The steady but precarious move towards universal health coverage

By Dhruv Pahwa and Vyoma Dhar Sharma
New Delhi:
The National Health Protection Scheme (NHPS) is commendable, both in terms of quantum of funds and population coverage. The devil, however, lies in the detail and demands that we orient ourselves to the nuances of this proposition.
The move towards Universal Health Coverage (UHC) is unprecedented. We first heard of NHPS in FY 2016-17, when it proposed a health cover up to rupees one lakh per family. Even as NHPS was not launched that year, Rs 1,500 crore was allocated towards the Rashtriya Swasthya Bima Yojana (RSBY) and 31% was utilized. The budget fell by 33.3% (Rs 1000 crore) in FY 2017-18 โ€“ the only year that NHPS appeared in the expenditure budget. RSBY currently aims to reach seven crore economically marginalized families with an annual cover of Rs 30,000 per family. In 2017, 3,63,32,475 beneficiary households were enrolled โ€“ 51.9% of the target population. The 10 crore families to be covered under NHPS will shift this goalposts further and cost Rs 12,000 crore per year. This year, RSBY has received an allocation of Rs 2000 crore โ€“ 16.6% of the requisite amount.
Greater clarity is needed on the architecture of this scheme โ€“ will state based health insurance schemes be incorporated within NHPS? What will be the annual premium amount? How will it be borne? Meanwhile, RSBY has been ineffective in reducing the financial burden on poor households. Providers either persuade families to avail of procedures not covered by RSBY or completely deny care due to delayed reimbursements. Consequently, out of pocket expenditure (OOPE) remains stubbornly high at 62%. RSBY provides coverage for low-cost in patient care but over 70% of all OOPE is on outpatient care and medicines.
Not only do people lack appropriate financial protection, poor service quality compels them to seek expensive routes to care. Specialists are in short supply with CHCs reporting a deficit of over 80%. Even as the budget was tabled, 2.75 lakh NHM workers were on a nationwide protest to demand formalized work status and better pay. Resource gaps have led to secondary and tertiary care being overloaded by cases that could be solved by comprehensive primary care. In this regard, 1.5 lakh subcenters are to be transformed into Health and Wellness Centers. But when the allocated Rs 1,200 crore is split across 1.5 lakh centers, the Rs 80,000 per centre is too low for any meaningful transformation.
Also, the Economic Survey did not rub off on the health budget. The health budget was silent on the three dimensions of gender equality posited in the Economic Survey – agency, attitudes and outcomes. The budget for the Pradhan Mantri Matritva Vandana Yojana (PMMVY) fell by 7.5%; reproductive and child health, communicable diseases and NHM as a whole received allocations that were less than FY 2017-18.
For the past five years, public health expenditure has been below 1.5% of GDP. By one estimate, public health spending will have to increase by 26.2% annually to attain the target of 2.5% of GDP by 2025. Beyond these targets lies the fact that battling an illness is tough enough without the added burden of high and, at times, catastrophic healthcare costs. Unless we infuse our health system with meaningful investments, we are only safeguarding our position as the disease capital of the world. This is a good place to start, if one is to steadily but surely progress towards UHC.

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