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SIHFW: an ISO 9001: 2008 certified Institution
1
Public Health Care : India An Overview
State Institute of Health & Family Welfare, Jaipur
Constitutional commitment: Health: State subjectCentral List
International Health, Port HealthResearchTechnical & Scientific Education
State ListAll other Health issues
Concurrent listEpidemics
2SIHFW: an ISO 9001: 2008 certified Institution
Mile Stones: NRHM-2005
NHP-2002 NPP-2000
RCH-1996
UIP-1985 NHP-1983
Alma Ata-1978 Small pox eradicated-July 5, 1975
NFPP-1952 India Joins WHO-1948
HSDC-1946
3SIHFW: an ISO 9001: 2008 certified Institution
Pop. Policy Draft 1976
Small pox free-July 5, 1975 &
ICDS started MTP Act-1969(1972) Birth & Death Reg. Act-1969
FW-1966 NSEP-1962 NMCP to NMEPP-1958 CHEB-1956 BCG Vaccination-1951 NMCP & NFPP-1951India joins WHO- 1948
1947HSDC-1946
Juggling Priorities
4SIHFW: an ISO 9001: 2008 certified Institution
NRHM-2005
NVBD CP(03-04
National Health
Policy- 2002
National Pop. Policy- 2000
RCH-1997
Target free approach -1996
Beijing conference-1995
Legislation on Transplantation of human organs enacted 1995
ICPD-1994
5SIHFW: an ISO 9001: 2008 certified Institution
ICDS renamed Integrated Mother and
Child Development (IMCD) 1995
CSSM-1992
National Blood safety program- 1989
NACP -1987
UIP-1985
NLCP-NLEP, 1983
NHP-1983
Alma Ata-Declaration( 1978)-HFA-2000
NFWP-19776SIHFW: an ISO 9001: 2008 certified Institution
NO Health Policy for 36 years Committees and Commissions Single issue addressed by Committee Comprehension was missing recommendations- reiterations of Bhore Committee Individual “Health” Programs - situational exigency Uni-purpose workers later baptized as Multi-purpose Programs worked in complete isolation till 1980 (e.g.
NTCP) Fragmented approach to Health
7SIHFW: an ISO 9001: 2008 certified Institution
Still…62 yrs. of Health Services
Crude Death Rate ↓Crude birth rate ↓Life expectancy ↑S.pox & G. worm eradicatedLeprosy eliminatedIMR ↓Infrastructure – expanded
8SIHFW: an ISO 9001: 2008 certified Institution
Core Functions of Public Health
Well developed administrative system
Skills
Reasonable Infrastructure
Poor health outcomes
Design
Misdirected efforts
9SIHFW: 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
SIHFW: an ISO 9001: 2008 certified Institution 10
Bhore Committee, 1946
PHCS : nodal points for Health care
Phased expansion
Prevention stressed
Population based
SIHFW: an ISO 9001: 2008 certified Institution 11
Health –State Subject ?
Centralized planning
Decentralized implementation
Fiscal control of central Govt.
Centre dictates States for Objectives &
Priorities
12SIHFW: an ISO 9001: 2008 certified Institution
Health Care in India
Entitlements by policy and not rights Focus on preventive and promotive care Grossly under-provided facilities Poor investments hitherto Declining public expenditures and new
investments Structural Adjustment programming under
World Bank dictate
13SIHFW: an ISO 9001: 2008 certified Institution
Service Delivery:3-tier Structure
Tertiary careSecondary CarePrimary care
CHC
PHC
SCUnderutilized for-
ServicesSuppliesFunding
14SIHFW: an ISO 9001: 2008 certified Institution
CHC 1: 100000 (Plains)
1:80000 (Hilly/ Tribal)
PHC 1:30000 (Plains)
1:20000 (Hilly/Tribal)
3043
23500
Sub- Centers 1:5000(Plains)
1:3000 (Tribal/ Hilly)
137407
HWF-134000
HWM-73000
Villages-AWW/ SBA/ VHG/ ASHA640000
1027 million People-200115SIHFW: an ISO 9001: 2008 certified Institution
Committees & Commissions
16SIHFW: an ISO 9001: 2008 certified Institution
1959-62 Mudaliar committee (Health Survey And Planning
Committee) Consolidate gains
Strengthen district hospitals
Regionalization of health services
PHC for 40000 population
Integration of medical & health
Creation of all India health services cadre
17SIHFW: an ISO 9001: 2008 certified Institution
1963: Chaddah Committee
TOR-Malaria
NMEP vigilance & maintenance by health
services Monthly home visits 10000 population per worker
Basic health worker vital statistics & family planning
18SIHFW: an ISO 9001: 2008 certified Institution
1964: Mukherjee Committee
TOR-Family planning
Exclusive family planning staff
(uni-purpose worker)
19SIHFW: an ISO 9001: 2008 certified Institution
1964-67: Junglewala Committee (Integration Of Health Services)
Unified cadre Common seniority Recognition of extra qualifications Equal pay Specialized pay No private practice
20SIHFW: an ISO 9001: 2008 certified Institution
1972-73: 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 workers21SIHFW: an ISO 9001: 2008 certified Institution
1974-75: Srivastav committee (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 between health
worker and PHC
22SIHFW: an ISO 9001: 2008 certified Institution
Population and Growth: India
23SIHFW: an ISO 9001: 2008 certified Institution
Demographic Facts
SIHFW: an ISO 9001: 2008 certified Institution 24
Second most populous country in the world 17% of world’s population in 3% of earth’s land
area Last century
Global population increased 3 times India’s population increased 5 times
2030: Population to exceed that of China
SIHFW: an ISO 9001: 2008 certified Institution 25
1901 1911 1921 1931 1941 1951 1961 1971 1981 1991 20010
2000
4000
6000
8000
10000
12000
2384 2520.92513.22789.8 3186.6
3610.94392.3
5481.6
6833.3
8464.2
10286.1
Census: Population 1901-2001Source: CBHI, NHP, 2006
Male Female Total
1901 1911 1921 1931 1941 1951 1961 1971 1981 1991 2001 20100
200
400
600
800
1,000
1,200
238 252 251 278
378 361439
548
683
846
1,0271,107
Population of India (In Millions)Source: CBHI NHP, 2006
SIHFW: an ISO 9001: 2008 certified Institution 26
SIHFW: an ISO 9001: 2008 certified Institution 27
1901 1911 1921 1931 1941 1951 1961 1971 1981 1991 2001900
910
920
930
940
950
960
970
980
972
964
955950
945 946941
930934
926
933
Sex Ratio 1901-2001Source: CBHI NHP, 2006
28
NFHS-3 NFHS-2 NFHS-10
0.5
1
1.5
2
2.5
3
3.5
4
2.72.9
3.43.2
3.83.6
Total Fertility Rate
India Rajasthan
SIHFW: an ISO 9001: 2008 certified Institution
15-19 20-24 25-29 30-34 35-39 40-44 45-490
0.1
0.2
0.3
0.4
0.5
0.6 0.57
0.166
0.123
0.0480.013
0.00400000000000001 0.001
0.069
0.177
0.129
0.0570.00400000000000001
0.00800000000000002 0
India Rajasthan
Age Specific Fertility Rate Source- NFHS-III
29SIHFW: an ISO 9001: 2008 certified Institution
SIHFW: an ISO 9001: 2008 certified Institution 30
1 Child 2 Child 3 Child 4+ Child 0
10
20
30
40
50
60
70
80
90
100
76.6
20.5
2.8 0.2
31.9 32.5
18.8 16.8
6.4
14.8 13.5
65.3
2.7 2.9 3.3
91.1Birth Order, Mother age group (in
years)Source: NFHS-315-19 20-29
30-39 40-49
Marriage and Fertility
SIHFW: an ISO 9001: 2008 certified Institution 31
4550
54
28
53
NFHS-1 NFHS-2 NFHS-3 Urban Rural
Marital StatusPercent of women age 20-24 married by age 18
NFHS-3
32SIHFW: an ISO 9001: 2008 certified Institution
Mean Age at Marriage for Boys-Years
23.821.6
22.8
29.6
22.9
26.128.3
21.8
25.3
28
20.7
26.7
21.6
24.7
0
5
10
15
20
25
30
35
AP BIH
CHT
GO
A
JRK
KAR
KER
MP
ORS
PON
RAJ
TN UP
WB
DLHS-3 DLHS-2
33SIHFW: an ISO 9001: 2008 certified Institution
WB
UP
TN
SIK
RJ
PND
ORI
MP
KER
KAR
JHK
GOA
CG
BH
AP
0 10 20 30 40 50 60
47
44
16
12
51
5
25
46
7
31
48
4
34
57
39
41
33
10
16
41
4
19
29
7
23
36
3
21
46
29
DLHS-3DLHS-2
Percentage of Girls Married below Age 18
34SIHFW: an ISO 9001: 2008 certified Institution
Marriage (DLHS-3)
35
Rajasthan is the only state where mean age at marriage for boys and girls is lower than the legal age at marriage
Bihar is the other state where female mean age at marriage is lower than legal age. Bihar reported the lowest (17.6 years) mean age while it was the highest in Goa (25.1 years)
In case of males, Goa reported the highest (29.6 yrs) while Rajasthan (20.7 yrs) reported the lowest
% of females marrying before reaching 18 years of age had come down in high-focus states yet it has a long way to go to attain the stage reached by Kerala and Goa.
SIHFW: an ISO 9001: 2008 certified Institution
SIHFW: an ISO 9001: 2008 certified Institution 36
Total Rural Urban Total Rural UrbanDLHS-3 (2007-08) DLHS-2 (2002-04)
0
10
20
30
40
50
60
70
20.7 20.222.8
20.3 19.523.1
17.7 17.120
17.2 16.519.6
48.4
53.7
27.6
53.4
61.5
26.3
41
47
18.6
50.8
58.8
23.8
57.6
61.6
38.8
0 0 0
Marriage, Rajasthan Mean age at marriage for boys
Mean age at marriage for girls
Boys married below age 21
Girls married below age 18
Currently married women age 20-24 who were married before age 18
SIHFW: an ISO 9001: 2008 certified Institution 37
15-19 20-24 25-29 30-34 35-39 40-44 45-490
0.1
0.2
0.3
0.4
0.5
0.6 0.57
0.1660.123
0.0480.013
0.00400000000000001 0.001
0.069
0.1770.129
0.0570.004000000000000
01 0.00800000000000002 0
India Rajasthan
Age Specific Fertility rateSource NFHS III
1 Child 2 Child 3 Child 4+ Child 0
10
20
30
40
50
60
70
80
90
100
76.6
20.5
2.80.2
31.9 32.5
18.8 16.8
6.4
14.8 13.5
65.3
2.7 2.9 3.3
91.1
Birth Order, Mother age group (in years)Source: NFHS-3
15-19 20-29 30-39
40-49
SIHFW: an ISO 9001: 2008 certified Institution 38
SIHFW: an ISO 9001: 2008 certified Institution 39
NFHS-3 NFHS-2 NFHS-10
0.5
1
1.5
2
2.5
3
3.5
2.062.27
2.7
2.21
2.982.77
TFR (15 - 49 yrs.)India Rajasthan
40SIHFW: an ISO 9001: 2008 certified Institution
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 200850
55
60
65
70
75
7271
7270
6866
63
6058 58
5755
53
IMR India, 1994- 2008Source SRS Oct.2008
Total Rural Urban Total Rural Urban Total Rural Urban Total Rural Urban Birth rate Death rate Natural growth rate Infant mortality rate
0
10
20
30
40
50
60
70
80
CBR, CDR, GR & IMRSource: SRS bulletin Oct. 2008
India
Rajasthan
41SIHFW: an ISO 9001: 2008 certified Institution
Problems:
Indirectly related to healthEnvironmentEducationEmpowerment
Directly affecting HealthDiseases
Communicable Non CommunicableNew emerging
FertilityPopulationGrowth rate Total Fertility
NutritionMalnutritionObesity
42SIHFW: an ISO 9001: 2008 certified Institution
Problems- Why
Access
Availability
Utilization
43SIHFW: an ISO 9001: 2008 certified Institution
Health Care in India
Entitlements by policy and not rights Focus on preventive and promotive care Grossly under-provided facilities Poor investments hitherto Declining public expenditures and new
investments Structural Adjustment programming under
World Bank dictate
44SIHFW: an ISO 9001: 2008 certified Institution
Policies
NHP-1983…….NHP-2002
NPP-2000
45SIHFW: an ISO 9001: 2008 certified Institution
NHP-1983 Re-orientation of Medical education Re-structuring and Re-organizing the then
existing health care services Population stabilization Re-orientation of existing health personnel Role of practitioners of ISM in Health care
delivery Goals -
Achievement? CDR & Life expectancy
46SIHFW: an ISO 9001: 2008 certified Institution
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 -extremely
expensive the rural health staff has become a vertical
structure exclusively for the implementation of family welfare activities
Low utilization- 20 % seeking OPD services, <45 percent seeking indoor treatment, go to public hospitals.
NHP-2002
47SIHFW: an ISO 9001: 2008 certified Institution
Policy Prescriptions-NHP-2002
Increase health sector expenditure to 6 %of GDP
Increased allocation (55 %)for the primary health sector
Gradual convergence of all health programs Developing the capacity Strengthening of the primary health User charges Contract employment Manpower deployment norms
48SIHFW: an ISO 9001: 2008 certified Institution
Integrated disease control network
Increase in postgraduate seats in Public
Health & Family Medicine
Decentralization- Role of LSG/ NGO
Medical Grants commission
legislation for regulating clinical
establishments/medical institutions by 2003
49SIHFW: an ISO 9001: 2008 certified Institution
Eradicate Polio and Yaws 2005
Eliminate Leprosy 2005
Eliminate Kalazar 2010
Eliminate Lymphatic Filariasis 2015
Achieve Zero level growth of HIV/AIDS 2007
Reduce Mortality by 50% on account of TB, Malaria and Other Vector and Water Borne diseases
2010
Reduce Prevalence of Blindness to 0.5% 2010
Reduce IMR to 30/1000 And MMR to 100/Lakh 2010
Increase utilization of public health facilities from current Level of <20 to >75%
2010
Establish an integrated system of surveillance, National Health
2005
Goals to be achieved by 2000-2015
50SIHFW: an ISO 9001: 2008 certified Institution
NPP-2000 NPP-2000 TFR-2.1 : 2010
May 11, 2000: Pop.-1 Billion
July 1993
NHP-1983: ( Replacement TFR (2.1) by 2000)
NFWP-1977 Cafeteria, Education, Motivation, Compulsion,
Incentive, Target free
June, 1977
April 16, 1976
NFPP-1952
51SIHFW: an ISO 9001: 2008 certified Institution
National Pop. Policy Objectives Immediate
To address the unmet needs for Contraception Health care infrastructure Health personnel
To provide integrated service delivery for basic reproductive and child health care
Medium To bring TFR to replacement levels by 2010
Long term To achieve a stable population by 2045
52SIHFW: an ISO 9001: 2008 certified Institution
Challenges
Manpower- Number & Norms Rural/Urban differential Geographical divide across States S-E groups- accessibility/reach Gaps between Policy & Action Health sector expenditure Newer Infections
53SIHFW: an ISO 9001: 2008 certified Institution
SIHFW: an ISO 9001: 2008 certified Institution 54
Sector Pop.BPL (%)
IMR/Per 1000Live Births (1999 SRS)
<5Mort-alityPer 1000(NFHS II)
Weight For Age-% ofChildrenUnder 3 years(<2SD)
India 26.1 70 94.9 47
Rural 27.09 75 103.7 49.6
Urban 23.62 44 63.1 38.4
Rural : Urban Differentials in Health Status
Rural-Urban Disparities – India Rural (per 1000 population)
Hospital Beds = 0.2Doctors = 0.6Public Expenditures
= Rs.80,000Out of pocket =
Rs.750,000________________IMR = 74/1000 LBU5MR = 133/1000
LBBirths Attended =
33.5%Full Immunz.=37%Median ANCs=2.5
Urban (per 1000population)
Hospital Beds = 3.0Doctors = 3.4Public Expenditures =
Rs.560,000Out of Pocket =
Rs.1,150,000
____________________
IMR = 44/1000 LBU5MR = 87/1000 LBBirths Attended =
73.3%Full Immunz.= 61%Median ANCs=4.2
55SIHFW: an ISO 9001: 2008 certified Institution
SIHFW: an ISO 9001: 2008 certified Institution 56
Better States
Pop.BPL (%)
IMR/Per1000LiveBirths (1999SRS)
<5Mort-alityPer1000(NFHS II)
Weight For Age-% ofChildrenUnder3 years(<2SD)
MMR/Lac (Annual Report 2000)
Leprosy cases per
10000 population
Malaria +ve Cases in year 2000 (in thousands
Kerala 12.72 14 18.8 27 87 0.9 5.1
Maha. 25.02 48 58.8 50 135 3.9 138
TN 21.12 52 63.3 37 79 4.1 56
Differentials in Health Status Among States
SIHFW: an ISO 9001: 2008 certified Institution 57
PoorStates
Pop.BPL (%)
IMR/Per1000LiveBirths (1999SRS)
<5Mort-alityPer1000(NFHS II)
Weight For Age-% ofChildrenUnder3 years(<2SD)
MMR/Lac (Annual Report 2000)
Leprosy
cases per
10000 population
Malaria +ve Cases in year 2000 (in thousands
Orissa 47.15 97 104.4 54 498 7.5 483
Bihar 42.60 63 105.1 54 707 11.8 132
Raj. 15.28 81 114.9 51 607 0.8 53
UP 31.15 84 122.5 52 707 4.3 99
Differentials in Health Status Among Socio-
Economic Groups Indicator Infant
Mortality<5 Mortality % Children
Underweight
India 70 94.9 47
Social Inequity
S/C 83 119.3 53.5
S/T 84.2 126.6 55.9
OBC 76 103.1 47.3
Others 61.8 82.6 41.1
58SIHFW: an ISO 9001: 2008 certified Institution
Health Care Governance in India
SIHFW: an ISO 9001: 2008 certified Institution 59
Health System’s Organization-India
Central Govt.
Planning Commission National Development Council CCHFW MOHFW
FW Medical & Public Health ISM&H Secretary Secretary Secretary Jt.Secy. Addl.Secy. Director Director Jt.Secy. Jt.Secy. DGHS Addl.DGHS
60SIHFW: an ISO 9001: 2008 certified Institution
National Developmental Council
Highest constitutional Policy making body Approves Policies and strategies for development
Composition: Chairman- Prime Minister Members- Central Ministers Chief Ministers Lt.Governors & Administrators of
UTs Dy. Chairman & members of
Planning Commission
61SIHFW: an ISO 9001: 2008 certified Institution
Planning CommissionConstituted on March 15,1950Composition: Chairman— PM Dy. Chairman Members 5-7(Full time) 2-3(Part time)Functions : To Assess & augment resources-Man, Money,
Material To Formulate Plan for utilization of resources To Decide on priority based phased implementation To Decide on nature of executing machinery To review the Periodic progress To Make appropriate interim recommendations
62SIHFW: an ISO 9001: 2008 certified Institution
MoHFW
Official Organ of health & Family welfare at National Level
Headed by Cabinet Minister, Minister of State & Deputy Health Minister
Functions Union List Concurrent List
SIHFW: an ISO 9001: 2008 certified Institution 63
Role of Central Govt. in Health Care
Policy formulation Maintaining International health relations Administration of central health institutions Regulating Medical education through statutory
bodies-MCI/DCI/Councils Medical & Public health research-funding Standards- laying &
maintenance(Drugs/Education) Coordination-Other ministries/States/Statutory
bodies Central Health Acts Negotiation with International agencies
64SIHFW: an ISO 9001: 2008 certified Institution
Functions of Dept of Family Welfare
Policy preparation & Planning Information collection & Evaluation Contraceptive-Research /Supply Seeking International support EPI/UIP/CSSM/RCH/ARI/ORT-Trainings &
area development IEC Rural Health Paraprofessional training NGO support Development of Sub-center
65SIHFW: an ISO 9001: 2008 certified Institution
Functions of Medical & Public Health Dept.
Health Policy preparation National Health Programs conduction Drug Control PFA enforcement Diseases
control-Communicable/Non-communicable
Supplies & Disposal Maintenance CME & Trainings Medical Education & Research Vital statistics & Health intelligence International support
66SIHFW: an ISO 9001: 2008 certified Institution
Organization at State Level State Government
Minister Medical Education MoH & FWSecretary-ME Principal Secretary-Health Secretary-FW
Principals Directors (Service divisions)(Medical Education)
FW Public Health AIDS IEC
Addl. Directors Jt. Directors Dy. Directors State Program Officers Zonal Directors
67SIHFW: an ISO 9001: 2008 certified Institution
District Health Care Administration
SIHFW: an ISO 9001: 2008 certified Institution 68
District
An Administrative unit
which has
Defined Geographical boundary and Population
Peripheral most Planning unit A self contained segment of National Health
System
69SIHFW: an ISO 9001: 2008 certified Institution
District Health Organization CMHO PMO (Rural),Preventive (Urban),Curative
Dy.CMHO Program Officers (registered society-DHS)
C H CPop.-80000-120000 Beds(30)
Specialists(7-IPHS) Referral
P H C (20-3000) Primary health Medical Officer(2-IPHS)
SC (3-5000)HW-M/F SBA/AWW/VHG/ ASHA
70SIHFW: an ISO 9001: 2008 certified Institution
Functions of District Health System
Liaison between Field units & HeadquarterField reportsInspectionsMeetings
Implementation of Policy & Programs District level planning & Action Plans Rationale use of Finance & Resources Communication Management
Plans/Schedules/Progress/Problems Control & Monitoring
71SIHFW: an ISO 9001: 2008 certified Institution
Problem Areas at District
Quantity v/s Quality Cluttered Policy guidelines Decentralization on papers Roles/Responsibilities poorly defined Program integration? HMIS-generation & use? Managerial skills Donor initiative – “Societies” Resource restriction
72SIHFW: an ISO 9001: 2008 certified Institution
Health- A Dynamic Phenomenon
Health System ought to be, for-
Rising costs
Changing political situations, and
Social contexts (expectations of
people from System)
SIHFW: an ISO 9001: 2008 certified Institution 73
Core Functions of Public Health
Monitoring health situation Disease surveillance Health promotion Regulations Partnerships Planning & Policies HRD Reducing impact of emergencies on
health
74SIHFW: an ISO 9001: 2008 certified Institution
System?
A set of interrelated and independent
parts designed to achieve a set of goals
75SIHFW: an ISO 9001: 2008 certified Institution
Health System ?
Structure & functions of a Country’s MoH having
Resources
Management
Organization
Economic support
Service delivery as it’s main component
76SIHFW: an ISO 9001: 2008 certified Institution
Development of Health Systems
Organization-changes in character with time Resource expansion Increase in utilization Increase in expenditure & Financing pattern of health
care Cost-control strategies & Increasing system’s efficiency Technological advances-demand & application Prevention emphasized Quality assurance Public-Private interaction Pattern of service delivery Public participation in Policy decisions
77SIHFW: an ISO 9001: 2008 certified Institution
Why Study Health Systems?
To provide perspective to understand self To observe & examine strategies for achieving
equity under different situations To draw generalizations To create System’s influence on health status
78SIHFW: an ISO 9001: 2008 certified Institution
National Health Systems
Issues : Generalizations of performance & trend Political dimensions-Dynamism Forces deciding character Impact on Health Relevance to human rights
79SIHFW: an ISO 9001: 2008 certified Institution
Development of Health Systems Organization-changes in character with time Resource expansion Increase in utilization Increase in expenditure & Financing pattern of health
care Cost-control strategies & Increasing system’s
efficiency Technological advances-demand & application Prevention emphasized Quality assurance Public-Private interaction Pattern of service delivery Public participation in Policy decisions 80SIHFW: an ISO 9001: 2008 certified Institution
Components of Health System
Production of Resources
Organization of Programs
Economical support
Management
Delivery of Services
81SIHFW: an ISO 9001: 2008 certified Institution
Health- A Dynamic Phenomenon
Health System ought to be, for:
Rising costs
Changing political situations
Social contexts(expectations of
people from System)
SIHFW: an ISO 9001: 2008 certified Institution 82
Basis of Classification
In relation to service delivery
Based on nature of service
Based on doctrine
In relation to traditional Medicine
83SIHFW: an ISO 9001: 2008 certified Institution
Public Sector Primary Care
Primary Health centers
Sub centersSecondary care
CHCHospitals
Tertiary careTeaching Hospitals
OthersDefense Railway & ESI
Private sectorTrust HospitalsCorporate HospitalsNursing HomesMedical Insurance
Others NGOsVoluntary agencies
Based on Service Delivery
84SIHFW: an ISO 9001: 2008 certified Institution
Based on Nature of Service
Indigenous-Rural
General care
Specialty
Super specialty/Corporate
85SIHFW: an ISO 9001: 2008 certified Institution
Based on Doctrine Official
Allopathic Traditional
AyurvedaUnaniSiddhaHomeopathyChineseTibetan
86SIHFW: an ISO 9001: 2008 certified Institution
Allopathic/Modern System[Cost, Coverage, Coordination & Culture]
Strengths SystematicStrong Data base PharmacopoeiaDiagnostic supportQuickInterventional
proceduresEpid.
developments
WeaknessesCostIsolated approach-
Anatomical approachDependence on
technologyHuman touch missingIatrogenic diseaseVoracious resource
eaterDrug use-irrationalWestern
87SIHFW: an ISO 9001: 2008 certified Institution
Traditional [Ethno/Alternative/Indigenous]
Root - acceptability Respect of healers Reach in masses Rural base Renaissance/Re-birth Role in present system
88SIHFW: an ISO 9001: 2008 certified Institution
Types of Health Systems in Relation to
Traditional Medicine
Exclusive (tolerant) : UK, Germany
Inclusive : India, Pakistan, Burma, Sri Lanka, Bangladesh, Thailand
Integrated : China, Nepal
89SIHFW: an ISO 9001: 2008 certified Institution
Public Health: Rajasthan
90SIHFW: an ISO 9001: 2008 certified Institution
India’s largest State:3.42 lakh sq. kms33 Districts241 Tehsils, 237 Blocks
Rajasthan accounts for:10.4% of the country’s area5.49% of its population10.6% of the cultivated area
91SIHFW: an ISO 9001: 2008 certified Institution
Health Infrastructure: March 31, 2009
SC : 10742 PHC: 1503 CHC: 367 DH: 33 Satellite hospitals: 06 SDH: 12 City dispensaries: 199
SIHFW: an ISO 9001: 2008 certified Institution 92
Special recruitment drive with hard duty allowances
Sanjivani scheme for providing specialist services in tribal and desert areas through health camps
Swasthya Chetna Yatra: 31 lakh people benefited through multi-speciality health check camps at panchayat headquarters.
Mukhya Mantri Balika Sambal Yojana: Rs. 10,000 to be given to each girl (max 2) on family planning adopted by parents without boys.
Free Medicines to senor citizens, BPL and pregnant women in up to 50 bedded CHCs
Promotion of generic medicines at lower cost93SIHFW: an ISO 9001: 2008 certified Institution
Doctor aap ke Dwar Yojana: 52 Mobile Medical Vans for far-flung areas in all districts (Rajasthan Firsts) Charak Aapke Dwar Yojana: free surgical services at rural areas Rajasthan University of Health Sciences (Rajasthan
Firsts) MoU with North Shore Hospital, New York for upgradation of infrastructure in health care institutions and medical research cooperation (Rajasthan Firsts) Telemedicine being implemented with ISRO support, connecting 6 medical college hospitals with 32 district hospital and 1 block (Rajasthan Firsts) Policy to promote private investment in Health Care Facilities
94SIHFW: an ISO 9001: 2008 certified Institution
Challenges
Manpower- Number & Norms
Rural/Urban differential
Geographical divide across States
S-E groups - accessibility/reach
Gaps between Policy & Action
Health sector expenditure
Newer Infections 95SIHFW: an ISO 9001: 2008 certified Institution
Performance, Progress & Punctuations
96SIHFW: an ISO 9001: 2008 certified Institution
SIHFW: an ISO 9001: 2008 certified Institution 97
To
tal
Ru
ral
Urb
an
To
tal
Ru
ral
Urb
an
To
tal
Ru
ral
Urb
an
To
tal
Ru
ral
Urb
an
Birth rate Death rate Natural growth rate
Infant mortality rate
0
10
20
30
40
50
60
70
80
23.1 24.718.6
7.4 8 6
15.7 16.812.7
5360
36
27.9 29.223.7
6.8 7 6
21.1 22.217.7
63
71
39
Child IndicatorsSource : SRS Oct’2008
India
Rajasthan
SIHFW: an ISO 9001: 2008 certified Institution 98
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
50
55
60
65
70
75
72 71 7270
6866
63
6058 58 57
5553
IMR India, 1996- 2008
SIHFW: an ISO 9001: 2008 certified Institution 99
0
3000000
6000000
9000000
12000000
15000000
18000000
21000000
24000000
27000000 No. of cases of C D reported- 2008
No. of cases of C D reported- 2008
SIHFW: an ISO 9001: 2008 certified Institution 100
29%
7%
7%
2%8%
36%
11%
Major causes of Death: India 2005
Cardioavascular
Cancer
Chronic Respira-tory
Diabetese
other
Communicable, Perinatal and ma-ternal conditions
Injuries
SIHFW: an ISO 9001: 2008 certified Institution 101
2000 2001 2002 2003 2004 2005 2006 2007 2008*0
1000
2000
3000
4000
5000
6000
7000
8000
9000
32783455
4135 4286
5370
4114
3736
6948
4681
7509
8302
8205
8459
8058
73007244
6037
3604 38244063
4165
36053513 3342 3456
3765
Mortality Pattern- 2000-2008Source: NHP, CBHIARI Pul. TB Pneumonia
SIHFW: an ISO 9001: 2008 certified Institution 102
2000 2001 2002 2003 2004 2005 2006 2007 2008*
0
500
1000
1500
2000
2500
3000
3500
4000
29182787
34753433
2939
2147
3176
3603
2841
390 606 542839
807419 638
452 338
1038 1147 9141006 1186
718 694544 510
Mortality Pattern 2000-2008 Source: CBHI, NHP
Ac. Diar-rheal Diseases
Enteric fever
All Viral Hepatitis
SIHFW: an ISO 9001: 2008 certified Institution 103
2000 2001 2002 2003 2004 2005 2006 2007 2008*0
200
400
600
800
1000
1200
1400
1600
1800
991 1015 979 1006949 969
1704
1311
878
33
215
45
157 17169 80
536479 466
707
367
1682
658
963
662
Mortality Pattern 2000-2008Source: CBHI, National Health Profile
Malaria
Dengue
JE
SIHFW: an ISO 9001: 2008 certified Institution 104
2000 2001 2002 2003 2004 2005 2006 2007 2008*
0
100
200
300
400
500
600
700
800
900 892
755682
536488
340 365325
253
355331
260
164 141116
80 10056
Mortality Pattern 2000-2008Source: CBHI, NHP
Tetanus NNT
SIHFW: an ISO 9001: 2008 certified Institution 105
India Rajasthan
11231039
354799
284138
Cases and Deaths Due to Acute Diarrhoeal Disease, Dec. 2008
Source: CBHI NHP, 2008
Cases Death
SIHFW: an ISO 9001: 2008 certified Institution 106
India Rajasthan
25541645
1233978
3467
228
Cases and Deaths Due to Acute Respiratory Infection , Dec. 2008
Source: CBHI NHP, 2008
Cases
Death
SIHFW: an ISO 9001: 2008 certified Institution 107
India Rajasthan
720454
92501
3765
229
Cases and Deaths Due to Pneumonia, Dec. 2008
Source: CBHI NHP, 2008
Cases Death
SIHFW: an ISO 9001: 2008 certified Institution 108
India Rajasthan
811
30
569
Cases and Deaths Due to Tetanus Neonatal, Dec. 2008
Source: CBHI NHP, 2008
Cases Death
SIHFW: an ISO 9001: 2008 certified Institution 109
India Rajasthan(excep May & Oct. )
48181
549188 0
Cases and Deaths Due to Measles, Dec. 2008
Source: CBHI NHP, 2008
Cases Death
SIHFW: an ISO 9001: 2008 certified Institution 110
India Rajasthan 0
200000
400000
600000
800000
1000000
916161
1552
3388
Cases and Deaths Due to Enteric Fever (Typhoid) in India Dec. 2008
Source: CBHI NHP, 2008
Cases
Death
SIHFW: an ISO 9001: 2008 certified Institution111
India Rajasthan
90440
2000510 6
Cases and Deaths Due to Viral Hepatitis (All Causes), Dec.2008
Source: CBHI NHP, 2008
Cases Death
SIHFW: an ISO 9001: 2008 certified Institution 112
India Rajasthan
789135
711807073
695
Cases and Deaths Due to Pulmonary Tubercu-losis, 2006 (Latest)
Source: CBHI, NHP, 2006
Cases
Death
2002 2003 2004 2005 2006 2007 2008Malaria, Pf AND Malaria deaths-2002-2008: India
0
20000
40000
60000
80000
100000
120000
140000
160000
180000
0
20
40
60
80
100
120
133931
139502151390
89543 85270
108573
24964
2296620624
19697
1164813893
18262
3934
63
41
62
71
100 103
0
Deaths
P.f
Cases
113SIHFW: an ISO 9001: 2008 certified Institution
SIHFW: an ISO 9001: 2008 certified Institution 114
142738
105022
52286
99529
55043
57482
Malaria: Rajasthan
Source: CBHI NHP, 2008
200320042005200620072008*
SIHFW: an ISO 9001: 2008 certified Institution115
20032004
20052006
20072008*
0
200000
400000
600000
800000
1000000
1200000
1400000
1600000
1800000
2000000 1869403 1915363
18165691780777
1508927
1366517
1006949
963 17041331 8878
Malaria: IndiaSource: CBHI NHP, 2008
CasesDeaths
116SIHFW: an ISO 9001: 2008 certified Institution
SIHFW: an ISO 9001: 2008 certified Institution 117
case
s
De
ath
case
s
De
ath
case
s
De
ath
case
s
De
ath
Ca
ses
De
ath
Ca
ses
De
ath
Ca
ses
De
ath
2002 2003 2004 2005 2006 2007 2008*
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1926 3312754 215 4153 45
11985 15711308 171 5534 69
12440 80
325 5685 11 207 5
370 51224 17 540 10
682 4
Cases and Death due to Dengue in India 2002-2008Source: CBHI NHP, 2008
Rajasthan India
SIHFW: an ISO 9001: 2008 certified Institution 118
0-14 years
15-49 years
50+ years
Male Female All ages0
20
40
60
80
100
120
0.10.600000000000
001
77.3
10.2 12.2 11.20.1 0.8
109.5
13.1 16.1 14.6
Prevalence of Blindness in India 2004, Per 1000 population
Source: CBHI NHP, 2008
India
Rajasthan
SIHFW: an ISO 9001: 2008 certified Institution 119
0-14 years 15-49 years 50+ years Male Female All ages
6396 57565
2068087
10020631129985
2132048
345 3103111480
54016 6912111928
Estimated Incidences of Blindness, 2004
Source: CBHI, NHP, 2008 India
Rajasthan
SIHFW: an ISO 9001: 2008 certified Institution 120
2001 2002 2003 2004
3665116723 14954 18937
234368 243399 244671258326
Incidence of Deaths due to Accidents in India 2001-2004
Source: CBHI NHP, 2006
Natural Causes Un- Natural causes
SIHFW: an ISO 9001: 2008 certified Institution 121
Children 12-23months fullyimmunized
(BCG, measles,
and 3 doseseach of
polio/DPT) (%)
Children 12-23months who
have receivedBCG (%)
Children 12-23months who
have received3 doses of
poliovaccine (%)
Children 12-23months who
have received3 doses of
DPTvaccine (%)
Children12-23 monthshave reveived
measlesvaccine (%
Children are12-35 monthswho received
avitamin A dose
in last 6months (%)
0
10
20
30
40
50
60
70
80
90
43.5
78.2 78.2
55.258.8
2126.5
68.565.2
38.742.7
13.2
Percentage of Children Immunized In IndiaSource: CBHI, NHP, 2008
India
Rajasthan
SIHFW: an ISO 9001: 2008 certified Institution 122
1 2 3 0 1 2 3
BCG DPT Polio1 Measles All basic vaccina-
tions
No vac-cina-tions
Percent-age with a vaccina-tion card
seen
0
10
20
30
40
50
60
70
80
90
100
78.1 76
66.7
55.3
48.4
93.188.8
78.2
58.8
43.5
5.1
37.5
68.565
53.2
38.7
30
93
84
65.2
42.7
26.5
5.5
20.8
ImmunizationSource: NFHS-3
India
Rajasthan
SIHFW: an ISO 9001: 2008 certified Institution 123
0
10
20
30
40
50
60
70
80
90
76.4
52
43.9
76.3
65.1
23.1
3.8
74.9
41.2
34
65.2
57.7
13.1
1.4
Ante Natal Care Source:NFHS-3
India
Rajasthan
SIHFW: an ISO 9001: 2008 certified Institution 124
0
5
10
15
20
25
30
35
40
45
50
15
38.7
46.6
41.2
37.3
8.6
29.6
41
31.828.9
ANC and Delivery Care Source:NFHS-3
India
Rajasthan
Health Care Infrastructure : India
125SIHFW: an ISO 9001: 2008 certified Institution
126
I II III IV V VI VII VIII IX X 0
20000
40000
60000
80000
100000
120000
140000
160000
0 0 0
33509
47112
84376
130165
136258
137311145272
Sub-centers over FYPs
Five Year Plans
SIHFW: an ISO 9001: 2008 certified Institution
I II III IV V VI VII VIII IX X 0
5000
10000
15000
20000
25000
2565
5283 5484
9115
18671
22149
22875
22370
PHCs over FYPs
Five Year Plans
127SIHFW: an ISO 9001: 2008 certified Institution
I II III IV V VI VII VIII IX X 0
500
1000
1500
2000
2500
3000
3500
4000
4500
0 0 0 0 214
761
1910
26333054
4045
CHCs over FYPs
Five Year Plans
128SIHFW: an ISO 9001: 2008 certified Institution
No. of HospitalsNo. of Beds
Pop. Per Bed
0
50000
100000
150000
200000
250000
300000
350000
400000
450000
500000
9976
482522
2339
47532067 1997
Hospitals, Beds and Pop. Served per Bed, Dec. 2007
IndiaRajasthan
129SIHFW: an ISO 9001: 2008 certified Institution
130
CHC-X-F
YP
Physic
ian
Surge
on
Ob. &
Gy
Pediat
rician
Anest
hest
ists
Public
Hea
lth
0
500
1000
1500
2000
2500
3000
3500
4000
45004045
1177 1113703 526 698
269
IPHS: Institutions & PG seats
SIHFW: an ISO 9001: 2008 certified Institution
131
I II III IV V VI VII VIII IX X 2007-2008
0
2500
5000
7500
10000
12500
15000
17500
20000
22500
25000
27500
30000
32500
35000
37500
40000
42500
0 0 0 0 0 0 0 0 0 337 349
6798
9459
12241
1545017397
21916
28867
36967 37918
4118542220
Rajasthan
Hospitals C.H.C PHC
Sub-Centers Beds Doctors
SIHFW: an ISO 9001: 2008 certified Institution
0
2000
4000
6000
8000
10000
12000
1 2 3 4 5 6 7 8 9 10
Nu
mb
er
FY Plan
Infrastructure development: Rajasthan
PHC
SC
CHC
132SIHFW: an ISO 9001: 2008 certified Institution
Human Resource in Health
SIHFW: an ISO 9001: 2008 certified Institution 133
134
Rajasthan0
100000
200000
300000
400000
500000
600000
700000
10605
598189
Average pop. Served by Govt Doctors in Rajasthan(01.01.08)
Average pop. Served by Govt Dentists in Rajasthan (01.01.08)
Source :CBHI
SIHFW: an ISO 9001: 2008 certified Institution
135
India Rajasthan0
5000
10000
15000
20000
2500022272
1316
3979
592
Staff Position at PHC & CHC, 2006Source: CBHI NHP, 2006
Doctors at PHCSpecialists at CHC
SIHFW: an ISO 9001: 2008 certified Institution
SIHFW: an ISO 9001: 2008 certified Institution 136
Doctors at PHC
Specialists at CHC
HA(M) HA (F) HW (M) HM (F)300
10300
20300
30300
40300
50300
60300
70300
80300
90300
100300
110300
120300
130300
140300
22608
5117
20234 15486
62881
147439
1318 600 714 1358 2428
12271
Human Resource in HealthSource: CBHI:NHP :Oct 2008
india rajasthan
SIHFW: an ISO 9001: 2008 certified Institution 137
Total Doctors Govt. Doctors Dental Surgeons100
50100
100100
150100
200100
250100
300100
350100
400100
450100
500100
550100
600100
650100
700100
750100
800100
725190
73057 84852
265926285 364
Health Man Power (31.03.07) Source National Hlth. Profile 2008
India
Rajasthan
SIHFW: an ISO 9001: 2008 certified Institution 138
ANM GNM LHV Pharmacist0
50000
100000
150000
200000
250000
300000
350000
400000
450000
500000
550000
600000
650000
700000
750000
800000
850000
900000
950000
1000000
549292
971574
51497
681692
223937667
850 18214
Health Man Power (31.03.07) Source National Hlth. Profile 2008
India
Rajasthan
SIHFW: an ISO 9001: 2008 certified Institution139
632
1988
1227
291
Nursing SchoolsIndian Nursing Council Nov.2009
ANM
GNM
B Sc.
M Sc.
Medical EducationSource MCI/DCI/INC
Colleges India Rajasthan
Medical Colleges 300 10
Recognized 211 7
Non Recognized 89 3
Dental Colleges 290 13
Recognized 154 8
Non Recognized 136 5
SIHFW: an ISO 9001: 2008 certified Institution 140
SIHFW: an ISO 9001: 2008 certified Institution 141
CHC-X-FYP
Physician
Surgeon
Ob. & Gy
Pediatricia
n
Anesthesti
sts
Public Health
Anatomy
Physiology
0
500
1000
1500
2000
2500
3000
3500
4000
4500 4276
1529 1444
894708 698
897
338 337
CHCs – IPHS Vs PG seats (March 2008)
Performance
SIHFW: an ISO 9001: 2008 certified Institution 142
143
0
10
20
30
40
50
60
70
47.244.4
34.2
0.8 2 1.65.7
52.856.3
48.5
37.3
1
3.1 1.7 5.2
43.748.2
42.8
34.2
1.9 2.1 1.63.1
51.8
40.7
36.5
27.4
3.5
1.21.9
2.4
59.3
Family Planning Method Uses
Rajasthan NFHS-3
Ind. NFHS-3
Ind. NFHS-2
Ind. NFHS-1
SIHFW: an ISO 9001: 2008 certified Institution
144
Children 12-23months fullyimmunized
(BCG, measles,and 3 doses
each ofpolio/DPT) (%)
Children 12-23months who
have receivedBCG (%)
Children 12-23months who
have received3 doses of
poliovaccine (%)
Children 12-23months who
have received3 doses of DPT
vaccine (%)
Children12-23 monthshave reveived
measlesvaccine (%
Children are12-35 months
who received avitamin A dose
in last 6months (%)
0
10
20
30
40
50
60
70
80
90
43.5
78.2 78.2
55.258.8
2126.5
68.565.2
38.742.7
13.2
Percentage of Children Immunized In IndiaSource: CBHI, NHP, 2006
India
Rajasthan
SIHFW: an ISO 9001: 2008 certified Institution
145
1 2 3 0 1 2 3
BCG DPT Polio1 Measles All basic vaccina-
tions
No vaccina-tions
Percentage with a vac-
cination card seen
0
10
20
30
40
50
60
70
80
90
100
78.176
66.7
55.3
48.4
93.188.8
78.2
58.8
43.5
5.1
37.5
68.565
53.2
38.7
30
93
84
65.2
42.7
26.5
5.5
20.8
ImmunizationSource: NFHS-3
India Rajasthan
SIHFW: an ISO 9001: 2008 certified Institution
146
0
10
20
30
40
50
60
23.4
46.3
55.8
38.4
19.1
45.9
13.3
33.2
38.7
33.7
19.7
44
Children Breastfed in India and their Nutritional StatusSource: CBHI, NHP, 2006
India
Rajasthan
SIHFW: an ISO 9001: 2008 certified Institution
147
Wo
me
nw
ho
seB
od
y M
ass
Ind
ex
isb
elo
wn
orm
al (
%)
Me
n w
ho
seB
od
yIn
de
x is
be
low
no
rma
l (%
)
Wo
me
nw
ho
are
ove
rwe
igh
to
r o
be
se(%
)
Me
n w
ho
are
ove
rwe
igh
to
r o
be
se(%
)
Ch
ildre
na
ge
6-3
5m
on
ths
wh
o a
rea
na
em
ic(%
)E
ver-
ma
rrie
dw
om
en
ag
e 1
5-4
9w
ho
are
an
ae
mic
(%)
Pre
gn
an
tw
om
en
ag
e 1
5-4
9w
ho
are
an
ae
mic
(%)
Eve
r-m
arr
ied
me
n a
ge
15
-4
9 w
ho
are
an
ae
mic
(%)
Nutritional Status of Ever-Married Adults (Age 15-49) Anaemia among Children and Adults
0
10
20
30
40
50
60
70
80
90
3328.1
14.8 12.1
79.1
56.1 57.8
24.3
33.6 33.8
10.2 8.4
79.6
53.161.2
20.5
Anemia among Children and Adults, 2005-2006
Source: CBHI, NHP, 2006India
Rajasthan
SIHFW: an ISO 9001: 2008 certified Institution
Health Expenditure Patterns
SIHFW: an ISO 9001: 2008 certified Institution 148
Some Facts
1125000 Practitioners, 125000 in Govt., 59% in cities
49% of beds, 42% of occupancy (private sector) 40 Doctor/100000, 32 Nurses/ 100000 pop.
(National average-59/ 100000, 79/100000)Developed country average: 200/ 100000
76 drugs (25% of essential) under price control 50% of spending in health is on drugs
SIHFW: an ISO 9001: 2008 certified Institution 149
< 1% of GDP
Proportion of Total Health Exp.: Govt-20%
Private health exp.:
80% of total health cost
97% : OOP
One hospitalization: 60% of annual income
Outpatient care accounts for 61 per cent of
private healthcare spendingSIHFW: an ISO 9001: 2008 certified Institution 150
SIHFW: an ISO 9001: 2008 certified Institution 151
People are resources
But
To maintain this resource
We need Resources
Who Pays?
Health Authority?
Government?
Taxpayer?
SIHFW: an ISO 9001: 2008 certified Institution 152
25%
2%
3%2%
68%
Share in health care spendingSource: CBHI, NHP, 2006
Govt.
Public/Private Enterprises
Insurance
NGOs
Households
SIHFW: an ISO 9001: 2008 certified Institution 153
1951-56
1956-61
1961-66
1969-74
1969-74
1974-79
1979-80
1980-85
1985-90
1990-91
1991-92
1992-97
1997-02
2002-07
2007-12
0
1
2
3
4
5
6
7
3.43.1
2.93.2
3.9
3.12.8
3.1 3.12.9 2.9
3.2
4.09 3.97
6.5
Health Expenditure as % of total Plan OutlaySource: CBHI, NHP, 2006
SIHFW: an ISO 9001: 2008 certified Institution 154
1950-51
1951-55
1960-61
1965-66
1970-71
1975-76
1980-81
1985-86
1990-91
1995-96
2000-01
2001-02
2002-03
2003-04
0
0.2
0.4
0.6
0.8
1
1.2
0.22
0.49
0.6300000000000060.610000000000001
0.7400000000000040.81
0.91
1.05
0.960000000000001
0.88 0.90.8300000000000010.860000000000001
0.91
Total Govt. Expenditure on Health as % of GDP
Source: CBHI, NHP, 2006
SIHFW: an ISO 9001: 2008 certified Institution 155
1950-51
1951-55
1960-61
1965-66
1970-71
1975-76
1980-81
1985-86
1990-91
1995-96
2000-01
2001-02
2002-03
2003-04
0
20
40
60
80
100
120
140
160
180
200
220
0.6100000000000011.36 2.48 3.47 6.22 11.1519.37
38.63
64.83
112.21
184.56 183.56
202.22214.62
Per Capita Public Exp. on HealthSource: CBHI, NHP, 2006
SIHFW: an ISO 9001: 2008 certified Institution 156
SIHFW: an ISO 9001: 2008 certified Institution 157
I II II IV V VI VII VIII IX X XI100
100100200100300100400100500100600100700100800100900100
1000100110010012001001300100140010015001001600100170010018001001900100200010021001002200100
0
20000
40000
60000
80000
100000
120000
140000
160000
1960 4672 8576.515778.8
39426.2109291.7 218729.6
434100
859200
1484131
2156571
65.3 145.8 250.8613.5
1252.6 3412.26809.4 14102.2
35204.9
58920.3
140135
Total planned Outlay and Health Budget including FW and AYUSH ( in crores)
Source : CBHI:2009:national health Profile Oct 2009 Total plan outlay
Heath sector
Status of Expenditure in Five Year Plans
FYPsTotal Plan
Investment Health Family WelfareI 1960 65.2 0.1II 4672 140.8 2.2III 8576 225 24.9IV 15778.8 335.5 284.4V 39322 682 497.4VI 97500 1821 1010VII 180000 3392 3256.2VIII 798000 7575.9 6500IX 859200 10818 15120.2X 1484131.3 31020.3 27125XI NA 46669 89478
158SIHFW: an ISO 9001: 2008 certified Institution
SIHFW: an ISO 9001: 2008 certified Institution 159
0
500000
1000000
1500000
2000000
2500000
0
20000
40000
60000
80000
100000
120000
140000
160000
1960 4672 8576.5 15778.839426.2 109291.7
218729.6
434100
859200
1484131
2156571
65.3 145.8 250.8 613.5 1252.6 3412.26809.4
14102.2
35204.9
58920.3
140135
Total Outlay – Plan and Health
Total plan outlay
Heath sector
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I II II IV V VI VII VIII IX X XI0
1
2
3
4
5
6
7
3.33
2.6
2.1 1.9 1.8 1.7
1.7
2.31
2.09
6.31
% of total budget allocated to health
Per capita expenditure
Household Public Other0
200
400
600
800
1000
1200
1400 1377
73.5 22 4.5
808
7024.5 5.5
Health Care Spending (2004-05)Source: NCMHGI, 2005
India
Rajasthan
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Expenditure Patterns
Public expenditures – declining trends
Out of pocket – increasing burden, especially the poor and in rural areas
162SIHFW: an ISO 9001: 2008 certified Institution
Health Spending: Facts
Public Domain Center: Rs.35 bi (0.13% GDP) State: Rs.186 bi (0.72% GDP) Local: Rs.25 bi estimated (0.10% GDP) Social Insurance: Rs. 12 bi (0.05% GDP)
Private Domain Out-of-pocket: Rs.1200 bi (4.62% GDP) Insurance (public sector) Rs.8 bi (0.03%
GDP) Pharma Industry Rs. 250 bi (0.96% GDP)
163SIHFW: an ISO 9001: 2008 certified Institution
0
20000
40000
60000
80000
100000
120000
1 2 3 4 5 6 7 8 9 10
Rs. in Lacs
Five year Plans
Budget: Rajasthan
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165
Health Legislations in India
A. Legislations Related to Health in General
The Epidemic Diseases Act, 1897
Indian Air Craft (Public Health) Rules, 1954
The Registration of Births and Deaths Act, 1969
The Persons with Disabilities (Equal Opportunity, Protection Of Rights & Full Participation) Act, 1995
Legislation on Transplantation of human organs, enacted 1995
The Biomedical Waste (Management And Handling Rules 1998) Act
166SIHFW: an ISO 9001: 2008 certified Institution
B. Legislation Related to Mother/ women’s Health
Hindu Marriage Act, 1955 The Special Marriage Act, 1954 Hindu Succession Act, 1956 The Maternity Benefits Act, 1961 The Dowry Prohibition Act, 1961 Hindu Adoption and Maintenance Act, 1956 The Immoral Traffic (Prevention) Act, 1956; amended
in 1986 The Immoral Traffic (Prevention) Act, 1956; amended
in 1986 Medical Termination Of Pregnancy Act, 1971
(The MTP Rules, 1975)
Pre-natal Diagnostic Techniques (Regulation & Prevention of misuse) Act,1994;Rules, Nov.26, 1996
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C. Legislations Related to Child Health
The Child Marriage Restraint Act,1929 Children Act, 1960 The Juvenile Justice Act, 1986 The Child Labor (Prohibition and Regulation)
Act, 1986 Infant Milk substitute Act, 1992
168SIHFW: an ISO 9001: 2008 certified Institution
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