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Debating Universal Health Coverage in India

By Rakhal Gaitonde – October 12, 2012

The July 2012 release of the Indian government’s draft strategy for universal health coverage (UHC) has generated intense debate, with civil society groups such as Jan Swasthya Abhiyan (People's Health Movement chapter in India) and even the Ministry of Health expressing their opposition to its main thrust. The debate still rages, and as I write this blog there is news of yet another version which would be the third in as many months.

The UHC strategy currently on the table is the result of the Government of India’s stated commitment to this goal that took form in the constitution of a High Level Expert Group (HLEG) to suggest a road map. A number of key policy making bodies and processes have taken part in this dialogue over the last year, as well as civil society groups and academics.

The UHC strategy can be found in the Chapter on Health in the soon to be finalized Approach Paper to the Twelfth Five Year Plan, a chapter that expands upon the HLEG report. Each of the drafts presented since July have somewhat responded to criticism, but there are a number of underlying themes that have remained untouched or only superficially changed. These core elements of the strategy signal a very concerning paradigm shift in the way the government views health systems.

Key concerns

Creating health ‘consumers’

The suggested road map would shift the logic of governance from social accountability and commitment to the right to health to citizen “choice.” Thus health institutions would be driven by the need to “attract” clients as financing would depend on the number of people who “choose to avail services from a given institution / network,” instead of being driven by equity and epidemiology. The consequences can easily be imagined: public health systems already starved of funds and leadership over decades of structural adjustment would only see increased commodification and mesmerization of communities with “technological solutions to health” championed by the private sector. Closely linked is the proposal to convert institutions into financially autonomous ones, forcing them to attract patients or perish.

Limited “package” of services

Another important element is the extremely limited “package” of services that is being “universalized.” What is being suggested is a very small number of preventive and minimal curative services. The concern is that other essential services would be left outside the “essential package” forcing people to make a co-payment for even basic curative services, leading to potential reduction in access.

Lack of commitment to invest

The other major concern is the meager quantum of funds allocated for this whole process. The initially low figure was blamed on fear of poor management and allocation, and other factors explaining under-spending. While there is no doubt that merely increasing funding without addressing core questions of governance is wasteful, contracting out is not a panacea. The road to UHC is impossible without a strong public health system.

What about equity?

Another continuing concern is the absence of the word equity in the chapter on health (including the most recent draft). The calls for multiple pilots to test out various models or paths for reaching UHC seem hollow when the logic to evaluate these is based on the market concepts of 'efficiency' and 'cost effectiveness' rather than 'equity' and 'protection of the right to health'.

While the present set of core elements in the chapter on health is not surprising given the drift toward commercialization of public services in India, the insistence on private sector participation in the new UHC strategy appears like an ideological commitment rather than one based on meeting the real needs of the people.

Dr. Rakhal Gaitonde is Training and Research Associate, Society for Community Health Awareness Research and Action (SOCHARA), Chennai, India. He is also a Member of Jan Swasthya Abhiyan (Indian Chapter of the People's Health Movement) and of Medico Friend Circle. He can be contacted at: