India’s Health Challenges: Will Universal Health Coverage

Provide The Platform For Response?

Prof. K. Srinath ReddyPresident,

Public Health Foundation of India,President, World Heart Federation

India’s Health Status

Lags Behind

Economic Growth

And

Threatens To Slow

Down Development

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India is Under performing its Income Group Peers in Health

We lose 1,400,000 infants every year, 4000 every day…equivalent to 12 full Jumbo Jets crashing every day. Our children die early, prematurely, and needlessly

SOURCE: WHO 2012

Out of 100 live births, 5 die before their first birthday – 3 within the first month

Our infant mortality rate is 3X more than China, 4X Thailand or Sri Lanka

Believe it or not…we are actually worse than Botswana, Bangladesh & Nepal

It is Lottery of Life - death in childbirth more likely in poorer states - MP (76), 600% higher than Kerala (13)

Most are needless deaths, from preventable causes such as malnutrition, lack of immunisation, diarrhoea, pneumonia and malaria

Infant Mortality RateDeaths per 1000 live births

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And has Lagged Behind

Source: WDI. WHO

On providing basic immunization to our children, we are behind Bangladesh, Nepal, Thailand, Ghana, Pakistan, to name a few

China Sri LankaThailandBrazilBotswana 96Bangladesh 95Ghana 94Myanmar 90Pakistan 88Nepal 82India 72

DPT immunisation rate% of children covered

30% of children in India go without DPT coverage, 50% without full immunization

99999998

Nearly 100% children covered in China, Nearly 100% children covered in China, Brazil, Sri Lanka or ThailandBrazil, Sri Lanka or Thailand

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Very few go undernourished in China, Very few go undernourished in China, Brazil or Thailand. We Brazil or Thailand. We do worse than do worse than

sub-Saharan Africa sub-Saharan Africa

Despite all the progress, 40% children in India are undernourished. A “national shame!”

Brazil 2China 7Thailand 7Ghana 14Sri Lanka 22Sub Saharan Africa 28Nepal 39Bangladesh 41

Of those who survive the first year, 43% are underweight, and 66% anaemic by age of three

Undernourishment severely

limits cognitive

development and increases

vulnerability to heart

disease & diabetes

25% of India’s newborns start life with Low Birth Weight

Source: WDI. WHO

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% underweight below 5

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Our maternal mortality rate is 4X of China and Brazil, 6X of Sri Lanka

We only compare favorably with Pakistan, Gabon and Cambodia

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A sacrifice to give life – a preventable tragedy

60,000 plus mothers die every year. More deaths in a week than in a whole year in Europe

Incidence and prevalence of infectious diseases remains high

(A) 9.7 million cases, with 40,000+ deaths every year (recent ICMR study)

(B) Over 70% of India at risk of malaria infection

TB incidence

(A) 2 million new cases every year

(B) Incidence rate 200-300% more that of China and Brazil. In the range of Afghanistan and Pakistan

(C) Drug resistant TB a major threat

Malaria prevalence

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In Chronic (non-communicable) diseases such as diabetes and cardiovascular disorders, we are facing advancing epidemics

2000

2030

India China Russia USA

Every 8th adult has or is at high-risk. 40-60 working age group most affected

India could lose US$ 237 billion (over 2005-2015) to cardiovascular disease and diabetes (WHO)

Underlying risk factors - unhealthy diets, physical inactivity, alcohol consumption and tobacco use

If neglected, this will be a source If neglected, this will be a source of continuing productivity lossof continuing productivity loss

Diabetes epicenter of the world – 61 million cases in 2011 to rise to 101 million in 2030

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Potentially productive years of life lost due to cardiovascular deaths (36-64 years age group); In millions

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Quality of Primary Care

Scored For:

• 24 Hour Availability of Services

• Clinical Staff In Position

• Training In Past 5 Years

• Basic Infrastructure

• Equipment

• Essential Drugs

India : 52%Low Performing States : 48% High Preforming States : 57%North East : 53%

Powell T et alEPW (May 2013)

Country

Public expenditure on health as % of GDP

Per capita public expenditure on health (PPP$)

Sri Lanka 1.8 87

India 1.2 43

Thailand 3.3 261

China 2.3 155

More funding needed with right investments such as Primary healthcare | Education and training facilities – medical and public health | Availability of essential drugs to all | Expansion of universal health coverage

Public health spend not yet a high priority. Our public expenditure on health is among the lowest in the world

Source: WHO database, 2009

Need for doubling of public spending on health to at Need for doubling of public spending on health to at least 2% of GDP by end of 12th Planleast 2% of GDP by end of 12th Plan

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Low Public, High Out of Pocket Health Expenditure

Over 60 million people thrown below the poverty line every year due to OOP on health

70% of health spend from own pockets on health. Out of pocket (OOP) expenditure amongst highest in the world

Unaffordable and unsustainable healthcare costs

Huge social burden on the poorHuge social burden on the poor

28% of rural residents and 20% of urban residents had no funds for health care

Over 40% of hospitalised persons had to borrow money or sell assets to pay for their care

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High costs of out-patient and medicine costs

Current scenario of DoctorsNumber of Doctors – 8.58 lakh (as per IMR)Those available – 6 - 6.5 lakh (75%) (approx) Present Doctor Population Ratio 0.5 per 1000 Target by 2025– 0.8 per 1000

China 1.6 per 1000USA 2.6 per 1000UK 2.3 per 1000Sweden 3.3 per 1000

• Additional Doctors required – 4 lakh by 20201.5 lakh in 50,000 PHCs0.8 lakh in 12,500 CHCs1.1 lakh in 5,642 SDH/DH 0.5 lakh in 800 MCHs

Current Scenario of Nurses

Nurses registered 11.2 lakh Available 9 lakh (Approx)Nurse-Population Ratio 0.4 per 1000(Nurses +ANM) Vs Doctor Ratio 1.5 : 1 (Desired 3:1)Target by 2025 2.2 : 1

---------------------------------------------------------------------------------------Brazil 3:1South Africa 5:1USA 3:1UK 5:1

--------------------------------------------------------------------------------------------Additional Nurses required – 16.2 lakhs by 2020

Allied Health Workforce shortfall- National estimateAllied Health Workforce Category Demand Supply Gap

Unadjusted Efficiency-Access Adjusted

Ophthalmology related 145,236 17,678 127,558 136,039Rehabilitation /other related 1,862,584 40,265 1,822,319 1,841,637Surgical intervention technology 205,088 7,215  197,873 208,618Medical lab technology 76,884  15,214 61,670 70,603Radiography and imaging technology 23,649 4,352  19,297 20,971Audiology/ speech language pathology

10,599 3,263  7,336 8,901

Medical technology 239,657  3,587 236,070 237,791Dental assistance related technology 2,048,391 6,243 2,042,148 2,045,143Surgery and anesthesia related technology

862,193  4,050 8,58,143 860,086

Miscellaneous 1,074,473 181,511 

8,92,962 980,045

Total 45,14,271 64,09,834

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Our Definition of UHC

“Ensuring equitable access for all Indian citizens resident in any part of the country, regardless of income level, social status, gender, caste or religion, to affordable, accountable and appropriate, assured quality health services (promotive, preventive, curative and rehabilitative) as well as public health services addressing wider determinants of health delivered to individuals and populations, with the government being the guarantor and enabler, although not necessarily the only provider, of health and related services.”

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Universal Health Coverage is when ALL people receive the quality health services

they need without suffering financial hardship

 

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National Rural Health Mission (NRHM)

HIGHLIGHTS

▪ Decentralized planning and implementation through community participation (through various initiatives such as ASHA, VHSC, SHGs)

▪ Pro poor-based equitable systems ▪ Emphasis on convergence▪ Flexibility and adequacy of central

funding with accountability framework to ensure public action

▪ Judicious mix of dedicated budget lines – untied funds to all public institutions

▪ Provision of incentives for CHWs in hard-to-reach areas

▪ Monitoring progress against standards (such as IPHS)

▪ Targeted interventions to measureable outcomes, reviewed annually through the CRM process

SHORTFALLS

▪ Focus on maternal and child health – other primary health care needs not addressed

▪ Quality of care not assured, even for institutional deliveries

▪ Health workforce deficiencies (numbers; skills) affect delivery of services

▪ Impact on out-of-pocket not demonstrated

▪ Continuum of care (10 +20 +30) not developed

Rashtriya Swasthya Bima Yojna (RSBY)

HIGHLIGHTS

▪ India’s first social-security scheme with a profit motive, involving insurance companies, hospitals, state governments and the Centre

▪ Encourages increased contributions to health and augments financial resources of the State governments

▪ Attempts to address several lacunae regarding enrolment, utilisation levels and fraud control

▪ Mandatory enrolment and technology-based cashless policies address the problem of risk selection and selective rejection of claims by insurers.

SHORTFALLS

▪ Low coverage with financial protection available only for hospitalization, and not for out-patient care

▪ Focus on hospital networks rather than primary care services

▪ Difficult to maintain quality of healthcare at accredited hospitals due to induced demand and fraud

▪ Potential for inferior health outcomes and high healthcare cost inflation

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• Adopt UHC As A National commitment - To Be Initiated in 2012 and Fulfilled By 2022

• Commit 2.5% of GDP As Public Financing for Health During The 12th Plan and suggest MOHFW prepare a road-map for implementation of the UHC

• Prioritize Primary Health Care For Financing And Human Resource Development & Deployment

• Conduct A Review of Government Funded Insurance Schemes & Propose A Plan for Their Integration Into The UHC Framework

• Provide Essential Drugs Free Of Cost

• Establish Credible And Effective Regulatory Systems For Administering UHC (Accreditation; Standards; Financing; Drugs; Information Systems; M&E)

• Enable Community Participation By Institutionalising Health Councils & Health Assemblies With Government Support

• Facilitate focusing future MOHFW agendas on a) Gender -UHC though a gendered lens b) Urban Health c) Social Determinants Of Health (Health Promotion & Protection Trust), while preparing its implementation plan

Key Recommendations of HLEG

Universal Health Coverage By 2022: The Vision

• Universal Health Entitlement for every citizen - to a National Health Package (NHP) of essential primary, secondary & tertiary health care services that will be principally funded by the government

Package to be defined periodically by an Expert Group; can have state specific variations

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Impoverishment due to OOP on Drugs, 2011-12

Issues for Debate(Financing)

• Tax funded model Vs. Insurance Model

• Financing and Impact of Government Funded Insurance Schemes

• Role of Private Insurance

• Fee for Service Vs. Per Capita Vs. ?

• User Fee Exemption : All / Poor only?

• Role of Central and State Governments

Issues for Debate(Provision)

• Role of Public and Private Sectors

• ‘Corporatization’ of Public Sector Healthcare Facilities

• ‘Managed’ Vs. ‘Integrated’ Care

• Continuum of Care : Overcoming Fragmentation

• Extent of Integration of Health Programmes

(NRHM+NUHM = ? NHM)

Options• Options based on coverage (who is covered for what)

– All the services to all the population– Some services to all the population– Some services to certain sections of the population

• Provision – Within the existing government health services (in an enhanced manner) – Through the private sector (Purchasing, contracting, PPP)

• Finance – Enhanced budgetary support based on evidence – Pooling (insurance) –Increasing existing benefit package, coverage under existing schemes

(coverage, benefits etc. under RSBY & other schemes)

– Incentives (payment for performance), Case based payment, capitation etc.

• Based on the options - populations to be covered, services (benefit package) to be provided, method of delivery, estimation regarding financial requirements

• Options could be a mix of delivery systems providing the services selected from the health package.

• Realignment & convergence of programmes and schemes• Development of a essential health package of services into

various categories to choose (e.g. primary, secondary, tertiary, etc.) and move towards it systematically & phased manner.

• Costing of the benefit package• Broad roadmap on how best to provide the services to the

populations and what needs to be strengthened or systems in place and their implications.

Options

Human Resources For Health

Increase numbers and skills of frontline health workers:

• Doubling of ASHAs and ANMs;

•Male MPW and Mid Level Health Professional (3 year

trainee)/AYUSH at Sub-Centre level;

•Expand Staff (esp. nurses) at PHC and CHC;

•Nurse-Practitioners for Urban Primary Health Care

Human Resources For Health

• Establish new medical and nursing colleges in underserved states and districts with linkage to district hospitals; Increase the number of ANM schools

• Scale up number and quality of Allied Health Professional training institutions

• Establish District Health Knowledge Institutes to coordinate and conduct training of different categories of health workers

• Develop Public Health and Health Management Cadres (District, State, National)

Registry

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“If we don’t create the future, the present extends itself”

- Toni Morrison (Song of Solomon)