A paramedic distributes free medicine provided by the government to patients inside a ward at Rajiv Gandhi Government General Hospital, Chennai, 2012. Photo: Reuters/Babu/Files.
International Universal Health Coverage (UHC) Day, observed on December 12 every year, is a way to urge countries to speed up progress towards implementing a UHC. UHC aims to achieve financial protection – meaning coverage for everyone, which pays for their healthcare services and protects them from financial shocks in health expenditure. In this sense, population coverage is an important indicator with which we can track progress towards UHC.
In India, diverse means exist for expanding population coverage, each of which targets different people, and differs in scale, method and reporting of coverage.
Employee state insurance covers more than 3.49 crore workers and their dependents. Private health insurance covers more than 12.27 crore people. Various health schemes target serving and retired government and public enterprises’ personnel. The Pradhan Mantri Jan Arogya Yojana (PMJAY) aims to cover 10.74 crore deprived households. Various state initiatives aim to cover an increasing share of those who are not covered by any other means and aim to achieve universal, or near-universal, coverage.
It’s not possible to sum-up the different coverage figures, so it is tricky to report cumulative coverage at the national or at a state’s level. But an estimated 35-40 crore households are not covered at all in India.
Population coverage data from the National Family Health Survey (NFHS) is useful to track progress towards UHC. The survey reports coverage as the fraction of households in a state or UT that is covered in any health scheme or health insurance. This UHC Day, on December 12, 2020, the Government of India released NFHS-5 data for 17 states and 5 UTs.
In 2019-20 when this survey took place, PMJAY was being rolled out, so the coverage data does not include PMJAY’s impact.
Since NFHS-4 in 2015-2016, coverage has increased in all states and UTs except in Andaman and Nicobar Islands, Andhra Pradesh, Sikkim, Telangana, Tripura, West Bengal and Karnataka. The data on coverage types collected in the survey is not yet available. Still, there are reasons to believe state initiatives are driving coverage.
For example, National Sample Survey data from July 2017 to June 2018 (NSSO 75) supports this view: it shows way higher coverage in government-sponsored schemes.
Also, coverage grew the most in Assam (from 10.4% to 60%) and Goa (from 15.9% to 66%). Since 2016, both places have state initiatives in place to cover more than 90% of the population.
The decreased coverage may imply a loss in coverage. A steep decline in Tripura (from 58.1% to 33%), for example, may have been the result of PMJAY subsuming the Rashtriya Swasthya Bima Yojana (RSBY). In Tripura, RSBY targeted 6.8 lakh households, which dropped to 4.79 lakh under PMJAY.
In fact, despite the growth, the coverage remains low. In 13 out of 22 states and UTs, coverage is at best 40%. Karnataka (28.1%), Maharashtra (20%) and Gujarat (39%) have long-running state initiatives and higher ESI and private insurance coverage. These states also claim universal or near-universal coverage. The low levels of reported coverage in these states are very perplexing. We must rule out reporting errors and deliberate concealment of information by households.
Also, in government initiatives, demand-side issues such as lack of awareness about coverage are common. Government initiatives also suffer from supply-side issues, such as complicated rules, lack of transparency and targeting errors (that exclude eligible households and include ineligible ones). Such issues may be keeping state initiatives in these states from covering eligible people in the most effective manner.
Moreover, none of the states or UTs is anywhere close to universal coverage. The reported coverage in Andhra Pradesh (70.2%), Goa (66%), Meghalaya (63.5%), Telangana (60.8%), Lakshadweep (60.1%), Assam (60%), Dadra and Nagar Haveli (52%) and Kerala (51.5%) indicates good progress towards UHC. The figures are consistent with the long periods over which government initiatives have been implemented, and higher coverage in other initiatives.
For UHC, these states must address various supply- and demand-side challenges facing the government to reach the entire eligible population. They must also extend the coverage of their state initiatives to any uncovered populations in the state.
We need detailed survey data from all states for a complete picture. In the states and UTs discussed here, state-level initiatives appear to be driving UHC progress. Most states are now also implementing PMJAY, which has added to the momentum of the state initiatives. So with time, we should expect our coverage to become universal.
Arun Kumar Tiwari is a specialist in health finance with the Health System Transformation Platform, New Delhi.