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Dr Nata Menabde
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The concept of Universal Health Coverage (UHC) is core to the health development and needs of the people, anywhere in the world. In the words of Dr Margaret Chan, Director-General of the World Health Organization (WHO), UHC is the “the single most powerful concept that public health has to offer.” Understandably, in last few years, UHC has caught the imagination of a number of national governments, political decision makers and people alike. It has received a further boost with experience emerging from a number of countries clearly indicating that UHC is possible even in low and middle income countries. Evidence suggests that the ‘returns on investment’ in health are greater than previously thought, accounting for as much as 24 per cent of growth in developing countries as a result of better health outcomes
UHC entails that ‘all people have access to needed promotive, preventive, curative and rehabilitative health services, of sufficient quality to be effective, while also ensuring that people do not suffer financial hardship when paying for these services.’ The major challenges in moving towards UHC are cited as poor political will, weak and poorly performing health system, limited evidence for decision making and low government spending on health, among others.
There are global examples that low GDP can’t be a hurdle in adopting, implementing and progressing towards UHC. A number of countries, categorised as low and middle-income countries, in Asia and Africa have successfully moved towards UHC. Experience from these countries re-affirms that political will is the first and foremost for moving towards UHC. The governments must have the political will to commit to UHC which needs to be translated into right instruments i.e. changes to a country’s policy and legal framework to facilitate the process and adoption of new laws and regulations to implement UHC reforms.
UHC implementation in the countries has often been complemented by efforts such as developing mechanisms to generate additional revenue through taxing products such as tobacco and alcohol that are harmful to people’s health (sin taxes). Tackling corruption in the health system, innovating financing mechanisms and increasing efficiency in tax collection for raising revenue for UHC are other approaches successfully attempted by a number of countries.
The policy decision for UHC needs to be informed by evidence. However, there is limited research capacity in a majority of developing countries. The need for setting up research wings, where evidence informs policy making, has been aired. Brazil, Mexico and Thailand have done so and it has worked.
There is something to learn for UHC from India’s polio eradication programme. The programme was based on high political will and meticulous planning to the extent that every functionary knew what his/her role was. Micro-plans available at all levels and implementation of these plans was well monitored. UHC in India could follow a similar approach. Experts believe that not enough time has been given for planning for UHC in India. What is needed at this moment is to step back, take stock of the situation, plan effectively, prepare a detailed implementation plan and develop a monitoring mechanism before embarking upon UHC.
UHC efforts in low and middle-income countries, with large informal sectors and many outside the formal sector (where direct taxation is harder to implement), would require a number of reforms. This approach moves away from a principal focus on earmarked payroll taxes and a contributory basis for entitlement. Such are the lessons from recent innovations in Brazil’s expanded “right to health,” Kyrgyzstan’s Mandatory Health Insurance Fund, Mexico’s ‘Seguro Popular’ and Thailand’s Universal Coverage scheme, among others.
International experiences also show that reforms in large federal systems (for example, China and Mexico) must devote attention to the role of local governments, with the centre using inter-governmental incentives to stimulate attention to health at state/provincial levels. The core empirical lesson from Brazil, China, Mexico and Thailand is that reforms to make progress towards UHC can and indeed must, given the expectations of the population, be implemented at a faster pace than in Europe in the last century. The main lesson is that the same degree of thought and effort that goes into developing policies should also go into developing an implementation strategy, distinguishing between the long steady necessary processes and the importance of seizing political windows of opportunity when they arise. While global evidence is useful, any effective strategy needs to be ‘home-grown’. There is clearly no ready-made solution or approach to be ‘copied’ or ‘imported’ from other countries; each one needs to arrive at its own solutions.
As India moves towards implementation of UHC, two points are worth keeping in mind. First, no country (with the possible exception of China) has ever taken on such a complex endeavour at such massive scale. The 12th Five Year Plan rightly recognises that the pursuit of UHC will last for at least two to three plan periods i.e. 10–15 years. This would require strategies to go beyond the script of one single plan period. Therefore, attention needs to be paid by policy makers to identify priority issues, key implementation challenges and main barriers, as also customising solutions across health system functions. Second, implementation needs to be accompanied by analysis, so that the solutions are found through policy analysis and research embedded into implementation. This calls for strengthening ‘evidence-to-policy’ links. State-level experiences and good practices need to be documented and shared widely.
In parallel, India needs to carefully design the institutional/organisational arrangements for implementation. The tools, management of partnerships, access to up-to-date health analyses for informed decision making, etc. need to be crafted. However, one caution for policy makers in this process is to temper ambition with realism in terms of what could be implemented and then move forward. To conclude, political will, rather than national wealth, is the critical pre-requisite for moving towards UHC. Experience has shown that UHC is needed and is feasible. Necessary knowledge and skills exist to implement it in the country. Policy makers need to design a detailed plan supported by an implementation strategy and appropriate legislative steps.
Countries have shown that a strong political will is the first and the most important step to achieve UHC.