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Progressing towards Universal Health Coverage: Can the developing world learn anything from India?

By on December 1, 2017

Manager Quality Improvement and Quality of Life (MNCH & NCD), at the Karnataka Health Promotion Trust, Bangalore, India

Earlier this month, I was shocked to see a headline in a leading national newspaper  stating how a recent doctors’ strike against the proposed medical establishment amendment bill in Karnataka had resulted in the death of six patients. Karnataka, one of the southern states in India, was first in the country when it announced its plan of rolling out of universal health coverage (UHC), by framing a comprehensive health insurance scheme called “Arogya Bhagya” providing essential and emergency health services for all its denizens. Under the proposed UHC scheme, all the 14 million households in the state will be eligible for cashless treatment for up to 150000 Indian Rupees (≈ 2320 USD) in government and private hospitals. A group of state run health insurance schemes were merged to form the Arogya Bhagya scheme. As an immediate follow up to the announcement, the ruling government (of the Indian National Congress) proposed an amendment to the Karnataka Private Medical Establishment Act (KPMEA) of 2007 – called the KPME (Amendment) Bill 2017, with a plan to fix rates for each class of treatment, and to provide grievance redressal systems for patients. The bill also plans to ban the practice of demanding advance payment in case of emergency treatment, and not releasing dead bodies to relatives till all dues have been settled. Also proposed, is a heavy increase in penalty (both monetary and custodian) for those private establishments found to be non-registered. As an immediate backlash, within days of this “proposed” move, the private healthcare industry including private doctors went on a state-wide protest against the amendments causing disruption of services across the state. This issue also got political mileage when the opposition party (the Bhartiya Janata Party) labelled the move as an “undue haste” and asked government to withdraw the bill immediately. Finally, that settled into a compromised bill with the most critical components of regulation removed. Private hospitals in Karnataka, like other such hospitals across the country, are known to charge patients heavily and force patients to undergo unnecessary diagnostics. Clearly this shows how private health sector interests go against public interest in the state, and for that matter across the country. The backlash is being seen as a serious jolt to the UHC move by the state.

UHC, by definition, is “the desired outcome of health system performance whereby all people who need health services receive them, without undue financial hardship.” UHC cuts across all (or at least most) health related sustainable development targets.  Zooming in on India, then: despite the fact that the country is one of the fastest growing economies in the world, India’s public healthcare spending still stands at a meagre 1.2% of its GDP.  This is very low as compared to minimum global requirements and is a rollback on a previous commitment, and stands against its commitment to achieve UHC. However, finance is not the only challenge. It may seem obvious that with increased fiscal space, many developing countries have the potential to achieve UHC but as the Karnataka example shows, many other aspects (vested interests, political economy issues and a weakened public health system) play a role in making progress (or not). With poor infrastructure (including thin human resources!) at public health facilities coupled with questionable quality of services at both public and private government set-ups, and government failing to control an unruly private sector, the achievement of UHC in the country, even in the long run (by 2030), is surely in jeopardy.

We are already over two years into the adoption of SDGs, the first ever (really) “global” to-do list for a fairer, safer and healthier world (by 2030), and nothing seems to have gotten more attention in the global health community than SDG target 3.8, UHC, and rightly so. Yet, 400 million people globally still lack access to essential health services and 150 million are being pushed into poverty each year due to health related costs. We cannot just wait and wait till the end of 2030; a typical “business as usual” approach will take us nowhere, we all agree. WHO rightly pointed out  that all countries (i.e. at all income levels) can do more (even though some of them won’t be able to achieve UHC by 2030), to improve health outcomes and tackle poverty, by increasing coverage of health services, and by reducing the impoverishment associated with payment for health services.

In September, at the Social Good Summit in New York, dr. Tedros, the new WHO DG, called upon countries to “come to their senses” and “make UHC happen”. India presents valuable insights for countries in the developing world to realise this unique challenge, “come to their senses” and of course adopt bold solutions on the UHC path.  The Indian case shows that’s anything but straightforward, but episodes like the recent one in Karnataka still provide lessons for other countries. As we are inching towards UHC Day in about 10 days, it’s high time we realise what needs to be considered to move towards UHC:  definitely it’s not just about (lots of) money (more public money for health surely helps!) but also about a change in set rules in order to be able to manage that money more effectively.

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