Urgency of achieving Universal Health Coverage

Context:

• The World Health Organization (WHO) highlighted the importance and urgency of achieving Universal Health Coverage (UHC) choosing “UHC — for everyone everywhere” as theme for the World Health Day, 2019.

About:

• India’s latest and most comprehensive health report card was released recently which reflects overallchange in the disease pattern in the country.
• In 1990, 61% of the total disease burden in India was attributed to communicable, maternal, neonatal, and nutritional diseases.
• This figure has dropped to 33% in 2016. At the same time, the contribution of non-communicable diseases (heart disease, cancers, respiratory diseases, neurological disorders) has risen to 55% from 30% in 1990.
• Many Indian states are bigger than most countries in the world. It is necessary to plan health interventions based on the specific disease burden situation of each state.
• The disease burden due to unsafe water and sanitation has also reduced significantly in India, but this burden is still 40 times higher per person in India than in China.
• The contribution of air pollution to disease burden has remained high in India between 1990 and 2016, with levels of exposure among the highest in the world.
• The burden of household air pollution has decreased during this period due to decreasing use of solid fuels for cooking, and that of outdoor air pollution has increased due to a variety of pollutants from power production, industry, vehicles, construction, and waste burning.
• This knowledge has the potential of making fundamental and long-term contributions to improving health in every state.

Background:

• The status of health and its essentiality calls upon to focus on universal health coverage.
• Universal health coverage (UHC) is about ensuring that people have access to the health care they need without suffering financial hardship.
• UHC is also an essential part of the Sustainable Development Goals (SDGs): SDG 3 includes a target to “achieve universal health coverage (UHC), including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all.
• SDG 1, with the goal to end poverty in all its forms everywhere, is also in peril without UHC, as hundreds of millions of people are impoverished by health expenses every year.

Universal health coverage and health financing

• 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.

UHC cuts across all of the health-related Sustainable Development Goals (SDGs) and brings hope of better health and protection for the world’s poorest.

Universal Health Coverage: Challenges

• The total expenditure on health care in India, including public and private expenditure is broadly comparable to other developing countries at similar levels of per capita income.
• The total expenditure on health care (both public and private together) is 3.7 per cent of the GDP.
• According to the World Health Statistics 2013, public expenditure on health very low constitutes 28.2 per cent of total health expenditure.
• According to the Government of India’s 12th Five Year Plan, public health expenditure in India was only 1.04 per cent of GDP in 2011–12 as compared to the global average of 5.4 per cent.

Current Operating norms:

• The Union Government’s Ministry of Finance disburses funds to the Ministry of Health and the States.
• The public sector also funds a number of insurance schemes.
• Currently, Union-funded insurance schemes cover an estimated population of 181 million through the Employee State Insurance Scheme (ESIS) – (60 million); Central Government Health Scheme (CGHS) – (3 million) and Rashtriya Swasthya Bima Yojana (RSBY) – (118 million).

Structural ambiguity on UHC:

• What services are to be universally provided to begin with?
• What level of financial protection is considered acceptable?
• Should UHC commence by offering the same set of services to the entire population and progressively expand the service package to all as more resources accrue?
• Should UHC first prioritize certain services to the poor and vulnerable sections, to ensure both access and affordability, while leaving the rest of the population for coverage at a later stage?
• There is an option to provide a basic package of services to all, with full financial protection, along with an additional set of publicly funded services to the poor and vulnerable sections.

The Operational foresight:

• To meet the standard set by the WHO and the SDGs, UHC has to include all persons in a population, even if the service package is modest to begin with.
• In terms of financial protection, the Out Of Pocket Expenditure (OOPE) on health should not exceed 15-20 per cent.
• This requires a high level of public financing.
• Even countries which follow an insurance model have a high level of public funding to support several health services.
• Mandated contributory insurance model will not work in India which has over 90 per cent of the workforce in the informal sector.

How does India measure up presently and can it achieve the 2030 target?

• OOPE is still around 63 per cent, despite several government health insurance and benefit schemes.
• Impoverishment due to unaffordable healthcare expenditure affects 7 per cent of our population.
• Healthcare induced financial distress is a leading cause of suicide among farmers.
• Access to health services varies widely among states and between rural and urban populations.
• Qualified healthcare providers are in short supply nationally and those available are maldistributed, with marked density differences across regions.

To achieve 2030 target, what needs to be done?

• Raise public spending on health to at least 2.5 per cent by 2022 and 3 per cent by 2024.
• Primary health care has to be recognized as the foundational basis of an efficient and equitable healthcare system
• It has the highest number of beneficiaries (the whole population), provides a wide range of services and can prevent a large spillover into hospitals for advanced care through effective prevention and timely care.
• Government funded programmes should ensure that financial barriers should not stop access to needed advanced care.
• UHC has to be cashless at the point of care and health benefits under the programme have to be available for access anywhere in the country.
• The health work force has to be expanded to make available multi-layered, multi-skilled teams which can deliver the needed services.
• Basic and specialist doctors, nurses, nurse practitioners, physician assistants, pharmacists and an array of allied health professionals need to be developed in large numbers and deployed across the country.
• Strengthening of primary care infrastructure and district hospitals has to be a government priority.
• Free provision of essential drugs and diagnostics at public healthcare facilities will have an immediate impact on OOPE.

Practice Question:

According to WHO, Universal Health Coverage (UHC)“means that all individuals and communities receive the health services they need without suffering financial hardship”. Given low support from the State, evaluate the effectiveness of health related policy and support infrastructure in realization of UHC in India.