What Afreen’s Story Says About Poor Healthcare Funding In India
Two of Delhi’s biggest government hospitals are right in Afreen’s backyard. But her struggle to access healthcare for her husband when he had a stroke underlines why the government needs to spend more on health
Afreen lives in Delhi’s Mirdard, barely a kilometre away from two of the city’s biggest public hospitals – the GB Pant Hospital and Lok Nayak Jai Prakash Narain (LNJP) Hospital. Yet, when her 35-year-old husband Aamir had a stroke two months ago, she could not manage to get a consultation at the GB Pant hospital and was refused admission at both, LNJP and the Ram Manohar Lohia hospital, a little further away. Exhausted and distraught, she had to rely on private doctors and quacks.
India’s healthcare system is understaffed and overstressed. There are fewer primary and secondary healthcare facilities than needed and the existing centres have high vacancies of essential medical staff. Lack of adequate primary and secondary healthcare adds pressure to tertiary centres, delaying access to care while increasing the costs.
It also creates gendered barriers to accessing healthcare with fewer women accessing these tertiary centres in the cities. A 2016 analysis of 2 million patient records from AIIMS Delhi found that the sex ratio of the patients was 1.69 men to every woman. The ratio became worse with the distance the patient had to travel. It was 1.41 for Delhi, 1.70 for Haryana, 1.98 for Uttar Pradesh and 2.37 for Bihar.
Almost half of the total expenditure in India is out-of-pocket and is a significant cause of debt for many households. Over one and a half months since Aamir had a stroke, Afreen spent around Rs 80,000 on medicines and medical care, for which she had to borrow around Rs 35,000. Additionally, this puts a disproportionate economic and emotional burden on women as carers.
Reducing out-of-pocket expenditure and improving access and affordability of healthcare facilities are key pathways to achieve Universal Health Coverage, said the National Health Policy, 2017. One of the objectives listed in the policy is increasing healthcare funding to 2.5% of GDP by 2025, but the central government’s allocation has barely increased. In fact, it has decreased when adjusted for inflation with a year left to achieve this goal. An analysis by senior journalist Rema Nagarajan in the Times of India shows that it has dropped from 0.3% in 2018-19 to 0.28% in 2023-24 when it should have increased to 0.8% of GDP by 2023-2024.
Apart from patients, underfunding of the healthcare system has severe implications for the safety and security of healthcare workers as Christianez Ratna Kiruba wrote for Behanbox after the recent rape and murder of a young postgraduate resident doctor at Kolkata’s RG Kar Medical College and Hospital.
Close But Far
On an afternoon in early June, Aamir was working on his sewing machine as usual when he suddenly felt a sharp pain in his left arm. Soon, he collapsed. Afreen rushed him to the closest government hospitals.
“At GB Pant, they only take patients who have a referral,” said 27-year-old Afreen. “We first went to Lok Nayak hospital hoping they would refer us to GB Pant. But they did not even look at him.” GB Pant and Lok Nayak hospitals are opposite each other with the former having super speciality doctors but Aamir got care at neither. So Afreen then decided to go to a well-known Ayurvedic dispensary around 30 km away, in Ghaziabad.
“They gave us desi medicines – some powders and pills,” said Afreen. By the time they returned home, it was evening. And then Afreen found that Aamir could not swallow the prescribed Ayurvedic pills. “He could not even swallow water. I called the [Ayurvedic] dispensary and they told me to take him to a hospital,” said Afreen who then took him to the central government-run Ram Manohar Lohia hospital. “The dispensary people said he needed to be admitted but the hospital refused. They did a CT scan, gave him an injection and prescribed two tablets and sent us home.
Even with a referral, accessing these hospitals are difficult, said Afreen, who had been trying for days to see a doctor for her cervical pain. “A physiotherapist gave me a referral and I went to the hospital twice but have not been able to get the form. Yesterday I was there all morning but it did not work out. I was planning to go today but he was not well.”
Government hospitals in the capital city are understaffed and lack the required medical infrastructure, the Delhi High Court-appointment committee found in its interim report. The lack of resources have led to many incidents of government hospitals refusing treatment and even patient deaths.
As per the Indian Public Health Standards, in rural areas, there should be one primary health centre for 30,000 people but there is only one for over 36,000 people. Similarly, instead of one community health centre for every 80,000 people, there is only one for over 1 lakh people. And in the existing centres, there are not enough medical staff with an almost 80% shortfall of specialists in community health centres.
This infrastructure gap impacts women disproportionately. In the latest National Family Health Survey (NFHS) conducted between 2019 and 2021, 62.4% of the women respondents said that they face problems accessing healthcare. Distance to the healthcare centre (26%), getting money for treatment (29.1%) and concern that no provider will be available (39%) were the major barriers.
In the absence of adequate facilities, millions of people travel from villages and towns to metropolitan cities like Delhi, Mumbai and Chennai for treatment, adding to the costs. But there is significant gender disparity amongst patients who are able to travel and receive this treatment. Our recent series on gender and cancer explores how women with cancer face increased barriers in accessing healthcare and getting treatment.
Rising Costs, Expensive medicines
As per the 2019-20 National Health Accounts, 47.1% of the total expenditure on health was out-of-pocket expenditure. While this has decreased from 64.2% in 2013-14, it might be due to decreased utilisation of healthcare facilities, IndiaSpend had reported in April 2024. And nearly half of this expenditure is on medicines.
When Aamir’s condition did not improve in a couple of days after visiting the hospital, Afreen took him to another private doctor, this time around 5 km away from her home, in Chandni Chowk. He too gave Aamir an injection, which Afreen said helped. Over the next four days, the couple made that journey everyday, spending Rs 2,000 per day at the clinic. When this reporter met Afreen, it had been a month and a half since Aamir had a stroke. He was recovering and was able to hoist himself up and move around their windowless 200 sq ft room.
Afreen had just returned from Meerut with 10 days worth of medicines for Aamir. She had been told of a private practitioner there who was supposed to be good. But he, she said, instead of giving a prescription, tells the patients to buy the medicines from there. “I spent Rs 4,000 on the medicines. It is a business to make money but what can I do?” said Afreen.
Within 6 weeks, the family had racked up a debt of Rs 35,000 with no avenues to repay.
“Our relatives and friends have been helping us out and that is how we are surviving but I don’t know how long we can go on like this,” said Afreen, who said she will soon be looking for jobs. “I will take up any job, most likely as a domestic worker, so we can have some income. But I will have to wait till Aamir manages to go to the toilet alone.”
In the last five years, cost of treatment for common ailments that require hospitalisation has more than doubled, the Times of India reported in August 2023, with medical inflation estimated to be at 14%–twice as high as retail inflation.
Declining Public Health Budget
India’s healthcare budget, however, has not kept up with the inflation. In the latest 2024-25 budget, the central government allocated Rs 98,761 towards healthcare, an increase of 2.9% from the amount allocated for 2023-24.
While it might seem like an increase, in real terms, the funding has dropped, according to the TOI analysis. Adjusting for wholesale price index makes the 2023-24 revised estimates just Rs 1,000 crore more than the amount spent in 2019-20. As a share of the budget, the central government’s outlay on health dropped from 2.4% 2018-19 to 2% in 2024-25.
Still, this still does not account for the fact that healthcare costs are increasing at a much faster rate. Senior journalist Rema Nagarajan illustrated this with the example of OPD consultation rates at an online public health forum on health financing, conducted by Nivarana, a public health research and advocacy platform.
In April 2023, the central government revised the OPD consultation rates from Rs 150 to Rs 350. “Suppose the government had budgeted Rs 15,000 for consultation for 100 people in 2018. In 2023, if the government says they will double the budget to Rs 30,000, it will still not be enough to fund 100 people’s consultations,” said Rema in the Nirvana online discussion. “This is why government health services fall short. Because they are never able to keep up with what is required.”
Also, allocation does not necessarily mean spending. In 2022-23, the actual spending of Rs 80,229 was much lower than the Rs 91,495 that was allocated. In 2023-24, the Rs 95,963 crore allocation got cut by 10% to Rs 86,216 crore for revised estimates. The actual spend on this might be lower than that as one of the problems is underutilisation of outlays.
Moreover, since its introduction in 2018-19, the insurance scheme Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PMJAY) has been receiving increased allocations while the National Health Mission which focuses on strengthening public health infrastructure has seen a drop in funding in real terms from Rs 24,775 crore in 2019–20 to Rs 19,777 crore in 2024–25.
“Insurance is a demand side strengthening but where is the supplier,” said Sujatha Rao, former Secretary at the Ministry of Health and Family Welfare at the Nivarana forum. “If I have been given a voucher of Rs 20,000 to buy mangoes, but if there are no mangoes, what do I do with the voucher? It is a lazy way of saying ‘I am paying so much for health’ but where are the healthcare facilities?”
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