Universal Health Coverage

Pradeep Salve , Ph.D.

Assistant Professor,
Department of Population & Development,
International Institute for Population Sciences.
 Universal health coverage is not a new concept;
from Ancient Egypt to the world today, most
societies have recognized the importance of
ensuring all individuals have access to quality health
care.

Brief Our understanding of UHC has been shaped by

philosophers, economists, and political scientists as
History of much as it has been by the health sector, individuals,
caregivers and communities.
UHC We have enshrined health as a human right, linked
the need for strong health systems to achieving
health equity, and built a global health architecture
that supports collaboration and mutual
accountability.
 Introduction
• WHO define Universal health coverage (UHC) means that all people have access to the full range of quality
health services they need, when and where they need them, without financial hardship.

• It continuum of essential health services, from health promotion to prevention, treatment, rehabilitation and
palliative care.

• Every country has a different path to achieving UHC and deciding what to cover based on the needs of their
people and the resources at hand.

• To make health for all a reality, all people must have access to high quality services for their health and the health
of their families and communities.

• To do so, skilled health workers providing quality, people-centred care; and policy-makers committed to
investing in universal health coverage are essential.

• Universal health coverage requires strong, people-centred primary health care.

• Good health systems is not only focus on preventing and treating disease and illness, but also on helping to
improve well-being and quality of life.
 WHO Constitution recognizes the right to health - 1946

• Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

• Enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of
race, religion, political belief, economic or social condition.

• Health of all peoples is fundamental to the attainment of peace and security and is dependent upon the fullest co-operation of
individuals and States.

• Unequal development in different countries in the promotion of health and control of disease, especially communicable disease, is a
common danger.

• Extension to all peoples of the benefits of medical, psychological and related knowledge is essential to the fullest attainment of health.

• Governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and
social measures.
Alma Ata Declaration reaffirms the need to achieve health for all - 1978

WHO member states emphasized the role of governments in protecting the right to health and the importance of Primary Health Care as a cornerstone of
health system reforms to achieve health equity.

"Governments have a responsibility for the health of their people which can be fulfilled only by the provision of adequate health and social measures.”

Abuja Declaration 2001

African Union members met in Abuja, Nigeria in 2001 and pledged to allocate more resources to health challenges, highlighting in particular HIV, malaria
and tuberculosis.

"We pledge to set a target of allocating at least 15% of our annual budget to the health sector.”

Launch of International Health Partnership 2007

IHP+ began in 2007 as an international partnership that aimed to improve effective development cooperation in health to help meet the MDGs. IHP+
included support to strong and comprehensive country and government-led national health plans in a well-coordinated way.

The World Health Report 2008 ; Primary Health Care: Now More Than Ever

Published 30 years after the Alma Ata declaration, this report reasserted the role of PHC in health systems and focused on ac hieving equity. It suggested
reforms in four core PHC principles: (a) Universal Health Coverage (b) People-Centered Services (c) Healthy Public Policies (d) Leadership.

“The fundamental step a country can take to promote health equity is to move towards universal coverage: universal access to the full range of personal
and non-personal health services they need, with social health protection.”
World Health Report on Health System Financing: The Path to UHC 2010

WHO’s World Health Report in 2010 maps out action items in three areas: (a) raising more funds for health or diversifying funding sources, (b) providing

or maintaining an adequate level of financial risk protection, (c) improving efficiency and equity in the way funds are used.

“Universal coverage requires a commitment to cover 100% of the population. Every country can do something to move closer to

universal coverage or maintain what it has achieved.”

First UN Resolution endorsing UHC 2012

When managing the transition of the health system to universal coverage, each option will need to be developed within the particular

epidemiological, economic, sociocultural, political and structural context of each country in accordance with the principle of national

ownership.

“It is essential to take into consideration the needs of vulnerable segments of society, including the poorest and marginalized segments of

the population, indigenous peoples and persons with disabilities.”

Launch of Sustainable Development Goals 2015

UN Summit adopted 17 Sustainable Development Goals (SDGs) as part of the 2030 Agenda.

SDG 3: Good Health and Well-being: Ensure healthy lives and promote well-being for all at all ages

Target 3.8: Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and
access to safe, effective, quality and affordable essential medicines and vaccines for all.

“To promote physical and mental health and well-being, and to extend life expectancy for all, we must achieve universal health coverage
and access to quality health care. No one must be left behind.”

G20 Leaders’ Declaration: Shaping an Interconnected World (Hamburg) 2017

We call on the UN to keep global health high on the political agenda and we strive for cooperative action to strengthen health systems
worldwide, including through developing the health workforce.”

First WHO Africa Health Forum 2017

Theme of “Putting People First: The Road to Universal Health Coverage in Africa”, the forum explored the priorities and chall enges of
health care systems in Africa and recommendations to achieve health for all.
First UHC Day 2017

The United Nations proclaimed 12 December as International UHC Day. The UHC brought together governments, multilateral and bilateral
institutions, academia, private sector and civil society to mobilize around the global call for UHC.

Astana Declaration on Primary Health Care 2018

To strengthen their PHC systems it includes four key areas: (1) make bold political choices for health across all sectors; (2) build sustainable
primary health care; (3) empower individuals and communities; and (4) align stakeholder support to national policies, strategies and
plans.

We find it ethically, politically, socially and economically unacceptable that inequity in health and disparities in health outcomes persist…We
envision primary health care and health services that are high quality, safe, comprehensive, integrated, accessible, availabl e and affordable
for everyone and everywhere, provided with compassion, respect and dignity by health professionals who are well -trained, skilled, motivated
and committed.

Group of Friends of UHC and Global Health launched 2018

The Group of Friends of UHC was established in December 2018 as an informal platform for UN Member States to build momentum t owards achieving UHC by 2030.
This Group contributed to the Political Declaration of the High-level Meeting on Universal Health Coverage in September 2019. The Group has 64 member countries.
UN High-Level Meeting on UHC 2019 : Political Declaration commits to achieve UHC by 2030

“Ensure that no one is left behind, with an endeavour to reach the furthest behind first, founded on the dignity of the human person
and reflecting the principles of equality and non-discrimination, as well as to empower those who are vulnerable or in vulnerable
situations and address their physical and mental health needs which are reflected in the 2030 Agenda for SGD, including all children,
youth, persons with disabilities, people living with HIV/AIDS, older persons, indigenous peoples, refugees and internally displaced
persons and migrants.”

UN Secretary-General’s policy brief on UHC and COVID-19 2020

All countries have agreed to work towards universal health coverage as part of the 2030 SGD Agenda. But, we cannot wait 10 years.
We need universal health coverage, including mental health coverage, now, to strengthen efforts against the pandemic and prepare for
future crises.”
 Launch of the Global Action Plan (GAP) 2020
Global Action Plan for Healthy Lives and Well-being for All brings together 13 multilateral health, development and
humanitarian agencies to better support countries to accelerate progress towards the health-related SDGs.

•World Health Organization

•World Food Programme
•The Global Fund to Fight AIDS, Tuberculosis & Malaria
•United Nations Development Fund
• Joint United Nations Programme on HIV/AIDS
•United Nations Population Fund
•Unitaid
•United Nations Children’s Fund
•United Nations Entity for Gender Equality & the Empowerment of Women
•Gavi, the Vaccine Alliance
•World Bank Group
•Global Financing Facility for Women, Children & Adolescents
•International Labour Organization
Launch of the Coalition of Partnerships for UHC and Global Health 2021

Coalition will work together to assist Member States and other stakeholders in: (a) Accelerating high-level political efforts around socio-
political accountability to ensure UHC delivers for vulnerable populations (b) Supporting coordination among the various existing health
initiatives and joint follow-up actions of UN for the preparation of the future UN on the health agenda (c) Strengthening existing SDG
accountability mechanisms to scale up efforts on health-related SDGs by 2023 and beyond.

UN High-Level Meeting on UHC 2023

Looking ahead to 2023, the UN High-Level Meeting on UHC will be a critical time to direct attention to UHC and reignite commitments
from countries around the world.

UHC ensures all people, everywhere, can get the quality health services they need without financial hardship. Every 12 December,
advocates worldwide mobilize on UHC Day to call for strong, equitable health systems that leave no one behind.
 1) Universal Coverage reforms; ensure that health systems contribute to

Primary Health health equity, social justice and the end of exclusion, primarily by moving
towards universal access and social health protection
Care 2) Service Delivery reforms; reorganize health services as primary care, i.e.
around people’s needs and expectations, so as to make them more
socially relevant and more responsive to the changing world while producing
better outcomes

3) Public Policy reforms; secure healthier communities, by integrating public

health actions with primary care and by pursuing healthy public
policies across sectors

4) Leadership reforms; replace disproportionate reliance on command and

control on one hand, and laissez-faire disengagement of the state on the other,
by the inclusive, participatory, negotiation-based leadership required by
the complexity of contemporary health systems .
 India adopt following definition of Universal Health Coverage (UHC)

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.

High Level Expert Group Report on Universal Health Coverage for India 2011, Government of India
 I. Universality

II. Equity

III. Non-exclusion and non-discrimination

Ten principles have
IV. Comprehensive care that is rational and of good quality
guided the formulation of V. Financial protection

our recommendations for VI. Protection of patients’ rights that

guarantee appropriateness of care, patient choice,
introducing a system of portability and continuity of care

UHC in India: VII. Consolidated and strengthened public health provisioning

VIII. Accountability and transparency

IX. Community participation; and

X. Putting health in people’s hands

High Level Expert Group Report on Universal Health Coverage for India 2011, Government of India
 Expected
Outcomes from
UHC
It is possible for India, even within the financial resources available to it, to devise an
effective architecture of health financing and financial protection that can offer UHC to
every citizen.
Committee developed specific recommendations in six critical areas that are essential
to augment the capacity of India’s health system to fulfil the vision of UHC.

1. Health Financing and Financial Protection

2. Health Service Norms
3. Human Resources for Health
4. Community Participation and Citizen Engagement
5. Access to Medicines, Vaccines and Technology
6. Management and Institutional Reforms
 Health Financing and Financial Protection
We have identified three principal objectives of the reforms in health financing and financial protection:

1 2 3
Objective 1: ensure Objective 2: provide Objective 3: put in place
adequacy of financial financial protection financing mechanisms which
resources for the provision and health security against are consistent in the long-run
of essential health care to all impoverishment for the with both the improved
entire population of the wellbeing of the population
country as well as containment of
health care cost inflation
Government (Central government and states combined)

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.

 Health Service Norms
Norms of health care need to be reconfigured to ensure quality, universal reach, and accessibility of health care
services. A panel of experts should determine the package of services taking into account the resource
availability as well as the health care needs of the country. Timely preventive, promotive, diagnostic,
curative and rehabilitative services should be provided at appropriate levels of health care delivery.

The packages should correspond to disease burdens at different levels, such that appropriate services can be
provided at different levels of care.

Level 1 packages should correspond to services that are guaranteed at the village and at the community level in
urban areas,

Level 2 packages should be offered at the Sub-Health Centre (SHC),

Level 3 packages should correspond to services guaranteed at the Primary Health Centre (PHC),

Level 4 packages should be offered at the Community Health Centre (CHC), and

Level 5 packages should cover services guaranteed at the district hospitals, medical college hospitals and other
tertiary institutions.
 Human Resources for Health

India’s health care delivery system faces multiple shortages.

The increased emphasis on primary health care as the core of the UHC system
requires appropriately trained and adequately supported practitioners and providers with relevant
expertise to be located close to people, particularly in marginalised communities.
Community health workers (CHWs): Doubling the number of community health workers (CHW’s or ASHAs)) from one per 1000 population to
two per 1000 population in rural and tribal areas.

At least one of them should be female and offered the opportunity to train as an auxiliary nurse midwife in future.

Rural health care practitioners: Introduction of a new 3-year Bachelor of Rural Health Care (BRHC) degree programme that will produce a

cadre of rural health care practitioners for recruitment and placement at SHCs.

Nursing staff: Increased availability and absorption of nurses into the UHC system will ensure that the nurse and midwife (including Auxiliary

Nurse/ Midwives [ANMs]) per allopathic doctor ratio goes up from the present level of 1.5:1 to the preferred ratio of 3:1 by 2025.

Allopathic doctors: Improvement in the country’s allopathic doctor-to-population ratio from around 0.5 per 1,000 population today to a well-

measured provision approaching one doctor per 1,000 by the end of the year 2027.

AYUSH doctors: Active engagement and participation of appropriately trained AYUSH practitioners, especially in states where there are

existing shortages of allopathic doctors.

Allied health professionals: Ensuring effective delivery of the National Health Package will require the recruitment of adequate numbers of

dentists, pharmacists, physiotherapists, technicians, and other allied health professionals at appropriate levels of health care delivery.
Village and community level: On average, two community health workers (ASHA) who should work alongside and

in partnership with Anganwadi Workers (AWW) and their sahayikas (helpers) in villages. There should also be one

similarly trained CHW for every 1000 population among low-income vulnerable urban communities.

Sub-health centre level (SHC): It would help to ensure that there are at least two ANMs and one male health

worker in every SHC as per the existing 2010 IPHS norms.

PHC level: In addition to the existing staff prescribed as per the 2010 IPHS norms, we recommend an

AYUSH pharmacist, a full-time dentist, an additional allopathic doctor and a male health worker to ensure that

primary health care needs are adequately met.

CHC level: The CHC should serve as the access point for emergency services including caesarean section

deliveries, new born care, cataract surgeries, sterilisation services, disease control programmes and dental care. For a

‘standard’ CHC, substantial increase in the number of nurses (to around 19) and the addition of a head nurse, a

physiotherapist and a male health worker.

Nursing schools and colleges: There have been some improvements since 2005, with the addition of new

nursing schools in as many as 12 states. But these are still insufficient to meet the requirements of UHC due to the

inequitable distribution of these schools. Some 149 districts in 14 high focus states do not have any nursing school

or nursing college as of 2009.

Schools for ANMs: Many Sub-Health Centres (SHCs) face shortages of ANMs. For instance, most SHCs in

Bihar and Uttar Pradesh do not have ANMs even though the mandate is to have two ANMs per SHC.

Medical colleges: The highly uneven distribution of medical colleges has resulted in the skewed production and

unequal availability of doctors across the country. There is, for instance, only one medical college for a population

of 11.5 million in Bihar and 9.5 million in Uttar Pradesh, compared to Kerala and Karnataka who have one

medical college for a population of 1.5 million.

 Community Participation and Citizen Engagement

• Transform existing Village Health Committees (or Health & Sanitation Committees) into participatory Health
Councils.

• Organize regular Health Assemblies.

• Enhance the role of elected representatives as well as Panchayati Raj institutions (in rural areas) and local bodies
(in urban areas).

• Strengthen the role of civil society and non-governmental organizations.

• Institute a formal grievance redressal mechanism at the block level.

 Access to Medicines, Vaccines and Technology

Ensuring effective and affordable access to medicines, vaccines and appropriate technologies is critical for
promoting health security.

• Almost 74% of private out-of-pocket expenditures today are on drugs;

• Millions of Indian households have no access to medicines because they cannot afford them and do not
receive them free-of- cost at government health facilities;

• Drug prices have risen sharply in recent decades;

• India’s dynamic domestic generic industry is at risk of takeover by multinational companies; and

• Market is flooded by irrational, nonessential, and even hazardous drugs that waste resources and
compromise health.
• Enforce price controls and price regulation especially on essential drugs.

• Revise and expand the Essential Drugs List.

• Strengthen the public sector to protect the capacity of domestic drug and vaccines industry
to meet national needs.

• Ensure the rational use of drugs.

• Set up national and state drug supply logistics corporations.

• Protect the safeguards provided by the Indian patents law and the TRIPS Agreement against
the country’s ability to produce essential drugs.

• Empower the Ministry of Health and Family Welfare to strengthen the drug regulatory
system.
 Management and Institutional Reforms
Effective management systems are crucial to the successful coordination of multiple
resources, diverse communities and complex processes.

Better management would also allow for effective coordination of public and private sector efforts
to ensure universal health coverage.

The public health sector needs to assume the roles of promoter, provider, contractor, regulator, and
steward.

The private sector’s role also needs to be clearly defined and regulated.

Systemic reforms must ensure effective functioning and delivery of health care services in both rural and
urban areas.

Good referal systems, better transportation, improved management of human resources, robust supply
chains and data, and upgraded facilities are essential.
• 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.

• This cadre will be responsible for all public health functions, with an aim to improve the functioning of the health system by

enhancing the efficacy, efficiency and effectiveness of health care delivery.

• Adopt better human resource practices to improve recruitment, retention motivation and performance; rationalize pay and

incentives; and assure career tracks for competency-based professional advancement.

• Develop a national health information technology network based on uniform standards to ensure inter-operability between

all health care stakeholders.

• Ensure strong linkages and synergies between management and regulatory reforms and ensure accountability to patients and

communities.

• Establish financing and budgeting systems to streamline fund flow.

Regulation of the public and the private
sectors to ensure provision of
assured quality and rational pricing of
health care services are essential for the
implementation of the UHC system.

A structured regulatory framework is

needed to monitor and enforce essential
health care regulations in order to
control entry, quality, quantity and price.
Thank you
The High Level Expert Group on Universal Health Coverage in India, after great
deliberation, has identified the following as a working definition of UHC:
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.
While discussing the principles of adopting and achieving UHC, it is imperative to
consider the right to health as the key underlying theme.
i) Universality
covering all socio-economic classes and sections of the Indian population including
the marginalised and hard-to-reach. Achieving universality will entail cross-
subsidisation, social solidarity, and effective public voice for all individuals seeking
healthcare. 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.
Universality also implies that no one, including marginalised, hard-to-reach,
mobile or traditionally discriminated groups would be excluded,
while acknowledging that the relationship between health, income and social
class not a threshold relationship but a continuous one that requires social
protection across the board.