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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
Universal health coverage   concept and vision for india

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Universal health coverage concept and vision for india

  • 1. Universal Health Coverage Concept and Vision for India Vikash Keshri
  • 2. 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.
  • 3. 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,
  • 4. • 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
  • 6. 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
  • 7. 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 •
  • 8. 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.
  • 10. 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.
  • 11. • 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.
  • 12. 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,
  • 13. 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
  • 14. 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.
  • 15. 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
  • 16. 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
  • 17. 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

Editor's Notes

  1. Universal coverage - three dimensions The path to universal coverage involves important policy choices and inevitable trade-offs. The way the pooled funds – which can come from a variety of sources, such as general government budgets, compulsory insurance contributions (payroll taxes), and household and/or employer prepayments for voluntary health insurance - are organized, used and allocated, influences greatly the direction and progress of reforms towards universal coverage. The pooled funds can be used to extend coverage to those individuals who previously were not covered, to services that previously were not covered or to reduce the direct payments needed for each service. These dimensions of coverage reflect a set of policy choices about benefits and their rationing that are among the critical decisions facing countries in their reform of health financing systems towards universal coverage. Choices need to be made about proceeding along each of the three dimensions, in many combinations, in a way that best fits their objectives as well as the financial, organizational and political contexts. Extending the coverage from pooled funds along the three dimensions calls for health financing reforms and actions leading to an increase of available funds for health, to an increase in the share of these funds collected through prepayment and the arrangements for pooling them, to efficiency gains and to upholding and increasing the quality of the health services. More on health system funding More on prepayment and pooling More on increasing health system efficiency and equity In the section on country developments, more can be learned on the technical and political choices countries have taken in order to expanded coverage along the three axes. More on country development
  2. The path to universal coverage involves important policy choices and inevitable trade-offs. The way the pooled funds – which can come from a variety of sources, such as general government budgets, compulsory insurance contributions (payroll taxes), and household and/or employer prepayments for voluntary health insurance - are organized, used and allocated, influences greatly the direction and progress of reforms towards universal coverage. The pooled funds can be used to extend coverage to those individuals who previously were not covered, to services that previously were not covered or to reduce the direct payments needed for each service. These dimensions of coverage reflect a set of policy choices about benefits and their rationing that are among the critical decisions facing countries in their reform of health financing systems towards universal coverage. Choices need to be made about proceeding along each of the three dimensions, in many combinations, in a way that best fits their objectives as well as the financial, organizational and political contexts.
  3. 2010 World Health Report builds upon the 2005 WHA recommendations and aims at assisting countries in quickly moving towards universal coverage.'5 The report highlights three basic requirements of universal health care: raising sufficient resources for health, reducing financial risks and barriers to care, and increasing efficient use of resources. '
  4. The ambit of universal health coverage will include not only the poor, but also includes those that relatively better off, so that they have an interest in building and benefiting from an efficient and equitable health system. The democratization of healthcare through UHC should enable individuals, groups and communities to improved access to healthcare services and empower them to make better health choices. Empowerment could take various forms and can be at multiple levels e.g., behaviour change to avoid risk, training of community health workers, community monitoring of health services, and demand generation for attention to local health concerns. promotive, preventive, curative and rehabilitative care at primary, secondary and tertiary levels that covers the broadest range of health conditions possible. Health care providers must be competent, and infrastructure, equipment, essential medicines, laboratory investigations, medical supplies and patient transport must be sufficiently and equitably available The benefits and continuity of coverage under UHC should be available to any person or family moving across the country. Migrant workers, those changing place of residence across states, districts or cities, beneficiaries of any health insurance programme, and those who change employers or become unemployed should be assured continuity of care Indian context, a substantial increase in tax-based public financing is required to finance UHC, given the relatively small proportion of the population employed in the formal sector.