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Public Health Care : India An Overview State Institute of Health & Family Welfare, Jaipur 1 SIHFW: an ISO 9001: 2008 certified Institution

Public Health Care in India

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Page 1: Public Health Care in India

SIHFW: an ISO 9001: 2008 certified Institution

1

Public Health Care : India An Overview

State Institute of Health & Family Welfare, Jaipur

Page 2: Public Health Care in India

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

Page 3: Public Health Care in India

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

Page 4: Public Health Care in India

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

Page 5: Public Health Care in India

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

Page 6: Public Health Care in India

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

Page 7: Public Health Care in India

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

Page 8: Public Health Care in India

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

Page 9: Public Health Care in India

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

Page 10: Public Health Care in India

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

Page 11: Public Health Care in India

Bhore Committee, 1946

PHCS : nodal points for Health care

Phased expansion

Prevention stressed

Population based

SIHFW: an ISO 9001: 2008 certified Institution 11

Page 12: Public Health Care in India

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

Page 13: Public Health Care in India

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

Page 14: Public Health Care in India

Service Delivery:3-tier Structure

Tertiary careSecondary CarePrimary care

CHC

PHC

SCUnderutilized for-

ServicesSuppliesFunding

14SIHFW: an ISO 9001: 2008 certified Institution

Page 15: Public Health Care in India

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

Page 16: Public Health Care in India

Committees & Commissions

16SIHFW: an ISO 9001: 2008 certified Institution

Page 17: Public Health Care in India

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

Page 18: Public Health Care in India

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

Page 19: Public Health Care in India

1964: Mukherjee Committee

TOR-Family planning

Exclusive family planning staff

(uni-purpose worker)

19SIHFW: an ISO 9001: 2008 certified Institution

Page 20: Public Health Care in India

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

Page 21: Public Health Care in India

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

Page 22: Public Health Care in India

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

Page 23: Public Health Care in India

Population and Growth: India

23SIHFW: an ISO 9001: 2008 certified Institution

Page 24: Public Health Care in India

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

Page 25: Public Health Care in India

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

Page 26: Public Health Care in India

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

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Page 27: Public Health Care in India

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

Page 28: Public Health Care in India

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

Page 29: Public Health Care in India

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

Page 30: Public Health Care in India

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

Page 31: Public Health Care in India

Marriage and Fertility

SIHFW: an ISO 9001: 2008 certified Institution 31

Page 32: Public Health Care in India

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

Page 33: Public Health Care in India

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

Page 34: Public Health Care in India

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

Page 35: Public Health Care in India

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

Page 36: Public Health Care in India

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

Page 37: Public Health Care in India

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

Page 38: Public Health Care in India

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

Page 39: Public Health Care in India

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

Page 40: Public Health Care in India

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

Page 41: Public Health Care in India

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

Page 42: Public Health Care in India

Problems:

Indirectly related to healthEnvironmentEducationEmpowerment

Directly affecting HealthDiseases

Communicable Non CommunicableNew emerging

FertilityPopulationGrowth rate Total Fertility

NutritionMalnutritionObesity

42SIHFW: an ISO 9001: 2008 certified Institution

Page 43: Public Health Care in India

Problems- Why

Access

Availability

Utilization

43SIHFW: an ISO 9001: 2008 certified Institution

Page 44: Public Health Care in India

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

Page 45: Public Health Care in India

Policies

NHP-1983…….NHP-2002

NPP-2000

45SIHFW: an ISO 9001: 2008 certified Institution

Page 46: Public Health Care in India

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

Page 47: Public Health Care in India

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

Page 48: Public Health Care in India

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

Page 49: Public Health Care in India

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

Page 50: Public Health Care in India

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

Page 51: Public Health Care in India

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

Page 52: Public Health Care in India

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

Page 53: Public Health Care in India

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

Page 54: Public Health Care in India

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

Page 55: Public Health Care in India

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

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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

Page 57: Public Health Care in India

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

Page 58: Public Health Care in India

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

Page 59: Public Health Care in India

Health Care Governance in India

SIHFW: an ISO 9001: 2008 certified Institution 59

Page 60: Public Health Care in India

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

Page 61: Public Health Care in India

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

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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

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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

Page 64: Public Health Care in India

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

Page 65: Public Health Care in India

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

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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

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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

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District Health Care Administration

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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

Page 70: Public Health Care in India

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

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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

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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

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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

Page 74: Public Health Care in India

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

Page 75: Public Health Care in India

System?

A set of interrelated and independent

parts designed to achieve a set of goals

75SIHFW: an ISO 9001: 2008 certified Institution

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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

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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

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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

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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

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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

Page 81: Public Health Care in India

Components of Health System

Production of Resources

Organization of Programs

Economical support

Management

Delivery of Services

81SIHFW: an ISO 9001: 2008 certified Institution

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Health- A Dynamic Phenomenon

Health System ought to be, for:

Rising costs

Changing political situations

Social contexts(expectations of

people from System)

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Page 83: Public Health Care in India

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

Page 84: Public Health Care in India

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

Page 85: Public Health Care in India

Based on Nature of Service

Indigenous-Rural

General care

Specialty

Super specialty/Corporate

85SIHFW: an ISO 9001: 2008 certified Institution

Page 86: Public Health Care in India

Based on Doctrine Official

Allopathic Traditional

AyurvedaUnaniSiddhaHomeopathyChineseTibetan

86SIHFW: an ISO 9001: 2008 certified Institution

Page 87: Public Health Care in India

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

Page 88: Public Health Care in India

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

Page 89: Public Health Care in India

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

Page 90: Public Health Care in India

Public Health: Rajasthan

90SIHFW: an ISO 9001: 2008 certified Institution

Page 91: Public Health Care in India

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

Page 92: Public Health Care in India

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

Page 93: Public Health Care in India

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

Page 94: Public Health Care in India

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

Page 95: Public Health Care in India

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

Page 96: Public Health Care in India

Performance, Progress & Punctuations

96SIHFW: an ISO 9001: 2008 certified Institution

Page 97: Public Health Care in India

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

Page 98: Public Health Care in India

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

Page 99: Public Health Care in India

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

Page 100: Public Health Care in India

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

Page 101: Public Health Care in India

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

Page 102: Public Health Care in India

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

Page 103: Public Health Care in India

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

Page 104: Public Health Care in India

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

Page 105: Public Health Care in India

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

Page 106: Public Health Care in India

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

Page 107: Public Health Care in India

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

Page 108: Public Health Care in India

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

Page 109: Public Health Care in India

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

Page 110: Public Health Care in India

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

Page 111: Public Health Care in India

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

Page 112: Public Health Care in India

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

Page 113: Public Health Care in India

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

Page 114: Public Health Care in India

SIHFW: an ISO 9001: 2008 certified Institution 114

142738

105022

52286

99529

55043

57482

Malaria: Rajasthan

Source: CBHI NHP, 2008

200320042005200620072008*

Page 115: Public Health Care in India

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

Page 116: Public Health Care in India

116SIHFW: an ISO 9001: 2008 certified Institution

Page 117: Public Health Care in India

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

Page 118: Public Health Care in 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

Page 119: Public Health Care in India

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

Page 120: Public Health Care in India

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

Page 121: Public Health Care in India

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

Page 122: Public Health Care in India

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

Page 123: Public Health Care in India

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

Page 124: Public Health Care in India

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

Page 125: Public Health Care in India

Health Care Infrastructure : India

125SIHFW: an ISO 9001: 2008 certified Institution

Page 126: Public Health Care in India

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

Page 127: Public Health Care in India

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

Page 128: Public Health Care in India

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

Page 129: Public Health Care in India

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

Page 130: Public Health Care in India

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

Page 131: Public Health Care in India

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

Page 132: Public Health Care in India

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

Page 133: Public Health Care in India

Human Resource in Health

SIHFW: an ISO 9001: 2008 certified Institution 133

Page 134: Public Health Care in India

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

Page 135: Public Health Care in India

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

Page 136: Public Health Care in India

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

Page 137: Public Health Care in India

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

Page 138: Public Health Care in India

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

Page 139: Public Health Care in India

SIHFW: an ISO 9001: 2008 certified Institution139

632

1988

1227

291

Nursing SchoolsIndian Nursing Council Nov.2009

ANM

GNM

B Sc.

M Sc.

Page 140: Public Health Care in India

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

Page 141: Public Health Care in India

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)

Page 142: Public Health Care in India

Performance

SIHFW: an ISO 9001: 2008 certified Institution 142

Page 143: Public Health Care in India

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

Page 144: Public Health Care in India

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

Page 145: Public Health Care in India

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

Page 146: Public Health Care in India

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

Page 147: Public Health Care in India

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

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Health Expenditure Patterns

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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

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< 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

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People are resources

But

To maintain this resource

We need Resources

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Who Pays?

Health Authority?

Government?

Taxpayer?

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25%

2%

3%2%

68%

Share in health care spendingSource: CBHI, NHP, 2006

Govt.

Public/Private Enterprises

Insurance

NGOs

Households

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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

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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

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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

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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

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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

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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

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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

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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)

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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

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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

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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

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Thank You