Healthcare in India

2022-07-02T05:59:40Z

2405:204:508D:D75C:483:4221:7D94:DC1E:

{{Short description|Overview of the health care system in India}}
{{Use Indian English|date=November 2015}}
{{Use dmy dates|date=April 2022}}

[[File:AIIMS central lawn.jpg|thumb|[[All India Institute of Medical Sciences, New Delhi|AIIMS New Delhi]]]]
[[File:JIPMER admin block.jpg|thumb|[[Jawaharlal Institute of Postgraduate Medical Education and Research]] at [[Puducherry (union territory)|Puducherry]]]]
[[File:IGMC SHIMLA.jpg|thumb|[[Indira Gandhi Medical College|Indira Gandhi Medical College and Hospital, Shimla, Himachal Pradesh]]]]
India has a [[Single-payer healthcare#History of the term|multi-payer universal health care]] model that is paid for by a combination of public and private health insurance funds along with the element of almost entirely tax-funded public hospitals.<ref name="Zodpey et al 2018">{{cite journal |last1=Zodpey |first1=Sanjay |last2=Farooqui |first2=Habib Hasan |title=Universal Health Coverage in India: Progress achieved & the way forward |journal=The Indian Journal of Medical Research |date=2018 |volume=147 |issue=4 |pages=327–329 |doi=10.4103/ijmr.IJMR_616_18 |pmid=29998865 |pmc=6057252 }}</ref> The public hospital system is essentially free for all Indian residents except for small, often symbolic co-payments in some services.<ref>{{cite web|url=https://www.commonwealthfund.org/international-health-policy-center/countries/india|title = India | Commonwealth Fund|date = 5 June 2020}}</ref> At the federal level, a national publicly funded health insurance program was launched in 2018 by the Government of India, called [[Ayushman Bharat]]. This aimed to cover the bottom 50% (500 million people) of the country's population working in the [[unorganized sector]] (enterprises having less than 10 employees) and offers them free treatment at both public and private hospitals.<ref name="Zodpey et al 2018" /> For people working in the organized sector (enterprises with more than 10 employees) and earning a monthly salary of up to ₹21,000 are covered by the social insurance scheme of [[Employees' State Insurance]] which entirely funds their healthcare (along with unemployment benefits), both in public and private hospitals.<ref>{{cite web|url=https://indianexpress.com/article/opinion/columns/covid-india-pension-scheme-health-insurance-7282123/|title=Covid is an opportunity to make structural changes to our largest health insurance and pension schemes|date=21 April 2021}}</ref><ref>https://www.esic.nic.in/coverage</ref> People earning more than that amount are provided health insurance coverage by their employers through either one of the four main public health insurance funds which are the [[National Insurance Company]], [[The Oriental Insurance Company]], [[United India Insurance Company]] and [[New India Assurance]] or a private insurance provider.

As of 2020, 300 million Indians are covered by insurance bought from one of the public or private insurance companies by their employers as group or individual plans.<ref>{{cite web|url=https://indianexpress.com/article/business/why-you-should-not-miss-out-on-your-health-insurance-renewal-7281399/|title = Why you should not miss out on your health insurance renewal|date = 20 April 2021}}</ref> Indian nationals and foreigners who work in the public sector are eligible for a comprehensive package of benefits including, both public and private health, preventive, diagnostic, and curative services and pharmaceuticals with very few exclusions and no cost sharing. Most services including state of the art cardio-vascular procedures, organ transplants, and cancer treatments (including bone marrow transplants) are covered.<ref>{{cite web|url=https://cghs.gov.in/index1.php?lang=1&level=1&sublinkid=6020&lid=3946|title=Eligibility for Joining CGHS - CGHS: Central Government Health Scheme}}</ref> Employers are responsible for paying for an extensive package of services for private sector expatriates (through one of the public or private funds) unless they are eligible for the [[Employees' State Insurance]]. Unemployed people without coverage are covered by the various state funding schemes for emergency hospitalization if they do not have the means to pay for it.<ref>{{cite web|url=https://www.godigit.com/health-insurance/government-health-insurance-schemes|title = 17 Government Health Insurance Schemes in India: Govt Mediclaim Policy}}</ref>
In 2019, the total net government spending on healthcare was $36 billion or 1.23% of its GDP.<ref>₹2.6 trillion</ref> India had allocated 1.8% of its GDP to health in 2020–21. Since the country's independence, the public hospital system has been entirely funded through general taxation.

The National Health Policy was endorsed by the [[Parliament of India]] in 1983 and updated in 2002, and then again updated in 2017. The recent four main updates in 2017 mentions the need to focus on the growing burden of non-communicable diseases, on the emergence of the robust [[healthcare]] industry, on growing incidences of unsustainable expenditure due to health care costs and on rising economic growth enabling enhanced fiscal capacity.<ref name=":0" /> In practice however, the private healthcare sector is responsible for the majority of healthcare in India, and a lot of healthcare expenses are paid directly out of pocket by patients and their families, rather than through health insurance due to incomplete coverage.<ref name=":2">{{cite journal|jstor=25664359|title=The Impoverishing Effect of Healthcare Payments in India: New Methodology and Findings|journal=Economic and Political Weekly|volume=45|issue=16|pages=65–71|last=Berman|first=Peter|date=2010}}</ref> Government health policy has thus far largely encouraged private-sector expansion in conjunction with well designed but limited public health programmes.<ref name="Palgrave">{{cite book|last1=Britnell|first1=Mark|title=In Search of the Perfect Health System|date=2015|publisher=Palgrave|location=London|isbn=978-1-137-49661-4|page=60}}</ref>

According to the [[World Bank]], the total expenditure on health care as a proportion of GDP in 2015 was 3.89%.<ref>{{cite web|url=https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS|title=Health expenditure, total (% of GDP)|work=[[World Bank]]|access-date=1 April 2015}}</ref> Out of 3.89%, the governmental health expenditure as a proportion of GDP is just 1.8%,<ref>{{cite web|url=https://data.worldbank.org/indicator/SH.XPD.GHED.GD.ZS|title=Domestic general government health expenditure (% of GDP)|website=[[World Bank]]}}</ref> and the out-of-pocket expenditure as a proportion of the current health expenditure was 65.06% in 2015.<ref>{{cite web|url=https://data.worldbank.org/indicator/SH.XPD.OOPC.CH.ZS|title=Out-of-pocket expenditure (% of current health expenditure)|website=[[World Bank]]}}</ref>

Attracting 45 percent of [[Medical tourism|health tourists]] visiting India and 30 to 40 percent of domestic health tourists, [[Chennai]] is termed "India's health capital".<ref>{{cite web | title = Chennai – India's Health Capital | publisher = India Health Visit | url = http://www.indiahealthvisit.com/chennai-health-capital.htm | access-date = 1 September 2012}}</ref><ref>{{cite news | title = The quality of air you breathe in Chennai is worse than in Delhi | newspaper = [[The Hindu]] | url = http://www.thehindu.com/news/national/the-quality-of-air-you-breathe-in-chennai-is-worse-than-in-delhi/article7422559.ece
| access-date = 15 July 2015}}</ref><ref>{{Cite news|url=https://www.thehindu.com/news/cities/chennai/air-quality-takes-a-turn-for-the-worse-nungambakkam-sees-pm10-levels-touch-a-maximum-of-173-microgramscubic-metre-in-2018-19/article28068120.ece|title=Chennai's air quality takes a turn for the worse|last=Ramakrishnan|first=Deepa H.|date=19 June 2019|work=The Hindu|access-date=17 August 2019|language=en-IN|issn=0971-751X}}</ref> The Human Rights Measurement Initiative<ref>{{Cite web|title=Human Rights Measurement Initiative – The first global initiative to track the human rights performance of countries|url=https://humanrightsmeasurement.org/|access-date=2022-02-24|website=humanrightsmeasurement.org}}</ref> finds that India is doing 80.5% of what should be possible at its level of income for the right to health.<ref>{{Cite web|title=India - HRMI Rights Tracker|url=https://rightstracker.org/|access-date=2022-02-24|website=rightstracker.org|language=en}}</ref>

==History==
{{See also|Ayurveda|Siddha medicine}}
[[File:GovernmentHospitalChennai.JPG|thumb|265x265px|The [[Rajiv Gandhi Government General Hospital]] in [[Chennai]], the first hospital in [[India]].]]

== Healthcare system ==
=== Public healthcare ===
{{Further|Public health system in India}}
[[Publicly funded health care|Public healthcare]] is free for every Indian resident.<ref>{{cite web|url=http://www.ipsnews.net/2020/07/pathway-universal-healthcare-india/|title=A Pathway to Universal Healthcare in India|date=5 July 2020}}</ref><ref name=":5">{{cite web|last=Rajawat|first=K. Yatish|url=http://qz.com/324487/modis-ambitious-health-policy-may-dwarf-obamacare/|title=Modi's ambitious health policy may dwarf Obamacare|publisher=Quartz – India|website=qz.com|date= 12 January 2015|access-date=18 September 2017}}</ref> The Indian public health sector encompasses 18% of total [[Ambulatory care|outpatient care]] and 44% of total [[inpatient care]].<ref name=":127">{{cite journal|last1=Thayyil|first1=Jayakrishnan|last2=Jeeja|first2=MathummalCherumanalil|date=2013|title=Issues of creating a new cadre of doctors for rural India|journal=International Journal of Medicine and Public Health|language=en|volume=3|issue=1|pages=8|doi=10.4103/2230-8598.109305}}</ref> Middle and upper class individuals living in India tend to use public healthcare less than those with a lower standard of living.<ref name=":72">{{cite journal |last1=Dey |first1=Dipanjan Kumar |last2=Mishra |first2=Vishal |title=Determinants of Choice of Healthcare Services Utilization: Empirical Evidence from India |journal=Indian Journal of Community Health |date=31 December 2014 |volume=26 |issue=4 |pages=356–363 |url=https://iapsmupuk.org/journal/index.php/IJCH/article/view/439 }}</ref> Additionally, women and the elderly are more likely to use public services.<ref name=":72" /> The public health care system was originally developed in order to provide a means to healthcare access regardless of socioeconomic status or caste.<ref name=":9">{{cite journal |last1=Chokshi |first1=M |last2=Patil |first2=B |last3=Khanna |first3=R |last4=Neogi |first4=S B |last5=Sharma |first5=J |last6=Paul |first6=V K |last7=Zodpey |first7=S |title=Health systems in India |journal=Journal of Perinatology |date=December 2016 |volume=36 |issue=S3 |pages=S9–S12 |doi=10.1038/jp.2016.184 |pmid=27924110 |pmc=5144115 }}</ref> However, reliance on public and private healthcare sectors varies significantly between states. Several reasons are cited for relying on the private rather than public sector; the main reason at the national level is poor quality of care in the public sector, with more than 57% of households pointing to this as the reason for a preference for private health care.<ref name="nfhs3 436-440">{{cite web|url=http://www.measuredhs.com/pubs/pdf/FRIND3/FRIND3-Vol1AndVol2.pdf|title=National Family Health Survey (NFHS-3), 2005 –06|author=International Institute for Population Sciences and Macro International|date=September 2007|publisher=Ministry of Health and Family Welfare, Government of India|pages=436–440|access-date=5 October 2012}}</ref> Much of the public healthcare sector caters to the rural areas, and the poor quality arises from the reluctance of experienced healthcare providers to visit the rural areas. Consequently, the majority of the public healthcare system catering to the rural and remote areas relies on inexperienced and unmotivated interns who are mandated to spend time in public healthcare clinics as part of their curricular requirement. Other major reasons are long distances between public hospitals and residential areas, long wait times, and inconvenient hours of operation.<ref name="nfhs3 436-440" />[[File:Osmania General Hospital Hyderabad.JPG|thumb|[[Osmania General Hospital]] Hyderabad|left|251x251px]]

Different factors related to public healthcare are divided between the state and national government systems in terms of making decisions, as the national government addresses broadly applicable healthcare issues such as overall family welfare and prevention of major diseases, while the state governments handle aspects such as local hospitals, public health, promotion and sanitation, which differ from state to state based on the particular communities involved.<ref name=":9" /> Interaction between the state and national governments does occur for healthcare issues that require larger scale resources or present a concern to the country as a whole.<ref name=":9" />

Considering the goal of obtaining [[universal health care]] as part of [[Sustainable Development Goals#Goal 3: Good health and well-being|Sustainable Development Goals]], scholars request policy makers to acknowledge the form of healthcare that many are using. Scholars state that the government has a responsibility to provide health services that are affordable, adequate, new and acceptable for its citizens.<ref name=":72" /> Public healthcare is very necessary, especially when considering the costs incurred with private services. Many citizens rely on [[Subsidised healthcare|subsidized healthcare]].<ref name=":72" /> The national budget, scholars argue, must allocate money to the public healthcare system to ensure the poor are not left with the stress of meeting private sector payments.<ref name=":72" />

Following the [[2014 Indian general election|2014 election]] which brought Prime Minister [[Narendra Modi]] to office, the government unveiled plans for a nationwide [[universal health care]] system known as the [[National Health Assurance Mission]], which would provide all citizens with free drugs, diagnostic treatments, and insurance for serious ailments.<ref>{{Cite news|url=http://in.reuters.com/article/uk-india-health-idINKBN0IJ0VN20141030|title=India's universal healthcare rollout to cost $26 billion|work=Reuters|date=2014-10-30}}</ref> In 2015, implementation of a universal health care system was delayed due to budgetary concerns.<ref>{{Cite news|url=http://in.reuters.com/article/india-health-idINKBN0MM2UT20150327|title=Exclusive: Modi govt puts brakes on India's universal health plan|author=Aditya Kalra|date=27 March 2015|work=Reuters|location=India}}</ref> In April 2018 the government announced the [[Ayushman Bharat Yojana|Aayushman Bharat scheme]] that aims to cover up to Rs. 5 lakh to 100,000,000 vulnerable families (approximately 500,000,000 persons – 40% of the country's population). This will cost around $1.7 billion each year. Provision would be partly through private providers.<ref>{{cite magazine |title=INDIA IS INTRODUCING FREE HEALTH CARE—FOR 500 MILLION PEOPLE |url=https://www.newsweek.com/india-introducing-free-healthcare-500-million-people-1075607 |access-date=2 September 2018 |magazine=Newsweek |date=16 August 2018}}</ref>

===Private healthcare===
[[File:Hinduja Hospital, Mahim, Mumbai.jpg|thumb|[[P.D. Hinduja National Hospital and Medical Research Centre|Hinduja National Hospital]] at [[Mumbai]], [[India]]|left|262x262px]]

Since 2005, most of the healthcare capacity added has been in the private sector, or in partnership with the private sector. The private sector consists of 58% of the hospitals in the country, 29% of beds in hospitals, and 81% of doctors.<ref name=":127" />
[[File:Max Building.jpg|alt=|thumb|[[Max Healthcare]] in [[Delhi]], [[India]]|252x252px]]
According to National Family Health Survey-3, the private medical sector remains the primary source of health care for 70% of households in [[urban area]]s and 63% of households in rural areas.<ref name="nfhs3 436-440" /> The study conducted by IMS Institute for Healthcare Informatics in 2013, across 12 states in over 14,000 households indicated a steady increase in the usage of private healthcare facilities over the last 25 years for both Out-Patient and In-Patient services, across rural and urban areas.<ref>{{cite news|url=http://www.thehindu.com/sci-tech/health/policy-and-issues/more-people-opting-for-private-healthcare/article4967288.ece|title=More people opting for private healthcare|author=Ramya Kannan|date=30 July 2013|access-date=31 July 2013|newspaper=The Hindu|location=Chennai, India}}</ref> In terms of healthcare quality in the private sector, a 2012 study by Sanjay Basu et al., published in ''[[PLOS Medicine]]'', indicated that health care providers in the private sector were more likely to spend a longer duration with their patients and conduct physical exams as a part of the visit compared to those working in public healthcare.<ref>{{cite journal |last1=Basu |first1=Sanjay |last2=Andrews |first2=Jason |last3=Kishore |first3=Sandeep |last4=Panjabi |first4=Rajesh |last5=Stuckler |first5=David |title=Comparative Performance of Private and Public Healthcare Systems in Low- and Middle-Income Countries: A Systematic Review |journal=PLOS Medicine |date=19 June 2012 |volume=9 |issue=6 |pages=e1001244 |doi=10.1371/journal.pmed.1001244 |pmid=22723748 |pmc=3378609 }}</ref>
However, the high out of pocket cost from the private healthcare sector has led many households to incur Catastrophic Health Expenditure, which can be defined as health expenditure that threatens a household's capacity to maintain a basic standard of living.<ref name=":0">{{cite web|url=http://iussp.org/sites/default/files/event_call_for_papers/T.V%20Sekher-IUSSP%20pdf.pdf|title=Catastrophic Health Expenditure and Poor in India: Health Insurance is the Answer?|last=Sekher|first=T.V.|website=iussp.org|access-date=18 September 2017}}</ref> Costs of the private sector are only increasing.<ref name=":87">{{cite journal|last1=Balarajan|first1=Y|last2=Selvaraj|first2=S|last3=Subramanian|first3=SV|title=Health care and equity in India|journal=The Lancet|volume=377|issue=9764|pages=505–515|doi=10.1016/s0140-6736(10)61894-6|pmid=21227492|pmc=3093249|date=2011-02-05}}</ref> One study found that over 35% of poor Indian households incur such expenditure and this reflects the detrimental state in which Indian health care system is at the moment.<ref name=":0" /> With government expenditure on health as a percentage of GDP falling over the years and the rise of private health care sector, the poor are left with fewer options than before to access health care services.<ref name=":0" /> Private insurance is available in India, as are various through government-sponsored health insurance schemes. According to the [[World Bank]], about 25% of India's population had some form of health insurance in 2010.<ref name=":3">{{cite web|url=https://www.worldbank.org/en/news/feature/2012/10/11/government-sponsored-health-insurance-in-india-are-you-covered|title=Government-Sponsored Health Insurance in India: Are You Covered?|date=11 October 2012|website=worldbank.org|publisher=The World Bank Group|access-date=18 September 2017}}</ref> A 2014 Indian government study found this to be an over-estimate, and claimed that only about 17% of India's population was insured.<ref name=":4">{{Cite news|url=http://www.thehindu.com/news/national/only-17-have-health-insurance-cover/article6713952.ece|title=Only 17% have health insurance cover|last1=Mehra|first=Puja|date=9 April 2016|newspaper=The Hindu|access-date=18 September 2017}}</ref> Private healthcare providers in India typically offer high quality treatment at unreasonable costs as there is no regulatory authority or statutory neutral body to check for medical malpractices. In [[Rajasthan]], 40% of practitioners did not have a medical degree and 20% have not completed a [[secondary education]].<ref name=":87" /> On 27 May 2012, the popular show [[Satyamev Jayate (TV series)|Satyamev Jayate]] did an episode on "Does Healthcare Need Healing?" which highlighted the high costs and other malpractices adopted by private clinics and hospitals.<ref>{{cite book|title=In Search of the Perfect Health System|last1=Britnell|first1=Mark|date=2015|publisher=Palgrave|isbn=978-1-137-49661-4|location=London|page=58}}</ref>

===Medication===
{{See also|Pharmaceutical industry in India}}

In 1970, the Indian government banned medical patents. India signed the 1995 [[TRIPS Agreement]] which allows medical patents, but establishes the [[compulsory license]], where any pharmaceutical company has the right to produce any patented product by paying a fee. This right was used in 2012, when Natco was allowed to produce Nexavar, a cancer drug. In 2005, new legislation stipulated that a medicine could not be patented if it did not result in "the enhancement of the known efficacy of that substance".

Indians consumed the most antibiotics per head in the world in 2010. Many antibiotics were on sale in 2018 which had not been approved in India or in the country of origin, although this is prohibited. A survey in 2017 found 3.16% of the medicines sampled were substandard and 0.0245% were fake. Those more commonly prescribed are probably more often faked. Some medications are listed on Schedule H1, which means they should not be sold without a prescription. Pharmacists should keep records of sales with the prescribing doctor and the patient's details.<ref>{{cite news |title=Fake drugs: the global industry putting your life at risk |url=https://mosaicscience.com/story/fake-drugs-global-antibiotics-amr-counterfeit-meds/ |access-date=13 December 2018 |publisher=Mosaic |date=30 October 2018}}</ref>

=== Mental healthcare ===
{{See also|Mental health in India}}[[File:Nimhans garden 4.jpg|thumb|Psychiatry Department, [[NIMHANS]], the apex centre for [[Mental health in India|mental health]] and neuro studies education in the country.]]

==Access to healthcare==
As of 2013, the number of trained medical practitioners in the country was as high as 1.4 million, including 0.7 million graduate allopaths.<ref name=":127"/> Yet, India has failed to reach its [[Millennium Development Goals]] related to health.<ref name=":105">{{cite journal|last1=Dutta|first1=Sabitri|last2=Lahiri|first2=Kausik|date=2015-07-01|title=Is provision of healthcare sufficient to ensure better access? An exploration of the scope for public-private partnership in India|journal=International Journal of Health Policy and Management|volume=4|issue=7|pages=467–474|doi=10.15171/ijhpm.2015.77|pmid=26188811|pmc=4493587}}</ref> The definition of 'access is the ability to receive services of a certain quality at a specific cost and convenience.<ref name=":87"/> The [[Health care|healthcare]] system of India is lacking in three factors related to access to healthcare: provision, [[utilization management|utilization]], and attainment.<ref name=":105"/> Provision, or the supply of healthcare facilities, can lead to utilization, and finally attainment of good health. However, there currently exists a huge gap between these factors, leading to a collapsed system with insufficient access to healthcare.<ref name=":105"/> Differential distributions of services, power, and resources have resulted in inequalities in healthcare access.<ref name=":87"/> Access and entry into hospitals depends on gender, [[socioeconomic status]], education, wealth, and location of residence (urban versus rural).<ref name=":87"/> Furthermore, inequalities in financing healthcare and distance from healthcare facilities are barriers to access.<ref name=":87"/> Additionally, there is a lack of sufficient [[infrastructure]] in areas with high concentrations of poor individuals.<ref name=":105"/> Large numbers of [[tribe]]s and ex-[[Untouchable (social system)|untouchables]] that live in isolated and dispersed areas often have low numbers of professionals.<ref name=":145">{{cite journal|last1=De Costa|first1=Ayesha|last2=Al-Muniri|first2=Abdullah|last3=Diwan|first3=Vinod K.|last4=Eriksson|first4=Bo|title=Where are healthcare providers? Exploring relationships between context and human resources for health Madhya Pradesh province, India|journal=Health Policy|volume=93|issue=1|pages=41–47|doi=10.1016/j.healthpol.2009.03.015|pmid=19559495|year=2009}}</ref> Finally, health services may have long wait times or consider ailments as not serious enough to treat.<ref name=":105"/> Those with the greatest need often do not have access to healthcare.<ref name=":87"/>
[[File:Kerala Institute of Medical Sciences Thiruvananthapuram.jpg|alt=|thumb|Institute of Medical Sciences in Thiruvananthapuram, [[Kerala]].]]

===Electronic health records===

The Government of India, while unveiling the National Health Portal, has come out with guidelines for [[Electronic health record]] standards in India. The document recommends a set of standards to be followed by different healthcare service providers in India, so that medical data becomes portable and easily transferable.<ref>{{cite web|url=http://blog.digmed.in/2013/09/22/e-h-r-standards-for-india-goi-report/ |title=E.H.R Standards for India : GOI Report |publisher=GOI|access-date=30 September 2013}}</ref>

India is considering to set up a National eHealth Authority (NeHA) for standardisation, storage and exchange of electronic health records of patients as part of the government's [[Digital India]] programme. The authority, to be set up by an Act of Parliament will work on the integration of multiple health IT systems in a way that ensures security, confidentiality and privacy of patient data. A centralised electronic health record repository of all citizens which is the ultimate goal of the authority will ensure that the health history and status of all patients would always be available to all health institutions. Union Health Ministry has circulated a concept note for the setting up of '''NeHa''', inviting comments from stakeholders.<ref>{{Cite news|url=http://indianexpress.com/article/india/india-others/digital-india-programme-govt-mulls-setting-up-ehealth-authority/|title=Digital India programme: Govt mulls setting up eHealth Authority|date=2015-04-11|work=The Indian Express|access-date=2017-10-12|language=en-US}}</ref>

=== Rural areas ===
Rural areas in India have a shortage of medical professionals.<ref name=":127"/> 74% of doctors are in urban areas that serve the other 28% of the population.<ref name=":127"/> This is a major issue for rural access to healthcare. The lack of human resources causes citizens to resort to fraudulent or ignorant providers.<ref name=":127"/> Doctors tend not to work in rural areas due to insufficient housing, healthcare, education for children, drinking water, electricity, roads and transportation.<ref name=":145"/> Additionally, there exists a shortage of [[infrastructure]] for health services in rural areas.<ref name=":127"/> In fact, urban public hospitals have twice as many beds as rural hospitals, which are lacking in supplies.<ref name=":87"/> Studies have indicated that the mortality risks before the age of five are greater for children living in certain rural areas compared to urban communities.<ref name=":10">{{cite journal|last1=BARU|first1=RAMA|last2=ACHARYA|first2=ARNAB|last3=ACHARYA|first3=SANGHMITRA|last4=KUMAR|first4=A K SHIVA|last5=NAGARAJ|first5=K|date=2010|title=Inequities in Access to Health Services in India: Caste, Class and Region|jstor=25742094|journal=Economic and Political Weekly|volume=45|issue=38|pages=49–58}}</ref> Full [[immunization]] coverage also varies between rural and urban India, with 39% completely immunized in rural communities and 58% in urban areas across India.<ref name=":10" /> Inequalities in healthcare can result from factors such as socioeconomic status and [[caste]], with caste serving as a social determinant of healthcare in India.<ref name=":10" />

==== Case study in Rural India ====
A 2007 study by Vilas Kovai et al., published in the ''[[Indian Journal of Ophthalmology]]'' analyzed barriers that prevent people from seeking eye care in rural [[Andhra Pradesh|Andhra Pradesh, India]].<ref name=":11">{{cite journal |last1=Kovai |first1=Vilas |last2=Krishnaiah |first2=Sannapaneni |last3=Shamanna |first3=BindiganavaleRamaswamy |last4=Thomas |first4=Ravi |last5=Rao |first5=GullapalliN |title=Barriers to accessing eye care services among visually impaired populations in rural Andhra Pradesh, South India |journal=Indian Journal of Ophthalmology |date=2007 |volume=55 |issue=5 |pages=365–71 |doi=10.4103/0301-4738.33823 |pmid=17699946 |pmc=2636013 }}</ref> The results displayed that in cases where people had awareness of eyesight issues over the past five years but did not seek treatment, 52% of the respondents had personal reasons (some due to own beliefs about the minimal extent of issues with their vision), 37% economic hardship, and 21% social factors (such as other familial commitments or lacking an accompaniment to the healthcare facility).<ref name=":11" />

The role of technology, specifically mobile phones in health care has also been explored in recent research as India has the second largest wireless communication base in the world, thus providing a potential window for mobile phones to serve in delivering health care.<ref name=":13">{{cite journal |last1=DeSouza |first1=Sherwin I. |last2=Rashmi |first2=M. R. |last3=Vasanthi |first3=Agalya P. |last4=Joseph |first4=Suchitha Maria |last5=Rodrigues |first5=Rashmi |title=Mobile Phones: The Next Step towards Healthcare Delivery in Rural India? |journal=PLOS ONE|date=18 August 2014 |volume=9 |issue=8 |pages=e104895 |doi=10.1371/journal.pone.0104895 |pmid=25133610 |pmc=4136858 |bibcode=2014PLoSO...9j4895D |doi-access=free }}</ref> Specifically, in one 2014 study conducted by Sherwin DeSouza et al. in a rural village near [[Karnataka]], India, it was found that participants in community who owned a mobile phone (87%) displayed a high interest rate (99%) in receiving healthcare information through this mode, with a greater preference for voice calls versus SMS (text) messages for the healthcare communication medium.<ref name=":13" /> Some specific examples of healthcare information that could be provided includes reminders about vaccinations and medications and general health awareness information.<ref name=":13" />

==== Rural north India ====
The distribution of healthcare providers varies for rural versus urban areas in North India.<ref name=":6">{{cite journal|last1=De Costa|first1=Ayesha|last2=Diwan|first2=Vinod|title=Where is the public health sector?|journal=Health Policy|volume=84|issue=2–3|pages=269–276|doi=10.1016/j.healthpol.2007.04.004|pmid=17540472|year=2007}}</ref> A 2007 study by Ayesha De Costa and Vinod Diwan, published in ''[[Health Policy (journal)|Health Policy]],'' conducted in [[Madhya Pradesh]], India examined the distribution of different types of healthcare providers across urban and rural Madhya Pradesh in terms of the differences in access to healthcare through number of providers present.<ref name=":6" /> The results indicated that in rural Madhya Pradesh, there was one physician per 7870 people, while there was one physician per 834 people in the urban areas of the region.<ref name=":6" /> In terms of other healthcare providers, the study found that of the qualified paramedical staff present in Madhya Pradesh, 71% performed work in the rural areas of the region.<ref name=":6" /> In addition, 90% of traditional birth attendants and unqualified healthcare providers in Madhya Pradesh worked in the rural communities.<ref name=":6" />

Studies have also investigated determinants of healthcare-seeking behavior (including socioeconomic status, education level, and gender), and how these contribute to overall access to healthcare accordingly.<ref name=":7">{{cite journal |last1=Raza |first1=Wameq A. |last2=Van de Poel |first2=Ellen |last3=Panda |first3=Pradeep |last4=Dror |first4=David |last5=Bedi |first5=Arjun |title=Healthcare seeking behaviour among self-help group households in Rural Bihar and Uttar Pradesh, India |journal=BMC Health Services Research |date=December 2015 |volume=16 |issue=1 |pages=1 |doi=10.1186/s12913-015-1254-9 |pmid=26728278 |pmc=4698810 }}</ref> A 2016 study by Wameq Raza et al., published in ''BMC Health Services Research,'' specifically surveyed healthcare-seeking behaviors among people in rural [[Bihar]] and [[Uttar Pradesh]], India.<ref name=":7" /> The findings of the study displayed some variation according to acute illnesses versus chronic illnesses.<ref name=":7" /> In general, it was found that as socioeconomic status increased, the probability of seeking healthcare increased.<ref name=":7" /> Educational level did not correlate to probability of healthcare-seeking behavior for acute illnesses, however, there was a positive correlation between educational level and chronic illnesses.<ref name=":7" /> This 2016 study also considered the social aspect of gender as a determinant for health-seeking behavior, finding that male children and adult men were more likely to receive treatment for acute ailments compared to their female counterparts in the areas of rural Bihar and Uttar Pradesh represented in the study.<ref name=":7" /> These inequalities in healthcare based on gender access contribute towards the differing mortality rates for boys versus girls, with the mortality rates greater for girls compared to boys, even before the age of five.<ref name=":16">{{cite journal|last1=Pandey|first1=Aparna|last2=Sengupta|first2=Priya Gopal|last3=Mondal|first3=Sujit Kumar|last4=Gupta|first4=Dhirendra Nath|last5=Manna|first5=Byomkesh|last6=Ghosh|first6=Subrata|last7=Sur|first7=Dipika|last8=Bhattacharya|first8=S.K.|date=2002|title=Gender Differences in Healthcare-seeking during Common Illnesses in a Rural Community of West Bengal, India|jstor=23498918|journal=Journal of Health, Population, and Nutrition|volume=20|issue=4|pages=306–311|pmid=12659410 }}</ref>

Other previous studies have also delved into the influence of gender in terms of access to healthcare in rural areas, finding gender inequalities in access to healthcare.<ref name=":16" /> A 2002 study with data taken from June 1998 to May 1999 was conducted by Aparna Pandey et al., published in the ''Journal of Health, Population, and Nutrition,'' analyzed care-seeking behaviors by families for girls versus boys, given similar sociodemographic characteristics in [[West Bengal]], India.<ref name=":16" /> In general, the results exhibited clear gender differences such that boys received treatment from a healthcare facility if needed in 33% of the cases, while girls received treatment in 22% of the instances requiring care.<ref name=":16" /> Furthermore, surveys indicated that the greatest gender inequality in access to healthcare in India occurred in the provinces of [[Haryana]], and [[Punjab, India|Punjab]].<ref name=":16" />

=== Urban Areas ===
The problem of healthcare access arises not only in huge cities but in rapidly growing small urban areas.<ref name=":24">{{cite journal |last1=Sharma |first1=J |last2=Osrin |first2=D |last3=Patil |first3=B |last4=Neogi |first4=S B |last5=Chauhan |first5=M |last6=Khanna |first6=R |last7=Kumar |first7=R |last8=Paul |first8=V K |last9=Zodpey |first9=S |title=Newborn healthcare in urban India |journal=Journal of Perinatology |date=December 2016 |volume=36 |issue=S3 |pages=S24–S31 |doi=10.1038/jp.2016.187 |pmid=27924107 |pmc=5144125 }}</ref> Here, there are fewer available options for healthcare services and there are less organized governmental bodies.<ref name=":24"/> Thus, there is often a lack of accountability and cooperation in healthcare departments in urban areas.<ref name=":24"/> It is difficult to pinpoint an establishment responsible for providing urban health services, compared to in rural areas where the responsibility lies with the [[District administration in India|district administration]].<ref name=":24"/> Additionally, health inequalities arise in urban areas due to difficulties in residence, [[Socioeconomic status|socioeconomic]] status, and [[discrimination]] against unlisted [[slum]]s.<ref name=":24"/>

To survive in this environment, urban people use [[Non-governmental organization|non-governmental]], private services which are plentiful.<ref name=":24"/> However, these are often understaffed, require three times the payment as a public center, and commonly have bad practice methods.<ref name=":24"/> To counter this, there have been efforts to join the public and private sectors in urban areas.<ref name=":24"/> An example of this is the [[Public-private partnerships in India|Public-Private Partnerships]] initiative.<ref name=":105"/> However, studies show that in contrast to rural areas, qualified physicians tend to reside in urban areas.<ref name=":145"/> This can be explained by both [[urbanization]] and specialization. Private doctors tend to be specialized in a specific field so they reside in urban areas where there is a higher market and financial ability for those services.<ref name=":145"/>

=== Financing ===
Despite being one of the most populous countries, India has the most private healthcare in the world.<ref name=":112">{{cite journal |last1=Duggal |first1=Ravi |title=Healthcare in India: Changing the Financing Strategy |journal=Social Policy & Administration |date=August 2007 |volume=41 |issue=4 |pages=386–394 |doi=10.1111/j.1467-9515.2007.00560.x }}</ref> Out-of-pocket private payments make up 75% of the total expenditure on healthcare.<ref name=":132">{{cite journal|last1=Bhardwaj|first1=Geeta|last2=Monga|first2=Anuradha|last3=Shende|first3=Ketan|last4=Kasat|first4=Sachin|last5=Rawat|first5=Sachin|date=1 April 2014|title=Healthcare at the Bottom of the Pyramid An Assessment of Mass Health Insurance Schemes in India|journal=Journal of the Insurance Institute of India|volume=1|issue=4|pages=10–22}}</ref> Only one fifth of healthcare is financed publicly.<ref name=":112" /> This is in stark contrast to most other countries of the world.<ref name=":132" /> According to the [[World Health Organization]] in 2007, India ranked 184 out of 191 countries in the amount of public expenditure spent on healthcare out of total [[Gross domestic product|GDP]].<ref name=":132" /> In fact, public spending stagnated from 0.9% to 1.2% of total GDP in 1990 to 2010.<ref name=":132" />

Medical and non-medical [[Out-of-pocket expense|out-of-pocket]] private payments can affect access to healthcare.<ref name=":105"/> Poorer populations are more affected by this than the wealthy. The poor pay a disproportionately higher percent of their income towards out-of-pocket expenses than the rich.<ref name=":132" /> The Round National Sample Survey of 1955 through 1956 showed that 40% of all people sell or borrow assets to pay for hospitalization.<ref name=":112" /> Half of the bottom two quintiles go into debt or sell their [[asset]]s, but only a third of the top quintiles do.<ref name=":112" /> In fact, about half the households that drop into the lower classes do so because of health expenditures.<ref name=":87"/> This data shows that financial ability plays a role in determining healthcare access.<ref name=":132" />

In terms of non-medical costs, distance can also prevents access to healthcare.<ref name=":87"/> Costs of transportation prevent people from going to health centers.<ref name=":105"/> According to scholars, [[Outreach|outreach programs]] are necessary to reach marginalized and isolated groups.<ref name=":87"/>

In terms of medical costs, out-of-pocket hospitalization fees prevent access to healthcare.<ref name=":105"/> 40% of people that are hospitalized are pushed either into lifelong debt or below the [[Poverty line in India|poverty line]].<ref name=":132" /> Furthermore, over 23% of patients don't have enough money to afford treatment and 63% lack regular access to necessary medications.<ref name=":105"/> Healthcare and treatment costs have inflated 10–12% a year and with more advancements in medicine, costs of treatment will continue to rise.<ref name=":132" /> Finally, the price of medications rise as they are not controlled.<ref name=":87"/>

There is a major gap between outreach, finance and access in India. Without outreach, services cannot be spread to distant locations.<ref name=":105"/> Without financial ability, those in distant locations cannot afford to access healthcare.<ref name=":105"/> According to scholars, both of these issues are tied together and are pitfalls of the current healthcare system.

== Initiatives to improve access ==
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=== Government-led ===

==== The Twelfth Plan ====
The government of India has a Twelfth Plan to expand the [[National Rural Health Mission]] to the entire country, known as the [[National Health Mission]].<ref name=":24"/> Community based health insurance can assist in providing services to areas with disadvantaged populations.<ref name=":93">{{cite journal|last1=Prinja|first1=Shankar|last2=Kaur|first2=Manmeet|last3=Kumar|first3=Rajesh|date=2012-07-01|title=Universal Health Insurance in India: Ensuring equity, efficiency, and quality|journal=Indian Journal of Community Medicine|language=en|volume=37|issue=3|pages=142–9|doi=10.4103/0970-0218.99907|pmid=23112438|pmc=3483505}}</ref> Additionally, it can help to emphasize the responsibility of the local government in making resources available.<ref name=":93"/> Furthermore, according to the [[Indian Journal of Community Medicine]] (IJOCM) the government should reform health insurance as well as its reach in India. The journal states that [[Universal health care|universal healthcare]] should slowly yet steadily be expanded to the entire population. Healthcare should be mandatory and no money should be exchanged at appointments.<ref name=":93"/> Finally, both private and public sectors should be involved to ensure all marginalized areas are reached. According to the IJOCM, this will increase access for the poor.<ref name=":93"/>

See [[Twelfth Five Year Plan (India)]].

==== National Rural Health Mission ====
To counteract the issue of a lack of professionals in rural areas, the government of India wants to create a '[[Cadre (military)|cadre]]' of rural doctors through governmental organizations.<ref name=":127"/> The [[National Rural Health Mission]] (NRHM) was launched in April 2005 by the Government of India. The NRHM has outreach strategies for disadvantaged societies in isolated areas.<ref name=":93"/> The goal of the NRHM is to provide effective healthcare to rural people with a focus on 18 states with poor public health indicators and/or weak [[infrastructure]].<ref>Umesh Kapil and Panna Choudhury [http://medind.nic.in/ibv/t05/i8/ibvt05i8p783.pdf National Rural Health Mission (NRHM): Will it Make a Difference?] Indian Pediatrics Vol. 42 (2005): 783</ref> NRHM has 18,000 ambulances and a workforce of 900,000 community health volunteers and 178,000 paid staff.<ref>{{cite book|title=In Search of the Perfect Health System|last1=Britnell|first1=Mark|date=2015|publisher=Palgrave|isbn=978-1-137-49661-4|location=London|page=60}}</ref> The mission proposes creating a course for medical students that is centered around rural healthcare.<ref name=":127" /> Furthermore, NRHM wants to create a compulsory rural service for younger doctors in the hopes that they will remain in rural areas.<ref name=":127" /> However, the NRHM has failings. For example, even with the mission, most construction of health related infrastructure occurs in urban cities.<ref name=":127" /> Many scholars call for a new approach that is local and specialized to each state's rural areas.<ref name=":93" /> Other regional programs such as the Rajiv Aarogyasri Community Health Insurance Scheme in [[Andhra Pradesh]], India have also been implemented by state governments to assist rural populations in healthcare accessibility, but the success of these programs (without other supplemental interventions at the health system level) has been limited.<ref>{{cite journal|last1=MITCHELL|first1=ANDREW|last2=MAHAL|first2=AJAY|last3=BOSSERT|first3=THOMAS|date=2011|title=Healthcare Utilisation in Rural Andhra Pradesh|jstor=27918082|journal=Economic and Political Weekly|volume=46|issue=5|pages=15–19}}</ref>

==== National Urban Health Mission ====
The National Urban Health Mission as a sub-mission of [[National Health Mission]] was approved by the cabinet on 1 May 2013.<ref name=":18">{{cite web|url=http://nrhm.gov.in/nhm/nuhm.html|title=NUHM|access-date=6 May 2015}}</ref> The National Urban Health Mission (NUHM) works in 779 cities and towns with populations of 50,000 each.<ref name=":24"/> As urban health professionals are often [[specialty (medicine)|specialized]], current urban healthcare consists of [[Secondary hospital|secondary]] and [[Tertiary referral hospital|tertiary]], but not [[primary care]].<ref name=":24" /><ref name=":145"/> Thus, the mission focuses on expanding primary health services to the urban poor.<ref name=":24" /> The initiative recognizes that urban healthcare is lacking due to [[overpopulation]], exclusion of populations, lack of information on health and economic ability, and unorganized health services.<ref name=":172">{{cite journal|last1=John|first1=Denny|last2=Chander|first2=SJ|last3=Devadasan|first3=Narayanan|date=2008-07-02|title=National Urban Health Mission: An analysis of strategies and mechanisms for improving services for urban poor|url=https://www.researchgate.net/publication/264259923|doi=10.13140/2.1.2036.5443|publisher=Unpublished}}</ref> Thus, NUHM has appointed three tiers that need improvement: Community level (including [[Outreach|outreach programs]]), Urban Health Center level (including infrastructure and improving existing health systems), and Secondary/Tertiary level ([[Public–private partnership|Public-Private Partnerships]]).<ref name=":172" /> Furthermore, the initiative aims to have one Urban Public Health Center for each population of 50,000 and aims to fix current facilities and create new ones. It plans for small [[Municipal Government|municipal governments]] to take responsibility for planning healthcare facilities that are prioritized towards the urban poor, including unregistered slums and other groups.<ref name=":24" /> Additionally, NUHM aims to improve [[sanitation]] and drinking water, improve [[Community outreach|community outreach programs]] to further access, reduce out-of-pocket expenses for treatment, and initiate monthly health and nutrition days to improve community health.<ref name=":24" /><ref name=":172" /><ref name=":18" />

==== Pradhan Mantri Jan Arogya Yojana (PM-JAY) ====
Pradhan Mantri Jan Arogya Yojana (PM-JE) is an initiative to ensure health coverage for the poor and weaker population in India.
This initiative is part of the government's view to ensure that its citizens – particularly poor and weaker groups, have access to healthcare and good quality hospital services without facing financial difficulty.

PM-JAY Provides insurance cover up to Rs 5 lakh per annum to the 100 million families in India for secondary and tertiary hospitalization. For transparency, the government made an online portal (Mera PmJay) to check eligibility for PMJAY.
Health care service includes follow-up care, daycare surgeries, pre and post hospitalization, hospitalization expenses, expense benefits and newborn child/children services. The comprehensive list of services is available on the website.<ref>{{cite web|url=https://mera.pmjay.co.in/|title= Pradhan Mantri Jan Arogya Yojana|date= 2018-10-11}}</ref>

=== Public-private partnership ===
One initiative adapted by governments of many states in India to improve access to healthcare entails a combination of public and private sectors. The [[Public–private partnerships in India|Public-Private Partnership Initiative]] (PPP) was created in the hopes of reaching the health-related [[Millennium Development Goals]].<ref name=":105" /> In terms of prominence, nearly every new state health initiative includes policies that allow for the involvement of private entities or non-governmental organizations.<ref name=":12">{{cite book|last1=Bhat|first1=Ramesh|title=Public–Private Partnerships: Managing contracting arrangements to strengthen the Reproductive and Child Health Programme in India.|last2=Huntington|first2=Dale|last3=Maheshwari|first3=Sunil|publisher=World Health Organization|year=2007}}</ref>

==== Major programs ====
Fair Price Shops aim to reduce the costs of medicines, drugs, [[implant (medicine)|implant]]s, [[Prosthesis|prosthetics]], and [[Orthopedic surgery|orthopedic]] devices. Currently, there is no competition between pharmacies and medical service stores for the sale of drugs.<ref name=":105" /> Thus, the price of drugs is uncontrolled.<ref name=":87" /> The Fair Price program creates a [[bidding system]] for cheaper prices of medications between drugstores and allows the store with the greatest discount to sell the drug. The program has a minimal cost for the government as fair price shops take the place of drugstores at government hospitals, thus eliminating the need to create new infrastructure for fair price shops.<ref name=":105" /> Furthermore, the drugs are [[unbranded]] and must be prescribed by their [[Generic drug|generic]] name.<ref name=":105" /> As there is less advertising required for generic brands, fair price shops require minimal payment from the private sector.<ref name=":105" /> Fair Price Shops were introduced in the [[West Bengal]] in 2012. By the end of the year, there were 93 stores benefiting 85 [[lakh]] people. From December 2012 to November 2014, these shops had saved 250 [[crore]] citizens.<ref name=":105" /> As doctors prescribe 60% generic drugs, the cost of treatment has been reduced by this program. This is a solution to affordability for health access in West Bengal.<ref name=":105" />

The largest segment of the PPP initiative is the tax-financed program, [[Rashtriya Swasthya Bima Yojana]] (RSBY).<ref name=":162">{{cite journal|last1=Karan|first1=Anup|last2=Yip|first2=Winnie|last3=Mahal|first3=Ajay|date=May 2017|title=Extending health insurance to the poor in India: An impact evaluation of Rashtriya Swasthya Bima Yojana on out of pocket spending for healthcare|journal=Social Science & Medicine|volume=181|pages=83–92|doi=10.1016/j.socscimed.2017.03.053|pmc=5408909|pmid=28376358}}</ref> The scheme is financed 75% by the central government and 25% by the state government.<ref name=":105" /> This program aims to reduce medical out-of-pocket costs for hospital treatment and visits by reimbursing those that live below the [[Poverty line in India|poverty line]].<ref name=":105" /> RSBY covers maximum 30,000 [[rupee]]s in hospital expenses, including [[pre-existing condition]]s for up to five members in a family.<ref name=":105" /> In 2015, it reached 37 million households consisting of 129 million people below the poverty line.<ref name=":105" /> However, a family has to pay 30 rupees to register in the program.<ref name=":152">Borooah, Vani and Mishra, Vinod and Naik, Ajaya and Sabharwal, Nidhi (2015): ''Capturing Benefits from Public Policy Initiatives in India: Inter-Group Differences in Access to and Usage of the Rashtriya Swasthya Bima Yojana Health Insurance Cards.'' Published in: Amity Journal of Economics , Vol. 1, No. 1 (2016): pp. 1–17.</ref> Once deemed eligible, family members receive a yellow card.<ref name=":152" /> However, studies show that in [[Maharashtra]], those with a lower socioeconomic status tend to not use the service, even if they are eligible.<ref name=":152" /> In the state of [[Uttar Pradesh]], geography and council affect participation in the program. Those in the outskirts of villages tend to use the service less than those who live in the center of villages.<ref name=":152" /> Additionally, studies show household non-medical expenses as increasing due to this program; the probability of incurring out-of-pocket expenses has increased by 23%.<ref name=":162" /> However, RSBY has stopped many from falling into poverty as a result of healthcare.<ref name=":105" /> Furthermore, it has improved opportunities for family members to enter the workforce as they can utilize their income for other needs besides healthcare.<ref name=":162" /> RSBY has been applied in 25 states of India.<ref name=":152" />

Finally, the National Rural Telemedicine Network connects many healthcare institutions together so doctors and physicians can provide their input into diagnosis and consultations.<ref name=":105" /> This reduces the non-medical cost of transportation as patients do not have to travel far to get specific doctor's or specialty's opinions.<ref name=":105" /> However, problems arise in terms of the level of care provided by different networks. While some level of care is provided, telemedical initiatives are unable to provide drugs and diagnostic care, a necessity in rural areas.<ref name=":19">{{cite journal|last=Ravindran|first=T. K. Sundari|date=26 November 2011|title=Public-Private Partnerships in Maternal Health Services|journal=Economic and Political Weekly|volume=46|issue=48|pages=43–52}}</ref>

==== Effectiveness ====
The effectiveness of public-private partnerships in healthcare is hotly disputed. Critics of PPP are concerned of its presentation as a cure-all solution, by which the health infrastructure can be improved.<ref name=":19" /> Proponents of PPP claim that these partnerships take advantage of existing infrastructure in order to provide care for the underprivileged.<ref name=":12" />

The results of the PPP in the states of Maharashtra and West Bengal show that all three of these programs are effective when used in combination with federal health services. They assist in filling the gap between outreach and affordability in India.<ref name=":105" /> However, even with these programs, high [[Out-of-pocket expense|out-of-pocket payments]] for non-medical expenses are still deterring people from healthcare access.<ref name=":105" /> Thus, scholars state that these programs need to be expanded across India.<ref name=":105" />

A case study of tuberculosis control in rural areas, in which PPP was utilized showed limited effectiveness; while the program was moderately effective, a lack of accountability forced the program to shut down.<ref>{{cite journal|last1=Rangan|first1=S. G.|last2=Juvekar|first2=S. K.|last3=Rasalpurkar|first3=S. B.|last4=Morankar|first4=S. N.|last5=Joshi|first5=A. N.|last6=Porter|first6=J. D. H.|date=2004|title=Tuberculosis control in rural India: lessons from public-private collaboration|journal=International Journal of Tuberculosis and Lung Disease|volume=8|issue=5|pages=552–559|pmid=15137530}}</ref> Similar issues in accountability were seen by the parties involved within other PPP schemes. Facilitators and private practitioners, when asked about PPP, identified lack of state support, in the form of adequate funding, and a lack of coordination, as primary reasons why PPP ventures are unsuccessful.<ref>{{cite journal |last1=Yadav |first1=Vikas |last2=Kumar |first2=Somesh |last3=Balasubramaniam |first3=Sudharsanam |last4=Srivastava |first4=Ashish |last5=Pallipamula |first5=Suranjeen |last6=Memon |first6=Parvez |last7=Singh |first7=Dinesh |last8=Bhargava |first8=Saurabh |last9=Sunil |first9=Greeshma Ann |last10=Sood |first10=Bulbul |title=Facilitators and barriers to participation of private sector health facilities in government-led schemes for maternity services in India: a qualitative study |journal=BMJ Open |date=June 2017 |volume=7 |issue=6 |pages=e017092 |doi=10.1136/bmjopen-2017-017092 |pmid=28645984 |pmc=5541501 }}</ref>

In the most successful PPP ventures, the World Health Organization found that the most prominent factor, aside from financial support, was ownership of the project by state and local governments.<ref name=":12" /> It was found that programs sponsored by the state governments were more effective in achieving health goals than programs set by national governments.<ref name=":12" />

India has set up a National Telemedicine Taskforce by the Health Ministry of India, in 2005, paved way for the success of various projects like the ICMR-AROGYASREE, NeHA and VRCs. Telemedicine also helps family physicians by giving them easy access to speciality doctors and helping them in close monitoring of patients. Different types of telemedicine services like store and forward, real-time and remote or self-monitoring provides various educational, healthcare delivery and management, disease screening and disaster management services all over the globe. Even though telemedicine cannot be a solution to all the problems, it can surely help decrease the burden of the healthcare system to a large extent.<ref>{{cite journal |title=Telemedicine in India: Where do we stand? |year=2019 |publisher=PMC |pmc=6618173 |last1=Chellaiyan |first1=V. G. |last2=Nirupama |first2=A. Y. |last3=Taneja |first3=N. |journal=Journal of Family Medicine and Primary Care |volume=8 |issue=6 |pages=1872–1876 |doi=10.4103/jfmpc.jfmpc_264_19 |pmid=31334148 }}</ref>

== Quality of healthcare ==
[[File:Hospital .jpg|alt=|thumb|A community medical provider in Kerala which promotes traditional Indian medicine, or Ayurveda.]]
Non-availability of diagnostic tools and increasing reluctance of qualified and experienced healthcare professionals to practice in rural, under-equipped and financially less lucrative rural areas are becoming big challenges.
Rural medical practitioners are highly sought after by residents of rural areas as they are more financially affordable and geographically accessible than practitioners working in the formal public health care sector.<ref>{{cite journal|last=Kanjilal|first=B|title=A Parallel Health Care market: Rural Medical Practitioners in West Bengal, India|journal=FHS Research Brief|date=June 2007|volume=02|url=http://www.futurehealthsystems.org/storage/Indianinformalproviderbrief1.pdf|access-date=30 May 2012|display-authors=etal|url-status=dead|archive-url=https://web.archive.org/web/20120324152019/http://www.futurehealthsystems.org/storage/Indianinformalproviderbrief1.pdf|archive-date=24 March 2012}}</ref> But there are incidents where doctors were attacked and even killed in rural India.<ref>{{cite journal |title=Assaults on public hospital staff by patients and their relatives: an inquiry |journal=[[Indian Journal of Medical Ethics]] |url=http://www.ijme.in/index.php/ijme/article/view/646/1613 |access-date=2016-10-20 }}</ref>
In 2015 the [[British Medical Journal]] published a report by Dr Gadre, from [[Kolkata]], exposed the extent of malpractice in the Indian healthcare system. He interviewed 78 doctors and found that kickbacks for referrals, irrational drug prescribing and unnecessary interventions were commonplace.<ref>{{cite news|last1=Fox|first1=Hannah|title=I've seen first-hand how palliative care in India is compromised by privatisation|url=https://www.theguardian.com/healthcare-network/2015/apr/08/palliative-care-india-compromised-privatisation|access-date=19 April 2015|newspaper=The Guardian|date=8 April 2015}}</ref>

According to a study conducted by Martin Patrick, CPPR chief economist released in 2017 has projected people depend more on private sector for healthcare and the amount spent by a household to avail of private services is almost 24 times more than what is spent for public healthcare services.<ref>{{Cite news|url=http://www.newindianexpress.com/cities/kochi/2017/jun/11/researchers-in-kochi-call-for-revival-of-public-healthcare-system-1615300.html|title=Researchers in Kochi call for revival of public healthcare system|work=The New Indian Express|access-date=2017-10-01}}</ref>

=== South India ===
In many rural communities throughout India, healthcare is provided by what is known as informal providers, who may or may not have proper medical accreditation to diagnose and treat patients, generally offering consults for common ailments.<ref name=":1">{{cite journal |last1=Gautham |first1=M. |last2=Shyamprasad |first2=K. M. |last3=Singh |first3=R. |last4=Zachariah |first4=A. |last5=Singh |first5=R. |last6=Bloom |first6=G. |title=Informal rural healthcare providers in North and South India |journal=Health Policy and Planning |date=1 July 2014 |volume=29 |issue=suppl 1 |pages=i20–i29 |doi=10.1093/heapol/czt050 |pmid=25012795 |pmc=4095923 }}</ref> Specifically, in [[Guntur]], Andhra Pradesh, India, these informal healthcare providers generally practice in the form of services in the homes of patients and prescribing allopathic drugs.<ref name=":1" /> A 2014 study by Meenakshi Gautham et al., published in the journal ''Health Policy and Planning'', found that in Guntur, about 71% of patients received injections from informal healthcare providers as a part of illness management strategies.<ref name=":1" /> The study also examined the educational background of the informal healthcare providers and found that of those surveyed, 43% had completed 11 or more years of schooling, while 10% had graduated from college.<ref name=":1" />

In general, the perceived quality of healthcare also has implications on patient adherence to treatment.<ref name=":8">{{cite journal |last1=Mekoth |first1=Nandakumar |last2=Dalvi |first2=Vidya |title=Does Quality of Healthcare Service Determine Patient Adherence? Evidence from the Primary Healthcare Sector in India |journal=Hospital Topics |date=3 July 2015 |volume=93 |issue=3 |pages=60–68 |doi=10.1080/00185868.2015.1108141 |pmid=26652042 |s2cid=44984389 }}</ref><ref name=":15" /> A 2015 study conducted by Nandakumar Mekoth and Vidya Dalvi, published in ''Hospital Topics'' examined different aspects that contribute to a patient's perception of quality of healthcare in [[Karnataka]], India, and how these factors influenced adherence to treatment.<ref name=":8" /> The study incorporated aspects related to quality of healthcare including interactive quality of physicians, base-level expectation about primary health care facilities in the area, and non-medical physical facilities (including drinking water and restroom facilities).<ref name=":8" /> In terms of adherence to treatment, two sub-factors were investigated, persistence of treatment and treatment-supporting adherence (changes in health behaviors that supplement the overall treatment plan).<ref name=":8" /> The findings indicated that the different quality of healthcare factors surveyed all had a direct influence on both sub-factors of adherence to treatment.<ref name=":8" /> Furthermore, the base-level expectation component in quality of healthcare perception, presented the most significant influence on overall adherence to treatment, with the interactive quality of physicians having the least influence on adherence to treatment, of three aspects investigated in this study.<ref name=":8" />

=== North India ===
In a particular district of [[Uttarakhand]], India known as Tehri, the educational background of informal healthcare providers indicated that 94% had completed 11 or more years of schooling, while 43% had graduated from college.<ref name=":1" /> In terms of the mode of care delivered, 99% of the health services provided in Tehri were through the clinic, whereas in Guntur, Andhra Pradesh, 25% of the health care services are delivered through the clinic, while 40% of the care provided is mobile (meaning that healthcare providers move from location to location to see patients), and 35% is a combination of clinic and mobile service.<ref name=":1" />
[[File:Vaccination-polio-india.jpg|alt=|thumb|A healthcare worker gives pediatric polio vaccination to a young boy.]]
In general throughout India, the private healthcare sector does not have a standard of care that is present across all facilities, leading to many variations in the quality of care provided.<ref name=":15">{{cite journal|last1=Sharma|first1=J K|last2=Narang|first2=Ritu|date=2011-01-01|title=Quality of Healthcare Services in Rural India: The User Perspective|journal=Vikalpa|language=en|volume=36|issue=1|pages=51–60|doi=10.1177/0256090920110104|s2cid=59352669}}</ref> In particular, a 2011 study by Padma Bhate-Deosthali et al., published in ''[[Reproductive Health Matters]],'' examined the quality of healthcare particularly in the area of maternal services through different regions in [[Maharashtra]], India.<ref name=":14">{{cite journal |last1=Bhate-Deosthali |first1=Padma |last2=Khatri |first2=Ritu |last3=Wagle |first3=Suchitra |title=Poor standards of care in small, private hospitals in Maharashtra, India: implications for public–private partnerships for maternity care |journal=Reproductive Health Matters |date=January 2011 |volume=19 |issue=37 |pages=32–41 |doi=10.1016/S0968-8080(11)37560-X |pmid=21555084 |s2cid=24276199 }}</ref> The findings indicated that out of 146 maternity hospitals surveyed, 137 of these did not have a qualified midwife, which is crucial for maternity homes as proper care cannot be delivered without midwives in some cases.<ref name=":14" /> In addition, the 2007 study by Ayesha De Costa and Vinod Diwan analyzed the distribution of healthcare providers and systems in Madhya Pradesh, India.<ref name=":6" /> The results indicated that among solo practitioners in the private sector for that region, 62% practiced [[Allopathic medicine|allopathic]] (Western) medicine, while 38% practiced Indian systems of medicine and traditional systems (including, but not limited to [[ayurveda]], sidhi, [[unani]], and [[homeopathy]]).<ref name=":6" />

In certain areas, there are also gaps in the knowledge of healthcare providers about certain ailments that further contribute towards quality of healthcare delivered when treatments are not fully supported with thorough knowledge about the ailment.<ref name=":17">{{cite journal |last1=Mohanan |first1=Manoj |last2=Vera-Hernández |first2=Marcos |last3=Das |first3=Veena |last4=Giardili |first4=Soledad |last5=Goldhaber-Fiebert |first5=Jeremy D. |last6=Rabin |first6=Tracy L. |last7=Raj |first7=Sunil S. |last8=Schwartz |first8=Jeremy I. |last9=Seth |first9=Aparna |title=The Know-Do Gap in Quality of Health Care for Childhood Diarrhea and Pneumonia in Rural India |journal=JAMA Pediatrics |date=1 April 2015 |volume=169 |issue=4 |pages=349–57 |doi=10.1001/jamapediatrics.2014.3445 |pmid=25686357 |pmc=5023324 }}</ref> A 2015 study by Manoj Mohanan et al., published in ''JAMA Pediatrics,'' investigate
the knowledge base of a sample of practitioners (80% without formal medical degrees) in Bihar, India, specifically in the context of childhood [[diarrhea]] and [[pneumonia]] treatment.<ref name=":17" /> The findings indicated that in general, a significant number of practitioners missed asking key diagnostic questions regarding symptoms associated with diarrhea and pneumonia, leading to misjudgments and lack of complete information when prescribing treatments.<ref name=":17" /> Among the sample of practitioners studied in rural Bihar, 4% prescribed the correct treatment for the hypothetical diarrhea cases in the study, and 9% gave the correct treatment plan for the hypothetical pneumonia cases presented.<ref name=":17" /> Recent studies have examined the role of educational or training programs for healthcare providers in rural areas of North India as a method to promote higher quality of healthcare, though conclusive results have not yet been attained.<ref>{{cite journal |last1=Das |first1=J. |last2=Chowdhury |first2=A. |last3=Hussam |first3=R. |last4=Banerjee |first4=A. V. |title=The impact of training informal health care providers in India: A randomized controlled trial |journal=Science |date=7 October 2016 |volume=354 |issue=6308 |pages=aaf7384 |doi=10.1126/science.aaf7384 |pmid=27846471 |s2cid=3885140 }}</ref>

==Rankings==
In the 2016 [[Global Burden of Disease Study]] Report, India was ranked 145 out of 197 countries in "healthcare access and quality". India was ranked behind war-torn Yemen, Sudan and North Korea.<ref name="India Ranking">{{cite news |last1=Bose |first1=Mihir |title=An indictment of India's descent towards despotism |url=https://www.irishtimes.com/culture/books/an-indictment-of-india-s-descent-towards-despotism-1.4595185 |access-date=16 January 2022 |work=The Irish Times |date=26 June 2021 |language=en}}</ref>

==See also==
* [[Health in India]]
* [[List of government schemes in India]]
* [[Medical tourism in India]]
* [[Swachh Bharat Abhiyan]]
* [[Women's health in India]]
* [[Health insurance in India]]

==References==
{{Reflist|3|}}

{{India topics}}
{{Economy of India}}
{{Social issues in India}}
{{Health in India}}
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Healthcare in India