A healthcare system that reaches all: Dr Soumya Swaminathan

India has made significant progress in expanding access to healthcare over the past decade. Yet for millions of families, the experience of seeking care remains fragmented, expensive and uncertain. Bridging this gap between coverage and care is the next frontier of health reform. As we work towards the goal of Viksit Bharat by 2047, building a healthier population will be as important as building a stronger economy.

Universal health coverage (UHC) is central to that vision, not only because it improves health outcomes but because it underpins productivity, resilience and inclusive development. India has taken important steps towards this goal. The launch of Ayushman Bharat–Pradhan Mantri Jan Arogya Yojana (PM-JAY) has expanded financial protection for hospital care, health and wellness centres have broadened access to comprehensive primary healthcare (PHC), and digital health initiatives are beginning to improve continuity of care. While these are important achievements, the challenge now is to ensure they become the building blocks of a health system that is equitable, efficient and centred on people's needs. Continuum of care and good referral mechanisms are important, with most health problems addressed at the primary and secondary levels, rather than in tertiary hospitals.

Much of the discussion around UHC tends to focus on health insurance. While insurance is essential, it is only one element of a well-functioning health system. The true measure of UHC is whether people can access the care they need, when they need it, without financial hardship. This includes preventive services, early diagnosis, management of chronic diseases, essential medicines, rehabilitation and palliative care, in addition to hospital treatment. Currently, out-of-pocket health expenditure still accounts for about 40% of health spending in India.

No country offers a perfect model in this regard. The United Kingdom relies largely on a tax-funded National Health Service, while countries such as Germany and France have social health insurance systems. The United States spends considerably more on healthcare than any other country (17% of GDP) yet continues to grapple with inequities in access and affordability. The lesson from countries that have achieved universal health coverage is that, despite differences in financing, they have invested consistently in strong primary healthcare, effective regulation, public health and accountable institutions.

Learning From Others

Many of these high-income countries spend considerably more on healthcare than India. Yet their greatest strength lies not simply in higher expenditure, but in how they organise care by placing primary healthcare at the centre, regulating providers effectively and ensuring continuity across the health system. These are lessons India can adapt, even within its own resource constraints.

India's path, however, will necessarily be shaped by the unique characteristics of its own health system. One of its defining features is the significant role of the private sector, which provides most outpatient care and a substantial proportion of hospital services. Rather than viewing public and private healthcare as competing models, the focus should be on how both can contribute to better health outcomes. This places a premium on the government's role as the steward of the health system: setting standards, ensuring quality, regulating where necessary, ensuring transparency and creating incentives that reward good outcomes rather than volume of care.

The Clinical Establishment Act is still poorly implemented in most states. Well-designed public-private partnerships demonstrate what this can achieve. Tamil Nadu’s Nammai Kaakkum 48 initiative under the Chief Minister’s Comprehensive Health Insurance Scheme ensures that people injured in road traffic accidents receive timely emergency care through a network of empanelled public and private hospitals. The initiative illustrates how clearly defined protocols, accountability mechanisms and effective coordination can harness private sector capacity in the service of public health. As India expands partnerships with private providers, similar approaches can help improve access while maintaining quality and accountability.

Equally important is strengthening primary healthcare, which is the foundation of the health system. Hospital-based insurance cannot substitute for accessible, high-quality primary care and support the long-term management of chronic conditions. India's investment in health and wellness Centres is therefore one of its most important health reforms. Their success, however, will depend on empowered frontline teams comprising Community Health Officers, nurses and ASHAs, supported through continuous training, mentoring and digital tools that enhance care rather than add to administrative burdens. The team approach is important, with the PHC medical officer and the entire team under him/her responsible for the health of the population under that PHC. Incentives can be provided for teams at block or district level that achieve the best population health outcomes.

Tech As An Enabler

Health financing must also evolve. While publicly financed insurance has reduced the financial burden of hospitalisation for many families, out-of-pocket expenditure on outpatient consultations, diagnostics and medicines remains high. Greater investment in primary care, uninterrupted supply of essential diagnostics and medicines, prevention and health promotion will not only improve health outcomes but also reduce avoidable hospital admissions. Financing mechanisms should increasingly encourage quality, continuity and better health outcomes, alongside sustained public investment and greater flexibility for states to address local priorities. Technology can support this transformation if used wisely. Digital health records, telemedicine and clinical decision-support systems have the potential to improve continuity of care, strengthen disease surveillance and support frontline health workers. But technology is an enabler, not an end.

Its value lies in making healthcare more accessible, more coordinated and more responsive to people’s needs. Ultimately, UHC cannot be achieved by the health sector alone. Air pollution, climate change, unhealthy diets, education, sanitation and other social and commercial determinants of health increasingly shape disease patterns and health outcomes. Addressing these challenges requires coordinated action across sectors and stronger engagement with communities, who should be recognised not merely as beneficiaries of health services but as partners in shaping them. Jan Swasthya committees, Gram Vikas Sabhas and Panchayats must all play a major role in ensuring that quality health care is provided and social determinants of health addressed.

Every state must have a public health cadre—this was envisioned in the National Health Policy 2017 but not realised. The health care sector can also be a big employer of people and an opportunity to address the lack of jobs for our youth. We will need more lab technicians, pharmacists, occupational therapists, optometrists, palliative care givers, and emergency care technicians as public provisioning of health care expands. We also need more public health entomologists and nutritionists at the district level to address the growing burden of vector-borne diseases and nutritional problems (including obesity).

The challenge now is to build on the progress already made. Sustained investment in primary healthcare, greater emphasis on prevention, effective stewardship by government and accountable partnerships with the private sector will be essential to creating a health system that is equitable, resilient and responsive to people’s needs. If these elements come together, India’s journey towards Viksit Bharat can become a powerful example of how better health drives inclusive growth, social equity and national development.

The author is the Principal Advisor to the National Tuberculosis Elimination Programme, Ministry of Health and Family Welfare and the Chair of M. S. Swaminathan Research Foundation (MSSRF). She was the first Chief Scientist of the World Health Organisation (WHO). Previously, she was the Director General of the Indian Council of Medical Research (ICMR), Ministry of Health and Family Welfare, Government of India (2015-17). Roubitha David has also contributed to this column.

Views are personal.