The Lancet Commission on Investing in Health (CIH) has come up with an ambitious framework (1) and an editorial comment accompanying it (2) in the recent issue of the journal.
The Editorial makes a strong pitch for a systematic adoption of pro-poor strategies to bolster the adoption of UHC. In this commentary authored by the participants of the Bellagio Workshop on Implementing Pro-Poor Universal Health Coverage, the authors state (emphasis mine):
We call on national governments committed to UHC to adopt three key principles as the foundation of UHC: aim for pro-poor universalism from the start (ie, ensure that poor people are covered as the first priority on the road to covering the entire population), provide adequate financial protection, and strengthen the health service delivery system to be accessible by all, especially poor and vulnerable individuals. National governments should provide vocal political leadership to implement pro-poor policy reforms; successful reforms will result in greater use of needed services by the poor, which is the foundation for pro-poor UHC outcomes. Governments should also show political commitment by ensuring that, as the economy grows, there is a corresponding rise in domestic resources dedicated to health (with financial risk protection) and high priority health-related investments (eg, water and sanitation, education). Governments also need to ensure that the political leadership of the health sector has adequate capacity and technical skills, and to establish explicit, transparent national decision-making mechanisms and processes for deciding how best to allocate resources to UHC. Adequate resources should be directed to the development of strong health systems; in particular, functioning primary health care is a cornerstone of UHC. Governments should actively work with citizens in designing UHC and they should ensure that they are responsive to public demands through participatory multistakeholder governance. Finally, they should monitor progress towards and achievement of UHC goals, and document and publish experiences of successes and setbacks on the pro-poor path to UHC.
While this makes for reasonable theoretical approach to the problem, pondering on the evolving situation in India, certain thoughts pop into my mind. Here are some of the proverbial spanners that can jam up the wheels of the juggernaut of UHC in India.
(Disclaimer: I realize that healthcare can be a charged topic. Please do consider the fact that these are my personal opinion and if you detect any elements of error in them, kindly point them out politely. Let us have a decent conversation here!)
A Complex Healthcare System
India has a largely heterogeneous sort of medical care provision environment. We have a whole host of service providers, right from the practitioners of modern medicine (allopathic doctors) to state-authorized practitioners of AYUSH (Ayurveda, Yoga, Unani, Siddha, and Homeopathy: a legion of practitioners of alternative medicine) and the most ubiquitous of rural service providers, the euphemestically named “registered medical practitioners” (RMPs).
A brief note on the RMPs before I proceed further: They are basically non-licensed practitioners, who, having worked with doctors previously, or having worked in a hospital in a non-clinical capacity have subsequently winged it out on their own to practice medicine as local physicians. There is a slowly growing movement, led by some physicians, who, jaded with the system’s inability to incentivize “rural service”, have given up on the hope of providing these underserved areas with a licensed crop of doctors. Instead, they have decided to focus on training and retraining the RMPs to the highest level of their capacity to act as first responders and referral agents. This is a system that has had me in two minds… maybe food for thought for a future post!
With such a complex system of overlapping medical capacities, the best way forward remains a very calculated progress where equitable distribution of health work force needs to be ensured. The prolonged failure of the system to be able to formulate a non-punitive approach to deploy medical workforce in this area is a dangerous precedence, which endangers the concept of provision of healthcare where it is needed the most.
The Affinity for Quick Fixes
In the Indian policy setting, where quick fixes are a crowd favorite, the rapid answer to a lack of medical healthcare is deploying only healthcare workers in the underserved area. This narrow and myopic interpretation of health coverage needs to be amended before any further meaningful progress can be made in this domain.
Healthcare provided without systematic infrastructural support is unlikely to be sustainable in the long term or make meaningful impact in the short term. Without investing in the infrastructure of the existing three-tiered healthcare system already in place, moving to establish healthcare coverage will be difficult.
Systemic Evil of Corruption
Of late, the Indian healthcare system has come under the scrutiny for corruption and there has been quite a fair bit of clamour about it in the popular media, as well as within academic circles. Without uprooting the systemic evil of corruption that pervades the environment, it is difficult to ensure proper implementation of policies. Just framing a policy is not adequate; ensuring that it is effectively implemented is the real challenge.
Establishing self-sustaining monitoring and evaluation frameworks, creating policies and programs in a transparent fashion, engendering a culture of accountability, and most importantly, addressing corruption swiftly and mercilessly are essential to ensure that the benefits outlined in the reams of documents that are authored by the think tanks actually reach the intended targets.
Political Will: Poor Demand, Poor Supply
I have my doubts when the discussion veers in the direction of health as a political priority. With only 1.04% of the GDP being committed to the healthcare system from the publicly funded coffers, it continues to live in the shadow of other priority areas like agriculture, technology, development, etc.
This is, in my view, a symptom of the fact that we, as citizens of the nation, do not consider health as a major priority. To a majority of Indians, the bare essentials of life are yet to be assured. The lure of two square meals a day puts octogenarian women, bent over with arthritis and age, on the pavement, begging for alms. The country has grown, and not everyone has been a part of the growth. Naturally, health has been viewed as the disposable one amongst the essential services. Only now, of late, have we been clamoring for better care. Yet, amidst the clamor for food and shelter, this need for money in the health sector is (legitimately) drowned out.
In Conclusion…
The health of the nation, unfortunately, is not viewed within the holistic framework and continues to work within isolated silos. Instead of tying up agriculture, development, health and a vast network of other determinants within a single implementation framework, they continue to function within isolated framework, working in isolation, often in duplicative circles, inefficiently replicating work that could have powered intersectoral growth.
UHC in India will be a pipe dream till the day we realize that universal coverage should bring a meaningful array of services to those that need it the most. Until that day, the pursuit of the inflexible, utopian definition of health shall be an exercise in futility.
References:
- Jamison, DT, Summers, LH, Alleyne, G et al. Global Health 2035: a world converging within a generation. Lancet. 2013; 382: 1898–1955
- Bump, J., Cashin, C., Chalkidou, K., Evans, D., González-Pier, E., Guo, Y., Holtz, J., Htay, D., Levin, C., Marten, R., Mensah, S., Pablos-Méndez, A., Rannan-Eliya, R., Sabignoso, M., Saxenian, H., Feachem, N., Soucat, A., Tangcharoensathien, V., Wang, H., Woldemariam, A., & Yamey, G. (2016). Implementing pro-poor universal health coverage The Lancet Global Health, 4 (1) DOI: 10.1016/S2214-109X(15)00274-0
