Mark Time: India's March to Universal Health Care Coverage

Abstract

This article evaluates the efforts underway in India to achieve universal health care coverage and the conditions that fostered its contemporary evolution. It finds that India's health system is characterized by private provision and financing, horizontal and vertical fragmentation, and weak governance arrangements. The article argues that these defining characteristics, which have solidified over time, account for poor health outcomes and make the system impervious to reforms as they deny the government levers to intervene and shape outcomes in the sector. While the government's recent efforts of increased public funding of national programmes have helped to reduce out of pocket spending, these are unlikely to work in the long run unless the government addresses the sources of the problems. The article argues that building health care governance, strengthening regulatory architecture, and stewardship over the system, in conjunction with increased public spending, are essential if the health care system is to provide affordable care to the entire population.

Program design, implementation and performance: the case of social health insurance in India

“…A number of empirical reviews have identified governance as a key factor shaping performance of social programs (Romzek and Johnston, 2005; Fernandez, 2009; Amirkhanyan et al ., 2011; Bali and Ramesh, 2015). Studies on health financing have focused extensively on the links between program design and performance, especially the effects of specific design elements such as resource collection, risk pooling and purchasing functions on performance measures such as financial protection, service utilization and financial sustainability (Lu and William, 2003; Llyod-Sherlock, 2006; Bansak and Raphel, 2007; Ekman et al ., 2008; Kwon, 2009; Witter and Garshong, 2009; Liu et al ., 2014).…”

Assessing health reform: studying tool appropriateness & critical capacities

“…Canada, Cuba, U.K, Hong Kong) where they have been bulwarks of efficiency. The challenge in India stems from the operational and political dimensions: hospitals are administered by State governments, many of which suffer from weak fiscal and administrative capacities (Bali & Ramesh, 2015b). This is aggravated by, until recently, central government's own very limited leverage to intervene in service delivery or regulate standards of care due to its peripheral role in financing and provision of health care in the country.…”

“…Health agencies in both state and central governments are staffed by non-specialists and career bureaucrats that are rotated across different agencies every few years which denies them opportunity to develop domain expertise. Hospital superintendents have limited autonomy and discretion in important administrative and personnel decisions (Bali & Ramesh, 2015b). At a political level, successive governments have been unable to divert more resources to these cash strapped hospitals (La Forgia & Nagpal, 2012).…”

“…India's earliest health policy document -The Bhore Committee Report published in 1946envisioned a largely publicly financed system with primary care delivered through a network of sub-centres and primary healthcare centres; secondary care through community healthcare centres; and advanced treatment at specialist hospitals in large cities across India (Bhore 1946). Seven decades since, this vision has not been realised (Bali & Ramesh, 2015b). Most healthcare in India is paid for privately, with limited risk-pooling, through OOP payments (Figure 1), and delivered at privately owned hospitals (Gupta and Chowdhury, 2014;Rao and Choudhury, 2012).…”

Designing Effective Healthcare: Matching Policy Tools to Problems in China

“…Achieving universal health coverage at a fiscally sustainable cost has been a key goal of governments in the developing world in recent decades (Bonilla-Chacin and Aguilera 2013;Hanvoravongchai 2013;Somanathan et al 2013;Marten et al 2014;Harimurti et al 2013;Bali and Ramesh 2015a). Despite their efforts in the form of increased expenditures and new programmes, a large share of total healthcare expenditure in developing countries continues to be financed by out-of-pocket payments (OOPs), for example, about 50 per cent of total health expenditure in China, India, Indonesia, Philippines and Vietnam (WHO 2016).…”