India's Healthcare Reality: Universal Coverage Exists on Paper, Not in Practice
For millions of Indians, accessing healthcare continues to be a daily struggle marked by long queues at distant hospitals, repeated diagnostic tests, and substantial out-of-pocket expenses for medicines and diagnostics—even when they are officially enrolled in government health schemes. This persistent gap between policy promises and lived experience has become India's central health challenge according to a comprehensive new report.
The Citizen-Centred Health System Analysis
The Lancet Commission on a Citizen-Centred Health System for India has conducted extensive research revealing that while health infrastructure has expanded significantly, weak implementation, poor coordination, and governance gaps continue to undermine patient care nationwide. The commission's findings are based on more than four years of research spanning 2020 to 2024, drawing from national data and a citizens' survey of nearly 50,000 households across 29 states.
Families across India continue to drain their savings to manage chronic illnesses, while elderly patients struggle to navigate multiple healthcare providers. Those in rural or marginalized communities face particularly severe challenges, including treatment delays and poor-quality care that further exacerbate health inequities.
Stark Variations in District-Level Performance
The commission's district-level analysis of 687 districts reveals dramatic variations in healthcare performance even within the same state. Identical national policies produce vastly different outcomes depending on local implementation capacity and the strength of primary care infrastructure.
"What stands out is that the report is citizen-centred," emphasized Mirai Chatterjee, Commissioner and Director of SEWA Social Security. "The findings highlight how people continue to travel long distances, repeat investigations, and spend heavily on medicines and diagnostics despite being enrolled in government schemes."
The Persistent Financing Mismatch
The data exposes a critical financing mismatch in India's healthcare system. Public health spending remains below 2% of GDP, while existing insurance schemes focus predominantly on hospitalization coverage. This leaves outpatient care, medicines, and diagnostics—which constitute the biggest healthcare costs for families—largely unprotected.
Case studies and interviews with health workers and administrators point to several systemic issues:
- Fragmented governance structures
- Critical staff shortages across facilities
- Weak accountability mechanisms
- Broken referral systems between different care levels
These factors collectively explain why well-designed health programs often falter at the implementation stage.
From Access to Assurance: The Quality Challenge
The commission concludes that India's main barriers to achieving Universal Health Coverage are no longer political will or infrastructure gaps, but rather uneven quality of care, inefficient spending, fragmented delivery systems, and poor governance. While access to healthcare facilities has expanded significantly, assurance of quality care has not kept pace.
"Access has expanded, but assurance has not," the report notes, highlighting the critical distinction between having healthcare facilities available and receiving reliable, high-quality care when needed.
A Roadmap for Health Equity
At the heart of the commission's recommendations is a call to rebuild the public health system as the backbone of universal coverage. Vikram Patel, Commission co-Chair and Professor at Harvard Medical School, emphasized that only a high-performing, publicly financed and publicly provided system—with nationwide reach from community health workers to tertiary hospitals—can deliver genuine health equity at scale.
Industry leaders have echoed this focus on strengthening primary care and improving coordination. Dr. Harsh Mahajan, Founder & Chairman of Mahajan Imaging & Labs, noted that strengthening preventive and primary care through Ayushman Arogya Mandirs is essential for sustainable healthcare improvement.
Dr. Dharminder Nagar, MD of Paras Health, highlighted persistent challenges in states like Bihar and Uttar Pradesh, where patients continue to face long travel distances, repeated tests, and high costs despite national reductions in out-of-pocket spending. This underscores the urgent need for:
- Stronger public-private coordination mechanisms
- Faster PM-JAY empanelment processes
- Expanded outpatient coverage in insurance schemes
Turning Promise into Reality
The Lancet Commission's comprehensive analysis suggests that India still has the opportunity to transform Universal Health Coverage from a policy promise into a lived reality for all citizens. However, this transformation requires fundamental changes in how care is delivered, not just how it is announced or designed at the policy level.
The report serves as both a stark assessment of current challenges and a hopeful roadmap for creating a truly citizen-centred health system that delivers equitable, high-quality care to every Indian, regardless of their location or socioeconomic status.
