Last year, a Kasba resident rushed his 75-year-old father to two government hospitals after the older man suffered a cerebral stroke. Both times, doctors said an ICU bed was needed — and both times, none was available.
The son was forced to admit his father to a private hospital instead, where more than 20 days of treatment cost around ₹10 lakh. The son, who runs a small business, borrowed from friends and relatives to pay the bill. He is still repaying the debt.
His story is not an outlier. It is the human face of a number: out-of-pocket health expenses in Bengal are among the highest in India, a pattern that health officials say points to a deeper accountability problem among the state’s public healthcare providers — including a section of doctors who devote more time to private practice than their government duties.
According to the National Health Accounts Estimates 2022-23, prepared by the Union health ministry, households in Bengal spent ₹41,409 crore out of their own pocket on treatment — 62.3 per cent of the state’s total health expenditure. The per capita figure stood at ₹4,183.
The trend line suggests the state has made — and then lost — ground. Bengal’s out-of-pocket health expenses stood at 68.7 per cent of the total health expenditure in 2018-19, improved to 65.1 per cent in 2020-21, and fell further to 58.3 per cent in 2021-22, before rising again to 62.3 per cent in the latest survey. Two consecutive years of improvement have been undone by the most recent numbers.
The contrast with other states remains stark. Karnataka’s out-of-pocket expenditure was ₹13,933 crore, accounting for 29.2 per cent of its total health spending, with a per capita figure of ₹2,049. Odisha recorded ₹10,329 crore, or 42.4 per cent of the total health expenditure, with the per capita out-of-pocket expenses at ₹2,245.
Kerala posted higher per capita out-of-pocket expenses than Bengal. Maharashtra’s absolute figure was marginally higher but since its total health expenditure was far bigger, the out-of-pocket expenditure as a percentage of the total health expenditure was less than Bengal’s.
The National Health Accounts defines out-of-pocket expenditure as payments made directly by households at the point of care covering inpatient and outpatient care, childbirth, antenatal and postnatal care, family planning, therapeutic appliances, transportation, immunisation, over-the-counter drugs and other medical costs such as blood or oxygen.
Chinks in system
A Bengal health department official attributed the high costs to two failures under the previous Mamata Banerjee government: poor quality of care and underuse of existing facilities.
“Doctors not doing their duties properly at government hospitals, patients being refused and forced into the private sector — these are the real issues,” the official said, adding that OPD attendance and surgical caseloads per surgeon in Bengal’s government hospitals lagged national norms.
The complaint is not new, the official acknowledged, but a solution has remained elusive.
“The problem is acute in the district hospitals, so government medical colleges in Calcutta end up overburdened,” he said.
“Despite Swasthya Sathi, fair-price medicine shops and free diagnostics, the out-of-pocket burden stays high — because the previous government could never enforce discipline among its own staff.”
Officials could not offer specific data on how the burden differed between urban Calcutta and the rural districts, though health officials, doctors and public health experts agree that the rural-urban gap has persisted for decades.
Doctors’ counter
Doctors’ associations reject the government’s framing of the issue, arguing that a chronic shortage of infrastructure and manpower — not absenteeism — is the real reason for the poor service at government hospitals.
“According to WHO recommendations, there should be three beds for every 1,000 patients. The international average is 2.7; in Bengal, it is 0.9,” said Swapan Biswas, treasurer of the Service Doctors’ Forum.
“Bengal has 34,000 beds in the private sector and 78,000 in government hospitals — just over one lakh in all. The actual requirement is more than three lakh beds.”
Biswas said government hospitals faced a 30-40 per cent shortage of doctors, alongside shortages of nurses and Group D staff. “Instead of addressing these problems, successive governments have offered superficial fixes — Swasthya Sathi, 10 per cent free beds at private hospitals,” he said.
Less for more
The National Health Accounts data show that Bengal allocated ₹2,500 crore to Swasthya Sathi in 2022-23 — more than comparable schemes elsewhere. Karnataka spent ₹100 crore on the Yeshasvini Health Insurance and ₹1,279 crore on Ayushman Bharat-Arogya Karnataka; Kerala allocated ₹902 crore to PMJAY-KASP. Despite the outlay, Bengal’s returns — measured by household costs — trail states spending far less.
New govt’s fix
Bengal health minister Sharadwat Mukherjee told The Telegraph that reform was overdue and was under way. He identified four drivers of the cost of healthcare: drugs, implants, diagnostic investigations and ambulance services.
Janaushadhi Kendras — generic-medicine outlets under the Pradhan Mantri Bhartiya Janaushadhi Pariyojana — will be rolled out at all government facilities in phases over the next two to three months, a state health department official said.
“The earlier government did not allow these,” Mukherjee said. AMRIT pharmacies, which sell implants and surgical consumables at 50-90 per cent discounts, will follow on the same timeline, alongside a blueprint for ambulance services.
On discipline, Mukherjee said all government doctors had been directed to observe their full duty hours, and a “zero refusal policy” was now in force for genuine admissions.
To enforce it, he said, the department was tracking admission and OPD data at government hospitals — though he did not specify what action would follow if hospitals or doctors fell short.