Perhaps most worrisome is India’s gross inability to spend more on health, the starting point for any change.


Policymakers and thought leaders across the world have drawn much political capital by talking at first about “Health for All”, and then Universal Health Care. While the framing, terminology and timelines have changed over the years, the matter has remained a consistent topic of debate in almost every country. The reality of the ongoing pandemic—one with no parallel in recent history in terms of the disruption caused—has thrust this matter back to the forefront of all policy formulation. Add to this pandemic the grave reality of widening income disparities, and it’s easy to understand why expeditiously attaining broader health coverage has now become the topic of the hour.

To better understand the subject of universal health care, it is useful to start with the modern genesis of this desirable measure. Post the carnage of the Second World War, which saw over 55 million direct deaths and another 30 million casualties due to war related disease and famine, Fabianism-imbued welfare became the hallmark of most democratic governments, especially in Europe. The Conservative Premier Winston Churchill, who had led Great Britain to victory over the Nazis, was replaced by a pronounced Socialist in Clement Attlee. Just months after the war ended, Attlee emerged as the leader in national polls, promising a national health scheme and additional state-funded welfare. In fact, health care became a north-star of a new social orientation, as a series of nations ranging from the Nordic countries to Japan and Canada gradually rolled out their variations of universal health care.

Fast forward to 1977, and the General Assembly of the World Health Organization unanimously declared that the major social goal of governments should be the attainment of a level of health that would permit all people of the world to lead an economically and socially productive life. Perhaps too ambitiously, the date to reach this target was set for the year 2000. The following year, the Declaration of Alma-Ata was adopted by 134 member nations including India, identifying primary health care as the key to achieving “Health for All”.

The Declaration emphasised the role of the State in actively providing adequate health care and recommended that Third World countries use a decentralised approach based on setting up rural health units instead of city-hospitals and prioritise low-cost preventive care measures over high-cost curative ones. The reformulated approach based on a holistic concept of health and equitable redistribution of resources, was tantamount to the State taking responsibility for comprehensive health care provision.

India, an enthusiastic participant of the Declaration, announced its first National Health Policy in 1983 and echoed the WHO call for “Health for All” by laying down specific goals on various health indicators it hoped to achieve by different time-frames such as 1990 and 2000.

While many would applaud the idealistic intention, most member-nations fell grossly short of reaching the objective of “health for all” by 2000, with many nations in fact, giving up this goal soon after adoption. Social scientists reviewing this failure point first towards a design flaw that overestimated the political power of rural people and questioned the belief of commonality of interest within the communities. Western drug manufacturers and their international aid agencies had all along projected primary health-care as a second quality care, and something primitive to keep people under social control. By the late 1980s itself, the more redistributive state-led health care had begun to be replaced by free-market neo-liberal policies.

Badly hurt in terms of its image, with the WHO itself giving up the laudable goal, the United Nations Organisation came up with the 8-point Millennium Development Goals (MDG) to be reached by 2015, with three of these goals being specifically health related. While some of the initiatives were “financeable” in the marketplace (with multilateral agencies generally willing to put up grant funds at the initial stages), the mission was never really subject to independent evaluation and was quickly replaced in late 2015 by the alternative Sustainability Development Goals (SDG) to be achieved by 192 signatories by 2030. Once again, health is central in its stated vision of “Leave No One Behind”, and although not explicitly spelt out, the attainment of Universal Health Care (UHC) by all member nations is a key objective.

Today, the progress globally towards UHC has been underwhelming, with 64% of the population covered—worse, improvements have been very uneven, particularly in poorer countries. While developed economies have struggled due to the politicisation of the issue, in countries such as India—which one should point out is always enthusiastic to embrace multilateral pronouncements (with authorities also quick to tout acronyms like “Education for All”, “Food for All”, “Housing for All”)—there have been far more substantive issues. Undoubtedly, some progress has been made—notably, enhancing life expectancy to 69.4 years, keeping population growth in check by lowering the net fertility rate to sub two, and having success in vertical programs such as polio and small-pox eradication, tuberculosis and malaria control. However, so far we’ve plucked only the low hanging fruit.

With the poor and lower middle class accounting for a billion people (three- fourths of population), acceptable health care has remained a distant dream. Public health insurance coverage is confined only to the organised sector—armed forces, public service workers with engagement contracts—and only a fraction of the rest can afford the significant premia for private insurance. 65% of India is in rural areas and apart from minimal access to functioning secondary care, they usually lack even basic primary health care and access to potable water, a prerequisite for healthy living and maintenance of essential personal hygiene and sanitation. A 2020 report on the “State of Food Security & Nutrition in the World” by the FAO drove India’s current situation home—when detailing the cost and affordability of health diets around the world, it concluded that a staggering 18% of South Asians (586 million, with India representing the largest chunk) are unable to afford a “nutrient-adequate” diet, and 58% (1.3 billion) unable to pay for a “healthy” diet. During the pandemic, when employment and income have steeply declined, these numbers would have only ballooned.

These inadequacies manifest themselves in a number of health metrics—India’s infant mortality rate remains abnormally high (37 per 1,000), our maternity mortality rate (MMR) stands at 117 deaths per 100,000 mothers, and the high incidence of undernourishment is responsible for a third of the deaths of infants under five. As a data point, the SDG goal for MMR is 70, with India’s health policy target being to virtually eliminate it—yet, in recent years in states like Uttar Pradesh and Madhya Pradesh, this rate has accelerated to 197 and 220. With hospital beds at one of the lowest levels in the world at 5 per thousand people, health care has remained skewed towards urban areas with an ineffective network of health centres and greater neglect of women and rural areas has taken a heavy toll on this marginalised population.

Perhaps most worrisome is India’s gross inability to spend more on health—the starting point for any change. With our population expected to reach 1.64 billion people by 2048, India would not just have surpassed China but would be more than double the population of Europe (all 44 countries combined). At 1.6% of its modest GDP, India’s annual public health care spend of US $2 per capita is amongst the lowest, comparable only with the poorest sub-Saharan nations. Contrast this, with the average out of pocket private expenditure being twice that amount (Rs 300), and we’re left with an unvirtuous cycle of poor households slipping further into debt and impoverishment after treatment of any sickness.

In today’s day and age, apart from being grossly inequitable, this is unsustainable and calls for a renewed attempt at overhauling our health care system. Universal Health Care may seem a distant goal, but its attainment must now become non-negotiable and the fulcrum of a more people-centric public policy.

Part II of the article, “Reorienting Public Health Care in India for Sustainability” will appear in the next edition of The Sunday Guardian.

Dr Ajay Dua, a development economist and a former Union Secretary, had specialised in health care and its administration at London School of Economics and was a former DG of ESIC.