Health · Sub-pillar 2.3

Access and affordability

The availability of primary care and hospitals, and how much families pay out of their own pockets for treatment.

What is access and affordability?

Access and affordability is sub-pillar 2.3 of the 47 BH framework for a developed Bharat by 2047, the third of five sub-pillars under the Health pillar. It asks whether people can reach primary care and a hospital when they need one, and whether paying for treatment pushes families into debt or hardship.

Why it matters for 2047

A health system is judged at the moment a family needs it: whether there is a doctor within reach, whether the medicine is in stock, whether a specialist is available at the community health centre or only in a distant city, and whether the bill can be paid without selling land or borrowing at ruinous interest.

Illness is one of the commonest reasons families fall into poverty in India. When most health spending comes from people's own pockets at the time of illness, the poor delay care, stop treatment early, or pay with their future. A developed Bharat is one in which no one has to choose between treatment and solvency.

Access is also a question of fairness between places. The same country has districts with world-class hospitals and districts where a community health centre has no surgeon, no gynaecologist and no paediatrician. 47 BH tracks the gap, not just the average.

Where India stands

  • 43.4%

    of India's total health spending in 2022-23 came out of people's own pockets, up from 39.4% in 2021-22, though far below the 64.2% of 2013-14, according to the National Health Accounts.[1]

  • 1.43%

    of GDP was government health expenditure in 2022-23 (1.48% on the new GDP series), down from 1.84% in 2021-22. The National Health Policy 2017 set a target of 2.5% by 2025.[1]

  • 79.9%

    was the shortfall of specialist doctors at rural community health centres in March 2023: 4,413 in position against 21,964 required, according to Health Dynamics of India 2022-23.[3]

  • 60.2%

    of households had at least one member covered by health insurance or a financing scheme in 2023-24, up from 41.0% in 2019-21, according to the sixth National Family Health Survey.[4]

Access has widened. India had 13.88 lakh registered allopathic doctors and 7.52 lakh AYUSH practitioners in early 2026, and the government puts the doctor-population ratio at 1:811 assuming 80% are available, better than the WHO benchmark of 1:1000; MBBS seats have grown from 51,348 before 2014 to 1,28,875 in 2025. [2][5] Under the national hospital insurance scheme, 42.48 crore cards had been issued and 10.98 crore hospital admissions authorised by December 2025, and over 1.8 lakh Ayushman Arogya Mandirs offer primary care. [5]

Affordability has gone backwards recently. After falling for a decade, the out-of-pocket share of health spending rose from 39.4% to 43.4% in 2022-23 as government health spending fell back from its pandemic peak, and government spending as a share of GDP slipped to 1.43%. [1] Indians still pay roughly Rs 2,767 per person a year from their own pockets for health. [1]

The distribution is the sharpest problem. Four in five specialist posts at rural community health centres were vacant or unfilled in 2023, so a rural patient needing a surgeon or an obstetrician often has to travel to a district town or beyond. [3] A note on the numbers: the doctor ratio counts registered practitioners, including those who have retired, emigrated or left practice, which is why the 80% availability assumption is applied; the National Health Accounts are published with a lag of about three years.

On the 47 BH report card

Every 15 August, 47 BH reports how far India has come on each sub-pillar. For this sub-pillar, the headline indicators are:

  • Out-of-pocket expenditure as a share of total health expenditure, and government health expenditure as a share of GDP (National Health Accounts).
  • Doctors and nurses per 10,000 people, and the specialist shortfall at rural community health centres (Health Dynamics of India; WHO).
  • Share of households with health insurance or financing cover (National Family Health Survey).

Two lenses on access and affordability

City and village

47 BH asks whether a villager can see a qualified doctor without a day's travel, and whether a family in a city slum can afford the private clinic that is the only one nearby. The specialist shortfall at rural centres was 80%, against 44% at urban ones; the cost problem is shared, since out-of-pocket spending burdens the poor in cities and villages alike. [3]

Learn, avoid, protect

Learn
What can India learn from countries that cover everyone through a mix of public provision and insurance while keeping out-of-pocket payments low, and from Indian states that staffed their primary care well?
Avoid
Which mistakes should it avoid, such as insuring hospital stays while leaving the far larger cost of medicines and outpatient care uncovered, or building hospitals without the doctors and nurses to run them?
Protect
What of its own should it protect, such as the public primary care network that reaches every block, India's generic medicine industry that keeps drug prices low for the world, and the frugal innovation of its hospitals that deliver care at a fraction of global cost?

What this sub-pillar does not cover

Each topic has one home in the framework. These related topics sit elsewhere:

Questions about access and affordability

How much do Indians pay for healthcare out of pocket?

In 2022-23, out-of-pocket payments were 43.4% of India's total health expenditure, or about Rs 2,767 per person for the year, according to the National Health Accounts estimates released in May 2026. The share was 39.4% in 2021-22 and 64.2% in 2013-14. [1]

How much does the Indian government spend on health?

Government health expenditure was 1.43% of GDP in 2022-23 (1.48% on the new GDP series) and 43.7% of total health expenditure, according to the National Health Accounts. It was 1.84% of GDP in 2021-22. [1]

Does India have enough doctors?

The government counts 13,88,185 registered allopathic doctors and 7,51,768 AYUSH practitioners and, assuming 80% are available, puts the ratio at one doctor per 811 people, better than the WHO benchmark of 1:1000. The shortage is in distribution: rural community health centres had only 20% of the specialists they required in 2023. [2][3]

How many Indian families have health insurance?

60.2% of households had at least one member covered by a health insurance or financing scheme in 2023-24, up from 41.0% in 2019-21, according to the National Family Health Survey. [4]

Why does 47 BH track out-of-pocket spending?

Because it is the single best measure of whether illness causes financial hardship. When families pay most health costs themselves at the time of illness, the poor delay care or fall into debt, which is exactly what a developed Bharat should prevent.

Sources

  1. National Health Systems Resource Centre, Ministry of Health and Family Welfare, "National Health Accounts Estimates for India 2022-23", released May 2026. https://nhsrcindia.org/sites/default/files/2026-05/NHA%202022-23%20Report.pdf
  2. Ministry of Health and Family Welfare, "Update on Health Workforce Availability in Public Health Facilities", Rajya Sabha written reply, Press Information Bureau, 10 February 2026. https://www.pib.gov.in/PressReleseDetailm.aspx?PRID=2225755&reg=3&lang=2
  3. Ministry of Health and Family Welfare, "Health Dynamics of India (Infrastructure and Human Resources) 2022-23", September 2024, data as of March 2023; specialist figures as reported by ThePrint, 10 September 2024. https://theprint.in/health/rural-india-has-an-80-shortfall-of-specialist-doctors-mp-gujarat-tamil-nadu-worst-off/2259874/
  4. Ministry of Health and Family Welfare, "Union Health Ministry Releases National Family Health Survey - 6", Press Information Bureau, 29 May 2026. https://www.pib.gov.in/PressReleasePage.aspx?PRID=2266600&reg=3&lang=1
  5. Ministry of Health and Family Welfare, "Initiatives and Achievements 2025", year-end review, Press Information Bureau, January 2026. PM-JAY figures as of 1 December 2025; Ayushman Arogya Mandirs as of 30 November 2025. https://static.pib.gov.in/WriteReadData/specificdocs/documents/2026/jan/doc202611749801.pdf

47 BH cites every figure so that it can be checked. If you find an error, it will be corrected openly and the date below will change.

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