abstract

India has long faced a challenge of high Out-of-Pocket Expenditure (OOPE) on healthcare, which historically accounted for over 60 percent of total health spending and remains one of the highest globally despite recent progress (NHA data shows a decline from 62.6% to 39.4% between 2015 and 2022) (Ministry of Health and Family Welfare; ORF analysis). Heavy reliance on direct payments continues to cause financial hardship for households, pushing millions into poverty each year. In response, the Government of India has expanded its healthcare financing architecture, notably with the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY), state health insurance programs, and growth in private health insurance coverage (Business Standard).

This paper evaluates how these elements shape healthcare affordability and financial risk protection for vulnerable populations. Using a secondary research methodology, the study synthesizes data from government reports, the National Sample Survey, National Health Accounts, international databases (WHO, World Bank), and peer-reviewed literature. Comparative studies suggest PMJAY has effectively eliminated OOPE for certain inpatient procedures in select settings, while private insurance often reduces but does not fully mitigate financial burden (e.g., zero OOPE under PMJAY vs significant OOPE in private plans for surgical care) (PubMed studies). However, evidence from national surveys indicates mixed results, particularly regarding outpatient care and childbirth expenditures, where insurance coverage has not always reduced household spending (NFHS-based research). Additionally, critical gaps persist in outpatient services, medicines, diagnostics, informal payments, and equitable access across regions (Science Direct).

The paper anticipates that while public insurance schemes have partially reduced OOPE, persistent affordability barriers highlight the need for structural reforms including expanded coverage beyond hospitalization, strengthened primary care financing, and improved regulatory oversight to enhance financial risk protection and advance universal health coverage in India.