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Dr. J. E. Park Memorial Oration

Public Health in India: Issues and Challenges

*L. S. Chauhan
Director, National Centre for Disease Control, Directorate General of Health Services, Ministry of Health and Family Welfare,
Govt of India, New Delhi, India

Summary
Health is determined not only by medical care but also by determinants outside the medical sector. Public health
approach is to deal with all these determinants of health which requires multi sectoral collaboration and inter-disciplinary
coordination. Although there have been major improvements in public health since 1950s, India is passing through
demographic and environmental transition which is adding to burden of diseases. There is triple burden of diseases,
viz. communicable, non-communicable and emerging infectious diseases. This high burden of disease, disability and
death can only be addressed through an effective public health system. However, the growth of public health in India
has been very slow due to low public expenditure on health, very few public health institutes in India and inadequate
national standards for public health education. Recent years have seen efforts towards strengthening public health in
India in the form of launch of NRHM, upgradation of health care infrastructure as per IPHS, initiation of more public
health courses in some medical colleges and public health institutions and strengthening of public health functional
capacity of states and districts under IDSP.

Key words: Public health, Health problems, India

Public Health and Health Determinants

Age old definition of health given by WHO states that,
Health is a state of complete physical, mental and
social well being and not merely the absence of disease.
Medicine or curative services is not the only soul
contributor to health and well being of population. There
are several other determinants of health which include
environmental, biological, socio-economic factors,
information and communication, availability of health
services, utilization of health services, age structure of
the population etc. By influencing these factors or these
*Corresponding Author: Dr. L. S. Chauhan,
Director, National Centre for Disease Control (NCDC),
Govt of India, 22, Sham Nath Marg, New Delhi-110054, India.
E-mail: dirnicd@gmail.com

Access this article online

Website: www.ijph.in
DOI: 10.4103/0019-557X.85237
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determinants we may play quiet a substantial role in

improving the health.
Public health, which is, Art and Science of protecting
and improving the health of a community through an
organized and systematic effort that includes education,
provision of health services and protection of the public
from exposures that will cause harm.
Thus, public health approach is to deal with all these
determinants of health which requires multi sectoral
collaboration and inter disciplinary coordination. Health
care includes medical care and care of the determinants
of health (this collective approach will help to improve
the health of the community).
Public Health approach is a holistic approach which
encompasses all elements required for healthy living.
It controls disease through health promotion, specific
protection and by restoration and rehabilitation. In
addition, disease surveillance which informs about
ongoing as well as emerging public health issues is a
core public health function. Other important functions are
developing partnerships, formulation of regulations/laws,
planning/policies and Human Resources Development.

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Chauhan LS: Public Health in India: Issues and Challenges

Health status of Indian Population

India is passing through demographic and environmental
transition which is adding to burden of diseases. The
first half of the 20th century witnessed a large number of
communicable disease epidemics.
There have been major improvements in public health
since 1950s. Affordable medicines and tools are
now available which are highly effective, when used
appropriately. Examples are: Anti-tubercular medicines,
Anti-malarials, Insecticide-treated bednets, and condoms
(to prevent HIV infection).
However, there have also been health consequences of
urbanization and industrialization. There is persisting
inequality in health status due to varying economic, social
and political causes.
Developing countries like India currently face a TRIPLE
BURDEN of diseases from:
1. Unfinished agenda of Communicable Diseases.
2. Emerging Non-communicable disease related to
lifestyles, and
3. Emerging Infectious Diseases.
This high burden of disease, disability and death can only
be addressed through an effective public health system.
Ever increasing population with increasing geriatric
population and changing lifestyle with more urbanization
is putting pressure on environmental as well as on
nutritional requirement resulting in nutritional deficiency,
poor sanitation increasing communicable and noncommunicable diseases etc.

Disease Burden
India has the highest number of TB cases in the world. Out
of 9.2 million cases of TB that occur in the world every
year, nearly 1.9 million occur in India which accounts
for one-fifth of the global TB cases. Experts estimate that
about 2.5 million persons have HIV infection in India.
This is nearly 7.6% of the global burden of 33 million
cases. More than 1.5 million persons are affected with
malaria every year. Almost half of them suffer from
falciparum malaria. One third of global cases infected
with filarial disease live in India. Nearly half of leprosy
cases detected in the world in 2007 were contributed by
India. More than 300 million episodes of acute diarrhea

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occur every year in India in children below 5 years of age.

Although data are limited, perhaps more than 35 million
persons are carriers of viral hepatitis B.
Emerging infectious diseases are a major public health
problem in developing countries like India. Because
of the existing environmental, socio-economic and
demographic factors, developing countries like India are
vulnerable to rapidly evolving micro-organisms. During
the past three decades more than 30 new organisms
have been identified worldwide including HIV, Vibrio
cholera O139, SARS, corona virus, highly pathogenic
avian influenza virus A, and novel H1N1 influenza virus.
Many of these organisms emerged in the developing
countries of Asia.
Infectious diseases, especially the new emerging and reemerging diseases, result in high morbidity and mortality
and affect the public health and economy adversely. For
example, plague which was not reported from any part
of India for almost a quarter of the century, caused a
major outbreak in Beed district in Maharashtra and Surat
in Gujarat in 1994 and resulted in huge economic loss
to the country.
In the recent times, avian influenza virus A H5N1 created
pandemic scare by affecting birds/poultry in more than
60 countries including India and affecting human beings
in 15 countries. But pandemic finally occurred due to
novel H1N1 virus in 2009. As of 20th of November 2009,
more than 0.5 million cases and 6770 deaths due to lab
confirmed novel H1N1 infections have been reported to
WHO by more than 206 countries, although countries
are no longer required to test and report all cases. During
previous pandemics, influenza viruses took more than 6
months to spread as widely as the new influenza A H1N1
pandemic virus did in less than 6 weeks since the first
cases started in Mexico in April 2009. Infection, first
confirmed in India on 16th of May 2009 in a traveler,
has spread to 30 States in 6 months causing more than
46460 lab confirmed cases and 2735 deaths (data till
March 2011).
Burden of non-communicable diseases is not less. Overall
non-communicable diseases are the leading causes of
death in the country, constituting 42% of all deaths.
Communicable, maternal, perinatal and nutritional
conditions constitute another 38% of deaths. Injuries
and ill-defined caused constitute 10% of deaths each.
However, majority of ill-defined causes are at older ages

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Chauhan LS: Public Health in India: Issues and Challenges

(70 or higher years) and most of ill-defined deaths are

likely to be from non-communicable diseases.
Rural areas report more deaths due to communicable,
maternal, perinatal and nutritional conditions (41%).
The urban areas have a lower number of deaths from
communicable, maternal, perinatal and nutritional
conditions but a higher proportion from noncommunicable diseases (56%). Their proportion is less
in rural areas (40%). Injuries constitute about the same
proportion in both rural and urban areas; however, the
specific causes of injury vary.
Overall, the leading cause of death is cardiovascular
disease (19%), followed by respiratory diseases (namely
chronic obstructive pulmonary disease or COPD, asthma,
other respiratory diseases; 9%), diarrhoeal diseases (8%),
perinatal conditions (6.3%), respiratory infections such
as acute pneumonia (6.2%), tuberculosis (6%), malignant
and other neoplasms (5.7%), senility (5.1% - which
is concentrated at ages 70 and higher), unintentional
injuries: other (4.9%), and symptoms, signs and ill-define
conditions (4.8%). (Source: Report on causes of death in
India, 2001-03; Registrar General of India).
Besides, India has the highest number of blind persons
in the world. An estimated 2-2.5 million persons in India
have cancers at any given point of time. More than 7
lakh cases of cancer occur every year. National Family
Health survey-III has revealed that more than 56% of the
women in India have some degree of anaemia and about
one-third are undernourished. Similarly, three-fourths of
young children are also anaemic.
Despite high disease burden and shortage of funds, the
country has achieved noteworthy successes. Smallpox
and guineaworm have been eradicated; their last cases
occurred in the country in May 1975 and July 1996
respectively. Yaws, which mainly occurs in remote
tribal areas, has been eliminated. Prospects of polio
eradication in the near future are very bright. Last case of
Polio In January 2011 in west Bengal. UP and Bihar, the
traditional pockets of pockets of polio, have not reported
a case for a long time. Malaria which used to cause 75
million cases in early 1950s has been reduced to less than
2 million cases every year. Revised national tuberculosis
control programme, launched in 1997, presently covers
the entire country and detects over 70% of new sputum
cases with treatment success rate of 87%. TB mortality
has decreased from over 5 lakh deaths every year at

the beginning of programme to about 2.8 lakh deaths

presently despite growth in population. Leprosy has
been eliminated as a public health problem from most
of the states.
Life expectancy has increased from 36.5 years in
1951 to more than 63.1 years. While Crude birth rate
declined from 40.8 in 1951 to 22.8 in 2008, crude death
rate declined from 25.1 in 1951 to 7.4 in 2008. Infant
Mortality Rate (IMR) declined from 146 per 1000 live
births in 1951 to 53 per 1000 live births in 2008. Maternal
Mortality Ratio (MMR) declined from 398 per 100,000
live births in 1997-98 to 254 per 100,000 live births in
2006. However, India has a long way to go in further
reducing mortality among infants, mothers and the people
in the most productive age-groups (15-45 years).

Evolution of Public Health in India

Many Expert Committees, dating back to the Bhore
Committee in 1946, reviewed the existing health
infrastructure/situation in the country and made
recommendations needed to prevent and control diseases
including communicable, non-communicable and
emerging diseases. Based on these recommendations
huge health care infrastructure has been created in the
country. The health care has three tiers systems i.e.
Primary, secondary and tertiary. A large number of
primary health centers, community health centers and
Sub-centers have been established in the country. More
recently, the Expert Committee on Public Health system
(1996) and the National Commission on Macroeconomics
and Health (2005) examined these issues. National Five
Year Plans, National Health Policy (1983, 2002) and
many international initiatives such as Health for All by
2000, Calcutta Declaration on Public Health in southEast Asia (1999), UN Millennium Development Goals
(2000), Global Commission on Macroeconomics and
Health (2001), revised International Health Regulations
(2005), an Asia Pacific Strategy for Emerging Diseases
(2005) have also provided strong policy directives for the
development of health care delivery system to control/
prevent diseases. As a result of these efforts, a strong
health infrastructure has been developed. Many national
disease programmes to control/eliminate/eradicate
diseases have been set up in the country. In the current
Five-year Plan, pilot projects for leptospirosis and rabies
control and pilot projects on non-communicable diseases
have also been initiated.

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Inspite of the efforts mentioned above, the growth of

public health in India is very slow. The impeding factors
for this include very few public health institutes in
India, inadequate national standards for public health
education including curriculum and methods. This results
in inadequate public health workforce in the country.
Over and above health care in the country more emphasis
is on more curative services and with inadequate lab
capacity in the system and poor participation of private
sector in public health activities. As per NFHS III, the
pattern of health care expenditure in India shows that
more than 70% of expenditure is from out of pocket
by house holds. Estimates suggests that in India the
total health expenditure is around 6% of GDP, and is
dominated by out of pocket spending i.e. around 5%.
The government/public expenditure on health care is
around 1% of GDP. Due to this low public expenditure
the reach and quality of public health services are below
the desired level.

course being conducted by PHFI. Public health functional

capacity of states and districts is being developed under
IDSP. Department of Health Research has been created
in the Ministry of Health & Family Welfare. NICD has
been upgraded to NCDC. Public Health Bill has been
drafted and many programme on non-communicable
diseases such as diabetes, cardiovascular disease and
stroke have been initiated. To further give impetus to the
growth of public health in India, the priority is to ensure
access, availability and utilization of primary health care
to all including urban slum population for which there is
need to strengthen the health care infrastructure, increase
public health workforce with a dedicated public health
cadre, enhancing public private partnership, formulation
and enforcement of public health laws and over and
above increase public health financial allocation and
expenditure as well as to strengthen disease surveillance
and response system. All such efforts are being made
under NRHM.

However, many initiatives have been taken recently

for the growth of public health in India which include
National Rural Health Mission (NRHM) wherein thrust
has been given to upgrade health care infrastructure as
per IPHS, augmentation of human resources, flexible
financing and involvement of the community in health
care planning and utilization of services.

I would like to end the oration quoting a phrase from

Laurie Garrett, Focusing on clinical services while
neglecting services that reduce exposure to disease is
like mopping up the floor continuously while leaving the
tap running and it is a never ending exercise. Thus the
growth of public health is the need of the hour.

More public health courses are being started in the

medical colleges and public health institutions like MPH
course at NCDC, Delhi and NIE, Chennai as well as MPH

Cite this article as: Chauhan LS. Public health in India: Issues and Challenges.
Indian J Public Health 2011;55:88-91.
Source of Support: Nil. Conflict of Interest: None declared.

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