TOWARDS HEALTHCARE FOR ALL INDIANS

GROUP 2
SRINIVAS NAIK- 216
SHRADDHA SHRIKANDE- 240
SPANDANA A- 243
SURBHI KOTHARI- 247
YUWALI DABUR-250
SONAKSHI JAISWAL-358
Research Questions
The relationship between health care and economic progress
and importance of efficient health care system for a country
Current state of Indian healthcare sector
key public health care programmes
Feasibility of universal health coverage scheme in India
Model suitable to Indian contexts


INTRODUCTION - RIGHT TO HEALTH

Principal Factors Influencing Accessibility

GEOGRAPHICAL
BARRIERS
ECONOMIC BARRIERS
CULTURAL
Universal Access
Availability
Acceptability & Dignity
Quality
Non-Discrimination
Transparency
Accountability Participation
Disease burden indicators Demographic And Socio Economic Indicators
HEALTH PROFILE OF INDIA
Healthcare finance indicators
Infrastructure indicators
HEALTH PROFILE OF INDIA CONTD.
HEALTHCARE SECTOR IN INDIA
Making healthcare affordable and accessible for all its citizens is one of the key focus areas of the
country today.
73% population lives in rural area and 26.1% below poverty line
The health care delivery segment is dominated by the private sector in India more than 70% of
the total delivery market
35 % of people who are hospitalized are BPL
40 % borrow/sell assets to pay for their care
Allocated fund for healthcare 4.1% of GDP, but the government funding is low - <1% of GDP
(compared to other countries)
High in-patient treatment cost, low insurance penetration and the high out-of-pocket expenditure
Central government making significant investments jointly with state govt. through NRHM,
NUHM, NHI, PPP
HEALTHCARE SECTOR IN INDIA Contd..

Milestones in Independent India
Primary Health centers - 1952
Family Planning 1952
National Health programs from 1957
National health Policy 1982 & 2002
NRHM 2005
PHFI 2008
Rashtriya Swasthya Bima Yojana 2008

Expenditure on Healthcare sector in India
Total expenditure on Health 5.2% of GDP
Public Health investment 0.9% of GDP
Budget allocation for health 1.3% of Central
budget
Government expenditure 25%
Out of pocket expenditure 75%
Central contribution to state 15%
Indias proposed health budget for
2013-2014 was 37,330 crore
2012-13 was 30,700 crore
HEALTHCARE DELIVERY SYSTEM IN INDIA
. Public health sector
a. Primary Health care
i. Primary Health centers
ii. Sub-centers
b. Hospitals / Health centers
i. Community Health Centers
ii. Rural Hospitals
iii. District Hospitals
iv. Specialist Hospitals
v. Teaching Hospitals
c. Health Insurance schemes
i. Employee State Insurance
scheme
ii. Central Govt. health scheme
d. Other agencies
i. Defence
ii. Railways
2. Private Sector
a. Private Hospitals, Polyclinic
b. General Practitioners and Clinics

3. Indigenous systems of medicines
a. Ayurveda and Sidda
b. Unani
c. Homeopathy
d. Un-registered practitioners

4. Voluntary Health Agencies

5. National Health Programmes


Total Public Out of pocket External resources Per capita Per capita
% of GDP % of total % of total % of total $ PPP $
2011 2011 2011 2011 2011 2011
Bangladesh 3.7 36.6 61.3 6.6 27 67
Brazil 8.9 45.7 31.3 0.3 1,121 1,043
China 5.2 55.9 34.8 0.1 278 432
India 3.9 31 59.4 1 59 141
Indonesia 2.7 34.1 49.9 1.2 95 127
Mexico 6.2 49.4 46.5 0 620 940
United States 17.9 45.9 11.3 0 8,608 8,608
Hospital beds
Physicians Nurses and midwives Community health workers
per 1,000 people per 1,000 people per 1,000 people per 1,000 people
2006-11 2006-11 2006-11 2006-11
Bangladesh 0.4 0.2 0.3 0.6
Brazil 1.8 6.4 .. 2.3
China 1.8 1.7 0.8 3.8
India 0.6 1 .. 1
Indonesia 0.3 2 .. 0.6
Mexico 2 .. .. 1.7
United States 2.4 9.8 .. 3
Health workers
INTERNATIONAL COMPARISON OF HEALTH PARAMETERS FOR THE YEAR 2011
Sector Direct employment Revenues/GDP
Million, 2000-2001 Per cent, 2000-2001
4.0
5.3
1.0
1.2
1.6
0.8
1.7
0.4
5.2
4.8
3.5
3.0
1.8
1.4
0.9
1.7
Healthcare
Education
Retail banking
Power
Railways
Telecom
Hotels, restaurants
Source: National Accounts Statistics, 2001; Manpower profile; CBHI; McKinsey analysis
IT
Healthcare is the largest
service industry in terms of
revenues and the second
largest after education in
terms of employment
THE HEALTHCARE DELIVERY SECTOR PLAYS AN
IMPORTANT ROLE IN THE ECONOMY TODAY




HEALTHCARE AND ECONOMIC PROGRESS
Health systems need financing and
investment to improve their
performance
National income has a direct effect
on the development of health
systems, through insurance coverage
and public spending
Countries with weak health and
education conditions find it harder
to achieve sustained growth
Emergence of deadly communicable
diseases has become an obstacle for
the development of sectors
Economic Growth
10% improvement in life
expectancy at birth
Rise in economic growth 0.3-0.4
percentage points a year

NEED FOR IMPROVEMENT IN HEALTH CARE
According to a 2005 report, 42% of Indias children below the age of three were
malnourished, which was greater than the statistics of sub-Saharan African region of 28% Malnutrition
Approximately 1.72 million children die each year before turning one. Reduced funding for
immunization leaves only 43.5% of the young fully immunized High Infant mortality rate
Only 11% of Indian rural families dispose of stools safely whereas 80% of the population
leave their stools in the open or throw them in the garbage
Poor sanitation
Prevalence of hepatitis B is estimated to be 2 8% of the population, Hepatitis C is estimated
to be in the range of 1.8-2.5%
Hepatitis
Dengue fever, hepatitis, tuberculosis, malaria and pneumonia, Diarrheal diseases, HIV
Increasing diseases
only 26% of the slum population has access to safe drinking water, and 25% of the total
population has drinking water on their premises. Safe drinking water
Malnutrition, Breast cancer, Stroke, polycystic ovarian disease, Maternal mortality
Female health issues
Postpartum maternal illness is a serious problem in resource-poor settings and contributes to
maternal mortality, particularly in rural India
Rural health
ISSUES IN HEALTHCARE REFORMS IN INDIA
The ratio of hospital beds to population in rural areas is fifteen times
lower than that of urban areas
The ratio of Doctors to population in rural areas is almost six times lower
than that in urban areas
Per capita expenditure on public health is seven times lower in rural
areas, compared to govt. health spending for urban areas
Only 38% of all PHCs have all the essential manpower and only 31% have
all the essential supplies
UNEQUAL DISTRIBUTION OF HEALTHCARE RESOURCES
Geographical distance
Socio-economic distance
Gender distance
ACCESS DIFFICULTIES TO HEALTHCARE
The growth of private healthcare sector has been largely seen as a boon,
however it adds to ever increasing social dichotomy
Denies access to poorer sections
Skews the balance towards urban biased, tertiary health services
with profitability overriding equality
One in three people who need hospitalization and are paying out of
pocket are forced to borrow money or sell assets to cover expenses
PRIVATE HEALTHCARE AND ECONOMIC INEQUALITY
ISSUES IN PUBLIC HEALTH INFRASTRUCTURE
Shortfall by 16% in PHCs and in 58% in CHCs
PHI not satisfying as service delivery since it is hampered by policy & management concerns
Non availability of staff
Poor availability and access
Very low use of massive PH infrastructure
Lack of accountability for quality of care
Recurring funding shortfalls
Weak referral system
Only 20% of OPD and 45% of inpatient care obtained from govt. health infrastructure while the
rest is from private sector
National Rural Health
Mission
Launched by the UPA
government on 12
th

April 2005
Decentralization
Communization
Public private
partnerships
Organizational
structural reforms
in health sector
Inter-sectoral
convergence
Mainstreaming
Indian medicine
system under
AYUSH
Objectives of the NRHM
It envisaged effective healthcare to the rural population with special focus on18 states which had weak
infrastructure and weak public health indicators
It aimed at reducing the infant mortality rate to 30 of 1000 live births, maternity mortality rate 100 per 100
thousand live births & total fertility rate to 2.1 by 2012
Operationalizing existing health facilities to meet Indian public health standards in each block of the country
Objectives comprised primarily of an increase in the public spending on health and family welfare from 0.9 % to 2-3
% of the Gross Domestic Product (GDP) during 2005-12.
Provisioning of Health services to households through Accredited Social Health Activists (ASHA),strengthening rural
public health facilities, enhancing capacity of panchayats to control and manage health facilities at local level
NRHM has categorised states into two groups: focus states and non-focus states. 8 north-eastern (NE) states are
focus states & other are major but non-focus states
Modus operandi of the scheme





Important and impacting link between the community
and the public health system
Are provided with induction training which includes
fieldwork and visits and an AYUSH drug kit
Promoting immunization referral and escorting services
for reproductive child health(RCH) and other delivery
programs
While they will be working as volunteers and will be
selected through Aganwadi workers and ANMS, they
will be given performance based incentives






To meet the drug shortages in rural areas, NHRM seeks
to revitalize and local health traditions mainstream
AYUSH infrastructure
Provides AYUSH & generic drugs to the rural areas
through public health centers(PHCs),community health
centers(CHCs)
Single doctor PHCs will be upgraded to two doctor PHCs
by incorporating an AYUSH practitioner,
They will act as an supplement for the allopathic staff if
the workforce is inadequate at the requirement





Decentralization will facilitate integrated delivery of
health services such as safe drinking water, sanitation,
nutrition and empowerment
The Integrated Health Action Plan is a major instrument
leading to the inter-sectoral convergence. It will involve
planning the district level through the involvement of
panchayats.
The main objective will be to involve ANMs, ASHAs and
representatives of PRIS & NGOs to prepare the action plan
and help in the implementation of the sane through self
help groups
Backward social classes should also be represented
ASHA scheme AYUSH scheme
DECENTARLIZATIONN
Success and failures of the scheme


1.Positive impact of ASHA on women opting for post and
pre-delieveries checkups
2. To play an activist role in communities encourages to
work as social workers rather than mere health workers
3.Duggal reports suggest that the expenditure for the
AYUSH scheme turns fourfold indicating success of the
scheme
4.Concerted attempt to incorporate AYUSH components in
the state programme implementation plans (PIPs) and in
different organisations like health societies, state health
missions, rogi kalyan samitis (RKS) and ASHA training
5. Able to involve panchayats in the planning process, led
to identification of important micro-level issues and
problems.








1.Deficiencies in the physical infrastructure
2.Shortage of equipment
3.Allotmnent of the funds to the SCs, PHCs & CHCs less
than stated
4.Deficiencies in manpower
5.Selection of the ASHAs on the basis of the influential
family backgrounds
6.26.6% of them received the 5
th
level of training
7.Old stock of medicines and no vital drugs provided with
8.Lack of AYUSH practitioners
integration with the allopathic doctors in the priority
areas
9.No representation of the backwards classes in VHSCs
10. No maintenance of the registers at PHC & CHC level
by health mangers
11.Overall didnt take into account the disparity based
on caste and gender and micro-politics







s
u
c
c
e
s
s
fa
il
ur
es
Lessons from the scheme
The annual expenditure on health
increased by 41% in 2006-07 & share
in GDP too increased from 0.9% to
1.05%
There is equitable distribution of the
funds in per capita terms but there is
comparatively more benefit to non-
focus states then focus states
Some states have also increased their
expenditure in the 12
th
finance
commission, have introduced various
schemes and programs at the state
level
States are the principals, as they
contribute to 70% of the total
government health spending
The ability to spend on the health
schemes is defined by the allocations
made by the center in the budget and
not the expenditure
Unutilized portions of the budget
should be accounted by the states
lying in their treasury so that
spending can be done alongside the
increased expenditure

Rashtra Swasthya Bima Yojana(RSBY)
For people living below poverty line, an illness not only represents
a permanent threat to their income earning capacity, in many
cases it could result in the family falling into a debt trap.
Objective of RSBY:
to provide health insurance coverage for
Below Poverty Line (BPL) families
to provide protection to BPL households from
financial liabilities
Salient Features of the Scheme:
1. Empowering the beneficiary RSBY provides the participating BPL household with freedom of choice between public
and private hospitals and makes him a potential client
2. Business Model for all Stakeholders a business model with incentives built for each stakeholder
3. Information Technology (IT) Intensive For the first time IT applications are being used for social sector scheme on
such a large scale. Every beneficiary family is issued a biometric enabled smart card containing their fingerprints and
photographs
4. Safe and foolproof The key management system of RSBY ensures that the card reaches the correct beneficiary and
there remains accountability in terms of issuance of the smart card and its usage
5. Portability The key feature of RSBY is that a beneficiary who has been enrolled in a particular district will be able to
use his/ her smart card in any RSBY empanelled hospital across India
6. Financing for RSBY - 75 percent by the Government of India (GOI), remainder by the respective state government.
Beneficiaries need to pay only Rs. 30 as the registration fee for meeting administration expenses
7. Cash less and Paperless transactions
8. Robust Monitoring and Evaluation

By paying only a maximum
sum up to Rs. 750/- per family
per year, the Government is
able to provide access to
quality health care to the
below poverty line population
The intermediaries like
MFIs and NGOs will be
paid for the services
they render in reaching
out to the beneficiaries
A hospital has the
incentive to provide
treatment to large
number of beneficiaries as
it is paid per beneficiary
treated
The insurer is paid
premium for each
household enrolled for
RSBY
Insurer Hospital
Government Intermediaries
Stakeholders of RSBY
MODUS OPERANDI OF RSBY
Claim Settlement
Utilization of Services by Beneficiaries
Empanelment of Health Care Providers
These hospitals should install necessary hardware and software so that smart
card transactions can be processed
The insurer must also provide a list of RSBY empanelled hospitals, to the
beneficiaries at the time of enrollment
Enrollment of Beneficiaries
Mobile enrollment stations are set up at local centers at each village to
collect biometric information (fingerprints) and photographs of the members
The list of enrolled households is maintained centrally
Selection of Insurance Company
competitive public bidding process by State Government
The insurer with the lowest financial bid (annual premium per household) is
selected
Preparation of BPL Data
State Government must prepare and submit the BPL data in an electronic
format specified by GOI
state governments alone are responsible for the accuracy of their BPL lists
CHALLENGES
1. The RSBY faces the same challenges faced by other health insurance schemes around the world
2. Provider-induced demand
3. Hospital accreditation
4. Quality control
5. Negligence or even hostility by certain state governments
6. Widespread lack of compliance with rules regarding enrolment

LOOKING TOWARDS THE FUTURE
1. The potential effects go beyond health insurance and even beyond the health sector
2. Greater institutional capacity is required to addressing the immediate challenges
3. This capacity falls into two categories improved monitoring systems and increased human resources
4. The approach and platform of RSBY may also be useful in delivering other social programs. An obvious
candidate is the Public Distribution System
5. Using the RSBY approach to PDS could lead to improvements through two channels competition and
accountability
6. efficiency gains to be attained in converging on a single platform rather than duplication administrative
structures
Universal Health coverage (UHC)
Equitable access for all Indian citizens, resident in any part of the country, to affordable,
accountable, appropriate health services of assured quality as well as public health services
addressing wider determinants of health, with government being the guarantor and enabler
Critical factors for UHC
Achieving sustainable UHC without addressing the social determinants of health is difficult
Gender insensitivity and gender discrimination needs to be addressed
Main Underlying Principles of UHC

Universality Equity
Non exclusion
and non
discrimination
Comprehensive
care
Financial
protection
Protection of
Patients Rights
Accountability
and
transparency
Community
participation
Consolidated and
strengthened
Public health
provisioning
Restructure the physical and financial norms to ensure quality, universal reach and
access to health care services
Reforms for health-care delivery services
Constructive participation of communities and the private-for profit and non-profit
sectors in the delivery of health care
System for access to essential drugs, vaccines etc
Proper framework for health financing and financial protection
Not viable because:
Difficult to identify the target- failure of UIDAI
Inability to effectively utilise the provided funds
Inability to meet the set standards of safety case of penalising Ranbaxy Laboratories Ltd
Import duty on medical instruments has not been lowered- preventing eady development by the
private sector
Neglect of healthcare related to non-communicable and chronic diseases, accidents, injuries and
ageing of the population.
Financing and monitory efficiency has become the central issue to shape the services rather than
peoples health needs and the inequalities they face in accessing healthcare and achieving a
reasonable health status.
Surveys have shown the inadequacy of our health infrastructure and that health workers are not
staying where they are posted
lack of services is underfunding and poor management of medicines, leading to a lack of availability.
Conditional cash transfers, even if they reach all those eligible to benefit from them, cannot cater to
differential healthcare needs of families with varied morbidity rates and patterns, specifically in the
context of the techno-centric healthcare provisioning.
Universal Health Coverage(UHC)
O
b
j
e
c
t
i
v
e
s

UHC- Planning
Increase public spending
Improve human resources in India
Achieve who stated density of 23 health workers per 1000 people
Current situation
Procedure
Train selected Ayurvedic, Unani, siddha and homeopathy doctors to support primary care
Set up 187 new medical colleges in ten years, specifically in currently underserved districts like Bihar, U.P.
Regulation
Establish national health regulatory and development authority to regulate and monitor.
Similar bodies at state level to be set up
Access to medicine, vaccines and technology
Enforce price controls, regulate essential drug prices
Expand essential drug list
Strengthen public sector manufacturing capacity
Safeguards for essential drugs production provided by Indian patents law, trips agreement



Current WHO Density
Doctors 6
Mid wives & Nurses 13
Total 19 23
Difficult to identify the target- failure of UIDAI
Inability to effectively utilise the provided funds
Inability to meet the set standards of safety case of penalising Ranbaxy Laboratories Ltd
Import duty on medical instruments has not been lowered- preventing ready development by the private
sector
Neglect of healthcare related to non-communicable and chronic diseases, accidents, injuries and ageing
of the population.
Provision for UHC not viable in India

Provision for UHC not viable in India

Financing and monitory efficiency has become the central issue to shape the services rather than
peoples health needs and the inequalities they face in accessing healthcare and achieving a
reasonable health status.
Inadequacy of health infrastructure and that health workers frequent request for transfer
lack of services is underfunding and poor management of medicines, leading to a lack of
availability.
Conditional cash transfers, even if they reach all those eligible to benefit from them, cannot cater
to differential healthcare needs of families with varied morbidity rates and patterns, specifically
in the context of the techno-centric healthcare provisioning.
Change in Financing Options
Private providers opting for inclusion in the UHC system
would
At least 75 per cent of outpatient care and 50 per cent of in-patient Services
under NHP
The services would be Reimbursed at standard rates as per levels of services
offered
Activities would be regulated and monitored
Out-patient (up to 25%) and in-patient (up to 50%) coverage, service
providers offer additional non-NHP services payments from individuals or
through Privately purchased insurance policies
Institutions participating in UHC commit to provide only the cashless
services related to the NHP and not provide any other services which
would require private insurance coverage or out of pocket payment
Suggestions
The national government should increase health funding from less than one per cent to two to three
per cent of the GDP.
More efficient systems
Doctors and other medical workers should be penalised by authorities like Indian Medical
Association for errant practices
Dedicated department for rigorously identifying, implementing cost effective and efficient methods
for detection and curing
Incentives for doctors and nurses who work in remote areas
More schemes like Chiranjeevi in Gujarat
Suggestions
Recommendations
Improvement in financial aspects through extensive insurance coverage( currently 25%)
Healthcare resources gaps filled(aim for bed density of 2.1 per 1K in rural and 3.8-4.2 per 1K in
urban areas)
Overcome workforce shortages: incorporating the AYUSH and Rural Medical Practitioners into
mainstream healthcare at a national level
Greater spending on Healthcare and a much lower level of OOP
Focus on quality by standardisation of treatment practices, clinical establishments and
malpractice mitigation
Better integration of Health facilities-tracking patient treatment
Push for long-term care models as opposed to present event based models. This helps in
tackling the non communicable diseases burden.
Increasing awareness of disease, prevention and treatment
Scaling up of public infrastructure
Strong regulatory framework to shape efficiency and performance levels of the private sector
PPP- A viable option for India- Our Stand
State
Quality Control Roles:
Regulator
Licensor
Accreditor
Increase in public
expenditure on health
Investment in
infrastructure in rural
areas
Incentivize private entry
in rural areas
Promotional schemes for
banking and financial
sector for expansion of
health insurance
coverage in India
Private players
Investment in Research,
encouraged by the State
Investment in
infrastructure, both in
urban and rural areas
Quality healthcare, a
motivation for
accreditation
FII and FDI boost
Medical tourism- growth
strategy
Standardized policy on
admission of patients
Telemedicine




Medical Colleges
India leads the world in
the number of medical
colleges
At present, these
emphasize only on
specialty care
A reorientation of
medical education
towards the social angle
of healthcare
Create a separate cadre
of healthcare workers for
rural areas (Bachelor of
Primary Health Practice)
Telemedicine