ArticleInternational journal for equity in health2026
The role of health financing system and pluralism in achieving sustainable development goal health outcomes in India: a multilevel analysis.
Article in International journal for equity in health, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
introductionThe health system in India is pluralistic, with different sources of financing and multiple, overlapping financing systems across states. Existing studies often neglect system-specific factors such as fragmented health insurance schemes and state-level financing mechanisms. This study examines how health insurance pluralism, financing systems, and contextual state factors influence SDG health outcomes, integrating both individual and structural dimensions.
methodsData from NFHS-5, RBI database (2019-20), and National Health Accounts (2019-2020) were analysed. States were classified by financing systems (public, prepaid, and out-of-pocket) and categorized into low, medium, and high fragmentation groups using a fragmentation index. Multilevel logistic regression accounted for the hierarchical structure of health data, analysing both individual-level characteristics and state-level contextual factors. The descriptive analysis summarized sample characteristics and variable distributions.
resultsStates demonstrated diverse financing systems, with significant fragmentation in out-of-pocket-dominated systems. Public and pre-paid systems had beneficial effects on child mortality, vaccination rates, and WASH access. While fragmentation occasionally enhanced outcomes, it also increased expenditures. Out-of-pocket expenditures persisted as a key driver of inequity and financial risk.
conclusionStrengthening India's health system requires reducing fragmentation, promoting equitable financing, and aligning policies with the objectives of universal health coverage and the Sustainable Development Goals.
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