Reimagining India's health system: a Lancet Citizens’ Commission

The COVID-19 pandemic and response are having profound impacts on India's people, leading to myriad health-care challenges, a looming economic recession, and humanitarian crises.¹ The long-standing need for universal health coverage (UHC) in India has been brought into sharp focus by the pandemic. The mission of the Lancet Citizens’ Commission on reimagining India's health system is to lay out the path to achieving UHC in India in the coming decade.

A guiding principle for this Commission is that structural change towards UHC can only be attained through consultative and participatory engagement with the diverse sectors involved in health care and, most importantly, with India's citizenry. We expect that the Commission will formulate a roadmap for realising a resilient health system that offers comprehensive, accountable, accessible, inclusive, and affordable quality health care to all citizens in India. Although we recognise the important role that social determinants have in influencing health, the focus of the Commission will be on the architecture of India's health system.

Health care in India was in dire need of reform long before the COVID-19 pandemic. Despite considerable progress across health indicators such as maternal and infant mortality, disease burden in India is disproportionately high, less than two-thirds of children were fully immunised in 2017–18,² and malnutrition and other risk factors for disease and injury are widespread.3, 4 The pandemic has highlighted structural weaknesses in India's health system, ranging from inadequate medical supplies and insufficient numbers of health-care workers in public hospitals⁵ to irrational treatments and profiteering by private hospitals.6, 7 Out-of-pocket payments for health care in India continue to be among the leading causes of poverty for many households.8, 9 In a country with low public spending per capita on health care relative to its middle-income peers,¹⁰ the COVID-19 pandemic has further eroded an already fragmented health system.¹¹

The situation is exacerbated by structural inequities of caste, class, gender, geography, and community in India that translate into health inequalities and are amplified by the state of the health system. Poor and marginalised populations, particularly children, adolescents, and older people, among others, are more likely to suffer than the wealthy when afflicted by the same health condition. An estimated 400 million people could fall deeper into poverty¹² in the coming year as India's gross domestic product contracts by a projected 10·3%.¹³ The pandemic could worsen health disparities since much of the public health system has been redeployed in the COVID-19 response, disrupting routine health services. Data from India's National Health Mission showed there was a 64% decrease in child immunisation, a 50% drop in BCG vaccinations, and a 39% fall in oral polio immunisation in April, 2020, compared with January, 2020.¹⁴ At the heart of this crisis is the lack of accountability of the health system and a breakdown of trust between the public and the health system. A broad societal coalition is needed to remedy this trust deficit by working towards an adequately resourced and well governed system that responds to the health needs of all sections of India's population.

Dating at least as far back as the 1943 Bhore Committee, many expert committees, a 2011 Series in The Lancet,¹⁵ a High-Level Expert Group on UHC constituted by the Indian Government, and government national health policies in 1983, 2002, and 2017 have wrestled with the challenges of delivering quality health care in India. Our Commission will build on this important body of work and is guided by four principles of UHC. First, UHC covers all health concerns. Second, it includes the prevention of mental and physical health problems and long-term care, not only clinical treatment. Third, financial protection must be in place for all health-care costs, beyond health insurance cover for hospitalisation for a section of the population. Fourth, the UHC vision aspires to a health system that can be accessed by all people who enjoy the same quality of care.

Underpinning the Commission's work is a normative commitment to strengthening India's public health system in all its dimensions, including promotive, preventive, and curative care. The state must take a leadership role as provider, financier, regulator, and steward of the health system. But for the state to fulfil this role, it must grapple with the complex and fragmented architecture of India's health system. Key questions include: negotiating the intersections and complementarities between public and private health provision and the design of a regulatory structure that holds each component of the health system accountable; addressing the role of traditional systems of medicine;¹⁶ negotiating the federal dimensions and associated heterogeneity of health systems’ capacity across India's states to articulate the distinctive roles and responsibilities of the central, state, and local governments in delivering and regulating health care; and building health system capacity for enabling and regulating the use of technology in a way that supports and strengthens health delivery while protecting citizens’ rights. There are inherent tensions across these domains that need careful negotiation. The Commission will seek to unpack these tensions to identify the core principles of a health system that is inclusive, equitable, and accountable for the provision of quality health care.

This Commission will base its recommendations on a consultative and participatory effort that brings together key stakeholders across India's health-care landscape. The Commissioners include leaders from diverse sectors, including academia, the scientific community, civil society, and the private health-care industry, with a strong representation of women. We also recognise it is necessary to go beyond the traditional boundaries of expertise to actively engage stakeholders whose voices have rarely been heard in previous reports: those who deliver health care and those who receive it. Thus, we frame our goal as a Citizens’ Commission that will invite and elicit the opinions of medical providers, hospital chiefs, front-line and primary health-care workers, and a wide cross-section of people from diverse socioeconomic backgrounds. The Commission will enable participatory public engagement to develop a citizens’ blueprint for the implementation of UHC. The work of the Commission could also serve as the foundation for propelling a citizens’ movement to demand the practical realisation of the aspiration of health as a fundamental right. To this end, we now launch the Lancet Citizens’ Commission website and invite any persons or organisations who wish to contribute or partner in this initiative to contact us through the website.

While the COVID-19 pandemic has shown that health care is a crucially important investment for the economy, such an investment must be accompanied by a social compact that all Indians must have access to a similar quality of care without the risk of impoverishment. Health care cannot be viewed through the prism of charity for the poor and a commodity for the rich, but as an essential, fundamental element of sustainable development for the entire nation. The deep, historical, and structural problems that have afflicted health care in India must be addressed and the Lancet Citizens’ Commission aims to make recommendations that can improve the country's ranking among the world's health systems.¹⁷ Our Commission seeks to work with citizens, those who work in the health system, and the Indian Government to realise this aspiration. We aim to publish our Commission's report by Aug 15, 2022, when India will have completed its 75th year as an independent nation.