| UPSC Relevance Prelims: PMJAY, SHIPs, Bhore Committee (1946), National Health Policy 2017. India’s health expenditure = 1.3% of GDP (2022). Mains (GS-II / GS-III):Issues of Public Health & Governance: Essay Topics:“Health insurance cannot substitute for public health care.”“Universal Health Care is a right, not a privilege.” |
Why in News
India has witnessed a sharp expansion of State-sponsored health insurance programmes in the last decade, particularly under Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (PMJAY). However, concerns are mounting that this insurance-driven model may not deliver Universal Health Care (UHC), and instead deepen inequalities in India’s health-care system.
Background;What is Universal Health Care (UHC)?
According to the Bhore Committee Report (1946), a minimal definition of UHC is that “quality health care should be guaranteed to all members of the community irrespective of their ability to pay.”
What is Health Insurance?
Health insurance is a financial mechanism where a premium or state subsidy enables access to medical services, covering hospitalisation and treatment costs either fully or partly. In India, most government schemes cover in-patient hospitalisation only.
India’s Health Insurance Expansion
- PMJAY (2018): Covers 58.8 crore individuals, budget ₹12,000 crore (2023-24).
- State Health Insurance Programmes (SHIPs): Cover similar numbers, budget ₹16,000 crore.
- Total: Approx. ₹28,000 crore annually, growing 8–25% yearly in many States.
- Coverage: Together, PMJAY and SHIPs claim to cover around 80% of India’s population.
Key Faultlines in India’s Insurance Model
1. Profit-Driven Medicine
- About two-thirds of PMJAY spending goes to private hospitals.
- These hospitals often push unnecessary tests/procedures to earn more, but patient outcomes don’t always improve.
- Weak regulation allows overcharging and exploitation.
2. Bias Towards Hospitalisation
- Insurance mostly covers in-patient (hospital) care, not primary care or prevention.
- As India’s population ages, costly hospital treatments will drain most funds, leaving little for early-stage care.
3. Low Utilisation Despite High Coverage
- Nearly 80% of Indians are insured, but only 35% of hospital patients actually use insurance (HCE Survey 2022-23).
- Reasons:
- People don’t know how to use it.
- Hospitals discourage insurance (due to low payouts).
- Complicated claim procedures.
4. Discrimination Between Patients
- Private hospitals prefer uninsured patients (they pay more directly).
- Public hospitals prefer insured patients (they get reimbursements).
- This leads to unequal treatment and worsens inequity.
5. Provider Complaints & Withdrawal
- The government owes hospitals ₹12,161 crore in pending dues — more than the annual PMJAY budget.
- As a result, 609 hospitals have exited PMJAY, reducing service availability.
6. Corruption and Fraud
- 3,200 hospitals flagged by NHA for fraud.
- Common tricks:
- Denying treatment despite insurance.
- Charging insured patients extra.
- Doing unnecessary surgeries to claim money.
- Poor auditing and lack of transparency erode public trust.
Structural Issues Behind the Crisis
- Underfunded Public Health: Public health expenditure is 1.3% of GDP (2022, World Bank) vs global average of 6.1%.
- Over-reliance on Private Sector: India’s system is profit-driven, unlike many welfare-based models.
- Weak Regulation: No strong monitoring of private hospitals under PMJAY/SHIPs.
Global Comparisons
- Canada: Universal public-funded system, non-profit orientation, robust primary care.
- Thailand: Social health insurance with universal coverage, strong government role.
- Europe: Public health is the foundation; insurance supplements, not replaces, public facilities.
- India: Insurance-driven without universal access, weak public infrastructure.
Constitutional & Governance provision
- Article 21 – Right to life includes right to health (judicially recognized).
- Directive Principles (Art. 38, 39, 41, 47) – State must ensure public health.
- Challenges: Health is a State subject, leading to fragmented policies.
Way Forward
1. Strengthen Public Health Infrastructure
- Raise health spending to 2.5% of GDP (as promised in National Health Policy, 2017).
- Invest in primary health care, diagnostics, and outpatient services, not just hospitals.
2. Reform Health Insurance
- Expand insurance to cover outpatient care and prevention, not only hospitalisation.
- Ensure timely reimbursements so hospitals don’t withdraw.
- Introduce strict regulation and transparent audits to check fraud and overcharging.
3. Promote Equity in Care
- Guarantee universal coverage without discrimination between insured/uninsured patients.
- Special focus on poor and marginalised groups who face the biggest barriers.
4. Public Awareness & Health Literacy
- Run campaigns to educate people about how to use insurance and their patient rights.
5. Long-Term Strategy
- Move from an insurance-centred model to a public health-centred Universal Health Coverage (UHC) system.
- Learn from Thailand (low-cost universal care) and Canada (non-profit delivery model) for sustainable, equitable systems.
Conclusion
Health insurance in India, while offering short-term relief, is not a pathway to Universal Health Care. Instead, it risks creating a profit-oriented, inequitable system that neglects preventive and primary care. True UHC will require transforming India’s public health sector, increasing investment, ensuring regulation, and embedding equity and dignity in health care delivery.
Insurance can be a supplement — but not the foundation — of UHC in India.
UPSC Mains Practice Question
Question:
Health insurance coverage in India has expanded significantly in recent years through government schemes, private sector participation, and digital innovations. However, gaps in affordability, accessibility, and quality of care persist.Critically examine the rise of health insurance in India and discuss whether it can realistically deliver Universal Health Care (UHC). Suggest policy measures to address existing challenges.( 250 words, 15 marks)
SOURCE- THE HINDU
Found this helpful?
Bookmark for revision, Practice the mains question, and
Share with fellow aspirants! THANK YOU