Universal coverage" refers to a scenario where everyone is covered for basic healthcare services. This is a scheme, under which all Indian citizens, regardless of their economic, social or cultural backgrounds will have the right to affordable, accountable and appropriate health services of assured quality defined in a published package of services and benefits. It is also a supplemental system of financing to protect people from increasing medical expenses.
In other words, UHC is basically means providing affordable, accessible and quality health care facility to all citizens of India irrespective of their income, caste, gender or religion.
Under this every Indian citizen will be covered by a National Health Package that has a choice of facilities that are guaranteed by the government. The package will cover, free-of-charge, all Primary, Secondary and some Tertiary care services.
Hurdles in achieving UHC
• Poor financial resource: Financing is the main problem in achieving the milestone of UHC as India only spends 1.2% of its GDP on public health.
• Infrastructure: Public and Private sectors do not have enough capacity to provide better health care facility to all citizens of India. As per WHO statistics, India has ranked very low in global scenario with only 0.9 beds per 1000 population while global average is about 2.9 beds per 1000 population. Hence the availability of health care services provided by the public and private sectors taken together is inadequate.
• The quality of healthcare services varies considerably in both the public and private sector as regulatory standards for public and private hospitals are not adequately defined and, are ineffectively enforced.
• The affordability of health care is a serious problem for the vast majority of the population, especially at the tertiary level.
• Human Resource: However India is providing quality medical professionals to many countries but India itself has As per WHO statistics, India currently had only 1 doctor per 1700 citizens while WHO standard is 1 doctor per 1000 citizens. So India would need four lakh more doctors by 2020 in addition of current capacity.
• Inter-state gap in medical and health care facilities is another major area of concern to make healthcare accessible for all citizens of India. For instance, only one medical college for a population of 11.5 million in Bihar and 9.5 million in Uttar Pradesh compared to Kerala and Karnataka who have one medical college for a population of 1.5 million. Further there are very low penetration of hospitals and medical professionals in naxal and hilly areas of the country.
• Affordable medicines, effective preventive care, awareness and citizen participation are other major hurdles in achieving the target of UHC.
Health finance and delivery system in India
Health finance and delivery in India have developed along four main and mostly parallel lines.
The first is out-of-pocket spending by households. This method of finance places considerable financial burden on poor households, and is seen as one of the important reason for impoverishment in India. As per NSSO statistics, Private sector accounts for as much as 80 per cent of outpatient and 60 per cent of inpatient care services in India. The private sector accounts for more than 75% of total health spending in India.
The second is tax-financed public health sector which is available for all. This public health delivery system is operated mainly by the states and sometimes financed by centre under Centrally Sponsored Activities like NRHM, runs facilities at primary, secondary as well as tertiary levels. The public health delivery system accounts for about 20 and 40 per cent of outpatient and inpatient utilization in the country, respectively.
The third segment consists of social insurance schemes for formal private sector workers and government employees. These schemes are generally mandatory and are financed through employee and employer contributions via a payroll tax, but also benefit from partial government subsidies.
The fourth segment is voluntary private insurance (PHI) which emerged in the late 1980s but has grown rapidly in the 2000s. In 2004-05, PHI accounted for 1.6 per cent of total health expenditure, but reached an estimated 3 per cent by 2008-09.
Now the question arises how to implement the UHC in India? How to combine public and private providers effectively for meeting UHC goals in a manner that avoids perverse incentives, reduces provider induced demand, and that meets the key objectives specified above?
The concept of contracting private sector to provide cashless healthcare facility to poor such as in Rashtriya Swasthya Bima Yojana (RSBY) might be the best method to provide UHC facility to all. Under RSBY, smart cards are given to all BPL families and they can avail health care facilities of limited amount in govt contracted private hospitals.
Now next question is which type of health care services shall be included in UHC package such as primary, secondary, tertiary services, etc. Either in-patient or out-patient or both of the services should be included in UHC package. (Out Patient services means medical procedures or tests like X-ray or MRI scan which can be done in a hospital or clinic or laboratory without an overnight stay in that center, whereas In-Patient care requires admission of patients into a hospital).
HLEG Planning Commission: Recommendations
The recommendations of HLEG on UHC is based upon ten principles that are as follows: (i) universality; (ii) equity; (iii) non-exclusion and non-discrimination; (iv) comprehensive care that is rational and of good quality; (v) financial protection; (vi) protection of patients’ rights that guarantee appropriateness of care, patient choice, portability and continuity of care; (vii) consolidated and strengthened public health provisioning; (viii) accountability and transparency; (ix) community participation; and (x) putting health in people’s hands.
Now look at major recommendations of HLEG on various aspects of UHC.
Range of Services: Two different options emerged: In the first option, private providers opting for inclusion in the UHC system would have to ensure that at least 75% of outpatient care and 50% of in-patient services are offered to citizens under the National Health Package (NHP). For these services, they would be reimbursed at standard rates as per levels of services offered, and their activities would be appropriately regulated and monitored to ensure that services guaranteed under the NHP are delivered cashless with equity and quality.
The second alternative entails that institutions participating in UHC would commit to provide only the cashless services related to the NHP and not provide any other services which would require private insurance coverage or out of pocket payment.
Health Financing and Financial Protection: Government should increase public expenditure on health from the current level of 1.2 per cent of GDP to at least 2.5 per cent by the end of the Twelfth Plan, and to at least 3 per cent of GDP by 2022. Expenditures on primary healthcare should account for at least 70 per cent of all healthcare expenditure.
Access to Medicines, Vaccines and Technology: The Essential Drugs List should be revised and expanded, and rational use of drugs ensured. Public sector should be strengthened to protect the capacity of domestic drug and vaccines industry to meet national needs. The various safeguards provided by Indian patents law and the TRIPS Agreement such as compulsory licensing etc. should be used to produce essential drugs at lower cost.
Human Resources for Health: Ensure adequate numbers of trained health care providers and technical health care workers at different levels by increasing HRH density to achieve WHO norms of at least 23 health workers per 10000 populations (doctors, nurses, and midwives).
District Health Knowledge Institutes, a dedicated training system for Community Health Workers, State Health Science Universities and a National Council for Human Resources in Health (NCHRH) should be established.
Health Service Norms: A National Health Package should be developed that offers, as part of the entitlement of every citizen, essential health services at different levels of the healthcare delivery system. There should be equitable access to health facilities in urban areas by rationalizing services and focusing particularly on the health needs of the urban poor.
Management and Institutional Reforms: All India and State level Public Health Service Cadres and a specialized State level Health Systems Management Cadre should be introduced in order to give greater attention to Public Health and also to strengthen the management of the UHC system.
The establishment of a National Health Regulatory and Development Authority (NHRDA) a, National Drug Regulatory and Development Authority (NDRDA) and National Health Promotion and Protection Trust (NHPPT) has also been recommended.
Community Participation and Citizen Engagement: Existing Village Health Committees should be transformed into participatory Health Councils.
Gender and Health: There is a need to improve access to health services for women, girls and other vulnerable genders (going beyond maternal and child health).
But Before rolling out UHC in pilot mode, preparations for the following items need to be initiated:
i. Prepare the UHC Plan along with the District Health Action Plan (DHAP) of NRHM for the pilot district and identify the items to be covered for EHP;
ii. Frame and ensure compliance with Standard Treatment Guidelines;
iii. Strengthen the State and District programme management units to implement the EHP;
iv. Empanel private providers following due-diligence and introduce a transparent selection system;
v. Enlist beneficiary households and issue ‘Entitlement Cards’;
vi. Build an effective system of community involvement in planning, management, oversight and accountability;
vii. Build an effective community oversight and grievance redressal system through active involvement of Local Self-Government agencies and civil society; and
viii. Develop and strengthen Monitoring and Evaluation Mechanisms.