Accelerating India’s Progress towards UHC in the Post- COVID era

Authors: Dr. Rahul S Reddy Kadarpeta, National Coordinator with Health Systems Transformation Platform (HSTP), and Aaliyah Ali Khan, Program Associate at HSTP. 

12 December 2022, the UHC day culminates a decade of focused work around creating momentum for building strong health systems for universal health coverage (UHC). According to the World Health Organization, UHC refers to a health system where all people have access to health services, especially those who may find it difficult to afford healthcare, with the end goal of improving health outcomes for all. Emphasis is on a full range of essential health services when they need, from health promotion to prevention, treatment, rehabilitation, and palliative care without undergoing financial hardship. Countries have begun their UHC journey acknowledging that there is no one pathway to achieve this, but to be inclusive and make consistent strategic efforts to progress.

In the last decade, consecutive Indian governments have taken steps to improve the health system. The National Health Policy 2017 states universal health coverage as a goal. The National Health Mission’s mandate was expanded beyond maternal – child health to converge disease control programs. “Ayushman Bharat’ launched in 2018, channelized policy direction through a two pronged approach –  Health and Wellness Centers for comprehensive primary healthcare and Pradhan Mantri Jan Arogya Yojana (PMJAY) for cashless coverage for inpatient care services for the poor and vulnerable families. The COVID-19 pandemic exposed several gaps in policy and program implementation. As a systemic response, the government has expanded focus to include strengthening health infrastructure at all service levels and implementing integrated digital health solutions. In the post-covid era, as India struggles with a sluggish economy, health policy and strategy should focus on the following aspects to accelerate progress towards UHC:

• Centre – State collaboration with a focus on equity: India contributes disproportionately to the global burden of disease, with health indicators that compare unfavorably with other middle-income countries and our regional neighbors. There exist large health disparities between states, rural and urban populations, and across social classes. The NITI Aayog’s Health Index shows widespread disparity among states, with Uttar Pradesh, Nagaland and Assam performing poorly while as compared to Kerala, Mizoram and Delhi. To bridge these disparities, ‘public health’ should be acknowledged as an area of State’s collective action rather than Centre’s action alone. Various levels of government and bureaucracy should embrace collaborative efforts to respond to resource needs of each state. Further, solutions to a particular state’s challenges should be embedded in the local context to enable sustainable impact.

• Private sector engagement: India’s Service Coverage Index is 61 according to the World Bank-Universal Health Coverage Global Monitoring Data, 2021 which is far from optimal.  This indicates challenges in access to healthcare and ensuring service availability of optimal quality. Strengthening the public health system, which services only 50% in-patientcare and 20% of out-patient care is not the only solution. Government should establish pathways to engage with the private sector (including the not-for profit) as it is a key contributor in healthcare service provision. Policy should focus on accreditation or empanelment-based health facility networks to integrate the private and public sectors. Standards should be formulated with regards to operations, quality and payments through integrated process design as we  observe in the Pradhan Mantri Jan Arogya Yojana (PMJAY) or COWIN etc. It is necessary that preventive care services and out-patient care services are the focus to enable expansion of the health and wellness centers by leveraging the not-for profit or private sector nursing home/ physician networks, in urban areas where these do not exist.

• Ensuring fiscal sustainability:  Government health spending has been consistently growing between 2013-14 and 2018-19 and now occupies almost 50% of total health expenditures. For the existing mandate of the government this is already a stretch, and this growth may not sustain in the post- COVID years. Even prior to COVID,  research on age structure transition effect and fiscal sustainability on India’s proposed UHC policy reveals, public health expenditure is marked by age specificities, and the elderly population is costlier to support for their health-care needs. Given the discount and productivity growth rates, the vision for UHC is not fiscally sustainable under India’s current fiscal policies. A well targeted approach is required to pool resources for health from households that have the capacity to pay. For instance, PMJAY health insurance coverage could be expanded to the non-poor populations at affordable premiums. This would decrease the reliance on out -of -pocket payments for seeking care. In 2014, about 55 million people in India were pushed to poverty due to OOPE on healthcare among them 38 million fell below poverty line due to medicine purchases alone. Financial burden of the Indian households has further exacerbated. Analysis on global poverty indicates an increase in the number of poor by 75 million in India due to pandemic-driven recession accounting for nearly 60 percent of global poverty increase.