Understanding the concept of Universal Health Coverage (UHC) and how can we reach it, both globally and also in India. The presentation also includes HLEG report , which is the proposed architecture for India's guide to reach UHC.

1. Universal Health
coverage
By: Sourav Goswami
Moderator : Dr P R Deshmukh
MGIMS, Sevagram

2. Framework
Magnitude of problem (Key facts)
What is UHC?
Why UHC?
Dimension and principles of UHC
HLEG report: proposed architecture
Challenges
Examples

3. Key facts- global picture
• 400 million people globally lack access to one
or more essential health services.
• Every year 100 million are pushed into poverty
and 150 million people suffer financial
catastrophe because of out-of-pocket
expenditure on health services.
• 32% of total health expenditure worldwide
comes from out-of-pocket payments. - WHO

4. Key facts
B. Indian picture
• Highest number of malnourished children in the world
• MMR – 212 /100,000 live births
• IMR ---- 39/1000 live births
• Health expenditure is largely out – of – pocket ( 67%)
‘India’s public financing for health care is less than
1 per cent of the world’s total health expenditure,
although it is home to over 16 per cent of the world’s
population’ World Bank
• Public expenditure on Health – 1.2 % 4
• Only about 17% of the population is covered
by some form of health insurance 5

5. • Health situation is not uniform across India
• 12 year difference in life expectancy between MP
( 61.9 years) and Kerala ( 74 years) 6
• MMR in Kerela is 81, but in Assam it is 390 per
100,000 live births 6,7
• Considerable gaps between rural and urban areas with
respect to disease morbidity and mortality
Under nutrition is a dominant problem in the rural
areas while overweight and obesity accounts for half
the burden of malnutrition in urban areas8
• Urban areas have 4 times more health workers per
10,000 population than rural areas 9
Keyfacts_ India contd…

6. Per year 35% among poor households incurred
catastrophic health expenditure
Impoverishment effect due to catastrophic health
expenditure is 8% in Rural and 5% in urban areas per
year
Keyfacts_ India contd…

7. UHC is an aspirational goal:
The 58th
session of the World Health assembly in
2005 defined UHC as providing ‘access to key
promotive, preventive, curative and rehabilitative
health interventions for all at an affordable cost ’

8. What do we need to be Healthy???
Health workers?
Safe & effective care?
Medicine?
Who pay for it?
Policies
Information

9. People +
Services +
Products +
Finances +
Policies +
Information
UNIVERSAL
=
EVERYONE
THIS IS UNIVERSAL HEALTH COVERAGE

10. The UHC Cube
Three
dimensions
of UHC:
1.Population
coverage ( and
equity)
2.Service
coverage
3. Financial risk
protection

11. The objective: Universal Health Coverage
• All people have access to needed services
• Without the risk of financial ruin linked to paying
for care

12. Why is moving towards UHC
important?
For 3 reasons:
1.Health benefits-
Example : Story of Brazil
2. Economic benefits
Examples: Thailand lowers out of pocket
expenditure
3.Political Benefits:
Examples:

13. 1988 Brazil initiated an extensive program of health
forms with the intention of increasing the coverage of
fective services for the poor and otherwise vulnerable.
ior to 1988, just 30 million Brazilians had access
health services.
oday, coverage is closer to 140 million, roughly
ree-quarters of the population.
Health Benefits of UHC: Story from Brazil

14. There has been significant improvements across a range
of health indicators, notably IMR which fell from 46 per
1000 live births in 1990 to 17.3 per 1000 live births in
2010. Life expectancy at birth has also improved,
reaching 73 years in 2010 compared to 70 years just a
decade earlier.
The reforms also reduced health inequalities with the
life expectancy gap between the wealthier south of the
country and poorer north falling from 8 years to 5 years
between 1990 and 2007.
Continues…..

15. n independent review report on the first ten years of
hailand’s Universal Coverage Scheme(UCS) shows a
ramatic reduction in the proportion of out-of-pocket health
xpenditure,& associated falls in the number of households
uffering catastrophic health expenditures &impoverishment
ue to health care costs. Between 1996 and 2008 the
ncidence of catastrophic health care expenditure amongst
he poorest quintile of households covered by the UCS fell
om 6.8 % to 2.8 %.
THAILAND LOWERS OUT OF POCKET SPENDING

16. he incidence of non-poor households falling below the
overty line because of health care costs fell from 2.71 %
n 2000 to 0.49 % in 2009. The review calculated that the
Comprehensive benefit package provided by the UCS
nd the reduced level of out-of- pocket expenditure protecte
a cumulative total of 292,000 households from health
elated impoverishment between 2004 and 2009.
Continues…….

17. UHC is popular across the world and if UHC reform
are implemented properly they can build peace
and security in countries & deliver substantial
Political benefits to governments.
Many leaders coming to power after a national crisi
(be it economic or political) have implemented rapid
UHC reforms as a way to deliver a quick-win for
their people. Examples include Rwanda, Nepal,
Thailand,Brazil and also the UK after World War II
UHC and political benefits

18. Dispelling myths about UHC
•UHC is not just health financing, it should cover all
components of the health system to be successful
•UHC is not only about assuring a minimum package of
health services
•UHC does not mean free coverage for all possible health
interventions, regardless of the cost, as no country can
provide all services free of charge on a sustainable basis.
•UHC is comprised of much more than just health;
taking steps towards UHC means steps towards equity,
development priorities, social inclusion and cohesion.

19. Evolution of UHC in India
1. Bhore Committee 1946
2. Mudaliar Committee 1959-61
3. Jungalwalla Committee 1967
4. Kartar Singh Committee 1973
5. Shrivastava Committee 1975
6. Rural Health Scheme 1977
7. Health for all by 2000, 1980
8. National Health policy, 1983
9. National population policy 2000
10. National health
policy 2002
11. NRHM 2005
12. NHM 2013
13. National Health Policy
2015 (draft)

20. • CONSTITUTED IN OCTOBER 2010
• REPORT IN NOVEMBER 2011
High Level Expert Group Report India

21. Ensuring equitable access for all Indian citizens, resident
in any part of the country, regardless of income level,
social status, gender, caste or Religion, to affordable ,
accountable, appropriate health services of assured
Quality ( promotive, preventive, curative and rehabilitative)
as well as public health services addressing the wider
determinants of health delivered to individuals and
populations, with the government being the guarantor and
enabler, although not necessarily the only provider, of
health and related services.
Defining UHC ( as per HLEG report)

22. Universal Health Coverage By 2022:The vision

23. Expected Outcome from UHC

24. Architecture for UHC ( as proposed by HLEG)
1. Heath financing and Financial Protection
2. Health Service Norms
3. Human Resources for Health
4. Community participation and citizen engagement
5. Access to Medicines, vaccines and technology
6. Management and institutional reforms

25. 1. Heath financing and Financial Protection
Health financing is concerned with how
financial resources are generated, allocated and
used in health systems.
Health financing policy focuses on how to move
closer to universal coverage with issues related
to:
 (i) how and from where to raise sufficient
funds for health;
(ii) how to overcome financial barriers that
exclude many poor from accessing health
services; or
 (iii) how to provide an equitable and efficient
mix of health services

26. 1. Heath financing and Financial Protection
Recommendations by HLEG
 The Government
spending on healthcare
in India is only 1.04% of
GDP which is about 4 %
of total Government
expenditure, less than
30% of total health
spending.
 JSY (2005)
 Chiranjeevi Yojna (2006)
 Rastriya Swasthya Bima
Yojna (2008)
Present Indian scenario
 increase public
expenditures on health
from the current level of
GDP to at least 2.5% by
the end of 12th plan
(2012-17) and to at least
3% of GDP by 2022.
• Use general taxation as
the principal source of
health care financing

27. The Rashtriya Swasthya Bima Yojna
(launched in 2007) by the Ministry of Labour & Employment
• Cashless coverage of all health services
• Smart-card-based system;
• Only hospital admission and day-care
• Total of INR30000 insured per family below poverty line per year.
• Pre-existing illnesses also covered;
• Reasonable expenses for before and after hospital admission for 1 da
before and 5 days after;
• Transport allowance (actual with limit of INR100 per visit) subject to
a yearly limit of INR1000

28. • Only BPL Family
• Up to five members for 1 year;
• renewal yearly;
• registration fee for a family is INR30;
• Central government contribution 75% &
State government 25% of the premium
RSBY contd….

29. 2. Health Service Norms
Present Indian Scenario
 Indian Public health
Standard (IPHS) norms
prevailing among the
different levels of heath
facilities.
Recommendations by HLEG
 Develop a National
Health Package
 Lot of emphasis on
primary health care
 IT-enabled National
Health Entitlement Card
(NHET)

30. 3. Human resource for health
Present Indian Scenario
 India is facing a crisis in
human resources for
health
 2.2 million health workers
which roughly translates
to a density of 22
health/10,000
 ASHA
 AYUSH
 Health workers are
unevenly distributed
between the rural and
urban areas, and across
states
Recommendations by HLEG
 Increasing the number of
trained health care providers
for providing primary health
care
 District Health Knowledge
Institutes (DHKIs)
 National Council for Human
Resources in Health
(NCHRH) to prescribe,
monitor and promote
standards of health
professional education.

31. Recommendation of HLEG
3. Human resources for Health

33. 4.Community participation and citizen
management
Present Indian Scenario
 Village Health,
Nutrition and
Sanitation Committee
(VHNSC)
 Rogi kalyan samiti
(RKS)
Recommendations by HLEG
 In order to improve
community participation, it
recommended transforming
existing VHNSC into
participatory Health Councils.
 The Health Councils should
organize annual Health
Assemblies at different levels
(district, state, and nation) to
enable community review of
health plans and their
performance as well as record
ground level experiences that
call for corrective responses
at the systemic level.

34. 5.Access to Medicines, vaccines and Technology
Present Indian Scenario
 There were 376
medicines listed in NLEM
2015.
 Jan Aushadhi programme
(2008)
 MCTS
Recommendations by HLEG
 Revise and expand the
essential drugs list
 Enforce price regulation
especially on essential
drugs
 Ensure rational use of
drugs

35. 6. Management and institutional reforms
(Recommendations by HELG)
• Introduce All India and state level Public Health
Service Cadres and a specialized state level Health
Systems Management Cadre in order to give greater
attention to public health and also strengthen the
management of the UHC system (managerial
reforms)
Among Institutional reforms, it recommended the
establishment of the National Health Regulatory and
Development Authority (NHRDA) with three key
units.:
1. System Support unit (SSU)
2. National Health and Medical Facilities Accreditation Unit
(NHMFAU)
3. Health System Evaluation Unit (HSEU)

36. • National Health Mission
• Janani Suraksha Yojana
• The Rashtriya Swasthya Bima Yojna
• The Jan Aushadhi programme
Schemes to promote universal health coverage in India

37. Increase of fund for public health from 0.9% of GDP to
1.8% .of GDP in 2013
To revitalize the public sector in health by increasing fundin
Integration of vertical health and family welfare programs,
Employment of female accredited social health activists in
every village,
Decentralized health planning, community involvement in
health services,
Strengthening of rural hospitals,
Providing untied funds to health facilities,
NHM

38. Jan Aushadhi programme (2008)
• public-private partnership,
• Aim to set up in every district,
• To provide quality generic drugs and surgical products
at affordable prices 24 h a day

39. Global momentum for UHC
1. MDG 2000
UHC and the Millennium Development Goals
(MDGs) are strictly connected.
UHC implies open access for all to health
services,& involves strengthening efforts to
improve the quality, availability & affordability
of services linked to the current MDGs
including, for example, the fight against
HIV/AIDS, TB, malaria & child and maternal
mortality.
Mental illnesses and injuries.

40. Global momentum for UHC
2. Post- 2015 Development Agenda
Sustainable Development Goal ( SDG) 3
“ Ensure healthy lives and promote well being for
all at all ages”
SDG Target 3.8
“ Achieve UHC, including financial risk protection
access to quality essential health care services and
access to safe, effective, quality and affordable
essential medicines and vaccines for all”

41. 3. Dr Margaret Chan, WHO Director-General
“I regard universal health coverage as the single
most powerful concept that public health has to
offer. It is inclusive. It unifies services and delivers
them in a comprehensive and integrated way, based
on primary health care.”

42. Challenges
1.Pursuing unrealistic goals-
a. UHC doesn't require a universally applicable package
of health care services that must be covered.
b. There is a problem that equal financial access that
may be facilitated by health insurance doesn't necessarily
mean equal physical access to high quality health care
c. Problems with egalitarian percepts – concepts of
opportunity costs.

43. Challenges contd…
2. Problem with medicines:
a. Underuse of generic and higher than necessary prices
for medicine
b. Use of substandard and counterfeit medicine
c. Inappropriate and effective use of medicine
3. Heath care products and services:
Overuse or supply of equipment, investigations and
procedures.
4. Heath workers:
Inappropriate or costly staff mix, unmotivated workers

44. Challenges contd…
5. Health care services:
Inappropriate hospital admissions and length of stay
6. Health care services:
A. Inappropriate hospital size ( low use of infrastructure)
B. Medical errors and suboptimal quality of care
.
7. Heath system leakages:
Waste, corruption and fraud
8. Heath interventions:
Inefficient mix/ inappropriate level of strategies

45. To sum up the Challenges for UHC
• The availability of health care services provided by the
public and private sectors taken together is inadequate;
• The quality of healthcare services varies considerably in
both the public and private sector as regulatory standards
for public and private hospitals are not adequately defined
and, are ineffectively enforced; and
• The affordability of health care is a serious problem for the
vast majority of the population, especially at the tertiary
level.

46. Conclusion

47. Conclusion
The Member States of WHO have endorsed
universal coverage as an important goal for the
development of health financing systems but, in
order to achieve this long-term solution,
flexible short-term responses are needed.
There is no universal formula. Indeed, for many
countries, it will take some years to achieve
universal coverage and the path is complex.
The responses each country takes will be
determined partly by their own histories and
the way their health financing systems have
developed to date, as well as by social
preferences relating to concepts of solidarity.

49. References
World Health Organization. Universal health coverage factsheet [Internet].
ted 2016 Aug 10]. Available from:
p://www.who.int/mediacentre/factsheets/fs395/en/.
World Health Organization. The world health report: health systems financing:
path to universal coverage. Geneva: World Health Organization; 2010.
Gina Lagomarsino, Alice Garabrant, Atikah Adyas, Richard Muga,
haniel Otoo ;Moving towards universal health coverage: health insurance
orms in nine developing countries in Africa and Asia; Lancet 2012; 380:
3–43;
High Level Expert Group Report on Universal Health Coverage for India
ituted by Planning Commission of India; New Delhi,November, 2011
K Srinath Reddy, Vikram Patel, Prabhat Jha, Vinod K Paul, A K Shiva Kumar
it Dandona, for The Lancet India Group for Universal Healthcare; Towards
ievement of universal health care in India by 2020: a call to action;
cet 2011; 377: 760–68

50. References
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51. 11. Office of Registrar General, India. Sample Registration System.
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52. Thank you
Any questions please…………