1. Financial Protection

Providing universal health service coverage so that every individual would achieve health gain from a health intervention when needed by appropriate provisioning of health services. WHO devoted the World Health Report 2010 to “Universal Coverage” to highlight the conviction that access to and utilization of services according to need is a critical challenge everywhere (and probably the biggest challenge India faces). WHO has contributed to the report by the High Level Expert Group (HLEG) on Universal Healthcare Coverage established by the Planning Commission.

WHO will play an important role in: (i) dissemination, technical and policy advice by creating and sustaining a sense of urgency and a strong drive from the Report to implementation; (ii) advocacy for raising key technical aspects higher on the political health policy agenda, including development of common IT/HMIS standards in the public and private sector; and (iii) emphasizing quality standards, as well as embedding monitoring and evaluation in the reform implementation process.

WHO will also support the Government in helping stakeholders assess the services to be covered, starting from a review of the existing vertical services arrangements and health programmes, a number of which have already been integrated under the NRHM. The GoI is committed to increasing the number of affordable, efficiently networked and sustainable quality services to provide cover for the entire population and up scaling the necessary workforce accordingly. To facilitate this, feasibility studies are needed to examine the coverage of different packages.

A health technology assessment-inspired mapping exercise will thus be implemented addressing the personal and population health services that should be produced (profiles, not necessarily full details), their numbers and target populations, the delivery approaches and quality standards, service structures and organizations. If measured by the results obtained in the OECD countries and many countries in transition to higher development stages, primary health care services should be a clear priority in India. The fact that they are not covered under the Rashtriya Swasthya Bima Yojana (RSBY) but only through the National Rural Health Mission (NRHM) makes them especially relevant for UHC as stated in the report of the HLEG on UHC. One lesson learnt from the experience of other countries is that a unified IT system (or at least one with common standards so that different systems can “talk” to each other) is a critical prerequisite for fast, efficient progress towards a universal health financing system. Most importantly, while some aspects of reform implementation can proceed step-by-step, the IT/HMIS must not; standards and architecture have to be identified to avoid an over-fragmented reality that will be very difficult to put right a few years from now. 

2. Quality

Properly accrediting service delivery institutions (primary health care facilities and hospitals) to deliver the agreed service package is the supplement to ensuring coverage. WHO will support the Government of India in the process of accrediting service delivery institutions (primary health care facilities and hospitals) able to deliver the “covered” package with adequate staff and proper standards.

WHO will support a qualitative leap forward in the quality of licensing, accreditation and certification of public and private health services delivery institutions and existing schemes. This would ensure that chosen hospitals are really able to deliver the required package of services if and when accredited or quality certified to do so, in order to increase demand for the package of services offered, coupled with synergized patient charters with explicit mention of patients’ rights.

Given the current ownership structure in service delivery, it is envisaged that the planned increase in public expenditure will involve a substantial supply-side intervention; it is intended in principle that there will be at least one public hospital able to deliver the required package of services in each defined area. Private hospitals (perhaps initially from the not-for-profit voluntary sector) may be contracted by the government to provide services using public funds wherever necessary.

To that end, improvements in the entire field of contracting arrangements (formulated in the NRHM as “increasing district accountability for the money received by making certain specifications”) also need support; districts and particularly hospitals need to have the necessary measurement, accounting and managerial instruments to make them accountable. Better Programme Implementation Plans and District Action Plans should also be developed, supported by refinements in the Health Management Information System (HMIS), contractual arrangements and other tools.

Access to high-quality, affordable essential pharmaceuticals and other technologies will also be promoted in the context of accreditation; this is something that also connects with India’s duties in addressing health challenges globally through S-SC, BRICS commitments and beyond.

Realistic health workforce plans including, for example, initiatives to encourage migrants willing to return to India at the end of their careers will become important in the efforts to meet the required standards of practice in India (numbers, skills and ethics). WHO would advise in work on the human capital that might entail different modalities, to be determined by the government and the concerned institutions, for example:

• increasing the production of professionals;
• providing intensive, specific training to targeted groups;
• changing the skill mix of the workforce; and
• providing incentives, either positive (e.g. better job conditions or bonuses) or negative (e.g. tighter discipline and more sanctions).

WHO will also support refinements in the HMIS needed for modern licensing and accreditation. As indicated in the section on Stewardship, better registration and reporting systems will have to be simple but effective. Professionals in the public sector are supposed to already have reporting obligations. For health authorities, better involving private doctors and institutions (clinics and hospitals) in the pursuit of national health objectives is an obligation that cannot be renounced – more so if private institutions aspire to contractual arrangements which would allow them to provide services using public funds. The human resource and technological implications of these improvements in HMIS should be taken into account.