Universal Health Coverage

• Universal Health Coverage (UHC) means that all individuals and communities receive the health services they need without suffering financial hardship. It includes the full range of essential, quality health services from health promotion to prevention, treatment, rehabilitation and palliative care.
• The basic idea of Universal Health Coverage is that no one should be deprived of quality health care for the lack of ability to pay. UHC, in recent times, has become a critical indicator for human equity, security and dignity.
• UHC has become a well-accepted objective of public policy around the world. It has even been largely realised in many countries, not only the richer ones (except the US) but also a growing number of other countries such as Brazil, China, Sri Lanka and Thailand.
• Protecting people from the financial consequences of paying for health services out of their own pockets reduces the risk that people will be pushed into poverty because unexpected illness requires them to use up their life savings, sell assets, or borrow – destroying their futures and often those of their children.
• Achieving UHC is one of the targets the nations of the world set when adopting the Sustainable Development Goals in 2015. If achieved by India it will result in good overall health in children and adults ultimately pulling them out of poverty, and will become the basis for long-term economic development.
• The time has come for India (or some Indian States at least) to take the plunge.

Significance of Universal Health Coverage

• Universal health coverage has a direct impact on a population’s health and welfare.
• Access and use of health services enables people to be more productive and active contributors to their families and communities.
• It also ensures that children can go to school and learn.
• At the same time, financial risk protection prevents people from being pushed into poverty when they have to pay for health services out of their own pockets.
• Universal health coverage is thus a critical component of sustainable development and poverty reduction, and a key element of any effort to reduce social inequities.
• Universal coverage is the hallmark of a government’s commitment to improve the wellbeing of all its citizens.

What are the Routes to Achieve UHC?

• UHC typically relies on one or both of two basic approaches: public service and social insurance. In the first approach, health care is provided as a free public service, just like the services of a fire brigade or public library.
• The second approach (social insurance) allows private as well as public provision of health care, but the costs are mostly borne by the social insurance fund(s), not the patient,
  • Quite different from a private insurance market, it is the one where insurance is compulsory and universal, financed mainly from general taxation, and run by a single non-profit agency in the public interest.
    • The basic principle is that everyone should be covered and insurance should be geared to the public interest rather than private profit.

What are the Challenges to UHC?

• Unavailability of Public Health Centres: Even in a system based on social insurance, public service plays an essential role. The absence of public health centres, dedicated to primary health care and preventive work, create the risks of patients rushing to expensive hospitals every other day thus making the whole system wasteful and expensive.
• Containing Costs: Containing costs is a major challenge with social insurance, because patients and health-care providers have a joint interest in expensive care — getting better healthcare for one and earning for the other.
  • A possible remedy is to make the patient bear part of the costs but that conflicts with the principle of UHC.
  • Recent evidence suggests that even small co-payments often exclude many poor patients from quality health care.
• Identifying Services under UHC: Another big challenge remains in identifying what services are to be universally provided to begin with and what level of financial protection is considered acceptable.
  • Offering the same set of services to the entire population is not economically feasible and demands huge resource mobilisation.
• Regulation of Private Sector: Another challenge with social insurance is to regulate private health-care providers. A crucial distinction needs to be made between for-profit and nonprofit providers.
  • Non-profit health-care providers have done great work around the world
  • For-profit health care, however, is deeply problematic because of the pervasive conflict between the profit motive and the well-being of the patient.

What is the HOPS Framework and How will it Help Achieve UHC?

• It is possible to envisage a framework for UHC that would build primarily on health care as a public service. The framework might be called “Healthcare As An Optional Public Service” (HOPS).
  • Under HOPS, everyone would have a legal right to receive free, quality health care in a public institution if they wish. It would not prevent anyone from seeking health care from the private sector at their own expense.
  • But the public sector would guarantee decent health services to everyone as a matter of right, free of cost.
• Example: Some Indian States are already doing so, such as in Kerala and Tamil Nadu, most illnesses can be satisfactorily treated in the public sector at little cost to the patient.
• Significance: If quality health care is available for free in the public sector, most patients will have little reason to go to the private sector.
  • Social insurance could also play a role in this framework by helping cover procedures that are not easily available in the public sector (e.g., high-end surgeries).
  • Although HOPS would not be as egalitarian as the national health insurance model initially, it would still be a big step toward UHC.
    • Moreover, it will become more egalitarian over time, as the public sector provides a growing range of health services.

Steps taken up currently related to health sector

• The National Health Policy (NHP) 2017 advocated allocating resources of up to two-thirds or more to primary care as it enunciated the goal of achieving “the highest possible level of good health and well-being, through a preventive and promotive healthcare orientation”.
• A 167% increase in allocation this year for the Pradhan Mantri Jan Arogya Yojana (PMJAY) — the insurance programme which aims to cover 10 crore poor families for hospitalisation expenses of up to ₹5 lakh per family per annum.
• The government’s recent steps to incentivise the private sector to open hospitals in Tier II and Tier III cities.
• Individual states are adopting technology to support health-insurance schemes. For instance, Remedinet Technology (India’s first completely electronic cashless health insurance claims processing network) has been signed on as the technology partner for the Karnataka Government’s recently announced cashless health insurance schemes.

PPP model for providing Universal Health Care

Prospects:

• Enhancing affordability: There has been a steady increase in the number of drugs under price control, to make medicines affordable.
• Enhances Inclusivity: It’s difficult for government alone to meet the healthcare infrastructure and capacity gaps in Tier II and Tier III cities as well as rural areas. To provide Health insurance- Karnataka’s Yeshasvini Cooperative Farmer’s Healthcare Scheme and Andhra Pradesh’s Arogya Raksha Scheme can be cited as successful examples.
• Financing Mechanism: The partnership between the public and the private sectors in healthcare is important for several reasons including equity and for promoting economic development.
• Infrastructure: NITI Aayog has sought to infuse fresh life into PPP in healthcare delivery through a new model focused on district hospitals and new norms on pricing of procedures. The provisions for making available infrastructure of district hospitals to private providers for 30 years along with viability gap funding appears that we have got the design right for the PPP model.
• Quality of Service: Private healthcare in India usually offers quality service but is often expensive and largely unregulated. The Delhi government’s new scheme is a novelty for the common man but has a precedent in several government schemes for employees which use public funds to provide private healthcare. e.g the Central Government Health Scheme (CGHS) has existed for decades and has been emulated by several states.
• Capacity building and training: private players can play a key role in capacity building and training through PPP modes by  working  with  the  public  sector  to  better  utilize  the  infrastructure  of  government

Issues in public private partnership

• There lack of inbuilt mechanism to decide how the government and the private sector share revenue and risks.
• Aim of Private sector is to maximize profit, which is inconsonance with governments aim of providing universal quality services to all
• Lack of a proper regulatory framework to regulate the health sector and partnership.
• Some PPP projects attempted earlier have failed, so there is apprehension about success of large scale PPP in health sector.

Measures needed:

• Staunch and well-defined governance: An institutional structure should be set up to foster, monitor and evaluate the PPPs. This needs to be established at the state-level under the leadership of the state health ministry.
• Equitable representation of partners in the institutional framework: Institutional structure is a cornerstone for development of a sustainable PPP project. It will help to meet consensus on shared responsibilities and roles and will facilitate communication among the partners leading to a strong sense of ownership and trust.
• Evidence-based PPP: Systematic research initiatives and mechanisms must be established to constantly understand the evolving needs and benefits to end users.
• Regulate user fee: One of the hurdles of engaging the private providers for public health service delivery is OOP expenditure. Therefore, it is important to regulate user fees of this sector under partnership.
• Effective risk allocation and sharing: Risks shall be allocated to the party best able to control and manage them so that value for money is maximised.

Way Forward

• Vibrant Health System: A vibrant health system shall include not only good management and adequate resources but also a sound work culture and professional ethics.
  • A primary health centre can work wonders, but only if doctors and nurses are on the job and care for the patients.
• Standards for UHC: The main difficulty with the HOPS framework is to specify the scope of the proposed health-care guarantee, including quality standards. UHC does not mean unlimited health care: there are always limits to what can be guaranteed to everyone.
  • HOPS shall lay down certain health-care standards along with a credible method to revise these standards over time. Some useful elements are already available, such as the Indian Public Health Standards.
• State Specific Legislation on Health: Tamil Nadu is well placed to make HOPS a reality under its proposed Right to Health Bill. The state is already successful in providing most health services in the public sector with good effect.
  • A Right to Health Bill would be an invaluable affirmation of the State’s commitment to quality health care for all; it would empower patients and their families to demand quality services, helping to improve the system further.
  • Tamil Nadu’s initiative could be an emulation for other states.
• Health Financing: In order to achieve UHC, it is vital that governments intervene in their country’s health financing system to support the poor and vulnerable.
  • This requires establishing compulsory publicly governed health financing systems with a strong role for the state in raising funds fairly, pooling resources and purchasing services to meet population needs.
  • Greater targeted financing for public health systems will help tackle inherent weaknesses around quality of care and access, reduce out of pocket spending on drugs and improve human resource and infrastructure shortfalls.