The past, present, and future of health economics in India

**Background:** Health economics, a blend of classical economics and healthcare, faces unique challenges due to third-party payers, subjective outcomes (e.g., QALYs), and heavy government involvement. In India, the healthcare sector has grown to over $40 billion, with >80% of spending in the private sector and out-of-pocket. Despite this, India's healthcare expenditure is only 4.1% of GDP, the lowest among BRICS nations, and there are only 860 beds per million people compared to the WHO global average of 3,960. The aging population (200 million ≥60 years by 2030) and high burden of non-communicable diseases strain the system.

**Methods:** This is a narrative review without a systematic search strategy. The authors synthesize existing literature and reports to discuss the economic burden of key diseases in India, including diabetes, hypertension, tuberculosis, and overpopulation. They also analyze the impact of the COVID-19 pandemic and propose solutions such as health technology assessments (HTAs) and improved data collection.

**Key Results:** - Diabetes: Direct diabetes costs are positively linked with GDP per capita; India faces high costs for dialysis and ophthalmic complications (cataract, glaucoma). Diabetes is the 13th most dangerous cause of death in India. - Hypertension: Affects nearly 3 in 10 Indians, responsible for 17.5% of all deaths and 9.7% of disability-adjusted life years (DALYs). Treatment costs include expensive interventions like stenting and anticoagulant therapy. - Tuberculosis: TB-related fatalities cost India $32 billion per year (over Rs 2 lakh crore). Despite free diagnosis and treatment, patients may become impoverished. - Overpopulation: 33% of households with one member ≥60 years and 38% with two or more ≥60 years experience catastrophic health expenditures, compared to 20% of households with all members <60 years. - COVID-19: The pandemic reduced private institutions' operating profit by nearly half. The government deployed the Aarogya Setu app for contact tracing.

**Clinical Implications:** The authors advocate for implementing HTAs to guide reimbursement and clinical practice, improving data collection and processing, and fostering education in pharmacoeconomics. They stress that 20% of work (Pareto's principle) could solve 80% of problems, urging targeted interventions for high-burden diseases. Better policies and collective effort are needed to strengthen India's health economy and ensure equitable access to care.