India tackled COVID-19 with a law.

When was that law written?

By the end of today, you will be able to

  1. Explain what a health policy is, and how it differs from a plan or a programme
  2. Name India’s three eras of health policy and one feature of each
  3. Give three colonial decisions that still shape the health system, including the Bhore Committee

Quick check

  1. Is health a Union, State or shared subject?
  2. About how many people does one rural PHC serve in the plains?
  3. Name any health committee from before independence.

Policy, plan, programme, scheme

What it does Example
Policy Sets direction: what and why NHP 2017
↓ Plan Says how, when, and with what money State health plan
↓ Programme Does the work on the ground National Health Mission
↓ Scheme Gives one specific benefit Janani Suraksha Yojana

Pulse Polio: policy, plan, programme or scheme?

India’s health policy in three eras

Era Years The government’s main question What it left behind
1. Colonial 1859–1946 How do we protect soldiers, officials and trade? Health as a State subject · 1897 Act · research institutes
2. Nation-building 1946–2004 How do we give basic care to every village? PHC network · Community Medicine · NHP 1983, 2002
3. Missions & UHC 2005–now How do we fix gaps and protect people from health costs? NHM · ASHAs · Ayushman Bharat · NHP 2017

A teaching framework, drawn from Duggal (2001) and Raj et al. (2024).

1859–1900: health for the army

Royal Commission on the army in India (1859–63)

  • After 1857, a Royal Commission studied the health of British troops in India
  • Troops died at about 69 per 1,000 a year, mostly from preventable disease
  • The response: sanitation in army cantonments and the areas around them
  • Villages were mostly left out. Historians call this “enclavism” (Ramasubban 1988)

Who was this health policy for?

Bengal sepoy infantry, lithograph c. 1858 · National Army Museum, London · public domain. Death rate: Nightingale (1874)

Who got healthier?

Cantonments and lock hospitals

  • Cantonments Act, 1864: a sanitary police force for cantonments
  • Section 20 allowed the registration and control of sex workers near troops
  • Indian Contagious Diseases Act, 1868: compulsory examination of women; lock hospitals for those found infected
  • The aim was soldiers’ health. The women had no say
  • Repealed in 1888 after protests in Britain and India

Plan of Secunderabad cantonment, 1843 · public domain, via Wikimedia Commons. Mushtaq (2009); Rama Gopalakrishnan (2022)

Civil lines and the old town

  • Europeans lived in civil lines and cantonments, with drains, piped water and wide roads
  • The old walled city stayed crowded, with little sanitation
  • Bengal district boards, 1910–11: £21,000 on medical relief, only £1,700 on sanitation (House of Lords 1913)

Delhi, from Murray’s Handbook for India, Burma and Ceylon, 1911 · Internet Archive Book Images

1896–1918: plague

Plague in Bombay (1896–97)

  • Plague reached Bombay in 1896
  • Epidemic Diseases Act, 1897: officials could search homes, isolate people and stop travellers
  • Soldiers enforced it, and people resisted
  • In Pune, plague commissioner W.C. Rand was shot dead in 1897

House-to-house visitation with military escort, Bombay, 1896 · Wellcome Collection, CC BY 4.0

How big was the plague?

  • Weekly plague deaths in Bombay city, 1896–97: one sharp peak
  • In India, over 8 million died of plague by 1914 (Chandavarkar 1992)
  • Over 13 million plague deaths were reported from 1898 to 1949 (Tennant et al. 2020)
  • The worst years were 1903–07

INFOGRAPHIC slot: annual plague deaths in India, 1896–1918 (Klein 1988). See infographic-review.md.

Nathan R. The Plague in India, 1896, 1897, Vol. IV (1898) · Internet Archive

The 1897 Act itself

  • Passed on 4 February 1897. Only 4 sections
  • Section 2: the government may take any measure it thinks fit, including inspecting rail travellers and segregating suspects in hospital
  • Section 3: disobeying an order is an offence (IPC s.188)
  • Section 4: officials acting “in good faith” cannot be sued

Act No. III of 1897, as first printed · Unrepealed General Acts, Vol. VI · Internet Archive. Government of India (1897); Yadav and Muraleedharan (2024)

Inspection and segregation

  • Left: railway plague inspection stations across India, 1897
  • Right: a segregation camp in Karachi, 1897. Contacts were held here, away from home

Left: Nathan, The Plague in India, Vol. IV (1898) · Internet Archive. Right: Segregation camp, Karachi, 1897 · Wellcome Collection

Plague: hidden deaths

  • Circles on the wall marked deaths from plague
  • Officials noted that many plague deaths were probably reported as other illnesses

What does this teach us for COVID-19, or any outbreak?

Plague house, Kalbadevi Road, Bombay, 1896–97 · Wellcome Collection · public domain

Haffkine’s plague vaccine

  • Waldemar Haffkine made a plague vaccine in Bombay in 1896–97
  • His laboratory at Parel was renamed the Haffkine Institute in 1925
  • 1902, Mulkowal (Punjab): 19 people died of tetanus from one contaminated vaccine bottle. Haffkine was blamed, then cleared in 1907

W.M.W. Haffkine; Plague inoculation, Bombay, c. 1897 (Clifton & Co.) · Wellcome Collection. Hawgood (2007)

From 1897 to 2020

Epidemic Diseases (Amendment) Act, 2020

  • Violence against health workers: cognizable and non-bailable
  • 3 months to 5 years in jail, and a fine of ₹50,000 to ₹2 lakh
  • Grievous hurt: 6 months to 7 years, and ₹1 lakh to ₹5 lakh
  • The Centre may inspect buses, trains, ships and aircraft

Still missing

The Act still has no definition of an epidemic and no rights for patients. Critics call it “merely a ‘policing’ Act” (Rakesh 2021).

Ministry of Law and Justice (Legislative Department) (2020); Rakesh (2021); Bahurupi et al. (2020)

1897–1932: science and institutes

Ronald Ross in Secunderabad (1897)

  • 20 August 1897, Begumpet, Secunderabad: Ross found malaria parasites in the stomach of a mosquito
  • 20 August is now World Mosquito Day
  • Nobel Prize, 1902

Room in Secunderabad where Ross made his discovery (Lala Deen Dayal) · Wellcome Collection, CC BY 4.0. Notebook page, 20 Aug 1897 · public domain. Malpe et al. (2024); Ross (1897)

Research institutes

Year Institute
1900 Pasteur Institute, Kasauli
1905 Central Research Institute, Kasauli
1911 Indian Research Fund Association (became ICMR in 1949)
1925 Plague laboratory at Parel renamed Haffkine Institute
1932 All India Institute of Hygiene and Public Health, Calcutta

Laboratory, Pasteur Institute, Kasauli, c. 1910 · Wellcome Collection. Mushtaq (2009); Directorate General of Health Services (2026); Indian Council of Medical Research (2026); Hawgood (2007); All India Institute of Hygiene and Public Health (2026)

1876–1943: famine and flu

Famine

  • Repeated famines in the late 1800s. This photo is from Madras Presidency, 1876–78
  • Famine Commission, 1880: led to the Famine Codes for relief works and early warning
  • The codes managed famine. They did not prevent hunger or disease

W.W. Hooper, 1876–78 · Wellcome Collection. Indian Famine Commission (1880)

The 1918 influenza

INFOGRAPHIC slot: province-level 1918 influenza mortality map (Chandra et al. 2012). See infographic-review.md.

“Influenza in India, 1918”, Public Health Reports 34(30), 1919 · public domain

Bengal famine, 1943

  • 1.5 to 3 million people died
  • It happened during the Second World War
  • The same year, the government set up the Bhore Committee (October 1943)

The Statesman, Calcutta, 22 August 1943 · public domain, via Wikimedia Commons. Famine Inquiry Commission (1945); Sen (1981)

Life expectancy stayed low

1919–1940: provinces and Indian voices

Health becomes a provincial subject (1919)

  • Government of India Act, 1919: public health became a provincial subject
  • Indian ministers ran it, with very little money
  • Our Constitution kept it: State List, Entry 6, “public health and sanitation; hospitals and dispensaries”

Why does it matter to you that health is a State subject?

British Indian Empire, 1909 (British India pink, princely states yellow) · Imperial Gazetteer of India · public domain

How little money?

Province (1939–40) Spent per person per year
Bihar 1 anna 7 pies
United Provinces 1 anna 9 pies
Bengal 2 annas 7 pies
Bombay 5 annas 9 pies
Britain (1934–35) about ₹54
  • In 1944–45, provinces spent only 2.5% to 7.3% of their budgets on medical relief and public health

Report of the Health Survey and Development Committee, Vol. IV, paras 333–339 (Health Survey and Development Committee 1946b)

Women in medicine

  • 1885: Countess of Dufferin’s Fund, to bring “female medical aid” to Indian women
  • 1886: Anandibai Joshi (left) earned an MD in Pennsylvania, USA
  • Kadambini Ganguly (right) was the first Indian woman to practise Western medicine in India
  • 1916: Lady Hardinge Medical College, Delhi, opened for women

Anandibai Joshi, c. 1886 (Drexel Legacy Center) and Kadambini Ganguly · public domain. Lal (1994); Doomra (2024); Verma et al. (2024); Arnold (2025)

The Sokhey Sub-committee (1938–40)

  • Set up by the Indian National Congress’s National Planning Committee, before independence
  • Health is a state responsibility
  • One trained village health worker per 1,000 people (9 months of training)
  • Long-term goal: 1 doctor per 1,000 and 1 hospital bed per 600 people
  • Report published in 1948

Does “one village health worker per 1,000 people” remind you of a worker you know?

National Planning Committee (1948); Duggal (2001)

1943–1946: the Bhore Committee

Bhore Committee (1943–46)

  • Set up in October 1943, during the war and the Bengal famine. Reported in 1946
  • Infant mortality was about 162 per 1,000 live births (1937)

Four key ideas:

  1. Prevention and treatment in one service
  2. PHCs: one per 40,000 people, two doctors each (short term)
  3. A Department of Preventive and Social Medicine in every medical college: today’s Community Medicine
  4. No one should go without care because they cannot pay

Report of the Health Survey and Development Committee, Vol. I and IV (1946). Health Survey and Development Committee (1946a); Health Survey and Development Committee (1946b)

Bhore’s long-term plan: three tiers

Tier Covers Hospital Staff
District 3–5 secondary units (about 3 million people) 2,500 beds Specialists
↑ Secondary unit 15–25 primary units 650 beds
↑ Primary unit 10,000–20,000 people 75 beds 6 doctors, 6 public health nurses

Short term (first 10 years): one PHC per 40,000 people, with 2 doctors and 4 beds

Sir Joseph Bhore, 1922 · Agence Rol, Bibliothèque nationale de France, via Wikimedia Commons. Health Survey and Development Committee (1946b), paras 21–35

Bhore’s staff gap

Bhore targets and the situation today

Feature Bhore (1946) Today Done?
People per PHC 40,000 ~30,000 plains; 20,000 hilly/tribal
Doctors per PHC 2 Usually 1
Teaching community health A department in every college Community Medicine in every college
Care whatever you can pay Core principle Many still pay out of pocket

Mothers given a ride home from a PHC, Tamil Nadu, 2015 · CDC Public Health Image Library

Take Home Message

  1. A policy sets direction. Plans, programmes and schemes carry it out
  2. Colonial health policy protected soldiers, officials and trade first. Historians call this enclavism
  3. Colonial decisions are still with us: the 1897 Act, health as a State subject, and the research institutes
  4. Bhore (1946) drew the plan we still follow: PHCs, prevention with treatment, and Community Medicine

Next class: What did India do with Bhore’s plan after 1947?

References

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