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Year : 2018  |  Volume : 4  |  Issue : 1  |  Page : 16-23

How far we are from achieving universal health coverage? A situational analysis and way forward for India

1 Senior Resident, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
2 Junior Resident, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
3 Assistant Professor, Department of Family Medicine and Community Medicine, All India Institute of Medical Sciences, Jodhpur, India
4 Public health Specialist and Trainer (Saudi Board of Community Medicine), Ministry of Health, Riyadh, Kingdom of Saudi Arabia

Date of Submission12-Jun-2018
Date of Acceptance20-Jun-2018
Date of Web Publication1-Feb-2019

Correspondence Address:
Rama Shankar Rath
Senior Resident, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi-29
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2395-2113.251342

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Introduction: Universal Health coverage (UHC) is required for fulfilment of Health for All. Currently World Health Organization has proposed indicators for tracing coverage of UHC. This study aimed to find the current status of the UHC in India and Indian States. Material and Methods: Data were collected from the national data portals, national surveys and annual reports of ministry. In case of non-availability, numerator and denominator were used from different sources. Data were entered in to Microsoft excel and analysed using Stata-12. Results: Coverage indicators for Non Communicable diseases and cataract surgery were not available in any national survey or national report of ministry. Coverage of none of the health system indicators were found to be 100%. Few indicators like Skilled attendance at birth, TB cure rate, Preventive chemotherapy against filariasis, access to improved water source had a coverage of 80%. Across the states and union territories the coverage was variable but no significant difference was observed between the EAG and Non EAG states. Very few states have achieved the minimum coverage of 80% in various coverage indicators. Conclusion: There is non-availability of some data and some data were collected in duplication. Because of the lack of data, it is not yet possible to compare the UHC service coverage index across key dimensions of inequality. Until these data gaps are overcome, inequalities in service coverage cannot be assessed.

Keywords: Universal Health coverage, DLHS-4, NFHS-4

How to cite this article:
Rath RS, Pathak VK, Goel A, Rizwan S A, Lohiya A. How far we are from achieving universal health coverage? A situational analysis and way forward for India. Indian J Community Fam Med 2018;4:16-23

How to cite this URL:
Rath RS, Pathak VK, Goel A, Rizwan S A, Lohiya A. How far we are from achieving universal health coverage? A situational analysis and way forward for India. Indian J Community Fam Med [serial online] 2018 [cited 2021 Jan 24];4:16-23. Available from: https://www.ijcfm.org/text.asp?2018/4/1/16/251342

  Introduction Top

Universal Health Coverage (UHC) which emerged in the World Health Assembly 2005 is defined as “The access to key promotive, preventive, curative and rehabilitative health interventions for all at an affordable cost, thereby achieving equity in access”.[1] UHC is an important prerequisite not only for attaining health related Sustainable Development Goals (SDG) but also for poverty reduction and economic growth.[2],[3] UHC has three main dimensions – universal population coverage by quality health care, providing universal range of comprehensive health services and universal financial protection towards health expenditure.[4] Each domain is stand alone and has equal impact on the universalization of health. India in 2010 constituted a High level Expert Group (HLEG) on Universal Health Coverage to formulate a framework for accessible & equitable, affordable & assured quality, comprehensive & appropriate healthcare system entitling every citizen to essential primary, secondary and tertiary health care services guaranteed by the government.[5] This HLEG planned to achieve UHC through increase in public health expenditure, reorientation of health care to primary health care system, health insurance and trained health care personals.

Recently, World Health Organization (WHO) has recommended types of indicators for tracking UHC - one related to health services and other to cost, with equity being the underlying components in both.[6] Health services indicators include both treatment and prevention. Although around 100 core indicators are available from this only thirteen indicators were selected. These indicators were related to maternal and child health, sanitation and hygiene, family planning, coverage of Non communicable disease, tuberculosis, Human Immunodeficiency Virus (HIV) treatment, cataract treatment and preventive chemotherapy against any Neglected Tropical Diseases. WHO proposed at least 80% coverage for health service related components irrespective of the social and economic status.[6]

This study aims to review the current situation of Indian states and the country as a whole for Universal Health Coverage in light of the prescribed WHO health system tracer indicators.

  Material and Methods Top

This was a cross-sectional secondary data analysis conducted in year 2017. We searched for nationally representative data conducted on or before 2016. More specifically data related to the thirteen WHO UHC coverage indicators were the focus of the search. For this recent national surveys done in India were reviewed from government web portals.[7],[8],[9],[10],[11],[12],[13],[14] For each indicator a different source was searched if not available from a single survey. Those surveys which were not nationally representative or conducted after 2016 were excluded from the survey. We also reviewed the national report of the concerned ministry in case the indicators were not covered in the national surveys. If the indicators were not available from a single source, the numerator and denominators from different surveys or national reports (difference between the surveys being no less than five years apart) were used for calculation of the Indicator. In case of non-availability of state wise records, the survey data dissemination authority was contacted for providing data. If multiple national sources were available national surveys were given preference than the annual reports. If multiple national surveys were conducted, then the recent ones were selected. No state level indicators were included in this study.

Detailed description of Indicators

Maternal and child health indicators: There were four maternal and child health indicators in the list. All were commonly reported in various national and state level surveys. Family planning coverage which indicates the proportion of sexually active women protected by any modern contraceptive method. Antenatal care coverage indicates the proportion of live births in which mother had 4 or more ANC visits. Skilled attendance defined as the proportion of live births attended by the skilled health personnel. Immunization is only one of the child health component included in the indicator list, which includes the proportion of children younger than one year immunized with 3 doses of vaccine.

Indicators related to safe water and sanitation: proportion of population with improved source of water like piped water/ public tap/ tube well/ rain water collection. Proportion of population having access to latrine with piped sewer system.

Indicators related to protection against any one of the neglected tropical diseases from those population requiring the same. Similarly, treatment coverage indicators include two of the important diseases HIV and Tuberculosis. The numerator includes the people receiving ARV therapy among those diagnosed with HIV. Tuberculosis coverage indicators used the proportion of the cured new diagnosed tuberculosis population. Non-Communicable Disease (NCD) treatment coverage included the proportion of population diagnosed with NCDs aged more than 18 years receiving medication for hypertension and diabetes. Cataract surgical coverage includes persons aged ≥ 50 years who have operable cataract either in one eye or both and operated for cataract either in one or both eye.


Data were entered in to Microsoft excel and were analysed using Stata 12. Data were represented in distribution dot plot and bar diagram. Matrix plot was used to show the coverage in different quintiles. Data were segregated according to type of state i.e. Empowered Action Group (EAG) or Non Empowered Action Group (NEAG).

  Results Top

Availability of Data

All maternal and child health component indicators and indicators of sanitation & water were available in national surveys like National Family and Health Survey-4 (NFHS-4), District Level Family and Health Facility Survey-4 (DLHS-4) and Annual Health Survey 2011-12 (AHS).[7],[8],[10] In DLHS-4 all states were not covered neither the compiled all India data was available. For the same reason Annual health survey was also not taken in to account. Data on tobacco use was also available in NFHS-4, DLHS-4 and AHS. Tobacco use data separately for male and female were available in NFHS and DLHS reports. But combined data was not available in the NFHS/ DLHS survey, thus GATS (Global Adult Tobacco Survey) conducted in 2009 was taken in to account.[13] In Anti-Retroviral Therapy coverage the numerator was taken from annual report of NACP 2014-15 and denominator was taken from the HIV estimates (2015) of National AIDS Control Program (NACP).[14],[15] Similarly, tuberculosis treatment coverage was collected from annual report (2016) of Revised National Tuberculosis Control Program (RNTCP).[11] Non communicable disease related data was not available in any of the national reports. Similarly, cataract surgical coverage data (neither numerator nor denominator) was not available from neither the national surveys nor the program national reports.

India as a whole

Available data suggests that none of the service components has 100% population coverage, including basic factors like water and sanitation. Family planning coverage, PLHA receiving ART therapy, and Improved Sanitation has not covered half of the population in India while ANC with 4 or more ANC visits has just covered half of population. Whereas 90% population had access to safe water. Preventive Chemotherapy against Filariasis (Mass Drug Administration) although not done throughout India, but in the affected areas it had a coverage of around 86%. Around 35% of the population aged more than 14 years were found to be consuming tobacco in last 30 days. [Figure 1]
Figure 1: Progress of various indicators for UHC in India

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Distribution of Indicators across the states and union territories

Family planning coverage, ANC visit coverage, PLHA receiving treatment and access to improved sanitation showed a wide variation across different states. Whereas the TB cured, MDA against filariasis had very narrow distribution. For coverage of family planning, and TB cured in all states lied below the minimum acceptable coverage of 80%. Whereas the treatment coverage in PLHA in most of the states lied below the acceptable range of 80% except two states Himachal and Chandigarh. [Figure 2]
Figure 2: Distribution of various indicators among different states

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When segregated in to categories of EAG (Empowered Action Group) and Non EAG states, we found that majority of the coverage indicators for EAG states were below the level of 80% except skilled attendance at birth, access to improved water source, MDA against Filariasis. Coverage indicators for EAG states for family planning were below 80% in all states where as treatment coverage indicator for PLHA remained below 80% in most of the states except two states. [Figure 4] showed the coloured matrix of quintile distribution of various indicators across the different states.

Maternal and Child Health Services including family planning

Overall at the national level modern methods of family planning coverage was around 48% in NFHS-4 survey which is nearly same as NFHS-3 report (48.5%). So we can say that there is nearly no improvement of up taking of family planning methods in last decade. Among all states Manipur (12.7%) has the lowest coverage of family planning services followed by Lakshadweep (14.9%). The reason can be attributed to the fact that most of the young women in Manipur are still practicing natural method of contraception (rhythm/calendar method) as family planning method[16] and also rate of sterilization is decreased due to non-availability of facility. Many of the low performing EAG states has low coverage including Bihar, Uttar Pradesh, where as in Non EAG states the coverage ranged from 69% in Andhra Pradesh to as low as 13% in Manipur.

Pregnant women with four or more ANC check-ups ranges from 14% in Bihar to 59% in Chhattisgarh in EAG states where as in Non EAG states it ranges from 26% in Nagaland to 81% in Tamil Nadu. The reason for four ANC visit in Bihar can be due to poor doctor-patient ratio especially at PHCs and CHCs and also poor coverage of health facility at hard to reach area[17]. Many states lie above the national average of 51.2% with North Eastern States mainly laying below the national average.

Skilled attendance at birth which included trained personnel including the trained dais, national average lies at 81.4%. Among EAG states except Odisha, Rajasthan all other states had skilled attendance at birth below the national coverage. Among Non EAG states all north Eastern States lies below the national average whereas all other states lies above the national average.

From immunization services, DPT3 coverage at national level was around 62%. In EAG states it varies from as low as 47% in Assam to 78% in Odisha. In non EAG states it varies from as low as 50% in Gujrat to as high as 93% in Kerala.

Tuberculosis & HIV treatment coverage [Figure 3]
Figure 3: Distribution of various indicators according to type of state

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In India the tuberculosis cure rate was 88% according to national report. In EAG states Chhattisgarh (91%) and in Non-EAG states Nagaland (90%) had their cure rate above the national average and they have also achieved the target for End TB strategy 2016-2035 for TB cure rate. Rest all the states had their cure rate below the national average with Bihar having the lowest rate of 76%. In Bihar premature TB treatment discontinuation and symptom persistence is particularly high among individuals who have failed to complete treatment for a prior episode. Another reason could be rise in XDR TB in the Bihar state and hence there cure rate decrease.[18]

Similarly, for PLHIV receiving ART was at a very low level around 37%. Among all states Himachal Pradesh has achieved the 100% coverage of ART. In EAG states Uttarakhand has the highest coverage while Odisha has the lowest coverage. While in Non EAG states Tripura has the lowest coverage of 15% which is lowest among all Indian states. The reason could be doubled the rate of new infection of HIV in the state during 2010-2016 (consistent condom use was only 36% among FSW, in comparison to national coverage of 55%) and also only 15% of PLHIV were aware of their status.[19]

Access to Improved supply of water and Hygiene [Figure 4]
Figure 4: Matrix plot showing distribution of Indicators according to type of state

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Around 90% population in India had access to improved water while improved sanitation was available to only 48% population. When analysed state wise among EAG states Chhattisgarh (98.2%) and among non EAG states & overall Meghalaya (99.1%) had highest proportion of population having access to improved water supply. But when it comes to sanitation in Jharkhand had the lowest sanitation coverage while Uttar Pradesh has highest coverage among EAG states. Similarly, among non EAG states Arunachal Pradesh (97.7%) had highest while Manipur (29.4%) had the lowest coverage of improved sanitation.

Preventive chemotherapy against Filariasis

Currently preventive chemotherapy against Filariasis is done in coastal areas and few other affected states. In India the overall coverage rate was around 87% while highest was in Odisha with coverage around 98% while lowest was in West Bengal with coverage of 83% among the covered states.

Not Consuming Tobacco in Last 30 Days

According to GATS-09 report, in India around 65% people with age more than or equal to 15 years had not consumed tobacco in last 30 days, while this proportion was highest in Goa followed by Punjab and lowest in Mizoram among all states.

  Discussion Top

Universal Health Coverage is important determinant of health of Individual in the country. It not only covers comprehensive and quality health care but also involved the important component of financial protection at the individual level in health care utilization. Indian statistics using the World Health Organization we have found that indicators like hypertension coverage, diabetes coverage and cataract surgical coverage neither have numerator nor denominator reported by any national surveys. The reason for that can be attributed to the fact that in developing countries like India, the national survey are still aiming to capture only important health outcome data like IMR, U5MR, IMR, immunization coverage etc. and data on NCDs is still incomplete at national level because of the program related to it (NPCDCS) is relatively new.

Although basic indicator like Coverage of improved water was in nineties but maternal and child health indicators had a very poor coverage except skilled attendance at birth which has just crossed 80% level. When we compared state wise among EAG states Chhattisgarh and Odisha has better indicators than other states while among Non EAG states Tamil Nadu and Kerala has higher coverage than other states. For tuberculosis almost, all states have coverage rate around 80% or above. But in HIV treatment coverage except Himachal Pradesh rest all states have coverage less than 60%. Access to improved water is more than 60% in almost all states except Himachal Pradesh. But improved sanitation is available to less than 60% in majority of states.

From the four indicators related to maternal and child health coverage of family planning and DPT3 immunization was found to be lower than that of the South East Asia Region (SEAR). Whereas the four or more ANC visits and skilled attendance at birth was found to be higher than the South East Asia Region.[6] The currently reported coverage was also found higher than that reported by Campbell et al. for all Low and Middle Income countries.[20] Maternal and child health services although received special attention in recent years but the progress was mainly in institutional delivery and skilled attendance at delivery. This is mainly attributed to the Janani Suraksha Yojana (JSY).[21] Improvement of these services was poor in the EAG and north eastern states which could be attributed to the difficult terrain in these areas, non-availability of institutional delivery facility, poor referral mechanism and poor penetration of health services.[22] The main reason being the poor political will which is evident from poor surveillance, monitoring and inadequate training of human resources.[23] Tuberculosis is one of the well- implemented programs with coverage more than 80% in almost all states. This was found to be higher than the coverage of tuberculosis in SEAR (54%) as reported by Global Tuberculosis Report.[24] This higher coverage can be attributed to well managed and planned program, political will as well as Information Education Communication activities.[25] HIV treatment coverage was found to be as low as 37% in India. This was lower than that reported in SEAR (39%) and also throughout the world (46%).[26] This low prevalence of ART may be attributed to treatment strategy previously adapted in India i.e. treatment below CD4 count 350. According to the recent guidelines, Anti-Retroviral Therapy (ART) is started regardless of CD4 count (test & treat).[27] Preventive chemotherapy against filariasis DEC was given in few states according to the national guidelines. Although the coverage was very high in these states, compliance to the drug was questionable.[28],[29] Coverage of improved water in SEAR was found to be similar to that of India. But coverage of sanitation was found to be higher than the SEAR region.[6] Poor supply of improved water and sanitation was directly linked to political support and will.

Achievement of UHC lies on pillars of affordable and efficient health system with access to relevant medicines, and sufficient human resources for the health system. Majority of this depends on the political will and efficiency.[30] According to Economic survey of India 2016-17, total expenditure in health was around 1.4% of the GDP which is very low as compared to other South East Asian counterparts and that proposed by HLEG.[31]

This study was limited by the fact that the study has not focused on the equity measures and also using different sources for creating source of some indicator

  Conclusion Top

India has many national level surveys which can be utilized to generate indicators for tracking the health related indicators. This shows a gap in the requirement and availability of indicators for UHC. For many of the indicators there is no appropriate survey and for many there is duplication of records. Because of the lack of data, it is not yet possible to compare the UHC service coverage index across key dimensions of inequality. Until these data gaps are overcome, inequalities in service coverage cannot be assessed. In India none of the indicators have 100% coverage including basic like water and sanitation. For many indicators like skilled attendance at birth, Tuberculosis cure rate, preventive chemotherapy against NTD and access to improved water has achieved minimum acceptable level of 80% but still a lot needs to be done. While state wise results show a wide variation in the coverage of various services, but the difference between the EAG and Non EAG states looks blurred.
Table 1: Definitions of Indicators for UHC coverage with their availability in Surveys/ National Report

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  References Top

W+HO | Universal health coverage (UHC) [Internet]. WHO. [Cited 2017 Apr 23]. Available from: http://www.who.int/mediacentre/ factsheets/fs395/en/  Back to cited text no. 1
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World Health Organization, Health: essential for sustainable development [Internet]. World Health Organization. [Cited 2017 Jun 9]. Available from: http://www.who.int/universal_health_ coverage/un_resolution/en/  Back to cited text no. 3
World Health Organization | Financing for Universal Health Coverage [Internet]. World Health Organization. [Cited 2017 Apr 23]. Available from: http://www.who.int/healthsystems/topics/ financing/healthreport/en/  Back to cited text no. 4
High Level Expert Group Report on Universal Health Coverage for India [Internet]. Planning commission, GOI; 2011 [cited 2017 Sep 6]. Available from: http://planningcommission.nic.in/reports/ genrep/rep_uhc0812.pdf  Back to cited text no. 5
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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