Eighty-two per cent of the persons with disabilities in the country do not have any health care protection despite the claims of the government to the contrary. Forty-two per cent of them are not even aware of the central government’s flagship programme for people’s health, Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (ABPMJAY), according to a recent national survey by the Centre for the Promotion of Employment for Disabled People.

The number of persons with different kinds of disabilities in the country is enormous, 26.8 million or 2.21 per cent of the population as per the 2011 census. While the next census, which was due in 2021 but postponed to this year, can provide the most dependable update since it covers the entire population, other studies, which, too, cannot be ignored since they are based on scientific statistical sampling methods, have shown a marked increase in this number; the NFHS-5 (2019-21) reported it to be 63.28 million people, equivalent to 4.52 per cent of the population.

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This is not to say that those already covered under some government-sponsored schemes are getting hassle-free healthcare. The overall health of the health sector is not well. The experience of the enrolled suggests that many of the hospitals empaneled refuse the treatment with great impunity; the needy have either to pay, if they can, out of pocket or go without treatment if they can’t, and live or die with the disease.

The Ayushman Bharat scheme, wherever it is accepted, covers only in-patient costs, not the out-patient services that comprise a significant 80 per cent of healthcare needs. Another issue is massive corruption at different levels in the implementation of the scheme, as observed by the CAG in one of its reports. Coming to healthcare in general, the pure commercial interest and market force philosophy takes precedence over the public health responsibility of the government. The health infrastructure is neither adequate nor suitable for the masses of people in the country. It encourages private profits and helps private insurance. It has a poor 1:1,500 doctor-to-patient ratio and 1.7 nurses to 1,000 people as per IBEF’s observation. However, other official claims dispute this; in response to a parliamentary question, the minister of state for health and family welfare said this ratio was 1:836 doctors ~ more than the WHO standard of 1:1,000.

It seems that the government calculated the ratio based on the 13,86,000 allopathic doctors registered and 5,65,000 lac Ayurveda, Unani, Homoeopathy practitioners, etc. to inflate the numbers. The dimensions of the health sector neglect are multifold. The health care public spending in India as a percentage of its GDP is set at 1.9 per cent in 2026, whereas other countries the world over are already spending between 5 to 12.5 per cent of their GDP. The US, for instance, spent 16 per cent in 2023, and the OECD countries spent 9.2 per cent in 2022.

The private sector in India dominates health care in many ways. It accounts for 58 per cent of the number of hospitals.

The sector employs 81 per cent of the medical professionals. By 2022-23, there were 43,186 private hospitals with 1.18 million beds and 29,631 ventilators. The macro data doesn’t reflect the true picture because there is a wide gap between rural and urban areas in the availability of hospitals and doctors. Also, there are regional imbalances. For instance, Maharashtra has the highest number of allopathic doctors (2.10 lac), followed by Tamil Nadu (1.49 lac) and Karnataka (1.41 lac) as per 2024 data; that means more than 38 per cent of the allopathic doctors in India are concentrated in three states.

The inefficient and inadequate health care is deepening and widening the poverty in India. Due to heavy out-of pocket spending, an estimated 7 per cent of the population ~ about 10 crore ~ falls below the poverty line every year, as a Niti Aayog report asserts. Besides high medical costs, people have to put up with unethical medical practices by unscrupulous players in the system because there is no effective mechanism to stop them. Look at some of the most disturbing practices reported on and off in media. This is only an exemplary, not an exhaustive list:

* Unscrupulous hospitals accept patients not based on their severity of disease and urgency for treatment but on their paying capacity; those with disease but no money are kicked out while those with sufficient money but no disease get unnecessary treatment.

* Doctors prescribe tests lured more by the kickbacks that diagnostic centres offer than by the need for such tests. They write a battery of tests codenamed “sink tests” with one or two ‘marked tests.’ Patients are charged for all the tests and blood samples, for instance, are collected for all of them. But the actual test is conducted only for the ‘marked test,’; fake normal results are given for the rest of the tests. The excess blood collected is thrown in the sink, so the name ‘sink’ tests.

* Patients are unnecessarily referred to other doctors just to get a cut from them; those who offer higher commissions get higher referrals.

* Prenatal sex determination tests are conducted defying the legal ban on it.

* Unnecessary surgeries are conducted on the gullible persons. The types of procedures to make money include hysterectomies, C-sections, cataracts, knee replacements, and lower back operations.

* Pharmaceutical companies supply expensive gifts and medical equipment to entice doctors to prescribe their drugs. Not only gifts, they also offer foreign trips and five-star accommodations to doctors and their families.

* Poor and illiterate people are used as guinea pigs for clinical trials. * The ambulance services are paid bribes for bringing emergency patients to private hospitals.

* Hospitals force doctors to generate monthly targeted revenue to justify their high salaries, whereby doctors play mischief by subjecting innocent people to unnecessary tests and procedures.

The Medical Council of India prohibits all these unethical practices, but they have little impact on the errant doctors and hospitals. The National Health Policy 2017, too, commits itself “to the highest professional standards, integrity and ethics”. These goals are not achievable without first halting the ongoing mindless commercialization of the health sector in India. While people are worried about grossly inadequate and inaccessible healthcare, the sector flourishes and provides the best facilities to those who can afford them in India and abroad.

The Indian Brand Equity Foundation (IBEF) says the Indian healthcare market, which was valued at $110 billion in 2016, is poised to reach $635 billion (Rs.54.87 lac crore) level by the end of this year. It adds that the premiums underwritten by health insurance in the financial year 2024 (up to February) grew to Rs.2.63 lac crore (about $ 32 billion). The health segment alone accounts for a 33.33 per cent share of the total gross written premiums earned in the country. Indian medical tourism is worth $7.69 billion in 2024 and is expected to reach $14.31 billion by 2029; about 6.34 lac foreign tourists came for medical treatment in India in 2023. With the above five lac international patients annually, India has found a place among the global leader destinations for international patients seeking advanced treatment.

All this suggests that India has a robust health sector and, given the will, it can be further strengthened and reformed to meet the comprehensive needs of every Indian. What we need is universal health care. What we need is the de-commercialization of the healthcare industry. What we need is to learn lessons from the damage market forces are causing to the health sector and public health. And what we need to do all this, at the cost of repetition, is the will. Delay will causes further damage, and that damage will be irreparable.

(The writer is a Development Economist and commentator on economic and social affairs)