Towards Health for All

The aim of Universal Health Coverage is not to provide free healthcare to entire population but to make sure that people can avail accessible and affordable quality health services. The government will do well to build upon the public infrastructure already available, augment it with private capacity, and judiciously implement the government-sponsored health insurance schemes
By Dr Gridhar Gyani

Universal Health Coverage (UHC) aims to provide accessible, affordable and appropriate health services for all the citizens in any part of the country, regardless of the socio-economic status/class to which an individual belongs. It offers financial protection to an individual during illness thereby reducing the out of pocket expenditure while ensuring quality healthcare for all.
Most of the nations, which have implemented UHC, spend between 5-12% of GDP on health. In our case although government spending is about 1%, we should not forget that private sector has put in 4% and that makes it healthy 5%. This suggests that if public and private sectors join hands, it should be possible to have UHC in our country. As per the 12th Five year Plan (2012-2017), India is committed to provide UHC for all. The NDA government had announced to launch National Health Assurance Mission but has not been able to do, as the scheme is envisaged to cost over one trillion rupees.
In the backdrop of above, it will be interesting to examine how some of the states have already implemented partial UHC by way of government-sponsored health insurance schemes (GSHISs). Some of the innovative features common to all these schemes include giving patients the choice to visit any public or private provider empanelled by the government. In most schemes transactions are fully cashless, requiring no payment to be made by the patient to the hospital. These schemes target low-income groups, make impressive use of information and communication technology, and use pre-agreed package rates for payment. These schemes as such use PPP model as win-win formula for government, private health sector and above all the populations.
The World Bank report:‘Government sponsored Health Insurance in India: Are you covered?’ says that these schemes were introducing explicit entitlements, improving accountability, and leveraging private capacity, particularly with an aim of reaching the poor. The report had provided figure of 300 million populations, which was covered under these schemes by end of year 2010 and had extrapolated that by 2015, this figure will touch 630-million i.e. 50% of population would get covered under these schemes.
The first such scheme under the name AAROGYASRI was started in the year 2007 by the then Chief Minister of Andhra Pradesh YS Rajshekhar Reddy. The scheme continues to run in divided states under the same name in Telangana and under the new name NT Rama Rao Vaidya Scheme in AP.
The scheme provides financial protection to families living below the poverty line for the treatment of serious ailments requiring hospitalization and surgery through an identified network of healthcare providers.
All transactions are cashless for covered procedures. A BPL beneficiary can go to any hospital either public or private and come out without making any payment to the hospital for the procedures covered under the scheme.
Andhra Pradesh and Telangana have managed to cover as much as 70% of their population under the health insurance umbrella, providing cover up to Rs 2 lakh. Other states such as Tamil Nadu, Karnataka, Gujarat, Maharashtra and of late Rajasthan have similar health insurance schemes with coverage ranging from 30-50% of their population. The schemes are run directly by respective state governments through trusts except in case of Rajasthan, where scheme has been recently rolled out through ‘New India Assurance Company’ with budgetary allocation of Rs 375-crore and expected to benefit 65% of the state’s population.
Table-I shows seven states, which have government insurance schemes covering BPL and in some cases APL (Above Poverty Line) population. These states spend on the average 5% of their total budget on health. States like AP and Telangana allocate about 12% of their health budget on their insurance schemes, with actual amounts as Rs 800-crore and 650 crore respectively, whereas TN allocates little over 9% of health budget (780 crores) on the insurance schemes. These states are role model in demonstrating how to cover their majority of venerable population (near UHC) to provide quality healthcare through network of empanelled private and public hospitals. In contrast, Table-II shows some of large states like UP, Bihar, MP and WB, which provide on the average only about 3% of their budget on healthcare which is simply inadequate to operate health insurance schemes.
The states in Table-I providing government health insurance schemes, account for 40% of country’s population. Similarly, other 4-states in Table-II, not providing any insurance also account for 40% of country’s population.
Central Government Health Insurance Schemes: Rashtriya Swasthya Bima Yojana (RSBY), launched in year 2008 provides health cover to BPL households pan India up to Rs 30,000 for most diseases that require hospitalization. It empowers BPL beneficiaries to choose between public or private hospitals. The scheme is IT enabled as beneficiaries are issued with biometric enabled smart card, with portability across India. The scheme has already issued 40-million smart cards with estimated coverage of 200-million populations.Now the government has plans to replace this with ‘National Health Protection Scheme’ with enhanced cover of Rs 1lakh
Then there are schemes run by the government of India for various segments of their employees. These include Central Government Health Scheme(CGHS) catering to central government employees, pensioners and their dependents. Then there is Ex-Servicemen Contributory Health Scheme (ECHS) covering retired defense personnel and their families. Other noteworthy central scheme is Employee State Insurance Scheme (ESIS), which is tailored to provide health protection to worker population and their dependents. The three schemes roughly cover 100-million population.
Road Map & Way Out: Going by the above, it is evident that more than 50% population has definitely some or other kind of cover for health services. This includes 40-70% population of seven states which have state government insurance schemes and these states represent 40% of national population. Then we have RSBY, which cover about 200-million populations. Another 100-million populations gets covered under various central government health schemes. We also need to include some percentage of populations, which get covered under private insurance and employer insurance schemes. This is a big positive, against the general belief that majority Indian populations was burdened with out of pocket expenses.
It is to be realized that UHC is not about providing FREE healthcare to entire population but to make sure that populations get health services, which are available, accessible and are affordable. It is equally important that health services conform to safety protocols. In a developing country like India, the immediate struggle is always about ROTI, KAPDA & MAKAAN. Education & Healthcare until recently were not considered as priorities. After implementing Right to Education, the obvious focus has shifted to Health and hence the need for UHC. Considering the fact that India still cannot afford to have bigger share of GDP towards healthcare, we can begin with consolidating and expanding of existing success models rather than thinking of nationwide new model. This can come through planned & focused interventions as follows;
1-We need to encourage and cater for some extra budgetary allocation for states so as to enable them to launch schemes for BPL/ APL populations like ones in seven states. This would mean that states have about 8-10 lakhs per capita in the budget for health. This would enable states to contribute 8-10% of health budget to execute government insurance schemes for BPL/APL populations. If required, certain APL category of populations can be covered for part insurance and rest coming through co-payment, a practice in vague in many developed nations.
2-Government can simultaneously strengthen RSBY by extending its reach among those states, which do not have state run insurance schemes. Government may also progressively expand cover from present limit of Rs 30,000 to Rs 100,000. Populations will not mind raising the contribution from Rs 30 to Rs 100. 3-Government needs to be open in roping private sector in all UHC related efforts. We need to treat all private facilities as providers of national health. Presently there exists a kind of trust deficit between the two. Let us not forget that some of the best state run insurance schemes in AP, TN &Telangana are based on government buying health services from private empaneled hospitals. Even the World Bank report quoted above suggests a balanced approach, building upon the public infrastructure already available, augmenting it with accessible private capacity, and utilizing the lessons learned from the GSHISs.
4-Benefit from GSHISs is largely confined to urban populations for the simple reason that majority of tertiary care hospitals are confined to tier-I and tier-II towns. For rural populations, the healthcare although is available but not accessible more so during emergencies. The Community Health Centers (CHCs) which are 30-bedded secondary care government hospitals located at TALUK level are ill equipped in most cases. It will be worthwhile if private sector could be invited to operate some of the CHCs with immovable fixtures remaining with government and movable including all manpower coming from private sector. Private sector is ready to undertake this within the government earmarked budget.
5-Finally for long term sustenance of UHC, it is necessary that we rationalize the way reimbursements are made to private sector under various government schemes. Rates of many critical medical procedures are found to be illogical, which directly and indirectly affects patient safety. We need to incentivize quality by linking payment to the clinical outcomes and patient satisfaction, the practice prevalent in most developed nations.

The Author is Director General, Association of Healthcare Provider, India