According to the World Health Organisation, Universal health coverage means that all people have access to the health services they need, when and where they need them, without financial hardship. In the spirit of the 1978 Alma Ata Declaration, it includes the full range of essential health services, from health promotion to prevention, treatment, rehabilitation, and palliative care. The public health system in India has been the primary provider of healthcare, especially in terms of reach and access to the poorest of the poor. However, the public health system has been mired with structural and systemic issues jeopardizing the goal of universal health coverage.

Public Health System In India Is Riddled By Several Challenges

According to Amartya Sen, the key to UHC is a frontline role of public health institutions. Unless public health institutions are robust enough, UHC is an unrealisable goal. Sen believes that the reach, affordability and prioritisation of people’s health care rather than profits are key ingredients that make public health institutions central to the goal of UHC. Healthcare should be the primary responsibility of the state. They ensure accessibility and equity in access to health care. However public health institutions in India suffer from various issues like:

1. Meagre budgetary allocation at 1.4% of GDP, against the proposed 2.5% in National Health Policy 2017 keeps them underfunded. Without adequate financial resources, public health institutions remain underfunded and underequipped, without adequate medical provisioning. It also disincentivizes talented healthcare professionals to choose public institutions over private. The lower pay to doctors also promotes a parallel private practice which compromises on the quality of care poor people get in the public health institutions.
2. Inadequacy of resources impedes efficiency of care provided to people. For example in India government hospital bed to patient ratio is 1: 1844, while the doctor to patient ratio is 1:11,082 patients, much below the globally mandated standards. This crisis has been most visible during the Covid crisis, revealing the poor state of affairs.
3. Public health institutions also suffer from the crisis of neglect and quality in public health systems: for example 2017 Gorakhpur hospital deaths due to medical negligence. A World Bank study pins this to the phenomena of “Know-do” gap. The gap between the knowledge of doctors and their response in a real situation. Due to a general sense of apathy, doctors do not even follow through basic procedures they have learnt in medical school.
4. Further, there exists an urban bias in the public health system: for example, 80% of all tertiary healthcare institutions are concentrated in Tier I cities. Quality healthcare, especially at tertiary level therefore becomes a far fetched dream. Barriers to mobility and affordability become stronger. We, therefore, see the phenomena of what health activists like Dinesh Thakur call “cancer refugees”. Cancer patients living in slums and streets of metropolitan cities like Delhi while seeking care in hospitals of these cities.

Private Sector Has A Unique Role In Bridging The Gap

1. Creating health infrastructure: creating new medical institutes with state of the art technology as well as providing cost-effective health care in Tier II, Tier III cities and villages.
2. Bridging the Skill gap: through skill development of medical professionals, whether it is through medical institutions or on the job training.
3. Developing the technological interface of health: the private sector has a key role in developing low-cost diagnostics, improving access through drone delivery of blood etc.
4. Developing the PPP model of healthcare for enhanced healthcare access. Niti Aayog’s proposal to link private medical institutes to district medical colleges for optimum resources utilisation is a proposal worth a mention.

Key Challenges With The Private Sector

1. Unfair profiteering, for example, an independent study of Ayushman Bharat -Jan Arogya Yojana shows disproportionately higher treatments of expensive procedures under the scheme.
2. Frauds and scams by quacks, and unlicensed professionals for example unnecessary procedures like C-sections, a higher number of hysterectomies even done for benign cases.
3. Challenges of affordability and equity as private sector institutions are run by private motives. The barrier of cost is the highest one.
4. Quality and standardisation due to the lack of uniform regulatory standards across the country as health remains a state subject under the seventh schedule.

Way Forward

Therefore, private sector participation in itself is no panacea for achieving the golden goal of UHC. It can be achieved by harmonising various other alternatives like:

1. Increased budgetary allocation to 2.5% as envisaged by National Health Policy 2017.
2. Focus on preventive health care especially to combat the burden of NCDs: example through schemes like Fit India, promoting lifestyle changes.
3. Instituting Public Health and Management Cadre in states for a professional and motivated cadre of healthcare professionals.
4. Effective operationalisation of the National Digital Health Mission that would create a holistic and interoperable digital architecture for healthcare. This should make health care provisioning qualitatively better and seamless.
5. Introduce Public health act in states that also provide statutory recognition to Public Health Agencies in states.
6. Empowering the troika of grassroots health workers (ASHA, Anganwadi and Auxiliary Nurse Midwives) through training and capacity building.

As the COVID-19 pandemic has revealed, UHC is no longer a desired goal, rather a necessity. In line with Article 47, it is the constitutional duty of the State to improve public healthcare. According to Dr Indu Bhushan, better insurance coverage, focus on underserved areas and digitisation can augment this pursuit. The force of multiple stakeholders, communities and global health architecture should be harnessed to secure Universal health coverage in India.