Public Health in IndiaMoving Ahead?

Prof. Shiv Chandra Mathurshiv_mathur@hotmail.com

Objective of this presentation is to let viewers get an overview on the progress of Public

Health in India, and the contribution of interventions by health systems in the public sector in this process particularly in context

of first decade of the new millennium.

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Understanding India

• Over a billion people in over a million places.• Persistence of poverty and under nutrition.• Low public exp./high out of pocket on health.• Regional disparities – Kerala/Bihar.• Large unregulated private sector• Medicalized versus health – water, sanitation.• Several systems concurrently• Human resource challenges - urban - rural.

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7%

8%36%

11%

7% 2%

29%

CVD

Chronic resp. ds.

Other chronic ds

Communicable ds, perinatal,maternal conditions & nutritionaldeficiencies

Injuries

Cancer

Diabetes

Deaths In India (2005)

Source : WHO3/26/2011 4Shiv Chandra Mathur

Children Under 3 Who Are Underweight

All India

1998-99 46.7%2005-06 45.9%

Negligible change in 7 years

Source: NFHS – 3, 2005-06

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Anemia

Married women (15-49 years) who are anemic (%)

1998-99 51.8%2005-06 56.1%

Situation worsened in 13 states; improves in 7

Source: NFHS – 3, 2005-063/26/2011 6Shiv Chandra Mathur

Children (6-35 months) who are Anemic (%)

All India

1998-99 74.2% 2005-06 79.1%

Situation worsened in 13 states; improves in 7

Source: NFHS – 3, 2005-06

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Children 12-23 months fully immunized (BCG, measles and 3 doses each of polio/DPT)

All India

1998-99 42.0% 2005-06 43.5%

Negligible improvement …

Source: NFHS – 3, 2005-06

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ACTUAL AND PROJECTED NUMBERS OF ACTUAL AND PROJECTED NUMBERS OF DEATHS IN INDIA BY CAUSE 1990DEATHS IN INDIA BY CAUSE 1990 AND AND 20202020

0.0

2.0

4.0

6.0

1990 2020Nu

mb

er o

f d

eath

s (m

illio

ns)Communicable diseasesCardiovascular diseasesOther non-communicable diseasesInjuries

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2000 2025

No. of Persons with HYPERTENSION

118 Million 214 Million

No. of Persons with DIABETES

32 Million 69.8 Million

No. of Persons Dying from TOBACCO

900,000 2 Million +

RISING CHRONIC DISEASE BURDENS

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SICK INDIVIDUALS

ARISE FROM

SICK POPULATIONS

- Geoffrey Rose

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• In 2005, it is estimated that India lost 9 billion USD in national income from premature deaths due to heart disease, stroke and diabetes.

• These losses are expected to cumulatively lead to 237 billion USD over the next 10 years.

Source: World Health Organization

NEGLECTED CHRONIC DISEASES CARRY ECONOMIC COSTS

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“Medicine has imperceptibly led us into the social

field and placed us in a position of confronting

directly the great problems of our time”.

- Rudolf Virchow, Report on the Typhus Epidemic in Upper Silesia, 1848

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HandicapsLack Of Sufficient Public Health Expertise

needed for

• Policy Development

• Program Design, Delivery And Evaluation

• Health System Management

• Public Health Research

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BIOLOGICAL SCIENCES

EPIDEMIOLOGY & ALLIED SCIENCES

ECONOMICS AND MANAGEMENT

SOCIAL SCIENCES

PUBLIC HEALTH

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SCIENCE DISCOVERS

TECHNOLOGY DEVELOPS

PUBLIC HEALTH DELIVERS3/26/2011 16Shiv Chandra Mathur

CRAFTING CREDIBLE PUBLIC SYSTEMS IN HEALTH

NRHM - MAKING MDGs ACHIEVEABLE

What is the Change ?

• Health – a priority in States as never before.• Public health thrust recognized.• NRHM – A platform for innovations.• NRHM – A Framework for decentralization.• Human Resource as priority.• Community Worker – connecting households • A statement that public systems can deliver.• Managers of the system – professional skills.

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NRHM in India has made a difference

• A true partnership with States.• Space for innovations.• Distrust to trust.• Community institutions as focus.• Public health focus – addressing local specific

mortality and morbidity.• Building capacities for local action.• Recognizing the need for management skills.

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NRHM has created in each Indian Village

1.A worker : she is ASHA2.An institution : that is VH&SC3.An event : which is VHND.

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Examples of Innovations

• Making PHCs 24X7 in Tamil Nadu – 3 Nurse model.

• Assam’s initiative – Boat Clinics

• Rajasthan’s initiative – CMJRK; SNCUs.;108

• MP’s initiative –HSC Delivery, SNCUs.

• Haryana’s initiative – Free drugs, 102; surgery package.

• Gujarat’s initiative – Chiranjeevi, 108,

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Examples of Innovations

• Kerala’s initiative –Ban private practice; Quality.

• Bihar – Block pooling; PPPs – Diagnostics.

• Chhatisgarh – Mitanin, VHSCs.

• Orissa – ASHAs; AYUSH doctors;

• Andamans – High salary for Specialists; RKS.

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The impact of NRHM - 1

• MMR significantly down – 450 to 230 - SRS.

• IMR decline – 60 in 2004; 53 in 2008; <50now

• TFR steadily declining – 2.9 in 05 to 2.6 in 2008.

• Institutional deliveries – 41% to 73%

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The impact of NRHM - 2

• TB, Malaria, NPCB, Surveillance better.

• Substantial addition of human resources.

• Infrastructure – more and better managed.

• Doctors, drugs and diagnostics – OPD, IPD.

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What Doctors in Public Systems can do further?

1. Strengthen medical care2. Help strengthen HMIS3. Sanitary Stringency4. Induce Behavior Change5. Disease Surveillance6. Educate on Better Food Practices7. Rational Drug Use

A Health Professional Must

ELUCIDATE - As a health researcher

EDUCATE - As an informed facilitator

ALLEVIATE - As a care giver

ADVOCATE - As a health activist

and if need be

AGITATE - As a concerned citizen 3/26/2011 26Shiv Chandra Mathur