Transcript Title

India’s Health Challenges:
Will Universal Health Coverage
Provide The Platform For Response?
Prof. K. Srinath Reddy
President,
Public Health Foundation of India,
President, World Heart Federation
1
India is Under performing its Income Group Peers in Health
2
We lose 1,400,000 infants every year, 4000 every
day…equivalent to 12 full Jumbo Jets crashing every day.
Our children die early, prematurely, and needlessly
Out of 100 live births, 5 die before their
first birthday – 3 within the first month
Our infant mortality rate is 3X more than
China, 4X Thailand or Sri Lanka
Believe it or not…we are actually worse
than Botswana, Bangladesh & Nepal
Infant Mortality Rate
Deaths per 1000 live births
It is Lottery of Life - death in childbirth
more likely in poorer states - MP (76), 600%
higher than Kerala (13)
Most are needless deaths, from
preventable causes such as malnutrition,
lack of immunisation, diarrhoea,
pneumonia and malaria
SOURCE: WHO 2012
3
And has Lagged Behind
4
On providing basic immunization to our children, we are
behind Bangladesh, Nepal, Thailand, Ghana, Pakistan, to
name a few
DPT immunisation rate
% of children covered
China
Sri Lanka
Thailand
Brazil
Botswana
Bangladesh
Ghana
Myanmar
Pakistan
Nepal
India
Source: WDI. WHO
30% of children in India go without DPT
coverage, 50% without full immunization
99
99
99
98
96
95
94
90
88
82
72
Nearly 100% children covered in China,
Brazil, Sri Lanka or Thailand
5
Despite all the progress, 40% children in India are
undernourished. A “national shame!”
Of those who survive the
first year, 43% are
underweight, and 66%
anaemic by age of three
% underweight below 5
Very few go undernourished in China,
Brazil or Thailand. We do worse than
sub-Saharan Africa
Source: WDI. WHO
Brazil
China
Thailand
Ghana
Sri Lanka
Sub Saharan Africa
Nepal
Bangladesh
India
2
7
7
14
22
28
39
41
43
6
Our maternal mortality rate is 4X of China and Brazil, 6X of
Sri Lanka
We only compare favorably with Pakistan, Gabon and
Cambodia
60,000 plus mothers die every year. More deaths in a
week than in a whole year in Europe
A sacrifice to give life – a preventable tragedy
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Incidence and prevalence of infectious diseases remains
high
TB incidence
(A) 2 million new cases every year
(B) Incidence rate 200-300% more that
of China and Brazil. In the range of
Afghanistan and Pakistan
(C) Drug resistant TB a major threat
Malaria prevalence
(A) 9.7 million cases, with 40,000+
deaths every year (recent ICMR
study)
(B) Over 70% of India at risk of malaria
infection
8
In Chronic (non-communicable) diseases such as diabetes and
cardiovascular disorders, we are facing advancing epidemics
Diabetes epicenter of the world – 61
million cases in 2011 to rise to 101
million in 2030
Every 8th adult has or is at high-risk.
40-60 working age group most affected
India could lose US$ 237 billion (over
2005-2015) to cardiovascular disease
and diabetes (WHO)
Potentially productive years of life lost due to cardiovascular
deaths (36-64 years age group); In millions
2000
2030
Underlying risk factors - unhealthy diets,
physical inactivity, alcohol consumption
and tobacco use
If neglected, this will be a source
of continuing productivity loss
India
China
Russia
USA
9
Quality of Primary Care
Scored For:
• 24 Hour Availability of Services
• Clinical Staff In Position
• Training In Past 5 Years
• Basic Infrastructure
• Equipment
• Essential Drugs
India
: 52%
Low Performing States : 48%
High Preforming States : 57%
North East
: 53%
Powell T et al
EPW (May 2013)
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Public health spend not yet a high priority. Our public
expenditure on health is among the lowest in the world
Country
Public expenditure
on health as % of
GDP
Per capita public
expenditure on
health (PPP$)
Sri Lanka
1.8
87
India
1.2
43
Thailand
3.3
261
China
2.3
155
More funding needed with right investments such as Primary
healthcare | Education and training facilities – medical and public health
| Availability of essential drugs to all | Expansion of universal health
coverage
Need for doubling of public spending on health to at
least 2% of GDP by end of 12th Plan
Source: WHO database, 2009
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Low Public, High Out of Pocket Health Expenditure
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Unaffordable and unsustainable healthcare costs
70% of health spend from own
pockets on health. Out of pocket
(OOP) expenditure amongst highest
in the world
Over 60 million people thrown
below the poverty line every
year due to OOP on health
Over 40% of hospitalised
persons had to borrow money
or sell assets to pay for their
care
28% of rural residents and
20% of urban residents had
no funds for health care
Huge social burden on the poor
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High costs of out-patient and medicine costs
Breakdown of private out-of-pocket
expenditures (%)
Medicines and other expenses
Others
28%
Inpatient
24%
Outpatient
76%
Medicines
72%
Current scenario of Doctors
Number of Doctors –
Those available –
Present Doctor Population Ratio
Target by 2025–
China
USA
UK
Sweden
8.58 lakh (as per IMR)
6 - 6.5 lakh (75%) (approx)
0.5 per 1000
0.8 per 1000
1.6 per 1000
2.6 per 1000
2.3 per 1000
3.3 per 1000
• Additional Doctors required – 4 lakh by 2020
1.5
0.8
1.1
0.5
lakh
lakh
lakh
lakh
in 50,000 PHCs
in 12,500 CHCs
in 5,642 SDH/DH
in
800 MCHs
Current Scenario of Nurses
Nurses registered
11.2 lakh
Available
9 lakh (Approx)
Nurse-Population Ratio
0.4 per 1000
(Nurses +ANM) Vs Doctor Ratio
1.5 : 1 (Desired 3:1)
Target by 2025
2.2 : 1
---------------------------------------------------------------------------------------
Brazil
South Africa
USA
UK
3:1
3:1
5:1
5:1
-------------------------------------------------------------------------------------------Additional Nurses required – 16.2 lakhs by 2020
Allied Health Workforce shortfall- National estimate
Allied Health Workforce Category Demand Supply
Gap
Unadjusted Efficiency-Access
Adjusted
Ophthalmology related
Rehabilitation /other related
Surgical intervention technology
Medical lab technology
Radiography and imaging technology
Audiology/ speech language
pathology
Medical technology
Dental assistance related technology
Surgery and anesthesia related
technology
Miscellaneous
Total
145,236 17,678 127,558
1,862,584 40,265 1,822,319
205,088 7,215
197,873
136,039
1,841,637
208,618
76,884
23,649
15,214
4,352
61,670
19,297
70,603
20,971
10,599
3,263
7,336
8,901
239,657
2,048,391
3,587 236,070
6,243 2,042,148
862,193
4,050
8,58,143
1,074,473 181,511 8,92,962
45,14,271
237,791
2,045,143
860,086
980,045
64,09,834
Our Definition of UHC
“Ensuring equitable access for all Indian citizens
resident in any part of the country, regardless of
income level, social status, gender, caste or
religion, to affordable, accountable and
appropriate, assured quality health services
(promotive,
preventive,
curative
and
rehabilitative) as well as public health services
addressing wider determinants of health
delivered to individuals and populations, with
the government being the guarantor and enabler,
although not necessarily the only provider, of
health and related services.”
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Universal Health Coverage is
when ALL people receive the
quality health services they
need without suffering
financial hardship
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National Rural Health Mission (NRHM)
HIGHLIGHTS
SHORTFALLS
▪ Decentralized planning and
▪ Focus on maternal and child
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implementation through community
participation (through various
initiatives such as ASHA, VHSC,
SHGs)
Pro poor-based equitable systems
Emphasis on convergence
Flexibility and adequacy of central
funding with accountability
framework to ensure public action
Judicious mix of dedicated budget
lines – untied funds to all public
institutions
Provision of incentives for CHWs in
hard-to-reach areas
Monitoring progress against
standards (such as IPHS)
Targeted interventions to
measureable outcomes, reviewed
annually through the CRM process
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health – other primary health care
needs not addressed
Quality of care not assured, even
for institutional deliveries
Health workforce deficiencies
(numbers; skills) affect delivery of
services
Impact on out-of-pocket not
demonstrated
Continuum of care (10 +20 +30) not
developed
Rashtriya Swasthya Bima Yojna (RSBY)
HIGHLIGHTS
SHORTFALLS
▪ India’s first social-security scheme
▪ Low coverage with financial
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with a profit motive, involving
insurance companies, hospitals,
state governments and the Centre
Encourages increased
contributions to health and
augments financial resources of
the State governments
Attempts to address several
lacunae regarding enrolment,
utilisation levels and fraud control
Mandatory enrolment and
technology-based cashless
policies address the problem of
risk selection and selective
rejection of claims by insurers.
▪
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protection available only for
hospitalization, and not for outpatient care
Focus on hospital networks rather
than primary care services
Difficult to maintain quality of
healthcare at accredited hospitals
due to induced demand and fraud
Potential for inferior health
outcomes and high healthcare cost
inflation
Key Recommendations of HLEG
• Adopt UHC As A National commitment - To Be Initiated in 2012 and Fulfilled
By 2022
• Commit 2.5% of GDP As Public Financing for Health During The 12th Plan
and suggest MOHFW prepare a road-map for implementation of the UHC
• Prioritize Primary Health Care For Financing And Human Resource
Development & Deployment
• Conduct A Review of Government Funded Insurance Schemes & Propose A
Plan for Their Integration Into The UHC Framework
• Provide Essential Drugs Free Of Cost
• Establish Credible And Effective Regulatory Systems For Administering UHC
(Accreditation; Standards; Financing; Drugs; Information Systems; M&E)
• Enable Community Participation By Institutionalising Health Councils & Health
Assemblies With Government Support
• Facilitate focusing future MOHFW agendas on a) Gender -UHC though a
gendered lens b) Urban Health c) Social Determinants Of Health (Health
Promotion & Protection Trust), while preparing its implementation plan
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Universal Health Coverage By 2022: The Vision
• Universal Health Entitlement for every citizen - to a National
Health Package (NHP) of essential primary, secondary &
tertiary health care services that will be principally funded by the
government
Package to be defined periodically by an Expert Group; can have
state specific variations
ENTITLEMENT
• Universal health
entitlement to
every citizen
NATIONAL
HEALTH
PACKAGE
• Guaranteed
access to an
essential health
package
(including
cashless inpatient and outpatient care freeof-cost))
• Primary care
• Secondary care
• Tertiary care
INTEGRATED
HEALTH CARE
DELIVERY
• People provided
services by:
• Public sector
facilities and
• Contracted-in
private
providers
Impoverishment due to OOP on Drugs, 2011-12
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Issues for Debate
(Financing)
• Tax funded model Vs. Insurance Model
• Financing and Impact of Government Funded
Insurance Schemes
• Role of Private Insurance
• Fee for Service Vs. Per Capita Vs. ?
• User Fee Exemption : All / Poor only?
• Role of Central and State Governments
Issues for Debate
(Provision)
• Role of Public and Private Sectors
• ‘Corporatization’ of Public Sector Healthcare
Facilities
• ‘Managed’ Vs. ‘Integrated’ Care
• Continuum of Care : Overcoming Fragmentation
• Extent of Integration of Health Programmes
(NRHM+NUHM = ? NHM)
Options
• Options based on coverage (who is covered for what)
– All the services to all the population
– Some services to all the population
– Some services to certain sections of the population
• Provision
– Within the existing government health services (in an enhanced manner)
– Through the private sector (Purchasing, contracting, PPP)
• Finance
– Enhanced budgetary support based on evidence
– Pooling (insurance) –Increasing existing benefit package, coverage under
existing schemes (coverage, benefits etc. under RSBY & other schemes)
– Incentives (payment for performance), Case based payment, capitation etc.
•
Based on the options - populations to be covered, services (benefit package) to be
provided, method of delivery, estimation regarding financial requirements
Options
• Options could be a mix of delivery systems providing the
services selected from the health package.
• Realignment & convergence of programmes and schemes
• Development of a essential health package of services into
various categories to choose (e.g. primary, secondary,
tertiary, etc.) and move towards it systematically & phased
manner.
• Costing of the benefit package
• Broad roadmap on how best to provide the services to the
populations and what needs to be strengthened or systems
in place and their implications.
Human Resources For Health
Increase numbers and skills of frontline health workers:
• Doubling of ASHAs and ANMs;
• Male MPW and Mid Level Health Professional (3 year
trainee)/AYUSH at Sub-Centre level;
• Expand Staff (esp. nurses) at PHC and CHC;
• Nurse-Practitioners for Urban Primary Health Care
Human Resources For Health
• Establish new medical and nursing colleges in
underserved states and districts with linkage to
district hospitals; Increase the number of ANM
schools
• Scale up number and quality of Allied Health
Professional training institutions
• Establish District Health Knowledge Institutes to
coordinate and conduct training of different
categories of health workers
• Develop Public Health and Health Management
Cadres (District, State, National)
Registry
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“If we don’t create the
future, the present
extends itself”
- Toni Morrison (Song of Solomon)