Where is India on the Road to

Universal Health Coverage?

Prof. K Srinath Reddy
President, Public Health Foundation of India
DISCLAIMER: This presentation does not necessarily reflect the views of ADB or the Government concerned, and ADB and the Government cannot be held liable for its contents.

UHC In India : Not A Straight Path

2005 2007

NRHM + RSBY Provide Platform

(Improved MCH Services + Partial Financial Protection)

2010 2011

HLEG On UHC (Planning Commission)

2012

UHC In 12th Five Year Plan

2012-2014

Economic Slowdown & Food Security Act Push UHC off Radar

2014

Government Change : Promise Of National Health Assurance

2015

National Health Policy Drafted- Yet To Be Released;

Responsibility Shifts Further To States; RSBY Moves To Health

2016

Centre Takes Re-look At UHC; RSSY Proposed; Framework Discussion Still On

NRHM

NHM

RSBY

Gains

Gains

Improved MCH Services

Large Scale Enrolment

RMNCH + A
Improved Control of TB, Malaria
Improved Emergency Services
Infrastructure Strengthening
Attention to HMIS

Shortcomings
NCDs, Mental Health etc. excluded
Shortages of Human Resources:
Limit Access, Quality and Affordability
Marked Inter-State Differences;
Performance And Governance
Urban Component Yet to Take Off

Increased Access to 2o Care

Private Sector Engagement
IT Platforms Established

Shortcomings
Confined to Hospital Care
Limited / No Impact On OOPS
Regulatory Challenges + Fraud
Competition With State Programmes

Trends in Rural Infant Mortality Rates for Select Indian States:

Pre-NRHM (1998-2005) and Post-NRHM (2005-2012)

Source: SRS

Challenges of Primary Care : Human Resources

PHCs without even one doctor: 9.3%

Shortfall of Allopathic Doctors at PHCs: 11.9%

Shortfall of Physicians at CHCs: 83%
Shortfall of Obstetricians at CHCs: 76.3%
Shortfall of Paediatricians at CHCs: 82.1%
Shortfall of Surgeons: 83.4%

Govt. of India; Rural Health Statistics 2015

Primary Care Quality Score for India: 52%

Powell T et al; 2013

HRH Density Across Indian States

(Doctor, Nurse and Midwife per 10,000 Population)
Number Doctor, nurse and midwife per
10,000 population

60

WHO threshold of
22.8 per 10,000

53.9 52.6

50
40

39.9
32.4

30
20
10

30.4 30.3 29.3 29.0

27.1 25.8 25.6

23.7 23.6 20.7

18.7 17.9 17.8 17.3
13.9
9.8 9.8 9.6

7.9

6.3 5.3

Considering only doctors, nurses and midwives, HRH density comes out
Source: NSSO, 2011-12
to be 20.7 per 10,000 population

Rural Urban Distribution of Health Workforce

All health workers

36.3

Pharmacist

Physiotherapy, diagnostic and others

41.1
14.7

Nurse & midwife

58.9
85.3

33.0

Health Associates and assistants

67.0

45.3

AYUSH

54.7

35.8

Dental practitioner 3.2

pysician allopatthic
Physician
Allopathic

63.7

64.2
96.8

34.1

65.9

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0
Rural
Urban
Source: NSSO 2012-13

UHC in India
Changing Role of Centre and States
14th Finance Commission : Higher share of tax revenues to States
Central Government : States should take up more responsibility for resources, design
and delivery
NHM will continue to advance RMNCH+A; NCDs to be added at primary care level
(HT + DM + 3 Cancers: Cervix; Breast; Oral)

RSBY is being expanded as RSSY (NHPS) with a National Health Agency (NHA) to
administer with link to State Health Agencies (SHAs); States may add to and
co-brand with NHPS; some may continue with State Funded Health Insurance What
will progressive universalization mean in each state context?
Will health inequities between high performers and low performers widen?

Revitalizing Primary Health Services

Invest More In Rural and Urban Primary Health Services
Strengthen Sub Centres With Technology Enabled Non-Physician Health Care Providers
Convert Static Facilities Into Nearer To Home Outreach Facilities

Improve Physical and IT Connectivity Between Sub-Centres, PHCs, CHCs and District
Hospitals

Improve Referral and Follow Up Systems

Promote Integrated Care Through Networks of Providers
Enhance Community Participation and Monitoring

Envisioning UHC in 2016

India needs to evolve a UHC Framework which features:
Mandatory coverage for all population groups
Contributions from those who can afford them, with subsidization
for those who cannot

Decrease in the number of pools and schemes in the country to increase efficiency
Concentration on a comprehensive benefit package for all people and in all schemes
Increased allocation for public health services
Reliance on strategic purchasing, including purchasing from empaneled private
sector providers
Supplementary role of open market private health insurance
Provide portability across the country