Despite the rising demand for quality public healthcare, its infrastructure and delivery across India continues to be woefully insufficient.
While middle-class and urban elite inhabitants can access health insurance programs through the private healthcare system, most Indians, particularly those residing in rural and remote areas, along with those who are considered to be below the poverty line (BPL), are dependent on public healthcare and are only partially covered by different public insurance programmes.
The percentage of total government expenditure on healthcare in India is a meager 2.9 per cent of the GDP, a very low figure compared to most economically advanced countries across the globe.
Why has the development of the country's health apparatus not kept pace with its economic development?
The pandemic emphasised stark differences in the quality of healthcare across rural and urban areas, as well as between public and private healthcare providers. We discuss some empirical insights on the complex nature of challenges faced by the country’s public healthcare system and its inability to ensure better services for all while addressing issues of access, equity, and quality.
Navigating Health Issues of India's Geriatric Population
The latest report by the UNFPA (United Nations Population Fund) on India's aging population predicts that by 2050, India's aging population will be higher than the population size of children aged 0-14. Given the country's lagging healthcare, there is an immediate need to devise policies and strategies that would help address issues of India's geriatric population.
These policies must accentuate increased public health expenditure, emphasising social support and palliative care. The success stories of Japan's Social Health Insurance model and China's Public Health Insurance model can serve as a much-needed guide for India as it navigates its way out of this predicament.
Policymakers can also look at Kerala's policy on palliative care, which provides care for chronically and terminally ill people through community involvement, accountability, and improvement in services.
So far, the policy has successfully established 1,550 palliative care units, out of which 450 are managed by civil organisations. The policy has made palliative care available for more than 26 per cent of the population that needs it which is far above the global average of 14 per cent.
The same, however, is not the case for the rest of the Indian states, where only 2 per cent of the affected population receives the help they need. It is about time that the rest of the country learns from the globally recognised model of Community Based Palliative Care. This, along with an increase in the center’s health expenditure, appears to be the only way for India to get out of the prominent quagmire.
Out-of-Pocket Expenditure on Healthcare: A Pressing Concern
Informing policy and examining healthcare delivery in any country is only possible if there are robust and accurate data collection models in place. Low and lower-middle-income countries often grapple with inadequate and poor-quality health data collection, creating challenges for health policy. India recognises this issue dating back to its National Health Policy in 2002, but it still faces challenges like insufficient data on non-communicable diseases, injuries, and district-level information.
Out-of-pocket expenditure (OOPE) on healthcare in India remains a pressing concern, posing a substantial risk of impoverishing households, particularly those in the lowest income brackets. High OOPE on health is impoverishing some 55 million Indians annually, with over 17 per cent of households incurring catastrophic levels of health expenditures every year.
OOPE varies significantly among Indian states, with several, including Uttar Pradesh, Kerala, Jharkhand, Andhra Pradesh, Bihar, Madhya Pradesh, Odisha, Punjab, and West Bengal, surpassing the national average. Kerala, however, stands out due to its robust health-seeking behaviour and substantial government health expenditure per capita, indicating a unique situation.
Out-of-pocket expenditure (OOPE) in Rajasthan, like much of India, has been a significant concern, burdening households with healthcare costs. The recent enactment of the Right to Health Act in Rajasthan, aimed at addressing this issue, underscores the urgency of reducing OOPE and ensuring equitable access to healthcare.
This legislation provides residents of Rajasthan with guarantees of emergency treatment without upfront payments and free healthcare services in public health institutions. This progressive step holds the potential to alleviate the financial strain on individuals and families, ultimately contributing to improved healthcare accessibility and well-being in the state of Rajasthan.
Organisations Advancing and Tackling India’s Healthcare
In 2012, India initiated efforts toward Universal Health Coverage through its twelfth five-year plan, focusing on enhancing healthcare availability, quality, and affordability.
The 2018 launch of the Ayushman Bharat program reinforced this commitment by providing primary care through wellness initiatives and insurance coverage. The program targets the 10.74 crore economically weaker population, intending to discern occupational categories of urban workers according to the Socio-Economic Caste Census (SECC) data.
As an initiative under the National Health Protection Mission, the yojana will subsume the ongoing centrally sponsored schemes - Rashtriya Swasthya Bima Yojana (RSBY) and the Senior Citizen Health Insurance Scheme (SCHIS).
India aims to increase government health spending to 2.5 per cent of GDP by 2025 to facilitate universal healthcare within its diverse healthcare system.
Notably, the Indian Medical Association advocates for increased public healthcare spending, while the Indian Council of Medical Research (ICMR) focuses on biomedical research, innovation, and human resource development, albeit with criticism regarding its handling of the COVID-19 pandemic, including questionable decisions on drug recommendations and a lack of transparency on data related to variants.
These organisations tackle different domains of healthcare delivery services, enabling higher accountability and transparency between the state and its citizens. Despite the repudiations, their initiatives also aid in painting a comprehensible picture of the state of public health, which in turn, is used to facilitate imperative modifications within the system.
In moving forward, addressing India's healthcare challenges is crucial for the nation's well-being and its global aspirations. The disparities in healthcare access, quality, and equity are stark and demand urgent action. The Rajasthan model can serve as a template for addressing disparities, focusing on government-funded public systems, drug distribution, and expanding outpatient services. India's journey towards universal healthcare and improved equity and quality necessitates sustained commitment and action. Recent schemes like Swachh Bharat and Ayushman Bharat set the foundation, but successful implementation is vital.
For effective planning and delivery, a statutory legislative framework is of utmost importance, and this has been explored in the fifth part.
As India aspires to global prominence and Vishwaguru status, its healthcare performance and safeguarding of people’s well-being need stronger alignment with the nation’s fiscal and economic development priorities. Ensuring access to affordable, quality public healthcare services for all citizens must be the government’s principal focus in this budget and in its longer term fiscal developmental roadmap.
[Deepanshu Mohan is Professor of Economics and Director, Centre for New Economics Studies (CNES), Jindal School of Liberal Arts and Humanities, O.P Jindal Global University. He is currently a Research Fellow with Birkbeck College, University of London. Samragnee Chakraborty and Hima Trisha M are Senior Research Assistants (CNES), and Aditi Desai, Amisha Singh, and Nitya Arora are Research Assistants (CNES). Authors would also like to thank public health experts, Dr Sunil Kaul, co-founder of the ANT, Dr Indranil Mukhopadhyay, Professor at O.P Jindal Global University, and Mr Murari Mohan Goswami, Senior Development Consultant for their continuous support and guidance. This is an opinion article and the views expressed above are the author’s own. The Quint neither endorses nor is responsible for them.]
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