Universal health coverage in India: muddling through the quagmire

A guest editorial I co-wrote with Upendra Bhojani and Werner Soors on the International Health Policies blog on the quagmire of Universal Health Coverage issue and how it is unfolding in India.

Ever since the Indian government’s Planning Commission’s (PC) high-level expert group (HLEG) came out with their 300-odd page report on universal health coverage in October last year, how to reach that much desired universal health coverage has become the central question. The HLEG report made clear statements about existing policy alternatives, distancing itself from insurance in spite of ambitious insurance schemes being piloted all and sundry in various Indian states, instead unequivocally calling for a government guarantee for cashless primary, secondary and tertiary care. This position was repeated last week by the chairman of the expert group. However, the HLEG stopped short of providing a more detailed roadmap. This, it left to the PC and ultimately to the policymakers.

The recommendations of the HLEG clearly do not find their place in policy automatically, at least not without “significant misrepresentation”, as is being claimed by several activists and public health experts, including some from the HLEG itself. In a bold move, India’s Health Ministry itself took a stand opposing the Planning Commission. Not the first conflict between the Indian health and development community and the PC deputy chairman: earlier this year, the latter had solved India’s poverty problems by suggesting that half-a-dollar a day would be a reasonable watershed for defining poverty in India, junking his idea facing stiff criticism.

Although a variety of policy options are under consideration to move closer to universal health coverage, the one facing opposition from many quarters – while apparently being backed by other interests – is a system similar to the US model of managed care. Less than a week ago, the national newspaper The Hindu carried an editorial “Don’t take the wrong pill”, cautioning Indian government against giving in to short-term economic interests. Earlier, the Indian branch of the People’s Health Movement identified the latest move by the Planning Commission as a sell-out to the private sector. The think tank Medico Friend Circle cautions against any private sector involvement or embracing any kind of insurance or managed care dubbing such options illusory and high-cost. From a distance, as David Chinitz notes in this week’s JAMA, while reviewing the book International Health and Aid Policies: The Need for Alternatives, “The focus on regulated competition, contracting out, and consumer choice, although not devoid of constructive lessons about policy, has left policy makers, academics, and citizens a bit disillusioned. It is clear that there are no panaceas, and after every major swing of the pendulum from a socialist to a capitalist orientation and back, there is a need to pick up the pieces and fine-tune the system.”

At present, the universal health coverage debate in India is happening largely at the federal level, locally called the centre. The challenge of how the states will take up recommendations of the centre is yet to be seen. According to the Indian constitution, it is up to each and any of the 28 states to implement health. Laws, frameworks and financing might correspond to the central government, but are by no means binding. States can be entirely different, including in health profiles. While inhabitants of Kerala rank at par with the healthiest in the world, Orissa natives suffer from the worst malnutrition. Indian states have different political inclinations, often very different from the centre.

So which road will India take toward universal health coverage? Possibly more than one. As good old Dylan sung back in 1965: “Something is happening here, but you don’t know what it is”…

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