loksatta's roadmap to universal healthcare

Without health nothing is of any

use, not money nor anything else

Democritus in his book On Diet

2

”“

Contents

1. Growing Population – Growing Challenges

2. Progress so far

3. Avoidable Suffering

4. Increasing Burden of Non-Communicable Diseases

5. System Failures

A. Budget Allocations

B. Public Health Facilities –Shortages

C. Dependence on Private Providers

D. Impact of Out of Pocket Expenditure (OOPE)

E. Poor Health Record Keeping

6. The Global Experience

7. Reform Agenda

8. Framework for Universal Healthcare Model

9. Health Sector Can Create Jobs !

10. Issues to be resolved

11. Annexures

3

Growing Population – Growing Challenges

A Decade of Tracking Progress for Maternal, Newborn and Child Survival, The 2015 Report*World Bank -data.worldbank.org** WHO,2015

The Financial Express – Jan 21st,2015

The population is set to rise to

1.4 billion by 2026 (Annex 1)

Demographics

Total Population(000) 1,311,051

Total under-five Population(000) 123,711

Births (000) 25,794

Total under-five deaths(000) 1,201

Neonatal Deaths (% of under-five deaths)) 58

Neonatal Mortality Rate (per 1000 live births) 28

Infant Mortality Rate (per 1000 live births) 38

Maternal Mortality Rate(2014)(per 1,00,000 live births)

181*

Total maternal deaths 45,000**

Adolescent birth rate (per 1000 girls) 26

Total Fertility Rate (per woman) 2.4

4

Progress so far…

The Hindu- May 14th,2015

5

National Health Profile, 2015

6

GDP (PPP) Per Capita ($)

Sources: World Bank Data 2015

10

15

20

25

30

35

40

45

50

0 2,000 4,000 6,000 8,000

India

Kyrgyzstan

Zimbabwe

Vietnam

Bangladesh

Nepal

Papua New Guinea

Tajikistan

Philippines

Infant Mortality Rate

A lot to learn from the neighbours –Bangladesh and Nepal have lower IMR

7

Sources: 1. Estimates of National Vector Borne Disease Program,20142. Balarajan, Y., Selvaraj, S. and Subramanian, S. (2011) healthcare and equity in India,TheLancet,377, 505; 3. Global TB control, WHO 20154. World Bank Data, 20125. Unicef: Rapid Survey of children 2013-14 (Annex 2)

Avoidable Suffering!

1.2 million under-five year old children died in

2015

Total annual cases of 9.7 million malaria

infections

2.5 million new cases of Tuberculosis in 2015

Out of pocket (OOP) expenditure for health

forces 55 million people below the poverty line

28% of deaths are caused by mostly

preventable communicable diseases and maternal, perinatal and nutritional diseases

Only 65.2% of the children aged between

1-2 years are fully immunised

8

An increasing Non Communicable Disease (NCD) burden!

Sources: Healthcare: The neglected GDP driver by KPMG- September 2015, page- 16.

9

Economic Burden!

Sources: Healthcare: The neglected GDP driver by KPMG- September 2015, page- 17

10

Effects on Labour Productivity….

Sources: Healthcare: The neglected GDP driver by KPMG- September 2015, page- 18

11

System Failures

Illness is neither an indulgence for which people have to pay, nor an offence for which they should be penalised, but a misfortune, the cost of which should be shared by the community.

“

”Aneurin Bevan, Architect of National Health Service (United Kingdom)

12

Critical Issues and Challenges

Doctors accessibility in rural healthcare

Unaffordable family care to the people

Inefficient public-private partnerships

Accountability in public healthcare

High out-of-pocket health expenditure

Low public health expenditure share

Decline in family care – over-specialization

Alternative systems –integration

13

Budget

Allocations

Public health expenditure

is roughly 1.3% of our GDP.

Out of which currently

around 1.05% is spent by

the state governments

14

Source: Connecting the Dots – An Analysis of the Union Budget 2016-17,Center for Budget and Governance Accountability(CBGA)

The public health expenditure of India is one of the lowest in the world and it needs

to be increased to atleast 2.5% of our GDP

Livemint – Dec 15th,2015

Public Heath Expenditures in Select Countries18

In India too, While increasing the health expenditures,

the Union and States expenditures ratio should rise to 1:10%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

USA Australia Brazil India

Share of Federal and State health

expenditures in select countires

Federal States

In countries such as USA, Australia and Brazil, the

federal governments health expenditure is almost 50%

of the total public health expenditure

The share of the Union government allocations out of

total public expenditure has been decreasing. The

current ratio of Union and States expenditures is 1:4.

Health Public Expenditure: Share of Center and States

19

Source: Connecting the Dots – An Analysis of the Union Budget 2016-

17,Center for Budget and Governance Accountability(CBGA)

Public Health Facilities - Shortages

Shortage of PHC’s and CHC’s in different states (Annex 7 & 8)

NormHilly/tribal/ desert

areas

(Population)

Plain areas

(Population)

PHC 20,000 30,000

CHC 80,000 1,20,000

Currently, India has 1 PHC for every

50,000(approx.) population and 1 CHC for

every 2,30,000(approx.) population

While the norm is..


Shortfalls(%) in PHC’s and CHC’s

20

Planning Commission of India

Dependence on private providers

As per the National Family Health Survey(NFHS-3),

only 34.4% of the people used public health

facilities when they fell sick.

Around 65% of the people did not use the public

healthcare facilities due to various reasons.

The widely reported reasons were

a. Poor quality care (57%)

b. No nearby facility (48%)

c. Waiting time is too long (24%)(Annex 4 & 5)

This eventually led to heavy dependence on private healthcare facilities, increasing the costs. (Annex 6)

41.932

58.168

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Rural Urban

Percentage distribution of hospitalised

cases

Public Hospitals Private Hospitals

Source: NSSO report- Key Indicators of Social Consumptionin India: Health, January-June, 2014

21

Around 78% of total health expenditure in

India is private

Rural India

(Average)14,935

Average Expenditures Per Hospitalization

(Rural)

Livemint- Dec 2nd,2015

22

While the average monthly incomes of an individual hover around ₹ 7000, the average expenditure per

hospitalization is twice and thrice the incomes in rural

and urban areas respectively (Annex 3)

Urban India

(Average)24,436

Livemint- Dec 2nd,2015

Average Expenditures Per Hospitalization

(Urban) 23

Out-of-Pocket expenditure in India is 86%* of total private health expenditure

Of the households that descent into poverty more than 50% are due to ill-health and Healthcare expenditures**.

Source:

*http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS**Balarajan, Y., Selvaraj, S. and Subramanian, S. (2011) healthcare and equity in India,TheLancet,377, 505; ***Assuring health coverage for all in India – Lancet , December 2015

Impact of Out-of-Pocket Expenditure (OOPE)

Hospitalized Indians spend 48% of total annualexpenditures/savings on healthcare.

Hospitalized Indians draw more than 33% of hospitalizationexpenses by borrowing money or selling assets.

While the Compound Annual Growth Rate(CAGR) in outpatientcare is same for both public and private hospitals(9.5%), theCAGR in inpatient care is higher for private(11.4%) thanpublic(5.8%) (Annex 6)***

220 319

554

788

OUTPATIENTS (PUBLIC HOSPITALS) OUT PATIENTS (PRIVATE

HOSPITALS)

OOP expenditure incurred by

Outpatients

2004 2014

4733

88046120

25850

INPATIENTS (PUBLIC HOSPITALS) INPATIENTS (PRIVATE HOSPITALS)

OOP expenditure incurred

by Inpatients

2004 2014

24

Poor Health Record Keeping

• Lack of robust data collection

mechanisms

• Inadequate information sharing

with different levels of healthcare

providers

• Many of the epidemics cannot

be prevented without knowing

the source of such maladies


As a result, preventive health care is undermined

26

The Global Experience

27

BROAD FEATURES

Healthcare Models in various countries

Great Britain, Spain,

Scandinavia, New Zealand, Hong Kong

Germany, FranceBelgium, Netherlands,

Japan, Switzerland, Latin America

Canada,Taiwan and South Korea

Africa, India, China and South America

United States of America

• Healthcare is provided

and financed by the govt

through tax payments

• There are no medical bills

• Medical treatment is a

public service

• Providers can be govt

employees

• Lows costs b/c the govt

controls costs as the sole

payer

• This model uses a health

insurance system which is

usually financed by both

employers and employees

through payroll deduction.

• Health insurers are required

to insure everybody and

they are not profit-making

ventures.

• Provides insurance through

competing social funds

• Offers multiple sources of

provision

Bismark Free-MarketOut-of-PocketBeveridgeNational Health

Insurance

• Providers are private

• Payer is a government-run

insurance program that

every citizen pays into;

• Has considerable market

power to negotiate lower

prices

• National insurance collects

monthly premiums and pays

medical bills

• Plans tend to be cheaper

and much simpler

administratively than

American-style insurance

• Most medical care is

paid for by the patient,

out-of-pocket

• No Universal Health

Coverage

• Only the rich get

medical care; the poor

stay sick or die

• Maintains safety net through

public payment of premiums

• Offers services and

insurance through private

sector

The United States has a fragmented

system, with different plans for

different populations (i.e.,

government-sponsored Medicare for

those over 65, free care for military

veterans, employer-funded

insurance for those who are working,

private medical insurance for those

who can afford it, and out-of-pocket

care or medical assistance for those

who have no insurance).

28

United

Kingdom

Community Healthcare

1.Primary care services are delivered by a wide variety of providers including General Practitioners (GPs), dentists, optometrists, pharmacists, walk-in centres and NHS 111. There are more than 66351 general practitioners in UK providing primary care services

2.Community health services are delivered by foundation and non-foundation community health trusts. Services include district nurses, health visitors, school nursing, community specialist services, hospital at home, NHS walk-in centres and home-based rehabilitation.

Tertiary Care

Acute trusts provide secondary care and more specialised services. The majority of activity in acute trusts are commissioned by Clinical Commissioning Groups(CCG). However, some specialised services are commissioned centrally by NHS.

Accountability

Revalidation is the process by which clinicians have to demonstrate to their regulatory bodies (for example, General Medical Council and Nursing and Midwifery Council) that they are up to date and fit to practice. It is a way of regulating the professions and contributing to the ongoing improvement in the quality of care delivered to patient

Incentives/Performance

Clinical Excellence Awards Scheme, merit pay schemes based on individual performance; NHS scheme is still attempting to assess and reward individual performance, when the NHS and many private sector workplaces rely on the activities of teams.

Health Information Data

The Health and Social Care Information Centre (HSCIC) was formed in April 2013 as an executive, non-departmental public body and the national provider of information, data and IT systems for patients, service users, clinicians, commissioners, analysts, and researchers in health and social care base

Drug Supply

Under laws governing the supply of medicines, medicines can be obtained under three categories:

1.Prescription-only medicines need a prescription issued by a GP or another suitably qualified healthcare professional. One can take the prescription to a pharmacy or a dispensing GP surgery to collect the medicines.

2.Pharmacy medicines are available from a pharmacy without a prescription, but under the supervision of a pharmacist.

3.General sales list medicines can be bought from pharmacies, supermarkets and other retail outlets without the supervision of a pharmacist. These are sometimes referred to as over-the-counter medicines.

Universal Coverage

National Health Service (NHS) is a public funded healthcare system in all the four regions of the UK. The NHS is made up of a wide range of organisations specialising in different types of services for patients. Together, these services deal with over 1 million patients every 36 hours. Providers of ‘primary care’ are the first point of contact for physical and mental health and wellbeing concerns, in non-urgent cases. These include general practitioners (GPs), but also dentists, opticians, and pharmacists (for medicines and medical advice)

The money for the NHS comes from the Treasury. Most of the money is raised through taxation.

Public Expenditure on

Health

as % of GDP (2013)7.6 IMR/MMR (2015) 4/9 Life Expectancy

(2013)81

29

MexicoPublic Expenditure

on Health

as % of GDP (2013) 3.2IMR/MMR (2015)

11/38Life Expectancy

(2013) 77Primary Care :

Mexican health system is fragmented based on employment status and respective insurance institutions. Each institution has respective independent network of primary, secondary and tertiary service providers and necessary infrastructure. In addition, many pharmacies in Mexico have a doctor on staff or next door who charges a few dollars for a basic consultation. These pharmacy clinics continue to grow and provide underserved populations in semi urban and rural areas with an inexpensive and convenient way to obtain medications.

Tertiary Care :

Hospitals and clinics that provide medical care for social security recipients are of variable quality. While major urban institutions may provide adequate to excellent tertiary care, rural hospitals often have outdated equipment, long waits and inadequate staffing.

Drug Supply :

Although many drugs in Mexico are available over the counter at a pharmacy, certain prescription drugs in Mexico do require a prescription from a Mexican pharmacist. Mexicoís social insurance programmes achieve very significant savings over the retail cost of medicines through a system on which manufacturers of interchangeable generics bid for business, designating the price at which a particular volume of medicines can be offered.

Universal Coverage

Mexico recognises health as a constitutional right and offers basic levels of universal healthcare. Introduction of "Seguro Popular" in 2003 was a landmark event towards universal coverage. In spite of the availability of basic universal healthcare, approximately 20% of Mexicans remain uncovered and health equality in Mexico remains low even for those with healthcare coverage

Finance

Mexico’s public healthcare sector, which is predominantly funded by taxes, consists of social security institutions and government-sponsored healthcare. Each of these public sectors covers approximately 40% of the Mexican population. The social security institutions cover private employees, retirees, and their families. Those who are not eligible for social security have the option to subscribe to Seguro Popular (SP; Popular Insurance), which is government-sponsored health insurance.

Health Information Database

Mexico has disjointed data systems and patient registers to monitor quality and outcomes. To change this, New Mexico Health Information Collaborative (NMHIC) is envisaged to provide a statewide Health Information Exchange (HIE) that allows authorized healthcare professionals with patient consent to quickly access the patient’s history in one centralized record.

Accountability

Poor monitoring and evaluation of reforms are important impediments which led to inefficient healthcare system.

Incentives for Performance

Affiliation to the Seguro Popular is voluntary, yet the reform includes incentives for expanding coverage. States have an incentive to affiliate the entire population because their budget is based on an annual, per family fee.. The voluntary nature of the affiliation process is an essential feature of the reform that helps democratize

the budget by introducing an element of choice. It discourages adverse selection and provides incentives not only for universal coverage, but also for good quality and efficiency.

30

Sri LankaPublic Expenditure

on Health

as % of GDP (2013) 1.4IMR/MMR (2015)

8/30Life Expectancy

(2013) 74Community Healthcare :

Community healthcare service is provided through 'Health Units’ comprising up to 80,000 to 100,000 inhabitants. The activities of the health unit are as following: 1) Conduct a general and special health survey on all aspects of the health problems in the district, 2) Collect and study vital statistics of the area, 3) Promote health education, 4) Undertake measures to control infectious disease, 5) Organize maternal and child health programs, 6) Conduct school health programs, 7) Develop rural and urban sanitation projects

Tertiary Care :Curative care is provided through teaching hospitals, provincial general hospitals, district general hospitals and base hospitals (type A and type B). Secondary hospitals provide four basic specialties (medicine, surgery, pediatric, obstetrics and gynecology) and manage patients needing specialist care that are not available in primary care hospitals, while tertiary hospitals provide added specialties.

Drug Supply :

State Pharmaceuticals Corporation(SPC) of Sri Lanka procure and supply drugs to the Health Ministry and to the private sector market through an open competitive tender procedure. SPC distribute drugs to the general public through island wide network of Rajya Osu Salas,Franchise Osu Salas and distributors. In Sri Lanka there are about 5000 pharmacies for 21 million people. The total pharmaceutical market of Sri Lanka today is approximately US$ 365 million of which the private retail market accounts for approximately 60% of sales while the government hospital purchases account for approximately 28%, private hospitals account for approximately 10% and dispensing family physicians account for approximately 2% of the total pharmaceutical business.


Performance-based non-financial incentives such as career development, training opportunities and fellowships were found to be appropriate for central and provincial managers, while hospital managers preferred financial incentives

Universal Coverage :

Sri Lanka’s model of primary health care, available free through a government health system with island wide availability, forms a sound basis for providing universal health coverage. However, with high burden of non-communicable diseases (NCDs), increasing elderly care needs and the growing out of pocket expenditure for chronic diseases, this system is under pressure. Whilst the government’s commitment to maintaining universal health services of good quality for all continues, the need for change has been recognized. Primary health care in Sri Lanka developed as two parallel services: Community health services and Curative services.

Finance

Financed mainly by the government, with some private sector participation as well as limited donor financing. Public sector financing comes from the General Treasury, generated through taxation. Public sector services are totally free at the point of delivery for all citizens through the public health institutions distributed island-wide, while private sector services are mainly through ‘out-of-pocket expenditure’ (OOPE), private insurance and non- profit contribution.

Health InformationDatabase

The following systems are present: Patient Administration System (PAS), Laboratory Information Management System (LIMS), Electronic Medical Records (EMR), Electronic Health Records (EHR) and Management Information System (MIS)

Accountability

Sri Lanka is an example of how democratic politics can provide a means of government accountability for services to the poor (World Bank 2003). The small size of electorates encouraged a form of “parish pump politics,” in which national politicians, some elected by as few as 5,000 voters (Wriggins 1960), competed to ensure that the government built dispensaries and further, hospitals in their constituencies.

31

ThailandPublic Expenditure

on Health

as % of GDP (2013) 3.7IMR/MMR (2015)

11/20Life Expectancy

(2013) 74Community Healthcare :

Community hospitals are at the district level and further classified

by size: Large community hospitals have a capacity of 90 to 150

beds, Medium community hospitals have a capacity of 60 beds,

Small community hospitals have a capacity of 10 to 30 beds. While

all three types of hospitals serve the local population, community

hospitals are usually limited to providing primary care, while

referring patients in need of more advanced or specialised care to

general or regional hospitals.

Tertiary Care :

The inpatient care is provided differently in all the three

schemes namely – Civil Servant Medical Benefit Scheme

(CSMBS), Social Security Scheme (SSS) and Universal Coverage

Scheme (UCS). The idea is to provide universal care while

incentivising the fiscal prudence. For example, while care is

provided under UCS, it is capped at global budget. Similarly,

under CSMBS, Diagnosis Related Group (DRG) payment system is

used to disincentivise over-treatment

Drug Supply :

The drugs are procured by the National Health Security

Office (NHSO) and distributed through primary distribution

system ( in which the government drug procurement office

establishes a contract with a single primary distributor, as

well as separate contracts with drug suppliers) attached to

each of the clinics. The drugs can be sourced at subsidised

price on furnishing prescription.

Health Information Database

Ministry of Public health is currently reforming its health information system to

streamline its administrative, financial management and to assess health outcomes

of the intervention in order to improve targeting. The UCS contributed significantly

to the development of Thailand’s health information system through hospital

electronic discharge summaries for DRG reimbursement, accurate beneficiary

datasets and data sharing. The creation of the NHSO’s disease management system

increased better achievement of outcomes

Finance

Mainly funded through taxation and co-contribution of both employer and

employee

Universal Coverage :

99.5% of the population is covered under three of the schemes i.e.,

CHMBS, SSS and UCS

Accountability

Various mechanisms established by the NHSO to

protect beneficiaries: a “1330” hotline, a patient

complaints service, a no-fault compensation fund,

stepwise quality improvement and tougher hospital

accreditation requirements.


The government enforces a three-year compulsory public service for new medical graduates and many financial incentives for rural doctors, including hardship allowances,

no-private practice allowances, overtime payments, and non-official hours special service allowances. These financial incentives have been allowed to increase up to 20

percent after the implementation of the universal coverage scheme. Measures to hire retired physicians is also implemented. For long term measures, the government

approved a project to accept additional 10,678 medical students from 2005-2014 (The Secretariat of the Cabinet 2004). In order to ensure equity of education, longer

rural retention, and local acquaintance, the additional new medical students will be recruited from the rural provinces/districts and trained in provincial hospitals.

32

The best form of providing health protection would be to change the

economic system which produces ill health, and to liquidate ignorance,

poverty and unemployment. The practice of each individual purchasing his

own medical care does not work. It is unjust, inefficient, wasteful and

completely outmoded ... In our highly geared, modern industrial society,

there is no such thing as private health — all health is public. The illness and

maladjustments of one unit of the mass affects all other members. The

protection of people's health should be recognised by the Government as its

primary obligation and duty to its citizens.

- Norman Bethune

Reform Agenda

33

”

National Commission on Macroeconomics and Health, 2005

Health

Financing

• Increase public spending to 3% of GDP

• Increase public investment to primary health care for providing universal access to a basic package of services at CHCs and facilities below it, alongside reorganizing the structure for enhancing accountability and increased sharing of oversight functions by the communities and local bodies

Utilization of IT services

• Introduce and intensively promote use of IT in health care for patient care in 3 areas : 1) Telemedicine, 2) computerized data management and record keeping; 3) training through the Edusat facility

Drug Delivery

• Centralized pooled procurement of drugs reduce government expenditure by over 30%-50%

• For making drugs available at reasonable prices in the public health system, autonomous bodies should be established at the Central and State levels

Standardized

Treatment Protocols

• Standardization of treatment protocols and unit cost estimations should be taken up and a schedule of benefits published. This then could be the basis for public funding of health in both public and private facilities. This will also enable people to get an idea of how much a service ought to cost and protect them from being exploited

Organizational

restructuring

• Gradually shift towards a mandatory Universal Health Insurance System for secondary and tertiary care

• Action should be initiated to put in place the appropriate regulatory and institutional mechanisms, for example, the necessary health laws to govern health insurance business and a health regulator to oversee the enforcement of such regulations

Institutional infrastructure

• National Drug Authority (NDA) with an autonomous status to take up the functions of drug pricing, quality, clinical trials, etc. need to be implemented

• National Institute for Health Information and Disease Surveillance to be established for a systematic policy approach to research and evidence

Various committees of experts have been appointed by the government from time to time to render advice about different healthproblems. The reports of these committees have formed an important basis of health planning in India. (Annex 10)

34

High Level Expert Group Report on Universal Health Coverage for India, 2010

Financing

• Increase public expenditure to 2.5% and 3% of GDP by 2017 and 2022 respectively

• Ensure availability of free essential medicines

• Do not use insurance companies to purchase health care services

Service Norms

• focus significantly on primary health care

• Strengthen District Hospitals

• equitable access to functional beds for guaranteeing secondary and tertiary care

Human Resources

• Establish a dedicated training system for Community Health Workers

• increasing HRH density to achieve WHO norms of at least 23 health workers per 10,000 population (doctors, nurses, and midwives)

Community Participation

• Transform existing Village Health Committees into participatory Health Councils

• Strengthen the role of civil society and non-governmental organizations

• Institute a formal grievance redressal mechanism at the block level

Access to Medicines

• Revise and expand the Essential Drugs List

• Enforce price controls and price regulation especially on essential drugs

• Empower the Ministry of Health and Family Welfare to strengthen the drug regulatory system

Institutional Reforms

• Develop a national health information technology network to ensure inter-operability between all health care stakeholders

• Ensure accountability to patients and communities

• Invest in health sciences research and innovation to inform policy, programmes and to develop feasible solutions

35

Limitations of existing approaches

1. Public sector provider model:

- Lacks incentive to provide quality healthcare

- Huge Corruption

-Lost public confidence

2. Fee for service model:

- Over treatment

- Cost escalation

3. Capitation payment model:

- Under treatment

4. Traditional Insurance model:

- Causes avoidable suffering and escalates costs

- Adverse selection of beneficiaries

- Moral hazard

36

Spending does not improve health automatically!

0

2

4

6

8

10

12

14

16

18

United States Japan Australia Italy Spain Iran Thailand Singapore India Bangladesh

COMPARISON OF HEALTH EXPENDITURE WITH D ISABIL I TY -ADJUSTED L I FE YEAR (DALY) RANKING

Total health expenditure as % of GDP

51*1*36*47*

4*

41*

3*5*2*

24*

* The numbers indicate DALY rankings (Annex 9)

37

Health Outcomes

Public Spending on

Health

High Quality

Institutions

Cost-Effective

Interventions

Source: Spence and Lewis 2009. Health and Growth: The World Bank and the Commission on Growth and Development.

Appropriate

Delivery Models

Spending does not improve health automatically!

What we need…

38

Health Domains Public Funded Private FundedCost-effective

option

Public and Preventive

Health

Strong Positive

ExternalitiesNo Markets Public

Primary Care

Positive Externalities

No choice - No

Accountability

Disincentive for

preventive part

Public- Private

Partnership

Secondary Care Inefficiency OvertreatmentChoice and

Competition

Tertiary Care Centres of Excellence Overtreatment Public and NGOs

Cost-effectiveness in Healthcare

39

40

Framework for a Universal Healthcare Model

Primary and Preventive Healthcare – Main Features

At the heart of the Primary and Preventive Care lies the Family

Physician (FP)

FP is a private provider who is contracted by a Regional Health

Trust (RHT) from a pool of available doctors

S/he is a qualified doctor who is certified in family healthcare. (Eg. 3-month certification courses can be

tailored to suit this need)

3 to 4 additional staff including assistant, lab technician, data analyst, etc. will assist the FP

Basic diagnostic facilities such as blood and urine tests will be

provided at the clinic

The FP would generally reside in the community/area s/he practices. In

rural areas, the FPs will reside in small towns where nearby villages

are covered. This will ensure sufficient rural penetration where

the FP need not necessarily have to be in the village s/he serves

Each FP is expected to register about 5000 people with him

Doctor – patient relationship

Registration and electronic records

Primary and preventive healthcare

Referrals and LinkagesChoice and competition

The Family

Physician

41

Family Physician – Main Features

Doctor-Patient Relationship

The core aspect of the model is the directinteraction of the patient with the FamilyPhysician, This will build a bond of trustand act as a psychological booster. Thus,such consultations can ensure holistichealthcare rather than merely treatingthe patient.

Choice and Competition

It is up to the people to choose their

Family Physician from a pool of

available doctors. This element of

choice would enable competition

where FPs in a geographic area

would vie to provide the best services

in order to attract registrations.

Registration and electronic records

AADHAR will be the mandatory basis for

registration and availing of services.

Subsequently, electronic health records

of the patients will be available. These

records will be monitored by the

Central Health Monitoring Agency

(CHMA). They can be digitally

transferred to respective FP if the

patient changes his provider.

Referrals and Linkages

A key aspect of FPs is to make referrals to

secondary care. These are mandatory for

elective non-emergency procedures. This will cut

down overdiagnosis and overtreatment.

Also, FPs will have linkages with Primary Health

Center (PHC), Regional Health Trust (RHT) and

secondary referral hospitals in order to improve

accessibility to needed services. Feedback

mechanisms from FPs to RHT and secondary

referral hospitals and vice versa will ensure better

healthcare practices.

42

Primary Health Center (PHC) – Basic Functions

The linkages between the FP and the PHC is crucial for smooth access to health services such as basic diagnostics, etc.

Free generic drug supply

Diagnostics such as X-ray, Scanning

etc.

Local nutrition and sanitation programmes

Mosquito control and disease

control programmes

And other related tasks

Field visits and epidemiological

surveys

There are 25,308 PHCs and 1,53,655 sub-centers in India as of 2015.*

They can be integrated into the FP model by concentrating on those services which complement the Family Physician’s duties.

43

Free generic drug

supply

Diagnostics such as

X-ray, etc.

Field visits and

epidemiological

surveys

Local nutrition and

sanitation

programmes

Mosquito control and

disease control

programmes, etc.

Primary Health Center

Primary and

preventive

healthcare

Basic diagnostics like

Urine and Blood test;

Referrals

Electronic records

Registration

Free generic drug

supply

Family Physician

Primary and Preventive Health Care 44

Primary and Preventive Healthcare Expenditure Estimates (by 2022)

Per capita expenditure proposed Rs. 700

Population projected 1.4 billion* (140 Crores)

Projected out patient public health expenditure 700*140 crores

Costs including Out patient care, Immunization, Family

planning, Simple diagnostics, Generic drugs, Maternal and

child care

Rs. 1,00,000 crores (Approx.)

Cost of maintaining existing infrastructure and primary health

centers(auxiliary staff , administration etc.) Rs. 25000 crores (Approx.)

Expected Cost for outreach, cold chains, diagnostic centers,

CHMA, drug supply, electronic patient record, etc. Rs. 25000 crores (Approx.)

Total projected public health expenditure on primary and

preventive healthcare

Rs. 1,50,000 Crores

* Provisional by 2022, World Population Prospects, The 2015 Revision by Department of Economic and Social Affairs, UN.

45

Central Health Monitoring Agency (CHMA)

This government agency is envisioned ascentral level IT infrastructure-basedmonitoring and controlling agency.

Patient records are linked to theirAADHAR.

All the FP clinics, PHCs, CHCs, drug dispensaries of approved private hospitals, diagnostic centers and Drug Supply Agency are digitally linked to this central database.

46

Secondary Healthcare

A number of carefully chosen

small nursing homes (30 bed)

subject to certain minimum

standards where costs, quality of

service are predefined will be

contracted and paid by the RHT.

CHCs will act as

polyclinics and

cater to advance

diagnostics like

radiology, CT Scan

etc. Pooling of

diagnostics can be

looked into.

Call centers can be

constituted for

information

dissemination and

appointment/queueing

mechanisms.

Free drug dispensary (both at

CHCs and pvt. nursing homes) to

provide free generic medicine

through electronic prescription

linked to DSA and CHMA.

Linkages including feedback

mechanisms among

contracted private nursing

homes, CHCs and tertiary

referrals hospitals. Feedback to

FPs/PHCs regarding referrals

from primary care level.

There are 5396 CHCs in India.*

Over the next 5-10 years they

can be increased to 10,000.

This would ensure at least one

CHC for every 125000

population

Referrals from FP/PHC is

mandatory for elective

non-emergency

procedures in both

contracted private

nursing homes and

CHCs.

Predefined conditions for

allowing pvt. nursing homes

in emergency care and life

saving techniques including

basic trauma care. Patient

mobility from home to

CHC/pvt. nursing homes.

The basic aim is to ensure healthy competition between Community Health Centers (CHCs)/public

providers and private nursing homes and adequate choice to the patient.

CHC’s and small

private nursing homes

will compete except

in the case of pooled

facilities.

47

Polyclinic

Free generic drug

supply

Advanced

Diagnostics such

as MRI, CT scan,

etc.

Electronic records

Referrals and

Linkages

Trauma/

Emergency care

Free generic drug

supply

Specialists

Community Health

Centers (CHCs)Private nursing homes

contracted through RHTs.

Secondary Healthcare

48

Secondary Healthcare Expenditure Estimates (by 2022)

Population projected 1.4 billion* (140 Crores)

Assuming number of beds (public hospitals, accredited small nursing

homes, etc.)10,00,000

Assuming, per bed cost per annum (including interventions,

diagnostics and drugs)

Rs.10,00,000

Total projected public health expenditure on secondary care Rs.10,00,000*10,00,000

= Rs.1,00,000 crores

Expenditure on support agencies such as RHT, Ombudsman, etc. Rs. 50,000 crores

Total projected public health expenditure on secondary healthcare

(including support agencies)

Rs. 1,00,000 crores

+50,000 crores =

Rs. 1,50,000 crores

* Provisional by 2022, World Population Prospects, The 2015 Revision by Department of Economic and Social Affairs, UN.

49

Regional Health Trust (RHT)

Money flows to RHT from the Govt.on capitation basis.

RHT contracts/pays the FamilyPhysician at the Primary Level andPvt. Nursing homes at the

secondary level.

RHT will spend more on primary and preventive care to curtail tertiary care costs.

Model 1

Model 2

Private agencies will bid to

provide comprehensive

healthcare for a geographical

region as an RHT.

Alternatively, instead of private

agents, a body of govt. officials,

representatives from local

governments, medical

profession, family physicians,

pvt. nursing homes at the

secondary level can form an

RHT.

How is an RHT constituted?

1 RHT would cover a population of roughly 1,00,000

The area covered by RHT and CHC will be coterminous

50

51

Tertiary Care

Private run public funded

Referrals & Linkages

Independent consultants

Private services in addition to free public care

Private Financial Initiative (PFI) will design,

build, finance, and operate the hospital

facilities. Government pays an annual

fee to cover both the capital cost,

including the cost of borrowing, and

maintenance of the hospital and any

nonclinical services provided over the 30-

35 year life of the contract on a "no

service, no fee" performance basis

On a rotation basis, consultants

take up the leadership role. Such a

system of independent work,

leadership opportunities and

incentivised private work along with

a reasonable remuneration (Rs. 2-3

lakhs) to begin with will drive many

private specialists and NRIs with

experience to join these institutions

To drive the standards up not just for revenues. Large private

care blocks will be built in the hospital.

Doctors earn extra money through these services. This will

provides a strong incentive for the bright and best to join

and sustain in these hospitals.

Referrals from secondary care on

elective procedures. Linkages with

private nursing homes (contracted at

secondary care level), CHCs as well as

RHTs including feedback mechanisms

with all the mentioned entities.

Upgradation

All district hospitals(approx. 500+)will be upgraded and willfunction as tertiary care centers

Education and Research

Public sector teaching hospitals

will also serve as centers of

excellence for education,

training and research

Tertiary Healthcare Expenditure Estimates (by 2022)

Building or upgrading of 500 SIMS tertiary hospitals (Including Govt.

Teaching hospitals)(1 per 2.8 million population)

PFI lease per hospital per year Rs. 50 crore

Running cost per hospital per

year

Rs.150 crore

Total cost per hospital per

year

Rs. 200 crore

Total Tertiary Care 500*200 crores

Rs. 1,00,000 crore

52

Key Institutions – DHB/SHBs

Every state constitutes a State Health Board which will oversee the healthcare of the state through District Health Boards

(DHB)s.

DHB will have control of all the data in the district to aid

all its operations.

It is responsible to reach the targets of the national

programmes with different geographically appropriate

goal posts.

It will have autonomy in deciding the payments. It

can also provide for financial incentives to attract

professionals to remote areas

Expected Funding - central and state governments.

District Health Boards(DHB) & State Health

Board(SHB) DHB and SHB are fully in-charge of Tertiary Healthcare and

Teaching Hospitals respectively

53

Support Institutions – Trauma Trust

A single authority to streamline measures to

prevent road accidents, ‘golden hour’ care, further treatment and integrating

the existing private third party insurance for the road

vehicles.

Merging Road Safety Authority of India with

Trauma Trust

Implementing preventive measures working closely with transport authorities

RTA registry: to monitor the patterns of the accidents

Major trauma centres along the national highways

Trauma ambulance network for highways

Trauma networks – Linking Govt. and private trauma

care and ambulance services

Massive education campaigns- educating the road users should be taken

up in a big way.

Contracting treatment by the private hospitals if there is no Govt. hospital within 30

km.

Extensive training of ambulance personnel, strict

Advanced trauma life support (ATLS) protocol based management

Workforce management, liaising with paramedical

education standard institute

Constant monitoring and feedback to study the

effect of the preventive measures

54

Key Institutions – DSA/ Regulatory Bodies

Drug Supply Agency(DSA) Regulatory Bodies

Direct free distribution of the necessary

‘low cost but high quality’ generic drugs

Digital logging of the prescriptions (linked

to Aadhaar no.) in the primary, secondary

and tertiary centers linked to CHMA

Drug dispensaries on replenishment model

will curtail over-prescription

Digital Monitoring to check over-

prescription, unusual patterns, excessive

antibiotic usage, etc

Expected funding through central

government

There should be independent bodies to

check quality of services, standard of

protocol, costs, diagnostics, etc

In addition, an ombudsman at the district

level :

With real authority to prosecute- blacklist,

cancel registration of FPs, etc.

Restructure Medical Council of India to suit

the present needs of the system

Specialization

There is a need to substantially increase the number of specialists, nurses and technicians.

Legal FrameworkStates should come up with respective legal framework.Sharing mechanisms for finances between the center and the states should be worked out. It should be on the basis of 50 : 50.

55

Overview

Primary and Preventive Healthcare Model

Secondary Healthcare Model

Teritary Healthcare Model

Family Physician Primary Health Center

Private Nursing Homes/Hospitals

Community Health Center

Government hospitals (private

build / maintenance /operation)Specialist/Teaching hospitals

CHMA

RHT

DHB

SHB

DSA

Ombudsman

Trauma Trust

56

Integrated Public Health

Mandatory health

education air-time in all the

Govt. and private TV channels

High quality epidemic team

Massive public health

education programmes

Health helpline

Integrating sanitation and clean water

provision to the healthcare system in

accountability pathways

Extended immunisation

schedule including MMR and Hepatitis B

Digitalised primary care network of Family Physician

clinics linked to CHMA as described above solves the

problem of deficiency of population health data

Integrating the proposed CHMA and National Institute of Clinical Excellence with the existing Public Health

Foundation of India (PHFI) and

Indian Institutes of Public Health (IIPH) will pave the way to develop real-time evidence and research

based planning model of excellence.

Public Health initiatives

• ‘No injection needed’ campaign• Sanitation campaign• Hand hygiene campaign• Early detection campaigns for of TB, cancer, diabetes, hypertension• Maternity care campaign, Vaccination campaign

57

Public Private Partnerships as described so far

Careful regulation to avoid hindering the growth

Encouraging the private centres of excellence

Encouraging proactive disclosure of information on public domains

Integrating in health education campaigns

Grievance mechanisms for the patients (technology based)

Private Health Care

58

Universal Healthcare Expenditure Estimates (by 2022)

Primary and Preventive Rs. 1.5 lakh crore

Secondary Rs. 1.5 lakh crore

Tertiary Rs. 1 lakh crore

Total Rs. 4 lakh crore

Projected nominal GDP of India by 2022 Rs. 240 lakh crores

Universal Health Expenditure as % of GDP

by 20221.67% (Currently 1.3%)

59

CountryPopulation(in millions)

Health Workforce(in millions)

% of Health Workforce in

total population

USA 318.9 12.2 3.8

UK 64.1 1.6 (NHS) 2.4

India 1250 3.6(2013)* 0.28

• Compared to countries such as USA

and UK, India has a very low health

workforce to population ratio

• By correlation, the expected number

of people employed in healthcare in

India should be around 10 times what

it is now i.e. almost 40 million

• Even a conservative number of 20

million(half of the ideal scenario)

shows a wide gap given the existing

workforce of 3.6 millions i.e. a deficit of

82%

Universal Healthcare has huge potential to

generate employment in the health industry, at

different levels(support staff, pharmacists,

administration staff, regulation staff, IT staff etc.) to

the tune of atleast 15 million jobs over a decade.

Health Sector Can Create Jobs !

*Human Resource and Skill Requirements in the Healthcare Sector- NSDC,KPMG

Workforce demand projections of India across various roles in healthcare (Annex 11)

60

Primary and Preventive Healthcare

1. Training for the Family Physician (FP)- Period, curriculum

Views :

2. Certification of the FPs- Certifying authority?

Views :

3. The registration of people with the FP- Minimum Duration

Views :

4. What should be the FP to population ratio?

Views :

5. For registration, who/what will be considered as a unit- Individual or a family?

Views :

6. Suggest supporting staff for an FP such as ANM, lab technicians, data management staff etc.

Views :

7. Supply of generic drugs by an FP-

a. Feasibility of prescribing only generic medicines.

b. Procurement and supply.

Views :

8. What are the lab facilities that should be made available at a PHC?

Views :

ISSUES TO BE RESOLVED61


9. Generic drug pooling at the PHC level- procurement and supply to the FPs

Views :

10. How will the existing PHC staff be involved in the proposed model? – Surveillance, traditional services etc.

Views :

11. Linkages-

• FP to PHC

• FP to RHT

• FP to Referral hospitals at the secondary level and vice versa.

Views :

12. Integration of informal medical practitioners (AYUSH,RMP etc.)

a. Is it required?

b. If yes, will it be feasible to integrate them into the proposed model and how?

Views :

ISSUES TO BE RESOLVED

62


13. What should be the capitation fee which would fulfil the requirements of a Family Physician? (our proposal is Rs. 700/patient)

Views :

14. Lab technicians – mechanism to monitor and quality control?

Views :

15. Transport linkages from village to FP-

a. Should transport facilities be provided to the villagers to travel to the respective FP residing in towns?

b. Mechanism by which transport facilities can be provided?

Views :

16. How to monitor the PHCs in the changed context?

Views :


63


17. Family physician-

a. Norms for accessing- How many number of times can the patients be allowed to visit the doctor ?(need based, routine, pregnancy check-ups)

Views :

b. Standard Protocols- Family practice – National template and local protocols

Views :

c. Drug procurement- contractual agreements

Views :

d. Feedback Mechanisms – How can each patient give feedback about the doctors?

Views :

e. The respective FP’s feedback to public health system on sanitation, water supply, nutrition etc.

Views :

f. How should we provide Continuous Medical Education(CME) to an FP?

Views :

18. What should be the composition of the Regional Health Trust (RHT)?

Views :


64

Secondary Care

1. Standards for choosing a Private Nursing Home as a referral hospital?

Views :

2. What should the CHC, population ratio be ideally? (1:1,00,000?) (currently, it is 1:2,30,000)

Views :

3. How much geographic area should a CHC cover?

Views :

4. Can the patient choose the secondary care provider or is it up to the FP to refer?

Views :

5. What should be the minimum requirements of secondary level hospital? – (number of doctors, beds, diagnostics, facilities etc.).

Views :

6. a. How can we attract specialists (ophthalmology, ENT, Dental, orthopaedics, etc.) at the secondary level?

b. Should there be separate facilities for each speciality at the secondary level?

Views :

7. Standards and norms for diagnostic facilities at CHCs

Views :

8. Scope of care in secondary care facilities

Views:


65

Secondary Care9. Information and Billing Mechanisms- (fee per service model)

a. Standard Services provided at the CHCs and Private Nursing Homes?

b. Standard Costs for each service

Views :

10. Emergency Care –How can we ensure 24*7 emergency services?

Views :

11. Transport – from villages to the secondary healthcare providers – is it necessary?

Views :

12. Generic Drugs- Surgical consumables and Medicines

a. Procurement and Distribution of Generic Drugs

b. Would generic drugs suffice at the secondary level?

c. If no, mechanism for procurement, costing, supply etc. of branded drugs

Views :

13. Linkages-

• CHC- FP

• CHC- RHT

• CHC- Private Service providers

• CHC- Tertiary care (referrals) and vice versa

Views :

14. Feedback Mechanism –

• Patients feedback on CHCs and Pvt. providers

• FP’s feedback on CHCs and Pvt. providers

• CHC feedback on FPs

Views :


66

ISSUES TO BE RESOLVEDSecondary Care

15. Fee for service- Mechanisms to monitor care and billing by the CHCs and pvt. providers by RHT/DHB

Views :

16. What kind of pooled diagnostic facilities should be made to host sophisticated diagnostic tools (MRI, CT Scan etc.)

Views :

17. Do we need a separate pooled pathology lab at the secondary level?

Views :

18. Call Centre –

a. Should there be a call centre to address patients’ need for information (costs, ratings, availability, etc. ) and manage appointments – pros and cons

b. Should we have it at the RHT level or District level?

Views :

19. Elective services - Appointment procedure and Queuing process

Views :

20. Record keeping and Data Integration at the secondary level

Views :

21. Review of the secondary care services – costs, people to bed ratio etc.

Views :

22. Training of new specialists – through Diplomate of National Board (DNB)- total number of doctors needed, how can we ensure quality of education at

the secondary level?

Views :

23. Road trauma issues – ensuring availability of ambulance services and integration with secondary care hospitals

Views :

24. What should be the composition of District Health Board (DHB)?

Views :

67

Tertiary Care

1. How should the queuing be for elective procedure at the tertiary level?

Views :

2. What should be the minimum requirements for a district level tertiary care centres? –

a. No. of beds

b. Basic amenities

c. Diagnostic equipment, etc.

Views :

3. How can we retain doctors at the tertiary level? What kind of incentives need to be given to attract enough tertiary care specialists?

Views :

4. If there is a shortage of specialists at the tertiary level, should the private specialists be hired on a contractual basis?

Views :

5. How can the tertiary level be linked with the secondary level?

Views :

6. What should the feedback mechanism at the tertiary level so that they can advise and train the personnel of secondary level?

Views :

7. How should the drug supply be managed at the tertiary level? Should it be done at central level or local level?

Views :


68

Tertiary Care

8. What models should be considered to build and maintain the private infrastructure at the tertiary level?(Build operate transfer etc.)

Views :

9. Should there be any tax incentives/exemptions for the health equipment at tertiary level?

Views :

10. How can the tertiary care hospitals be linked with the teaching hospitals?

Views :

11. Should there be specialized referral centres for complex cases?

Views :

12. Feedback mechanisms and linkages of-

a. District Health Board (DHB)

b. State Health Board (SHB)

c. Secondary Care Centres

d. Teaching Hospitals

Views :

13. Is insurance model a better option at the tertiary level?

Views :


69

ISSUES TO BE RESOLVEDSupporting Institutions

1. How can we manage/secure data at different levels (Primary, secondary & tertiary)?

Views :

2. How should a district ombudsman mechanism be designed? Does it require legal backing?

Views :

3. Ensuring funds

a. How can we ensure guaranteed funding to RHTs, DHBs?

b. If it is done by a law, should each state enact separate laws (or) should there be a national law?

Views :

4. What should be the composition of the following institutions

• State Health Boards (SHB),

• Drug Supply Agency (DSA)

Views :

Financing

6. The ratio of state and union financing for universal healthcare.

Views :

7. What are the key reforms needed to suit universal healthcare model?

Views:

70

Next Steps >>>71

72

Margaret Mead

Never doubt that a small group

of thoughtful, committed

citizens can change the world;

indeed, it's the only thing that

ever has.

ANNEXURES

73

Annex 1

74

Annex 2

75

Annex 3

76

Annex 4

77

Annex 5

78

Annex 6

79

Annex 7

80

Annex 8

81

Sr. No Country

GDP (in

billion

dollars)

Per Capita

Income

(2014)

HDI Rank

(UNDP)

Out-of-Pocket

expenditure

( % of private

expenditure

out of total

expenditure)

Life

expectancy

(years)

Private

Health

Expenditure

(% of GDP)

(2013)

Public

Expenditure

(% of Total

Health

Expenditure)

(2013)

Age Standardized

Disability Adjusted

Life Years (DALY)1

rates

(per 1,00,000

population)

(2012)

DALY

Rank

1 USA 14796.6 54629.5 5 22.3 78.84 9 47.1 22775 24

2 China 5274.1 7590 91 76.7 75.35 2.5 55.8 24811 26

3 Japan 4779.5 36194.4 17 80.2 83.33 1.8 82.1 15700 2

4 Germany 3212.7 47821.9 6 55.6 81.04 2.6 76.8 19224 12

5 U.K 2642.8 46332 14 56.4 80.96 1.5 83.5 20376 20

6 France 2361.4 42732 20 32.9 81.97 2.6 77.5 19104 11

7 Italy 1747.1 34908 26 82 82.29 2 78 16957 3

8 India 1600.3 1581 135 85.9 66.46 2.7 32.2 47950 51

9 Canada 1361 50235 8 50.1 81.4 3.3 69.2 18838 10

10 South Korea 1238.7 27970 15 78.6 81.46 3.3 53.4 17921 7

11 Brazil 1206.1 11384 79 57.8 73.89 5 48.2 31632 42

12 Spain 1188.8 29767 27 77.1 82.43 2.6 70.4 16984 4

13 Mexico 1067.9 10325 71 91.5 77.35 3 51.7 26763 29

14 Russia 999.8 12735 57 92.4 71.07 3.4 48.1 39906 48

15 Australia 888.6 61925 2 57.1 82.2 3.2 66.6 17696 5

16 Netherlands 727.1 52172 4 41.7 81.1 1.7 79.8 18770 9

17 Turkey 672.8 10515 69 66.3 75.18 1.3 77.4 29027 37

18 Saudi Arabia 523.4 24161 34 55.3 75.7 1.1 64.2 27174 32

19 Indonesia 471.7 3491 108 75.1 70.82 1.9 39 36015 46

20 Sweden 446.3 58938 12 88.1 81.7 1.8 81.5 18308 8

21 Poland 429.5 14342 35 75 76.85 2.2 69.6 25415 27

22 Belgium 425 47352 21 82.3 80.39 2.7 75.8 19878 19

23 Austria 350.6 51190 21 65.2 80.89 2.7 75.7 19763 16

24 Norway 345.4 97307 1 95.9 81.45 1.4 85.5 19615 14

25 Argentina 332.6 12509 49 65.3 76.19 2.4 67.7 26808 30

26 South Africa 328.7 6482 118 13.8 56.74 4.6 48.4 67514 53

27 Denmark 268.1 60707 10 87.4 80.3 1.6 85.4 20451 21

28 Hong Kong 247.8 40169 15 - 83.83 - - - N/A

29 U.A.E 243.4 43962 40 63.2 77.13 1 70.3 25546 28

30 Thailand 232 5977 89 56.7 74.37 0.9 80.1 28993 36

Source: World Bank, UNICEF & UNDP

Health Data of top 50 countries (in terms of GDP)

31 Iran 231.4 5442 75 88 74.07 4 40.8 30911 41

32 Ireland 227.7 54374 11 52.1 81.04 2.9 67.7 19319 13

33 Colombia 222.6 7903 98 58.1 73.98 1.6 76 27188 33

34 Malaysia 220.5 11307 62 79.9 75.02 1.8 54.8 29765 40

35 Finland 212.2 49823 24 75 80.83 2.3 75.3 19843 18

36 Singapore 208.3 56284 9 94.3 82.35 2.7 39.8 14354 1

37 Israel 201.6 37208 19 64.5 82.06 3 59.1 17719 6

38 Greece 201.4 21498 29 86.6 80.63 3 69.5 19627 15

39 Nigeria 194.9 3203 152 95.8 52.5 2.8 27.6 84764 54

40 Portugal 190.3 22132 41 75.4 80.37 3.4 64.7 19815 17

41 Venezuela 186.9 12,771(2012) 67 90.2 74.64 2.6 27.1 29410 39

42 Chile 175 14528 41 60.3 79.84 4.1 47.4 21333 22

43 Philippines 165.1 2872 117 82.9 68.71 3 31.6 41446 49

44 Czech Rep. 157.1 19529 28 94.1 78.28 1.2 83.3 22380 23

45 Pakistan 151.6 1316 146 86.8 66.59 1.7 36.8 50534 52

46 Qatar 137.9 96732 31 52.2 78.61 0.4 83.8 22923 25

47 Algeria 132.4 5484 93 97.2 71.01 1.7 74.2 34790 43

48 Egypt 131.4 3198 110 97.7 71.13 3 40.7 35784 45

49 Peru 127.7 6541 82 84.6 74.81 2.2 58.7 26911 31

50 Romania 123.4 9996 54 97 74.46 1.1 79.7 28496 34

51 Bangladesh 119 1086 142 93 70.69 2.4 35.3 38814 47

52 Hungary 117.2 14028 43 75.5 75.27 2.9 63.6 28707 35

53 Vietnam 97.8 2052 121 85 75.76 3.5 41.9 29226 38

54 Kazakhstan 96.4 12601 70 98.9 70.45 2 53.1 42804 50

55 Ukraine 89 3082 83 94 71.16 3.5 54.5 35121 44

1. DALY(Disability Adjusted Life Years) = YLD(Years lived with Disability) + YLL(Years of life lost).

YLD and YLL are calculated as a function of Cause, Age,Sex and Time. Higher the DALY poorer the health conditions in a country

Sr. No Country

GDP (in

billion

dollars)

Per Capita

Income

(2014)

HDI Rank

(UNDP)

Out-of-Pocket

expenditure

( % of private

expenditure

out of total

expenditure)

Life

expectancy

(years)

Private

Health

Expenditure

(% of GDP)

(2013)

Public

Expenditure

(% of Total

Health

Expenditure)

(2013)

Age Standardized

Disability Adjusted

Life Years (DALY)1

rates

(per 1,00,000

population)

(2012)

DALY

Rank

Source: World Bank, UNICEF & UNDP

Health Data of top 50 countries (in terms of GDP)Annex 9

82

Various Committee Recommendations

1. BHORE COMMITTEE, 1946.

This committee, known as the Health Survey & Development Committee, was appointed in 1943 with Sir Joseph Bhore as its Chairman. It laid emphasis on integration of curative and preventive medicine at all levels. It made comprehensive recommendations for re-modelling of health services in India.

2. MUDALIAR COMMITTEE, 1962.

This committee known as the “Health Survey and Planning Committee”, headed by Dr. A.L. Mudaliar, was appointed to assess the performance in health sector since the submission of Bhore Committee report. This committee found the conditions in PHCs to be unsatisfactory and suggested that the PHC, already established should be strengthened before new ones are opened.

3. CHADHA COMMITTEE, 1963.

This committee was appointed under chairmanship of Dr. M.S. Chadha, the then Director General of Health Services, to advise about the necessary arrangements for the maintenance phase of National Malaria Eradication Programme. The committee suggested that the vigilance activity in the NMEP should be carried out by basic health workers (one per 10,000 population), who would function as multipurpose workers and would perform, in addition to malaria work, the duties of family planning and vital statistics data collection under supervision of family planning health assistants.

Annex 10

83

Source : National Institute of Health and Family Welfare(last accessed on 5th April 2015)

4. MUKHERJEE COMMITTEE, 1965.

The recommendations of the Chadha Committee, when implemented, were found to be impracticable because the basic health workers, with their multiple functions could do justice neither to malaria work nor to family planning work. The Mukherjee committee headed by the then Secretary of Health Shri Mukherjee, was appointed to review the performance in the area of family planning. The committee recommended separate staff for the family planning programme. The family planning assistants were to undertake family planning duties only. The basic health workers were to be utilised for purposes other than family planning. The committee also recommended to delink the malaria activities from family planning so that the latter would received undivided attention of its staff.

5. MUKHERJEE COMMITTEE. 1966.

Multiple activities of the mass programmes like family planning, small pox, leprosy, trachoma, NMEP (maintenance phase), etc. were making it difficult for the states to undertake these effectively because of shortage of funds. A committee of state health secretaries, headed by the Union Health Secretary, Shri Mukherjee, was set up to look into this problem. The committee worked out the details of the Basic Health Service which should be provided at the Block level, and some consequential strengthening required at higher levels of administration.

6. JUNGALWALLA COMMITTEE, 1967.

This committee, known as the “Committee on Integration of Health Services” was set up in 1964 under the chairmanship of Dr. N Jungalwalla, the then Director of National Institute of Health Administration and Education (currently NIHFW). It was asked to look into various problems related to integration of health services, abolition of private practice by doctors in government services, and the service conditions of Doctors.

84


7. KARTAR SINGH COMMITTEE. 1973.

This committee, headed by the Additional Secretary of Health and titled the "Committee on multipurpose workers under

Health and Family Planning" was constituted to form a framework for integration of health and medical services at

peripheral and supervisory levels.

8. SHRIVASTAV COMMITTEE. 1975.

This committee was set up in 1974 as "Group on Medical Education and Support Manpower" to determine steps needed to

(i) reorient medical education in accordance with national needs & priorities and (ii) develop a curriculum for health

assistants who were to function as a link between medical officers and MPWs.

9. BAJAJ COMMITTEE, 1986.

An "Expert Committee for Health Manpower Planning, Production and Management" was constituted in 1985 under Dr. J.S.

Bajaj, the then professor at AIIMS.

OTHER COMMITTEES AND COMMISSION REPORTS

• National Commission on Macroeconomics and Health

• Indian health information network developmentreport on use of ict in health care and knowledge management

recommendations for the national knowledge commission

• Col. S. S. SOKHEY ON NATIONAL HEALTH

• Udupa K.N. Committee on Ayurveda Research Evaluation, 1958

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Annex 10Annex 11

86

State/UT wise Health Human Resource in Rural Areas(Govt.) in India

as on 31.03.2014

National Health Profile 2015

87Annex 12