expenditure on health is low as compared to 
other developing countries like Brazil (46%), China 

(56%), and Indonesia (39%).6  Among developed countries, the public spending on healthcare in United Kingdom and United States of America is 83% and 48% respectively.  The public-private split in the total health expenditure is shown in Figure 2 below. 

## 

Further, India also spends one of the lowest amounts ($23) in terms of per capita public health expenditure, in comparison to other developing countries like Indonesia ($38), Sri Lanka ($71), and Thailand ($177).7 It is estimated that 68% of the health expenditure is borne by consumers in India.8  Household health expenditures are the expenditures incurred by households on health care and includes out of pocket expenditures and prepayments (for example, insurance).  Out of pocket expenditure are the payments made directly by individuals at the point of service where the entire cost of the health good or service is not covered under any financial protection scheme.  In India, such expenditure is typically financed by household revenues (71%) (see Figure 3).  Only nine countries (out of 192) have a higher out of pocket spending as a proportion of total healthcare expenditure.19 The highest percentage of out of pocket health expenditure (52%) was made towards medicines.8 This was followed by private hospitals (22%), medical and diagnostic labs (10%), and patient transportation, and emergency rescue (6%). Due to high out of pocket healthcare expenditure, about 7% population is pushed below poverty threshold every year.11   

## National Health Protection Scheme

A new insurance scheme, the National Health 
Protection Scheme was proposed in the Union 
Budget 2018-19.9  This scheme will provide 
coverage to 10 crore poor and vulnerable 
families of up to Rs 5,00,000 per family per year 
for secondary and tertiary care hospitalisation.  
However, the funding for this scheme is not 
specified in the budget books.   

The two major insurance schemes funded by the 
central government are Rashtriya Swasthya 
Bima Yojana (RSBY) and Central Government 
Health Scheme.  Note that RSBY has seen the 
biggest increase in its budgetary allocation at 
325% (Rs 2,000 crore) in 2018-19 over the 
revised estimates of 2017-18. 

## Insurance And Universal Health Coverage

Out of the total number of persons covered under 
health insurance, three-fourths of the persons are 
covered under government sponsored health 
insurance schemes and the balance one-fourth are 
covered by policies issued by general and health 
insurers.10  Note that 86% of rural population and 
82% of urban population are still not covered under 
any scheme of health expenditure support.11    

In terms of government sponsored health insurance, 
the Net Incurred Claims Ratio (ICR) increased 
from 87% during 2012-13 to 122% in 2016- 17.10  
A higher Net ICR means more claims have been 
paid in comparison to the premiums collected 
leading to losses.  On the other hand, there has been 
a gradual decline in the Net ICR of other private 
insurance providers.   

 

## Rashtriya Swasthya Bima Yojana

The Rashtriya Swasthya Bima Yojana (RSBY), launched in 2008, aims to (i) provide financial protection against high health cost, and (ii) improve healthcare access for below poverty line households.12  The beneficiaries under RSBY are entitled to hospitalisation coverage up to Rs 30,000 per annum on family floater basis, for most of the diseases that require hospitalisation.  The beneficiaries need to pay Rs 30 as registration fee for a year.  Only 12% of the urban and 13% of the rural population from the targeted population was covered by schemes such as the RSBY or other similar state sponsored schemes.12  
 
Sources: Union Budget 2011-12 to 2018-19; PRS. 

Figure 4 shows the RSBY allocation since 2009. The total allocation to the scheme is Rs 2,000 crore in 2018-19, a 325% increase over the revised estimates of 2017-18.  The CAGR between 2009- 18 has been 22% for RSBY allocation.   

## Central Government Health Scheme

With regard to the Central Government Health Scheme (CGHS), the allocation for 2018-19 is Rs 1,305 crore (5% increase over the revised estimates of 2017-18).  The scheme provides healthcare services to central government employees, Members of Parliament, among others. The Standing Committee noted the low capacity of utilising financial resources by CHGS.19  For example, only 60% of the funds had been used under CGHS and yet an increase in allocation was sought for 2017-18.19  Further, it noted that many hospitals have de-empanelled themselves from CGHS mainly due to non-settlement of their dues by the government. 

## Universal Health Coverage

With regard to health insurance in general, the High Level Expert Group (HLEG) (2011) recommended that all government funded insurance should be integrated with the Universal Health Coverage (UHC) system.13  In addition, all health insurance cards must be replaced by a national health entitlement card. 

UHC includes ensuring equitable access for all 
Indian citizens to affordable and appropriate health 
services of assured quality.  This universal 
coverage is not linked to the consumer's ability to 
pay.13  The Finance Minister mentioned in his 
2018-19 Budget Speech that India is making steady 
progress towards UHC.9   

The World Bank measures the progress made in the 
health sector in select countries of the world 
according to the UHC Index.  On this Index, India 
ranks 143 among 190 countries in terms of per 
capita expenditure on health.14,15   

Experts have recommended that decisions must be 
taken with respect to whether a consolidation of 
existing services will be undertaken or a new 
package will be offered in parallel with the existing 
services under UHC.16  It has been estimated that to 
achieve UHC, the public expenditure in health must 
increase to at least 2.5% of the GDP by the end of 
2017 and at least to 3% of GDP by 2022.13  Further, 
it is estimated that the government would require a 
substantial spending increase at Rs 1,160 per capita 
per year if it is to be the sole provider of the 
comprehensive package of services.16 

## Financial Allocations To Outcomes National Health Mission

The National Health Mission (NHM) consists of 
two sub missions, the National Rural Health 
Mission (NRHM) (includes health interventions in 
rural areas) launched in 2005 and the National 
Urban Health Mission (includes health 
interventions in urban areas) launched in 2013.   

## Components Of Nhm

NHM includes various components, these include: 
(i) reproductive, maternal, new born and child 
health services (RCH Flexi Pool), (ii) NRHM 
Mission Flexi Pool for strengthening health 
resource systems, innovations and information, (iii) 
immunisation including the Pulse Polio 
Programme, (iv) infrastructure maintenance, and 
(v) National Disease Control Programme. 

## Funding Of Nhm

The allocation for NHM in 2018-19 (Rs 30,130 crore) saw a 2% decrease over the revised estimates of 2017-18.  

NHM's percentage share in the total budget has 
decreased from 73% in 2006-07 to 55% in 2018-
19.  This may be on account of increased 
devolution of resources to states following the 
recommendations of the 14th Finance Commission.  
The break up between central and state funding for 

NHM can be seen in Table 5 for the period between 2014 to 2017. 

Corresponding 
Year 
state share 
Total 
outlay 
Central 
Revised       
Estimate 
2014-15 
17,628 
5,167 
22,795 
2015-16 
18,295 
9,952 
28,247 
2016–17 
20,000 
10,103 
30,103 
2017–18* 
21,941 
12,084 
34,025 

Source: Unstarred Question No. 1080, Ministry of Health and Family Welfare, Lok Sabha, July 21, 2017. 

*For 2017-18, outlay is as per Budget Estimate The funding for NHM is done through flexible pools, such as NRHM-RCH flexible pool, and flexible pool for communicable diseases.  The rationale for creating of the flexible pool is to allow more financial flexibility and efficient distribution of funds in order to obtain desired health outcomes. Note that in 2018-19, among all the flexible pools, the pool of funds for non-communicable diseases has increased by 5% at Rs 1,005 crore.  The allocation for the funding pool for communicable diseases and immunisation has decreased by 27% and 30% respectively.  Between 2004-06 and 2010- 13, the percentage of deaths caused by communicable diseases (27.7%) has seen the biggest decrease out of all the other causes of death.  These diseases include fever, diarrhoea, and acute respiratory infection.  On the other hand, the percentage of deaths due to non-communicable diseases (49.2%) has risen.17  These diseases include cardiovascular diseases, cancer, diabetes, and hypertension. The Standing Committee highlighted that in view of the increasing burden of non-communicable diseases in the country, fund constraint should not be the reason for increase in disease burden.19  Note that the challenge of noncommunicable diseases typically arises following the elimination of communicable diseases.  Noncommunicable diseases are closely associated to lifestyle changes, and require large investments for both promotive and curative health.18 

## State Level Spending

Following the 14th Finance Commission recommendations, there has been an increase in the states' share in the central pool of taxes from 32% to 42% in 2015-16.  In addition, the fund sharing pattern of some schemes was altered to reduce the central government share.  This was done to give states greater autonomy and flexibility to spend according to their priorities. It was noted in 2017 that despite the enhanced share in central taxes, all states have not increased their health budgets commensurately in 2016-17 and expenditure in sectors like health are higher in more developed states (See Appendix for more details).19,20  In fact, some of the state health 

budgets for 2016-17 have declined as compared to 
2015-16.  For example, Assam (-7%), Chandigarh 
(-3%), Daman & Diu (- 15%), and Karnataka (-
2%).19  

India faces a challenge to control communicable 
diseases even as it seeks to shift attention towards 
an increasing threat from non-communicable 
diseases.  This challenge varies across states as 
richer states have a higher incidence of non-
communicable diseases (such as hypertension and 
diabetes).  For example, a report by the 14th 
Finance Commission noted that the comparatively 
better developed states like Kerala and Tamil Nadu 
have better health outcomes in comparison to other 
states.18  However, these states also face a health 
crisis of another kind.  This leads to an additional 
financial burden for tackling non-communicable 
diseases.   

Further, differences in the cost of delivery of health 
services in several states, have contributed to health 
disparities among and within states.    

## Release And Utilisation Of Funds

The release of funds under NHM has often been 
delayed.  For example, out of the total funds of Rs 
8,242 crore released in 2016 under the reproductive 
and child healthcare, and the health systems 
strengthening components of NHM, Rs 7,460 crore 
were transferred with a delay.21    

Despite delay in release of funds, effective 
utilisation of funds has occurred in the case of 
NHM where fund releases have been around 98%.  
The Standing Committee observed that timeliness 
of transfer of funds is important as delayed 
transfers hamper fund utilisation.  In this regard, 
the existing fund release mechanism for NHM 
needs to be reviewed for better transfer of funds.21  

## Implementation

| Targets (2012-17)             | Status (as on March, 2017)    |
|-------------------------------|-------------------------------|
| Reduce IMR to 25              | IMR has reduced to 37 in      |
| 2015.                         |                               |
| Reduce MMR to                 |                               |
| 100/1,00,000 live births      |                               |
| MMR has reduced to 167 in     |                               |
| 2011-13.                      |                               |
| Reduce TFR to 2.1             | TFR has reduced to 2.3 in     |
| 2014.                         |                               |
| Annual Malaria Incidence      |                               |
| to be < .001                  |                               |
| Annual Malaria Incidence      |                               |
| is 0.67 in 2016.              |                               |
| Less than 1 % microfilaria    |                               |
| prevalence in all districts   |                               |
| Out of 256 endemic districts, |                               |
| 222 have reported incidence   |                               |
| less than 1% till 2016.       |                               |
| Kala-Azar  elimination by     |                               |
| 2015, <1 case per 10,000      |                               |
| population in all blocks      |                               |
| Out of 628 endemic blocks,    |                               |
| 492 (78%) have achieved       |                               |
| elimination till 2016.        |                               |

Source:  Unstarred Question No. 2667, Ministry of Health and 
Family Welfare, Lok Sabha, March 17, 2017; PRS. 
Note: IMR-Infant Mortality Rate; MMR-Maternal Mortality 
Rate; TFR-Total Fertility Rate. 

## Healthcare Infrastructure

Depending on the level of care required, health institutions in India are broadly classified into three types.  This classification includes primary care 
(provided at primary health centres), secondary care (provided at district hospitals), and tertiary care institutions (provided at specialised hospitals like AIIMS).  Primary health care infrastructure provides the first level of contact between health professionals and the population. 22  The HLEG (2011) observed that focus on prevention and early management of health problems can reduce the need for complicated specialist care provided at the tertiary level.13  It recommended that the focus of healthcare provision in the country should be towards providing primary health care.13 Broadly, based on the population served and the type of services provided, primary health infrastructure in rural areas consists of a three tier system.  This includes Sub-Centres (SCs), Primary Health Centres (PHCs), and Community Health Centres (CHCs).23  A similar set up is maintained in urban areas.24  The number of SCs, PHCs, and CHCs in 2005 and 2016 respectively are given in Figure 5.   
As of 2015, there are 20,306 government hospitals (including community health centres) in India, of which 82.8% are rural hospitals and 17.2% are urban hospitals.25  Table 7 contains the norms, status, and shortfall in rural SCs, PHCs and CHCs (between 2010-14).  A shortfall has been observed at different levels of the healthcare delivery system. As of 2016, there is a shortage of 20% in SCs, 22% in PHCs, and 30% in CHCs.23  It has also been noted that the existing ones are also poorly equipped and have inadequate infrastructure with many PHC's functioning in erstwhile single room SCs and many SCs in thatched accommodation.26   

Required 
% shortfall 
Type of Infrastructure 
number 
Status 
(As on 
2015) 
Sub-Centre 
1,79,240 
1,55,069 
20% 
Primary Health Centre 
29,337 
25,354 
22% 
Community Health Centre 
7,322 
5,510 
30% 

Sources: Rural Health Statistics 2016, Ministry of Health and Family Welfare, and Rural Health Infrastructure, Ministry of Statistics and Programme Implementation; PRS.  

Note that under NRHM, states were permitted to 
establish facilities as per need. However, not many 
states did so due to lack of funds and the inability 
to close down even existing facilities (not in use) 
due to administrative bottlenecks.26   

The Standing Committee on Health and Family 
Welfare observed that the proposal to transform 
1,50,000 Health Sub-Centres into Health and 
Wellness Centres (as announced in the budget 
speech 2017-18) has not been implemented and has 
no "solid roadmap" as of now.27 

With regard to secondary and tertiary care, the 
HLEG (2011) recommended that in order to 
guarantee secondary and tertiary care, equitable 
access to functional beds must also be provided.13 

According to the World Health Statistics, India 
ranks among the lowest in this regard, with 0.9 
beds per 1000, far below the global average of 2.9 
beds.  It recommended functional bed capacity 
should be expanded to 2 beds per 1000 population 
by 2022.13   

## Pradhan Mantri Swasthya Suraksha Yojana

Pradhan Mantri Swasthya Suraksha Yojana 
(PMSSY) has been implemented since 2003 with 
objectives of: (i) correcting regional imbalances in 
the availability of affordable and reliable tertiary 
healthcare services, and (ii) to augment facilities 
for quality medical education in the country.  This 
includes establishing AIIMS like institutions and 
upgrading certain state government hospitals.   

Six AIIMS from Phase I of the scheme are still 
underway and are at various stages of their 
completion and it would take some time to make 
them fully functional.  The Standing Committee on 
Health and Family Welfare (2017) noted that this 
indicates poor assessment of time and cost which 
have left the allocated funds unused.19 

Notes:  Values for 2017-18 and 2018-19 are revised estimates and budget estimates respectively  
Sources: Union Budget 2008-09 to 2018-19; PRS. In 2018-19, the allocation to PMSSY increased by 20% over the revised estimates of 2017-18 (see Figure 6) at Rs 3,825 crore.  Note that the Budget Speech for 2018-19 mentioned that 24 new government medical colleges and hospitals will be set up by upgrading existing district hospitals.9 
Regulation of private health services As per the National Sample Survey 2015, most hospitalisation cases were seen in private hospitals (68% in urban and 58% in rural areas).28  Further, in case of hospitalised, the cost of treatment (excluding childbirth) was four times higher in private hospitals (Rs 25,850) as compared to that in public hospitals (Rs 6,120).28 The HLEG observed that regulatory standards for public and private hospitals are not adequately defined and are poorly enforced.  Further, the quality of healthcare services varies considerably in the public and private sector.29  It has also been observed that many practitioners in the private sector are not qualified doctors.29 The 14th Finance Commission study group observed that the unregulated nature of the private sector is one of the issues leading to the high financial burden on households (which is not commensurate with the quality of care).30  It recommended that a policy measure must be taken to regulate the private healthcare sector. 

## Human Resources In Health

Between 2008 and 2016, the number of registered doctors increased from 7,61,429 to 10,05,281 (32% increase).31  Note that despite the increase, there has been a steady increase in the shortfall of doctors, specialists and surgeons.  For example, as of 2015, there is a shortfall of 83.4% of surgeons, 76.3% of obstetricians and gynaecologists, 83.0% of physicians and 82.1% of paediatricians.25  Table 8 shows the number of health professionals in India.  Refer to the appendix for the shortfall (in percentage) of doctors at PHCs and nursing staff at CHCs and PHCs across various states as of 2016. 

Average 
Profession 
Number of 
professionals 
population 
served per 
professional  
Allopathic Doctors 
1,13,328 
11,097 
AYUSH Doctors** 
7,71,468 
1,630 
Nurses and Pharmacists 
35,19,796 
357 

Notes: **includes Ayurveda, Unani, Siddha, Naturopathy, and Homeopathy. Source: Human Resources in Health Sector, National Health Profile, 2017, Ministry of Health and Family Welfare, PRS. 

Issues concerning medical practice 

Certain reasons identified for the shortage of 
personnel in government facilities include: (i) poor 
working environment, (ii) poor remuneration 
making migration to foreign countries and to the 
private sector more attractive, and (iii) procedural 
delays in recruitment and poor forward planning 
for timely filling up of positions.  It has been 
estimated that filling up human resource gaps in 16 
states, would require an outlay equivalent to 0.6% 
to GDP.13  

With regard to health professionals, the HLEG 
(2011) recommended that adequate number of 
trained healthcare providers and workers must be 
ensured at different levels of the health system.13     

Issues concerning medical education 

Expert committees have examined issues related to 
medical education in India.  Certain key 
observations and recommendations include:32,33  

i. 
Focus on infrastructure over education 
quality: Major focus on maintenance of 
quality in medical education only in terms of fulfilling infrastructural requirements which has meant inadequate evaluation of the other 
standards of medical education. 
ii. 
Post-graduation qualification:  Presently, 
there are two systems of post graduate certification, namely Diplomate of National Board and MD/MS (master's degree).  The Parliamentary Standing Committee recommended that the current system of postgraduate admission must be integrated into 
one national qualification.  
iii. 
'For- profit' organisations to establish 
medical colleges:  Currently, only 'not-forprofit' organisations are permitted to establish medical colleges.  It has been observed that many private institutions of higher education charge exorbitant fees.  In the absence of welldefined norms, fees charged by such universities have remained high.34  In 2002, the 

Supreme Court ruled that the fees charged by 
private unaided educational institutes could be 
regulated.35  Also, while banning capitation fee 
(fees exceeding the tuition fee), it allowed 
institutes to charge a reasonable surplus.  NITI 
Aayog recommended that the sector should be 
opened to 'for-profit' organisations as well to 
address the supply gaps in medical education.32   

iv. 
Accreditation:  The Medical Council of India 
(MCI) is entrusted with the responsibility of establishing as well as ensuring the quality of medical institutions.  Committees have observed that these functions of the MCI may lead to a conflict of interest.  Therefore, an independent and autonomous accreditation body must be set up which will be responsible for ensuring the quality of education. 

## The National Medical Commission Bill, 2017

A legislation regarding the medical regulatory 
authority is pending in Parliament which shall 
oversee medical education and practice.  The 
National Medical Commission Bill, 2017 was 
introduced in Lok Sabha on December 29, 2017.  
The Bill seeks to repeal the Indian Medical 
Council Act, 1956 and dissolve the current 
Medical Council of India (MCI).  The MCI was 
established under the 1956 Act to establish 
uniform standards of medical education and 
regulate its practice. 

The Bill seeks to provide for a medical 
education system which ensures: (i) availability 
of adequate and high quality medical 
professionals, (ii) adoption of the latest medical 
research by medical professionals, (iii) periodic 
assessment of medical institutions, and (iv) an 
effective grievance redressal mechanism. 

## Health Research

The Standing Committee on Health and Family Welfare noted that there is a huge, persistent, and recurring mismatch between the projected demand for funds and actual allocation to the Department of Health Research.36  In 2018-19, its allocation has seen an increase of 3% over the revised estimates of 2017-18 at Rs 1,800 crore.  The Committee also noted that the Department had reported underutilisation of funds and on the other hand, the Department had also given an enhanced amount as its requirement for the next financial year.36 This mismatch between the demanded and allocated funds has led to impact in terms of restrictions in the sanctioning of new labs, providing recurring grants to the ongoing projects, and upgradation of health research infrastructure.36 This also led to repercussions in the medical research output.  For example, in two years i.e. 2015 and 2016, only 1,685 research papers have been published by the Indian Council of Medical Research and 3 patents have been granted against the 45 patents filed.36   

## Drug Regulation

The central and state agencies for drug regulation 
are governed by the Drugs and Cosmetics Act, 
1940 (DCA).  The DCA provides for the regulation 
of import, manufacture, sale, and distribution of 
drugs.  Although the DCA is a central legislation, it 
is implemented by the states. 

Over the years, various Committees have examined 
the issues relating to the regulation of drugs.   

The Mashelkar Committee Report (2003) 
highlighted the following challenges of the drug 
regulatory system: (i) inadequacy of trained and 
skilled personnel at the central and state levels, (ii) 
lack of uniformity in the implementation of 
regulatory requirements and variations in 
regulatory enforcement, and (iii) inadequate or 
weak drug control infrastructure at the state and 
central level.37 

Expert committees have recommended many steps 
to address these concerns regarding drug regulation 
in the country.37,38,39   They include: (i) a new 
independent and professionally run regulatory 
body, Central Drug Administration reporting 
directly to MoHFW, (ii) categorising the states in 
terms of scale of industry (manufacturing and sale) 
and investment in their regulation accordingly, (iii) 
the revision and imposition of higher fees for drug 
applications, clinical trials, and registration of 
imported drugs and foreign manufacturers, and (iv) 
establishment of technical expert committees for 
new drug approvals.  

## Quality Of Drugs

The Parliamentary Standing Committee Report 
(2013) found that the prevalence of poor quality 
drugs to be around 7-8 % where non-standard drugs 
outnumber spurious drugs.40 

'spurious' drugs (2013-2015) 
Samples declared 
Year 
Samples 
not of standard 
tested 
quality 
Samples declared 
spurious 
2013-14 
72,717 
4.16% 
0.16% 
2014-15 
74,199 
4.98% 
0.11% 
2015-16 
74,586 
4.96% 
0.31% 

Source: Unstarred Question No. 719, Ministry of Health and 
Family Welfare, Lok Sabha, Answered on February 7, 2017; 
PRS.  Note: 'Standard quality' means that a drug which 
complies with the standards set out in the Second Schedule of 
the DCA; A drug shall be deemed to be 'spurious' if:  (i) it is 
manufactured under a name which belongs to another drug, (ii) 
if it is an imitation of another drug, (iii) if it has been substituted 
wholly or partly by another drug, and (iv) if it wrongly claims to 
be the product of another manufacturer.41 
 

The extent of 'non-standard quality' drugs in a country wide survey between 2013 and 2015 has been in the range of 4.16% and 4.98% (see Table 9).42  The extent of 'spurious' drugs during the same time period has been in the range of 0.11% to 
0.31% (see Table 9).42 With regard to quality of drugs, the Mashelkar Committee recommended that: (i) states should take more samples to check the quality of drugs manufactured and sold in the market, (ii) states should also monitor the source of purchase and quality of drugs stocked by registered medical practitioners, and (iii) number of drug inspectors and their skills must be upgraded according to the load of work of inspections and monitoring.37 It was also observed that lower number of cases were decided as compared to the number of cases which were being filed with regard to low quality of drugs.  Table 10 provides details on the number of prosecutions and cases decided related to spurious drugs.   
1 Demand Nos. 42 & 43, Ministry of Health and Family Welfare, Union Budget 2018-19, http://www.indiabudget.gov.in/ub2018-19/eb/sbe42.pdf; http://www.indiabudget.gov.in/ub2018-19/eb/sbe43.pdf. 2 Economic Survey, 2015-16, Ministry of Finance, http://indiabudget.nic.in/budget2016-2017/es2014-15/echaptervol1.pdf.  
3 Economic Survey, 2016-17, Ministry of Finance, http://indiabudget.nic.in/es2016-17/echapter.pdf. 4 National Health Policy, 2017, Ministry of Health and Family Welfare, March 16, 2017, http://mohfw.nic.in/showfile.php?lid=4275. 5 National Health Accounts, estimates for 2013-14 Ministry of Health and Family Welfare, http://www.mohfw.nic.in/sites/default/files/8949831122147141 6058.pdf. 6 Unstarred question no. 2201, Ministry of Health and Family Welfare, Lok Sabha, Answered on July 29, 2016, http://164.100.47.190/loksabhaquestions/annex/9/AU2201.pdf. 7 Unstarred Question No. 5019, Ministry of Health and Family Welfare, Lok Sabha, answered on March 31, 2017, http://164.100.47.190/loksabhaquestions/annex/11/AU5019.pdf. 8 Household Health Expenditures in India (2013-14), December 2016, Ministry of Health and Family Welfare, http://www.mohfw.nic.in/sites/default/files/3830041175148956 2625.pdf. 9 Budget Speech, 2018-19, http://www.indiabudget.gov.in/ub2018-19/bs/bs.pdf. 10  Annual Report, 2016-17, Insurance Regulatory and Development Authority of India, https://www.irdai.gov.in/ADMINCMS/cms/frmGeneral_NoYea rList.aspx?DF=AR&mid=11.1. 

Table 10:  Number of prosecutions and cases decided in cases of spurious drugs 
Year 
No. of cases 
No. of cases 
decided 
2012-13 
214 
6 
2013-14 
237 
44 
2014-15 
152 
10 

Source: Unstarred Question No. 640, Lok Sabha, Ministry of Health and Family Welfare, Answered on February 26, 2016; 
PRS. 

## Drug Pricing

The National Pharmaceutical Pricing Authority 
(NPPA) monitors the availability and pricing of 
drugs in the country.  NPPA fixes the prices of 
drugs/devices included in Schedule I of Drugs 
(Prices Control) Order (DPCO), 2013 after their 
notification under National List of Essential 
Medicines (NLEM).  NLEM, 2015 consists of 375 
medicines in total (this includes 23 medical 
devices).  Wherever instances of manufacturers/ 
importers charging prices higher than the prices 
fixed by the NPPA are reported, these cases are 
examined in detail.  Since the inception of NPPA in 
1997 till 2012, 1,664 demand notices have been 
issued to pharmaceutical companies for having 
overcharged patients on the sale of formulations at 
prices above the ceiling prices notified by NPPA.43  
Demand notices have been issued for an amount of 
Rs 5,778 crore and an amount of Rs 3,454 crore is 
under litigation.44 

11 "Chapter three, Summary of Findings, Key Indicators of 
Social Consumption in India in Health", 71st Round, National 
Sample Survey (NSS), Ministry of Statistics and Programme, 
http://mail.mospi.gov.in/index.php/catalog/161. 

12  "Rashtriya Swasthya Bima Yojana", Last accessed on March 
8, 2016, http://www.rsby.gov.in/about_rsby.aspx. 

13 "High Level Expert Group Report on Universal Health 
Coverage for India", Planning Commission of India, November 
2011, 
http://planningcommission.gov.in/reports/genrep/rep_uhc0812.p
df.   

14  "Health expenditure per capita (US $)", World Health 
Organisation, 
http://data.worldbank.org/indicator/SH.XPD.PCAP. 

15  National Health Profile, 2016, Ministry of Health and Family 
Welfare, http://www.cbhidghs.nic.in/E-Book%20HTML-
2016/index.html. 

16 
"Essential Health  Package for India:  Approach and  Costing", 
Institute of Economic Growth, Finance Commission, 
http://fincomindia.nic.in/writereaddata/html_en_files/fincom14/
others/40.pdf.  

17 Causes of death, 2010-13, Office of the Registrar General & 
Census Commissioner, 
http://www.censusindia.gov.in/vital_statistics/causesofdeath.htm
l. 

18 "Inter-State Comparisons on Health Outcomes in Major States 
and a Framework for Resource Devolution for Health", Centre 
for Economic & Social Studies, Hyderabad, 14th Finance 
Commission, 
http://fincomindia.nic.in/writereaddata/html_en_files/fincom14/
others/39.pdf. 

                                                                                                                                                                                     
mis.nic.in/RURAL%20HEALTH%20STATISTICS/(A)%20RHS%20-%202014/Rural%20Health%20Care%20System%20in%20India.pdf. 24 Framework for Implementation, National Urban Health Mission ,May, 2013, http://nrhm.gov.in/images/pdf/NUHM/Implementation_Framework_NUHM.pdf. 25 Health and Family Welfare Statistics in India 2015, Ministry of Health and Family Welfare, October 2015, https://nrhmmis.nic.in/Pub_FW_Statistics2015/Complete%20Book.pdf. 26 "Survey Report & Recommendations of Clinical Establishments", Ministry of Health and Family Welfare, 2013, http://clinicalestablishments.nic.in/WriteReadData/788.pdf. 27 "Report no.99: Demands for Grants 2017-18 (Demand No.42) of the Department of Health and Family Welfare", Standing Committee on Health and Family Welfare, Rajya Sabha, March 20, 2017, http://164.100.47.5/newcommittee/reports/EnglishCommittees/Committee%20on%20Health%20and%20Family%20Welfare/99.pdf. 28 "Chapter three, Summary of Findings, Key Indicators of Social Consumption in India in Health", 71st Round, National Sample Survey (NSS), Ministry of Statistics and Programme Implementation, June 2015, http://mospi.nic.in/Mospi_New/upload/nss_71st_ki_health_30june15.pdf. 29 "Chapter: 20, Health, Twelfth Five Year Plan (2012-17)", Planning Commission of India, http://planningcommission.gov.in/plans/planrel/12thplan/pdf/12fyp_vol3.pdf. 30 "Essential Health Package for India Approach and Costing", Report submitted to the 14th Finance Commission, Ministry of Finance, September 2014, http://fincomindia.nic.in/writereaddata%5Chtml_en_files%5Cfincom14/others/40.pdf. 31  National Health Profile, 2017, Ministry of Health and Family Welfare, http://cbhidghs.nic.in/E-Book%20HTML-2017%20PART- I/files/assets/basic-html/page-1.html. 32 "A Preliminary Report of the Committee on the Reform of the Indian Medical Council Act, 1956", NITI Aayog, August 7, 2016, http://niti.gov.in/writereaddata/files/document_publication/MCI%20Report%20.pdf. 33 "Report no. 92 on 'Functioning of the Medical Council of India'", Standing Committee on Health and Family Welfare, March 8, 2016, http://164.100.47.5/newcommittee/reports/EnglishCommittees/Committee%20on%20Health%20and%20Family%20Welfare/92.pdf 34  "Report no. 236: Prohibition of Unfair Practices in Technical Educational Institutions, Medical Educational Institutions and Universities Bill, 2010", Standing Committee on Human Resource Development, May 30, 2011, http://164.100.47.5/newcommittee/reports/EnglishCommittees/Committee%20on%20HRD/236.pdf. 35  TMA Pai Foundation vs. State of Karnataka & Ors [(1994)2SCC195]. 36 "Report no. 100: Demands for Grants 2017-18 (Demand No.43) of the Department of Health Research", Standing Committee on Health and Family Welfare, March 20, 2017, http://164.100.47.5/newcommittee/reports/EnglishCommittees/Committee%20on%20Health%20and%20Family%20Welfare/100.pdf. 37 Report of the Expert Committee on "A Comprehensive Examination of Drug Regulatory Issues, including the problem of Spurious non-commercial purposes in part or in full to any other person with due acknowledgement of PRS Legislative Research ("PRS").  The 

Major Heads 
2016-17 
Actuals 
2017-18 BE 
2017-18 RE 
2018-19 BE 
Department of Health Research 
1,324 
1,500 
1,743 
1,800 
32% 
3% 
Department of Health and Family Welfare 
37,671 
47,353 
51,551 
52,800 
37% 
2% 
Pradhan Mantri Swasthya Suraksha Yojana 
1,953 
3,975 
3,175 
3,825 
63% 
20% 
Family Welfare Schemes 
575 
755 
788 
770 
37% 
-2% 
National AIDS and STD Control Programme 
1,749 
2,000 
2,163 
2,100 
24% 
-3% 
National Health Mission 
22,454 
26,691 
30,802 
30,130 
37% 
-2% 
-National Rural Health Mission  
19,826 
21,189 
25,459 
24,280 
28% 
-5% 
-National Urban Health Mission 
491 
752 
652 
875 
33% 
34% 
-National Mental Health Programme  
34 
35 
45 
50 
32% 
11% 
1,497 
4,025 
4,025 
4,225 
169% 
5% 
-Human Resources for Health and Medical Education Infrastructure Development for Health Research 
76 
104 
127 
138 
67% 
9% 
Rashtriya Swasthya Bima Yojna 
466 
1,000 
471 
2,000 
1% 
325% 
Autonomous Bodies 
5,467 
6,088 
6,971 
6,900 
28% 
-1% 
Others 
6,254 
8,240 
8,799 
8,737 
41% 
-1% 
Total 
38,995 
48,853 
53,294 
54,600 
37% 
2% 

Sources:  Demand for Grants, Ministry of Health and Family Welfare, Union Budget, 2018-19; PRS. 

State-wise and global numbers on the health sector 

State 
Average health expenditure 
(rural) 
Andhra Pradesh 
         13,227  
         31,242  
Arunachal Pradesh 
           5,678  
           8,926  
Assam 
           6,966  
         47,064  
Bihar 
         11,432  
         25,004  
Chhattisgarh 
         12,149  
         22,647  
Delhi 
         30,613  
         34,730  
Goa 
         29,954  
         23,165  
Gujarat 
         14,298  
         20,155  
Haryana 
         18,341  
         32,370  
Himachal Pradesh 
         18,860  
         28,590  
Jammu & Kashmir 
           8,442  
         13,948  
Jharkhand 
         10,351  
         13,151  
Karnataka 
         14,091  
         22,190  
Kerala 
         17,642  
         15,465  
Madhya Pradesh 
         13,090  
         23,993  
Maharashtra 
         20,475  
         29,493  
Manipur 
           6,061  
         10,215  
Meghalaya 
           2,075  
         18,786  
| % Change RE                |
|----------------------------|
| (2017-                     |
| 18)/Actuals                |
| (2016-17)                  |
| between RE                 |
| 2017-18  and               |
| BE 2018-19                 |
| Average health expenditure |
| (urban)                    |
| Mizoram                   |            8,744     |          13,461     |
|---------------------------|----------------------|---------------------|
| Nagaland                  | 5,628                | 15,788              |
| Odisha                    | 10,240               | 19,750              |
| Punjab                    | 27,718               | 29,971              |
| Rajasthan                 | 12,855               | 16,731              |
| Sikkim                    | 8,035                | 9,939               |
| Tamil Nadu                | 11,842               | 23,757              |
| Telangana                 | 19,664               | 20,617              |
| Tripura                   | 5,694                | 11,638              |
| Uttar Pradesh             | 18,693               | 31,653              |
| Uttarakhand               | 9,162                | 25,703              |
| West Bengal               | 11,327               | 24,875              |
| Andaman & Nicobar Islands | 3,373                | 8,389               |
| Chandigarh                | 16,389               | 35,158              |
| Dadra & Nagar Haveli      | 4,219                | 7,749               |
| Daman & Diu               | 10,223               | 6,930               |
| Lakshadweep               | 10,418               | 8,604               |
| Puducherry                | 7,965                | 14,076              |
| All India                 | 14,935               | 24,436              |

Sources: District Level Household and Facility Survey -4 (2012-13); PRS. 

| State                       | Doctors at PHCs    |
|-----------------------------|--------------------|
| Nursing staff at PHCs       |                    |
| and CHCS                    |                    |
| Andhra Pradesh              | **                 |
| Arunachal Pradesh           | 15%                |
| Assam                       | 8%                 |
| Bihar                       | 1%                 |
| Chhattisgarh                | 56%                |
| Goa                         | **                 |
| Gujarat                     | 16%                |
| Haryana                     | **                 |
| Himachal Pradesh            | 18%                |
| Jammu and Kashmir           | **                 |
| Jharkhand                   | 17%                |
| Karnataka                   | 9%                 |
| Kerala                      | **                 |
| Madhya Pradesh              | 19%                |
| Maharashtra                 | **                 |
| Manipur                     | **                 |
| Meghalaya                   | 4%                 |
| Mizoram                     | **                 |
| Nagaland                    | 5%                 |
| Odisha                      | 27%                |
| Punjab                      | **                 |
| Rajasthan                   | **                 |
| Sikkim                      | **                 |
| Tamil Nadu                  | **                 |
| Tripura                     | **                 |
| Uttarakhand                 | 16%                |
| Uttar Pradesh               | 36%                |
| West Bengal                 | 21%                |
| Andaman and Nicobar Islands | **                 |
| Chandigarh                  | 33%                |
| Dadra and Nagar Haveli      | 0%                 |
| Daman and Diu               | **                 |
| Delhi                       | **                 |
| Lakshadweep                 | **                 |
| Puducherry                  | **                 |
| All India                   | 13%                |

Source:  Rural Health Statistics 2015, Ministry of Health and Family Welfare; PRS. Note: Norm for nursing staff:  One per Primary Health Centre and seven per Community Health Centre; for doctors:  One allopathic doctor per Primary Health Centre; ** : surplus human resources exceeding the norms.  

| % of                                           | Reasons for not generally using government health facilities among households which do    |
|------------------------------------------------|-------------------------------------------------------------------------------------------|
| not generally use government health facilities | households                                                                                |
| that do not                                    |                                                                                           |
| State                                          |                                                                                           |
| Facility                                       | Health                                                                                    |
| No nearby                                      | Waiting time                                                                              |
| generally use                                  |                                                                                           |
| government                                     |                                                                                           |
| facility                                       | too long                                                                                  |
| Other                                          |                                                                                           |
| reason                                         |                                                                                           |
| timing not                                     |                                                                                           |
| convenient                                     |                                                                                           |
| personnel                                      |                                                                                           |
| often absent                                   |                                                                                           |
| health                                         |                                                                                           |
| facilities                                     |                                                                                           |
| 74.3                                           | 49.2                                                                                      |
| Pradesh                                        |                                                                                           |
| Assam                                          | 34.8                                                                                      |
| Bihar                                          | 93.3                                                                                      |
| Chhattisgarh                                   | 63.7                                                                                      |
| Gujarat                                        | 72.5                                                                                      |
| Haryana                                        | 72.3                                                                                      |
| Jharkhand                                      | 77.7                                                                                      |
| Karnataka                                      | 64.0                                                                                      |
| Kerala                                         | 50.0                                                                                      |
| 62.6                                           | 50.8                                                                                      |
| Pradesh                                        |                                                                                           |
| Maharashtra                                    | 70.3                                                                                      |
| Odisha                                         | 24.0                                                                                      |
| Punjab                                         | 80.8                                                                                      |
| Rajasthan                                      | 29.8                                                                                      |
| Tamil Nadu                                     | 47.0                                                                                      |
| Uttar Pradesh                                  | 84.7                                                                                      |
| West Bengal                                    | 71.2                                                                                      |
| 17.5                                           | 50.1                                                                                      |
| Pradesh                                        |                                                                                           |
| Delhi                                          | 70.7                                                                                      |
| Goa                                            | 70.4                                                                                      |
| 17.3                                           | 34.1                                                                                      |
| Pradesh                                        |                                                                                           |
| 37.1                                           | 33.2                                                                                      |
| Kashmir                                        |                                                                                           |
| Manipur                                        | 21.0                                                                                      |
| Meghalaya                                      | 35.2                                                                                      |
| Mizoram                                        | 9.4                                                                                       |
| Nagaland                                       | 47.9                                                                                      |
| Sikkim                                         | 8.2                                                                                       |
| Tripura                                        | 20.1                                                                                      |
| Uttarakhand                                    | 55.6                                                                                      |
| All India                                      | 65.6                                                                                      |

Sources: District Level Household and Facility Survey -4 (2012-13); PRS. 

| Country      | Population    | Infant    |   Life  |
|--------------|---------------|-----------|---------|
| (Million)    |               |           |         |
| Crude Birth  |               |           |         |
| Rate 2013    |               |           |         |
| Total        |               |           |         |
| Fertility    |               |           |         |
| Underweight  |               |           |         |
| children (%) | Expectancy    |           |         |
| Maternal     |               |           |         |
| Mortality    |               |           |         |
| 2013         | Rate, 2013    |           |         |
| Under 5      |               |           |         |
| mortality    |               |           |         |
| rate, 2013   | (2009-13)     | Ratio     |         |
| (MMR) 2015   |               |           |         |
| at Birth     |               |           |         |
| (Years)      |               |           |         |
| 2013         | $             |           |         |
| Mortality    |               |           |         |
| Rate (per    |               |           |         |
| 1000 live    |               |           |         |
| Births)      |               |           |         |
| 2013         |               |           |         |
| India        | 1252.1        | 20.0      |     2.5 |
| Afghanistan  | 30.6          | 34        |     4.9 |
| Bangladesh   | 156.6         | 20        |     2.2 |
| China        | 1385.6        | 13        |     1.7 |
| North Korea  | 24.9          | 14        |     2   |
| Indonesia    | 249.9         | 19        |     2.3 |
| Iran         | 77.4          | 19        |     1.9 |
| Japan        | 127.1         | 8         |     1.4 |
| Malaysia     | 29.7          | 18        |     2   |
|              |               |           |         |
Myanmar 
53.3 
17 
1.9 
51 
40 
23 
65 
178 
Nepal 
27.8 
21 
2.3 
40 
32 
29 
68 
258 
Pakistan 
182.1 
25 
3.2 
86 
69 
32 
67 
178 
Philippines 
98.4 
24 
3.0 
30 
24 
20 
69 
114 
South Korea 
49.3 
10 
1.3 
4 
3 
1 
82 
11 
Singapore 
5.4 
10 
1.3 
3 
2 
3 
82 
10 
Sri Lanka 
21.3 
18 
2.3 
10 
8 
26 
74 
30 
Thailand 
67.0 
10 
1.4 
13 
11 
9 
74 
20 
Vietnam 
91.7 
16 
1.7 
24 
19 
12 
76 
54 
Botswana 
2.0 
24 
2.6 
47 
36 
11 
48 
129 
Cambodia 
15.1 
26 
2.9 
38 
33 
29 
72 
161 
Congo 
4.4 
38 
5.0 
49 
36 
12 
59 
442 
Guatemala 
15.5 
31 
3.8 
31 
26 
13 
72 
88 
South Africa 
52.8 
21 
2.4 
44 
33 
9 
57 
138 
Zimbabwe 
14.2 
31 
3.5 
89 
55 
10 
60 
443 
Australia 
23.3 
13 
1.9 
4 
3 
- 
82 
6 
France 
64.3 
12 
2.0 
4 
4 
- 
82 
8 
Germany 
82.7 
8 
1.4 
4 
3 
1 
81 
6 
UK 
63.1 
12 
1.9 
5 
4 
- 
81 
9 
USA 
320.1 
13 
2.0 
7 
6 
1 
79 
14 

Sources: Health and Family Welfare Statistics, 2015 (Rural); PRS. 

| Parameter                                                          | NFHS 3 (2005-06)    | NFHS 4 (2015-16)    |
|--------------------------------------------------------------------|---------------------|---------------------|
| Total children age 6-23 months receiving an adequate diet          | n/a                 | 9.6%                |
| Children under 5 years who are stunted (low height-for-age)        | 48.0%               | 38.4%               |
| Children under 5 years who are wasted (weight-for-height)          | 19.8%               | 21.0%               |
| Children under 5 years who are severely wasted (weight-for-height) | 6.4%                | 7.5%                |
| Children under 5 years who are underweight (low weight-for-age)    | 42.5%               | 35.7%               |
| Children age 6-59 months who are anaemic                           | 69.4%               | 58.4%               |
| Children under age 3 years breastfed within one hour of birth      | 23.4%               | 41.6%               |
| Source: National Family Health Survey 3 & 4; PRS.                  |                     |                     |
| Parameter                                                          | NFHS 3 (2005-06)    | NFHS 4 (2015-16)    |
|--------------------------------------------------------------------|---------------------|---------------------|
| Women whose Body Mass Index (BMI) is below normal (BMI < 18.5 kg/m |                     |                     |
| 2                                                                  |                     |                     |
| )                                                                  | 35.5%               | 22.9%               |
| Men whose Body Mass Index (BMI) is below normal (BMI < 18.5 kg/ m  |                     |                     |
| 2                                                                  |                     |                     |
| )                                                                  | 34.2%               | 20.2%               |
| Women who are overweight or obese (BMI ≥ 25.0 kg/ m                |                     |                     |
| 2                                                                  |                     |                     |
| )                                                                  | 12.6%               | 20.7%               |
| Men who are overweight or obese (BMI ≥ 25.0 kg/ m                  |                     |                     |
| 2                                                                  |                     |                     |
| )                                                                  | 9.3%                | 18.6%               |

Source: National Family Health Survey 3 & 4; PRS. 

| State/UT                    | Stunted    | Wasted    |
|-----------------------------|------------|-----------|
| Under-                      |            |           |
| weight                      |            |           |
| Andaman and Nicobar Islands | 17.1%      | 19.1%     |
| Andhra Pradesh              | 28.3%      | 15.5%     |
| Arunachal Pradesh           | 24.0%      | 11.4%     |
| Assam                       | 22.3%      | 13.2%     |
| Bihar                       | 39.8%      | 21.3%     |
| Chandigarh                  | 27.6%      | 11.4%     |
| Chhattisgarh                | 31.6%      | 20.6%     |
| Delhi                       | 32.4%      | 17.2%     |
| Dadra and Nagar Haveli    | 35.8%    | 21.4%    | 27.4%    |
|---------------------------|----------|----------|----------|
| Daman and Diu             | 21.9%    | 23.8%    | 27.2%    |
| Goa                       | 18.3%    | 27.7%    | 25.3%    |
| Gujarat                   | 31.7%    | 23.4%    | 32.0%    |
| Haryana                   | 33.4%    | 21.0%    | 28.5%    |
| Himachal Pradesh          | 21.4%    | 19.1%    | 17.1%    |
| Jammu and Kashmir         | 23.0%    | 16.1%    | 17.0%    |
| Jharkhand                 | 33.7%    | 26.8%    | 39.3%    |
| Karnataka                 | 32.6%    | 24.8%    | 31.5%    |
| Kerala                    | 19.8%    | 16.0%    | 15.5%    |
| Lakshadweep               | 27.1%    | 13.2%    | 22.6%    |
| Madhya Pradesh            | 37.5%    | 22.0%    | 36.5%    |
| Maharashtra               | 29.3%    | 24.9%    | 30.7%    |
| Manipur                   | 24.1%    | 6.4%     | 13.1%    |
| Meghalaya                 | 36.5%    | 13.7%    | 22.9%    |
| Mizoram                   | 22.7%    | 4.5%     | 8.5%     |
| Nagaland                  | 22.5%    | 10.1%    | 13.6%    |
| Odisha                    | 27.2%    | 17.0%    | 26.2%    |
| Punjab                    | 27.6%    | 15.0%    | 22.4%    |
| Puducherry                | 24.7%    | 26.1%    | 23.3%    |
| Rajasthan                 | 33.0%    | 21.6%    | 30.7%    |
| Sikkim                    | 22.9%    | 13.2%    | 12.0%    |
| Tamil Nadu                | 25.5%    | 19.0%    | 21.5%    |
| Telangana                 | 20.9%    | 14.6%    | 22.2%    |
| Tripura                   | 17.2%    | 13.4%    | 21.7%    |
| Uttar Pradesh             | 37.9%    | 18.0%    | 33.7%    |
| Uttarakhand               | 32.5%    | 18.6%    | 25.6%    |
| West Bengal               | 28.5%    | 16.7%    | 26.2%    |
| India                     | 38.4%    | 21.0%    | 35.7%    |

Note:  Deaths caused by diseases in India can be attributed to four main causes: (i) communicable, perinatal, and nutritional conditions: diseases, and congenital anomalies, (iii) injuries:  includes unintentional injuries (for example, caused by motor vehicles) and intentional injuries (for example, caused by suicide), and (iv)  symptoms, signs, and ill-defined conditions:  includes abnormal clinical findings Sources:  State Finances: A Study of Budgets, RBI; PRS. 

Note:  Figures of 2016-17 and 2015-16 are Budget Estimates and Revised Estimates respectively. 