Quality or Accessibility: What should be the priority to achieve UHC for India?
By Bhanu Pratap Yadav
There’s a great focus by the Government on building medical colleges and hospitals to improve healthcare access. But this might be a hasty step to achieving UHC for India, writes Bhanu Pratap Yadav.
A 2018 Lancet report found that in the year 2016, around 2.4 million Indians died of treatable conditions, of which 1.6 million lost their lives due to poor quality of care. Almost twice as many as people died due to non-utilization of healthcare services (838,000 person). About 122 people per 100,000 in India die due to poor quality of care each year. This is worse than the neighbouring countries viz. Pakistan (119), Nepal (93), Bangladesh (57) and Sri Lanka (51). So where does the lacunae lie?
What Went Wrong?
The report mentions the case of Janani Suraksha Yojna. The scheme provides cash incentives to mothers who opt for institutional delivery. It was launched with an aim to reduce maternal and infant mortality rates in India. Undoubtedly this resulted in a significant hike in institutional deliveries but maternal and child mortality rates have not gone down measurably. Why? Dr. Harshad Thakur, Professor at Tata Institute of Social Sciences, believes, “Quality is an integral part of all the health programs, be it new or old. But during actual implementation of the programs, the focus on quality is lost;. The possible reasons include irregularly measuring/monitoring quality, inadequate manpower, poor training of manpower, etc.”
Dr. Vivekannad Jha, Executive Director, George Institute for Global Health says “In JSY focus was on improving the accessibility, but we did not have enough of the resources at the facility level and lack of set protocols and processes led to the poor outcomes of the program in terms of mortality.”
Dr. Arun Gadre, Health Activist states “The concept of institutional deliveries is ideal but India rushed in implementing the scheme without having a structure in place.”
Our Dream to Achieve UHC
India aspires to achieve the Universal Health Coverage by providing quality care to everyone without putting the financial burden on them. But the report is seriously questioning this dream. Dr. Gadre explains, “In 2012, appointed HLEG committee came out with a very detailed document on UHC. Coverage is not care. In the UK, UHC first began with commitment of government and declaration of healthcare as a right. In India, the Right to health and healthcare Act is yet to be tabled in the parliament. Whatever measures have been taken are fragmented and targeted in nature. And targeted approach is not UHC.”
Ayushman Bharat Yojna has made headlines globally as the largest government-sponsored healthcare scheme ever to launched. However, Dr. Gadre opines that it’s not necessarily a step towards increasing accessibility and affordability. “Health and wellness clinics of scheme are an illusion. There is no infrastructure, no human resources available and most importantly no gatekeepers. It’s a pyramid without a base. Outsourcing the care to private players without any regulation in place is self-defeating; there’s a huge risk of moral hazard,” he elaborates.
Dr. Harshad Thakur on the other hand believes that updating health centres into Health and Wellness Centres is a very good initiative, adding, "The Ayushman Bharat Scheme is expected to take care of the health needs of the poor and needy individuals, which often used to get ignored due to lack of the financial resources. But we cannot only depend upon such public-private partnership-based health insurance schemes to improve the health situation and achieve universal health care in the country.”
Dr. Vivekannad Jha says, “We still have a long way to go to achieve the UHC. It has been neglected since independence. The structure of Indian healthcare currently is such that private sector has good amount of stake and its motive is towards profit-making. Expanding services till the end user of the community would definitely require a big boost in human resources. It can be achieved through proper training of frontline workers but again its implementation is something that needs to be looked at,” he adds.
The Road Ahead
The report is a stark reality check that without quality, the very purpose of a scheme is an exercise in futility. “We have to set the processes and protocols to check the quality of services. We have the tools in place to do so; we just need to implement evidence-based practices, concretize our policies and plans. We definitely should learn from our neighbouring countries,” says Dr. Vivekannad Jha.
“Without strict ground level enforcement of regulation, without standard treatment protocols in place with demonstrable punishment for those who violet the protocols, it’s a myth that any government scheme is one step towards UHC,” concludes Dr. Gadre.