India has outlined its commitment to achieving universal health coverage and several states in India are rolling out strategies to support this aim. In 2011, Rajasthan implemented an ambitious universal access to medicines programme based on a centralized procurement and decentralized distribution model. In terms of the three dimensions of universal health coverage, the scheme has made significant positive strides within a short period of implementation. The key objectives of this paper are to assess the likely implications of providing universal access to essential medicines in Rajasthan, which has a population of 70 million. Primary field-level data were obtained from 112 public health-care facilities using multistage random sampling. National Sample Survey Organization data and health system data were also analysed. The per capita health expenditure during the pre-reform period was estimated to be ₹5.7 and is now close to ₹50. Availability of essential medicines was encouraging and utilization of public facilities had increased. With additional per capita annual investment of ₹43, the scheme has brought about several improvements in the delivery of essential services and increased utilization of public facilities in the state and, as a result, enhanced efficiency of the system. Although there was an attempt to convert the scheme into a targeted one with the change in government, strong resistance from the civil society resulted in such efforts being defeated and the universality of the scheme has been retained.

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For the last three decades, healthcare systems have been under pressure to adapt to a neoliberal world and incorporate market principles. The introduction of market-based instruments, increasing competition among health care providers, introducing publicly -funded private sector provisioning of healthcare through health insurance financing systems to replace public provisioning of health care, promoting individual responsibility for health and finally, the introduction of market relations through privatization, deregulation and decentralization of health care have been some common elements seen globally. These reforms, undertaken under the guise of increasing efficiency and quality through competition and choice, have in fact harmed the physical, emotional and mental health of communities around the world and also contributed to a significant rise in inequities in health and healthcare access. They have weakened the public healthcare systems of countries and led to commercialization of healthcare. This article presents three case studies of resistance, to the commercialization of health care, by the People’s Health Movement (PHM) and associated networks. It aims to contribute to the understanding of the way neoliberal reforms, including those imposed under structural adjustment programmes and some promoted under the Universal Health Coverage (UHC) paradigm, have impacted country-level health systems and access of people to health care, and bring out lessons from the resistance against these reforms.

On March 21, 2023, Rajasthan became the first state in the country to pass an Act implementing the right to health, titled "Rajasthan Right to Health Act, 2022" [1]. This is the realisation of a long standing demand of civil society groups and can be considered a landmark initiative by any state government towards guaranteeing "health for all". While the Act cannot be considered very robust, given some of its shortcomings discussed later, there is no denying that, if implemented in its true spirit, it will give the public healthcare system a huge boost, and lead to reducing out-of-pocket expenditure on healthcare, and safeguarding patients' rights. The trajectory of the Act and civil society involvementThe passing of the Act has not been smooth sailing, first with Covid-19 putting the entire drafting process on the backburner for almost two years; and then, the draft Bill being received with the most vehement protests in the country's history by doctors [2].Tracing its chronology, the major push for the Act came from civil society networks, especially from Jan Swasthya Abhiyan (JSA), Rajasthan, actively working in the state for health and health rights. JSA vigorously pushed for the Act, right from its inclusion in the 2018 state election manifestos of political parties, to later engaging with the newly formed government in the drafting of the Bill [3]. The first ever draft of the Right to Health Bill was, in fact, prepared by JSA Rajasthan and given to the government in 2019, based on which the state further developed its own draft -though a much diluted version -in March 2022 [4], and finally put it up in the public domain for suggestions. The private sector resistance to the Act had begun to grow gradually from then onwards.Considering suggestions from various organisations, groups and individuals, a modified version of the Bill was then tabled in the state legislative assembly on September 21, 2022 * which fuelled huge protests by private sector doctors. The Bill was then referred to a Select Committee for further deliberation. The Committee, after several rounds of consultations with the agitating doctors, incorporated most of their demands in the Bill and an amended version was then tabled in the Assembly on March 21, 2023 and passed [1].The private sector doctors, however, continued to protest against the Bill, demanding its complete withdrawal, condemning it as "draconian", "anti-patient", and completely hostile to the private healthcare sector in the state [5]. It was only after 17 days of vehement protests and complete shutdown of work by the private healthcare sector across the state that an agreement was finally reached between the government and the agitating doctors on April 4, 2023, with the protests being called off, and services resumed. The Bill received the Governor's assent on April 12, 2023.