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 Table of Contents  
Year : 2016  |  Volume : 4  |  Issue : 2  |  Page : 271-279

Mitigating India's health woes: Can health insurance be a remedy to achieve universal health coverage?

1 School of Management, Manipal University, Manipal, Karnataka, India
2 National Institute of Bank Management, Pune, Maharashtra, India
3 School of Management, National Institute of Technology Karnataka, Mangalore, Karnataka, India

Date of Web Publication20-Dec-2016

Correspondence Address:
B Savitha
School of Management, Manipal University, Manipal - 576 104, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2321-4848.196186

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A low level of public investments in preventive health facilities and medical care facilities and health professionals has given rise to poor health status for an average Indian. Insufficient government funding for health care, inadequate and ineffective health financing mechanisms, poor delivery of health care, especially in public facilities, and excessive reliance on unregulated high-cost private providers have contributed to the poor accomplishment of Millennium Development Goals, especially in the informal sector. Sustainable Development Goals (SDGs) consider health to be one of the important objectives to be achieved by all the nations in the world. This paper reappraises the current status, unmet needs, challenges, and the way forward to implement and achieve universal health coverage (UHC) in India by thrusting the focus on three elements (pillars) of universal access to health services. Despite seven decades of independence, India does still face the formidable challenge of providing health services to its population at an affordable cost. One of the major obstacles in reaching universal coverage and universal health entitlement of every Indian citizen has been the absence of effective health financing mechanism that promotes affordable access to weaker and vulnerable sections of the society. In this respect, health insurance certainly does have the potential to expedite the process of UHC if various stakeholders work in cohesion under the government stewardship. In rural India, the health infrastructure and workforce are inadequate to serve the unserved and underserved population. Hence, the government should invest in public health facilities while promoting pan-India health insurance to ensure and guarantee easy access and affordability for its citizens. The way forward should not only be centered on financial protection, but also to have renewed emphasis on restructuring the health-care system, ensuring the adequate availability of infrastructure, skilled workforce, and access to affordable drugs and technologies. Integration and strengthening of different health financing and delivery mechanisms would undoubtedly enable us to achieve the Alma-Ata declaration of “health for all” and the ambitious target United Nations SDGs of “UHC” by 2025 in India's “Bharat” and “modern” India.

Keywords: Affordable access, health financing, health insurance, sustainable development goals, universal health coverage

How to cite this article:
Savitha B, Kumar K N, Kiran K B. Mitigating India's health woes: Can health insurance be a remedy to achieve universal health coverage?. Arch Med Health Sci 2016;4:271-9

How to cite this URL:
Savitha B, Kumar K N, Kiran K B. Mitigating India's health woes: Can health insurance be a remedy to achieve universal health coverage?. Arch Med Health Sci [serial online] 2016 [cited 2023 Mar 29];4:271-9. Available from: https://www.amhsjournal.org/text.asp?2016/4/2/271/196186

“As long as poverty, injustice and gross inequality persist in our world, none of us can truly rest.

–Nelson Mandela

  Introduction Top

Ill health causes poverty through loss of wages, catastrophic expenses, and repeated medical treatment.[1] Spiraling health-care expenses often lead to the impoverishment of poor households who have to borrow money, mortgage or sell assets to pay for expenses, or just forgo treatments.[2] On the other side, poverty is associated with ill health due to low income, over indebtedness, and social expenses.[3] There is an intricate relationship between poverty and ill health, resulting in indebtedness and impoverishment. Hence, health has the highest priority in international development goals as an issue of economic growth and not just a medical issue.[4]

Health security should be an integral part of any poverty reduction program of a country. This is more important in developing countries since majority of the population live in rural areas or work in informal sector. They account for 84% of the world's population, 90% of the worldwide burden of disease, 20% of the global gross domestic product (GDP), and 12% of the global health spending.[5] The International Labour Organization (ILO)[6] highlights the gloomy picture of 1.3 billion people lacking access to affordable and effective health-care facilities and 44 million households facing financial difficulties due to high medical expenditure. Many nations promised to adopt Alma-Ata declaration “Health-for-all” of 1978 that urged countries all over the world to provide universal access to quality health care to their population by the year 2000, with the hope that such an intervention would reduce iatrogenic poverty by curtailing the negative impact of ill health on the life of people. Furthermore, Millennium Development Goals (MDGs) considered the achievement of an equitable provision of health care as one of the priorities for all the nations, especially the developing countries, by 2015. However, the performance of India in achieving these goals has been mixed due to India's failure to invest in adequate health infrastructure, health financing, and health workforce that thwarted the efforts to achieve MDGs.[7]

Despite having 16% of the world's population, 18% of the world's mortality, and 20% of the world's morbidity, India spends a minuscule 1% of global expenditure on health.[8] It is worth mentioning here that $280 billion industry in India has a growth rate of 17%. Yet, one million people die every year and nearly 700 million face barriers to specialist care in India where huge gaps are observed between urban and rural health-care systems. Almost 70% of the Indian population lives in rural areas that lack access to facilities and specialist care.[9]

As MDG era came to an end in 2015, the United Nations General Assembly unanimously adopted health as an essential element of Sustainable Development Goals (SDGs) that aimed to promote the well-being for all at all ages. The 13 targets of SDGs-3 include the domains of maternal and neonatal health, deaths from accidents, prevention of mortality from noncommunicable diseases (NCDs), and universal access to sexual and reproductive health-care services. These targets bind all the nations to provide universal health coverage (UHC) to the entire population and access to quality health services and essential medicines and vaccines for all by 2030. This powerful concept in public health contemplates to reduce poverty and enhance health security, better health outcome at lower cost.[10]

The United Nation's policy of UHC, as a route to achieve SDGs' health target, aimed to provide financial protection against catastrophic illness, health equity, and long-term sustainability and higher utilization of health services in terms of five As, namely, accessibility, affordability, acceptability, accommodation, and availability.[10],[11] The successful implementation and delivery of “pro-poor” UHC should take into consideration (i) the population covered, (ii) the type of services and quality of the covered services, and (iii) the payment mechanisms for these services. Other than protecting population against hardship financing for accessing health services,[12] the UHC also mandates the countries to equitable distribution of resources to achieve health equity.

  Pillars of Universal Health Coverage: India's Challenges Top

India faces several challenges to achieve UHC for its citizens that may be discussed under the categories of target population, types of services, and quality and payment mechanisms. Although the life expectancy in India has increased, India's population does face the an alarming upward trend in non-communicable diseases (NCDs) like diabetes, blood pressure, cancer, childhood obesity, stroke, ischemic heart disease, metabolic syndrome giving rise to premature mortality, in addition to the cost escalation associated with use of cutting-edge technology and treatments. It is a worrying fact that India's share in NCD has increased and is one of the highest in South East Asia Region (SEAR), higher than many African countries as well as most countries in the Americas, including the United States. This would necessarily need to implicate and address the issue of influencing public behavior to improve health and wellbeing by adopting healthier behaviours and lifestyle intervention programmes. India has 92% of population working in informal sector, deprived of any social security and risk pooling mechanisms. There is a wide gap in the availability of health services in rural and urban areas, and there is acute shortage of doctors, nurses, and paramedical staff. The government spends very less on health as evident in the shortage of skilled workforce, medicine, and diagnostic facilities in public hospitals. Tertiary care has become the niche services offered at private hospitals known for expensive and unregulated health services.

  Financial Protection: Health-Care Financing Top

Despite seven decades of independence, successive governments not only neglected the provision of health services by reducing the budget outlay for health sector but also failed to promote affordable care at the private sector through appropriate regulations and policies. The World Bank notes that India's growth rate of health expenditure at 4% in 2010 to be below the GDP growth rate of India.[9] When India's health expenditure as a percentage of GDP is compared with that of the world, we get a dismal picture. In 2008, India's outlay was 1.39% whereas Sri Lanka (4.2%), Nepal (5.1%), Chile (5.3%), and other comparable underdeveloped countries had higher outlay for health. The total health expenditure as a percentage of GDP (3.6%) is lower than that of some of the low-income countries (5.32% of GDP).[13] In 2012, the United States having a total healthcare spending of $2.6 trillion spent $8500 per capita whereas India with a GDP of $1.6 trillion spent a meager $40 per capita. Almost 67% of the total health spending in India constitutes private expenditure, of which 86% is out-of-pocket (OOP) and point-of-service expenditure and public expenditure is 33% of the total health expenditure.[14],[15] It means that individual households pay at the time of illness. It is accepted that this form of payment is very inefficient and inequitable.

Of the main health financing mechanisms, public budget on health expenditure is an important component in many countries. In case of India, a discernible fact is the low and downward trend in government spending on health as a proportion of GDP. The public health investment as a percentage of GDP has increased from 0.22% of GDP in 1950–1951 to 1.05% in 1985–1986, and it declined to 0.96% in 1990–1991 and 0.86% in 2003–2004. It was 1.36% in 2006–2007 but decreased to 0.9% in 2009, which is very low in global comparison.[13] The aggregate expenditure in the health sector [Table 1] has decreased from 4.2% of the GDP in 1997 to 4.12% in 2006 but later increased to 5.1% in 2009. Public expenditure as percentage of the total health expenditure was 25% in 2006 which increased to 32.76% in 2009, and the remaining is the private expenditure (75% in 2006, of which 91.4% is OOP expenditure). Insurance contributes only 1.1% of the total expenditure on health. Private health expenditure as percentage of total health expenditure was 78.43% in 1975–1976, 77.8% in 1998, and increased to 80% in 2009.[13] The public expenditure on health was Rs. 34.4 crores in 2005–2006 that increased to Rs. 58.6 crores in 2008–2009. The private health expenditure during the same period was Rs. 115 crores and Rs. 157.39 crores, respectively.[14] Despite the government's health subsidy aimed at the poor, the World Health Organization's (WHO) report observed only one-tenth of it going to the poorest while one-third of the subsidy is reaped by the richest.[16]
Table 1: Expenditure ratios and financing sources' measurement

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Another health financing mechanism is mandatory social health insurance (SHI) that provides risk coverage to nearly 1% of population in the formal sector of the economy through Employees' State Insurance Scheme and the Central Government Health Scheme (CGHS). ESIS's revenue has been growing substantially from Rs. 1564.28 crores in 2000–2001 and Rs. 3989.31 crores in 2007–2008, and surplus has increased from Rs. 1132.65 crores in 2005–2006 to Rs. 2,383.6 crores in 2008–2009, attributed to an increase in new memberships. Despite having surplus income over a period of 7 years, it was unable to provide quality services to the insured.[17] In case of CGHS, the budget allocation has increased from Rs. 252.85 crores in 2000–2001 to Rs. 407.14 crores in 2003–2004; later, it was decreased to Rs. 203.5 crores in 2004–2005 but later increased to Rs. 387.85 crores in 2008–2009.[18] CGHS and ESIS do not provide insurance coverage to 92% of productive economy of India that work in informal sector due to lack of cohesion and solidarity and poor institutional capacity to organize schemes.

Private health insurance is often recognized as a desirable financing mechanism worldwide. Indian insurance companies usually target middle-upper income class to shore up bottom line that restricts their coverage to elite 5% of the population. Despite being the fastest growing segment of the nonlife industry in the country today, it still remains vastly underdeveloped.[19],[20] Recent relaxation in foreign direct investment norms where foreign companies are allowed to increase shareholding up to 49% in Indian insurance companies has opened a plethora of opportunities to penetrate the bottom of the pyramid population. However, the health financing needs of low-income population are largely unattended by insurance companies due to high transaction cost, low-profit margins, and information asymmetry.

Another alternative to health insurance is cost recovery strategies that involve autonomy at public hospitals, revenue generation through user fees, and case-based insurance reimbursement.[21] This alternative may ignore the needy groups and promote discrimination in the quality of care, hence insurance that pools health risk can be a better option. Health insurance covers nearly 20% of the Indian population despite implementation of Rashtriya Swasthya Bima Yojana (RSBY) at a larger scale.[22] However, it is underdeveloped and lacks deep penetration, especially in rural market. The main reasons for the slow development of rural insurance market were (i) high administration costs, (ii) lack of regulation and control on provider behavior, (iii) unaffordable premiums, (iv) high claim ratios, (v) exclusion of many diseases from the coverage, and (vi) co-variate risks.[23] Private insurance, being expensive and urban-centric, is unaffordable by majority of population working in informal sector.

Being partially inspired by the US ObamaCare that provides insurance to all the population, our policymakers reallocated the financial resources from the delivery of health services to financing of through several health insurance schemes targeted at below poverty and low-income population, known as micro health insurance (MHI). RSBY is being implemented to achieve “complete transformation” of health sector in India. MHI finances health-care expenses through the principle of risk pooling aimed primarily at the informal sector in which the members participate in its management.[24] MHI schemes intend to provide financial protection to low-income families and safeguard them from falling into indebtedness or impoverishment. Additional benefits are low transaction costs and better health behavior through the health education. MHI has the advantage of scientific organization of the private insurance and advantages of local knowledge and trust enjoyed by non-governmental organizations (NGOs) at the grass-roots level. It brings down the burden of health-care expenditure on poor, increases utilization of services, and reduces hardship financing to access health services.[25],[26],[27],[28],[29],[30]

The limitation of small pool due to modest size of membership, unsatisfactory products, and lack of awareness does inhibit the successful working of such schemes.[31] Other risks to successful functioning of MHI to achieve SDGs are adverse selection in which sick individuals have higher likelihood of joining the scheme due to lack of screening and absence of waiting period; moral hazard where behavioral changes in insured give rise to higher than the warranted utilization of health services; higher than average charges billed for insured patients because of supply moral hazard; and higher claims ratio owing to larger outflows from the program under adverse selection and moral hazard and lack of funds when the penetration of membership is abysmally low.

  Provision of Services and Its Quality Top

India's health system is challenged by NCDs and non-NCDs, pushing it to the forefront of becoming disease capital of the world. The upper-income class faces an increased incidence of lifestyle diseases whereas the poor in rural and urban areas suffers mainly from communicable diseases along with NCDs.[32] In fact, 60% of deaths in India occur due to NCDs and account for 40% of hospital stays and 35% of outpatient visits.[33] India still battles communicable diseases witnessing 253 deaths per 100,000 persons, a higher average than Nepal and Bangladesh. Despite this, preventive and promotive health-care spending in India is far less compared to other countries, and a major proportion of curative care spending is incurred on tertiary hospitals located in urban areas. The private sector caters to 70% of outpatient and 60% of inpatient services. The single most important source of treatment is private doctors; in fact, 79% of urban population and 72% of rural population sought care from private doctors.[22] The cost of the same treatment on an average was Rs. 14,778 in a private hospital and Rs. 1587 in a public hospital in rural areas and Rs. 20,328 and Rs. 2117 in urban areas, respectively.[22]

Efficiency of system would be negatively affected when people resort to self-treatment including self-prescription when drugs are freely available in the market and seeking care directly from specialists, while bypassing primary care providers.[34] Self-medication has been associated with lack of access to professionals, lack of government-sponsored health insurance coverage and socioeconomic status related to lower education, living in rural areas, lower income, and fewer assets.[35] As health insurance removes any financial barrier to access care in good quality hospitals, insured would use inpatient facilities and private providers more than uninsured that may reduce the demand for self-medication and change the perceptions about the benefits of modern medicine.[35] Schneider [36] documented a shift of demand for care from traditional to modern health sector by insured members. Studies from China,[37] Congo,[38] Kenya,[24] Tanzania,[39] and Senegal [30] revealed increased utilization of health services by insured members in those schemes that cover hospital inpatient care.

  Health-Care Infrastructure Top

Health-care infrastructure in rural areas is irregularly distributed, and health facilities have acute shortage of doctors and nurses. Although private sector offers services of good quality through high-end tertiary care and new delivery models, the cost of treatment at these facilitates is exorbitant and unregulated. Nearly three-fourths of doctors work in urban areas and two-thirds of medical colleges are in South India. There is wide variation in the availability of hospital beds among the states; Bihar and Odisha has one bed per 3000 population whereas Gujarat and Maharashtra has one bed per 1000 population. The cost of hospitalization is higher in urban areas (average of Rs. 9367) than in rural areas (Rs. 6225).[40]

India faces acute shortage and skewed maldistribution of skilled and trained health-care personnel that derailed its efforts to reach MDG health-care goals. The current level of its investment in and supply of human resource is not only inadequate given the huge demand for health services but also lacks intersectoral coordination and capacity.[41] In fact, the ILO estimates 7.1 million shortages of health workers in Asia [42] which exposes the countries to the danger of escalation of health-care cost. There were 9.1 lakh doctors, 1.2 lakh dentists, 15.6 lakh registered nurses, 7.26 lakh auxiliary nurse midwives, and 6.4 lakh pharmacists in 2015.[43] However, India has only 0.7 doctors per 1000 patients (as against the WHO ratio of 1:1000) (World Health Statistics, 2014) and 0.9 million are needed to meet the global average of 14.1 doctors per 10,000 people.[32] India has a lower ratio of 1.7 nurses per 1,000 patients (as against the WHO ratio of 2.5:1000)[44] and requires 2.4 million more to meet the growing demand.[32] Total bed density at 1.3 per 1000 population is below the world average of 3.5 beds per 1000 population.[40] One of the reasons for shortage of specialists is that the number of postgraduate seats in medical education is 15,000 while 50,000 medical students graduate every year.[32] Faced with shortage of facilities to pursue further studies in India, students usually migrate abroad either for higher studies or for seeking job opportunities.[32] Another reason for shortage of skilled personnel in rural areas is the poor infrastructure, lack of basic health facilities, medicines, and equipment that makes working conditions less attractive.

India's performance in health-related MDG is unsatisfactory owing to inadequate infrastructure and workforce; almost 90% of primary health centers and community health centers are located in government buildings and the rest in rented or voluntary society buildings [40] and the population covered by a subcenter is 8372 (against the norm of 3000–5000) and by primary health centre is 49,193 (as against the norm of 20,000–30,000). In 2012, primary health centers had a shortfall of 3.8% of auxiliary nurse midwives, 10.3% of doctors, 38.2% of female health assistants, 52.6% of male health assistants, 36.5% of laboratory technicians, and 23.1% of pharmacists of the total requirement.[40] In such a grim scenario, how can we achieve SDG-3 when we fail to provide health services to a large number of populations living in informal and rural sectors?

  Services for Everyone: Target Population Top

When we consider health-care system in India, there are two parts; “Bharat” belonging to poor who face financial and nonfinancial barriers to services and “an affluent India” that belongs to middle and rich classes who can access quality care easily. This is due to the fact that health financing mechanisms ignore the needs of financially challenged population in a quest to pursue lucrative business at upper-income class in the formal sector of the economy.

Majority of population in informal sector solely rely on government hospitals and their infrastructure that are underfunded, understaffed, and underfinanced. As a result, they seek care at unregulated and expensive private sector health hospitals and nursing homes that pushes them to high-cost-induced poverty known as iatrogenic poverty.[45] It is true that nearly one-fourth of the hospitalized Indians fall below the poverty line and more than two-thirds of inpatients take loans or sell assets to pay for hospitalization.[46] In addition, indirect cost of care is high in rural areas due to traveling to nearby providers in city or towns and loss of wages, as most of them are daily laborers.[47]

Equity has been considered as a major objective of health-care policy in international community since income and self-rated health are linked, and the very poor are most likely to report bad health compared to high-income earners.[48] Equity implying both horizontal and vertical equities is absent in India, the former aims to distribute health benefits across groups of people of similar socioeconomic status whereas the latter expects the distribution of benefits across groups of people differing in socioeconomic status. Considering direct and indirect cost involved in seeking care, the effective decision for the very poor may be not to seek care at all or to go to traditional healers or resort to partial treatment.[49] All the more, the poorest are 2.6 times more likely to forgo the health services than the richest and 28% of rural ailments and 20% of urban ailments were untreated in 2004 due to financial barriers.[22] It finds financial constraint (55%–60%) to be the primary factor followed by lack of medical facilities in neighborhood for postponement of care (15%).

  Universal Health Coverage: Experience of Other Countries Top

Worldwide, different countries have taken different routes to achieve UHC determined by political factors, socioeconomic factors, and health financing sources. On the issue of whom to cover, China sets a good example to emulate. It has covered 170 million uninsured people under health insurance scheme in less than a decade and increased insurance enrollment in rural areas by 97%. Oman could decrease the health outlay in providing curative care for chronic illness by opening 200 primary health centers across the country that focus on prevention and early diagnosis.

Among the other countries that focus on the type of services provided, Mexico, for example, provides comprehensive health package, an insurance scheme that covers over sixty diseases to achieve an effective and affordable access to high-quality health services. Turkey covers 98% of its people under insurance scheme that provides a broad range of services that primarily include primary and emergency care. This initiative could reduce maternal mortality by half in the next 10 years. The experience of countries on the coverage of cost incurred to implement UHC varies; Rwanda entrusts 55% of budget to be managed at the community level who are accountable to reach the specific health targets. The government's subsidy to 25% of the population could increase the coverage to 97% from 7% in the last decade; child mortality has been cut by half and deaths due to communicable diseases have been decreased by two-thirds.[12]

Worldwide, various countries have experimented mixes of health-care financing mechanisms to achieve affordable and universal access to health-care services that mainly include supplementary health insurance, tax-based financing, and SHI. These solutions aim to contain cost escalation and improve technical, allocative, and dynamic efficiency of health-care delivery. SHI is the widely observed financing where private and public sector employees contribute premiums from the payroll or the poor informal sector are covered by tax-financed government-managed mandatory SHIs or full premium contribution by the households or tax-subsidized premiums. Many Asian countries shifted from full contributions to tax funding depending on political leadership. Some countries chose to provide free health services at public hospitals to achieve UHC and some failed to match the demands for better facilities with dwindling public spending on health infrastructure resulting in high OOP expenses incurred by the households. In Malaysia and India, wealthy people prefer private services over public services whereas in the Pacific Island States, public facilities have minimized OOP expenses by providing good quality of care. Both health-care delivery and health financing are two faces of the coin, and evidence from the Organisation for Economic Co-operation and Development suggests that efficient system is the one where health-care purchaser has close ties with health-care provider and not the one where health delivery is carried out by the purchaser organization.[50] India, with a vast informal sector, finds it difficult to collect premium through contributor schemes such as SHI.[51]

Brazil has driven financial coverage while leveraging private sector for delivery of health services (payer and provider model) whereas Thailand adopted social insurance to enhance financial access and South Korea focuses on “single payer” model and promotes private sector investment while regulating the provision of care. India has several lessons to learn from these nations to reach SDG-3, (i) political leadership for long-term change, (ii) primary focus on universal access than efficiency or quality, (iii) reduce high OOP expenses, (iv) government should decide either to be a payer or provider, and (v) partnership with private sector based on regulatory framework and effective dialog.[52]

Indian government has taken several steps to achieve UHC which includes opening of 3000 Jan Aushadhi Stores under Pradhan Mantri Jan Aushadhi Yojana (PMJAY); launching fecal incontinence management system “Qora;” preparation of technical documents on traditional medicine to popularize it worldwide; outsourcing primary to private doctors; initiation of National Dialysis Services Programme; a scheme to protect against health financial risk that cover Rs. 1 lakh per family; opening up 3000 medical stores and 3000 generic drug stores under PMJAY across the country; launch of “Sehat” (Social Endeavour for Health and Telemedicine) to provide access to information, knowledge, skills, and digital technologies; launch of National Deworming initiative; provision of insurance, free drugs, and diagnostic treatment under National Health Assurance Mission; immunization of children under Mission Indradhanush, and E-health initiative.

  Universal Health Coverage: the Road Ahead Top

The industry is witnessing haphazard growth culminating in uneven quality, misaligned incentives, rising costs, and burden of hardship financing on hapless financially challenged population. The cost inflation poses a grave challenge to our system. Technological advances fuel cost inflation instead of curtailing the cost when per capita usage of tech-intensive services intensifies. There is also evidence that health insurance as a health financing mechanism may prevent cost containment activities owing to strong forces outside the purview of individual health plans.[53] Health insurance can control claims cost by monitoring and ensuring cost of treating insured reasonable, reducing frauds, and setting standardization of treatment at network hospitals. These efforts can be fruitful if there is a team of dedicated third party administrators (TPAs), investigators and doctors, network management, and grievance management system. Many insurance companies are moving away from TPA services by having own in-house teams for cashless services while others who use TPA model pay meager commission for the services of TPA. According to one school of thought, the growth of health insurance industry depends on a large extent on TPAs and their cost containment efforts where tariff and discounting are incorporated in the memorandum of understanding with providers of health services. This is contradicted by another school of thought that attributes cost escalation to health insurance moral hazard that incentivizes providers to take advantage of cashless facility and charge more for insured patients.

Because of lack of standardization or benchmarking of cost of health services or database, price charged to insured has increased by multifold. We need a significant transformation in health-care system that strictly adheres to standard treatment protocols, audits, and authenticates reasonableness of cost of health services by benchmarking against the established standards. The system then would help various stakeholders such as manufacturers of diagnostic equipment, pharmaceutical companies, insurance companies, and the researchers to analyze cost escalation and suggest remedial measures to curtail the same. If not, unprofitability owing to cost escalation would force insurance companies to increase the premium and restrict access to cashless benefits to an extent that low-income population would be left out of the insurance coverage and thus hamper the growth and penetration of health insurance in the country. Recently, Insurance Regulatory Development Authority of India has taken steps to reform the health insurance industry by allowing life insurers to sell health policies, review of capital requirements, creation and maintenance of health insurance database to monitor claims and streamline pricing of health insurance products, and extending risk coverage to low-income population. The Registry of Hospitals in Network of Insurance, a registry of unique hospitals in the health insurers and TPAs, is a recent innovative repository that stores and disseminates data from various stakeholders including hospitals, customers, regulators, health insurance, insurers, and beyond.

Owing to low tax base, weak tax compliance, and ineffective tax collection machinery, a tax-funded health system is difficult to develop in India. However, the government should increase health spending to 2%–3% of GDP and 15% of public budget since the highly bureaucratized system of governance in India may not be well equipped to organize a nation-wide SHI system. This is complicated further owing to bad or nonexistent roads, telecommunications, and banking facilities making premium collection, claim management, and monitoring of health and financial information difficult.

Public sector hospitals are considered to be of low quality that should be seriously addressed by the government. The government spending on preventive, promotive and curative care with reorientation towards the procurement of medicines, equipments and physical infrastructure to enhance the quality of services is highly essential. Providers should consider cost-effectiveness of particular line of treatment and balance marginal benefits and costs so that iatrogenic poverty can be prevented.

The government has to augment the resources allocated to health sector. It has to increase tax revenue from untapped areas and revamp tax collection system to reduce tax evasion to create funds for health services' provision. Innovations to extend social protection in health to poor population include opening voluntary affiliation to self-employed and informal workers; providing public subsidies to SHI systems to enroll the poor or subsidizing premiums for poor self-employed or informal workers; mandatory universal participation; and expanding the pool through the integration of private health insurance.[5]

Appropriate legislatory and regulatory framework on insurance mechanism favoring microfinance institutions has to be drafted and implemented to facilitate inclusion of health-care sector into the social security ambit. MHI should be supported through government intervention in the form of subsidies, technical assistance, and should be regarded as a supplement to other forms of health financing. Corporations could finance the insurance premiums for severely low-income families in need of greater access to the health system as part of their corporate social responsibility initiatives.

Pro-poor “UHC 2025” for India to achieve universal health entitlement of every Indian citizen can undoubtedly be achieved by synergistic interventions of improving physical (strengthening delivery of care) and financial access (risk protection through health insurance) to health facilities.[54] While doing so, the needs of the poorest and disadvantaged population such as women, children, and elderly should not compromised and the rich–poor disparity in access to health services should be reduced. It has been observed that higher skilled birth attendance could reduce rich–poor gap of child mortality,[55] and Thailand could reduce rich–poor gap of child mortality and achieve UHC of maternal and child health by having 100% skilled birth attendance.[56] This finding should motivate public health policymakers to invest in primary health facilities to improve pro-poor outcomes and subsidize the premium for higher health insurance package to the poor that provides protection against catastrophic illness.[57]

Achievement of UHC requires collaboration with large private sector to meet shortage of human resources and investment in public facilities. Public–private partnerships are necessary to distribute the financial burden of illness, to improve the quality of services, and to strengthen the capacity of private sector. This can take the form of subsidies to superspecialty hospitals, management of primary health centers by NGOs, adoption of villages by corporate sector, and provision of better transport facilities to regional health centers.[58] Both sectors are trying to improve functional efficiencies such as clinical research, accreditations, and outsourcing of noncore areas that would go a long way to improve availability and accessibility of health services.

Telemedicine is a potential option that can provide health services to rural population using the country's mobile technology infrastructure and benefit from low-cost consultation and diagnostic facilities. Before doing so, appropriate regulatory frameworks on standardization of treatment, cost of treatment, use of generic drugs, and close monitoring of performance of private facilities is required. Health promotion program should be implemented on a priority basis to prevent disease and inculcate good health value and practice. This is essential when India faces an increasing burden of mortality and morbidity burden due to NCDs which could be prevented from health promotion and adoption of healthy lifestyles. Over and above the provision of health insurance and public health facilities, access to sanitation, water disposal systems, nutrition, and safe drinking water has to achieve SDG-3.

India has to increase the professional educational institutions, should use modern technology, invest in faculty development programs, create newer models of nursing and paramedical education, link the educational institutions to a district hospital, forecast human resource requirements, and frame policies to address some of these issues. We need more medical, nursing, and allied health colleges to meet the shortage in workforce.

UHC and the extent to which SDG has been achieved can be better understood by setting relevant outcome-oriented indicators and not input-based measures as India had used for MDG. There is an urgent need to earmark larger outlay under social sector schemes to implement SDG that requires approximately US$14.4 billion,[59] and the United Nations MDG 2014 report provides evidence for dissociation between high growth and redistribution, hence India should not assume that higher economic growth would result in inclusive growth. Instead, use of private and public finance aimed at the equity in health-care access is essential.

  Conclusion Top

A low level of public investments in preventive health facilities and medical care facilities and health professionals has given rise to poor health of an average Indian. Because of inadequate health financing mechanisms such as government spending, social health insurance, individual health insurance or MHI, reaching UHC in India is challenging.

Health should be given the highest priority along with education under social sector outlay; this not only requires political commitment but also collective efforts of strategic nature. Health sector's reform requires various incentives and stimulus to invest in health sector, higher outlay for infrastructure expansion, reallocation of resources of the government toward prepayment schemes to ensure access at low cost, impetus to health insurance sector, and encouragement of low-cost private sector participation through changes in medical education system. Public health services should be improved with a special focus on quality and equity. SHI has to be implemented through organized cooperatives or community-based organizations that would collect premium at the source of income. We feel that expansion of MHI on a pan-India scale would require the stewardship role of the Indian government and corporate sector through corporate social responsibility. India as a humane society must be able to provide basic health access to its citizens irrespective of their paying capacity. The plan of the Indian government to achieve universal health coverage to its citizens through the ambitious National Health Assurance Mission (NHAM) as an example of Government-sponsored Health Insurance schemes (GSHISs) may prove the way forward to mitigate India's health woes.

To conclude, it is worthwhile to be cognizant that there is no “one-size fits all” model to achieve SDGs-3 and UHC. Based on the historical development, the current health-care system, ability and capacity in terms of the speed and scope of coverage, each country has to plan, strategize, and implement various actions and programs including health insurance. The basic primary care to prevent diseases or diagnose early should be the step that every country should take as early as possible to create healthier community and healthy lives for all. There has to be pluralistic and integrated efforts that work toward reducing financial barriers to access care, fill the gaps in health resource needs, and overcome shortages in skills, workforce, affordable medicines, and technologies with quality of care that would actualize universal health entitlement for our citizens. This would unquestionably be the way forward to achieve the larger picture of “health capital and mental wealth” protection and thereby ensuring “well-being” of our citizens, only to reiterate the concept of “Health as Human capital.”

“The goal of real healthcare reform must be high-quality, universal coverage in a cost-effective way.”

Bernie Sanders

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Conflicts of interest

There are no conflicts of interest.

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