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What universal health assurance can mean for India ()Hindu

t is achievable for this country that has made tremendous progress in universal immunisation.

Over the last few weeks, India and the world watched in disbelief as Chennai, the fourth largest city in country was crippled by unusually vicious monsoon rains. As the city and neighboring areas were pounded with over 400 mm of continuous rain, many parts of the metropolis gave way to the deluge of water that inundated large swathes of land - sweeping away its residents, infrastructure and powerlines in its wake.

In the aftermath amidst now fetid pools of receding water, city and state and society take stock of the devastation- more than 300 people dead, several hundred missing and thousands of homes destroyed by flood waters. While poor urban planning, illegal construction and lack of storm water drainage are attributed in large part to the disaster, the huge health implications of this calamity are only just manifesting themselves. Water logged areas infested with sewage debris, un-cleared garbage and rain damaged medical facilities present myriad opportunities for infectious/vector borne disease outbreaks, resurgence of chronic diseases and nutritional challenges especially for vulnerable populations.

On Saturday, the 12th of December, hundreds of organisations across the world celebrated Universal Health Coverage (UHC) day – marking three years since the passing of a United Nations General Assembly resolution that committed all countries to achieving UHC. This goal is achieved when everybody receives the quality health services they need without suffering financial hardship and it has also been included in the new United Nations Sustainable Development framework. The Director General of the World Health Organisation simply says: “UHC is the best concept that public health has to offer”.

But what are the implications for UHC for India? The ability to deliver quality health services that does not impoverish populations has meant balancing the demands of complex health systems with the ability to fund a progressive range of services. In addition to shielding populations from spiraling healthcare and medicine costs UHC is also seen as route to building build robust, responsive and efficient health systems capable of addressing growing inequalities in healthcare demands and access. UHC has become a critical indicator for human equity, security and dignity.

The State government’s relief efforts include protecting sanitary workers involved in the clean-up efforts with preventive vaccines, conducting monitored emergency health camps, and providing chlorine tablets to purify water sources. But even as these initial public health measures are being implemented, the health system demands are enormous. Active surveillance is required of affected areas including hospitals for fever and disease outbreaks. Monitoring drug shortages and stock-taking of health infrastructure are also critical next steps. Ongoing health outreach has to include both curative care for affected citizens as well as preventive measure for populations at risk. Needless to say, with the healthcare workers, facilities and drugs in short supply, costs to accessing health services and medical supplies will go up. All this requires systems level coordination, cooperation and action across both health and non-health sectors that influence health outcomes like water, sanitation and rebuilding efforts.

The floods present a wake-up call to take stock of healthcare delivery mechanisms at the centre and states with their expanding cities – and its ability to deliver, particularly in disasters when its capability is truly tested. Universal Health Assurance presents a first step to addressing these concerns. UHC can help build resilience against shocks be they in the form of epidemics (e.g. Like Ebola in W Africa), financial crashes or natural disasters like the terrible situation in Chennai.

Adopting UHC involves three fundamental components. The first step that underpins all others is to invest more public spending on health (from the current 1% to 2.5% of the GDP). Greater targeted financing for public health systems will help tackle inherent weaknesses around quality of care and access, reduce out of pocket spending on drugs and improve human resource and infrastructure shortfalls. The second phase involves strengthening overall health system capacities that include: prioritising primary health as part of a cohesive care continuum; integrating surveillance systems; and co-opting the strengths of a vibrant private health sector through prudent regulation. The final phase involves restructuring governance and accountability mechanisms to better manage health delivery. The single biggest obstacle to achieving integrated national healthcare in the country has been the lack of convergence between various ministries dealing with education, health services and national vertical targeted programmes with non-health sector bureaus like water, sanitation and infrastructure.

The 2010 World Health Report recognizes that implicit in the definition of UHC, is a requirement that healthy and wealthy people in society cross-subsidise health services needed by the poor and vulnerable. It also recognizes that in a free market where people buy and sell health services voluntarily, by paying user fees or buying private health insurance, this equitable outcome will never occur. In order to achieve UHC, it is vital that governments intervene in their country’s health financing system to support the poor and vulnerable. This requires establishing compulsory publicly governed health financing systems with a strong role for the state in raising funds fairly, pooling resources and purchasing services to meet population needs. UHC requires a health financing strategy that replaces private voluntary financing (fees and private insurance) with compulsory public financing (from progressive tax revenues and compulsory social health insurance).

A recent paper by Vikram Patel and colleagues in The Lancet, documenting India’s progress in health, calls for prioritising services for groups across the whole population, based on their vulnerability and risk with gradual expansion of health coverage of high-priority services to everyone. This would involve integrating the country’s various health insurance schemes and targeted vertical programmes into a national health assurance fund under a National Health (Assurance) Mission.

Regionally, Southeast Asia has exhibited dramatic health financing transitions for UHC from predominantly private systems to public ones governed by the state. Notable examples include Japan (from 1961) Korea (1977), Taiwan (1995) Thailand (2002) and most recently China which increased coverage from around 30% i in 2003 to over 96% within a decade. These countries managed to extend population coverage by rapidly increasing public financing, by mixing tax financing with contributions from compulsory health insurance schemes. Often the key to achieving full population coverage involved injecting large sums of tax financing into the system to close coverage gaps in the informal sector. In Thailand, in 2002, this involved injecting 0.5% of GDP of public financing into the health system in one year.

India’s economic and social progress eventually hinges on a healthy demography that has access to health services they need at all times good and bad. Universal Health Assurance is achievable for this country that has made tremendous progress in universal immunisation and establishing care continuum for reproductive, maternal, child and adolescent health. But for this to happen, the government needs show the political will to mandate health as a fundamental public good, central to India’s developmental ambitions, on a par with education economic progress.

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