Work in progress: On the Household social consumption (health) survey. 

India must strengthen public sector hospital capacity. 

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.