PHM-Exch> TOWARDS A TRULY UNIVERSAL HEALTH SYSTEM

[Claudio Schuftan]

Although this piece was written for the India context, it applies globally.

 Claudio





*TOWARDS A TRULY UNIVERSAL INDIAN HEALTH SYSTE*M

Amit Sengupta, Vandana Prasad, People’s Health Movement-India (Jan Swasthya
Abhiyan) chaukhat at yahoo.com

www.thelancet.com  Published online January 12, 2011



Most are likely to agree that the accompanying call for

action towards achieving universal health care in India

by 2020 (hereafter referred to as the call) is timely and

overdue. However, we disagree with the call in two

crucial areas.

First, the call treads dangerous territory by asserting

that India’s economic growth offers an opportunity

to address the serious inequities in health, rather than

acknowledging that this economic growth is the basis of

inequities in health in many ways. It is not only, as the

call states, that “impressive economic growth in India...

has not yet resulted in commensurate investments

and health gains”.1 Rather, the current framework of

economic growth is not designed to address the concerns

of very large sections of the population, for whom it

has directly perpetuated the situation of ill health and

inadequate health care.2,3 This position is not one of

mere semantics, since any sustainable recommendation

needs to be set in an honest and robust analysis of the

causes of ill health in India. For example, the explanation

of what ails the health sector states that “Several

adverse social determinants combine to corrode health

of vulnerable populations”.1 However, little mention

is made of the severe, persistent, and near ubiquitous

poverty that has characterised this era of so-called

economic growth, in which 77% of Indians live on less

than INR20 a day.4 The word poverty is mentioned only

as a consequence of ill health. Thus, although the call

comprehensively lists acts of omission, it carefully steers

clear of acts of commission. Its underlying premise,

that economic growth stimulated by neoliberal policies

can be translated into equitable sharing of resources,

is fundamentally flawed. This premise severely

compromises its recommendations, the most important

of which is the need for integration of the private sector

into a universal Indian health system.

Second, just as the call accepts the present framework

of economic development as desirable and well

established, so also it accepts the value of integration

of the private sector into a universal health system. We

understand that public-private partnerships are too

powerful to ignore. However, the composition of the

private medical sector in India needs to be understood.

In metropolitan centres the sector is increasingly

composed of facilities run by large corporations, which

are in the process of integrating smaller organisations

within themselves and creating large monopolies.

By contrast, in vast areas of rural India and in smaller

towns, the private sector is mainly composed of

unqualified practitioners or small medical practices

that are struggling to survive. Nowadays, large private

corporations have more influence than do public

institutions and can overpower them if any attempt

at integration is made, keeping equity indicators or

the public good in mind. Recent attempts to impose

legally binding commitments on private organisations

to provide health care for poor people exemplify this

power imbalance.5 Small practices and individual

practitioners can at best make marginal contributions to

an integrated system. Issues of regulation versus costs,

quality, and rationality of care relating to both small and

large health providers have not even been broached yet.

The corporate-led private sector in India cannot be

controlled by integration—it has to be confronted by

being made to compete against a well resourced and

managed public system that is run with public funds,

rather than building public assets and infrastructure

only in areas where the private sector does not exist.

Similarly, other recommendations of the call, such as

that to depend on private sector provisioning, and

concerning provision of universal health insurance, merit

closer investigation on questions of feasibility, costs, and

control over rational practice and quality.2,3 Although

harnessing capacity in the private sector can be a short-

term measure to fill gaps in availability of public health

infrastructure, it cannot substitute for a publicly funded

and managed health-care system. Unfortunately, the call

falls well short of advocating such a system.

We welcome and endorse the call to build a universal

health system. But for the call to be effective and robust

it must be a clear reversal of public policy in India that

is based on the premise of neoliberal economics.

Furthermore, it must be committed to the primary and

stated effort to establish a comprehensive and universal

public health system. That is what would make the call

truly radical.
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