Decoding Universal Health Care in India
By Arunima Rajan
The way a country approaches UHC depends on a wide range of factors-political, economic, social, epidemiological and technical. Will UHC lead to more inclusive healthcare in India?
According to the World Health Organization, UHC "means that all people have access to the health services they need, when and where they need them, without financial hardship. It includes the full range of essential health services, from health promotion to prevention, treatment, rehabilitation, and palliative care."
Dhruv Mankad, a trustee of Anusandhan Trust, says that UHC is not a new concept but has developed further, including other perspectives, to become consistent with the current health coverage and status of Indian people. "It was the key goal of the Bhore Committee's report, 1946. It was reiterated at the Almaty Declaration in 1978 focused on Primary Health Care as a part of UHC. Current Public Health Care System in India is based on these two important components which developed further," explains Mankad.
Will India be able to achieve UHC by 2030?
"It is an aspiration, plus right now because it has set the direction earlier if one looks at the velocity of its implementation both in terms of quantity and quality for a population and geographic reach: IPH Standards of Infrastructure, its HR, ranges of services and quality, it's still not anywhere near the goals it has set for itself," he adds.
What are the reasons?
"Reasons are mainly – 1. lack of political will while politically acceptable know-hows are available 2. People demand health care services when ill, but people require awareness for health as a right - and responsibility for appropriate healthy behaviour and demanding its own right.3. Others were allowed to pass without much regulation, e.g. Pvt hospitals/medical college 4. curative care centric, top-down models (efforts are made during the pandemic for home care also)," he adds.
Which countries have achieved some measure of UHC, and what are the lessons that we can learn from the successful implementation in those countries?
Mankad points out that India has a diversity of all factors: geographical, cultural, socioeconomic etc. Hence, it is difficult to compare the success/failure of another country for its UHCs. "But some directions can be considered as possible innovations to be adapted in the Indian context.
The shift from curative to promotive and preventive care:
Countries like Bosnia and Herzegovina, Cambodia, Ecuador, India, Lesotho, Liberia, Morocco, Marshall Islands, Mongolia, Nigeria, Sri Lanka and Turkey have launched psychological support programs to address the negative impact of the COVID-19 pandemic on mental well-being. Yoga is one example India can universalise for improving the health of the people.
Enhance the role of nurses: Countries like Australia, Belgium, Canada, Cyprus, Czech Republic, Finland, France, Ireland, Japan, Poland, the United Kingdom and the United States have nurse practitioners as a part of the UHC. This exists in India informally but can be made part of the UHC system at the HWC level for mass screening and routine health care for illnesses like anaemia and diabetes, high blood pressure etc.
Raising Revenues for UHC: Financial Constraints can be overcome by integrating both the cost and revenue to make it sustainable. Instead of having donor-driven projects and infrastructure, donor's support can be streamlined through a single source, as Bangladesh started in 1990 and through local bodies. Ghana, Peru and Vietnam had increased their share in National Health Expenditure from 6.3% in 2002 to 47% in 2016 (India had 26.5% in 2018, according to the World Bank)," he explains.
COVID-19 has severely disrupted progress in all areas of health and reminded us of the urgent need for coordinated action and robust health systems.
Ravi Duggal points out that health is a public good and hence health spending is a state responsibility. "The high growth Indian economy over the years has failed to deliver on the health front. Healthcare of the vast majority continues to be neglected while the private health sector and health insurance expand to help the private sector profiteer. Out of pocket expenditure is unfair and leads to inequity and denial of healthcare. World over tax financing of healthcare is the predominant mode even in developed capitalist countries except for the USA, where 40 million people have poor access to healthcare because they can't afford insurance premiums. India should not blunder and fall into the trap in which the USA is," adds Duggal.
How important is it to adopt a gender lens to UHC?
"Gender lens is critical for not only UHC but for all social and public services. In healthcare, while there is a major focus on women through specific programs like JSY, various family planning services, ANC/PNC and childbirth services etc., there is no guarantee that gender discrimination will not happen. For example, if you don't have women doctors, many diseases like leprosy, reproductive infections, STDs etc., amongst women may go undetected. In health studies literature, it is also well established that gender discrimination and caste/minority discrimination are highly prevalent even in the public health system. Women are also often targets of invasive family planning programs or misuse of procedures like unnecessary hysterectomies," adds Duggal.
National Rural Health Mission and Insurance Programmes
India's attempt to improve access and affordability has led to initiatives like National Rural Health Mission and National Health Insurance Programmes like RSBY and PMJAY.
"The NRHM was certainly a well thought out initiative, and it improved the public health system in rural India, but much more needs to be done to build a comprehensive primary healthcare system. This requires at least tripling of public expenditure so that all vacant positions are filled, all supplies, including medicines, are freely available, and proper infrastructure maintenance is possible. However, the insurance-based schemes of the government like PMJAY and similar state schemes are not a good option as they mainly benefit by subsidising the private health sector and transferring public resources to the private sector. NSSO data tells us that schemes like PMJAY, on the contrary, have increased out of pocket burdens. The quest for UHC insurance is not a feasible option. For realising UHC, India needs to break away from this segmented approach to healthcare where health schemes are targeted to specific populations as this leads to huge discrimination. For instance, the CGHS scheme for central govt employees and MPs spends over Rs 10000 per capita, Defence services spend Rs 12000 per capita for health care of their employees, but the Ministry of Health (Centre and States combined) spends only Rs 1800 per capita for common citizens, and this shows in the type of healthcare access for each of these populations. For UHC, such segmentation needs to be removed, and a rights-based universal access healthcare system needs to be put in place," he adds.
PPP= Private Profits Through Public Resources?
Public-Private Partnership has often been highlighted as a part of the path to UHC. Are there any successful examples of PPP? What needs to be done for its successful implementation?
According to Duggal, PPP has been a miserable failure in India mainly because of the insufficient capacity of the state to regulate private players and call them to account. "PPPs have more often than not resulted in Private Profits through Public resources. Ambulance service is the only sustained successful PPP initiative. NITI Aayog is obsessed with PPPs and wants to give away district hospitals to the private sector. This should not happen as it will deliver a death blow to the public health system in the country. We need to strengthen primary health care using the Health and Wellness Centre concept and upgrade district hospitals to either "teaching" hospitals or medical college hospitals so that they become strong referral and higher-level health care centres," adds Duggal.
How can the private sector help India to achieve quality, sustainable universal health coverage? Would a regulatory framework like Clinical Establishments Act help?
"Let's be clear, the private sector in no way can contribute to UHC. With its huge presence, the Public Health System can source its services within a regulatory framework where public services are deficient. Overall the private health sector needs strong regulation, including price regulation and audit, and the CEA is only a first step towards it," adds Duggal.
NDHM and PMJAY Integration
Dr Harish Pillai points out that Universal Health Coverage is a highly effective mechanism to achieve health equity in any society and helps to have a better' Gini coefficient' that measures the gaps between the 'haves' and 'have nots'. The financing of Universal Health coverage varies from country to country; however, the aim remains the same. Indeed it is both an ideological and political choice of a region. Usually, UHC models can provide a consistent and steady volume of patients to a private entity that has been empanelled; from this point of view, it is a crucial source of patients and steady revenue. However, there remains the challenge of a cap in cost inflation, thereby reducing operating margins from this segment. Those players who have instituted treatment package principles like 'design to cost' will succeed while others fail. The PM-JAY or Ayushman Bharat is the flagship program of UHC in India; looking at the performance over the past couple of years, the most significant challenge has been to enrol more private players across the country. Unfortunately, the scheme missed out on the empanelment of the significant private players due to the unscientific costing methodology adopted thus far, similar to the prevailing central schemes like ESI, CGHS or ECHS. Even though some corrections have been made in the price anomaly, it needs a relook. Integrating the PM-JAY with UHID -Aadhar and the rollout of the National Digital Health Mission - NRHM will further enable data privacy and proper record keeping that will be portable. The IT backbone will be a crucial facilitator long term in the seamless and efficient implementation of the scheme," explains Pillai.
Philippines and UHC
"If we look at the Philippines where I am currently based, the Philhealth UHC covers all citizens yet gives a much-needed safety net to the poor. During the pre-pandemic period, this was a well-funded scheme that has also been hailed by the WHO & World Bank as an efficient tool in bringing equity to the health care delivery system. Unfortunately, due to the severe effects of the Covid pandemic, the Philhealth system has been struggling lately to reimburse private hospitals on time, thus resulting in mounting receivables and working capital deficits. Overall from an Asian context, the key lessons will be :
The steady political will to support a UHC system in the long term
To decide whether it is universal or a targeted scheme for poor beneficiaries
Adequate budgetary support - can be tax-funded and through social health insurance models
The necessity of an excellent national IT grid that makes accessibility easy
Constant stakeholder feedback and review," adds Pillai.
What range of capabilities are private providers already bringing to the challenges of expanding delivery of essential health services to all? Which of these capabilities blend best with existing public institutions and programmes?
"The entrepreneurial spirit and risk-taking appetite is the critical ingredient for the widespread availability of private health care services in the country. The ability to quickly invest capital and create a new asset, deploy efficient and professional management and attract and hire good talent are other facets that contribute to success. However, the quality of care rendered varies, and the recent rollout of the clinical establishment act will facilitate a minimum quality threshold in the delivery mechanism.
In the public services, we have examples of states where the services are on par, if not superior, to the private sector. This is a clear reflection of the political will and ideological rigour in rendering efficient welfare systems. On the other hand, we have many laggard states that continue to suffer due to many issues. If continuous stakeholder feedback on the services combined with periodic audits is conducted, this could be a first step to upgrade services," adds Pillai.
Why is the private sector pursuing opportunities to contribute to Universal Health Coverage?
Pillai notes that both the public and private sectors have vital roles in emerging economies to address different segments; the private players can effectively fulfil several gaps in the public system.
"In addition to this, as mentioned above, UHC offers a steady supply of patients that mitigates the risk of market conditions and seasonal variations. It further helps to absorb the fixed costs provided the private entity also has access to alternative channels of patient acquisition and has put in place cost-efficient operating models," he adds.
David Boucher has worked in healthcare for over 40 years and currently serves as the Chief of Service Excellence at the corporate level for Aster DM Healthcare. "I think that UHC is one way to achieve greater parity in India, but of course, it depends upon the minimum benefits offered and the availability, accessibility and acceptability of healthcare professionals and hospitals. Certainly, a necessary complement to medical care is potable water and flushing toilets, so those efforts must be continued," adds Boucher.