Universal health coverage is considered one of the key targets of the 17 Sustainable Development Goals that were set in stone in New York in September. But just how feasible is it in a country like India?
Important questions have been raised over India’s ability to deliver UHC in a country of more than 1.2 billion, when it only spends just over 1 percent of its gross domestic product on health.
Under the National Health Assurance Mission, essential and generic drugs and diagnostics would be free at public health care facilities, while at the tertiary level for in-patients and outpatients in geriatric and chronic care, drugs would also be free or subsidized.
More than 60 million Indians are propelled into poverty each year because of unaffordable health care costs, driven by high out-of-pocket expenditure on medicines. According to the World Health Organization, 65 percent of Indians do not have regular access to essential medicines, yet the country is one of the world’s leaders in manufacturing such medicines.
So how exactly does the government plan to effectively deliver medicines to the poor in rural populations for free?
Dr. Krishna Rao from the Public Health Foundation of India, and an associate professor at Johns Hopkins School of Public Health, told Devex that even if medicines were provided for free, a sizeable portion of the population would still be without access.
“The main reason why many in India don’t have access to essential medicines is that in most of rural India, where the majority of India lives, there isn’t a functional public sector through which citizens can access care and essential drugs,” explained Rao. “So even if the drug prices were lowered, the systems of delivering them to people at a low cost are largely dysfunctional.”
Secondly, Rao said, in urban areas where there is “a vibrant qualified private sector and easy physical access to chemist shops,” the pricing of drugs can affect financial access to medicines, even though the public sector is “generally functional.”
Rao told Devex that because the private sector imposed substantial mark-ups on the cost of drugs, it affected people’s ability to access them.
“I think the government has an important role to play here. It has the power to ensure that people in need of drugs get them.”
Oxfam India, which has been working on policy and advocacy around UHC, agrees.
“The government bears the obligation of providing affordable access to medicines for all. Out-of-pocket expenditure on medicines is a major contributing factor to poverty and indebtedness,” said Malini Aisola, Oxfam India’s program coordinator for Access to Medicines. “The best solution is through implementation of state-led free medicines initiatives that involve government procurement and free provisioning of essential medicines through public health systems. Because procurement and supply are guided by an essential medicines list, rational use is also promoted.”
Rajasthan is one state in India’s north that has demonstrated the effectiveness of such a model. It has been running a free medicines scheme since 2011; the state government spends $50 million a year to provide 400 types of free medicines to patients in government hospitals. Every day about 200,000 people benefit from the scheme.
Aisola said free medicines initiatives were cost-effective strategies with the potential to limit impoverishment, yet warned that because medicines are predominantly accessed through the private sector, regulating prices at which they are sold was crucial to ensuring affordable access.
She explained that national price regulation under the Drug Prices Control Order 2013 has not only been ineffective at reducing prices, but several formulations of essential and lifesaving medicines have been excluded from price control.
“It stands to reason that a mechanism where ceiling prices are based on the cost of production should be adopted, instead of the market-based system that is currently in place,” she added.
Manoj Jhalani, joint secretary of policy at the Indian Ministry of Health and Family Welfare, told Devex that providing essential medicines free of cost at public health facilities was a “key priority of the central and most state governments.”
“States have set up, or are setting up, effective systems of procurement of essential generic medicines, quality assurance, standard treatment guidelines, prescription audits, and orientation of service providers to prescribe generic names and so on,” he said. “These states are being incentivized to roll out [the] National Health Mission — Free Essential Drugs Initiatives and get 5 percent more NHM resources if they declare a policy of providing free essential drugs in public health facilities.”
The government estimates that such an initiative will help raise access to health care from its current 22 percent to about 52 percent by 2017.
But despite this, the availability and affordability of medicines is still a major issue.
Rao said that making the public sector functional would take a lot more public spending than current levels. In addition, some essential drugs on the WHO list are missing from the country’s list, such as several diabetes, tuberculosis, HIV and cancer drugs.
Oxfam also raised concerns about the lack of mechanisms to check the high prices of patented medicines. It said the Indian industry could better support the affordability of medicines, including refraining from attempting to dismantle pro-public health drug price control policies aimed at improving access for patients buying medicines from the private sector. In the case of patented medicines, it could support and pursue legal provisions such as compulsory licenses to introduce generics quickly into the market.
Only time will tell whether India can deliver on its promise of UHC. This will require building a robust health care system that, to a great extent, will be reliant on appropriate public spending.
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