1. 1. PRESENTED BY : DR SABA GUIDED BY : DR HEMANT KUMAR 1
2. 2. 2
3. 3. UNIVERSAL HEALTH COVERAGE Also called as* Universal Coverage Social Health Protection Universal Health Access Universal Health Protection 3 *The world health report: health systems financing: the path to universal coverage-2010
4. 4. THE CONCEPT Universal health coverage as a concept was born in 1883 when Germany introduced health coverage for achieving health status of its young population. Later, in 2005, World Health Assembly adopted the term "UHC" and in 2010, World Health Report focused on health systems financing for countries to build a platform for UHC 4*HLEG
5. 5. UHC is considered as a standalone measure for a country; as conceptualized today and attempts to provide promotive, preventive, diagnostic, curative and rehabilitative services without financial hardships to its citizens. The world health report: health systems financing: the path to universal coverage-2010 5 The world health report: health systems financing: the path to universal coverage-2010
6. 6. DEFINITION: Universal coverage (UC), or universal health coverage (UHC), is defined as Ensuring that all people have access to needed promotive, preventive, curative and rehabilitative health services, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship. 6 http://www.worldhealthsummit.org- 2013
7. 7. This definition of UC embodies three related objectives: 1. Equity in access to health services - those who need the services should get them, not only those who can pay for them; 2. that the quality of health services is good enough to improve the health of those receiving services; and 3. financial-risk protection - ensuring that the cost of using care does not put people at risk of financial hardship. 7http://www.worldhealthsummit.org -2013
8. 8. 8 *The world health report: health systems financing: the path to universal coverage-2010
9. 9. Contd The global aspiration to achieve UHC is evident as countries having gross domestic product (GDP) less than that of India have embarked upon and adopted the concept. China, Sri Lanka and Bangladesh have also adopted UHC and aim to achieve 100% coverage in times to come. 9
10. 10. GLOBAL HEALTH SCENARIO AND LEAD TO UHC 1948 Universal Declaration of Human Rights states: Everyone has the right to a standard of living adequate for the health and wellbeing of himself and of his family, including food, clothing, housing and medical care and necessary social services. 10
11. 11. Contd..... In 1966, member states of the International Covenant on Economic, Social and Cultural Rights recognised: the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. 11 http://www.refworld.org/docid/3ae6b36c0.html
12. 12. Contd... In 1978, Alma-Ata Declaration signatories, noted that Health for All would contribute both to a better quality of life and also to global peace and security. 12
13. 13. Contd... 100 million people are pushed into poverty because of direct health payments.* 79 countries devote less than 10% of general government expenditure to health* Health also frequently becomes a political issue as governments try to meet peoples expectations 13*http://www.who.int/healthsystems/en/ Jun 2015
14. 14. a. Member States of WHO committed in 2005 to develop their health financing systems so that all people have access to health services and do not suffer financial hardship paying for them. b. This goal was defined as universal coverage, or universal health 14
15. 15. The 2010 World Health Report builds upon the 2005 WHA recommendations and aims at assisting countries in quickly moving towards Universal Health Coverage. 15
16. 16. 16
17. 17. India, is still attempting to find a way for providing appropriate, affordable and accessible health care to its population. India was among the first countries in the world that enshrined in its constitution the "socialist model of health care for all, being a "Welfare state". 17
18. 18. The Bhore Committee suggested the norms at the time of Independence for implementing this philosophy but till date India has been struggling to achieve "health care for all". Some progress was made but the enormity of the task presents huge challenges for the public health system across the country. 18
19. 19. WHY IS HEALTH SYSTEM REFORM NEEDED IN INDIA 19 18% of all episodes in rural areas and 10% in urban areas received no health care at all*. 28% of rural residents and 20% of urban residents had no funds for health care*. Over 40% of hospitalized persons have to borrow money or sell assets to pay for their care *. *http://www.frontierweekly.com/articles/vol-46/46-51/46- 51-Health%20Coverage.html
20. 20. Over 35% of hospitalized persons fall below the poverty line because of hospital expenses* . Over 2.2% of the population may be impoverished because of hospital expenses*. The majority of the citizens who did not access the health system were from the lowest income quintiles. 20 *http://www.frontierweekly.com/articles/vol-46/46-51/46- 51-Health%20Coverage.html
21. 21. India has Highest number of malnourished and underweight (46% under 3 yrs); children in the world* Has high IMR of 50 per 1000 live births and MMR of 212 per 100 000 live births.* Has huge challenge to meet national(MDG) goals of 28 per 1000 , (IMR) and 100 per 100 000 (MMR) by 2015. Immunization coverage is dismal > 44%* 21UHC: DR SABA Source: World Health Organization (2011)
22. 22. KEY HEALTH INDICATORS: INDIA COMPARED WITH OTHER COUNTRIES Indicator India China Brazil Sri Lanka Thailand IMR/1000 live-births 50 17 17 13 12 Under-5 mortality 66 19 21 16 13 Fully immunized (%) 66 95 99 99 98 Birth by SBA 47 96 98 97 99 (SKILLED BIRTH ATTENDANT) 22 Source: World Health Organization (2011)
23. 23. Contd.... Rising burden of NCDs 2011 (in Millions) 2030 (in Millions) Diabetes 61 84 Hypertension 130 240 Tobacco Deaths 1+ 2+ 23 Source: World Health Organization (2011)
24. 24. 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 rural Tamil Nadu 24 http://www.who.int/countryfocus/cooperation_str ategy/ccs_ind_en.pdf
25. 25. Health expenditure is largely out of pocket (OOP) 67%. Public expenditure on Health 1.2% of GDP. Lack of an efficient and accountable public health sector has led to the burgeoning of a highly variable private sector. 25HLEG-2011
26. 26. LOW PRIORITY TO PUBLIC SPENDING ON HEALTH INDIA AND OTHER COUNTRIES : 2009 26 Total public spending as % GDP (fiscal capacity) Public spending on health as % of total public spending Public spending on health as % of GDP India 33.6 4.1 1.2 Sri Lanka 24.5 7.3 1.8 China 22.3 10.3 2.3 Thailand 23.3 14.0 3.3 http://uhc-india.org/reports/hleg_report_chapter_2.pdf
27. 27. National programs like National Rural Health Mission (NRHM), Rashtriya Swasthya Bima Yojana (RSBY), Janani Suraksha Yojana (JSY), etc. have been running in the country, but they themselves are insufficient to provide and sustain UHC for the nation at large. 27
28. 28. With demographic transition, rise in burden of NCDs is another major area of concern. Dual burden of diseases in the country poses huge economic losses. An emerging economy like India cannot afford such losses. Therefore, urgent actions are required to the reframe existing infrastructure and in a way to developments provide UHC to the country. 28
29. 29. High Level Expert Group (HLEG) on Universal Health Coverage (UHC) 29
30. 30. Keeping in view the urgent requirement for UHC , Planning Commission of India in October 2010,constituted a High Level Expert Group (HLEG) on Universal Health Coverage (UHC):- to develop a framework for providing easily accessible and affordable health care to all. review the experience of Indias health sector and suggest a 10-year strategy going forward 30
31. 31. 1. Develop a blue print for human resource requirements to achieve health for all by 2020. 2. Rework the financial norms needed to ensure quality, universal access of health care services, particularly in under-served areas and to indicate the relative role of private and public service providers in this context. 3. Suggest critical management reforms in order to improve efficiency, effectiveness and accountability of the health delivery 31
32. 32. 4. Develop guidelines for the participation of communities, local elected bodies, NGOs, the private or- profit and not-for-profit sector in the delivery of health care. 5. Propose reforms in policies related to the production, import, pricing, distribution and regulation of essential drugs, vaccines and other essential health care related items, for enhancing their availability and reducing cost . 32
33. 33. Contd.. 6. Explore the role of health insurance system that offers universal access to health services with high subsidy for the poor and a scope for building up additional levels of protection on a payment basis. 33
34. 34. 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 34
35. 35. DEFINITION OF UNIVERSAL HEALTH COVERAGE (UHC) BY HLEG 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. 35
36. 36. GUIDING PRINCIPLES FOR UHC 1. Universality 2. Equity 3. Non-exclusion and non-discrimination 4. Comprehensive care that is rational and of good quality 5. Financial protection 36
37. 37. 6. Protection of patients rights that guarantee appropriateness of care, patient choice, portability and continuity of care. 7. Consolidated and strengthened public health provisioning. 8. Accountability and transparency. 9. Community participation & 10. Putting health in peoples hands 37
38. 38. UHC : FOCUS AREAS 38 1.Human Resource Requirements 2.Access to Health Care Services 3.Management Reforms 4.Community Participation 5.Access to Medicines 6.Health care Financing 7.Social Determinants of Health
39. 39. ADDITIONAL FOCUS AREAS 39 8. Urban health 9. Female Gender 10. Public-Private Partnerships 11. Information Technology-enabled Health services
40. 40. 40 THE VISION
41. 41. 41 Universal health entitlement for every citizen - to a national health package (NHP) of essential primary, secondary & tertiary health care services funded by the government. * Package to be defined periodically by an Expert Group; can have state specific variations
42. 42. VISION OF HLEG FOR UHC IT-enabled National Health Entitlement Card (NHEC) 42
43. 43. EXPECTED OUTCOMES FROM UHC 43
44. 44. PROVISIONING OF UHC 44 Strengthen Public Services (Especially: Primary HealthCare- Rural And Urban; District Hospitals) Contract Private Providers (As Per Need And Availability) With Defined Deliverables Integrate primary, secondary and tertiary Care through Network of Providers (Public; Private; Public- Private) Regulate and Monitor For Quality, Cost And Health Outcomes
45. 45. PRE-REQUISITES To achieve UHC, three basic prerequisites are of paramount importance. Firstly, sufficient resources are needed to cater for the health service requirements. Secondly, we need to reduce the financial risks and barriers which obstruct the optimal usage of available resources . Thirdly, we need to focus on increasing the capability of the population to effectively utilize the available resources. 45HLEG-2011
46. 46. Acknowledging the potential of non-public sector in achieving UHC. HLEG recognizes that only public sector cannot aim to achieve UHC. Representation from private sector is also required to provide services. These services can be provided through two options. 46HLEG-2011
47. 47. In the first option, all those private providers who enroll themselves under UHC will provide minimum 75% of outpatient department services and 50% of in-patient services to those entitled under NHP. The services will be cashless and the provider will be reimbursed at standardized rates. For remaining portion of services available, the institutions could accept payments or provide services through privately purchased insurance policies. 47HLEG-2011
48. 48. In the second option, institutions enrolled under UHC 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. 48HLEG-2011
49. 49. However, HLEG envisages that over time, every citizen will be issued an IT enabled National Health Entitlement Card (NHEC) This will lead to greater equity, improved health, efficient and transparent health system and further reduction in poverty, greater productivity and financial 49HLEG-2011
50. 50. 50 HEALTH FINANCING AND FINANCIAL PROTECTION
51. 51. Health finance is the backbone of a self-sustaining health care system. The per capita health expenditure of our country is far less than that of Sri Lanka and China and is around a third of that in Thailand. As a consequence, per capita OOP expenditure in the country has escalated to 67% of total expenditure on health. 51HLEG-2011
52. 52. Inequity among states as far as public spending on health (Kerala stands at Rs. 498 when compared to Rs. 163 in Bihar) further suggests an urgent need for substantial changes in current health care system. To streamline the health care system, we need to move from the concept of insurance to assurance. 52HLEG-2011
53. 53. HEALTH FINANCING AND FINANCIAL PROTECTION BY HLEG 53
54. 54. 1:Central government and states 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 54
55. 55. Projected Sharing of Health Expenditure by Public and Private 55
56. 56. 2: Ensure availability of free essential medicines by increasing public spending on drug procurement. 3: Use general taxation as the principal source of health care financing complemented by additional mandatory deductions from salaried individuals and tax payers, either as a proportion of taxable income or as a proportion of salary. 56
57. 57. 4:Do not levy sector specific taxes for financing. 5:Do not levy fees of any kind for use of health care services under the UHC. 6:Introduce specific purpose transfers to equalize the levels of per capita public 57
58. 58. 7: Accept flexible and differential norms for allocating finances so that states can respond better to their needs. 8: Expenditures on primary health care, should account for at least 70% of all health care expenditures. 58
59. 59. 9:Do not use insurance companies or any other independent agents to purchase health care services . 10: Purchases of all health care services under the UHC system should be undertaken directly by the Central or state governments . 59
60. 60. 11:All government funded insurance schemes should, be integrated with the UHC system. All health insurance cards should, in due course, be replaced by National Health Entitlement Cards. The technical capacities developed by the Ministry of Labour for the RSBY should be transferred to the Ministry of Health and Family Welfare. 60
61. 61. HEALTH SERVICE NORMS Recommendations 61
62. 62. 1:Develop a National Health Package that offers every citizen, essential health services at different levels of the health care delivery system. 2.Develop effective contracting-in guidelines with adequate checks and balances for the provision of health care by the formal private sector. 62
63. 63. 3:Re-orient health care provision to focus significantly on primary health care. 4: Strengthen District Hospitals. 5: Ensure equitable access to functional beds for guaranteeing secondary and tertiary care. 63
64. 64. 6:Ensure adherence to quality assurance standards in the provision of health care at all levels . 7: Ensure equitable access to health facilities in urban areas by rationalizing services and focusing particularly on the health needs of the urban poor. 64
65. 65. HEALTH SERVICE NORMS 65
66. 66. ACCESS TO MEDICINES, VACCINES AND TECHNOLOGY 66
67. 67. Millions of Indian households have no access to medicines as they can neither afford them nor are these available at government health facilities. Almost 74% of private out-of- pocket expenditures today are on drugs. Drug prices have risen sharply in recent decades. Indias domestic generic industry is at risk of takeover by multinational companies. 67 http://www.searo.who.int/publications/journals/seajph/is sues/seajphv3n3p289.pdf
68. 68. The market is flooded by irrational, non- essential, and even hazardous drugs that compromise health. Despite available expertise and technology, health care system has been facing a huge challenge of providing essential medicines and vaccines to those who require it. 68
69. 69. Generic drug industry in India provides lifesaving medicines to many countries but at the same time has been struggling to increase access in our country. This has resulted largely from lack of reliable drug supply systems, irrational prescriptions, stringent product patent regimes as well as limited availability of public health facilities 69www.who.int/whr/en/report04_en.pdf
70. 70. RECOMMENDATIONS 1:Enforce price controls and price regulation especially on essential drugs. 2:Revise and expand the Essential Drugs List. 3:Strengthen the public sector to protect the capacity of domestic drug and vaccines industry to meet national needs. 70
71. 71. 5: Set up national and state drug supply logistics corporations. 6:Protect the safeguards provided by the Indian patents law and the TRIPS Agreement against the countrys ability to produce essential drugs. 7:Empower the Ministry of Health and Family Welfare to strengthen the drug regulatory system. 71
72. 72. 8.Central procurement with decentralized distribution has to be followed. Tamil Nadu model has proven its success and the same needs to be replicated on a large scale. 72
73. 73. 73
74. 74. Required HRH were recommended by Bhore committee in 1948 up to recent formulation of Indian Public Health Standards in 2010. The country holds largest number of medical colleges than anywhere in the world. Despite this, the country faces acute shortage of HRH. 74
75. 75. In contrast to WHO recommendation of 25 health workers per 10,000 population, India stands at 52nd rank with 19 health workers per 10,000 population. The distribution of medical colleges is skewed with Kerala and Bihar as extreme examples. 75
76. 76. In addition, the training of health workforce doesnt address the challenges of changing dynamics of public health. This is apparent form the fact that the time allotted to Community Medicine during internship has been reduced from 3 months 76
77. 77. Launch of NRHM in 2005 gave a boost to the HRH with creation of 8 lakhs ASHAs with a target of 1/1000 population. But, availability of qualified practitioners is lacking with gross shortage of doctors and nurses . 77
78. 78. HLEG RECOMMENDATIONS on HRH 78
79. 79. There are two implications of the recommendations:- 1. It will result in a more equitable distribution of human resources 2. can potentially generate around 4 million new jobs (including over a million community health workers) over the next ten years 79
80. 80. 1:Increase HRH density to achieve WHO norms of at least 23 health workers per 10,000 population (doctors, nurses, and midwives). 2.Establish a dedicated training system for Community Health Workers under the aegis of District Health Knowledge Institutes(DHKIs) 80
81. 81. 7:Establish State Health Science Universities to award degrees in health sciences and prospectively add faculties of health management, economics, social sciences and information systems. 8:Establish the National Council for Human Resources in Health (NCHRH) to prescribe, monitor and promote standards of health professional education. 81
82. 82. Health Service Management and Institutional Reforms 82
83. 83. Structural and functional improvements are prerequisites for achieving UHC in any country. With the dismal state of key health indicators, there is a need to regulate the vast private sector existing in the country. 83
84. 84. There is a need to provide adequate hospital beds. As per World Health Statistics, Indias hospital bed capacity has remained among the lowest in the world at 0.9 beds/1000 population against average of 2.9 beds/1000 population globally. 84planningcommission.nic.in/reports/genrep/rep_uhc2111.
85. 85. HOSPITAL BED CAPACITY, BY COUNTRY 85www.who.int/whosis/whostat/2011/en
86. 86. 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 86 MANAGERIAL REFORMS HLEG 2011
87. 87. INSTITUTIONAL REFORMS Establish financing and budgeting systems to streamline fund flow: by establishment of National Drug Regulatory Authority (NDRDA) & National Health Promotion and Protection Trust (NHPPT). 87HLEG 2011
88. 88. a. National Drug Regulatory Authority (NDRDA): The main aim of NDRDA would be to regulate pharmaceuticals and medical devices and provide patients access to safe and cost effective products. b.National Health Promotion and Protection Trust (NHPPT): It will promote public awareness about key health issues, track progress and impact on the social determinants of health, and provide technical expert advice to the Ministry of Health 88HLEG 2011
89. 89. Community Participation & Citizen Engagement 89
90. 90. Primary health care without community participation is incomplete. For UHC, citizen engagement needs scaling up for better delivery of resources. ASHAs have proved their worth under NRHM. NRHM has shown a positive effect on mobilization of community through civil society organizations and Panchayati Raj Institution (PRIs). 90 ASHA WORKER HLEG 2011
91. 91. However, Village Health and Sanitation Committees and Rogi Kalyan Samitis have achieved limited success. In addition, lack of knowledge of available health services hampers their optimal usage by the population. 91HLEG 2011
92. 92. Transformation of existing village health committees into participatory health councils is required to be done. 92
93. 93. Social Determinants of Health 93
94. 94. UHC cannot be achieved until we address social determinants of health. The status of social determinants including nutrition, water and sanitation, work security, occupational health, disasters, etc. remains abysmal . 94www.who.int/contracting/UHC_Country_Support.pdf
95. 95. RECOMMENDATIONS 1. Initiatives, both public and private, on the social determinants of health and towards greater health equity should be supported 2.A dedicated Social Determinants Committee should be set up at the district, state and national level 3. Include Social Determinants of Health in the mandate of the National Health Promotion and Protection Trust (NHPPT) 4.Develop and implement a Comprehensive National Health Equity Surveillance Framework, as recommended by the CSDH 95HLEG 2011
96. 96. 96
97. 97. 1: Improve access to health services for women, girls and other vulnerable genders (going beyond maternal and child health). 2:Recognize and strengthen womens central role in health care provision in both the formal health system and in the home. 97HLEG 2011
98. 98. 3.Build up the capacity of the health system to recognize, measure, monitor and address gender concerns through improved monitoring . 4: Support and empower girls, women and other vulnerable genders to realize their health rights. 98HLEG 2011
99. 99. THE CHALLENGES 99
100. 100. Broad agreement on the financing model for health-care delivery. Type and duration of training for senior functionaries in public health,. 100 Challenge in fulfilling the objectives of achieving UHC by 2022 :
101. 101. Entitlement package and the cost of health-care interventions. Enactment of National Health Bill 2009 as Health Act and declining State budget allocations for public health. 101
102. 102. Enrolling profit making big pharmacy companies and private health care providers under UHC will face a huge opposition from them . 102
103. 103. Further, enforcement and acceptance of Standard Treatment Guidelines (STGs) to vast private lobby remains a big challenge 103
104. 104. The HLEG recommends having a NHP. This will be through a nationwide distribution of NHEC. A difficult challenge as on December 2014, only 14.1% of Indians have been issued PAN cards . 104http://www.incometaxindia.gov.in/PAN/Overview.
105. 105. Looking toward reimbursement to the contracted-in private hospitals the issue itself will face a lot of resistance. As happened with JSY, timely reimbursement of even Rs. 1400 for beneficiaries was a challenging issue. 105
106. 106. REASONS FOR HOPE 106
107. 107. The governments has much higher capacities to spend on health and Political commitment seems evident from the fact that Prime Minister of India, on the eve of Independence day i.e. 15 Aug 2014 deaclred health as Utmost Priority. 107
108. 108. The Planning Commission has acknowledged the same and recently assured an increase in public health spending to 2% of GDP from current 1.2% by end of 12th 5 years plan 108
109. 109. Global experience has shown that Universal Health-Care is affordable and feasible. Further, Clinical Establishments (Registration Regulation) Act 2010, Fundamental Right to Education Act -2009 and Food Security Act- 2013 will help in reducing the burden of illiteracy, poverty , unemployment and disease . 109
110. 110. CRITICAL ANALYSIS OF UNIVERSAL HEALTH COVERAGE People may not 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. 110
111. 111. 111
112. 112. The Indian people deserve, desire and demand an efficient and equitable health system which can provide UHC. This needs sustained financial support, strong political will and dedication of public health functionaries and other stake holders as well as active participation of the community . 112
113. 113. UHC is the way to move beyond health care. It is the way for providing health assurance to the countrys population. Challenges are ahead but consistent efforts can achieve the goal of UHC. 113
114. 114. 114
115. 115. REFERENCES 1. World Health Organization (November 22, 2010)."The world health report: health systems financing: the path to universal coverage" . Geneva: World Health Organization. ISBN 978-92-4-156402-1. Retrieved April 11, 2012 2. Planning Commission. High Level Expert Group report on Universal Health Coverage for India; 2011. 3. http://www.worldhealthsummit.org/fileadmin/downloads/2014/WHS/Yearbook- Essays/ WHS_Yearbook2013_Kieny.pdf 4. Singh Z. Universal Health Coverage for India by 2022: A Utopia or Reality?Indian Journal of Community Medicine : Official Publication of Indian Association of Preventive & Social Medicine. 2013;38(2):70-73. 5. Reddy KS, Patel V, Jha P, Paul VK, Kumar AK, Dandona L, et al. Towards achievement of universal health care in India by 2020: A call to action. Lancet 2011;377:760-8. 6. Rao M, Rao KD, Kumar AK, Chatterjee M, Sundararaman T. Human resources for health in India. Lancet 2011;377:587-98. 7. WHO. The World Health Report 2004: Changing History.Geneva: World Health Organization ; 2004. 8. Dhingra B, Dutta AK. National rural health mission. Indian J Pediatr 2011;78:1520-6. 115
116. 116. Contd.. 9. Balarajan Y, Selvaraj S, Subramanian SV. Health care and equity in India. Lancet 2011;377:505-15. 10.Savedoff WD, de Ferranti D, Smith AL, Fan V. Political and economic aspects of the transition to universal health coverage. Lancet 2012;380:924-32. 11.Chauhan LS. Public health in India: Issues and challenges.Indian J Public Health 2011;55:88-91. 12. Jindal Ashok Kumar . Universal health coverage: The way forward .Year : 2014 | Volume: 58 | Issue Number: 3 | Page: 161-167 13. International Institute for Population Sciences (IIPS) and Macro International. National Family Health Survey (NFHS-3), 2005-06. Vol. 2. Mumbai, India: IIPS; 2007. 14 .Evans DB, Etienne C. Health systems financing and the path to universal coverage. Bull World Health Organ 2010;88:402. 116
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