Universal Health Coverage

"Universal Health Coverage — for everyone everywhere", this was the theme The World Health Organisation had adopted for this year’s World Health Day which is celebrated every year on 7^th April. The theme echoes the target set by the United Nations Sustainable Development Goals (SDGs) that all countries must achieve UHC by 2030 to which India is also a party.

India has taken great leaps in the field of health care in recent times and has set for itself ambitious targets in the healthcare system.

However desired targets do not always reflect realities and there remains a lot of ground to be covered in order to reach anywhere near those targets. Therefore it remains important to analyse what affects India’s health.

Universal Health Coverage

UHC means that all individuals and communities receive the health services they need without suffering financial hardship. It includes the full range of essential, quality health services from health promotion to prevention, treatment, rehabilitation and palliative care.

It enables everyone to access the services that address the most significant causes of disease and death, and ensures that the quality of those services is good enough to improve the health of the people who receive them.

Protecting people from the financial consequences of paying for health services out of their own pockets reduces the risk that people will be pushed into poverty because unexpected illness requires them to use up their life savings, sell assets, or borrow – destroying their futures and often those of their children.

Achieving UHC is one of the targets the nations of the world set when adopting the Sustainable Development Goals in 2015. If achieved by India it will result in good overall health in children and adults ultimately pulling them out of poverty, and will become the basis for long-term economic development.

Problems grappling Indian health sector

India has the world's second-largest population, rising from 760 million in 1985 to an estimated 1.3 billion in 2015 and the existing healthcare infrastructure is not enough to meet the needs of the population.

The central and state governments do offer universal healthcare services and free treatment and essential drugs at government hospitals. However, the hospitals are, understaffed and under-financed, forcing patients to visit private medical practitioners and hospitals.

Qualified healthcare providers are in short supply nationally and those available are mal-distributed, with marked density differences across regions. Majority of healthcare professionals happen to be concentrated in urban areas where consumers have higher paying power, leaving rural areas underserved.

Impoverishment due to unaffordable healthcare expenditure affects 7 per cent of our population, as noted even in recent national surveys.

India has one of the lowest per capita healthcare expenditures in the world. Government contribution to insurance stands at roughly 32 percent, as opposed to 83.5 percent in the UK. The high out-of-pocket expenses in India stem from the fact that 76 percent of Indians do not have health insurance. Healthcare induced financial distress is a leading cause of suicide among farmers.

Rural-urban disparity: The rural healthcare infrastructure is three-tiered and includes a sub-center, primary health centre (PHC) and CHC. PHCs are short of more than 3,000 doctors, with the shortage up by 200 per cent over the last 10 years to 27,421.

Challenges in implementation of UHC

Biggest challenge remains in identifying what services are to be universally provided to begin with and what level of financial protection is considered acceptable. Offering same set of services to the entire population is not economically feasible and demands huge resource mobilisation.

Prioritising certain services to the poor and vulnerable sections to ensure both access and affordability, while leaving the rest of the population for coverage at a later stage is also not a good option as it essentially leaves out the tenet of universality.

Even countries which follow an insurance model have a high level of public funding to support several health services. Mandated contributory insurance model will not work in India which has over 90 per cent of the workforce in the informal sector.

Addressing the concerns of healthcare sector

Public financing is the lifeline of UHC. So, public spending on health should be increased to at least 2.5 per cent by 2022 and 3 per cent by 2024

Primary health care has to be recognised as the foundational basis of an efficient and equitable healthcare system. It has the highest number of beneficiaries (the whole population), provides a wide range of services and can prevent a large spill over into hospitals for advanced care through effective prevention and timely care.

While establishing seamless bidirectional linkages with advanced care facilities, primary care needs to become the engine of UHC.

Emergency health services should also be given high priority, to provide the link between these services and also lifesaving care on location and during transport. All such services have to be provided free of cost.

UHC has to cover several services like commonly needed surgeries and treatments that can protect life. The component of advanced care expands as more resources accrue, but not at the expense of primary care.

The health work force has to be expanded to make available multi-layered, multi-skilled teams which can deliver the needed services.

Basic and specialist doctors, nurses, nurse practitioners, physician assistants, pharmacists and an array of allied health professionals need to be developed in large numbers and deployed across the country. This calls for expediting reforms in health professional education, cadre planning and incentives for rural postings.

Strengthening of primary care infrastructure and district hospitals has to be a government priority. Free provision of essential drugs and diagnostics at public healthcare facilities will have an immediate impact on out of pocket expenditure.

Way Forward

Government funded programmes should ensure that financial barriers should not stop access to needed advanced care. As UHC evolves, the poor and near-poor must get full cost coverage while others may seek protection through employer funded schemes or privately purchased insurance.

It’s a long way before we reach the base camp of UHC, even as the ascent to the 2030 summit seems very steep but concerted effort of government and private players involved can effectively act as steel rope.