Universal Health Coverage in India: Journey of Progress, Challenges and the Road Ahead

Universal health coverage (UHC) aims to ensure that all people have access to the health services they need, when and where they need them, without suffering financial hardship.[1] The philosophy of UHC stresses on developing a comprehensive healthcare system designed ensuring that all individuals and communities receive the necessary, high-quality health services without experiencing financial hardship. This includes a wide spectrum of services such as preventive measures, treatment for illnesses and injuries, rehabilitation and palliative care. UHC aims to provide equitable access to quality health care for everyone, regardless of their socioeconomic status, geographic location or personal circumstances. By eliminating financial barriers and promoting inclusivity, UHC seeks to improve overall public health outcomes, reduce health disparities and enhance the well-being of populations. UHC has become a global public health aspiration with many countries actively working towards achieving UHC through policy reforms, international collaborations and innovative health solutions, recognising its crucial role in building healthier and more resilient societies. The concept of UHC originates from the principle that health is a fundamental human right. Its roots can be traced back to the 1948 Universal Declaration of Human Rights, which emphasised the right to appropriate health care.[2] The philosophy gained momentum with the 1978 Alma-Ata Declaration, where the World Health Organization and UNICEF outlined primary healthcare as the cornerstone of global health efforts, emphasising equity and community participation.[3] UHC gained traction globally following the 2012 United Nations General Assembly resolution urging nations to prioritise healthcare access for all.[4] In the 21st century, UHC was formally included in the United Nations Sustainable Development Goals 3.8 in 2015, calling for access to essential health services without financial hardship.[5] UHC has since become a global priority, urging countries to strengthen health systems, ensure equity and reduce out-of-pocket expenses. UNIVERSAL HEALTH COVERAGE IN INDIA UHC in India has roots in post-independence health reforms. The foundational Bhore Committee report of 1946 was among the first to advocate for free, equitable health care for all citizens, suggesting the establishment of primary health centres accessible to every village (REF). This vision laid the groundwork for policies aimed at inclusive healthcare. In 1983, India’s National Health Policy emphasised ‘Health for All’, aligning with the Alma-Ata Declaration of 1978 on primary health care.[3] Efforts continued with the 2005 National Rural Health Mission, which expanded rural healthcare infrastructure and improved maternal and child health services. Building on these historical foundations, the vision for UHC in India is realised through Ayushman Bharat, launched in 2018 to address the country’s healthcare challenges. This initiative comprises two main components: Health and Wellness Centres (HWCs) and the Pradhan Mantri Jan Arogya Yojana (PM-JAY), aiming to improve accessibility, availability and affordability across primary, secondary and tertiary healthcare levels.[6] NITI Aayog has been pivotal in shaping Ayushman Bharat by evaluating healthcare indicators, promoting competition amongst states, creating a performance-based ‘scorecard’ and addressing key issues such as partnerships with private hospitals and funding allocation.[6] HWCs, are restructured versions of India’s existing sub-centres and primary health centres, designed to offer a range of services, focused on prevention and wellness, including non-communicable disease management, maternal and child health services, immunisations and wellness counselling. These centres focus on lifestyle guidance, mental health support and nutritional counselling, bringing healthcare closer to communities while easing the patient load on higher-level care facilities.[7] PMJAY provides financial security to low-income families, covering cashless treatments up to INR 5 lakh per family per year. Designed to alleviate the financial burden of significant illnesses, PMJAY’s coverage includes treatments such as cardiac surgery and oncology across public and private hospitals, serving as a vital safety net for vulnerable families at risk of health-induced poverty. Overseen by NITI Aayog, Ayushman Bharat targets low-income, vulnerable households in rural and urban areas and marginalised groups, aiming to cover over 500 million citizens.[6,8] COVERAGE, SERVICES AND THE IMPACT OF AYUSHMAN BHARAT Ayushman Bharat’s dual approach serves both preventive and curative healthcare needs. HWCs provide routine check-ups, screenings for chronic diseases, immunisations, family planning and health promotion programmes that reduce chronic illness incidence and lower long-term healthcare costs. PMJAY covers about 1393 medical procedures, including surgeries and advanced treatments across a network of over 24,000 hospitals. It excludes outpatient consultations, cosmetic treatments, fertility services and other non-essential care. These exclusions are primarily done to allow resources to focus on critical health needs.[9] Ayushman Bharat has significantly impacted India’s healthcare landscape by increasing access to healthcare, providing financial protection and fostering a culture of preventive health. HWCs have improved healthcare accessibility, especially in rural and underserved areas, facilitating early detection and treatment of illnesses. This approach empowers communities with health information and services that promote wellness, particularly benefitting populations with limited access to healthcare. In 2021, 5.25% of the surveyed individuals reported utilising inpatient care, with this proportion rising to 5.56% in 2022. Studies indicate that nearly 90% of the population in the state is now enrolled under AB-PMJAY, reflecting a significant improvement from the pre-scheme days when enrolment was around 60%.[10] PMJAY’s extensive coverage limit provides financial security to 500 million poor and vulnerable people, reducing catastrophic healthcare expenditures that could otherwise push households into poverty. By including private hospitals in PMJAY’s network, Ayushman Bharat has also broadened access to tertiary care, allowing for greater availability of high-quality services beyond the limitations of the public sector. In turn, this has fostered effective public-private partnerships, expanding healthcare access to millions across the country.[6,7] CHALLENGES AND BARRIERS Achieving UHC in India is a challenging yet critical goal. India’s progress towards UHC is impeded by certain issues that includes fragmented healthcare delivery system, insufficient financing, regulatory weaknesses and organisational barriers. Addressing these multifaceted challenges is essential to advancing UHC and ensuring accessible and quality health care. Some of these challenges are highlighted below: Lack of a Systemic Approach to Health Reforms: Health policies in India have often been disease-specific and fragmented rather than comprehensive. This limited approach focuses more on infrastructure and access than on quality, efficiency and the interlinkages between various parts of the healthcare system, including public and private sectors[11] Health Financing Issues: Health financing faces constraints in fund allocation, pooling and service purchasing. Low government health expenditures and inefficient use of funds in some states hinder UHC. Inadequate insurance coverage and the focus on hospitalisation, rather than outpatient care, increase out-of-pocket expenditures, often leading to impoverishing healthcare expenses[11] Organisational Barriers in Healthcare Delivery: Fragmentation between public and private healthcare sectors and among various care levels leads to inequities, with better care often accessible only to those who can afford private services. This structure is skewed towards hospital-centric, physician-led care, rather than comprehensive primary care, causing inefficiencies and unmet health needs, especially in primary facilities[11] Regulation, Stewardship and Decentralisation: Weak regulatory enforcement, lack of governance and limited capacity at decentralised levels make it difficult to address private sector overcharging, ensure accountability and implement UHC reforms effectively. Insufficient political priority and weak local governance further challenge the UHC mission in India.[11] WAY FORWARD Ayushman Bharat, represents a significant step toward realising the pipe dream of ensuring equitable healthcare and reduce health inequalities. Although the journey is challenging, by addressing current limitations and focusing on sustainable development, the programme has the potential to provide inclusive and high-quality healthcare for all Indians. Moving forward, policies should focus on: Increasing Healthcare Expenditure: To sustain UHC, India needs to increase its healthcare spending to at least 2.5% of GDP, as recommended by the National Health Policy, 2017. Enhanced funding can support infrastructure improvements, workforce expansion and procurement of quality medical supplies. Strengthening Primary Healthcare: Improving primary healthcare through further expanding the package of services provided at HWCs. Greater integration of preventive services at primary care level will reduce the need for hospital-based treatments. Ensuring Equity in Access: Addressing regional disparities is essential to achieving UHC. The government should implement tailored interventions to support underserved regions and monitor outcomes to ensure that all Indians benefit equally from the program. Enhancing Quality Standards: The quality of care in empanelled hospitals needs standardisation. Introducing quality assessment mechanisms, setting minimum standards and implementing regular audits will improve patient outcomes and ensure that services meet acceptable standards. Expanding Digital Health Initiatives: Investing in telemedicine, EHR systems and other digital health tools will support service delivery in remote areas, improve continuity of care and help monitor patient health trends. The NDHM can play a pivotal role in these efforts. Encouraging Community Involvement: Involving local communities in decision-making and awareness campaigns can improve UHC programme uptake and make healthcare services more accessible. Building healthcare literacy and involving grassroots organisations will strengthen the programme’s reach and efficacy.