Universal health coverage - There is more to it than meets the eye

Dear Editor,

We congratulate the Journal of Family Medicine and Primary Care for their continuing discourse and articles on Universal Health Coverage (UHC).[1,2,3] We were especially impressed by many pertinent issues raised by Kumar and Roy in the last issue of the journal.[1] While India depends on a flourishing private healthcare industry, one wonders whether public interest policies such as the UHC will be left alone without conceding to their interests. At a time, when there is a lot of ongoing debate on the continuance and budgeting of National Health System of the United Kingdom, when dilution of Universal Health Care is being discussed in developed nations, the ostensible push toward UHC in countries such as India may be because of the epidemiological transitions such as projected rise of noncommunicable diseases in India, signalling a potentially lucrative business opportunity for the global health industry.[1]

Apart from the arguable intents behind the UHC, we believe that it would be naïve to assume that UHC plan for India is the same as universal (and comprehensive) health care, or an extension to “Health for all” based on primary healthcare policies. Universal Health Coverage, as opposed to Universal Health Care, has a completely different logic. The word “coverage” itself finds its origin in the insurance sector and supports a selective and medicalized approach to health. As highlighted by Sengupta, the beneficiaries of health insurances may be insured for hospitalization requiring ailments but not for diseases that are treated in outpatient clinics, especially chronic diseases such as tuberculosis, diabetes, and cancer, which constitute a huge disease burden in India.[4] Consequently, this selectivity is neither motivated by the local public health burden nor cost-efficiency, both being supremely important for a developing country like India. Rather, the insurance-based health financing is extremely vulnerable to exploitation by the private healthcare industry for profit. The Arogyasri insurance scheme in Andhra Pradesh is a case in point, where a “coverage” meant only 2% of the burden of diseases at an exorbitant cost utilizing 25% of state health budget.[5]

Not only can this make healthcare expensive in a country known for its cost effectivity - which makes it a hub for medical tourism; but it also weakens the existing public health system because of the greater likelihood of people opting for private healthcare. Should such a model persist, the private healthcare will maximize their profits by taking more cost-effective cases and pushing the chronic, complicated, and cost-ineffective ones to the already burdened public health system. Furthermore, despite the momentum and progress around the UHC, it is safe to assume that the continued neglect of the elements of primary health care as outlined in the Alma-Ata will stay the same.[6] Previous research have pointed out that a tax-based public health system ensures more health equity and comprehensiveness and is more affordable to low- and middle-income countries than the “insurance”-based UHC.[4,7]

We agree with the authors that despite the limitations of National Health Mission, together with the Indian Public Health Standards, it has strengthened the public health system of the country.[1] Therefore, the UHC should focus and consolidate on the gains of National Health Mission and strengthen the primary health care further, rather than presenting the Indian health care as a potentially profitable venture for private players. The essential elements for the proposed UHC should include the ingredients highlighted by the authors, especially financial cover for outpatient care and gatekeeping of tertiary-care facilities.[1,8] Much needs to be discussed and debated, and the Indian public health journals should take a cue from the Journal of Family Medicine and Primary Care and continue further academic discussions on UHC because any future health budget increase is likely to be spent on UHC.[1] In the absence of such analysis and discussions, the UHC in India may prove to be a failure of commitment at best, or another highly profitable venture for private healthcare at the cost of government's money at worst.

In an ode to the demise of Dr. Halfdan Mahler, the third Director-General of the World Health Organization and a true champion of primary health care and public health, it is worthwhile to remember what he said in his address to the 61^st World Health Assembly in 2008, “The Health Universe is only complete for those who see it in a complete light, it remains fragmented for those who see it in fragmented light!”[9]

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Conflicts of interest

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