The World Health Organisation (WHO) sought to highlight the importance and urgency of achieving Universal Health Coverage (UHC) when choosing this year’s theme for the World Health Day. It called for “UHC — for everyone everywhere”. This echoes the target set by the United Nations Sustainable Development Goals (SDGs) that all countries must achieve UHC by 2030. India, too, accepted that target date while signing up to the SDGs.
How countries will be measured for success in reaching that target depends on how UHC is defined and monitored. The WHO states that UHC “means that all individuals and communities receive the health services they need without suffering financial hardship. It includes the full spectrum of essential, quality health services from health promotion to prevention, treatment, rehabilitation and palliative care.”
Interpretation, however, has varied on what services are to be universally provided to begin with and what level of financial protection is considered acceptable. Should UHC commence by offering the same set of services to the entire population and progressively expand the service package to all as more resources accrue? Or, should UHC first prioritise certain services to the poor and vulnerable sections, to ensure both access and affordability, while leaving the rest of the population for coverage at a later stage? Another option is to provide a basic package of services to all, with full financial protection, along with an additional set of publicly funded services to the poor and vulnerable sections. These are all possible beginnings in the path of progressive universalisation that ultimately leads to UHC for everyone, with levels of service and cost coverage that meet the health needs of all persons without financial hardship to any.
To meet the standard set by the WHO and the SDGs, UHC has to include all persons in a population, even if the service package is modest to begin with. In terms of financial protection, the WHO recommends that out of pocket expenditure (OOPE) on health should not exceed 15-20 per cent. This requires a high level of public financing. Even countries which follow an insurance model have a high level of public funding to support several health services. Mandated contributory insurance model will not work in India which has over 90 per cent of the workforce in the informal sector.
How does India measure up presently and how can we achieve the 2030 target? OOPE is still around 63 per cent, despite several government health insurance and benefit schemes. Impoverishment due to unaffordable healthcare expenditure affects 7 per cent of our population, as noted even in recent national surveys. Healthcare induced financial distress is a leading cause of suicide among farmers. Access to health services varies widely among states and between rural and urban populations. Qualified healthcare providers are in short supply nationally and those available are maldistributed, with marked density differences across regions. It’s a long way before we reach the base camp of UHC, even as the ascent to the 2030 summit seems very steep.
What do we need to do? Public financing is the lifeline of UHC. So, we should raise public spending on health to at least 2.5 per cent by 2022 and 3 per cent by 2024. Both these are within the term of the government we elect in 2019. Will it deliver? This electoral season has seen UHC being promised in one form or another by most political parties, either in published manifestos or proclaimed promises. Not only the national parties but the state-level contestants in Andhra Pradesh, too, are competing in promises of good and affordable healthcare. Post-June, the electorate will see if health remains a priority.
Even the governments which earnestly wish to implement UHC will face the challenge of exercising choices within the limited budgets. First, they need to get the priorities right within the funding available. Primary health care has to be recognised as the foundational basis of an efficient and equitable healthcare system. It has the highest number of beneficiaries (the whole population), provides a wide range of services and can prevent a large spillover into hospitals for advanced care through effective prevention and timely care. While establishing seamless bidirectional linkages with advanced care facilities, primary care needs to be the fulcrum of UHC. Emergency health services are also a high priority, to provide the link between these services and also lifesaving care on location and during transport. All such services have to be provided free of cost.
What about people who need advanced care? Even at the start, UHC has to cover several services like commonly needed surgeries and treatments that can protect life. The component of advanced care expands as more resources accrue, but not at the expense of primary care. Government funded programmes should ensure that financial barriers should not stop access to needed advanced care. As UHC evolves, the poor and near-poor must get full cost coverage while others may seek protection through employer funded schemes or privately purchased insurance. Even for them, OOPE must remain low.
UHC has to be cashless at the point of care and health benefits under the programme have to be available for access anywhere in the country. The health work force has to be expanded to make available multi-layered, multi-skilled teams which can deliver the needed services. Basic and specialist doctors, nurses, nurse practitioners, physician assistants, pharmacists and an array of allied health professionals need to be developed in large numbers and deployed across the country. This calls for expediting reforms in health professional education, cadre planning and incentives for rural postings. Strengthening of primary care infrastructure and district hospitals has to be a government priority. Free provision of essential drugs and diagnostics at public healthcare facilities will have an immediate impact on OOPE.
We have just a decade to go before we are measured for success in reaching the SDG target of UHC. More important, and even more immediate, is the need for elected governments to redeem the promises to the electorate. That account has to be presented to the people in 2024. Will UHC appear well on the way by then?
(The writer is President, Public Health Foundation of India. Views are personal)