By Mridula Shankar & Radhika Arora (EVs 2012)
Universal Health Coverage currently stands as the front-runner for the Health goal in the post MDG development agenda. India is at the crossroads. Are we going to prioritize health for all?
As the deadline for the achievement of the Millennium Development Goals (MDGs) is fast approaching, global, national and sub-national consultations are well underway for the development of a new global agenda for action. Notwithstanding the fair criticism that the MDGs have received, the progress that countries have made towards their realization has demonstrated that political commitment towards shared goals of human development can be sustained over time. The next phase of sustainable development is especially pertinent in an era where we are faced with the collective threats of environmental degradation, economic crises and growing social inequalities.
Health, no doubt, will continue to remain a priority and mounting evidence, the latest of which is the passing of the resolution on Universal Health Coverage (UHC) at the UN General Assembly, points to UHC winning as the global health goal. Among other aspects, establishing UHC as a desired target will: a) emphasize the significance of health and access to healthcare both as a precursor to and an outcome of development, b) serve as a shared aspiration for donor nations/regions and aid recipients alike, c) allow for greater versatility of fund usage based on burden of disease patterns within countries, d) focus on the development of robust sustainable health systems rather than the creation of targeted health programs alone.
A vision of UHC is of particular importance in the Indian context where a burgeoning healthcare crisis looms large. Since independence, the trend in health policy within the country has shifted gradually from the provision of free, universal care by the government, to the state being the chief financier of care (primarily through targeted insurance schemes for the poor) in a rapidly growing unregulated private healthcare market that provides the lion’s share of services. More recently, under the National Rural Health Mission (NRHM), the Indian government has made a concerted effort to promote primary public health care provision. Yet issues around weak governance, management and health workforce inadequacies have prevented the program from reaching its full potential. Overall, public expenditure on health stands at approximately 1.2% of GDP1 and hence unsurprisingly, 70% of healthcare costs are financed through out-of-pocket payments1 leading to catastrophic expenditures for households. Growing inequalities in health status are clearly evident across the various axes of economic class, gender and geographies.2 Finally, the country is faced with having to deal with the rising burden of non- communicable diseases (NCDs), whilst still battling an unfinished agenda of combating high rates of maternal and infant mortality and communicable illnesses. In short, the time is ripe for India to adopt a comprehensive framework for equitable healthcare provision in the form of UHC to promote health among its citizens.
In Oct 2010, the Planning Commission (PC) of India constituted a High Level Expert Group (HLEG) with a mandate to provide a blueprint for the provision of UHC to all Indians. Set within a framework of rights, the report calls for increased public spending on health, the procurement of generic drugs, introduction of state public health cadres and increased community engagement in various aspects of healthcare management and delivery.3 Recognizing that equity and social justice are integral to any discussion on UHC, the importance of integrating cross cutting themes such as the social determinants of health and gender has been highlighted. Yet, the draft chapter on Health in the 12th Five Year Plan prepared by the PC, purportedly drawing on inputs from the HLEG report, was disappointing to say the least. The chapter itself deviated considerably from the framework set by the HLEG for UHC and lacked the essential elements that would constitute a roadmap to move towards such an ideal. Fortunately due to widespread criticism both within the health ministry and by civil society groups the PC agreed to re-examine the chapter.
While the Prime Minister has publically declared that Health would be given the highest priority in the 12th Five Year Plan for the country, there has been insufficient action on the issue, rendering the feeling that this is just empty rhetoric. However, given the recognition that the country has gotten as an emerging economy in the global arena of politics and diplomacy, there will be pressure for India to act in conformity with the global movement towards sustainable development. Hence, UHC as a post MDG Health goal might serve as a crucial driver in ensuring that Health truly gets incorporated into the long term political agenda of the country.
1. National Health Accounts India 2004-05. National Health Accounts Cell, Ministry of Health and Family Welfare. Government of India. Available at: http://planningcommission.nic.in/reports/genrep/health/National_Health_Account_04_05.pdf
2. Iyer, A, Sen, G and George, A. The dynamics of gender and class in access to health care: Evidence from Rural Karnataka, India. International Journal of Health Services. 2007; 37(3): 537-554.
3. High Level Expert Group Report on Universal Health Coverage for India. Available at: http://planningcommission.nic.in/reports/genrep/rep_uhc2111.pdf