essay on public health in india

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7 ways public health in India has changed over the last decade

August 23, 2018 by Neeraj Jain

A national strategy focused on digital health, nutrition, and other high-impact interventions has dramatically improved health outcomes across India—but more work remains to be done.

Neeraj Jain (right), PATH’s country director for India since 2016, has helped to lead health improvements across the country and strengthen organizations for more than 27 years. Photo: Katherine De Bruyn.

India has entered a new era in public health during the past ten years. Thanks to improvements across the spectrum of health and development, average life expectancy has risen steadily from 64 to 68 years between 2005 and 2015.

But we must continue to build on this progress. India still ranks 154th out of 195 countries in terms of quality and accessibility of health care, according to a recent Lancet study .

While plenty of work remains ahead of us, together we have achieved tremendous positive change. Neeraj Jain, PATH’s country director for India, shares seven major trends over the last decade that have brought us this far:

1. A downtrend in communicable diseases

India has been polio-free since 2014. In a country of 1.2 billion people, this is a big deal. We have also been free of tetanus since 2015 and have set strict targets for the elimination of malaria, tuberculosis (TB), and lymphatic filariasis in the coming years. While we still represent a large percentage of the global burden for these diseases, we’ve made significant progress.

The Swachh Bharat Abhiyan , or Clean India Movement, has provided a big push in the right direction to reduce the spread of communicable diseases. As recently as 2014, 65 percent of our population defecated in the open—and now that number is down to 20 percent. This shows how quickly progress can take root when communities and government leaders work together and how it will have a huge impact on health going forward.

With its last case of polio in 2014 and tetanus in 2015, India has set its sights on eliminating malaria, tuberculosis, and lymphatic filariasis. Photo: PATH/Gabe Bienczycki.

2. A focus on prevention

As communicable diseases trend downward, we’ve seen new challenges emerge around noncommunicable diseases like hypertension, diabetes, cardiovascular diseases, stroke, and cancer. These diseases impact the rich in India as much as they impact the poor, but most poor people don’t have the resources to combat diseases like cancer. Our public health system isn’t geared toward noncommunicable diseases. So for India as a country, the challenge going forward is to focus on prevention, support, and awareness.

In an encouraging sign of progress, we’ve seen a big increase in health and wellness centers in the past decade. We are now starting to think beyond primary health and toward universal health coverage. Coupled with an emphasis on preventive care, this shift will increase all-around wellness. The National Health Mission (NHM)—the result of a 2013 merger between the National Urban Health Mission and the National Rural Health Mission—is a prominent example. The program’s primary focus is on disease control, prevention, and surveillance, and it has already made a huge impact on our health care system.

Widespread improvements in sanitation, immunization coverage, and institutional birthing have led to more infants surviving across India. Photo: PATH/Tom Furtwangler.

3. Reduced neonatal mortality rates

Neonatal mortality rates have improved markedly, dropping from 57 deaths per 1,000 live births to 37 between 2005 and 2015. In the past decade, India has saved a huge number of infants through multiple interventions—including an increase in institutional birthing, immunization coverage, and improved sanitation.

Is it enough? Absolutely not. Have we done well? Yes. Do we still have work to do? Absolutely.

4. Tackling antimicrobial resistance

Like several other low- and middle-income countries, India has room to improve in how we handle antibiotics. Production and distribution are not regulated, and retailers sell antibiotics to pretty much anyone—no prescription needed. Most people don’t complete their full course of antibiotic doses, so while they may feel better, the remaining bacteria can develop resistance and make them sick again. Many new kinds of resistance are cropping up, and drugs aren’t working quite as well as they used to.

The 2017 National Action Plan on Antimicrobial Resistance and Red Line campaign—which demands that prescription-only antibiotics be marked with a red line to discourage the over-the-counter sale of antibiotics—are both steps in the right direction. But these efforts need firm legal backing and sustained financial support. Growing antimicrobial resistance is a challenge that India and the world will increasingly face in the coming decade.

Cooking micronutrient-fortified rice for a school lunch program in India. 70 percent of India’s population now has access to subsidized food. Photo: PATH/Satvir Malhotra.

5. Improved nutrition

After significant progress in the last few years, 70 percent of India’s population now has access to subsidized food. PATH has been looking into the massive potential offered by rice fortification and is currently working with the state government to reach 450,000 schoolchildren each day in Karnataka State. Over the coming decade, India plans to introduce fortified food to two-thirds of the country via the National Food Security Act, which will dramatically reduce anemia and childhood stunting.

6. Using digital health and artificial intelligence for social impact

India’s government and our health minister led the conversation around digital health at the recent World Health Assembly in May. India is a digital powerhouse that still faces challenges with our health infrastructure, and it was exciting and inspiring to see India leading strategic discussions around how to best leverage digital health and artificial intelligence (AI) to improve public health.

In the past decade, India has implemented a digital health program called eVIN to track immunization. The program is critically important for the country because of the size of our population. ANMOL is another important digital health tool, providing better health care services to pregnant women, mothers, and newborns. India continues to struggle with high maternal and neonatal mortality rates, so tracking and providing services to new moms is important—especially for the country’s poorest and most vulnerable people.

India is taking the lead on using AI to drive social impact. We are concentrating our efforts where the need is greatest, starting with a focus on some of the most infectious diseases—especially TB. By using AI to improve diagnostics and ensure higher treatment adherence rates, we can accelerate the elimination of TB in every state.

7. Stronger government accountability

As a country, India allocates only 1.15 percent of our gross domestic product (GDP) to health care—one of the world’s lowest rates considering the size of our population. Much of the funding that is allocated to health care is not being used, and a major lack of staff further leads to the underutilization of budgets. Indian health care organizations often have trouble recruiting, as we don’t have enough trained professionals who want to work in rural villages or health centers. Without reliable health services, people living outside of major cities suffer from a growing economic disadvantage.

Recently, largely due to pressure from the public and the media, the Indian government is beginning to vocalize firm timelines and budgets for new health programs. The government has committed to dedicate 2.5 percent of our GDP to health care by 2025. More and more programs are using 100 percent of their health care budgets. New programs are bringing medical insurance to the poor, allowing access to both government facilities and private facilities.

When you look at India’s history, this is a great place to be. Of course, as we drive to fully utilize health budgets, we need to keep working with the government to increase funding—but we are moving by leaps and bounds in the right direction.

Moving forward

So where do we go from here? In the next ten years, a lot still needs to change in India. The public must come to trust the public health system if it is to serve them. Seventy percent of the Indian population still chooses to see a private and likely unqualified health care provider for their health needs. Indians also face some of the highest out-of-pocket costs for health services, driving many struggling households back into poverty and debt.

But perceptions have started to shift. People are demanding better public services, and they expect that health services are going to improve in the coming years. In the next decade, however, it’s not just the public health care system that needs to be strengthened to solve this problem of public perception. We must also strengthen the link between health insurance, private health care providers, and the public, whether they live in cities or far beyond them.

As these forces come together, we’re going to see real progress in health for all Indians—especially those who need it most. That means a healthier, happier world, where people can live up to their full potential.

That’s where we are headed, and you can help to get us there.

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Issues in Public Health in India - Keynote address by Keshav Desiraju, Former Secretary of Health and Family Welfare to the Government of India

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Keshav Desiraju, Issues in Public Health in India - Keynote address by Keshav Desiraju, Former Secretary of Health and Family Welfare to the Government of India, Journal of Public Health , Volume 43, Issue Supplement_2, October 2021, Pages ii3–ii9, https://doi.org/10.1093/pubmed/fdab305

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The state of public health in India can be studied in terms of disease burden, health human resources and health care financing. There are many regional variations within these broad areas, and many complexities. Communicable and non-communicable diseases remain major challenges, as do maternal and infant mortality. At every level, trained human resources are scarce. Government budgetary resources are inadequate and the current discussion in India on universal health care appears to be biased towards privately provided care. At the same time, there have been remarkable achievements, often diminished by the size of India’s population.

Public health is about social justice and the task before India today is to demonstrate the political will, the administrative ability and the democratic vision to achieve universal health care. Can this come about?

In calling this talk ‘Issues in Public Health in India’, my intention is, quite simply, only to identify the issues which have a bearing on the health and welfare of a very large population. There are many complications and regional variations, whether in disease burden, health infrastructure, health human resources or styles of governance. There are many implications for the establishment of better health systems arising from India’s federal structure where the primary, constitutional, responsibility for health care is that of the states even if a not insignificant share of public spending on health care is by the central government.

Clearly, these issues will need to be addressed in a sensible and inter-connected manner if efficient health systems are to be built.

This talk comes at the end of a conference on mental illness and mental health, but while there are critical issues at the heart of a mental health policy or programme, it is essential that those issues are understood within the context of the health of a people, the public health context. And I would like to spend a little time on this. There can be no mental health without public health.

A good place to start is to look at what has gone wrong. In a recent piece entitled ‘Archives of failures in global health’, Professor Madhukar Pai of the McGill University looks not at the dramatic successes with which we are all familiar but at failures, areas where the global health community and individual governments have been either unable or unwilling to make a difference. 1 Several of the failures identified by Prof. Pai relate to India. These include India’s failure to invest in health, India’s premature declaration in 2005 of leprosy elimination and India’s failure to address child malnutrition and stunting. There are also situations where India is not alone but where there is still a recognized shortcoming such as the failure to deliver on the Alma Ata Declaration, the failure of the global Malaria Eradication Programme, the failure to achieve the Millenium Development Goal [MDG] 5 goal on maternal deaths, failure to address the NCD epidemic, the weakening of the campaigning to end AIDS by end-2030 and the failure to address global mental health.

This sorry list gives a very good outline of the ‘range’ of India’s public health issues. One very striking feature is the continued prevalence of communicable disease along with the rapid increase in the spread of non-communicable disease in a country where maternal and infant mortality are still unacceptably high. India is forever in a state of transition. Several developed countries have reduced maternal and infant mortality and have also brought communicable disease under control. This allows them the resources and the space to address the threat to non-communicable disease. India does not have this luxury. If we have successfully eliminated small pox and polio, we still are fighting malaria, tuberculosis, leprosy, AIDS and a string of what are rather sadly called ‘neglected tropical diseases’.

None of this is actually new. The Alma-Ata Conference on primary Health Care of September 1978 urged that ‘Governments have a responsibility for the health of their people which can be fulfilled only by the provision of adequate health and social measures’. Alma Ata also recognized the importance of promotive, preventive, curative and rehabilitative services, of nutrition and safe drinking water, of public health education, of access to drugs, immunization, family planning, maternal and child health. Most importantly, the Alma Ata Declaration recognized the need for health human resources both at the local and referral level, for ‘health workers, including physicians, nurses, midwives, auxiliaries and community workers as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community’.

Communicable disease

Public health policy and practice in India has traditionally been driven by ‘communicable disease’. There have been significant achievements in the past and also very recently in the case of polio, where it has been over 7 years without an incidence of wild polio virus. India’s polio campaign was a combination of financial resources, superior technology and dedicated manpower. There have not been comparable results in routine immunization where the all India average is 62%. 2

‘Malaria and other vector borne diseases’ such as dengue still pose a major public health challenge. A reduction has been seen in the number of cases; about 9.5 million malaria cases in 2017, but 1.25 billion Indians—94% of the population—are still at risk of malaria. The government has set 2030 as the target year for eliminating malaria. 3

Despite reduction in mortality of ‘tuberculosis’ by 42 per 100 000 persons in 1990 to 23 per 100 000, India still contributes 25% of the global burden, with an estimated 2.8 million new cases in 2018. 4 The Global TB Report of 2018 reported an incidence of 28 million persons, about a quarter of the world’s cases. 5 Of these 28 million, about 1.47 million are afflicted with Drug Resistant TB, a situation which has arisen almost entirely because of unregulated treatment of tuberculosis by private providers. If India is to achieve elimination of tuberculosis by 2025, a much publicized objective, much more will need to be done.

Non-communicable disease

We also recognize the major threat of ‘non-communicable’ disease. ‘Diabetes, cardio-vascular disease and cancers contribute significantly to the disease burden’. For many years India, with the rest of the world, believed that non-communicable diseases such as hyper tension and diabetes were the result of inappropriate diet in high income countries. We now know more realistically that diabetes and hyper tension as also cancers and mental illnesses have comparatively little to do with incomes and much more to do with the now clearly identified risk factors of tobacco use, uncontrolled use of alcohol, lack of exercise and poor diet.

India, which moved the global mental health resolution in the World Health Assembly 2012 which led to the action plan adopted at the World Health Assembly 2013, has consistently called for a ‘greater recognition of the fact that mental illness be regarded as one of the major non-communicable diseases’, calling for medication, treatment and long-term management. Approximately 5% of India’s population is believed to have common mental disorder with a further 1.5% with severe mental disorder. This translates into about 80 million persons, a staggering number on any reckoning. 6

While all non-communicable ailments need continuous and regular treatment, the stigma surrounding mental illness makes it the more difficult for appropriate measures to be taken. India’s Mental Health Policy of 2014 and the National Mental Health Care Act of 2017 lay down very salutary principles which place the interest of persons with illness at the fore, and not necessarily the interest of families and guardians, and of treating psychiatrists. It is a legislation that recognizes the rights of persons with illness to appropriate treatment, a major move forward in a country where the right to healthcare is not easily understood.

Other diseases, whether communicable or non-communicable, may affect smaller number of persons but still add to the burden of disease and require appropriate responses. These include rheumatic heart disease, leprosy, thalassemia, sickle cell anaemia, congenital disorders and accidental deaths.

Maternal and infant mortality

Numbers do not tell us everything but we must still know what they are. Despite magnificent efforts, largely driven by Government, maternal mortality, nation-wide, is still at 142 deaths per 100 000 births. We were not successful in achieving the MDG target of 109 by 2015. The Sustainable Development Goals (SDGs) now require us, by 2030, to reduce the global maternal mortality ratio to less than 70 per 100 000 live births. Some states have indeed achieved this; Kerala at 61, Maharashtra at 68 and Tamil Nadu at 79 have shown what is possible but we must also recognize Rajasthan at 244, Uttar Pradesh at 285 and Assam at 300.

Infant mortality, nation-wide, is still 39 deaths per 1000 live births. SDG 3.2 requires us to reduce neonatal mortality to at least as low as 12 per 1000 live births and under-5 mortality to at least as low as 25 per 1000 live births. We were not successful in achieving the MDG of not more than 41 deaths per 1000 live births in the under-5 age group. The actual estimate in 2015 was nearer 48 deaths per 1000 live births. Here, again there is wide variation among states with Kerala at 12, Tamil Nadu at 23 and Delhi at 26 at one end of the range, already having achieved the SDG, and Odisha at 66, Madhya Pradesh at 69 and Assam at 73 at the other.

These numbers indicate the scale of the challenge. What they conceal are the details. True, more women and infants are surviving the trauma of childbirth; however, not much else is changing in their lives. Women continue to be underweight, anaemic, married too early, are becoming mothers too early and are giving birth to underweight babies at some risk of wasting and stunting. The Lancet has recently called attention to the fact that ‘Malnutrition was the predominant risk factor for death in children younger than 5 years of age in every state of India in 2017, accounting for 68·2% of the total under-5 deaths’. 7 The additional details are grim. ‘The prevalence of low birth weight in India in 2017 was 21·4%, child stunting 39·3%, child wasting 15·7%, child underweight 32·7%, anaemia in children 59·7%, anaemia in women 15–49 years of age 54·4%, exclusive breastfeeding 53·3% and child overweight 11·5%’. With 28 million babies born every year, the actual numbers are staggering. And even more recently, the 2019 Global Hunger Index places India at a rank of 102 of 117 countries assessed.

Any study of disease burden in India must, obviously, recognize population size. The relationship between health policy and population policy in India has been contentious. For too long, population policy has been seen as a question of population control and it is only relatively recently that more voices are heard, primarily from civil society, calling for a population policy that addresses the questions of women’s health, nutritional status, the ability of women within families and communities to take decisions relating to themselves, women’s literacy and education, awareness among both men and women of the options for family planning available to them and the recognition that higher standards of primary care impact significantly on the health of women and children.

It is also necessary to recognize that whatever efforts are made by India today howsoever heroic and howsoever well-funded, the impact will not really be felt for the next 15 or 20 years. India’s population today stands approximately at 1.3 billion. In population growth as well as in communicable disease, there is significant variation across the states many of whom have achieved replacement fertility rate of 2.1. Other states, more particularly Uttar Pradesh, Bihar, Jharkhand, Madhya Pradesh and Rajasthan have not yet reached this level.

More positively, in the 70 odd years since independence life expectancy has increased significantly, from 26 at independence, to 70.3 years for women and 66.9 years for men.

There is a real danger in a country of India’s size and as divided in access to resources that we concentrate only on the diseases of the urban population, of the relatively better off sections of the society, of persons who have access to health care facilities and of persons who are in a position to pay for health care. It is possible that the diseases of those persons who are unable to access health care fall outside the area of interest of health policy makers.

Health care financing

Prof. Pai’s list of failures also, significantly, highlights India’s failure to invest in health care. Most discussions of this subject tend to highlight the fact that, as against the Alma Ata objective of 3% GDP to health care, India has never gone beyond 1.1%. There are several important riders to this.

Expenditure as a percentage of GDP is by both the centre and the state, though traditionally, it is the central government that has made substantial contributions towards this. This expenditure also includes the cost of maintaining the hospitals and salaries of nurses within the government system, expenditures largely borne by the states many of whom do not find it easy to generate significant resources of their own.

We must also look at how the public expenditures are divided across infrastructure, human resources, hospital care, public health, medical education and medical research. Each of these would require a formidable level of investment and the tendency has been for both the government of India and the states to look for the low hanging fruit such as construction of hospital buildings or the purchase of expensive equipment rather than the more time consuming effort involved in investing in the education of nurses and public health workers or clinical and health research.

Most issues in health care financing are well-known but I would like to speak a little about India’s current policy as reflected in the scheme known as the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana, or Prime Minister’s Health India Programme. There has been a widely publicized, social media driven campaign promoting this Programme but it is necessary not to be diverted by the glitz of the campaign and to look at actual and projected achievements.

The PMJAY has two components. The first is an insurance-based hospital care scheme. Persons enrolled under the PMJAY are entitled to seek treatment at empanelled government and private hospitals the payment for which, up to a maximum of Rs. 500 000, for any one of 1350 packages, at prior negotiated rates, is to be made to the treating facility by the insurance company. This is the way many health insurance schemes work including the Rashtriya Swasthya Bima Yojana which India launched in 2008 and has now, for all practical purposes, abandoned. The latest figures are that 4.46 million persons have received cashless treatment in over 18 000 hospitals, and while figures are frequently released of the numbers of claims settled with hospitals, information is not necessarily forthcoming on improved health outcomes, if any.

There are several difficulties in the entire structure. Where it is government’s intention to negotiate lowest possible rates for prescribed treatment, it is the endeavour of private hospitals to increase these as much as they can, and while it is possible that negotiated rates have been announced, it is perfectly clear that private hospitals will render only as much treatment as they believe they can do so do within the negotiated rate. Another very serious problem with PMJAY is that it only supports cases of hospital admission ignoring the fact that a substantial number of cases could conveniently be dealt with in the outpatient wards. Indeed, in these cases, hospitalization probably brings on a range of unrelated additional costs not covered by the insurance payment. There is, of course, also the issue of useless hospitalization and useless surgeries being undertake only in return for the insurance claims. 8

All of this leads to the suspicion that the scheme has been designed primarily to make use of unused capacity in private hospitals. Interestingly, a recent article authored by the two senior most civil servants in the health establishment relates with some pride that more than half the hospitals empanelled under the scheme are private, and that private hospitals have witnessed a 20% increase in footfall. 9

I have said that there are two parts to the PMJAY programme. The second is the establishment of Health & Wellness Centres. This really appears to be a programme for up-gradation and strengthening of existing sub-centres and primary health centres; 12 services have been identified which the Wellness Centres are expected to provide, unlike the limited range of services currently provided, or expected to be provided, in Sub Centres or PHCs. In an ideal situation, this would have been addressed first on the understanding that the bulk of people’s health concerns would be taken care of within at the level of primary care with only more complicated cases being referred to a secondary or tertiary level, either in the government or in the private sector, where hospitalization would be more or less essential and the cost would be covered by insurance.

Comparatively, little information is available on how successfully the Wellness Centres have been established. A figure of ‘more than 20 000’ is cited in official reports. 10 Given that there are about 24 000 PHCs and over 1 56 000 Sub Centres, this is not a large number. It is also not clear whether a simple conversion of existing centres into the newly christened Wellness Centres would be able to successfully address the problems of inadequate human resources, limited availability of drugs and disposables and general poor maintenance. The eco-system in which the Wellness Centres are to function remains the same and it is not clear that renaming them has effectively solved anything. 11

There is also the more fundamental question of who should pay for healthcare. Having an insurance-based system still requires substantial amounts of government funds to be paid out as insurance premium on population cover. There is no sign in any of the annual budgets since the scheme was launched of increased funding of the order that is required to make it work. Even the Chief Executive of the PMJAY, in a much publicized interview, admitted that he hoped India’s investment in health care would reach 2.55 of the GDP by 2025, of which only a small amount would come to the PMJAY. 12 If government has not budgeted for the insurance claims which will be received in increasing volume, if it has not budgeted for the up-gradation of the Wellness Centres, it is not very clear that the scheme can continue to function. It is also not clear why if the government has the resources, or plans to have the resources, to pay the insurance companies, why these funds could not be used to strengthen existing systems, and to better equip them to function or to ensure the reliable presence at all times of trained health human resources in public sector facilities.

Health human resources

The availability of well-trained and suitably motivated human resources remains one of the most challenging issues in public health in India. The requirement is huge, whether of doctors with a first degree, super specialists or doctors with post-graduate qualifications, nurses, allied health professionals and public health workers. Each of these categories is a crisis situation in itself.

As per the most recent information, the Medical Council of India, of which more anon, has approved, for the award of MBBS, the first degree, 80 312 seats every year of which 42 222 or slightly over 50% are in government colleges, the remainder being in private colleges. Everything to do with the establishment of medical colleges, and the conduct of the Medical Council of India, needs careful examination. The Council itself has recently been abolished with an interim body holding charge till the National Medical Commission takes office. Relevant legislation, the National Medical Commission Act of 2019, has been approved by Parliament. It is much too early to say how this reform will play out. ‘Whether this leaner avatar of the MCI in the form of the NMC will be transparent, impartial, free of corruption and improve efficiency remains to be seen’. 13

Clearly, a very large number of medical graduates are being produced every year. It is unclear how many of them are actually available for public service. It is also the case that there is a very wide variation in the quality of these graduates. Those leaving government medical colleges are generally regarded to have been better trained. While there are outstanding institutions of medical education in the private sector such as the Christian Medical College in Vellore, many of them do not have the same reputation. They survive on the strength of high fee structures, a feature that does not appear to be deterrent given the very high status given to doctors in India. The fact is, however, that a student graduating from a private college, howsoever well or badly trained, is not going to be available for public service if she is to repay the debt that she has incurred in acquiring a medical education.

Issues of medical curriculum and syllabus were not given adequate attention by the Medical Council of India prior to its unlamented demise, and the same is true of nursing education. As per the most recent information available on the Nursing Council of India which for some peculiar reason has not been abolished along with the Medical Council of India and appears to continue outside the newly created National Medical Commission, there are 1630 colleges for the training of midwives, 2960 colleges for the training of staff nurses and 1703 colleges for the training of graduate nurses. The overwhelming majority of these are privately owned and run, of indeterminate quality. Not enough positions have been created by the state governments for nurses, many of whom look for employment opportunities abroad. The nursing council also has regulatory control over the training of midwives, another shamefully neglected area.

On the positive side, we must note that there is legislation currently pending, The Allied and Healthcare Professions Bill, 2018, which aims to define and regulate the conduct and training of allied health professionals, defined as an associate, technician or technologist trained to support the diagnosis and treatment of any illness, disease, injury or impairment. The Bill further lists 15 categories of professionals, with 53 specific professions, with the possibility of including new professions as they emerge in the course of time. India is strong in the drafting of legislation and we must wait and see how effective the proposed national and state councils will be in laying down and maintaining high standards of training and professional practice.

The National Medical Commission to which have referred earlier has livened the debate considerably by proposing the introduction of a Community Health Worker, the liveliness stemming from the fact that there is no clear idea of who this person will be, and how well trained and with what specific responsibility.

Public health

In identifying three big areas where both policy and programme attention is required, disease burden, financial resources and human resources, I have still followed what might be called a hospital driven approach to healthcare. How differently do we need to think if we look at a public health policy for India?

India’s leading public health specialist, also one of India’s leading cardiologists, Dr K. Srinath Reddy has recently called attention to the six key elements of a health system identified by the WHO. 14 These are healthcare infrastructure, health work force, availability of drugs and technologies, the level and use of health financing, health information systems and overall governance of health services. Dr Reddy makes the important point that these six elements do not include the role of the community in driving demand for adequate healthcare.

It is still common in India for public health to be understood as basically concerned with hygiene and sanitation, with controlling the spread of communicable disease. ‘It could however be more usefully understood as the establishment of a viable and functioning primary healthcare system serving the community which takes into its fold all matters relating to health and welfare of the public including preventive measures, appropriate nutrition and well-functioning drinking water and sanitation systems, for all members of the public and particularly for women and children, and over their life course’.

This is a description that I have created but it covers all the relevant issues: the prevention of communicable disease, the treatment of non-communicable diseases over the life course, the need for government investment, the need for qualified persons at all levels and the role of the community. I may add that all of this said in one form or the other in India’s National Health Policy issued in 2017. The policy actually says more, including an emphasis on traditional systems of medicine, and as in the case of much of India’s legislation, is more a statement of aspiration than of commitment.

All this is easier said than done. It is not necessarily only a question of resources. Nothing can be done without resources, but resources without the necessary motivation, political will and executive ability will also not deliver satisfactory health outcomes.

I should also call attention to remarkable civil society interventions which in their motivation and work on the ground reflect the best elements of what I have defined as a public health policy. I think here of Dr Yogesh Jain and his colleagues at the Jan Swasthya Sahyog, in Chhattisgarh, at the heart of India. The JSS runs a hospital which provides a very high quality of care to a large and vulnerable population. I am grateful to Dr Jain for always calling my attention to what he describes as the diseases of the very poor. I think also of Dr Vandana Gopikumar and her colleagues at The Banyan in Chennai, an organization that has worked for 25 years now with homeless women with mental illness. In India, to be female, poor and sick is to be very vulnerable indeed and it is in the work of The Banyan that one sees a combination of professional excellence and compassionate imagination. I must also mention two institutions for children with disability, the Latika Roy Foundation in Dehradun run by the remarkable Jo Chopra and Vidyasagar in Chennai set up by Poonam Natarajan. I must also mention my friend Dr M.R. Rajagopal of Pallium India in Thiruvananthapuram, an organization devoted to establishing palliative care services.

These institutions and many more that I have not mentioned are marked in many ways but most importantly by the human and ethical quality of the individuals behind them. And while this gives these institutions their distinction, it also makes us ask the question of what one may expect from institutions which are not guided by a hugely charismatic figure. Government does not believe in charisma. Yet, it is government’s responsibility to establish fund and manage healthcare institutions. The best examples we have in India are in the non-profit sector. Where and how are we going to bring about a union?

India’s experience in tackling the AIDS epidemic stands as a lesson in how appropriate health policy and programmes can be framed in response to medical evidence, and how community involvement can significantly impact on the efficacy of health investments. My distinguished friend Sujatha Rao in her book ‘Do We Care?’ makes the point that India showed the capacity to respond to a situation which require not only clinical intervention but also changes in the societal attitudes. 15 For possibly, the first time issues of sexuality and sexual orientation were brought into the public discourse, with a recognition of the fact that behavioural change needed to drive India’s response to controlling the epidemic. India’s national AIDS control programmes will always be remembered for their pioneering efforts. Since 2014, ostensibly because the prevalence of AIDS in India has reduced, and also because the government of the day believed that abstinence was a more appropriate response to sexually transmitted diseases, public investment in AIDS control has declined. This is a worrying situation.

Public health is about social justice. The SDGs recognize this, and in their different areas, they target inequality. But it is also true that even where substantial progress has been made towards achieving the SDGs, gaps between countries and between communities within countries continue to rise enormously. 16

The distinguished psychiatrist and public health practitioner Vikram Patel has urged, ‘Inequality corrodes the fabric of a society that is crucial for all people to feel they belong to it and have a stake in a shared future. Social scientists refer to this connectedness as social capital. It acts as an invisible glue that binds us all together, both rich and poor, through good times and bad. It is this communion of hearts and minds which promotes individual, and ultimately, societal well-being. In short, inequality destroys the soul of nations, of societies, of communities and, ultimately, of every individual’s well-being’. 17

And when governments aim at making quality health care accessible and affordable, when they strive, in the words of Alma Ata, for ‘the provision of adequate health and social measures’, they work towards removing inequalities. That is the core of good governance. These noble thoughts have been reiterated in the UN General Assembly’s High Level Resolution of 23 September 2019.

Everything lies with national governments, and in the context of today’s address, India’s government and its ability to show leadership and ownership in establishing effective health governance, to promote access to safe, effective, quality and affordable essential medicines and vaccines, to invest adequate sustainable resources, to invest in the education, recruitment and retention of a fit-for-purpose and responsive public health workforce and to address the social, environmental and economic determinants of health and health inequity. These are monumental challenges and of great importance to all who care for the future of India.

Oxford-India Sustainable Centre, Somerville College, University of Oxford.

Pai   M . Archives of Failures in Public Health, Microbiology , 29 July 2019 .

Universal Immunization Programme Comprehensive Multi-Year Plan . 2018-22, Ministry of Health & Family Welfare .

Yadavar   S . Indiaspend , 23 November 2018 .

Dinesh   C . Sharma, India launches tuberculosis prevalence survey, The Lancet , 10 October 2019 .

India TB Report . Annual Status Report . Ministry of Health & Family Welfare , 2018 .

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A situational analysis of mental health in India Prepared for the National Mental Health Policy, Ministry of Health and Family Welfare, Government of India . Soumitra Pathare and Laura Wood , 2015 .

The burden of child and maternal malnutrition and trends in its indicators in the states of India: the Global Burden of Disease Study 1990-2017 . Lancet , 19 September 2019 .

Rukmini   S . Cracks in our Healthcare System, The Mint , 23 September 2019 .

Sudan   P , Bhushan   I . In one year, PM-JAY has created a framework for comprehensive universal healthcare . The Indian Express , 23 September 2019 .

Sudan   P , Bhushan   I , op cit

Unpacking Ayushman Bharat and other Recent Health Policy initiatives: Parts I and II , T.   Sundararaman , https://medium.com/from-prof-sundararamans-desk/unpacking-ayushman-bharat-and-other-recent-health-policy-initiatives-part-ii-545b93f17f32 .

The Times of India , 26 July 2019 .

Dash   S , Nagral   S . The National Medical Commission: A Renaming or Transformation?   The India Forum , 1 November 2019 .

Srinath Reddy   K . Make Health in India, Reaching a Billion Plus . Orent Blackswan Pvt. Ltd. , 2019 .

Sujatha Rao   K . Do We Care?   Oxford University Press , 2017 .

Bill & Melinda Gates Foundation . 2019 Gatekeepers Report .

Patel   V . The Indian Express , 28 January 2017 .

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Improving Health in India

As the world’s second-most-populous country and one of its fastest-growing economies, India faces both unique challenges and unprecedented opportunities in the sphere of public health.

For more than a decade, India has experienced record-breaking economic growth that has been accompanied by significant reductions in poverty. According to the World Bank, infant mortality in India fell from 66 to 38 per 1,000 live births from 2000 to 2015. Life expectancy at birth has increased from 63 to 68 years, and the maternal mortality ratio has fallen from 374 to 174 per 100,000 live births over the same period.

India also has dynamic pharmaceutical and biotechnology industries; world-class scientists, including a burgeoning clinical trials industry; and leading hospitals that attract foreign patients and treat its better-off citizens.

Yet Indian government and public health officials agree that the country also faces persistent and daunting public health challenges, particularly for the poor. These include child undernutrition and low birth weights that often lead to premature death or lifelong health problems; high rates of neonatal and maternal mortality; growth in noncommunicable diseases such as obesity, diabetes, and tobacco use, leading to cancer and other diseases; and high rates of road traffic accidents that result in injuries and deaths.

As the Indian government strives to provide comprehensive health coverage for all, the country’s rapidly developing health system remains an area of concern. There are disparities in health and health care systems between poorer and richer states and underfunded health care systems that in many cases are inefficiently run and underregulated. New government-financed health insurance programs are increasing coverage, but insurance remains limited.

Public and private health systems are placing huge demands on the country’s capacity to train exceptional health leaders and professionals. Rising to meet these challenges, the people of India have an opportunity to have a major influence on their own future health and on the future of public health and medical efforts globally.

Supporting Development of India’s Health Workforce

The Harvard T.H. Chan School of Public Health is collaborating with partners across India to address those challenges. Together, the School and its partners are introducing educational innovations to India to expand skills training, degree programs, and leadership development at new schools and institutes of public health. We seek to leverage the School’s resources to help strengthen public health training and build capacity across the health sector in India.

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• Society in Transition: Impacts of the Pandemic

The COVID-19 pandemic in India caused considerable suffering, along with economic and social disruption. Till October 2021, 34.3 million people were infected by COVID-19, and an estimated 0.45 million people died. One of the defining features of the pandemic was a public reckoning of the state of the health system. Was the healthcare system in India capable of responding to a large-scale pandemic? What were the economic costs of the lockdowns imposed to control the pandemic? And what is the direction of public healthcare in India?

The Indian Healthcare System

The good news is public health expenditure in India has increased. Revised estimates for 2020-21 place the share of overall spending on health at 1.8% of GDP. The SDG India Index Report (2019-20) by NITI Aayog reports that India aims to increase health expenditure to 2.5% of GDP by 2025. Furthermore, important health schemes such as Ayushman Bharat , launched by the National Health Policy 2017, aim to widen tertiary health coverage.

While these measures are promising, India lags in public health investments and infrastructure, both in contrast to its international peers as well as compared to its own aspirations. Current health expenditure in India is lower than the world average of 9.8% of GDP as of 2018. According to World Bank data, current health expenditure (% of GDP) was 9.51% for Brazil, 5.32% for Russia, 4.12% for Turkey and 2.18% for Indonesia in 2018. India’s federal structure implies that both the centre and state governments spend on healthcare. However, state health expenditure in India is highly divergent, ranging from 3.4% to 12.66% of state budgets, as of 2020-21.

What is more concerning is the health infrastructure investments in India – which fall short of the demands of its large population, and the expenditure levels as well. Total number of government hospital beds per thousand vary widely across states. In 2019, for instance, Karnataka and Kerala had 67 and 61 government hospital beds per thousand, respectively, while states like Punjab and Uttar Pradesh had 22 and 11 government hospital beds per thousand people respectively. Indeed, the covid facility camps and beds may have increased during the pandemic (data not yet available on this), yet disparity in health infrastructure across states is a standing issue.

Economic Costs of the First Lockdown

During the first wave of infections in India in March-May 2020, the Government of India implemented the “world’s strictest lockdown” ( Hale et al. 2020 ). This lockdown severely disrupted business activity and mobility, with millions of migrants traveling back to their villages as opportunities for work in the cities dried up.

The rationale behind implementing this lockdown was to curtail the spread of Covid-19 and to reduce the consequent burden on the healthcare system to save lives. The government hoped that the lockdown would allow for a quicker resumption of normal economic activity over time. However, the trade-off from the lockdowns was short-run reductions in economic activity. In contrast to wealthier countries, the lockdown potentially affected the Indian economy more as per capita incomes were lower; remote working was less prevalent; the extent of digitisation was lower, and social protection was weaker.

What was the economic cost of this lockdown? One perspective is that Gross Domestic Product (GDP) contracted by 24.4% in the second quarter of 2020. However, this headline number conflates both lockdown effects, as well as potentially self-imposed restrictions as citizens restrict their own activities due to the spread of Covid-19 infections. To isolate the impact of government-imposed restrictions (separately from other factors), Beyer, Jain and Sinha 2020 examined the economic implications of a graded ‘unlock’ in May and June 2020, when the central government decided to vary containment rules across districts in the country).

The Impact of Zonal Containment on Economic Activity

The Government of India announced a comprehensive nationwide lockdown on 25 March 2020, which was implemented uniformly across all states and districts. During this phase, nearly all offices, commercial and private establishments, industrial units, as well as public services were closed. Most transportation services – including international and domestic flights, railways, and roadways – were suspended. Hospitality services and educational institutions were shut. This nationwide lockdown lasted until 3 May 2020.

To facilitate a gradual resumption of economic activity, the government announced in May 2020 a differentiated unlock of districts, with some districts retaining strict restrictions, some with intermediate measures, and the remaining districts returning to “business as usual”. The authors of this article contrasted how these districts fared on a range of outcomes – individual mobility (measured by location tracking on cell phones), economic activity (measured by satellites from outer space), and household consumption and income (measured by household surveys).

What were the findings? First, phone location data corroborated that the restrictions were indeed effective in reducing mobility, as the government mandated. The main finding is that the economic recovery was lower by 9.3% in districts with the maximum restrictions relative to districts with minimal restrictions. The recovery was 1.6% lower in districts with intermediate restrictions compared to districts with minimal restrictions. These results are not driven by India’s large metropolitan cities and hold even when they are excluded from the analysis. Some districts were more impacted by the restrictions than others. More developed districts with above-median population density, share of employment in services, credit per capita, and average age, experienced larger impacts.

Households reported both lower income as well as reduced consumption as a consequence of the lockdowns, worrying for the long run if this impacts human capital investments in nutrition, health, and education.

India suffered a lot less economically during the second wave of the pandemic due to imposition of micro-containment zones, in contrast to nationwide lockdown during the first wave. Policymakers can continue to follow similar approaches and maintain preventive measures and protocols which could enable least disruption to economic activity, trade, and travel even as threats of further variants emerge.

Policy Trade-offs

Could greater public health expenditures insure against the need for large scale lockdowns in future health emergencies? For policymakers, GDP decline estimates offer a useful benchmark to contrast with public health expenditures.

India’s economic policymakers well understand the value of increased investments in healthcare. During the pandemic, Indian public health expenditure rose from 1.5% of GDP to 1.8% of GDP. The PM Ayushman Bharat Health Infrastructure Mission scheme aims to increase infrastructure, with financing from the central government. Furthermore, the private sector played a major role during the pandemic, from the development and manufacture of vaccines, to diagnosis of COVID-19 infections and vaccination. To prevent high prices, the government regulated private sector with extensive price controls. Whether this expansion of private sector activities sustains (both in COVID-19 related and other healthcare needs) is an open question.

The way forward should involve building public consensus on the importance of healthcare investments and recognizing the potential economic gains from greater investments.

Disclaimer: The views expressed in the article are those of Dr.  Sinha and Prof.  Jain and not the Reserve Bank of India. The usual disclaimer applies.

Further Reading:

Beyer, R., T. Jain and. S Sinha (2020), ‘ Lights out? COVID-19 containment policies and economic activity ’, World Bank Policy Research Working Paper 9485.

Essay on Healthcare in India

Students are often asked to write an essay on Healthcare in India in their schools and colleges. And if you’re also looking for the same, we have created 100-word, 250-word, and 500-word essays on the topic.

Let’s take a look…

100 Words Essay on Healthcare in India

Introduction.

Healthcare in India is a critical sector. It includes public and private hospitals, clinics, and other medical facilities.

Public Healthcare

The government provides public healthcare. It’s often free or low-cost, making it accessible to many people.

Private Healthcare

Private healthcare, on the other hand, is usually more expensive. However, it tends to have better facilities and shorter wait times.

India faces challenges in healthcare, like inadequate facilities in rural areas and a shortage of trained medical professionals.

Despite these challenges, India is striving to improve its healthcare system for everyone.

250 Words Essay on Healthcare in India

Healthcare in India is a multifaceted system, encompassing public and private sectors, traditional and modern medicine, and urban and rural disparities. This essay explores the current state of healthcare in India, its challenges, and potential solutions.

Current State of Healthcare

India’s healthcare sector has made significant strides, with increased life expectancy and decreased infant mortality. However, it is riddled with disparities. While urban areas enjoy better healthcare facilities, rural regions grapple with inadequate infrastructure and lack of trained medical personnel.

The challenges are manifold. Accessibility and affordability remain major concerns. A large portion of the population lacks access to quality healthcare, while high out-of-pocket expenses push many into poverty. Furthermore, there is a significant shortage of healthcare professionals, particularly in rural areas.

Public-Private Partnership

A public-private partnership (PPP) is seen as a viable solution. The private sector’s resources and efficiency can supplement the public sector’s reach and affordability. However, the implementation of PPPs requires stringent regulations to prevent exploitation.

Role of Technology

Technology can bridge the urban-rural divide. Telemedicine, AI, and mobile health technologies can facilitate remote consultations, predictive diagnostics, and health monitoring, making healthcare more accessible and affordable.

While India’s healthcare system faces significant challenges, the combination of public-private partnerships and technology can pave the way for an efficient, inclusive, and affordable healthcare system. It is crucial for policymakers, healthcare providers, and technology companies to work together towards this common goal.

500 Words Essay on Healthcare in India

India’s healthcare sector is a study in contrasts, presenting a complex tapestry of cutting-edge advancements and systemic challenges. With an expansive population and diverse health needs, the healthcare system in India is a critical component of the nation’s development agenda.

The Landscape of Indian Healthcare

India’s healthcare infrastructure is a mix of public and private providers. The public system, under the aegis of the Ministry of Health and Family Welfare, provides primary, secondary, and tertiary care. However, it suffers from inadequate funding, lack of infrastructure, and a dearth of healthcare professionals. The private sector, on the other hand, is burgeoning. It is technologically advanced, offers high-quality services, but is often criticized for being expensive and inaccessible to the poor.

Healthcare Accessibility and Affordability

Access to quality healthcare is a significant issue in India. Rural areas, in particular, face a shortage of healthcare facilities and professionals. The urban-rural divide is stark, with the majority of quality healthcare services concentrated in cities. Affordability is another concern. High out-of-pocket expenses push many into poverty every year. The situation calls for a robust health insurance framework to protect citizens from catastrophic health expenditures.

Government Initiatives

Recognizing these challenges, the Indian government has launched various initiatives. The National Health Mission aims to improve health outcomes, particularly for the rural population. The Ayushman Bharat scheme, launched in 2018, provides health insurance coverage to the underprivileged, aiming to make healthcare more affordable. These initiatives, while commendable, need effective implementation and monitoring to ensure their success.

Technological Innovations

Technological innovations have the potential to revolutionize India’s healthcare landscape. Telemedicine, artificial intelligence, and digital health records can address the issues of accessibility and affordability. Telemedicine can bridge the urban-rural divide by providing remote consultations. AI can assist in disease prediction and management, while digital health records can streamline patient data, improving efficiency and patient care.

Challenges and Future Prospects

Despite these advancements, India’s healthcare system faces significant challenges. The COVID-19 pandemic has exposed the fragility of the healthcare infrastructure, with hospitals overwhelmed and resources stretched thin. India also grapples with a dual disease burden – communicable diseases like tuberculosis and non-communicable diseases like diabetes and heart disease.

The future of healthcare in India lies in adopting a holistic approach. This includes increasing public health expenditure, strengthening primary healthcare, improving health literacy, and leveraging technology.

India’s healthcare sector, while fraught with challenges, is teeming with potential. With the right mix of policy interventions, technology adoption, and a focus on equitable access, India can transform its healthcare landscape, ensuring a healthier future for its citizens. The journey is long and arduous, but with concerted efforts, a robust and inclusive healthcare system is achievable.

That’s it! I hope the essay helped you.

If you’re looking for more, here are essays on other interesting topics:

• Essay on Handloom and Indian Legacy
• Essay on Growth of Banking Sector in India
• Essay on Greatness of India

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Health Sector in India

Last updated on November 11, 2023 by ClearIAS Team

What is the current Scenario of the Health Care Sector of India? What are the major concerns? How to use India’s huge potential in the health sector to rectify the problems? Read further to know more about  Health Sector in India.

The Constitution considers the “Right to Life” to be essential, and the government is required to protect everyone’s “ Right to Health .”

The healthcare industry in India includes hospitals, medical tourism, health insurance, medical equipment, telemedicine, outsourcing, clinical trials, and medical gadgets.

The public and private sectors make up the two main components of India’s healthcare delivery system.

Table of Contents

The Scenario of the Health Care Sector in India

Let us look at an overview of the current healthcare sector in India

Health Infrastructure

The government, or public healthcare system, concentrates on establishing primary healthcare centres (PHCs) in rural areas while maintaining a small number of secondary and tertiary care facilities in major cities. The majority of secondary, tertiary, and quaternary care facilities are run by the private sector.

India has 1.3 beds per 1,000 people, 0.5 pharmacists per 1,000 people, and 0.8 physicians per 1,000 people, which are all less than half the global average.

Quality of Health Care Services

India is ranked 145 th out of 180 nations in terms of the accessibility and quality of healthcare, according to the Economic Survey (Global Burden of Disease Study 2016)

To achieve an ideal doctor-to-population ratio of 1:1000 by 2030, India will require an additional 2 million doctors.

Disease Burden

Despite having 17% of the world’s population, India bears a disproportionately large portion of the global disease burden (20%).

India’s public healthcare spending was 2.1% of GDP in 2021–2022, up from 1.8% in 2020–2021, according to the  Economic Survey of 2022 .

Challenges in Health Sector

Although India’s healthcare sector has made significant progress in terms of health indicators, it still has some serious flaws in service delivery due to inadequate healthcare infrastructure.

Inadequate Accessibility

Insufficient access to basic healthcare services to all, due to a shortage of medical professionals, a lack of quality assurance, and insufficient health spending.

Insufficient Funding

One of the major concerns is the administration’s lack of financial resources and insufficient funding for research and development.

India’s government will only spend 2.1% of its GDP on healthcare in 2021–22, compared to 10% for Japan, Canada, and France.

No focus on Preventive Care

Despite being shown to be quite beneficial in alleviating a variety of difficulties for patients in terms of unhappiness and financial losses, preventive care is undervalued in India.

Shortage of Medical Workforce

Doctors, nurses, and other healthcare professionals are in short supply in India. According to a minister’s study presented in Parliament, India is short 600,000 doctors.

Lack of Infrastructure

Private hospitals are expensive, whereas Government hospitals are either inadequate or lacking in basic facilities for the Indian population.

Optimal Insurance

The concept of health insurance is still unclear in India, and the market is underdeveloped.

Policymaking

Policymaking is undeniably important in providing effective and efficient healthcare services. The problem in India is one of supply rather than demand, and policy can help.

Potential in Health Care Sector in India

Despite the challenges, there were opportunities. The Indian healthcare system has a unique opportunity to advance while taking stock of the past and getting ready for the future while keeping the welfare of its people in mind.

Strong Demand

According to Aspire Circle, the Indian healthcare sector is expected to reach $744 billion by 2030, driven by greater access to insurance, better health awareness, lifestyle diseases, and rising income.

Innovative Technologies

As part of the National Digital Health Mission ( NDHM ), the digital Health ID will be introduced, which will save patient data. It would aid in effective policymaking, and private firms would benefit from a competitive advantage in the market introduction of innovative technology.

With the advent of information technology and big data, it would be simple for private players to spend strategically.

Rising Manpower

The abundance of highly qualified medical personnel in India is a competitive advantage. With 4.7 million workers as of 2021, the Indian healthcare industry is one of the country’s largest employers.

From 0.83 million in 2010 to 1.3 million in November 2021, the number of allopathic doctors with recognised medical qualifications (under the I.M.C Act) registered with state medical councils/national medical council

Cost Competent

India’s costs are competitive with those of its countries in Asia and the West. Surgery in India costs roughly a tenth of what it does in the US or Western Europe.

Attractive Opportunities

Two vaccines Bharat Biotech’s Covaxin and Oxford-Covishield, AstraZeneca’s both made by SII were critical in protecting the Indian population from COVID-19.

India has emerged as a hub for R&D activities for international players due to its relatively low cost of clinical research.

With the help of the government and private stakeholders, a climate conducive to start-ups and entrepreneurship can be created in this field.

Hub of Medical Tourism

India is already one of the world’s most popular medical tourism destinations, and this industry has significant potential in the coming years.

The low cost of medical services has resulted in a rise in the country’s medical tourism, attracting patients from across the world.

India possesses all the necessary factors for this industry to grow rapidly, including a sizable population, a strong pharmaceutical and medical supply chain, more than 750 million smartphone users, the third-largest global start-up pool with simple access to Venture Capital funding, and innovative tech entrepreneurs looking to address global healthcare issues.

Measures Required in the Health Sector

These are the following major measures for improving the health sector in India:

• Strengthening the Infrastructure: Because of India’s large population, there is an urgent need to improve the infrastructure of public hospitals, which are overburdened.
• Encourage Private Hospitals: The government should support private hospitals because they contribute significantly to the Indian Health sector. The challenges are severe and cannot be addressed solely by the government, the private sector must also participate with Government for the public good.
• Increased efficiency: More medical personnel must be hired in order to improve the sector’s capabilities and efficiency.
• Utilization of Technology: Technology must be used to connect the dots in the health system. Medical devices in hospitals and clinics, mobile health apps, wearables, and sensors are just a few examples of technology that should be considered.
• Improving Mental Health Care Services: Increasing financing for mental health services, educating healthcare professionals on how to effectively treat mental health issues, and lowering the stigma attached to mental illness are all part of improving mental health services.
• Addressing the Root Causes of Health Disparities: To address the social determinants of health and reduce overall health inequities, the healthcare system should collaborate with other sectors, such as education, housing, and sanitation.
• Sustainable Health governance: To promote more effective and efficient healthcare services, sustainable health governance may involve implementing better management systems, bolstering healthcare regulatory organisations, and developing independent oversight mechanisms.
• Make Public Awareness: People should be made aware of the value of early detection and prevention. It would also help them save money on out-of-pocket expenses.
• One Health Approach: The need for communal health programmes that address a healthy environment, healthy animals, and healthy people is urgent. This is known as the “one health approach,” and it aims to address these connections between human and animal health.

Also read: Medical Device Sector in India

Major Steps Taken by the Government

Despite the fact that health is a state issue, the Central Government assists state governments in providing health services through a variety of primary, secondary, and tertiary care systems.

In the Union Budget 2023-24:

• Rs. 89,155 crore was allocated to the health sector, an increase of over 13% from the previous budget.
• Allocated Rs. 6835 crore for establishing 22 new  All India Institute of Medical Sciences (AIIMS).
• Additionally, the National Health Mission’s budget allocation increased from Rs. 28,974 crore in the preceding years to Rs. 29,085 crore in the current 2023–24 budget.
• Budgetary support for the National Digital Health Mission increased from the previous year’s Rs. 140 crore to the current Rs. 341 crore.
• The funds allotted for autonomous bodies were also scaled up, going from Rs. 10,348 crore in the previous budgeted allocation to Rs. 17,322 crore at the moment.

In order to promote medical tourism in the country, the government of India is extending the e-medical visa facility to the citizens of 156 countries.

Prime Minister Mr. Narendra Modi introduced the Ayushman Bharat Digital Mission in September 2021. The endeavour will link the digital health solutions of hospitals across the country. Every citizen will now have access to a digital health ID, and their medical records will be safeguarded online.

In July 2021, the Ministry of Tourism established the ‘National Medical & Wellness Tourism Board’ to promote medical and wellness tourism in India.

In July 2021, the Union Cabinet approved the continuation of the National Ayush Mission , responsible for the development of traditional medicines in India, as a centrally sponsored scheme until 2026.

In July 2021, the Union Cabinet approved the MoU between India and Denmark on cooperation in health and medicine . The agreement will focus on joint initiatives and technology development in the health sector, with the aim of improving public health status of the population of both countries.

India is a land full of opportunities for Health Care and Services. Along with being one of the top places for high-end diagnostic services, the nation has made significant capital investments in advanced diagnostic facilities to serve a larger proportion of the population.

Future demand for healthcare services is anticipated to increase due to factors such as advancing income levels, an ageing population, rising health awareness, and shifting attitudes toward preventative healthcare.

A comprehensive strategy is required to address issues in India’s healthcare industry. This necessitates active collaboration between all stakeholders, including the public, private, and individual sectors.

In 2023, India’s approach to social determinants of health (SDH) could be consolidated and expanded. As a major economic pillar, India must now maintain its existing interest in strategic health policy.

Read:  Climate Resilient Health Systems

Article written by: Aryadevi E S

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The Transformation of The Indian Healthcare System

Ankit kumar.

1 Respiratory Medicine, King George's Medical University, Lucknow, IND

The Indian healthcare system is a diverse and complex network of public and private sectors that provide a wide range of medical services to India's 1.4 billion inhabitants. Despite undergoing significant changes over the years, the system continues to face multiple challenges. These challenges include inadequate infrastructure, a shortage of healthcare professionals, urban-rural disparities, limited health insurance coverage, insufficient public healthcare funding, and a fragmented healthcare system. India is grappling with a growing burden of non-communicable diseases, which poses a significant challenge to its healthcare system.

The Indian government has initiated multiple programs to improve the healthcare system. The National Health Mission improves the availability of medical equipment and supplies. This also promotes community participation and engagement in healthcare decision-making and service delivery. The Ayushman Bharat scheme is a health insurance program that provides coverage of up to INR 5 lakhs per family per year for secondary and tertiary care hospitalization.

The Indian healthcare system is also witnessing multiple healthcare innovations, ranging from low-cost medical devices to innovative healthcare delivery models. The country's healthcare regulatory system is evolving to ensure patient safety, promote high-quality care, and control costs.

Furthermore, India has emerged as a leading destination for medical tourism due to the relatively low cost of medical procedures, the availability of skilled doctors, and advanced technology. Factors such as cost-effective treatment, advanced technology, a wide range of specialities, alternative medicine, English language proficiency, and ease of travel have contributed to India's growing medical tourism industry.

The Indian healthcare system has made significant progress in recent years. The positive transformation of the Indian healthcare system involves a range of changes and initiatives. Despite challenges, the continued investment in healthcare and innovation provides reasons to be optimistic about the future of healthcare in India.

The structure and organization of healthcare systems vary widely across different countries and regions. Some countries have a predominantly public healthcare system, where the government is responsible for providing healthcare services to the population. Other countries have a predominantly private healthcare system where healthcare services are provided by private hospitals. A well-functioning healthcare system provides high-quality healthcare services to the people, and it should be accessible, affordable, and sustainable over the long term [ 1 ].

The Indian healthcare system is a complex and diverse network made up of the public and private sectors, which offer a range of medical services and infrastructure to the 1.4 billion people living in India. It has undergone significant transformations over the years but still faces several challenges. The public sector includes primary, secondary, and tertiary care facilities managed by the central and state governments. Primary healthcare services are the individual's first point of contact and are provided through primary health centers, community health centers, and sub-centers. Secondary care focuses on acute and specialist services provided by district hospitals. Tertiary care refers to advanced medical services, including specialty and super-specialty services provided by medical colleges. The private sector consists of individual practitioners, nursing homes, clinics, and corporate hospitals [ 2 ].

The Indian healthcare system faces several challenges that impact its ability to deliver quality healthcare services to its large and diverse population [ 3 ]. Some of the key challenges are:

Inadequate infrastructure

India has a shortage of healthcare facilities, especially in rural areas, where the majority of the population resides. Many primary health centers and sub-centers lack essential infrastructure, medical equipment, and resources, making it difficult to provide even basic healthcare services to the population. The insufficient number of healthcare facilities, poorly maintained facilities, inadequate medical equipment and resources, and limited access to advanced healthcare services exacerbate the existing challenges in providing quality healthcare services to the population [ 3 ].

Shortage of healthcare professionals 

India has a significant shortage of healthcare professionals, including doctors, nurses, and paramedical staff. This is a critical challenge facing the Indian healthcare system, affecting the quality and accessibility of healthcare services across the country. The scarcity of trained medical staff has consequences like inadequate patient care. This is particularly evident in rural areas, where the majority of the population resides but has limited access to trained medical professionals. The limited capacity of medical and nursing schools to train healthcare professionals is a contributing factor to the shortage of skilled staff.

Urban-rural disparities

There is a marked disparity in the quality and accessibility of healthcare services between urban and rural areas. Urban areas tend to have better infrastructure, access to skilled professionals, and availability of specialized care, while rural areas often struggle with inadequate facilities and limited human resources.

Financial constraints and health insurance

The high out-of-pocket expenses for healthcare services can be a major burden for many Indians. Health insurance in India is not as widespread as in some other countries. This can lead to delayed or avoided treatments, causing further complications and health issues.

Insufficient public healthcare funding

The Indian government's expenditure on healthcare has historically been low compared to other countries, which contributes to the inadequacy of public healthcare facilities and the high reliance on private healthcare services, which may not be affordable for all citizens.

Fragmented healthcare system and inequity in access to care

The Indian healthcare system is characterized by a complex mix of public and private providers with varying degrees of quality and regulation. Socioeconomic disparities and regional differences in access to healthcare services result in unequal healthcare outcomes for different population groups, with poorer communities and those living in remote areas often facing greater challenges in accessing quality healthcare.

Growing burden of non-communicable and communicable diseases

Non-communicable diseases, such as diabetes, cardiovascular diseases, and cancer, have been on the rise in India, putting additional strain on the healthcare system. Despite progress in recent years, India still faces challenges in controlling communicable diseases like tuberculosis, malaria, and HIV/AIDS, which continue to pose significant public health risks.

The positive transformation of the Indian healthcare system is a multifaceted and ongoing process that involves many different changes and initiatives. The statistical data shows that the average life expectancy at birth in India has increased by approximately three years in the last ten years. The government has been working to improve the healthcare system through various initiatives to strengthen primary, secondary, and tertiary healthcare services. The Indian government spent two percent of India's gross domestic product (GDP) on healthcare in financial year 2022 and is forecast to reach over 2.5% of the GDP by 2025. In the financial year 2022, the government of India allocated approximately 860 billion Indian rupees to the Ministry of Health and Family Welfare in the Union Budget. The health tech sector in India secured private equity and venture capital investments worth nearly 1,740 million U.S. dollars in 2021. India's healthcare sector was worth about 280 billion U.S. dollars in 2020, and it was estimated to reach up to 372 billion dollars by 2022. The country's healthcare market had become one of the largest sectors in terms of revenue and employment, and the industry was growing rapidly [ 2 ].

Indians spend approximately 20 percent of their health spending as an out-of-pocket expenditure. In 2019, Indians spent around 55 percent of their total health spending as an out-of-pocket expenditure. This was at 74 percent in 2001, showing a gradual decrease in the share of healthcare expenses that people pay directly to the providers [ 2 ].

Some of the key elements of this positive transformation of India's healthcare system are the National Health Mission, Ayushman Bharat, and medical tourism.

The National Health Mission (NHM) was launched in 2013 and comprises the National Rural Health Mission (NRHM) and the National Urban Health Mission (NUHM). The NHM aims to strengthen primary healthcare infrastructure and services by upgrading existing facilities, building new ones, and improving the availability of medical equipment and supplies. This initiative also seeks to enhance human resources for health by training and recruiting more doctors, nurses, and paramedical staff, especially in rural areas. The NHM also aims to improve maternal, neonatal, and child health by expanding access to essential services such as antenatal care, skilled birth attendance, and immunization programs. Finally, it targets communicable and non-communicable diseases through targeted interventions and public health campaigns. The National Health Mission was allocated a budget of over 290 billion Indian rupees for the financial year 2024 [ 2 ].

Ayushman Bharat is another flagship healthcare initiative launched in 2018. This scheme provides financial protection and health coverage to India's vulnerable populations through Health and Wellness Centers (HWCs) and the Pradhan Mantri Jan Arogya Yojana (PMJAY). As of December 2022, there were about 117 thousand Ayushman Bharath Health and Wellness Centers (AB-HWCs) across India. AB-HWCs provide free essential medicine, diagnostic services, and teleconsultation. The HWCs aim to provide comprehensive primary healthcare services to rural and urban populations, including preventive, promotive, and curative care. The HWCs focus on maternal and child health, non-communicable diseases, communicable diseases, and palliative care while providing essential drugs and diagnostic services. The PMJAY is a health insurance scheme that provides coverage of up to INR 5 lakhs per family per year for secondary and tertiary care hospitalization. This initiative targets approximately 100 million economically disadvantaged families, covering around 500 million beneficiaries, and covers a range of medical procedures and treatments at empanelled hospitals. PMJAY aims to reduce out-of-pocket expenses and improve access to quality healthcare for India's poorest and most vulnerable populations. Over 217 thousand public health facilities were reported in India as of the financial year 2022. Over 1.4 billion services were performed by outpatient departments across India, a significant increase from the previous year's value of over 1.1 billion [ 2 ].

Digital healthcare

The shift towards digital healthcare in India is transforming the way healthcare services are delivered, particularly in remote areas. Telemedicine, digital health records, and mobile health apps are all being used to improve healthcare service quality and efficiency [ 4 ].

Non-communicable disease prevention and management

India is facing a growing burden of non-communicable diseases, but there are efforts underway to prevent and manage these diseases. This includes initiatives to promote healthy lifestyles, increase awareness of disease prevention, and provide specialized care and treatment for those with chronic conditions.

The penetration of health insurance across India stood at around 35 percent as of the financial year 2018. This was a slight increase compared to the previous year, when penetration levels were about 33 percent. In the financial year 2021, nearly 514 million people across India were covered under health insurance schemes, and the value of premiums for the government-sponsored health insurance schemes across India aggregated to around 43 billion Indian rupees [ 2 ].

Healthcare innovation and regulation

There are many examples of healthcare innovation happening in India, from low-cost medical devices to innovative healthcare delivery models. These innovations have the potential to improve healthcare outcomes and reduce costs in the long term. India's healthcare regulatory system is evolving to ensure patient safety, promote high-quality care, and control costs. The government is taking steps to streamline the regulatory system and ensure that healthcare providers adhere to high standards of care [ 5 ].

The private healthcare sector in India plays a vital role in achieving universal health coverage, as recognized by the government. India offers healthcare services at comparatively low costs, attracting international patients seeking quality treatment at affordable prices. The private healthcare sector has made significant advancements in infrastructure, technology, specialized services, and healthcare access. Private healthcare providers have invested in modern hospitals, clinics, and diagnostic centers equipped with advanced medical technology. They have embraced digital innovations such as electronic medical records, telemedicine, health apps, and remote monitoring systems to improve patient care. Increased health insurance coverage has facilitated access to private healthcare services, with insurance companies collaborating with private hospitals and clinics. The government has encouraged public-private partnerships to enhance healthcare access and infrastructure, particularly in underserved areas. Collaborative efforts between the public and private sectors, along with targeted interventions, can help bridge gaps and create a more inclusive healthcare system.

Medical tourism

India has become a popular destination and thrived due to the availability of advanced treatments at relatively lower costs, the availability of skilled doctors and advanced technology in private hospitals contributing to foreign exchange earnings, and a positive reputation. India has emerged as a popular destination for medical tourism in recent years, attracting patients from around the world. The factors contributing to India's growing medical tourism industry include cost-effective treatment, skilled medical professionals, advanced technology, a wide range of specialties, alternative medicine, English language proficiency, and ease of travel.

Despite the challenges, the Indian healthcare system has made significant positive progress in recent years, particularly in terms of expanding access to healthcare services and improving health outcomes. These government initiatives, programs, and policies address the various challenges faced by the Indian healthcare system and improve access to quality healthcare services for all citizens. The positive transformation of India's healthcare system is ongoing and involves a range of changes and initiatives. While there are still significant challenges to overcome, such as healthcare access disparities and the burden of disease, the continued investment in healthcare and innovation in the sector are reasons to be optimistic about the future of healthcare in India. However, sustained efforts and investments are required to ensure that the benefits of these initiatives reach the intended beneficiaries and lead to lasting improvements in health outcomes.

The authors have declared that no competing interests exist.

Francis Collins: Why I’m going public with my prostate cancer diagnosis

I served medical research. now it’s serving me. and i don’t want to waste time..

Over my 40 years as a physician-scientist, I’ve had the privilege of advising many patients facing serious medical diagnoses. I’ve seen them go through the excruciating experience of waiting for the results of a critical blood test, biopsy or scan that could dramatically affect their future hopes and dreams.

But this time, I was the one lying in the PET scanner as it searched for possible evidence of spread of my aggressive prostate cancer . I spent those 30 minutes in quiet prayer. If that cancer had already spread to my lymph nodes, bones, lungs or brain, it could still be treated — but it would no longer be curable.

Why am I going public about this cancer that many men are uncomfortable talking about? Because I want to lift the veil and share lifesaving information, and I want all men to benefit from the medical research to which I’ve devoted my career and that is now guiding my care.

Five years before that fateful PET scan, my doctor had noted a slow rise in my PSA, the blood test for prostate-specific antigen. To contribute to knowledge and receive expert care, I enrolled in a clinical trial at the National Institutes of Health, the agency I led from 2009 through late 2021.

At first, there wasn’t much to worry about — targeted biopsies identified a slow-growing grade of prostate cancer that doesn’t require treatment and can be tracked via regular checkups, referred to as “active surveillance.” This initial diagnosis was not particularly surprising. Prostate cancer is the most commonly diagnosed cancer in men in the United States, and about 40 percent of men over age 65 — I’m 73 — have low-grade prostate cancer . Many of them never know it, and very few of them develop advanced disease.

Why am I going public about this cancer that many men are uncomfortable talking about? Because I want to lift the veil and share lifesaving information.

But in my case, things took a turn about a month ago when my PSA rose sharply to 22 — normal at my age is less than 5. An MRI scan showed that the tumor had significantly enlarged and might have even breached the capsule that surrounds the prostate, posing a significant risk that the cancer cells might have spread to other parts of the body.

New biopsies taken from the mass showed transformation into a much more aggressive cancer. When I heard the diagnosis was now a 9 on a cancer-grading scale that goes only to 10, I knew that everything had changed.

Thus, that PET scan, which was ordered to determine if the cancer had spread beyond the prostate, carried high significance. Would a cure still be possible, or would it be time to get my affairs in order? A few hours later, when my doctors showed me the scan results, I felt a rush of profound relief and gratitude. There was no detectable evidence of cancer outside of the primary tumor.

Later this month, I will undergo a radical prostatectomy — a procedure that will remove my entire prostate gland. This will be part of the same NIH research protocol — I want as much information as possible to be learned from my case, to help others in the future.

While there are no guarantees, my doctors believe I have a high likelihood of being cured by the surgery.

My situation is far better than my father’s when he was diagnosed with prostate cancer four decades ago. He was about the same age that I am now, but it wasn’t possible back then to assess how advanced the cancer might be. He was treated with a hormonal therapy that might not have been necessary and had a significant negative impact on his quality of life.

Because of research supported by NIH, along with highly effective collaborations with the private sector, prostate cancer can now be treated with individualized precision and improved outcomes.

As in my case, high-resolution MRI scans can now be used to delineate the precise location of a tumor. When combined with real-time ultrasound, this allows pinpoint targeting of the prostate biopsies. My surgeon will be assisted by a sophisticated robot named for Leonardo da Vinci that employs a less invasive surgical approach than previous techniques, requiring just a few small incisions.

Advances in clinical treatments have been informed by large-scale, rigorously designed trials that have assessed the risks and benefits and were possible because of the willingness of cancer patients to enroll in such trials.

I feel compelled to tell this story openly. I hope it helps someone. I don’t want to waste time.

If my cancer recurs, the DNA analysis that has been carried out on my tumor will guide the precise choice of therapies. As a researcher who had the privilege of leading the Human Genome Project , it is truly gratifying to see how these advances in genomics have transformed the diagnosis and treatment of cancer.

I want all men to have the same opportunity that I did. Prostate cancer is still the No. 2 cancer killer among men. I want the goals of the Cancer Moonshot to be met — to end cancer as we know it. Early detection really matters, and when combined with active surveillance can identify the risky cancers like mine, and leave the rest alone. The five-year relative survival rate for prostate cancer is 97 percent, according to the American Cancer Society , but it’s only 34 percent if the cancer has spread to distant areas of the body.

But lack of information and confusion about the best approach to prostate cancer screening have impeded progress. Currently, the U.S. Preventive Services Task Force recommends that all men age 55 to 69 discuss PSA screening with their primary-care physician, but it recommends against starting PSA screening after age 70.

Other groups, like the American Urological Association , suggest that screening should start earlier, especially for men with a family history — like me — and for African American men, who have a higher risk of prostate cancer. But these recommendations are not consistently being followed.

Our health-care system is afflicted with health inequities. For example, the image-guided biopsies are not available everywhere and to everyone. Finally, many men are fearful of the surgical approach to prostate cancer because of the risk of incontinence and impotence, but advances in surgical techniques have made those outcomes considerably less troublesome than in the past. Similarly, the alternative therapeutic approaches of radiation and hormonal therapy have seen significant advances.

A little over a year ago, while I was praying for a dying friend, I had the experience of receiving a clear and unmistakable message. This has almost never happened to me. It was just this: “Don’t waste your time, you may not have much left.” Gulp.

Having now received a diagnosis of aggressive prostate cancer and feeling grateful for all the ways I have benefited from research advances, I feel compelled to tell this story openly. I hope it helps someone. I don’t want to waste time.

Francis S. Collins served as director of the National Institutes of Health from 2009 to 2021 and as director of the National Human Genome Research Institute at NIH from 1993 to 2008. He is a physician-geneticist and leads a White House initiative to eliminate hepatitis C in the United States, while also continuing to pursue his research interests as a distinguished NIH investigator.

An earlier version of this article said prostate cancer is the No. 2 killer of men. It is the No. 2 cause of cancer death among men. The article has been updated.

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This Futuristic Public Toilet In China Analyses Your Urine To Measure Health

Shanghai-based documentary director christian petersen-clausen shared a photo of one such urinal and shared his experience in a twitter thread..

These urinals quickly and accurately test urine on-site for just 20 yuan

Several futuristic urinals have recently begun popping up in China to help people better manage their health through automated monitoring and analysis of urine. These smart toilets have been rolled out in public men's restrooms in major Chinese cities, such as Beijing and Shanghai. According to the New York Post , these urinals quickly and accurately test urine on-site for just 20 yuan, which equals about $2.76 (approximately Rs 230).

Shanghai-based documentary director Christian Petersen-Clausen shared a photo of one such urinal and shared his experience in a Twitter thread. He wrote, ''Recently Health Checking Urinals have begun popping up in Men's restrooms all over Shanghai. A private company is offering the urine analysis for RMB 20. Naturally, I tried that out.''

''The whole process is about as easy as one might think. I paid my fee via WeChat and before I even made it down the escalator had my results,'' he further wrote, while sharing photos of the high-tech machine, which shows a man peeing into the urinal along with an explanation written in Mandarin.

See the post here:

Recently Health Checking Urinals have begun popping up in Men's restrooms all over Shanghai. A private company is offering the urine analysis for RMB 20. Naturally I tried that out. Here's how that went. pic.twitter.com/1enzII4b7E — Christian Petersen-Clausen (@chris__pc) April 22, 2024

His results, which said he lacked Calcium, were ''otherwise unremarkable,'' he said.

After a few days, he tumbled over another of these urinals and did another test. ''Apparently, I had been drinking enough milk by then. The tests seem to be rather comprehensive as well,'' he wrote, informing users that his  Calcium levels had gotten better.

I don't think this shall replace a visit to your doctor but it might very well prompt one. A cardiologist told me that thanks to Apple Watches he now saw more people before they had heart attacks. That's kind of what I am hoping for here. pic.twitter.com/VpTOHYa97Y — Christian Petersen-Clausen (@chris__pc) April 22, 2024

''The company seems to be installing them all over China and given how important early detection of health issues is I think this is quite good. I don't think this shall replace a visit to your doctor but it might very well prompt one. A cardiologist told me that thanks to Apple Watches he now saw more people before they had heart attacks. That's kind of what I am hoping for here.,'' he added. 

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A Life Overtaken by Conspiracy Theories Explodes in Flames as the Public Looks On

Friends of Max Azzarello, who set himself on fire outside Donald J. Trump’s trial, said he was a caring person whose paranoia had led him down a dark path.

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By Michael Wilson ,  Tracey Tully and Jan Ransom

The journey that ended with a man setting himself on fire on Friday outside the Manhattan courthouse where Donald J. Trump was being tried seemed to have begun in Florida, with a series of increasingly bizarre outbursts.

Standing in the afternoon chill, the man, Max Azzarello, 37, of St. Augustine, Fla., threw pamphlets into the air before dousing himself with an accelerant and setting his body ablaze. The police hurried to extinguish the flames, and he was taken to a hospital burn unit, gravely injured. He died on Friday night.

The fire just a block or two from the courthouse appeared calculated to draw widespread attention, horrifying bystanders and temporarily overshadowing the momentous trial of a former president.

But a closer look at the path the man had traveled to this moment of self-destruction revealed a recent spiral into volatility, one marked by a worldview that had become increasingly confusing and disjointed — and appeared to be unattached to any political party. His social media postings and arrest records suggest the immolation stemmed instead from a place of conspiracy theories and paranoia.

Until last summer, Mr. Azzarello seemed to have lived a relatively quiet life. After high school, where he was a member of a bowling team, he graduated from the University of North Carolina at Chapel Hill in 2009, with degrees in anthropology and public policy.

As a student at Rutgers University in New Brunswick, N.J., where he received a master’s degree in city and regional planning in 2012, he was known for leaving supportive Post-it notes for classmates in the hallways and for his karaoke performances of Frank Sinatra and Disney tunes, said a former classmate, Katie Brennan.

“He was super curious about social justice and the way things ‘could’ be,” Ms. Brennan said. “He was creative and adventurous.”

He began a career in which, according to his LinkedIn profile, he moved among jobs in marketing, sales and technology. In 2013, he worked on the campaign of Representative Tom Suozzi of Long Island, who was then running for Nassau County executive.

An old friend from high school, Steven Waldman, called Mr. Azzarello one of the smartest people he knew.

“He was a good friend and person and cared about the world,” he said.

But there was cause for concern, too.

By last year, he had apparently settled in St. Augustine, where he lived in a modest apartment near the Matanzas River in that historic city. He was a pleasant if sometimes peculiar neighbor.

“An extremely nice person,” said Larry Altman, the property manager at his apartment building, who added: “He had political views that I would not consider mainstream. He called our government and the world government a Ponzi scheme.”

But there were no signs that he was harboring an urge to harm himself, Mr. Altman said.

“If you met Max, he’d shake your hand, and you’d have a nice conversation,” he said. “He’d treat you with respect.”

He was clearly deeply affected by the loss of his mother, however. Elizabeth Azzarello died on April 6, 2022, near Sea Cliff, N.Y., on Long Island, where she had fought pulmonary disease, Mr. Azzarello wrote on Instagram in April 2022.

“I am immensely proud to say that she navigated the awful challenges of this disease with strength, dignity and spirit through the very end,” he wrote.

After this loss, his old friends saw a change. “That was around the time when he became more outspoken,” Mr. Waldman said. “They were close, and they had a good relationship. He was heartbroken.”

By the following year, the clarity Mr. Azzarello had shown in writing of his grief was gone, and a troubled image emerged.

In March 2023, he listed his profession on LinkedIn as “Research Investigator,” self-employed. In June of that year, he tagged Ms. Brennan and several others to make sure they had seen something he had written. She described it as a “manifesto” and called him immediately and tried to intervene. Eventually she wrote to one of his family members to make sure that they were aware that he was in crisis, she said.

About five months later, in early August 2023, he posted on Facebook about visiting a mental health treatment facility: “Three days in the psych ward, and all I got were my new favorite socks.”

Days later, in picturesque St. Augustine, he went for dinner at the Casa Monica Hotel on Cordova Street. Afterward, Mr. Azzarello walked into the lobby, approached an autograph left by former President Bill Clinton, who had signed the wall several years earlier, and threw a glass of wine at it, the police said. He admitted what he had done to officers, the police said. The episode was most likely written off as one man’s bad night.

Two days later, he was back, standing outside the hotel in just his underwear, ranting and cursing into a bullhorn, the police said. And just three days after that, he vandalized a sign outside a nearby United Way office before climbing into the bed of a stranger’s truck and rifling its contents, the police said.

All these events played out within walking distance of the apartment where even his most far-afield views had only recently been delivered politely.

In the months that followed, Mr. Azzarello promoted his disjointed preoccupations in a document he posted on Facebook. The pages attacked fascism and the general complacency of the public. They espoused general anti-government sentiment but did not seem directed at a discernible political party.

“Like frogs in water coming to a boil, the public didn’t notice the rotten truth behind the illusion of freedom,” the writings state. The man who had written fondly of his mother just a year earlier — “gracious and warm, silly and catty, compassionate and supportive” — and their time together seemed to have disappeared.

His greatest vexation appeared to be cryptocurrency, which he cast as a threat to humanity.

It was unclear when he arrived in New York, taking a room at the Soho 54 Hotel on Watts Street in Lower Manhattan and making his way to the running sideshow outside the downtown criminal courthouse.

The area he chose, Collect Pond Park, has been an on-and-off stage for supporters and opponents of Mr. Trump for months. Mr. Azzarello was there by Thursday, holding a sign and speaking in ways that, perhaps bizarre elsewhere, fit in with the disparate voices of the park.

On Friday, the crowd in the park had thinned. At about 1:35 p.m., people began to scream. A blur followed: a man on fire, bright flames licking his clothing and hair; officers scrambling over barricades; a departing ambulance.

His oldest friends were left struggling to make sense of this act.

“He was kind and a gentle soul,” said Carol Waldman, the mother of his childhood friend. “A real wonderful, terrific young guy. Who had his whole life ahead of him.”

If you are having thoughts of suicide, you can call or text 988 to reach the 988 Suicide and Crisis Lifeline or go to SpeakingOfSuicide.com/resources for a list of additional resources.

Nate Schweber , Stefanos Chen , Nichole Manna , Nicholas Fandos , Chelsia Rose Marcius and Claire Fahy contributed reporting. Susan C. Beachy contributed research.

Michael Wilson , who covers New York City, has been a Times reporter for more than two decades. More about Michael Wilson

Tracey Tully is a reporter for The Times who covers New Jersey, where she has lived for more than 20 years. More about Tracey Tully

Jan Ransom is an investigative reporter on the Metro desk focusing on criminal justice issues, law enforcement and incarceration in New York. More about Jan Ransom

Our Coverage of the Trump Hush-Money Trial

News and Analysis

Donald Trump’s criminal trial in Manhattan is off to an ominous start for the former president, and it might not get any easier  in the days ahead. Here’s why.

The National Enquirer was more than a friendly media outlet  for Trump’s presidential campaign in 2016. It was a powerful, national political weapon that was thrust into the service of a single candidate , in violation of campaign finance law.

As prosecutors argued that Trump had repeatedly broken a gag order , they called one episode “very troubling”  — his sharing of a commentator’s quote disparaging prospective jurors as clandestine operators for the left.

More on Trump’s Legal Troubles

Key Inquiries: Trump faces several investigations  at both the state and the federal levels, into matters related to his business and political careers.

Case Tracker:  Keep track of the developments in the criminal cases  involving the former president.

What if Trump Is Convicted?: Could he go to prison ? And will any of the proceedings hinder Trump’s presidential campaign? Here is what we know , and what we don’t know .

Trump on Trial Newsletter: Sign up here  to get the latest news and analysis  on the cases in New York, Florida, Georgia and Washington, D.C.