Work in progress: On the Household social consumption (health) survey
The 80th, and latest, round of the household social consumption (health) survey conducted by the National Statistical Office is the first comprehensive survey of its kind in both the post-pandemic era and the period in which the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY) scheme attained maturity. The previous two surveys of the same kind revealed that most Indians did not have any form of health insurance. Since PMJAY’s launch in 2018, the
80th round shows that insurance coverage has expanded around threefold, accounting for an increasing share of health-care financing in hospitals. However, the hospitalisation rate has not recovered to the 2014 level, meaning that having an insurance card still does not guarantee access to a bed, and hidden costs continue to limit access. The reimbursement rates under PMJAY and State-funded insurance schemes are often below market rates, so private hospitals compensate by billing patients separately for diagnostics and ancillary services. In other words, while state-funded health insurance is subsidising private health-care providers’ access to low-income markets without also enforcing regulated prices, the combined system provides a safety net where insurance covers hospitalisation and the public network has improved financial protection for households seeking primary care. Second, the Proportion of Population Reported Ailing has doubled, while infectious diseases have declined and non-communicable diseases have increased. Economists have interpreted this as a sign of more people seeking care, thus becoming ‘visible’ to the health-care sector.
Previous surveys singled out out-of-pocket expenses (OOPE) on health care as a leading cause of poverty. In the 80th round, while the mean OOPE has roughly doubled, the median OOPE has dropped, to ₹11,285 per hospitalisation and at nearly nothing for public outpatient care. Health-care expenses in India are a mix of many low-cost consultations and a few significant and expensive interactions, such as surgeries and chronic care. The two trends thus mean that while health care is becoming more affordable, thanks to the public sector absorbing the cost of primary and secondary care, health care’s ability to inflict financial deprivation in a few cases remains high. Part of the problem is the AAM network, which provides free medicines and diagnostics, of Ayushman Bharat still being significantly underfunded relative to the needs of managing chronic diseases, and where the private sector dominates. Thus, overall, the poor have nominal coverage but are often excluded from the benefits of coverage in practice while the more insured middle class faces rising catastrophic costs. The next phase of health-care reform, after shielding care-seekers from poverty and achieving near-universal institutional delivery, will need to strengthen public sector hospital capacity to compete with the private sector for tertiary care.
- 1The article underscores the government's critical role in healthcare provision through schemes like PMJAY and NSO surveys, reflecting the State's constitutional duty to public health. Article 21, guaranteeing the Right to Life, implicitly includes the right to health, further supported by Article 47 of the DPSP which mandates improving public health standards. Effective governance is crucial to regulate private healthcare and strengthen public infrastructure, ensuring welfare schemes provide universal access and financial protection, as emphasized by the Supreme Court in cases like Paschim Banga Khet Mazdoor Samity (1996).
- 2Given the absence of an international relations angle, the domestic policy implications of the health survey are paramount, revealing gaps in India's social welfare framework. The expansion of PMJAY reflects a policy commitment towards universal health coverage, aligning with India's pledge to achieve Sustainable Development Goal 3 (Good Health and Well-being) by 2030, which targets universal health coverage. However, persistent issues like hidden costs and underfunded public networks necessitate a robust National Health Policy, like the 2017 iteration, to strengthen public sector capacity and regulate private healthcare, ensuring equitable access for all citizens.
- 3The article highlights critical regulatory shortcomings where state-funded health insurance subsidises private providers without enforcing regulated prices, leading to hidden costs for patients. This regulatory vacuum undermines the intent of schemes like PMJAY, often leaving patients vulnerable to exorbitant charges, despite the existence of the Clinical Establishments (Registration and Regulation) Act, 2010, which aims to set minimum standards. Strengthening the legal framework to cap treatment costs, ensure transparent billing, and effectively implement patient rights under the Consumer Protection Act, 2019, is crucial to prevent financial exploitation and ensure equitable access to quality healthcare services.
- 4Economically, the survey reveals a complex picture where median Out-of-Pocket Expenses (OOPE) have dropped, suggesting improved affordability for many, yet the mean OOPE doubling indicates persistent catastrophic costs for a few, perpetuating financial deprivation. This disparity highlights the challenge of India's low public health expenditure, which historically hovers around 2.1% of GDP, significantly below the 2.5% target set by the National Health Policy 2017. Socially, the doubling of the "Proportion of Population Reported Ailing" and the rise of non-communicable diseases (NCDs) like diabetes and hypertension signify an epidemiological transition, demanding a robust, equitable, and adequately funded healthcare system.