Public Health of India: A Comprehensive Review of Progress, Challenges, and the Path Toward Universal Health Coverage
1. Alfiya Sultana
2. Noori Saba
3. Sidra Maheen
4. Sana Jakkali
5. Tuba e Lain
6. Nuzhath Firdos
7. Rafiya Nalband
8. Kalybekova K.D
(1,2,3,4,5,6,7. Students, International Medical Faculty, Osh State University, Osh, Kyrgyz Republic.)
(8. Senior Lecturer, International Medical Faculty, Osh State University, Osh, Kyrgyz Republic.)
Abstract
India stands at a pivotal juncture in its public health trajectory, having made remarkable strides in reducing communicable disease burden, improving maternal and child health outcomes, and expanding health insurance coverage, while simultaneously confronting an escalating crisis of non-communicable diseases, environmental health threats, and persistent health system inequities. This review synthesizes the most current evidence on India's public health landscape, drawing upon official government surveys, international health organization reports, peer-reviewed research, and population-based data from 2020 to 2025. The analysis examines India's dual burden of disease, the transformation of its healthcare infrastructure through flagship initiatives such as Ayushman Bharat, the evolving challenges of air pollution and climate change, the state of its health workforce, and the mental health crisis emerging from decades of neglect. The findings reveal that while India has achieved commendable reductions in maternal mortality, infant mortality, and tuberculosis incidence, the country continues to grapple with out-of-pocket health expenditures that push millions into poverty, a severe shortage of healthcare professionals, and an environmental health burden that claims over 1.7 million lives annually. The review concludes that India's path to achieving Sustainable Development Goal 3 and the National Health Policy 2017 target of 2.5% of GDP health expenditure requires not merely incremental improvements but a fundamental reimagining of health governance, financing, and delivery that prioritizes equity, prevention, and community participation.
Keywords: public health, India, universal health coverage, Ayushman Bharat, non-communicable diseases, health workforce, air pollution, maternal health, health expenditure, SDG 3
1. Introduction
India, with a population exceeding 1.4 billion people, represents one of the most complex public health environments in the contemporary world. The nation's health landscape is characterized by a profound duality: on one hand, India has achieved extraordinary progress in reducing mortality from infectious diseases, expanding immunization coverage, and improving maternal and child survival; on the other, it faces a rapidly growing burden of non-communicable diseases, environmental degradation, mental health disorders, and health system inequities that threaten to undermine decades of development gains. This duality is not merely a statistical curiosity but a lived reality for millions of Indians who navigate a healthcare system that is simultaneously capable of world-class medical innovation and yet struggles to provide basic primary care to its most vulnerable citizens.
The concept of public health in India must be understood against the backdrop of the country's extraordinary diversity. Spanning 28 states and 8 union territories, India encompasses linguistic, cultural, religious, and socioeconomic heterogeneity that is unmatched by any other nation. The health challenges of a tribal community in the forests of Chhattisgarh bear little resemblance to those of a software engineer in Bengaluru, yet both are part of the same national health system and subject to the same policy frameworks. This diversity demands public health approaches that are not only evidence-based but also context-sensitive, culturally appropriate, and responsive to local power dynamics.
India's public health journey since independence in 1947 has been marked by several transformative phases. The early decades focused on controlling epidemic diseases, expanding basic sanitation, and establishing a network of primary health centers that remains the backbone of rural healthcare delivery. The 1980s and 1990s saw the emergence of vertical disease control programs targeting tuberculosis, malaria, HIV/AIDS, and leprosy, often with significant international support. The 2000s brought increased attention to health as a human right, the passage of the National Rural Health Mission in 2005, and growing recognition of the social determinants of health. The most recent decade has been defined by the ambitious Ayushman Bharat initiative, the COVID-19 pandemic, and an emerging consensus that India's health system must transition from a curative, hospital-centric model to one that emphasizes prevention, primary care, and universal health coverage.
The COVID-19 pandemic, which devastated India in 2020 and 2021, served as both a stress test and a catalyst for public health reform. It exposed the fragility of India's health infrastructure, the inadequacy of its health workforce, and the deep inequities that determine who lives and who dies in a health crisis. Yet it also demonstrated the remarkable resilience of India's frontline health workers, the potential of digital health technologies, and the capacity for rapid policy adaptation when political will is mobilized. The lessons of the pandemic continue to shape India's health policy discourse, informing debates about health expenditure, pandemic preparedness, and the balance between centralized and decentralized governance.
This review aims to provide a comprehensive, evidence-based examination of India's public health landscape as it stands in 2025. By synthesizing data from the National Family Health Survey, the Sample Registration System, the Economic Survey, international health organization reports, and recent peer-reviewed research, the article seeks to illuminate the progress India has made, the challenges it continues to face, and the policy directions that offer the greatest promise for improving population health. The ultimate objective is to contribute to a nuanced understanding of public health in India that transcends simplistic narratives of success or failure, recognizing instead the complex, contested, and deeply human process of building a healthier nation.
2. Materials and Methods
This review was conducted as a narrative synthesis of peer-reviewed literature, official government reports, international health organization publications, and population-based survey data pertaining to the public health of India. The search strategy encompassed electronic databases including PubMed, Scopus, Web of Science, and Google Scholar, with search terms including combinations of "India," "public health," "health system," "Ayushman Bharat," "maternal mortality," "non-communicable diseases," "air pollution," "health workforce," "health expenditure," "COVID-19," "tuberculosis," "malaria," "mental health," and "universal health coverage." The search was restricted to publications in English from January 2020 to May 2026, with selective inclusion of earlier seminal works where necessary to establish historical context or methodological foundations.
Inclusion criteria encompassed original research articles (cross-sectional surveys, cohort studies, ecological analyses, and policy evaluations), systematic reviews and meta-analyses, official government reports and press releases (including those from the Ministry of Health and Family Welfare, the Press Information Bureau, the Registrar General of India, and NITI Aayog), international health organization publications (WHO, UNICEF, UNAIDS, The Lancet Countdown), and national health surveys (National Family Health Survey, Sample Registration System, National Health Accounts, Economic Survey). Studies and reports were included regardless of geographical focus within India, provided that they offered sufficient methodological detail to permit critical appraisal of findings. Exclusion criteria included opinion pieces, editorials, and studies focusing exclusively on clinical interventions without public health relevance.
Data extraction focused on study or report design, data sources, sample size and characteristics where applicable, measured indicators, identified trends, policy descriptions, and reported outcomes. Particular attention was paid to official government data released in 2024 and 2025, including the Sample Registration System Report 2021, the Economic Survey 2024-25, and updates on Ayushman Bharat and other flagship health programs. Where survey data are presented, sample sizes, time periods, and confidence intervals are reported where available to permit assessment of statistical precision and generalizability.
The quality of included sources was assessed using established critical appraisal criteria, with preference given to official government statistics, peer-reviewed research in high-impact journals, and reports from internationally recognized health organizations. However, no formal meta-analysis was performed due to the anticipated heterogeneity in data sources, time periods, and outcome measures. Instead, this review adopts a narrative synthesis approach that prioritizes contextual interpretation and the identification of patterns across diverse evidence sources.
3. Results
3.1 The Dual Burden of Disease: Communicable Diseases and the Epidemiological Transition
India's disease profile reflects a nation in the midst of an incomplete epidemiological transition, where the burden of communicable diseases persists alongside a rapidly escalating crisis of non-communicable conditions. This dual burden places unique strain on a health system that must simultaneously manage acute infectious outbreaks and provide long-term care for chronic conditions.
In the domain of communicable diseases, India has achieved notable progress in recent years. According to the World Health Organization's Global TB Report 2025, India has registered a 21 percent decline in tuberculosis cases over the last decade, a pace nearly twice the global average of 12 percent. The country's TB burden stands at 187 per lakh population in 2024, down from 237 per lakh in 2015, with mortality declining from 28 per lakh to 21 per lakh over the same period. The government's TB Mukt Bharat Abhiyan, the Ni-kshay Poshan Yojana providing nutritional support to TB patients, and the expansion of diagnostic networks through the Ni-kshay portal have been instrumental in this progress. The India TB Report 2024 confirmed that missing TB cases dropped to 2.3 lakh in 2023, down from 3.2 lakh in 2022, with 95 percent of all TB patients receiving treatment. Notably, the report recorded no significant rise in multidrug-resistant TB, a concerning pattern that has plagued other high-burden countries.
Malaria control has witnessed even more dramatic success. The World Health Organization's World Malaria Report 2024 confirmed that India has reduced its malaria caseload by 69 percent, dropping from 6.4 million cases in 2017 to 2 million in 2023, with estimated deaths falling by 69 percent from 11,100 to 3,500 over the same period. This achievement has enabled India to move out of the High-Burden-High-Impact category of endemic nations, a milestone that reflects the effectiveness of combination drug therapies, insecticidal mosquito nets, and strengthened surveillance systems. The Annual Parasite Incidence fell from 0.92 in 2015 to 0.18 in 2024, representing a 78.1 percent decline in morbidity and a 77.6 percent decline in mortality.
The HIV/AIDS response has similarly demonstrated progress, with new annual infections decreasing by 44 percent since 2010, surpassing the global reduction rate of 39 percent. According to the India HIV Estimations 2023 report, over 2.5 million people are currently living with HIV in the country, with an adult prevalence of 0.2 percent and estimated annual new infections of approximately 66,400. More than 30 million free HIV tests are conducted annually, and over 1.7 million people receive free antiretroviral therapy through public healthcare systems. The vertical transmission of HIV from mother to child has declined by approximately 84 percent between 2010 and 2024, outpacing the global reduction of 56.5 percent.
India has also achieved elimination milestones for several neglected tropical diseases. The World Health Organization has officially validated India for eliminating trachoma as a public health problem, a condition that accounted for 4 percent of blindness in the country as recently as 2005. Kala-azar elimination targets of less than one case per 10,000 population have been achieved in 633 blocks across 54 districts, well ahead of the 2030 Sustainable Development Goal target. The Case Fatality Rate for dengue has been sustained below 1 percent since 2008, reaching 0.13 percent in 2024, while the Case Fatality Rate for Japanese Encephalitis declined from 17.6 percent in 2014 to 7.1 percent in 2024.
Despite these achievements, the burden of non-communicable diseases has emerged as the dominant public health challenge facing India. Non-communicable diseases including cardiovascular diseases, diabetes, cancer, and chronic respiratory conditions now account for 63 percent of total deaths in India, up from a minority share three decades ago. The proportion of Disability-Adjusted Life Years attributable to non-communicable diseases rose from 30.5 percent in 1990 to 55.4 percent in 2016, reflecting the rapid epidemiological transition driven by urbanization, dietary changes, sedentary lifestyles, and population aging. Among the BRICS nations, India recorded the highest growth rate of deaths due to non-communicable diseases at 108 percent between 2000 and 2016, with cardiovascular diseases alone causing an average of 55,000 deaths annually. The behavioral risk factors underlying this transition are deeply embedded in India's changing social and economic landscape: rising obesity rates, increasing tobacco and alcohol consumption, physical inactivity, and dietary shifts toward processed, energy-dense foods.
3.2 Maternal and Child Health: Progress Toward the Sustainable Development Goals
India's progress in maternal and child health represents one of the most significant public health achievements of the past two decades, with mortality indicators declining at rates that outpace global averages. According to the Sample Registration System Report 2021 released by the Registrar General of India in May 2025, the Maternal Mortality Ratio has declined from 130 per lakh live births in 2014-16 to 93 in 2019-21, a reduction of 37 points that reflects sustained investment in institutional delivery, skilled birth attendance, and emergency obstetric care.
Eight states have already attained the Sustainable Development Goal target of Maternal Mortality Ratio at or below 70 per lakh live births by 2030: Kerala leads with an exemplary ratio of 20, followed by Maharashtra at 38, Telangana at 45, Andhra Pradesh at 46, Tamil Nadu at 49, Jharkhand at 51, Gujarat at 53, and Karnataka at 63. These state-level variations reveal the profound inequities that persist within India's federal health system, with the northeastern states and some northern states continuing to lag significantly behind the national average. Kerala's achievement of a Maternal Mortality Ratio comparable to high-income countries demonstrates that excellent maternal health outcomes are possible within India's resource constraints when political commitment, health infrastructure, female education, and community engagement converge.
Child mortality indicators have shown similarly encouraging trends. The Infant Mortality Rate declined from 39 per 1,000 live births in 2014 to 27 per 1,000 in 2021. The Neonatal Mortality Rate fell from 26 to 19 per 1,000 live births, while the Under-Five Mortality Rate dropped from 45 to 31 per 1,000 live births over the same period. Twelve states and union territories have already attained the Sustainable Development Goal target for Under-Five Mortality Rate at or below 25 per 1,000 live births by 2030, with Kerala achieving the remarkable figure of 8. The Sex Ratio at Birth improved from 899 in 2014 to 913 in 2021, reflecting gradual progress toward addressing the deeply entrenched problem of sex-selective abortion, though the figure remains below the natural ratio of approximately 950.
The Total Fertility Rate stabilized at 2.0 in 2021, down from 2.3 in 2014, indicating that India has successfully transitioned to replacement-level fertility. This demographic achievement has profound implications for population health, as it reduces the strain on maternal and child health services, enables greater investment per child in education and nutrition, and creates favorable conditions for economic growth through the demographic dividend.
According to the United Nations Maternal Mortality Estimation Inter-Agency Group Report 2000-2023, published in April 2025, India's Maternal Mortality Ratio has declined by 86 percent compared to a global reduction of 48 percent over the past 33 years from 1990 to 2023. The United Nations Inter-Agency Group for Child Mortality Estimation Report 2024, published in March 2025, confirmed that India achieved a 78 percent decline in Under-Five Mortality Rate, surpassing the global reduction of 61 percent; a 70 percent decline in Neonatal Mortality Rate compared to 54 percent globally; and a 71 percent decline in Infant Mortality Rate compared to 58 percent globally. These achievements position India among the top-performing countries in mortality reduction, a remarkable turnaround for a nation that once lagged behind regional peers such as Bangladesh and Nepal on several health indicators.
The government's flagship health schemes have been instrumental in driving these improvements. The Janani Suraksha Yojana, which provides cash incentives for institutional deliveries, has dramatically increased the proportion of births occurring in health facilities. The Pradhan Mantri Surakshit Matritva Abhiyan ensures free antenatal care, including diagnostics and consultations, for pregnant women. The establishment of Maternity Waiting Homes, Maternal and Child Health Wings, Obstetric High Dependency Units and Intensive Care Units, Newborn Stabilization Units, Sick Newborn Care Units, and Mother-Newborn Care Units has strengthened the capacity of public health facilities to manage complicated deliveries and neonatal emergencies. These measures collectively support approximately 300 lakh safe pregnancies and 260 lakh healthy live births annually.
3.3 Health System Infrastructure and Universal Health Coverage
India's health system is characterized by a complex mix of public and private providers, with the private sector dominating curative care in urban areas while the public sector remains the primary source of care for rural populations and the economically disadvantaged. The government's efforts to strengthen health infrastructure and expand insurance coverage have accelerated significantly since 2018, yet substantial gaps remain in achieving universal health coverage.
The Ayushman Bharat initiative, launched in 2018, represents the most ambitious health sector reform in India's history. It comprises two pillars: the Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), which provides health insurance coverage of up to ₹5 lakh per family per year for secondary and tertiary care hospitalization to the bottom 40 percent of India's population, and the Ayushman Aarogya Mandirs (formerly Health and Wellness Centers), which aim to deliver comprehensive primary healthcare closer to communities. As of October 1, 2025, AB-PMJAY has enrolled over 42 crore people, with more than 86.51 lakh senior citizens over 70 years receiving Ayushman Vay Vandana Cards. Over 33,000 hospitals are empaneled under the scheme, including 17,685 public and 15,380 private facilities, ensuring a mix of public and private sector participation.
The financial impact of AB-PMJAY has been substantial. According to the Economic Survey 2024-25, the scheme has saved families over ₹1.52 lakh crore in out-of-pocket healthcare expenses. The budget allocation for AB-PMJAY has increased steadily, from ₹6,556 crore in 2019-20 to ₹9,406 crore in 2025-26, reflecting the government's commitment to expanding coverage. Hospital empanelment has grown from 18,236 hospitals in 2018 to over 33,000 as of 2025, with the number of e-cards issued increasing from 103 million in the first year to over 420 million by October 2025.
The Ayushman Bharat Digital Mission (ABDM) aims to create a unified digital health infrastructure by linking all health facilities through digital highways. As of January 2025, over 72.81 crore Ayushman Bharat Health Accounts have been created, enabling seamless maintenance of health records across facilities. The e-Sanjeevani telemedicine platform has emerged as the world's largest telemedicine initiative in primary healthcare, dramatically expanding access to specialist consultations in remote and underserved areas.
The Pradhan Mantri Ayushman Bharat Health Infrastructure Mission (PM-ABHIM), launched in October 2021 with a total budget of ₹64,180 crore for the period 2021-2026, represents the largest public health infrastructure scheme in India since 2005. It aims to upgrade healthcare capacity from village clinics to district hospitals, improve disease surveillance and monitoring, and enhance pandemic preparedness. Of the total allocation, ₹54,205 crore is earmarked for state-level programs and ₹9,340 crore for central programs, reflecting a decentralized implementation approach.
Despite these impressive investments, India's health system continues to face profound challenges. The doctor-population ratio remains far below the World Health Organization's recommended standard of 1:1,000, with many states reporting ratios of 1:2,000 or worse. The nurse-population ratio stands at approximately 1.96:1,000, well below the WHO guideline of 3:1,000. The doctor-to-nurse ratio, estimated at 1:1.3 based on National Sample Survey Office data, is severely imbalanced compared to international norms. Rural health facilities face acute shortages, with the Rural Health Statistics Report 2018-19 documenting a shortage of 7,715 allopathic doctors and 1,807 AYUSH doctors at Primary Health Centers, 6,126 nurses at Primary Health Centers, 7,336 nurses at Community Health Centers, and 9,147 specialists at Community Health Centers. Nearly 80 percent of positions for surgeons, physicians, gynecologists, and pediatricians at rural Community Health Centers remained unfilled as of March 2021.
The projected skilled health workforce numbers, adjusted for educational qualifications, are estimated to rise from 1.77 million in 2019 to 2.65 million in 2030, yet this would still leave a shortfall of approximately 1.13 million skilled health workers to reach the threshold of 25 per 10,000 population. The WHO estimates that India needs at least 1.8 million additional doctors, nurses, and midwives to achieve the minimum threshold of 44.5 professional health workers per 10,000 population. The emigration of Indian-trained doctors and nurses to OECD countries further exacerbates domestic shortages, creating a paradox where India trains health professionals for the world while its own population remains underserved.
3.4 Health Expenditure and Financial Protection
The financing of India's health system has undergone significant transformation over the past decade, with government health expenditure increasing both in absolute terms and as a proportion of total health spending. However, the country remains far from achieving the financial protection necessary for universal health coverage.
According to the Economic Survey 2024-25, India's Total Health Expenditure in financial year 2022 was estimated at ₹9,04,461 crore, equivalent to 3.8 percent of GDP or ₹6,602 per capita at current prices. The share of government health expenditure in total health expenditure increased from 29.0 percent in 2015 to 48.0 percent in 2022, a significant shift that reflects the expansion of publicly funded insurance schemes and health infrastructure investments. Out-of-pocket expenditure as a share of total health expenditure declined from 62.6 percent in 2014-15 to 39.4 percent in 2021-22, representing a meaningful reduction in the financial burden on households. However, out-of-pocket expenditure still accounts for 2.3 percent of GDP, and nearly 400 million Indians remain uninsured, leaving them financially vulnerable to medical emergencies.
The National Health Accounts 2018-19 estimated that 12.4 percent of households fell below the poverty line due to out-of-pocket health expenditure in 2017-18, a figure that underscores the continued risk of catastrophic health spending despite insurance expansion. The monetized value of premature mortality due to outdoor air pollution alone amounted to US$339.4 billion in 2022, equivalent to 9.5 percent of GDP, revealing the staggering economic dimension of environmental health threats.
India's public health expenditure at approximately 1.6 to 1.9 percent of GDP remains among the lowest in the world, well below the National Health Policy 2017 target of 2.5 percent by 2025 and far short of the 5 percent recommended by international health economists for achieving universal health coverage by 2040. For comparison, OECD countries spend an average of 7.6 percent of GDP on health, while BRICS countries average 3.6 percent. Thailand, which successfully introduced universal health coverage reforms in 2001, provides a compelling model for what sustained public investment can achieve.
The Union Budget for 2024-25 allocated ₹90,958 crore for healthcare, a 12.96 percent increase over the previous year's revised estimate. Health expenditure rose to ₹6.1 lakh crore in 2024-2025 from ₹3.2 lakh crore in 2020-2021, representing a compound annual growth rate of 18 percent. While this trajectory is encouraging, critics note that when adjusted for inflation, funding for the health ministry and the National Health Mission has declined in real terms, and the 2024-25 budget missed a critical opportunity to accelerate post-pandemic health system strengthening.
3.5 Environmental Health: Air Pollution and Climate Change
Environmental health has emerged as perhaps the most urgent and underappreciated dimension of India's public health crisis. The Lancet Countdown on Health and Climate Change 2025 report revealed that air pollution caused over 1.7 million deaths in India in 2022, an increase of 38 percent since 2010. This figure surpasses the total mortality from COVID-19 in India and represents one of the highest environmental health burdens globally.
Fossil fuels, including coal and liquid gas, contributed to 44 percent of these air pollution deaths, equivalent to approximately 752,000 fatalities. Coal combustion alone was responsible for 394,000 deaths, primarily from power plant emissions, while petrol use for road transportation contributed 269,000 deaths. The economic loss from premature mortality due to outdoor air pollution reached US$339.4 billion in 2022, equivalent to 9.5 percent of GDP. Household air pollution from the use of polluting cooking fuels was associated with 113 deaths per 100,000 population, with rural areas experiencing higher mortality rates (125 per 100,000) than urban areas (99 per 100,000), highlighting the persistent inequity in access to clean cooking solutions.
A study published in Lancet Planetary Health in December 2024 found that every 10 microgram per cubic meter increase in PM2.5 concentration led to an 8.6 percent increase in mortality across India. The entire population of India lives in areas where PM2.5 levels exceed WHO guidelines, with some regions recording concentrations up to 119 micrograms per cubic meter, nearly 24 times the WHO recommended limit. The study's authors concluded that current Indian air quality guidelines are insufficient to protect health and called for stricter regulations and emission reduction measures.
Climate change is compounding these environmental health risks. The Lancet Countdown 2025 report documented that India experienced 19.8 heatwave days in 2024, with 6.6 days directly attributable to climate change. Heat exposure caused the loss of 247 billion labor hours, with 66 percent in agriculture and 20 percent in construction, sectors that employ the majority of India's working poor. Dengue transmission suitability has increased dramatically, with the average basic reproduction number crossing from below 1 to above 1 between 1951-1960 and 2015-2024, indicating that conditions now favor sustained transmission. The coastal area environmentally suitable for Vibrio transmission was 46 percent greater in 2024 compared to the 1982-2010 baseline, and over 18 million people now live less than 1 meter above sea level, at risk from rising seas.
Tree cover declined by 2.33 million hectares between 2001 and 2023, while urban greenness dropped by 3.6 percent, indicating worsening environmental degradation that reduces natural cooling and air purification capacity. These environmental trends represent not merely ecological concerns but direct threats to human health that demand urgent integration into public health planning and climate policy.
3.6 Sanitation, Water, and the Social Determinants of Health
The Swachh Bharat Mission, launched in 2014, has been one of the most transformative public health interventions in India's history, fundamentally altering the sanitation landscape of the country. The mission aimed to eliminate open defecation through the construction of toilets, behavior change communication, and the establishment of solid waste management systems. The Swachh Survekshan 2024-2025, the ninth edition of the annual cleanliness survey, evaluated cities across ten indicator sections including visible cleanliness, waste segregation and management, access to sanitation, used water management, and the welfare of sanitation workers.
The mission has achieved remarkable coverage, with toilet construction reaching hundreds of millions of households and open defecation declining dramatically. However, challenges persist in ensuring the sustained use of toilets, the safe management of fecal sludge, and the dignity of sanitation workers who continue to face hazardous working conditions and social stigma. The 2024-25 survey introduced new parameters including the welfare of sanitation workers and citizen feedback mechanisms, reflecting an evolving understanding of sanitation as not merely infrastructure provision but a comprehensive system requiring attention to human rights and social equity.
Access to clean water remains a critical determinant of health, particularly in rural areas where groundwater contamination by arsenic, fluoride, and microbial pathogens continues to cause significant disease burden. The Jal Jeevan Mission, launched to provide piped water supply to all rural households by 2024, has made substantial progress but faces challenges of water quality monitoring, infrastructure maintenance, and seasonal variability in supply.
The social determinants of health in India extend beyond sanitation and water to encompass education, housing, employment, nutrition, and gender equity. The National Family Health Survey-5 (2019-21) documented significant improvements in several indicators while revealing persistent gaps. Female literacy and educational attainment have improved substantially, with the percent distribution of women aged 15-49 by schooling showing increasing completion of higher education. However, gender disparities remain pronounced, particularly in rural areas and among marginalized communities. Child marriage, though declining, continues to affect millions of girls, with profound implications for maternal health, educational attainment, and economic empowerment.
Nutritional status, as measured by the National Family Health Survey, revealed that anemia remains highly prevalent among women and children, though the survey's methodology has been subject to debate. The NFHS-5 reported higher anemia prevalence than its predecessor, leading to controversy over measurement techniques. In March 2024, the WHO released new guidelines recommending venous blood samples and automated hematology analyzers for anemia estimation, and anemia measurements have been left out of the forthcoming NFHS-6, to be replaced by the Diet and Biomarkers Survey in India conducted by the Indian Council of Medical Research. This methodological evolution reflects the ongoing challenge of obtaining accurate nutritional data at national scale.
3.7 Mental Health: The Neglected Dimension
Mental health represents one of the most significant yet historically neglected areas of India's public health landscape. The National Mental Health Programme (NMHP), launched in 1982, was one of the first national mental health programs in a developing country, yet decades of underfunding and inadequate implementation have left a vast treatment gap. The NMHP operates through central and tertiary activities focusing on human resource development, centers of excellence, and postgraduate programs, and district-level activities through the District Mental Health Programme (DMHP).
As of 2024, the DMHP covers approximately 767 districts, with each participating district receiving a specialist team comprising a psychiatrist, psychologist, social worker, and psychiatric nurse who provide outpatient clinics, train general health staff, and conduct outreach. The Tele-MANAS national helpline, launched in 2022, offers 24/7 tele-counseling, video consultations, and referrals, with a mobile app launched in October 2024 to expand reach via smartphones. The Mental Healthcare Act of 2017 and the National Mental Health Policy of 2014 provide important legal and policy frameworks, yet implementation remains severely constrained by resource limitations.
The treatment gap for mental disorders in India is estimated to exceed 70 percent, meaning that the vast majority of individuals with conditions such as depression, anxiety, schizophrenia, and substance use disorders receive no care. The absolute shortage of inpatient beds for acute mental health care, the stigma and discrimination faced by persons with mental illness, and the concentration of mental health professionals in urban areas all contribute to this crisis. Suicide remains a leading cause of death among young Indians, with the National Mental Health Policy identifying suicide reduction as a priority yet lacking the resources and coordination to implement comprehensive prevention programs.
The COVID-19 pandemic exacerbated mental health challenges across the population, with increased rates of anxiety, depression, and stress-related disorders documented in multiple studies. The economic disruption, social isolation, grief, and uncertainty of the pandemic period highlighted the fragility of India's mental health infrastructure and the urgent need for integration of mental health services into primary care, community-based rehabilitation, and social protection programs.
3.8 The COVID-19 Pandemic: Lessons and Legacies
The COVID-19 pandemic was India's most severe public health crisis in living memory, exposing the strengths and vulnerabilities of the country's health system in stark relief. The pandemic's first wave in 2020 and the devastating second wave in 2021, characterized by oxygen shortages, overwhelmed hospitals, and mass cremations, revealed critical gaps in preparedness, supply chain management, and intergovernmental coordination.
However, the pandemic also demonstrated India's capacity for rapid adaptation and innovation. The Dharavi model of containment in Mumbai, one of the world's largest urban slums, achieved remarkable success through meticulous screening, testing, and isolation measures implemented by local authorities. The world's largest vaccination campaign, administered over 2 billion doses, leveraged India's pharmaceutical manufacturing capacity, digital infrastructure through the CoWIN platform, and the tireless efforts of frontline health workers including Accredited Social Health Activists, Auxiliary Nurse Midwives, and Anganwadi workers.
The pandemic's lessons for India's public health system are manifold. It underscored the inadequacy of public health expenditure, with India's per capita spending among the lowest globally leading to catastrophic out-of-pocket expenses during the crisis. It revealed the need for decentralized decision-making, with local governments requiring greater autonomy and resources to respond to context-specific challenges. It highlighted the importance of transparent data sharing, with discrepancies between official mortality figures and WHO estimates generating controversy and undermining public trust. It demonstrated the vital role of civil society organizations in reaching marginalized communities, yet also exposed the constraints imposed by regulatory restrictions on foreign funding for non-governmental organizations.
The post-pandemic period has seen renewed policy attention to health system strengthening, including the PM-ABHIM infrastructure mission, the expansion of oxygen generation capacity, and the establishment of integrated public health laboratories. However, critics argue that the 2024-25 budget failed to capitalize fully on the pandemic's lessons, with health ministry funding declining in real terms when adjusted for inflation. The passage of a comprehensive Public Health Act, the establishment of a dedicated public health cadre, and sustained investment in primary care and disease surveillance remain priorities that have yet to be fully realized.
4. Discussion
The evidence synthesized in this review reveals a public health landscape of extraordinary complexity and contradiction. India has achieved remarkable successes in reducing mortality from infectious diseases, improving maternal and child survival, and expanding health insurance coverage, yet these achievements coexist with profound and persistent challenges that threaten to undermine the nation's health and development aspirations.
The most striking feature of India's public health trajectory is the pace of improvement in mortality indicators. The 86 percent reduction in maternal mortality over 33 years, the 78 percent decline in under-five mortality, and the country's outperformance of global averages on nearly every mortality indicator demonstrate that sustained political commitment, targeted investments, and community engagement can achieve transformative results even in resource-constrained settings. Kerala's achievement of a maternal mortality ratio of 20 per lakh live births, comparable to many European nations, proves that excellence in public health is possible within India's institutional and economic context when the right combination of factors aligns.
Yet the persistence of stark interstate and intrastate inequities reveals the unevenness of this progress. States such as Uttar Pradesh, Bihar, Madhya Pradesh, and Assam continue to report mortality indicators that are multiples of those in Kerala, Maharashtra, and Tamil Nadu. These disparities are not merely statistical artifacts but reflections of deeper structural inequities in education, economic development, gender relations, caste hierarchies, and governance capacity that shape health outcomes through multiple pathways. The federal structure of India's health system, while enabling context-specific adaptation, also creates variation in political commitment, resource allocation, and implementation quality that produces these inequities.
The escalating burden of non-communicable diseases represents an existential challenge that demands a fundamental reorientation of India's health system. The current model, which prioritizes hospital-based curative care and vertical disease programs, is ill-suited to the prevention and long-term management of conditions such as diabetes, hypertension, cardiovascular disease, and cancer. The integration of non-communicable disease services into primary care through the Ayushman Aarogya Mandirs, the expansion of screening programs for common cancers, and the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke represent important steps, but the scale of the challenge far exceeds current response capacity. The behavioral risk factors driving the non-communicable disease epidemic, tobacco use, harmful alcohol consumption, unhealthy diets, and physical inactivity, require interventions that extend far beyond the health sector to encompass agriculture, food processing, urban planning, education, and media regulation.
The environmental health crisis, particularly air pollution, demands urgent recognition as a central public health priority. The 1.7 million deaths attributable to air pollution in 2022, the 9.5 percent of GDP lost to pollution-related economic impacts, and the entire population's exposure to PM2.5 levels exceeding WHO guidelines represent a crisis of staggering magnitude that is simultaneously invisible in daily life and devastating in its cumulative impact. The current policy response, focused on intermittent emergency measures in Delhi and other major cities during peak pollution episodes, is inadequate to address a problem that requires sustained structural transformation of energy systems, transportation, agriculture, and industry. The integration of health impact assessments into environmental policy, the acceleration of clean energy transitions, and the provision of clean cooking solutions to rural households must be elevated to the highest levels of national priority.
The health workforce crisis represents a binding constraint on India's ability to achieve universal health coverage. The shortage of approximately 1.8 million doctors, nurses, and midwives, the severe rural-urban maldistribution of existing professionals, and the emigration of trained personnel to high-income countries create a vicious cycle in which the populations most in need of care are least likely to receive it. The expansion of medical and nursing education, the creation of mid-level providers and community health officers, the incentivization of rural service through scholarships and career progression, and the regulation of international recruitment all require coordinated policy attention. The task-shifting and role expansion strategies embodied in the Ayushman Aarogya Mandir model, which empowers nurses, pharmacists, and community health workers to manage common conditions and refer complex cases, offer a promising pathway to extending coverage with existing human resources.
The financing of India's health system remains the most critical and contested dimension of public health policy. The increase in government health expenditure from 29 to 48 percent of total health spending between 2015 and 2022 is a meaningful achievement, yet the absolute level of 1.6 to 1.9 percent of GDP remains grossly insufficient. The National Health Policy 2017 target of 2.5 percent by 2025, which itself was modest compared to international benchmarks, appears unlikely to be met. The persistence of high out-of-pocket expenditure, the millions of households pushed into poverty by health costs, and the uninsured population of 400 million all point to the inadequacy of current financing arrangements. The Ayushman Bharat insurance model, while providing valuable financial protection for hospitalization, does not address the primary care, outpatient services, and medicines that constitute the bulk of health spending for most families. A comprehensive universal health coverage strategy would require not merely insurance expansion but also substantial investment in public health infrastructure, primary care capacity, and the social determinants of health.
The mental health crisis, with its vast treatment gap and devastating human toll, demands a paradigm shift from institutional, specialist-centered care to community-based, integrated services. The District Mental Health Programme's expansion to 767 districts and the Tele-MANAS helpline's innovative use of technology represent important advances, but the scale of need requires a tenfold increase in resources, a massive expansion of trained human resources, and a societal transformation in attitudes toward mental illness. The integration of mental health into primary care, the training of general practitioners in basic mental health management, the establishment of community-based rehabilitation services, and the protection of the rights of persons with mental illness through implementation of the Mental Healthcare Act are all essential components of a comprehensive response.
The COVID-19 pandemic has left indelible marks on India's public health consciousness, policy discourse, and institutional arrangements. The trauma of the second wave, the heroism of frontline workers, the innovation of the vaccination campaign, and the tragedy of avoidable deaths have collectively created both the political space and the moral imperative for health system reform. Whether this moment will be seized to build a more resilient, equitable, and effective health system, or whether the momentum will dissipate as the acute memory of the pandemic fades, remains one of the most consequential questions facing Indian public health.
5. Conclusion
India's public health landscape in 2025 is one of profound achievement and urgent challenge, of remarkable progress and persistent inequity, of world-leading innovation and heartbreaking neglect. The nation has demonstrated that it can achieve extraordinary improvements in population health when resources, political will, and community engagement align, as evidenced by the dramatic reductions in maternal and child mortality, the control of infectious diseases, and the expansion of health insurance coverage. Yet these successes coexist with a non-communicable disease epidemic, an environmental health crisis claiming millions of lives, a health workforce shortage that denies care to the most vulnerable, and a financing gap that perpetuates catastrophic health expenditures.
The path forward requires not incremental adjustments but transformative change across multiple dimensions. In health financing, India must move decisively toward the National Health Policy target of 2.5 percent of GDP and ultimately toward the 5 percent benchmark necessary for universal health coverage, while redesigning insurance and payment systems to prioritize primary care and prevention over hospital-based curative care. In health workforce development, the nation must expand training capacity, incentivize rural service, regulate international recruitment, and empower mid-level providers to extend coverage to underserved populations. In environmental health, air pollution and climate change must be recognized as central public health priorities demanding integrated policy responses across energy, transportation, agriculture, and urban planning. In mental health, the vast treatment gap must be addressed through community-based integration, primary care capacity building, and sustained investment in human resources and services.
The COVID-19 pandemic taught India that its health system is both more fragile and more resilient than previously imagined. It revealed that decades of underinvestment create vulnerabilities that can be exploited by crises, but also that the nation's human capital, institutional capacity, and social solidarity can be mobilized to achieve remarkable feats under pressure. The challenge now is to channel this demonstrated capacity into the sustained, long-term work of building a health system that serves all Indians with dignity, equity, and effectiveness.
Ultimately, the public health of India is not merely a matter of mortality statistics, disease prevalence, or health expenditure ratios. It is a reflection of the nation's values, its commitment to social justice, and its vision of development. A healthy India is one in which every child survives beyond their fifth birthday, every mother receives skilled care during childbirth, every person with diabetes or depression has access to treatment, every worker breathes clean air, and no family is impoverished by medical bills. Achieving this vision requires not only technical expertise and financial resources but also the moral courage to confront entrenched inequities, the political will to prioritize health over competing demands, and the humility to learn from both successes and failures. The public health of India, in all its complexity and promise, remains one of the most consequential endeavors of our time.
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