As the Union Budget 2026 approaches, the public health debate once again risks drifting towards new schemes rather than fixing delivery failures that have persisted for over a decade. Evidence across NFHS-5, National Health Accounts, NHM reviews, NITI Aayog assessments, CPCB data, Global Burden of Disease estimates and WHO benchmarks points to a consistent diagnosis: India’s health constraint is not intent or spending announcements, but weak delivery capacity.
The consequences are visible in routine use of government facilities—unavailable staff, missing medicines, long waits, indifferent responsiveness and avoidable referrals to private providers. Budget 2026 therefore needs to privilege structural correction over incremental expansion.
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Infrastructure, staffing and facility responsiveness
A large share of public facilities still does not meet Indian Public Health Standards. India has roughly 1.4 hospital beds per 1,000 population, far below the global norm of about 3.5. But infrastructure deficits explain only part of the problem.
Patients routinely encounter non-availability rather than outright absence of facilities. OPDs run with skeletal staffing. Doctors and specialists are shared across multiple locations. Pharmacists, lab technicians and radiographers are often absent. Services are unavailable despite notified timings. Overstretched staff, weak accountability and poor facility management translate into long waits, rushed consultations and declining public trust.
Buildings without assured staff presence and functioning services cannot deliver care.
Medicines, diagnostics and the persistence of high OOPE
NFHS-5 and National Health Accounts show that close to half of out-of-pocket health spending is on medicines and diagnostics. Despite free drug and diagnostic schemes, stock-outs of essential medicines, reagents and consumables remain routine, and equipment is frequently non-functional. Even patients who reach public hospitals are pushed to private pharmacies and labs.
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Insurance coverage offers limited protection when basic supplies are missing. Ayushman Bharat–PM-JAY has expanded inpatient coverage, but OPD care—where an estimated 60–70 per cent of health-seeking occurs—remains largely uncovered. This leaves a structural gap in financial protection. Extending PM-JAY coverage to OPD services, alongside systematic expansion of Jan Aushadhi Kendras, would directly reduce household spending without new institutional complexity.
Specialist access below the district hospital
Specialist services are largely absent below district hospitals. Routine referrals in medicine, paediatrics, obstetrics, orthopaedics and psychiatry overload district and tertiary facilities and increase patient costs.
Replication is neither feasible nor necessary. A more pragmatic approach lies in structured specialist networks: regular outreach clinics at CHCs and selected PHCs; hub-and-spoke linkages between district hospitals and sub-district facilities; and tele-consultation combined with periodic physical presence. Carefully designed engagement of private specialists, with defined service obligations and capped payments, can plug gaps without permanent expansion of payrolls.
Retaining health workers in rural and semi-urban areas
Staff shortages are driven less by recruitment failure than by poor retention. Rural and semi-urban postings often involve professional isolation, inadequate housing, unsafe transport and limited career progression.
Evidence suggests non-monetary incentives matter as much as pay. Defined rural tenure with assured transfer pathways, preferential access to skill development and postgraduate training, staff housing, family support and performance-linked incentives tied to service continuity have all shown impact. Budget choices should shift from ad-hoc allowances to predictable career pathways.
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Ayushman Arogya Mandirs as functional primary care units
Ayushman Arogya Mandirs at sub-centre and PHC levels were envisaged as the backbone of comprehensive primary care, yet many function largely as renamed facilities. Where properly staffed and supplied, they can manage a large share of routine OPD care close to communities, particularly in rural and semi-urban areas.
Priority actions are straightforward: assured availability of doctors, mid-level providers and nurses during notified hours; expanded OPD services with basic diagnostics and essential medicines; integration of NCD care, mental health, geriatric services and preventive screening; and functional referral linkages with CHCs and district hospitals. Effective Arogya Mandirs reduce unnecessary referrals, crowding and household spending.
Health outcomes beyond hospitals
Public health outcomes depend as much on municipal services as on clinical care. Around one-third of urban households still lack closed drainage. Untreated wastewater, open drains and poor garbage management remain common.
Air pollution compounds this burden. Beyond vehicles and industry, open waste burning, landfill fires, biomass combustion, construction activity and road dust significantly degrade air quality. CPCB and Global Burden of Disease estimates attribute nearly 18 per cent of deaths in India to air pollution driven largely by fine particulate matter from these sources. Clean water, sewerage treatment, scientific waste management, elimination of waste burning and dust control are among the most cost-effective health interventions, yet rarely treated as health priorities in budgetary terms.
Prevention and early detection
NFHS-5 shows that over one in five adults has hypertension and about one in ten has diabetes, yet screening, counselling and follow-up remain uneven. Late detection of cancer and cardiovascular disease drives avoidable complications and costs.
Prevention requires systematic population screening and sustained engagement with everyday risk factors. This includes promotion of physical activity, integration of yoga and meditation into routine care, and regulation and awareness around ultra-processed foods, excess salt, sugar and trans-fats. Lifestyle-focused prevention remains among the most cost-effective long-term health investments.
Budget 2026 must focus on affordable care
The private sector delivers a large share of care but remains weakly regulated. A persistent distortion is price discrimination. Hospitals accept relatively moderate package rates under CGHS, ECHS and PM-JAY, yet charge uninsured patients four to five times more for the same services, pushing quality care beyond the reach of ordinary households.
Budget 2026 should move from passive purchasing to active stewardship. Reference pricing for common procedures, diagnostics and OPD services linked to CGHS and PM-JAY rates; mandatory price transparency; enforcement of the Clinical Establishments Act; and district-level contracting with private providers to fill specialist gaps at capped rates would materially reduce financial distress while improving access.
Budget 2026 presents a clear choice. The government can continue adding schemes at the margins, or it can fix the foundations: functional facilities, responsive staffing, assured medicines and diagnostics, OPD and specialist access, effective Arogya Mandirs, predictable private pricing, clean air, safe water and credible prevention. Addressing these fundamentals would do more to restore trust in public facilities than any new announcement.
Dr Rattan Chand is Founding Director, EGROW Foundation, a Noida based think tank.