Universal Health Coverage to Universal Healthcare
Core Context
This phrase is used to critique the dominant UHC model, often linked to the World Bank and the World Health Organization (WHO), which tends to focus on financial protection through insurance systems.
The main points of this perspective are:
- UHC as a limited goal: The UHC approach is sometimes seen as only ensuring access to a limited set of services, often through private insurance, which might not guarantee access to comprehensive care and can still lead to high out-of-pocket costs and inequality.
- UHS as a comprehensive goal: The call for "universal healthcare" advocates for a more complete, rights-based system where the state plays a main role in providing health services as a public good based on fairness, social justice, and collective responsibility.
- Reclaiming the PHC path: The argument emphasizes that achieving real universal access and fairness requires returning to the core ideas of the 1978 Alma-Ata Declaration on Primary Health Care, which calls for comprehensive, community-based, people-focused care that addresses both medical needs and the social factors affecting health.
Universal Health Coverage (UHC) vs Universal Healthcare
UHC primarily focuses on financial protection and access to services, while UHS is often used to advocate for a specific model of public, rights-based, and comprehensive service provision.
Normative Foundations
Alma-Ata emphasized reorienting systems toward PHC to address social determinants, rejecting selective care for holistic approaches. WHO's 2019 Astana Declaration reaffirmed PHC as UHC's foundation, with 14 operational levers for multisectoral action, governance, and community engagement.
Post-COVID frameworks integrate UHC with global health security via equity, rights-based narratives, and PHC prioritization.
Key Distinctions
| Dimension |
Universal Health Coverage (UHC) |
Universal Healthcare (PHC-Centric) |
| Scope |
Financial protection + essential services |
Comprehensive PHC: multisectoral, people-centered |
| WHO Priority |
SDG 3.8 target; 1 billion more covered by 2025 |
Engine for UHC, SDGs, health security |
| Implementation Focus |
Insurance, hospital coverage |
Gatekeeping primary care, prevention |
| Equity Mechanism |
Reduces out-of-pocket costs |
Addresses determinants, empowers communities |
Insurance-Centric UHC – Emerging Concerns
An insurance-centric approach to Universal Health Coverage (UHC) faces several significant emerging concerns, primarily centering on exacerbating inequities, promoting a hospital-centric, for-profit system, and failing to provide adequate financial protection for all health needs.
Key Emerging Concerns
- Inadequate Coverage of Essential Services: Many public health insurance schemes focus heavily on hospitalisation and disease-specific packages, often excluding critical services like outpatient care, diagnostics, and essential medicines.
- Perpetuation of a For-Profit Bias: In systems where public insurance heavily relies on private providers, a significant portion of public funds can flow to profit-oriented hospitals.
- Neglect of Primary and Preventive Care: An emphasis on high-cost, hospital-based (secondary and tertiary) care often draws resources and policy attention away from strengthening the foundational primary healthcare system.
- Persistent Inequities and Access Issues: Despite high reported insurance coverage rates, significant access and utilization challenges remain. Geographic disparities also persist, with quality facilities often concentrated in urban areas, leaving rural populations underserved.
- Financial Unsustainability and Operational Issues: The financial models often face challenges, including low and delayed reimbursement rates for providers.
- Lack of a Comprehensive Systems Approach: The insurance-centric approach is often fragmented, failing to integrate effectively with other public health initiatives, such as global health security or health promotion programs.
Comparative Experience – East and Southeast Asia
- Countries like China and South Korea achieved near-universal insurance coverage.
- However, fiscal burden on the exchequer became unsustainable, and ageing populations and chronic diseases increased costs.
- China’s course correction (2015):
- Cost containment
- Strengthening primary and secondary care
- Focus on prevention, early detection, follow-up
- Investment in human resources and population outreach
- Lesson: Insurance works best when anchored in a well-financed public health system with PHC as a gatekeeper.
Key Roles of Public Health Systems
- Foundation of Primary Healthcare (PHC): A robust public sector is necessary to deliver comprehensive PHC, including preventive, promotive, curative, rehabilitative, and palliative care.
- Cost Containment and Regulation: A strong public system acts as a bulwark against cost escalation, which has been a major challenge in countries like South Korea with high private sector involvement.
- Ensuring Equity and Access: Public systems are vital for ensuring equitable access for the poor and vulnerable populations, including the "missing middle" in the informal sector.
- Addressing Public Health Emergencies: PHC-oriented public health systems capable of effective outbreak surveillance and response.
- Integrated Service Delivery: Public systems facilitate a "systems approach" to health, integrating insurance schemes with existing public health initiatives (e.g., nutrition, sanitation, disease control programs), which is difficult to achieve with fragmented, private insurance models.
India’s Historical Commitment and Policy
- Bhore Committee (1946):envisioning a publicly financed system with Primary Health Centres (PHCs) for every 40,000 population, integrating preventive, curative, and rehabilitative care.
- Post-Independence Shelving (1947-1980s): Scarce resources prioritized economic recovery over Bhore's 3-million plan for integrated PHCs, leading to piecemeal district hospitals instead of comprehensive primary networks.
- Selective Implementation (1980s-2000s): NRHM (2005) expanded sub-centres but underfunded workforce; focus shifted to vertical disease programs, diluting holistic primary care.
- Insurance Pivot (2010s): RSBY (2008) and PMJAY (2018) emphasized hospitalization coverage (₹5 lakh/family), neglecting outpatient/preventive services amid rising NCDs.
- Fiscal and Structural Gaps: Public spending stagnated at 1.3-2.1% GDP, fueling private dominance (70% provision) and 57% out-of-pocket expenses.
- Post-Covid Critique (2020s): Insurance-centric UHC exposed inequities; Ayushman Bharat 2.0 proposes HWC strengthening, but lacks mandatory referrals and primary gatekeeping.
Major Reforms in india
- NRHM (2005): Expanded sub-centers (2.6 lakh+) and workforce; reduced IMR from 58 to 28/1000 by 2025 via ASHAs.
- National Rural Health Mission (NRHM, now NHM): Improved access but systemic gaps persist.
- Rashtriya Swasthya Bima Yojana (2008)
- Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB–PMJAY
- Ayushman Bharat (2018): Dual pillars—HWCs (1.76 lakh by 2025) for primary care; PM-JAY covers ₹5 lakh/family hospitalization for 500M+.
- PM-JAY Expansion (2025): Added seniors (70+ years, 6 crore beneficiaries); integrated OPD, diagnostics in select states.
- ABDM (2021-25): Digital ecosystem with ABHA IDs (50 crore+); enables seamless records, telemedicine.
- Labour Codes (Nov 2025): Mandates workplace health checks, social security for gig workers; unifies 29 laws.
- Budget 2025-26: Cancer care hubs, UPF taxation for NCD prevention; medical education boost (AIIMS expansion).
- Quality Initiatives: Free Drugs/Diagnostics (FDDSI); Jan Aushadhi Kendras (10,000+); mid-level providers in HWCs.
Key Challenges and forward
India's shift from insurance-centric Universal Health Coverage to comprehensive Universal Healthcare faces structural, fiscal, and implementation hurdles but offers clear pathways via primary care revival.
Key Challenges
- Low Public Financing: Health spending at 2.1% GDP (vs. 5% needed); 57% out-of-pocket expenses persist despite PM-JAY.
- Primary Care Neglect: HWCs (1.76 lakh) lack workforce (1 doctor/10,000), diagnostics, and referral systems; NCDs drive 60% hospitalizations.
- Private Sector Dominance: 70% provision unregulated; PM-JAY fraud (₹500 Cr+ claims rejected) and urban bias exclude rural poor.
- Insurance Limitations: PM-JAY covers hospitalization only (no OPD/prevention); excludes 50% informal sector gaps in equity.
- Workforce Shortages: 2M doctor deficit; migration and burnout hinder HWC functionality.
- Digital/Equity Gaps: ABDM (50 Cr ABHA IDs) uneven adoption; gender/rural disparities in access.
Way Forward
- Boost Public Spending: Raise to 2.5% GDP by 2027 via health cess; prioritize HWCs with capitation funding.
- Strengthen Primary Gatekeeping: Mandate referrals from HWCs; add OPD coverage (₹5,000/family) in PM-JAY 2.0.
- Regulate Private Sector: Enforce price caps, quality standards; incentivize rural postings via bonds/subsidies.
- Workforce Expansion: Train 1 lakh mid-level providers; integrate AYUSH in HWCs for task-shifting.
- Digital Integration: Universalize ABHA with AI triage; telemedicine for remote areas.
- Legislative Push: Enact Right to Health Act (Articles 39/47); monitor via independent UHC authority.
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