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Towards a Better Healthcare
Group 2 - Section CArka Biswas (132) | Ashima Aggarwal (135) | Divyaveer Sachin (142) | Panii Ngaonii (152) | Pradeep Dutta (156)
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Agenda
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Public health in India
- The real picture- Deepening health insecurity in India- Government Spending- India vs. South East Asian Region
Government Flagship Programmes – Success & Failure- National Health Rural Mission- Rashtriya Swasthya Bima Yojana
Universal Health Care in India- Implementation- Role of PPP in UHC
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THE REAL PICTURE
India is home to -23% of the tuberculosis patients,
86% of diphtheria patients, 54% of leprosy patients,
29% of pertussis patients,
42% of polio victims and
55% of malaria patients in the world
43.5% underweight children below the age of five years
Only 21% of the rural population had access to “improved” sanitation
facilities in 2008
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What is Public Health?
KEY GOAL – To reduce a population’s exposure to disease
Assuring food safety
Vector Control
Monitoring waste disposaland water systems
Health Education Health Regulations
Medical Services
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Neglect of public regulations and their implementation
- Public Health Acts have not been updated- Deficiencies in “ Prevention of Food Adulteration Act”
Diversion of funds from public health services- Focus on aspects other than health care
Organizational changes needed to maintain public health
- Health is primarily a state responsibility
- Funds allocated from centre to the states
- States are not free to reallocate funds to higher priority issues
Public Health in Independent India
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Deepening Health Insecurity in India
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Declining Public Provisions
Increase in reporting of ailments can reflect(a) an increased morbidity burden in the country, and
(b) increased health-seeking behaviour of the population in general
Figure: Share (Percentage) of Public to Total Short-duration
Treated Ailments in Rural and Urban India (1986-87, 1995-
96 and 2004)
Figure: Reporting of Short Duration Ailment, Hospitalization
and No Formal Treatment (1987-88, 1995-96 and 2004; in %)
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Deepening Health Insecurity in India
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Figure: Per Episode Average Cost of Treatments for
Outpatient and Inpatient in Government and Private
Sector, Rural, Urban and Combined (2004)
Increasing cost of treatments
For outpatient treatments, private healthcare
facilities are, one and a half times more
expensive than the public facilities.
Government healthcare facilities, are forcing
patients to procure drugs and receive
diagnostic services from private sector
providers.
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Deepening Health Insecurity in India
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Figure: Increase in Number of Poor Due to OOP
Payments (in million)
Impact
Increase in poverty ratio is
contributed mainly by households’
expenditure on health, i.e. the OOP.
In 2004-05, 39 million additional
people plunged into poverty because
of OOP payments.
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Government Spending from 1999 to 2005
Figure: Government Health Expenditure as
Per Cent of GDP till 2004-05
Figure: Share of Government Health
Expenditure in Total Government
Expenditure till 2004-05 (%)
States account for three quarters of all government health spending, any rise or fall in states’
health spending influences total spending much more than the centre’s.
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Government Spending since April 2005
Figure: Government Health Expenditure as
Per Cent of GDP since 2004-05
Figure: Share of Government Health
Expenditure in Total Government
Expenditure since 2004-05 (%)
Total Government Health Expenditure increased from Rs 27,704 crore in 2004-05 to Rs 39,046
crore in 2006-07 or by 41 per cent, its share in GDP too increased from 0.97 per cent to about
1.05 per cent during this period
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Where do we stand
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India vs. SEAR
1. The density of doctors per 1000 of population is about 6 in India while
the average for SEAR is 5 and the global average is 14.
2. The density of nurses/midwives per 1000 is 13 in India as compared with
SEAR’s average of 11 and global average of 28
3. In the pharmaceutical field, manpower at a density of 6 per 1000 beats
the SEAR and global average of 4.
4. In PPP terms, per capita annual expenditure on healthcare is $109 in
India compared with $ 104 in SEAR.
Life expectancy at birth, healthy life expectancy, low birth – weight babies,neo natal mortality rate, <5 years mortality rate, MMR, India s
consistently performs below SEAR & the global average.
Gross Urban Bias in government
expenditure !!!
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National Rural Health Mission(NHRM)
“carry out necessary architectural correction in the basic health
care delivery system … to improve the availability of and access
to quality health care by people, especially for those residing in
rural areas, the poor, women and children”
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Objectives
Infant mortality rate (IMR) of 30 per 1000 live births
Maternal mortality 100 per 100 thousand live births
Total fertility rate of 2.1 by 2012
1/3rd population
lives in rural
Grass rootlevel
BuildingInfrastructure
Eradicatediseases
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Objectives
Decentralization
Communitization
Organizational structural reforms
Operationalizing existing health facilities to meetIPHS
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Funding
Funds allocation
District
State
National
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Implementation of Strategic options
1
• HEALTH INFRASTRUCTURE AND
FACILITY UPGRADATION
2• HUMAN RESOURCE
3
• UTILIZATION OF PUBLIC HEALTH
SERVICES
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Health Infrastructure And Facility
Upgradation
Facility - Upgradation work
Upgradation to IPHS
PHC functioning on 24x7basis
Rogi Kalyan Samities (PPP)
Village Health and SanitationCommittees (VHSCs)
Village Health and NutritionDays (VHNDs)
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HUMAN RESOURCE
ANMs
ASHAs
Referral andEmergency Transport
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Utilization of Public Health Services
Institutional deliveries
Children immunization
AYUSH program
The National Disease Control Programme (NDCP)
Family planning
Chronic diseases services
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Expenditure
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Scope for Improvement
Even after many years very few hospitals fall under the purview of IPHs(Indian Public Health Standard)
Doctors abhor rural centres because of poor infrastructure and working
conditions
The lack of a good and transparent human resources policy encourages
corruption and discourages good work
The average ASHA is hardly getting the promised Rs 1,400 per month ASHAs are not equipped to undertake their complex social roles in rural
areas
Training is poor, barely halfway and accreditation is yet to even begin
Involvement of the private sector with a well thought-out long-term
plan for integration of the two sectors through regulation is necessary
The Indian healthcare system has become an inverse pyramid with verylittle primary care as foundation and ever-ballooning “medical” sector
through a hospital-doctor-centric
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Rashtriya Swastya Bima Yojana (RSBY) - 2007
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• “To provide protection to BPL households from financial liabilities
arising out of health problems leading to hospitalization”
• Hospitalization coverage up to Rs.30000
• No age limit, up to 5 family members,
completely cashless
•
Pays only Rs. 30 as registration fee• Central (75%) and State (25%)pays the
premium to insurer
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Issues in implementation
•Poor knowledge of how and where to utilise the scheme
•Lack of coordination & implementation among variousstakeholders
Awareness
•Pre-requisite of BPL card
• People need to be registered as BPL in their home state, makingthis scheme out of reach of migrant workers who are far from home
Conditionality
•Verification process of BPL
•Delay & related delivery hassles
Issuance of smartcards
•0.4% of enrolled households
•Lack of preparedness of empanelled hospitals
•Problems with Smart Card Technology and Reimbursement System
Utilization
•Insurance company interested in premium
•Hospitals interested in cost recovery
Misalignedincentives & Frauds
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Current scenario & outcomes of RSBY
Active smart cards: 34,146,596 (penetration: around 50%)
hospitalisation cases: 4,909,728 (as of 20th February 2013)
Hailed by World Bank, UN & ILO as world’s one of the best
health insurance schemes
Germany showed interest of implementing this smart card basedhealth insurance scheme, which has the world's oldest social
security system
Infrastructure build-up regarding healthcare in semi-urban &
rural areas regarding catering to the huge BPL population,
which were previously dominant in urban areas only
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Moving along the path: Universal Health
Coverage(UHC)
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UHC In India: A dream in progress
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In October 2010, the PlanningCommission of India with the approval of
the prime minister, appointed a HighLevel Expert Group (HLEG) to develop aframework for universal health coverage(UHC) to be implemented over 2010-20.
India aims to introduce universal healthcoverage during the 12th five year plan(2012-2017)
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High Level Expert Group – Strategy and
Recommendations
• “.”
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What to Achieve ?
“ 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.”
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Architecture
E N T I T L E
M E N T Health package
for every kind of citizen, depending
upon theaffordability &other conditions
N
a t i o n a l H e a l t h
P a c k a g e Guaranteed access
to essential healthcare, including
cashless in-patient& out-patient care
-Primary
-Secondary
-Tertiary care
C h o i c e o f F
a c i l i t i e s People can choose
over private &public facilities to
cure themselves
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Wh’s of Implementation…1
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Health Financing and Financial Protection• Establish a financial mechanism to drive UHC
• Increase government spending to at least 3% of GDP by 2022
Health Service Norms
• Ensure last mile connectivity to poor, quality, and accessibility• Develop national health package and ensure quality of health services at
all levels
Human Resources for Health
• Ensure trained and adequately supported practitioners with relevantexpertise
• Invest in educational institutions to produce and train the requisite healthworkforce and strengthen existing ones
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Wh’s of Implementation…2
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Community Participation and Citizen Engagement
• Strengthen the institutional mechanisms to improve publicdecision-making
• Transform existing Village Health Committees (into participatoryHealth Councils
Access to Medicines, Vaccines and Technology
• Revise and expand the essential drugs from National Essential DrugsList
• Price control and regulation on drugs and vaccines
Management and Institutional Reforms
• Develop a national health information technology network
• Establish financing and budgeting systems to streamline fund flow
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In search of Light: “McKinsey” Way
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Growth
Rural Drive
Border Crossing
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…“Extracts”
“Emphasis access through Health Insurance”
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“Ensure smooth implementation of Patent Law”
“Support capability building in R&D”
“Continued emphasis on public health resources & infrastructure”
“Adopt a broader view of Healthcare cost”
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India: UHC Can the dream come
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Need of a political leadership which can make the most of
economic and political windows of opportunityService should be prioritized attending the rural poor first
Reach country's most isolated regions to dispense health
Develop models of decentralized district level planning anddelivery of health services
Emphasize on preventive and primary care servicesNon primary services to be left for the private players
Accounting for a large informal sector
Contribution from the formal sector could be useful to cross-subsidize
Implement health care rationing and waiting lists for certainprocedures and treatments to deal with increasing demand
India: UHC – Can the dream come
true?
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PPP in PHC
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PPP in PHC
PPP is a mode of implementing government programs/schemes inpartnership with the private sector
Includes corporate sector, voluntary organizations, self-help groups,
partnership firms, individuals and community based organizations
PPP is essential for infrastructure development, management andoperations, capacity building and training, financing, IT infrastructure,
and materials management
Shift in emphasis is from delivering services directly, to service
management and coordination
Could be at primary level, secondary level or tertiary levels across
various states in India
Dimensions of PPP
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Dimensions of PPP
• Full retention of responsibility by thegovernment for providing the serviceResponsibility
• PPP may continue to retain the legalownership of assets by the public
sector
Ownership
• nature and scope of service iscontractually determined between thetwo parties
Service nature
• shared between the government(public) and the private sector
Risk andreward
Contractual framework
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Contractual framework
PPPcontract
servicecontract
operations &maintenance
(management)contract
capitalprojects, with
operations &maintenancecontract
PPP: Pros and Cons
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PPP: Pros and Cons
Pros:
PPP brings together resources and expertise from both the public and
private sectors
Increase accessibility and availability of services to rural India
Increase the quality and quantity of manpower available
It would improve primary care services which in turn would improve
quality of life
Cons:
It would corporatize healthcare
It could lead to widespread corruption The Government could completely get out of the healthcare sector
PPP: Major schemes under DoH
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PPP: Major schemes under DoH
Major Schemes implemented through PPP under Ministry of Health & Family
Welfare Department of Health:
The RevisedNational TB
Control Program(RNTCP)
National Programfor Control of
Blindness
National Cancer
Control Program
National AIDSControl Program
National Leprosy
EliminationProgram (NLEP)
CentralGovernment
Health Scheme(CGHS)
Issues in PPP in healthcare
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Issues in PPP in healthcare
• The capacity limitation is the major hurdle in
scaling
Capacity of
Private Partner
• General public's fear about PPPs being a façade forprivatization
• Central and state must reassure the public aboutthe PPP process
Advocacy
• Accreditation of Private NGO Hospitals forInstitutional DeliveryAccreditation
• Insufficient regulation by the governmentRegulation by
the Government
Major concerns
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Major concerns
• Free and fair selection of partners does not happen• Often mediated through money & political
patronage
Inadequatenumber of playersin the market
• Inadequacies pertaining to fair process of selection• No serious rules for non-compliance with the outputs
• Do not clearly spell out the breach of contract by eitherparty
Absence of a well-articulated “MoU”
• Bureaucratic professionals within the public sectorare not ready to adhere to rules and regulations asan equal partner with the private sector
Poorly definedroles: Lack of accountability
Major concerns
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Major concerns
• Non-monetary parameters not included
• Non-monetary factors like trust, accountability,responsiveness, interactive quality not adequatelyaccounted for
Incorrect view of “cost-efficiency”
• Private sector actually has a minor role of mainlydemand generation in most cases
• Often major terms of agreement (e.g. renewal of contract) are controlled by Government
Asymmetry:Skewed towardsGovernment
• No third party institutional mechanism that canplay the role of an independent arbitrator
• Only recourse is the court of law; cumbersomeand prolonged settlement not viable for PPPs
Absence of aneutral arbitrationmechanism
Standardization: The road ahead
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Standardization: The road ahead
Currently no standardization of PPP in Healthcare
PPPs are happening at both state level and at national level and atvarious points of the value chain
The scale and magnitude are different at each level
Need for a model framework acting as policy framework
Need a central approach to execution of PPP projects while the
components of the model may differ from state to state
Standardization of model would embolden major healthcare players to
venture in PPPs in a big way
Case study: Chiranjeevi Project in Gujarat
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Case study: Chiranjeevi Project in Gujarat
Announced by the Government in April 2005 to target group is women living BPL
who face socioeconomic hardships due to complications during delivery
Implementation:
The private practitioners were chosen by the district health centers after a
detailed survey of their infrastructure assess their conditions of services
The contracted practitioners were reimbursed through a capitation payment
basis under they are paid for each delivery at a fixed rate
Performance:
Institutional deliveries in the five states increased from 38 to 59 per cent No
maternal deaths and only 13 infants death
Reasons for Success: Transparent pricing mechanism
Involves a network of private practitioners
Built trust with doctors by ensuring regular payments and there is constant
monitoring of the program
References
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References
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THANKYOU
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