1. DR.SIVA.P.M
JUNIOR RESIDENT
DEPARTMENT OF COMMUNITY MEDICINE

2. SYNOPSIS
• INTRODUCTION OF UHC
• THREE DIMENSIONS OF UHC
• HEALTH STATUS OF INDIA
• EVOLUTION OF UHC IN INDIA
• HIGH LEVEL EXPERT GROUP RECOMMENDATIONS
• SWOT ANALYSIS

3. INTRODUCTION
Definition of UHC
• “Ensuring equitable access for all Indian citizens
• to affordable, accountable, appropriate health services of assured
quality (promotive, preventive, curative and rehabilitative)
• 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”

4. UNIVERSAL COVERAGE
The definition of UC embodies three related objectives:
(a) Equity in access to health
(b) that the quality of health services is good enough
(c) Financial-risk protection

6. HEALTH STATUS IN INDIA
• Highest number of malnourished children in the world
• MMR – 212/ 1,00,000 live births
• Health expenditure is largely out of pocket (67%)
• Public expenditure on Health – 1.2%
• Only about one fourth of the population is covered by some form of health
insurance

7. • 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 Kerala

8. • 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 & obesity accounts for half the burden of
‘malnutrition’ in the urban areas
• Urban areas have 4 times more health workers per 10,000
population than rural areas

9. EVOLUTION OF UHC IN INDIA
Bhore
Committee,
1946
Mudaliar
committee,
1956-61
Jungalwalla
committee,
1967
Kartar Singh
Committee,
1973
Shrivastava
committee,
1975
Rural Health
Scheme, 1977
Alma ata
declaration,
1978
Health for all
by 2000,
1980
National
Health
Policy, 1983
National
population
policy, 2000
MDGs, 2000
National
health Policy,
2002
NRHM, 2005

10. HIGH LEVEL EXPERT GROUP (HLEG) ON
UNIVERSAL HEALTH COVERAGE (UHC)
• Constituted by the Planning Commission of India in October 2010
• Mandate: Developing a framework for providing easily accessible
and affordable health care to all India
• Assigned the task of reviewing the experience of India’s health
sector and suggesting a 10-year strategy going forward

11. 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

12. GUIDING PRINCIPLES FOR UHC
1. Universality
2. Equity
3. Non exclusion and non
discrimination
4. Comprehensive care
5. Financial protection
6. Protection of patient’s rights
7. Consolidated and strengthened
public health provisioning
8. Accountability and transparency
9. Community participation
10. Putting health in peoples hand

13. CRITICAL FACTORS TO ACHIEVE UHC
1. Attention to Social determinants of health
• Nutrition, food security, water sanitation, gender, caste, religion,
housing, environment, employment, occupational safety, disaster
management
2. Gender insensitivity and discrimination
• Special attention to girl/women/mother

14. VISION OF UHC
ENTITLEMENT
• Universal
health
entitlement to
every citizen
NATIONAL
HEALTH
PACKAGE
• Primary
• Secondary
• Tertiary
CHOICE OF
FACILITIES
• Public
sector
• Contracted
in private
provider

15. NATIONAL HEALTH PACKAGE
Non NHP services
On Payment/ Insurance
(Provided in same setup)
OPD services – 25%
Inpatient services – 50%
Provider Capability
Cashless Services (NHP)
OPD Services >75%
Inpatient Services > 50%
Provider Capability
Cashless Services (NHP)
OPD Services – 100%
Inpatient Services – 100%
Non NHP services
On payment/ Insurance
(Not available in same setup)
OPTION 1
INSTITUTIONS
UNDER NHP
(PUBLIC/PRIVATE)
OPTION 2

16. EXPECTED OUTCOME OF UHC
UHC
Greater
Equity
Improved
Health
Outcomes
Efficient Accountable
And Transparent
Health System
Reduction
Poverty
Greater
Productivity
Increased
Jobs
Financial
Protection

17. AREAS OF FOCUS TO FULLFIL VISION
1. Health financing and financial protection
2. Health service norms
3. Human resource for health (HRH)
4. Community participation and citizen engagement
5. Access to medicines, vaccines and technology
6. Management and institutional reforms

18. 1. Health financing and financial norms
• Increase public
expenditure on health 3.30
2 1.5
1.20
2.5 3
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
4.50
5.00
2011 2017 2022
PercentageGDP
Chart Title
PRIVATE PUBLIC

19. • Increase public spending on drug procurement
• 0.1% GDP to 0.5% GDP
• Rational prescription of quality generic drugs
• Use general taxation – principle of source
• Complemented by – mandatory deductions - proportion of
taxable income or proportion of salary
• Do not impose sector specific taxes
• Raise tax to GDP ratio - additional resources
• Widening of tax base

20. • Do not impose fees on any kind of health services
• Introduce specific purpose transfer from center
• Equitable per capita public spending
• Take away resistance to resource mobilization from center
• State has to contribute not substitute the funds from center
• Accept flexible and differential norms for allocating finances

21. • Expenditure on primary health care – >70% of health care
expenditure
• Do not use independent agent to purchase health care services on
behalf of govt.
• All govt. funded insurance system – integrate with UHC

22. 2. Health Service Norms
• Develop a National Health Package
• service at difference levels of
delivery
1
• VILLAGE LEVEL
2
• SHC
3
• PHC
4
• CHC
5
• DISTRICT HOSPITALS/MEDICAL
COLLEGES ETC.,

23. • Village level
• 2 CHWs, 1 AWW, 1 Volunteer
• Community health worker (CHW)
• Maternal and new born health
• Sexual and reproductive health and adolescent health
• Child health and nutrition for children, adolescent and women
• Communicable disease control and sanitation
• Chronic disease control
• Gender based violence prevention

24. • Subcenter level
• One fully functional bed – observation and stabilizing pregnant
women
• 1 BRHC, 2 ANM, 1 MHW, 1 Multitask worker
• Custodian of local untied funds
• Daily OP service

25. • PHC level
• First level access to Allopathic doctor
• Minimum 6 functional beds
• 24 electricity, telephone, internet connection, computers

26. • CHC level
• 24*7 functional referral centers
• Emergency obstetric care
• Paediatric specialist care, sick newborn unit
• Surgical care, trauma care
• Well equipped lab
• AYUSH services
• >30 beds by 2017 and > 100 beds by 2025

27. • District level
• Major center for health care delivery
• 90% of health care needs should met here
• Three pillars
• Clinical care
• Health human resource development
• Public health

28. • District health knowledge institute (DHKI)
• BRHC college
• Nursing school
• Training
• ANM, CHW, Staff Nurse, BRHC

29. • Develop effective contracting in guidelines – provision of health care
by private sector
• Government as purchaser and private sector as provider
• Reorient health care provision – focus on primary care
• Strengthen district hospitals
• Equitable access to functional beds – secondary and tertiary care
• Increase capacity to 2 beds per 1000 population by 2022

30. • Quality assurance at all levels of service delivery
• IPHS standard
• Creation of National Health and medical facility Accreditation Unit
(NHMFAU)
• Equitable access to health facilities in urban areas – focus on urban poor

31. 3. Human Resource For Health
• Appropriately trained and supported practitioners and providers – close to
community
• Augment and strengthen the performance of professional and technical health
workers

32. • Ensure adequate number of health care providers
• 19/10,000 to WHO norm of 23/10,000 population
• CHW – 1/1000 to 2/1000 pop ( 1- FM)
• BRHC
• Nursing staff – 90k to 1.7 mill by 2017 and 2.7 mill by 2025
• Nurse, Midwives : Doctor - 1.5 :1 to 3:1 by 2025
• Allopathy doctors – 0.5/1000 pop to 1/1000 pop by 2027
• AYUSH doctors – especially in allopathy doctor deficit areas
• Allied health professionals

33. • Enhance quality of HRH education and training – competency based
health system
• Invest in additional health institutions to produce and train health
workers
• Establish district health knowledge institutes per 500,000
population/district
• Strengthen existing state and regional institutes of family welfare
• Develop regional faculty development centers
• Coordination of induction and in-service training

34. • Training system for CHWs – 3/team in DHKI – train 300 CHWs
• Establish state health service universities
• Establish the national council for human resources in health
(NCHRH)
• Monitor and promote – standards of health professional
education

35. 4. Community Participation And Citizen
Engagement
• Transform village health and sanitation committee – participatory
health council
• Existing members + civil society organization members +
health worker
• Every 6 month - evaluation

36. • Organize regular health assemblies
• Ground level experience assessment – changes
• Enhance role of elected persons as well as PRI in (RURAL) and
local bodies (URBAN)
• Strengthen the role of civil society and NGOs
• Institute a formal grievance redressal mechanism at block level
• Develop people facilitation center – provide information to
local people

37. 5. Access To Medicines, Vaccines And
Technology
• Enforce price control and regulations
• Revise and expand essential drug list
• Strengthen public sector to protect capacity of domestic drug and
vaccines industries to meet national needs
• Ensure rational use of drugs

38. • Setup national and state drug supply logistics corporations
• Procurement of cost effective generic essential drugs
• One ware house per district
• Protect safeguards provided by Indian patent law and TRIPs
agreement
• Empower the ministry of health and family welfare to strengthen
the drug regulatory system
• Transfer the dept of pharmaceuticals from ministry of chemical
and fertilizers to MOHFW

39. 6. Management And Industrial Reforms
• MANAGERIAL REFORMS
• Introduce all India and state level public service cadres
• Public service cadre – public health service
• Management cadre – administrative responsibilities

40. • Develop a national health information technology network –
uniform standards
• Electronic medical records
• Provide epidemiological database
• Track health expenditures
• Adopt better human resource practices to improve recruitment,
retention, motivation and performance
• Rationalize pay and incentives
• Assure career tracks

42. • Ensure strong linkages and synergies between management and
regulatory reforms
• Establish financial and budgeting systems to streamline fund flow
• Transparent performance based

43. INSTITUTIONAL REFORMS
Establishment of following agencies
National health regulatory and development
authority(NHRDA)
3 units under NHRDA
•System support unit (SSU)
•National health and medical facilities accreditation
unit (NHMFAU)
•The health system evaluation unit (HSEU)

44. • National drug regulatory and development authority
(NDRDA)
• National health promotion and protection trust (NHPPT)
• Invest in health sciences research and innovation to inform
policy, programme and to develop feasible solutions

45. SWOT ANALYSIS
• STRENGTH
• Free service to all irrespective of status – poor people in need
will be benefitted
• IT involvement
• Increased human resource for health
• Improved care for the patients

46. WEAKNESS
• People may mot 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.

47. • OPPRTUNITY
• Job opportunity
• Improvement in health indicators
• Ground level evaluation and research helps to improve
programme thereby health care delivery
• IT field

48. • THREATS
• High political commitment needed
• If the programme fails- huge economic loss
• Private hospitals misuse the programme fund