Implementation of equity and access in Indian healthcare: current scenario and way forward
The Indian healthcare system is evolving towards better healthcare implementation and coverage. However, even today, the health-care system faces several challenges, a few of which are yet to be addressed. The present review is aimed to delineate the past and present healthcare scenarios in India, health-care policies, and other initiatives for achieving universal health coverage (UHC). Reimbursement
A literature search was done on various government databases, websites, and PubMed for obtaining data and statistics on healthcare funding, health insurance schemes, healthcare budget allocations, categories of medical expenses, government policies, and health technology assessment (HTA) in India.
The available data indicates 37.2% of the total population is covered by any health insurance of which 78% are covered by public insurance companies. Around 30% of the total health expenditure is borne by the public sector, and there is high out-of-pocket (OOP) expenditure on healthcare.
Several new health policies and schemes, an increase in 2021 budget for healthcare by 137%, vaccination drives, augmenting manufacturing of medical devices, special training packages, Artificial Intelligence/Machine Learning (AI/ML)-based standard treatment workflow systems to ensure proper treatment and clinical decision-making have been initiated by the government for improving healthcare funding, equity, and access.
KEYWORDS: Equityaccesshealthcarehealth insuranceIndia
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The Indian healthcare system is undergoing a major transition due to increased income and health consciousness among the population, reduction in bureaucracy, price liberalization, and introduction of private healthcare funding. [Citation1] In the National Health Policy 2009, health was prioritized as a fundamental right [Citation2]. The National Health Policy set by the central Government of India provides a regulatory framework for the healthcare delivered to people by Indian states [Citation3]. The Indian healthcare system is faced with several challenges, including increased healthcare costs, need for nursing and long-term care for senior citizens due to the rise of the nuclear family system, high financial burden on the poor, increasing burden of new diseases, and negligence of public health functions due to inadequate funding for healthcare sector. Although India achieved the World Health Organization (WHO)-recommended doctor-to – population ratio of 1:1000 in 2018 [Citation4], there is uneven distribution of health workers in rural and urban areas in the counry [Citation5]. For addressing out-of-pocket problems, health insurance has emerged as a financing option in India, which is not well-established – unlike in developed nations [Citation1]. However, only 37% of the total Indian population is covered by health insurance [Citation3].
In this article, we discuss the current scenario of healthcare in India with respect to universal health coverage (UHC), healthcare schemes, and fund allocation for different public sector undertakings. This paper analyzes health expenditure in private and public sectors in India, including out-of-pocket expenditure (OOPE), and discusses various recent schemes launched by the Indian government for improving healthcare delivery. Thereafter, recent proposals and strategies by the Government of India for improving healthcare coverage and delivery.
Data were derived from different Government of India databases (such as Health Sector Financing by Center and States/Union Territories in India, Ayushman Bharat – National Health Protection Mission, National Health Authority, Ministry of Health and Family Welfare, Department of Health Research), healthcare websites, and relevant articles on PubMed. The search keywords used were equity, access, healthcare, health insurance, health economic evaluation, health technology assessment (HTA), India. The findings are reported by leveraging information from the literature published in the last 10–12 years; databases were last accessed in May 2021. The data analysis has been adapted from these sources.
The $41 billion healthcare industry in India is growing due to a decline in infant mortality, longer life expectancy, an increasing population, emphasis of the government on the eradication of diseases, more disposable income, and, therefore, the ability to afford private healthcare facilities [Citation6,Citation7]. Public health expenditure in India, including that by both the central and state governments, was maintained constant at approximately 1.3% of GDP between 2008 and 2015 and increased marginally to 1.4% in 2016–17. The National Health Policy 2017 proposed to increase this figure to 2.5% by 2025. The total health expenditure, including the private sector, is estimated to be 3.9% of the total GDP [Citation8]. About one-third of the total health expenditure (30%) comes from the public sector; this is lower compared to the corresponding figures for other developing and developed countries [Citation8]. This implies that the individual consumer bears the cost of their healthcare [Citation8].
The allocation to the Department of Health and Family Welfare has increased from USD 1552.096 million in 2006–07 (revised estimate) to USD 9732.214 million in 2021–22 (budget estimate). Over this period, the Compound Annual Growth Rate (CAGR) has been 13%, which is the annual growth rate over a certain period of time. In 2020–21 (revised estimates), the Department is expected to exceed the budget estimate by 21%. Overall, the Ministry is expected to have an additional spending of USD 2159.907 million at the revised stage in 2020–21. Out of this, USD 1941.417 million was spent for COVID-19 emergency response and health system preparedness package, and COVID-19 vaccination for healthcare and frontline workers [Citation9]. (Dollar rate for the study was 1 USD = INR 73.23.)
OOPE is made directly by households at the point of receiving health care. This indicates that the extent of financial protection available for households towards healthcare payments is very limited [Citation10]. The highest percentage (52%) of OOPE is made toward medications (Figure 1) [Citation8]. Public spending on health majorly involves the delivery of allopathic medications in both urban and rural areas (38.01% and 26.29% respectively) [Citation11]. Overall, only 14% in rural areas and 19% in urban areas are covered under any insurance scheme of health expenditure support. Nearly 7% of the population is pushed below the poverty threshold annually due to high OOPE [Citation8] and with the pandemic the percentage of the population below the poverty line has increased to 28% [Citation12].
Health insurance: implemented health insurance schemes in India
Health insurance schemes began in the early 1950s in India, with the launch of the Central Government Health Scheme (CGHS, 1954) and Employees State Insurance Scheme (ESIS, 1952). In December 1999, the Insurance Regulatory and Development Authority (IRDA) Bill was passed to create a regulatory authority for governing the insurance industry in India. Until 2007, India had only three health insurance programs, viz. ESIS, CGHS, and PHI (Public Health Insurance); from then on, the country has been swamped by several insurance programs [Citation13]. The scenario of health insurance in the country changed when state governments announced health insurance schemes specifically covering the poor or those below the poverty line [Citation13].
At present, numerous public health insurances are available, including Employees’ State Insurance Scheme (1948), CGHS (1954), Private Insurance – Mediclaim (1986), Ex-Servicemen Contributory Health Scheme (2003), Universal Health Insurance scheme (UHIS) (2003), Health Insurance Scheme for Handloom Weavers (2005), Shilpi Swasthya Yojana for handicraft artisans (2006), Rashtriya Swasthya Bima Yojana (RSBY) (2008), Niramaya health insurance scheme continued as Swavlamban Health Insurance Scheme in 2016 (2009), Senior Citizen Health Insurance Scheme (SCHIS) within RSBY (2016), National Health Protection Scheme (NHPS)/Ayushman Bharat – National Health Protection Mission (AB-NHPM)/Pradhan Mantri Rashtriya Swasthya Suraksha Mission (PM-RSSM) (2018) [Citation14].
Existing health insurance schemes are as follows: (1) Voluntary health insurance schemes or private, for-profit schemes. For private insurance, premiums are collected from private insurance buyers, while in the public sector, voluntary schemes are provided by the General Insurance Corporation (GIC) and its four subsidiary companies, viz. National Insurance Corporation, Oriental Insurance Company, New India Assurance Company, and United Insurance Company, which has offered Mediclaim since 1986, limited mostly to the middle class owing to high premiums. (2) Mandatory health insurance schemes or government-run schemes include ESIS and CGHS; these cover people employed in factories and central government employees (including retirees, certain autonomous, semi-government organizations), respectively. (3) Insurance offered by non-government organizations (NGOs)/community-based health insurance is funded by NGOs or charitable trusts with nominal premiums and is financed by government grants, patient collection, and donations. (4) Employer-based schemes are provided by employers to their employees; benefits include lump-sum payments, reimbursement of health expenditures, medical allowances, or coverage under group health insurance schemes [Citation1].
The most recent health protection Scheme ‘Ayushman Bharat’ was launched in September 2018; it will cover more than 10 crore poor families and around 50 crore beneficiaries, providing coverage of up to five lakh rupees per family. Entitlement based on the criteria in the Socio Economic and Caste Census (SECC) database and premium cost will be shared between the central and state governments. PMJAY is expected to significantly reduce OOPE, covering nearly 40% of the population – including the poorest and most vulnerable sections [Citation15].
The progress of AB-PMJAY (as on 26th Nov 2019) is as listed below [Citation16].
Currently, 32 States/UTs are implementing PM-JAY
Hospital admissions = 0.191 million
Amount authorized for admissions = USD 2394.51 million
Hospitals empaneled = 24,653 (Public: Private = 54:46)
E-Cards issued = 1.734 million
Portability cases = 0.15 million
14 hospital admissions per minute
13 beneficiaries verified per minute
8 hospitals get empaneled per day
However, implementation of Ayushman Bharat, the largest government-funded health insurance scheme in the world, is associated with several challenges: ensuring the provision of high-quality care, high cost of services, lack of beneficiary awareness, maintaining the quality and security of data, and building capacity of the health workforce. For overcoming these hurdles, the Government of India has issued ‘a call for action’ to the Indian startup community (Startup India) [Citation17].
Current health systems and policies in India have evolved from the landmark Bhore Committee Report, 1946, which laid the foundation for a three-tier public healthcare (PHC) system comprising subcenters, primary and community centers. It was meant for ensuring equitable access to primary healthcare; however, the poor capacity of PHC systems resulted in the parallel evolution of the private healthcare industry in India [Citation18].
Currently, the Ministry of Health and Family Welfare, state governments, and local municipal bodies are key public stakeholders in the healthcare system. States regulate healthcare delivery through a dedicated Directorate of Health Services and the Department of Health and Family Welfare [Citation3]. However, private sector regulation is unclear, with multiple agencies under different ministries having overlapping jurisdictions over the private healthcare sector as shown in Figure 2 and 3 [Citation3].
Figure 2. Organization of Healthcare Structure in India. The different levels in the Indian healthcare sector according to hierarchy are national level, state level, district level and block level. The flow of information and line of reporting between the different levels and their respective departments has been delineated [Citation3].
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