PYQ Relevance[UPSC 2023] Examine the pattern and trend of public expenditure on social services in the post-reforms period in India. To what extent this has been in consonance with achieving the objective of inclusive growth? Linkage: The expansion of Pradhan Mantri Jan Arogya Yojana (PM-JAY) and State Health Insurance Programmes (SHIPs) shows rising public expenditure on health but largely towards insurance reimbursements rather than strengthening primary health infrastructure. This trend benefits private hospitals and tertiary care but fails to reduce out-of-pocket costs or enhance inclusivity, as utilisation remains low. Thus, the expenditure pattern reflects growth without true inclusiveness, misaligned with the objectives of inclusive growth. |
Mentor’s Comment
The debate on health insurance in India has intensified in recent years, especially with the expansion of State-sponsored schemes like Pradhan Mantri Jan Arogya Yojana (PM-JAY). While these initiatives provide some relief, the core question remains: can insurance-driven models substitute for robust public health infrastructure? This article unpacks the illusion of universal health coverage (UHC) through insurance, its systemic risks, and the urgent need for course correction.
Introduction
The Bhore Committee Report (1946) defined UHC as guaranteed access to quality health care for every citizen irrespective of their ability to pay. Eight decades later, India still falls far short of this goal. Instead of strengthening public health infrastructure, India has leaned heavily on health insurance schemes like the PMJAY and State Health Insurance Programmes (SHIPs). Though they provide relief to some, these schemes have created new distortions, risks, and inequities in the health system.
The Surge of Health Insurance Schemes
- PMJAY Launch (2018): Landmark scheme under Ayushman Bharat with ₹5 lakh annual cover per household for in-patient care.
- Massive Coverage: In 2023–24, PMJAY covered 58.8 crore individuals with an annual budget of ₹12,000 crore.
- Parallel SHIPs: State-level schemes cover a similar number with a budget of at least ₹16,000 crore.
- Rising Budgets: SHIP allocations grew at 8–25% annually (2018–19 to 2023–24) in States like Gujarat, Kerala, Maharashtra.
Commercialisation of Healthcare under Insurance
- Two-thirds of the PMJAY budget flows to private hospitals, often profit-oriented.
- Study findings: Minimal change in hospitalisation rates, but rise in private hospital use.
- Weak regulation: India’s poorly regulated profit-seeking providers dominate the system.
Hospitalisation Bias in Insurance Models
- Bias towards hospitalisation: Insurance covers only in-patient care, neglecting primary and outpatient care.
- Ageing challenge: Expanding coverage to elderly (70+) risks disproportionate spending on tertiary care.
Challenges in Effective Utilisation of Coverage
- High theoretical coverage: 80% of the population enrolled under PMJAY + SHIPs.
- Low effective use: Only 35% of insured patients could utilise benefits (2022–23 HCES).
- Barriers: Lack of awareness, procedural hurdles, and discrimination by providers.
Discrimination in Healthcare Delivery
- Private hospitals: Prefer uninsured patients for higher commercial charges.
- Public hospitals: Prefer insured patients for reimbursement incentives.
- Result: Discriminatory treatment and pressure on patients to enrol immediately.
Financial Strains Leading to Hospital Withdrawals
- Pending dues: PMJAY arrears reached ₹12,161 crore, more than its annual budget.
- Provider dissatisfaction: Low reimbursement, long delays.
- Hospital exits: 609 hospitals opted out of PMJAY since inception.
Corruption and Irregularities in PMJAY and SHIPs
- Fraudulent practices: NHA flagged 3,200 hospitals for irregularities.
- Common issues: Overcharging, denial of treatment, unnecessary procedures.
- Weak safeguards: No evidence of effective audits or transparency in scheme portals.
The Systemic Risk of Insurance-Led Health Care
- Profit over patients: Insurance reinforces commercial medicine rather than correcting it.
- Underfunded public health: India spends only 1.3% of GDP on health (World Bank, 2022), vs world average of 6.1%.
- Comparative failure: Unlike Canada and Thailand, India’s schemes lack universal coverage and non-profit focus.
- Result: Insurance becomes a “painkiller”, not a cure for India’s broken public health system.
Conclusion
Health insurance in India has expanded rapidly, but it remains a fragile foundation for UHC. It fosters profit-driven medicine, neglects primary care, suffers from poor utilisation, and is riddled with corruption. Without massive investment in public health infrastructure, primary care, and regulation, India cannot hope to achieve universal health coverage. Insurance schemes, at best, provide temporary relief, not sustainable health security.
Value Addition |
|
Get an IAS/IPS ranker as your 1: 1 personal mentor for UPSC 2024
