Context

• The article underscores the need to move forward with a newer concept of UHC, with an intersectoral convergence beyond medical and health departments.
• It also put emphasis to move forward from the Alma Ata declaration of primary health care towards a holistic model governing all levels of healthcare.

Universal Health Coverage

• It means that all people have access to full range of quality health services they need, when and where they need them, without financial hardship.
• It covers the full continuum of essential health services, from health promotion to prevention, treatment, rehabilitation and palliative care.
  • It thus encompasses primary, secondary and tertiary care for all who need it at affordable cost without discrimination.
• The slogan “Health for All by 2000” proposed by Halfdan Mahler and endorsed by the World Health Assembly in 1977 had an inherent implication, i.e., “for All”, which means universalisation.
  • This implied that nobody is denied healthcare and everybody is eligible without being discriminated against on the basis of financial status, gender, race, place of residence, affordability to pay or any other factors.
• The UHC has become a well-accepted objective of public policy around the world.
• A globally accepted health systems concept since the Beijing Health Systems Research Conference 2012 is that of a multi-nodal system of varied sectors, professional streams and specialities with a variety of staff to deliver Comprehensive Universal Health Care.

Limiting the UHC Concept

• The WHO adopted pro-market driven reform guidelines during the period of 2004-2010 by yielding to the World Bank and the Rockefeller Foundation.
  • This involved for instance, reducing state regulation and selectivity of uneconomical service coverages.
  • This backtrack from “Health for All” dilutes the UHC concept.
• The Astana Declaration of 2018 also called for “partnership” with the private sector to make primary health care the mainstay of universal health coverage.
  • But it is well established that alcohol, tobacco, ultra-processed foods, and industrial and automobile pollution are contributed by the commercial private sector.
  • The poorer countries too miserably fail or are unwilling for “private sector regulation”.
  • Also, Astana declaration never addressed poverty, unemployment and poor livelihood, but praises quality primary health care only as the cornerstone for Universal Health Coverage (UHC) and ignores broader Universal Health Care.
• The World Health Assembly resolution of 2011, urges countries for timely finance of the health sector to reduce out-of-pocket expenses and a catastrophic expenditure in health resulting in the impoverishment of families.
• However, the sloganeering of Universal Health Coverage must be avoided as it seems deceptive.
  • This is because it is neither universal in its implementation nor comprehensive in its coverage of services.
  • It also never assures accessibility or affordability as its financing is conditional to insurance premiums paid either by the individual or state.

India’s UHC Approach

• Indian Constitution guarantees health as a basic human right under right to life in line with WHO definition.
  • WHO defines health as mental and social well-being and happiness beyond physical fitness, and an absence of disease and disability.
  • India, through its National Health Policy 1983, committed itself to the ‘Health for All’ goal by 2000.
• This underlines that India cannot achieve health in its wider definition without addressing health determinants, necessitating need for intersectoral thrusts.
  • For instance, the National Health Mission has concurrent focus on Poshan Abhiyan, National Food Security, MNREGA, water sanitation, Sarva Shiksha Abhiyan, etc., and is a better model of fully tax-funded Universal Health Care.
• This is in contrast to the Ayushman Bharat Jan Arogya Bhima Yojana that has with small levels of public spending, implying the inability to afford enough protection against catastrophic health expenses to the poor.
  • As per latest estimates, the scheme has covered just 21.9 crore beneficiaries which is less than 50% of the originally targeted approximately 50 crore beneficiaries under the scheme.
• Also, high insurance coverage cannot not be equated with effective financial protection.
  • For example, Andhra Pradesh has among the highest public health insurance coverage scores (71.36%), 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%) has a lower out-of-pocket (46.4%).

Conundrum while Addressing Health Challenges

• A focus on primary care: The International Conference on Primary Health Care, at Alma Ata, 1978, listed eight components of minimum care for all citizens.
  • It mandated all health promotion activities, and the prevention of diseases including vaccinations and treatment of minor illnesses and accidents to be free for all using government resources, especially for the poor.
  • Any non-communicable disease, chronic disease including mental illnesses, and its investigations and treatment were almost excluded from primary health care.
• Limited spotlight on other levels of healthcare: The secondary and tertiary care, on the other hand was left to the individual to either seek it from a limited number of public hospitals or from the private sector by paying from their own pockets.
  • Also, there were not enough government-run institutions for the people who could not afford exploitative and expensive private care.
• Unsolicited consequences: The abdication of responsibility to provide secondary or tertiary care by the state, led to thriving of dominant, unregulated, profit-making private sector and health insurance sector.
  • This created a dichotomy between peripheral primary and institutional-referred specialist care at the secondary and tertiary levels.

Adopting a New Approach Towards Healthcare

• Primary Health Care (PHC) Version 2 or Comprehensive PHC was operationalized through the National Rural Health Mission (NRHM) in India from 2013.
  • This was defined with the realization that even the poor contract chronic illnesses and non-communicable diseases such as cardiac, neural, mental and metabolic disorders.
• The second half of the last decade also saw operationalization of the Health and Wellness Centre as a model of implementation of Comprehensive Primary Health Care.
• The Alma Ata declaration of primary health care thus could be replaced with a newer concept of UHC which encompasses primary, secondary and tertiary care for all who need it at affordable cost without discrimination.

Conclusion

• Every individual has a right to be healed and not have complications, disability and death. That right is guaranteed only by individualism in public health, the new global approach to UHC, where “nobody is left uncounted and uncared for”.