About Us

Interviews of International Experts on Universal Health Coverage

Dr. Robert Yates
(Senior Social Policy Advisor, DFID)

Dr. Yates is an economist by background and is a senior health adviser working for the UK’s Department for International Development. After working in oil trading for Shell International, Mr Yates trained as a manager in the NHS before managing a community based HIV/AIDS hospice in Swaziland in 1995. He then worked in the planning departments of the Ministries of Health in Mozambique and Uganda providing technical assistance in the areas of health financing, planning and management. In 2001, he witnessed the impact of introducing free public health care Uganda and has subsequently advised governments in Zambia, Mozambique, Ghana, Nepal, Sierra Leone and Burundi in this area. In 2008, following a three year posting in the Democratic Republic of Congo, he returned to the London headquarters of DFID where he advises on health financing policy.

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. Yates: The most important thing in achieving universal health coverage is to recognize the importance of public financing over private financing. In India, the health system is being financed primarily through out-of-pocket expenses, and by looking at the situation the world over, it can be understood that the foundation of your health system should be largely publicly financed. Reaching that point is a major achievement, and there is also the aspect of ensure that the benefits of having public expenditure are maximized. The key point about public financing is essential.

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

Dr. Yates: You can raise a lot of money, and spend it unwisely. One good thing about the report is that it recognizes the importance of improving the purchasing of healthcare and the allocation and management of resources. The financing is an absolutely necessary condition, but you also have to improve the management of those resources. Generating a large pool (in the order of 2.5% of GDP) of public financing is a necessary but not a sufficient condition for success. It will also be essential that these funds are allocated and managed efficiently and equitably. The priority given to cost-effective primary health care services is commendable, as this is where the country will extract maximum value for money out of its health investment.

Q: What is your stand on user fees?

Dr. Yates: I think the evidence has shown that fees are the worst way to finance a health system, because they raise remarkably little revenue. They’re a very inefficient way of collecting resources, but the most important aspect is that they exclude millions of people from accessing healthcare. I think we have learnt now that it’s a good idea to remove fees for the packaged services that are offered. In emphasising the importance of health financing reforms the report is consistent with the large body of evidence contained in WHO’s World Health Report for 2010. In particular, the main recommendation that public financing (especially tax) should replace less efficient and equitable private financing (notably out-of-pocket fees) is consistent with international findings.

It is essential that these fees don’t exist and that everybody is aware of the fact that the fees are not levied on the services offered under National Health Package. The moment you start clouding that, it’s very easy for people to abuse the system or get confused. I think a system offering free services at the point of delivery would be a huge sell to the population, and people would flock to those services. Thus, from a marketing perspective, I think zero price is essential.

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. Yates: Given the experiences of other comparable countries, it is highly likely, that if sufficient political commitment and public resources are secured and vital institutions are reformed, this strategy will enable India to take a giant step towards universal health coverage during the 12th Plan. The proposed focus on cost-effective primary care, especially guaranteeing access to free medicines, appears very wise and should generate appreciable health, economic and political benefits in a short time frame. I think the report has been approached in a very logical and comprehensive way. They’re looking at the different subsystems, and trying to label those together. We, as a group, all agree that the broad strategy has a very sensible approach.

There are undoubtedly areas that need working out and nailing down before implementation. There are tricky issues around the purchaser, the provider, the role of the private sector, and the remuneration of health workers and incentives. Those things aren’t clear at the moment, but I think they’re all perfectly feasible things to sort out in reasonable time frames. We certainly don’t want to give the impression that we think that the government should hold back on the reforms.

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

Dr. Yates: I think that the new arrangements can potentially improve the quality of the private sector, and be beneficial to both the private and the public sector. What you’re looking for is encouraging good value for your money and good services in the private sector. Those private sector organizations or small suppliers who aren’t providing good value are not going to do well thanks to the arrangements made. At the moment, you have a lot of people buying services of indifferent quality, in both the public and the private sector. This new public financing model is a good way to improve standards in both sectors to the benefit of the entire population.

Dr. Frans Stobbelaar
Consultant, Pharin International

Dr. Stobbelaar is a senior consultant in pharmaceutical sector management. He has a professional background in strategy and policy development. Dr. Stobbelaar previously worked for the World Health Organization and Deloitte Management Consultants. He has many times visited Armenia and provided professional assistance to the Armenian pharmaceutical sector in various areas including of strategic and business planning, pharmaceutical supply chain management and GMP implementation and investment programmes.

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. Stobbelaar: In my opinion the most notable recommendation is the link between universal coverage and universal coverage by drug suppliers. Without medicine, universal coverage of health services is a utopia and will never happen. Thus, it’s a crucial element in the entire package.

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. Stobbelaar: I think it’s a very good report because it’s comprehensive and it sets out an agenda for several years ahead, which is something you don’t see often. Even if most of the recommendations are not achieved within the first plan period, this lays out a long term policy- an overarching framework- clearly saying what the country's stand in on each of the issues- like drug pricing and regulation, access to medicines, service norms etc. I like it very much, and altogether, it’s a good approach and a strong strategy.

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

Dr. Stobbelaar: I think so. While it may be unwise to assume an automatic transformation and improvement in the health indicators, I do believe that increasing expenditure is the starting point. The current financing of less than two percent of the GDP on health is very low, and that indicates that a large part of the population has no access to healthcare when needed. Thus, if the financing improves, then the access should also improve.

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

Dr. Stobbelaar: Currently, the private sector in India is largely unregulated. I would like to have a little bit more regulation in the private sector. Thus, the private sector should only be contracted once they comply with those regulations and quality requirements. In Holland, we had a mixed system of public sector insurance and private insurance for people that were earning more than a certain amount of money, which functioned quite well. Thus, the state had a strong influence on the insurance and on the system. That might be an option here as well but this largely depends on implementation of the plan.

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

Dr. Stobbelaar: I think it is ambitious in terms of the plan and its setting up. I wonder whether, for drugs, for example, a certain level of mixed financing would be more appropriate, as opposed to taking it through the state procurement system entirely. An alternative system could also be developed in parallel. I agree that for the poor, and for the rural areas, you need a strong state influence. However, for the more affluent, it might not be necessary. These are details that need to be worked out and fleshed-out with more discussion from all stake-holders. One cannot ignore that, as of now, private players are the majority stake-holders in providing healthcare in India- so ignoring them completely might not yield the kind of results the government is expecting.

Dr. Ashfaq Bhat
Senior Advisor, Health at Royal Norwegian Embassy

Prior to this, Dr Bhat has been affiliated with the World Health Organization as State Routine Immunization Officer and Surveillance Officer.

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 Bhat: The synergism with the human resources for health is a very notable aspect of the report. I think that has been identified by the Government of India as the top most priority and this report is synergizing with the government’s viewpoint on that. That is one element we need to focus on. Another aspect would be the out of pocket expenses, because ultimately, these out of pocket expenses for healthcare for an individual and his family constitute a major chunk of his expenses. The focus is not only on providing financial protection from the costs of health care for Indian citizens but also on ensuring that citizens are able to physically access to the needed medical care. This vision of getting into public expenditure has been established, as opposed to opting for private expenditure, which is another highlight of the report.

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

Dr Bhat: If we make a comparison with the National Rural Health Mission, we notice that the expenditures are still very low. The financial capacity or financial institutional mechanisms are still not in place. I think we could have definitely helped the Government of India if this report had dwelled more into how to strengthen the financial capacity of the state. It is commendable that the report, instead of focussing on short-term narrow focus on financial availability, recommends comprehensive reform on the healthcare structure. It will be critical to improve policy and public health management capacity- for all of which increasing expenditure is a right step provided it is followed with the necessary political commitment.

Q: What is your stand on user fees?

Dr Bhat: The report is right in not levying a user fee for the services offered under the National Health Package. The recommendation to totally remove user fees is consistent with the successful policies of Brazil, Mexico, Sri Lanka and Thailand. I don’t think user fees need to be applied because we have learnt from the experiences of the American and the UK health systems, which are being funded completely by national health services with the government, so I feel that user fees should be eliminated.

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

Dr Bhat: I’m not very clear on this aspect. How do we operationalize and get into the public-private partners into business, because I think the National Rural Health Mission has failed completely at executing public-private partners, excluding the big players in the market. That link is definitely missing. I’m unaware of how these partnerships can be strengthened, since my knowledge on the subject is limited.

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 Bhat: I think this report has done a comparative analysis of all the health systems of the low-income, mid-income and high-income countries and has managed to incorporate their experiences and challenges, thus making it a comprehensive report. In the past two decades, international experiences have shown that countries that have adopted for the 'universal' coverage instead of targeted schemes only for the poor, have been successful. Most countries adopting for Universal Health Coverage have been able to deliver significant health benefits and successfully change health indicator amongst their populations. Besides, it is also necessary to tie the advantages of a successful public health system to the political benefits coming from it.

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

Dr Bhat: We need to have some health policy reforms. We have recommendations, taking into account the 1946 Bhore Committee report, of having the PHC at a population number of 30,000, whereas it has been catering to a population of 150,000. I think, essential to the success or failure of the universal health care scheme, would be the political commitment and ownership this proposal will get. The proposed framework indicates a paradigm shift and major reforms in the health system, which cannot be achieved if the public, media and policy-makers are not included in rolling out the scheme. It is crucial that policy changes are made keeping in mind the easy implementation of the scheme.