MUMBAI, India -- Shanta had a good life for a working class woman in Mumbai. Her husband Manoj was a watchman in a factory compound in a western suburb, and they lived in a room with running water, free electricity, even firewood for cooking. She commuted to work, an hour each way, into south Mumbai, where she cleaned three households. But in 2007, Manoj suffered a stroke, and though they went to a municipal hospital for treatment, they spent thousands of rupees (hundreds of dollars) on prescriptions. Shanta became the sole earner and they continued to spend on local healers. Then, Shanta was hospitalized for a severe bout of falciparum malaria (a virulent strain of the mosquito-borne disease, once limited to northeastern India, but now common in Mumbai). Recently, Manoj fell and broke a hip and required surgery, which cost $426 for subsidized treatment at a municipal hospital. To put that number in perspective, the monthly per capita income for 80 percent of the urban population is less than $42. In Shanta's case, the cost of her husband's hip surgery was four months' wages.
As medical costs rise, hospitalization can send a family to the local money lender, running up debts at exorbitant interest rates. Treatment for a single illness can push them to the brink. During one of her health crises, Shanta borrowed $213 at a 60 percent annual interest rate--money she paid back with a loan from one of her employers. India's annual health care expenditure per capita is $21, an amount the government believes is sufficient for all health care services. However, barely 15 percent of this money comes from federal finances, so people must pay for most health care out of pocket. When a country spends just 1 percent of its GDP on health, as India does, there is an intimate link between its health expenditure and the insecurity of its poor. The uncertainties of wages, housing and nutrition are critical factors that can mean the difference between survival and destitution. More than 450 million people (nearly half the population of India) live below the poverty line and make less than $1.25 per day. Trapped between expensive private services and an inaccessible (and still pricey) public sector, the poor can either seek medical treatment and risk pauperization, or go without.
Health care is a matter of affordability and accessibility. Spending in India's health sector totals $32 billion, but only 15 percent of this comes from government...