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It's not hard to find people caught in the gap between India's dreams of greatness and the awful reality of its broken health system. Most of the country lives there. Take Abhishek Khushwa. He would be a normal kid but for the fact that nine years after his birth with a bladder defect, his family is still struggling to get him what should be a simple and relatively cheap operation. Like many sick Indians, Abhishek is both symptom and cause. His lack of proper treatment is reason enough for national shame but his ill health hurts the country in turn, not only forcing the frail-looking boy to miss school for a week or two every few months while he searches hospital by hospital for some relief, but dragging his uninsured family into debt when they should be benefiting from India's economic boom. Together, Abhishek's parents — his mother Sunita is a clerk in a local government office in the northern city of Farrukhabad, his father Sunil works in a small clothes shop — make just under $200 a month, no fortune but enough to buy a small TV for their modest home. They would have bought a motorbike too, Sunil says, perhaps even a patch of land somewhere, were it were not for the hospital bills that never seem to end.

Standing in the crowded entrance hall in the outpatients department of New Delhi's All India Institute of Medical Sciences (AIIMS), one of India's best public hospitals, Sunil explains that because there are no decent public hospitals in Farrukhabad, he and his wife take Abhishek to New Delhi about three times a year for checkups and to try to get him the operation he needs. Last year, after years bouncing between hospitals and clinics, their son got an appointment to have the vital tests he needs before an operation. The family scraped together the $120 fee and traveled the 180 miles (290 km) to India's capital by train. But when they arrived they discovered the machine at the government hospital they had been visiting was broken and unlikely to be working anytime soon. Which is how the family came to be at AIIMS one morning late last year, hoping, cajoling, pleading for an appointment at the better-equipped hospital, and praying that one day they could make the system work for them. "Nine years is a very long time," says Sunil. "My son should have been operated on and recovered years ago."

A Paradoxical State
The same could be said of india's health system. Sixty years after independence, India remains one of the unhealthiest places on earth. Millions of people still suffer from diseases and ailments that simply no longer exist almost anywhere else on the planet. Four out of five children are anemic. Almost one in four women who give birth receives no antenatal care. What makes the picture even bleaker is the fact that India's economic boom has had, so far at least, little impact on health standards. Think of it this way: in the five years between 2001 and 2006 India's economy grew almost 50%, the country's biggest expansion in decades. Meantime, its child-malnutrition rate, a number that measures the percentage of children under 3 who are moderately or severely underweight, dropped just a single percentage point, to 46%. That's worse than in most African countries, and means almost half India's children remain at risk of "health problems such as stunted growth, mental retardation, and increased susceptibility to infectious diseases," according to the most recent National Family Health Survey, a study of more than 230,000 people, from which the figures are taken.

Perversely, the incredible economic growth is having an impact in other ways, driving up rates of rich-world diseases such as obesity and diabetes and encouraging high-end health services, some of which offer world-class care but remain far beyond the reach of the vast majority of Indians. It's these services — think of last year's surgery to save an Indian girl born with four arms and four legs — and the skill of India's world-class doctors that the country brags about when its marketers sell India as a medical-tourism destination and an emerging health-services giant. The truth behind the glossy advertising is less incredible: India remains the sick man of Asia, malnourished and obese at the same time, beset by epidemics of AIDS and diabetes, and with spending levels on public health that even Prime Minister Manmohan Singh has conceded "are seriously lagging behind other developing countries in Asia."

The sorry state of India's medical services might not matter so much if tens of millions of Indians weren't already so sick. Part of the problem is the lack of infrastructure — not fancy hospitals or equipment but basic services such as clean water, a functioning sewage system, power. The World Health Organization estimates that more than 900,000 Indians die every year from drinking bad water and breathing bad air. The Indian government says that 55% of households have no toilet facilities. Many cities lack sewers. The missing infrastructure is not unique to India. Parts of Africa face similar underdevelopment. But some public-health experts believe that India's massive population adds to the burden, overloading systems where they do exist and aiding the spread of disease in the many places they don't.

There are other reasons for India's ill health. Over the past decade or so, funding for public-health initiatives such as immunization drives and programs to control the spread of communicable diseases has been cut; some critics blame shifting government priorities. One of the best ways a country can improve its health, for instance, is by making sure its children are immunized against measles, polio and other life-threatening illnesses. But immunization rates in India are significantly lower than in other developing nations such as Bangladesh, China and Indonesia. Just 43.5% of very young children are fully immunized. "It's shameful," says A.K. Shiva Kumar, an economist and public-health expert who consults to the United Nations Children Fund in India and was a member of the government's recently disbanded National Advisory Council. "All this high income, this growth of the past few years is well and good, but numbers like this show you can't get complacent about health or you'll go nowhere."

Cycle of Illness
In the past few years, diseases such as dengue fever, viral hepatitis, tuberculosis, malaria and pneumonia "have returned in force or have developed a stubborn resistance to drugs," according to a report on health care in India by consultancy PricewaterhouseCoopers. "This troubling trend can be attributed in part to substandard housing, inadequate water, sewage and waste management systems, a crumbling public health infrastructure, and increased air travel." Pylore Krishnaier Rajagopalan, who was head of the government Vector Control Research Centre in the southern city of Pondicherry between 1975 and 1990, blames policies that concentrate on the latest scientific techniques and not enough on basic controls. "Field work is almost dead," Rajagopalan says. "These mosquitoes are sun loving. How can a shade-loving, lab-bound, white-coated scientist control the mosquitoes through research? It may be the future but millions of people in India are suffering and dying now because we're not doing the basics."

If all that explains why Indians are so sick, look to public hospitals and medical services to understand why they are not getting better. In many parts of the country, but especially in rural India, where two-thirds of the population lives, health services are poor to nonexistent. Clinics are badly maintained and equipped. India needs hundreds of thousands more doctors and more than a million more nurses. Current staff often don't turn up for work. "It is a well-recognized fact that the system of public delivery of health services in India today is in crisis," begins the paper "Understanding Government Failure in Public Health Services" published in the influential Economic and Political Weekly last October. "Recent analyses show that high absenteeism, low quality in clinical care, low satisfaction with care and rampant corruption plague the system."

Such dire conditions force millions of people to head to the better public hospitals in India's cities. The Dr. Ram Manohar Lohia Hospital (RML) in New Delhi is well maintained, relatively clean and is probably one of the best. Unlike most hospitals, which get their funding from state governments, the RML is financed directly by the central government and caters to the thousands of public servants and senior government officers, including members of Parliament, who are lucky enough to have state-funded medical insurance. But its high standards are also a magnet for sick people for hundreds of miles around. About 60% of the 4,500 patients the hospital sees every day travel not from the New Delhi area but from neighboring states. Some of them are complicated cases that have rightly been referred to a tertiary-care hospital, but many are simple cases of malaria or dengue fever that other hospitals should treat easily. "The challenge is that our facilities are totally at saturation point," says Dr. Nishith K. Chaturvedi, the hospital's medical superintendent. "If states were doing a better job it would cut our case load by 35%."

The crush of numbers means that the RML is sometimes forced to have patients share beds. "For a short period only," Dr. Chaturvedi says, looking slightly sheepish. "But it happens." A tour of the emergency and outpatient departments brings the problem into stark relief: the crowds of patients and visiting relatives are as thick and suffocating as the heady fug of chloroform and the sounds of children screaming. A few cases on trolley beds wait outside under a small awning. Though generally well kept, "it's very hard to maintain cleanliness even if you clean every half an hour," says the head of the outpatient department, Dr. P.K. Misra, waving his hand at a heap of bloodied sheets in a corner. "I have visited a few hospitals in the U.S. They are like five-star hotels for us. But we can never match that. It's the population load."

Progress Report
Later, taking a break in an unoccupied office, a tired Misra laments the state of public health. "This place is one of the good ones," he says. "I have seen hospitals with dogs below the beds." After graduating, Misra spent a few years in India's northeast, one of the poorest parts of the country. "I went to the rural area to serve the people but the government doesn't recognize that," he says, explaining that classmates who went to big cities "are now professors and earning big bucks." The system, he says, is set up so that rural areas will never have good doctors or other medical staff, tens of thousands of whom leave to work in cities or abroad. "It's better to start a practice in the city than go to the country and ruin your life."

With such problems in the public system, it's little wonder that private operators have boomed. Some 80% of all spending on health care in India is now private, some of it by large companies insuring their staff, some by nongovernmental groups running health programs, and a bit by rich Indians using the best private facilities. But the overwhelming majority of the spending is by poor citizens. Money is so tight that many rural Indians skip doctors and rely on advice from local pharmacists, who too often prescribe cough syrup or tablets that do nothing to help. Because only one in 10 Indians has any form of health insurance, out-of-pocket payments for medical care amount to 98.4% of total health expenditures by households, according to the PricewaterhouseCoopers study, which estimates that 20 million people in India fall below the poverty line each year because of indebtedness due to health-care needs. In Brazil and China, both countries India often compares itself with, the public share of health-care spending is around 40%, while the average for G7 countries is 70%. In India it is just 17%.

The good news is that the current Indian government seems to get it. "Health is slowly becoming an important focus," says Krishna Rao, who heads health economics and funding for the Public Health Foundation of India. The organization was set up in 2006 by the government, NGOs like the Bill and Melinda Gates Foundation and private health providers to influence policy and research, and to set up world-class public-health schools around the country. The government has also promised more money for rural health through its ambitious National Rural Health Mission. The Congress Party, which leads India's coalition government, says it will increase public-health spending from the current 1% of India's GDP to up to 3% by 2010, but that's still just half the rate at which countries with comparable per capita incomes such as Senegal and Mongolia fund their health sectors. "What has been a fatal flaw in our approach is that we have gradually abandoned comprehensive health care and a public-health perspective for focused attention on selective diseases," Prime Minister Singh said at the April 2005 launch of the National Rural Health Mission. "We have grievously erred in the design of many of our health programs. We have created a delivery model that fragments resources and dissipates energies. Most importantly we have paid inadequate attention to the public-health issues and the possibilities of social and preventive medicine."

If that is to change, one of the first myths that need to go is the idea that economic growth alone will lead to better health. Though health indicators vary widely across India, the link between wealth and good health isn't clear cut. Poor states such as Orissa and Chhattisgarh that have made efforts in child immunization over the past few years now have better coverage than richer states, where immunization has actually slipped.

Other sacred cows will need to be challenged. India's old socialist system may have had its problems, says Imrana Qadeer, one of India's foremost public-health experts, but the belief that private enterprise can cure all of India's woes is dangerously misguided. "The private sector doesn't want to do basic things like treating diarrhea, improving nutrition, immunizing babies because that's not where the money is," says Qadeer. "In India we cannot live without a strong public sector."

In the end that will mean spending hundreds of billions of dollars more on public health, perhaps even creating a basic national insurance scheme. "Unfortunately there may not be any low-cost solutions," says public-health expert Kumar, who believes current government promises do not go far enough. "India needs to be prepared to spend on health but whenever it's mentioned there's always this debate about cost. Why don't we have the same debate when we spend tens of billions on new arms? It's totally unacceptable to shortchange a system that will save lives." And it's hard to be an economic superpower if you're too sick to work.

• Simon Robinson