Professional Insight
India has achieved nationwide implementation of free diagnostic pathology services. The next challenge is to move from nominal availability to assured access: reliable networks, quality testing, timely results and diagnostics that genuinely reduce out-of-pocket expenditure.
Where we are — and what the next phase should focus on
Professional Perspective · Free Diagnostics · Health Systems · Laboratory Services
India’s Free Diagnostic Services Initiative has moved well beyond the question of whether free diagnostics should be part of public healthcare. The more important question now is whether diagnostic services are consistently available, quality-assured, timely and clinically useful at every level of care.
The Free Diagnostic Services Initiative (FDSI) was launched under the National Health Mission in 2015, with the objective of providing essential diagnostic services free of cost in public health facilities and reducing out-of-pocket expenditure. The original framework defined minimum diagnostic packages appropriate to different facility levels and covered laboratory medicine, radiology and other diagnostic services.
A decade later, the programme has substantial national reach. The Ministry of Health and Family Welfare’s 2024–25 Annual Report states that, as of 1 October 2024, free diagnostic pathology services were operational in all 36 States and Union Territories—24 predominantly through in-house delivery and 12 through PPP arrangements. CT services were operational in 34 States/UTs, while tele-radiology through PPP was operational in 14.
That is important progress. But national coverage on paper is not the same as assured diagnostic access for every patient.
India no longer has a single model of free diagnostics
One of the strengths of FDSI has been its flexibility.
States have adopted different combinations of in-house laboratories, hub-and-spoke networks, public-private partnerships, CT services and tele-radiology. Current NHSRC information illustrates this diversity clearly: Karnataka, for example, reports in-house laboratory services with PPP arrangements for X-ray/CT, while several other States use PPP models for laboratory services themselves.
This flexibility is necessary. A district hospital, an urban PHC and a remote Health and Wellness Centre cannot necessarily use identical operating models.
The policy question therefore should not be:
Which model is universally best?
It should be:
Which combination provides the most reliable, equitable and quality-assured diagnostic service in a particular health-system context?
That distinction becomes increasingly important as diagnostic networks mature.
The next frontier is the laboratory network, not the individual laboratory
The most recent operational direction is particularly significant.
The 2025 Operational Guidelines for Strengthening Laboratory Services under FDSI place considerable emphasis on hub-and-spoke laboratory networks, organised sample transportation, quality assurance, laboratory safety and rational diagnostic testing. They also distinguish between high-volume services that should preferably be strengthened within the public system and selected low-volume or specialised services that may appropriately be accessed through PPP arrangements.
This represents an important evolution in thinking.
Historically, diagnostic strengthening could easily become facility-centric: Does this PHC have an analyser? Does this CHC have a laboratory? Does this district hospital have a CT scanner?
A network approach asks a different question:
Can a patient entering any appropriate point in the public health system obtain the required diagnostic test with acceptable quality and turnaround time?
That may involve collection at one facility, transport to another, testing at a hub and electronic transmission of the result back to the treating clinician.
The unit of planning therefore becomes the diagnostic network, not merely the machine or laboratory room.
Free must also mean available
A diagnostic test can be officially included in the free package and still be functionally unavailable.
The reasons are familiar across health systems: equipment downtime, reagent stock-outs, lack of trained personnel, sample transport failure, delays in reporting, inappropriate equipment placement, incomplete maintenance arrangements or gaps in laboratory quality systems.
This is why the next phase of FDSI should move beyond measuring whether a test is listed as available.
We need to increasingly measure whether it is actually available when clinically required.
For a patient, the distinction is fundamental.
If a test is theoretically free but unavailable today—forcing the patient to obtain it privately—the programme has not achieved its financial-protection objective for that encounter.
The same principle applies to turnaround time. A free result that arrives after the clinical decision has already been made is of limited value.
Quality assurance must become inseparable from access
Expanding test menus is relatively easy to describe administratively. Assuring the quality of those tests is more demanding.
The current operational guidelines appropriately emphasise internal quality control, external quality assurance, laboratory processes and safety.
This needs to remain central.
Free diagnostics should never create a false choice between access and quality.
An inaccurate laboratory result can lead to unnecessary treatment, missed treatment, additional investigations and avoidable harm. A diagnostic service therefore becomes genuinely valuable only when availability is combined with confidence in the result.
Over time, monitoring systems should increasingly examine not only volume of tests performed but also indicators such as quality-control performance, proficiency testing, sample rejection, turnaround time and repeat testing.
Sample transportation is health infrastructure
One of the most underappreciated components of modern public diagnostic systems is sample logistics.
A strong hub-and-spoke system can dramatically expand access without reproducing sophisticated laboratory infrastructure at every facility. But the model succeeds only if specimens move predictably and safely.
Transport routes, collection schedules, cold-chain requirements where applicable, specimen integrity, tracking and reporting therefore become part of the diagnostic service itself.
In a networked system, the sample-transport vehicle is as operationally important as some of the equipment inside the laboratory.
This is especially relevant for rural and geographically difficult areas, where patients should not have to travel simply because the specimen needs to travel.
Technology should connect the diagnostic journey
The next stage should also be increasingly digital.
A patient’s diagnostic journey may involve registration, test ordering, specimen collection, transport, processing, validation, reporting and clinical action.
If these stages remain disconnected, programmes have limited visibility of where delays and failures occur.
Integrated laboratory information systems can potentially provide much more than electronic reports. They can help monitor test volumes, turnaround times, rejected samples, equipment utilisation, stock requirements and network performance.
Digitalisation should therefore not merely reproduce the paper register on a computer.
It should create management intelligence.
Outsourcing should solve a service problem, not substitute for system design
PPP has an important place within free diagnostics, particularly where specialised technologies, high capital costs or scarce expertise make universal in-house provision inefficient.
But outsourcing is a delivery mechanism—not the objective.
Whether services are provided in-house or through a private partner, government must remain capable of defining the service requirement, monitoring quality, verifying performance and protecting the patient’s entitlement.
The important question is not whether a test was performed by a public or private laboratory.
It is whether the patient received a free, timely, accurate and clinically usable result.
This is particularly important as States use increasingly sophisticated mixed models.
What should we measure next?
The evolution of FDSI may require an equally important evolution in its performance indicators.
Counting laboratories, machines and tests remains useful. But a mature programme should increasingly ask:
- What proportion of the prescribed test menu is actually available?
- How often are patients referred outside the free system?
- What is the median turnaround time for common tests?
- What proportion of samples complete the hub-and-spoke pathway successfully?
- How frequently are key analysers unavailable?
- Are internal and external quality-assurance requirements being met?
- Are results reaching clinicians in time to influence treatment?
- Are patients avoiding out-of-pocket diagnostic expenditure?
These measures move the programme from inputs and activity towards reliability and outcomes.
The insight: India has built the platform; now we need assurance
The first decade of Free Diagnostics established an important principle: essential diagnostics should form part of publicly financed healthcare rather than remain a major source of household expenditure.
India now has nationwide implementation of free pathology services, broad expansion of imaging services and multiple State-specific models for delivering them.
The current policy direction towards laboratory networks, sample transport, quality assurance and rational diagnostics indicates that the programme itself is entering a more mature phase.
The next transformation therefore may not be defined primarily by how many additional tests we add.
It will be defined by whether every promised diagnostic service becomes:
available, accessible, quality-assured, timely, connected to clinical care and dependable enough that patients no longer need to seek the same service outside the public system.
Free diagnostics began as an access and financial-protection initiative.
Its next phase should be about diagnostic assurance.