Universal Health Coverage

This article is based on “Guaranteeing healthcare, the Brazilian way” which was published in The Hindu on 21/01/2020. It talks about challenges and ways to achieve Universal Health Coverage.

The goal of universal health coverage (UHC) as stated in the UN Sustainable Development Goals (SDGs no. 3) is one of the most significant commitments to equitable quality healthcare for all. India moved a step closer towards its commitment to the SDGs, when in 2018 the country launched a national health protection scheme, Ayushman Bharat, to achieve UHC.

However, achieving UHC is a very complex task, especially for developing countries. India, for instance, faces many challenges in this pursuit.

Significant Challenges in the Healthcare Value Chain

• Gaps in healthcare infrastructure: A crucial component of Ayushman Bharat is the strategic purchasing of secondary and tertiary healthcare services from the private sector.
  
  • While private healthcare caters to around 70% of India’s population there are 0.65 doctors, 1.3 nurses and 1.3 hospital beds per 1,000 people in the country.
• Inadequate Public Funding: Public health expenditure is still very low in India, at around 1.3% of GDP in the 2017-2018 fiscal year.
• Acute shortage of skilled personnel: Global estimates reveal that only half of all countries have the requisite health workforce required to deliver quality healthcare services.
  
  • Furthermore, the twin burdens of communicable and non-communicable diseases (NCDs) are projected to generate additional demand for 40 million health workers globally by 2030.
  • India, too, requires twice the number of doctors, triple the number of nurses and quadruple the number of paramedic and support staff.
  • Worse still, even if we meet the WHO’s benchmark of one doctor for every 1,000 people in the next six years, there is a large imbalance among individual states.
• Another major challenge is that a one-size-fits-all approach is not feasible for heterogeneous regional realities in India.

In this context, India can draw inspiration from Brazil's pursuit of universal health coverage.

• Sistema Unico de Saüde (SUS) or Unified Health System relies on a community-based healthcare network. It is the backbone of the rapid expansion of coverage in Brazil.
• It guarantees free health coverage that includes pharmaceutical services. It was written into Brazil's Constitution in 1988.
• In the last 30 years, Brazilians have experienced a drastic increase in health coverage as well as outcomes:
  
  • Life expectancy has increased from 64 years to almost 76 years.
  • Infant Mortality Rate has declined from 53 to 14 per 1,000 live births.
  • A 2015 report said that 95% of those that seek care in the SUS are able to receive treatment.
  • Every year, the SUS covers more than two million births, 10 million hospital admissions, and nearly one billion ambulatory procedures.
• SUS' strategy is based on an extensive work of community health agents who perform monthly visits to every family enrolled in the programme.
• These agents carry out a variety of tasks. For example, they conduct health promotion and prevention activities, oversee whether family members are complying with any treatment they might be receiving, and effectively manage the relationship between citizens and the healthcare system.
• SUS has expanded from 4% of coverage in 2000 to up to 64% of the overall population in 2015; it was able to reach even the rural areas and the poorest states of the country.
• SUS is also economically sound, while universal health systems generally tend to consume around 8% of the GDP (for example the National Health Scheme of Britain takes up 7.9% of Britain’s GDP). Brazil spends only 3.8% of its GDP on the SUS, serving a population three times larger than that of the U.K.
  
  • A study conducted by the Brazil-based Institute for Health Policy Studies (IEPS) forecasts that public health spending in Brazil will need to increase by nearly 1.6% of the GDP by 2060 in order to cover the healthcare needs of a fast-ageing society.
• The Brazilian experience can inform the design of the expansion of primary care that underlies Ayushman Bharat, that is, the creation of 1,50,000 wellness centre by 2022.

Local Community Level Healthcare Intervention To Achieve ‘Health for All’

• Local community-level intervention is the first source of comprehensive and accessible healthcare that meets the immediate needs of individuals. Addressing issues at this level can result in risk screening for early disease detection bringing down the overall disease burden of the country.
• Provision of preventive services at the local level like vaccinations and family planning, nutrition and maternal care can reduce the need for secondary and tertiary healthcare services.
• Management of chronic health conditions and palliative care at the local level can reduce the out-of-pocket expenditure for people.
• Maintaining the physician-patient ratio at the grassroots level can ensure the availability of doctors for all, reducing the dependence on quacks and eliminating preventable causes like incorrect treatment.
• The healthcare intervention at local community level should be supplemented by upgradation of infrastructure, technological advancement and capacity building of health workers.
• Decentralised policy making that involves local community health workers can effectively address the local healthcare needs.

Hence, it is important to address these issues at the community level to achieve ‘Health for All’.

Way Forward

• For UHC to become a reality, it is important to expedite steps beyond infrastructural interventions to include water, sanitation, nutrition and a healthy lifestyle. The challenge is to incentivize wellness-seeking behaviour.
  
  • An encouraging aspect of India’s commitment to UHC has been the active and participatory role of the government.
  • From Poshan Abhiyaan, which aims to eliminate the malaise of malnutrition, to the Prime Minister’s call for a Fit India Movement, new emphasis has been given to multi-stakeholder engagements.
• India has to align the vision of medical education with the vision of “one nation, one healthcare sector”.
  
  • The National Medical Commission (NMC) 2019 Bill recognizes the much-needed reforms in medical education.
• The challenge of building capacity of people in a short time needs to be addressed through more transformational public-private partnerships (PPPs), presenting another opportunity to develop and adopt e-learning models.
• Digital health has emerged as a game-changer in achieving UHC goals. India has taken rapid strides here and digital health is bringing healthcare within reach of 70% of our population residing in rural and remote areas.
  
  • With the use of digital technology, India is positioned to not only bridge gaps in our healthcare delivery but also to have the capability to contribute to global UHC goals through its telemedicine and digital health tools.
• India’s healthcare providers are already working on new frontiers of digital technologies.
  
  • Machine learning, blockchain and AI will continue to strengthen India’s ability to engage effectively with other geographies towards achieving global UHC targets.
• Regional disparities in times of resources & institutional capabilities must be addressed.
  
  • For example, Tamil Nadu, Sikkim, and Bihar differ in so many ways and this diversity must be met by an intricate combination of standardised programmes and autonomy to adopt policies according to their characteristics.

For a sustainable UHC model, maintaining a balanced trade-off between cost, quality and access to healthcare services is critical. A collaborative approach aligning patients, payers and providers, along with innovative partnerships, will hasten efforts to mitigate risks, drive impact, forge stronger social returns and achieve sustainable UHC targets.

Drishti Mains Question

For a sustainable Universal Health Coverage model, maintaining a balanced trade-off between cost, quality and access to healthcare services is critical. Discuss.