India’s UHC challenge is intimidating and covering NCDs calls for a radical shift in prioritisation of budgets by accounting for respective disease burdens
Non-communicable diseases (NCDs) have emerged as the leading cause of death globally. According to the Institute for Health Metrics and Evaluation (IHME) estimates, NCDs were responsible for 70% of total deaths and 59% of aggregate disability-adjusted life years (DALYs) in 2013. To prevent impoverishment of citizens, governments have endeavoured to provide enhanced and affordable access to healthcare services via the universal health coverage (UHC) framework. In September 2015, UHC deliberations led to the adoption of SDG 3.8—to achieve financial risk protection, access to quality essential healthcare services and access to effective and affordable essential medicines and vaccines for all.
Health systems so far, especially in low- and middle-income countries, are resource-constrained and are inadequately equipped to deal with the burden of NCDs. Essentially, UHC may be perceived as redefining the standard objectives of health systems—accessibility, availability, affordability, quality and viability—with a focus on better outcomes for the vulnerable sections of the population. A typical UHC model is hard to define as approaches differ across countries and health systems are constantly evolving, based on socioeconomic fundamentals.
Given NCDs require long-term care and treatment adherence, assuring uninterrupted access to drugs and medical services is crucial, yet challenging. However, incorporating NCDs in benefit packages of UHC programmes is at a nascent stage and is largely missing from international health policy discourse. Nevertheless, coverage for NCDs in many UHC programmes has increased. For instance, Jamaica’s National Health Fund (NHF) covers NCD-related benefits and has been able to increase overall utilisation of NCD services along with reducing out-of-pocket expenditures (OOP).
India also launched the Jan Aushadhi scheme in 2008 to provide affordable essential drugs and surgical instruments for diabetes, cardiovascular diseases, respiratory diseases, neoplasms and disorders of the central nervous system.
UHC can be achieved in two ways—by ensuring coverage is accessible for all or by guaranteeing treatments for all diseases to a limited section. Almost all UHC programmes, initially, follow a bottom-up approach, targeting the vulnerable population. Thailand’s Universal Coverage Scheme (UCS), for example, evolved from an earlier initiative, The Medical Welfare System, meant to focus exclusively on the poor. Seguro Popular in Mexico and Subsidised Regime in Colombia were launched to provide subsidised healthcare to the poor while necessitating co-payments from non-poor segments. But summary inclusion requires the non-poor to contribute in a mandatory prepaid mechanism so that the poor can be exempted from co-payments.
In some cases, health systems are becoming responsive about covering their populations against health-related economic crises. Thailand’s UCS, for instance, guarantees financial protection to 99.5% of its population. Introduced in 2001 as ‘30 baht universal coverage programme’, it offered comprehensive healthcare including free outpatient care, prescription drugs, hospitalisation, ambulatory care, radiotherapy and other costly medical procedures. However, the scheme did not cover renal replacement therapy (RRT) as it was not cost-effective and contributed significantly to long-term fiscal burden. Despite anticipating such monetary challenges, Thai government decided to include RRT in its UCS benefit package. Providing financial protection to acute renal disease patients was commendable and reflects growing political consciousness toward complete attainment of UHC.
Chile, too, deserves a special mention as its UHC provides explicit legal guarantees for all beneficiaries. Implemented in 2005, the programme known as ‘Universal Access with Explicit Guarantees (AUGE)’ has broadened its benefit package from 56 priority health problems to 80 in 2015. In addition to providing guarantees for curative procedures, AUGE caps maximum waiting times, co-payments and deductibles.
India, on the other hand, has largely developed a number of Centre sponsored-and-managed disease-specific programmes—mostly for diseases/conditions considered critical from a public health perspective, including HIV/AIDS, TB, maternal and child health concerns, etc. Theoretically, India possesses a public health system that provides inclusive healthcare since Independence.
Starting from Bhore Committee (1946) to Draft National Health Policy (2015), all major policy documents have emphasised that healthcare should be accessible for all, irrespective of their capacity to pay. More recently, the High Level Expert Group 2011 on UHC, proposed a clear-cut model of healthcare entitlements for several conditions, including NCDs. A viable financing structure for these entitlements was however missing. While the Alma Ata declaration (1978) relied on the principle of public financing and provisioning of healthcare, the HLEG report proposed a framework wherein publicly financed healthcare could also be privately delivered. It was apparently critical of purchasing healthcare ‘voluntarily’ through insurance and suggested that government revenues should form the basis of purchasing healthcare services for all.
Health systems in India have been perennially underfinanced—public health expenditure (as % of GDP) increased from 1.02 to 1.4 between 2004 and 2014. Moreover, despite overwhelming success of federal schemes like NRHM and RSBY, OOP expenditures remain high. While OOP payments for Thailand and Chile have dropped from 20% and 42% in 2004 to 8% and 32% in 2014, respectively, OOP expenses for India fell marginally, from 68% to 62%. Many state governments have introduced state-sponsored health insurance covering in-patient care, and in some cases, out-patient care to fight mounting OOP expenditure.
NCDs have been addressed rather passively in recent international discourse on UHC and in the context of global health financing. In 2015, NCD finances accounted for only 1% ($480 million) whereas finances allocated to HIV/AIDS constituted 30% ($11 billion) of global health flows. Likewise, maternal and child health together comprised 28% ($10.1 billion). Health systems, however, are trying to widen coverage and/or benefits under UHC.
Given that 58%, or 3.4 million, NCD-related deaths were premature (under 70 years) in 2012—the highest worldwide—India’s UHC challenge is intimidating and calls for an increase in allocations.
Even if NCDs were to be addressed passively, a radical shift in prioritisation of budgets is required, by accounting for respective disease burdens. UHC can offer enormous opportunity for integrating NCDs in the package of essential health interventions. This will, of course, require robust nationwide and state-specific approaches. Such transformative strategies are critical for not only preventing premature mortality, but also to avoid significant potential loss of human capital. Implications for households also merit attention as most NCD-related expenses are financed through either incomes or savings, thereby inhibiting ability of households to save for or invest in productive capital accumulation.
The authors, Divya Chaudhary and Priyanka Tomar are researchers with the Health Policy Initiative at ICRIER, New Delhi. Views are personal