Universal Health in India

There is a strong global momentum on Universal Health Coverage, re-enforced by the Tokyo Declaration of December 2017. The core principles of UHC are a part of National Health Policy 2017. Our country has witnessed many incremental changes and India@70 is an opportune time for transformational approaches to improve the health of citizens. This provides a ‘once in 15 year opportunity’ to transform health of the people with renewed zeal.

Recent Developments

National Health Authority

  • The Union Cabinet on 3rd January, 2019 restructured the existing National Health Agency as “National Health Authority” for better implementation of Pradhan Mantri-Jan Arogya Yojana (PM-JAY) under Ayushman Bharat.
  • The existing multi-tier decision making structure has been replaced with the Governing Board chaired by the Minister of Health & Family Welfare, which will enable the decision making at a faster pace, required for smooth implementation of the scheme.
  • The composition of the Board is broad based with due representations from the Government, domain experts, etc. Besides this, the States shall also be represented in the Board in on rotational basis.

Ayushman Bharat-National Health Protection Mission

  • Ayushman Bharat is National Health Protection Scheme, which will cover over 10 crore poor and vulnerable families providing coverage upto 5 lakh rupees per family per year for secondary and tertiary care hospitalization.
  • Ayushman Bharat - National Health Protection Mission will subsume the on-going centrally sponsored schemes - Rashtriya Swasthya BimaYojana (RSBY) and the Senior Citizen Health Insurance Scheme (SCHIS).
  • Under the over-arching ‘Ayushman Bharat’ programme, it is aimed at addressing health holistically, in primary, secondary and tertiary care system, covering both prevention and health promotion.
  • Ayushman Bharat rests on the twin pillars of Health and Wellness Centres (HWCs) for provision of comprehensive primary healthcare services and the Prime Minister's National Health Protection Mission(NHPM) for secondary and tertiary care to 100 million families.

Universal Health in India

  • Universal Health Coverage (UHC) means that all individuals and communities receive the health services they need without suffering financial hardship. It includes the full spectrum of essential, quality health services, from health promotion to prevention, treatment, rehabilitation, and palliative care.

Objectives of Universal Health

    • Equity in access to health services - everyone who needs services should get them, not only those who can pay for them
    • The quality of health services should be good enough to improve the health of those receiving services
    • People should be protected against financial-risk, ensuring that the cost of using services does not put people at risk of financial harm.
  • India’s current program of universal health coverage aims to provide reasonable access to health care for its 1.3 billion population.
  • Government of India and the State Governments have the general obligation to provide free and universal access to the health-care services and ensure that there shall not be any denial of health-care directly or indirectly to anyone, by any health-care service provider, public or private, by laying down minimum standards and appropriate regulatory mechanism.

Indicators of Universal Health Coverage

World Health Organization (WHO) uses 16 essential health services in 4 categories as indicators of the level and equity of coverage in countries.

Government Initiatives of Attain the UHC

National Health Policy, 2017

  • The primary aim of the National Health Policy, 2017, is to inform, clarify, strengthen and prioritize the role of the Government in shaping health systems in all its dimensions- investments in health, organization of healthcare services, prevention of diseases and promotion of good health through cross sectoral actions, access to technologies, developing human resources, encouraging medical pluralism, building knowledge base, developing better financial protection strategies, strengthening regulation and health assurance.
  • The policy proposes free drugs, free diagnostics and free emergency and essential health care services in all public hospitals in a bid to provide access and financial protection.
  • It also envisages a three-dimensional integration of AYUSH systems encompassing cross referrals, co-location and integrative practices across systems of medicines.
  • It also boasts of having an effective grievance redressal mechanism.

National Rural Health Mission (NRHM)

  • The National Rural Health Mission (NRHM) was launched in 2005, to provide accessible, affordable and quality health care to the rural population, especially the vulnerable groups.
  • NRHM seeks to provide equitable, affordable and quality health care to the rural population, especially the vulnerable groups.
  • Under the NRHM, the Empowered Action Group (EAG) States as well as North Eastern States, Jammu and Kashmir and Himachal Pradesh have been given special focus.
  • The thrust of the mission is on establishing a fully functional, community owned, decentralized health delivery system with inter-sectoral convergence at all levels, to ensure simultaneous action on a wide range of determinants of health such as water, sanitation, education, nutrition, social and gender equality.

Indicators of Universal Health Coverage (UHC)

Categories

Indicators

Reproductive, maternal, newborn and child health care

  • family planning
  • antenatal and delivery care
  • full child immunization
  • health-seeking behaviour for pneumonia

Infectious diseases

  • tuberculosis treatment
  • HIV antiretroviral treatment
  • Hepatitis treatment
  • use of insecticide-treated bed nets for malaria prevention
  • adequate sanitation

Non-communicable diseases

  • prevention and treatment of raised blood pressure
  • prevention and treatment of raised blood glucose
  • cervical cancer screening
  • tobacco (non-)smoking

Service capacity and access

  • basic hospital access
  • health worker density
  • access to essential medicines
  • health security: compliance with the International Health Regulations

Universal Health Insurance Scheme (UHIS)

  • The Universal Health Insurance Scheme was launched with effect from July 14, 2003 on a nationwide basis with an aim to provide health care to the poorest section of the society.
  • The scheme is open to both BPL (Below Poverty Line) and APL (Above Poverty Line) families.
  • The UHIS have been reformed to improve the access to the health care to the exclusive below poverty line families.
  • UHIS has the features like:
    • The Universal health insurance policy is available to both individuals as well as in a group.
    • The individual policy will be in the name of the earning head of the family with details of other insured members.
    • The Group policy will be issued in the name of the Group/Association/Institution with a schedule of names of the members including his/her eligible family members forming part of the policy.
    • Members covered in one group policy cannot be covered in any other group in the same health scheme.

Pros and Cons of Universal Health Coverage

Pros

  • It lowers the costs of health care for the economy.
  • It reduces administrative costs for care access.
  • It simplifies the rules and processes.
  • It creates a workforce that is healthier.
  • It removes the competition.

Cons

  • It requires people to pay for services they do not receive.
  • It may limit the accuracy of patient care.
  • It may have a longer waiting period.
  • It limits the payouts which doctors receive. It can limit new technologies.
  • It requires significant budgeting skills.

High-Level Expert Group Report on Universal Health Coverage, 2011

  • High Level Expert Group (HLEG) on Universal Health Coverage (UHC) was constituted by the Planning Commission of India in October 2010, with the mandate of developing a framework for providing easily accessible and affordable health care to all Indians.
  • While financial ‑protection was the principal objective of this initiative, it was recognised that the delivery of UHC also requires the availability of adequate healthcare infrastructure, skilled health workforce and access to affordable drugs and technologies to ensure the entitled level and quality of care given to every citizen.

Challenges to Achieve Universal Health Coverage

  • Firstly, wide disparity in the quality of healthcare services in the public and private sector as regulatory standards are neither established nor enforced properly by the Government of India.
  • Secondly, the issue of local quacks and traditional healers treating patients at the grass-root level is a serious concern. This is connected to the poor availability of healthcare services and service providers in rural areas. The government has not formulated any Bill to curb these malpractices.
  • Thirdly, the non-affordability of healthcare services is a major problem with the vast majority of our people. As a result, they are impoverished because of high out-of-pocket healthcare expenditures. They also suffer the adverse consequences of the poor quality of care.
  • Fourthly, the coverage is still not universal but linked to poverty. Government should de-link current provision of entitlement based on poverty line.

Interesting Facts on UHC

  • Universal Health Coverage is firmly based on the 1948 WHO Constitution, which declares health a fundamental human right and commits to ensuring the highest attainable level of health for all.
  • The goal of universal health coverage was first set out in the Declaration of Alma-Ata, made at the International Conference on Primary Health Care in September 1978 at Alma-Ata in the former Union of Soviet Socialist Republics (USSR).
  • At least half of the world’s population still do not have full coverage of essential health services.
  • About 100 million people are still being pushed into “extreme poverty” (living on 1.90 USD (1) or less a day) because they have to pay for health care.
  • Over 800 million people (almost 12% of the world’s population) spent at least 10% of their household budgets to pay for health care.
  • Universal Health Coverage Day is celebrated on 12th of December every year.
  • All UN Member States have agreed to try to achieve universal health coverage (UHC) by 2030, as part of the Sustainable Development Goals.
  • India’s Ministry of Health has estimated that rolling out UHC will cost approximately $6.5 billion per year for four years (2015-19).
  • India’s current GDP is estimated at $2.25 trillion by the World Bank. Consequently, the cost of rolling out UHC is actually only 0.28% of India’s GDP and well within the country’s public heath expenditure.
  • Karnataka became the first State in India to provide Universal Health Coverage to its population. It achieved the distinction with the launch of Rajiv Arogya Bhagya Yojana on 9 January 2014.

Improvements Required

  • There is a huge potential for the government, academia and private sector to actively engage with each other to achieve UHC and SDGs.
  • Currently, major animosity exists between the government, academia, and private sector with each speaking their own language and in their own silos and for their own benefit. They are like three corners of a rigid triangle. This engagement has to be active, visionary and intensive, creating a win-win situation under the strong stewardship of the government.
  • The Indian people deserve desire and demand an efficient and equitable health system which can provide UHC. This needs sustained financial support, strong political will and leadership, dedication of public health functionaries and other stake holders as well as active participation of the community in the absence of which the realization of the goal of achieving UHC by 2022 will remain a Utopian concept.

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