The WHO defines Universal Health Coverage (UHC) as all people having access to the full range of quality health services they need, when and where they need them, without financial hardship. It covers the full continuum of essential health services, from health promotion to prevention, treatment, rehabilitation, and palliative care across the course of one’s life.
India is a signatory to the 2030 Agenda for Sustainable Development Goals (SDG), of the United Nations.
This has 17 goals, of which the 3rd is, Good Health & Wellbeing of all at all ages. UHC is an overarching target to achieve this goal of good health by 2030. The billion lives question is whether it is achievable.
The short answer to that is yes and no! It completely depends on the political will of the government – both Centre and of the states.
How Can We Achieve This? First, Where Do We Stand?
The latest NSSO survey shows that, nearly 58 percent of hospitalisation cases in India, barring for child-birth, are provided by for-profit providers.
However, public facilities account for approximately 70 percent of childbirths in rural India and 48 percent in urban India.
For out-patient services the coverage is nearly 2/3rds in private for-profit set ups in rural India and nearly three quarters in urban India. This increasing skew towards privatized healthcare delivery has led to significant out-of-pocket expenditure (OOPE).
OOPE contributing nearly 55 percent of the total health expenditure in India. A study published this year in Lancet, showed that, in India (in 2018) 1 in 6 people faced catastrophic health expenses and close to 50 million people were pushed into poverty due to OOPE on health.
It forces them to cut down subsistence costs, like food, clothing etc. It could also contribute to sub-optimal utilisation of health services as people may avoid using unaffordable services. OOPE is inherently an inequitable and regressive health expenditure method as everyone pays the same fee for healthcare services regardless of their paying capacity.
Hence the burden is greater on people in lower income groups. Most efforts for Universal Health Coverage (UHC) are to mitigate OOPE.
Most developed countries have systems by which, people have to pay very little out of pocket for health. Among lower-middle income countries, Thailand has been a great success story, by giving health coverage to nearly all and reducing OOPE to just 8 percent of all healthcare spending.
The Story So Far
As the public health system weakened from falling government investments post the 1990s liberalisation, more people were forced to access services in for-profit private hospitals.
To protect people, particularly the poor, from the risk of financial shock at private hospitals, several states launched government funded health insurance schemes (GFHIS). In 2012, the High-level Expert Group report on UHC in India proposed that GFHIS should cover all primary and specific secondary- and tertiary level services including free inpatient and outpatient care at all public and contracted-in private healthcare facilities for all citizens, regardless of economic class.
However, the new National Health Policy (NHP) in 2017 recommended an insurance scheme excluding primary care services and focusing only on vulnerable populations rather than universal coverage.
Based on this model, in 2018, PMJAY, (Pradhan Mantri Jan Arogya Yojana), was launched. Rather than providing universal coverage, it is meant only for the bottom 40 percent of the socio-economic class of the population. The scheme provides a cover of Rs 500,000 per household for secondary and tertiary-level health services to about 500 million beneficiaries.
The Challenges
The single biggest challenge to achieve this, is government funding for public health. At present the total spending on health in India is 3 percent of GDP.
The government (central+ states) spends about 1 percent of the GDP on health in India of which states account for 60 percent The remaining 2 percent (ie 2/3rd of the spending) comes out of people’s pockets. In comparison, Thailand spends 4 percent of GDP on health (not much above India) but, nearly 72 percent of that spending is by government (i.e nearly 3 percent of GDP).
The High Level Expert Groups recommended increasing government spending to 2.5-3 percent of GDP to make significant progress in healthcare. But under-funding continues. Even the funds allocated to PMJAY were substantially less than the estimated costs (88.5 percent–95.5 percent lower). The per-capita expenditure on the scheme (Rs 126), is much lower than the average national per-capita OOPE incurred (Rs 2440).
The drawback of the PMJAY model is that since it covers only the bottom 40 percent , a part of the population, also known as the “missing middle”, is not protected from health-related financial shocks.
The relatively organized and affluent class is covered by schemes like ESIS or CGHS or private health insurance. The health ministry informed the Lok Sabha that there was no plan to expand PMJAY to other economic classes for now.
The difference in monthly mean per capita household consumption between the 40th and 80th percentiles of the welfare distribution is just Rs.1000, which is far less than a hospital bill. Thus, a far larger share of the population needs health insurance coverage and therefore the need for universality
A review of PMJAY in a recent Lancet study, by Dubey et al, states that,
“The PMJAY scheme overall is failing to target the most vulnerable population. This mis-targeting can risk inequitable demand and utilization of PMJAY…..States with higher poverty headcounts and disease burdens are considered to have a higher need for PMJAY and vice versa. However, the utilization in terms of claim volume and value is higher in states with lesser needs e.g. Kerala and Himachal Pradesh, and lesser in states with higher needs e.g. Bihar, MP, UP, and Assam. This discrepancy in need vs. utilization is due to poor supply-side factors including a low number of empanelled hospitals, an inefficient beneficiary identification system, and weak health governance in states with greater poverty and disease burdens. A similar pattern is seen at the district level….”
On one hand, there was a low level satisfaction (35.5 percent) among healthcare providers due to lower health packages rates, poor grievance redressal mechanisms and delays in processing claims. This has resulted in a lack of interest in implementing the scheme and sometimes suspension of implemented scheme. On the other hand there is rampant overbilling and inappropriate billing, and overtreatment in the form of unnecessary tests and procedures.
There is an urgent need to improve quality and accountability for delivery of healthcare in both private and public set ups and challenges are different for the two.
Accreditation processes have to be widened and strengthened across the board. As the predominant mode of healthcare delivery is through private healthcare providers, there is a need to re-look reimbursements for procedures and disease processes and link it to quality of care.
Mechanisms for strong oversight, punitive action, along with more efficient reimbursement and grievance redressal mechanisms for both patients and healthcare providers is an absolute necessity for UHC to work.
Our Strengths
One of India’s most remarkable achievements is its volunteer community health work force, led by the one-million strong workforce of ASHAs (Accredited Social Health Activist workers) who have played a crucial role in the reduction of maternal and infant mortality. ASHA workers were recognised in the 2022 WHO Director-General’s Global Health Leaders Award for connecting the community to primary health-care services.
Unfortunately, they are paid way below minimum wages and their tasks are expanded irrationally. With better training and remuneration these community workers could be our greatest resource for implementing UHC.
A major strength we have in India, is the scale and scope of medical education. We produce close to 90,000 doctors and 3 lac nurses every year. The potential for scaling up the number of healthcare providers to deliver UHC is there. Unfortunately, in the rush to produce more, the quality of training, has declined drastically.
States like Tamil Nadu, Kerala, Himachal Pradesh have made immense progress in UHC, showing the potential for excellent delivery if there is political will. The recent Right to Health Act, in Rajasthan shows that healthcare delivery has finally become an area of political debate and discussion, a positive development.
The Future
In the process of buying curative healthcare from private players through public insurance schemes at the secondary and tertiary levels, to achieve the goal of UHC and reducing OOPE, we shouldn’t forget the basic tenet of public health which is to strengthen publicly-delivered primary healthcare. This itself, is estimated, can take care of 90 percent of essential UHC interventions.
The long term goal of a public health system cannot be about buying health from for-profit healthcare providers or use insurance mechanisms to deliver health care to the people of our country.
There are multiple examples to prove that this could be counter-productive in the long run.
Two recent studies (one in Lancet and another in PNAS) found that, if the US had a single payer model of universal healthcare like, for example the UK, (where everyone has access to every level of healthcare through public hospitals) it would have saved anywhere between 68,000 to 212,000 lives during the COVID-19 pandemic and would bring down annual healthcare costs by $450 billion.
Though Universal Health Coverage 2030, by itself is a Herculean task to achieve for our country and it requires strong political will and money, it cannot be the target for the long-term future of healthcare in our country. For that, we need Universal Healthcare, not Universal Health Coverage!
(Sumit Ray is a Critical Care specialist and Medical Director of a not-for-profit hospital in Delhi. This is an opinion piece, and the views expressed are the author’s own. The Quint neither endorses nor is responsible for them.)
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