DR J E PARK MEMORIAL ORATION

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DR J E PARK MEMORIAL ORATION

• Prof N K Sethi
• Senior Adviser (Health)
• Planning Commission
• Government of India

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• HEALTH CARE IN INDIA
• CONCERNS CHALLENGES
• AND
• ROAD MAP

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BACKGROUND

• Health of a Nation
• Development
• Economic Growth
• Strides since Independence
• Infrastructure
• Human Resources for Health
• Institutions
• Health Indices
• Problems exist
• Health status Malnutrition Cost of Health
  Care Equity Quality of care

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CURRENT SCENARIO

• INTERNATIONAL COMPARISON

Projected (2001-06) Source IndiaRGI, Govt. of
India (Latest Figures) OthersState of World
Population, 2006
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CURRENT SCENARIO

• TENTH PLAN GOALS WHERE ARE WE?

Source 1. Technical Group on Population
Projections set up by National Commission on
Population (Dec 2006), RGI, GOI 2. SRS 2006 3.
200103 Special Survey of Deaths using RHIME
(routine, re-sampled, household interview of
mortality with medical evaluation), RGI (2006)
GOI
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Time Bound Goals for the Eleventh Five Year Plan

• Reducing Total Fertility Rate to 2.1
• Reducing Infant Mortality Rate (IMR) to 28 per
  1000 live births
• Reducing Maternal Mortality Ratio (MMR) to 1 per
  1000 live births

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TOTAL FERTILITY RATE
Projected
Projected
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MATERNAL MORTALITY RATIO
MMR IN INDIA TRENDS BASED ON LOG LINEAR MODEL
1996-2013
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INFANT MORTALITY RATE
IMR IN INDIA
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WHAT AILS OUR HEALTH SYSTEM?

• Low Public Health Expenditure
• Planning and Approach
• Infrastructure and Human Resources
• Monitoring and Evaluation
• Lack of Convergence
• Lack of Integration
• Preventive and Community health
• Geographical Imbalances
• Emerging Threats
• Lack of emphasis on Equity and Inclusiveness

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DISPARITIES DIVIDES
URBAN --- RURAL
Source Ministry of Health Family Welfare
(GOI), 2006 and NHFS 3, IIPS (200506).
URBAN SLUM ---------- NON - SLUM
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DISPARITIES DIVIDES
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DISEASE BURDEN
Source NCMH, 2005
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HEALTH CARE INFRASTRUCTURE GAPS
Note All India shortfall is derived by adding
state-wise figures of shortfall ignoring the
existing surplus in some of the states Source
Bulletin of Rural Health Statistics in India,
Special Revised Edition, MOHFW (GOI), 2006
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HUMAN RESOURCES FOR HEALTH GAPS
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HUMAN RESOURCES FOR HEALTH GAPS
NUMBER OF PERSONS PER SPECIALIST AT CHCs (2006)
Source Bulletin of Rural Health Statistics in
India, Special Revised Edition, MOHFW (GOI), 2006
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HEALTH CARE UTILIZATION
PERCENTAGE OF CASES OF HOSPITALIZED TREATMENT BY
TYPE OF HOSPITAL IN RURAL AREAS, INDIA
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HEALTH CARE UTILIZATION
PERCENTAGE OF CASES OF HOSPITALIZED TREATMENT BY
TYPE OF HOSPITAL IN URBAN AREAS, INDIA
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HEALTH CARE UTILIZATION
PERCENTAGE OF TREATED AILMENTS RECEIVING
NON-HOSPITALIZED TREATMENT FROM GOVT. SOURCES
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COST OF TREATMENT
AVERAGE MEDICAL EXPENDITURE (Rs.) PER
HOSPITALIZATION CASE
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EXPENDITURE ON HEALTH
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EXPENDITURE ON DRUGS
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WAY FORWARDGOALS

• To strive towards health as a right for all
  citizens.
• To facilitate convergence and development of
  public health systems and services responsive to
  health needs and aspirations of the people for an
  accountable, accessible and affordable system of
  quality services.
• To restructure policies to achieve a faster,
  broad-based and inclusive growth and to achieve
  good health for people, especially the poor and
  the underprivileged.
• To provide cash less health care to the poor and
  needy.

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CONCERNS TO ADDRESS

• Making Public Health Care system functional
• Reducing disease burden and level of risk
• Investing in human resources
• Promoting equity by reducing household
  expenditure
• Governance, Regulation Accreditation

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APPROACHES NEEDED

• Increased public spending on health (Centre and
  States)
• At least 2 of GDP
• Large share of allocation for primary health
  care
• Adopt system centric approach rather than disease
  centric
• Organic integration of funds, functions and
  functionaries under NRHM
• Do not allow vertical structures below district
  level under different programmes

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APPROACHES NEEDED

• Comprehensive approach by convergence Encompass
  health care, sanitation, clean drinking water
  and nutrition through integrated district action
  plans for health based on village health plans
• Address State/area specific health problems
• Covered through funds provided under NRHM
  flexi-pool

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APPROACHES NEEDED

• Implement flexible norms for health care
  facilities and personnel
• Based on distance, terrain, travel time and
  socio-cultural scenario instead of population
  norms alone
• Up grade health infrastructure and set up new
  medical, dental, nursing and paramedical
  institutions in deficient areas through public
  private partnership

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APPROACHES NEEDED

• Tackle the problem of human resources for health
• Meet the health needs of the urban poor
• Prevent indebtedness due to expenditure on health
• Create mechanisms for health insurance and
• community risk-pooling
• Reduce fertility
• Meeting the unmet need, enhanced male
  participation,
• reducing child mortality and other factors
  affecting fertility

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APPROACHES NEEDED

• Reduce infant mortality
• Home based neonatal care provided by trained
  community health workers
• Reduce maternal mortality
• Skilled attendance at birth
• Application oriented health system and
  bio-medical research for
• Improved health
• Propagation of low cost indigenous technology

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APPROACHES NEEDED

• Improve governance, transparency and
  accountability in the delivery of health services
• Involve PRIs, Community and Civil Society
  Groups
• Monitor outlays vs outputs and outcomes based on
• Numerical achievements
• PLUS
• Improved functioning through adoption of
  Indian Public Health Service Standards at all
  levels

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PROGRAMMES ACTIVITIES REQUIRED

• National Rural Health Mission (NRHM) for rural
  India
• National Urban Health Mission (NUHM) based on
  health insurance and public-private partnership
  (PPP) to meet the unmet needs of the urban
  population
• Aligned with NRHM and existing urban schemes
• Initially, focus on urban slums
• Sarva Swasthya Abhiyan aims for inclusive growth
  by finding solutions for strengthening health
  services and focusing on neglected areas and
  groups

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ACTIVITIES REQUIRED

• Strengthening Health Systems
• Primary Health Care
• Secondary Tertiary Health Care
• Access to Essential Drugs
• Decentralized Governance Affecting Convergence
• Role of PRIs and Civil Society
• Enhancing Public-Private Partnership
• Service delivery
• Operation and Maintenance
• Asset Creation

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ACTIVITIES REQUIRED

• Health Insurance
• Community Risk Pooling
• Community Based Health Insurance
• Insurance for Unorganized Sector
• Regulation and Accreditation
• Appropriate Technology
• Low Cost and Innovative Technology
• eHealth

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IMPROVEMENT REQUIRED

• Gender Responsive Health Care
• Sex ratio particularly child sex ratio
• ANC
• Safe deliveries
• Emergency Obstetric Care - 2 hrs travel time
• Post Partum Care
• Safe Abortion Services
• RTI/STI

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IMPROVEMENT REQUIRED

• Child Health
• Home Based Neonatal Care (HBNC)
• IMNCI
• Skilled Care at Birth
• Breast Feeding
• Immunization
• Care of Common Illnesses

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OTHER ACTIVITIES REQUIRED

• Non-Communicable Diseases Prevention and
  Control
• School Health
• Adolescent Health
• Public Health Education
• Research For Finding Solutions
• Health Care for Older Persons

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• Transform Public Health Care into an accountable,
  accessible and affordable system of quality
  services
• Role of Public Health all facets
• (Indian Public Health Cadre?)

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• Plan ahead it was not raining when Noah built
  the ark
• As quoted in Parks Textbook of Preventive and
  Social Medicine

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• THANK YOU

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HEALTH FINANCING
SOURCE OF HEALTH CARE FINANCING IN INDIA (2001-02)
HEALTH SPENDING 4.5-6 OF GDP
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HEALTH FINANCING
GROWTH OF PER CAPITA HEALTH EXPENDITURE BY
CENTRE AND STATES NOMINAL AND REAL TERMS
(1993-2004)
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HEALTH FINANCING

• To meet the target expenditure level
• Total Plan expenditure needs to grow annually
• Total health expenditure by 2011-12
• Centre 0.40 to 0.87 of GDP
• States 0.76 to 1.13 of GDP
• States should assign at least 7-8 of expenditure
  towards health
• Monitoring Outcomes vs Outlays Block Budgeting

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HUMAN RESOURCES FOR HEALTH
ISSUES

• Shortage of key cadres in rural areas
• Absenteeism and irregular staff attendance
• Lack of motivation or will to serve in rural
  areas
• Weak or non-existent accountability framework
• Non-transparent transfer and posting policy
• Inadequate systems of incentive for all cadres
  especially in difficult area postings
• Lack of career progress
• Lack of standard protocols
• Non-availability of drugs and diagnostic tests at
  health facilities

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HUMAN RESOURCES FOR HEALTH

• Possible Solutions

• State-specific human resource management policy
• Incentives for difficult areas
• System for career progression
• Devolution of power and functions to local health
  care institutions, local communities and
  Panchayats
• Improved drugs, diagnostics and tele-linkages
• Training and utilization of locally available
  paramedics, RMPs, VHWs and overall capacity
  building

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Capacity Building for Health

• As per requirement of States
• ASHA
• State Mission Officers State PMU Officials
• District Mission Officers District PMU
  Officials
• Medical Colleges PSM, OG, Pediatrics Faculty
• Faculty of Nursing Schools
• Public Health Specialists
• MOs 24 hrs PHC/FRU, EOC
• MTP, Mini Lap, NSV, EC
• Newer Aspects
• Lab Technicians
• ANM Reorientation EOC, JSY, ASHA etc.
• Traditional Birth Attendants

NRHM
H. System
Outside H. System

• Related Depts, Media NGOs
• District Collectors/PRIs/Civil Society
• IAS SCS Probationers

• State Health Department
• Professional Development Course for CMOs
• CME for MOs, Para-medicals and RMPs
• Professional Bodies other Organizations