WHY INDIA NEEDS TO RAMP UP INVESTMENTS IN HEALTH
At the 2012 World Health Assembly, the then director general of the World Health Organization, Margaret Chan, declared that universal health coverage (UHC) is the most powerful concept that public health has to offer. Last year, WHO director-general, Tedros Adhanom Ghebreyesus, listed UHC as his foremost priority. Keeping with that commitment, WHO has chosen the theme of this year’s World Health Day as ‘Universal Health Coverage: Everyone Everywhere’.
UHC is visualised as an ideal state of health system organisation in which every person gets quality health services as per her needs, without suffering financial hardship. While an overnight transformation of the health system is not possible, a planned and progressive evolution towards achievement of the SDG targets is imperative. UHC has been graphically depicted by WHO as a cube with three dimensions: population coverage; service coverage; and, cost coverage. While all of these need to be addressed in unison from the very start, the scale of each has to be periodically revised, as per resources available at that time.
The first (what proportion of the population is covered by the programme?) is of interest to political decision-makers, as they would like to please the largest number of voters. The second (what is the range of health services covered?) is the priority of doctors, as they would like to make the maximum range of tests and treatments available to patients. The third (how to reduce the financial burden of healthcare on individuals, while keeping the health budget within limits of fiscal prudence?) is the concern of economists. There is a dynamic tension between these competing perspectives, even as the questions have to be answered in a complementary manner to progressively fill the UHC cube.
Universality invokes the principle of benefits to all through ‘horizontal equity’. However, the health gaps between the rich and poor also need to be bridged through ‘vertical equity’. This calls for a UHC which initially provides facilitated access to several essential benefits for all, with prioritised provision of additional benefits to poor and vulnerable sections. As UHC evolves, the programme must encompass the whole population with the largest band of common benefits.
At every stage, an ‘essential health package’ needs to be defined, listing the common services that will be provided to all, while supplementing these with additional services to the vulnerable sections. Disease burdens, cost-effectiveness and equity are factors that usually determine these services.
Primary care and emergency care must take priority, as must maternal and child health services. Without robust primary health services, preventable or easily treatable diseases will flood secondary and tertiary care facilities demanding expensive care for complications that should have been avoided. UHC will then tilt heavily towards advanced hospital care, disproportionately draining the health budget and leaving little impact on population health indicators.
Public financing of health is key to the success of UHC. Tax revenues and employer contributions must contribute to bulk of the funding for UHC, which must be capable of serving the whole population. This will create a large ‘risk pool’ where the healthy subsidise the sick and the rich subsidise the poor.
India is still far from the UHC target. Government-funded insurance programmes targeting the poor have increased their access to hospitalised care but have failed to provide financial protection. High, out-of-pocket expenditure on outpatient care and medicines, uncovered by these schemes, are the reason, apart from add-on hospitalisation costs. Primary care too has been weak in many parts of the country.
The centrally-sponsored Ayushman Bharat - National Health Protection Mission aims to galvanise frontline primary care and scale up the financial coverage of hospitalised care for the poor and near poor. While this is welcome, the whole chain of health services must be strengthened. The health budgets must rise substantially if the sluggish journey towards the SDG target is to speed up. More than to the UN or WHO, India must keep the promise to her people.
INDIA HAS TO GO A LONG WAY TO ACHIEVE UNIVERSAL HEALTH COVERAGE. FOCUS ON PRIMARY HEALTHCARE AND PUBLIC FINANCING OF HEALTH WILL HELP IN THIS DIRECTION