<br><div><p class="MsoNormal"><span style="font-size:11.0pt;color:blue">Although this piece
was written for the India
context, it applies globally.</span></p>
<p class="MsoNormal"><span style="font-size:11.0pt;color:blue"><span style="mso-spacerun:yes"> </span>Claudio</span></p>
<p class="MsoNormal"> </p>
<p class="MsoNormal"> </p>
<p class="MsoNormal"><b>TOWARDS A TRULY UNIVERSAL INDIAN HEALTH SYSTE</b>M</p>
<p class="MsoNormal"><span style="font-size:10.0pt">Amit Sengupta, Vandana Prasad,
People’s Health Movement-India (Jan Swasthya Abhiyan) <a href="mailto:chaukhat@yahoo.com">chaukhat@yahoo.com</a></span></p>
<p class="MsoNormal"><span style="font-size:10.0pt"><a href="http://www.thelancet.com">www.thelancet.com</a> <span style="mso-spacerun:yes"> </span>Published online January 12, 2011 </span></p>
<p class="MsoNormal"> </p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">Most are likely to agree that the accompanying call for</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">action towards achieving universal health care in India</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">by 2020 (hereafter referred to as the call) is timely and</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">overdue. However, we disagree with the call in two</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">crucial areas.</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">First, the call treads dangerous territory by asserting</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">that India’s
economic growth o<span style="font-family:"Arial Unicode MS"">ff</span>ers an
opportunity</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">to address the serious inequities in health, rather than</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">acknowledging that this economic growth is the basis of</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">inequities in health in many ways. It is not only, as the</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">call states, that “impressive economic growth in India...</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">has not yet resulted in commensurate investments</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">and health gains”.1 Rather, the current framework of</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">economic growth is not designed to address the concerns</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">of very large sections of the population, for whom it</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">has directly perpetuated the situation of ill health and</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">inadequate health care.2,3 This position is not one of</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">mere semantics, since any sustainable recommendation</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">needs to be set in an honest and robust analysis of the</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">causes of ill health in India. For example, the explanation</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">of what ails the health sector states that “Several</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">adverse social determinants combine to corrode health</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">of vulnerable populations”.1 However, little mention</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">is made of the severe, persistent, and near ubiquitous</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">poverty that has characterised this era of so-called</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">economic growth, in which 77% of Indians live on less</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">than INR20 a day.4 The word poverty is mentioned only</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">as a consequence of ill health. Thus, although the call</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">comprehensively lists acts of omission, it carefully steers</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">clear of acts of commission. Its underlying premise,</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">that economic growth stimulated by neoliberal policies</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">can be translated into equitable sharing of resources,</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">is fundamentally flawed. This premise severely</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">compromises its recommendations, the most important</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">of which is the need for integration of the private sector</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">into a universal Indian health system.</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">Second, just as the call accepts the present framework</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">of economic development as desirable and well</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">established, so also it accepts the value of integration</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">of the private sector into a universal health system. We</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">understand that public-private partnerships are too</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">powerful to ignore. However, the composition of the</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">private medical sector in India needs to be understood.</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">In metropolitan centres the sector is increasingly</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">composed of facilities run by large corporations, which</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">are in the process of integrating smaller organisations</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">within themselves and creating large monopolies.</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">By contrast, in vast areas of rural India and in
smaller</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">towns, the private sector is mainly composed of</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">unqualified practitioners or small medical practices</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">that are struggling to survive. Nowadays, large private</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">corporations have more influence than do public</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">institutions and can overpower them if any attempt</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">at integration is made, keeping equity indicators or</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">the public good in mind. Recent attempts to impose</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">legally binding commitments on private organisations</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">to provide health care for poor people exemplify this</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">power imbalance.5 Small practices and individual</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">practitioners can at best make marginal contributions to</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">an integrated system. Issues of regulation versus costs,</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">quality, and rationality of care relating to both small and</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">large health providers have not even been broached yet.</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">The corporate-led private sector in India cannot be</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">controlled by integration—it has to be confronted by</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">being made to compete against a well resourced and</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">managed public system that is run with public funds,</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">rather than building public assets and infrastructure</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">only in areas where the private sector does not exist.</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">Similarly, other recommendations of the call, such as</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">that to depend on private sector provisioning, and</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">concerning provision of universal health insurance, merit</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">closer investigation on questions of feasibility, costs, and</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">control over rational practice and quality.2,3 Although</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">harnessing capacity in the private sector can be a short-</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">term measure to fill gaps in availability of public health</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">infrastructure, it cannot substitute for a publicly funded</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">and managed health-care system. Unfortunately, the call</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">falls well short of advocating such a system.</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">We welcome and endorse the call to build a universal</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">health system. But for the call to be e<span style="font-family:"Arial Unicode MS"">ff</span>ective and robust</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">it must be a clear reversal of public policy in India that</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">is based on the premise of neoliberal economics.</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">Furthermore, it must be committed to the primary and</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">stated e<span style="font-family:"Arial Unicode MS"">ff</span>ort
to establish a comprehensive and universal</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">public health system. That is what would make the call</font></p>
<p class="MsoNormal"><font class="Apple-style-span" size="4">truly radical.</font></p></div>