Universal Health Coverage for India by 2022: A Utopia or Reality?

Abstract

It is the obligation of the state to provide free and universal access to quality health-care services to its citizens. India continues to be among the countries of the world that have a high burden of diseases. The various health program and policies in the past have not been able to achieve the desired goals and objectives. 65^th World Health Assembly in Geneva identified universal health coverage (UHC) as the key imperative for all countries to consolidate the public health advances. Accordingly, Planning Commission of India constituted a high level expert group (HLEG) on UHC in October 2010. HLEG submitted its report in Nov 2011 to Planning Commission on UHC for India by 2022. The recommendations for the provision of UHC pertain to the critical areas such as health financing, health infrastructure, health services norms, skilled human resources, access to medicines and vaccines, management and institutional reforms, and community participation. India faces enormous challenges to achieve UHC by 2022 such as high disease prevalence, issues of gender equality, unregulated and fragmented health-care delivery system, non-availability of adequate skilled human resource, vast social determinants of health, inadequate finances, lack of inter-sectoral co-ordination and various political pull and push of different forces, and interests. These challenges can be met by a paradigm shift in health policies and programs in favor of vulnerable population groups, restructuring of public health cadres, reorientation of undergraduate medical education, more emphasis on public health research, and extensive education campaigns. There are still areas of concern in fulfilling the objectives of achieving UHC by 2022 regarding financing model for health-care delivery, entitlement package, cost of health-care interventions and declining state budgets. However, the Government's commitment to provide adequate finances, recent bold social policy initiatives and enactments such as food security bill, enhanced participation by civil society in all health matters, major initiative by some states such as Tamil Nadu to improve health, water, and sanitation services are good enough reasons for hope that UHC can be achieved by 2022. However, in the absence of sustained financial support, strong political will and leadership, dedicated involvement of all stakeholders and community participation, attainment of UHC by 2022 will remain a Utopia.

Introduction

Government of India and the State Governments have the general obligation to provide free and universal access to the health-care services and ensure that there shall not be any denial of health-care directly or indirectly to anyone, by any health-care service provider, public or private, by laying down minimum standards and appropriate regulatory mechanism.(1) The 11^th Plan health outcome indicators set as time-bound goals for lowering maternal and infant mortality, malnutrition among children, anemia among women and girls, fertility, and raising the child sex ratio have not been fully met. India trails in health outcomes behind Sri Lanka and Bangladesh. The health-care system in the country suffers from inadequate funding, lack of integration between disease control and other social sector programs, suboptimal use of traditional systems of medicines, weak regulatory mechanisms and poor capacity in health management. There are wide interstate disparity and differences between rural and urban indicators of health.(2)

The twelfth plan seeks to provide a safe and healthy environment to communities, delivering universal access to basic health services, and to medicines, and regularly evaluating the health system. It also seeks to make the communities more health conscious by using the techniques of communication, behavior change, and participatory governance.(3)

The 65^th World Health Assembly meeting in Geneva identified universal health coverage (UHC) as a key imperative for all countries to consolidate the public health advances. Several countries have been working to reform their health systems during the last few decades. The high level expert group (HLEG) on UHC was constituted by the planning Commission of India in October 2010, with the mandate of developing a frame-work for providing easily accessible and affordable health-care to all Indians. HLEG submitted its report to the planning commission in November 2011.(4) Keeping in view the outcomes of recommendations of previous many other committees, National health policies and programs, whether the recommendations of HLEG will have desired outcomes or remain a Utopia is the moot question to ponder over.

Health-care

Means testing, treatment, care, procedures, and any other service or intervention toward a therapeutic, nursing, rehabilitative, palliative, convalescent, preventive, diagnostic, research, and/or other health related or combinations thereof, including reproductive health-care and emergency medical treatment, in any system of medicine, and also includes any of these as a result of participation in a medical research program.(1)

UHC

Ensuring equitable access for all Indian Citizens, regardless of income level, social status, gender, caste or religion, to affordable, accountable, appropriate health services of assured quality as well as public health services addressing the wider determinants of health delivered to individuals and populations, with the Government being the guarantor and enabler, although not necessarily the only provider, of health and related services.(4)

Universal access

It is a concept, which implies, the absence of geographic, financial, organizational, socio-cultural and gender based barriers to care.(5)

Critical Areas for Provision of UHC

The critical areas for the provision of Universal Coverage as per HLEG recommendations, which need to be addressed include, health financing, health infrastructure, health services norms, skilled human resources for health (HRH) access to medicines, vaccines and technology, management and institutional reforms, and Community Participation. The key recommendations of HLEG are as follows:(4)

Health financing

There should be an increase in spending for public procurement of medicines from 0.1% to 0.5% of Gross Domestic Product (GDP). General taxation plus deductions for health-care from salaried individuals and tax-payers as the principal source of health-care financing should be used, and no fees of any kind be levied for the provision of health-care services under UHC. There should be flexibility in central financing to help meet diverse health requirements of states and at least 70% of all health-care spending should go to primary health-care. No insurance companies or other agencies should be used to the purchase health-care services on behalf of the Government and all Government funded Insurance Schemes should be integrated with the UHC system. Government should an increase public expenditure on health from the current level of 1.2% GDP to at least 2.5% by the end of the 12^th plan and to at least 3% of GDP by 2022.

Health services norms

National Health Package offering essential health services as part of citizen entitlement should be developed and a system of National Health Entitlement Cards to be introduced. Well defined service delivery partnership with Government. As purchaser and private sector as provider under strong regulation, accreditation and supervisory framework should be ensured. The district hospitals network to be strengthened and upgraded for health-care delivery and training. All health facilities to be licensed by 2017 to comply with the latest Indian Public Health Standards. In Urban areas, there is a need to rationalize services and focus on health needs of the poor. It should be ensured that all citizens have an entitlement to the same level of essential health-care strictly adhering to the quality assurance standards.

HRH

Adequate numbers of trained health-care providers and technical health-care workers should be ensured by giving primacy to Primary Health-Care, increasing HRH density to achieve World Health Organization norms of at least 23 health workers (Doctors, Nurses, Auxiliary Nurse Midwives)/10,000 population, as well as recruiting adequate number of dentists, pharmacists, physiotherapists, technicians, and other allied health professionals at appropriate levels of health-care delivery, strengthening existing State Regional Institutes of Family Welfare State, establishing District Health Knowledge Institutes, Health Science Universities, and National Council for Human Resources in Health.

Community participation

Existing village and health sanitation committees should be transformed into participating health councils. The role of elected representatives, Panchayat Raj Institutions in rural areas and local bodies in urban areas should be enhanced. Regular health assemblies at different levels to enable community review of health plans and their performance should be organized. Civil society and non-governmental organizations should be strengthened and utilized to contribute effectively for community mobilization, information dissemination; community based monitoring of health services. A system of the formal grievance redresssal mechanism should be instituted at the block level to deal with confidential complaints and grievances about the health services.

Access to medicines and vaccines

Price control and price regulation on essential and commonly prescribed drugs should be enforced. The essential drugs list should be revised and extended and rational use of drugs should be ensured. The public sector to be strengthened to protect the domestic drug and vaccine industry to meet national needs and the Ministry of Health and Family Welfare should be empowered to strengthen the drug regulatory system.

Management and institutional reforms

The public health sector should assume the roles of promoter, provider, contractor, regulator, and steward. Good referral systems, better transportation, improved management of human resources, robust supply chains and data, and upgraded facilities should be ensured. This could be done by introducing, All India and State Public Health Cadres, adopting better human resource practices, developing a national health information technology network, streamlining regular fund flow and ensuring accountability to patients and communities. To achieve the above reforms establishment of National Health Regulatory and Development Authority having a system support unit, a National Health and Medical Facil ities Accreditation Unit and Health System Evaluation Unit have been recommended. In addition, establishment of a National Drug Regulatory and Development Authority to regulate pharmaceuticals and medical devices as well as National Health Promotion and Protection Trust to facilitate the promotion of better health culture amongst people, health providers and policy makers has also been recommended.

Challenges to achieve UHC by 2022

There are a number of challenges to be overcome to achieve UHC by 2022 such as the largest disease burden in the world,(6) reproductive and child health problems, malnutrition,(7,8) issues of gender equality,(9) poor availability of trained human resources in health,(10) inadequate research to achieve health-care for all(11) commercialized, fragmented, and unregulated health-care delivery systems,(12,13,14) inequalities in access to health-care,(15) imbalance in resource allocation, high out of pocket health expenditures,(16,17) rising ageing population, social determinants of health such as poverty, illiteracy, alcoholism etc.,(18) too frequent and too severe natural disasters, lack of inter-sectoral co-ordination and political pull and push of different forces and interests.

Way Forward

Through a paradigm shift in the planning, implementation and monitoring of the health-care delivery, there can be a way forward for ensuring UHC for India by 2022 by according priority to the needs of the most deprived groups, improving non-medical preventive health action related to employment, incomes, food security, water and sanitation, removing constraints in the health seeking behavior of people, improving outlay on health to 5-6% of GDP at the rate of Rs. 2000/capita/year,(19,20) augmenting the existing network of health-care delivery system especially in rural, tribal and inaccessible areas, intensive use of technology for diagnosis, pricing, and quality control, regulating public private partnerships with clear definitions of shared objectives and priorities, rewarding the states financially for recording improved health outcomes,(21) planning of HRH based on local epidemiological needs, health-care needs and cost effectiveness, transparency in mapping and estimating the pattern of health-care services required in each district,(22) restructuring the cadre structure for public health workers, reorienting medical undergraduate education toward public health and sustained intensive health education campaigns.

Areas of Concern

The key areas of concern in fulfilling the objectives of achieving UHC by 2022, which remain to be addressed include broad agreement on the financing model for health-care delivery; type and duration of training for senior functionaries in public health, entitlement package and the cost of health-care interventions, enactment of National Health Bill 2009 as Health Act and declining State budget allocations for public health.

Reasons for Hope

Global experience has shown that Universal Health-Care is affordable and feasible. The political will reflected by the Government's commitment for higher allocation of resources, recent bold social policy initiatives and enactments such as Mahatma Gandhi National Rural Employment Guarantee Act 2005, Disaster Management Act 2005, Clinical Establishments (Registration Regulation) Act 2012, Fundamental Right to Education 2012 and Food Security Bill 2012 will help in reducing the burden of disease and sufferings by generation of more employment, alleviation of poverty, improvement of literacy etc., Enhanced participation by civil society in all health matters, success of polio elimination, smallpox and guinea worm eradication, and a major initiative to bring rigorous quality control measures in Maternal and Child Health services in Primary Health Centres in Tamil Nadu(23) are good enough reasons for hope that UHC can be achieved by 2022.

Conclusion

The needs of the health sector in the context of India's diversity are so complex that it is rather impossible to engage with all its dimensions. The Indian people deserve desire and demand an efficient and equitable health system which can provide UHC. This needs sustained financial support, strong political will and leadership, dedication of public health functionaries and other stake holders as well as active participation of the community in the absence of which the realization of the goal of achieving UHC by 2022 will remain a Utopia.