Weak public healthcare could let India’s development drive down

Equal access to healthcare is a key component of an equitable social set-up.
Equal access to healthcare is a key component of an equitable social set-up.


  • What glares out of India’s 2022-23 household consumption survey done by the NSSO is a gross disparity in medical expenses. Ayushman Bharat will not suffice. We need quality public health services for all.

No survey of household expenses in a country as large and diverse as India can claim much accuracy beyond a point, but such studies offer us much to mull over all the same. Even a hazy X-ray, after all, can tell us what’s crucial. Down the decades, India’s long-cycle check has been the Household Consumption Expenditure Survey (HCES), conducted by the National Sample Survey Office. 

Although it was marred by a controversy over a whole set of field-work being binned and this scanner of multitudes being tweaked, the results of its 2022-23 round do offer us some points to ponder. The biggest of these is India’s dispiriting disparity between haves and have-nots, with unequal money spent on healthcare glaring out. 

In rural India, our monthly medical spend per head was found to be just above 89 for hospitalization and about 180 for other health needs, with urban estimates of 123 and 258 not much higher. This is not a sign of us being a very healthy lot with a paltry medical-expense burden. That we know of hospital bills thousands of times larger only points to how easily averages can mislead us. 

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Look closer: HCES data split up into equal slabs will show that the top 5% spend more than 100 times the lowest 5% on hospital care. If we took finer fractiles—such as percentiles, to compare the richest 1% with the poorest—then the difference would be even more stark. While huge gaps are also visible on a few other counts, such as rent, the medical contrast is one that should make us squirm the most. In a way, it’s at the core of our inequality, as covid reminded us.

Equal access to healthcare is a key component of an equitable social set-up and our failure on this front is rivalled only by the dismal state of our public education. For even basic health services, those of us who struggle to make ends meet also find we must turn to the private sector. 

Most bills are paid out of our pockets, and although bill backstops are available, what we have by way of a state-run apparatus to keep us healthy is an apology of a system. As proof, think of public figures openly opting for pricey private alternatives, a preference that invites no scandal because even hard-up voters understand it. Thankfully, medicines are mostly cheap in India, but private services are not, with the result that getting well is costly for most people. 

As healthcare gets dearer by the day, at least partly in response to demand, this unfair state of affairs needs to end. In the interim, a stop-gap solution has taken hold of Indian policy circles. Over the past decade or so, the Centre has focused on casting a wider net of insurance coverage. 

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Its Ayushman Bharat scheme has been hailed as an answer to uneven access to healthcare. In stacking up numbers, it has been a roaring success; 345.6 million cards have been issued so far, with almost 30,000 hospitals empanelled, as its official dashboard shows, while over 1.7 million admissions were okayed over the past 30 days. 

The state offering to pick up bills, however, involves the rigmarole of eligibility and treatment checks. It cannot compare with a system of universal care that serves everyone’s health needs at high quality with no hoops to leap across, as seen in equality-oriented welfare states across the world.

As the government spends heavily on business-boosting infrastructure, it must not lose sight of glaring gaps that could make its Viksit Bharat ambition of a developed India by 2047 look illusory. We need a massive upgrade of public healthcare. And we must start now.

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