Context:

• December 12 is observed as Universal Health Coverage (UHC) Day, highlighting the global commitment to ensuring access to essential health services without financial hardship.
• The 2025 theme — “Unaffordable health costs? We’re sick of it!” — underscores growing public frustration over rising healthcare expenses and persistent out-of-pocket expenditure (OOPE).

Universal Health Coverage (UHC) vs Universal Healthcare:

• UHC: Focuses primarily on financial risk protection, often through insurance schemes covering hospitalisation and select treatments.
• Universal healthcare: A broader concept ensuring equitable access to comprehensive primary healthcare, including preventive, promotive, curative, rehabilitative, and palliative care. Thus, having ‘Right to Health’ at its core.

Global Normative Framework:

• Right to Health recognised in international covenants. For example, Alma-Ata Declaration, 1978 (WHO) emphasised Primary Healthcare (PHC) as the foundation of health systems.
• WHO World Health Report, 2010 shifted focus towards financial reform and insurance-based risk protection.
• UN Resolution on UHC and SDGs institutionalised UHC as a global development goal (SDG 3).

Insurance-Centric UHC - Emerging Concerns:

• Many countries, including India, have adopted public health insurance-led UHC.
• These schemes focus on hospitalisation and disease-specific packages, but often exclude outpatient care, diagnostics, and medicines.
• Evidence shows continued OOPE due to -
  • Services not covered or inadequately covered
  • Provider-induced demand and misuse of insurance packages
• This means, financial protection without system strengthening is inadequate.

Comparative Experience - East and Southeast Asia:

• Countries like China and South Korea achieved near-universal insurance coverage.
• However, fiscal burden on the exchequer became unsustainable, and ageing populations and chronic diseases increased costs.
• China’s course correction (2015):
  • Cost containment
  • Strengthening primary and secondary care
  • Focus on prevention, early detection, follow-up
  • Investment in human resources and population outreach
• Lesson: Insurance works best when anchored in a well-financed public health system with PHC as a gatekeeper.

Role of Public Health Systems:

• East and Southeast Asian countries maintain strong public provisioning, and a regulated private sector.
• A robust public system must act as a bulwark against cost escalation, and help regulate quality and pricing.
• Yet, private sector influence on health policy remains an unresolved concern.

India’s Historical Commitment and Policy Drift:

• Bhore Committee (1946): Advocated universal healthcare through a strong public PHC system. It explicitly cautioned against introducing insurance before PHC strengthening.
• Post-Independence reality: Chronic underfinancing of primary healthcare, weak public provisioning, and growing dependence on private healthcare.
• National Sample Survey (NSS): Increasing reliance of the poor on expensive private care. Rising household indebtedness due to health expenses.

Health Reforms in India:

• National Rural Health Mission (NRHM, now NHM): Improved access but systemic gaps persist.
• Insurance-based interventions:
  • Rashtriya Swasthya Bima Yojana (2008)
  • Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB–PMJAY)
• These institutionalised UHC discourse, but largely retained a hospital-centric

Covid-19 as a Turning Point:

• Pandemic exposed inequities in insurance coverage, limitations of hospital-focused health systems.
• Renewed calls globally and in India to move from UHC to Universal Healthcare, address social determinants of health.

Challenges and Way Forward:

• Overemphasis on financial protection over service provision: Integrate insurance schemes within a robust public health system. Focus on prevention and health promotion, early diagnosis and continuity of care.
• Weak primary and secondary healthcare infrastructure: Strengthen comprehensive primary healthcare as the first point of care.
• High out-of-pocket expenditure: Regulate private sector, reorient policy from coverage for illness to care for health. Regulatory reforms focussing on social determinants of health (nutrition, sanitation, housing).
• Inadequate public health spending: Increase public investment in health (especially PHC).

Conclusion:

• Universal Health Coverage, when reduced to insurance-based financial protection, risks missing the core objective of health equity.
• India’s experience — reinforced by global evidence and the Covid-19 pandemic — highlights the urgency of transitioning towards universal healthcare rooted in strong primary care systems.
• Reclaiming the Alma-Ata vision through sustained public investment is essential to make healthcare truly affordable, accessible, and equitable.