Achieving Universal Health Care | 13 Apr 2022

The Covid-19 crisis has provided a good time to revive an issue that is, oddly, slow to come to life in India — Universal Health Care (UHC).

Universal Health Care is seen as a route to building robust, responsive and efficient health systems capable of addressing growing inequalities in healthcare demands along with shielding populations from spiralling healthcare and medicine costs.

What is Universal Health Care (UHC)?

• The basic idea of UHC is that no one should be deprived of quality health care for the lack of ability to pay. UHC, in recent times, has become a critical indicator for human equity, security and dignity.
• UHC has become a well-accepted objective of public policy around the world. It has even been largely realised in many countries, not only the richer ones (except the US) but also a growing number of other countries such as Brazil, China, Sri Lanka and Thailand.
• The time has come for India (or some Indian States at least) to take the plunge.

What are the Routes to Achieve UHC?

• UHC typically relies on one or both of two basic approaches: public service and social insurance. In the first approach, health care is provided as a free public service, just like the services of a fire brigade or public library.
• The second approach (social insurance) allows private as well as public provision of health care, but the costs are mostly borne by the social insurance fund(s), not the patient,
  • Quite different from a private insurance market, it is the one where insurance is compulsory and universal, financed mainly from general taxation, and run by a single non-profit agency in the public interest.
    
    • The basic principle is that everyone should be covered and insurance should be geared to the public interest rather than private profit.

What are the Challenges to UHC?

• Unavailability of Public Health Centres: Even in a system based on social insurance, public service plays an essential role. The absence of public health centres, dedicated to primary health care and preventive work, create the risks of patients rushing to expensive hospitals every other day thus making the whole system wasteful and expensive.
• Containing Costs: Containing costs is a major challenge with social insurance, because patients and health-care providers have a joint interest in expensive care — getting better healthcare for one and earning for the other.
  
  • A possible remedy is to make the patient bear part of the costs but that conflicts with the principle of UHC.
  • Recent evidence suggests that even small co-payments often exclude many poor patients from quality health care.
• Identifying Services under UHC: Another big challenge remains in identifying what services are to be universally provided to begin with and what level of financial protection is considered acceptable.
  
  • Offering the same set of services to the entire population is not economically feasible and demands huge resource mobilisation.
• Regulation of Private Sector: Another challenge with social insurance is to regulate private health-care providers. A crucial distinction needs to be made between for-profit and nonprofit providers.
  
  • Non-profit health-care providers have done great work around the world
  • For-profit health care, however, is deeply problematic because of the pervasive conflict between the profit motive and the well-being of the patient.

What is the HOPS Framework and How will it Help Achieve UHC?

• About: It is possible to envisage a framework for UHC that would build primarily on health care as a public service. The framework might be called “Healthcare As An Optional Public Service” (HOPS).
  
  • Under HOPS, everyone would have a legal right to receive free, quality health care in a public institution if they wish. It would not prevent anyone from seeking health care from the private sector at their own expense.
  • But the public sector would guarantee decent health services to everyone as a matter of right, free of cost.
• Example: Some Indian States are already doing so, such as in Kerala and Tamil Nadu, most illnesses can be satisfactorily treated in the public sector at little cost to the patient.
• Significance: If quality health care is available for free in the public sector, most patients will have little reason to go to the private sector.
  
  • Social insurance could also play a role in this framework by helping cover procedures that are not easily available in the public sector (e.g., high-end surgeries).
  • Although HOPS would not be as egalitarian as the national health insurance model initially, it would still be a big step toward UHC.
    • Moreover, it will become more egalitarian over time, as the public sector provides a growing range of health services.

What can be the Way Forward?

• Vibrant Health System: A vibrant health system shall include not only good management and adequate resources but also a sound work culture and professional ethics.
  
  • A primary health centre can work wonders, but only if doctors and nurses are on the job and care for the patients.
• Standards for UHC: The main difficulty with the HOPS framework is to specify the scope of the proposed health-care guarantee, including quality standards. UHC does not mean unlimited health care: there are always limits to what can be guaranteed to everyone.
  
  • HOPS shall lay down certain health-care standards along with a credible method to revise these standards over time. Some useful elements are already available, such as the Indian Public Health Standards.
• State Specific Legislation on Health: Tamil Nadu is well placed to make HOPS a reality under its proposed Right to Health Bill. The state is already successful in providing most health services in the public sector with good effect.
  
  • A Right to Health Bill would be an invaluable affirmation of the State’s commitment to quality health care for all; it would empower patients and their families to demand quality services, helping to improve the system further.
  • Tamil Nadu’s initiative could be an emulation for other states.
• Health Financing: In order to achieve UHC, it is vital that governments intervene in their country’s health financing system to support the poor and vulnerable.
  
  • This requires establishing compulsory publicly governed health financing systems with a strong role for the state in raising funds fairly, pooling resources and purchasing services to meet population needs.
  • Greater targeted financing for public health systems will help tackle inherent weaknesses around quality of care and access, reduce out of pocket spending on drugs and improve human resource and infrastructure shortfalls.