Dr. Umar Nazir
Universal Health Care (UHC) is a health care system that provides health care and financial protection to all citizens of a particular country. It is organized around providing a specified package of benefits to all members of a society with the end goal of providing financial risk protection, improved access to health services, and improved health outcomes.
UHC in most countries has been achieved by a mixed model of funding. General taxation revenue is the primary source of funding, but in many countries it is supplemented by specific levies (which may be charged to the individual and/or an employer) or with the option of private payments (by direct or optional insurance) for services beyond those covered by the public system.
The journey of UHC started way back when Declaration of Alma-Ata was adopted at the International Conference on Primary Health Care , Almaty , Kazakhstan in 1978.
It expressed the need for urgent action by all governments, all health and development workers, and the world community to protect and promote the health of all people. It was the first international declaration underlining the importance of primary health care.
This Declaration emerged as a major milestone of the twentieth century in the field of public health, and it identified primary health care as the key to the attainment of the goal of "Health for All" around the globe. The declaration highlighted the inequality of health status between the developed and the developing countries and termed it politically, socially and economically unacceptable.
Recently The World Health Organization, UNICEF and the Government of Kazakhstan co-hosted the Global Conference on Primary Health Care in Astana on 25-26 October, 2018. The conference marked the 40th anniversary of the Alma-Ata Declaration, and United World leaders to affirm that strong primary health care is essential to achieve universal health coverage. They were reaffirming what their predecessors had done in Alma Ata in 1978.
The Alma Ata Declaration, as it was called, had been criticized as wishful thinking without a clear road map on strategies and financing — an allegation that could be levelled against the present declaration too.
In order to achieve Universal Health Coverage in India we have to transform health care, attempt to re-design its primary health care to address the current and future epidemiological situation.
The Astana Declaration would “aim to meet all people’s health needs across the life course through comprehensive preventive, promotive, curative, rehabilitative services and palliative care”.
In order to revamp primary health care in our country, we must try to provide these services in a very accessible, affordable, attractive, effective manner without compromising Quality of Health care.
These services cannot be provided without adequate human resources. It is nearly impossible to provide them with the current Indian norm of one primary health care team for a population of 30,000.
The main reason why people in India don’t rely on public health sector is poor quality of care in the public sector. Most of the public healthcare in India caters to the rural areas; and the poor quality arises from the reluctance of experienced healthcare providers to visit the rural areas.
Consequently, the majority of the public healthcare system catering to the rural area and remote area relies on inexperienced and unmotivated interns who are mandated to spend time in public healthcare clinics as part of their curricular requirement.
Other major reasons are distance of the public sector facility, long wait times, and inconvenient hours of operation. Few States in India like Kerala have tried to reduce the target population to 10,000 for one primary health care team. Even the reduced target turned out to be too high to be effective.
Such experience suggests that providing comprehensive primary care would require at least one Primary Health care team for 5,000 populations. This would mean a six-fold increase in cost of manpower alone.
Since supply of more human resources would generate demand for services, there would be a corresponding increase in the cost of drugs, consumables, equipment and space. So a commitment to provide comprehensive Universal Health Care — even in the limited sense in which it is understood in India, would be meaningful only if there is also a commitment to substantially increase the allocation of funds.
India presently spends a little over 01percent of GDP on health which is very much less what W.H.O has recommended minimum viz:5 percent of GDP. It is sobering to remember that most successful primary health care interventions in developed countries allocate not more than 2,500 beneficiaries per primary health care team.
Providing the entire set of services, even if limited to diagnosis and referral, is beyond the capacity of medical and nursing graduates without specialized training. Practitioners in most good primary care systems are specialists, often with postgraduate training.
The Post Graduate Course in Community Medicine, which is the very important course in achieving primary health care/Universal Health care is available all over India, but their services are not utilized properly in the field because of dearth of doctors as well as absence of separate Directorate of Public Health in the country which would have made lots of difference in achieving UHC.
If the services are to be provided by mid-level service providers, as is planned in many States, building their capacity will be even more of a challenge. It would be a long time for this to be built.
Certain States like Kerala has tried to get over this through short courses in specific areas such as management of diabetes mellitus, hypertension, chronic obstructive pulmonary disease, and depression with some success.
The primary care system will be effective only when the providers assume responsibility for the health of the population assigned to them and the population trusts them for their health needs. Both are linked to capacity, attitude and support from referral networks and the systemic framework. It will not be possible unless the numbers assigned are within manageable proportions.
Discussion on primary care in India focusses only on the public sector while more than 50percent of care is provided by the private sector. The private sector provides primary care in most developed countries though it is paid for from the budget or insurance.
The private sector can provide good quality primary care if there are systems to finance care and if the private sector is prepared to invest in developing the needed capacities. Devising and operating such a system (more fund management than insurance though it can be linked to insurance) will be a major challenge but a necessary one if good quality primary care is to be available to the entire population.
In this Regard GOI has launched a scheme namely Aayushman Bharat that aims to cover up to Rs.5 lakh to 100,000,000 vulnerable families (approximately 500,000,000 persons -40percent of the country’s population). This will cost around $1.7 billion each year.
Achieving Universal Health Coverage — one of the Sustainable Development Goals to which India is committed — is not possible without universal primary health care. The experience of states like Kerala in transforming primary care reveals the steepness of the path India will have to cover to reach the goals committed to in the Astana Declaration.
Lastly, I want to conclude at this point that to achieve UHC is a sweet dream to think off without realization of the ground situation of the Healthcare delivery system in India.
Author is working as a Senior Resident in the Department of Community Medicine, GMC Sgr