Universal Health Coverage and AYUSH systems

1. New India budget

The New India's Budget 2018–19 is projected as ‘budget for growth and prosperity’. Claimed to be the world's largest government funded health care program with ambitious initiatives such as Ayushman Bharat (AB) and National Health Protection Scheme (NHPS), the government is aiming to transform the public health care system. The AB initiative aims at comprehensive health care, establishment of 150,000 wellness centers, management of non-communicable diseases, mother and child health services along with free essential drugs and diagnostic services. The NHPS aims at insurance cover for 100 million households for secondary and tertiary care hospitalization. While the AB initiative focuses on health assurance, the NHPS will provide health insurance. The success of these ambitious initiatives will depend on careful design, execution and maximum governance as well as mainstreaming the potential of AYUSH as envisaged by the National Health Policy 2017. J-AIM welcomes these initiatives and appreciates the reasonable increase in the budget allotment for the Ministry of AYUSH.

These initiatives need to be viewed in the light of few contemporary developments. A recent global monitoring report by the World Health Organization (WHO) and World Bank reveals that half of world's population does not have access to essential health services. The United Nations through the Sustainable Development Goals (SDGs) has given a universal call for action to end poverty, protect the planet and ensure that all people enjoy peace and prosperity. The rapidly growing burden of lifestyle and non-communicable diseases (NCDs) is indicating increasingly more limitations of current therapeutic approaches mainly based on pharmaceutical medicine. The concept of ‘Universal Health Coverage’ (UHC) embraced by WHO declares health as a fundamental human right and commits to ensuring the highest attainable level of health for all.

2. Universal Health Coverage

The theme of World Health Day 2018 is ‘Universal Health Coverage: Everyone, Everywhere’. This, in a way, is re-endorsement of the 1948 WHO Constitution and Alma Ata declaration ‘Health for All by 2000 AD’. While during last seven decades the WHO has contributed to influencing national policy building for healthier world, ‘Health for All’ seem to be too distant a dream. The gulf between potential healthcare services and technologies and their access to people is widening. The challenge of healthy planet seems to be shifting its goal post. The advances in medicine, surgery, devices, technologies and discovery of new drugs have not yet translated in making world healthier.

The UHC initiative reiterates commitment for providing health services for all the people without suffering any financial hardship. It also envisages promotive, preventive, curative, rehabilitative and palliative services for betterment of public health [1]. The universal health coverage cannot be assured merely through medicines, treatments, hospitals and insurance provisions. Today 70% of population spends out of own pockets for basic health care thus facing financial hardship. The UHC while not meeting basic health needs also aims to promote equity, development priorities, and social inclusion and cohesion. This appears unreal and unreachable.

The common notion of ‘health care’ systems in India is dominated by ‘medical care’ services consisting of doctors, clinics, diagnostic and hospitals. In fact, this is quite contrary to our cultural underpinning stemmed on principle of Swasthyasya Swastha Rakshanam. Undoubtedly, a fresh perspective is needed for upgrading public health systems and transforming mindsets of planners in favor of health protection and assurance.

3. AYUSH and UHC

The High Level Expert Group on UHC appointed by the Planning Commission in 2010 could not make much dent as it grossly ignored value of AYUSH systems. The WHO recognizes that each country is unique, thus need to focus on own priorities and develop its own ways to achieve UHC. Therefore, India must develop own strategy for UHC pivoted to its culture and traditional medicine practices comprising AYUSH systems. There is emerging consensus that inclusion of traditional and complementary medicine (T&CM) services might help to empower people to be proactive to take charge of their health and health system. The WHO Traditional Medicine Strategy 2014–2023 emphasizes importance of harnessing traditional knowledge for achieving universal health care. It recommends that member states should develop policies, regulations and guidelines for mainstreaming potential of T&CM for improving health care delivery systems, progressing towards wellness and people centric services.

India has unique opportunity to demonstrate role of AYUSH systems in transforming current health scenario first in India and then globally. The healthcare choices on the ground in India are pluralistic as the concepts and practices of AYUSH systems are deeply rooted in its culture. The pluralistic foundation provides the required base for integration. The phenomenon of integration is mostly therapeutic, patient driven but generally lacks appropriate strategies, policies and protocols. This is an opportunity for stakeholders of AYUSH systems to address public health challenges. Recent studies suggest that AYUSH systems can play an important role for planning healthcare customized to the needs and context of the society [2].

The world morbidity statistics indicates urgent need for prevention and control of NCDs as the most important targets of UHC. Integrative interventions based on Ayurveda (diet and lifestyle modification) and Yoga (mind and body synergy) can play significant role in prevention of NCDs. Value of AYUSH systems is receiving global appreciation. For instance, the International AYUSH conference 2017 organized in Dubai received overwhelming response. The Ministry of Health, Government of Brazil is hosting 3rd International Ayurveda Conference in March 2018 at Rio de Janeiro followed by 3rd International conference on Integrative Medicine in June 2018 on theme ‘role of Ayurveda and Yoga in cancer and palliative care, at Harvard.

The evidence based integration of modern medicine and AYUSH systems can prevent enormous loss of lives and resources. Already some efforts in this direction are in progress in India and abroad. For instance, S-VYASA Bengaluru has undertaken large studies on integrative management of diabetes and cancer. Prestigious international institutions including Harvard Medical School, Massachusetts General Hospital, University of California at San Francisco, MD Anderson Cancer Center, Memorial Sloan Kettering Cancer Center are involved in collaborative research on Yoga and Ayurveda. Interest in Yoga and Ayurveda research is increasing globally among government bodies and institutions. It is heartening to note that visionary medical scientist like Dr Soumya Swaminathan is inducted as Deputy Director General of WHO while J-AIM Editor and eminent Ayurveda scholar Dr Geeta Krishnan is now representing India at the WHO headquarter in Geneva.

4. Assurance and insurance

In today's medicalized society, importance of health insurance to cover ever increasing costs of treatments cannot be ignored. However, the health protection cannot be guaranteed through insurance. We need to learn from experiences of other countries where health care services are linked to insurance industries. Health protection can be best obtained by strengthening public health infrastructure. The first task of any government should be to provide assurance of health protection. A simple principle that must be followed is ‘insurance follows assurance’. The AB and NHPS schemes should be designed around Indian strengths and needs where health assurance strategies are given top priority with a focus on disease prevention, human behavior, nutrition, maternal child health and needs of aging population. Current model of health care seem to be based more on creating ‘health scare’ and the business of medical industry appears to be inked to ill health of the people. There is growing realization that such a model will be difficult to sustain for long. The new business models of pharmaceutical and medical establishments are likely to be based on health protection than disease treatments. Innovative steps in the direction of positive insurance can be imagined where wellness credit or incentives for healthier behavior are offered. Inclusion of Swasthavritta based programs and adherence to Yoga can be considered as incentives for insurance. Emerging field of health technology assessment will contribute for evaluation of social, economic, and ethical issues of health interventions.

J-AIM has already proposed vision and strategy regarding AYUSH for New India [3]. The sustainable development goals and universal health coverage can be a reality only if we effectively implement AB and NHPS in the right spirit by mainstreaming the potentials of AYUSH systems to transform Indian health care. This can be achieved mainly by strengthening the state public health system to provide health assurance. This is an opportunity to build New India's innovative health care model that provides assurance of insurance cover for hospitalization to poor and utilizes strengths of AYUSH systems for health assurance to all.