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The Lancet: Assuring health for India's people: A call to action by leading academics

The Lancet

A paper published in The Lancet today calls for a radical transformation in the architecture of India's healthcare delivery system, if the country is to achieve the government's vision of assuring health for all.

The paper, authored by Professor Vikram Patel (Public Health Foundation of India and London School of Hygiene & Tropical Medicine) and colleagues, documents India's progress on major health indicators in the past decade, but also its many deficiencies; it identifies the structural problems with the health care system, and reasserts the recommendations of previous expert groups on the need for a radical new vision for India's health care delivery system.

The most disturbing indicator of the deficiencies of the Indian health care system is the observation that health care costs are driving millions into poverty. The authors argue not only for more resources, but for an integrated national health care system, built around a strong public primary care system with a clearly defined supportive role for the private and indigenous sectors, that (i) addresses acute as well as chronic health care needs; (ii) offers choice of care that is rational, accessible, and of good quality, (iii) is cashless at the point of service delivery, and (iv) is governed by a robust regulatory framework to ensure accountability.

The paper records the considerable efforts being made in the health sector, with national and local governments investing in targeted disease control programmes and the National Health Mission focusing on maternal and child health. Despite this, a variety of structural weaknesses have led to a situation where India's health system performance is unable to cope with the enormous demands placed on it by the country's growing population. According to the paper, India continues to lag behind regional neighbours especially on health indicators like mortality rates for children aged under five years, with India recording 27% of all neonatal deaths and 21% of all child deaths in the world. Chronic nutrition deficiency manifesting as stunting continues to affect a third of children under five years. Compounding this burden is the large and rapidly rising burden of non-communicable and chronic conditions.

According to Dr Vikram Patel, "The health time-bomb ticks on due to the rising burden of non-communicable diseases. Suicide is now a leading cause of death of young Indians, and an Indian is likely to suffer from a heart attack at least ten years earlier than in developed countries and yet the health care system has barely responded to these urgent health crises".

Further, Dr Patel notes, there are, "widespread inequities in health outcomes that are apparent in the large morbidity and mortality differentials across socioeconomic status, caste, class, sex, and geographic location." The paper states that an important cause of this large and inequitably distributed burden of disease in India can be attributed to social determinants beyond the conventional health-care delivery sector such as urbanisation, poor access to water and sanitation, food insecurity, environmental degradation, and the pervasive caste system.

According to the authors, India's current health system needs to correct its course urgently across seven key challenges. The first involves prioritising primary care and massively strengthening the country's weak primary health system. Despite an expansion and investment in primary health infrastructure through the National Rural Mission since 2005, there are wide disparities between and within states. Of greater concern is poor quality of care that plagues public health facilities. According to the paper, "in 2011, in the high focus states, 60% of the district hospitals did not offer intensive care services and nearly a quarter of these hospitals were struggling to cope with basic issues like drainage and sanitation."

Second is the challenge of skilled human resources, where an overall shortage was further compounded by inequitable distribution of skilled workers. At the beginning of the Twelfth Five Year Plan, barely 4% of all doctors were working in the public sector in rural areas.

Third, India needs to better harness and regulate its large private sector--in 2014, more than 70% of outpatient care and 60% of inpatient care was provided in the private sector. However, lack of regulation has led to corruption across the sector, with consequent poor quality of care and impoverishment of patients.

Fourth, dismally low public spending on health has crippled the public sector and created large barriers in quality and access--the total expenditure on health in India fell from 4·5% of gross domestic product (GDP) in 2004-05 to 4·0% of GDP in 2013-14, and most of this expenditure was out-of-pocket leading to catastrophic health care expenditure for millions.

Fifth is the issue of fragmented and uncoordinated health information systems--health metrics data in India are gathered by multiple agencies and surveillance systems but are often incomplete and inadequate; for example, private sector data are rarely captured. This lack of connectivity between agencies has led to compromised data quality and poor feedback in the use of data to improve health system efficiencies.

Sixth, curbing the irrational use, and containing the spiralling costs, of drugs and technology. With India spending as little 0·1% of its GDP on publicly funded drugs, close to two-thirds of the total out-of-pocket expenditure on health was incurred on drugs, often used irrationally.

And finally, to deal with the issue of weak governance and accountability--according to the paper, the single biggest impediment to a holistic approach to health governance in the country is the lack of convergence between ministries related to health, water, sanitation, and national vertical targeted programmes. The authors argue that it is essential for the state to prioritise health as a fundamental public good, central to India's developmental aspirations, on a par with education.

The paper outlines a three point action plan to both combat and counter these constraints and weaknesses facing India's health sector. The first step involves prioritising services for groups across the whole population, based on their vulnerability and risk. The second step involves expansion of health coverage of high-priority services to everyone, and the third step is to eliminate out-of-pocket payments by increasing mandatory, progressive prepayment with pooling of funds to ensure that disadvantaged groups and vulnerable populations are not left behind. A key requisite, says the paper, is to "... move away from a standard health insurance model of care to an entitlement-based model. This shift will require that the plethora of insurance schemes and vertical programmes be integrated into a national health assurance fund and that the National Health Mission be converted into the Universal Health Coverage mission". Health assurance encompasses not only universal health coverage but also includes the need to address social determinants of health as well as the notion of accountability, which is in line with the government's commitment to good governance.

The authors conclude: "In the immediate future, both the central and state governments should jointly launch a campaign to explain the principles and benefits of universal health coverage and engage with all concerned stakeholders in an atmosphere of a national mission. The role of communities and civil society is critical and they must be actively empowered to engage with this more radical vision of health care. To complement and, indeed, actively encourage the state governments to act towards making universal health coverage a people's goal, a nationwide campaign will have to be led by civil society groups, along the lines of recent campaigns to combat corruption and sexual violence".

"Delivering on its promise of assuring a healthy India should be the topmost priority of the Indian Government...In the context of the enormous challenges and constraints faced by India's health-care system, this goal might seem like wishful thinking. However, we believe that this goal is within reach provided there is the political will. Only a radical restructuring of India's health care system will assure health care for all Indians, both improving its health indicators equitably and eliminating impoverishment due to health care, by the time the country reaches the milestone of 75 years of independence in 2022".

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