Published May 06, 2026 | 7:00 AM ⚊ Updated May 06, 2026 | 7:03 AM
Hospital beds. (iStock)
Synopsis: Kerala has the cheapest outpatient care in India at ₹583 per spell. It also has the highest hospitalisation rate and one of the highest hospital bills. Tamil Nadu sends half its outpatients to government facilities for nearly free, then charges the highest doctor fees in the country in its private wards. And Telangana, the outlier of the south, charges ₹1,058 for an outpatient visit, above the national average, while recording the highest hospitalisation costs among major states in India at ₹46,316. A new national survey documents the South’s defining healthcare contradiction.
The average Indian spends ₹975 on an outpatient visit for illness, including a doctor’s visit, a prescription, and a diagnostic test.
In Kerala, that figure is ₹583. In Karnataka, it is ₹629. In Tamil Nadu, ₹824. In Andhra Pradesh, ₹873. Telangana, with ₹1,058, is the only southern state above the national average.
Four of the five southern states, all but Telangana, sit below the national outpatient average. Kerala and Karnataka are the two cheapest major states in the country for day-to-day medical care. Telangana is eighth on the national list, and its hospitalisation bill of ₹46,316 is the highest among major states.
However, southern states are not known for cheap healthcare. Kerala has the highest hospitalisation costs per case among states with large rural populations. Tamil Nadu has the most expensive private hospital doctor fees in India. Karnataka’s private hospital bills are well above the national average for most serious diseases.
The outpatient numbers do not fit the story most people tell about southern healthcare. That is because the story most people tell is incomplete.
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The NSS 80th Round survey, released by the Ministry of Statistics and Programme Implementation on 20 April, covering 1,39,732 households across 2025, tracks what people spend over 15 days when they fall ill and seek treatment without being hospitalised.
The expenditure has two components. Medical costs cover doctor fees, medicines, and diagnostics. Non-medical costs cover transport, food, and the expense of an attendant.
In Kerala, the medical component of an outpatient spell is ₹503, and the non-medical component is ₹81. Total: ₹583.
In Karnataka, medical is ₹547 and non-medical is ₹82. Total: ₹629.
Compare this to the most expensive states for outpatient care. Haryana charges ₹1,527 per spell. Punjab ₹1,437. Uttar Pradesh ₹1,333. Bihar ₹1,270.
A person who falls ill in Kerala and visits a doctor pays less than half of what their counterpart in Haryana pays for the same thing — less than half.
And yet, Haryana’s overall hospitalisation expenditure, what patients pay when they are admitted to a hospital, is ₹33,713 per case, and Kerala’s is ₹35,338 — higher than Haryana, despite its outpatient care being dramatically cheaper.
The explanation begins with a single number buried in the survey: The median out-of-pocket expenditure for an outpatient visit to a government hospital is zero.
Not low. Zero.
Half of all outpatient visits to government hospitals across India result in no payment. Consultation, medicines and diagnostics are all covered by the government facility without any charge to the patient.
This median figure of zero shapes states averages in a direct way. States where a large proportion of outpatient visits happen in government facilities will have lower average outpatient costs, not because private care is cheap, but because a large share of their outpatient activity costs the patient nothing.
In Tamil Nadu, 49 percent of all outpatient spells are handled by government hospitals. The national average is 30.9 percent.
In Kerala, 42.7 percent go to government facilities. In Karnataka, 35.5 percent. In Andhra Pradesh, 31.8 percent.
Four of the five southern states are above the national average for government outpatient utilisation. Tamil Nadu is the highest of any major state in the country.
When nearly half your outpatient visits are free, your average cost per spell will be low, even if the private sector charges as high as it wants.
There is a second mechanism pulling southern outpatient costs down, and it is less intuitive.
The survey measures the PPRA, the proportion of persons who reported being ill during a 15-day reference period, per 1,000 population. It is a measure of how much illness a state reports, and how willing its people are to seek care for it.
Kerala’s PPRA is 397 per 1,000. Almost two in five people in Kerala reported being ill during the reference period.
The national average is 131 per 1,000.
Kerala is reporting illness at three times the national rate. Andhra Pradesh at 211, Telangana at 150, Tamil Nadu at 140, all well above the national average.
What drives a high PPRA is not necessarily more sickness. It is a more health-seeking behaviour. In states with strong primary care infrastructure and high health awareness, people visit a doctor for conditions that would often go untreated elsewhere. A mild fever, a persistent cough, a routine diabetes check-up, and a thyroid review generate outpatient visits in Kerala that would not generate outpatient visits in Bihar.
The consequence for cost averages is significant. When you have a large volume of low-intensity, routine, chronic management visits, many of them free at government facilities, the average cost per spell is pulled down by sheer volume.
In contrast, Bihar’s PPRA is just 99 per 1,000, and its outpatient cost is ₹1,270. People in Bihar seek care less frequently. When they do, it is often for an illness that has progressed to a serious stage, which means the visit involves more diagnostics, more medicines, and more expenditure. The average cost per spell is high precisely because the low-cost routine visits are not happening.
The South is paying ₹583 per spell partly because half those spells are free at government hospitals, and partly because they are generating thousands of visits for mild, manageable conditions that the North does not count.
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The urban-rural breakdown sharpens the picture further.
In rural Kerala, an outpatient spell costs ₹609. In rural Karnataka, it is ₹549, the cheapest in the country.
In rural Bihar, the same spell costs ₹1,199. In rural Haryana, ₹1,481. In rural Punjab, it is ₹1,496, more than two and a half times what rural Karnataka pays.
The urban numbers tell a similar story. Urban Kerala is at ₹559, the cheapest urban outpatient market in India. Urban Karnataka is ₹759. Urban Tamil Nadu ₹796.
Urban Bihar costs ₹1,783. Urban Uttar Pradesh ₹1,793. Urban Delhi ₹1,704.
A sick person in urban Kerala pays one-third of what a sick person in urban Bihar pays for an outpatient visit.
The north’s higher per-visit costs are driven by a combination of lower government utilisation, less frequent care-seeking, which means visits are for more serious conditions, and higher private clinic fees in states where the public outpatient network is thinner.
Telangana does not fit the southern pattern.
Its outpatient cost is ₹1,058, the only southern state above the national average, and the eighth most expensive among all major states. Its rural outpatient cost of ₹1,169 is particularly elevated.
The reason follows from the same logic. Telangana’s government outpatient utilisation rate is 34.6 percent, slightly above the national average of 30.9 percent, but well below Tamil Nadu’s 49 percent and Kerala’s 42.7 percent.
More importantly, 30.2 percent of Telangana’s outpatient visits go to private clinics and 33.4 percent to private hospitals. The private sector dominates outpatient care in a way that it does not in Tamil Nadu or Kerala.
The result is that Telangana pays for its outpatient care at private rates rather than public rates. Its PPRA of 150 per 1,000 is above average, but its public infrastructure is not absorbing that demand the way the rest of the South does.
Telangana is the southern state that proves the rule. Where the public outpatient network does not dominate, outpatient costs are similar to the rest of India.
The southern paradox is not a contradiction. It is a system with two very different parts operating simultaneously.
The public primary care network in Kerala, Tamil Nadu, and Karnataka is doing something unusual. It is providing free or near-free outpatient care at high volume for a population that frequently reports illness and seeks treatment early. This is, by any measure, a public health achievement. Chronic diseases get managed. Minor infections get treated before they escalate. The data shows it is working.
However, the same states have built a private hospital sector that prices inpatient care at rates seen nowhere else in the country.
Kerala’s overall hospitalisation OOPME is ₹35,338. Tamil Nadu’s is ₹44,535. Telangana’s is ₹46,316, the highest among major states. Karnataka’s is ₹37,606.
All four are above the national average of ₹34,064.
The private hospitals in the South have effectively been freed from competing for routine care. Government clinics handle the headache and the blood pressure check. Private hospitals handle heart attacks and cancer.
And when they handle a heart attack or a cancer, in Tamil Nadu, Karnataka, Telangana, the bill that arrives is among the highest in India.
The South has socialised the cost of daily illness through a functioning public network. The same states have privatised the cost of serious illness at a premium that the national average does not capture.
A person in Kerala who visits a doctor for a cold pays ₹583 or nothing. The same person admitted to a private hospital for cardiovascular treatment pays ₹70,456, the second-highest private cardiovascular cost in the country after Telangana.
That is the southern paradox. The most accessible daily healthcare in India. And some of the most expensive hospital care when the illness turns serious.
(Edited by Muhammed Fazil.)
