Edition 27 | December 20, 2023

2023: A Year of Progress and the Path Forward for Lancet Citizens' Commission on Reimagining India’s Health System.

As 2023 comes to a close, we're reflecting on our transformative journey over the past year. The pinnacle was hosting a full day in-person meeting to discuss final steps for publishing the Commission the coming year in Bengaluru in August, a dynamic gathering that brought together Commissioners, Experts and Authors, to advance Universal Health Coverage in India. Within this newsletter, we invite you to explore a repository of publications and resources published as part of the Commission's work this year.

As always, we express our gratitude for the unwavering support of our partners and eagerly anticipate continued collaboration in the year ahead!

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Work from the Commission

The Barriers to Universal Health Coverage in India and the Strategies to Address Them: A Key Informant Study

India has adopted several policies toward improving access to healthcare and has been an enthusiastic signatory to several global health policies to achieve Universal Health Coverage (UHC). However, despite these policy commitments, there has been limited success in realizing these goals. The COVID-19 pandemic has highlighted the urgent need for health system re-design and amplified the calls for such reforms, write Anuska Kalita, Noah Carton-Rossen, Linju Joseph, Deepshikha Chhetri, Vikram Patel.

Evolution of community health workers: the fourth stage

Comprehensive primary care is a key component of any good health system. Designers need to incorporate the Starfield requirements of (i) a defined population, (ii) comprehensive range, (iii) continuity of services, and (iv) easy accessibility, as well as address several related issues. They also need to keep in mind that the classical British GP model, because of the severe challenges of physician availability, is all but infeasible for most developing countries. There is, therefore, an urgent need for them to find a new approach which offers comparable, possibly even superior, outcomes. The next evolutionary stage of the traditional Community health worker (CHW) model may well offer them one such approach, write Nachiket Mor, Bindu Ananth, Viraj Ambalam, Aquinas Edassery, Ajay Meher, Pearl Tiwari, Vinayak Sonawane, Anagha Mahajani, Krisha Mathur, Amishi Parekh and Raghu Dharmaraju.

Teleradiology and technology innovations in radiology: status in India and its role in increasing access to primary health care

There is an inequitable distribution of radiology facilities in India. This scoping review aimed at mapping the available technology instruments to improve access to imaging at primary health care; to identify the facilitators and barriers, and the knowledge gaps for widespread adaptation of technology solutions, write Anuradha Chandramohan, Viswajit Krothapalli, Ann Augustin, Madhavi Kandagaddala, Hannah Mary Thomas, Thambu David Sudarsanam, Ammar Jagirdar, Shalini Govil, Arjun Kalyanpur.

Estimating funds required for UHC within Indian States

Universal Health Coverage (UHC) has been high on national and international agendas since its adoption as one of the Sustainable Development Goals (SDGs). Within India, there is a wide variation in the total amounts per capita spent by each state government (Government Health Expenditure or GHE) on healthcare. Bihar, with a GHE of 556 per capita (per annum), has the lowest state government spending, but there are many states in which governments spend more than four times that amount on a per capita basis. However, despite this, no state offers UHC to its residents. This failure to provide UHC could be because even the highest amounts spent by the state governments are too low for them to offer UHC or because the cost differences between states are very high, write Nachiket Mor, Sudheer Kumar Shukla.

Is contributory health insurance indeed an addiction to a bad idea? A comment on its relevance for low- and middle-income countries

Despite the strength of their case against contributory insurance, we suggest that the path forward may be more complex than they envisage for a number of reasons. The problem of a high proportion of informal sector workers that they argue impacts contributory approaches is also an issue with taxes because of the very low numbers of people who file returns. Taxes in most developing countries are in fact largely derived from highly regressive indirect taxes which the poor are forced to pay. Additionally, in most developing countries, including large ones like India and Nigeria, the only choice on offer is continued dependence on out-of-pocket expenditures, write Nachiket Mor, Hasna Ashraf.

Views & Opinions 

प्राथमिक चिकित्सा का मतलब डॉक्टर और दवाखाना नहीं है

प्राथमिक चिकित्सा में कमी आगे चलकर क्षेत्रीय महामारियों की वजह बन सकती है, इससे बचने के लिए नियमित स्वास्थ्य जांच को लेकर जागरुकता लाने और इसके नए तरीक़े खोजने की ज़रूरत है, नचिकेत मोर और राजकुमारी मोर लिखते हैं।

Take PMJAY to the next level

Given its funding limitations, PMJAY has not yet moved towards total health system financing in any part of the country, but its move towards paying hospitals on a package basis and not on a procedure-by-procedure basis has shown beneficial impacts, write Nachiket Mor Shuchin Bajaj.

Palliative care, a way to reduce financial distress for people with life limiting diseases 

Palliative care, a way to reduce financial distress for people with life limiting diseases, write Parth Sharma & Deepak Sudhakaran.


Organising for One Health in a developing country

Globally, zoonotic diseases pose an enormous and growing public health challenge, and developing countries like India are at the epicentre of it. Although there is general recognition of this reality, governments around the world have struggled to organise appropriately to respond to it. The widely held view is that organising for One Health requires effective cross-sectoral collaboration, but the prerequisites to enable such collaboration appear almost unattainable. Perhaps an entirely different approach is needed, which is over and above effective collaborations between competing government ministries, writes Nachiket Mor.

Evidence-based traditional medicine for transforming global health and well-being

In the current Anthropocene epoch, characterized by intensified, human-induced environmental crises, the interconnectedness of human health and the health of the planet has become more evident with the resulting responsibility to promote healthy living conditions. In our interconnected world, health challenges transcend borders, and addressing them necessitates comprehensive solutions that consider the complex interplay of factors influencing health outcomes. The COVID-19 pandemic has shown that current healthcare systems have limitations and vulnerabilities. This highlights the importance of adopting preventive and health-promoting strategies that go beyond national boundaries. Concepts such as planetary health and One Health are emerging as integrated, unifying strategies to optimize the health of people, animals, plants, and the planetary ecosystem., write Bhushan Patwardhan, L. Susan Wieland, Obijiofor Aginam, Anchalee Chuthaputti, Ricardo Ghelman, Roshanak Ghods, Goh Cheng Soon, Motlalepula G. Matsabisa, Georg Seifert, Sione Tu’itahi, Kim Sung Chol, Shyama Kuruvilla, Kathi Kemper, Holger Cramer, H.R. Nagendra, Anup Thakar, Tanuja Nesari, Sanjeev Sharma, Narayanam Srikanth, Rabinarayan Acharya.

Health seeking behaviour in four Indian States

The study sheds light on the questions of out-of-pocket spending, catastrophic health expenditure and distress financing, and treatment pathways in four states of India - Odisha, Uttar Pradesh (UP), Maharashtra and Punjab. The rationale for this is to better understand the differences between health seeking behaviour in more and less developed health systems at the State level in India, and to sharpen hypotheses about the evolution of health seeking behaviour as health systems develop effectively. The study provides valuable insights for health system interventions yet to be introduced, that seek to strengthen elements such as public primary care, write Barbara McPake, Sumit Kane, Ajay Mahal.

Reimagining the journey to recovery: The COVID-19 pandemic and global mental health

The pandemic has reminded us that social connectedness and solidarity are essential, with disruptions of our social behaviors having manifold implications for individual and societal well-being. We have also been reminded of the need for clear and transparent communication of science and the necessity of universal health coverage, stewarded by the state, with a strong population health and equity focus. And, of course, the pandemic has highlighted the critical importance of mental health to overall well-being. For those of us who have often complained of the low priority afforded to mental health, surely this is a truly historic moment that we must not let slip from our grasp, write Vikram Patel, Daisy Fancourt, Toshi A. Furukawa, Lola Kola.

Population, health and nutrition profile of the Scheduled Tribes in India: a comparative perspective, 2016–2021

The Scheduled Tribes (ST) are recognized under Article 342 of the Constitution of India. But despite specific policy provisions, health and socioeconomic underdevelopment has been a long-standing policy concern with the ST population, who account for 8.6% of India’s population. The commitment of India to the 2030 Sustainable Development Goals (SDGs) provides a new catalyst to promote the welfare of STs, especially as India still has some distance to cover with regard to its progress on SDGs, write S. V. Subramanian & William Joe.

Featured Partner

Association for Socially Applicable Research (ASAR) aims to create and communicate evidence for shaping public ideas to influence better policies. The initiative is providing research support to the Human Resources for Health (HRH) workstream of the Commission.

Help us develop a roadmap to achieve universal health coverage in India by visiting our website: https://www.citizenshealth.in/

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