The commitment to achieve Universal Health Coverage (UHC) by 2030 is a mandate set by the Sustainable Development Goals (SDG) of the UN and signed up to by India in September 2015. It is now clear that the National Health Mission (NHM) and a revamped Rashtriya Swasthya Bima Yojana (RSBY) — soon to be renamed the Rashtriya Swasthya Suraksha Yojana (RSSY) — are the two tracks on which this train will be moved by the Central government. The States will attach their own additional compartments to this national express as it traverses their territories, but may run some independent ‘locals’ as well.
Even from the SDG dateline, it is clear that UHC will not be achieved immediately. The World Health Organisation (WHO) describes UHC as a state where the health needs of all citizens are met without any of them experiencing financial hardship. It depicts UHC as a cube, with three dimensions: population coverage (what proportion of people and which sections are covered); service coverage (what is the package of health services that is covered) and cost coverage (what proportion of the health-care cost is incurred as out-of-pocket spending and how much is met by the government or employer). WHO acknowledges that the cube will be filled progressively, as resources for UHC increase in different health systems. Hence, the need for prioritisation, within and across each of these dimensions.
Contending pathways There will be a dynamic tension between the perspectives of those engaged predominantly with each of these dimensions. Politicians are likely to look at population coverage as the key priority — wanting to ‘protect’ (and please) as many citizens (voters) as possible in the shortest time frame. They will advocate from the platform of equity. Health-care professionals (especially influential clinicians) are prone to recommend as many clinical services as possible, especially expensive high-end technologies. They will argue from the pulpit of quality health care. Economists will argue for reduction of poverty-inducing personal expenditure, while limiting the cost to the public exchequer. They will expound from the lectern of socially responsive and fiscally prudent public financing.
How does one reconcile these seemingly complementary, but also potentially conflicting, priorities to get the UHC train moving? Some advocate the process of ‘progressive universalisation’, in which a limited package of clearly identified essential health services is available to all without financial hardship (cost covered through tax funding or government-subsidised social insurance). Other services are provided to the poor at government-subsidised low cost but the non-poor will have to pay full cost or purchase private insurance cover. Others suggest a large package of health services to be provided free of cost to the poor, with government funding, while the non-poor will have to pay for all services at the beginning of the UHC process. This approach of ‘pro-poor’ universalisation appears to champion the poor but is flawed in many respects. First, it is not truly universal because it only targets the ‘poor’. It ignores the fact that targeted social sector programmes fail because influential sections of society have no stake in the success, sustainability, scalability, quality and integrity of such programmes which end up as false promises. Such an approach also fails to recognise the financial vulnerability of a large fraction of the ‘non-poor’ to health care-related impoverishment.
Progressive universalisation If we are to adopt the approach of progressive universalisation, prioritising the poor but not excluding the non-poor from the essential package that UHC begins with, there is a need to carefully select the services that go into that package. The criteria for inclusion and exclusion need to be transparent, explicit and rational. Rich countries, that can afford to cover a wide range of services, adopt a ‘negative list’ of services specifically excluded from the package. Low- and middle-income countries, with less resources, begin with a list of services specifically included in the package and progressively expand it as more resources accrue.
Criteria should include: disease burden (whether it is a major health problem in a country or State); expected size of health impact of the intervention (based on effectiveness estimated in research studies and then modelled for a standard population); cost-effectiveness (value for money) compared to other interventions; affordability (total budgetary impact); degree of financial risk protection (impact on out-of-pocket and catastrophic health expenditures and health care-related poverty); equity (attention to vulnerable groups); feasibility (technical and legal constraints); health system readiness (resourced, responsive); scope (scalability, sustainability) and acceptability (alignment amongst stakeholders and public acceptance).
Unfortunately, technocratic approaches to the development of an essential package, in many countries, have been dominated by cost-effectiveness as the principal criterion. What is cost-effective in a specific health condition may not have a large population health impact, nor may it be affordable if large-scale application demands a big chunk of the health budget. Also cost-effectiveness must always be balanced with respect for equity, lest some vulnerable groups get excluded from the benefits of UHC. Further, a short-term perspective must be avoided. Otherwise, the medium- and long-term gains of health promotion, disease prevention and primary health care services will be ignored. Their co-benefits for other sectors (like education and environment) and inter-generational benefits (through better health for the progeny) are also outside the count of conventional economic analyses.
In order to ensure that all relevant criteria are appropriately integrated into the choice pathway for package development, wide-ranging consultations are needed, involving a large array of stakeholders. Community perspectives and civil society engagement are as important as the expertise of economists and health-care providers. This public health agenda, which will radically reconfigure our health system, should not be derailed by the populism of electoral politics, personal preferences of prominent medical professionals or the parsimony of public financing. It needs an all-of-society consensus and commitment, developed through participatory leadership.
K. Srinath Reddy is President, Public Health Foundation of India. The views expressed are personal.
