Universal Health Coverage in India: Constraints and Strategies (UPSC Economy)

The COVID-19 pandemic underscored what public health experts have warned for decades — a healthcare crisis can quickly transform into an economic and social crisis. India’s pursuit of Universal Health Coverage (UHC) combines the flagship Ayushman Bharat programme, a network of Health and Wellness Centres (HWCs), a Digital Health Mission, and a strengthened National Health Policy 2017. But despite rapid progress, out-of-pocket expenditure, low public spending, and uneven access continue to constrain the goal of health for all.

Background: Defining Universal Health Coverage (UHC)

UHC means ensuring equitable access for all Indian citizens to quality healthcare — promotive, preventive, curative, rehabilitative, and palliative care — without financial hardship. It rests on the 4 A's:

• Availability: Adequate infrastructure and human resources.
• Accessibility: Physical and digital reach.
• Affordability: No catastrophic health expenditure.
• Accountability: Quality, transparency, grievance redressal.

UHC must be delivered through both public and private sectors, with the government as enabler and regulator.

Problems in Ensuring UHC in India

1. Low public expenditure on health

Combined Centre and State spending is around 1.9-2.1% of GDP (2023-24), below the National Health Policy 2017 target of 2.5% by 2025. Countries like Bhutan (~2.5%), Sri Lanka (~2%), and Vietnam (~3.7%) spend more proportionately.

2. Low insurance penetration (pre-PMJAY)

Before Ayushman Bharat, around 86% of rural and 82% of urban households lacked insurance. Rising health costs forced families to deplete savings, borrow, or delay treatment. Estimates suggested 55-60 million Indians were pushed into poverty annually due to health expenditure.

3. High out-of-pocket expenditure (OOPE)

OOPE in India has been among the highest globally — around 48-55% of total health expenditure (down from 62% earlier). Global average is ~18%.

4. Accessibility gaps

Secondary and tertiary hospitals are concentrated in Tier-1 and Tier-2 cities. Rural areas face shortage of doctors, specialists, diagnostics, and emergency transport.

5. Affordability gaps in private sector

Private sector provides ~70% of outpatient care and ~60% of inpatient care but operates on profit motives. High fees exclude poor patients.

6. Human resource shortages

India has around 0.9 doctors per 1,000 vs WHO's 1 per 1,000. Specialists are even more scarce. Nurses and ASHA workers carry the bulk of primary care.

Critical Analysis of Ayushman Bharat

Scheme design

Ayushman Bharat has two pillars:

1. Health and Wellness Centres (HWCs) — 1.6 lakh upgraded sub-centres/PHCs delivering comprehensive primary care.
2. Pradhan Mantri Jan Arogya Yojana (PM-JAY) — Rs 5 lakh per family per year for secondary/tertiary hospitalisation, covering ~55 crore beneficiaries (bottom 40% + extended categories).

Achievements

Economic Survey 2020-21 compared NFHS-4 (2015-16) and NFHS-5 (2019-21), and PMJAY-adopting vs non-adopting states:

• Insurance coverage rose 54% in PMJAY states, declined 10% in non-PMJAY states.
• IMR, MMR, institutional births, access to family planning — improvements stronger in PMJAY states.
• PMJAY cumulative hospital admissions: over 7.5 crore.
• Treatment value authorised: over Rs 1 lakh crore.

Concerns and challenges

• Low package rates: Hospitals criticise rates as arbitrary and low (e.g., Rs 9,000 for C-section) — risk of quality erosion or private-sector exit.
• Frauds: Ghost enrolments, false eligibility claims.
• Politicisation: Some states (West Bengal, Odisha, Delhi earlier) did not implement PM-JAY; Odisha has now agreed.
• Budget stagnation: PM-JAY allocation has remained around Rs 7,500-8,000 crore; demand may need over Rs 25,000 crore annually.
• Low coverage in some backward districts due to absence of empanelled hospitals.
• Unethical practices: Unnecessary procedures in private hospitals.

Strategies to Ensure UHC in India

Learn from peers

South Korea, Singapore, Thailand, Switzerland, Sri Lanka have achieved UHC through:

• Steadily rising public health expenditure.
• Strong primary care and referral systems.
• Mandatory insurance with government subsidy for the poor.
• Tight hospital regulation and price transparency.

India-specific actions

Declaration of Right to Health: Add health as a Fundamental Right (as in Brazilian Constitution). Rajasthan Right to Health Act 2023 is a state-level precedent.

Reducing information asymmetry: Independent hospital and doctor ratings, as proposed by Economic Survey 2020-21.

Universal Health Coverage roadmap (Srinath Reddy Committee, 2010):

• Raise public spending to 3% of GDP via higher tax-to-GDP ratio.
• Free essential medicines and diagnostics.
• 70% of public funds for primary care.
• Ayushman Bharat Health and Wellness Centres delivering comprehensive primary care.
• Human resources: More MBBS/PG seats, nursing schools, mid-level providers.
• Digital Health: Ayushman Bharat Digital Mission (ABDM) — ABHA IDs, digital records, telemedicine.
• Preventive and promotive health: Mission POSHAN 2.0, Fit India, Eat Right, Khelo India.
• Antimicrobial resistance: NAP-AMR implementation.
• Non-communicable diseases (NCDs): NPCDCS expansion.

Strengthen primary care

• 15th Finance Commission Rs 70,051 crore grant for health at PRI/ULB level.
• Aspirational Districts and Blocks: Health as core focus.
• Tele-consultation (eSanjeevani) — over 30 crore consultations.

Latest Developments (2024-26)

Updated context: In September 2024, Ayushman Bharat PM-JAY was extended to all senior citizens aged 70 and above, regardless of income, adding 6 crore more beneficiaries. Coverage is now cumulatively over 60 crore Indians.

The Union Budget 2024-25 announced:

• Expansion of Ayushman Bharat Digital Mission (ABDM) — cumulative 67 crore ABHA IDs.
• Missions in critical care, maternal and child health, and mental health.
• Tax relief on health insurance premiums.
• Medical education expansion: 75,000 new medical seats, 10,000 PG seats.

The Union Budget 2025-26 allocated around Rs 98,311 crore for health (up ~13% YoY). It announced:

• Day Care Cancer Centres in all district hospitals.
• Jan Aushadhi Kendras expansion to 25,000 outlets.
• Broadband in every PHC and school.
• PM E-DRIVE and heat action plans as public health measures.

Out-of-pocket expenditure declined to around 39-42% of total health expenditure (as per National Health Accounts 2021-22, released 2024) — significant progress.

UPSC Relevance

GS Paper III topics directly connected: inclusive growth; investment models; issues related to development and management of social sectors.

GS Paper II links: health; welfare schemes; education.

Possible questions:

• Critically evaluate Ayushman Bharat in achieving Universal Health Coverage. Suggest measures.
• "India's health system suffers from the triple burden — low public spending, high OOPE, and uneven access." Discuss.
• Discuss the role of Digital Public Infrastructure in building a universal and accountable health system.

Essay and interview angles include health as a human right, pandemic preparedness, UHC-SDG 3, and health-wealth linkage. Aspirants should recall public health spend, OOPE trend, PMJAY coverage, and 2024-26 expansions (70+ coverage, ABDM).