This article was co-authored with Oommen C. Kurian
Latest available data indicates that India has administered 699.6 million first doses and 286.3 million second doses of COVID-19 vaccines to its adult population. The coverage is markedly higher amongst the 45+ population (Graph 1), with about 80 percent within the age group having received at least one dose, and more than 40 percent fully vaccinated. The Government of India’s goal is to vaccinate all adults against COVID-19 by 31 December 2021, and therefore, the pace of vaccination in the last quarter is of importance.
Graph 1: Vaccination Coverage Across Age and Occupational Categories
The numbers in the recent weeks have been disappointing. Instead of accelerating to the required average daily vaccination rate of more than 11 million per day (required on October 1), the number of daily vaccine doses administered has shown a stagnation and, indeed, a decline. From 8.2 million doses on 8 October, the daily numbers have declined considerably, taking down the seven-day moving average from 6 million per day to 3.9 million per day on 18 October. While the festivities across the country may be part of the explanation, there are clearly other factors at play, which may undermine the 31 December target that the Government of India has set for itself. This, therefore, needs to be explored in-depth; the possible reasons behind such a surprising slowdown in the vaccine uptake uncovered and remedial measures instituted need to be examined.
Graph 2: Number of Vaccine Doses Administered per Day
Is the decline in numbers due to supply constraints?
While it is a legitimate question to ask, given the history of delays in capacity ramp up for different vaccines in India, this does not seem to be the driver of the slowdown. A look at the unutilised vaccine doses still available within the vaccine cold-chain—the difference between doses supplied to the states and those administered—strongly points to this. A weekly analysis of the available doses with the states (Graph 3) shows that there is substantial build-up of vaccine inventory at the state level. During a month between 15 September and 14 October, the doses available with states almost doubled from 46.3 million to 88.9 million. The data made available on 18 October indicates that there are currently 107.2 million doses awaiting to be administered at the states and union territories. This trend indicates one possibility: There is a strong tapering off of demand for COVID-19 vaccines.
Earlier this year, at the beginning of the vaccination drive, when both number of cases and deaths were low, there was a distinct lack of demand for vaccines, which shot up only with the surge in cases. However, with more than 70 percent adult Indians already vaccinated with one dose, this may not be the major contributor. Demand may be flagging as many Indian states may have already reached almost all of the “willing” adults with one dose at least. Perhaps the undecided and the ‘vaccine hesitants’ are now the ones left and the tapering of numbers could be an outcome of this.
Graph 3: Weekly Analysis of Doses Available in the State-level Cold Chains
Weekly vaccination data disaggregated by doses from the 1st of September onwards (Graph 4) underlines this possibility. As a proportion of the weekly doses, first doses are on a clear decline over the last six weeks. In the first week of September, first doses constituted almost 70 percent of total vaccinations, but in the second week of October, it was just over 50 percent. This could only mean that the vaccination drive in many parts of the country may have already reached the easy-to-reach population. Vaccinating all of the remaining 30 percent or so of adult Indians will require additional efforts from the government, local leaders, and civil society.
Graph 4: Proportion of Weekly First and Second Doses
Towards herd immunity: the last mile will be the hardest
In the third week of October so far, second doses have outstripped first doses by a big margin. Between 14th and 18th October, of the total 14.8 million doses administered in India, only 6.3 million were (42 percent) first doses, showing clearly that the second doses are now driving the overall numbers. With the offer of free vaccine for all adult citizens, the Government of India has removed financial access barriers from the picture. However, for many sub-populations, physical access to vaccination centres may be difficult for a range of reasons. Vaccine hesitancy will also be a problem in a small but significant proportion of the population. To overcome these, the government must run the vaccination drive in surgical mode, focusing on communication, community engagement and hard-to-reach populations. Many states are already deploying mobile vaccination teams to take vaccines to the people in the margins, with success.
At the same time, the centre and state governments must now focus on district-level champions to win the battle of perception, and to take vaccines to the constituency that is the most difficult to reach—those hesitant to take vaccines. That many of them may be highly vulnerable to COVID-19 due to age or comorbidities makes such an initiative an ethical imperative. In short, first doses are drying up across the country, which could be either due to access-related issues or vaccine hesitancy. India needs district level mop-up operations. The vaccination drive’s initial phases leveraged technology in a big way, but the last mile needs to leverage communities and personalities alongside technology. Many countries are finding ways to nudge and even push the citizenry towards COVID-19 vaccination, focusing on employers and travellers. Canada, for example, is planning to place unvaccinated government employees on unpaid leave and has also made COVID-19 shots mandatory for air, train, and ship passengers.
The vaccination drive’s initial phases leveraged technology in a big way, but the last mile needs to leverage communities and personalities alongside technology. Many countries are finding ways to nudge and even push the citizenry towards COVID-19 vaccination, focusing on employers and travellers. Canada, for example, is planning to place unvaccinated government employees on unpaid leave and has also made COVID-19 shots mandatory for air, train, and ship passengers.
Throughout the pandemic, India has had one of the highest proportions of population willing to be vaccinated when compared with other countries. For the same reason, a smart communication campaign should do in India what vaccine mandates are failing to do in many other countries. With almost 100 crore vaccine doses administered, and a robust information backbone tracking tests, vaccinations and cases, it should not be difficult to convince those still doubtful about the efficacy or the safety of vaccines. Popular personalities, political and religious leaders, and civil society organisations should be engaged actively to take evidence-based messaging to the district level, particularly in those areas where vaccine uptake remains low. Given the deceleration in vaccination we observed over the last few days, it is easy for India to be in a situation where vaccine doses to meet the 31 December target are available but demand becomes the binding constraint.
Prime Minister Narendra Modi’s ambitious decision and the Government’s announcement to vaccinate all adults against COVID-19 by 31 December 2021 is now within reach. At the time of its announcement, the vaccination plan was seen to be both implausible and impossible by many who doubted India’s capacity and capability in dealing with this gigantic task. Some were also skeptical of the Indian State’s capacity to deliver the doses to a very diverse demography across the country. With the quick evolution of the CoWin platform, India has surmounted the challenge of having a reliable vaccination management solution at scale with the capability of working online and offline while providing a verifiable database. With the vaccine run rate of September where India delivered over 230 million doses, and assuming a modest increase in vaccine availability for the remainder of the year—relative to the significant buildup in the past five months—India has shown that it may just be able to dispense close to 1900 million doses by the end of this year.
Almost three-fourths of the elderly population in India has already gotten at least one dose, and the coverage in the 45-59 age group was even higher. Overall, more than one-third of the 45+ aged citizens in India are fully vaccinated.
It is now widely acknowledged among experts that the national vaccination drive is doing well when compared with other lower middle-income countries, and even some middle-income countries. At the end of September, India had managed to administer around 890 million doses among adult citizens. According to government communication at the end of September, more than 45.7 million vaccine doses are still available in stocks with States/UTs, with under 8.4 million doses in the pipeline. Almost three-fourths of the elderly population in India has already gotten at least one dose, and the coverage in the 45-59 age group was even higher. Overall, more than one-third of the 45+ aged citizens in India are fully vaccinated (Graph 1).
Graph 1: Vaccine Coverage in India (30 September 2021)
This is an admirable and astonishing achievement by a lower middle-income country and a feat that, for obvious reasons of scale and size, will have no parallel in the free world. Even as we are within a whisker of meeting the (self-imposed) deadline in terms of number of vaccine doses that we need for the task, some policy posers stare back at us and need to be addressed now to complete the job. And this must be an imperative.
In the recent past, we have witnessed that countries confronted with new waves of the pandemic have had two distinct characteristics; the relatively richer countries are seeing waves that are moderate while the poorer countries in general are experiencing their peak surges. This also typifies the global “Vaccine Divide”. The US represents a starkly unique geography where we have seen both play out simultaneously. The vaccine divide in the US is shaped more by political and ideological factors with deleterious consequences.
From the early days of the Liberalised Pricing and Accelerated National COVID-19 Vaccination Strategy in May, when the daily vaccine doses administered were around 2 million, India’s vaccination drive has come a long way with the month of September witnessing an average of over 7.5 million doses a day.
Experts have observed a general “decoupling” within the pandemic landscape, where countries and communities with access to vaccines are able to separate the intensity of transmission (case numbers) and the adverse outcomes such as severe disease, hospitalisation and death. Many nations with a high number of vaccinated people are now beginning to approach SARS-CoV-2 like an endemic virus. However, while there has been a general lowering of cases and adverse outcomes these past days, it would be dangerous to believe that we are at the tail of the pandemic. Mutations and large swathes of unvaccinated people offer the virus a chance to continue to be lethal and for the pandemic to take a dangerous turn. Vaccinating all adults and teenagers still has to be a national priority.
From the early days of the Liberalised Pricing and Accelerated National COVID-19 Vaccination Strategy in May, when the daily vaccine doses administered were around 2 million, India’s vaccination drive has come a long way with the month of September witnessing an average of over 7.5 million doses a day. An analysis of monthly vaccination numbers from the start of the vaccination drive (Graph 2) reveals a substantial scale up. While 61 million doses were administered in May, September saw over 230 million doses being administered, indicating an impressive quantum of capacity buildup of nearly 400 percent.
India set itself an ambitious aim of inoculating all its adult population by the end of 2021. That means, in real terms, giving two doses of vaccines to around 950 million people—delivering, in all, 1.9 billion doses. As on the end of September, India had managed to administer a total of 889 million of those doses, with 650 million being first doses and 239 being second doses.
Over the remaining days in this year, India needs to deliver over a billion doses and deliver them as per the dosage cycles of the two main vaccines—Covishield and Covaxin—currently dominating the vaccination drive. This would mean India now has to achieve the next quantum leap and achieve more than 11 million doses a day on average, which is a ramp up of 46.5 percent in the last three months. With more vaccine manufacturing facilities coming online and given the substantial scale-up already achieved by the vaccination drive, it just may be possible, judging from past experience.
COVID vaccine(s) used and its impact on the speed of the vaccination drive
But the rub lies elsewhere, the mainstay of the Indian vaccine effort is the Serum Institute’s Covishield, which accounts for approximately 88 percent of all doses delivered as of now and has a dosage cycle of 12 weeks (Graph 3). As of October 1st, there were nearly 300 million adults who were yet to receive the first dose. Some of them can be vaccinated with Covaxin or Sputnik-V (both have a dosage cycle of one month or below) while a substantial number of them will have to spill over into January if the Covishield dosage cycle of 12 weeks is to be followed.
The policy poser, therefore, may not just be about a vaccine capacity ramp up of about 47 percent, which is eminently doable, but the composition of the vaccine candidates given the dosage gap.
India needs to deliver over a billion doses and deliver them as per the dosage cycles of the two main vaccines—Covishield and Covaxin—currently dominating the vaccination drive. This would mean India now has to achieve the next quantum leap and achieve more than 11 million doses a day on average, which is a ramp up of 46.5 percent in the last three months.
There are three hypothetical responses that can be considered by the health ministry. First, is there a genuine possibility of Covaxin finally ramping up its production and stepping up to the plate? Even if they were able to double their production, we will still have a large, uncovered population unless Sputnik V exponentially increases its production. The second option is to reduce the gap between two doses of Covishield. This will allow the bulk of the vaccine capacity to be used for second doses in much of November and all of December. And the third, of course, is that a new vaccine with large capacity (doses) and shorter dose gap enters the scenario latest by October end.
In a situation of major delays in the scale-up of all the other candidates, it is Serum Institute’s “over performance” in Covishield production, going beyond even the most optimistic projection five months back, that has helped India’s vaccination drive.
Of the other major vaccines that will be available in India soon, application for emergency use authorisation of Covovax is likely to be made only by the end of 2021, according to Serum Institute and, thus, it is unlikely to make a big difference in the timeline we analyse here. Similarly, reports indicate that a surge in cases in Russia will affect Sputnik-V’s plans in India, although the vaccine with a short 21-day dosage gap would be ideal, given the tight timelines. Biological-E’s production of Johnson & Johnson’s vaccine will likely take off only by the end of the year, and no information on timelines is currently available. Zyduc Cadila’s three dose vaccine is also bound to start production at a modest rate of 10 million doses a month; and as the first vaccine approved in India for use in children, it may not make a difference in the adult vaccination numbers at least in 2021. Although Zydus Cadila’s doses can be available for the adult vaccination drive, as the only vaccine yet approved for children, the initial doses should go to children with co-morbidities.
Covaxin is reportedly expanding production from 35 to 55 million doses from October onwards. The Government of India has also clarified that, for now, there is no plan to reduce the mandatory three-month wait for second shots of Covishield. However, with more doses being available for the national vaccination drive, this may be revisited.
Possible pathways for India’s vaccination drive
The following exercise discusses two possible scenarios among a cluster of pathways that are likely to emerge in the coming months that would allow India to fully vaccinate its adult population
(Table 1). Available information till date suggests that there are three factors influencing the December deadline of the immunisation drive, namely, manufacturing capacity which is fast improving; the three-month gap between Covishield doses; as well as the need to have an exportable surplus. Scenario 1 assumes that the availability of vaccines will remain at the September 2021 levels, which is around 230 million per month. In such a scenario, it will be possible to vaccinate all adults in India only by February 2022 and at the end of December, India will be 321 million doses short (Table 1).
Scenario 2 assumes an average 46.5 percent increase in the vaccine doses compared to the September 2021 levels. Given that between May and September, daily vaccine doses administered increased by 400 percent, such an increase is not impossible. After Covishield recently announced that its production capacity has been ramped up from 160 million doses a month to 200 million doses, reports already suggest that that the company will be delivering 220 million doses in October, indicating an accelerated scale-up like in the previous months. In Scenario 2, India will vaccinate every adult with one dose in December 2021, and with both doses in January 2022, with 251 million second doses of Covishield spilling over to January 2022.
These scenarios ignore Sputnik-V as the surge in cases in Russia is holding up imports of vaccine components. Indeed, India has not made vaccination mandatory, and a considerable proportion of the adult population will be reluctant to take the jab voluntarily, for a range of reasons. Our analysis assumes that any Indian citizen above 18 years of age should be able to demand and receive two vaccine shots within the timeline. Thus, it does not discount for vaccine hesitancy and considers every eligible individual in the analysis. This analysis also does not consider possible innovations in the future like fractionation of COVID-19 vaccine doses among the relatively less vulnerable population or mixing of vaccines (something we already do within other disease control programmes in India), which can extend limited supplies, reduce mortality and also accelerate the journey towards universal vaccine coverage.
Table 1: India’s Journey towards Vaccinating all Adults by December 2021: Two Scenarios
As is clear from the numbers, in light of the global context, scenario 2 seems feasible, whereby all adults are covered with at least one vaccine dose by the end of November 2021, and their respective second doses spill over into 2022. For a country of 950 million people over 18 years, securing universal coverage of a single dose in 11 months will itself be a commendable achievement. Scenario 2 also accounts for considerable exportable surplus of vaccine doses from November 2021.
Even as India accelerates its vaccination process among adults, unfortunately, there is no such thing as herd immunity threshold exclusively for the adult population. Herd immunity for COVID-19 will have to be achieved at the overall population level, and for a very young India, this means a need for a substantial number of its under-18 population to be vaccinated. Even if India manages to inoculate all its willing adult population by December 2021 or even January 2022, unless its hundreds of millions of children are vaccinated, the country cannot reach anywhere close to herd immunity levels. Achieving that, while respecting renewed commitments to export vaccines to the rest of the world, will be the next ambitious goal for India as the country tries to turn COVID-19 into a manageable risk, controlled by access to vaccination and responsible behaviour.
This exercise proves that the goal of vaccinating all adults by 31st December 2021 is not as unrealistic as it may have seemed earlier. As India continues to steadily ramp up Covishield and Covaxin production as it has in the past, it can achieve the ambitious tasks of vaccinating all adults by January 2022, sharing doses with the world, and to also consider provision of booster doses to severely immunocompromised citizens.
 Based on calculations done by the authors using the statistic that between May and September, daily vaccine doses administered increased by 400 percent
In 2005, the Government of India launched the National Rural Health Mission (NRHM), promising to re-imagine primary healthcare and address the under-served needs of rural areas. The thrust of the mission was to establish a fully functional, community owned, decentralised health delivery system with inter-sectoral convergence that ensured parallel improvements in areas that impact health outcomes – such as water, sanitation, education, nutrition, and social and gender equality. It subsequently published the Indian Public Health Standards (IPHS) as a reference point for public healthcare infrastructure planning and upgrade of existing facilities. In May 2013, the Manmohan Singh Cabinet approved the framework, with Rural Health and Urban Health Missions as the two sub-Missions of the over-arching National Health Mission (NHM).
Complementing NHM at the secondary and tertiary level care is the Rashtriya Swasthya Bima Yojana (RSBY) at the national level, and a number of state-level government health insurance initiatives. However, many big states like Uttar Pradesh do not implement RSBY, and the overall budget for such schemes remains limited. They often offer light financial protection and narrow coverage.
By the time the government established the NRHM, it had also made international commitments to achieve the Millennium Development Goals (MDGs). In fact, the 11th Plan laid out goals and targets that were more ambitious than the MDGs. In 2015, the government ratified the Sustainable Development Goals (SDGs), committing itself to the inclusive and universal development of people and planets through cross-sectoral collaboration for equitable prosperity. Unlike the MDGs, the 17 SDGs and 169 targets announced at the UN General Assembly 2015 were developed by the countries themselves and aim to stimulate action over the next 15 years. Ensuring Universal Health Coverage for all citizens was seen as a critical strategy to achieve the SDGs. The 12th five year plan, Niti Aayog’s Three Year Action Agenda, as well as the National Health Policy 2017 have health targets well in line with the ambitious SDG targets.
The Lancet Commission findings for India revealed that a $1-investment in health would yield a $10-increase in gross domestic product (GDP) by 2035. Over the last eight years for which detailed official data are available, India’s health spending has gone up considerably, as Graph 1 shows. The seemingly sudden decline in the Centre’s share in 2014-15 is due to a change in statistical method – from that year, transfers to states through the treasury route were taken as part of state expenditure. The recent devolution and the changes in the structure of fund flows in the health sector (Box 1) have increased the proportion of money spent on health by the states. However, the increase in public spending on health – when considered as a percentage of GDP – remains more conservative, increasing over the last decade from 1.1 percent of GDP to 1.4 percent.
Box 1: Recent Changes in the Structure of Fund Flows in the Health Sector
India has a federal structure of government, wherein a number of schemes in various sectors (including the health sector) are initiated at the national level and implemented at the subnational level. Till March 2014, the bulk of funds for these schemes were released by the central government directly to implementing agencies without involving the treasuries of the state governments. After March 2014, these funds have been released to the treasuries of the state governments, which in turn release them to state-level implementing agencies. The state-level implementing agencies further release funds to district-level, block-level and lower level implementing units. Public funds therefore, have to flow through multiple levels of governments and administrative units before these can be spent on the designated goods and services.
In 2014-15, the first year in which NHM funds were routed through the state treasuries, the utilisation ratio was much lower in ‘high-focus’ states than in ‘non-high focus’ states. This could possibly be a reflection of relatively weak institutions in the ‘high-focus’ states, which hindered easy adaptability to the change in the mode of fund flows. Source:
Despite the recent successes in disease elimination and the largest ever decadal decrease in neonatal, infant and maternal mortality, a large section of the Indian population still has limited access to quality healthcare. The newly released disease burden estimates underscore the health challenges faced by the Indian people.
Health Challenges for India
Life expectancy at birth improved in India from 59.7 years in 1990 to 70.3 years in 2016 for females, and from 58.3 years to 66.9 years for males. State statistics however showed inequalities, with a range of 66.8 years in Uttar Pradesh to 78.7 years in Kerala for females, and from 63.6 years in Assam to 73.8 years in Kerala for males in 2016.
While the per person disease burden measured as the disability-adjusted life years (DALYs) rate dropped by 36 percent from 1990 to 2016 in India, there was an almost two-fold difference in this rate between states in 2016. Amongst the states, Assam, Uttar Pradesh and Chhattisgarh had the highest rates, and Kerala and Goa the lowest.
For India as a whole, the DALY rate for diarrhoeal diseases, iron-deficiency anaemia, and tuberculosis was 2.5 to 3.5 times higher than the average for other geographies at a similar level of development, indicating that this burden can be brought down substantially.
Source: India: Health of Nation’s States (2017)
The most important health system issue emerging out of the latest disease burden statistics is the considerable shift from infectious and maternal/child health conditions to non-communicable disease (NCD) conditions across states. India’s public health delivery system is still geared towards infectious diseases as well as maternal/child health conditions. There is very little in the existing structure to address emerging concerns like non-communicable disease conditions or mental health. If drastic changes are not made followed by sufficient funding, these emerging challenges will soon blindside India’s economic growth story.
Primary health services remain extremely inequitable within the country, both in terms of access and delivery. For example, according to data from 2017 calculated using the prescribed norms on the basis of rural population from Census 2011, Andhra Pradesh has a primary health centre (PHC) shortfall of four percent, Uttar Pradesh of 30 percent, Bihar of 39 percent and Madhya Pradesh of 41 percent. Overall, the country still has a 19 percent shortfall of sub-centres, 22 percent shortfall of PHCs, and a 30 percent shortfall on community health centres (CHCs).
Access and delivery problems are compounded by severe human resource constraints. Challenges prevail in three aspects of human resources for health: numbers, distribution, and skills. In terms of numbers, the country faces a shortage of physicians and specialists, with a doctor-patient ratio of 0.7 per 1,000. This is significantly lower than the global average of 1.4, as well as that of several other developing countries and emerging economies, including Brazil (1.9), Turkey (1.7) and China (1.5). In March 2017, nearly eight percent of PHCs in India had no doctor and 18 percent were unsupported by pharmacists.
While the National Health Policy (NHP) and its main implementation arm, the NHM, outline an ambitious vision, India’s investment is healthcare remains low. The majority of the population continue to bear the brunt of healthcare costs with limited accessibility to quality health services.
Indeed, despite a rapidly growing economy, government expenditure on health has seen no significant increase for a decade (2005-2014). It hovers between 1.1–1.4 percent of GDP, significantly lower than that of Nepal (2.3 percent), Bhutan (2.6 percent) and Sri Lanka (two percent), and shamefully lower than the global average of six percent. While the NHP talks about an increase to 2.5 percent by 2025, there is no clarity on how much the increase will be on an annual basis. The 2.5 percent allocation is despite the increase to three percent of GDP by 2022 recommended by the High-Level Expert Group (HLEG) on UHC set up in October 2010 under the auspices of the previous Planning Commission, and takes no cognisance of a study conducted by Ernst & Young which estimated that government expenditure on health will need to account for 3.75-4.5 percent of GDP by 2022. As a result of the low priority given to public healthcare spending, Indians on average have a very high burden of out of pocket (OOP) expenditure on health (Graph 2).
Graph 2: Public Health Expenditure and Out-of-pocket Expenditure
The poor availability and quality of public health services is forcing people to seek care in the private sector. In India, the private sector provides more than 80 percent of outpatient care and 60 percent of inpatient care. With no widespread financial protection scheme in place, private spending on healthcare negatively impacts the financial stability of millions of Indians every year. Latest research using National Sample Survey Office (NSSO) data from 2014 found that the percentage of Indian households that fell below the poverty line due to OOP health expenditure was seven per cent of the total; this is a massive number. OOP expenditure remains alarmingly high at 62.4 percent, as already discussed. Based on NSSO 2014 data, of all health expenditure, 72 percent in rural and 68 percent in urban areas was on buying medicines for non-hospitalised treatment.
Against this backdrop, Global Health Strategies (GHS), in partnership with the International Vaccine Access Centre (IVAC), Johns Hopkins Bloomberg School of Public Health, and the IKP Trust, undertook a study to evaluate public financing mechanisms capable of sustainably delivering UHC in India. The key recommendations of the study were that India urgently needs to re-examine both the provisioning and financing of healthcare. In terms of provisioning, the government should aim to universalise free primary healthcare at the point of service. This will ease the load on the secondary and tertiary care centres. To finance this provision, a higher proportion of GDP will need to be allocated from tax revenues. There should be a national social health insurance (SHI) covering secondary and tertiary care for the entire population. Additionally, supplementary taxes such as sector-specific taxes, so-called ‘sin’ taxes, corporate social responsibility (CSR) contributions, tax-free bonds and trust funds could also be explored for specific health interventions over short periods of time.
The GHS study report was drawn up through literature review, interviews with experts and a high-level, national consultative meeting. This Special Report builds on the findings of the study and presents recommendations for a policy audience.
Why the Public Sector Must be Involved in Healthcare
Nobel laureate Kenneth Arrow had laid down the reasons why healthcare cannot be treated simply like any other commodity, to be sold and bought at prices determined solely by market forces. His argument was that the very unpredictability of health needs and expenses makes people less likely to provide for future health expenses than, say, for future housing or clothing needs—a phenomenon that he called ‘hyperbolic discounting’. A healthy person tends to think that health lasts forever. Access to health information is limited, making the patient dependent on doctors for crucial decisions about treatment and that too at a time when s/he is physically and mentally vulnerable and extremely easy to exploit. Trust is therefore the most important component of the doctor-patient relationship. Unpredictability of health outcomes, and the fact that patients are billed once a non-refundable service has been delivered, means that it is not possible to shop for health services the same way as one would shop for, say, toothpaste. There is also a demand-supply gap: the number of doctors available is limited; years of study and a licence to practice medicine are entry level barriers and justifiably so. That again makes it different from shopping for toothpaste because, in theory at least, there is no limit to the number of companies that can manufacture toothpaste.
International examples bear out Arrow’s argument that governments need to be the actively involved in healthcare, as it is not a standard market good. In Japan, for example, 82 percent of all health expenditure is publicly funded. The Organisation for Economic Co-operation and Development (OECD) countries’ average is 72 percent. Japan has a mandatory health insurance scheme, with premiums based on the socio-economic status of beneficiaries. Healthcare in Sweden is primarily funded by the government, which raises money through taxes. At 11.9 percent of GDP, the Swedish government’s spending on healthcare is one of the highest in Europe. International precedents show that when public spending on healthcare rises to around six percent of GDP (the global average for UHC systems) OOP payments fall below 20 percent of total health expenditure.
In India, the over-reliance on a largely unregulated private sector is fraught with risks of unnecessary costly interventions being chosen over more cost-effective options. That this is already happening is clear from National Family Health Survey 2015-16 (NFHS-4) data that shows that approximately twice the number of babies are delivered by Caesarean section (C-sec) in the private sector as compared to the public sector. While World Health Organization (WHO) guidelines suggest that C-sec should be prescribed within the range of 10-15 percent of total births, private sector rates range from 87.1 percent of deliveries in urban Tripura (compared to 36.4 percent in the public sector) to 25.3 percent in urban Haryana (compared to 10.7 percent in the public sector). WHO also says that while C-secs can reduce chances of maternal and child mortality, there is no evidence of any extra benefits if the rate rises above 10 percent in a population.
The quality of care in the private sector is not always up to standards prescribed by Indian Public Health Standards (IPHS). A study in rural Madhya Pradesh found that only 11 percent of the sampled health-care providers had a medical degree, and only 53 percent of providers had completed high school. Thriving quackery, not just in rural areas but also in urban pockets, is an open secret. Recent examples from Delhi private hospitals show that high-end, expensive hospitals can also have uninterested and callous administrations, thus not necessarily providing quality care to paying patients. Big hospitals may not be available near most rural or low-income communities, being concentrated mostly in urban areas where people have the capacity to pay high amounts. However, what keeps the private sector hospitals – which are a highly differentiated set in terms of size, quality and cost – receiving the bulk of the patient load is that they are available round the clock, at close proximity to the community.
This is not to say all private sector hospitals are bad and should be done away with. They have an important role to play in a country with a large population and limited government intervention. The problem is an over-reliance on the largely unregulated private sector where payments are mostly out-of-pocket and high. This can and does result in negative conditions of over-treatment, poor quality, selective care, and cost escalations.
India Needs to Spend More and Spend Better
Health is a state subject. Yet it is the Centre that is the prime mover behind the National Health Mission, which is a core central scheme. Despite the focus on healthcare in the Budget 2018, the actual allocation for NHM decreased from INR 31,292crore in 2017-18 (revised estimate) crore to INR 30,634 crore (budget estimates) in 2018-19. This is a decline of about two percent from the revised estimates of 2017-18.
In addition to the inadequacy of funds, the inconsistency in the timing of funds released by the Centre to state governments has contributed to inequity in terms of service delivery across the country. On average, there were more unutilised funds at the end of the year in the states that needed them most. A 2017 study by the influential National Institute of Public Finance and Policy (NIPFP) and WHO India on utilisation, fund flows and public financial management under the NHM found that at the state level, a file with a request for release of funds has to cross a minimum of 32 desks while going up the administrative hierarchy, and 25 desks on the way down. The study recommended streamlining processes to ease the rigidities of the state treasury system.
One of the primary operational hurdles that the NHM faces is the absorption of funds by states because of their erratic periodicity of release. Sometimes this can be a chicken-and-egg situation. In the first quarter of 2015-16, for instance, 57 percent of NHM allocations were released. However, the corresponding figure was 29 percent in 2014-15 and 46 percent in 2013-14. Similarly, analysis by CBGA shows that while the overall central health budget in 2018-19 was increased, allocation for , Reproductive and Child Health (RCH) component in 2018-19 (budget estimate) has in fact declined by 33 percent from 2017-18 (revised estimate). Along with this , the allocation for Pradhan Mantri Matru Vandana Yojana (PMMVY), which was earlier called the Maternity Benefit Scheme, has also decreased by eight percent over 2017-18 (RE)
It is believed that strengthening health systems will increase the states’ capacity to absorb increased allocations, and should be prioritised, particularly in high-burden states and districts. Poor absorption and distribution of funding at the state level leads to an accumulation of unspent resources each year. This lack of absorptive capacity at the state level has been used both as a justification for the Centre’s non-release of funds, as well as an argument for decreasing overall funding for healthcare.
Primary-Care Network: The Gatekeeper
For India, both generating resources for UHC and designing health systems to implement it are challenges. The best solution to both may be for a comprehensive and quality primary care network to act both as the preventive pillar of the health system and also as a gatekeeper to higher levels of care. Patients need not reach secondary and tertiary care centres without being referred there. This primary care network has to be accessible to all, and free at the point of access so that the OOP expenditure problem can be dealt with. There are international precedents of such an approach. Spain, Thailand, Kyrgyzstan and Colombia have successfully rationalised hospital care through referral management. In Thailand, a gate-keeping system prevents patients from going directly to general or regional hospitals without a referral from district hospitals (except in an emergency or when paying OOP directly). Today 45.3 percent of patient visits are to healthcare centres, 37 percent to district hospitals, and only 17.8 percent to tertiary care centres. The National Health Accounts (2013-14) showed that of the overall expenditure, primary care took up 45.5 percent, secondary care 34.8 percent and tertiary care 16.1 percent. 
A study by Harvard University in 2017 on state-level, primary-level expenditure trends found that among the 16 states studied, some poorer states have already started focusing on primary care, and that states like Chhattisgarh, Rajasthan and Assam spend more on it in per-capita terms than better-off states like Kerala or Gujarat. However, the study also found that the primary care expenditure as a percentage of total government health expenditure has either plateaued, or shown a downward trajectory for the last three to four years in 11 out of the 16 states. It is well established that a functioning primary-level care delivery system can take considerable patient load off the secondary and tertiary hospitals. There are yawning gaps in the existing primary care network with some states being far better organised than others. Addressing the infrastructural and human resource gaps in primary care will go a long way in addressing overcrowding in urban hospitals, as well as controlling household costs.
The private sector’s focus on costly tertiary interventions rather than primary prevention has given rise to a situation where the limited number of doctors available crowd these better paying centres while there are few doctors to be found for primary care. This pushes people to seek treatment at the tertiary centres. Investment in primary care therefore has benefits at multiple levels: prevention, gate keeping, and putting an end to the crowding at tertiary care centres whether public or private.
Medical education in India is currently geared towards producing specialists rather than family physicians who are the bedrock of primary care. Every year 60,645 medical graduates qualify to be part of the public health system but opt out of it for a variety of reasons – poor pay, remote locations, and lack of facilities. Across the world, countries have tried to contend with this problem in their own way, but for India, perhaps, the best option could be for the government to train non-physician medical providers like nursing practitioners (with BSc Nursing degrees), Ayurvedic practitioners (with Bachelor of Ayurvedic Medicine and Surgery degrees), and Dentists (with Bachelor of Dental Surgery degrees), all of whom would require additional training and formal certification in allopathic primary care. The Supreme Court, in its ‘Dr. Mukhtiar Chand & Others Versus the State of Punjab’ judgment in 1998, acquiesced in legal feasibility of such an approach, specifically for BAMS doctors, who are in adequate supply. In this vein, the National Medical Commission Bill, 2017, has suggested a bridge course to enable practitioners of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathic (AYUSH) systems to practice modern medicine, despite widespread protests from professional associations. Given the limited MBBS output, the best solution here too may be focused training of MBBS doctors, rather than looking at the long-term option of increasing post-graduate seats in medicine.
CASE STUDY: Immunisation
Every dollar spent on vaccines in low-income countries yields a $16 return in direct costs and a $44 return in indirect costs within a decade. It is one of the most cost-effective options of preventive health. India has its own vaccine success stories. It followed up its 2014 achievement of polio-free certification, with the elimination of maternal and neonatal tetanus in 2015. It owes both these achievements to a concerted immunisation effort. However, children in India continue to die of vaccine-preventable diseases. It has the largest number of under-five deaths in the world, at 1.2 million, comprising 20 percent of the global total. India’s share of pneumococcal, rotavirus and measles deaths is 25.6 percent of the global toll. India’s per capita immunisation spend is just $8.88, far less than Bangladesh ($34.61), Nepal ($29.96), China ($22.09) and Pakistan ($13.14). It was among the last four countries to approve Haemophilus influenza type B (Hib) vaccine to prevent pneumonia, along with Indonesia, Belarus and South Sudan, and it has only recently introduced the vaccine in its immunisation programme.
Recent data shows that India’s performance in ensuring immunisation coverage has been slow, with worrying reversals in some key states. Research by Observer Research Foundation has shown that prior to the NRHM, full immunisation coverage in India improved at a sluggish pace from 35.4 percent in 1992-93 to 42 percent in 1998-99 and 44 percent in 2005-06. NFHS-4 found that immunisation coverage had increased to 62 percent in 2015-16. Although post-NRHM, the pace of immunisation has accelerated, the improvement is far less than, for instance, in the case of institutional births (births taking place in a medical institution rather than at home) which grew from 39 percent in 2005-06 to 79 percent in 2015-16. The following graph shows the current levels of full immunisation coverage across Indian states and UTs.
In the last few years, there have been many additions to the Universal Immunisation Programme (UIP), and Mission Indradhanush – introduced in 2014 – which aims to fully inoculate all children under the age of two with seven essential vaccines by 2020. Pneumococcal Conjugate vaccine (PCV) was introduced in 2017; Inactivated Polio Vaccine (IPV) has been rolled out nationally; rotavirus vaccine is available in nine states, and Japanese Encephalitis (JE) vaccine in all priority districts. However, the projected cost of these vaccines will have to be taken into account as India increases allocation to healthcare as it has committed to do in the NHP. The procurement cost for these life-saving UIP vaccines is expected to go up 6.5 times, from $88 million to $565 million for complete scale-up of Pneumococcal Conjugate Vaccine (PCV), Rotavirus, Measles Rubella (MR), Inactivated polio vaccine (IPV) and Pentavalent vaccines as per the comprehensive multi-year strategic plans (cMYP) costing and financing tool for immunization. With a forecasted budget increase from $694 million to $1.44 billion, the funding gap for UIP is set to rise to 37 percent of total programme costs, or $534 million. For now, the Global Alliance for Vaccines and Immunisation (GAVI) has contributed $500 million but it is targeted only at poor countries; and as India graduates to middle-income country status by 2021, it will no longer be eligible for GAVI support. Sustainable domestic funding options will have to be explored. India has historically never rolled back a vaccine once it was introduced in the UIP.
At a high level national consultative meeting organized by GHS, a panel of experts recognised that maternal and child health have to be seen as an investment rather than expenditure and the most cost-effective intervention, vaccination, is a priority investment for the nation’s future. It should also therefore be classified as capital expenditure rather than revenue expenditure.
Financing Options for UHC
In most countries in the world that have managed to implement UHC, the bulk of the funding comes from general government revenues (tax financing) and public contributions towards a social health insurance programme. In India, general tax revenue is the source of 90 percent of public health funding, but the low tax to GDP ratio (17.7 percent) is the spoiler. However, countries with lower GDP growth and economic potential than India have done it. Mexico moved towards UHC by increasing public spending on health from 1.9 percent in 1996 to 3.25 percent of GDP in 2014. Thailand doubled its public expenditure on healthcare from 1.66 percent in 1995 to 3.2 percent of GDP in 2014. Both countries have a tax to GDP ratio almost identical to India’s, although both are much richer.
While increased allocations from the general tax pool could help finance primary healthcare, supplementary resources will be required to fund secondary and tertiary healthcare. No examples of a universal healthcare system funded purely by general taxation exist anywhere in the world. Even the National Health Service (NHS) in the UK is funded by a combination of general taxation (around 80 percent) and national insurance contributions (close to 20 percent). The UK’s tax to GDP ratio is around double that of India’s but public funding on health is more than five times (as a percentage of GDP). That is why a mandatory social health insurance may be a good option; however the relatively small size of India’s organised sector may prove a roadblock. The effort should be to pool the already large OOP expenditure on health into pre-payment pools and enable users to spread the expenditure over a longer time-frame by pooling of risks.
Statutory health insurance (SHI) schemes function by mandating payroll contributions from workers, pooling the resources collected, and earmarking them for a comprehensive health benefits package for all. Risk pooling is a mechanism by which revenues are aggregated to spread financial risk of health expenditures across individuals and over time. Pooled revenues are used to pay for healthcare needs of individuals, reducing or eliminating the need for OOP expenditure at the point and time of service. It is also essential for a universal care package to be clearly defined and to include outpatient services, cost of medicines and a continuum of care feature.
Mandatory health insurance contribution may have political implications in a cost-sensitive society like India. However, if the resources raised by the government are effectively earmarked for healthcare, the willingness of the middle and higher income-groups to contribute will be higher since their expenses would then amount to an investment with a clear return. There are some existing insurance schemes like the Employees’ State Insurance Scheme (ESIS) for factory workers and the RSBY for the informal sector workers, which are now being planned to serve as blueprints for wider health protection schemes. In the Indian context, a national social health insurance scheme should cover the entire population, where the government pays for the poor and vulnerable, the formal sector pays through mandatory payroll contribution, and innovative mechanisms are explored to charge fees from the informal sector. The current UHC plan of the government seems to be around National Health Protection Scheme (NHPS), which is an enhanced version of the RSBY.
Nearly 22 percent of Indians live below the national poverty line, and the poorest 40 percent have access to only 20 percent of total income. Reaching these sections will involve substantial administrative costs. Community outreach may be an important first step before moving on to more sophisticated tools to decide eligibility. In 2012, both Turkey and Indonesia replaced community targeting based on local expertise, with rigorous registry through a clearly defined methodology, with increased and more equitable enrolment success. The Philippines also initially used community-based targeting where local governments identified beneficiaries, enrolling millions of people identified as poor in a health insurance scheme financed by the central government. But in 2009, the central government imposed a more rigorous methodology through the National Household Targeting System. The new system revealed that only 800,000 of the beneficiaries qualified as poor and were thus eligible for subsidies, and that many households that were poor had not been enrolled in the subsidised health insurance programme. Given such inclusion and exclusion errors, any such mechanism should have the required flexibility and consider the households that fall into poverty every year due to health related expenses.
What kind of money can mandatory payroll contributions generate? An early estimate based on income-tax collections in 2014-15 of INR 284,266 crore (PPP $160 billion), shows that between INR 14,000 to INR 34,000 crore (PPP $7.7 billion to $18.9 billion) could be raised, with contributions ranging from 5-12 percent. This figure would provide a significant contribution to the NHP target of 2.5 percent of GDP for universal coverage, equivalent to 25 percent of the current shortfall in spending.
Reaching informal sector workers may prove to be the real roadblock for India in rolling out an SHI. The informal sector employs 91 percent of the workforce in India. However, countries like Vietnam (68.2 percent in the informal sector) and Thailand (42.3 percent) can serve as models. Vietnam uses tax funding to reduce the premium for the informal sector by 50 percent, while Turkey employs a sophisticated system to determine appropriate premium payments for informal sector workers through scoring estimated income, property value and car cost. Multiple governments, including those of Colombia, Mexico and Thailand, originally charged the informal sector for participating in health insurance schemes, but have since extended full subsidies to these populations. For India, the platform of Jan Dhan, Aadhaar and extensive use of mobiles could provide the building blocks for identifying and enrolling the target population.
General tax revenues and SHIs can be supplemented by sector specific taxes. The erstwhile education cess, for example, was instituted to fund the government’s Right to Education (RTE) obligations; the National Clean Energy Fund was set up to tax INR 200 per tonne of coal imported or produced in India. There is also the Central Road Fund since 2000, to improve road infrastructure, which taxes petrol and diesel, and which was increased in 2015 from INR 2 per litre to INR 6. The existing 3 percent education cess on personal income and corporation tax was converted into a 4 percent “health and education cess” by Budget 2018 to fund the initiatives for families in rural areas and those below the poverty line. The increased cess is expected to collect an additional ₹11,000 crores per year, and be a main source of funding for the proposed National Health Protection Scheme (NHPS). The education cess had increased total allocation for elementary education from INR 5,000 to INR41, 000 crore between 2004 and 2013. Another source of funding could be “sin” taxes, a concept that currently applies to tobacco and alcohol in India, though such taxes are not a sustainable long-term source. . A tax on aerated sugary drinks and junk food can be considered, with the added advantage of thereby reducing their consumption and impacting NCDs in the process.
The CSR contributions of the private sector too could be harnessed for health purposes. Section 135 of the Companies Act 2013 made India the first country in the world to legislate for mandatory CSR contributions. All companies with a net worth above INR500 crore, or a turnover above INR 1000 crore or an annual net profit of above INR 5 crore are required to spend 2 percent of their net profit on CSR related activities. The Act lists a series of legitimate recipients of CSR contributions, including campaigns such as reducing child mortality and improving maternal health.
The scheme stands to raise a significant amount of money for development projects. In the first year of implementation in 2014-15, Indian companies paid out around INR 6,400 crore in CSR payments. Reliance Industries Ltd was the top contributor, funding approximately INR 761 crore of the total collection, followed by the state-run Oil and Natural Gas Corporation Ltd with INR 495.2 crore. However, in 2015, KPMG found that more than half the 100 largest Indian companies had failed to meet their targets. CSR contributions, along with funding by the government, could possibly help strengthen the primary care network. Tax free bonds and trust funds too could generate some funds, though CSR may be the most promising option.
Budget 2018 as an Ambitious Foundation for the Way Forward
Budget 2018 with the proposed Ayushman Bharat initiative is a landmark moment in India’s healthcare policy. After the launch of NRHM, it is perhaps for the first time that health is getting such attention in the union budget. However, despite the ambitious beginning, NRHM (now NHM) failed to improve the primary healthcare infrastructure in any substantial way. GHS (2018) found that more than 80 percent of the increased service provision under the NHM was attributed to just 20 percent of health facilities. In 2017, only 11 percent sub-centres, 16 percent primary health centres (PHCs), and 16 percent community health centres (CHCs) were found to be functioning as per Indian Public Health Standards (IPHS) norms.
The ambitious National Health Protection Scheme (NHPS), which promises to expand insurance cover from current low levels to a substantial 100 million households is expected to improve access to secondary and tertiary healthcare tremendously. Building on the gains of the past decade, India continues to follow a two-pronged strategy of demand side as well as supply side interventions in healthcare. The Empowered Programme Committee of NHM approved ₹1,200 crore for 2018-19, and ₹1,600 crore for 2019-20 for setting up 1.5 lakh health and wellness centres. This means that the sub-centres, the lowest rung of the NHM structure, will for the first time, move beyond providing antenatal and postnatal care, and immunization services. The Finance minister in his budget speech confirmed this commitment this year. If implemented well, this initiative will take comprehensive primary healthcare services closer to the people who need them the most. It also has the added benefit of taking some burden off the secondary and tertiary care delivery system. However, per sub centre, current year’s allocation translates to only ₹80,000, which may prove to be inadequate given the ambitious objectives.
The Budget 2018 makes it clear that India’s medium-term pathway to UHC is a continuation of the last decade’s strategy of provisioning-insurance mix at an expanded scale. It will be key how the government addresses the severe health workforce shortages in the public hospitals so that part of the huge insurance bonanza (amounting to INR 15000 Crores) flows back into the public healthcare delivery system and rejuvenates it. It is expected that the proposed merger of three unlisted public sector general insurance companies will help keep the insurance premium within NHPS substantially low compared to RSBY. The rapid expansion of the insurance coverage is also expected to kick in economies of scale and help keep costs low. Yet, offering a substantial health insurance cover of INR 500,000 for 100 million households with the available resources will be a big challenge within the current cost parameters.
Increase in government investment in healthcare is the most preferred option on the road to universal health coverage. This is not just because it has the highest benefit to cost ratio, but also because increased public sector investments would better enable a significant section of the population to access improved healthcare. This would also enable emerging lower middle-class groups that demand better healthcare but find the rates in the private sector unaffordable. However, apart from looking at increasing the spending on health, India also needs to look at more efficient means of spending that money. This can be achieved by prioritising high impact system design changes and interventions like immunisation which give the biggest impact for every rupee spent.
The focus has to be on improved, accessible and quality primary care. To chalk out the implementation blueprint, a committee of diverse stakeholders and policy makers needs to be established to further evaluate these recommendations and use them to develop implementable guidelines. Given the potential of rapid expansion of fiscal space, it should be possible for India to eventually bring in the remaining 150 million households into a truly universal system, which integrates NHPS with the primary healthcare delivery system in the medium run. How a diverse India choses to do it will offer lessons to dozens of other countries who plan to make UHC a national mandate and expand health coverage to yet uncovered population groups.
About the Authors
Anjali Nayyar is Executive Vice President, Global Health Strategies. Dhruv Pahwa is Senior Director, Global Health Strategies. Samir Saran is Vice President, Observer Research Foundation. Oommen C. Kurian is Fellow, Observer Research Foundation.
 Liu L, Oza S, Hogan D, et al. Global, regional, and national causes of under-5 mortality in 2000-15: An updated systematic analysis with implications for the Sustainable Development Goals. Lancet 2016.