Universal health coverage for India

In 1946 the Health Survey and Development Committee for India recommended a health service that was “as close to the people as possible . . . with no individual failing to secure adequate care because of inability to pay.”1 Commitments were made to achieve this vision in 25 years, by 1971, but these are yet to be realised. A high level expert group on universal health coverage was instituted by the Indian Planning Commission in 2010 to revisit this ethical imperative. Its mandate was to create: a blueprint for human resources in health; physical and financial norms to ensure quality, universal reach, and access; crucial management reforms; pathways for constructive participation of communities and the private sector; systems to access essential drugs, vaccines, and medical technology; and a framework for health financing and financial protection. The committee also decided to examine the social determinants of health.2 Recently, after a year of gathering evidence and consultation that reviewed policy, process, and the complex nature of the Health for All challenge, the group has presented its findings and recommendations, all of which are highly commendable.2

The four elements that the expert group recommended should underpin the core principles of an Indian healthcare service were: “equitable access for all Indian citizens; affordable, accountable, and appropriate health services of assured quality; public health services that tackle the wider determinants of health; and government as guarantor and enabler, not necessarily the only provider of health and related services.”2

Guiding principles developed by the group in response to the public policy debate that preceded the report included universality, equity, empowerment, comprehensive care, non-exclusion and non-discrimination, quality and rationality of care, financial protection, protection of health rights that guarantee appropriate care and patient choice, consolidated and strengthened public health provisioning, accountability, and transparency.3 4 5

A review of 16 case studies from countries as diverse as the United Kingdom, Bangladesh, Brazil, China, Thailand, and Canada led to the inclusion of the following criteria: a tax based public financing with a single payer system and community participation, with citizen engagement in service delivery, governance, and accountability.

The group promoted a “health rights” framework and called for a paradigm shift from a market based healthcare model to a system that worked towards the goal of Health For All, which would require shifts in policy towards ensuring free essential drugs, a national health package, and quality assurance. Health councils in which patients and communities participate, mechanisms to redress grievances, an all-India public health framework, and a strategy to involve practitioners of traditional and complementary medicine were recommended.

Despite these laudable imperatives, however, the report lacks adequate engagement with ground reality in its recommendations that focus on “what and why” and not adequately on “how.” This may reflect the methodology, which comprised literature review and limited expert consultation rather than dialogue with stakeholders, providers of care, civil society, and communities within India’s large and diverse federal system. Notably absent is any mention of the mechanisms by which these new currents in policy will be put into operation within a national policy and economic strategy that has also consistently developed a “commercialised medical tourism” policy since the 1990s. In 1975 an expert report exhorted policy makers to create a viable economic alternative suited to India’s own conditions, needs, and aspirations.6 The recent report remains inadequately grounded in the current political economy of health in India, and without historical analysis its recommendations may serve as a placebo.

It is crucial to understand context and process when developing policy and mediating conflicts between the interests of patients and the community, medical professionals (public and private), drug and diagnostic industries, and the state (Narayan T. A study of policy process and implementation of the National Tuberculosis Control Programme in India [PhD thesis]. University of London, 1998). Funding for universal healthcare in India will attract a variety of similar conflicts of interests. The recent report does not deal with this matter and offers no suggestions for mediation and resolution of conflicts, and this limits it to a set of aspirational ideas.

Commercialisation and erosion of professional ethics are of concern in India as elsewhere. Regulation and improved governance are needed. Practical concerns—such as incentivising health providers to work in disadvantaged areas, ensuring that continuing medical education supports the goals of universal healthcare, and developing health promotion strategies that tackle health disparities—are examples of challenges that are not adequately dealt with by the report, which remains somewhat top down in its approach to offering financial and management solutions. A recent review highlighted the report’s silence regarding the private sector, which “commands the market,” and it pointed out that drug regulation and non-availability of high quality generics remain as challenges.7

On the positive side the report signals the beginning of a robust public debate. Furthermore, the Indian report is relevant to health sector reforms globally, particularly in the context of the current financial crisis. A review that compared health system changes in South Africa in the 1990s and recent reforms in the NHS in the UK highlighted common debates and challenges in these dissimilar health systems with respect to decentralisation, regulation, partnerships, community engagement, and strengthening the public health system amid ethical concerns and consequences of commercialisation.8 All these concerns are echoed in the Indian report.

Certain tasks now need urgent action. The Indian health package must be defined along with desirable norms and standards. Standard treatment guidelines and management protocols must be developed, along with mechanisms to redress grievances. Health councils need strengthening. Governance should be decentralised. Academics, researchers, and civil societies who believe in Health For All need to join with policy makers and health providers to keep universal health coverage high on the economic, social, and political agenda in India, and to promote progressive reform. Universal health coverage is an ethical policy imperative globally, and the challenge now is to get it right.