What is UHC and why is it ill-suited for the Indian People?

Imrana Qadeer & Kasturi Sen

[In the global discourse, Universal Health Coverage (UHC) is viewed as the panacea for addressing poor and costly access to health services in Low income countries. Most are struggling with ill-fated health and welfare provision. Under pressure from bi-lateral and multilateral agencies, the idea of UHC has raised centre stage in the national policy arena on health care and is being implemented with much fanfare. Public health scholars aware of the paradoxes built into the UHC discourse have begun to unravel this Janus.This paper highlights the reasons why UHC is ill-suited for India and could even be a death knell for public health services.]

Most developed countries rebuilding their welfare economies in the post-World War II era, attempted to provide Universal Health Coverage (UHC) to people. Their rapid economic growth with resources drawn from their colonies overshadowed the contribution of the social determinants of health making medical care the focus of UHC and many European countries involved the private sector in this enterprise with strict legislatively defined guidelines. The US and the USSR with other socialist counties were the exceptions with starkly opposite framework for services, one based totally on the market and the others on their socialist collective strategy. For the rest of the world much of which was coming out of its colonial phase with national governments seeking a better deal for their people, their sources of inspirations were equally varied depending upon their political perspectives. The interesting fact is that even within the welfare capitalist experiment there was no one model that was tried. It ranged from tax-based NHS of Britain to Social Health Insurance in Europe with various mixes of state funding, private insurance and out of pocket expenditure. The three common features across countries were the state commitment for basic services (with an expanding scope of the basic), a strong legislation for mandatory state-supervision, regulation of finances and monitoring rooted in the value of social solidarity. Thirdly, even though the economic crisis of the 1970s and '80s, the state protected investments in the health sector. The socialist countries evolved an integrated system of curative and preventive services for all as a right; it was viewed as a full responsibility of the state which also covered, working conditions, housing and food availability for working people.

Following independence (1947), India searched its way in these models of welfare societies and chose to build its universal basic health service system within the framework of a mixed economy. Though the fact that ill-health of its people was rooted in their poverty and deprivation was fully recognised and economic policies proposed to promote growth and job creation. However, no steps were taken to ensure that health planning was linked to developmental milestones—the two had independent trajectories. The first two decades saw a great deal of transformation in both the arenas such as land reforms, introduction of minimum wages, systems of loans for productive activities, growth of co-operatives, development of heavy industrial base, community development programmes, and the setting up of welfare structures for education, medical care, promotion of science and setting up public distribution systems. Along with these, in most of these sectors, the private entrepreneurs took advantage of the infrastructures to create their own productive outlets and usurp profits. In other words, the social constraints of economic policies distorted the distributive networks that remained limited. Science grew in higher institutions though its spread remained limited—given the poor quality of government schools and colleges—and technology acquired greater significance compared to the development of a scientific culture. As financial inputs started declining especially in the welfare sectors, developmental priorities shifted.

The decline of the healthcare services in India and its changing priorities from rural to urban healthservices and, training of doctors as against paramedical worker, medical care at the cost of an integrated health care system has to be seen within the larger context of a socio-economically stratified low income country. The shifts were reinforced by the winding down of its welfare state and its experiment in societal reorganisation. Two critical set of factors in this setback were the prevailing class; first were the caste, gender divides and the ensuing biases and values of inequality embedded in the social structure and second was the attraction of technological solutions, without addressing the inequities built in the social structure. While these structural issues were not adequately tackled, the glamour of technology and turn-key projects—the malariaor small pox eradication programmes, the green revolution or PL 480—all induced dependence on foreign consultants. The promise of a universal basic health service infrastructure based on a three tier service with peripheral centers supported by well -equipped middle level district facilities and tertiary institutions at the top, remained a partially fulfilled dream. Even if the institutional structures were built, their working left much to be desired.

In an interconnected world, the fast growing neoliberal strategies promoted by global finance institutions to save itself from a crisis of capitalism struck the welfare economies forcing them into austerity and less developed countries into giving up control over their economies. Through the World Bank and the IMF's proposed financial reforms, these economies were supported through conditional loans and absorbed into the global markets. These shifts were pushed not only by the World Bank that talked of technological packages, population control, user fee, and financial roll back from public sector to bring in financial efficiency through private sector (World Bank 1993). It proposed selective mass based intervention and leaving medical care to the private sector. Later on the WHO also fell in line with The Commission on Macro Economic and Health (WHO 2001). It joined this drive to argue for investing in health for increasing economic growth ignoring that jobs were declining under the new economic policies. Its growing financial dependence on the WB was behind its co-optation with WB's priorities—Selective PHC and Universal Health Coverage. By 2010, the DG WHO was focused on 'efficiency' and 'diseases focused approaches'and opined that, UHC was the way to equity, quality and universality (WHO 2010) [http://www.who.int/dg/speeches/2010/launch_ WHR_20101122/en/]. The Lancet Commission, representing global health experts also joined in and were, ready to lift the developing world out of its poverty and disease ridden existence believing that, a grand convergence in health was achievable in their lifetime, because of the collective will of their generation and their financial and technical capacity for selective interventions (Lancet Commission 2013).

With the compulsions of weaning-off the developing world away from the ideological attraction of the socialist block gone(with the collapse of the USSR), and the oil crisis of the seventies, the global powers stepped up pressure for Structural Adjustments Programmes (SAPs) that encouraged roll back of the welfare sectors and their privatisation. A more than willing Indian government wanting to retain its political hold and its support base among the rich industrial and agricultural elite and middle classes gave in to these pressures and, opted for the growth oriented model of the economy for their benefit. Over the latter half of the seventies then, instead of handling the difficult issues of technological choices, organisation to deliver the same and implication of social and economic structures for the delivery health services, the government chose the easier way out. Despite its formal acceptance of the Alma Ata declaration of the WHO on Comprehensive Primary Healthcare (CPHC)of 1978, its implementation remained in the frame of selective PHC—a strategy limited to technology dependent goals, and focused on medical care that was proposed at a meeting organised by the World Bank and the WHO a year after the Alma Ata declaration by Walsh and Warren (1979). The 1983 Indian Health Policy document proposed opening up of medical service, provisioning to private sector whilst financial allocations further declined. With these informal inroads of reforms, HSR were formally accepted in 1991.

The promise of social security net for the vulnerable in SAP was soon discarded unceremoniously leaving the poor to carry the burden of reforms. Apart from roll back of investments in health sector it called for private investment in public sector, encouraged privatisation of tertiary health care, casualisation of health manpower, contracting out to (hospital food supply, laundry sanitationetc), user fee and, contracting in private services (diagnostics, management of hospitals, Primary Health Centres etc) public private partnerships and private health insurance. The return of the epidemics, plague (2002), blood dysentery and malaria made it clear that drastic budgetary cuts were politically unwise. It was thenthat the WHO (with percent of its fund coming from the WB), proposed the idea of Universal Health care/Coverage (UHC). Without any reference to its history it was projected as a magic bullet no different from CPHC but not as impractical as it could be materialised.

Preference for UHC over PHC
The two pathways to universal care were thus defined differently by the WHO: PHC (Primary Health Care) was defined under Alma Ata(1978) as, "essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing" (WHO, 1978). If implemented, it could have served as a critical gate keeping function for referrals to secondary and tertiary care but it was never adequately implemented in India. However in contrast, 27 years later the WHO shifted to UHC which it considered not different but more practical as, "Universal coverage of health care means that everyone in the population has access to appropriate promotive, preventive, curative and rehabilitative health care when they need it and at an affordable cost. Universal coverage in the current ideological discourse implies equity of access and financial risk protection. It is also based on the notion of equity in financing, i.e. that people contribute on the basis of ability to pay rather than according to whether they fall ill. This implies that a major source of health funding needs to come from prepaid and pooled contributions rather than from fees or charges levied once a person falls ill and accesses services" (WHO, 2005). Revenue collection pooling and purchasing became UHC's main strategy. The critical shifts of priorities and approach are: (a) the state responsibility was towards protection from financial risks and equity rather than for provisioning. So, UHC shifted from public provisioning to public financing. (b) Illness management and curative treatment became a central featureat the cost of systemic approach to illness and health. (c) Integrated health services critical to population health were no more an integral part of the developmental process. (d) Since state was no more a single provider, purchasing from the private sector became a major turning points of UHC (WHO, 2005), promoting further public private partnerships (PPP). Its acceptance was reflected by the National health bill 2009 of the government of India that shifted state responsibility from being single provider to PPPs with emphasis on coverage where financial support for those who can't pay for hospitalisation alone came from the state

Unfolding UHC in India
The move towards bringing the private sector centre stage brought in several distortions in the theoretical conception of UHC and had serious implications for public sector in health. The track changes were far too sharp to be taken as stream lining of PHC, as they were transformative. "Catastrophic expenditures" on hospitalisation, was used to shift emphasis to curative care. Ignoring chronic deprivation of resources, paucity and poor functioning of public institutions became the reason for promoting PPPs and state subsidies were transferred to private sector medical care to increase coverage, not necessarily care. These shifts came despite the knowledge that public sector has the value for money (Draft NHP 2015)and that, for health medical care is not sufficient. The contradictions they create are antithetical to any possibility of revival of the systemic approach to comprehensive health care due to the following reasons:
a.   While the private provider is responsible only to its users and hence its profits, investments and outcomes are not public knowledge, the public sector is accountable to the public and the state and is therefore bound to transparency regarding reinvest-ments of its profits and patterns of investment. It also functions on the basis of cooperation and harmony with its other institutions and therefore unlike the private sector, is non—monopolistic.

b.   The objectives are service to all for the public sector and maximising profits with service for the select in private sector. While the state argues that given its size, the private sector cannot be ignoredas a part of healthcare system in India. In reality, its serious and negative impact on public sector cannot be ignored. It fragments and commercializes systems, ignores epidemiological needs of the majority, feasible low cost solutions and PHC. Its business model pushes unregulated technological growth for maximizing profits and rising costs. In contrast, the public sector is more efficient as recognized by the Draft National Health Policy 2015.
c.    Biased towards clinical medical care, the major inputs in health of nutrition, availability of drinking water, sanitary conditions and housing are entirely overlooked as the key factors of poor health, and the systemic approach to health is lost in pursuit of monetary"efficiency" for gain.

These contradictions are visible in the UHC model being promoted in the name of 'progressive universalization' through a state supported insurance strategy without time lines, clarity about resources and, concern about welfare inputs of any kind not even underlying serious mal and under-nutrition and hunger in India. The 12th Five Year Plan rejected the HLEG (Higher Level Expert Group's 2011) proposal for a state financed public sector which it recommended was to only selectively use the private sector where at all necessary. Yet the National Health Policy 2017 furthered the process of commercialisation of public hospitals, corporatization of medical care and expansion of public subsidy to private sector under the garb of state led health insurance (NHP 2017). In reality there is no 'pooling of resources' from users of different incomes and the rich are encouraged to go in for private or employee insurance. At the same time, in general taxation, the taxes for the rich have been lowered over time. The state subsidies for the targeted population go to providers mostly private in a large number of the states. This is because of prolonged deprivation of resources, decline of public sector and absence of a level playing field for which the public sector loses further as their subsidies are now not fixed but depend upon the number of families choosing them for services. Yet, till now, only about 40 percent of even the targeted BPL population is covered (NFHS 2016) and, 35 percent of the eligible don't even know of this scheme (India spends Report 2017).

The Rashtrya Swasth Surakshna Yojana (RSBY) was the first state led insurance which on a registration fee of Rs 30, offered an insurance cover up to Rs 30,000 per year to a family. It was followed by several Indian states announcing State led insurances, and then in the insurance cover was increased to one lakh in 2017 with its renaming as the National Health Protection Scheme (NHPS). Now, this has become a NHP Mission or Ayushman Bharat of 2018 which uses insurance companies as well as trusts for running the scheme to offer an insurance of five lakhs. RSBY Evaluation studiess how that it could not reduce out of pocket expenditure as it did not cover out- door treatment which is their major expense. The amount insured was also extremely limited compared to treatment costs of serious illnesses and costs have consistently risen. The resources for increased coverage (to one lakh) could not be mobilized by the state and the latest avatar, Ayushman Bharat, expands it to cover 10 crore BPL families. The previous scheme itself needed Rs 480 crore per year and hence failed to meet its target (S and I) where this five times larger sum is going to come from is still not clear. A way out is to link it to Aadhar which is what the Commission papers indicate. These schemes not only barely help in absence of strengthened institutions of the public sector;they can be destructive in the face of spiraling costs of private sector hospitals subsidised by the state through the insurance scheme. With poor coverage of even the targeted population and, without any time-line, it is unpredictable when the relief will reach the border-line families that are on or above BPL in its progressive coverage. Schemes such as Yashswasini and Vajpayee Arogyashree insurance have become a bonanza for the corporate sector who use public services to identify the poor needing tertiary care and herd them to their five star hospitals in 'special wards' where their rights and privileges are limited. The choice of cases is not on the basis of need but on the basis of assured passage through hi-tech and therefore high cost diagnostic investigations and surgery. Risky cases are rejected for fear of losing out financially nor are patients allowed to change their minds or go for a second opinion (Vasan 2015).

RSBY in West Bengal
Recent research undertaken in selected districts of West Bengal (Sen and Gupta 2015; Banerjee and Sen 2017) suggests that RSBY has not been able to alleviate problems with access to health care "by choice" in accordance with its intent. Despite access to private hospitals through RSBY most of those interviewed preferred to utilise public hospitals and doctors already known to them. This is contrary to what is proclaimed by donors and policy makers at the national and International levels: that given the choice, poor people would use private clinics and hospitals. Whilst the empanelment process throughout the country makes this claim patently untrue, more than one study found that BPL groups in West Bengal for example, preferred what is known and trusted by them- that is public doctors and public providers despite the long waits, among other problems.

As a result, the whole RSBY funded scheme in West Bengal from 2009 nearly collapsed with the state being forced to intervene in 2014. The intervention involved an increase in the empanelment of public hospitals from less than 16%of the total (public and non-profits) to just under 40 percent, over a period of two years (2014-2016). With this intervention, the use of RSBY in hospitalisation cases increased 74% in one year (2015-2016) whilst utilisation of public hospitals alone jumped by 159.5%. For private hospitals and clinics in the state, the increase was a mere 1.3% during the same period (2015-2017) (Banerjee and Sen 2017). This is a loud and clear sign for the State about poor people's preference for public hospitals when needed. The implication is that unless more public hospitals are included in the so-called free access scheme state budgets could collapse due to the high cost of subsidies to private providers as well as loss to private insurers when the value of premiums reduces through introduction of public hospitals in the scheme. For the private empaneled hospitals, this leads to lower profits and BPL populations' preference for public doctors and hospitals increasingly challenges the plan for commercialised health care in WB through RSBY. The most significant point which maybe applicable elsewhere for health care in India is that despite the systematic undermining of public health services over the past 3 decades, in many cases as in WB, it retains the trust of the majority of the poor, and if supported materially with adequate investment it will provide better health outcomes at a much lower cost.

Frontier
Autumn Number 2018
Vol. 51, No.14 - 17, Oct 7 - Nov 3, 2018