Health policies in India and China: towards Universal Health Coverage?

Gita Sen

International Workshop on Feminist Economics in China and India, New Delhi, 11-12 November 2013

Introduction – Challenges of Reforming Health

• Life and death issues• Medical poverty trap – considerable evidence

in both India and China• Information asymmetry – provider-patient• Complexity – levels, supply chain (rel to

education)• Evolving needs – demographic, CD to NCD• Public – private mix

India – China: many similarities

• Size – India will overtake China before 2050; only countries with > 1 billion population

• Rural-urban – rapidly urbanising but still > half the popn is rural; rising inequality

• Rapid growth – China over 30 years; India over 20 years

• Federal structure• Governance challenges

…. But many differences…

• Stage of demographic transition - Age structure – India higher dependency ratio

• Stage of epidemiological transition – communicable vs non-communicable diseases burden – China much further along

• Availability of funds for health – China has much more due to earlier rapid growth + high savings rate

• Governance – India has older private sector in health care delivery, drugs – vis a vis public sector

Some indicatorsChina India

Popn > 64 years (2005) < 15 years

8%20%

4%36%

Total fertility rate (2004) 1.7 3.0

Life expectancy at birth (2004)

72 years 62 years

Maternal death rate (per 100,000 women) (2000)

56 540

Low birth weight (1999) 6% 30%

Communicable diseases (2000)

<25% > 40% but NCD also > 40%

Health Policy Pathways 1950s – 1980s: similar but divergent

• China: 1950 – First National Health Work Conference; central govt’s 4 principles: service for workers, peasants, soldiers; prevention first; integrating Chinese + Western medicine; role of mass campaigns

• India: 1946 Bhore Committee Report – free health care; importance of prevention, nutrition, health education; 3 tier system; National Health Service (not implemented)

• Major difference – the role of the private sector in health care, drugs, medical education; difficulties of controlling mixed system

Health Policy Pathways 1950s – 1980s: similar but divergent (2)China India

Health care delivery 3 tier system 3 tier system but health is a state subject

Priority to health Commune – based guarantees + transfers via central govt to poorer provinces

Bhore Cttee only partially implemented; emergent health care system top-heavy and urban biased; insufficient invt at lower levels

Human resources Barefoot doctors + integration of Chinese medicine

RMPs + parallel AYUSH

Strong public health Communes + campaigns (e.g. schistosomiasis) with strong central agency

Weak public health except for vertical programs

Social Determinants of Health

Strong focus on nutrition, sanitation, education

Weak focus

Health investment by govt Significant Around 1% of GDP (among lowest in the world)

Results of pre-economic reforms phase

• Health indicators much better in China (IMR 34 by 1982; well on the way to epidemiologic transition)

• India much slower: – National Sample Survey (1986-87) shows high

untreated morbidity, significant rural-urban differences, critical gender-based differences

– In addition, > 70% out-of-pocket expenditure; poor quality and uneven reach of services; highly unregulated private sector (irrational health care; cross-practice; high costs; unnecessary interventions)

Health Policy Pathways 1980s – 2000s: ‘perverse’ catch-up by China

• Unintended collateral damage of economic reforms – privatisation and decentralisation– Reduced central govt’s share from 32% (1978) to 15%

(1999); decentralised financing favoured rich coastal provinces and severely curtailed poorer; nominally public facilities began to function like private ones

– Form of price regulation – basic care prices controlled but facilities allowed to earn profits from new drugs, technologies etc + doctors’ bonuses based on revenues – distortions in services, explosion in costs and unaffordability for poor, emergence of high-tech facilities for the emerging wealthy

Health Policy Pathways 1980s – 2000s: ‘perverse’ catch-up by China (2)

– Dismantling of agri communes – ripped up the health care safety net in rural areas; barefoot doctors adrift, began selling drugs and IV for survival – explosion of rural drugs prices also

– Reduced funding for public health but local areas allowed to charge for sanitary inspections etc – distortions at the expense of health education, MCH and epidemic control (SARS, avian flu threats)

– OOP expenses: 20% (1978) to 58% (2002)

• Consequences: similar to India

Health Policy Pathways: post 1991 India – worsening situation

Despite inequities and high OOP, poor public health, some positive features pre-reforms:Public hospitals (even if doubtful quality) were

available to the poor especially for inpatient care

Significant drug price control (over 300 drugs) in the essential, controlled price list

Thriving (pre-WTO) indigenous drug production (through reverse engineering) kept drugs available and competitively priced

Health Policy Pathways: post 1991 India – worsening situation (2)

• 3 key policy shifts after economic reforms:– Sharp reduction in the controlled drugs list leading to

significant increases in drug prices– 100 % FDI in pharma + product patents + bilateral

trade agreements with TRIPS + clauses (data exclusivity forcing repeat trials for generics; customs inspections; versus Doha’s compulsory licensing provisions)

– Entry of user fees and two-tier services in public hospitals – those below the poverty line are supposed to get services free including drugs, but this is rarely the case (under the counter payments, and drugs have almost always to be purchased outside)

Summary results of the comparison

• Overall, reporting on illness, extent of non-treatment and discontinued treatment went up sharply

• Serious increases in the costs of care, and in financial reasons for non-treatment (related largely to drug prices but also possibly to user charges?)

• Micro level in-depth studies on reasons for households falling into poverty (e.g. Anirudh Krishna) show that health expenditures are a major reason (among the top 3)

Summary results of the comparison

• Class gradients sharply worse in the mid-1990s with some moderation in 2004 but still sharp

• Gender gaps persist but moderated in some instances – perverse catch up by poorest men in terms of non-treatment and financial reasons for it

• Hospital use for care – the better off are more likely to go to private hospitals for inpatient care but they use more of both private AND public hospitals (some reversal in urban public hospitals in 2004)

• The poorest still depend on public hospitals (>55% of use) even in 2004 even though they cater more to the rich

Summary of current policy challenges in both countries

• High unmet need for care + public health• High and rising inequities – rich-poor, rural-

urban• High out of pocket expenses• Weak focus on public health (prevention –

promotion) and social determinants• Powerful lobbies• Decentralisation

Current Policy Directions

China – investment in facilities and human resources,

payment system and internal management of primary care

– Use of health insurance – very rapid expansion– Movement towards Universal Health Coverage– Corporatisation of large public hospitals

Current Policy Directions (2)

India– NRHM – maternal mortality thrust, facilities,

emphasis on flexibility and innovations, NHSRC, third party review mechanisms, community involvement, mgmt reforms; NHM including both rural and urban

– Planning Commission’s High Level Expert Group on Universal Health Coverage – working under 6 TORs: human resources, physical facilities and norms, management reforms and regulation, community involvement, drugs and devices, financing

– But weak funding in the 12th Plan

Women focused health policies

• Attempt to mitigate the growing challenges of the health sector through specific programmes for women; focus on reproductive health

• National Rural Health Mission – focus is on maternal mortality – very ambitious but can it mitigate or compensate for the larger challenge of a weak public sector or system?

TOWARDS UNIVERSAL HEALTH COVERAGE: GLOBAL DILEMMAS

Two (e)merging trends ? Trend 1: HSR

• From the perspective of women’s health, 2 important health policy trends in the 1990s and 2000s:

• First, Health Sector Reform (HSR) – attempt to pick up the pieces and glue them back together after the Humpty Dumpty of Health was thrown off the wall by the structural adjustment programs of the 1980s.

• H Dumpty pieces may have been too small and too many – reduced financing; the ‘medical poverty trap’ of user fees; the deterioration of services; the evaporation of the health work force; the collapse of state capacity to ensure health planning, management or governance – to be handled effectively without a full-scale revamping.

Contd.• Nonetheless, the 2000s saw a number of attempts to

correct the consequences – – ‘diagonal’ thinking – drawing health system wide results from

vertical programs– human resource planning through task-shifting– Improved coordination of donor actions and governance – Demand side financing with or without conditionalities

• Fair to ask how effective these have been in addressing Humpty Dumpty’s problem

• Certainly some improved outcomes: reduced incidence of malaria and absolute number of <5 deaths; ART access for HIV has gone up; and TB spread appears to be reversing even as M and XDR TB have risen

E-Q-A syndrome• However, huge inequalities in outcomes and

access to care; rapidly rising NCDs incidence; continuing reservoir of CDs; and weak health system capacities at country level

• Where access to care has gone up, serious quality concerns continue to exist, e.g. concerns about ‘obstetric violence’ in Mexico, Brazil, India

• Horizontal accountability still not built into governance; exacerbated by the big inflow of private funds

The E-Q-A syndrome of health systems

Two (e)merging trends ? Trend 2: Human right to health

• WHO Constitution – fundamental right to health• UDHR – 1948 – Art. 25 : refers obliquely as “…everyone

has the right to a std of living adequate for health and well being … including … medical care”

• ICESCR – Jan 1976 – Art. 12 on Right to Health – very broad

• Alma Ata Declaration on PHC – 1978 – “…health …is a fundamental human right…”

• CEDAW – Sept 1981 – Art 12 on Right to Health – also very broad

with some references to maternal health, family planning

Contd.

• Until 1990, right to health referred largely to health services and other actions (nutrition, water, sanitation) to be taken by states for their citizens

• Even though Alma Ata said that people have a right and duty to participate in health planning and implementation

• 1990s – UN conferences of the 1990s – women’s movement threw a spanner into traditional thinking about human rights

Contd.

• Vienna 1993: International Conference on Human Rights – recognition of women’s rights as human rights (UDHR had equality between men and women only in its Preamble); and VAW as a violation of women’s human rights in both public and private life– Except during conflict, most VAWG is not by the state but

by people, predominantly intimate partners and harmful practices

– Brings the violation of women’s human rights down to families and communities; embedded in gender power relations that are experienced and reinforced in the life of the community

Contd.• Cairo 1994 – International Conference on Population

and Devt – took this further in shifting the population paradigm from Malthusian population control to sexual and reproductive health and rights– Defined these rights as part of daily life even in the

absence of violence – they became women’s rights to exercise choice on a wide range of fronts from marriage to sex and reproduction; to bodily autonomy and integrity; to decision-making and control versus not only states and religious bodies but also versus families, partners, communities

– Spelled out many of the harmful practices that violate women’s human rights

Contd.• Beijing 1995 – Fourth World Conference on Women –

reinforced Cairo 1994 and specified women’s equal right to sexuality “free of coercion, discrimination and violence”

• Vienna, Cairo and Beijing affirmed a new meaning for the right to health: – for women and girls in particular, the right to health is not only

about obtaining health services; it is about rights to decision-making, control, autonomy, choice, and freedom from violence and fear of violence

– For men, this approach spoke not only of duties towards women and girls, but also of the need to break away from ‘destructive masculinities’ that result in self-destructive behaviours, violence and death

Contd.• New fillip to both CEDAW and the ICESCR:

– CEDAW Committee’s General Recommendation 24 on Health – 1999 – a number of comments (not well organized) on both SRH and VAW

– CESCR’s General Comment 14 on Right to Health – 2000 • follows the logic of “respect, protect, fulfil” • includes clear guidance on states parties’ responsibilities to provide

SRH services; remove barriers to access; protect women and girls from domestic violence and from the effects of harmful traditional and cultural practices and norms that violate reproductive rights such as early marriage and FGM ++; ensure non-discrimination including on the basis of sexual orientation; provide adolescents with youth-friendly, confidential, private and appropriate SRH services; and ensure non-retrogression and progressive realization of these rights

• Non-binding but useful normatively

Contd.• Like all human rights, the emergence of the

agenda of women’s human rights to health has been contentious

• SRHRights were contentious to begin with and continue to be so because they challenge real power

• But these rights are central to laws, policies and programs that can respect, protect and fulfil the health of girls and women

• Cannot be obviated by falling back to supposedly ‘safe’ silos such as MCH or FP

HSR and SRHR – can the twain meet?

Divergences•Older HSR dependence on user fees and rising OOP expenses vs public financing and programs of entitlements to reinforce rights•Vertical programming vs integrated and comprehensive SRH services•Top-down vs rights-based participation and horizontal accountability

Convergences•Demand side financing and targeting

UHC – PUTTING HUMPTY DUMPTY TOGETHER ON A HUMAN RIGHTS BASIS?

UHC – a rising tide to lift all boats?

• Growing drumbeat of support for Universal Health Coverage in the debates on the post 2015 development agenda – WHO, UNICEF, growing number of countries at the UN

• Rising global debate and understanding of UHC, its potential and its challenges

• Strong civil society support from various development NGOs

• Time for a careful and sober appraisal of experiences with UHC in high and LMIC countries

Contd.• Power of UHC – promise of universality, realization of

the right to health, reintegration of social determinants of health (after earlier abortive WHO attempt)

• LMIC countries such as Mexico claim to have achieved it with a strong dose of demand side financing, but others have not depended on CCTs (conditional cash transfers)

• Others like Thailand and Brazil have had a strong element of popular participation

• Flexibility – ‘ekam sad vipr bahudha vadanti’ – one God but many paths?

UHC – a sober look

• Two basic questions:– Will UHC help health systems to overcome the E –

Q – A syndrome ? (equality, quality and accountability)

– Will UHC integrate human rights and, in particular, make it possible to integrate sexual and reproductive health and rights that are so critical for women and girls? (if UHC cannot address centrally the critical needs of half the population, its claim to universality will be open to challenge)

UHC and Equity

• Inverse Equity hypothesis (Cesar Victora)• Path dependence – which people and what

services are included at which points in time? (Davidson Gwatkin) – politics of choice & voice

UHC cube – WHR 2010

Contd.• Equity not only by income / wealth• UHC has not done well so far in recognizing other bases of

inequality – gender, race/ethnicity, indigeneity, disability, age – intersecting with each other

• Women and adolescents are together too large group to be ‘added on’ as an after-thought – specific health needs and susceptibility to power relations that cannot be collapsed into income/wealth status

• World Bank LMIC review of UHC experience, Jan 2013 – one key lesson of the review is the importance of linking services to specific needs of different groups to achieving universality – which people? What services? At which time?

• Language of ‘targeting’ carries too much baggage that is seen as antithetical to universality. But equity requires ensuring that a core of services are available to all, but that specific needs and vulnerabilities should be addressed in that core.

Contd.• To be consistent in achieving women’s sexual and

reproductive health, UHC has to ensure inter alia:– that girls and women are centrally included (not only

maternal health family planning as a silo);– a recognition of the importance of a rights focus –

addressing critical elements of gender inequality that govern the acknowledgement of women’s health needs, the practices and behaviours within homes, communities and in health centres that govern access and affordability

– that services packages include essential services for women’s health

– that girls’ rights – issues such as early marriage, access to schooling, against violence – are built in

UHC and Quality

• UHC’s focus on systemic factors such as financing, services packages and health personnel can ease pressure on services, but may not ensure quality. Why?

• Path dependence : demand side financing may generate too much demand before services and providers are ready for them, e.g., concerns from community level evidence on the issue of ‘obstetric violence’ in Brazil, Mexico and India

• Also, quality may be subservient to social hierarchies leading, for example, to low quality treatment of poor, low caste women in India

Ways forward for Humpty Dumpty• If UHC and SRHR are to become compatible, minimum

requirements are:– The path is equitable and equalizing with multiple vulnerabilities

addressed– The focus on individual rights is strengthened – not just

traditional right to health but rights to autonomy, bodily integrity, choice, agency – core of gender equality and sexual and reproductive rights for women and girls

– Top down pushes for universality through silo’ed programs or demand side financing do not compromise quality or violate women’s human rights – must give way to integrated and comprehensive service packages

– Both vertical and horizontal accountability are built in to ensure equality and quality

Contd.• Human resources policies must train for and reward

compliance with human rights generally and women’s rights in particular, a focus on equality and quality of services; and should disincentivize non-compliance, including punishing the most egregious failures

• The mixed public-private systems of the foreseeable future must be well regulated and governed to ensure equality, quality and accountability for rights compliance

• Horizontal accountability must be built into regulatory and M&E systems with clear participation by girls and women to ensure rights compliance and redress of abuses.

Possible resolution for the Post 2015 Devt Agenda?

• Issue-focused goal + people-focused targets / indicators?

• i.e. use the SDSN goal + main targets should be health lives for women and young people

• Focus on the life course as a way of breaking through the silos?

• Will this avoid the lightning rod effect that SRHR can have?

• Next critical 18 months will tell…..

Thank you.