India’s healthcare system stands at a critical crossroads. While it boasts of several remarkable strides in tech-based medical innovation and digital health, it continues to grapple with stark inequalities and underfunding in the delivery of health services.
Despite being home to one of the world’s largest populations, India spends not more than 2% of its GDP on public healthcare, far below the global average. Despite debates and a push for better healthcare facilities, this limited investment for years has created a fragmented system where top-tier private hospitals coexist with overburdened public facilities, leaving millions without consistent access to quality and affordable health services.
Limited to a meagre increase in health expenditure over the past five years, from 1.28 per cent of GDP in 2019-19 to 1.9 per cent in 2023-24 (Economic Survey 2023-24), most Indians struggle to access even basic healthcare leading to the burden of treatment falling heavily on them, increasing catastrophic out-of-pocket expenses.
During this same time, although there has been a steady decline in the out-of-pocket expenditure, from 48.8% in 2017-18 to 39.4% in 2021-22, the dominance of the private sector, the rising fragmented regulation, and geographic disparity between urban and rural services continue to make healthcare not just expensive, but deeply inequitable. As a result, healthcare in India remains more of a consumer good than a guaranteed right.
However, as India moves forward to achieve the Universal Health Coverage (UHC), the question is no longer whether reform is needed, but how urgently we can reimagine healthcare as an affordable, quality public service rather than a privilege.
Making healthcare accessible to all
Health dictates all other factors, leading to a country’s long-term growth and development. Promoting health and well-being is one of the 17 UN Sustainable Development Goals (SDGs) in the 2030 Agenda for Sustainable Development. While private healthcare services continue to promise world-class healthcare services, India must prioritise affordable healthcare services to the last mile. In this regard, our ‘Smile on Wheels’ programme sets an example of transforming healthcare services, such as delivering health services to India’s undeserved communities and rural areas, which house more than 65% of the population.
‘Smile on Wheels’ are custom-tailored mobile medical unit vans armed with modern equipment, with doctors and qualified nursing attendants on board, available to cater to the primary health needs of people in inaccessible areas. The programme provides free of cost doorstep consultation, medical tests like blood sugar and blood pressure, measuring weight and height and free medicines to the underserved. To date, 105 vans have been operational as fully equipped mobile healthcare units with doctors and paramedics, providing OPD services, point-of-care test facilities, medicines, etc.
These services and initiatives are key to addressing the crucial gaps in India’s healthcare services and supporting UHC and the government’s vision of Ayushman Bharat.
Ayushman Bharat: Reimagining India’s healthcare services
India’s healthcare industry is steadily gaining prominence through several recent health initiatives and programmes. The launch of the flagship Ayushman Bharat Program in 2018 has been a significant step in this direction. The primary focus has been its two main components—Health and Wellness Centres, which aim to improve primary healthcare services, and Pradhan Mantri Jan Arogya Yojna (PMJAY), which provides insurance for secondary and tertiary hospitalisation for the poorest 40% of the population.
As of September 9, 2024, the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) has significantly improved healthcare accessibility across India, with over 35.4 crore Ayushman cards empowering millions of families with health coverage.
Further, through the initiative, there has been a push towards developing an integrated and interoperable digital health infrastructure, with the launch of Ayushman Bharat Digital Mission, which is instrumental in reshaping the healthcare industry. Through this, Cowin, e-Sanjeevani, Arogya Setu, e-Hospital, and other digital healthcare projects have sped up development and improved healthcare delivery and accessibility.
These programmes seek to guarantee that affordable healthcare reaches every home and establish a strong healthcare environment with partnerships with the commercial sector, non-profits, healthcare entrepreneurs, and foreign partners. These partnerships have played a key role in advancing health equity nationwide, encouraging innovation in healthcare delivery, and increasing access to cutting-edge medical treatments.
However, challenges continue to remain large towards India’s affordable health services.
Dearth of primary healthcare services
Lack of a strong primary healthcare infrastructure remains one of the most significant challenges in India’s healthcare system. Data suggests that India has an average of fewer than 1.4 beds per 1000 people, much lower than the WHO-recommended threshold of 3.5 beds per 1000.
The government’s investment in healthcare is less than 2% of GDP, while the private sector’s expenditure is slightly less than 3% of GDP, both falling well short of the global average of 9.5% of GDP invested. The shortage of beds and lack of adequate funding pose a fundamental challenge in providing health and wellness access to the masses.
Poor accessibility to healthcare services
A greater difficulty is found in the glaringly unequal accessibility, particularly concerning the urban-rural divide. Bihar, for instance, has just 0.29 beds per 1000 people, while Karnataka has 4.2 beds per 1000 people. Only a few districts have tertiary or quaternary care facilities; significant disparities remain between districts even within states. People are deprived of timely care due to travelling great distances within and beyond the state.
Not enough trained frontline workers
In addition, the lack of qualified frontline health personnel worsens the persistent healthcare challenges. Although there are over 1.3 million registered allopathic physicians and 5,00,000+ registered AYUSH physicians nationwide, there remain gaps in primary healthcare services.
For example, the Community Health Centres (CHCs) lack between 74.2% and 81.6% of trained frontline health workers, with ASHA workers often protesting unfair treatment and gaps in payment. Similarly, an average of 3.3 million registered nurses nationwide still totals less than the required one-third doctor-to-nurse ratio.
The 3s: Availability, Accessibility, Affordability
Services designed in the Smile Foundation may help the above-mentioned situations, ensuring mobility to make primary healthcare accessible for people living in hard-to-reach areas, rugged terrains, remote rural areas, and tribal belts.
Along with curative, our focus has been on increasing awareness and promoting health-seeking behaviour in these communities. For instance, with the Smile on Boat mobile health project in South Salamara, Assam, we have modified our flagship Smile on Wheels project, with the same core objective.
Further, we believe that healthcare growth in India depends on taking care of its frontline workers, who form the backbone of a resilient health system. This was evidenced during the COVID-19 pandemic, where they were at the forefront of managing the pandemic despite the severe risk it posed to their health.
Our experience working with frontline workers reveals that investing in health workers is imperative, as they are central to last-mile service delivery and ensure comprehensive healthcare. To create resilience among primary healthcare providers, 23 training programmes were organised across India on First Aid, Nutrition, Health, Immunisation, Family Planning and Non-Communicable Diseases.
At a time when there has been a growing emphasis on public-private partnerships to fill in the gaps, there must be more syncronisation between the government and private sectors, with the support of NGOs, to strengthen India’s healthcare.
Smile Foundation continues to support government services by implementing a threefold strategy—availability, accessibility, and affordability—by creating service infrastructure support and health awareness. Its many programmes and telemedicine services bring essential health services to underserved regions. We also enhance public health facilities and builds sustainability into communities via training and awareness drives. These integrated efforts address both immediate and long-term healthcare challenges, especially for women and children in rural and marginalised communities.
Affordable Healthcare Requires Collective Will
The journey toward affordable and equitable healthcare in India cannot rest solely on policy blueprints or technological breakthroughs—it must be rooted in people, partnerships, and purpose.
Smile Foundation’s community-driven models like Smile on Wheels and Smile on Boat demonstrate that when innovation meets empathy, even the most marginalised can be reached. The path forward lies in scaling such integrated, inclusive approaches, strengthening frontline capacity, and forging deeper collaborations between the public, private, and civil society sectors. Healthcare should no longer be a luxury determined by geography or income. It must be a right, upheld for every Indian, every day.
