The World Universal Health Coverage Day, observed on December 12, builds on growing global momentum towards introducing universal health coverage (UHC) in national health plans and reinforces the case for including UHC as a prominent sustainable development goal to be adopted by the UN next year. India proposes to implement a programme of national health assurance, which embraces the principles of UHC. It is expected that the government will use the National Health Mission (NHM) and the Rashtriya Swasthya Bima Yojana (RSBY) to propel UHC.
The WHO portrays UHC as a cube with three dimensions. One is breadth of coverage, or proportion of the population covered. The second is depth of coverage, or range of professional services offered. The third is the height of financial protection provided, to reduce out-of-pocket expenditure while ensuring system-wide financial prudence for sustainability. In progressively implementing UHC, countries have to address each of the three dimensions with the resources available. To begin with, some services must be provided to all, while others may be provided free or at highly subsidised rates to those below and just above the poverty line. The breadth and depth of coverage will increase as the level of financing for UHC rises.
Each country has to begin with the essential and move towards the optimal. Several countries have opted to include the full range of primary health services, comprehensive maternal and child health services, emergency medical care and essential surgical services in the initial package offered under UHC. Primary health services include promotive and preventive services as well as basic diagnostic, curative, palliative and rehabilitative services. Even the routine treatment of high blood pressure, diabetes and mental illness can be brought under the purview of primary care, apart from traditional areas like mother and child care or treatment of malaria and tuberculosis. Over 90 per cent of the health needs of a population can be met through this.
Health financing for UHC in most countries draws substantially on public financing, which comes from tax revenues. Employer-provided insurance helps if most of the workforce is in the organised sector but is inadequate when countries have large numbers of informal workers, as in India. Few here can purchase private insurance. Even then, it does not cover many health conditions. For UHC to succeed via insurance, a large risk pool is needed where the rich subsidise the poor and the healthy majority subsidises the care of the sick minority at any given time. In the absence of such a large insurance pool, tax funding is the most feasible way of financing UHC. A progressive tax system ensures that the rich subsidise the poor, as part of a social obligation to pay higher taxes.
Virtually no insurance scheme in India covers primary health services. Even a government subsidised social insurance scheme like RSBY caters only to hospitalised care. The largest proportion of out-of-pocket spending stems from the recurring costs of outpatient care and medicines, neither of which are covered by insurance. Selective financing of secondary or tertiary care fragments the health system, which is expected to provide continuity of care from home to hospital. Tax funding has to be the foundation of UHC, with different forms of insurance as supplements rather than substitutes.
Integrated care is possible only when healthcare providers are paid a fixed sum for the comprehensive healthcare of a person over a year rather than a fee for each consultation or procedure. This incentivises the healthcare provider to invest in prevention and early effective care, to avert complications that demand high-cost procedures. Fee for service, on the other hand, encourages excessive use of medical procedures, escalating health costs. Such integration is seen in public systems like the NHS in Britain or managed care systems like Kaiser Permanente in parts of US. If the RSBY is to be expanded, it should be closely linked to the NHM, to provide a pathway for integrated care.
For effective UHC, we also need to ensure other elements in the health system: a multi-layered, multi-skilled health workforce that is well distributed, affordable access to essential drugs, vaccines and technologies, adequate infrastructure and equipment at accredited health facilities, reliable health information systems, the participation of empowered communities and good governance, which includes the establishment of robust regulatory systems.
Many of the determinants of health lie in other sectors, such as water, sanitation, agriculture and food systems (for nutrition), urban design (for physical activity, air pollution, road safety), finance (such as taxes on tobacco, alcohol, unhealthy foods and beverages), poverty alleviation, education and gender equity. These must be aligned with public health objectives, alongside UHC, to provide a broad framework for health assurance.
Fortunately, Prime Minister Narendra Modi has voiced a vision of health assurance that goes beyond insurance, calling for greater emphasis on health promotion, disease prevention and provision of basic health services. That holistic vision can integrate UHC with the social determinants of health, to create Swasth Bharat along with Swachh Bharat.
The writer is president, Public Health Foundation of India. Views are personal
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