Dr. Sanjiv Kumar Universal Health Coverage (UHC) aims to ensure everyone receives the quality services they need, and is protected from health threats, without suffering financial hardship ( WHO ). These two aspects i.e. access to quality health care and financial protection is important. It's a way of reducing poverty and increasing health security, so that no-one is left behind. Achieving UHC is a challenge in any country. However presuming that UHC, as currently defined, will ultimately achieve health is not true. Let’s take a step back to understand what health is and what it entails.The concept of health has evolved from comprehensive health of the population to focus on those with diseases and some recent efforts to bring back comprehensive health. UHC has received a lot of attention in India and abroad in recent years. Every year 12 December is celebrated as UHC Day in which many organizations participate, review the progress and prepare a roadmap. The global push to UHC is led by WHO and World Bank . In India, High Level Expert Group has spearheaded the approach towards UHC.UHC concept is largely confined to care of the sick and financial protection of those seeking health care. India’s High Level Group of Experts set up by Planning Commission of India in 2011 too focussed on medical care. Health is missing in current UHC approaches. Is it because these expert committees are dominated by medical specialists and economist who are trained to look at health as clinicians or economists? ‘Health’ is a goal in Indian Constitution and WHO Health Charter.The current concept of health has evolved from the definition of Health in WHO charter, “A state of physical, mental and social wellbeing not merely absence of disease and infirmity”. The recognition that health is not a state but dynamically changing and adapting all the time is closer to reality. The move towards universal health started in 1978 with Alma Ata Declaration of Primary Health Care as a means to achieve ‘ Health For All ’.In 1980s the global focus moved towards selective primary health care targeting selected disease rather than promotion of comprehensive primary health care for all. Since 1970’s there have been efforts to strengthen health systems rather than disease focussed vertical programmes which received more attention in National Health Mission launched in 2005.Since British rule in India modern medicine (allopathic) has received a lot of attention from government and public. Public has developed faith in medical care and medical advancements have increased demand for specialist and expensive medical care in India and abroad. The preventive and promotive aspects of health have not received the attention it deserves even in the public health system.Health insurance is widely promoted as a panacea to all ills in health care. Today, health insurance covers about 17 percent of India's population and there is an effort to increase coverage. Global experience shows that universal insurance coverage can be sustained only if the basic determinants of health such as access to safe water, nutrition and sanitation, environment etc. are ensured. We need to ensure access to safe drinking water, sanitation including waste disposal systems, controlling environmental pollution and ensuring a measure for nutritional safety nets. Mere provision of medical insurance is insufficient to secure health of the people.Since independence medical care has been promoted with great success; demand for medical care including specialised medical care has gained tremendously but without parallel strengthening of public health system and control on private medical practitioners and hospitals.Globally, 150 million people annually experience financial catastrophe due to medical expenses. Emergence of NCDs is a warning bell that comprehensive health care approach to the population is the only rescue. There has to be an immediate and adequate action by other sectors such as local Government, industry (walking, cycling tracks, public transport, environmental factors such as mosquito breeding, air, water, soil and noise pollution), (vehicle emission and safety standards) Road and Transport (road safety) contributes to fasten escalating epidemic of these diseases.Lack of action by other sectors will not only add burden on health sector which is already struggling to deal with these conditions but also increase global burden of disease. Therefore there is a need for action in all sectors to address causes of the diseases.Lack of action in the sectors is also reflected in regular outbreaks of some communicable and non-communicable diseases. The dengue and cholera where health departments bear a heavy load of cases and faces all the criticism whereas the prevention of mosquito breeding lies in the areas of Municipal Corporation and local bodies that leads to accidents and injuries, and other NCDs like diabetes, Cardiovascular and life style diseases.The concept of health in Ayurveda is comprehensive. The philosophy of Yoga with its eight elements: Yama (non-violence, truthfulness, control of the senses and celibacy, non-stealing, non-covetousness and non-acceptance of gifts); Niyama (cleanliness, contentment, austerity, self-study, surrender to God's will); Asana (posture); Pranayama (control of prana or breath); Pratyahara (withdrawal of the senses); Dharana (concentration); Dhyana (meditation) and; Samadhi (super-conscious state) includes norms of behaviour and address life style for healthy living.Two major shifts required to address health needs in the country: The current approach under UHC needs two major shifts to address the health needs of Indian population in a comprehensive manner. The preventive and promotive approach to health needs equal attention while we are addressing the access to quality health care at affordable cost for the population and the country. Without this shift it is akin to trying to mop the floor dry while leaving the water taps on.A belief that more investments in medical care will result in better health, would mean ignoring the fact that other sectors outside health are more important in keeping the population healthy. This conceptual framework is useful in addressing the determinants of health to keep the population healthy while addressing the needs of the sick (Kumar S, Preetha GS 2012). The entire population of any society will fall into four categories a) healthy population, b) population with risk factors, c) population with symptoms and d) population with disease conditions. Each one of these four category of population groups needs to be targeted with specific interventions to comprehensively address the need of the whole population. In brief, it encompassed prevention for healthy population to curative and rehabilitative care of the population with disease.A clinician’s approach to health care will look at only providing medical care to those with diseases and detect those with undetected diseases and an economist will look at even narrower approach of how to reduce out of pocket payment and prevent catastrophic expenditure. What we need is both these and a lot more emphasis on keeping those who are healthy, healthy. Building resilience of the healthy population and population with risk factors; early detection, treatment and care including limiting disability and rehabilitation along with healthy lifestyle for population with undetected disease; and treatment and care along with healthy lifestyle for population with disease. To keep a population healthy, social determinants of health have received attention in 90s both globally and in India. This will necessitate working with sectors other than health as health sector traditionally reaches out only to the sick.The whole of society approach is more important today when non communicable diseases are on the increase and have reached epidemic proportions. Of estimated 98, 16,000 lakhs Indians who die in a year (WHO’s ‘Country Profiles’ for Non Communicable Diseases, 2014), 27,48,480 deaths are attributed to Communicable, maternal, perinatal and nutritional conditions, 25, 52,160 to cardiovascular diseases, 12,76,080 to chronic respiratory diseases, 11,77,920 to injuries, 11,77,920 to other NCDs, 6,871,20 to cancers, and 1,96,320 deaths to diabetes. The communicable diseases, maternal new-born deaths and nutritional diseases are declining as a proportion of deaths in India and account for 24,48,480. The need for increased financial allocations on medical interventions, is necessary but this alone would not pay off towards controlling such a huge and continuously rising NCD burden. The current approach needs to be modified to a comprehensive health care that encompasses preventive and promotive health care engaging other sectors to play a critical and indispensable role. This integrated approach at policy and operational level needs involvement of the leaderships at the highest political and governance level.There has been a global movement to address health in a sustainable and equitable manner through social determinants of health. Global evidence shows that 80 to 90% of health is attributable to factors outside the health sector. To improve population health, we must invest in these social determinants of health such as healthy behaviours, education, job development, housing and the environment.There is realisation at global level on various detrimental effects on health which falls outside the medical arena; WHO Health in All Policies (HiAP). One good example of such realisation is Sustainable Development Goals (SDGs) 3 which is a very good opportunity now. The SDGs being very comprehensive, provides flexibility to address the causes of diseases in sectors outside health, often referred to as social determinants of health. The SDGs can be broadly divided in following three groups (Kumar S et al 2016):i. The Environment Goals (7); include other health areas such as water and sanitation, sustainable and modern energy, resilient infrastructure, combating climate change, conservation of natural resources, terrestrial ecosystem etc.ii. The Poverty Goals (4); on the other hand aspires to end all form of poverty, end hunger by sustaining agriculture and achieving food security, promotes sustainable economic growth by provision of productive employment and decent work for all, and ensuring sustainable consumption and production etc.iii. The Inequality and peace goals (5); include inclusive and equitable quality education with lifelong learning opportunity for all, gender equality and empowering to all women and girls, reducing inequality within and among countries, promotion of peaceful and inclusive societies for sustainable development, access to justice for all and build effective, accountable and inclusive institution at all levels. Also, strengthening the means of implementation of and revitalization of the global partnership for sustainable development.With the growing burden of non-communicable diseases and the increasing costs of health care, keeping the population healthy is an important goal with benefits for all. This approach focuses on understanding, recognizing and measuring the ‘health’ impact. Health in All Policies Approach -a. Maximizes health benefits of government policies;b. Enables addressing complex health challenges;c. Contributes to sustainable development;d. Supports high priority government goals that positively affect multiple sectors including health;e. Evaluates window of opportunity that arise from changing economic, social and political realities during new policies formulation;f. Suggests monitoring and evaluation to help determine the impact of new policies on health.Identifying this inter-linkage, the Ministry of Health and Family Welfare may consider establishing a ‘Health Cell’ to identify policies, plans, projects, strategies etc. that have potential impact on health and collaborate with respective ministries in conducting Health Impact Assessments of developmental schemes.The fact that there are as many as more than twenty ministries whose policies can impact health outcomes, it is important that a robust technical support mechanism is created to support these ministries in taking relevant actions and also to initiate Health Impact Assessments. At the same time we need enormous bureaucratic will to let other ministries to take initiatives to improve health. India’s ‘Draft Health Policy 2015’ includes the need to look at health in a comprehensive manner.To conclude, often health and health care are misunderstood as medical care and associated parameters of reducing morbidity and mortality. However, health is more than just medical care and the outcome of ‘good health’ (articulated as the goal of health systems across globe) is dependent on interventions pertaining to preventive, promotive and social determinants of health. Similarly water quality, sanitation and hygiene are also central to health. Taken together, dietary and water-sanitation risk factors are responsible for almost 10 million deaths annually and 20% of the global disease burden.(The author is the Executive Director at NHSRC, Ministry of Health & Family Welfare, Govt of India)