Health system by- Dileep Mavalankar

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Overview of Health Service Delivery in India – Issues and problems

Dr. Dileep MavalankarDean

Indian Institute of Public Health (IIPH), Gandhinagar( Public Health Foundation of India)

Prof. IIM Ahmebad ( on leave)

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India is diverse – overview in 20 minutes is not simple

• Kashmir to Kanyakumari – Dwarka to Arunachal – languages, culture, economy, power and gender, age, …..

• Political parties – governance- governments – people

• Lands – climate – environment – water… different

• But one nation – one constitution – one supreme court -…. Similar problems…..!!!!

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Under 5 mortality will reach 54, MDG target is 38

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MMR decline – will reach 153 by 2015, MDG target is 100

Can we meet any targets ??? In the past we have not met many health goals set by planning commission

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Causes of Under-five mortality – infections and birth related causese

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Historical development

• Ayurveda and long local healing tradition• Historically “civil hospitals”, “district Hospitals”

..Leprosy, TB, ID hospitals, charitable hospitals • Bhore committee inspired – planning

commission funded – Primary Health Care System – PHC, SC, CHC –

• There is a central government driven – state government funded public system

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Public health system was built on the British health development pattern

• Epidemic act 1897

• Madras nursing act 1928….. Bengal nursing act 1937

• Sanitary commissions, “sanitary inspector”

• Birth and death registration…

• Medical schools (LMP) and then medical colleges..MBBS .. Many docs trained in Britain

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Current Health Delivery system – As a “Jugad”

• Jugad is make-shift arrangement done by the poor, of the poor, for the poor

• Make-shift health system – many things on paper but not on ground.

• Hotchpotch – mix of public – private – insurance – NGO – Traditional medicine…

• ( may be like Bhel-puri !!!)

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The current scenario- mega trends

• Gross under- investments in public health care system – curative and preventive -0.9% to 1.14% of GDP

• Poor management capacity and practices -

• Neglect of Human Resource management – hardly any HR planning. NO HR cell / division at any level – no qualified HR managers in health department

• Drive by private sector – major provider of care – major attractor of top level HR (Docs)

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Professional Councils - mismanaged

• Medical and nursing councils small – unrepresentative – corrupt – but powerful

• No oversight from government• Dominated by private practioners • Structure oriented norms rather than process

oriented• Not much regulation of practice of health care• No alignment of curricula with need of the

public and majority health system.

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Government system – fund starved – bound by bureaucratic procedures, political

interference, lack of management

• Gross under investment – 1% of GDP – need 4-5%• In UK NHS has 1 GP per 1-2000 population – Indian PHCs

have 1 MO for 15-30,000 population. • Sweden has 1 public nurse:100 people – India 1:1000• Medicine/supplies budget in PHC 2- 3 Rs per capita/yr• Buildings dilapidated, equipment not available or

working, no supplies…….• Health workers – few and absent – un-welcoming –

frustrated, …… old • Very little research – funded by state governments

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Underlying causes of there problems

• Lack of political commitment to health – education and social welfare – disinterested political class, - health is low priority ministry

• Too much commitment to economic development, business, private market development, Industrialization…… IIP numbers produced every quarter – birth and death takes 1 years to compile in SRS

• Neglect of public health and lack of public health leadership -

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Underlying causes (continued)

• “Taj Mahal Sysdrome” – building monuments rather than building human resources - “AIIMS like institutions” – rather than district and sub-district hospitals, PHCs….

• Lack of “equality”, PM/CM are tread in private hospitals – poor go to public hospitals.

• Lack of concern for the poor,

• Lack of political / social dialogue on health and social- welfare - more of slogans and advertisements rather than real programs

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More operational reasons

• No public health cadre at central or state level – any doctor can be posted as public health officer

• “Babu- Neta” syndrome - IAS/State Ad. Service - officers and politicians decide public health priorities and programs…..

• Lack of standards in much of health care – “how many patients can a doc see in 1 hour”, what infection rate is too high ?? What is an epidemic?? What is deaths due to malaria?

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Who will bell the Cat ?? Who will say that emperor does not have clothes??

• Purposeful denial of the PH problems – no deaths in Chikungunya in spite of 3000 additional death in Ahmedabad. WHO and other international agencies not bothers to finding out what is the truth – just helping the government in saying what it want to say

• Policies are made in air-conditioned rooms for rural scorching realities – blood banking policy

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New and emerging problems

• Health is understood as medical care

• Medical care is what “cardiologists advise”

• Ministers seem to hear what super-specialists - high profile private sector doctors are saying –

• Company – interest driven policies – CII - FICCI

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Lack of data and understanding of data

• No birth and death recording – RGI has become an administrative position

• No cause of death recording & analysis on regular basis

• Not even maternal and child death, TB deaths, Malaria deaths are recorded and analyzed properly.

• There are hardly and epidemiologists and demographers in the health departments

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• Neglect of water / sanitation…… nutrition • Neglect of social determinants of health

• Hygiene & infection control / Asepsis poor

• Over use of antibiotics….

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How do we move forward??

• Tripling the health public expenditure on health

• Making it simple to spend money

• Make outcome accountability – mortality & morbidity reduction – not just coverage

• “people pleasing services”

• Better HR management – people produce health services -

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• Set standards and measure quality

• Reward performance and quality

• Do not run after targets, numbers and quick successes…

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Silver lining???

• NRHM – increasing resources, TA, managerial staff.. Flexibility….

• PPP – Cataract surgery, chiranjeevi scheme, other programs

• HR discussions – augmentation – ASAH, contract docs and specialsits

• Task shifting/sharing – Nurse-midwife, MO – CEmOC, NN care trg…

• Health insurance through RSBY, Arogya shree in AP…• Vibrant NGO….• New institutions – focus on Public Health

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Can we make a desert like heath system to a blooming garden ?

Thanks