Universal health coverage (UHC) encompasses two primary objectives – universal service coverage and universal financial coverage. The first objective underscores the principle that all individuals should have an equal opportunity to access high-quality healthcare at all times. Meanwhile, the second objective emphasizes the importance of preventing individuals from facing financial hardships when seeking essential healthcare services.
The measurement of financial hardship involves assessing catastrophic health expenditure, where health-related costs exceed 10% of a family’s budget. Additionally, it considers impoverishing health expenditure, which can lead to individuals being pushed into poverty. Extreme poverty is defined as an income that is less than $2.15 a day in 2017 PPP terms, while relative poverty is defined as less than 60% of the median per capita income, a criterion used in mid-to-high-income countries. Foregone essential health needs are also considered within this framework.
The current indices of service coverage gauge a spectrum of services related to maternal and child health, vaccinations, specific infectious diseases (such as malaria, TB, and HIV), certain non-communicable diseases (including hypertension, diabetes, and tobacco control), and the overall capacity of the health system. This capacity is measured through indicators like health worker density, hospital bed density, and the International Health Regulations (IHR) core capacity index. These indices collectively provide a comprehensive assessment of a healthcare system’s ability to deliver essential services across various domains while considering both service and financial dimensions of access.
As per the UHC tracker report released recently as part of the UN general assembly meeting, India’s service coverage index is in the 60-79% range group; impoverishing health expenses were >20% of the population for extreme poverty and 2-10% for relative poverty; 10-20% of the population experienced catastrophic health expenditure, and foregone care is estimated to be in the range of 15%. While the tracker is useful to get a macro view of the UHC and its progress over the years at a global level, each state in India needs to evolve its own set of indicators and robust data sets to monitor the state’s progress toward the goal of UHC by 2030.
The four pillars of Ayushman Bharat, namely 150,000 Jan Arogya Mandirs (formerly called health & wellness centers) to strengthen primary health care, Pradhan Mantri Jan Arogya Yojana (PMJAY) that provides financial cover to 500 to 600 million poor people, Ayushman Bharat Health Infrastructure Mission (ABHIM) that aims to strengthen public health infrastructure in underserved areas, and Ayushman Bharat Digital Mission (ABDM) that aims to achieve digital health transformation across the country are intended to move India to achieve UHC and SDG 3.0 goals by 2030. In addition to these, many health (health workforce and health goods related) and non-health policies (hygiene, sanitation, clean cooking energy, safe drinking water, healthy diet, physical fitness, air pollution, etc.,) will contribute to achieving the goal by 2030.
India needs to overcome certain barriers to realize its goals. There is a high variation in progress between various states and even within states. While service coverage has improved in urban areas due to private healthcare, it remains inadequate in rural areas, especially with regard to emergency and specialty services. While access is improving, there is no mandated quality assurance for the service providers leading to highly variable quality and safety of care that people receive. In addition, as every state in India has transitioned to the majority burden from non-communicable diseases, there is a need for continuity of care. While primary health care is being strengthened through Jan Arogya Mandirs, their integration with public health services and higher health services is essential to ensure continuity of care. Adoption of a standards-based, integrated, interoperable national health information system as envisaged under ABDM is a big challenge both in public and private healthcare provider systems.
As per the latest national health accounts, out-of-pocket expenses have reduced from ~62.6% in 2014-15 to 48% in 2019-20. The incidence of catastrophic health expenditure (CHE) arrived at from the NSS-75 round was 16.5% in 2018. The presence of children and elders in a family, large family, the presence of chronic diseases, and the use of private health care increased this proportion significantly. The CHE was nearly 44% for those families using private healthcare in 2018. Data on impoverishing health expenses and foregone healthcare is not available to assess the degree of financial hardship. The impact of the rollout of PMJAY and Jan Arogya Mandirs (Health & Wellness Clinics) since 2018 will only be evident when national health accounts for 2022-23 are published. While poor, rich, and formal laborers have some form of health insurance coverage, ~ 500 million informal labor and middle-income families (so-called missing middle) do not have any form of financial protection and are most vulnerable to financial hardship.
The following approaches may offer a few solutions towards the goal of UHC by 2030:
- Increased focus on social, environmental, economic, and commercial (SEEC) determinants (water, sanitation, air quality, clean cooking energy, employment, education, digital connectivity, healthy diet, pro-health taxes, and subsidies, physical fitness, etc.,) to promote health and reduce illnesses.
- Building district-level capacities in health status and systems assessment, undertaking disease surveillance and control measures, robust monitoring, evaluating and learning systems, leadership, and management to improve the efficiency and effectiveness of operations
- Deploying Ayushman Bharat Digital Mission (ABDM)-compliant health information systems across healthcare services and insurance providers (both public and private)
- Focus on community health literacy, engagement, participation, and self-care
- Ensuring last-mile digital connectivity and inclusivity to prevent the digital divide
- Innovative use of digital applications (telemedicine, digital diagnostics and therapeutics, wearable monitoring devices, clinical decision support systems, etc.,) in improving services and financial coverage
- Integration of comprehensive primary healthcare with secondary and tertiary healthcare through care pathways, clinical practice guidelines, interoperable digital health records, and bi-directional referral systems
- Active engagement of primary health care with communities through community health workers, community health volunteers, health councils, etc.
- Expanding ambulance networks and emergency rooms for timely access to time-sensitive emergency services
- Providing round-the-clock helplines to guide patients when they need
- Equal focus on preventive, early detection, and control measures for non-communicable diseases
- In addition to ensuring the highest quality standards of drugs, devices, digital tools, diagnostic equipment, etc., similar standards should be mandated for healthcare service providers. Technical and financial support can be extended to these providers, where needed.
- Institution of robust surveillance, alert, and response systems to secure people against mounting public health crises.
- Preparing infrastructure and human resources for possible future health shocks based on current demand-supply assessment and predictive modeling for surges in demand and disruptions to the supply of healthcare services and goods to make health systems resilient
- Increased public health investments to strengthen health systems and build capacities for efficient public health financial management (PHFM). Priority to health promotion, disease prevention, and early detection in budget allocations
- Moving towards an inclusive digital economy, formalizing informal labor thereby bringing them into mandated social health insurance, providing subsidies to attract missing middle to purchase essential health insurance products, user-friendly and innovative private health insurance products leveraging insuretech, innovative health consumer financing using fintech applications, expanding the public health insurance coverage in breadth and depth to reduce out of pocket expenses, making free or affordable primary healthcare services (consults, diagnostics, and drugs) accessible to all, blending public and philanthropic funds to expand the coverage are some of approaches to moving towards universal health coverage to eliminate financial hardships in procuring essential health needs.
- Adopting good participatory governance models on the premise of defined roles, rights, and responsibilities of various stakeholders of health and other social systems. Focus on building institutional mechanisms for strengthening cross-cutting and crucial functions of information sharing, transparent and reliable communications, and relations based on mutual respect.
The above approaches have to be adopted at different levels (local to global) as per the given context. Emerging concepts of One Health, whole of governments, systems, and societies have to be incorporated into these approaches. India has to invest in building capacities for generating the right research evidence to inform policies, strategies, and operations from national to local levels. Let us aim at a healthy nation by the 100th year of our independence!
