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Towards a Better Healthcare

Group 2 - Section CArka Biswas (132) | Ashima Aggarwal (135) | Divyaveer Sachin (142) | Panii Ngaonii (152) | Pradeep Dutta (156)



Agenda

3/1/2013Indian Institute of Management, Kozhikode

Public health in India

- The real picture- Deepening health insecurity in India- Government Spending- India vs. South East Asian Region

Government Flagship Programmes – Success & Failure- National Health Rural Mission- Rashtriya Swasthya Bima Yojana

Universal Health Care in India- Implementation- Role of PPP in UHC

2



THE REAL PICTURE

India is home to -23% of the tuberculosis patients,

86% of diphtheria patients, 54% of leprosy patients,

29% of pertussis patients,

42% of polio victims and

55% of malaria patients in the world

43.5% underweight children below the age of five years

Only 21% of the rural population had access to “improved” sanitation

facilities in 2008



What is Public Health?

KEY GOAL – To reduce a population’s exposure to disease

Assuring food safety

Vector Control

Monitoring waste disposaland water systems

Health Education Health Regulations

Medical Services



Neglect of public regulations and their implementation

- Public Health Acts have not been updated- Deficiencies in “ Prevention of Food Adulteration Act”

Diversion of funds from public health services- Focus on aspects other than health care

Organizational changes needed to maintain public health

- Health is primarily a state responsibility

- Funds allocated from centre to the states

- States are not free to reallocate funds to higher priority issues

Public Health in Independent India

3/1/2013Indian Institute of Management, Kozhikode 5



Deepening Health Insecurity in India


Declining Public Provisions

Increase in reporting of ailments can reflect(a) an increased morbidity burden in the country, and

(b) increased health-seeking behaviour of the population in general

Figure: Share (Percentage) of Public to Total Short-duration

Treated Ailments in Rural and Urban India (1986-87, 1995-

96 and 2004)

Figure: Reporting of Short Duration Ailment, Hospitalization

and No Formal Treatment (1987-88, 1995-96 and 2004; in %)

6





Figure: Per Episode Average Cost of Treatments for

Outpatient and Inpatient in Government and Private

Sector, Rural, Urban and Combined (2004)

Increasing cost of treatments

For outpatient treatments, private healthcare

facilities are, one and a half times more

expensive than the public facilities.

Government healthcare facilities, are forcing

patients to procure drugs and receive

diagnostic services from private sector

providers.

7





Figure: Increase in Number of Poor Due to OOP

Payments (in million)

Impact

Increase in poverty ratio is

contributed mainly by households’

expenditure on health, i.e. the OOP.

In 2004-05, 39 million additional

people plunged into poverty because

of OOP payments.

8



Government Spending from 1999 to 2005

Figure: Government Health Expenditure as

Per Cent of GDP till 2004-05

Figure: Share of Government Health

Expenditure in Total Government

Expenditure till 2004-05 (%)

States account for three quarters of all government health spending, any rise or fall in states’

health spending influences total spending much more than the centre’s.



Government Spending since April 2005

Figure: Government Health Expenditure as

Per Cent of GDP since 2004-05

Figure: Share of Government Health

Expenditure in Total Government

Expenditure since 2004-05 (%)

Total Government Health Expenditure increased from Rs 27,704 crore in 2004-05 to Rs 39,046

crore in 2006-07 or by 41 per cent, its share in GDP too increased from 0.97 per cent to about

1.05 per cent during this period



Where do we stand




India vs. SEAR

1. The density of doctors per 1000 of population is about 6 in India while

the average for SEAR is 5 and the global average is 14.

2. The density of nurses/midwives per 1000 is 13 in India as compared with

SEAR’s average of 11 and global average of 28

3. In the pharmaceutical field, manpower at a density of 6 per 1000 beats

the SEAR and global average of 4.

4. In PPP terms, per capita annual expenditure on healthcare is $109 in

India compared with $ 104 in SEAR.

Life expectancy at birth, healthy life expectancy, low birth – weight babies,neo natal mortality rate, <5 years mortality rate, MMR, India s

consistently performs below SEAR & the global average.

Gross Urban Bias in government

expenditure !!!



National Rural Health Mission(NHRM)

“carry out necessary architectural correction in the basic health

care delivery system … to improve the availability of and access

to quality health care by people, especially for those residing in

rural areas, the poor, women and children”



Objectives

Infant mortality rate (IMR) of 30 per 1000 live births

Maternal mortality 100 per 100 thousand live births

Total fertility rate of 2.1 by 2012

1/3rd population

lives in rural

Grass rootlevel

BuildingInfrastructure

Eradicatediseases



Objectives

Decentralization

Communitization

Organizational structural reforms

Operationalizing existing health facilities to meetIPHS



Funding

Funds allocation

District

State

National



Implementation of Strategic options

1

• HEALTH INFRASTRUCTURE AND

FACILITY UPGRADATION

2• HUMAN RESOURCE

3

• UTILIZATION OF PUBLIC HEALTH

SERVICES



Health Infrastructure And Facility

Upgradation

Facility - Upgradation work

Upgradation to IPHS

PHC functioning on 24x7basis

Rogi Kalyan Samities (PPP)

Village Health and SanitationCommittees (VHSCs)

Village Health and NutritionDays (VHNDs)



HUMAN RESOURCE

ANMs

ASHAs

Referral andEmergency Transport



Utilization of Public Health Services

Institutional deliveries

Children immunization

AYUSH program

The National Disease Control Programme (NDCP)

Family planning

Chronic diseases services



Expenditure



Scope for Improvement

Even after many years very few hospitals fall under the purview of IPHs(Indian Public Health Standard)

Doctors abhor rural centres because of poor infrastructure and working

conditions

The lack of a good and transparent human resources policy encourages

corruption and discourages good work

The average ASHA is hardly getting the promised Rs 1,400 per month ASHAs are not equipped to undertake their complex social roles in rural

areas

Training is poor, barely halfway and accreditation is yet to even begin

Involvement of the private sector with a well thought-out long-term

plan for integration of the two sectors through regulation is necessary

The Indian healthcare system has become an inverse pyramid with verylittle primary care as foundation and ever-ballooning “medical” sector

through a hospital-doctor-centric



Rashtriya Swastya Bima Yojana (RSBY) - 2007


• “To provide protection to BPL households from financial liabilities

arising out of health problems leading to hospitalization”

• Hospitalization coverage up to Rs.30000

• No age limit, up to 5 family members,

completely cashless

•

Pays only Rs. 30 as registration fee• Central (75%) and State (25%)pays the

premium to insurer

23



Issues in implementation

•Poor knowledge of how and where to utilise the scheme

•Lack of coordination & implementation among variousstakeholders

Awareness

•Pre-requisite of BPL card

• People need to be registered as BPL in their home state, makingthis scheme out of reach of migrant workers who are far from home

Conditionality

•Verification process of BPL

•Delay & related delivery hassles

Issuance of smartcards

•0.4% of enrolled households

•Lack of preparedness of empanelled hospitals

•Problems with Smart Card Technology and Reimbursement System

Utilization

•Insurance company interested in premium

•Hospitals interested in cost recovery

Misalignedincentives & Frauds




Current scenario & outcomes of RSBY

Active smart cards: 34,146,596 (penetration: around 50%)

hospitalisation cases: 4,909,728 (as of 20th February 2013)

Hailed by World Bank, UN & ILO as world’s one of the best

health insurance schemes

Germany showed interest of implementing this smart card basedhealth insurance scheme, which has the world's oldest social

security system

Infrastructure build-up regarding healthcare in semi-urban &

rural areas regarding catering to the huge BPL population,

which were previously dominant in urban areas only




Moving along the path: Universal Health

Coverage(UHC)




UHC In India: A dream in progress


In October 2010, the PlanningCommission of India with the approval of

the prime minister, appointed a HighLevel Expert Group (HLEG) to develop aframework for universal health coverage(UHC) to be implemented over 2010-20.

India aims to introduce universal healthcoverage during the 12th five year plan(2012-2017)

27



High Level Expert Group – Strategy and

Recommendations

• “.”




What to Achieve ?

“ 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, appropriate health services of assured quality

(promotive, preventive, curative and rehabilitative) as well as public health

services addressing the 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.”




Architecture

E N T I T L E

M E N T Health package

for every kind of citizen, depending

upon theaffordability &other conditions

N

a t i o n a l H e a l t h

P a c k a g e Guaranteed access

to essential healthcare, including

cashless in-patient& out-patient care

-Primary

-Secondary

-Tertiary care

C h o i c e o f F

a c i l i t i e s People can choose

over private &public facilities to

cure themselves




Wh’s of Implementation…1


Health Financing and Financial Protection• Establish a financial mechanism to drive UHC

• Increase government spending to at least 3% of GDP by 2022

Health Service Norms

• Ensure last mile connectivity to poor, quality, and accessibility• Develop national health package and ensure quality of health services at

all levels

Human Resources for Health

• Ensure trained and adequately supported practitioners with relevantexpertise

• Invest in educational institutions to produce and train the requisite healthworkforce and strengthen existing ones

31



Wh’s of Implementation…2


Community Participation and Citizen Engagement

• Strengthen the institutional mechanisms to improve publicdecision-making

• Transform existing Village Health Committees (into participatoryHealth Councils

Access to Medicines, Vaccines and Technology

• Revise and expand the essential drugs from National Essential DrugsList

• Price control and regulation on drugs and vaccines

Management and Institutional Reforms

• Develop a national health information technology network

• Establish financing and budgeting systems to streamline fund flow

32



In search of Light: “McKinsey” Way


Growth

Rural Drive

Border Crossing

33



…“Extracts”

“Emphasis access through Health Insurance”


“Ensure smooth implementation of Patent Law”

“Support capability building in R&D”

“Continued emphasis on public health resources & infrastructure”

“Adopt a broader view of Healthcare cost”

34

India: UHC Can the dream come




Need of a political leadership which can make the most of

economic and political windows of opportunityService should be prioritized attending the rural poor first

Reach country's most isolated regions to dispense health

Develop models of decentralized district level planning anddelivery of health services

Emphasize on preventive and primary care servicesNon primary services to be left for the private players

Accounting for a large informal sector

Contribution from the formal sector could be useful to cross-subsidize

Implement health care rationing and waiting lists for certainprocedures and treatments to deal with increasing demand

India: UHC – Can the dream come

true?

35

PPP in PHC



PPP in PHC

PPP is a mode of implementing government programs/schemes inpartnership with the private sector

Includes corporate sector, voluntary organizations, self-help groups,

partnership firms, individuals and community based organizations

PPP is essential for infrastructure development, management andoperations, capacity building and training, financing, IT infrastructure,

and materials management

Shift in emphasis is from delivering services directly, to service

management and coordination

Could be at primary level, secondary level or tertiary levels across

various states in India

Dimensions of PPP



Dimensions of PPP

• Full retention of responsibility by thegovernment for providing the serviceResponsibility

• PPP may continue to retain the legalownership of assets by the public

sector

Ownership

• nature and scope of service iscontractually determined between thetwo parties

Service nature

• shared between the government(public) and the private sector

Risk andreward

Contractual framework



Contractual framework

PPPcontract

servicecontract

operations &maintenance

(management)contract

capitalprojects, with

operations &maintenancecontract

PPP: Pros and Cons



PPP: Pros and Cons

Pros:

PPP brings together resources and expertise from both the public and

private sectors

Increase accessibility and availability of services to rural India

Increase the quality and quantity of manpower available

It would improve primary care services which in turn would improve

quality of life

Cons:

It would corporatize healthcare

It could lead to widespread corruption The Government could completely get out of the healthcare sector

PPP: Major schemes under DoH



PPP: Major schemes under DoH

Major Schemes implemented through PPP under Ministry of Health & Family

Welfare Department of Health:

The RevisedNational TB

Control Program(RNTCP)

National Programfor Control of

Blindness

National Cancer

Control Program

National AIDSControl Program

National Leprosy

EliminationProgram (NLEP)

CentralGovernment

Health Scheme(CGHS)

Issues in PPP in healthcare



Issues in PPP in healthcare

• The capacity limitation is the major hurdle in

scaling

Capacity of

Private Partner

• General public's fear about PPPs being a façade forprivatization

• Central and state must reassure the public aboutthe PPP process

Advocacy

• Accreditation of Private NGO Hospitals forInstitutional DeliveryAccreditation

• Insufficient regulation by the governmentRegulation by

the Government

Major concerns



Major concerns

• Free and fair selection of partners does not happen• Often mediated through money & political

patronage

Inadequatenumber of playersin the market

• Inadequacies pertaining to fair process of selection• No serious rules for non-compliance with the outputs

• Do not clearly spell out the breach of contract by eitherparty

Absence of a well-articulated “MoU”

• Bureaucratic professionals within the public sectorare not ready to adhere to rules and regulations asan equal partner with the private sector

Poorly definedroles: Lack of accountability

Major concerns



Major concerns

• Non-monetary parameters not included

• Non-monetary factors like trust, accountability,responsiveness, interactive quality not adequatelyaccounted for

Incorrect view of “cost-efficiency”

• Private sector actually has a minor role of mainlydemand generation in most cases

• Often major terms of agreement (e.g. renewal of contract) are controlled by Government

Asymmetry:Skewed towardsGovernment

• No third party institutional mechanism that canplay the role of an independent arbitrator

• Only recourse is the court of law; cumbersomeand prolonged settlement not viable for PPPs

Absence of aneutral arbitrationmechanism

Standardization: The road ahead



Standardization: The road ahead

Currently no standardization of PPP in Healthcare

PPPs are happening at both state level and at national level and atvarious points of the value chain

The scale and magnitude are different at each level

Need for a model framework acting as policy framework

Need a central approach to execution of PPP projects while the

components of the model may differ from state to state

Standardization of model would embolden major healthcare players to

venture in PPPs in a big way

Case study: Chiranjeevi Project in Gujarat



Case study: Chiranjeevi Project in Gujarat

Announced by the Government in April 2005 to target group is women living BPL

who face socioeconomic hardships due to complications during delivery

Implementation:

The private practitioners were chosen by the district health centers after a

detailed survey of their infrastructure assess their conditions of services

The contracted practitioners were reimbursed through a capitation payment

basis under they are paid for each delivery at a fixed rate

Performance:

Institutional deliveries in the five states increased from 38 to 59 per cent No

maternal deaths and only 13 infants death

Reasons for Success: Transparent pricing mechanism

Involves a network of private practitioners

Built trust with doctors by ensuring regular payments and there is constant

monitoring of the program

References



References



THANKYOU


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