How to ensure universal healthcare in India

The World Health Organisation’s (WHO) Alma Ata conference defined the concept of Primary Healthcare (PHC) in 1978. It formed the basis of ‘Health for All’ by year 2000. However, competing priorities and differential interpretation by the member-states have resulted in varied levels of implementation and outcomes. Political, demographic, economic, social and other factors influence the understanding that a country derives from the concept and expresses through its PHC policies.

From ambulatory or first-contact personal healthcare services, priority health interventions for low-income populations, to an essential condition of human development, the concept of PHC has been interpreted differently for different economies. Forty years down the road, WHO has rekindled its approach to PHC with a Universal Health Coverage (UHC) led ‘Asthana declaration’. It reiterated the commitment that, “…A primary healthcare (PHC) approach is the most effective way to sustainably solve today’s health and health system challenges…”

The concept of universal health coverage (UHC) was first touched upon by the Sickness Insurance Law, a national social health insurance policy, in Germany in 1883. Over the next few decades, the concept evolved in many countries and was implemented in many forms. In recent years, global bodies such as the WHO and the World Bank have adopted the concept, which found its place in the United Nations’ Millennium Development Goals (MDG) and Sustainable Development Goals (SDGs).

Over 50% of the world population lack full coverage for essential health services and 12% spend over 10% of household income on medical care. Given the context, UHC aims to provide a range of essential medical care services that are accessible, affordable and ensure financial protection for all.

Contrary to the wide perception, UHC does not mean free medical care for all possible health interventions. It is, however, inclusive of legislation and governance at the highest level, supported by health financing, skilled and qualified human resource, medical, diagnostic and pharmaceutical care, health innovation and technologies, and quality assurance mechanisms.

Essential to the UHC is PHC, which is the first step towards ensuring health and well-being for all. PHC remains a proven, equitable, efficient and effective strategy to deliver the universal fundamental right of holistic health for everyone without stigma and discrimination.

PHC in India

Adapting to the evolved understanding of PHC, the Health and Wellness Centres (HWCs) under the ambit of the Ayushman Bharat programme are providing services directed towards the achievement of holistic health. Along with the traditional PHC services, the HWCs include non-communicable diseases management; ophthalmic and ENT care, geriatric care, emergency medical services for burns and trauma, and mental healthcare.

Proper implementation and robust PHC services will take India closer to achieve health-related SDGs. On the one hand, the comprehensive PHC system will reduce dependency on secondary and tertiary care, reduce the country’s disease burden and reduce expenditure on countering diseases; on the other hand, it will increase job opportunities, better overall health of the nation, and contribute to economic growth. Most significantly, while providing equal access to quality healthcare across social strata, the system will prevent people from plunging into poverty due to out-of-pocket expenses.

While the government decision of transforming PHC centres into HWCs, followed by a NHPS, is a step in the right direction, the transformation in the healthcare scenario will require considerable administrative willingness and effort.

Over 68% people are based in rural areas that face acute shortage of healthcare facilities. The healthcare workforce is far from being adequate, with 1:921 doctor-patient ratio, while the country is short of an estimated 1.94 million nurses. In terms of facilities, India has around 0.9 beds per 1,000 people. There are around 25,650 PHC centres across India, with 61% of them having only one doctor each and around 7.6% PHCs having none.

It is important that adequate steps be taken so that the HWCs do not meet the same fate as that of the PHC centres. The fundamental principles of health system strengthening are being addressed to make this a reality. There are six pillars of health systems strengthening needed to build a robust healthcare system.

• Health governance. Investing in health governance is to ensure that a transparent and accountable system is developed, which has multiple stakeholder participation for stronger health advocacy at various regional and community levels.

• Health information is needed for the creation of evidence-based decision-making culture, furthered by improved approaches and tools, and which ultimately support strategic and incremental improvement of integrated health information systems. Demographic health surveys, civil registrations and vital statistics, district health information systems are some of the tools used.

• Health finance. The institution of preferential public financing, increasing of public and private resources for shared goals, and incentivising private sector investment in health via philanthropy or shared value creation of public-private partnerships are some of the ways through which a robust health financing structure can be built.

• A robust service delivery mechanism includes setting up of quality, coordinated delivery of essential and evidence-based health services and developing and implementing cost-effective essential health services.

• Healthcare workforce. The creation of strong human resource is essential for strengthening health system. Conceiving and implementing effective models of imparting health education and ensuring skill training competence are important steps in building a strong health workforce.

• Supply chain strengthening is crucial for healthcare systems as it ensures continuous delivery of quality healthcare commodities and products, such as medicines, equipment, etc. Technology-enabled logistic information management system is playing a key role in efficient and smooth services at primary, secondary and tertiary care level.

(The writer is CEO, Wadhwani Initiative
of Sustainable Healthcare)