Universal Health Coverage In India Is Still A Long Way To Go, Say Experts

New Delhi: “Universal Health Coverage (UHC) means that all individuals and communities, receive the health services they need without suffering financial hardship,” says the World Health Organization (WHO). UHC includes a range of essential health services, from health promotion to prevention, treatment, rehabilitation, as well as palliative care for lifetime.

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The delivery of these services require adequate and competent healthcare workers with optimal skills at facility, outreach and community level. They must be equitably distributed and adequately supported, according to WHO.

It further explains that UHC strategies enable everyone to access the services that address the most significant causes of disease and death. Moreover, it ensures that the quality of those services is good enough to improve the health of the people who receive them.

The idea of coverage in UHC is considered as a fundamental right of all the people under the Article 21 of the Indian constitution – Right To Life – and not just a benefit restricted by income, occupation, or social criteria.

Dr Nalini Trivedi, Public Health Expert from Bhopal explains,

The concept of UHC for India is not new, in fact it was imagined back in 1946 by the landmark Bhore Committee Report, which talked about a country where no individual would fail to secure adequate health care because of inability to pay for it. However, several decades down the line, health expenditure is still a factor that either pushes the economically disadvantaged population of India into further poverty or they are simply unable to afford quality healthcare.

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Dr Pavitra Mohan, Secretary – Basic HealthCare Services at Public Health Foundation of India shared the example of his on-ground experience of working with the people of rural Rajasthan, with NDTV.

In remote, rural  areas of Rajasthan we work in, we see many people either not able to access healthcare, which is often far, expensive and unresponsive; or falling in debt trap on account of expenditure on healthcare. India has committed to provide universal healthcare coverage. In practice, however, families with limited means in rural and urban areas continue to face huge discrimination in accessing healthcare. This is because of inadequate budgetary allocations to healthcare (we continue to hover around 1 per cent of GDP), despite the fact that COVID pandemic highlighted the importance of strong health systems. States such as Kerala that had strong public health systems were able to manage the pandemic much better than those where public systems were weak. Even now, COVID vaccination is largely being driven by public system, he said.

Dr Trivedi too, points out that UHC requires adequate healthcare financing and human resources to provide financial protection to the underprivileged by covering their medicine, diagnostics, and service costs.

Only sufficient governmental spending can ensure UHC, as individual voluntary insurance schemes are inadequate even in the developed world. However, ensuring sufficient healthcare in developing country remains a major challenge, since the government spending on healthcare is low, she adds.

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In India, in light of the COVID-19 pandemic, the government in the financial year 2021-22, announced an increase in the budget for ‘health and well being’ by a whopping 137 per cent. Union Finance Minister Nirmala Sitharaman announced the allocation for ‘health and wellbeing’ at Rs. 2.23 lakh crore (Rs. 2,23,846 crore) from the previous year’s budget estimate of over Rs. 94,000 crore (Rs. 94,452 crore).

A closer look at the breakup of these numbers show that when it comes to ‘health and wellbeing’, this allocation was distributed among Ministry of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy (AYUSH), the entire budget for the Department of Drinking Water and Sanitation (D/o W&S) under the Ministry of Jal Shakti, the budget allocated for POSHAN Abhiyaan (or National Nutrition Mission) under the Ministry of Women and Child Development (MWCD), Ministry of Health, Finance Commission (FC) grants for Drinking water and sanitation and health and the one time grant for COVID-19 vaccines.

Allocation under Ayushman Bharat or the Pradhan Mantri Jan Arogya Yojna (PMJAY), which aims to provide UHC, has more than doubled from Rs 3,100 crore in 2020-21 to Rs. 6,400 in 2021-22.

In December 2020, during his address at the WHO’s virtual event for the International Universal Health Coverage Day 2020, Dr Harsh Vardhan, Union Minister of Health & Family Welfare, gave an overview of the work done under the Ayushman Bharat. The programme has two wings – the Health and Wellness Centres (HWCs) and the Pradhan Mantri Jan Aarogya Yojana (PMJAY). Dr Vardhan shared that the government has been making quality healthcare affordable and accessible for crores of people in the country, he said,

We have made remarkable progress in operationalising Ayushman Bharat – Health and Wellness Centers and crossed a major landmark in our journey. With 51,500 centers now functional, more than 1/3 rd of the target has been met. This has led to improved access to affordable primary healthcare services for more than 25 crore people. It is our aim to establish 1.5 lakh such centers by December 2022. This also includes 12, 500 AYUSH Health and Wellness Centers being set up by Ministry of AYUSH.

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Dr Harsh Vardhan further added that we must settle for nothing less than strong health systems that protect everyone.

It has been my long-standing belief that India has the ability to deliver to the world, a robust model for providing Universal Health Coverage.

Dr Mohan says that the underfunded public health systems in India are not able to realise their potential. He explained,

Even the meagre allocations on health are increasingly being diverted towards secondary and tertiary care through insurance (such as PMJAY or its state equivalent); and not on primary healthcare. For example, in Rajasthan state health budget, while the allocations on health insurance have increased, funding for National Health Mission has remained largely same. It is well known that countries that invest in primary health care have not only better health outcomes, but also have more equitable health outcomes, that is, rich and poor enjoy similar levels of care.

Dr Mohan also says that UHC in India will remain a dream, especially for the poor, unless the budgetary allocations are significantly increased and public health systems, especially primary healthcare, are strengthened.

Such investments will help ensure improved health for every resident, as well as ensure that any crisis such as COVID pandemic is tackled well, he added.

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Dr Trivedi says that the major barriers in achieving UHC in India remain inadequate public healthcare financing and the lack of skilled human resources.

To strengthen the Indian healthcare system, we can see the significant increase in budgetary allocation towards healthcare, a national health protection scheme targeting low-income households, upgrading of primary health-care and expansion of the health work-force. However, we need an evolving model for improving holistic health, nutrition, sanitation, medicine accessibility and affordability, initiatives in national health programs to reduce maternal deaths, tuberculosis and HIV burden as well as the utilisation of technology in healthcare sector. These represent a genuine innovation towards fulfilment of UHC for India, Dr Trivedi said.

When it comes to the shortcomings in skilled human resources for healthcare sectors in India, Dr Trivedi refers to a study that was published in the journal PUBMED titled – ‘Doctor population ratio for India – The reality’.

As per this study, India has only 0.7 physicians per 1000 persons and 1.8 nurses/midwives per 1000 persons against the recommended norms of 1:1000 and 4:1000, respectively. Moreover, the distribution of health resources is rather scattered, with a shortage of doctors in rural areas despite governmental measures to retain doctors in rural India. The lack of healthcare workers in rural areas is then fulfilled by unlicensed practitioners who may or may not have of any strong medical qualifications, Dr Trivedi signed out.

NDTV – Dettol Banega Swasth India campaign is an extension of the five-year-old Banega Swachh India initiative helmed by Campaign Ambassador Amitabh Bachchan. It aims to spread awareness about critical health issues facing the country. In wake of the current COVID-19 pandemic, the need for WASH (Water, Sanitation and Hygiene) is reaffirmed as handwashing is one of the ways to prevent Coronavirus infection and other diseases. The campaign highlights the importance of nutrition and healthcare for women and children to prevent maternal and child mortality, fight malnutrition, stunting, wasting, anaemia and disease prevention through vaccines. Importance of programmes like Public Distribution System (PDS), Mid-day Meal Scheme, POSHAN Abhiyan and the role of Aganwadis and ASHA workers are also covered. Only a Swachh or clean India where toilets are used and open defecation free (ODF) status achieved as part of the Swachh Bharat Abhiyan launched by Prime Minister Narendra Modi in 2014, can eradicate diseases like diahorrea and become a Swasth or healthy India. The campaign will continue to cover issues like air pollution, waste management, plastic ban, manual scavenging and sanitation workers and menstrual hygiene.