From coverage to assurance: Fixing India’s health system

As India stands at a pivotal moment in its journey toward universal health coverage (UHC). The challenge now is to strengthen the health system—its workforce, primary care and medicine supply—so that coverage translates into assured care for every citizen.

The Ayushman Bharat programme provides a strong vehicle for delivering UHC, working alongside vertically designed national health programmes that address specific health challenges. However, translating these programmes into assured outcomes requires a new set of initiatives to expand system capacity and execution capability.

The World Health Organization (WHO) estimates that India faces a shortage of nearly 1.8 million health workers. It falls short of the threshold of 44.5 doctors, nurses and midwives per 10 000 population, recommended by WHO’s 2016 Global Strategy on Human Resources for Health for achieving health-related sustainable development goal (SDG) targets. Current estimates place India’s availability between 28 and 33.5 per 10,000.

Although India reportedly has 1.05 million registered doctors, the number of active and available practitioners is closer to 0.66 million. While technology-enabled non-physician providers can support many primary-care functions, doctors remain indispensable, particularly at higher levels of care. The shortage of specialists at community health centres is especially acute.

Even if rural service is made compulsory, doctors trained in surplus states are likely to serve only within those states. Correcting this imbalance requires a centrally managed pool of health professionals who can be deployed anywhere in the country.

Such a pool would involve national recruitment and deployment of doctors, nurses and allied health professionals through a transparent merit-cum-choice process. Short cultural and linguistic orientation programmes would prepare professionals for service outside their home states, supported by incentives such as preferential weightage for postgraduate seats. Initially created through short service commissions, this pool could evolve into a regular national cadre over time.

This proposal aligns with Prime Minister Narendra Modi’s commitment to help build a Global Healthcare Response Team comprising experts from G20 countries to address global health challenges. A national health workforce pool is a necessary precursor to that ambition and would allow India to lead by example.

These cadres should blend clinical, public health and managerial competencies required at sub-district and district levels. Clearly defined roles, recruitment norms and career pathways would ensure continuity, strengthen disease surveillance, improve programme management and support coordinated responses during health emergencies.

Such reforms will require catalytic central funding through the Union Budget, including multi-year allocations for building the national health professional pool, enhanced financial support for states to operationalize public health cadres, and investment in a National Health Workforce Registry to underpin planning, deployment and future global health engagement.

Financing for the Jan Aushadhi scheme should be enhanced to expand coverage and availability, while ensuring that quality assurance protocols match those applied to government-procured medicines. Maintaining public trust requires that affordability does not come at the cost of therapeutic efficacy.

A voluntary quality certification programme for private pharmacies would further strengthen last-mile access. Certified pharmacies could operate as satellite Jan Aushadhi outlets, expanding reach while maintaining quality standards. At the same time, medical colleges and district hospitals should be granted limited decentralized procurement powers under strict audit controls to ensure timely supply of essential medicines.

For high-cost drugs and treatments for rare diseases, a national pooled procurement mechanism is necessary. Aggregating demand across states would improve bargaining power, reduce prices and promote equitable access. This must be supported by professionalized procurement and inventory management teams within state directorates, equipped with supply-chain and quality assurance expertise.

Primary-level screening for major conditions should be tightly integrated with PM-JAY-accredited secondary and tertiary hospitals, ensuring seamless referrals and continuity of care. Preventive services for non-communicable diseases and persistent communicable diseases must receive greater emphasis through health education, risk-factor reduction and early intervention.

Home-based care should be strengthened for elderly persons, individuals with neuro-developmental disabilities and patients discharged from intensive care units who remain bedridden. Community workers supported by telehealth can significantly improve outcomes while reducing hospital burden.

As service demand grows, frontline health workers—including accredited social health activists (ASHAs), auxiliary nurse midwives (ANMs), community health officers (CHOs) and urban health workers—must be expanded, with clearly defined and non-overlapping roles. Community- and family-based care models should also be strengthened to ensure culturally appropriate, continuous and locally responsive care.

K. Srinath Reddy, former president of the Public Health Foundation of India (PHFI), is an author at the Centre for Universal Health Assurance, ISPP, along with Anuradha Jain and Shalini Singh. The Centre recently released the report – ‘Road to Viksit Bharat – From Achieving Universal Health Coverage to Attaining Universal Health Assurance.