A comprehensive review of India’s health system released Wednesday urges the nation to establish publicly provided care as the primary vehicle for universal coverage, arguing that governance failures and fragmented delivery, rather than a lack of financing, are now the biggest barriers to health equity for 1.4 billion people.
The Lancet Commission report, based on a survey of 50,000 households in 29 states, outlines a roadmap to achieve universal health coverage by 2047, the centenary of India’s independence. It concludes that while India has become a global power in manufacturing vaccines and pharmaceuticals, its national healthcare system is crippled by uneven quality and inefficiencies that leave millions of people vulnerable.
“Healthcare reforms are not merely technical: they are deeply political,” the report states, acknowledging that vested interests and ideological divisions often hold back progress.
To overcome these obstacles, the commission proposed six structural reforms. He called for empowering citizens in local governance, decentralizing authority to districts, and expanding technology to coordinate care. It also recommended that the public sector move from being a passive financier to a strategic purchaser of services, while incorporating a culture of “health system learning” to improve accountability. Finally, he urged to involve the private sector as a partner for universal coverage instead of ignoring it.
The report’s push for public sector dominance challenges the status quo in India, where government data shows nearly half of households rely on private providers despite higher costs.
“Historically, only the public sector has had the mandate and mission to achieve health equity,” said co-chair Vikram Patel of Harvard Medical School. He noted that only the government has the necessary infrastructure, from community workers to tertiary hospitals, to reach every corner of the country.
However, the commission recognized the huge footprint of the private sector and recommended that it be aligned with national objectives through “a balanced mix of incentives and regulations” rather than sidelined. This would involve moving away from fee-for-service payment to models that reward quality and long-term disease management.
The review comes as India aims to achieve “Viksit Bharat” (developed nation) status by 2047. While the government’s Ayushman Bharat insurance scheme currently covers 600 million people, the report notes that it is limited to hospitalization, leaving families with the crushing burden of outpatient and medication costs.
“India is at a pivotal moment,” said co-lead author Anuska Kalita. “We have a historic opportunity to transform the health system so that it truly works for all citizens.”
