health care delivery sys

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Health Care DeliverySystem in India

Arun S NathLecturer

SCS College of Nursing

Mangalore

2/09/2011 1ARUN S NATH,ASST.PROFESSOR, SCSCOLLEGE OF NURSING


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Introduction

The political economy context

The organisational structure and delivery

mechanism Health financing mechanisms

Coverage patterns

Current status of health and health care



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Concept of a Four-Level Health CareSystem

ENVIRONMENTRegulatory, market and policy

framework

ORGANIZATIONInfrastructure, resources

CARE TEAMFrontline care providers

PATIENT

Source: Building aBetter DeliverySystem, A NewEngineering/HealthCare Partnership, IOM,2005



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The Political Economy Context

A democratic federal system which is subdivided into

28 States, 7 union territories and 593 districts

In most of the states three local levels of government(Panchayati-raj)

Per capita income US $440 435 million Indians are estimated to live on less than US $ 1 a

day

36% of the total number of the worlds poor are in India

Tax based health finance system with health insurance

80% health care expenditure born by patients and theirfamilies as out-of -pocket payment (fee for service and drugs)

Expenditure on health care is second major cause ofindebtedness among rural poor



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System

A set of interrelated and independent partsdesigned to achieve a set of goals.



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Health system

Structure & function of countrys MOH

1. Resources

2. Management3. Organization

4. Economic support

5. Service delivery



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National health system

Public Private

Traditional

Informal sectors Essential functions

Service provision

Resource generation Financing

Leadership



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Key to effective health system

Motivated staff Equipment

Information

Finance Adequate drugs for

improving access

Coverage Quality of health services



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Evolution of health systems

Early health systems

Traditional practices and medicine

Effect of industrial revolution

Politicization of workers in Germany

UK National health system(1938)

Bhore committee( 1946)



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Cont.. Alma Atta declaration 1978

Primary health care themes

Equity

Social justice

Community participation

Prevention/promotion

Intersectoral coordination

Appropriate use of resources

Sustainability2/09/2011 12ARUN S NATH,ASST.PROFESSOR, SCSCOLLEGE OF NURSING


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CONT.

Health economics brought in healthcare(1980-90)

Efficiency & effectiveness

Structural program adjustment

Health sector reform

Dominance of world bank over WHO



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CONT

1990-2000

One size does not fit all Recognition of key elements- equity,

empowerment & poverty reduction

Standardization & improving performance World health report 2003

Primary health care

Access, equity ,community participation &intersectoral coordination



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CONT

MDG

o 8 goals, 18 targets



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Determinants of healthsystems

Economic

o Affordability ?

o

Availability ? political

Priorities

Appropriateness Accessibility

Equity2/09/2011 16ARUN S NATH,ASST.PROFESSOR, SCS

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Cultural

Accessibility

Utilization Participation



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Forces for changing healthsystems

New emerging diseases

Changing disease profile

Technological & diagnostic advancements Longevity of life

Expectation sof people

Subsidies & cross subsidies Increasing non plan expenditure

Competing priorities

Improving awareness among people2/09/2011 18ARUN S NATH,ASST.PROFESSOR, SCS

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Classification

Service delivery

Nature of service

Doctrine Tariditional medicine



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Based on service delivery

Public sector primary care

PHC

Sub centers Secondary care

CHC

Hospitals Tertiary care

Teaching hospitals2/09/2011 20ARUN S NATH,ASST.PROFESSOR, SCS

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Cont.

Private hospitals

Trust hospitals Corporate hospitals

Nursing homes

Medical insuranceOthers

NGOs

ESI& railways

Voluntary agencies

Defense2/09/2011 21ARUN S NATH,ASST.PROFESSOR, SCS

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Nature of service

Indigenous- rural

General care

Specialty Super specialty / corporate



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Based on doctrine

Official

Allopathy

Traditional AYUSH



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Characteristics of IndianHealth System

Complex mixed health system

- Publicly financed government

health system

- Fee-levying private health sector



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Different Phases of IndianHealth System Development

Pre-independence phase

Development centred phase

Comprehensive Primary Health Care phase Neoliberal economic and health sector reform

phase

Health systems phase



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Main Systems of Medicine

Western allopathic

Ayurveda

Unani Siddha

Homeopathy



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Government Health System

Three levels of responsibilities-

- First-

- health is primarily a state responsibility

-

Second-- the central government is responsible for developing andmonitoring national standards and regulations

- sponsoring various schemes for implementation by stategovernments

- providing health services in union territories

- Third-

- both the centre and the states have a joint responsibility

for programmes listed under the concurrent list.2/09/2011 27ARUN S NATH,ASST.PROFESSOR, SCS

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Administrative Structure

1. Central Ministries of Health and FamilyWelfare

- Responsible for all health related

programmes- Regulatory role for private sector

2. State Ministries of Health and Family

Welfare3. District Health Teams headed by Chief

Medical and Health Officer2/09/2011 28ARUN S NATH,ASST.PROFESSOR, SCS

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Service Delivery Structure

Sub Health Centres- staffed by a trainedfemale health worker and/or a male health workerfor a population of 5000 in the plains and a

population of 3000 in hilly and tribal areas. Primary Health Centres-

staffed by a medical officer and other paramedicalstaff for a population of 30,000 in the plains and a

population of 20,000 in hilly, tribal and backwardareas. A PHC centre supervises six to eight subcentres.



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Service Delivery Structure

Community health centres- with 30-50 bedsand basic specialities covering a populationof 80,000 to 120,000. The CHC acts as a

referral centre for four to six PHCs.

District/General hospitals- at district level withmulti speciality facilities (City dispensaries)

Medical colleges, All India institute of MedicalSciences and quasi government institutes(NIHFW and SIHFWs)

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Health Financing Mechanisms..

Revenue generation by tax

Out of pocket payments or direct payments Private insurance

Social insurance

External Aid supported schemes


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Spending on Health

Annually over 150,000 crores or US$34 billion,which is 6% of GDP (Government spending onhealth Is only 0.9% of GDP)

Out of this only 15 % is publicly financed 4% fromsocial insurance, 1% by private insurance remaining80% is out of pocket spending ( 85% of which goesin private sector)

Only 15% of the population is in organised sectorand has some sort of social security the rest is left tothe mercy of the market


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The Aspects of Neoliberal EconomicReforms Affecting Public Health

Increasing unregulated privatisation of the health caresector with little accountability to patients

Cutting down government Health care expenditure

Systematic deregulation of drug prices resulting in

skyrocketing prices of drugs and rising cost of healthservices

Selective intervention approach instead comprehensiveprimary health care

Measure diseases in terms of cost effectiveness Techno centric approach( emphasis on content instead

processes)


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Contradictions

India has the largest numbers of medicalcolleges in the world

It produces the largest numbers of doctorsamong developing countries

It gets medical Tourists from developed

countries

This country is fourth largest producer ofdrugs by volume in the world


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But... the current situation.

Only 43.5% children are fully immunised. 79.1% of children from 6 months to 5 years of age are

anaemic. 56.1% ever married women aged 15-49 are anemic. Infant Mortality Rate is 58/1000 live births for the country with

a low of 12 for Kerala and a high of 79 for Madhya Pradesh. Maternal Mortality Rate is 301 for the country with a low of

110 for Kerala and a high of 517 for UP and Uttaranchal in the2001-03 period.

Two thirds of the population lack access to essential drugs. 80% health care expenditure born by patients and their

families as out-of -pocket payment (fee for service and drugs) Health inequalities across states, between urban and rural

areas, and across the economic and gender divides havebecome worse

Health, far from being accepted as a basic right of the people,is now being shaped into a saleable commodity


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Contd.

poor are being excluded from health services

Increased indebtedness among poor

(Expenditure on health care is second

major cause of Indebtedness amongrural poor)

Difference across the economic class spectrumand by gender in the untreated illness has

significantly increased Cutbacks by poor on food and other

consumptions resulting increased illnesses andincreasing malnutrition


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Health Inequities

The infant mortality Rate in the poorest 20% of thepopulation is 2.5 times higher than that in the richest20% of the population

A child in the Low standard of living economicgroup is almost four times more likely to die inchildhood than a child in a better of high standardliving group

A person from the poorest quintile of the population,

despite more health problems, is six times less likelyto access hospitlisation than a person from richestquintile.


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Health Inequities

A girl is 1.5 times more likely to die beforereaching her fifth birthday

The ratio of doctors to population in ruralareas is almost six times lower than that forurban areas.

Per person, government spending on public

health is seven times lower in rural areascompared to government spending urbanareas


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Inter-Sectoral Co-ordination

Health is intrinsically related to development.

However, the inter-linkages between health

and development were brought to the limelight

at the Alma Ata conference on Primary Health

Care (PHC) in 1978.

The Alma Ata conference not only gave a new

impetus to the inter- linkages between health

and development but also restated the fact that

`Health for All' could not be achieved without

inter-sectoral co-ordination.2/09/2011 39ARUN S NATH,ASST.PROFESSOR, SCS

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Cont.

This restatement gave a new direction not only

to those involved in promoting health but also

to those participating in the process of

community development.


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Cont.

The scholars, the policy makers and thedevelopment functionaries promoting an inter-

sectoral approach to health tend to consider

seriously three major sectors that are crucial

for health and development.

They are:

Agriculture

Education

Environment


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Guiding Principles

Development is basic to health

Equity

Equity in terms of health is that "every man,woman and child, no matter where he or she

lives, has the right to enjoy good health and

deserves to have access to health care

services.

Availability

Accessibility2/09/2011 42ARUN S NATH,ASST.PROFESSOR, SCS

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CONT.

Promoting economic capacity of the people(poor)


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Health and Agriculture


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Health and Agriculture

More than two thirds of the people in

developing countries

Some of the factors of agriculture that havedirect influence on the health of the people

are:1. adequate farm income

2. income from agricultural labour

3. enough food (energy) for agricultural work4. nutritional value of the food eaten

5. health hazards of agricultural technology2/09/2011 44ARUN S NATH,ASST.PROFESSOR, SCS

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Impact of Agriculture on Health


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Impact of Agriculture on Health

Policies:

1. Food crop vs cash crops1.2. Shift in consumption (locally grown food vs meal

processed in cities)

1.3. Investment (productive regions vs poor regions)2. Land fertility

3. Crops with harmful effects (dangerous to health)

e.g. health of farm labourers

4. Food with direct health hazards (toxic substances)

5. Agricultural products with major health hazards

(tobacco and narcotics)

6. Equity in accessibility to food2/09/2011 46ARUN S NATH,ASST.PROFESSOR, SCS

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Health and Environment

Poverty and Environment

Poverty and Environment

Water, Air, Land and Health


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Action for Co-ordination

The strategies are broadly categorized into four,

they are:

1. Asset creation2. Providing needed capital

3. Employment generation

4. Establishing marketing linkages


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Education and Health


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Education and Health

In some countries, states (Kerala in India) and

communities, the fall in mortality, morbidityand birth rates is mostly due to the level of

education and literacy than to mere economic

growth. The positive impact of education on health is

the result of improvement in personal and

public hygiene, life style, environmentalsanitation, appropriate nutrition, and better

understanding and positive attitudes towards

preventive, curative and promotive care.2/09/2011 49ARUN S NATH,ASST.PROFESSOR, SCSCOLLEGE OF NURSING


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HEALTH AND FAMILY WELFARE

The Union Ministry of Health & Family Welfare is

instrumental and responsible for implementation of

various programmes on a national scale in the areas

of Health & Family Welfare, prevention and controlof major communicable diseases and promotion of

traditional and indigenous systems of medicines.

Apart from these, this Ministry also assists States inpreventing and controlling the spread of seasonal

disease outbreaks and epidemics through technical

assistance.2/09/2011 50ARUN S NATH,ASST.PROFESSOR, SCS

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STRUCTURE

The Ministry comprises of four departments,namely,

Department of Health & Family Welfare,

Department of AYUSH,

Department of Health Research and Department

of AIDS Control.

The Directorate General of Health Services

(DGHS) is an attached office of the Department

of Health & Family Welfare and has subordinate

offices spread all over the country.2/09/2011 51ARUN S NATH,ASST.PROFESSOR, SCS

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A. Programmes on Health Sector:

Cancer Control Programme:

Mental Health Programme:

Emergency Facilities of State Hospitals located on

National Highways:

Prevention and Control of Diabetes, Cardiovascular

Disease and Strokes:

Central Government Health Scheme (CGHS):

Health Ministers Discretionary Grant:

Borne Disease Control Programme (NVBDCP):(vector

borne diseases namely Malaria, Filaria, Kala-azar,

Japanese Encephalitis (JE), Dengue and Chikungunya2/09/2011 52ARUN S NATH,ASST.PROFESSOR, SCS

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CONT


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CONT

Pradhan Mantri Swasthya Suraksha Yojana (PMSSY):

(i) setting up of six AIIMS-like institutions and (ii)

upgradation of 13 existing Government medical

college institutions.

Other Health Programmes: Other major health

programmes are Prevention and Control of Deafness;Prevention and Control of Fluorosis; Rashtriya Arogya

Nidhi, Leprosy Eradication Programme (NLEP); TB

Control Programme (RNTCP); Programme for Controlof Blindness (NPCB); and Iodine Dificiency Disorders

Control Programme.


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B Rural Health Services:


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B. Rural Health Services:

146036 Sub-Centres,

23458 Primary Health Centres and

4276 Community Health Centres

Indian Public Health Standards (IPHS):

Mobile Medical Units/Health Camps:

National Rural Health Mission (NRHM):

(1) Increasing Participation and Ownership by the

Community, (2) Improved Management Capacity(3) Flexible Financing (4) Innovations in human

resources development for the health sector, and (5)

Setting of standards and norms with monitoring.2/09/2011 54ARUN S NATH,ASST.PROFESSOR, SCS

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C Maternal Health Programmes:


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C. Maternal Health Programmes:

Maternal Mortality Ratio (MMR): number of

maternal deaths per 100,000 live births due to

causes related to pregnancy

Schemes for Improving Obstetric Care Services:

Janani Suraksha Yojana (JSY):

Village Health and Nutrition Day:


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E. Family Welfare:

Checking of Female foeticide:

Family Welfare Linked Health InsuranceScheme (FWLHIS):


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F. Ayurveda,

Yoga and

Naturopathy,Unani,

Siddha,Homoeopathy (AYUSH):2/09/2011 58ARUN S NATH,ASST.PROFESSOR, SCS

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G. Medical Education:

Medical Council of India (MCI):

Dental Council of India (DCI):

Central Council of Indian Medicine(CCIM):

Central Council of Homoeopathy (CCH):

Pharmacy Council of India:

Indian Nursing Council:


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H. Health Organisations/Institutions:

National Academy of Medical Sciences (NAMS):

All India Institute of Medical Sciences (AIIMS):

Central Bureau of Health Intelligence (CBHI):

International Institute for Population Sciences

(IIPS):

National Institute of Health and Family Welfare

(NIHFW):

Indian Medicines Pharmaceutical Corporation

Limited (IMPCL):2/09/2011 60ARUN S NATH,ASST.PROFESSOR, SCS

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Information, Education and


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,Communication IEC can be defined as an approach which attempts to

change or reinforce a set of behaviours in a target

audience regarding a specific problem in a predefined

period of time.

It is multidisciplinary and client-centred in itsapproach, drawing from the fields of diffusion theory,

social marketing, behaviour analysis, anthropology,

and instructive design.

IEC strategies involve planning, implementation,

monitoring and evaluation.


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CONT


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CONT

When carefully carried out, health communicationstrategies help to foster positive health practices

individually and institutionally, and can contribute

to sustainable change toward healthy behavior


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Information, education and communication (IEC)

combines strategies, approaches and methods that

enable individuals, families, groups, organisations

and communities to play active roles in achieving,protecting and sustaining their own health.

Embodied in IEC is the process of learning that

empowers people to make decisions, modifybehaviours and change social conditions.


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Activities are developed based upon needs

assessments, sound educational principles, and

periodic evaluation using a clear set of goals and

objectives.


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Channels

Channels might include interpersonal

communication (such as individual discussions,

counselling sessions or group discussions and

community meetings and events) or

mass media communication (such as radio,

television and other forms of one-way

communication, such as brochures, leaflets andposters, visual and audio visual presentations and

some forms of electronic communication).


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Steps in Developing IEC


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Steps in Developing IECActivities

Conduct a needs assessment.

Set the goal. This is a broad statement of what

you would like to see accomplished with the

target audience in the end.

Establish behavioural objectives that will

contribute to achieving the goal.


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C t


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Cont

Develop the IEC activities and involve as many

other partners as possible. After their successful

implementation, you should be able to have a

significant impact on achieving the behavioural

objectives. Identify potential barriers and ways of

overcoming them.

Identify potential partners, resources, and otherforms of support for your activities and gain their

sustained commitment.

Establish an evaluation plan.2/09/2011 67ARUN S NATH,ASST.PROFESSOR, SCSCOLLEGE OF NURSING


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Conselling

Counseling is a key component of an IEC

programme.

counselors should strive to ensure that every

service user has the right to the following:

Information: to learn about the benefits and

availability of the services.

Access: to obtain services regardless ofgender,creed, colour, marital status or location.


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Cont


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Cont

Choice: to understand and be able to apply all

pertinent information to be able to make an

informed choice, ask questions freely, and be

answered in an honest, clear and comprehensive

manner. Safety: a safe and effective service.

Privacy: to have a private environment during

counselling or services. Confidentiality: to be assured that any personal

information will remain confidential.2/09/2011 70ARUN S NATH,ASST.PROFESSOR, SCS

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Dignity: to be treated with courtesy,consideration and attentiveness.

Comfort: to feel comfortable when

receiving services.

Continuity: to receive services andsupplies for as long as needed.

Opinion: to express views on the servicesoffered.


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Thank You.

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