Universal coverage minus health?

Universal Health Coverage (UHC) is at the heart of the government's healthcare agenda. But the UHC in India, as elsewhere in the world, looks only at universalising care of the sick and making it affordable. This is a very limited objective. It completely neglects the health needs of the rest of the population which includes the healthy, people with risk factors and those with symptoms. Each of these categories needs specific healthcare facilities.

The World Health Organisation (WHO) defines UHC as "promotive, preventive, curative, rehabilitative and palliative health services of sufficient quality for all citizens which do not put users to excessive financial burden". Both access and financial protection are important, especially in a country like India where 80% of health spending is out-of-pocket and health crises often land people in debt and penury.

According to the Planning Commission's estimates, health problems push 39 million people every year into poverty. About 47% of hospital admissions of rural Indians and 31% of urban Indians are financed by loans and asset sales; and 30% of the former and 20% of the latter go untreated because of financial constraints.

In such a scenario, it would seem that the goal of universal coverage would be considered achieved if citizens can access quality and affordable healthcare services without being pushed into poverty by devastating healthcare expenditures.

But this is not enough. The WHO Charter defines health as, "A state of physical, mental and social wellbeing, not merely the absence of disease and infirmity". This concept reflects the other dimension of health beyond care of the sick in UHC, and includes clean drinking water, pollution-free air, proper sanitation facilities, adequate nutrition, preventive health-check-ups, vaccination and immunisation.

However, the Indian concept of UHC falls far short of this internationally-accepted definition. It needs to be enlarged to include quality and affordable healthcare services for the entire population. To achieve this, India needs to leverage all available resources, public and private, formal and informal.

Every year, December 12 is celebrated as the UHC Day. Organisations across the world participate and review the progress of UHC and prepare future roadmaps. The global push to UHC is led by the WHO and the World Bank. In India, high-level expert groups discuss and deliberate the UHC agenda.
But 'health' appears to be missing in our current approach. This may be because these expert committees are dominated by medical practitioners and economists who are not trained to look at health holistically.

Health insurance is widely promoted as a panacea to all ills in healthcare. Today, health insurance covers about 17% of the Indian population and there are efforts to increase the coverage. Global experience, however, shows that universal insurance coverage can be sustained only if the basic determinants of health, such as access to safe water, nutrition and sanitation, environment etc are ensured.

Basics first

India needs to first ensure access to safe drinking water, sanitation including waste disposal systems, control environmental pollution and provide a measure for a nutritional safety net. Mere provision of medical insurance would be insufficient to secure the health of the citizens.

The preventive and promotive aspects of health need greater attention while focussing on the access to quality healthcare at an affordable cost for the country's population. Without this shift, it is akin to trying to mop the floor dry while leaving the water taps on.

To tackle the challenge of UHC, two major shifts are required: the need for a whole-of-population approach to health and addressing the social determinants of health through all policies. The first would include preventive healthcare for the healthy t the curative and rehabilitative care of the sick.

The need for increased financial allocations for medical interventions is necessary, but it must also be enough to control a huge and continuously rising non-communicable disease (NCD) burden that the country has. There are more than 20 ministries whose policies impact health outcomes.

The current approach to UHC needs to be modified to a comprehensive healthcare that encompasses preventive and promotive health care engaging other sectors to play a critical and indispensable role. This integrated approach at the policy and operational levels need the involvement of the leadership at the highest political and social levels.

(The writer is Director, International Institute of Health Management Research, New Delhi)