India On Its Way To Achieve Universal Health Coverage By 2030?

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India On Its Way To Achieve Universal Health Coverage By 2030?

Universal Health Coverage entails ensuring all people have access to quality healthcare services – including prevention, treatment, promotion, rehabilitation, and palliation – without incurring financial constraints. India is committed to achieving UHC for all its citizens by 2030, which is fundamental to achieving the other Sustainable Development Goals.

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The health of India's population has witnessed drastic changes in a positve way over the last 20 years. The infant mortality rate (IMR) has dipped from over 71 per 1000 live births in 1998 to 31 per 1000 live births in 2017. Maternal mortality has fallen even more significantly, from 540 maternal deaths in 1998 to 170 maternal deaths per 100 000 live births in 2013, a fall of nearly 70 per cent.

These reductions in mortality were accompanied by a significant shift in the country's disease burden. Non-communicable diseases (NCDs) like heart complications, diabetes and cancer, which accounted for 30 per cent of disease burden in 1990, represented over 55 per cent of the disease burden in 2016, while communicable, maternal and child diseases accounted for about one-third of the load.

Universal Health Coverage

Addressing these rapid shifts requires a fit-for-purpose health system to move towards Universal Health Coverage (UHC). UHC entails ensuring all people have access to quality healthcare services – including prevention, treatment, promotion, rehabilitation, and palliation without incurring financial constraints. India is committed to achieving Universal Health Care for all its citizens by 2030, which is fundamental to achieving the other Sustainable Development Goals.

The ruling BJP government launched the Ayushman Bharat Programme in 2018, a potentially important step in this direction with two major components. Primary healthcare improvements through investment in 1,50,000 Health and Wellness Centres (HWCs) and a new cadre of mid-level health providers, were accredited for primary care and public health competencies. More than 38,000 HWCs were functional as of April last year, according to NITI Aayog.

An insurance mechanism, the Pradhan Mantri Jan Arogya Yojana (PM-JAY), covering hospital-level care in both public and private hospitals for more than 100 million low-income families was introduced. Since its launch in September 2018, PM-JAY has reimbursed over 9.5 million hospitalisation events and provided insurance cover to the poorest 40 per cent of the population. Over 50 crore Indian population are covered under this scheme with an insurance cover of Rs 5 lakh per each family. PMJAY provides comprehensive hospitalisation cover for secondary and tertiary care.

However, health experts suggest that the latest reform to move India closer to UHC requires alignment between its parts. The significance of such alignment is exemplified in the current response to the COVID-19 pandemic, which demands close coordination across the community, primary and tertiary levels of care. The long-term success of this reform requires greater alignment of service delivery, provider payment mechanisms and information systems.

Burden Of Household OOP

As India moves towards the path of UHC, the burden of household Out-of-Pocket (OOP) spending on non-hospitalisation care must be the focus, according to researchers. Average OOP spending on out-patient care is more than Rs 1,250 per person per year. Lack of financial protection for out-patient care leads millions into poverty annually. An average individual seeks 1.8 consultations per year, almost 70 per cent of which are in the private sector, and most of the out-patient spending is on medicines.

The National Health Policy (NHP) 2017 commits to free provision of primary care by the public sector, assured, comprehensive primary care with linkages to referral hospitals, emergency services, and free drugs to all in public hospitals.

What The Experts Say?

Keeping with globally recommended best practices on health systems strengthening for UHC, India's ongoing reform effort makes complementary investments to strengthen primary healthcare and reduce barriers to hospitalisation. As per medical experts, roles and responsibilities need to be allocated between the different health system levels. Two-way referral mechanisms between well-equipped health facilities need to be supported by incentives for patients and providers to seek and provide care at the most appropriate level. It calls for more significant investments at the primary care level and strengthening HWCs' role in gatekeeping care.

Also, aligning primary and hospital care will help limit the overburdening of higher-level facilities, travel time, unnecessary hospitalisations, loss of economic productivity for patients and ultimately, cost inflation across the health system. Incentives for patients who initially seek care at the primary care level could include shorter waiting times for referred surgeries or consultations than those who access higher-level facilities directly.

In an artcicle published in medical journal BMJ, experts suggest there is also a need to align provider payment mechanisms. Once established, payment systems are challenging to reverse, hence these systems must be appropriately aligned from the beginning.

With respect to hospital-level care, PM-JAY pays hospitals a fixed rate to provide specified care packages. For government hospitals, current arrangements indicate that while patients covered under PM-JAY are a source of additional revenue, non–PM-JAY patients are not included. This arrangement sets up an incentive to prioritise receiving PM-JAY patients relative to other patients.

Health information systems are another area where alignment could transform the country's reform. The PM-JAY insurance programme has developed a large scale provider-linked information system encompassing empanelled public and private providers as the basis for making payments. Steps must be taken to integrate this system with the existing health management information system (HMIS) in the public health sector.

Road Ahead

The way forward requires a careful thought process and planning. The National Digital Health Mission (NHDM) gives the opportunity by improving data linkages between the National Health Mission (NHM) and PMJAY. Availability of portable benefits, a wide network of diagnostic labs and telemedicine does hold the promise of expanding the reach of primary care to all country citizens.

India has come a long way in its UHC journey. However, it is also a reminder of the long and difficult road that lies ahead.

Also Read: Govt to Launch National Helpline To Report Atrocities Against SCs/STs


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Editor : Palak Agrawal
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Creatives : Tashafi Nazir

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