Everyone has the right to a standard of living adequate for the health and well-being

of himself and of his family, including food, clothing, housing and medical care and

necessary social services, and the right to security in the event of unemployment,

sickness, disability, widowhood, old age or other lack of livelihood in circumstances

beyond his control.

- Universal Declaration of Human Rights (Article 25, Para. 1)

1.1 Definition of Health

The most commonly quoted definition of health is that formalized by the World

Health Organization (WHO) over half a century ago; “a complete state of physical,

mental and social well-being, and not merely the absence of disease or infirmity.”

Bircher1 defines health as “a dynamic state of well-being characterized by a physical

and mental potential, which satisfies the demands of life commensurate with age,

culture, and personal responsibility”, while Saracchi2 defines health as “a condition of

well being, free of disease or infirmity, and a basic and universal human right”.

Australian Aboriginal people generally define health thus “…Health does not just

mean the physical well-being of the individual but refers to the social, emotional,

spiritual and cultural well-being of the whole community.”

1.2 Health Indicators

A Health indicator is a characteristic of an individual, population, or environment

which is subject to measurement (directly or indirectly) and can be used to describe

one or more aspects of the health of an individual or population (quality, quantity and

time). Health indicators can be used to define public health problems at a particular

point in time, to indicate change over time in the level of the health of a population or

individual, to define differences in the health of populations, and to assess the extent

to which the objectives of a program are being reached. Health indicators may

include measurements of illness or disease which are more commonly used to

measure health outcomes, or positive aspects of health (such as quality of life, life

1 Bircher J. Towards a dynamic definition of health and disease. Med. Health Care Philos 2005;8:335-41

2 Saracci R. The World Health Organization needs to reconsider its definition of Health. BMJ 1997;314:1409-10.

skills, or health expectancy), and of behaviors and actions by individuals which are

related to health. They may also include indicators which measure the social and

economic conditions and the physical environment as it relates to health, measures

of health literacy and healthy public policy. This latter group of indicators may be

used to measure intermediate health outcomes, and health promotion outcomes.

1.3 Types of Health Indicators:

1.3.1 Health expenditure per capita:

Total health expenditure is the sum of public and private health expenditures as a

ratio of total population. It covers the provision of health services (preventive and

curative), family planning activities, nutrition activities, and emergency aid

designated for health but does not include provision of water and sanitation.

1.3.2 Public Health Expenditure:

Government expenditure on health comprises the direct outlays earmarked for the

enhancement of the health status of the population and/or the distribution of medical

care goods and services among population by the following financing agents:

central/federal, state/provincial/regional, and local/municipal authorities; extra

budgetary agencies, social security schemes; parastatals. All can be financed

through domestic funds or through external resources.

1.3.3Out of Pocket Health Expenditure:

Out of pocket expenditure is any direct outlay by households, including gratuities and

in-kind payments, to health practitioners and suppliers of pharmaceuticals,

therapeutic appliances, and other goods and services whose primary intent is to

contribute to the restoration or enhancement of the health status of individuals or

population groups. It is a part of private health expenditure.

1.3.4 Private Health Expenditure:

Private health expenditure includes direct household (out-of-pocket) spending,

private insurance, charitable donations, and direct service payments by private

corporations.

1.3.5 Total Fertility Rate:

Total fertility rate represents the number of children that would be born to a woman if

she were to live to the end of her childbearing years and bear children in accordance

with current age-specific fertility rates. It is the number of births per 1000 women of

all ages.

1.3.6 Adult Literacy Rate:

Total adult literacy rate is the percentage of the population age 15 and above who

can, with understanding, read and writes a short, simple statement on their everyday

life. Generally, ‘literacy’ also encompasses ‘numeracy’ the ability to make simple

arithmetic calculations. This indicator is calculated by dividing the number of literates

aged 15 years and over by the corresponding age group population and multiplying

the result by 100.

1.3.7 Adolescent Fertility Rate:

Adolescent fertility rate is the number of births per 1,000 women ages 15-19.

Adolescent Fertility Rate

Source: World Bank

1.3.8 Infant Mortality Rate:

Infant mortality rate is the number of infants dying before reaching one year or five

years of age, per 1,000 live births in a given year.

1.3.9 Crude Death Rate:

Crude death rate indicates the number of deaths occurring during the year, per 1,000

populations estimated at midyear. Subtracting the crude death rate from the crude

birth rate provides the rate of natural increase, which is equal to the rate of

population change in the absence of migration.

1.3.10 Maternal Mortality Rate:

The maternal mortality ratio (MMR) is the annual number of female deaths from any

cause related to or aggravated by pregnancy or its management (excluding

accidental or incidental causes) during pregnancy and childbirth or within 42 days of

termination of pregnancy, irrespective of the duration and site of the pregnancy, per

100,000 live births, for a specified year.

1.3.11 Human Development Index:

The Human Development Index (HDI) is a summary measure of average

achievement in key dimensions of human development: a long and healthy life,

being knowledgeable and have a decent standard of living. The HDI is the geometric

mean of normalized indices for each of the three dimensions.

Source: hdr.undp.org

1.4 Current Scenario

1.4.1 Women:

Very young adolescents are more likely to experience complications during

pregnancy and childbirth than adult women and are at greater risk of maternal-

related death. The infants of adolescent mothers are at higher risk of mortality and

morbidity. The adolescent fertility rate (births per 1000 women aged 15–19 years in

2013) was highest in the WHO African Region (114) and in low-income countries

(111) compared with a global average of 49. In the WHO African Region, fertility is

high at all ages and adolescent pregnancies are common. Adolescent fertility is

declining in many countries but at a far slower rate than adult fertility.

Globally, an estimated 289,000 women died during pregnancy and childbirth in 2013,

a decline of 45% from levels in 1990. Hemorrhage and eclampsia alone account for

more than half of the maternal deaths. The other major causes of maternal death

include complications from unsafe abortions and sepsis. Together, these four causes

of death account for approximately 70% of global maternal mortality. Focusing on

these causes alone could save an additional 110,000 lives by 2015. Most of them

died because they had no access to skilled routine and emergency care. Since 1990,

some countries in Asia and Northern Africa have more than halved maternal

mortality.

There has also been progress in sub-Saharan Africa. But here, unlike in the

developed world where a woman's lifetime risk of dying during pregnancy and

childbirth is 1 in 3700, the risk of maternal death is very high at 1 in 38. Increasing

numbers of women are now seeking care during childbirth in health facilities and

therefore it is important to ensure that quality of care provided is optimal.

Globally, over 10% of all women do not have access to or are not using an effective

method of contraception. It is estimated that satisfying the unmet need for family

planning alone could cut the number of maternal deaths by almost a third. Lack of

access to family planning results in 80 million unintended pregnancies annually, or

40% of all pregnancies worldwide. Meeting 25% of the unmet need for family

planning could prevent more than 11 million unintended pregnancies and, in turn,

avert the deaths of 25,000 mothers and 250,000 newborns.

Maternal deaths and gaps in family planning are largely concentrated in two regions:

Sub-Saharan Africa and South Asia, which represent 57% and 29% of the global

maternal mortality burden, respectively. Within these regions, just 10 countries

account for approximately 170,000 maternal deaths annually, around 60% of the

global burden.

1.4.2 Children:

Between 1990 and 2012, mortality in children under 5 years of age declined by 47%,

from an estimated per 1000 live births. This translates into 17,000 fewer children

dying every day in 2012 than in 1990. The risk of a child dying before their fifth

birthday is still highest in the WHO African Region (95 per 1000 live births)–eight

times higher than that in the WHO European Region (12 per 1000 live births). There

are, however, signs of progress in the region as the pace of decline in the under-five

mortality rate has accelerated over time; increasing from 0.6% per year between

1990 and 1995 to 4.2% per year between 2005 and 2012. The global rate of decline

during the same two periods was 1.2% per year and 3.8% per year, respectively.

1.5 Millennium Development Goal

“We should judge the progress in humanity and the progress of any society or

country by the way they treat their women and children. They have been lagging

behind in the last 20 to 30 years of development. We should give them special

attention”

- WHO Director-General Margaret Chan.

At the current rate of progress, the projected 2015 maternal deaths will be 230,000

deaths/year. The agenda of MDG Health Envoy is to accelerate progress to meet the

target of MDG 5 by:

Lowering maternal deaths from 260,000 per year to fewer than 140,000/year

Increasing access to contraception for 30 million women, in order to meet 25% of the

current unmet need for family planning

“In an effort to deliver greater impact on a global scale, we are undertaking an

intensive review of our global health portfolio in the 24 priority countries where more

than 70 percent of under-five and maternal deaths occur annually. By aligning our

resources more strategically, we can make evidence-based investments that that will

accelerate development and, most importantly, save more lives,"

–USAID Administrator Dr. Rajiv Shah.

The UN Secretary-General’s Every Woman Every Child movement mobilizes and

intensifies global action to improve the health of women and children around the

world by working with leaders from governments, multilateral organizations, the

private sector and civil society. MDG4 focuses exclusively on reducing infant

mortality rate. The UNICEF report underscores that most of these 6.6 million child

deaths in 2012 were preventable, as they stem from such easily and affordably

treated afflictions as pneumonia, diarrhea, malaria and neonatal complications. The

simplicity of the problem has been the key guide reason to consider reducing infant

mortality rate as one of the MDGs. UNICEF along with other organizations and state

governments have amplified the provision of life-saving interventions in key

countries, lending essential support at every step.

UNICEF Executive Director Anthony Lake SAID, “MDG 4 is about children’s health,

but it doesn’t mean that we can reach that goal only through health programmes. To

achieve this goal, especially in the most deprived areas, we need to work on all the

killers of children in an integrated way or we will not achieve MDG 4.”

1.6 Types of Healthcare

Healthcare can be stratified mainly under three categories; primary, secondary and

tertiary in the order of their curative stage, primary healthcare being the preventive

care and tertiary being the advanced care. Recently, a new sector has been added

to the list called Quaternary Healthcare. It is the most advanced section of the

healthcare industry looking after some of the most complicated cases of health

disorders.

1.6.1 Primary Healthcare

Primary healthcare denotes the first level of contact between individuals and families

with the health system. According to Alma Atta Declaration of 1978, Primary Health

care was to serve the community it served; it included care for mother and child

which included family planning, immunization, prevention of locally endemic

diseases, treatment of common diseases or injuries, provision of essential facilities,

health education, provision of food and nutrition and adequate supply of safe

drinking water. Primary care providers (PCPs) may be doctors, nurse practitioners or

physician assistants. There are some primary care "specialties" like OB-GYNs,

geriatricians and pediatricians, too.

1.6.2 Secondary Health Care

Secondary Healthcare refers to a second tier of health system, in which patients

from primary health care are referred to specialists in higher hospitals for treatment.

Secondary care is where most of us end up when we have a medical condition to

deal with that can't be handled by primary care. Specialists focus either on a specific

body system or on a specific disease or condition. Cardiologists focus on the heart

and its pumping system; endocrinologists focus on hormonal systems; Oncologists

work on cancer cases.

1.6.3 Tertiary Health Care

Tertiary Health care refers to a third level of health system, in which specialized

consultative care is provided usually on referral from primary and secondary medical

care. Specialized Intensive Care Units, advanced diagnostic support services and

specialized medical personnel on the key features of tertiary health care.

1.6.4 Quaternary Health Care

Quaternary care is considered to be an extension of tertiary care - even more

specialized and highly unusual. Because it is so specialized, not every hospital or

medical center even offers quaternary care. The types of care that might be

considered to be quaternary would be experimental medicine and procedures, and

highly uncommon, specialized surgeries.

1.7 Health Financing

Health financing is concerned with how financial resources are generated, allocated

and used in health systems. Health financing policy focuses on how to move closer

to universal coverage with issues related to: (i) how and from where to raise

sufficient funds for health; (ii) how to overcome financial barriers that exclude many

poor from accessing health services; or (iii) how to provide an equitable and efficient

mix of health services

Financing health care is one of the crucial determinants that influence health

outcomes in a country. The health system goals of equity and accessibility

necessitate adoption of a financing strategy that will ensure protection of the majority

of individuals from catastrophic health expenditure. To arrive at an appropriate

strategy, policy makers would need to assess health system performance and

prioritize allocation of resources across various competing ends of the sector to

obtain the best possible health outcomes; however, this prioritization and allocation

is difficult in developing nations due to the complexity of the health system.

Source: Schieber G. Baeza. C et al, Financing Health Systems in the 21st Century, Chapter 12, Disease Control Priorities in

Developing Countries, OUP, World Bank, 2006

National Health Accounts (NHA) is an effective tool to support health system

governance and decision making by not only capturing financial flows but by also

providing information relevant to designing better and more effective health policies.

By providing a matrix on the sources and uses of funds for health, the NHA

framework facilitates in tracing how resources are mobilized and managed, who

pays and how much is paid for healthcare, who provides goods and services, how

resources are distributed across services, intermediaries and activities the health

system produces etc3.

National Health Accounts (NHA) provides large set of indicators based on the

expenditure information collected within an internationally recognized framework.

NHA is a synthesis of the financing and spending flows recorded in the operation of

a health system, from funding sources to the distribution of funds across providers

and functions of health systems and benefits across geographical, demographic,

socioeconomic and epidemiological dimensions.

Some of the core indicator of health financing systems

1.7.1 Total Health Expenditure as a Percentage of GDP

Total Expenditure on Health (THE) is measured as the sum of all financing agents

managing funds to purchase health goods and services. Level of total expenditure

on health (THE) expressed as a percentage of gross domestic product (GDP).

This indicator contributes to understanding the relative weight of private entities in

total expenditure on health. It includes expenditure from pooled resources with no

government control, such as voluntary health insurance, and the direct payments for

health by corporations (profit, non-for-profit and NGOs) and households. As a

financing agent classification, it includes all sources of funding passing through these

entities, including any donor (funding) they use to pay for health. It provides

information on the level of resources channeled to health relative to a country's

wealth.

Method of measurement*4:

3 Ganga Murthy, Economic Advisor, National Health Accounts, India. 2005.iii

NHA synthesize the financing flows of a health system, recorded from the origin of

the resources (sources), to the purchasing agents (financing schemes), which

distribute their funds between providers, to pay for selected health goods and

services to benefit individuals. Beneficiaries are analyzed across geographical,

demographic, socioeconomic and epidemiological dimensions.

1.7.2 Public Health Expenditure:

Level of Public Health Expenditure (PHE)/ General government expenditure on

health (GGHE) is expressed as a percentage of total expenditure on health (THE).

This is a core indicator of health financing systems. This indicator contributes to

understanding the relative weight of public entities in total expenditure on health.

It includes not just the resources channeled through government budgets to

providers of health services but also the expenditure on health by parastatals, extra-

budgetary entities and notably the compulsory health insurance payments. It refers

to resources collected and pooled by the above public agencies regardless of the

source, so includes any donor (external) funding passing through these agencies.

Method of Measurement*:

NHA indicators are based on expenditure information collected within an

internationally recognized framework. In this indicator resources are tracked for all

public entities acting as financing agents: managing health funds and purchasing or

paying for health goods and services.

1.7.3 Private Expenditure on Health

Level of private expenditure on health expressed as a percentage of total

expenditure on health.

This indicator contributes to understanding the relative weight of private entities in

total expenditure on health. It includes expenditure from pooled resources with no

government control, such as voluntary health insurance, and the direct payments for

health by corporations (profit, non-for-profit and NGOs) and households. As a

4 *The NHA strategy is to track records of transactions, without double counting and in order to reaching a comprehensive coverage. Specially, it aims to be consolidated not to double count government transfers to social security and extra budgetary funds.Monetary and non-monetary transactions are accounted for at purchasers' value. Guides to producing national health accounts exist. (OECD, 2000; WHO-World Bank-USAID, 2003).

financing agent classification, it includes all sources of funding passing through these

entities, including any donor (funding) they use to pay for health.

Method of Measurement*:

In this indicator resources are tracked for all private entities acting as financing

agents: managing health funds and purchasing or paying for health goods and

services.

1.7.4 Out-of Pocket Health Expenditure:

Level of out-of-pocket expenditure expressed as a percentage of private expenditure

on health.

It contributes to understanding the relative weight of direct payments by households

in total health expenditures. High out-of-pocket payments are strongly associated

with catastrophic and impoverishing spending. Thus it represents a key support for

equity and planning processes.

Method of Measurement*:

NHA traces the financing flows from the households as the agents who decide on

the use of the funds to health providers. Thus in this indicator are included only the

direct payments or out-of-pocket expenditure.

1.8 Nexus between Health Care and Political System

It is a widely accepted fact that improving the health status in any country entails

more than just the provision of effective preventive and curative medical services.

Gains in health status are the result of a long-term process involving complex

mechanisms and factors operating at a societal and collective level which often

requires changes in the nature of society and in the allocation of national resources.

In recent years there has been considerable research examining the various social,

cultural and behavioral determinants of lower mortality. Along with female literacy,

nutritional levels, one of the main determinants of health had been identified as

political priorities for health i.e., achieving better health is inevitably a political

process. As was concluded by the Rockefeller Conference in 1985, ‘political will’ or

‘a sustained political commitment to universal health and well-being’ is a major factor

responsible for health success in poor developing countries (Summary Statement,

1985).

The correlations between health status and political system can be explained in at

least three different ways:

Good health status may make the establishment of certain political systems more

likely or increase the probability of their continued existence; better health status

might itself be a cause of a type of political system;

There are other factors which are independent determinants of both political system

and of health status over the longer term

The political system itself influences health status.

On the ground of previous evidences and experiences it can be states that

differences in political system might influence health status, either positively or

negatively.

1.8.1 Communist:

It might be argued that communist regimes committed to an ideology, which

especially emphasizes the elimination of material deprivation, are more likely “to

create national health services based on the principle of universal entitlement to care

(Cereseto and Waitzkin, 1986), and thus improve the health status of their

populations.

1.8.2 Democratic:

Complete democratic system is highly representative and therefore open forms of

government are more likely to allow individuals and their organizations to work for

those changes that will enable them to meet their own health needs. In a fully

democratic country health is regarded as a commodity like any other commodity.

Competition in the health sector has led to significant betterment in health care.

Health care industry has boomed, private expenditure is high, government initiatives

is consistent along the market players.

In a study conducted by Ramesh Govindaraj and Ravindra Rannan Eliya, 1994 it

was found that, controlling for income, democracies on average have better health

status than non-democracies; that communist regimes do not have better health

status, on average, compared to non-communist regimes; and, finally, that

democracies have a significantly better health status compared to communist

regimes.

1.8.3 Socialist:

There have been many arguments and discussions with regard to the impact of

socialist political system on the health care. Socialist system is the amalgamation of

both communist and state monitored health care system and capitalist or market

controlled health care system. Socialist economies idealism lies in providing health

services from both private and public sectors.

Unlike the capitalist economies, socialist economies have not been able to achieve

the health targets; however, it cannot be denied that for developing economies,

socialist political system has been of great aid in improving the health status. “In

short, socialist regimes do not do better than the average of all capitalist countries,

but do perform better than non-democracies.

1.9 Importance of Healthcare to Economy

"It's important to remember that healthcare is the economy. A massive part of our

economy. The idea that we can separate out the two is a fantasy”.

–Barak Obama, President of the United States of America.

For any nation, the path to well-being includes its citizens' good health. Indeed it is

arguable that nations with a healthy population have an advantage over those

encumbered by a huge disease burden; they are more likely to realize their potential

and prosper in the long haul. Health makes an important contribution to economic

progress, as healthy populations live longer, are more productive, and save more.

1.9.1 Importance of Public Health Care

Public health is fundamental to 21st century healthcare and shares the same overall

goals as the rest of the health care system - reducing premature death and

minimizing the effects of disease, disability, and injury. The main intent of public

health is to promote a healthier population. This is prototypical to a sustainable

health care system, and also provides economic and social benefits for the nation,

due in part to increased human productivity.

Health is fundamental to national progress in any sphere. In terms of resources for

economic development, nothing can be considered of higher importance than the

health of the people which is a measure of their energy and capacity as well as of

the potential of man-hours for productive work in relation to the total number of

persons maintained by the nation. For the efficiency of industry- and of agriculture,

the health of the worker is an essential consideration.5

The two main underlying principles that distinguish public health programs, services

and institutions from clinical medicine are:

1. The focus of public health is prevention rather than treatment of diseases; and

2. Public health addresses the health needs of populations as a whole instead of

individuals.

Core functions in public health include health promotion and protection, disease

prevention, health assessment and disease surveillance. Public health not only

includes direct treatment and care but also comprises of research and development

to promote better health facilities. Advertisements, regulations, guidelines, etc on any

health related products are part of public health.

1.9.2 Importance of Private Health Care

The role of private sector in promoting substantial health care in both developed and

developing nations is growing intensely in the recent years. The private sector is

involved in healthcare through two mechanisms:

1. The first is where services are provided at a fee, usually with a profit motive,

as in the case of self-employed health care professionals.

2. The second is where for-profit companies get involved in providing health care

services with no intention of making a profit i.e., by providing healthcare

services to their employees or to the community on a philanthropic basis.

Whether philanthropic driven or profit driven, the role of private sector is to eradicate

diseases, promote healthcare services, enhance the availability of healthcare, and to

5 Eleventh Five Year Plan Report, Planning Commission of India

address health issues at a micro level. The efficiency and outreach of public health

care need not be perfect, for which private sector is required to fill the gap between

the demand and supply of healthcare. Besides, the general roles, private sector also

induces innovation and development in the healthcare industry as a consequence of

the element of competition that is involved in it.

It is quintessential to well-functioning health care system that Public health and

clinical medicine coexist. Allocation of equal weightage to both is imperative to both

individual and population health.