India – towards universal health coverage

The 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 – The potential for public debate to put health high on the political agenda is great. But health is rarely a decisive political issue in national or state elections. vast organisational and technological successes are taking place in a country that, according to a new Multidimensional Poverty Index (MPI) released earlier this year, has more poverty (421 million people in just eight states) than all of sub-Saharan Africa.
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? How credible are political parties in India in their stated commitments to health sector reform? Can those parties deliver on their promises? What are today’s effects of 250 years of colonialism on Indian health? What are the health expectations of a largely new and expanded middle class? Is India’s historical scepticism about technocratic solutions for its predicaments an impediment to health reform? Where is power located in India to make a difference for health? – Richard Horton, Pam Das (The Lancet)

Universal 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. Furthermore, we are encouraged by a vibrant economic climate that has propelled the nation into the ranks of middle income countries, and by the advocacy for health from civil society organisations that speak for people. The growing confidence manifest in bold social-policy initiatives (such as the Right to Information Act of 2005, the Right to Free and Compulsory Education Act of 2009, and the proposed Right to Health Bill) off ers an opportunity to revisit the case for universal health care.
India has one of the most fragmented and commercialised healthcare systems in the world, where world-class care is greatly outweighed by unregulated poor-quality health services. Because public spending on health has remained low, private out-of-pocket expenditures on health are among the highest in the world. Health care, far from helping people rise out of poverty, has become an important cause of household impoverishment and debt. The average national health indicators, though showing improvements in recent decades, hide vast regional and social 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. Between the early 1990s, when the process of economic reforms began, and now, the yearly per head consumption of food grains in the country has drastically deteriorated. The latest National Family Health Survey (2005–06) provided grim evidence of very slow improvement in infant mortality, persistently low rates of child immunisation, and shocking rates of malnutrition. 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. Public awareness of the need to end inequities in the health status and health entitlements of the people is not new. As early as 1946, the Health Survey and Development Committee set forth a vision of health services in India based on equity, universality, and comprehensiveness of care. Actual progress in realising these goals, and particularly in achieving equity, has been extremely sluggish. 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.
The final irony is that any recourse to public action and public finance is necessarily to be based on the manifest commitment of the state to the welfare of its citizens. In India today, such an assumption does not always appear tenable. The state, in its commitment to blind indicators of growth, stands before the people as the guarantor of widespread sequestration of resources in the hands of Indian affiliates of international finance capital. There is widespread displacement and disenfranchisement of citizens and, in large parts of the resource-rich hinterland of the country, loss of livelihood and loss of access to common property resources vitiates the right to health. It is difficult to fit this scenario into one in which public funds are being used for public welfare. – 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. Impediments to maternal health in India (eg, young marriage, and inadequate access to and control over use of family planning, contraceptives, and abortion services)6 are directly attributable to the low status of women and girls in society. Furthermore, young, rural, and poverty-affected women are most vulnerable. Improvement of this situation, in conjunction with improved delivery of health services, will be needed to change maternal health in the country. Too many Indian women and girls are unnecessarily affected by gender-based violence and inequities in health-care access and use. There is also inadequate female knowledge and autonomy to maintain good health and reproductive control. Universal health-care coverage, in the absence of gender empowerment to address these issues, will be of no use to millions of women and girls in India, leaving poor and rural women, and adolescent wives and mothers, who are in greatest need, without assistance. – Anita Raj (Department of Social and Behavioral Sciences, Boston University School of Public Health)

India: access to affordable drugs and the right to health – The right to health is covered by several international human rights instruments, including article 12 of the International Covenant on Economic, Social and Cultural Rights. Specific obligations are set out by General Comment 14, under which countries are bound to respect, protect, and fulfil the right to health and make good-quality services and goods available, accessible, and acceptable. Access to affordable drugs has been interpreted to be part of the right to health.
Competition from generic companies is the key to affordable drugs. The absence of patent protection for drugs in India from 1972 to 2005 allowed drug companies to use alternative non-infringing processes to manufacture generic 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. Low prices also allow India to provide free first-line antiretroviral treatment to 340,000 people with HIV in the country. The governments of developed nations, under pressure from multinational drug companies, are employing new ways to thwart competition from generic drugs. 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. The move to raise global standards in enforcement of intellectual property rights through the proposed multilateral Anti-Counterfeiting Trade Agreement (ACTA) will also deter generic competition. The agreement, purportedly a response to the global trade in counterfeit and pirated goods, negates the flexibilities available to World Trade Organization members under TRIPS with respect to enforcement of intellectual property rights. – 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. A review of the pharmacies in Karnataka showed that nearly half lacked a qualified pharmacist. However, there have been only 14 prosecutions since 2008. Drug price-control orders are routinely used by governments to ensure transparency, efficiency, and quality when buying drugs. However, such reforms are rendered useless if the system lacks good governance.
Karnataka’s Lokayukta (a statutory authority set up in 1984 to improve the standards of Public Administration) estimates that “nearly 25% of the health budget gets siphoned off due to corruption at various levels”. Dishonesty in health-service delivery is another major concern. Corruption has roots in many areas—from recruitment, to transfers, to promotions — and is found at all hierarchical levels, from low-paid workers to investigation offi cers. From childbirth to post mortems, informal payments often occur for all services in government hospitals and, most often, it is the poorest people who are most at harm because of power imbalances. – 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. Health-system research was more evident in public health research reports than in published public health papers. However, the scarcity of research about the routine health-information system in both reports and in published papers is concerning because it is crucial to track the response of the health system to the health needs of the population. Only one in four public health research reports were rated as being of adequate quality. The quality was higher for reports produced by collaborations between Indian and international organisations, indicating that there is merit in promoting such collaborations for more useful research output. An analysis has shown that evaluations of population level health interventions and policies in India are commissioned mostly by international organisations, suggesting that governmental organisations in India should pay more attention to commissioning evaluations of key interventions and policies. The study design and analytical approach were generally poor in these evaluations, a weakness that should be urgently addressed. – 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)

Universal 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. Equity, solidarity, and public good must be central even when insurance, partnerships, and other strategic recommendations are outlined. Without this directional focus many recommendations in the call would inadvertently enhance the commercial mobilisation of health care and the policy divide. 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. Otherwise, curative medical care will take precedence over provisions for wellbeing, including preventive medicine and health promotion. The call mentions these aspects only in passing and apologises for omitting the distal determinants of health due to space constraints, forgetting that these are basic health needs. Even success of the National Rural Health Mission, without links to the larger challenges of the right to food, water, and employment, will remain highly unlikely. Unsurprisingly, the call and Series fail to mention serious health challenges such as agrarian distress, including farmer suicide and childhood malnutrition, displacement, migration, and social confl ict relating to communicable and noncommunicable diseases. The call focuses too heavily on the top-down policy of universal insurance, autonomous councils, governance, and legislation, and fails to emphasise in a meaningful way the bottom-up policy of community involvement, civil-society engagement, and action on the social determinants, as well as confusing preventive public health systems with health care. – 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 call treads dangerous territory by asserting that India’s economic growth off ers an opportunity to address the serious inequities in health, rather than acknowledging that this economic growth is the basis of inequities in health in many ways. It is not only, as the call states, that “impressive economic growth in India…has not yet resulted in commensurate investments and health gains”. Rather, 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. For example, the explanation of what ails the health sector states that “Several adverse social determinants combine to corrode health of vulnerable populations”. However, 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. The word poverty is mentioned only as a consequence of ill health. Thus, although the call comprehensively lists acts of omission, it carefully steers clear of acts of commission. Its underlying premise, that economic growth stimulated by neoliberal policies can be translated into equitable sharing of resources, is fundamentally flawed. This premise severely compromises its recommendations, the most important of which is the need for integration of the private sector into a universal Indian health system.
In vast areas of rural India and in smaller towns, the private sector is mainly composed of unqualified practitioners or small medical practices that are struggling to survive. Nowadays, large private corporations have more influence than do public institutions and can overpower them if any attempt at integration is made, keeping equity indicators or the public good in mind. Recent attempts to impose legally binding commitments on private organisations to provide health care for poor people exemplify this power imbalance. Small practices and individual practitioners can at best make marginal contributions to an integrated system. Issues of regulation versus costs, quality, and rationality of care relating to both small and large health providers have not even been broached yet. The corporate-led private sector in India cannot be controlled by integration — it has to be confronted by being made to compete against a well resourced and managed public system that is run with public funds, rather than building public assets and infrastructure only in areas where the private sector does not exist. – Amit Sengupta, Vandana Prasad (People’s Health Movement-India [Jan Swasthya Abhiyan], Uttar Pradesh, India)

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