The challenge of universal health coverage Premium
T he ongoing national conversation on what India needs to do for universal health coverage (UHC) often misses the complexity of multiple health systems and the unique challenges they bring. Almost every health system type that is seen globally is present in different parts of India. Sometimes, more than one type can be seen within the same State.
Government expenditure (per capita) on healthcare, for example, varies significantly from State to State. Himachal Pradesh, Kerala, and Tamil Nadu spend ₹3,829, ₹2,590, and ₹2,039, respectively, while Uttar Pradesh and Bihar spend only ₹951 and ₹701, respectively (National Health Accounts — Estimates for India 2019-20).
West Bengal, a predominantly rural State, has a low fertility rate at 1.64, but it also has one of the highest teenage pregnancy rates (16%). This is very different from other States with low fertility, such as Kerala and Himachal Pradesh, where teenage pregnancy rates are 2.4% and 3.4%, respectively (National Family Health Survey-5, 2019-2021). A UHC plan for States must be developed considering these very different realities.
Government health expenditure in West Bengal, which was ₹1,346 per capita in 2019-20, is only about 61% of the estimated ₹2,205 (research-based and inflation-adjusted) required to offer UHC. This number compares with a similarly populated State such as Madhya Pradesh where government health expenditure is ₹1,249 per capita.
Growing government health expenditure is good but may not solve the problem. West Bengal’s government health expenditure has been growing at 11% per annum over the last few years and, at this rate, could grow to fully meet the funds estimated to be required for UHC by 2030. However, the State’s out-of-pocket expenditure was high at 67% in 2019-20 and had only reduced by 2-3% from the previous years (National Health Accounts — Estimates for India 2019-20). The story is no different in Andhra Pradesh, which saw a 3% increase in per capita government health expenditure in 2019-20 from the previous years, but had a high out-of-pocket expenditure of 64% (National Health Accounts — Estimates for India 2019-20).
Thus, increasing government health expenditure does not appear to be working to contain a key issue relating to the health burden on citizens. This suggests that there are deeper design challenges with the health system. Without addressing these, increased government expenditure on health may do little to reduce out-of-pocket expenditure rates.
The implications of this are significant. Out-of-pocket expenditure already accounts for a majority of health spending in most of the States. A paper published recently (Sangar et al. 2018) noted that out-of-pocket expenditure accounted for more than 50% of health spending not just in poor States such as Jharkhand, Bihar, and Uttar Pradesh, but also in comparatively prosperous States such as Kerala and Punjab, which have strong healthcare systems.
In the case of West Bengal, high C-section rates even within the public sector strongly indicate that there is an adequate supply of public sector hospitals at which free care can be offered. This negates the need and relevance of the State’s Swasthya Sathi scheme, which is intended to allow patients to seek care in private hospitals using the government’s limited tax resources. It is designed to compensate for a deficiency in the supply of government hospitals.
On the other hand, that there is a significant share of adults with high blood sugar rates across West Bengal, relative to the rest of the country; and also relatively low rates of hypertension in the State suggests high rates of genetically inherited insulin insufficiency, which needs to be addressed with urgency in primary care settings. Similar trends are observed in Bihar and Gujarat, which also have high blood sugar levels and relatively lower hypertension rates, in contrast to Kerala, Tamil Nadu, and Telangana, where both conditions are prevalent. This necessitates tailored health system strategies and region-specific public health messaging to address the varying trends in non-communicable diseases across different areas.
Data also show that while there is an income gradient, even the very poor in West Bengal have high blood sugar rates. It is clear from the high blood sugar rates that the current, largely out-of-pocket expenditure-driven health system design cannot address this challenge and that a much more proactive approach needs to be taken at the primary care level. However, with a 58% shortfall in primary health centres and health and wellness centres, the primary healthcare system in the State faces enormous challenges in meeting the healthcare needs of its population; this needs to be addressed urgently.
The data here illustrate how healthcare is an interconnected system that presents a complex mosaic of challenges and opportunities. These cannot be addressed by blanket solutions that are unmindful of the uniqueness of the local area health profile, and its deeper relations to history, culture, and ways of working. Thus, leverage points vary and blunt instruments or even throwing resources can have little impact and, in some cases, make the situation worse. A holistic approach is essential, integrating public health initiatives, regional policy adaptations, and climate resilience, to build a robust and equitable healthcare system.
Dyuti Sen, Public health professional and an International Health and Tropical Medicine graduate from the University of Oxford. (Through ‘The Billion Press’)
Published - December 18, 2024 12:15 am IST
)
)
)
