India’s bumpy road to universal health coverage

One of Narendra Modi’s campaign promises last year was to give “high priority” to the health sector, promising to unroll a universal health assurance plan before his term ends. But shortly before celebrating his first year in office, Prime Minister Narendra Modi asked for a massive cutback in the proposed budget to roll out his ambitious universal health care plan, after estimates pegged total costs at $18.5 billion over five years. Modi still has four years to deliver on his promise. But with the first two proposed budgets both sent to the chopping block, and India’s main health department receiving a meager 2 percent rise in funding, workers in the health care sector are left wondering: How will the government fund and actually deliver not just its national health policy but also universal health coverage? Further, how can universal health coverage be delivered in a country of more than 1.2 billion? In a country with a health system that attracts millions of medical tourists but which propels more than 60 million Indians into poverty each year because of unaffordable health care costs? While the draft policy reiterates previous health care goals to increase government spending on health care from 1 percent of gross domestic product to 2.5 percent, no details on how and when this increase will occur were provided. The proposed UHC program Universal health coverage is considered one of the key components of the sustainable development goals as the world moves beyond 2015 and the Millennium Development Goals. Led by the World Health Organization’s India office, 10 organizations — including the World Bank, U.S. Agency for International Development, UNAIDS, U.N. Development Program and UNICEF — are working together to promote greater commitment to UHC in India. Under India’s proposed UHC program, which it calls the National Health Assurance Mission, each individual will be provided “assured access to a defined essential range of medicines and treatment at an affordable price, which would be entirely free for a large percentage of the population.” Its primary goal is “the attainment of the highest possible level of good health and well-being, through a preventive and promotive health care orientation in all developmental policies, and universal access to good quality health care services without anyone having to face financial hardship as a consequence.” Given the country’s rapidly growing urban population, the policy would make urban primary care services a key focus. Continuity of care would be ensured through linkages with secondary and tertiary care facilities. Essential and generic drugs and diagnostics would be free at public health care facilities, and would also be free or subsidized for geriatric and chronic care inpatients and outpatients at tertiary hospitals. Both public and private sector providers would be engaged to deliver the package, which would be paid for by government-funded health insurance schemes. Civil society concerns Despite the government’s ambitious plan, some nongovernmental organizations have cited concerns about what the policy doesn’t cover and how it will actually be delivered. Access Health International is a nonprofit think tank and advisory group that works to improve access to affordable, quality health care. In India, the organization works with state governments across the country and focuses on advancing health finance systems. In a recent policy position paper, the organization stressed there had to be a focus not just on access to care but, more importantly, access to high-quality care. It noted there was an absence of standard treatment guidelines and little clarity in the roles and responsibilities of different actors in the health care system. Siddhartha Bhattacharya, Access Health’s country director in India, told Devex UHC has to focus on preventive rather than reactionary medicine. “UHC won’t work if people end up going to a clinic when they are sick,” he said. “The disease burden for the next 50 years will be noncommunicable diseases. For many of these diseases, an approach from health system has to be proactive. We need proactive screening of populations and we need preventive medications.” Oxfam India agrees. In a policy position paper released late last year, it recommended that India had to set standard treatment protocols to ensure quality of health and to establish mechanisms to empower communities to hold health authorities to account. Another major barrier to service delivery, which Bhattacharya and other health experts have noted, was the severe shortage of qualified health care personnel, especially in the rural areas. The government is planning to address this shortage not only by setting up new training institutions, but also by tapping nurses, paramedics and community health workers to deliver primary care services. “There is a huge shortage of generalists and specialists — most concentrate in urban areas so the rural areas are depleted. Yes, nurses can fill gaps but that’s not encouraged,” said Priya Balasubramaniam, a senior public health researcher at the Public Health Foundation of India who is also the director of the Universal Health Coverage for India Initiative. “We need good governance, we need to build good primary health care facilities with enough staff that are well run. Unless health is taken up as a political mandate, UHC is not possible.” Bhattacharya meanwhile said there is an opportunity to encourage migrant doctors to go back to their communities as a way to address the shortage of qualified health professionals in rural areas. “Such an idea would provide income [and] jobs, and tap into talent pools rather than doing migration of a talent pool from one part of the country to another,” he said. Can India fund UHC? Several experts have also raised concerns about the policy’s continued support for public insurance schemes, which only cover hospital care and don’t tackle health inequities or drug costs. This is echoed by calls for the government to have a larger role as a health care payer to reduce reliance on the private sector. Moreover, some even cast doubt on the need for UHC in India, including Jeff Hammer, who had worked at the World Bank for 25 years and is currently researching the quality of medical care in India at the Woodrow Wilson School of Public and International Affairs at Princeton University. Hammer believes that UHC in India cannot be funded. At the minimum, it would require a fivefold increase in public spending. Presently, 80 percent of primary care services are provided by the private sector. The government, he noted, does very little in terms of providing “actual services.” “Ask yourself: ‘Why do I think publicly provided medical care is a good thing?’ Do rich countries do it? No. While there is a wide variety of institutional arrangements, almost all rich countries have public insurance and private provision of primary care,” Hammer said. “Why does the international community tell poor countries to do something that has not worked in the rich [countries]?” Dr. Girdhar Gyani, director of the Association of Health Care Providers, which is working closely with key stakeholders on UHC, believes the government has to lead the formulation of the policy for it truly work. “For [UHC], the government should have its own infrastructure, which is not the case. Over 60 percent [of inpatient] beds are with private sector and about 75 percent [of outpatient] services are also being provided by the private sector,” he said. “Under the circumstances, the only way out is that the government procures services from the private sector and delivers to the citizens. This once again is not easy. The government has to find the suitable models and at the same time arrange for finances.” ‘India has to decide its own path and timing’ Nonetheless, some states have moved toward implementing UHC, including the southern state of Kerala, which is piloting UHC in some districts, and Hyderabad, which is revamping its health services. Andhra Pradesh was the first state to come out with a comprehensive state-level health insurance scheme called Aarogyasri, which initially just covered people living the below poverty line. It has gradually increased coverage to include more of the population. However, utilization remains low and concerns remain about poor outcomes and whether state governments can afford UHC. Balasubramaniam said states shouldn’t be expected to implement UHC without fiscal support. She said there had to be a focus on promoting preventive medicine and reducing drug costs. “At some point, health care must become a fundamental need for every citizen. If people are not protected, it’s only going to drive costs up,” she said. “You cannot afford to not be healthy. It’s just ridiculous and defeats the purpose of living. But right now, where things are at, UHC at a central level remains at a policy stage.” Speaking on the condition of anonymity, a source working on UHC at the Ministry of Health told Devex that while India was “continuing to move toward UHC” it likely take “about two to three plan periods to achieve substantial UHC.” A World Bank official confirmed this, adding that “while UHC is an important objective to follow, India has to decide its own path and timing.” To read additional content on global health, go to Focus On: Global Health in partnership with Johnson & Johnson.