High level expert group for universal health coverage

Abstract

Ensuring equitable access for all Indian citizens, resident in any part of the country, regardless of income level, social status, gender, caste or religion, to affordable, accountable, appropriate health services of assured quality (promotive, preventive, curative and rehabilitative) as well as public health services addressing the wider determinants of health delivered to individuals and populations, with the government being the guarantor and enabler, although not necessarily the only provider, of health and related services. Our definition incorporates the different dimensions of universal health assurance: health care,which includes ensuring access to a wide range promotive, preventive, curative, and rehabilitative health services at different levels of care; health coverage, that is inclusive of all sections of the population, and health protection, that promotes and protects health through its social determinants. These services should be delivered at an affordable cost, so that people do not suffer financial hardship in the pursuit of good health. The foundation for UHC is a universal entitlement to comprehensive health security and an allencompassing obligation on the part of the State to provide adequate food and nutrition, appropriate medical care, access to safe drinking water, proper sanitation, education, health-related information, and other contributors to good health. It is our belief that the State should be primarily and principally responsible for ensuring and guaranteeing UHC for its citizens. The State should not only provide health and related services, but should also address the wider determinants of health to effectively guarantee health security. Ten principles have guided the formulation of our recommendations for introducing a system of UHC in India: (i) universality; (ii) equity; (iii) non-exclusion and non-discrimination; (iv) comprehensive care that is rational and of good quality; (v) financial protection; (vi) protection of patients’ rights that guarantee appropriateness of care, patient choice, portability and continuity of care; (vii) consolidated and strengthened public health provisioning; (viii) accountability and transparency; (ix) community participation; and (x) putting health in people’s hands. Intrinsic to the notion of universality, nondiscrimination, non-exclusion and equity is a fundamental commitment to health as a human right. Universality implies that no one (especially marginalised, remote and migrant communities as well as communities that have been historically discriminated against) is excluded from a system of UHC. At the same time, while society should pay special attention to the concerns of disadvantaged populations and the poor, a universal system should provide health coverage and care for everyone. This will ensure the creation of a robust and sustainable system of UHC in whose success every section of society has a vital interest. It will also protect both the poor and non-poor from the risk of impoverishment due to unaffordable health care expenditures. A system of UHC can succeed only if it is established on the strong foundations of common interest, social solidarity and cross-subsidisation. Instituting a system of UHC for India requires a flexible architecture to deal with inequities in health outcomes, regional and sociocultural diversity, and the differential health care needs of populations in different locations. It should also take into account the challenges of rapid urbanisation, simultaneous demographic, epidemiological and nutritional transitions underway, as well as social and political changes occurring in the country. Embedded in our understanding of UHC is recognition of two critical factors. First of all, it will be difficult, if not impossible, to achieve and sustain UHC without addressing the social determinants of health. Urgent and concrete actions addressing the social determinants of health are needed to move towards greater health equity, bridge gaps and reduce differentials in health by class, caste, gender and region across the country. In other words, UHC can be achieved only when sufficient and simultaneous attention is paid to at least the following healthrelated areas: nutrition and food security, water and sanitation, social inclusion to address concerns of gender, caste, religious and tribal minorities, decent housing, a clean environment, employment and work security, occupational safety and disaster management. Secondly, the very framework and principles of UHC for India will be severely undermined if gender insensitivity and gender discrimination remain unaddressed. An inclusive approach to health should attend to the needs and differentials between men, women and other genders, along with the interaction between social and biological markers of health. In making UHC truly gender-sensitive, we specifically recommend critical actions to improve access for women and girls to health services (going beyond maternal and child health), to recognise and strengthen women’s central role in health care provision in both the formal health system and in the home, to build up the capacity of the health system to recognise, measure, monitor and address gender concerns, and to support and empower girls and women. Finally, our review of the global experience with UHC leads us to make two comments. One, there doesn’t appear to be a single ‘universal method’ of financing and financial protection that assures guaranteed UHC in any country. Two, what we are proposing for India is somewhat unique. It is a hybrid system that draws on the lessons learned from India as well as other developed and developing countries. Our vision and recommendations that follow take cognizance of the extraordinary opportunities that India offers – and the possibility for India to take a lead in introducing a well-designed UHC system that is eminently suited to the needs and resources of countries at a similar level of development.