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Panel on health coverage addresses World Bank concerns by Aarti Dhar

The High Level Expert Group on Universal Health Coverage for India on Sunday held a brainstorming session here to address concerns raised by the World Bank over some of the recommendations in its report for the 12th Five Year Plan. Among the issues raised were marginalisation of the private sector and the “elimination of intermediation by insurance companies.”

The expert group, which will revert to the Planning Commission on Monday with answers to the queries, however, remained committed to providing universal health coverage to all and said it was important to strike a balance between “cost-effectiveness [and] affordability in terms of budget and equity.”

The World Bank had said that the report lacked an analysis of the private sector, a dominant financier and provider of health services in India, and that its role seemed to have been marginalised in the report. Describing this as unfortunate, the World Bank said: “There is a growing number of high-quality, low-cost providers that may be willing to engage with the government in providing defined packages of care to the poor. Policies need to be in place to foster more effective engagement with the private sector.”

Disagreeing with the report's recommendation to eliminate intermediation by insurance companies or other independent purchasing agencies, the organisation said recent experience had shown that these intermediaries had contributed substantial administrative and technical capacity to the government agencies. It said large investment in health worker training did not guarantee greater supply of human resource in the public sector and much of the subsidy was likely to be captured by individuals.

According to expert group chairperson Srinath Reddy, while the panel was committed to providing equity and coverage in health care at the primary and district level as recommended in the report, it was open to the option of setting up a separate group that would look into the possibilities of providing tertiary care. Mr. Reddy said monitoring would be ensured.

Appreciating the panel's report, Rob Yates, senior health economist at the World Health Organisation, said that given the experiences of other comparable countries, it was highly likely that if sufficient political commitment and public resources were secured and vital institutions reformed, this strategy would enable India to take a giant step towards universal health coverage during the 12th Plan. “The proposed focus on cost-effective primary care, especially guaranteeing access to free medicines, appears very wise and should generate appreciable health, economic and political benefits in the short timeframe.”

Citing the experiences of other developing nations such as Indonesia, Vietnam, Cambodia and the Philippines, which had managed to deliver impressive health benefits using the universal approach, Mr. Yates said the suggestion to scale up coverage rapidly, to include the informal sector and not “target the poor” was a wise one. “Furthermore, achieving universal health coverage has generated considerable political benefits both domestically and internationally,” Mr. Yates said.

He said India's universal health coverage strategy would be much more successful in delivering health, economic and political benefits, if it could focus on achieving results at the primary and district level rather than improving access to expensive tertiary care. “Unfortunately, the current Rashtriya Swasthya Bima Yojana insurance scheme, in covering only in-patient care, appears to be having an opposite effect,” Mr. Yates said.

Anne Mills, Vice Director of the London School of Hygiene and Tropical Medicine, said universal healthcare could not be a reality without the availability of services. Hence, the group, she said, needed to be pragmatic, and structure relations with private providers carefully. Supporting stronger regulations and incentives to ensure that zero-use fees and improved accessibility did not result in gross overcrowding of the hospital level, she said a long-term goal should be to introduce a gate-keeper role for primary care.