Universal health coverage (UHC) is a major target of the sustainable development goals adopted by the UN and intended to be accomplished by all member states by 2030. India, a signatory to the goals, proclaimed her commitment to UHC in the National Health Policy of 2017.
Though many countries are not on track to achieve this goal by 2030, Ayushman Bharat initiatives provide India a unified framework to move towards the goal. These include strengthening of primary care, progressive expansion of public-funded health insurance schemes steered by the central and state governments, expansion of the care infrastructure and a pluripotent digital health system that amplifies the efficiency of health services and integrates disease surveillance systems.
Two metrics used for assessing progress towards UHC are degrees of ‘financial protection’ offered to those accessing healthcare and of ‘service coverage’ offered by the system to meet varied health needs. The former is measured by three indicators: overall out of pocket expenditure (OOPE), catastrophic health expenditure and healthcare-related impoverishment due to the cumulative burden of expenditures.
The largest part of OOPE comes from frequent out-patient expenditure on drugs and diagnostics, while catastrophic expenditure is usually related to an acute event that imposes a severe financial strain. Healthcare-related impoverishment can result from one or a combination of the two. Poverty often results when the financial strain is compounded by loss of wages due to illness or disability.
Service coverage is measured through an index developed by the WHO. It combines 14 indicators across health domains. They cover reproductive, maternal, newborn and child health, infectious diseases, non-communicable diseases, service capacity and access.
It is essential to measure service coverage, because inadequate availability or use of health services may result in low reporting of OOPE. If the services are unavailable, people cannot spend on them. If they are considered very expensive even when available, people may desist from accessing them. In both these situations, where people are distanced or deterred, there is ‘forgone care’. It means that people do not seek and obtain healthcare even when they perceive a clear need for it.
Forgone care is high among the poor, less educated, rural-dwelling, tribal, geographically-isolated and gender-discriminated sections of the population. It is also high in states with weak health systems. A study that analysed data on maternal and child health from the National Family Health Survey of 2015-16 found high levels of forgone care even for essential services (antenatal care: 17.8 percent; child with fever or cough: 32.4 percent; child with diarrhoea: 33.8 percent). Apart from poverty and rural status, low maternal education were predictors of forgone care. Tellingly, states with low per-capita health expenditure had high levels of forgone care.
Since the study only looked at maternal and child health, many other areas were obscured. Non-communicable diseases (NCDs) like cardiovascular conditions and cancers are likely contributors to high levels of forgone care. This happens because chronic care imposes high OOPE due to prolonged need for daily drugs and frequent diagnostic tests.
Acute events, too, may warrant high-cost procedures and hospital stay. Government health insurance may not cover the full cost of treatment. Loss of wages of the family’s breadwinner and caregivers are also a deterrent to poor families from seeking hospitalised care.
Even when healthcare needs are recognised for a major disorder at the level of primary care, a lack of well-functioning referral systems and inability to assure free tertiary care results in forgone care. Nearly 25 years ago, Tamil Nadu introduced pilot programmes for prevention and control of NCDs. In that World Bank-funded programme, hypertension and cervical cancer were chosen as the initial targets. Community-based primary level screening and subsequent provision of the needed care were the principal components of that programme.
On evaluation a few years later, it was observed that highly cost-effective results were obtained for hypertension control in primary care. While screening for cervical cancer was effective at the primary care level, lack of adequate referral linkages and inability to assure free treatment at tertiary centres made the cancer component of the programme cost-ineffective.
Mental health disorders are another area of forgone care. This results from poor levels of detection, reluctance to seek care due to perceived social stigma and lack of trained personnel who can provide competent and compassionate community care. Even where services are available for adults, children and adolescents often do not get the needed care. For adolescents experiencing high stress due to academic and social pressures, health services are unavailable at schools and colleges. Programmes for adolescents must be geared up to protect both physical and mental health.
Forgone care was a major problem during the Covid pandemic, when many elective procedures were postponed or cancelled. Travel restrictions prevented people from travelling to healthcare facilities. Such disruptions can also occur during extreme weather events that are increasing today. We need to build climate-resilient health systems that can withstand such challenges.
While forgone care refers to the unmet need for recognised health problems, many have health conditions that are undiagnosed and uncared for. Many NCDs are unrecognised in the early stages without screening. This is especially true of hypertension, diabetes and early cancers. Care forgone in the early stages inflicts high disease and financial burdens later on.
Unless primary healthcare services are strengthened for early detection of NCDs, missed opportunities will amount to ‘forsaken care’, which will add to the burden of forgone care for diagnosed health problems. We must minimise both by creating efficient and equitable health systems. Only then can we be assured of delivering UHC to the nation.
(Views are personal)
(ksrinath.reddy@phfi.org)
K Srinath Reddy | Author of Pulse to Planet. Distinguished Professor of Public Health, PHFI