Abstract 

This paper explores India's journey towards achieving universal health coverage (UHC) and health for all, focusing on the challenges and strategies for integrating marginalized groups into the healthcare system. The World Health Organization’s (WHO) framework for health system building blocks service delivery, health workforce, health information systems, medical products, healthcare financing, and governance forms the basis for analyzing India’s healthcare evolution. The paper examines key phases of India’s health policy, including the National Health Policy 1983, the National Health Mission (2005), and Ayushman Bharat (2018), which have progressively expanded healthcare access to underserved populations. Despite these efforts, challenges such as inadequate infrastructure, a shortage of healthcare professionals, fragmented health information systems, and high out-of-pocket expenditures persist. The paper also analyzes successful healthcare models from countries like Cuba, Brazil, and Thailand, offering insights into India’s path forward. Key policy recommendations emphasize strengthening primary healthcare, expanding health insurance, addressing social determinants of health, and increasing public-private partnerships. The paper concludes that, through integrated policy frameworks, enhanced governance, and leveraging technology, India can make significant strides towards achieving Health for All, ensuring equitable access to quality healthcare services across all segments of society.

Introduction

To achieve sustainable development goal 3 i.e. health for all the World Health Organization (WHO) has outlined six essential building blocks to build a robust health system. The six pillars of these building blocks are Service Delivery, Health Workforce, Health Information Systems, Medical Products, Vaccine & Technology, Healthcare Financing, and Leadership & Governance (Figure 1). These pillars form the foundation for achieving universal and equitable health coverage (UHC), ensuring that all individuals receive essential health services without financial hardship.

Figure 1: WHO Health System Building Blocks Framework

India has significantly improved healthcare access and outcomes over the past few decades. However, disparities in healthcare services remain, particularly among marginalized populations, including rural communities, tribal groups, low-income families, and other vulnerable sections of society. Historically, healthcare initiatives in India have focused on addressing the needs of these marginalized groups through targeted interventions such as the National Health Mission (NHM) and Rashtriya Swasthya Bima Yojana (RSBY). While these efforts have expanded healthcare coverage, they have not fully addressed systemic gaps that prevent equitable access to quality healthcare for all. The transition from a healthcare system primarily catering to the marginalized to one that ensures "Health for All" requires a holistic, multi-pronged approach that strengthens the entire health system (Bobade & Asutkar, 2024). India's current healthcare challenges, such as inadequate infrastructure (Deb Roy et al., 2023), shortages of healthcare professionals (Hongal & Kshirsagar, 2023), fragmented health information systems (Kapoor, 2022), high out-of-pocket expenditures, and governance inefficiencies (Reddy et al., 2023), pose significant barriers to achieving this goal. The COVID-19 pandemic further exposed vulnerabilities in the healthcare system, emphasizing the need for stronger public health infrastructure, digital health integration, and resilient supply chains (Scott et al., 2022).

This paper is an attempt to explore India's journey from focusing on health for marginalized populations to advancing towards universal health coverage, with an emphasis on system challenges, lessons learned, and the way forward. The next section has delved into how the health system has evolved in India by discussing key policies & programs like the National Health Policy and Ayushman Bharat, steps towards Health for All. The next section focused on the health system challenges faced by India such as inadequate infrastructure, financial constraints, and the growing burden of non-communicable diseases, impeding health for all. The paper also analyzed successful health system models from countries like Brazil, Thailand, and Costa Rica, emphasizing their strategies for achieving universal health coverage and the integration of marginalized groups into the healthcare system. Comparative analysis offered valuable insights into India’s path forward. The final section focused on policy recommendations, emphasizing the need for strengthening primary healthcare, improving funding, leveraging technology, and addressing social determinants of health. 

The Evolution of India’s Health System

India's health system has been marked by a gradual shift from focusing solely on the health of marginalized groups to an inclusive model aiming at health for all. This journey can be broken down into several key phases:

• Post-Independence Era: After gaining independence in 1947, India’s health policy primarily focused on the provision of basic healthcare services. The country focused on curbing communicable diseases and improving maternal and child health, with a strong emphasis on urban centers.

• National Health Policy (1983): The Indian government recognized the importance of addressing healthcare disparities across urban and rural areas, especially for marginalized groups, such as Scheduled Castes (SCs), Scheduled Tribes (STs), and economically disadvantaged populations.

• National Rural Health Mission (2005): This mission was introduced to bridge the gap in healthcare between urban and rural areas. It aimed at improving rural healthcare infrastructure and addressing disparities in healthcare access. Targeted efforts under NRHM resulted in improved healthcare delivery in rural areas, with a focus on maternal and child health, sanitation, and immunization in backward states like Bihar, UP, MP, Rajasthan, etc.

• National Health Policy 2017 (NHP 2017): NHP 2017 is a transformative step in India’s commitment to achieving Health for All by addressing key challenges in the healthcare sector and providing a comprehensive framework for improving health outcomes. It emphasizes universal health coverage (UHC), access to affordable and quality healthcare, and equitable health services for all segments of the population, including marginalized communities. One of the significant components of NHP 2017 is its commitment to increasing public health expenditure to 2.5% of India’s GDP by 2025, a substantial boost to financing healthcare. This funding increase is intended to strengthen the country’s healthcare infrastructure, including the expansion of primary healthcare facilities, particularly in rural areas, to ensure access for all, irrespective of socioeconomic status (Ministry of Health and Family Welfare [MoHFW], 2017). The policy also prioritizes preventive healthcare, with a focus on improving nutrition, sanitation, and education to reduce the burden of non-communicable diseases and other preventable conditions (MoHFW, 2017). Furthermore, NHP 2017 envisions strengthening the healthcare workforce, addressing shortages of healthcare professionals, and ensuring their equitable distribution across the country, especially in rural and remote areas (Gauttam et al., 2021) by recognizing the workforce of AYUSH system (traditional medicine system of India).

• Ayushman Bharat (2018): This is one of the most ambitious health schemes introduced in India, which seeks to provide health insurance to 500 million individuals, with a focus on economically disadvantaged and marginalized populations. Under this scheme, beneficiaries get cashless hospitalization, treatment for pre-existing conditions, and coverage for a wide range of medical services. Taking a step towards universal health coverage, recently, the Ayushman Bharat scheme has been expanded to cover senior citizens aged 70 and above, who are often at higher risk for health issues. The initiative also focused on strengthening primary healthcare through the establishment of Health and Wellness Centers. Ayushman Bharat Health and Wellness Centers (AB-HWCs), now renamed Ayushman Arogya Mandirs. These centers will be the foundation of India's health system, providing comprehensive primary healthcare services, including preventive, promotive, curative, rehabilitative, and palliative care, closer to the community. 

• National Digital Health Mission (NDHM): NDHM also named Ayushman Bharat Digital Mission (ABDM) was launched by the Government of India in 2020. It is poised to be a game changer in India’s pursuit of Health for All. The initiative aims to leverage digital technologies to create a cohesive, interoperable, and accessible health ecosystem that can address India’s healthcare challenges, particularly those related to accessibility, efficiency, and quality of care. By digitizing health records and services, the NDHM has the potential to bridge gaps in healthcare delivery, enabling comprehensive and equitable access to healthcare across the country (Ministry of Health and Family Welfare [MoHFW], 2020). A key feature of the NDHM is the Health ID, which provides each citizen with a unique digital health identifier. This allows for the creation of an electronic health record (EHR) that is accessible across multiple healthcare providers and platforms. With the Health ID, patients can access their health information seamlessly, regardless of where they receive care. This digitization can significantly enhance healthcare coordination, reduce duplication of tests, and improve the overall quality of care (Stoumpos et al., 2023). Moreover, the NDHM facilitates the telemedicine ecosystem, which is critical in ensuring healthcare access in remote and underserved areas, particularly in rural regions where healthcare facilities are scarce (Kerketta and Balasundaram, 2024). Additionally, NDHM can promote the use of data analytics and artificial intelligence (AI) to inform health policy and decision-making, improve health outcomes, and address gaps in the healthcare system (Kerketta and Balasundaram, 2024). By facilitating better health data management, improving service delivery, and enhancing access to care, the NDHM plays a pivotal role in moving India closer to achieving Health for All.

Challenges in Health care System India

• Service Delivery: India's healthcare system faces significant challenges, particularly the inequitable distribution of healthcare facilities in rural areas. Many rural regions lack well-equipped primary healthcare centers (PHCs), increasing disease burden and mortality rates (Deb Roy et al., 2023). Before key health initiatives, the system had a severe shortage of infrastructure. The National Health Mission (NHM), launched in 2005, aimed to strengthen public health infrastructure by improving Sub-Centers, PHCs, and Community Health Centers (CHCs) (Nath et al.). Ayushman Bharat (2018) further expanded service delivery through the establishment of Health and Wellness Centers (HWCs), focusing on preventive care. These initiatives have improved healthcare coverage, institutional deliveries, and immunization rates. The COVID-19 pandemic emphasized the need for robust healthcare infrastructure, leading to the Emergency COVID-19 Response Package and increased use of telemedicine (Hongal & Kshirsagar, 2023; Arora et al., 2024). Mental health care faces treatment gaps, and rising non-communicable diseases (NCDs) in rural areas exacerbate the challenge (Munikrishnappa et al., 2024; Nath et al., 2024).

• Despite progress, challenges remain in rural areas, where PHCs still lack medical equipment, trained staff, and proper referral systems (Deb Roy et al., 2023). The urban-rural divide forces rural populations to travel long distances for specialized care, exacerbating health inequalities. Moreover, integration between public and private healthcare sectors is weak, hindering continuous and coordinated care (Bobade & Asutkar, 2024). Addressing these gaps requires more inclusive and culturally sensitive healthcare models for marginalized communities (Reddy et al., 2023; Birje et al., 2022).

• Health Workforce: India faces a significant shortage of trained healthcare professionals, particularly in rural and remote areas, exacerbating the urban-rural divide. The Accredited Social Health Activist (ASHA) program, launched under the National Rural Health Mission (NRHM), has helped bridge some gaps by deploying over 900,000 community health workers. However, the shortage of trained doctors and specialists persists, and the low doctor-to-patient ratio remains a challenge (Hongal & Kshirsagar, 2023). The Medical Council of India (MCI) reforms in 2019 aimed to expand medical education, but shortages continue. The COVID-19 pandemic highlighted the need for a resilient workforce and led to emergency recruitment and training initiatives (Munikrishnappa et al., 2024). Rural areas face poor working conditions, high attrition rates, and inadequate mental health support for frontline workers (Hongal & Kshirsagar, 2023). Addressing these issues requires investment in medical education and offering incentives for healthcare workers in underserved areas. Regions, and leveraging community health workers (Deb Roy et al., 2023).

• Health Information System: Before the early 2000s, India's health information systems were fragmented, hindering disease surveillance and policy planning. The Health Management Information System (HMIS) under the National Health Mission (NHM) improved data collection, but integration issues persisted. The National Digital Health Mission (NDHM), launched in 2020, aims to address these gaps by creating a unique health ID and enabling interoperability across healthcare providers (Kapoor, 2022). The Integrated Disease Surveillance Program (IDSP), established in 2004, plays a critical role in real-time disease monitoring, exemplified by platforms like CoWIN and Aarogya Setu during the COVID-19 pandemic (Scott et al., 2022).

Despite progress, challenges like data privacy, digital literacy, and interoperability persist (Kapoor, 2022; Scott et al., 2022). Weak health information systems contribute to gaps in healthcare access, particularly in rural regions. Inconsistent internet connectivity, a lack of standardized protocols, and resistance to digital change impede digitization (Arora et al., 2024). Furthermore, the fragmentation of healthcare services, inadequate governance, and cultural barriers, especially in tribal communities, impact access (Bobade & Asutkar, 2024; Deb Roy et al., 2023).

• Medicines, Vaccines, and Technology: High out-of-pocket expenditure on medicines remains a significant barrier to healthcare in India, especially for marginalized and rural populations (Toppo et al., 2024). The Pradhan Mantri Bhartiya Janaushadhi Pariyojana (PMBJP) and the National List of Essential Medicines (NLEM) aim to make medicines more affordable, but their reach is limited (Arora et al., 2024; Toppo et al., 2024). Inefficiencies in supply chain management lead to stockouts and treatment disruptions (Toppo et al., 2024). To address these issues, improving supply chain management, increasing funding, and ensuring the affordability and availability of essential medicines are crucial (Scott et al., 2022; Munikrishnappa et al., 2024).

Telemedicine has emerged as a potential solution to address healthcare access barriers, especially in rural areas. However, challenges such as limited internet connectivity, lack of standardized telemedicine protocols, and resistance from healthcare providers hinder its implementation (Arora et al., 2024). Strengthening digital health infrastructure, training healthcare providers, and developing standardized guidelines are necessary to enhance the effectiveness of telemedicine services (Kapoor, 2022).

• Financing Health Care: India's healthcare financing has been inadequate, with high out-of-pocket expenses leading many families into poverty. The Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (PMJAY), launched in 2018, improved financial protection by offering health insurance to vulnerable populations (Bobade & Asutkar, 2024). However, public health spending remains low, hindering infrastructure expansion and service delivery, especially in rural areas (Arora et al., 2024; Munikrishnappa et al., 2024). To achieve universal health coverage, increased public funding and sustainable financing models are necessary (Deb Roy et al., 2023; Kapoor, 2022).

• Leadership and Governance: India's healthcare governance has faced challenges such as centralized decision-making, lack of accountability, and poor intersectoral collaboration. The National Health Policy 2017 and Ayushman Bharat aimed to decentralize governance and improve transparency (Bobade & Asutkar, 2024). However, inefficiencies persist in resource allocation and coordination (Hongal & Kshirsagar, 2023). Weak leadership and poor integration of traditional healing practices reflect broader governance issues (Reddy et al., 2023). Marginalized populations, especially tribal communities and women, face cultural and systemic barriers, exacerbating health inequities (Birje et al., 2022; Deb Roy et al., 2023). 

Learnings from Other Countries

Several countries worldwide have made significant strides in providing universal health coverage and addressing healthcare disparities. India can learn from the experiences of these nations:

Cuba’s healthcare system, renowned for its emphasis on primary healthcare and community integration, offers valuable insights. The Family Doctor Program, which embeds medical professionals within communities, ensures consistent, preventive, and curative care (Kengadaran et al., 2020). India’s Ayushman Bharat initiative, with its Health and Wellness Centers (HWCs), mirrors this approach but requires deeper community integration and a stronger focus on preventive care. Additionally, Cuba’s investment in medical education and equitable distribution of healthcare workers has resulted in one of the highest doctor-to-patient ratios globally (Prasad, 2020). India, facing a severe shortage of healthcare professionals, especially in rural and tribal areas, must prioritize medical and nursing education, expand training facilities, and introduce incentives for healthcare workers to serve in underserved regions. Community health workers (CHWs) can also play a pivotal role, as seen in Rwanda’s community-based health insurance scheme (Khatri et al., 2024).

Thailand’s Universal Health Coverage (UHC) Scheme highlights the importance of reducing out-of-pocket expenditures through tax-financed healthcare models (Hughes & Leethongdee, 2007). India, where out-of-pocket expenses remain high, must increase government investment in healthcare and explore innovative financing mechanisms. Expanding insurance coverage under Ayushman Bharat and integrating community-based health insurance models, as seen in Rwanda, can further reduce financial burdens on marginalized populations. Similarly, Brazil’s Farmácia Popular program has successfully ensured access to affordable medicines for low-income populations (Massard da Fonseca & Shadlen, 2017). India’s Pradhan Mantri Bhartiya Janaushadhi Pariyojana (PMBJP) aims to achieve similar outcomes but requires scaling up and strengthening supply chain management. By implementing stricter drug price regulations and expanding public-private partnerships, India can ensure universal access to essential medicines.

Rwanda’s healthcare transformation underscores the importance of strong political will and transparent governance (Binagwaho & Kyamanywa, 2016). India’s healthcare governance often suffers from bureaucratic inefficiencies and lack of accountability. By adopting evidence-based policymaking, strengthening intersectoral collaboration, and enhancing public-private partnerships, India can create a more efficient and equitable healthcare system. Estonia’s E-Health System demonstrates the transformative potential of digital health records and data-sharing mechanisms. India’s fragmented health information systems can benefit from adopting similar technologies to improve coordination, efficiency, and epidemic preparedness. By integrating digital health tools like telemedicine and e-prescriptions, India can bridge accessibility gaps, particularly for marginalized populations in remote areas.

Cuba’s resilience in maintaining healthcare quality despite economic constraints highlights the importance of self-reliance in medical supplies—a lesson India must internalize following the vulnerabilities exposed by the COVID-19 pandemic. By integrating traditional healing practices, as seen in Cuba’s respect for ethnomedicine, India can address cultural barriers and improve trust in modern healthcare systems (Reddy et al., 2023). Additionally, Cuba’s emphasis on preventive care and medical diplomacy aligns with India’s goals under Ayushman Bharat (Walker, 2024). Strengthening primary health care, investing in the health workforce, leveraging digital health, ensuring access to medicines, improving financing mechanisms, and enhancing governance are critical steps toward realizing the vision of "Health for All."

By examining the strategies employed by these nations, India can identify gaps in its regulatory infrastructure and strengthen its position in global health governance. For instance, Cuba’s emphasis on self-reliance and Chile’s focus on innovation in healthcare technology offers valuable lessons for India. Addressing these gaps could enhance India’s ability to regulate medical devices effectively, ensuring safety and accessibility for its population while fostering international partnerships (Khan & Sharma, n.d.).

Way Forward for India

Drawing from the successes and challenges of other countries, India can take the following steps to improve its healthcare system and move towards achieving "health for all":

• Strengthening Primary Healthcare: India needs to prioritize strengthening its primary healthcare infrastructure, especially in rural areas. This would reduce the burden on tertiary healthcare facilities and ensure early diagnosis and prevention of diseases.

• Universal Health Insurance: Expanding the scope of schemes like Ayushman Bharat to cover more marginalized populations including EWS and ensuring comprehensive financial protection for all could help reduce the financial burden on citizens.

• Addressing Social Determinants of Health: Policies should focus not only on healthcare access but also on improving education, sanitation, nutrition, and housing conditions, as these are key determinants of health.

• Increased Public-Private Partnerships: India can benefit from engaging private healthcare providers in a more structured manner to fill the gaps in public healthcare delivery, especially in remote areas.

• Investing in Human Resources: A long-term strategy must include the training, retention, and deployment of healthcare workers in underserved regions. Incentives such as better salaries, career development, and housing could help attract more healthcare professionals to rural areas.

• Public Awareness Campaigns: Educating the population on health prevention, hygiene, and the importance of regular check-ups can help reduce the overall burden on the healthcare system.

Conclusion

India’s journey from focusing on health for marginalized groups to aiming for health for all is a challenging but necessary path. By learning from successful international examples and implementing comprehensive, community-focused healthcare policies, India can make significant strides in overcoming its health system challenges and achieving universal health coverage for its population.

References

1. Arora, S., Huda, R. K., Verma, S., Khetan, M., Sangwan, R. K., Huda Sr, R. K., & Sangwan, R. K. (2024). Challenges, barriers, and facilitators in telemedicine implementation in India: a scoping review. Cureus, 16(8).

2. Birje, S., Patil, A. D., Munne, K. R., Chavan, V., Joshi, B. N., Akula, A., ... & Babu, B. V. (2022). Enablers & challenges of tribal women & health system for implementation of screening of non-communicable diseases & common cancers: A mixed-methods study in Palghar district of Maharashtra, India. Indian Journal of Medical Research, 156(2), 319-329.

3. Bobade S, Asutkar S.(2024).The Path Towards a Unified Health System in India: From Fragmentation to Integration: A Narrative Review, J Clin of Diagn Res. 18(12), IE01-IE05. https://www.doi.org/10.7860/JCDR/2024/74200/20271

4. Bobade, S., & Asutkar, S. (2024). The Path Towards a Unified Health System in India: From Fragmentation to Integration: A Narrative Review. Journal of Clinical and Diagnostic Research (JCDR), IE01-IE05. https://doi.org/10.7860/JCDR/2024/74200.20271

5. Gauttam, P., Patel, N., Singh, B., Kaur, J., Chattu, V. K., & Jakovljevic, M. (2021). Public health policy of India and COVID-19: Diagnosis and prognosis of the combating response. Sustainability, 13(6), 3415.

6. Gudi, N., Yadav, U. N., John, O., & Webster, R. (2023). Challenges and opportunities in employing digital health to address self-management needs of people with NCDs in India. BMJ Innovations, 9(1).

7. Guite, Nemthianngai & Reddy, Sunita & Subedi, Bamdev. (2023). Ethnomedicine and Tribal Healing Practices in India: Challenges and Possibilities of Recognition and Integration. 10.1007/978-981-19-4286-0. 

8. Hongal, P., & Kshirsagar, Y. (2023). Healthcare Management in India: Issues, Challenges and Prospects. International Journal of Engineering and Management Research, 13(2). https://doi.org/10.31033/ijemr.13.2.11

9. Kafczyk T, Hämel K. Primary mental healthcare for older people in India: between stigmatization and community orientation. Discov Ment Health. 2023 Jul 28;3(1):14. doi: 10.1007/s44192-023-00040-7. 

10. Kapoor, Suraj. Digital Health Ecosystem in India: Present Status, Challenges, and Way Forward. D Y Patil Journal of Health Sciences 10(4): p. 202-205, Oct-Dec 2022. | DOI: 10.4103/DYPJ.DYPJ_27_22 

11. Kengadaran, S., Anusha, D., Kengadaran, S., & Koyi, S. (2020). Family health care model—A lesson to be learned from the Cuban health care system. Journal of Family Medicine and Primary Care, 9(8), 4481-4482. 

12. Kerketta, A., & Balasundaram, S. (2024). Leveraging AI Tools to Bridge the Healthcare Gap in Rural Areas in India. medRxiv, 2024-07.

13. Khan, M. I., & Sharma, T. From Aspiration to Affiliation in IMDRF By 6 Countries (Egypt, Cuba, Chile, Montenegro, Israel, and Chinese Taipei) And Investigating the Absence of India.

14. Khatri, R. B., Endalamaw, A., Erku, D., Wolka, E., Nigatu, F., Zewdie, A., & Assefa, Y. (2024). Enablers and barriers of community health programs for improved equity and universal coverage of primary health care services: A scoping review. BMC Primary Care, 25(1), 385.

15. Lal, Aparna & Patel, Mahomed & Hunter, Arnagretta & Phillips, Christine. (2020). Towards resilient health systems for increasing climate extremes: insights from the 2019–20 Australian bushfire season. International Journal of Wildland Fire. 30. 1-5. 10.1071/WF20083. 

16. Ministry of Health and Family Welfare, Government of India. (2017). National Health Policy 2017. Retrieved from https://www.mohfw.gov.in/sites/default/files/9147562941489753121.pdf 

17. Ministry of Health and Family Welfare, Government of India. (2020). National Digital Health Mission (NDHM) Launch. Retrieved from https://www.mohfw.gov.in 

18. Munikrishnappa, D., Majumder, J., Kalita, M., Shivarudraiah, M., Saha, I., & Chakrabarti, A. (2024). Bridging the Mental Health Treatment Gap in India: Opportunities and Challenges: A Narrative Review. Journal of Mental Health and Human Behaviour, 29(2), 55-61. 

19. Nath, A., Shalini, M. A., & Mathur, P. (2021). Health systems challenges and opportunities in tackling non-communicable diseases in rural areas of India. Natl Med J India, 34(1), 29.

20. Prasad, A. J. (2020). The primacy of Primary Healthcare: Cuban Experience and Lessons for India. The Indian Practitioner, 73(9), 7-10.

21. Roy, A. D., Das, D., & Mondal, H. (2023). The tribal health system in India: Challenges in healthcare delivery in comparison to the global healthcare systems. Cureus, 15(6).

22. Scott, K., Ummer, O., Chamberlain, S., Sharma, M., Gharai, D., Mishra, B., ... & LeFevre, A. E. (2022). At the frontlines of digitization: a qualitative study on the challenges and opportunities in maintaining accurate, complete and timely digital health records in India’s government health system. BMJ open, 12(2), e051193.

23. Stoumpos, A. I., Kitsios, F., & Talias, M. A. (2023). Digital transformation in healthcare: technology acceptance and its applications. International journal of environmental research and public health, 20(4), 3407.

24. Toppo, M., Gour, D., Singh, A. R., Shewade, H. D., & Kamble, M. (2024). “TB drug stock planning in advance is a futile activity” is the health system’s perceived challenge and suggested solutions pertaining to the Nikshay Aushadhi portal in central India. Indian Journal of Tuberculosis, 71(4), 395-404.

25. Walker, C. A. R. (2024). Confronting colonial legacies and neoliberal hegemony in global health and development: creative Cuban social medicine adaptions from Venezuela to Timor-Leste.