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Is The Time Right For Free Universal Healthcare In India?

Dr Trehan outlines the need for India to revamp its healthcare system whilst comparing it to other nations as well.

Achieving Universal Health Coverage has been on the agenda for various nations across the world, and this has been further exacerbated since the advent of COVID-19. The need to provide healthcare, which is accessible and affordable, now more than ever, has become a necessity.

COVID-19 has highlighted the need for India to revamp its healthcare system. Building the necessary healthcare infrastructure to cater to the needs of the population is imperative, however, it is equally critical that insurance and coverage is provided to the citizens of India so that they can find an affordable means to access healthcare. In order for this, a push for convergence of Healthcare continuum is required to break down the economic barriers and constraints that are currently prevalent and help provide Healthcare services and value at a much more cost effective and efficient manner.

Government intiatives

Multiple initiatives by the Government of India, strong regulatory push by IRDAI and multiple innovations by insurers across products, channels and service delivery have pushed insurance penetration in the country over the past decade. Guaranteeing health insurance for all will help provide the necessary safety net for citizens across the country, drastically reducing the number of people falling into poverty as a result of financing healthcare expenditure.

In India’s fight to make Healthcare more affordable and accessible to the citizens of India, the Government in 2018 approved the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY). This is the largest health assurance scheme in the world as it provides a health cover of INR 5 lakh per family per year for secondary and tertiary care hospitalization to approximately 50 crore beneficiaries that constitute the 40 per cent of the Indian population.

Ayushman Bharat has represented a unique opportunity to institutionalise quality healthcare, free at the point of service for some of the most marginalised sections of the population. It essentially provides a safety net for these citizens from falling into poverty due to health-related expenses as India currently still witnesses high levels of out-of-pocket expenditure.

PM-JAY covers close to 50 crore people (India’s poorest 40 per cent). States cover an additional 13-15 crore people under the own schemes. The Central Government schemes such as ESIC, ECHS, CGHS covers close to 15-18 crore people. Finally, around 12 crore people are covered through private insurance. This covers a totally of 90-94 crore people in the country. Although, such a vast number of people have the option of insurance, there is still a lack of awareness that is prevalent leading to low insurance of penetration. Also, there is still a significant portion of the population, known as the missing middle, that lacks health insurance.

Insurance and its implementation

In order to accommodate this “missing middle”, there is an urgent need to make quality healthcare accessible to all Indians while ensuring sustainability for healthcare providers. To achieve this a dual approach is required; Continue to scale the health infrastructure with a focus on public health, clean drinking water, sanitation, public hygiene and primary care, additionally, 'Universalize' health insurance for the entire population with a focus on secondary and tertiary care. This is coupled with the mandate to address the following aspects: Segmented population with complementary public – private participation, Affordable Product, Scalability and Standardization. The above approach shall also help healthcare providers utilize idle capacities in a sustainable manner.

Under this segmented population approach, India can Universalize health insurance by leveraging 'nudge' principles. India needs to focus on driving coverage through individual nudges via providing incentives through 80D tax rebate, while making it imperative to avail government benefits, ridding of any asymmetry of information that is prevalent while citizens opt for Health insurance, either private or public.

Looking to the west, the UK Healthcare system is seen as one of the most efficient in the world. It has a government sponsored universal healthcare system, the National Health System.

Health Service

The NHS is a series of publicly funded healthcare systems in the UK, where the citizens are entitled to healthcare under this system, however, they have the choice to purchase private health insurance as well. As all citizens are entitled to healthcare, the advent of the pandemic saw growing waiting lists for NHS treatments, leading to increase of out-of-pocket expenditure for private treatment, essentially, creating a two-tier health system, however, they continue to be seen as a traditional version of universal healthcare, with a minimal use of privatized care.

The US healthcare system is one of the costliest in the world, as they do not have fully fledged universal health insurance system. A mixed public/private approach to healthcare has been used and studies compared to other developed economies healthcare system highlights the inefficiencies in terms of access, patient safety, and coordinations.

Although India is moving towards its own version of universal healthcare, convergence of the healthcare continuum is required. Conversations between payors and providers are necessary, and we need to move away from working in silos. Protecting lives and livelihoods of all Indians needs to be our fundamental concern, and the measures undertaken by Governments at all levels indicate that India is on the right path to insure a billion lives.


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Dr. Naresh Trehan universal healthcare

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