Dec 18, 2024 08:35 PM IST
The success of the universal benefit package rests on the careful design of the benefit package. It must align with both the cost and health care needs of the country.
International Universal Health Coverage (UHC) Day falls in December. For India, the road to UHC starts with increasing government spending on health, a national priority as per the government’s policy documents. The Ayushman Bharat programme provides the structure for translating such investment into concrete outcomes for the people. It includes Ayushman Arogya Mandirs for comprehensive primary health services — promotive, preventive, curative, palliative and rehabilitative care —without incurring any financial burden. It also features the Pradhan Mantri Jan Arogya Yojana (PMJAY) which uses the health insurance model to provide access to secondary and tertiary health care to nearly 50% of the population. These are ambitious policies that depend on an improved fiscal context and coordinated governance across the central and state governments. Directed investments towards strengthening institutional governance and capacities for regulation, quality control, enforcement, fraud control, grievance redressal and research have to be prioritised.
Even if all of this is achieved, current policies still leave out about 30% of our population from any coverage for secondary and tertiary care that is potentially high-impact and impoverishing. Addressing coverage for this missing middle is especially important as India seeks to achieve developed nation status.
The Union government has fiscal constraints that prevent the provision of a comprehensive universal benefit package (UBP) in publicly-funded health facilities to all its population. Expanding PMJAY coverage to those currently uninsured, for instance, will require, at the minimum, doubling of the current PMJAY budget. On the other hand, the experience of countries such as China suggests that without significant government subsidisation, voluntary uptake of health insurance remains poor. India could consider introducing a shallow UBP for the entire population, for a limited set of high-priority and high-cost services as a first step towards UHC.
The pandemic provided proof of concept when the government was the principal provider of Covid-related health services for all. It also helped strengthen the social contract between the government and society.
A UBP could offer a standardised package designed nationally, as a minimum that must be covered and adhered to for all. The states and the Centre can coordinate through the National Health Authority and its state-level counterparts that already operate under PMJAY to arrive at the specific health services to be covered under this UBP. Key inclusion criteria could be arrived at through the identification of priority health areas and taking into account budget and administrative realities. Service users would be free to pick their providers since all legal providers would be automatically enrolled under the UBP.
Defragmenting India’s health insurance landscape through merging existing risk pools and financial flows will be an important step towards UHC. While a single universal pool as envisaged for UHC will remain the long-term agenda, harmonisation of pools with some merging through a UBP could be an immediate step on the UHC pathway. Digital systems will be central for data and claims management while giving individuals easy access to their health status. In all of this, data privacy will strictly be maintained. Internal migrants will get continuity under the UBP, similar to the set-up in Thailand that achieved UHC in 2002.
The success of the UBP rests on the careful design of the benefit package. It must align with both the cost and health care needs of the country. A poorly designed UBP that dilutes existing services will be extremely detrimental to the UHC. One example of the type of package that can be covered under the UBP could be emergency trauma care, such as in Thailand where emergency services for up to 72 hours are included. Over time, more packages from PMJAY can be gradually included in the UBP. Thus, the UBP would prioritise breadth of coverage initially, albeit for a limited number of health conditions, moving towards greater depth over time. Thailand and many other countries such as Brazil and Turkey have introduced legislation to mandate UHC and provide an institutional imperative for greater prioritisation of health. A legislatively mandated UBP will facilitate bringing the missing population under the ambit of existing health policies and institutionalise collective solidarity and progress towards health for all.
Neethi Rao is fellow, Alok Kumar is research associate, and Sandhya Venkateswaran is senior fellow at the Centre for Social and Economic Progress (CSEP). The views expressed are personal
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