Post on 04-Apr-2018
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rduggal57@gmail.com
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Preamble
Health is one of the goods of life towhich man has a right; wherever this
concept prevails the logical sequenceis to make all measures for theprotection and restoration of healthto all, free of charge; medicine like
education is then no longer a tradeit becomes a public function of the
State ...
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The Development Paradigm
The notion of the welfare state Socialist pattern of development Limited entitlements approach Support to private capital growth The ruralurban planning divide
CDP and rural development Social sectors neglected Persistence of poverty
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Healthcare Development
The legacy of Joseph Bhore The colonial continuumenclave
pattern of development Constitution: Concurrent Crowding The Centres role
The program based approach andelaborate bureaucracies The rural--urban dichotomy Consolidation of private healthcare
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Heath Policy and Planning
Health policy through 5-year Plansand Committees
Dilution of Bhore recommendations Program based approach Revival under Minimum Needs
Program and post Alma Ata -
reducing the rural/urban gap The first National Health Policy-
1983 The decline of public healthcare
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Health Policy
The big leap of the private healthsector
2002 Health Policy Common Minimum Program Rural Health Mission
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Health System andStructures - Public
Primary Healthcare VHW- SubcentrePHC (rural) VHW- Health posts (urban) National programs
Secondary and Tertiary care Rural Hospitals District and sub-district hospitals
Teaching Hospitals Public Health Administration
Public Health, Medical and Medical Educatn
Financing : General taxes/Socialsecurity
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Health Systems andStructures - Private Private Provision
GPs and Consultants Private for-profit Hospitals
Private not-for-profit hospitals !! Multiple systems unified practice! Unqualified pracxtitioners Traditional practitioners
Financing Out of pocket Private Insurance
Social security
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India Health Profile...
Facts and Figures Doctors (all systems): 1.3 mi. (769 per
doc) Doctors (allopathy): 540,000 (1852 per
doc) Nurses: 580,000 (1724 per nurse)
Hospital Beds: 950,000 (1053 per bed) Public Expenditure: $7 bi. (1% of GDP) Private Expenditure: $37 bi. (5.5% of GDP) Health Outcomes: IMR-72, CDR-9, CBR-24
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Indias Global Share In
%
Population 17Total deaths 17
Child deaths 23
Maternal deaths 20
TB cases 30Leprosy cases 68
Persons with HIV 14
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Country Under 5
Mortality
Maternal
Mortality Ratio
Korea 14 30
Malaysia 14 34
Sri Lanka 19 30
China 43 95
Indonesia 75 390
India 95 440Bangladesh 115 850
Pakistan 127 340
Nepal 131 1500
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33
50
17
64
1818
40
44
16
81
712
Communicable
Non-Communicable
Injuries
India China
Low & Middle
Income HighIncome
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19
6
17
8
50
Infectious and
parasitic
diseases
RespiratoryInfections
Maternal
Conditions
PerinatalConditions
Nutritional
deficiencies
INDIA 1998
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10%
2%
4%
30%
6%
2%
8%2% 3%
7%
26%
A. Malignant neoplasms
B. Diabetes mellitus
C. Neuropsychiatric disorders
D. Sense organ disorders
E. Cardiovascular diseases
F. Respiratory diseases
G. Digestive diseases
H. Musculo-skeletal diseases
I. Congenital anomalies
J. Oral diseases
K. Other noncommunicable
diseases
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Outpatient care share is only 23% andInpatient share is 45%Decline greater in inpatient share
Poor, larger users of PHCs and urbanpublic hospital OPDs
Rich, larger users of inpatient care
Declining public spending andinvestment impacting on utilisation
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Over 75% share for services likechild immunisation,contraceptivesANC and child birth 50% share
Coverage levels for above serviceslowUrban coverage twice better
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Outpatient care nearly 80% shareWide inter-state variationsInpatient care 55% share and growing
rapidlyAcross classes private care is largestcategoryRich use private care in much larger
proportion but rich are also the largestusers of public hospitals for inpatient careVery low preventive care, but increasingshare in ANC and childbirth
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55%
12%
0%
10%
20%
30%
40%
50%
60%
Low Standard of Living High Standard of Living
16%
48%
0%
10%
20%
30%
40%
50%
60%
Low Standard of Living High Standard of Living
Malaria TB
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0 5 10 15 20
Poorest2
0%20%
-40%
Mid
dle20
%60
%-80%R
iche
st20%
Percent With Regular UseSmoking Tobacco (non-smoking) Alcohol
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10.1
13.4
17.8
25.6
33.1
0
5
10
15
20
25
30
35
Poorest
20%
2nd 3rd 4th Richest
20%
Income Quintiles
ShareofPublic
Subsid
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0 10 20 30 40 50 60 70 80
North East
Andhra Pradesh
Tamil Nadu
Karnataka
Bihar
Kerala
Maharashtra
All India
Haryana
Uttar Pradesh
West Bengal
Gujarat
Madhya Pradesh
Rajasthan
Public Private
BELOW POVERTY LINE HOUSEHOLDS
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0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100
%
Outpatient Care
Hospitalization
Institutional Deliveries
Antenatal Care
Immunizations
Public-Private Sector Shares
Private Public
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33%
45%
52%
58%
61%
0 500 1000 1500 2000 2500 3000 3500 4000
Poorest 20%
20%-40%
Middle 20%
60%-80%
Richest 20%
Hospitalizations Per 100,000 Population
Public Hospitals Private Hospitals
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Social
Group
No ANC TFR IMR U-5Mortality
CompletedImmunisatn
Delivery byDoctor
LOW 45.1 3.37 88.8 130.0 30.4 15.8
MEDIUM 32.8 2.85 70.3 94.6 43.2 31.1
HIGH 12.4 2.10 42.7 51.5 64.7 60.9
ALL 34.0 2.85 73.0 101.4 42.0 30.3
SC 38.2 3.15 83.0 119.3 40.2 23.5
ST 43.1 3.06 84.2 126.6 26.4 14.5
OBC 34.8 2.83 76.0 103.1 43.0 31.8
OTHER 27.9 2.66 61.8 82.6 46.8 37.3
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Percent Women 15-49 Children < 3 yrs % below -3SDSocial
Group
Below145 cms
Below BMI18.5kg/m2
AnyAnemia
Wt. ForAge
Ht. ForAge
Wt. ForHeight
LOW 17.7 48.1 60.2 25.3 29.8 3.9
MEDIUM 12.5 35.6 50.3 16.5 22.4 2.4
HIGH 7.5 17.3 41.9 6.7 10.7 1.5
SC 17.0 42.1 56.0 27.2 27.5 3.0
ST 13.5 46.3 64.9 26.0 27.6 4.4
OBC 13.5 35.8 50.7 18.3 23.1 3.4
OTHER 10.9 30.5 47.6 13.8 19.4 1.8
ALL 13.2 35.8 51.8 18.0 23.0 2.8
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Life ExpectancyTotal Health
Expenditure
as % of GDP
Public health
expenditure
as % of total
U-5
mortality
Male Female
India 5.0 17 95 59.6 61.2
China 2.7 24.9 43 68.1 71.3
Sri Lanka 3 45.4 19 65.8 73.4
Malaysia 2.4 57.6 14 67.6 69.9
Korea 6.7 37.8 14 69.2 76.3
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Private
Investment/
Insurance
2%
Public-States
10%
Public-Centre
3%
Private Out-of-
pocket85%
I di C t S i
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India Current Scenario:Health
Resurgence of Communicable Diseases Declining Public Investments and
Expenditures in Health and Healthcare
Breakdown of the Public Health System Access to Basic Healthcare Declining Absence of Regulation and Control, and
Quality Standards in Private
Healthcare Corporatisation and Rising Costs of
Healthcare and Changed Character ofthe Economy
d
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India Current Scenario:Disability
Physical disability affects 2% of thepopulation and the trend is upwardswith a worsening economic scenario
Mental disability affects about 3% of thepopulation and another 1% suffersmental illness due to increased stress ofthe changing environment
Social Disability based on caste, genderand community getting worse under thecurrent socio-economic dispensation
Other disabilities like, HIV/AIDS, elderly
etc.
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Minimum Needs Program phaseof expansion
Liberalisation phase for growth
of private capital andstagnation of public investment Enter World Bank and
globalisation Centre Abdicates Responsibility State governments follow footsteps
Reduced Level of Expenditures The impact of the fifth pay
commission
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Health Sector Reforms
World Bank assisted Health Systems
Development Projects in 5 States New public management Systems -
societies, contracting out (missionapproach)
Initiative towards private sectorregulation - quality, accreditationetc.
User Fees Opening up of Insurance to the Private
Sector Collaborations with the Private Sector RCH Approach??
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Health Sector Reforms.
Raising levels of Allocations Improving Allocative Efficiencies Improving Technical Efficiencies Improving Quality of Care Enhancing Access to services
removing rural/urban disparities Improving consumer satisfaction Reducing Costs Regulating the private health sector
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Reforming the ExistingSystem
Restructuring and reforms Organising a system Public-private mix Referral system Standards and regulation
Single payer mechanism
I di F t H lth
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India Future HealthPriorities
Priorities for making it work An Act of Parliament - Health
Authority Tackling the medical profession Licensing, registration, minimum
standards
Integration of systems Continuing medical education Pricing mechanisms Raising additional resources
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Strategies and Approaches
Right to Health and Healthcare Awareness Raising and Participation
of Civil Society Groups Organising and Educating Medical
Profession Healthcare as part of Social Security
Universal Access to Healthcare New Public Management Systems and
Governance Structures
I ti i H lth Fi i