Not everything about the United States is ideal for India to emulate—least of all its insurance-driven healthcare model, marked by skyrocketing costs and denial of basic health services to the poor and uninsured. Increasing claim denials, used by insurance companies as a strategy to boost profits, have led to endless litigations.
In India, the educated middle class and the wealthy can easily obtain insurance. But what about the large informal workforce—especially rural agricultural laborers, seasonal workers, partially skilled but mostly unemployed individuals, migrant laborers, and the urban poor? Are 36 crore Ayushman Cards and 31,000 empanelled hospitals sufficient to meet the health needs of 1.4 billion people?
The government has increased the PMJAY budget by another ₹2,000 crore, bringing it to ₹9,406 crore, and has allowed 100% FDI by venture capitalists in the insurance sector (up from 74% in 2021), without any government stake. Is this not an abdication of accountability by an elected democratic government?
We have better models to emulate closer to home—Thailand, for instance, operates a completely tax-funded public health system with community-based primary healthcare and a referral network for specialized care, aiming for universal coverage.
India, too, has laid an exemplary foundation for a robust public health system:
- 731 medical colleges
- 741 district hospitals
- 5,491 community health centers (CHCs) for specialized care
- 25,140 primary health centers (PHCs)
- 1.38 lakh health and wellness centers
- 1,56,101 sub-health centers
With this vast infrastructure, India need not rely on an insurance-driven, medicalized model of curative care. Such a model cannot ensure universal healthcare, nor comprehensive medical coverage for all. The Indian system’s underlying ethos has always been “communitization”, formalized through the National Rural Health Mission (NRHM) since 2005.
Are we now relinquishing our communitization agenda?
A significant milestone in India’s public health history was the introduction of the Target-Free Approach in 1996 by visionary Health Secretary Shri J.C. Pant. It marked a shift from centrally imposed targets to community-driven programming, based on local needs and priorities. This liberated health staff—from auxiliary nurse midwives (ANMs) to district medical officers and state supervisors—from the burden of numerical targets.
Before this shift, since the inception of national programs like Family Planning and Malaria Control, health performance had been assessed solely through targets and numbers—devoid of human focus, patient rights, service quality, or client satisfaction. The Target-Free Approach encouraged local adaptation, community involvement, and participatory planning.
Nearly a decade later, in 2005, the National Rural Health Mission (NRHM) was launched under Health Secretary Shri P.K. Hota and Joint Secretary Shri Amarjeet Sinha. It aimed to improve access to equitable, affordable, and accountable primary healthcare for rural and marginalized populations, especially poor women and children. The mission emphasized bottom-up planning, decentralization, and community participation—anchored in the communitization approach.
Key components of this approach included:
- Selection and training of Accredited Social Health Activists (ASHAs)
- Formation of the ASHA–ANM–Anganwadi Worker triad at the village level
- Establishment of Village Health, Nutrition, Water, and Sanitation Committees
- Creation of Rogi Kalyan Samitis at PHC/CHC and district hospitals
The goal was to ensure accountability, service quality, and client satisfaction.
This wasn’t a prescription from textbooks but an evolved process—first demonstrated in Chhattisgarh through a unique Civil Society–Government partnership, which led to the creation of the State Health Resource Centre (SHRC) in 2000.
SHRC Chhattisgarh pioneered the Mitanin program (meaning “friend of women”), selecting and training one community volunteer per 1,000 population—later adopted nationally as the ASHA model under NRHM. Over 15–18 rounds of cascade training, using innovative and locally adapted modules, Mitanins gained substantial knowledge and skills over two decades.
They conducted house visits, provided basic medicines from their “Dawa Peti” (medicine kit), mobilized mothers and children for immunization, diagnosed pregnancies, collected sputum and blood smears for tuberculosis and malaria, and administered treatment for TB and leprosy.
Their work was continuously mentored by Mitanin Trainers and district resource personnel. Remarkably, before NRHM’s launch, 25,000 Mitanins provided free services for nearly three years—their only reward being respect and recognition in their communities. With NRHM’s introduction, they began receiving performance-based honoraria.
SHRC provided technical support for project planning, budgeting, recruitment, and operationalization of First Referral Units (FRUs) for emergency obstetric and newborn care. It also helped establish the 108 Ambulance Emergency Transport System and organized policy workshops on malaria, tuberculosis, leprosy, and sickle cell anemia.
A Drugs and Equipment Procurement Corporation, modeled after Tamil Nadu’s system, was set up. SHRC also managed pilot projects and staff recruitment for NRHM, Urban Health Mission, and NACO.
Recognizing its success, the National Health Mission (NHM) encouraged other states to replicate the Chhattisgarh model. By 2019, 12 states had established SHRCs, and today 18 states have them. The National Health Systems Resource Centre (NHSRC) was later formed with similar objectives to support the Government of India.
In 2022, NHM raised the budget allocation for each major SHRC’s operating costs to ₹2.5 crore annually. The Union Health Ministry, in June 2024, issued a Framework on SHRC Operationalization, recognizing SHRCs as apex technical assistance bodies to help states with implementation research, monitoring, evaluation, and system development.
SHRC Chhattisgarh has pioneered these practices since before NRHM’s inception and continues to serve as a role model for sustainable, tax-funded healthcare aimed at universal coverage—not an American-style insurance model.
However, despite the Union Government promoting Chhattisgarh’s example, the irony is that the current state government has dismantled its own acclaimed model. Instead of encouraging independent, innovative thinking, it has restricted the autonomy of public health experts, pushing for a fully government-controlled setup.
If this continues, the ethos of communitization may be replaced by the ethos of profiteering, driven by venture capitalist models of healthcare. This would be a regressive step, detrimental to marginalized and underserved populations.
An urgent policy correction is both necessary and overdue.