“Between Policy and Practice: The Limits of Public Health Insurance in Achieving Universal Health Coverage in India”

Historically, the idea of Universal Health Coverage has been central to the imagination of Right to health and public financed health insurance has been envisaged as the most effective means to achieve the goal of “˜healthcare for all’. However, despite expansive health insurance schemes by central government of India, such as AB PMJAY, a significant gap persists between policy intent and healthcare accessibility, as out-of-pocket expenditure on healthcare remains very high. This paper critically examines how structural and socio-economic barriers hinder the realization of UHC through PHI in India. It aims to analyse policy-level gaps in the design and implementation of public health insurance schemes, and explore socio-economic factors that limit accessibility to state-provided healthcare entitlements. The paper is based on qualitative research work done over a period of six months analysing on-ground implementation of public health insurance in the state of Rajasthan in India. The data is mainly collected through Ethnography (field-based observations and in-depth interviews of many stakeholders in private hospitals) and analysis of major policy documents. The analytical approach here incorporates a rights-based and socio-legal framework to examine institutional accountability, inclusion, and equity in access. The study identifies multiple loopholes in PHI design such as inadequate empanelment of hospitals, exclusionary eligibility criteria, and lack of regulatory oversight. Simultaneously, socio-economic barriers like low awareness, digital exclusion, poverty, and backwardness further restrict uptake. The absence of enforceable accountability mechanisms renders health coverage more aspirational than actionable, especially for marginalised populations. It concludes that PHI in India, while ambitious in scope, falls short in practice due to design flaws and deep-rooted social inequities. Without addressing structural exclusions and embedding accountability within the system, UHC remains an unfulfilled promise. These findings call for re-imagination of health financing that centres equity, entitlement, and rights-based delivery, with implications for global health systems seeking similar goals.

Keywords: Health Systems and Universal Health Coverage (UHC), Universal Health Care, Public Health Insurance, Right to Healthcare