1. Healthcare system in India have failed to deliver its mandate

2. Healthcare sector- challenges and prospects

3. Does Healthcare Need Healing?

On 27 May 2012, the popular actor Aamir Khans program Satyamev Jayate did an episode on “Does Healthcare Need Healing?” which highlighted the high costs and other malpractices adopted by private clinics and hospitals.

In India, there are issues of rural and urban/  public and private/ rich and poor accessibility gap, quality and coverage, full of complexity and paradoxes.

India is presently in a state of health transition. Infectious diseases and antimicrobial resistance remain a continued threat to health and economic security. At the same time, the country is faced with the emerging problem of chronic non-communicable diseases which are now the leading cause of mortality. This epidemiological transition is being fueled by social and economic determinants of health, as well as by demographic changes such as an ageing population, by environmental factors such as climate change, and by factors such as globalization, urbanization and changing lifestyles. As a result, the health infrastructure is already under severe strain. Moreover, the high cost of health care and out of pocket expenditure force families to sell their assets, pushing nearly 60 million people every year into poverty.

There is a strong relationship between economic growth and better health – it being a two way relationship. The health sector in India is at the crossroads. This is partly due to an interesting relationship between development and health, which is known as the Preston Curve.

• In 1975, Samuel Preston showed that if the health of nations as measured by life expectancy is plotted against the wealth of nations as measured by GDP per capita, then up to a point, there is a sharp increase in life expectancy for even the modest increase in GDP per capita. Then the curve suddenly flattens out – and after this point, large increases in public health expenditure are required for modest increase in life expectancy.

India’s Constitution- 

State list- Public health and sanitation; hospitals and dispensaries.

Concurrent list – Population control and family planning.

Structure of healthcare system in India-

• National level – Union Ministry of Health and Family Welfare. (India’s Ministry of Health was established  in 1947)
• State Level – the State Department of Health and Family Welfare headed by Minister and with a Secretariat under the charge of Secretary/Commissioner
• Regional level – covers three to five districts and acts under authority delegated by the State Directorate of Health Services.
• District Level – middle level management organisation and it is a link between the State as well as regional structure on one side and the peripheral level structures such as PHC as well as sub-centre on the other side.
• Sub-divisional/Taluk level -healthcare services are rendered through the office of Assistant District Health and Family Welfare Officer (ADHO).
• Community level – one Community Health Centre (CHC) has been established for every 80,000 to 1, 20,000 population, and this centre provides the basic specialty services in general medicine, pediatrics, surgery, obstetrics and gynecology.

Primary Healthcare

• It denotes the first level of contact between individuals and families with the health system.
• According to Alma Atta Declaration of 1978, Primary Health care was to serve the community it served.
• In India, Primary Healthcare is provided through a network of Sub centres and Primary Health Centres in rural areas, whereas in urban areas, it is provided through Health posts and Family Welfare Centres.
• The Sub centre consists of one Auxiliary Nurse Midwife and Multipurpose Health worker and serves a population of 5000 in plains and 3000 persons in hilly and tribal areas.
• The Primary Health Centre (PHC), staffed by Medical Officer and other paramedical staff serves every 30000 population in the plains and 20,000 persons in hilly, tribal and backward areas. Each PHC is to supervise 6 Sub centres.

Secondary Health Care

• It is second tier of health system, in which patients from primary health care are referred to specialists in higher hospitals for treatment.
• In India, the health centres for secondary health care include District hospitals and Community Health Centre at block level.

Tertiary Health Care

• It is a third level of health system, in which specialized consultative care is provided usually on referral from primary and secondary medical care.
• In India, under public health system, tertiary care service is provided by medical colleges and advanced medical research institutes.

MDGs–

4. Reduce child mortality

• Reduce by two thirds the mortality rate among children under five.

5. Improve maternal health

• Reduce by three quarters the maternal mortality ratio.

6. Combat HIV/AIDS, malaria and other diseases

• Halt and begin to reverse the spread of HIV/AIDS.
• Halt and begin to reverse the incidence of malaria and other major diseases

SDGs- 

• Goal 3. Ensure healthy lives and promote well being for all at all ages

National Health Poliy 1983

• The first  National Health Policy of 1983 was a response to the commitment to the Alma Ata Declaration to achieve “Health for All by 2000”.
• It accepted that health was central to development and had a focus on access to health services, reiterated the resolution of taking health services community and ensuring cooperation of the community.
• It recognizes nutrition, prevention of food adulteration and maintenance of the quality of drugs, water supply and sanitation, environmental protection; immunization programme, maternal and child health services, school health programme, and occupational health services as priority attention for inputs required for improved health care.
• It called for re-orientation of the existing health personnel and inclusion of various systems of medicine and health care at the appropriate levels, within specified areas of responsibility and functioning, in the over-all health care delivery system, specially in regard to the preventive, promotive and public health objectives.

National Health Policy 2002

The main objective of this policy is to achieve an acceptable standard of good health amongst the general population of the country.

• increase access to the decentralized public health system by establishing new infrastructure in deficient areas, and by upgrading the infrastructure in the existing institutions.
• more equitable access to health services across the social and geographical expanse of the country.
• increasing the aggregate public health investment through a substantially increased contribution by the Central Government to render effective service delivery.
• The contribution of the private sector in providing health services would be much enhanced, particularly for the population group which can afford to pay for services.
• preventive and first-line curative initiatives at the primary health level through increased sectoral share of allocation.

NHP-2002 will endeavour to achieve the time bound goals.

National Health Policy, 2017

The context for health policy has changed in four major ways.

1. First, the health priorities are changing. Although maternal and child mortality have rapidly declined, there is growing burden on account of non-communicable diseases and some infectious diseases.
2. The second important change is the emergence of a robust health care industry estimated to be growing at double digit.
3. The third change is the growing incidences of catastrophic expenditure due to health care costs, which are presently estimated to be one of the major contributors to poverty.
4. Fourth, a rising economic growth enables enhanced fiscal capacity.

Therefore, a new health policy responsive to these contextual changes was required.

The National Health Policy, 2017 seeks to reach everyone in a comprehensive integrated way to move towards wellness. It aims at achieving universal health coverage and delivering quality health care services to all at affordable cost.

The primary aim of the National Health Policy, 2017, is to inform, clarify, strengthen and prioritize the role of the Government in shaping health systems in all its dimensions- investments in health, organization of healthcare services, prevention of diseases and promotion of good health through cross sectoral actions, access to technologies, developing human resources, encouraging medical pluralism, building knowledge base, developing better financial protection strategies, strengthening regulation and health assurance.

Goal

• The attainment of the highest possible level of health and well-being for all at all ages, through a preventive and promotive health care orientation in all developmental policies, and universal access to good quality health care services without anyone having to face financial hardship as a consequence.
• This would be achieved through increasing access, improving quality and lowering the cost of healthcare delivery.

Objectives

Improve health status through concerted policy action in all sectors and expand preventive, promotive, curative, palliative and rehabilitative services provided through the public health sector with focus on quality.

1. Progressively achieve Universal Health Coverage
2. Assuring availability of free, comprehensive primary health care services, for all aspects of reproductive, maternal, child and adolescent health and for the most prevalent communicable, non-communicable and occupational diseases in the population.
3. The Policy also envisages optimum use of existing manpower and infrastructure as available in the health sector and advocates collaboration with non -government sector on pro-bono basis for delivery of health care services linked to a health card to enable every family to have access to a doctor of their choice from amongst those volunteering their services.
4. Ensuring improved access and affordability, of quality secondary and tertiary care services through a combination of public hospitals and well measured strategic purchasing of services in health care deficit areas, from private care providers, especially the not-for profit providers
5. Achieving a significant reduction in out of pocket expenditure due to health care costs and achieving reduction in proportion of households experiencing catastrophic health expenditures and consequent impoverishment.
6. Reinforcing trust in Public Health Care System: by making it predictable, efficient, patient centric, affordable and effective, with a comprehensive package of services and products that meet immediate health care needs of most people.
7. Align the growth of private health care sector with public health goals; Enable private sector contribution to making health care systems more effective, efficient, rational, safe, affordable and ethical. Strategic purchasing by the Government to fill critical gaps in public health facilities.

Specific Quantitative Goals and Objective

Health Status and Programme Impact

1. Life Expectancy and healthy life
   • Increase Life Expectancy at birth from 67.5 to 70 by 2025.
   • Establish regular tracking of Disability Adjusted Life Years (DALY) Index as a measure of burden of disease and its trends by major categories by 2022.
   • Reduction of TFR to 2.1 at national and sub-national level by 2025.
2. Mortality by Age and/ or cause
   • Reduce Under Five Mortality to 23 by 2025 and MMR from current levels to 100 by 2020.
   • Reduce infant mortality rate to 28 by 2019.
   • Reduce neo-natal mortality to 16 and still birth rate to “single digit” by 2025.
3. Reduction of disease prevalence/ incidence
   • Achieve global target of 2020 which is also termed as target of 90:90:90, for HIV/AIDS i.e, – 90% of all people living with HIV know their HIV status, – 90% of all people diagnosed with HIV infection receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral therapy will have viral suppression.
   • Achieve and maintain elimination status of Leprosy by 2018, Kala-Azar by 2017 and Lymphatic Filariasis in endemic pockets by 2017.
   • To achieve and maintain a cure rate of >85% in new sputum positive patients for TB and reduce incidence of new cases, to reach elimination status by 2025.
   • To reduce the prevalence of blindness to 0.25/ 1000 by 2025 and disease burden by one third from current levels.
   • To reduce premature mortality from cardiovascular diseases, cancer, diabetes or chronic respiratory diseases by 25% by 2025.

Health Systems Performance

1. Coverage of Health Services
   • Increase utilization of public health facilities by 50% from current levels by 2025.
   • Antenatal care coverage to be sustained above 90% and skilled attendance at birth above 90% by 2025.
   • More than 90% of the newborn are fully immunized by one year of age by 2025.
   • Meet need of family planning above 90% at national and sub national level by 2025.
   • 80% of known hypertensive and diabetic individuals at household level maintain “controlled disease status” by 2025.
2. Cross Sectoral goals related to health
   • Relative reduction in prevalence of current tobacco use by 15% by 2020 and 30% by 2025.
   • Reduction of 40% in prevalence of stunting of under-five children by 2025.
   • Access to safe water and sanitation to all by 2020 (Swachh Bharat Mission).
   • Reduction of occupational injury by half from current levels of 334 per lakh agricultural workers by 2020.
   • National/ State level tracking of selected health behaviour.

Health Systems strengthening

1. Health finance
   • Increase health expenditure by Government as a percentage of GDP from the existing 1.1 5 % to 2.5 % by 2025.
   • Increase State sector health spending to > 8% of their budget by 2020.
   • Decrease in proportion of households facing catastrophic health expenditure from the current levels by 25%, by 2025.
2. Health Infrastructure and Human Resource
   • Ensure availability of paramedics and doctors as per Indian Public Health Standard (IPHS) norm in high priority districts by 2020.
   • Increase community health volunteers to population ratio as per IPHS norm, in high priority districts by 2025.
   • Establish primary and secondary care facility as per norm s in high priority districts (population as well as time to reach norms) by 2025.
3. Health Management Information
   • Ensure district – level electronic database of information on health system components by 2020.
   • Strengthen the health surveillance system and establish registries for diseases of public health importance by 2020.
   • Establish federated integrated health information architecture, Health Information Exchanges and National Health Information Network by 2025.

 Key Policy Principles

1. Professionalism, Integrity and Ethics
2. Equity
3. Affordability
4. Universality
5. Patient Centered & Quality of Care
6. Accountability
7. Inclusive Partnerships
8. Pluralism
9. Decentralization: Dynamism and Adaptiveness

Policy thrust

1. Ensuring Adequate Investment– raising public health expenditure to 2.5% of the GDP in a time bound manner.
2. Preventive and Promotive Health– coordinated action on seven priority areas for improving the environment for health:
   1. The Swachh Bharat Abhiyan
   2. Balanced, healthy diets and regular exercises.
   3. Addressing tobacco, alcohol and substance abuse
   4. Yatri Suraksha – preventing deaths due to rail and road traffic accidents
   5. Nirbhaya Nari – action against gender violence
   6. Reduced stress and improved safety in the work place
   7. Reducing indoor and outdoor air pollution
3. Organization of Public Health Care Delivery– The policy proposes seven key policy shifts in organizing health care services.
   1. In primary care – from selective care to assured comprehensive care with linkages to referral hospitals
   2. In secondary and tertiary care – from an input oriented to an output based strategic purchasing
   3. In public hospitals – from user fees & cost recovery to assured free drugs, diagnostic and emergency services to all
   4. In infrastructure and human resource development – from normative approach to targeted approach to reach under-serviced areas
   5. In urban health – from token interventions to on-scale assured interventions, to organize Primary Health Care delivery and referral support for urban poor.
   6. In National Health Programmes – integration with health systems
   7. In AYUSH services – from stand-alone to a three dimensional mainstreaming
4. Closing Infrastructure and Human Resource/Skill Gaps
5. Urban Health Care

Private and Public/ Urban and rural gap

Rich and poor divide/ Social gap   (issue of Equity)

Healthcare between states and rural and urban areas can be vastly different. Rural areas often suffer from physician shortages, and disparities between states mean that residents of the poorest states, like Bihar, often have less access to adequate healthcare than residents of relatively more affluent states.

Lack of adequate coverage by the health care system in India means that many Indians turn to private healthcare providers, although this is an option generally inaccessible to the poor. To help pay for healthcare costs, insurance is available, often provided by employers, but most Indians lack health insurance, and out-of-pocket costs make up a large portion of the spending on medical treatment in India.

On the other hand private hospitals in India offer world class quality health care at a fraction of the price of hospitals in developed countries. This aspect of health care in India makes it a popular destination for medical tourists. India also is a top destination for medical tourists seeking alternative treatments, such as ayurvedic medicine. India is also a popular destination for students of alternative medicine.

The public health care system was originally developed in order to provide a means to healthcare access regardless of socioeconomic status. However, reliance on public and private healthcare sectors varies significantly between states. Several reasons are cited for relying on the private rather than public sector; the main reason at the national level is poor quality of care in the public sector, with more than 57% of households pointing to this as the reason for a preference for private health care. Most of the public healthcare caters to the rural areas; and the poor quality arises from the reluctance of experienced healthcare providers to visit the rural areas. Consequently, the majority of the public healthcare system catering to the rural and remote areas relies on inexperienced and unmotivated interns who are mandated to spend time in public healthcare clinics as part of their curricular requirement. Other major reasons are distance of the public sector facility, long wait times, and inconvenient hours of operation.

Different factors related to public healthcare are divided between the state and national government systems in terms of making decisions, as the national government addresses broadly applicable healthcare issues such as overall family welfare and prevention of major diseases, while the state governments handle aspects such as local hospitals, public health, promotion and sanitation, which differ from state to state based on the particular communities involved.

Private healthcare

• With the help of numerous government subsidies in the 1980s, private health providers entered the market. In the 1990s, the expansion of the market gave further impetus to the development of the private health sector in India. After 2005, most of the healthcare capacity added has been in the private sector, or in partnership with the private sector.
• According to National Family Health Survey-3, the private medical sector remains the primary source of health care for 70% of households in urban areas and 63% of households in rural areas. However, the high out of pocket cost from the private healthcare sector has led many households to incur Catastrophic Health Expenditure (CHE), which can be defined as health expenditure that threatens a household’s capacity to maintain a basic standard of living. One study found that over 35% of poor Indian households incur CHE and this reflects the detrimental state in which Indian health care system is at the moment.
• With government expenditure on health as a percentage of GDP falling over the years and the rise of private health care sector, the poor are left with fewer options than before to access health care services. Private insurance is available in India, as are various through government-sponsored health insurance schemes. According to the World Bank, about 25% of India’s population had some form of health insurance in 2010. A 2014 Indian government study found this to be an over-estimate, and claimed that only about 17% of India’s population was insured. Private healthcare providers in India typically offer high quality treatment at unreasonable costs as there is no regulatory authority or statutory neutral body to check for medical malpractices.

Rural health

• In addition, only 2% of doctors are in rural areas – where 68% of the population live. Studies have indicated that the mortality risks before the age of five are greater for children living in certain rural areas compared to urban communities. Full immunization coverage also varies between rural and urban India, with 39% completely immunized in rural communities and 58% in urban areas across India. Inequalities in healthcare can result from factors such as socioeconomic status and caste, with caste serving as a social determinant of healthcare in India.
• The willingness to pay for healthcare services of all types were greater in the urban areas compared to the rural areas, attributing this statistic to the greater awareness of healthcare importance in urban areas. In addition there is link between education and access to healthcare.
• The role of technology, specifically mobile phones in health care has also been explored in recent research as India has the second largest wireless communication base in the world, thus providing a potential window for mobile phones to serve in delivering health care.  In general, it was found that as socioeconomic status increased, the probability of seeking healthcare increased.

Urban health

• The National Urban Health Mission as a sub-mission of National Health Mission was approved by the Cabinet on 1 May 2013. It aims to meet health care needs of the urban population with the focus on urban poor, by making essential primary health care services available to them and reducing their out of pocket expenses for treatment.
• Rapid urbanisation and disparities in urban India
• Child health and survival disparities in urban India
• Maternal healthcare disparities in urban India
• High levels of undernutrition among the urban poor
• High levels of stunted growth and underweight issues among the urban poor

Quality of healthcare

Non-availability of diagnostic tools and increasing reluctance of qualified and experienced healthcare professionals to practice in rural, under-equipped and financially less lucrative rural areas are becoming big challenges. Rural medical practitioners are highly sought after by residents of rural areas as they are more financially affordable and geographically accessible than practitioners working in the formal public health care sector.

The health care challenges for tribal populations, adolescents and young people, women and the North East region-  (discuss in detail as per requirement)

Challenges

• Related to human resource
• Related to legal framework
• Related to physical infrastructure
• Related to disease burden
• Related to accessibility/ universality
• Related to equity

Schemes/ Programmes by Central Government

Preventive and Promotive Healthcare

• Mission Indradhanush
• National immunization programme
• RBSK

Programmes for communicable diseases

• Integrated Disease Surveillance Programme(IDSP)
• Revised National Tuberculosis Control Programme(RNTCP)
• National Leprosy Eradication Programme(NLEP)
• National Vector Borne Disease Control Programme
• National AIDS Control Programme(NACP)
• Pulse Polio Programme

Programmes for Non-communicable diseases

• National Tobacco Control Programme(NTCP)
• National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases & Stroke (NPCDCS)
• National Programme for Control Treatment of Occupational Diseases
• National Programme for Prevention and Control of Deafness (NPPCD)
• National Mental Health Programme
• National Programme for Control of Blindness

National Nutritional Programmes

• Integrated Child Development Services (ICDS)
• National Iodine Deficiency Disorders Control Programme
• Mid-Day Meal Programme
• WIFS- weekly iron and folic acid supplements
• Deworming drive

Programmes related to system strengthening / welfare

• National Program of Health Care for the Elderly (NPHCE)
• RMNCH+A
• NHM
• The National Rural Health Mission (NRHM)  2005. This mission focuses resources on rural areas and poor states which have weak health services in the hope of improving health care in India’s poorest regions.
• National Urban Health Mission (NUHM)

Miscellaneous

• Voluntary Blood Donation Programme
• Universal Immunization Programme (UIP)
• Pradhan Mantri Swasthya Suraksha Yojana (PMSSY)
• Janani Shishu Suraksha Karyakaram (JSSK)
• Rashtriya Kishor Swasthya Karyakram(RKSK)
• RBSK
• National health scheme
• Kilkari-  The government has launched Kilkari (literally baby noises), a mobile voice message service that delivers weekly messages to families about pregnancy, family planning, nutrition, childbirth and maternal and child care.

The database for the Kilkari programme will be taken from the successful Mother and Child Tracking System (MCTS) to monitor pregnant women and babies. As per plans, every woman registered with MCTS will receive weekly messages relevant to the stage of pregnancy and age of the infant.

• Ayushman Bharat Programme– budget 2018-19
  1. Primary sector- development of 1,50,000 subcentres as health and wellness centres with a. maternal and child health services b. mental health services c. vaccination for certain communicable diseases d. screening for hypertension, diabetes and certain cancers.
  2. Secondary and tertiary sector- NHPS national health protection scheme.

Some of the schemes/programmes of state government (visit https://www.nhp.gov.in/healthprogramme/state-health-programmes for all states and UTs)

Rajasthan

Chief Minister’s Free Medicine Scheme

Mukhya Mantri Jeevan Raksha Kosh

Under this scheme, Complete diagnotic testing and drugs are made available free of cost to the patients who are below BPL.

Mukya Mantri Shubhlaxmi Yojna

Under this scheme, Women are given a sum of Rs 2100 after giving birth to a girl child and the same sum is given again after completion of one year and full immunization schedule . A sum of Rs 3100 is given on completion of 5 yrs and when seeking admission into school.

Mukhyamantri Nishulk Janch Yojna

To provide comprehensive health care to people basic diagnostic services should be made available to them. This scheme aspires to reduce the treatment cost and decrease the out of pocket expenditure.

Madhya Pradesh

Hamaribityan

Sex Selection is the practice of determining the sex of the unborn foetus and eliminating it if found to be female. Sex Selection is commonly referred to as Female Foeticide. This scheme gives a provision for registering complaints online.

Ladli Laxmi Yojana

The objective of this scheme is to lay a firm foundation of girls’ future through improvement in their educational and economic status and to bring about a positive change in social attitude towards birth of a girl.

Deen Dayal Mobile Health Clinic   

Deendayal Mobile Hospital Yojana was launched in Madhya Pradesh with the objective of expanding the outreach of health services to far-flung areas that are not easily accessible and where there is a concentration of SC/ST population.

Deendayal Antyodaya Upchar Yojana

The scheme aims at providing medical treatment to patients belonging to BPL families of all the categories. Under the scheme, medical checkup and treatment worth up to Rs 20 thousand is given to a family in one financial year.

Andhra Pradesh

Aarogyasri:

It covers those below the poverty line. The government issues an Aarogyasri card and the beneficiary can use it at government and private hospitals to obtain services free of cost.

Tamil Nadu

Chief Ministers Comprehensive Health Insurance Scheme

The Tamil Nadu Health Systems Project (TNHSP), implemented by the Health and Family Welfare Department (Government of Tamilnadu)  and focusses on improving the health status of people belonging to the lower socio-economic strata.

Every member of a family whose annual family income is less than Rs.72,000/- as certified by Village Administrative Officer and such other person who may be declared to be eligible for coverage under the “Chief Minister’s Comprehensive Health Insurance Scheme” by the Government will be “Eligible Persons” under the Scheme.

Medical Tourism – India is a popular destination for medical tourists, given the relatively low costs and high quality of its private hospitals.

 “Health is Wealth” may be an oft quoted dictum, but, it is also a reality that a healthy person is more able to take care of himself/herself and his/her family and the nation. A Nation with a healthy population is more capable of contributing to and achieving its development goals and making India vivid and vibrant.

A continuum of care system/ integrated healthcare system also needs to be established by linking institutions or hospitals, with health centres and the community. Community engagement is thus crucial in planning and implementation of the programme and in ensuring that the health and wellness centres and the primary health centres are responsive to the needs of the community.