rectify the various inefficiencies that have befallen the health care system — calling for yet another round of well-directed reforms. India has the option of either moving towards a comprehensive UHC program or investing on primary care for now, and building UHC on a strong health system subsequently. While improving social determinants of health would go a long way to improve inequities in the system — as is clear from the case of South Africa — this is a broader developmental issue that can happen simultaneously, and should not stop specific health sector reforms from happening.
While India’s poor governance record puts up a natural constraint on any fast-paced reforms, it needs to at least acknowledge the country’s need for comprehensive health coverage and draw up a vision document that can be used as a benchmark to tally progress. Clearly, such a document can only be drawn up with serious prioritization of health, which is not evident yet from its public financing patterns. Also, it would require wider consultation with multiple stakeholders, backed up by solid evidence-based research, as has been happening in Brazil. Civil societies have been able to work with the government in Brazil, and to a much lesser extent in South Africa, but not so much in China and Russia.8 Wider consultations and inputs from civil societies are critical for reality checks. So far, in India, the health sector programs, including the launch of various health insurance schemes, has happened in a very centralized manner without wider stakeholder participation in the processes. This has meant that neither criticisms nor constructive suggestions have been taken on board before launching new schemes or scaling up old ones.
A very important issue that emerges from the analysis is the issue of decentralization and regional factors. All the BRICS countries have federal structures where the structure of decentralization has played a key role in access to health services. In fact, much of the complexity in delivering equitable and efficient health services has to do with the tiered federal structures in these countries. While South Africa grapples with intense inequalities in access between poor and rich areas and populations, China’s fiscal decentralization has often led to uneven outcomes, and the matching funds arrangement has meant many facilities are dependent on their local governments’ fiscal capacities. Russia has inequalities in human resources and infrastructure across regions, and despite increased funds at the center, the allocations of finances have been quite uneven. Also, it has a very complicated system of federal and regional health budget financing and health insurance funds. While Brazil is also dealing with uneven quality and availability of infrastructure and personnel, it is nowhere as stark as in some of these other countries, and higher spending on health and better allocations with enhanced funds might be able to improve the situation.
India on the other hand, has yet to articulate its own vision of UHC and financing in the context of its federal structure, where health is a state subject and the state governments are the major spenders. It makes little sense then for the central government to plan UHC on its own, when neither service provision nor significant financing come from it. The Fourteenth Finance Commission has decreed that a greater part of the divisible pool taxes would now go to the states, making the states squarely responsible for prioritizing health. In this scenario, India would need very careful planning around the center and states’ roles in financing and provisioning of health services. Should there be one consolidated scheme or should each state decide on how it wants to design a UHC package? Given that there are significant personnel and infrastructure gaps currently in many states, and states have historically not prioritized health in the sense of higher spending, what role can the central government play? Here, the Brazil model is useful, and evidence-based planning around UHC is the first step India should take. The planning would also require understanding where reforms are absolutely necessary and which reforms can happen during the course of the roll out.
A key area requiring focus is the public–private split in financing and provision. This is going to be a key issue in India where the private providers are the major players. Each of the BRICS countries has had their own private sector issues. Brazil’s private health insurance sector has emerged as a very important player though within rules set out by the relevant federal government institutions. China has been actively encouraging private players and has taken steps to remove regulatory barriers for greater ease of entry and stay; in fact, selected private hospitals are now eligible to provide reimbursable treatment for patients funded through social healthcare insurance.9 South Africa already has a large private provider and insurance sector. India will have to understand how lack of proper regulation in some of these countries has increased inequalities and decide how long it should wait before putting in place a series of regulation that would curb malpractices and economic burden on households. Whether or not it decides to have UHC, regulation is an area where reforms have been long overdue.
In sum, lessons from BRICS countries indicate that since India has yet to articulate a plan or vision for UHC, it can prepare itself better by learning from experiences of other countries, including BRICS. Such experiences are, after all, the best evidence base that the country can have in hand, to plan better for a future where a majority of Indians can access health services that they require at costs that they can easily bear.
Appendix
Table A.1:On governance indicators.
Source: World Development Indicators, World Bank.
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