Seminar Report: Strengthening of Public Sector Health System for Universal Access to Health Care (UAHC),Council for Social Development Seminar,New Delhi (July 16–17)

Inaugural Session

The seminar got off to a start with Prof. K. B. Saxena of CSD explaining the immediate context for discussion on strengthening the public sector to provide universal health care as having been provided by the steering committee of the Planning Commission which rejected a number of recommendations by the HLEG headed by Dr Srinath Reddy and showed a marked bias in favour of the private sector. ⁹

Dr Saxena’s introduction initiated a debate among Dr Vishwa Mohan Katoch, DG ICMR, Dr Rakesh Sanwal, Advisor (Health) Planning Commission and Prof. Imrana Qadeer. Dr Katoch did not dwell on the specifics of HLEG or steering committee recommendations, but made a strong pitch for political intervention which, he said, was the key to actualising universal health care. ‘Programmes work when politicians drive them,’ he said.

The averments of Dr Rakesh Sanwal, Advisor (Health) Planning Commission, indicated the direction which the government is taking to realise universal health care. The central government, he said, does not have the sole responsibility of realising this goal. According to him, health is achieved by ‘all Indians being resilient to disease, as individuals living in a community that is resilient and is strong enough to ward off any risk to health; they are part of system that is strong’. This definition does not absolve any individual or institution of responsibility. Health is not just curative, it is preventive and promotive. It is not just allopathic health but encompasses a wide base of midwives, paramedics and involves giving a choice to each citizen to the kind of health care they want. It is also a choice to an individual to pick a government, private or an NGO-run health facility. This definition focusing on resilience, adaptability and self-management as elements of health contrasts with the World health Organisation’s (WHO) definition of health ¹⁰ which lays stress on ‘absence of disease’ as the condition defining well-being.

To this end, Dr Sanwal said, merely increasing health allotment in the GDP is not going to be enough. Health, he said, ‘has to be paid for by those who can and provided to those who cannot’.

Prof. Imrana Qadeer agreed with Dr Katoch in that providing access to universal health care is a ‘political challenge’, but presented a sharp critique of the planning process that deviates from the responsibility of the state to ensure health care for all. She said poverty is the root cause of ill health and health has to be located there. Therefore, to those who make the argument that health is an ‘individual issue and individual resilience is critical’, it is necessary to analyse political and economic structures and see what people can and cannot do. Responsibility cannot be fixed on people who have no food, whose children are dying and who have to make a choice about which one in a family should eat in a day. In a discourse of this nature, it is essential to talk of classes, of inclusive development, of equality, which is a much bigger political challenge, and not just of equity, which is about distributive justice.

She said that since universalising health is the theme for making the 12^th Plan, it is essential to reclaim the Nehruvian planning process that made use of available date to plan for complex processes. The discussion around the 12^th Plan claims that this is the same tradition as what the Bhore committee ¹¹ talked about. But the Bhore committee was very clear in identifying poverty as the root cause of ill health. The definition of universal health care that is now being presented ¹² is a clear departure from the Bhore committee in that there are two very critical distinctions—first, that the present process separates public health from health services; and second, that it talks of services not only by the public sector but by other players, which obviously means the private sector.

While a majority of the HLEG’s recommendations can be considered, Prof. Qadeer expressed reservations about ‘contracting in’ of the private sector ¹³ . She said without any conditionalities or even identifying the complexity of the private sector and the problems at each level, the stress on ‘contracting in’ of health services is a matter of concern.

Sessions II and III: Social Determinants to Access to Health Care

As highlighted by the Public Report on Health (C. Sathyamala et al., 2011), caste identity and gender are key factors in determining access not just to health care but to education, anganwadis, public distribution system (PDS), land and even employment opportunities of an individual.

Prof. Ritu Priya, of the CSMCH in JNU, pointed out that the attempt behind collating the Public Report on Health was to get a bottom-up perspective. The data that is now available through this multi-method study is developed to triangulate people’s perceptions, providers’ perspective as well as epidemiological rationality to get a picture of what health really meant to the people at a time when the NRHM was being formulated.

Very often when social determinants are discussed, the focus is on intersectoral coordination as being the final step. But the political dimension of this issue, regional variations as well as public policy that impacts each of the social determinants also have to be taken into account while designing for health care. The analysis in the Public Report was based on the social category of caste, which was still found to be the basis of social structuring. The health status of the SC/STs was poorer, but vast regional variations existed, based on caste, which determines economic status and political power. So the SCs of Tamil Nadu have better access than upper caste population in Madhya Pradesh. Aggregate analysis takes away from these variations.

However, social structuring invariably played a part in access. In a Tamil Nadu village, for instance, the central part was inhabited largely by upper castes while the SCs lived in the periphery. In an MP village, tribal households were clustered in a hamlet separated from the main village by paddy fields. The location of anganwadis or health centres and the access thereof will necessarily be dependent on such caste-based segregations (ibid.: 44).

At the same time, gender too is a key factor inhibiting access to health care for women as well as affecting the general well-being of female members of a family. In the six states that were surveyed to bring out the Public Report on Health, barring the exception of Himachal Pradesh where women are entitled a share in both their natal and husband’s property, a large number of women were found to be either deserted/widowed/divorced with little social standing and low economic status. The general well-being and nutritional status of these women bringing up children on their own was pitiable (ibid.: 45).

Women without spouses, who form single-member households, form a sizeable population in the old age group, that incurs excess of energy expenditure in heavy labour work (ibid.: 48). While planning for universalising health care such social factors as caste, religion and gender will have to be kept in mind.

Similarly, as cities have moved from having manufacture as chief economic activity, to a predominance of the service sector, several processes have followed. The high premium on land and property means that the poor have had to move out and exist in the peripheries. Dunu Roy of the Hazards Centre demonstrated how norms for provision of the most basic services—drinking water and sanitation—are not rights-based but class-based.

The idea of a ‘slum free Delhi’, ¹⁴ demonstrated Roy, means that the slum clusters exist outside what would be classified as the ‘urban area’. The location of hospitals run by the Delhi government, the Municipal Corporation of Delhi, as well as the central institutions such as AIIMS is too far to be within reach for most of these clusters. Besides, an analysis of the basic rights such as access to potable water revealed a marked discrimination among the lower class, middle class and upper class clusters.

Session IV: Infrastructure, Personnel and Coverage

Dr T. Sunderraman of the National Health Systems Resource Centre, a technical support institution with the NRHM, dwelt on shifting of the discourse on health coverage. Universal Health Coverage (UHC) is a terminology that is currently dominating international discourse in the same way that Health for All ¹⁵ did till 2008. The difference is that HFA implicitly was about public provisioning of health services.

There were gaps in this kind of coverage which were explained through the US-led or what is also called the ‘Harvard discourse’. This is the dominant discourse internationally that primarily believes that allocation of resources is best done by the markets and that the states are inherently inefficient in allocation of resources. That is the reason why ‘public provisioning’ of health is inherently flawed. The focus, therefore, needs to shift from public provisioning to public financing of health care. The public hospital system has to be consciously dismantled so that the entire population opts for insurance, whatever the cost.

This is the kind of reasoning that has led to a set of health sector reforms with the objective of reducing the role of the government and to allow the market to take over in India. In the 1990s, the role of the government was consciously restricted to just a few priorities and this led to a sharp decline in the public share of total health expenditure. As a result, there was rapid growth of the private sector with a simultaneous increase in the cost of care. Financial barriers led to exclusion from access to health care.

The catastrophic expenses promoted the terminology of Universal Health Care to become dominant, which basically implied that purchase of health care by the individual would be replaced by purchase of health care by the governments, at least for the poor. The meaning of coverage now moves from the supply side to purchase and what is the best models of purchase—whether it is cash transfers, capitation fee, and so on.

The world now has extensive experience with purchasing care. Does paying a premium for everyone provide universal access to health care? In practice, the package of services purchased tends to be very limited, making for persistent large dependence on out-of-pocket expenditure. Second, there are several instances of denial of care by insurance companies which had been paid a premium by the Health Management Organisations (HMOs). It also costs the government a lot more. There is also an issue about a lot of people not being poor enough for the government to pay premiums for their health insurance. In India, the problem is aggravated due to lack of a qualified private sector in most rural areas and the problems of governance and institutional capacity to manage such a programme.

Session V: Regulation of Public Health System

This session commenced with Prof. Ranjit Roychaudhury from National Institute of Immunology (NII) providing the broad legislative framework of regulation of health care in India. He said the pending legislation, the National Commission for Human Resources for Health (NCHRH) bill, ¹⁶ seeks to set up NCHRH as well as National Board for Health Education (NBHE) and the National Evaluation and Assessment Council (NEAC) as well as various professional councils at the national and state level to determine and regulate the standard of health education in the country.

Dr Indira Chakravarty of CSMCH, JNU asserted that implications of the transformation in the corporate medical sector are central to envisaging regulation of the health sector. There is negligible regulation of this sector because there is very little available in terms of research of the processes of privatisation and the extent and nature of corporate presence in India in the delivery of health care services. Dr Chakravarty’s own study (Social Medicine 5:195–204) proves that there is explicit encouragement and support from the government to this sector in the form of tax holidays, provision of land at concessional rates, duty-free import of equipment and so on.

She highlighted the rapid corporatisation of hospital care as well as diagnostic facilities. Accordingly, the modes of finance have changed. Companies setting up hospitals and diagnostic facilities are raising funds through public offerings, venture capital, loans and equities from Indian and international financial institutions including the World Bank. These funds are not meant solely for setting up facilities but are also used for expansion and acquisition. There is considerable corporate investment in this sector through FIIs and foreign equity.

She said there are serious implications of this untrammelled corporatisation of the health sector in terms of the loss of government control, no marked improvement in the quality of care, high cost of such care, lack of transparency and resistance to monitoring/regulation, besides undermining of the public health system.

Dr Chakravarty’s deliberations were followed by Dr Prachinkumar Ghodajkar, also from CSMCH, JNU, deliberating on issues of quality in health care in a working paper during the session. According to Dr Ghodajkar, the most important question is to define what constitutes ‘hospitality service’ as opposed to what defines ‘necessary hospital service’.

The literature on quality of health care shows different streams of thought—some discuss the quality of care delivered to a patient, while others dwell on the quality of health service systems that provide care services to populations. The history of discourse on quality shows that the shift towards purchasing, rather than funding, health services has resulted in increased attention being given to ways of measuring hospital performance and quality of hospital care (Draper and Hill, 1996).

Prof. Rama Baru of CSMCH, JNU, questioned whether regulation can be effective if the private sector in health is not addressed. The HLEG is silent on this aspect. The alliances between not just the pharmaceutical industry and hospital services, but also in medical education cannot be ignored. There is no regulatory mechanism because it is seen to be contributing to the economic growth. The Ministry of Health is not regulating the private equity funds that are coming into the health sector.

One issue that needs to be focused on, said Prof. Baru, is the way the private sector is moulded and the way it changes shape, tweaks it to their advantage whenever regulations are being suggested. There is a technical aspect to regulation but the socio-political aspect of regulation has to be looked at.

Session VI: Resources for Strengthening Public Health Care

There are problems with the ‘managed care’ model, pointed out by Amit Sengupta of the Delhi Science Forum in the deliberations on health financing. Systems of health financing, he said, were built mainly around two basic ways of generating resources—through general taxation or an insurance mechanism. The earliest model (Bismarckian) was introduced in unified Germany in the nineteenth century. This model, evolved within a larger concept of the welfare state, continued to thrive in many countries in Europe as well as in Japan and some Latin American countries. The other, the Beveridge model, introduced initially in post-World War II Great Britain, was based on public funding of health care through general taxation as well as public provisioning of care. A third variant of state intervention is the Social Health Insurance (SHI) model where care is financed through a national, publicly administered insurance scheme that is financed through contribution from users, employers and the government. Unlike the Bismarckian model, it is a ‘single payer scheme’ but provisioning can be public or private or, usually, a combination of both.

The Alma Ata conference in 1978 was not explicit in combining public financing and public provisioning of health care. Its intent was clearly to indicate a central role for the government in both provisioning and financing of health care. There is clear evidence that developing countries which chose to build systems which combined both, such as Sri Lanka, Costa Rica and Cuba, did much better in ensuring health care.

He asserted that the explanation offered for the poor spending on the health sector is that the money actually does not get spent. The absorption of a system that has been allowed to be dismantled over the years will, according to him, be very miniscule. It has to be augmented.

How do you spend the money—do you use it to build a system or use it to provide universal health coverage as a package? This is really the central question. Who provides health care is important because fragmented provisioning of services does not allow for development of integrated health systems. The concept of ‘managed care’, he said, where public and private providers compete to provide services, may make perfect market sense but does not apply within the logic of health systems.

Advancing the logic of fragmentation, an attempt would first be made to promote segregation of health systems into primary care by the public sector and tertiary care by the private sector. As the private sector would grow to fill the vacuum, a lot of noise would then be made about ‘catastrophic payments’. The state would then step in and assert that a ‘minimum package’ would be ensured. The argument for this is lopsided because the private sector, despite being a ‘partner’ in providing tertiary care, would then be financed through public funds, that is, through ‘minimum packages’ ensured by the state.

There is enough evidence, said Dr Sengupta, that the best performing systems are those that are publicly financed and provisioned. Public provisioning needs to be located in a range of other social protection measures, while public financing has to be located in a progressive taxation system that is premised on the notion of equity.

According to Dr Indranil Mukhopadhya of the Public Health Foundation of India, the discussions on the thrust on ‘managed/packaged care’ leaves several questions answered. ‘What about system strengthening? Do state-run insurance models really lead to reduction of catastrophic health expenditure? What about price regulation? Cost of regulation? Does regulation control prices?’ he asked.

Session VII: Drugs and Vaccines

According to S. S. Srinivasan of the All India Drug Action Network, HLEG recommendations about medicines are by and large a positive step because they come with obvious benefits to free public health services in terms of less exploitation, decrease in related indebtedness and impoverishment. The provision of free medicine also attracts people back to the public health system.

This marks a change from the current situation where India has more than 20,000 drug formulations in the market. A great many of these formulations are irrational and unscientific. There are too many combination drugs. In fact, as many as 62 per cent of the 300 top selling drugs are not in the National List of Essential Medicines! The market also has very poor regulation by drug authorities because of corruption and inefficiency. This level of corruption, which is part of the rent/fee to the regulators, undermines quality in that it makes the receiver/regulator not ask relevant questions. These issues have been spelt out by the 59^th departmental committee of Parliament.

Srinivasan pointed out several pricing anomalies of drugs, main among which is over-pricing of drugs where profit margins go up to a staggering 4000 per cent. In addition to this, there are practices such as selling of the same drug by different brands at vastly different prices. To top it, most of these drugs are out of the government’s price regulation. In the run-up to the UHC, one of the arguments that Srinivasan said activists were afraid of is that since drugs are to be given free of cost, where is the question of regulation of prices? This can be advanced to further undermine regulation. However, the reality is that not everyone is going to access it immediately and by the time access is actualised, a lot of people would have got impoverished because of undermining of price regulations.

Srinivasan concluded with the following recommendations:

Right to medicine and health should be a fundamental right

Dr Biswajit Dhar of Research and Information System (RIS) for Developing Countries said that free medicine availability also depends on the supply lines not drying up. The realisation in India in the 1980s was that unless we have a robust domestic industry, ability to supply medicines will be inhibited. That was the thrust that led to the tremendous growth seen in the pharma sector. The time today is to discuss other issues such as impact of intellectual property regime on the pharma industry and the implications of TRIPS. He said:

Look at the numbers thrown up by the pharma industry. Today, almost every week there is news of takeovers of Indian pharma companies. The situation clearly is that the companies are willing to give themselves up. There is clearly something wrong with the incentive structure. The pharma industry is facing a serious problem. When we talk to them about the supply of free medicine, they say that it is impossible to take any more hits because their profitability has already come down. We have to look at it from a more holistic fashion.

He further added:

Let me tell you the problems—TRIPS has been implemented. We are all aware of the pressures to get into the TRIPS Plus regime. WTO is very active on enforcing interpretation of certain provisions such as data exclusivity. What was supposed to be a mere protection of data will effectively mean that generic producers will be barred from the market. WTO is negotiating a TRIPS Plus agreement and attempting a relook at the TRIPS agreement which had been left open and flexibility was allowed. At least in India we had inserted a provision to stop frivolous patents from being patented. 20 year patent was only going to be given to a substantive innovation and minor innovations were to be left out.

But there is an attack on that school of thought. Moves are afoot to nullify the gains that had been made in the WTO by developing countries, towards providing them with compulsory licences in the Doha Round. Another problem arises out of the bilateral free trade agreements. These are not just the classic free trade agreements dealing with market access for certain goods. These include intellectual property provisions. Dr Dhar said:

We have been going through the negotiations with the EU and took a lot of effort to get a handle on the intellectual property aspect of this agreement. It took a lot of effort to get an assurance from the government that there will be no data exclusivity clause or intellectual property agreement. Then there are, in terms of bilateral aspects, special 301 provisions of the US in the late eighties. Every year, they do a review of the intellectual property law. In India’s case, constantly there is a mention of the pharmaceutical industry and we are on the watchlist. They are always on the lookout for amending the intellectual property laws.

There is another issue, highlighted Dr Dhar, of a series of cases in the EU where generic producers’ interests were compromised. These producers were only using EU countries as transit for transport to other countries. But EU countries have provisions entailing seizure when the generic products are found to be in violation of the intellectual property rights in the EU. In the case of anti-AIDS drugs, CIPLA offered cheap drugs in Africa. But at the behest of the US and EU, many of these countries are now enacting counterfeit laws. They make very little difference between generic and spurious drugs and create a deliberate confusion. The overall constraints that the industry faces as a result of these practices are phenomenal.

Therefore, things need to change domestically in terms of our own policy regime. One of the worrying signs in the domestic market is a reversal of the trend till the 1990s when we were supplying our own ingredients for the bulk drugs. Suddenly, this has changed. The worrying part is that 70 per cent of the bulk drugs are being imported. China has replaced India as suppliers. We are standing on thin ice and the basis of the industry is becoming weaker.

Dr Amit Sengupta of the Delhi Science Forum said while the recent announcement of free medicine for all is welcomed, it should not be forgotten that this was talked about in the 11^th Plan as well. The fact that it was not worked on is an indication of the government’s inability to carry it forward. At the same time, this should not become a PR exercise for the government. All that this announcement really means is that in the public sector, free medicine will be available. This has been the assumption for the last three decades. All that the proposal entails is that the government should act on this assumption—to provide free medicines to those in OPD and in-house patients in the public sector hospitals.

Dr Sengupta came up with following recommendations for ensuring free medicines for all:

Revival of the public sector in the manufacture of vaccines and drugs.

Session VIII: Communicable Diseases, Non-Communicable Diseases and Integration of AYUSH

The Report of the steering committee of the Planning Commission suggests ‘integration’ of AYUSH in teaching, research and practice. Prof. Ritu Priya felt that the perspective for ‘integration’ is inspired more as a strategy for ensuring presence of doctors in the health system rather than a strategy for providing a choice to the patients. AYUSH doctors, she felt, should not substitute the other doctors, but be present in addition to other doctors. The idea of public systems ensuring universal health has to be actualised with verve and force, with a political thrust. The steering committee visualises it as a cross-cutting system, but it needs to be a central system, she felt.

Several committees and Five Year Plans have recommended using the availability of traditional practitioners to advantage, as they are providing services in otherwise underserved populations. Some states have recruited them to provide allopathic services in public health centres (PHC) such as in Maharashtra, Jammu and Kashmir and UP. What public health has ignored until now is the inherent worth that is recognised in the ‘other systems’ by lay people, elements of which are now increasingly being validated even by the frontiers of inter-disciplinary bio-medical research (Priya, 2011).

Dr Yogesh Jain of Jan Swasthyay Sahyog, Chhattisgarh, made a strong case against classification and differential treatment of communicable and non-communicable diseases, as attribution of the cause is highly problematic. For instance, to argue that chronic lifestyle diseases are the outcome of nutrition transition is erroneous and hazardous. How does this definition account for low body weight diabetes? In such cases, advice of eating less, exercising more and not having tobacco is not likely to be universally useful. Both types of diseases, in fact, deserve treatment on the following lines:

Same principles guiding the diagnostic work-up

Such rigid classifications, according to Dr Jain, translate into some diseases falling through the cracks, such as rheumatic heart disease with critical MS Vesico, vaginal fistula and prolapse uterus. Where do patients with these afflictions go? Which programme looks after them?

The Chairman of the HLEG, Dr Srinath Reddy said that besides raising the issues of the neglect of communicable diseases and the whole area of appropriate definitional identification to the programmes that are poorly delivered, an important question had been raised by Dr Jain, about the link of non-communicable diseases with poverty. Dr Reddy said:

We know now that the social gradient gets reversed for the various risk factors of non-communicable diseases as these epidemics advance and mature and ultimately, it is the poor who are the most vulnerable to NCDs. In terms of life style, it has a pejorative connotation and it is also inaccurate because it places the responsibility on the individual rather than on the society.

According to him, the link of under-nutrition is now well established with various non-communicable diseases. Even in the case of diabetes where under-weight diabetes has been earlier mentioned, as far back as the 1970s and 80s an entity of malnutrition diabetes was described by Dr Kochupillai. The incorrect understanding of the word over-nutrition has unfortunately been attached to non-communicable diseases. It assumes that there is adequate nutrition, whereas there is recognition now that it is not caloric adequacy that is important but where the calories come from that is important. It is not the just amount of fat, but the source of fat and which oils you use, that is important.

Healthy nutrition has protective elements which are often missing in diets. Fruit and vegetables have protective elements. According to 2010 global disease burden data that is going to be published in October–November this year, not only is there shows a rise in NCDs but a simultaneous increase in inadequate intake of fruits and vegetables. So it is now known that poverty has multiple pathways for leading to NCDs. For instance, tobacco is consumed in a big way by low income groups. The idea of linking non-communicable diseases with an affluent lifestyle should be discarded and poverty should be seen as a major driver of disease transition.

Dr Reddy said that in terms of integration of AYUSH, there is adequate knowledge that is rationally utilised. There is an attempt to divert AYUSH resources into a poorly performing allopathic stream. There has to be an attempt to utilise AYUSH in a meaningful way, particularly in the area of NCDs from health promotion as well as delivery services. He stated:

If we are going to integrate at various levels, are classic medical students going to be exposed to areas of knowledge related to AYUSH and vice-versa? If we are interested in bringing in mid-level workers, it may be an idea to train the three-year Bachelor of Rural Health Care who are going to be renamed as BSc (Community Health) in public health, AYUSH as well as some of elements allopathic care so that a much more integrated professional can be promoted. Why can’t we utilise existing programmes and their integration. For instance, why can’t the Tobacco Control Programme be integrated into Tuberculosis Control Programme, why can’t we look at antenatal clinics be used to promote family nutrition. The critical message is that having non-physician health care professionals can play a role rather than a doctor-dependent model.

Session IX: Commercialisation as Barrier to Strengthening of Public Health Systems

Dr Bijoya Roy of the Centre for Women’s Development Studies (CWDS) outlined the evolution of the PPP system over the past 20 years. She gave a power point presentation on how PPP have made inroads into the primary, secondary, tertiary levels. Starting from the periphery, they have entered diagnostics and are now expanding into secondary and tertiary level hospital care.

Dr Roy described the policy milestones for PPP expansion in India and the type and nature of private providers from a wide range of empanelled private service providers—individuals, NGOs and For Profit companies. These companies are competing for more than one government health care scheme. In the light of sustaining and expanding business, small and medium size private sector companies have begun to collaborate with the public sector. This magnifies the gaps in public health care system in terms of fragmenting support services besides not necessarily enhancing the capacity and quality of the public sector.

An important intervention made by Dr Roy was that the much lauded suggestion in the HLEG to abolish user charges ¹⁷ will be difficult to implement. The policy direction can be accessed from the fact that the Department of Economic Affairs has drafted the National PPP Policy last year which states in the introduction that to provide a broader cross-sectoral fillip to PPPs, extensive support has been extended through project development funds, viability gap funding, user charge reforms, provision of long tenure financing and refinancing as well as institutional and individual capacity building.

Dr Sunita Reddy, of JNU, presented a paper on Rajiv Arogyasree, a community health insurance scheme in Andhra Pradesh launched in 2007 for BPL families with the aim to ensure health care at critical and catastrophic times. Dr Reddy gave a critical review of the scheme on some important counts:

On shifting priorities of health care of rural poor: The scheme has doubtless created access to specialised health care for the rural poor. But there is a clear shift in focus in terms of setting priorities. The scheme prioritises tertiary health care that requires surgery and hospitalisation. There are pressing concerns about strengthening of the PHC system as a majority of the poor continue to suffer from infectious diseases.

Session X: Access to Health Care: Communitisation of the Public Health System

Dr Abhay Bang, Director, Search (Gadchiroli, Maharashtra) and also a member of the HLEG, described commercialisation, centralisation, bureaucratisation and disempowerment of people as major barriers to the availability of health care. He said the HLEG lays stress on the village health council, which will provide training to Community Health Worker (CHW) and organise the village level activities. According to HLEG, a Bachelor of Rural Health Care, two Auxiliary Nurses and Midwives (AN&Ms) and one male multi-purpose worker should be sent to each sub-centre catering to rural populations. Civil society organisations should be involved to galvanise village communities. HLEG recommends community monitoring system and a grievance redressal mechanism, as well as the control of social determinants. Dr Bang said UHC cannot be provided merely by the government. The best way is to generate universal capacity in communities to care for health. Involving people and communities is a more important, doable and permanent solution to India’s health problems than guaranteeing health facilities.

Dr Sanghmitra Acharya came back to discuss certain social conditions peculiar to South Asia which result in differential access to care, with the result that certain groups find it more difficult to access systems. She said while gender and economic factors are amply probed and understood, social identities, especially caste-based determinants of denial of access have not found adequate illustration in this discourse. It is important is to look at the social heterogeneity of people who are to be provided health care. Social barriers to access need to be assessed in order to convert availability of care to actual access and utilisation of care. This would be an outcome of awareness, of being informed and of the presence of a conducive environment to overcome inhibitions for interaction with the providers. Inhibitions arise out of lack of education, income generation activity and social sensitivity. If service providers are not sensitive to the vulnerable users’ sensibilities, utilisation gets jeopardised.