Nine years ago, on a sultry afternoon, inside an unused warehouse on the outskirts of the temple town of Tiruchirapally, I had a conversation with an young mother I will never forget. She was a Sri Lankan Tamil refugee, one of the many who had fled a civil war in her island home so that her children could have a better future. Now, this warehouse-turned-refugee camp was her home. “If I had money, I could do many things. But if I have just `10, I know how I will spend it — an egg, and an exercise book for my child,” she said. I remember her because she showed conviction and clarity in face of adversity.
I thought of the woman last Sunday while watching Aamir Khan’s Satyamev Jayate. The programme showcased a lightning rod issue: the horrific and spreading menace of medical malpractices in India told through real-life anecdotes of predatory doctors and clinics and hapless patients.
The response to the programme strengthens the case for clarity in the ongoing debate on Universal Health Coverage (UHC), one of the UPA government’s more inspirational ideas. There is a vision. But clarity? We are still waiting. On the face of it, everything is going swimmingly. Prime Minister Manmohan Singh talks about his resolve to do more for healthcare. India affirmed its support to UHC at the World Health Assembly in Geneva last week. The topic was a big draw. Everything seems to be going hunky-dory. But some of India’s best-known health advocates are worried. Why?
Last week, activist doctor Binayak Sen and his wife Ilina Sen, also a public health advocate, gave a hint of what is simmering beneath the surface by expressing their reservations publicly about the way the UHC idea was shaping up in a signed article in the Week.
Like many public health advocates in the country, the Sens endorse the recommendations of the High Level Expert Group (HLEG) for UHC, set up by the Planning Commission in 2010, to work out a framework for the UHC. The HLEG report calls for an increase in public spending on health from 1.2 per cent of the GDP to 2.5 per cent of the GDP in the 12th Five Year Plan, and to three per cent by the end of 2022. It proposes that every Indian citizen should “be entitled to essential primary, secondary and tertiary healthcare services that will be guaranteed by the Central government”. The Expert Group has suggested that a panel of experts should determine the National Health Package taking into account the resource availability as well as the healthcare needs of the country.
Who would offer these healthcare services? The HLEG recommends that such services be made available through the public sector and contracted-in private facilities (including NGOs and non-profits).
Now, the plot thickens. Another group of experts, the Planning Commission’s Steering Committee on Health for the 12th Five Year Plan, have come out with their report as well. This group has a somewhat different take on how to implement the UHC on the ground. From Dr Sen’s article, it appears that these two groups, with their two separate reports, are not on the same page on key issues.
What is going on? Talking to several people following the UHC discussion closely, I got the impression that the differences between the two sets of experts centres on some eternally prickly issues — who will pay for this grand scheme? Will it be the Centre or the state governments that will eventually cough up most of the additional money required to put the scheme in place? The HLEG thinks it should be the Centre. Apparently, the Planning Commission’s committee on health, which also has a few civil society activists, wants the state governments to pay more. HLEG supporters say that asking bankrupt state governments to foot the bill is effectively aborting the UGC. Then, there is the question of how to mesh the public and private sector to make the UHC happen in a cost-effective and transparent way.The two groups differ. The HLEG wants more of a role for the government, whereas the Planning Commission’s latest document roots for public-private-partnership with the private sector taking up a chunkier role in public health.
All this is disheartening. India has woeful health indicators. Most Indians have no health insurance. Most pay for treatment out of their pocket. A woman who works as a part-time cook in my neighbourhood told me tearfully that she had to let her mother die, because the family did not have the money to pay for the medicines and hospitalisation any longer. No one in any civilised country should have to let this happen.
Look at our neighbour, China, with whom we are constantly comparing ourselves. At the World Health Assembly, the Chinese health minister said basic medical and health security system now covers 1.295 billion people, more than 95 per cent of China’s total population.
The next few months will be critical. The 12th Plan’s chapter on health is likely to be finalised in the coming weeks. The plan itself will then be reviewed by the National Development Council, chaired by Dr Singh and chief ministers of various states, for endorsement. The final shape of the 12th Plan will be known only around July 2012. There is time to sort out the differences between the different sets of experts.
The bottomline: India needs healthcare that is accessible, affordable, and we have a right to demand that we are not exploited when we seek treatment. One key reason the Chinese government has been spending so much public money on health has been to take the burden of families so that they spend more in the domestic economy.
Satyamev Jayate showed how emotive healthcare costs and malpractices are becoming. With 2014 not so far away, UPA-2 could add some much-needed sheen to itself, and the country’s image, by taking up universal healthcare. Now is the time to show some conviction and clarity, like the young refugee woman whose words still ring so fresh.

The writer focuses on development issues in India and emerging economies.
She can be reached at patralekha.chatterjee@gmail.com