Answer

Introduction 

India’s healthcare access has improved significantly with rising institutional deliveries, greater insurance coverage, and higher public facility use. Yet, high out-of-pocket expenditure persists, showing that financial protection remains incomplete despite expanded health insurance schemes.

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Reasons Why OOPE Persists

• Limited Coverage: Insurance schemes mainly cover hospitalization, while outpatient care, diagnostics, and medicines often remain uncovered.
  Eg: Ayushman Bharat-PMJAY primarily focuses on secondary and tertiary hospitalization, leaving routine OPD expenses largely outside coverage.
• Private Dependence: Many patients continue relying on private hospitals due to quality gaps in public healthcare facilities, increasing direct spending.
  Eg: NSO survey shows public outpatient usage in rural areas is only 35% in 2025, meaning many still depend on private care.
• Medicine Costs: High spending on medicines forms a major share of household healthcare expenditure, especially for chronic diseases.
  Eg: National Health Accounts show medicines remain a major component of OOPE despite public schemes.
• Diagnostic Burden: Lab tests and specialist investigations are often paid directly even when consultations are subsidized.
  Eg: Patients with diabetes, cancer, or heart disease frequently incur repeated diagnostic expenses outside insurance packages.
• Informal Payments: Hidden charges, transport costs, and wage loss during treatment are not covered by insurance mechanisms.
  

Comprehensive Measures

• OPD Inclusion: Expand insurance beyond hospitalization to cover outpatient care, diagnostics, and essential medicines.
  Eg: Health Benefit Packages under PMJAY can be gradually expanded for chronic OPD treatment coverage.
• Strong Primary Care: Strengthen Health and Wellness Centres to reduce dependence on costly private treatment and late-stage hospitalization.
  Eg: Ayushman Arogya Mandirs support preventive and primary healthcare at the local level.
• Free Medicines: Ensure universal free essential drugs and diagnostics in public hospitals to directly reduce OOPE.
  Eg: Tamil Nadu Medical Services Corporation model improved affordable medicine access through centralized procurement.
• Better Public Hospitals: Improve staffing, infrastructure, and specialist availability so people trust government facilities over expensive private care.
• Portable Protection: Integrate e-health records, insurance portability, and migrant-friendly access for seamless healthcare protection nationwide.
  Eg: Ayushman Bharat Digital Mission supports continuity of care and easier claim access across states.

Conclusion

Reducing OOPE requires moving beyond insurance expansion toward complete financial protection. Strong public healthcare, affordable medicines, OPD coverage, and equitable access must work together to achieve truly universal health coverage in India.

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