Healthcare for all must be built on the voices of all
The state of health care in India is far from optimal, a statement with which few of its 1.3 billion citizens would disagree. Even prior to the pandemic, reforming the health system was overdue, evidenced by poor health indicators, unequal delivery of quality care and inadequate protection from financial risk. Despite significant improvements in areas like antenatal care, infant mortality and life expectancy, structural reform was hampered by nominal attempts to make health care a policy priority or to tell a story of success of implementation at scale.
This resulted in deep fault lines within the health care landscape. One long-standing tension is seen between the public and private sectors, where questions about each sector’s role in the provision and financing of health care remain unresolved. The debate has been complicated by the rise of technology in recent years – and in particular, during the ongoing pandemic – which has highlighted the role of innovation in health care, from telemedicine and e-pharmacies to Artificial Intelligence-based diagnostics and biomarkers for early diagnosis, as well as the gaps in healthcare access reflected in the well described shortages. Technological developments have led to the advent of issues related to data privacy, inaccessible digital systems posing a massive risk for marginalised communities in the form of the digital divide, and questions about the role of governments vis-à-vis other stakeholders. Within the public sector, reform is complicated by varying levels of implementation capacity, commitment and resources across states. Elsewhere, rifts have emerged concerning modern and traditional systems of medicine, and how different medical approaches can and should be integrated in a holistic health system.
While these fault lines in policies and implementation have existed in some form since India’s Independence, they are not problems of the past. Just in the past year, an announcement to allow AYUSH doctors to perform surgeries revived the debate on the roles of ayurvedic practitioners’ vis-a-vis allopathic doctors. Elsewhere, the pandemic exposed the twin challenges of insufficient health care workers in public hospitals and perceived profiteering by private hospitals. Recently the Commission, in a Lancet Comment, called for India's central and state governments to take eight urgent actions to address one of the greatest humanitarian crises facing the country since its independence.
The impact of these unresolved dilemmas is not simply an abstract failure. The cost of these rifts has been borne predominantly by the voiceless poor and marginalised, and less so by those in charge of health systems. A study by the Public Health Foundation of India estimated that out-of-pocket health expenses drove 55 million Indians into poverty in 2017. The National Health Accounts (2016-17) found that Indians paid nearly 60% of health expenses out-of-pocket, among the highest proportions globally.
A country which takes pride in being one of the largest producers of doctors, drugs and technology in the world also experiences the largest unmet needs for basic health care. In a deeply fragmented health system, these statistics are symptoms, not causes, of long-standing inequalities in access to quality health care. They are merely illustrative of the fact that for too long and increasingly, health care in India has been viewed through the prism of charity for the poor and a commodity for the rich, and not as an essential ingredient for sustainable development.
These underlying tensions are what motivated the formation of the Lancet Citizens’ Commission on Reimagining India’s Health System. The Commission is guided by the idea that structural change in the health system can only be attained through consultative and participatory engagement with the diverse sectors involved in health care and, most importantly, with Indias citizenry. For India to achieve universal health coverage in the next decade, it is imperative to understand and negotiate the tensions inherent to: The public and private health sector relationship; the integration of multiple health systems; shared emphasis on promotive, preventive, curative, and rehabilitative care; the relative roles of central, state, and local governments in delivering and regulating healthcare, among others. The exercise aims to initiate dialogue with diverse and often-siloed viewpoints and be informed by the views of citizens – to whom any health system is ultimately accountable – and frontline workers – by whose tireless efforts the health care system runs. Our goal is to develop a citizens’ roadmap towards a health system that offers comprehensive, accountable, accessible, inclusive, and affordable quality healthcare to all citizens of India.
To this end, the Commission’s work is structured across five workstreams: financing, governance, human resources, technology and citizens’ engagement. Each workstream does a deep-dive into specific issues, e.g., the technology workstream seeks to understand how technology is being, and can continue to be, harnessed to improve healthcare delivery in a manner that would have been unimaginable a decade ago. While the first four workstreams provide lenses through which structural challenges in the health system can be overcome, the last – citizens’ engagement – serves as the foundation for the Commission’s broader philosophy. This workstream is an unprecedented attempt to gather insights into the expectations and experiences of healthcare from Indian citizens across gender, age, reproductive stage, geographic location and social groups – and to involve citizens in the design of a system that can best serve them. This spirit of collaboration is also reflected in the Commission’s growing partnerships with research institutions and civil society groups across India (such as IIM-B, Population Foundation of India, Centre for Policy Research, SEWA, DBT India Alliance, and Dvara Research) as well as a nation-wide network of young researchers. In the next 12 months, we hope to deepen this engagement with citizens and health workers through a series of surveys, district and program case studies and stakeholder interactions.
The Commission is currently in the first phase of research, reviewing the existing literature; conducting secondary analyses of recent datasets; preparing the protocol for conducting stakeholder consultations and case studies of high and poorly performing districts; and organising Theory of Change workshops with Commission members and external experts.
Further, in order to promote discourse on a variety of topics related to universal health coverage in India, the Commission has started a monthly webinars series since May 2021. The webinars provide a platform for open discussions and deliberations by the audience with health experts, frontline workers, researchers, and practitioners.
Finally, the Commission is launching its newsletter this month to share timely and relevant resources relating to universal health coverage with those interested in the work of the Commission. The Commission strongly believes that solutions for universal health coverage will not emerge from a handful of authorities in one sector, but through a collective effort involving diverse sectors of the economy, spurred and supported by an engaged public. As co-chairs of the Commission, we invite you to join us in realising the vision of universal health coverage in the same spirit.
The Lancet Citizens’ Commission on Reimagining India’s Health System is a cross-sectoral endeavor to develop a citizens’ roadmap to achieving universal health coverage for the people of India in the next decade.
(The piece has been authored by Tarun Khanna, Kiran Mazumdar Shaw, Vikram Patel and Gagandeep Kang)