In the first three months of 2018, Venezuela’s economic crisis is not recovering as the political and humanitarian emergency are largely inflicted by the Government’s own policies. At the end of this year, the country’s GDP is expected to contract by double digits for the third consecutive year. Furthermore, the economic output fell by 16% in 2016, 14% in 2017, and is foreseen to drop by 15% this year. Meanwhile, after jumping from 112% in 2015 to 2,400% last year, inflation is expected to hit 13,000% in 2018.

Currently, the economic crunch has exacerbated the healthcare system disaster. If in 2016 the situation was dramatic, now it is even worse. As Maduro’s administration has stopped issuing bulletins on health, thus frustrating information retrieval, Venezuela’s Congress has asked doctors and hospital workers to report the situation of their institution.  Since the beginning of 2018, 104 public hospitals and 33 private clinics were surveyed across 52 cities in 22 states. The results highlight one of the most difficult challenges Venezuela physicians must face in their daily practice: the almost complete absence of tools universally found everywhere, such as X-rays (Rx) or CAT scans, necessary for a diagnosis.

Nutritional services are also in critical condition. Halted or working intermittently in 96% of all evaluated centers, there’s an alarming 11% increase compared to last year’s numbers. Infant milk formula is unavailable in 66% of all hospitals. Moreover, only 7,95% of Emergency Rooms in the country are working normally, most of them in private centers. Additionally, operation rooms aren’t doing any better, with 79,37% working intermittently and 15, 19% completely halted. Approximately 88% of all hospitals suffer a lack of basic medicines, a 10% increase compared to last year, and an astonishing 33% rise compared to 2014.

The lack of medicines and precarious living conditions have led to the emergence of diseases considered to be under control, such as malaria, diphtheria, measles and tuberculosis. As official data are not available, single institution data helps understand the trend of a specific disease. As such, two relevant tuberculosis centers in Caracas show that the amount of new patients who tested positive for tuberculosis has increased by 40% over the last year. Experts fear the same trend in the other municipalities and Country’s states.

The catastrophe is worsened by the high rate of emigration that is hitting all societal sectors. Since the beginning of the crisis, 2.7 million Venezuelans are calculated to have crossed borders towards Colombia, Ecuador, Brazil, Argentina and Trinidad and Tobago. A huge amount of doctors, healthcare specialists and healthcare workers left the country as well thus reducing the capacity of the healthcare system of addressing disease management and increasing the risk of the spread of epidemics.

Moreover, the high migration rate is affecting relationships with neighboring countries. Brazil and Colombia are sending extra troops to patrol frontier regions where Venezuelans have arrived in record numbers over recent months. Colombia, which officially took in more than half a million Venezuelans over the last six months of 2017, also plans to make it harder to cross the frontier or stay illegally in Colombia. Brazil said it will shift refugees from regions near the border where social services are badly strained.

Maduro’s administration is called upon to concretely face the situation. Concerns on the capacity and willingness to solve problems increase, as President Maduro is playing the blame game with Trump’s sanctions in order to explain Venezuela’s failure to recover. After Maduro held “illegitimate elections” in July 2017, the United States sanctioned him, making him one of four heads of state under sanction. Moreover, just a few days ago, the sanctions have been hardened because of Venezuela’s new currency, the Petro, a cryptocurrency that the U.S. government says intends to evade international penalties on the nation’s regime.

The order issued on Monday 19^th prohibits all transactions related to the Petro or other digital currencies issued to benefit Venezuela’s government.

International sanctions are leaving Venezuela without the economic power needed to pay for imports of food and medicine, but, on the other hand, the economic and social calamity is linked to an acute political crisis. In March of last year, the government of Nicolás Maduro deprived the parliament of authority since it was controlled by the opposition. On July 2017, about 7 million Venezuelans voted against the president, but the results were ignored and violent protests have caused more than a hundred dead and hundreds of injured and arrested.

Next May Venezuelans will call for a presidential election. There is no more time to spare. The cataclysm is in front of everyone’s eyes and the Government has to make concrete steps in order to recover the healthcare system and all the other sectors of society.

In the words of Nelson Mandela “We must use time wisely and forever realize that the time is always ripe to do right”. Probably, Maduro’s administration is not aware of this, but now or never, is the moment to be compliant with its people’s needs.

By definition Community Health Workers are individuals “carrying out the functions related to health care delivery [who are] trained in some way in the context of the intervention [but have] no formal professional or paraprofessional certificate, or degrees tertiary education [in a health-related field]”. Furthermore, the WHO states that CHWs “should be members of the communities where they work, selected by the communities, answerable to the communities for their activities, and supported by the health system but not necessarily a part of its organization.”

CHWs played an important role in working towards the health related Millennium Development Goals (MDGs). Their contributions extended from work on reducing child mortality and improving maternal health, to combating HIV/AIDS, malaria and other diseases. It seems likely CHWs will play an even bigger role in the Sustainable Development Goals (SDGs). As a recent editorial in the Lancet Global Health put it, CHWs seem to be emerging from the shadows (at last). The current SDG momentum around CHWs has a number of reasons. Among others, SDG target 3C explicitly asks governments “to increase health financing, and recruitment, development, training and retention of the health workforce”. CHWs also play a role with respect to other SDG goals and targets, not just the “health” SDG 3, and are already doing so in many settings. The deployment of CHWs is increasingly considered as a key strategy to respond to the scarcity of health personnel, particularly in low-income and middle-income countries (LMICs).  There is strong evidence that if appropriately and adequately trained and supported (and thus more or less part of the “formal” health system), CHWs can be effective in providing preventive, promotive and limited curative primary health care services  and improving health outcomes in LMICs, including in sub-Saharan Africa.

Almost 3,590 lives were lost during the 2014 Ebola outbreak in Sierra Leone. The epidemic devastated society, tearing apart families and communities with a health system ill-equipped to provide basic health services, let alone contain an epidemic of this scale. In such a situation, CHWs were fundamental to the activities undertaken to manage and contain the epidemic. Community health workers working with NGOs were deployed for contact tracing (defined as the identification and diagnosis of people who may have come into contact with an infected person), community sensitization, and promotion of epidemiologically and culturally appropriate protective practices, and data collection. They worked with community leaders, went house-to-house to provide information about Ebola, and search for active cases and contacts. They helped local religious leaders expand their education and outreach strategies, especially in efforts to minimize the risk of transmission during funerals and burials.

The Ebola outbreak presented a wake-up call on the implications of weak health systems, not just in poorer countries, but also for global health and the world at large. For Sierra Leone the epidemic was deadly with society still facing implications from the epidemic three years on. However, the epidemic also presented the country with some critical learnings, one of which being the recognition of the role played by CHWs during the crisis, and their fundamental contribution to a health system.

On February 2, 2017, Sierra Leone’s Ministry of Health and Sanitation (MOHS) launched the revised Community Health Worker (CHW) Policy, 2016-2020. The policy aims at formalizing the role of CHWs within the health system, and includes among others a shared CHW definition, selection criteria of new members, training, outlining the scope of their work, incentives and motivation. The 2017 presents a much clearer roadmap for CHWs as compared to the 2012 plan that was in place till now.

According to the 2017 plan, CHWs will focus on high-impact, cost-effective and evidence-based interventions that will reduce maternal and child morbidity and mortality, and improve maternal, newborn and child health outcomes. The plan expands the CHWs’ work to include the assessment and treatment of pneumonia, malaria, and diarrhea in children between the ages of two to 59 months and in adolescents. Additionally, CHWs are expected to practice infection prevention and control measures for their own safety and for the protection of their communities, with the scope to add more services under a particular program in a specific geographic area according to the context. In terms of remuneration, the new policy is clearer on the financial and non-financial incentives to CHWs, including those aimed at attracting new recruits. The 2017 policy on CHWs indicates that each CHW must receive Le100,000 per month (just over USD13) and monetary logistics support to reach areas where they have to work. Non-financial incentives, such as awards for an outstanding job, and opportunities to pursue career pathways in the health system for those who meet the minimum training requirements for other cadres, are also outlined.

The role of CHWs during the Ebola outbreak in Sierra Leone presents an interesting case on the scale-up of the position of CHWs in a health system. In Sierra Leone, the Ebola outbreak brought to light the importance of CHWs, and encouraged the health department to formalize their scope of work and remuneration. In other, similar low-resource settings, where health systems struggle to provide even basic care and face a chronic shortage of trained health workers, CHWs present a useful solution towards the provision of primary health care services, water and sanitation issues, behaviour change for health, etc. – particularly in the communities in remote areas.  CHWs can and do play a critical role in a health system, and it’s time that the international community focuses its attention on the formalization of CHWs. Slowly but gradually, that seems to be the case.

The year 2016 left in its wake an economic and political crisis in Venezuela which shows no signs of abating. Between 2015 and 2016, the GDP of the country went down by 18% and inflation is expected to exceed 1600% in 2017. The IMF predicts that the country’s economy will shrink by a further 6% in 2017. These are some of are the worst figures in the world, with the exception of Syria, and there’s no data for Syria.

Social programs such as “Barrio Adentro Mission”, a program seeking to provide comprehensive publicly funded health care, dental care, and sports training to poor and marginalized communities, are almost not working. The reasons for this can be many, ranging from the government’s dependency on unstable oil revenues to fund them, to highly centralized and politicized administrative practices, to inadequate training of the health care providers serving low-income areas. In addition, the program may be hampered by the protracted political stalemate between President Nicolás Maduro and the Venezuelan opposition and the failure of the Maduro regime to acknowledge the worsening health and nutrition indicators.

Every day the situation becomes more unsustainable. In response, more and more Venezuelans have decided their future is brighter outside of the country, resulting in an increased exodus of citizens. This could also be, in part, driven by the August reopening of the border with Colombia, which the Venezuelan government had closed two years before due to alleged security concerns. The collapse of oil prices has severely limited the country’s ability to pay for imports, causing shortages of basic household goods and impairing social services, including health services which are barely functional. By 2016, the country’s public hospitals faced shortages of medicines, basic equipment and even food shortages. Lack of electricity and radiology materials impaired the delivery of basic health services and more specialized services such as cancer treatment. It also resulted in higher out of pocket (OOPs) expenditure and the growth of the black market. If this isn’t bad enough, the poor conditions are encouraging qualified medical professionals to immigrate – approximately 15,000 doctors have already left the country between 2015 and 2016.

Along with previously tackled health issues, including maternal and child health, the country also faces new health threats such as Zika. There are approximately 60 confirmed cases of microcephaly in the population today with Venezuela’s Institute of Tropical Medicine estimating numbers to be higher – between 563 and 1,400.  The Venezuelan government, however, has not acknowledged a single case of Zika-related microcephaly in the country. Beyond health warnings and a handful of televised comments about Zika at the start of the year, the leftist Maduro government has largely kept quiet about the virus. Diphtheria, which was eradicated from the national territory 24 years ago, resurfaced, and in just six months 86 cases were recorded, with at least 200 documented by the end of last November. The Venezuelan government’s apparent denial of the resurgence of diphtheria has prompted confusion over the scope of the outbreak and renewed criticism of the Ministry of Health’s lack of transparency. A crumbling health system led to a 63.5% increase in the maternal mortality rate during the time of Maduro’s government.

The challenges facing healthcare and services do not end here. Venezuela was the first nation in the world to be certified by the World Health Organization for eradicating malaria in its most populated areas in 1961. Unfortunately, because of the economic turmoil, malaria has resurfaced in the country with 73,806 cases registered by end July 2016, and 180,000 by October 2016. Eighty percent of these are concentrated in the Bolivar State. Initially the spread of malaria was considered a state secret. The government did not publish epidemiological reports on the disease in the past year, and it said there is no crisis; now the data is too obvious to be denied. In addition, the Bengoa Foundation for Food and Nutrition, through its research projects, estimates that approximately       30% of Venezuelan children suffer from some degree of malnutrition. And if we add those who are at risk of malnutrition, the figure can rise to 40%. The situation forces Venezuelan families to give their children away in a last ditch effort to save them as severe food shortage is mounting.

The situation in Venezuela is getting worse by the day. The government has failed to ensure basic health services to its people. It has failed to provide the public health care system with medicines and supplies. Currency exchange rules and price controls interfere with the import of medicines and health care products, resulting in a grossly inadequate supply of essential medications and medical supplies. Possibly, Maduro is trying to mask the country’s stark state of affairs, but how long can he continue to do this? How many people would have to die before the Venezuelan government will take broad countermeasures? And yet, there is a faint glimmer of hope as global oil prices are rising again after the recent OPEC agreement but the ongoing failure of the Maduro administration to accept external aid to facilitate the population’s access to essential stuff is really putting a strain on the population.

Since the introduction of “Seguro Popular” in 2004, a system of public and voluntary insurance by the Government of Mexico, aimed to expand coverage of health services for low-income populations who are employed or are self-employed, and are not beneficiaries of any social institution, the Mexican healthcare system has made significant progress in insurance coverage. Since 2004, some 56 million people at risk of catastrophic expenditure on health now have access to health insurance and 93 out of 100 Mexicans have some kind of health coverage. Additionally, key parameters such as infant mortality and maternal mortality have improved. Furthermore, according to an OECD report, from 2003 to 2013 public investment in Mexico’s health system has risen from 2.4% to 3.2% GDP; in 2014, health expenditure was 6.3% of the GDP. Yet, doubts remain about how this money is invested and translated into health gains. Some indicators, such as Out of Pocket Payments (OOPs) or data about the quality of health services, suggest that the system is not working as efficiently as it could. For instance, about 45% of spending on healthcare and medicine is still OOP by patients and their families, often resulting in dire financial consequences.

Some fundamental reasons behind inefficiencies of the scheme have been attributed to the structure of the Mexican health system, which based on several disconnected sub-systems that provide different levels of care, at different prices and with different outcomes, thus producing marked inequalities in access and quality and reflecting socio-economic disadvantages.

This fragmentation is detectable in the health information infrastructure too. Finally, Mexico has started to build a national health information infrastructure for quality monitoring and the “Sistema Nacional de Indicadores de Calidad en Salud” (INDICAS) has published several indicators over the past decade. Additionally, a number of other initiatives are underway in the separate sub-systems. Despite an effort to collect data, their systematic use to improve care appears rare. Directly related to the weak information infrastructure, information about healthcare quality is relatively limited. In 2015, Mexico was able to report on only 8 out of the 52 indicators requested by OECD and their analysis gives cause for concern showing a low quality level of the services provided in the public system. Due to this, individuals quite often rely on the private system. In fact, more than 90% of Mexicans have some coverage in the public system, but millions of insured shun public hospitals and opt for private health, with subsequent purchase of medicine in private pharmacies, fueling exorbitant private spending.

Inequities are also reflected in the access to health among indigenous people, especially those speaking indigenous languages. A 2012 Health Secretariat report revealed that there are 485 municipalities in Mexico in which at least seven of 10 inhabitants speak an indigenous language. In those 485 municipalities, there are fewer doctors, fewer nurses, fewer health facilities, fewer hospital beds, fewer specialists and less medical testing equipment than in the rest of the municipalities. Besides the lack of personnel and supplies, in indigenous municipalities there are 10 times more medical interns in charge of health clinics than in other municipalities across the country. This also implies, that the poorest communities don’t just lack medicine and medical equipment they are also assigned often very inexperienced healthcare providers.

Despite these issues, an effort is being made to improve the system. A few months ago, on the 7^th of April, the President Peña Nieto signed the National Agreement about the creation of universal coverage of health services. The plan aims at gradually achieving health coverage for the whole population and at obtaining increased coordination among the federal institutions, the social security agencies and the healthcare service providers. As such, since last June, a patient can be treated in hospitals of the “Instituto Mexicano del Seguro Social (IMSS)”, of the “Instituto de Seguridad y Sevicios Sociales de los Trabajadores del Estado (ISSSTE)” and of the Federal and states health secretaries. This was not possible before.

Additionally, last month, the Mexican government signed two agreements with Canada and Germany towards improving the health sector. Both agreements aimed at facilitating the exchange of information on the regulation of therapeutic, pharmaceutical, biological products and medical devices and herbal products, cosmetics, controlled drugs and environmental health. In addition, the Governments will work together on areas such as quality of care, patient safety, health regulation and best medical practices, which will help to raise the level of care provided to the population.

Definitely, these are small steps; despite noteworthy achievements in expanding health insurance coverage to most of its citizens, with the introduction of the “Seguro Popular”, the Mexican healthcare system continues to face challenges to ensure that citizens have access to needed health services that is timely and of a reasonable quality. While the government is clearly dedicated in its efforts to improve access to healthcare for its people, accelerating efforts would enable many more to benefit from these efforts.

The issue of open defecation persists in India leaving millions vulnerable to disease. Is India’s Swacch Bharat Abhiyan (SBA) or Clean India Mission the solution to this deeply entrenched social and structural issue?

Train travel on Indian railways – one of the largest train networks in the world – offers a delightful view of the country. Early mornings offer warm tea, omelets in bread and first-row seats to a view of squatty-bottoms – of the millions who use the fields and other ‘empty’ spaces across rural and urban areas, often along railways lines, to complete their morning ablutions. Even the open toilets aboard the trains leave a proud trail of poo – one which is perhaps nothing, but a reflection of the (lack of) priority modern sanitation has traditionally received in the country.

Adequate sanitation is a basic human right. The lack of adequate sanitation exacerbates social inequities, increases vulnerability to disease, increases living costs, impacts a household’s ability to spend on education and nutrition. In fact, diseases caused by lack of hygiene and sanitation have a huge impact on people’s health and financial resources. The issue of sanitation is particularly pressing for a country such as India, which still has the largest number of people defecating in the open. Adequate sanitation is critical for a country which has expressed ambitious plans of economic growth and development, and yet continues to lag behind in terms of basic health and development indicators.

Some telling stats, perhaps. In 2011, almost 53% of households in India did not have access to toilet facilities, resulting in almost 595 million people defecating in the open. In China, Mao famously proclaimed “women make up half the sky”; Modi might want to consider an Indian version for his ‘Clean India Mission’ (see below) – something with “let’s clean up half the soil”, perhaps.  The implications of this range from proximity to feces and the risk of disease, vulnerability to snake and insect bites, and often as in the case of millions of young girls and women, vulnerability to sexual abuse. For example, every year, diarrhea kills 188,000 children under five in India. Even when diarrhea does not kill, it severely debilitates, making children susceptible to a host of conditions such as acute respiratory infection and chronic undernutrition. Further, recurring diseases impact household expenditure on health; they also have implications on other development objectives such as education and nutrition.

In the case of women and young girls, the need to access safe, clean toilets becomes even more necessary at the time of menstruation and pregnancy. In fact, 35% of schools do not have private toilets available, and only 55,7% of them had usable girls’ toilets in 2014. This has implications on the willingness of girls to attend school during menstruation. An estimated 23% of girls in India drop out of school when they start menstruating. Research data also suggest that pregnant women who are accustomed to open defecation are more likely to have premature delivery or give birth to an underweight baby than those who use toilets, issues perhaps linked to poverty and poor nutrition – issues which again tie in with access to sanitation and hygiene.

Title: Open defecation and contamination of water bodies (Original description: Many people defecate on the banks of the holy river. above is the line to the temple. Photo by Yaniv Malz in mid 2008.); Source: From Wikimedia Commons;  Author: The Sustainable Sanitation Alliance (SuSanA).  

But, this is not news anymore. At least not for the average Indian.

In recent years, there has been some progress, though. The percentage of urban population with access to sanitation facilities increased from 55% to 63% between 2001 to 2015, but much more muscle is needed as in rural areas only 24.7% of the households have access to sanitation. As already hinted at above, almost a year ago, the Indian Prime Minister, Mr. Narendra Modi launched the Swacch Bharat Abhiyan ‘Clean India Mission’ – a plan aimed to make India ‘clean’ by October 2, 2019. Eliminating open defecation is an explicit goal of the mission. For the moment, even though the central government has delivered toilets to 8 million households against a target of 110million, the campaign could fail to achieve its objectives.

Indeed, although important, infrastructure, i.e. constructing toilets is but one aspect of tackling the issue of sanitation and/or open defecation. You can build toilets, but this needs to go hand-in-hand with access to water, both for toilets and for hand washing etc.; access and money for soap, and of course intense behavior change communication strategies. Since the start of the campaign there have been plenty of efforts in the form of articles, radio jingles, television spots and others to increase awareness both on the campaign, as well as on sanitation and hygiene.  Changing habits and beliefs is not an easy task, though. Some widely employed methods such as the Community-led total sanitation-CLTS have had limited results. CLTS is an innovative methodology for mobilizing communities to completely eliminate open defecation (OD). Clearly, communities must be involved more. Prominent members of the community, men and women need to be brought in to design their programs, and implement strategies to improve use and access of toilets, reduce open defecation and adopt other practices for overall sanitation and hygiene. The Jharkhand’s case is very useful in this sense. In fact, the Government of Jharkhand has successfully established a workable strategy for creating and sustaining Nirmal Grams (clean villages) through a people-centred, participatory and demand-driven approach. This initiative aims to create Open Defecation Free villages through the construction of a functional toilet in every household. Having been successfully piloted in Gadri village, the initiative is being scaled up across the state, with convergence and community involvement as its underlying principles.

In India, even though states have engaged frontline workers for the Swacch Bharat Mission, there are no mechanisms yet for proper training, management, and supervision. These gaps make it difficult to achieve the levels of effectiveness needed at the central and local government level.   Earmarked investments for frontline worker recruitment are required. Earmarked funding is also needed to allow schools to implement sanitation workshops and programs as they are instrumental to better knowledge of the benefits of an open defecation-free society. Local governments should act in unison in order to improve awareness. In the end however, much like other aspects of health a multi-pronged approach involving health, education, information and poverty alleviation would be needed to improve sanitation related health indicators. Supplying toilets is just one face of the coin. Earmarked funding for frontline worker recruitment is required. What is a major asset to accomplish the ‘Clean India Mission’ is the – now obvious – political will. As such, it is good news that just a few days ago in the Uttar Pradesh State, the Gonda District Magistrate announced that government employees and officials without a toilet in their homes would be immediately denied salaries. The slogan “civil servants in India without toilets will lose half their salary” comes to mind. Might be a game changer.

This move unveils that changes are feasible and that the Indian government is producing bold efforts in the right direction even though a more comprehensive approach would likely result in gains well beyond those harvested so far. Anyway, the road taken seems good. Foreseeably, it will pave the way for India to tackle open defecation. Might make the train journeys a bit less romantic, perhaps… but this is the 21^st century.

Pietro received some editorial input from Radhika Arora (consultant).

Despite large improvements in recent years, basic health indicators continue to be poor in India. Life expectancy remains below countries at a similar level of development, at an average of 68,13 years in 2015; almost 40% of India’s children are malnourished. Wide inequalities exist in access to health services, service provision and health outcomes across states. Moreover, although the public health services, in principle, offer free basic health care services to all, publicly funded health services are weak and in poor condition, a reflection perhaps of insufficient public expenditure on health. The wide gap in public health services has resulted in a booming private health industry. Almost 80% of India’s people turn to the private health sector for their outpatient needs. Care in the private sector can vary dramatically in quality and cost. Out of pocket expenditure on health in India is high.

The achievement of UHC can be a solution to some of these issues and yet, India’s quest for UHC is a difficult goal to reach, despite the Central Government’s acknowledgment of universal health access as a priority. The National Health Mission (NHM) which succeeded the landmark National Rural Health Mission (NRHM) of 2005-2012, is a major step towards achieving UHC (as a component of the twelfth five-year plan 2012-17). In addition, less than a year ago, the government outlined steps towards universal coverage in its draft national health policy (DNHP). Yet, much more needs to be done to meet the health needs of both urban and rural populations.

The DNHP aimed to streamline the public health system framework by reorganizing expenditure for health by both the Central Administration and individual States; substantially reducing out-of-pocket payments (OOPs) through a restyling of the health sector financial and managerial systems; and bettering the performances of skilled health personnel through continuous education.

The plan also emphasizes three strategies aimed at dismantling the barriers to access by the disadvantaged and people living in places far from facilities; making special services available for the disabled and other vulnerable groups; and strengthening the monitoring and evaluation framework relevant to health targets.

Bridging the Gaps 

That’s what the plan encompasses, but to what operational extent and what will be the real impact? Unfortunately, judging from current progress “after all is said and done, more is said than done”, in the words of Aesop, a lot more needs to be done.

To begin with, there is the issue of adequate funding which is critical towards reforms. Almost a quarter of India’s population is unable to access health facilities due to financial barriers. In addition, major inequities in the availability and access of health services caused by geography (rural-urban) and socio-economic differences still persist; since health is a state subject in India, spending on health, health policies and outcomes, as well as other socioeconomic factors often varies across states. The Indian Government’s current health spending does not reach the much anticipated 2.5% of GDP (public health expenditure  is only 1,3% of GDP and the Government has ordered a cut of nearly 20%  in its 2014-15 health care budget due to fiscal strains). OOP expenditure is as high as 58,2% of total expenditure on health.

Private health care providers dominate service provision today, with public facilities providing only 20% of primary and community-based health care services. This presents challenges not just in terms of affordability, but also in the quality of services. Regulation of health services is an area which needs to be addressed urgently. With few barriers to entry and quality regulation that is barely enforced or limited to a small number of high end hospitals, a large number of private facilities are delivering services without the equipment and expertise for their work.

Trying to solve the private expenditure on health is an issue, also to improve people’s access to primary health services, and finance outpatient and hospital  tertiary care. One of the ways this is being addressed is through publicly financed health insurance schemes for hospitalization, such as the Rashtriya Swasthya Bima Yojana (RSBY), launched in 2008. As a result, health coverage increased from almost 55 million people in 2003-04 to nearly 370 million in 2014. Yet, the scheme only covers inpatient expenses  with a yearly ceiling limit of Rs.30,000 per family of five, per year (405€). In addition, the scheme is faced with issues  such as low awareness by beneficiaries; and refusal by private hospitals to provide services for a number of illnesses, while other services are over supplied. Reports of hospitals, insurance companies and administrators who have been culpable of fraudulent tactics, including  charging informal payments, are not wholly uncommon.

Call for an Operational Agenda

Some of the aspects of healthcare in India highlighted here are not new, nor unknown. Yet, it’s necessary to remind ourselves of the unchanging nature of health care in India. To illustrate just some of the challenges facing efforts to expand coverage and access to health care is the harmonization of policy intentions and program implementation.

Along with improved evidence-based policy, investments in public health should be streamlined following the 2012-2017 plans, along with earmarked grants related to the amount and quality of delivered services in order to align to the SDGs just adopted by the UN. The Government should invest more in public health and enhance mechanisms to ensure that people enjoy access to quality health services at all levels of care. Reducing OOP on health care for the people is critical as is well known from the literature – Chan et al have come up with the UHC agenda for a reason. Concurrently, an efficient monitoring scheme ought to be implemented to allow data and information to be at hand when needed from the Central Government and States, and make the policy making/implementation process easier while curbing inequities.

The Indian case is unique, especially if seen from a European – in this case: Italian – perspective. Even though it is one country, its geographical, religious, racial and other social characteristics are very diverse. The heterogeneity of its social, cultural and geographical context adds further layers of complexity and challenges for the development sector and in terms of health equity. But step by step, India can make progress towards universal health coverage for its 1.2 billion people. For UHC to become a reality, though, the Central Government and individual States must demonstrate “political will” – whatever that means – and mobilize sufficient resources. Unfortunately, today’s outlook shows that too many conflicting interests dilute the otherwise good intentions of Indian politicians.  The measures are written, it is high time for them to become operational!