The challenging quest for universal health coverage

Better insurance coverage, higher investments in underserved areas, and digitisation will augment it

The dream of providing universal health coverage (UHC) has never been as close to reality as it is now. As we mark the UHC Day, let us acknowledge that India needs UHC. The World Health Organization defines UHC as ensuring that all people have access to needed health services (preventive, curative, palliative and rehabilitative) of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship. The UHC does not necessarily mean free health services, but ensuring access to affordable health services of adequate quality. People should not be exposed to catastrophic health expenditures. Ideally, health care costs should not be paid for outof-pocket by users at the time of seeking services, but through a prepayment mechanism or tax revenues.

Contrary to this vision, about 60 million Indians fall into poverty annually due to expenditure on health. Out of pocket spending by families currently comprises over 60% of health care expenditure in India. This is the highest among the G20 countries. The comparable figures for China and Indonesia are around 35%. This expenditure is highly regressive, as it disproportionately punishes the poor, the sick, the women and the elderly. They are also inefficient, since they deter families from seeking timely care, and often, any care at all.

However, this may change soon. Why so and why now? First, the political will to support UHC has never been greater in India. The leadership has put health care for all at the top of the development agenda. Indeed, Prime Minister Narendra Modi has been so closely involved with the government’s flagship health initiative, Ayushman Bharat, that it is often referred to as “Modicare”.

Second, this political commitment comes with sufficient financial resources as well as the creation of enabling organisational structures at the national and state levels. Third, states have shown strong leadership and willingness to adopt UHC as their primary health goal. Most have used their own resources to expand the coverage of the Centre’s Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (ABPM-JAY) to groups beyond those originally targeted. The expanded ABPM-JAY covers more than 13 crore families, against the originally planned 10 crore. Some states, like Uttarakhand and Karnataka, have expanded the scheme to almost their entire populations.

Fourth, the initial momentum of the ABPM-JAY provides strong conceptual basis and a viable framework for achieving UHC. In slightly over a year, the ABPM-JAY has supported treatment for over 65 lakh people, saved about ~20,000 crore for poor households, and prevented lakhs of them from falling deeper into poverty. The private sector has been an enthusiastic partner, having provided about 60% of the treatments under the scheme.

The scheme has also provided the fulcrum for the Centre and states to expand health coverage to other vulnerable groups. For example, the ministry of labour and employment plans to bring, under it, all construction workers. Some states are using the scheme’s IT system to cover government employees and retirees. The other pillar of the Ayushman Bharat is also off to a strong start, with over 20,000 health and wellness centres now providing expanded preventive, primary and promotive health services.

While strong momentum has undeniably been achieved, the progress towards UHC is not preordained. Several constraints pose challenges. In its 2019 report titled, Health System for a New India: Building Blocks, the Niti Aayog identifies the deep fragmentation of the health system with respect to health service providers, purchasers and payers, and the digital technology that powers it, as a critical constraint. Addressing this constraint will be important.

Currently, outside the ABPM-JAY and the state schemes, less than 10% of India’s population has comprehensive health insurance. A large section of India’s middle class lacks health insurance coverage. Within the public sector, a multiplicity of organised payers — entities of the Central and state governments — operate multiple health care schemes, further fragmenting health insurance in the country. Consolidating these schemes could strengthen strategic purchasing, as a single — and larger — payer can negotiate better rates from hospitals and diagnostic centres. It can also better enforce quality standards, improve efficiency and protect consumers. A consolidated government scheme can plausibly extend benefits to the “missing middle”.

Service delivery in India is also highly fragmented, with a large number of mainly small providers delivering over 64% of health care. Ninety eight percent of providers operate informally and employ less than 10 people. More than 80% of tertiary care facilities are based in the tier-1 cities. If UHC is to be achieved, this will have to change. By putting buying capacity in the hands of the bottom 40%, who live mostly in rural areas and smaller towns, the ABPM-JAY will help in this transformation. However, a separate set of incentives and policies will be needed to encourage investment in larger tertiary care hospitals in the tier-2 and tier-3 cities.

Currently, the health records of millions of patients get lost in the quagmire of manual systems or fragmented, non-standardised IT systems, offering no scope of interoperability or cross-sharing, thereby limiting the data-driven and evidence-based patient care. We will need to build a robust, secure and interoperable digital health care backbone that can seamlessly provide patient information to health care providers across hospitals. The recently released National Digital Health Blueprint provides a clear road map for achieving this vision.

The country has irreversibly set itself on course to achieve UHC. Removing the current fragmentation in health insurance, incentivising investments in hospitals in underserved areas, and building a strong digital health care backbone will accelerate this process.