Universal health care in India: the time is right

India has supported the ideal of health for all since it become an independent nation more than 60 years ago. The Bhore Committee report¹ in 1946 recommended a national health system for delivery of comprehensive preventive and curative allopathic services through a rural-focused multilevel public system, financed by the government, through which all citizens would receive care irrespective of their ability to pay. However, a newly independent India faced monumental challenges in 1947. The country had been divided by a bloody partition, poverty was widespread, the economy was weak, and the administrators were new. The population’s health was grim. Memories of the Bengal famine of 1943, which killed 2–3 million people, were still fresh, health services were concentrated in urban areas, and health indicators were universally poor with a life expectancy at birth of 37 years. Much progress has been recorded since then. Life expectancy is greater than 60 years, and the India of 2011 is a thriving democracy with a diversified production base, a large scientific community, and an impressive information technology sector.

During the same period, however, India’s record in expanding social opportunities has been uneven. The health and nutritional status of children and women remains poor, and India is routinely ranked among countries performing weakly on overall health performance.^2,3 But there is good reason for hope. The country has withstood the recent global financial crisis and quickly returned to rapid economic growth. There is a refreshing openness to participation by civil society and to the power of ideas to improve performance and governance. We are enthused by India’s recent commitments to invigorate the public health-care system to address health disparities. Furthermore, we are encouraged by a vibrant economic climate that has propelled the nation into the ranks of middle-income countries, and by the advocacy for health from civil society organisations that speak for people. The growing confidence manifest in bold social-policy initiatives (such as the Right to Information Act of 2005, the Right to Free and Compulsory Education Act of 2009, and the proposed Right to Health Bill) offers an opportunity to revisit the case for universal health care.

Unsurprisingly, this Series in The Lancet shows both achievements and failures in health. India has one of the most fragmented and commercialised health-care systems in the world, where world-class care is greatly outweighed by unregulated poor-quality health services. Because public spending on health has remained low, private out-of-pocket expenditures on health are among the highest in the world.⁴ Health care, far from helping people rise out of poverty, has become an important cause of household impoverishment and debt.⁴ The average national health indicators, though showing improvements in recent decades, hide vast regional and social disparities. Although some privileged individuals enjoy excellent health outcomes, others experience the worst imaginable conditions.^5,6 Health disparities are being exacerbated by unequal economic growth, growing commercialisation of health care, and poor regulation of costs and quality of care.⁴ As citizens of India, we have witnessed these injustices not only professionally, but through our experiences of sickness in our families.

After 3 years of studying the evidence, this Series calls for immediate actions to promote universal access to health care. Activities in health promotion and prevention of ill health need to be guided by principles of equity, affordability, effectiveness, and accountability.⁷ To achieve this goal, India will need to invest substantially greater resources in health to strengthen the public health system, while also developing sustainable ways to minimiseout-of-pocket health-care expenditure through integration of the private sector.⁷

The spirit of the Bhore Committee report needs to be revived and realised, while recognising that contemporary India has more complex health challenges, diverse players in health care, and opportunities provided by unprecedented economic growth.

India can no longer tolerate the paradox in which child mortality and undernutrition rates are worse than in many poorer nations, in which women face an unrelenting burden of unsafe childbirth, and in which communicable diseases, mental disorders, chronic diseases, and injuries prevent people from leading healthy lives.^6,8,9 India can no longer accept a health-care system that is frequently exploitative, almost completely unregulated, and so poorly performing. The health conditions for most have to improve if all Indians want to enjoy the freedoms that lend value to their lives. A healthy India is also crucial for the country to make the most of its demographic advantage and to sustain economic prosperity.

The recommendations that we propose are not intended to be rigid. The final shape of a new and just health-care system in a country that is characterised by pluralism and a vibrant civil society will require much wider consultation and consensus building than we have been able to achieve. At the very least, we hope that this Series will trigger more concerted public debate and action for advancing health care in India by explicitly establishing health as the centre of planning and development. We are aware that the goals are ambitious and the challenges huge, but we believe that 21st-century India can channel political commitment and resources to help realise the nation’s founding vision of health for all. The time to act has come.