Universal Health Coverage
Concept and Vision for India
Vikash Keshri
UHC: What?
“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”.
World Health Organization
“ 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”.
HLEG on UHC, Planning Commission.
Historical Perspectives:
• 1883 Health Insurance Bill, Germany became the first country to make
nationwide health insurance mandatory
• In U. K. Enactment of the National Insurance Act in 1911 and the
National Health Service (NHS) in 1948. which caters to all legal
residents of Great Britain.
• Article 25.1 of the 1948 Universal Declaration of Human Rights states
right to health as an important fundamental right.
• 1966, The International Convention on Economic, Social and Cultural
Rights recognized "the right of everyone to the enjoyment of the
highest attainable standard of physical and mental health.
• 1978: Alma-Ata declaration & the vision of "health for all.“
• World Health Assembly adopted the term 'Universal Health Coverage'
in 2005,
• WHO Definition: Three objectives:
 Equity in access to health services.
 Quality of health services.
 Financial-risk protection.
• WHO:
Constitution of 1948 Declaring health a fundamental human right and on
the Health for All agenda set by the Alma-Ata declaration in 1978.
Achieving the health Millennium Development Goals and the next wave
of targets looking beyond 2015 will depend largely on how countries
succeed in moving towards universal coverage
Three Dimensions for UHC
10 Facts:
1. Universal coverage ensures that all people can use health services
without financial hardship.
2. All people should have access to the health services they need.
3. Out-of-pocket payments push 100 million people into poverty every
year.
4. The most effective way to provide universal coverage is to share the
costs across the population.
5. All countries are continually seeking more funds for health care.
6. In 2010, 79 countries devoted less than 10% of government
expenditure to health.
7. Countries are finding innovative ways to raise revenue for health.
8. Only eight of the world’s 49 poorest countries have any chance of
financing a set of basic services with their own domestic resources by
2015.
9. Globally, 20–40% of resources spent on health are wasted.
10. All countries can do more in order to move towards universal
coverage
Current Scenario: A Global Movement
towards UHC
• 50 countries have attained universal or near universal
coverage
• Asia, Africa and the Middle East.
• 2010 World Health Report builds upon the 2005 WHA
recommendations:
 Highlights three basic requirements of universal
health care:
 Raising sufficient resources for health
 Reducing financial risks and barriers to care,
 Increasing efficient use of resources
•
2010 World Health Report :
Recommendations Cont……
• To generate adequate funds,
– Spurs high-income countries to "honour their commitments" to
international aid .
– low-income countries "increase the efficiency of revenue
collection, reprioritize government budgets, [and introduce]
innovative financing" to increase domestically available funds.
– financing that makes health care accessible to all.
• Subsidy to Poor.
• Compulsory contribution Alternative to free for service.
Vision for UHC: HLEG
Contextualizing UHC in INDIA.
• Considerable Progress in Public Health.
• NRHM : Many states significant development.
• Progress not as desired.
• Health system:
– Responsible for sluggish progress on key health
indicators and outcomes.
– Poor financing, governance and management.
• Health Financing: Several Forms exist but mostly OOP.
• Only 1/4th population covered by some Insurance.
• The current programmes not adequate for achieving
UHC.
• Lack of efficient public system encourages Private
system to flourish.
• Wide variations b/w states:
– Tamil Nadu and Kerala Model system
– EAG states
– Probability of dying within 1st birthday 6 times more in
M. P. compared to Kerala.
– Life expectancy in M. P. 56 compared to 74 in Kerala.
• UHC in India: Flexible approach for regions.
– Rural Vs. Urban: 43 % Malnutrition in rural Vs. 49%
Obesity in urban children.
– 42% of doctors in rural area has no formal training.
Guiding Principles:
1. Universality,
2. Equity,
1. Equity in access to services and benefits:
2. Equity ensured by special measures to ensure
coverage of sections with special needs:
3. Non-exclusion and non-discrimination,
4. Comprehensive care that is rational and of good quality,
5. Financial protection,
1. Equity in financing:
2. Cashless Financing
6. Protection
of
patients'
rights
that
guarantee
appropriateness of care,
7. Patient choice
8. Portability and continuity of care,
9. Consolidated and strengthened public health provisioning,
10. Accountability and transparency,
11. Community participation and
12. Putting health in People’s hands.
Two critical factors to achieve and sustain UHC:
• Social determinants of health and
• Gender Issues
Envisioning the Future: Seeking Stability and
Health Protection in the Midst of Multiple
Transitions
•
•
•
•
•
Demographic transition.
Epidemiological and Nutritional Transitions.
Managerial transitions
Political transition.
federal nature of India's polity
In conceptualizing a UHC system, a focus on India's
future will be crucial to ensure the implemented
system is able to exist in, make the best of and
respond to the country's changing demographic,
health, political and economic scenario.
Health Beyond Health Care: Addressing
the Broader Determinants of Health
Social Determinants of Health:
“The conditions in which people are born, grow, live, work
and age, including the health system“
2008 Report, CSDH.
Gender as a Determinant of Health
Positive Externalities of Health and
Universal Health Coverage
• Benefits of Improvement in Health of Population.
• Strengthened Primary system reduce load on secondary
and tertiary system: Economic Implications.
• Employment Opportunity : To strengthen Health
System.
Areas of Convergence and Consensus: for charting
India’s Path to UHC:
Technical, managerial and political barriers
Conclusions:
• Constitutionally committed to improve public health (Directive
Principle 42).
• Several supreme court judgments directs right to health as extension
of fundamental right.
• GOI signatory to international conventions that obligate it to ensure
the Right to Health.
• Organizing and Operationalizing Universal Health Coverage in India
is an urgent necessity.
• Evidence demonstrate that health care systems with universal
coverage address economic inequality.
• This fundamental right that can be eventually achieved only by
strengthening health services and addressing the social determinants
of health, including food security and nutrition, water supply,
sanitation and living conditions