Achieving Universal Health Coverage  in India

Introduction 

• India is on a transformative journey to achieve Universal Health Coverage (UHC), ensuring every citizen, no matter their socio-economic background, has access to quality healthcare. 
• The Pradhan Mantri Bhartiya Janaushadhi Pariyojana (PMBJP), alongside the establishment of Jan Aushadhi Kendras, plays a crucial role in this mission by offering affordable medicines. 
• These efforts are part of India’s broader commitment to UHC, aimed at making healthcare accessible, equitable, and affordable for all.

What is Universal Health Coverage (UHC)?

• Universal Health Coverage (UHC), according to the World Health Organization (WHO), is the principle that everyone should have access to the health services they need without suffering financial hardship. 
• UHC is enshrined in the Sustainable Development Goals (SDG 3.8), reflecting the global ambition to ensure equitable healthcare for all individuals.

Key Principles of UHC

• Equitable Access: Health services should be available to everyone, regardless of their socio-economic status.
• Quality Healthcare: Services must meet high standards, ensuring improved health outcomes.
• Financial Protection: No one should face financial ruin due to healthcare costs.
• UHC ensures that healthcare is not a privilege, but a basic human right that everyone can access without being pushed into poverty.

 Global Evolution of UHC and India’s Progress Towards UHC

• UHC has evolved globally as an essential part of health policy, starting with the Alma-Ata Declaration (1978), which emphasized “Health for All”. This declaration laid the groundwork for UHC as a global priority. Fast forward to 2015, when UHC was officially included in the Sustainable Development Goals (SDGs), with a commitment to achieving UHC by 2030. Countries like Thailand, Rwanda, and Costa Rica have been successful in implementing UHC, offering models for other nations to follow.
• In India, the path to UHC has been long and evolving. Following independence, efforts to build a public healthcare system were initiated with the Bhore Committee (1946), which led to the creation of a three-tier healthcare system consisting of Primary Health Centres (PHCs), Community Health Centres (CHCs), and District Hospitals. 

How Has UHC Evolved in India? 

• • India’s journey toward achieving Universal Health Coverage (UHC) has evolved over several decades, shaped by various policies, programs, and health reforms. The aim has always been to ensure access to quality healthcare for every citizen, irrespective of their socio-economic background. Here’s an overview of how UHC has developed in India from the early post-independence era to the present day, highlighting key events and initiatives.

• Early Post-Independence Era (1950s-1980s): Following independence, India’s focus was on building a robust public health infrastructure. The Bhore Committee (1946) played a crucial role during this period by recommending a state-funded, free healthcare system. This recommendation led to the establishment of a three-tier healthcare system:

• • • Primary Health Centres (PHCs)
    • Community Health Centres (CHCs)
    • District Hospitals
    • This system was designed to provide accessible healthcare, especially in rural areas, where access was limited. 
    • However, the focus during this period was largely on curative healthcare rather than preventive care or universal health coverage.

• First Five-Year Plan (1951-1956): Foundation for Public Healthcare

• • • The First Five-Year Plan (1951-1956) laid the foundation for public healthcare in India, emphasizing the need for primary healthcare and rural health centers. 
    • The government began establishing more PHCs and CHCs to cater to the rural population, and the plan included provisions for healthcare as part of the broader public welfare system.

• National Health Programs (1950s-1980s): During the 1950s to 1980s, National Health Programs were introduced to tackle specific diseases such as malaria, tuberculosis, and leprosy. These programs were largely disease-centric, focusing on specific health conditions rather than adopting a more holistic UHC approach. While these programs did help reduce certain diseases, they did not significantly address the broader goal of universal health coverage.

• Rise of Private Healthcare (1990s-2000s):

• 1991 Economic Reforms: A Shift Toward Privatization: The 1991 Economic Reforms marked a significant shift in India’s economic policies, including the healthcare sector. The liberalization of the economy led to the growth of the private healthcare sector, with private hospitals and health insurance schemes seeing rapid expansion. However, this shift also resulted in stagnation in public healthcare investment. As a result, there was a growing disparity in the quality of healthcare available in public versus private sectors.

• 1997 Rashtriya Swasthya Bima Yojana (RSBY): In 1997, India launched the Rashtriya Swasthya Bima Yojana (RSBY), a health insurance scheme targeted at families living below the poverty line (BPL). This program marked a shift toward demand-side financing, providing financial protection to low-income families for healthcare expenses. The RSBY scheme, while important in providing financial protection, focused primarily on hospital-based care, leaving gaps in primary healthcare access.

• National Rural Health Mission (NRHM) – 2005: In 2005, the government introduced the National Rural Health Mission (NRHM), which aimed to expand healthcare access in rural areas. The NRHM focused on strengthening PHCs and CHCs, and introduced ASHA (Accredited Social Health Activist) workers to improve maternal and child healthcare. This program began to incorporate principles more aligned with UHC, focusing on expanding healthcare access to underserved rural populations.

• Strengthening UHC Initiatives (2010s-Present):

• National Health Policy (NHP) 2017: The National Health Policy (NHP) 2017 explicitly emphasized the goal of achieving Universal Health Coverage. It proposed strategic purchasing of healthcare services from both public and private sectors, advocating for better quality healthcare, especially in underserved regions. The policy also aimed to ensure that every citizen had access to essential healthcare without facing financial hardship.

• Ayushman Bharat (2018-Present): India’s most ambitious step toward UHC came in 2018 with the launch of Ayushman Bharat, which focuses on two key components:

• • • PM-JAY (Pradhan Mantri Jan Arogya Yojana): A free health insurance scheme covering 500 million low-income citizens, providing coverage for secondary and tertiary care. This scheme aims to reduce the financial burden of healthcare for the most vulnerable populations.
    • Health & Wellness Centres (HWCs): Aiming to provide comprehensive primary healthcare services, these centers are being established across India by upgrading existing PHCs to cater to non-communicable diseases (NCDs), mental health, and maternal and child health services. This initiative addresses the need for more preventive healthcare and primary care services, which are crucial to the success of UHC.

• Ayushman Bharat Digital Mission (ABDM): The Ayushman Bharat Digital Mission (ABDM) is another key initiative launched to enhance equitable access to healthcare by leveraging digital technologies. The ABDM aims to create a unified platform for healthcare services, promoting telemedicine, digital health records, and the Ayushman Bharat Health Account (ABHA) for citizens. The ABHA number will enable national portability of health services, allowing citizens to access care anywhere in India. In addition to Ayushman Bharat, several other programs have been introduced to address specific aspects of public health:

• • • Fit India Campaign: Promotes healthy lifestyles and preventive health measures.

• The Universal Health Care Bill (2021): The Universal Health Care Bill (2021) was introduced with the aim of providing quality healthcare to all citizens. The bill focuses on integrating primary healthcare into government health schemes, increasing transparency in the healthcare system, and ensuring that every citizen, especially those in underserved areas, has access to essential healthcare services. The bill is an important step toward strengthening the country’s commitment to UHC.

• • National Mental Health Programme (NMHP): Addresses the growing need for mental health services in India.
  • National Programme for Health Care of the Elderly: Focuses on improving healthcare services for the elderly.
  • POSHAN 2.0: Aims to tackle malnutrition and promote better nutrition.

Importance of UHC for India’s Future

• Economic Growth: UHC is not just a healthcare reform but an economic strategy. By improving workforce health and productivity, UHC contributes to national economic growth. Countries like China, with robust UHC systems, have shown how health reforms can reduce poverty and drive economic progress. According to a report by the Indian Council of Medical Research (ICMR), non-communicable diseases (NCDs) are projected to cost India $6.2 trillion in lost economic output over the next 20 years. Strengthening UHC could help mitigate these losses by ensuring early detection, treatment, and management of NCDs, thereby improving workforce health and productivity. 
• Reducing Out-of-Pocket (OOP) Expenditure: High OOP expenses push millions of Indians into poverty each year. The World Health Organization (WHO) estimates that about 60 million Indians are pushed into poverty every year due to healthcare costs. This financial hardship disproportionately affects low-income groups who face catastrophic health expenditures when seeking treatment. UHC aims to protect people from catastrophic health expenditures. India’s AB-PMJAY (Pradhan Mantri Jan Arogya Yojana) has been instrumental in reducing these costs. By providing free health insurance to over 500 million low-income citizens, the scheme has significantly alleviated the financial strain of healthcare. For instance, ₹1.25 lakh crore has been saved in OOP expenses for inpatient care alone under AB-PMJAY, allowing families to avoid devastating financial consequences and improving their financial security. 

• Additionally, Ayushman Bharat covers treatments for conditions like heart disease, cancer, and kidney dialysis, which typically incur high costs. By reducing OOP expenses, these initiatives make healthcare more affordable for vulnerable populations, enabling them to focus on recovery rather than financial distress. 

• Improved Health Outcomes: States with better public health spending, such as Kerala, Tamil Nadu, and Himachal Pradesh, have significantly better health outcomes. These states demonstrate how public health investment can improve overall health and reduce disparities.

•  Kerala, known for its robust healthcare system, has one of the highest life expectancies in India at 77.8 years and a maternal mortality ratio (MMR) of just 42 per 100,000 live births, much lower than the national average. 
• Tamil Nadu has seen remarkable success in improving infant mortality rates, which have fallen to 17.9 deaths per 1,000 live births, compared to the national average of 28. 
• Himachal Pradesh has effectively reduced the incidence of communicable diseases, thanks to consistent investment in healthcare infrastructure.

• Disease Burden Reduction: Preventive healthcare, which is a key component of UHC, can significantly reduce the long-term disease burden. According to the World Bank, addressing non-communicable diseases (NCDs) such as diabetes and hypertension could save ₹4.8 lakh crore by 2030, boosting productivity and reducing health-related economic losses.
• Social Equity: UHC ensures that healthcare is available to all, especially marginalized communities such as Scheduled Tribes, women, and low-income groups. It addresses health inequalities, providing equitable healthcare access to those most in need. A great example of this is Ayushman Bharat, which targets India’s poorest households, providing them with free health insurance that covers a range of treatments, including high-cost procedures like organ transplants and cancer treatments. This is especially important for marginalized communities that often face the highest OOP expenses, as reported in the National Sample Survey 75th Round.
• Boost to Medical Tourism: India’s affordable and high-quality healthcare services are attracting international patients. The medical tourism industry generated $7.69 billion in 2024, and it is expected to grow to $14.31 billion by 2029. This further strengthens India’s position as a global healthcare hub. India’s success in affordable healthcare has made it a global leader in medical tourism, attracting international patients for procedures like cardiac surgery, joint replacements, cosmetic surgery, and fertility treatments. For example, hospitals like Medanta and Apollo provide world-class services at competitive prices, drawing patients from countries like the Middle East, Africa, and South Asia. 

What are the Challenges in Achieving UHC in India?

• Low Public Health Expenditure: India’s public health expenditure is 1.9% of GDP, far below 
• High Out-of-Pocket Spending: Outpatient care is largely uncovered by schemes like AB-PMJAY, leaving a significant gap in financial protection. Most OOP costs are incurred for outpatient services, diagnostics, and medicines.
• Reliance on the Private Sector: Two-thirds of outpatient care is provided by the private sector, which places a heavy burden on patients. While government schemes like Employees’ State Insurance (ESI) and CGHS provide better coverage, they remain limited to specific groups, excluding informal sector workers.
• Underfunded Primary Healthcare: Primary healthcare remains underfunded, and the allocation to the National Health Mission (NHM) has stagnated. This gap leads to an imbalance between hospital care and primary healthcare services, weakening the overall healthcare system.
• the WHO recommendation of 5%. This impacts the quality of public healthcare infrastructure and services.
• Regional Disparities: There is a stark difference in healthcare access between urban and rural areas. 70% of healthcare professionals are in urban areas, while 65% of the population lives in rural areas. This imbalance limits healthcare access for rural communities.
• Low Health Awareness: Health literacy remains low in India, especially in rural areas. A lack of awareness about preventive care, immunization, and nutrition contributes to higher morbidity and mortality rates, particularly among vulnerable groups.
• Quality and Accessibility Issues: Many AB-PMJAY empaneled hospitals are located in urban areas, limiting access for rural populations. Supply-side constraints such as insufficient healthcare professionals, beds, and diagnostic facilities also hinder UHC implementation.
• Low Insurance Penetration: Despite schemes like AB-PMJAY, only 41% of Indian households have health insurance. This low penetration highlights the need to expand coverage to more people, especially those in the informal sector.

Way Forward

• Increase Public Health Spending: Raising public health spending to 3-5% of GDP will be essential for strengthening the healthcare system. The government could consider sin taxes and corporate health levies to finance this expansion.
• Strengthen Primary Healthcare and Preventive Care: Focus on improving PHCs and integrating outpatient services into health insurance schemes. A stronger focus on preventive care will help address the rising burden of non-communicable diseases (NCDs).
• Expand Insurance Coverage: A unified health insurance framework should be established to provide comprehensive coverage to all citizens, including those in the informal sector, using models such as the Japanese Universal Insurance system.
• Leverage Digital Health and Telemedicine: India should expand the Ayushman Bharat Digital Mission to create a more integrated healthcare system, using technologies like telemedicine and AI-driven diagnostics to enhance healthcare access, particularly in underserved regions.
• Address Regional Disparities: Increase investment in healthcare infrastructure in rural areas and incentivize healthcare professionals to work in underserved regions to reduce the urban-rural divide.
• Promote Health Literacy: A national focus on health education and awareness campaigns can empower individuals to take control of their health and make informed decisions.