Health in India
India has a universal health care system run by the constituent states and territories of India. The Constitution charges every state with "raising the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties". The National Health Policy was endorsed by the Parliament of India in 1983 and updated in 2002.
Parallel to the public health sector, and indeed more popular than it, is the private medical sector in India. Both urban and rural Indian households tend to use the private medical sector more frequently than the public sector, as reflected in surveys.
India has a life expectancy of 64/67 years (m/f), and an infant mortality rate of 46 per 1000 live births.
- 1 High Level Expert Group on Universal Health Coverage
- 2 Twelfth Five Year Plan
- 3 Quality
- 4 Health issues
- 5 Health care system
- 6 See also
- 7 References
- 8 External links
High Level Expert Group on Universal Health Coverage
Pre-HLEG recommendations on Health for all
The idea of health care for all was present, though not explicitly, in the (i) Bhore committee Report of 1946; (ii) the Sokhey Committee report of 1948 (iii) National Health Policy of Health 1983 and 2002. India is also a signatory to the Universal Declaration of Human Rights that recognizes the right to a standard of living adequate for the health and well-being of himself and of his family…" The idea was re-emphasized when India endorsed the "Health for All" declaration in Alma Ata in 1978 and endorsed the conclusions of the 1994International Conference on Population and Development (ICPD) in Cairo
Formation, members, and mandate
The High-Level Expert Group (HLEG) on Universal victor(UHC) was constituted by the Planning Commission of India in October 2010, under the chairmanship of Prof. K. Srinath Reddy, with the mandate of developing a framework for providing easily accessible and affordable health care to all Indians.The other members of the expert group are: Abhay Bhang (Society for Education, Action and Research in Community Health), A.K. Shiva Kumar (member, National Advisory Council), Amarjeet Sinha (senior IAS officer), Anu Garg (Principal Secretary-cum-Commissioner (Health and Family Welfare department, Orissa), Gita Sen (Centre for Public Policy, IIM Bangalore), G.N. Rao (Chair of Eye Health, L.V. Prasad Eye Institute, Hyderabad), Jashodhara Dasgupta (SAHYOG, Lucknow), Leila Caleb Varkey (Public Health researcher), Govinda Rao (Director, National Institute of Public Finance and Policy), Mirai Chatterjee (Director, Social Security, SEWA), Nachiket Mor (Sughavazhu Healthcare), Vinod Paul (AIIMS), Yogesh Jain (Jan Swasthya Sahyog, Bilaspur), a representative of the Ministry of Health and Family Welfare, and N.K. Sethi (Advisor (Health), Planning Commission).
Definition of Universal Health Coverage
HLEG defined UHC for the purpose of report as follows:
“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, appropriate health services of assured quality (promotive, preventive, curative, and rehabilitative) as well as public health services addressing the 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”
Recommendations of the High Level Expert Group (HLEG)
The recommendations of the High Level Expert Group (HLEG) on Universal Health Coverage encompass the area of health financing, health services norms, humanresources for health, community participation and citizen engagement,access to medicines, vaccines and technology and management and institutional reforms. The recommendations of the HLEG, inter-alia,include:
- Increase public expenditure on health to at least 2.5 percent of GDP by the end of the 12th Plan and to at least 3% of GDP by 2022.
- Ensure availability of free essential medicines by increasing public spending on drug procurement.
- Purchase of all health care services under the Universal Health Coverage (UHC) system should be undertaken either directly by the Central and state governments through their Departments of Health or by quasi-governmental autonomous agencies established for the purpose.
- All government funded insurance schemes should, over time, be integrated with the UHC system. All health insurance cards should, in due course, be replaced by National Health Entitlement Cards. The technical and other capacities developed by the Ministry of Labour for the Rashtriya Swasthya Bima Yojana should be leveraged as the core of UHC operations and transferred to the Ministry of Health and Family Welfare.
- Develop a National Health Package that offers, as part of the entitlement of every citizen,essential health services at different levels of the health care delivery system.
- Reorient health care provision to focus significantly on primary health care.
- Strengthen District Hospitals.
- Ensure adequate numbers of trained health care providers and technical health care workers at different levels by
- a) giving primacy to the provision of primary health care
- b) increasing Human Resources for Health (HRH) density to achieve WHO norms of at least 23 health workers (doctors, nurses, andmidwives).
- Establish District Health KnowledgeInstitutes (DHKIs).
- Establish the NationalCouncil for Human Resources in Health (NCHRH).
- Transform existing Village Health Committees (or Health andSanitation Committees) into participatory Health Councils.
- Ensure the rational use of drugs.
- Set up national andstate drug supply logistics corporations.
- Empower the Ministry of Health and Family Welfare tostrengthen the drug regulatory system.
- Introduce All India and state level Public Health Service Cadres and a specialized state level Health Systems Management Cadre in order to give greater attention to public health and also strengthen the management of the UHC system.
- Establishment of National Health Regulatory and Development Authority(NHRDA).
- National Drug Regulatory and Development Authority (NDRDA): The main aim of NDRDA should be to regulate pharmaceuticals and medical devices and provide patients access to safe and cost effective products.
Twelfth Five Year Plan
Based on the recommendation of HLEG and other stakeholder consultations, the key elements of Twelfth Five Year plan strategy is outlined. The long term objective of this strategy is to establish a system of Universal Health Coverage(UHC) in the country. Following are the 12th plan period strategy:
- Substantial expansion and strengthening of public sector health care system, freeing the vulnerable population from dependence on high cost and often unreachable private sector health care system.
- Health sector expenditure by central government and state government, both plan and non-plan, will have to be substantially increased by the twelfth five year plan. It was increased from 0.94 per cent of GDP in tenth plan to 1.04 per cent in eleventh plan. The provision of clean drinking water and sanitation as one of the principal factors in control of diseases is well established from the history of industrialized countries and it should have high priority in health related resource allocation. The expenditure on health should increased to 2.5 per cent of GDP by the end of Twelfth Five Year Plan.
- Financial and managerial system will be redesigned to ensure efficient utilization of available resources and achieve better health outcome. Coordinated delivery of services within and across sectors, delegation matched with accountability, fostering a spirit of innovation are some of the measures proposed.
- Increasing the cooperation between private and public sector health care providers to achieve health goals. This will include contracting in of services for gap filling, and various forms of effectively regulated and managed Public-Private Partnership, while also ensuring that there is no compromise in terms of standards of delivery and that the incentive structure does not undermine health care objectives.
- The present Rashtriya Swasthya Bhima Yojana (RSBY) which provides cash less in-patient treatment through an insurance based system should be reformed to enable access to a continuum of comprehensive primary, secondary and tertiary care. In twelfth plan period entire Below Poverty Line(BPL) population will be covered through RSBY scheme. In planning health care structure for the future, it is desirable to move from a 'fee-for-service' mechanism , to address the issue of fragmentation of services that works to the detriment of preventive and primary care and also to reduce the scope of fraud and induced demand.
- In order to increase the availability of skilled human resources, a large expansion of medical schools, nursing colleges, and so on, is therefore is necessary and public sector medical schools must play a major role in the process. Special effort will be made to expand medical education in states which are under-served. In addition, a massive effort will be made to recruit and train paramedical and community level health workers.
- The multiplicity of Central sector or Centrally Sponsored Schemes has constrained the flexibility of states to make need based plans or deploy their resources in the most efficient manner. The way forward is to focus on strengthening the pillars of the health system, so that it can prevent, detect and manage each of the unique challenges that different parts of the country face.
- A series of prescription drugs reforms, promotion of essential, generic medicine and making these universally available free of cost to all patients in public facilities as a part of the Essential Health Package will be a priority.
- Effective regulation in medical practice, public health, food and drugs is essential to safeguard people against risks and unethical practices. This is especially so given the information gaps in the health sector which make it difficult for individual to make reasoned choices.
- The health system in the Twelfth Plan will continue to have a mix of public and private service providers. The public sector health services need to be strengthened to deliver both public health related and clinical services. The public and private sectors also need to coordinate for the delivery of a continuum of care. A strong regulatory system would supervise the quality of services delivered. Standard treatment guidelines should form the basis of clinical care across public and private sectors, with the adequate monitoring by the regulatory bodies to improve the quality and control the cost of care.
The 12th five year plan document on health has received a lot of criticism for its limited understanding of universal health care and failure to increase public expenditure on health. While the HLEG report recommends an increase in public expenditure on health from 1.58 per cent of GDP currently to 2.1 per cent of GDP by the end of 12th five year plan it is far lower than the global median of 5 per cent. The lack of extensive and adequately funded public health services pushes large numbers of people to incur heavy out of pocket expenditures on services purchased from the private sector. Out of pocket expenditures arise even in public sector hospitals, since lack of medicines means that patients have to buy them. This results in a very high financial burden on families in case of severe illness. Though , the 12th plan document express concern over high out-of-pocket (OOP) expenditure , it does not give any target or time frame for reducing this expense . OOP can be reduced only by increasing public expenditure on health and by setting up wide spread public health service providers. But the planning commission is planning to do this by regulating private health care providers. It takes solace from the HLEG report which admits that, "the transformation of India’s health system to become an effective platform for UHC is an evolutionary process that will span several years".
Instead of developing a better public health system with enhanced health budget, 12th five year plan document plans to hand over health care system to private institutions.The 12th plan document express concern over Rashtriya Swasthya Bhima Yojana being used as a medium to hand over public funds to private sector through insurance route. This has also incentivised unnecessary treatment which in due course will increase costs and premiums. There has being complaints about high transaction cost for this scheme due to insurance intermediaries. RSBY does not take into consideration state specific variation in disease profiles and health needs. Eventhough these things are acknowledged in the report, no alternative remedy is given.There is no reference to nutrition as key component of health and for universal Public Distribution System (PDS) in the plan document or HLEG recommendation.In the section of National Rural Health Mission (NRHM) in the document, the commitment to provide 30-50 bed Community Health Centres (CHC) per lakh population is missing from the main text.It was east for the government to recruit poor women as ASHA (Accredited Social Health Activist) workers but it has failed to bring doctors, nurses and specialist in this area. The ASHA workers who are coming from a poor background are given incentive based on performance. These people lose many days job undertaking their task as ASHA worker which is not incentivised properly. Even the 12th plan doesn't give any solace.
The quality of Indian healthcare is varied. In major urban areas, healthcare is of adequate quality, approaching and occasionally meeting Western standards. However, access to quality medical care is limited or unavailable in most rural areas, although rural medical practitioners are highly sought after by residents of rural areas as they are more financially affordable and geographically accessible than practitioners working in the formal public health care sector.
According to a 2005 report, 42% of India’s children below the age of three were malnourished, which was greater than the statistics of sub-Saharan African region of 28%. Although India’s economy grew 50% from 2001–2006, its child-malnutrition rate only dropped 1%, lagging behind countries of similar growth rate. Malnutrition impedes the social and cognitive development of a child, reducing his educational attainment and income as an adult. These irreversible damages result in lower productivity.
High infant mortality rate
Approximately 1.72 million children die each year before turning one. The under five mortality and infant mortality rates have been declining, from 202 and 190 deaths per thousand live births respectively in 1970 to 64 and 50 deaths per thousand live births in 2009. However, this decline is slowing. Reduced funding for immunization leaves only 43.5% of the young fully immunized. A study conducted by the Future Health Systems Consortium in Murshidabad, West Bengal indicates that barriers to immunization coverage are adverse geographic location, absent or inadequately trained health workers and low perceived need for immunization. Infrastructure like hospitals, roads, water and sanitation are lacking in rural areas. Shortages of healthcare providers, poor intra-partum and newborn care, diarrheal diseases and acute respiratory infections also contribute to the high infant mortality rate.
Diseases such as dengue fever, hepatitis, tuberculosis, malaria and pneumonia continue to plague India due to increased resistance to drugs. In 2011, India developed a totally drug-resistant form of tuberculosis. India is ranked 3rd highest among countries with the amount of HIV-infected patients. Diarrheal diseases are the primary causes of early childhood mortality. These diseases can be attributed to poor sanitation and inadequate safe drinking water in India. India also has the world's highest incidence of Rabies.
Indians are also at particularly high risk for atherosclerosis and coronary artery disease. This may be attributed to a genetic predisposition to metabolic syndrome and adverse changes in coronary artery vasodilation. NGOs such as the Indian Heart Association and the Medwin Foundation have been created to raise awareness of this public health issue.
Based on the prevalence of Hepatitis B carrier state in the general population, countries are classified as having high (8% or more), intermediate (2-7%), or low (less than 2%) Hepatitis B virus (HBV) endemicity. India is at the intermediate endemic level of hepatitis B, with hepatitis B surface antigen (HBsAg) prevalence between 2% and 10% among the populations studied. The prevalence does not vary significantly by region in the country. The number of HBsAg carriers in India has been estimated to be over 40 million (4 crore). The prevalence of Hepatitis C is estimated to be in the range of 1.8-2.5 per cent .
As more than 122 million households have no toilets, and 33% lack access to latrines, over 50% of the population (638 million) defecate in the open.(2008 estimate) This is relatively higher than Bangladesh and Brazil (7%) and China (4%). Although 211 million people gained access to improved sanitation from 1990–2008, only 31% use the facilities provided. 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. Open air defecation leads to the spread of disease and malnutrition through parasitic and bacterial infections.
Safe drinking water
Access to protected sources of drinking water has improved from 68% of the population in 1990 to 88% in 2008. However, only 26% of the slum population has access to safe drinking water, and 25% of the total population has drinking water on their premises. This problem is exacerbated by falling levels of groundwater caused mainly by increasing extraction for irrigation. Insufficient maintenance of the environment around water sources, groundwater pollution, excessive arsenic and fluoride in drinking water pose a major threat to India's health.
Female health issues
Women's health in India involves numerous issues. Some of them include the following:
- Malnutrition : The main cause of female malnutrition in India is the tradition requiring women to eat last, even during pregnancy and when they are lactating.
- Breast Cancer : One of the most severe and increasing problems among women in India, resulting in higher mortality rates.
- Polycystic ovarian disease (PCOD) : PCOD increases the infertility rate in females. This condition causes many small cysts to form in the ovaries, which can negatively affect a woman's ability to conceive.
- Maternal Mortality : Indian maternal mortality rates in rural areas are one of the highest in the world.
Rural India contains over 68% of India's total population, and half of all residents of rural areas live below the poverty line, struggling for better and easy access to health care and services. Health issues confronted by rural people are many and diverse – from severe malaria to uncontrolled diabetes, from a badly infected wound to cancer. Postpartum maternal illness is a serious problem in resource-poor settings and contributes to maternal mortality, particularly in rural India. A study conducted in 2009 found that 43.9% of mothers reported they experienced postpartum illnesses six weeks after delivery.
Health care system
Public and private sector
According to National Family Health Survey-3, the private medical sector remains the primary source of health care for 70% of households in urban areas and 63% of households in rural areas. Reliance on public and private health care sector varies significantly between states. Several reasons are cited for relying on private rather than public sector; the main reason at the national level is poor quality of care in the public sector, with more than 57% of households pointing to this as the reason for a preference for private heath care. Other major reasons are distance of the public sector facility, long wait times, and inconvenient hours of operation. The study conducted by IMS Institute for Healthcare Informatics in 2013 , across 12 states in over 14,000 households indicated a steady increase in the usage of private healthcare facilities over the last 25 years for both Out Patient and In Patient services, across rural and urban areas.
National Rural Health Mission
The National Rural Health Mission (NRHM) was launched in April 2005 by the Government of India. The goal of the NRHM was to provide effective healthcare to rural people with a focus on 18 states which have poor public health indicators and/or weak infrastructure.
- Environment of India
- HIV/AIDS in India
- Indian states ranking by institutional delivery
- National Centre for Disease Control (NCDC)
- Poverty in India
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