The slides are a point of statement on the feasibility of Universal health coverage. It talks about what is UHC and can it be sustained by India over time

1. IS UNIVERSAL HEALTH COVERAGE
SUSTAINABLE?
Dr Nishant Kumar
Assistant Professor
Department of Community Medicine
Madhubani Medical College , Madhubani ,
Bihar
SUSTAINABLE DEVELOPMENT GOALS &
UNIVERSAL HEALTH COVERAGE –
UNDERSTANDING ECONOMIC, SOCIAL AND
POLITICAL SUSTAINABILITY

2. Universal Health Coverage
(UHC)
•Universal coverage is access to key promotive, preventive,
curative, and rehabilitative health interventions for all at an
affordable cost, thereby achieving equity in access.
•The principle of financial risk protection ensures that the
cost of care does not put people at risk of financial
catastrophe.
•A stated objective of health –financing policy is equity in
funding: household contributes to the health system by the
ability to pay.

3. UHC – Principles
Access to care
or insurance
Coverage
Packages of
Service's
Rights – based
approach of
UHC
Social and
economic risk
protection

4. Sustainable Development
Goals (SDG)
1.No Poverty 2. Zero Hunger
3. Good Health
and Well -being
4.Quality
Education
5. Gender Equality
6. Clean Water
and Sanitation
7. Affordable
Clean Energy
8 Decent Work
and Economic
Growth
9 .Industry ,
Innovation , and
Infra structure
10. Reduced
Inequalities
11. Sustainable
Cities
12. Responsible
consumption and
Production
13. Climate Action
14 Life below
water 15. Life on Land
16. Peace and
Justice
17. Partnership for
the Goal

5. Health Targets of SDG
•Target 3.8 : Achieve universal health coverage ,
including financial risk protection , access to quality
essential health –care services, medicine and vaccine
for all.

6. Why Health is so important
?
Health
End
Poverty (1)
End
Hunger (2)
Inclusive
and Equity
education
(4)
Gender
Equality
(5)
Water
Sanitation
(6)
Promote
peace and
inclusive
society (16)

7. Sustaining UHC
Political
Economical
Social

8. Economical Sustainability
• It signify the amount of GDP a nation can afford to allocate
for the healthcare of its citizen.
• The competence over time of the health care workforce.
• Chatman house report suggest that a country needs to
spend 5% on it GDP on health, to achieve a target of US $
86 on health per capita.
• Governments should target an out of pocket expenditure
less than 20% of the total health spending.

9. How to be economically
sustainable ?
Extend to
non-covered
Include other
services
Reduce Cost Sharing
Population : who is covered ?
Services : which
services are
covered?
Current pool
Source : The world health report 2008 : Primary health care –now more than ever , Geneva , World Health
Organization

10. Economical
Sustainable
UHC
Increase
Public
Funding
Increase
Resources
Efficiency
Partnership
9 .Industry ,
Innovation , and
Infra structure
17.
Partnership
for the Goal
8.Decent Work
and Economic
Growth
1.No
Poverty
2. Zero
Hunger
3. Good
Health and
Well -being

11. Social Sustainability
•The term socially sustainable is to incorporate equality,
diversity, democracy, and interconnectedness.
•The social determinants of health are the circumstances in
which an individual is born, grows, live, work and age.
•Universal health coverage is vital and with its introduction
discrepancy in service utilization and access across
socioeconomic class reduces but health status gradient does
not completely disappear.

12. Challenges for Social
Sustainability?
•Assuring diversity for all will require accepting and
respecting the source of diversity in the societies they
serve including gender, race and age.
•A truly socially sustainable health system should be
democratic and based on high degree of participation
of the member of the society.

13. Benefits of Socially Sustainable
UHC
Sense of solidarity
Interconnectedness
Sense of exclusion,
Vulnerability
Distrust of public
institutions
10. Reduced
Inequalities
5. Gender
Equality
16. Peace and
Justice

14. Political Sustainability
•It is associated with the development and
maintenance of political resolve, which is essential for
sustaining major policy direction in the health care
system.
•It also implies how much the affluent population in
society are willing to pay (in taxes or community-
related health insurance plan) to fund the health of
impoverished.
•It is the result of a nation social ethics, which is a
product of its history, culture and education.

15. Cultural Theory of
Governance and
Management
Fatalist Hierarchist
Individualist Egalitarian
Grid
Group
High
Low High
Low
Source : The Art of the State : Culture, Rhetoric, and Public Management, Hood C .1998

16. Political Sustainability
Challenges
Lack of diversity, autonomy
Lack of trust on professional,
implementation difficulty
Not eager to share resources
Pessimistic outlook
Hierarchist
Egalitarian
Individualist
Fatalist

17. Benefits of Political
Sustainability
Efficient &
responsible
to its citizen
Empowerment
Participation
of citizen
Easily Attain
UHC
Sustainable
UHC
6. Clean
Water and
Sanitation
4.Quality
Education
7. Affordable
Clean
Energy
10. Reduced
Inequalities
16. Peace
and Justice

18. Indian Scenario
Disease
burden
• 20% of the global burden of disease in 2013
(1).
Children
• 27% of all neonatal death and 21 % of the under 5
children death in the world.
• Diarrhoea, pneumonia, preterm birth
complication, birth asphyxia and neonatal sepsis
account for 68% of all death in children under
five.(2)
Nutrition
• 38.7% of children under five have chronic
malnutrition, and 29.4% are underweight (3)
• Six percentage of women are severely
undernourished which is highest among the low
and middle-income countries (4)

19. Communicable
Diseases
• Leading cause of death from communicable
diseases are tuberculosis, lower respiratory tract
infection, diarrhoeal diseases, malaria and typhoid
fever.
Non-
Communicable
Diseases
• 52% burden of all diseases and accounts for 60% of
all death.(1)
• Nearly 65 million Indian are diabetic.(5)
• Average age of heart attack is 50 year, which is less
than 10-year compared to world average (6)it will
cause a loss of 16 million productive life year in 35-
64 in age group.(7)
• The suicide rate in India is one of the highest and
one of the leading cause of death among young
adults.(8)
Indian Scenario (contd.)

20. Indian Scenario (contd.)
• Low public spending as a percentage of GDP(1.2%)
• Very high out of pocket expenditure (65%) .
• 76% of expenditure in on outpatient services Vs 24% in- patient
services ; 72% on purchase of drugs which , pushing 40 million into
poverty every year.
• Central government contributes 0.30% of GDP and the States
contribute the rest.
• 25% of population is under medical insurance

21. India’s Economic Challenges
Resources
• Small Direct Tax Base (7%)
• Poor GDP to tax Ratio.(16.6%)
Manpower
• Short fall of Doctor by 49.1%
• Nurses and midwifery by 177.5%
• Inequitable distribution of human resource
• Large unregulated private sector
Infrastructure
• One hospital bed for 1833 person
• Inequitable distribution. (614 vs 8789)
• Short fall by 20% of health sub center,22%by
PHC, 32% for CHC
• 60% have no ICU at district hospital
Efficiency
• Ineffective stewardship , fragmented health
system.
• High corruption and poor accountability.

22. India Social Challenges
Diversity
• Large diverse
population.
• Meeting
Aspiration of
all.
• Values ,norms
relationship
• One size fit
all
Democracy
• Increasing
patients
participatio
n
• Mechanism
Interconnectedness
• Size
• Barrier
• Privacy

23. Indian Political Challenges
•Health is a state subject
•Almost one third of funding is from center.
•Weak State Center co-ordination
•Inequitable spending among states.

24. Indian States Indicator
4213
961
323
1959
33% 12% 9% 82%22 12 42 32
67%
83%
42%
49%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
0
500
1000
1500
2000
2500
3000
3500
4000
4500
Sikkim Kerala Bihar ArunachalP
Public Spending in Health (INR) % of Registed allopatic Doctors in Public Sector
IMR Social Determinants (% of women who are liiterate
Social Determinant – Input – Process - Output

25. Way Forward
Political
Political
stewardship
Prioritize Health
Build Partnership
Social
Address social
Determinants
Equity
Address Diversity
Democracy
Economical
Increase Public
Expenditure and
Resources
Improve
Manpower,
Infrastructure,
Efficiency
Insurance

26. Pradhan Mantari Swasthya
Suraksha Yogna(PMSSY)
989
1273
822
1577.85
2450
3975
0 1000 2000 3000 4000 5000
2012-13
2013-14
2014-15
2015-16
2016-17
2017-18
In Crores.
Years
Source –Compiled by CBGA from Union Budget of various years

27. Pradhan Mantri Bhartiya Jan
Aushadhi Yogna (PMBJP)
1.7
15.2 16.91
35
49.75
74.65
0
10
20
30
40
50
60
70
80
2012-2013 2013-2014 2014-2015 2015-2016 2016-2017 2017-2018
FinancialYear
In crores
Source –Compiled by CBGA from Union Budget of various years

28. Percentage of GDP on NHM
0.18 0.17
0.16
0.15 0.15
0.16
0
0.02
0.04
0.06
0.08
0.1
0.12
0.14
0.16
0.18
2012-2013 2013-2014 2014-2015 2015-2016 2016-2017 2017-2018
%ofGDP
Years
Source –Compiled by CBGA from Union Budget of various years

29. Total Health Expenditure as % of
GDP
0.28 0.27 0.26 0.26 0.27
0.3
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
2012-2013 2013-2014 2014-2015 2015-2016 2016-2017 2017-2018
%OfGDP
Years

30. Summary(World)
• Universal Health coverage is essential for growth of any nation
and investment in health will enhance human productivity
• UHC is key to attaining health related goals of SDG and other
important Goals
• Sustainable UHC should be Economic , Social and Political
sustainable.
• Achieving all the three components will be challenging
• Every nation has to formulate their own strategy and also learn
form each other experiences.

31. •India’s challenge will be to achieve a truly sustainable UHC as
it hold key to its demographic dividend
•Health should be focus of the government (through increase
public spending, efficient management of resources)
•Build health cadre which can provide leadership to lead the
nation into to an era to sustainable UHC.
•The goal should be to address not only the economic but the
social determinants of health.
Summary( India)

32. “ Life is full of
suffering,
Strife on
Diligently”

33. Thank
you.

34. Bibliography
1. GBD 2013 Mortality and Causes of Death Collaborators. Global and regional and national age-sex specific all-cause
and cause -specific mortality from 240 cause of death ,1990-2013: A systematic cause analysis for global Burden of
disease Study. Lancet. 2015; 385(117-71).
2. Liu L, Oza S, Hogan , et. a. Global, regional and national cause of child mortality in 200-13 with projection to inform
post -2015 priorities: an updated systematic analysis. Lancet. 2015; 385(430-40).
3. Ministry of Women and Child Development. Rapid survey on children 2013-14.India Fact sheet. New Delhi:
Government of India; 2015.
4. F R, Cor D, Slutsky A. Prevalence of body mass index lower than 16 among women in low and middle income
countries. JAMA. 2015; 314(2164-71).
5. International Diabetes association. Diabetes Atlas 6th edn. Brussels: International Diabtes Federation ; 2013.
6. Patel V, Chatterji S, Chisholm D. Chronic Disease and injuries in India. Lancet. 2011; 377(413-28)
7. S H, Leeder S, Huffman M, Jeemon P, Prabhakaran D. A race against time : the Challenges of cardiovascular
disease in developing economies 2nd edition. New delhi:, Center for Chronic Disease Control; 2014.
8. Global burden of Disease Study 2013. Global burden od Disease Study (GBD2013) Incidence , prevalance ,
and Year lived with Disabilty 1990-2013. Seattle: Instittue of Heath Metric and Evaluation (IHME); 2015.