Implementation of a single health programme such as the Universal Health Coverage cannot overcome the challenges of weak governance, lack of accountability and poor implementation.
Universal Health Coverage (UHC) by 2030 is the primary health-related objective defined under the Sustainable development goals (SDG). The World Health Organization has defined UHC as “the desired outcome of health system performance whereby all people who need health services receive them, without undue financial hardship”.
India’s national health policy has reiterated the government’s commitment to achieving UHC, and has begun brainstorming about mechanisms to maximise existing resources to increase coverage across populations and services, while ensuring quality. A high-level expert group (HLEG) was constituted by the then prime minister in 2010 to help set out a direction in this regard. The report of the HLEG laid out the principles that should guide the formulation of UHC in India. Among the ten principles were equity, non-discrimination and patients’ rights. Though the idea is closely aligned with financial risk protection, the HLEG conceived UHC as going beyond health insurance. Instead, it focused on the aspirational goal of an entitled provision, where all citizens have a right to health, assured by the government. Health, in turn, was broadly defined as all-encompassing. So health assurance denoted an obligation on the state to provide adequate food, nutrition, access to safe drinking water, sanitation, and education in addition to health services. While the HLEG report lays out the broad ambition for the nation, the onus of operationalising these ideas rests with Indian state governments.
Karnataka recently became the first state in India to roll out UHC by assuring health for its population of over 60 million under the Arogya Bhagya scheme. This announcement is an encouraging statement of political commitment from the state government of Karnataka towards providing healthcare for all. The new scheme seeks to merge existing health schemes under a single umbrella to offer cashless treatment of up to Rs 1.5 lakh ($2300) at all government and private hospitals. Other states such as Kerala and Tamil Nadu are also mulling similar initiatives.
Converging existing health schemes implies the merging of resources associated with various health insurance or assurance schemes into a single pool for UHC. This process is a good opportunity to review ongoing health programmes and ask what services should be provided by the government under the new UHC umbrella, for whom and at what price. Critically, the move could also improve efficiency by removing overlaps and duplication.
The development of an appropriate health benefits package for UHC however is no trivial task. It involves the alignment of political, technical and practical components of health system delivery in order to provide a sustainable model leading up to UHC. The Union government has recently set up India’s first health technology assessment (HTA) agency to commission systematic assessment of cost-effectiveness of health interventions. The initiative taps academic capacity across the country to conduct economic evaluations based on contextual social and political value judgements. The government of Karnataka has the advantage of leveraging this national initiative to carry out the technical analysis that would underpin the process of developing the Arogya Bhagya benefits package.
The primary focus of Karnataka’s UHC programme under Arogya Bhagya is to achieve a comprehensive financing mechanism for the delivery of health services. Health officials in Karnataka have indicated a figure of close to Rs 10 billion that is available for implementing UHC. Rather than repackage coverage under existing schemes, the government would do well to allocate these resources thoughtfully. Both health benefits and costs of exclusion from coverage would need to be considered in order to maximise the health gain from existing resources. Choosing to follow this more deliberate, but arguably more fruitful approach, would require that explicit criteria for inclusion of health services within the Arogya Bhagya scheme are developed and made public. These decisions can then be translated into implementable policy interventions for resource use and service delivery.
Current schemes in Karnataka are a combination of health insurance and assurance models, primarily target BPL populations, and offer secondary and tertiary care services. Without careful rethinking, the new Arogya Bhagya may worsen the imbalance against primary care and public health for more expensive secondary and tertiary care. The decisions on coverage and beneficiaries for existing schemes were made in the context of their respective histories and the agendas of their proponents when they were launched. For example, Yeshaswini, one of Karnataka’s earliest insurance schemes covers only surgical procedures to be availed by members of co-operative societies. Vajpayee Arogya Shree (VAS), on the other hand, offers tertiary care for all below-poverty-line families. Features introduced in targeted schemes may or may not be appropriate for a state-wide umbrella scheme like Arogya Bhagya. Thus, these schemes are not necessarily aligned with the explicit priorities of the state government or its latest integrated public health policy (2017).
However, the experience of running multiple targeted schemes has enabled the identification of useful operational features that remain relevant to Arogya Bhagya. For example, empanelment under VAS requires hospitals to conduct outreach camps, which likely contributes to the high population coverage achieved under VAS relative to other schemes. A transparent evidence-based approach that involves close monitoring will be necessary to ensure that the new UHC scheme lives up to its promise.
Any move towards UHC has to reduce expenditure incurred for drugs since that is the largest source of out of pocket payments by patients. Current efforts to provide free or subsidised medicines in the country have met with mixed results and the Karnataka UHC scheme will be able to learn from past experience.
Service provision under the current model assumes the presence of high-quality private providers, which clearly is not uniformly true with locational clustering and uneven quality of service. The proposed design of Arogya Bhagya is progressive in the sense that better off populations will have to pay more to receive benefits. Careful consideration of who benefits from the existing entitlements and whether this conforms to the principles of distributive justice might suggest policy measures beyond the scope of the Arogya Bhagya scheme. However, policies enabling physical access or incentivizing care provision in specific geographic areas do indeed fall under the broader remit of UHC. It is imperative that Karnataka recasts existing models of service delivery within specified frameworks of equity, efficiency and sustainability.
Arguably, building a mosaic of the most efficient aspects of existing programmes in a way that brings the focus to critical health services for everybody through the Arogya Bhagya would be a huge achievement. However, implementation of a single health programme such as this cannot overcome the challenges of weak governance, lack of accountability and poor implementation. Current regulatory mechanisms have proved inadequate as demonstrated by the protracted attempts to reform the Karnataka Private Medical Establishments Act, 2007. Ensuring quality of care for all remains a challenge. The government would therefore need to invest much more in building public infrastructure and robust health systems. One hopes that the announcement of Karnataka’s UHC scheme is the beginning of a much deeper engagement towards a broad conception of health as envisioned by the HLEG.
Neethi Rao is a health policy researcher associated with Imperial College, London and the Institute of Public Health, Bengaluru. She served on Karnataka government consultative committees for amending state legislation to regulate private providers.
The author would like to acknowledge Tony Culyer, Kirthi V. Rao and Laura Downey for their contributions.