K Srinath Reddy :
It is my firm belief that our focus needs to go beyond health insurance. The way ahead lies in health assurance. We need to focus on preventive healthcare, where public participation has a major role to play.” This remarkable passage from the recent address by the prime minister to the American Association of Physicians of Indian Origin (read out by the health minister in San Antonio) bodes well for our new health policy.
Health assurance is different from health insurance – often incorrectly used as the basis for universal health coverage (UHC) – in three major ways. First, it denotes a concept of health that goes beyond healthcare. It correctly emphasises the need for providing health in all dimensions, from promotion of positive health and disease prevention to effective illness care. In contrast, health insurance usually covers only clinical care for developed diseases – often selective even in that. Policies in sectors other than health have a profound impact on the health and nutritional status of populations. Potable water, sanitation, environment, agriculture, food processing, education and urban transport are among the sectors where policies and programmes can either enable or erode health. Health insurance does not touch any of these.
Second, even in the arena of healthcare, health assurance encompasses many essential elements of the system, besides the component of financial protection against personal expenditure.
To provide an assurance of health, we need to ensure a numerically adequate, technically skilled and socially committed health workforce, which is multilayered but functions as a cohesive team. We need to provide the required physical infrastructure, drugs, equipment and supportive services to make every healthcare facility fully functional and easily accessible. We have to develop accurate real time health information systems that can assist decision-making at all levels, from policymakers to healthcare providers and patients. Innovative technologies need to be developed to enhance the outreach and effectiveness of health services.
Access to essential medicines, vaccines and technologies has to be promoted, along with their rational use. Robust regulatory systems have to be created to streamline health-professional education, quality of care and drug control.
People have to be empowered, as communities and as individuals, to participate in healthcare design and delivery as informed partners of health professionals and administrators. Good governance and managerial efficiency have to be demonstrated with clearly defined measures of accountability. Health insurance does not address these.
Third, even when it comes to financial protection, health assurance reaches beyond the narrow definition of insurance to provide cost coverage through a combination of several financing mechanisms: tax-funded free provision of essential health services to all citizens; employer-provided health insurance for additional services; government-funded social insurance programmes that provide the unorganised workforce and poor with additional services not covered in the universal free package; and private insurance for those who desire and can afford to purchase services.
Ideally, all or most of these must be routed through a single-payer system to avoid the problems of fragmentation so evident in the maze of American health insurance. Health assurance incorporates but is not limited to health insurance.
One of the major problems of government-funded insurance schemes that exist today is that they do not cover primary healthcare and the outpatient component of advanced care.
Most often, the cost of medicines required on a long-term basis is also not covered. As a result, there is little impact on out-of-pocket spending which, at 70 per cent in India, is among the highest in the world. Worse still, it concentrates the government’s attention and health budget on advanced medical care, to the neglect of primary healthcare, which is essential for many common conditions. Efficient primary health services also act as a responsible gatekeeper for advanced care, thereby prudently curtailing healthcare expenditure.
To confuse health insurance with UHC is a cardinal error. Indeed, the report of the high level expert group (HLEG) on UHC, submitted to the Planning Commission in 2011, affirmed “…the UHC, in its understanding, moves beyond ‘insurance’ to providing an ‘assurance’ of healthcare for multiple needs and includes health beyond healthcare, going beyond a mere illness response”.
Now, it is time for UHC to be assembled on that broad platform, to be supported by the four sturdy legs of a well-resourced health system, pro-health policies in other sectors, an efficient and equitable system of financial protection and empowered communities.
(The writer is president, Public Health Foundation of India. Views are personal)
