First Step to Universal Healthcare: Making Diagnostics Accessible and Cheap

Diagnostics as the First Step to Universal Healthcare: A Neglected Cornerstone

India’s ambition of achieving Universal Healthcare (UHC) rests precariously on its diagnostic infrastructure—a crumbling foundation that remains unaffordable, inaccessible, and unregulated for millions. The government’s piecemeal efforts through Ayushman Bharat Health and Wellness Centres or the ICMR’s updated National List of Essential Diagnostics (NLED) are important but insufficient. Diagnostics are the crux; their neglect jeopardizes India's ability to deliver effective, equitable healthcare. Without accessible and cost-effective diagnostics, even the most robust treatment frameworks falter, disproportionately harming lower-income populations and rural India.

Diagnosing the Institutional Malaise: Legal Frameworks and Systemic Gaps

Universal Health Coverage (UHC) features prominently in India’s National Health Policy 2017, underscoring equitable access and financial protection. Diagnostics, however, make up less than 5% of India’s total health spending, despite their critical role in guiding over 60% of clinical decisions globally. The Prime Minister Jan Arogya Yojana (PM-JAY), India’s ambitious health insurance scheme, restricts its focus to inpatient care, excluding routine diagnostic tests entirely. This exclusion perpetuates financial hardships; diagnostics comprise 10-15% of out-of-pocket healthcare expenditure.

Compounding this are infrastructural voids. Only 12% of Primary Health Centres (PHCs) in the country have labs that meet minimum standards. Private laboratories dominate diagnostic services, but affordability remains a major barrier, with rural and marginalized populations disproportionately excluded. Quality assurance is another glaring problem—fewer than 2% of India's estimated 100,000 labs are accredited by the National Accreditation Board for Testing and Calibration Laboratories (NABL), leaving patients vulnerable to misdiagnoses and irrational treatments that often exacerbate their conditions.

The Argument for Prioritizing Diagnostics: Evidence and Impact

Timely and accurate diagnosis is a cost-effective multiplier in healthcare. It reduces the economic burden of advanced treatments by enabling early intervention, and it curtails the misuse of resources caused by misdiagnosis. Evidence from Rwanda underscores this: its community health worker model integrates basic diagnostic tools for early detection of diseases like malaria, significantly lowering mortality rates. Thailand's universal coverage scheme goes further by providing free diagnostics, driving down out-of-pocket expenses and improving health equity.

Diagnostics gain added importance in the context of India’s evolving health landscape. Non-Communicable Diseases (NCDs)—diabetes, hypertension, and cardiovascular conditions—now account for over 50% of morbidity and mortality. Yet India's diagnostic ecosystem remains focused on infectious diseases, neglecting routine screenings for NCDs and exacerbating long-term health costs. Initiatives like the NLED's inclusion of HbA1c tests for diabetes monitoring are welcome, but they require deeper integration into PHC-level services.

Technological innovations may offer solutions. Molecular diagnostics, tele-diagnostics (e.g., tele-pathology, tele-radiology), and portable devices have expanded diagnostic capabilities. Yet these innovations must reach underserved areas, aided by public-private partnerships for localization. Decentralized manufacturing, advocated by the G20 Health Working Group, can further reduce costs and dependency on imports. For instance, India’s successful scale-up of RT-PCR testing during COVID-19 demonstrates its capacity for technology diffusion, but similar action is needed for NCD-related diagnostics.

The Counter-Argument: Financial Realities and Systemic Tensions

Critics argue that foregrounding diagnostics in resource-constrained systems diverts funds from treatment and infrastructure. Administrative inertia and fiscal constraints make it unlikely that diagnostics—still seen as auxiliary rather than foundational—will receive their due. India's public health budget remains abysmally low, accounting for less than 3% of GDP in 2023, leaving little room to expand diagnostic services. Moreover, the focus on preventive healthcare doesn’t yield immediate, visible results, making investment politically unpalatable.

Yet, this critique ignores the cascading costs of exclusionary diagnostic practices. Delayed or inaccurate diagnoses inflate downstream expenses on tertiary care and long-term treatments, often placing enormous financial strain on low-income families. Further, improved diagnostics align with India's global commitments, including the SDGs, by reducing deaths from preventable conditions. Evidence from programs like free TB testing under the National Tuberculosis Elimination Programme shows that diagnostics can, indeed, coalesce with existing infrastructure to deliver measurable improvements.

Lessons from Abroad: Rwanda and Thailand

India’s diagnostic gaps stand in stark relief when compared to Rwanda’s low-cost community-based diagnostic framework or Thailand's universal coverage model. Rwanda employs community health workers armed with basic diagnostic tools to deliver early intervention in hard-to-reach areas. Thailand integrates free diagnostics into its UHC, reducing out-of-pocket expenditures while ensuring early detection of chronic and acute diseases. India's reliance on out-of-pocket financing—accounting for over 60% of healthcare expenditure—runs counter to these successful global examples.

Where Does This Leave Us?

Universal healthcare in India will remain aspirational unless diagnostics are democratized—made affordable, accessible, and reliable. This involves decentralized manufacturing, expanded insurance coverage, quality assurance via NABL accreditation, and workforce development. Without systemic interventions, disparities in healthcare access will persist, undermining India’s global aspirations and domestic commitments to equity-led development.

Preliminary Questions

• Q1: What percentage of clinical decisions globally are guided by diagnostic tests?
  (a) 40%
  (b) 50%
  (c) 60%
  (d) 70%
• Q2: The ICMR’s National List of Essential Diagnostics (NLED) includes diagnostic tests targeting which of the following conditions? (1) Diabetes
  (2) Thalassemia
  (3) Sickle Cell Anemia
  (4) Hepatitis B
  Select the correct answer using the code below: (a) Only (1) & (4)
  (b) (1), (2), (3), & (4)
  (c) Only (2) & (3)
  (d) (1), (3), & (4)

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