India will observe Universal Health Coverage (UHC) Day on December 12. The country has many promises to keep as it moves towards the 2030 target for delivering UHC and before it can become Viksit Bharat by 2047. This calls for assured success in two endeavours: By 2030, all health benefits promised by UHC must be efficiently and equitably delivered; and by 2047, policies across multiple sectors must create a healthy society where security of health, nutrition, and income, among others, are assured.
To deliver UHC, India’s health system needs to be agile (in responding to present health needs), adaptive (readily recalibrate resources and services to match altered circumstances) and anticipatory (predict and prepare for future health needs). At all times, it must provide wide service coverage with minimal financial hardship to persons seeking care, while reducing barriers to utilization of care (foregone care).
It has to be nimble in readjusting priorities and service delivery mechanisms when unanticipated developments, such as epidemics, pandemics, natural disasters and conflict, disrupt the functioning of the health system. Health systems must maintain a reserve of rapidly mobilisable health workforce, to enable a swift surge response when needed. Protection of supply chains and ramped-up production of drugs, vaccines and equipment must be planned ahead. Under UHC, disconnects between primary, secondary and tertiary care, allopathic and alternative medicine systems, and public, private and voluntary health care providers must be bridged. The government must guarantee all promised services, even if it is not the sole provider.
The health system has to anticipate future challenges in a rapidly changing world where many social, economic, environmental and commercial determinants of health are in a churn. As several complex adaptive systems (such as health, environment, food systems, urban growth) are connected, challenges to population health will change in nature and number. Health systems should proactively prepare for foreseeable future needs. Demographic shifts will propel future health needs. About 193 million Indians will be over 65 years by 2030. By 2050, they will number between 319 million and 347 million. Health and social systems, therefore, must promote healthy ageing, disease prevention and provision of timely health care for a variety of age-related disorders and multi-morbidity.
By 2030, around 40% of India’s population will be living in urban areas, rising to 50% by 2050. Unplanned urban growth will result in crowded, insanitary human habitation with increased susceptibility to malnutrition, infectious diseases, addictions, non-communicable diseases(NCDs) and mental health disorders. This calls for healthy urbanization alongside robust primary health care systems.
India must also ensure gender equity in access to affordable health care. The gap between life expectancy (LE) and healthy life expectancy (HLE) is greater in Indian women than in men. Compression of morbidity and increased well being among women should be essential health system goals. Besides striving to reduce maternal mortality, we need to address maternal morbidity, alongside NCDs and mental health disorders among women.
Education opens doors to income-generation that enables better housing, better nutrition and access to health care. Pathways for formal education must be widened and non-formal education must be promoted through diverse channels.
Health threats are rapidly escalating as the climate crisis plays out. Be it oppressive heat or inundation risks that coastal areas face, health systems must respond to both acute and chronic health care needs of vulnerable communities. Agriculture will suffer too, with reduction in yield and nutrient quality of staples, increased perishability of fruits and vegetables, lower milk yield from cattle and reduced fish yields. Policies across sectors must respond to these challenges. Vector-borne and water-borne diseases will gain speed and spread. NCDs such as cardiovascular diseases and cancers will rise in incidence, while mental health disorders will become more widely prevalent. As humans and animals migrate across land and sea, fleeing heat and floods, zoonotic infections could rise — this calls for robust cross-species microbial surveillance systems (One Health).
Global economic instability and a disrupted trade environment will stoke uncertainties through food price volatility and energy pricing, which can impact household incomes and endanger health. India must guard against the health impact of growing economic inequalities. The journey from UHC to Universal Health Assurance (UHA) must be enabled by our ability to withstand a turbulent world economy and an egalitarian commitment to reduce income and social inequality.
We must guard against commercial determinants that can derail health by promoting the consumption of unhealthy products. Tobacco and ultra-processed foods (UPF) lead to maladies such as cardiovascular diseases, cancers, diabetes and obesity. India’s aspiration to create a healthy society needs multi-sectoral efforts to curb this menace.
Health promotion and disease prevention are critically dependent on policies and programs in other sectors becoming aligned with health system priorities. Even for accessing health care, functional roads and transport services are needed, while no health care facility can function efficiently without an assured supply of water and electricity.
To realize collaboration between different sectors, we need both top-down and bottom-up pressure. The former will come from political directives given by the Prime Minister (at the Centre) or chief ministers (in the states) and inter-departmental committees giving executive direction. Bottom-up pressure will come from active community engagement at different levels of program planning and execution.
Much needed reforms in health systems (at the central and state levels) cannot come from amorphous intentions but will need the form and strength of legislation. We must enact a Right To Health law, along with a Public Health law which should be enacted nationally and in all states. The Clinical Establishments Act must be adopted by all states and Union Territories. Only then can the UHC and UHA vision materialize.
K Srinath Reddy is chair, Center of Universal Health Assurance (CUHA), Indian School of Public Policy. The views expressed are personal
