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THE LANCET CITIZENS’ COMMISSION ON

REIMAGINING INDIA’S HEALTH SYSTEM

Vikram Patel ∞ * †, Anuska Kalita ∞ *, Kheya Melo Furtado*, Nachiket Mor* †, Shubhangi
Bhadada*, Yamini Aiyar†, Sandra Albert†, Hasna Ashraf, Satchit Balsari, Indu Bhushan†, Vijay
Chandru†, Mirai Chatterjee†, Sarika Chaturvedi, Sapna Desai†, Raghu Dharmaraju, Atul Gupta†,
Kiran Mazumdar-Shaw†, Gautam Menon, Arnab Mukherji†, Poonam Muttreja†, Anjali Nambiar,
Thelma Narayan†, Bhushan Patwardhan†, Tejasvi Ravi, Sharad Sharma†, Devi Shetty†, Sudheer
Kumar Shukla, SV Subramanian†, Leila Varkey†, Sandhya Venkateswaran†, Siddhesh Zadey,
Tarun Khanna* †

∞ Joint First and Corresponding Authors

* Core Writing Group. Authors in the Core Writing Group are listed by contribution. All other
authors are listed alphabetically.
†
Commissioner

The Lancet Commission on Reimagining India’s Health System (“Commission”) was established
in December 2020, amid the COVID-19 pandemic, to identify reforms needed to realise the goal
of Universal Health Coverage (UHC) for the people of India. The Commission framed itself as a
Citizens’ Commission in that our analyses and reform options would be rooted in the lived
experiences, expectations, and preferences of the Indian people, as expressed through participation
in research and consultations. Further, we were guided by the principles that all of India’s people
have a universal, fundamental, and inalienable Right to Health; and that the government must be
responsible and accountable for financing and operating the public sector and stewarding and
regulating both the public and private sectors. To this end, the Commission engaged a diverse
spectrum of expertise, including leaders of civil society organisations, and drew systematically
upon extensive existing and new research to arrive at our observations and recommendations.

Why reimagine India’s health system?

India has achieved commendable but uneven progress on health outcomes. There have been
remarkable improvements, especially in life expectancy, maternal and child survival, and control
of infectious diseases. However, several of these gains have stagnated, and health gains are highly
inequitable, with worse outcomes for lower-income households, marginalised castes and tribes,
and low-resource districts. India faces an unprecedented rise in non-communicable diseases and
mental health problems, and emerging threats, including climate change, antimicrobial resistance,
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and new infectious diseases, occurring within the context of deep social inequities and population
ageing.
Physical availability and access to care have improved significantly, but services are often of
poor quality. There have been significant improvements in healthcare infrastructure driven by an
expansion in service capacities across levels of care; the deployment of multiple cadres of frontline
health workers; and civil society engagement in diverse ways. Yet, the health system has remained
deeply fragmented, hospital-centric, and curative-focused. Comprehensive primary healthcare has
fallen short of meeting people’s needs. Poor quality across public and private sectors has had
serious implications for health outcomes and has resulted in low-value care.

Government health expenditures have been historically low, and there are widespread
inefficiencies. Although there are large State-level variations, national health budgets as a
proportion of GDP have been static for two decades. This chronic underfunding has been
compounded by the fragmentation of these budgets, their sub-optimal allocation, and inefficient
utilisation, consequently weakening institutional capacities, especially at decentralised levels, and
contributing to fragmented care focused on episodic treatment of acute conditions. The
predominance of line-item budgets (public sector) and fee-for-service (private sector) as payment
methods has limited the health system’s flexibility to tailor services to population needs and
promote rational care.

Inadequacies in the health system have forced people to make poor health choices and
experience high out-of-pocket expenses and financial hardship. Financial risk protection has
improved over the last decade, but many households still experience catastrophic health expenses
primarily driven by medications and diagnostics. Without care coordination, citizens are left to
fend for themselves and obtain discontinuous care from a myriad of providers, often at expensive
hospitals rather than primary healthcare providers. Existing government, social, and voluntary
health insurance have provided limited protection, resulting in large population and service
coverage gaps.

Several policies and programs have sought to engage citizens with varying levels of success,
but they need more support. The National Health Mission (NHM) and the National Health Policy
2017 emphasised people’s participation in UHC through initiatives like the Accredited Social
Health Activist (ASHA) programme and community action for health. While there is scope for
further improvement in these programs to more fully address information asymmetries and power
imbalances, along with the need to reduce administrative centralisation in governing health, these
initiatives provide valuable lessons for enabling active citizen participation.

Regulations and laws related to payors, providers, and patients’ rights exist but are poorly
enforced. Limited state capacity, fragmented administration, misaligned incentives, and regulatory
capture have challenged the effective governance of the health system. The multiple administrative
procedures have promoted a low-trust culture, demotivating providers while doing little to improve
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their efficiency or effectiveness. The lack of timely and reliable data on key health system
parameters, inadequate disease surveillance, and weak health research networks have limited the
government’s ability to respond in a timely way to emerging healthcare challenges.

A reimagined health system

A confluence of factors makes this a historically unique moment to reimagine India’s health
system: an extensive architecture of providers and facilities in the public and private sectors; an
increase in the production of human resources for health, and self-sufficiency in medications and
diagnostics; robust economic growth, and rising government health expenditures in several States;
the preference of a majority of citizens for the public sector and a stable primary healthcare
provider; a strong foundation for citizens’ engagement and community action for health; and
growing access to digital technology and Digital Public Infrastructures (DPIs). Several guiding
principles underscore our reimagination of the health system. First, a transition from a facility-
centric, reactive, and fragmented delivery system focused on specific diseases towards a
comprehensive, coordinated, people-centred health system. Second, a transition from citizens
being passive recipients of services towards becoming active agents with rights engaged in the
health system. Third, a transition from focusing merely on physical access to healthcare services
to ensuring high-quality healthcare that treats everybody with respect and dignity. Fourth, a
transition from centralised towards decentralised, people-centric governance, informed by
comprehensive and timely data that report local population-level outcomes. Fifth, a transition from
providing weightage to only professional qualifications to emphasising provider competencies and
motivations and empowering frontline workers and practitioners of Indian systems of medicine
(AYUSH). Sixth, to responsibly and ethically leverage the power of innovative technology to
support the reimagined health system and deliver people-centred care. Finally, to explicitly
acknowledge rights and health equity as a core value of UHC and the reduction of inequities as a
measure of progress across UHC goals.

Variations in State and district health systems, including vast urban-rural differences, across India
highlight the importance of decentralised processes in health system design, implementation, and
evolution. Recognising this, we present our reforms as non-mutually exclusive options for
governments to choose from based on local realities. We intend our reforms to be considered
through extensive consultations with local governments, civil society, scholars, and healthcare
providers in both public and private sectors, to ensure that they are appropriate and adaptable to
local needs and scaled up after adequate piloting and evaluation. While our reform options
present different combinations of public and private sector financing, provider payments,
and delivery, our clarion call is for increasing and efficiently spending government health
expenditures and creating a publicly-financed and publicly-provided integrated delivery
system, which has the promise to be the most equitable. The reforms toward citizens’
engagement, better governance, and fostering a learning health system are integral to all these
options.
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The Commission proposes reform options in the following areas:

• To enable meaningful citizen engagement, the health system should be firmly built upon
people’s participation.
• To implement a people-centred health system through financing, purchasing, and service
delivery reforms in the public sector.
• To engage and steward the private sector to align with UHC goals.
• To leverage technological innovations.
• To enable transparent and accountable governance of the entire health system, there needs
to be decentralisation and strengthened regulatory capacities.
• To foster a learning health system, it should be grounded in robust, real-time data and
research.