MAKING PRIMARY HEALTH VISIBLE, OFFERING ACCESSIBLE AND AFFORDABLE HEALTH CARE

THE CONTEXT: Public health today is not merely the absence of disease but a dynamic interplay of lifestyle, environmental, social, and economic determinants. Challenges such as NCDs (60%+ of global deaths), antimicrobial resistance, mental illness, and zoonoses demand a systemic transformation of health governance. The need is not just access but trust, visibility, quality, and financial protection in public healthcare delivery.

INDIA’S RECENT INITIATIVES (AYUSHMAN BHARAT 2.0)

ACHIEVEMENTS AT A GLANCE

• • Life‑expectancy ↑ to 70.9 yrs (SRS 2023); IMR ↓ to 26/1000 live births.
  • OOPHE share of total health spending fell from 64 % (2013‑14) → 39.4 % (2021‑22)—but absolute OOPHE rose ₹2,097 → ₹2,600 per capita (NHA 2023).
  • 17,017 facilities NQAS‑certified → alignment with ISQua benchmarks.

THE CHALLENGES:

1. Trust & Visibility Deficit in Public Health Infrastructure

• • User Experience as a Blind Spot: Health outcomes depend not only on service availability but also on user satisfaction, continuity of care, and perceived empathy — parameters rarely measured in India’s health metrics.
  • Low Visibility of Public Facilities: A significant number of citizens are unaware of their designated PHC/CHC. NDHM lacks GPS-enabled facility directories accessible to users.
  • Result: Migration to private providers, often unaffordable, leading to catastrophic health expenditure (CHE) — defined by WHO as OOPE > 40% of a household’s capacity to pay.
  • As per the National Health Accounts (2021–22), even though OOPE % has fallen to 39.4%, per capita OOPE rose from ₹2,097 (2017–18) to ₹2,600 (2021–22).

2. Primary Care Neglect vs Tertiary-Centric Insurance Bias

• • The design of Ayushman Bharat–PMJAY inadvertently promotes hospitalisation over prevention, distorting care priorities.
  • Bhore Committee Vision (1946): Advocated a pyramid structure with a strong PHC base tapering into specialised care. This has been diluted by a top-heavy tertiary-care model incentivised by insurance reimbursements.
  • Budget Reality: ₹9,406 crore allocated to PM-JAY in 2025–26, promoting surgical/curative interventions in private hospitals over comprehensive PHC.
  • Implication: Fragmented care, late-stage disease detection, and systemic over-medicalisation.
  • NITI Aayog Evaluation (2021) noted that 65% of PM-JAY claims came from Tier-1 cities and large private hospitals, bypassing rural poor and PHCs.

3. Underfinancing and Skewed Budgetary Priorities

• • Health remains chronically underfunded in India despite constitutional and global commitments.
  • India’s public health spending hovers around 1.9% of GDP, well short of 2.5% target by 2025 set by the National Health Policy (2017).
  • Declining NHM Share: Despite its critical role in grassroots care, the National Health Mission’s share is declining in relative budget terms, while allocations to digital health and tertiary medical education expand.
  • Lancet Citizens’ Commission (2021) calls for predictable, pooled, and progressive funding for health, not fragmented scheme-based allocations.

4. Insurance Sector Liberalisation without Guardrails

• • Unregulated expansion of private insurance without beneficiary literacy risks exclusion, cost inflation, and inefficiencies.
  • FDI Cap Raised to 100%: Without robust checks, this can lead to “cream-skimming” (insuring low-risk clients), denial of claims, and escalating medical costs—as seen in the U.S.
  • Insurance Illiteracy: IRDAI reports show less than 35% rural population understand policy clauses or claim procedures; migrant and informal workers often rely on intermediaries.
  • Data Deficit: India’s last Census (2011) and PLFS (2020–21) are outdated, making targeting of vulnerable populations via insurance unreliable.
  • International Parallel: In the U.S., private insurance–led systems have contributed to 25–30% of GDP in administrative overheads, with coverage exclusions rampant (Commonwealth Fund, 2022).

5. Rural–Urban and Inter-State Inequities

• • Stark disparities in health workforce and infrastructure quality across states and between rural and urban areas.
  • NITI Aayog’s Health Index (2024) notes <30% of qualified doctors serve rural areas, with CHCs reporting over 75% vacancy in key specialities like gynaecology and paediatrics.
  • Infrastructure Gaps: Only 11% of public facilities in rural India are NQAS certified (MoHFW, Nov 2024); urban centres fare better.

6. Fragmented Governance and Siloed Implementation

• • Public health governance suffers from inter-ministerial overlap, jurisdictional ambiguities, and decentralisation without devolution.
  • Centre–State Tensions: Health is a State Subject (Entry 6, State List), but vertical schemes like PM-JAY are centrally driven, leading to reduced State autonomy.
  • Parallel Silos: Schemes like NHM, PM-ABHIM, and PM-JAY operate with independent dashboards, fund flows, and accountability chains.

COMPARATIVE INSIGHTS & GLOBAL BENCHMARKS

THE WAY FORWARD:

THE CONCLUSION:

A rights‑based, PHC‑centric, high‑quality and trusted public‑health ecosystem—financed adequately and regulated wisely—is India’s surest path to Universal Health Coverage, SDG‑3 fulfilment and realisation of Article 21’s health guarantee.

UPSC PAST YEAR QUESTION:

Q. In a crucial domain like the public healthcare system the Indian State should play a vital role to contain the adverse impact of marketisation of the system. Suggest some measures through which the State can enhance the reach of public healthcare at the grassroots level. 2024

MAINS PRACTICE QUESTION:

Q. Financial protection alone cannot assure universal health coverage; quality and trust are equally critical. Examine in the context of Ayushman Bharat and India’s pursuit of SDG‑3.

SOURCE:

https://www.thehindu.com/sci-tech/health/making-primary-health-visible-offering-accessible-and-affordable-health-care/article69456336.ece