Kingsuk Sarkar, MDAsst. Professor,Dept. of Community MedicineDSMCH

SOCIAL AGENCIES

Social agencies are an integral part of socio-cultural tradition of India they are coordinated & assisted by Ministry of Social Welfare & Women’s AffairsAutonomous Central Social Welfare Board implements women oriented programsWomen centered activities are : training, welfare, provision of health care, women’s hostel, legal aid & support to women against exploitation by employers or by their own families.

All India Women’s conferenceNational Council for WomenNational Association for Rural WomenIndian Social InstituteCentre of Science for VillagesEastern India Women’s Association

Administrative Pattern of India: a)Centre, b)State & c)Local Government

centre:- 28 states & union territories- Indian constitution came into effect from 26.01.1950- President, vice President, Prime Minister, Council of Ministers→ Union Executives•India: sovereign, Republic with parliamentary democracy•Parliament: President & two Houses – the Rajya Sabha & Lok Sabha•Parliament assisted by several committes•Lok sabha members get elected every 5 years

State:-Closely resembles center-Governor, Council of Ministers with a Chief Minister as Head→ State Executive-Governor appointed by president for 5 years-Vidhan Sabha: Legislative Assembly; members chosen by direct election-Vidhan Parishad: Legislative Council, Upper House-Union territories are governed by the President through

Local Government:1) Urban:- Corporation, Municipal Committee,

Council- Corporations headed by elected Mayors,

Municipalities headed by Presidents- Executive power of the corporation lies on

the hands of the Commissioners- Corporation deals with public health &

sanitation, maintenance of roads, bridges, markets, playgrounds, parks & education

2) Rural:- Ruled by PRI systems

•Process of Democratic Decentralization:

oGram Panchayats→ elected by Gram Sabhas( entire adult pop. Of village)oPanchayats responsible for: agricultural production, relief, rural industries, MCH, maintenance of roads, tanks & sanitationoPanchayats exercise control over schools, PHCsoVillage Courts/ Judicial Panchayats→ speedy disposal of

Panchayati Raj Institutions

Level Institution

Village Gram Panchayat

Block Panchayat Samiti

District Zilla Parishad

•Laws:-Some came into existence out of sheer tradition- few enacted by Parliament & State Legislatures- Constitution is the Supreme-Important laws in the field of community health :a) The Prevention of Food Adulteration Act,1954b) The MTP Act,1971c) The ESI Act,1948d) The Indian factories Act,1948e) The Central maternity Benefit Act,1961f) The Children Act,1960g) The central Birth & Death Registration Act,

1969h) The Epidemic Diseases Act, 1897i) Juvenile Justice Act,1986

•Cooperatives: -A form of conducting business in the society-After the recovery of costs, profits are distributed among members-Government encourages establishment of cooperatives for uplifting poor by providing loans at easier terms (soft loans)-Societies on dairy, poultry, irrigation projects, consumer societies

•Educational Services:-Obtaining basic education: fundamental rights-Education: important community service-Education socialize children to implant social values & norms & prepare for future role as citizen-Education is a state responsibility-Constitution guarantees free & compulsory education up to 14 years -Central government determines & controls educational standard, technical & scientific education , research-MCI prescribes standards of medical education-Ministry of Education: State & Central level

•Recreation & Cultural Activities:-Three National Academies to promote Indian Art, Music, Drama-State Academies also promote art-AIR & Doordarshan are influential mass media even in remote areas-Indian movies are largest in volume-Documentary movies expresses life, art, culture of Indian people belonging to various regions

CONCEPTS OF HALTH ECONOMICS

•Resources of India:-India is rich in both natural resources & manpower1) Agriculture: mainstay of economy,

employs 70% of population2) Forestry: 20% land covered by forests

which are a major source of timber, resins, gum, bamboo, canes, tendu leaves, rubber, dyes, honey

3) Fisheries: marine product help to bring coveted foreign exchange

4) Minerals: coal, bauxite, mica, iron, manganese, nickel, copper,

5) Manpower: greatest resource, accounts for 16% of global pop.

Principal categories of Industrial WorkersNam of the Industry

Primary SectorAgricultural & Allied ActivitiesMining & quarryingSecondary SectorManufacturingElectricity, Gas, Water supply ConstructionTertiary SectorWholesale & Retail Trade, Hotel & Restaurant Transport, storage & communitiesOther Services

•Challenges of industrialization:-principal industries were jute, cotton, coal-Emerging industries: steel, sugar, cement, chemicals, glass, vanaspati, soap, heavy electrical, machine tools-Shifting of rural to urban population-Community Health problems of urbanizations: slum dwelling, air & water pollution, accidents, increases incidence of communicable diseases like tb & STDs, mental health problems-Social problems: alcoholism, drug dependence, prostitution, gambling, generalized crime

Health has a price Sickness has costResources are scarce & hence to be allotted in a priority basisPrinciple of Health Economics:-“best ways to spend limited resources available in a country for Health Care”India ranks low among developed & developing countries in per capita health expenditure

Financial impact of Tuberculosis in India-India’s biggest health as well as social problem-Man days lost due to tuberculosis:- Indian worker with tuberculosis lost an average of 83 work days because of disease-2 million new cases reported in India-National loss per year→166 million lost work days at a cost of $200 million

•If we add indirect cost, TB costs India Rs.12000 crores annually•Non –disease costs 300000 school dropouts due to TB•High cost for diagnosis & successful treatment of TB→ account more than half of avg, income of daily wage earner•Rejection of married women by their families•>80% TB patients are in economically productive age group

Economic impact of Tobacco Use:-Another economic burden-cost f treating tobacco related disorders e.g., COPD, CAD, cancers are very high-It offsets the monetary effects earned as revenue or employment opportunities in tobacco industries

Cost:-Value of resources used to produce something, including a specific or a set of health services-The patient should be considered as customer & he wants ‘value for the money spent’

Benefit:-Refers to ‘outcomes’ which can be measured I terms of money-Outcomes may be: oProducts & Services(output)oImproved KAP(effects)oImprovement in health statusoReduction in- morbidity, mortality & fertilityoImprovement n nutritional status(outcome)-effectiveness or effects are outcomes in a natural way which are not expressed in natural terms; e.g,, no. of lives saved by a health intervention or life years gained or no. of heart attacks prevented

Cost by Input: Capital Cost:-Vehicles: bicycles, motorcycles, trucks-Equipments: refrigerators, sterilizers, manufacturing machinery, scales, equipments-Buildings: health centres, hospitals, training schools, administrative office, storage facilities-Trainings: non-recurrent training activities for health personnel which occur rarely-Social mobilization: non-recurrent social mobilization activities, e.g. promotion & publicity campaigns

Recurrent Cost:-Personal cost- supervisors, health workers, administrators, consultants, casual labor-Supplies: drugs, vaccines, syringes, small equipments -Vehicle operation & maintenance: petrol, diesel, lubricants, tyres, spare parts, registration & insurance-Building operation & maintenance: electricity, water, heating, fuel, telephone, telex, insurance, cleaning, painting, repairs of electrical supply & appliances, plumbing, roofing -Training: -Social mobilization: operational costs-Other operational costs not mentioned above

Opportunity Cost:-Central concept in economic analysis-Explains the consequences of choosing between two alternatives•E.g. among two possible interventions; a cancer screening program & a smoking cessation program, only one can be funded with the view to limited budget- The opportunity cost of funding 1st program will be the benefits we forgo by not choosing the 2nd plan i.e. no. of life years that could have been gained through smoking cessation program

Average Cost:- Total cost for intervention ∕ total no. of units provided for treatment;e.g. average cost of OPD treatment at PHC per patient per dayincremental Cost:- Difference in cost between two interventions i.e. the intervention & its comparator

Marginal Cost:-An additional cost or extra cost of producing one unit of output or expanding a program-E.g. additional cost of adding MMR vaccine to the universal immunisation program-Increasing hospital stay by single day

Methods of Economic Evaluation

i. Cost minimization analysis (CMA)ii. Cost-effectiveness analysis (CEA)iii. Cost utility analysis (CUA)iv. Cost benefit analysis (CBA)

Cost Minimization Analysis(CMA)-CMA compares the costs of different interventions which are assumed to provide equivalent benefits-Here only the costs are compared , not the benefits-Cheaper the intervention, better the value for money-It is rarely found for two health interventions to churn out exactly same benefits

Cost Effectiveness Analysis:-Here benefits are measured in natural units-E.g. heart attacks avoided, life years gained (no. of years by which the life is extended as a result of intervention),-CEA presented as ratio-CEA=Cost/No. of lives saved-Effectiveness is an expression of desired effect of a program, service or institution or support activity to reduce a health problem or to improve a health situation

-Effectiveness measures degree of attainment of predetermined objectives & targets of a program, service or institution-Population based services e.g. nutrition, immunization, fertility, tobacco & other drugs, household & external environments[ indoor air pollution, provision of safe water & sanitation, vector control], HIV/AIDS ---highly cost effective

Cost Utility Analysis (CUA):-CUA can be used to compare the costs & benefits of health technologies where treatments can influence both quality & quantity of life in a multidimensional way-Most widely used QALY, DALY, healthy year equivalent-CUA=Cost/QALY gained or DALY averted-Dominant intervention: an intervention both cheaper & more effective than its comparators-To select between 2 treatments, incremental cost-effectiveness ration (ICER) should be calculated

Cost Benefit analysis:-benefits measured in monetary terms-Final result expressed as net monetary gain(or loss) or Cost Benefit Ratio-CBA= Cost in Monetary terms/Benefits in Monetary terms-Two main methods to measure health gains from CBA, human capital approach & willingness to pay approach

Efficiency:-An input-output ratio -An expression of relationships between the results obtained from the health program/activity and the efforts obtained in terms of human, financial & other resources, health processes, technology & time-Assessment of technology→ aimed at improving implementation

Quality Adjusted Life Years• a common measure of benefit that combines quantity & quality of life•Calculated by estimating the total no. Of life years gained from treatment & weighing each other with a quality of life score to represent the quality of life in that year•E.g. a patient living for 10 years with a quality of life of 0.6 on a scale of 0-1 (with 0 as death & 1 as perfect health), would live for six (0,6X10) Quality of Life Years

Disability Adjusted Life Years (DALYs)-Used to determine disease burden-Another indicator similar to QALY-Developed by World Bank & WHO to quantify global burden of disease-Incorporates both quality & quantity of life in a common measure-It measures losses of healthy life rather than life years gained -One DALY≈ one year of healthy life lost