Universal coverage challenges require health system approaches; the case of India

This paper uses the case of India to demonstrate that Universal Health Coverage (UHC) is about not only health financing; personal and population services production issues, stewardship of the health system and generation of the necessary resources and inputs need to accompany the health financing proposals. In order to help policy makers address UHC in India and sort out implementation issues, the framework developed by the World Health Organization (WHO) in the World Health Report 2000 and its subsequent extensions are advocated. The framework includes final goals, generic intermediate objectives and four inter-dependent functions which interact as a system; it can be useful by diagnosing current shortcomings and facilitating the filling up of gaps between functions and goals. Different positions are being defended in India re the preconditions for UHC to succeed. This paper argues that more (public) money will be important, but not enough; it needs to be supplemented with broad interventions at various health system levels. The paper analyzes some of the most important issues in relation to the functions of service production, generation of inputs and the necessary stewardship. It also pays attention to reform implementation, as different from its design, and suggests critical aspects emanating from a review of recent health system reforms. Precisely because of the lack of comparative reference for India, emphasis is made on the need to accompany implementation with analysis, so that the "solutions" ("what to do?", "how to do it?") are found through policy analysis and research embedded into flexible implementation. Strengthening "evidence-to-policy" links and the intelligence dimension of stewardship/leadership as well as accountability during implementation are considered paramount. Countries facing similar challenges to those faced by India can also benefit from the above approaches.