Health systems governance: Advancing universal health coverage in India through recognition of allied and healthcare professionals

Governance gaps undermining healthcare service delivery

   A recent directive from the Director General of Health Services (DGHS) concerning physiotherapists’ professional standing, despite its partial withdrawal, reveals how governance decisions can directly affect patient care, impact patient health outcomes, reduce the health workforce’s trust in the health systems, and hinder India’s progress towards Universal Health Coverage (UHC) (SDG 3.8). On 9th September 2025, the DGHS issued a notice casting doubt on physiotherapy professionals’ status, partially withdrawn on the 10th September, yet leaving lingering ambiguity. This unsolved issue affects the practitioners and affects patients like “Meena, a 68-year-old stroke survivor”, caught in the ripple effects of this governance gap. The incident highlights the need for a robust governance framework and clear statutory recognition to ensure patient care, health workforce confidence (SDG 3.c), and, importantly, for India’s aims towards UHC and Sustainable Development Goal 3 (SDG).(Health – United Nations Sustainable Development, n.d.; Health Systems Governance, n.d.; National Health Policy, 2017| National Portal of India, n.d.).

The foundations of care: The significance of the NCAHP Act for physiotherapy

  The National Commission for Allied and Healthcare Professions (NCAHP) Act of 2021 lays the foundation for statutory authority for allied and healthcare professions, including physiotherapy. This framework protects professional dignity and public trust by safeguarding physiotherapists’ recognition and standards from arbitrary evaluation. It provides standardized criteria for physiotherapy education, certification, professional development, and improved quality of care for patients. Additionally, it gives physiotherapists the legal confidence to offer evidence-based treatment and practice capability.(Home Page – National Commission for Allied and Healthcare Profession, n.d.)

Fragilities in health system building blocks

   The World Health Organization (WHO) outlines health systems in terms of six primary building blocks.  A governance lapse like the DGHS notice could challenge India’s health system and weaken these building blocks.(Health Systems Governance, n.d.). This notice on physiotherapy illustrates significant fragilities across the WHO framework, such as fragmented service delivery (SDG 3.8), a strained health workforce (SDG 3.c), and escalating patient costs (SDG 3.b, 3.8).(Health System Building Blocks, n.d.)

A demoralized health workforce: Ambiguity in professional recognition can diminish confidence challenge health workforce retention, and contribute to brain drain, especially in rural areas (SDG 3.c) (Health System Building Blocks, n.d.).

Fragmented service coverage: Regulatory gaps can interrupt Non-Communicable Diseases (NCDs) care continuity, weaken multidisciplinary teams, and lead to poorer patient outcomes, higher disability, and increased hospital readmission (SGD 3.8) (Health System Building Blocks, n.d.).

Increased financial burdens: Underutilizing physiotherapy creates a dual financial strain, with patients facing higher out-of-pocket costs and more expensive treatments. At the same time, the health system may not fully leverage a cost-effective method for managing long-term chronic diseases (SDG 3.b, 3.8).(Health System Building Blocks, n.d.).

Governance barriers to patient access to physiotherapy
  Levesque et al.’s framework conceptualizes healthcare access as the ability of patients to recognize their healthcare needs, seek services, reach and utilize them, and ultimately have those needs met. The framework identifies five key dimensions of healthcare accessibility: approachability, acceptability, availability, affordability, and appropriateness, each interacting with patients’ capabilities to enable effective access.(Levesque et al., 2013).

• Approachability: Ambiguity over the legal recognition of physiotherapists can diminish public trust and discourage patients from seeking care(Levesque et al., 2013).
• Acceptability: Limited awareness of the physiotherapist’s role in patient care may make patients hesitant to engage with these services(Levesque et al., 2013).
• Availability: Workforce instability and professional ambiguity may deter physiotherapists from practicing in smaller towns or communities, contributing to gaps in service and “care deserts(Levesque et al., 2013).”
• Affordability: Restricting access to physiotherapy can increase patient treatment costs, raise out-of-pocket expenses, and slow progress toward Universal Health Coverage(Levesque et al., 2013).
• Appropriateness: Unclear recognition of physiotherapists can perpetuate a doctor-centric model, undermining their integration into multidisciplinary teams to manage NCDs (Levesque et al., 2013).

“Meena’s experience highlights the practical impact of higher healthcare costs that can result in interruptions in therapy and may lead to long-term disability.”

Physiotherapist’s role in addressing India’s NCD burden

   India faces a rising burden of NCDs, and physiotherapists play a vital role in the management of these diseases. NCDs significantly impact lower-middle-income nations like India, making physiotherapists critical in tackling this burden.(Disease Burden Initiative in India, n.d.).

• Stroke:   According to the Global Burden of Disease study (GBD), India faces a substantial burden of stroke, which ranks as the fourth leading cause of death and the fifth leading cause of disability in the country, with an incidence rate that varies from 119 to 145 per 100,000 population annually(Behera et al., 2024)
• Diabetes: Diabetes is a significant public health challenge for India, resulting in high morbidity and mortality. Data from the Global Burden of Disease study indicate that the incidence rate of diabetes in India has increased from 163 to 264 per 100,000 population between 1990 and 2021, creating a burden on the Indian health system(Chauhan et al., 2025).
• Osteoarthritis (OA): Moreover, the GBD study shows that the number of people living with osteoarthritis in India has increased from 23.46 million in 1990 to 62.35 million in 2019, making it one of the leading causes of disability in the country(Singh et al., 2022). Nearly 47% of older adults in India are affected by OA.(Daniel et al., 2025).

   In chronic care, physiotherapists are crucial in prescribing exercises, managing pain, improving functional health through rehabilitation, and providing lifestyle education. These interventions support effective management of chronic conditions and enhance patients’ overall quality of life. This will also help to achieve SDG targets 3.4, 3.a, 3.b, 3.c, and 3.8(Health – United Nations Sustainable Development, n.d.; Indian Public Health Standards :: National Health Mission, n.d.; National Health Policy, 2017| National Portal of India, n.d.).

Integrating physiotherapy services into rural primary healthcare systems

  Two critical measures can improve the role of physiotherapy in India’s primary healthcare system. 

• Early identification and intervention: Integrating physiotherapists into primary health care (PHCs) can improve screening programs for at-risk adults and children, allowing for more timely treatment and reducing long-term disabilities. 
• Proactive NCD and disability prevention: Physiotherapists can oversee structured exercise programs for musculoskeletal and heart health and conduct disability screenings to avoid severe impairments by implementing a preventative care approach in PHCs.

  These initiatives are critical because they raise awareness of the benefits of physiotherapy, which is still underutilized in rural India (Home Page – National Commission for Allied and Healthcare Profession, n.d.; Indian Public Health Standards :: National Health Mission, n.d.; National Health Policy, 2017| National Portal of India, n.d.).

Recommendations on governance or policy

• Reconfirm the statutory authority of the NCAHP: Issue, through the NCAHP, any requests for allied & healthcare professions to address legal ambiguity (SGD 3.c). 
• Recommendations around primary care staffing: Develop clear regulations around staffing for physiotherapists at Primary Health Centres (PHCs) to ensure patients receive appropriate and quality rehabilitative services (SDG 3.8).
• Establish inter-professional collaboration: Groups such as joint task groups or training programs with physiotherapists working alongside physicians and other health professionals. 
• Start public education campaigns: Educate communities about physiotherapy’s role in care, involving many vulnerable patients with chronic illness (SDG 3.a).
• Develop digital health solutions: Invest in providing tele-rehabilitation programs to provide appropriate physiotherapy in some remote & underserved locations (SDG 3.4, 3.b)(National Health Policy, 2017| National Portal of India, n.d.).

Conclusion

  India is at a turning point for healthcare governance. Acknowledging physiotherapists as essential health professionals under NCAHP is critical for patient care, workforce retention (SDG 3.c), and delivering cost-effective physiotherapy services in rural and underserved communities (SDG 3.8, 3.b). Incorporating physiotherapists into multidisciplinary teams ensures that patients like Meena receive complete care, bringing India closer to achieving Universal Health Coverage (SDG target 3.8).

 

References

Behera, D. K., Rahut, D. B., & Mishra, S. (2024). Analyzing stroke burden and risk factors in India using the Global Burden of Disease Study data. Scientific Reports, 14(1), 1–18. https://doi.org/10.1038/s41598-024-72551-4

Chauhan, S., Khatib, M. N., Ballal, S., Bansal, P., Bhopte, K., Gaidhane, A. M., Tomar, B. S., Ashraf, A., Kumar, M. R., Chauhan, A. S., Shabil, M., Jena, D., Bushi, G., Satapathy, P., Jain, L., Jaiswal, V., & Pant, M. (2025). The rising burden of diabetes and state-wise variations in India: Insights from the Global Burden of Disease Study 1990–2021 and projections to 2031. Frontiers in Endocrinology, 16, 1505143. https://doi.org/10.3389/fendo.2025.1505143

Daniel, R. A., Kalaivani, M., Aggarwal, P., & Gupta, S. K. (2025). Prevalence of knee osteoarthritis among elderly persons in India: A systematic review and meta-analysis. Journal of Family Medicine and Primary Care, 14(5), 1675–1684. https://doi.org/10.4103/JFMPC.JFMPC_1254_24

Institute for Health Metrics and Evaluation. (n.d.). Disease burden initiative in India. Retrieved September 14, 2025, from https://www.healthdata.org/research-analysis/health-by-location/disease-burden-initiative-india

National Health Mission. (n.d.). Indian Public Health Standards:: National Health Mission. Retrieved September 14, 2025, from https://nhm.gov.in/index1.php?lang=1&level=1&sublinkid=284&lid=154

Government of India. (n.d.). National Health Policy, 2017 | National Portal of India. Retrieved September 14, 2025, from https://www.india.gov.in/national-health-policy-2017

United Nations. (n.d.). Health – United Nations Sustainable Development. Retrieved September 14, 2025, from https://www.un.org/sustainabledevelopment/health/

World Health Organization. (n.d.). Health system building blocks. Retrieved September 14, 2025, from https://extranet.who.int/nhptool/buildingblock.aspx

World Health Organization. (n.d.). Health systems governance. Retrieved September 14, 2025, from https://www.who.int/health-topics/health-systems-governance#tab=tab_1

National Commission for Allied and Healthcare Professions. (n.d.). Home page. Retrieved September 14, 2025, from https://ncahp.abdm.gov.in/

Levesque, J. F., Harris, M. F., & Russell, G. (2013). Patient-centred access to health care: Conceptualising access at the interface of health systems and populations. International Journal for Equity in Health, 12(1), 1–9. https://doi.org/10.1186/1475-9276-12-18

Singh, A., Das, S., Chopra, A., Danda, D., Paul, B. J., March, L., Mathew, A. J., Shenoy, P., Gotay, C., Palmer, A. J., & Antony, B. (2022). Burden of osteoarthritis in India and its states, 1990–2019: Findings from the Global Burden of Disease Study 2019. Osteoarthritis and Cartilage, 30(8), 1070–1078. https://doi.org/10.1016/j.joca.2022.05.004