India: Towards Universal Health Coverage
Published January 11, 2011
This Series of papers on India’s path to full health coverage reveals that a failing health system is perhaps India’s greatest predicament. The papers in this Series 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. The Series brings together a rapidly growing body of evidence to show that Indian health is in crisis. As the country with the largest democracy in the world, India is well positioned to put health high on the political agenda.
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.
The Lancet, Early Online Publication, 11 January 2011
Securing the right to health for all in India
The debates around securing the right to health for all in India are at a complex and sensitive stage. In India, we have gross inequity in health-care delivery. The huge inequity is evident, on the one hand, in flourishing international medical tourism, and high-technology biomedical interventions done cheaply, and, on the other, minimum levels of health care being unavailable to those unable to pay.1
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.2 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.3 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.4 Actual progress in realising these goals, and particularly in achieving equity, has been extremely sluggish.5 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.
Any programme for the articulation of universal entitlements to health care has necessarily to base itself on public action and, more specifically, public finance. In this context, the recently prepared National Health Bill (2009) becomes relevant.6 The Jan Swasthya Abhiyan, the Indian chapter of the People’s Health Movement, had a major role in lobbying for and preparing the grounds for the draft bill, which for the first time addresses questions of equitable entitlements to essential health facilities, goods, drugs, services, and conditions for all, especially vulnerable and marginalised groups. The bill also mandates similar access to food, safe water, housing, and sanitation, and seems to recognise the social determinants of health. However, there are no clear guidelines in the text about actual and operational public responsibility for ensuring these lofty goals, nor a clear commitment to public financing to attain these rights. One becomes fearful, thus, that this is yet another addition to our national list of beautiful documents of intent.
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.7 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.
However, resources for hope do exist, even if not in the putative bona fides of state action. Instead, we note widespread challenges to the hegemony of the market, and the breaking forth of civil political action. Important changes have already occurred in the Indian scenario as a result, including a stronger public distribution system, laws about right to information, employment guarantees, and rights in forest areas. For health care, the Universal Access to Health Care Bill is already much debated. Such debates are strengthened by the presence, in the Indian Constitution, of the Directive Principles of State Policy,8 which enjoin on all of us the responsibility to ensure that all state action is directed towards the reduction of inequity. It is in these resources that the people of India must seek relief from their current impasse.