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Traditionally, development refers to achieving consistent per capita income growth rates that allow a country to increase its output more quickly. During 1950s and 1960s, when many emerging countries did achieve their economic growth targets besides this the standard of life for most people remained largely unaltered. This experience underlines the narrow scope of development. According to Amartya Sen, “Economic growth cannot be sensibly treated as an end itself. Development must be more concerned with enhancing the lives we lead and the freedom we enjoy.” Development means to increase availability of and widen the distribution of basic life sustaining goods such as food, shelter, health and protection (Todaro). World health organisation (1948) in the preamble to its constitution defined “health is a state of complete physical, mental and social well-being, not merely an absence of disease or infirmity (WHO). The 1993 “World Development Report” in the topic “investing in Health” suggested a three-pronged strategy for government programmes to enhance health.[1] Foster an environment that enables households to improve health.[2] Improve government spending on health.[3] Promote diversity and competition. India is an example of a nation that has seen significant change in the expansion of the global healthcare industry. In 1943, government established the health survey and improvement committee, chaired by Sir Joseph Bhore, to analyse current health conditions and make recommendations for future development. The committee recommended a district health programme, and was of the opinion that healthcare services should be offered to all citizens, regardless of their financial situation. The group suggested district health schemes for the development of health infrastructure, also known as the “three million” plans, which served as the foundation of the existing three tier system of sub centre, primary health centre, and community health centre. It is a nation with a wealth of medical expertise and ability, giving it an advantage in the medical industry through a variety of health services offerings. However, the rate of development in the Indian medical industry does not reflect the reality that it has faced numerous challenges both historically and currently. Despite considerable changes since independence, India’s health industry still faces serious obstacles. Healthcare in India is largely provided by the private sector, which covers urban areas and provides services to those who are financially better off, which usually places a heavy financial burden on the patients (Kataria 2018). Since health is a state concern, the state government must deal with matters of public health. Each state has created its own healthcare delivery system to fulfil its obligation. The state department of health and family welfare, which is the division of the Ministry of Health and Family Welfare, is in charge of overseeing the health sector in Punjab. Five sub departments, including the Punjab Health System Corporation, Health Services ESI, Punjab State AIDS Control Society, National Health Mission, Director Health and Family Welfare are working under the control of the state Ministry of Health and Family Welfare. Through a network of medical facilities, the state offers health services (Punjab.gov.in). The health-care system in Punjab is controlled by public and private providers. Only a few hospitals affiliated with medical universities provide tertiary health care in the state's main cities. Furthermore, several corporate hospitals run by private trusts in major cities offer specialised in-patient and out-patient care. The State Government operates a vast network of district hospitals, sub divisional hospitals, community health centres (CHCs), and rural hospitals in medium towns and a few larger villages. People in rural Punjab are served by a network of primary health centres (PHCs), subsidiary health centres (SHCs), and sub centres (SCs), which provide both curative and preventive health services (Punjab Health System Corporation, 2022).

To understand the problem regarding health, quality of health services and about disparities in health sector some author’s work has been reviewed:

Jackson et.al. (2013) analysed the standard of primary health care in the country. The study reveals that there was broad inequity in the distribution of health over geographical, caste, gender, and educational level. To mark these problems, the central government has taken daring steps to promote healthcare in the country. The government launched the National Rural Health Mission (NRHM) in 2005, to strengthen the public health system. And in 2008, the Indian government launched the Rastriya Swasthya Bima Yojana (RSBY) scheme to supply free hospital treatment for families living below the poverty line. The RSBY now covers almost 33 million households.

Malhotra and Do (2013) analysed the socio- economic disparities in health system. The Indian health system was a blend of public and private health care services, with the majority of the population opting for private health care due to better quality of care. Public health services were mostly used by poor people who were not able to get private healthcare services. Within private health care, there was also a noticeable difference in the cost and quality of health care services provided.

Saikia and Kulkarni (2016) analysed that there were health inequalities in India across states, caste, religion, and region. The measurement of health inequalities was life expectancy at birth, which was the highest at 77.9 years in Kerala and the lowest 64.1 percent in rural Assam during 2009-2013. The child mortality rate was the other measurement of health inequality. The child mortality rate among mothers with 12 years of schooling was lower than 10 times the mother with no education. These important issues remained in India even after almost 70 years of independence, due to a lack of data quality.

Mackenbach (2018) examined health trends by education in European countries, paying special attention to probability of current trends disturbance, including 2008 economic crisis. The data has collected from 27 European countries. The study reveals that in most western European countries, mortality has decreased fastly among both low and high educated groups. Relative declines were generally high amid the highly educated and absolute declines were normally high between the low educated groups. Due to this health inequalities have increased.

In eastern Europe trends were totally different from western Europe. In most eastern European countries a trend of reversal to western European has taken place that’s why, absolute health inequalities have declined. Normally trends were unchanged. This shows that there was a favourable change in eastern Europe, not favourable in western Europe. In spite of the incident of an economic crisis, the health status of low educated groups has upgraded in current years, and health disparities have occasionally narrowed.

Malaviya (2022) examined the outcome of ISHAD (Insurance System of Advancing Health in Dubai) law passed in November 2013 on the fulfilment and out of pocket (OOP) expenditure for small and large socio-economic level groups. The DHHS (Dubai Household Health Survey) has been used as a representative survey. The study reveals that the total health expenditure of Dubai increased from 3.4 billion US$ in 2014 to 4.6 billion US$ in 2017 after the implementation of ISHAD. Simultaneously, the OOP share in total health expenditure in country fell to 13 percent in 2017 from 25 percent in 2014. During 2014 to 2018, there were rise in fulfilment of inpatient, outpatient, and other health related services for all peoples except foreigners living in the country. After the implementation of ISAHD, compulsory insurance schemes completely replaced voluntary insurance schemes and population of Dubai spends more on outpatient services than inpatient services. Due to this the burden of healthcare expenditure shifted from households to government.

Health is a main component of human development. In India health sector falls in the concurrent list due to this both centre and state governments give funding for the health sector. After economic reforms in 1991, Punjab government established Punjab Health System Corporation (PHSC) in 1996 to enhance the health care services in terms of quality and access with the financial help from world bank.

The list of Indian states according to health Index scores has been shown in table 1. The table reveals the ranking of states as per their health index scores, Kerala ranks first with health index scores of 82.20 followed by Mizoram with (75.77), Tamil Nadu (72.42), Tripura (70.16), Telangana (69.96), Andhra Pradesh (69.95), Maharashtra (69.14), Gujarat ranks (63.59), Himachal Pradesh (63.17), Punjab ranks (58.08), Karnataka (57.93), Sikkim (55.53), Goa (53.68). These are above the average score of 52.71.  The states which are having health index scores less than average health index score of 52.71 are Chhattisgarh with health index score of 50.70 followed by Haryana (49.26), Assam (47.55), Jharkhand (47.55), Odisha (44.31), Uttarakhand (44.21), Meghalaya (43.05), Rajasthan (41.33). There are few states which are having health index scores even less than 40 i.e., Madhya Pradesh (36.72), Manipur (34.26), Arunachal Pradesh (33.91). There are two states Uttar Pradesh and Nagaland which are having health index score 30.57 and 27.00 respectively.

Table 1. List of Indian states by health index scores 2021.

Rank	State	Index Score
1.	Kerala	82.20
2.	Mizoram	75.77
3.	Tamil Nadu	72.42
4.	Tripura	70.16
5.	Telangana	69.96
6.	Andhra Pradesh	69.95
7.	Maharashtra	69.14
8.	Gujarat	63.59
9.	Himachal Pradesh	63.17
10.	Punjab	58.08
11.	Karnataka	57.93
12.	Sikkim	55.53
13.	Goa	53.68
14.	Chhattisgarh	50.70
15.	Haryana	49.26
16.	Assam	47.74
17.	Jharkhand	47.55
18.	Odisha	44.31
19.	Uttarakhand	44.21
20.	Meghalaya	43.05
21.	Rajasthan	41.33
22.	Madhya Pradesh	36.72
23.	Manipur	34.26
24.	Arunachal Pradesh	33.91
25.	Bihar	31.00
26.	Uttar Pradesh	30.57
27.	Nagaland	27.00
28.	Average	52.71

Source: Niti Aayog report (2021).

The districts of Punjab sorted by population has been shown in table 2. Table reveals that in Punjab there are huge disparities in health care infrastructure between districts. In top three districts Amritsar, Ludhiana and Patiala there is 25.35 percent hospitals, 25 percent of PHCs, 18 percent CHCs, 21.88 percent sub-centres and 35.28 percent of beds are located out of the physical health care infrastructure. Human resources are also concentrated in these three districts as there is 43.47 percent doctors, 25.52 percent midwives and 25.96 percent nurses are providing services in these districts. However, in these three districts 28.41 percent of the population lives.

However, in the bottom three districts Fatehgarh Sahib, Fazilka and Pathankot there is only 7 percent hospitals, 10 percent CHCs, 8.96 percent PHCs, 8.33 percent SCs and 6 percent beds are available. These districts are also lack of human resources as there is only 2.36 percent doctors, 2.98 percent midwives and 3.38 percent nurses are available. Almost 8.42 percent of the total population lives in these three districts.

Table 2. List of districts of Punjab sorted by population.

Sr. No.	District	Population	Literacy Rate	Gender Ratio	Percentage of the total population	Urban Population Percentage	Rural Population Percentage
1.	Ludhiana	3,498,739	82.2	873	12.61	59.16	40.84
2.	Amritsar	2,490,656	76.27	889	8.97	53.58	46.42
3.	Jalandhar	2,193,590	82.48	915	7.90	52.93	47.07
4.	Patiala	1,895,686	75.28	891	6.83	40.26	59.74
5.	Sangrur	1,655,169	67.99	885	5.96	31.17	68.83
6.	Gurdaspur	1,621,725	79.95	895	5.84	22.27	77.73
7.	Hoshiarpur	1,586,625	84.59	961	5.71	21.11	78.89
8.	Bathinda	1,388,525	68.28	868	5.00	35.95	64.05
9.	Tarn Taran	1,119,627	67.81	900	4.03	12.66	87.34
10.	Fazilka	1,063,737	68.9	898	3.83	23.6	76.4
11.	Moga	995,746	70.68	893	3.58	22.82	77.18
12.	S.A.S Nagar	994,628	83.8	879	3.58	54.76	45.24
13.	Firozpur	965,337	68.92	893	3.47	27.23	72.22
14.	Shri Muktsar Sahib	901,896	65.81	896	3.25	27.96	72.04
15.	Kapurthala	815,168	79.07	912	2.93	34.65	65.35
16.	Mansa	769,751	61.83	883	2.77	21.25	78.75
17.	Rupnagar	684,627	82.19	915	2.46	25.97	74.03
18.	Pathankot	676,598	84.6	860	2.43	44.07	55.93
19.	Faridkot	617,508	69.55	890	2.22	35.15	64.85
20.	S.B.S Nagar	612,310	79.78	954	2.20	20.48	79.52
21.	Fatehgarh Sahib	600,163	79.35	871	2.16	30.91	69.09
22.	Barnala	595,527	67.82	876	2.14	32.02	67.98
23.	Punjab	27,743,338	75.84	895	100	37.48	62.52

Source: Census of Punjab (2011) https://www.punjabdata.com/District-Wise-Population-of-Punjab.aspx

Note: In 2011, two new districts Pathankot and Fazilka were created. Pathankot district was created from Gurdaspur district and Fazilka district was created from Firozpur district. According to census held in 2011, the population of Gurdaspur before the creation of Pathankot was 2,298,323 and the population of Firozpur before the creation of Fazilka was 2,029,074.

The demographic, socio-economic, and health profile of Punjab in comparison to India has been shown in table 3. The table reveals that the total population of Punjab in 2011 was 27.74 million and the decadal growth rate of population was 13.89 which was lower as compared to 17.64 in India. Crude birth rate in Punjab was 14.3 which was lower than 19.5 in India. Crude death rate in Punjab was 6.6 which was marginally higher as compared to 6.0 in India. Infant mortality rate in Punjab was 18 which was quite lower than that of 28 in India. Neo-Natal mortality in Punjab was 12 as compared to India which was 20 in 2020. The under-five mortality rates in Punjab were quite better than India. The U5MR in Punjab was 22 which was 32 in India. Sex ratio in Punjab was lower as compared to India. Which was 895 in Punjab as compared to 904 in India. The general fertility rate in Punjab was 52.6 which was 67.0 in India. The total fertility in Punjab was 1.5 which was 2.1 in Overall India. There was marginal difference in literacy rate of Punjab and India. The Population density of Punjab was 551 in 2011 as compared to 382 in India. The demographic, socio-economic and health situation of Punjab is quite better than overall India’s situation.

Table 3. Demographic, Socio-economic and Health Profile of Punjab in Comparison to India.

Sr. No.	Indicator	Punjab	All India
1.	Total population (In millions)	27.74	1210.85
2.	Decadal percentage population growth	13.89	17.64
3.	Crude birth rate	14.3	19.5
4.	Crude death rate	6.6	6.0
5.	Infant mortality rate	18	28
6.	Neo-Natal mortality rate	12	20
7.	Under five mortality rates	22	32
8.	Gender ratio	895	904
9.	General fertility rate	52.6	67.0
10.	Total fertility rate	1.5	2.1
11.	Gross reproductive rate	0.7	0.9
12	Literacy rate (%)	75.85	74.04
13.	Female literacy (%)	70.73	65.46
14.	Male literacy (%)	80.44	82.14
15.	Schedule caste Population (In millions)	8.86	201.37
16.	Population density (Per square km)	551	382

 

 

 

 

 

 

 

 

 

 

Source: Sample Registration System (SRS)-Statistical Report (2020).                                                                   

Source*: Census of India (2011).

The growth of medical and health institutions and human resources in Punjab has been shown in table 4. Table reveals that the growth of health infrastructure from 2011 to 2021 is not impressive in Punjab. During last ten years there is a marginal increase in no of hospitals from 91 to 99. Primary health centres (PHCs) increased to 534 which was 444 in 2011. The growth rate of dispensaries or sub centres (SCs) is very impressive as the total number of dispensaries increases from 1412 to 3140 during last 10 years. There is a small growth of community health centres (CHCs) from 130 in 2011 to 150 in 2021. There is no change in number of Ayurvedic, Unani or Homeopathic institutions in Punjab from last one decade. However, there is a noticeable growth in medical and para-medical staff. As number of doctors increases to 33,263 from 23,926, mid-wife’s 60,533 from 32,642 and nurses increases to 89,874 from 47,816 during past ten years.

Table 4. Growth of medical and health institutions and human resources in Punjab.

Sr. No	Institutions/Human resources	2011	2021
1.	Hospitals	91	99
2.	PHCs	444	524
3.	SCs	1412	3140
4.	CHCs	130	150
5.	Ayurvedic	495	495
6.	Unani	34	34
7.	Homeopathic	111	111
8.	Beds	21620	19367
9.	Doctors	23926	33263
10.	Midwifes	32642	60533
11.	Nurses	47816	89874

     Source: Statistical Abstract of Punjab.

The number of state medical and state special medical institutions in Punjab has been shown in table 5. Table reveals in rural areas only 6 hospitals are available for medical care which is 6.06 percent of the total hospitals. And number of community health centres (CHCs) in rural areas is 88 out of 150. Which is 58.66 percent of the total CHCs. The number of Primary health centres in rural areas of Punjab is 413 out of 524, which is 78.81 percent of the total PHCs. Out of 3,140 dispensaries in Punjab 2,969 dispensaries are situated in rural areas, which is almost 94.55 percent of total dispensaries/sub centres.

Table 5.  Number of State medical and State special medical institutions in Punjab.

Sr. No.	Institution	Rural	Urban	Combined
1.	Hospitals	6	93	99
2.	CHCs	88	62	150
3.	PHCs	413	111	524
4.	Dispensaries	2969	171	3140
5.	Total	3476	437	3913

Source (1); statistical abstract of Punjab, various issues. * Calculated from Statistical abstract of Punjab.

The number of beds in state public medical and special medical institutions in Punjab has been shown in table 6. The table reveals that in rural areas of Punjab there is only 260 beds in state medical hospitals as compared to 11,002 beds in urban state medical hospitals. However, in CHCs situated in rural areas the total number of beds is 2790 which is almost 1.5 times more than the total number of beds in CHCs situated in urban areas. As PHCs are majorly situated in rural areas therefore, almost 95 percent of beds in PHCs are available in rural areas. There are only 37 beds in state dispensaries situated on rural areas as compared to 418 beds in dispensaries located in urban areas. In rural areas of Punjab, the burden of health care services is mainly on CHCs and PHCs. However, these institutions provide only preventive and curative healthcare services not secondary and tertiary care services. Therefore, in rural areas of Punjab the healthcare services are not available for secondary and tertiary care treatment. 

Table 6. Number of Beds in state public medical and state special public medical institutions in Punjab.

Sr. No.	Institutions	Rural	Urban	Combined
1.	Hospital	260	11002	11262
2.	CHCs	2790	1800	4590
3.	PHCs	2913	147	3060
4.	SCs/Dispensaries	37	418	455
5.	Total	6000	13367	19367

The population served by per institution, bed, medical and para medical staff in Punjab is shown in table 7. The table reveals that due to growth of dispensaries/sub-centres the population served by per medical institution decreases to 8032 in 2021 which was 13339 in 2011. Besides this there is a large jump in population served by per bed from 1,281 in 2011 to 1,615 in 2021. This is the result of decrease in beds in medical institutions and increase in Population of the state. In 2021 population served by per doctor is 957 as compared to 1207 in 2011. Population served by per midwife in 2021 is 525 as compared to 851 in 2011 and population served by nurse in 2021 is 354 as compared to 598 in 2011.

Table 7. Population served by per institution, bed, medical and para medical staff in Punjab.

Sr. No.	Person/ Institution	2011	2021
1.	Institutions	13339	8032
2.	Bed	1281	1615
3.	Doctor	1207	957
4.	Mid-Wife	851	525
5.	Nurse	598	354

The district wise number of health care institutions in rural and urban areas of Punjab has been shown in table 8. The table reveals that in rural areas of Punjab, the state public hospitals are available in only 4 districts namely Amritsar, Tarn Taran, Shri Muktsar Sahib and Bathinda. While in other districts of Punjab there is no public hospitals in rural areas. The distribution of Government hospitals of Punjab is not accurate in urban area also. Moga and Pathankot each has only 1 government hospital in urban areas. while Amritsar and Patiala each has 6 hospitals and Ludhiana has 5 hospitals in urban areas. This shows that distribution of state public hospitals is not accurate in urban areas also.

The availability of other state medical institutions like Community Health centres is not correct as Rupnagar has no community health centre in rural areas and S.A.S. Nagar has only 1 CHC in rural areas while Tarn Taran has 10 CHCs, Gurdaspur and Hoshiarpur each has 8 CHCs and Ludhiana has 7 CHCs. In urban areas seven districts Pathankot, Tarn Taran, Kapurthala, Fazilka, Faridkot, Shri Muktsar Sahib and Moga each has only 1 CHC while Jalandhar has 7 CHCs. Bathinda, Gurdaspur and Sangrur each has 5 CHCs and Hoshiarpur, Rupnagar, S.A.S. Nagar, Ludhiana and Patiala each district has 4 CHCs. This indicates the disparities of healthcare infrastructure between districts.

Table 8. District wise number of health care institutions in rural and urban areas of Punjab.

Source: Statistical Abstract of Punjab (2021).

The distribution of Primary Health Centres between districts is also not error free in both rural and urban areas. In rural areas Faridkot has 8 PHCs, Pathankot has only 9 PHCs, Barnala has 10 PHCs, Kapurthala and S.A.S Nagar each has 11 PHCs. While other side Gurdaspur has 30, Ludhiana has 29, Patiala has 28, Amritsar and Jalandhar each has 27 PHCs in rural areas. in Urban areas the disparities are also large as Pathankot and S.A.S. Nagar each has only 1 PHC in urban areas. While Amritsar and Ludhiana each district has 16 PHCs and Patiala has 12 PHCs in urban areas.

The condition of Sub-Centres is not good in terms of distribution in both rural and urban areas. In rural areas some districts i.e., Ludhiana has (265) SCs, followed by Gurdaspur (222), Sangrur (192), Patiala (185), Jalandhar (139).  On the other side Rupnagar has only (86), followed by S.A.S. Nagar (76), Fatehgarh Sahib (73), Barnala (72), Pathankot (68), Faridkot (62). In urban areas of Punjab six districts, Pathankot, Tarn-Taran, S.B.S. Nagar, Moga, Mansa and Barnala has no SCs. On the other side Ludhiana has 21, Jalandhar has 12, Patiala has 11 and Bathinda has 10 SCs in urban areas. This shows that the disparities of sub-centres between districts is very large.

The distribution of beds in state medical institutions is also not accurate in rural and urban areas. In rural areas some districts have more beds in state medical institutions compared to others such as Tarn Taran has (499) followed by Gurdaspur (448), Hoshiarpur (443), Ludhiana (431), Amritsar (431). There are few districts having very a smaller number of beds i.e., districts Mansa and Rupnagar has 133 followed by Pathankot (126), Faridkot (124), and S.A.S. Nagar (62). The condition is same in urban areas also as in urban areas Amritsar district has 2522 beds, Patiala has 1992 beds in urban state medical institutions. While Pathankot has only 160 beds in urban areas and Tarn district has only 180 beds in sate medical institutions situated in urban areas.

There are huge disparities in health care infrastructure in Punjab among various districts. The health infrastructure disparities are also situated in rural and urban areas. Where sub centres are situated majorly in rural areas of Punjab but sub centres are providing only primary health care services so in rural areas of Punjab there is lack of secondary and tertiary health care services. 

The study is based on secondary data. Secondary data taken from Statistical abstract of Punjab, Punjab-At-A-Glance, Sample Registration System Statistical Report, Census of India, Census of Punjab, related research papers and various other related websites. The data analysed by using appropriate statistical and econometric tools.

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