Opinion Not just insurance, Indians need universal healthcare
A commitment to public spending is an important aspect of strengthening primary and secondary care. East Asian and several Southeast Asian countries have robust public systems with a private presence in provisioning
When public health insurance schemes are designed within a well-financed public health system, with robust primary and secondary care working as gatekeepers, the outcomes seem to be better. 
December 12 was Universal Health Coverage (UHC) Day. This year’s theme was “Unaffordable health costs? We’re sick of it!’’ This draws attention to a growing frustration with the rising financial burden of healthcare. In observing UHC Day, it is important to distinguish between universal health coverage and universal healthcare. The latter goes beyond coverage for illness alone and encompasses equitable access to comprehensive primary healthcare — preventive, promotive, curative, rehabilitative, and palliative.
UHC is grounded in the universal human right to health, articulated in several international covenants and reinforced by the World Health Organisation (WHO) in the Alma-Ata Declaration, 1978. However, the WHO’s 2010 World Health Report emphasised financial reform and risk protection as a pathway to UHC. The subsequent UN resolution on UHC reaffirmed this agenda, and later, UHC was included in the Sustainable Development Goals.
In practice, recent reforms in many countries, including India, have undermined the primary care approach and privileged financial protection through public health insurance. These schemes focus on covering costs for hospitalisation and often define packages for different disease conditions. Evidence suggests that patients often have to incur out-of-pocket expenditure. Such expenditure is due to services that are not covered or inadequately covered by packages, or due to abuse of coverage provision by service providers.
Conversely, when public health insurance schemes are designed within a well-financed public health system, with robust primary and secondary care working as gatekeepers, the outcomes seem to be better. Several East Asian countries adopted UHC through an insurance approach, but have also strengthened primary and secondary care over time. An ageing population and chronic diseases have necessitated such changes. Countries like China and South Korea have near-universal insurance coverage, but the cost to the exchequer has been very high. Nearly a decade ago, China decided to contain costs and invest in strengthening primary and secondary care, focusing on prevention, early detection and follow-up care. Efforts were made to invest in human resources and comprehensive population outreach programmes.
A commitment to public spending is an important aspect of strengthening primary and secondary levels of care. East Asian and several Southeast Asian countries have robust public systems with a private presence in provisioning. A strong public sector seems to act as a bulwark to regulate the private sector in terms of quality and cost. Even in these countries, the private sector’s power to influence policy is an unresolved issue.
India has a legacy of being committed to universal healthcare as articulated by the Bhore Committee just before Independence. In fact, the committee opined that public insurance schemes must not be introduced until a robust primary healthcare system is in place. Despite this, chronic underfinancing of primary healthcare has resulted in weak public sector provisioning, contributing to increased reliance on the private sector. National Sample Survey data show growing reliance of the poor on increasingly expensive privately provided healthcare — an important contributor to household indebtedness.
Despite initiatives such as the National Rural Health Mission (NRHM, now NHM), systemic weaknesses remain. Some states sought to address inequity in access and the rising cost of care through public health insurance programmes. In 2008, the Rashtriya Swasthya Bima Yojana insurance scheme was launched and subsequently, the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana. With these initiatives, the focus on universal health coverage came to stay.
The Covid pandemic drew attention to inequities in access to health insurance schemes and the need to shift from universal health coverage to universal healthcare in many countries. Given multiple health challenges, it is imperative for India to take this path with increased public investment in comprehensive primary healthcare and social determinants of health.
Baru is professor, Jindal School of Public Health and Human Development, O P Jindal Global University. Keshri is associate professor, Jindal School of Public Health and Human Development, O P Jindal Global University and adjunct senior lecturer, UNSW, Sydney, Australia. Views are personal
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