Context

The Covid-19 pandemic has exposed the fault lines of Indian healthcare. This has strengthened calls for universal health coverage (UHC) in the country as a long-term reform.

Background

• Public health services, politically neglected for decades in most Indian states, have proven their irreplaceable value during this crisis.
• Although despised by the rich and middle classes, they are shouldering the lion’s share of not just preventive and outreach services but also clinical care.
• Nearly 80%-90% of critical Covid-19 cases are currently being treated by public health services.
• States with robust public health systems like Kerala have been far more successful in containing Covid-19, compared to richer states like Maharashtra and Gujarat, which have under-staffed public health systems.
• Given this background, now is the time to reinvent and rejuvenate public health services across the country, for which health budgets must be substantially upgraded.

Analysis

Health Infrastructure of India

• In the 2019 Global Health Security Index, which measures pandemic preparedness for countries based on their ability to handle the crisis, India ranked 57, lower than the US at 1, the UK at 2, Brazil at 22, and Italy at 31, suggesting it is more vulnerable to the pandemic than countries that have seen a high number of fatalities so far.
• India’s low investment in the health sector, dedicating only 1.3% of its GDP, is now making it vulnerable to COVID-19.
• It contrasts with other developing countries such as Brazil, which spends 7.5% of its annual GDP on health, Bhutan, which has allocated 3.6%, and Bangladesh, which dedicates 2.2%.
• Among developed nations, South Korea has kept its healthcare expenditure at a whopping 8.1%, Japan 10.9%, and the US at 8.5%.
• According to data from the Organization for Economic Co-operation and Development (OECD) available for India for 2017, India has 0.53 beds for 1,000 people compared with 0.87 in Bangladesh, 1.1 in Indonesia, 2.11 in Chile, 2.73 in Turkey, 1.38 in Mexico, 4.34 in China and 8.05 in Russia.
• In a recent study, the Center for Disease Dynamics, Economics & Policy (India) and Princeton University said the country currently has 713,986 beds, including 35,699 in intensive care units, and 17,850 ventilators for 1.3 billion people.
• India lags behind its BRICS peers on the health and quality index (HAQ index).
• As per the National Health Profile 2018, India’s public health spending is less than 1 per cent of the country’s GDP, which is lower than some of its neighbours, countries such as Bhutan (2.5 per cent), Sri Lanka (1.6 per cent) and Nepal (1.1 per cent).
• According to the World Health Organisation, India finishes second from the bottom amongst the 10 countries of its region for its percentage spending of GDP on public health.

What is Universal Health Coverage?                                                                                      

• Universal health coverage (UHC) means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.
• This definition of UHC embodies three related objectives:
  • 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
• UHC is firmly based on the WHO constitution of 1948 declaring health a fundamental human right and on the Health for All agenda set by the Alma Ata declaration in 1978.

Why Health matters?

• Health is clearly tied to other socio-economic indicators which signify the development of a nation. Health related policies strongly impact our national progress.
• The health policies that we plan and implement as a nation is imperative for us to achieve the 17 UN Sustainable Development Goals (SDG’s) by 2030. The dynamics associated with health has largely boiled down to one topic that compendiously covers it all; Universal Health Coverage (UHC).

Key roadblocks for India's healthcare industry:

• Population:India has the world's second-largest population, rising from 760 million in 1985 to an estimated 1.3 billion in 2015.
• Lack of Skilled Medical Personnel: India has a severe shortage of healthcare workers. There is one doctor for every 11,082 people. The WHO mandates that the doctor to population ratio should be 1:1,000, while India had a 1:1,404 ratio as of February 2020. In rural areas, this doctor-patient ratio is as low as 1:10,926 doctors as per National Health Profile 2019.
• Insurance:India has one of the lowest per capita healthcare expenditures in the world. Government contribution to insurance stands at roughly 32 percent.
• Lack of infrastructure: India's existing infrastructure is just not enough to cater to the growing demand.
• Concentration in urban areas: The majority of healthcare professionals happen to be concentrated in urban areas where consumers have higher paying power, leaving rural areas underserved.
• Dominance of private sector: While the private sector dominates healthcare delivery across the country, a majority of the population living below the poverty line (BPL). It continues to rely on the under-financed and short-staffed public sector for its healthcare needs, as a result of which these remain unmet.
• Politicisation: Another important point is politicisation of the pandemic, which is visible through the Centre-state divide. There have been attempts to centralise the authority and dictate terms with states. This is visible in the allocation of relief funds to states, there was no transparency over why there was inequitable distribution of the funds.

How Universal Health Coverage can change the situation?

• In ideal conditions, universal health coverage would extend to legions of currently uninsured citizens and reduce financial barriers to care, both over a short period.
• It could also help bring a large chunk of private healthcare under the public ambit, reduce informality in healthcare provision, pave the way for better regulation and oversight, and allow monopsonistic power to the state to negotiate for better and affordable care.
• It may also contribute to reducing regional disparities in healthcare services and fostering the adoption of cost-effective healthcare innovations.

Suggestive measures

• Making health universal: UHC is expected to bridge inequalities relating to health and its access. As UHC evolves, it must take into consideration providing additional benefits to poor and vulnerable belts of people. Health equality has to transcend into health equity for the policies to stay relevant and sustainable.
• Incentivizing medical personnel: Incentivizing medical personnel to work in rural areas would be a great idea, additionally leveraging the help of technology for preventative measures can help complement the ongoing reformative efforts.
• Better coordination: Better coordination of the various technological developments through greater synergy between the government, academia and industry concerning research and manufacturing, could help minimise the duplication of efforts. It could hence result in more effective use of resources at this time of crisis.

Conclusion

In India, the state’s depth of ambition for public health failed to match the provision of infrastructure and resources and the state continued to rely on ‘narrowly targeted, techno-centric programmes assisted by foreign aid’. India, over the decades, has invested in many vertical programmes like malaria, tuberculosis, vaccine preventable diseases, population control and HIV. However, these programmes had limited success because of the limited integration with general health services, fragmentation of the health system and decision making being concentrated with a few, and they are formulated based on evidence that are not context specific.