The new mantra in health in recent times is Universal Health Care (UHC) where pages have been written in journals and periodicals and words have been spoken in seminars and meetings. Unfortunately, there is absence of clarity regarding its operationalization and there are continued roadblocks in its implementation. Universal Health Coverage (UHC) is based on the World Health Organization (WHO) constitution of 1948 declaring health as a fundamental human right and additionally, on the ‘Health for All’ agenda set by the Alma-Ata declaration in 1978. According to the WHO, “The goal of universal health coverage is to ensure that all people obtain the health services they need without suffering financial hardship when paying for them.” Notwithstanding the positive features in the recognition of linkages between Health for All and UHC, the greatest weakness of this term is its focus on making available health services without financial hardships which makes the term amenable to insurance lobbies, privatization and other cost-sharing arrangements.
The shift in public health in India with the neoliberal reforms in 1990s bringing at the forefront the increasing role of NGOs and the private sector for health reforms is another road bloc that the universality has to encounter. The shift is double-edged with apparently logical statements such as though health is the responsibility of the state, but as the government is inefficient, the health services should be catered to by strengthening the participation of the private sector. What goes wrong with proposing such solutions to ensure universal health care are the side-lining of many underlying factors such as social determinants to health and important inter-sectoral factors like access to safe drinking water, food, housing and sanitation.
To begin with, the term universal health “Coverage” does mean coverage by medical services, and more specifically by medical insurance. This is not just a puny hook up in terminologies but giant jump in policies where under UHC, access to health services is ensured but not necessarily the provision of it. The increasing affinity of the state towards the private sector misses out the very core value of ensuring universal health care, as the private sector is guided by profit maximization rather than social welfare. So, how one understands universal access is not the easy provision of health services by the state but that of state support needed in accessing providers of the same. Hence, whichever public-private provider (PPP) is economically more affordable to the state would automatically be implied as the public’s economic access point to that health service. This would mean that corporate insurance, pharmaceutical and bio-technological giants and the multi-crore hospital industry sector that already feed on massive state subsidies are further privileged. An example of this is the RSBY (Rashtriya Swasth Bima Yojna) scheme which is based on the model of social insurance, where the premium is paid by the government to private providers enhancing public financing. However, this insurance model does not take into account risk pooling and cross subsidization and is only limited to secondary healthcare procedures where outpatient care is not included. This has become a softer mechanism to usher in neo-liberal packages and channelize public money to private hands.
It appears that the state is responsible to a certain extent, for payments made towards medical care services to the private sector but in effect it channelize public money to private hands and it does not lead to a shared objective of making of a healthy India. There are many conditionalities placed in this kind of partnership with the private sector that are not questioned including the quality of the services delivered, absence of regulatory mechanisms, assertion of power hierarchies by corporates that are making ever greener pastures for the entry of CII, FICCI and ASSOCHAM. We are pushing macroeconomic formulae in a low-income country like India riddled with hunger and mass poverty. Division from the course of comprehensive primary health care (CPHC) to curative and preventive care in the form of a PPP model inclined towards cost recovery may in fact lead to negative fallouts in India where there are inequalities and inequities based on intense social stratifications guided by caste, class, power and gender. The poor will be increasingly left out of the ambit of a life support system meant for them.
Given such distortions in the principle for achieving universal health care, why does the state not invest directly in strengthening the already existing public health institutions that are a viable and cost-effective. This way, the crisis of shortage of human resources in health services in India may be also be solved by increasing recruitment of health staff at the primary level, decreasing the salary differentials between high and low ranking staff, which would in turn make a career in public health services attractive.
The UHC further entirely neglects and ignores the presence of traditional health systems in India and the fact that approximately 57% of the population use Ayurveda, Yoga, Unani, Naturopathy, Homeopathy, Siddha and Sowa-Rigpa. This implies that a major concern for UHC should be reforms within medical education aimed at balancing differences in medical systems. Moreover, the UHC fails in addressing the constraints that people face in improving their overall health status that is directly and indirectly influenced by social determinants of health. According to WHO, “The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels.”
On one hand, these provisions are again entirely left to be taken care of by separate ministries and departments without any integration of them in provision of care to the weak and marginalized. The UHC thus, has reduced itself to just provisions of techno-managerial packages.
Given the political economy of health approach, the only assistance UHC has given in is with bringing revenues for economic growth for investments in the health industry disregarding the evolution of public health in India where preventive health care is a very important component for controlling the spread of diseases. Sadly, given such fragmentations and conflict of ideologies in delivering UHC, this in fact leads to a non-universal approach in health care. It could well end up as another distant mirage for achieving health for all.
This article previously appeared online in NewsYaps policy series. It was republished as a conference brief in February 2017. To cite — Goel, Ina (2017): Roadblocking Universal Health Coverage, Difficult Dialogues: Is India’s health a grand challenge? International Centre Goa, 10–12 February 2017, UCL, pp 17–18