New Delhi:  Fragmented governance, weak accountability and a public health system organised around facilities rather than patients continue to undermine health-care delivery in India, the Lancet Commission on a citizen-centred health system has said, even as it acknowledges India’s steady gains in life expectancy and reductions in infant and maternal mortality.

The Commission notes that improvements in health outcomes have not been matched by comparable progress in how care is delivered. Persistent gaps in coordination and accountability, it says, limit access and quality and weaken public trust in the health system.

“The system remains organised around facilities rather than patients,” the report says, arguing that governance failures, rather than the absence of schemes, are now the principal constraint to achieving universal health care.

A central concern identified by the Commission is the lack of effective incentives in the public health system. High and unpredictable rates of health worker absenteeism, particularly in rural areas, combined with low effort even when staff are present, continue to affect service delivery.

Under the current structure, the report says, even intrinsically motivated providers may rationally limit effort. “Delivering better care simply attracts more patients without increasing their pay or resources,” it notes, creating little incentive for improved performance.

These conditions, the Commission adds, encourage many public sector doctors to maintain private practices, offer only basic services in public facilities, and focus their effort where compensation reflects performance. This dynamic, it says, helps explain why many patients, including low-income households, seek outpatient care from private providers despite higher out-of-pocket costs.

Building an effective universal health-care system on a foundation of publicly provided care, the Commission warns, will be difficult “without addressing these fundamental governance challenges”.

While endorsing the principle of greater community oversight, the Commission cautions that simply mandating such oversight is unlikely to be effective. Evidence from other sectors suggests that power asymmetries between citizens and highly educated providers, limited accountability tools, and the exit of affluent groups from public services weaken community control.

“As a result, those who have the power to improve public services are typically not users, and those who rely on public services have limited power to demand accountability,” the report says.

To make the health system genuinely citizen-centred, the Commission argues for giving patients real agency over where and how they receive care. A key step, it says, is separating purchaser and provider roles and ensuring that public financing follows the patient.

A practical way to do this, the report suggests, is to allow households to register annually with a primary care provider, public or private, with the government making a fixed, risk-adjusted payment per registered patient linked to a unique health identifier. “This would effectively create an annual voucher for primary care,” the Commission notes, initially targeted at low-income households and gradually expanded.

Such a model would reward quality and continuity of care, discourage unnecessary procedures, and strengthen accountability in public clinics by tying funding to patient choice rather than historical budgets.

The Commission also points to the potential for innovation in low-cost delivery models, including nurse-led clinics supported by telemedicine. Advances in electronic medical records, referral systems and remote consultations, it says, make it possible to improve quality and continuity of care, particularly for rural and underserved populations.

However, the report stresses that technology alone is not enough. “Realising this potential requires a financing architecture that incentivises managers to leverage technology,” it says.

While elements of this approach exist under Ayushman Bharat, they currently apply only to tertiary care. Extending a money-follows-the-patient model to primary care, the Commission argues, would allow such innovations to scale and improve cost-adjusted quality of care over time.

Recognising the complexity and path dependence of India’s health system, the Commission does not advocate a single, sweeping redesign. Instead, it calls for incremental reform and clearer prioritisation of recommendations.

To support implementation, the report suggests piloting integrated, whole-system reforms at the district level. Testing coordinated changes across financing, human resources, digital systems, public health functions and community engagement would allow governments to identify operational bottlenecks and develop realistic cost estimates.

If its recommendations are to be fully realised, the Commission concludes, reform must focus on governance, incentives and patient agency, not expanded spending alone.