According to WHO, “Universal Health Care (UHC) means that all individuals and communities receive the health services they need without suffering financial hardship. It includes the full spectrum of essential, quality health services, from health promotion to prevention, treatment, rehabilitation, and palliative care. UHC does not mean free coverage for all possible health interventions, regardless of the cost, as no country can provide all services free of charge on a sustainable basis”.
Universal Health Care could be an afterthought in the light of increasing realization that Primary Health Care principles evolved during the International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978 had lost their appeal due to many countries going through structural adjustment and had taken loans from the World Bank and IMF. Primary health care is an approach to health and wellbeing centred on the needs and contexts of individuals, families and communities. It focuses on comprehensive and integrated care to achieve physical, mental and social health and wellbeing. Rather than addressing specific diseases, it is about providing whole-person care for health needs throughout life. The whole-person and community approach involves promotion and prevention to treatment, rehabilitation and palliative care as close as feasible to people’s every day environment.
The Indian Council of Social Science Research-Indian Council of Medical Research (ICSSR-ICMR) committee although not completely bureaucratically visualized and operationalized was set-up as a follow-up of the Alma Ata conference on Primary Health Care. It prepared a report on an alternative strategy on HEALTH FOR ALL which also served as a pre-cursor to the National Health Policy of 1983 (ICSSR-ICMR committee, 1980). The committee had a progressive vision (being outside the Ministry set-up) which adopted a comprehensive definition of health and placed it in the context of socio-economic transformation in the country.
The committee recognized that the existing health sector is exotic, top down, elite-oriented, urban-based, centralized, and bureaucratic with overemphasis on curative care. It suggested an alternative model rooted in the community which could provide adequate, efficient, cost-effective and equitable referral services; integrate promotive, preventive and curative aspects; and combine valuable elements in our culture and tradition with the best elements of the Western system. The report suggested: integrated plans for health and development including family planning; • reorientation of existing priorities so that bulk of the funds can be spent on (a) programs on nutrition, improvement of environment, immunization and education rather than on curative services (b) on basic community services at the bottom than super-specialties at the top; replacement of the existing model of health care with an alternative model which integrated promotive, preventive and curative services and is community-based, participatory, decentralized, and democratic. Despite a strong pressure to change the direction of the health services in the country, all the negative trends that the ICSSR-ICMR committee noted continued to plague delivery of health care in this country.
THE EROSION OF COMPREHENSIVENESS
The eighties saw further erosion in the primary health care ideals and the broader vision for health services. It started with a national health policy of 1983, which selectively picked up points from the ICSSR-ICMR committee such as integrated preventive, promotive, and rehabilitative services, health education and some specific program while advancing the agenda of population stabilization, privatization etc. The policy gave indication to the impending privatization plans of the government and to the reduction of government expenditure in in the health field when it stated that private medical professionals and non-governmental agencies be allowed to establish curative centers and offered to provide logistical, financial and technical support to voluntary agencies. According to the policy, private investments in the health sector should be sought to reduce government expenditure for setting-up such centers.
The intention to privatize government health care system and to gradually withdraw from health sector was implicit. Especially, from the 9th plan onwards, there is a move towards the reorganization of health services with explicit stated intentions towards privatization, individual-family orientation etc. The stated intention of keeping the health services available and accessible to the masses still found a place in plan documents but only as a mere opening ritual. The policy guidelines clearly showed the influence of international donor agenda. The latter policy instruments, approaches and programs in the new millennium were clearly influenced by these historical trends and could be called as the amalgamation of the continuities and discontinuities that were present at various milestones. That mere availability of health centers does not always lead to better utilization is evident from the Planning Commission’s evaluation study on functioning of the Community Health Centers in 1999. The Community Health Centers (CHC) were established as referral centers with the objective of minimizing the hardships of the rural people for accessing the specialized medical services available at the district and other referral hospitals, which are overcrowded. But this objective was never achieved due to shortage of manpower, drugs and other facilities. The country subsequently went through a financial crises and had to go through Structural Adjustment Program in the new millennium and had to depend heavily on the World Bank. After 2010, there was also an effort to strengthen the Health For All strategy by suggesting that health should be part of all activities and sectors in an economy which was called Health in All strategy. Social Determinants framework in health also became a prominent landmark in the history of public health during this time. These existed as counter forces to negate the ill-effects of Structural Adjustment.
Given these counter forces, a structural adjustment approach could not be completely implemented in many countries which went through adjustment for almost a decade and more. And therefore, there were efforts to constantly bring back ‘old wine in new bottles’ which appeared to be progressive but with an underlying reformative touch. It is against such a background that the present approach to universality has to be examined.
The services as suggested under Universal Health care include the ones which address the’ most significant’ causes of disease and death and they should be able to improve the health of the people. However, such services should not have any financial consequences and should not involve any out of pocket expenditure which would push people to further poverty. The philosophy and rationale of Universal Health Care appear to be dominantly economistic with a structural adjustment model. It is a reorientation of ‘Selective Primary Health Care’ principles which invited considerable critique from many public health scholars. ‘Universal’ also appear to be a term to justify an insurance approach in the name high cost of care and sharing of expenses between the State and the people. It also indirectly implies a reduced role of the State. Unfortunately such an approach does not have enough evidence except in some well-off and better states which already have some infrastructural provisioning.
There is indeed a need for bringing back comprehensive, social determinants, participatory and rights-based approaches to public health care especially in the context of the present pandemic (Loewenson et al., 2020). A progressive vision requires cooperation, communication, participatory decision-making and action that safeguards the Siracusa principles which respect people’s dignity, local-level realities and capacities. This may not be possible through an insurance-oriented universal health care (UHC) approach. In other words, what is needed is not an economistic orientation to public health but a vision which brings back the ideals of primary health care as contained in the Alma Ata declaration.
(Kesavan Rajasekharan Nayar is affiliated to Global Institute of Public Health and Santhigiri Research Foundation, Thiruvananthapuram, Kerala)
Kesavan Rajasekharan Nayar (2014). Critical Reflections on Health Services Development in India: The Teleology of Disorder. Lanham, Maryland: The Lexington Books.
WHO (2013). Health in All policies: Report on perspectives and intersectoral actions in the South-East Asia Region. WHO.
Rene Loewenson et al. Reclaiming comprehensive public health. BMJ Global Health. 5(9). 2020 http://dx.doi.org/10.1136/bmjgh-2020-003886