Public Health Care in India - SIHFW) Rajasthan Care System in india.pdf · Public Health Care in...

Public Health Care in India

State Institute of Health and Family Welfare, JaipurJaipur

InfrastructureInfrastructure H R & PerformancePerformanceIssues

2SIHFW: an ISO 9001:2008 certified Institution

SIHFW: an ISO 9001:2008 certified Institution 3

Health & DiseaseHealth & DiseaseDisease

a

Health DeathDoctors, Drugs, Diagnostics

4

Disability4SIHFW: an ISO 9001: 2008 certified Institution

Health ?Health ?

State of complete physical mental and socialp p y

and spiritual well-being and not merely the

absence of disease or infirmity.

5SIHFW: an ISO 9001: 2008 certified Institution

System ?System ?

A set of interrelated andA set of interrelated and

independent parts designed to

achieve a set goals.


Health System ?

• Traditionally- based on capacityindicators & activities. (e.g.Programs, hospital beds, Physicians& N )& Nurses)


Health System ?

Structure & functions of a Country’s MoH havingRResources,ManagementOrganizationEconomic support and Service delivery as it’s main component


Public HealthPublic Health• What is public health?

• Why does it matter?

• How is the public health system

structured?

• What does the public health system do

for people?

• How is it done?• How is it done?9SIHFW: an ISO 9001: 2008 certified Institution

Core functions of Public Health

• Monitoring health situationMonitoring health situation• Disease surveillance• Health promotionHealth promotion• Regulations• Partnerships• Partnerships• Planning & Policies• HRD• HRD• Reducing impact of emergencies on health


Why study Health SystemsWhy study Health SystemsProvides perspective to understand selfProvides perspective to understand self

Prompts and tutors

Observe & examine strategies for achieving

equity under different situationsequity under different situations

Draw generalizations

System’s influence on health status


Determinants of Health System• Economic-

– Affordability?– Availability?

• PoliticalP i iti– Priorities

– Appropriateness?Accessibility– Accessibility

– Equity • CulturalCultural

– Acceptability– Utilization– Participation


National Health SystemsNational Health Systems

Issues :Issues :• Generalizations of performance & trend• Political dimensions Dynamism• Political dimensions-Dynamism• Forces deciding character

Impact on Health• Impact on Health• Relevance to human rights


Forces asking for a change in SystemSystem

a. New emerging diseases, g gb. Changing disease profile, c. Technical and diagnostic advances, d L i f lifd. Longevity of life, e. Expectations of people, f Subsidies and cross subsidiesf. Subsidies and cross-subsidiesg. Increasing non-plan expenditure,h. Competing priorities and Co pet g p o t es a di. Improving awareness among people, andJ. Rising Cost of health care delivery

14SIHFW: an ISO 9001: 2008 certified institution

Problems:

• Indirectly related to h lth

• Directly affecting Health– Diseaseshealth

– Environment– Education

• Communicable • Non Communicable• New emerging– Education

– Empowerment• New emerging

– Fertility• Populationp• Growth rate • Total Fertility

Nutrition– Nutrition• Malnutrition• Obesity


Problems-Whyy

• Access• Availability• Utilization


Policies:

• NHP-1983…….NHP-2002• NPP-2000


NHP-1983• Re-orientation of Medical education• Re structuring and Re organizing the then• Re-structuring and Re-organizing the then

existing health care services• Population stabilizationPopulation stabilization• Re-orientation of existing health personnel• Role of practitioners of ISM in Health care p

delivery• Goals -

• Achievement? • CDR & Life expectancy


A f h l h i di hid di i iNHP-2002• Averages of health indices hide disparities• large gap in facilities still persists• shortfall in the number of SCs/PHCs/CHCs is of

the order of 16 percent. (CHC-58%)‘ ’• ‘Vertical’ implementation structure -extremelyexpensiveth l h lth t ff h b ti l• the rural health staff has become a verticalstructure exclusively for the implementation offamily welfare activitiesfamily welfare activities

• Low utilization- 20 % seeking OPD services,<45 percent seeking indoor treatment go to<45 percent seeking indoor treatment, go topublic hospitals.


• Integrated disease control networkIntegrated disease control network• Increase in postgraduate seats in Public Health

& Family Mediciney• Decentralization-Role of LSG/ NGO• Medical Grants commission• legislation for regulating clinical

establishments/medical institutions by 2003


Goals to be achieved by 2000-2015Eradicate Polio and Yaws 2005 Eliminate Leprosy 2005

2015

Eliminate Kalazar 2010Eliminate Lymphatic Filariasis 2015A hi Z l l th f HIV/AIDS 2007Achieve Zero level growth of HIV/AIDS 2007Reduce Mortality by 50% on account of TB, Malaria and Other Vector and Water Borne diseases

2010

Reduce Prevalence of Blindness to 0.5% 2010Reduce IMR to 30/1000 And MMR to 100/Lakh 2010Increase utilization of public health facilities from current Level of <20 to >75%

2010

Establish an integrated system of surveillance, National 2005g y ,Health


Challenges g• Manpower- Number & Norms

R l / U b diff ti l• Rural / Urban differential• Geographical divide across States• S-E groups –accessibility/ reach• Gaps between Policy & Action• Health sector expenditure• Newer Infections


Five year Plan Period Major areas addressed

I 1951-55 Infrastructure

II 1956-61 Industry

III 1961-66 Panchayat & Green Revolution

IV 1969-74 Expenditure , Agriculture

V 1974-79 Agriculture

VI 1980-85 Health , Technology

VII 1985-89 Poverty, Agriculture & Justice

VIII 1992-97 Pop., Agriculture , Poverty

IX 1997-02 Employment, Basic facilities

X 2002-07 HRD, Industry, Technology

XI 2007-12 Education, Health, Empowerment


Bhore Committee, 1946

PHCS : nodal points for Health carePhased expansionPrevention stressedPopulation based


Constitutional commitment:Health: State subjectj

Central ListCentral ListInternational Health, Port HealthResearchTechnical & Scientific Education

State ListAll other Health issues

Concurrent listE id iEpidemics


• Centralized planning ,Decentralized implementationimplementation

• Fiscal control of central Govt.Di t t St t f Obj ti & P i iti• Dictates States for Objectives & Priorities

H lth St t bj t ?Health –State subject ?


• NO Health Policy for 36 yearsH lth l ft t C itt d C i i• Health left to Committees and Commissions

• Each Committee addressed to a single specific issue.issue.

• Comprehension was missing• Majority of recommendations of every

itt it ti f Bhcommittee were reiterations of Bhore Committee.

• Individual “Health” Programs developed inIndividual Health Programs developed in isolation based on situational exigency.

• Uni-purpose workers later baptized as Multi-purposepurpose.

• Some Programs worked in complete isolation till 1980 (e.g. NTCP).

• Fragmented approach to Health 27SIHFW: an ISO 9001: 2008 certified Institution

Health Care InfrastructureHealth Care Infrastructure


Sub Center over FYPSub Center over FYP

137311145272SC over FYP

120000

140000

160000

130165136258

137311 146036

There was no SC till III FYP

80000

100000

120000

84376

SC till III FYP

40000

60000

3350947112

0

20000

I II III IV V VI VII VIII IX X XI

0 0 0

Source: CBHI NHP-2010



PHC over FYP

2500022149 22875 22370

23458

PHC over FYP

20000 18671

10000

15000

9115

50002565

5283 5484

0


0 0

Source: CBHI,NHP-2010


CHC over FYP

5000

CHC over FYP

4000

4500

5000

40454510

There was no SC till IV FYP

2500

3000

3500

1910

26333054

1000

1500

2000

761

1910

0

500


0 0 0 0214

Source: CBHI,NHP-2010SIHFW: an ISO 9001:2008 certified Institution 31

Total Beds (India)ota eds ( d a)

898000

1052865

504538

664135

117000229634

348655

1951 1961 1971 1981 1991 2001 2011

117000

1951 1961 1971 1981 1991 2001 2011


Health Facilities 2011

India Rajasthan4510

3882

India Rajasthan

1813376

CHC

376365

237

CHCsCHCs owned

building Total FRUs


Health Facilities 2011ea t ac t es 0

146036

India Rajasthan

146036

23458 1970678803

1517 1473 11488

Primary Health PHCs

owned Sub

9740

Centers owned building

Sub Centers SCs

owned building


Infrastructure Statusast uctu e Status

164632 178396

140000160000180000 164632 178396

80000100000120000

India

200004000060000

5089

31743

5714

43679 Rajasthan

0Population per

Sub centre Ratio

Population per PHC

Population per CHC

Ratio

Source: DLHS-3SIHFW: an ISO 9001:2008 certified Institution 35

Healthcare Delivery Statusea t ca e e e y Status

80

607080

54.154.1 52.6

47

5748.8

52.7

70.4

304050

19 1

47

India

0102030 19.1

6.6Rajasthan

0Couple

Protection Rate

Proportion of fully

immunized children [12-24 months]

Proportion of Pregnant receiving ANC [Full

ANC]

Proportion of Safe

Deliveries

Institutional Deliveries

24 months] ANC]

Source: DLHS-3SIHFW: an ISO 9001:2008 certified Institution 36

Health Care Infrastructure: R j th (M h 2011)Rajasthan (March, 2011)

199

7 33

199

7 336 12


Medical Colleges, 2011g ,

Non Recognized Recognized

97

g g

218

97 3

2187

IndiaRajasthan


Dental Colleges, 2011g ,

Recognized Non Recognizedg g

136 5

154 8

IndiaRajasthan


Nursing Schools (India)

632291

1227ANMGNMB S

1988

B Sc.M Sc.

1988

Source: Indian Nursing Council SIHFW: an ISO 9001:2008 certified Institution 40

CHCs : IPHS Vs PG seatsM h 2008March 2008

4500 4276

25003000350040004500

0500

100015002000 1529 1444

894708 698 897

0 338 337

Source: CBHISIHFW: an ISO 9001:2008 certified Institution 41

Some Medical Statistics: RajasthanSo e ed ca Stat st cs ajast a

Population : Medical College 6675000

Undergraduate Intake 1150Undergraduate Intake 1150

Post Graduate seats 739

UG:PG Seats 1.56

N f S i lti 35No. of Specialties 35

Source: CBHI


Health Expenditure


Share in health care spending source:CBHI,NHP-2010

%27%

71%2% Private Expenditure

External flow

Public Expenditure

SIHFW: an ISO 9001: 2008 certified Institution 44

Health Expenditure as % of total Plan

6.5

6

7

Health Expenditure as % of total Plan Outlay

Source: CBHI, NHP, 2010

3 9 4.093.974

5

6

3.4 3.1 2.9 3.23.9

3.1 2.8 3.1 3.1 2.9 2.9 3.2

2

3

4

1

2

0

9/3/2011SIHFW: an ISO 9001:2008 certified Institution 45

Who really pays?o ea y pays

• Opportunity cost -pp yif we choose to do onething, the cost of doing that isthe value which would havethe value which would havebeen obtained from the bestalternative choice

• Who pays - the person whodoes not receive treatment


Total Govt. Expenditure on Health as % of GDPof GDP


1 11.2

0 810.91

1.050.96

0.88 0.90 83 0.86

0.910.96 0.98

1.031.1

0 8

1

0 49

0.63 0.61

0.740.81 0.83

0.6

0.8

0.22

0.49

0 2

0.4

0.22

0

0.2


Per Capita Public Exp. on Health

214.62220


184.56 183.56202.22

214.62

160180200220

112.21

100120140160

19 3738.63

64.83

406080

0.61 1.36 2.48 3.47 6.22 11.15 19.37

020


Status of Expenditure in FYPsSource: CBHI NHP 2010Source: CBHI, NHP, 2010


Total Outlay – Plan and Health (including AYUSH & FW) Source: CBHI NHP 2010Source: CBHI, NHP, 2010

Total plan outlayHeath sector

120000

140000

160000

2000000

2500000

80000

100000

120000

1500000

40000

60000

80000

500000

1000000

0

20000

0

500000

I II II IV V VI VII VIII IX X XI


7 % of total budget allocated to health6.49

6

7 % o tota budget a ocated to ea tSource: CBHI, NHP, 2010

3 34

5

3.33

2.62 1 1 9

2.313

2.1 1.9 1.8 1.71.7

3.97

1

2

0I II II IV V VI VII VIII IX X XI


Budget Rajasthang j

2.07

140000160000

2230

.7

.14 14

776 2

80000100000120000140000

2 6287

0.95 10

2

8717

1

in la

khs

400006000080000

67.2

1

83.9

9

64.5

3

775.

6836

.79

9493

.06

2022

8.1 2 6

Am

ount

i

020000

1 2 3 4 5 6 7 8 9 10 11

16 38 66 17 333 9

Five Year plans


Health Care Spending (2004-05)

14001377

India

1000

1200

808

India

Rajasthan

600

800

200

400

0

200

Per capita Household Public Other

73.5 22 4.570 24.5 5.5

Per capita expenditure

Household Public OtherSource: NCMH, 2005


Out of pocket expenditure on H lth (2004 05)Health (2004-05)

25002500

2000

2500

15001700

1000

1500

800 750550 550

1500

1000 900

0

500550 550

0

Based on NHA-2000-01, extrapolated for 2004-05SIHFW: an ISO 9001:2008 certified Institution 54

Health Spending: Facts• Public Domain

– Center: Rs 35 bi (0 13% GDP)– Center: Rs.35 bi (0.13% GDP)– State: Rs.186 bi (0.72% GDP)

Local: Rs 25 bi estimated (0 10% GDP)– Local: Rs.25 bi estimated (0.10% GDP) – Social Insurance: Rs. 12 bi (0.05% GDP)

Private Domain• Private Domain– Out-of-pocket: Rs.1200 bi (4.62% GDP)

I ( bli t ) R 8 bi (0 03%– Insurance (public sector) Rs.8 bi (0.03% GDP)Pharma Industry Rs 250 bi (0 96% GDP)– Pharma Industry Rs. 250 bi (0.96% GDP)


Human Resource in Health


People are resourcePeople are resourceBut

To maintain this resourceTo maintain this resource We need Resources


Doctors (Allopathic in India)( p )

577100

757377

268712398238

61800 83700 151129

1951 1961 1971 1981 1991 2001 20112011


Nurses (India)( )

671341

865135

311235

16550 35584 80620 150399311235

1951 1961 1971 1981 1991 2001 20112011


Average Population Served in R j th 2010Rajasthan;2010

598189598189

10605

DoctorsDentists


Manpower Status 2010a po e Status 0 0

India Rajasthan

757377

463485

84569 93332323328013 6285 107 23861

Allopathic Doctors

Allopathic Doctors in Govt.

Dentist Dentist in Govt. Sector

Ayurvedic Doctors

323328013 6285 364 107 23861


Manpower Status 2010a po e Status 0 0

India Rajasthan

1043363

j

557022

1535685177622239 12150 37667 850

Registered ANMs

ANMs in Govt

Registered GNMs

Registered LHVs

22239 12150 850

ANMs Govt. GNMs LHVs


Manpower Status 2010p

India Rajasthan

24375

j

42791379

Specialist at CHCs MBBS Doctors at PHCs

811 1379

Specialist at CHCs MBBS Doctors at PHCs


Service Provider Status (2008)( )

1 37

11.21.4

1.37

0.94

0 40.60.8

10.63 0.460.41 0.43

India

00.20.4

D t D t N

Rajasthan

Doctor Population Ratio [per

1000]

Doctor Nurse Ratio

Nurse Population Ratio [per

1000]1000] 1000]

Source: DLHS 3SIHFW: an ISO 9001:2008 certified Institution 64

Health system’s performanceHealth system s performance


Goals to be achieved by 2000-2015Eradicate Polio and Yaws 2005 Eliminate Leprosy 2005

2015

Eliminate Kalazar 2010Eliminate Lymphatic Filariasis 2015A hi Z l l th f HIV/AIDS 2007Achieve Zero level growth of HIV/AIDS 2007Reduce Mortality by 50% on account of TB, Malaria and Other Vector and Water Borne diseases

2010

Reduce Prevalence of Blindness to 0.5% 2010Reduce IMR to 30/1000 And MMR to 100/Lakh 2010Increase utilization of public health facilities from current Level of <20 to >75%

2010

Establish an integrated system of surveillance, National 2005g y ,Health


Population and Growth: India


Population Growth-Indiap

1150000

1200000

11241351140566

11568981173108

1210193

1100000

1150000

10402851057251

10741591090973

11076241124135

1000000

1050000 10232951040285

900000

950000

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 20112001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Source: Census India,201168SIHFW: an ISO 9001: 2008 certified institution

Population Pyramid: India, 2011

Source:U.S Census Bureau69SIHFW: an ISO 9001: 2008 certified institution

Crude Birth Rate(India)C ude t ate( d a)

41.7 41.245 41.237.2

33.929.5 2930

3540

22.5202530

51015

05

1951 1961 1971 1981 1991 2001 2009

Source: SRS 2011


Crude Death Rate (India)C ude eat ate ( d a)

22 825 22.8

1920

25

1512.5

9.8 10 9 910

15

9 96.8 7.3

5

10

01951 1961 1971 1981 1991 1995 1996 1997 2008 2009

SIHFW: an ISO 9001: 2008 certified Institution71

Source: SRS 2011

Infant Mortality Rate (India)a t o ta ty ate ( d a)

134146

138140

160

110100

120

140

80

58.55060

80

100

50

20

40

60

0

20

1951 1961 1971 1981 1991 2001 2009

Source:SRS,2011SIHFW: an ISO 9001: 2008 certified Institution 72

Maternal Mortality Ratio(India)ate a o ta ty at o( d a)

400

500

600 501445

200

300

400 212148

0

100

1999 2001 2009 2012

Source: SRS ,July 2011

1999 2001 2009 2012

Source: SRS ,July 2011


Total Fertility Rate (India)y ( )

3.43.4 3.4

3.3

3.35 3.3 2.6

3 15

3.2

3.25

3 1

3.05

3.1

3.15 3.1

2.95

3

1995 1997 2000 2008 2009

Source: SRS,July2011SIHFW: an ISO 9001: 2008 certified Institution

74

1995 1997 2000 2008 2009

How did Health system evolve


1947


1950


Committees & CommissionsCommittees & Commissions


Committees & CommissionsCommittees & Commissions

1946: Bhore Committee1946: Bhore Committee

1959-62 Mudaliar committee (Health Survey And

Planning Committee): Health services

t t irestructuring

1963: Chaddah committee: TOR-Malaria

1964:Mukherjee committee: Family planning


1964-67:Junglewala committee: Integration Of

Health Services

1972-73:Kartar Singh committee: MPW scheme1972-73:Kartar Singh committee: MPW scheme

1974-75:Srivastav committee: Medical

Education & Support Manpower


1959-62 Mudaliar committee (Health Survey And Planning(Health Survey And Planning

Committee)

• Consolidate gains• Strengthen district hospitals• Strengthen district hospitals• Regionalization of health services• PHC for 40000 population• PHC for 40000 population• Integration of medical & health

C ti f ll I di h lth i d• Creation of all India health services cadre


1963: Chaddah committee

• TOR-MalariaTOR Malaria• NMEP

– vigilance & maintenance by health servicesvigilance & maintenance by health services – Monthly home visits – 10000 population per worker

• Basic health worker– vital statistics & – family planning


1964:Mukherjee committee1964:Mukherjee committee

• TOR-Family planning

• Exclusive family planning staff (uni-purpose

worker)


1964-67:Junglewala committee (Integration Of Health Services)

• Unified cadre• Common seniorityCommon seniority• Recognition of extra qualifications• Equal payEqual pay• Specialized pay• No private practice• No private practice


1972-73:Kartar Singh committee1972-73:Kartar Singh committee

• Conversion of ANM to MPHW (F)• Uni-purpose to multi-purpose workers• One PHC per 50000 population

• 16 S/C per PHC • 3000-3500 population per S/C • One supervisor for 4 workers


1974-75:Srivastav committee (Medical Education & Support(Medical Education & Support

Man-Power Committee)

• Cadre of community health workers

(CHW)

• Medical officer for maternal health at PHC

• Heath assistant to be a link betweenHeath assistant to be a link between

health worker and PHC


Bajaj Committee, 1986• An "Expert Committee for Health Manpower

Pl i P d ti d M t"Planning, Production and Management" was

constituted in 1985 under Dr. J.S. Bajaj.

• Recommendations :

F l ti f N ti l M di l & H lthFormulation of National Medical & Health

Education Policy.

Formulation of National Health Manpower

PolicyPolicy.87SIHFW: an ISO 9001: 2008 certified Institution

Establishment of Educational Commission for

Health Sciences (ECHS) on the lines of UGC.

Establishment of Health Science Universities inEstablishment of Health Science Universities in

various states and union territories.

Establishment of health manpower cells at

t d i th t tcentre and in the states.


4 Reasons based on 4 lesser known facts


• Reason 1: – Public doctors in India are among the most absent

in the world– Absences are never below 30 percent!

• Reason 2: – When public doctors do show up for work, the

exert very little effort • Reason 3:

– Public doctors in PHCs are not particularly competent to begin with

• Reason 4: – You still have to bribe public doctors to do their

work 90SIHFW: an ISO 9001: 2008 certified Institution

One important question…

Why don’t the poor usepublic health facilities more?


Some facts about Public Health care in Indiain India


F #1• Fact #1:– Most spending is private; the fraction on

i bli d i tigenuine public goods is tiny• Fact #2:

– The poor use private care as much as the rich• Fact #3:

– More public money on health goes to the richthan the poor (because hospital use isregressive)regressive)


A summary of why poor people may not be using the PHC systemnot be using the PHC system

• The doctors are low on competence• They don’t show up for workThey don t show up for work• When they do show up, they don’t work to

the level of their knowledgeg• And patients have to pay bribes anyway


Service delivery:3-tier structurey

Tertiary C

DHCare

Secondary CHC

yCare

PrimaryPHC

Primary Care SC

Underutilized for-Services Supply


Supp yFunding

CHC 1: 100000 (Plains)

1:80000 (Hilly/ Tribal)

3043

1:80000 (Hilly/ Tribal)

PHC 1:30000 (Plains)

1:20000 (Hilly/Tribal)

23500

• .

S b C 1 000(Pl i )137407

Sub- Centers 1:5000(Plains)

1:3000 (Tribal/ Hilly)HWF-134000

HWM-73000

Villages-AWW/ SBA/ VHG/ ASHA

640000

1027 million People-2001


The Political Economy Contexty

• A democratic federal system which is subdivided• A democratic federal system which is subdivided into28 States, 7 union territories and 593 districts,

• In most of the states three local levels of government (Panchayati-raj)

• Per capita income US $440• 435 million Indians are estimated to live on less

th US $ 1 dthan US $ 1 a day


• 36% of the total number of the worlds’ poor are

in India

T b d h lth fi t ith h lth• Tax based health finance system with health

insurance

• 80% health care expenditure born by patients

and their families as out-of -pocket payment (fee

for service and drugs)g )

• Expenditure on health care is second major

cause of indebtedness among rural poor98SIHFW: an ISO 9001: 2008 certified Institution

Characteristics of Indian Health S tSystem

• Complex mixed health system

- Publicly financed government health system

- Fee-levying private health sector


Different Phases of Indian Health S t D l tSystem Development

• Pre independence phase• Pre-independence phase• Development centred phase

C h i P i H lth C h• Comprehensive Primary Health Care phase• Neoliberal economic and health sector reform

phasephase• Health systems phase


Main Systems of Mediciney

• Western allopathicWestern allopathic• Ayurveda• UnaniUnani• Siddha• Homeopathy• Homeopathy


Government Health SystemThree levels of responsibilitiesThree levels of responsibilities-First-- Health is primarily a state responsibility- Health is primarily a state responsibility Second-- The central government is responsible forThe central government is responsible for

developing and monitoring national standards and regulations

- Sponsoring various schemes for implementation by state governmentsProviding health services in union territories- Providing health services in union territories

Third-both the centre and the states have a joint- both the centre and the states have a joint responsibility for programmes listed under the concurrent list. SIHFW: an ISO 9001:2008 certified Institution 102

Administrative Structure1. Central Ministries of Health and Family

Welfare –- Responsible for all health related

programmes p g- Regulatory role for private sector

2. State Ministries of Health and Family Welfare

3. District Health Teams headed by Chief Medical and Health Officer


Service Delivery Structurey

• Sub Health Centres-staffed by a trained female health worker and/ora male health worker for a population of 5000 inh l i d l i f 3000 i hill dthe plains and a population of 3000 in hilly and

tribal areas.• Primary Health Centres• Primary Health Centres-

staffed by a medical officer and otherparamedical staff for a population of 30,000 inpa a ed ca sta o a popu at o o 30,000the plains and a population of 20,000 inhilly, tribal and backward areas. A PHC centresupervises six to eight sub centressupervises six to eight sub centres.


Service Delivery Structurey• Community health centres- with 30-50 beds and

basic specialities covering a population ofbasic specialities covering a population of 80,000 to 120,000. The CHC acts as a referral centre for four to six PHCs.

• District/General hospitals- at district level with multi speciality facilities (City dispensaries)

• Medical colleges, All India institute of Medical Sciences and quasi government institutes (NIHFW and SIHFWs)


Health Financing Mechanisms..g

– Revenue generation by tax– Out of pocket payments or direct paymentsOut of pocket payments or direct payments– Private insurance

Social insurance– Social insurance– External Aid supported schemes


Spending on Healthp g

• Annually over 150,000 crores or US$34Annually over 150,000 crores or US$34billion, which is 6% of GDP (Governmentspending on health Is only 0.9% of GDP)

• Out of this only 15 % is publicly financed 4%from social insurance, 1% by private insuranceremaining 80% is out of pocket spending ( 85%of which goes in private sector)O l 1 % f h l i i i i d• Only 15% of the population is in organisedsector and has some sort of social security therest is left to the mercy of the marketrest is left to the mercy of the market


The Aspects of Neoliberal Economic R f Aff ti P bli H lthReforms Affecting Public Health

• Increasing unregulated privatisation of the healthcare sector with little accountability to patients

• Cutting down government Health care expenditureS f• Systematic deregulation of drug prices resulting inskyrocketing prices of drugs and rising cost ofhealth serviceshealth services

• Selective intervention approach insteadcomprehensive primary health care

• Measure diseases in terms of cost effectiveness• Techno centric approach( emphasis on content

instead processes)108SIHFW: an ISO 9001: 2008 certified Institution

Contradictions

• India has the largest numbers of medicalIndia has the largest numbers of medical colleges in the world

• It produces the largest numbers of doctors p gamong developing countries

• It gets “medical Tourists” from developed g pcountries

• This country is fourth largest producer of drugs by volume in the world


But... the current situation….• Only 43.5% children are fully immunised.• 79.1% of children from 6 months to 5 years of agey g

are anaemic.• 56.1% ever married women aged 15-49 are

anemic.• Infant Mortality Rate is 58/1000 live births for the

country with a low of 12 for Kerala and a high of79 for Madhya Pradesh.M t l M t lit R t i 301 f th t ith• Maternal Mortality Rate is 301 for the country witha low of 110 for Kerala and a high of 517 for UPand Uttaranchal in the 2001 03 periodand Uttaranchal in the 2001-03 period.


Two thirds of the population lack access to essentialdrugs.g

80% health care expenditure born by patients andtheir families as out-of -pocket payment (fee for service

d d )and drugs)Health inequalities across states, between urban and

rural areas and across the economic and genderrural areas, and across the economic and genderdivides have become worse

Health, far from being accepted as a basic right of, g p gthe people, is now being shaped into a saleablecommodity

Contd….• poor are being excluded from health services • Increased indebtedness among poorIncreased indebtedness among poor

(Expenditure on health care is second major cause of Indebtedness among j grural poor)

• Difference across the economic class spectrum and by gender in the untreated illness has significantly increased Cutbacks by poor on food and other• Cutbacks by poor on food and other consumptions resulting increased illnesses and increasing malnutrition g


Health Inequitiesq

• The infant mortality Rate in the poorest 20% of y p %the population is 2.5 times higher than that in the richest 20% of the populationA hild i h ‘L d d f li i ’ i• A child in the ‘Low standard of living’ economic group is almost four times more likely to die in childhood than a child in a better of highchildhood than a child in a better of high standard living group

• A person from the poorest quintile of the population, despite more health problems, is six times less likely to access hospitalization than a person from richest quintileperson from richest quintile.


Health Inequitiesq

• A girl is 1.5 times more likely to die beforeA girl is 1.5 times more likely to die beforereaching her fifth birthday

• The ratio of doctors to population in rural areasp pis almost six times lower than that for urbanareas.

• Per person, government spending on publichealth is seven times lower in rural areas

d di bcompared to government spending urban areas


Pop. Policy Draft 1976Small pox free-July 5,

1975 & ICDS started1975 & ICDS startedMTPAct(1969) in force-1972

MTP Act-1969Birth & Death Reg. Act-1969

Dept. of Family welfare -1966

NSEP-1962 NMCP to NMEPP-1958

Juggling Priorities

CHEB-1956 BCG Vaccination-1951NMCP & NFPP-1951NMCP & NFPP-1951

India joins WHO- 19481947

HSDC-19461947


ICDS renamed Integrated Mother d Child D l t (IMCD) 1995and Child Development (IMCD) -1995

CSSM-1992N ti l Bl d f t 1989National Blood safety program- 1989National Aids Control Program -1987UIP-1985

NLCP-NLEP, 1983 NHP-1983

Alma Ata-Declaration( 1977)-HFA-2000NFWP-1977


NRHM-2005NRHM 2005National Health Policy- 2002

National Pop Policy- 2000National Pop. Policy 2000RCH-1997

Family Planning Program madeFamily Planning Program made target free -1996

Beijing conference-1995Beijing conference 1995Legislation on Transplantation of human

organs enacted 1995organs enacted 1995ICPD-1994


Public Health Care in India

• Well developed administrative systemWell developed administrative system • Skills• Reasonable InfrastructureReasonable Infrastructure

Something is wrong• Poor health outcomes• Poor health outcomes• Design• Misdirected efforts• Misdirected efforts1999 Plague epidemic-loss of $ 1 billion (WHO)


“Ten Great Public HealthA hi t f th 20th C t ”Achievements of the 20th Century”• Vaccination • Safer and healthierVaccination• Motor-vehicle safety• Safer workplaces

Safer and healthier foods

• Healthier mothers and babiesSafer workplaces

• Control of infectiousdiseases

and babies• Family planning• Fluoridation ofdiseases

• Decline in deaths from coronary heart

Fluoridation of drinking water

• Recognition of tobacco use as afrom coronary heart

disease and stroketobacco use as a health hazard

Source: Center for Disease Control, Morbidity and Mortality Weekly Report, 48(12) 241-243 (April 2, 1999)


But we have known this for 64 years

“If it were possible to evaluate the loss, which thiscountry annually suffers through the avoidablewaste of valuable human material and thelowering of human efficiency throughmalnutrition and preventable morbidity, we feelthat the results would be so startling that thegwhole country would be aroused and would notrest until a radical change has been broughtg gabout.”


After 64 years of Health Services:After 64 years of Health Services:– Crude Death Rate ↓– Crude birth rate ↓– Life expectancy ↑y ↑– S.pox & G. worm eradicated– Leprosy eliminatedp y– IMR ↓– Infrastructure – expandedInfrastructure expanded


Health care in India

• Entitlements by policy and not rightsEntitlements by policy and not rights• Focus on preventive and promotive care• Grossly under-provided facilitiesGrossly under-provided facilities • Poor investments hitherto• Declining public expenditures and new• Declining public expenditures and new

investments • Structural Adjustment programming under World• Structural Adjustment programming under World

Bank dictate


Major Programs

• National AIDS Control ProgramNational AIDS Control Program • National Cancer Control Program• National Diarrheal Disease Control ProgramNational Diarrheal Disease Control Program• National Filaria Control Program*• National Family Welfare Program• National Family Welfare Program• National Iodine Deficiency Disorders Control

ProgramProgram• National Leprosy Eradication Program


N ti l M l i E di ti P *• National Malaria Eradication Program*• National Program for Control of Blindness

& Visual Impairment& Visual Impairment• National Reproductive and Child Health

Programg• National Program for surveillance Program

for Communicable diseases• National Tuberculosis Control Program

(Revised)

(* Programs are merged into

National Vector Borne Disease Control Program since 2003-04)


Epidemiological ProfileEpidemiological Profile


Diarrhea CasesSource:CBHI,NHP-2010 and MOHFW ,

11408666

10112845

2009

2010

1097841710993639

2007

2008

10970089

109784592005

2006

10510476104812382003

2004

9287758

9441456

2001

2002

8870507

0 5000000 10000000 15000000

2000


Diarrhea DeathsSource:CBHI,NHP-2010 and MOHFW

36034000

2918 2787

3475 3433

29393176

3603

30883000

3500

21472365

18182000

2500

1000

1500

0

500

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010


Enteric Fever CasesSource:CBHI,NHP-2010 and MOHFW

10346421200000

789004820360916161

10393111000000

471502490377

488033596684

685960695114

820360

600000

800000

471502 488033

400000

0

200000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010


Measles CasesSource:CBHI,NHP-2010 and MOHFW

6351570000

63515

4818150000

60000

36711 3690040840

2980840000

50000

29808

20000

30000

0

10000

2005 2006 2007 2008 2009 2010


Measles deathsSource:CBHI,NHP-2010 and MOHFW

188200

140160180

99100120140

54 50 4432

6080

32

02040

02005 2006 2007 2008 2009 2010


Polio

741800

559

741

600

700

400

500

Cases

116

238200

300 Deaths

11642

1 4 3276

10

100

2006 2007 2008 2009 2010


ARI CasesS CBHI NHP 2010 d MOHFWSource:CBHI,NHP-2010 and MOHFW

27486422 26152951 2554164530000000

1965760520555848

2213966624250256

2748642225452972 26171496 26544613

2472014425000000

19657605

15000000

20000000

10000000

0

5000000

02000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010


ARI DeathsSource:CBHI,NHP-2010 and MOHFW

8000

5470

6948

6000

7000

3278 34554235 4286

5470

41413736

4681

36124000

5000

3278 34552813

2000

3000

0

1000

02000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010


Neonatal tetanus CasesS CBHI NHP 2010 d MOHFWSource:CBHI,NHP-2010 and MOHFW

937 8991000

821 811899

700800900

620

500600700

373

200300400

0100200

2005 2006 2007 2008 2009 2010


Neonatal tetanus DeathsSource:CBHI,NHP-2010 and MOHFW

140

116

100100

120

80

56

80

100

56

3140

60

11

0

20

2005 2006 2007 2008 2009 2010


Tetanus other than Neonatal casesSource:CBHI,NHP-2010 and MOHFW

321835002981

2815

32182903

2500

3000

2051

15742000

2500

1000

1500

0

500

2005 2006 2007 2008 2009 2010


Tetanus other than Neonatal DeathsSource:CBHI,NHP-2010 and MOHFW

365400340

365325

300

350

253

160200

250

160139

100

150

0

50

2005 2006 2007 2008 2009 2010


Malaria Cases : IndiaSource:CBHI NHP 2010 and MOHFWSource:CBHI,NHP-2010 and MOHFW

2500000

2085484

18420191869403

18444131816569

1780777 15635741563574

2000000

15089271563574 1495817

1500000

336545500000

1000000

0

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011


Malaria Deaths :IndiaSource:CBHI NHP-2010 and MOHFWSource:CBHI,NHP-2010 and MOHFW

17041800

13111400

1600

1005 973 1006 949 9631055

1144

7671000

1200

767

400

600

800

750

200

400

02001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011


Dengue Cases : IndiaSource:CBHI,NHP-2010 and MOHFW

2829230000 28292

20000

25000

30000

12754 12317 1256115535

15000

20000

944 6503306 1926

4153938

5534

15985000

10000

944 650 1926 938 15980


Dengue Deaths : IndiaSource:CBHI NHP 2010 and MOHFWSource:CBHI,NHP-2010 and MOHFW

250215

157184200

8096

110100

150

17 7

5333

4569 80

850

7 80


TB Cases : IndiaSource:CBHI,NHP-2010 and MOHFW,

14755871517363

153330915221471600000

1800000

11884121293083

1397498

1200000

1400000

906472

800000

1000000

471658623323

400000

600000

0

200000

400000

02001 2002 2003 2004 2005 2006 2007 2008 2009 2010


TB Deaths : IndiaSource:CBHI,NHP-2010 and MOHFW

64539 64824 66204 6634570000

56471

50000

60000

2722031455

37639

30000

40000

10463

2107620000

30000

0

10000

2000 2001 2002 2003 2004 2005 2006 2007 2008 20092000 2001 2002 2003 2004 2005 2006 2007 2008 2009


Chikunganya Cases : IndiaSource : NRHM India

2500022113

20000

15000

6271

10000

2001 1826 2461

0

5000

02006 2007 2008 2009 2010


Kala Azar Cases : IndiaSource : NRHM India

50000

39178

44533

3323435000

40000

45000

33234

2120025000

30000

35000

21200 20040

15000

20000

0

5000

10000

02006 2007 2008 2009 2010


Kala Azar Deaths : IndiaSource : NRHM India

250

187203

200

146150

71 65

50

100

0

50

2006 2007 2008 2009 2010


Viral Hepatitis Cases : IndiaSource:CBHI,NHP-2010

236493250000

153034200000

149262135859

151287161621152623

124085150000

97827 92291 85164100000

0

50000

02000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010


Viral Hepatitis Deaths : IndiaS CBHI NHP 2010Source:CBHI,NHP-2010

2000

1718

1400

1600

1800

10381147

9141006

1186

1000

1200

1400

694

480 530 600416

600

800

0

200

400

02000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010


Thank You

For more details log on towww. sihfwrajasthan.com

or contact : Director-SIHFW

on

[email protected]


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