Sustainable Development Goals: Leveraging the Global Agenda for Driving Health Policy Reforms and Achieving Universal Health Coverage in India

Abstract

Universal Health Coverage (UHC) is now the critical yardstick for countries to measure and track progress toward the “Sustainable Development Goals (SDGs).” Being a signatory, India has started taking measures to attain the targets laid out within the SDG framework and achieving the UHC. With India's National Health Policy (NHP) – 2017 in place, the policy environment for transforming country's health landscape coincides with that of the global approach toward strengthening of health systems and achieving UHC. It is imperative that for achieving the desired outcomes laid down in the SDGs and NHP-2017, coordinated actions are required including political action for making health an individual's right; effective stewardship from the National Ministry of Health and Family Welfare; reorganization of health-care service delivery implementing a “systems approach;” ensuring financial protection against health-care costs; and enhancing community participation and accountability. Undertaking these steps, imbibing the learning, and dwelling upon global experiences can help the country strongly move forward towards achieving global and national targets, thereby ensuring UHC for all its citizens.

SUSTAINABLE DEVELOPMENT GOALS AND UNIVERSAL HEALTH COVERAGE: THE NEW GLOBAL AGENDA

September 25, 2015, marked the adoption of the “Sustainable Development Goals” (SDGs) by all the 193 United Nations' (UN) member states, including India. Based on the reports from the “Open Working Group on SDGs” and the “Intergovernmental Committee of Experts on Sustainable Development,” constituted as a recommendation of the UN Conference on Sustainable Development (Rio+20 Summit, Rio de Janeiro, 2012), the SDGs comprise a set of 17 goals and 169 targets, which are comprehensive, ambitious, universally applicable, and relevant to both developing and developed countries.[1] Overall, SDGs are unprecedented in their scope and significance and are characterized by a strong focus on equity and inclusiveness and addressing the needs of the disadvantaged and the most vulnerable.

In spite of its inclusive nature, SDGs emphasize focus on individual thematic areas, including health. The “Health Goal” or SDG-3 aims toward “ensuring healthy lives and promoting well-being for all at all ages.” It is interwoven with nine other goals and underpinned by 13 targets covering a wide spectrum of health issues pertinent to the global as well as the Indian context, fostering equity and inclusive growth and acting as a fulcrum for most of the other goals.[2] While retaining focus on maternal and child health and infectious diseases, SDG-3 also stresses on noncommunicable diseases (NCDs), mental health, injuries, pollution-related morbidity and mortality, health systems' strengthening, and alignment with global health frameworks for policy support and reforms.

The centerpiece of SDG-3 is “Universal Health Coverage” (UHC), which signifies that all people should have access to quality health services, when in need, without facing any financial hardship.[3] UHC encompass a range of preventive, promotive, curative, rehabilitative, and palliative services across the primary, secondary, and tertiary levels of care, throughout the life course, and for all citizens. In addition, it also emphasizes on the need for investing in research and development for vaccines and medicines and increasing allocation for financial and human resources.

Gains and challenges in the Indian health sector

India today stands at a crossroad. While there have been impressive gains in terms of improved health outcomes over the past decade, on the other hand, country and its citizens are facing multiple health-related challenges. The leadership from the Ministry of Health and Family Welfare (MoHFW), Government of India (GOI), and collaborative efforts of the state governments have resulted in significant gains, and strategized efforts have brought down the country's infant mortality rate from 58 (2005) to 34 (2016) per 1000 livebirths[4] and maternal mortality ratio from 556/100,000 livebirths (1990) to 130/100,000 livebirths (2014-16).[5] These reductions in mortality rates excel the global averages for the same period and had called for appreciation on the global forums.[6] In addition, India has succeeded in eliminating diseases such as polio, yaws, and maternal and neonatal tetanus and achieving Millennium Development Goal (MDG-6) on combatting human immunodeficiency virus, tuberculosis, and malaria.

Despite these improvements, critical challenges still exist. With an annual birth cohort of 26 million children, India accounts for 1.2 million under-five deaths or 17% of global annual child deaths. It contributes to 22% of the global burden of communicable, maternal, perinatal, and nutritional conditions.[7] Full immunization coverage is in the range of 61% with wide interstate variations.[8] The life expectancy of 68.3 years in India is the second lowest in the WHO South-East Asia Region, and nearly 26.2% of country's premature mortality is now attributed to NCDs and injuries.[9,10] High rates of nutritional deficiencies and emerging and remerging infectious diseases such as dengue, chikungunya, and viral encephalitis are the other important challenges, particularly in urban areas.[11] In addition, the burden of preventable disease and deaths remains disproportionately high and vast health inequities continue to persist.[12]

Universal Health Coverage roadmap for India: Learning from experiences

India's health scenario is marred by wide intra- and inter-state disparities in terms of health infrastructure, workforce, service delivery, and financing. To address the existing health challenges, the national government has taken important policy-level initiatives in the recent years, especially after the launch of SDGs. The establishment of “National Institution for Transforming India” (NITI Aayog) and the roll out of the National Health Policy-2017 (NHP) are welcome steps demonstrating the pro-activeness of the government. In order to continue efforts toward achieving UHC, sustaining the momentum, and achieving the demographic dividend, it is important to follow a roadmap toward UHC with a comprehensive action agendum. Key actions required on this front include the following.

Political action for health

1. Strong political commitment is a fundamental must for increasing investments in health and driving the major policy reforms. Roll-out of Seguro Popular in Mexico, Universal Coverage Scheme in Thailand, Health Transformation Programme in Turkey, and Obamacare model in the United States exemplify strong political commitment toward improving health of the citizens.[13,14,15] At about 1.2% of the gross domestic product (GDP) which converts to US $18 (or Indian ₹1042) per capita, the Indian government's expenditure on public health as part of the total health expenditure is only about 30%, which is the 17^th lowest globally.[9] Nearly 64.2% of the total health expenditure in India is paid out of pocket, and every year, over 63 million people are faced with poverty due to health-care costs alone, owing to lack of financial protection of health-care needs.[16,17] Given health's role in overall economic development, and potential for wooing the electorate, the government should proactively undertake systemic reforms as outlined in the NHP-2017, including the increased investments in health from 1.15% to 2.5% of GDP[18]

2. Making “health” a citizen's right can push the governments to raise investments in health, drive sectoral reforms, and improve health outcomes.[15,19] Owing to “civil society-” led movements and recognition of health as an electoral instrument, several countries have adopted health as a right. India missed this opportunity when the proposal for “Right to Health” in the draft of the NHP-2017 was removed from the finalized version on the pretext of health systems not being ready.[17,18] However, evidences show that making health “A Fundamental Right” is crucial to accelerate health system's readiness and potentiate short- and long-term gains

3. Health is currently a “State Subject,” implying that state legislatures are responsible for its enforcement. To ensure policy coherence, coordinating public health and epidemic responses, and for portability of health benefits across the country, there is a need to bring health on the “Concurrent List” where both central and state governments are responsible for its enactment

4. To improve center–state coordination and guide multisectoral actions, role of political platforms on health-related issues needs to be enhanced. At present, the “National Health Mission Steering Group (NHMSG)” is the highest policymaking and steering institution, while the “Central Council of Health and Family Welfare (CCHFW)” provides support and advice to the Department of Health on policy formulation. It is imperative that the ambit of NHMSG must be expanded to the entire health sector by bringing it under the chairmanship of the Prime Minister, with the Union Minister for Health and Family Welfare designated as co-chair. Similarly, as per the vision of the NHP-2017, the role of CCHFW should be realigned to guide “Health Sector Plans (HSPs).”

Effective Stewardship from the National Ministry of Health and Family Welfare

1. Health care is one of the fastest growing industries in India, and despite being a large exporter of health workforce to developed nations, the country itself faces a massive shortage of doctors and nurses.[20,21,22] Therefore, sharing vision, providing oversight, engaging with key stakeholders within and outside the health sector, building strategic partnerships with private and voluntary sectors, and reviewing the progress must be the core functions of the MoHFW. It should strengthen regulatory frameworks; establish standards for health care; incentivize good performers; and steer the development of human resource, information systems, and research. In addition, there is a need for rearticulating its vision and standardize objectives to help states align toward the common goal of UHC

2. Formulate an actionable implementation framework based on NHP-2017 with specific activities, milestones, clear targets, timelines, and responsibilities. The national framework must be nonprescriptive, providing adequate flexibility to states to choose their own path and pace with the feedback based on inherent monitoring mechanisms to guide policy adjustments and mid-course corrections. Strategies within the framework should dovetail into an integrated UHC roadmap with frameworks for resource allocation and monitoring and evaluation, rather than a plethora of fragmented programs and schemes. This will facilitate progressive realization and achievement of UHC roadmap through a step-wise approach.

Reorganizing health with “systems approach”

1. “State Health Investment Plans” should be integrated as part of HSPs aiming for progressive strengthening of infrastructure, human resources, and information systems. These plans must be realistic based on the self-assessment of state's health system, with a clear emphasis on building capacity, inducting mid-level providers, contracting private providers, especially in the urban areas, and ensuring availability and access to essential medicines, vaccines, and medical products. An integrated health information system with the capability for interoperability is critical, in which each transaction could be captured using electronic health records and a unique health identifier for patients and providers to ensure transparency and quality of care

2. Appropriate focus should be laid on strengthening primary health-care-centered integrated service delivery. The NHP-2017 proposal for establishment of “Health and Wellness Centers” to provide a comprehensive package of essential services by a primary care team, headed by a mid-level provider, is an appropriate model for the Indian context.[18] The primary care provider should be the entry point for seeking care and should be effectively linked with secondary and tertiary providers to ensure a continuum of care. The beneficiaries should be free to choose the providers who could initially be paid on a fee-for-service basis. In addition, capitation or blended models with performance management framework can be introduced later with increase in demand for health services

3. The government should prioritize prevention and health promotion through investing more for improving coverage and driving multisectoral actions for addressing NCDs, road traffic injuries, and antimicrobial resistance. For timely detection and management of health security threats and building on the learning from “Integrated Disease Surveillance Programme,” the disease surveillance and response systems must be strengthened by involving a well-coordinated network of public and private providers, laboratories, hospitals, and surveillance cells manned by qualified workforce. These must be connected to a nationally networked real-time web-based reporting and feedback system, led by the “National Centre for Disease Control.”

Provision of financial protection against health-care costs for all

1. For ensuring access to essential services by all, the government should develop a system with a prepaid pool of public funds that can finance essential package of health services to the citizens, thereby reducing out-of-pocket expenditures. The GOI should be responsible for ensuring universal nationwide access to the defined package of essential services, with the state governments adding services as per specific requirements. In addition, private health insurance should serve as a supplementary service covering conditions not included under the government schemes

2. Evidence shows that “Purchaser Provider Split,” i.e., separating the function of purchaser and provider leads to benefits such as improved efficiency and cost containment through negotiating better package rates, tackling information asymmetry in health, as well as indirect regulation and quality assurance. Given India's federal structure, the purchasing bodies should be at the state level (state health agencies), supported by a national standard-setting body (national health agency). Equally important is to reduce inefficiencies in the health sector and improve public finance management

3. The country's mixed public–private health system has witnessed a progressive decline in public services, with growing dominance of unregulated formal and informal private providers.[23] For managing provider networks, the state and national health agencies should have a strong information communication technology framework to monitor provider behaviors and for fraud management. In addition, measures to tackle moral hazards can be put in place, including standard treatment guidelines, diagnosis-related groups, electronic health records, and conditional co-payments.

Community participation and greater accountability are vital

Engaging communities and civil society in health-related decision-making and sector reviews are essential to make health systems more responsive to people's needs and foster transparency.

DISCUSSION AND CONCLUSION

The SDG-3 has charted UHC as the key theme for future growth and progress of countries. In India, while government initiatives pulled 90 million people out of poverty between 2009 and 2012, at the same time, an estimated 60 million people were pushed into poverty due to out-of-pocket expenditure on health.[16,17] Investing in health contributes to poverty alleviation, but poverty alleviation programs cannot meet their targets unless adequate financial protection against health costs is in place. Macroeconomic studies have shown that one additional year of life expectancy contributes to an annual increase of 4% GDP per capita.[24,25] By preventing premature deaths due to NCDs alone, India can save as much as US $4.58 trillion by 2030.[24] Thus, to continue efforts toward achieving UHC, India needs to optimize the current positive policy environment as well as investment in health sector.

Global experiences have shown that well-coordinated health sector reforms can contribute to “inclusive development” by improving health and well-being of the citizens, reducing inequities and averting situations adversely affecting health of the citizens. Improved health financing and revamping of policies and overall health system can help in achieving UHC and build a healthier country. However, progress on UHC cannot be made overnight and a key principle for achieving it is “progressive universalization,” i.e., starting with whatever is available and gradually adding health services and improving financial protection for larger populations as the capacity of health system grows. Overall, in India, the integration of SDG agenda in NHP-2017 and NITI Aayog's Vision for Health (2032) has provided an unprecedented opportunity to re-position health.

The new flagship “National Health Protection Scheme,” recently launched by the union government, assures a health insurance cover of ₹5 Lakh a family per annum and has a scope to cover 10 crore vulnerable families and approximately 50 crore beneficiaries.[26] This ambitious scheme has a great potential to improve financial protection, reforming how services are financed, purchased, and provided, and enhancing private participation through empanelment. Incrementally, the package can be expanded to cover larger population, including the middle classes and the rich, and increasing the gamut of existing services.

Health has been conferred a higher priority in the country, and not investing in health systems for achieving UHC at this opportunity can have devastating economic consequences. This is the time to imbibe lessons from the past, build upon the gains, and embark on an ambitious journey.

Financial support and sponsorship

This work was made possible by the support of the American people through the United States Agency for International Development (USAID) and its VRIDDHI (Scaling Up RMNCH + A Interventions) Project, implemented by IPE Global Ltd., under the terms of Cooperative Agreement Number AID-386-A-14-00001. The contents of this paper represent the views of the authors and do not necessarily reflect the views of USAID.

Conflicts of interest

There are no conflicts of interest.