By the time one may finish reading this article, more than fifty Indians will be pushed deeper into poverty - not by unemployment, not by floods or conflict, but by illness. In the world’s fastest-growing economy, falling sick and chronically ill is a silent occurrence from the lowest class to the upper most class in wealth and income distributions.
In a year when India celebrated its climb into the ranks of the world’s top five largest economies, at least in size, a quieter, yet critical statistic tells a more sobering story: millions of Indians were pushed into poverty due to rising out of pocket health-related expenses.
These people are part of the Indian citizenry who did not fall victim to a sudden calamity or a pandemic shock. They were simply ill at the wrong time, in the wrong place, within a wrongly unjust healthcare system. For them, India's size of growth is perhaps less relevant or insignificant. A broken leg or a failed kidney was enough for those affected to collapse their financial futures.
It is a quiet emergency, but not an accidental one.
Not Just Bureaucratic Oversight
India’s public health crisis is no longer a matter of benign neglect or bureaucratic sluggishness. It suffers from state and deeply embedded institutional apathy, being a direct consequence of poor political and economic design. The nation-state has chosen to outsource its responsibility to the market, to reduce healthcare to a budget line item, and to paper over systemic failures with insurance schemes and digital dashboards.
The headlines may suggest otherwise. For the first time in history, public health expenditure has overtaken out-of-pocket expenditure by households.
The National Health Accounts (NHA) 2020–21, released in September 2024, confirms that the Indian government spent Rs 2.1 lakh crore on health, while households spent slightly less - Rs 1.95 lakh crore. This milestone is being hailed as evidence of systemic progress. But this is not a tipping point; it is a rounding error. The numbers have improved, but from such a low base that even this reversal reflects more on the previous scale of neglect than on current levels of ambition.
This marginal shift is being portrayed as a breakthrough. According to the same NHA data, government spending accounts for only 41.4 percent of the country’s total health expenditure, while 48.2 percent still come out of citizens' own pockets.
The rest is covered by insurance schemes, employers, or development partners For India, The latest value from 2021 is 3.28 percent, a decline from 3.34 percent in 2020. In comparison, the world average is 7.21 percent, based on data from 181 countries.
In effect, the Indian state continues to invest less in the health of its people than almost any comparable middle-income country.
For perspective, Brazil spent nearly 9.89 percent of its GDP on healthcare in 2021, among the highest in Latin America and globally prominent economies. In Thailand, Health spending climbed to 5.16 percent of GDP in 2021, up from around 4.36 percent in 2020, and hitting a decade-high. India, with its vast and unequal population, remains near the bottom of this critical metric.
Private Boom and Public Sector Decline
The problem is not just in how little we spend, but where and how we spend it. Much of the increase in public health investment has been routed through high-profile insurance schemes like Ayushman Bharat, formally known as the Pradhan Mantri Jan Arogya Yojana (PM-JAY).This programme, billed as the world’s largest public insurance scheme, offers Rs 5 lakh coverage to more than 50 crore people.
But it is not insurance in the traditional sense. It does not guarantee continuity of care, quality control, or price regulation. It outsources critical care to private hospitals while bypassing the need to rebuild the crumbling infrastructure of India’s public hospitals.
The Ministry of Health proudly claims that PM-JAY has enabled over 6 crore hospital admissions, as per official press releases.
Yet multiple independent studies, and on-the-ground reports, reveal a disturbing pattern: beneficiaries often still pay for medicines, diagnostic tests, and post-operative care. Insurance coverage exists, but comprehensive care does not.
In essence, the state is subsidising hospital bills without addressing the deeper deficits of rural clinics, primary care staffing, or public pharmaceutical access. The crisis of trust is deep: even insured families routinely fall back on informal borrowing, distress sales, or black-market medicines to close the gaps left by policy.
According to the RBI’s 2023 Handbook of Statistics, more than 1 in 5 Primary Health Centres (PHCs) - the first line of medical care for most Indians have no qualified doctor at all. The problem only deepens as you move up the healthcare ladder.
At Community Health Centres (CHCs), which are supposed to provide specialised secondary care, the numbers are devastating: over 80% of specialist positions are vacant nationwide. Breaking it down, and the picture is worse - 83.2 percent of surgeon posts, 74.2 percent of gynaecologist posts, 79.1 percent of physician posts, and 81.6 percent of paediatrician positions lie empty. These aren’t statistics; they’re warnings. A broken leg, a complicated childbirth, a sudden cardiac arrest-if it happens in rural India, the chances are chillingly high that there simply won’t be a qualified doctor within reach.
Even Delhi, the capital of the world’s most populous country, has just three government hospitals offering functioning MRI services. This causes diagnostic wait times that can stretch into months - months that many patients simply cannot afford to wait.
In smaller cities, even middle-class families face the grim routine of being bounced between overcrowded emergency rooms and facilities that have neither the staff nor the equipment to offer timely care.
This causes diagnostic wait times that can stretch into months - months that many patients simply cannot afford to wait.
In smaller cities, even middle-class families face the grim routine of being bounced between overcrowded emergency rooms and facilities that have neither the staff nor the equipment to offer timely care.
The Economic Survey 2024–25 reports that India’s total health expenditure has doubled in just four years, now touching Rs 6.1 lakh crore. But this projected rise is misleading.
It reflects a boom in private healthcare expansion-corporate hospitals, diagnostics chains, and telemedicine platforms not a revitalisation of the public health ecosystem. The growth is real, but it is exclusionary. High-end hospitals are multiplying in urban clusters, while entire districts lack access to basic anaesthesia or ventilator facilities. The geography of healthcare is increasingly split between gated zones of excellence and vast deserts of neglect.
Health is Politically Invisible
What makes this all the more frustrating is that health is politically invisible. It is rarely debated, almost never central to electoral manifestos, and entirely absent from the kind of polarised public discourse that fuels Indian political life.
Even during Covid-19, when oxygen ran out and bodies floated in the Ganga, the outrage was temporary. The system was not reformed. It was simply forgotten. This invisibility is not an accident. It is the result of decades of bipartisan neglect. Both UPA and NDA regimes have underinvested in health, preferring roads and ration cards over hospital beds and clean water. This is short-termism at its worst. Economists agree that a healthy population is the foundation of productivity and growth.
India’s healthcare crisis is no longer about misallocation. It is about misdirection. It is not a failure of ideas. It is a failure to care.
Some progress has occurred. Rajasthan’s Right to Health Bill, 2022 was a political experiment. Kerala continues to offer a working public model. But these are scattered islands in a sea of dysfunction.
What India needs now is not more slogans or schemes. It needs a structural transformation. Rajasthan’s 2023 attempt to legislate such a right met with fierce resistance from private hospitals and was diluted in execution. But, it was a spark. A true national law would not only guarantee essential health services but also force the state to invest in the systems, personnel, and infrastructure necessary to deliver them.
It is also time to move beyond metrics like insurance coverage or number of hospital beds per 1,000 people. A modern health state must be measured by continuity of care, equity of access, and the affordability of essential services. India has world-class pharmaceutical manufacturing capacity. It has digital health potential. It has brilliant public health scientists. But what it lacks is political imagination.
India has the resources. What it lacks is outrage.
No politician has yet lost an election for the death of a mother in childbirth or the absence of a ventilator. No party has ever won by campaigning for PHC reform. Until this changes, nothing else will.
Because in the end, the true strength of a republic is not in how many unicorns it funds, but how many children it saves. Not in how fast it grows, but in how fairly it heals. India cannot afford to ignore this emergency any longer.
And neither can we.
(Deepanshu Mohan is a Professor and Dean, OP Jindal Global University. He is a Visiting Professor and Fellow at LSE, and University of Oxford. Geetali Malhotra is a Research Assistant with Centre for New Economics Studies (CNES), OP Jindal Global University. This is an opinion piece and the views expressed above are the author’s own. The Quint neither endorses nor is responsible for the same.)