Is new health insurance policy India’s pathway to achieving Universal Health Coverage?

From being a former head of the Department of Cardiology at India’s leading medical institute to now being a public healthcare advocate, Padma Bhushan awardee and President Public Health Foundation of India (PHFI) Prof. K Srinath Reddy is a global leader in public health. He has served numerous WHO expert panels, led the World Heart Federation and was a physician to two Prime Ministers of India.

He talks to Deepika Khurana about future of medicine, concerns regarding generic drugs, achieving universal health coverage that provides health care and financial protection to people in a vast country like India.

As part of the United Nations Sustainable Development Goals, all UN Member States have agreed to achieve Universal Health Coverage by 2030. The essence of the goal is to ensure quality healthcare to all individuals while protecting them from financial hardship. In India, the government has launched one of the world’s biggest health-insurance plan called Ayushman Bharat, meaning Long-Life India to provide a safety-net for the poorest half-billion of India’s 1.3bn citizens.

In a vast and diverse nation like India, attaining UHC is not going to be a straightforward task. Uneven geographic distribution of poor families is expected to pose an additional challenge. “There are going to be hurdles. And, unless all the elements of the health system fall into place and support efficient, effective, equitable delivery of services, we will not be able to achieve Universal Health Coverage,” said Professor K Srinath Reddy.

Prof. Reddy is the Co-chair of the United Nations ‘Health for All’ under the United Nation’s Sustainable Development Solutions Network global initiative. He also chaired the High-Level Expert Group on Universal Health Coverage, set up by the Planning Commission of India.

In an exclusive interview, Prof. Reddy talks about the success of Ayushman Bharat scheme, the recently reformed medical bill, biggest healthcare challenge, rise of cardiovascular diseases, concerns regarding medical misinformation and much more.

Here are edited excerpts from the interview:  

The success of UHC is usually based on universality and affordability – but with the over-populated and diverse country like ours, do you think Ayushman Bharat is good enough to take care of India’s dwindling healthcare? 

Ayushman Bharat is a beginning. Universal Health Coverage is a progressive journey where we’d like to achieve as much coverage of services, for as many people as possible. But recognising that it’s not always possible to provide an entire set of services to everybody, at the very beginning, one plans it as progressive universalisation. And therefore, Ayushman Bharat or the Pradhanmantri Jan Arogya Yojna (PM-JAY) which is looking at cost services for hospitalised services (for 40% of the most vulnerable section) is a move towards achieving universal healthcare. We cannot call it as an accomplishment of universal health coverage. But, at least, we have begun the journey. And, anyways the target date to achieve UHC as set by the United Nations and accepted by member countries is 2030.

Also, some of the steps that were initially taken through the National Health Mission and the Rashtriya Swasthya Bima Yojna were incomplete in terms of coverage – of both services and the target groups. Therefore, Ayushman Bharat is definitely a step ahead and if properly built upon, it can translate into Universal Health Coverage over a period of time.

Do you foresee any hurdles while achieving universal health coverage in India?

 Certainly, achieving UHC in a diverse and vast country like India is not going to be an easy task. It will require a greater amount of public financing as well as a greater degree of commitment. This will help to strengthen the various components of the health system especially, the health workforce, provision of drugs and vaccine, technologies and to ensure that there’s a greater degree of transparency and efficiency. Health financing is critical – particularly, public financing without which none of the other things can really be delivered. It is necessary, but not sufficient. Unless the other elements of the health system fall into place and support efficient, effective, equitable delivery of services, we will not be able to achieve Universal Health Coverage. So it is definitely a challenge. Infact, there are multiple challenges in each of these areas, like health workforce is very deficient and it also requires a great deal of centre-state coordination and cooperation. It is not only important to allocate more money for health but also to get more health for the money because otherwise how do you get the greatest efficiencies? Secondly, equity has to be very central, priority has to be given to the poor and vulnerable and make sure they get served, but it cannot be confined only to them. So equity is the guiding principle as we move towards the UHC in the progressive journey.

The recently introduced National Medical Commission bill states that the government can grant a licence to Community Health Providers (CHPs) to practice modern medicine. Do you think it will help to fill the healthcare resource gap prevalent in rural India?

While achieving UHC, we are looking at three dimensions; population coverage, service coverage, and cost coverage. In terms of population coverage, we would like to cover everybody; that is universal. In terms of service coverage, we would like to provide as many services as possible. But, they may have to be progressively scaled up in terms of the service package based on the resources available. Third is cost coverage. Firstly, the aim is to reduce the financial burden on individuals and families. That will reduce the level of poverty. At the same time efforts are being made to keep the healthcare costs under check so that there is fiscal prudence and the budget doesn’t go bust. Now, when you take all of these three dimensions, incidentally, there will be different constituencies looking at each of these. The politicians will be looking at the population coverage – because the more the number of people they please, the greater the voter base. The health care providers- the clinician, in particular, will be looking at service package. They would want their patients to get the best – right from renal transplant to cochlear transplant and multiple cardiac stents.

If you look at primary healthcare then you are providing 100% health coverage. Everybody at some stage in life requires something in primary healthcare -be it in the prevention or health promotion or in the form of services such as vaccination to the treatment of fevers, etc. This will also avoid excessive spillage into secondary and tertiary care and will also save costs. So that way primary healthcare is absolutely critical and to strengthen it further, we would need CHPs.

The medical fraternity is of the view that the introduction of CHPs will give rise to quackery. Do you agree? 

It all depends on how the new bill is configured and also if you have a fairly good curriculum to train this new category. For instance, physician assistants are trained for four years and they are used extensively in some countries abroad, the US in particular. Even in India, some of the institutions in Tamil Nadu and West Bengal are producing this four-year category that functions under the supervision of doctors. Now, if you ask me, four years is not a short period of training. They support doctors in hospitals but they are also well-equipped to handle Primary Health Care at sub-centre level. So, everything depends upon the nature of training. And, between quacks or totally untrained, they are a category who are not trained to the level of being a full-fledged doctor but at least they are better than a quack. Also, they will have some set of defined skills. Similar to nurses, nurse practitioners, physician assistants, CHPs is another category that’s being introduced. And, nobody is denying the role of doctors. But, just as doctors and nurses are recognised, we can also have another set of category that’s trained and tested.

What do you see India’s biggest healthcare challenge would be in the next decade?

In the next decade, the biggest challenge would be to ensure that our primary healthcare succeeds across the country with the adequate number of healthcare personnel, appropriate financing and distribution of drugs and diagnostics. Of course, linkage of secondary and tertiary care is also going to be very important but the make or break of health will come in primary healthcare.

Despite medical advancements and improvement in diagnostics, India has witnessed an alarming rise in a number of deaths owing to heart diseases. Where do you think we are going wrong?

There are multiple reasons or contributing factors and the trend has been witnessed in all parts of the world. If we talk about Europe and the US, heart diseases were not this common. Or, at least, this form of heart diseases were not very common at the beginning of the 19th century. Of course, they had heart diseases that were linked with infectious diseases but the big surge in the coronary heart disease and stroke started happening towards the middle of the last century. Then, with advances of knowledge and social conditions, the age at which heart diseases started striking people shifted from middle ages to the older age group. Although many people in the West die of heart diseases today, they are dying beyond 70 years. So, that is exactly what we are witnessing in India these days except that Indians seem to have a higher propensity for heart diseases. This could be due to low birth weight, pool of genes (we are not clear about), our diet that’s rich in refined carbohydrate, etc. We may not be overall obese, but we have a much greater percentage of body fat and a much lower amount of lean muscle mass than the westerners. And much of our fat is concentrated in the abdomen.

So, we do have some problems, whether it is related to our dietary pattern, low physical activity or low birth weight and we have to modify this as much as possible.

There are a lot of concerns about generic drugs. Are generic drugs poisoning us?

Well, countries across the globe have shifted to generic drugs. Infact, many have shifted to Indian generic drugs which imposes on us a greater responsibility to ensure that they are quality assured. So, definitely, we need better drug testing laboratories with a focus on drug quality. However, generic drugs themselves are not to be blamed as a category. If AIDS epidemics was substantially controlled in Africa, it was largely due to Indian generic drugs. So, we should not condemn generics as a whole.

With the coming of social media in recent years – fake news and medical misinformation has gained unprecedented amplitude – be it about cancer cures or messages that encourage vaccine hesitancy – so how do you think we can counteract medical misinformation? 

Social media can be a boon or a curse. Of late, we have seen a lot of unscientific videos getting widely disseminated. But, that’s because there is a human tendency to believe negative stories. People like to see myths busted. So there will always be a mix of truth and falsehood when it comes to social media dissemination. In that case, one has to make sure that the truth surfaces. False beliefs or particularly false information should not be allowed to subvert sound scientific practices. That is where I believe we need more educated public who can discriminate these categories on social media. But, we also need some credible agencies who can sift the truth from falsehood and sound a caution. For instance, the issue of vaccine hesitancy has proved to be so catastrophic to countries like Europe and America that deadly diseases like measles, which were once eradicated, have come back again, in a big way. It’s frightening.

How do you see the future of medicine?

I see the future of medicine to be substantially moving towards public health because people have started to realise that eventually, it pays a greater amount of dividend. I also see the future of medical practice being benefitted from technology. However, I hope it’s not entirely dominated by the obsession of technology by exclusion of the human element. Ultimately, teamwork is going to be critical and that’s where, I believe, technology can be a beautiful bridge.

What made you switch your career from being a high profile Cardiologist to now being a public healthcare advocate. Do you miss that part of your life? 

For 32 years, I was a cardiologist dealing with individual patients. But, I was also dealing with public health issues over a period of time -whether it was trying to prevent Rheumatic fever or looking at how we can control hypertension in community settings. It’s just that at some point in time you realise you have to do a lot more especially, to prevent more and more patients flooding the health system. And that also gives satisfaction. Now, with a number of young students and researchers emerging we are trying to build a multi-disciplinary public health system in this country which again is an important element. So, I have missed some important career opportunities whether it was at AIIMS, World Health Organisation or with the Government of India, but that’s because this was something I wanted to prioritise. And, I have no regrets.