Views & Reviews Personal View

How India can provide healthcare for all

BMJ 2012; 345 doi: (Published 12 November 2012) Cite this as: BMJ 2012;345:e7693
  1. Devi Shetty, heart surgeon and founder and chairman of Narayana Hrudayalaya Health City, No 258/A, Bommasandra Industrial Area, Hosur Road, Anekal Taluk, Bangalore 560099, India
  1. devishetty{at}

Every day 60 to 80 patients consult me, mostly children.1 Typically, I might examine a child and tell the mother that an operation is needed to save the child’s life. She has only one question: “How much will it cost?” I tell her 80 000 rupees (£920; €1150; $1460). If she does not have the money she will lose her child. Most people cannot afford to pay for treatment themselves, and society does not make it available. Few government hospitals operate on babies, and even here at Narayana Hrudayalaya Health City often treatment is not entirely free.

A huge 60% of all spending on healthcare in India is paid for by citizens out of their own pocket, says the World Health Organization.2 Many people borrow money or sell assets to pay medical bills, and this is a key cause of rural indebtedness. Our maternal and infant mortality healthcare indicators are only slightly better than those of sub-Saharan Africa. Even government employees with means and influence—for example, police officers—rarely get reimbursed their medical expenses, despite struggling with the bureaucracy for more than a year.

Indian healthcare is predominantly the responsibility of state governments. Some have adopted innovative schemes. The Yeshasvini insurance scheme in Karnataka offers surgery to farmers who are members of cooperatives. Arogya Bhagya, also in Karnataka, insures police personnel. Rajiv Aarogyasri in Andhra Pradesh insures people below the poverty line. Gujarat’s voucher scheme has reduced maternal and infant mortality. Rajasthan has a scheme to supply generic drugs. Assam has a rural doctors training programme. And Tamil Nadu has a comprehensive insurance scheme. But such schemes are few, and those that states have introduced have inevitable flaws.

Increasing life expectancy means that funding healthcare from taxation is getting harder. A mechanism should be created so that rich people pay for their own care, and poor people receive free care through innovative schemes that collect tiny amounts of money from millions of people. Considering healthcare as a fundamental right would encourage all states to innovate. Here are some ideas that should be explored.

Increase healthcare budgets. The current allocation of 1.1% of gross domestic product is much less than what other Asian countries spend—for example, Sri Lanka’s 1.8%, Thailand’s 3.3%, and China’s 2.3%.2

Invest in infrastructure and expertise. District hospitals should provide tertiary services, such as cardiology, neurology, and orthopaedics, and be able to treat chronic illness, such as kidney disease, diabetes, and mental illness. The government should set up medical, nursing, and paramedical colleges to encourage children from underdeveloped areas to become healthcare workers.

The Employees’ State Insurance (ESI) is a social security and health insurance scheme for low paid employees of larger employers, financed by contributions from both. A similar system is needed to deliver healthcare to unorganised workers, including agricultural labourers, beedi rollers, domestic help, drivers, construction workers, and so on. Every employer should by law have to offer healthcare insurance to employees. An organisation like ESI that accepts monthly premiums from the employer towards the healthcare of self employed workers would be appreciated by citizens because they already spend lots more money informally.

The government could create a not for profit, self funding entity to offer health insurance to richer citizens who are not covered by other schemes. Currently, many government schemes work independently, with expensive systems and expertise that they do not share.

The concept of “health insurance” must be redefined to help schemes operate legally within their budgets. For example, beneficiaries of Yeshasvini insurance are entitled only to surgery in affiliated hospitals, which offer procedures at a pre-fixed price, and not inpatient care. There are instances when courts have ruled that the scheme must provide more, based on the current definition of health insurance by the government’s Insurance Regulatory and Development Authority.

India needs at least a million doctors and two million hospital beds. The government alone lacks the resources to build this capacity. The private sector can fill the gaps, with clear terms so that profit is not the only motivation.

We know from micro-insurance schemes such as Yeshasvini that poor people are willing to contribute tiny amounts of 5-10 rupees a month for healthcare, but we lack a simple way to collect this. India has more than 925 million mobile phone users who spend at least 150 rupees a month each. Would they mind paying an additional 20 rupees through their bill for healthcare? Alternatively, small premiums could be collected through electricity bills.

India produces the largest number of doctors, nurses, and medical technicians in the world. Outside the United States we have the most drug manufacturing units approved by the US Food and Drug Administration. What we lack is the cash to pay for healthcare for most people. The government must facilitate mechanisms to deliver healthcare by multiple sources of funding rather than tax alone. Declaring access to healthcare to be a fundamental right would provide the impetus for states to act.

The Rashtriya Swasthya Bima Yojana (RSBY) scheme has covered more than 100 million poor people.3 This excellent programme should be scaled up, with modifications in eligibility and sum insured. The scheme is only for holders of the BPL (below poverty line) card, but many poor Indians do not have this.

Provenance and peer review: Commissioned; not externally peer reviewed.

Competing interests: None declared.


Cite this as: BMJ 2012;345:e7693