Healthcare and Equality: Indian Realities, Kerala’s Decentralised Model, and the Costa Rican Approach

Healthcare and Equality: Indian Realities, Kerala’s Decentralised Model, and the Costa Rican Approach

1. India’s Unequal Landscape of Care

Aspect	Reality
Supply mix	Public services have stagnated while private facilities—clinics, diagnostic chains, corporate hospitals—have mushroomed, especially in cities.
Cost burden	• Medicines and tests are expensive; barely 1 in 5 Indians can consistently afford all prescribed drugs. • Around 40 % of hospitalised patients must borrow money or sell assets to meet bills. • Even “non-poor” families slide into debt after prolonged illness.
Quality concerns	Profit pressures lead to over-prescription of costly drugs, injections, IV saline, or diagnostic panels when cheaper or simpler options suffice.
Vulnerable groups	• Women’s symptoms often treated late or dismissed. • Tribal and remote areas lack both well-run public centres and private alternatives. • Undernourished households face a vicious cycle—poor nutrition → higher illness → deeper poverty.

2. Why Health Inequity Persists

1. Under-investment in public health: India spends < 2 % of GDP on government health, well below many developing peers.

2. Urban bias: Private providers cluster where paying clientele live; rural and peri-urban belts are underserved.

3. Weak regulation: Pricing, quality, and ethical standards for the private sector are only patchily enforced.

4. Social determinants: Unsafe water, inadequate housing, poor sanitation, and low literacy magnify disease risk—medical care alone cannot fix these.

3. Government’s Constitutional Duty

• Article 21 (Right to Life) obliges the State to ensure timely, affordable, quality health care.

• Courts have ruled that denial or delay of essential treatment violates this right; governments can be ordered to reimburse out-of-pocket costs.

4. Kerala’s Decentralised Experiment (1996 onwards)

Feature	Impact
40 % of state budget devolved to elected panchayats	Local councils could tailor spending to real village needs.
Integrated village plans (water, sanitation, education, women’s development)	Tackled root causes of ill-health alongside curative care.
Monitoring of schools, anganwadis, and health centres	Reduced staff absenteeism, improved immunisation and maternal services.
Remaining gaps	Drug stock-outs, bed shortages, uneven doctor distribution—showing decentralisation must be paired with adequate state-level support and HR planning.

5. Costa Rica: Health Through Peace and Social Spending

• Abolished its army in 1948; defence savings redirected to universal primary health care, education, safe water, sanitation, and housing.

• Comprehensive health education is embedded from primary school onward.

• Achieved life-expectancy and infant-mortality figures comparable to high-income nations, despite modest GDP.

6. Lessons and Policy Directions for India

Domain	Key Actions
Public financing	• Raise government health spending to at least 3 – 4 % of GDP. • Broaden tax-funded insurance (e.g., PM-JAY) to cover outpatient drugs and diagnostics.
Primary care first	Strengthen Health & Wellness Centres, PHCs, mobile clinics; ensure 24×7 drug supplies and diagnostics.
Regulate the private sector	Enforce transparent pricing; mandate rational prescription practices; accredit facilities for quality and patient-safety standards.
Decentralised governance	Give panchayats/urban local bodies real budgets and data dashboards to plan water, sanitation, waste management, and health outreach.
Gender & tribal equity	Recruit female health workers; run culturally sensitive campaigns; locate sub-centres within easy reach of remote hamlets.
Tackle social determinants	Parallel investment in potable water, housing upgrades, clean energy, and nutrition (e.g., fortified foods, POSHAN 2.0).
Health literacy	Integrate school-level health education; leverage digital media for preventive-care messaging.
Community accountability	Social audits, patient charters, and grievance-redress portals to keep both public and private providers answerable.

7. Concluding Insight

Adequate, equitable health care is impossible without robust public systems, fair regulation of private players, and simultaneous investment in the everyday conditions that keep people healthy. Kerala’s decentralisation proves local empowerment can close gaps; Costa Rica shows what is possible when a nation prioritises welfare over warfare. For India, combining these lessons with increased public funding and strong governance offers the clearest path toward health justice for every citizen.