India
India, officially the Republic of India (Hindi: ), is a country in South Asia. It is the seventh-largest country by area, the second-most populous country, and the most populous democracy in the world. Bounded by the Indian Ocean on the so ...
has a
multi-payer universal health care model that is paid for by a combination of public and private health insurance funds along with the element of almost entirely tax-funded public hospitals.
The public hospital system is essentially free for all Indian residents except for small, often symbolic co-payments in some services. At the federal level, a national publicly funded health insurance program was launched in 2018 by the Government of India, called
Ayushman Bharat
Ayushman Bharat Pradhan Mantri Jan Arogya Yojana ( or PM-JAY'';'' also referred to as Ayushman Bharat National Health Protection Scheme or NHPS) is a national public health insurance fund of the Government of India that aims to provide free acc ...
. This aimed to cover the bottom 50% (500 million people) of the country's population working in the
unorganized sector (enterprises having less than 10 employees) and offers them free treatment at both public and private hospitals.
For people working in the organized sector (enterprises with more than 10 employees) and earning a monthly salary of up to ₹21,000 are covered by the social insurance scheme of
Employees' State Insurance which entirely funds their healthcare (along with unemployment benefits), both in public and private hospitals. People earning more than that amount are provided health insurance coverage by their employers through either one of the four main public health insurance funds which are the
National Insurance Company
National Insurance Company Limited (NICL) is a central public sector undertaking under the ownership of Ministry of Finance, Government of India. It is headquartered at Kolkata and was established in 1906 by Gordhandas Dutia and Jeevan Das Dut ...
,
The Oriental Insurance Company
The Oriental Insurance Company Ltd. is a central public sector undertaking under the ownership of Ministry of Finance, Government of India. The headquarters is present in New Delhi. It has 29 regional offices and more than 1500 active branches ...
,
United India Insurance Company
United India Insurance Company is a central public sector undertaking under the ownership of Ministry of Finance, & Government of India. Its headquarters is located in Chennai, India, and was incorporated on 18 February 1938. The company was ...
and
New India Assurance
The New India Assurance Co. Ltd., is a central public sector undertaking under the ownership of Ministry of Finance, Government of India. It is based in Mumbai, Maharashtra. "It is the largest nationalised general insurance company of India ...
or a private insurance provider. All employers in India are legally mandated to provide health insurance coverage to their employees and dependents as part of
Social Security in India.
As of 2020, 300 million Indians are covered by insurance bought from one of the public or private insurance companies by their employers as group or individual plans. Indian nationals and foreigners who work in the public sector are eligible for a comprehensive package of benefits including, both public and private health, preventive, diagnostic, and curative services and pharmaceuticals with very few exclusions and no cost sharing. Most services including state of the art cardio-vascular procedures, organ transplants, and cancer treatments (including bone marrow transplants) are covered. Employers are responsible for paying for an extensive package of services for private sector expatriates (through one of the public or private funds) unless they are eligible for the
Employees' State Insurance. Unemployed people without coverage are covered by the various state funding schemes for emergency hospitalization if they do not have the means to pay for it.
In 2019, the total net government spending on healthcare was $36 billion or 1.23% of its GDP. India had allocated 1.8% of its GDP to health in 2020–21. Since the country's independence, the public hospital system has been entirely funded through general taxation.
The National Health Policy was endorsed by the
Parliament of India
The Parliament of India ( IAST: ) is the supreme legislative body of the Republic of India. It is a bicameral legislature composed of the president of India and two houses: the Rajya Sabha (Council of States) and the Lok Sabha (House of the ...
in 1983 and updated in 2002, and then again updated in 2017. The recent four main updates in 2017 mentions the need to focus on the growing burden of non-communicable diseases, on the emergence of the robust
healthcare industry, on growing incidences of unsustainable expenditure due to health care costs and on rising economic growth enabling enhanced fiscal capacity.
In practice however, the private healthcare sector is responsible for the majority of healthcare in India, and a lot of healthcare expenses are paid directly out of pocket by patients and their families, rather than through health insurance due to incomplete coverage.
Government health policy has thus far largely encouraged private-sector expansion in conjunction with well designed but limited public health programmes.
According to the National Health Accounts report, the total expenditure on health care as a proportion of GDP in 2018 was 3.2%. Out of 3.2%, the governmental health expenditure as a proportion of GDP is just 2%, and the out-of-pocket expenditure as a proportion of the current health expenditure was 42.06% in 2019 while expenditure of the government and health insurance funds increased to 57%.
Attracting 45 percent of
health tourists visiting India and 30 to 40 percent of domestic health tourists,
Chennai
Chennai (, ), formerly known as Madras ( the official name until 1996), is the capital city of Tamil Nadu, the southernmost Indian state. The largest city of the state in area and population, Chennai is located on the Coromandel Coast of th ...
is termed "India's health capital". The Human Rights Measurement Initiative finds that India is doing 80.5% of what should be possible at its level of income for the right to health.
History
Healthcare system
Public healthcare
Public healthcare
Publicly funded healthcare is a form of health care financing designed to meet the cost of all or most healthcare needs from a publicly managed fund. Usually this is under some form of democratic accountability, the right of access to which are ...
is free for every Indian resident.
The Indian public health sector encompasses 18% of total
outpatient care
Ambulatory care or outpatient care is medical care provided on an outpatient basis, including diagnosis, observation, consultation, treatment, intervention, and rehabilitation services. This care can include advanced medical technology and proce ...
and 44% of total
inpatient care
Inpatient care is the care of patients whose condition requires admission to a hospital. Progress in modern medicine and the advent of comprehensive out-patient clinics ensure that patients are only admitted to a hospital when they are extreme ...
.
Middle and upper class individuals living in India tend to use public healthcare less than those with a lower standard of living.
Additionally, women and the elderly are more likely to use public services.
The public health care system was originally developed in order to provide a means to healthcare access regardless of socioeconomic status or caste.
However, reliance on public and private healthcare sectors varies significantly between states. Several reasons are cited for relying on the private rather than public sector; the main reason at the national level is poor quality of care in the public sector, with more than 57% of households pointing to this as the reason for a preference for private health care.
Much of the public healthcare sector caters to the rural areas, and the poor quality arises from the reluctance of experienced healthcare providers to visit the rural areas. Consequently, the majority of the public healthcare system catering to the rural and remote areas relies on inexperienced and unmotivated interns who are mandated to spend time in public healthcare clinics as part of their curricular requirement. Other major reasons are long distances between public hospitals and residential areas, long wait times, and inconvenient hours of operation.
![Osmania General Hospital Hyderabad](https://upload.wikimedia.org/wikipedia/commons/3/35/Osmania_General_Hospital_Hyderabad.JPG)
Different factors related to public healthcare are divided between the state and national government systems in terms of making decisions, as the national government addresses broadly applicable healthcare issues such as overall family welfare and prevention of major diseases, while the state governments handle aspects such as local hospitals, public health, promotion and sanitation, which differ from state to state based on the particular communities involved.
Interaction between the state and national governments does occur for healthcare issues that require larger scale resources or present a concern to the country as a whole.
Considering the goal of obtaining
universal health care
Universal health care (also called universal health coverage, universal coverage, or universal care) is a health care system in which all residents of a particular country or region are assured access to health care. It is generally organized ar ...
as part of
Sustainable Development Goals, scholars request policy makers to acknowledge the form of healthcare that many are using. Scholars state that the government has a responsibility to provide health services that are affordable, adequate, new and acceptable for its citizens.
Public healthcare is very necessary, especially when considering the costs incurred with private services. Many citizens rely on
subsidized healthcare.
The national budget, scholars argue, must allocate money to the public healthcare system to ensure the poor are not left with the stress of meeting private sector payments.
Following the
2014 election which brought Prime Minister
Narendra Modi
Narendra Damodardas Modi (; born 17 September 1950) is an Indian politician serving as the 14th and current Prime Minister of India since 2014. Modi was the Chief Minister of Gujarat from 2001 to 2014 and is the Member of Parliament fro ...
to office, the government unveiled plans for a nationwide
universal health care
Universal health care (also called universal health coverage, universal coverage, or universal care) is a health care system in which all residents of a particular country or region are assured access to health care. It is generally organized ar ...
system known as the
National Health Assurance Mission
National may refer to:
Common uses
* Nation or country
** Nationality – a ''national'' is a person who is subject to a nation, regardless of whether the person has full rights as a citizen
Places in the United States
* National, Maryland, c ...
, which would provide all citizens with free drugs, diagnostic treatments, and insurance for serious ailments. In 2015, implementation of a universal health care system was delayed due to budgetary concerns. In April 2018 the government announced the
Aayushman Bharat scheme that aims to cover up to Rs. 5 lakh to 100,000,000 vulnerable families (approximately 500,000,000 persons – 40% of the country's population). This will cost around $1.7 billion each year. Provision would be partly through private providers.
Private healthcare
![Hinduja Hospital, Mahim, Mumbai](https://upload.wikimedia.org/wikipedia/commons/0/0c/Hinduja_Hospital%2C_Mahim%2C_Mumbai.jpg)
Since 2005, most of the healthcare capacity added has been in the private sector, or in partnership with the private sector. The private sector consists of 58% of the hospitals in the country, 29% of beds in hospitals, and 81% of doctors.
![Max Building](https://upload.wikimedia.org/wikipedia/commons/6/6b/Max_Building.jpg)
According to National Family Health Survey-3, the private medical sector remains the primary source of health care for 70% of households in
urban area
An urban area, built-up area or urban agglomeration is a human settlement with a high population density and infrastructure of built environment. Urban areas are created through urbanization and are categorized by urban morphology as cities ...
s and 63% of households in rural areas.
The study conducted by IMS Institute for Healthcare Informatics in 2013, across 12 states in over 14,000 households indicated a steady increase in the usage of private healthcare facilities over the last 25 years for both Out-Patient and In-Patient services, across rural and urban areas. In terms of healthcare quality in the private sector, a 2012 study by Sanjay Basu et al., published in ''
PLOS Medicine
''PLOS Medicine'' (formerly styled ''PLoS Medicine'') is a peer-reviewed weekly medical journal covering the full spectrum of the medical sciences. It began operation on October 19, 2004, as the second journal of the Public Library of Science (PLO ...
'', indicated that health care providers in the private sector were more likely to spend a longer duration with their patients and conduct physical exams as a part of the visit compared to those working in public healthcare.
However, the high out of pocket cost from the private healthcare sector has led many households to incur Catastrophic Health Expenditure, which can be defined as health expenditure that threatens a household's capacity to maintain a basic standard of living.
Costs of the private sector are only increasing.
One study found that over 35% of poor Indian households incur such expenditure and this reflects the detrimental state in which Indian health care system is at the moment.
With government expenditure on health as a percentage of GDP falling over the years and the rise of private health care sector, the poor are left with fewer options than before to access health care services.
Private insurance is available in India, as are various through government-sponsored health insurance schemes. According to the
World Bank
The World Bank is an international financial institution that provides loans and grants to the governments of low- and middle-income countries for the purpose of pursuing capital projects. The World Bank is the collective name for the Inte ...
, about 25% of India's population had some form of health insurance in 2010.
A 2014 Indian government study found this to be an over-estimate, and claimed that only about 17% of India's population was insured.
Private healthcare providers in India typically offer high quality treatment at unreasonable costs as there is no regulatory authority or statutory neutral body to check for medical malpractices. In
Rajasthan
Rajasthan (; lit. 'Land of Kings') is a state in northern India. It covers or 10.4 per cent of India's total geographical area. It is the largest Indian state by area and the seventh largest by population. It is on India's northwestern s ...
, 40% of practitioners did not have a medical degree and 20% have not completed a
secondary education
Secondary education or post-primary education covers two phases on the International Standard Classification of Education scale. Level 2 or lower secondary education (less commonly junior secondary education) is considered the second and final pha ...
.
On 27 May 2012, the popular show
Satyamev Jayate
Satyameva Jayate (, ) is a part of a ''mantra'' from the Hindu scripture '' Mundaka Upanishad''. Following the independence of India, it was adopted as the national motto of India on 26 January 1950, the day India became a republic.
It is inscr ...
did an episode on "Does Healthcare Need Healing?" which highlighted the high costs and other malpractices adopted by private clinics and hospitals.
Medication
In 1970, the Indian government banned medical patents. India signed the 1995
TRIPS Agreement
The Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) is an international legal agreement between all the member nations of the World Trade Organization (WTO). It establishes minimum standards for the regulation by nat ...
which allows medical patents, but establishes the
compulsory license
A compulsory license provides that the owner of a patent or copyright licenses the use of their rights against payment either set by law or determined through some form of adjudication or arbitration. In essence, under a compulsory license, an i ...
, where any pharmaceutical company has the right to produce any patented product by paying a fee. This right was used in 2012, when Natco was allowed to produce Nexavar, a cancer drug. In 2005, new legislation stipulated that a medicine could not be patented if it did not result in "the enhancement of the known efficacy of that substance".
Indians consumed the most antibiotics per head in the world in 2010. Many antibiotics were on sale in 2018 which had not been approved in India or in the country of origin, although this is prohibited. A survey in 2017 found 3.16% of the medicines sampled were substandard and 0.0245% were fake. Those more commonly prescribed are probably more often faked. Some medications are listed on Schedule H1, which means they should not be sold without a prescription. Pharmacists should keep records of sales with the prescribing doctor and the patient's details.
Mental healthcare
Access to healthcare
As of 2013, the number of trained medical practitioners in the country was as high as 1.4 million, including 0.7 million graduate allopaths.
Yet, India has failed to reach its
Millennium Development Goals
The Millennium Development Goals (MDGs) were eight international development goals for the year 2015 that had been established following the Millennium Summit of the United Nations in 2000, following the adoption of the United Nations Millenn ...
related to health.
The definition of 'access is the ability to receive services of a certain quality at a specific cost and convenience.
The
healthcare system of India is lacking in three factors related to access to healthcare: provision,
utilization, and attainment.
Provision, or the supply of healthcare facilities, can lead to utilization, and finally attainment of good health. However, there currently exists a huge gap between these factors, leading to a collapsed system with insufficient access to healthcare.
Differential distributions of services, power, and resources have resulted in inequalities in healthcare access.
Access and entry into hospitals depends on gender,
socioeconomic status, education, wealth, and location of residence (urban versus rural).
Furthermore, inequalities in financing healthcare and distance from healthcare facilities are barriers to access.
Additionally, there is a lack of sufficient
infrastructure in areas with high concentrations of poor individuals.
Large numbers of
tribe
The term tribe is used in many different contexts to refer to a category of human social group. The predominant worldwide usage of the term in English is in the discipline of anthropology. This definition is contested, in part due to confli ...
s and ex-
untouchables that live in isolated and dispersed areas often have low numbers of professionals.
Finally, health services may have long wait times or consider ailments as not serious enough to treat.
Those with the greatest need often do not have access to healthcare.
Electronic health records
The Government of India, while unveiling the National Health Portal, has come out with guidelines for
Electronic health record standards in India. The document recommends a set of standards to be followed by different healthcare service providers in India, so that medical data becomes portable and easily transferable.
India is considering to set up a National eHealth Authority (NeHA) for standardisation, storage and exchange of electronic health records of patients as part of the government's
Digital India
Digital India is a campaign launched by the Government of India in order to ensure that the Government's services are made available to citizens electronically by improved online infrastructure and by increasing Internet connectivity or making ...
programme. The authority, to be set up by an Act of Parliament will work on the integration of multiple health IT systems in a way that ensures security, confidentiality and privacy of patient data. A centralised electronic health record repository of all citizens which is the ultimate goal of the authority will ensure that the health history and status of all patients would always be available to all health institutions. Union Health Ministry has circulated a concept note for the setting up of NeHa, inviting comments from stakeholders.
Rural areas
Rural areas in India have a shortage of medical professionals.
74% of doctors are in urban areas that serve the other 28% of the population.
This is a major issue for rural access to healthcare. The lack of human resources causes citizens to resort to fraudulent or ignorant providers.
Doctors tend not to work in rural areas due to insufficient housing, healthcare, education for children, drinking water, electricity, roads and transportation.
Additionally, there exists a shortage of
infrastructure for health services in rural areas.
In fact, urban public hospitals have twice as many beds as rural hospitals, which are lacking in supplies.
Studies have indicated that the mortality risks before the age of five are greater for children living in certain rural areas compared to urban communities.
Full
immunization
Immunization, or immunisation, is the process by which an individual's immune system becomes fortified against an infectious agent (known as the immunogen).
When this system is exposed to molecules that are foreign to the body, called ''non-se ...
coverage also varies between rural and urban India, with 39% completely immunized in rural communities and 58% in urban areas across India.
Inequalities in healthcare can result from factors such as socioeconomic status and
caste, with caste serving as a social determinant of healthcare in India.
Case study in Rural India
A 2007 study by Vilas Kovai et al., published in the ''
Indian Journal of Ophthalmology
The ''Indian Journal of Ophthalmology'' is a peer-reviewed open-access medical journal published on behalf of the All India Ophthalmological Society. The journal publishes articles on ophthalmology and vision science.
Abstracting and indexing
T ...
'' analyzed barriers that prevent people from seeking eye care in rural
Andhra Pradesh, India
Andhra Pradesh (, abbr. AP) is a States and union territories of India, state in the south-eastern Coastal India, coastal region of India. It is the List of states and union territories of India by area, seventh-largest state by area covering ...
.
The results displayed that in cases where people had awareness of eyesight issues over the past five years but did not seek treatment, 52% of the respondents had personal reasons (some due to own beliefs about the minimal extent of issues with their vision), 37% economic hardship, and 21% social factors (such as other familial commitments or lacking an accompaniment to the healthcare facility).
The role of technology, specifically mobile phones in health care has also been explored in recent research as India has the second largest wireless communication base in the world, thus providing a potential window for mobile phones to serve in delivering health care.
Specifically, in one 2014 study conducted by Sherwin DeSouza et al. in a rural village near
Karnataka
Karnataka (; ISO: , , also known as Karunāḍu) is a state in the southwestern region of India. It was formed on 1 November 1956, with the passage of the States Reorganisation Act. Originally known as Mysore State , it was renamed ''Karnat ...
, India, it was found that participants in community who owned a mobile phone (87%) displayed a high interest rate (99%) in receiving healthcare information through this mode, with a greater preference for voice calls versus SMS (text) messages for the healthcare communication medium.
Some specific examples of healthcare information that could be provided includes reminders about vaccinations and medications and general health awareness information.
Rural north India
The distribution of healthcare providers varies for rural versus urban areas in North India.
A 2007 study by Ayesha De Costa and Vinod Diwan, published in ''
Health Policy,'' conducted in
Madhya Pradesh
Madhya Pradesh (, ; meaning 'central province') is a state in central India. Its capital is Bhopal, and the largest city is Indore, with Jabalpur, Ujjain, Gwalior, Sagar, and Rewa being the other major cities. Madhya Pradesh is the seco ...
, India examined the distribution of different types of healthcare providers across urban and rural Madhya Pradesh in terms of the differences in access to healthcare through number of providers present.
The results indicated that in rural Madhya Pradesh, there was one physician per 7870 people, while there was one physician per 834 people in the urban areas of the region.
In terms of other healthcare providers, the study found that of the qualified paramedical staff present in Madhya Pradesh, 71% performed work in the rural areas of the region.
In addition, 90% of traditional birth attendants and unqualified healthcare providers in Madhya Pradesh worked in the rural communities.
Studies have also investigated determinants of healthcare-seeking behavior (including socioeconomic status, education level, and gender), and how these contribute to overall access to healthcare accordingly.
A 2016 study by Wameq Raza et al., published in ''BMC Health Services Research,'' specifically surveyed healthcare-seeking behaviors among people in rural
Bihar
Bihar (; ) is a state in eastern India. It is the 2nd largest state by population in 2019, 12th largest by area of , and 14th largest by GDP in 2021. Bihar borders Uttar Pradesh to its west, Nepal to the north, the northern part of West ...
and
Uttar Pradesh
Uttar Pradesh (; , 'Northern Province') is a state in northern India. With over 200 million inhabitants, it is the most populated state in India as well as the most populous country subdivision in the world. It was established in 1950 ...
, India.
The findings of the study displayed some variation according to acute illnesses versus chronic illnesses.
In general, it was found that as socioeconomic status increased, the probability of seeking healthcare increased.
Educational level did not correlate to probability of healthcare-seeking behavior for acute illnesses, however, there was a positive correlation between educational level and chronic illnesses.
This 2016 study also considered the social aspect of gender as a determinant for health-seeking behavior, finding that male children and adult men were more likely to receive treatment for acute ailments compared to their female counterparts in the areas of rural Bihar and Uttar Pradesh represented in the study.
These inequalities in healthcare based on gender access contribute towards the differing mortality rates for boys versus girls, with the mortality rates greater for girls compared to boys, even before the age of five.
Other previous studies have also delved into the influence of gender in terms of access to healthcare in rural areas, finding gender inequalities in access to healthcare.
A 2002 study with data taken from June 1998 to May 1999 was conducted by Aparna Pandey et al., published in the ''Journal of Health, Population, and Nutrition,'' analyzed care-seeking behaviors by families for girls versus boys, given similar sociodemographic characteristics in
West Bengal
West Bengal (, Bengali: ''Poshchim Bongo'', , abbr. WB) is a state in the eastern portion of India. It is situated along the Bay of Bengal, along with a population of over 91 million inhabitants within an area of . West Bengal is the fou ...
, India.
In general, the results exhibited clear gender differences such that boys received treatment from a healthcare facility if needed in 33% of the cases, while girls received treatment in 22% of the instances requiring care.
Furthermore, surveys indicated that the greatest gender inequality in access to healthcare in India occurred in the provinces of
Haryana
Haryana (; ) is an Indian state located in the northern part of the country. It was carved out of the former state of East Punjab on 1 Nov 1966 on a linguistic basis. It is ranked 21st in terms of area, with less than 1.4% () of India's land a ...
, and
Punjab
Punjab (; Punjabi: پنجاب ; ਪੰਜਾਬ ; ; also romanised as ''Panjāb'' or ''Panj-Āb'') is a geopolitical, cultural, and historical region in South Asia, specifically in the northern part of the Indian subcontinent, comprising a ...
.
Urban Areas
The problem of healthcare access arises not only in huge cities but in rapidly growing small urban areas.
Here, there are fewer available options for healthcare services and there are less organized governmental bodies.
Thus, there is often a lack of accountability and cooperation in healthcare departments in urban areas.
It is difficult to pinpoint an establishment responsible for providing urban health services, compared to in rural areas where the responsibility lies with the
district administration.
Additionally, health inequalities arise in urban areas due to difficulties in residence,
socioeconomic
Socioeconomics (also known as social economics) is the social science that studies how economic activity affects and is shaped by social processes. In general it analyzes how modern societies progress, stagnate, or regress because of their l ...
status, and
discrimination against unlisted
slums.
To survive in this environment, urban people use
non-governmental
A non-governmental organization (NGO) or non-governmental organisation (see spelling differences) is an organization that generally is formed independent from government. They are typically nonprofit entities, and many of them are active in ...
, private services which are plentiful.
However, these are often understaffed, require three times the payment as a public center, and commonly have bad practice methods.
To counter this, there have been efforts to join the public and private sectors in urban areas.
An example of this is the
Public-Private Partnerships initiative.
However, studies show that in contrast to rural areas, qualified physicians tend to reside in urban areas.
This can be explained by both
urbanization
Urbanization (or urbanisation) refers to the population shift from rural to urban areas, the corresponding decrease in the proportion of people living in rural areas, and the ways in which societies adapt to this change. It is predominantly t ...
and specialization. Private doctors tend to be specialized in a specific field so they reside in urban areas where there is a higher market and financial ability for those services.
Financing
Despite being one of the most populous countries, India has the most private healthcare in the world.
Out-of-pocket private payments make up 75% of the total expenditure on healthcare.
Only one fifth of healthcare is financed publicly.
This is in stark contrast to most other countries of the world.
According to the
World Health Organization
The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level of ...
in 2007, India ranked 184 out of 191 countries in the amount of public expenditure spent on healthcare out of total
GDP
Gross domestic product (GDP) is a monetary measure of the market value of all the final goods and services produced and sold (not resold) in a specific time period by countries. Due to its complex and subjective nature this measure is ofte ...
.
In fact, public spending stagnated from 0.9% to 1.2% of total GDP in 1990 to 2010.
Medical and non-medical
out-of-pocket
An out-of-pocket expense (or out-of-pocket cost, OOP) is the direct payment of money that may or may not be later reimbursed from a third-party source.
For example, when operating a vehicle, gasoline, parking fees and tolls are considered out-of ...
private payments can affect access to healthcare.
Poorer populations are more affected by this than the wealthy. The poor pay a disproportionately higher percent of their income towards out-of-pocket expenses than the rich.
The Round National Sample Survey of 1955 through 1956 showed that 40% of all people sell or borrow assets to pay for hospitalization.
Half of the bottom two quintiles go into debt or sell their
asset
In financial accounting, an asset is any resource owned or controlled by a business or an economic entity. It is anything (tangible or intangible) that can be used to produce positive economic value. Assets represent value of ownership that can ...
s, but only a third of the top quintiles do.
In fact, about half the households that drop into the lower classes do so because of health expenditures.
This data shows that financial ability plays a role in determining healthcare access.
In terms of non-medical costs, distance can also prevents access to healthcare.
Costs of transportation prevent people from going to health centers.
According to scholars,
outreach programs are necessary to reach marginalized and isolated groups.
In terms of medical costs, out-of-pocket hospitalization fees prevent access to healthcare.
40% of people that are hospitalized are pushed either into lifelong debt or below the
poverty line
The poverty threshold, poverty limit, poverty line or breadline is the minimum level of income deemed adequate in a particular country. The poverty line is usually calculated by estimating the total cost of one year's worth of necessities for t ...
.
Furthermore, over 23% of patients don't have enough money to afford treatment and 63% lack regular access to necessary medications.
Healthcare and treatment costs have inflated 10–12% a year and with more advancements in medicine, costs of treatment will continue to rise.
Finally, the price of medications rise as they are not controlled.
There is a major gap between outreach, finance and access in India. Without outreach, services cannot be spread to distant locations.
Without financial ability, those in distant locations cannot afford to access healthcare.
According to scholars, both of these issues are tied together and are pitfalls of the current healthcare system.
Initiatives to improve access
Government-led
The Twelfth Plan
The government of India has a Twelfth Plan to expand the
National Rural Health Mission
The National Health Mission (NHM) was launched by the government of India in 2005 subsuming the National Rural Health Mission and National Urban Health Mission. It was further extended in March 2018, to continue until March 2020. It is headed b ...
to the entire country, known as the
National Health Mission
The National Health Mission (NHM) was launched by the government of India in 2005 subsuming the National Rural Health Mission and National Urban Health Mission. It was further extended in March 2018, to continue until March 2020. It is headed b ...
.
Community based health insurance can assist in providing services to areas with disadvantaged populations.
Additionally, it can help to emphasize the responsibility of the local government in making resources available.
Furthermore, according to the
Indian Journal of Community Medicine
The ''Indian Journal of Community Medicine'' is a peer-reviewed open-access medical journal published by Medknow Publications on behalf of the Indian Association of Preventive & Social Medicine. The journal publishes articles on family health ca ...
(IJOCM) the government should reform health insurance as well as its reach in India. The journal states that
universal healthcare
Universal health care (also called universal health coverage, universal coverage, or universal care) is a health care system in which all residents of a particular country or region are assured access to health care. It is generally organized ar ...
should slowly yet steadily be expanded to the entire population. Healthcare should be mandatory and no money should be exchanged at appointments.
Finally, both private and public sectors should be involved to ensure all marginalized areas are reached. According to the IJOCM, this will increase access for the poor.
See
Twelfth Five Year Plan (India) The Twelfth Five Year plan for health services in India covering 2012-2017 was formulated based on the recommendation of a High Level Experts Group (HLEG) and other stakeholder consultations. The long-term objective of this strategy is to establish ...
.
National Rural Health Mission
To counteract the issue of a lack of professionals in rural areas, the government of India wants to create a '
cadre
Cadre may refer to:
*Cadre (military), a group of officers or NCOs around whom a unit is formed, or a training staff
*Cadre (politics), a politically controlled appointment to an institution in order to circumvent the state and bring control to th ...
' of rural doctors through governmental organizations.
The
National Rural Health Mission
The National Health Mission (NHM) was launched by the government of India in 2005 subsuming the National Rural Health Mission and National Urban Health Mission. It was further extended in March 2018, to continue until March 2020. It is headed b ...
(NRHM) was launched in April 2005 by the Government of India. The NRHM has outreach strategies for disadvantaged societies in isolated areas.
The goal of the NRHM is to provide effective healthcare to rural people with a focus on 18 states with poor public health indicators and/or weak
infrastructure. NRHM has 18,000 ambulances and a workforce of 900,000 community health volunteers and 178,000 paid staff. The mission proposes creating a course for medical students that is centered around rural healthcare.
Furthermore, NRHM wants to create a compulsory rural service for younger doctors in the hopes that they will remain in rural areas.
However, the NRHM has failings. For example, even with the mission, most construction of health related infrastructure occurs in urban cities.
Many scholars call for a new approach that is local and specialized to each state's rural areas.
Other regional programs such as the Rajiv Aarogyasri Community Health Insurance Scheme in
Andhra Pradesh
Andhra Pradesh (, abbr. AP) is a state in the south-eastern coastal region of India. It is the seventh-largest state by area covering an area of and tenth-most populous state with 49,386,799 inhabitants. It is bordered by Telangana to the ...
, India have also been implemented by state governments to assist rural populations in healthcare accessibility, but the success of these programs (without other supplemental interventions at the health system level) has been limited.
National Urban Health Mission
The National Urban Health Mission as a sub-mission of
National Health Mission
The National Health Mission (NHM) was launched by the government of India in 2005 subsuming the National Rural Health Mission and National Urban Health Mission. It was further extended in March 2018, to continue until March 2020. It is headed b ...
was approved by the cabinet on 1 May 2013.
The National Urban Health Mission (NUHM) works in 779 cities and towns with populations of 50,000 each.
As urban health professionals are often
specialized, current urban healthcare consists of
secondary and
tertiary
Tertiary ( ) is a widely used but obsolete term for the geologic period from 66 million to 2.6 million years ago.
The period began with the demise of the non-avian dinosaurs in the Cretaceous–Paleogene extinction event, at the start ...
, but not
primary care
Primary care is the day-to-day healthcare given by a health care provider. Typically this provider acts as the first contact and principal point of continuing care for patients within a healthcare system, and coordinates other specialist care ...
.
Thus, the mission focuses on expanding primary health services to the urban poor.
The initiative recognizes that urban healthcare is lacking due to
overpopulation
Overpopulation or overabundance is a phenomenon in which a species' population becomes larger than the carrying capacity of its environment. This may be caused by increased birth rates, lowered mortality rates, reduced predation or large scal ...
, exclusion of populations, lack of information on health and economic ability, and unorganized health services.
Thus, NUHM has appointed three tiers that need improvement: Community level (including
outreach programs), Urban Health Center level (including infrastructure and improving existing health systems), and Secondary/Tertiary level (
Public-Private Partnerships).
Furthermore, the initiative aims to have one Urban Public Health Center for each population of 50,000 and aims to fix current facilities and create new ones. It plans for small
municipal governments to take responsibility for planning healthcare facilities that are prioritized towards the urban poor, including unregistered slums and other groups.
Additionally, NUHM aims to improve
sanitation
Sanitation refers to public health conditions related to clean drinking water and treatment and disposal of human excreta and sewage. Preventing human contact with feces is part of sanitation, as is hand washing with soap. Sanitation syste ...
and drinking water, improve
community outreach programs to further access, reduce out-of-pocket expenses for treatment, and initiate monthly health and nutrition days to improve community health.
Pradhan Mantri Jan Arogya Yojana (PM-JAY)
Pradhan Mantri Jan Arogya Yojana (PM-JE) is an initiative to ensure health coverage for the poor and weaker population in India.
This initiative is part of the government's view to ensure that its citizens – particularly poor and weaker groups, have access to healthcare and good quality hospital services without facing financial difficulty.
PM-JAY Provides insurance cover up to Rs 5 lakh per annum to the 100 million families in India for secondary and tertiary hospitalization. For transparency, the government made an online portal (Mera PmJay) to check eligibility for PMJAY.
Health care service includes follow-up care, daycare surgeries, pre and post hospitalization, hospitalization expenses, expense benefits and newborn child/children services. The comprehensive list of services is available on the website.
Public-private partnership
One initiative adapted by governments of many states in India to improve access to healthcare entails a combination of public and private sectors. The
Public-Private Partnership Initiative (PPP) was created in the hopes of reaching the health-related
Millennium Development Goals
The Millennium Development Goals (MDGs) were eight international development goals for the year 2015 that had been established following the Millennium Summit of the United Nations in 2000, following the adoption of the United Nations Millenn ...
.
In terms of prominence, nearly every new state health initiative includes policies that allow for the involvement of private entities or non-governmental organizations.
Major programs
Fair Price Shops aim to reduce the costs of medicines, drugs,
implants,
prosthetics
In medicine, a prosthesis (plural: prostheses; from grc, πρόσθεσις, prósthesis, addition, application, attachment), or a prosthetic implant, is an artificial device that replaces a missing body part, which may be lost through trau ...
, and
orthopedic
Orthopedic surgery or orthopedics ( alternatively spelt orthopaedics), is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal ...
devices. Currently, there is no competition between pharmacies and medical service stores for the sale of drugs.
Thus, the price of drugs is uncontrolled.
The Fair Price program creates a
bidding system
A bidding system in contract bridge is the set of Glossary of contract bridge terms#agreement, agreements and understandings assigned to Glossary of contract bridge terms#call, calls and sequences of calls used by a Glossary of contract bridge te ...
for cheaper prices of medications between drugstores and allows the store with the greatest discount to sell the drug. The program has a minimal cost for the government as fair price shops take the place of drugstores at government hospitals, thus eliminating the need to create new infrastructure for fair price shops.
Furthermore, the drugs are unbranded and must be prescribed by their
generic
Generic or generics may refer to:
In business
* Generic term, a common name used for a range or class of similar things not protected by trademark
* Generic brand, a brand for a product that does not have an associated brand or trademark, other ...
name.
As there is less advertising required for generic brands, fair price shops require minimal payment from the private sector.
Fair Price Shops were introduced in the
West Bengal
West Bengal (, Bengali: ''Poshchim Bongo'', , abbr. WB) is a state in the eastern portion of India. It is situated along the Bay of Bengal, along with a population of over 91 million inhabitants within an area of . West Bengal is the fou ...
in 2012. By the end of the year, there were 93 stores benefiting 85
lakh people. From December 2012 to November 2014, these shops had saved 250
crore citizens.
As doctors prescribe 60% generic drugs, the cost of treatment has been reduced by this program. This is a solution to affordability for health access in West Bengal.
The largest segment of the PPP initiative is the tax-financed program,
Rashtriya Swasthya Bima Yojana
Rashtriya Swasthya Bima Yojana (RSBY, literally "National Health Insurance Programme",) is a government-run health insurance programme for the Indian poor. The scheme aims to provide health insurance coverage to the unrecognised sector workers ...
(RSBY).
The scheme is financed 75% by the central government and 25% by the state government.
This program aims to reduce medical out-of-pocket costs for hospital treatment and visits by reimbursing those that live below the
poverty line
The poverty threshold, poverty limit, poverty line or breadline is the minimum level of income deemed adequate in a particular country. The poverty line is usually calculated by estimating the total cost of one year's worth of necessities for t ...
.
RSBY covers maximum 30,000
rupees in hospital expenses, including
pre-existing condition
In the context of healthcare in the United States, a pre-existing condition is a medical condition that started before a person's health insurance went into effect. Before 2014, some insurance policies would not cover expenses due to pre-existi ...
s for up to five members in a family.
In 2015, it reached 37 million households consisting of 129 million people below the poverty line.
However, a family has to pay 30 rupees to register in the program.
[Borooah, Vani and Mishra, Vinod and Naik, Ajaya and Sabharwal, Nidhi (2015): ''Capturing Benefits from Public Policy Initiatives in India: Inter-Group Differences in Access to and Usage of the Rashtriya Swasthya Bima Yojana Health Insurance Cards.'' Published in: Amity Journal of Economics , Vol. 1, No. 1 (2016): pp. 1–17.] Once deemed eligible, family members receive a yellow card.
However, studies show that in
Maharashtra, those with a lower socioeconomic status tend to not use the service, even if they are eligible.
In the state of
Uttar Pradesh
Uttar Pradesh (; , 'Northern Province') is a state in northern India. With over 200 million inhabitants, it is the most populated state in India as well as the most populous country subdivision in the world. It was established in 1950 ...
, geography and council affect participation in the program. Those in the outskirts of villages tend to use the service less than those who live in the center of villages.
Additionally, studies show household non-medical expenses as increasing due to this program; the probability of incurring out-of-pocket expenses has increased by 23%.
However, RSBY has stopped many from falling into poverty as a result of healthcare.
Furthermore, it has improved opportunities for family members to enter the workforce as they can utilize their income for other needs besides healthcare.
RSBY has been applied in 25 states of India.
Finally, the National Rural Telemedicine Network connects many healthcare institutions together so doctors and physicians can provide their input into diagnosis and consultations.
This reduces the non-medical cost of transportation as patients do not have to travel far to get specific doctor's or specialty's opinions.
However, problems arise in terms of the level of care provided by different networks. While some level of care is provided, telemedical initiatives are unable to provide drugs and diagnostic care, a necessity in rural areas.
Effectiveness
The effectiveness of public-private partnerships in healthcare is hotly disputed. Critics of PPP are concerned of its presentation as a cure-all solution, by which the health infrastructure can be improved.
Proponents of PPP claim that these partnerships take advantage of existing infrastructure in order to provide care for the underprivileged.
The results of the PPP in the states of Maharashtra and West Bengal show that all three of these programs are effective when used in combination with federal health services. They assist in filling the gap between outreach and affordability in India.
However, even with these programs, high
out-of-pocket payments for non-medical expenses are still deterring people from healthcare access.
Thus, scholars state that these programs need to be expanded across India.
A case study of tuberculosis control in rural areas, in which PPP was utilized showed limited effectiveness; while the program was moderately effective, a lack of accountability forced the program to shut down. Similar issues in accountability were seen by the parties involved within other PPP schemes. Facilitators and private practitioners, when asked about PPP, identified lack of state support, in the form of adequate funding, and a lack of coordination, as primary reasons why PPP ventures are unsuccessful.
In the most successful PPP ventures, the World Health Organization found that the most prominent factor, aside from financial support, was ownership of the project by state and local governments.
It was found that programs sponsored by the state governments were more effective in achieving health goals than programs set by national governments.
India has set up a National Telemedicine Taskforce by the Health Ministry of India, in 2005, paved way for the success of various projects like the ICMR-AROGYASREE, NeHA and VRCs. Telemedicine also helps family physicians by giving them easy access to speciality doctors and helping them in close monitoring of patients. Different types of telemedicine services like store and forward, real-time and remote or self-monitoring provides various educational, healthcare delivery and management, disease screening and disaster management services all over the globe. Even though telemedicine cannot be a solution to all the problems, it can surely help decrease the burden of the healthcare system to a large extent.
Quality of healthcare
![Hospital](https://upload.wikimedia.org/wikipedia/commons/0/0a/Hospital_.jpg)
Non-availability of diagnostic tools and increasing reluctance of qualified and experienced healthcare professionals to practice in rural, under-equipped and financially less lucrative rural areas are becoming big challenges.
Rural medical practitioners are highly sought after by residents of rural areas as they are more financially affordable and geographically accessible than practitioners working in the formal public health care sector. But there are incidents where doctors were attacked and even killed in rural India.
In 2015 the
British Medical Journal published a report by Dr Gadre, from
Kolkata
Kolkata (, or , ; also known as Calcutta , the official name until 2001) is the capital of the Indian state of West Bengal, on the eastern bank of the Hooghly River west of the border with Bangladesh. It is the primary business, comme ...
, exposed the extent of malpractice in the Indian healthcare system. He interviewed 78 doctors and found that kickbacks for referrals, irrational drug prescribing and unnecessary interventions were commonplace.
According to a study conducted by Martin Patrick, CPPR chief economist released in 2017 has projected people depend more on private sector for healthcare and the amount spent by a household to avail of private services is almost 24 times more than what is spent for public healthcare services.
South India
In many rural communities throughout India, healthcare is provided by what is known as informal providers, who may or may not have proper medical accreditation to diagnose and treat patients, generally offering consults for common ailments.
Specifically, in
Guntur, Andhra Pradesh, India, these informal healthcare providers generally practice in the form of services in the homes of patients and prescribing allopathic drugs.
A 2014 study by Meenakshi Gautham et al., published in the journal ''Health Policy and Planning'', found that in Guntur, about 71% of patients received injections from informal healthcare providers as a part of illness management strategies.
The study also examined the educational background of the informal healthcare providers and found that of those surveyed, 43% had completed 11 or more years of schooling, while 10% had graduated from college.
In general, the perceived quality of healthcare also has implications on patient adherence to treatment.
A 2015 study conducted by Nandakumar Mekoth and Vidya Dalvi, published in ''Hospital Topics'' examined different aspects that contribute to a patient's perception of quality of healthcare in
Karnataka
Karnataka (; ISO: , , also known as Karunāḍu) is a state in the southwestern region of India. It was formed on 1 November 1956, with the passage of the States Reorganisation Act. Originally known as Mysore State , it was renamed ''Karnat ...
, India, and how these factors influenced adherence to treatment.
The study incorporated aspects related to quality of healthcare including interactive quality of physicians, base-level expectation about primary health care facilities in the area, and non-medical physical facilities (including drinking water and restroom facilities).
In terms of adherence to treatment, two sub-factors were investigated, persistence of treatment and treatment-supporting adherence (changes in health behaviors that supplement the overall treatment plan).
The findings indicated that the different quality of healthcare factors surveyed all had a direct influence on both sub-factors of adherence to treatment.
Furthermore, the base-level expectation component in quality of healthcare perception, presented the most significant influence on overall adherence to treatment, with the interactive quality of physicians having the least influence on adherence to treatment, of three aspects investigated in this study.
North India
In a particular district of
Uttarakhand
Uttarakhand ( , or ; , ), also known as Uttaranchal ( ; the official name until 2007), is a state in the northern part of India. It is often referred to as the "Devbhumi" (literally 'Land of the Gods') due to its religious significance and ...
, India known as Tehri, the educational background of informal healthcare providers indicated that 94% had completed 11 or more years of schooling, while 43% had graduated from college.
In terms of the mode of care delivered, 99% of the health services provided in Tehri were through the clinic, whereas in Guntur, Andhra Pradesh, 25% of the health care services are delivered through the clinic, while 40% of the care provided is mobile (meaning that healthcare providers move from location to location to see patients), and 35% is a combination of clinic and mobile service.
In general throughout India, the private healthcare sector does not have a standard of care that is present across all facilities, leading to many variations in the quality of care provided.
In particular, a 2011 study by Padma Bhate-Deosthali et al., published in ''
Reproductive Health Matters,'' examined the quality of healthcare particularly in the area of maternal services through different regions in
Maharashtra, India.
The findings indicated that out of 146 maternity hospitals surveyed, 137 of these did not have a qualified midwife, which is crucial for maternity homes as proper care cannot be delivered without midwives in some cases.
In addition, the 2007 study by Ayesha De Costa and Vinod Diwan analyzed the distribution of healthcare providers and systems in Madhya Pradesh, India.
The results indicated that among solo practitioners in the private sector for that region, 62% practiced
allopathic
Allopathic medicine, or allopathy, is an archaic term used to define science-based modern medicine. Citing: ''Gale Encyclopedia of Medicine'' (2008) and ''Mosby's Medical Dictionary'', 8th ed. (2009). There are regional variations in usage of th ...
(Western) medicine, while 38% practiced Indian systems of medicine and traditional systems (including, but not limited to
ayurveda
Ayurveda () is an alternative medicine system with historical roots in the Indian subcontinent. The theory and practice of Ayurveda is pseudoscientific. Ayurveda is heavily practiced in India and Nepal, where around 80% of the population rep ...
, sidhi,
unani
Unani or Yunani medicine (Urdu: ''tibb yūnānī'') is Perso-Arabic traditional medicine as practiced in Muslim culture in South Asia and modern day Central Asia. Unani medicine is pseudoscientific. The Indian Medical Association describes U ...
, and
homeopathy).
In certain areas, there are also gaps in the knowledge of healthcare providers about certain ailments that further contribute towards quality of healthcare delivered when treatments are not fully supported with thorough knowledge about the ailment.
A 2015 study by Manoj Mohanan et al., published in ''JAMA Pediatrics,'' investigate
the knowledge base of a sample of practitioners (80% without formal medical degrees) in Bihar, India, specifically in the context of childhood
diarrhea
Diarrhea, also spelled diarrhoea, is the condition of having at least three loose, liquid, or watery bowel movements each day. It often lasts for a few days and can result in dehydration due to fluid loss. Signs of dehydration often begin w ...
and
pneumonia
Pneumonia is an inflammatory condition of the lung primarily affecting the small air sacs known as alveoli. Symptoms typically include some combination of productive or dry cough, chest pain, fever, and difficulty breathing. The severi ...
treatment.
The findings indicated that in general, a significant number of practitioners missed asking key diagnostic questions regarding symptoms associated with diarrhea and pneumonia, leading to misjudgments and lack of complete information when prescribing treatments.
Among the sample of practitioners studied in rural Bihar, 4% prescribed the correct treatment for the hypothetical diarrhea cases in the study, and 9% gave the correct treatment plan for the hypothetical pneumonia cases presented.
Recent studies have examined the role of educational or training programs for healthcare providers in rural areas of North India as a method to promote higher quality of healthcare, though conclusive results have not yet been attained.
Rankings
According to global healthcare security index 2021 India ranked 66 out of 195 countries with an overall Index score of 42.8 and along with a change of -0.8 from 2019.
According to Health and health systems ranking of countries worldwide in 2021, by health index score India was ranked 111 out of 167 countries.
In the 2016
Global Burden of Disease Study
The Global Burden of Disease Study (GBD) is a comprehensive regional and global research program of disease burden that assesses mortality and disability from major diseases, injuries, and risk factors. GBD is a collaboration of over 3600 research ...
Report, India was ranked 145 out of 197 countries in "healthcare access and quality". India was ranked behind war-torn Yemen, Sudan and North Korea.
See also
*
Health in India
India's population in 2021 as per World Bank is 1.39 billion. Being the world's second-most-populous country and one of its fastest-growing economies, India experiences both challenges and opportunities in context of public health. India is a ...
*
List of government schemes in India
*
Medical tourism in India
*
Swachh Bharat Abhiyan
*
Women's health in India
*
Health insurance in India
References
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