1. PRESENTED BY : DR SABA GUIDED BY : DR HEMANT KUMAR 1
2. 2
3. UNIVERSAL HEALTH COVERAGE Also called as* Universal Coverage
Social Health Protection Universal Health Access Universal Health
Protection 3 *The world health report: health systems financing:
the path to universal coverage-2010
4. THE CONCEPT Universal health coverage as a concept was born
in 1883 when Germany introduced health coverage for achieving
health status of its young population. Later, in 2005, World Health
Assembly adopted the term "UHC" and in 2010, World Health Report
focused on health systems financing for countries to build a
platform for UHC 4*HLEG
5. UHC is considered as a standalone measure for a country; as
conceptualized today and attempts to provide promotive, preventive,
diagnostic, curative and rehabilitative services without financial
hardships to its citizens. The world health report: health systems
financing: the path to universal coverage-2010 5 The world health
report: health systems financing: the path to universal
coverage-2010
6. DEFINITION: Universal coverage (UC), or universal health
coverage (UHC), is defined as Ensuring that all people have access
to needed promotive, preventive, curative and rehabilitative health
services, of sufficient quality to be effective, while also
ensuring that the use of these services does not expose the user to
financial hardship. 6 http://www.worldhealthsummit.org- 2013
7. This definition of UC embodies three related objectives: 1.
Equity in access to health services - those who need the services
should get them, not only those who can pay for them; 2. that the
quality of health services is good enough to improve the health of
those receiving services; and 3. financial-risk protection -
ensuring that the cost of using care does not put people at risk of
financial hardship. 7http://www.worldhealthsummit.org -2013
8. 8 *The world health report: health systems financing: the
path to universal coverage-2010
9. Contd The global aspiration to achieve UHC is evident as
countries having gross domestic product (GDP) less than that of
India have embarked upon and adopted the concept. China, Sri Lanka
and Bangladesh have also adopted UHC and aim to achieve 100%
coverage in times to come. 9
10. GLOBAL HEALTH SCENARIO AND LEAD TO UHC 1948 Universal
Declaration of Human Rights states: Everyone has the right to a
standard of living adequate for the health and wellbeing of himself
and of his family, including food, clothing, housing and medical
care and necessary social services. 10
11. Contd..... In 1966, member states of the International
Covenant on Economic, Social and Cultural Rights recognised: the
right of everyone to the enjoyment of the highest attainable
standard of physical and mental health. 11
http://www.refworld.org/docid/3ae6b36c0.html
12. Contd... In 1978, Alma-Ata Declaration signatories, noted
that Health for All would contribute both to a better quality of
life and also to global peace and security. 12
13. Contd... 100 million people are pushed into poverty because
of direct health payments.* 79 countries devote less than 10% of
general government expenditure to health* Health also frequently
becomes a political issue as governments try to meet peoples
expectations 13*http://www.who.int/healthsystems/en/ Jun 2015
14. a. Member States of WHO committed in 2005 to develop their
health financing systems so that all people have access to health
services and do not suffer financial hardship paying for them. b.
This goal was defined as universal coverage, or universal health
14
15. The 2010 World Health Report builds upon the 2005 WHA
recommendations and aims at assisting countries in quickly moving
towards Universal Health Coverage. 15
16. 16
17. India, is still attempting to find a way for providing
appropriate, affordable and accessible health care to its
population. India was among the first countries in the world that
enshrined in its constitution the "socialist model of health care
for all, being a "Welfare state". 17
18. The Bhore Committee suggested the norms at the time of
Independence for implementing this philosophy but till date India
has been struggling to achieve "health care for all". Some progress
was made but the enormity of the task presents huge challenges for
the public health system across the country. 18
19. WHY IS HEALTH SYSTEM REFORM NEEDED IN INDIA 19 18% of all
episodes in rural areas and 10% in urban areas received no health
care at all*. 28% of rural residents and 20% of urban residents had
no funds for health care*. Over 40% of hospitalized persons have to
borrow money or sell assets to pay for their care *.
*http://www.frontierweekly.com/articles/vol-46/46-51/46-
51-Health%20Coverage.html
20. Over 35% of hospitalized persons fall below the poverty
line because of hospital expenses* . Over 2.2% of the population
may be impoverished because of hospital expenses*. The majority of
the citizens who did not access the health system were from the
lowest income quintiles. 20
*http://www.frontierweekly.com/articles/vol-46/46-51/46-
51-Health%20Coverage.html
21. India has Highest number of malnourished and underweight
(46% under 3 yrs); children in the world* Has high IMR of 50 per
1000 live births and MMR of 212 per 100 000 live births.* Has huge
challenge to meet national(MDG) goals of 28 per 1000 , (IMR) and
100 per 100 000 (MMR) by 2015. Immunization coverage is dismal >
44%* 21UHC: DR SABA Source: World Health Organization (2011)
22. KEY HEALTH INDICATORS: INDIA COMPARED WITH OTHER COUNTRIES
Indicator India China Brazil Sri Lanka Thailand IMR/1000
live-births 50 17 17 13 12 Under-5 mortality 66 19 21 16 13 Fully
immunized (%) 66 95 99 99 98 Birth by SBA 47 96 98 97 99 (SKILLED
BIRTH ATTENDANT) 22 Source: World Health Organization (2011)
23. Contd.... Rising burden of NCDs 2011 (in Millions) 2030 (in
Millions) Diabetes 61 84 Hypertension 130 240 Tobacco Deaths 1+ 2+
23 Source: World Health Organization (2011)
24. Health situation is not uniform across India.18 year
difference in life expectancy between Madhya Pradesh (56 years) and
Kerala (74 years) A girl born in rural Madhya Pradesh, the risk of
dying before age 1 is around 6 times higher than that for a girl
born in rural Tamil Nadu 24
http://www.who.int/countryfocus/cooperation_str
ategy/ccs_ind_en.pdf
25. Health expenditure is largely out of pocket (OOP) 67%.
Public expenditure on Health 1.2% of GDP. Lack of an efficient and
accountable public health sector has led to the burgeoning of a
highly variable private sector. 25HLEG-2011
26. LOW PRIORITY TO PUBLIC SPENDING ON HEALTH INDIA AND OTHER
COUNTRIES : 2009 26 Total public spending as % GDP (fiscal
capacity) Public spending on health as % of total public spending
Public spending on health as % of GDP India 33.6 4.1 1.2 Sri Lanka
24.5 7.3 1.8 China 22.3 10.3 2.3 Thailand 23.3 14.0 3.3
http://uhc-india.org/reports/hleg_report_chapter_2.pdf
27. National programs like National Rural Health Mission
(NRHM), Rashtriya Swasthya Bima Yojana (RSBY), Janani Suraksha
Yojana (JSY), etc. have been running in the country, but they
themselves are insufficient to provide and sustain UHC for the
nation at large. 27
28. With demographic transition, rise in burden of NCDs is
another major area of concern. Dual burden of diseases in the
country poses huge economic losses. An emerging economy like India
cannot afford such losses. Therefore, urgent actions are required
to the reframe existing infrastructure and in a way to developments
provide UHC to the country. 28
29. High Level Expert Group (HLEG) on Universal Health Coverage
(UHC) 29
30. Keeping in view the urgent requirement for UHC , Planning
Commission of India in October 2010,constituted a High Level Expert
Group (HLEG) on Universal Health Coverage (UHC):- to develop a
framework for providing easily accessible and affordable health
care to all. review the experience of Indias health sector and
suggest a 10-year strategy going forward 30
31. 1. Develop a blue print for human resource requirements to
achieve health for all by 2020. 2. Rework the financial norms
needed to ensure quality, universal access of health care services,
particularly in under-served areas and to indicate the relative
role of private and public service providers in this context. 3.
Suggest critical management reforms in order to improve efficiency,
effectiveness and accountability of the health delivery 31
32. 4. Develop guidelines for the participation of communities,
local elected bodies, NGOs, the private or- profit and
not-for-profit sector in the delivery of health care. 5. Propose
reforms in policies related to the production, import, pricing,
distribution and regulation of essential drugs, vaccines and other
essential health care related items, for enhancing their
availability and reducing cost . 32
33. Contd.. 6. Explore the role of health insurance system that
offers universal access to health services with high subsidy for
the poor and a scope for building up additional levels of
protection on a payment basis. 33
34. EVOLUTION OF THE REPORT Phase 1: An initial progress review
presented to the Planning Commission at the end of January 2011.
Phase 2: Interim recommendations developed by the HLEG at the end
of April 2011. Phase 3: The final framework on achieving Universal
Health Coverage for India was submitted on the 21st of October,
2011 34
35. DEFINITION OF UNIVERSAL HEALTH COVERAGE (UHC) BY HLEG
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. 35
36. GUIDING PRINCIPLES FOR UHC 1. Universality 2. Equity 3.
Non-exclusion and non-discrimination 4. Comprehensive care that is
rational and of good quality 5. Financial protection 36
37. 6. Protection of patients rights that guarantee
appropriateness of care, patient choice, portability and continuity
of care. 7. Consolidated and strengthened public health
provisioning. 8. Accountability and transparency. 9. Community
participation & 10. Putting health in peoples hands 37
38. UHC : FOCUS AREAS 38 1.Human Resource Requirements 2.Access
to Health Care Services 3.Management Reforms 4.Community
Participation 5.Access to Medicines 6.Health care Financing
7.Social Determinants of Health
39. ADDITIONAL FOCUS AREAS 39 8. Urban health 9. Female Gender
10. Public-Private Partnerships 11. Information Technology-enabled
Health services
40. 40 THE VISION
41. 41 Universal health entitlement for every citizen - to a
national health package (NHP) of essential primary, secondary &
tertiary health care services funded by the government. * Package
to be defined periodically by an Expert Group; can have state
specific variations
42. VISION OF HLEG FOR UHC IT-enabled National Health
Entitlement Card (NHEC) 42
43. EXPECTED OUTCOMES FROM UHC 43
44. PROVISIONING OF UHC 44 Strengthen Public Services
(Especially: Primary HealthCare- Rural And Urban; District
Hospitals) Contract Private Providers (As Per Need And
Availability) With Defined Deliverables Integrate primary,
secondary and tertiary Care through Network of Providers (Public;
Private; Public- Private) Regulate and Monitor For Quality, Cost
And Health Outcomes
45. PRE-REQUISITES To achieve UHC, three basic prerequisites
are of paramount importance. Firstly, sufficient resources are
needed to cater for the health service requirements. Secondly, we
need to reduce the financial risks and barriers which obstruct the
optimal usage of available resources . Thirdly, we need to focus on
increasing the capability of the population to effectively utilize
the available resources. 45HLEG-2011
46. Acknowledging the potential of non-public sector in
achieving UHC. HLEG recognizes that only public sector cannot aim
to achieve UHC. Representation from private sector is also required
to provide services. These services can be provided through two
options. 46HLEG-2011
47. In the first option, all those private providers who enroll
themselves under UHC will provide minimum 75% of outpatient
department services and 50% of in-patient services to those
entitled under NHP. The services will be cashless and the provider
will be reimbursed at standardized rates. For remaining portion of
services available, the institutions could accept payments or
provide services through privately purchased insurance policies.
47HLEG-2011
48. In the second option, institutions enrolled under UHC will
provide only those services, which are available under NHP. There
are pros and cons of both the options. Rigorous monitoring and
supervision will be required for smooth functioning of any of the
options. 48HLEG-2011
49. However, HLEG envisages that over time, every citizen will
be issued an IT enabled National Health Entitlement Card (NHEC)
This will lead to greater equity, improved health, efficient and
transparent health system and further reduction in poverty, greater
productivity and financial 49HLEG-2011
50. 50 HEALTH FINANCING AND FINANCIAL PROTECTION
51. Health finance is the backbone of a self-sustaining health
care system. The per capita health expenditure of our country is
far less than that of Sri Lanka and China and is around a third of
that in Thailand. As a consequence, per capita OOP expenditure in
the country has escalated to 67% of total expenditure on health.
51HLEG-2011
52. Inequity among states as far as public spending on health
(Kerala stands at Rs. 498 when compared to Rs. 163 in Bihar)
further suggests an urgent need for substantial changes in current
health care system. To streamline the health care system, we need
to move from the concept of insurance to assurance.
52HLEG-2011
53. HEALTH FINANCING AND FINANCIAL PROTECTION BY HLEG 53
54. 1:Central government and states should increase public
expenditures on health from the current level of 1.2% of GDP to at
least 2.5% by the end of the 12th plan, and to at least 3% of GDP
by 2022 54
55. Projected Sharing of Health Expenditure by Public and
Private 55
56. 2: Ensure availability of free essential medicines by
increasing public spending on drug procurement. 3: Use general
taxation as the principal source of health care financing
complemented by additional mandatory deductions from salaried
individuals and tax payers, either as a proportion of taxable
income or as a proportion of salary. 56
57. 4:Do not levy sector specific taxes for financing. 5:Do not
levy fees of any kind for use of health care services under the
UHC. 6:Introduce specific purpose transfers to equalize the levels
of per capita public 57
58. 7: Accept flexible and differential norms for allocating
finances so that states can respond better to their needs. 8:
Expenditures on primary health care, should account for at least
70% of all health care expenditures. 58
59. 9:Do not use insurance companies or any other independent
agents to purchase health care services . 10: Purchases of all
health care services under the UHC system should be undertaken
directly by the Central or state governments . 59
60. 11:All government funded insurance schemes should, be
integrated with the UHC system. All health insurance cards should,
in due course, be replaced by National Health Entitlement Cards.
The technical capacities developed by the Ministry of Labour for
the RSBY should be transferred to the Ministry of Health and Family
Welfare. 60
61. HEALTH SERVICE NORMS Recommendations 61
62. 1:Develop a National Health Package that offers every
citizen, essential health services at different levels of the
health care delivery system. 2.Develop effective contracting-in
guidelines with adequate checks and balances for the provision of
health care by the formal private sector. 62
63. 3:Re-orient health care provision to focus significantly on
primary health care. 4: Strengthen District Hospitals. 5: Ensure
equitable access to functional beds for guaranteeing secondary and
tertiary care. 63
64. 6:Ensure adherence to quality assurance standards in the
provision of health care at all levels . 7: Ensure equitable access
to health facilities in urban areas by rationalizing services and
focusing particularly on the health needs of the urban poor.
64
65. HEALTH SERVICE NORMS 65
66. ACCESS TO MEDICINES, VACCINES AND TECHNOLOGY 66
67. Millions of Indian households have no access to medicines
as they can neither afford them nor are these available at
government health facilities. Almost 74% of private out-of- pocket
expenditures today are on drugs. Drug prices have risen sharply in
recent decades. Indias domestic generic industry is at risk of
takeover by multinational companies. 67
http://www.searo.who.int/publications/journals/seajph/is
sues/seajphv3n3p289.pdf
68. The market is flooded by irrational, non- essential, and
even hazardous drugs that compromise health. Despite available
expertise and technology, health care system has been facing a huge
challenge of providing essential medicines and vaccines to those
who require it. 68
69. Generic drug industry in India provides lifesaving
medicines to many countries but at the same time has been
struggling to increase access in our country. This has resulted
largely from lack of reliable drug supply systems, irrational
prescriptions, stringent product patent regimes as well as limited
availability of public health facilities
69www.who.int/whr/en/report04_en.pdf
70. RECOMMENDATIONS 1:Enforce price controls and price
regulation especially on essential drugs. 2:Revise and expand the
Essential Drugs List. 3:Strengthen the public sector to protect the
capacity of domestic drug and vaccines industry to meet national
needs. 70
71. 5: Set up national and state drug supply logistics
corporations. 6:Protect the safeguards provided by the Indian
patents law and the TRIPS Agreement against the countrys ability to
produce essential drugs. 7:Empower the Ministry of Health and
Family Welfare to strengthen the drug regulatory system. 71
72. 8.Central procurement with decentralized distribution has
to be followed. Tamil Nadu model has proven its success and the
same needs to be replicated on a large scale. 72
73. 73
74. Required HRH were recommended by Bhore committee in 1948 up
to recent formulation of Indian Public Health Standards in 2010.
The country holds largest number of medical colleges than anywhere
in the world. Despite this, the country faces acute shortage of
HRH. 74
75. In contrast to WHO recommendation of 25 health workers per
10,000 population, India stands at 52nd rank with 19 health workers
per 10,000 population. The distribution of medical colleges is
skewed with Kerala and Bihar as extreme examples. 75
76. In addition, the training of health workforce doesnt
address the challenges of changing dynamics of public health. This
is apparent form the fact that the time allotted to Community
Medicine during internship has been reduced from 3 months 76
77. Launch of NRHM in 2005 gave a boost to the HRH with
creation of 8 lakhs ASHAs with a target of 1/1000 population. But,
availability of qualified practitioners is lacking with gross
shortage of doctors and nurses . 77
78. HLEG RECOMMENDATIONS on HRH 78
79. There are two implications of the recommendations:- 1. It
will result in a more equitable distribution of human resources 2.
can potentially generate around 4 million new jobs (including over
a million community health workers) over the next ten years 79
80. 1:Increase HRH density to achieve WHO norms of at least 23
health workers per 10,000 population (doctors, nurses, and
midwives). 2.Establish a dedicated training system for Community
Health Workers under the aegis of District Health Knowledge
Institutes(DHKIs) 80
81. 7:Establish State Health Science Universities to award
degrees in health sciences and prospectively add faculties of
health management, economics, social sciences and information
systems. 8:Establish the National Council for Human Resources in
Health (NCHRH) to prescribe, monitor and promote standards of
health professional education. 81
82. Health Service Management and Institutional Reforms 82
83. Structural and functional improvements are prerequisites
for achieving UHC in any country. With the dismal state of key
health indicators, there is a need to regulate the vast private
sector existing in the country. 83
84. There is a need to provide adequate hospital beds. As per
World Health Statistics, Indias hospital bed capacity has remained
among the lowest in the world at 0.9 beds/1000 population against
average of 2.9 beds/1000 population globally.
84planningcommission.nic.in/reports/genrep/rep_uhc2111.
85. HOSPITAL BED CAPACITY, BY COUNTRY
85www.who.int/whosis/whostat/2011/en
86. 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 86 MANAGERIAL REFORMS
HLEG 2011
87. INSTITUTIONAL REFORMS Establish financing and budgeting
systems to streamline fund flow: by establishment of National Drug
Regulatory Authority (NDRDA) & National Health Promotion and
Protection Trust (NHPPT). 87HLEG 2011
88. a. National Drug Regulatory Authority (NDRDA): The main aim
of NDRDA would be to regulate pharmaceuticals and medical devices
and provide patients access to safe and cost effective products.
b.National Health Promotion and Protection Trust (NHPPT): It will
promote public awareness about key health issues, track progress
and impact on the social determinants of health, and provide
technical expert advice to the Ministry of Health 88HLEG 2011
89. Community Participation & Citizen Engagement 89
90. Primary health care without community participation is
incomplete. For UHC, citizen engagement needs scaling up for better
delivery of resources. ASHAs have proved their worth under NRHM.
NRHM has shown a positive effect on mobilization of community
through civil society organizations and Panchayati Raj Institution
(PRIs). 90 ASHA WORKER HLEG 2011
91. However, Village Health and Sanitation Committees and Rogi
Kalyan Samitis have achieved limited success. In addition, lack of
knowledge of available health services hampers their optimal usage
by the population. 91HLEG 2011
92. Transformation of existing village health committees into
participatory health councils is required to be done. 92
93. Social Determinants of Health 93
94. UHC cannot be achieved until we address social determinants
of health. The status of social determinants including nutrition,
water and sanitation, work security, occupational health,
disasters, etc. remains abysmal .
94www.who.int/contracting/UHC_Country_Support.pdf
95. RECOMMENDATIONS 1. Initiatives, both public and private, on
the social determinants of health and towards greater health equity
should be supported 2.A dedicated Social Determinants Committee
should be set up at the district, state and national level 3.
Include Social Determinants of Health in the mandate of the
National Health Promotion and Protection Trust (NHPPT) 4.Develop
and implement a Comprehensive National Health Equity Surveillance
Framework, as recommended by the CSDH 95HLEG 2011
96. 96
97. 1: Improve access to health services for women, girls and
other vulnerable genders (going beyond maternal and child health).
2:Recognize and strengthen womens central role in health care
provision in both the formal health system and in the home. 97HLEG
2011
98. 3.Build up the capacity of the health system to recognize,
measure, monitor and address gender concerns through improved
monitoring . 4: Support and empower girls, women and other
vulnerable genders to realize their health rights. 98HLEG 2011
99. THE CHALLENGES 99
100. Broad agreement on the financing model for health-care
delivery. Type and duration of training for senior functionaries in
public health,. 100 Challenge in fulfilling the objectives of
achieving UHC by 2022 :
101. Entitlement package and the cost of health-care
interventions. Enactment of National Health Bill 2009 as Health Act
and declining State budget allocations for public health. 101
102. Enrolling profit making big pharmacy companies and private
health care providers under UHC will face a huge opposition from
them . 102
103. Further, enforcement and acceptance of Standard Treatment
Guidelines (STGs) to vast private lobby remains a big challenge
103
104. The HLEG recommends having a NHP. This will be through a
nationwide distribution of NHEC. A difficult challenge as on
December 2014, only 14.1% of Indians have been issued PAN cards .
104http://www.incometaxindia.gov.in/PAN/Overview.
105. Looking toward reimbursement to the contracted-in private
hospitals the issue itself will face a lot of resistance. As
happened with JSY, timely reimbursement of even Rs. 1400 for
beneficiaries was a challenging issue. 105
106. REASONS FOR HOPE 106
107. The governments has much higher capacities to spend on
health and Political commitment seems evident from the fact that
Prime Minister of India, on the eve of Independence day i.e. 15 Aug
2014 deaclred health as Utmost Priority. 107
108. The Planning Commission has acknowledged the same and
recently assured an increase in public health spending to 2% of GDP
from current 1.2% by end of 12th 5 years plan 108
109. Global experience has shown that Universal Health-Care is
affordable and feasible. Further, Clinical Establishments
(Registration Regulation) Act 2010, Fundamental Right to Education
Act -2009 and Food Security Act- 2013 will help in reducing the
burden of illiteracy, poverty , unemployment and disease . 109
110. CRITICAL ANALYSIS OF UNIVERSAL HEALTH COVERAGE People may
not value free services. Tax payers maybe unwilling to pay extra
taxes for the benefit of those who cannot afford. Services beyond
the scope of the NHP will have to be borne by the individuals.
Quality of services to those paying and to the non-paying may
differ. State specific recommendations have not been laid out.
110
111. 111
112. The Indian people deserve, desire and demand an efficient
and equitable health system which can provide UHC. This needs
sustained financial support, strong political will and dedication
of public health functionaries and other stake holders as well as
active participation of the community . 112
113. UHC is the way to move beyond health care. It is the way
for providing health assurance to the countrys population.
Challenges are ahead but consistent efforts can achieve the goal of
UHC. 113
114. 114
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