Dr. Prithwi Jyoti Bhowmik
Asst. Professor, KNM. Sonamura
Dr. Jhilly Choudhury
SRO, DHE.

1. Introduction
India's healthcare system faces numerous challenges, particularly in terms of cost and quality of care. This review examines the interplay between health facility environments and treatment costs in India, highlighting key factors that influence both. The review explores infrastructure, availability of medical technology, healthcare workforce, and administrative efficiency, alongside the impact of these factors on treatment costs. By analyzing existing literature, this article aims to provide insights into how improvements in health facility environments can potentially reduce treatment costs and enhance patient outcomes.

Healthcare in India is a complex system influenced by economic, social, and political factors. The disparity between urban and rural healthcare facilities, the burden of non-communicable diseases, and the high out-of-pocket expenses for treatment are critical issues. This review focuses on understanding how the environment of health facilities, including infrastructure, technology, and workforce, affects treatment costs in India.

1.1 Economic Factors
1.1.1 Income Disparities
India's economic diversity includes both affluent urban centers and impoverished rural areas. This economic disparity significantly affects healthcare access and quality. Wealthier individuals can afford private healthcare, which is often superior in terms of infrastructure and service, while poorer populations rely on underfunded public health facilities.

1.1.2 Healthcare Expenditure
India's healthcare expenditure as a percentage of GDP is relatively low compared to other countries.
Inadequate funding results in insufficient healthcare infrastructure, a shortage of medical staff, and limited availability of essential medicines. This underfunding forces a large segment of the population to incur high out-of-pocket expenses, leading to financial hardship.
1.1.3 Insurance Coverage
The penetration of health insurance in India is growing but remains limited. Government initiatives like
Ayushman Bharat aim to provide health coverage to the underprivileged, yet the overall insurance landscape is fragmented. This lack of widespread insurance coverage leaves many vulnerable to catastrophic health expenditures.
1.2 Social Factors
1.2.1 Population Demographics
India's large and diverse population presents unique healthcare challenges. With over 1.3 billion people,
the demand for healthcare services is immense. Additionally, there is a significant variation in health needs across different age groups, regions, and socioeconomic statuses. The growing elderly population and the burden of non-communicable diseases require tailored healthcare strategies.
1.2.2 Education and Awareness
Health literacy is crucial for the effective utilization of healthcare services. In many parts of India, particularly in rural and underserved areas, there is a lack of awareness about health issues and available services. This can lead to delayed treatment and poor health outcomes. Enhancing health education and awareness is essential for improving public health.
1.2.3 Cultural Beliefs and Practices
Cultural beliefs and practices significantly influence health behaviors and attitudes towards medical treatment. Traditional medicine and alternative therapies are commonly used alongside modern medicine. While these practices are culturally significant, they can sometimes lead to delays in seeking professional medical care.
1.4 Political Factors
1.4.1 Policy and Governance
Healthcare policies and governance play a pivotal role in shaping the system. Effective policy-making
requires addressing the diverse health needs of the population, ensuring adequate funding, and implementing robust regulatory frameworks. Political will and commitment are crucial for the successful implementation of health initiatives.
1.4.2 Public Health Programs
Government-led public health programs, such as vaccination drives, maternal and child health initiatives, and disease control measures, are vital for improving health outcomes. However, the effectiveness of these programs often depends on the efficiency of implementation, which can be hampered by bureaucratic hurdles and corruption.

1.4.3 Healthcare Infrastructure Development
Political decisions significantly impact the development and maintenance of healthcare infrastructure.
Investments in building and upgrading hospitals, clinics, and diagnostic centers are essential for providing quality care. Political priorities and funding allocations directly influence the availability and quality of these facilities.

2. Health Facility Environment
2.1 Infrastructure
Infrastructure is a fundamental component of healthcare delivery. Well-equipped hospitals with advanced medical technology can provide more efficient and effective care, potentially reducing the length of hospital stays and associated costs. However, the disparity between urban and rural areas in India is significant. Urban hospitals are generally better equipped, while rural areas often lack basic healthcare facilities, leading to increased treatment costs due to travel and delayed care.
2.2 Availability of Medical Technology
The availability and use of medical technology in Indian hospitals vary widely. High-end technologies like
MRI machines, robotic surgery, and telemedicine can improve diagnostic accuracy and treatment outcomes. However, the high cost of these technologies can increase the overall cost of treatment. Balancing the use of advanced technology with cost-effective care is crucial.
2.3 Healthcare Workforce
The availability of qualified healthcare professionals is another critical factor. India's healthcare system
faces a shortage of doctors, nurses, and allied health professionals, particularly in rural areas. This shortage can lead to higher treatment costs due to overtime pay for existing staff and the need for patients to seek care in distant, more expensive urban centers.
2.4 Administrative Efficiency
Administrative efficiency in healthcare facilities can significantly impact treatment costs. Efficient administration can reduce wastage, streamline patient flow, and improve resource allocation. Conversely, bureaucratic inefficiencies can lead to increased operational costs, which are often passed on to patients.
3. Treatment Costs in India
India is known for its relatively low treatment costs, particularly in comparison to Western countries. This is a major factor in the growth of medical tourism in India. However, these costs can vary significantly within the country, influenced by the type of healthcare facility (public vs. private), the region, and the specific medical treatment required.
3.1 Comparative Analysis
3.1.1 Hospitalization Costs
According to the World Health Organization (WHO), the average cost of hospitalization in India is
significantly lower than in many developed countries. The WHO Global Health Expenditure Database
provides a broad comparison:

a) India: The average cost of hospitalization can range from $500 to $3,000 depending on the treatment
and the hospital.
b) United States: The average cost of hospitalization is approximately $18,000.
c) United Kingdom: The average cost of hospitalization is around $5,000.
d) Australia: The average cost of hospitalization is about $7,500.

1. 3.1.2 Specific Treatments
   I. Cardiac Procedures
   a) India: A coronary artery bypass graft (CABG) surgery costs between $3,000 and $5,000.
   b) United States: The same procedure can cost between $70,000 and $200,000.
   c) United Kingdom: The cost is approximately $25,000 to $30,000.
   d) Singapore: Costs range from $17,000 to $22,000.
   II. Orthopedic Procedures
   a) India: A hip replacement surgery costs between $4,000 and $7,000.
   b) United States: The cost is about $30,000 to $50,000.
   c) United Kingdom: The cost is around $12,000 to $15,000.
   d) Australia: Costs approximately $20,000 to $25,000.
   III. Cancer Treatments
   a) India: Chemotherapy costs around $2,000 to $3,000 per cycle.
   b) United States: Costs range from $10,000 to $50,000 per cycle.
   c)d) Germany: Costs range from $7,000 to $12,000 per cycle.

3.1.3 Out-of-Pocket Expenditures
The World Bank and WHO data indicate that out-of-pocket expenditures (OOP) as a percentage of total
health expenditure are much higher in India compared to many developed countries:

a) India: Approximately 62% of healthcare expenditure is OOP.
b) United States: Around 11%.
c) United Kingdom: Approximately 10%.
d) Canada: About 15%.

3.1.4 Factors Influencing Cost Differences

I. Economic Factors
a) Labor Costs: Lower salaries for healthcare professionals in India contribute to reduced
treatment costs.
b) Infrastructure: Lower construction and maintenance costs for hospitals.
c) Pharmaceuticals: Generic drug production in India significantly reduces medication costs.
II. Healthcare Systems
a) Public vs. Private Sector: India's large private healthcare sector offers various pricing
levels, whereas countries with predominantly public healthcare systems (e.g., UK, Canada)
have standardized costs.
III. Regulatory Environment
a) Price Controls: The Indian government regulates the prices of essential medicines and
procedures, keeping them affordable.
b) Insurance Coverage: Limited insurance penetration in India leads to higher OOP expenses,
whereas countries with comprehensive insurance coverage (e.g., UK, Canada) have lower
OOP costs.

IV. Medical Tourism
a) India's competitive pricing and quality care attract international patients, further influencing
treatment costs.
3.2 Out-of-Pocket Expenditure
A significant portion of healthcare costs in India is borne out-of-pocket by patients. This high out-of-
pocket expenditure is a major barrier to accessing healthcare, particularly for the poor and uninsured.
Treatment costs can vary widely depending on the type of facility (public vs. private), location, and the
nature of the illness.
3.3 Government Expenditure
Government expenditure on healthcare in India is relatively low compared to other countries. Public hospitals provide subsidized care, but they are often overcrowded and under-resourced. Increasing government funding for healthcare could improve the infrastructure and availability of services in public hospitals, potentially reducing treatment costs.
3.3.1 Government of India Health Schemes (2024)
The Government of India has launched various health schemes aimed at providing affordable and accessible healthcare to its citizens. These schemes target different segments of the population, addressing various health needs. Here is a comprehensive list of the key health schemes in 2024:

a) Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (PMJAY)

• Description: This flagship health insurance scheme aims to provide a health cover of Rs. 5
  lakh per family per year for secondary and tertiary care hospitalization.
• Beneficiaries: Over 10.74 crore poor and vulnerable families (approximately 50 crore
  beneficiaries).
• Website: PMJAY

b) National Health Mission (NHM)

• Description: NHM encompasses two sub-missions, the National Rural Health Mission (NRHM) and the National Urban Health Mission (NUHM), aiming to provide accessible, affordable, and quality healthcare to rural and urban populations.
• Components: Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCH+A), Communicable and Non-Communicable Diseases, Health System Strengthening.
• Website: NHM

c) Pradhan Mantri Swasthya Suraksha Yojana (PMSSY)

• Description: This scheme aims to correct regional imbalances in the availability of afford able and reliable tertiary healthcare services and augment facilities for quality medical education.
• Components: Establishment of AIIMS-like institutions and upgradation of existing Government Medical Colleges.
• Website: PMSSY

d) Ayushman Bharat Health and Wellness Centres (AB-HWCs) 

• Description: Transforming 1.5 lakh sub-centres and primary health centres into Health and Wellness Centres to provide comprehensive primary healthcare services.
• Services: Preventive, promotive, curative, rehabilitative, and palliative care.

e) Rashtriya Swasthya Bima Yojana (RSBY)

• Description: Health insurance scheme for the BPL (Below Poverty Line) families, providing protection from financial liabilities arising out of health shocks.
• Coverage: Hospitalization expenses up to Rs. 30,000 per annum for a family of five.

f) Janani Suraksha Yojana (JSY)

• Description: A safe motherhood intervention under the NHM, focusing on reducing ma
  ternal and neonatal mortality by promoting institutional delivery among poor pregnant
  women.
• Incentives: Cash incentives to mothers for institutional deliveries.

g) Pradhan Mantri Matru Vandana Yojana (PMMVY)

• Description: A maternity benefit program providing partial wage compensation to pregnant and lactating mothers for wage-loss during childbirth and childcare.
• Benefits: Rs. 5,000 in three installments for the first living child of the family.
• Website: PMMVY

h) National Programme for Control of Blindness and Visual Impairment (NPCBVI)

• Description: Program aimed at reducing the prevalence of blindness through comprehen f) Janani Suraksha Yojana (JSY)
• Description: A safe motherhood intervention under the NHM, focusing on reducing maternal and neonatal mortality by promoting institutional delivery among poor pregnantwomen.
• Incentives: Cash incentives to mothers for institutional deliveries.

g) Pradhan Mantri Matru Vandana Yojana (PMMVY)

• Description: A maternity benefit program providing partial wage compensation to pregnant and lactating mothers for wage-loss during childbirth and childcare.
• Benefits: Rs. 5,000 in three installments for the first living child of the family.
  Website: PMMVY

h) National Programme for Control of Blindness and Visual Impairment (NPCBVI)

• Description: Program aimed at reducing the prevalence of blindness through comprehen
  sive eye care services.
• Services: Free cataract surgeries, eye screenings, and distribution of glasses.
  
  

i) Revised National Tuberculosis Control Program (RNTCP)

• Description: Aims to achieve universal access to TB control services, including early diagnosis and complete treatment of TB.
• Components: DOTS strategy, free diagnosis, and treatment.
• Website: RNTCP

j) National AIDS Control Programme (NACP)

• Description: A comprehensive program to prevent and control HIV/AIDS in India.
• Services: Free testing, treatment, counseling, and support services.
• Website: NACO

k) National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases,
and Stroke (NPCDCS)

• Description: Focuses on preventing and controlling major non-communicable diseases through early diagnosis, treatment, and health promotion.
• Components: Health education, screening, and management services.

l) National Mental Health Programme (NMHP)

• Description: Aims to promote mental health and provide equitable and accessible mental health care to all.
• Services: Establishment of mental health facilities and training of healthcare providers.
• Website: NMHP

m) Integrated Child Development Services (ICDS)

• Description: Aimed at improving the nutritional and health status of children below six years, pregnant women, and lactating mothers.
• Components: Supplementary nutrition, immunization, health check-ups, and referral services.
• Website: ICDS

n) National Iodine Deficiency Disorders Control Programme (NIDDCP)

• Description: To reduce the incidence of iodine deficiency disorders through iodine supplementation and public awareness.
• Services: Distribution of iodized salt and monitoring of iodine levels.

3.4 Insurance Penetration
Insurance penetration in the Indian public health sector has been steadily increasing over the years, driven by government initiatives and private sector participation. This has significant implications for accessibility, affordability, and quality of healthcare services in India. This section examines the effects of increased insurance penetration on the public health sector in India, considering various aspects such as financial protection, healthcare utilization, and overall health outcomes.
3.4.1 Current State of Insurance Penetration
India has traditionally had low health insurance penetration, with a large proportion of healthcare expenses being out-of-pocket (OOP). However, recent years have seen efforts to expand insurance coverage through schemes like Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (PMJAY) and other state- specific health insurance programs.
Key Statistics

a) Insurance Penetration Rate: As of 2023, around 40% of the population is covered under some form of health insurance.
b) Government Initiatives: Ayushman Bharat - PMJAY covers over 10.74 crore poor and vulnerable families (approximately 50 crore individuals).
c) Private Sector: Private health insurance companies are also expanding their reach, albeit more in urban and semi-urban areas.

3.4.2 Positive Effects of Increased Insurance Penetration
a) Financial Protection
One of the primary benefits of increased insurance penetration is enhanced financial protection for households:
i) Reduced Out-of-Pocket Expenditure: Insurance coverage helps mitigate the financial burden of healthcare expenses, particularly for costly treatments and hospitalizations.
ii) Prevention of Medical Bankruptcy: Families are less likely to face catastrophic health expenditures that can lead to debt or impoverishment.

b) Improved Access to Healthcare
Insurance schemes can improve access to healthcare services in several ways:
i) Increased Hospital Visits: Insured individuals are more likely to seek timely medical care, including preventive services and regular check-ups.
ii) Access to Quality Healthcare: Insurance enables access to better-quality healthcare facilities, including private hospitals that may offer more advanced treatments.
c) Enhanced Health Outcomes
Better access to healthcare services and financial protection contribute to improved health outcomes:
i) Early Diagnosis and Treatment: Insurance facilitates early diagnosis and timely treatment of diseases, which can improve recovery rates and reduce morbidity.
ii) Reduction in Disease Burden: With increased access to preventive care and management of chronic diseases, the overall burden of disease in the population can be reduced.
d) Increased Utilization of Public Health Facilities
Government-funded insurance schemes often empanel public health facilities, leading to increased utilization:
i) Strengthening Public Health Infrastructure: Higher demand for services can drive improve ments in public health infrastructure and capacity.
ii) Better Resource Allocation: Increased insurance coverage can lead to more efficient allocation of resources within the public health sector.

3.4.3 Challenges and Negative Effects
a) Quality of Care
Despite improvements, challenges remain in ensuring consistent quality of care:
i) Variation in Quality: There can be significant variation in the quality of care provided by different healthcare providers under insurance schemes.
ii) Monitoring and Regulation: Ensuring compliance with quality standards and preventing fraud requires robust monitoring and regulatory mechanisms.

b) Access Inequities
Insurance penetration has not been uniform across all segments of the population:
i) Urban-Rural Divide: Insurance coverage is often higher in urban areas compared to rural areas, leading to disparities in access to healthcare services.
ii) Socioeconomic Disparities: Marginalized communities and those in remote areas may still face barriers to accessing insurance benefits.
c) Financial Sustainability
The financial sustainability of large-scale insurance schemes is a critical concern:
i) Funding and Premiums: Ensuring adequate funding and managing premiums while keeping them affordable for the population is challenging.
ii) Cost Control: Managing rising healthcare costs and preventing over-utilization of services is essential to maintain the viability of insurance programs.

3.4.4 Case Studies
Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (PMJAY)
Launched in 2018, PMJAY is one of the world's largest government-funded health insurance schemes:
i) Coverage: Provides health coverage of Rs. 5 lakh per family per year for secondary and tertiary care hospitalization.
ii) Impact: Early reports suggest a significant reduction in out-of-pocket expenses for beneficiaries and improved access to quality healthcare services.

3.4.5 State Health Insurance Schemes
Several states have implemented their own health insurance schemes, such as:
i) Tamil Nadu Chief Minister's Comprehensive Health Insurance Scheme: Offers free medical and surgical treatment in government and private hospitals.
ii) Mahatma Jyotiba Phule Jan Arogya Yojana (MJPJAY) in Maharashtra: Provides insurance coverage for low-income families.

4. Impact of Health Facility Environment on Treatment Costs
4.1 Urban vs. Rural Disparities
India's healthcare system exhibits significant disparities between urban and rural areas. These disparities affect access to healthcare services, quality of care, and health outcomes. Understanding the root causes and current state of these disparities is crucial for formulating policies aimed at achieving equitable healthcare for all. This review explores the differences between urban and rural healthcare in India, highlighting the underlying factors and potential solutions.
4.1.1 Access to Healthcare Services

a) Urban Areas
Urban regions generally have better access to healthcare services due to the higher concentration of healthcare facilities and professionals. Key characteristics include:
i) Availability of Facilities: Urban areas are home to numerous hospitals, clinics, and specialized medical centers, both public and private.
ii) Healthcare Professionals: A higher density of doctors, nurses, and other healthcare workers is found in urban settings.
iii) Advanced Medical Technology: Urban hospitals are often equipped with the latest medical technology and equipment.
iv) Pharmaceutical Access: Greater availability of pharmacies and drugstores ensures easy access to medications.

b) Rural Areas

In contrast, rural areas face significant challenges in accessing healthcare services:
i) Shortage of Facilities: Many rural areas lack adequate healthcare infrastructure, with a scarcity of hospitals and clinics.
ii) Human Resources: There is a severe shortage of healthcare professionals in rural regions, with many preferring to work in urban areas.
iii) Limited Technology: Rural healthcare facilities often lack advanced medical technology and equipment.
iv) Drug Availability: Access to essential medicines is limited, with fewer pharmacies and irregular supply chains.

4.1.2 Quality of Care
a) Urban Areas
The quality of care in urban areas tends to be higher due to better resources and infrastructure:
i) Specialized Services: Availability of specialized medical services and departments.
ii) Trained Personnel: Urban healthcare facilities attract more qualified and experienced healthcare professionals.
iii) Regular Training: Opportunities for continuous medical education and training are more accessible in urban settings.
iv) Research and Development: Urban hospitals are more likely to be involved in medical research and clinical trials, contributing to advancements in care.

b) Rural Areas
Rural areas often struggle with maintaining high-quality healthcare services:
i) General Practitioners: Predominantly general practitioners with limited access to specialists.
ii) Training Deficits: Fewer opportunities for continuing medical education and professional development.
iii) Infrastructure Gaps: Poorly equipped facilities and inadequate infrastructure.
iv) Quality Control: Less stringent quality control measures and oversight compared to urban healthcare facilities.

4.1.3 Health Outcomes
a) Urban Areas
Health outcomes in urban areas are generally better due to improved access and quality of care:
i) Lower Infant Mortality:rates.
ii) Chronic Disease Management: Better management of chronic diseases such as diabetes and hypertension.
iii) Higher Life Expectancy: Urban populations typically enjoy higher life expectancy rates.

b) Rural Areas
Health outcomes in rural areas are often poorer due to several factors:
i) High Mortality Rates: Higher infant and maternal mortality rates compared to urban areas.
ii) Infectious Diseases: Greater prevalence of infectious diseases such as tuberculosis and malaria.
iii) Chronic Illness: Poorer management of chronic illnesses due to lack of access to specialists and medications.
iv) Life Expectancy: Lower life expectancy rates in rural populations.

4.1.4 Socio-Economic Factors
a) Urban Areas
Urban areas benefit from better socio-economic conditions which positively impact health:
i) Income Levels: Higher average income levels enable better access to private healthcare services.
ii) Education: Higher literacy rates and better health literacy.
iii) Infrastructure: Superior public health infrastructure, including sanitation, water supply,  and transportation.

b) Rural Areas
Rural areas face several socio-economic challenges that affect health:
i) Poverty: Higher levels of poverty restrict access to healthcare services.
ii) Education: Lower literacy rates and poor health awareness.
iii) Infrastructure Deficits: Inadequate infrastructure, including poor transportation, affects access to healthcare facilities.

4.1.5 Government Initiatives
a) Urban Areas
Government initiatives in urban areas focus on upgrading existing infrastructure and ensuring high standards of care:
i) National Urban Health Mission (NUHM): Targets urban poor, providing essential healthcare services.
ii) Public-Private Partnerships (PPP): Encourages private sector participation in urban healthcare.

b) Rural Areas
Government initiatives aim to bridge the gap in rural healthcare through targeted programs:
i) National Rural Health Mission (NRHM): Focuses on improving healthcare infrastructure and accessibility in rural areas.
ii) Ayushman Bharat Health and Wellness Centres: Upgrading sub-centres and primary health centres to provide comprehensive primary healthcare.
iii) Telemedicine: Expansion of telemedicine services to reach remote rural areas.
iv) Mobile Medical Units: Deployment of mobile medical units to provide healthcare services in underserved regions.

4.1.6 Potential Solutions
I. Infrastructure Development

a) Invest in building and upgrading healthcare facilities in rural areas.
b) Improve transportation infrastructure to facilitate access to healthcare services.

II. Human Resource Allocation
a) Provide incentives for healthcare professionals to work in rural areas.
b) Increase training and educational opportunities for rural healthcare workers.
III. Technology Integration
a) Expand telemedicine and digital health services to rural areas.
b) Ensure availability of essential medical equipment and supplies in rural healthcare facilities.
IV. Health Education and Awareness
a) Implement community-based health education programs to improve health literacy.
b) Promote preventive healthcare practices and early diagnosis.
V. Policy and Funding
a) Increase government funding for rural healthcare programs.
b) Develop policies that address the specific health needs of rural populations.

5. Conclusion
Improving the environment of health facilities in India, including infrastructure, technology, workforce, and administrative efficiency, is crucial for reducing treatment costs and improving patient outcomes. Policymakers must focus on bridging the urban-rural divide, increasing government expenditure on healthcare, and expanding insurance coverage to make healthcare more affordable and accessible.

Increased insurance penetration in the Indian public health sector has the potential to significantly improve access to healthcare, reduce financial hardship, and enhance health outcomes. However, achieving these benefits requires addressing challenges related to quality of care, access inequities, and financial sustainability. Continued efforts to expand and refine health insurance schemes, along with robust regulatory frameworks and monitoring mechanisms, are essential to maximizing the positive impact of insurance on public health in India.

The disparities between urban and rural healthcare systems in India are stark, with rural areas lagging
significantly behind in terms of access, quality, and health outcomes.comprehensive and targeted efforts, including infrastructure development, improved human resource allocation, integration of technology, enhanced health education, and supportive policies and funding. By focusing on these areas, India can move towards a more equitable healthcare system that ensures quality healthcare for all its citizens, regardless of their geographic location.

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