Transforming Indian Healthcare Pt.III: A Primer on Universal Health Coverage for India

Navigating the Road to Universal Health Coverage in India: The World Health Organization provides a healthcare assessment summary for health-related Sustainable Development Goals

This article is fifth in a series of articles titled State of Indian Healthcare where we will compile analytical reports to provide an overview of healthcare accessibility in India. The report utilises the available Indian government healthcare data to examine various aspects related to healthcare accessibility, including availability, affordability, and quality of healthcare services across different regions of the country. The findings indicate several challenges that need to be addressed to improve healthcare accessibility in India. If you want to get the final list of data sources and references for the analytics, it will be available at the end of the last article of this series.

"It shows we are still killing millions of girls," he said. "If there are 26 million births in India every year, they add up to 130 million births in the past five years. This means we've killed 2.6 million girls in just the past five years. This is a disgrace for the country. There's nothing to celebrate."

- Mr. Sabu George, researcher and activist

source: BBC, NFHS: Does India really have more women than men?

It’s 2024 finally! I hope you started off with a bang. And we are still here talking about girl child killings! Speculating with a sample of data is dangerous and by default all assumptions should be considered wrong until unless proved otherwise. This is why I had written in one of my previous articles about the surprising participation of women in the NHFS-5 survey. Read it here:

Indian Women: The changing face of Indian healthcare survey

Today I want to answer the questions lingering from my past article by revisiting the same surveys and highlight a plausible solution afterwards.

Transforming Indian Healthcare Pt. II: Health Coverage & Revisiting National Health Survey

The Problem

Going through one of the few popular investment agencies online ads in India, I saw one that had advertised in its campaign to invest in health insurance as an SIP with the statuary warning of general rising cost of treatment for surgeries as below:

Open Heart Surgery: ₹2-5 lakh

Angioplasty: ₹2-5 lakh

Dengue Fever: ₹1-2 lakh

Kidney Failure: ₹2-5 lakh

I talked about the origins of Universal Health Coverage in the previous article and I hope you can now see the kind of impact it can have when the aforementioned costs burn a hole in the pocket. (Yes, you should consider healthcare related financial planning but this article is more about the underlying issues and solution and I am not a SEBI registered advisor but I know a good one if you care to know!)

Transforming Indian Healthcare Pt. I: Adapting to Demographic Shifts

A quick look into the trends will tell us the story of our healthcare expenditures. We use these compiled graphs for a comparative trend which gives a broader evidence and not for its particulars.

CHE or Current Health Expenditure, is a measure of the economic commitment to healthcare relative to the overall economic activity in terms of the country's GDP. Figures shown are to be interpreted in thousands/K. For instance, Population figure 1407564 translates to 1407564K or roughly 1.4 billion.

Although the government has increased its commitment towards healthcare expenditure every year, the Out Of Pocket Expenses, though now down to ~50% of CHE, are at an all time high.

But first, if you would like to access the full article in the series, a small caveat here. Subscribe to our newsletter and be updated on how we are tackling the challenges in healthcare accessibility with our non-profit service which has also been mainly open-source and runs on the support of many hearty volunteers from across the globe. For us, your support through sharing is a form of caring. When you read this article, it does not help us drive to a unicorn status or flashy media banterings. Instead, your comments and messages guide us on piecing the unknowns and parts that we missed while gathering data and helps us understand better the missing link between you and healthcare infrastructure and how we can better it through the commons health-tech platform.

The Current Healthcare Expenditure or CHE, a measure of the economic commitment to healthcare relative to the overall economic activity, refers to the total expenditure in a country on health over a specific period, usually a year. It encompasses all healthcare spending, including preventive and curative services, family planning activities, nutrition activities, and emergency aid designated for health. CHE’s allocation is comprised of government health expenditure, private healthcare bodies such as private health insurance, out-of-pocket expenses and other private sources (such as non-profit organizations, private corporations' spending on employee healthcare).

Although, the good news is that there has been an increase year on year on CHE, the bad news is that the Out-Of-Pocket Expenses or OOPS, which in lay man terms is the gratuities and in-kind payments, made to health practitioners and suppliers of pharmaceuticals, therapeutic appliances, and other goods and services by regular folks like you and me, are at an all time high. OOPS is a significant component of private expenditure on health as against Universal Health Coverage.

The trend in Current Health Expenditure (CHE) per capita in India indicates an increase in the amount spent on healthcare per person. Typically, an increase in healthcare spending per capita is associated with improved access to healthcare services and possibly better healthcare outcomes.

According to the NFHS-5 report, for instance, the average out-of-pocket expenditure per delivery in a public health facility in India is Rs. 2916​​, with a higher average in urban areas (Rs. 3385) compared to rural areas (Rs. 2770)​​. The Praxis Report also discusses out-of-pocket expenditures in the context of the outpatient healthcare market in India, noting that Indian families spend more than 60 percent of their family healthcare expenditure on primary care​.

UHC: A (The) Solution?

I rest my case to this cause, due to the scale of the problem. Universal Health Coverage (UHC) is a global aspiration, ensuring everyone has access to the health services they need without financial hardship. As we navigate the complexities of achieving this goal, it's essential to delve into the interplay of health financing schemes, insurance coverage, service access, and service coverage. This newsletter draws on recent WHO reports and various health statistics to understand where we stand and the road ahead.

Triple Billions: targeting a better future. Source: https://www.who.int/data/stories/triple-billions-targeting-a-better-future

The World Health Organization (WHO) has been a significant proponent of UHC, tracking progress through indicators like those found in the World Health Statistics report. The 2023 edition highlights advances and challenges towards this goal, focusing on 50 health-related indicators from the UN Sustainable Development Goals (SDGs) and WHO’s Thirteenth General Programme of Work.

UHC is integral to achieving Sustainable Development Goal 3: "Ensure healthy lives and promoting well-being for all at all ages." This goal is not just about health; it's interlinked with all other 16 goals, emphasizing the multifaceted nature of health in development.

The Backbone of Universal Health Coverage

UHC is not just an ideal but a critical target under SDG 3.8.1, focusing on providing extensive health service coverage without imposing financial distress. Achieving UHC requires a multifaceted approach, addressing everything from the availability of essential health services to the financial mechanisms that support access to these services.

The Indicators and Challenges

By 2023, an additional 477 million people are expected to be covered by essential health services. Yet, the world remains off track to meet the 2025 UHC targets, largely due to setbacks from the COVID-19 pandemic.

The journey toward UHC is measured by indicators like service access and coverage. Service access refers to the availability of health services, considering geographic, financial, and cultural factors. Service coverage, on the other hand, looks at the proportion of people actually using these services when needed.

Despite progress, challenges persist. A significant number of people still lack access to essential health services, and many are pushed into poverty due to health expenses. The world is off track to meet the UHC target by 2025 and the related SDGs by 2030, with the COVID-19 pandemic exacerbating these issues.

Service Access and Coverage: The Indicators of Progress

To gauge progress toward UHC, it's vital to understand and measure service access and coverage:

• Service Access: This encompasses the availability and affordability of health services, geographic accessibility, and cultural acceptability.

• Service Coverage: This measures the proportion of the population using health services when needed, reflecting the actual utilization of healthcare.

UHC Service Coverage Index (SDG 3.8.1).

Challenges and Observations

Several key challenges impede the path to UHC:

• Infrastructure Shortages: Many regions lack adequate hospitals and clinics, a gap highlighted by the need for comprehensive zonal statistics to understand coverage effectively.

• Under-resourced Facilities: Existing healthcare facilities often suffer from inadequate staffing and equipment, leading to unmet health needs. Geographic and accessibility analyses are crucial in understanding and addressing these issues.

• Financial Barriers: High healthcare costs and out-of-pocket expenses, exacerbated by costly drugs and low healthcare professional salaries, create significant hurdles. Innovative insurance schemes like India's PM-JAY aim to alleviate these burdens for the underprivileged.

• Socio-Economic Factors: Travel times and distances to access healthcare vary significantly, influenced by age, socio-economic status, and geography, demonstrating the need for tailored solutions.

Head over to UHC Data Portal and see how your country is performing

Universal Health Financing: A Piece of the Puzzle

The world is off track to meet the universal health coverage billion target by 2025 and related Sustainable Development Goals by 2030. The disruptions caused by the COVID-19 pandemic have had a significant impact on many indicators, only some of which are recovering.

The world is offtrack: https://www.who.int/data/triple-billion-dashboard

Universal Health financing schemes are often seen as the linchpin for achieving UHC. These schemes aim to pool risks and funds so that everyone has access to necessary health services without financial hardship. However, financing is just one aspect. Equally critical are service access and coverage, which ensure that services are not just paid for but also available and used by those in need.

For instance, the WHO notes a lack of hospitals and clinics, poorly equipped facilities, high healthcare costs, and a high rate of non-communicable diseases. Each of these points to the multifaceted nature of the challenge – it's not just about financing healthcare but also about improving infrastructure, affordability, and preventive care.

The SCORE Assessment Summary for India can be accessed here.

Now that you have had an awareness of the WHO and what of Universal Health Coverage plans, stay tuned to this series, for in the next article I will expand upon WHO’s assessment summary, the solutions and challenges in the road to achieving UHC goals in the Indian context.