ASSIGN NO.3

8/8/2019 ASSIGN NO.3

1/14

HEALTH CARE REFORMS IN ANDHRA PRADEsh

Andhra Pradesh state profile------

Introduction --- The state of Andhra Pradesh was formed on 1st November, 1956under the States' reorganization scheme. It is the fifth largest State with an area of 2,76, 754 sq. km, accounting for 8.4 % of India's territory and also the fifth most

populous state with a Population of 75 crores. The state has varied physiographicfeatures ranging from high hills, undulating plains to a coastal deltaic environment.

Administratively, Andhra Pradesh is divided into 23 districts, 79 revenue divisions,1123 mandals, about 27000 villages and 264 towns. AP's economy grew at 7.2%during 2006-07 -- the fourth consecutive year of 6% plus growth. The latest povertyheadcount ratio stands at 16%, compared to 23% for India . the third-highest creditrating among the major Indian states; the third best investment climate in the country;and the fourth-lowest corruption level among Indian states Andhra Pradesh was thefirst Indian state to receive a multi-sector Bank operation - the Andhra PradeshEconomic Restructuring Program for US$ 550 million in 1997 - aimed at helping thestate accelerate policy and institutional reforms across a wide range of sectors under acommon fiscal framework. It is also the only Indian state where the Bank hasdisbursed three budget support operations - the First Andhra Pradesh Economic

Reform Loan (APERL-1) in March 2002, the Second APERL in February 2004, and


2/14

the Third APERL in January 2007 - that sought to support the state's developmentprogram.


3/14

HEALTH STATUS AND DEMOGRAPHICS OF THE STATE--------------------------

During the last few decades there is a considerable improvement in the health statusof the population in the State.Andhra Pradesh Population by the end 2010 AD will be 10 crores. There has been

positive change in the demographic indicators particularly in the Total Fertility Rate(TFR). The causes for this good performance are the all round efforts made to deliverquality services and to increase health consciousness particularly among the ruralwomen. The positive trends in Andhra Pradesh on comparing national family healthsurvey 1993 and 1999 are--

1. Crude Birth Rate reduced from 24.1 to 22.3 per 1000

2. Higher order births reduced from 41.0% to 31.2%

3. Couple Protection Rate increased from 45.3% to 59.6%

4. Total Fertility Rate reduced from 2.6 to 2.25 per women.

5. Women receiving ante-natal care increased from 86.6% to 92.7%

6. Safe deliveries increased from 49.3% to 65.2%

7. Infant Mortality Rate declined from 70.4 to 65.8 per 1000 live births

8. Full immunization risen from 45% to 58.7%

State population policy-

The gains in family planning programme have been sustained over the recent yearsalso.The population stabilization objectives which form part of the policy statementare ----

Reduction in the fertility rate through-----

1. Promotion of use of spacing methods: minimum spacing of 2 years before

first birth and 3-5 years between 1st and 2nd births.

2. Promotion of use of terminal methods with concentration on couples with 2

children and above.


4/14

3. Increasing the use of male contraceptive methods.

Reduction in MMR through--------

1. Increase in coverage of pregnant women with tetanus toxoid, IFA tablets and

other

ante-natal care from the current level of 86% to 100% by 2000 A.D

2. Increase in institutional deliveries (current level 32.9%) and domiciliary

deliveries by

medical and para medical personnel and trained traditional birth attendants

3. Improved referral systems for emergency obstetric care.

4. Increase in accessibility to quality services for medical termination of

pregnancies and for treatment of reproductive tract infections.

Reduction in IMR/CMR through----------

1. Eradication of polio cases and deaths by 1998.

2. Elimination of neo-natal tetanus by 1998.

3. Elimination of measles deaths by 1998.

4. Sustained universal immunization of children.

Resource allocation in health care sector----The state government has increased the health expenditure from 1500 crores in 2001to more than 80000 crores at present.

Health Finance Indicators---

Health Finance indicators provide an understanding of patterns of investments,expenditure, sources of funding and proportion of allocation vis--vis other totalallocation. It also provides an important tool to understand health outcomes in relationto the expenditure.Health Finance Indicators include allocations under Five Year Plans, details ofexpenditures on health, trends in public and private spending.


5/14

HEALTH CARE DELIVERY INFRASTRUCTURE IN ANDHRA PRADESH------

Primary Health Care delivery------

Service Facility number


6/14

Primary Health Centres 1386

Sub Centres 10568Mobile medical units 45

Urbanfilariacontrol units 28

Filaria clinics 4

Filaria survey units 2

District TB Centres 24

Leprosy control units 104

Secondary Health Care delivery----

Service facility Number

District Hospitals 20

Area Hospitals 56

Community Health Centres 117

Others (MCH) 8

C.D. Hospitals 2

Civil Dispensaries 25

Total 228

Service facility Bed Strength

District Hospitals 5250


7/14

Area Hospitals 5600

Community Health Centres 4640

Speciality Hospitals 500

C.D. Hospitals 324

All institutions beds 16314

Staff available----

Medical 1900

Nursing

Paramedical 2519

All others 2733

Total 11351

STATE GOVT. STRATEGIC PRINCIPLES-------

a. Universal access to primary and secondary health care.

b. Strengthening tertiary care in existing Government Hospitals.

c. Focus on communicable diseases.

d. Increasing role for Indian Systems of Medicine.

e. Strengthening process of institutional development.

f. Setting up self-supporting health insurance scheme.

g. Increase community participation.

h. Establishment of village level health workers and provide trained communityhealth workers in the village areas.

i. In the urban slums the system of link volunteers, each one catering to the basichealth needs of 20 families will be strengthened.

j. Institute a regular health camp approach where the PHC Medical Officer and hisstaff will hold camps in a minimum of 2 villages every week.


8/14

STRATEGIES FOR PREVENTION AND CONTROL OF COMMUNICABLEDISEASES

A) Communicable diseases have to be controlled through serious efforts byGovernment machinery at field level involving Non-Governmental Organisations ,

Self-Help Groups and community. This is possible only if Panchayat Raj Bodies andMunicipal Bodies take effective steps for controlling mosquito breeding and supply ofsafe drinking water to the people.B) Government has decided to appoint two High Level Expert Committees to suggestmeasures to control communicable diseases. A National workshop was conductedwhose recommendations are available in regard to measures to be taken to controlcommunicable diseases.

C) State Level Action Plan

Action plans are being prepared to tackle diseases like (a) tuberculosis (b) Blindness

(c) Leprosy and (d) Filaria.Respective departments will identify the problem and prepare action plans to reduce

the levels of diseases by 20 percent every year. These plans have to be made at theState level and later on District level plans have to be preparedD) Training Programmes

Training programmes are also planned for all levels of staff and Non-governmentorganizations and self-help groups for prevention and control of communicablediseases.

E) AIDS Prevention and Control Programme---------

a) Andhra Pradesh has a population of 7 million people. As of November 2000 theState has reported 6463 HIV infections in Andhra Pradesh, out of which 67 peoplehave AIDS. The prevalence of HIV positive is 28.5% among the attendees of STDClinic and 2.25% among the attendees of Antenatal clinic.

b) The State has established 28 STD clinics to diagnose and treat STD patients out ofwhich 20 clinics are strengthened in terms of equipment and provision of medicines.

The incidence of STD in the state is showing an upward trend from 17942 cases in1996, to 22627 cases in 2001 which is more than 25%.

c) The State Government is committed to bring awareness, knowledge andunderstanding about HIV/AIDS, prevention and transmission in general populationand to bring about desired behavioural change of seeking information on HIV/AIDSand condom use involving NGOs, electronic and print media, out door publicity.

d) It is proposed to provide the AIDS Testing facilities in all the District Head

Quarters Hospitals. Necessary training will be imparted to the staff and posted to theAIDS detection centres.


9/14


10/14

One of the major reform initiatives underway is the Secondary Health SystemStrengthening Project funded by the World Bank in seven states (Andhra Pradesh,Karnataka, Punjab, West Bengal, Maharashtra, Orissa and Uttar Pradesh). The

projects include strengthening FRUs /CHCs and district hospitals so as to improve theavailability of emergency care services to patients, to reduce overcrowding at district

and tertiary care hospitals, construction works, procurement of equipment, increasedavailability of ambulances, drugs; improvement in quality of services following skillup gradation training in clinical management, changes in attitudes and behaviour ofhealth care providers; reduction in mismatches in health personnel / infrastructure;improvement in hospital waste management, disease surveillance and responsesystem.It is essential to assess both progress and problems in implementation of the reforms

in each state and to appropriately modify the content and pace of implementation.In the Indian Constitution, health is a state responsibility. During Adjustment, manystate governments in India had recourse to Health Systems Development Project loansfrom the World Bank for carrying out health sector reforms (HSR), of which one of

the key policies has been to raise public spending on health care from the abysmallylow levels seen up to then. The Health Systems Development Project seeks to developstrategic management capacity; strengthen performance, accountability, andefficiency; and build implementation capacity. Further, it seeks to improve clinicalservice quality by renovating and expanding district, sub district, and communityhospitals and improving access to services. In ANDHRA PRADESH , around 15% ofthe total project cost is borne by the state governments. All the project documentsnote the low levels of funding for secondary hospitals in the reforming states. This isattributed to the small share of overall public spending allotted to health, the limited

portion of total health spending going to hospitals, and, within this, a skeweddistribution of funds in favour of the tertiary hospitals.Govt . of AP have took the responsibility which are: (i) to enhance the overall size ofthe health budget; (ii) to redress imbalances in public expenditure between secondaryand tertiary care levels; (iii) to safeguard the operations and maintenance componentsof current expenditure allocations for the secondary health-care sector; (iv) to chargeuser fees for selected services; and (v) to address workforce issues. The HealthSystems Development Project initiated in state recognizes the need for enhanced

public spending on health and identifies it as the foremost policy reform to bepursued.Andhra Pradesh is the first state to go with the HSR.Within AP there are regional, social and gender disparities. Health outcomes are

worst among Scheduled Castes (16% of population) and Scheduled Tribes (7% ofpopulation), especially those living in underserved areas in North tribal and Southdrought prone districts, and for women. Effective delivery of quality basic healthservices is hampered by demand and supply side issues, including poor healthinfrastructure and staffing.

The reform history in health sector in the State can be traced to Andhra PradeshFirst Referral Health System Project, one of the first World Bank aided health system

projects in the country. This project, launched in 1995 had been implemented by APVaidya Vidhana Parishad (APVVP). Agencies like World Bank and DFID aresupporting the reform process in the State. The Bank supported the AP EconomicRestructuring Project which included improvement of primary health care as one of

the component.


11/14

The priority reforms focus on improved access to quality and responsive healthservices, strengthened governance and management in health sector, improvedinstitutional mechanisms for community participation and systems for accountability;and strengthened financial management systems.The government of Andhra Pradesh Vision 2020 document identifies a seven-point

set of priorities for health sector reform:

1. providing universal access to primary healthcare;2. encouraging private investment in tertiary healthcare;3. focusing on specific programmes to promote family planning;4. focusing on improving health levels in disadvantaged groups and backwardregions;5. ensuring a strong prevention focus;6. enhancing the performance of the public health system;7. formulating a state information education and communication (IEC) programme to

broadcast information on preventive healthcare.

The Government of Andhra Pradesh is embarking on a major health sector reforms toimprove health care delivery in the State. D.F.I.D. has expressed its willingness tosupport these initiatives with a grant of 100 Million pounds in five years (2006-2011).The reform initiative will include measures to improve the effectiveness andaccountability of public health services, measures to focus on community centric

preventive healthcare system and enhance access to quality healthcare for the poorersections of the populationThe sector support will build synergy with National Rural Health Mission (NRHM)which is a health sector reform program of the central government fordecentralisation, pro-poor focus, strengthening service delivery.The health sector support will be provided over three years (2007-08 - 2009- 10). It

aims at increased use of quality health services, especially by the poorest people andin underserved areas. The main outputs will be:a) Improved access to quality and responsive services, especially in remote and

interior areas;b) Governance and management of health sector strengthened;

c) Institutional mechanisms for community participation and systems foraccountability in functioning; and Financial management systems strengthened andimproved public expenditure on health.

The performance of health services would be measured against-----------------

* greater effectiveness and improved outcomes of existing programs;* improved efficiency in the allocation of resources;* greater access and equity; and* consumer satisfaction

REFORMS CLASSIFIED IN FIVE YEAR PLANS AND THEIR

IMPLEMENTATION BY THE STATE GOVT.----


12/14

1. Reorganization and restructuring of existing government health care system

Establishment of Andhra Pradesh Vaidya Vidhana Parishad

Strengthening of referral institutions and fixing of service normsImprovement in drug suppliesFormation of Andhra Pradesh Health, Medical & Housing Infrastructure DevelopmentCorporation (APHM&HIDC)Strengthening of PHCs as 24-hour MCH centersEstablishment of Comprehensive Obstetric & Neonatal Care (CEmONC) centres

2. Changes in health system organisation, delivery and Management

Formation of Hospital Advisory Committee/ Hospital Development Societies for allPHCs and FRUs/ teaching hospitals

Provision of free travel bus passes to pregnant women for antenatal check upsPublic Private Partnership

3. Changes in financing methods

Sukhibhava Scheme (Improvement of Institutional Delivery Services Scheme)User fees

4. Reforms related to human resources

Integration and responsibilities of functionaries for planning, implementation andmonitoring of programmes of HM & FW department

5. Involving community in health service delivery and Provision

Women Health Volunteers Scheme

6. Reforms to quality of care

Performance indicators for grading the PHCsPerformance rating of secondary hospitals

GOALS OF HEALTH CARE PLANNING IN ANDHRA PRADESH------

i) Every person will have access to responsive basic health care and specialised

health care at affordable prices.

ii. Women will have safe and successful pregnancies

iii. Infant/child mortality due to ailments like Diarhoea will be reduced drastically.

iv. The spread of AIDS will be contained.

v. Communicable diseases like GE, Malaria and TB will be effectively prevented.


13/14

vi. Families will be small and better spaced

vii. Equitable access to quality health care will be ensured

viii Health sector will be equipped to deliver quality services for non-communicablediseases . trauma and injury cases.

ix. Life expectancy levels will reach 68 years males and 70.6 years for femalesfrom current 62 to 64 respectively.

x. Ensuring equality and access to affordable health care.

xi. Enhancing technical efficiency of key programs and clinical effectiveness.

xii. Ensuring micro/macro economic effectiveness in the use of resources

xiii. Improving quality of care /consumer satisfaction

INITIAL INITIATIVES----

The following steps were initiated which shall contribute to the overall improvementsin the health sector.

1. PHCs and secondary Hospitals Grading

2. All Systems of Medicine under one roof Ayurveda, Homeo ,Unani in DH, AH& CHCs.

3. Master Health check up periodic speciality Medical camps.

4. Blood Banks in all DH, AH & CHCs on National Highway.

5. Health Check ups in schools and welfare hostels.

6. Incentives & Disincentives.

7. Affiliation for DNB (Family Medicine) in all District Hospitals.

8. To all advanced diagnostic facility including Telemedicine to all district levelthrough public private participation by taking the help of corporate sector.

9. Clean & green programmes and horticulture development in all hospitals.

GAPS IN HEALTH DELIVERY IN THE STATE---


14/14

1. Inadequate ENVIRONMENTAL MONITORING ; environment being animportant factor in consideration for planning and implementing health

programmes.2. Occupational safety is needed to be considered in detail.3. Nutritional deficiencies must be targeted also like communicable diseases.

4. Inter sectoral coordination should be there.

Recommendations ---1. Trained HR----------------- reduces cost

Improves service qualityReduces service delivery time.Better coordination

2. Incorporation of the technology driven system in health care system.3. Planning, implementation and monitoring should be decentralized to ensureadequate control at district level.

THANKYOU.

Documents

ASSIGN NO.3