Social Justice

Context: The Lancet Commission on Universal Health Coverage (UHC) has called for a citizen-centric healthcare delivery system in India, arguing that people’s lived experiences and long-term care needs must guide reforms. The recommendation comes amid persistent out-of-pocket (OOP) costs, rising non-communicable diseases (NCDs), and uneven access to quality care.

Why Citizen-Centric UHC is Essential for India

India’s health system continues to impose a heavy financial burden on households. Out-of-pocket expenditure remains around 47–50% of total health spending, exposing families to medical impoverishment.

At the same time, public health expenditure is below 2% of GDP, well short of the National Health Policy target of 2.5%.

Epidemiological transition further strengthens the case for reform. Non-communicable diseases account for nearly 60% of all deaths, demanding continuous, preventive and primary-level care rather than episodic hospitalisation. Additionally, India has about 140 million elderly persons (60+), increasing demand for chronic disease management, rehabilitation and long-term care.

Key Challenges in the Existing System

• Human Resource Gaps: Many states report 20–30% vacancies in specialists and medical officers in public facilities, affecting service quality and continuity.
• Weak Financial Protection: Around 14–17% of households face catastrophic health expenditure, indicating gaps in effective risk pooling.
• Fragmented Care Delivery: Nearly 70% of outpatient care is delivered by the private sector, leading to discontinuity, duplication of tests and variable standards.
• Limited Preventive Focus: Low screening rates mean conditions like diabetes and hypertension often remain undiagnosed for years, raising complication costs.

Lancet Commission’s Key Recommendations

1. Citizen-Centric Integrated Care

The Commission advocates shifting from top-down planning to including people’s priorities and feedback in health decisions. Kerala’s People’s Plan demonstrates how local participation can strengthen accountability.

Publicly financed and provided care should form the backbone of UHC, with Ayushman Bharat Health and Wellness Centres (HWCs) acting as the primary vehicle.

Further, AYUSH practitioners should be integrated into care teams to expand preventive and promotive services.

2. Workforce and Frontline Empowerment

Instead of relying only on formal qualifications, the focus should move towards competency, ethics, and motivation in real-world service delivery.

Frontline workers must be empowered through training and decision support, as seen in Tamil Nadu’s “Makkalai Thedi Maruthuvam”, which delivers doorstep care for chronic patients.

3. Digital Technology-Led Reform

Digital platforms should integrate providers, payers and patients for seamless care pathways. The Ayushman Bharat Digital Mission (ABDM), using ABHA IDs, is central to this vision.

Emerging technologies such as AI-enabled diagnostics, genomics and portable innovations can bring advanced care closer to communities.

4. Governance and Financing Reforms

Efficient digital fund flows and simplified procedures are needed to improve utilisation.

The Commission recommends shifting from line-item budgeting to outcome-based financing, linking funding to measurable health outcomes to build trust and accountability.

Conclusion

A citizen-centric approach to Universal Health Coverage can transform India’s health system from episodic and fragmented care to continuous, preventive and people-responsive healthcare, aligning equity, efficiency and dignity.

Context: Despite nearly three decades of the Transplantation of Human Organs and Tissues Act (THOTA), 1994, India’s deceased organ donation ecosystem remains underdeveloped. According to The Hindu, the deceased donor rate continues to be critically low, highlighting systemic, legal, and operational constraints.

Organ Donation Performance in India

India’s deceased organ donation rate stood at 0.77 per million population (pmp) in 2023, starkly lower than Spain’s 49.38 pmp, the global leader. An estimated 5 lakh Indians die annually due to non-availability of organs. Although over 50,000 Brainstem Death (BSD) cases are medically eligible each year, only 700–900 deceased donors are realised.

Further, 85% of transplants rely on living donors, unlike developed countries where 70–80% are from deceased donors. Alarmingly, only 2–3% of ICU deaths undergo BSD certification. The apnea test is mandatory for confirming irreversible loss of brainstem function and is central to BSD determination.

Legal and Institutional Framework

The THOTA, 1994 provides the statutory backbone for organ transplantation in India. It:

• Recognises Brainstem Death as legal death, enabling deceased donation.
• Regulates living donations, transplant hospitals, and penalises organ trade.
• Prescribes certification and consent norms (Form 10 for BSD declaration; Form 8 for consent).

Institutional mechanisms include:

• NOTTO: National apex body for organ allocation, registry, and coordination.
• ROTTO: Regional coordination across States.
• SOTTO: State nodal agencies for training, hospital networking, and awareness.

Key Challenges

• Low BSD Utilisation: Massive gap between eligible and certified BSD cases.
• Dual Death Certificate Ambiguity: Issuance of both BSD and cardiac death certificates causes legal uncertainty and delays.
• Restricted Certification Locations: BSD certification allowed only in registered transplant centres, excluding over 90% of public ICU hospitals.
• Doctor Approval Bottleneck: Less than 8% of government doctors are authorised for BSD certification.
• Consent Timing Errors: Families often approached before formal BSD certification, leading to 60–70% refusal rates in major public hospitals.

Way Forward

• Universal BSD Certification: Permit all ICU-equipped hospitals to certify BSD, as practiced in Spain.
• Single Death Certificate Rule: Recognise BSD as the final legal time of death; Kerala’s 2020 order is a best practice.
• Trained Transplant Coordinators: Deploy certified counsellors in ICUs; Tamil Nadu’s model increased donations by over 400%.
• Digital BSD Registry: Establish a real-time, integrated BSD and organ availability platform linked with NOTTO and SOTTO.

Context: The Union Government informed Parliament that India’s doctor–population ratio stands at 1:811, better than the WHO norm of 1:1000, highlighting quantitative progress in healthcare availability while masking structural challenges.

India’s healthcare system has undergone significant expansion over the last decade, driven by a shift towards universal health coverage, preventive care, and infrastructure strengthening. However, challenges related to financing, equity, and quality of care continue to demand policy attention.

Current Status of India’s Healthcare System

Public health expenditure has increased gradually to 1.9% of GDP (FY 2023–24), yet remains below the National Health Policy (2017) target of 2.5% by 2025. While financial protection has improved, Out-of-Pocket Expenditure (OOPE) still accounts for 39.4% of total health spending, exposing households to catastrophic health shocks.

India’s improved doctor–population ratio reflects expanded medical education capacity, but rural–urban disparities, uneven specialist distribution, and shortages in public facilities persist. The disease profile has also shifted decisively towards non-communicable diseases (NCDs), which account for over 60% of deaths, necessitating long-term, preventive, and primary-care-driven interventions.

A major structural reform has been the transition to Comprehensive Primary Health Care (CPHC) through the establishment of over 1.7 lakh Health and Wellness Centres, now renamed Ayushman Arogya Mandirs (AAMs). These centres focus on NCD screening, mental health, geriatric care, and preventive services.

Government Measures and Initiatives

The flagship Ayushman Bharat programme anchors India’s healthcare reforms through two pillars.

First, PM-JAY provides health insurance coverage of ₹5 lakh per family per year for secondary and tertiary care to about 12 crore vulnerable families, reducing financial hardship.

Second, Ayushman Arogya Mandirs strengthen grassroots healthcare delivery.

The National Health Mission (NHM) continues to support states in expanding healthcare access, improving maternal and child health, and addressing regional disparities.

Complementing this, the PM Ayushman Bharat Health Infrastructure Mission (PM-ABHIM) focuses on building critical care blocks, disease surveillance units, and public health laboratories to enhance pandemic preparedness.

To tackle medicine affordability, the Pradhan Mantri Bhartiya Janaushadhi Pariyojana (PMBJP) has expanded access to quality generic medicines through thousands of Janaushadhi Kendras, directly contributing to the reduction in OOPE.

Way Forward

India’s healthcare priorities must now focus on increasing public spending, addressing human-resource imbalances, strengthening urban and rural primary care, and integrating digital health solutions.

Greater emphasis on preventive care, mental health, and geriatric services is essential to manage the rising NCD burden.

Overall, India’s healthcare sector reflects meaningful progress, but achieving equitable, affordable, and quality healthcare for all will require sustained fiscal commitment, cooperative federalism, and systemic reforms.

The World Health Organisation (WHO) has issued its first-ever global guidelines on the use of GLP-1 (Glucagon-Like Peptide-1) receptor agonists for treating obesity, marking a major shift in international clinical and public-health policy. These medicines—originally developed for diabetes—have shown significant weight-loss benefits but raise concerns regarding affordability, long-term safety, and unequal access.

GLP-1 drugs mimic the natural hormone that increases insulin secretion, suppresses appetite, slows gastric emptying, and reduces glucagon levels. Popular therapies include liraglutide, semaglutide, and tirzepatide.

Key Features of the WHO Guidelines

1. Conditional Recommendations

WHO issued two conditional guidelines owing to limited long-term evidence and substantial cost barriers:

• GLP-1 Therapies for Adults: Medicines such as semaglutide and tirzepatide may be used for long-term treatment, except in pregnant women.
• Behavioural Interventions Mandatory: Drug therapy must be accompanied by structured dietary counselling, physical activity programmes, and regular follow-up.

2. Obesity as a Chronic Disease

The guidelines adopt a lifelong care model, positioning obesity as a chronic metabolic condition requiring sustained clinical management rather than short-term weight-loss attempts.

3. Three-Pillar Strategy

WHO recommends a multilevel approach that integrates:

• Population-level measures (healthy food policies, regulation of marketing, active-living environments)
• Targeted screening and early interventions
• Lifelong, person-centred care, including pharmacotherapy where appropriate

4. Health Equity Concerns

The guidelines highlight the limited global capacity to manufacture GLP-1 drugs and project that less than 10% of people with obesity worldwide will benefit by 2030 due to cost and supply constraints.

Global and Indian Burden of Obesity

Obesity is defined by WHO as BMI ≥ 30 in adults.

• Global Burden (2024): Over 1 billion people affected; 3.7 million deaths linked to obesity-related conditions.
• India (NFHS-5): 24% of women and 25% of men are overweight or obese.
• Projections: India may exceed 163 million adults with obesity by 2030, nearly doubling current levels.

Obesity’s rapid rise, combined with the expanding but inequitable availability of GLP-1 therapies, underscores the need for integrated public-health measures and affordable access strategies.