Elsevier

The Lancet

Volume 377, Issue 9767, 26 February–4 March 2011, Pages 760-768
The Lancet

Series
Towards achievement of universal health care in India by 2020: a call to action

https://doi.org/10.1016/S0140-6736(10)61960-5Get rights and content

Summary

To sustain the positive economic trajectory that India has had during the past decade, and to honour the fundamental right of all citizens to adequate health care, the health of all Indian people has to be given the highest priority in public policy. We propose the creation of the Integrated National Health System in India through provision of universal health insurance, establishment of autonomous organisations to enable accountable and evidence-based good-quality health-care practices and development of appropriately trained human resources, the restructuring of health governance to make it coordinated and decentralised, and legislation of health entitlement for all Indian people. The key characteristics of our proposal are to strengthen the public health system as the primary provider of promotive, preventive, and curative health services in India, to improve quality and reduce the out-of-pocket expenditure on health care through a well regulated integration of the private sector within the national health-care system. Dialogue and consensus building among the stakeholders in the government, civil society, and private sector are the next steps to formalise the actions needed and to monitor their achievement. In our call to action, we propose that India must achieve health care for all by 2020.

Introduction

The Lancet Series about India draws attention to the challenges affecting the health-care system of the world's second most populous country.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 With the impressive economic growth in India during the past two decades, the political commitment towards the social sector has increased but has not yet resulted in commensurate investments and health gains. Although substantial achievements have occurred in the improvement of population health in India in the 60 years since independence as shown by the doubling of life expectancy during this period, the health outcomes remain inadequate when India is compared with other countries that were at similar economic stages of development at the time of independence; preventable disease burden remains high; health care is far from equitable, accountable, or affordable; government health expenditure is very low and has risen only slightly during the past decade; and most spending on health care is paid out of pocket and is rising in cost. Thus, catastrophic health-care expenditures are a major cause of household debt for families on low and middle incomes; indeed, costs of health care are now a leading cause of poverty in India. The country's health system ranks as one of the most heavily dependent on out-of-pocket expenditure and private health care in the world. However, progress has occurred in the past 5 years with new commitments by central and state governments to correct some of these inequities and gaps in health care. The health system in India needs to be reconfigured if these commitments are to provide optimum benefits to the people.

The evidence presented in this Series shows the co-existence of substantial burdens of infectious diseases,1 reproductive and child health problems,2 nutritional deficiencies,2 chronic diseases,3 and injuries.3 India still has unacceptably high infant, child, and maternal mortality rates, and high numbers of premature deaths that are attributable to chronic diseases. The burdens of disability are further worsened by unrecognised and inadequately treated mental illness and the increasing toll of intentional and unintentional injuries. Several adverse social determinants together corrode the health of vulnerable populations, whereas behavioural risk factors like smoking, oral tobacco consumption, and binge drinking of alcohol account for much death and disability. These burdens of ill health are inequitably distributed across geographical, social, gender, income, and educational strata, with substantial differences in health indicators between and within the different states in India. Caste, class, and gender are key factors that affect not just the occurrence of disease and ill health but also the likely outcomes. Individuals who are poor bear a disproportionate burden of death and disability. The threats to the health of the people of India are being further compounded by the rising risks posed by distal determinants—ie, unequal economic growth, unplanned urbanisation, water and sanitation crises, inequitable global trade, unhealthy trade policies, and climate change. We do recognise that multisectoral actions need to be initiated to favourably change the distal determinants to promote health and prevent disease, and hope that these will receive detailed deliberation in subsequent reports and action. This Series focuses on issues that need to be addressed to achieve a health-care system that ensures health care for all in India. Specific action within the health system can begin even while the more distal determinants are being addressed.

Key messages

We propose the following targets to be achieved by 2020 through the creation of the Integrated National Health System with three overarching goals: ensure the reach and quality of health services to all in India; reduce the financial burden of health care on individuals; and empower people to take care of their health and hold the health-care system accountable.

Service delivery

  • The entire population should be covered by an entitlement package of health care with financing from a combination of public, employer, and private sources. Full range of relevant diseases need to be included in the entitlement package of health services with cost-effective interventions that include health promotion and disease prevention.

  • All health practitioners and facilities in the public and private sectors have to be registered with the Integrated National Health System.

Health financing

  • Public spending on health should be increased from 1% to 6% of the gross domestic product, and 15% of tax revenues—including new taxes on tobacco products, alcohol, and food with little nutritional value—should be earmarked for this purpose.

  • Reduce the proportion of out-of-pocket spending from 80% to 20% of the total health expenditure.

  • Increase spending on health research to 8% of the health budget.

Human resources for health

  • Establish the Indian Health Service with guidelines developed through an autonomous National Council for Human Resources in Health.

  • An updated training curriculum should be fully in place for medical and allied professions that is relevant to the situation in India.

  • Establish suitable incentive structures to retain health providers in underserved areas.

Health information system

  • Have in place a comprehensive health information and surveillance system that covers all major diseases, health-system issues, and key social determinants, which also facilitates assessment of public health interventions.

  • Establish adequate research capacity in India to investigate and report key issues that affect the health system and policy for further improvements.

  • Have in place a fully functional autonomous council that compiles and synthesises relevant information to develop guidelines for evidence-based health care and its assessment.

Drugs and technology

  • Implement a national network of pharmacies for generic low-cost drugs for the entire population.

  • Establish mechanisms for bulk purchase of patented drugs to make them available at low cost.

  • Have in place mechanisms to check and control the use of perverse incentives by pharmaceutical and biotechnology companies for health-care providers.

Governance

  • Have in place mechanisms to make functional the components of the National Health Bill 2009.

  • Have a system in place that requires all middle and senior functionaries in public health to have relevant training in public health.

  • Ensure devolution of responsibility for health care to district management systems along with accountability mechanisms and explicit community participation.

Consensus building

  • To formalise the mechanisms to achieve universal health care in India and to discuss the implementation of the recommended actions, a national debate involving all stakeholders in India including government, civil society, health professions, private sector, academia, and the media is needed.

Although the Indian economy had high growth rates in recent years (9·4% in 2005–06 and 9·6% in 2006–07, with a consistent 7·0% growth rate even during the period of global economic slow down), according to the Human Development Index India is ranked 134 among 182 countries.12 India's economic transformation does not seem to have produced tangible improvements in the health of the nation, and the recognition that improvement in health contributes to accelerated economic growth has not led to adequate investment in or improved the efficiency of health care. The people of India are exposed to a huge variation in health-care services, from one extreme in which the best possible care is provided to a small proportion of the population who can afford to pay for these services (now increasingly accessed by people from other countries as a result of medical tourism) to the other extreme in which even basic or essential services and technologies are lacking for a large proportion of the Indian people who are poor and living in rural and urban areas.

Several reasons exist why the health indicators for India have lagged behind those of many other developing countries, including some that are poorer. Immediately after independence, Indian health policy was affected by an egalitarian ethos that placed the main responsibility for provision of health care to all citizens on the government. However, lack of political commitment in recognising health as an essential component of human development, shown by consistently low investment, badly formulated policies, and inadequate implementation of programmes, led to inadequate delivery of health care by the public sector. The views of local civil society were not considered in a systematic manner during centralised planning, and neither was civil society substantially engaged in the implementation of the programmes. The private sector, already dominant at the time of independence, grew in an uncoordinated manner, to become the default option in many cases. In an unregulated environment, neither the private sector nor the public sector provided an assurance of quality or access. The recent change towards a liberal market has resulted in a further redefinition of the role of the government, even in the health sector. The increasing dependence on the private sector, in addition to very weak regulation and corruption, has led to a huge increase in health-care costs with the result that out-of-pocket payments are now one of the leading causes of direct debt and poverty in India.4

Even though there has been a small increase in the governmental allocations for health in the past few years, the proportions remain very low compared with nearly all the other developing countries. However, even these low funds are often underused or inefficiently used by some states. The inadequate absorption capacity of state health-care systems is largely attributable to a deficiency in public health and managerial expertise. Until the advent of the National Rural Health Mission, states did not have the freedom that was provided by flexible funding. This dichotomy, wherein the central government has the mandate and the money for launching national health programmes, whereas the states have the primary responsibility for the implementation of these programmes and the delivery of a wide range of other health-care services, has led to a serious disconnection between planning and implementation. Lack of dependable and affordable primary health care for rural populations and the people living in urban areas who are poor, in many states, has been the main manifestation of the absence of a connection. The National Rural Health Mission is a huge initiative that seeks to correct this imbalance in rural areas. It is soon to be transformed into the National Health Mission, with addition of programme components that are related to urban health.

Human resources for health too have been severely deficient, particularly in rural areas. Shortfalls in training, inequities in distribution, and migration of staff to other countries have worsened these deficiencies. A doctor-centred approach to health care has led to a systematic underproduction, undervaluation, and underuse of public health professionals, nurses, and community health workers. The quest to use high-tech, specialist-delivered, and hospital-based medical care, with little regard for primary health care or evidence-based practices has worsened the huge health inequities and increased the costs of health care.

These findings help account for the underperformance of India's health-care system. Although central and state governments have taken several ambitious and welcome steps to correct some of these problems, we argue that the time has come for the health-care system to be radically reconfigured, along with attention to the social determinants of health, if India's health indicators are to rapidly improve and the health inequities are to be substantially reduced.

Section snippets

Call to action

Access to appropriate, adequate, and affordable health care is the legitimate entitlement of every Indian citizen during his or her life. We therefore call for a radical transformation of the health-care system to promote equity, efficiency, effectiveness, and accountability in the delivery of health care at all stages through the establishment of the Integrated National Health System in which all major providers—ie, the public and the private sectors and the allopathic systems of medicine—are

Integrated National Health System

We propose the Integrated National Health System as an overarching strategy for the achievement of the broad goals set out previously. This system should provide free health care at the point of use—consisting of health promotion, disease prevention, and acute, emergency, and chronic care throughout the patient's life. Three guiding principles lie at the heart of our vision for the Integrated National Health System. First, the system should be financed through sources other than out-of-pocket

Conclusions

We propose some targets and timelines to map the milestones for the achievement of universal health care in the table. We chose not to include disease-specific targets, such as reduction in infant mortality rate, because we believe that these will be addressed implicitly if our broader recommendations for radical transformation of India's health-care system are realised. We have proposed targets for 2012, 2015, and 2020. We call on India to ensure the achievement of a truly universal

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