Overview of Universal Health Care (UHC) and Health Insurance in India

Universal health care (UHC) aims to provide quality health care to all community members irrespective of their ability to pay, as envisioned by the Bhore Committee in 1946. Despite advancements, India still lags in achieving this goal, unlike many other countries. There is a growing illusion that UHC can be realized through the expansion of health insurance.

State-sponsored Health Insurance Schemes

• The Pradhan Mantri Jan Arogya Yojana (PMJAY), initiated in 2018 under Ayushman Bharat, represents a significant step in state-sponsored health insurance.
• Every major state has its own State Health Insurance Programme (SHIP), often modeled after PMJAY, offering a maximum cover of ₹5 lakh per household annually.
• In the fiscal year 2023-24, PMJAY covered 58.8 crore individuals with an annual budget of about ₹12,000 crore, complemented by SHIPs with a budget of at least ₹16,000 crore.

Critical Evaluation of Health Insurance Schemes

• Promotion of For-Profit Medicine: About two-thirds of the PMJAY budget is allocated to private, profit-oriented hospitals, which may not effectively address public health needs.
• Emphasis on Hospitalization: Health insurance schemes focus on hospitalization, detracting from the urgent need for investments in primary and outpatient care.
• Utilization Challenges: Despite high coverage claims, only 35% of insured hospital patients utilized their insurance in 2022-23, highlighting awareness and accessibility issues.
• Discrimination Concerns: Targeted insurance schemes foster discrimination between insured and uninsured patients, with private hospitals preferring uninsured patients due to higher commercial charges.
• Provider Complaints: Health-care providers express concerns about low reimbursement rates and delayed payments, with pending dues under PMJAY amounting to ₹12,161 crore.
• Corruption and Abuse: The National Health Authority reported fraudulent activities by 3,200 hospitals under PMJAY, indicating systemic corruption risks.

Comparison with International Models

While social health insurance is part of UHC frameworks in countries like Canada and Thailand, the Indian model lacks essential features like universal coverage and a focus on non-profit providers. India's profit-centric health-care system is a result of severe under-investment in public health facilities, with public health expenditure at 1.3% of GDP compared to the world average of 6.1%.

Conclusion

India's reliance on health insurance schemes is insufficient to achieve UHC. Significant investment in public health facilities and reforms in health-care standards are essential for true progress. Some states are making headway, but substantial gaps remain, highlighting that health insurance alone cannot compensate for the lack of robust public health infrastructure.