Health in 2018: Prime Minister Modi, unknowingly, has given a vision for Universal Health Coverage in India

The year 2017 started with a high note of 27% increase in financial allocation, for health sector, in union budget 2017-18. During the year, union cabinet approved new National Health Policy (NHP) of India and National Medical Commission (NMC) Bill, aiming to repeal Medical Council of India (MCI) Act of 1956, once bill is passed in Parliament. The Indian parliament passed the Mental Healthcare Act, 2017 and the HIV & AIDS (Prevention and Control) Act. The prices of cardiac stents and orthopedic implants were capped through regulations and the authorities advised doctors in India to write generic names of drugs on their prescriptions. NITI Aayog released three year Action Agenda (health as one of the sections); India’s first ever state level disease burden data was released and the National Nutrition Mission (NNM) was announced.

The second half of the year was dominated by reports of poor quality of health services, across the country, both from government and private sector. Children had died in a government medical college in Gorakhpur & a few other government district hospitals in different parts of the country, a private hospital in Delhi erroneously declared a live baby dead and a few hospitals were alleged to have over charged the patients.

Amongst the major developments at state levels, the Mohalla Clinics of Delhi received attention from Indian state governments as well as from international media and public health experts. However, the expansion of these clinics failed to meet the proposed timelines. A few Indian states attempted to strengthen healthcare regulation with The Karnataka Private Medical Establishment Act, 2017 being the most prominent examples.

In the missed opportunities, the year passed by waiting for launch of the ‘National Health Protection Scheme (NHPS), announced in the union budget 2016-17. The ambitious announcement to transform 150,000 health sub-centres into ‘Health and Wellness Centres’ (HWCs), had an unimaginative and unaspiring target of converting only 4,000 of 150,000 (or 3% of total) sub-centres into HWC during the year.

Necessary but not sufficient

The release of policies and enactment of legislations was highlight of the year. The NHP 2017 has goal of “universal access to good quality health care services without anyone having to face financial hardship as a consequence”, which is a commendable and well-aligned with global discourse on ‘Universal Health Coverage (UHC)’. However, fifteen years ago, the national health policy of 2002 (NHP 2002) had proposed a few targets including the following: (a) “increase utilization of public health facilities from <20% to 75%” by yr 2010”; (b) increase health expenditure by govt. as a % of Gross Domestic product (GDP) from 0.9% to 2.0%; and (c) “increase state sector health spending from 5.5% to 7% of the budget” by 2005, and further increase to 8% by year 2010. Twelve years afterwards, the 71st round of National Sample Survey data on health reported that in most of Indian states, governments share in total health services had fallen between 2004 to 2014. The government spending on health had increased marginally to 1.15% of GDP in 2013-14. The state government’s expenditure on health remained largely unchanged or declined.

In late 2010, the Government of India had set up high level expert group on universal health coverage, which had submitted its detailed report in 2011. In run up to General election 2014, the party which eventually formed government had promised to launch a ‘National Health Assurance Mission (NHAM). Within months of forming the government, there were series of deliberations on universal health assurance (UHA), the Indian equivalent of UHC, it soon fizzled out and nearly forgotten. The announcement of NHPS in budget 2016 had almost similar trajectory.

Therefore, when NHP 2017 was released, it was largely well received except a few critiques that most targets were rehash of NHP 2002, with change in the goalpost only, i.e., increase utilization of public/government health facilities by 50% from current level by 2025 and increased government expenditure on health from existing 1.15% to 2.5% of by 2025. Something which indirectly points that, in last 15 to 20 years, very little has changed at ground level, if at all.

Way forward in 2018

Policies or regulations are not the solutions in themselves. Clearly, if health system in India has to be strengthened, the approaches have to drastically different than what has been done in the past. The solution could be found in a speech by Prime Minister Modi in June 2014, when he said “The need of the hour is to think big. The more we focus on skill, scale and speed, the more it will increase India’s growth trajectory”. Though, remark made for a different context, three and half years on, it could very well be India’s vision for health sector for yr 2018 and years ahead.

Think economic growth and health together: The economic growth is a legitimate interest of most LMICs, aspiring to change life of their citizens, with India being no different. Therefore, any health discourse has to be contextualized with economy. Healthy people are essential for accelerating and sustaining economic growth of a nation. Independent reports of the UN High Level Commission on health employment and economic growth, Harvard University and The Lancet have estimated that one extra year of life expectancy adds 4% to GDP and that for every Dollar spent on health, the return on investment is 9 times. A stronger engagement between ministries of health and finance has potential to create a ‘virtuous cycle’, where rapid economic growth creates fiscal space, for higher government resources for health. Health expenditures are one of the biggest causes of people falling into poverty and linked to poverty alleviation as well.

Think big: There is a strong global momentum on universal health coverage (UHC), re-enforced by Tokyo declaration of Dec 2017. The core principles of UHC are part of NHP 2017. Country has witnessed many incremental changes and India@70 is opportune time for transformational approaches to improve health of citizen. This provides a ‘once in fifteen year opportunity’ to transform health of the people with renewed zeal. Achieving UHC in India might appear challenging but it is feasible. ‘Thinking big’ also mean India should take leadership role for global discourses on advancing UHC and health should be integrated with part of India’s foreign policy engagements and exchanges.

Think skills: Achieving better health and UHC in India would require re-skilling of the existing health workforce and increasing the annual production capacity of skilled human resources for health. A public commitment to UHC will help. The job creation and skilled health workforce contribute to economic growth and also to achieve the objectives and targets of ‘Skill India’ initiative.

Think scale: The way nibbling doesn't help if you are very hungry; there is need for a few ‘big bites’ for health initiatives in India. Sometimes, the health system needs to be pushed to boundaries to deliver. The universal immunization program (UIP) in India, launched in 1985, had full immunization (FI) coverage hovering between 50 to 60% for almost two decades with annual increase of around 1 percent point only. It was a bold initiative by PM Modi, called ‘Mission Indradhanush’ that a target of 90% FI has been set up for yr 2018. It has shown unprecedented increase in immunization coverage. Pradhan Mantri Jan Aushadhi Yojana (PMJAY) and AMRIT scheme are very good initiatives to reduce financial burden on people. The NHPS, announced in 2016 should be designed to cover at least 50% of total population in the beginning with a road map to cover at least up to 80% population in fast track, time-bound manner.

Think speed: A lot need to be aimed and targets for now and in next 2 years. At least 2- 3 states should make public commitment and aim to achieve UHC in next 3 to 5 years. Select Indian states have to show leadership to allocate 8% of state budget for health as proposed in NHP 2017. A road map needs to be developed on how 3- 4% of GDP for health sector would be ensured in next 6 to 7 years.

For decades, health sector in India has had far too much focus on planning and very little attention on implementation. While PM Modi has dismantled the erstwhile planning commission, the mindset of Indian policy makers still is in ‘policy, planning & regulation’ mode. 2017 in health could easily be termed as ‘Year of policies and regulation’. It will serve country well, if concerted efforts are made to implement the existing polices at large scale. PM Modi has, unknowingly, given a vision which could be road map for better health in India and 2018 could be year to kick-start the ‘Decade of implementations and actions for health sector’ in India.

(Views are personal)