India’s universal health coverage is within reach but needs accountability: Lancet report on what needs fixing

What was the purpose of the Lancet Commission?

The Lancet Commission on a citizen-centred health system for India began in 2020, about a year into the Covid pandemic, which reminded us of the fragility of our health system. Our goal was to identify the reforms needed to advance UHC, a critical component of India’s Viksit Bharat vision for 2047. Over the past five years, we have assembled the largest body of data to address this goal, including a survey of 50,000 households conducted in 121 districts and across 29 states. The report has been written by a team of 30 authors drawn from a range of institutions in India and from the diaspora representing diverse sectors of health care.

What are key findings?

The most significant finding is a fundamental shift in the conventional narrative of barriers to realising universal health coverage. These are no longer driven by a lack of political will, underfunding, inadequate human resources and physical infrastructure or lack of awareness about health-care services. Indeed, we observe that both the supply and demand for health care has reached unprecedented levels.

Instead, uneven quality of care, inefficiencies in spending, fragmented delivery, inadequate design and implementation of financial protection programmes, and poor governance emerge as key challenges. Promoting a rights-based approach to health, the Commission calls for a healthcare delivery system grounded in comprehensive primary health care and increasing people’s participation in the planning, delivery and monitoring of health services.

We recommend several strategies to empower structures for community participation, for example, making health system performance data publicly available and supporting citizens in accessing health benefits through more efficient resource hubs and effective grievance redressal systems.

You have said that this is a positive report but the Achilles’ heel is lack of accountability. Please elaborate.

As the Commission lays out, universal health coverage is within reach. Let me emphasise what a historic inflection point this is, when we consider how meagre our health system was at independence. There are large-scale government initiatives such as Ayushman Bharat Pradhan Mantri Jan Arogya Yojana, Ayushman Arogya Mandirs, e-Sanjeevani telemedicine platform and so on. Concurrently, we have a vibrant private sector offering some of the most sophisticated healthcare in the world.

That said, we also note major challenges and gaps which require attention, in particular the quality of every aspect of the health system, from medical education to the care citizens receive. Citizens are left to fend for themselves and obtain fragmented care from a myriad of providers often at expensive hospitals rather than primary health care facilities. This is particularly problematic for chronic conditions like diabetes or mental illness.

At the heart of the transformation of our health system is a commitment to accountability and integrity by all actors in the health system. In practical terms, such a culture change would need to permeate every corner of the health system beginning with the training of health care providers, ensuring high-quality primary care and coordinated care for every citizen.

Additionally, we recommend implementing major reforms of the financing of health care and the governance of the health system. State, district, and local government institutions must be empowered to design and implement responsive reforms and to be accountable to the communities they serve. The Commission recognises the unique role of technologies to catalyse governance. Finally, the Commission calls for a learning health system, one that continuously learns from and shares health system data, collaborates in learning networks with other health systems in the country and constantly strives to improve its performance.

Do we have adequate medical personnel? What is your concern?

As of 2023–24, India’s MBBS doctor to population ratio was 1:1263. With AYUSH physicians, this ratio is 1:834, an increase of over 40% since 2010. Similarly, there has been a dramatic increase in the numbers of nurses and other health providers. These increases are largely driven by Central government policies to expand medical education. However what is of concern is that this massive expansion in training capacity has been marred by variations in the quality of education being provided. Additionally, a critical challenge is the inequitable distribution of healthcare personnel, with an over-supply in some parts of the country and too few in other parts.

ASHA (Accredited Social Health Activist) workers are still considered voluntary health workers despite them being a growing workforce. What needs to be done?

As of 2025, India has over one million community health workers (ie, ASHAs), who are now supplemented by a growing workforce of over 1,00,000 community health officers. Embedded in their respective communities, ASHAs are considered the first point of contact with the public sector health system, mobilising the community for local health planning and delivering most of the preventive–promotive health services. However, ASHAs are considered voluntary health workers who are paid only task-based incentives, although some States have introduced small, fixed honoraria to supplement these incentives.

The Commission has suggested that ASHAs, who I personally consider the foundation of UHC, be regularised and empowered.