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Interviews of International Experts on Universal Health Coverage

Dr. David Lynn
Head - Strategic Planning and Policy, Wellcome Trust

Dr. Lynn joined the Trust in April 2004. David was responsible for producing the Trust's Strategic Plan 2005-2010: Making a Difference. He has responsibility at the Trust for policy and advocacy, planning and risk management, and assessment and evaluation. He was previously Director of Science and Innovation at the UK Natural Environment Research Council and has worked in both the Cabinet Office and the UK Office of Science and Technology.

Q: What in your opinion is the most notable recommendation made by the High Level Expert Group (HLEG) in the report on Universal Health Coverage for India?

Dr. Lynn: I think the report itself is very ambitious, since it brings together the need to look at new ways of delivering health care, and it also focuses on public health system, aside from calling for greater attention on social determinants. I think that bringing those three elements together is a great move forward. In terms of recommendations, the biggest recommendation that I think the government should take note of, is the increasing of public expenditure for health through taxes. Another crucial aspect of the report is the expansion of healthcare infrastructure, changes in service norms and human resource development. It will be necessary to develop clear career pathways for attracting and retaining health professionals. In order to accelerate training in some areas, it could be possible for India to partner with other countries and learn from their experiences.

Q: Does an increase expenditure on health automatically guarantee improvement in health indicators?

Dr. Lynn: Increased expenditure on health is by itself not enough. The comprehensiveness of the report is a very important element, since all the strands have to be taken forward together to ensure that universal health coverage is achieved. In particular, I think training and building of healthcare capacity is an enormous challenge. Additionally, research and training would be the key to success of the scheme along with political leadership and commitment to implement the scheme. One of the issues that the report does not raise too clearly is that if the public budget is increased significantly, as outlined in terms of increases in GDP, whether the absorptive capacity exists within the country to spend that money wisely.

Q: What is your stand on user fees?

Dr. Lynn: The rejection of user fee is a critical recommendation as access to health services and provisions should be free if the objective is to ensure better access to the public, especially the poor. Although the report states that there was some disagreement within the high level expert group, particularly for whether the rich should actually be asked to pay for healthcare provision, I think that taxes would be the way forward. I support the recommendation to increase pre-payment and pooling for a health policy though tax-based revenues.

Q: How does the HLEG report made for India compare with several other versions of Universal Health Coverage currently in place in several other countries?

Dr. Lynn: I think the uniqueness of the report is the breadth and comprehensiveness of it. Bringing the need to develop healthcare service delivery, strength in public health services, and also figuring out social determinants, is a unique characteristic of this report. It looks more broadly than just the medical profession, which I think is very important for a country like India. One of the elements that is not as clear as it might be, is setting out the accountabilities and governance arrangements for the management and distribution of any increase in public funding. I think that’s absolutely essential, especially at a time when India has faced challenges over corruption, and the population at large wants to be assured to that its taxes are being used effectively and efficient. One area that could be worked on more in the report is to ensure that the resources themselves are spent in the best possible way.

Q: What is the feasibility in contracting private players for public purposes?

Dr. Lynn: The report itself does mention the need for great regulation. I think that will be essential both for the private sector and the public sector. Service providers will need to operate to the same standards to ensure universal health coverage and equity across India. Private players can see it as an opportunity to move into markets which they’re not currently operating in at the moment. The report does not stop them from developing services on a strictly private basis. I think there is an opportunity for the private sector to have a role in the primary care system, which is very underdeveloped in India at the moment.

Patrick Mullen
(World Bank)

Mr Mullen, PhD, is a Senior Health Specialist with the World Bank in New Delhi, India. Mr. Mullen provides support to the national tuberculosis program and the state government of Karnataka on health programs partly financed by World Bank credits and is also managing pilots and studies in the areas of health insurance and nutrition. Along with numerous World Bank reports on health system analysis in a variety of countries, Mr. Mullen has researched in the areas of socio-economic disparities in health and the impact of conflict on physical and mental health outcomes. Mr. Mullen received his PhD in Public Health from the Johns Hopkins Bloomberg School of Public Health and also holds an MPH from Columbia University as well as an MA from Carleton University (Ottawa).

Q: What in your opinion is the most notable recommendation made by the High Level Expert Group (HLEG) in the report on Universal Health Coverage for India?

Mr Mullen: The vision of the report itself is assuring with many defined set of services to the population. Some of the elements on how to achieve them have a lot of potential though it will be difficult to implement. The very act of defining services to which people are entitled to and empowering the beneficiary with information makes both – the public and private sectors - accountable for delivery. Among other things, the proposal to purchase services from the private sector is very interesting and has a lot of potential; given the fact that private sector healthcare in the country is larger and more important than the government sector. Recognizing that fact and making use of that capacity is quite good in the report.

Q: Does an increase expenditure on health automatically guarantee improvement in health indicators?

Mr Mullen: The expenditure on health in India in the last 10 years has been very constructive. There has been increase- both in government spending and private sector spending. Also, on out-of-pocket household spending by the people as the economy has grown. Even though the level of public spending has not changed, there is a proportionate increase in the number of rupees the government is spending. You can see it in indicators that service coverage over this time in basic things like immunization and other things have improved. Overall indicators have improved. The problem which this report is in confronting the next step. How to do better with even more resources? As more resources will not guarantee better health indicators because it depends on how the money is used finally. That is very clear.

Q: What is your stand on user fees?

Mr Mullen: I don’t have any particular stand on user fees as it depends on the objective and the implementation. I think for the Indian context, the question of user fees is much less important than other financial burdens on households, specially drug costs, out-of-pocket payments for private care and also payments for hospitalization. Those issues are much more important than user fees. Drugs provided free-of-charge and effectively implemented would reduce the burden on households because it is a larger portion of their expenditure in healthcare. There is mixed evidence on the usefulness of user fees. In some studies it shows it can improve accountability of service providers as there are direct payments by the patients and the use of money for the facility can improve the quality. Other studies are showing that the amount of money raised is small and is much less than the transaction cost of collecting the money and implementing exemptions. So it really depends on the context of the country.

Q: What is the feasibility in contracting private players for public purposes? Will this report regulate private players?

Mr Mullen: There are a number of proposals in the report, both in terms of what such regulation should look like to building the capacity of the government to do this kind of regulation. One of the proposals is to apply criterion standards both to the public and private sector. This is also very interesting and challenging. However, I think it this is something the country needs to pursue. I am not sure if you can really micro-prescribe regulation details, as much as it would be done individually at the state level. So setting up the vision and setting up some of the strategies or options for strategies is already a very good step.

Q: How does the HLEG report made for India compare with several other versions of Universal Health Coverage currently in place in several other countries?

Mr Mullen: My experience with this is limited to my own country- Canada and other developing countries where I worked for the World Bank. Now the process for India is very comparable to the process possibly made 5-6 years ago in Canada when there was a commission on healthcare in Canada. One requires a very thorough strategy for a way forward for the system and this is basically what is required as a practice process for India. Though the report for India, as of now, is fairly good.

Q: Do you think there are any missing elements that need to be introduced in the report to make it more robust?

Mr Mullen: The thrust of the report is to strengthen the government health service delivery system along with contracting or purchasing services from the private sector and possibly building on some of the government insurance schemes. I think it is a perfectly valid strategy if it fits with the experience of what is happening in the country. One thing that I think the report needs to convince the reader more is that the increased resources into the public sector service delivery system and the government healthcare service delivery system will be effectively used, given the problems with accountability and the other historical problems with the Indian system currently. Basically, one needs more clarity on what are the mechanisms that will change the status quo and provide assurance that this increase in resources will be effectively used.

Dr. Monica Dasgupta
(World Bank)

Dr. Dasgupta is a Senior Demographer in the Development Research Group of the World Bank. Trained in demography and social anthropology at the London School of Economics and IDS Sussex, she has worked extensively on issues of population, public health, and gender. Before joining the Bank, she worked at the National Council of Applied Economic Research, New Delhi, and at the Harvard University Center for Population and Development Studies.

Q: What in your opinion is the most notable recommendation made by the High Level Expert Group (HLEG) in the report on Universal Health Coverage for India?

Dr. Dasgupta: The most notable recommendation made by the committee is the fact that it will be tax based financed, because the experience with private insurance has been so really grotesque as you can see it in the United States of America. Once again, if you set that in, it is very hard to reverse as seen in the US as they have been trying for the last 50 years and have not succeeded. The European countries, a couple of them which do have private insurance, are very heavily regulated and that is not something that India has the capacity to do. So tax based financing is what that works really well for most of the developed countries and the developing countries.

Q: Does an increase expenditure on health automatically guarantee improvement in health indicators?

Dr. Dasgupta: Obviously increasing expenditure will not automatically guarantee anything unless key issues like implementation and accountability are strictly adhered to. Having said that, increase in public health spending is a step in the right direction, on the basis of which a strong healthcare reform can be built. I am of the belief that most classic public health interventions are pure public goods that governments should provide, whatever approach they may choose to take with regard to the provision of other health services, for which increasing expenditure is the first step.

Q: What is your stand on user fees?

Dr. Dasgupta: I completely support the report on doing away with user fee. International experience has shown that levying a user fee acts as a deterrent in health seeking behaviour of the public. The negative impact of user fee is abundantly documented from the experiences of several countries. India's objective is to increase the access its population have to quality healthcare services and imposing a fee will just defeat this purpose and add to the disease burden and more and more people fall out of the fold of institutional healthcare delivery system. This report, very rightly, suggests that the policy be funded through a general pool based on taxation.

Q: What is the feasibility in contracting private players for public purposes? Will this report regulate private players?

Dr. Dasgupta: Comprehensive reforms, the kind this report recommends, depend heavily on market regulation. In my opinion, there is a need to regulate private players in the Indian markets. It will be necessary to clearly divide the agencies purchasing and providing services. This de-linking will , essentially, ensure that the purchasers do not have a hierarchical control over the providers. While more detailing is required, contracting in private providers to enable government services is an idea that can be used if there is strict regulation from the government.

Q: How does the HLEG report made for India compare with several other versions of Universal Health Coverage currently in place in several other countries?

Dr. Dasgupta: I think the report- given that this is an overarching framework- is very comprehensive. This report has factored in international debated around health policies. The low-cost model in Sri Lanka is a good example to learn from if India were to achieve universal health coverage as it shows that the objective can be achieved even within given financial constraints. Effective preventive services, environmental sanitation etc can help sharply reduce communicable disease loads, as demonstrated by the developed world’s reduction of their erstwhile heavy burdens of such diseases. Even within India, Tamil Nadu spends the same amount as any average state but it has a separate cadre of public health workforce and PHC is managed effectively. Tamil Nadu’s skeletal public health cadre manages its public health workforce to impressive effect: it ranks amongst the top in data reporting (disease surveillance, vital registration).

Q: Do you think there are any missing elements that need to be introduced in the report to make it more robust?

Dr. Dasgupta: There is a lot of detailing required in the report as far as capacity building towards delivering a robust plan like this report recommends. Overall, the report contains a number of proposals for institutional changes and reforms that hold the potential for addressing current problems as well as improving the prospects that increased resource flows into the system will be effectively used. The recommendations for reform need be clarified for the reader, prioritized, and that challenges and difficulties be better recognized. In my opinion, a standardized training curriculum needs to be developed for them and passing this should be a prerequisite for job candidates. Sri Lanka has a very good system for training Public Health Inspectors. Another way of improving public health services in urban areas, with collaboration between urban bodies and the State public health services.

A Public Health Act can specify the responsibilities and powers of all types of local bodies, as well as of the health department. The latter should have residual responsibilities and powers for assuring public health. Creating a separate Directorate of Public Health in the Health Department, staffed by a Public Health cadre, with its own budget and new posts as needed for epidemiologists, entomologists, Health Management Information Service staff, Health Inspectors, laborers, and other public health workforce with clearly specified job descriptions, supervisory arrangements, and continuing training for all the above staff, which meet the minimum requirements provided by the centre, will provide more clarity towards achieving the goals set in the report.