Upload
others
View
4
Download
0
Embed Size (px)
Citation preview
InfrastructureInfrastructure H R & PerformancePerformanceIssues
2SIHFW: an ISO 9001:2008 certified Institution
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.
6SIHFW: an ISO 9001: 2008 certified Institution
Health System ?
• Traditionally- based on capacityindicators & activities. (e.g.Programs, hospital beds, Physicians& N )& Nurses)
7SIHFW: an ISO 9001: 2008 certified Institution
Health System ?
Structure & functions of a Country’s MoH havingRResources,ManagementOrganizationEconomic support and Service delivery as it’s main component
8SIHFW: an ISO 9001: 2008 certified Institution
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
10SIHFW: an ISO 9001: 2008 certified Institution
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
11SIHFW: an ISO 9001: 2008 certified Institution
Determinants of Health System• Economic-
– Affordability?– Availability?
• PoliticalP i iti– Priorities
– Appropriateness?Accessibility– Accessibility
– Equity • CulturalCultural
– Acceptability– Utilization– Participation
12SIHFW: an ISO 9001: 2008 certified Institution
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
13SIHFW: an ISO 9001: 2008 certified Institution
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
15SIHFW: an ISO 9001: 2008 certified Institution
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
18SIHFW: an ISO 9001: 2008 certified Institution
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.
19SIHFW: an ISO 9001: 2008 certified Institution
• 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
20SIHFW: an ISO 9001: 2008 certified Institution
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
21SIHFW: an ISO 9001: 2008 certified Institution
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
22SIHFW: an ISO 9001: 2008 certified Institution
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
23SIHFW: an ISO 9001: 2008 certified Institution
Bhore Committee, 1946
PHCS : nodal points for Health carePhased expansionPrevention stressedPopulation based
24SIHFW: an ISO 9001: 2008 certified Institution
Constitutional commitment:Health: State subjectj
Central ListCentral ListInternational Health, Port HealthResearchTechnical & Scientific Education
State ListAll other Health issues
Concurrent listE id iEpidemics
25SIHFW: an ISO 9001: 2008 certified Institution
• 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 ?
26SIHFW: an ISO 9001: 2008 certified Institution
• 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
SIHFW: an ISO 9001:2008 certified Institution 28
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
I II III IV V VI VII VIII IX X XI
SIHFW: an ISO 9001:2008 certified Institution 29
PHC over FYP
2500022149 22875 22370
23458
PHC over FYP
20000 18671
10000
15000
9115
50002565
5283 5484
0
I II III IV V VI VII VIII IX X XI
0 0
Source: CBHI,NHP-2010
SIHFW: an ISO 9001:2008 certified Institution 30
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
I II III IV V VI VII VIII IX X XI
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
Source: CBHI,NHP-2010SIHFW: an ISO 9001:2008 certified Institution 32
Health Facilities 2011
India Rajasthan4510
3882
India Rajasthan
1813376
CHC
376365
237
CHCsCHCs owned
building Total FRUs
Source: CBHI,NHP-2010SIHFW: an ISO 9001:2008 certified Institution 33
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
Source: CBHI,NHP-2010SIHFW: an ISO 9001:2008 certified Institution 34
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
Source: CBHI,NHP-2010SIHFW: an ISO 9001:2008 certified Institution 37
Medical Colleges, 2011g ,
Non Recognized Recognized
97
g g
218
97 3
2187
IndiaRajasthan
Source: CBHI,NHP-2010SIHFW: an ISO 9001:2008 certified Institution 38
Dental Colleges, 2011g ,
Recognized Non Recognizedg g
136 5
154 8
IndiaRajasthan
Source: CBHI,NHP-2010SIHFW: an ISO 9001:2008 certified Institution 39
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
SIHFW: an ISO 9001:2008 certified Institution 42
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
9/3/2011SIHFW: an ISO 9001:2008 certified Institution 46
Total Govt. Expenditure on Health as % of GDPof GDP
Source: CBHI, NHP, 2010
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
SIHFW: an ISO 9001:2008 certified Institution 47
Per Capita Public Exp. on Health
214.62220
Source: CBHI, NHP, 2010
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
SIHFW: an ISO 9001:2008 certified Institution 48
Status of Expenditure in FYPsSource: CBHI NHP 2010Source: CBHI, NHP, 2010
SIHFW: an ISO 9001:2008 certified Institution 49
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
SIHFW: an ISO 9001:2008 certified Institution 50
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
SIHFW: an ISO 9001:2008 certified Institution 51
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
SIHFW: an ISO 9001:2008 certified Institution 52
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
SIHFW: an ISO 9001:2008 certified Institution 53
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)
SIHFW: an ISO 9001:2008 certified Institution 55
People are resourcePeople are resourceBut
To maintain this resourceTo maintain this resource We need Resources
SIHFW: an ISO 9001:2008 certified Institution 57
Doctors (Allopathic in India)( p )
577100
757377
268712398238
61800 83700 151129
1951 1961 1971 1981 1991 2001 20112011
Source: CBHI,NHP-2010SIHFW: an ISO 9001:2008 certified Institution 58
Nurses (India)( )
671341
865135
311235
16550 35584 80620 150399311235
1951 1961 1971 1981 1991 2001 20112011
Source: CBHI,NHP-2010SIHFW: an ISO 9001:2008 certified Institution 59
Average Population Served in R j th 2010Rajasthan;2010
598189598189
10605
DoctorsDentists
Source: CBHI,NHP-2010SIHFW: an ISO 9001:2008 certified Institution 60
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
Source: CBHI,NHP-2010SIHFW: an ISO 9001:2008 certified Institution 61
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
Source: CBHISIHFW: an ISO 9001:2008 certified Institution 62
Manpower Status 2010p
India Rajasthan
24375
j
42791379
Specialist at CHCs MBBS Doctors at PHCs
811 1379
Specialist at CHCs MBBS Doctors at PHCs
Source: CBHISIHFW: an ISO 9001:2008 certified Institution 63
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
SIHFW: an ISO 9001:2008 certified Institution 65
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
66SIHFW: an ISO 9001: 2008 certified Institution
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
SIHFW: an ISO 9001: 2008 certified Institution 70
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
SIHFW: an ISO 9001: 2008 certified Institution 73
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
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
79SIHFW: an ISO 9001: 2008 certified Institution
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
80SIHFW: an ISO 9001: 2008 certified Institution
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
81SIHFW: an ISO 9001: 2008 certified Institution
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
82SIHFW: an ISO 9001: 2008 certified Institution
1964:Mukherjee committee1964:Mukherjee committee
• TOR-Family planning
• Exclusive family planning staff (uni-purpose
worker)
83SIHFW: an ISO 9001: 2008 certified Institution
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
84SIHFW: an ISO 9001: 2008 certified Institution
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
85SIHFW: an ISO 9001: 2008 certified Institution
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
86SIHFW: an ISO 9001: 2008 certified Institution
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.
88SIHFW: an ISO 9001: 2008 certified Institution
• 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?
91SIHFW: an ISO 9001: 2008 certified Institution
Some facts about Public Health care in Indiain India
SIHFW: an ISO 9001:2008 certified Institution 92
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)
SIHFW: an ISO 9001:2008 certified Institution 93
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
94SIHFW: an ISO 9001: 2008 certified Institution
Service delivery:3-tier structurey
Tertiary C
DHCare
Secondary CHC
yCare
PrimaryPHC
Primary Care SC
Underutilized for-Services Supply
95SIHFW: an ISO 9001: 2008 certified Institution
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
96SIHFW: an ISO 9001: 2008 certified Institution
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
97SIHFW: an ISO 9001: 2008 certified Institution
• 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
99SIHFW: an ISO 9001: 2008 certified Institution
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
100SIHFW: an ISO 9001: 2008 certified Institution
Main Systems of Mediciney
• Western allopathicWestern allopathic• Ayurveda• UnaniUnani• Siddha• Homeopathy• Homeopathy
101SIHFW: an ISO 9001: 2008 certified Institution
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
103SIHFW: an ISO 9001: 2008 certified Institution
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.
104SIHFW: an ISO 9001: 2008 certified Institution
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)
105SIHFW: an ISO 9001: 2008 certified Institution
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
106SIHFW: an ISO 9001: 2008 certified Institution
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
107SIHFW: an ISO 9001: 2008 certified Institution
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
109SIHFW: an ISO 9001: 2008 certified Institution
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.
110SIHFW: an ISO 9001: 2008 certified Institution
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
112SIHFW: an ISO 9001: 2008 certified Institution
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.
113SIHFW: an ISO 9001: 2008 certified Institution
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
114SIHFW: an ISO 9001: 2008 certified Institution
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
115SIHFW: an ISO 9001: 2008 certified Institution
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
116SIHFW: an ISO 9001: 2008 certified Institution
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
117SIHFW: an ISO 9001: 2008 certified Institution
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)
118SIHFW: an ISO 9001: 2008 certified Institution
“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)
119SIHFW: an ISO 9001: 2008 certified Institution
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.”
120SIHFW: an ISO 9001: 2008 certified Institution
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
121SIHFW: an ISO 9001: 2008 certified Institution
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
122SIHFW: an ISO 9001: 2008 certified Institution
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
123SIHFW: an ISO 9001: 2008 certified Institution
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)
124SIHFW: an ISO 9001: 2008 certified Institution
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
SIHFW: an ISO 9001:2008 certified Institution 126
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
SIHFW: an ISO 9001:2008 certified Institution 127
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
SIHFW: an ISO 9001:2008 certified Institution 128
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
SIHFW: an ISO 9001:2008 certified Institution 129
Measles deathsSource:CBHI,NHP-2010 and MOHFW
188200
140160180
99100120140
54 50 4432
6080
32
02040
02005 2006 2007 2008 2009 2010
SIHFW: an ISO 9001:2008 certified Institution 130
Polio
741800
559
741
600
700
400
500
Cases
116
238200
300 Deaths
11642
1 4 3276
10
100
2006 2007 2008 2009 2010
9/3/2011SIHFW: an ISO 9001:2008 certified Institution 131
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
SIHFW: an ISO 9001:2008 certified Institution 132
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
SIHFW: an ISO 9001:2008 certified Institution 133
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
SIHFW: an ISO 9001:2008 certified Institution 134
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
SIHFW: an ISO 9001:2008 certified Institution 135
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
SIHFW: an ISO 9001:2008 certified Institution 136
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
SIHFW: an ISO 9001:2008 certified Institution 137
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
SIHFW: an ISO 9001:2008 certified Institution 138
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
SIHFW: an ISO 9001:2008 certified Institution 139
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
SIHFW: an ISO 9001:2008 certified Institution 140
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
SIHFW: an ISO 9001:2008 certified Institution 141
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
SIHFW: an ISO 9001:2008 certified Institution 142
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
SIHFW: an ISO 9001:2008 certified Institution 143
Chikunganya Cases : IndiaSource : NRHM India
2500022113
20000
15000
6271
10000
2001 1826 2461
0
5000
02006 2007 2008 2009 2010
SIHFW: an ISO 9001:2008 certified Institution 144
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
SIHFW: an ISO 9001:2008 certified Institution 145
Kala Azar Deaths : IndiaSource : NRHM India
250
187203
200
146150
71 65
50
100
0
50
2006 2007 2008 2009 2010
SIHFW: an ISO 9001:2008 certified Institution 146
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
SIHFW: an ISO 9001:2008 certified Institution 147
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
SIHFW: an ISO 9001:2008 certified Institution 148
Thank You
For more details log on towww. sihfwrajasthan.com
or contact : Director-SIHFW
on
SIHFW: an ISO 9001:2008 certified Institution 149