|Year : 2013 | Volume
| Issue : 4 | Page : 225-230
Universal health care in India: Panacea for whom?
Retired Professor, Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi, India
|Date of Web Publication||18-Dec-2013|
Retired Professor, Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi - 110 067
Source of Support: None, Conflict of Interest: None
| Abstract|| |
This paper examines the current notion of universal health care (UHC) in key legal and policy documents and argues that the recommendations for UHC in these entail further abdication of the State's responsibility in health care with the emphasis shifting from public provisioning of services to merely ensuring universal access to services. Acts of commission (recommendations for public private partnership [PPPs], definition and provision of an essential health package to vulnerable populations to ensure universal access to care) and omission (silence maintained on tertiary care) will eventually strengthen the private and corporate sector at the cost of the public health care services and access to care for the marginalized. Thus, the current UHC strategy uses equity as a tool for promoting the private sector in medical care rather than health for all.
Keywords: Access to health care, Contracting-in private providers, Equity, Universal health care
|How to cite this article:|
Qadeer I. Universal health care in India: Panacea for whom?. Indian J Public Health 2013;57:225-30
| Introduction|| |
India shifted course from comprehensive primary health care (CPHC) for all to bringing the private sector center stage, as prescribed by the health sector reforms that were part of the new economic policy and structural adjustment of the 1990s. A sharp decline in the public sector investment and the emergence of a strong private sector in health marked the turn of the century.  In this, we have a new gift from the state: Universal health care (UHC) which, simulates the original objective of health for all but, the minor shift in terminology hides a major policy jump where the state ensures access to and not necessarily provision of, services. 
There are those who say, "for India, now is the opportune moment of high economic growth, just right for UHC."  Others, argue that controlling child mortality, under-nutrition and high out-of-pocket expenditure on health care could be achieved by regulating the present mix of commercial and public sectors, investing in public health services and utilizing the "civil society's" refreshing openness to participate as well as the "enthusiasm of the professionals" enthused by the government!  The correlation between high growth rates of the reform period and the slowing of declines in under-nutrition and infant mortalities  does not bother them. The term civil society refers to NGOs (a number of whom survive on state patronage) and the enthused professionals, who often press for hi-tech institutions rather than worry about CPHC and its social co-ordinates, choices of technology and optimal health care systems.
What has made UHC acceptable to the state and why is it ready to go back to promoting access to health services, is a question that has been evaded by the enthusiasts of UHC whose affinity for the private sector is born out of a distorted definition of "systems," wherein provisioning of services by public and private sectors is seen as complementary and part of a single health care system, irrespective of their conflicting objectives private profits and social welfare. Thus, a-historicity and altered definitions of concepts are a part of the new genre of universality of health care. Its promoters have also helped big business to interpret "corporate social responsibility" as their right to enter the social sector and commercialize it instead of interpreting it as "ethical business practices!" The urgency with which the neo-liberal state pushes for achieving UHC "here and now" needs to be critically examined by those committed to the cause of health for all and not just access to health care services, even if universal.
To intervene in the debate, we first look at the official Indian efforts to build UHC, extract the dominant trends and locate them in their contemporary socio-political context.
| Current Official Efforts towards Providing UHC|| |
The UN millennium development goals (MDGs) addressed only "extreme poverty" that was to be halved by the target year 2015; universal "primary" education and not "secondary" education was the target; child mortality was to be reduced to two-third, maternal mortality ratio to three-fourth; human immunodeficiency virus infection/acquired immunodeficiency syndrome, tuberculosis and malaria were to be combated in collaboration with the pharmaceutical companies; and sanitation and drinking water supply were to be improved with better technology.  The National Rural Health Mission (NRHM) that was to work toward MGDs, succeeded only in narrowing the focus of PHC to reproductive health care, could not integrate vertical programs and fragmented the different levels of care by diverting referrals primarily to the private sector. It thus remained far from being genuinely inclusive. 
| The National Health Bill-2009|| |
Promising "protection and fulfillment of rights in relation to health and well-being, health equity and justice, including those related to all the underlying determinants of health and health care," the proposed National Health Bill  grants health as a fundamental human right. An overarching legal frame work, however, requires explicit definitions of terms, which are sorely lacking in the bill. For example, it uses terms such as essential public health system, essential health facilities and health care services, but does not make explicit their boundaries! The understanding of universal access itself is not that of an easily available service provided by the state but of state support in approaching providers. Thus, what is assured is economic access to health care (affordable for the state), of either public or private providers, promoting the cause of the private medical market and the process of liberalization.
The division of obligations of the state into general and core reduces the scope of essential health care facilities (undefined) for the marginalized and postpones universalization to an unknown future date. Secondly, while certain key social determinants are a part of the core responsibility of the state (safe drinking water, housing, sanitation, food), neither minimum standards to be achieved for these are spelled out nor are specific mechanisms set up to ensure inter-ministerial convergence. The bill is more concerned with the private providers and stewardship of the state and does not specify the responsibility of the public sector to provide CPHC, except for its role in public health services for the marginalized. By putting the private and public providers together in an integrated system, the bill ignores not only the basic contradictions between the two, it also tilts the balance in favor of profits for the private sector by making the state responsible for payments for medical care services without articulating shared objectives, conditionalities and liabilities of this partnership and issues of quality. State and district level public health boards are proposed to implement the obligations, evolve rules and regulations for recruitment from the open market, develop mechanisms for public private partnership (PPPs) and empower decentralized monitoring committees, but no principles are laid out for this implementation or regulation.
In other words, the bill is a policy document of the "steward" - in reality an agency in service of, rather than a partner of, the private sector.
| The 12 th 5 Year Plan Approach Paper|| |
Ignoring the fact that the public sector had suffered extensively in pride and prestige because of consistent reduction of investments, the approach paper laments that "it does not have the capacity to deliver services."  It proposes investments up to 2-3% of the gross domestic product and emphasizes preventive care while "creating an environment for healthy living." However its notion of prevention is limited to education and counseling without any reference to the constraint of poverty and the improvement of living standards. The entire conception of services is focused on the districts and participation and community based validation are all meant for the lower level of services. There is no mention of referral links with the tertiary institutions, public or private. The latter though known to be costlier than the former is seen as "competitively priced compared to similar services abroad." 
Although promising more resources, insurance system, training and expansion of health manpower and drugs, the approach paper makes it very clear that "publicly financed health care does not necessarily mean provisioning of services." It mentions appropriate regulation and oversight of private players and illustrates the virtues of PPPs such as Rashtriya Swasthya Bima Yojana, of outsourcing diagnostics and of a UHC system on the same lines. It is worth pointing out that detailed studies of PPPs and private insurances do not necessarily find these strategies worthwhile for the majority of the poor .  ,
| Report of the High Level Expert Group (HLEG) on UHC-2011|| |
Set up by the Planning commission in 2010, this committee HLEG consisted of public health professionals who upheld the principles of universality, equity and that the state must be primarily and principally responsible for a UHC, which is an entitlement to comprehensive health security inclusive of a broad range of welfare services.  Hence, public sector services must be strengthened, improved and brought center stage to ensure access and services to all sections of the people. The committee rejected both user fees in public institutions and private insurance and recommended genuine participation of citizens. It argued that UHC can succeed only if it is founded on social solidarity and cross-subsidization. Hence, it proposed a single universal method of financing through general and differential health taxation and recommended that 70% of it should go to PHC.
Based on these recommendations, four basic problems are noteworthy. Firstly, the recommendation to augment services is accompanied with a corollary that the private sector institutions and individuals could be contracted-in with specific health service packages under clearly prescribed contractual conditions (both of which remain unidentified) and adequate regulatory mechanisms. This may sound feasible but, given the nature of the private sector, the economic power of the corporate component, its range of services and the absence of self-regulatory mechanisms,  such partnerships are bound to marginalize all other recommendations. In addition, the private sector is no homogenous entity. However the HLEG makes no distinction between various levels of private providers and gives a general license for partnership, thus opening the door to corporate associations like confederation of Indian Industry (CII), federation of Indian chambers of commerce and Industry (FICCI) and Associated chambers of commerce and Industry of India (ASSOCHAM), who are just waiting to transform need based tertiary care into a full-fledged medical market for which the state is both a steward to harness the smooth operation of takeover  and client to buy tertiary care while neglecting its own tertiary institutions. The state is in no position to regulate the corporate sector given the latter's transnational character and economic power. The best it can do is to put its own house in order over the next 10-15 years and demand self-regulatory mechanisms from the private sector. Only when the public sector itself evolves its regulatory mechanisms for offering epidemiologically appropriate, effective and efficient services, can it regulate the private sector. Subsidizing the hi-tech and high-profit medical industry without this, actually leads to distorting services rather than rationalizing them. Why should the state not invest in its own institutions when it is known that public sector services are cheaper?
The second problem area is the package of services itself which is left to the experts/bureaucrats who until date have not found answers to the challenge of integration of vertical programs, nor clearly grasped the boundaries of medical service, health care service and health system or accepted that fertility is rooted in the same social determinants that cause ill-health. They also continue to mix primary level care with CPHC and are dazzled by hi-tech in medical care and by international standards. Even as a vision document, it would be necessary to set the guide lines for developing the package, using epidemiological reasoning for technological choices at different levels.
Thirdly, the recommendations totally ignore the vast presence of traditional practitioners and the fact that about 20-98% (average 57%) of the population in 18 major states is reported to use their services.  Equally disturbing is the absence of recognition that the challenge of UHC needs major reforms in medical education to balance the medical care and health care components of education and generate the excitement of practicing at home! Fourthly, while social determinants are included in health security, there is no mobilization of evidence to demonstrate the criticality of the impact of availability of food, drinking water and sanitation for improving the health status and the constraints they impose upon services. As a result, these are again left to their respective departments while the experts focus on intra-systemic techno-managerial solutions. UHC, then, might just stop at providing services but not necessarily health for all!
| The Steering Committee Report for the 12 th Plan|| |
The steering committee for health constituted by the planning commission to guide the 12 th plan, consisted largely of government officials, representatives of private and government medical institutions, private tertiary care providers and representatives of CII, FICCI and ASSOCHAM, with a few public health experts and activists.  Claiming a systemic approach and "worrying about the growing reliance on private providers," it underlines the financial and structural problems of the public sector, such as, disconnect of disease control programs with other social sectors, weak use of traditional systems, poor practice and drug regulatory system and public health management as well as community participation and emphasizes that "strategies of provision of inputs and creation of infrastructure under NRHM has not translated into assured health care services for people." Instead of paying attention to these, its focus is on defining and delivering the essential health package (EHP) consisting of RCH, emergency services, essential medicines for most of the disease burden in the country, inclusive of preventive and promotive interventions, without any prioritization.
The Steering committee proposes a UHC pilot project in one district of each state. These pilot projects will list all providers and households to set up a system of managed care! This would mean households enroll by choice under empanelled public or private providers who will be credited for their cash-free services. This is not preceded by constructing models and choosing the most appropriate one for trial even if the option of contracting - in or contracting - out are considered. In short the committee uses the small window provided by the HLEG and expands the involvement of private providers without addressing the structural problems of the public sector. No timelines are proposed for strengthening of the public sector, which is to follow the old strategies, such as: Focusing on high fertility states for fertility control, with abortion openly being a means for it; and proposing integration of vertical programs into NRHM. Training a range of personnel is left to the States in the name of States' autonomy and flexibility and appropriate noises are made about developing health information systems, referral services involving the private sector and a cadre of public health workers. Except for the proposal of State public health acts and a system of providing free drugs for EHP, not much is new!
Tertiary care is given prominence and placed outside UHC instead of being integrated into it to respond to the referral needs of lower level institutions. Thus private sector facilities are put center stage with the logic that they cater to 60% of inpatients. The 52 nd round of National Sample Survey shows that the majority of the poor still depend upon public sector tertiary care as they spent less than one-eighth of the rich on in-patient care, over three times did not seek care and 47% went into debt as against 32% of the richest.  The corporate institutions, which are under an obligation to serve the poor have failed to do so.  Urgency for UHC thus becomes a boon for the private sector as there is no long-term systematic thinking.
| Common Threads of the Strategy|| |
In these legal and policy documents, HLEG alone sets a discordant note making a distinction between public and private and insisting on the primacy of the public sector in providing UHC. The others push the state to:
These trends reveal why the HLEG's recommendations were not appreciated by the planning commission's steering committee for the 12 th plan. In its own assessment report to the Prime Minister recently, the Planning Commission criticized the HLEG for ignoring the well-established private sector and has commented that with the major share of personnel, beds and patients, "the private sector has to be partnered with for health care." It said that "the HLEG report proposes the creation of a new set up for implementation of its goal and has focused exclusively on UHC; thereby it lacks a holistic perspective."  Coming from the planning commission this is nothing short of ignorance as it understands UHC as a limited concept and also deceit, as it has failed to keep its own promise to invest adequately in health care infrastructure in every year of the 11 th plan. The report to the PM also added that increase in public health spending, "will not translate into lower out-of-pocket expenditure on health as projected by the HLEG," thus accepting the Steering committee's arguments for rationalizing contracting - in private providers and opening the way for the corporate sector profit maximization.
- Ensure access, but not necessarily provide health services.
- Invest in health, but support the private sector through subsidies, credits and PPPs.
- Treat public and private as a single system to divert attention from the state's failure to improve and strengthen the public sector, blame it for non-performance and justify its dependence on the private sector for provisioning.
- Focus on medical care and not health care and present efficiency of the private sector medical care institutions (a questionable notion in itself), as a substitute to CPHC as well as present its institutions as a model of excellence.
- Allocate the not so profitable preventive services and disease control programs to the public sector's NRHM until the district level.
| The Contemporary Context|| |
This compulsive drive to deviate from state welfare to a market strategy is rooted in the reforms process that was formally accepted in the early 1990s. Despite two decades of declining welfare and the increasing gap between the rich and the poor,  the inability of the NRHM to achieve the MDGs and the accumulating evidence that PPPs do not contribute to equity, this line is being consistently pushed. The single most critical argument in favor of reforms like UHC, has been the revenue that medical care brings in and the value of investing in health for economic growth. ,, This matches the vision of the Steering committee that talks of public health and social determinants but essentially believes that, "Health sector primarily focuses on the delivery of curative services". It thereby ignores the entire history of evolution of public health services in India that emphasized promotive, preventive and curative aspects of care as tools for changing the course of diseases.
This indicates that the powers that be have their own vision of UHC, rooted in the thesis that investment in health leads to economic development, not necessarily only by increasing the health of labor and their productivity but also by indirect investments of the state as a client purchasing services for the poor in the medical market and direct profits through open medical markets, transfer of technology, knowledge and skills as well as manpower. In this vision the resource inputs and public institutions (such as medical colleges, regulatory bodies, financial institutions) of the state are required to grease partnerships and sustain medical markets, while the paucity of public sector facilities is used as an excuse to seek private partners rather than evolve steps and time lines to strengthen public sector services.
What UHC then reveals is that the health sector reforms are a continuum of more and more stringent measures to commoditise health services. The role that the state plays in shaping these services also reveals that the withdrawal of state control does not mean retreat of the state, but a much more hardened state, reengineered as the safety net for capitalism  and nicknamed as the "steward!" Its direction is anti-welfare, as has become evident from the prevailing neglect of hunger and poverty reduction in the country. This transformed state is therefore heavily guided by class.  Therefore, the resolution to the challenge of UHC, be it resources, the vision of an infrastructure, priorities and choice of technology, lies in evolving differential strategies for public and private sector health services and key social determinants and not just a limited focus on achieving access to medical care. This task of midway correction in policies must be taken by the professionals.
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