11 February 2016

Universal Health Coverage: A Perspective

The importance of Universal Health Coverage (UHC) is very high in a relatively poorer state like Odisha. In the health sector, Odisha’s performance is relatively worse-off than the all-India average. The Odisha Economic Survey 2014-15 shows that Infant Mortality Rate (IMR) in 2013 is 51 for Odisha and 40 for India, and Maternal Mortality Rate (MMR) in 2010-12 is 235 for Odisha and 178 for India. The state of Odisha is also known to be a malaria prone belt, as around one-fourth of the total malaria affected persons of the country are found in the state.

A paper in the December 2015 issue of Lancet Global Health on age- and sex-specific mortality risk for adults (15-69 years in India shows that in 2014 in Odisha 40.5% of the adult males resided in 16 districts where the conditional probability of a man dying at these ages was more than 50% and 46.8% of the adult females resided in 18 districts where the conditional probability of a woman dying at these ages was more than 40%. These high mortality districts were common for both males and females in 13 districts of Odisha (Bargarh, Jharsuguda, Sambalpur, Debagarh, Sundargarh, Dhenkanal, Baudh, Sobarnapur, Balangir,Nuapada, Rayagada, Nabrangpur, Koraput), only for males in three districts (Mayurbhanj, Kandhamal, and Malkangiri), and only for females in five districts (Kendujhar, Anugul, Nayagarh, Gajapati and Kalahandi). In short, 21 of the state's 30 districts are high mortality risk for adults. All the tribal dominated areas are coming under these 21 districts, in which both the incidence and infirmity of poverty is very high. Except for the coastal region, all other regions are coming under it.

At a time when the world is moving towards Sustainable Development Indicators from January 2016, economists (including one of the current author’s) have come up with a declaration on universal health coverage. To paraphrase that declaration, some of the arguments contextualised for Odisha will be as follows.

We are at a critical juncture to reflect on the financial investments that will help us maximise progress by 2030. Hence, it is essential that leaders and policy makers in Odisha and India, as in the rest of the globe, prioritise a pro-poor pathway to UHC as an essential pillar of development.

UHC means ensuring that everyone can obtain essential health services at high quality without suffering financial hardship. Resource constraints imply that the state of Odisha should determine its own definition of “essential”—while recognising, in the words of former WHO Director-General Gro Harlem Brundtland, that “…if services are to be provided for all, not all services can be provided. The most cost-effective services should be provided first.”

Odisha is one of the poorest states in India. Health of its residents has implication for addressing poverty and improving wellbeing. Over the past decade, health improvements (measured by the value of life-years gained (VLYs) constituted 24% of full income growth in low-income and middle-income countries. UHC is not only a matter of right, but in times of crisis (including droughts, floods and cyclones that Odisha is vulnerable to) it will provide a multitude of benefits by mitigating the aftereffects of shock. Of course, the state government’s efforts in anticipating the calamity from the cyclone Phailin in 2013 and putting in place mitigating efforts before the calamity struck needs to be applauded. UHC also has positive role during times of calm, as they foster cohesive societies and productive economies. UHC will reduce reliance on out-of-pocket expenditure and does away with financial-risk of the sick and poor. It is said that economic benefits are estimated to be more than ten times greater than costs.

One of the successes of public health has been in reducing preventable and communicable diseases. A major initiative in Odisha almost 15 years ago is that of Pancha Byadhi (malaria, leprosy, diarrhoea, acute respiratory infection, and scabies) interventions. This was in additional to other programmes on immunisation, tuberculosis, and other major communicable diseases. There is also an increasing concern on non-communicable diseases. For instance, there has been a recent initiative in Odisha to provide 22 chemotherapy drugs free to all cancer patients undergoing treatment at Acharya Harihar Regional Cancer Centre. Independent of these initiatives, a matter of concern in Odisha as also elsewhere globally is the difficulties in delivery gap, particularly in primary and secondary care in both the public and private sectors. Continued progress toward UHC will require addressing these delivery problems.

The Ebola epidemic in recent times exposes our vulnerability in resource poor settings. However, the epidemic could have been averted by building of health system at one-thirds of the cost of the response so far. Today, we are at a juncture where Odisha and every state in India as also every country have the opportunity to achieve UHC.

The Government of Odisha should realise that there is great value in financing for everyone. They should increasingly devote more and more resources to expand the package of essential services. With increasing growth, one expects that the state of Odisha independently as also through the Government of India has additional resources to invest in health services and delivery.

A panel discussion at the Nabakrushna Choudhury Centre for Development Studies (NCDS) on UHC day (12 December 2015) had an agreement on three broad things.

First, UHC in Odisha, as also India, should integrate multiple systems that should include the AYUSH (Ayurveda, Yoga, Unani, Siddha, and Homeopathy) systems of care. These systems should complement and supplement each other and not work in silos. The thinking that preventive care is limited to vaccination and curative care is based on a supplier-induced-demand driven by market interests should be questioned.

Second, achievement of universal health will require a multi-sectoral approach involving convergence across many government departments with emphasis on agriculture, nutrition, water, sanitation, hygiene and sports among others. Besides, there is need to combine state's interventions with community involvement. At an individual level, the importance of the DATES approach (appropriate Diet, moderate or no Alcohol, no Tobacco, proper Exercise, and Stress-free life), an acronym borrowed from an earlier work of one of the author’s (Public Health in India, India Development Report 2004-05, OUP, 2005).

Third, appropriate information and communication channels should be used to inform public about checks and balances used by the Government to ensure quality control. The state should also come up with adequate measures to address vested interests that could affect the system adversely.

The above points along with the economist’ declaration provides ground for us to urge the Government of Odisha, as also Government of India, to:
  • Increase domestic funds for convergence and provide vocal political leadership to implement policy reforms toward pro-poor UHC
  • Ensure that adequate funds are put towards diseases of poverty and this requires the coming together of the bio-medical dimension with the socio-economic aspects. At a global level, the donors also need to commit to this.
  • Address the question of equity with respect to financing – who pays and who benefits.
  • Ensure that health policy for Odisha as also India embrace UHC, as defined above, as an integrated approach for measuring progress toward health targets in the post-2015 global development framework.
The pro-poor path to UHC needs adequate commitment to resources. Despite constraints, this is achievable. We should not let go of this opportunity because UHC is right, smart and overdue.

(This has been co-authored with Biswabas Patra as a syndicated op-ed. This has been published in Health Line all Odisha 2016 (December 2015, pp.330-31). Similar write-ups translated in Odia have been published or are forthcoming in Odia dailies or fortnightly - The Samaja (21 December 2015), Odisha Bhaskar (24 December 2015), The Samaya (31 December 2015), Samadrustri (16-31 January 2016).

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