By Amandeep Singh Bamrah

Abstract : First in a series of six, this article presents an overview of progress made over the last decade, and places in perspective key insights from Amartya Sen and Jean Dreze, that continue to remain relevant in our time. The series intends to lay out blueprints for crucial reforms, and to explore the path towards an efficient and universal healthcare system.

The UHC Day Logo from the World Health Organization

Introduction

Amartya Sen and Jean Dreze present a powerful analysis of the underlying problems hindering India’s flight to true progress and freedom. Education and healthcare form the foundational blocks upon which the socio-political and economic journeys of a nation are built, and the two distinguished economists urge the government, and more importantly the people of India, to go back to the basics. They prescribe the overarching path of social awareness and collective action to move towards sustainable economic and human development. This powerful diagnosis and prescription, presented in their seminal work “An Uncertain Glory”, was published in 2013. This article intends to revisit the findings and recommendations of this powerful work, and also analyse how far they remain relevant eight years later.

In their meditative analysis of India’s health care crisis, Sen and Dreze begin with a frontal lament on the seeming absence of healthcare as a topic of concern in the public eye. Newspapers, media, and civil society in India at large, were seen to provide relatively less attention to healthcare (as well as education) when compared with liberal democracies on similar levels of development. Sen and Dreze point out two significant healthcare challenges, “first, its massive inadequacy, and second, the near-absence of public discussion of this inadequacy.”

Bringing Healthcare into the Living Room

On the second problem, the country may have just made unintentional yet fortunate progress with its experience of the coronavirus pandemic. Discussions around health, ranging from medication, hygiene and public health to relatively conspicuous things like ventilators and oxygen cylinders, were violently propelled into living rooms and forums across the country. . The media coverage provided to the pandemic at large was also reflected in the increased frequency of editorials and eminent pieces on public policy in the healthcare sector. Brutal as it was, it took a pandemic to extinguish to some extent the public and governmental apathy towards the health system. It is now imperative that this newfound energy and focus pertaining to the health sector is constructively steered towards better public policy outcomes. The most impactful outcomes on healthcare are not to be found in shiny new super speciality hospitals, but rather in a renewed focus on primary and public health, with an agenda to keep people “healthy and at home”.

Miles to Go with Little to Go Around: Public Expenditure Levels

Following Sen and Dreze’s check-up of the Indian healthcare sector, this article will trace the trajectory of select indicators as discussed by the two economists. This analysis begins by revisiting  the issue of low public expenditure on health.

Table 1: Public Expenditure on Health, 2010 and 2018
	As a share of GDP	As a share of total health expenditure
2010	2018	2010	2018
India	0.9	1.0	26.2	27
South Asia	0.8	1.0	25.8	27.3
World Average	5.8	5.9	60.2	59.5

Source: World Development Indicators

There has been practically no progress towards the government’s self-declared intention of 2 to 3 per cent share of the GDP being reserved for the public expenditure on health. According to Sen and Dreze, such low levels of public health spending are not seen anywhere else in the world, and this low level is a major reason for the abysmal condition of public health facilities in India.

Healthcare is the best example of a publicly provided private good with tremendous positive externalities for society, and equally disastrous consequences if it is not properly provided to all. In the call for increasing public spending on health, there is no question of political ideology of the left versus the right. State funding for healthcare forms an integral part of mature capitalist societies in Scandinavia (for instance, Norway) and Northern Europe (for instance, the Netherlands), and this funding has led to the admirable standard of healthcare for citizens in these countries, irrespective of their position on the economic ladder..These economies have their own share of problems in the form of serious wealth inequality, but the public commitment for education and health ensures that the capabilities of the people are not affected by their relative position on the socio-economic ladder. This public commitment, of course, requires the basic prerequisite of decent levels of public spending to begin with.

Problems with Targeted Insurance

India’s poor face the double whammy of lack of access to public health, as well as an unaffordable, and arguably equally inaccessible private health sector. This is where the Indian state has decided to skip the essential step of social infrastructure creation and move towards the ambition of targeted health insurance. However, it is nearly impossible to implement a sustainable “targeted” health insurance scheme due to issues such as adverse selection and moral hazard, the basic economic arguments which are already well entrenched, for instance, in the government school system. Unless the relatively well-off (and politically and visibly influential) groups participate as stakeholders, it becomes difficult for the government to look at social infrastructure as more than just a “welfare” nuisance that it has to carry forward for the sake of it.

Progress on Key Performance Indicators

Table 2: Progress on health-related indicators
Women and Child Health
	2011	2020	Change
Infant Mortality Rate (IMR)	44	28	(-)36.36%
Maternal Mortality Ratio (MMR)	212	113	(-)46.6%
Life Expectancy
Female	67.7	70.95	(+)4.8%
Male	64.6	68.46	(+)5.9%

Source: World Development Indicators

While there has been significant progress on the general health-related indicators, India still has a lot to catch up to, and all efforts must be made to exploit efficiencies in the health system to further improve these indicators. The Maternal Mortality Ratio (MMR), which gives the estimate of maternal deaths per 100,000 live births, has seen commendable reduction, pointing to positive steps being taken to improve the health and safety of pregnant mothers. This improvement in Key Performance Indicators (KPIs) is further supported by positive results coming from National Family Health Survey data, which points to better state support for antenatal care both before and after childbirth. This progress has been made possible with consistent efforts and dedication of resources. The remaining gaps in this system need to be plugged to hasten the reduction in the Infant Mortality Rate (IMR), MMR and related health-indicators.

Immunization Progress

Table 3: Proportion of one-year old children who are immunized against:
	BCG		DPT		Polio		Measles		Hep B
2012	2020	2012	2020	2012	2020	2012	2020	2012	2020
India	87	85	72	85	70	85	74	89	37	85
World Average	90	85	85	83	86	83	85	84	75	83

Source: UNICEF The State of the World’s Children Statistical Tables

Table 4: Proportion of children aged 12-23 months with full immunization
India	2005-06	2015-16
43.65	62.46

Source: National Family Health Survey

What Needs to be Done?

India’s progress across health indicators points to an optimistic path for the future. At the same time, there is a need for impatience when it comes to increasing the level and pace of this progress. Since healthcare involves multiple stakeholders, there is no definitive one stop solution. As a result, this article is the first, in a series of solution-oriented pieces looking towards addressing persistent problems and moving towards an efficient healthcare system that takes everyone along. With that said, all roads and efforts towards better healthcare must ultimately contribute to the idea of “Universal Health Coverage” (UHC). This focus on UHC would surely start at the very basic level, with a truly “primary” role for the Primary Health Centres.

The efforts towards UHC will happen in multiple sub-sectors that need special attention, and the instruments for change would primarily centre around three interlinked directions: renewed policy direction, focused investment, and socio-political change.

These three directions of efforts will need to happen in five critical subsectors of the healthcare ecosystem to ensure a gradual move toward efficient UHC. These five sub sectors are: nutrition, financing, technological interventions, institutions and culture, and finally, the triad of pharmaceuticals, alternative medicine and AMR.

Figure 1: The Framework for a Gradual Move towards Efficient UHC in India

This first article, therefore, serves as an overview of the progress achieved in the last decade, and provides perspectives for finding solutions to lingering problems. India is uniquely positioned to quicken its pace of progress towards better health outcomes for all. However, the task ahead is complex, and our efforts will need to rise beyond the realm of public policy alone. It is the solemn imperative of all stakeholders: civil society, academia, government, the corporates and the citizenry, to work towards better health outcomes with a rapid and multi-directional approach. The task at hand is not so much as finding a good health system, but building one. The positive outcomes of an efficient and universal health system will be necessary in propelling the country towards its limitless potential, in the truest sense of the phrase.

Amandeep Singh Bamrah is a Young India Fellow at Ashoka University

Image credit – Oxfam International