With the COVID-19 pandemic hanging like the Sword of Damocles over every human’s head, there is the desperation in everyone to neither contract nor spread the virus to the near and dear ones. Amidst the almost war-like scenes in many countries where streets are empty with no shops, cinemas, offices open; where everyone is either in self-imposed or government-imposed home quarantine; where states and countries are in lock-downs, people are fast arriving at that oft-overlooked interconnectedness of this world, that realization of a “mere virus” from “distant lands” bringing all their countries to a standstill, that fear about a few sick people end up making them and many others sick. And more importantly, people are realizing that it is not just enough to have one’s own friends and families stay healthy but it is imperative that total strangers’ families and friends – be them rich or be them poor- ought to stay healthy too, perhaps not out of charity but out of one’s own interest in self-preservation.
The series of epidemic outbreaks of the last two decades and now the COVID-19 pandemic are now giving impetus to the importance of Universal Health Coverage (UHC). What otherwise were always dismissed by many as unrealistic, impractical and unachievable, are now being actively discussed by the “laypeople”, and these discussions have moved beyond the echo chambers of the experts and stalwarts of Public Health and Economics.
In his 2018 speech ‘Can we create a pandemic free world?’(1), Dr Tedros Adhanom Ghebreyesus, the Director-General of the World Health Organization (WHO), highlighted the need for prevention of epidemic outbreaks by making essential health services accessible and affordable to the most vulnerable people in the society. He said, “Ebola taught us several painful but valuable lessons. The most important is this: that a fragile health system in one country can potentially expose the world to a global health catastrophe. When surveillance systems are inadequate, or health workers do not show up to work because they have not been paid in months; or medicines are in short supply; or infection prevention and control is lacking, disaster is just around the corner.” Dr Tedros stressed that the key to creating a pandemic free world is to acknowledge that Universal Health Coverage and Health Security are two sides of the same coin and to invest in strengthening the fabrics of Health Systems everywhere. He added that for most countries, the only real barrier is political will and that ultimately, Universal Health Coverage is a political choice.
At the 2019 United Nations General Assembly, as all the U.N. member nations adopted the political declaration “Universal Health Coverage: Moving Together to Build a Healthier World” of the High-Level Meeting on Universal Health Coverage, there were celebrations that this is a step in the right direction towards allowing everyone’s access to quality health services without suffering financial hardship when paying for them and to develop mechanisms of equitable access, financial protection and efficient service delivery. Of course, questions do exist in some quarters about the ulterior motives in the WHO’s sudden zeal to champion UHC, whether there is more than what meets the eye in this neoliberal world.
In his article, ‘Universal healthcare: the affordable dream’, the Nobel Laureate and philosopher and economist Prof Amartya Sen elucidate the results of Universal Health Coverage of many countries. He gives point-by-point rebuttal of the alleged common-sense argument that if a country is poor, it cannot provide Universal Healthcare. Drawn from the studies on many countries and states within some countries which are already having Universal Healthcare or are rapidly progressing towards achieving them, Prof Sen notes that the critical ingredients of success appear to include “a firm political commitment to the provision of universal healthcare, running workable elementary healthcare and preventive services covering as much of the population as possible, paying serious attention to good administration in healthcare and ancillary public services and arranging effective school education for all. Perhaps most importantly, it means involving women in the delivery of health and education in a much larger way than is usual in the developing world.” While Prof Sen calls for Universal Healthcare which is not same as Universal Health Coverage, many countries are moving towards Universal Health Coverage.
Broadly speaking, the targets of Universal Health Coverage can be furnished along three lines viz (1) Who should be covered? (2) What costs should be covered? and (3) What services should be covered? The UHC aims to have 100% population coverage wherein all population groups and all income groups shall be covered. There will be no exceptions based on any social criteria for population groups. Formally employed, self-employed, unemployed, informal workers, students, pensioners will all be encompassed in the income groups. The cost coverage need not necessarily be 100% but a large portion of the costs are to be covered by pre-payments and only a smaller fraction of costs are to be covered by direct payments. As for services covered, again it need not be all, but a defined package of services defined by a country’s available resources, health priorities, preferences in respect to vulnerable population groups.
For India, when Ayushman Bharat (Pradhan Mantri Jan Arogya Yojna or PM-JAY) was rolled out in 2018, many hailed it as a milestone movement for the country as this can eventually lead India to UHC path. Almost one and a half years old now, this scheme has already proven why it’s bad news to the common man and good news to the private players. And the bad news does not end there, as the scheme faces challenges of sustainability, synchronization and financial fulfilment (2). And with COVID-19 on the brink of causing an exponential rise in positive cases in the next few weeks and months, the National Health Authority is considering a COVID-19 special package under the Ayushman Bharat scheme. Ultimately, in whose favour this package pans out to be, is to be waited and watched.
While acknowledging the Ayushman Bharat but also raising concerns that the scheme is unbalanced and too skewed towards costly inpatient care, the UHC in India (2) Report published by ‘The Elders’, gives four key policy recommendations to put India on the track of Universal Health Coverage viz (1) Increase public financing for health from 1.0% to 2.5% of GDP by 2021 (2) Prioritise reaching full population coverage and meeting the needs of the poor and vulnerable (3) Focus additional resources on primary care services including vital public health services (4) Guarantee universal access to free essential medicines and diagnostic services.
Whichever citizen we are, living in wherever part of the world in these lock-downs, as we continue to live in these uncertain times for the next few weeks and months, having our lives brought to a standstill and watching the world economies shake, rattle and roll: all because of a virus; maybe we can pause and reflect why it took a pandemic to make us start our conversations about Universal Health Coverage. Even though it is a matter of shame, nevertheless, if indeed a pandemic has jolted us into the “wokeness” of healthcare, then, by all means, let us ignite it towards a renewed Health For All movement.
*With Inputs from Priya Shreedhar (University of Heidelberg) & Prasanna Saligram (JSA Karnataka)
1^ Ghebreyesus, Tedros A. “Can we create a pandemic-free world?” Speeches-World Health Organization, 12 Feb 2018, https://www.who.int/dg/speeches/2018/pandemic-free-world/en/
2^ Sharma, Neetu Chandra. “A year on, Ayushman Bharat faces sustainability, funding challenges.” Livemint, 23 Sep 2019, https://www.livemint.com/science/health/ayushman-bharat-completes-1-year-what-s-done-what-s-not-1569213058573.html
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