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Interviews of International Experts on Universal Health Coverage

Dr. Joe Kutzin
(World Health Organization)

Dr. Kutzin is currently Senior Resident Adviser for the WHO Regional Office for Europe. Prior to this, he was heading the WHO Barcelona Office for Health Systems Strengthening. He has been affiliated with the Department of Economics, Boston University and has been the regional advisor for Health System Financing in the European Region of the WHO. Earlier, Dr Kutzin has provided technical support to several countries including Estonia, Kyrgyzstan, Moldova and Spain and believes that it possible for developing countries to progressively implement a modern and transparent health-financing system whose organisation is coherent with the crucial objectives of providing financial protection to citizens and to align incentives to produce services efficiently. He has published extensively on the topic.

Q: What in your opinion is the most notable recommendation made by the High Level Expert Group (HLEG) in the report on Universal Health Coverage for India?

Dr Kutzin: I think it is the combination of funding of the system from general government revenues combined with non contributory basis for entitlement. In other words, that many countries have gone the route of linking the entitlement benefits under such a program with a contribution that they make. The experience shows that where most of the population is not included in the formal sector of the economy, it is very difficult to get major improvements in coverage or really make progress towards universality. This idea is safe from the general revenues that everyone contributes and is the more appropriate approach for this country in this context.

Q: Does an increase expenditure on health automatically guarantee improvement in health indicators?

Dr Kutzin: For this there is an answer given by every economist that says "it depends". What we have seen in other countries is that in general there is a relationship between having more public spending and greater availability of services and less dependence on systems for people to pay from their pockets. But transferring it into health quality depends more than just on funding, So, it is really around the incentives, the trainings and the implementation. I think I will put it the other way; that it would be very difficult to make improvements in health without an increase in public spending on health. But increased spending alone will not solve the problem.

Q: What is your stand on user fees?

Dr Kutzin: I am against out of pocket payment and so I think it makes sense that when you are at the magnitude of dependence on out of pocket payment as India is now, it is a major problem in terms of financial access and burden that it places on households. However most of the out of pocket payments is not user fees but it informal payments; its payments to private providers and its payments for medicines. So, if this reform can put in place a system that really addresses these main sources in addition to being free of charge, it basically empowers the citizens to resist the pressure of informal payments. In this case, the package also includes the essential drugs and delivers those to the patients- this will make a whole difference to people. So, it has to more than just a slogan or a declaration of non-user fees. There is a lot more that needs to be done.

Q: What is the feasibility in contracting private players for public purposes?

Dr Kutzin: I don’t know enough about the Indian context to know what is feasible. In general, I think it is very a good reason to try and move in this direction and put a couple of things in parallel. One is to strengthen the regulatory system, infrastructure and ensure implementation of the regulation upto expected standards from all providers − public and private. My understanding from the data is that people predominantly see private providers as 'careful' in comparison to the government hospitals and it would be best to include them to give people better access to services along with options of choosing a provider. So in a way in many states, the key is to make sure that you get good quality and through the contracting process hold those providers accountable and use payments methods that don’t greatly increase the level of spending. So I think it is essential for India.

Q: Will this report regulate private players?

Dr Kutzin: Yes, of course and it is needed.

Q: How does the HLEG report made for India compare with several other versions of Universal Health Coverage currently in place in several other countries?

Dr Kutzin: I think the report made for India is more comprehensive. One of the real strengths of the report is that more than just health financing, it channels human resource services and delivery reform. So by taking a more comprehensive approach it is very good. It is backed by a lot of research and is not just written by technical experts but has been through a political process and review. It offers a lot in terms of building ownership. Also, it is backed by a very strong political commitment to move in this direction by the government committed to achieve Universal Health Research. In my opinion it is a good report. It is large of course but so is the country and its challenges, so it is necessary. Overall, it is excellent.

Q: Do you think there are any missing elements that need to be introduced in the report to make it more robust?

Dr Kutzin: The disadvantage of such a large report is that one can always find things to quibble about. I think at this point there would be diminishing returns to refining the report. The policy in a way is still to be defined in detail in the implementation process and inevitably implementation differs. So, it is critical now that this is great foundation provided by HLEG is improved upon. There is a lot of work to be done on implementation, accompanied by strong policy, analysis and research.

Dr. Ravi Rannan Eliya
Institute for Health Policy,
Colombo & IHP Research Hub,
Asia-Pacific Observatory on Health Systems and Policies

Dr. Rannan-Eliya is Executive Director & Fellow of the Institute of Health (IHP). He has expertise in a number of areas relating to health systems equity, health systems financing and policy, social protection and public expenditure analysis. He is a leading international expert in health expenditure estimation and projection methods and health accounts systems, collaborating extensively with WHO, World Bank, OECD and Eurostat and has been lead analyst of several assessments of pension and social security schemes in Sri Lanka, and currently leading the team of a new pension scheme for informal workers.

Q: What in your opinion is the most notable recommendation made by the High Level Expert Group (HLEG) in the report on Universal Health Coverage for India?

Dr. Rannan-Eliya: Public financing. The need for tax based financing to achieve better coverage is the most important recommendation in this report.

Q: Does an increase expenditure on health automatically guarantee improvement in health indicators?

Dr. Rannan-Eliya: An increase in public financing would not necessarily guarantee better outcomes but I think it is a pre-condition for getting better coverage. So, it is a critical and necessary step but not necessarily a sufficient step. The report raises an important issue about increasing public financing, also pointing out that it must be accompanied with strengthening the delivery system, particularly the public delivery system which would require very large scale reform.

Q: What is your stand on user fees?

Dr. Rannan-Eliya: As a health economist, I cannot see any rational reason to have user fees in the public sector as they do not raise any significant resources as already in the case in India to cover the transaction cost. They have a discouraging effect on the use of services by the poor and also it does not contribute to equity. There are arguments that user fees at least discourages the use of inappropriate services but in fact there is very strong global evidence that even in developed countries if you have user fees people cannot distinguish between the inappropriate and appropriate services, especially non-medical people. That is why they go to the doctor. So, they reduce the need of 'needed services' as well as the 'not needed services'.

On top of that, my sense is that India does not have a problem with excessive healthcare use. In comparison to Sri Lanka, people go to a qualified doctor in India maybe one-third less in India and get admitted in a hospital at one-tenth the level as seen in Sri Lanka. I don’t see a problem of over use of medical services in India. The major problem here is many people; especially the poor do not use the services available enough.

Q: What is the feasibility in contracting private players for public purposes? And will this report regulate private players?

Dr. Rannan-Eliya: In principle yes, but it all depends on the details of the system and its implementation. In some ways it could be a disaster but I cannot comment on that recommendation of contracting private players for public purposes any more. I don’t think the report, as of now, has enough details of regulation. It needs to be fleshed out but I think I can see a situation when contracting private players for public purposes could be done in a bad way which can have worse outcomes. And yet there are other ways which could hood have good outcomes. So it really depends how it is done.

Q: How does the HLEG report made for India compare with several other versions of Universal Health Coverage currently in place in several other countries?

Dr. Rannan-Eliya: That is a very difficult comparison to make because I think India is more complex, large and diverse. We cannot compare it to smaller countries which have simpler systems. The report for India is relatively comprehensive and it is not just a financing document but it talks about provisions, quality and regulation. I think that is very good and detailed. My colleague from South Africa might have a better sense to compare it with India as they have a similar document. I know that in the case of China, they had a very comprehensive reform document which is not perfect but their system is very different.

They have a lot more insurance in the system and don’t really have a private sector, as it is pretty much all public provision. They spent a much longer time, almost three years preparing their reform report. So maybe, some details are missing in India’s document and one year is not sufficient to prepare a comprehensive report. I think for India’s report more details need to be fleshed out and those are going to be critical.

Q: Do you think there are any missing elements that need to be introduced in the report to make it more robust?

Dr. Rannan-Eliya: I think there is insufficient attention to how these reforms will play out in different states, given that states in India are very different with their political economies and issues. So, there has been very little discussion about how each state- on the basis of their potential- will implement the reforms. Also, there has not been sufficient discussion in India’s political economy and how it will be implemented realistically.

Dr. Anne Mills
London School of Hygiene and Tropical Medicine

Dr. Mills has a degree in in history and economics from Oxford. She has spent 3 years researching the planning system of the UK's NHS. After completing her PhD on Malaria in Nepal, she took up the post of a lecturer at the LSHTM. Between 1990-2010, she was the Director of the Health Economics and Financing Programme, which was supported by a variety of research grants from funders such as DFID, the Wellcome Trust, EU and WHO. In 2006 she became Head of the Faculty of Public Health and Policy, and in 2011 she took up the position of Vice Director for Academic Affairs.

Q: What in your opinion is the most notable recommendation made by the High Level Expert Group (HLEG) in the report on Universal Health Coverage for India?

Dr. Mills: The most notable recommendation is to aim, in India, for a universal system that encompasses everyone. I think it will take many years to effectively achieve that but I think it is also a really important aim. Also, there can be very substantial progress towards achieving the desired goals as in the report by 2020. It is very important in the long term to aim for a system of healthcare where everyone has access to it and that which has common standards across the country.

Q: Does an increase expenditure on health automatically guarantee improvement in health indicators?

Dr. Mills: I think there definitely should be an association between improvement in increasing health expenditure and improvement in health quality. Having said that, I think between those two things lies one of the key decisions like how the money will be spent. Greater expenditure is a necessary condition but it is more important to see on how that money will be spent and also that it is spent effectively. Some of the key recommendations of the report are really to do with 'how' that money will be best spent, particularly, in terms of channelling a lot of additional money into the publicly funded health services. The major challenge is how to improve that performance.

Q: What is your stand on user fees?

Dr. Mills: The report is absolutely correct in arguing for zero user fees for the defined benefit package. I think that one can argue that on equity grounds, one can also argue it on efficiency grounds because it costs money to collect user fees.

Q: What is the feasibility in contracting private players for public purposes?

Dr. Mills: I certainly think it is feasible. India needs to do that because it has many-many resources in the private sector and it needs to make use of it. But it is very important how you structure that relationship and that you need to have a strong purchasing role in the public sector in order to purchase services from the private sector.

Q: Will this report regulate private players?

Dr. Mills: There needs to be a much stronger regulation in the private sector anyway. Additionally, if you purchase certain services from the private sector that can be a strong means of improving the private sector delivery services because the contract gives you a powerful tool to do that.

Q: How does the HLEG report made for India compare with several other versions of Universal Health Coverage currently in place in several other countries?

Dr. Mills: There has a lot of concern globally and countries should be adopting Universal Health Coverage programs. I think India is one of the early countries to make some practical recommendations for that. So I think India is a very important leader in this area.

Q: Do you think there are any missing elements that need to be introduced in the report to make it more robust?

Dr. Mills: It is really a big challenge as Universal Health Coverage is an enormous subject and you cannot cover it in just one report. This report is very strong on the vision. But I think there is a need for further investigation on some of the mechanisms in order to achieve it. There will be more detailing required to work out how best to do it.