Infrastructure deficits and a lack of awareness about available healthcare benefits remain significant obstacles to achieving universal health coverage in India
This essay is part of the series titled: World Health Day 2024: My Health, My Right
As World Health Day 2024 casts a spotlight on the range of global healthcare challenges and triumphs, India stands at a defining moment in its healthcare journey. The healthcare narrative in India is one of contrast and complexity. Ensuring equitable access to health services in such a context is a multilayered challenge and a critical lever for driving sustainable development and fostering social cohesion. India’s multi-sectoral efforts over the last decade to improve the health of its citizens, within the overarching Social Determinants of Health(SDOH) framework, have been gaining attention.
Two-thirds of public sector hospital beds in India are concentrated in urban areas, supporting only one-third of the population. The private sector is even more embedded in urban areas because private infrastructure tends to be drawn to areas with greater financial resources. However, the catchment areas for many urban hospitals are vast, ranging from nearby districts, and states to even nearby countries. These patients often come for conditions that could have been addressed earlier if there were functional primary healthcare infrastructure in rural areas. Thankfully, this is an issue India is focusing on now, through the National Health Mission (NHM) and Ayushman Bharat Health and Wellness Centres (AB-HWC), renamed Ayushman Arogya Mandirs recently.
The private sector is even more embedded in urban areas because private infrastructure tends to be drawn to areas with greater financial resources.
Moreover, the rural healthcare landscape, often overshadowed by the historical focus on urban centres, faces its own set of challenges. With limited access to healthcare facilities, a shortage of medical professionals due to unwillingness and lack of incentives to shift there, and inadequate infrastructure, rural India's healthcare system struggles to meet the needs of its population. Thus, many of the urban healthcare sector challenges are spillover challenges from the rural healthcare sector.
With a comparatively low tax-GDP ratio, and health mostly being a state subject, any dramatic change in the sector will be impossible unless there is tremendous political will, as seen in the case of drinking water, sanitation, and housing, among others. Within the health sector, operating under limited resources, we have seen major progress too, be it the coverage by Jan Aushadhi (PMBJP), or the implementation of Ayushman Bharat. Under the NHM, around 10,000 doctors were available in sub-divisional hospitals in 2014, and the number improved to close to 19,000 in 2022. Around 18,500 doctors were available in district hospitals in 2014, and the number improved to close to 30,000 in 2022. These numbers are improving further. Public infrastructure is being created in medical education in a major way, and the system will start reaping its dividends soon.
At the heart of India's healthcare reform efforts lies Ayushman Bharat, a programme that embodies the government's ambition to transform the healthcare landscape. Its foundational pillars—Pradhan Mantri Jan Arogya Yojana (PM-JAY) for hospitalisation coverage, the establishment of HWCs for primary care, the Ayushman Bharat Digital Mission to leverage technology in healthcare, and the Pradhan Mantri—Ayushman Bharat Health Infrastructure Mission (PM-ABHIM) to enhance healthcare infrastructure—collectively seek to address the multifaceted challenges of the Indian healthcare system. However, despite a solid foundation and a tech backbone for the universal health coverage (UHC) push being prepared over the last decade, we have yet to see focused, additional resources being ploughed into the sector like in other sectors like sanitation, drinking water, and housing.
With Ayushman Bharat also strengthening comprehensive primary healthcare delivery through HWCs, things are bound to improve.
Significantly, hundreds of millions of Indian households now have 5 lakhs rupees per year to be spent on healthcare, at a facility of their choice. There has been a dramatic reduction over the last decade in out-of-pocket spending on health; the most reliable indicator of progress from the Indian health system point of view. Ayushman Bharat PMJAY could potentially help bring in quality private sector in many of our smaller cities and towns. In parallel, new AIIMS are being created with 18,000 public sector beds of which some 6,000 are already in place across India along with bed capacity expansion in government medical colleges. With Ayushman Bharat also strengthening comprehensive primary healthcare delivery through HWCs, things are bound to improve.
Despite the progress heralded by Ayushman Bharat, India's healthcare system continues to grapple with formidable challenges. Infrastructure deficits and a lack of awareness about available healthcare benefits remain significant obstacles to achieving UHC. The disparity in the distribution of healthcare personnel and facilities, particularly between urban and rural areas, exacerbates these challenges.
More than half of PMJAY claims came from South India, with just 20 percent of the population. Unfortunately, many eligible people in the most needy regions in India don't know yet that they have access to 5 lakh rupees for their healthcare needs—a substantial sum often much higher than their annual income. We need to build awareness on a war footing while bringing in focused investments. National Health Accounts have shown out-of-pocket spending coming down tremendously. Schemes like PMBJP have expanded at a rapid pace, with 80 centres in 2015 becoming almost 11,000 now, helping bring down everyday health expenses for millions of households. The Ayushman Bharat Health and Wellness Centres and the new Community Health Officers cadre will also have a major impact on outpatient spending. More funding and more awareness of the schemes could accelerate benefits.
The Ayushman Bharat Health and Wellness Centres and the new Community Health Officers cadre will also have a major impact on outpatient spending.
Looking forward, the ambition to increase the health budget to 2.5 percent of GDP signals a recognition of the need for sustained and substantial investment in healthcare. Such investment is crucial for expanding infrastructure, improving the quality of care, and making healthcare more accessible to all segments of the Indian population. India is going through a demographic transition, and challenges are bound to get more complex.
The most important development in the last decade has been sustained political visibility for health as a major policy issue. This is irreversible, and it will take India to UHC faster. The Opposition parties also see how health has helped the NDA in the past, and “Right to Health” figured prominently in the Congress election manifesto last time. This electoral competition is good for the development of a sustainable, resilient health system in India.
Apart from what was discussed earlier, health grants to the states from the 15th Finance commission are currently building more than 200 hundred-bedded hospitals and more than 150 fifty-bedded hospitals across the country, something unprecedented in the recent past. However, given India’s low baseline, a focused inflow of capital expenditure like in drinking water, sanitation, and housing sectors is needed to make amends for the historical neglect of the health sector. The enhanced allocations over the last decade to the drinking water, sanitation, and housing sectors were not predicted by anyone. According to experts, these efforts are bound to have a tremendous impact on the disease burden in the country, and their externalities have primed the health sector for a major infrastructure push towards UHC, with very high electoral dividends. It is finally the health sector’s turn.
Oommen C. Kurian is a Senior Fellow and the Head of Health Initiative at the Observer Research Foundation
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Oommen C. Kurian is Senior Fellow and Head of Health Initiative at ORF. He studies Indias health sector reforms within the broad context of the ...
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