DR.SIVA.P.M

JUNIOR RESIDENT

DEPARTMENT OF COMMUNITY MEDICINE

SYNOPSIS

• INTRODUCTION OF UHC

• THREE DIMENSIONS OF UHC

• HEALTH STATUS OF INDIA

• EVOLUTION OF UHC IN INDIA

• HIGH LEVEL EXPERT GROUP RECOMMENDATIONS

• SWOT ANALYSIS

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”

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

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

• 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

• 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

EVOLUTION OF UHC IN INDIA

Bhore Committee,

1946

Mudaliarcommittee,

1956-61

Jungalwallacommittee,

1967

Kartar Singh Committee,

1973

Shrivastavacommittee,

1975

Rural Health Scheme, 1977

Alma ata declaration,

1978

Health for all by 2000,

1980

National Health

Policy, 1983

National population

policy, 2000MDGs, 2000

National health Policy,

2002NRHM, 2005

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

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

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

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

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

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

EXPECTED OUTCOME OF UHC

UHC

Greater Equity

Improved Health

Outcomes

Efficient Accountable And Transparent Health System

Reduction Poverty

Greater Productivity

Increased Jobs

Financial Protection

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

1. Health financing and financial norms

• Increase public

expenditure on health 3.302 1.5

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2.50

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PRIVATE PUBLIC

• 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

• 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

• 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

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.,

• 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

• 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

• PHC level

• First level access to Allopathic doctor

• Minimum 6 functional beds

• 24 electricity, telephone, internet connection, computers

• 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

• 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

• District health knowledge institute (DHKI)

• BRHC college

• Nursing school

• Training

• ANM, CHW, Staff Nurse, BRHC

• 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

• 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

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

• 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

• 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

• 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

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

• 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

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

• 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

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

• 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

• Ensure strong linkages and synergies between management and

regulatory reforms

• Establish financial and budgeting systems to streamline fund flow

• Transparent performance based

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)

• 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

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

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.

• OPPRTUNITY

• Job opportunity

• Improvement in health indicators

• Ground level evaluation and research helps to improve

programme thereby health care delivery

• IT field

• THREATS

• High political commitment needed

• If the programme fails- huge economic loss

• Private hospitals misuse the programme fund