NEED FOR DEVELOPMENT OF HEALTH INFRASTRUCTURE IN INDIA

INFRASTRUCTURE LAW

Submitted by:
HARSHIT MALVIYA

2016039
SEMESTER X
Submitted to:
Bhagyalaxmi Mam
DAMODARAM SANJIVAYYA NATIONAL LAW UNIVERSITY
Visakhapatnam

1
 ACKNOWLEDGEMENT

“I have taken efforts in this project. However it would not have been possible without the
kind support and help of many individuals. I would like to extend my sincere thanks to all of
them. I am highly indebted to Bhagya Laxmi Mam for her guidance and constant supervision
as well as for providing necessary information regarding the project.”
“I would like to express our special gratitude and thanks to our faculty member for their
patience, time and helping me in developing the project and people who have willingly
helped us out with their abilities.”A

AMNJABA
Introduction

“Life is not merely being alive but being well.”

– Martial, 66 AD, Epigrams

“Health infrastructure is an important indicator for understanding the health care policy
and welfare mechanism in a country. It signifies the investment priority with regards to the
creation of health care facilities. India has one of the largest populations in the world;
coupled with this wide spread poverty 1 becomes a serious problem in India. The country is
geographically challenged; this is due to its tropical climate which acts both as a boon and a
bane, a Sub Tropical Climate is conducive to agriculture however it also provides a ground for
germination of diseases2. Due to a cumulative effect of poverty, population load and climatic
factors India’s population is seriously susceptible to diseases.”

“Infrastructure has been described as the basic support for the delivery of public health
activities.3 Five components of health infrastructure can be broadly classified as: skilled
workforce; integrated electronic information systems; public health organizations,
resources and research. When we talk about health infrastructure we are not merely talking
about the outcomes of health policy of a particular country, but the focus is upon material
capacity building in the arena of public health delivery mechanisms.”

“The Government of India’s 1946 Report on the Health Survey and Development Committee
(also known as Bhore Committee) had declared the inadequacy of existing medical and
preventive health organization as one of reasons for India’s poor health condition in its report.
Moreover, the recommendations included an infrastructure plan for a three-tier health care
system4 at the district level to provide preventive and curative health care to dwellers in both”
rural and urban

1
As of the year 2010, more than 37% of India’s population lives below the poverty line.
2
The research conducted by various institutions and individuals over the past decades has exposed the vulnerability
of Tropical Countries to spread of infectious diseases. See: Science Daily (20 th February, 2008). “Emerging
Infectious Diseases on the Rise: Tropical Countries Predicted as Next Hot Spot”, available at
<http://www.sciencedaily.com/releases/2008/02/080220132611.htm>, site accessed on 31th November, 2011.
3
Lloyd F. Novick, Cynthia B. Morrow, Glen P. Mays (2008). Public Health Administration (Principles for
Population-based Management), 2nd edition, Jones and Bartlett Publications, Massachusetts, p.56.
4
At the lowest level, primary health centers (PHCs) were designed to provide basic medical care, disease
prevention, and health education. The next tier, sub centers (SCs), were intended to provide public health services. A
top tier of community centers and district hospitals offers specialist services.
areas. “The Bhore committee report stressed on access to primary health care as a basic right,
which subsequently became the basis of national health care system. Since the Bhore Committee
nine other committees have been formed, to examine the challenges faced by the healthcare
sector in the post-independence period, the latest being the National Commission on
Macroeconomics and Health, 2005. The report highlighted the problem of lack of resources
which have made the health system unaccountable and disconnected to public health goals, and
inadequately equipped to address peoples growing expectations. The estimated total investment
of Rs 74,000 crore consists of a whopping projected Rs 33,000 crore for capital investment
required for building up the battered health infrastructure alone. The commission recommended
that an institutional infrastructure which constitutes of a number of autonomous and self-
financed bodies is a bare minimum to cope up with the health situation in India. Thus in the
period of about 60 years the problem of health infrastructure has remained unresolved.”

Background

“India has the 2nd largest population in the world. Robust growth and steady fiscal consolidation
have been the hallmarks of the Indian economy in the recent years. The growth rate has been 8.6
per cent in 2010-11 and is expected to be around 9 per cent in the next fiscal year. 5 However in
terms of health infrastructure the country is lagging behind. Economic development is not a
necessary indicator of public health in a nation; in this regard reference to Human Development
Index6 gives a quite different picture as India is placed at the 119 th position in the HDI out of a
total of 169 countries.7 China, the country with the largest population in the world features at the
89th position and is far better off than India. Life expectancy at birth in India is 64.4 years which
is below the World Average of 69.3 years, and as per the HDI report this figure for China is
73.5”

5
Rediff Business (25th February, 2011). “Indian Economy: A tale of robust growth” available at
<http://www.rediff.com/business/slide-show/slide-show-1-budget-2011-economic-survey-indian-economy-a-tale-of-
robust-growth/20110225.htm>, site accessed on 2nd December, 2011.
6
“The first Human Development Report introduced a new way of measuring development by combining indicators
of life expectancy, educational attainment and income into a composite human development index, the HDI. The
breakthrough for the HDI was the creation of a single statistic which was to serve as a frame of reference for both
social and economic development. The HDI sets a minimum and a maximum for each dimension, called goalposts,
and then shows where each country stands in relation to these goalposts, expressed as a value between 0 and 1.”<
UNDP (2011). For more info see: “Human Development Index” available at <http://hdr.undp.org/en/statistics/hdi/>,
site accessed on 2nd December, 2011.
7
As per HDI index 2010 (available at http://hdr.undp.org/en/media/Lets-Talk-HD-HDI_2010.pdf).
years. The following data obtained from National Health Profile 2010 shows condition of health
infrastructure in India:

A). Insufficiency of Hospital Beds: “There are 12,760 hospitals having 576,793 beds in the
country. Out of these 6795 hospitals are in rural area with 149,690 beds and 3,748
hospitals are in urban area with 399,195 beds. Average Population served per
Government Hospital is 90,972 and average population served per government hospital
bed is 2,012.8 This figure is far more dismal in states like Assam, Bihar and Jharkhand
where there is only one bed for every 39,114,163 and 5,494 persons respectively.”

B). Dismal Number of Healthcare Centers: “There are 1,45,894 Sub Centers, 23,391
Primary Health Centers and 4,510 Community Health Centers in India as on March 2009
(Latest). These figures are insufficient keeping in mind the model of 2005 National
Commission on Macroeconomics and Health, which recommended a Sub Centre for
every 5,000 population, a Primary Health Centre for every 30,000 population and a
Community Health Centre for every 1,00,000 population.9”

C). Insufficient Number of Blood Banks: “Total number of licensed Blood Banks in the
Country as on January 2011 is 2,445. States in North East India are severely low on
availability of Blood Banks except for state of Assam; remaining six states only have 43
licensed Blood Banks.”

D). Urgent Need of more Medical Colleges: “In terms of Medical education infrastructures
the country has 314 medical colleges, 289 Colleges for BDS (Bachelor of Dental
Surgery) courses and 140 colleges conduct MDS (Master of Dental Surgery) courses with
total admission of 29,263 (in 256 Medical Colleges), 21,547 and 2,783 respectively
during 2010-11. Population of the country during this period increased by” about 1.3 %
(

8
In 2006 the bed per thousand population ratio stood at 1.03 compared to an average 4.3 of comparable countries
like China, Thailand, and Korea. Global Average in the same regard is 2.6, Indian Health Sector, Indian Law Offices
p. 14
9
Further lack of Public Health Facilities can be gauged from the fact that, India needs 74,150 CHC’s per million
population but has less than half that number, for more info see: Price Water House Coopers (2007). “Healthcare in
India Emerging Market Report” available at <http://www.pwc.com/en_GX/gx/healthcare/pdf/emerging-market-
report-hc-in-india.pdf>, site accessed on 4th December, 2011
 approx 1.5 crores), thus, e.g., “presuming that all these new admissions would serve the
increased population for the period 2010-11, each medical professional (from medical
college) would be serving a population of more than 500 people. 10 Nurses and midwives
are not properly trained due to inadequate infrastructure, in several places nursing school
were functioning more as appendages of the district hospitals. In 2004, 61.2% of nursing
11
schools/colleges were found unsuitable for teaching. Public hospitals and clinics have
been found to be understaffed by 15-20 %, on average, this problem is more rampant in
rural areas.12”

E). Concentration of Healthcare in Metro-cities: “Central Government Health Scheme

(CGHS) has health facilities in 24 cities having 246 Allopath Dispensaries and Total 438
Dispensaries in the Country with 8, 47,081 registered cards/ families. This scheme shows
wide discrepancies as majority (almost two-thirds) of these facilities are concentrated in
four metro cities.”

F). Non-Availability of Urgently Needed Vaccines: “The availability of life saving

vaccines is also not up to the mark, e.g. the gap between demand and supply of DPT in
2009-10 was above 26%; for the same period the gap for TT was about 16%, for ASVS
(Scorpion) the gap was 54%. Substandard drugs are also a concern for India, poor
enforcement of regulations are due to weak and inadequate drug control infrastructure at
the State and Central levels, only 17 of the 31 States and Union Territories have drug-
testing facilities, this is coupled with lack of manpower for enforcement of the
regulations. Infrastructure is also inadequate in the area of production for medical”

10
Insufficiency of manpower in terms of doctors can be inferred from the fact that India has a doctor- population
ratio of 59.7 physicians for 100,000 populations; however the same statistic for developed countries goes up to 200.
11
Ministry of Health and Family Welfare (2005), Report of the National Commission on Macroeconomics and
Health”, available at
<http://www.who.int/macrohealth/action/Report%20of%20the%20National%20Commission.pdf>, site accessed on
5th December, 2011, p. 6.
12
Rajat K. Gupta, Gautam Kumra, and Barnik C. Maitra (2005). “A foundation for Public Health in India”, The
McKinsey Quarterly Special Edition: Fulfilling India’s Promise, available at
<http://www.gken.org/Docs/A%20Foundation%20for%20Public%20Health%20in%20India_Gupta.pdf>site
accessed on 5th December 2011.
 equipment because according to an estimate India imports about 65 % of its medical
equipments.13

Role of Government and need of an Integrated Approach

As per the Constitution of India health care delivery is in the hands of the States. 17 In
reality, States have struggled to maintain and administer health care facilities; they have
become

13
supra 7 p. 15
14
Ma, Sai & Sood, Neeraj (2008). A Comparison of Health Systems in India and China, Occasional Paper 212,
Center For Asia Pacific Policy (RAND) at pg. 19, 20.
15
Ibid. p. 32; A laissez- faire approach has resulted in concerns with regard to the quality of care, the absence of
public regulation, mandatory registration; regular service evaluations are root cause of the problem. Due to
insufficient or non- implementation of existing laws such private entities cannot be effectively checked and made to
comply with minimal requirements.
16
Ibid p. 37
17
The State List (List- II) in the Seventh Schedule provides for the following entries relating to health care:
Entry 6- Public health and sanitation; hospitals and dispensaries. Also article 47 of Constitution (relating to
Directive Principles of State Policy) provides for duty of the state to raise the standard of living and improve public
health in the following wording:
“The State shall regard the raising of the level of nutrition and the standard of living of its people and the
improvement of public health as among its primary duties and, in particular, the State shall endeavour to bring
“dependent on the Central Government for financial and programmatic assistance to
implement health policies. For example, although states now account for 75 to 90 percent of
public spending on health, most of these funds go to salaries and wages of healthcare
personnel, making states dependent on the central government’s fund for non-wage items
such as drugs and equipment.18 The system of following five year plans has crystallized the
control of Central Government over states and all decision making powers rests in their
hands. There is a structural mismatch in the institutions at the Centre and State levels, with many
departments and agencies duplicating work or working at cross-purposes make governance in
health ineffective e.g. de-recognition of certain nurse training institutions, by the Indian Nursing
Council (INC) had no impact as they continue to function with the permission of the State
Nursing Council. Thus correction by one body is made ineffective due to intervention of another.
The health programmes mooted by the centre do not necessarily address the local and
community problems of the people. These programs concentrate on achieving policy objectives
and ignore problems at the micro-level which vary from place to place depending on geographic
and other demographic factors.19 Thus they end up becoming ineffective and unsustainable. An
integrated and comprehensive approach20 can solve this problem where requirements of
infrastructure can be determined district-wise on the basis of population so that effectual
infrastructure is established by the population present at the ground level. Such a decentralized
system would provide for better administration and surveillance of local health problems, also
emphasis would shift to long term strengthening and enhanced sustainability, finally it would
result in saving public money as infrastructure solutions can be determined in a more cost-
effective manner at the micro-level.”

about prohibition of the consumption except for medicinal purposes of intoxicating drinks and of drugs which are
injurious to health.”
18
Supra 5, at pg. 25
19
A.K. Jain (2004). “Planning Norms for Health Infrastructure” available at
<http://www.helpageindia.org/helpageprd/download.php?fp=aW1hZ2VzL3B1Ymxpc2hpbmc=&f=MTMwNzA4NT
I0Ny5wZGY=>, site accessed on 6th December, 2011. The article lays emphasis on the significance of local
knowledge in the fields of urban and regional planning; adoption of comprehensive approaches for water supply,
sanitation, operation and maintenance; role of town planners and architects in the creation of a healthy environment
and medical infrastructure.
20
According to the authors such an approach would imply, a separation of programme policy, design issues, budget
requirements and overall actual field implementation. Devolution of authority needs to be at central, state, district
and local levels. Involvement and empowerment of local bodies like the Panchayats (created by the 73rd and 74th
Constitutional amendments) will provide for a more democratic and autonomous system, and will ensure that no-
mismatch results between requirement and supply. Such delegation will not merely encompass right of such local
bodies to use the government finance but would create a system of decision-making, responsibility and
accountability to the immediate higher authority.
“The phenomenon of rapid growth of private health sector has resulted in a situation where
a large share of health infrastructure has come under the private players, the result of it is
that these institutions have become commercial units and the social-welfare objective has
taken a backseat. The Supreme Court in a recent judgment 21 directed government hospitals in
Delhi to refer poor patients to private hospitals. This decision has been described as a pro-poor
decision which aims at bringing the poor rural patients at par with the urban rich patients who till
now had been the sole beneficiaries of such private institutions. The court directed that the
private institutions would provide medical care free of cost to the poor, pending preparation of a
scheme which would involve private players in treating the poor. The appeal was filed against an
earlier decision of the Delhi High Court whereby, the High court had directed certain private
hospitals to ensure free treatment to 10 percent in-patients and 25 percent outpatients, this
mandatory ruling was given on the ground that the land for construction was given on an
undertaking which bound the private players to provide free health care to people who belong to
economically weaker sections of the society. The apex court directed that the Delhi Government
and Private Health institutions should come together and draw up a plan for serving the poor.
This decision would go a long way in strengthening the public health system as it would act as a
bridge between the economic inequalities existing in our country. Among other health related
problems existing in India, access to quality health care is a major issue. This may be addressed
by collaboration between State Governments and private players, this would ensure that poor get
their due from private institutions when government facilities prove insufficient or the
government is unable to provide the necessary access to quality health care.”

“The Apex Court’s concern for child health care was reflected in a case 22 involving the
universalisation of the Integrated Child Development Scheme (ICDS) where the court directed
extensive creation of infrastructure with regard to effectively serve the vast population
(13.12.2006). Some of the directions included:”

“(i) Government of India shall sanction and operationalize a minimum of 14 lakh AWCs in a
phased and even manner starting forthwith and ending December 2008. In doing so, the Central
Government shall identify SC and ST hamlets/habitations for AWCs on a priority basis.

21
Viswanathan, S (2006). “Getting for the Poor their Due in Private Hospitals” in The Hindu, 31st July, 2011.
22
People’s Union for Civil Liberties vs. Union of India, Writ Petition (Civil) No. 196 of 2001.
(ii) “Government of India shall ensure that population norms for opening of AWCs must not
be revised upward under any circumstances. While maintaining the upper limit of one AWC per
1000 population, the minimum limit for opening of a new AWC is a population of 300 may be
kept in view. Further, rural communities and slum dwellers should be entitled to an Anganwadi
on demand (not later than three months) from the date of demand in cases where a settlement
has at least 40 children under six but no Anganwadi.”

“However, this ambitious plan is yet to be fulfilled. As per status report filed by Director,
Ministry of Women and Child Development (representing Union of India), in pursuance of
directions of the court, the required infrastructure is yet to be built. Yet substantial work has been
done in regards to the direction of the court, as per affidavit (status report) the total number of
sanctioned AWCs and mini AWCs stood at 10.90 lakhs (2007). This has been achieved by
appropriate enforcement mechanism utilised by the court. Such a Scheme- Specific approach
(herein, ICDS) has provided positive results and can be repeated for other welfare schemes as
well.”

Judicial Intervention
“The Indian Constitution provides for a framework for Welfare and Socialist model of
development. Health rights are social rights provided under the Directive Principles and
are not justiciable. The right to life provided under Art. 21 of the Constitution of India or
various Directive Principles have been used time and again to demand access to health
care. However, it would be too much to expect from a country predominantly filled with
poor people to get their rights enforced in the law courts. In State of Punjab vs. Ram
Lubhaya Bagga23 the Supreme Court observed that the State had an obligation to provide
health care facilities to government employees and to citizens, the obligation was however
only to the extent of its financial resources for fulfilling the obligation. In regards to the
constitutional obligation of the State, it is incumbent that it must provide for basic
infrastructure for maintaining and improving public health. The State renders this obligation
by opening Government hospitals and health centers, but”
23
(1998) 4 SCC 117
in order to make it meaningful, it has to be within the reach of its people and provide all the
facilities which are provided for in other hospitals.

“The need for health infrastructure especially in emergency situations was further discussed in
the landmark case of, Paschim Banga Khet Mazdoor Samiti vs. State of W.B. 24 the issue before
the Supreme Court was the legal obligation of the Government to provide facilities in
government hospitals for treatment of persons who had sustained serious injuries and
required immediate medical attention. The petitioner who had suffered brain hemorrhage in a
fall from the train was denied treatment at various government hospitals because of non-
availability of beds. The court held that, providing adequate medical facilities is an essential part
of the obligation undertaken by the State in a welfare state. The Government discharges this
obligation by running hospitals and health centers. Article 21 imposes an obligation on the State
to safeguard right to life of every person. Preservation of human life is thus of paramount
importance. Any failure on part of the government hospitals to provide timely medical treatment
to a person would result in violation of the right to life. An Enquiry committee was set up in this
case to investigate the problem, the committee recommended that proper medical aid with scope
of equipments and facilities should be made available at all health centers and hospitals to cater
to emergency patients, it also suggested other infrastructure improvement measures and issued
directions to that effect which would be applicable to all the states. The Supreme Court observed
that while financial resources would be required for the implementation of the above directions,
the constitutional obligation of State to provide adequate medical services to the people cannot
be ignored.”

“The Supreme Court has held that the failure to provide timely medical care amounts to violation
of the right to life under Article 21. The state has an obligation to provide medical facilities in
such circumstances, and financial inability or lack of infrastructure is no justification to avoid
this obligation. Whenever the state fails to discharge its constitutional obligation, the patient or
immediate kin may approach either the Supreme Court or the High court under Articles 32 or
226 of the Constitution, as a legal remedy.25”
Conclusion

“Today the public infrastructure in India is becoming more and more inaccessible to the public at
large, because of the inadequate government healthcare services and high cost of treatment at the
private medical institutions. The Central Government should increase the share of healthcare
expenditure from one percentage of GDP to around three percent of GDP; the state governments
should also increase their share of funds allotted for healthcare. To provide equitable access to”

49
The government started Janani Suraksha Yojana, under which direct conditional cash transfer schemes was
initiated, it has been observed that the schemes has emerged as a big success both in reducing the maternal mortality
and reducing the expenditure of healthcare during the delivery and afterwards.
50
Jacob, K.S. (2011). “For a New and Improved NHRM” in The Hindu, 7th August, 2011.
51
In India around 350 million people have no access to safe drinking water, which directly affects their healthcare. If
the government would invest substantially in providing the people safe water and sanitation facilities, it would bring
down the case of malnutrition and other many disease, For more info. See: PTI (2011). India to Blame itself for Low
HDI Ranking: Infosys Chairman Narayana Murthy” in The Economic Times, 18th July, 2010. The government must
expand the NRHM to provide water purifiers to the rural people on subsidized rates, and creating sufficient physical
infrastructure for sanitation facilities.
the healthcare services and to continuously raise the standards of healthcare services must be the
twin goals of the government.

“It has to be remembered that education and healthcare are two sectors which must be given
more and more importance by the government because of our dependence on service sector. The
prospect of service sector would depend upon the human capital (professionals), and a better
health among the general populace would definitely have a positive impact on the service sector.
There are no ready-made solutions or exact steps which can guide us to improve the healthcare
facilities and nutritional level of people, but rather there is need to take action from different
angles. Diversion of more monetary resources towards the healthcare is an extremely necessary
but insufficient step, unless there is a motivation among the healthcare professionals towards
serving the people even the diverted funds would not yield extraordinary results. 52 The
government must focus on the healthcare infrastructure both qualitatively as well as
quantitatively.”

“Many times there have been outbreaks of different diseases in one country, and the same was
actually not disclosed by it at international level. But in this globalised world there are chances
that disease may be transmitted to other nations, hence it must be provided by WHO that the
States should be obliged to share information about the outbreak of diseases. Moreover, an
international surveillance network must also be created to take appropriate steps to take
preventive measures to stop the transmission of disease 53. Although the step may involve
cooperation among the countries yet, the Indian government must take an initiate in this regard
and present such a plan before the international community.”

“Many scholars have suggested Public Private Partnership as a solution to the problem to deal
with budgetary constraints which the government faces frequently while implementing different
healthcare plans and schemes. But it has to be remembered that with the advent of private
players the cost of services is increased considerably, and in India where the majority of the
population is poor it may lead to inaccessibility to healthcare services. The government must”
52
It must be ensured by the government that the resources granted for the purpose of different plans of healthcare are
used by the authorities for public purpose in a sustainable manner; rampant corruption and mismanagement have the
potential to reduce the effectiveness of government expenditure.
53
Although International Health Regulations have been issued by World Health Organisation, which have also been
agreed upon by 194 countries of the World, but still their strict compliance could not have been secured till now.
Moreover there is need of some more broad guidelines with regard to different health issues.
rather focus on the better utilization of the funds and the resources employed by it in the
healthcare services.

“The government must also review its health policy at regular intervals, possibly every two years
to assess the impact of different schemes and programmes which are run by it. The government
must identify the areas which are lagging behind in healthcare services, and special focus must
be provided for such areas. Special attention must also be given to the areas which are hit by
epidemics, floods, and other natural disasters, because the chances of the spread of disease are
greater in such areas. Suitable preventive measures must also be taken by the government in the
form of vaccination and creation of better sanitation facilities to stop the occurrences of
diseases.”

“The National Rural Health Mission is a wonderful programme which has brought many changes
in the quality of healthcare services in the rural areas. But the mission must also include in its
ambit the urban poor and specially the people who live in slums. The mission can be more
effective if there would be a better utilization of resources; a better monitoring and auditing
system would further expand the horizons of the mission. There is also need of better
coordination among the different actors which are working directly or indirectly in the areas of
healthcare namely Central Government, State Government, and the Civil Society. A more
comprehensive, coordinated, and integrated approach would yield more fruitful results and bring
radical changes in our healthcare system.”
Bibliography

Books

Lilly Srivastava, (2010). Law and Medicine, Universal Publication, New Delhi.

Ramani et. al.(ed) (2008). Strategic issues and Challenges in Health Management, Sage Publications, New Delhi.

Journals

Lauridsen, Jorgen., & Pradhan, Jalandhar (2011). “Socio-economic Inequality of Immunization Coverage in

India”

Health Economics Review, Vol. 1, available at <http://www.healtheconomicsreview.com/content/1/1/11