Universal health coverage in India: the time has come.

In 2006, the National Sample Survey Organization reported that 28% of rural Indians and 20% of urban Indians could not access healthcare because of financial barriers. These percentages had doubled over the previous two decades. At the same time, 39 million Indians were noted to have been pushed below the poverty line because of unaffordable healthcare costs. These numbers rise every year. There is no denying that India’s economic growth over the past two decades has not been reflected in its health indicators. Though the country’s infant mortality rate has improved recently, it stands at 47 per 1000 live-births, in comparison to Sri Lanka’s 10. Similarly, India’s maternal mortality ratio of 212 per 100 000 live-births compares poorly with Sri Lanka’s 39. In the past decade, the progress of our other neighbours, such as Bangladesh and Nepal, in these vital health indicators has been much more impressive than ours. The fact that the prevalence of undernutrition among our young children is 42% has been described as a ‘national shame’ by the Prime Minister. Within India, there are huge inequities in health across states, between rural and urban areas and among various social strata. A girl born in Madhya Pradesh is six-times more likely to die before her first birthday than her counterpart born in Kerala. A woman from a Scheduled Tribe is far more likely to be anaemic and underweight than an urban upper-caste woman. The two major contributors to India’s poor health status are the lack of attention given to the social determinants of health (such as drinking water, sanitation, nutrition, the environment, education and livelihoods) and the failure of the health system to provide essential promotive, preventive, diagnostic, therapeutic and rehabilitative services to all citizens, with assurance of easy access, appropriate quality and financial affordability. Together, these factors have undermined the average Indian’s ability to enjoy good health across a long life span, with the poor being the worst victims of imposed and ignored ill-health. While paying special attention to the needs of the poor, the principle of universality must be applied to assure essential health services to all citizens. This is because many persons above the controversially defined ‘poverty line’ are also very vulnerable to the impoverishing impact of health expenditure. Also, programmes designed ‘only for the poor’ are likely to end up as poor programmes, in design as well as delivery. Every section of society must have a stake in the success and sustainability of social sector services. Targeted programmes often fail to deliver the promised services and do not offer real help to the intended beneficiaries. A low level of public financing (stagnant at around 1% of our gross domestic product [GDP] for many years) has contributed to the inability of the health system to provide requisite services. This has led to a high level of ‘out-of-pocket’ or private expenditure on health (currently estimated at 71% of all spending on health). In per capita terms, India’s public spending on health is US$ 43, compared to Sri Lanka’s US$ 87. Public financing of health varies widely among the Indian states—Kerala’s per capita expenditure is three-times more than that of Bihar.