Opinion India is still some way from achieving universal health coverage. Here’s why

To address gaps in the coverage of BPL households and financial protection mechanisms, government of India launched the Pradhan Mantri Jan Arogya Yojana (PM-JAY) in 2018 to provide publicly financed health insurance to around 500 million individuals comprising the poorest 40 per cent of the population. PMJAY aimed to address gaps in RSBY with an increased ceiling of Rs 500,000 (an increase from the previous sum of Rs 30,000) and an expanded service package for secondary and tertiary healthcare. In addition, it aimed to address the gaps in beneficiary enrolment by applying deprivation and occupational criteria of socio-economic caste census (SECC) 2011.

With the introduction of this ambitious programme, the question after five years of its introduction is to what extent has this helped address coverage gaps? An analysis of the recently released household consumption expenditure survey (HCES) data (2022-23) indicates that while the coverage of public health insurance (PMJAY and state-specific insurance) programmes for the first two population, quintiles (poor and poorest) has increased since 2018 it remains low, with less than 30 per cent of the population in this category covered. HCES data shows that of the 50 crore eligible people from the bottom 40 per cent population, about 13 crore are reported to be covered. And, the share of people from higher quintiles is reported to be more than 50% of the overall coverage of public health insurance programme.

Further, about 25 per cent of the population in the first two quintiles who utilised hospitalization services had public health insurance, with 34 per cent of those enrolled and utilised the healthcare system received insurance benefits. In contrast, 36 per cent from the higher quintiles received benefits. Therefore, even though the increase in utilisation by covered people has doubled since 2017-18, the overall healthcare utilisation under the health insurance scheme remained low. Clearly, the overall increase in population coverage and consequent distribution of health insurance benefits for inpatient services remained low in the last 5 years preceding the survey. The reasons for this need further examination.

A quintile-wise analysis of survey data revealed that the cumulative participation of middle and upper-middle-income groups in public health insurance programs continues to be higher than low-income groups. The reasons need deeper examination but could be due to public insurance being extended to the entire population in several states.

A detailed analysis of HCES data revealed that 68 per cent of the total hospitalization cases were treated in government facilities, which shows that people covered by public health insurance mainly relied on government health facilities for inpatient care. This remained unchanged since 2017-18. A further analysis of the data shows that a considerable percentage of the population (>50 per cent) who did not have public health insurance also utilized government facilities. Thus, irrespective of public health insurance, people rely on government health facilities for inpatient care.

Achieving UHC requires the provision of financial protection to prevent households incurring high OOPE. Social Consumption of Health Survey (NSSO 75th Survey) 2018 showed that people in the first two quintiles were incurring a higher burden of OOPE than the people in the last two quintiles for both inpatient and outpatient care. However, HCES data 2022-23 indicates a shift of burden from lower income group to higher income group for inpatient services. This indicates a positive impact of public health insurance on OOPE due to hospitalisation in low-income groups which needs further examination. However, the scenario of the financial burden for outpatient care remained the same as the low-income groups still incur a higher burden of healthcare expenditure.

Even though the HCES data indicates a lowering of the burden of healthcare expenditure for hospitalisation for the first two quintiles, they are still incurring a considerable amount while utilising inpatient services. As per HCES data, people across all quintiles are incurring significant expenditures, an average of Rs 6,700 per beneficiary while receiving treatment for inpatient care. Aligned with the findings of the Comptroller and Auditor General of India (CAG) report 2023, this shows that public health insurance beneficiaries had to pay from their pocket for the treatments received.

The findings of the HCES data for 2022-23 suggest that progress on UHC through targeted public health insurance in India is lagging in two crucial aspects – One, the coverage of the targeted population, and two, financial protection to people in the first two quintiles. Even though HCES 2022-23 is not strictly comparable with NSSO 75th Survey 2017-18 mainly due to the differences in questionnaire and recall periods, a broad comparison of population coverage and medical expenditure shows that the progress towards UHC is slow., and coverage of the target population in the two lowest income quintiles remains low. In addition, the participation of middle and upper-middle-income groups in targeted public health insurance schemes is reported to be higher. All these show that drawbacks in the previous erstwhile National Health Insurance Scheme, such as gaps in identification and enrollment of targeted beneficiaries, low population coverage, and weaker financial protection mechanisms, have not been addressed fully.

The writer is research associate in the health vertical at CSEP