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

1
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

2
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

3
India China many similarities

• Size India will overtake China before 2050
  only countries with gt 1 billion population
• Rural-urban rapidly urbanising but still gt half
  the popn is rural rising inequality
• Rapid growth China over 30 years India over 20
  years
• Federal structure
• Governance challenges

4
. 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

5
Some indicators
China India
Popn gt 64 years (2005) lt 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) lt25 gt 40 but NCD also gt 40
6
Health Policy Pathways 1950s 1980s similar but
divergent

• China 1950 First National Health Work
  Conference central govts 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

7
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)
8
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, gt 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)

9
Health Policy Pathways 1980s 2000s perverse
catch-up by China

• Unintended collateral damage of economic reforms
  privatisation and decentralisation
• Reduced central govts 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

10
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

11
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

12
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 Dohas 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)

13
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)

14
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
  (gt55 of use) even in 2004 even though they cater
  more to the rich

15
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

16
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

17
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 Commissions 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

18
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?

19
Towards Universal Health coverage global dilemmas
20
Two (e)merging trends ? Trend 1 HSR

• From the perspective of womens 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.

21
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 Dumptys problem
• Certainly some improved outcomes reduced
  incidence of malaria and absolute number of lt5
  deaths ART access for HIV has gone up and TB
  spread appears to be reversing even as M and XDR
  TB have risen

22
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

23
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

24
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 womens
  movement threw a spanner into traditional
  thinking about human rights

25
Contd.

• Vienna 1993 International Conference on Human
  Rights recognition of womens rights as human
  rights (UDHR had equality between men and women
  only in its Preamble) and VAW as a violation of
  womens 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 womens human rights down
  to families and communities embedded in gender
  power relations that are experienced and
  reinforced in the life of the community

26
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 womens
  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 womens human rights

27
Contd.

• Beijing 1995 Fourth World Conference on Women
  reinforced Cairo 1994 and specified womens 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

28
Contd.

• New fillip to both CEDAW and the ICESCR
• CEDAW Committees General Recommendation 24 on
  Health 1999 a number of comments (not well
  organized) on both SRH and VAW
• CESCRs 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

29
Contd.

• Like all human rights, the emergence of the
  agenda of womens 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

30
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

31
UHC Putting Humpty Dumpty Together On a Human
Rights Basis?
32
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

33
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?

34
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)

35
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

36
UHC cube WHR 2010
37
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.

38
Contd.

• To be consistent in achieving womens 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
  womens 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 womens health
• that girls rights issues such as early
  marriage, access to schooling, against violence
  are built in

39
UHC and Quality

• UHCs 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

40
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 siloed
  programs or demand side financing do not
  compromise quality or violate womens human
  rights must give way to integrated and
  comprehensive service packages
• Both vertical and horizontal accountability are
  built in to ensure equality and quality

41
Contd.

• Human resources policies must train for and
  reward compliance with human rights generally and
  womens 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 ME systems with clear
  participation by girls and women to ensure rights
  compliance and redress of abuses.

42
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..

43

• Thank you.