Health for All: Accelerating Universal Health Coverage in India

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ABOUT: A critical component of the United Nations' 2030 agenda for Sustainable Development Goals is health for all. However, despite a decade-long work under the National Rural Health Mission, a vast majority of Indians remains out of the heath care-for-all umbrella. The more recent National Urban Health Mission of 2013 and the Rashtriya Swasthya Bima Yojana have only just begun. The WHO representative to India, Dr. Henk Bekedam, suggests ways to marry national and state priorities to bring quality health care to every Indian citizen.

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In the words of Dr. Margaret Chan, Director General of the World Health Organization, "Universal Health Coverage (UHC) is the single most powerful concept that public health has to offer."

UHC refers to a goal for each nation, whereby all citizens have access to quality health services they need, and don't suffer financial hardship when they pay for them. UHC assumes even greater importance in the context of the recent adoption by the United Nations of the 2030 agenda for Sustainable Development Goals (SDGs). It is a key element for the success of health-related SDG (SDG 3); it also underpins other SDGs.

Moving towards UHC in India

India has made rapid strides towards increasing access to health services in the past few years through a number of initiatives, including the flagship National Rural Health Mission (NRHM), launched in 2005. This was expanded to the urban population through the National Urban Health Mission (NUHM) in 2013.

To provide financial protection to targeted populations, including those below the poverty line, the government has implemented the Rashtriya Swasthya Bima Yojana (RSBY). It covers the cost of secondary-level hospitalisation.

In addition, there are a number of state-specific schemes. Some involve running free diagnostics facilities and offering free medicines; others are government-funded health insurance schemes in several states. Evidence suggests that these can reduce the financial burden on patients and increase attendance at public health facilities.

The need to accelerate UHC in India

While these initiatives provide some financial protection to those seeking health care, tens of millions still fall into poverty after an illness or abstain from accessing the health services they need.

At 60 per cent, India's out-of-pocket expenditure (OOP) for health is one of the highest in the world. This exacerbates health inequities. To sustain its economic growth, India will need to have a healthy population and address health inequities. In this context, UHC can be the driver and benefit the entire population.

Accelerating UHC is the key to successfully addressing the new public health challenges and inequities in health outcomes.

Despite remarkable achievements such as polio eradication and maternal and neonatal tetanus elimination, to name a few, there are several health challenges. The country is facing a double burden resulting from significant increase in non-communicable diseases (NCDs) associated with lifestyle and the pre-existing burden of communicable diseases.

Cardiovascular diseases, cancer, chronic respiratory diseases and diabetes are the largest contributors to morbidity and mortality in the country. The four NCDs accounted for 56 per cent premature deaths in the 30-69 age group in 2010 in the WHO South-East Asia Region.

Environmental issues such as air pollution have also become a major concern. The high pollution levels in Delhi is a case in point.

Another challenge is inequities in health outcomes and access to health services. The Maternal Mortality Ratio (MMR) varies from 61 per 100,000 live births in Kerala to 300 in Assam. Differences also exist in health indicators between urban and rural/remote areas - infant mortality rate, or IMR, estimated at 27 per 1,000 live births in urban areas, is 44 per 1,000 live births in rural areas. In addition, disparities in coverage of essential intervention exist even within the well-performing states. For example, immunisation coverage in Tamil Nadu varies from about 34 per cent in Kanyakumari district to 75 per cent in Vellore district.

Here are the eight recommendations for accelerating the progress towards UHC.

1. In order to start a journey, one should know where to go. It is important, therefore, to define and agree on the vision and goals for 2030. This involves agreeing on a process for developing such a vision. This will entail development of a national framework and roadmap that define roles of the Centre and the states, besides that of both public and private sectors. This goal needs to be operationalised into five-year plans, which due to their step-by-step approach allow for different processes to converge and adjustments to be made.
2. Opportunities to accelerate UHC in states: As the states are at varying levels of development, the UHC vision for the country needs to be cognizant of these diversities. In this context, there are opportunities for the states to accelerate the process of moving towards UHC. They could choose a model that they can follow for 5-10 years to develop their own path and determine their own pace. The overall national framework ensures convergence in the long term. 
3. High-level political commitment beyond the health ministry: High-level political commitment to invest in the health sector is essential for advancing the UHC agenda at both the Centre and the states. This commitment is also needed beyond the Ministry of Health, notably the ministries of finance, skill development and human resources development, and the NITI Aayog. A similar commitment is needed in the states also.
4. Participatory processes for designing and implementing UHC: While political commitment is a must, community involvement is equally essential for moving towards UHC. Institutions, both in the government as well as NGOs, including think-tanks and private sector players, have an important role to play in advocating UHC and pushing for its effective implementation. Building a UHC vision for the country on the basis of strong commitment and holistic participation will be a strong bedrock for the country's future.  
5. More money for health but also more health for the money: The health sector has tremendous potential for directly contributing to enhancing the quality of human capital, which will drive other sectors to more productive outputs. This is particularly relevant for India, which has over 20 per cent of the global burden of disease with 17.5 per cent of the world's population. While the private sector plays an important role in provision of services, the role of the government is fundamental and central to achieving health goals and needs to be strengthened, both in the provision and regulation of services. This requires adequate public funding to improve the safety and quality of services, addressing of inequities and investments in prevention efforts. Increasing public spending in health would not only be instrumental in accelerating UHC implementation but would also be an investment in human capital, especially given that Indias public health spending, at 1.1 per cent of GDP, is among the lowest in the world. However, it is not only about spending more money on health but also about spending it efficiently. International evidence suggests that we can improve efficiency of health spending for better outcomes. The World Health Report 2010 estimates that 20-40 per cent of all health spending is wasted. In the Indian context, irrational use of medicines and lack of absorption capacity to spend allocated funds are serious concerns.
6. A strong health system: Intrinsically related to efficiency in government health spending is the need for a robust health system. A weak health system cannot produce a healthy population. Put another way, the factors of production of health need to be optimised so that the sector can function optimally. It is imperative to strengthen government health facilities and improve the working conditions of government health staff, especially in rural areas. This involves having essential medicines and supplies, training and ensuring an appropriate skill mix, besides a functional referral system for complicated cases. It is imperative that the system is geared to meet the matters of global health security and international health regulations. What is essential is to ensure that health care is of good quality so that health spending remains efficient. This is of paramount importance in the UHC vision. {quote}
   
7. Monitoring and accountability mechanisms for UHC implementation: Progress towards UHC entails developing a monitoring and accountability framework as part of the same process that defines the UHC vision for India. This can be achieved through defining a set of indicators and time-bound goals, including IMR, MMR, life expectancy, OOP and access to services. Disaggregation of data by gender, economic status and geographical area will be the key to understanding the progress made and the remaining challenges. Overall, time-bound goals will help maintain the momentum for UHC implementation as well as make the process open to direct audit by stakeholders.
   
   
   
8. Evaluation and adaptability for UHC reforms: Finally, it is important to build mechanisms for regular review and adaption based on ongoing monitoring and accountability processes. The UHC models we choose should have the scope for revision as more hands-on experience is gathered. In addition to allowing for course correction regularly, there should also be a forum for the states to share experiences.