Prologue: Where We Left Off
In the first part of this series, “The Political Question: Who Owns Health?” (https://thinkinghealer.com/praxis-and-policy), we explored the moral and constitutional foundations of Universal Health Coverage (UHC). From Hobbes to Ambedkar, from Rawls’s idea of fairness to Sen’s notion of freedom, the argument was simple—health is not charity; it is citizenship expressed through care [7–9].
But moral legitimacy alone does not heal the sick. Between political philosophy and the hospital ward lies a terrain of bureaucracy, budgets, and broken systems—the terrain of praxis. This second essay begins there, where principle meets performance.
Introduction: The Gap Between Vision and Reality
India’s aspiration for universal health coverage is among the most ambitious globally. Launched under Ayushman Bharat, the Pradhan Mantri Jan Arogya Yojana (PM-JAY) promises health assurance of ₹5 lakh per family per year for over 55 crore citizens (the bottom 40% of the population, including seniors aged 70+ added in 2024) [1].
The architecture is revolutionary on paper: a cashless hospitalization scheme, a network of empanelled hospitals, and a digital backbone powered by the National Health Authority (NHA). The NHA said that by October 2025, more than 34.5 crore Ayushman cards had been issued and more than 9.19 crore hospitalizations had been approved, worth ₹1.29 lakh crore [1].
Yet, the National Family Health Survey (NFHS-5, 2019–21) and recent National Health Accounts (NHA 2021–22) reveal a stubborn truth—out-of-pocket (OOP) expenditure, while declining to ~39% nationally, remains 48–55% for specific services like institutional deliveries [2, 14]. The paradox persists: how can a country insure over half its population yet leave many vulnerable to financial distress at the pharmacy? The answer lies not in the what of policy, but in the how—how good ideas falter in practice, how moral intent gets diluted in design.
1 .Design Flaw—Insurance Without Infrastructure
PM-JAY was conceived as a demand-side intervention—money follows the patient. The logic: let citizens choose hospitals freely, and let competition drive quality. But the supply side—the availability of functioning, staffed hospitals—remains underaddressed. India’s doctor-population ratio has improved to ~1:900 (13.86 lakh allopathic doctors for ~1.44 billion people), nearing the WHO norm of 1:1000, yet rural shortages persist [12].
Over 38% of sub-centers and Primary Health Centers (PHCs) lack laboratory facilities; ~8–10% of PHCs have no doctor [12]. While PM-JAY covers hospitalization costs, empanelled facilities are often distant. Patients in Uttar Pradesh, Jharkhand, or Madhya Pradesh may travel 50–70 km to reach one—by which time emergencies often turn tragic.
2 .Governance Flaw—Central Design, Local Delivery
Health is a State List subject in India’s Constitution, meaning states handle service delivery. Yet PM-JAY is centrally designed and digitally driven [4]. The NHA sets package rates, claims protocols, and empanelment criteria, while State Health Agencies (SHAs) execute them—with varying capacity. Kerala’s SHA excels; Bihar’s remains understaffed. This asymmetry breeds inequity. Uniform package rates ignore regional cost diversity: a hernia repair in Mumbai cannot cost the same as in Motihari.
Private hospitals in urban areas often refuse PM-JAY patients, citing unviable rates and payment delays. In August 2025, over 650 hospitals in Haryana suspended services under Ayushman Bharat, citing unpaid dues of ~₹500 crore [6]. This dual control—central ambition, state execution—blurs accountability. When failures occur, Delhi blames states; states blame Delhi. The patient has nowhere to appeal.
3. Workforce Flaw—Policy Without People
No policy runs on paper alone; it runs on people. Yet India’s healthcare workforce crisis is chronic and moral. The Health Dynamics of India 2024 report shows ~30% of doctor posts vacant in public facilities; specialist shortages reach ~80% at Community Health Centers (CHCs) [12]. In rural India, a ‘24×7 PHC’ often means one doctor working 24×7.
When that doctor falls ill, the center shuts. There are no locums, no ambulance drivers after dark, and no replacements during festivals. Digital dashboards display coverage metrics, but they cannot substitute human presence. A nation that demands endless duty but offers little dignity cannot deliver humane care.
4. Finance Flaw—Money Flows, Meaning Does Not
India’s health budgets appear robust. The Union Budget 2025–26 allocated ₹99,859 crore to the MoHFW, an 11% increase from 2024–25 [13]. But financing without flow is stagnation. Funds move slower than illness. Private hospitals under PM-JAY face months-long reimbursement delays; public hospitals lack spending autonomy.
Package rates, last revised in 2021, lag behind inflation and rising input costs [5]. Kerala’s government health expenditure (GHE) is ~₹4,338 per capita (total ~₹10,000+ including OOP); Bihar’s GHE is ~₹1,497 [16]. Such disparities make ‘universal coverage’ rhetorical—one’s postcode determines access to care.
5. Data Flaw—Digitization Without Deliberation
India’s digital health revolution is real—but relentless. Schemes demand data uploads, claim entries, biometric logs, and dashboard analytics. Yet technology without purpose becomes tyranny by spreadsheet [4]. Doctors spend hours on portals instead of treating patients. Digitization has improved fraud detection but reduced human discretion. India still lacks a comprehensive health-data protection law—patient consent and privacy remain aspirational [14]. Data systems without deliberation amplify inequity; metrics without meaning erode morale.
6. Accountability Flaw—No Owner for Outcomes
Healthcare governance in India resembles a relay race with no finish line. Responsibility passes endlessly: from center to state, bureaucrat to contractor, and doctor to algorithm. When success is collective, accountability dissolves [3]. Unlike education or electricity, health lacks a citizen charter of enforceable rights. Rajasthan’s Right to Health Bill (2023) was a start but faced resistance from private hospitals, resolved by exempting ~98% of smaller facilities [12]. Universality is endorsed until accountability costs money.
7. Ethical Crisis of Implementation
Every moral ideal collapses when patients face humiliation. The poorest arrive clutching Ayushman cards, only to hear: ‘No beds.’ ‘Not under this package.’ ‘Come tomorrow.’ A system designed to protect dignity often erodes it through bureaucracy [9]. Empathy—the oldest technology of healing—is lost amid forms, screens, and transactions.
8. What Robust Implementation Would Require
True reform treats implementation as a continuous moral process [1]. Six shifts are essential: rebuild primary care (e.g., strengthen health and wellness centers); balance central design with state flexibility; make rural postings aspirational; publish payment timelines; measure continuity of care, not just claims; and institutionalize social audits and local health assemblies. Implementation is the ethics of policy. Without it, universality remains a word, not a world.
9. Interim Reflection—Praxis as Performance Under Constraint
Ambition is national, execution is local, and accountability is nowhere [3]. This captures India’s healthcare paradox. Grand plans from Delhi are implemented in overburdened district hospitals with leaky roofs and fewer staff than assumed. Each reform adds reporting layers but removes trust. UHC will succeed not with new budgets, but when old promises are reliably fulfilled.
10. Conclusion—Policy Without Praxis
India’s UHC journey reveals a sobering truth: good policy can fail ethically. Coverage is statistical; care is relational. We can insure millions and still fail to heal them if systems remain impersonal, hierarchical, and opaque [7–9]. Praxis—the act of doing—is where morality becomes measurable. Part 3 steps into the spaces of practice—the district hospital, the PHC, and the private clinic—to see how universality looks when lived.
“Ambition is national. Execution is local. Accountability is nowhere.”
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