With public trust and political capital, India must seize the moment for health reforms: Robert Horton

INdia has a “ erst in a propagation” chance to transmute health care for 1.4 billion people, and Prime Minister Narendra Modi should “seize” the moment created by high public trust and booming economic growth to implement sweeping reforms, the editor of The Lancet medical journal said.Richard Horton’s direct appeal to the prime minister comes as he released a major commission report identifying poor quality care, fragmented delivery and governance failures as the main barriers to universal health coverage — barriers that have created conditions where hundreds of thousands are estimated to die from substandard healthcare by some estimates. Horton sat down with HT for an expansive discussion on the report ahead of its release on Wednesday.Horton said the convergence of public confidence, political stability and economic growth creates the perfect storm of conditions for major reform. “What are you going to do with all the money? You have a war chest,” he said, pointing to India’s 7%-plus economic growth — the world’s fastest among major economies. “This is a real golden moment: stable government, political capital, economic growth. My message to the prime minister is: Seize it.”He cited studies showing an overwhelming majority of Indians are “extremely optimistic” about their country’s future. However, he pointed to a striking “paradox” in India’s post-pandemic landscape. Despite estimates, such as the Global Burden of Disease study, placing India’s Covid-19 death toll at over 4 million—far higher than official figures—public trust has not eroded.“The public in India coming out of the pandemic is even more trustful of government than before,” Horton said, noting that in countries like the UK, such a discrepancy would have triggered massive backlash. “The data suggests the public has enormous trust in the government and commitment to the public sector. If you put those lines of argument together — optimism plus trust — the conditions in India for a pretty big transformation are really quite good.”.The Lancet Commission on a Citizen-Centred Health System for India, launched in 2020, is based on what researchers say is the largest household health survey conducted in India. The commission surveyed 50,000 households across 121 districts in 29 states to identify health system reforms.The report identifies uneven quality of care, inefficiencies in spending, fragmented delivery, and poor governance as the main barriers to universal coverage — a shift from previous assessments that focused on lack of political will or funding. The commission includes 26 experts from academia, civil society, and industry, co-chaired by Horton and Vikram Patel of Harvard Medical School.Horton pointed to the life expectancy differences between India and China, another nation with 1.4 billion people. “There is no good reason why Indians should be losing nine years of life compared with people living in China,” Horton said. “That’s an unacceptable difference.”.Among the report’s observations – a lived experience for most Indians – was the finding that Indians often bypass government primary care facilities to go directly to specialists or private providers. Horton called this behaviour “perfectly rational” given quality concerns.“If I had a sick child, I would want to go directly to a paediatrician too,” he said. “The public is behaving rationally.”.“The problem in India isn’t just access to care. It’s about the quality of care,” Horton said, describing the situation as a “real double whammy” where patients struggle to access the system, and once they do, face unregulated standards. He pointed to data from other scientific estimates indicating that 1.6 million people die every year in India specifically because of poor quality care.Test the doctorsTo address the quality crisis, Horton proposed India adopt mandatory re-licensing for doctors, similar to revalidation systems in the UK where doctors are assessed every five years.“You can’t just get the green light at 25 and then spend 40 years doing whatever you like,” he said, referring to what has been termed a “learning health system” in the report — which he admitted was “a sugar-coated way of saying: we are going to hold you accountable.”.The commission identified high levels of prescription errors and antibiotic overprescribing as key contributors to poor care quality.On the politically sensitive issue of traditional medicine practitioners — Ayurveda, Yoga, Unani, Siddha, and Homeopathy — Horton proposed integrating them into the system with clear referral pathways to advanced care, rather than demanding randomised clinical trials for all treatments.“I don’t want to be the colonial critic asking for randomised trials for everything,” he said. “There is a therapeutic relationship” that matters beyond clinical evidence.But he noted that referrals do not happen now “because there isn’t an effective primary healthcare system” to refer patients to. The proposal would make AYUSH practitioners part of a functional gatekeeping system rather than isolated practitioners.To ensure reforms do not fail like a similar 2011 report presented to then-Prime Minister Manmohan Singh, Horton said he would target publishing an annual “State of India’s Health System” report, modelled on The Lancet’s decade-long Climate Countdown that tracks 40-45 indicators.“Our mistake in 2011 was taking a very technocratic approach — experts telling the prime minister what to do,” Horton said. “This time we are saying you can’t have a top-down technocratic response. This needs to be citizen-led. The community has to demand these reforms.”.The Climate Countdown, published annually before UN climate meetings, helped shape global climate policy debates. Horton said the same model would apply to India’s health system — tracking progress, celebrating achievements, and identifying gaps. “The government knows that you’re not going away,” he said..A significant ingredient of any reform is demand. “In Britain, the NHS is always the number two issue in political debate after the economy,” Horton said, adding that the commission hopes healthcare becomes a central political talking point in India as well.The commission’s main recommendation calls for a high-performing, publicly financed and publicly provided integrated healthcare delivery system as the primary vehicle for universal coverage.