Universal Health Coverage (UHC): Where the India lies?

India’s journey toward achieving Universal Health Coverage (UHC) has been a mix of challenges and gradual progress. Despite implementing multiple health schemes since 1948, only 41% of Indian households currently have health insurance, and nearly 50% avoid government health facilities due to concerns over poor care quality. Achieving true UHC will require a targeted approach that focuses on reducing inequalities, enhancing service quality, and ensuring equitable health outcomes across all socioeconomic groups and regions.

Current Status of India’s Healthcare Sector

Overview:

• India’s healthcare sector reached a valuation of US$ 372 billion in 2023, employing 7.5 million people, with notable growth in telemedicine, health-tech, and medical tourism.
• The hospital market, valued at US$ 98.98 billion in 2023, is expected to double by 2032.
• The telemedicine market is projected to grow to US$ 5.4 billion by 2025, while the e-health market may reach US$ 10.6 billion in the same period.

Doctor-Population Ratio and Medical Tourism:

• India’s doctor-to-population ratio is 1:854, accounting for both allopathic and AYUSH practitioners.
• Medical tourism has made India a global hub, contributing US$ 7.69 billion in 2024, with an expected growth to US$ 14.31 billion by 2029.

Foreign Investment:

• Foreign investments in drugs and pharmaceuticals reached US$ 22.57 billion by March 2024, reflecting strong growth and global confidence in India’s healthcare ecosystem.

Issues Hindering Universal Health Coverage in India

Inadequate Public Health Expenditure and Weak Primary Healthcare System

• Despite being the world’s most populous country, India spends only 1.9% of its GDP on healthcare (Economic Survey 2023-24).
• The healthcare pyramid is inverted, with excessive dependence on tertiary care and neglect of primary healthcare systems.
• Diseases like diabetes and hypertension, which could be managed at the primary level through early screening, often go undiagnosed until they become severe, leading to tertiary care dependence.
• In states like Uttar Pradesh and Bihar, the absence of robust primary screening programs exacerbates the burden on higher-tier facilities.

Regional Disparities in Healthcare Access

• Healthcare infrastructure is concentrated in urban areas, while 65% of India’s population resides in rural regions.
• 70% of healthcare professionals are based in cities, leaving rural areas underserved.
• According to the Rural Health Statistics, Community Health Centers (CHCs) in rural areas face critical shortages, with over 80% gaps in surgeons, physicians, and pediatricians, and 75% gaps in obstetricians and gynecologists.

High Burden of Non-Communicable Diseases (NCDs)

• NCDs, such as diabetes, cardiovascular disorders, and cancers, account for 65-66% of total deaths in India (WHO, 2022).
• These diseases place immense pressure on a healthcare system still focused on communicable diseases.
• Factors such as pollution, malnutrition, and poor sanitation worsen health inequities.
• Air pollution caused 1.67 million deaths in 2019, while 40% of rural households lack access to safe drinking water, increasing susceptibility to diseases like cholera and typhoid.

Inefficiencies in Implementation of Government Schemes

• Flagship programs like Ayushman Bharat face challenges such as poor awareness and uneven implementation.
• A CAG report revealed irregularities, such as 7.5 lakh beneficiaries linked to a single cell phone number and patients declared “dead” continuing to avail benefits.
• The highest number of such cases were reported in states like Chhattisgarh, Haryana, Kerala, and Madhya Pradesh.

Poor Health Insurance Penetration

• 95% of India’s population remains uninsured, with 73% lacking health coverage entirely.
• The unorganized sector, which constitutes 90% of the workforce, is excluded from employer-based insurance.
• This results in high out-of-pocket expenditure (OOPE), which impoverishes approximately 55 million Indians annually, with 17% of households incurring catastrophic health expenditures.

Fragmentation in Healthcare Governance

• India’s federal structure leads to fragmented healthcare policies and limited coordination between the central and state governments.
• For instance, during Covid-19, the absence of a uniform testing policy led to confusion and inefficiencies in disease management.
• States with better health governance, like Kerala, outperformed others, highlighting disparities in administrative capacity.

Low Focus on Preventive Healthcare

• Preventive measures such as immunization, screening, and lifestyle interventions remain underutilized despite their cost-effectiveness.
• Full immunization coverage in India was only 76.4% in 2021 (NFHS-5), leaving millions of children vulnerable to preventable diseases.
• Programs like the Fit India Movement and Poshan Abhiyaan face sluggish implementation, limiting their ability to reduce long-term health burdens.

Limited Use of Technology and Digital Health

• While initiatives like the Ayushman Bharat Digital Mission (ABDM) aim to digitize health records, digital adoption in rural areas remains low.
• The lack of standardized data exchange protocols hampers information sharing and coordinated care.
• This hinders the effectiveness of nationwide health initiatives like the ABDM.

Dependence on the Private Sector

• Overburdened public healthcare systems force many patients to rely on the private sector, which handles 60% of hospitalizations and 70% of outpatient services (NSSO’s 75th Round on Social Consumption of Health, 2017-18).
• The unregulated nature of private healthcare often leads to price gouging, inequitable access, and financial hardship, undermining the goal of affordable UH

Measures to Accelerate Universal Health Coverage (UHC) in India

Enhancing Public Health Expenditure and Health Insurance

• Increase public health spending to at least 2.5% of GDP by 2025, as outlined in the National Health Policy 2017, to improve infrastructure, recruit more healthcare workers, and ensure the availability of essential medicines.
• Expand programs like the PM Ayushman Bharat Health Infrastructure Mission, focusing on establishing critical care hospitals in every district to bridge infrastructure gaps.
• Promote targeted insurance schemes to reduce the financial burden on vulnerable populations.

Learn from global models:

• Beveridge Model (UK, Nordic countries): Implement taxation-funded universal healthcare for equitable access.
• Bismarck Model (France, Japan): Adopt insurance-based healthcare with contributions from employers and employees.

Strengthening Primary Healthcare

• Revamp Primary Health Centers (PHCs) and sub-centers by equipping them with adequate staff, equipment, and medicines.
• Expand initiatives like the Ayushman Arogya Mandir under Ayushman Bharat, with a stronger emphasis on preventive care and managing non-communicable diseases (NCDs).
• Integrate telemedicine services such as eSanjeevani with PHCs to enhance rural healthcare access.
• Make mandatory preventive screenings for NCDs and other diseases at the primary level to reduce the long-term disease burden.
• Organize large-scale health camps, especially in rural and tribal areas, modeled on successful programs like the Rashtriya Swasthya Bima Yojana (RSBY).

Addressing Workforce Shortages

• Scale up medical and paramedical education and improve working conditions for healthcare professionals.
• Expand the Skill India initiative to provide healthcare-specific training for nurses, midwives, and community health workers.
• Increase seats in medical colleges and incentivize rural postings through higher salaries and career advancement opportunities.
• For instance, Assam’s financial incentives for doctors in remote areas offer a replicable model for bridging urban-rural divides.

Leveraging Digital Health Technology

• Accelerate the rollout of the Ayushman Bharat Digital Mission (ABDM) to establish a unified digital health ID system for streamlined patient records.
• Improve internet connectivity in rural areas through BharatNet and provide digital training for healthcare workers to ensure inclusivity.
• Expand telemedicine platforms like Tele-Manas for mental health services to address unmet needs.

Focusing on Preventive Healthcare

• Strengthen preventive measures such as vaccination, health education, and lifestyle interventions to reduce disease burdens and healthcare costs.
• Broaden the scope of the Poshan Abhiyaan to tackle adult malnutrition alongside childhood malnutrition to combat rising NCDs.
• Improve urban sanitation through Swachh Bharat Mission 2.0 and increase funding for national programs like NPCDCS (Non-Communicable Disease Control Program) for long-term benefits.

Promoting Public-Private Partnerships (PPPs)

• Leverage PPPs to enhance healthcare infrastructure, diagnostics, and tertiary care.
• For example, Rajasthan’s Mukhyamantri Free Medicine Scheme, which partnered with pharmaceutical companies to supply affordable drugs, demonstrates the potential of such collaborations.
• Expand initiatives like Viability Gap Funding (VGF) to incentivize private hospitals to operate in underserved areas.

Reducing Regional Disparities

• Incentivize states with lower health indices to invest in healthcare infrastructure and workforce development.
• Link NITI Aayog’s Health Index rankings with performance-based grants under the 15th Finance Commission to encourage improvements in lagging states like Bihar and Uttar Pradesh.
• Adopt Kerala’s decentralized governance model, which prioritizes local health institutions through higher budget allocations.

Strengthening Regulatory Mechanisms

• Enforce price control of essential medicines and standardize treatment costs in private hospitals to curb exploitation.
• Expand the role of the National Pharmaceutical Pricing Authority (NPPA) and mandate transparent pricing under the Clinical Establishments Act.
• Previous price reductions in cardiac stents and knee implants saved patients significant costs, showcasing the effectiveness of regulation.

Investing in Research and Indigenous Innovations

• Increase funding for institutions like ICMR to develop affordable, indigenous healthcare solutions.
• Establish regional research hubs to address localized health issues, such as vector-borne diseases in the Northeast.
• Promote public health innovations, such as the development of Covaxin, to enhance self-reliance.

Integrating Traditional Medicine with Modern Healthcare

• Incorporate AYUSH (Ayurveda, Yoga, Unani, Siddha, and Homeopathy) into Health and Wellness Centres (HWCs) under Ayushman Bharat to complement modern healthcare and reduce the burden on allopathic practitioners.

Comprehensive Mental Health Coverage

• Increase funding for the National Mental Health Programme (NMHP) and integrate it with primary healthcare through telemedicine platforms like Tele-Manas to expand accessibility.

Adopting the One Health Approach

• Implement the One Health approach, recognizing the interconnection between human, animal, and environmental health.
• Establish integrated monitoring systems for zoonotic diseases like Nipah and Avian Influenza to ensure rapid responses.
• Expand the National Centre for Disease Control (NCDC) to collaborate with veterinary and wildlife departments.

India has made notable progress in its quest for Universal Health Coverage (UHC), but several critical challenges persist. Key issues include low public health expenditure, regional inequalities, limited insurance coverage, and an overburdened healthcare system. To achieve UHC, India needs to prioritize increasing public health spending, fortifying primary healthcare services, and improving the efficiency of government healthcare initiatives.

The End of the Blog: Universal Health Coverage (UHC): Where the India lies?