India

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Indias Health Challenges
Will Universal Health CoverageProvide The
Platform For Response?
Prof. K. Srinath Reddy President, Public Health
Foundation of India, President, World Heart
Federation
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Indias Health Status Lags Behind Economic
Growth And Threatens To Slow Down Development
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India is Under performing its Income Group Peers
in Health
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We lose 1,400,000 infants every year, 4000 every
dayequivalent to 12 full Jumbo Jets crashing
every day. Our children die early, prematurely,
and needlessly
SOURCE WHO 2012
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And has Lagged Behind
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On providing basic immunization to our children,
we are behind Bangladesh, Nepal, Thailand, Ghana,
Pakistan, to name a few
30 of children in India go without DPT coverage,
50 without full immunization
DPT immunisation rate of children covered
China
99
Sri Lanka
99
Thailand
99
Brazil
98
Botswana
96
Bangladesh
95
Ghana
94
Myanmar
90
Pakistan
88
Nepal
82
India
72
Nearly 100 children covered in China, Brazil,
Sri Lanka or Thailand
Source WDI. WHO
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Despite all the progress, 40 children in India
are undernourished. A national shame!
25 of Indias newborns start life with Low Birth
Weight
Of those who survive the first year, 43 are
underweight, and 66 anaemic by age of three
Undernourishment severely limits cognitive
development and increases vulnerability to
heart disease diabetes
Brazil
2
China
7
Thailand
7
Ghana
14
Sri Lanka
22
Sub Saharan Africa
28
Nepal
39
Very few go undernourished in China, Brazil or
Thailand. We do worse than sub-Saharan Africa
Bangladesh
41
India
43
Source WDI. WHO
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Our maternal mortality rate is 4X of China and
Brazil, 6X of Sri Lanka
We only compare favorably with Pakistan, Gabon
and Cambodia
60,000 plus mothers die every year. More deaths
in a week than in a whole year in Europe
A sacrifice to give life a preventable tragedy
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Incidence and prevalence of infectious diseases
remains high
TB incidence

1. 2 million new cases every year
2. Incidence rate 200-300 more that of China and
   Brazil. In the range of Afghanistan and Pakistan
3. Drug resistant TB a major threat

Malaria prevalence

1. 9.7 million cases, with 40,000 deaths every year
   (recent ICMR study)
2. Over 70 of India at risk of malaria infection

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In Chronic (non-communicable) diseases such as
diabetes and cardiovascular disorders, we are
facing advancing epidemics
Diabetes epicenter of the world 61 million
cases in 2011 to rise to 101 million in 2030
Every 8th adult has or is at high-risk. 40-60
working age group most affected
India could lose US 237 billion (over 2005-2015)
to cardiovascular disease and diabetes (WHO)
Potentially productive years of life lost due to
cardiovascular deaths (36-64 years age group) In
millions
Underlying risk factors - unhealthy diets,
physical inactivity, alcohol consumption and
tobacco use
2000
2030
If neglected, this will be a source of continuing
productivity loss
India
China
Russia
USA
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Quality of Primary Care

• Scored For
• 24 Hour Availability of Services
• Clinical Staff In Position
• Training In Past 5 Years
• Basic Infrastructure
• Equipment
• Essential Drugs

India 52 Low Performing States 48 High Preforming States 57 North East 53 Powell T et al EPW (May 2013)

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Public health spend not yet a high priority. Our
public expenditure on health is among the lowest
in the world
Country Public expenditure on health as of GDP Per capita public expenditure on health (PPP)
Sri Lanka 1.8 87
India 1.2 43
Thailand 3.3 261
China 2.3 155
More funding needed with right investments such
as Primary healthcare Education and training
facilities medical and public health
Availability of essential drugs to all
Expansion of universal health coverage
Need for doubling of public spending on health to
at least 2 of GDP by end of 12th Plan
Source WHO database, 2009
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Low Public, High Out of Pocket Health Expenditure
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Unaffordable and unsustainable healthcare costs
70 of health spend from own pockets on health.
Out of pocket (OOP) expenditure amongst highest
in the world
Over 60 million people thrown below the poverty
line every year due to OOP on health
Over 40 of hospitalised persons had to borrow
money or sell assets to pay for their care
28 of rural residents and 20 of urban residents
had no funds for health care
Huge social burden on the poor
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High costs of out-patient and medicine costs
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Current scenario of Doctors

• Number of Doctors 8.58
  lakh (as per IMR)
• Those available 6 -
  6.5 lakh (75) (approx)
• Present Doctor Population Ratio 0.5 per 1000
• Target by 2025
  0.8 per 1000
• China 1.6 per 1000
• USA 2.6 per 1000
• UK 2.3 per 1000
• Sweden 3.3 per 1000

• Additional Doctors required 4 lakh by 2020
• 1.5 lakh in 50,000 PHCs
• 0.8 lakh in 12,500 CHCs
• 1.1 lakh in 5,642 SDH/DH
• 0.5 lakh in 800 MCHs

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Current Scenario of Nurses

• Nurses registered 11.2 lakh
• Available 9 lakh (Approx)
• Nurse-Population Ratio 0.4 per 1000
• (Nurses ANM) Vs Doctor Ratio 1.5 1
  (Desired 31)
• Target by 2025 2.2 1
• --------------------------------------------------
  -------------------------------------
• Brazil 31
• South Africa 51
• USA 31
• UK 51
• --------------------------------------------------
  ------------------------------------------
• Additional Nurses required 16.2 lakhs by 2020

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Allied Health Workforce shortfall- National
estimate
Allied Health Workforce Category Demand Supply Gap Gap
Unadjusted Efficiency-Access Adjusted
Ophthalmology related 145,236 17,678 127,558 136,039
Rehabilitation /other related 1,862,584 40,265 1,822,319 1,841,637
Surgical intervention technology 205,088 7,215  197,873 208,618
Medical lab technology 76,884  15,214 61,670 70,603
Radiography and imaging technology 23,649 4,352  19,297 20,971
Audiology/ speech language pathology 10,599 3,263  7,336 8,901
Medical technology 239,657  3,587 236,070 237,791
Dental assistance related technology 2,048,391 6,243 2,042,148 2,045,143
Surgery and anesthesia related technology 862,193  4,050 8,58,143 860,086
Miscellaneous 1,074,473 181,511  8,92,962 980,045
Total 45,14,271 64,09,834
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Our Definition of UHC

• Ensuring equitable access for all Indian
  citizens resident in any part of the country,
  regardless of income level, social status,
  gender, caste or religion, to affordable,
  accountable and appropriate, assured quality
  health services (promotive, preventive, curative
  and rehabilitative) as well as public health
  services addressing wider determinants of health
  delivered to individuals and populations, with
  the government being the guarantor and enabler,
  although not necessarily the only provider, of
  health and related services.

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Universal Health Coverage is when ALL people
receive the quality health services they need
without suffering financial hardship    
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National Rural Health Mission (NRHM)

• SHORTFALLS
• Focus on maternal and child health other
  primary health care needs not addressed
• Quality of care not assured, even for
  institutional deliveries
• Health workforce deficiencies (numbers skills)
  affect delivery of services
• Impact on out-of-pocket not demonstrated
• Continuum of care (10 20 30) not developed

• HIGHLIGHTS
• Decentralized planning and implementation through
  community participation (through various
  initiatives such as ASHA, VHSC, SHGs)
• Pro poor-based equitable systems
• Emphasis on convergence
• Flexibility and adequacy of central funding with
  accountability framework to ensure public action
• Judicious mix of dedicated budget lines untied
  funds to all public institutions
• Provision of incentives for CHWs in hard-to-reach
  areas
• Monitoring progress against standards (such as
  IPHS)
• Targeted interventions to measureable outcomes,
  reviewed annually through the CRM process

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Rashtriya Swasthya Bima Yojna (RSBY)

• HIGHLIGHTS
• Indias first social-security scheme with a
  profit motive, involving insurance companies,
  hospitals, state governments and the Centre
• Encourages increased contributions to health and
  augments financial resources of the State
  governments
• Attempts to address several lacunae regarding
  enrolment, utilisation levels and fraud control
• Mandatory enrolment and technology-based cashless
  policies address the problem of risk selection
  and selective rejection of claims by insurers.

• SHORTFALLS
• Low coverage with financial protection available
  only for hospitalization, and not for out-patient
  care
• Focus on hospital networks rather than primary
  care services
• Difficult to maintain quality of healthcare at
  accredited hospitals due to induced demand and
  fraud
• Potential for inferior health outcomes and high
  healthcare cost inflation

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Key Recommendations of HLEG

• Adopt UHC As A National commitment - To Be
  Initiated in 2012 and Fulfilled By 2022
• Commit 2.5 of GDP As Public Financing for Health
  During The 12th Plan and suggest MOHFW prepare a
  road-map for implementation of the UHC
• Prioritize Primary Health Care For Financing And
  Human Resource Development Deployment
• Conduct A Review of Government Funded Insurance
  Schemes Propose A Plan for Their Integration
  Into The UHC Framework
• Provide Essential Drugs Free Of Cost
• Establish Credible And Effective Regulatory
  Systems For Administering UHC (Accreditation
  Standards Financing Drugs Information Systems
  ME)
• Enable Community Participation By
  Institutionalising Health Councils Health
  Assemblies With Government Support
• Facilitate focusing future MOHFW agendas on a)
  Gender -UHC though a gendered lens b) Urban
  Health c) Social Determinants Of Health (Health
  Promotion Protection Trust), while preparing
  its implementation plan

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Universal Health Coverage By 2022 The Vision

• Universal Health Entitlement for every citizen -
  to a National Health Package (NHP) of essential
  primary, secondary tertiary health care
  services that will be principally funded by the
  government
• Package to be defined periodically by an Expert
  Group can have state specific variations

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Impoverishment due to OOP on Drugs, 2011-12
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Issues for Debate(Financing)

• Tax funded model Vs. Insurance Model
• Financing and Impact of Government Funded
  Insurance Schemes
• Role of Private Insurance
• Fee for Service Vs. Per Capita Vs. ?
• User Fee Exemption All / Poor only?
• Role of Central and State Governments

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Issues for Debate(Provision)

• Role of Public and Private Sectors
• Corporatization of Public Sector Healthcare
  Facilities
• Managed Vs. Integrated Care
• Continuum of Care Overcoming Fragmentation
• Extent of Integration of Health Programmes
  (NRHMNUHM ? NHM)

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Options

• Options based on coverage (who is covered for
  what)
• All the services to all the population
• Some services to all the population
• Some services to certain sections of the
  population
• Provision
• Within the existing government health services
  (in an enhanced manner)
• Through the private sector (Purchasing,
  contracting, PPP)
• Finance
• Enhanced budgetary support based on evidence
• Pooling (insurance) Increasing existing benefit
  package, coverage under existing schemes
  (coverage, benefits etc. under RSBY other
  schemes)
• Incentives (payment for performance), Case based
  payment, capitation etc.
• Based on the options - populations to be covered,
  services (benefit package) to be provided, method
  of delivery, estimation regarding financial
  requirements

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Options

• Options could be a mix of delivery systems
  providing the services selected from the health
  package.
• Realignment convergence of programmes and
  schemes
• Development of a essential health package of
  services into various categories to choose (e.g.
  primary, secondary, tertiary, etc.) and move
  towards it systematically phased manner.
• Costing of the benefit package
• Broad roadmap on how best to provide the services
  to the populations and what needs to be
  strengthened or systems in place and their
  implications.

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Human Resources For Health

• Increase numbers and skills of frontline health
  workers
• Doubling of ASHAs and ANMs
• Male MPW and Mid Level Health Professional (3
  year trainee)/AYUSH at Sub-Centre level
• Expand Staff (esp. nurses) at PHC and CHC
• Nurse-Practitioners for Urban Primary Health Care

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Human Resources For Health

• Establish new medical and nursing colleges in
  underserved states and districts with linkage to
  district hospitals Increase the number of ANM
  schools
• Scale up number and quality of Allied Health
  Professional training institutions
• Establish District Health Knowledge Institutes to
  coordinate and conduct training of different
  categories of health workers
• Develop Public Health and Health Management
  Cadres (District, State, National)

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Registry
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If we dont create the future, the present
extends itself - Toni Morrison (Song of
Solomon)