To: The Committee on Health & Family Welfare, Rajya Sabha

From: FORUM FOR EQUITY IN HEALTH (FEH)

Date: 13/07/2025 (Sunday)

The Forum for Equity in Health is comprised of medical practitioners, healthcare professionals, and citizens participating in the governance of health, who work across the country in rural and urban settings, at primary, secondary, and tertiary care, who are concerned with equity in health and healthcare for all, especially the deprived and marginalized.

Background

Over the past five decades, India’s healthcare landscape has undergone a significant transformation, marked by the rapid expansion of the private sector at the cost of citizens' health through the systematic degradation of public health infrastructure. The government has underinvested in public health facilities and facilitated and actively encouraged processes of the commodification, capitalisation, and expansion of the private sector through widespread corporatisation.

The public health system focuses on providing primary care to economically disadvantaged people, but faces challenges such as overcrowding, lack of infrastructure, equipment, diagnostics, medicines and specialists. The quality of public health care is often poor and uneven, with many facilities falling short of minimum standards.

The private sector, based on its business models, offers a wider range of services, but at a higher cost, with major concentration in metros, tier-I, and tier-II cities, and is inaccessible to the vast majority of poor people in our country. There are concerns about the profit-oriented, target-driven culture, high costs of care, inappropriate testing, treatments, and procedures, as well as inadequate governance and accountability mechanisms.

It is essential to secure the Right to Health and Healthcare, as citizens of India do not have entitlements to health and healthcare, and the healthcare system is not accountable. 

There is a need for a system of universal health provision, where every citizen can be provided good quality and accessible health care.

We need to strengthen the public health system, as a counterbalance to the dominance of the private health system.

The government needs to enforce regulation of the private sector through laws such as the Clinical Establishments Act and provisions such as the Patient Rights Charter.

Policymakers can draw on international norms such as laws that ban discrimination by insurers and hospitals on financial grounds, or require a minimum quota of low-cost beds in private hospitals, which have been used in various countries to maintain equity.

Issues On Affordability And Accessibility

1. Out-of-Pocket Expenditure (OOPE): India has one of the highest OOPEs globally, accounting for approximately 39.4% of total health expenditure in 2021-22. About 10 crore people are pushed into poverty every year due to the money they spend on healthcare.

2. Cost of Services in Private Sector: Lack of standardized pricing mechanisms in the private sector results in wide variations and often exorbitant charges for consultations, procedures, and hospitalization.

Reports of exorbitant charges, opaque and commercially driven unscientific treatment practices, and the denial of basic patient rights have become alarmingly frequent.

3. Drug availability: Drugs outside the National List of Essential Medicines (NLEM), even if essential for their condition (like many newer patented cancer drugs or biologics), face unregulated and often exorbitant prices. Drugs on the NLEM, which are price-controlled, face stock-outs and inconsistent availability in public facilities. Hence, patients are forced to purchase them from the private market at a much higher price. 

4. Lack of accessibility of health care in rural areas: Approximately 75% of health infrastructure and resources are concentrated in urban areas, where only 27% of the population resides. Public health facilities, especially in rural or remote areas, often face shortages of specific medicines, reagents for diagnostic tests, or functioning equipment. Patients are forced to purchase them from private pharmacies or get tests done at private laboratories. 75 per cent of the semi-rural and rural population in India do not have access to modern healthcare within their localities.

5. Scarcity and Uneven Distribution of blood banks: The vast majority of licensed blood banks in India are concentrated in urban centres. Several districts in India with significant healthcare needs, lack even a single blood bank. This creates "blood deserts" where timely access to blood is virtually impossible. Strengthening Blood Banking Infrastructure and Network, capacity building and community-based solutions are essential.

6. Inadequate Public Health Infrastructure and staffing: India is reportedly 16% below the required number of Primary Health Centres and approximately 50% below the required number of Community Health Centres.

a. Inadequate standards: Even when PHCs and CHCs exist, their "functional" status is a major concern. Many do not meet the Indian Public Health Standards (IPHS) regarding infrastructure, manpower, equipment, and essential services (as of March 2020 (RHS 2019-20), A concerning statistic indicated that only 13% (3,278) of the 24,918 PHCs and 8.4% of CHCs adhered to basic IPHS standards.

b. Lack of 24x7 Functionality: A significant number of PHCs, particularly in rural areas, do not operate on a 24x7 basis.

c. Infrastructure Deficiencies: Many PHCs and CHCs lack basic physical infrastructure, including proper buildings, adequate space, sanitation facilities, and reliable electricity. Shortfalls in essential equipment for diagnostics (e.g., lab equipment, X-ray machines) and treatment are common. 3

d. Lack of Essential Drugs and Diagnostics: The consistent availability of free or subsidized essential medicines and basic diagnostic tests is often a challenge, leading to out-of-pocket expenses for patients and undermining trust in the public system.

e. Staffing: Even in sanctioned posts in rural Primary Health Centres (PHCs) and Community Health Centres (CHCs), there are high vacancy rates for doctors. 27% of doctor posts at PHCs are vacant. Rural CHCs face a nearly 80% shortfall in specialist doctors.

7. Informal workforce: 91% of the workforce continues to work in the informal sector. There has been little effort to provide health care provision for the informal workforce. Informal workers are excluded from social security schemes like the Employees' State Insurance Scheme (ESIS) or the Central Government Health Scheme (CGHS), which are for organized sector employees.

8. Gender Norms and Inequality: Healthcare facilities are organised around gender binaries (male/female). Transgender, non-binary, and intersex individuals face challenges in terms of admission forms, ward allocation, washrooms, and even medical records, leading to discomfort, isolation, and denial of appropriate care.

Many healthcare professionals lack adequate training and sensitivity regarding LGBTQ+ specific health needs and Gender-Affirming Care. There is a severe shortage of trained doctors to provide these services. The lack of availability of these services in public hospitals and the high cost of private health care exacerbates these disparities.

9. Health access of vulnerable communities: Wide sections of our society face health vulnerability and challenges in accessing health care. These include: women, Dalits, tribal communities, migrant populations, manual scavengers, the homeless, the differently abled, refugees, people living in conflict areas, the elderly, and children.

10. Growth of tertiary care at the expense of basic primary and secondary care: Weak primary care leads to delayed diagnosis and management, causing disease progression, requiring expensive tertiary care, which is inaccessible or unaffordable. 4

This perpetuates a cycle of poor health outcomes and financial distress, widening the health equity gap.

Suggestions For Improvement

1. Right to health care: India needs to legislate Right to healthcare as a justiciable right, in line with India’s international obligations, such as Article 12 of the International Covenant on Economic, Social and Cultural Rights (ICESCR), the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), the Convention on the Rights of the Child (CRC), and the Universal Declaration of Human Rights (UDHR).

2. Universal health coverage: We need a system of universal health coverage with all citizens being able to access good quality and accessible health care.

3. Strengthen the Public Healthcare sector: providing adequate human resources, drugs, devices, equipment and infrastructure.

4. Regulate the Private healthcare sector: through effective implementation of the Clinical Establishment Act with emphasis on transparency, regulation of rates, an effective grievance redressal system for patients and adoption of standard treatment protocols. There is need to prevent further privatisation of public health services and public medical colleges through PPP. The charter of patient rights should be displayed in all hospitals.

5. Availability of affordable and quality essential drugs & diagnostics: effective and rational price control, promoting generic, fair priced medicine outlets.

6. Health care provision for the unorganised sector: Strengthen, reform and expand the Employee State Insurance (ESI) system to provide healthcare for workers in both organised and unorganised sectors.

7. Providing health care for vulnerable communities: Ensure the provision of comprehensive, quality health services and rights-based entitlements for those with vulnerabilities related to social background, health status, lifecycle position, occupation and other factors. Ensure that the health needs of minority, vulnerable, and deprived groups are addressed, ensuring the right to healthcare for all with dignity, abiding by the Constitutional mandate of equality and non-discrimination. Ensure gender-sensitive health services, eliminating all forms of discrimination in the health sector and ensuring access to healthcare for all without barriers.

8. Comprehensive mental health care: Put in place a system of comprehensive management of mental health problems, including community-oriented care and wider promotion of mental health, through effective implementation of an expanded mental health programme.

9. Increase the Budgetary Allocation for Health: Public health expenditure needs to reach from the current 1.94%. This is merely the minimum investment required as per the National Health Policy of 2017, a modest target as compared to the OECD average of around 8 to 9%.

10. Accountability in the health system: Develop systems for accountability of the health system to the community, with active, diversified participation and strong grievance redressal mechanisms.

11. Aligning health systems to social determinants of Health: Existing health programmes should address the social determinants of health. For example, the TB elimination programme should include nutritional supplementation. Formulate processes, procedures, and policies that prioritise inter-sectoral coordinated action on areas related to health, like food security, nutrition, sanitation, environmental pollution, climate change, working conditions, road safety, substance abuse, and violence.

To note:  At the time of publishing this open letter, the Rajya Sabha has not responded to the Forum for Equity in Health.

Edited by Christianez Ratna Kiruba

Image by Gayatri