Beyond Insurance: Reimagining a People-Centric Public Health System for India
An examination of recent shifts in India's health policy, the move towards individual wellness and digital records, and the debate over strengthening public health institutions versus insurance-led models.
The Pre-requisite
To understand the current debate surrounding India's public health direction, it is essential to grasp the foundational concepts, historical context, and the key institutions involved in policymaking.
KEY TERMS
- Universal Health Coverage (UHC) — A goal wherein all individuals and communities receive the health services they need without suffering financial hardship.
- Ayushman Bharat (AB) — India's flagship public health initiative launched in 2018, comprising two main components: Health and Wellness Centres (HWCs) for primary care and the Pradhan Mantri Jan Arogya Yojana (PM-JAY) for secondary and tertiary care insurance.
- Ayushman Bharat Digital Mission (ABDM) — A national initiative launched in 2021 to create an integrated digital health infrastructure, providing every citizen with a unique health ID and a repository for their health records. (Note: The official name is Ayushman Bharat Digital Mission, not Health Mission).
- ABHA (Ayushman Bharat Health Account) — A 14-digit unique identifier, previously known as a Health ID, that enables citizens to link, access, and share their health records digitally with their consent across multiple systems and stakeholders.
BACKGROUND & TIMELINE
India's vision for a public health system has evolved significantly since independence. The Bhore Committee Report of 1946, chaired by Sir Joseph Bhore, laid the first comprehensive blueprint for a three-tier public health system emphasizing primary care. Post-independence, health policy was guided by Five-Year Plans until the first National Health Policy (NHP) was formulated in 1983. This was followed by the NHP 2002, which set time-bound goals for disease eradication and infrastructure development.
The launch of the National Rural Health Mission (NRHM) in 2005 marked a major investment in strengthening rural public health infrastructure and human resources. The current policy framework is guided by the National Health Policy of 2017, which aims to achieve UHC and proposes increasing public health expenditure to 2.5% of GDP. A significant policy reorientation occurred in 2018 with the launch of Ayushman Bharat, which pivoted the national strategy towards a twin approach of strengthening primary care through HWCs and providing insurance for hospitalisation through PM-JAY. The subsequent launch of the Ayushman Bharat Digital Mission (ABDM) in September 2021 signalled a major push towards leveraging technology and data to streamline healthcare delivery.
INSTITUTIONAL FRAMEWORK
The primary institution governing health policy in India is the Ministry of Health and Family Welfare (MoHFW), Government of India. It is responsible for formulating national policies and implementing various health programmes. The National Health Authority (NHA), an attached office of the MoHFW, is the apex body responsible for implementing Ayushman Bharat PM-JAY and the ABDM. Since health is a State Subject under the Indian Constitution (Entry 6, List II, Seventh Schedule), state governments play a critical role in the financing and delivery of healthcare services, leading to significant variations in performance across the country.
The Main Explanatory
Recent shifts in India's public health policy, particularly under the Ayushman Bharat umbrella, have moved the focus towards individual wellness and digital infrastructure. While these initiatives aim to modernise the health system, they have sparked a debate about whether they address the foundational challenges of access, affordability, and quality in public healthcare.
### What is the central tension in India's current health policy?
The core tension lies between two competing visions for achieving Universal Health Coverage (UHC). One vision prioritises strengthening the three-tiered public health system—Sub-Centres (SCs), Primary Health Centres (PHCs), and Community Health Centres (CHCs)—to ensure direct provisioning of care. The other, which has gained prominence, focuses on a publicly funded, insurance-based model to finance care, primarily in the private sector, coupled with a digital ecosystem to manage health information. The National Health Policy 2017 advocates for a 'progressively incremental' approach, but recent initiatives have been critiqued for heavily favouring the latter vision. Critics, such as Mathew George, Professor at the Central University of Kerala, argue that this shift risks neglecting the 'felt needs' of the population, such as access to affordable curative care, in favour of top-down policy priorities (Source: The Hindu, June 24, 2023).
### How have Health and Wellness Centres shifted the focus?
The Ayushman Bharat Health and Wellness Centres (HWCs) initiative, launched in 2018, was designed to transform 1,50,000 SCs and PHCs into comprehensive primary healthcare providers. The stated government objective was to move from selective to comprehensive primary care, including screening for non-communicable diseases, maternal and child health services, and diagnostics. However, a key criticism revolves around the implementation and its conceptual underpinnings. The mandatory renaming of all grassroots institutions by adding 'Health and Wellness Centre' as a prefix has, according to some public health experts, created ambiguity about their specific roles within the district health system.
More fundamentally, the emphasis on 'wellness' is seen as a move away from measurable population health outcomes towards subjective, individual well-being. The wellness concept, which gained popularity in the 1950s, places significant responsibility on individuals to modify their health choices. This approach, critics argue, often underestimates the structural determinants of health, such as poverty, sanitation, and nutrition. As Mathew George notes, framing health outcomes in terms of individual well-being makes it difficult to systematically measure and address unmet health needs at a population level, undermining the principle that 'if you cannot measure it, you cannot improve it' (Source: The Hindu, June 24, 2023).
### What is the role of the Ayushman Bharat Digital Mission (ABDM)?
The Ayushman Bharat Digital Mission (ABDM) represents the government's flagship effort to build a national digital health ecosystem. Its principal objective, as stated by the National Health Authority, is to create a seamless online platform through the provision of a wide range of data, information, and infrastructure services. This is operationalised through the creation of a unique Ayushman Bharat Health Account (ABHA) number for every citizen, with over 50 crore ABHA IDs generated by late 2023. The mission also aims to create comprehensive registries of all health facilities (Health Facility Registry) and healthcare professionals (Healthcare Professionals Registry). The government's rationale is that this digital backbone will improve efficiency, transparency, and continuity of care by allowing patients to store, access, and consent to share their health records with providers anywhere in the country.
### What are the primary criticisms of this digital-first approach?
While the potential benefits of a digital health ecosystem are acknowledged, the primary criticism is that it does not address the fundamental barriers to healthcare in India: the unaffordability of private care and the poor quality of public facilities. Critics question the allocation of significant resources—an annual budget of around ₹300 crore for the ABDM—to an information portal when the physical infrastructure for care delivery remains inadequate (Source: The Hindu, June 24, 2023). The core argument is that a digital repository of health records, by itself, cannot guarantee access to a hospital bed, a qualified doctor, or an affordable medical procedure.
Public health experts further argue that the ABDM's design focuses heavily on generating information on individuals and facilities that operate in silos. The mission, they contend, has 'little to say about the provisioning of care' or how the digital infrastructure will strengthen the public system (Source: The Hindu, June 24, 2023). Without robust institutional mechanisms for care delivery, the concern is that the digital mission may primarily serve to create databases rather than improve health outcomes. Critics question how an ABHA card can ensure access to care when the underlying health infrastructure remains 'grossly inadequate and unaffordable for large sections of the population,' arguing this approach prioritises policymaker needs over the curative needs of the people (Source: The Hindu, June 24, 2023).
The Way Forward
India's health policy, with its dual emphasis on wellness and digitalisation, stands at a critical juncture. The debate it has ignited has profound implications for how the nation will care for its citizens, particularly as high out-of-pocket expenditure—constituting 47.1% of total health spending as per the National Health Accounts 2019-20—continues to push millions into poverty. The policy choices made now will determine whether India builds a resilient, equitable public health system or a fragmented one that deepens existing inequalities. The current focus on individual wellness and digital records is critiqued for sidestepping the population's immediate 'felt need' for reliable and affordable curative care.
In the next five years, the expansion of the digital health ecosystem under ABDM is set to accelerate, with the government likely to push for near-universal ABHA card penetration by 2028 and greater integration of private sector providers. The central policy question will be whether this digital architecture is used to strengthen public health institutions or to facilitate a more extensive network of private, insurance-empanelled providers. The recommendations of the 16th Finance Commission, expected by late 2025, will be a crucial indicator of the government's commitment to increasing health financing for states, which is essential for strengthening grassroots infrastructure.
These policy directions challenge the traditional understanding of public health as a state-provided public good and raise complex questions about data privacy, federalism, and equity. A system heavily reliant on individual data and private insurance markets may struggle to address population-level health crises, a vulnerability exposed during the COVID-19 pandemic. Critics argue that a people-centric health system must be anchored in robust public institutions accountable to their communities. They contend that reconnecting policy with immediate curative needs is a necessary foundation upon which preventive and promotive health interventions can be meaningfully built.