THE CONTEXT: The Covid-19 pandemic has shown the inadequacies of the healthcare provisions in India which once again created a debate on Universal Health Care (UHC). There are many approaches to providing the UHC to the people of a country and Healthcare as an optional public service (HOPS) is one of them. This article examines the benefits and challenges of HOPS in providing a UHC.
NOTE: For the purpose of our discussion, Universal Health Coverage and Universal Health Care are used interchangeably.
ALL YOU NEED TO KNOW ABOUT UNIVERSAL HEALTH CARE?
DEFINITION:
- According to WHO, Universal Health Coverage means that all people have access to the health services they need, when and where they need them, without financial hardship.
- It includes the full range of essential health services, from health promotion to prevention, treatment, rehabilitation, and palliative care.
- The basic idea of UHC is that no one should be deprived of quality health care for the lack of ability to pay.
NEED:
- Currently, at least half of the people in the world do not receive the health services they need.
- About 100 million people are pushed into extreme poverty each year because of out-of-pocket spending on health.
- This must change.
THE INDIAN SCENARIO:
- India has one-of-the highest levels of Out-Of-Pocket Expenditures (OOPE) contributing directly to the high incidence of catastrophic expenditures and poverty, notes the Economic Survey.
- It suggested an increase in public spending from 1% to 2.5-3% of GDP — as envisaged in the National Health Policy 2017 — can decrease the OOPE from 65% to 30% of overall healthcare spending.
- The Survey observes that the health of a nation depends critically on its citizens having access to an equitable, affordable, and accountable healthcare system.
- Public and private expenditures on healthcare in India do not exceed 5.5% of its GDP.
MODES OF UHC:
- UHC generally relies on one or both of two basic approaches: public service and social insurance. But there is another approach that aims to leverage the strength of both while minimising the limitations. (Read Ahead).
TEN PRINCIPLES OF UHC IN INDIA
THE PREVAILING ROUTES TO THE UHC
PUBLIC SERVICE:
- Health care, like the services of a fire department or a public library, is offered as a free public service.
- Surprisingly, this socialist vision has been successful not only in communist countries like Cuba but also in capitalist ones (well beyond the United Kingdom).
- Britain’s National Health Service (NHS) which is the best example of this genre, is free at the point of use for anyone who is a UK resident.
- Healthcare is provided by a single-payer – the British government – and is funded by the taxpayer although there are multiple providers.
- All appointments and treatments are free to the patient (though paid for through taxes), as are almost all prescription drugs.
- Responsibility for health services is devolved to local boards or trusts.
- These local units directly manage or contract services in their communities. Britain spends 9.9% of its GDP on the NHS.
SOCIAL INSURANCE:
- This method provides for both private and public health care.
- But the expenses are borne mostly by the social insurance fund(s), rather than the patient.
- Everyone has access to high-quality health care.
- A social insurance market is not the same as a private insurance market.
- The most basic version is one in which insurance is mandatory and universal.
- It is funded mostly by general taxation and administered by a single public-interest non-profit organisation.
- That’s how it works in Canada (at least in some provinces) and to varying degrees in other nations with “national health insurance” (e.g., Australia and Taiwan).
- This single-payer system makes it easier for the state to negotiate with healthcare providers for a decent price.
- However, various countries have different social models.
WHAT ARE THE CHALLENGES IN BOTH THE APPROACHES?
PUBLIC SERVICE:
- Providing free public health care to all will put a huge financial burden on the exchequer.
- The capacity of public health infrastructure in the country is hugely inadequate.
- There is a severe shortage of human resources in the health sector including medical, paramedical, and other staff as pointed out by the National Health Policy-2017.
- The profit-private healthcare system is highly developed and too entrenched in India. And hence, it is too costly to displace it.
SOCIAL INSURANCE:
- In the absence of public health centers, there is a danger of patients rushing to expensive hospitals every other day.
- This would make the system wasteful and expensive.
- Containing costs is a major challenge with social insurance because patients and healthcare providers have a joint interest inexpensive care — one to get better, the other to earn.
- Expanding social insurance to commercial healthcare providers is especially dangerous given their power and influence
- Another challenge with social insurance is to regulate for-profit private healthcare providers.
WHAT IS INDIA’S APPROACH TO UHC AS OF NOW?
Ayushman Bharat is National Health Protection Scheme, which covers over 10 crore poor and vulnerable families (approximately 50 crore beneficiaries) providing coverage up to 5 lakh rupees per family per year for secondary and tertiary care hospitalization the most important strategy for a UHC. Ayushman Bharat – National Health Protection Mission subsumes the ongoing centrally sponsored schemes – Rashtriya Swasthya Bima Yojana (RSBY) and the Senior Citizen Health Insurance Scheme (SCHIS). Benefits of the scheme are portable across the country and a beneficiary covered under the scheme will be allowed to take cashless benefits from any public/private impaneled hospitals across the country. It is an entitlement-based scheme with entitlement decided based on deprivation criteria in the SECC database. Also, there is a Primary Health Infrastructure system in place that caters to a wide range of medical health needs although there is a huge state-wide disparity in its reach and quality. There are also state-level medical insurance schemes and departmental medical facilities including defence, railways, etc.
HEALTHCARE AS AN OPTIONAL PUBLIC SERVICE(HOPS)- THE WAY FORWARD FOR THE UHC IN INDIA
WHAT ARE HOPS?:
- It is a framework for UHC that is based primarily on health care as a public service, with the potential to eventually converge toward some kind of NHS.
- Everyone would have the legal right to access free, high-quality health care at a public facility if they so desired. It would not restrict someone from seeking private health care on their own expenses.
- The public sector, on the other hand, would provide adequate health care to everyone as a matter of right and at no expense.
HAS IT BEEN PRACTICED IN INDIA?:
- This is something that some Indian states are already attempting. Most ailments can be properly treated in the public sector in Kerala and Tamil Nadu, for example, at a low cost to the patient.
- A vibrant private sector exists as well, which needs better regulation.
- However, as an optional public service, everyone has access to adequate health care.
ARE HOPS TRULY EGALITARIAN?:
- HOPS is not as egalitarian as the NHS and the National Health Insurance model as those with the means can access private healthcare. However, it will still be a big step toward UHC.
- Moreover, as the public sector offers an increasingly wide range of medical services, it can become more egalitarian over time.
- If quality medical care is available free of charge in the public sector, most patients have little reason to rely on the private sector.
ROLE OF SOCIAL INSURANCE IN HOPS:
- It can cover medical procedures that are not readily available in the public sector and thus can play a limited role in this framework.
- Social insurance needs to be built around public and non-profit private healthcare.
WHAT ARE THE DIFFICULTIES WITH HOPS?:
- Difficult to specify the scope of the proposed healthcare guarantee, including quality standards.
- UHC does not mean unlimited health care: there are always limits to what can be guaranteed to everyone.
- Not only does HOPS need health standards, but it also needs a reliable way to revise those standards over time.
- Some useful items are already available like the Indian Public Health Standards.
- But a major challenge is administrative and operational which do not have easy answers.
RIGHT TO HEALTH BILL- THE TAMIL NADU WAY FOR HOPS
Tamil Nadu is in a good position to achieve HOPS under the proposed Health Rights Bill. Tamil Nadu can already effectively provide most public-sector medical services.
According to the 4th National Family Health Survey, the majority of households in Tamil Nadu are going to the public sector for medical care in the event of illness. The scope and quality of these services have steadily improved over time. The proposed Health law is very supportive of the state’s commitment to quality medical care for all. The Bill seeks to cover all age groups and include people with disabilities and mental illnesses. It enables patients and their families to demand quality service and helps further improve the system. It will serve as a model and inspiration for all Indian states.
THE CONCLUSION: Healthcare provision in India faces many challenges and it requires multiple interventions. A good beginning can be ensuring a legal right to health in the nature of HOPS. Although not devoid of challenges, HOPS can provide “hopes” to the millions who are outside the formal medical care system.
QUESTIONS:
- What do you understand by Healthcare as an Optional Public Service? Explain.
- No society can legitimately call itself civilised if a sick person is denied medical aid because of a lack of means. Hence, a fully publicly funded healthcare system is required. Elaborate
