Sustained effort required for universal health coverage

The director general of World Health Organisation (WHO) Margaret Chan firmly believes that Universal Health Coverage (UHC) is ‘the single most powerful concept that public health has to offer.’

UHC entails that ‘all people have access to needed promotive, preventive, curative and rehabilitative health services, of sufficient quality to be effective, while also ensuring that people do not suffer financial hardship when paying for these services’.

In India, the biggest manifestation of problems in the current system of healthcare financing is the number of people who incur high out of pocket (OOP) expenditure on health that often leads to impoverishment.

There is a rather small portion of the population covered by contributory schemes, benefiting mostly those in the formal employment sector.

The remaining major portion is nominally covered through Central and state government funds allocated to earmarked schemes or for the direct provision of services in public health care facilities.  

The population pushed into poverty due to OOP expenditure on health increased from 26 million in 1993-94 to 39 million in 2004-05. Consequently, a considerable proportion of ailments in the country go untreated due to financial reasons.

Ailments that are treated are largely serviced by the private health sector (around 80 per cent on average nationally), which remains mostly unregulated and achieve low levels of quality and responsiveness.

The situation of poor access to health services and the attendant financial hardships outlined above is linked to the per capita government expenditure on health in India being among the lowest in the world.

Only 28.2 per cent of total health expenditure is paid by government, making OOP expenses more than 60 per cent of total health expenditure (86.0 per cent of private expenses).

To address these critical challenges, in 2005, the Central government introduced the National Rural Health Mission (NRHM).

While NRHM attempts to improve coverage of some services with funds generated from the tax-based route, the Rashtriya Swasthya Bima Yojna (RSBY) run by the ministry of labour and employment seeks to provide financial protection to the underprivileged households through insurance mechanisms to cover hospital expenses.

The RSBY currently covers 118 million beneficiaries, whereas the other more comprehensive Union-funded insurance schemes, the Employee State Insurance Scheme and the Central Government Health Scheme cover 60 million and three million beneficiaries respectively.

In recent years, many states have also started to fund health insurance schemes. Private insurance is another area in health financing with health premiums touching Rs133.25 billion in 2011-12. 

New Strategy

To address the huge coverage-related challenges, a high level expert group was constituted by the Planning Commission to define a comprehensive strategy for health for the Twelfth Five Year Plan.

Based on the HLEG report and after extensive consultations, a new strategy for health has been spelt out in the Twelfth Plan (2012-17) towards rolling out UHC.

It seeks to realise the goal of UHC in two parallel steps: The first is to make available clinical services at different levels, defined in an essential health package that is financed by the government and provided by the public health sector, and supplemented whenever required by contracted-in private providers to fill in critical gaps.

The second is the universal provision by the government of high impact, preventive and public health interventions.

The ministry of health and family welfare (MoHFW) has planned to operationalise the above strategies through the National Health Mission (NHM).

The NHM envisions providing universal access to equitable, affordable and quality health care services, which are accountable and responsive to the needs of people living in both, rural and urban India.

Pilots are being planned to develop and test effective and sustainable UHC models for scaling up across the country.

The steps taken by the MoHFW are laudatory and a good beginning.

Additionally, the ministry needs to engage with the Central ministry of labour and employment and the states, which currently run public health insurance schemes in order to streamline and coordinate efforts toward advancing financial coverage in a more systematic and coherent manner.

Approaches for enhanced and mutually beneficial engagement with other Central ministries engaged in direct provision of services as well as the for-profit and voluntary health sectors with effective regulation of these sectors to improve affordability and quality of care is also essential.

India's progress towards UHC does not merely require a higher level of public financing for providing and purchasing health care in an integrated manner but also sustained efforts to speed up development of systems allowing better access to quality medicines, vaccines and new and appropriate technologies; strengthening of human resources for health both in quantitative terms as well as performance; and facilitating increased participation of communities through institutional and management reforms for ensuring accountability, transparency and responsiveness of the health system to the citizens.

In summary, India can largely benefit from three broad strategies.

First, increasing the share of total public spending devoted to health to increase the level of compulsory prepaid revenues for health. Second, reduction of fragmentation in pooling to expand the redistributive capacity of prepaid funds. Third, improving efficiency and equity in the use of funds.