Year : 2013 | Volume
: 57 | Issue : 4 | Page : 193--196
Toward a community-centered public service system for universal health care in India
Professor & Chairperson, Centre of Social Medicine & Community Health, Jawaharlal Nehru University, New Delhi, India
Professor & Chairperson, Centre of Social Medicine & Community Health, Jawaharlal Nehru University, New Delhi
|How to cite this article:|
Priya R. Toward a community-centered public service system for universal health care in India.Indian J Public Health 2013;57:193-196
|How to cite this URL:|
Priya R. Toward a community-centered public service system for universal health care in India. Indian J Public Health [serial online] 2013 [cited 2020 Feb 23 ];57:193-196
Available from: http://www.ijph.in/text.asp?2013/57/4/193/123237
The present, evidently widespread, concern regarding universal access to health care (UAHC) is an opportunity for dealing with the inadequacies in conceptualizing, provisioning and financing of health services. It must deal with the inequalities and irrationalities in practice of the existing health care system, whose serious adverse consequences for the majority of India's citizens call for urgent action with a long-term vision. However, the complexity of issues also demands carefully thought out approaches and strategies.
Universal Health Coverage (UHC) has become the current slogan for health services development, both internationally and within India. The Planning Commission's High Level Expert Group on UHC,  Steering Committee on Health and Steering Committee on Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy (AYUSH) for the 12 th Plan , have come in the wake of civil society concerns with UAHC. Though UAHC and UHC could conceptually be the same, in this discourse they have come to acquire varying and sometimes opposite meanings. Recent discussions on UAHC got initiated in the attempts to revive the spirit of Primary Health Care (PHC), both at World Health Organization (WHO) and in civil society, , keeping people and their health central. However, UHC, coined internationally as universal health "coverage," connotes coverage by medical services as well as by medical insurance, with the focal concern being the health of institutional and financing mechanisms. In the Indian context, official documents have used UHC as UHC and as UHCare interchangeably. , UHCare appears similar to UAHC, but UHC makes the medical service providers central. Not merely a play of words, this reflects the larger debate on "how" UAHC is to be provided.
A set of people-centered values and principles were articulated in the PHC approach that accompanied the Alma-Ata "Health for All" slogan of 1978. The Health Sector Reforms of the 1990s espoused a different set of values and principles. This shift echoed the movement of the overall development policy framework from welfare to a market model. It was accompanied by a decline in public systems and increasing commercialization of the health services, leading to increasing unmet need for services on one hand and unnecessary medical interventions on the other. Increasing medical expenses including catastrophic expenditures, continuing geographic mal-distribution of health facilities and highly variable quality of services have made access to good quality services a major issue. Thus, the neo-liberal policy framework, escalating health care costs and increasingly over- medicalizing mindsets have made the designing of health service systems with a PHC approach even more challenging in the present times.
Civil society and health activists in India have also been involved for several years in the Right to Health Care campaign led by the Jan Swasthya Abhiyan and its member organizations. The Medico Friend Circle's discussions over 2 years on designing a model for UAHC for India culminated in its annual meet at Nagpur in January 2011  followed by another in January 2012. Although the designs were being painstakingly developed for UAHC by such civil society groups and by one section within WHO, the Global Symposium on Health Systems Research was organized on the theme "Science to Accelerate Universal Coverage" in November 2010 jointly by several international health research networks and funders such as Rockefeller Foundation, Centers for Disease Control and Prevention (USA) and WHO.  A special issue of The Lancet was released in January 2011 focusing on UHC in India  and, in late 2010, the Planning Commission set up the High Level Expert Group on UHC by 2020.
To discuss the nature of the present discourse and designs of the universal health system that are being proposed, a meeting was organized at the Centre of Social Medicine and Community Health at Jawaharlal Nehru University in late January 2011. The concern was how to optimize the opportunity this provides to improve access of all sections, while simultaneously analyzing possible negative outcomes. One outcome of the deliberations was a statement that was published in the Economic and Political Weekly and got dubbed the "Delhi statement".  Subsequently, several of the participants wrote papers that were presented and discussed in a second meeting at Jawaharlal Nehru University in January 2012 titled "Toward a Public Services and Community Centered Health Care System". This issue of IJPH contains several of the papers and this editorial draws on that statement. Although this issue was under preparation, the draft chapter on Health of the 12 th Plan (2012-17) generated much debate and when the final plan document became available, it was evident that the issues discussed and recommendations for action put forth in these papers remain relevant.
As analyzed in the statement, perspectives differ on the definition and content of UAHC as well as on the optimal mechanisms to achieve it. One approach focuses on achieving universal access by expanding the role of the commercial sector in financing and provisioning i.e., medical insurance and private providers playing the major role. A second approach is for enhanced public financing with private provisioning, i.e., social insurance with government paying premiums for services of private providers (the RSBY model or UK's NHS model). A third argues for enhanced public spending with a central role for the state in provisioning, i.e., government spending on a strong public service system and a regulated private sector. A fourth approach proposes a vital role for the notion of active agency of communities in health care, with the supportive back up of a comprehensive health service system primarily provided and financed by government (the PHC approach). While the first three dwell primarily on financing structures in a top down approach with only a secondary role for the communities, the fourth emphasizes a bottom up and epidemiological basis for designing the health service system.
It needs to be noted that planning discussions in India, incorporating lessons from international experience, have led to a rejection of the first approach by all committees and working groups, with the acceptance that public services are to be the "backbone" of the health service system and government has to fund its strengthening. That the services must be free at the point of provisioning is another widely accepted fundamental. Integrating the AYUSH systems of medicine with the mainstream services is a third point of wide agreement. How to strengthen and improve quality of the public system, what should be the role of the private sector, how to regulate the private sector as well as public sector providers and how to integrate the AYUSH systems are the major set of issues under consideration.
Issues that find much less space in the present attempts to design a system for UHC are, limitations to eliciting genuine community involvement in planned health care and the role of knowledge base of lay persons as well as of service providers outside the formal allopathic and AYUSH systems in ensuring access to health care. Since one of the major limitations of the health services in the early post-independence decades has been identified as its alienation of the health services from the majority of people,  will we not be committing the same mistake again? Can health be "delivered" universally through completely top down approaches?
The "Delhi statement"  takes the view that analysis of available evidence demands thinking of health services development for UAHC in India along the lines of the fourth approach. It describes the recent discussions on UHC/UAHC as a-historical, largely a-theoretical, led by de-contextualized "international health" perspectives emerging from the first world, avoiding any examination of the political dimensions of health services development and viewing markets as bringing efficiency and promoting consumer choice and insurance as the mechanism for financing of health care, without due consideration of any comparative input-output analysis between the public and private sector services or the differences in governance structures and user profiles. However, there is also the prevailing reality in our country that 80% of the outdoor services and over 50% of the indoor services are being accessed from the private sector and that is where over 80% of the doctors are. Hence, reshaping the system even in the 21 st century requires going back to basics. The statement spells out eight points for such a basic paradigm and indicates 14 measures for present action based on this paradigm. The papers in this collection relate to this overall context of health services development in the country and provide details on points made in the statement.
The varied perspectives inherent in the present UHC/UAHC discussions are presented in three papers of this issue, those by Qadeer, Bisht and Phadke. The first two argue that the present discourse distorts the very notion of public health and undermines the basic values and principles of PHC, to the detriment of the objective of UAHC. Phadke's paper, while in agreement with Qadeer's position on the need for strengthening and reform of the public services, argues for "realism" under the present conditions. Listing the present limitations and conflicting interests within the public health services, a contracting-in of the private sector is proposed, so that it can be "socialized".
Social Determinants as Barriers to UAHC
However, two papers, one by Baru and the other by Reddy and Mary, examining the mechanisms adopted for regulation of the private sector and the recent Public-Private-Partnerships initiated in India, challenges the "realism" of Phadke's approach. Nayar's paper analyses the health care crisis to argue that it cannot be understood without its social dimensions and therefore techno-managerial fixes alone will not work. Acharya's paper exemplifies this through an empirically generated framework for pathways of poor utilization of health services by socially discriminated sections even when there is physical availability and free access.
Institutional Design for Strengthening the Public Services
The public system has been faulted on four major grounds: lower technological capability as against the private sector, poor quality and efficiency of services, inability of the state health departments to absorb funds and low capacity to attract and retain health personnel. Papers addressing each of these dimensions are included. While agreeing with Nayar that techno-managerial solutions alone will not do, it must also be recognized that it is necessary to seriously engage with operational, system and sub-system design issues to meet the expectations of efficiency, accountability and technical quality. The challenge is to creatively design systems such that they address the social dimensions together with the technical and managerial. In fact, what one needs to be conscious about while making design choices is the politics that underlies all social, technical and managerial solutions. For a PHC approach, empowering the people has to be the politics. Several neglected policy areas are discussed in this spirit from a historical and systems perspective in the last set of papers.
We hope the issues raised in these articles will contribute to creating a cost-effective, community-centered, quality public services system as against a commercialized and expensive system that is also more iatrogenic. The vantage point from which public health analysis is undertaken shapes its perspective. Even while the analyst, the advocacy activist and the implementer may have shared objectives and may even adopt a similar ideological approach, they have divergent views because of their immediate engagement and the outcomes they are expecting. The analysts tend to take a realist long-term view and set sights on logically ideal scenarios. The advocacy activists and the change implementers are dialoguing with the mainstream and therefore target for what is the "best possible" that is "acceptable" within the present conditions and dominant policy framework. The change implementers restrict the domain of action and target operational issues through the "low hanging fruit" to maximize quick outcomes in the desired direction. While the implementers view the analysts as "too theoretical", the analysts, in turn may view the other two as adopting "positions of compromise". What we need to recognize is the complementarity of each of the perspectives, since no one will be of much consequence without the other! Similarly, social science analysis is crucial for public health, but its disciplinary language often makes its use difficult by public health policy makers, planners and implementers. We hope this set of articles can act as a bridge across these divides, so that all those interested in the larger principles of public health can dialogue with each other, attempt to understand and draw from the other's views and thereby meet the severe challenges that confront systems working for the marginalized.
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