Universal Health Coverage

India has committed to achieving Universal Health Coverage (UHC) through the National Health Policy (NHP), 2017 and Sustainable Development Goal-3 (SDG-3). The flagship programme driving this goal is Ayushman Bharat (AB). Despite notable progress, India still faces a significant access–affordability–quality gap, indicating that UHC objectives remain partially unmet.

What is Universal Health Coverage (UHC)?

Universal Health Coverage means that all individuals and communities have access to the full range of essential health services they need, without experiencing financial hardship.

Key Components of UHC

1. Access to Care: Everyone should be able to obtain necessary health services when they need them.

2. Quality of Services: Health services should be effective, safe, and of high quality.

3. Financial Protection: Individuals should not face financial difficulties due to medical expenses.

UHC is grounded in the universal human right to health, recognised in international covenants and reaffirmed by the Alma-Ata Declaration (1978), which prioritised comprehensive primary healthcare.

Need for UHC in the Indian Context

Historical Commitment to Universal Healthcare

The Bhore Committee (1943–46) recommended a tax-funded universal public healthcare system, rejecting an insurance-heavy model and emphasising preventive and primary care.

Policy Evolution After Independence

India’s National Health Policy, 1983 emphasised “Health for All”, highlighting the importance of primary healthcare and equitable distribution of resources.

Shift Towards Insurance-Led UHC

Schemes such as Rashtriya Swasthya Bima Yojana (RSBY), 2008 and Ayushman Bharat–PMJAY institutionalised UHC. However, these schemes reinforced a hospitalisation-centric, insurance-based approach.

Weak Public Health System and Rising Private Dependence

Chronic underfunding of primary healthcare has led to poor quality of public services and infrastructure gaps. National Sample Survey (NSS) data show growing dependence of the poor on private healthcare, leading to high out-of-pocket expenditure (OOPE) and rising household indebtedness.

Constitutional Basis for UHC

The Directive Principles of State Policy (Part IV) provide a constitutional foundation for the right to health:

• Article 39(e): The state must secure workers’ health.

• Article 42: Ensures just and humane working conditions and maternity relief.

• Article 47: Directs the state to improve nutrition, living standards, and public health.

Furthermore, panchayats and municipalities are empowered under Article 243G to strengthen public health infrastructure.

Post-COVID Realisation

The COVID-19 pandemic exposed inequities in access to healthcare, highlighting the exclusion of informal workers and migrants and the fragility of hospital-centric, insurance-driven models.

Present Policy Direction

India currently aims to achieve UHC primarily through Ayushman Bharat–Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), the flagship publicly financed health insurance (PFHI) scheme.

Challenges in Implementing UHC in India

Resource Constraints

India spends approximately 2.1% of GDP on public health, below the NHP target of 2.5%, which limits the ability to provide comprehensive services.

Infrastructure Gaps

Many rural areas lack adequate hospitals, clinics, diagnostic facilities, and medicines, which restricts access to care.

Healthcare Workforce Shortages

There is a shortage of trained medical personnel, particularly in rural areas, creating disparities in access and quality of care.

Fragmented Health System

India’s healthcare system is a mix of public and private providers, resulting in inconsistencies in quality, accessibility, and cost.

Federal Challenges

Health is a State subject, while financing and flagship schemes are centrally driven. This dual structure often leads to uneven outcomes across states.

Lessons from Global Experience

• The Alma-Ata Declaration (1978) emphasised primary healthcare as the foundation of UHC.

• Several East Asian countries initially adopted insurance-based UHC, but later strengthened primary and secondary care to manage ageing populations and chronic diseases.

• Countries like China and South Korea achieved near-universal insurance coverage but faced high fiscal costs. China subsequently focused on:

  • Strengthening primary and secondary care

  • Emphasising prevention, early detection, and follow-up

  • Investing in human resources and population outreach

  • Maintaining a strong public sector to regulate private providers

Making Ayushman Bharat 2.0 More Effective

Shift from Coverage to Care

Move from hospitalisation-centric insurance to comprehensive, primary healthcare-led UHC, ensuring care is the first priority rather than insurance coverage.

Strengthen Primary and Secondary Care

• Invest in health infrastructure, diagnostics, medicines, and referral systems

• Use Health and Wellness Centres (HWCs) as gatekeepers to reduce avoidable hospitalisation

Increase Public Investment

Raise health spending to at least 2.5% of GDP and prioritise preventive and promotive care, including addressing social determinants of health.

Digital and Human Resource Reforms

• Integrate ABHA IDs, interoperable health records, and disease surveillance systems

• Address workforce shortages through task-shifting, local recruitment, and continuous training

Better Regulation and Strategic Purchasing

• Implement standard treatment guidelines

• Enforce cost controls and accountability mechanisms

• Align insurance schemes within a robust public health system, ensuring efficiency and quality

Conclusion

While India has made significant strides toward UHC through Ayushman Bharat, persistent gaps in access, affordability, and quality indicate that a care-centred, publicly funded health system is essential. Strengthening primary healthcare, increasing public investment, integrating digital health tools, and regulating the private sector are key to achieving true Universal Health Coverage in India.