Health Insurance, Assurance, and Empowerment in India
Please see the summary below of a Lancet report on the state of universal health coverage in India. The report highlights many of the shortcomings of the Indian health system, a system that fails hundreds of millions.
The report does not emphasize the success in catastrophic health coverage in central and South India. Many of the central and southern states do provide affordable, accessible health services to the majority of people, again to hundreds of millions. Many of these involve public private partnerships and work well. The central and South Indian universal health coverage systems are mostly for catastrophic health events that are best treated in hospitals. Many countries seek to learn from the Indian example. It is a tragedy that similar systems are not prevalent throughout India, especially in the northern states.
Access to primary healthcare services remains a serious issue throughout India, even in states with the most advanced programs for coverage of catastrophic health events. We at ACCESS Health are working to broaden access to universal health coverage within India and to work with cities and states of India to provide access to primary care in rural and urban settings.
In this issue of The Lancet, Vikram Patel and colleagues present a balance sheet of universal health coverage policy in India. They describe progress and the failures, identify seven challenges, and call for a “restructuring of India’s healthcare system” to implement universal health coverage. Their analysis is evidence based and the prescription reiterates the 2011 recommendations of the High Level Expert Group appointed by the government of India. But universal health coverage in India faces four questions.
The first question of whether India needs universal health coverage has been almost settled with a policy consensus in its favor under the name of universal health coverage or the National Health Assurance Mission. Second, is there a strong political will for the implementation of universal health coverage in India? The answer to this question remains doubtful. Successive governments have promised money equal to two to three percent of gross domestic product (GDP) for the public health sector; however, government health expenditure currently stands at 1.28 percent of GDP. While the national governments at various times have announced commitment to universal health coverage or the National Health Assurance Mission, public healthcare in states suffers from inadequate money, manpower, coverage, and quality. Although people badly need universal health coverage, there isn’t a visible, massive public demand for it. People in India generally do not view healthcare as their political right. What will generate the required political will?
The third, and most contentious, question is how best to supply and finance universal health coverage in India? Political and expert opinion is polarized around a tax financed, government run public health system or market driven private healthcare based on cash payment or private insurance – with various combinations in between. In their Comment in this issue, Bibek Debroy and Alok Kumar articulate the problems of efficiency and accountability of the public sector and remind us that India’s present healthcare system is largely a private one. But others question the ethics, cost, and quality of private healthcare in India. Private hospitals and doctors are often vandalized by dissatisfied relatives of patients who suspect malpractice. Can India’s private sector be relied upon to provide universal health coverage?
Ideologically based positions are likely to interminably prolong the debate and indecision about health coverage in India. It would be better to let the evidence of real practice decide how best to deliver universal health coverage. For such evidence to accumulate bold experiments are needed. The government’s Twelfth Five Year Plan (2012–17) recommends undertaking district pilots of universal health coverage. However, not a single district pilot has yet been started.
Public or private, both the visions of healthcare face the fourth question. With increasing life expectancy and the high burden of noncommunicable diseases, will a professionally delivered high tech model of healthcare generate new problems of healthcare dependence and unsustainable costs? The per person annual cost of such healthcare in the USA in 2013 was US$9,255 or 17.4 percent of GDP. How can India avoid this trap?
The ancient Indian understanding of health is very positive. The Sanskrit word for the healthy is swa-stha, one who is not dependent on others. This term denotes autonomy and freedom. Universal health coverage should not depart from this ideal. Moreover, social determinants and risk factors need attention. People in a poor district like Gadchiroli in Maharashtra annually spend substantial amounts on tobacco products—about seven times more than the annual expenditure by the government on rural healthcare in the district. Hence, universal health coverage should involve modification of individual lifestyle and also control of the social determinants of health. The Swachcha Bharat (Clean India) campaign, the international Yoga Day launched by Prime Minister Modi, and the ban on tobacco and alcohol introduced by some states are actions in this direction. Mobile phones, health apps, and the internet combined with the power of community offer new opportunities to empower citizens and families for health promotion and wellness. Community healthcare is an important part of health promotion. Home based neonatal care and nearly 860,000 community health workers in India called Accredited Social Health Activists (ASHA) offer a glimpse of this potential. The recommendation of the High Level Expert Group for two community health workers per village indicates this direction. The shortage of qualified healthcare personnel that Debroy and Kumar highlight in their Comment could be overcome more productively by deploying two million community health workers and by introducing a three year diploma in rural healthcare, rather than by training a small number of specialists at the six new tertiary medical institutes announced by the government of India in 2012.
While health insurance promises only financial protection, universal health coverage promises healthcare, and the National Health Assurance Mission is expected to promise health – obviously a more desirable and loftier vision. But both universal health coverage and the National Health Assurance Mission should be based on the foundation of empowering the people. The first step toward this goal can be to plan and implement two district pilots of universal health coverage or the National Health Assurance Mission in each state of India. A high level committee appointed by the government of Maharashtra state has already detailed a phased path to universal health coverage. What is missing is the action.