First steps in the journey to universal health care

Description

Context:

About 20 years ago, Thailand rolled out universal health coverage for its population at a per capita GDP similar to today’s India. What made this possible was a three decade-long tradition of investing gradually but steadily in public health infrastructure and manpower.
This meant that alongside the availability of funds, there also existed robust institutional capacity to assimilate those funds.
For India, the lesson of COVID-19 entails setting forth on a steady and incremental path to universal health coverage; not attempting a sudden and giant leap. This is important because enough evidence exists on weak fund-absorbing capacities particularly in the backward States.

Budgetary allocations:

The Union Ministry of Health and Family Welfare budget for 2021-22, viz . Rs. 73,932 crore, saw a 2% increase over the Budget estimate (BE) of 2020-21 — a modest increase even nominally.
Also, a corpus of Rs. 64,180 crore over six years has been set aside under the PM Atma Nirbhar Swasth Bharat Yojana, (PMANSBY) for strengthening health institutions, and Rs. 13,192 crore has been allocated as a Finance Commission grant.
These could make the first steps of a journey that steadily builds towards sustainable universal health coverage through incremental strengthening of grass-root-level institutions and processes.
Two important and prominent arms of universal health coverage in India merit discussion here.

Universal insurance:

The BE for the Pradhan Mantri Jan Arogya Yojana (PM-JAY), which covers over 50 crore poor Indians for hospital expenses up to Rs. 5 lakh per annum, has stagnated at Rs. 6,400 crore for the current and the preceding couple of years.
And so have the actuals and revised estimates at around 50% of the BEs, which should be cause for concern.
Large expenditure projections and time constraints involved in input-based strengthening of public health care have inspired the shift to the insurance route for achieving universal health coverage.
Insurance does not provide a magic formula for expanding health care with measly levels of public spending. Given these circumstances, making do with such paltry spending year after year would mean that the scheme benefits are being spread out too narrowly or too thin, implying the inability to afford enough protection against catastrophic health expenses to the poor.
Beyond low allocations, poor budget reliability merits Another related issue is the persistent and large discrepancies between official coverage figures and survey figures across Indian States.
Robust research into the implementational issues responsible for such discrepancies and addressing them is warranted.
Finally, even high actual coverage should not be equated with effective financial protection. For example, Andhra Pradesh has among the highest public health insurance coverage scores (71.36%, NSS 75), but still has an out-of-pocket spending share much above the national average (72.2% of total health expenditure).
In contrast, Himachal Pradesh (H.P.) with a much lower public health insurance coverage (3.87%, NSS 75) has a lower out-of-pocket (46.4%).

Comprehensive primary care:

Health and Wellness Centres — 1,50,202 of them — offering a comprehensive range of primary health-care services are to be operationalised until December 2022.
Of these, 1,19,628 would be upgraded sub health centres and the remaining would be primary health centres and urban primary health centres.
Initially, most States prioritised primary health centres/urban primary health centres for upgradation over sub health centres, since the former required fewer additional investments.
This offers huge cost projections — as per early (conservative) estimates, turning a sub health centre into a health and wellness centre would require around Rs. 17.5 lakh, and around Rs. 8 lakh annually to run it thereafter.
Additional funding under the PMANSBY and Finance Commission grants is reassuring, but a greater focus on rural health and wellness centres would be warranted.

Issues with funds:

Two untoward implications could result from under-investing and spreading funds too thinly.
Continuing the expansion of health and wellness centres without enough funding would mean that the full range of promised services will not be available, thus rendering the mission to be more of a rebranding exercise.
Second, under-funding would squander an opportunity for the health and wellness centre initiative to at least partially redress the traditional rural-urban dichotomy by bolstering curative primary care in rural areas.
This opportunity arises on account of the expanded array of services that health and wellness centres are supposed to provide, and the fact that an overwhelming majority of them will be in rural areas.
Since curative care implies larger costs, they could be largely confined to delivering merely preventive, wellness, and referral services without adequate funding.