Missing links in universal health care

A number of announcements have been made by the Central and State governments on their intent to offer Universal Health Care (UHC). These welcome developments are timely as India is now rapidly becoming one of the few countries that do not seem to have a concrete plan for UHC in place. Even poorer countries such as Ghana, Kyrgyzstan, Rwanda, and Vietnam have now started to make significant progress in this area.

A fact often overlooked in these discussions, however, is that UHC is a complex idea and contains several prerequisites that need to be carefully incorporated into its conceptualisation, design and implementation. This article attempts to outline four of these essential elements.

Providing integrated care

The first, and perhaps the most important, element is the need to distinguish UHC from universally available health insurance. UHC seeks to ensure financial protection with the provision of appropriately priced, high quality, and integrated health care (combining primary, secondary, and tertiary care into a single, patient-centred health-care system). Ideally, financial protection and comprehensive health care are bundled together into an integrated ‘managed care’ proposition where the financial-protector (or the risk-manager) and the provider are a single entity. One of the key benefits of this model is the significant shift in incentives for the health provider — from the current focus on promoting hospitalisation and needless care-procedures, to incentives for promoting health and prevention of illness. Since the provider receives only a fixed amount per year, irrespective of the actual treatment provided, ‘managed care’ places rational treatment and cost-effectiveness at the centre of the model. Because of their very nature, health-care systems owned and financed by ministries of health are ideally suited for offering this type of ‘managed care’. And, if, but only if, there is very strong confidence in the ability of the system to regulate and monitor both patient and provider behaviours as well as population level outcomes, it is possible — as Thailand has done successfully — to invite large non-government players to also bid to provide such ‘managed care’ services. And, while the regulatory challenge in outsourcing ‘managed care’ to the private sector is quite considerable, it is very clear that fragmented health systems with different providers taking care of different parts of the health system, such as the private sector providing hospital-based care and the government focussing on primary care, with patients free to bypass it, is the worst of all possible choices. This fragmentation is the principal reason why a country like the United States finds itself in a situation where insurance premiums and costs of health care are both rising rapidly but population level health indicators are well below those of other comparable countries.

Primary care with gatekeeping

The second element is the need to shift the focus of attention from hospital-based care, to primary care — in terms of financing, development of infrastructure and usage. In order for India to achieve UHC, both in terms of financial feasibility as well as its well-being goals, it is clear that fewer than 2.50 per cent of patients in any given year should need hospital-based care. This implies that 97.5 per cent of all conditions would need to be dealt with at the primary-care level. UHC would therefore need substantial investments at the primary level combined with a strong gatekeeping framework that does not allow patients to seek hospital-based care unless they have been referred by a primary-care provider. It is believed that over 95 per cent of patients who visit tertiary care facilities such as JIPMER in Puducherry and AIIMS in Delhi are at the wrong place and have incurred all the hardship and costs that they did needlessly when they could easily have been cared for locally if good primary care was available. Evidence from Andhra Pradesh also shows that under ‘Arogyasri’, people are overwhelmingly seeking care at hospitals even for conditions which are patently treatable at primary-care facilities. While India undoubtedly needs additional hospital beds to provide adequate coverage even at the 2.50 per cent level mentioned earlier, it is imperative that the focus of immediate attention should not be hospitals or more AIIMS-like centres but well-designed and capable primary-care facilities so that patients can go there directly. Should they inadvertently end up at hospitals for seeking such care, they must be directed back. Only this combination of improved-availability and mandatory-gatekeeping will start to reduce the excess demand for hospital beds even as we gradually seek to address the unmet needs for hospital beds in deficient regions. Otherwise, we run the serious risk of this turning into a vicious cycle of ever increasing demand for hospital beds, further fuelled by an in-patient, insurance-led financial protection strategy, leading eventually to continual and rapid increases in health insurance premiums with no resultant improvements in health outcomes.

Covering everybody

The third key element relates to coverage — any universal health programme would need to include the entire population and not just be targeted at the poor. This is because India has a very steep poverty gradient and single health shocks have the potential to draw entire households back into poverty for all but the very top sliver of the population. For this very reason, globally, citizens of the most developed and several developing nations, who have significantly higher per capita incomes than do even the top percentiles of our population, have also been provided with full access to health care and financial protection. Engagement of the middle class also allows additional resources to be pooled along with tax resources since the amounts that they are currently expending on health care could be included as well. It is clear that development of integrated risk pools and their investment into an integrated UHC framework of the type discussed earlier (as would be implied by grouping the rich and poor together) would allow a significantly higher level of expenditure-volatility compression and the delivery of rational care. This would benefit both segments, with only the resultant net savings to the middle class being used to cross-subsidise the poor. Another benefit of including the middle class is in ensuring accountability of the health system. Being more conscious of its rights and with more resources to participate in the political process, the middle class is better placed to hold the public system accountable to higher quality of care, and perhaps, place health care centrally on political agendas — a feat that the Below Poverty Line (BPL)-targeted Indian health system has not been able to accomplish.

Separating out social determinants

The fourth key element is the urgent need for separation of core health care from extended health care, in a focussed discussion on UHC. While broader social determinants of health (or extended health care) such as provision of clean drinking water, improved sanitation and improved education of girls, have the potential to produce a very big impact on health outcomes, UHC is much more narrowly focussed on what the health-care system itself can provide directly in terms of primary, secondary, and tertiary care (or core health care). The reasons for the desirability of this separation are many and have to do principally with the appropriate allocation of responsibilities and resources. First, these broader determinants, for the most part, fall outside the domain of the ministries of health. Second, in India, the resources currently allocated for health care by the government have to go up three times, from 1 per cent to 3 per cent of GDP even to provide the essential elements of core health care at a reasonable level of quality and availability. Provision of extended health care would need a much larger level of resource allocation and would perforce have to be included in the domain of other ministries. And, finally, the benefits that accrue from extended health care go well beyond health (for example, time savings account for over 70 per cent of the benefits of home-delivered, clean drinking water and are not necessarily the most cost-effective interventions if viewed only from the narrow lens of health care.

There are a number of very important challenges that we face as a country. It is important to ensure that we are focussed on solving those using strong evidence-based strategies and with a very sharp sense of focus. Offering UHC to all our citizens is one such challenge. Here we need to be careful that we use the limited resources we have at our disposal in the most effective way, even if it means that some very important ideas need to be revisited or deferred for the time being.

(Nachiket Mor and Anuska Kalita are with the IKP Trust. The views expressed are entirely personal.)

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Printable version | Sep 21, 2020 9:18:35 PM | https://www.thehindu.com/opinion/lead/missing-links-in-universal-health-care/article6618667.ece

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