Health

2016 READ:
http://www.livemint.com/Opinion/CcE7fkG3behtIalLdiw3oO/Hidden-hunger-
and-the-Indian-health-story.html

Although India has done well to be on track to achieve some of the MDGs like
reduced MMR and IMR, there are still many infectious diseases which the system
has failed to respond to. There is also a growing burden of non-communicable
diseases. Incidence of catastrophic expenditure due to healthcare costs is
growing and is now being estimated to be one of the major contributors to
poverty.

The 12th FYP aims at ‘Universal Health Coverage’, that assures access to a defined
essential range of medicines and treatment at an affordable cost, which should
be entirely free for a large percentage of the population.

Read:
https://nagahistory.wordpress.com/2014/03/12/indian-health-care-system/

Spending on Health: Public expenditure on health in India is very low (about 1%

of the GDP) and has remained at this fraction for about two decades now. Only 9
countries in the world have a lower ratio. In comparison, China spends 2.7% of
its GDP, Latin America 3.8, and the world average is 6.5%.

Overall expenditure on healthcare, on the other hand, stands at 4% of GDP

(as against public, which is 1% => private expenditure is 3%, much higher
than public).

The total spending on healthcare in 2011 in the country is about 4.1% of GDP. Global
evidence on health spending shows that unless a country spends at least 5–6% of its
GDP on health and the major part of it is from Government expenditure, basic health
care needs are seldom met.

In addition to this low public expenditure on health, what stands out is that
public expenditure accounts for only 30% of the total health expenditure (world
average: 63%; most EU countries: over 70%). Thus, India has one of the most
commercialized healthcare systems in the world. This is largely a result of
the fact that the country’s public health facilities are very limited, and quite often,
badly run. Even where the health facilities exist, absenteeism rates among health
workers range from 35-58%.

Private health facilities, given their extensive spread, are virtually

unregulated. About 80% of all outpatient and 60% of all inpatient care comes
from the private sector. About 40% of all private healthcare is provided by
informal, unqualified professionals. 72% of all private healthcare enterprises are
household-run businesses, who provide health services without hiring a worker
on a fairly regular basis.
Malnutrition: No country for which data is available has a higher proportion of
underweight children than India, which has 43% of its children as
underweight, as measured by the weight-for-age figures (China- 4%; Sub-
Saharan Africa- 20%). There is also a serious issue regarding a lack of
improvement over time; for example, the proportion of underweight children
was not much lower in 2006 as compared to 1992.

Immunization rates: Immunization rates in India are among the lowest in the
world for almost all vaccines (BCG, DPT, Polio, Measles, and Hepatitis B). In fact,
outside Sub-Saharan Africa, one has to go to conflict-ravaged countries like
Afghanistan, Haiti, and Iraq etc. to find immunization rates that are lower than
India’s.

Overall, problems with the health sector can be summarized as follows:

1. Health indicators like IMR and MMR continue to lag behind global
averages
2. Healthcare spend is growing at a much slower average as compared to the
growth of national income
3. OOPS (out of pocket spending) continues to be high
4. Infrastructure gap remains substantial (only 1.3 beds per 1000 people in
2010; global average is 2.6, WHO guideline is 3.5. 63% of these beds are in
the private sector)
5. Health workforce inadequate; only 0.7 doctors per 1000 people
(including nurses, 2.2 / 1000); a high proportion of these are also
inactive, so the effective ratio is much lower
6. About 50% of the existing medical workforce does not practice in
the formal health system
7. Regulatory system has been partially defined, and implementation is still
laggard
8. PPPs haven’t really taken off

Amidst this backdrop, the NRHM was launched with much fanfare in 2005 by the
then new UPA government.

NRHM:
 Run by Ministry of Health and Family Welfare
 It was seen that where human resource capacities are sub-optimal, logistics
are weak, and infrastructure is inadequate, all national health programmes
were doing badly
 Thus, NRHM was launched to carry out necessary architectural correction
in and strengthen the basic healthcare delivery systems
 Special focus on 18 states that have weak public health infrastructure/
indicators (north east, UP, Bihar, Uttarakhand, MP, Rajasthan, J&K
(‘improvement in healthcare infrastructure in demographically backward
states and districts’)
 Key components:
  The thrust of the mission is on establishing a fully functional, community
owned, decentralized health delivery system to ensure simultaneous
action on a wide range of determinants of health such as water,
sanitation, education, nutrition, and social and gender equality
 Provision of a female health activist in each village (ASHA); ASHAs would
not be drawing any fixed salary and would be given performance based
compensation, a concept which matches closely with recruitment pattern
in private organizations
 A village health plan prepared through a local team headed by the Health
& Sanitation Committee of the Panchayat
 Strengthening of the rural hospital for effective curative care and made
measurable and accountable to the community through Indian Public
Health Standards (IPHS)
 Integration of vertical Health & Family Welfare Programmes and Funds
for optimal utilization of funds and infrastructure and strengthening
delivery of primary healthcare
 Aims at effective integration of health concerns with determinants of
health like sanitation & hygiene, nutrition, and safe drinking water
through a District Plan for Health
 Seeks decentralization of programmes for district management of health

 Goals:
 Reduction in Infant Mortality Rate (IMR) and Maternal Mortality Ratio
(MMR)
 Universal access to public health services such as Women’s health, child
health, water, sanitation & hygiene, immunization, and Nutrition
 Prevention and control of communicable and non-communicable
diseases, including locally endemic diseases
 Access to integrated comprehensive primary healthcare
 Population stabilization, gender and demographic balance
 Revitalize local health traditions and mainstream AYUSH
 Promotion of healthy life styles

 Performance:
 NRHM has done well in augmenting depleting numbers of health workers
in the public health system, and deployed about 20,000 ambulances for
free emergency response (helping poor households save on transport
costs)
 Provided cash transfers to over a million pregnant women annually
 Across states, major increases in outpatient attendance, and institutional
delivery of healthcare
  However, gaps between the desired norms and actual levels of
achievement were worse in high focus states
 Inefficiencies in fund utilization, poor governance and leakages have
been a greater problem in some of the weaker states
 Much of the increase in service delivery was related to select
reproductive and child health services and to the national disease
control programmes, and not to the wider range of health care services
that were needed
 The National Rural Health Mission was intended to strengthen State
health systems to cover all health needs, not just those of the national
health programme. In practice, however, it remained confined largely to
national programme priorities
 All the disease conditions for which national programmes provide
universal coverage account for less than 10% of all mortalities and only
for about 15% of all morbidities. Over 75% of communicable diseases
are not part of existing national programmes

National Health Policy 2015:

 Aims to achieve universal health coverage by advocating health as a

fundamental right, whose denial will be ‘justiciable’
 Aims to increase public expenditure on health from the current 1% of GDP to
2.5% over the next 5 years (public + private is at about 4% currently)
 Problems: Currently, national programmes provide coverage only with
respect to certain interventions such as maternal ailments, which account for
less than 10% of all mortalities. Over 75% of communicable diseases are
outside their purview and only a limited number of non-communicable
diseases are covered
 Even if ratified by the parliament, since health is a state subject, adoption by
the different states will be voluntary. Thus, adoption might not be uniform
across the country, and that sort of defeats the purpose
 Read:
http://www.business-standard.com/article/opinion/a-misguided-approach-
115010601238_1.html

ICDS:
 India has one of the highest malnutrition rates in the world (43% are
underweight, 48% have a lower than average height for age, and 28% infants
are born with a low birth weight)
 A child’s nutritional status is hard to correct if it is ignored initially; given the
extent of illiteracy and counter-productive social norms in many areas in
India, care of young children cannot be left to the household alone
 ICDS is the only national programme aimed at children under 6 years of
age; it aims to provide integrated health, nutrition, and pre-school education
services to children under 6 through local anganwadis
 However, ICDS tends to be starved of resources, attention, and political
support
 Several people criticize ICDS as a failure, and consider any spending on it to be
wasteful
 However, in states where ICDS is managed well, it has shown rather good
results. Even in not so well-run states (such as Rajasthan, UP, Chhatisgarh),
results aren’t all bad
 Results show that regardless of how they are run, AWCs atleast open regularly
and have an active ‘supplementary nutrition programme’. This means that
India has a functional, country-wide infrastructure that makes it possible, in
theory, to reach out to children under 6

Amidst these faltering moves towards consolidation of India’s public health

services, there are also developments towards an ever-greater reliance on
private provision of healthcare and private insurance, as can be seen by the
championing of Rashtriya Swasthya Bima Yojana (RSBY):

RSBY:
 Was initially handled by Ministry of Labour; now handled by Ministry of
Health and Family Welfare
 Under this scheme, BPL families are enrolled with private insurance
companies
 Government pays the insurance premium, which entitles the beneficiaries
to Rs. 30,000 (maximum annual expenditure for a family of five) of
healthcare in an institution of their choice, to be picked from a given list
 The scheme is funded in a 3:1 ratio by the central and state
governments
 RSBY is certainly an improvement over the existing Out-of-Pocket-System
(OOPS), whereby the bulk of healthcare is purchased for cash from
private providers
 Evaluations show that RSBY has gone some way towards increasing the
usage of institutional healthcare by the most deprived sections of the
population
 Despite its attractive sounds, there are several reasons to be deeply
concerned about this healthcare model:
 Efficiency issues: Since the government will pay the insurance
premium, neither the insured patients nor the healthcare providers
will have any incentive to contain costs
 Accessibility issues: Far-flung rural areas are unlikely to have easy
access to quality private healthcare, even with insurance
 Distortion issues: Commercial health insurance is likely to be biased
against preventive healthcare and towards hospital care. This will
happen, even though various major diseases such as cancer, diabetes
etc. can be best dealt with by early, pre-hospitalization treatment
 Targeting issue: how to identify BPL families?
 Further, this model gives the government an easy opportunity to shrug
its shoulders and further wash its hands off the responsibility of
providing public health services
  Other issues included a multiplicity of similar schemes run by various
state governments; low awareness among beneficiaries about when to
use RSBY, denial of services by healthcare providers etc.
 Modi government has decided to ban private insurers from RSBY
now; only public sector insurers will be allowed under the scheme

Reforms (Sen and Dreze):

 We need to stop believing, despite all evidence, that India’s transition to
good healthcare can be easily achieved through private healthcare and
insurance; this hasn’t happened anywhere in the world, and most
developed countries contribute to well over half of the national health
expenditure
 Need a renewed focus on PHCs, village-level health workers,
preventive health measures etc.
 We need to devote much more resources as a proportion of GDP to public
expenditure on health

Bhagwati and Panagariya:

 Reforms are necessary in 5 key areas: public health, routine healthcare,
care involving hospitalization or outpatient surgeries, human resources,
and oversight of the health system

 Public Healthcare:
 Public healthcare system in India is biased towards allocation of health
expenditures in favor of medical services rather than public health; this
is a result of the post-independence decision to merge the medical and
public health services into a single department; later, medical and
public health cadres of services were also merged into a single cadre
 This has resulted in neglect of public health services in favor of medical
services in India; in principle, establishment of a separate agency
entrusted with public health services with its own separate budget
should help boost the provision of these services
 Additionally, the government should run regular information
campaigns to inform the citizens about benefits of a health local
environment
 Secondly, FSSAI (Food Safety and Standards Authority of India) needs
to be made more effective

 Routine Healthcare:
 This includes ailments such as cold, cough, fever, and minor injuries
that are widespread and do not cost very much to treat per episode
 Panagariya says government has tried to provide healthcare of this
kind to people via PHCs for 50-odd years, and there’s not much to show
for it (only 20% of rural patients seek routine outpatient care at PHCs;
rest choose private healthcare providers (many of whom are
underqualified)
 He says best solution is cash transfers
  Major Illnesses are perfect candidates for insurance. RSBY is on the right
track here.

 Human Resources:
 Many of the unregulated private sector healthcare practitioners (Rural
Medical Providers- RMPs) are under-qualified
 Replacing them all with ‘proper’ MBBS doctors might not be feasible in
the short run, but maybe we can run one-year accreditation courses
 Simultaneously, need to loosen the stranglehold of the Medical Council
of India over new medical institutions in the country

Government Schemes

Janani Suraksha Yojana:

 Was launched in 2004 to promote institutional deliveries as against
traditional, home deliveries
 Is a part of NRHM
 Largely as a result of JSY, Maternal Mortality Rate (MMR) has declined
from 600 in 1990 to 178 in 2010 (highest declines have been seen in the
post JSY period)
 Janani Shishu Kalyan Yojana was launched in 2011 to provide service
guarantee in the form of entitlements to pregnant women, sick new borns,
and infants; facilities include free transport to and from health centers,
diet, diagnostics, drugs etc. for free
 Despite all this, about 50,000 women die during childbirth annually. A
host of socio-economic factors like illiteracy, child marriage, low
awareness etc. contribute significantly to this

Regulation:
The Government’s regulatory role extends to the regulation of drugs through
the CDSCO, the regulation of food safety through the office of the Food Safety
and Standards Authority of India, support to the regulation of professional
education through the four professional councils and the regulation of clinical
establishments by the National Council for the same.