The Challenges That Must Be Addressed For India To Achieve Universal Health Coverage

Posted by Ambar Sharma in Education
January 16, 2018

Any Union health minister has their task cut out for them in terms of reaching universal coverage. Here are just a few challenges that need to be addressed.

Public health is a state subject in India according to the Seventh Schedule of the Constitution. However, just because it is under the domain of the states does not mean the Centre has no role to play. In fact, the Centre compliments the efforts of the states by providing funds, ensuring the policy framework is robust and framing adequate laws that are up to the states to implement. The Centre also supports the efforts of the states through centrally sponsored schemes (CSS) such as the National Health Mission (previously the National Rural Health Mission), Rashtriya Swasthya Bima Yojana (RSBY) and National Program for Prevention and Control of Cancer, Diabetes, CVDs and Stroke (NPPCDS). CSS are for specific schemes. After the 14th Finance Commission’s report, since states have more funds to utilise (and flexibly) which means there is less interventionist need by the Centre in various schemes.

The problem is seen when we look at India’s spending on healthcare, Central Government and State Government combined, which is substandard for a growing country like India. According to Lok Sabha Question No. 1317, the expenditure on healthcare as a percentage of the GDP for the last three years is –

2014-15 – 1.2%
2015-16 – 1.4%
2016-17 – 1.5%

Like I mentioned, substandard. It might seem that the government is listening, as the National Health Policy 2017 envisages increasing public expenditure on health to 2.5% of GDP in a time bound manner. The time? By 2025. The need for 2.5% is not time-bound, but, urgent and expedient. By 2025 – the 2.5% must be above 5% seeing as we would have an older population. Lancet, an international medical journal called this a ‘lack of ambition‘ since the global average is around 6%. It also states that there is no road-map to get there and the government is only following up on a target set 15 years ago.

Even if you see healthcare as being better left to the private sector with government only playing the role of a regulator, there are certain economic benefits that investing in health gives a government. According to the Centers for Disease Control And Prevention in the USA, there was a $10 return on investment for every $1 spent on childhood vaccinations.

Investing in healthcare also means a better economic return due to a healthier workforce, which can work for longer years. Our investment in healthcare would also lead to a qualitative effect of having people leading better lives and ensuring they spend more time at work or with family, rather than, in government/private hospitals. An ill workforce will be quite harmful to our economic growth story.

Unfortunately, India also has one of the highest OOP (out-of-pocket) expenditures in the world. The government’s own figures mention that our citizens spend one of the most on healthcare (and certainly do not get the equivalent quality). We rank 182 out of 192 in terms of OOP expenditure as percentage of total health expenditure. This shows the wide gap we need to overcome to provide universal healthcare for all our citizens.

Talking of universal healthcare, there was a scheme named The Universal Health Insurance Scheme (UHIS) where the government subsidized the cost of healthcare for below poverty line (BPL) families, this is a failure as the coverage is still only 27% (according to the Central Bureau of Health Intelligence). Health insurance needs to be spread better. Private health insurance companies need to be encouraged to come to the market and compete alongside government health insurance programs.

Since the above-mentioned excessive OOP spending on healthcare is a serious issue, health insurance seems like a natural solution, and yet, the low coverage seems to be one reason that a massive 63 million people faced poverty every year due to healthcare expenditure, according to the health ministry.

Primary health centres which are owned by states have seen a substantial jump in numbers. However, they are faced with a shortage in terms of doctors, nurses, specialists and even medical equipment. Beds also, were facing acute shortage and the blame must go on the respective states for this. There must be a concentrated effort to ensure that just building the infrastructure for healthcare is not seen as an end goal, but a small step, and the human resource infrastructure must be at the heart of healthcare. To give some perspective on our shortage, the doctor:population ratio, as recommended by the WHO, is 1:1000. One doctor per a thousand people. In India, it is 0.62:1000 as per the current population which is estimated to be around 1.33 billion.

Here, I believe the most important question that any civil servant or heath minister needs to ask themselves is – how do we motivate doctors, nurses and other medical professionals including specialists, to join the public health system of our country? Will it be better pay? Benefits? Perhaps the promise of lesser working hours which is almost always above the ceiling of 12 hours a day?

One solution to reach rural, hard to access areas such as tribal areas, could be to utilize technology. This is where Digital India comes in. Tele-medicine remains grossly underutilized in India. Of course, the problem is the presence of internet in hard to reach areas. However, a broadband line would be cheaper than building a community health center and it would provide easy medical assistance and save healthcare costs for patients in India, which again pay exorbitant amounts in health expenditure. Tele-medicine could be used to provide solutions to a problem in real-time remotely without the doctor actually being there. This does not work for longer-term diseases, but, the majority of problems could be easily advised by the doctor as to which medicine the patient should get or what the correct course of action should be.

A side-note for this specific government would be to promote Ayurveda and other forms of medical practice that have originated in India as an ‘alternative’ to traditional medicine, rather than, a substitute to it. The National Medical Commission Bill 2017 which mandates homeopaths and others to prescribe allopathic medicine if they complete a ‘bridge’ course. This was not the case previously. You could not just switch medical practices and venture into the territory of another practice. A heart surgeon surely would not give solutions to someone needing neurosurgery if they happened to complete a ‘bridge’ course. I hope the government moves away from that approach.

Other incremental changes in our healthcare system need to be standardising rates for diagnostic tests so that no private hospital can go over a certain ceiling and penalising private hospitals for incorrect claims of surgery.

The Union health minister in India over the coming years, will have a tough and unenviable job. Their responsibility to ensure equitable access and affordable health care to all citizens will be very difficult. They could start by investing more into the sector and increasing coverage of the poorest sections of our society. The expenditure as a part of the GDP may be the most generic indicator to judge them by. But, to go a bit deeper, wider reforms in healthcare need to be addressed effectively – and I hope they do.

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