Universal Health Coverage For India Recommendations Of The High Level Expert Group (Planning Commission) Prof. K. Srinath Reddy President, Public Health Foundation of India Bernard Lown Professor of Cardiovascular Health, Harvard School of Public Health WORLD THE CHINDIAN CENTURY With so many of the world's economies in tatters, the combined might of China and India could spearhead global growth in the coming decades. Are they up to the job? By ZOHER ABDOOLCARIM TIME : NOVEMBER 21, 2011 THE CASE FOR INDIA: FREE TO SUCCEED By MICHAEL SCHUMAN
KEY HEALTH INDICATORS: INDIA COMPARED WITH OTHER COUNTRIES Indicator India China Brazil Sri Lanka Thailand IMR/1000 live births 50 17 17 13 12 Under 5 mortality/ 1000 live births 66 19 21 16 13 Fully immunised (%) 66 95 99 99 98 Birth by skilled attendants 47 96 98 97 99 Source: World Health Organization (2011) IMR Infant Mortality Rate LOW PRIORITY TO PUBLIC SPENDING ON HEALTH INDIA AND COMPARATOR COUNTRIES, 2009 Total public spending as Public spending on Public spending on health as % % GDP health as % of of GDP (fiscal capacity) total public spending India 33.6 4.1 1.2 Sri Lanka 24.5 7.3 1.8 China 22.3 10.3 2.3 Thailand 23.33 14.0 33 3.3 Source: WHO database, 2009 Indian governments devote very low per cent of public spending to health 3 4% amongst the lowest of any country in the world.
Financing: a challenge and an opportunity India s health hfinancing system is a cause of and an aggravating factor in the challenges of: health inequity and impoverishment inadequate availability poor reach unequal access poor quality and costly health care services Why so? Seven key features of India s y health financing
1. Low levels of health spending Total Per capita total 2009 expenditure on health as % of expenditure on health (PPP$) GDP Sri Lanka 4.0 193 India 4.2 132 Thailand 4.3 345 China 46 4.6 309 Source: WHO database, 2009 2. Low levels l of public expenditure on health h 2009 Public Per capita public expenditure on expenditure on health as % of health (PPP$) GDP Sri Lanka 1.8 87 India 12 1.2 43 Thailand 3.3 261 China 2.3 155 Source: WHO database, 2009
3. High burden of private out of pocket expenditures Proportion on private out of pocket of expenditures (%) Pakistan 83 India 78 Bangladesh 71 China 61 Sri Lanka 54 Thailand 36 0 10 20 30 40 50 60 70 80 90 4. High costs of out patient and medicine costs Breakdown of private out of pocket expenditures (%) Medicines and other expenses Inpatien t 24% Others 28% Outpati ent 76% Medicine s 72%
CURRENT SCHEMES FOR FINANCIAL PROTECTION MOSTLY DO NOT COVER OUT PATIENT CARE DRUGS LAB DIAGNOSTICS Which collectively contribute to the larger fraction of OOP! 5. Centre State financing issues State governments are primarily responsible for the funding and delivery of health services State governments bear close to two thirds (64%) of thetotal total government health expenditure. The Centre accounts for the remaining third. Though the Centre's financial contribution is relatively small, its influence is substantial. National Rural Health Mission Rashtriya Swasthya BimaYojana (RSBY) strongly motivated increased contributions to health from State governments.
Large inter state differentials in public spending Per capita public health spending, 2004 05 (Rupees) Proportion of children fully immunized (%) 2005 06 Source: NFHS 3 Bihar 93 Bihar 33 Uttar Pradesh 128 Uttar Pradesh 23 Tamil Nadu 223 Tamil Nadu 81 Kerala 287 Kerala 75 0 100 200 300 400 0 20 40 60 80 100 6. Limited financial protection and failure of insurance markets Insurance coverage remains low with financial protection available only for hospitalization, and not for outpatient care India's medical insurance sector remains weak and fragmented The benefits of traditional insurance coverage accrue only to a privileged few and mostly to those working in the organised sector.
RSBY: Government Financed Insurance Schemes Unorganised sector (BPL Families) No. of Smart Cards: 26,491,093 (as on 23/1/2012) Coverage Limit : USD 600/Family/Year AROGYASRI: BPL + Other vulnerable sections Patients Registered : 5,183,179 Coverage Limit : USD 3000 4000 Government Financed Insurance Schemes RSBY (Targeting BPL) Strengths Rapid Enrollmentand ExpandingCoverage; Portability Engagement of Public & Private Providers for 2 o care Some S Quality Improvement Effective Use of I.T Improved Fraud Detection Systems
Government Financed Insurance Schemes RSBY (Targeting g BPL) Weaknesses Only Covers Hospitalized 2 o Care neglect of preventive and promotive care Financial i l Non Sustainability If Utilization Rate is High (e.g., in Kerala) Cost Escalation Paradoxical Rise in OOP(!) Impact on Health Outcomes Questionable; Fragmentation of Care (Lack of Continuum of Care) Government Financed Insurance Schemes State Level Programmes Cover hospitalised 3 o care High proportion of state health budget diverted for 3 o care in private hospitals Neglect of 1 o care and public facilities High level of induced demand and inappropriate i care
7. Poor value for money Poor quality of services Wastage and inefficiency i Corruption Weak management Lack of accountability Universal Health Coverage For India Recommendations Of The High Level Expert Group (Planning Commission) Mirai Chatterjee Director, SEWA Social Security & Member, National Advisory Council
UNIVERSAL HEALTH COVERAGE BY 2022: THE VISION ENTITLEMENT Universal health entitlement to every citizen NATIONAL HEALTH PACKAGE Guaranteed access to an essential health package (including cashless inpatient and out patient care free of cost)) Primary care Secondary care Tertiary care CHOICE OF FACILITIES People free to choose between Public sector facilities; and Contracted in private providers Our Definition of UHC 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 and appropriate, assured quality health services (promotive, preventive, curative and rehabilitative) i as well as public health h services addressing wider determinants of health dli deliveredd to individuals id and populations, with ih the government being the guarantor and enabler, although hnot necessarily the only provider, of health h and related services.
Our Vision Universal Health Entitlement for everycitizen to a National Health Package (NHP) of essential primary, secondary & tertiary health care services that t will funded dby the government. Package to be defined df dperiodically by an Expert Group; can have state specific variations How to finance UHC? Eight Key Recommendations
Recommendation 1 Government (Central government and states combined) should increase public expenditures on healthfrom the current level of 1.2% of GDP to at least 25%by 2.5% the end of the 12th plan, and to at least 3% of GDP by 2022 Projected share of public and private Health spending in India 5 4.5 4 35 3.5 3 1.2 2.4 3.0 % of GDP 2.5 Public spending 2 1.5 1 0.5 3.3 21 2.1 1.5 Private spending 0 2011 2017 2022
Recommendation 2: Ensure availability of free essential medicinesby increasingpublic spending on drug procurement. increasein the public procurement of medicines from around 0.1% to around 05%of 0.5% GDP Streamline and Centralise procurement like in Tamil Nadu Recommendation 3 Expenditures on primary health care, should account for at least 70% of all health care expenditures and cover general health information and promotion curative services at the primary level screening i for risk ikfactors at the population level
Recommendation 4: Use general taxation as the principal source of health hcare financing i complemented dby additional mandatory deductions from salariedindividuals individuals and tax payers either as a proportion of taxable income or as a proportion of salary. Recommendation 5 Do not levy sector specific specific taxes for financing None of these options is likely to meet substantially the financial requirements of UHC. Such levies distort overall fiscal prioritisation. Earmarking from a specific tax may not actually add to the health budget if the increased funds from the earmark are offset by reductions from discretionary revenues
Recommendation 6 Do not levy fees of any kind for use of health care services under the UHC Evidence suggests that user fees have: increased inequalities in access to healthcare. negative impacts on the usage of health services even from those that need them. Not an effective source of resource mobilization. challenges of means testing and errors of inclusion and exclusion Out of pocket payment at the point of care is the most important reason why healthcare expenses turn catastrophic for all healthcare users. NO USER FEE INSURANCE (PVT./EMPLOYER) OR OOP UHC PACKAGE OF HEALTH SERVICES (NHP WITH NHEC) HOSPITALITY COMPONENT (Pvt. Ward) NON NHP SERVICES PERSONS OPTING FOR NON NHEC ACCREDITED HOSPITALS
How to generate additional resources? enhance the overall tax to GDP ratio widen the tax base improve the efficiency of tax collections do away with unnecessary tax incentives explore possibilities of reallocating funds to health Recommendation 7 Address state financing issues Introduce specific purpose transfers to equalize the levels of per capita public spending on health across different states Accept flexible and differential norms for allocating finances so that states can respond better to differentials and diversities across districts
Recommendation 8 Do not go the insurance route All government funded insurance schemes should, over time, be integrated with the UHC system. Purchases of all health care services under the UHC system shouldbe undertaken either directly by the Central and state governments through their Departments of Health or by quasi governmental autonomous agencies Registry
Universal Health Care (UHC) Report s Recommendations on SDH 1. Initiatives, both public and private, on the social determinants of health and towards greater health equityshould be supported 2. A dedicated Social Determinants Committee should be set up at district, state and national level 3. Include Social Determinants of Health in the mandate of the National Health Promotion and Protection Trust (NHPPT) 4. Develop and implement a Comprehensive National HealthEquitySurveillance Framework, as recommended by the CSDH