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Indian health systemOverview, issues & challenges

Prashanth N S MBBS, MPH, PhD

Institute of Public Health, Bengaluru

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Outline• Part 1: Introduction, human resources in health in India, health

(in)equity patterns in India and social determinants of health

• Part 2: Structure and functioning of the health system and services in India with respect to – Health Services– The disease burden– Human resources– Medicines– Governance– Financing of Indian health services

• Part 3: Bringing it together – health system frameworks

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India• India is a

– Sovereign– Socialist– Secular– Democratic– Republic

• Promote – Justice– Liberty– Equality– Fraternity

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India - Demography

• 1.21 billion people• 74% literacy; 65 F literacy• 30% of population live in urban area• 940 females per 1000 males• 47% of population are below 25 years

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India - Social

• Secular – Hindus (83%), Muslims (13%), Christians (2%), Others (2%)

• Social stratification along caste lines though the system is abolished

• 38% of population classified as socially vulnerable

Do health workers save lives? More health workers, more health. True?

Do health workers save lives?

• Doctor anomaly

• Cardiologists’ holiday paradox

WHR 2006

WHR 2006

WHR 2006

Karnataka state– Regional/sub-regional disparitiesRole of (mis)management?

For example, in 2006Immunisation coverage – 96% in Kodagu district and <50% in Raichur.

114 ‘backward’ talukas, nearly half in ‘forward’ districts

“Systemic failure” as a cause? (George, 2007&2009), Sen (2006)

NS Prashanth, PhD Committee meeting, UCL

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What is capacity?

Brown, L., LaFond, A., & Macintyre, K. (2001). Measuring capacity building. Chapel Hill: MEASURE Evaluation.

06/12/13

A few characteristics of HR/health systems

So, then what is a system? Is it called a system because it works “systematically”?

-> Systems thinking

Complexity

• Simple, complicated and complex problems• Health service versus a health system…& HR (& health) systems are complex…

WHO – Alliance for Health Policy and Systems Research

Layered dimensions of HRM in a system

• Individual• Institutional (workplace)• Meso/Macro policy level factors• Environmental, societal, socio-political

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Inequities

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India – a land of contrasts

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India – a land of contrasts

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India – a land of contrasts

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Layered inequalities• Economic

inequalities most well researched & possibly most “obvious”

• Economic inequalities: income, wealth and consumption (also applies to health)

Barton and Grant (2006) adaptation of Dahlgren and Whitehead (1991)

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Indian health system worsens income/class inequity

• Healthcare expenditure financed by people out of pocket, at the point of service delivery (high OOPs)

• Poor social protection: Neither universal nor well targeted

Oxfam

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Class/income inequalities

• Income positively correlated with health outcomes globally

• Income as one of the drivers of health

• The poor cannot buy into health

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Equity ≠ Equality• Absence of particularly unfair

differences; Social and political disadvantages -> adverse societal conditions that prevent these populations/population sub-groups from realising individual measures to overcome health or social inequalities.

• “ (lack of) social justice is killing people on a grand scale”

• “inequitable distribution of power, money and resources as one of the underlying causes of inequities in health”.

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Broad patterns and correlates• Clear income gradient in public health across states and districts with positive associations with

literacy and rural residence. Wealth strongest marker of anaemia status, more so than education and caste

• Economic constraints influence choice of various health services, in several contexts public services “a lesser good” (cf. childbirth, inpatient care, skilled birth attendance)

• Unequal access to a variety of services, schemes and programmes for poorer sections

• Somewhat a pattern of rich seeking care in for-profit organised private while the poor delaying care or at public (although not generalisable)

• Postnatal care most unequal among maternal health services (cf. discrimination)

• Although inequalities generally lower in economically better-off states (many of them in south India), paradoxically being in a “better-off” state not always good for the poor in these states. Similar patterns in outcomes (cf. U-5 mortality inequalities better in “poorer” states, but…)

IPH/Shree Chitra Equity mapping 2015

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Part 2: System vs services

• What is Indian health services like? • How is it perceived and utilised by different

sections of the population?• What is the disease burden and how is it

financed?• How does the Indian health system perform

with respect to enabling health and social protection?

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Health services - Multiple systems of medicine

Allopathy

Ayurveda

Yoga

Homeopathy

Unani

Siddha

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Health services – multiple providers

• Certified / Uncertified

• Government / Private / Private not-for-profit

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Health services – multiple facilities

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Organisation of Health services

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Health services – Govt. & Private

G - U

G - R

P -U

P -R

NSSO

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Provision of health services

Outpatient care Inpatient care Deliveries0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

22%

42%

Government; 52%

Private , 78%

58%38%

NSSO data

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India – disease burden

IHME2010India

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Medicines

• Under Ministry of Chemicals• Largest producer of generics in the world• Multi billion dollar industry• Regulatory policies exist, but not implemented• Medicines freely available – over the counter• Government spends just € 0.10 cents per

person on medicine

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Financing of health care

Mostly through out of pocket payments by

individual patients at the time of illness

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Sources of financing for health

State Govt; 12%

Federal Govt; 7%

Local Govt; 1%

OOP; 71%

Firms; 6%

Insurance; 1% External aid; 2%

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Health financing – source of funds

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

10

20

30

40

50

60

70

80

90

100

Government

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Out-of-pocket

94

Int.

$ PP

P

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Health insurance in IndiaNumber of people covered (millions)

Social health insurance*

Private health insurance #

Government health insurance ^

Outpatient 58

Secondary care 58 55 130

Tertiary care 58 117

TOTAL 58 55 147

* - Civil servants

# - Mostly the formal sector high & middle-income groups

^ - Those below the poverty line

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Effect of this

• Inadequate health staff in the government sector– 0.6 doctors per 1000 population– 1 doctor to 1.3 nurses

• Inadequate medicines in the government sector

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Effect of this ….

Financial barrier

Do not seek care

Seek sub standard care Seek care

Manage with savings Borrow Sell Asset Labour

substitution

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Effect of this …

63 Million Indians are impoverished every year

because of medical expenses

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Effect of this …

Full A

ntenatal ch

eck up

Institutional

Delivery

Immunisa

tion of child

ren

Treatment o

f Pneumonia

0%

20%

40%

60%

80%

100%

6%19%

36%

67%

36%

80% 73%88%

Poorest Quintile Richest Quintile

NSSO data

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Effect of this …

• Multi billion dollar industry – US$ 80 billion and growing @ 17%

http://www.ibef.org/industry/healthcare-india.aspx

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Government response

• 2005 – National Rural Health Mission

• 2008 – National Health Insurance Scheme

• 2015 – Subsidised medicines to all

But Government health expenditure still remains at 1.1% of GDP

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Governance• Many regulations

– Drugs– Medical practice– Infrastructure– Certification of health staff– Medical negligence– Food safety– Pollution control

• Many ministries – Health, Medical education, Chemicals, Environment, Food and Civil Supplies, Water and Sanitation, Women and Child Welfare, etc.

But poorly implemented

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Health status - Life expectancy (in years)

18001813182618391852186518781891190419171930194319561969198219952008-5

5

15

25

35

45

55

65

75

85

India

66

Sri Lanka

74

UK

81

Year

s

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Health status – under nutrition

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Part 3

• Assessing a health system: frameworks

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Eg framework:Building Blocks & Systems Thinking

WHO 2007, WHO 2009

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Eg: Reform/Control Knobs framework

Roberts et al, 2004

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Framework – a full overview?

• Who are actors in the Health System?• What are issues in the Health System?

Leadership & governance:* policy – making

* regulation* coordination

Organisation and delivery of health care services:

* primary health care – specialised * health problem specific – general

* prevention – curative care* public – private, for profit – not for profit,

formal - informat

Guiding by values and principles:* health care as a right* autonomy <> security

* protection of public <> response to individual suffering * effectiveness <> efficiency

* participation, accountability, trust* social justice and equity

* global social responsibility* sustainability: at which level?

Outcomes:* universal access

* quality of care

Goals:* improved health* responsiveness * social & financial

protection

Interaction with context:* with national policies, culture, values

* with international context* with other sectors and actors

Interaction with population:* demand generation

* participation of individuals and groups in community* accountability

human resources

Organisation of resources:

financing

Medical supplies & technologies

Monitoring & evaluation / information

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Van Olmen et al, Institute of Tropical Medicine, Antwerp

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Conclusion• A complex health system

– Pluralistic providers– A strong and unregulated private sector– Financed mostly by individual households at the point of care– Wide range of services, quality and access– Government trying hard to regain control

• Double burden of CD and NCD

• Inadequate and inefficient expenditure by the government on health services

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Conclusions

Has money?YES NO

Reasonable to high quality of care in

private health sector

Reasonable to poor quality of care in

government / private health sector

With inputs of Dr. Devadasan, IPH

Assistant Director (Research), IPHChairperson, Emerging Voices for Global Health

web @daktre.comedits @Wikipedia/User:Prashanthns

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