Revisiting India’s healthcare framework through capability approach and gender impact analysis

Abstract

The beginning of the preliminary National Health Policy (NHP) 2017 paints a picture of India's healthcare situation: “Despite being the world's third-largest economy in terms of Gross National Income, with ample resources and capabilities for healthcare, the country still grapples with widening health disparities. Despite the abundance of effective and accessible health interventions, the prevalence of illness, disease, premature mortality, and suffering remains unnecessarily high (MoHFW 2017).”

While there have been some advancements in certain aspects of India's healthcare, the overall situation reveals significant challenges that persist. Disparities are evident not only between states and regions but also among social groups. For instance, In Kerala, a high-performing state, there's significant diversity in Under-5 Mortality Rate (U5MR) and Neonatal Mortality Rate (NMR) rates among districts, with a 10.4-fold difference in U5MR. In contrast, Uttar Pradesh exhibits even greater disparity, with a 59.7-fold difference in U5MR rates among its districts (Lancet 2020). Additionally, disparities are prominent among social groups, with Dalits and Adivasis being overrepresented among India's undernourished children.

One of the main reasons behind India's poor health outcomes is the persistently low levels of public expenditure, accounting for about 41.4% of the total health expenditure. Currently, this equates to a mere 1.35% of the GDP, which is around 5.02% of the entire government spending (MoHFW 2023). In monetary terms, the Government Health Expenditure (GHE) amounts to Rupees 2014 per capita at current market prices (MoHFW 2023). International evidence suggests that for basic healthcare needs to be adequately met, a country should allocate at the very least around 5 to 6% of its GDP to the health sector, with the majority of it being funded by the government (ORF 2023). Health policies must address not only health outcomes but also the financial risks associated with healthcare expenses. In India, citizens often face substantial out-of-pocket expenditures (OOPE) for healthcare, leading to economic vulnerability. Data from the World Bank shows that nearly 47.1% of the money spent on healthcare in India is out-of-pocket, a figure significantly steeper than the global average of 18% for the same year (World Bank 2023). This high reliance on out-of-pocket payments pushes approximately 60 million Indians into poverty annually, as highlighted by a study conducted by the World Health Organization in March 2022.

The Indian Government has introduced and implemented several Publicly Financed Health Insurance schemes (PFHI) with the aim of achieving “Universal Health Coverage (UHC)” and reducing the financial burden of out-of-pocket healthcare expenses, especially for low-income households (GoI 2017). One significant initiative in this direction is the introduction of the “Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY)”, which is claimed to be the largest coverage health insurance program globally (GoI 2018). PM-JAY aims to improve the affordability and availability of healthcare services, particularly targeting marginalized populations (Garg et al. 2020).

Despite continuous government efforts to improve healthcare services, both in terms of accessibility and affordability, out-of-pocket healthcare expenses remain unreasonably high, particularly for marginalized groups based on factors such as caste, class, or gender. This raises doubts about the effectiveness of policies like the PM-JAY. It is crucial to reevaluate existing health system mechanisms to understand the factors and complexities influencing their successful implementation in India.