Towards a Better Healthcare

Group 2 - Section C
Arka Biswas (132) | Ashima Aggarwal (135) | Divyaveer Sachin (142) | Panii Ngaonii (152) | Pradeep Dutta (156)

Agenda
Public health in India - The real picture - Deepening health insecurity in India - Government Spending - India vs. South East Asian Region Government Flagship Programmes – Success & Failure - National Health Rural Mission - Rashtriya Swasthya Bima Yojana

Universal Health Care in India - Implementation - Role of PPP in UHC

Indian Institute of Management, Kozhikode

2

3/1/2013

THE REAL PICTURE

India is home to -

23% of the tuberculosis patients, 86% of diphtheria patients, 54% of leprosy patients, 29% of pertussis patients, 42% of polio victims and 55% of malaria patients in the world 43.5% underweight children below the age of five years
Only 21% of the rural population had access to “improved” sanitation facilities in 2008

What is Public Health?

KEY GOAL – To reduce a population’s exposure to disease

Assuring food safety
Health Education Vector Control Health Regulations Medical Services

Monitoring waste disposal and water systems

Kozhikode 5 3/1/2013 .States are not free to reallocate funds to higher priority issues Indian Institute of Management.Funds allocated from centre to the states .Focus on aspects other than health care Organizational changes needed to maintain public health .Public Health in Independent India Neglect of public regulations and their implementation .Deficiencies in “ Prevention of Food Adulteration Act” Diversion of funds from public health services .Public Health Acts have not been updated .Health is primarily a state responsibility .

and (b) increased health-seeking behaviour of the population in general Figure: Reporting of Short Duration Ailment. Kozhikode Figure: Share (Percentage) of Public to Total Short-duration Treated Ailments in Rural and Urban India (1986-87. 1995-96 and 2004. Hospitalization and No Formal Treatment (1987-88.Deepening Health Insecurity in India Declining Public Provisions Increase in reporting of ailments can reflect (a) an increased morbidity burden in the country. in %) Indian Institute of Management. 199596 and 2004) 6 3/1/2013 .

Urban and Combined (2004) Indian Institute of Management. one and a half times more expensive than the public facilities. are forcing patients to procure drugs and receive diagnostic services from private sector providers. Kozhikode 7 3/1/2013 . Figure: Per Episode Average Cost of Treatments for Outpatient and Inpatient in Government and Private Sector. Rural. Government healthcare facilities.Deepening Health Insecurity in India Increasing cost of treatments For outpatient treatments. private healthcare facilities are.

39 million additional people plunged into poverty because of OOP payments. Figure: Increase in Number of Poor Due to OOP Payments (in million) Indian Institute of Management. Kozhikode 8 3/1/2013 . In 2004-05.Deepening Health Insecurity in India Impact Increase in poverty ratio is contributed mainly by households’ expenditure on health.e. i. the OOP.

any rise or fall in states’ health spending influences total spending much more than the centre’s.Government Spending from 1999 to 2005 States account for three quarters of all government health spending. Figure: Government Health Expenditure as Per Cent of GDP till 2004-05 Figure: Share of Government Health Expenditure in Total Government Expenditure till 2004-05 (%) .

704 crore in 2004-05 to Rs 39.97 per cent to about 1.05 per cent during this period Figure: Government Health Expenditure as Per Cent of GDP since 2004-05 Figure: Share of Government Health Expenditure in Total Government Expenditure since 2004-05 (%) .046 crore in 2006-07 or by 41 per cent.Government Spending since April 2005 Total Government Health Expenditure increased from Rs 27. its share in GDP too increased from 0.

Kozhikode 11 3/1/2013 .Where do we stand Indian Institute of Management.

The density of nurses/midwives per 1000 is 13 in India as compared with SEAR’s average of 11 and global average of 28 3. SEAR Life expectancy at birth. per capita annual expenditure on healthcare is $109 in India compared with $ 104 in SEAR. MMR. Gross Urban Bias in government expenditure !!! . 2. <5 years mortality rate. In PPP terms. The density of doctors per 1000 of population is about 6 in India while the average for SEAR is 5 and the global average is 14. healthy life expectancy. manpower at a density of 6 per 1000 beats the SEAR and global average of 4. low birth – weight babies. India s consistently performs below SEAR & the global average. In the pharmaceutical field. neo natal mortality rate. 1.India vs. 4.

especially for those residing in rural areas. women and children” .National Rural Health Mission(NHRM) “carry out necessary architectural correction in the basic health care delivery system … to improve the availability of and access to quality health care by people. the poor.

Objectives 1/3rd population lives in rural Grass root level Building Infrastructure Eradicate diseases Infant mortality rate (IMR) of 30 per 1000 live births Maternal mortality 100 per 100 thousand live births Total fertility rate of 2.1 by 2012 .

Objectives Decentralization Communitization Organizational structural reforms Operationalizing existing health facilities to meet IPHS .

Funding National State District Funds allocation .

Implementation of Strategic options 1 • HEALTH INFRASTRUCTURE AND FACILITY UPGRADATION • HUMAN RESOURCE • UTILIZATION OF PUBLIC HEALTH SERVICES 2 3 .

Upgradation work Upgradation to IPHS PHC functioning on 24x7 basis Rogi Kalyan Samities (PPP) Village Health and Sanitation Committees (VHSCs) Village Health and Nutrition Days (VHNDs) .Health Infrastructure And Facility Upgradation Facility .

HUMAN RESOURCE ANMs ASHAs Referral and Emergency Transport .

Utilization of Public Health Services Institutional deliveries Children immunization AYUSH program The National Disease Control Programme (NDCP) Family planning Chronic diseases services .

Expenditure .

barely halfway and accreditation is yet to even begin  Involvement of the private sector with a well thought-out long-term plan for integration of the two sectors through regulation is necessary  The Indian healthcare system has become an inverse pyramid with very little primary care as foundation and ever-ballooning “medical” sector through a hospital-doctor-centric .Scope for Improvement  Even after many years very few hospitals fall under the purview of IPHs(Indian Public Health Standard)  Doctors abhor rural centres because of poor infrastructure and working conditions  The lack of a good and transparent human resources policy encourages corruption and discourages good work  The average ASHA is hardly getting the promised Rs 1.400 per month  ASHAs are not equipped to undertake their complex social roles in rural areas  Training is poor.

Rashtriya Swastya Bima Yojana (RSBY) .2007 • “To provide protection to BPL households from financial liabilities arising out of health problems leading to hospitalization” • Hospitalization coverage up to Rs.30000 • No age limit. 30 as registration fee • Central (75%) and State (25%)pays the premium to insurer Indian Institute of Management. Kozhikode 23 3/1/2013 . completely cashless • Pays only Rs. up to 5 family members.

making this scheme out of reach of migrant workers who are far from home •Verification process of BPL •Delay & related delivery hassles •0.4% of enrolled households •Lack of preparedness of empanelled hospitals •Problems with Smart Card Technology and Reimbursement System •Insurance company interested in premium •Hospitals interested in cost recovery Conditionality Issuance of smart cards Utilization Misaligned incentives & Frauds Indian Institute of Management. Kozhikode 24 3/1/2013 .Issues in implementation Awareness •Poor knowledge of how and where to utilise the scheme •Lack of coordination & implementation among various stakeholders •Pre-requisite of BPL card • People need to be registered as BPL in their home state.

596 (penetration: around 50%) hospitalisation cases: 4.146.Current scenario & outcomes of RSBY Active smart cards: 34. Kozhikode 25 3/1/2013 . which has the world's oldest social security system Infrastructure build-up regarding healthcare in semi-urban & rural areas regarding catering to the huge BPL population. UN & ILO as world’s one of the best health insurance schemes Germany showed interest of implementing this smart card based health insurance scheme. which were previously dominant in urban areas only Indian Institute of Management.728 (as of 20th February 2013) Hailed by World Bank.909.

Kozhikode 26 3/1/2013 .Moving along the path: Universal Health Coverage(UHC) Indian Institute of Management.

UHC In India: A dream in progress In October 2010. Kozhikode 27 3/1/2013 . the Planning Commission of India with the approval of the prime minister. appointed a High Level Expert Group (HLEG) to develop a framework for universal health coverage (UHC) to be implemented over 2010-20. India aims to introduce universal health coverage during the 12th five year plan (2012-2017) Indian Institute of Management.

Kozhikode 28 3/1/2013 .” Indian Institute of Management.High Level Expert Group – Strategy and Recommendations • “.

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. caste or religion. although not necessarily the only provider. social status. resident in any part of the country. gender.” Indian Institute of Management.What to Achieve ? “Ensuring equitable access for all Indian citizens. of health and related services. accountable. to affordable. regardless of income level. preventive. Kozhikode 29 3/1/2013 . appropriate health services of assured quality (promotive.

Kozhikode 30 3/1/2013 .Architecture ENTITLEMENT Health package for every kind of citizen. including cashless in-patient & out-patient care -Primary -Secondary -Tertiary care Choice of Facilities People can choose over private & public facilities to cure themselves Indian Institute of Management. depending upon the affordability & other conditions National Health Package Guaranteed access to essential health care.

quality. Kozhikode 31 3/1/2013 .Wh’s of Implementation…1 Health Financing and Financial Protection • Establish a financial mechanism to drive UHC • Increase government spending to at least 3% of GDP by 2022 Health Service Norms • Ensure last mile connectivity to poor. and accessibility • Develop national health package and ensure quality of health services at all levels Human Resources for Health • Ensure trained and adequately supported practitioners with relevant expertise • Invest in educational institutions to produce and train the requisite health workforce and strengthen existing ones Indian Institute of Management.

Vaccines and Technology • Revise and expand the essential drugs from National Essential Drugs List • Price control and regulation on drugs and vaccines Management and Institutional Reforms • Develop a national health information technology network • Establish financing and budgeting systems to streamline fund flow Indian Institute of Management.Wh’s of Implementation…2 Community Participation and Citizen Engagement • Strengthen the institutional mechanisms to improve public decision-making • Transform existing Village Health Committees (into participatory Health Councils Access to Medicines. Kozhikode 32 3/1/2013 .

In search of Light: “McKinsey” Way Growth Border Crossing Rural Drive Indian Institute of Management. Kozhikode 33 3/1/2013 .

Kozhikode 34 3/1/2013 .…“Extracts” “Emphasis access through Health Insurance” “Ensure smooth implementation of Patent Law” “Support capability building in R&D” “Continued emphasis on public health resources & infrastructure” “Adopt a broader view of Healthcare cost” Indian Institute of Management.

Kozhikode 35 3/1/2013 .India: UHC – Can the dream come true? Need of a political leadership which can make the most of economic and political windows of opportunity Service should be prioritized attending the rural poor first Reach country's most isolated regions to dispense health Develop models of decentralized district level planning and delivery of health services Emphasize on preventive and primary care services Non primary services to be left for the private players Accounting for a large informal sector Contribution from the formal sector could be useful to crosssubsidize Implement health care rationing and waiting lists for certain procedures and treatments to deal with increasing demand Indian Institute of Management.

management and operations. IT infrastructure. partnership firms. financing. self-help groups. to service management and coordination  Could be at primary level.PPP in PHC  PPP is a mode of implementing government programs/schemes in partnership with the private sector  Includes corporate sector. individuals and community based organizations  PPP is essential for infrastructure development. capacity building and training. voluntary organizations. secondary level or tertiary levels across various states in India . and materials management  Shift in emphasis is from delivering services directly.

Dimensions of PPP Responsibility Ownership Service nature Risk and reward • Full retention of responsibility by the government for providing the service • PPP may continue to retain the legal ownership of assets by the public sector • nature and scope of service is contractually determined between the two parties • shared between the government (public) and the private sector .

with operations & maintenance contract PPP contract operations & maintenance (management) contract .Contractual framework service contract capital projects.

PPP: Pros and Cons Pros:  PPP brings together resources and expertise from both the public and private sectors  Increase accessibility and availability of services to rural India  Increase the quality and quantity of manpower available  It would improve primary care services which in turn would improve quality of life Cons:  It would corporatize healthcare  It could lead to widespread corruption  The Government could completely get out of the healthcare sector .

PPP: Major schemes under DoH Major Schemes implemented through PPP under Ministry of Health & Family Welfare Department of Health: The Revised National TB Control Program (RNTCP) National Program for Control of Blindness National Cancer Control Program National AIDS Control Program National Leprosy Elimination Program (NLEP) Central Government Health Scheme (CGHS) .

Issues in PPP in healthcare Capacity of Private Partner Advocacy Accreditation Regulation by the Government • The capacity limitation is the major hurdle in scaling • General public's fear about PPPs being a façade for privatization • Central and state must reassure the public about the PPP process • Accreditation of Private NGO Hospitals for Institutional Delivery • Insufficient regulation by the government .

Major concerns Inadequate number of players in the market • Free and fair selection of partners does not happen • Often mediated through money & political patronage Absence of a wellarticulated “MoU” • Inadequacies pertaining to fair process of selection • No serious rules for non-compliance with the outputs • Do not clearly spell out the breach of contract by either party Poorly defined roles: Lack of accountability • Bureaucratic professionals within the public sector are not ready to adhere to rules and regulations as an equal partner with the private sector .

renewal of contract) are controlled by Government • No third party institutional mechanism that can play the role of an independent arbitrator • Only recourse is the court of law.Major concerns Incorrect view of “cost-efficiency” • Non-monetary parameters not included • Non-monetary factors like trust.g. responsiveness. accountability. cumbersome and prolonged settlement not viable for PPPs . interactive quality not adequately accounted for Asymmetry: Skewed towards Government Absence of a neutral arbitration mechanism • Private sector actually has a minor role of mainly demand generation in most cases • Often major terms of agreement (e.

Standardization: The road ahead  Currently no standardization of PPP in Healthcare  PPPs are happening at both state level and at national level and at various points of the value chain  The scale and magnitude are different at each level  Need for a model framework acting as policy framework  Need a central approach to execution of PPP projects while the components of the model may differ from state to state  Standardization of model would embolden major healthcare players to venture in PPPs in a big way .

Case study: Chiranjeevi Project in Gujarat Announced by the Government in April 2005 to target group is women living BPL who face socioeconomic hardships due to complications during delivery Implementation:  The private practitioners were chosen by the district health centers after a detailed survey of their infrastructure assess their conditions of services  The contracted practitioners were reimbursed through a capitation payment basis under they are paid for each delivery at a fixed rate Performance: Institutional deliveries in the five states increased from 38 to 59 per cent No maternal deaths and only 13 infants death Reasons for Success:  Transparent pricing mechanism  Involves a network of private practitioners  Built trust with doctors by ensuring regular payments and there is constant monitoring of the program .

References .

THANKYOU Indian Institute of Management. Kozhikode 47 3/1/2013 .

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