Answer

Introduction

The Bhore Committee (1946) envisioned Universal Health Care (UHC) as quality health services for all, regardless of ability to pay. While schemes like PM-JAY and State Health Insurance Programmes have expanded financial protection, they remain inadequate for achieving holistic UHC.

Body

How Health Insurance Schemes Help in Achieving Holistic Health Care in India

• Financial Protection for the Poor: Schemes like PM-JAY and State Health Insurance Programme (SHIPs) shield low-income households from excessive hospitalisation costs.
  Eg: PM-JAY covers 58.8 crore individuals with ₹5 lakh per household annually, reducing out-of-pocket expenditure when public facilities are overcrowded.
• Increased Access to Hospitals: Beneficiaries gain access to a wider network of empanelled public and private hospitals.
  Eg: Around half of the empanelled hospitals under PM-JAY are private, expanding treatment options.
• Support During Emergencies: Insurance has proved crucial in times of crisis, such as the Covid-19 pandemic, when public hospitals were overburdened.
• Encourages State Participation: Most States have launched their own SHIPs, creating an expanding safety net and raising awareness about institutional health care.
  Eg: Gujarat, Kerala, and Maharashtra have steadily increased SHIP budgets by 8–25% annually.
• Step Towards UHC Framework: Though incomplete, these schemes signal intent towards wider health coverage, laying groundwork for a future UHC model.
  

Challenges of Health Insurance Schemes in Achieving Holistic Health Care in India

• Profit-Driven Bias: Majority of funds go to private hospitals, reinforcing for-profit medicine and neglecting public institutions.
  Eg: Two-thirds of the PM-JAY budget is spent on private hospitals without strong regulation.
• Neglect of Primary and Preventive Care: Focus is on hospitalisation, while outpatient and primary health services remain underfunded.
  Eg: Expanding PM-JAY to cover elderly citizens risks pushing more resources to costly tertiary care.
• Low Utilisation Despite High Coverage:Official data shows that PMJAY and SHIPs together cover up to 80% of the population, yet awareness about the scheme remains low.
  Eg: As per Household Consumption Expenditure Survey,  Only 35% of insured patients in 2022–23 could use their insurance which shows low utilization.
• Discrimination and Delays: Private hospitals discourage insured patients, while reimbursement delays strain providers whereas Public hospitals prefer insured patient, which creates imbalance.
  Eg: PM-JAY pending dues reached ₹12,161 crore; 609 hospitals opted out.
• Corruption and Fraud: Insurance schemes are vulnerable to abuse through fake claims, unnecessary procedures, and denial of care.
  Eg: National Health Authority (NHA) flagged 3,200 hospitals for fraudulent activities under PM-JAY.
  

Way Forward

• Strengthen Public Health Investment: Raise public expenditure on health closer to global standards (India spends only 1.3% of GDP vs. world average 6.1%).
• Integrate Primary and Preventive Care: Shift focus from hospitalisation to robust primary health centres, outpatient care, and preventive health services.
• Tight Regulation of Private Providers: Enforce strict monitoring, transparent audits, and fair reimbursement to curb profiteering and fraud.
• Universal Coverage Model: Gradually move from targeted schemes to universal, equitable coverage, similar to Canada or Thailand, with emphasis on non-profit providers.
• Improve Awareness and Accessibility: Invest in outreach, digital platforms, and grievance redressal to ensure beneficiaries know and can use their entitlements effectively.
  

Conclusion

Health insurance provides relief but cannot replace a robust public health system. Achieving UHC requires greater investment in public health, primary care, and accountability aligning with SDG 3 (Good Health and Well-being) to build a healthier and more inclusive India.

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