HEALTH CARE FOR ALL

GROUP 4 Ankita Choubey Anubhuti Gupta Priya Bhat Sanish MS Swaitlana Saha PGP/15/070 PGP/15/072 PGP/15/103 PGP/15/110 PGP/15/120

OUTLINE

Health care Scenario in India Existing problems Government Schemes NRHM Evaluation and critique National Health Insurance Scheme(RSBY) RWS TSC Government Spending on Health Care Universal Health Coverage for Indian Citizens Private Public Partnerships Conclusion and Suggestions

HEALTHCARE SCENARIO IN INDIA

India is the second most populous country in the world The death rate has declined but birth rates continue to be high in most of the states. Health care structure in the country is over-burdened by increasing population India faces the twin epidemic of continuing/emerging infectious diseases as well as chronic degenerative diseases. The former is related to poor implementation of the public health programs, and the latter to demographic transition with increase in life expectancy. India faces high burden of disease because of lack of environmental sanitation and safe drinking water, under-nutrition, poor living conditions, and limited access to preventive and curative health services Lack of education, gender inequality and explosive growth of population contribute to increasing burden of disease Full impact of the HIV epidemic and tobacco related diseases is yet to be felt

THE INDIAN SCENARIO: CURRENT STATUS

1% of GDP in 1999(one of the lowest in the world) to 6% of GDP today. Universal health care system run by Govt. of India.

Since 1990s, shift from public healthcare to private health sector

Private sector accounts for more than 80% of total healthcare spending Decline in public healthcare system adversely affected the poor and vulnerable sections of society. 75% of the resources and infrastructure was concentrated in urban India.

Current World Health Statistics 2010, released by (WHO)

Public health spend-ing would be raised to 3% of the gross do-mestic product (GDP).

HEALTHCARE SYSTEM ORGANIZATION

National level State level District level Community level Primary healthcare level Sub-centre level

INEQUITY IN HEALTH CARE

In addition the gap in health between rich and poor remains very wide. Addressing this problem, both between countries and within countries,

constitutes one of the greatest challenges of the new century. Failure to do

so properly will have dire consequences for the global economy, for social order and justice, and for the civilization as a whole.

EXISTING PROBLEMS
Infrastructural deficiencies
Deficits at community level Few PHCs at 24hour basis Low cleanliness Non-availability of important facilities

Neglect of Public healthcare

Non-implementation of basic public health regulations Public health acts have not been updated and rationalised since the colonial era Poor healthcare indicators compared to rest of the world. Inclination towards family planning programs

Shift from public to private

Lack of government run subsidized healthcare facilities in rural areas. Increasing healthcare costs Affordability and access to private healthcare

INCREASING COSTS: USER FEE

Implemented in order to ensure efficient utilization of services, undue demand, and generate revenue

check

Emerged as one of the major obstacles for the poorer households in terms of accessing care, complying with the treatment protocol, and making already poor people poorer

Repercussions: The proportion of the poor utilizing hospital services showed a marked decline, particularly for hospitalization, followed by outpatient department (OPD), surgeries, deliveries, and laboratory and diagnostic services. Low utilization by the scheduled caste and tribe (SC/ST) population over the same period.

Similar trend was noted in the utilization pattern of outpatient and inpatient services of the public health facilities in Maharashtra Even though the proportion of user fees utilization increased, it was still less than 100%, and acted as a support to meet the gap in the face of declining contribution from the state governments

LACK OF REFORMS TO CONTROL RISING HEALTHCARE COSTS: CASE OF WEST BENGAL

Since 2002, graded user fees were introduced in the secondary and tertiary level care, and over time, existing exemptions on services for different patient categories were eroded

In 2004, under the public-private partnership (PPP) framework, the government hospitals in the rural areas introduced paid diagnostic services.

Post mid-1990s, user fees have been revised thrice (1995, 1998 and 2002).

In early 2010, a differential user fees was introduced for the same services directly provided by the public sector hospitals and those provided by the PPP model within the premises of the government rural hospitals.

West Bengal has one of the highest shares of OOP expenditure in outpatient care in the country. In rural areas, OOP accounts for more than 80% of the increase in poverty

MEASURES TAKEN
State Health Systems Development Project II Introduced wideranging reforms in the states public health sector Brought significant changes in the provisioning pattern of services (clinical and non-clinical) and their financing mechanism

Healthcare reform policy Proposed to provide affordable health and preventive services Active engagement in partnership with PRI, CSO, NGO, donor group agencies, private sector and other development partners.

Provision of diagnostic services Initiated in rural hospitals in 2004 Outsourced services to the private sector under the PPP model

GOVERNMENT INITIATIVES

Rural water supply programme

Total sanitation programme

National rural healthcare mission

rashtriya swasthya bima yojana

NATIONAL RURAL HEALTHCARE MISSION

Objectives :
To provide access to primary healthcare services for the rural poor, with universal access for women and children

To see a concomitant reduction in IMR / MMR / TFR

To prevent and control communicable and non-communicable diseases

To revitalize local health traditions.

NRHM THE PLAN

Provision of a flexible financial pool for, decentralised utilisation of funds at the state level

Provisions for planning and management at the district level.

Creation of female health activists (ASHAs) and PRIs, such as village health and sanitation committees (VHSCs), as a means of fostering a true partnership between the community and peripheral health staff . Centrally-sponsored schemes

Through the NRHM, the UPA government has put rural public health care firmly on the agenda, and is on the right track with the institutional changes towards decentralisation (and communitisation) it has introduced within the health system

Did NHRM succeed in fulfilling the aim of increasing the govt. spending on healthcare to 2-3% of GDP ??
NO,implementation has been slow and usage of constructed facilities low

EXISTING SHORTCOMINGS
PHCs comprise only 36% at the all-India level and 27% in high focus states. The corresponding figures for CHCs are 93% and 88%, physical upgradation has been started in only 65% of the CHCs In PHCS and CHSCnon-availability of facilities like mobile medical units,3 blood storage, emergency care facilities for children and surgery absence of toilet facilities and medical waste disposal system in many SCs, PHCs and CHCs
community centres did not have any ECG machines, operation theatre (OT) ,care fumigation apparatus, and cardiac monitors. Shortage of baby cradles, laryngoscope, wheelchairs etc MEDICINE SHORTAGE significant gap in the supply of essential drugs to the PHCs basic medicines like albendazole/mabendazole tablets, bandages, cotrimoxazole syrup, etc, were found to be out of stock Patients forced to purchase them from private sources, where the cost of medicine is substantially higher only 49% of SCs,36% CHCs and 42% PHCs received funds allocated to them under the NHRM scheme also this money was generally spent on meeting telephone and power bills, maintenance, purchasing drugs and facilities for patients 11% of the PHCs do not have a doctor At the CHC level, only 49% of the required specialist posts have been sanctioned so far, and 25% positioned . Less than a third of the required number of staff nurses has been positioned REASONS FOR ABSTEESISM absenceof social facilities like educational infrastructure for children, irregular supply of electricity and potable water, and safety of women and unhygienic and insanitation in villages and health facilities complacency arising from the assured nature of regular lifetime employment in the government sector

Deficiencies in Physical Infrastructure

Shortage of Equipment and Medicine

Deficiencies in Manpower

WHY NHRM HAS NOT DELIVERED WHAT

IT SET OUT TO ACHIEVE

Decentralization and financing

Improving human resources

Inter-sectoral co-ordination

DECENTRALISATION AND FINANCING

Though flexibility is its keyword, the NRHMs design and budgeting leaves little creative freedom for states. The states have their own problems of rural health services and need special political will and strategies. The utilisation of NRHM funds in states is both tardy and ineffective. Many schemes are not understood properly even in the third year of NRHM. The NRHMs financing model fund flow from the centre to the state and then to district societies was to provide flexibility to the mission. But since the mission is treated as being outside the treasury system and therefore not subject to internal audit by the respective departments of the state, has only resulted in a situation where corruption and financial scandals rule the roost

IMPROVING HUMAN RESOURCES

Indian Public Health Standard (IPHS) Even after three years very few hospitals fall under the purview of IPHS. The causes are macroeconomic (power and water scarcity) and systemic paucity of doctors and nurses and ubiquitous governance problems.

Doctors abhor rural centres because of poor infrastructure and working conditions, salaries are poor and there is lack of work-satisfaction Not ensuring a right skill mix of doctors (for example, the presence of anaesthetists along with surgeons, etc) at every rural hospital is another reason for the mismanagement of rural health centres. The lack of a good and transparent human resources policy encourages corruption and discourages good work. The shortage of nurses is due to a thoughtless human resources management policy of the Nursing Council, and hence only 30 per cent nurses positions are filled and that too with great difficulty A major folly of NRHM is to completely bypass the MPhW system, which has fought major public health battles against diseases such as small pox, cholera, malaria, leprosy and now tuberculosis.

THE ASHA SCHEME

A male and female community health worker in each village To waste a potent programme like ASHA for merely escorting women to unwilling hospitals is a questionable strategy. The average ASHA is hardly getting the promised Rs 1,400 per month. Training is poor, barely halfway and accreditation is yet to even begin. Drug kits are either not supplied or not refilled ASHAs are supposed to be activists but in reality, ASHAs are not equipped to undertake their complex social roles in rural areas

INTER-SECTORAL COORDINATION

Sanitation work is still in the pits in most states, Anganwadi workers look at the ASHA as some kind of an adversary in the same field of work. The AYUSH medicine, equipment and knowledge base is inadequate in the ASHAs kit and capabilities coordination with the private sector, a proper form of it is not possible unless there is a concrete PPP policy and strategy for providing a guarantee for universal health coverage.

The private sector has a 70 per cent share in healthcare but is largely bypassed
in NRHM, leading to no great progress in the integration of the health sector. The NRHM is relying upon the private medical sector only for JSY maternity services. Public hospitals have started losing clients and government doctors have resented their counterparts in the private business of health.

RASHTRIYA SWASTYA BIMA YOJANA (RSBY)

Known as Health insurance for the poor Aims at providing protection to BPL households from financial liabilities arising out of health shocks that involve hospitalization Entitled to hospitalization coverage up to Rs. 30,000/Pre-existing conditions are covered from day one and there is no age limit. Coverage extends to five members of the family Pay only Rs. 30/as registration fee while Central and State Government pays the premium to the insurer

Empowering the beneficiary

Business Model for all Stakeholders

Information Technology (IT) Intensive

Safe and foolproof

Cash less and Paperless transactions

EVALUATION OF RSBY

The schemes management information system was built centrally for all stateled RSBY schemes to enable the collection of standardized information on all daily transactions at hospitals. Data from all districts flow to the central government at periodic intervals RSBY has been able to reach more than 8 million families in just over eighteen months. The Government of India intends to covers a total of 250300 million people in next four years. In addition, the scheme may be extended to additional groups (e.g., unorganized workers) More and more people are not only enrolling, but utilization of services is increasing, as well.

RURAL WATER SUPPLY PROGRAMME

Objectives: Providing safe drinking water to all villages Assisting local communities to maintain sources of safe drinking water in good condition Giving special attention for water supply to Scheduled Castes and Scheduled Tribes Accelerated Rural Water Supply Programme (ARWSP) To accelerate the coverage of the remaining Not Covered and Partially Covered To tackle problems of water quality in affected habitations To institutionalize water quality monitoring and surveillance systems. To promote sustainability, both of systems and sources, to ensure continued supply of safe drinking water

TOTAL SANITATION CAMPAIGN

Aim: To ensure adequate sanitation facilities in rural areas with the broader goal to eradicate the practice of open defecation by 2012 Objectives: Bring about an improvement in the general quality of life in rural areas Accelerate sanitation coverage Generate demand through awareness and health education Cover all schools and anganwadis in rural areas with sanitation facilities Promote hygiene behaviour among students and teachers Encourage cost effective and appropriate technology development and application Endeavour to reduce water and sanitation related diseases Emphasises information, education and communication, capacity building and hygiene education Involvement of panchayati raj institutions (PRIs), community based organisations (CBOs), and nongovernmental organisations (NGOs), etc.

GOVERNMENT HEALTH SPENDING

Over the years it has been a little more than 1 % of GDP

Aim of the 12th five year plan- make it 2-3% of GDP

Aims at serving two-thirds of the rural population Significant steps taken recently

Launch of NRHM in 2005- part of 11th five year plan

Rural Water Supply Scheme (RWS) Total Sanitation Campaign (TSC)

FUND UTILIZATION- NRHM

90% of the funds- released during the reference period, except in 2006-07 But, the cumulative expenditure by the states: only 72.27% of the funds in the first year. The two subsequent years witnessed a decline in utilization, wherein as much as a third of the funds remained unutilized. However, since 2008-09, the states managed to spend more raised expenditure up to 87.05%.

FUND UTILIZATION - RWS

During 2005-06, the states could spend only 71.93% of the funds available, which went up to 89.55% in 2007-08. Thereafter, the fund utilization declined and the level of expenditure was only 73.46% during 2009-10. This is not a very encouraging scenario- in the light of climate change and its fallout- intractable water quality issues plaguing the system.

FUND UTILIZATION - TSC

Fund utilization has improved over the years Still way below the acceptable levels

Expenditure incurred was less than the opening balance during 2005-06, 2006-07, 2007-08 and 2008-09
However, during 2009-10, the states managed to spend more than what they had as opening balance, making the fund release meaningful for the first time since 2005-06

UNIVERSAL HEALTH COVERAGE FOR INDIAN CITIZENS

A commitment to universal coverage means, in practical terms, that all people within a country should receive some degree of financial protection from the costs of at least some basic health services This means, in ethical terms, that no one in need of health care, whether curative or preventive, should risk financial ruin as a result of paying for this care Many countries, such as Canada and Germany, provide universal coverage to all of the country's inhabitants, meaning that all residents are covered for basic healthcare services

An individual cannot be denied healthcare as long as he or she is a legal resident of the country that offers the universal coverage
As with any type of insurance, there are a large group of payers, and only a few need a large amount of money quickly at any given time. The more contributors there are, the lower the payments are.

EXPERT GROUP ON UNIVERSAL HEALTH COVERAGE SET UP

With the approval of Prime Minister Manmohan Singh, Planning Commission has set up a high level expert group to develop a blueprint and investment plan- to achieve health for all' by 2020 The 15-member high level group on universal health coverage, chaired by K. Srinath Reddy, president of the Public Health Foundation of India to rework the physical and financial norms needed to ensure quality, universal reach and access to healthcare services, particularly in underserved areas and to indicate the role of private and public service providers will also explore the role of a health insurance system that offers universal access to health services with high subsidy for the poor and a scope for building up additional levels of protection on a payment basis

UNIVERSAL HEALTH COVERAGE FOR INDIA

The terms of reference (ToRs) are as follows:

Develop a blue print for human resources in health, for India

Rework the physical and financial norms needed to ensure quality, universal reach and access of health care services
Suggest critical management reforms in order to improve effectiveness and accountability of the health delivery system efficiency,

Identify pathways for constructive participation of communities and the private for-profit and not-for-profit sectors in the delivery of health care Develop systems which will ensure access to essential drugs, vaccines and medical technology by enhancing their availability and reducing cost to the Indian consumer Develop a framework for health financing and financial protection that offers universal access to health services.

It was also decided to develop a seventh chapter addressing the Social Determinants of Health, as this was seen as an important overlapping element to be covered by, and beyond, all ToRs

THE NEW ARCHITECTURE FOR UHC

Recommendations by the Expert Group:

Health Financing and Financial Protection Health Service Norms Human Resources for Health Community Participation and Citizen Engagement

Access to Medicines, Vaccines and Technology

Management and Institutional Reforms

PRIVATE PUBLIC PARTNERSHIPS

Organizations present WHO- partnerships between the state and market Various pharmaceutical companies, American bilateral, international NGOs

foundations,

Need for it ? Useful in handling the poorly performing primary health centers (PHCs) Helps in improving the services of these PHCs Influence on the national and local levels of planning and implementation of health policy

Strengthened and supported the free market ideology Reduced role for governments in economy and social sectors Breaking down the traditional boundaries between the state and market

TYPES OF PARTNERSHIPS
Simple PPP at Primary Level of Care Complex PPP at Primary Level of Care
State Government

State Government

Creates
Creates

NGO manages the primary health care in area

Private implementing agency

Autonomous body (created by state)

CONSTRAINTS IN BUILDING PARTNERSHIPS

process of partner selection is often mediated through money and political patronage in the award of contracts

Availability of an adequate number of players in the market

Blurring of roles between NGOs and government

Pool not large enough to choose potential partners

PPP

The process of partner selection is often mediated through money and political patronage in the award of contracts

Ambiguous demarcation of functions and rules governing the partnerships

The impact of these partnerships on comprehensive ness and equity.

The bureaucracy neither ready for change not do they acknowledge efforts put by NGOs

MAKING OF AN IDEAL HEALTH CARE SYSTEM

First universal access, and access to an adequate level, and access without excessive burden. Second fair distribution of financial costs for access and fair distribution of burden in rationing care and capacity and a constant search for improvement to a more just system. Third training providers for competence empathy and accountability, pursuit of quality care ad cost effective use of the results of relevant research. Last special attention to vulnerable groups such a children, women, disabled and the aged.

RECOMMENDATIONS

Planning to provide a better infrastructure Facilities like staff, electricity, medicine, water, ambulance

Giving incentives to doctors and nurses for rural postings Providing higher wages, better housing and other amenities
Make the health care workers accountable Checking the workers who do not stay at the health care centers Reducing the prevalent absenteeism

Better allocation and utilization of funds Budgets for health services will need to increase by a factor of three to five times Reducing the regulations that prevent the money being spent
Creating a division of technology assessment For identifying and rigorously evaluating potentially useful and cost effective technologies Improve the availability of medicines Training for top policymakers and managers in health department

RECOMMENDATIONS (CONTD)

Regulation of clinical establishments and improving the quality of healthcare Institutions Laying down minimum standards, both in public and private sectors and enforcing them rigorously. Imparting better medical education Improving the quality of education Having more doctors, nurses and medical staff to meet the requirements To improve the quality of education in Government medical colleges it is necessary to give incentive to the teaching faculty Expanding health insurance Implementing telemedicine To cover the remote areas too

Contracting private providers Eg. Chiranjeevi Scheme in Gujarat

THANK YOU