New Delhi: India supplies vaccines and generic medicines to much of the world. Yet at home, millions still leave hospitals without care. Clinics are shut, there is a shortage of doctors, or treatment stops because patients cannot afford it. A new Lancet report says this gap between promise and reality is not only about money, but about how India’s healthcare system is designed and run.
Published last week, ‘The Lancet Commission on a Citizen-Centred Health System for India’ examines why healthcare remains uneven despite decades of programmes and reforms. It also lays out a roadmap to universal health coverage.
Progress, but not enough
The picture the report presents is mixed. India has made progress on key indicators. The report notes that life expectancy has increased, maternal and infant deaths have declined, and access to health facilities has improved. Schemes such as Ayushman Bharat (government-sponsored initiative to achieve universal health coverage) have widened hospital coverage.
But at the same time, India continues to lag behind comparable countries when it comes to maternal health and children’s nutrition. While maternal and child survival and control of communicable diseases have improved, gaps remain. “Rates of malnutrition are high, 12 per cent of the population is undernourished, and 32.9 per cent of children younger than 5 years are stunted,” the report says.
It adds that rising non-communicable diseases, an ageing population, antimicrobial resistance, climate change, and health inequities pose serious challenges. “Universal, affordable, quality healthcare remains unavailable for most Indians,” the commission concludes.
A system built around facilities, not patients
At the centre of the problem, the report points out, is a system organised around facilities and schemes rather than patients. Public health services suffer from weak accountability, fragmented governance, and poor coordination.
Although India has expanded its health workforce, including more than one million accredited social health activists, introduced mid-level health providers, and increased medical and nursing institutions, numbers alone are not enough.
Commenting on the findings, Soumya Swaminathan, former deputy director of the World Health Organisation, wrote that “numerical expansion is insufficient to deliver high-quality care and sustain trust at the community level”. She adds that on-the-job training and mentoring must strengthen both technical and interpersonal skills, while emphasising teamwork and clarity of roles.
Dr Vinay Aggarwal, former National President, Indian Medical Association, told ThePrint that the government needs to reform Pradhan Mantri Jan Arogya Yojana (PMJAY) to include outpatient care, realistic package rates, direct benefit transfer and timely reimbursements.
PM-JAY is a flagship Indian government health insurance scheme launched in 2018. It provides cashless coverage of up to Rs 5 lakh per family per year for secondary and tertiary care hospitalisation to over 50 crore beneficiaries.
“In the upcoming budget, we would request the finance minister to provide GST exemption on lifesaving equipment, consumables and all vaccines,” Dr Aggarwal said.
Weak incentives and accountability
Economist Karthik Muralidharan, Professor of Economics at University of California, San Diego, and founder and scientific director of the Centre for Effective Governance of Indian States, in a linked Lancet Comment, points to governance failures as the core issue.
“The core governance challenge in India’s public healthcare system is weak incentives and accountability,” he writes. “This is reflected in high and unpredictable rates of health worker absence (especially in rural areas), and low effort even when staff are present.”
Muralidharan argues that the current system discourages better performance. “Under the current structure, it can be rational even for intrinsically motivated public sector providers to limit effort, as delivering better care simply attracts more patients without increasing their pay or resources.”
He adds that this encourages doctors to maintain private practices and provide only basic care at public clinics. “Together, these factors help explain why many patients, including low-income populations, seek private sector outpatient care despite the higher out-of-pocket costs.”
High costs, low public spending
The report highlights how out-of-pocket spending remains high, making up nearly half of India’s total health expenditure. Public health spending is still under 2 per cent of GDP, below national targets.
Dr Aggarwal advocates tax-funded universal healthcare with a basic health package for all citizens and to increase public health allocation to 2.5–5 per cent of GDP, strengthening government hospitals and human resources.
What the panel recommends
In its report, Lancet has called for strengthening the public health system as the backbone of universal health coverage.
Based on research from 2020 to 2024, it says India can still turn universal health coverage from policy into practice if it fixes how care is delivered, not just how schemes are announced.
The panel stresses stronger primary care, better coordination between governments, and funding models that reward outcomes. It recommends separating purchaser and provider roles, allowing patients to register with providers of choice, and piloting reforms at the district level before scaling them nationally.
(Edited by Viny Mishra)
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