Evolution of Health Care in India

Dr. P. R. Sodani
Associate Professor Health Systems, Health Economics and Financing

Course on Health Care Delivery System and Policies in India October 15-26, 2007

Some Basic Facts

India has one of the largest network of health care

Secondary and Primary level health services Both in Public Sector and Private Sector Voluntary Sector/NGO Huge Indian System of Medicine

Health Care Systems

Public Sector Private Sector Indigenous Systems of Medicines Voluntary Health Agencies National Health Programmes

Public Sector

Primary Health Care Primary Health Centers Sub-centers Hospitals/Health Centers Community Health Centers Rural Hospitals District Hospitals Specialist Hospitals Teaching Hospitals

Public Sector

Health Insurance Schemes Other Agencies Defence Services Railways

Private Sector
Private Hospitals Poly clinics Nursing Homes Dispensaries General practitioners and Clinics

Indian Systems of Medicines

Ayurveda and Siddhu Unani and Tibbi Homoeopathy Unregistered Practitioners

Growth of Public Sector

Primary Health Centre (725) Community Health Centre Medical Colleges (42) Dental Colleges (7) Hospital Beds (125,000) Allopathic Doctors (65,000) Nurses (18500) ANMs (12,780) Health Visitors (578)

163,181

146 54 870,161 503,900 737,000 203,451 22,144

State of Health: British India

The British Government appointed Health Survey and Development Committee in 1943 Also known as Bhore Committee Review the health situation Review health services Recommend a health system and package of services

State of Health: British India

Health services were non-existent. Especially, preventive and promotive services Only curative services available Urban areas Access and availability of even curative services was highly restricted Inequity Poor were deprived Unable to pay for services

State of Health: British India Poor environmental sanitation and hygiene Communicable diseases were rampant and high morbidity and mortality Human resources were grossly inadequate

State of Health: British India

Infant Mortality Rate Crude Death Rate Maternal Mortality Life Expectancy (Males) Life Expectancy (Female)

162/1000 LB 22.4/1000 popln 200,000 deaths 26.91 years 26.56 years

State of Health: British India

High incidence and prevalence of communicable diseases Malaria 2 million cases and 0.8 million deaths every year Tuberculosis 2.5 million active cases and 500,000 deaths annually High morbidity for Smallpox, Plague, Cholera Leprosy, Filariasis, Guinea worm and Hookworm diseases

State of Health: British India

High nutritional deficiency 30 % families had insufficient nutrients for energy requirements Population Problem: 336 million High growth rate High birth rate 41/1000 Popln High fertility rates No contraception services

State of Health: British India

Poor access and quality Health Institutions in rural areas: average 1 over 100, 000 covering more than 224 villages Average time for patients 48 seconds per patient Perfunctory and lack of modern technology and knowledge Unsatisfactory designs and overcrowding Lack of training

State of Health: British India

Inadequate Health Personnel Doctors (47000) 1:6000 Popln Nurses (7000) 1:43,000 Health Visitors (750) 1:400,000 Midwives (5000) 1:60,000 Pharmacist (75) 1:4,000,000 Dentist (1000) 1:300,000

Health Plans

The Health Survey and Development Committee suggested: Long term plan 3 million plan District Health Organization District Health Centre Secondary Health Centre Primary Unit Primary Health Centre Short term plan

Health in Independent India

Adoption of the Constitution of India (January 26, 1950) Recognized health as the state subject and put it in the Concurrent List State shall have the responsibility of the health of the citizen Re-organization of States Establishment of Planning Commission of India Launching of Five Year Plans Establishment of Central Council of Health Launching Community Development Programme

Community Development Programme

Health as an integral part of development Block became the unit of overall development Local self government 3 tier structure Rural development Roads, education, agriculture, animal husbandry, nutrition, electrification, rural water supply, housing Primary Health Centres established at the Block for better coordination

Comprehensive Health Care

Provide adequate preventive, curative and promotive health services Be as close to the beneficiaries as possible Has the widest cooperation between the people, the service and profession Is available to all irrespective of their ability to pay Look after specially the vulnerable and weaker sections of the community: and Create and maintain a health environment both in homes as well as working places

Basic Health Services

Medical care Maternal and Child Health Control of Communicable Diseases Environmental Sanitation Health Education School Health Services Collection of Vital Statistics Implementation of National Health Programmes

Primary Health Centers

Established at the Block Level Establishment of Sub-centres Village level committees Medical Officers, Health Supervisors, Auxiliary Nurse Midwives Technicians

Important National Health Programs

National Family Planning/Welfare program National Malaria Control Program. National Malaria Eradication program National Smallpox Eradication Program National Leprosy Control/Eradication Program National Tuberculosis Control program STD Control Program Filaria Control Program National Cholera Control Program/Diarrhoeal Disease Control Program National Trachoma Control Program

National Health Programs The Logic Soften morbidity and mortality load of specific diseases Unified command Vertical in nature Separate strategy Separate health personnel

Important National Health Programs

Program for Visual Impairments and Blindness Control/National Blindness prevention and Control Program National Goiter Control program/prevention and Control of Iodine deficiency Disease (IDD) National Guinea worm Eradication Program Water Supply and Sanitation Program Minimum Needs Program Universal Immunization Program/Child Survival and Safe Motherhood Program (CSSM) National AIDS Control Program

Health Survey and Planning Committee - 1961

AKA Mudaliar Committee Made several observations on the situation of health, access and availability, performance of health programs, health personnel distribution and training, etc. Expansion of health services and population coverage norms by health institutions Beds 1: 1000 population Financing of health services: health insurance (CGHS and ESI)

Health Survey and Planning Committee - 1961

Mobile units Private practice of medical officers Rural postings Linking district hospitals with teaching hospitals Indian System of Medicine

School Health Committee 1961 Special Committee of Central family Planning Council 1965 Organizational reforms of the family planning services Integration of FP with MCH IUCD Units

Convergence of Health Care: Multipurpose Health Workers Kartar Singh Committee 1975 Group on Medical Education 1975

Primary Health Care

Alma-Ata Declaration 1977 WHO Adopts Primary Health Care as the key approach to achieve Health for All By 2000 India was signatory with the other member states

Primary Health Care

Primary Health Care is essential health care made universally accessible to individuals and acceptable to them, through their full participation and at a cost the community and country can afford

Principles of Primary Health Care

Equitable distribution Community participation Intersectoral co-ordination Appropriate technology

Elements of Primary Health Care

1. 2. 3. 4. 5. 6. 7. 8.

Education concerning prevailing health problems and the methods of preventing and controlling them; Promotion of food supply and proper nutrition; An adequate supply of safe water and basic sanitation Maternal and child health care, including family planning Immunization against major infectious diseases; Prevention and control of locally endemic diseases; Appropriate treatment of common diseases and injuries; and, Provision of essential drugs.

National Health Policy 1983

Focus Areas
1. 2. 3.

Population stabilization Medical and Health education Special emphasis on the preventive and rehabilitative aspects

provide phased, time-bound programme network of comprehensive primary health care services. Involve large scale transfer of knowledge, simple skills and technologies selected by the communities,decentralization of services Decentralization of services Integrated packages of services seeking

.NATIONAL HEALTH POLICY

Location of curative services Establishment of practice by private medical professional, increased investment by nongovernmental agencies in establishing curative centers Establishment of comprehensive primary health care and public health care (referral system, equipments to provide specialty and super-specialty services, networking), Provide mental health care Emphasis on tribal, hill and backward areas Adequacy of mobility of personnel

.NATIONAL HEALTH POLICY

4. 5.

6.
7.

Re-orientation of the existing health personnel Private practice by governmental functionaries Practitioners of Indigenous and other systems of medicine and their role in health care Problems requiring urgent attention
Nutrition Prevention of blood adulteration and maintenance of the quality of drugs Water supply and sanitation Environmental protection Immunization Programme Maternal and child health services School health programme Occupational health services

.NATIONAL HEALTH POLICY

8. 9.

10.
11. 12. 13. 14. 15.

Health education Management information system Medical industry Health Insurance Health legislation Medical research Inter-sectoral cooperation Monitoring and review of progress

Health Organization
District (1.5-2.0 million)

Community Health Centers Number 8-10 in each CHC areas Each covering 30,000 population Sub Health Centers Number: 6 in each PHC area Each covering 5000 population 4-6 villages
Village level 1 TBA and 1 VLW at 1000 population

NATIONAL STRATEGY IN INDIA

Reduction of infant mortality to 60 per 1000 live births by year 2000 To raise life expectancy at birth to 64 years To reduce crude death rate to 9 per 1000 population To reduce birth rate to 1 per 1000 population To achieve NRR of 1.0 To provide potable water to entire rural population

Other Policy Indicators

Prenatal Mortality US MR MMR B.W.(%) CRR GR Family Size ANC (%) Delivery by Trained Person Immunization TB Leprosy Blindness

30-35 10 <2 10 60 1.2 2.3 100 100

Changing scene in Health Services

Expansion of health care network Expansion in health manpower specialists, generalists, Para-professionals Increasing availability and use of sophisticated technology for diagnosis and modern and effective methods of therapy Changing pattern of diseases Demographic transition and changing life style Increasing demand and expectations of community for selected services Rising cost of medical care Limited availability of financial resources Changing trends in health care financing

New Philosophy of HEALTH

Health is a fundamental right Health is the essence of productive life, and not the result of ever increasing expenditure on medical care Health is intersectoral Health is an integral part of development Health is central to the concept of quality of life Health involves individual, state and international responsibility Health and its maintenance is a major social investment Health is world-wide social goal

A countrys Health System

Global Driving Forces

Households

Government

Community

Households are the primary producers of health

Global Driving Forces

Households

Government

Community

Organization
STRUCTURE Matrix, Hierarchy Systems Hrs,Fin,Acct Material, Logistics etc.

STAFF
Person Top - Down

SHARED VALUES
STYLE LADERSHIP
SKILLS Tech, Super, Mgt, Working

STRATEGIES

Reproductive and Child Health Paradigm Shift ICPD 1994 National Population Policy 2000 National Health Policy 2002

Policy Prescriptions

Financial resources Equity Delivery of public health programmes Health infrastructure Expanding health systems Role of local self government Norms for deployment of health personnel Medical education Public health as specialty Urban Health Use of generic vaccines and drugs

Mental health IEC Health research Role of Private sector Role of Civil Society National Disease Surveillance Health Statistics and information Womens health Enforcement of quality standards Environmental and occupational health Globalization and impact on the health sector

Goals of NHP

Eradicate Polio Eradicate Leprosy Eliminate Kalazar Eliminate Lymphatic Filariasis Zero HIV Growth 50% reduction in mortality (TB etc) Reduce Blindness < 0.5% Reduce IMR 30/1000 and MMR <100 Increase utilization of services > 75% Est Surveillance, NHA, HS Health Expenditure 0.9% to 2 % State health sector spending up to 8%

2005 2005 2010 2015 2007 2010 2010 2010 2010 2005 2010 2010