Progress towards Universal Health Coverage
By Dr Charu C Garg1
India’s health care system is underfinanced, with the government spending just 1.15% of its Gross Domestic product (GDP)2 on health services. This is clearly reflected in different performance indicators, be it inadequate infrastructure, shortage of healthcare professionals, low access to primary health services, among others. Adding to the woes, private out-of-pocket expenditures (OOPE) on health is dominant with 64.2% of all health care spending in the country. In addition to household direct spending, private health insurance, health care provision and reimbursements by firms and industries, NGOs and charitable institutions account for about 8% of all health care spending.3 Coverage under private insurance is very narrow and is limited mostly to major urban areas and tertiary heath care services.
India, with 17.84% of the world’s population, is at high risk of economic implications due to the growing burden and pre-mature mortality due to NCDs. Every year, roughly 5.8 million Indians die from heart and lung diseases, stroke, cancer and diabetes accounting to 60% of all deaths in the country. One in 4 Indians risks dying from an NCD before they reach the age of 704. Although India has one of the largest disease burdens in the world, it continues to be a small spender ranking 166 from among 199 WHO member countries5 with per capita public spending on health at Rs. 1042 in 2013-146. While efforts have been undertaken to strengthen the health system with varying degrees of success, a large part of the population are still left to fend for themselves to meet their health care expenses.
In the last decade, there has been renewed interest in revitalizing the public health system through increased government spending through National Health Mission and Rashtriya Swasthya Bima Yojana (RSBY) and other pro-poor state specific insurance programs.
The 12th five-year plan; High-Level Expert Group on UHC7 and program implementation framework of NRHM and the recent National Health Policy 2017 have all emphasised the need to raise government expenditures to 2.5% of GDP by 2025 and increase states sector health spending to more than 8% of their budget by 2020 . The policy has also emphasised on Universal Health Coverage to reduce inequities in health and also reduce the proportion of households facing catastrophic health expenditure from the current levels by 25%, by 2025.
The total population coverage under any kind of insurance in India is about 32% or 41 crores in 2013-148. Social health insurance covered 8.8 crore individuals, Government-based insurance (RSBY and state level) covered 26 crore individuals, and 6.09 crore individuals are covered by private health insurance policies (employer/group based, individual and community health insurance). There is poverty link to increased coverage with almost 2/3rd increase (180 million) is in the population below the poverty line. The government spending through Social Security Mechanism and government-based voluntary health insurance schemes (prepayments through CGHS, ESI, and RSBY etc) is about 17% of government spending on health and the rest is direct spending on health and disease control programs9. Spending through voluntary prepayment mechanisms (insurance) is only about 5% of private spending10.
Current government allocations towards health care at 28.6% of total health expenditures are insufficient to fulfill the goal of Universal Health Coverage, as well as for designing sustainable and contemporary health systems that can keep pace with technological, demographic and epidemiological shifts in the country.
- The author is Advisor, Health Care Financing, National Health System Resource Center, MoHFW; Visiting Professor Institute for Human Development and international consultant for Health System and Policy. The author is grateful to J. Prateebha from NHSRC and Gaurav Chaudhary from PFCD for compiling some inputs for this paper. The view in this paper are those of the author and not of the organisation
2 National Health Systems Resource Centre (2016), National Health Accounts Estimates for India (2013-14). New Delhi: Ministry of Health and Family Welfare, Government of India.
3 National Health Systems Resource Centre (2016), National Health Accounts Estimates for India (2013-14). New Delhi: Ministry of Health and Family Welfare, Government of India.
4 Global Status Report on Non Communicable Diseases 2014, World Health Organisation, Geneva
5 WHO Global Health Expenditure database accessed from http://apps.who.int/nha/database/Key_Indicators/Index/en
6National Health Systems Resource Centre (2016), National Health Accounts Estimates for India (2013-14). New Delhi: Ministry of Health and Family Welfare, Government of India.
7HLEG Report on UHC,2011, Planning Commission of India
8 Health Insurance Expenditures in India 2013-14, NHSRC, MoHFW, GOI, November 2016
9National Health Accounts. Estimates for India 2013-14, NHSRC, MoHFW, GOI, August 2016
10Health Insurance Expenditures in India 2013-14, NHSRC, MoHFW, GOI, November 2016
11Peter B et al, Government health financing in India: Challenges in achieving ambitious goals, Health, Nutrition and Population (HNP) Discussion Paper, December 2010
12Independent Commission on Development and Health in India, VHAI(Need to provide year for both these references
13Independent Commission on Development and Health in India, VHAI
14 Health Sector Financing by Centre and States/UTs in India (2013-14 to 2015-16), NHA Cell, MOHFW, GOI; http://www.mohfw.nic.in/showfile.php?lid=3700
15Mita Choudhury H.K. Amar Nath ,An Estimate of Public Expenditure on Health in India, 2012, National Institute of Public Finance and Policy (NIPFP)
16 Ravi et. al. 2016 “Health and Morbidity in India (2004-2014),” Brookings India Research Paper No. 092016, Brookings Institution India Center: New Delhi
17 Karan A, Selvaraj S and Mahal A,2014, “Moving to Universal Coverage? Trends in the Burden of Out-Of-Pocket Payments for Health Care across Social Groups in India, 1999–2000 to 2011–12, PLOS ONE
18Global health expenditure database WHO and World bank (accessed 1 4 17) www.who.int/nha and http://data.worldbank.org/indicator/SH.XPD.OOPC.TO.ZS
19 National Health accounts Estimates for India 2013-14, NHSRC, MoHFW, GOI. August 2016. Economic survey 2013-14 shows expenditure on health including water supply and sanitation is 4.6 % of general government expenditures.
20 World Health Statistics Report, 2014, WHO
21National Health Policy 2017
22Peter B et al, Government health financing in India: Challenges in achieving ambitious goals, Health, Nutrition and Population (HNP) Discussion Paper, December 2010