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Health Policy 114 (2014) 269– 277

Contents lists available at ScienceDirect

Health Policy

journa l h om epa ge: www.elsev ier .com/ locate /hea l thpol

erspective

niversal coverage challenges require health systempproaches; the case of India

ntonio Durana,∗, Joseph Kutzinb, Nata Menabdec

Técnicas de Salud, Sevilla, SpainWHO HQ, Geneva, SwitzerlandWHO Country Office India, Delhi, India

a r t i c l e i n f o

rticle history:eceived 18 December 2012eceived in revised form 28 October 2013ccepted 18 November 2013

eywords:niversal Health Coverageealth systemealth system functions

ndia

a b s t r a c t

This paper uses the case of India to demonstrate that Universal Health Coverage (UHC)is about not only health financing; personal and population services production issues,stewardship of the health system and generation of the necessary resources and inputsneed to accompany the health financing proposals.

In order to help policy makers address UHC in India and sort out implementation issues,the framework developed by the World Health Organization (WHO) in the World HealthReport 2000 and its subsequent extensions are advocated. The framework includes finalgoals, generic intermediate objectives and four inter-dependent functions which interactas a system; it can be useful by diagnosing current shortcomings and facilitating the fillingup of gaps between functions and goals.

Different positions are being defended in India re the preconditions for UHC to succeed.This paper argues that more (public) money will be important, but not enough; it needsto be supplemented with broad interventions at various health system levels. The paperanalyzes some of the most important issues in relation to the functions of service produc-tion, generation of inputs and the necessary stewardship. It also pays attention to reformimplementation, as different from its design, and suggests critical aspects emanating froma review of recent health system reforms.

Precisely because of the lack of comparative reference for India, emphasis is made on theneed to accompany implementation with analysis, so that the “solutions” (“what to do?”,

“how to do it?”) are found through policy analysis and research embedded into flexibleimplementation. Strengthening “evidence-to-policy” links and the intelligence dimensionof stewardship/leadership as well as accountability during implementation are consideredparamount. Countries facing similar challenges to those faced by India can also benefit fromthe above approaches.

© 2013 Elsevier Ireland Ltd. All rights reserved.

. Background

International experience reveals a move towards Uni-ersal Health Coverage (UHC) as promoted by the Worldealth Report 2010 “Agenda for Action” [1]. Raising and

∗ Corresponding author. Tel.: +34 954282767; fax: +34 954280614.E-mail address: aduran@tecsalud.com (A. Duran).

168-8510/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved.ttp://dx.doi.org/10.1016/j.healthpol.2013.11.009

pooling funds provides the base for population coverage,and these mechanisms are most effective when prepay-ment comes on behalf of a large number of people, creatingan enabling environment in which the healthy subsidizethe sick, the rich subsidize the poor, those of working age

subsidize those beyond it, and health services purchasingis used strategically to promote efficient use of resources.

International experience also shows that general gov-ernment revenues have been at the core of recent UHC

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reforms in low and medium income countries with largeinformal sectors and numbers outside of salaried employ-ment (where direct taxation is harder to implement). Thisapproach moves away from a principal focus on earmarkedpayroll taxes and a contributory basis for entitlement, giventhe structure of the labor market yet recognizes the needto rely on compulsory funding sources (taxation) to movetowards universal population coverage [2]. Such is the les-son from recent innovations in Brazil’s expanded “right tohealth” [3], Kyrgyzstan’s Mandatory Health Insurance Fund[4], Mexico’s “Seguro Popular” [5] and Thailand’s UniversalCoverage scheme [6] among others.

These approaches are aligned with the concept ofUHC which shifted the underlying public policy rationalefor health coverage from being a condition of labor sta-tus (as was the case from the time of Bismarck untilshortly after World War II) to being a condition of cit-izenship, underpinned by emergent concepts of healthas a human right and human security often reflected innational constitutions [7,8]. Recent international experi-ences also show that reforms in large federal systems (forexample, China and Mexico) must devote attention to therole of local governments, with the center using inter-governmental incentives to stimulate attention to healthat state/provincial levels.

Those features can also be observed in India, with itsschemes since independence (including one for civil ser-vants and another one based on Social Health Insurancecontributions from the formal sector). During the pastdecade, national-level reforms de-linking coverage fromemployment and increasing public spending by transfer-ring health-specific funds to States have been introducedvia two innovative schemes1:

- The National Rural Health Mission (NRHM), an umbrellaprogram departing from earlier trends of financing spe-cific health care lines for identified diseases and healthconditions. Since 2005 it fosters district and village healthplans aggregated up to state level, plus primary care ser-vices and infrastructures, from Union level government,encouraging States to match grant money in varyingproportions [10]. NRHM takes into account disparitiesin revenue capacity and differentiates non-focus states,with a weight of 1 in the allocation of resources (AndhraPradesh, Goa, Gujarat, Haryana, Karnataka, Kerala, Maha-rashtra, Punjab, Tamil Nadu and West Bengal), high-focusnorth-eastern states (Arunachal Pradesh, Assam, Manipur,Mizoram, Meghalaya, Nagaland, Sikkim, and Tripura,with a weight of 3.2) and high-focus large states (Bihar,Chhattisgarh, Himachal Pradesh, Jharkhand, Jammu and

Kashmir, Madhya Pradesh, Orissa, Rajasthan, Uttarak-hand and Uttar Pradesh, with a resource allocation weightof 1.3).

1 Several State-level initiatives have been introduced as well, mostnotably the Rajiv Aarogyasri hospital insurance scheme that covers about80% of the population in Andra Pradesh, funded by state-level tax revenues[9]. Though state-level schemes are very important both within the stateswhere they are implemented and for informing future policy reforms, inthis paper we only focus on national level programs.

114 (2014) 269– 277

- The Rashtriya Swasthya Bima Yojna (RSBY) is a hospi-talization costs insurance scheme launched in 2008 toprotect below poverty line households – the vast majorityof people in the unorganized sector, including agriculture[11]. While managed nationally by the Labour Ministry,at state level (where implementation occurs) the Healthand Labour Ministries each manages the program inabout half the states. The usual funding split is UnionGovernment 75% and State government 25%, which inNortheastern states and Jammu and Kashmir goes up to90:10. About 33 million families have been covered and4.3 million persons used hospitalisation services underRSBY, according to the 12th Five-Year Plan document[12]. While nearly completely tax-funded, implemen-tation is contracted at state level to private insurancecompanies based on a tender process to become the sin-gle insurer for a state or for a defined geographic region ofa state. Beneficiaries can choose from public and privateproviders contracted (“empanelled”) by the insurer.

These programs are quite different in size and focus.Financially, the resources provided for NRHM are about10 times the amount provided for RSBY. NRHM is predom-inantly a supply-side funding mechanism, whereas RSBYinvolves an explicit purchaser–provider split, with publicfunds flowing to contracted private and public insurers thatpurchase inpatient care on behalf of the covered popula-tion. While difficult to fully identify the consequences, amajor concern has been the absence of explicit coordina-tion between these two mechanisms [13].

Analyses of each of these schemes have shown mixedresults – both achievements as well as problems in imple-mentation. In the Sixth Common Review Mission forNRHM, progress was reported in key health outcomes– notably in child survival, population stabilisation andmaternal mortality reduction plus improvements in immu-nisation in all states, increased outpatient attendanceand in-patient admissions. The Janani Shishu SurakshaKaryakram (JSSK) provides free cashless services to nor-mal deliveries and caesarean operations and care for sicknew born in Government health institutions [14]. On thedown side, problems have been reported concerning lack ofaccountability and poor quality of spending [15] and evenfinancial scandals [16].

RSBY has also been thoroughly analysed and achieve-ments as well as problems have been hotly debated. By bothleveraging increased levels of state spending on health andchannelling the combined public subsidies to an insurancefund to purchase services on behalf of covered persons,the scheme has enabled an increase in public spendingon health while introducing a purchaser–provider split foran explicit benefits package with no patient cost sharing(cashless care); it has also fostered improved access to bothpublic and private hospitals and enhanced financial protec-tion for the target population. RSBY has implemented aninnovative IT platform to support enrolment and providerpayment; it assesses regularly information on service use

[17] and patient satisfaction; in Delhi a survey of 390 hos-pitalized beneficiaries found that 18% were highly satisfied,67% were satisfied and only 3% dissatisfied [18]. Problem-atic areas include a large remaining gap in reaching the

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arget population, evidence of overuse or unnecessary ser-ice provision driven by the provider payment incentivessed, and the cap on financial protection offered to benefi-iaries [19–21].

Despite this mixed picture, one positive feature sharedy each of these schemes is that they have found waysround two core constitutional and administrative obsta-les to allow the central government to influence andupport health system development at state level: (a)nabling the Union government to play a catalytic rolen health financing despite the reality that “health is atate subject”; and (b) enabling the use of some (State andnion) budget funds for health free of the rigid line-itemonstraints that characterize the public sector financialanagement system.Recently India has approved a UHC program that can

sefully build on those foundations; as suggested by theigh Level Expert Group) [22] and pioneered by bothRHM and RSBY, the Government of India (GoI) is look-

ng to rely primarily on general tax revenues, rather thanrying to collect explicit insurance contributions from thenformal sector.

The attention given to the above issues may lead someo put the spotlight on health financing in isolation, perhapsver-emphasizing the effects attributable to this part of theealth system alone. This paper, as a matter of contrast,uggests that UHC is about more than financing. Withoutell thought out proposals on personal and population ser-

ices production, stewardship of the entire health systemnd the assembling of required inputs, any health systemeform would fall short of the expected results. All coun-ries struggle to turn good intentions into results (policymplementation), but the size and complex health gov-rnance in India make the magnitude of the challengesaunting; specific attention needs to be paid also to reform

mplementation, not merely its design.After this introduction/background, the structure of this

aper is as follows:

Section 2 includes the essentials of the WHO health sys-tems framework;

Section 3 addresses the implications of UHC in India; Section 4 finally outlines some implementation issues,using the lessons of recent international experience;

A table with conclusions and recommendations and thebibliographic references close the document.

. The health systems framework

According to the review by the World Health Organi-ation of what “determines” health, inter-sectoral actionsddressing the social determinants of health plus a mixf preventive, diagnostic, therapeutic, rehabilitative andaring personal- and population-based health services areequired [23]. The “ensemble of all public and private orga-izations, institutions and resources mandated to improve,aintain or restore health within the political and institu-

ional framework of a given country”, i.e. the health system24] achieves its results by the inter-play of four inter-ependent sets of repeated activities: (i) provision of theecessary services; (ii) financing, i.e. collection, pooling and

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allocation of resources to providers and services; (iii) gen-eration of the human, physical and other inputs that makeservice provision possible; and (iv) setting rules and pro-viding strategic direction for the actors involved. Thosefunctions interact in the pursuit of common final goals(improving health levels and equity, protecting peopleagainst the catastrophic financial consequences of pay-ing for health care, improving responsiveness to citizens’expectations, and performing) as well as generic inter-mediate objectives: effective coverage (reducing the gapbetween the need for and use of services in the population,and improving quality) and efficiency (Fig. 1).

Those functions, generic to all systems, are organizedby countries in response to national history, political andsocial values and preferences – thus no readymade solu-tion or approach to be “copied” or “imported” exists.The framework can support countries in diagnosing theiroutcome “problems” around pathways between the func-tions, intermediate objectives and goals, i.e. to explorehow and why the health system is under-performing asa basis for defining a country-specific reform agenda. Poorhealth outcomes usually reveal problems at various levels(e.g. inadequate service provision and/or poor informationand/or difficulties with human resources, and/or inappro-priate financial incentives, and/or insufficient supply oftechnologies, and/or weak regulation, etc.). Indeed, the val-ues and political reality of each society will in the enddetermine the adequacy of the solutions proposed, manyof them unavoidably subject to debate.

The framework facilitates aligning financial arrange-ments and services against the burden of diseases(maternal, child health and nutrition, accidents, commu-nicable and non-communicable diseases). Since serviceaccess and quality are intrinsic components of UHC, short-comings in service delivery need at least as much attentionas financing problems. The stewardship function – whichsubsumes most of the old “policy and planning” and “regu-latory/legal issues” – contributes in turn to the attainmentof health system goals by providing vision and directionfor other players through formulating strategy, regulatingand collecting and using intelligence while stakeholdersare held accountable for the resources endowed to them,etc.

Only core approaches with selected illustrations will beidentified in this paper, in the understanding that subse-quent work by the stakeholders concerned should expandon the arguments made. It is understood that this analysismight be important for other countries facing similar chal-lenges (see conclusions and recommendations at the endof the document).

3. UHC and the health system functions in India

3.1. Financing

The Economic Survey of India 2012–13 shows thatalthough government expenditure more than doubled

nominally during the period 2007–08 to 2012–13, expen-diture on health as a proportion of total governmentexpenditure shifted only from 4.6% to 4.8% and from 1.27%and 1.36% as a proportion of GDP [25]. Although the HLEG

272 A. Duran et al. / Health Policy 114 (2014) 269– 277

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Stewa rdship(oversight)

Financing (c ollecting , pooling and pur chasing )

Creating resources(invest ment and trainin g)

Delivering servic es(personal and

popul ation-based)

Health(level and equity)

Finan cial protec tionand equity in the

distribution of funding

Responsiveness(to people’s non-medical

expectations)

Performance(max imizing goals relative

to potential)

Eff ective coverage(Utilization/Need;

Quali ty)

Eff iciency

FUNCTIONS THE SYSTEM PERFORMS

GOALS / OU TCO MES OF THE SYSTEMINTERMEDIATE OBJECTIVES

8

system

detailed planning of the quantum of primary and hospitalservices; beyond the planning, “the package” ultimatelyhas to be translated into a form that enables (and thereby

Duran, Kutzin, Martin and Travis, 20 11, p.2

Fig. 1. Health

advised to increase public spending on health from slightlymore than 1% to 2.5% till 2017, and to 3% of GDP till 2022[26], the Planning Commission has settled to bring the pro-posal to 1.87% till 2017 [12] amidst substantial interest anddebate in the country.

While the authors of this paper agree with the generalopinion that more money is necessary, we however sustainthat it is not sufficient condition for improvement. Also,although allocation re-prioritizing is key, expressions like“Expenditures on primary health care, including generalhealth information and promotion, curative services at theprimary level, screening for risk factors at the populationlevel and cost effective treatment, targeted towards specificrisk factors, should account for at least 70% of all health careexpenditures”, “both in the short run and over the mediumterm” [27] should not be interpreted to suggest that meet-ing such a target is a sufficient condition for improvementeither.

Maintaining public accountability for the funds whileaddressing current “absorption capacity” issues (e.g. mas-sive volumes, short periods of time, complex institutionalmap, etc.) also remains a major challenge. One observernoted that “the stunted public health system is hardlygeared up to absorb the new increased allocation; alreadystate governments are returning money” [28]. A keycause of this “absorption” problem is the rigid pub-lic sector financial management system, with strict lineitem controls, which constrain the authority of line man-agers to reallocate resources to address problems on theground – so some budget lines are unspent despite theevident need. Alternatives are needed like the NRHM flex-ipools and the transfer of funds to intermediaries as inRSBY (or even perhaps a third option of quasi-publicautonomous “funds” that may be the state-level UHC singlepayer).

3.2. Service delivery

Recent reviews of performance-related provider pay-ments [29] and results-based financing in general [30]suggest that such payments could promote productiv-ity, increased use of priority services, and perhaps foster

framework.

quality of care2). How will Indian service delivery facilitiesreact?

3.2.1. What services?India is endowed with a third of facilities, beds, doctors

and nurses per capita compared to countries with similarincome levels [33,34]. Service delivery institutions rangefrom dysfunctional poorly staffed facilities [35] to verysolid hospitals in the All India Institute of Medical Sciences,AIIMS, to world-class organizations such as the NarayanaHrudayalaya Hospital [36] or the Aravind Eye Care System[37].

The private sector has a dominant position in the deliv-ery of both outpatient and inpatient personal care, humanresources and medical technology as well as diagnostics,pharmaceuticals, hospital construction and ancillary ser-vices – except some health programs [38]; it has around80% of an estimated 52,000 hospitals and around 63% of1,555,000 total functional beds, most in urban areas [39], afact that generates much debate in the country.

In this context, what matters is ensuring that patients dobenefit from quality services by increased access and uti-lization – not producing a super-detailed “list of servicescovered”. Many diseases require for their control morethan one intervention category – e.g. immunization usuallyinvolves both a personal service that benefits the individ-ual clients who receive it (in this case, administering thedose) and a population service delivered to groups or thepopulation (in this case, producing an education leaflet).Both personal and population services need to be organizedand delivered with the systematic approach to health sys-tem reform and the corresponding financing policy in mind[40].

India also needs to avoid problems faced elsewhere,notably in several ex-USSR countries [41] with over-

2 Other authors, however, reject them on ethical and professional bases[31]; or claim that pay for performance has not translated into break-through quality improvements [32].

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mpowers) citizens to understand their entitlements andbligations in the system.

.2.2. Delivered where and how?India has made extensive use of vertically integrated

public health programs”, defined as separated from theunding, organizational and delivery arrangements of theest [42], a solution under conditions of health systemeakness by which authorities thought the uptake of ser-

ices would be facilitated [43]. The dual burden of NCDsnd CDs now calls for other solutions; policies involvingultisectoral action (e.g., raising taxes on tobacco, enforc-

ng bans on tobacco advertisement in media, salt reductionn processed foods, subsidies for healthier edible oils, etc.)nd an enabling environment for the community to adoptealthy habits through information/education are crucial.arly detection and control of high blood pressure andiabetes; screening for common and treatable cancers;ost-effective prevention of complications and recurrentvents; providing rehabilitation/palliative care when fac-ng incurable disease, etc. are also needed [44].

For the emerging burden of disease to be confronted,acilities and structures will require transformation withmphasis on guaranteeing access and quality. Verticallements will have to become parts of well-organized,unctionally integrated, professionally run service net-orks with efficient referral and counter-referrals; linksith the voluntary and private sector will need over-auling, something already visible in the internal debatesreparing the service delivery schemes for the nascentrban Health Mission.

Re-converting vertical programs (especially Polio, TBnd AIDS, but also vector-, water- and food-borne dis-ases, etc.) into component parts of state-managed districtodels will challenge organizational skills. The process of

mplementing changes in service delivery will probablyeed to be done in phases -some issues could be addressedimultaneously while others only during a second phase.

.3. Relevant input generation

In addition to money, providing quality servicesepends on the availability, mix, etc. of many inputs,n area in which problems in India are extraordinarilyomplex. Being human resource-intensive, the serviceso be funded first require sufficient workforce with theight knowledge, skills and attitudes. For a start, how-ver, doctors with recognized medical qualifications underhe Medical Council of India Act and registered with state

edical councils are (mostly because of migration) below/1000 inhabitants and predominantly concentrated inrban areas. A realistic human resources plan is an obviousust; it should deal with the need for both clinicians (doc-

ors, nurses, paramedics, etc.) and health system workersmanagers, economists, lawyers, etc.) plus efficient time-rames for continuing education while encouraging staff to

ove to remote and underserved areas.

In October 2012, however, the National Commission

or Human Resources for Health Bill aimed at reforminghe regulatory framework and improving skilled person-el supply was returned by the Parliamentary Standing

114 (2014) 269– 277 273

Committee on Health and Family Welfare. The recommen-dation to the Ministry to “bring forward a fresh bill aftersufficiently addressing the views, suggestions and concernsexpressed by discussions with all the stakeholders includ-ing the State Governments” was a clear expression of theexisting debate in the country [45].

In the absence of such a bill, major HRH reforms are dif-ficult to undertake and remain a “critical field for progressin introducing change” [46]. Yet even in the absence ofsuch legislation, administrative measures are being intro-duced – e.g. the 21st May 2013 President of India Ordinanceon amending the Indian Medical Council Act 1956, whichallows Overseas citizens of India to practice medicine inthe country and removed the restriction on foreign doc-tors to practice only for the purpose of teaching, researchor charitable work [47].

Mainstreaming the Ayurveda, Yoga and Naturopa-thy, Unani, Siddha and Homoeopathy AYUSH traditionalmedicine systems, using their strengths (preventive andpromotive care, women and children and older per-sons’ conditions, stress management, palliative care,rehabilitation and health promotion) is another possibledevelopment. The 12th Five-Year Plan suggests the prac-tice and promotion of AYUSH in States to be carried outunder the broad umbrella of the National Health Mis-sion, with cross-disciplinary learning with modern systemsat post-graduate level and career tracks for professionaladvancement of nurses; it also suggest to develop dis-trict hospitals and Community Health Centres (CHCs) intotraining institutions; organise bridge courses for (AYUSH)graduates, empower them legally to practice as primarycare physicians; and encourage career progression ofAccredited Social Health Activists (ASHA) and Anganwadiworkers (AWW) into Auxiliary Nurse Midwives (ANM).

Reliable supply of consumables, diagnostic and othertechnologies are also needed. Essential pharmaceuticalsin UHC have to be seen in the context of proper quality,availability, prices and procurement systems. First, drugpricing is a concern in relation to the World Trade Organi-zation (WTO) and the Trade-Related Aspects of IntellectualProperty Rights agreement (TRIPS), which set minimumstandards for protecting intellectual property with poten-tial negative impact on access to treatment [48]. Bulkpurchase, distribution, prescription and delivery of drugsat central and state level are also required. Following thesuccess in Tamil Nadu and to a lesser extent Karnataka,Kerala, Delhi and Rajasthan in 2011, a quick push on pro-viding universal access to free medicines has been heard of,although the proposal has not been yet made formal. Par-allel massive interventions are also required in the fields oflogistics and office technologies.

Health facilities are another problem input. It hasbeen reported that about 12% of PHC centres and 28%of sub-centres lack regular water supply; 14% and 29%,respectively had no electricity; 8% in both groups lacked anall-weather, motorable approach road; and 54% and 47% ofPHC centres had no telephone or computer respectively.

The situation is worsened by poor functional buildingdesign and non-availability of clinical and maintenancesupport staff, making half the beds in the public sectorand one third in the private sector “non-functional” [49].

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Although thousands of PHC clinics, hundreds of hospitalsand six super-specialty AIIMS-like centres are being built[50], efforts are required to align facilities with the chal-lenges of service network re-design, for which reportingand IT requirements will also be crucial.

3.4. Stewardship issues

The right to health has top legal attention in India asit is recognized under article 21 of the Constitution [51].States have highest responsibility, with support and coordi-nation from the Union (broad policies, strategic framework,financial resources and medical education). After in pastdecades many Committees proposed improvements witharguable results [52], the stewardship challenge in devel-oping UHC is in our opinion three-fold: (a) clear policies,so that more people will be effectively covered; (b) shift-ing the focus from inputs-based to outcome-oriented goals;and (c) ensuring States’ involvement in collaborative healthpolicy to deliver on Constitutional guarantees.

In terms of regulation and influence, TransparencyInternational ranks India 95th out of 183 surveyed nationson a corruption perception index [53]; the Karnataka’sLokayukta estimates that “nearly 25% of the health bud-get gets siphoned off due to corruption at various levels;dishonesty in service delivery is a concern in many areas-from recruitment, to transfers, to promotions-and at allhierarchical levels, from low-paid workers to investigationofficers” [54].

In 2010 the Central Government enacted the ClinicalEstablishments (Registration and Regulation) Act, settingminimum standards (facilities and services) in all clinicalestablishments, in all systems of medicine, public and pri-vate. However, until recently the Act has been adoptedonly in Arunachal Pradesh, Himachal Pradesh, Mizoram,Rajasthan, Jharkhand, Sikkim, Uttar Pradesh, and all UnionTerritories. The approval by other states is “pending”, prov-ing the existence of different positions on the subject inthe country [55]. Transparent standards for contracting andrules of engaging as well as unambiguous reporting dutiesare also major issues.

Defining stewardship relationships with other sec-tors/outlining what is expected from “inter-sectoralactions” is another gigantic duty, especially regardingwater and sanitation, where evidence of cost-effectivenessis indisputable [56]. Producing population services –for example, public health surveillance – requires goodreporting from all stakeholders. The 12th 5-Year Planrecommends the creation of a dedicated cell within theMinistry to assess the impact of existing and new policiesof non-health sectors which have a bearing on health [57].

In addition, priority actions are needed to create a uni-fied, inter-operable information system, without whichgood stewardship will be impossible. India needs bet-ter health intelligence, understood as higher level ofdata/information. The ability of the Ministry of Health toguide the health system has been considered sub-optimal

due to limited evaluation, monitoring and analysis capacity[58], as well as an absence of a unified information system.If service monitoring, law enforcing and policy partneringwith state governments is to reach a new dimension in

114 (2014) 269– 277

the context of UHC, the organizational capacities of manystakeholders will need to be strengthened [59].

Given the census limitations, an independent evaluationsuggested a few years back that the Sample RegistrationSystem in use only captured 85% of deaths [60]; consolidat-ing the current progress towards a (near) universal deathcertification would be a fair aspiration for a UHC system.

A Citizen Health Information System (CHIS) has alsobeen proposed as a biometric-based system, updatingevery citizen-family’s health record (birth registration,deaths certificates, maternal and infant death reviews,nutrition, etc.); telemedicine should link district hospitals,tertiary care centres and service providers in a network;public and private laboratories will in this context gener-ate figures for policy making as well as the alerts neededfor disease surveillance [61]. Pending a closer scrutiny ofimplementation, plans have been presented for a uniqueidentification health card in the 12th 5-Year Plan; itremains to be seen how it will relate to the Unique Iden-tification Authority of India (UDAI)/National PopulationRegistry – recently issued “Aadhar” card.

4. Implementing UHC in India

4.1. Evidence of what works in implementing healthsystem reforms

This paper builds on the analyses of the challenges facedby India as described in the Lancet Series [62], the HLEGReport [63], the Country Cooperation Strategy 2012–17between the GoI and the WHO Office for India [64] anda non-systematic review of a substantial number of inter-national articles and books on the topic [65].

Attention has been paid to the role of evidence tosustain reforms, the influence of international organi-sations, the reactions of those affected, the timing andinteractions across different policy areas and the type ofinstitutions to support implementation [66]. The WHO’smessage that any effective health financing strategy needsto be “home-grown” [1] applies equally to a wider healthsystem reform strategy. There is clearly no readymade solu-tion or approach to be “copied” or “imported” by othercountries; each one needs to arrive at its own solutions.

Although no single mix of policy options works inevery setting and there is likely to be variation in boththe sequencing and mix of reform instruments in differ-ent places, potentially relevant lessons can be identifiedfrom the efforts devoted to review what has worked andwhat has not in reforming health systems in middle- andhigh-income countries. After in-depth review of reformsin Finland, Korea, Mexico, Switzerland and Turkey, OECDidentifies the following as key issues specific to the healthsector [67]:

- The role of professionals (as service providing monopo-lists in many cases);

- The role of information/analysis/evidence of each coun-

try’s system and reforms;

- The role of international system performance compar-isons;

- Clear diagnosis and compelling design for a reform;

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Taking advantage of political ‘windows of opportunity’; Communication/engagement between proponents ofreforms and key stakeholders – especially with vetopower;

The use of incentives, to align the interests of stakehold-ers with the intentions of the reform;

Sufficient resources to ‘oil the wheels of change’.

The core empirical lesson from Brazil, China, Mexicond Thailand these days is that reforms to make progressowards UHC can (and indeed, must, given the expectationsf the population) be implemented at a faster pace than inurope in the last century.

Implementation has been confirmed as the most impor-ant aspect in any health sector reform, as stakeholdersupport is paramount. A seminal work in developing coun-ries identified as equally critical as the proposed contentf reform (a) the actors (i.e. professionals, citizens, policylites, lobbies) as individuals and as members of a group,b) the context (i.e. social values, macroeconomic situa-ion, political environment) and especially (c) the processesi.e. operationalization of the reform policy, distribution ofower and authority, pace of reform implementation, etc.)68]. Difficulties have been reported that reflected inade-uate planning of implementation, be they with the timingf the steps needed to introduce reform (number andequence), the central and local governance/distribution ofower, the technical infrastructure (information systems,anagement skills, etc.), the way in which the reform was

resented to public and private stakeholders, the resourceseeded for the new organizational arrangements, etc.

The main lesson is that the same degree of thought andffort that goes into developing policies should also gonto developing an implementation strategy, distinguish-ng between the long steady necessary processes (includingeaks and valleys) and the importance of seizing politicalindows of opportunity when they arise [69], something

onsistent with previous findings about collective action70].

On the service supply side, reforms seem to have gener-lly fallen short of both rhetoric and expectations; theirimited impact stems in part from their limited effectsn clinical practice [71]. Public hospitals have in particu-ar emerged as extraordinarily complex environments toeform, subject to multiple relationships, more amenableo governance than to traditional management [72].

.2. Management of the implementation process in India

As India moves towards implementation, two points areorth keeping in mind:

First, no country (with the possible exception of China– and the political contexts are barely comparable) hasever taken on such a complex endeavor at such mas-sive scale. The 12th 5-Year Plan rightly recognizes thatthe pursuit of UHC will last for at least 2–3 plan peri-

ods – that is, 10–15 years – requiring strategies to gobeyond any script in any one plan. Therefore rather thanover-prescribing detailed recipes taken from anywhereelse, in our opinion attention needs to be paid by policy

114 (2014) 269– 277 275

makers to identifying priority issues, key implementa-tion challenges and main barriers, customizing solutionsacross the four health system functions;

- Second, implementation needs to be accompanied byanalysis, so that the solutions are found through policyanalysis and research embedded into implementation.This calls for strengthening “evidence-to-policy” linksand the intelligence dimension of stewardship as well asthe necessary accountability. State-level experiences andgood practices will need to be documented and circulatedin each State, informing also decision-making in others.

In parallel with making policy choices in terms ofprocesses, India needs to carefully design the institu-tional/organizational arrangements for implementation.The tools, management of partnerships, access to up-to-date health analyses for informed decision making, etc.need to be crafted. Clear system goals and the correspond-ing short-, medium- and long-term interventions need tobe articulated and negotiated with the various stakeholders(public and private) at all territorial levels, across sectors.

Incentives need to be devised to increase transparency.Professional self-regulation and a high-level inspectoratecould be promoted in our opinion, with key stakeholders’participation – at least at the level of policy design. Patientempowerment could be increased as necessary by actingon the Right to Information Act 2005 (modified in 2011)[73] – e.g. by individualized personal identification medicalcards, facilitated formulation of complaints in case of abuseas adequate, etc.

Looking for the sustainability of reforms, the criticalchallenge is to gather momentum for correctly implement-ing the key multi-faceted reforming steps; there will surelybe trade-offs between maximising the speed at whichreforms are carried out and minimising the resources tobe invested. Needless to explain, finally, the presence ofhigh caliber people at the “commanding heights” of reformwith a mandate to tailor an implementation process full ofadjustments needs to be continued.

Overall, our conclusion is that there are reasons to beoptimistic about UHC in India as there is: (i) political will tochange; (ii) availability of resources; (iii) a coherent outlinestrategy; and (iv) updated knowledge and skills for learningby doing.

Major conclusions and recommendationsCompulsory funding sources (taxation) are needed tomove towards Universal Health Coverage.No readymade solution or approach exists to be“copied” or “imported”. Accompanying the healthfinancing changes, countries wanting to promote UHCneed to address the functions proposed in the healthsystem framework developed by the World HealthOrganization.The framework can help diagnose shortcomings andfacilitate the filling up of gaps between functionsand goals, as poor outcomes usually reveal prob-lems at various health system levels. For that reason,

achieving the final health system goals require amulti-pronged approach towards generic intermediateobjectives.

276 A. Duran et al. / Health Policy

Shortcomings in service delivery need at least as muchattention as financing problems. Proposals are neededto produce preventive, diagnostic, therapeutic, reha-bilitative and caring personal – and population-basedhealth services, plus inter-sectoral actions addressingthe social determinants of health. Key issues are whatservices? delivered where (hospitals, PHC) and how(by the public or the private sector, what degree ofvertical organization, what type of management?)No health system can operate without assemblingthe necessary inputs. Sufficient clinicians (doctors,nurses, paramedics, etc.) and health system workers(managers, economists, lawyers, etc.) with the rightknowledge, skills and attitudes plus efficient time-frames for education are needed. Reliable supply ofpharmaceuticals, consumables, diagnostic, ICT andother technologies as well as health facilities (PHC cen-tres, clinics, hospitals, etc.) is also crucial.The stewardship function should ensure vision anddirection through clear outcome-oriented policies andstrategies involving stakeholders as well as regula-tion preventing the misuse of resources and ensuringtransparency and accountability by all. Institutions likethe Ministry of Health should have capacity to collectand share health intelligence, understood as higherlevel of data/information evaluation, monitoring andanalysis.Attention has to be paid to reform implementation,as different from its design: “how to implementreform?” needs to be found through policy analysisand research embedded into flexible implementationof the “what to do?” plans. Strengthening “evidence-to-policy” links and the intelligence dimension ofstewardship/leadership during implementation is thus

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