The road to universal health coverage: an overview of global and Indian scenarios

INTRODUCTION

The enjoyment of the highest attainable standard of health” which, as stated in WHOs constitution, is “one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.¹ This has been the objective that guided worldwide health care policies for three decades until the advancements made towards WHOs “Health for All” programme and the “Alma Ata Declaration” of 1978.² Addressing various health related issues through primary health care by providing equitable access to comprehensive health services to the communities was emphasised in the “Alma Ata Declaration”.³ Later on, the declaration of World Health Assembly in the year 2005 paved the way for all the member states to plan for the transition towards universal coverage to their respective citizens. This was underpinned by the notion that access to quality basic and essential health services has to be made available for everyone to combat poverty and to achieve the developmental goals worldwide.⁴ This global movement towards universal coverage is considered as one of the greatest transitions in health, the other being the demographic transition and epidemiological transition.^5,6

UNIVERSAL HEALTH COVERAGE

The key and essential way to human welfare and sustained economic, social development is by promoting and protecting health. Alma-Ata Declaration Signatories have recognised this more than 30 years ago. They noted that Health for All would definitely contribute both to a better quality of life and also to peace and security at the global level. But providing timely access to health services such as promotion, prevention, treatment and rehabilitation is also critical. This cannot be achieved, except for a small minority of the population, without a well-functioning health financing system. It determines whether people can afford to use health services when they need them and also determines if the services exist. Recognising this, Member States of the World Health Organisation (WHO) committed in 2005 to develop their health financing systems so that all people have access to services and do not suffer financial hardship paying for them. This goal was defined as universal coverage, sometimes called Universal Health Coverage (UHC).⁷

WHO constitution declaring the health as a fundamental human right and Alma-Ata declaration of Health for All agenda forms the firm basis for UHC.⁸ The resolution taken by the general assembly of United Nations (UN) in 2012 also have reiterated on the importance of equitable access to health-related services along with ensuring financial risk protection as the basis for achieving UHC.³

UNIVERSAL HEALTH COVERAGE - GLOBAL SCENARIO

The concept of UHC can be traced back to Europe in the 19th century when several ground-breaking reforms were introduced by in Germany by Bismarck. Also, the Beveridge Report helped in steering several reforms in Britain. This lead Aneurin Bevan in 1948 to introduce National Health Service (NHS). Since then, universal access to affordable healthcare has become a commonly shared ambition throughout the world. These changes were more and more widespread in the last 10 years where advance in this path was seen in many low and middle-income countries. Few such advances were the announcement of 100% coverage by Mexico, announcement of their own health coverage schemes by China and South Africa in late 2012. Since then, all the member states of United Nations (UN) around the world have adopted UHC and are restructuring their health-related systems and policies to achieve UHC.⁹ The paths taken around the globe to achieve UHC are as diverse as the world is. But, there also has been differences in opinions on how to achieve UHC and disagreements were raised on differences in the paths taken towards UHC. However, the emphasis was put more on how each country has to formulate its own plan based on its culture, needs and existing policies related to health systems in order to achieve UHC. This was recognised internationally and was also supported by developing joint systems across countries to enable communications and sharing knowledge related to various paths towards UHC. One of those systems is the Joint Learning Network of countries (JLN) for UHC. In a world where countries’ domestic finances are given vast importance, when compared to the outside contributions in the form of development aid, it makes more sense to adapt (make suitable for a new purpose) rather than blindly adopting what others do. This formed the basis for JLN.⁵ Establishing an evidence for importance of achieving UHC also was critical in order to take necessary steps in the right direction. A series of research findings in The Lancet have provided such evidence. The effects of progress towards UHC on the health of the population was studied by Rodrigo and Smith. They have concluded that UHC will have a positive effect on the health of the population as it increases the utility of health services by the population.¹⁰ Savedoff et al studied the economic and political dimensions of UHC. They have emphasized on the importance of political will in developing newer economic reforms in order to achieve UHC.¹¹ The formulation of policy reforms in the form of health insurance coverage to the people in low and middle-income countries (LMIC) was studied by Gina Lagomarsino and associates. They have explained the examples of reforms that were taken in countries like Thailand in achieving UHC by developing indigenous policies rather than adopting global policies.¹² As an overview and supporting the findings of all those studies, Jefrey Sachs concluded and called for continuous progress and a large role of the public sector.¹³

INDIA’S TRANSITION TO UNIVERSAL HEALTH COVERAGE

For a long time, paying for health-related services from out of pocket was prevalent worldwide. In India, the out of pocket payments accounts for more than 60% of the total health payments.¹⁴ However, all the countries around the world including India are forming policies that effects such out of pocket payments in order to achieve UHC as a major policy goal.¹⁵ Despite of such efforts, payments for health-care spending is still made by the households or families. The findings from the recent National Sample Survey (NSS) revealed that the percentage of population getting covered under any form of health protection in rural and urban households is 13% and 12% respectively.¹⁴ Also, sourcing money for health care either through borrowings or by assets selling constitute to nearly 26% of total health related spending among the households residing in rural areas. Further, an average of approximately 5% of population are being impoverished anually.¹⁶ In order to combat such impoverishments and poverty that arises from health-related expenditures, the policy makers in India have advocated for the expansion of health insurance as an essential component of the country’s healthcare reform. One of the most ambitious plans in Indian healthcare reform has been a call for ‘universal healthcare for all’ by 2020 now extended to year 2022. Reaching this goal would include implementing universal health insurance, which been seen as a potential way of reducing health disparities and Out of Pocket Expenditures (OOPE).¹⁷ In India, the focus of the health sector was on supply side predominantly and the formation of National Rural Health Mission (NRHM) in 2005 also served as an instrument for strengthening the supply-side requirements such as health care infrastructure and human resources.¹⁵ Taking this into account, the planning commission formed High Level Expert Group (HLEG) proposed a model to achieve UHC. This model proposed developing health insurance mechanisms that would enable and entitle all the citizens to health care in both private and public sectors without any financial burden.¹⁸ With this, not only the traditional supply side financing has been strengthened, but also the demand side financing mechanisms have been established, mostly in the form of government financed health insurance schemes.¹⁵ Since, such a shift of attention towards demand side aspects of health care in the country, various Government financed health insurance schemes were launched in the country sponsored either by the state governments or central government. The latest of all such schemes is National Health Protection Scheme under India’s ambitious Ayushman Bharat (long live India) programme, launched in the year 2018. All these schemes were launched with one goal aimed at achieving UHC by 2022.

INDIA’S NATIONAL HEALTH PROTECTION SCHEME

The flagship health scheme from Government of India was launched in the year 2018 as Ayushman Bharat (AB). The aim of this programme was to replace the conventional approaches to health care delivery with a holistic approach by providing comprehensive (preventive, promotive, curative, palliative and rehabilitative) health-care services at all the levels of health care delivery system (primary, secondary and tertiary). AB has two components, one is the establishment of Health and Wellness Centres (HWCs) and the other is Pradhan Mantri Jan Arogya Yojana (PM-JAY) also called as the Prime Minister’s National Health Protection Mission. HWCs in the form of upgraded Health Sub Centres (HSCs) and Primary Health Centres (PHCs) are aimed at bringing the basic and essential primary health-care services much closer to the communities. Whereas, PM-JAY also labelled as the World’s largest health insurance scheme is aimed at providing cashless health-care services, at PM-JAY empanelled secondary and tertiary health-care institutions, to the most vulnerable (economically weaker) sections of the society. Under PM-JAY, Government of India in collaboration with the state governments provides an insurance coverage of Indian National Rupee (INR) 0.5 million per family per year without any cap on the size of the family. The National Health Authority (NHA), which is the implementation body for Ayushman Bharat has estimated the total number of eligible beneficiaries to be 107.4 million families (approximately 500 million individuals), who constitute around 40 percent of total population in India.^19-21

CONCLUSION

The road taken by each country to achieve UHC is diverse and unique to its culture, needs of people and health systems in the respective country. However, all these approaches have a commonality of promoting and providing health insurance as an important mechanism to achieve UHC. Providing health insurance to ensure health coverage for all the citizens has been well tested and proved to be a viable option. But, addressing other needs and requirements of health systems such as expansion of health infrastructure, reinforcement of the health care workforce and reorganization of the existing health systems in line with newer policies is also extremely important. Further, the support mechanism to continuously monitor the progress towards UHC has to be strengthened. This can be done by measuring the indicators of financial risk protection, which is at the core of UHC. With an ever-increasing emphasis on achieving UHC for all, it is not only important to be optimistic, but to be able to sustain such an optimism in finding solutions to existing challenges is the way forward.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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