and financing.
The total health expenditure in India for 2013–2014 was 4.02% of the country’s GDP, with government expenditure at 1.15% of GDP (National Health Accounts, 2013–2014), which is lower than the average for low-income countries (National Health Profile, 2016). Out of total health expenditure in India, household out-of-pocket expenditures are 69.1%. The high OOPS and low public investment have remained more or less the main features of the Indian health care system over many years.
There have been a few attempts at moving towards a wider health coverage system, notably the High-Level Expert Group set up by the Planning Commission, which brought out a blueprint of the possible ways India could move towards UHC. With a change in the government at the Center, a National Health Assurance Mission was set up as well, which submitted another blueprint of UHC to the government. The recommendations of these committees were not implemented. Apart from these, there have been two major programs which can be thought of as highlights of India’s health sector journey over the years. These are the National Rural Health Mission (NRHM) launched in 2005 and the Rashtriya Swasthya Bima Yojana (RSBY) launched in 2008.
The NRHM — now called the National Health Mission or NHM — can possibly be called a true health sector reform in that it changed in some fundamental ways the workings of the health systems in the country. The aim of NRHM was to ‘carry out necessary architectural correction in the basic health care delivery system’ (Government of India, 2005) mainly to improve access by strengthening health systems especially in the rural areas. There have been numerous studies on the NRHM, and while some argue that it may not have improved the situation like envisaged initially, it has led to improvements in parameters like immunization, institutional deliveries, and antenatal care (Hussain, 2011). Like most programs that are across the health sector, the NHM may have played a relatively greater role in national program priorities like disease control programs of the government. While the changes were not uniform across states, the NRHM did usher in some significant process changes and strengthened health systems considerably in many states of India.
The RSBY is one of the largest social welfare schemes that provides health coverage to poor informal sector workers and currently covers more than 41 million poor families. It is a hospitalization scheme that was launched by the Ministry of Labor and Employment (MOLE); and only 2017, it was transferred to the Ministry of Health and Family Welfare (MOHFW). The RSBY is seen by some as the most successful health sector reform — and not merely a program — in India. There is little doubt that enrolment into the program is massive, but whether it has achieved its objective of reducing OOPS on hospitalization and improving access is still being contested. Few studies exist that look at the impact of health insurance on out-of-pocket spending (OOPS), and the evidence seem to be mixed on whether or not coverage for hospitalization like the RSBY reduces OOPS (Seshadri et al., 2012; Selvaraj and Karan, 2012; Fan et al., 2012; Shahrawat and Rao, 2011). Nevertheless, some argue that the mere fact that RSBY happened on such a massive scale was because of strong political will to make a difference in the social welfare situation in India, and it has the potential to move the UHC agenda forward (Zubin et al., 2015).
The reason why RSBY cannot be called a health sector reform in the true sense of the term, especially in the context of UHC, is because RSBY happened in isolation, as a scheme and not as a part of a coherent well-planned UHC strategy. RSBY was not based on the principle of risk and income pooling, was not comprehensive, and did not fit into any broader plan for UHC.
More worrying is the widespread trend across states to replicate the RSBY model, without paying attention to its merits and demerits and with very little evidence-based understanding of whether or not it will improve access and reduce costs in the system. In the last budget, the Prime Minister announced a National Health Protection Scheme, which is essentially RSBY in a scaled up fashion for the entire BPL population with a higher ceiling amount of Rs. 1,000,00.7
A set of health sector reforms for UHC has yet to take place in India, and it is yet to draw up a blueprint of a comprehensive UHC program. As for incremental reforms, there have not been that many over the years, evidenced by a poorly performing primary health care system, almost totally unregulated private market for health, and lack of comprehensive coverage for the majority of the population. The significant inequity in access and financing situation has remained somewhat the same over the years, and the government’s priorities in the health sector (MOHFW, 2015) can be further questioned based on its very low investment in the sector.
UHC in BRICS: Takeaways for India
The experiences of the four countries in improving access to health services in their countries towards universality offer valuable insights and lessons that India can learn from. In Table 5, we summarize the key points that emerged from the four-country (excluding India) analysis above.
The last column in Table 5 indicates that the two countries that have made substantial progress towards UHC are Brazil and China, with almost all the parameters showing positive results. While both the countries are struggling with concerns like shortage of physicians made worse by increasing NCDs, Brazil in particular has some way to go in raising the share of health in total government expenditure. Nevertheless, Brazil’s attempt at consolidation and pooling is commendable, because it uses general tax revenues to give similar services to all its population groups.
All the countries except India have a vision document for UHC, though Russia and South Africa have yet to translate all the stated objectives into action. Both Russia and South Africa could not implement all the administrative and legal reforms, and as a result these countries are struggling with complex and sticky issues of operational inefficiencies. Russia’s is a unique case because of its political economy legacy, but abrupt changes in policies and programs without proper groundwork have delayed and arrested progress towards UHC. As a result, Russia has been struggling with high OOPS. The only two countries with proper reforms and implementation are Brazil and China, despite the varied concerns with the current situation. The governance results indicate that with Brazil and China, Russia has also done well, and it may not be very difficult for it to turn things around with proper planning and foresight.
What Lessons Can India Draw from These Experiences?
While both Brazil and China have been able to make serious progress towards UHC, the differences between the two are quite stark. Brazil’s reforms were truly incremental, undertaken gradually over many years; China had a much faster process. Also — and this may be related to the previous point — the investment by the government in Brazil has been steady and has grown modestly, while China saw a sharp increase in government expenditure on health. If India wants to fast-pace its move towards UHC, it might want to consider China’s model and immediately prioritize health by moving from the very low expenditure levels to a level that can at least make it possible to take the initial steps towards UHC. Otherwise, if it wants to take it slow — the better model might be that of Brazil’s with numerous reforms preceding the actual UHC roll out and then working incrementally thereafter. The latter is in some ways superior because unless one is absolutely sure of what is being implemented, sudden and abrupt changes might not be the best way forward. The experiences of Russia and South Africa indicate that some legal and administrative reforms are absolutely necessary before making major changes in the architecture of health financing and service delivery.
Table 5:Key parameters in the progress towards UHC in BRICS nations.
The other important fact that emerges from these country experiences is the importance of strengthening primary care. In fact, while Brazil and China have been able to do so, Russia is another example of a country that is able to offer some basic services to its population, due to its historical legacy. While Russia has not done as well in UHC despite fairly high investments, given its positive governance outcomes, a moderately well-functioning primary