Citizen’s engagement is the backbone of Universal Health Coverage
Poonam Muttreja, executive director, Population Foundation of India
Covid-19 is a grim reminder of the fact that a robust health system is a necessity, not an option. The pandemic has brought to the forefront the need to reimagine India’s healthcare system – one that offers comprehensive, accountable, accessible, inclusive, affordable, and quality health care to all. To achieve Universal Health Coverage (UHC) goals, it is imperative to include the voices of communities, across sociocultural contexts, recognising the differential healthcare needs of people.
Citizen’s engagement is an essential element of democracy and the public institutions, including the public health system, and it must undertake all steps to achieve credible public participation. We know from past experience that participatory approaches are critical to the successful implementation of UHC. It is essential to include the involvement of communities, policymakers, civil society volunteers, health providers, both public and private, to make communities aware about their rights in order to reduce asymmetries and inequalities. The relationships between health care professionals and community members have an impact on the health and wellbeing of both groups. Outcomes of these interactions also influence and determine how the health system performs, on the whole.
In an attempt to bring ‘public’ back into public health, community action for health (CAH) was recognised as one of the five pillars for health systems strengthening in the design of the National Rural Health Mission when it was launched in 2005. This effort continued in 2013 when the National Rural Health Mission and the National Urban Health Mission National Health Mission were subsumed into the rebranded National Health Mission (NHM). The Population Foundation of India hosts the secretariat for CAH. On behalf of the ministry of health and family welfare (MoHFW), Government of India, the Advisory Group for Community Action (AGCA), a group of eminent public health experts, guided the implementation of a pilot on CAH in 36 districts across nine states between 2007 and 2009. Led by the MoHFW, CAH processes were scaled up and are currently being implemented in 2,24,186 villages in 372 districts including 51 aspirational districts and 72 cities across 24 states/UTs.
The key components of the communitisation strategy under the NHM, include (i) selection and training of a female community health activists--Accredited Social Health Activist (ASHA) to work as an interface between the community and public health system; (ii) constitution and strengthening of Village Health Sanitation and Nutrition Committees (VHSNCs) to take leadership in improving health awareness and promote access to health services, address specific local needs and serve as a mechanism for community-based planning and monitoring, and (iii) constitution and strengthening of Rogi Kalyan Samitis (Patient Welfare Committees) in public health facilities to ensure compliance to minimal standards for hospital care and to ensure accountability of health providers to the community.
The community action for health process has continued to evolve, with increasing civil society engagement that has led to strengthening of health service delivery at all levels in India--national, state, district, block and village. Those civil society organisations (CSO) which function through NHM have positively influenced service quality, utilization of services, coverage and health outcomes by providing technical support to the government, supporting trainings and capacity building of frontline health workers, nodal officers as well as supporting awareness and demand generation activities to improve health outcomes.
Despite all efforts, there have been formidable challenges in building citizen engagement in healthcare in India. First, there is limited engagement of citizens with the idea of UHC, as most citizens are not aware of their health entitlements, let alone the concept of UHC. Second, there is general distrust of the average person in the public health system – this distrust has only deepened during the Covid-19 pandemic. Third, inadequate quality services in the public sector and over-reliance on the private sector has led to high out-of-pocket expenditures (OOPE) for health care. OOPE accounts for 68% of the total health expenditure in India. Fourth, prevailing inequities in Indian society are mirrored in the inequities experienced in accessing healthcare services, especially for marginalised groups compromising health outcomes. Non-Communicable Diseases account for 61.8% of the total deaths, while communicable, maternal, neonatal and nutritional diseases account for 27.5% deaths.
Many well-intended initiatives to engage citizens have failed to gain traction due to information and power asymmetries between service providers and citizens, resulting in the neglect of vulnerable population groups. Building and sustaining trust within the community is an important contributor to successful outcomes. Key factors that have contributed to overcoming these constraints elsewhere, include political buy-in and an enabling environment in terms of a national framework that is inclusive of voices of citizens –who receive healthcare as well as those who provide it.
With the objective to lay out the path to guarantee universal access to quality and affordable health care services to every Indian, the Lancet Citizens’ Commission on Reimagining India’s Health System was constituted last year. The Commission’s work is spread across five work streams: finance, governance, human resources, technology and citizen’s engagement, which reflect critical pillars of the health system. The citizen’s engagement workstream, one of the five workstreams, is working towards the goal of going beyond the traditional boundaries of health care and actively engaging those whose voices have rarely been heard. Through stakeholder consultations and population surveys, we aim to gather insights into the expectations and experiences of health care from citizens of diverse social groups in our country across gender and age, public and private healthcare providers, frontline workers, CSOs, Self Help Groups, Village Health Sanitation and Nutrition Committees, Mahila Arogya Samitis among others. Our inclusive, solutions-driven approach, to promoting citizen’s engagement and establishing the views of diverse stakeholders on the architecture of UHC, would be an important a step towards improving health outcomes in India.
The Lancet Citizens’ Commission on Reimagining India’s Health System is a cross-sectoral endeavour to develop a citizens’ roadmap to achieving universal health coverage for the people of India in the next decade.
(Poonam Muttreja, executive director, Population Foundation of India)