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Introduction <p>The 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.</p> Methods <p>Data 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.</p> Results <p>States 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.</p> Conclusion <p>Strengthening 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.</p>

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The role of health financing system and pluralism in achieving sustainable development goal health outcomes in India: a multilevel analysis

  • 期刊论文

  • 出版模式：

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  • 发表日期：

    2026年5月30日

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  • Pragyan Monalisa Sahoo,
  • Himanshu Sekhar Rout

摘要

Introduction

The 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.

Methods

Data 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.

Results

States 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.

Conclusion

Strengthening 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.