Universal access to public healthcare

Relevance: G.S paper: III. Science and Technology- developments and their applications and effects in everyday life

Government’s flagship health insurance scheme, Ayushman Bharat, officially called the PM JAN AROGYA YOJNA (AB-PMJAY), has been widely lauded since it was launched last year. Various states are in the process of rolling it out.

The theme of this year’s World Health Day is ‘Universal health coverage (UHC): everyone, everywhere’. The ultimate goal of UHC is to ensure that everyone, everywhere, should have access to essential healthcare services without facing financial hardship. Progressive realization of UHC is also one of the key features of the United Nations’ Sustainable Development Goals. India’s commitment towards achieving UHC is clearly reflected in policies and institutional mechanism, which are directed towards increasing coverage and access to health services. India has launched Ayushman Bharat – one of the most ambitious health missions ever to achieve UHC. Ayushman Bharat encompasses two complementary schemes, Health and Wellness Centres and National Health Protection Scheme. Health and Wellness Centres are envisioned as a foundation of the health system to provide comprehensive primary care, free essential drugs and diagnostic services, whereas National Health Protection Scheme is envisaged to provide financial risk protection to poor and vulnerable families arising out of secondary and tertiary care hospitalization to the tune of five lakh rupees per family per year. Indeed, the dream of achieving UHC or health for all has been a long-standing one for India. India has supported the idea of health for all since independence, and the Bhore committee report had recommended a publicly financed national health services and system for comprehensive preventive and curative care for all, way back in 1946.

The World Health Organization (WHO) has identified four key financing strategies to achieve UHC –

• increasing taxation efficiency,
• increasing government budgets for health,
• innovation in financing for health and increasing development assistance for health.

Unfortunately, all of these measures fall beyond the control of Ministries of Health (MOH) and less likely to be influenced by their efforts alone.

• The MOH need to be more assertive in their demands for health budget and should use evidence-driven investment case scenarios to justify higher budgetary allocations.
• Evidence suggests that tax revenue is a key determinant in progress towards UHC in low- and middle-income countries (LMICs). To generate an additional $9.86 public health spending per capita, the tax revenue needs to increase by $100 per-capita⁷.
• Not only financing and institutionalization are critical for achieving UHC, but also measuring progress towards UHC is equally important.
• The three core dimensions of UHC proposed by the WHO are

1. “the proportion of a population covered by existing healthcare systems,
2. the range of healthcare services available to a population, and
3. the extent of financial risk protection available to local populations”.

An analysis of South Asian countries reported that access to basic care varied substantially within and across each country. In India, financial risk protection was only 17.9 per cent and prevention and treatment coverage for selected heath conditions was 83.5 per cent⁹. The study also raised equity concerns, highlighting that access to care for maternal and child health services was higher among rich as compared to poor mothers.

GENERAL ISSUES

Issues:

• Severe shortage of medical personnel, including doctors and nurses, as well as a dearth of hospitals and hospital beds. This shortage is especially stark in rural areas.
• In many places, primary health centres, community health centres, and sub-centres are located too far from people’s homes. Even in the big cities, patients often have to run from one hospital to another in search of a particular facility or a bed.
• Private facilities are the preferred option for most, if only because of treatment is assured. The poor, however, typically find themselves shut out not just by steep prices—which Ayushman Bharat expects to overcome—but also invisible class barriers.

ADDRESSING ISSUES

To address health inequalities and improve health outcomes,

an architectural correction in public healthcare system was made by the Ministry of Health and Family Welfare (MoHFW) through National Rural Health Mission, which was later redesigned as National Health Mission (NHM) to strengthen both rural and urban public health infrastructure, human resource capacity and service delivery.

NHM was complemented by other key initiatives that included Janani Suraksha Yojana and Mission Indradhanush. Rashtriya Swasthya Bima Yojana (RSBY) was another innovative initiative launched by the Ministry of Labour and Employment (now with MoHFW), which provided financial risk protection to poor families through government-funded health insurance.

However, in spite of all the efforts, the total health expenditures (THEs) in India remained at 4.7 per cent of gross domestic product (GDP) in 2014. The contribution of public health expenditure also remained stagnant at 30 per cent, which is one of the lowest among LMICs.

The press note on AB-NHPM suggests that the scheme is expected to have major impact on reduction of OOP expenditure on ground of

(i) increased benefit cover to nearly 40 per cent of the population (poorest and vulnerable),

(ii) covering almost all secondary and many tertiary hospitalizations (except a negative list), and

(iii) coverage of 5 lakh for each family, (no restriction of family size)

MORE CONCERNS

Healthcare need is not only uncertain and unpredictable but also catastrophic to families living on the margins. Poor and vulnerable families not only spend money out-of-pocket (OOP) due to ill health but also have to suffer wage loss to seek healthcare. Estimates suggest that in India, around 50 million households fall in poverty annually on account of OOP healthcare expenditures. One of the reasons for high rate of OOP expenditures is limited access to healthcare in public sector, which compels patients to seek care in the private sector.

Evidence suggests that a dynamic interaction between three factors forces patients towards private sector in India:

• healthcare provisioning dominated by private sector,
• (ii) high share of private expenditure as compared to public expenditure in THE, and
• (iii) scarcity of public services on account of deteriorated public health sector. For example, private sector accounted for 75 per cent of total outpatient visits and 62 per cent of total inpatient visits in India in 2014 and the contribution of OOP payments as per cent of THE was 61 per cent in 2012.

Given such a scenario, it is desirable to move towards UHC-based health system where complex and dynamic private sector is efficiently regulated and market competition and choices are used as tools to enhance quality of care and reduce cost of care. Given the fact that social determinants of health play key role in equity, all efforts should be made for multi-stakeholder engagement in design and delivery of an inclusive and pluralistic UHC-driven health care system.

SOLUTIONS

• Global evidence suggests that tax-based financing is the most progressive form of financing mechanism to fund healthcare services
• strategic reasons such as developing healthcare market or utilizing strengths of existing private sector, a cautious approach is warranted to prevent regulatory capture
• it is suggested to strengthen regulatory framework and institutions (such as Insurance Regulator and Development Authority and Competition Commission of India) and public health facilities to ensure competition and choice in the healthcare market.
• have synergy between AB-NHPM and Health and Wellness Centres as a desirable goal as this would ensure complementarity between secondary and tertiary care services covered through AB-NHPM with comprehensive primary care of Health and Wellness Centres and would prevent demand-side moral hazard and healthcare cost escalation.

Conclusion:

By budget figures of the last fiscal year, India spends just a shade over 1% of its gross domestic product (GDP) on healthcare. This includes central expenditure on the Ayushman Bharat scheme. The Interim Budget for this year upped the percentage, but only slightly. The government set a goal last year of 2.5% of GDP by 2025. For progress to be made towards that objective, however, this year’s budget need to pencil in a significant hike in the country’s health outlay.
Healthcare needs to be fixed in mission mode. Every child’s life claimed by a treatable disease is one life too many.