One of the important goals of universal health coverage is to ensure reach and coverage of the most marginalized population. However, the NFHS-5 results paint a different picture for India, where insurance coverage is lowest among households with the lowest wealth quintile. Also, coverage among minorities such as Muslims and Sikhs is lower than Hindus
Universal Health Coverage (UHC) is widely discussed around the world as an essential component of the development agenda. The Covid-19 epidemic necessitated the need for universal health coverage, as health systems failed miserably across the world at this time. Considering the importance of UHC, the United Nations declared December 12 as the International Day of Universal Health Coverage (UHC Day) in 2017.
The United Nations defines UHC as “everyone, everywhere should have access to the health services they need without the risk of financial hardship”. SDG target 3.8 (“Ensure universal health coverage, including financial risk protection, access to quality essential health services and access to safe, effective, quality and affordable essential medicines and vaccines”. affordable for all.”) also emphasizes the achievement of universal health coverage. UHC can be achieved by ensuring population coverage, service coverage and financial security.
India has pledged to achieve UHC by 2030. To achieve the goal of UHC, the Indian government has come up with a rather ambitious health insurance policy Pradhan Mantri Jan Arogya Yojana, under the Ayushman scheme Bharat launched by Prime Minister Narendra Modi on September 23. 2018, in Jharkhand. It has been popularized as one of the largest health insurance policies in the world and an important step towards universal health coverage.
However, household health insurance coverage from all sources stands at 41% (NFHS-5, 2019-21), lower than in many developing countries. This coverage is at a minimum of 30% and 33% for women and men (aged 15 to 49) simultaneously. It is not only the low coverage that is of concern, but also the fairness of distribution that is questionable.
Without achieving equity, we cannot achieve UHC, because the former is the guiding principle of the latter. There are substantial variations across states as on the one hand Rajasthan (88%) and Andhra Pradesh (80%) are at the top, on the other hand Bihar (17%) and UP (16%) are at the bottom of the scale. conditions of health insurance coverage. Districts within states also experience huge variations.
One of the important goals of UHC is to ensure reach and coverage of the most marginalized population. The NFHS-5 results paint a different picture for India, where insurance coverage is lowest (36.1%) among households with the lowest wealth quintile. Moreover, coverage among minorities such as Muslims and Sikhs is also lower than Hindus.
Another essential pillar of UHC is financial protection, ensuring that health services should not lead to financial hardship. The latest NFHS report revealed that the average out-of-pocket expenditure (OOPE) per delivery in a public health facility is 2,916, which in the case of urban and rural areas is 3,385 and 2,770 simultaneously. This number is an improvement over NFHS-4, but we also have to keep in mind that we are seeing these numbers even though we have a program like Janani Shishu Suraksha Karyakram, which offers free shipping as well as ‘incentives’. 1,400 to women who give birth in a public health facility.
Further, let’s explore the situation at the state level. The NFHS results are rather alarming as the OOPE for most North Eastern states (except Meghalaya and Nagaland) and even larger states (except Odisha, Bengal West and Rajasthan) increased between NFHS 4 and NFHS. 5. Considering the above scenario, it seems like a daunting task to achieve the target set by the National Health Policy 2017 to reduce the OOPE. Although the NFHS-5 does not consider the implementation of the PMJAY, recent studies have shown that, like earlier health insurance policies, the PMJAY is also not free from errors of inclusion and exclusion where we see the inclusion of ineligible households and the exclusion of eligible households.
Service availability is also a crucial element of UHC. In terms of establishment of hospitals under the PMJAY, of the total number of hospitals established, 56% belonged to the public sector and 40% to the private for-profit sector. Most hospitals are incorporated in states where the state has already established publicly funded health insurance schemes (Joseph, J, D Hari Sankar & Nambiar, D, 2021).
Hence, the implementation of the policy in terms of building hospitals is facing concentration towards states like Karnataka, Gujarat, Tamil Nadu, Rajasthan and Uttar Pradesh. The specialties provided by the incorporated hospital also vary enormously. Most hospitals are able to provide very limited specialties, leaving much of the population deprived of the political advantage.
India recorded growth in several health indicators. Growth in health indicators such as Maternal Mortality Rate (MMR) and Infant Mortality Rate (IMR), achievement of Total Fertility Rate (TFR) target and freedom from polio in India are some of the -some of the crucial milestones that have become a reality. However, when you turn to the goal of universalizing health, fundamental changes must be made.
The most important step in this direction should be the increase in health expenditure as a percentage of GDP, which is currently lower than in most developing countries. Strengthening the primary health care sector is another area of development that requires special attention. In this direction, the establishment of health and wellness centers under the Ayushman Bharat program was proposed in 2018, but the growth in this regard is questionable.
A big push in the health sector is the need of the hour, in the absence of which health and wellness centers will find themselves in deplorable conditions similar to the current primary health centers and sub-centers. India needs to make significant progress before making this initiative the imitable in the world.
(Pratap C Mohanty is Associate Professor, IIT Roorkee; Milind K Yadav is Senior Fellow, IIT Roorkee)
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