Universal Health Coverage

Universal Health Coverage (UHC) refers to a utopian society where all people have access to quality healthcare that is affordable. It encompasses all aspects of healthcare, including physical well-being and disease prevention, diagnosis, treatment, rehabilitation, and palliative care. UHC is also one of the Sustainable Development Goals, or Agenda 2030. It is widely agreed that healthy individuals make up good human resources that are essential for sustainable development. Hence, health is a prerequisite for development. Therefore, UHC enables a country to utilise its strongest asset: human capital. In this context, India introduced Pradhan Mantri Jan Arogya Yojana (PMJAY) in 2018, which is now the world's largest health insurance scheme, fully financed by the government. The Ayushman Bharat program addresses the needs of the UHC in a holistic way.

According to the World Health Organisation (WHO), health is ‘a state of complete physical, mental and social well-being and not merely the absence of disease’. Right to health is a basic human right under the WHO Constitution (1946) and later also recognised in the 1966 International Covenant on Economic, Social and Cultural Rights.

The International Conference on Primary Health Care was held in Alma Ata, Kazakhstan, in 1978. In this conference, the Alma Ata Declaration was agreed upon which called upon nations to focus on Primary Health Care in their national health policies. It also recognised the Right to Health as a basic human right and issued a call for action for governments to realise ‘Health for All’.

• SDG 3: Good Health and Well-being: Ensure healthy lives and promote well-being for all at all ages
  • Target 3.8: Achieve UHC, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.
    • Indicator 3.8.1: Coverage of essential health services
    • Indicator 3.8.2: Proportion of population with large household expenditures on health as a share of total household expenditure or income

According to the WHO, over 1 billion people worldwide are at risk of falling into poverty due to out-of-pocket health expenditures of more than 10% of the total household budget. Over 1.8 billion people, or 24% of the world population, live in a condition where quality health care is unavailable. In this context, UHC is of paramount importance for countries around the world, especially low-and middle-income countries.

• Accessible Health Care: Health care is accessible to everyone who is in need of it. It means it must be non-discriminatory and physically accessible.
• Affordable for all: Health care services are affordable so that people do not face financial hardship.
• Quality Health Care: This means health care must be safe, effective, timely, equitable, integrated, efficient, and people-centric.

• Poverty alleviation: Huge out-of-pocket spending on health care can push many people into poverty. An affordable and accessible health care system would protect the poor and most vulnerable from financial hardship, thus aiding in poverty alleviation.
• Developing human capital: Health is a prerequisite for the development of human capital. Human capital is essential for any country to grow.
• Reducing inequality: UHC is accessible to all, which means it is non-discriminatory in nature. Hence, UHC will ensure that access to health care is available to all, irrespective of any social inequality (caste, ethnicity, gender, sexual orientation, disability, etc.) or economic inequality.
• Job creation: Implementation of UHC will require a skilled workforce, quality infrastructure, and adequate investment. This will lead to job creation on a large scale.
• Reduce mortality and promote well-being: UHC will ensure that high mortality due to preventable situations such as child and mother mortality can be reduced. Also, preventive healthcare would promote physical and mental well-being.
• Sustainable development: Many sustainable goals are linked to health and well-being. Hence, UHC will play a pivotal role in achieving sustainable development.

National Health Policy, 2017

It aims to achieve a high level of health and well-being for all. It emphasises reorienting all development policies to provide accessible, affordable, and quality healthcare. It provides specific health targets to be achieved in a time-bound manner.

National Health Mission

The NHM envisages, achievement of universal access to equitable, affordable and quality health care services that are accountable and responsive to people’s needs. Under this mission, the Centre would provide financial and technical support to states to plan and implement state specific action plans. It has two sub-missions:

• National Rural Health Mission (NRHM)
• National Urban Health Mission (NUHM)

Started in 2018, Ayushman Bharat aims at providing comprehensive healthcare and well-being to all. In other words, it addresses all the needs of UHC. It brings a paradigm shift in healthcare strategy from a segmented approach to a holistic and need based approach. It has two interlinked components:

• Ayushman Bharat Health and Wellness Centres (HWCs): Creation of more than 1,50,000 HWCs to deliver Comprehensive Primary Health Care (CPHC).
• Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY): Health cover of INR 5 lacs per family per year for secondary and tertiary hospitalisation to over 12 crore poorest and most vulnerable households (more than 55 crore beneficiaries). Beneficiaries can avail benefits at any empaneled private or public hospital. The financial burden is shared between the state and the central government. Following are the benefits under AB PM-JAY:
  • Pre and Post hospitalisation covered
  • Medical examination, consultation, and treatment
  • Medicine and medical equipments covered
  • Food and accommodation
  • Intensive and non-intensive care
  In May 2023, AB PM-JAY achieved a milestone of 5 crore hospital admissions and more than 23 crore verified beneficiaries recently.

• Ayushman Bharat Digital Health Mission: It aims to provide integrated digital health infrastructure in the country. It will leverage technological advancement to provide equitable healthcare to all. The national portability of health services through the creation of Ayushman Bharat Health Account (ABHA) number for citizens is one of the components of ABDHM.
• Ayushman Bharat Health Infrastructure Mission (ABHIM): It aims to bridge the critical gaps in health infrastructure, surveillance, and research spanning both rural and urban areas. It was launched during the pandemic to implement the Atmanirbhar Bharat Package for health, as announced by the Finance Minister.
• National AYUSH mission: It aims at providing alternative and cost-effective healthcare by improving AYUSH hospitals and educational institutes.
• Pradhan Mantri Bhartiya Janaushadhi Pariyojana: Under this scheme, affordable and quality medicines are provided through Pradhan Mantri Bhartiya Janaushadhi Pariyojana Kendras.

• Lack of skilled workers: According to the WHO, the ideal doctor-to-patient ratio is one doctor per 1000 people. In India, this ratio is one doctor per 1511 people. Also, the number of other healthcare professionals, such as paramedical staff, research professionals etc is less than adequate.
• Unregulated Private Sector: The majority of outpatient care and hospitalisation is catered to by the private sector. But, the private sector is largely unregulated due to various reasons. This leads to unaffordable and low-quality healthcare services.
• Lack of funds: Government expenditure (both centre and states combined) is around 2.1% of GDP, which is still very low as compared to other democracies. This is the primary reason for the lack of infrastructure and substandard healthcare services for the masses.
• Issues plaguing PMJAY: PMJAY is facing some issues that hinder its effective implementation. These issues are:
  • Duplicate health IDs, unrealistic family size, invalid mobile numbers and other cases of fraud were pointed out by CAG.
  • Network hospitals complain of delayed payments, a high rejection rate, a low package rate and complicated process.
• Rural urban divide: Many health professionals do not prefer to go to rural areas due to poor infrastructure, inadequate facilities, etc. This leaves the majority of the population in the country vulnerable, as more than 68% (according to census 2011) of the population still lives in villages.
• Missing Middle: According to the NITI Aayog almost 30% of the population that mostly constitutes the middle class in the country does not have any kind of health insurance due to lack of awareness, unaffordability, pre-existing diseases etc.
• Neglect of preventive health care: There is increased focus on curative care, and preventive care is largely neglected.

• Increased government spending on public health.
• Bridging critical gaps in health infrastructure.
• Leveraging new emerging technologies such as Big Data , Artificial Intelligence (AI) etc in diagnosis and treatment.
• Proper regulation, surveillance, and accountability measures for both the private and public sectors.
• Creating skilled manpower to fulfil the demand.
• Special focus on elderly, disabled, and transgender needs, as they may differ from the rest of the population.
• Generating awareness about preventive healthcare and a healthy lifestyle with a special focus on AYUSH.
• Expanding health insurance schemes to other income groups.

In the last decade, India has made tremendous progress in the health sector. Ayushman Bharat has provided a clear roadmap to realise UHC as envisioned by SDG 3. Also, India is on track to achieve SDG 3 by 2030. Still there are some challenges that are a drag on progress and need attention. As India enters the Amrit Kaal, the vision of comprehensive health coverage for every citizen can be realised through concerted efforts by all the stakeholders and a commitment to excellence.