EDITORIAL

Universal Health Coverage in India: Towards Sustainable Development

Dr. R. N. Chaudhuri,

Director
All India Institute of Hygiene & Public Health, Kolkata
E. Mail : rnchaudhuri@yahoo.in

The year 2016 is going to be an important landmark in the history of mankind as we welcome the post- 2015 Agenda,“ Transforming Our World : 2030 - Agenda for Sustainable Development”, adopted by the 193 Member States at the UN Summit on Sustainable Development 2015, as a continuation of efforts to attain and sustain development goals and targets to be achieved by 2030. Although some progress has been made since the beginning of this century with the implementation of Millennium Development agenda, to combat poverty, hunger, disease, environmental degradation and gender discrimination, many targets have not been met yet. Hence, the UN General Assembly called for a new development action to take the unfinished agenda forward, launching the post-2015 Sustainable Development Agenda to be achieved through 17 Goals and 169 Targets .The aim is to provide a sustainable comprehensive and holistic framework for development through eradication of poverty and deprivation, improvement of economies, protection of health and environment and promotion of good governance and peace in all communities and countries around the world. The adoption of UN Sustainable Development Goals (SDG) and evidence of social and economic progress in some countries clearly signify that protecting and strengthening systems of human rights and civilian protection cannot be seen as optional, it is literally a matter of life and death. In reviewing the state of the world’s human rights in 2015, it is clear that denial of the fundamental right to health is an urgent and recurring theme that must be addressed by the Global Community 1. Implementation of Goal 3 of Sustainable Development Agenda ( Ensure healthy lives and promote well-being for all at all ages ) is intimately linked with the achievement of comprehensive sustainable development through reconciliation of social, environmental, and economic demands for healthy living , as focussed in SDG agenda2.

This health related agenda emphasises the need to achieve Universal Health Coverage (UHC) by ensuring financial risk protection and improving access to quality essential health-care services for all. Though the agenda of ensuring promotive, preventive, curative & rehabilitative health services without financial hardship towards beneficiary, is currently taking centre stage in debates & discussions over health policy issues, but the concept of UHC is not new. UHC as a concept was born in 1883 when Germany introduced health coverage for achieving health status of its young population 3. Article 25.1 of the 1948 Universal Declaration of Human Rights states, “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, and housing and medical care and necessary social services”. The International Covenant on Economic, Social and Cultural Rights (1966) recognised “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health”. The 1978 Alma-Ata declaration stands out as a landmark in the modern history of Public Health by promoting the vision of “Health for All”. World Health Assembly (2005) urged Member States to pursue equitable distribution of quality health care infrastructure and human resources, to protect individuals seeking care against catastrophic health care expenditure and possible impoverishment. 4 Today a large no. of Countries, have some system or form of Health

Coverage, but not in a comprehensive, holistic and universal manner. A lack of universal coverage means that tens of millions of people around the world either do not get the health care services they need or they have to pay dearly for it, often falling into poverty as a result (WHO 2010)5 .The quest for UHC has gathered real momentum over the past decade or so, with countries on every continent now taking part. A growing number of people worldwide are now demanding better access to care and the potential for healthier lives that modern medicine can offer 5.

Although considerable progress in Public Health has been made in past decades especially in some socio-demographic parameters, India is still contributing disproportionately to the global burden of diseases. The Country’s Health system continues to face many challenges through decades with sluggish progress on key health indicators & outcomes due to inadequate financing, governance, public health policy and management. Inadequate convergence between various departments within the Ministry of Health & Family Welfare and lack of intersectoral coordination between other Ministries or Departments directly or indirectly related to health including private sector, is a major impediment towards holistic approach to quality health governance in the Country. Since Independence several policy efforts and management initiatives have been made to provide universal & equitable health care to all citizens, but these programs by themselves have failed to accomplish UHC. Sharing global aspirations, today India is also committed to achieve UHC, as evident in setting up a High Level Expert Group (HLEG) on UHC in 2011 under Planning Commission, whose recommendations lay down the fundamental approach for its implementation. The HLEG adopted the working definition of UHC as “Ensuring equitable access for all Indian citizens, resident in any part of the country. Regardless of income level, social status, gender, caste or religion, to affordable, accountable, appropriate health services of assured quality (promotive, preventive, curative and rehabilitative) as well as public health services addressing the wider determinants of health delivered to individuals and populations, with the government being the guarantor and enabler, although not necessarily the only provider, of health and related services”.4

As a general concept UHC means ensuring all people receiving full spectrum of essential & comprehensive quality health services they need, without suffering financial hardship. The draft of National Health Policy 2015 by Govt. of India has also endorsed the goal of providing “Universal access to good quality health – care services without anyone having to face financial hardship as a consequence” 6 . At present major share of Country’s health services is being met by highly variable private sector, incurring catastrophic health expenditure on millions of Indians. Health care, far from helping people rise out of poverty, has become an important cause of household impoverishment and debt.7 Although several forms of health financing exist in India, most of Country’s health expenditure is supported by private spending, primarily out of pocket, with public funds constituting an insufficient amount. Despite several government initiatives in social protection, only about one fourth of the population is covered by some form of health insurance. India’s unregulated private sector and deficient public sector, which suffers from management shortfalls, human resource shortages and poor accountability, has resulted in a health system that is unable, at present, to cater to the needs of the entire population.4

The affordability of health care is a serious problem for the vast majority of the population, especially at the tertiary level and also the quality of services varies considerably as regulatory standards are not adequately defined and effectively enforced 8. The Social or Financial schemes ust be designed in a manner that no person should be excluded from services or benefits of the scheme due to his / her financial status / ability to pay and operated in such a manner that no person who needs essential or emergency health care is denied of that service because of inability to make a personal payment4. Success of any UHC scheme will depend on providing the financial and other related benefits through an integral system of connecting the promotive, preventive and early clinical care services with the referred secondary and tertiary care services, required by the individual. An optimum strategy is the call to action for implementing universal health coverage in India through systematic strengthening of the health care delivery system and addressing the issues of social determinants of health.

For the efficient delivery of a wide range of equitable, comprehensive and quality health services to all Indian citizens, the Health System needs to adopt sustainable financing mechanisms with appropriate policy implementations. A sustainable mechanism is to be developed at central and state levels to minimise out of pocket health care expenditure through integration of private sector. Universality should include not only the poor, marginalised, hard-to-reach, mobile or traditionally discriminated groups, but also those who are relatively better off, so that they have an interest in building and benefitting from an efficient and equitable health system.4

References:


  1. Editorial – Health : an explicit human right ,The Lancet, vol. 387, no. 10022,p917 , 5 March,2016, http;//www.thelancet.com/journals/article/PIIS0140-6376(16)00629-2 /fulltext (Accessed on 25.03.16 )

  2. Chaudhuri R. N, - MDGs to SDGs : Journey continues for a better world , Indian Journal of Public Health, Volume 59, Issue 4, October-December, 2015

  3. Jindal A. K.. – Universal Health Coverage: The way forward, Indian Journal of Public Health , 2014 , vol. 58 : 3

  4. Planning Commission of India - High level Expert Group Report on Universal Health Coverage for India (2011) , http://planningcommission.nic.in/reports/genrep/rep_uhc0812.pdf (Accessed on 25.03.16 )

  5. Daniel Cotlear et al - Introduction , Going Universal , World Bank Group, New Delhi, 2015, P19.

  6. Patel Vikram et al - Assuring health coverage for all in India, The Lancet , vol.386,no. 10011, p2422-2435, Dec. 2015, http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)00955-1/fulltext (Accessed on 01.04.16 )

  7. Patel Vikram et al - Universal health care in India : the time is right, The Lancet , vol.377,no. 9764, p448-449, Feb. 2011, http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)62044 -2/fulltext (Accessed on 01.04.16 )

  8. U N in India - Universal-health-coverage, http://in.one.un.org/task-teams/ (Accessed on 01.04.16 )