HRLN Using the Law for Public Health Dr Shrinath Reddy

8/3/2019 HRLN Using the Law for Public Health Dr Shrinath Reddy

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REPORT OF THE

HIGH LEVEL EXPERT GROUP ON

UNIVERSAL HEALTH COVERAGE

PRESENTATION TO THE

HONOURABLE MINISTER

FOR

HEALTH & FAMILY WELFARE

GOVERNMENT OF INDIA


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WORLD

THE CHINDIAN CENTURY

With so many of the world's

economies in tatters, the

combined might of China and

India could spearhead global

growth in the coming decades.

Are they up to the job?

By ZOHER ABDOOLCARIM THE CASE FOR INDIA:

FREE TO SUCCEED

By MICHAEL

SCHUMANTIME : NOVEMBER 21, 2011


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KEY HEALTH INDICATORS:

INDIA COMPARED WITH OTHER COUNTRIES

Source: World Health Organization (2011) IMR Infant Mortality Rate

Indicator India China Brazil Sri Lanka Thailand

IMR/1000 live-births 50 17 17 13 12

Under-5 mortality/

1000 live- births

66 19 21 16 13

Fully immunised (%) 66 95 99 99 98

Birth by skilled attendants 47 96 98 97 99


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LOW PRIORITY TO PUBLIC SPENDING ON HEALTH

INDIA AND COMPARATOR COUNTRIES 2009

Total public

spending as %

GDP (fiscal

capacity)

Public spending

on health as % of

total public

spending

Public spending

on health as % of

GDP

India 33.6 4.1 1.4

Sri Lanka 24.5 7.3 1.8

China 22.3 10.3 2.3

Thailand 23.3 14.0 3.3

Source: WHO database (2009)


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Change in poverty (USD 1.08 per day) head count ratio

by out of pocket payments in 11 countries in Asia

WHO Global Atlas on Cardiovascular Diseases Prevention and Control 2011


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Indias Current Health Scenario

Largest number of underweight children (46% under 3 yrs);

Current infant mortality rate of 50 per 1000 live births; Maternal mortality ratio presently 212 per 100 000 live births;

Challenge to meet national goals of 38 per 1000 (IMR) or 100

per 100 000 (MMR) by 2015

Rising burden of NCDs

2011(in Millions)

2030(in Millions)

Diabetes 61 101

Hypertension 130 240

Tobacco Deaths 1+ 2+

PPYLL Due to CVD Deaths

(35-64 Yrs)

9.2 17.9


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CHILD DEATHS : DISPARITY ACROSS STATES

IMR : MP : 72/1000

UP : 69/1000

Tamil Nadu : 35/1000

Kerala : 13/1000

Neonatal Mortality Rate VariesFrom 11/1000 in Kerala to 53/1000 in Odisha


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Impoverishment Due to OOP Payments in India

(In Millions)

Source: Selvaraj and Karan (2009)


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CURRENT SCHEMES FOR

FINANCIAL PROTECTION MOSTLYDO NOT COVER

OUT PATIENT CARE DRUGS LAB DIAGNOSTICS

Which collectively contribute tothe larger fraction of OOP!


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HOSPITAL BED CAPACITY, BY COUNTRY

Source: World Health Statistics (2011)


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HEALTH SERVICES : URBAN RURAL DISPARITY

80% of Doctors

75% of Dispensaries

60% of Hospitals

Qualified Physicians:

11.3/10,000 - Urban Areas1.9/10,000 Rural areas

Are Located In

Urban Areas


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HLEG: Terms of Reference

1. Human Resource Requirements

2. Access to Health Care Services

3. Management Reforms

4. Community Participation

5. Access to Medicines

6. Health Care Financing7. Social Determinants of Health


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Our Definition of UHC

Operational Definition

Ensure equitable access for all Indian citizens resident in any part ofthe country, regardless of income level, social status, gender, caste orreligion, to health services (promotive, preventive, curative, andrehabilitative) that are affordable, appropriate and of assuredquality.

Definition Ensuring equitable access for all Indian citizens resident in any part

of the country, regardless of income level, social status, gender, casteor religion, to affordable, accountable and appropriate, assured

quality health services (promotive, preventive, curative andrehabilitative) as well as public health services addressing widerdeterminants of health delivered to individuals and populations,with the government being the guarantor and enabler, although notnecessarily the only provider, of health and related services.


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Guiding Principles

Universality;

Equity;

Non-exclusion and non-discrimination;

Comprehensive care that is rational & of goodquality;

Financial protection;

Protection of patients rights that guaranteesappropriateness of care, patient choice, portability &continuity of care;

Consolidated & strengthened public healthprovisioning;

Accountability & transparency; and

Community participation


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Our Vision

Universal Health Entitlement for

every citizen - to a National Health

Package (NHP) ofessential primary,secondary & tertiary health care

services that will funded by the

government.

Package to be defined periodically by an Expert

Group; can have state specific variations


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Health Financing & Financial Protection

Government (Central government and statescombined) should increase public expenditureson health from the current level of 1.4% of GDPto at least 2.5% by the end of the 12th plan, andto at least 3% of GDP by 2022.

Ensure availability offree essential medicines byincreasing public spending on drug procurement;

General taxation as principal source of healthcare financing complemented by additional mandatorydeductions from salaried individuals & tax payers, either as a proportionof taxable income or as a proportion of salary


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Even on assuming total spending on health remains at the current level of

around 4.5% of GDP, there will be a sharp decline in the proportion of

private out-of-pocket spending on health - from 67% today to 33% by 2022


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Do not levy sector-specific taxes for health

financing;* Remove user fees for NHP services- this applies

even for the non-poor

Introduce specific purpose transfers to equalize

levels of per capita public spending on health bydifferent states - to ensure all citizens are entitled to samelevel of essential healthcare;

Accept flexible and differential norms for

financing that are proposed by states, recognizingphysical and socio-cultural diversities

Integrate government insurance schemes intoUHC through India Health Card


* Higher taxes on tobacco and alcohol recommended for other reasons


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User Fees for health care were put forward as a way

to recover costs and discourage the excessive use of

health services and the over-consumption of care.

This did not happen. Instead, user fees punished the

poor.

-Dr. Margaret Chan, Director-General, WHO (2009)

Among the quick win strategies recommended by

the Millennium Project was the removal of user fees

for primary education and essential healthcare by theend of 2006.

- Dr. Jeffrey Sachs (2005)


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NO USER FEE

UHC PACKAGE OF

HEALTH SERVICES

(NHP WITH NHEC)

HOSPITALITY

COMPONENT

(Pvt. Ward)

INSURANCE(PVT./EMPLOYER) OR OOP

PERSONS

OPTING FOR

NON-NHEC

ACCREDITED

HOSPITALS

NON-NHP

SERVICES


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NO USER FEE

UHC PACKAGE OF

HEALTH SERVICES

(NHP WITH NHEC)

HOSPITALITY

COMPONENT

(Pvt. Ward)

INSURANCE(PVT./EMPLOYER) OR OOP

PERSONS

OPTING FOR

NON-NHEC

ACCREDITED

HOSPITALS

NON-NHP

SERVICES

ADDITIONALSERVICESFOR THE

POOR


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Primary healthcare including preventive/curative services at

primary level along with health promotion targeted towardsspecific risk factors, should account for 70% of all govt.

healthcare expenditures

Provide universal financial protection and access to good health

care without involving insurance companies or any otherindependent agents to purchase healthcare services (NHP) on

behalf of govt.

BECAUSE

Independent agents fragment the nature of care beingprovided, leading to high health care costs and lower levels of

wellness at the population level

Central and State governments should purchase services

(through agencies linked to Department of Health)


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Technical and other capacities developed by

Ministry of Labour for RSBY should become

the core of UHC operations and transferred

to MoHFW.

Integrate the services provided under

different programs gradually (NRHM andother vertical programs such as, HIV/AIDS);


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HEALTH CARE SERVICES

BREADTH

ACCOUNTABILITYQUALITY

DEPTH

GOVERNANCE

EQUITY

EXC

ELLEN

CE

EFFICI

EN

CY


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PROVISION OF HEALTH CARE

Strengthen Public Services(Especially: Primary HealthCare-Rural And Urban; District Hospitals)

Contract Private Providers(As Per Need And Availability)

With Defined Deliverables

Integrate 10, 20, 30 Care

Through Networks of Providers(Public; Private; Public-Private)

Regulateand Monitor

For Quality,Cost AndHealth

Outcomes


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Access to Medicines, Vaccines &

Technologies

Ensure rational use of drugs;

Set up national & state drug supply

logistics corporations; Empower MoHFW to strengthen drug

regulatory system;

Transfer Department of Pharmaceuticalsto the Ministry of Health.


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Human Resources for Health

Ensure adequate numbers of trained health

care providers and technical health care

workers at different levels giving primacy to

the provision of primary health care.

Doubling ASHAs from one per 1000 population to

two per 1000 population in rural and tribal areas;

Introduction of mid-level health workers such asBachelor of Rural Health Care (BRHC) Practitioners

for recruitment & placement at rural Sub-Centres

and Nurse Practitioners in urban Sub-Centres


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Human Resources for Health

Improve human resource management and

supportive supervision mechanisms at block, district,state & national levels to complement health careservice providers;

Enhance the quality of HRH education and training byintroducing competency-based, health system-connected curricula and continuous education;

Invest in additional educational institutions toproduce and train the requisite health workforce;

Establish a dedicated training system for Community

Health Workers; Establish District Health Knowledge Institutes (DHKIs);

Establish the National Council for Human Resources inHealth (NCHRH).


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PROJECTED HRH AVAILABILITY (2012-2027)


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MANAGEMENT AND INSTITUTIONAL REFORMS

Develop capacity and cadres for public health and

health management Adopt better human resource practices to improve

recruitment, retention motivation and performance;rationalize pay and incentives; and assure career tracksfor competency-based professional advancement;

Develop a national health information technologynetwork based on uniform standards to ensureinteroperability between all health care stake holders;

Ensure strong linkages and synergies betweenmanagement and regulatory reforms and ensureaccountability to patients and communities;

Establish financing and budgeting systems to streamlinefund flow.


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Registry


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COMMUNITY PARTICIPATION AND

CITIZEN ENGAGEMENT

Transform existing Village Health Committees(or Health and Sanitation Committees) into

participatory Health Councils;

Organize regular Health Assemblies;

Enhance the role of elected representatives as

well as Panchayati Rajinstitutions (in rural

areas) and local bodies (in urban areas);

Strengthen the role ofcivil society and non-

governmental organizations.

Institute a formal grievance redressal

mechanism at the block level.


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HEALTH BEYOND HEALTH CARE

Health leaps out of Science and drawsnourishment from the Society around it

- Gunnar Myrdal

(Swedish Economist, Nobel Laureate)

POLICIES AND PROGRAMMES IN

Finance Water Sanitation Agriculture Food Processing

Education Rural Development Urban Design Transport

Communications Trade Environment

NEED TO BECOME SENSITIVE AND RESPONSIVE

TO PUBLIC HEALTH CONCERNS !

POLICY APPROACHES


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POLICY APPROACHES(Global; National; Local)

Financial TradeRegulatoryLegal

Environment To Enable Individuals To Make and

Maintain Healthy Choices

INDIVIDUAL

FAMILY

NEIGHBORHOOD, COMMUNITY

Enhancement of Knowledge, Motivation, and

Skills of Individuals

Media Settings BasedCommunity Interventions

HEALTH COMMUNICATION

Preventive,

Dia

gnostic,

Therapeutic,

Reh

abilitative

Services

HE

ALTHCAREDELIVERY

WIDER SOCIETY

DETERMIN

ANTS

Globalization

Access

toCare

Systems

Infrastructure

H

ealth

Wo

rkforce

Quality

ofCare

Drugs&

Technologies

Demographic

Change

Globalization

Social

Determinants

Health Inequities

Cultural and Social

Norms

Education

Biological

Risk

Behavioral

Risk


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HLEG Recommends.

Creation of National Health Promotion and Protection Trust

To Enable :

- Effective Health Communication, Dissemination andInformation Sharing

- UHC Related Education to People , Patients, Providers

- Health Impact Assessment of Policies and Programs inOther Sectors (to facilitate convergent action on the

Social Determinants of Health)

- Collaboration with International Partners to draw uponBest Practices, Policies, and Lessons from the GlobalContext


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If we dont create the

future, the present

extends itself

- Toni Morrison (Song of Solomon)

HRLN Using the Law for Public Health Dr Shrinath Reddy

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Transcript of HRLN Using the Law for Public Health Dr Shrinath Reddy