Beyond the Public-Private Binary: The Need for Innovative Local Healthcare Delivery Models
In India, we think about public health as a binary—the public and the private. The government, historically, has been regarded as the key player in healthcare delivery. By default, government-delivered healthcare is considered good and optimum, whereas private healthcare is considered exploitative and expensive.
In reality, Central government institutions like AIIMS provide premium healthcare, but the quality and scope of healthcare services tend to decline exponentially at the state, district, sub-district, and primary care levels. Primary care clinics in particular continue to face problems like insufficient staffing, healthcare provider absenteeism, and medication shortages. The private sector has stepped in to address the unmet demand and to fill in the gaps, giving many Indians access to essential and advanced healthcare.
The healthcare model in India follows a basic structure: patients seek care at clinics, nursing homes, or hospitals, and receive diagnoses and prescriptions. The majority of patients pay privately for the services they receive, while a few receive government subsidies and, based on income eligibility, an even smaller number receive treatment free of charge at government hospitals. The number of people who have personal or employment-based health insurance coverage is limited.
The public healthcare delivery system in India is centrally designed, so there is little room for local customizations. It primarily focuses on infectious diseases through various disease-specific national programs. On one hand, this centralized healthcare delivery model has had astounding success such as the targeted and time-bound Pulse Polio campaign, which led to the eradication of polio from India. On the other hand, the National Tuberculosis Elimination Program, designed to address complex and fragmented diseases like tuberculosis, continues to fall behind on its indicators.
The disease burden—from rural to urban areas and from north to south—has been rapidly shifting from communicable diseases to non-communicable diseases. Ground-level action has been slow in responding to the rising prevalence of diabetes, depression, substance use, Alzheimer’s, dementia, and other related conditions. There has been an increasing recognition of the need to focus on strengthening the public health system to tackle non-communicable diseases and mental health services. But the speed of the response is slow, and the scale is inadequate. This poses a major challenge, especially as the Indian population ages.
There has been recent interest in public-private partnerships, but these efforts are mostly focused on diagnostics and are designed at the central or state government level. Local authorities do not have sufficient authority to implement the flexible, locally specific modifications required to adapt to community needs. The system continues to struggle with non-communicable diseases like diabetes, and hypertension and communicable diseases like tuberculosis, which require regular monitoring and continuous care coordination.
One clear example is the lack of access to long-acting insulin. Many patients who could benefit from insulin therapy are instead prescribed oral medications because government programs only provide coverage for insulin when patients are admitted as inpatients. During my MBBS internship at a leading government hospital in Maharashtra, I observed an unusual scenario: patients were visiting the emergency department twice daily to get their daily insulin shots. These patients genuinely needed insulin but weren’t allowed to take it at home —a routine practice worldwide. A condition that could be managed in an outpatient setting with at most one visit every month was forcing patients to go to the emergency department multiple times a day. Now, imagine the number of patients who need this care but never make it to the emergency department at all. Addressing these gaps requires hyper-local actions and strategies.
To serve India’s vast population adequately, the healthcare system must shift from a centralized, rigid structure to one that empowers local initiatives and collaborations. Rather than introducing more top-down programs, the focus should be on removing barriers to innovation and partnerships between NGOs, startups, etc. Providing district and sub-district health officials with decision-making autonomy would help facilitate more responsive care and allow for the rapid scaling of effective interventions.
India needs flexible, community-based healthcare approaches tailored to the specific needs of each locality rather than a one‑size‑fits‑all solution. For example, different districts could implement regular diabetes screenings, offer discounted diagnostic services, organize disease literacy events, or provide a varied selection of medicines to support better disease management. Local authorities should have the autonomy to choose interventions that work best in their communities and to partner with local organizations. In a country with over a billion people, healthcare solutions must be adaptable, community‑driven, and responsive to local needs. It is unrealistic to think that a government‑led healthcare system can meet the needs of the entire population. Therefore, the private sector must recognize the critical role it plays in improving access to healthcare in India and work toward providing quality care that does not leave patients bankrupt.
[Acknowledgment: I would like to thank Prem Panicker for his wonderful course 'Clear Editing' and for his insightful edits to the draft of this post as part of the course assignment.]