Universal Health Care: A view from informal women workers in India

India’s Universal Health Care journey

India’s journey towards Universal Health Care (UHC) began before independence with two key policy documents issued in the 1940s: the Sokhey Committee report, which was part of the planning for an independent India led by Jawaharlal Nehru, and the Bhore Committee report, led by Sir Joseph Bhore of the colonial civil service. Both reports came up with remarkably similar and perceptive recommendations on what needed to be done to extend health care to all Indians. Although neither used the term Universal Health Care, they contained almost all the elements of what we would associate with UHC today. These two committees were followed by others tasked with preparing blueprints for people’s health in independent India. Under the Constitution, the responsibility for public health is assigned to each of the 29 states, while the central government sets health policy, allocates resources and is responsible for public health in eight Union Territories.

On the journey to UHC, another watershed moment was the Alma Ata declaration on Health for All in 1978 with primary health care as its core. India actively adopted the Alma Ata approach until 1983 when, like the global health community, it chose to focus on a few aspects of health such as those popularised through UNICEF’s GOBI FFF agenda – growth monitoring, oral rehydration, breastfeeding, immunisation, family planning, food supplements and female education (Dabade, 2018).

Following the International Conference on Population and Development in Cairo in 1994, India’s public health programme moved towards a more holistic approach. In 2005, the government launched the National Rural Health Mission (NRHM) in response to sustained advocacy by civil society organisations and the work of the National Advisory Council (NAC) led by the Chairperson of the United Progressive Alliance. In 2010, the government set up a High Level Expert Group on Universal Health Coverage (HLEG) to lay out the steps required to implement UHC in India. Their report, prepared after wide-ranging consultations with civil society, government, the private sector and officials from Thailand and other countries, ¹ called for major public health reforms and an increase in public health spending to at least 2.5% of gross domestic product (GDP) (HLEG, 2011). The NAC and HLEG report led to the establishment of the National Health Mission in 2013.

In 2014, the newly elected national government reaffirmed its commitment to UHC. A series of consultations led by the Health Minister culminated in the National Health Policy of 2017 which incorporated all the HLEG’s recommendations for UHC and placed strong emphasis on primary health care alongside traditional systems of medicine. In 2018, another game-changer came through a renewed focus on public health through the Ayushman Bharat (literally ‘long-lived India’) Mission. This includes two programmes: Health and Wellness Centres (HWCs), and the Prime Minister’s Jan Arogya Yojana (PMJAY) or People’s Health Programme. PMJAY covers 40% of Indian households, all below the poverty line, with health insurance for secondary and tertiary care. In the 2019 World Health Assembly, the Indian Health Minster declared that Ayushman Bharat was part of India’s growing commitment to UHC. (Watts, 2019).

With such an active policy commitment to UHC, the question is whether and how these commitments reach the grassroots and, in particular, the poorest and most vulnerable of Indians.

Reaching the poor and vulnerable: experiences of informal women workers

The informal workforce in India is estimated at around 500 million people or 93% of the total workforce and constitute the majority of those in poverty. Women informal workers are among the poorest, with the worst health, nutrition, literacy and other developmental indicators. Therefore, it is important to understand if and how this group has benefitted from recent developments in public health – both at the grassroots and policy levels.

Our knowledge about informal women workers’ health and well-being is rooted in the Self-Employed Women’s Association (SEWA), a national union of 1.8 million women in 18 states in India. Based in Ahmedabad, SEWA has focussed on economic empowerment of women and their families. Among the many activities that SEWA has undertaken over the past four decades is a primary health care programme that developed into a health cooperative in 1990, providing services and running low-cost pharmacies and an Ayurvedic medicines production unit. The work of the health cooperative – called Lok Swasthya or People’s Health – provides a number of insights for implementing the Ayushman Bharat programme.

First, and most importantly, the PMJAY (health insurance) does not cover all citizens or even all informal workers. It is based on the below poverty line lists prepared by each state government. The accuracy of these lists has been the subject of debate for many years (Mahamalik and Sahu, 2011). While the HWCs do serve everyone, the PMJAY does not. Thus, the principle of universality is not being adhered to, though it finds place in the National Health Policy 2017 and the government says it aims gradually to cover more citizens. SEWA and its health cooperative, Lok Swasthya, have been advocating for universal coverage and at least coverage of all poor, informal workers, allowing them to self-register with whatever worker’s identity card or other documentation they have. With Out of Pocket (OOP) expenditure making up about 67% of all health expenditure (The Elders, 2018), and disproportionately affecting the poor, covering informal workers who make up at least 90% of the working poor seems a logical starting point for extending coverage. Tax payers and government employees who already have access to insurance can be excluded or could join in solidarity by paying their own premiums.

Second, the HWCs and existing primary health centres in both rural and urban areas do not provide services according to the needs of informal workers, and especially women. Mental health and occupational health and safety are largely absent. There is no screening for these nor early preventive action or treatment at the primary level. A women’s health programme that comprehensively takes care of reproductive and sexual health, nutrition, mental health, maternal health and women’s occupational health is another critical gap at the primary health care level. Efforts are underway at the national and state levels to include some of these areas but have not yet translated into concrete programmes at the grassroots level.

Third, while the HWCs aim to be as close to people as possible, their hours of work and staffing do not meet the needs of informal women workers. The centres are usually shut when women come back from their farms or return from construction sites in the late evening. Workers reliant on a daily wage will rarely miss work to visit the health centres. With huge shortages in nursing staff, frontline health workers and even doctors, many of the HWCs are not fully functional. The HLEG report on UHC stressed the need for significant increases in health personnel – from frontline health workers and nurses to doctors, including a new cadre of rural doctors specifically trained in community-based work.

Fourth, a basic primary health care package including free or low-cost medicines, diagnostic tests and other services suggested in the HLEG report has not yet been fully implemented. While immunisation, family planning, maternal health and some NCD care are now more available, several essential services and medicines are not. This results in continuing high OOP payments, especially for medicines which constitute about 70% of health care costs.

Fifth, action on the social determinants of health is inadequate. At the policy level, this is well acknowledged. However, programmes for early childhood care, promoting employment and skills, enhancing women’s agency and pollution control measures, among others, are still absent. Two positive measures currently being implemented by central and state governments are a water and sanitation programme and a campaign to reduce malnutrition. The former has reportedly reduced open defecation through construction of subsidised toilets and the latter is being implemented through day care centres, health programmes and mid-day meals in schools, among other interventions. Progress is however at best mixed, with uneven implementation across states: southern states do better in most respects than those in the north and east which have the largest and poorest populations.

Finally, and perhaps most importantly from the perspective of informal women workers, there is limited participation of local people in action for health. State governments have set up local health committees in rural and urban areas to disseminate information, implement health programmes and educate local people on their health rights and entitlements. In practice, the committees in most states are either inactive or defunct. Their members require capacity-building support to develop and implement their own plans. In several states, civil society is providing this kind of support. SEWA’s health cooperative, for example, supports 200 rural and 200 urban health committees in four states. This experience has been encouraging, especially when informal women workers constitute at least 60% of the committees. We have seen that with capacity-building and supportive supervision, women and others exercise their rights and responsibilities in these committees and ensure that the funds for local health action are spent on community needs, such as extra food for a malnourished child or transport during a medical emergency.

There are of course many other aspects of UHC in India that will have to be addressed. Developing new programmes like Ayushman Bharat is a step forward, despite their operational challenges. However, to make UHC a reality, bottom-up demand and a people’s movement for health across India needs to develop. The Right to Education law passed the Indian parliament several years ago in response to a huge upsurge in the demand for quality education, as this became widely viewed as a key route out of poverty. The same link with poverty reduction has not emerged for health care despite the fact that sickness impoverishes 63 million Indians every year, causing loss of productivity and income and resulting in immense suffering.

As India’s largest organisation of informal women workers, SEWA is leading an effort to increase awareness about UHC at the grassroots level. Together with more than a hundred community-based organisations, unions and cooperatives in 20 states, and with the World Health Organization (WHO) country office, workshops have been organised to learn about local needs and share information about UHC. These are opportunities to have in-depth discussions about current public health programmes and how they can better serve the needs of informal workers and others across India. ² The responses to these efforts are encouraging. Following the first national workshop, a regional meeting was held for the eight north-eastern states. Representatives of various organisations spoke about the need for UHC tailored to the specificities of the North-East of India, an area with its own unique tribal culture and customs, including on health. One important recommendation, for example, was the incorporation of herbal medicine in UHC. Much more needs to be done to act on the recommendations for UHC that emerged from these consultations, tailored to local contexts, and with the people, especially informal women workers, who are central to all our efforts.