UHC Forward: Towards Universal Health Coverage

Sujatha Rao, former Principal Secretary for India’s Ministry of Health and Family Welfare, recently sat down with Meredith Kimball, Program Officer at the Results for Development Institute, to build on key themes that were identified during the plenary session, “Pathways to UHC: Debates on Critical Policy Choices” at the 2012 Prince Mahidol Awards Conference (PMAC) in Bangkok, Thailand.

In January 2012, Dr. Rao was named Senior Leadership Fellow in the Division of Policy Translation and Leadership Development at the Harvard School of Public Health. As a Senior Fellow, Dr. Rao will share her experiences with students and collaborate with renowned academic colleagues as they explore important issues pertaining to strategic decision-making and leadership development in health.

Kimball: If a program is targeted, how can resources be mobilized to sustain the program? What are the right questions to be asking around equity and how can it be best assured?

Rao: Targeting cannot be based on the principles of risk pooling. Similarly, an insurance product that is based on risk pooling – for the poor and by the poor – is likely to fail. The idea is to have government buying the insurance premium on behalf of the poor. So resource mobilization is from government taxes and the cross subsidy is based on the fact that the taxes, paid by the rich, are utilized to buy insurance cover for the poor.

In India’s context, the right questions to ask to ensure equity are related to all the inputs that make for well-being and good health such as water, sanitation, housing, nutrition, and education. In the absence of guaranteeing these basic goods, simply providing UHC is, in my opinion, an excuse for not making investments in those critical areas and only addressing the symptoms and not root causes of ill health and health deprivation.

The poor get diarrhea because they do not have access to safe water and are nutritionally compromised. How will the fact that they can go to any health center and pick up free medicines help? The fundamental question is why do they get diarrhea and why should so many children in India be dying of such an easily preventable disease? UHC is not the answer to well-being and good health even if it is politely packaged in saying that the benefit package will include prevention. The private sector, unless legally mandated, will never undertake prevention activities. I have seen too many private practitioners in an unregulated environment like India practice unethical medicine in primary care settings, contributing to the huge case load of TB, particularly the drug resistant TB. The first step is to implement regulations and tighten monitoring. That will help ensure quality and rational care for the poor. It comes back to the first question of the supply side being in equilibrium to the demand that UHC will generate.

Kimball: As we expand coverage, how can we incentivize efficiencies in the system, reduce fraud, motivate better performance, and ensure a higher standard of care? Quality can often be an afterthought, but as countries are contemplating reforms, do you think it should be integral to their designs?

Rao: Absolutely. Quality parameters need to be built into the financial system. In fact, two prerequisites that ought to be factored before rolling out UHC are one, laying down standards that are feasible for the health system to achieve; and two, enforcing machinery that is IT based. India’s experience with very limited insurance shows quality of care is an issue. National protocols need to be put in place and enforced. Mere coverage without quality is unacceptable as China’s experience shows – 98% “covered” yet catastrophic expenditure is still over 12 to 14%.

Kimball: As momentum around UHC continues to grow, do you anticipate UHC making its way onto the next wave of Millennium Development Goals (MDG)? How do we address the issue of measuring progress towards UHC in a practical way?

Rao: UHC addresses a serious issue, namely people having to pay for services to get well. When incomes are low, such expenditures can be catastrophic. So UHC must be the aspirational goal of every health system to strive. But making it into some kind of a measurable and monitorable target will and can be problematic. As it is under the UNDP HDI report and other reports, several indices of comprehensive health – access to water, sanitation, nutrition, life expectancy and rates under infant and maternal mortality etc. are being monitored. The MDG’s were also very comprehensive, including reduction of poverty.

The problem with UHC is getting indices that reflect its implementation. Merely reporting coverage is of little value if there is a system that is not delivering anything or if it is inaccessible. So what proxy indicators need to and can be developed more than what we already have needs to be examined. In any case, we need to gain a measure of clarity on the definition of UHC - what it means and must mean.

There are far too many variables, often not in the control of any country, to ensure for a meaningful measure of UHC. For example, if in a country with a high mental disability, mental health services is included in the benefit package, its enforcement can be problematic if the skilled manpower is constantly drawn away by the more advanced countries. On the other hand non-inclusion of mental health would make the UHC incomplete.

Including UHC in the MDG’s may help countries to think about UHC, but may divert attention and resources from essential services. Besides, measurement will be a problem given the fact that UHC is all about health systems and health systems are very context specific and dependent on various aspects not in the health domain. It’s a complex issue that needs careful thought.

This interview is part two of a two part series. Click here for Part I of this post.