Moving Beyond Universal Health Coverage

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Posted by: Arman
Category: Public Health and Nutrition
Moving Beyond Universal Health Coverage

The idea that development is nothing but health is based on the premise that all the human development indicators, such as income, education etc., are prerequisites for promoting better health. But such a development will be highly skewed if its fruits are not distributed equitably across all communities of the society.  

Even after years of ‘Alma-Ata Declaration‘ (with emphasis on primary health care as the key to attaining the goal of health for all) and progressive recommendations of Bhore Committee on health planning in 1943, India’s health statistics are not optimal for marginalized sections. As per the Tribal Health Report, only 10.7% of the ST population has access to clean water compared to 28.5% of the non-ST population. It is not surprising when the statistics reveal that an alarmingly high number of tribal populations are stunted and malnourished, with a high mortality rate.  

Despite the Bhore Committee recommendations to improve primary healthcare, there is a shortfall of 24% of sub-centers, 29% of primary health centers (PHCs) and 38% of community health centers (CHCs) as per the Rural Health Statistics (RHS) 2020. India doesn’t have as many qualified medical professionals to handle its population’s health issues. A report showed that India has less than one doctor for every 1000 people, which is less than the standard set by the World Health Organization (WHO).  

We often see the term ‘Universal Health Coverage’ (UHC) floating in the media and academic debates, striving to achieve better health accessibility. But young researchers and public health practitioners may lack the inherent understanding of specific terms and how they stem from different political-economic epistemologies.  

In India, UHC focuses more on financial coverage through insurance mechanisms and a market model of ‘managed care’ for a limited package of services to reduce out-of pocket-expenditure (OOPE).  

The following case studies from my research will allow us to understand UHC better:  

Case 1: Divya (Pseudonym) is a member of Ho community in Manoharpur block of West Singhbhum Jharkhand. She is a mother of two and the sole breadwinner of the family. She depends entirely on the Saranda Forest for her livelihood and subsistence. One morning, she goes to collect Sal leaves and is bitten by a snake. Since the village is located deep inside the forest with no proper road connectivity, she is carried on a charpai (cot) for 10 km to reach the nearest Primary Health Centre (PHC). The PHC doesn’t even have paracetamol, let alone something that could help counter snake venom. The nearest Community Health Centre (CHC) to her location is 60 km away. It takes almost 8 hours for her to reach there, and by the time she does, she is declared dead. Due to her passing, her children have taken up her job since their father suffers from an addiction problem. The endless cycle of the “poverty trap” is looming on the family now.  

Case 2: Jarayi (Pseudonym), a 24-year-old recently married male, is an MGNREGA (Mahatma Gandhi National Rural Employment Guarantee Act) laborer. One evening, on his way home from the local bazaar, he is bitten by a snake. He is taken to the local Raudiya (traditional healer) immediately but in vain. After 3-4 hours of delay and spending INR 2,000 trying to get there, he is taken to the CHC, where he is denied treatment because he belongs to a particular tribe.  

Health in India is not only dependent upon economic factors but also on social structure and social positioning. For example, an increase in income may not ensure good health for certain sections of society, as evident in Jarayi’s case. Similarly, a Dalit woman will have less access to health systems than a Dalit man; a Dalit male might have less accessibility to a health system than an ‘upper-caste’ male and female.  

Moving Beyond Universal Health Coverage

The case studies indicate that the ‘UHC model’ may not be the right path to achieve universal health or health equity, which is why it is time to move ahead and incorporate the ‘Universal Health System’ (UHS) in our approach.  

What is UHS, and how is it different from UHC? 

UHS is a system which offers comprehensive services based on an individual’s needs as a human without any means-testing, such as BPL /APL or citizenship. Such a practice caters to the most vulnerable, irrespective of their ability to pay.  

UHS provides greater solidarity, risk pooling and cross-subsidization while promoting social justice in which the rich make a progressively higher contribution to the system. This also removes the current segmentation and two-tier health services, which means five-star services for the rich and poor services for the poor.  

A UHC-based system could become fragmented due to various insurance providers in different territories ‘covering’ different ‘package’ of services, thereby hindering the continuum of care. On the other hand, UHS provides for both backward and forward integration of services.  

The ‘coverage’ model could leave out the preventive, promotive and primary health care and ‘cover’ only the lucrative secondary or tertiary care. However, UHS holds the promise of integrating primary health care with the social determinants of health, such as gender, caste, income etc.  

UHS vs Current forms of PPP and PFHI: 

Here, the proposed UHS does not mean the current forms of ‘Public Private Partnerships’ (PPP) or the various Publicly Funded Health Insurance (PFHI) schemes such as Ayushman Bharat.  

PPP arrangements resulted in more secondary and tertiary care than primary care (Shukla R et al. 2011). Furthermore, it is fragmented care, wherein providers charge both the public system and users, which ultimately doesn’t reduce out-of-pocket expenditures. Such arrangements also lead to ‘cream skimming’ in which complex cases are referred back to the public system. Most schemes, such as Janani Suraksha Yojana etc., have ‘fee-for-service’ payment mechanisms. This has led to supplier-induced demand and unethical practices like a spurt in hysterectomies (Oxfam, 2013) and a high proportion of C-section deliveries (NIHFW 2006). But the UHC system wouldn’t give irrational and unethical treatments second thoughts so long as they are ‘covered’.  

The PFHI schemes at present are not universal but targeted and fragmented. Sometimes multiple schemes cater to the same population run by different ministries, which results in efficiency losses. Providers under such schemes often demand increasingly high reimbursements for treatments and often threaten to stop providing treatments under the PFHI schemes.  

Therefore, the UHS model attempts to build a healthcare system based on a sound network of PHCs, a better referral system and the incorporation of ‘systems-thinking’ in health. It will fulfil the visions of public health, which are based on resource pooling and collective efforts rather than individualism. Eventually, we might be able to develop a hybrid system that takes the best of the world’s health systems (such as National Health Services, UK; National Health Insurance System, Taiwan; Statutory Health Insurance System, Japan) and improve on it by customizing it for the Indian context.  

Arman – Research Associate, Sambodhi

Author: Arman