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Health2016 READ: 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: 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:Health indicators like IMR and MMR continue to lag behind global averagesHealthcare spend is growing at a much slower average as compared to the growth of national incomeOOPS (out of pocket spending) continues to be highInfrastructure 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)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 lowerAbout 50% of the existing medical workforce does not practice in the formal health systemRegulatory system has been partially defined, and implementation is still laggardPPPs 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 badlyThus, NRHM was launched to carry out necessary architectural correction in and strengthen the basic healthcare delivery systemsSpecial 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 equalityProvision 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 organizationsA 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 healthcareAims at effective integration of health concerns with determinants of health like sanitation & hygiene, nutrition, and safe drinking water through a District Plan for HealthSeeks decentralization of programmes for district management of healthGoals: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 NutritionPrevention and control of communicable and non-communicable diseases, including locally endemic diseasesAccess to integrated comprehensive primary healthcarePopulation stabilization, gender and demographic balanceRevitalize local health traditions and mainstream AYUSHPromotion of healthy life stylesPerformance: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 healthcareHowever, 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 neededThe 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 prioritiesAll 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 programmesNational 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 coveredEven 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: 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 aloneICDS 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 anganwadisHowever, ICDS tends to be starved of resources, attention, and political supportSeveral people criticize ICDS as a failure, and consider any spending on it to be wastefulHowever, 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 6Amidst 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 companiesGovernment 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 listThe scheme is funded in a 3:1 ratio by the central and state governmentsRSBY is certainly an improvement over the existing Out-of-Pocket-System (OOPS), whereby the bulk of healthcare is purchased for cash from private providersEvaluations show that RSBY has gone some way towards increasing the usage of institutional healthcare by the most deprived sections of the populationDespite 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 costsAccessibility issues: Far-flung rural areas are unlikely to have easy access to quality private healthcare, even with insuranceDistortion 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 treatmentTargeting 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 servicesOther 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 schemeReforms (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 healthBhagwati 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 systemPublic 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 cadreThis 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 servicesAdditionally, the government should run regular information campaigns to inform the citizens about benefits of a health local environmentSecondly, 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 episodePanagariya 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 transfersMajor 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 coursesSimultaneously, need to loosen the stranglehold of the Medical Council of India over new medical institutions in the countryGovernment SchemesJanani Suraksha Yojana:Was launched in 2004 to promote institutional deliveries as against traditional, home deliveriesIs a part of NRHMLargely 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 freeDespite 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. ................
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