Adoption of a federal mandate for Universal Health Care in India


Universal healthcare is a topic that is increasingly being considered for adoption in India, and there have been a numbers of papers written on whether it is a utopian vision, and what it would look like when implemented with a view to efficiency, equity and quality.

At the present time, health expenditure in India is 5% of its GDP, which is more than other South Asian countries, but public spending is only 19% of that. That leaves around 70% of healthcare expenditure being paid for out-of-pocket by consumers, and has 25% of all those being hospitalized pushed below the poverty line because of health-related expenses.

As is the case with many low and middle income countries, India is also facing a epidemiologic transition, with a triple burden of infectious disease, non-communicable disease and injuries. It is estimated that 60% of premature loss of life is due to non-communicable illnesses, and that the loss in productivity to the Indian economy from non-communicable illnesses will exceed the GDP if there is no intervention in current trends.



In India, health is overseen by the centre and the states. Increasingly, states are receiving a greater proportion of tax monies from the center, but this leaves them with a greater responsibility for planning, financing and implementing health related spending, which requires systems strengthening and political will to implement some of these measures.

There is a need for nationally mandated provision of universal health coverage with a basic basket of health services, which need to be determined based on burden of disease, cost effectiveness, financial constraints and standard of care. This would require extensive reform of systems of administration, governance, data collection and surveillance of health, but would greatly improve health outcomes and productivity of India’s large population which currently has very poor access to healthcare.


6 Responses to “Adoption of a federal mandate for Universal Health Care in India”

  1. shivanip1892 Says:

    Thank you for this great post! It is very interesting to note that non-communicable diseases, infections and injuries are among the highest causes of burden in India. Though a overhaul of the health care system in India is overdue, maybe focusing resources at the community and local level could help ameliorate some of this preventable burden. By allocating funds to local and community level clinics, health care workers could be better equipped in identifying and treating infections. Campaigns for better overall health and dietary education could help reduce the burden of non-communicable disease at the community level.

    Maybe helping to fund the community clinics and scaling up community workers could help increase health education and positively influence health seeking behaviors. Starting at the community level could be of low cost to the consumer and could help save resources for unnecessary facility visits

  2. wcherniak Says:

    Very interesting read! I find it amazing that healthcare spending is only 5% of GDP in India while it is 17.5% in the USA ( – I wonder why the levels are so low in India?

    Given that the economy of a nation is only as strong as the people who are living within it’s boundaries, one would think that the government would want to ensure that it’s people are as healthy and productive as possible.

    That said, creating a universal healthcare program for the entire nation through a Federal mandate is an interesting idea, but I wonder if it is really feasible? While the NHS in the UK supplies care to around 55 million people, this Indian system would supply over one billion citizens – approximately 18 times larger. Perhaps working off of a system more similar to Canada built off of a Provincial/State healthcare system that is supported by Federal mandates and cash transfers would create more diversity and ensure that larger states with more urban populations or smaller with more rural can create their own programs specially tailored for their people but with broader support.

    • oluwatosinajayi Says:

      I absolutely agree with this comment. India with a population of 1 billion people would definitely struggle with coordinating a centralized system. A more efficiently run decentralized system with federal regulation might be more feasible in the Indian context. National involvement could take shape in form of specific programs targeted at perhaps the triple burden of infectious diseases, NCDs and Injuries.

    • madhunaga Says:

      Absolutely, Dr. Cherniak and Oluwato ( I hope I have your name right). My thoughts were revolving around a federal mandate or requirement of a common package of essential services at the primary and secondary care level, as opposed to what most of the state schemed do now which is provide community insurance to privately provided tertiary level care.
      I think that giving the states more flexibility is important, but there is a lot of capacity building required – since many states may not be able to set and track their own health outcomes or train healthcare workers with their current staff. There are exceptions – my home state of Tamil Nadu being one, with very good healthcare outcomes – but most of the states with the highest levels of illiteracy, poverty and disenfranchisement do not have public and governance structures that can handles receiving large amounts of cash from the centre and being told to do their own thing.
      Also, what’s interesting, Dr. Cherniak, is that of that 5%, around 70% of the spending comes from out of pocket expenditure by patients – the *highest* levels of OOP spending in the world. A dubious honor, indeed.

  3. socbehphcjm Says:

    One challenge I would imagine India would have in introducing an NHS-style health insurance scheme would be incorporating its very large informally-employed sector. Collecting taxes from these citizens would presumably be quite difficult. What do you think of the idea of Community-Based Health Insurance (CBHI)? Perhaps such smaller risk pools could be set up by communities of informal sector workers, and later incorporated into a national system?

    • madhunaga Says:

      Hi. Thanks for your comment, socbehphcjm! I agree about the tax base being small because of the informal sector – again, one of the largest in the world – but one of the articles I referenced in the post mentions that CBHI has disadvantages because it does not permit of economies of scale, risk pooling, etc. It ends up being more expensive and may fall apart (though it is better than nothing) because may lead to sicker people selecting to join it and costs spiraling. I don’t think there are any simple answers, honestly, but I wish India would start making some moves in the direction of UHC.
      Even with the tax base that we have at present, we could certainly spend more on healthcare, and perhaps more effectively.
      Obviously it’s very easy to be an armchair critic, and I respect all the hundreds of thousands of health workers there who make the system work at all – but I believe that they’re being subverted by not receiving enough support.
      Thank you again, for taking part in this discussion of a topic very close to my heart.

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