India’s rough road to health equity

On December 12, 2012, the United Nations General Assembly adopted a resolution on Universal Health Coverage (UHC), envisioning a world where everyone can access essential health services without financial hardship. This vision goes beyond healthcare, aiming to foster health equity, economic growth, and overall well-being. Each year, UHC Day – on December 12 – highlights global efforts to make affordable and quality healthcare accessible to all.

UHC is a cornerstone of Sustainable Development Goal 3.8, which seeks to achieve universal healthcare access and financial protection by 2030. It is guided by three key dimensions: population coverage, ensuring equity in who receives services; service coverage, defining the scope and quality of health services available; and financial protection, safeguarding individuals from financial ruin due to healthcare costs. Rooted in the principles of equity, non-discrimination, and the right to health, UHC strives to reach the weakest and marginalised sections of society.

Globally, there are several success stories of UHC. Thailand, for instance, launched its Universal Coverage Scheme in 2002, achieving over 99% population coverage. Countries like Japan, Germany, Sri Lanka, and Turkey have also demonstrated how inclusive healthcare systems can transform lives and drive progress. It is time to reflect on India’s journey towards UHC, the progress made and the challenges that persist. India has made notable progress towards UHC through various policies and programmes. The National Health Policy of 2017 was a significant step forward. It emphasised on primary healthcare, preventive services, and equitable access. The policy aimed to increase public health expenditure to 2.5% of the GDP. Another key achievement is the Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (PMJAY). Launched in 2018, it is the world’s largest government-funded health insurance scheme and provides an annual health cover of Rs 5 lakh per family to over 100 million low-income households. By 2023, it had enrolled over 50 crore beneficiaries and enabled more than 4 crore hospitalisations, reducing financial barriers to healthcare.

Some states too have shown innovative approaches, like Tamil Nadu with a strong drug procurement system that ensures free medicine availability, and Kerala with a focus on strengthening primary healthcare. Despite these efforts, India’s healthcare coverage remains far from being universal. An abysmal patient-doctor ratio, lack of hospital beds, and lack of a trained workforce remain major challenges. More than 70% of the rural Community Health Centres (CHCs) lack the full range of specialists, with 83% of them operating without surgeons. Additionally, 75% lack obstetricians and gynaecologists, and 82% are without physicians. Urban CHCs too are facing a 45% shortfall in specialist availability.

According to Oxfam India (2021), the number of sub-centres, Primary Health Centres (PHCs), and CHCs also falls short of the requirement. With the public healthcare sector failing to meet the standards, there is over-dependence on the private sector which steepens the rich-poor divide in healthcare access. Low insurance coverage leads to high out-of-pocket expenditure – 39.4% of the total health expenditure, according to the National Health Accounts report for 2021-22 by the Ministry of Health and Family Welfare. More than 50 million people are pushed towards poverty because of this and most of them end up in distress financing such as selling assets and borrowing.

The biggest challenge in achieving UHC in India is the over-reliance on insurance-based models. While expanding insurance coverage is a step forward, it must be supported by substantial government spending, which currently stands at a mere 1.84% of the GDP. Private insurance remains inaccessible to a significant portion of the population, and public insurance schemes are limited in reach. The majority of India’s workforce is employed in unorganised sectors, which lack both a proper pay structure and social security benefits. In India, a significant proportion of the health costs comprises consultation fees and diagnostics charges which are generally not covered by most insurance schemes.

The healthcare sector is further threatened by the demographic and epidemiological shifts. The elderly population, currently 8.6%, is expected to rise to 20% by 2050, creating additional demand for healthcare services and a potentially heightened risk of non-communicable diseases. Existing health policies and programmes have focused more on maternal and child health compared to geriatric care.

Focus on funding, inclusion

UHC has been a primary health goal for Indian policymakers, and achieving it has the potential to mitigate many persisting health inequalities. Beyond bridging the rich-poor divide, UHC must address disparities across gender, residence, class, caste, and religion. While India has made commendable progress in the health sector, the current approach has fallen short in many critical areas. India’s primary step towards UHC should be to increase the budgetary allocation for health. This would play a key role in improving the existing infrastructure, recruiting more healthcare workers, and reducing out-of-pocket expenses. The ambit of health insurance must be widened to integrate informal workers into health insurance schemes like PMJAY, along with specific welfare programmes for gig and informal sector workers.

Strengthening the roles of ASHAs and ANMs can enhance outreach and health awareness. Preventive health campaigns with active community participation can lead to better health outcomes. Public-Private Partnerships (PPPs) can help expand healthcare access in underserved areas. Improving PHCs and CHCs is essential, especially in rural areas. Urban areas also need expanded tertiary care facilities to meet the demand for specialised treatments. India can learn from global examples like Thailand, which prioritised primary healthcare and innovative health financing, and Japan, which achieved equitable access through strong government regulation.

Achieving UHC requires political commitment, adequate resources, and effective governance. The COVID-19 pandemic exposed gaps in primary healthcare but it also encouraged digital health adoption. Initiatives like the Ayushman Bharat Digital Mission promise to enhance efficiency. Strengthening primary care, improving digital infrastructure, and preparing for future crises must remain priorities for India’s UHC goals. By addressing gaps, leveraging technology, and prioritising equity, India can build a stronger healthcare system and ensure health for all.

(Nitin is a research intern, Indian Council of Social Science Research, Delhi; Paramita is a doctoral fellow, International Institute for Population Sciences, Mumbai)