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Universal health coverage in India, economic growth, and social justice

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The Lancet, 08-14 January 2011 issue, India health coverageThe Lancet has published, in its 08-14 January 2011 issue, a series of papers on India’s path to full health coverage. Taken together, the papers and comments show that a failing health system is perhaps India’s greatest predicament. The papers (pay only, the comments are free to read) reveal the full extent of opportunities and difficulties in Indian healthcare, by examining infectious and chronic diseases, availability of treatments and doctors, and the infrastructure to bring about universal health care by 2020. This Lancet issue with the India health coverage special brings together a rapidly growing body of evidence to show that Indian health is in grave crisis. As the country with the largest democracy in the world, India is well positioned to put health high on the political agenda.

Introduction to the Lancet Series – Indian health: the path from crisis to progress – Can India’s vibrant political process and civil society create the public demand for health reform? Do Indian health institutions — the Ministry of Health and Family Welfare and the health professions, for example — have the capacity to lead reform? In India, community identity rivals individual identity in importance. How do community identities shape attitudes and policies towards health? – Richard Horton, Pam Das (The Lancet)

The Lancet, 08-14 January 2011 issue, India health coverageUniversal health care in India: the time is right – India’s record in expanding social opportunities has been uneven. The health and nutritional status of children and women remains poor, and India is routinely ranked among countries performing weakly on overall health performance. But there is good reason for hope. The country has withstood the recent global financial crisis and quickly returned to rapid economic growth. There is a refreshing openness to participation by civil society and to the power of ideas to improve performance and governance. We are enthused by India’s recent commitments to invigorate the public health-care system to address health disparities. – Vikram Patel, A K Shiva Kumar, Vinod K Paul, Krishna D Rao, K Srinath Reddy (London School of Hygiene and Tropical Medicine, London, UK and Sangath Centre, Goa, India; UNICEF India; All India Institute of Medical Sciences; Public Health Foundation of India)

Securing the right to health for all in India – The health status of people transcends the health-care sector, and the social determinants of health, such as food, water, sewerage, and shelter, still elude large numbers of the poorest citizens in India. Inequity in social determinants of health and health care in a market-based system itself becomes a pathogenic factor that drives the engine of deprivation. These inequities are set to increase even further in the near future even as major investments are being projected and planned in the health sector from 0·9% to 3·0% of the gross domestic product. The stunted public health system is hardly geared up to absorb this increased allocation; already state governments are returning allocated money because of the inability to absorb increased allocations. – Binayak Sen (Christian Medical College, Tamil Nadu, India) (The Lancet writes: “One notable absentee from the launch of the Series on Jan 11, 2011 is paediatrician and Comment author Binayak Sen. He remains in prison, an appalling situation discussed in an Editorial in the Jan 8-14 issue of The Lancet.”)

Gender equity and universal health coverage in India – The findings presented on health-care coverage in India emphasise that maternal health concerns, such as fertility and maternal mortality, continue to affect large numbers of women and girls in India. Although these concerns are diminishing, present trends indicate that India is not on target to reach national and Millennium Development Goals. Too many Indian women and girls are unnecessarily affected by gender-based violence and inequities in health-care access and use. – Anita Raj (Department of Social and Behavioral Sciences, Boston University School of Public Health)

The Lancet, 08-14 January 2011 issue, India health coverageIndia: access to affordable drugs and the right to health – Competition from generic companies is the key to affordable drugs. Generic companies in India can therefore produce drugs at prices that are among the lowest in the world. This cost advantage means more than 89% of the adult antiretroviral drugs purchased for donor-funded programmes in the developing world are supplied by companies in India. The European Union and India free-trade agreement seeks to introduce TRIPS-plus and other measures, such as patent term-extensions, data exclusivity, increased border and enforcement measures, and investment protection agreements, all of which would impede generic competition. – Anand Grover, Brian Citro (Lawyers Collective HIV/AIDS Unit, Mumbai)

Good governance in health care: the Karnataka experience – The health sector, with high public interaction and large societal impact affecting almost the entire population, was the second most corrupt sector in India. Bribes related to health care comprised the highest portion of all bribes paid in the state of Karnataka in 2008, at 40%. More than 150,000 estimated households below the poverty line paid bribes for seeking basic health care in 2005 in the state. In 2008, 64% of all bribes paid in the state for basic services was by people living below the poverty line and amounted to INR650 million. – Hanumappa Sudarshan, N S Prashanth (Karuna Trust, Karnataka, India; Institute of Public Health, Bangalore, Karnataka, India)

Research to achieve health care for all in India – Many of the leading causes of disease burden across communicable diseases, non-communicable diseases, and injuries continue to be under-represented in this published research output, indicating that even among the limited papers on public health research, a large proportion do not address public health priority conditions in India. Distinct from published papers, an analysis of public health research reports produced in India also showed that the leading chronic non-communicable diseases and injuries were under-represented between 2001 and 2008. – Lalit Dandona, V M Katoch, Rakhi Dandona (Public Health Foundation of India, New Delhi, India; Institute for Health Metrics and Evaluation, University of Washington; Department of Health Research and Indian Council of Medical Research, Ministry of Health and Family Welfare, Government of India)

The Lancet, 08-14 January 2011 issue, India health coverageUniversal health care in India: missing core determinants – India’s growing economic strength is based on an economic model that has enhanced the very disparities that the call is concerned about. Promotion of medical tourism at the cost of universal primary health care has not been accidental, but the result of a policy that places the market above people’s basic needs. All health-care reforms have to respond to this political dichotomy in the economy of health. Any health-care reforms, including the national health bill and integrated national health system suggested, have to be placed within a national effort to provide food, water, shelter, sanitation, education, and other basic needs. – Ravi Narayan (Centre for Public Health and Equity, Society for Community Health, Awareness, Research and Action, Bangalore, India)

Towards a truly universal Indian health system – The current framework of economic growth is not designed to address the concerns of very large sections of the population, for whom it has directly perpetuated the situation of ill health and inadequate health care. This position is not one of mere semantics, since any sustainable recommendation needs to be set in an honest and robust analysis of the causes of ill health in India. Little mention is made of the severe, persistent, and near ubiquitous poverty that has characterised this era of so-called economic growth, in which 77% of Indians live on less than INR20 a day. – Amit Sengupta, Vandana Prasad (People’s Health Movement-India [Jan Swasthya Abhiyan], Uttar Pradesh, India)

Please see this page on the Lancet series for longer summaries of the comments.


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