A universal health coverage in India-a possibility?


The global goal of “Health for all as a human right” could see India could striding to acquire universal health coverage by 2020. This goal is imperative for sustainable development and for alleviating poverty and social inequality. The National Rural Health Mission’s current strategies are broadly right and have already improved health outcomes and strengthened the public health system.


There have been measures taken towards providing universal health coverage. At the ground or village level, programmes to increase community engagement have included community health volunteers and village health and sanitation committees. The hospitals have designed ways of developing patient welfare committees and other innovations which include the mother and newborn survival scheme, health insurance for the poor, free generic drug supply scheme, and toll-free ambulance systems.


Equitable primary healthcare-the need of the hour is what India is trying to attain by deploying nearly 900 000 community health volunteers in the countryside, micro-planning of services, and the provision of mobile clinics and outreach sessions on health and nutrition are fast becoming the part of the Indian healthcare scenario. The integration of multiple vertical programmes under the auspices of the National Rural Health Mission has improved efficiency and health outcomes.


India should be able to afford universal health coverage with its consistent 7% economic growth rate in the past decade, despite the temporary setback to the economy through the current devaluation of rupees and a projected downfall of gross domestic product (GDP) to 5.3% in the year 2013-14.4


However, there are many obstacles to scale.  Some 22% of the world’s population lives in India, and the gap between the rich and poor is widening. In addition to poverty, there are the problems of communicable and non-communicable diseases.


Every fifth ailment goes undiagnosed. The mode of self-treatment is a common practice here, with many Indians delaying treatment or opting for services of cheaper informal medical practitioners who are locally available.


Apart from providing access to health services, universal health coverage needs a financing system to protect people from financial hardship through healthcare costs. Government spending on health is currently low (1.1% of gross domestic product (GDP) in 2008-09), so much of the costs of healthcare are shifted directly to patients. The World Health Organization estimates that out of pocket expenditure of more than 15-20% can lead to impoverishment; India’s proportion is 61%. This flies in the face of the hope that the state should ensure and guarantee universal health coverage for its citizens. 


It is estimated that to provide universal health coverage, a total of around 3% of GDP must be allocated to the health sector, with incremental increases reaching 6%. Additionally, it is vital to sponsor the healthcare of citizens from a “pooled resource” of mainly tax funds. It cannot be left to the inconsistencies of market forces or the contributions of mandatory or voluntary insurance schemes, which have a poor level of coverage so far.


We find that the country is inclined towards renouncing public responsibility for providing healthcare and relying on the uncontrolled, profit oriented private sector is unfortunate. The solution for an “inefficient poorly performing public health system” is not the much touted public-private partnership model, but a restructured and revived public system. This is more likely to last and to serve the interests of the poor.


It is viewed that partnership business models are skewed and are likely to benefit the private sector while weakening immensely, the public health system. With its potential for undermining the public health system, the system of “contracting in” or “contracting out” of private agencies must not be a permanent feature.


The role of media is also prominent in highlighting the corruption and inefficiency of the public health system. This in turn is fuelling support for the privatisation of health services rather than leading to efforts to rescue public health services. Yet privatisation has similar problems of inefficiency, quality compromise, exploitation of the naive, and lack of transparency and accountability to tax payers.


Universal health coverage calls for the decentralization of health planning and the allocation of resources to district and village levels. Communities must be empowered to take responsibility for healthcare, including monitoring with community and social audits. Concerns over the accountability of the private sector and quality of care must be dealt with, as exemplified by the recent compulsory registration under the Clinical Establishment Act.


Policy makers and technical experts need to agree on what universal health coverage should encompass. Ideally, it should include health promotion (including immunisation), disease prevention, primary and secondary level curative care, rehabilitation, palliative care, and cost effective tertiary care. Currently, secondary and tertiary level care are delivered mainly by the private sector. Community health centres and district hospitals administered by the government need to be strengthened substantially for specialist care. Over the past few decades, staffing has emerged as a problem, with shortages of medical and paramedical staff, as well as a lack of diagnostic services, drugs, and technologies.


Currently, India has 6.5 doctors per 10 000 people, less than half the global average of 14.2 per 10,000. These numbers vary widely between states, with Karnataka, Delhi, and Goa having a much higher proportion of doctors than Haryana, Bihar, and Uttar Pradesh. There are high vacancy rates for specialists in 4535 community health centres.


Despite India’s 355 medical colleges, there is a move to allow the private sector to open medical and nursing colleges to reduce the shortfall in skilled staff. But increasing the numbers won’t necessarily improve the distribution of healthcare staff, many of whom will probably migrate to urban areas or overseas. About two thirds of doctors already work in urban areas, whereas two thirds of the population live in rural areas. 


The cost of drugs could be reduced. This would require a national procurement programme and the supply of generic drugs, consumables, and diagnostics through a corruption-free, transparent, e-tendering process by an independent agency. Such a system was developed in Tamil Nadu and has spread to six other states.


The universal health coverage by 2020 will get relinquished if there is lack of political will, system inefficiencies, and poor fund allocation, rather than a lack of creative ideas and plans.