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India & Its Health System An Introduction Radhika Arora MPH2013-14 07/07/2015 1 A snapshot 1. 2 Billion People 940 women : 1000 men 41% less than 18 years 100million over the age of 60 years ©Telegraph 07/07/2015 2 A snapshot 28 states- 7 union territories 7 major religions 22 official languages Multiple ethnicities A terrain for every mood 07/07/2015 3 A country of contradictions 07/07/2015 4 Health in India • An introduction • Films • Discussion 07/07/2015 5 A grand tribute to 07/07/2015 maternal mortality 6 Some facts Maternal mortality: women dying at childbirth for every 100,000 live births Infant mortality: probability that a newborn baby will die before reaching age 5 (per 1,000) Complete antenatal care 07/07/2015 India Belgium Sri Lanka 200 8 43 61 4 21 37% 98% 98% 7 Nutrition • 20% of children under 5 undernourished • 43% underweight • Approximately 25% are breastfed in the first hour – Less than 50% exclusively breastfed for the first six months • Anaemia: – 90% adolescent girls – 50% women 07/07/2015 8 In addition • 41 million people with diabetes • 52% deaths due to CVD • 12% injuries and other Non Communicable Diseases are the leading cause of death in India 07/07/2015 9 Health system: India Rich traditional systems of medicine Western [modern medicine] Public & private health care 07/07/2015 10 Delivering services Vertical health programs • Tuberculosis • Malaria And others… Public services Medical colleges & Tertiary level care District health centres Community health centres Community health workers 07/07/2015 Primary health centres Anganwadi centres/ sub-centres 11 What the health system feels like Private hospitals Qualified & unqualified health providers Private pharmacies/diagnostic services 53% exclusive use Public 2% exclusive use/40% both 07/07/2015 12 Financing • 70% OOP people pay for services • 75% of their money medicines • Low insurance coverage 07/07/2015 13 Financing • Tax-based • Some Social health insurance – ESIS • Community health insurance – SEWA • Large private sector – 5 to10% in 1947 to 80% outpatient care (2005) • Health spending – 3.9% GDP 07/07/2015 14 Human Resources • 20 per 10,000 vs. recommended 25 – 8 per 10,000 if reduced for qualifications • Unqualified 37% (rural) & 63% (Urban) • Inequitable distribution 07/07/2015 15 Human Resources So many, yet few: Human resources for health in India Krishna D Rao1*, Aarushi Bhatnagar2 and Peter Berman3 http://www.human-resources-health.com/content/10/1/19 07/07/2015 16 All is not bleak: Changes: 2005 to 2012 • Need to strengthen public health system • 2005: National Rural Health Mission – Health for rural populations – Improve health indicators • 2012: National Health Mission – Improve basic health indicators – Health system strengthening – National programs 07/07/2015 17 Changes: 2005 to 2012 • Financing: Insurance schemes – Rashtriya Swasthya Bima Yojana (RSBY) • Below poverty line (BPL) families hospitalization – Janani Suraksha Yojana (JSY) • Maternal health (BPL) increase institutional deliveries/financial incentives – Rajiv Aarogyasri Scheme (RAS) • State specific BPL insurance scheme (inpatient) • Other: – Tamil Nadu Medical Services Corporation Ltd., (TNMSC) FILM 07/07/2015 18 Challenges & comments • Public system – Historically low resources allocated – Poor governance issues • If it was more efficient it could do better with limited efforts • Prioritization – Focus on vertical programs – Human resources for health constraints – Infrastructure, medicines • Efforts to revive the public health system 07/07/2015 19 Challenges & comments • Booming private sector – In remote locations – Accessible – Challenges: • Low/minimum regulation • Quality/Accountability • Money talks – Do we want to regulate? • Medical tourism • Income generation (?) 07/07/2015 20 Social change 07/07/2015 21 Challenges & comments • Public and private – How can the public sector be improved – Private: • Belgium has private providers: GPs, specialists • People have the freedom to choose • BUT regulation ensures quality – Social health insurance: financial protection for people 07/07/2015 22 Challenges & comments • Quality of care – Patient-doctor relationship • Investment in social factors that impact health • • • • 07/07/2015 Education Water & sanitation Social barriers and empowerment Gender equality 23 Moving forward… • Health indicators are improving • Investments in education, water & sanitation and other aspects of development • Public health as a field of study/practice has emerged • But a lot more needs to be done… 07/07/2015 24 Discussion • Can developing countries like India do without the private sector? • Should health be a public service (good)? 07/07/2015 25 Sources • Indian Government – censusindia.gov.in – mohfw.nic.in – planningcommission.nic.in/reports/peoreport/peo/peo_ch c.pdf – http://planningcommission.nic.in/reports/genrep/rep_uhc 0812.pdf – National Rural Health Mission nrhm.gov.in • WHO Building Blocks – Monitoring the building blocks of health systems: A handbook of indicators and their measurement strategies http://www.who.int/healthinfo/systems/WHO_MBHSS_20 10_full_web.pdf 07/07/2015 26 Leaping forward! Thank you 07/07/2015 27