INTRODUCTION:

India’s current health profile reflects the combined effects of multiple transitions (demographic, epidemiological, and nutritional) overlaid by uneven economic development, an under-resourced public health system, and inadequate multisectoral action on the determinants of health. Striking inequalities in health indicators are present across very diverse states and heterogeneous population groups [1].

Despite the availability of several health financing schemes in India, out of pocket expenditure remains unacceptably high, especially for drugs and outpatient care [2]. The limited access, insufficient availability, suboptimal or unknown quality of health services, and high out-of-pocket expenditure (OOPE) are amongst the key health challenges in India [3]. These challenges exist alongside a global discourse to achieve universal health coverage (UHC) – increasing access to quality healthcare services at affordable cost, by all people; and in times of fast economic growth in India [4]. Though, India’s National health policy-2017 (NHP2017) is fully aligned with global discourse and has the goal to achieve UHC, outside the policy discourses, health is often not considered high on the priorities by political leadership and is traditionally been underfunded [3,5,6]. The inappropriate mix of inputs (infrastructure, human resources and supplies) results in a failure to deliver the desired health services and public health system is grossly underutilized by people. The elaborate government primary healthcare system in rural India with nearly 185,000 facilities delivers only 8-10% of total health services, availed by people. One-fourth of health facilities in public sector deliver nearly three-fourths of total health services delivered by entire public sector facilities. This means that remaining 75% of health facilities are delivering much lower number of services per facility than these are capable of [7]. People are either compelled to, or prefer to, seek care from private providers, often at a cost beyond their paying capacity. Health expenditures is estimated to contribute to 3.6% and 2.9% of rural and urban poverty, respectively [8]. Annually, an estimated 60 to 80 million people in India either falls into poverty or get deeper into poverty (if already below poverty line) due to health-related expenditures [3,9]. Inequity in medicines access is widely perceived as symptomatic of weaknesses in the health-care system and represents a failure on the part of national governments to fulfill their rights towards their people in accordance to their right to health. Ensuring equitable access to quality pharmaceuticals is thus a key development challenge and an essential component of health system strengthening and primary health care reform programs throughout the world. It is estimated that the total number of people without access to essential medicines worldwide remains between 1.3 and 2.1 billion people comprising one-third of the world’s population [10,11]. Around 10 million people die each year as a result of this inaccessibility to essential medicines [12]. Lack of access due to economic reasons is particularly concentrated in Africa and Asia where the proportion increases to 50% of the population. Within India an estimated 649 people (comprising of 65% of its own population and 38% of world population) are known to lack access to essential medicines as per World Medicines Situation Report published by the World Health Organization, which also reveals that globally, about 150 million people suffer financial catastrophes annually while 100 million people are pushed below the poverty line [10]. Former WHO Director General Margaret Chan’s assertion [13] that universal health coverage is “the single most powerful concept that public health has to offer”, attests to the increasing worldwide attention given to universal coverage, even for less affluent countries, as a way to reduce financial impoverishment caused by health spending and in crease access to key healthcare services. At a conservative estimate, 20–40% of health resources are being wasted worldwide. Reducing this wastage could greatly improve the ability of health systems to provide quality services and improve health [14]. That is exactly why providing access to affordable essential medicines in developing countries w as listed as one of the Millennium Development Goals [15] by the United Nations Organization i.e., MDG 8E, Target 17, Indicator 46. The renewed 2030 agenda outlined in the Sustainable Development Goals (SDGs), sets a clear path for future action by placing equity and universal health coverage on the centre stage. The health goal, SDG-3: “Ensuring healthy lives and promoting well-being for all at all ages” underscores the importance of access to medical products by aspiring to end the epidemics of AIDS, tuberculosis, malaria and other communicable diseases by 2030; by achieving universal health coverage, providing access to safe and effective vaccines and medicines for all and by supporting the research and development of vaccines and medicines for the communicable and non-communicable diseases that primarily affect developing countries [16]. It is the moral duty of the stake holders of the country to provide free and universal access to quality health-care services to its people. India as a developing country continues to be among the countries of the world that have a high burden of diseases and the several health programmes and policies proposed in the past have not been able to achieve the desired goals and objectives. The 65 World Health Assembly -Geneva has identified universal health coverage (UHC) as the key imperative concept for all countries to consolidate the public health advances. Accordingly, Planning Commission of India constituted a high level expert meeting (HLEG) on UHC in October 2010 to chalk out the strategy for implementation of UHC. HLEG submitted its report in Nov 2011 to Planning Commission of India on UHC for India by 2022. The recommendations of the report for the provision of UHC encompasses to the critical areas such as health financing, health infrastructure, health services norms, skilled human resources, access to medicines and vaccines, management and institutional reforms, and community participation. India faces enormous obstacles to achieve UHC by 2022 viz. high disease prevalence, issues of gender equality, unregulated and fragmented health-care delivery system, non-availability of adequate skilled human resources, various social determinants of health, inadequate finances, lack of inter-sectoral co-ordination and push of different forces, and interests. These hurdles can be met by a shift in health policies and programs related to vulnerable population groups, restructuring of public health cadres, reorientation of undergraduate medical education, more emphasis on public health research, and elaborative education campaigns [17]. The World Health Report 2010 mentions that a health system providing Universal Health Coverage (UHC) should provide access to the necessary health services to all people needing them with good quality and without financial hardship [18]. UHC consists of 5 important aspects, namely access to healthcare, coverage, package of services, financial risk protection and rights-based approach [19]. The main components of UHC are quality and coverage. Coverage will comprise of service coverage and financial coverage. The three dimensions of UHC are the population covered; services covered and costs covered, reproduced from the WHO report (2015) [20].

What is Universal Health Coverage (UHC)?

Universal Health coverage in Indian context is defined as; “Ensuring equitable access for all Indian Citizens, regardless of income level, social status, gender, caste or religion, to affordable, accountable, appropriate health services of assured quality 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” [21]. It is a concept, which implies, the absence of geographic, financial, organizational, socio-cultural and gender based barriers to care [22]. The concept of Universal Health Coverage (UHC) arose out of a global concern for high levels of out of pocket expenditure for health care in many low- and middle-income countries (LMIC) [23]. UHC has the prime objective of “ensuring that everyone within a country can access the health services they need, which should be of efficient quality to be effective and providing all with financial protection from the costs of using health services” [24,25]. Core to the design of UHC is the health financing system and how it engages with the mechanisms for provision of healthcare. Progress towards UHC requires strengthened health system functioning [23,25–28] and a focus on equity [29–33]. Despite this broad vision, at country level, UHC has often focused on the establishment of state funded insurance schemes [34,35] and stopped short of addressing the health systems strengthening or equity aspects of UHC. Kutzin raises this as a concern and calls for a shift in emphasis from a scheme to the health system in its entirety and for the “impact of that scheme on the attainment of the objectives for the population and system as a whole” to be monitored. The impact of state funded insurance schemes on financial protection and health equity are currently a subject of keen debate the world over, including in India [27,35–38]. The path to universal health coverage involves important policy choices and inevitable trade-offs. The pooled funds – which can be contributed from a variety of sources, such as general government budgets, compulsory insurance contributions (payroll taxes), and household and/or employer prepayments for voluntary health insurance - are organized, used and allocated, impacts greatly the direction and progress of reforms towards achieving universal coverage. Even where funding is largely prepaid and pooled, there occurs need for tradeoffs between the proportions of the populations to be covered, the range of services to be made available and the proportion of the total costs to be met. Pooled funds can be employed to extend coverage to those citizens who previously were not covered, to services that previously were not covered or to reduce the direct payments needed for each service. These dimensions of coverage reflect a set of policy choices about benefits and their rationing that are among the important decisions facing countries in their reform of health financing systems towards achieving universal coverage [39].

Universal Health coverage in India:

India has a very low public health spending with only 0.94% of the GDP. The government contribution of the total health spending is only 22% with 78% of private health spending [40]. Every year around 39 million people are impoverished because of catastrophic health expenditure [41]. 74% of OOP spending was on outpatient care and only 26% on inpatient care. Public health care in India is free of cost in most cases or charges a minimal service charge [42]. However, the quality of services in the public health system is very poor, and people are unsatisfied. A majority of the people use private health services for their health care needs. Around 20%-28% of diseases in India are untreated because of the lackof financial protection. Around 30%-47% of inpatient care in India was financed by the sale of property and loans. There are difficulties in the expansion of insurance coverage in India because only 7% of the workforce is in the organized sector [43-45]. India does not currently have UHC. The 12th five-year plan (2012-17) of the Government of India (GOI) tries to achieve UHC [41]. GOI created a High Level Expert Group (HLEG) in 2010, which prepared a report for the achievement of UHC in India by 2022 [46]. The health insurance system in India is only rudimentary and available to only few groups of advantaged individuals [47-50]. In India, the unmet need for healthcare is very high with the people having the highest need having the least access to health care [51-54]. In India, the IMR among the poorest wealth quintile is around 82 per 1000 live births, while the IMR among the richest quintile is only 34 per 1000 live births [55]. Women in the richest quintile are more than six times more likely to have an institutional delivery compared to poorer women. These statistics show there are wide disparities between the rich and poor in access to healthcare. The approaches to achieve UHC in India currently target poor people [56].

Government of India and the State Governments have the general obligation to provide free and universal access to the health-care services and ensure that there shall not be any denial of health-care directly or indirectly to anyone, by any health-care service provider, public or private, by laying down minimum standards and appropriate regulatory mechanism [57]. The 11 Plan health outcome indicators set as time-bound goals for lowering maternal and infant mortality, malnutrition among children, anemia among women and girls, fertility, and raising the child sex ratio have not been fully met. India trails in health outcomes behind Sri Lanka and Bangladesh. The health-care system in the country suffers from inadequate funding, lack of integration between disease control and other social sector programs, suboptimal use of traditional systems of medicines, weak regulatory mechanisms and poor capacity in health management. There are wide interstate disparity and differences between rural and urban indicators of health [58]. The twelfth plan seeks to provide a safe and healthy environment to communities, delivering universal access to basic health services, and to medicines, and regularly evaluating the health system. It also seeks to make the communities more health conscious by using the techniques of communication, behavior change, and participatory governance [59,60]. Keeping in view the outcomes of recommendations of previous many other committees, National health policies and programs, whether the recommendations of HLEG will have desired outcomes or remain a Utopia is the moot question to ponder over. The critical areas for the provision of Universal Coverage as per HLEG recommendations, which need to be addressed such as health financing, health infrastructure, health services norms, skilled human resources for health (HRH) access to medicines, vaccines and technology, management and institutional reforms, and Community Participation. The key recommendations of HLEG are as follows:

Health financing Sources [60, 57]

Various health care financing sources should be devised and implemented. An increase in spending should be made for public procurement of medicines from 0.1% to 0.5% of Gross Domestic Product (GDP). General taxation plus deductions for health-care from salaried individuals and tax-payers as the main source of health-care financing should be used, and no fees of any kind be levied for the provision of health-care services under UHC. There should be flexibility in central financing to help meet various health requirements of states and at least 70% of all healthcare spending should go to primary health-care. No insurance companies or other agencies should be used to the purchase health-care services on behalf of the Government and all Government funded Insurance Schemes should be integrated with the UHC system. Government should increase public expenditure on health from the current level of 1.2% GDP to at least 2.5% by the end of the 12 plan and to at least 3% of GDP by 2022.

Health services norms:

The National Health Package offering essential health services as a part of citizen entitlement should be developed and a system of National Health Entitlement Cards should be introduced. Well defined service delivery partnership with Government, As purchaser and private sector as provider under strong regulation, accreditation and supervisory framework should be ensured. The district hospitals network to be strengthened and upgraded for health-care delivery and training to provide best health services. In Urban areas, there is a requirement to rationalize services and focus on health needs of the poor. It should be ensured that all citizens have an entitlement to the same level of essential health-care strictly adhering to the quality assurance standards.

Human resources for health (HRH):

Proper Adequate number of trained and skilled health-care providers and technical health-care personnel should be employed by giving importance to Primary Health-Care, increasing HRH density to obtain World Health Organization norms of at least 23 health workers (Doctors, Nurses, Auxiliary Nurse Midwives)/10,000 population, as well as employing adequate number of dentists, pharmacists, physiotherapists, technicians, and other allied health professionals at appropriate levels of health-care delivery, strengthening existing State Regional Institutes of Family Welfare State, establishing District Health Knowledge Institutes, Health Science Universities, and National Council for Human Resources in Health.

Community participation:

Various existing village and health sanitation committees should be changed into participating health councils. The role of elected representatives, Panchayat Raj Institutions in rural areas and local bodies in urban areas should be improved. Regular health assemblies at different levels to enable community review of health plans and their performance should be organized. Civil society and non-governmental organizations should be strengthened and utilized to contribute effectively for community mobilization, information dissemination; community based monitoring of health services. A formal grievance redresssal mechanism should be constituted at the community level to deal with confidential complaints and grievances about the health services [60,61].

Access to medicines and vaccines:

Price regulationand price control on important and commonly prescribed drugs should be enacted. The essential drugs list should be changed and extended and rational use of drugs should be ensured. The public sector to be strengthened to protect the domestic drug and vaccine industry to meet national needs and the Ministry of Health and Family Welfare should be empowered to strengthen the drug regulatory system [60,61].

Managerial and institutional reforms:

Public health sector should act as promoter, provider, contractor, regulator, and steward. Good referral systems, better transportation, improved management of human resources, robust supply chains and data, and upgraded facilities should be put in place. All this could be done by employing, All India and State Public Health Cadres, adopting better human resource practices, developing a national health information technology network, streamlining regular fund flow and ensuring accountability to patients and communities. To achieve the above reforms establishment of National Health Regulatory and Development Authority having a system support unit, a National Health and Medical Facilities Accreditation Unit and Health System Evaluation Unit have been recommended. Additionally, establishment of a National Drug Regulatory and Development Authority to regulate pharmaceuticals and medical devices as well as National Health Promotion and Protection Trust to facilitate the promotion of better health culture amongst people, health providers and policy makers has also been recommended, so that UHC can be achieved [60,61].

Obstacles to achieve UHC by 2022:

Various challenges need to be overcome to achieve UHC by 2022 such as the largest disease burden in the world [62], reproductive and child health issues, malnutrition [63,64], issues of gender equality [65], poor availability of trained human resources in health [66], inadequate research to achieve health-care for all [67] commercialized, fragmented, and unregulated health-care delivery systems, [68-70] inequalities in access to health-care [71], imbalance in resource allocation, high out of pocket health expenditures [72,73], rising ageing population, social determinants of health such as poverty, illiteracy, alcoholism etc. [74], too frequent and too severe natural disasters, lack of inter-sectoral coordination and political pull and push of different forces and interests. These issues need to be taken into consideration otherwise the dream of pursuit of UHC in India by 2022 would be a distant dream.

Way Ahead:

Through a shift in the planning, implementation and monitoring of the health-care delivery, there can be a way forward for ensuring UHC for India by 2022 by according priority to the needs of the most deprived groups, improving non-medical preventive health action related to employment, incomes, food security, water and sanitation, removing constraints in the health seeking behavior of people, improving outlay on health to 5-6% of GDP at the rate of Rs. 2000/capita/year [75, 76], augmenting the existing network of health-care delivery system especially in rural, tribal and inaccessible areas, intensive use of technology for diagnosis, pricing, and quality control, regulating public private partnerships with clear definitions of shared objectives and priorities, rewarding the states financially for recording improved health outcomes [77], planning of HRH based on local epidemiological needs, health-care needs and cost effectiveness, transparency in mapping and estimating the pattern of health-care services required in each district [78], restructuring the cadre structure for public health workers, reorienting medical undergraduate education toward public health and sustained intensive health education campaigns [79].

CONCLUSION:

Health sector needs in the context of India's diversity are so complex that it is rather impracticable to engage with all its stake holders. The Indian citizens deserve and desire an efficient and equitable health system which can help in providing UHC in India.UHC in India could only be achieved if the primary health care facilities receive a minimum of 70% of health spending, public spending on the purchase of medicines increase from 0.1% to 0.5% GDP, and all the health facilities in India are upgraded to match the Indian Public Health Standards. The health insurance programs currently available in India do not help in achieving these recommendations and only strengthen the private health infrastructure which mainly targets rich people. There are problems in sustainability of the health insurance programs because the mechanisms for financing the health system such as strong collecting systems are lacking in India [80]. For countries on the road towards UHC, there is no ‘one size fit all’ solution, and the strategies and plans have to be locally developed and implemented on the ground. Every strategy/program would have to build upon strengths and attempt to minimize limitations. Ayushman Bharat Program is a balanced program, which combines provision of comprehensive primary healthcare and secondary and tertiary care hospitalization. Although ABP would help India make rapid strides towards UHC, this program alone would not be enough and needs to be additionally supplemented by rapid scale-up and convergence of ongoing schemes and programs, and taking a few additional measures. The Ayushman Bharat Program(ABP) can prove as an effective and bigger initiative than simply delivering health services and rather provide a platform to prepare India for making health coverage universal in India. The patterns of utilization and differential Out-of-pocket health expenditures across public and private sectors under publicly financed health insurance warrant further investigation, so as to inform strategies that make best use of scarce public resources and deliver on the promise of equity under Universal Health Coverage.

REFERENCES:

1. Dilip T, Dandona R, Dandona L. The national employment guarantee scheme and inequities in household spending on food and non-food determinants of health in rural India. Int J Equity Health 2013;12:84.

2. High Level Expert Group. Report on universal health coverage for India. 2011. https://docs.google.com/viewer?url=http://planningcommission.nic.in/reports/genrep/rep_uhc0812.pdf.

3. Government of India. National Health Policy 2017. Ministry of Health and Family Welfare, NirmanBhawan, New Delhi, 2017. p. 1-32.

4. World Health Organization. World Health Report 2010: Health Financing for Universal Coverage. Geneva: WHO, 2010.

5. [No author listed]. Health in India, 2017. Lancet. 2017;389:127.

6. Shiva Kumar AK, Chen LC, Choudhury M, Ganju S, Mahajan V, Sinha A, et al. Financing health care for all: challenges and opportunities. Lancet. 2011; 377:668-79.

7. Government of India. Report of the Task force on Primary Health Care in India. Ministry of Health and Family Welfare, Nirman Bhawan, New Delhi, 2017. p. 1-60.

8. Gupta I. Out of Pocket Expenditure and Poverty: Estimates from 61 Rounds of NSS. Expert Group on Poverty. Planning Commission, New Delhi; 2009. Available from: http://planningcommission.gov.in/reports/ genrep/indrani.pdf. Accessed February 15, 2018.

9. World Health Organization and International Bank for Reconstruction and Development / The World Bank. Tracking Universal Health Coverage: 2017 Global Monitoring Report. Available from: http://www.who.int/health info/ universal_health_coverage/report/2017_global_ monitoring_report.pdf. Accessed February 15, 2018.

10. World Health Organization. World Medicines Situation Report 2004. WHO, Geneva. Available at: http://apps.who.int/medicinedocs/en/d/Js6160e/9.html (Accessed on October 9^th, 2017)

11. World Health Organization. World Medicines Situation Report 2011. Available at: http://www.who.int/medicines/areas/policy/world_medicines_situation/wms_intro/en/

12. Executive Summary. The selection and use of essential medicines (2015). Report of the 20^th WHO Expert Committee on the Selection and Use of Essential Medicines. Geneva: World Health Organization; 2015. Available at: http://www.who.int/medicines/publications/essentialmedicines/Executive-Summary_EML-2015_7-May-15.pdf?ua=1 (Accessed on October 9^th, 2017).

13. Schmidt H, Gostin LO, Emaneul EJ. Public health, universal health coverage and sustainable development goals: can they coexist? The Lancet 2015; 386(9996):928-30.

14. World Health Organization. The world health report: health systems financing: the path to universal coverage. Geneva: World Health Organization; 2010.

15. Millennium Development Goals and beyond. Goal 8: Develop a global partnership for development. New York (NY): United Nations; 2015 (http://www.un.org/millenniumgoals/global.shtml, accessed 9 October 2017).

16. UN Sustainable Development Summit 2015. New York (NY): 25-27 September 2015 http://www.who.int/mediacentre/events/meetings/2015/un-sustainable-development-summit/en/, accessed 9 October 2017).

17. Singh Z. Universal Health Coverage for India by 2022: A Utopia or Reality?. Indian J Community Med 2013; 38:70-3.

18. The World Health Report 2010: Health Systems Financing: The Path to Universal Coverage. Geneva: WHO 2010. Available at: www.who.int/whr/2010/en/. Accessed 05 March 2017.

19. Stuckler D, Feigl AB, Basu S, McKee M. The political economy of universal health coverage (background paper for the First Global Symposium on Health Systems Research). Geneva: WHO.2010. Available at: www.pacifichealthsummit.org/ downloads/UHC/the % 20 political % 20 economy % 20 of % 20uhc.PDF. Accessed 07 March 2017.

20. Joint WHO/World Bank Group Report. Tracking Universal Health Coverage. First Global Monitoring Report. WHO. 2015. Available at: http://apps.who.int/iris/bitstream/10665/174536/1/9789241564977_eng.pdf. Accessed 07 March 2017

21. New Delhi: Instituted by the Planning Commission of India; 2011. High level expert group report on universal health coverage for India.

22. Sundari Ravindran TK. Universal Access: making health systems work for women. BMC Public Health. 2012; 12(Suppl 1):S4.

23. World Health Organisation (WHO). The World Health Report–Health Systems Financing: The path to Universal Coverage. Geneva: World Health Organization; 2010

24. McIntyre D., Ranson M. K., Aulakh B. K. and Honda A. Promoting universal financial protection: evidence from seven low- and middle-income countries on factors facilitating or hindering progress. Health Research Policy and Systems 2013; 11:36. https://doi.org/10.1186/1478-4505-11-36 PMID: 24228762

25. House Chatham. Shared Responsibilities for Health: A Coherent Global Framework for Health Financing. Final Report of the Centre on Global Health Security Working Group on Health Financing. London: Chatham House; 2014.

26. Roberts M. J., Hsiao W. C., & Reich M. R. Disaggregating the Universal Coverage Cube: Putting Equity in the Picture. Health Systems & Reform. 2015; 1(1): 22–27.

27. Sen A. Universal healthcare: the affordable dream. The Guardian. 2015. Available from: www. theguardian.com/society/2015/jan/06/-sp-universal-healthcare-the-affordable-dream-amartya-sen

28. Kutzin J and Sparkes S. P. Health systems strengthening, universal health coverage, health security and resilience. Bulletin of the World Health Organisation. 2016; 94:2.

29. Frenz P., and Vega J. Universal health coverage with equity: what we know, don’t know and need to know. Background paper for the First Global Symposium on Health Systems Research, 16–19 November 2010, Montreux, Switzerland. 2010. Available from: www.healthsystemsresearch.org/hsr2010/ images/stories/9coverage_with_equity.pdf

30. Kutzin J. Anything goes on the path to universal health coverage? No. Bulletin of the World Health Organization. 2012; 90: 867–868. https://doi.org/10.2471/BLT.12.113654 PMID: 23226900

31. World Health Organisation (WHO). Arguing for Universal Health Coverage. Geneva: World Health Organisation; 2013.

32. Ooms G., Latif L. A., Waris A., Brolan C. E., Hammonds R., Friedman E.A. et al Is universal health coverage the practical expression of the right to health care? BMC International Health and Human Rights. 2014; 14 (3): 1–7.

33. World Health Organisation (WHO). Making fair choices on the path to universal health coverage: Final report of the WHO Consultative Group on Equity and Universal Health Coverage. Geneva: World Health Organization; 2014.

34. Kutzin J. Health financing for universal coverage and health system performance: concepts and implications for policy. Bulletin of the World Health Organisation. 2013; 91: 602–611.

35. Lagomarsino G., Garabrant A, Adyas A, Muga E., Otoo N. Moving towards universal health coverage: health insurance reforms in nine developing countries in Africa and Asia. Lancet. 2012; 380: 933–43. https://doi.org/10.1016/S0140-6736(12)61147-7 PMID: 22959390

36. Oxfam. Universal Health Coverage: Why health insurance schemes are leaving the poor behind. 2013. Available from: www.oxfam.org/sites/www.oxfam.org/files/bp176-universal-health-coverage-091013en_.pdf

37. Sundararaman T., Muraleedharan V. R., Mukhopadhyay I. NSSO 71st Round Data on Health and Beyond Questioning Frameworks of Analysis. Economic & Political Weekly. 2016a; 51 (3): 85–88 https://doi.org/10.1708/2304.24788 PMID: 27362818

38. Jain N., Kumar A., Nandraj S., Furtado K. M. NSSO 71st Round Same Data, Multiple Interpretations. Economic and Political Weekly. 2015; 50 (46 & 47): 84–87.

39. WHO. World Health Organization. Universal Coverage: three dimensions. WHO, Geneva. Available at: http://www.who.int/health_financing/strategy/dimensions/en/ (Accessed on October 9^th, 2017).

40. MoHFW, Government of India. National health accounts of India 2004–05, national health accounts cell. New Delhi: Ministry of Health and Family Welfare, Government of India, 2009. Available at: http://planningcommission.nic.in/reports/genrep/hea lth/National_Health_Account_04 _05. Accessed 12 March 2017.

41. Press Information Bureau, Government of India. Available at: http://pib.nic.in/newsite/erelease. aspx?relid=88129. Accessed 14 March 2017.

42. Kumar AKS, Chen LC, Choudhury M, Ganju S, Mahajan V, Sinha A, et al. Financing health care for all: challenges and opportunities. Lancet. 2011; 377(9766):668–79.

43. Ministry of Health and Family Welfare, Government of India. Select health parameters: a comparative analysis across the National Sample Survey Organization 42nd, 52nd, and 60th Rounds. 2007. Available at: http://www.whoindia.org/ LinkFiles/Health_Finance_NSSO_Report.pdf. Accessed on 15 March 2017.

44. National Commission for Enterprises in the Unorganised Sector. Report on the conditions of work and promotion of livelihoods in the unorganised sector. August, 2007. Available at: http://nceus.gov.in/Condition_of_workers_sep_2007 .pdf. Accessed 15 March 2017.

45. Government of India. Report of the national commission on macroeconomics and health. New Delhi: National Commission on Macroeconomics and Health, Ministry of Health and Family Welfare 2005.

46. Singh Z. Universal Health Coverage for India by 2022: A Utopia or Reality? Indian J Community Med. 2013;38(2):70–3.

47. Gupta I, Trivedi M. Health insurance: beyond a piecemeal approach. Econ Polit Wkly. 2006; 41:2525–8.

48. Acharya A, Ranson K. Health care financing for the poor: community-based health insurance schemes in Gujarat. Econ Polit Wkly. 2005; 40:4141–50.

49. Ellis RP, Alam M, Gupta I. Health insurance in India: prognosis and prospects. Econ Polit Wkly. 2000; 35:207–17.

50. Ranson MK, Sinha T, Chatterjee M, Acharya A, Bhavsar A, Morris SS, et al. Making health insurance work for the poor: learning from SEWA’s community-based health insurance scheme. SocSci Med. 2006; 62(3):707-20.

51. Hart JT. Three decades of the inverse care law. BMJ. 2000; 320(7226):18-9.

52. Sen G, Iyer A, George A. Structural reforms and health equity: a comparison of NSS surveys, 1986– 87 and 1995–96. Econ Polit Wkly. 2002; 37:1342– 52.

53. Singh CH, Ladusingh L. Correlates of inpatient healthcare seeking behavior in India. Indian J Public Health 2009;53:6–12.

54. Gaudin S, Yazbeck AS. Immunization in India 1993–1999: Wealth, Gender, and Regional Inequalities Revisited. SocSci Med. 2006;62(3):694-706.

55. National Family Health Survey (NFHS-3), 2005–06: India. International Institute for Population Sciences (IIPS) and Macro International. 2007. Available at: http://www.measuredhs.com/aboutsurveys/search/metadata.cfm?surv_id=264&ctry_id=57&SrvyTp. Accessed 16 March 2017.

56. Balarajan Y, Selvaraj S, Subramanian SV. Health care and equity in India. Lancet 2011; 377(9764):505–15.

57. MOHFW, GOI Working Draft, Version January – 09. National Health Bill-2009, 10

58. Srinivasan R. Health Care in India – Vision 2020, Issues and Prospects – Planning Commission. Planning Commission. Nic. In reports/genrep/----/26_bg 2020 doc

59. Report of the steering committee on health for the 12 five year plan. Health Div Planning Commission. 2012:5.

60. New Delhi: Instituted by the Planning Commission of India; 2011. High level expert group report on universal health coverage for India.

61. Sundari Ravindran TK. Universal Access: making health systems work for women. BMC Public Health. 2012;12(Suppl 1):S4. [PMC free article] [PubMed]

62. WHO. The global burden of disease: 2004 Updated. [Last accessed on 2010 Jun 20].

63. John TJ, Dandona L, Sharma VP, Kakkar M. Continuing challenge of infectious diseases in India. Lancet. 2011; 377:252–69. [PubMed]

64. Paul VK, Sachdev HS, Mavalankar D, Ramachandran P, Sankar MJ, Bhandari N, et al. Reproductive health, and child health and nutrition in India: Meeting the challenge. Lancet. 2011; 377:332–49. [PMC free article] [PubMed]

65. Raj A. Gender equity and universal health coverage in India. Lancet. 2011; 377:618–9. [PubMed]

66. Rao M, Rao KD, Kumar AK, Chatterjee M, Sundararaman T. Human resources for health in India. Lancet. 2011;377:587–98. [PubMed]

67. Dandona L, Raban MZ, Guggilla RK, Bhatnagar A, Dandona R. Trends of public health research output from India during 2001-2008. BMC Med. 2009; 7:59. [PMC free article] [PubMed]

68. Agarwal D. Universal access to health care for all: Exploring road map. Indian J Community Med. 2012;37:69–70. [PMC free article] [PubMed]

69. Prinja S, Kaur M, Kumar R. Universal health insurance in India: Ensuring equity, efficiency, and quality. Indian J Community Med. 2012; 37:142–9. [PMC free article] [PubMed]

70. Patel V, Shiva Kumar AK, Paul VK, Rao KD, Srinath Reddy K. Universal health care in India: The time is right. [Last accessed on 2011 Jan 15]. Available from: http://www.thelancet.com .

71. Singh CH, Ladusingh L. Correlates of inpatient healthcare seeking behavior in India. Indian J Public Health. 2009; 53:6–12. [PubMed]

72. Balarajan Y, Selvaraj S, Subramanyam SV. India: Towards universal health coverage 4-Health care and equity in India. Lancet. 2011; 377:505–15. [PMC free article] [PubMed]

73. 17. Executive summary WHO country co-operation strategy, India. 2012-2017, XV

74. Geneva: WHO; 2008. WHO commission on social determinants of health closing the gap in a generation: health equity through action on the social determinants of health: Final report of the commission on social determinants of health.

75. Gupta A, Jain A, Nair AB, Banerji D, Chakraborty G, Qadeer I, et al. Universal access to health care: Threats and opportunities. Econ Polit Wkly. 2011; 46:27–30.

76. Reddy KS, Patel V, PrabhatJha, Paul VK, Shiva Kumar AK, Danodana L. India: Towards universal health coverage 7. Lancet. 2011; 377:760–8. [PMC free article] [PubMed]

77. Shiva Kumar AK, Chen LC, Choudhury M, Ganju S, Mahajan V, et al. India: Towards universal health coverage 6-financing health care for all: Challenges and opportunities. Lancet. 2011; 377:668– 78. [PubMed]

78. Aarti D. National debate needed on Universal health coverage: JSA, The Hindu. 2012 Apr 7;

79. Ramya K. PHCs in state to be rated for quality care. The Hindu. 2013 Jan 8;

80. Sriram S. Critical evaluation of two approaches to achieve universal health coverage in India. Int J Community Med Public Health 2018; 5:3159-63.

Received on 13.03.2019 Modified on 21.04.2019

Research J. Pharm. and Tech 2019; 12(8): 4045-4051.

DOI: 10.5958/0974-360X.2019.00697.8