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Paper short abstract

Focusing on DEG hospital investments and the Indo-German UHC programme, this study shows how German development finance may reinforce healthcare financialisation in India, contributing to high out-of-pocket costs, inequities, and health-related debt.

Paper long abstract

Health-sector financialisation has increasingly positioned healthcare in low- and middle-income countries as a site for capital accumulation, with significant implications for affordability, access, and household financial risk. Development Finance Institutions (DFIs) play a growing role in this process, operating at the intersection of public mandates and profit-oriented investment logics. In India, rapid corporatisation of healthcare—supported by transnational finance—has coincided with persistently high out-of-pocket expenditure, raising concerns about health-related indebtedness. Yet the role of European, and specifically German, development finance in shaping these dynamics remains under-examined.

This exploratory qualitative study analyses German development engagement in India’s healthcare sector and its implications for financialisation and equity. Drawing on desk reviews and fourteen semi-structured interviews, it examines two linked case studies: a DEG-financed corporate hospital chain, and the Indo-German Programme on Universal Health Coverage (IG-UHC), which provides technical assistance to India’s publicly funded health insurance scheme, PM-JAY.

Findings show that DEG-financed hospital investments were embedded in opaque financing arrangements, limiting transparency and accountability, while prioritising high-margin specialised services. Reported practices of overcharging and restricted access to subsidised care contributed to continued out-of-pocket payments even among insured populations, increasing risks of exclusion and health-related debt. At the policy level, IG-UHC demonstrated limited influence in addressing structural drivers of financial hardship within PM-JAY.

Overall, the study argues that German development engagement risks reinforcing financialised healthcare pathways without adequately addressing their equity consequences, underscoring the need for stronger public accountability.