Bridging Access and Equity in India’s Healthcare 12 Mar 2026

Bridging India's Healthcare Divide: The Unfinished Agenda of Access and Equity

Despite significant policy ambition and increased budgetary outlays, India’s healthcare system continues to be defined by a profound access-equity paradox. While physical access to facilities has demonstrably improved in certain metrics, particularly institutional delivery, genuine equity in health outcomes remains elusive, especially for marginalized populations and across diverse geographies. The commitment to social justice, often championed by leaders like those who pay tribute to Kanshi Ram on his birth anniversary, is vital for addressing these disparities. This challenge transcends mere funding shortfalls, rooted deeply in the historical prioritization of curative healthcare over robust preventive and primary care, exacerbated by a fragmented federal structure where health remains largely a state subject, leading to uneven implementation and significant gendered health inequities. The persistent high out-of-pocket expenditure (OOPE) signals a systemic failure to adequately protect citizens from catastrophic health costs, even as central schemes aim to provide financial cover. Economic factors, including global trends like oil prices reflecting geopolitical risks, can indirectly impact national budgets and healthcare funding. This structural vulnerability to health shocks, coupled with disparities in service delivery, presents a critical developmental challenge. The aspiration for Universal Health Coverage, enshrined within Sustainable Development Goal 3, necessitates a recalibration of national strategies to move beyond incremental improvements in access towards guaranteed, equitable, and quality care for every citizen. This aligns with broader national goals of self-reliance and strategic alignment, as discussed in Atmanirbharta and Alignment- India’s.... The conversation must shift from simply building more infrastructure to ensuring functional, accountable, and accessible services that address the social determinants of health.

UPSC Relevance Snapshot

• GS Paper II: Governance, Social Justice – Government policies and interventions for development in various sectors and issues arising out of their design and implementation; Issues relating to development and management of Social Sector/Services relating to Health.
• GS Paper III: Economic Development – Inclusive growth and issues arising from it; Infrastructure: Energy, Ports, Roads, Airports, Railways etc. (digital health infrastructure).
• GS Paper I: Social empowerment, poverty and developmental issues (indirectly through social determinants of health).
• Essay Angle: Health as a fundamental right; Social justice and equity; India's demographic dividend and health challenges; Federalism and social sector reforms.

The Institutional Landscape of Indian Healthcare

India’s healthcare system operates under a complex institutional framework, where the constitutional division of powers places 'Public Health and Sanitation; hospitals and dispensaries' primarily under the State List (Seventh Schedule, Entry 6). This leads to significant variation in health infrastructure, budgetary allocation, and implementation priorities across states. While the Union government plays a crucial role in policy formulation, financial support, and setting national health goals, the actual delivery of services is largely decentralized, necessitating robust cooperative federalism. International collaborations, such as India-EU ties in focus as Jaishankar visits Brussels, can also influence policy frameworks and resource sharing in various sectors, including health. Key institutional actors and frameworks include:

• Ministry of Health and Family Welfare (MoHFW): The primary nodal agency at the central level, responsible for national health policy, programs (e.g., National Health Mission), and regulation.
• NITI Aayog: Provides policy direction and strategic inputs, often publishing reports on health sector reforms and tracking state performance (e.g., Health Index).
• National Health Mission (NHM): The umbrella program encompassing the National Rural Health Mission (NRHM) and National Urban Health Mission (NUHM), aimed at strengthening primary health infrastructure and human resources.
• Ayushman Bharat: Comprising Pradhan Mantri Jan Arogya Yojana (PMJAY) for health insurance and Health and Wellness Centres (HWCs) for comprehensive primary healthcare.
• Clinical Establishments Act, 2010: Aims to regulate and standardize private healthcare facilities, though its adoption and implementation by states remain incomplete.
• Drugs and Cosmetics Act, 1940: Regulates the import, manufacture, distribution, and sale of drugs and cosmetics.
• Medical Council of India (MCI) / National Medical Commission (NMC): Regulates medical education and practice.

Persistent Disparities: The Core of India's Healthcare Challenge

Despite rhetorical commitments to universal health coverage and substantial outlays under schemes like Ayushman Bharat, the fundamental indicators of equitable access and quality care reveal significant structural weaknesses. The National Family Health Survey-5 (NFHS-5, 2019-21) data, while showing improvements in certain areas, starkly highlights the persistent urban-rural divide and socioeconomic disparities that characterize Indian healthcare. For instance, while 88.6% of births were institutional, crucial indicators like childhood vaccination completion, nutritional status, and access to modern contraception still vary significantly across states and wealth quintiles. The Economic Survey 2022-23 underscored the continued high burden of Out-of-Pocket Expenditure (OOPE), accounting for approximately 48.2% of India’s Total Health Expenditure (THE) in 2019-20. This figure, though an improvement from 62.6% in 2014-15, remains critically high, pushing millions into poverty annually. Such a high OOPE directly contradicts the principles of health equity and financial risk protection. Key evidence points to the ongoing access-equity gap:

• Rural-Urban Divide: NFHS-5 shows that access to healthcare facilities within 5 km is significantly lower in rural areas. The availability of specialist doctors, advanced diagnostics, and critical care beds is disproportionately concentrated in urban centers.
• Human Resource Shortages: The doctor-to-population ratio stands at approximately 1:834 (Indian Medical Council, 2023), but this aggregate hides severe shortages, especially in rural and remote areas. The specialist doctor availability in Community Health Centres (CHCs) is abysmal, with over 80% vacancies in some disciplines according to the Rural Health Statistics (2022-23).
• Infrastructure Deficiencies: While the number of Primary Health Centres (PHCs) and CHCs has increased, many lack essential infrastructure, equipment, and round-the-clock services. A 2023 performance audit by the Comptroller and Auditor General (CAG) on the functioning of Health and Wellness Centres (HWCs) under Ayushman Bharat highlighted significant gaps in staffing, drug availability, and diagnostic capacity across multiple states, impacting their stated goal of comprehensive primary healthcare.
• Gendered Health Inequity: NFHS-5 data indicates that 57% of women aged 15-49 are anemic, a figure that has barely improved over the last decade and is worse in certain states. Access to reproductive and sexual health services, while improving, still faces significant social and structural barriers for women and adolescents, particularly in terms of autonomy and decision-making.
• Preventive Care Underperformance: Despite the emphasis on HWCs, the shift from a disease-centric, curative approach to a holistic, preventive and promotive model is slow. Public health spending on prevention remains inadequate, reflected in the persistence of communicable diseases and a growing burden of non-communicable diseases (NCDs).

The Government Narrative and its Gaps

The Union government frequently champions the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) for its unprecedented reach in providing financial protection to 50 crore beneficiaries through health insurance cover of up to ₹5 lakh per family per year. Official statistics from the National Health Authority (NHA) often highlight the crores of hospital admissions authorized and the reduction in catastrophic health expenditure for enrolled families. Similarly, the rapid establishment of over 1.6 lakh Health and Wellness Centres (HWCs) across the country is presented as a cornerstone of primary healthcare rejuvenation. These achievements are indeed significant in extending a safety net to previously uncovered populations and bringing care closer to communities. However, this narrative, while numerically impressive, often overlooks crucial implementation bottlenecks and systemic gaps. A 2024 analysis by the NITI Aayog itself indicated that while PMJAY has reduced OOPE for many, its effectiveness is contingent on the availability of empanelled hospitals, particularly in remote and rural areas, where private facilities are scarce and public hospitals are often overburdened. The limited range of medical packages covered, and issues related to portability across states, also constrain its full potential. Furthermore, the HWCs, envisioned as comprehensive primary care hubs, frequently struggle with inadequate staffing, especially Community Health Officers (CHOs), irregular supply of essential drugs, and a lack of diagnostic capabilities, as evidenced by the aforementioned CAG audit. The focus remains heavily on physical infrastructure creation rather than sustained functional excellence and human resource development, thus failing to fully realize the vision of comprehensive primary healthcare and exacerbating the access-equity paradox.

International Parallels: Lessons from Thailand

Examining healthcare systems in other developing nations provides valuable context. Thailand, for instance, offers a compelling model for achieving universal health coverage (UHC) with a strong emphasis on primary healthcare and equitable access. After implementing its Universal Coverage Scheme (UCS) in 2002, Thailand dramatically reduced its out-of-pocket expenditure and improved health outcomes for its population. Thailand's success is attributable to a long-term political commitment to UHC, significantly higher public health spending, a strong public sector primary healthcare network, and a unified health insurance system that covers the entire population. This contrasts sharply with India's lower public spending, fragmented insurance landscape, and the dominance of private, often unregulated, healthcare providers. Thailand prioritized strengthening its public health system as the bedrock of UHC, ensuring quality and affordability, a strategic choice that India is yet to fully embrace.

Structured Assessment of India's Healthcare Pathway

The journey towards equitable and accessible healthcare in India is constrained by a confluence of policy, governance, and societal factors, demanding a multi-pronged intervention strategy.

1. Policy Design Adequacy:
   • Curative Bias: Policies historically lean towards tertiary care and disease management rather than robust public health and primary prevention. The National Health Policy 2017 aims for a shift, but budgetary allocations and implementation lag.
   • Fragmented Approach: While Ayushman Bharat aims for integration, the overall policy landscape remains fragmented, with numerous central and state schemes often lacking synergy and comprehensive coverage.
   • Regulatory Deficits: Inadequate regulation of the burgeoning private healthcare sector leads to quality variations, unethical practices, and inflated costs, directly impacting OOPE and equity. The Clinical Establishments Act's uneven adoption exemplifies this.
   • Underfunding: Public health expenditure consistently remains below the 2.5% of GDP target set by the National Health Policy 2017, significantly hindering capacity building and service expansion.
2. Governance Capacity and Implementation:
   • Centre-State Coordination: Health being a State Subject creates challenges in standardizing care, resource allocation, and achieving uniform health outcomes across states, leading to disparities. The role of local governance, similar to the Panchayati Raj System in Jharkhand, is crucial for effective grassroots implementation.
   • Human Resource Management: Severe shortages of doctors, nurses, and allied health professionals, particularly in rural and remote areas, undermine the functionality of primary and secondary healthcare facilities. Issues like recruitment, retention, and rational deployment remain critical.
   • Data Infrastructure: While initiatives like the Ayushman Bharat Digital Mission (ABDM) are promising, a robust, interoperable, and universally adopted digital health infrastructure is still nascent, hindering evidence-based policy making and efficient service delivery. For deeper insights into technological advancements, explore AI at the Frontline of India's Public Healthcare Delivery: Innovations, Imperatives, and Ethical Governance for UPSC.
   • Corruption and Accountability: Instances of corruption in public health procurement, drug distribution, and insurance claim processing erode public trust and divert critical resources, as occasionally highlighted in investigative reports or state-level audits.
3. Behavioural and Structural Factors:
   • Socioeconomic Determinants: Health outcomes are profoundly influenced by poverty, education levels, sanitation, nutrition, and access to clean water, which are often outside the direct purview of the health ministry but are critical to public health.
   • Health-Seeking Behaviours: Low health literacy, cultural beliefs, and gender norms often delay care-seeking, particularly for women and marginalized communities, leading to worse health outcomes.
   • Digital Divide: While digital health solutions offer potential, the vast digital divide in terms of access to smartphones and internet connectivity, especially in rural areas, limits their equitable adoption and benefit.
   • Private Sector Dominance: The heavy reliance on the unregulated private sector for healthcare, especially for secondary and tertiary care, places a significant financial burden on households due to a lack of price controls and transparent practices.

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