Universalising Healthcare in India: From Care to Coverage

Foreword
Acknowledgements
Introduction: The Idea of Universal Healthcare—Its Passage Through Time
	The Background of Universal Healthcare
	The World Health Organisation: Transformations Within
	Healthcare Strategies for the Other Half: International to Global
	The Universalisation of Healthcare in India
	References
Contents
Editors and Contributors
	About the Editors
	Contributors
Abbreviations
List of Figures
List of Tables
List of Maps
Part I Ideas, Concepts, History, and Practice of UHC in India
1 Universal Health Coverage: The Trojan Horse of Neoliberal Policies
	The International Context
	The National Context of UHC for India
	Contemporary Official Strategies to Provide UHC in India
	The Trends and the Challenges for the Future
	References
2 Universal Healthcare and Health Assurance Through Healthcare Industry and Market Mechanisms: Evidence Versus Ideology
	Background
	UHC: Legacy of Social Protection and Welfarism
	UHC in India: Policy Proposals and Measures
	Private Healthcare Services in India
		Healthcare as ‘Big Business Opportunity’, Engine of Growth
		‘Targeting New Segments’—Setting Up Clinics and Hospitals Outside Metropolises and Big Cities
		Infusion of Private Equity
		Role of Development Finance Institutions
	Discussion
		Impact of Market-Oriented Reforms on Expenditure, Quality and Comprehensiveness
		Adverse Impacts of Corporate Presence
		Experience of USA with Private Capital Financing
	Conclusion
		UHC and Health Assurance in Times of for-Profit Healthcare: Evidence Versus Ideology
	References
3 National Health Policy 2017: Securing Interests of Profits
	The Current Policy Context: The Consensus and Few Contentions
	National Health Policy 2017: Healthcare an Avenue for Quick Returns Over Investments?
	Making Resources Available to States and Enhancing Capacity to Spend: The ‘Cloud-Rain Conundrum’
	Private Provisioning: Consolidation of Capital and Destruction of Petty-Production
	Is Regulation the Panacea?
	Conclusions
	References
4 Interrogating the Proposed Universal Healthcare in India Through a ‘Quality’ Lens
	Introduction
	Conceptual Underpinnings of ‘Quality’ in Healthcare
	Levels of Quality in Healthcare Services
	Definition of Quality of Care at an Individual Level
	Definition of Quality Healthcare at a Population Level
	Challenges to Assessment of Quality in Healthcare
	Social Determinants of Quality of Healthcare
	Tracing ‘Quality’ in Healthcare Services Development in the Indian Context
	Contemporary Currents of ‘Quality’ in Indian Health Services
	Special/Specific ‘Quality’ Related Policy Measures for Public Institutions
	Emerging Discourse for Health Services Strengthening: Implications for Quality HLEG and Steering Committee Recommendations
	National Health Policies (NHP): Draft 2015 and NHP 2017
	The Way Forward
	References
5 Growth of Private Medical Colleges in Maharashtra and Its Implications for Universal Healthcare
	Methodology
	Rise of Private Medical Colleges in India: Time-Trend Analysis
	Regional Distribution of Medical Colleges and Intake Capacity: Interstate Analysis
	The Case of Maharashtra State
	Brief Profile of the State
	The Emergence of Marathas as the Dominant Caste in Maharashtra
	Economic and Political Power in Maharashtra
	Link Between the Cooperative Sector and the Ownership of Private Medical Colleges
	Growth of Medical Colleges: Time Trends, Spatial Distribution and Social Basis
	Spatial Distribution of Medical Colleges
	Social Basis of Private Medical Colleges
	Implication of the Growth Pattern of Medical Colleges for Universal Healthcare
	References
Part II Evidences and Experiences of Public–Private Partnerships and Health Insurance Schemes
6 A Critical Look at Public Private Partnership for Health Services in Karnataka
	Introduction
	Background of RGSSH
	Salient Points from the Evaluation Report of the State Government (Government of Karnataka, 2011)
	Community Response to Apollo-Managed RGSSH
	Karuna Trust Model of Primary Healthcare
	Discussion
	References
7 Role of Public Private Partnerships in Ensuring Universal Healthcare for India
	Introduction
	Types of PPP and Structural Issues: 1995–2015
	Policies Enabling PPP
	First Phase (1995–2005)
	Second Phase (2006–2015)
	Creation of PPP Cells
	Infrastructure-Based PPP Projects
	Evidence on Access, Quality and Processes of Implementation
	Quality of Care
	Processes of PPP Implementation
	Discussion and Conclusion
	References
8 Unaccountable Deaths and Damages: An Analysis of Socio-Legal Implications of Sterilisation Camp Deaths in Bilaspur, Chhattisgarh
	Background
	Economic Transition and Fertility Changes in India
	Family Planning Programmes: Yesterday and Today
	Re-Emergence of Malthusianism
	Legal Articulation of Rights in the Indian Context
	Legal Battles in India
	Is India’s UHC Model a Solution?
	References
9 Universal Healthcare and Universalising Health Insurance: Examining the Binary Through the RSBY/MSBY in Chhattisgarh
	Introduction
	Provider Perspectives
	Technology
	Settlement of Claims
		For-Profit (Private) Hospitals
		Public Hospitals
		Not-For-Profit Hospitals
	Beneficiary Perspectives
		Demographic and Socio-Economic Characteristics of the Female Patients
		Enrolment
		Hospitalisation
	Utilisation of the UHIS
	Oope
	Childbirth
	Current Concerns
	References
10 Aarogyasri Scheme in Andhra Pradesh, India: Some Critical Reflections
	Introduction
	Is Public Private Partnership in Healthcare Desirable?
	Growth of Private Sector
	Health Insurance: Benefits to the Private Sector
	RACHI Scheme
	Coverage and Budget
	Key Stakeholders in RACHI
	Achievements of the RACHI Scheme
	Critical View of the Aarogyasri Scheme
	Skewed Towards Tertiary Sector
	State Sponsored Private Health Systems
	Under-Utilisation of Public Healthcare System
	Pressure Tactics and Lobbying
	Issues of Sustainability
	Ethical Issues
	Discussion
	References
11 Health Insurance to Achieve Health for All: A Critical Appraisal of Pradhan Mantri Jan Aarogya Yojana
	Grossly Inadequate Budget
	Inadequate Coverage and Containment of Out-of-Pocket Expenditure?
	An Inefficient Health Care Model
	No Protection from OPD Expenditures
	Undermining Primary Care
	Non-universal: A Faulty Application of Insurance Logic
	Conclusion
	References
Part III Drugs and Pharmaceuticals: Critique of Policies and Practices
12 Developments in India’s Domestic Pharmaceutical Sector and Implications for Universal Healthcare in India
	Introduction
	Genesis of a Domestic Pharmaceutical Industry
	Impact of Reforms on the Indian Pharmaceutical Industry
	Globalisation of the Indian Pharmaceutical Industry
	Implications for Universal Healthcare
	References
13 Vaccine Policy of the Government of India: Driven and Controlled by Vested Interests?
	Introduction of New Vaccines: Role of WHO
	Hepatitis B
	Evaluation of Benefits After Introduction of Hepatitis B
	H. Influenza B
	Accelerated Development and Introduction Plans (ADIP)
	Multivalent Pentavalent Vaccines and Adverse Events
	Rotavirus Vaccine
	Ad Hoc Revision of the AEFI Classification: Downplaying Adverse Events
	The Official Revision of the AEFI Classification
	Consistent Causal Association to Immunisation
	Inconsistent Causal Association to Immunisation
	Indeterminate
	CIOMS/WHO Report on Vaccine Pharmacovigilance
	TOKEN Study and Population Based Evidence of AEFI
	Inflating Benefits to Match Cost
	WHO Cost-Effective Thresholds
	Pandemic Flu: WHO-Vaccine Manufacturer Nexus
	National Technical Advisory Groups
	Public Interest Litigation for Vaccine Policy
	Immunisation Policy for Namesake
	Way Forward: A NICE Solution Suggested Previously
	The Health Economics Model
	References
14 Availability and Access to Medicines: Some Issues in Pricing
	Introduction
	A Brief Historical Context
	Medicine Pricing in India: Some Features
	What Can Be Done About Providing Medicines—To Those Who Need It—In the Public Health System?
	Feasibility of Public Provision: The Experience of Tamil Nadu and Rajasthan
		Drug Price Regulation
	Omission of Useful Life-Saving Drugs in the NLEM-2011 and NLEM-2015
	Case of Anti-Diabetics as Illustration of the Ineffective Price Control Policy
	Fixed Dose Combinations and Price Control
	Pricing of Patented Drugs
	Conclusion
	References
15 Vaccines and Vaccine Policy for Universal Healthcare
	Introduction
	Vaccines Under Universal Healthcare
	PPPs and Distorted Vaccine Needs
	Epidemiological Evidence from India for New Vaccines
	Rotavirus Vaccine
	Pentavalent Vaccine (DTP–Hepatitis B–Hib)
	The Need for an Evidence-Based Policy
	Critique of the Health Ministry’s National Vaccine Policy
	Conclusion
	References
16 Drugs and Vaccines in Healthcare: Problems and Possibilities
	Drugs
	Vaccines
	References
Part IV Missing Links in the Debate
17 The Elusive Development: Poverty, Inequality and Vulnerability
	Economic Growth
	Creation of Employment
	Wages
	Conditions of Work
	Poverty
	Inequality
	Vulnerability
	Development Policies
	Conclusion
	References
18 Water Governance and Supply in Urban Areas
	Postscript
	References
19 Challenges of Reclaiming the Public Health System: Experiences of Community-Based Monitoring and Planning in Maharashtra
	Deepening Democracy to Strengthen Public System
	Public Health Experience from India
	Overview of the CBMP Framework and Processes in Maharashtra
	Scale of CBMP in Maharashtra
	Key Processes in Community-Based Monitoring and Planning
		Formation/Expansion and Capacity Building of Community-Based Committees
		Community Data Collection and Filling Health Report Cards
		People’s Tribunals: Jan Sunwai or Jan Samvad
		Periodic State Level Dialogues
		Community-Based Planning
	Indicators of Positive Impact: People are Returning to the Public Health System
		Significant Rise in Positive Ratings of Public Health Services in CBMP Areas
		Significant Increase in Utilisation of PHC Services: Evidence from Thane District
	Selected Stories of Change Related to Community-Based Monitoring in Maharashtra2
		Community Monitoring Helps to Complete the Half-Built Sub-Centre
		Community-Based Planning Leads to Major Improvements in Nasarapur PHC
		Kavita Chooses the PHC for Her Delivery and ‘Trupti’ is Born
	Some Further Steps and Decisions Required to Carry Forward Community Action Processes
	Experiences of Experiments on Deepening Democracy in Public Health
	References
20 Constrained by Purchasing Power: The Story of Calorie Intake in India Post-liberalisation
	Introduction
	Trends in Calorie Intake
	Average Calorie Intake
	Percentage of Persons Above Calorie Cut-Off
	Factors Influencing Calorie Intake
		Increasing Mechanisation?
		Expenditures and Calorie Intake
	Engel Curves
	Role of Purchasing Power
	Relation Between Income and Calorie Intake
		Stress of Non-Food Requirements
	Pressure of Burgeoning Food Prices
		Effect on Food Budget
	Conclusion
	References
21 Is There an Escape Route from the Smog of COVID-19 Pandemic?
	The Delay
	The Lock Down: A One Dimensional Golden Arrow
	Building and Strengthening Infrastructure
	The Present Policy Concern
	Conclusions
	References
Postscript
What Has UHC Contributed and for Whom?
Justifying UHC and Carrying It Forward
At the Crossroad
References