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India’s march towards UHC: Where is the “political will”?

By Pietro Dionisio
on October 22, 2015

The path to Universal Health Coverage (UHC) is difficult for any country, but especially so for one such as India – a country struggling to provide even basic, essential care to its people; a  country where, even as UHC is exhibited as being a top priority, it risks being just a mirage.


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!

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