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8/3/2019 HRLN Using the Law for Public Health Dr Shrinath Reddy
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REPORT OF THE
HIGH LEVEL EXPERT GROUP ON
UNIVERSAL HEALTH COVERAGE
PRESENTATION TO THE
HONOURABLE MINISTER
FOR
HEALTH & FAMILY WELFARE
GOVERNMENT OF INDIA
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WORLD
THE CHINDIAN CENTURY
With so many of the world's
economies in tatters, the
combined might of China and
India could spearhead global
growth in the coming decades.
Are they up to the job?
By ZOHER ABDOOLCARIM THE CASE FOR INDIA:
FREE TO SUCCEED
By MICHAEL
SCHUMANTIME : NOVEMBER 21, 2011
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KEY HEALTH INDICATORS:
INDIA COMPARED WITH OTHER COUNTRIES
Source: World Health Organization (2011) IMR Infant Mortality Rate
Indicator India China Brazil Sri Lanka Thailand
IMR/1000 live-births 50 17 17 13 12
Under-5 mortality/
1000 live- births
66 19 21 16 13
Fully immunised (%) 66 95 99 99 98
Birth by skilled attendants 47 96 98 97 99
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LOW PRIORITY TO PUBLIC SPENDING ON HEALTH
INDIA AND COMPARATOR COUNTRIES 2009
Total public
spending as %
GDP (fiscal
capacity)
Public spending
on health as % of
total public
spending
Public spending
on health as % of
GDP
India 33.6 4.1 1.4
Sri Lanka 24.5 7.3 1.8
China 22.3 10.3 2.3
Thailand 23.3 14.0 3.3
Source: WHO database (2009)
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Change in poverty (USD 1.08 per day) head count ratio
by out of pocket payments in 11 countries in Asia
WHO Global Atlas on Cardiovascular Diseases Prevention and Control 2011
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Indias Current Health Scenario
Largest number of underweight children (46% under 3 yrs);
Current infant mortality rate of 50 per 1000 live births; Maternal mortality ratio presently 212 per 100 000 live births;
Challenge to meet national goals of 38 per 1000 (IMR) or 100
per 100 000 (MMR) by 2015
Rising burden of NCDs
2011(in Millions)
2030(in Millions)
Diabetes 61 101
Hypertension 130 240
Tobacco Deaths 1+ 2+
PPYLL Due to CVD Deaths
(35-64 Yrs)
9.2 17.9
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CHILD DEATHS : DISPARITY ACROSS STATES
IMR : MP : 72/1000
UP : 69/1000
Tamil Nadu : 35/1000
Kerala : 13/1000
Neonatal Mortality Rate VariesFrom 11/1000 in Kerala to 53/1000 in Odisha
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Impoverishment Due to OOP Payments in India
(In Millions)
Source: Selvaraj and Karan (2009)
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CURRENT SCHEMES FOR
FINANCIAL PROTECTION MOSTLYDO NOT COVER
OUT PATIENT CARE DRUGS LAB DIAGNOSTICS
Which collectively contribute tothe larger fraction of OOP!
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HOSPITAL BED CAPACITY, BY COUNTRY
Source: World Health Statistics (2011)
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HEALTH SERVICES : URBAN RURAL DISPARITY
80% of Doctors
75% of Dispensaries
60% of Hospitals
Qualified Physicians:
11.3/10,000 - Urban Areas1.9/10,000 Rural areas
Are Located In
Urban Areas
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HLEG: Terms of Reference
1. Human Resource Requirements
2. Access to Health Care Services
3. Management Reforms
4. Community Participation
5. Access to Medicines
6. Health Care Financing7. Social Determinants of Health
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Our Definition of UHC
Operational Definition
Ensure equitable access for all Indian citizens resident in any part ofthe country, regardless of income level, social status, gender, caste orreligion, to health services (promotive, preventive, curative, andrehabilitative) that are affordable, appropriate and of assuredquality.
Definition Ensuring equitable access for all Indian citizens resident in any part
of the country, regardless of income level, social status, gender, casteor religion, to affordable, accountable and appropriate, assured
quality health services (promotive, preventive, curative andrehabilitative) as well as public health services addressing widerdeterminants of health delivered to individuals and populations,with the government being the guarantor and enabler, although notnecessarily the only provider, of health and related services.
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Guiding Principles
Universality;
Equity;
Non-exclusion and non-discrimination;
Comprehensive care that is rational & of goodquality;
Financial protection;
Protection of patients rights that guaranteesappropriateness of care, patient choice, portability &continuity of care;
Consolidated & strengthened public healthprovisioning;
Accountability & transparency; and
Community participation
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Our Vision
Universal Health Entitlement for
every citizen - to a National Health
Package (NHP) ofessential primary,secondary & tertiary health care
services that will funded by the
government.
Package to be defined periodically by an Expert
Group; can have state specific variations
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Health Financing & Financial Protection
Government (Central government and statescombined) should increase public expenditureson health from the current level of 1.4% of GDPto at least 2.5% by the end of the 12th plan, andto at least 3% of GDP by 2022.
Ensure availability offree essential medicines byincreasing public spending on drug procurement;
General taxation as principal source of healthcare financing complemented by additional mandatorydeductions from salaried individuals & tax payers, either as a proportionof taxable income or as a proportion of salary
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Even on assuming total spending on health remains at the current level of
around 4.5% of GDP, there will be a sharp decline in the proportion of
private out-of-pocket spending on health - from 67% today to 33% by 2022
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Do not levy sector-specific taxes for health
financing;* Remove user fees for NHP services- this applies
even for the non-poor
Introduce specific purpose transfers to equalize
levels of per capita public spending on health bydifferent states - to ensure all citizens are entitled to samelevel of essential healthcare;
Accept flexible and differential norms for
financing that are proposed by states, recognizingphysical and socio-cultural diversities
Integrate government insurance schemes intoUHC through India Health Card
Health Financing & Financial Protection
* Higher taxes on tobacco and alcohol recommended for other reasons
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User Fees for health care were put forward as a way
to recover costs and discourage the excessive use of
health services and the over-consumption of care.
This did not happen. Instead, user fees punished the
poor.
-Dr. Margaret Chan, Director-General, WHO (2009)
Among the quick win strategies recommended by
the Millennium Project was the removal of user fees
for primary education and essential healthcare by theend of 2006.
- Dr. Jeffrey Sachs (2005)
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NO USER FEE
UHC PACKAGE OF
HEALTH SERVICES
(NHP WITH NHEC)
HOSPITALITY
COMPONENT
(Pvt. Ward)
INSURANCE(PVT./EMPLOYER) OR OOP
PERSONS
OPTING FOR
NON-NHEC
ACCREDITED
HOSPITALS
NON-NHP
SERVICES
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NO USER FEE
UHC PACKAGE OF
HEALTH SERVICES
(NHP WITH NHEC)
HOSPITALITY
COMPONENT
(Pvt. Ward)
INSURANCE(PVT./EMPLOYER) OR OOP
PERSONS
OPTING FOR
NON-NHEC
ACCREDITED
HOSPITALS
NON-NHP
SERVICES
ADDITIONALSERVICESFOR THE
POOR
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Health Financing & Financial Protection
Primary healthcare including preventive/curative services at
primary level along with health promotion targeted towardsspecific risk factors, should account for 70% of all govt.
healthcare expenditures
Provide universal financial protection and access to good health
care without involving insurance companies or any otherindependent agents to purchase healthcare services (NHP) on
behalf of govt.
BECAUSE
Independent agents fragment the nature of care beingprovided, leading to high health care costs and lower levels of
wellness at the population level
Central and State governments should purchase services
(through agencies linked to Department of Health)
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Health Financing & Financial Protection
Technical and other capacities developed by
Ministry of Labour for RSBY should become
the core of UHC operations and transferred
to MoHFW.
Integrate the services provided under
different programs gradually (NRHM andother vertical programs such as, HIV/AIDS);
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HEALTH CARE SERVICES
BREADTH
ACCOUNTABILITYQUALITY
DEPTH
GOVERNANCE
EQUITY
EXC
ELLEN
CE
EFFICI
EN
CY
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PROVISION OF HEALTH CARE
Strengthen Public Services(Especially: Primary HealthCare-Rural And Urban; District Hospitals)
Contract Private Providers(As Per Need And Availability)
With Defined Deliverables
Integrate 10, 20, 30 Care
Through Networks of Providers(Public; Private; Public-Private)
Regulateand Monitor
For Quality,Cost AndHealth
Outcomes
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Access to Medicines, Vaccines &
Technologies
Ensure rational use of drugs;
Set up national & state drug supply
logistics corporations; Empower MoHFW to strengthen drug
regulatory system;
Transfer Department of Pharmaceuticalsto the Ministry of Health.
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Human Resources for Health
Ensure adequate numbers of trained health
care providers and technical health care
workers at different levels giving primacy to
the provision of primary health care.
Doubling ASHAs from one per 1000 population to
two per 1000 population in rural and tribal areas;
Introduction of mid-level health workers such asBachelor of Rural Health Care (BRHC) Practitioners
for recruitment & placement at rural Sub-Centres
and Nurse Practitioners in urban Sub-Centres
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Human Resources for Health
Improve human resource management and
supportive supervision mechanisms at block, district,state & national levels to complement health careservice providers;
Enhance the quality of HRH education and training byintroducing competency-based, health system-connected curricula and continuous education;
Invest in additional educational institutions toproduce and train the requisite health workforce;
Establish a dedicated training system for Community
Health Workers; Establish District Health Knowledge Institutes (DHKIs);
Establish the National Council for Human Resources inHealth (NCHRH).
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PROJECTED HRH AVAILABILITY (2012-2027)
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MANAGEMENT AND INSTITUTIONAL REFORMS
Develop capacity and cadres for public health and
health management Adopt better human resource practices to improve
recruitment, retention motivation and performance;rationalize pay and incentives; and assure career tracksfor competency-based professional advancement;
Develop a national health information technologynetwork based on uniform standards to ensureinteroperability between all health care stake holders;
Ensure strong linkages and synergies betweenmanagement and regulatory reforms and ensureaccountability to patients and communities;
Establish financing and budgeting systems to streamlinefund flow.
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Registry
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COMMUNITY PARTICIPATION AND
CITIZEN ENGAGEMENT
Transform existing Village Health Committees(or Health and Sanitation Committees) into
participatory Health Councils;
Organize regular Health Assemblies;
Enhance the role of elected representatives as
well as Panchayati Rajinstitutions (in rural
areas) and local bodies (in urban areas);
Strengthen the role ofcivil society and non-
governmental organizations.
Institute a formal grievance redressal
mechanism at the block level.
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HEALTH BEYOND HEALTH CARE
Health leaps out of Science and drawsnourishment from the Society around it
- Gunnar Myrdal
(Swedish Economist, Nobel Laureate)
POLICIES AND PROGRAMMES IN
Finance Water Sanitation Agriculture Food Processing
Education Rural Development Urban Design Transport
Communications Trade Environment
NEED TO BECOME SENSITIVE AND RESPONSIVE
TO PUBLIC HEALTH CONCERNS !
POLICY APPROACHES
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POLICY APPROACHES(Global; National; Local)
Financial TradeRegulatoryLegal
Environment To Enable Individuals To Make and
Maintain Healthy Choices
INDIVIDUAL
FAMILY
NEIGHBORHOOD, COMMUNITY
Enhancement of Knowledge, Motivation, and
Skills of Individuals
Media Settings BasedCommunity Interventions
HEALTH COMMUNICATION
Preventive,
Dia
gnostic,
Therapeutic,
Reh
abilitative
Services
HE
ALTHCAREDELIVERY
WIDER SOCIETY
DETERMIN
ANTS
Globalization
Access
toCare
Systems
Infrastructure
H
ealth
Wo
rkforce
Quality
ofCare
Drugs&
Technologies
Demographic
Change
Globalization
Social
Determinants
Health Inequities
Cultural and Social
Norms
Education
Biological
Risk
Behavioral
Risk
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HLEG Recommends.
Creation of National Health Promotion and Protection Trust
To Enable :
- Effective Health Communication, Dissemination andInformation Sharing
- UHC Related Education to People , Patients, Providers
- Health Impact Assessment of Policies and Programs inOther Sectors (to facilitate convergent action on the
Social Determinants of Health)
- Collaboration with International Partners to draw uponBest Practices, Policies, and Lessons from the GlobalContext
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If we dont create the
future, the present
extends itself
- Toni Morrison (Song of Solomon)