Global commitments, like the earth, seem to be moving in a circle. First, we had the Alma Ata declaration of 1978 with one goal – Health For All (HFA), 12 global targets and 19 indicators, which India committed to, but did not achieve. Then the Millennium Development Goals (MDGs) were created with 8 goals, 18 targets and 48 indicators, which still remain a pipe-dream for India. And now, we have the Sustainable Development Goals (SDGs) with 17 goals, 169 targets and the number of indicators yet to be finalized, which I predict would be between 500-1000. So, the big question remains that when India could not reach the previous relatively less ambitious targets of HFA and MDGs, how can we achieve universal healthcare and the SDGs targets? I foresee 3 problems with the SDGs:
Practicality: The SDGs have been created as a legally binding document unlike the MDGs. However, legally binding documents are often ignored due to the lack of effective enforcement mechanisms.
Time consuming: It took almost three years to get the right globally acceptable wording inserted in the SDGs document. This could be a striking achievement in international diplomacy but leaves relatively less time to achieve the targets.
No intermediate targets: Politicians in power typically look for results within short time periods (e.g. five years) because after that period they are unsure of being re-elected. However, the SDGs do not have short-term targets and most of the targets are for 15 years, which is too long a period in a politician’s career. The SDGs have missed an opportunity to incentivize the politician and create an impetus for the much needed political will required for such endeavours.
Universal Health Care (UHC) is a very important goal in the SDGs but is affected by the same set of issues highlighted above. In the above context and specifically for achievement of UHC in India, I propose a move from Sustainable Development Goals to Smart Development goals. The Copenhagen Consensus Centre using economic evaluation as a tool has identified 19 out of 169 targets as the most cost-effective, giving four times the benefit. Nine of these 19 targets are directly related to health. These are:
- Lower chronic child malnutrition by 40%
- Reduce malaria infection by half
- Decrease tuberculosis deaths by 90%
- Avoid 1.1 million HIV infections due to circumcision
- Reduce early death from chronic diseases by one-third
- Reduce newborn mortality by 70%
- Increase immunizations to reduce child deaths by 25%
- Make family planning available to everyone
- Cut indoor air pollution by 20%
Keeping the Indian context in mind, I suggest that the above nine can be further modified into the following six smart targets for achieving UHC in India:
- Lowering child under-nutrition and chronic diseases
- Reducing Malarial infections
- Reducing Tuberculosis deaths
- Reducing the newborn mortality rate
- Increasing childhood immunisationsIncreased access to family planning
- Decreasing indoor air pollution
The reason for combining child under-nutrition and chronic diseases is because robust scientific evidence shows that childhood under-nutrition makes children more prone to diabetes and heart disease in adulthood. Hence, by addressing under-nutrition in children, we address the twin problems of nutritional deficiencies and Non-Communicable Diseases. Also, I have removed the target for HIV infection mentioned in the Copenhagen consensus centre because we have been able to significantly lower HIV infection and male circumcision (the strategy proposed) may not be socially and culturally acceptable in India.
There are no universal Standard Operating Procedures (SOPs) for achieving UHC in India. Health being a state subject, every state needs to develop its own SOP based on the local social, cultural, economic and political realities. While evidence and data generation is important, it is perhaps more important to convert these into actionable policies and programmes. Knowledge is only potential power unless converted to action. Hence, it is time for action to speak louder than words. There is a huge potential for the government to actively engage with academia and the private sector to achieve UHC. Currently, major animosity exists between the government, academia, and private sector with each speaking their own language and in their own silos. They are like three corners of a rigid triangle. If these three key groups come together and speak the same language with the peoples interest being the paramount focus, the triangle will be converted into a ball and the ball will start rolling for UHC in India. This engagement has to be active, visionary and intensive, creating a win-win situation under the strong stewardship of the government.
In terms of actionable strategies, I believe that the WIN strategy should be a starting point in India for achieving UHC. WIN stands for:
W: Women’s education and empowerment
I: Infrastructure development in rural areas (roads, electricity, water supply, schools, etc.) to attract trained doctors, nurses, etc.
N– Nutrition, both in terms of quantum and quality of food.
Universal Health Care is not an outcome but a journey, which will eventually lead us to Health For All to ensure that every human being achieves the highest possible level of physical, mental, social and spiritual well being.