Health and Healthcare in India

Ravi Duggal
rduggal57@gmail.com

Preamble
Health is one of the goods of life to which man has a right; wherever this concept prevails the logical sequence is to make all measures for the protection and restoration of health to all, free of charge; medicine like education is then no longer a trade it becomes a public function of the State ... Henry Sigerist

The Development Paradigm

The notion of the welfare state
Socialist pattern of development Limited entitlements approach

Support to private capital growth

The ruralurban planning divide CDP and rural development Social sectors neglected Persistence of poverty

Healthcare Development
The legacy of Joseph Bhore The colonial continuum enclave

pattern of development Constitution: Concurrent Crowding The Centres role The program based approach and elaborate bureaucracies The rural--urban dichotomy Consolidation of private healthcare

Heath Policy and Planning

Health policy through 5-year Plans

and Committees Dilution of Bhore recommendations Program based approach Revival under Minimum Needs Program and post Alma Ata reducing the rural/urban gap The first National Health Policy1983 The decline of public healthcare

Health Policy
The big leap of the private health

sector 2002 Health Policy Common Minimum Program Rural Health Mission

 Primary Healthcare VHW- Subcentre PHC (rural) VHW- Health posts (urban) National programs

Health System and Structures - Public

Secondary and Tertiary care Rural Hospitals District and sub-district hospitals Teaching Hospitals

Public Health Administration Public Health, Medical and Medical Educatn

Financing : General taxes/Social

security

Health Systems and Structures - Private

Private Provision GPs and Consultants Private for-profit Hospitals Private not-for-profit hospitals !! Multiple systems unified practice! Unqualified pracxtitioners Traditional practitioners Financing Out of pocket Private Insurance Social security

India Health Profile...

Facts and Figures
Doctors (all systems): 1.3 mi. (769 per

doc) Doctors (allopathy): 540,000 (1852 per doc) Nurses: 580,000 (1724 per nurse) Hospital Beds: 950,000 (1053 per bed) Public Expenditure: $7 bi. (1% of GDP) Private Expenditure: $37 bi. (5.5% of GDP) Health Outcomes: IMR-72, CDR-9, CBR-24

Indias Global Share In

Population Total deaths Child deaths Maternal deaths TB cases Leprosy cases Persons with HIV % 17 17 23 20 30 68 14

Under 5 & Maternal Mortality

Country Korea Malaysia Sri Lanka China Indonesia India Bangladesh Pakistan Nepal Under 5 Mortality 14 14 19 43 75 95 115 127 131 Maternal Mortality Ratio 30 34 30 95 390 440 850 340 1500

Disease Burden
17 50 33

India

China

18

18

Communicable Non-Communicable

64

16 44 40

Injuries

12

Low & Middle Income

High Income

81

Communicable Disease Burden

8

INDIA 1998
17

Infectious and parasitic diseases Respiratory Infections Maternal Conditions Perinatal Conditions Nutritional deficiencies

50 6

19

Non-Communic.Disease Burden
2% 3% 8% 2% 6% 10% 2% 26%
A. Malignant neoplasms B. Diabetes mellitus C. Neuropsychiatric disorders D. Sense organ disorders E. Cardiovascular diseases

7%

F. Respiratory diseases G. Digestive diseases H. Musculo-skeletal diseases I. Congenital anomalies J. Oral diseases

30%

4%

K. Other noncommunicable diseases

Public Facility Utilisation

Medical Care
Outpatient
Decline Poor, Rich,

care share is only 23% and Inpatient share is 45%

greater in inpatient share larger users of PHCs and urban public hospital OPDs larger users of inpatient care
Declining

public spending and investment impacting on utilisation

Public Facility Utilisation

Preventive Care Over 75% share for services like child immunisation, contraceptives ANC and child birth 50% share Coverage levels for above services low Urban coverage twice better

Use of Private Care

Outpatient

care nearly 80% share Wide inter-state variations Inpatient care 55% share and growing rapidly Across classes private care is largest category Rich use private care in much larger proportion but rich are also the largest users of public hospitals for inpatient care Very low preventive care, but increasing share in ANC and childbirth

Poverty And Health 1

60% 50% 40% 30% 20% 10% 0%

48%

Malaria
16%

60% 50% 40% 30% 20% 10% 0%

55%

TB
12%

Low Standard of Living

High Standard of Living

Low Standard of Living

High Standard of Living

Poverty And Health 2

Ri c 60 M 20 id

he 20 %
0

% -4

0%

dl

20

% -8

0%

st

20

Po o

re

st

10

15

20

Percent With Regular Use

Smoking Tobacco (non-smoking) Alcohol

Poverty And Health 3

Who Benefits From Public Subsidies?
35 30 25 20 15 10 5 0 33.1 25.6 17.8 13.4 10.1

Share of Public Subsidy

Poorest 20%

2nd

3rd

4th

Richest 20%

Income Quintiles

Poverty And Health 4

Indebtedness For Hospitalisations
Rajasthan Madhya Pradesh Gujarat West Bengal

BELOW POVERTY LINE HOUSEHOLDS

Public Private

Uttar Pradesh Haryana All India Maharashtra Kerala Bihar Karnataka Tamil Nadu Andhra Pradesh North East

10

20

30

40

50

60

70

80

Public-Private Share of Care

Immunizations Antenatal Care Institutional Deliveries Hospitalization Outpatient Care
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100 %

Public-Private Sector Shares

Private Public

Hospitalisation Share
Richest 20%
33%

60%-80%

45%

Middle 20%

52%

20%-40%

58%

Poorest 20%

61%

500

1000

1500

2000

2500

3000

3500

4000

Hospitalizations Per 100,000 Population

Public Hospitals Private Hospitals

Healthcare outcomes 1 Maternal and Child Health

Social Group
LOW MEDIUM HIGH ALL SC ST OBC OTHER

No ANC

TFR

IMR

U-5 Mortality

Completed Immunisatn

Delivery by Doctor

45.1 32.8 12.4 34.0 38.2 43.1 34.8 27.9

3.37 2.85 2.10 2.85 3.15 3.06 2.83 2.66

88.8 70.3 42.7 73.0 83.0 84.2 76.0 61.8

130.0 94.6 51.5 101.4 119.3 126.6 103.1 82.6

30.4 43.2 64.7 42.0 40.2 26.4 43.0 46.8

15.8 31.1 60.9 30.3 23.5 14.5 31.8 37.3

Healthcare outcomes 2 Nutrition

Percent Women 15-49
Children < 3 yrs % below -3SD

Social Group
LOW MEDIUM HIGH SC ST OBC OTHER ALL

Below 145 cms

Below BMI 18.5kg/m2

Any Anemia

Wt. For Age

Ht. For Age

Wt. For Height

17.7 12.5 7.5 17.0 13.5 13.5 10.9 13.2

48.1 35.6 17.3 42.1 46.3 35.8 30.5 35.8

60.2 50.3 41.9 56.0 64.9 50.7 47.6 51.8

25.3 16.5 6.7 27.2 26.0 18.3 13.8 18.0

29.8 22.4 10.7 27.5 27.6 23.1 19.4 23.0

3.9 2.4 1.5 3.0 4.4 3.4 1.8 2.8

Expenditure & outcomes

Total Health Public health Expenditure expenditure as % of GDP as % of total India China Sri Lanka Malaysia Korea 5.0 2.7 3 2.4 6.7 17 24.9 45.4 57.6 37.8 U-5 Life Expectancy mortality Male Female 95 43 19 14 14 59.6 68.1 65.8 67.6 69.2 61.2 71.3 73.4 69.9 76.3

Share Of Expenditure
Public-Centre 3% Private Investment/ Insurance 2%

Public-States 10%

Private Out-ofpocket 85%

India Current Scenario: Health

Resurgence of Communicable Diseases Declining Public Investments and

Expenditures in Health and Healthcare Breakdown of the Public Health System Access to Basic Healthcare Declining Absence of Regulation and Control, and Quality Standards in Private Healthcare Corporatisation and Rising Costs of Healthcare and Changed Character of the Economy

India Current Scenario: Disability

Physical disability affects 2% of the population and the trend is upwards with a worsening economic scenario Mental disability affects about 3% of the population and another 1% suffers mental illness due to increased stress of the changing environment Social Disability based on caste, gender and community getting worse under the current socio-economic dispensation Other disabilities like, HIV/AIDS, elderly etc.

Declining Public Investment and Expenditures

Minimum Needs Program phase

of expansion Liberalisation phase for growth of private capital and stagnation of public investment Enter World Bank and globalisation

Reduced Level of Expenditures The impact of the fifth pay commission

Centre Abdicates Responsibility State governments follow footsteps

Health Sector Reforms

Reform Processes Underway World Bank assisted Health Systems Development Projects in 5 States New public management Systems societies, contracting out (mission approach) Initiative towards private sector regulation - quality, accreditation etc. User Fees Opening up of Insurance to the Private Sector Collaborations with the Private Sector RCH Approach??

Health Sector Reforms.

Issues Raising levels of Allocations Improving Allocative Efficiencies Improving Technical Efficiencies Improving Quality of Care Enhancing Access to services removing rural/urban disparities Improving consumer satisfaction Reducing Costs Regulating the private health sector

Reforming the Existing System

Restructuring and reforms

Organising a system Public-private mix Referral system Standards and regulation Single payer mechanism

India Future Health Priorities

Priorities for making it work

An Act of Parliament - Health Authority Tackling the medical profession Licensing, registration, minimum standards Integration of systems Continuing medical education Pricing mechanisms Raising additional resources

Strategies and Approaches

Right to Health and Healthcare Awareness Raising and Participation

of Civil Society Groups Organising and Educating Medical Profession Healthcare as part of Social Security Universal Access to Healthcare New Public Management Systems and Governance Structures Innovations in Health Financing