|DR. K. N. RAO MEMORIAL ORATION PAPER
|Year : 2014 | Volume
| Issue : 3 | Page : 161-167
Universal health coverage: The way forward
Ashok Kumar Jindal
Department of Community Medicine, Armed Forces Medical College, Pune, Maharashtra, India
|Date of Web Publication||13-Aug-2014|
Prof. Ashok Kumar Jindal
Military Hospital, Nasirabad, Ajmer - 305 601, Rajasthan
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Universal health coverage (UHC) is the means to provide accessible and appropriate health services to all citizens without financial hardships. India, an emerging economy with demographic window of opportunity has been facing dual burden of diseases in midst of multiple transitions. Health situation in the country despite quantum improvements in recent past has enormous challenges with urban-rural and interstate differentials. Successful national programs exists, but lack ability to provide and sustain UHC. Achieving UHC require sustained mechanisms for health financing and to provide financial protection through national health packages. There is a need to ensure universal access to medicines, vaccines and emerging technologies along with development of Human Resources for Health (HRH). Health service, management, and institutional reforms are required along with enhanced focus on social determinants of health and citizen engagement. UHC is the way for providing health assurance and enlarging scope of primary health care to nook and corners of the country.
Keywords: Challenges, Health financing, Health protection, Human resource, National health package, Universal health coverage
|How to cite this article:|
Jindal AK. Universal health coverage: The way forward. Indian J Public Health 2014;58:161-7
| Introduction|| |
Universal health coverage (UHC) as conceptualized today attempts to provide promotive, preventive, diagnostic, curative and rehabilitative health services without financial hardships.  UHC is considered as a standalone measure of directing overall development of the country. It aims to develop a health care system, which is capable of providing equitable distribution of health resources as envisaged in the concept of primary health care stated during Alma ata declaration of 1948. 
Universal health coverage as a concept was born in 1883 when Germany introduced health coverage for achieving health status of its young population.  Later, as many countries joined the league, in 2005, World Health Assembly adopted the term "UHC" and in 2010, World Health Report focused on health systems financing for countries to build a platform for UHC. 
In the past two decades, many developing countries have introduced UHC for providing care to their populations. Currently, more than 50 countries claim to have UHC, complete or partial, in one form or other.  The global aspiration to achieve UHC is evident and even countries having gross domestic product (GDP) less than that of India have embarked upon and adopted the concept. China, Sri Lanka and Bangladesh have also adopted UHC and aim to achieve 100% coverage in times to come.
In the midst of such advancements globally, India, a known emerging economy with a demographic window of opportunity is still attempting to find out a way for providing appropriate, affordable and accessible health care to its population.  India was among the first countries in the world that enshrined in its constitution the "socialist model of health care" for all, being a "Welfare state". The Bhore Committee laid down the norms and infrastructure at the time of Independence for implementing this philosophy but till date India has been struggling to achieve "health care for all". Some progress has been made but the enormity of the task presents huge challenges for the public health system across the country. Successful National programs like National Rural Health Mission (NRHM), Rashtriya Swasthya Bima Yojana (RSBY), Janani Suraksha Yojana (JSY), etc. have been running in the country, but they themselves are insufficient to provide and sustain UHC for the nation at large. In fact, critics say that undue stress on Reproductive and Child Health has reduced the focus on tuberculosis and malaria control in the country. There is an urgent need of an efficient health care system, which amalgamates features and benefits of achievements made so far under various programs running in the country. Keeping these points in view, to make accessible and affordable comprehensive health care a reality for all Indians, The Planning Commission had set up a High Level Expert Group (HLEG) on UHC, whose report lays down a blueprint for policies to be followed in the current 5 years plan. This paper attempts to analyze the same, as an instrument for providing UHC in the country.
| Health Situation in India|| |
If we have a glimpse of current health situation in India, trends show a quantum improvement in past two decades. Various key health indicators such as maternal mortality rate and infant mortality rate (IMR). have been improving. However, despite improvements, enormous challenges in health care sector need to be addressed. Though life expectancy since independence has shot up from around 40-67, but there is little to rejoice. Public health indicators in India compare poorly with many countries having GDP lower than India.  Currently, IMR of India stands at 47 when compared to 17 of China and 13 of Sri Lanka. 66% of children in India are completely immunized when compared to 99% in Sri Lanka, which witnessed massive civil unrest. 
Recent estimates of National Health Family Survey III in 2005-2006 estimated that 42% of children are malnourished in the country.  This translates into highest number of malnourished children in any country in the world. With demographic transition, rise in burden of noncommunicable diseases is another major area of concern. The emerging dual burden of diseases in the country poses huge economic losses. An emerging economy like India cannot afford such losses and urgent actions are required to reframe the existing infrastructure and developments in a way to provide UHC to the country.
Further, disparity in health care exists across the states.  On one hand are the models for health care in Tamil Nadu and Kerala demonstrating success in providing care, and on the other are poorly performing Empowered Action Group states in the country. Life expectancy in Kerala is 18 years more than that in Madhya Pradesh. Chances of a girl child dying by age of one are 6 times higher in rural Madhya Pradesh than in rural areas of Tamil Nadu.  If we look at health care indicators within the states, they highlight coexistence of inequality of health care within the states in urban and rural areas. Health workers are 4 times more in urban areas than in rural areas, 42% of the self-acclaimed allopathic doctors do not have medical training in rural areas when compared to 15% seen in cities.  This poor state of affairs in health care settings has been largely attributed to the low priority given to health. Private spending for health care in form of out of pocket (OOP) expenditure has remained high in the country despite several health insurance and social security schemes. It is estimated that only 25% of Indian population is under some form of health insurance. 
National Rural Health Mission since launch in 2005 has developed infrastructure and human resource in form of more than 8 lakhs Accredited social health activists (ASHAs), establishment of health care centers, etc. RSBY, though in its infancy, attempts to demonstrate social insurance delivery in the form of a public private mix in the country. The huge expansion in public and private health facilities in the country could provide a platform for the launch of UHC in India.
| Universal Health Coverage: The Vision|| |
India is undergoing major transitions. Demographic transition has provided a window of opportunity for another two decades or so, but the challenges from nutritional transition and changing epidemiology of diseases poses a huge burden on the current health system in the country.
To achieve UHC, three basic prerequisites are of paramount importance. Firstly, sufficient resources are needed to cater for the health service requirements. Secondly, we need to reduce the financial risks and barriers which obstruct the optimal usage of available resources and thirdly, we need to focus on increasing the capability of the population to effectively utilize the available resources. 
Universal health coverage proposes a central government guaranteed scheme for all citizens that provide essential primary, secondary and tertiary care services through formulation of a national health package (NHP).  These packages are to be formed on basis of resources available as well as health care needs of the community. Acknowledging the potential of non-public sector in achieving UHC, HLEG recognizes that only public sector cannot aim to achieve UHC. Representation from private sector is also required to provide services. These services can be provided through two options.
In the first option, all those private providers who enroll themselves under UHC will provide minimum 75% of outpatient department services and 50% of in-patient services to those entitled under NHP.  The services will be cashless and the provider will be reimbursed at standardized rates. For remaining portion of services available, the institutions could accept payments or provide services through privately purchased insurance policies. In the second option, institutions enrolled under UHC will provide only those services, which are available under NHP. 
There are pros and cons of both the options. Rigorous monitoring and supervision will be required for smooth functioning of any of the options. However, HLEG envisages that over time, every citizen will be issued an IT enabled National Health Entitlement Card (NHEC) and this will lead to greater equity, improved health, efficient and transparent health system and further reduction in poverty, greater productivity and financial protection.
Let us now dwell upon the rationale for suggested changes in the health care system in India and recommendations as envisaged in the HLEG document.
| Health Financing and Financial Protection|| |
Health finance is the backbone of a self-sustaining health care system. The per capita health expenditure of the country is far less than that of Sri Lanka and China and is around a third of that in Thailand.  Simultaneously, proportion of total public spending on health is among the lowest in the world. This despite the fact that India's total public spending as percentage of GDP is at par with countries having UHC, including Sri Lanka and China. However, public spending on health as percentage of total public spending is 4.1% as compared to 10.3% of China and 14% of Thailand.  As a consequence, per capita OOP expenditure in the country has escalated to 67% of total expenditure on health. The situation reflects much lower allocation priority that health receives in the country. Inequity among states as far as public spending on health further suggests an urgent need for substantial changes in current health care system. Public health expenditure in state of Kerala stands at Rs. 498 when compared to Rs. 163 in Bihar. 
Improvement in health financing and health protection is a basic prerequisite for decreasing OOP spending on health by the people of the country. To streamline the health care system, we need to move from the concept of insurance to assurance. Government has to increase the current per capita public health spending on health to at least 3% of GDP by 2022.  This increase should be based on general taxation as principal source of health care financing and complemented by mandatory deductions from salaried and tax payers for sustainability. Sector specific taxes need not be levied as they are insufficient and distorts prioritization of resources. In addition, removal of user fees is recommended for removal of inequalities in access to health care. Weaker states require special efforts and specific purposes transfer schemes need to be incorporated to ensure that all citizens have an entitlement to same level of essential health care. The current expenditure on primary care is far less when compared with the amount spent on tertiary care services. This expenditure pattern has to be reformed with allocation of at least 70% of total expenditure for primary health care.  Strengthening of primary health care leads to decrease in demand for tertiary care services, thus leading to reductionin cost of sustenance of the health care system. Global experiences demonstrate catastrophic results when private insurance companies purchase health care services on behalf of the governments, thus, we have to strengthen health and finance ministries for sustaining UHC. All government based insurance schemes need to be amalgamated and principle of central procurement and decentralized distribution needs to be followed.
| Access to Medicines, Vaccines and Technology|| |
Access to medicines, vaccines and technology is an enormous challenge which has to be surmounted. Despite available expertise and technology, health care system has been facing the challenge of providing essential medicines and vaccines to those who require it and limiting the use of nonessential and expensive medicines among those who do not require them. Generic drug industry in India provides lifesaving medicines like antiretroviral therapy and vaccines across many developing countries but at the same time has been struggling to increase access to essential medicines, vaccine and technology in the country.  This has resulted largely from lack of reliable drug supply systems, poor quality of medicines, irrational prescriptions, stringent product patent regimes as well as limited availability of public health facilities. The dependence of the population on private chemists has increased substantially since independence highlighting limited protection received from the government.
To increase access to medicines, public spending on procurement of drugs should be increased to 0.5% of GDP.  Along with, price regulation and control for essential medicines is mandatory to make essential medicines accessible and affordable to all. Central procurement with decentralized distribution has to be followed. Tamil Nadu model has proven its success and the same needs to be replicated on a large scale. Strengthening of central and state regulatory agencies is to be done along with protection of laws and safeguards as under Trade-Related Aspects of Intellectual Property Rights agreement and Indian patents law to prevent escalation of prices of medicines in the market. An initiative on shifting Department of Pharmaceuticals to ministry of health can also be thought of to regulate the drug prices by better regulation of production and distribution in the country.
| Human Resources for Health|| |
Required HRH were recommended time and again since recommendations of Bhore committee in 1948 up to recent formulation of Indian Public Health Standards in 2010. The country holds largest number of medical colleges than anywhere in the world. Despite these facts, the country faces acute shortage of HRH. In contrast to WHO recommendation of 25 health workers per 10,000 population, India stands at 52 nd rank among countries facing human resource problem with 19 health workers per 10,000 population.  In the recent past admission capacities of institutions have been increased substantially for dentists, Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy doctors and pharmacists. However there is lack of data on HRH in the country and HRH management Information systems. The distribution of medical colleges is skewed across the country as the high HRH production states have a population of 31% when compared to low HRH production states having 46% of Indian population.  The shortage is to the tune of 63% for specialists to 10% for allopathic doctors and 9% of auxiliary nurse midwives (ANMs). In addition, the training of health workforce doesn't address the challenges of changing dynamics of public health. Training has been more inclined toward curative paradigm than towards population focussed health care. This is apparent form the fact that the time allotted to Community Medicine during internship has been reduced from 3 months to 2 months. Launch of NRHM in 2005 gave a huge boost to the HRH with incentives and created more than 8 lakhs ASHAs with a target of 1/1000 population.  Yet, ready availability of qualified practitioners is lacking with gross shortage of doctors at the primary health centers and above.
Human resource requirements can be accomplished by developing new medical colleges in underserved states and districts with linkage to district hospitals and by increasing the ANM schools at district level itself. This has to be accompanied with scaling up of allied health professional training institutions including establishment of District Health Knowledge Institutes (DHKIs) to coordinate and conduct training of various categories of health workers.  An increase as well as redistribution of health care has to be undertaken to remove the existing inequality among states. Development of a National Regulatory Development Authority with dedicated cadre and assured career progress has to be built for more recruitment and better functioning of health care system to sustain UHC in the country. 
| Health Service, Management and Institutional Reforms|| |
Structural and functional improvements are prerequisites for achieving UHC in any country. With the dismal state of key health indicators, there is a need to regulate the vast private sector existing in the country. The public health system has been able to reach to the entire country up to some extent through NRHM, however, private sector including non-governmental organization (NGOs) involvement in many hard to reach areas is minimal.  There is a need to provide adequate hospital beds. As per World Health Statistics, India's hospital bed capacity has remained among the lowest in the world at 0.9 beds/1000 population against average of 2.9 beds/1000 population globally.  The current situation demands for a robust financial management system with need for oversight and accreditation of service providers.
For provision of UHC we should strengthen public services, especially those providing primary health care, by providing resources and trained health workforce at frontline. If required, private providers should be contracted as per need and availability. In a nutshell, integration of primary secondary and tertiary care providers is to be done with stringent regulatory and quality assurance measures.
| Community Participation and Citizen Engagement|| |
Primary health care without community participation is incomplete. For UHC, citizen engagement needs scaling up for better delivery of resources. ASHAs have proved their worth under NRHM; however caution needs to be taken to prevent them from getting overburdened. NRHM has shown a positive effect on mobilization of community through civil society organizations and Panchayati Raj Institution (PRIs). However, Village Health and Sanitation Committees and Rogi Kalyan Samiti's have achieved limited success. In addition, lack of knowledge of available health services hampers optimal usage by the population. There have been inadequate legal frameworks for community participation in the health governance. Grievance redressal mechanisms exist but lack co-ordination with institutional mechanisms that are accessible to the poor.
Transformation of existing village health committees into participatory health councils is to be done.  These councils should organize regular health assemblies and enhance the role of elected representatives as well as PRIs and local bodies. Strengthening the role of civil society and NGOs along with formulation of formal grievance redressal at block level is required to increase community participation and citizen engagement for achieving UHC.
| Social Determinants of Health|| |
Universal Health Coverage cannot be achieved until we address social determinants of health. The status of social determinants including nutrition, water and sanitation, work security, occupational health, disasters, etc. remains abysmal in the country. Social determinants have to be addressed through formation of National Health Promotion and Protection Trust along with dedicated Social Determinants Committees at district, state and national levels.  These committees and trusts should be monitored through development and implementation of Comprehensive National Health Equity Surveillance Framework. Initiatives, both public and private, on the social determinants of health and towards greater health equity should be supported.
| Universal Health Coverage: The Challenges|| |
The governments have much higher capacities to spend on health. Political commitment seems evident from the fact that Prime Minister of India, on the eve of Independence Day stated health to be at utmost priority. The Planning Commission has acknowledged the same and recently assured an increase in public health spending to 2% of GDP from current 1.2% by end of 12 th 5 years plan.
However, implementation of UHC still faces enormous challenges in the field. The solutions are there but the decision lies with the politicians and administrators of the country. Foundation of self-sustained health care system in the country requires sustained political commitment. The center has to increase the priority allocation for health and improve the center state coordination.  Changing of priorities poses a challenge to achievement of UHC. Moreover, the speed with which the infrastructure develops will determine the outcomes in terms of inclusive health coverage.
The capacity development of the public sector health institutions, a basic prerequisite for achieving primary care has remained weak link in the past.  Resource generation remains a challenge for implementation of UHC. At the same time, managing with limited human resources until the time new trained manpower come into existence is a challenge in itself.
There is going to be huge opposition from the profit making big pharmacy companies and private health care providers.  Enrolling them under UHC packages present a herculean task before UHC. Standard Treatment Guidelines (STGs) are to be enforced across both public and private sectors to increase access to medicines. Acceptance of STGs by vast private lobby remains questionable. Requirement of stringent auditory measures in the country to ensure compliance to STGs are lacking and thus poses burden on the cost, availability and accessibility of medicines to the poor.
The urban sector was not considered as an area of priority in post independent era as health care in urban areas were considered adequate.  However with migration and scaling up, new sections of underserved and poor populations have emerged. Challenge exists to provide services to the urban poor in addition to the underserved rural population as the strategy varies significantly between them.
The report recommends having a NHP. This will be through a nationwide distribution of NHEC. In September 2011, it was stated that out of the 1.2 billion Indians, 50 million have a passport, about 100 million and 200 million have PAN card and a driving license respectively. As on December 2013, only about 60 million (6% Indians) have Adhar cards.  This has happened despite the publicity and a sound operational mechanism to enroll people into the program. Also, the National Identification Authority of India Bill was rejected by the Parliament Committee on Finance and it has not got the legal backing until date. In the similar sociopolitical scenario, how to come out with yet another card (the NHEC) within next few years, is a huge challenge.
Looking toward reimbursement to the contracted-in private hospitals and dispensaries, the issue itself will face a lot of resistance/unwillingness from private medical institutions. As happened with JSY, timely reimbursement of even Rs. 1400 for beneficiaries was a challenging issue (for example; as observed in the mid-term evaluation of Rajasthan State Institute of Health and Family Welfare report on JSY, 2008-2009). At a national level, mechanisms to bring about timely reimbursement to health providers will be a mammoth task.
To remove human resource crunch initiatives like creation of DHKIs, Bachelors of Rural Health care, involvement of medical colleges, etc. faces ambiguity within the public health cadre itself. Over a period of time, public health specialists in India have seen a vast gap in working pattern of those in practice and the academicians. The challenge lies in bridging this gap. Additional responsibility of districts by medical colleges needs to be elaborated further. Medical and dental colleges in the private sector have mushroomed in geometric proportions. However, it is highly unlikely that the products of such institutions will be available for service in the country's public health system. Role of medical colleges to take over the health responsibility without administrative and financial control of the health workers is a grey area that needs to be addressed.
| Conclusion|| |
Whatever critics may say, it is however evident that UHC is the way to move beyond health care. It is the way for providing health assurance to the country population. Challenges are ahead but consistent efforts can achieve the goals and objectives of UHC in the country. All classes of society including decision makers need to become sensitive and responsive to public health concerns. UHC is a path to achieve increased health outcomes. Efficient and transparent health systems are must to reduce poverty and increase productivity.
The document of the HLEG provides a window of opportunity to politicians, bureaucrats, academicians and health care providers to come together for enlarging the scope of Primary Health Care to the nook and corners of the country through UHC.
| Acknowledgments|| |
I acknowledge the help of Dr. Kapil Pandya and Dr. Gurpreet Singh, Residents of Community Medicine, Armed Forces Medical College in preparing the manuscript. Acknowledgements are also due to the authors of the HLEG document on "UHC" of the Planning Commission as the same has been repeatedly referred to in the paper.
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