Universal health care
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The document summarizes recommendations from the High Level Expert Group on achieving Universal Health Coverage in India. It discusses expanding health coverage to all citizens through a national health package, increasing public spending on health to 3% of GDP, strengthening primary healthcare and developing norms for facilities at each level of care. It also emphasizes improving human resources for health, community participation, and access to medicines. The overall vision is to ensure equitable access to quality health services for all Indians.
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Universal health care
- 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
Editor's Notes
- In the first option, all those private providers who enrol themselves under Universal Health Coverage will provide minimum 75% of OPD services and 50% of in-patient services to those entitled under NHP. The services will be cashless and the provider will be reimbursed at standardised rates. For remaining portion of services available, the institutions could accept payments or provide services through privately purchased insurance policies. In the second option, institutions enrolled under Universal Health Coverage will provide only those services which are available under NHP. There are pros and cons of both the options. Rigorous monitoring and supervision will be required for smooth functioning of any of the options. However, HLEG envisages that over time, every citizen will be issued an IT enabled National Health Entitlement Card (NHEC) and this will lead to greater equity, improved health, efficient and transparent health system and further reduction in poverty, greater productivity and financial protection.