India’s Manoeuvres towards Universal Health Coverage:
A Discourse from Governmental Schemes
Universal Health Coverage (UHC) has recently become a top item on the global health agenda pressed by multilateral and donor organizations, as disenchantment grows with vertical, disease-specific health programs all over the world. Many scholars utter that UHC can be described as “the single most powerful concept that public health has to offer” under the flagship of the World Health Organization. As a scheme, it ensures that people do not suffer financial hardship while paying for healthcare services. The UHC not only has a direct impact on people’s health but also enables people to be more productive and declines the possibility of being pushed into poverty and uncertainty. Thus, UHC is a critical component of sustainable development. India approached this scheme with some of its already existing programs and also with some of the newly drafted programs. Among these programs, Pradhan Mantri Swasthya Suraksha Yojana, Janani Suraksha Yojana, Rashtriya Swasthya Bima Yojana and Ayushman Bharat can be treated as four pillars of Indian approach. In this background, this paper tries to explain UHC as a concept and also tries to make detail discussion regarding India’s instrumentalities to achieve the UHC for securing better health for its citizens in the near future.
- Universal Health Care: The Concept
Out-of-pocket payments and lack of access to healthcare create ﬁnancial barriers for thousands of people that stop them from seeking and receiving required healthcare services. To solve this pan-globe issue, the World Health Organization propounded a new recommendation with the nomenclature “Universal Health Coverage” (UHC). Thus, from the inception, the UHC has become a focal point in global health conversations. As per the WHO’s scheme, UHC means “all people receiving quality health services that meet their needs without exposing them to financial hardship in paying for them.” However, this definition of the UHC varies with the requirement of time and as the frame of the social structure. In 2005, the 58th World Health Assembly, held in Geneva, indirectly defined UHC as “access to key promotive, preventive, curative and rehabilitative health interventions for all at an affordable cost.”
Somewhat differently from the earlier definitions, the World Health Report in 2010 specified the UHC as a goal under which “all people have access to services and do not suffer financial hardship paying for them”. Thus, the 2010 World Health Report offered UHC as an objective and a policy for its member States to reform their healthcare systems according to the needs of their people. Since then, most definitions have had an alike framework with some variation in phrasing. Among these variations, at least four kinds of phrasing are major. Firstly, some definitions declare that everybody must have “access” to healthcare services as opposed to “receiving” healthcare services. Secondly, some definitions refer to “needed services,” “key services,” or “necessary services,” as opposed to “services that meet people’s needs.” Thirdly, some definitions denote to “financial catastrophe,” “financial ruin,” or “poverty” rather than “financial hardship.” And fourthly, all definitions do not explicitly link the financial damage to payment for services.
Therefore, in general, the UHC broadly means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, and also ensure that the use of these services does not expose them to financial hardship. In the spirit of previous unifying concepts related to health such as Health for All, Basic Health Needs etc., the UHC offers a vision in which all individuals will enjoy (i) a strong and efficient healthcare system that widths preventive and curative medicine, (ii) affordable access to that required healthcare system, and (iii) get support from sufficient human resources for the healthcare system.
Hence, the detail scheming of the UHC reveals that the concept of the UHC symbolizes broadly three related objectives: (i) equal access to health services – every individual who needs services should get them, and thus, healthcare services should not be available only for those who can pay for them; (ii) quality of healthcare services should be good enough to improve the health of those who are receiving that service and should have the capacity to satisfy those needs, and (iii) people should be protected against financial hardship. Thus, reducing people’s responsibility towards the paying for healthcare services out of their pockets will also reduce the probability that people will be pushed into poverty because of the unexpected illness which requires them to use up their life savings or borrow financial supports and ultimately destroys their futures with regard to the financial support system. Thus, accordingly in 2015, the Sustainable Development Goals fixed achieving UHC as one of the targets.
In totality, the UHC has been endorsed as a social welfare strategy that can strengthen healthcare systems, raise revenue for healthcare, and improve social risk protection in low and middle-income countries. From the definitional scheme, it is clear that UHC incorporates two complementary dimensions in addition to ﬁnancial risk protection, those are: (i) the extent of population coverage (who is covered) and (ii) the extent of healthcare service coverage (what is covered). A broader answer to these questions is always the welcome step from the national perspective. Therefore, if any country achieves the UHC successfully with all its dimensions and corners, then the health scenario of the people of that country will obviously change.
III. India’s Response to Universal Health Care
Traditionally in India, the budget allocation in health is very low which causes the failure of the government sector to provide healthcare services to such a vast population. It compels patients to seek care in the private sector and thus, the chance of exploitation increases. Evidence suggests that a dynamic interaction between five factors forces patients towards private health sector in India: (i) healthcare provisioning dominated by private sector, (ii) high share of private investment as compared to public investment in the healthcare, (iii) scarcity of public services in critical areas, (iv) lack of efficiency and accessibility in the public sector and (v) better infrastructural availability in the private sector. As a result, by paying high-cost, people agree to move towards the private healthcare sector and thus, generally, patients have to pay more than three-quarters of health expenditure out of their pocket. Even the competition in the healthcare section sometimes forces the public sector to act as a private sector. However, India’s commitment towards achieving the UHC is clearly reflected in recent policy makings and institutional mechanism building, which are dedicated towards increasing healthcare coverage for its people. To attain these goals, India has initiated various policies like National Health Policy, National Rural Health Mission, National Urban Health Mission etc. In addition to these, there are various schemes of the Government of India which are also beneficial to include poor people within the health coverage mechanism. Majorly, four schemes are there to address these issues: (i) Pradhan Mantri Swasthya Suraksha Yojana, (ii) Janani Suraksha Yojana, (iii) Rashtriya Swasthya Bima Yojana and (iv) Ayushman Bharat – National Health Protection Mission. For a better understanding of India’s initiatives towards UHC, a detail deliberation of these abovementioned schemes is very much required.
- Pradhan Mantri Swasthya Suraksha Yojana
Among these schemes, the Pradhan Mantri Swasthya Suraksha Yojana (PMSSY) was declared in August 2003 with the aim of correcting regional imbalances in the availability of affordable or reliable tertiary healthcare services. It also includes the aim of attaining self-sufficiency in graduate and post-graduate medical education and training in India. Primarily, the PMSSY has two components (i) setting up of AIIMS like institutions, and (ii) up-gradation of Government Medical College Institutions (GMCIs) for securing health for all as stated in Alma Ata Declaration in 1978. In March 2006, the Phase-I of the PMSSY was approved by the Government which comprised of (a) setting up of 6 AIIMS like institutions (later re-named as new AIIMS), and (ii) up-gradation of 13 existing State Government Medical Colleges or Institutions. Upgradation of GMCIs envisaged improvement in healthcare infrastructure through the construction of Super Specialty Blocks or Trauma Centers. Further in Twelfth Five Year Plan, the Government again decided to increase the number of new AIIMS and to elevate other the GMCIs in subsequent phases. As a consequence, over the years, the scheme has been expanded. As of March 2017, twenty new AIIMS are to be set up and 71 GMCIs are to be promoted in six-phases. The Cabinet Committee on Economic Affairs approved the PMSSY for Rs. 332 crores per institution in March 2006. The cost, however, escalated to Rs. 820 crores per institution in March 2010.
The PMSSY Division of the Ministry of Health and Family Welfare is entrusted with the overall task of implementation and monitoring of PMSSY. Committees at Central, State and Institute levels has formed for monitoring the implementation of the scheme. In January 2004, the Ministry constituted a Project Management Committee (PMC) under the Chairmanship of the Secretary (Health) with representatives from the Ministry of Finance, Prime Minister Office, Planning Commission, Airport Authority of India and AIIMS Delhi. The PMC was the apex steering body and was responsible for guiding and monitoring activities relating to the establishment of new AIIMS and for up-gradation of GMCIs in the States in the primary stage. Further, for proper implementation of this policy, in November 2007, the Central Ministry of Health and Family Welfare asked the State Governments to set up State Project Monitoring Committees headed by the Principal Secretary of Health or Medical Education of the respective State Government for monitoring the up-gradation of GMCIs. Thus, by providing bust to the educational sector, the PMSSY tries to upgrade the health scenario as a whole and wants to secure the flow of health personals in public healthcare institutions. However, all these efforts to make the PMSSY a success story fails to achieve its glory in reality. Lack of any operational guidelines, engagement of inefficient staffs, lack of synchronization and coordination, insufficient infrastructure put this scheme under the scanner.
- Janani Suraksha Yojana
The Janani Suraksha Yojana (JSY) is a nationwide safe motherhood intervention scheme, under the National Rural Health Mission, implemented to reduce maternal and neonatal mortality by promoting institutional delivery among the poor pregnant women. This maternal health-centric scheme was launched on April 12, 2005. The important features of the JSY scheme are to motivate, counsel and ensure safe institutional delivery particularly among women belonging to BPL category and Schedule Castes and Scheduled Tribes and identifies them for antenatal care, delivery, postnatal care, immunization and family planning services. Notably, JSY was proposed by the Central Government by modifying the National Maternity Benefit Scheme (NMBS). While NMBS is linked to the provision of better diet for pregnant women from BPL families, the JSY scheme integrates cash assistance with antenatal care during the pregnancy period, institutional care during delivery and the immediate postpartum period in a health centre by establishing systems of coordinated care by the field-level health workers and government welfare mechanism. Therefore the JSY scheme has brought together functional maternity-nutrition benefit scheme and referral transport scheme for poor women into a single package and fixed the focus of this scheme on assuring institutional delivery. From the monetary aspect, JSY is a centrally-sponsored scheme. Some States, for example, Andhra Pradesh make their own similar scheme thereby increasing the amount of cash assistance for institutional deliveries by summing up with the scheme of the Central government. Tamil Nadu has introduced a separate scheme for providing poor mothers with Rs. 1000/- per month as cash assistance for six months i.e. three months before the delivery and three months after for securing institutional delivery.
Further, the JSY recognizes the Accredited Social Health Activist (ASHA) as an actual link between the Government device and the poor pregnant women mainly in the eight Empowered Action Group (EAG) States (Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttrakhand and Uttar Pradesh), in addition to Assam, Jammu and Kashmir and the remaining North-eastern States. All together these States are also known as the Low Performing States. In rest of the States or the High Performing States, along with ASHA activists, Anganwadi Workers and Trained Birth Attendants also have been engaged with JSY. ASHA women usually work under an Auxiliary Nurse Midwife and her work has to be supervised by a Medical Officer. The aim of appointing these ASHA people is to make a bridge between the provider and the client and thereby motivating women and their families to seek delivery care under a healthcare facility. Performance-based cash payments along with other allowances are also offered to this ASHA workers. Therefore, in totality, the larger institutional framework of National Health Mission complements the JSY by providing comprehensive healthcare, including ante-natal and post-natal services, transport to facilities, and support services from ASHAs. It also includes several support services administered by community health workers to encourage pregnant women to use institutional healthcare facilities for childbirth, along with at least three ante-natal check-ups.
In the Low Performing States, all women are within the ambit of the Scheme and the cash incentives are higher than in the remaining States. In other States, women are eligible for the cash benefit only for their first two live births, and only if they have a government-issued BPL card or if they are from Scheduled Caste or Tribe of the State. In case a poor woman does not have a BPL card then she can access the benefit upon certification by Gram Panchayat or Pradhan provided the delivery takes place in a government institution. The disbursement of cash assistance is made at the time of delivery. In the case of the High Performing States, cash assistance of Rs. 700 in case of the rural area and Rs. 600 in case of the urban area is given for institutional delivery, whereas in case of Low Performing States cash assistance of Rs. 1400 in case of the rural area and Rs. 1000 in case of the urban area is given for institutional delivery. In rural areas, cash assistance for transportation to the nearest health centre for delivery of the child is also provided under the scheme. Along with the pregnant women under the JSY, a newborn child is also entitled to emergency care including integrated management of neonatal and childhood illness, care of routine childhood illness, essential newborn care, promotion of exclusive breastfeeding for 6 months.
After launching in 2005, the annual number of JSY beneficiaries grew rapidly, from 7, 39,000 per year in 2005-2006 to more than 11 million in 2010-2011. Thus, undoubtedly, institutional delivery in India has increased and the maternal mortality ratio has reduced over time as a result of socio-economic development coupled with advancement in healthcare infrastructure. However, to date, the JSY scheme fails to reach all part of India in equal force. As a result, there is a disparity with regard to the success of the scheme. Further, lack of manpower, inadequate training, transportation responsibility on ASHA people, the improper survey also creates hurdles in the path of the JSY scheme implementation. Moreover. the scheme should also include the nutritional aspect of women during pregnancy and the post-delivery period within its ambit.
- Rashtriya Swasthya Bima Yojana
To address the issue related to out-pocket payment for accessing quality healthcare services, the Rashtriya Swasthya Bima Yojana (RSBY) is an ambitious public health insurance scheme for the needy people of India. It was launched in August 2007. The RSBY is the result of the report of High-Level Expert Group of the Planning Commission on UHC, which advocated for the integration of individual policies into a National Health Package, emphasizing the need for more supply-oriented resources. This report also encouraged the promotion of private healthcare in certain localities where public health care delivery is inadequate. RSBY aims to improve access to quality healthcare involving hospitalization and surgery through an identified network of healthcare providers for below poverty line families. By allowing the hospital to bill directly to the insurance company for the cost of treatment, the RSBY made it attractive for private and public hospitals so that they can be enthusiastic to provide healthcare facilities and by subsidizing the annual premium, the scheme makes healthcare nearly free for beneficiaries. The RSBY generally provides for annual coverage of up to Rs. 30,000 per household with a maximum of five members, for inpatient treatment in more than 8,000 empanelled hospitals. The Scheme explains these “five members” including the head of a household, spouse and up to three dependents. An important feature of the scheme is its national portability which has been made possible by the standard enrolment card and beneficiary identification process.
The scheme also covers hospitalization, related tests, consultations, day-care treatment and medicines along with the pre and post-hospitalization expenses for some 700 medical and surgical conditions and procedures. Pre-existing diseases are also included within the paraphrenia of the scheme and there is a provision for transport allowance maximum up to Rs. 1,000 per year. The Central Government will bear 75% and State Governments will bear 25% of the beneficiary’s premium to the insurer and the State Government has to select the insurer following a competitive bidding process. It is noteworthy that while in health schemes, generally, the Ministry of Health and Family Welfare plays the pivotal role, under this scheme, the Ministry of Labour and Employment (MOLE) plays a major role in decisions making and implementation. The RSBY is implemented at the state level through the State Nodal Agency (SNA). The choice of which department should form the SNA depends on the decision of State Governments. The SNA is involved in contracting insurance companies in accordance with the guidelines issued by the MOLE. The eligibility criteria for these insurance companies include a valid license from the Insurance Regulatory and Development Authority at the time of application. The insurance companies are accountable for empanelment of hospitals and ensuring that their institutional infrastructure meets scheme empanelment criteria. These insurance companies are also responsible for ensuring the enrolment of beneficiaries, which is conducted by the insurance company’s representatives in the presence of a government functionary assigned the role of a “Field Key Officer.” These officials are supervised by the District Key Manager. In addition to their role in authorizing the beneficiary enrolment, the District Key Managers are also responsible for monitoring and evaluation of the scheme in their jurisdiction. By using all these stages of connecting machinery, RSBY rapidly and successfully expanded inpatient benefits to more than 142 million people in India.
However, these strong infrastructures and this ambitious scheme failed in many sectors in case of practical implementation. The RSBY only provides insurance coverage for secondary care that is generally provided at Community Health Centers, District Hospitals, but it excludes both primary care and tertiary care. Further, the RSBY does not include expenses related to outpatient treatment also. Moreover, the poor condition of the RSBY hospitals and the previous bad experience of the patients and their relatives also creates hurdles for the fullest utilization of the RSBY scheme. The low awareness about the benefits of the scheme is also evident from various studies.
- Ayushman Bharat
Under the modern health structure, India cannot realize its demographic dividends without its citizen being healthy. Thus, the Central Government conceived “Ayushman Bharat – National Health Protection Mission” (Healthy India) on September 23, 2018, as a shift from traditional health planning tactics towards a comprehensive healthcare vision. The Ayushman Bharat Program aims to build a New India by 2022 and ensure enhanced productivity, well-being and avert wage loss and impoverishment. It warrants access to healthcare for all, specifically the poorest and most vulnerable section of the Indian society by utilizing core technology as its backbone. NITI Aayog highlights the imperative need to completely redesign the flow of people, money, and information, as well as introduces a layered approach to provide comprehensive foundational health functions for all the States through Ayushman Bharat Program.
The 2011 Socio-Economic Caste Census is the basis for determining the eligibility for this scheme. Thus, the benefits will eventually be a pan-India basis. This means that a beneficiary will be allowed to take cashless healthcare support benefits from any public or empanelled private hospital across the country. State Government will lead the implementation of this Ayushman Bharat Program. In addition to this, State Governments are free to continue to provide existing programs alongside the national program or integrate them with the new scheme. State Governments are also free to pick their own operating model to pay a private insurance provider to cover services or provide services directly (like Chandigarh and Andhra Pradesh), or a mix of these two (like Gujarat and Tamil Nadu). Expenditure for running this scheme will be shared between the Central and State Governments in a prespecified ratio depending on the legislative arrangements and relative wealth of the States, covering between 60% – 100% of the expenditure. In case of structural area, the Ayushman Bharat Program combines two initiatives: (i) delivering comprehensive primary health care by establishing 1,50,000 Health and Wellness Centers (HWCs) by the year 2022, and (b) providing financial protection for secondary and tertiary level hospitalization as part of National Health Protection Scheme (NHPS). Both of these are aiming for increased accessibility, affordability, availability and quality of primary, secondary and tertiary level healthcare services in India. The HWCs were proposed by the task force on strengthening primary healthcare in India in 2016 and first declared in the Union Budget of 2017-18, whereas the National Health Protection Scheme was first announced in Union Budget of 2016-17. However, subsequently, the National Health Protection Scheme has been renamed as Pradhan Mantri Rashtriya Swasthya Suraksha Mission. The Ayushman Bharat Program with these two components intends to bring back the attention on the delivery of the entire range of preventive and protective care. Thus, Ayushman Bharat Program is a public health scheme, the source of finance is from Government revenue, service providers are hospitals, and people at large are policyholders or beneficiaries.
Further, the combination of UHC and ‘Ayushman Bharat Program’ has the potential to place health higher in position in future public, social and political discourses in India. Ayushman Bharat Program aims to provide coverage of Rs. 50,000 per family annually, benefiting more than 10 crore poor families. It includes the beneficiaries beyond the traditional approach of levelling ‘below poverty line’ population like RSBY. Inclusion of ‘vulnerable and deprived population’ identified through socioeconomic and caste census will nearly double the number of people to be benefited. Hence, if this scheme lives up to its potential, then it presents a unique opportunity to institutionalise quality healthcare, free at the point of service, for the most marginalised Indians, to improve the health of the population and drastically to reduce medical-related impoverishment. However, the lack of willingness to adopt this Central Program by the State Governments creates the biggest obstacle in the path of implementation. Furthermore, there should be adequate financial support from the Central Government to avoid resource constraints in implementing this Program by the State Governments. In addition, the existing and interrelated structural deficiencies of the Indian healthcare system such as issues of public and private sector governance, stewardship, quality control, and lack of control on healthcare organisations will also put the success of this scheme far behind.  Thus, whilst these weaknesses pose a threat to the ability of proposed reforms to meet their ambitious objectives, Ayushman Bharat Program, as a step towards UHC, presents Indian healthcare structure a chance to tackle long-term and embedded shortcomings in governance, quality control, affordability and access related issues.
Like the international health arena, the Indian structure also focusing on the UHC to provide equal access to healthcare and to secure quality healthcare for all. The abovementioned schemes and programs are trying to take forward steps towards that end. However, though these initiatives majorly concerned with the healthcare, they failed to address the out-pocket costing for medicine and surgical instruments within its ambit. Further, the progress towards attaining UHC is hindered by the lack of strength of the health workforce and the absence of adequate skills among the workforce to deliver quality services to the entire population. Thus, in the long run, the healthcare system has to shift from the pricing and hospitalization to viability and sustainability. The balance between the expansion of coverage and utilization of the nation’s resources will be the major concern for policymakers in the coming days. Yet, the government initiatives to achieve UHC within 2030 should not be stopped as this is the only goal that can help us to see a better healthy future.