Focus on Universal Healthcare Coverage for PHC in Kerala – An illustration

                                                             Girish Bommakanti

                               This article represents personal views and analysis

Implementing Universal Health Coverage (UHC) focused solely on primary health care (PHC) in Kerala involves providing essential services—such as preventive care, health promotion, treatment of common illnesses, and basic chronic disease management—to all residents without financial hardship. PHC is the cornerstone of UHC, offering a cost-effective way to improve health outcomes. Estimating the budget for PHC-focused UHC in Kerala requires analyzing current health spending, population needs, and service costs, while leveraging the state’s existing infrastructure and initiatives like the Aardram Mission. Below, I outline the key considerations and provide an estimated budget.

Key Considerations for PHC UHC in Kerala

• Population: Kerala has approximately 35 million residents (based on recent estimates of 2024).
• Current Health Spending: In the 2023-24 state budget, Kerala allocated ₹10,037 crore (≈$1.2 billion) to health, or about ₹2,867 ($34.5) per capita, representing 5.7% of total expenditure. A portion of this already supports PHC through initiatives like Family Health Centres (FHCs).
• PHC Scope: PHC includes vaccinations, maternal and child health, screenings, management of diseases like diabetes and hypertension, and health education. Unlike full UHC, it excludes costly secondary (hospitalizations) and tertiary (specialized) care.
• Existing Infrastructure: Kerala’s Aardram Mission has upgraded PHCs into FHCs, providing a strong foundation. However, gaps remain in rural areas and workforce capacity.
• Cost Benchmarks: The World Health Organization (WHO) suggests a minimum of $86 per capita annually for basic health services in low- and middle-income settings, but Kerala’s higher development level and healthcare costs may require more.

Estimated Budget for PHC UHC in Kerala

To estimate the budget, we focus on the costs of delivering a comprehensive PHC package, including infrastructure, workforce, medicines, and administrative systems, tailored to Kerala’s context.

1. Per Capita Cost for PHC WHO Estimate: The WHO’s $86 per capita figure for basic services is a starting point, but studies like those from the Disease Control Priorities (DCP3) project suggest $60–100 per capita for essential PHC in middle-income settings, adjusted for local costs. Kerala Context: Given Kerala’s higher healthcare costs (e.g., higher salaries for professionals), a range of $80–120 per capita is more realistic. This covers consultations, diagnostics, generics, and preventive programs. Total Cost: For 35 million people: At $80 per capita: $2.8 billion (₹23,240 crore) At $120 per capita: $4.2 billion (₹34,860 crore)
2. Breakdown of Costs

• Infrastructure: Upgrading and maintaining FHCs, adding new centers in underserved areas, and ensuring equipment (e.g., diagnostic tools) could require ₹5,000–7,000 crore ($600–840 million) annually, including capital and operational costs.
• Workforce: Kerala needs more doctors, nurses, and community health workers. Training and salaries for an expanded workforce might cost ₹3,000–5,000 crore ($360–600 million) yearly, factoring in incentives for rural service.
• Medicines and Supplies: Providing free or subsidized generics and vaccines could cost ₹2,000–3,000 crore ($240–360 million), leveraging India’s generic drug industry.
• Preventive Programs: Scaling up vaccinations, screenings, and health education might require ₹1,000–2,000 crore ($120–240 million).
• Health Information Systems: Implementing electronic health records and data analytics could cost ₹500–1,000 crore ($60–120 million) initially, with lower maintenance costs.
• Administration and Monitoring: Managing PHC UHC, including governance and evaluation, might add ₹500–1,000 crore ($60–120 million).

Total Annual Budget Range: Combining these costs, the annual budget for PHC UHC in Kerala is estimated at ₹12,000–19,000 crore ($1.44–2.28 billion). Midpoint Estimate: A realistic target is ₹15,500 crore ($1.86 billion), or approximately $53 per capita, which aligns with conservative estimates for PHC in a high-performing middle-income context like Kerala.

Comparison with Current Spending Kerala’s current health budget of ₹10,037 crore ($1.2 billion) already funds some PHC services, but it also covers secondary and tertiary care. Allocating 50–60% of the current budget (₹5,000–6,000 crore) to PHC suggests a funding gap of ₹6,500–10,000 crore ($780 million–1.2 billion) to achieve comprehensive PHC UHC.

Financing Strategies

To bridge the funding gap and sustain PHC UHC, Kerala can adopt the following strategies:

• Increase State Health Budget: Raise health spending to 4–5% of Gross State Domestic Product (GSDP), currently ₹11.3 lakh crore ($135.6 billion). At 4.5%, this would yield ₹50,850 crore ($6.1 billion), covering PHC UHC and other health needs.
• Enhance Tax Revenue: Improve tax collection efficiency or introduce health-specific levies (e.g., on tobacco or alcohol), as Ghana did with its VAT levy for health.
• Expand Insurance Models: Extend the Karunya Arogya Suraksha Padhathi (KASP) to cover outpatient PHC services, using premiums and government subsidies. This could add ₹2,000–3,000 crore annually.
• Public-Private Partnerships (PPPs): Partner with private providers for diagnostics and telehealth, ensuring regulated costs, as seen in Kenya.
• Central Government Support: Leverage funds from the National Health Mission (NHM) and Ayushman Bharat to supplement state resources.
• International Aid: Seek grants or technical assistance from WHO or global health organizations for initial investments, as Rwanda did.

Process Steps for Implementation

1. Policy and Planning Develop a Kerala-specific PHC UHC policy, building on the Aardram Mission, with clear goals for coverage and equity. Form a task force with state health officials, private stakeholders, and community leaders to oversee implementation.
2. Infrastructure Development Conduct a gap analysis to identify underserved areas. Allocate funds for new FHCs and upgrades, prioritizing rural regions.
3. Workforce Expansion Launch training programs for doctors, nurses, and community health workers. Offer incentives (e.g., housing, bonuses) for rural postings.
4. Service Delivery Define a PHC package (e.g., vaccinations, maternal care, chronic disease management). Integrate services through FHCs, ensuring referrals to higher care when needed.
5. Financial Protection Expand KASP to cover PHC services, reducing out-of-pocket costs. Subsidize care for low-income groups, using means-tested eligibility.
6. Monitoring and Evaluation Implement an EHR system to track health outcomes and service use. Regularly assess progress toward UHC goals, adjusting strategies as needed.

Conclusion

Implementing PHC-focused UHC in Kerala requires an annual budget of approximately ₹12,000–19,000 crore ($1.44–2.28 billion), with a midpoint estimate of ₹15,500 crore ($1.86 billion). This can be achieved by increasing state health spending to 4–5% of GSDP, expanding insurance, and leveraging PPPs and central funds. By strengthening PHCs, training workers, ensuring financial protection, and using data-driven systems, Kerala can deliver equitable primary care to all, building on its strong healthcare foundation to achieve UHC goals.