Health Systems Transformation For UHC In India

When the book, “An uncertain glory: India and its contradictions” written by Jean Dreze and Amartya Sen was published in 2013, one sentence (on page ix) stood out as being brutally honest and disturbing, but painfully real. That statement was that the Indian style of governance and planning has successfully created “islands of California in a sea of Sub-Saharan Africa”.[1] When looked at through the lens of healthcare, this contrast is even more glaring. The rich have access to some of the best quality healthcare services of global standards, while the majority (69%) of the population [2] living in rural areas and poor have limited access to quality healthcare. Unfortunately, the situation remains the same even today. The recently published ranking of countries based on Healthcare Access and Quality (HAQ) index shows that although India improved on the overall HAQ index between 2000-2016 (but is ranked a dismal 145^th position among 195 countries), the gap between India’s highest and lowest scores widened during the same period,[3] and this is a more concerning sign of the growing inequalities within India.

Insufficient money is often quoted as the problem. However, there is evidence to suggest that it is not the amount of money but the inefficient utilization of the money that is the crux of the problem.[4,5]

In the context of Universal Health Coverage (UHC), within India, there has been extensive discussion around health systems transformation to achieve UHC. However, two fundamental aspects need to be understood before we consider any transformation:

1. The concept of Health Systems
2. The concept of UHC

Health Systems as defined by the World Health Organization (WHO) include all the organizations, people and actions whose primary purpose is to improve health.[6] By including the words ‘primary purpose’, this definition unfortunately draws a boundary between health systems and a whole set of systems with organizations, people and actions, which affect health secondarily, e.g., education system, water supply and sanitation system, caste system, etc. However, there is a huge volume of literature commissioned by the WHO showing the relation between these social determinants (education, sanitation, poverty, social exclusion, etc.) and health outcomes and equity.[7] In this context, it is important to conceptualize the health system as a societal system with organizations, people and actions to address both health outcomes and inequity. Hence, the first step in health systems transformation is to view health in a holistic manner so that the social determinants of health become a very visible and important target to be achieved to improve population health in an equitable manner and move towards UHC.

With respect to UHC, the WHO makes it clear that UHC is not just about health financing. In addition to financial protection, five other elements are considered as essential requirements of UHC. These include access to well-trained health worker, safe treatment and medicines, quality services, evidence informed decisions and good governance.[8] In addition, UHC is much more than health, and includes steps towards equity, development priorities and social inclusion and cohesion.[9] Unfortunately, in India, UHC is too often equated with financial risk protection. A health insurance card is useless, if the nearest health facility is miles away and access is limited. Even if a health facility is within walking distance, health outcomes will be affected if it has no trained healthcare worker or medicines available. In all these scenarios UHC is non-existent even with health insurance. Also, these insurance packages facilitate public tax money to be used to pay private health insurance companies. The opportunity cost of investing the same money to improve the primary healthcare infrastructure, healthcare work force, provision of medicines, etc., is enormous. The recent Astana declaration recommits the importance of primary health care, community ownership and social determinants of health,[10] and it is imperative that we seriously act on this to create a sustainable model of health systems transformation in India for UHC.

Health systems transformation for UHC is not about adding new technologies, new insurance packages or digitalization. Instead, it involves learning from the successful strategies globally and applying it locally. It is about looking at health systems more holistically and creating an environment of health in all policies. It is about a whole of government approach (cutting across different ministries and departments) to create a whole of society impact. The entire government framework is required to translate health into an approach that affects all elements of society. Health systems will transform once it starts to perform up to its potential. Bridging the gap between potential and actual performance is the transformation required in India’s health systems and this can be achieved by improving efficiency in the existing systems and investments in addressing social determinants of health. For building this bridge, it is important that all stakeholders like academia, private sector and government work collectively in designing and implementing policies and programmes, which reflect the collective voice of the community (and not few individual voices). This engagement has to be visionary and intensive, and involve a combination of short-term ‘smart’ targets and long-term sustainable targets.[11] UHC should not be seen as a distant dream but a continuous process of action, which will speak louder than words!

References

1. Jean Dreze and Amartya Sen. An uncertain glory: India and its contradictions. Penguin UK, 2013. [Google Scholar]
2. Census of India 2011. Available from: http://www.censusindia.gov.in/Census_Data_2001/India_at_glance/rural.aspx
3. GBD 2015 Healthcare Access and Quality Collaborators. Healthcare Access and Quality Index based on mortality from causes amenable to personal healthcare in 195 countries and territories: a novel analysis from the Global Burden of Disease study 2015. The Lancet 2017; 390 (10091): 231-266. [Google Scholar]
4. Mukherjee K, Haycox A and Walley T. Health Technology Assessment: A potential road map for India. International Journal of Medical Science and Public Health, 2017; 6(5): 969-73. doi: http://dx.doi.org/10.5455/ijmsph.2017.1269225012017
5. Mukherjee K. Achieving UHC in India: Inefficiency is the problem, not money. The BMJ opinion, June 2017. Available from: https://blogs.bmj.com/bmj/2017/06/26/achieving-universal-health-coverage-in-india-inefficiency-is-the-problem/
6. WHO. The world health report 2000. Health systems: Improving performance. [Google Scholar]
7. CSDH. Closing the gap in a generation: Health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. 2008. Geneva, World Health Organization. [Google Scholar]
8. WHO. UHC Available from: www.who.int/universal_health_coverage/en/
9. WHO Fact sheets UHC. Available from: www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc)
10. Astana Declaration on primary Health Care: From Alma-Ata towards UHC and the SDGs. Draft AA40 Declaration text.www.who.int/primary-health/conference-phc/DRAFT_Declaration_on_Primary_Health_Care_28_June_2018.pdf
11. Mukherjee K. MDGs to SDGs: Lessons for UHC for India. Global Journal of Medicine and Public Health, 2016; 5(4). Available from: http://www.gjmedph.com/uploads/C1-Vo5No4.pdf