Health beyond minimum
The objective of Universal Health Coverage in India needs to be modified and expanded to include affordable healthcare services for the healthy as well
Universal health coverage (UHC) is at the heart of the government's healthcare agenda. But UHC, in India, as elsewhere in the world, looks only at the universalizing care of the sick and making it affordable for all. This is a very limited objective. It completely neglects the health needs of the rest of the population which includes: a) the healthy; b) people with risk factors; and c) those with symptoms. Each one of these categories requires specific healthcare facilities.
The World Health Organisation (WHO) defines UHC as "promotive, preventive, curative, rehabilitative, and palliative health services of sufficient quality for all citizens which do not put users through an excessive financial burden." Both access and financial protection are important, especially in a country like India where 80 per cent of health spending is out-of-pocket expenditure and health crises often land people in debt and penury.
According to the Planning Commission's estimates, health problems push 39 million people, every year, into poverty. 47 per cent of hospital admissions of rural Indians and 31 per cent of urban Indians are financed by loans and asset sales; and 30 per cent of the former and 20 per cent of the latter, go untreated because of financial constraints. In such a scenario, it would seem that the goal of universal coverage would well be considered to be achieved if citizens can access quality and affordable healthcare services without being pushed into poverty by devastating healthcare expenditures.
But this is not enough. The WHO and the World Bank include other dimensions of health beyond the care of the sick in UHC. This includes clean drinking water, pollution-free air, proper sanitation facilities, adequate nutrition, preventive health-check-ups, vaccination, and immunisation. The Indian concept of UHC falls far short of the internationally accepted definition of universal health coverage. It needs to be enlarged to include quality and affordable healthcare services for the entire population. To achieve this, India needs to leverage all available resources, public and private, formal and informal.
December 12, every year, is celebrated as UHC Day. Organisations from across the world participate and review the progress of the UHC and prepare future roadmaps. The global push to UHC is led by the WHO and the World Bank. In India, high-level expert groups discuss and deliberate upon the UHC agenda. But 'health' appears to be missing in our current UHC approach. This is possibly because these expert committees are dominated by medical practitioners and economists, who are not trained to look at health holistically.
The WHO Charter defines health as, "A state of physical, mental and social well-being, not merely the absence of disease and infirmity." The Indian concept of UHC should incorporate this definition. Preventive and promotive aspects of health need to get more the attention than they currently attract in the public healthcare system.
Health insurance is widely promoted as a panacea to all ills in healthcare. Today, health insurance covers about 17 per cent of the Indian population and there are efforts to increase the coverage. Global experience, however, shows that universal insurance coverage can be sustained only if the basic determinants of health such as access to safe water, nutrition, and sanitation, environment etc. are ensured.
India needs to first ensure access to safe drinking water, sanitation including waste disposal systems, control environmental pollution and provide a measure of a nutritional safety net. The mere provision of medical insurance would be insufficient to secure the health of the citizens. The preventive and promotive aspects of health need greater attention while focusing on the access to quality healthcare at an affordable cost for the population and the country. Without this shift, it is akin to trying to mop the floor dry while leaving the water taps on.
To tackle the challenge of UHC, two major shifts are required: i) the need for the entire population to be able to approach health; ii) address the social determinants of health through attention to health in all policies. The first would include preventive healthcare for the healthy to the curative and rehabilitative care of the sick.
The need for increased financial allocations for medical interventions is necessary, but not enough to control a huge and continuously rising NCD burden that the country has. There are more than twenty ministries whose policies impact health outcomes.
The current approach to UHC needs to be modified to a comprehensive health care that encompasses preventive and promotive health care, engaging other sectors to play a critical and indispensable role. This integrated approach at the level of policy and operations demands the involvement of leadership at the highest political and social levels.