Issues in health sector;

India

Dr. P. P. Doke
M.D., D.N.B., Ph.D., FIPHA
Professor, Department of Community Medicine
BVDU Medical College, Pune

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 EXPECTATIONS: 2005 - 2012

•Universal Health care, well functioning health

care delivery system.
•IMR to be reduced to 30/1000
•MMR to be reduced to 100/100,000 live births
•TFR to be reduced to 2.1
•Malaria Mortality Reduction Rate – 60%
•Kala Azar to be eliminated by 2010,
•Filaria reduced by 80 % by 2010
•Dengue Mortality reduced by 50%
•RNTCP-2 – maintain 85% cure rate
•Responsive & Functional Health System

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 Expectations later:
targets under 12th plan
Indicator Target

IMR 25

MMR 100

Anemia 28

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Disease Twelfth plan goal

Tuberculosis Reduce annual incidence and mortality by half

Leprosy Reduce prevalence to <1/10000 population and incidence to zero in

all districts
Malaria Annual Malaria Incidence of <1/1000
Filariasis <1 per cent microfilaria prevalence in all districts

Dengue Sustaining case fatality rate of <1 per cent

Chikungunya Containment of outbreaks

Japanese Reduction in mortality by 30 per cent

Encephalitis
Kala-azar Elimination by 2015, that is, <1 case per 10000 population in all
blocks
HIV/AIDS Reduce new infections to zero and provide comprehensive care and
support to all persons living with HIV/AIDS and treatment services
for all those who require it.

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 Table: Health Problems of India, Mortality

Indicator Status-1990 Goal-2015 Status (Year)*

Infant Mortality Rate 80 27 34 (2016)

Under-five Mortality Rate 109 42 43 (2015)

Maternal Mortality Ratio 437 109 167 (2011-13)

* Source (Office of the Registrar General 2013)

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 Top leading causes of death, 2016
1.Heart disease
2.Chronic obstructive pulmonary disease
3.Diarrhoea
4.Stroke
5. Lower respiratory infections
6. Tuberculosis
7. Neonatal preterm birth
8. Self harm
9. Road injuries
10. Other neonatal conditions
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 Health indicators; Status (2016)
(S.R.S. September 2017)
S. no. State Birth Death Infant
rate rate mortality
rate
1 Kerala 14.3 7.6 10
2 Uttar Pradesh 26.2 6.9 43
3 Bihar 26.8 6.0 38
4 Madhya Pradesh 25.1 7.1 47
5 Maharashtra 15.9 5.9 19
India 20.4 6.4 34
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 RCH present status
NFHS - 1 NFHS - 2 NFHS – 3
Indicator
(1992-93) (1998-99) (2005-06)
Median Age at Marriage 16.1 16.7 -
Total Fertility Rate 2.9 2.5 2.1
Current use of any contraceptive method 54.1 60.9 66.9
Percent with total unmet need for Family
14.1 13.0 9.6
Planning
Delivery by Trained staff 53.1 59.5 70.7
% of children age 0-3 months exclusively
30.5 38.5 -
breastfed
Fully vaccinated children 64.1 78.4 58.8
Percent of children underweight (< 3 yrs) 51.4 49.6 39.7
Any Antenatal Care 85 91 93
Institutional Delivery 44.5 52.6 66.1
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 Challenges; Health transition
 Demographic; high to moderate birth rate
and moderate to low death rate, ageing
population increasing, dependency ratio,
declining sex ratio
 Epidemiological;
1. Continued agenda C.M.P.
2. Non-communicable diseases
 Various states at different levels of
transition
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 C.M.P.
1. Communicable diseases; emerging and
remerging diseases (malaria, dengue
tuberculosis, H1 N1, STI/RTI & HIV/AIDS)
Concern; resistance development
2. Maternal and malnutrition, anemia
3. Perinatal problems resulting in high mortality

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 Non communicable diseases
 Life style diseases
 Obesity, diabetes, hypertension resulting in to
ischemic heart diseases and cerebro vascular
stroke
 Malignancies
 Mental disorders
 Accidents
 Tobacco/drug abuse related
 COPD/Pollution related
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 New diseases
 Cost of treatment per episode very high
 Squelae common
 Long term treatment required
 Maintenance also costly
 Financial provision very difficult

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 Situational analysis
 Public health expenditure in India
has declined from 1.3% of GDP in
1990 to 0.9% of GDP in 1999.
 The Union Budgetary allocation for
health is 1.3% while the State’s
Budgetary allocation is 5.5%.

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 Situational analysis
 Union Government contribution to
public health expenditure is 15%
while States contribution about 85%
 Vertical Health and Family Welfare
Programmes have limited
synergisation at operational levels

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 Situational analysis
 Lack of community ownership of
public health programmes impacts
levels of efficiency, accountability
and effectiveness Lack of integration
of sanitation, hygiene, nutrition and
drinking water issues

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 Situational analysis
 Hospitalized Indians spend on an
average 58% of their total annual
expenditure
 Over 40% of hospitalized Indians
borrow heavily or sell assets to cover
Expenses
 Over 25% of hospitalized Indians fall
below poverty line because of
hospital expenses
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 Situational analysis
 Only 10% Indians have some form of
health insurance, mostly inadequate
 Curative services favour the non-poor: for
every Re.1 spent on the poorest 20%
population, Rs.3 is spent on the richest
quintile.
 Population Stabilization is still a challenge,
especially in States with weak
demographic indicators
 There are striking regional inequalities

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 NRHM: NHM
 Seeks to provide effective
 Healthcare to rural population
throughout the country with special
focus
 On 18 states, which have weak public
health indicators and/or weak
Infrastructure.

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 EAG states
These 18 States are Arunachal
Pradesh, Assam, Bihar, Chhattisgarh,
Himachal Pradesh, Jharkhand, Jammu
& Kashmir, Manipur, Mizoram,
Meghalaya, Madhya Pradesh,
Nagaland, Orissa, Rajasthan, Sikkim,
Tripura, Uttaranchal and Uttar Pradesh

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 THE VISION

 The Mission is an articulation of the

commitment of the Government to
raise public spending on Health from
0.9% of GDP to 2-3% of GDP

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 THE VISION

• Architectural correction in health care delivery

& financing
• Improve availability of quality health care in
rural areas
• Synergy between health and determinants of
good health
• Mainstream the Indian Systems of Medicine.
• Capacity Building.
• Involve the community in the planning
process.
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 WHAT’S NEW
 Public Health expenditure - 2 – 3 % of
GDP
 Merger of societies at State / District level
 Integration of existing schemes
 Fully trained ASHA in each tribal village/
habitation.
 Decentralized planning
 Intersectoral convergence with other
Health Determinants
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 WHAT’S NEW
• Community ownership of Health facilities

• Up gradation of CHCs / PHCs to IPHS

• Mainstreaming of AYUSH

• Partnership with non Government

providers.

• Risk Pooling
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 NRHM-5 MAIN APPROACHES

Monitor progress
Communitize against standards
Flexible
financing

Innovations in
Improved Management Human Resource
through capacity management

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 Issues in effective management
 Inadequate budget
 Shortage of medicines/equipments/
improper maintenance
 Unavailability of manpower
 Difficulties in referral transport
 Administrative delays
 Lack of ownership by community
 Instructions for only implementations of
programmes/no say in planning
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 Fag end of first phase of NRHM
 Last seven years capacity to incur under
NRHM expenditure improved
 Still not as desired
 Urban issues yet to address
 Universal access to health under
consideration in 12 th Plan

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 Challenges
 SINCE THE Indian independence, the
issue of poverty and health within the
country has remained a prevalent concern.
Poverty and health are the two sides of
the same coin. It has been noticed that
more than 22% of the entire rural
population and 15% of the urban
population of India lives in difficult
physical and financial predicament.
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 Challenges
 The poverty is one of the factor which also
gave rise to health related problems in
both urban and rural population. The
mushroom growth of the population,
especially the slum dwellers primarily
suffers from Tuberculosis, Malaria and
some water borne diseases. The major
cause of these diseases is unhygienic
environment.
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 Challenges
 The slums lack water, sanitation facility that
leads to the growth of some dreadful diseases
among the dwellers. The government has setup
number of medical facility centres for the poor
people. The government should implement some
new schemes for the slum dwellers. Some
cleanliness awareness programme should be
launched to teach them basic health knowledge.
Some of the diseases such as tuberculosis,
cholera transmit due to unhygienic atmosphere.
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 Challenges
 The people always counts pollution, being
the major cause of different diseases in
the cities. But, why the rural Indians are
suffering from different diseases? In rural
India, the major cause of health related
problems are poverty and lack of
education.
 Most of the villagers still believe in Tantra-
Mantra to cure a disease.
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 Challenges
 As a result the mortality rates have increased in
some of the remote villages. Poverty creates ill
health because it forces people to live in
environments that make them sick, without
decent shelter, clean water or adequate
sanitation. It is doubtless to mention that the
government has already setup number of
Primary Health Centres in almost every villages
of our country. But how many health
workers sincerely serve the rural patients ? In
most places, the health workers remain absent
from their duties for several days.

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 Challenges
 Most of the Indian villages do not have smooth
communication and transportation with the nearby
towns or cities. This problem is largely affecting the
rural people who fail to move to nearby towns to get
better treatment.
 The communication and lack of transport facilities are
largely noticed in the north eastern part of India. There
are still some remote villages in Arunachal Pradesh and
Nagaland which do not have any road, connected with
nearby towns. For this the patients lose their life without
getting any modern treatment. There are many
drawbacks for which the government policies are still
unsuccessful, especially related with health issues.
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 Per capita expenditure

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 Health expenditure Previous Last

External resources for health

1.3 1.6
(% of total expenditure on health) in India
Health expenditure per capita;
113.2 122.1
PPP (constant 2005 international dollar) in India
Health expenditure per capita (US dollar) in India 42.1 45.3

Health expenditure; private (% of GDP) in India 2.9 2.8

Health expenditure; public (% of GDP) in India 1.2 1.4

Health expenditure;
4.1 4.4
public (% of government expenditure) in India
Health expenditure;
29.6 32.4
public (% of total health expenditure) in India
Health expenditure; total (% of GDP) in India 4.1 4.2
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 Health insurance
 Many schemes
 Not yet popularized
 Expectation from the companies
 Expectation free services
 Hospitals non transparent, individual
based rates

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 Quality of health services

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 Purpose
 Minimize;
Failures
Complications
Deaths
 Service provision to all
 Satisfied beneficiary

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 Availability

Effectiveness
Access

Efficiency Dimensions of Quality

Acceptability

Equity
Technical Performance
Interpersonal Relationship

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 Dimensions of Quality
Equity: The degree to which
healthcare services are not
Efficiency: The ratio of Technical Performance:
hampered by gender, age,
the outputs of services the degree to which the
marital status or socio –
to the associated costs tasks carried out by
economic background
of producing those health workers adhere to
existing standards
services
Acceptability: The
Access: The degree degree to which
to which healthcare
healthcare is used
services are unrestricted
on the perceived needs
by geographic;
of the people
organizational & linguistic
Interpersonal
barriers
relations: Trust, respect,
Effectiveness: The
confidentiality, courtesy,
degree to which Availa responsiveness, empathy, effective
desired outcomes bility listening, and communication
of care are between providers
Achieved and clients
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 Quality era

PIL

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 Human resources

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 Health manpower; ideal

Doctors

Paramedicals

Nonmedicals

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 Health manpower; existing

Doctors

)(
Paramedicals

(
Nonmedicals

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 Age group ?

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 Trend; last three censuses
Region 1991 2001 2011 Difference

India 927 933 940 +13

Sex ratio

Maharashtra 934 922 925 -09

India 945 927 914 -34

Child
sex ratio
Maharashtra 946 913 883 -63

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52
 National situation

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 Child Sex Ratio in India 2001-2011

27 of the 35 States and UTs showed a decline in CSR

16 August 2018 between 2001
Doke and 2011.. 54
 Implications of declining sex ratio

 Increase in violence against women and denial

of basic rights to them.
 Increase in sex related crimes (rape, abduction,
polyandry)
 Impacts health of women –physical, mental and
reproductive
 Increase in sexual exploitation of women and
thereby increase in cases of RTI/STD, HIV/AIDS

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 Estimates of missing girls

 The Lancet
published a study
which stated that
one crore girls
have gone missing
in the last 20
years.
(It was believed by many that
this number could be an
overestimation)
Name of Paper : THE HINDU
Published at : NEW DELHI
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Dated : 10th January 2006
 Estimates of Missing Girls
(based on SRB 2006-08)
 India
Around 1600 per day (if SRB 904)
Six lakhs per year
4.8% of all birth are SSEs
 Punjab
35,833 per year
Around 100 per day
Four times of National SSEs (16.2%)
 Maharashtra
55,053 per year
152 per day
5.9% of all births are SSEs
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 Magnitude of the problem
 Sex ratio at birth for
first child is 871
 Sex ratio at birth
falls to 759 for
second child if first
is a girl
 Sex ratio at birth for
third child is 718 if
first two are girls
Source : Special Fertility and Mortality Survey
16 August 2018 Doke Sample Registration System, Registrar General Of India,
58
New Delhi, 2005
 Table: Sex ratio at birth by birth order and sex of previous child, India, 2011-13

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