Universal Health Coverage and India

Context

Ayushman Bharat-Pradhan Mantri Jan Arogya Yojna (AB-PMJAY) launched to achieve Universal Health Coverage.

What is Universal Health Coverage?

• UHC is visualised as an ideal state of health system organisation in which all individuals and communities receive quality health services as per needs, without suffering financial hardship.
• UHC is also key to achieving the World Bank Group’s (WBG) twin goals of ending extreme poverty and increasing equity and shared prosperity, and as such it is the driving force behind all of the WBG’s health and nutrition investments.

Objectives

• Equity in access to health services – everyone who needs services should get them, not only those who can pay for them;
• The quality of health services should be good enough to improve the health of those receiving services; and
• People should be protected against financial-risk, ensuring that the cost of using services does not put people at risk of financial harm.

Time line

• 1977: WHO set the target of Health for All
• 2000: MDG was formulated with the target of achievement set for 2015
• 2015: SDG was formulated with the target to be achieved by 2030
  • SDG 3 includes a target to “achieve universal health coverage (UHC), including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all.”

Fact Sheet

• At least half of the world’s population still does not have full coverage of essential health services.
• About 100 million people globally are still being pushed into “extreme poverty” (living on 1.90 USD (1) or less a day) because they have to pay for health care.
• Over 800 million people (almost 12% of the world’s population) spent at least 10% of their household budgets to pay for health care.

Indicators of Universal Health Coverage

WHO uses 16 essential health services in 4 categories as indicators of the level and equity of coverage in countries

Reproductive, maternal, newborn and child health:

• Family planning
• Antenatal and delivery care
• Full child immunization
• Health-seeking behavior for pneumonia.

Infectious diseases:

• Tuberculosis treatment
• HIV antiretroviral treatment
• Hepatitis treatment
• Use of insecticide-treated bed nets for malaria prevention
• Adequate sanitation.

Non-communicable diseases:

• Prevention and treatment of raised blood pressure
• Prevention and treatment of raised blood glucose
• Cervical cancer screening
• Tobacco (non-)smoking.

Service capacity and access:

• Basic hospital access
• Health worker density
• Access to essential medicines
• Health security: compliance with the international health regulations.

Universal Health Coverage and India

India has made rapid strides towards increasing access to health services in the past few years through a number of initiatives

• National Rural Health Mission (2005). It seeks to provide equitable, affordable and quality health care to the rural population, especially the vulnerable groups.

The main programmatic components include Health System Strengthening in rural and urban areas- Reproductive-Maternal- Neonatal-Child and Adolescent Health (RMNCH+A), and Communicable and Non-Communicable Diseases.

• Rashtriya Swasthya Bima Yojna (2008). It covers the cost of secondary-level hospitalization.
• National Program for Prevention and Control of Cancer, Diabetes, CVDs and Stroke (NPPCDS)
• National Urban health Mission. It provides health care to urban population. Later NRHM and NUHM were clubbed into National Health Mission
• In addition, there are a number of state-specific schemes. Some involve running free diagnostics facilities and offering free medicines; others are government-funded health insurance schemes in several states.
• Ayushman Bharat – Pradhan Mantri Jan Arogya Yojna (AB-PMJAY): Launched on 23^rd September 2018.

It has two components

1. Health and Wellness Centre:

• These Centers will provide Comprehensive health care.
• It will be responsible for providing free essential Drug and diagnostics Services.
  2. National Health Protection Mission:

NHPM will subsume the on-going centrally sponsored schemes –Rashtriya Swasthya Bima Yojana (RSBY) and the Senior Citizen Health Insurance Scheme.

Issues and Challenges

• Firstly, there is a large health disparity between social classes, urban and rural populations and geographical locations.
• Secondly, No actual database is available to provide actual financial cost of the programme. Without such a database, insurance agencies cannot estimate the required premium to adequately cover the pooled risk.
• Thirdly, there are large variations and inequities in the supply-side readiness, in terms of availability of infrastructure, equipment, essential drugs and staffing, to deliver on the promises of UHC.
• Fourthly, the current status of Primary Health Centres (PHC) in India is very grim. In the 25,650 PHCs in the country, 15,700 (61.2%) function with one doctor each. As many as 1,974 (7.69%) do not have even a single doctor.
• Fifthly, the non-affordability of healthcare services is a major problem with the vast majority of our people. As a result, they are impoverished because of high out-of-pocket healthcare expenditures. Studies says Rashtriya Swasthya Bima Yojna has not led to any reduction in out of pocket expenditure
• Sixthly, at present 70 percent of our healthcare needs are met by the private sector
• Seventhly, instances of insurance fraud require creating a strong regulatory framework for fraud control.
• Eighthly, the coverage is still not universal but linked to poverty. Government should de-link current provision of entitlement based on poverty line. The government could then proceed, to scale the health premium subsidy e.g. economically weaker sections (entitled to 75-90%), lower income (entitled to 50%), and middle income groups (entitled to 20%).

Best Practices

• Karnataka is the first state to provide UHC. Under the UHC, entire population of the State (1.43 crore families) would be brought under the health scheme, irrespective of the income of the families.

There would be no cap on the medical expenditure to be incurred by any patient in government hospitals at all levels — primary, secondary and tertiary care hospitalisation. The estimated annual expenditure for implementation of the scheme would be ₹1,500 crore.

• Thailand is one of the few developing countries in the world that have successfully implemented Universal Health Coverage (UHC). Beginning three decades ago, Thailand’s UHC first covered the poor, then the near-poor, the formal sector employees, and the children and the elderly, through various publicly funded and contributory schemes until it reached 71 percent of the entire population in 2000.

Way Ahead

• A national framework for universal health coverage needs to be developed with the help of UN member countries. This would involve inter-sectoral collaborations at the community level with local health teams, the private sector, non-government organizations and community-based organizations to strengthen primary health and support secondary and tertiary infrastructure.
• The government should appoint a commission which makes recommendations for the healthcare system and monitors its performance.
• Joint participation with health teams by trained volunteers in uniform, including those from National Cadet Corps (NCC), National Scout Services (NSS), nursing schools, etc., can provide a thrust for addressing social and environmental determinants and can bring about positive change in personal hygiene, healthy behaviour and cleanliness. The other schemes like Swachh Bharat programme must be incorporated in the health scheme
• A functioning health insurance system must ensure that patients neither under-treated nor over-treated nor over-charged. Ensuring this requires adaptive price setting, third-party monitoring, and strict regulation.
• The health budgets must rise substantially, at both state and central level
• State governments should draw up blueprints for universal health coverage and begin experimenting and innovating with pilot programmes
• Modern technology and innovation could be used to reduce costs of healthcare system in India