Opinion To be future ready, healthcare system has to ensure quality
Public health spending as a share of GDP has remained largely stagnant for two decades. Compounding this is the way money is spent — fragmented across schemes, departments, and line items, with limited flexibility.
India’s health outcomes have undoubtedly improved over the decades. Yet progress has slowed, and gains remain deeply unequal. With the Lancet Commission on Reimagining India’s Health System being launched last month, it is worth pausing to ask: Are we building a health system for yesterday’s diseases or tomorrow’s India? Soon after Ayushman Bharat was rolled out, a beneficiary asked me something that has stayed with me: “Card toh mil gaya hai, par ilaaj ka raasta kaun dikhayega (We have got the card, but who will guide us towards treatment)?” That goes to the heart of India’s health challenge — not just paying for care, but ensuring that people are guided through the system with dignity and continuity.
As the founding CEO of Ayushman Bharat, I have seen both the promise and the limits of health reform at close quarters. When the scheme was launched, many doubted whether India could pull off the world’s largest government-funded health assurance programme. Eight years on, the outcomes are hard to ignore. More than 10 crore hospital treatments have been provided, and by one estimate, households have saved nearly Rs 2 lakh crore in out-of-pocket expenditure.
India’s health outcomes have undoubtedly improved over the decades. Yet progress has slowed, and gains remain deeply unequal. A child born in a poor district or marginalised community still faces far worse health prospects than one born into an urban middle-class household. At the same time, NCDs and mental health conditions are rising steadily, while climate change and antimicrobial resistance pose new and serious risks.
As proud as I am of what Ayushman Bharat has achieved, I am conscious of its limitations. While physical access to care has expanded, the experience of care remains fragmented and often poor in quality. Our system continues to be hospital-centric and curative. Primary care, which should anchor prevention, continuity, and trust, remains underpowered. It is evident that even the best health assurance scheme cannot compensate for weak primary care.
Chronic underinvestment lies at the root of many of these problems. Public health spending as a share of GDP has remained largely stagnant for two decades. Compounding this is the way money is spent — fragmented across schemes, departments, and line items, with limited flexibility or accountability. Line-item budgeting in the public sector and fee-for-service payments in the private sector reward volume, not outcomes. They encourage episodic treatment rather than long-term health.
This is why the Lancet Commission argues that incremental change is no longer sufficient. India must move from a fragmented, facility-driven system to one that is comprehensive, coordinated, and people-centred. Quality, dignity, and respect must count as much as coverage numbers.
One of the Commission’s messages is the need for decentralisation. States, districts, and blocks face very different disease burdens, capacities, and social contexts. A reimagined health system must therefore empower states with greater financial flexibility, better data, and real autonomy — while holding them accountable for outcomes. Technology offers an opportunity to support this transformation. India’s DPI can enable continuity of care, real-time surveillance, and learning health systems. But digital tools can strengthen coordination and decision-making only if they are underpinned by trust, sound governance, and strong ethical safeguards.
The Commission also squarely addresses the role of the private sector. India cannot achieve universal health coverage without private providers. Managed care principles, emphasising prevention, gatekeeping, defined provider networks, and rational payment systems, must replace volume-driven incentives. Regulation should enable innovation while protecting the public interest.
Many of the Commission’s recommendations are already reflected in policy intent. The challenge lies in execution. Health governance reform is never purely technocratic; it is inherently political.
Yet, moments of crisis also open windows of possibility. India’s ambition to become a developed nation by 2047 cannot be realised without a health system that is fair, resilient, and people-centred. Ayushman Bharat demonstrated that bold reform at scale is possible. The Lancet Commission is a reminder that the next phase must go deeper.
The writer was founding CEO, Ayushman Bharat (AB-PMJAY) and is commissioner, Lancet Citizens’ Commission
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