CHANGING THE INDIAN HEALTH SYSTEM
Item
- Title
- CHANGING THE INDIAN HEALTH SYSTEM
- extracted text
-
No
August 2001
Draft. Not for citation
Changing the Indian Health System
Current Issues, Future Directions
Rajiv Misra
Rochel Chatterjee
Sujatha Rao
—i
i
INDIAN COUNCIL FOR RESEARCH ON INTERNATIONAL ECONOMIC RELATIONS
Core-6A, 4th Floor, India Habitat Centre, Lodi Road, New Delhi-110 003
J
Contents
Preface
iii
List of Abbreviations
v
List of Tables, Figures and Annexes
viii
Executive Summary
xv
Chapters
1.
Introduction
1
2.
The Current Health Scenario : An Overview
9
3.
The State Role in Health
42
4.
Economic Growth, Poverty and Health
51
5.
Towards Equity in Health
58
6.
Communicable Diseases
78
7.
Maternal and Child Survival
106
8.
HIV/AIDS
133
9.
Non-Communicable Diseases
144
10.
Private Healthcare in India
161
11.
Health Systems
190
12.
Health Finance
232
13.
External Assistance to the Health Sector
264
14.
Drug Policy and Regulations
283
15.
Indian Systems of Medicine
296
16.
Health Research : Its Potential in India
312
References
329
Preface
When I accepted this assignment, little did I realize that the exercise
would be so arduous, yet at the same time so rewarding. Never in my long
career has my intellectual stamina been so severely tested. But the
experience was also deeply satisfying, since the study was so timed that
it could make a contribution, however small, to the ongoing exercise of
formulating a new health policy. If this Report helps improve
understanding of health issues, generates awareness and stimulates an
informed debate, our labours will be amply rewarded.
Having worked mainly on global issues since leaving the Health Ministry
in 1994, I was glad to return once again to the national health scene. This
project provided an excellent opportunity to pick up the threads again and
to look at the issues more objectively and in greater depth. Despite some
welcome developments, what I found was deeply disappointing. The
problems that I had left behind seven years back had not only remained
largely unchanged, but had been greatly aggravated, with the health
system becoming even more dysfunctional and iniquitous. The fiscal
situation in the states had deteriorated to such an extent that they
seemed helpless, unable to correct the most glaring inadequacies, even
when there was a sincere desire to do so. On the positive side, there were
some welcome initiatives in the states that could be regarded as the
beginnings of a reform process. There was also a huge improvement in
the availability of data as a result of NSSO 42nd and 52nd rounds, NFHS 1
and 2, and NCAER household surveys. Regrettably though, the NIPFP
initiative in the early nineties to develop national health accounts was not
followed up, so that health finance had become the weakest link in the
database. More important, the new data had been analyzed in depth by
competent researchers, thanks to the collaborative initiatives of donor
agencies and the central government, making available critical inputs to
policymakers. The stage was now set for evidence-based policy
initiatives.
The Report brings out quite unambiguously the gross inadequacy of public
investment in health. It is true that no system can be expected to perform
at the current low levels of funding. However, it is also equally true that
an increase in funding levels by itself is unlikely to produce the desired
results without accompanying systemic changes. As in the case of the
energy sector, increased investment must to go hand in hand with system
reform. This is why we decided that the most appropriate title for the
document would be Changing the Indian Health System: Current
Issues, Future Directions.
I was ably assisted in my endeavours, by the two co-authors, Rachel
Chatterjee (formerly Health Secretary, Andhra Pradesh), and Sujatha Rao
(Joint Secretary in the Ministry of Health and Family Welfare). The former
made a huge contribution because of her intimate knowledge of the health
iii
system at the state level. The latter provided the valuable and
complementary perspective of policymaking and programme management
at the central level-. The three of us worked as a team and are jointly
responsible for every word in the document.
This study was conceived by Professor Jeffrey Sachs, Chair of the
Commission on Macroeconomics and Health, and he was instrumental in
arranging the funding support from the Bill and Melinda Gates Foundation
in record time. He has, all through, been the main inspiration for this
work, and has guided it from time to time despite his many commitments.
To Dr. Isher Ahluwalia, Director of ICRIER, goes the credit of giving
concrete shape to his proposal and sponsoring the study by ICRIER. But
for her sustained and ungrudging support, and that of all her colleagues at
ICRIER, this Report could never have been completed on schedule.
Studying any health system is a highly complex task, and this is
particularly true for a country as vast and diverse as India. Keeping this is
mind, we commissioned background papers by reputed scholars and
researchers. Despite the very tight schedule, all the contributors were
very understanding of our requirements and compulsions. To all the
contributors, we owe a debt of gratitude.
From the very beginning, we tried to make this a highly participatory
exercise. Consultations were organized with researchers, representatives
of the states, NGOs and public health experts - all of whom contributed
valuable inputs. A steering committee was constituted with representation
from relevant ministries/ departments of the central government, Planning
Commission and multilateral agencies involved with health such as the
WHO, the World Bank, UNDP, UNICEF and UNAIDS. The committee met
regularly and provided valuable guidance to our work. It was the active
support and cooperation of all agencies that enabled us to access
relevant information and data.
Finally, the support and dedication of our staff, Jai Mansukhani, Anidya
Ghosh and Prasanna Ash made it possible to complete the exercise in
such a short time. In particular, the contribution of Jai Mansukhani
deserves a special mention, as he worked tirelessly, with single-minded
devotion, to type out the Report and incorporate the seemingly endless
revisions of the drafts.
(Rajiv L. Misra)
Team Leader, India Health Study, ICRIER
New Delhi, August 16, 2001
iv
H
List of Abbreviations
1.
2.
3.
4.
5.
6.
7.
AP
HP
MP
NE
TN
UP
Lakh
8. Crore
9. Dai
10. Anganwadi
11. Panchayati Raj
Institutions
Andhra Pradesh
Himachal Pradesh
Madhya Pradesh
North Eastern
Tamil Nadu
Uttar Pradesh
Hundred thousand
Ten million
Traditional Birth Attendant
Village level worker in the nutritional and child welfare programmes
Elected local bodies, (Panchayat for group of villages, Panchayat Samiti
for around 1,00,000 population, and Zila Parishad for the district). These
Institutions discharge many responsibilities for local self government
and development in respect of rural areas
1.
2.
18. IIHMR
19. UPS
20. JICA
21. MHFW/MOHFW
22. MLEC
23. MRS
24. NACO
25. NCAER
26. NDA
27. NFHS
28. NICD
29. Nil
30. NIPFD
31. NMEP
32. NPPA
33. NSSO/NSS
34. PSPU
35. SIDA
36. SRS
37. TNSACS
38. USFDA
39. VHAI
All India Institute of Medical Sciences
Aids Prevention and Control
Central Bureau of Health Information
Central Drug Standard Control Organization
Canadian International Development Agency
Commission for Macroeconomic Health
Council of Scientific and Industrial Research
Central Statistical Organization
Drug Controller General
District Chief Health and Medical Officer
Department for International Development
Director General of Health and Medical Services
Director General of Health Service
Delhi Society for Promotion of Rational Use of Drugs
Government of India
Indian Council for Medical Research
Indian Institute of Chemical Technology
Indian Institute of Health Management and Research
Indian Institute of Popular Science
Japanese International Co-operative Agency
Ministry of Health and Family Welfare
Modified Leprosy Eradication Campaign
Medical Relief Societies
National AIDS Control Organization
National Council for Applied Economic Research
National Drug Authonty
National Family Health Survey
National Institute od Communicable Diseases
National Institute of Immunology
National Institute of Public Finance and Development
National Malaria Eradication Programme
National Pharmaceutical Pricing Authority
National Sample Survey Organization
Policy and Strategic Planning Unit
Swedish International Development Association
Sample Registration System
Tamil Nadu State Aids Control Society
United States Food and Drug Administration
Voluntary Health Association of India
1.
2.
WHR
WDR
World Health Report
World Development Report
1.
2.
3.
ANC
ANM
APAC
ARI
BIA
Antenatal Care
Auxiliary Nurse Midwife
Aids Prevention and Control
Acute Respiratory Infection
Benefit Incidence Analysis
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
AllMS
APAC
CBHI
CDSCO
CIDA
CMH
CSIR
CSO
DCG
DCH&MO
DFID
DGH&MS
DGHS
DSPRUD
GOI
ICMR
17. IICT
4.
5.
V
□ Mi
BOD
3. BPL
9. CAM
10. CBR
11. CCIM
12. CDR
13. CGHS
14. CHC
15. CHD
16. CHW
17. CMR
18. CMS
19. CVD
20. DALYs
21. DOTS
22. ECO
23. EDL
24. EMCP
25. EOC
26. GBDS
27. GDI
28. HAART
29. HDI
30. HMO
31. HPI
32. IAVI
33. IDU
34. IFA
35. IMR
36. IOL
37. IP
38. ISM
39. LEB
40. MCH
41. MDT
42. MMR
43. MPW
44. NAMP
45. NCD
46. NCE
47. NDDS
48. NHP
49. NMHP
50. NMHP
51. NTP
52. ODA
53. OP
54. ORS
55. ORT
56. PDS
57. Pf
58. PHC
59. PPP
60. QI
61. QOC
62. RCH
63. RMP
64. RNTCP
65. RTI
66. SCC
67. STD
68. TBA
69. TFR
70. UIP
Body Mass Index
Burden of Diseases
Below Poverty Line
Complementary Alternative Medione
Child Birth Rate
Central Council of Indian Medicine
Crude Death Rate
Central Government Health Scheme
Community Health Centre
Coronary Heart Disease
Community Health Worker
Child Mortality Rate
Commercial Sex Worker
Cardiovascular Disease
Disability Adjusted Life Years
Directly Observed Treatment, Short-course
Emergency Obstetric Care
Essential Drug List
Enhanced Malaria Control Programme
Emergency Obstetric Care
Global Burden of Disease Study
Gender Development Index
Highly Active Anti-Retroviral Therapy
Human Development Index
Health Maintenance Organization
Human Poverty Index
International Aids Vaccine Initiative
Intravenous Drug User
Iron and Folic Acid
Infant Mortality Rate
Intra Ocular Lenses
Inpatient
Indian Systems of Medicine
Life Expectancy at Birth
Maternal and Child Health
Multi Drug Therapy
Maternal Mortality Rate
Multipurpose Health Worker
National Anti - Malana Programme
Non Communicable Disease
New Chemical Entity
Novel Drug Delivery System
National Health Policy
National Mental Health Programme
National Mental Health Programme
National TB Programme
Official Development Assistance
Outpatient
Oral Rehydration Salt
Oral Rehydration Therapy
Public Distribution System
P falciparum
Primary Health Centre
Public Private Partnership
Quality Improvement
Quality of Care
Reproductive and Child Health Programme
Rural Medical Practitioners
Revised National TB Control Programme
Reproductive Tract Infection
Short Course Chemotherapy
Sexually Transmitted Diseases
Traditional Birth Attendant
Total Fertility Rate
Universal Immunisation Programme
1.
Established Market Economies
EME
u
vi
2.
3.
4.
5.
6.
7.
8.
9.
ESIS
IEC
IPR
MNC
PDS
SC/ST
TOR
TRIPS
Employees State Insurance Scheme
Information, Education, Communication
Intellectual Property Right
Multinational Company
Public Distribution System
Scheduled Caste / Scheduled Tribe
Terms of Reference
Trade Related Aspects of Intellectual Property Rights
vii
u
aBjfe^JFigures and Annexes
Page
No.
1
Table 1.1
Studies of the Indian Health System 1999-2000
Annex 1.1
Commission on Macroeconomics and
Reference
Proposal for an India Study for CMH
Annex 1.2
2
Table 2.1
Health
3
Terms
of
5
6
Table 2.3
International Comparison of Health Humanpower and Hospital
Beds, 1990-1998
International Comparison of Health Service Utilization and
DALYs Lost per 1000 Population, 1990-1998
India’s Share of the World’s Health Problems (in %)
12
Table 2.4
Burden of Disease - India and States
13
T^ble 2.5
Top 10 Specific Causes of Death in India, 1998
13
Table 2.6
HIV Prevalence in India 1998
17
Table 2.7
Select Goals Under National Health Policy and Achievement
22
Table 2.8
Availability of Health Humanpower in Rural Health Institutions
23
Table 2.9
Health Care Humanpower and Health Facilities in Public and
Private Sector in India
Comparative State Equity Performance for Curative Care
(Income Level)
Health Status Indicators - Comparison between the Poorest
and
Richest Quintiles of the Population, India. 1992-93
Health Outcomes according to Standard of Living, India,
1998-99
24
Table 2.2
Table 2.10
Table 2.11
Table 2.12
11
11
26
26
27
Table 2.13
Outlay for Health in the Central Sector (Actual Expenditure)
31
Figure 2.1
Under-5 Mortality and Crude Birth Rate: A Comparison
10
Figure 2.2
Burden of Disease by Cause - 1998
12
Figure 2.3
14
Figure 2.5
Mortality by Causes for India - 1998
(a) Burden of Communicable Diseases India, 1998
(b) Distribution of Burden of Non-Communicable Disease India,
1998
Projected Population of India
18
Figure 2.6
Burden of Diseases - 2020
18
Figure 2.7
19
Figure 2.8
Prevalence of Smoking, Tobacco, and Alcohol Use in India
by Income Quintile 1995-96
Sex Ratio : International Comparisons
20
Figure 2.9
Sex Ratio in India (1990-2001)
21
Figure 2.10
Infant Mortality Rates in India
Share of Public Subsidy for Curative Care Benefiting Income
Groups
22
Figure 2.4
Figure 2.11
14
25
viii
H
5
Figure 2.12
Undernutrition in Children in India
30
Figure 2.13
Anemia among Children
30
Figure 2.14
National Accounts, Public Sector Spending on Health
32
Figure 2.15
32
Annex 2.1
State-Level Per Capita Public Spending on Health (Rs.), 199596
Demographic and Health indicators - India and States
Annex 2.2
Health and Demographic Indicators - India and World
36
Annex 2.3
Health Infrastructure of India and its States as on 01.01.1996
37
Annex 2.4
Health Expenditure - India and World
38
Annex 2.5
Demographic Indicators - India and World
39
Annex 2.6
Literacy, Health and Poverty Indicators - India and World
40
Annex 2.7
Population Statistics - India and States
41
Table 5.1
60
Table 5.3
Health Indicators Among SC/ST and Others (Rate per 1000)
Differentials in IMR and Under 5 Mortality - Rural / Urban
Social Group
Nutritional Levels among 3C/ST Women
Table 5.4
Prevalence of Illness 1990
62
Table 5.5
Rate per 1000 of Treatment during Last 15 days
64
Table 5.6
64
Figure 5.4
Rate per 100,000 of Hospitalization
Percentage Utilization of Treatment in Public
Facilities for OP & IP
Costs of Care - Constant Prices 1986-87 (Rs.)
T reatment/Episode
Per Capita Releases by Center to Select States under National
Disease Control Programmes during 1998-00
Reasons for not Taking Treatment, % by Age and Sex
Share in Utilization of Public and Private Facilities for
Deliveries
Share in Utilization of Public and Private Facilities for
Hospitalization
Outpatient Care by Poverty Groups in Selected States
67
Figure 5.5
Share of Inpatient Days by Poverty Groups in Select States
67
Figure 5.6
Source of Funds for Medical Care
Distribution of Net Public Sector Subsidies by Level of Care by
Quintile Category - Combined for Rural and Urban
Average Total Expenditure (Rs.) Per Hospitalization by Type of
Hospital for Rural and Urban Areas of 15 Major States
69
Table 5.2
Table 5.7
Table 5.8
Table 5.9
Figure 5.1
Figure 5.2
Figure 5.3
Annex 5.1
Annex 5.2
6
Table 6.1
35
60
60
66
69
71
63
64
65
75
77
84
Table 6.3
Number of Filaria Cases and Disease Rates 1989-2000
Percentage Prevalence of Soil Transmitted Helminths in Pilot
Study Areas 1999-2000
Cases Reporting of Major Diseases - 2000
93
Figure 6.1
Mortality and Morbidity Estimates, 1998
78
Table 6.2
90
ix
Figure 6.2
Figure 6.3
Figure 6.4
Figure 6.5
Annex 6.1
Annex 6.2
Annex 6.3
Annex 6.4
Annex 6.5
7
8
Trends in Morbidity and Mc'tality on account of Communicable
Diseases
80
Leading Causes of Mortal :y and Burden of Disease 1 998
80
Number of Cases and Morality on Account of Malaria - Trends
Evaluation and Completior of Treatment under Conventional,
Short Course Chemotherapy and RNTCP
Malaria Cases in Selectee North-Eastern States, 1995-99
Performance of the RNTCP by States (Provisional figures as of
March 2001)
National Tuberculosis Control Programme - Statement
Showing the States and Union Territory-wise Targets and
Achievements with Regarc to Sputum
Outcomes of Treatment According to Category of Cases Under
Revised National Tuberculosis Control Programme from 1993
to 1 998 (first quarter)
Leprosy Case Detection Treatment and Discharge as on
30.3.2001
81
87
98
101
102
103
105
Table 7.1
MMR by Select Country
Table 7.2
Causes of Maternal Mortality
Table 7.3
Table 7.4
Percentage Decline in Infant Mortality and Under-5 Mortality,
1971-98
Nutritional Status by State
119
Table 7.5
Percentage Distribution of Births by Weight
120
Table 7.6
Anaemia as a Contributor to Perinatal Mortality
120
Table 7.7
Health Outcomes by Standard of Living
Table 7.8
Female and Male Health Outcomes and Social Indicators
Table 7.9
Demographic Goals Vs. Current Status
120
121
122
Figure 7.1
TFR, IMP and Under-5 MR by Time Periods
107
Figure 7.2
Excess Fertility and IMR
109
Figure 7.3
Framework
Figure 7.4
Causes of MMR
Figure 7.5
Assistance at Delivery
Figure 7.6
IMR of India Vs. Low Income Economies
109
111
112
117
Figure 7.7
IMR and Under-5 MR
118
Figure 7.8
Major Causes of Deaths of Infants and Children in India
118
Figure 7.9
Mother’s Education and IMR
121
Annex 7.1
Infant Mortality Indicators by Residence, India, 1971-1998
129
Annex 7.2
Infant and Child Mortality by Background Characteristic, India
130
Annex 7.3
131
Annex 7.4
Maternal Care Indicators, India and Major States, 1998-1999
Delivery Characteristics of Live Births, India, 1992-1993 and
1998-1999
Figure 8.1
Routes of HIV Transmission in India (1986-2001)
134
110
110
117
132
x
9
Figure 8.2
Adult HIV Prevalence
Figure 8.3
Opportunistic Infections among AIDS Patients
Figure 8.4
Rationale for Targeted Interventions among High-risk Groups
Figure 8.5
Trend in Condom Use among CSWs and Trukers in Tamil Nadu
Figure 8.6
Percentage Who Have Heard about Aids by State
Table 9.1
Midlife Mortality due to NCDs in India
Table 9.2
Early Mortality due to NCDs in India
Table 9.3
Estimated Number of Cases of Selected NCDs in India, 1998
Table 9.4
Figure 9.1
Annex 9.1
Annex 9.2
10
Table 10.1
Table 10.2
Table 10.3
Table 10.4
Table 10.5
Figure 10.1
Figure 1 0.2
Implementation : Operational Components
Assessment of National Capacity : Questions for Situational
Analysis
Growth and Share of Voluntary Hospitals and Beds
Average Charge (Rs.) for Select Services in Private Hospitals
Distribution of Facilities by Availability of Patient Redress
Systems
Distribution of Facilities with Some Consumer Redress
Systems by Frequency of Review
Percentage Share of Private Sector Hospitals,Beds, and
Doctors by Select States
Rural-Urban Distribution of Hospitals / Hospital Beds: Public
and Private Sectors
Share of Private Sector in Outpatient and Inpatient Care
Figure 10.5
Public and Private Sector Shares in Service Delivery
Figure 10.6
Distribution of Inpatients between Public and Private by State
Average Hospital Charge per Inpatient Day by Public and
Private, by Select States
A Framework for Policy and Action
Physical Standards in the Private Health Sector - Findings of
a Case Study of Rural Maharashtra
Private Practitioners and their Role in the Resurgence of
Malaria
- ;.i in
Mumbai : Serving
the the
Affected
or Aiding an
Serving
Affected
Epidemic?
Annex 10.2
Table 11.1
162
164
170
182
Growth and Share of Private Sector Hospitals and Beds
Percentage of Villages with NGOs, by Select States. 1994
Annex 10.1
11
Burden of CVD 1990-2020
Figure 10.4
Figure 10.8
145
145
147
150
146
158
160
Effect of Treatment of 1000 Patients with AMI
Figure 10.3
Figure 10.7
135
135
137
138
139
182
163
164
165
167
168
169
170
186
189
189
192
Table 11.2
Infant Mortality Rates, Total Fertility Rates, and Malnutrition in
Major Indian States
Percentage Female Literacy and Percentage Below Poverty
Line
Table 11.3
Select Indicators Relating to Public Services
Table 11.4
Percentage Covered by ANC and Immunization Services, by
195
196
193
xi
Standard of Living
Table 11.5
Table 11.6
Table 11.7
Table 11.8
Table 11.9A
Table 11.9B
Table 11,9C
Table 11.10
Table 11.11
12
Percentage Covered by ANC and Immunization Services, by
Caste
196
Percentage Not Seeking Care Due to Locational Reasons
197
Beds Per 10,000 Population in Public Hospitals
Number of Public and Private Hospitalisations per 100,000
Persons
Correlation Coefficients between Under-5 Mortality and Per
Capita Health Expenditure
Correlation Coefficients between IMR and Per-Capita Health
Expenditure
Correlation Coefficients between LEB (Female) and Per-Capita
Health Expenditure
Percentage Beds in the Primary, Secondary and Tertiary
Sector
198
199
201
201
201
208
209
Table 11.12
Micro-efficiency for Secondary (District) Hospitals
Health Humanpower in Rural Areas - Percentage Shortfall of
ANMs and Doctors
210
Table 11.13
Reported Figures of Immunization, State Data and NFHS 2
221
Table 11.14
Quality Care Indicators for Facility Visits
223
Figure 11.1
Goals of a Health System
191
Figure 11.2
198
Figure 11.3
Proportion of In-Patients Below the Poverty Line That
Borrowed
or
Sold
Assets
for
Public
and
Private
Hospitalizations, by State 1995-96
Percentage Vacant Posts in Public Facilities in Rural Areas
213
Annex 11.1
Organogram of the Department of Health and Family Welfare
227
Annex 11.2
Proposed Administrative Structure
Public Expenditure on Health - Flow of Funds from Centre to
State
228
Annex 11.3
Annex 11.4
Flow of funds in Andhra Pradesh Health Sector
230
Annex 11.5
Performance Monitoring Framework
231
Table 12.1
Real Per-Capita Spending on Health (Rs.)
Percentage Share of Salaries and Wages in Total Public
spending on Health
234
Table 12.2
Table 12.3
Table 12.4
Table 12.5
Table 12.6
Table 12.7
229
235
236
Estimates of Total Health Expenditure in India, 1990-91
Percentage of Total Health Expenditure Funded Through
Public/Social Insurance and Direct Government Revenue
Cost Recovery and Health Expenditure by States, 1996
Percentage Distribution of Persons by Income Group,
Employment Status and Main Industry Classification
Percentage Distribution by Employment and Income
Status
237
237
241
241
Table 12.8
Summary of External Assistance for Health Sectors (in ‘000 $)
245
Table 12.9
Additional Resource Mobilization Proposals: A Summary
249
Figure 12.1
Share of health in State and Central Budget (in %)
234
xii
u
Figure 12.2
Annex 12.1
Per-Capita Real Spending on Health by Selected Major States
(Rs.)
Trends in Government Expenditure (Revenue and Capital) :
1980-1981 to 1998-1999 (Rs. Lakhs)
Constituents of Primary, Secondary and Tertiary Care Services
Annex 12.2
Annex 12.3
Salient Features of Some Insurance Schemes in India
Annex 12.3a Salient Characteristics of Select NGOs Managed
261
Annex 12.10
Property Tax in Municipal Revenues
263
Table 13.1
ODA Received by Selected Countries
264
Table 13.2
Percentage Health to Total ODA - 1990-1996
265
Table 1 3.3
Project Profiles in Health - 1991-95
265
Table 13.4
Funding During 1970-80
266
Table 13.5
External Assistance by Major Donors in US $/m
268
Table 1 3.6
List of World Bank Assisted State Health Systems Projects
Percentage of ODA to Central Health and Family Welfare
Budget plans (Rs./Crores)
Budgetary Funding and External Aid for Disease Control
Programmes
List of Externally Funded Projects Under Implementation in
India
268
274
Figure 14.1
Movement of Price Indices of Drugs and Other Products
289
Figure 14.2
Price Control Regulations
289
Figure 15.1
Plan Allocation for Department of ISM & H (Rs. Crores)
Summary of Medical Care, Medical Humanpower and Medical
Education Facilities Available Under Indian Systems of
Medicine and Homeopathy as on 01.04.1999 (Provisional
Figures)
Statewise Number of Registered ISM and Homeopathic
Practioners As on 01.01.1999. (Provisional Figures)
Statewise / Systemwise Number of Hospitals and dispensaries with their Bed
Strength Under Indian Systems of Medicine and Homeopathy Functioning as
on 01.04.1999. (Provisional Figures)
302
Annex 12.6
Annex 12.7
Annex 12.8
Table 13.7
Table 13.8
Annex 13.1
15
252
253
254
Annex 12.9
Annex 12.5
14
251
Insurance Schemes
Assessment of Different Methods of Financing Health Care in
India
Employment by Industry in Organized and Unorganized
Sectors in
India : 1997
Percentage Distribution of Employed by Socio-Economic
Status under Employment Status, Main Industry Classification
and for Rural - Urban Areas
How Employees are Paid for their Healthcare
Utilization of Health Services and Average Expenditure
Incurred for Treatment as Outpatient and Inpatient
Revenue Receipts of States (Rs. Crore)
Annex 12.4
13
Health
235
Annex 15.1
Annex 15.2
Annex 15.3
255
257
258
259
260
272
279
309
)
310
311
xiii
16
Table 16.1
Financial Outlays for ICMR 1997-98 to 2001-02
319
Figure 16.1
Burden of Diseases and Mortality
312
Figure 16.2
World Health: Contrast in Premature Mortality Burden and
Allocation of Health Research Funds (%)
Sources of Funds for Global Health R&D, 1992
313
Figure 16.3
Figure 16.4
Figure 16.5
Indian R&D Expenditure by Objectives, 1996-1997
Central
Government Health R&D
Expenditure
(Constant Prices). Rs. (Million, 1980-1981 Prices).
Significant Research Achievements of Indian
Institutions
314
318
in
India
318
Research
326
326
Annex 16.4
Achievements of Research Institutions in Diagnostics
“Push” and “Pull" Interventions to Promote the Discovery/
Development of Drugs and Vaccines
ICMR Permanent Institutes/Centers
328
Annex 16.5
Regional Medical Research Centers
328
Annex 16.6
ICMR Centers for Advanced Research
328
Annex 16.1
Annex 16.2
Annex 16.3
xiv
327
H
Changing the Indian Health System: Current Issues,
Future Directions
Executive Summary
This Report had as its starting point the terms of reference of the WHOappointed Commission for Macroeconomics and Health (CMH). During the CMH
meeting hosted by ICRIER in New Delhi in April 2000, detailed presentations
made by four Indian states clearly brought out the diversity of socioeconomic
conditions, health outcomes and approaches in different parts of the country.
This diversity, together with the quality of research and data available,
suggested that India could make a significant contribution to the CMH exercise.
A team at ICRIER, led by Rajiv Misra, former Secretary Health, Government of
India, prepared the Report with a view to making inputs into the CMH thinking
and contribute to the ongoing debate on the National Health Policy. The Report
thus evolved into a country-specific study with a focus on national issues
relevant to Indian policymakers, while maintaining an international dimension
that addresses the CMH terms of reference. The project was funded by the Bill
and Melinda Gates Foundation.
i.
Introduction
It is increasingly recognized that good health is an important
contributor to productivity and economic growth, but it is, first and
foremost, an end in itself. In a poor country like India, where the
only asset most people have is their bodies, health assumes even
greater significance for their economic status. Good health, and its
natural corollary, defense against illness, is fundamental to every
man and woman and child, not only for their well being, but for their
very survival. If the State exists to safeguard the right of its citizens
to the fundamental prerequisites of survival, this same State must
own up to its responsibility to protect its citizens from illness and
premature mortality.
The Indian State has articulated this responsibility often enough.
Since Independence, the government, ostensibly driven by
socialistic goals, has expressed its intentions to discharge this
responsibility in one Five-Year Plan after the other. Ambitious
systems, programmes and schemes have been drawn up to alleviate
poverty while promoting the goal of universal healthcare, although
the close linkages between the two have not been fully appreciated.
There have indeed been large gains in health status since Independence. Life
expectancy has gone up from 36 years in 1951 to 62 years in 1995. Infant
Mortality Rate is down from 146 in 1951 to 71 in 1997. Crude Birth Rate has
been reduced from 36.9 in 1970 to 26.1 in 1998, and Crude Death Rate from
14.9 to 8.7 in the same period. One of the major reasons for these gains has
been the development of an impressively vast, three-tiered system of rural health
infrastructure, with sub-centres for each 5000 population, PHCs for each 30,000
XV
H
population, and CHCs for each 1,00,000 population. Immunization to control
communicable diseases has made a major contribution to these gains; success
stories include small pox eradication,, the near elimination of leprosy, and the
extraordinary social mobilization for polio eradication. Improvements in
determinants such as water supply and sanitation have also helped achieve
outcomes. These aggregations, however, mask the wide differentials between
and within states. The health indicators of Kerala are comparable to those of
middle-income countries, while Uttar Pradesh, Madhya Pradesh and Orissa are
almost at the level of Sub-Saharan Africa. There are huge disparities between
urban and rural areas, and between developed and relatively remote areas
inhabited by the marginalized sections of society.
Moreover, the figures regarding achievements present an impressive picture only
when viewed in splendid isolation. First, a comparison of targets and goals
dilutes the gains considerably. The National Health Policy 1983 set some targets
for 1985, 1990 and 2000. A comparison of goals with actual achievements
reveals the real picture: we are nowhere near targets, except for life expectancy,
Crude Death Rate and polio immunization. Second, while India seems to have
performed better than countries with the same level of per caoita income, such a
comparison is obviously misleading. With its knowledge base, its administrative
and institutional strengths, and its growth potential, India is capable of much
higher levels of achievement.
It is clear that those health systems that direct their resources and energies
towards the health needs of the poor have a better overall health status. This is a
logical association, since the poor carry the larger burden of disease. But the
facts make a mockery of such logic as they establish the raw deal the poor are
getting from the public healthcare system. A recent NCAER study reveals that
the richest 20% enjoy three times the share of public subsidy for health
compared with the poorest quintile. The poorest 20% of Indians have more than
double the mortality rates, fertility rates and undernutrition levels of the richest
20%. The poor suffer disproportionately more from pre-transition diseases such
as malaria and TB. On an average, they spend 12% of their incomes on
healthcare, as opposed to only 2% spent by the rich. Treatment or hospitalization
for chronic illness often means the liquidation of meagre assets, even permanent
indebtedness. One episode of hospitalization is enough to wipe out all the assets
of the family. It is no wonder then that the number of the poor who did not seek
treatment because of financial reasons increased from 15% to 24% in rural areas
and doubled from 10% to 21% in urban areas in the decade 1986-96.
The obvious question then is Why? If the State has universal healthcare and
poverty alleviation as basic objectives; if there have been gains, however patchy
and inadequate; if there are systems in existence if not actually thriving, why is
the current health scenario so bleak?
The obvious and most important reason is that for a State that promises
universal healthcare through the public health system, India has one of the
lowest health budgets in the world. How is the objective to be met if there are no
xvi
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II.
The Current Health Scenarc: Issues
1. Present Challenges
Communicable Diseases: Ore of the biggest blots in the current
health scenario is the failu'e to control communicable diseases,
despite the availability of cost-effective and relatively simple
technologies. These pre-transition communicable and infectious
diseases constitute a major cause of premature death in India: they
kill over 2.5 million children below the age of five and an equal
number of young adults every year. The proportion of total deaths
caused by communicable diseases (including maternity related
conditions and nutritional deficiencies) continues to be unacceptably
high at 42%. (Of the 269 million disability-adjusted life years or
DALYs lost, communicable diseases accounted for 50.3%.) Despite
the global eradication of small pox, and despite expectations that
current efforts will ensure the elimination of leprosy and polio within
the next five years, environmental and social factors impose severe
constraints on the control of two of the communicable diseases that
pose a special threat - malaria and TB. The total number of TB
patients is estimated at 15 million. Moreover, India has been
identified as a hot spot for Multi Drug Resistant (MDR) TB, which is
both difficult and expensive to treat. The resurgence of malaria and
TB in forms difficult to control or treat, along with the exponential
rate of development of HIV/AIDS, have imparted a new sense of
urgency to disease control. Special projects have been launched for
the control of communicable diseases such as malaria, TB and
leprosy with the support of the World Bank and other donors, and
they constitute an appropriate strategic response to the increasing
threat. They have improved performance considerably through
stable funding and programmatic reforms. However, except in the
case of leprosy where the objective of elimination appears
achievable, the coverage in other programmes is still low, and large
uncovered areas have been receiving even less attention than
before. These projects must cover the entire country, and central
funding support must be extended to 100%, rather than matching
50:50 with the states, as in many cases at present. The
sustainability of these special programmes once external assistance
ceases also needs to be addressed.
•
TB: India accounts for one-third of global TB, and the largest
number of persons suffering from active TB in the world.
According to available estimates, about 2.2 million persons are
added each year to the existing load of about 15 million active TB
cases. Of these new cases, about 800,000 are infectious, and
about 450,000 die. Most disturbing is that 20% of 15 year olds
are reportedly infected; and among women in the reproductive
age group of 15-44 years, it causes more deaths than all the
xviii
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resources to put policy and schemes into actual practice? This gross mismatch
between objectives and resources is at the heart of both the inadequacies and
the inequities of the Indian health system. Higher public health expenditures are
clearly and unequivocally assooared with better health outcomes, and thus
productivity, especially in a poor country. Any attempt at understanding the
failures of the health system, and setting these derailed intentions and structures
back on course, would involve, for a start, a much higher priority to the health
sector. This higher priority will tnen have to be translated into increased
allocation of resources. Otherwise financial risk protection for the poor, who are
beset by illness as well as the threat of loss of work, will remain what it has been
for the last several decades: pious ceclarations on paper.
The State’s role in health has been so far from its declared intentions that not
only has it failed to provide healthcare to the majority of the population through
the public sector; it has also countenanced a large and thriving private sector to
grow practically without regulation. In recent times, one point of view has offered
the private sector as the panacea for all ills; another view perceives the private
sector as a negative accompaniment to liberalization and links its growth with
that of inequity. Neither view takes into account two facts: one, that in the context
of a public health system that does not deliver services to those who need them,
the private sector has grown to be the main provider of curative healthcare. It
currently dominates both outpatien: and inpatient care, and this evidence shows
no significant variations by income group, rural/urban location, gender, caste or
tribe. Two, the private sector is almost entirely unregulated so that its costs, its
quality of care and its spatial disthoution are for the large part incompatible with
national health goals. It is not sumrising then that the poor are forced into a
situation where they have to pay for private healthcare they cannot afford. Their
deprivation and vulnerability make the poor ill more easily; and illness makes
them even poorer. There is no dearth of evidence that establishes this nexus. A
recent analysis of the World Bank (India - Raising the Sights; Better Health
Systems for India’s Poor, May 2001) concludes that “the hospitalized Indian
spends more than half of his total annual expenditures on buying healthcare;
more than 40% of hospitalized people borrow money or sell assets to cover
expenses and 35% fall below the poverty line.” The same study also suggests
that out-of-pocket medical costs alone may push 2.2% of the population below
the poverty line in one year.
Given this context, the first task of policymakers is to define realistic goals and
provide the necessary financial resources for their achievement. Besides, the
lack of clarity on the relative roles of the centre and the states has caused the
centre to focus on the day-to-day management of institutions and programmes,
rather than concentrating on its stewardship role. The result is that even the
meagre available resources have not been put to optimal use. Clearly, along with
increased resources, the need of the hour is wide-ranging systemic reforms, both
at the centre and the states. We believe that the reform process must begin with
a thorough restructuring of the Ministry of Health and Family Welfare on the lines
indicated in the Appendices of this Report.
xvii
> enhancement of community based action, such as undertaking
bioenvironmental control measures and promoting personal
prophylactic measures.
The effectiveness of these efforts is hampered by weak and often
non-functional public health systems, non-availability of required
manpower, inaccessibility of areas most effected (e.g. tribal areas),
and poor community participation. The removal of these constraints
is a major challenge for the programme.
•
Maternal and Child Health (MCH): Children below five and women
in the reproductive age group make up 36.2% of the population of
India, and in terms of survival and well being, they also constitute
the most vulnerable group in society. Income levels and social
exclusion only serve to exacerbate this vulnerability: health
indicators for SC and ST women and children reveal that they are
considerably worse off. As in other aspects of the health sector,
the database so essential for planning and setting of priorities is
not reliable. But the estimates available show that the Maternal
Mortality Rate (MMR) continues to remain at an unacceptable
level - 408 for 1,00,000 live births. The causes for these poor
indicators of maternal health are well documented: the low
socioeconomic status of women, the undernourishment and
anemia rampant among them, the low proportion of institutional
deliveries, and the absence of trained birth attendants in as many
as two-thirds of cases. Again, only a revamping of the primary
healthcare
system,
along
with
effective
referrals
for
complications, will help improve antenatal and maternity care.
Simultaneously, a fundamental link - between high mortality on
the one hand and high fertility and age at delivery on the other must be addressed to get a handle on the problem of maternal
survival and health.
The poor status of maternal health is inextricably linked with the
gender disparities that pervade all aspects of life in India. The
results of the 2001 Census seem to indicate that the reported
decline in the sex ratio during the last century has, at last, been
not only arrested but also marginally reversed. But the sex ratio
in the 0-6 age group has worsened, and this is cause for serious
concern. Again, the tempo of decline in Infant Mortality Rate
(IMR) and under-5 mortality achieved between 1981 and 1991
has not been sustained. The critical point is that IMR has been
hovering around 72, and under-5 mortality around 95 per 1000
live births, during the last few years. The rate of decline has,
during the last four years, reached a disturbing plateau.
•
Other Infections: Linked with child survival and health is the
range of water-related or soil-transmitted illnesses. Acute
XX
I
)
various causes of maternal mortality put together. Added to this
are the facts that every sputum positive case carries the potential
to infect 10-15 individuals in a year, and that TB is the principal
opportunistic infection of HIV. The result is the alarming
possibility that deaths caused by TB can go up to 4 million in the
next decade. At present, the DOTS strategy is implemented under
the aegis of the RNTCP in about 200 districts, covering a
population of 350 million. The programme is supported by about
Rs.746.76 crores of external funding. The results of the RNTCP
are impressive, but nevertheless the future scenario of TB control
appears grim. First, only an estimated 20-25% of TB patients in
the country have been brought under DOTS. The same familiar
reasons crop up as barriers to further expansion and better
performance : low budgets; weak institutional capacity; the
dangers of MDR exacerbated by unregulated private practitioners
ollowing their disparate, sometimes irrational treatment regimes,
as well as unplanned, unprepared and hasty expansion of the
programme. Multiple systems of TB control - conventional, SCO
and RNTCP - are all being implemented with different financing
mechanisms. And as in other programmes, poor community
support is a hindrance. In addition to all this, the future of TB
control has to be viewed in light of the ominous fact that nearly
two-thirds of opportunistic infection among AIDS patients is TB,
portending a dual epidemic of TB and HIV in the near future.
Malaria: The prevalence of malaria was brought down to about
2 million cases by 1984; but in 1994, once again, there were
several focal outbreaks resulting in high mortality. The most
dangerous strain of malaria, caused by the parasite Plasmodium
falciparum (Pf), has been steadily rising to account for almost
half of all malaria cases in 2001. As expected, the disadvantaged
sections are the worst hit: in Andhra Pradesh, the rate of Pf
malaria among tribal groups accounted for 75% of malarial
deaths in the state.
Several reasons have been cited for the failure to reduce malarial
prevalence: parasite resistance to drugs and vector resistance to
insecticides in some high endemic areas, environmental changes
caused by development activities such as irrigation projects, and
rapid urbanization. A three-pronged strategy was drawn up, which is
now being implemented throughout the country under the National
Anti-Malaria Programme (NAMP). The main objective of the strategy
is interrupting the transmission of disease by
> early detection and prompt treatment to reduce the reservoir of
infection;
> reduction of the vector population through selected vector
control using anti-adult and anti-larval measures;
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diarrhea, worm infestations and digestive tract infections become
illnesses to reckon with in view of their debilitating impact on the
immunity system, particularly those of children and of those
already undernourished. In addition to comprehensive health
education - which would promote community hygiene and healthy
living - India needs to make adequate investments in water
supply, sewerage systems and sanitation to reduce the infectious
disease load. Acute Respiratory Infections (ARI) continue to take
a heavy toll, especially among children, despite the availability of
inexpensive and effective anti-microbials, causing almost a
million avoidable deaths every year. This again is due to a
dysfunctional public health system and lack of access to quality
primary and secondary care.
The threat of communicable diseases, as well as perinatal morbidity
and mortality, looms larger because of the poor nutritional status of
a substantial part of the population. Despite a nationwide
programme for nutritional supplementation of pregnant women and
children, NFHS II (1998-99) shows only a slight improvement over
NFHS I (1992-93). The percentage of underweight children has only
reduced from 52% to 47%, and of the severely underweight from
20% to 18%. 74% of children were found to be anemic; the same
study found that 52% women have some anemia, which is a major
cause of maternal mortality.
The present challenges of communicable diseases and maternal and
child survival show up the weaknesses of the health system. But
even as the system struggles to meet the current demands of
disease control, a new challenge, again a communicable disease, is
emerging in the form of HIV/AIDS, threatening to sharpen existing
problems of resources, health infrastructure and inequities.
2. Emerging Challenges
HIV/AIDS: The threat presented by the rapidly growing HIV/AIDS
infection has not received the priority attention that it deserves,
partly because of the long gestation period between HIV infection
and the development of full-blown AIDS. Also, it is the opportunistic
infections (such as TB) that get noticed; the root cause of morbidity
and mortality often remains undiagnosed. The major route of
transmission in India is sexual contact, but sex as a subject is
weighed down with taboos in a traditional society. The high
prevalence of STDs in India also makes the country particularly
vulnerable to the AIDS threat. In the year 2000, the number of
Indians infected with HIV was estimated at 3.86 million, or roughly a
prevalence rate of 0.7%, quite low when compared to the prevalence
rates of 25% and over in South Africa, Zimbabwe and Botswana. But
the infection in India is no longer confined to high-risk groups or
xxi
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only to urban areas and it is spreading rapidly. And since the
epidemic is more than a decade old, mortality due to AIDS is
increasing: in 1999 alone, nearly 300,000 Indians are estimated to
have died of AIDS. As of March 2000, 1 1,251 cases have been
reported to NACO: 79% are males, 21% female. This is, however,
only a fraction of AIDS morbidity in the country, reflecting the stigma
and
the
ignorance
surrounding
the
infection.
Widespread
discrimination against the infected hinders their access to
healthcare. Similarly, the low income levels of the infected, coupled
with lack of resources in the government funded programme despite the manufacture and availability of the drugs in India at
more affordable prices - preclude the widespread use of highly
active anti-retroviral therapy (HAART). As a result, morbidity and
mortality of those infected continues to be high.
The most important contribution of the National AIDS Control
Programme (NACO) has been sentinel surveillance; it has also
heightened awareness regarding blood safety. The Programme has
now begun its second phase, which is to focus on targeted
interventions among high-risk behaviour groups. But awareness
levels are still low or uneven; information, education and
communication (IEC) remain a crucial element. If India is to avoid
the catastrophe that Africa is struggling with, far greater efforts will
have to be made to keep the epidemic at bay. Fortunately, we have
a model in the state of Tamilnadu, which has successfully arrested
the increase in the level of infection by concentrating on high-risk
segments of the population, and by devising innovative mechanisms
for programme implementation. India must act immediately and
vigorously to control the level of HIV infection so that it does not
grow beyond 3% of the population.
3. Future Challenges
As if present and emerging problems do not present enough of a
challenge to a resource-hungry and weak health system, there are
also the challenges of the future for which provisions must be made.
Projections of population increase indicate a changing demographic
profile with profound implications for health
planners and
economists. The next two decades will see a significant increase in
the 15-59 age group; the increase in longevity will almost double the
population of the elderly (> 60 years). As more individuals survive to
middle age, the years of exposure to the risk factors of chronic
disease increase. Non-communicable diseases (NCDs) will gradually
become the dominant contributors to the burden of disease - their
share increasing from an estimated 33% in 1998 to 57% in 2020. In
fact, even at the present stage of health transition, India contributes
substantially to the global burden of NCDs. In 1990, India accounted
for 19% of all deaths, 16% of all NCD deaths and 17% of all CVD
xxii
H
)
deaths in the world. CVD in India alone accounted for around 2.4
million deaths, in contrast to nearly 3.2 million CVD deaths in all the
industrialized countries put together. In addition, recent evidence
suggests that impaired fetal nutrition, reflected in small birth size,
results in programmed susceptibility to adult cardiovascular disease,
diabetes and some cancers. With NCDs positioned as a major public
health challenge, the existing health systems will need to be
reorganized and reoriented to deliver the expanded mandate of
healthcare - involving the prevention, surveillance and management
of chronic diseases along with primary and secondary healthcare.
The emerging burden of NCDs poses a special threat to the poor due
to the often prolonged and expensive treatment required for these
conditions, as well as much greater exposure to risk factors like
tobacco and alcohol.
)
i
The management of NCDs is often technology-intensive and
expensive.
Individual as well as societal resources are already
being drained at a disproportionately high level by the tertiary care
management of NCD, drawing scarce resources away from the
unfinished agenda of infectious disease and maternal and child
health. Though NCD epidemics usually originate in the upper
socioeconomic strata, they diffuse across the social spectrum, with
the social gradient ultimately reversing and the poor becoming the
most afflicted.
The exorbitant costs of treating chronic diseases make prevention
the most suitable option for India. Traditionally, public health
approaches to NCD control has consisted of a high-risk strategy,
targeting those with high levels of risk factors and employing
interventions to reduce them, usually with drugs; and a population
strategy that attempts to reduce risk factor levels in the whole
community, usually through lifestyle-related measures. Along with
these approaches, effective low-cost case-management strategies
are required for those who manifest disease. Such technologies are
available, but they await widespread dissemination and application.
Tobacco control is a major public health imperative providing the
largest benefit for NCD prevention. Tobacco-related cancers, CVD
and chronic obstructive airway disease can be effectively prevented
if the tobacco habit is discouraged and overcome among the
population. At present, programmes for NCD control are either non
existent or functioning at a low level in India. The National Cancer
Control Programme involves cancer registries at selected sites and
strengthening of facilities for clinical care (such as radiotherapy).
Pilot studies for the control of CVD and diabetes have been initiated
but have not had an impact on policy and programme development.
Tobacco control has received greater attention, but it still awaits the
passage of proposed legislation as well as a vigorous public
education campaign.
xxiii
N
Taken together, what do the present, emerging and future challenges
imply? To begin with, they call for the high-priority control of
communicable diseases to avoid the double burden of communicable
and non-communicable diseases. They call for appropriate public
health interventions to control the risk factors of NCDs such as
tobacco and unhealthy lifestyles, emphasize preventive strategies,
and set up arrangements for the early detection and cost-effective
treatment of NCDs at the primary and secondary levels.
4. Finance
The recurring refrain in any discussion of the Indian health system is
finance, a refrain that grows more shrill and urgent because of policy
failures and State neglect. The crux of the problem is abysmally low
public health expenditure - around 0.9% of GDP, below the average
of low-income countries and even Sub-Saharan Africa. Despite the
increasing urgency of problems in the health sector, public health
expenditure as a proportion of total government expenditure has in
fact declined over the years. ThiS has to be seen against a
background of fiscal deficits: the combined fiscal deficits of the
centre and the states are estimated at 10% of GDP. Following a
temporary stabilization in the early nineties, the fiscal situation has
deteriorated, so that government ability to increase investments in
health has been eroded further. Since the states typically account for
about 75% of public health expenditure, their financial health is
crucial for both general development and specific health outlays. But
the combined gross fiscal deficits of the states, which ranged
between 2.4-2.9% between 1993-94 and 1997-98, increased to 4.2%
in 1998-99 and to 4.9% in 1999-2000. Fiscal crises have meant
sharp reductions in the non-salary recurring expenditure in public
health facilities, leading to further deterioration of quality. In
addition, the increase in salary and pension liabilities after the Fifth
Pay Commission has aggravated the resource crunch.
The share of health expenditure in the major states, in the range of
6-7% up to the 1980s, has come down to just over 5% in the 1990s.
This is a significant decline in the proportion of health expenditure to
the total expenditure in the states in over two decades. As far as the
real per capita public spending on health is concerned, the evidence
of 11 states at 1980-81 constant prices shows a steady increase,
though in varying degrees. The sole exception is Uttar Pradesh, the
most populous state; the declining per capita public spending in this
state with very poor health outcomes is indeed a disturbing trend.
Moreover, trends of the real per capita public spending on health of
selected major states, and their distribution among primary,
secondary and tertiary healthcare, show that between the period
1985-86 and 1998-99, per capita public spending increased at the
xxiv
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primary and secondary levels by about 50%, while spending levels
increased by more than 100% in the tertiary sector. This has grave
implications for both the equity and efficiency of the health system.
The declared policy was for the State to provide free universal
healthcare to the entire population, but this policy objective has been
totally divorced from the reality on the ground. In fact, India has one
of the highest levels of private financing (87%), with out-of-pocket
expenses estimated to be as high as 84.6%. The highly skewed
pattern of health finance in India is a major contributor to the
• perpetuation of poverty. Indeed, the greatest failure of the Indian
health system is its inability to develop a financing mechanism for
the healthcare of the poor. It is clear then that the foremost objective
of the Indian health finance system is financial risk protection for the
poorer and weaker sections of the population. Access to health
services should depend on individual need, not on ability to pay. The
!----x
,
........................
most efficient way of providing financial protection is to pool the risk
between the rich and the poor, the young and the old,
old and the
employed and the unemployed, to enable cross subsidization. At the
international level, the main instrument used to achieve this
objective is health insurance, but this has remained relatively
undeveloped in India.
That there is a strong case for increasing the share of health in
resource allocation is by now self-evident. But the extent to which
tax revenues can be reallocated to the health sector would depend
not only on political will, but also on the fiscal situation. In a poor
country with a low tax base, mounting debt liabilities, undeniable
security concerns and a legacy of poorly targeted subsidies, we
cannot rest content with merely advocating reallocation of resources
for larger investment in health. Generally speaking, the available tax
resources should be used primarily for provision of public goods, the
healthcare of the poor — particularly those in the informal sector
outside the reach of insurance mechanisms, and for community
financing. To the extent possible, resources should be raised from
dedicated sources to eliminate competition, and to provide stable
and growing sources of revenue. At the same time, there must be
improvement in the targeting of public subsidies towards the
healthcare of the poor. This implies taking three steps:
•
•
•
Increase allocation for public health and primary and secondary
healthcare, which is better utilized by low-income families.
Utilize user fees at secondary and tertiary levels to reduce the
price advantage of public services, reducing their attractiveness
to the well off and simultaneously making arrangements for
exemptions of the poor.
Improve the efficiency of public services to encourage their
greater utilization.
XXV
11
Various options for different categories of the population in different
income groups need to be considered in the course of developing a
framework. As far as the rich are concerned, voluntary private health
insurance deserves government encouragement, but there is no
justification for public subsidies such as the recent tax concessions.
Increased competition would automatically spread the coverage of
voluntary health insurance,. leading to improved products and
services. The State’s role is essentially to develop an appropriate
legislative framework, and to appointt a dedicated and independent
regulatory authority that will monitor
the insurance
---------------) sector, and
formulate procedures and regulations to help avoid well-documented
market failures. But even in the absence of voluntary health
insurance, the rich, given their financial resilience, could continue to
depend on out-of-pocket expenses.
The objective for the middle income section is to cover all the
employees in the formal sector via social insurance, primarilyj
financed by employer and employee contributions. State participation
should at best be nominal. People in the informal sector could join
either voluntary health insurance schemes or community finance
schemes wherever feasible. If none of these options is chosen, they
could continue to rely on out-of-pocket expenses.
Schemes such as ESIS, CGHS, and employer-based schemes
already cover the low-income formal sector, though ESIS and CGHS
have demonstrated deficiencies of coverage and quality, as well as
high administrative costs. These schemes could be replaced by
social insurance, with the government playing facilitator and
financier, but not necessarily provider of services. The services for
social insurance could be contracted out; this would enhance
efficiency and reduce costs. The manufacturing and services sector
would grow with economic growth and industrialization, so that social
insurance could play an increasingly important role. At present,
approximately 10% of the population are covered by social insurance
and employer-based schemes; this can be increased to around 21%
of households, including all income groups, wherever social
insurance is feasible.
An estimated 46.6% of the poor population is in the informal sector,
and they deserve maximum State assistance since they are beyond
the reach of social insurance. The preferred option is Community
Financing Schemes. However, such schemes require strong local
leadership and organizational capabilities, often provided by NGOs.
Most current schemes do not receive any government support, but
state governments could design a package of incentives that will
encourage NGOs to develop such schemes in designated areas, with
the government contributing a fixed premium for every belowxxvi
H
poverty-line (BPL) family covered by such schemes.
Also, all
donations to genuine community finance organizations should be
exempted from tax. But most of the population would still need health
cover by the State, calling for 2 more efficient primary and secondary
healthcare system with a strong referral link. Moreover, even
community financing schemes and access to public primary and
secondary facilities do not provide financial risk protection to the
poor against costs of hospitalization
and
serious
illness.
This requires the setting up of Sickness Funds in each district to
directly reimburse such costs to the public or designated private
facility. On current estimates, a fund to .cover an approximate 300
million BPL population would require Rs.2,500 to Rs.4,000 crores
annually.
The total health spending in 1998-99 is estimated at Rs.161 billion or
Rs.16100 crores. This means the level of public investment will have
to be more than doubled to reach the average of lower middle
income countries, or 2.2% of GDP. The strategy is to develop
dedicated levies that provide a sustained source of finance to
strengthen the health sector and insulate it, at least partially, from
fiscal crises, emergencies and political upheavals.
Central Level:
Reallocation from General Revenues: Considering the tight fiscal
position and the competing claims of different sectors, diverting
significant resources from other sectors to health does not seem
feasible.
But a 50% increase,' or roughly an additional Rs.2000
crores, can be made available -- partly from General Revenues and
partly by reallocation from other programmes that have failed to
make the desired impact.
Increased External Assistance: From 1990 to 1995, the average
disbursement of external assistance to the health sector has been
216 million dollars or Rs.1000 crores — around Rs.10 per capita.
Considering the Indian context - population size, levels of income
and the burden of disease - the quantum of this assistance is
woefully inadequate.
But despite this, external assistance has
played a key role in directing resources to priority areas. Meanwhile,
in view of a better absorptive capacity, it would not be unrealistic to
expect assistance to increase to at least three times in the coming
years. The resulting yield would mean an additional Rs.2000 crores a
year.
The performance of externally aided schemes could
enhanced by reforms at both donor and recipient levels:
•
be greatly
Better project preparations involving full consultation with all
stakeholders.
xxvii
u
relefse of funds a|lowmg advance preparatory action for
procurement against the next year's allocation.
• Sufficient provision for maintenance of facilities
created for the
project.
• Identification, training and positioning of the project team before
the project begins, and not shifting them during
I the project period,
• At least one year’s preparatory time for all
major projects to
complete formalities such as land acquisition
, preparation of
building plans, finalization of technical
specifications and
development of training modules.
• Improvement of monitoring mechanisms.
• Simplification of procurement procedures, avoiding
multiple
references to, and approvals from, donor agencies.
lax on Tobacco: This tax has two main components - the basic
excise duty, a central levy; and additional excise duty in lieu of sales
behalT o? fh'p5 iTT
C0llected
the central government on
behalf of the states. This is a buoyant source of revenue with a
betWPPnS?nh
y in77ce for the 'mP°sition °f a cess. The linkage
se
thJ bHCC?
disease is well established, and taxation
serves the dual purpose of reducing consumption and yielding
resources. There is a r*'
---------------■ ■■ ■■
strong
case for dedicating
at least party of they
revenue to preventive and promotive health, particularly to
controlling the risk factors for NCDs.
Even a 15% cess could
contribute at least Rs.1,000 c
crores to the health sector without
disturbing existing sources of revenue.
Revenues
from
Disinvestment:
The
government’s
ambitious
programme
of' disinvestment
ci7
y'a'i""r k
Ul5investment in public
public sector enterprises has had a
slow start because of political pressures, resistance from trade
unions and procedural difficulties.
But the establishment of a
Of PRA?rnmJni -7 for dlsinvestment. and the successful privatization
of BAJ-GO despite political opposition, augurs well for rapid progress.
The Budget for 2001-02 set a target of Rs.12,000 crores from this
source. Out of this Rs.7,000 crores is earmarked for restructuring
PubliG sector enterprises, and the balance of
' ---” ““'“''‘ Rs.5,000 crores for
in
and social
social
infra
1 infrastructure
nfrastructure
and
sectors.
Although
^mnnr? HtUre 7 a h
'9J priorit
y- there are many other sources to
high
priority,
support it including thei cess on
petroleum products and private
c
It
is
in
this
context
that
Pc 7^7
IS 10
we urge earmarking at least
Rs.2,000 crores annually from disinvestment revenue for additional
investment in the health sector.
State Levies:
revy°n Excise: The rationale behind a dedicated levy on tobacco for
ealth applies equally to a cess on state excise duties, which
predominantly relate to taxes on alcohol consumption. Again, this is
a buoyant source of revenue with an annual yield of about 15,000
xxviii
crores - and a 33% surcharge on existing excise revenue could yield
5,000 crores annually.
Property Taxes: There are three categories of property-related taxes.
The first one, registration and stamps, is a tax on transfer of
property, and yields an annual Rs.10,000 crores. A 20% surcharge
could yield 2,000 crores annually. The second source is urban
property tax, collected by local bodies. The estimated income, based
on 1997-98 per capita estimates, works out to around 2,300 crores.
This is a rapidly growing source and the present yield would exceed
2,700 crores. A 33% cess could provide Rs.900 crores per year for
Sickness Funds and other healthcare services for the urban poor.
The third source is land revenue, which yields around 1,500 crores a
year; a 33% surcharge could yield 500 crores a year. Property taxes
are currently both low and progressive, and could make a significant
contribution towards the new mechanism of Sickness Funds. These
funds could be created by a suitable cess on both rural and urban
property as well as on their transfers, so that it takes into account
both equity considerations and ease of administration and collection.
The collections could be pooled state-wise, then allocated to district
level societies proportionate to the number of BPL families. The
identified BPL family member would be given free treatment in public
facilities and designated private facilities, and the costs charged
directly to the Fund. These sources of earmarked levies could yield
around 3,500 crores a year, sufficient to support Sickness Funds.
User Fees: This levy cannot be perceived only as a revenue raising
mechanism. It discourages the overuse of public facilities by the
affluent while correcting some distortions in the use of public
facilities. Revenues generated from this source can be used to
improve quality of care, in turn improving the utilization of these
facilities. User fees can also involve the local community in
managing public healthcare facilities, so that a sense of participation
and ownership is fostered. The present yield from this source is
small, but it is capable of considerable expansion, as indicated by
new initiatives in MP and Rajasthan. There are, however, hurdles to
a major expansion, and these include the lack of appropriate
mechanisms to review user charges; the minimal level of cost
recovery caused by low fee structure; the absence of mechanisms to
exempt the poor; and the lack of adequate arrangements to ensure
fund utilization at the point of collection. F
But again, recent state
initiatives provide lessons that can be applied to overcome these
weaknesses:
•
The income from user fees should be credited to a hospital-based
fund managed at the local level with the authority to review the
charges.
xxix
•
•
•
The income from user fees should be additional to the budget
allocations for the medical facility.
Use of the fund should be exclusively for improvements in the
relevant medical facility by the local fund management committee,
in accordance with state government guidelines.
All BPL families should have identification cards toi secure
automatic exemption. Mechanisms should also be in |place to
consider the exemption of other indigent families at the discretion
of the local committee.
In sum, while resources must be mobilized to change the health
system through measures such as dedicated taxes, particularly
property taxes, the critical guideline for mobilization is that the
resources must be stable as well as sustainable. Since the object of
the entire exercise is to provide financial risk protection, insurance
as a mechanism must be promoted wherever feasible. So should
community finance, which calls, however, for strong leadership from
NGOs and local bodies. What happens then to those who do not
have access to insurance or community finance schemes? It is for
these weaker and disadvantaged sections that mechanisms such as
Sickness Funds are necessary; and most of all, an improved primary
and secondary health system that delivers care to those who need it
most.
5. Health Systems
A. Public:
Our vast rural health infrastructure received substantial financial
support during the 1980s, or the Sixth and Seventh Five Year Plan
periods. But this substantial investment has not yielded optimal
benefits: many institutions are not fully functional as a result of staff
shortage and the lack of drugs and consumables. One of the major
and persistent causes of a malfunctioning healthcare infrastructure in
the rural areas is a critical shortage of key health manpower,
particularly of doctors in public facilities. This is partly due to
inadequate incentives and poor working conditions, and partly
because the posting of doctors in rural areas suffers from a lack of
transparency. The result is that the under-served areas, where even
private sector facilities are not available, are completely deprived of
any healthcare facilities.
The non-availability of key personnel in public health facilities is
often cited as the main reason for under-utilization of public health
facilities. But an analysis of manpower shortage at the primary level
suggests that more than shortfalls of personnel, it is the organization
and management of existing human resources that is the key to
better performance. The lesson is clear: efficiency in the use of
XXX
existing resources should take precedence over mobilizing additional
resources.
The deteriorating environment, the lack of safe drinking water and
poor nutritional status, all conditions that affect disease burden and
health outcomes, are poverty-related. These health hazards threaten
the growing slum population in cities - as much as 30-50% of the
total urban population. But in the absence of functioning institutional
mechanisms, it is difficult to put the required coordinated and
integrated action into practice. Divisions within the MHFW have also
aggravated compartmentalization. The Ministry is now divided into
three independent departments of health, family welfare and ISM.
Since population control was considered a priority, an independent
department of family planning was created even though public health
and family planning services had to be delivered through the
common rural health infrastructure. The emphasis on family planning
targets transferred the entire rural health portfolio to that
department, divorcing it from other health programmes. The result
was poor utilization; the PHC, in many states, was in the public eye,
only a family planning facility.
An analysis of disparities in health outcomes shows that certain
states in India have consistently worse health outcomes. A crosssectional regression analysis was carried out for 25 states to assess
whether differentials in health service delivery capacity have a
significant association with health outcomes. The analysis was based
on
three
independent
variables,
namely
female
literacy,
immunizations and use of ORT therapy in diarrhea episodes^ Since
MCH preventive services are mostly delivered in the public sector, it
was concluded that public sector capacity is considered a relevant
and critical determinant of health outcomes. Jean Dreze and Haris
Gazdar advance the same hypothesis in an analysis of development
experiences in Uttar Pradesh, Kerala and the southern states. The
authors argue that the relevant determinant of the development
status of these states is the reach and functioning of public services,
and support this argument with a comparative picture of select public
services. This reinforces our hypothesis that public health sector
capacity in terms of provisioning of services is a critical determinant
for improved health outcomes.
That access to health services is a key mechanism for better health
outcomes is also indicated by utilization data: states that have high
utilization rates reveal lower mortality rates. NSS data shows that the
percentage of people who did not access healthcare for reasons of
location is higher in the poor performing states. The analysis
indicates a strong association between health outcomes and equity
in the public financing of healthcare. Health outcomes appear to be
strongly associated with higher per capita public health spending,
xxxi
and with higher allocations to the secondary sector. Scarce financial
resources are being inefficiently used, not only in terms of allocative
patterns, but also in the management of fund flow and monitoring.
Several of the problems confronting public health service delivery
call for the reorganization and better management of existing
resources. Access to healthcare is hindered not only by geographic,
social and cost barriers, but also by inherent systemic and structural
weaknesses of the public healthcare system:
•
•
•
•
compartmentalized structures and inadequate definition of roles at
all levels of care; inefficient distribution, use and management of
human resources so that people have to contend with lack of key
personnel, unmotivated staff, absenteeism, long waiting times,
inconvenient clinic hours/outreach, service times, unauthorized
patient charging;
inadequate
planning,
management
and
monitoring
of
services/facilities; displaying insensitivity to local/community
needs; ineffective or non-existent referral systems, resulting in
under-utilization of PHCs, over-utilization of hospital services,
duplication of services and cost-ineffective provision of services;
inadequate systems to enforce accountability and assure quality;
inefficient systems for purchasing drugs, supplies and services,
which fail to ensure quality and value for money;
inadequate attention to health education and public disclosure.
Setting priorities in health sector policy and planning is a matter of
intense debate. International opinion emphasizes the bias in favour
of hospital care and the need to reform health systems in favour of
primary care. Our analyses suggest that the state must focus on both
primary and secondary sectors simultaneously, linked as they are for
the delivery of basic health services. The focus on secondary care in
the context of referral linkages with the primary sector, and the
welfare objective of insuring the poor against costs of illness, is
considered as essential as the focus on primary care. Most important
is reforming administrative structures to integrate primary and
secondary levels through administrative and technical controls at the
referral hospital level.
The capacity of the public health system to monitor morbidity, and to
respond to changes in disease patterns, is greatly hampered by the
lack of reliable epidemiological data. The current reporting systems
are confined only to public facilities that deal with barely one-fifth of
the illness episodes. Hence the huge under reporting, generating a
sense of complacency. The model developed by the Christian
Medical College, Vellore, and implemented in Kottayam District,
Kerala, needs to be replicated as soon as possible all over the
country to improve the quality of epidemiological data.
xxxii
Another important area that has suffered neglect is public health as a
discipline. Even the highest technical positions in public health,
whether at central or state level, do not require a public health
background; specialized institutions as well as faculties of
Preventive and Social (Community) Medicine remain in an equally
sad state of neglect. Unless public health as a field gets the
recognition and importance it deserves, the planning of health
systems will continue to over-emphasize curative services.
The foremost problem in designing an efficient health system is the
top-down approach with negligible community participation and
ownership.
Is
it
possible,
for
instance,
to
conceive
of
bioenvironmental control of vectors, or improvement in sanitation and
hygiene, without the active participation of the people making up the
community? Similarly, the monitoring and supervision of peripheral
health services from state and district headquarters has invariably
failed, underscoring the need for active local involvement.
One of the ways to address this deficiency is decentralization of
authority to local bodies (Panchayati Raj institutions). But the fact is
that decentralization could have conflicting results without sufficient
preparation of local bodies to take on this expanded role. The Kerala
experience indicates that decentralization has to be preceded by a
long period of planning, defining and clarifying responsibilities,
capacity building and advocacy. Capacity building of local bodies as
well as the community is an essential prerequisite to reap the full
benefits of decentralization. It is evident that such devolution
encourages local bodies to consider health as integral to other
development activities, facilitating coordinated action on other
determinants of health such as water and sanitation.
The states provide several examples finking the issue of community
participation with institutional autonomy and delegation of powers to
local committees to raise and use resources for improvements in
medical facilities. The experiences of Madhya Pradesh and
Rajasthan, for instance, show a marked improvement in the quality of
services, availability of drugs and consumables as well as patient
satisfaction. These are welcome initiatives; but they are yet to be
converted into a comprehensive policy to secure community
participation in all health programmes.
B. Private:
Without in any way underestimating the importance of the public
health system, it must be recognized that the private sector has
grown to be the main provider of curative healthcare. At the all-lndia
level, the private sector currently dominates both outpatient and
inpatient care: 82% of all outpatient visits take place in the private
xxxiii
sector. An important dimension to the utilization of in-patient care in
the public and private health sector is the share between the rich and
the poor. Overall for India, the percentage of the poorest quintile
using private sector hospitalization facilities is, at 39%, almost half
that of the richest at 77%. Tertiary care institutions, providing
specialized and super-specialized care in the private sector,
constitute only 1-2% of the total number of private institutions; and
corporate hospitals, which have in recent times gained in visibility
and publicity, actually constitute less than 1%.
The evidence is that the people of India, including the poor, make
considerable use of the private health sector. But at what cost? This
is a crucial dimension of the private health sector in India,
unfortunately under-researched. NSS data reveals that the average
cost of treatment in the private sector for rural inpatients is 2.1 times
higher, and for urban inpatients 2.4 times higher, than in the public
sector during 1995-96. Technology advances are usually associated
with a decrease in costs, but the reverse holds true for the medical
sector, where technological developments have been capitalintensive, making the provision of healthcare increasingly expensive.
A proliferation of medical equipment and technologies in urban areas
has led to excess capacities, and the consequent unnecessary and
irrational use of these technologies.
In sum, rather than private providers developing into partners with
the State in the achievement of national health goals, the technical
quality of care provided in the private sector is often poor - ranging
from poor infrastructure to inappropriate and unethical treatment
practices, to over-provision of services and exorbitant costs, to
delivery by unqualified providers. Information asymmetry among
users, arising out of a lack of information and an inability to make
sound judgements about available types of healthcare, compounds
the problem. The natural corollary to the concentration of qualified
practitioners and facilities in urban areas, and the limited spread of
the voluntary sector, has been the rise of unqualified, rural medical
practitioners. The estimated one million illegal practitioners are said
to be managing 50-70% of primary consultations, mostly for minor
illnesses, and, in this sense, form the de facto primary curative
healthcare system of rural India. A clear policy promoting private
health facilities in the under-served areas, along with a set of clearly
defined incentives, would correct these imbalances.
Given the extent of private sector dominance in the healthcare
system, any significant improvement in healthcare is inconceivable
without the active involvement and cooperation of the private sector,
particularly the voluntary sector. According to a rough estimate, the
number of voluntary organizations working in healthcare areas is
more than 7000. Despite the lack of comprehensive documentation
xxxiv
on the contribution of NGOs, there is no disputing the fact that NGOs
have the potential to improve access, quality and equity of services,
either through direct provision or through advocacy and other action.
This potential to contribute substantially to public health goals has
not been realized due to several reasons. Their limited size and
spatial distribution is a major cause. That they are missing where
they are most needed hinders effective partnerships with the public
health system. The challenge is to find strategies that will facilitate a
far more substantial participation by NGOs in the health sector,
particularly in backward states and remote areas, and to ensure
systems that will keep such participation accountable and
transparent.
Public-private partnership would make a considerable contribution to
the successful implementation of public health programmes. Also
necessary are continuing medical education, and the active
involvement of professional bodies - to disseminate standard
treatment protocols for diseases such as TB and malaria, to check
the irrational use of drugs, and to regulate unethical practices.
Equally important is the task of developing appropriate independent
mechanisms for the regulation of the private sector - mechanisms
that involve all stakeholders, set up and enforce standards, ensure
quality control, transparency of charges, control unethical practices
and promote accreditation systems. The challenge is to devise
innovative mechanisms that address the acknowledged distortions
and malpractices, yet do not stifle private initiative - so important for
the expansion of healthcare facilities to meet growing demand. The
legislations under consideration in Andhra Pradesh and Karnataka,
and the initiative taken by Maharashtra in developing accreditation
mechanisms, deserve commendation.
Finally, each state needs to work out the problem of unqualified
practitioners with a view to their eventual elimination. The ban could
be enforced straightaway in well-served areas; in the under-served
areas, they will be gradually eliminated as alternative facilities get
established. In the interim, the registration and training of such
practitioners, limiting the scope of their use of allopathic drugs for
treating minor ailments, needs to be attempted as a temporary
measure.
6. Drug Policy and Regulations
The Indian pharmaceutical industry is already feeling the impact of
globalization, even though the WTO mandated legislation to
recognize product patents is to be brought into force only in the year
2005. The agreement on Trade Related Aspects of Intellectual
Property Rights (TRIPS) came into force with the formation of the
XXXV
World Trade Organization (WTO) in January 1995. TRIPS obliges all
developing countries to make available 20 year patent protection for
novel, non-obvious and useful inventions, whether products or
processes, in all fields of technology including pharmaceuticals.
Violations of TRIPS obligations can lead to trade retaliation or
compensation to affected WTO members. India has so far recognized
only process patents in pharmaceuticals, and legislation for
compliance with WTO obligations is pending passage in Parliament.
As of December 1999, only-16 WTO countries, including India,
continued to exclude pharmaceuticals from product patent protection.
India has no option but to fall in line; but the government should
actively explore ways in which the advantages of the new regime can
be maximized and the disadvantages minimized.
The public policy question will have to be resolved in such a way that
a balance is maintained between the need to keep new drugs
affordable to those who need them, while retaining strong incentives
for the invention of new drugs and the development of new and
better treatments. The selective use of compulsory licensing
provisions for the manufacture of generic substitutes for patented
drugs having major public health significance has to be explored with
international cooperation. So far, the Indian pharmaceutical industry
has paid scant attention to research because of the absence of
product patent protection, and concentrated its energies on
producing generic substitutes for foreign patented and branded
products. But the Intellectual Property Rights Regime (IPR) is set to
change with the introduction of product patents in conformity with
WTO mandated regulations. The Indian pharmaceutical industry
already commands a major advantage over its rivals in the West
since the cost of bringing a new chemical entity into the market is
estimated at $250-500 million in the US, but only $90-100 million in
India. According to a recent study by the Administrative Staff College
of India (The Indian Pharmaceutical Industry, May 2000), “India has
the potential to become the hub of pharmaceutical research.” In
order to harness the resources and skills of the Indian
pharmaceutical industry towards the neglected diseases of the poor,
the government needs to develop an appropriate incentive
framework.
At present, the administration of drugs and pharmaceuticals is
divided between the Ministry of Chemicals and Fertilizers (MCF) that
is responsible for drug policy; and the Ministry of Health and Family
Welfare (MHFW) that sets standards and deals with quality control,
the introduction of new drugs and the enforcement of relevant laws
and regulations. This arrangement prevents the government from
taking a holistic view that includes the interests of both the industry
and the consumer. Often, the policy of one ministry is at cross
purposes with that of the other. As early as 1975, the J. L. Hathi
xxxvi
)
Committee recognized this dichotomy and suggested that an
independent National Drug Agency be set up to take over all the
drug-related functions performed by the two Ministries. The proposed
NDA could be supported by a small cess on the manufacture and
import of pharmaceuticals, conveniently collected along with excise
and customs duties. Significant public sector support would be
necessary to motivate the pharmaceutical industry to invest in R&D
• in diseases of the poor such as TB and malaria, and the proposed
National Drug Fund could provide one such avenue of support. The
current situation is unlikely to improve merely by tinkering with the
existing system. The only option that would make a noticeable
difference is an independent National Drug Authority, supported by
adequate financial resources from the National Drug Fund.
Elsewhere
in
the
Report, we
have
recommended
greater
decentralization and devolution of powers to the states. However, the
indiscriminate licensing of drugs by the states, the poor enforcement
of quality standards, and the open violation of laws regarding sale of
prescription of drugs, compels us to suggest an enlarged role for the
central authority. The proposed NDA, armed by a new law that
provides for more stringent scrutiny before licensing, could weed out
irrational combinations and ensure stricter enforcement. The
National Drug Fund should be used primarily to support the NDA,
upgrade public health laboratories, and strengthen the enforcement
machinery. The unauthorized and irrational use of anti-microbials by
unqualified practitioners and registered practitioners of other
systems of medicine, a situation encouraged by the free sale of
prescription drugs across the counter, has been a major factor in the
development of drug-resistant bacteria. Similarly, the proliferation of
over 20,000 manufacturers without the requisite infrastructure to
monitor GMP, and the large-scale manufacture and sale of sub
standard and spurious drugs, pose -a major health hazard. Only
stringent laws that are effectively enforced can check these
problems.
7.
Health Research
India has great potential and unique capabilities in health research.
Its acknowledged strengths in all knowledge-based activities, its
infrastructure and trained manpower, its vast clinical material, rich
bio-diversity, unparalleled heritage of traditional systems of medicine
and a dynamic and technologically capable pharmaceutical industry
all add up to this potential. But only a national health research policy
that creates an incentive environment for both public and private
sectors will help the country realize this potential to the fullest.
Timely enactment of IPR related legislation would bring the present
phase of uncertainty to an end. Next, a substantial increase of public
investment in basic and strategic research is required, with a specific
xxxvii
focus on the neglected diseases of the poor. The international
support for health research has so far been nominal — the estimate is
5% of the total health R&D expenditure in 1992-93. Indian potential
in this area justifies a major increase in external assistance. A
priority should be health policy and systems research, to date a
neglected area except for the recent interest shown by the World
Bank and some bilateral donors.
The lack of available expertise in disciplines such as health
economics, health finance and epidemiology is a major constraint on
health policy and systems research, and special efforts need to be
made to train researchers in these fields. Research capacity should
be strengthened - with the improvement of infrastructure, the
training of scientists, and through new collaborations with institutions
in the North and the South.
In particular, capacity needs to be
developed quickly to undertake clinical trials for new molecules likely
to be introduced for the various communicable diseases. Existing
public sector institutions could produce higher quality of research
with more appropriate management structures. Most important, for
both public and private sectors, is a network of alliances among
academia, research institutions and industry. The utilization of basic
and strategic research outputs by industry to take the process further
toward product development should be the goal of such an alliance.
The ICMR should develop suitable mechanisms to facilitate such an
alliance, and the inter-mediation between research outputs from
academia and research institutions, and the pharmaceutical industry
along the lines of TDR in WHO. It is also essential to establish
institutional mechanisms that will promote interaction between
policymakers and programme managers on the one hand, and
researchers on the other, for setting the research agenda and for
utilization of research outputs.
8. Indian Systems of Medicine (ISM)
The term ISM comprises six different systems - ayurveda, siddha,
unani, yoga, naturopathy and homeopathy - out of which only
ayurveda, siddha and yoga are entirely indigenous. India has a rich
heritage in ancient systems of medicine that make up a veritable
treasure house of knowledge, and these systems can make a
significant contribution to the healthcare of the population. But
despite a vast parallel infrastructure of hospitals, dispensaries and
teaching institutions, and over 6,00,000 registered practitioners, this
potential has not been realized. Over 90% of illness episodes are
treated by allopathy. Even registered practitioners of ISM treat
patients with modern drugs though they are not authorized to do so,
often with undesirable consequences. The failure to evolve the
synthesized national system recommended by the ICSSR/ICMR
Committee has prevented the use of even proven ISM remedies in
xxxviii
)
public healthcare facilities. Also, the vast army of ISM manpower
has rarely been utilized for public health programmes. The failure to
evaluate traditional remedies scientifically has prevented their wider
acceptance in India as well as abroad. What is most important is for
ISM to develop its strengths in providing relief in apparently
incurable chronic ailments such as digestive disorders, asthma and
arthritis. At the same time, ISM needs to popularize preventive
practices such as yoga, which could be an important element in the
strategies being evolved to cope with the threat of NCDs. Some
recent initiatives of the new Department of ISM seem to address
these deficiencies; but on the whole, this area requires priority
attention to explore and realize its full range of possibilities.
9. Conclusion :
The above analysis clearly underscores the need for a quantum
jump in the public investment for health, accompanied by wideranging reforms at every ^evel. This can be achieved only with
strong political will and commitment, which can in turn be generated
only through a strong people’s movement cutting across party
affiliations. The first step is better awareness and the widest
possible dissemination of information on health issues. It is only
vigorous informed debate on health issues — in Parliament, in the
state legislatures, in the media, and in various public forums — that
will eventually grow and gel into a broader people’s movement. It is
in the context of this long and complex process that this Report
seeks to identify, describe and analyze the current issues in Indian
health and the future directions of change.
III.
Future Directions: Summary of Recommendations
1.
Communicable Disease Control:
•
Acceleration of India’s epidemiological transition by vigorous
public policy to control communicable diseases; malaria control
to focus on those areas with an API above 2; rapid expansion of
DOTS so that the entire country is covered for TB control.
• Substantial increase of central funding without stipulation of
matching contribution by the states.
• The central government to consider a more direct intervention in
actual implementation, if necessary through trained personnel on
contract in weak performing states; in well performing states,
release of block grants against certain clearly defined
deliverables to provide greater flexibility in the implementations
of the programmes.
• Establishment of a comprehensive disease surveillance system in
all districts with central funding for a period of ten years.
xxxix
and sustained efforts to prevent the spread of
nIV/AIDS, with focus on IEC and interventions involving high risk
population following the example of Tamilnadu; simultaneously,
arrangements for medical care of AIDS patients through clinical
training in treatment protocols and sensitization of health workers
on HIV/AIDS patients.
• Strengthening of the health system in high malariogenic areas,
particularly tribal regions, for early detection and prompt radical
treatment to reduce the reservoir of infection.
• Development of treatment protocols and regulations for co-opting
the private sector in communicable disease programmes; this
may include continuing medical education and active participation
of professional bodies like the IMA.
2. Facing the Rising Threat of NCDs:
Identification of a menu of q:vre comPonen^s to provide an
‘essential package’ of chronic ci.are with possible extension to an
‘optimal package’
• Integration of these services into various levels of healthcare.
• Development of evidence-based, context-specific and resource
sensitive clinical practice guidelines that can be integrated into
various levels of healthcare to facilitate the use of low-cost, highimpact interventions.
• Modification of the training of healthcare providers of diverse
categories to enhance skills relevant to chronic disease
prevention, surveillance and management.
• Sequential prioritization of ‘essential’ elements for early
implementation and ‘optimal’ elements for later integration.
• Vigorous efforts to control risk factors by sustained health
education, community participation and legal action with regard
to tobacco and alcohol.
•
3. Reduction of Infant and Maternal Mortality:
Targeting of high IMR states first, and within states, high IMR
districts and regions; all CHCs and 24-hour PHCs in high IMR
districts and regions to be fully equipped to handle basic newborn
care and referral.
• Focus on the disadvantaged and poorest groups; trained CHWs
to be located in identified remote regions with a large proportion
of disadvantaged groups such as Scheduled Tribes for the
delivery of essential MCH services.
• Arrangements to effectively screen and identify all high risk
cases, and ensure their deliveries in appropriately equipped
health facilities; in general, promotion of institutional deliveries
by providing appropriate facilities and incentives including
emergency transportation.
•
xl
)
>
)
•
•
Strengthening antenatal ca'e by screening every pregnant woman
for anemia, hypertension, diabetes, urinary and reproductive tract
infections, malaria, and TB.
Convergent action at the cutting edge level between health
personnel and anganwadi workers for ensuring full coverage of
child health services.
4. Finance:
Public health expenditure to be more than doubled to raise the
level of public investment from the present 0.9% of GDP to at
least the level of the average of lower middle-income countries
(2.2% GDP); additional resources to be mobilized largely through
dedicated levies to avoid competition from other sectors and to
provide increasing and sustainable funding.
• Increase of allocation for public health and primary and
secondary healthcare that is better utilized by low-income
families.
• Differential planning and deployment of budgets in line with the
extent of disease burden, economic backwardness of the
state/region and poverty levels; the government to bear a special
responsibility to ensure good quality care through appropriate
incentives and strengthening of facilities in backward and poorly
developed areas/states, since public sector facilities may be the
only facilities available.
• Utilization of user fees at secondary and tertiary levels to reduce
the
price advantage of public
services,
reducing their
attractiveness to the affluent and simultaneously making
arrangements for exemptions of the poor.
• Setting up of systems of social insurance such as Sickness
Funds to provide financial risk protection to the poor against
serious illness and hospitalization.
• Coverage of employees in the formal sector with social insurance
primarily financed by employer and employee contributions;
social insurance to replace low coverage existing schemes,
especially in the low-income formal sector, with services
contracted out to enhance efficiency and reduce costs.
• Package of incentives to encourage NGOs to develop community
finance schemes in designated areas, with the government
contributing a fixed premium for every BPL family covered by the
scheme.
•
5. Health Systems:
•
Restructuring of Central Ministry of Health and Family Welfare so
that it withdraws from day-to-day management and concentrates
on its stewardship role by strengthening its planning, analytical
and public health expertise.
xli
H
•
Restructuring of the health systems of the states based on three
principles: (i) decentralized authority, responsibility and decision
making; (ii) integration of preventive, promotive and curative
services; and (iii) local community participation.
• Removal of identified constraints and inadequacies at the primary
healthcare level to improve their efficiency and utilization, and
reducing the load on over-utilized hospital services by providing
essential
drugs,
consumables
and
diagnostics,
making
arrangements for proper maintenance of facilities, and removing
constraints on mobility of health personnel.
• Addressing manpower shortages by an appropriate combination
of incentives, legislative measures, and management reforms:
reservation of PG seats for those candidates in service with a
record of rural service; making rural service compulsory for
admission to PG courses; contractual appointments to fill
vacancies; a transparent transfer policy that requires every
doctor to work in rural areas by rotation for a prescribed period;
preference for foreign training given to doctors with rural service
records; better residential facilities, rural service allowance;
allowing private practice only in under-developed areas where
even private facilities are inadequate.
• Mapping the availability of health facilities in hilly regions and
areas inhabited by tribal populations; the provision of mobile
health teams and community health workers to cover identified
gaps.
• Decentralization and devolution of powers to local authorities
after careful preparation and adequate training.
• Delegation of administrative and financial powers to medical
facilities to be exercised through local committees to promote
efficiency, accountability and mobilization of resources.
• Institutionalization of coordination arrangements at different
levels.
• Involvement of community self help groups and women’s groups
for people’s participation in health programmes.
• Institutional arrangements for regulating the private sector with
the participation of all stakeholders to set and enforce standards,
control unethical practices, and ensure transparency of charges
and non-denial of emergency care.
• Development of capacities for contracting out services to the
private sector; promoting new partnering initiatives with the
private sector for service delivery and management of public
institutions.
• Development of an incentive package for the voluntary sector to
set up facilities in the identified under-served areas.
• Promotion of accreditation networks for identified services
through voluntary organizations/professional bodies.
xlii
)
)
•
Elimination of unqualifiec practitioners in
beginning with well-served areas.
a
phased
manner,
6. Drug Policy and Regulations:
•
•
Creation of an independent National Drug Agency to take over all
drug-related functions, supported by a National Drug Fund
financed by a small cess on the manufacture and import of
pharmaceuticals; institution of a more stringent law to deal with
the proliferation of sub-standard manufacturing units and
irrational fixed dose combinations, poor laboratory facilities, sub
standard and spurious drugs, weak enforcement machinery, and
open violation of law by chemists selling prescription drugs over
the counter.
Selective use of compulsory licensing to produce generic
substitutes for patented drugs of public health significance, and
to provide the necessary incentives and financial support to
pharmaceutical companies for the same.
7. Health Research:
•
Development of a health research policy to create an incentive
framework to promote research, particularly on the diseases of
the poor.
• Higher investment in development of infrastructure for basic and
strategic research in the public sector, with changes in the
management structures to promote quality research outputs.
• Development of alliances among academia, research institutions
and the pharmaceutical industry to promote the utilization of
research leads by the industry for product development; ICMR to
develop capacities for such inter-mediation on the lines of TDR in
WHO.
• Emphasis on health policy and systems research and reducing
the deficiency of researchers by providing training avenues in
epidemiology, health finance and health economics.
• Creation of an incentive environment for the pharmaceutical
industry to invest in research through tax concessions, pricing
incentives for new molecules, facilitating clinical trials and
regulatory approvals, and supporting promising products for the
neglected diseases of the poor with financial support from the
National Drug Fund.
xliii
8. Indian Systems of Medicine:
•
•
•
•
•
Development of a national health system incorporating the best of
all systems; including proven remedies of ISM as first drugs of
choice in the public healthcare system.
Encouraging scientific evaluation of traditional remedies.
Utilization of ISM manpower in public health programmes.
Emphasis on the special strengths of ISM in treating chronic
ailments such as digestive disorders, asthma and arthritis.
Popularizing ISM practices such as yoga to prevent and treat
NCDs.
xliv
I
1
Introduction
I
Background
The Commission for Macroeconomics and Health (CMH), appointed by the
WHO in September 2000, held its second meeting in Delhi in April 2000.
This meeting devoted a full day to the Indian experience in the health
sector. Detailed presentations were made by the states of Kerala, Andhra
Pradesh (AP), Karnataka, and Rajasthan. Taken together, they brought
out the diversity of the socio-economic conditions, health outcomes and
approaches in different parts of the country. It became apparent that this
diversity, coupled with the relatively high quality of available data and
standards of research, would enable India to make a significant
contribution to the CMH exercise. The Chair of CMH explored funding
possibilities for an India Study focused on the terms of reference of CMH
(Annex 1.1). A proposal (Annex 1.2) was sent to the Bill and Melinda
Gates Foundation in October 2000, which was approved in December
2000, paving the way for this study.
Scope and Objectives
The original intention was to study areas of relevance to CMH. But
confining the study to a background paper for CMH would have also
meant limiting interest among Indian policymakers. A comprehensive
study of the Indian health sector had not been attempted since the 1946
Shore Committee, and the support of the CMH and the Foundation
provided a great opportunity to fill in this gap. Also, a new National Health
Policy was being formulated, and a broader study of interest to
policymakers could make a contribution to this process. Thus the present
study was designed to cover the CMH terms of reference as well as all
areas relevant to the ongoing health policy exercise.
The basic objective of this Report is to study the diverse experiences
of Indian states - with their varying socio-economic and cultural
settings, health systems and status - and draw lessons relevant to
the CMH and Indian policymakers at both central and state levels. The
Report is a country-specific study with an international dimension; it
addresses the Indian health establishment for nationally relevant issues,
and the CMH for lessons of global significance.
Focus
Though the study began with a broad mandate, it was soon apparent that
an in-depth examination of the entire range of issues was impossible
1
within the limited time framework of the Report. The focus was then
sharpened to health systems in the broadest sense of the term. WHR
2000 defines the health system “to include all the activities whose primary
purpose is to promote, restore or maintain health.” Thus the study pays
maximum attention to analyses of the health system’s operation in both
public and private sectors. A major effort has been made to examine the
financing mechanisms of the health system and their reform to provide
financial risk protection to the poor. Given widespread poverty and huge
income disparities, equity of access to health facilities has received
special emphasis. The core area of the Report - health systems includes both health finance and equity.
Methodology
)
The Gates Foundation gave the study a year to complete its work. But it
was conducted in less than six months so that its findings and
recommendations would be ready in time for the draft of the CMH report in
August 2001. Obviously this imposed limitations on the study’s
methodology. It ruled out collecting new data or conducting field surveys,
so that the analyses instead drew on existing literature and data. The
study
received
considerable
support from the ongoing
studies
commissioned by the World Bank in collaboration with the Government of
India (Table 1.1). In particular, the first five studies and the synthesis
report, India: Raising the Sights - Better Health Systems for India’s Poor,
(2001), were made available by the World Bank. The Bank document
covers much the same ground as this report, with two significant points of
difference.
•
•
1
Wider Scope: This Report covers all critical aspects of the health
sector.
Feasible Solutions: Going beyond the identification of problems
and the examination of available options, this Report suggests
workable solutions, supported by the insights of those who have
hands-on experience in the management of the Indian health
system.
The study commissioned 19 papers, including intensive studies of the
health systems of eight states: Andhra Pradesh (AP), Kerala, Madhya
Pradesh (MP), Maharashtra, Orissa, Rajasthan, Tamilnadu (TN), and Uttar
Pradesh (UP). The result is a wide spectrum of experiences, ranging from
top performers (Kerala, TN), to good performers with significant recent
success (Maharashtra, AP), to relatively poor health outcomes (UP,
Rajasthan, MP, Orissa). These reports are brought together in the chapter
on health systems, which examines the strengths and weaknesses of the
Indian public health system.
1
2
u
Table 1.1
Studies of the Indian Health System 1999-2000
Title of Study
Main Research Question
Private Market Analysis
How can India take advantage of the
private sector to meet social goals?
Distribution of Health Benefits and
Costs
How well do public and private
investments in health reach the
poor?
Pharmaceutical Analysis
How can safe, effective, affordable
drugs be made accessible to
Indians?
Consumer Protection in Health: Legal
Framework and Current Practices
How can consumers be more
empowered over health issues?
Health Financing Options: Health
Insurance
How can health insurance be used to
improve equity and efficiency of
health services?
Quality of Health Services
How can India systematically
improve quality assurance in
healthcare?
Hospital Reorganization (financed by
How can hospitals be organized to
DFID)
_______________________ meet sectoral goals?_________________
Source: India: Raising the Sights - Better Health Systems for India’s Poor, World Bank.
2001
Structure
Chapters: Volume I of the Report comprises the executive summary and
the chapters. Volume II contains appendices,. Chapter 2 presents an
overview of the current health scenario in India, the major issues and
challenges. Chapter 3 delineates the roles of the federal government and
the states in health, in the background of the ongoing liberalization
process and economic reforms. Chapter 4 directly addresses the first TOR
of the CMH - linkages among economic growth, poverty and health. On
the strength of international experience and Indian data, improvement in
health status is established as a significant factor in economic growth and
poverty alleviation. Chapter 5 is concerned with the central issue of
equity, presenting evidence of gross inequities in health status and
access to healthcare facilities, and suggesting policies geared to narrow
these disparities. Chapter 6 examines the private sector in health as it
has evolved in India. Chapters 7 and 8 take on the unfinished agenda of
communicable diseases, and maternal and child health, highlighting the
avoidable burden of morbidity and mortality. Given the gravity of the
HIV/AIDS threat, Chapter 9 examines it apart from other communicable
diseases. Chapter 10 considers the future challenges of non3
communicable diseases, trauma and injury - likely to contribute
increasingly to the burden of disease in view of the changing demographic
and epidemiological profile. Chapter 11 deals with health finance, both
public and private, including mobilization of additional resources. Chapter
12 supplements this discussion with the role of external assistance.
Chapter 13 presents a synthesis of studies of public health systems
conducted in eight states. Chapter 14 deals with Indian systems of
medicine, their present role and future direction of development. Chapter
15 deals with drug policy and regulations, as well as the impact of the
WTO-mandated intellectual property regime on drug prices in India.
Chapter 16 focuses on health research and its potential. It addresses an
important CMH concern (TOR 2), making a case for India’s potential to
develop improved tools for health delivery to the poor, given the
appropriate policy framework.
Appendices: The
Report contains six appendices. Appendix 1,
Restructuring the Ministry of Health and Family Welfare, is based on
the assumption that a reorganization of the Ministry of Health and Family
Welfare (MHFW) should spearhead a meaningful reform process.
Appendix 2 reproduces the background paper of Indrani Gupta et al on
Economic Growth, Health and Poverty, which is summarized in Chapter
4. Appendix 3 traces the evolution of health policy in India, offering
causes of present deficiencies and guidelines for future policy
formulation. Appendix 4 provides additional information about the ancient
system of medicine, ayurveda. Appendices 5 and 6 are detailed studies of
health systems in AP and Kerala. Both cases are unique, the former for its
dynamic political leadership, and the latter for its outstanding
achievements.
Conclusion
Given the diversity of Indian experiences, the study recommendations
cannot be prescriptive. Instead they suggest broad directions of reform steps that must be taken if we are to address the wide-ranging distortions
and deficiencies in the health system. These conclusions and
recommendations will hopefully generate informed debate on health
sector reform in India, while contributing to the CMH examination of global
issues.
4
d
Annex 1.1
Commission on Macroeconomics and Health
Terms of Reference
The WHO established the Commission on Macroeconomics and Health (CMH) to
critically assess and extend, where appropriate, the evidence base of the following
topics:
•
the nature and magnitude of the economic outcomes (income and productivity
growth, poverty reduction and social protection) of investing in health;
•
the economics of incentives for research and development for drugs, vaccines and
other technologies that address diseases primarily affecting the poor;
•
effective and equitable mobilization of resources (including reallocation of current
public budgets) to finance control of major and specific health problems of the
poor, and to develop and sustain health systems more generally;
•
health and the international economy, particularly trade-related issues;
•
costs and efficiency in the use of resources to improve health outcomes of the
poor, including consideration of interventions and policies within and outside the
health sector; and
•
development assistance and health (including consideration of efficiency in the
use of assistance to improve health and debt relief and external assistance for
international public goods).
1. The CMH may add topics and it may choose to exemplify its findings with disease,
country or regionally specific analyses. It will draw on and contribute to ongoing
initiatives elsewhere.
2. The CMH will provide analysis to assist the WHO and the international community
in their consideration of issues relating to health and development in low- and
middle-income countries. Thus it is foreseen that the results of its work will be
published by WHO and widely disseminated.
3. The CMH is intended to include macroeconomists from academia, governments and
agencies. It may, in addition, include a health economist, a public health
specialist, a biomedical scientist and a current or former health minister. Members
will serve in their personal capacities but those from governments or agencies may
designate alternates for some meetings. The Director-General of WHO will appoint
the members and Chair of the CMH.
4. The CMH will complete its work by December 2001, unless the Director-General of WHO authorizes
a later date.
5
u
Annex 1.2
Proposal for ar, India Study for CMH
Rationale
The principal objective of the CMH is to address a wider audience of policymakers on
the important contribution that investmerrs in health can make in ameliorating poverty
in developing countries. C
CMH is not onsy expected to argue for higher investments in
health but to make specific recommercations on )where
'
and how they, should be
directed to achieve optimal results. Ar important element of this exercise is the
identification of policies and systems most likely to succeed and those best avoided.
The wealth of experience available globally can guide CMH in this endeavour. But
there are, in most cases, a host of variable factors contributing to the success or
failure of any health investment, and it is not easy to isolate the key elements, given
the variety of factors influencing the outcomes.
Admittedly, wide differences exist globally among developing countries, and what is
good for one country may not work in another setting. Yet it seems possible to cull out
from past experience valuable lessons with universal significance and validity, based
on an in-depth study of a country as large and diverse as India, where health
outcomes vary from levels comparable to middle-income countries at one end, to
levels of Sub-Saharan Africa at the other. The country offers a wide range of
experiences from totally state dominated health systems to a flourishing and
increasingly important private sector. Not only does India nave large numbers of the
poor, it also bears the highest aggregate disease burden -- with a significant
contribution coming from infectious diseases, the central problem in the poorest
countries. The India Study could provide interesting insights into the complex issues
being considered by CMH, while making a valuable contribution to the process of
policymaking at a time when the national health policy is under review.
Objectives
The objective of the study is to provide the CMH with important inputs on the entire
range of issues covered by its terms of reference, through in-depth study and analysis
of the large variety of experiences in different states. A useful, and not in anyway
less significant, spin-off of this report would be the contribution it could make to the
current health policy formulation exercise of the Indian Government. The National
Health Policy of 1983 is presently under review by the national government. India thus
provides an ideal laboratory to test the validity and feasibility of various policy options
for developing countries.
Focus
While the report will attempt to cover the range of issues being addressed by the
CMH, the focus will be on key issues of major concern both to CMH and the Indian
government. Examples include the mobilization of resources for health from both
domestic and external sources; the enhancement of allocative and technical
efficiency, the improvement of access and equity for the poor; the definition of the
respective roles of the public and private sectors and the evolution of policies and
instruments for their synergistic development; responses to new challenges like
globalization, changing demographic and disease profiles and new epidemics such as
HIV/AIDS. In particular, it will try to examine sustainable and affordable options for
financing health care for the poor - by far the biggest challenge faced by
policymakers in developing countries.
Methodology
The study will be launched with a conference of representatives of all the 14 major
states presenting their experiences of and responses to major policy and health
systems issues and challenges. The conference will conclude with identification of key
issues for study, and selection of 3 or 4 states for intensive work. The states will be
6
identified keeping in mind the need to cover diverse conditions and circumstances as
well as the responsiveness of the state administrations.
Following the conference, researchers will be identified t_
: analyze key
to address and
issyes in the selected states with the fullest participation of state governments, local
bodies and civil society. No
I
new field study is proposed and the attempt will be to
draw lessons from-the analysis of existing data and studies, a broad range of
consultations and field visits.
It is difficult at this stage to fix the number of studies but it should be confined to 4 or
5. The study reports will be presented at another conference of state health
representatives where they will be discussed thoroughly. The draft report of this study
will be prepared on the basis of these deliberations, and the report given its final
shape in consultation with the national government, CMH members, and international
and donor agencies.
Participants
The national and state governments wouid need to be closely involved with the study.
Key inputs will also be provided by CMH members, co-chairs of working groups and
international agencies such as the WHO and the World Bank. Wide-ranging
consultations will also be organized with civil society representatives actively involved
in health issues.
Time Frame
The total time framework proposed for the project is six months beginning November
1. 2000. The tentative schedule is as follows.
I
1.
Identification of key issues
November 1-15
2.
Conference of state representatives
November 1 5-20
3.
Selection of states and researchers
November 20-30
4.
Working out TORs for the studies
December 1-10
5.
Papers from the studies due
March 1 0
6.
Consultations with states and
field visits
December 1 0 March 1 0, 2001
7.
Preparation of the draft report
March 10-31, 2001
8.
Conference of state representatives
April 1-5, 2001
9.
Drafting of final report
April 5-30, 2001
Since the most complex and challenging issue is financing healthcare for the poor,
and since sufficient expertise is not likely to be available within the country, an
internationally renowned expert such as Professor Bill Hsiao could provide guidance
for this aspect of the study. Needless to say, the CMH members, the co-chairs of
working- groups,
. > and other international experts associated with the CMH, are
expected to contribute handsomely to this exercise, <and impart an international
perspective to the study though it is confined to one country.
Conclusion
The Report will be based on lhigh-level
_‘
research and policy consultations, and is
expected to provide inputs and insights to the CMH on a range of important issues. It
should also assist the national government in the review of the National Health Policy
- through the final report as well as through the earlier process of mutual consultation
7
and interaction with key players. The Report will present to the CMH analyses of
Indian experiences on a variety of healtr related issues with global relevance. To
national policymakers, it will offer a study of the Indian health sector with an
international dimension, providing valuable inputs into the current health policy review
exercise from a new perspective.
8
2
The Current Health Scenario: An Overview
Background
Writing about India is always a formidable challenge. With its endless
diversity - of population, climate, topography, religious beliefs, languages
and socio-economic and cultural settings - generalizations become
difficult. Attempts at aggregations mask the wide differentials between and
within the different regions. On the one hand, India has its rich heritage,
brain power, entrepreneurial genius and vibrant democratic polity; today, it
aspires to be an IT superpower. On the other hand, over a quarter of its
population live in absolute poverty, and the country has the largest
population of illiterates. The paradox is that different parts of India seem
to live in different ages. This gap between India's acknowledged potential
and its achievements has attracted comment from scholars around the
world.
Demographic and Health Indicators
The health scenario also reflects this diversity in ample measure. Among
the demographic and health indicators of 16 major states (Annex 2.1),
Kerala compares favourably with most middle-income countries (1) and
even some high-income countries in West Asia. But MP, Orissa, Rajasthan
and UP are well below the average of low-income countries, and just
above the levels of Sub-Saharan Africa (Annex 2.2). Together the different
states represent the whole range of health outcomes within these two
extremes. The indicators conceal the wide disparities existing within the
states - between urban and rural areas (Annex 2.3), and between
relatively developed areas, and remote areas inhabited by tribal and other
marginalized groups. While metropolitan cities have what would be
considered modern tertiary care facilities by international standards,
people in many remote rural areas do not even have access to primary
care. These disparities do not allow India to be placed in any well-defined
category.
Among the Indian states, the remarkable success of Kerala has been
attributed to historical factors contributing to high literacy and women’s
empowerment. But recent experience in TN, AP and West Bengal suggests
that significant improvement is possible without accompanying progress in
literacy and gender equality. Despite the disparities among the states,
however, there are strong common features as well. All the states have
followed more or less the same development and administrative model,
and thus their health systems exhibit, in varying degrees, the same
strengths
and
weaknesses.
This
common
thread
facilitates
generalizations, though the extent of their application varies from state to
state.
9
India and the World
India’s health indicators are almost at the same level as the average of
low-income economies (Annex 2.2). But with per capita income as the
benchmark, India is at the level of Sub-Saharan Africa (Annex 2.4). India
seems to have performed better in comparison with countries at the same
level of per capita income; but obviously this comparison is unfair and
misleading. With its knowledge base, its administrative and institutional
strengths, and its growth potential, India is capable of much higher levels
of achievement. Comparing India with countries with similar health
outcomes and growth potential in the 1960s (Annex 2.5), seems more
appropriate. A comparison with China, Brazil, Indonesia and Thailand for
under-5 mortality and Crude Birth Rate (Figure 2.1), indicates a lower rate
of progress despite initial advantages. India compares unfavourably even
with low-income countries in terms of availability of health infrastructure
and its utilization, as well as the overall disease burden (Tables 2.1 and
2.2). The combined factors of population and unsatisfactory health status
also accounts for India’s substantial contribution to global health problems
(Table 2.3). The same trends are apparent in poverty reduction,
sanitation, access to safe drinking water and literacy - all important
determinants of health status (Annex 2.6). Though the proportion of the
population below the poverty line has declined from 36% in 1993-94 to
26.10% in 1999-2000 (2), the overall picture indicates that social
infrastructure in India has remained relatively neglected.
Figure 2.1
Under-5 Mortality and Crude Birth Rate: A Comparison
CRUDE BIRTH RATE CHART
UNDER - 5 MORTAUTY RATE CHART
300.0
50.0
Brazil
45.0 »•
g 200.0
-•-China
| 35.0 ;-
£ 150.0
-A- India
250 0
LU
Braal
40.0 ■
<
h-
Ch na
X 30.0 la
- 25 0
India
CQ
K 1000
zo
-e-Indonesia
g 20.0 F -
-e- Thailand
5 150 "
50.0
Thailand
0.0
1960
1970
1960
YEARS
1995
10.0
• Indonesa
5.0 i—0.0 —
1965
1988
1970
1995
YEARS
Source; Health, Nutrition and Population Indicators, A Statistical Handbook,
Development Network, Health, Nutrition and Population Series, World Bank, 1999
10
Human
J
Table 2.1
International Comparison of Health Manpower and Hospital Beds, 1990-1998
Physician per
Nurses per 1000
1000 population
population
Indian public sector
India total
World
Low income countries
Middle income countries
High income countries
0.2
1.0
1.5
1.0
1.8
1.8
0.9
3.3
1.6
1.9
7.5
Midwife per
1000
population
Hospital beds
per 1000
population
0.2
0.2
0.4
0.3
0.6
0.5
0.4
0.7
3.3
1.5
4.3
7.4
Note. Income category is defined by per capita GNP in 1999: low income countries < $755;
middle income countries $756-9265; high income countries > $9265. Country income averages
are unweighted.
Source: India data: (CBHI 1995 and MHFW 2000); Nurses and midwife data: WHO, 1999; All
else. World Development Indicators, 2000. Reproduced from India: Raising the Sights Better Health Systems-for India’s Poor, World Bank, 2001
Table 2.2
International Comparison of Health Service Utilization and DALYs Lost per 1000
Population, 1990-1998
Inpatient
Average length
admissions per
of inpatient stay
capita per year
(days)
(%)
Indian public sector
India total
World
Low income countries
Middle income countries
High income countries
0.7
1.7
9
5
10
15
14
12
13
13
11
16
Outpatient
visits per
capita per
year
0.7
3.9*
6
3
5
8
Disability Adjusted
Life Years Lost
(per 1000
population)
274
234
256
119
Note: Income category is defined by per capita GNP in 1999: low income countries < $755;
middle income countries $756-9265; high income countries > $9265. Country income averages
are unweighted.
** Includes all visits to health providers, regardless of system of medicine
Estimated for low and middle income countries combined
Source: India utilization data: 52nd Round NSSO (1998); DALYs: WHO, 1999; All else: World
Development Indicators, 2000. Reproduced from India: Raising the Sights - Better Health
Systems for India’s Poor, World Bank, 2001
11
Table 2.3
__________ India’s Share of the World’s Health ProbIems (in %)
People living
“
Childhood
Child Maternal
Child
vaccine
Persons
TB
Maternal DALYs
DALYs
deaths
lost
preventable with HIV cases
deaths
in poverty
Total
Population (< 1 US$/day) deaths
17
17
36
23
20
20
14
26
30
Leprosy
cases
68
Source: World Development Indicators, 2000 WHO, 1999. Reproduced from India: Raising the
Sights - Better Health Systems for India’s Poor, World Bank, 2001
Burden of Disease 1998
The above disparities are also reflected in the burden of disease (BOD)
estimates (3). The distribution of the BOD in 1998 between communicable
and non-communicable diseases and injuries in India, China, high-income,
low- and middle-income countries (Figure 2.2), highlights our failure to
control communicable diseases. These account for 50.3% of the burden
compared to 18.1% in China, and 43.8% in low and middle-income
countries. The BOD estimates of 5 states (Table 2.4) present a similar
picture; UP, for example, is almcst at the same level as Sub-Saharan
Africa in epidemiological transition. Communicable diseases account for
62% of the burden in UP, compared to 65.9% for Sub-Saharan Africa (4).
Figure 2.2
Burden of Disease by Cause - 1998
India
China
Iniunet
Non
iniufW*
Comman,cu Ole
18%
18%
CommurncaWfl
CommxncaOte
50%
33%
Non-
CommuiKible
64%
High Income Economies
InfuHM
12%
India
ConrrunicaU*
7%
NonComnvncaUa
81%
World
iHfUHM
Commamcabie
Non-
Commurwcable
43%
12
Source: World Health Report 1999, WHO, Geneva
u
Taole 2.4
Burden of Disease - India and St tes
CATEGORY
INDIA*
ANDHRA
PRADESH
KARNATAKA
PUNJAB
w
>
Category 1
50.3
54.0
56.5
53.5
56.0
62.0
O o
Category 2
33.0
30.0
28.0
29.0
28.0
26.0
Category 3
16.7
16.0
15.5
17.5
16.0
12.0
*b
WEST
UTTAR
BENGAL PRADESH
Category 1: Communicable Diseases
Category 2: Non-Communicable Diseases
Category 3: Injuries
Data from India: Raising the Sights - Better Health Systems for India’s Poor World
Bank, 2001
Source: India :: “
New Directions in Health Sector Development at the State Level, An
Operational Perspective, World Bank, February 11, 1997
Causes of Mortality 1998
Listing 10 major and specific causes of death, the mortality data for 1998
(Table 2.5) brings out the disproportionate
mortality share of
communicable diseases in India. (See Figure 2.3 for the distribution of
causes of mortality in different categories.)
Table 2.5
Top 10 Specific Causes of Death in India, 1998
(000)
India_______
% total
India / World
% of world
TOTAL POPULATION
TOTAL DEATHS
982223
9337
100
16.7
17.3
Ischemic heart diseases
Acute lower respiratory infections
Diarrheal diseases
Cerebrovascular diseases
Tuberculosis
Road traffic injury
Measles
HIV/AIDS
Tetanus
Chronic obstructive pulmonary disease
1471
969
711"
557
421
217
190
179
165
153
15.8
10.4
7.6
6
4.5
2.3
2
1.9
1.8
1.6
19.9
28.1
32.1
10.9
28.1
18.5
21.4
7.8
40.3
6.8
Source: WHO. 1999. Reproduced from India: Raising the Sights - Better Health Systems for
India’s Poor, World Bank, 2001
13
u
Figure 2.3
Mortality by Causes for India - 1998
Injuries
10%
Communicable
42%
NonCommunicable
48%
Source: World Health Report 1999, WHO, Geneva
Communicable Diseases
The break-up of BOD estimates for communicable and non-communicable
diseases (NCDs) for 1998 (Figure 2.^), indicates, that the dominant
communicable diseases are infections and parasitic diseases (49%),
respiratory infections (18.9%), and perinatal conditions (17.3%).
Figure 2.4
Burden of Communicable Diseases India - 1998
Fterinatal
conditions
17%^
Nutritional
deficiencies
8%
Maternal
conditions
6% i
Respiratory
infections
19%
' Infectious
and parasitic
diseases
50%
14
u
Distribution of Burden of Non-Communicable Diseases India, 1998
2% 3%
8%
2% //
10%
\ 2%
□ A. Malignant neoplasms
0 B. Diabetes mellitus
□ C. Neuropsychiatric disorders
6%
□ D. Sense organ disorders
1
vQ E. Cardiovascular diseases
7%
26%
□ F. Respiratory diseases
□ G. Digestive diseases
□ H. Musculo-skeletal diseases
□ I. Congenital anomalies
30%
4%
□ J. Oral diseases
□ K. Other noncommunicable
Source: World Health Report 1999, WHO, Geneva
Among the communicable diseases, tuberculosis (TB) and malaria pose a
special threat. The estimated total number of TB patients is 14 million;
around one-third of all new cases, globally, are from India. India has been
identified as a hot spot for MDR TB (5), which is difficult and expensive to
treat. The emergence of MDR TB is primarily due to inadequate treatment
and poor compliance by patients; but with India finally adopting the WHOrecommended DOTS programme (6), these conditions are being
addressed. The programme was initially delayed by the World Bank
because of procurement procedures, but it has since been expanded to
cover a population of 350 million in 2000-2001, and is expected to cover
the entire country by 2005 (7). The rapid extension and efficient
implementation of the DOTS programme is crucial in reducing the risk of a
dual epidemic of HIV and TB.
Malaria, brought down to negligible proportions in the 1960's under the
National Malaria Eradication Programme (NMEP), came back into the
picture in the 1970's with 6.47 million cases in 1976. Since then the
malaria epidemic has been contained to 2-3 million cases a year, but
worrying features persist (8). The proportion of the more dangerous
parasite P. Falciparum has been steadily rising to almost half of all cases
in 2001 (9). Also, an increasing number of reported cases indicate the
resistance of parasites to drugs, and of vectors to insecticides. The more
vulnerable North Eastern (NE) states and tribal areas are being given
special attention and financial assistance on this count.
15
u
Maternal Health
The Maternal Mortality Rate (MMR) continues to remain at an
unacceptable level of 408 per 1,00,000 live births, although there are
statewise variations (10). Among the well-documented causes of such a
level are the socio-economic status of women, the low proportion of
institutional deliveries, and the non-availability of trained birth attendants
(TBAs) in two-thirds of cases. Revamping the primary healthcare system,
with an effective referral system for dealing with complications, is
essential for the improvement of ante-natal and maternity care.
HIV/AIDS
The threat presented by the rapidly growing HIV/AIDS epidemic has not
received the attention it deserves. The long gestation period between HIV
infection and development of full-blown AIDS has led to a sense of
complacency, while the infected population continues to spread the
disease. Also, it is the opportunistic infections that get noticed; in most
cases the root cause of both morbidity and mortality remains undiagnosed.
India's high prevalence of sexually transmitted diseases (STDs) makes it
particularly vulnerable to the /MDS th-eat.
The first case of HIV in India was detected in TN in 1986. The National
AIDS Control Programme was drawn up in 1987; the National AIDS Control
Organization (NACO) was set up in 1991 after the first loan from the World
Bank was approved. The response to the programme was slow and
uneven: most people thought international organizations and interested
bureaucrats were diverting attention from more pressing health needs. The
most important contribution of the programme has been sentinel
surveillance, providing the pace and direction of the spread of infection.
Another positive fallout has been heightened awareness regarding blood
safety, detailed regulations for blood banks and attention to their
enforcement. It has also led to the phasing out of professional donors in
1998, at least on paper. The programme has now entered Phase II with
the World Bank providing more assistance in collaboration with USAID and
DFID. The awareness level, however, is still low or uneven, indicating that
IEC (Information, Education, Communication) remains a crucial element.
According to NHFS II surveys (1998-99), only 11.2% in Bihar and 20% in
UP had heard of AIDS, while some NE states, Kerala and TN show a high
level of awareness ranging from around 87% to 93%. (See Chapter 8 on
HIV/AIDS.)
On the basis of statewise HIV prevalence for 1998 (Table 2.6), the total
estimated population infected in the year 1999 is 3.09 million, with a range
of 2.47 to 3.71 million (11). Some commentators believe these are
underestimates, and that around one per cent of the adult population
(5 million) is infected (12). But by ail accounts, the epidemic is spreading
rapidly - in metropolitan as well as rural areas, through transporters and
16
migrant labour. In other words, if India is to avoid the kind of catastrophe
that has befallen Africa, far greater efforts will have to be made to keep
the epidemic at bay. Fortunately, we have a successful model in the state
of TN, which has arrested the increase in the level of infection principally
by concentrating on high-risk segments of the population, and innovative
mechanisms for the implementation of the programme.
Table 2.6
HIV Prevalence in India 1998
India/ States
Total number of HIV
infected persons
Andhra Pradesh
567.078
Assam___________
29.153
Bihar____________
114.012
Gujarat
_______
81.873
Haryana__________
34.287
Himachal Pradesh
3.318
Karnataka________
309.772
Kerala___________
169.34
Madhya Pradesh
137.814
Maharashtra_______
747.049
Orissa
44.775
Punjab___________
43.734
Rajasthan_________
50.47
Tamilnadu _______
307.994
Uttar Pradesh
108.631
West Bengal
117.081
INDIA____________
2933.736
(Figures in thousand)__________________
Source: Annual Report 1999-2000, Ministry of Health and Family Welfare (MHFW), GOI
Demographic Transition
Fertility levels have been reducing slower than in many other countries,
but the demographic transition, from high fertility/high mortality to low
fertility/low mortality, has been taking place with varying speed in all
states (Annex 2.7). According to Planning Commission estimates, the
population will increase from 934 million in 1996, to 1264 million in 2016.
These projections - based on the Crude Birth Rate and Crude Death
Rates - decline from 24.10 to 21.41, and from 8.99 to 7.48 respectively,
between the periods 1996-2001 and 2011-16. The result is that the net
growth rate of population will reduce from 1.51% to 1.39 in the same
period. This changing demographic profile has profound implications for
health planners as well as economists. The next two decades will witness
an increase in the 15-59 age group from 519 million to 800 million, with a
significant reduction in the dependency ratio. The increase in longevity
will almost double the population of the elderly (> 60 years), from 62.3
million in 1996 to 112.9 million in 2016 (Figure 2.5).
17
F cdre 2.5
Projected Peculation of India
900
800
700
600
o 500
± 400
2 300
200
100
0
2001
1996
2006
2011
2016
Source: Registrar General India, reproduced from Ninth Plan Document, Planning Commission,
India
Burden of Disease Projections for 2020
Comparing the Indian distribution of communicable and non-communicable
diseases and injuries to that of China, established market economies and
Sub-Saharan Africa (Figure 2.6), the BOD projections for 2020 reflect the
same trends (13). The proportion of communicable to non-communicable
diseases is expected to almost reverse between 1998 and 2020, with the
former dropping from 50.3 to 24.4%, and the latter rising from 33 to
56.5%. But China is expected to have a communicable disease burden of
just 4.3% in 2020, not only less than the 7% estimate for industrialized
countries in 1998, but also lower than their 5% projection for 2020.
Figure 2.6
Burden of Diseases - 2020
China
India
InjunM
19%
16%
CorrmnciO*
Non|
Commuracabie
57%
’Communeabie
24%
World
NonConmnctble
80%
EME
InjurtM
20%
Non|
Communcabte
60%
'Communfc«b4*
20%
Source: Health, Nutrition and Population Indicators - A Statistical Handbook,
Development Network, Health, Nutrition and Population Series, World Bank, 1999
18
Human
The implications of this transition are as follows:
•
high priority to the control of communicable diseases to avoid
the double burden of communicable and non-communicable
diseases (NCDs);
•
strenuous and sustained efforts, including the use of yoga and
naturopathy, to control the risk factors for NCDs caused by
tobacco, alcohol and unhealthy lifestyles;
•
the equipment of peripheral health institutions for early
diagnosis of chronic NCDs and referral to secondary level
institutions for treatment; and
•
the development of cost-effective interventions, including
equipment and training support, to deal with NCDs at the
peripheral level.
The epidemiological transition is likely to affect the poor more for two
reasons: their exposure to the major risk factors - tobacco and alcohol is greater (Figure 2.7); and they lack the resources for the prolonged,
expensive treatment many NCDs require.
Figure 2.7
Prevalence of Smoking, Tobacco, and Alcohol Use in India by Income
Quintile 1995-96
Richest
20%
1
60%-80% L
I
[
J
□ Smoking
i
Middle 20%
3 Tobacco
□ Alcohol
20%-40%
Poorest
20%
0
5
10
15
20
25
Percentage with regular use
Source: NSSO, 1995-96, reproduced from India: Raising the Sights - Better Health Systems
for India’s Poor, World Bank, 2001
Given
the
state-wise
differentials
in
demographic
transition,
epidemiological transition also progresses at varying paces in different
states. While Kerala and TN may be ripe for a shift of focus of the public
health system to NCDs, other states may need such a change of emphasis
only when they reach that stage.
19
Key Factors Influencing Health Outcomes
Poverty, literacy and fertility are the three interlinked key areas that
influence
health
outcomes,
and
Indian
performance
has
been
disappointing on all three fronts. A comparison with China reveals striking
differences. The population below the poverty line is estimated at 26.1% in
India and only 6% in China. Similarly, illiteracy rate is just 9% for males
and 25% for females in China, compared to 24% for males and 46% for
females in India. The TFR in China is 1.9 as against 3.2 in India (Annexes
2.6 and 2.7). Thus poverty is both a cause and a consequence of poor
health. It is true that some states, such as TN and AP, have shown
significant improvement in some demographic indicators without a
corresponding rise in literacy. But the link between poor literacy levels,
and a lack of awareness and poor health status, is well established. So is
the impact of high infant and child mortality on fertility. The risk of loss of
children is the biggest impediment to limiting the number of childbirths,
particularly when offspring are viewed as the only available social
security.
Gender Disparity
The reportdfc decline in the sex ratio dunng the last century has been a
legitimate cause for concern. The results of Census 2001 indicate that this
trend has been arrested, and indeed, marginally reversed. However, the
further decline in the sex ratio in 0-6 age group is a cause for serious
concern. But international comparisons (Figure 2.8) demonstrate the still
unsatisfactory situation (Figure 2.9), pointing to gender disparity and the
consequent discrimination that underpins an adverse sex ratio.
Figure 2.8
Sex Ratio: International Comparisons
1150 T
* 1100 •
i
7
1050 ■
1000
Wortd Avwaga 9M
5 950 - H
F=1
E
o
iE
3
800 —1—LLJ.
I f
ra
©
5
_c
II
I i3 .ih
a
o
ro
O)
5
£
I
ro
CO
Countries
Sources: Census of India 2001, Provisional Population Totals, Registrar General and Census
Commissioner, India
20
11
Figure 2.9
Sex Ratio in India (1901-2001 )
V)
05
2
o
o
o
980 p
970 U
960 a 950
g 940 « 930 S 920 t 910 - .3
do 900 U
z
o
CD
'T
..
■V,'
O)
CM
CD
CO
O)
s
LA
CD
CD
CD
CD
CO
CD
CD
CD
O
O
Osl
Census Year
Sources: Census of India 2001, Provisional Population Totals, Registrar General and Census
Commissioner, India
Progress since Independence
In the years since Independence, there have been significant gains in
health status in India, but they do not compare favourably with those in
many similarly placed developing countries. In isolation, Indian figures
represent an impressive record. Life expectancy has gone up from 36
years in 1951 to 62 years in 1995 (14). Infant mortality rate is down from
146 in 1951 to 71 in 1997 (15) (Figure 2.10). Crude Birth Rate has been
reduced from 36.9 in 1970 to 26.1 in 1998, and Crude Death Rate from
14.9 to 8.7 during the same period (Annex 2.5). (Figure 2.11 indicates,
though, a worrying levelling off in the IMR since 1993.) These gains have
been made possible by the growth and development of health
infrastructure, efforts such as immunization to control communicable
diseases, and improvements in determinants such as water supply and
sanitation. Major success stories include the eradication of small pox and
guinea worm; the extraordinary social mobilization for polio eradication;
the near elimination of leprosy and the significant contribution of the
National Blindness Control Programme in controlling cataract - induced
blindness in selected states. The National Health Policy 1983 (16), set
some targets for 1985, 1990 and the year 2000. A comparison (Table 2.7)
indicates that despite impressive gains we are nowhere near targets,
except for life expectancy, Crude Death Rate and polio immunization.
21
Figure 2.10
Infant Mortality Rates in India
Infant Mortality Rates in India
120 110
100 -
90
80 70
60
o
co
CD
CXI
00
CD
3
CD
CO
CO
Q)
CO
CO
CD
o
CD
CXI
3
o
CO
CD
CD
CO
CD
Q)
Source: Registrar General (multiple years), reproduced from India: Raising the Sights Better Health Systems for India's Poor, World Bank, 2001
Table 2.7
Select Goals Under National Health PoPcy and Achievement
SI. No.
Level as quoted
in NHP
Indicator
2 infant Mortality Rate
2 Pennatai Mortality
3 Crude Death Rate
4 Life Expectancy at Birth(yrs.)
Male
Female
5 Crude Birth Rate________________________
6 Growth Rate (annual)____________________
Pregnant mother receiving ante-natal care(%)
8 Deltvenes by trained birth attendant
9 immunization Status Coverage by %
TT(for pregnant woman)__________
2r
____ _______
TT(for school children)
DPT( Children below 3 years)________
Polio(lnfants)_________________ ____
BCG^Infants)______________________
DT (New School Entrants 5-6yrs ).
Typhoid (New School Entrants 5-6yrs.)
125(1978)
67(1976)
Around 14
52.6(1976-81)
51 6(1976-81)
Around35
2 24(1971-81)
_______ 40-50
30-35
20
10 years
16 years
20
25
_5
65
20
2
Latest
Available
Achievement
Goals
1985
106
1990
90
__ 12
55.1
54.3
__ 31
__ 1 9
50-60
50
10 4
57,6
57.1
29 1
1 66
60-70
80
2000
<60
30-35
___ 9
__ 64
__ 64
__ 21_
__ 1 2
100
100
60
40
60
_70
50
70
80
70
100
100
100
85
85
85
85
85
100
100
100
100
100
100
100
85
1985
1990
___ 97
____ 80
72(1998)‘
53.8
49 6
42.5(1994)
11.7
8 9(1997)
_ __ 96
58 1
58 1
64 1(2001-06)
59 1
59.1
65 8(2001-06)
30 2
27 2(1997)
32.9
2 07
1 87 1 66(1996-2016)
40-50
60(88)
65 4(98-99)
30-35 40-50( 88) ______ 35( 99)
78 16
60.6
82
60 5
92.7
8645
96.2
98 19
98 86
93.9
101.51
47.3
112 ____ 82
70.3 62.6C88)
78 7(1996-97)
55 1(1996-97)
47 6(1996-97)
89.3(1996-97)
90 7(1996-97)
97 1(1996-97)
58 7(1996-97)
* Data obtained from Annual Report (1999-2000), MHFW, India
Source: Health Information of India 1995 & 96, Central Bureau of Health Intelligence, MHFW,
forthcoming.
Rural Health Infrastructure
Our vast rural health infrastructure, which received substantial financial
support during the 1980s (Sixth and Seventh Five Year Plans), is a major
achievement. A three-tiered system, it has sub-centres for each 5,000
population, Primary Health Centres (PHCs) for each 30,000 population,
and Community Health Centres (CHCs) for each 1,00,000 population.
Lower norms meet the special requirements of hilly areas. The sub-centre
is the most peripheral contact point between the primary healthcare
22
H
underreporting. Of the 1 1,25,000 practitioners registered with various
system medical councils, only 1,25.000 are reported to be in government
service (19). The balance consists of around a million registered
practitioners of different systems in the private sector. The number of
unqualified practitioners of various systems is also large, and according to
a study done by UNICEF/SRI-IMRB in UP, their number practically equals
that of registered practitioners (20). These comprise traditional
practitioners of indigenous systems as well as quacks, and some studies
show that all of them freely practice modern medicine (21), often with
disastrous consequences.
Table 2.9
Health Care Manpower and Health Facilities in the Public and
Private Sector in India
Doctors
Nurses
Hospitals
Hospital Beds
PHCs
Total Number (1998) (includes all systems) (CBHI)
Population Per Doctor
% age of Doctors in Rural Areas (1981) (Census)
% age of all Doctors in Private Sector (Estimated)
Total Number (1996)
Population Per Nurse
Doctors Per Nurse (1996)
Total Number (1996)
Population Per Hospital
% age of Hospitals in Pnvate Sector
Estimated Total Number of Hospitals
Estimated Population per Hospitals
Estimated % age of Hospitals in Private Sector
Total Number (1996) (CBHI)
Population Per Hospital Bed
% age of Beds in Rural Areas
% age of Beds in Private Sector
Estimated Total Number of Beds
Estimated Population per Bed
% age of Beds in Privaie Sector
Total Number
Rural Population Per PHC
1109853
880
41
80-85
867184
976
1.4
15097
56058
68
71860
11744
93
623819
1357
21
37
1217427
693
64
22975
27364
Notes: Estimates are from Duggal (2000) and Nandraj (Background Paper 6).The estimates for
manpower are based on medical council lists. The estimates for the number of hospitals and
beds are based on the extent of under-estimation in government (CBHI) data found in AP in a
1993 Census of all hospitals by the Director of Health Services and the Andhra Pradesh
Vaidya Vidhan Parishad. They found 2802 hospitals and 42192 hospital beds in the private
sector in AP as against 266 hospitals and 11103 beds officially reported by the CBHI in that
year. The official (CBHI) data under-reported private hospitals by 10.5 times and beds by 3.8
times.
Source: India: Raising the Sights - Better Health Systems for India’s Poor, World Bank
2001
Although the private sector has filled the critical gaps caused by the non
performance or overcrowding of public facilities, its rapid expansion has
been characterized by concentration in urban areas and the continued
neglect of under-served areas (Table 2.9 and Annex 2.3). Besides, the
private sector is almost entirely unregulated. In the absence of any
regulatory mechanisms or standards, there are serious complaints of poor
quality, irrational drug use, overcharging and unethical behaviour. It needs
to be noted, however, that regulating private practitioners in a country with
multiple
systems
and
inadequate
standardization
does
present
24
u
the c°mmu2ity' There were 1-37,271 sub-centres functioning
m
;rr:tc:o7t:c,;nPaon^db9;-7„
village community and the medical officer, and there are 22,975 PHCs
operational in the country. The PHC, as the name suggests, has facilities
Da iPntq PT?ryth°U rPuanient Care W'th merel7 nominal arrangements for in
patients, while the CHC has facilities for secondary care, with specialists
and in-patient beds. There are 2935 functioning CHCs (17).
Eut despite the fact that investment in this infrastructure has been
nnMi h"1/3 ’ f'1 has^not y|e*ded optimal benefits. Many institutions are
fully ^nctl°2a due t0 staff shortage and non-availability of drugs and
pnHSH mfb eS’ J66 Table 2 8 f°r the reP°rted availability of specialists
and doctors in the rural health systems.)
Table 2.8
Availability of Health Manpower in Rural Health
A.
B.
Institutions
Specialists :
1
Posts
required as
per norms
2
Posfs
sanctioned
3
Specialists in
positions
11652
6556
3731
2825
7332
2
Posts
sanctioned
3
Doctors in
position
4
Posts
Vacant (23)
5
Shortfall (13)
25418
4284
- 2186
4___
Posts
Vacant (23)
5
Shortfall (1 3)
J
Doctors in PHCs :
1
Posts
required as
per norms
23179
___
29699
Source: Health Information of India 1995-96, forthcoming
Posts sanctioned in excess of norms are generally in well-located PHCs to
give doctors credit for rural service, aggravating the shortage in
underserved areas. The problem is more grave than the vacancy position
indicates, the data does not capture the large-scale absenteeism of
doctors in rural areas. Government doctors practice privately with or
without permission, and this means inadequate attention for patients in
government institutions. The overall result is the poor utilization and nearcollapse of the rural health infrastructure, particularly the PHCs and
CHCs, in most states (18).
Growth of the Private Sector
A look at the position of hospitals and hospital beds in public and private
lSlef °,rS.lLab e_2'9^ lU9gests the raP'd expansion of healthcare facilities in
the private sector. But private sector
data is
----------------.j incomplete, with substantial
23
i1
considerable administrative complexmes. The ‘not-for-profit’ private sector
(NGOs and charitable trusts) has nade a significant contribution to public
health programmes such as family planning, HIV/AIDS, leprosy, blindness,
and Maternal and Child Health (MCH), as well to the provision of
healthcare to the poor, but their contribution has not been fully
documented.
Equity
Despite decades of socialistic, welfare-oriented government goals, the
health system is plagued with inequities, partly as a reflection of income
disparities - aggravated, according to one view, in the post-liberalization
period. But even the State-financed healthcare system is increasingly
utilized by the relatively affluent sections of the population. A recent
NCAER study establishes the raw deal the poor get from the public
healthcare system (Figure 2.11), although there are substantial state-level
variations (Table 2.10). Glaring differentials in health status indicators in
different income groups, and health outcomes as per standard of living
index (Tables 2.11 and 2.12) confirm inequities in healthcare and status.
Figure 2.11
Share of Public Subsidy for Curative Care Benefiting Income Groups
33.10%
35.00%
’</)
30.00%
25.60%
JO
□
cn
o
Z
3
O.
•*o
Q
ro
x:
co
25.00%
------------- 17.80%.
20.00%
15.00%
10.00%
13.40%
r~
2 nd
Middle 20%
10.10%
5.00%
0.00%
Poorest 20%
4 th
Richest 20%
Income Quintiles
Source: Who Benefits From Public Health Spending In India, unpublished paper, NCAER,
2000
25
u
Table 2.10
Comparative State Equity Performance for Curative Care (Income Level)
Rank
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
State
Ratio of Curative Care
Subsidy to Richest
Concentration Index
Versus Poorest
Quintile
Kerala
Gujarat
Tamilnadu
Maharashtra
Punjab
Andhra Pradesh
West Bengal
Haryana
Karnataka
All India
North East
Orissa
Madhya Pradesh
Uttar Pradesh
Rajasthan
Himachal Pradesh
Bihar
1.1
1.14
1.46
1.21
2.93
1.85
2.73
2.98
3.58
3.28
3.16
4.87
4.16
4.09
4.95
5.88
10.3
-0.041
0.001
0.059
0.06
0.102
0.116
0.157
0.201
0.208
0.214
0.22
0.282
0.292
0.304
0.334
0.34
0.419
Source: Background Paper 18, reproducea from India: Raising the Sights - Better Health
Systems for India’s Poor, World Bank, 2001
Table 2.11
Health Status Indicators - Comparison Between the Poorest and Richest Quintiles
of the Population, India, 1992-93
Poorest 20 %
Richest 20 %
Poor / Rich Risk Ratio
Infant Mortality (Deaths under 12 months
per 1000 births)
109.0
44.0
2.5
Under 5 Mortality (Deaths under 5 years per
1000 births)
155.0
54.0
2.8
Childhood Underweight (Percent below -2
sd z-score, weight/age, children under 4
years)
60.0
34.0
1.7
Total Fertility Rate (Births per woman age
15-49 years)
4.1
2.1
2.0
Source: Gwatkin et al, Socio-Economic Differences in Health, Nutrition, and Population in
India, 2000. HNP Poverty Thematic Group of the World Bank, based on NFHS, 1992-93.
Reproduced from India: Raising the Sights - Better Health Systems for India’s Poor, World
Bank, 2001
26
Table 2.12
Health Outcomes According to Standard of Living, India 1998-99
Standard of living
index
Under
Infant
Five
Mortality
Mortality
(per 1000
(per 1000
births)
births)
Low
Medium
High
Low/High Ratio
88.8
70.3
42.7
2.08
130
94.6
51.5
2.52
Total
Fertility
Rate
Children
Underweight
(% below -2
SD)
Children
with
anemia
3.37
2.85
2.1
1.6
56.9
46.8
26.8
2.12
78.7
73.5
67.3
1.17
(%)
Children with
Children
acute
Anemia
with diarrhea
respiratory
among
in past 2
infection in
women
weeks
past 2 weeks
(%)
(%)
(%)
19.9
60.2
19.7
50.3
16.1
41.9
1.24
1.44
___________________________
Source: National Family Health Survey 1998-99 (UPS ?
----- ~ . rReproduced
_J___
2000),
from India: Raising
the Sights - Better Health Systems for India’s Poor, World Bank, 2001
21
19.4
15.7
1.34
Poor and undependable public sector services in rural areas and their
consequent under-utilization, and the cornering of secondary and tertiary
care services in urban and metropolitan areas by the rich, leads to a
skewed pattern in many states. The result is the diversion of a majority of
patients to the private sector, now accounting for 82% of out-patient care
and 56% of nondelivery hospitalizations (22). The bulk of the cost of
treatment is met by out-of-pocket expenses, estimated at 84.6% of the
total health expenditure (Annex 2.4). This has serious consequences for
the poor: a World Bank analysis showed that direct out-of-pocket medical
costs may push 2.2% of Indians to poverty in one year (23). Thus many
episodes of illness remain untreated, and their proportion has increased
significantly between the 42nd round (18%, 1986-87) and 52nd round
(33%, 1995-96) of NSS. The greatest failure of the Indian health
system is its inability to develop a financing mechanism for the
healthcare of the poor.
Manpower Shortages
The critical shortage of key health manpower, particularly in public
facilities, is explained by inadequate incentives, poor working conditions,
and lack of transparency in postings, especially in rural areas. As many as
165 medical colleges produce 12,000 medical graduates and 4,139
postgraduates every year, yet shortages persist (24). There is also a
critical shortage of specialists - surgeons, pediatricians, gynecologists
and anesthesiologists - in government secondary institutions.
Public Health
Public health has also been neglected, both as a discipline and a
profession. The highest technical position in public health, the Director
General of Health Services (DGHS), does not necessarily require a public
health background. Similarly, heads of public health departments in many
states, the Directors of Health Services (DHS), often have medical, not
public health backgrounds. In most states this also applies to the district
27
level. The neglected All India Institute of Hygiene and Public Health,
Kolkata, run as a subordinate office of the Director General of Health
Services, is the only institution devoted exclusively to public health.
Departments of Preventive and Social Medicine/Community Medicine in
medical colleges are often the weakest, and perceived by students as the
least desirable choice. Naturally, despite policy pronouncements, public
health issues receive low priority in the Indian health system (25).
Indian Systems of Medicine
More than 4000 years old, the holistic system of ayurveda also provides a
way of life that can help prevent lifestyle related diseases. But traditional
systems - ayurveda, siddha, unani, yoga, naturopathy - have not
contributed significantly to the healthcare of the masses, despite their
increasing appeal abroad and to the affluent at home. According to the
42nd Round NSS, 96% of illness episodes were treated with allopathic
medicines. NCAER Household Surveys also confirm that 90.8% of illness
episodes in rural areas received allopathic treatment; urban areas report
just over a 2% higher share for allopathy. Thus the surmise of dependence
on faith healers is overturned; they account for only 0.5% in rural areas
and 0.2% in urban areas. Generally, the government-funded parallel
infrastructure of traditional system health facilities and trained personnel
are not utilized for either public health programmes or primary healthcare.
There were reportedly 5,76,101 registered practitioners of Indian Systems
of Medicine and Homeopathy in 1996 (26). The parallel and uncoordinated
development of the two streams of healthcare indicates that no attempt
has been made to synthesize different systems as suggested by the
ICSSR/ICMR Committee 1981; nor has there been a serious, sustained
effort to evaluate traditional remedies scientifically.
Coordination
Determinants of health status such as sanitation, drinking water,
environment and nutrition, are outside the purview of health ministries and
departments at central and state levels. There are no active and
functioning institutional mechanisms for coordinated and integrated action.
The deteriorating environment, the non-availability of safe drinking water
and poor nutritional status, all conditions that affect disease burden and
health outcomes, are poverty-related. These health hazards are faced by
the growing slum population in cities - between 30% to 50% of the total
urban population (26% according to 1991 census) (27). Delhi has at least
30% of its population (28) living in slums. The urban child population of
Jammu, Delhi and Mumbai are vulnerable to increased levels of lead
exposure (29). Similarly, a study (30) of the Moradabad brassware
industry shows high respiratory morbidity due to chronic exposure to the
fumes and dust of metals. The worst damage is obviously the impact of
occupational and environmental hazards on children. Coordinated action
could alleviate the condition of the most vulnerable sections of society,
28
but such coordination is hampered by a multiplicity of agencies, and
the fragmentation of responsibility.
Divisions within the Ministry of Health and Family Welfare (MHFW) have
aggravated compartmentalization. The Ministry is now divided into three
independent departments - health, family welfare and Indian systems of
medicine and homeopathy. With population control considered a priority,
an independent department of family planning (later family welfare) was
created, though public health and family planning services had to be
delivered through the common rural health infrastructure. The emphasis
on family planning targets transferred the entire rural health portfolio to
that department, divorcing it from other health programmes. The result
was poor utilization; the PHC in many states was, in the public eye, only a
family planning facility (31). Separate departments give their respective
programmes greater focus, but at the cost of coordinated functioning; the
absence of a holistic view outweighs the advantages. Several committees
and reports - such as the World Bank’s India: Policy and Finance
Strategies for Strengthening Primary Health Care Services (1995), the
Expert Committee on Public Health Systems 1996, and the Committee on
Restructuring of the Health Ministry (2000), have recommended the
integration of all departments.
Epidemiological Surveillance
The near collapse of the surveillance system makes accurate estimates of
the epidemiological situation difficult; the exceptions are HIV/AIDS and
polio, which have special surveillance systems. The reporting in
government documents is from public healthcare institutions, capturing
only a fraction of illness episodes. In the words of the 1996 Expert
Committee on Public Health Systems, “Surveillance data generated
through the system and through various programmes are considered at
best indicative of trend rather than the actual situation in the community...
mortality and morbidity numbers reported are grossly underestimated.”
Clearly, a working, cost-effective epidemiological surveillance and vital
registration system is an urgent priority.
Nutrition
Despite a nationwide programme for nutritional supplementation for
pregnant women and children, available indicators present a pessimistic
scenario. The latest NFHS-2 data (1998-99) shows 36.8% women with BMI
(32) of 18.5 Kg/m2 or less, indicative of chronic energy deficiency. Anemia
in women varies from 41.9% in high-income groups to 60.2% in lowincome families. 47% of under-3 children are underweight, and 18% are
severely underweight; there has been a marginal improvement since
NFHS-I
(92-93) (Figure 2.12). Anemia among children is as high as
74% (Figure 2.13). The 1994 ban on the sale of edible non-iodized salt
produced some results, but this ban was lifted in September 2000, despite
protests from public health and scientific communities and international
29
organizations.
Figure 2.12
Undernutrition in Children in India
o
= f 60
s 5
50
c
O 3
_
®
□) o
40
TO JZ
® co
2 ®
®
Q.
O)
TO
52
-rl
47
□ NFHS1
30
■?i'
20
20
18
HNFHS2
10
0
Underweight
Severely Underweight
Source: National Family Health Survey (NFHS-2) India, 1998-99
Figure 2.13
Anemia among Children
80
[----- 74-
70 I
60 I50
C
O)
O 40
0)
n. 30
20
10
: ft
46
w
-23
S
■
5
]
0
Any Anemia
Mild Anemia
Moderate
Anemia
Severe Anemia
Source: National Family Health Survey (NFHS-2) India, 1998-99
Public Health Expenditure
Overall, the health scenario reflects persistent neglect by the State
despite its socialistic model, and despite the close link between health
30
status and productivity in a poor ccuntry. Investments in health yield only
medium or long-term gains, and inis seems to have been at odds with
short-term political gains. The consequence has been the inadequacy of
public health expenditure - arour.d 0.9% of GDP (33), below the lowincome countries average (one per cent) and even Sub-Saharan Africa
(1.7%) (Annex 2.4). Public health expenditure as a proportion of total
government expenditure has declined over the years (Figure 11.1); only 12
countries in the world spent lower proportions on health (34). This has
sometimes been attributed to the economic reform process (35). The
economic reforms introduced in the nineties should have released more
funds for investment in social sectors, following government withdrawal
from investment in industry and to some extent infrastructure. But
following a temporary stabilization in the early nineties, the fiscal situation
deteriorated, eroding the government’s ability to step up investments in
health. The central government has, however, increased support to
developmental health programmes by leveraging external resources (Table
2.13). The states, typically, account for around 75% of public health
expenditure (36). Thus the states' financial health is crucial for general
developmental outlays, as also for health. The combined gross fiscal
deficits of the states, which ranged between 2.4% to 2.9% (1993-94 to
1997-98), increased to 4.2% in 1998-99, and to 4.9% in 1999-2000 (37).
Rather than economic reforms, this can be linked to a lack of reforms in
containing subsidies, privatizing losing PSUs and downsizing government.
Fiscal crises have meant sharp reductions in the non-salary recurring
expenditure in public health facilities, and quality has deteriorated even
further. The increase in salary and pension liabilities subsequent to the
recommendations of the Fifth Pay Commission has also aggravated the
resource crunch (38). The combined fiscal deficits of the centre and the
states are estimated at 10% of GDP (39). An analysis of trends in public
spending (Figure 2.14) indicates a steady increase in per capita spending,
but low overall levels. In current prices, total public-sector health
expenditure was Rs161 billion (Rs165 per capita; US$ 3.9 or Rs97 at 9394 constant prices) (40). Major variations among states (Figure 2.15) point
to the increasing divide between rich and poor states.
Table 2.13
Outlay for Health in the Central Sector (Actual Expenditure)
(Rs. Crore)
1992-93 1993-94 1994-95 1995-96 1996-97(RE)~
315.44 348.43
489.71
207.96 201.87
305.63
523.4
201.87
305.63
Total Centrally Sponsored Schemes
208.17 232.04
Total Purely Central Schemes_____
174.36
183.19
Grand Total
__________________
382.53 415.23
Source: Ninth Plan Document, Planning Commission, GOI
31
Figure 2.14
National Accounts, Public Sector Spending on Health
e
100
a
95 •
I
90 •
1.20
®
Q.
Q
1.10
1.00
O
0.90
0.80
©
85 •
0.70
3
s
Q
0.60
80
2
cn
OJ
cn
ra
Io
0.50
Q.
0.40
75
cd
r*.
co
CO
CO
03
CO
m
co
CT)
cd
co
CT)
r^
co
CT)
cd
co
cn
T-
T-
T—
I
I
I
a>
cn
co
cn
S
cn
9 ?
s i
m
o
r>
3
CT)
CD
CT)
in
CT)
CT)
CT)
cd
CT)
CT)
co
CT)
t^.
CT)
CT)
CT)
CT)
cd
CT)
CT)
O
s
CM
CT)
CT)
CT)
■ Per capita public health expenditure (Constant Prices in 93-94
Rs.)
■•—Public Health Expenditure/ GDP mp %
Source: Central Statistical Office; Ministry of Finance; Reserve Bank of India,
reproduced from India: Raising the Sights - Better Health Systems for India’s
Poor, World Bank, 2001
Figure 2.15
State-Level Per Capita Public Spending on Health (Rs.), 1995-96
C
132Rs./$4
-ct
[
; 123RS./S3.7
■i 120Rs/S3 6
106Rs./$3.1
-t
104Rs,/$3.1
102RS./S3
102Rs./$3
99Rs./$3
r
95Rs./$2.8
89Rs./$2.7
I 85Rs./$2.5
78Rs./$2.3
i 72Rs./$2.2
■ 66Rs./$2
57RsJ$1.7
k’4
MP
[■taBaattaaaa
0
25
50
75
100
125
150
Central Per Capita B State Per Capita
Source: India: Raising the Sights - Better Health Systems for India’s Poor, World Bank,
2001
32
u
Conclusion
A great leap in levels of investment is imperative if we are to meet the
epidemiological and systemic challenges facing the country. The
ICCSSR/ICMR Committee suggested a public investment of 6% of GDP in
health, analogous to the Education Commission’s recommendation for that
sector. India has traditionally spent much more on education, around 3.4%
of GDP (38). Matching health outlays do not appear feasible, nor does
matching public investment levels of high-income countries (6% of GDP).
Aiming at the average level of lower middle-income countries (41) - 2.2%
of GDP (42) - means just over double the outlay, to around $10 per
capita. The World Development Report 93 calculated the cost of a
minimum package of basic health services at $12 per capita for lowincome countries at 1993 prices. Even with an investment of 2.2% of GDP,
we would still fall short of that target. But higher financial resources must
be accompanied by major structural reforms in the health system.
Essential to the mobilization of additional resources and to systemic
reform is increased popular awareness about health issues, an awareness
that will generate the necessary political support.
Notes
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Low Income ($760 and less), Middle Income (S761-S9360) and High Income
Countries ($9361 and above) are defined on the basis of per capita incomes in
1998 in World Development Report 2000.
Economic Survey - 2000-2001. The comparability of the latest estimates with
earlier data is, however, disputed on account of the change in methodology.
Although the concept of Disability Adjusted Life years (DALYs) used for
estimating burden of disease is widely accepted by international organizations,
there are some who question the reliability of these estimates. (See Ritu Priya
2001).
Ad Hoc Committee on Health Research, WHO 1996.
Multi Drug Resistant.
Directly Observed Treatment Short Course.
Note on TB epidemic from MHFW.
Annual Report - 1999-2000, MHFW.
NAMP - DGHS 2001.
Annual Report - 1999-2000, MHFW. MMR estimates are for 1997.
Annual Report 2000-2001, MHFW.
Siddharth Dube, Sex, Lies and AIDS, 2000.
Ad Hoc Committees on Health Research 1996.
Annual Report of the MHFW, 1999-2000.
Address of Director General Health Services, GOI, to the Regional Conference
on Public Health in South East Asia in the 21st Century, Kolkata, November
1999.
For a fuller discussion of the evolution of health policy in India, see
Appendices.
Annual Report 2000-2001, MHFW.
NSS 42nd and 52nd Round, NCAER Household Surveys 1991-1992.
Ravi Duggal, The Private Health Sector in India, 1996.
Rohde and Vishwanathan, The Rural Practitioner, 1994.
33
Ii
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
NCAER Household Surveys. 1995.
52na Round NSS.
India: Raising the Sights - Better Health Systems for India's Poor. World Bank,
2001.
Health Information of India - 1995-96.
For a fuller discussion see Report of the Expert Committee on Public Health
Systems, 1996.
CBHI - Health Information of India. 1995-96.
Indrani Gupta, Arup Mitra, Basic Amenities and Health in Urban India, 2000.
Indrani Gupta, Arup Mitra et al, IEG, 1998.
B. Kaul, Lead Exposure and Iron Deficiency among Jammu and New Delhi
Children, and R.P. Shenoi et al, Sources of Lead Exposure in Urban Slum
School Children.
V. Bihari et al, Occupational Morbidity Among Children Employed in Brassware
Industry.
Ravi Duggal, For a New Health Policy, discussion paper.
Body Mass Index
India: Raising the Sights - Better Health Systems for India’s Poor, World Bank,
2001.
WHR 2000.
Tulsidhar, Government Health Expenditures in India 1996, Ravi Duggal, Public
Health Budgets, Recent Trends.
World Bank 2001.
RBI Bulletin, October 2000.
Sjlvaraiu et al 2001, background paper, 2001.
Finance Minister’s Budget Speech, February 28, 2001.
World Bank, 2001.
WDR 2000.
WDR 2000 categorizes countries with per capita incomes between $761 and $3030 as Lower
Middle Income Countries.
WDR 2000.
34
Annex 2.1
Demographic and Health Indicators - India and States
MAJOR STATE
Andhra Pradesh
Assam
Bihar
% of Birth Attended
By Trained Health
Personnel *
CBR ***
CDR *
IMR *
TFR
Under - 5
Mortality
Rate**
FEMALE
1999
1999
1995
1998
1995-98
64,5
1993-98
54
22.3
8.3
66
2.25
58.7
85.5
58.5
30 2
27,7
96
78
2.31
60.8
89.5
60.1
13 8
31.1
10.5
67
3.49
105.1
85 1
MMR *
Life Expectency At
Birth(1991-96) *
1997
MALE
154
61.4
401
451
Gujarat
29
60.9
62 7
416
Harayana
25.3
76
105
64 2
25 5
27,6
8
64
69
2.72
65.2
2 88
76 8
37 8
22.5
8.6
68
2.14
42 4
69.8
Himachal Pradesh
Karnataka
195
64 2
65.3
52.5
Kerala
22
7,6
58
195
498
2.13
68.6
75
58
96.6
18.2
6
1.96
18.8
24
30.6
11.1
3.31
52.8
22.3
7.4
16
97
49
2.52
137.6
58."
20.9
402
21 8
76 3
25.7
10.8
104.4
73
98
54
2.46
22 4
2.21
72 1
31 5
9.1
83
3.78
114.9
18.9
7.9
53
2.19
63.3
168
37.4
32.4
10.4
85
3.99
122.5
53
2.29
67.6
35
26 1
70“*
2.85
94.9
Madhya Pradesh
Maharashtra
Orissa_____
Punjab
Rajasthan
Tamilnadu
Uttar Pradesh
West Bengal
India
Source : *
59.2
64
135
361
60.1
65 9
58.4
196
677
66.6
60.5
66 5
61.3
76
62.3
63.1
707
264
57.1
52.8
61 9
61.7
408
61.9 ,
60.6
21.3
8.7***
Annual Report 1999-2000, MHFW, GOI
■
National Family Health Survey (NFHS-2),1998-99
Annual Report 2000-2001, MHFW, GOI
35
1/
Annex 2.2
Health and Demographic Indicators ■ India and World
COUNTRIES
CBR
1995
CDR
1995
TFR
1995
IMR
1995
< 5 MR
1995
MMR
reported
Life Expectancy at
Birth (1999) ”2
1980-99**’
Male
Bangladesh
Brazil_________
China_________
Costa Rica_____
Cuba__________
Egypt. Arab RepIndia__________
Indonesia______
Korea, Rep.
Malaysia_______
Mexico________
Myanmar______
Nepal_________
Pakistan_______
Philippines_____
South Afhca
Sh Lanka______
Thailand
Viet Nam
Zimbabwe
HIE___________
MIE___________
LIE___________
SSA
World
28.0
21.0
17,0
25.0
14.0
27.0
26.0
23.0
16.0
27.0
26.0
28.0
37.0
38.0
29.0
30.0
20.0
17.0
26.0
31.0
13.0
22.0
26.0
41,0
23.0
10
3.5
80.0
115.0
7
2.4
45.0
57.0
7
1.9
35.0
430
4
2.9
13.0
16 0
7
1.7
9.0
10 0
8
3.5
57.0
76.0
9
3.2
69.0
95.0
8
2.7
52.0
75.0
6
1.8
10.0
140
5
3.4
12.0
14.0
5
3.0
33.0
410
IV
3.5
84,0
119.0
12
5.3
92.0
131.0
9
5.3
91.0
127.0
7
3.8
40.0
53.0
8
3.9
51.0
6
2.3
16.0
440,0
160.0
55.0
29.0
27.0
170.0
410,0
450.0
20.0
39.0
55.0
230.0
540.0
57.5
63.7
68.1
74.2
73.5
64.2
59.6
66.6
Female
% of Birth
attended by
trained health
personnel
(1995-2000)**-1
58.1
13
71.7
92
71.3
67
78.9
98
77,4
100
65.8
61
61.2
35“
69
56
98#
67,6
69.9
96
71
77,1
86
58.4
59.2
56
57.3
57.8
9
62.6
64.9
19
64.1
69.3
56
67 0
47.3
49.7
84
19.0
65.8
73.4
94
71#
170.0
60.0
44.0
160.0
400.0
66
70.4
64,7
68.8
77
40.9
40
84
6
1.8
35.0
42.0
7
3.1
410
49.0
9
3.9
55.0
83.0
8
1.7
7.0
9.0
99
8
3.0
39.0
53.0
52
10
3.2
690
1040
28
15
5.7
920
1570
37
9
2.9
55.0
81.0
56
HIE : High Income Economies
MIE : Middle Income Economies
LIE : Low Income Economies
SSA: Sub-Saharan Africa
Source :
Health, Nutrition, and Populatin lndicators:A Statistical Handbook, Human Development
Network, World Bank -1999
S-1 : The State of the World’s Children 2001, UNICEF
S-2 : The World Health Report 2000,
Health Systems : Improving Performance, WHO
* Data refer to the most recent year available during the period specified in the column.
“Data obtained from Annual Report (1999-2000); MHFW, GOI
# Indicates data that refer to years or periods other than those specified in the column heading,
differ from the standard definition, or refer to only part of a country.
36
Annex 2.3
Health Infrastructure of India and its States as on 01,01.1996
Rural
S. No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Urban
]
Total
States
Andhra Pradesh
Assam
______
Bihar
Gujarat_________
Haryana_________
Himachal Pradesh
Karnataka_______
Kerala_________
Madhya Pradesh
Maharashtra_____
Orissa_________
Punjab
Rajasthan________
Tamilnadu_______
Uttar Pradesh
West Bengal
ndia
Hospitals
Beds
Beds per lakh
of Population
Hospitals
Beds
Beds per lakh
of Population
Hospitals
Beds
883
151
100
179
8
19
25
1443
245
469
287
75
14
89
83
112
4621
10117
3949
3018
5798
543
549
3015
44103
6128
10209
5115
2330
1150
4235
2585
6352
122453
20.81
19.82
4.02
21.42
4.38^
11.63
9.70
205.92
12.05
21.10
18.65
16.31
3.39
11.51
2.32
12.87
18.50
2007
117
228
2349
71
38
268
597
118
2646
' 143
145
204
319
652
287
10416
35715
8712
26072
57619
6637
4519
35434
33096
11959
68711
9769
12491
20037
44545
44693
48878
501366
199.67
350.16
229.65
404.46
163.67
1006.46
254.77
430.94
77,96
224.97
230.67
208.43
199.04
233.49
161.90
261.27
232.36
2950
268
328
2528
79
57
293
2040
363
3115
430
220
218
408
735
399
15097
45832
12661
29090
63417
7180
5068
38449
77199
18141
78920
14884
14821
21187
48780
47278
55230
623819
Beds per lakh
of Population
68.91
56.49
33.68
153.51
43.61
98.01
85.49
265.30
27.41
99.98
47 01
73.0/
48.15
87.33
33.99
81.13
73.71
Source : Health Information Of India (1995 & 1996), CBHI, MHFW. Census of India, 1991
37
u
Annex 2.4
COUNTRIES
Per
Capita
GNP
Per
Capita
GNP
Health Expenditure - India and World
Public Health
Total Health
Per Capita
Public Health
Out-of-pocket
Expenditure
Expenditure Expenditure as expenditure as %
Public Health
(% of GDP)
Expenditure as % of GDP 52
% of Total
of Total
Bangladesh
350
1100
1.2
32
4.9
46
54
Brazil
4570
6160
1.9
208
6.5
48.7
45.6
China
750
3220
2.1
18
2.7
24.9
Costa Rica
2780
6620
6.0
377
8.7
77.1
75.1
22.3
96
6.3
1290
3130
1700
1.7
32
3.7
87.5
27
73.1
0.7***
11
0.7
21
5.2
1.7
13
36.8
84.6
47.4
Cuba
Egypt, Arab Rep.
India
12.5
Korea, Rep.
Malaysia
430
680
7970
2790
12270
2.3
3600
6990*
1.4
85
2.4
Mexico
3970
8190*
2.8
172
5.6
57.6
41
0.4
10
2.6
12.6
3.7
4
26
74
22.9
77.1
Indonesia
Myanmar
42.4
52.9
87.4
Nepal
210
1090
1.2
11
Pakistan
480
0.8
16
Philippines
1050
1560
3540
1.3
48.5
49.1
2880
6990*
7.1
810
35
3
46.5
45.4
46.3
Sh Lanka
3.6
1.4
48
184
3.4
South Africa
Thailand
Vietnam
2200
5840
5.7
33
1690
2.0
1.1
108
330
13
4.8
Zimbabwe
610
2150
1.7
62
6.2
20
43.4
HIE
23440
MIE______
25510
2950
6.0
2.4
Lower Middle
Income
1710
3709.4
Upper Middle
Income
4860
4606.3
LIE
380
2130
1430
6200
SSA
480
World
4890
4080
51.8
65.4
80
38.2
2.2
3.0
1.0
2.5
Estimate based on regression; others are extrapolated from the latest International Companson Programme
benchmark estimates.
“ Estimated to be low income ($760 or less).
The latest estimates compiled by the World Bank seem to indicate a slight rise in public health expenditure
as a percentage of GDP to 0.9%.
Sources :
S1 - World Development Report 1999 / 2000
S2 - The World Health Report 2000
38
Annex 2.5
Demographic Indicators - India and World
CBR
COUNTRIES
1965
Bangladesh
Brazil________ _
China__________
Costa Rica_____
Cuba _________
Egypt, Arab Rep.
India___________
Indonesia_______
Korea, Rep.
Malaysia_______
Mexico________
Myanmar_______
Nepal__________
Pakistan________
Philippines______
South Africa
Sri Lanka_______
Thailand________
Viet Nam_______
Zimbabwe______
HIE____________
MIE
LIE_____________
SSA____________
World
47.0
39.0
38.0
35.0
1970
48.0
35.0
33.0
33.0
43.0
45.0
43.0
35.0
40,0
45.0
40.0
46.0
48.0
42.0
40.0
33.0
41.0
46.0
48.0
38.0
39.0
29.0
39.0
55.0
19.0
38.0
42.0
48.0
35.0
53.0
18.0
35.0
39.0
48.0
34.0
40,0
41,0
42.0
30.0
36.0
43.0
CDR
TFR
UNDER-5 MORTALITY
IMR
RATE
1988
1995
1965
1970
1988
1995
1960
1970
1980
1995
1960
1995
1960
400
28.0
21.0
27.0
28 0
21.0
17.0
25.0
14.0
27.0
26.0
23.0
16.0
27.0
26.0
28.0
37.0
38.0
29.0
30.0
20.0
17.0
26.0
31.0
13.0
22.0
26.0
41.0
23.0
21.0
11.0
10.0
8.0
21.0
10.0
8.0
7.0
15 0
8.0
7,0
4.0
7 1
6.2
70
5.0
5.8
5.1
3.9
19.0
20.0
20.0
11.0
12.0
11.0
18.0
24,0
21.0
12.0
16.0
8.0
17.0
18.0
18.0
9.0
10.0
10.0
9.0
11.0
9.0
6.0
5.0
6.0
TOO
15.0
13.0
7.0
10.0
6.0
70
7.0
8.0
9.0
8.0
10.0
16.0
9.0
10
7
7
4
7
8
9
8
6
5
5
10
12
9
7
8
6
6
7
9
8
8
10
15
9
6.2
4.0
2.5
3.7
2.0
5.2
5.0
4,4
2.6
4.2
4.6
5.1
6.4
7.0
49
4.9
3.5
3.6
5.1
6.8
3.5
2.4
1.9
2.9
1.7
3.5
3.2
2.7
1.8
3.4
3.0
3.5
5.3
5.3
38
3.9
2.3
1.8
3.1
3.9
1.7
3.0
156.0 1400 133.0 80.0
116.0 96.0 72.0 45.0
132.0 69.0 42.0 35.0
74.0 62.0 20.0 13.0
35.0 39.0 20.0
9.0
179.0 160.0 112.0' 57,0
165.0 139.0 119.0 69.0
139.0 119.0 93.0 52.0
85.0 48.0 270
10.0
73.0 46.0 31.0
12.0
92.0 74.0 52.0 33.0
158.0 129.0 110.0 84,0
195.0 168.0 134.0 92.0
163.0 143.0 125.0 91.0
80.0 67,0 53.0 40.0
89.0 80.0 68.0 51.0
71,0 55.0 _36.0_ 16.0
103.0 75.0 50.0 35.0
156.0 108.0 570 41,0
110.0 970 83.0 55.0
35.0 26.0 13.0
70
120,0 94,0 69.0 39.0
143.0 114.0 98.0 69.0
1700 138.0 115.0 92.0
128.0 98.0 82.0 55.0
247.0
177.0
173.0
124.0
49.0
34.0
32.0
28.0
16.0
30.0
28.0
30.0
42.0
46.0
31,0
35.0
22.0
22.0
31.0
38.0
14,0
29.0
31.0
47.0
27.0
10.0
22.0
19.0
11.0
14.0
8.0
9.0
17.0
10.0
13.0
16.0
22.0
20.0
16.0
10.0
11.0
14.0
21.0
13.0
3.4
7.0
4,2
70
6.6
5.4
5.7
68
6.8
6.0
5.8
6.9
70
6.5
5.3
64
6 1
8.0
3.0
4,9
5.1
6.6
4 9
6.1
5.8
5.5
4.3
5.5
3.5
5.9
6.3
7.0
6.4
5.7
4.3
5.6
59
7.8
2.5
4,4
5.5
6.6
5.1
1.9
38
4.3
6.7
3.7
12
5.7
2.9
1970
1980
1970
237.0
135.0
115.0
85.0
43.0
235.0
242.0 202.0
216.0 1720
127.0 55.0
134.0 111.0
179,0
300.0 232.0
226.0 183.0
107.0 82.0
133.0 100.0
148.0 102.0
159.0 137.0
1980
1995
207 0 115.0
86.0 57,0
60.0 43.0
29.0 16.0
22.0 10.0
175.0 76.0
173.0 95.0
124.0 75.0
18.0 14.0
14.0
76.0 41.0
134.0 1190
179,0 1310
161.0 127.0
69.0 53.0
67.0
48.0 19.0
58.0 42 0
60.0 4 49.0
107.0
83.0
9.0
53,0
104.0
157.0
81.0
HIE : High Income Economies
MIE : Middle Income Economies
LIE : Low Income Economies
SSA : Sub-Saharan Africa
Source : - World Development Reports, World Bank - 1993
- Health, NutriUon, and Populatin Indicators : A Statistical - Handbook Human Development Network, World Bank - 1999
39
Annex 2.6
Countries
Bangladesh
Year
1995-96
1990
1996
Literacy, Health and Poverty Indicators - India and World
Adult Illiteracy Rate (%
% of Population
% of Population
Population below poverty
of People 15 and
with Access to
with Access to
line (%) *
above) 1997
Sanitation
Water
Rural
39.8
32.6
7.9
Urban
14.3
13.1
<2
Total
35.6
17.4
6
M
50
16
9
5
F
73
16
25
5
Brazil_________
China_________
Costa Rica
Cuba_________
Egypt, Arab Rep.
35
60
India_________ 1999-2000# 27.09
23.62
26.1
24“
46“
Indonesia______
1990
14.3
16.8
15.1
9
20
Korea, Rep.
1
4
Malaysia______
1989
15.5
10
19
Mexico________
1988
10.1
8
12
Myanmar______
11
21
Nepal_________
1995-96
44
23
42
44
79
Pakistan_______
1991
36.9
34
28
45
75_
Philippines_____
1997
51.2
22.5
37.5
5
6
South Africa
15
17
Sri Lanka______
1990-91
38.1
28.4
35.3
6
12
Thailand_______
1992
15.5
10.2
13.1
3
7
.Viet Nam______
1993
57.2
25.9
50.9
5
11
(Zimbabwe
1990-91
25.5
6
12
* On the basis of National Poverty Line
Data obtained from Census of India 2001, Registrar General & Census Commissioner, India
# Data Obtained from Economic Survey of India (2000-2001)
s9urce 1 Entering the 21st Century, World Development Report 1999 / 2000, World Bank.
1995
35
67
97
70
16
55
100
94
76
43
23
__33_
77
1_75_
96
60
66
Prevalence of Child
Malnutrition (% of
Children < 5 Years)
1995
84
69
83
100
1992-97
56
6
16
5
84
85
65
83
89
95
60
59
62
83
59
70
89
47
77
15
53
34
20
14
43
47
38
30
9
38
45
16
40
Annex 2.7
Population Statistics - India and States
INDIA/STATES
Andhra Pradesh
Assam
Bihar
Gujarat
Haryana
Himachal Pradesh
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Orissa
Punjab
Rajasthan
Tamilnadu
Uttar Pradesh
West Bengal
India
Total
Population
(in Lakhs)
% Decadal
Variation in
Population
Total
Population
(in Lakhs)
% Decadal
Variation in
Population
Total
Population
(in Lakhs)
% Decadal
Variation in
Population
Total
Population
(in Lakhs)
% Decadal
Variation in
Population
Total
Population
(in Lakhs)
% Decadal
Variation in
Population
Population
Projection
(in Lakhs)
1961
1951-61
1971
1961-1971
1981
1971-1981
1991
1981-91
2001
1991-2001
2016
359.83
1,083.73
464.47
206.33
75.91
28.12
235.87
169.04
323.72
395.54
175.49
111.35
201.56
336.87
737.55
349.26
4,392.35
15.65
34.98
19.76
26.88
33.79
17.87
21.57
24.76
24.17
23.60
19.82
21.56
27.83
22.30
19.78
26.87
21.51
435.03
146.25
563.53
266.97
100.36
34.60
292.99
213.47
416.54
504.15
219.45
135.51
257.66
411.99
883.42
443.12
5,481.60
20.90
34.95
21.33
29.39
32.23
23.04
535.51
180.41 *
42.81
23.10
23.56
24.06
27.67
28.75
23.71
24.22
26.29
28.67
27.45
25.05
21.70
27 83
22 30
19.78
26.87
24.80
371.36
254.54
521.79
627.83
263.70
167 89
342 62
484 08
1,108.63
545.81
6,833.29
26.75
19.24
25.27
24.54
20.17
23.89
32 97
17 50
25 49
23 17
24.66
699.15
340.86
129.22
665.08
224.14
863.74
413.10
164.64
51.71
449.77
290.99
661.81
789.37
316.60
202.82
440.06
558.59
1,391.12
680.78
8,463.03
24.20
24.24
23.54
21.19
27.41
20.79
21.12
14.32
26.83
25.73
20.06
20.81
28 44
15 39
25.48
24.73
23.85
757.27
266.38
828.78
505.96
210.82
60.77
527.33
318.38
603.85
967.52
367.06
242.89
564.73
621.1
1660.52
802.21
10270.15
13.86
18.85
28.43
22.48
28.06
17.53
17.25
9.42
24.34
22.57
15.94
19.76
28.33
11.19
25.80
17.84
21.34
886.23
325.02
1323.05
593.38
251.73
79.45
627.83
368.77
1051.55
1078.02
410.23
280.45
714.13
698.66
2428.61
. 962.31
12635.43
* The population figure of Assam for 1981 have been worked out by interpolation as the 1981
census could not be conducted in Assam due to disturbed conditions.
Source : Census of India
Note: ILakh = 100 Thousands
41
u
3
The Stats Role in Health
Background
The lack of clarity about the Site’s (1) role, whether in the changing
economic scenario or in health, has had a range of negative
consequences. First, there has been a gross mismatch between available
resources and stated goals, which has inevitably, led to the erosion of
accountability and morale, as well as the inadequate monitoring of
performance. Second, there has been a lack of prioritization, contributing
to the misallocation of limited resources in response to political and other
pressures. Finally, state interventions have been stretched to areas best
left to the private sector, resulting in financial and human resources being
spread too thinly for impact. Given an overburdened, under-motivated and
inefficient health system, these consequences can mean almost total
breakdown.
Role of the State
The State’s role has been active y debated, particularly in the context of
globalization and economic liberalization. One school of thought is that
excessive State intervention has stifled private initiative, creating a
burgeoning bureaucracy and fiscal imbalances. With inefficiency and
corruption eroding public confidence, leading commentators have
suggested limiting State role to essential functions such as defense, law
and order and external relations (2). Economic reforms over the last
decade have liberalized an over-regulated economy, and increased the
role of market forces and competition. This recent experience has raised
the expectation that an increased role for market forces could remedy the
ills of the health system.
Focusing on the role of the State in a changing world, the 1997 World
Development Report (WDR) identifies five fundamental State tasks:
• establishing a foundation of law;
•
maintaining a non-distortionary policy environment
macroeconomic stability;
investing in basic social services and infrastructure;
•
protecting the vulnerable; and
•
protecting the environment.
•
including
Of the failure of State-dominated development strategies in the
developing world and the decisive shift in favour of market mechanisms,
World Bank President James Wolfensohn says, “Many have felt that the
logical end point of all these reforms was a minimalist state. Such a state
would do no harm, but neither could it do much good.” (3)
42
u
Suggestions for a bigger role for the private sector in health do not always
recognize that the private sector already plays a dominant role in India;
and that it is, unlike the industrialized world and many developing
countries, almost entirely unregulated with many negative consequences.
Amartya Sen points out that “while the case for economic reforms may
take good note of the diagnosis that India has too much government
interference in some fields, it ignores the fact that India also has
insufficient and ineffective government activity in many other fields,
including basic education, health care, social security, land reform, and
the promotion of social change.” (4)
WDR 1993 examined the rationale of government role in health,
identifying three economic rationales for government action.
• The poor cannot always afford healthcare that promotes
productivity and well being. Publicly financed investment in
health can lead to the alleviation of poverty and its
consequences.
• Some health-promoting actions are pure public goods or create
large positive externalities. Private markets would either not
produce them at all, or produce too little.
• Government intervention can improve how these markets in
healthcare and health insurance function, thus raising welfare.
WHR 2000 describes government role as stewardship, listing three basic
tasks:
• formulating health policy - defining vision and direction;
• exerting influence - approaches to regulation; and
• collecting and using intelligence.
The specific areas of State intervention in public health recommended by
WDR 1993 are :
• immunization;
• school-based health services;
• information and selected services for family planning and
nutrition;
• programmes to reduce tobacco and alcohol consumption;
• regulatory action, information, and limited public investments to
improve household environment; and
• AIDS prevention.
Despite the lack of unanimity over the State's role in healthcare, there
seems to be agreement that universal access and equity in a poor country
are dependent on the State's provision, or financial support, of basic
healthcare for the poor. Protecting the vulnerable is considered a core
function of the State; and publicly financed healthcare is an important tool
in poverty alleviation. But what services should the State provide or
support, and how?
43
u
In the WDR 93 package of essential clinical services, five groups of
interventions are listed on the basis of their cost-effectiveness, each
addressing large disease burdens:
• services to ensure pregnancy-related care (prenatal, childbirth,
postpartum);
• family planning services;
• tuberculosis control;
• the control of Sexually Transmitted Diseases (STDs); and
• care for common childhood illnesses (diarrheal diseases, acute
respiratory infections, measles, malaria, acute malnutrition).
Circumscribing State intervention only on the basis of cost considerations
has serious moral, ethical and equity implications. What happens, for
example, if a poor child has a cancer that does not yet have cost-effective
treatment? State mechanisms that protect the poor from the financial
consequences of illness - through risk pooling and prepayment schemes
— must be put in place. The WHO Director General, Dr. Brundtland,
says: “Health Systems are not just concerned with improving people’s
health but with protecting them against the financial costs of illness. The
challenge facing governments in low income countries is to reduce the
regressive burden of out-of-pocket payment for health by expanding
prepayment schemes, which spread financial risk and reduce the specter
of catastrophic health care expenditures.” (5)
Even without directly providing these interventions or supporting them
financially, the State has to put in place institutional arrangements that
deliver services to the targeted population, particularly the poor and
vulnerable. In our present situation, the State cannot escape the
responsibility of directly funding and providing most public health
interventions and clinical services. The objective then is to encourage the
role of facilitator wherever possible, so that eventually the State’s
predominant role moves from provider to facilitator, financier and
regulator, ‘less to row and more to steer.’ J
In sum, the essential functions of the State in health are as follows.
Stewardship functions:
• Formulating health policy; defining its vision and direction.
• Regulating and framing laws, setting standards and
enforcing them.
• Monitoring
the
main
determinants
of
health
and
demographic indicators and evaluating the impact of health
related interventions.
• Collecting and using health intelligence for epidemiological
surveillance and policy formulation.
• Guiding and overseeing the health system for universal
access, equity, quality and consumer satisfaction.
• Mobilizing resources and facilitating a health finance
framework that ensures fairness and financial risk
protection.
44
•
•
Planning and encouraging the development of human
resources for health.
Mobilizing
public
opinion
and
promoting
popular •
participation in public health activities.
Public health interventions:
• Providing and promoting public goods (6), such as health
research, health education, sanitation, safe drinking water,
protection of the environment, and the control of risk
factors such as tobacco and alcohol.
• Arranging the delivery of merit goods (7) that benefit the
individual but have large externalities - immunizations,
control of infectious diseases, family planning services and
nutrition.
• Arranging clinical services for disadvantaged sections,
including services for pregnancy care; childhood illnesses
such as diarrheal diseases and acute respiratory infections;
and all other forms of primary and secondary healthcare
with a referral mechanism for tertiary care.
Constitutional Provisions
The Indian constitution does not list health as a fundamental right. The
recommendatory Directive Principles of State Policy enjoin the State to
raise nutrition level and improve public health (Article 47). But many court
rulings have interpreted the fundamental right of protection of life and
liberty (Article 21) as inclusive of the right to health, implying State
obligation to protect citizens from medical negligence. The State
concentrated on the development of health infrastructure because of its
welfare-oriented goals, the near absence of rural health facilities, an
insignificant private sector presence in modern medical facilities, and the
recommendations of the 1946 Bhore Committee. Thus the State emerged
as the main provider of healthcare.
The roles of the centre (8) and the states must be defined in the light of
constitutional provisions. The Indian constitution divides all State
functions into three lists: the union list, the concurrent list and the state
list. The union and state lists comprise subjects exclusively under the
jurisdiction of the centre and the states respectively; the concurrent list
represents subjects where both have concurrent jurisdiction, but where
central laws always prevail over state laws in the event of a conflict.
Under Article 252, the resolution of two or more state legislatures
empowers the centre to frame laws, even for subjects in the state list; but
these become applicable only on adoption by the state legislature. Central
legislation on state subjects have been frequent, to encourage legal
uniformity, and to take initiatives in areas important for the country as a
whole (9).
The constitution places 'public health and sanitation, hospitals, and
dispensaries’ in the state list. But some related activities
medical
45
u
H
education, drugs, family planning, the control of the spread of
communicable diseases from one state to another, mental health and the
medical professions - are in the concurrent list. The only areas of
exclusive central jurisdiction (the union list), are institutions of national
importance in medical education and research. But the centre has played
a dominant role in all aspects of health, mainly because of its financial
clout in a centrally planned economy. The Five Year Plans have
determined strategy, priority and allocation of resources for development.
Though these plans were nominally formulated in consultation with the
states, they generally reflect policy perceptions of the Planning
Commission and the concerned Central Ministries. The states receive
annual block development assistance for development activities, but the
centre exerts considerable influence on allocations because of annual
plan consultations. In the numerous centrally sponsored schemes, the
centre provides full or partial funding and programme content; only
implementation is left to the states. These schemes include the control of
major communicable diseases (HIV/AIDS, TB, malaria, leprosy), and even
some non-communicable diseases (cancer and blindness). Many public
health activities (family planning, maternal and child health) and a
s gnificant part of rural health infrastructure, are supported by such
hemes. Increasing external assistance, usually channeled through the
^ntre, has enhanced the central role. With economic liberalization, there
has been a perceptible shift in center-state relations - in the state’s
favour - over the last decade. The deregulation of industry, the delegation
of powers to the states in many economic spheres, and the increasing
role of the private sector, have all reduced state dependence on the
central government. This has encouraged new initiatives by the states in
health finance, decentralization and public-private partnerships. The
donor community is also encouraging this trend by directly negotiating
projects with the states (with central approval), for example, the World
Bank - supported health systems projects in five states.
But the centre remains a dominant actor in the health sector. A clear
demarcation of central and state roles has never been attempted, not
even by the only national policy on health, the 1983 National Health
Policy. The result is an overlap between the two roles: the centre not only
dictates the development agenda but often engages itself in day-to-day
programme management. This has stifled state initiative and diverted the
centre’s attention from its more important functions of stewardship.
Roles of Central and State Governments
The Report on the Restructuring the Ministry of Health and Family Welfare
(July 2000) defines the core functions of the Central Ministry as follows.
• Setting national goals for citizens’ health status, delivery of
health services, achieving zero growth population in different
regions in definite time frames.
• Monitoring progress towards goals.
• Formulating national policies, strategies and investment priorities
to achieve goals.
46
u
•
•
Developing national syste~s ;3f' control
- • of- major communicable
and non-communicable diseases.
Developing national programmes of medical education, training
and research, including tre establishment and control of some
nationally important institutions.
In summary, the main functions constituting central and state roles are as
follows.
Central Government
1.
Stewardship
Formulating health policy, defining vision and direction;
Framing laws, setting standards, arranging enforcement;
Monitoring the determinants of health and demographic
indicators, evaluating performance of health interventions;
• Collecting and using health intelligence for epidemiological
surveillance and policy formulation;
• Promoting inter-sectoral coordination to achieve health
goals;
• Guiding and overseeing the health system to achieve
universal access, equity, quality and consumer satisfaction;
• Mobilizing public opinion and support and promoting active
popular participation in public health activities.
Health Finance:
Mobilizing resources and facilitating a fair health financing
• MODinzmg
framework that ensures financial risk protection;
• Mobilizing external aid and channeling to priority areas.
Manpower Development:
• Planning human resources for health and developing an
appropriate incentive system to motivate and retain health
workers in priority areas.
Health Research:
• Promoting and supporting relevant health research in public
and private sectors.
• Establishing institutional mechanisms for analyses of
research inputs and utilization for health policy and
programmes.
Public Goods;
• Promoting and supporting health education, sanitation, safe
drinking water, better environment, control of the risk
factors of tobacco, alcohol and unhealthy life styles.
Merit Goods:
• Planning and supporting delivery of merit goods such as
immunizations,
control
of
communicable
diseases,
population control and nutrition.
Public Health:
• Arranging technical expertise to guide and oversee state
programmes.
•
•
•
2.
3.
4.
5.
6.
7.
47
u
8.
9.
Drugs and Pharmace_: cals:
• Developing policy framework to ensure availability
essential drugs at affordable costs;
• Standardization, quality control and their enforcement;
• Encouraging rational drug use.
Food Standards:
• Creating standards and regulations and enforcing them.
of
This list is illustrative, not exhaustive. With its enormous political and
financial clout, the centre can persuade the states to make the health
system respond to identified national objectives, and provide the
necessary technical expertise, information, and financial resources for the
achievement of these goals. The states would be involved with many of
these issues at the micro level, their main concern the actual
management of health systems and implementation of health programmes.
State Governments
1.
Stewardship:
• Planning and overseeing the health system.
• Framing state laws and enforcing central and state
regulations.
• Epidemiological surveillance and response to epidemics.
• Monitoring health indicators and evaluating performance of
public interventions.
• Promoting coordinated action by health related agencies to
achieve convergence and mutually reinforcing programmes
at the cutting edge ievel.
2.
Health Finance:
• Mobilizing resources, allocating state and central resources
to meet priority objectives.
• Developing, managing and regulating health financing
system to meet stated objectives.
3.
Manpower Development:
• Planning development of health manpower and providing
institutional facilities.
4.
Public and Merit Goods:
• Implementing programmes for efficient access to public and
merit goods.
5.
Public Health:
• Setting up and managing institutional framework for
implementations of public health programmes at different
government levels.
6.
Drugs and Food Standards:
• Enforcing laws and regulations.
• Rationalizing procurement and distribution of public sector
drugs.
7.
Healthcare services:
• Providing or funding essential healthcare services, primary
and secondary, targeted at the poor.
48
11
•
•
•
Developing an effec.ive referral system for tertiary care for
the poor with a supporting financing mechanism.
Regulating private sector accountability and consumer
satisfaction;
Developing partnerships with the private sector to provide
healthcare services and support public health programmes.
Conclusion
The centre's involvement in the routine management of various
programmes and institutions has Hampered the effective discharge of its
role as steward. This is partly due to structural weaknesses (10). The
National Health Policy 1983, the only policy exercise post-independence,
contains good ideas and intentions, but does not examine human and
financial resource requirements, management structure and institutional
frameworks that would translate these into action. Initiatives to regulate
the private sector’s growth and development have been largely haphazard
and unplanned. A health finance system to ensure equity and risk
protection has not been evolved. Central capacity, in respect of policy
analysis and public health expertise, remains limited. Like the centre, the
states exhibit structural weaknesses Dependent on the centre, urea to
playing only the role of implementers, the states have lost initiative and
developed a routine management style. There have been some
developments towards^ restoring the position assigned to the states by the
Constitution. The 73rd and 74th
lh amendments of the constitution (1992)
formally recognized and defined the role of local bodies, the
municipalities, and the panchayats. This has encouraged some states to
delegate many responsibilities, including health, to these local
institutions, with far-reaching consequences for health systems in the
future.
Clarifying the role of the State in health is only a first step. With the
present levels of State investment, at $3 to $4 per capita (11), no system
can be expected to perform. A major effort to mobilize resources from
both external and domestic sources is required to achieve the necessary
higher levels of state investment. Meanwhile, a comprehensive health
sector reform initiative should direct resources to priorities and raise
utilization efficiency; restructuring the central health ministry and state
level departments would provide the management and institutional
frameworks to carry out assigned functions. Above all, a high level of
political support and popular participation are required to make this
exercise a success.
49
u
N otes
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
The concept of the State is broader than that of the government and includes
legislatures and autonomous para-statal institutions. The State as a concept is
distinguished here from the states of the union by using the capital letter S.
For a fuller discussion see Bimal Jalan, India’s Economic Policy: Preparino for
the 21st Century, 1996.
James D Wolfensohn, Foreword. World Development Report 1997.
Jean Dreze, Amartya Sen, India - Economic Development and Social
Opportunity, 1995.
World Health Report 2000, Message from the DG.
Public goods are interventions that do not benefit individuals directly, but
benefit the community as a whole.
Merit goods are interventions that benefit the individual, and also have large
externalities, thus benefiting the community.
The term ‘centre’ here denotes the federal or union government.
The central legislation on organ transplants is a good example of central
legislation on a subject in the state list.
For a fuller discussion see Appendices, The Restructuring of the Ministry of
Health and Family Welfare.
1993-94 constant prices, World Bank, 2001.
50
ii
4
Economic Growth, Poverty and Health
Introduction (1)
The model of development in the post-colonial period rested on the belief
that economic growth was a sufficient condition for removing poverty and
triggering development. The realization of the lack of an automatic linkage
between growth and poverty elimination led to the stepping up of
affirmative action, through massive poverty alleviation and employment
generation programmes. However, the limitations of this strategy began to
surface with the inequitable access to social goods that continued to
persist despite improved incomes. In addition to income increases,
adequate social investment and consumption - at the macro level and by
individual households at the micro level - were seen as essential
prerequisites for people to live longer and healthier for the greater
accumulation of wealth. Thus the evolution of the definition of what
constitutes progress brought to the foreground the interconnectivity
between economic growth, poverty and social goods, namely health
adding new dimensions to the understanding of development economics.
For a better understanding of the factors that influence growth and human
development, a great deal of research has recently been conducted on the
nexus between health and economic growth on the one hand, and health
and poverty on the other. With most research based on household data,
there is a good body of knowledge available to establish the link between
health and poverty; and through that, the link between good health and a
better quality of life. However, the absence of any substantial research
taking time series data to assess the impact of economic growth on
health, has been a serious handicap in arriving at any conclusive
evidence of the hypothesis that economic growth contributes to good
health and vice versa.
This chapter will review some of the empirical evidence available in
international research to understand the extent to which economic growth,
poverty and health influence each other; it will also assess the centrality
of health to the process of higher economic growth and poverty
alleviation. The understanding of such evidence is critical to developing
countries like India, particularly in helping them restrategize their
development policies to ensure that the “conception of development...
goes much beyond the accumulation of wealth and the growth of gross
national product and other income related variables” (2), a line of thinking
that seems dominant among economic planners.
51
?
oo\
u
Economic Prosperity and Good Health
If development must, as argued by Amartya Sen, be “primarily concerned
with enhancing the lives we lead and freedoms we enjoy... the freedom
from avoidable ill health and from escapable mortality” (3), then it is
important to understand the connection between economic development
and health. This link is illustrated by the African American example,
citizens of the richest and the highest health-spending country. Their
survival prospects, in terms of longevity of life, are comparable to, if not
less than, that of the people of China, or Kerala in India. This indicates
that beyond incomes, good health is also influenced by other factors such
as access to medical care facilities, education, prevalence of violence and
so on (4).
While there is substantial evidence available to establish the strong
statistical connection between longevity of life and income levels, such
evidence also seems to suggest that this connection works particularly
through two variables: public spending on health and increase in incomes
among the poor (5). This takes us to the next important aspect, of how the
gains of economic growth are being used, suggesting that such outcomes
are the result of the gains being shared equitably and on life enhancing
activities such as health, nutrition and education. For example, South
Korea and Taiwan achieved much higher levels of life expectancy than
other countries with a similar GNP growth such as Brazil, countries that
have wide income disparities, unemployment and relatively poor public
health systems. The example of South Korea is also relevant for another
reason - longevity of life resulting in the reduced dependency ratios.
Usually countries with high fertility and high mortality not only have a
reduced labor force, but also lower productivity. In the case of South
Korea, reduced dependency ratios were accompanied by policies aimed at
exploiting this “demographic dividend” for accelerating growth rates, by
harnessing the increased workforce through new technology, investment
in education and human capital development and exploiting global
markets. Studies of Bloom, Canning and Malaney (in press) also show
that such interaction of demographic influences with human and physical
capital development can “lead to a virtuous cycle of growth, enabling a
country to break free of the poverty trap.”
Though there are many examples of longer life expectancies consequent
to economic growth, there is little evidence as yet to suggest a causal
relationship. In other words, it is not as if longer life spans automatically
cause increases in incomes or vice versa. Thus it is not usually easy to
correlate periods of high growth with lengthening life spans. As argued by
Richard Easterlin, richer societies can have improved health, but it is not
52
I
“inevitable as health shifts are influenced by other factors, such as the
role of health technologies.”
As in the case of individuals, so also in the case of countries. Evidence
indicates that the poorer countries have lower life expectancies and
poorer health indices. An econometric exercise of 31 countries showed
that had the life expectancy in these countries been 10% higher in 1990,
there would have been a positive effect on income growth, and a modest
negative effect on income inequality. The result would have been that 30
million would have been lifted out of poverty by 2015. Russia is yet
another example of the impact of poor economic growth and political
instability on health, reflected in reduced life expectancy and premature
deaths.
The health-wealth connection is, however, most well amplified in the
impact that a healthy workforce has on increasing overall productivity higher outputs, less absenteeism on account of illness, less expenditure
on health bills by employers, higher foreign direct investment and higher
savings. Thus, though there may be no direct link between longevity of life
and economic growth, no one can doubt the existence of a strong
relationship and interdependence between the two.
Health, Nutrition and Poverty
The world over, ill health disproportionately affects the poor, leading to
higher morbidity and mortality. The physical body is the poor man’s main
asset. Ill health due to disease or injury triggers a spiral of chain
reactions - loss of work, deprivation of earnings and expenditures for
medical treatment, often supported by borrowings. This, along with
reduced financial capacity to restore earlier health status, lower
productivity and earnings, and the burden of debt repayments, inevitably
push low-income families into the poverty trap. Studies of TB patients in
Bangladesh and Uganda demonstrate these devastating consequences on
the family as a result of the earning member contracting TB.
An examination of adult anthropometric measures such as height, weight
and body mass index (BMI), and illness patterns on labor productivity as
measured by wages, showed that height and mortality were inversely
related, resulting in a reduced number of productive working years (6).
Similarly, short height and low BMI result in chronic morbidity in midlife
and male deaths in late life (Fogel, 1994). Basically, increased height and
better productivity is the cumulative impact of parental nutrition and
childhood nutrition over the course of the life cycle, underscoring the
importance of access to nutrition early in life. In Ghana (7), height was
found to affect wages - a one cm. increase resulted in an 8% increase in
hourly wages for men and 7% for women. Leiburstein (1957) and Mirrlees
53
J
(1975) show that the link between human energy intake and nutritional
deficiencies significantly affects peop e's ability to work; they indicate a
positive relationship among earnings, productivity and energy intake (8).
Thomas and Strauss (1998) perceive nealth as an important determinant
of productivity. They argue that the marginal productivity of good health is
likely to be higher in lower income countries because of the predominance
of infectious diseases, and correspondingly higher infant and childhood
mortality. This is in contrast to industrialized societies that experience
higher levels of morbidity among older age groups. Lower income
countries are also more labour dependent, and hence must value a
healthier workforce to maximize production in these settings. A study in
Indonesia found that men with anemia were 20% less productive than nonanemic men. Another study, in which the education variable was
controlled, showed that height, BMI, energy and protein intake had a
positive effect on wages. In fact, the study showed that taller men and
women earned higher wages even if less educated. In sum, there are
thresholds to health status below which functioning and productivity are
seriously impaired. Thus targeting the poorest for improved health would
yield maximum dividends in terms of incomes. It is equally true that there
is a positive causal link between incomes and nutritional status as
improved incomes enable accessing food and nutrition.
Another important variable with a positive effect on health and wages is
schooling. Leslie and Jamieson (1990) showed how school performance is
affected by ill health. A late start in schooling, inadequate learning and
unequal participation of girls were found to be on account of seven
possible health grounds: nutritional deficiencies, helminth infections,
other infections, disabilities, reproductive and sexual problems, injury and
substance abuse. This study also shows that prenatal iodine deficiency
causes permanent mental retardation and chronic iodine deficiencies
severe mental impairment. A similar study conducted in Bolivia found that
programs providing iron and iodine supplementation to nutritionally
deficient girls improved their cognitive functions and school performance.
Thus increased investments in child health could benefit better education,
in turn leading to higher productivity and earnings at individual and
societal levels.
Geography and demography are also variables that link economic
performance and health, life expectancy and mortality levels. Geography
is linked to disease burden, due to the impact of tropical climates and age
structures on health status. Studies show that lower mortality and higher
levels of life expectancy have statistically significant effects on incomes
and growth. An analysis of 5 countries by Bhargava showed that good
health resulted in increased productivity due to lower sick leave and
increased savings. Similarly, empirical country-specific estimates of the
54
iI
effects of adult survival rates on natical incomes generated estimates of
the contribution of health to economic growth. Jamieson’s study showed
that in India, income per capita grew at 2% during 1965-90 and adult
survival rate improved by 20%. 13% cf income growth was on account of
improved health. A sample of 58 countries showed that of the 2.4% per
capita increase in incomes, 8% was cue to increase in adult survival. At
another level, a study of England during 1780-1979 showed a 30%
30%
increase in per capita income because of improvements in health and
nutritional status.
Or special concern is the devastating impact of malaria, TB and HIV/AIDS
on the prospects of higher economic growth in developing countries. In
different studies, Chima and Mills (1999), Malaney (1998), and Leighton
and Foster (1993) demonstrated significant direct and indirect costs on
the household in terms of reduced earnings on account of malaria. In
Kenya, it was calculated that the total annual value of malaria related
production loss was 2-6% of GDP; in Nigeria it was 1-5%. Malaria related
costs as a percentage of total household costs for small farmers was 0.85.2% in Kenya and 7.2-13.2% in Nigeria. Several studies have
demonstrated the economic impact of TB in Bangladesh, Uganda, South
Africa and India, demonstrating significant direct and indirect costs to the
household as well as to the health system. In Bangladesh, Croft and Croft
(1998) estimated a mean financial loss of $245 or four months of
household income for meeting the costs of medicines, fees, laboratory
tests etc. Besides, seeking TB treatment resulted in several patients
being forced to close down their businesses or stopping or reducing work,
lower incomes, and the removal of children from school. Studies have
shown a significant impact of HIV/AIDS on GDP: if AIDS treatment is
financed by savings and afflicted workers’ productivity is reduced by 50%,
the net loss is in the region of 0.8% of GDP in Tanzania and 1.5% in
Malawi (Cuddington and Hanscock). Assuming only 50% being treated
from savings, the impact on annual GDP growth in Sub-Saharan Africa is
about 0.9% (Over). The findings of these studies on three communicable
diseases are significant for India with its high morbidity and mortality on
account of malaria, TB and HIV/AIDS.
Lessons Learnt
International experience seems to corroborate the Indian experience. (See
Appendix 2, paper by Indrani Gupta and Arup Mitra commissioned
specially for this report.) Gupta and Mitra examine the complex
relationships among health, other non-health consumption, consumption
goods, public spending on medical care, and total income, to seek
answers with regard to three issues - the impact of increased health
expenditures on health indicators; the impact of improved health
indicators on investment and growth; and the linkages, if any, between
55
u
poverty and health. Taking state-leve data for health status for the years
that data on poverty estimates was also available, variations across
states and time between poverty and health indicators were plotted and
examined. States were grouped for each health indicator taking five yearly
averages of growth into account. The exercise brought out the following
significant insights:
>
Yk
a strong association between IMR and poverty, both
reducing alongside increased growth in most states;
strong linkage between CBR and poverty in some states,
though association in the poorest states (Bihar and Orissa)
seem marginal;
improved life expectancy and decline in morbidity
associated with improved growth rates;
overall, a positive suggestion that growth did reduce poverty
and result in improved health indicators, despite state
variations on degree of association among growth, poverty and
health indicators.
The trends and associations were tested by econometric analysis, and
controlled for other exogenous variables possibly influencing each of
these variables. The first variant took each of the endogenous variables to
influence the other two; the second demonstrated a causal connection
running from growth to poverty to health; and the third variant estimated
impact of growth and health on each other, then together on poverty. The
results of such modeling showed that
>
>
>
per capita public health expenditure is unambiguously and
positively related to health status: higher per capita health
expenditures improve health status in all three equations;
poverty is reduced with improved health;
there is a positive linkage between growth and health
status on a two-way basis;
higher growth improves health status; better health status
reinforces trends in income growth.
On the basis of empirical analysis, the paper by Gupta and Mitra
concludes that though there has been a decline in Indian poverty, further
reduction would depend on a significant improvement in health conditions.
This improvement is contingent on a substantial increase in health
investment among other exogenous variables, namely literacy and
industrialization - yielding higher growth as well as better quality of life. It
appears to be dear that if India is to reduce poverty and achieve
accelerated growth, investments in health and education will have to be
substantial.
56
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5
Towards Equity in Health
Introduction
The concept of equity, based on social justice, is concerned with narrowing
the gap between the rich and the poor. The measurement of such gaps or
inequities has moved beyond the narrow definition of incomes and
consumption expenditures to cover a set of basic human needs. The first
concrete expression of this new generation of analytics was the Human
Development Index (HDI), followed by the Gender Development Index (GPI)
and the Human Poverty Index (HPI). The HPI is a powerful tool to measure
inequality and evaluate development in terms of the numbers who die before
the age of forty, are illiterate, lack access to safe water and sanitation, and
have a disproportionate percentage of underweight children below the age of
five. The resulting body of empirical evidence demonstrates that the overall
economic growth per se does not necessarily mean good health, or a better
quality of life for all.
The reduction of socio-economic inequalities has been the cornerstone of
development planning in India. Article 38 of the Constitution provides for the
State to "strive to minimize inequalities in income and endeavor to eliminate
inequalities in status, facilities and opportunities...” Between 1950 and 1990,
the political agenda was vigorously pro-poor. Attempts were made to
implement policies such as land reform, affirmative action of quotas and the
mechanism of Special Component Plans (1), and poverty alleviation
programmes to liquidate rural debt, ban bonded labor and fix minimum
wages (2). Such efforts reduced poverty from 54.4% in 1973-74 to 35.57% in
1993-94 (3), though in gross terms, 320 million continue to be below the
poverty level (4). Recent NSSO estimates (5) show a sharp decline of
people below the poverty line to 26.10%, but these estimates are being
disputed because of a change in methodology.
Equity and Health
The 1978 Alma Ata Declaration was the first international effort to mobilize
global commitment to reduce gross inequalities between and within
countries, by exhorting governments to strengthen primary health systems
and assume responsibility for an acceptable level of health for their people
(6). In India, the post Alma Ata period saw the rapid expansion of rural
primary health facilities. This increased access among rural populations and
accelerated investments in preventive and promotive health - access to
water, immunization, ante-natal care and female literacy. Literacy increased
from 43.5% to 62% during 1981-97; so did access to safe water in rural
areas from 73.9% to 92.5% during 1990-98 (7). Morbidity and mortality due
to vaccine preventable diseases reduced. But despite these developments,
and despite policy pronouncements and international resolutions, goals
58
H
continue to be expressed in terms of societal averages that hide wide
epidemiological differentials (8). Disproportionate numbers of the poor suffer
from pre-transition diseases. On an average, 12% of income is spent by the
poor on healthcare, as against 2% by the rich (9). Ill health means the loss
of daily wages or even loss of work. Chronic illness or hospital treatment
may call for liquidation of meagre assets, even pledging the child in dire
cases: between 1986 and 1996 (10) those sick but not availing treatment for
financial reasons increased from 15% to 24% in rural areas, and doubled
from 10 to 21% in urban areas. Evaluation reports of the Department of
Rural Development also indicate that health expenditure, particularly for
hospital treatment, is the second major cause of rural indebtedness. All this
evidence reveals the nexus between ill health and deprivation - the poor
become ill and illness makes them poorer - and calls for public policy that
ensures access to health services as an integral component of poverty
alleviation strategies.
Inequity is multidimensional, hence the need to assess relative inequities
among three broad groups: those below the poverty line, marginalized
groups (SC/STs), and women. Since inequity is dje
’nccme differentials
as v.ell as societal prejudices, analysis based soleiy on income criteria
would be incomplete. The SC/ST (11) populations serve as a sensitive
indicator for inequity - the most socially and economically marginalized
sections of the population, they face the double burden of social exclusion
and poverty. They comprise 22% of the total population, but have a higher
proportion of families below the poverty line; 81% (12) are landless labor
with practically no assets. Similarly, women command a lower social value,
reflected in the family's lower expenditure on their healthcare, or delays in
referral, denial of treatment or underreporting. Thus, typically, an SC/ST
woman could face the triple disadvantage of income, caste and sex.
Differentials in Health Status
A review of data collected in NFHS II, NSSO surveys and sample studies
carried out from time to time clearly indicates the extent of inequity in health
status. The data for important indicators highlights differentials in levels of
mortality among children of disadvantaged sections compared to others, for
rural and urban areas (Tables 5.1 and 5.2). Data also reveals differentials in
malnutrition and health status among SC/ST women compared to others
(Tables 5.3 and 5.4), and differentials in the prevalence and nature of illness
among rich and poor, urban and rural (Table 5.5). NHFS II shows that SC/ST
children, at greater risk, record 1.3 to 1.7 times more deaths than others.
Data indicates that STs are at greatest risk of early death followed by SC
children (Table 5.1). Rural SC/ST children die in larger numbers than their
urban counterparts, mainly due to the lack of timely care.
59
Table 5.1
Health Indicators among SC/ST and Others (Rate per 1000)
Mortality Indicators
sc
ST
Others
NeoNatal
53.2
53.3
40.7
Post Neo Natal
29.8
30.9
21.1
Infant <1 year
83
84.2
61.8
Child Mortality1-5
39.5
46.3
22.2
Under 5 Years
1 19.3
126.6
82.6
Source: NFHS II
Table 5.2
Differentials In IMR and Under-5 Mortality according to Rural /Urban Social Group
_______ Indicator
Under 5 Mortality
Rate/1000
Rural
Urban
SC
127.3
ST
OTHERS
____ Indicator
Infant Mortality
Rate /1000
Rural
84
SC
88.1
60.4
131.4
79.6
ST
86.9
57.6
93.1
5.7
OTHERS
69.3
43.5
Urban
Source: NHFS II
When data in Table 5.2 is correlated with incidence of cough, fever, and
moderate/severe diarrhea (no significant variations between different social
segments), factors like malnutrition surface to influence chances of survival
among SC/ST children. Over the years, there has been an improvement of
the Body Mass Index (BMI) and Chronic Energy Deficiency (CED) (13), yet
malnutrition among women continues to be severe, particularly among
disadvantaged sections (Table 5.3). The three parameters pertaining to
height, body mass index and hemoglobin level influence outcomes of
pregnancies. The data on these nutritional conditions offer explanation for a
higher risk of maternal mortality, the birth of low-weight babies with long
term health consequences, and failed pregnancies.
Table 5.3
Nutrition Levels among SC/ST Women
Category
%Women< 145cm
%Women<18.5kg/m
% Anemia
SC
17
42.1
56
ST
13.5
46.3
64.9
__ Others
I
Source: NFHS II
10.9
30.5
47.6
60
11
Data clearly indicates that tribals as a community are most at risk. This is
corroborated by information from the Tribal Research Institute in AP (1995):
maternal mortality among tribal women was 8/1000, double the state
average of 4/1000; IMR ranged between 120-150 per 1000 among different
tribal groups against the state average of 72/1000; and Crude Death Rate
(CDR) among some tribal groups was as high as 15 per 1000 compared to 9
for the state (14). The estimate is that 75% of children are stunted or
wasted, and Pf malaria rate was 18 1000, accounting for 75% of malarial
deaths in the state. These wide differentials are not surprising since tribals
live in geographically isolated forest areas and suffer poor access to
facilities, information and participation. The SCs are slightly better off, but a
1992 NCAER study shows the wice differentials in health status and
outcomes among the poor, in particular the SCs. Persistent societal
prejudices also appear to affect their access to health facilities (Box 5.1). A
survey of 18,000 households conducted by the NCAER in 1990 (Table 5.4)
indicated a higher prevalence of ailments such as gastroenteritis, respiratory
infections, fever, aches and pains, accounting for more than 50% of total
morbidity among urban and rural poor.
Box 5.1
Health Status of SC Population in Rural Tamilnadu
Sample size: 1472 households of whom 1381 were SC’s
(Details at Annex 5.1)
Socio-Economic Features :
65% men and 71% SC women were wage labour, earning
respectively per day. The rest had an average of 1.1 acre land.
75% lived in one room tenements and only 5 had toilets.
90% depend on public wells and taps for water.
56% illiterate, and of 78% of women illiterate.
Rs.15
and
&
Rs.7
Health Status :
75% Home Deliveries against 41% for the state.
61/1000 pregnancies were miscarriages against 28.4 for others.
31% of women had reproductive health problems against 22% for others and 1% for
the rich.
60% women did not seek treatment.
Of the 209 deaths under the age of 5, 48% were newborn infants and 36% were
deaths of children between 1-12 months due to diarrhea, measles, jaundice, fevers
and chest infections etc.
32% of children reported illness on the day of the survey; 47.2% suffered from
respiratory infections: 20% not taken for treatment and 23% treated at home.
Source: Sundari, T K Sundari, CDs, Trivandrum 1992 (15)
61
H
Table 5.4
Prevalence of Illness 1990
Rural per 1 000
Urban per 1000
Poore R s/lI2,00 0
87.42
77.2
Rich>Rs.56,000
47.25
57.62
Total
79.06
67.71
Women
59.8
46.62
Category
Men._____________________J______ 105.34
Source: Household Survey of India, NCAER 1990
88.07
The NCAER survey shows a reduced prevalence of illness among women,
but since most investigators were men, this is more indicative of
underreporting. Though information is inadequate regarding differentials in
morbidity among rich/poor and urban/rural, the study also showed that wage
earners suffered disproportionately in rural areas with a morbidity rate of
94.05/1000, much higher than any other category. A recent NCAER survey
of 2000 households in Delhi and Chennai slums showed that women suffered
more from body pains and nutritional disorders, including weakness,
dizziness, anemia and non communicable diseases, compared to men.
Children accounted for 80-90% of morbidity due to infectious diseases
requiring inexpensive treatment. The high prevalence of infectious diseases
among slum populations was explained by living conditions - such as open
drains and the lack of waste disposal systems. The largest data sets on
morbidity levels income quintile, sex and social category wise is available in
the 52nd Round of the NSS. As in other low-income countries, data indicates
that reporting of illness increases with income: reporting of chronic and
acute illness was three times higher among the richest 20% than the poorest
20%. Morbidity is largely self-perceived, and the ailment is either not
recognized unless it disrupts the ability to work, or downplayed because of
the expense of treatment. This is particularly true of women; it is the
perception of “not serious” followed by financial reasons that influence the
decision to seek care (Figure 5.1).
62
h
Figure 5.1
Reasons for Not Taking Treatment, % by
Age and Sex
%
100.0
90.0
80.0
70.0
I
■
60.0
50.0
40.0
30.0
■
20.0
10.0
0.0
■
0-14 Yrs
15-59 Yrs
□ Not Serious
60+
Male
■ Financial
□ No Time / Others
Female
Total
Source: NCAER, 2000
Differentials in the health status of the poor and socially marginalized
sections show the inadequate and incomplete nature of disaggregated data,
and that a majority of their ailments are easily curable with timely medical
attention and a little money. Yet unsatisfactory public facilities force the
poor to spend their meagre earnings on private healthcare.
Public Health Facilities: Differentials of Access and Utilization
Even among the lower percentages of the poor who eventually do take
treatment, data shows that of the total illness episodes treated during the
last 15 days of survey, the poorest 20% quintile obtained treatment three
times less than the richest 20% quintile (52nd Round of NSS). In the case of
hospitalization, the differential was six times (16). Utilization reflects
access. The differentials between the rich and the poor were substantial in
terms of the rate of treatment availed during the last 15 days of survey and
rate of hospitalization, linking rate of utilization to income. Similarly, the
striking differentials between states (Tables 5.5 and 5.6), show Bihar at one
end with the largest number below the poverty line, and Punjab at the other
end with the lowest number.
63
h
Table 5.5
Rate per 1000 of Treatment during last 15 days
State
POP<BPL In millions
%BPL
Families
QI
QV
Total
Bihar
49
55
14
36
24
Punjab
25
12 63
94
72
All
320
36
28
BPL = Below Poverty Line; Q = Quintile; All = the whole country
Source: 52nd NSSO From BIA Study OF NCAER, 2000
61
42
Table 5.6
Rate per 100,000 of Hospitalization
State
POP<BPL in millions
%BPL
Families
QI
QV
T otal
Bihar
49
55
198
1728
722
25
12
754
2998
1622
320
36
563
3447
1653
4
Punjab
All
Source: 52
NSSO From BIA Study of NCAER, 2000
A further disaggregation of the data on utilization of public facilities for
hospitalization and deliveries (Figures 5.2 and 5.3), shows that 20% of the
poorest utilize public hospitals for treatment and deliveries two times more
than the 20% of richest.
Figure 5.2
Share in Utilization of Public and Private Facilities For Deliveries
Distribution of Institutional Deliveries Per 1,000
Births in Public and Private Facilities According to
Income Quintile
Richest 20%
60%-80%
Middle 20%
53%
20%-40%
Poorest 20%
63%
[
68%
I 73%
0
100
200
300
400
500
600
700
Institutional Deliveries per 1,000 Births
Public ^Private
Source: NSSO 52nd Round.
64
h
Figure 5.3
Share in Utilization of Public and Private Facilities For Hospitalization
Public and Private Sector Hospitalization Rates by Income Quintile
Richest 20%
I:
33%
60%-80%
45%
Middle 20%
52%
20%-40%
58%
Poorest 20%
61%
0
500
1000
1500
2000
2500
300c
3500
4000
Hospitalizations Per 100,000 Population
□ Public
□Private
Source : NSSO 52nd Round
While the utilization of public hospitals for deliveries and hospitalization by
the richest 20% quintile is only 36% and 33% respectively, compared to 73%
and 61% by the poorest 20%, their share of inpatient treatment is nearly six
times more than the poorest (Table 5.7). This suggests that even the rich
resort to government hospitals for care requiring long term hospitalization.
The gradual decline in the use of public facilities for outpatient treatment is
disturbing. Though the overall utilization for all fractile groups is barely 19%,
the utilization by the poorest 2' % is particularly low (Bihar 5.5%, HP 6.1%,
Haryana and Karnataka 9.9%, MP, 11.4%, Orissa 13%, and Rajasthan
10.5%). The utilization of public facilities for outpatient treatment by the
poorest two quintiles is only about 15%, compared to 24.2% by the richest
20%. The position of inpatient treatment is dismal in almost all states.
Barring Kerala, Maharashtra, AP and TN, the poorest 20% have a low
percentage of utilization. In Bihar, MP, Orissa and Rajasthan, the richest
20% have utilized more than 50% of total inpatient days, a finding to be
viewed against the fact that these are among the poorest states, accounting
for nearly 100 million of the poor.
65
11
Table 5.7
Percentage Utilization of Treatment in Public Facilities for OP & IP
Name of the State
% of Out Patient Treatment
QI
QV
Total
BPL
J1.0
15.3
29.0
5.5
30.5
35.2
28.1
12.1
26.3
J)r9
29.9
10.1
6.1
27.1
5.3
~25.6
33.5
1’7.8
34.5 ’
25?6
25.3F
11.4
26.4
22.2
Tejf
34.0
17.9
18.9
34.3_
26.0~
13.0
49.3
2.7 _ ~
19.2
33.3
10.5'
39.8
12.1
18.8
19.5
36.1
15.5
30.9
32.3
20.8
26.7
44.0
1.03
1.64
2.1
% of In Patient days
QI
QV
T otal
BPL
10.3
36.6
17.1
I. 7
64.9
16.8
6.9
20.5
11.4
II. 4
42.1
6.6
6.8
42.4
6.5
5.6
41.5
17.2
18.6
25.9
28.0
3.1
50.3
22.5
J 3.7
24.6
32.1
8.1
42.9
15.8
6.8
56.5
28.6
5.6
46.9
0.5
Andhra Pradesh
Bihar_
Gujarat
Haryana
Himachal Pradesh
Karnataka
Kerala
Madh ya Pr ad e s h
Maharashtra
North East
Orissa
..Punjab
R'a j ais th a n^
8.4~
59.2
11.1
Ta m i I nadu
10.0
27.4
29.0
Uttar Pradesh
6.6
44.6
13.0
West Bengal
7.1
32.7
29.9
All India/
0.05
0.34
0.19
Cases/days/million
A [12ndia_
15.2___ 2£.2
31.1
6.6
38.5
21.7
Source: NSS6“ 52nd Round, from the BIA Study of NCAER, 2001 All India Total Days/Visits of
utilization in Public Facilities (Rural and Urban): OP =6.78 million; IP = 0.885 million
Based on inpatient and outpatient utilization levels of the poor in different
states (Figures 5.4 and 5.5), the total costs of services have been
apportioned among different income quintiles to assess benefits from such
public expenditure. NCAER analysis indicates that disparities in distribution
of benefits (subsidies) are most skewed in Bihar, Orissa, Rajasthan, and UP.
The states where the benefits were most equitably distributed between the
poorest 20% and the richest 20% were TN, Kerala, Maharashtra and Gujarat.
The differentials were most marked in hospitalization, even in a relatively
equitable state like AP, with the results skewed in favour of the rich. This is
significant in view of the fact that it is hospitalization that hurts the poor
most (Annex 5.1).
66
u
Figure 5.4
Outpatient Care by Poverty Groups in Selected States
Outpatient Care by Poverty Groups in Selected States
100%
!
80%
3C
8
2C
y
3E
22
3C
31
25
4C
45
42
55
53
22
60%
22
22
35
4C
40%
16
13
42
4B
35
-3
57
4C
36
48
31
io
10
37
34
20%
12
3
15
25
2"
31
I I
03
32
35
_re
re
o
I
3d
3E
4C
re
.c
re
5C
5
0% S
■i
■o
re
CL
re
re
re
d'
T
tn
03
To
re
re
tr
5re
W
t
z
re
re
re
5
re
i
i
z
re
re
I
re
re
re
O)
<D
CD
re
h-
2
m
•o
re
i
<y
5
□ % Population Below the Poverty Line
□ % outpatient visits at Primary Care Clinics by population Below the Poverty Line
□ % outpatient visits at Public Hosp by population Below the Poverty Line
Source: Ajay Mahal et al, The Poor and Health Service Use in India, 2001
Figure 5.5
Share of Inpatient Days by Poverty Groups in Selected States
60
56
54
50
40
34
20
10
34
28 30 r
30
8
Rjnjab
ifll
Himachal
FYadesh
Gujarat
Kerala
40
39
38
37
46
44
42
2£
30
ie
1f
North-East
□ % of Inpatient Bed Days Used by Population BPL
2S
25
24
i?
If
Karnataka
Madhya
FYadesh
West Bengal
Orissa
□ % of Population BPL
Source: Ajay Mahal et al, The Poor and Health Service Use in India, 2001
67
u
In monetary terms (Benefit Incidence Analysis based on 52nd INSSO),
/ the
NCAER quantified utilization of pubic facilities; less than 10.2% of total
government investment on health went to the poor, 31% to the rich (See
Figure 2.12, and Tables 2.12 and 2.13. Chapter 2).
NSS data shows that the poor utilize public sector facilities for inpatient
treatment and very little for outpatient treatment; while the rich tend to use
the private sector hospitals more, though when they do use the public
hospitals, they tend to use them for longer periods of time. However, this is
an area that needs further analysis, and the attempt to draw inferences
about some states being more equitable than others needs to be read with
some caution till more information is made available.
Barriers to Access
In the Indian context, the poor face numerous barriers to their access to
public facilities: lack of information on availability and location of services;
physical barriers (distances, difficult terrain); lack of transportation; the lack
of financial resources; and insensitive or unreliable treatment in public
hospitals. Of all these, the biggest barriers are prohibitive costs in the
private sector, and poor responsiveness to needs in the public health
system.
Cost of Care: Data on the unit cost of treatment per episode in
hospitals/outpatient clinics, particularly in the private sector, is not
available, Hence the comparison of costs incurred in public and private
facilities is based on expenditures
<
(“out-of-pocket” spending category)
indicated by surveyed households. The NCAER’s Benefit Incidence Analysis
(BIA) of data from the 52nd Round of the NSSO, its 1993 survey of 33,000
households to estimate expenditure of the poor on healthcare, and some
other isolated studies carried out at different points of time all indicate the
following trends.
• The poor spend a disproportionately higher percentage of their
incomes on health services than the rich.
• More than three-quarters of spending is on minor ailments,
infectious and communicable diseases.
• The poor delay seeking treatment to avoid expenditure; nearly a
fifth do not avail treatment for financial reasons.
• Borrowings and interest bearing loans are important financial
sources for healthcare for the poorest; the proportion reduces as
income increases.
• One episode of hospitalization can wipe out family assets.
The 52nd Round
r
- ---------NSSO shows that expenditure incurred, particularly for
inpatient treatment, has increased in both rural and urban areas during
1986-96. While the expenditure on outpatient treatment has remained
constant, and even declined marginally, the costs of hospital care have more
than doubled in urban areas. Hence the sharp decline in overall utilization of
68
H
public health facilities, for hospitalization
outpatient treatment 26% to 19% (Table 5.8).
from
60%
to
44%,
and
for
Table 5.8
Costs of Care - Constant Prices 1986-87 (Rs.) Treatment / Episode
INDICATOR
_________ RURAL___________________URBAN__________
1986-87
1995-96
1986-87
1995-96
OP PUBLIC
73
48
74
64
OP PRIVATE
78
74
81
81
ALL
76
69
79
78
IP PUBLIC
722
912
653
963
IP PRIVATE
1156
1886
1570
2344
ALL
886
1404
1007
1720
Source: CSO, GOI
With the poverty line at Rs.244 in rural areas and Rs.352 in urban areas,
and with per capita annual consumption at Rs.2395 in rural areas and
Rs.3320 in urban areas, the ^oor aie being heavily charged indeed for
private inpatient treatment, as much as 3-6 times more than their income.
According to the 52nd NSS, the average total expenditure per episode of
hospitalization by all quintile groups in the private sector was Rs.4300 in
rural areas and Rs.5344 in urban areas. (For state-wise differentials see
Annex 5.2). This is double the figures for public hospitals (Rs.2080 rural,
Rs. 2195 urban). A study of slum populations in Delhi and Chennai indicates
strategies used by the poor to meet health bills (Figure 5.6).That the poor
utilize services fully when they are efficient and involve no or minimum outof-pocket expenditure is illustrated by immunization (93%), antenatal care
(74%), inpatient bed days (66%) and the percentage of delivery-related
inpatient bed days (63%). Utilization of public and private hospitals for
trauma care is a gray area: the Intensive Care Unit costs more than an
average of Rs.2000 per day (17).
Figure 5.6
Source of Funds for Medical Care
Source of Funds for OP Treatment
Source of Funds for Hospitalization
5%
12%
□ Own Resources
2% 2%
5%
□ Own Resourcesi
□ Liquidating assests I
^r%
□ Loans from friends
■ Loan from
moneylenders
■ Others
\4 *
M-I
□ Loans from
friends
/
□ Loan from
moneylenders
32%
□ Others
7%
91%
H
Clearly, it is capacity for resource mobilization that determines the source,
frequency and nature of health seeking behaviour among the poor. Again, in
view of the marginal difference in costs for treatment of minor ailments, the
poor tend to go to the ubiquitous Rural Medical Practitioners (RMPs). The
RMPs are easily accessible because of flexible payment terms, willingness
to treat on credit, delivery of drugs at the doorstep, and willingness to
transport the patient in case of need to a private doctor in town - for which
the RMP gets a commission from the doctor, abiding gratitude from the
patients, and further bonding with the poor household (18). These
subsystems of health financing are critical to understanding why RMPs,
legally debarred from “practicing”, cannot be replaced with trained medical
doctors by regulation alone.
Poor Responsiveness in Public Facilities: The market share of PHCs is less
than 8% (19), down from 29% in 1986. The non-availability of doctors or
drugs, rude behavior, corrupt practices, long waiting periods, unsuitable
timings, unclean surroundings and lack of privacy explain the reluctance to
use PHCs. Their quality of treatment and indirect costs force the poor to
choose private practitioners or deny themselves treatment. This situation of
free but unreliable, poor quality care, versus local practitioner or selfmedication, is acute in tribal areas. Often they do not have a choice: in
1994-95 most hospitals in tribal areas of AP did not have basic facilities
(a labor room or a laboratory), and had ANMs who did not know 7 out of the
11 procedures required for conducting a safe delivery (20).
Lessons Learnt: Four lessons emerge with clarity:
1) Health policy is not adequately pro-poor in programme content or in
the allocation of budgets and other resources.
2) In the absence of a pro-poor focus, the
rich
receive a
disproportionately higher subsidy.
3) More than half the country’s population is unable to meet the
increasing costs of care, entailing widespread economic hardship to
families.
4) Inequities are exacerbated among and within states and within sub
populations, due to the inherent limitations of markets in rectifying
imbalances.
A Pro-Poor Policy Framework: The health sector has not developed the
approach of economic sectors where the poverty-equity debate resulted in
the development of indicators (21).
The traditional focus has been on
diseases of poverty (22) and maternal and child health (MCH) to address the
problem of inequity, because disaggregated data on the health status of
those below the poverty line, SC/ST, women and migrant labor is not
available on a regular basis. The absence of relevant epidemiological and
disaggregated data is a major constraint in evaluating the-equity dimensions
of budgetary allocations, as well as the nature and content of programmes
being implemented in the health sector. The consequence has been low
priority to pro-poor interventions.
70
H
For example, a 1997 TRC study in Chennai covering 304 TB patients (23),
showed that the average direct and indirect costs incurred by the patients
were about Rs.1443 and Rs.3610-4100 respectively. The average debt
incurrec by a TB patient was Rs.2079. 70% of the patients expressed mental
agony caused by the disease’s economic impact on the family. About 12% of
the children discontinued schooling, and another 8% took up employment to
support the family. Illness reduced activity levels by at least 30-35%; on an
average, about 85 workdays were lost. Extrapolating this information to
quantify the resulting impoverishment would justify raising priority for the TB
programme, and increasing budgetary allocations from the existing 10% of
the central budget (24), to double the amount (25). Using such information in
programme design would help include components that provide safety nets
for the affected families, instead of confining intervention to treatment and
drugs, and that too for those who come to public facilities. Though disease
control has such wide externalities and hurt the poor so disproportionately,
they do not command the budget allocations they deserve: for all five
National Disease Control Programmes (26), the per capita release from the
centre to the states is about Rs.3.5 on average. Also, Bihar and UP, (with
100 miH'on families below the poverty line), get a meagre Rs.2.28 and
Rs.1.. 9 respectively (Table 5.9).
Table 5.9
Per Capita Releases by Centre to Select States under National Disease Control
Programmes during 1998-00
STATE
%BPL
FAMILIES
TOTAL AMT
RELEASED/
Rs. (million)
PER CAPITA/Rs.
98-99
99-00
98-99
99-00
Bihar
55
223
273
2.26
2.79
UP
41
297
398
1.79
2.40
Orissa
49
181
225
5.12
6.34
MP
43
277
376
4.81
3.54
Rajasthan
22
! ALL
320
|
Source: Department of Health, GOI
299
230
5.69
4.38
3456
4439
3.52
4.5
Public Facilities for Whom? Evidence suggests that public policy falls short
in addressing the special needs of the poor. This is reflected in inadequate
budgetary allocations for areas affecting the poor; in insufficient attention
paid to the functioning of public facilities; and in the disproportionate
attention paid to the management of a few city-based hospitals. On the
grounds that health is a state subject, the central government has failed to
develop a comprehensively articulated policy on primary healthcare. Such
71
u
systemic neglect of the health concerns of the poor has become a virtual tax
on the impoverished, leading to the inequitable consumption of public
subsidies.
Markets as an Efficient Allocator: Its abysmally poor public health spending
makes India one of the lowest health spending countries in the world. With a
predominantly private health system, the payment system is fee for service an inflationary practice that also increases the vulnerability of the poor. The
process of globalization is yet another destabilizing force to be reckoned
with: India is expected to face an increase in drug prices after 2005, though
this refers mainly to patented drugs, even now out of reach of the poor. If
left uncorrected, globalization - and accompanying high cost advanced
technology facilities with foreign investment - will widen already
unacceptable healthcare disparities between rich and poor. The urgent need
then is to ensure that such developments go hand in hand with affirmative
action to upgrade access, and the quality of healthcare provided to the poor.
The establishment of islands of excellence is likely to raise costs and
generate pressure for investments in the latest technologies in public
facilities. This is not to suggest that public hospitals need not be
modernized, or that they should not strive to be at the technological
forefront; but to reiterate that the government must intervene effectively and
decisively with a package of incentives and disincentives that are directed to
correct the potential distortions of an unbridled global market. Such an
interventionist role of the government is justified not only for the purpose of
ensuring equity, but also to protect public health due to the large
externalities it entails, and the market failures that are so typical to the
health sector.
Future Directions
Solutions to the inequities of the Indian health system call for
restructuring the delivery system and modes of financing; no one
should be denied care for inability to pay. A comprehensive review of the
health system could begin with the following indications of future directions.
> An outright substantial increase in public health spending:
Health budgets at the state and central levels must be increased in
relative and absolute terms. Increased budgets must be allocated to
address the health needs of the poor, with.a higher priority given to
the control of communicable diseases, to MCH, to promotive and
preventive health, and to improving the functioning of the primary
and secondary healthcare systems. This is particularly applicable to
low-performing states such as UP and Bihar, where the overall
health spending is low, where public facilities are poor, and the
presence of the private sector is weak.
> Promotion of the third sector, namely the charitable, not-for-profit
sector through tax breaks and subsidized inputs such as power,
72
u
water, land
regions
and
concessional
credit,
particularly
in
backward
> Adequate safeguards and incentives in the Insurance Bill
towards low cost community insurance programmes, run on the
principles of risk pooling by local bodies/NGOs or autonomous
government hospitals
> Restructuring
the
public
health
system
to
increase
accountability: Available resources should be reallocated to
backward states, areas, regions, and to disadvantaged sections
within; and policy attention must be shifted from running hospitals
or sanctioning medical colleges.
> MIS for data on health indicators for the poor and vulnerable for
basing policy formulation and programmatic interventions on such
disaggregated data
> Improving public sector .fficiencies and utilization through the
correct mix of inputs; linking upgradation of facilities with reform
in hospital management and financing systems;
> Social insurance (sickness funds) to provide financial
protection
to
the
poor
against
serious
illness
hospitalization costs in the private sector.
risk
and
> Differential planning and deployment of budgets by government
in accordance with the extent of disease burden, economic
backwardness of the state/region and poverty levels
> Incentives, regulations and redressal mechanisms: non-denial of
emergency care; transparency in the pricing of services, systems of
medical audit to minimize exploitation or malpractice.
Notes
1.
2.
3.
4.
5.
The Special Component Plan is a mechanism to earmark a proportion of the budget
and physical achievements equivalent to the population of the disadvantaged
sections of society, to be used for the exclusive benefit of these sections, namely
SC and ST who constitute 16% and 8% of the population.
These were a part of the 20 Point Programme implemented at the district level and
monitored at state and central levels.
Poverty estimates for 99-2000 based on 52nd Round NSSO of consumer expenditure
suggests that the percentage of population below the poverty line is 26.10.
However, the figure of 35.57 is being used to be consistent with the figures used
during Round NSSO.
Economic Survey - 1999-2000, GOI. Based on NSS Consumer Expenditure of 50th
Round (93-94).
Economic Survey 2000-2001, GOI based on NSSO 1999-2000.
73
h
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
II and V of the Declaration of Alma Ata.
Planning Commission, 2001.
D. Gwatkins' study showed that the world's 20% poorest died on account of
pretransition diseases and before reaching 15 years of age almost 8 to 10 times
more than the top 20% of the richest (The Poor: When and How Do They Die, 1977)
NCAER Study of HDI - 2000.
Savrekhshana, GOI March 2000.
Various Articles of the Indian Constitution provide for special protection to be
extended to SC/ST, particularly in matters of education, employment etc.
Census 1991, Planning Commission.
The percentage distribution of BMI has shown an increase from 42.1% in 1975-76 to
50.5% in 1996-97, and CED has come down from 55.6% to 45.5% during the same
period among adult males. (Planning Commission Review of the Ninth Plan)
Tribal Research Institute, Government of Andhra Pradesh, 1995-96.
Social Inequality and Access to Health: Study of SC Population in Rural TN by TK
Sundari, CDS, Trivandrum, 1992.
A caveat would be in order. The fractile grouping of NSSO is based on the
expenditures incurred on health and therefore does not specifically indicate the
level of poverty except by inference. This has to be borne in mind as the detailed
survey reports in the utilization of the secondary hospitals in AP showed that 75%
of the patients were all persons below tne poverty line.
Tulasidhar, Utilization of Hospitals, 1995.
Sujatha Rao et al, Health Financing of PHC in AP, 1997.
52nd Round NSSO, also corroborated b\ studies by Alex George and NCAER.
A Mimeo on the skill assessment of ANMs working in tribal areas prepared for the
Government of AP, 1994.
The concept of Below Poverty Line BPL), for instance., that has enabled the
targeting of beneficiaries in government programmes.
Pertain to communicable diseases and reproductive health, as they are believed to
affect the poor disproportionately as opposed to lifestyle diseases.
R. Balambal et al, Economic Impact of TB on Patients and Family, TRC, Chennai,
1997.
TB was allocated Rs.1100 million out of a total Plan budget of Rs.12778 million for
the year 2000-2001 to the Department of Health.
The estimated deficit for covering the whole country is Rs.1000 million. (Joint
Review of TB by WHO).
National Programmes for the control of malaria, TB. leprosy, HIV/AIDS, blindness.
74
H
Annex 5.1
Distribution of Net Public Sector Subsidies by Level of Care by Quintile Category,
Combined for Rural & Urban
Name of the
State
Andhra
Pradesh
Bihar
Gujarat
Hai
wa
Himachal
Pradesh
Karnataka
Type of facility
Short Hospitalizations
Hospitalizations
PHC & Others
Immunizations
__ Tota£
Short Hospitalizations
Hospitalizations
PHC & Others
Immunizations
Total
_
Short Hospitalizations
Hospitalizations
PHC & Others
Immunizations
JTotal___________
Short Hospitalizations
Hospitalizations
PHC & Others
Immunizations
T otal
Short Hospitalizations
Hospitalizations
PHC & Others
Immunizations
Total
Short Hospitalizations
Hospitalizations
PHC & Others
Immunizations
ToJaJ_________
Kerala
Madhya
Pradesh
Maharashtra
North East
Short Hospitalizations
Hospitalizations
PHC & Others
Immunizations
Total_______________ __
Short Hospitalizations
Hospitalizations
PHC & Others
Immunizations
i Total__________________
■ Short Hospitalizafions
i Hospitalizations
PHC & Others
I Immunizations
Total_____________
Short Hospitalizations
Hospitalizations
j PHC & Others
Immunizations
Total
QI
18.1
14.8
20.5
29.3
16.3
3.1
2.3
7.2
20.7
4.1
17.9
12.4
26.9
28.4
15.0
18.6
12.7
13.8
21.4
13.5
6.4
6.4
21.2
18.9
7.5
10.1
7.6
17.1
22.5
9.3
28.1
21.7
28.3
30.8
21.9
8.6
6.4
17.2
24.1
8.8
16.8 i
Qll
Qlll
QIV
QV
17.0
16.6
30.5
17.8
14.4
15.0
25.5
30.4
21.6
35.5
15.2
9.2
23.0
21.5
17.9
8.4
15.7
17.4
23.9
26.7
12.9
19.1
27.4
37.5
8.3
12.5
21.8
55.1
31.6
8.5
25.6
27.2
21.7
21.3
18.3
18.0
9.4
14.4
21.8
50.3
24.4
17.8
21.4
18.4
16.9
38.6
14.8
17.3
27.1
15.6
21.4
9.0
25.1
20.0
17.7
8.8
36.2
17.3
15.6
15.9
17.4
13..
19.5
31.2
12.7
11.9
35.7
27.0
19.4
22.6
25.8
18.5
25.7
23.3
19.8
9.7
13.7
14.4
25.9
32.5
11.1
18.0
24.5
40.0
11.0
12.6
23.9
46.1
22.7
15.2
24.0
17.0
22.7
20.5
24.8
13.1
1 1.4
13.4
23.9
43.8
17.8
23.3
28.5
22.3
14.2
18.9
24.1
35.2
20.7
31.3
15.5
15.4
26.3
26.6
17.9
9.8
16.4 _J9.5
22.9
32.0
20.9 ’ 24.3 ’ 15.8 ' 11.1
17.8
23.3
17.3
19.9
11.7
30.4
14.8
14.7
23.7
22.4
10.4
12.8
23.0
17.2_ 19.7
9.3 '
12.2 . 32.3 ” 37.7
9.2
12.5
29.1
42.8
22.5
29.4
18.8
12.1
21.1
20.9 i 19.1
14.8
11.5 ' 15.0 __2L3_ 37.4 *
15.5 '
17.6 ; 22.7 ’ 27.3
i 13.1 ; 13.5 I 21.3 | 32.1
19.9 i
: 35.6
24.8 ' 23.4
7.0
9.2
30.4
23.2 ! 23.9 i 14.0
8.6
_16^8_
15.4 : 21.7
28.1
18.0
11.3
9.5
19.4
37.3
22.5
____
9.0
10.9 I 17.7
21.0 i 41.2
19.9 | 23.5
20.2 : 21.9 i 14.5
23.3
21.0
18.8
22.0 i 15.0
11.6
18.2
21.2 i 35.3
13.6
Total (in
Rs.
Million)
1229
2053
263
158
2474
586
949
68
91
1108
663
1189
149
93
1431
464
677
59
80
796
474
675
45
12
732
1148
1803
216
101
2120
2490
3921
393
34
4049__
1 601
2179
302
172
2653__
1728
2624
387
172
_3483___
’ 1099
1387
346
51
1784
75
ii
Name of the
State
Orissa
I
Type of facility
QI
Qll
______ I
16?2
7.8
8.6
13.6
11.2
23.2
24.4
27.9
9.4
15.3
. 11 6
Qlll
QIV
QV
Total (in
Rs.
Million)
20.4
Short Hospitalizations
17.3
38.3
950
Hospitalizations
15.5
1 1.8
50.5
1605
PHC & Others
20.6
22.6
22.4
240
Immunizations
18.6
15.7
64
13.3
_Tptaj_________________
16.3
13.3
45.7
_ 19 0_9_
’ 16.1
"41’2
Punjab
Short Hospitalizations
34.1
18.1
20. i
Hospitalizations
18.5
29.7
11.5
15.1
25.2
447
PHC & Others
30.4
15.7
30.6
19.0
4.3
39
Immunizations
20.4
31.2
14.9
24.5
8.9
49
Total
14.7_
17.1
18.5
27.6
22.2
535
Rajasthan
Short Hospitalizations
7.2 ’ 12.6
12.0
23.1
45.1
1085
Hospitalizations
9.5
10.8
19.7
8.8
51.2
1425
PHC & Others
10.1
26.6
21.6
1 1.0
30.6
130
Immunizations
21.4
23.0
21.3
20.9
13.3
86
Total_________________
11.5
12.2
19.1
1841__
47.6
: Tamilnadu
Short Hospitalizations
■ 19.5
24.1
18.2
22.6
151.5
2203
Hospitalizations
13.7
20.1
20.7
25.4
20.1
3177
PHC & Others
22.8
14.1
20.5
18.8
23.8
209
Immunizations
30.8
25.5
18.6
17.2
7.9
125
Total
___
14.8 _J9.9
20.7
24.7
19.9
3511
Uttar
Short Hospitalizations
12.4
11.9
17.2
20.0
1764
38.5
Pradesh
Hospitalizations
8.1
8.1
12.3
30.3
41.2
2875
PHC & Others
17.4
13.1
1 1.6
16.5
41.4
384
Immunizations
22.1
21.5
20.0
20.9
15.6
297
Total
10.2
9.8
12.9
28.1
39.0
3537
West Bengal
Short Hospitalizations
13.0
12.6
20.0
26.8
27.5
2163
Hospitalizations
9.2
18.0
19.3
30.7
22.9
3260
PHC & Others
22.5
25.5
16.0
18.2
14.9
283
Immunizations
25.6
19.6
19.9
24.6
10.2
120
T otal
11.0
18.8
19.0
22.4
28.8
3662
India
... 11.1
Short Hospitalizations
26.4
27.6
14.3
20.6
20083
Hospitalizations
8.4
13.0
18.2
26.9
33.5
30252
PHC & Others
20.3
20.7
21.7
17.0
20.3
3196
Immunizations
23.7
22.2
22.0
1687
19.6
12.5
Total______
, 10.2
14.1
18.7
26.0
31.0
35138__
Source: Ajay Mahal et al, Who Benefits from Public Health Spending In India, Benefit
Incidence Study, NCAER, 2001
76
H
Annex 5.2
Average Total Expenditure (Rs.) Per Hospitalization by Type of Hospital for Rural
and Urban Areas of 15 Major States
State
Rural
Urban
other
All
Govt.
other
All
hospitals
hospitals I hospitals
Andhra Pradesh
7822
6428
1310
7080
4886
Assam
2 003
1 9 4 5_
2201
7102
3790
Bihar
_4069
3860
2804
4512
3724
Gujarat
___
1465
3285
2663
1897
4185
3327
Haryana
2667
_3496_
3224
8888
5087
6537
Karnataka
1791
4100 2997
1564
4502
3593
Kera I a
_J 61 6
2805
2293
1527
2254
1927
__2207
M adh ya p r a d e s h
3842
2191
1678
3889
2774
Maharashtra
1529
3836 i 3089
J 439
5345
3997
Orissa__________
1681
2 583
1641_
__2142
11829
3868
Pu njab
__
6171* _4988
5436
3645
6130
5712
2634
3971
303
8
_2544
4949
R aias * ha_n_____
3149__
751 '
Tamilnadu______
4333
2840
_1_934
5827
3934_
Uttar Prad_esh_
4521
___ 43 49
~ 5191
4237
6515
5896
__ <500
Wesit B e n g al
__4303
1957
1348
7836
3217
India
____________2080
__4300“_____ 32 02_
2195
5344
3921
Source: Ajay Mahal et al, Who Benefits from Public Health Spending In India . Benefit
Incidence Study, NCAER 2001
Govt.
hospitals
2070__
2092
__ 3488__
77
6
Communicable Diseases
Introduction
Communicable and infectious diseases constitute a major cause of
premature death in India, killing over 2.5 million children below the age of
5 and an equal number of young adults every year. Despite the
remarkable progress achieved in the overall quality of life, and despite a
reduction in absolute poverty, the proportion of total deaths on account of
communicable diseases, maternal and perinatal conditions and nutritional
deficiencies continues to be unacceptably high at 42%.
Figure 6.1
Mortality and Morbidity Estimates, 1998
Mortality Estimates in India
Communicable Diseases Mortality
Respiratory
Infections
25%
Maternal
Conditions
3%
Communicable
Diseases
42%
NonCommumcable
Diseases
48%
infectious &
Parasitic
53%
Nutritional
Deficiencies
3%
Injunes*
10%
Perinatal
Conditions
16%
Infectious and Parasitic Mortality
□ Dengue
0%
CD Hepatitis
1%
□ Malaria
1%
□ Intestinal Nematode
Infection
0%
□ Others
10%
□ Diarrhoeal
Diseases
34%
□ Leishmaniasis
1%
□ Meningitis
2%
□ STDs excluding HIV
3%
□ HIV/AIDS .
8%
0 Childhood Diseases
(UIP excluding
tuberculosis)
20%
□ Tuberculosis
Source: World Health Report 1999
78
IJ
Between 1950-1990, there was a significant improvement in health
indicators, mainly because of rising incomes and expanding access to
healthcare. But a range of non-health determinants - environmental
pollution, unsafe water, improper water management, poor sanitation
practices, malnutrition, behavioral attitudes, illiteracy, climatic conditions
and poverty - continue to be responsible for the persistence of pre
transition diseases. The successful control of these diseases, which are
dynamic, resilient, and driven by a complex network of ecological, social,
political and economic factors, demand the skilful negotiation of all these
factors by an efficient public health system.
•s
w
0
)
|
Since the global eradication of small pox, 30 new pathogens have been
identified, including HIV/AIDS, Hepatitis C and E, and new strains of
Vibrio cholerae. The resurgence of infections, and of malaria, dengue and
TB in forms difficult to control or treat, and the exponential rate of the
development of HIV/AIDS, have all imparted a new sense of urgency to
disease control. With most infections not responding favorably to
commonly used and economical anti-microbial agents, the management of
these infections has become difficult, long, and expensive.
I
)
i
i
While current efforts will ensure the elimination of leprosy and polio
within the next five years, environmental and social factors impose severe
constraints on the eradication of malaria, TB or HIV/AIDS. Thus efforts
will have to be aimed at reducing disease transmission, minimizing drug
resistance, and reducing mortality and morbidity; this is an economic
imperative as it is the poor who suffer the most.
3.
This chapter assesses the disease burden in India caused by the
principal diseases - malaria, TB and leprosy, and examines the strategies
formulated to contain them. It also identifies the programmatic issues for
future direction of policy. These disease control programmes are currently
under implementation throughout the country as Centrally Sponsored
National Programmes, with substantial funding from the central
government. HIV/AIDS and childhood diseases will not be covered here
as they have been dealt with separately in the relevant chapters.
Disease Burden: An Overview
■f
Infections and parasitic diseases accounted for 34.6% of the total 269
million DALYs lost, and 33% of 9.3 million deaths in 1998 (1). India's
burden of disease (BOD) on account of communicable diseases is more
than three times that of China’s, and accounts for 23.3% of total global
DALYs lost. From the very First Five Year Plan, the control of
communicable diseases has been a priority, Despite limited technical
manpower, weak health infrastructure and modest financial resources,
India was able to bring down its disease load, and eradicate small pox
and guinea worm. The Cause of Death time trends for 1961-99 show an
overall decline in mortality due to infectious and parasitic diseases and
79
u
Control Strategies of Major Causes
Malaria and Other Vector Borne Diseases
Malaria: Initial efforts aimed at malaria eradication brought down the
caseload from an estimated 75 million to a record 0.1 million cases, and
negligible deaths. But various financial, administrative, technical and
logistic factors ensured that this success was short-lived. Constraints
included the disbanding of malarial teams to assign them duties such as
family planning; the failure to supply several recurrent critical
components that states were to provide (4) under the pattern of
assistance; reports of drug and insecticide resistance, particularly from
Assam; and an overall sense of complacency, affecting the required level
of vigilance. These and other factors contributed to the resurfacing of
malaria in 1976, to a high of 6.47 million cases. The Modified Plan of
Operation was launched in 1977 to contain the disease, with the 3 main
objectives of preventing deaths, reducing morbidity, and consolidating
gains. By 1984, malaria was brought down to about 2.18 million cases.
Efforts towards a further reduction were not successful due to vector and
parasite resistance to conventional insecticides and drugs respectively in
some
high
endemic areas,
environmental
changes
caused
by
development activities such as irrigation projects, and rapid urbanization.
1994 once again witnessed several focal outbreaks of malaria, resulting
in high mortality due to a multiple set of reasons: poor disease
management (5). increasing malarial risk factors, and an overall failure of
the health system caused by the gradual depletion of trained personnel
(6). The data is not complete enough to be conclusive but it seems fairly
clear that the emergence of parasite resistance to drugs and vector
resistance to insecticides is a key factor. A major cause of concern is that
between 1995 and 1999, Plasmodium falciparum (Pf), the more
dangerous strain of malaria, increased from 38.84% to 49.96% (7).
Figure 6.4
Number of Cases and Mortality On Account Of Malaria - Trends
Trencte in Fitiaria Cases
LL
0.
o<5
£
co
0)
Q
M—
o
d
Z
7000000
6000000
5000000
4000000 J
3000000 )
3X0000
1000000 :
0-
No. of Deaths due to fvteiaria
1600
(/)
co
0)
Q
In B~]_
8
1976
■ hb-ofCases
1985
1989
1994
Yerrs
1995(F) 1996(F)
□ Nb.cfFF
d
Z
1400 ■
1200 •
1000 •
800 i
600 J
400 ■
200
0
1976
□
□
1985
1989
1994
1995
(P)
1996
(P)
Years
Source: GOI Annual Repcn 1996-96, DGHS, New Delhi
81
H
digestive disorders (2), except in the case of TB and respiratory infections
(Figure 6.2). There has been some reduction in overall morbidity and mortality. Of the
ten leading causes of BOD and mortality, almost 50% were on account of respiratory
infections, diarrheal diseases, TB and measles (Figure 6.3).
Figure 6.2
Trends in Morbidity and Mortality on account of Communicable Diseases
Trends in Common Communicable Diseases in
Trends in Mortality due to Communicable
India
Diseases in India
lOOOOO
10000000
Tifh*rn tlncic
10000
1000000 .
Virol Hepatitis
a
Viral Hepatitis
.4
-C
o>a»
V
.T
Fnrrnhnlitit
o
»•-
100000 .
Tetanus
Diphtheria
o
z
?
Tetanus
■*
6
Z
Diphtheria
10°
’alia
10000 10
nChaleff
J. Encephalitis
.Polio
1000 ■
19*1
1971
197»
19»1
19M
1991
1999
1999
19*1
196*
1971
1976
1961
1966
1991
1996
1999
Years
Years
Source: DGHS, GOI. India (3)
Figure 6.3
Leading Causes of Mortality and Burden of Disease 1998
Leading Causes of Mortality - 1998
1400 •
1200 '
1000 1
800
600
400
Leading Causes of Burden of Diseases - 1998
K71
1600
■
200 I
b
30000
25000
421
n 217
1S3 15J
24806
f— 23316
_ 22005
20000
15000
0 —
10000
5000 1
0 • *—
U69710898
—| _ 9679
n
7454 7204 M74
0DDODO
Source : WHR, 1 999
80
u
The average caseload (8) of about 2 to 3 million malarial cases hide the
wide state differentials in disease prevalence. Overall, ten states account
for 93% of the total disease burden (Annex 6.1). While MP, Orissa,
Rajasthan, Bihar, AP and Maharashtra account for over 80% of total
caseload, MP and Orissa alone account for 50% of mortality.
On the basis of recommendations from an expert committee, high-risk
malarial areas within high endemic states were identified for more
focused control measures. A three-pronged strategy was drawn up, now
being implemented throughout the country under the National Anti-Malaria
Programme (NAMP). 29 cities/towns, 318 districts, 10% of PHCs and
about 24,844 villages (roughly a population of 200 million) were identified
as high-risk (9), on the basis of the following parameters:
> a doubling of SPR (Slide Positivity Rate) for 2-3 years and an
SPR of 5% or more;
> proportion of Pfalciparum (Pf) malaria more than 30%;
> chloroquin resistant Pf;
> tropical aggregation of labor and new settlements.
The main strategy objective is the interruption of disease transmission by
> early detection and prompt radical treatment to reduce the
reservoir of infection;
> the reduction of the vector population through selected vector
control, using anti-adult and antilarval measures (use of DDT,
Malathion and synthetic pyrethroids in DDT- and malathion
resistant areas); and
> the enhancement of community based action (bio-environmental
control and personal prophylactic measures).
This strategy is being implemented as a centrally sponsored scheme
under three different packages of assistance.
1) In the NE states, the centre provides 100% assistance to cover
insecticide and drug supply, spray operations, contingencies for
POL and other operational expenses.
2) In non high-risk areas, the package is based on a 50:50 sharing
basis, with the centre providing drugs and insecticides, but no
operational expenditures.
3) In the high endemic areas, 100% central assistance is provided
under the World Bank-assisted Enhanced Malaria Control Project
(EMCP). This project provides synthetic pyrethroids in triple
resistance pockets, impregnated bed nets for personal protection,
rapid diagnostic kits and Artimisinin injections, vehicles,
microscopes, consumables and supplies, and funds (for
contracting
lab technicians, IEC and social mobilization
activities).
The EMCP covers the 100 most endemic districts in AP, Orissa,
Jharkhand, Gujarat, MP, Chattisgarh, Maharashtra and Rajasthan, and 19
82
u
cities/towns, all of which together account for 90% mortality. Over 90% of
Pf malaria cases occur in tribal areas that are vulnerable to
environmental factors, weak health systems, poor communications and
above all, extreme poverty. The EMCP strategy reflects the shift from
NAMP reliance on chemical control to integrated methods. The three
specific initiatives of EMCP are epidemic planning for rapid response to
inter-sectoral coordination, strengthening of institutional management,
and personal protection through the use of medicated acts. In addition,
meteorological data regarding rainfall, temperature and humidity, along
with epidemiological information, are being monitored for the first time
since 1997, to assess mosquitogenic potential and forewarn states.
EMCP has been under implementation only since 1997; it had a slow start
for operational reasons and is now getting into gear.
The urban malaria vector An. step hen si breeds in stored water and
domestic containers; construction activities and the aggregation of labor
also provide a conducive environment for breeding. Implemented in 131
towns, the strategy for tackling urban malaria consists of early case
detection
and treatment;
recurrent anti-larval measures through
conventional larvicides in .owns; minor engineering methods such as
source reduction, channelization and deweeding; and biological control
using larvivorous fish at appropriate breeding sites. Under the Urban
Malaria Scheme, the central government provides the states with
larvicides and a 2% Pyrethrum extract on a 50:50 sharing basis, with the
states meeting operational costs. Since 1994, the NE states receive 100%
grant aid from the central government. The success rate has not been
promising: from 1997 to 1999, malaria-positive cases have increased from
174,000 to 289,000 cases, and the proportion of Pf cases has doubled
from 15,627 cases to 53,619 (10). TN. West Bengal and Delhi accounted
for more than 80% of this increase.
NAMP also covers other vector borne diseases - leishmaniasis or Kala
azar, lymphatic filariasis, dengue haemorrogic fever and Japanese
encephalitis.
Kala azar: This disease was controlled with mass insecticidal spraying in
1958 but resurfaced due to the lack of insecticidal pressure on the vector
population. Reappearing in 4 districts of Bihar in 1974, it spread to
become endemic in 36 districts of Bihar, and 10 of West Bengal. Nearly
101 million are at risk; the annual average is about 15,000 cases and 200
deaths. The number of cases declined from 1993 to 1996, but increased
again in 2000. The Kala azar strategy consists of the interruption of
transmission through vector control by residual spraying in affected
areas; early diagnosis and treatment in PHCs; and community
participation. The central government provides the entire requirement of
Sodium Stibo Gluconate vials, pentamidine vials, Amphoteracin-B and
DDT. Subsequent to the report of a recent Expert Committee, efforts are
underway to eliminate this disease in a time-bound manner. Control
83
u
efforts have been tardy partly because of weak implementation. Health
system deficiencies are already high in the endemic areas, and the
capacity for optimal utilization of assistance low. However, the time
bound control of this disease will be enhanced if the new drug Miltifocin
proves to be successful.
Lymphatic Filariasis: After a marginal decline, the rate of this disease has
increased from 1.01 per thousand in 1989, to 2.33 in 2000. During the
same period, the microfilarial rate decreased from 2.02 to 1.11. About 29
million people are estimated to be disease carriers, and another 22 million
non-infective.
The
National
Filaria
Control
Programme
provides
assistance to all 18 endemic states (454 million people); the most
endemic being AP, Orissa, UP, West Bengal, TN, Kerala and Bihar.
Originally conceived as an urban programme, anti-filarial measures are
being implemented through the 206 Filaria Control units and 199 clinics.
Since 1994, the anti filarial drug Diethycarbamazine (DEC) is available in
rural PHCs for the treatment of acute and chronic cases of filariasis.
Since 1997, a pilot project to study the feasibility of Annual Single Dose
DEC mass drug administration is in operation in 13 districts of 7 states.
The central government provides larvicides and anti-filaria drugs, while
operational and equipment costs are borne by the states. The strategy vector control, environmental engineering and antiparasitic measures has not led to any appreciable reduction in disease rates (Table 6.1),
despite the mass single annual dose administration of DEC in 13 pilot
districts. The co-administration of DEC and Albendazole for the
elimination of lymphatic filariasis in a few districts of Kerala, Orissa and
TN, is now being considered. The strategy consists of early case
identification and treatment in view of the absence of effective
chemoprophylaxis or cost effective vaccines.
Table 6.1
Number of Filaria Cases and Disease Rates 1989-2000
Year
No. of
Blood smear
MF Rate
No. of
Persons
positive for
filaria cases
examined
microfilaria
2953375
_198JL
59658
2.02
29829
| 1994
3960013
47427
1.2
37720
1 997
2620615
30317
J. 15
21012
1998
2492788
22046
0.88
26142
1999
2381377
16534
0.70
16643
i 2000 *
1202828
13293
1.11
28032
Source: NAMP, GOI
Disease
Rate
1.01
0.99
0.80
104
0^70
’2.33
Japanese Encephalitis (JE): This vector-borne disease i? prevalent in
about 65 districts in 10 endemic states; the annual caseload is about
2500 and 500 deaths, mostly of children below the age of 5. Nearly 90%
of cases are reported from AP, UP, Karnataka and West Bengal, with 50%
of deaths consistently reported from AP and Karnataka since 1997. But
JE is spreading to non-traditional areas: in 1996 Kerala reported 105 JE
cases and 31 deaths, and the numbers have been steadily increasing in
84
h
the last four years. Control strategies continue to focus on early
diagnosis, case management, vector control (two rounds of residual
insecticidal spraying), fogging by malathion insecticide, segregation of
pigs and promotion of personal prophylaxis. While high costs limit the use
of vaccination, no effective chemoprophylaxis or curative drugs exist. But
vaccination as prophylaxis continues to be an option, as early reports of
trials in highly endemic areas indicate safety as well as high levels of
protection.
Dengue Hemorrhagic Fever (DHF): There was an outbreak of DHF in 1996
in 9 states: 16,517 cases and 545 deaths. Preventive action has brought
down the caseload to 605 and about 7 deaths in 2000; intensive training
and standardized patient management have helped reduce case fatality
by 50%. Inadequate epidemiological information, however, hinders
drawing definitive conclusions.
There are five essential problems in the implementation of the vector
control programme:
weak and dysfunctional health system; ouor surveillance in
endemic areas;
delayed supply of inputs due to time consuming procurement
procedures; weak logistic monitoring;
> limited involvement of community and local bodies;
inadequate allocation and delayed release of recurring budgets;
*inadequate
research
on
vector
and
human
behavior,
anthropological and operational issues, drug and parasite
resistance.
Tuberculosis (TB)
The ICMR nationwide survey of TB conducted between 1955-59 covered
40% of the population and indicated an active TB prevalence level of
1.5%. These estimates continue to be used. Given the socio-economic
changes over the past five decades, a new nationwide study to estimate
the rate of Annual Risk Infection (ARI) has been launched by the National
Tuberculosis Institute and the TRC (11) Chennai. This should enable a
more accurate estimation of TB prevalence. India accounts for one-third
of global TB, and the largest number of persons suffering from active TB.
Thus available estimates are that about 2.2 million persons are added
each year to the existing load of about 15 million active TB cases; of
these, about 800,000 are smear positive (infectious), and about 450,000
die (12). TB is the leading cause of death among women in the
reproductive age group of 25-44 years, more deaths than those due to all
the causes of maternal mortality. TB accounts for almost 7.57 million
DALYs lost (WHR 1998). 20% of 15 year olds are reportedly infected with
the bacteria (13). Since every sputum-positive case has the potential to
infect 10-15 individuals in a year, and since TB is one of the important
opportunistic infections of HIV, it is feared that deaths due to TB can go
up to 4 million (14) in the next decade if not controlled.
85
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The National TB Programme (NTP) was launched in 1962, and an
impressive infrastructure of 446 District TB Centers, 330 TB Clinics, 764
hospitals (15), and 47,600 beds was established. These hospitals
diagnose nearly 1.3 million patients and treat 250,000 sputum positives
every year. But despite an annual expenditure of about Rs.300 crores
(16), double what is spent on the National TB Programme covering the
whole country, the outcomes are unsatisfactory due to poor diagnosis, the
administration of dangerous regimens and the lack of patient evaluations
or follow-up. Despite expert committee reviews in 1975 and 1988, the TB
programme languished for want of a credible strategy and political and
administrative support, as well as low resource allocation not exceeding
Rs.20 crores per year. An exhaustive review of the National TB
Programme (NTP) was taken up in 1992 and the findings showed
> completion of treatment by less than 40% of patients;
an inadequate budget and a chronic shortage of drugs, enough
only for one-third of detected cases;
> an emphasis on x-ray diagnosis,
resulting in inaccurate
diagnosis, centralization to TB district centers, and more
expense;
poor quality sputum microscopy, due to poorly trained technicians
and non and irregular supply of consumables;
a multiplicity of treatment regimens, administered primarily by an
unregulated private sector; and
insufficient managerial capacity and weak technical leadership.
The WHO extended technical support to pilot test the DOTS (Directly
Observed Treatment, Short-course) strategy to detect at least 70% of
sputum-positive patients, and cure at least 85% (17). Based on these
reviews, and the results of controlled pilot projects, the Revised National
TB Control Programme (RNTCP) was formulated with the DOTS strategy
as its cornerstone. The DOTS strategy is based on 5 principles: case
detection among patients spontaneously attending health facilities,
primarily by the microscopic examination of sputum; ensuring adequate
drug supply; the administration of Short Course Chemotherapy (SCC)
under direct observation; systematic monitoring and accountability for
every patient diagnosed; and political will. The DOTS strategy is now
implemented under the RNTCP in about 200 districts covering 350 million
people. External funding support of about Rs.746.76 crores (18) has been
mobilized; TB Units are being established at subdistrict level for every
500,000 people. Each unit oversees the work of 5 microscopy centers,
with a trained laboratory technician in each, and provided with state-ofthe-art binocular microscopes and reagents. Units are given a vehicle
each, and funds to meet recurring costs and ensure close supervision of
quality, reliability, and prompt reporting by microscopy centers. Most
critical to this strategy is the high priority given to microscopy - as the
appropriate technology to identify patients most likely to spread TB and
most likely to die if untreated.
86
Ii
About 0.5 million persons have beer treated under DOTS during 2000;
there has been a qualitative improvement in diagnosis, with a 1.2 ratio of
smear-negative pulmonary TB for every case of smear-positive TB. The
cure rate has doubled from less than 40-80%, though not uniformly. The
death rate has also been reduced to ^%, compared to at least 20% under
the NTP. These achievements of RNTCP, over a short three-year
implementation period, are due to the quality training given to health
staff; the increasing involvement of NGOs; improved management
systems and the standardization of treatment regimens according to
patient typology to ensure the uninterrupted supply of drugs in patient
wise boxes; the increased availability of sufficient funds with district
societies; and intensive monitoring (19). The DOTS strategy is to be
expanded throughout the country by 2005, and successful implementation
will improve cure rates, reduce mortality, prevent multi-drug resistance,
and prove effective on HIV infected patients.
The NTP is implemented along with RNTCP in the remaining parts of the
country with the central government providing drugs for short-course
chemotherapy. The results continue tc be poor in these districts, for want
of adequate inputs, irregular supp y of drugs, low budgets, poor
supervision and weak monitoring (Figure 6.5).
Figure 6.5
Evaluation and Completion of Treatment under Conventional,
Short Course Chemotherapy and RNTCP
CtnverticrEl Tredrrert
80000
70000
co 60000
O 50000
g 40000
=530000
Z 20000
Short Course Chemotherapy
100000
cn 80000
o 60000
-Q
E 40000
23
z
20000
0
k_
_
J
10000
o-l—L
1992
1993
19M
1995
1996
1997
1992
□ Treabrert Qxrpleted
1994
1995
1997
1996
Years
Years
□ Edited
1993
□ Evaluated
□ Treatment Completed
87
RNTCP
10000
8000
£2
Q
6000
J3
E 4000
3
Z
2000
0
I
1993
1994
1995
1996
1997
Years
□ Smear-Positive patients
_ Cured
Source: DGHS, GOI
The expansion of DOTS to cover the country by 2005 is a priority. The
achievement of this goal will depend on how soon and how well
constraints are overcome. It will depend on the required infrastructure microscopy centers, trained personnel, and the regular supply of drugs
(20) and funds - being ensured. Finally, it will also depend on the
mobilization of political and administrative will. Thus despite the
impressive results of RNTCP, the future scenario of TB control appears
grim because of
> low coverage: DOTS covers only about 20-25% of TB patients;
expansion is constrained by weak institutional capacity, low
budgets and the dangers of MDR due to unplanned expansion;
> the weak involvement of civil society and the community;
> the weak health system, particularly in urban areas without
primary healthcare infrastructure;
> unsupervised private practitioners following their own lines of
treatment, contributing to MDR;
> the
implementation
of multiple
systems
of TB
control
(conventional, SCC and RNTCP), with different financing
mechanisms; and
> the threat of a dual epidemic; HIV/AIDS and TB as an
opportunistic infection are likely to increase the number of cases
substantially.
Leprosy
Available estimates indicate a leprosy caseload of about 2 million cases,
of which 20% are infectious (21). 50.39% are multibacillary, 37.28% are
other bacillary, and 12% are single skin lesion cases. In the two MLEC
surveys conducted in 1998 and 2000, 4.63 and 2.13 lakh new cases were
detected. Systematic efforts to eradicate leprosy by March 2000 have had
success in about 24.64% of the country; in the other 15%, the prevalence
rate is between 1 and 2/10,000. The only states with a high prevalence of
leprosy now are Bihar, MP, UP, Orissa and West Bengal. Only 12 districts
88
h
have a prevalence rate of more than 20/10.000; 9 are in Bihar, 2 in Orissa
and one in MP. Bihar has the highest number of MB cases, while Orissa
has the highest number of single skin lesion cases. The National Leprosy
Elimmation Programme was launched in 1965, when prevalence rate was
57 per’10,000 persons. The programme, which was strengthened with the
introduction of Multi Drug Therapy (MDT), is vertically driven.
Implementation is through an impressive infrastructure of 778 Leprosy
Control Units, 907 Urban Leprosy Centers, 5744 Treatment Centers and
350 Mobile Leprosy Treatment Units. The control strategy includes active
case finding, MDT and the rehabilitation of cured cases for economic
productivity. Its strength has been low treatment costs, verticalized
implementation structure up to the sub-district level, and the active
participation of about 300 NGOs. Disease elimination stage has been
reached in 10 states; nearly 8.9 million persons have been cured in the
last two decades. At the current level of implementation, leprosy
elimination (prevalence of less than 1/10,000) is likely in most parts of
the country in a few years. The programme, however, must be sustained
to ensure that the disease does not resurface. Accordingly, in areas
where leprosy is less than 1/10,000, the programme is being integrated
with the PHCs with staff provided at the district level for monito"’'iy.
Other Infections
Acute diarrhea, dysentery, worm infestations and digestive tract
infections are soil-transmitted, or caused by the consumption of
contaminated water. Hence the need to promote community hygiene and
healthy living is imperative. Comprehensive health education that cuts
across sectors is the key to eliminating these diseases; the campaign to
eradicate guinea worm demonstrates the success of this strategy. The
high morbidity and mortality of water- and sanitation-related diseases
continue due to the absence of such convergence at the field level. Data
on the prevalence and spread of helminth diseases (roundworm and
hookworm) are not routinely monitored at the state or central levels, and
documentation is weak, though roundworm is known to cause ascaris
pneumonia and serious illness, and hookworm to cause anemia. The
fatality caused by these soil-transmitted parasites may not be substantial,
but they pose a serious health hazard to small children (22). In 19992000, the National Institute of Communicable Diseases carried out pilot
studies to estimate the prevalence and intensity of soil-transmitted
helminths among 9-10 year old children in 7 ecological zones of the
country (Table 6.2).
Water-related and helminth diseases have a debilitating impact on the
immunity system, particularly in the malnourished. Hence the need to
make adequate investments in health education as well as water supply,
sanitation and sewage systems. Locally elected bodies must be involved
in the maintenance of water supply sources. Since poor children suffer
most with infections affecting physical and mental growth, investments in
community level chemotherapeutic interventions must be considered.
89
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Table 6.2
Percentage Prevalence Of Soil Transmitted Helminths
__________ in Pilot Study Areas !999-2000
State of Study
A. Lumbricoides
T. Trichuria
Hookworm
_______ Area_____
Haryana________
1.37
0.37
0
Rajasthan______
4,7
4
0.9
Sikkim_________
30.7
4
4.3
Karnataka______
21.7
0.6
0.6
Maharashtra
13.3
2.85
0.6
i
Kerala__________
15.1
21.5
3.8
Source: NICD, GOI
T
Sexually Transmitted Diseases (STDs): HIV/AIDS has highlighted the
importance of STDs, which make a significant contribution to the BOD.
There are a reported 3.6 million HIV infected persons, and an even
larger number suffering from various STDs. A comprehensive strategy is
being implemented nationwide to contain these diseases. An emerging
concern is the rapid spread of hepatitis, particularly Hepatitis B (HBV).
HBV is known to cause chronic hepatitis, later developing into cirrhosis of
the liver or liver cancer. Those in the productive age group of 35-60 years
are most at risk. Like HIV, HBV is transmitted through unsafe injections
and transfusions, sexual contact, child to child transmissions and from
mother to baby at birth. But unlike HIV/AIDS, though 50-100 times more
infectious, it is curable. Studies based on laboratory findings in hospitals
indicate that the prevalence of chronic HBV is in the 2-10% range,
classifying India as a country with intermediate to high endemicity. These
studies also show that the HBV antigen among pregnant women ranges
between 12-47%, with most studies showing 18% or less. An estimated
15-25% HBsAg carriers die prematurely due to the long-term
consequences of HBV infection. Thus in each birth cohort in India, over
1.5 million persons develop this infection, and about 200,000 die of it
(23). Another study has estimated that 4% of the population are
chronically infected with the HBV, and about 30 to 40% have serological
markers indicating past infection with this virus (24). These studies
predict that 20% of the 40 million chronic carriers will eventually die of
liver cirrhosis or primary liver cancer. The treatment costs for hepatitis
through interferon or lamivudine therapy, or liver transplants, are
prohibitive; and hepatitis vaccination as prophylaxis is gaining importance
in the private sector, and to a limited extent, in the public sector, where
this service is available for the protection of health personnel working in
hospitals.
Programmatic Issues
Technical strategies for disease control seem to be efficacious and
affordable, yet India continues to struggle to bring down disease
incidence. The wide gap between
policy statements, technical
prescriptions and actual implementation persists. While gross deficiencies
in the primary healthcare system explain much of the unsatisfactory
90
h
implementation of disease control programmes, correcting shortcomings
would certainly improve implementation quality.
Need to intensify rigour in programme monitoring: Preliminary studies
(25) carried out by the MRC and ICMR indicate a range of factors
contributing to the poor implementation of the malaria programme: poor
supervision; poor monitoring of drug quality and improper storage
facilities; the lack of evidence-based planning of malaria control activities;
and the lack of coordination among different sectors and research inputs.
Vector control activities seem particularly affected by
• the untimely procurement of insecticides;
• low limits for the payment of wages and the non-availability of
recurring budgets to engage labor for spraying operations;
• the lack of systems for the evaluation of insecticide application
equipment; inadequate monitoring of insecticide resistance
against malaria; lack of evidence-based data on vectors
responsible for malaria transmission and transmission period;
• the lack of evidence for the introduction of new insecticides; and
• the lack of control on the free availability and use of antimalarials; delayed slide examinations and lack of information on
the status of drug resistance.
A field survey of the TB programme under the SCC was conducted by the
All India Institute of Hygiene and Public Health, Kolkata, in an estimated
population of 8.6 million with 37,703 reported cases, and about new
23,457 cases in 2000-2001 (Box 6.1). With Short Course Chemotherapy
being implemented in 70% of the country, close monitoring is essential to
ensure the timely supply of drugs and consumables. World Bank funding
under DOTS has enhanced programme quality, but it has also led to the
neglect of the ongoing strategy in non-DOTS areas, entailing implications
of drug resistance.
Sox 6.1
Findings of TB Survey by AIIHPH, Kolkata
>
>
>
>
>
>
Sample size - 540 TB patients of whom 70% were illiterate
In 28% of the centers, laboratory reagents and ethambutol were inadequate;
In 42% of the centers supplies of rifampicin, pyrizinamide and streptomycin
were inadequate;
Drug regimens were being adapted to suit the actual availability of the drugs;
Though defaulters in one center was as high a$ 13.6%, action to retrieve the
patient by letter or visit was rare;
Default registers were not available in 71% of the centers, lab registers in 42%
and transfer forms were inadequate in about 28%;
Client satisfaction was also low as 50% of the patients felt that the timing of
the center was not convenient;
Default usually happened during the 4th - 7th month, due to toxicity of drugs /
side effects.
91
h
Inadequate budgets and their poor utilization: The central budget
allocation for the control of communicable diseases, as a percentage of
total health budget, has gradually recuced during the period 1988-2001,
from 58% to 47%. This is a matter o' grave concern. Under-funding is
most acute in the malaria control programme, with no real increase in
budget utilisation over the past few years. From 1992-93 till date, the
programme has not been able to incur an average expenditure of more
than Rs.150 crores, the highest being Rs.193 during 2000-2001. While
allocations do not get spent, the malathion needed in North Eastern states
resistant to DDT is not provided. Similarly, partly for want of funds and
partly due to environmental concerns, the supply of DDT is only half of the
technical demand (26). An analysis of the causative factors and of areas
of high endemicity suggest an “epidemiological polarization.” A mapping
of disease occurrence across geographical areas and sub populations
establishes a convergence of illness, poverty, malnutrition, the denial of
access to basic needs, and low economic development. Not surprisingly,
the least developed states of Bihar, UP, MP, Rajasthan, Orissa and
Assam account for the highest percentage of morbidity and mortality due
to communicable diseases. The programme deficiencies in these states
are aggravated by their inability to provide the required recurring costs
under the package of assistance.
The lack of adequate recurring budgets leads to a disruption of activities.
Inadequate resources present a problem in other states as well; the
analysis of budgetary allocations in a good-performance state like TN,
showed that during 1995-96 and 1996-97, the percentage of allocation for
public health fell from 40% to 38.7%. The budget allocated for disease
control constituted only 15.4% and 18.1% of the total public health budget
respectively, and about 6-7 % of the total health budget (recurring and
non-recurring) (27). The central share is also low - only about 7.6% of the
total budget for disease control. To ensure timely availability and quicker
absorption of funds, state and district level societies have recently been
constituted under each disease control programme. Funds are released to
these societies directly by the centre. This has led to a higher absorption
of funds, but not to effective programme decentralization. The quality and
pace of implementation continues to be a problem, with non-availability of
the requisite technical expertise, of adequate delegation of powers
needed to take timely decisions, and a lack of flexibility in spending.
Need for involvement of private practitioners: 80% of OP care is
provided by private practitioners, making their involvement in the control
of major communicable diseases such as TB and malaria an obvious
requirement. A study (28), conducted on the role of private practitioners in
the resurgence of malaria in Mumbai, showed that practitioners had poor
qualifications,
and
adopted
diagnostic
and
treatment
practices
inconsistent with guidelines. Few of those practicing in low-income areas
relied on peripheral blood smear tests for diagnosis. They commonly
resorted to injectible anti-malarials and broad-spectrum antibiotics for
92
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febrile patients, with the justification trat patients could not afford a blood
smear test or a full prescription.
Delayed procurement and poor monitoring of logistics: Timely
procurement and supply of inputs affects implementation of all national
programmes; central procurement appears to be an advisable option for
economy of scale. In the best of cases, the average time required for the
procurement process is not less than 6-8 months; starting the process a
year before is not possible because the budget is not sanctioned. With
more flexibility, the centre can procure in cases where state governments
make a specific request, or lac< institutional capacity. Besides
procurement, delivery and utilization, close monitoring, and inventory
control to ensure timely diversion of surplus stocks to deficit areas, need
to be given equal attention.
Need for Comprehensive Surveillance System:
Planning
and
programme formulation based on partial data may lead to faulty design.
The poor enforcement of compliance to report notifiable diseases (29) is
a serious gap. The wide difference in the quantum of “missing data" can
be gauged from a review of two districts, where surveillance teams have
been trained in field epidemiology and provided with computers. In
Udaipur, Rajasthan (population 2.08 million), information against the list
of notifiable diseases is collected only from government facilities; in
Kottayam, Kerala (population 1.82 million) (30), information is received
from both public and private facilities. (See Table 6.3 for reported cases
for 2000). Misreporting, delayed reporting and underreporting from
government facilities are aggravated by lack of infrastructure. Udaipur
has no public health laboratory, while Kottayam has laboratory facilities
for cholera, viral hepatitis, dengue, meningococcal meningitis, typhoid
fever, diphtheria and water bacteriology. The absence of a surveillance
system affects the ability to recognize early warning signals, and take
timely measures in the event of disease outbreaks.
Table 6.3
Case Reporting of Major Diseases -2000
Disease___________________
Kottayam
Udaipur
Acute Watery Diarrhea
43344
11933
Cholera___________________
103
1
Measles___________________
571
12
Acute Respiratory Infection
647470
22583
Pneumonia________________
1114
467
Pulmonary Tuberculosis
298
1062
Total All Cases____________
2.26 million
0.16 million
Source: NICD, GOI
Low priority to health education and community involvement: Health
education has always occupied a lower priority in Indian public policy: its
allocation under different programme budgets, taken together, is not more
than 1-2% of the annual health budget. A lack of information is one of the
major barriers to the effective access of services.
The Polio Pulse
93
u
Campaign is an example of how peoole change behavior in response to
information. An activity associated with health education is the securing
of social support to enable the effective implementation of disease control
measures. The inclusion of health concerns with water and sanitation
programmes, adult literacy, poverty alleviation and developmental
projects is limited. So is the co-option of local bodies and NGOs to share
responsibility, except in the cases of the leprosy and HIV/AIDS control
programmes. For example, in a highly community based and localized
programme such as malaria, the involvement of local bodies is almost
non-existent - whether in introducing bio-environmental control methods,
or ensuring compliance to sanitary laws, or providing the required
administrative and political leadership. Such involvement of the
community and local bodies, at both village and town levels, is emerging
as an imperative for effective malaria control.
Impact of Campaigns: Campaigns cost money; they can also distort
priorities and exhaust the staff. Even so, there has been a growing
tendency to use campaigns even for routine tasks. Campaigns can be
useful, but they need to be applied selectively, as a means to mop up
residual cases. In one state for example, the entire health staff was busy
for two months with one campaign after another - the catch up round, the
3rd round of the polio pulse, family health awareness, tetanus. Needless
to say, this affected routine work such as malaria surveillance or leprosy.
Frequent Shifts in Programme Priorities: The Leprosy Control
Programme has been successful mainly because of the sustained
implementation of strategy. Frequent policy changes have an adverse
impact on a programme; the TB programme first advocated long-term
conventional treatment, later introduced Short Course Chemotherapy, and
has now introduced the DOTS. All three run concurrently and none is fully
provided for.
Policy Issues: Future Directions
On the basis of the analysis of programmatic issues, recommendations
for future action include the following.
> Revise public policy for quick epidemiological transition:
Policy revision must aim to ensure, in the short term, the
elimination of leprosy and Kala azar, and the control of malaria,
HIV/AIDS and TB, targeting a drastic reduction in mortality. A
focus on areas with an API above 2 will help malaria control;
bringing the entire country under DOTS rapidly will help TB.
> Increase total quantum of funds: Central funding to the states
is at present Rs.3-5 per capita for all four major communicable
disease control programmes. A substantial increase is required
for these, and 100% central assistance is required for the control
94
iI
programmes of vector borne diseases, TB, HIV/AIDS and leprosy
in high endemic areas, covering all non-recurring and recurring
costs to fill critical gaps.
> Consider a more direct central intervention in actual
implementation: If necessary, the deployment of trained
personnel, on a contractual basis, will offset poor institutional
and managerial capacity for programme implementation in weak
performance states. In states with the capacity to implement and
monitor, bulk grants, subject to certain deliverables, may be
released. The release of bulk grants to the states will impart a
greater sense of responsibility and accountability, besides
developing capacity and providing operational flexibility. Proper
utilization must be ensured through close monitoring of the
agreed outcomes, based on performance indicators.
Revise procurement systems suitably: The central government
must consider the decentralization of procurement to states and
districts by developing requisite capacity.
It mcy, however,
..ontinue to procure equipment, consumables, drugs, and
pesticides only on the specific request of state governments, or
where it is unviable for the states to procure.
Consider the inclusion of hepatitis vaccination in UIP:
Though hepatitis does not kill, it contributes to disease load that
is expensive to treat; also, the vaccine is now more affordable.
> Invest on improving public health institutions and enhance
the quality of laboratory support
> Establish a comprehensive surveillance system: A high
priority in all districts, this should be done with central funding
for a period of 10 years.
> Develop protocols and regulations to co-opt the private
sector into reporting and treatment in disease control
programmes
>
Increase investment and put a set of incentives in place: This
will improve the functioning and accountability of the health
system; incentives and disincentives will help worker motivation
and discipline.
> Undertake more evidence-based research: The priority is drug
and insecticide resistance, given the exorbitant costs of
alternatives.
Operational
research
on
programmes
and
management-related problems will enable corrective action.
95
u
> Strengthen technical units related to disease control: This
should be done at both central ministry and state levels to
enhance the capacity for impact assessment studies. A critical
mass of trained epidemiologists is the highest priority at the
district level.
> Monitor and supervise at close intervals: This should be
substantially intensified at centre, state and district levels.
> Focus on HIV/AIDS: This will help control associated infections
that may become unsustainable for the health system to cope
with later.
> Improve routine functioning of primary healthcare system:
This must ensure the full integration of implementation of
communicable disease control programmes with the primary
health system and referral units.
> Focus on Health EIC programmes: Popular participation and
empowerment can be strengthened with more intensive use of
mass media channels, as well as interpersonal communication.
Notes
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
World Health Report (WHR), 1999.
Ramana, Peters and Sastry, Health Transitions in India: Issues and Challenges,
(forthcoming).
Given difficulties in reporting and surveillance, trends in reported cases should
not be assumed to accurately reflect trends in incidence.
Under this package, states are to provide resources for all recurring expenditures
such as travel grants for the malaria worker, wages for the sprayer, procurement
of sprayers, POL, maintenance and repair of equipment and consumables etc.
Again, a system fault due to the inconvenient siting of facilities, impractical
distances for workers to travel, and non-release of travel costs -- making it
unsustainable and demoralizing for the workers.
According to the latest data available, only an estimated 61% of laboratory
technicians and 63% of Male Health Workers’ posts have been sanctioned and
over 25% of the Primary Health Centers have no laboratories. Add to this the
factors of vacancies and absenteeism.
NAMP, DGHS, GOI, 2001.
Malaria and Its Control in India -- Country Scenario, March 1999, GOI.
Ibid.
NMAP, GOI, 2001.
Tuberculosis Research Centre (ICMR institution).
Joint TB Programme Review, India, February 2000, SEARO, WHO.
TB India 2001, RNTCP Status Report, DGHS, GOI
Ibid.
The Revised NTCP: A Status Report on First 100,000 Patients, lead article by Dr.
Khatri published in Ind.J.Tub, 1999, 46,157.
TB India 2001, DGHS, GOI.
In the 50’s and 60’s, TRC, Chennai first demonstrated the safety and efficacy of
domiciliary treatment, the effectiveness of intermittent chemotherapy and the
feasibility of direct observation of treatment (TB India 2000, RNTCP Status
96
u
Report, DGHS, GOI). Internationally, however, the DOTS strategy is attributed to
the work of Dr. Styblo.
18. Rs.604.86 Cr. from the World Bank, Rs.110 cr. from DFID; and Rs.31.9 cr. from
DANIDA.
19. Joint TB programme Review - India, Feb 2000 by SEARO, WHO.
20. “The problem of default is closely linked to the poor administration of the
programme....prescriptions to buy from the market and advice to come again to
collect drugs not available are the two most demoralizing factors for those who
leave a days’ wage or borrow money at usurious interest to reach the PHC...more
often treatment is discontinued not because they do not wish to take it but
because they have no other options. ...Migration to other places is search of work
is another problem, for the poor cannot live on tablets and need sustenance as
well." Report on Multisectoral Approach to Health in UP, Chandramouli, UNDP,
1999.
21. DGHS, GOI.
22. The Global Parasite Control for the 21st Century - A Report of the Working
Group on Global Parasite Control, Govt, of Japan. May 1998.
23. Craig Shapiro and Charu Prakash, Hepatitis B in India: Burden of Disease
Analysis July 2000, SEAR, WHO.
24. Kane and Miller, Routine Hepatitis B Immunization in. India, 1997.
25. Situation Analysis of Malaria in Tumkur District of Karnataka by the Malaria
Research Center, 2000.
26. DDT, till recently listed a one of the persistent organic pollutants by the UNEP,
which put a constraint on the extent of its utilization. The quantity of DDT to be
used in a particular year is also as per mandate of a High Level Inter
departmental Committee under the chairmanship of the Secretary, Health, GOI.
27. Government of Tamil Nadu.
28. Vijay Kamat, Private Practitioners and their Role in the Resurgence of Malaria in
Mumbai, CEHAT.
29. “...Notification of a list of diseases is legally required in Tamil Nadu State
(Madras Public Health Act, 1930)...hardly anyone complies with this requirement
because there has been no system of enforcement....rural health centers did not
report non vaccine preventable diseases...Physicians, both in government and in
private institutions, face no consequences for not reporting disease...In the
absence of action people lose interest in reporting." Jacob John et al, Disease
Surveillance at District Level: A Model for Developing Countries in Lancet 1998;
352; 58-61.
30. The Kerala Model of Surveillance is based on the model developed by the CMC
Vellore, Tamil Nadu. “The success and sustainaoiiity of this model is because it
includes simplicity in reporting procedures (just a postcard with 14 notifiable
diseases printed) low budget, private sector participation, regular feedback of
information through bulletins and interventions consequent on reporting." Jacob
John et al, Public Health, in Lancet 1998; 352; 58.
97
H
Annex 6.1
Malaria Cases in Selected North-Eastern States, 1995-99
J
;
■
I
I
J ______
Year j.[Positi.
CasejP.f
Case;
P.f% -Positive
CasesiP.f Cases,
___ 1_________ ----------------------------------------------1--------------------
S.No;'
States/UT
—j—-------------—
Deaths due
! to Malaria
-1“
I
_____J___ *_______ 1_____ 1--------- ?
5’l’l”l'5:””z'5'i
’27”'i'4
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14.70!
llArunachal ----------.Pradesh!
“____ 10051
4 19951H..
-------------- --------------------- L--------------- J----------
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__________
Malaria Cases in High Risk States, 1995-99
:
}
;
!
I Percent increase (+)/decrease (-) I
• Year positi. Cast* P.f Case; P.f % ;
over last year
I Deaths due
;
!
•
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I
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1
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__ I.............. i-i99.6! __
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h
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S.Noi
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to Malaria
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’-’39’.’97|
17.94}
?5i76’47
'-4’277'1?'
10671} 60.49}
!
Ii 1995?' 2’858307" 39287l"~l'3774t
7’19967' 2791987' 3241'61 14.79'!
}1997}
i8i456T"4'35'4'6:"‘2’765:
7'199'87 il87l’2T' 263’3’31 22.18!
}1999}
2} -----------Karnataka
^ss'.
’o’g:'
-33.09!
9
6
37
I
7996?
91014;"j"’i'72267'"l'8793!’’
87686? 747251 16.79 I
■ 1997|
23545fl 4?701
4-f——T’ 155209; ' ______
! 1998! 1320887' 25156}' l’9’04!
■1999; 227480T"72755l" 317987'
A-------*.,
I
-3‘.’66!
r'
’-’14?52”
77.01}
59.90!”
I
-14.90ll
6?84!r'
72.22!
189.22}
140
56
74
77
144
Source : NMAP, DGHS, MHFW, GOI
100
Annex 6.2
Performance of the RNTCP by States (Provisional figures as of March 2001)
! j New s+ve !
Annual detection rate
;
!
!
! Popn. Covered (in ! % of state covered!
!
3-months
j
t---------------- :
}
cases
; lakhs) by RNTCP !
by RNTCP by
I Total Cases
•
NewSwe ; Totalcases j R^oofS+veto {conversion rate of} uccess ,
___________ 1
NewSfve
' °’NewS^,
.. 4
4
4
*
! S-ve patients
;
by 31.12.00
■
31.12.00
! ! treated in 2000 !! treated in I}
New
S+ve
!I
patients • treated
* !
2000
i
pa
»i»nf
c
/•/.»
I
Patients
patients (%)
41-----------I
States
j----------- i----------- [
Andhra Pradesh
Assam
Bihar
Delhi
Gujarat
Haryana
i
—I—
Himachal Pradesh
Karnataka
Kerala
12-------}_.
110}
7787
380!
—---f48}
43?
j
141!
’JTTTT’319:
.4
15;
ib’oT
24}
-72T
—
28!
---- u.
100}
Madhya Pradesh
Maharashtra
Manipur
Orissa
Rajasthan
Tamilnadu
Uttar Pradesh
West Bengal
;
?
;
Total
•2871+____________ ;________________ 30!
£4=
40?
---282!
10
69}
4977
225;
■7Z“"r
189}
3307
8:
32!
____ L.
?0
20;
967
13}
437
j______ i______ L
6444!
14401
4698'
23907;
348491
4161}
6098:
6035!
75652;
’52'1’6:
- ----26575!
77591
1759
9632;
39919;
14985!
14756}
29009;
-------245135;
‘ Rate calculations include only districts implementing for all of 2000
+ Some districts which began implementing in December 2000 will report starting in 2001
Source : National TB Control Programme, DGHS, MHFW, GOI
4-..........I.... ......... t
2632^___________ _45!________ 111!
649'1
_____
15677
14082^
1589}
2’3197
2661!
66991
79887
8677!
’euT
4385T
j~6984T
20 j
68;’
71;”
4,
68}
28I
27}
54}
46j
61;
___.
71}
—»
89!
5644!
6093t
705297
95091 ;47*
64;
36;
120;
61}
203!
j’3’9!
i’go;
66!
62'!
i’4*2!I
140!
j76!
158}
____0.8!
_________
0.5I
3tE
____ 831
o.e:
"’as? ””
847"”
’"b’s;
'"'"'BO;"'"
""p"67’”........
”0.61
b'6;
’”927""
zzgpz
___ 88;
~~~~857
”9’37
0.7}
226:
0 zT
•j
_1_2l!
154}
—I
99}
*i
0.9!
0.8}
i’.i-I i
o.sj
89!
i
r
r
8
.....BZl.....
87;
8
a:
10
h
Annex 6.3
National Tuberculosis Control Programme
Statement Showing the States & Union Territory-wise Targets & Achievements with Regard to Condition of Sputum
[_______ 1997-98
States/ Uts
1998-99
____ ;
. .'Achievement; _
11! '36480?
.r.9
i 9et i
'6'3?8'l?'””3’6'48b!
i
Andhra Pradesh
’’”’509!
15?63?'
1’2’94’6:'
”””l”627’”
’n’i’oo:’”"
74'2’31
■’'49960 i””
73?577'
””’8’0’6:””
146.81J.
■.94?4'37
'24'720:
■9926:
.1.15.90,
’78?24
17.24:
12.11!
3360!
'4'97’6:
16.70
78?7lT
’2’6’6’5’61
100.32
7.881
79'Z53':
23_100j_
”94561
192.30:
23100:
”1’8’96!'
’’9456^
85.47!
24'30:
2924!
Gujarat
I
47’3335:'
””683!
Himachal Pradesh
;
Uammu & Kashmir
|Kamataka
!
2924!
43’467
!
25030;
79.24!
25030;
Kerala
f 156727
LMapilYa Pradesh. [..’37773:
'es’s'g':
'e’g'g’s;
75’6721
37773;
’777711
43461
[Marnpur__________ I./jPZil?????66J07?’’’'’l’6’777
Meghalaya
T
•r*
i
4
[Rajasthan
Sikkim
Tamil Nadu
I
[Tripura
'Uttar Prtadesh
West Bengal
•k
t
T
iA&N Island
iChandigarh
T"
D&N Haveli
i
Daman & Diu
•b
Pondicherry
ffOTAL
""4"9'3?'?'?_’4'96'6'b:
"4'6'2’77
7'00:
2'58'94?
2'3'7'8'61'
’"6'6?6b7"”??’977o:'
’”l'6?33?........'2'97'6;'
2970!
’4’4'66:
40?7bT
81?95;
25720:
75990:
77687
'39'77'6:
j’ijo:'
W6?78T
;
6’6'46?
1041;
3.94;
1041J
4077
b'zbjjT
4’0'7’:'
_55.53l.
420!
9T7t7
47?48?
7l"i97
717:
23.43;
l’5?83!‘
717:
1’7’41’31'
74'61
77770:
71'3'5'3!
73.64:
'37’487'
’9’5?28?
58.89!
17413!
— - ------ .L.
11353;
253611'
104.47;
2’4.’.92l'
25361:
239;
’3’6'048F
233.89;
91’56!
239;
■3’0’64’8!
1617;
’3'2’84':
7’?807T
74'2?:
37884;
23.38;
j’esT
3797'
j6T82T
75745:'
'ib’s:
-------
82!
827
60?
50007
VZ •
b'io'sbT
I
11640:
'263’2’6:
'"g'gjTi"
'leTz;
38.10;
j1660;
’eeo!
79807!
3'7'88’4’:
71.86!
3'79:'
””60!'
’soboi'
---+..............r-l......... --11.
475£
"—-j"I 47298'0?
1070;
■’Tso!
250:
■3’06’3’6:
60;
’2’63”2’:'
’3’2’66?
18.38;
•r-4.
80!
0.00;
’”'6’6’o?.......
60;
60’96:'
252.21i
4751
7’4'41?’"'4'7'2'98’6:'
---4<
””3'6:
378.531.
e'e's'b'e?
490;
as’sTso;
0.00
4.36
..39880:...
■"1’26’6:
_54-84
io9?92
’"1'22'6;"........
54.51
I
70.00
s’e’sb’:'’
'840:
40.71
68'737
_84_0_5i
87?2’lT
77936:
18.37
jee.sT
s’-i’b’gT'
’’’’■’’sg^ioT
s’sTso!' :?’’?78_'867
. ..'"jo"?'0''"
o’obT
_0.00
34?38
48’6:
'3’8'9'90!
'”34’3’07......... ’”3'3’9'61
_6_2.fr7
”0?94
ieTso:
7l’9b6:
75.5
26780:
28’6;
92.20
...... s'gb'i"
146.07
30890:"’
42.28
"1890!’”
.----- -V** 1-- --
293.92
'ss’o’eo:’’^
."39506:
’”i23?537'
””3'l!'
Lakshwadeep
i
’72'5’7’5!
...... ..
Punjab
(%)
; Achievement
:
(%)
3'7'7'30;
50.54
Target
t............ ""■"I--------------------- ””'™r-------------------------- r
" " 7'"'683T
Orissa
Target
66.72;
Bihar
Mizoram
[Nagaland
:
2000-2001
37310;
’’.5’26:'
97’25:'
’’O^j’?
Haiyana
t(%)
:
; Achievement;
67.98:
8T531
Arunachal Pradesh 1 ,...5O9J______
Assam
7 12575:
Goa
1999-2000
!
: Achievemen;
73.83
9.42
139_47_
"Tie
2’33?75T
44Q!
i’0’6:
255'6’o7
70;
242.86
44l"89[
6980!
”'40[
.101.82,
"l2?50
26’5’92?'
"’’’seo:
.256.43
'"76'6'67
498590!
””60.8
’"'6'6b7
0.00
Source : National TB Control Programme, DGHS, MHFW, GOI
102
u
Annex 6.4
Outcomes of Treatment According to Category of Cases under Revised National Tuberculosis
Control Programme from 1993 to 1998 (First Quarter)
•
New
I
; smearpositive ;
i patients evaluated!
Year
-i ;Completed;
; Remained ;_ .
; treatment}Died (%);smearpositive;
<(%)
%) !
(%)
!
!
(•/.)
i
(%)
I
i
Out(%’
4---------------------- i--------- !------------- f----------- !----------------- i------------ 1-------------•T —— — —
I
1993
1994
1995
1996
1997
.4.
I
I
I
1998-1 st Qtr.;'
---- ---- _T.
Total
I
I
I
T' 70.7 'T
81.3
—r--------------------------T —
392
1058
2138
6345
7672
1989
19594
-------------------——r.
. —
i
_..76.5_
l”.80.5
80.5”l
-84.4i ^-t-4 J;
:’”78.9”l
4.3
0.9
3.2
2.7
1.4
0.9
2.0
-u.
New
i
■ smearpositive
: patients evaluated;
3.9
I
T'i
3.3
I
3.6
I
I
T'
•r*
3.5
3-7
1—.
;
3.6
T
Year
I
g2
I
■
•
I
i
T
T
New estraPulmonary
■ patients evaluated;
;
Year
54.2
74.2
74.9
79.1
84.4
87.3
80.8
Completed
treatment (%)
i
6.4
7.8
10.2
8.7
6.6
i:
i
8.8
I
■r
i
failed (%)
2.3
3.6
3.6
.L.
2.9
T‘
3.7
IU
I
tI
5.4
4.5
7.0
2.9
2.5
1.4
3.2
;1
lx
.1 _
(%)
I
I
4.6
T'i
i
I
.L.
603
651
1264
5538
7099
1916
17071
11.0
i
:
:
Found
I_ .
iDied(%)ismearpoyivei 6
Completed
treatment (%)
I
I
1993
1994
1995
1996 .4.
1997
1998-1 st Qtr.T
Total
T'
it
ii
I
i
i
•
0.5
3.0
3.6
4.1
3.4
3.0
3.5
3.2
T
T
i
I
1.7
1.1
0.9
1.6
1.6
1.4
1.5
t
t 35.7
20.3
t
15.9
13.1
9.7
6.7
12.3
r
3.8
2.2
4.7
3.0
1.4
0.9
2.2
I Died (%)ismearpositivei D°f yU'tedi TrQnSt,(y,)ed
j failed (%)
I
i
(%)
( ’
I
* ’
I
1993
1994
1995
1996
1997
i
i
i998-’ist Q’trl
.4.
Total
.4.
■t
13
169
467
1669
2181
616
5115
'T
I
.4.
T■
61.5
92.3
86.1
86.2
89.5
92.4
88.4
• L.
I
L.
0.0
T'
i
1.2
2.4
4-'
.L. 1.4
2.2
I
t
’T
i
i
i
T'
1.8
1.8
.4.
0.0
0.0
0.0
0.4
0.1
0.5
0.2
T'
i
I-
Ti
38.5
4.1
5.8
9.8
7.1
4.4
7.5
T'
i
4.
T'
0.0
2.4
5.8
2.3
1.2
1.0
2.0
103
u
I
Year
(/o) i
T
■4'
.i998-j‘st’Qtr[
:"52.3”:
.4.
^___75._5_
]”59.4
59.4 ”:
t
*T
69.7
73.9
.4.
(%)
:
_________________;
1
4“””
44
376
4-33
838
1023
285
2999
!
;
(%)
!
1993
1994
1995
1996
1997
i
■
Relapsed
< Cured iComPletedi
i
Found
.
I Defaulted! Transferred
; smearpositive ;
/0/x ■ treatment ;Di<ed (%);smearpositive;
i
(%) i Out (%)
I patients evaluated!
•4'
■_---------
6.8
1.1
7.4
2.9
2.91.4
3.2
!
9.1
4.5
I
r"5.i
4.3
r 7.o •44.
:_ 5.8
r 5.6
4-
i
T*
2.3
2.9
3.5
11.0
5.6
5.1
6.3
.u,
22.7
5.6
r
16.6
:
I 14.0
t
11.0 I
8.5
I
6.8
10.4
8?
5.7
3.1
2.0
5.4
Total
T
Year
:
:
:
:
i
i
;
I Other retreatment! Cured
d
J
F°Undf. ! Defaulted: Transferred
|
patients
i
I treaUnent ;D«d (%)|smearposlt1ve:
(%)
; ^ (%)
1"
67.0
i
:
;
I
■4----------- i
I 100.0 I
■4'
•4.
1998-1 st Qtr.|
Total
cm
cm
2
217
43.8
563
: 59.9
:
1598
64.0
2511
: 63.0
:
557 ______ 65.7
I______ 5448
:
:
I
i
0.0
20.7
8.7
4.3
5.4
7.2
T o’o 4.
f“S.7
6.2
I
' /0‘
■4'
12.1
;
I
I
1993
1994
1995
1996
1997
' /0‘
T
! 62.5
;
T 8.3
I
6.6
68
r-----
6.6
4
'T'
0.0
8.8
5.0
7.1
5.4
4.1
5.8
L.
0.0
14.7
T
13.5
i
4
13.2
15.0
14.8
14.3
f
r
r
!
r
0.0
3.7
7.5
4.8
4.2
2.1
4.5
Source : National TB Control Programme, DGHS. MHFW, GOI
104
u
Annex 6.5
Leprosy Case Detection Treatment and Discharge as on 30.03.2001
Cases
:
; Prevelance rate/1000
S.no I
State/UT
_. .
.
; Cases on record ;• No. of MB ;
. x
Discharged
I
!
!
population
, I
;
67445'
235671
1
[Andhra Pradesh
3.77
r---------------------j
’
s
’
s;
....... 148:
2
[Arunachal Pradesh
1.52
3
i
■Bihar
r-------
4
!Goa
L------------
5
; Gujarat
1
TeeT
76576;
136’7’1’:
’64’97'
’522:
1.53
141;
0.28
2.18
3.83
3.1
7.05
4.1
285l'
6
Uammu Divn.
”’646:
7
Divn.
r;Kashmir
----------------
1'58?
8
9
10
11
12
: Karnataka
13
[Madhya Pradesh
[Maharashtra
■Orisa
i
[Tamil Nadu
14
;Uttar
Pradesh
J.-.
—----------:West Bengal
15
;A&N Islands
16
[Chandigarh
17
• D& N Haveli
18
;Daman & Diu
19
! Delhi
20
[Lakshwadeep
21
iPondicnerry
»«4.
•i
I
I
[Haryana
r----^----------------
3
[Himachal Pradesh
4
5
■Kerala
IMampur
.1.________________ _
6
[Meghalaya
7
: Mizoram
8
9
10
11
[Nagaland
... 12
"".7
[Rajasthan
[Sikkim
40978]
52975;
52975]
44578:
Z'"3l0Z°Z
Z2Z94zZ
____ 2587J;
204:
4958;
XX
f
'57’8'2:
j895’5[
’1’4’2’22:
13247;
'
'
I
254497
■"254497
719317'
44810;
55736:
63;
373!
.... 223967'
15’2’08:
3’0’2:'
734?
108681;
-J 1?L.
ast”'”
31.’
io76o:
1.66
4.12
2.79
69;
3.15
’"2’4’4:
3.14
6.09
2.41
4.51
3.83
3.43
3.71
33:
3247;
-i-
4’867:
6_2_11_l_
63:
______ _23j_
n:
4
5_46l
596425:
Z'3-?-4!
Z39'36-?-1!
16’4:
220660:
Less Reported Cases of Prevelance Rate Per 1000 Population
2
[Punjab
18325:
44’7’68:
1-?3J
’" 14997
xJ I |
[TOTAL
I• Assam
1
i
4
11.83
11.83
-29926;
474T'
83987
.. ~ U;
142499;
j:
I
I
I
I
2988:
832:
2347:
764;
_33_9I_
28747
1907!
5_20:
0.88
0.36
2’9’5:
0.56
2’74:
.....I,
4225:
J.
i
I
1
’’260:
------ ..4.
1774;
’"eg:
""89;
207j_
68[
66?
eiT
j’3:'
72;
55;
"2’677
50;4
’956:
4660;
487
3018;
38:
113;
88l'8!
1’644!
----------- 4.
.-...-A.
3104[
42:
...4.
45;
[Tripura ............................ ...............................------------------------105;
____168;
1
I
T
128607
ITOTAL______________
I____________ 13701:___________
0.9
0.87
0.29
0.68
0.28
0.52
0.83
0.89
0.53
0.63
Source : National leprosy Eradication Programme. DGHS, MHFW, GOI
105
7
Maternal and Child Survival
Children below five and women in the reproductive age group (15-44
years) constitute 36.2% (1) of the Indian population. In terms of survival
and well being, they also make up the most vulnerable group in society.
Efforts to improve their survival rates and health status have a long
history in India. Successive Five Year Plan documents have enunciated a
strong maternal and child health (MCH) component, but from the third
Five Year Plan period, the overriding focus has been population control.
Even after the transition of the Programme from family planning to family
welfare, and the launching of the Expanded Programme of Immunization
in 1979, the Universal Immunization Programme in 1985, and the Child
Survival and Safe Motherhood Programme in 1990, MCH services have
frequently been crowded out by family planning. The programme again
underwent a critical change at the policy level when the central
government adopted the reproductive health approach proposed by the
NDC Commission on Population and the International Conference on
Population and Development (Cairo 1994), and dropped family planning
targets.
This chapter examines the current status of maternal and child survival,
and the causes hindering better performance on this count. It focuses on
mortality, considers the key priorities of policies and programmes, and
proposes options for interventions/programmatic improvements to achieve
a reduction in mortality rates for women and children. The general
morbidity of women and children can be addressed through general health
services for the people, and^ should not clutter the targeted interventions
specific to maternal and child survival. The recommendations made in this
chapter should be viewed against this background. While we are aware
that initiatives to address maternal mortality would simultaneously
address perinatal and neonatal mortality, we have chosen to deal with
maternal mortality and child mortality separately for focus and clarity.
Fertility and Maternal and Child Survival
Key demographic indicators used to assess the efficacy of initiatives for
MCH include Total Fertility Rate (TFR); Infant Mortality Rate (IMR);
Under-5 Mortality Rate; and Maternal Mortality Ratio (MMR). TFR, IMR
and under-5 mortality show a positive trend (Figure 7.1). All three
indicators show a reduction by about a half between 1970 and 1999. MMR
figures are not available over a time period, but available figures, though
considered unreliable, indicate the enormity of the problem. There is
adequate evidence worldwide that a poor society can get caught in a
vicious 'fertility-mortality' trap, in which high fertility rates lead to high
106
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mortality rates and vice-versa. NFHS 1 and NFHS 2 (2) have revealed that
high fertility, coupled with early and frequent childbearing, has grave
consequences for the survival rates of mothers and children. A significant
proportion of births in India is high-risk (3) because
One-fifth of fertility is contributed by women aged 15-19 years.
Children of very young mothers have an infant mortality rate (IMR)
almost one and a half times higher than for mothers in their
twenties; yet half of Indian women in the age group 20-24 have their
first child before the age of 20.
> One-fourth of births in the age group 15-19 is within 18 months of a
previous birth. The IMR for births within 24 months of a previous
birth is almost three times higher than births after an interval of four
years or more.
> More than a quarter of births is of order 4 or more. Children at
higher birth orders have a higher risk of dying during infancy, and
the risk increases with birth order.
>
Figure 7.1
TFR, IMR & U-5 MR by Time Periods
300
7
6.6
6
250
242
200
150
100
50
0
5.2
5
4.5
202
173
Il I
1960
1971
■ IMR
1981
DU-5MR
4
3 6
3 2
3
101
2
1 19
80
71
1
0
1991
1998
TFR
Source: SRS of various years, Census, NFHS (Under-5 mortality for 1991 coversl 988-93).
Maternal survival is similarly affected. The pregnancy pattern in India “too early, too many and too close together" - enhances the risk of
maternal mortality and complications. Research findings indicate that
maternal deaths could be reduced by 25-40% if all unwanted pregnancies
are prevented. If childbearing is confined to the age group 20-29, MMR
would be reduced by 11%. The elimination of the 5th and higher order of
birth would reduce MMR by about 4%(4). The need to raise the age at
marriage, delay the first child, and ensure a minimum period of 3 years
between children, cannot be over-emphasized.
Fertility preferences are conditioned by various factors, not the least
being gender preferences, over-compensation for high infant/child
mortality rates, and children being seen as economic providers. NFHS 2
107
H
(1998-99) reveals that the current perceived ideal family size is 2.7
children, only a slight reduction from 2.9 children in NFHS 1 (1992-93). As
many as 33% of Indian women want more sons than daughters, and only
2% want more daughters than sons. The consequences, understandably,
are adverse for the replacement level of fertility and reduction in
mortality. The percentage wanting more sons than daughters is highest in
UP (53%), Bihar (48%) and Rajasthan (48%), and lowest in Kerala (15%)
Karnataka (13%) and TN (10%) (5).
While fertility impacts strongly on mortality rates, the converse - that
infant and child mortality is a major determinant of fertility rates - is also
true. Poor households facing a high rate of infant and child mortality tend
to have a larger number of children. High fertility rates and childbearing
patterns also have a bearing on age structure, showing a high youth
dependency ratio (6), as high as 67.2 in India (7), weighing heavily on per
capita national income. High fertility rates also have a direct bearing on
human capital formation, with lower investments by parents in each child’s
education and health. Gender differentials get further accentuated. Thus
high fertility has several adverse consequences for economic and social
development.
Family Planning Programme Review
The TFR in India has shown a consistent decline from 6.6 in 1960 to 2.85
in 1997, a reduction of almost 60%. However, inter-state differentials are
enormous: the southern states, Maharashtra, Gujarat and West Bengal
show a fairly rapid decline in both fertility and infant mortality; while
Bihar, UP, Rajasthan and MP, accounting for over 40% of the country's
population, have the highest maternal and child mortality as well as
fertility. Family planning, the major intervention for fertility reduction,
must also be recognized as an intervention for reducing infant and
maternal mortality. NFHS 2 revealed that 25% of births included in the
TFR are unwanted. If these unwanted births could be eliminated, fertility
would drop to replacement levels, while promoting maternal and child
survival. An analysis of the level of unwanted births and IMR in the
states reveals the positive association between the two: the lower the
level of unwanted births, the lower the mortality.
108
H
Figure 7.2
Excess Fertility and IMR
1,4 r
- 100
■ 90
1.2 1 0.8 -0.6
0.4
0.2
0
■
II
Bihar
• 80
70
60
• 50
; 40
■I 30
; 20
; 10
0
-'v
&<■
MP
UP
Kerala
TN
Man.
Kar.
TFR-TV^RIMR
TWFR : Total Weighted Fertility Rate
Source: NFHS-2
Meeting unmet needs for family planning services through efficient
programme management will lead to fertility reduction, a necessary
condition (though not sufficient), for reducing IMR and maternal mortality
rates in India. A clear understanding of maternal and child survival and
the fertility cycle is central to developing a more effective strategy to
reduce maternal and child mortality, as well as fertility (Figure 7.3).
Figure 7.3
Framework
Maternal Fertility &
Health Outcomes
Maternal
mortality
Adolescent health
(girls) outcomes
Child health
outcomes
Birth
outcomes
Child
mortality
Infant
mortality
Infant health
outcomes
109
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Maternal Survival and Well Being
Though reliable national and state estimates of maternal mortality are
unavailable, the existing estimates reflect the relative neglect of women’s
health in India. The latest NFHS 2 estimate is 540 deaths per 100,000 live
births (8), compared to 350 among low and middle-income countries (9).
The 1998 Sample Registration Survey places MMR at 407 per 100,000
live births, apparently an underestimate given the variations in state
estimates. Even at this rate, more than 100,000 Indian women die of
pregnancy related causes every year, which is about 18% of total global
maternal deaths. India compares unfavourably with most other countries
in the egion (Figure 7.1). In addition to deaths, many women are disabled
by complications of pregnancy and childbirth.
Table 7.1
MMR by select country
Country
MMR
Korea____
30
Sri Lanka
30
Malaysia
34
China_____
95
Pakistan
340
Indonesia
390
India_____
440
Bangladesh
850
| Nepal________________
1500 i
Source: The State of the World’s Children. UNICEF, 2001
Determinants of Maternal Mortality
Maternal mortality can be broadly divided into direct and indirect obstetric
deaths. The relative share of causes of Indian MMR shows that about
three-fourths of maternal deaths are direct deaths and one-fourth indirect
(Table 7.2). The major direct causes are hemorrhage, obstructed labour,
infection or sepsis, toxemia and unsafe abortions. Indirect causes include
women’s health status: nutrition (anemia, height, weight); infections and
parasitic diseases (malaria, hepatitis, TB); chronic conditions (diabetes
and hypertension); and prior history of pregnancy complications.
Table 7.2
_____________________________ Causes of Maternal Mortality___________
Direct Causes
Hemorrhage___________
Puerperal complications
Obstructed Labour_____
Abortions______________
Toxemia
Indirect causes
_________________ Anemia___________________________________
Pregnancy with TBZ malaria/ viral hepatitis / others
Source: SRS, 1998, Registrar General, Census of India
29.65%
16.1%
9.5%
8.9%
8.3%
19%
8.4%
110
i I
C
The trend of major causes of maternal death in rural India over a period of
time (Figure 7.4) shows no significant improvement. Hemorrhage and
sepsis top the direct cause list, and anemia the indirect. Abortion-related
deaths show a downward trend (possibly because of lack of information),
while toxemia and malposition ofr the child remain almost at the same
level.
©
Figure 7.4
Causes of MMR
30
«-
-
= 25
2
t 20
o
0)
U)
......
15
ao5 10
5 -
©
*
♦
*
t
8-
85
86
87
0
81
82
83
€
Years
—♦—abortion
anemia
—*— malposition of child
—»- toxemia
hemorrhage & puerperium
—puerpenum sepsis
Source: Survey on Causes of Death. Radical Journal of Health, vol 1:2
A number of socioeconomic and cultural factors (distant determinants)
operate through a set of intermediate determinants (health status,
reproductive status, access to health services, extent of utilisation of
health services), to determine the level of maternal mortality in a given
population. All these determinants must operate through a sequence of
three outcome components: a pregnancy, a complication and the
treatment of the complication (10). All interventions to reduce maternal
mortality must therefore aim at reducing pregnancies to the extent
possible; preventing complications in pregnancy and childbirth; and
improving the outcomes for women with complications (11).
Family planning services can reduce pregnancies, and complications in
pregnancy and childbirth can be prevented by comprehensive antenatal
care, deliveries in health institutions or by trained health professionals,
safe abortion services, and the improvement of the nutritional, health and
socio-economic status of adolescent girls and women. However, neither
interventions to reduce pregnancies, nor to prevent complications, will
eliminate maternal deaths: 15-20% of pregnant women develop
complications, most of which cannot be predicted. Thus the effective
management of obstetric complications is the most important intervention
measure in preventing maternal deaths, as borne out by the experience of
m
*
I
9
1
u
the developed countries in reducing maternal mortality. In India, with 66%
home-based deliveries, effective screening for obstetric complications and
getting the woman to medical care in time are critical. A study (12) in
Anantapur (AP) reveals that about half the women who were transported
died on the way to hospital, underlining the direct relationship between
maternal mortality and distance from health centre. The mortality level is
lowest where a PHC is located, followed by where a sub-centre is located
(13).
Performance Review
In the sixties and seventies, maternal health services within the Indian
MCH programme focused on ante-natal care and safe deliveries.
Traditional Birth Attendants (TBA) such as dais were trained to improve
delivery practices, and ANMs to identify and refer high-risk cases. But the
MMR remained high despite these interventions, and research showed
that Emergency Obstetric Care (EOC) was required to reduce the MMR. In
consequence, the Safe Motherhood initiatives of the CSSM Programme
were begun to promote institutional deliveries, and the management of
obstetric emergencies, in addition to essential obstetric care - the early
registration of pregnancy, a minimum of 3 ante-natal check-ups, the
provision
of safe
delivery services and
post-natal
care.
The
implementation of these two components remains tardy; NFHS 2 also
rates the performance on essential obstetric care as unsatisfactory. Only
65% of mothers received ante-natal check-ups, 67% received 2 or more
doses of tetanus toxoid, 58% received IFA supplements, 34% of deliveries
were institutional, and 42% of deliveries were assisted by a health
professional (Figure 7.5). State disparities are huge: Goa, Kerala and TN
consistently rank in the top five, while UP, Bihar and Rajasthan show a
consistently poor performance.
Figure 7.5
Assistance at Delivery
Relative/
friends etc'
23%
Dai*
35%
Doctor
^30%
ANM’nurse/
LHV
11%
Other health
professional
1%
S Doctor
/WMnurs€/LH\Z
Other health professional IDai
Other( Retativefriends etc)
Source: NFHS-2
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A review of programme interventions vis-a-vis the major causes of
maternal mortality helps assess adequacy and efficacy. The most common
cause of maternal deaths in India is post-partum hemorrhage, which is
sudden, unpredictable and most dangerous in an anemic woman, hence
the importance of screening for anemia and high-risk conditions, and
access to EOG including blood transfusion. But in the current safe
motherhood initiatives, screening for complications and EOC are still
inadequate. NFHS 2 puts high-risk identification at 36%, but there is no
information regarding hospitalisation of these cases. Most of the 1748
first referral units (FRU) for EOC are not fully functional. Nor is the staff
adequately trained or the supply of essential equipment timely. 82% of the
posts of obstetricians and gynecologists in FRUs remain vacant (14).
Puerperal Sepsis, the next major cause of maternal deaths, is most often
a consequence of poor hygiene during delivery. Over 70% of deliveries
are conducted at home in unsafe conditions, in 142 districts in 15 states
of the country (15). The earlier mass training of dais has not yielded
results as the dai was expected to learn from the ANM, who conducts a
minimal number of deliveries. Of the 42% of deliveries assisted by a
health professional, only 11% were by the ANM/LHV/nurse. In UP and
Bihar, deliveries by health professionals were 22% and 23% respectively.
Only 17% of non-institutional deliveries were followed by a check-up
within two months of delivery. In UP and Rajasthan, it was less than 10%.
Clean deliveries and quick detection, and the management of infection
during the postnatal period, can substantially reduce mortality due to
puerperal sepsis.
Obstructed labour is often associated with a woman’s age (very young
mothers), parity (first births), and short stature (16). Such cases need to
have deliveries in institutions, again underscoring the need for high-risk
screening and referral. Other barriers to accessing care are illustrated by
a micro study conducted in UP (17): only 36% of "high risk pregnant
referrals” by the area PHO were actually taken to an institution for
delivery. Women who did not benefit from referral services cited financial
reasons as a major factor for non-use.
Death after induced abortion is yet another cause for frequent maternal
deaths. The Medical Termination of Pregnancy Act, 1972, enhances the
access of MTP facilities to women in need. But the required infrastructure
has not been built, and poor knowledge of the provisions and elaborate
procedures involved have prevented women from seeking MTP from the
public healthcare system. Though the private sector is also eligible to
provide services, the licensing process has been mired in procedural
delays and politicking. The ratios of population to centre are very high;
centres also have an urban bias, forcing rural beneficiaries to often resort
to risky unqualified practitioners. Given the inadequacy of MTP centres,
the illegal to legal abortion ration could vary between 3: 1 to 8:1 (18).
Toxaemia is estimated to account for over 8% of maternal deaths. The
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recording of blood pressure during antenatal check-ups and treatment for
hypertension could substantially reduce mortality due to this cause. NFHS
records that only 55% of pregnant women in rural areas had their blood
pressure checked.
Several studies have revealed that anemia is a major contributing cause
of deaths: a micro study (19) reported anemia as the major contributor to
20-40% of maternal deaths; NFHS 2 revealed disturbing levels of anemia
among women (52% with some anaemia). Moderate and severe anemia
among pregnant women (28%) is almost double that of non-pregnant
women (16%). India has the largest number of women in the world with
severe anemia, and the safe motherhood initiative has covered only 58%
of births (20) with iron and folic acid supplementation. Also, the
programme distributes supplements universally, regardless of individual
hemoglobin levels. Routine oral iron supplementation has not been shown
to reverse severe anemia, and the most rational approach would be to
detect and correct anemia among younger and non-pregnant women.
The programme review reveals strategic gaps in addressing the major
causes of maternal mortality. The current RCH Programme has additional
elements to address gaps: 24-hour facilities at PHCs and CHCs to
encourage
institutional
deliveries;
assistance
for
transport
for
disadvantaged families; blood supply at FRUs, and expanded services for
MTP and treatment of Reproductive Tract Infections and Sexually
Transmitted Infections, malaria, TB and other infections of pregnant
women. Since these interventions are in the initial stages of
implementation, it is too early to assess their impact.
Future Strategic Directions
The National Population Policy has set an ambitious goal of reducing
MMR to less than 100 per 100,000 live births by 2010. While a host of
socio-economic, environmental and behavioural factors impact on
maternal mortality, the focus on medically driven interventions is based on
world-wide evidence that the key to reduction in maternal mortality is
institutional capacity for the provision of timely and appropriate
medical care. Such institutional capacity can be established in a
relatively short time frame, and for this, the following strategies become
critical:
• Generation of political commitment to goal: There is political
sensitivity to high child mortality rates but not maternal mortality,
mainly because of lack of information on maternal mortality levels in
states. Dissemination of regular and reliable statistics on maternal
deaths at national and state levels will increase sensitivity to the issue
and help planning and prioritisation.
• Urgent need to establish systems to estimate MMR at regular
intervals:
A reliable database is critical to planning and priority
setting. A good civil registration system recording all births and deaths,
could be the basis for such a system
114
H
•
Prioritise interventions for maternal mortality in high infant
mortality districts; target poorest sections with least access to
essential and emergency obstetric care; reallocate resources to
reflect priorities: NFHS 2 estimates MMR at 619 for rural India as
compared to 267 in urban India; rural ratios are typically 2 to 3 times
higher than urban ratios, a situation with significant policy relevance.
Since cross-country comparison of data reveals a strong correlation
(r=0.87) between maternal and infant mortality (21/ it would be
appropriate to prioritise interventions for maternal mortality in the high
infant mortality districts.
• Effective screening for high-risk. The key strategy is to effectively
screen and identify all high-risk cases and ensure that all such cases
deliver in an appropriately equipped health facility. Cases for EOC
should be reduced to emergencies arising in labour; ANM skills in
screening and risk identification must be upgraded; PHC medical
officers must be held responsible for screening and identification of
high-risk cases, and follow-up for delivery at an institution. Monitoring
systems at PHC, district and state level have to be so instituted as to
follow up -'n each and every high-risk case identified, including those
who move to their mothers’ place for delivery, to ensure they actually
deliver in an institution.
• Promotion of institutional deliveries: All CHCs must be made fully
operational to handle institutional deliveries. The initiative in a few
states to convert certain PHCs into 24-hour units equipped for
institutional deliveries improves access, but given the non-resident
status of PHC doctors, the introduction of a cadre of trained nurse
midwives for PHCs must be considered, particularly in high MMR
districts. The initiative of providing transportation charges to and from
the health institution is an effective motivational strategy for
institutional deliveries. Sepsis accounts for over 10% of maternal
deaths and institutional deliveries can reduce the possibility of
infections. While the focus across states should be on promoting
institutional deliveries, in districts where home deliveries are high,
strengthening midwifery services through training of ANMs and dais is
critical. Anganwadi workers must also be drawn in to ensure
cleanliness during home deliveries, to recognise the danger signals
requiring referral, and to co-ordinate for transport if the need arises.
• Provision of effective emergency obstetric care: Haemorrhage is the
major cause of maternal mortality, accounting for some 30% of deaths.
The focus of the safe motherhood initiative to address this cause
should be provision of effective EOC at conveniently located facilities.
If this is to happen, radical steps must be taken to combat the non
availability of specialists, if necessary through the introduction of
short-term diploma courses for MBBS doctors in anaesthesiology,
emergency obstetrics and paediatrics. Systematic efforts must be made
to improve the supply of blood at FRUs, or ensure transportation to
facilities where it is available. Where public sector facilities for EOC do
115
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not exist, contracting out of services to the private sector, if available,
must be considered.
• Availability of emergency transportation: A corpus fund is being
placed with gram panchayats under the RCH programme, and systems
should permit for easy access. It must be made compulsory for the
ANM to inform the gram panchayat in writing of the high-risk women
who will need transportation, and the anganwadi worker involved to
ensure transportation. Referral pathways should be well defined,
facility-wise services clearly mapped, demarcated, and publicised, so
that patients are reached to the appropriate referral services with the
least possible delay. Transport funds or a vehicle must be provided to
PHCs and FRUs for emergency cases.
• Increase number of approved facilities for MTP in both public and
private sectors: All public health facilities that have gynaecologists,
from the district hospital down to the CHC, must be equipped as MTP
centres. Approval procedures should be simplified to increase private
sector facilities. ICMR trials have shown the safety and efficacy of RU
486 and prostaglandin for non-surgical MTP up to 8 weeks. Phased
introduction of the programme must be taken up quickly, starting with
Medical Colleges and District Hospitals.
• Screening and identification of anaemic women: Anaemia causes
around 19% of maternal deaths. Intervention must be supported with
adequate nutrition during pregnancy, and not merely restricted to the
supply of IFA tablets. Women identified as malnutritioned by health
personnel must be followed up through the ICDS programme of
nutritional supplements for pregnant women. IFA tablets should be
strip-packed to improve compliance.
• Comprehensive antenatal care: Every pregnant woman must be seen
at least once by a doctor and screened for anaemia, hypertension,
diabetes, urinary and reproductive tract infections, malaria and TB. If
laboratory support is not available in the facility, private services must
be contracted and funds provided by the RCH programme. Antenatal
care and immunisation sessions at PHCs should be so organised that
every woman is screened step by step - height and weight, urine and
blood tests, followed by screening by the doctor, as is done in
Indonesia and Sri Lanka. This can easily be organised, with specific
duties at every counter being allotted to PHC personnel, including the
supervisory cadre.
• Involve women and community in implementation of interventions:
The current programme has a limited component of community
participation, so important in promoting institutional deliveries,
ensuring timely referrals and reducing maternal deaths. When a woman
has an emergent pregnancy related complication, she is at the mercy
of those around her to ensure her access to a medical facility. The
programme must involve the community and women themselves in
planning and implementing interventions, so that their explicit needs
are taken into account.
116
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•
Effective supervision and monitoring: Safe motherhood initiatives
have not been subject to regular monitoring like family planning and
immunisation. Institutional deliveries in health institutions, caesarians
and EOC cases in referral units must be closely monitored.
Every
maternal death must be subjected to an audit as in the case of the
Tamilnadu model, where protocols have been clearly defined, district
level investigation teams set up, and monthly reporting systems to the
district and state-level RCH Committees established.
Child Survival
The Indian performance on the key indicators of child survival, IMR and
under-5 Mortality Rate has been, significant. The rate of decline in infant
and child mortality has been slightly better than the average in other lowincome countries (Figure 7.6). But a comparison of IMR and under-5
mortality rates with other comparable countries such as Brazil, China,
Indonesia and Thailand (Figure 2.1, Chapter 2) indicates India’s less than
satisfactory performance.
Figure 7.6
IMR of India Vs. Low-Income Economies
200
165
139
150
143
100
TT4
--------- 119“
—
98
69
50
0
60
70
India
88
95
-•-Low Income Economies
Source: Health, Nutrition and Population Indicators, World Bank, 1999
Despite the notable long-term reduction in infant and child mortality, data
for recent years indicates the rate of decline is slowing down (Table 7.3).
Table 7.3
Percentage Decline in Infant Mortality and Under-5 Mortality, 197 - 98
Period
% Decline in
% Decline in Under- 5
Infant Mortality
Mortality
1971-81
14.7
20.6
1981-91
27.3
35.7
1991-98
ToTo
15.1
Source: SRS, Registrar-General, Census of India
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The tempo of decline in IMR and under-5 mortality achieved in the decade
1981-1991 has not been sustainec, and has shown a disturbing tendency
to plateau during the last 4 years. The IMR has been hovering around 72
and under-5 mortality around 95 per 1000 live births during the last few
years (Figure 7.7).
Figure 7.7
IMR and Under-5 MR
300
250
200
•.’ n ■r'- .*
&
150
■
100 -- I
50
0 J
|202^ -
173
|»! V*-'
•
74
■•■'■■■I
Bv
s
1960
1980
1970
95
72
95
.'-d
1995
□ IMR
□ U-5MR
1998
Source: SRS, various years, State of the World's Children, UNICEF.
Progress has been uneven across states: 20 states and union territories
achieved the national goal of 60 for IMR, by the year 2000. Kerala’s IMR
of 14 and under-5 mortality of 19 per 1000 live births is comparable to
figures in developed countries; while MP, Rajasthan, UP and Orissa are
comparable to some countries in Sub-Saharan Africa (Annexes 2.1 and
2.2, Chapter 2).
Determinants of IMR and CMR
Figure 7.8
Major Causes of Deaths of Infants and Children in India
Major Causes of Infant Deaths in 1996
Congenital
3%
Major Causes of Child Deaths in 1996
(1-4 yrs.)
Others
13%
Others
24%
\
Infectious/P
arasitic
6%
Respiratory 1
19%
Respiratory
\
Perinatal
59%
28%
Inflamatory
(central
nervous
system)
7%
Diseases of
the blood
9%
''
Viral
Infectious/
Parasitic '
19%
13%
Source: SRS, Registrar General, Census of India
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Child mortality determinants have been the subject of many studies, and
income determinants (per capita income), are shown to have an inverse
relationship with IMR. However, non-income factors have a more
significant impact in lowering IMR (22). One study has analyzed non
income factors contributing to a decline in IMR as proximate factors (non
medical factors and medical care curing pregnancy, at birth and the post
natal period); maternal factors (age, parity and birth intervals), and
household and community factors (water, sanitation and housing) (23).
Though there is a lack of data on the relative importance of these
determinants, several studies conclude that access to an essential
package of MCH services can significantly reduce high IMR and child
mortality (24).
Perinatal / Neonatal/ Post-Neonatal Determinants: Post-neonatal mortality
has declined more and faster than perinatal mortality (28 weeks of
gestation to first 7 days after birth), and neonatal mortality (28 days after
birth). This is because programme interventions have focused on
immunization and the management of diarrhea and ARI, interventions that
address the major post-neonatal cau~?s of death. Perinatal conditions
account for a significant percentage of infant mortality. The perinatal
mortality rate at the national level was estimated at 46 per 1000 births in
1991 and at 42 in 1998. Significantly, it has shown only a marginal decline
during the decade. Neonatal mortality now accounts for two-thirds of
infant mortality. Micro studies conducted across the country suggest that
the causes of perinatal/neonatal mortality could be significantly different
from the causes of post-neonatal mortality. The ICMR has identified risk
factors that have a direct impact on perinatal deaths: the age of the
mother, birth intervals less than 24 months, previous stillbirth/pre-term
birth-, untrained birth attendants, low birth weight and illiteracy. Given the
relative importance of perinatal/neonatal determinants in child survival,
effective interventions to address these causes must be implemented to
achieve significant declines in infant mortality.
Nutritional determinants: Undernutrition is estimated to be a major
contributory factor in over 50% of child mortality. The synergistic
relationship between undernutrition and mortality is clearly revealed by
the fact that those states that have high mortality rates are also generally
those with high levels of undernutrition (Table 7.4).
Table 7.4
______ State_____
Bihar___________
Madhya Pradesh
Uttar Pradesh
Rajasthan_______
Orissa__________
Tamil Nadu_____
Maharashtra
Kerala__________
Source: NFHS -2
Nutrition Status by State ______
Under -5MR Weight for age below 2 SD
105.1
137.6
122.5
114.9
104,4
63.3
58.1
18.8
___________ 54.4____________
___________ 55.1____________
___________ 51.7____________
___________ 50.6____________
___________ 54,4____________
___________ 36.7____________
___________ 49.6____________
26.9
119
9
a
r
J
a
1
7
3
11
The nutritional status of children is strongly related to maternal nutrition
status, which reflects in infant birthweight. Poor recording of birthweight
under the programme has led to the lack of reliable figures on the
percentage of low birthweight babies (Table 7.5). The effect of maternal
anemia on perinatal mortality was reported in a study conducted in the
Government Hospital, Patiala (Table 7.6).
Table 7.6
Table 7.5
Percentage Distribution of Births
by Weight_______
Birth weight
% Distribution
Anemia as a Contributor to
Perinatal Mortality_____________
Severe anaemia
65/1000 live births
< 2.5 Kg
5.7
Moderate anaemia
49/1 000 live births
2.5 Kgs or more
19.4
Healthy
19 /1 000 live births
Don’t know
4.8
Not weighed
70.1
Source: Aditi Iyer, Women’s Reproductive
Health. 1998
Source: NFHS-2
Standard of Living and Household Determinants: Children from
households with a low standard of living are twice as likely to be
undernourished, and have double the mortality rates as children from
households with a high standard of living (Table 7.7).
Standard of living
Index
Table 7.7
Health Outcomes by Standard of Living
IMR
Under -5
Children under weight
MR
for age
% below 2SD
% below 3SD
Low
76.1
130
56~9
25?3
Medium
51.5
94.6
46.8
16.5
High
33
51.5
26.8
6.7
Source: NFHS -2
Undernutrition generally sets in during the first two years of life. The most
vulnerable age group has been identified as 6 months to 2 years, the
“period of perpetual hunger" when the child is dependent on another
person for feeding. NFHS 2 findings indicate that only 55% of infants
under 3 months of age are exclusively breast-fed; only 33% receive
complementary feeding in the age-group 6-9 months; half the children in
rural areas and 38% in urban areas are underweight and stunted; and
75% of children aged 6-35 months are anemic. Relating undernutrition
with childhood diseases, the Independent Commission of Health in India
states that “every infection is a potentially fatal illness," and the risk of
death is doubled for the mildly undernourished child, tripled for the
moderately undernourished child, and may be as many as 8 times for a
severely undernourished child. While 77.9% of households in India have
access to piped water or from a hand pump, only 36% have access to a
toilet facility (25). The water supplied, especially through hand pumps, is
120
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!•
not always safe, and diarrheal diseases continue to be a major cause of
mortality. Providing improvements in water availability could reduce
diarrhea morbidity by 17-25 %, while improving excreta disposal could
reduce it by 22-36%. Also, a child in a household that uses clean fuels for
cooking has over 50% less health hazard than a child in a household
using dung or wood.
Maternal determinants: Apart form maternal nutritional status, levels of
female literacy and age of marriage have a strong association with child
survival. The more educated the mother, the less the hazard for the child
(Figure 7.9).
Figure 7.9
Mother's Education and IMR
I
high school and above
I
“T
»32.S
I
middle school complete _____ 348.1
Literate, < middle school
_
53.5
1
Illiterate
■
0
20
186.5
60
40
80
100
IMR
Source: NFHS-2
Gender differentials: Gender disparities in health outcomes in India are
prominent and disturbing. Since their biological resilience is higher, girls
begin with lower mortality rates than boys during the first month of life.
But from the post-neonatal period to 5 years, girls have higher mortality
rates. Girls also have higher levels of malnutrition that place them at
higher risks of both illness and death (Table 7.8).
Table 7.8
Female and Male Health Outcomes and Social Indicators
Indicator
Male
Female
NNMR
50.7
44.6
Post NNMR
24.2
26.6
IMR
74.8
71.1
CMR
24.9
36.7
Underweight for age (below 2 SD)
45.3
48.9
Attending primary school
85.2
78.3
Attending secondary school
80.2
67.0
Fully immunized
43
41
Source: NFHS-2
Gender discrimination also surfaces when it comes to the child's access
to medical attention and care. An UPS study (1995) found that compared
121
H
to 29% males, 39% of female under-fours displaying symptoms of
pneumonia were not given treatment, either through healthcare providers
or at home. New forms of discrimination accompany technology: prenatal
diagnostic techniques are misused for sex selective abortions. The most
tragic figure of the 2001 census is the sex ratio for children under-6: from
962 girls (1981 census), it was down to 945 (1991 census), and is now
927 (2001 census).
Performance Review: Table 7.9 indicates the goals set for child survival in
the National Health Policy of 1983, the current status and the recently set
goals for 2010 under the National Population Policy, 2000. No goal set for
the year 2000 has been achieved overall for India, but individual states
have not only met but also surpassed goals.
Table 7.9
________________________ Demographic Goals vs. Current Status
1983 Health policy
Current
Indicator
goal for 2000
status
IMR
Less than 60
70
CMR (0-4)
Less than 10
23.9(1996)
Perinatal Mortality
Less than 35
44(1996)
Immunization against 6
85%
42%
vaccine preventable diseases____________________
Source: Health Policy 1983, National Population Policy 2000, MHFW
National
Population
Policy goal for
2010
30
100%
The package of services for child survival under the Child Survival and
Safe Motherhood initiative include essential newborn care, immunization,
appropriate management of diarrhea and Acute Respiratory Infections
(ARI), and iron and Vitamin A prophylaxis. NFHS records the performance
of India and the states in terms of coverage under programme
interventions: essential newborn care is a neglected component of the
programme; immunization coverage has improved between NFHS 1 and 2,
from 36% to 42% of children being fully immunized. Yet the fact that only
4 out of every 10 children are fully immunized in the country, a matter of
great concern. States as usual show wide disparities, from TN (89%) to
Bihar (11%). States with good coverage levels invariably have lower
mortality rates than poor performers. Immunization coverage is
significantly influenced by the mother’s education and by the standard of
living of the household. However, effective and efficient programme
management can counter the negative effects of these factors, as shown
by TN’s achievement of the highest immunization coverage despite an
unimpressive female literacy rate of 58% (26).
Five doses of Vitamin A are expected to be administered to children under
the age of 3; 65% of children received the first dose but coverage for the
remaining doses fell to 23.2% in 1998-99. Though iron and folic acid
tablets are also administered to counter iron deficiency anemia, NFHS 2
122
H
records an unacceptably high anemic level of 74.3% among children under
the age of 3. The intervention obviously needs a review.
The child survival programme has also focused on the management of
diarrhea and ARI, two major killers accounting for over 50% of child
mortality; but NFHS 2 records the unsatisfactory treatment performance
on both counts. 62% of mothers know about Oral Rehydration Salts (ORS)
(up from 43% in 1992-93) but only 27% have actually used them; no Oral
Rehydration Therapy (ORT) was given to 52% of affected children. Of the
19% of children who suffered from ARI, only 64% received treatment from
a health facility or provider.
This review reveals that child survival programmes have focused on postneonatal mortality. Left to ANMs and TBAs, the critical interventions for
neonatal mortality, essential newborn care, and low birthweight, remain
largely undelivered. The neglected areas of programme provision,
monitoring and supervision have again been highlighted under the RCH
programme, though
yet to be operationalized
through
specific
interventions.
Future Strategic Directions
There is an urgent need for new approaches and priorities in the overall
strategy to reduce under-5 mortality. Such a need is clearly indicated by
the near-stagnation of infant and child mortality in the last few years, the
relatively large share of neonatal mortality, and the regional variations
and inequities in child survival and health outcomes.
Political commitment and policy focus on high IMR states/districts
and disadvantaged groups: A key advocacy strategy to gain political
support (as in the case of MMR) is regular and reliable reporting on
levels of infant and child mortality by district and region. Policy must
also focus on the poorest groups who have the worst mortality and
health outcomes.
• Policy emphasis on interventions to address perinatal and
neonatal mortality: Antenatal care, safe delivery and guality newborn
care are key requirements for reduction of perinatal/neonatal mortality.
All CHCs and 24-hour PHCs should be fully equipped to handle basic
newborn care, and to transport emergencies to the nearest referral
hospital where a pediatrician is available. Again, ANMs must be
involved in screening, and referral for institutional delivery, when fetus
weight is low. Guidelines and treatment protocols must be designed to
address low birthweight for every level of care and staff trained
accordingly.
• Training of ANMs, dais and anganwadi workers: The training of
ANMs, dais and anganwadi workers in clean deliveries, newborn care
and the management of infections will have to continue in districts
where home delivery is high. The Anganwadi worker should be
specifically trained in first day care of the newborn, to ensure referral
•
123
II
and transportation of babies weighing less than 2.2 kgs, those
suffering from hypothermia/fever, convulsions, or signs of asphyxia.
• Timely medical interventions to control infections of the newborn:
That this plays a major role in reducing NNMR is borne out by an
intervention implemented in a district of Maharashtra between 1993-98
(27). The most important medical causes of NNMR were found to be
sepsis, meningitis and pneumonia, and a home-based package was
designed to manage these infections (US $5.3 per neonate),
administered through village-based, trained health workers. The study
results are phenomenal, with a reduction in the NNMR by 50%. The
female health worker is the key in the delivery of the planned action.
The ICMR is undertaking operational research to explore the
possibilities of replicating this experiment; if replicable, the current
RCH programme must make provision for this intervention in high IMR
districts. The anganwadi worker could also be trained to deliver this
package with an extra remuneration per case.
Box 7.1
______________________ Interventions to Lower Neonatal Mortality
NNMR Intervention- Maharashtra by SEARCH
’
Background
The team developed a package of home-based neonatal care, Including management of sepsis
(septicemia, meningitis, and pneumonia) and tested it In the field with the hypothesis that it j
would reduce NNMR by at least 25% in 3 years.
Methods
39 Intervention villages and 47 control villages were selected in Gadchiroli district and
baseline data was collected for 2 years (93-95).
Neonatal care was Introduced in the intervention villages (1995-98).
Village health workers from the community were trained in neonatal care. They made home
visits and managed birth asphyxia, premature birth or low birthweight, hypothermia and
breast-feeding problems. They also diagnosed and treated sepsis.Assistance was provided !
by trained TBAs. Health education and fortnightly supervisory visits were also provided.
Other workers recorded all births and deaths in the intervention and control area (1993-98) to
estimate mortality.
Findings
In the 3r year, 93% of neonates received homebased care.
The neonatal, infant and perinatal mortality in the 3rd year showed a net reduction of 62%,
46% and 71% respectively.
Case fatality In neonatal sepsis declined from 16.6% to 2.8% over 3 years.
Homebased neonatal care cost US $ 5.3 per neonate.
Interpretations
|
Homebased neonatal care, including management of sepsis, is acceptable, feasible, and has
reduced neonatal and infant mortality by nearly 50% in the undernourished, illiterate, rural
study population. The approach could reduce NNMR substantially.
Source: Abhay Bang et al, Effect of Homebased Neonatal Care and Management of Sepsis
on Neonatal Mortality, SEARCH, Lancet, 1999
•
Peripheral trained community health workers for delivery of
essential MCH services: This is essential in identified remote regions
where disadvantaged groups such as STs are located. The time span
for preventing infant and child mortality is very often short, and the
presence or absence of a trained health worker (anganwadi worker or
community health worker) can mean the difference between life and
death. AP has trained and appointed 8500 tribal girls in every
habitation in the scheduled areas of the state for the delivery of basic
health services, with an honorarium of Rs.300 per month. Given the
124
j
I
positive impact of this measure, the state proposes to expand this
initiative to other remote regions of the state. The RCH Programme
must consider the inclusion of this critical component.
• Effective supervision and monitoring systems to improve coverage
levels: Given unsatisfactory coverage levels, the post-neonatal
components of the child survival programme provide cause for concern.
Again, AP has initiated a pilot computerized name-based registry
system for monitoring immunization coverage. The system will track
each child by vaccine and by due date; information will be available
online, from the PHO up to the state directorate and secretariat. The
system can be expanded to cover other interventions for MCH. Another
key to improved immunization coverage levels is the convergence of
services between ICDS and health personnel, and a fixed day
programme for outreach services.
• Examine the feasibility of the campaign mode to improve coverage
levels: Given the low coverage of Vitamin A and iron prophylaxis, a
campaign mode on the lines of the pulse polio immunization campaign
could be considered. Orissa has implemented Vitamin A prophylaxis
through a campaign mode every 6 months. To save on costs, one dose
is given every year with the Pulse Polio Campaign, and the other after
6 months through an individual campaign. The state reports coverage
of over 90% compared to the earlier 40%. This effort has not yet been
independently evaluated for coverage and cost-benefit, but it appears
to be a good model for replication.
• Define specific prevention and treatment protocols for major
causes of childhood death: This applies to ARI, diarrhea, measles,
malaria in some areas, and undernutrition, and staff at each level of
care must be trained to deliver services.
• Key support strategies for ANMs: ANMs are the key functionaries in
the delivery of MCH services, and support strategies should include
(i)training to improve skills, (ii)mobility, and (iii)communication
facilities. The mobility of the ANM is critical to effective delivery of her
work. The ANM must be encouraged, as in Tamilnadu, to acquire a
motorised two-wheeler, on a soft loan basis, taught to drive it, and be
given a reasonable allowance or allotment of fuel per month. In fact,
driving a two-wheeler must be made a compulsory component of the
ANMs training in all the training schools in the country. An evaluation
study of the Tamilnadu scheme shows that ANMs were able to save up
to 60% of their time on travel, covering 3 to 4 villages a day compared
to 1 to 2 villages a day (28). Additionally, the ANM must be provided
with a telephone facility, which will enable her to respond quickly to
emergencies, manage her work schedule more effectively, and keep in
closer touch with the community she serves.
• Promote required convergence: This can be done by delivering the
training package to the ANM, the anganwadi worker/community health
worker, and the dai, as a team. Convergent action at the cutting edge
level - by utilizing the services of the anganwadi worker for follow-up
during pre-, peri-, intra- and post-natal periods for newborn care and
125
u
full coverage of child health services - will harness synergies in
service delivery and ensure a better coverage (29).
• Infant and child death audits to investigate and report on causes
of death: Current performance indicators and evaluation do not take
infant and child deaths into account. Performance evaluation focuses
on programme coverage, and the ANM is, by and large, held solely
responsible. The performance evaluation of supervisory staff, the
Medical Officers of PHCs, the sub-district and district-level medical
officers must include the incidence of infant and child deaths under the
civil registration system.
• Systems to monitor and check the misuse of technologies:
Although appropriate Authorities have been formed, the Prenatal
Diagnostic Techniques Act to prevent and control misuse is a non
starter in most states. Wide publicity among the medical fraternity and
the public must aim at concerted action to prevent this continuing
tragedy.
• Identify priority targets for health and the nutritional status of
schoolchildren and plan interventiohs: Data in micro studies reveal
that school children are plagued by health and nutrition problems such
as TB, helminthic infestations, parasitic worms, and deficiencies in
iron, iodine and vitamin A. Health check-ups and supplements can be
easily delivered in a school setting: In Gujarat, 3 million primary school
children receive a midday meal which includes vitamin A, an iron
supplement, and an anti-worm drug.
• Address interrelated dependent variables in long term strategies:
The experiences of countries which have undergone a rapid reduction
in under-5 mortality suggest that reduction below a level of 30 per 1000
live births implies change in interrelated dependent variables, such as
female literacy, female age at marriage, sanitation, water supply and
indoor air pollution. Long-term strategies must address these variables.
In summary, the gaps identified in this review, the policy options, and
specific strategies to address the gaps are indicated in Box 7.2. It is not
our claim that it is comprehensive or state specific. However, it will,
hopefully, facilitate design and planning for the rapid reduction of
maternal and child mortality at the national and state level.
126
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Box 7.2
A. Policy
_____________ Focus_________________
1. Area: Focus attention on states/districts/
regions with high maternal and child
mortality rates
2. Poverty:
Focus
on
poorest
and
disadvantaged groups
3. Cause of death: Prioritise interventions to
address cause of mortality
B. Interventions______________________
____________ Maternal survival_________
1. Meet unmet needs for contraception
2. Fccus on maternal anemia and nutrition
3. Provide effective
• Essential Obstetric Care
• Emergency obstetric care &
• MTP services
4. Increase institutional deliveries
5. Improve access & referrals through
• transport networks
• placing trained community
health
worker/ anganwadi worker/dai
• incentive strategies_________
C. Long term measures___________
1. Improve female literacy
2. Increase age at marriage
3. Improve household environment
• Fuel
• Water
• Sanitation
4. Reduce gender inequalities
5. Reduce poverty
_____________ Operation
support:
Generate
political
commitment.
2. Demand
generation:
mobilise
local
communities for improved health/nutrition
seeking behaviour.
3. Management:
• Identify critical gaps and implementation
bottlenecks and plan feasible solutions.
• Reallocate resources to reflect priorities
• Empower providers through training,
mobility and logistics
• Institute systems for regular/reliable data at
state & district level.
• Promote convergence between health and
nutrition services
1. Political
___________ Child survival_______________
1. Pregnant woman’s care and clean and safe
2.
3.
4.
5.
6.
delivery as in - eternal turvival.
Improve maternal supplementary feeding to
address low birth weight
Prioritise focus on neonatal care and
management of infections
Emphasise focus on breast feeding and
complementary food practices
Improve immunisation coverage
Treat childhood illness
Notes
1.
2.
3.
4.
5.
6.
7.
8.
Computed from NFHS 2.
National Family Health Survey, 1992-93 & 1998-99.
NFHS 2.
J. Trussel and A.R. Pebley, 1984, The Potential Impact of Changes in Fertility on
Infant, Child and Maternal Mortality, Studies in Family Planning, 15(6)
November/December.
NFHS 2.
Youth dependency ratio is defined as the number of persons in the age group
0-14 years per 1000 persons aged 15-59 years.
Census of India 1991.
NFHS 2, 2000.
127
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9.
World Bank 1997.
James McCarthy and Maine, A Framework for Analysing the Determinants of
Maternal Mortality, 1992, Studies in Family Planning, 23(1), January/February.
11. K. Balasubramanian, Improvement of Maternal Survival in India: Issues and
Strategies for Intervention, News Bulletin, Vol 4, SRC, Osmania University,
Hyderabad.
12. J. C. Bhatia, A Study of Maternal Mortality in Anantapur District, Andhra Pradesh,
India, IIM, Banglore, 1988.
13. The key findings of the study on MMR and causes in Anantapur district, Andhra
Pradesh, 1988 are that out of a total of 391 deaths, 333 were in rural areas, 58
in urban. Only 44.6% deaths matched with government records; maternal deaths
in total female mortality (15-49 years) was 36%. 40% deaths were at home, about
11% on the way to hospital. Deaths were lowest where a PHC is located, followed
by a sub-centre. 1/5th of family members of MMR cases indicated non
comprehension of the seriousness of patient’s condition. Causes of maternal
death: sepsis (36%), haemorrhage (12%), eclampsia (9%), severe anemia (9%);
surviving women made more ante-natal visits: on examination of data collected
by an expert obstetrician, 40.8% deaths were definitely preventable, 37%
possibly preventable, 22.2% not preventable; over 50% of cases could have been
averted by treating infection (20%), early shifting of patient and treatment (19%).
treatment of anemia (12%).
14. Aditi Iyer, Women’s Access to Healthcare, CEHAT, Bombay, 1988.
15. Training of Traditional Birth Attendants, MHFW, 2001.
16. David Rush, Nutrition and Maternal Mortality in the Developing World.
17. Aditi Iyer, Women’s Access to Healthcare, 1998.
18. Aditi Iyer, Women’s Reproductive Health, 1998.
19. David Rush, Nutrition & Maternal Mortality in the Developing World, American
Society for Clinical Nutrition, 2000.
20. NFHS 2.
21. K. Balasubramanian, Improvement of Maternal Survival in India, IIHFW, 2000.
22. Mariam Claeson et al, Reducing Child Mortality in India, World Bank. 1999.
23. Jain and Visaria, Infant Mortality in India: Differentials and Determinants, 1988.
24. Jain and Visaria 1988, Ghai 1985, Pratinidhi et al 1987, Bhargava 1991, Sandell
et al 1 985.
25. NFHS 2.
26. Census 1991.
27. Abhay Bang et al, Effect of Homebased Neonatal Care and Management on
Neonatal Mortality, Lancet, 1999.
28. V.R. Muraleedharan, Public Healthcare System in Tamilnadu: A Critical Overview
of its Strengths and Weaknesses, IIT, Madras, 2001.
29. The Review of the ICDS programme by Independent Commission on Health,
1998: ICDS was initiated in 1975 in 33 blocks and now covers 3702/5239 blocks.
It covers 1.76 crore children. Services include supplementary nutrition to
children, pregnant women in the last trimester and lactating mothers;
immunization; health check-ups; referral services; non-formal education; nutrition
and health education. The worker at the cutting edge is the Anganwadi worker
(AWW) who operates from the Anganwadi centre (AWC). ICDS has benefited
women and children, but allocated money and infrastructure need better
utilization. Operation of AWCs during late afternoon hours to enable more
mothers and young children to take benefit should be considered and the AWWs’
responsibilities prioritized. The emphasis on ICDS as a nutrition improvement
programme must give way to an MCH and development programme in partnership
with health services. (Source: Child Health, VHAI).
10.
128
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Annex 7.1
Infant Mortality ndicators by Residence, India, 1971-1998
Year Infant mortality rate Neo-natal mortality
Post neo-natal
Peri-natal mortality
rate
mortality rate
rate
Total Rural Urban Total Rural Urban Tota Rural Urban Total Rural Urban
1971 129
138
82
75.2
80.6
45.4
54.2
57.4
36.6
53.4
56.7
35.6
1976 129
139
80
77.0
83.0
49.0
52.0
56.0
31.0
66.8
76.6
43.7
1981 110
119
63
69.9
75.6
38.5
40.5
43.5
24.0
54.6
58.8
31.5
96
105
62
59.8
65.5
36.2
36.6
39.1
25.8
48.1
51.8
32.7
1990 80
86
50
52.5
57.4
30.9
27.2
28.9
19.5
48.4
51.7
34.0
1991
80
87
53
51.1
55.4
32.2
29.3
31.3
20.6
46.0
49.1
32.7
1992
79
85
53
50.0
53.6
33.0
29.4
31.4
20.0
47.5
50.3
34.0
1993
74
82
45
47.1
52.3
28.4
25.5
28.2
15.8
44.2
47.9
31.0
1994
74
80
52
47.7
52.0
32.6
26.0
27.5
19.6
42.5
43.4
38.7
1995
74
80
48
48.1
52.3
29.2
25.9
27.5
19.0
44.6
47.6
31.2
1996
72
77
46
47.0
50.0
28.0
25.0
27.0
17.0
44.0
46.0
32.0
1997
71
77
45
46.1
50.5
26.2
25.1
26.5
19.0
43.2
46.3
29.1
1998
72
77
45
45.0
49.0
27.0
27.0
28.0
18.0
42.0
45.0
29.0
X
1000
1986
Perinatal mortality rate =
Number of still births and infant deaths of less 7
days during the year
Number of live births and still births during the year
Source: Registrar General (1999). Compendium of India’s Fertility and Mortality Indicators
1971-1997 (Based on the Sample Registration System), Office of the Registrar General. New
Delhi
129
11
Annex 7.2
Infant and Child Mortality by Background Characteristic, India
S.
Background
NFHS-1 (1992-93)
NFHS-2 (1998-99)
No
Characteristic
Neo
Post- i Infant Under Neo
PostInfant
Under 5
natal neonatalj mort.
5
natal neonatal mort.
mort.
mort. j_____ mort. mort. mort.
mort.
1
Mother's Education
j_____
Illiterate_____________
60.6
40.0 I 100.6 140.5 55.3
31.2
86.5
122.8
Literate, <middle
38.8
23.7
62.5
83.9
40.5
18.0
58.5
75.8
complete____________
Middle school complete
37.6
18.5
56.1
64.8
33.7
14.4
48.1
58.1
High school and above
25.3
11.9
37.2
43.2
24.3
8.5
32.8
37.1
2
Caste/Tribe__________
Scheduled Caste
63.1
44.2
107.3 149.1
53.2
29.8
83.0
119.3
Scheduled Tribe_______ 54,6
35.9
90.5
135.2
53.3
30,9
84,2
126.6
Other Backward class
NA
50.8
25.2
76.0
103.1
Others_______________ 50.6
31.6
82.2
111.5 40.7
21.2
61.8
82.6
3 Medical Maternity Care
No antenatal or delivery
57.5
39.3
96.8
145.8 53.6
35.5
89.1
NA
care_________________
Either antenatal or
41.2
22.5
63.7
85.1
35.8
19.0
54.8
NA
delivery care__________
Both antenatal & delivery 29.8
14.5
44.2
56.8
22.2
11.8
34.0
NA
care________ ________
4
Place of Delivery______
I____
Public Health Facility
40,3
18.7 j 59.1
77.2
NA
NA
NA
NA
Private Health Facility
27.5
11.0 I 38.5
42.3
NA
NA
NA
NA
Home________________ 46.5
30.9
77.5
114.3
NA
NA
NA
NA
5
Religion_____________
Hindu________________ 55.0
35.4
90.4
124.0
50.4
26.7
77.1
107,0
Muslim_______________ 47.1
29.6
76.6
38.0
106.3
20.8
58.8
82.7
Christian______________ 32.6
17.3
49.9
68.4
29.8
19.4
49.2
68.0
Sikh_________________ 27.7
19.5
47.2
64,8
38.0
15.3
53.3
64.9
Buddist_______________ 36.6
19.8
56.4
99.3
39.5
14.0
53.6
66.9
6 Standard of Living
Index________________
Low_________________
NA
NA
NA
NA
55.8
33.1
88.8
130.0
Medium______________
NA
NA
NA
NA
47.0
23.4
70.3
94.6
High_________________
NA
NA
NA
NA
30,9
11.8
42.7
51.5
7 Total________________ 52.7
33.7,
86.3
118.8
47.7
25.3
73.0
101.4
Note • |In NFHS-2, medical• care includes (I) antenatal care received from a health worker, (ii)
delivery assistance given by a doctor, nurse, trained midwife, or other health professional
and (iii) postnatal care received in a health facility or at home within two months of delivery
The three categories under medical maternity care in NFHS-2 are (1) No care (2) One or two
.types of care (3) all three .types of
f care.
----In NFHS-1, caste status was classified into 3 categories: 1) scheduled caste 2) scheduled
tribe and 3) others. In NFHS-2, caste status was grouped into 4 categories: 1) scheduled
caste 2) scheduled tribe, 3) other backward class and 4) other
Source: 1. UPS (1995). National Family Health Survey, India, 1992-93 Bombay: UPS.
2. UPS and ORC Macro (2000). Natinal Family Health Survey (NFHS-2), 1998-99, India.
Mumbai: UPS.
130
u
India/State
India
Annex 7.3
Maternal Care Indicators, India and Major States, 1998-99
Percentage who Percentage of, Percentage of
Percentage of
Percentage of
received all
births
deliveries
non-institutional
nonrecommended delivered in a assisted by a
deliveries with a
institutional
types of
medical
health
post partum
deliveries with a
antenatal care
institution
professional (2) check-up within
post partum
two months of check-up within
(1)
birth (3)
two days of
birth (3)
20.0
33.6
42.3
16.5
2.3
Andhra
Pradesh
Bihar
35.6
49.8
6.4
14.6
Gujarat
25.0
46.3
Haryana
20.8
22.4
Jammu &
Kashmir
Karnataka
30.7
35.6
41.5
51.1
Kerala
64.9
93.0
Madhya
Pradesh
Maharashtra
10.9
20.1
31.0
Orissa
i
65.2
44.9
1.6
23.4
10.0
1.4
53.5
10.4
1.6
42.0
15.7
2.5
42.4
27.6
1.1
59.1
35.3
3.6
94.0
27.4
7.5
29.7
10.0
0.5
52.6
59.4
29.8
6.9
21.4
22.6
33.4
19.2
2.2
Punjab
31.7
37.5
62.6
20.3
5.7
Rajasthan
8.3
21.5
35.8
6.4
0.5
Tamil Nadu
50.8
79.3
83.8
53.0
Uttar Pradesh
4.4
15.5
22.4
7.2
10.1
1.5
West Bengal
19.7
40.1
44.2
31.6
i
T
I
I
7.1
Note: Table includes only the two most recent births during the three years preceding the
survey.
1. Three or more antenatal check-ups (with the first cjeckup with in the first timester of
pregnancy), two or more tetanus toxoid injections, and iron and folic acid tablets or syrup
for 3 or more months.
2. Doctor, auxiliary nurse midwife, nurse, midwife, lady health visitor or other health
professional.
3. Based on births in the 2-35 months preceding the survey.
Source: UPS and ORC Macro (2000). Natinal Family Health Survey (NFHS-2), 1998-99, India
Mumbai: UPS.
131
L
SI. No
Annex 7.4
Delivery Characteristics of Live Births, India, 1992-93 and 1998-99
Delivery
NFHS-1 (1993-93)
NFHS-2 (1998-99)
Characteristics
Urban
Rural
Total
Urban
Rural
Total
!
1
2
Birth weight
10.0
1.9
3.8
2.5 KG or more
28?0
5J
Don't know/missing
12.3
4.5
ioJ
"eT
Not weighted
49/7
Total Percent
100.0
87.8
100.0
79.1
100.0
10.8
40.3
8.7
4.2
5.7
13.4
19.4
3.7
40.2
100.0
78.6
100.0
4.8
70.1
100.0
Size of Birth
Large
15.3
63J
13.4
16.0
13.3
13.9
63.5
13.8
63.6
61.2
61.4
61.4
2T4
2VT
2Z5
24.9
24.4
Don't know/missing
20.0
0.9
1.6
"oT
0.4
0.4
Total percent
100.0
100.0
1.5
100.0
100.0
100.0
100.0
Average
Small*
I
I
<2.5 KG
_________ |______ I____________________ 1____
Note: Table include only the two recent births during the three years preceding the survey.
The NFHS-1 include births during four years preceding the survey and NFHS-2 include births
during three years preceding the survey
• In NFHS-2, the categories of small and very small are added and shown as 'small'
Source: 1. UPS (1995). National Family Health Survey, India, 1992-93. Bombay: UPS
2. UPS and ORC Macro (2000). Natinal Family Health Survey (NFHS-2). 1998-99,
India. Mumbai: UPS.
132
8
HIV/AIDS in India
Introduction (1)
UNAIDS and the WHO estimate that by the end of the year 2000, the
number of persons living with HIV/AIDS stood at 36.1 million, and the
number of deaths since the start of the epidemic was 16.3 million. HIV is
today the single largest infectious killer and the fourth leading cause of
death in the world; it is a global crisis demanding action that cuts across
all nations, all sectors and all strata of society (2). The numbers falling
prey to the infection show no signs of abating, with 5.3 million new
infections in 2000 alone. New infections are largely among the under-25
age group, including a large proportion of women.
Current Indian Scenario
HIV infection and AIDS cases were detected in 1986, first in Maharashtra,
later in TN. In the year 2000, the number of Indians infected with HIV is
estimated at 3.86 millions (3), exceeded only by South Africa. This
number corresponds to a prevalence rate of around 0.7% of the general
adult Indian population, quite low compared to the prevalence rates of
25% and over in South Africa, Zimbabwe and Botswana. HIV infections
have been detected in all the states and union territories of India;
infections are no longer confined to high-risk behaviour groups such as
commercial sex workers (CSWs) and transport workers, or only to urban
areas. Epidemic proportions have been reached in some states. Since the
epidemic is more than a decade old, mortality due to AIDS is increasing:
nearly 300,000 Indians were estimated to have died of AIDS in 1999 alone
(4).
Unprotected sexual intercourse is the predominant mode of HIV
transmission, accounting for nearly 83% of the total (Figure 9.1). In NE
states like Manipur and Nagaland, the predominant route of HIV
transmission is the sharing of needles by intravenous drug users (IDUs),
accounting for nearly 4% of the total. Transmission through blood and
blood products accounts for another 4%. Nearly 2% of AIDS cases were
due to perinatal transmission - from an infected mother to child during
pregnancy. These figures are derived from confirmed AIDS cases reported
to the National Aids Control Organisation (NACO), cumulatively from
1986.
133
Figure 8.1
Routes of HIV Transmission in India (1986-2001)
1.787-52
3.96
4.16
Sexual
■ IDU
■ Blood
■ Perinatal
Others
Source: NACO, 2001
As of March 2000, 11,251 cases of full-blown AIDS have been reported to
NACO, of which 79% are males and 21% are females. This is only a
fraction of AIDS morbidity in the country, reflecting both the stigma and
the ignorance surrounding the infection. Widespread discrimination
against HIV infected people hinders their access to healthcare. The lowincome levels of most of the infected preclude widespread use of highly
active anti-retroviral therapy (HAART). Consequently, morbidity and
mortality of those infected continues to be high (5).
AP. Maharashtra, Karnataka, TN, Manipur and Nagaland are currently
classified as high prevalence states where infection levels have crossed
the one per cent mark among ante-natal women, considered a proxy for
the general population. Data for 2000 clearly shows the great variation in
the severity of the HIV epidemic among the states: the ANC prevalence
ranges from zero in Assam, Haryana, Kerala, Meghalaya, Punjab and
Arunachal Pradesh, to 2% or over in Mumbai City and AP. HIV prevalence
among CSWs in Goa and Mumbai is well over 50%. The prevalence
among IDUs ranges from 64% in Manipur, to less than 5% in Karnataka,
Meghalaya and West Bengal (6). Thus HIV infection trends are
characterized by wide regional variations (Figure 8.2), and simultaneous
epidemics due to differing transmission routes: heterosexual epidemics in
Maharashtra and the southern states, and an IDU epidemic in Manipur.
Nearly two-thirds of the opportunistic infection among AIDS patients
is TB, portending a dual epidemic in the future (Figure 8.3). Already
there is evidence from Mumbai City regarding the increasing role of TB as
a cause of death among AIDS cases (7).
134
Figure 8.2
Adult HIV Prevalence
■ >1% Ante-natal Women
E >5% High Risk Group
□ <5% High Risk Group
Source: NACO, 2001
Figure 8.3
Opportunistic Infections among AIDS Patients
□ Percentage
50
40
30^
20
10 /0
■
it
Tuberculosis
Si
12
I
9
0.17
Cryptospondiasis
Toxoplasmosis
Cryptococcal meningitis
Kaposis
Source: NACO, 2001
Several factors increase Indian vulnerability to a devastating AIDS
epidemic: widespread poverty; illiteracy; poor nutritional and health
status; social inequalities based on caste and gender; inadequate health
infrastructure; taboos about the subject of sex; lack of political
commitment; and a persistent denial of the AIDS epidemic in many states.
Without the immediate and sustained implementation of control measures,
the adult HIV prevalence rate could be 5% within the next 5 years - a
total of nearly 25 million HIV infected people by the year 2006, roughly
equal to the number of current infections in Sub-Saharan Africa (8).
Government Response to the Epidemic
Funding: The government responded soon after the first reported case in
1986. In the initial years of the epidemic, AIDS prevention efforts were
135
confined to "hot spots" - Maharashtra, TN, Manipur and selected big
cities. Since 1992, the World Bank has been funding a countrywide
National AIDS Control Project. The first phase of this Project (1992-1999),
with an IDA credit of US $84 million, focused on strengthening blood
banks, STD clinics, surveillance systems and increasing awareness. The
program was implemented through State AIDS Cells, functioning under the
apex body, NACO. Targeted interventions among high-risk behaviour
groups were implemented only in a few states; care and support activities
received little attention in the first phase. With more information about the
epidemic since the mid-1990s, and learning from the experience of the
first phase, the second phase of the Project was launched in 1999 with an
IDA credit of US $190 million. It focuses on targeted interventions among
high-risk behaviour groups. In terms of management, state-level
autonomous societies have been established, resulting in the easy and
timely transfer of funds, increasing decentralization and ownership of the
project by the respective states (9).
In addition to the World Bank, state-level AIDS control proiects are also
being ii plemented by several bilateral donors such as USAID of the US
government (TN and Maharashtra), DFID of the UK government (AP,
Gujarat, Kerala and Orissa), and CIDA of the Canadian government
(Karnataka and Rajasthan). For 1999-2005, the World Bank outlay is
Rs11,550 million, that of USAID Rs1,660 million, and of DFID Rsl.040
million. (47 Indian rupees equalled one USD in April 2001.) While the
World Bank project, implemented through NACO, covers the whole range
of prevention, care and capacity building, bilaterally funded projects focus
on the prevention of sexual transmission of HIV. There is a good degree
of coordination between the World Bank-funded and bilaterally-funded
projects and government sponsored programs.
Programme Management: Management capacity is a critical requirement
for a complex program like AIDS control. The initial model of State AIDS
Cells within the Medical Department of state governments, headed by a
senior medical professional, did not produce results. A breakthrough was
made in TN in 1994, when the Tamil Nadu State AIDS Control Society
(TNSACS) was set up as an autonomous body with delegated financial
and administrative powers. The change in leadership, from a medical
professional to a general administrator, ensured a broad, evidence-based
prevention and control approach rather than a medical approach to the
program. Today, many states (AP, Maharashtra, Bihar, Gujarat, Kerala,
West Bengal), have general administrators heading the projects,
facilitating inter-sectoral collaboration with other departments, and paving
the way for a wider support base in prevention and control.
Programme Components
Surveillance: In 1986, the government set up an HIV sero-surveillance
system to establish the presence of HIV infections in specific
geographical areas and population groups. At its full implementation level
136
u
in the early 1990s, there were 71 designated sero-surveillance centres
functioning. But this system was not designed for measuring trends in the
infection rates, and NACO established the sentinel surveillance system in
55 centres in 1994. These centres focused on two population groups: STD
clinic attendees as a proxy for high-risk groups, and ante-natal clinic
(ANC) attendees as a proxy for the general adult population. By testing a
fixed number of blood samples at 12-month intervals by the "unlinkedanonymous” method, the trend in HIV prevalence among these two
population groups could be tracked. The number of sentinel surveillance
centres has grown over the years, and during the latest round in 2000,
samples were drawn from 232 centres, more than four times the original
number in 1994. Similarly, the number of population groups sampled has
also increased, and now covers CSWs, IDUs and men who have sex with
men (MSM).
The USAID-funded AIDS Prevention and Control (APAC) project in TN has
also conducted one round of a survey of community prevalence of STDs
and HIV, and is in the process of doing the second round (10). This
survey indicates that the actual community prevalence of HIV is nearly
twice the level indicated by ANC prevalence data from sentinel
surveillance. This has serious implications for the healthcare system; it
also makes improved surveillance mechanisms imperative to track
prevalence rates and facilitate action.
Targeted Interventions for High-Risk Groups: Evidence from successful
AIDS control projects around the world, including some from India,
indicates that intervention programs by peer educators among high-risk
groups are the most effective in containing the rapid spread of HIV.
Figure 8.4
Rationale for Targeted Interventions among High-Risk Groups
Infections Averted
per year by Riising
8 0 %
i■ \ i Ir o h i
Cond o m
Use
t <>
In f• c tio n s i v t rtid p e r y e a r
Population
5 0 0 sex
w o rk e rs
5 0 0 Io w in c o m e
m en
s.
1 0 ;s
in te c tv J
4 pa
ef
88
Source: Confronting AIDS, World Bank, 1999
This approach, now central to prevention efforts in India, clearly shows
the rationale behind the interventions among core-transmitter groups such
as CSWs, rather than among a widely dispersed group like the male
clients of CSWs. Lessons learnt from successful Indian projects, such as
137
h
the Sonagachi Project of Kolkata (Box 8.1), have been utilized in
designing and implementing similar intervention projects in other parts of
India.
Box 8.1
Sonagachi Project
The STD/HIV Intervention Project in Sonagachi, Kolkata, is one of the best
examples of targeted interventions among sex workers. The project, implemented
by an NGO, organized CSWs into informal groups and empowered them with
negotiating skills for promoting condom use with their clients. Condom use has
increased from 0% in 1992 to over 70% in 1993-94, and sustained these levels
thereafter. VDRL positivity has also reduced from over 20% in 1992 to 5% in
1998. This has ensured that the HIV prevalence rate among CSWs in Kolkata has
remained at around 5%. In stark contrast, HIV prevalence rates among the CSWs
in Mumbai rose rapidly from below 5% in the early 1990s to over 50% by 2000.
Impact of Interventions
100n
♦
c
o
a>
60 -
Q_
40-
♦
VDRL (>1:8)
80O)
Condom Use
—HIV
20 •
0
Source: NACO.
1
1992
1993
1995
1998
The APAC project (TN) has conducted five annual rounds of behaviour
sentinel surveys (BSS) to track changes in knowledge and behaviour of
certain high-risk groups (CSWs, transport workers and factory workers).
These surveys indicate rapid behaviour change among CSWs and
transport workers in terms of condom use (11). Condom use among CSWs
has risen sharply from around 55% in 1996 to nearly 90%, and among
truckers to nearly 80% by 1999.
Figure 8.5
Trend in Condom Use among CSWs and Truckers in Tamil Nadu
100
74
80
60
75
56.
55
80
88.1
79.6
~*-CSWs
66
40
—Transport
workers
20
0
1996
1997
1998
1999
Source : APAC, 2000.
138
u
Following the Sonagachi model, one study among CSWs in AP has shown
that condom usage among CSWs has gone up to 73%, their knowledge of
STDs and AIDS has risen to 92%, and all of them know where they can
access services in case of need. Similarly, interventions initiated with
prison inmates (considered a high-risk group) in 11 prisons in AP, have
shown significant results in bringing about behavioural change among
primary stakeholders and their spouses, and in identifying and curing
infections such as TB and STDs/RTIs. The very nature of the targeted
interventions among high-risk groups requires implementation through
carefully selected and trained NGOs, and this is the pattern followed in
states.
Awareness Campaigns: While raising awareness level alone is not enough
to change behaviour, knowledge about modes of transmission and
methods of prevention ensure the success of intervention programs. TN
has been a pioneer in implementing highly effective awareness campaigns
since the early nineties, resulting in almost universal knowledge levels
(12). (See Figure 8.6 for percentage who have heard about AIDS by
state.) Several states are now implementing similar AIDS awareness
programmes. AP has involved celebrities like film and sports personalities
and even roped in religious leaders to talk about HIV/AIDS and condom
usage. Several organizations of the major religions have also involved
themselves in awareness generation and care and support initiatives.
Figure 8.6
Percentage Who Have Heard about AIDS by State
West Bengal
Tamil Nadu
Punjab
Maharashtra
3
| YWrV.'ZAW.
Kerala
WZW*jOTW
Haryana
Bihar
Andhra Pradesh
0
20
40
60
80
100
Percent
Source: National Family Health Survey (NFHS-2) India, 1998-99
Sexually Transmitted Diseases (STD) Control: There is strong evidence to
show that the presence of STDs in sexual partners may increase
139
H
transmissibility if one of the partners is HIV infected. Since heterosexual
transmission is the predominant mode of transmission in India, controlling
STDs has been a priority intervention in the programme since its
inception. Government STD clinics have been strengthened, and health
workers trained in the syndromic approach to diagnosing and treating STD
patients. A significant intervention for prevention and control of RTI/STDs
has been the Family Health Awareness Campaigns launched in May 1999
in select districts, and now held countrywide every year. Separate camps
for men and women are held in each village by doctors or paramedics,
and the attendees are counselled and referred for treatment. During the
last round in June 2000, 42.7 million persons attended the camps, of
which 23.6 were women, 3.65 million were referred for treatment, and
1.86 million were treated.
Blood Safety: The first phase of the World Bank funded project focused on
blood safety. This, coupled with a Supreme Court order in 1999
prohibiting paid blood donors, and laying down stringent guidelines for
licensing of blood banks, has resulted in the share of blood-borne HIV
infections falling sharply from about 8% in the mid 1990s, to about 4% in
2000. The second phase of the project continues this emphasis, and
transmission through this route is expected to fall further.
Care and Support of People Living with HIV/AIDS (PLWA): With over 99%
of Indians not infected by HIV, prevention continues to be the
predominant focus of the HIV/AIDS control programme. But about 3.86
million Indians live with the virus, and providing care and support to them
is also an essential component. Current care programs consist of
palliative treatment and treatment of opportunistic infections, free of cost
at government hospitals. The largest number of AIDS patients in India is
treated at the Government Hospital for Thoracic Medicine at Tambaram, a
suburb of Chennai in TN. Several support groups of HIV positive people
such as the Indian Network of Positive People (INP + ) have been formed
and nurtured by the TNSACS in their formative years. AP has also been
supporting such clubs, termed the People’s Positive Network, and has
facilitated one of them in Vishakapatnam to organise a Care and Support
Centre to address the needs of similarly affected persons.
Indian pharmaceutical firms now offer hope to millions of affected persons
in poor countries by offering AIDS drugs at $350 a year for every patient,
compared to western market prices of almost $10,000 to $12,000. But
even at this reduced rate, the total cost for each patient per year for both
drugs and monitoring of side effects, would work out to over Rs.40,000.
Assuming that only around 20% to 30% of the infected require therapy,
this would mean an annual expenditure of Rs 3400 to Rs. 4300 crores
every year (13). Even if coverage was limited to one-third of those
requiring treatment, assuming that the rest could afford private services,
the public health system would not be able to afford the cost. However,
the ethical issue remains: can the infected be abandoned to certain death
140
when a proven therapy, made more affordable recently, is available? A
broad-based consultation was held in April 2001 with representatives of
the central government, the WHO and pharmaceuticals to discuss this
issue. The broad consensus was that even at the currently reduced
prices, HAART could not be made a part of the government’s AIDS
Control Programme yet. What needed to be urgently included in the
Programme were research initiatives, preparatory to mass application, on
the following issues:
> the appropriate stage of HIV infection at which HAART should
commence;
> the optimal combination, dosage and periodicity of the therapy;
> the most appropriate methods of delivering HAART on a mass scale;
> the appropriate protocol for monitoring patients in a mass application;
and
> the benefits of HAART in areas facing a dual epidemic of HIV and TB.
It was agreed that NACO, in collaboration with the ICMR, should take up
multicentric trials to prepare for HAART as a public health intervention, as
and when drug prices and resource availability make the therapy a
feasible option.
Socio-Economic Impact of the Epidemic
The current low level of HIV prevalence in India has not yet led to any
adverse macro-economic impact. However, in select pockets where HIV
prevalence is very high, there is evidence of adverse effects on families
and communities. Well known examples are the CSWs of Mumbai, the
IDUs of Manipur and the transport workers of Namakkal in TN. Since the
epidemic will worsen before it eventually levels off, it would be advisable
to plan for these situations. This inevitable cycle in a HIV/AIDS epidemic
is well documented in Africa: infections, followed by morbidity, stigma,
mother-to-child transmission, mortality and orphans. India would do well
to learn from the African experience and prepare for the future.
Lessons Learnt and Future Directions
The HIV/AIDS epidemic in most parts of the country is at an early stage,
though spreading rapidly; so there is still a window of opportunity to
contain the epidemic within manageable levels.
• Evidence-based approach: The development of a reliable database
drawing from different kinds of surveys and surveillance systems, and
a mapping of high-risk or core-transmitter groups, are essential in the
design and implementation of targeted interventions among tnese
groups - the key strategy for AIDS control. The relative success in
containing the epidemic in Thailand and TN is largely due to this
approach.
141
H
9
Non-Communicable Diseases
Introduction (1)
Among the health transitions, the most pervasive change has been the
rising burden of non-communicable diseases (NCDs). NCD epidemics
are emerging or accelerating in most developing countries (2), and
cardiovascular diseases (CVD), cancers, diabetes, neuropsychiatric
ailments and other chronic diseases are becoming major contributors to
the burden of disease (BOD). Health transition, whereby NCDs become
the dominant contributor to BOD, is principally due to a combination of
demographic and lifestyle changes resulting from socioeconomic
development.
Demographic transition is characterized by changes in
population age structure with fertility decline and aging population. As
more individuals survive to middle age, the years of exposure to the risk
factors of chronic disease increase. Simultaneously, urbanization,
industrialization and globalization are often accompanied by undesirable
lifestyle alterations: a diet rich in saturated fat, salt and excess calories,
decreased physical activity, addictions such as tobacco and alcohol, and
the augmentation of psychosocial stress.
Thus both the dose and
duration of the risk factor exposure increase, resulting in larger numbers
manifesting lifestyle-related diseases and their consequences.
Recent evidence suggests that impaired fetal nutrition - reflected in
small birth size - results in a programmed susceptibility to adult
cardiovascular disease, diabetes and some cancers.
Migrant Indians
have also been shown to have excess rates of coronary heart disease
(CHD) and diabetes in comparison to other ethnic groups, indicating a
magnified response to environmental change. As India experiences
health transition (5, 6), these factors will have an adverse effect on the
future burden of NCDs and present a major public health challenge.
Hence the existing health systems will need to be reoriented to deliver
the expanded mandate of primary and secondary healthcare involving
the prevention, surveillance and management of chronic diseases.
Changing Burden of Disease and Equity Issues
Even at the present stage of health transition, India contributes
substantially to the global burden of NCDs. In 1990, India accounted for
19% of all deaths, 16% of all NCD deaths, and 17% of all CVD deaths in
the world. CVD in India alone accounted for around 2.4 million deaths,
in contrast to nearly 3.2 million CVD deaths in all the industrialized
countries together (2). An even greater cause for concern is the early
age of these deaths in India compared to those in the developed
countries. More NCD deaths in India occur in middle age (35-69 years)
than in industrialized countries, where they occur largely in old age
144
i1
(>70years). Even as overall NCD burdens rise sharply by 2020 (Figures
2.2 and 2.7), a disproportionate loss of lives in midlife will continue to
constitute a major burden (Table 9.1). In India, 52.2% of all CVD deaths
in 1990 occurred before the age of 70 years, in contrast to 22.8% in the
EME countries (2,5) (Table 9.2).
Table 9.1
Midlife Mortality due to NCDs in India_________________
Percentage of Cause-Specific Mortality
Cause of Death
Occuring in the Age Group of 30-69
________________ Years
1990
2020
Total NCD
48.9
51.3
Cardiovascular
48.2
Malignant Neoplasm
64.6
69.2
Neuropsychiatric
40.6
39.6
Total Injuries
36.3
52.8
Unintentional
34.0
52.0
Intentional
45.0
56?4”
"
47.7
Source: CJL Murray, hD Lopez, The Global Burden of Disease, 1 996
Table 9.2
Early Mortality due to NCDs in India
Age Profile of NCD Deaths
(% of NCD Deaths in each Age Range)
------- 1
Age at Death
India
EME
1990
1990
India
2020 I
<30 yrs
12.2
3
4.1
30-69 yrs
48.9
23
_________ >70 yrs _______________
38.9
74
Source: Global Burden of Disease Study, 1996
!
t
51.3
44.6
J
EME
202i
2±J
2
Diabetes has a high prevalence in urban and migrant Indians: urban
estimates in adults over 35 years are in the range of 16-20% while
corresponding rural estimates are around 4%. As the quality of dietary
habits and physical activity decreases and obesity increases diabetes
becomes a greater contributor to NCD. The number of persons in the
world with diabetes is expected to rise from 19.4 million in 1995 to 57.2
million, even as India leads the global table for the number of diabetics
(’10). These estimates are based on older and higher cut-off values for
the diagnosis of diabetes, and also do not take into account the category
of impaired glucose tolerance; hence the overall BOD attributable to
diabetics and pre-diabetics may be even higher than those projected.
I
145
i
H
There will also be a sharp rise in disability adjusted years (DALYs) lost
due to NCDs between 1990 and 2020. This is illustrated by the rise in
the DALY loss attributable to CVDs, where India will be the global leader
(Figure 9.1). The CVD spectrum in India principally comprises CHD,
cerebrovascular disease (stroke) and rheumatic heart disease (RHD)’
with the first two rapidly advancing, and the third slowly receding as
health transition proceeds. The principal cancers are those occurring in
the lung, cervix, breast, oral cavity and the gastrointestinal tract.
Figure 9.1
Burden of CVD 1990-2020
50 -i
40 -
IND
DALYs
(millions) 30 -
CHI
SSA
MEC
LAC
EME
FSE
OAI
20 -
10 -
1990
2000
2010
2020
IND = lndia; CH = China; SSA=Sub Saharan Africa; MEC = Middle Eastern Crescent
LAC = Latin America; EME = Established Market Economies; FSE = Former Somalis
Economies; OAI = other Asia and Islands
Source : C.J.L. Murray and A.D. Lopez. The Global Burden of Disease, 1996
While these estimates (present and projected) are based on a variety of
data sources of limited coverage and uncertain validity, they are the best
available estimates from a globally acknowledged data source (the
GBOD study). Some Indian investigators have questioned the estimates
for 1990, based on independent secondary analysis and modeling (11);
however, the differences are not substantial.
While the precise
dimensions of the epidemic may be difficult to gauge at present, the
directions of its growth are indisputable. The prevalence/incidence of
various NCDs for 1998 has also been estimated for India based on
various published studies from different regions (11) (Table 9.3). These
estimates may be relatively conservative, as suggested by the
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comparison with the diabetes prevalence estimates of the WHO. Even
then, about one-fifth of the population would have at least one of these
selected NCDs.
Table 9.3
Estimated Number of Cases of Selected NCDs in India, 1998
Disease
Prevalence I
Number of
% of Total
Incidence
Cases
Population
All Cancers_______________
Prevalence
2 million
0.2
Heart diseases
Prevalence
65 million
6.6
(IHD, HT, Stroke, RHP)_______
Respiratory diseases______
Prevalence
65 million
6.6
Diabetes mellitus_____________
Prevalence
13 million
1.3
Injuries___________________ ____________________________________
Incidence
7 million
0.70
Source:
K. Anand, P
Report on Assessment of Burden of Major Non-communicable
Disease In India, WHO, 2000
The lag period between exposure to risk factors of NCDs and their
clinical manifestations make current mortality rates unsuitable for
prospective public health planning, since they only represent past
exposures over some decades. The present levels of risk factor
exposure would be more meaningful in predicting fu^Tc risk, and in
driving public health policy. The rising levels of hypertension, diabetes,
obesity, tobacco consumption and blood lipids in Indian population
groups have been well documented in recent years (8-12). These also
portend a major rise in future NCD burdens in India. Hypertension and
diabetes are classified as diseases with distinct clinical identities, but
are also risk factors for other diseases such as cardiovascular, renal,
ophthalmic and neuropsychiatric disorders. Their disease burdens will be
underestimated if they are only considered as hypertension and
diabetes, without taking into account the death and disability they cause
through coronary, stroke, blindness or renal failure outcomes. Their role
as risk factors means a high priority status for public health
interventions for their prevention and control. An integrated programme
for the control of tobacco, high blood pressure and diabetes will have a
major impact on the downstream burdens of multiple NCDs.
Disorders of mental health merit special attention because of the large
burden of disability (DALY loss) resulting from them, even though they
are not major contributors to mortality. The prevalence of major mental
illness in the country has been estimated to be 1-2 per thousand, while
minor mental illness occur in 5-10% of the population, as
various
as per
per various
estimates. The GBOD study estimates that neuropsychiatric disorders
contributed to 7.0% of total DALY loss that occurred in 1990 in India
and would account for 12.6% of the total DALY loss projected to
to occur
occur in
in
2020. Mental disorders contribute to the burden of mortality too, through
suicides
estimated to occur at a- rate
----- ---of 11
• I per 100,000. Poverty has
been linked to high burdens of mental disorders, with about 80% of
suicides occurring in the lower socioeconomic strata. The indications are
that women bear a high burden of these disorders (Figure 2.8). Again,
alcoholism is also more widely prevalent among the poor.
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injuries are currently estimated to contribute between 9-11% of total
deaths in India, and also account for significant morbidity, disability and
economic losses. For every fatal injury, at least 10 persons are
hospitalized, and nearly 50-100 receive emergency care. But under
reporting of injuries affects these estimates, and better data gathering
systems are urgently required to identify both injury burdens and main
contributory factors with accuracy. Among injuries, traumatic brain
injuries, burn-related injuries, agricultural injuries and orthopedic
injuries contribute most to disability and death.
With the causes of
these injuries varying widely from farm implements to road traffic
accidents, the burdens are high in both rural and urban settings.
Domestic violence has also been identified as a significant contributor to
both injuries and mental ill-health, but the magnitude of the problem has
not been adequately studied.
Social Impact of NCDs
Death or disability due to NCD in productive middle age results in major
economic burdens on affected individuals, their families and society as a
whole. The management of established NCDs (diagnosis and therapy) is
often technology-intensive and expensive. Individual as well as societal
resources are already being drained at a disproportionately high level by
the tertiary care management of NCD, often drawing scarce resources
away from the unfinished agenda of infectious disease and nutritional
disorder control.
Though NCD epidemics usually originate in the upper socioeconomic
strata, they diffuse across the social spectrum, with the social gradient
ultimately reversing so that the poor become the predominantly afflicted.
Indeed, in the more mature stages of these epidemics, the poor are
often the worst afflicted in terms of disease, and the most marginalized
in terms of care. This historical experience of the developed countries
where NCD epidemics matured over the past half-century, is likely to be
replicated in developing countries in the coming half-century. Studies
show that the social gradient for CVD has already begun to reverse in
some population groups in India, especially in large urban settings (7).
Tobacco consumption is also higher in rural populations compared to the
urban, and among the poor compared to the rich (Figure 2.8). Thus the
future risk of tobacco-related NCD is likely to be higher in these groups
(8-9).
These post-transitional diseases also have macro and micro economic
impacts which may prolong the high burden of pre-transitional diseases
in developing country settings. The loss of persons in middle life, either
to death and disability, cripples development, and perpetuates social
conditions that foster communicable and nutritional disorders. The twin
agendas of healthcare, mandated by pre- and post-transitional
diseases, are not competitively exclusive, but are synergistically
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complementary. The goal of extending healthcare benefits across an
expanding life span requires that these two agendas be harmonized
in India.
Much of these economic and health burdens could be obviated by short
term and long-term strategies:
• Short-term strategies call for low-cost screening for the early
detection of NCDs as early interventions effectively alter the
natural history of disease, also the use of readily available lowcost, high-impact interventions for secondary prevention and
clinical care.
• Long term investment in population-based prevention strategies
would prevent the acquisition or augmentation of risk in low-risk
populations, and also reduce risk in populations already
affected by health transition.
Strategies: Focus on Prevention and Low Cost
)
■)
)
Traditional Public Health Approaches: The exorbitant costs of treating
chronic diseases make orevention the most cost-effective option and
suitable strategy for India. Traditional public health approaches to NCD
control consist of i) a high-risk strategy targeting those with high-level
risk factors and employing interventions to reduce them, usually with
drugs; and ii) a population strategy to reduce risk factor levels in the
whole community, usually through lifestyle related measures (13,14).
The first provides higher benefits to individuals at maximum risk, but
since they comprise a small segment of society, there is no major impact
on national morbidity or mortality. The population approach aims at
relatively modest reductions in the risk for each individual, but
cumulative community benefits are large - there are many more in the
mild or moderate range of risk factor elevation than in the highest range,
The two strategies are not mutually exclusive butt are synergistically
complementary.
However,
population-based
and
lifestyle-linked
strategies are likely to prevent the acquisition or augmentation of NCD
risk factors in transitional societies like India, while avoiding the
economic and biologic costs of pharmacological risk reduction strategies
practiced in the developed countries.
______________________________________ Box 9.1_____________________________
Principles of Prevention Underlying Strategies for NCD Control
Principle 1: Risk operates in a continuum, not across arbitrary thresholds;
Risk reduction benefits across the range.
Principle 2: Majority of NCD events arise in a population from the middle of
the distribution (of a risk factor) than from its high end.
Principle 3: Co-existence of risk factors leads to interactive risk which is
multiplicative.
Principle 4: The absolute risk of a imajor -----NCD event (e.g. CHD/Stroke) is
dependent on the overall risk profile contributed by co-existent risk factors
operating in a continuurn.
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Simultaneously, effective low-cost, case-management strategies are
required for persons who manifest disease. Such technologies are
available, but await widespread dissemination and application: oral
aspirin administration in cases of suspected heart attack saves as many
lives
as
the
intravenously administered
clot
dissolving
drug
streptokinase (15). Information would empower the community to avail of
technologies that are feasible for wide application and are cost-effective
(Table 9.4).
Aspirin
Table 9.4
Effect of Treatment of 1000 Patients w11h AMI
Cerebral
Premature
Hemorrages
Cost Per Life
Deaths Avoided _
Caused
Saved
I
23
0
Rs. 152
Streptokinase
25
2-3
Source: Srinath Reddy, background paper, 2001
Rs.1,23,560
At the population level, programmes likely to counter a wide range of
NCDs - especially CVD, diabetes, hypertension and some cancers
related to saturated fat intake - consist of advocating i) a health
promoting diet (calories appropriate to level of physical activity:
moderation in intake of saturated fat, salt, refined sugar; high intake of
fresh fruit and vegetables; fish rather than red meat in non-vegetarian
diets); and ii) adequate and regular physical activity.
Tobacco Control: This is a major public health imperative providing the
largest benefit for NCD prevention: it can effectively prevent diseases
such as tobacco-related cancers, CVD and chronic obstructive airway
disease. The estimate is that half of all current teenage smokers will
eventually die of tobacco-related diseases, a quarter in middle age and
a quarter at an older age. For those who die of tobacco related illnesses
in middle age, the average loss of life expectancy compared to nonsmokers is 20-26 years. Tobacco and AIDS represent the most rapidly
growing causes of death; tobacco is the foremost preventable cause of
death in the modern world (7), and clearly population-based control
strategies are high
priority. The success of population-based
interventions, addressing the multiple risk factors common to many
NCDs through lifestyle linked community programmes, has been
demonstrated both in developed and developing countries (16, 17). Such
population strategies require both 'bottom up’ (community health
education and empowerment), and 'top down’ (legislation and
regulation) approaches. An enlightened policy and an empowered
community can together stall the advance of the emerging
epidemics of NCDs in India.
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At present, programmes for NCD control are non-existent, or functioning
at a low level in India. The National Cancer Control Programme involves
cancer registries at selected sites, and strengthening of facilities for
clinical care (e.g. radiotherapy). Though pilot studies for the control of
CVD and diabetes have been initiated, they have not had an impact on
policy and programme development. Tobacco control has been given
greater importance, but awaits the passage of proposed legislation and a
vigorous public education campaign.
Mental Health: India was among the first developing countries to initiate
a community-based mental health programme. Based on the Bellary
model developed in Karnataka, the programme is now being
implemented in 22 districts across the country. The National Mental
Health Programme (NMHP) of India envisages active participation by
NGOs and other community based organizations in the delivery of health
services. The programme awaits extension to the hundreds of other
districts that are not yet covered by it.
Injury Prevention and Management: The programmes need to be based
on multi-disciplinary research — involving epidemiologists, clinical
specialists, physiologists, behavioural scientists, engineers, lawmakers,
and enforcement agencies such as the police and community groups;
and multi-sectoral interventions - involving transport regulations, traffic
safety,
vehicle
manufacturing,
housing
construction,
emergency
healthcare at various levels, and referral linkages. But such structured
programmes are currently unavailable, and this area of healthcare has
been limited to the provision of emergency care that functions with
limited access and coverage.
Controlling Risk Factors at Different Levels of Care: Programmes for the
prevention and control of NCDs must adopt a ‘lifespan’ approach, and
attempt to reduce risk at stage of life through appropriate public health
interventions. They also need to be variably integrated into different
levels of healthcare - primary, secondary and tertiary. The principal
functions of such a programme would be
providing information and an enabling environment that
increases community awareness and adoption of healthy livino
habits;
> early detection of persons with risk factors and cost-effective
interventions for reducing risk;
> early detection of persons with clinical disease and costeffective care to prevent complications;
> utilizing low cost-high yield technologies for acute care;
> secondary prevention to reduce risk of recurrent events; and
> rehabilitation and palliative care in cases where the disease iis
incurable or has resulted in complications.
Many of these activities can be performed in primary care settings health education, blood pressure checks, tobacco cessation,, chest pain
151
)
algorithms, and oral cancer screening. Some need to be strengthened in
secondary care, such as the management of some cancers and the
treatment of left ventricular dysfunction. In settings of tertiary care, the
cost-effective use of technology will provide advanced care along
defined guidelines. (See Annex 9.1 for operational components.)
Issues in the Delivery of Chronic Care
Since chronic care has many demands, and since available resources
are restricted, efforts to optimize resources should include the following
elements.
•
Identifying a menu of core components providing an
‘essential package’ of chronic care, with possible extension
to an ‘optimal package’: Resource constraints and the
inception stage of programmes call for the identification of a set
of essential components constituting the minimal agenda of
chronic care. Components must be chosen on the basis of cost
effectiveness and impact on population attributable risk;
prevalance rates (Table 10.3) could be the starting point. This
list has to be customized for each regional context: in regions
where stroke is the predominant contributor to cardiovascular
mortality, algorithms for the management of stroke may need to
be included in the ‘essential’ package of chronic care.
•
Integration of services into various levels of healthcare The
expanded mandate of healthcare, involving the addition of
chronic care to pre-existing services (MCH, population control,
control of infectious diseases), can be delivered only when
healthcare providers of all categories are adequately mobilized
and involved at each level. The private sector is usually
responsive to the needs of chronic care since such services are
considered financially remunerative. However, imbalances in
the type of care provided (arising from frequent use of high
cost-low yield technologies) must be corrected. The public
sector has to be more responsive to the needs of chronic care
and the private sector more responsible in the use of resources.
•
Clinical practice guidelines: The integration of evidencr
based, context-specific, resource-sensitive guidelines in o
various levels of healthcare will facilitate the greater use of lowcost, high-impact interventions.
•
Provider training: The modification of education and training of
healthcare providers of diverse categories would enhance the
skills relevant to chronic disease prevention, surveillance and
management.
152
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•
Referral linkages and follow-up systems: The establishment
of efficient systems for referred care, linking primary care to
secondary and tertiary levels of provider services for advanced
forms of chronic care, and effective systems for subsequent
follow-up care by all providers, will ensure the cost-effective, bi
directional movement of patients across the healthcare chain.
•
Providing patient education and promoting self-care:
Investing in patient education and encouraging self-care that
reduces follow-up care will help overcome the constraints of
limited healthcare provider resources. This requires investment
in educational programmes but will prove cost-effective in the
long-term management of chronic diseases.
•
Essential drugs and technology needs: Any programme for
chronic care must ensure the availability of essential drugs at
affordable prices, and meet the technology needs of managing a
variety of diseases. The advent of compulsory ‘product
patenting’ under the WTO regime will restrict the scope of local
production, but countries like India and Brazil have used
‘process patenting' to build self-sufficiency in the production of
many drugs including most essential drugs. These are available
as generic drugs, at relatively low cost.
The Indian
pharmaceutical industry must be encouraged to invest more in
research and development to produce new drugs for the local
market. The technology required for the 'essential' package of
care at the primary level would be easier to provide than more
advanced technologies for secondary and tertiary care. SouthSouth cooperation for technology exchange, international
assistance for subsidising essential technology acquisition and
guideline-based use of available technology will help developing
countries to overcome the technology barrier. Well conducted
research, involving the economic evaluation of various
healthcare technologies, will aid decisions about cost-effective
technologies at each level of healthcare, and the extent to
which they should be deployed. The capacity for such research
must be quickly established and integrated into the planning
process at policymaking levels.
•
Situational Analysis: Estimates of existing and required
capacity for delivering chronic care to communities must guide
the process of planning. Situational analysis based on
qualitative and quantitative research methods will help identify
key indicators. While planning for the delivery of chronic care to
a community in any region, cognisance of capacity within that
community to meet current chronic care needs - in terms of
policy, programmes and infrastructure - is essential. The
anticipated growth in ‘capacity’ (defined as a composite whole
comprising these components), vis a vis the projected rise in
153
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the burden of chronic diseases, would also need to be
appraised. (See Annex 9.2 for suggested components of such a
‘situational analysis’ study.)
•
Customization: The magnitude of different chronic diseases
varies across geographical regions, social classes, gender and
age groups. Within the broad framework of integrated chronic
care, these varied needs have to be addressed through an
appropriate mix of the most relevant and cost-effective
interventions. Since disparities of socioeconomic status, gender
and age result in a diversity of health status and variable
access to healthcare, provisions for chronic care also need to
be customized within a country. This applies, for example, to
guidelines and algorithms for the detection and management of
risk factors and disease states. Ideally, such a cost
effectiveness analysis should be generalized with a sectoral
approach, seeking to evaluate a wide range of interventions and
resource allocation options.
•
Influencing policymakers and health system managers:
Policymakers and health system managers at various levels
must be sensitized to the potential impact of cost-effective
chronic care interventions and the high costs of 'missed
opportunities', so that they become motivated agents for
improving the delivery of chronic care.
•
Overcoming the Barriers: These operational priorities face
several barriers to effective implementation: short supply and
maldistribution
of trained
healthcare
providers
with
a
disproportionately large urban clustering of physicians and
shortage of trained paramedics; inadequate knowledge and
skills for providing chronic care in currently deployed primary
care providers; ill defined roles of public, private and voluntary
sectors in providing chronic care; and inadequate purchasing
power among consumers for accessing chronic care. Some
potential methods of overcoming these barriers are
a) community participation: Integration of promotive and
preventive care, early detection of risk factors and
disease, and certain types of emergency care into the
ambit of primary healthcare will be effective when the
community is adequately mobilized to participate in these
activities. The size of the Indian population has
traditionally been viewed as the major constraint to the
delivery of adequate healthcare. Facilitating community
participation would mean the conversion of these numbers
into abundant resources for the delivery of essential
chronic care services.
b) broadening the base of providers in primary healthcare:
Using
trained
public
health
nurses,
CHWs
and
154
H (
practitioners of traditional systems of medicine to deliver
some services currently assigned to physician care
providers in primary healthcare, will extend outreach at a
lower cost. The existing strength of physician care
providers is low or grossly maldistributed with selective
urban clustering; while the need to provide essential
chronic healthcare to underserved populations, especially
in rural areas, is urgent. The current numbers and
workload of MPWs reduce their availability for the delivery
of chronic care services, hence a cadre of CHWs recruited
from within communities could be considered. The
feasibility of training such health care auxiliaries in the
prevention and early detection of oral cancer and
precancerous lesions has been demonstrated by studies
conducted in parts of India and Sri Lanka (18). Similarly,
the development of a cadre of public health nurses will
heJP increase the number of primary healthcare providers
with skills to deliver essential
— chronic
—----- ; care - such as
counseling
on
health
behaviors,
detection
and
management of high blood pressure and diabetes,
screening for common cancers, initial management of
chest pain syndromes suggestive of acute coronary
events, and management of acute asthmatic attacks.
c) training and reorientation of existing primary healthcare
providers to deliver chronic care services: Present primary
healthcare providers of different categories need to be
retrained and their work schedules restructured. They
must be supported by guidelines and equipped with the
required knowledge and skills required to deliver the
essential elements of chronic care. Time-motion studies
must be conducted to examine how their current work
schedules can be modified to accept this expanded
mandate of healthcare, through the redefinition of their
assigned work. Preparation of guidelines and management
algorithms is essential to such retraining and redefinition
of work.
d) promoting public, private and voluntary sector mix and
quality of care: The delivery of chronic care in primary and
secondary healthcare settings requires a partnership of
public, private and voluntary sectors, with a definition of
standards, the adoption of guidelines and the monitoring
of practice patterns to ensure quality of care. Ensuring
quality and definition of standards are relevant to all three
sectors. Standards need to be defined on the basis of
expert consensus and adopted through a process
involving wide-ranging consultations among different
categories of stakeholders. The development and adoption
of guidelines, as well as periodic profiling of practice
155
patterns, along with technology audits, would help ensure
reliable delivery of rational health care.
e) healthcare financing: Evolving a mix of public sector
provision of free healthcare, social insurance and private
insurance, will enable universal access to essential
chronic care. The public sector cannot disengage itself
from chronic care for equity considerations. Besides,
public sector supply of good medical services can exert
pressure on the high costs of private sector medical
services. The public sector also fulfills a training and
research mandate far beyond the capacity or the aptitude
of the private sector in the developing countries.
f) multi-disciplinary research: This is required to inform
policy and empower programmes for NCD prevention and
control by i) identifying cost-effective and sustainable
methods of applying available knowledge; and ii)
generating new information required to bridge critical
information gaps. Since the causation of most NCDs is
multifactorial, research must integrate resources from
epidemiology to social sciences and molecular biology to
macroeconomics.
Cost-effectiveness,
feasibility
for
integration into primary healthcare and sustainability are
key elements of potential interventions to be identified by
research.
g) inter-sectoral coordination: The multiple determinants of
NCDs also mandate efficient inter-sectoral coordination to
generate and implement policies for NCD prevention and
control. Health sector interventions in isolation will not
impact on disease burdens of NCDs, especially if policies
in other sectors are in conflict. Such harmonized
interaction
needs
to
be
institutionalized
through
dependable mechanisms.
Conclusion: Prioritization of Interventions
Of the several operational components of chronic care, a process of
prioritization must sequentially select ‘essential’ elements for early
implementation and ‘optimal’ elements for later integration. The
prevention and control of high blood pressure and tobacco consumption
are high priorities, because of their high contribution to global burden of
disease, as well as their relationship to multiple chronic diseases. While
planning the organization of health services, the center of gravity of
chronic care delivery must be progressively shifted toward the base of
the health care pyramid. The responsibility of delivering chronic care
must devolve downwards - closer to the community and away from more
expensive and less accessible health care stations. This shift will be set
in motion by strengthening the capacity for care by self, family,
community, paramedic or traditional healer; encouraging guideline-based
practice; and promoting a rational referral-follow-up pattern obviating the
156
need for frequent revisits to seconcary and tertiary care providers. Only
such a shift can ensure a sustainable system of chronic care in India
with the promise of extended coverage and containment of costs.
Notes
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
The chapter draws extensively from the background paper by K.S. Reddy,
Professor of Cardiology, All India Institute of Medical Sciences, New Delhi.
C.J.L. Murray and A.D. Lopez, Global Health Statistics: Global Burden of
Disease and Injury Series, volumes I and II, Harvard School of Public Health,
Boston, 1 996.
A.R. Omran, The Epidemiologic Transition: A Key of the Epidemiology of
Population Change, Millbank Mem Fund Q, 1971; 49:509-38.
S.J. Olshansky and A.B. Ault, The Fourth Stage of the Epidemiologic
Transition: The Age of Delayed Degenerative Diseases, Millbank Mem Fund
0,1986, 64: 355-91.
K.S. Reddy and S. Yusuf, Emerging Epidemic of Cardiovascular Disease in
Developing Countries, Circulation, 1998, 97:596-601.
K.S. Reddy, Primordial Prevention of Coronary Heart Disease in India:
Challenges and Opportunities, Prev Med. 1999, 29:S119-23.
Curbing the Epidemic, Governments and Tobacco control, World Bank,
Washington,1999.
S.L. Chadha, N. Gopinath, S. Snekhawat, Urban-rural differences in the
prevalence of coronary heart disease and its risk factors in Delhi, Bulletin of
WHO, 1997, 75(1): 31-38.
KS Reddy, Cardiovascular Disease in India. Wld hlth statist Quart 1993
46:101-107.
H. King, R.E. Aubert, W.H. Herman. Global Burden of Diabetes, 1995-2025.
Prevalence, numerical estimates and projections
Diabetes care
1998,
21:1414-1431.
K. Anand, Report on Assessment of Burden of Major Non-communicable
disease in India, WHO, New Delhi, March 2000.
R. Gupta, N.A. Al-odat, V.P. Gupta Hypertension Epidemiology iin. India: Meta
Analysis of 50 year Prevalence Rate and Blood Pressure Trends. Journal of
Human Hypertension, 1996, 10:465-472.
G. Rose, Sick Individuals and Sick Populations, Int. J. Epidemiol 1985 14:
32-8.
G. Rose and S. Day, The population mean predicts the number of deviant
individuals, Br. Med. J. 1990, 301:1031-4.
Antiplatelet Trialists Collaboration. Collaborative overview of randomized
trials of antiplatelet therapy, I. Prevention of death, myocardial infarction and
stroke by prolonged antiplatelet therapy in various categories of oatients Br
Med. J. 1994, 308:235-46.
P. Puska, J^Tuomilehto, N. Aulikki. V. Enkki, The North Karelia Project, 20
years Results and Experiences,
r:
National Public Health Institute, Helsinki,
1995.
G.K. Dowsen, H. Gareeboo, K. George et al, Changes in Population
Cholesterol Concentrations and other Cardiovascular Risk Factor Levels after
5 years of Non-Communicable Disease Intervention Programme in Mauritius
Br. Med. J. 1995, 31 1: 1255-9.
R. Shankaranarayanan, Health Care Auxiliaries in the Detection and
Prevention of Oral Cancer, Oral Oncol, 1997, 149-54.
157
1 j
Annex 9.1
Implementation: Operational Components
Area
PREVENTION
Essential Package
(core components)
Tobacco Control
(Taxation, Regulation,
Education)
Promotion of Healthy Diets
(Production, Pricing, Consumer
Empowerment) including the
preparation and dissemination
of national food based dietary
guidelines
Promotion of Physical Activity
(Planning of cities and work
sites, community education)
Optimal Package
(other components)
Phasing out tobacco
agriculture and industry
(alternate crops and
occupations)
National Nutrition Policy
(involving agriculture and
industry)
National Transport Policy
(Pollution control and
promotion of physical
activity)
Mass media campaigns +
targeted special group
programmes for community
health education
School based programmes for
‘Learning to Live Healthy’
SURVEILLANCE
Tobacco Consumption Habits
H/o Diabetes, Hypertension
Blood Pressure
Body Mass Index
Waist circumference
NCD mortality (by cause, age
and sex)
National Aggregate Indicators
(e.g., production and
consumption of tobacco, fruit
and vegetables)
Injury surveillance
(incidence; mortality)
Blood lipids (total
cholesterol, HDL
cholesterol)
Diabetes (by blood
chemistry)
Health Beliefs
Dietary Consumption
Patterns
Physical Activity Patterns
NCD Morbidity (Disability)
SCREENING
‘Opportunistic’ screening for:
‘Targeted’ Screening for:
- Tobacco consumption
- High Blood Pressure
- Overweight
- Central Obesity
- COPD
- Cervical cancer
- Oral cancer
- Common mental disorders
- Common eye problems
- Common orodental problems
- Diabetes
- Dyslipidemia
- Other Cancers
- Transient Ischemic
Attacks
158
u
Annex 9.1 (contd.)
Area
MANAGEMENT
HEALTH SYSTEMS
Essential Package
(core components)
Optimal Package
(other components)
Clinical Algorithms for:
Clinical Algorithms for:
- Acute myocardial Infarction
- High Blood Pressure
- Congestive Heart Failure
- Diabetes
- Transient Ischaemic Attacks
- Childhood Leukaemias
- Other cancers (eg., oral,
breast, cervical)
- COPD
- ^Initial care of injuries
- Depression
- Epilepsy
- Angina
- Dyslipidemia
- Stroke
- Other cancers
- Other mental disorders
- Obesity
- Advanced care for multi
organ injuries
Integrate core components of
prevention, surveillance,
screening and management into
primary and secondary health
care
Strengthen Quality
Assurance in NCD related
health care delivery
Strengthen Health Provider
Education (Learning and Skills
relevant to NCD control)
Enhance the knowledge and
decision making ability of
health care managers in the
elements of NCD control
Perform technology audits
to identify and correct
inappropriate use of
expensive technologies
Strengthen the production
and distribution of costeffective drugs and devices
for NCD care in
collaboration with industry
Implement essential drugs'
policy for provision of NCD
related drugs
RESEARCH
Strengthen capacity for
research relevant to NCD
control through national and
international partnerships
(Implementation Research, to
effectively apply available
knowledge)
Support innovative research
in the etiology of NCDs (as
relevant to Indian
Population Groups) and for
the identification of new
technologies which are
contextually cost-effective
159
IJ
Annex 9.2
Assessment of National Capacity: Questions for Situational Analysis
1. What is the current capacity, within a defined community setting, for
community
|
participation
in programmes related to the prevention and
control of NCDs?
(health beliefs; access to information; networking within the community;
community;
partnerships with external agencies; availability, affordability, acceptability of
and access to promotive, preventive and therapeutic health care)
2. What is the current capacity, within the provincial/regional health
--------- 1 care
delivery system, to provide promotive, preventive and therapeutic health
care, as relevant to prevention and control of NCDs in that community?
(currently operational programmes: content, resources, outreach; health care
providers: numbers, training, skills, motivation, time; resources for essential
care: community
health education, essential drugs, equipment, guidelines,
patient education; referral linkages and follow-up services; surveillance
systems)
3. What is the current capacity, within the provincial and national policy
framework (regulation, legislation, taxation), to provide a supportive
environment for people, patients and providers to adopt practices
conducive to the prevention and control of NCDs in that community?
(tobacco control; food and nutrition; education; drug production, pricing and
supply;
resource allocation; urban planning; health care financing; media)
4. What are the critical deficiencies in the capacity for and major barriers to
the prevention
and control
of NCDs, in the perception ofT (a)
( ‘ community
2
1
_‘
representatives, (b) health care providers (c) health administrators and (d)
policymakers? What are the prioritised solutions recommended by each of
these groups?
5. What is the required augmentation of capacity that is considered (a)
desirable and (b) feasible, by policymakers, to meet the projected rise in
needs for the prevention and control of NCDs over the next twenty years?
Adapted from the project protocol of
Initiative for Cardiovascular Health in the Developing Countries
(www.ichealth.org)
160
i1
10
Private Healthcare in India
Introduction
It is, in a sense, inexplicable that the private sector in health in India,
which has always played a significant role in health service delivery, has
been largely overlooked by Indian policymakers while formulating policy,
plans and strategies towards achieving the ‘health for all’ goal. According
to some estimates, well over half the available health services were being
provided by the private sector even as early as the 1950’s (1). Evidence
from studies in 1963 reveal that most illness episodes in rural areas were
treated by private providers and that only around 10% of the population
used government facilities (2). The idealism and faith of early planners
that the public sector could indeed 'provide all things to all people’,
coupled with the low visibility of the private sector and its low involvement
with western medicine, might explain this initial oversight. Managing
private sector providers is undoubtedly among the most complex
stewardship tasks of government, but turning a blind eye to the growing
influence of the private sector has proved expensive, whether in terms of
the undesirable consequences of its unregulated and unplanned growth, or
in terms of the opportunities lost in using its relative strengths to achieve
public policy goals. This chapter attempts to define the characteristics and
current role of the private sector in health, analyze its strengths and
weaknesses, and propose options to include it in a coherent framework of
policy and action to meet national health objectives. We do not deal with
private health financing, as this is dealt with in a separate chapter.
Composition, Size and Spread of the Private Health Sector
What do we mean by the private health sector in India? The oft-repeated
cliche that India lives simultaneously in several centuries is well
exemplified in this sector, with corporate hospitals, super-speciality
consultants and state-of-the-art technologies at one end of the spectrum,
and illiterate, unqualified practitioners dispensing their own brand of
healing at the other end. Its structure is complex: different types of
providers practise formal and informal systems of medicine in a wide range
of facilities. That classification is equally difficult is evident from the
following attempt, vulnerable as it is to inadequate description or overlaps:
• nature of provider: private company, trust, NGO, qualified and
unqualified individual provider;
• nature of service: hospitals, maternity and nursing homes, clinics,
dispensaries,
traditional
practitioners,
ancillary
services
(pharmacies, diagnostic facilities, ambulance services);
• system of care: formal (allopathy, ayurveda, unani, siddha,
homeopathy); informal - unqualified, traditional (faith-healers,
local medicine men and women, traditional birth attendants);
• ownership styles: for profit and not for profit.
161
ll
The private health sector in India is commonly understood to refer to the
for-profit, qualified provider. However, the sector includes not-for-profit
NGOs, trusts, charitable and religious endowments. There is a growing
concern about trusts and charitable institutions changing character to be
more aptly classified as for-profit. Similarly, some expensive for-profit
hospitals are registered as trusts to avail tax exemptions. The sector also
includes the often overlooked uncualified practitioner, who has a far more
significant presence in India’s 600,000 villages than is readily
acknowledged (3).
Data on the share of the private sector in total health infrastructure is
limited by inadequacy as well as poor quality. There is no reliable data on
the number of hospitals, beds, clmics/dispensaries or practitioners in the
private sector. Government data, based on incomplete information
collected from state governments and medical councils, is faulty, and
hence available figures base estimates on various studies or indirect
extrapolations. One study, for instance, estimates the number of private
practitioners using the assumption that all doctors compiled from the lists
of • medical councils (about 12,00,000), minus government doctors
(1,40,000), equals doctors in the private sector. Assuming that 80% are
active, the study arrives at a figure of 8,50,000 private sector doctors (4).
Data on facilities is also weak. For example, a hospital census conducted
in AP in1993 listed 2802 hospitals, more than 10 times the official figure,
and 42,192 beds, almost 4 times the official figure (5). Allowing for such
under-estimation, a World Bank study has estimated that 90% of hospitals
in India are in the private sector (6). Table 10.1 indicates government data
on the growth and percentage share of private and public sector hospitals
and beds.
Year
1974
1979
1984
1988
1996
Table 10.1
Growth and Share of Private Sector hospitals and Beds
____ Hospitals
Hospital Beds
Public
2832
(81-4)
3735
(64.7)
3925
(54.6)
4334
(44,1)
4808
(31.9)
Private
644
Total
Public
3176
| 211335
' (78.5)
(18.6)
(100)
2031
5766
331233
(35.3)
(74.2)
(100)
3256
7181
362966
I
(72.5)
(45.4)
(100)
5497
9831
410772
(55.9)
(70.1)
(100)
10289
15097
295664
(68.1)______________
(100)
(63.4)
Private
57550
(21.5)
115372
(25.8)
137662
(27.5)
175117
(29.9)
228155
T otal
268885
(100)
446605
(100)
500628
(100)
585889
(100)
623819
(100)j
(36.6)
Figures in brackets denote percentage share
Source: Health Information of India, CBHI, GOI, various years, Directory of Hospitals in India,
CBHI, DGHS. GOI, various years
While these institutions have an impressive range of bed capacity (5 to
over 700), most of them have small capacities, with 85% of them having
less than 25 beds, and the average bed size being 10 beds (7). Most
smaller institutions offer maternity and general services and are managed
by doctor entrepreneurs (8), either singly or in partnership. Some studies
162
u
estimate that the sole-proprieto-j-.ip category may comprise more than
80% of the private sector (9). HcAever. small and large institutions differ
widely in their range of services, equipment and facilities. Private tertiary
care institutions providing speciality and super-speciality care are few and
far between - only 1-2% of the total number of private institutions (10).
Corporate hospitals, increasingly visible in recent times, actually constitute
less than one per cent. The growing profile of these institutions, run mainly
by trusts, private or public limited companies, has coincided with the entry
of more advanced medical technology and the production of super
specialists from the country's leading institutions. A study on capital
investment
in large
I
T.
----- ------- : .'.i
private hospitals reveals that investment in high
technology equipment is viewedI as a competitive strategy for increasing
market share (11).
Physical access to healthcare is a prime need. But the spatial distribution
of private facilities and doctors between states, and between urban and
rural areas, does not facilitate the policy objective of equal access (Figure
10.1). State differentials indicate the private sector’s propensity to set up
facilities/practice in the more advanced states: HP has 12% of its hospitals
in the private sector as compared to Kerala’s 95%. HP and MP (possibly a
case of non-reporting) show a negligible presence of qualified private
practitioners, as compared to Keraia, Maharashtra and Punjab.
Figure 10.1
Percentage Share of Private Sector Hospitals, Beds, and Doctors by Select States
120
100
95.31
86.84
6’
74.7
80
62.23
60
40
20
*
0 -1
<
<
(X
LU
80 14
I
8‘
62.69
<
or
H
T
09
<
<
T
<
57 95
I
59 0> j
18.46 19 1
16 96 18 16
.EJJ
or
<
x
12.31
10.12
en»
CD
<
z
D
CL
P
cr
x cl
12 48
o
"0
x w
<r
<
o
z
CL
■ No.of Hospitals DNo. Beds in Hospitals DNo. of Doctors
Source: ((i)
..............
Number of Hospitals anchBeds: M. Uplekar, A. George, Access to Health Care
in India, 1995, (ii) Number of Doctors: R. Bhat, Regulation of the Private Sector in India
1996
163
11
Rural-urban differentials are ever sharper, with the spatial distribution of
doctors and facilities showing a ciear urban bias. The national average of
urban hospitals and beds was 15 times the recommended norm in 1987
(12). But unexpectedly, private hospitals are relatively less urban-biased
than public hospitals: about 31% of hospitals and 20% of beds are in rural
areas, while only 25% of public sector hospitals and 10% of its beds are in
rural areas (Figure 10.2).
Figure 10.2
Rural-Urban Distribution of Hospitals / Hospital beds: Public and Private Sectors
Hospitals
Government
Rural
25%
Private
Rural
31%
\
Urban
75%
Urban
69%
Government
Hospital
Beds
Private
Rural
29% 4^1
Rural
10%
Urban
90%
Urban
71%
Source: Directory of Hospitals in India. 1998; Nandraj. Private Health Sector. Issues.
Challenges, Options, 2000
The National Health Policy in 1983 called for expanding the coverage of
services through the voluntary sector to improve access (Table 10.2). Till
the mid-sixties, voluntary effort in healthcare was confined to hospital
based care. Later, inspired perhaps by the Chinese experience of a
motivated health cadre delivering care at the community level, models of
community health programmes and decentralized curative services began
to receive attention.
Table 10.2
Growth & Share of Voluntary Hospitals and Beds
1983
Ownership
1
1987
Hospitals
%
Beds
Government and
local___________
Voluntary
4065
55
569
Private
Total
Hospitals
%
Beds
%
374755 "73
4180
43
395062
69
8
53513
11
935
10
74498
13
2764
37
84206
16
4488
47
104018
18
7398
100 512474
100
9603
100
573578
100
I %
Source: Directory of Hospitals in India, 1985 and 1988
164
4
H
Voluntary effort in healthcare today covers a wide range of activities and
can be classified broadly into
organizations implementing government programmes (Family
Planning,
Reproductive and Child
Health,
AIDS
Control,
Integrated Child Development Services);
• organizations running specialised community health or integrated
programmes for basic healthcare delivery and community
development;
• organizations delivering care and rehabilitation services for
disadvantaged groups (leprosy patients, the handicapped);
• organizations sponsoring healthcare for blindness control, polio
eradication, management of blood banks and support during
disasters/epidemics (Lions Club, Rotary Club, Red Cross and
Chambers of Commerce); and
• organizations / individuals health researchers and activists who
undertake applied research in health service delivery, health
economics, health education, and who play an advocacy role.
•
According to a rough estimate, more than 7000 voluntary organizations in
the country work in these areas of healthcare (13). The NCAER survey on
human development indicators (1994) reveals that only 10.6% of the
sample villages report the presence of some type of NGO. As in the forprofit sector, wide state differentials exist: UP reports only 1.4% villages
with any kind of NGO, while Maharashtra reports a high of 34.4% (Figure
10.3). While the voluntary health sector has a higher presence in rural
areas, unlike the for-profit sector, hard data on rural-urban presence is not
available.
Figure 10.3
Percentage of Villages with NGOs, by Select States, 1994
40
35
30 1
25 |
20
15
10
5
0 I
n
21.2
1i.5 12.9
9.1
8.8
8
7.8
10.6
6.4
6.4
. ..
_□ 14
ro
-iz
cn
03
k_
cu
03
Z
H
03
03
03
C
03
03
’5
0
Q_
I
c
03
-C
(f)
03
’03
Q_
ZD
CD
O
CD
CD
or
Source: Ajay Mahal et al, Decentralization, Democratization
Delivery of Services: Evidence from Rural India, 1999
O
03
&
Public
165
Sector
u
Although a systematic documentation of NGO contribution is lacking, it is
indisputable that NGOs can improve access, quality, and equity of
services, either through direct provision, or through advocacy and other
action. An empirical analysis based on the 1994 NCAER survey of human
development
indicators,
reveals
that
NGO
presence
enhanced
immunization rates : BCG immunization rates were a significant 11 %-12%
higher with NGO presence (14).
The potential of NGOS in helping reach public health goals has not been
fully realized for several reasons, beginning with their limited size and
spatial distribution. That they are missing where they are most needed
hinders effective partnerships with the public health system. For instance,
the state government’s widely publicized call to take over the management
of PHCs in the tribal areas of AP has found few takers. Performance in
some cases has left much to be desired, with poor coverage levels as
against the targeted population. Importantly, evidence from several
schemes reveals that the poor are not well-represented in schemes unless
there is an element of subsidy, which is most often provided by the
government (15). Additionally, several NGOs have misused funds, thus
seriously hindering expanded and effective partnerships.
A 1990 World Bank study (16) concluded that NGO involvement was
limited because of
• the small numbers of NGOs involved in health or family welfare,
their uneven geographic spread, and their limited areas of
operation;
• low funds;
• bureaucratic
rigidities
affecting
funds
transfer
from
the
government, particularly limitations imposed by government rules
of audit and disbursements;
• weak financial management and accounting practices, limited
technical and managerial capacity; and
• inadequate organizational capacity in the government to manage
government-NGO interaction.
The challenge is to find strategies that will facilitate a far more
substantial NGO participation in the health sector, particularly in
backward states and remote areas, and to ensure systems that will
keep participation accountable and transparent.
The natural corollary to this urban concentration of qualified practitioners
and facilities, and the limited spread of the voluntary sector, is the rise of
unqualified rural medical practitioners (RMPs). The estimated one million
illegal practitioners manage about 50-70% of primary consultations, mostly
for minor illnesses, and comprise the de facto primary curative healthcare
system of rural India (17). The fact that they are unqualified seems to
matter little to their clientele, who appear to judge them mostly by
convenience and costs. Despite government attempts at license and
regulation more than 25 years ago, subsequent proliferation has made
prevention almost impossible (18). This complicated issue involving
166
H
arguments and counter-arguments will be discussed in the section on tne
quality of care in the private sector, but briefly, the options before us are
to
•
•
•
repeat attempts to prevent their practice;
continue ignoring them, hoping that improved public health services and
quality awareness will undermine demand for their services:
acknowledge their presence, define the parameters, and include them in
th-e overall framework for health policy and planning.
Utilization Patterns of Private Healthcare
At the all-lndia level, the private sector currently dominates both outpatient
(OP) and inpatient (IP) care (Figure 10.4). Reasons for the poor use of
public health facilities are many, but distance, long waiting time, non
availability of doctors and lack of medicines are commonly quoted in
several studies.
Figure 10.4
Share of private sector in Outpatient & Inpatient care
90
80
70
60
50
40
30
20
10
0
82
□ 1985-86
E1995-96
74
.■/..‘ft?
56
40
■1
OP
IP
Source: National Sample Survey. 42 no & 52"° Round
The private sector accounts for 82% of all OP visits at the all-lndia level,
with no significant variations by income group. The range is from 79-85%
from poorest to richest quintile, by urban and rural, by gender, caste, or
tribe (19). While the private sector shows a slight edge over the public
sector in hospitalizations and institutional deliveries, there is a dramatic
decline for ante-natal care and immunizations (Figure 10.5). The private
sector's overriding presence in curative care has perhaps led to the view
that India does not have a private health sector but a private medical
sector; and that this sector has not taken up, either voluntarily or
otherwise, a worthwhile role in achieving national health goals (20).
167
I j
Figure 10.5
Public and Private Sector Shares in Service Delivery
Immunizations
Ante-natal Care
.
40
■
Institutional
deliveries
#0
Hospitalization
55
1
□ Private
□ Public
Outpatient care
52
i
0
20
40
60
80
100
120
Source: Mahal et al, Who Benefits from Public Health Spreading in India, tyCAER. 2000
The states show sharp variations for IP care (Figure 10.6). Certain states
with underdeveloped and thinly spread private sector facilities, show lower
utilization, such as HP (7%), Orissa (11%), West Bengal (19%), the NE
states (23%), Rajasthan (26%) and MP (37%). More advanced states, with
a developed private sector, show a greater reliance on private health
facilities. These include Haryana (76%), Punjab (65%) and Maharashtra
(64%). The trend indicates that where the private sector is better
developed and distributed, there appears to be a growing preference for its
services.
Urban-rural
differentials for
hospitalized
care
are
not
pronounced, with urban residents utilizing more of private sector facilities
(57% of all IP days), and rural residents using more of public facilities
(56% of all IP days).
An important dimension to utilization of IP care in the two sectors is the
share between rich and poor. Overall for India, the percentage of the
poorest
puurebi quintile
quinine using private sector hospitalization facilities, at 39%, is
almost half that of the richest at 77%. However, there are dramatic
variations among the states in terms of reliance of the poor on private
sector hospitalizations. HP, Rajasthan and Orissa rely heavily on public
sector services, perhaps because they happen to be the only available
source. Haryana, Punjab and Maharashtra rely more on private sector
services. Across India, the perception is that the private sector res ponds
bend6r t0 the patient s interest than the public sector. Data from the NSS
52
Round reveals that 44% of patients chose the private sector because
the doctor was more easily available, 36% because they were not satisfied
with the treatment in the public sector, and 7% because medicines were
not available (21).
168
u
Figure 10.6
Distribution of Inpatients between Public and Private by State
liaoaaa [
Paajab £
c
c
J
bb ~
$4
JH
b2~
Blkar C
Gajaral £
45~
1■ m 11■*da r
53
su
Kerala T
Public share
~bti
All
□ Private sh
5U
c
I liar Pr
J
3
4B
t
Rajailhta £
3
Nerlb tail
]
c
T9
BT
c
c
o
]
J
20
40
60
80
100
120
Source: Mahal et al, Who Benefits from Public Health Spreading in India. NCAER. 2000
Costs of Private Healthcare
The preceding sections have shown that the people of India, including the
poor, make considerable use of the private health sector. The logical
question would then be: at what cost? This is a crucial dimension of the
private health sector in India, unfortunately under-researched. The few
studies that estimate health expenditures at household level show that 79% of annual household consumption expenditure is spent on healthcare
needs (22), about 85% of which goes to the private sector. The NSS 52nd
round reveals that per capita out-of-pocket expenditure per year to private
facilities ranges from over Rs.500 among the richest, to Rs.75 among the
poorest. In terms of percentage share of per capita expenditure by quintile
to the private sector, the poorest quintile contributes 88%. compared to
84% by the richest quintile. NSS data also reveals that the average cost
of treatment in the private sector for rural inpatients is 2.1 times higher,
and for urban inpatients 2.4 times higher, than in the public sector during
1995-96. The difference in costs between the private and public sector
varies significantly across states, with private in-patient costs higher in the
more advanced states (Figure 10.7).
169
u
Figure 10.7
Average Hospital Charge per Inpatient Day by Public and Private, by Select States
350 :
297
300 •
I
□ Public
269
251
F
250 I
□ Private
203
Q 200 i
I
o
£ 150
o:
140
i
wo ;
201
■
115
-
r
I 16
E
24
12
0 Lri
€
m
51
41
26!
ro
IX
ro
ro
€
2
ro -c
2
QJ
k.
CO <D
= XJ
™ 2
So.
O
jz
>s
JZ ©
■O TJ
w
t/>
2
Q.
6
x: tn
u a;
ro tj
I £
i
5
Source: Mahal et al, Who Benefits from Public Health Spending in India. NCAER. 2000
Data on rates in the private sector by facility, by
state,
by service, state,
urban/rural, and region, is inadequate. However, the average charges for
select services in private hospitals are revealed by a recent World Bankfunded, centre-sponsored study in AP and UP. UP has higher prices than
AP for most services, possibly due to higher establishment and transaction
costs, and the lower spread of private facilities (Table 10.3). Most of the
expenditure by the household goes towards doctors’ fees and drugs. A
1987 field study in Jalgaon district, Maharastra, found that 66% of the
average cost per illness episode was spent on doctors’ fees and drugs,
12% on hospitalization and surgery, 6% on diagnostic tests, 8% on
transport costs, and 8% on other costs (23).
Table 10.3
Average Charge (Rs) for Select Services in Private Hospitals
Andhra Pradesh
Uttar Pradesh
Services
Small
Big
Small
Big
Hospitals Hospitals
Hospitals Hospitals
OP Generalist
' 45
; 50
54
37
OP Specialist
64
i 82
104
170
I Normal Delivery
1060
1613
2263
2400
I-----------------Cesarian Section
3676
: 3708
7388
5545
I Ultrasound
233
; 330
374
381
Chest X-Ray
92
I 107
99
98
s0urce: lnd'a: Raising the Sights -- Better Health Systems for India’s Poor
2001
World Bank
170
u
The costs of private sector healthcare are Iinfluenced by provider payment
mechanisms. Most payments in India are1 on an out-of-pocket, fee-forservice basis, an iinflationary and cost-escalating method that induces the
over-supply of care. The alarming increase ini cesarean deliveries in
Chennai (above 40%), has been attributed to the fee-for-service
—----- ! payment
systems prevalent in private hospitals (24). Over-prescribing, and
subjecting patients to unnecessary investigations, are characteristics of a
fee-for-service payment method. Additionally, the influence of pharmacies
and diagnostic centres over doctors’ prescribing behaviour is a frequent
consumer complaint. So is the nexus between qualified and unqualified
practitioners for commission-based referrals. In the coastal districts of AP,
cesarians and hysterectomies are on the rise, with unqualified
practitioners referring patients to nursing homes for a commission. This
‘cut-practice’ operates in most urban-centred private hospitals (25).
Usually, technology advances are associated with a lowering of costs. But
the reverse is true of the medical sector, with capital-intensive
technological development increasing healthcare expenses. Excess
capacities, caused by the proliferation of medical equipment and
technologies in urban areas, have led to both the excessive and irrational
use of technologies. An example is the overuse of expensive diagnostic
tests such as MRI, CT scan, ultrasound and ECG. Many hospitals fix the
amount of ‘business' a doctor has to bring in to ensure that beds are
occupied and equipment fully utilized (26). Hospital managers have also
admitted that they are forced to recover the investment on high-technology
equipment through ‘excessive’ referrals (27). This growing tendency to
over-refer, over-test, over-medicate. and over-use diagnostic techniques,
has been making healthcare unaffordable and a major drain on the
resources of the poor.
Quality of Private Healthcare
While the general assumption is that the quality of care in the private
sector is superior to that in public institutions, this is not borne out by the
limited existing studies. A 1997 study in two districts of Maharashtra found
that a large number of unqualified doctors were practising modern
medicine, and that several hospitals did not have even basic infrastructure
or personnel (Annex 10.1). More recent studies of private medical
hospitals in Kolkata and Mumbai confirm the poor state of facilities in
private hospitals, and the frequency of medically unnecessary procedures
(28). Studies also reveal that medically unsound early discharges were
being resorted to since most procedure-derived profits are made in the
first days of hospitalization (29). Private providers have been reported to
prescribe excessive, expensive and more risky drugs. In Satara district,
Maharashtra, a study on drugs supply and use showed that irrational drug
prescription in the private sector was more than double that in the public
sector. The problem is compounded by self-medication, facilitated by
pharmacists: 47-64% patients are reported to buy medicines over the
counter without prescriptions (30).
171
H
Quality of care is seriously compromised by inappropriate treatment
protocols and drug regimes, as well as inadequate patient counselling /
education. It is a sad comment on the functioning of the public sector that
despite the widely publicized national disease control programmes offering
free treatment and drugs, people still choose private providers. An
estimated 60-85% of TB cases seek treatment from private providers (31);
and about two-thirds stay with them (32). Similarly, 80% of consultations
for childhood diarrhea are with private providers, mostly unqualified (33).
Private providers are also the first choice for STDs, perhaps for reasons of
greater confidentiality. Though they dominate treatment of diseases
contributing most to the national disease burden, their treatment practices
are under-researched, and existing studies reveal questionable practices.
TB care, for example, reports failure to test sputum, reliance on X-rays,
use of incorrect drugs/dosages and failure to educate patients. Almost half
the TB patients consulting private doctors failed to complete their
treatment (34). A Mumbai study revealed that 100 private doctors
prescribed 80 different regimens for TB treatment, most of them expensive
and inappropriate (35). Similarly, incorrect drug regimens and dosages
affect the treatment of malaria (Annex 10.2). Poor prescribing practices
and inadequate dosages harm individuals, promote resistance to drugs,
and contribute to the spread of communicable diseases.
A recurrent theme relating to quality has been the need to redesign the
medical curricula to address the major disease burden of the country, and
to ensure knowledge of standard treatment protocols and drug regimens.
The recent move to prescribe a minimum number of hours of Continuing
Medical Education (CME) and re-registration every 5 years by MCI,
pending approval of the central government, has been welcomed. But
current CME programmes in the states focus on speciality and super
speciality care. Given the fact that private sector services in the treatment
of common diseases (TB, malaria, RTI/STD, diarrheal diseases), do not
conform to standard treatment practices, there is an urgent need for the
dissemination of standard treatment and clinical protocols. Legislation
must, therefore, prescribe minimum CME hours covering major disease
burdens in the local context.
The review of studies reveals that the technical quality of care provided in
the private sector is often poor, ranging from poor infrastructure, to
inappropriate, inadequate and unethical treatment practices, to over
provision of services and exorbitant costs, to delivery by unqualified
providers. “Information asymmetry” among users, arising out of a lack of
information and an inability to make a sound judgement about the available
types of healthcare, compounds the problem.
Private Healthcare and Health Sector Goals
The importance of the private sector in terms of size, spread and
utilization, as also the negative consequences of its unplanned and
unregulated growth, are obvious. It is clear that the private sector must fit
better into a broader strategy to meet health sector goals. The obvious
172
11
question is; what are the current government strategies used to engage
the private sector in these goals? Despite the lack of an explicit,
comprehensive public policy for the private sector, certain government
mechanisms or tools for oversight (36) have been used to influence the
private sector. The mechanisms in use at present are incentives,
regulations and contracting. The next section analyses how effectively
these mechanisms have been used to improve the quantity, quality, equity
and efficiency of healthcare services, and what the options are for more
effective engagement. In addition, mechanisms not widely used so far public disclosure, consumer education and institutional mechanisms to
promote dialogue and consensus - need to be discussed. The analysis is
then rounded off with a suggested policy framework to direct the private
sector toward meeting national health goals.
Access, Equity and Efficiency
Incentives: The mechanism of incentives can improve access, equity,
efficiency and quality by influencing private providers to locate in
underserved areas, to provide services to targeted groups, and can be
built into contracting arrangements to use resources efficiently, improve
quality and target services to the poor. It can also promote access to
public health products. Incentives need not be financial; they can include
the provision of supplies such as drugs, vaccines, and contraceptives, or
the recognition of providers (accreditation/other forms). Incentives in India
have included direct and indirect subsidies, covering private facilities,
private providers, services and products.
Direct subsidies for the location of facilities and the provision of improved
technology have been used to improve access to facilities and services.
These include land at subsidized rates, customs duty exemptions for
equipment, fiscal concessions such as exemption from sales tax and octroi
for equipment, plant, machinery, and institutional finance at low interest
rates. The 1983 National Health Policy recommended the promotion of
private investment in tertiary care, acknowledging that the central and
state financial situation would limit public investment in capital intensive
care. Hence concessions have been made mainly to tertiary-level
speciality and super-speciality facilities, but concentrated, however, in
urban areas. Conditions of a percentage of free treatment for the poor
have been worked in to address equity considerations. A recent study (37)
on this initiative in Rajasthan, Punjab and Delhi, reveals weaknesses,
including the offers of land in urban rather than rural locations; inadequate
information to participants (except Rajasthan); no specifications on free
care for the poor (Punjab); a lack of coordination among departments and
inadequate management structures to handle new tasks. The results were
delays, legal wrangling in some cases, and ultimately, failure to establish
joint ventures (38). A House Committee set up by the state legislative
assembly of AP has also concluded that hospitals in the state which
received the concession of subsidized land were not providing free
treatment to the poor (40% out-patients and 10% in-patients), and that
there were no monitoring systems to ensure this obligation. The story
173
Ii
repeats itself in the scheme of customs duty exemption on import of
medical equipment, a scheme recently withdrawn (39). Some states have
used non-monetary incentives to motivate expansion of tertiary care. AP
recently permitted medical and dental colleges to be set up only in
identified backward locations, a policy that has paid dividends with large
private investment in rural locations, taking specialist care closer to the
people. Conditions on treatment of the poor, however, have not been
prescribed.
Though incentive mechanisms have not improved access to quality
healthcare and equity for obvious reasons, the initiative should be
promoted with the necessary correctives. Some of the lessons learnt for
effective action are that
•
Mapping and zoning exercises must be undertaken to identify
under-served areas. Incentives must be offered, such as
subsidized land, the use of unutilized public buildings, tax-breaks,
and low-cost capital with appropriate scaling to attract investment
in the most needy areas. (Data from local stakeholders will
indicate
conditions and safeguards
to
improve
incentive
mechanisms.)
• Remote and tribal areas must be targeted, with strong efforts
and adequate incentives to motivate voluntary organizations,
trusts and charitable hospitals to set up hospitals/services where
most needed. Stable funding mechanisms (timely and assured
release of agreed budgets), the simplification of procedures and
clarity regarding objectives, expectations and outcomes will
persuade a larger voluntary sector participation in health service
delivery.
• Non-monetary incentives, such as permissions to set up
medical/dental colleges in rural areas, can develop specialist
services in needy areas.
• Both monetary and non-monetary incentives must include
conditions of a percentage of free services to the poor.
Referrals of the poor from government hospitals must be linked to
these institutions and closely monitored.
• The monitoring of obligatory service provision must be
decentralized to local bodies or appropriate local committees.
• Management capacities must be developed
> pre-project:
to set specifications,
formulate
guidelines,
coordinate with departments and manage negotiations;
r- post-project: to monitor and regulate obligatory service
provision at state and local levels.
•
A regulatory framework and enforcement capacity should be in
place prior to such incentive-based expansion.
Regulation: This mechanism can improve access to qualified practitioners
and distribute doctors / services more equitably between urban and rural
areas. In Maharashtra, a landmark legislation requires doctors to serve 3
years in rural areas to be eligible for post-graduate admission. Similar
174
legislation has oeen enacted by \erala and Orissa. In fact, the Medical
Council of India should amend its legislation on standards for education
across the country, through a similar provision. Additionally, the rural
areas in which they are required to serve should be notified by each state
to ensure spatial distribution as per need, and to prevent a clustering
around cities.
Contracting: This mechanism improves access to services by contracting
for the delivery of specified services, or through the provision of training or
supplies such as drugs, vaccines and IEC material. Contracting
arrangements with the private sector also imply the expectation of
improvement in efficiency. The private sector, whether for-profit or not-forprofit, have long been associated with family planning, leprosy and
blindness control programmes. Payment is made on a per case/per bed
basis for services rendered. Partnering in the family planning programme
also takes place through free supply of contraceptives - condoms, pills
and IUDs. But private sector participation in this crucial national
programme has been stagnating at around 17%, belying the expectation of
increasing access, because of insufficient incentive amounts, the
cumbersome procedures for government reimbursement, and the income
tax problems that could follow the inspection of books of accounts. In the
blindness control initiative, the expectations of improved efficiencies are
belied by recurrent complaints of the over-reporting of cases, facilitated by
inadequacies in monitoring performance of private sector providers. Newer
initiatives include private contracting to expand essential health services
(primary healthcare in urban slums and remote PHCs), and specialist
services (gynecologists, anesthetists under the RCH programme), to
underserved, targeted population groups. A recent initiative, TB treatment
and control through a trust hospital in Hyderabad, points the way to
contracting for TB control services in urban areas where public sector
infrastructure is inadequate (Box 10.1).
Box 10.1
Public-Private Partnership for the DOIS Programme in Hyderabad City
A public-private partnering initiative for TB control, sponsored by WHO and DFID, is
being implemented in Hyderabad, AP, through the not-for-profit trust Mahavir Hospital
covering a population of 500,000. Since more than 60% of patients first approach private
practitioners for TB care, the project utilizes the services of more than 350 doctors who
practice in the catchment area. These private practitioners, allopaths and non-allopaths,
refer chest symptomatics to Mahavir’s chest clinic, where they are investigated and
categorized as per DOTS. After 3 initial treatments at Mahavir when patient education
and counselling takes place in the presence of a family member, patients are given the
choice of continuing treatment in Mahavir or being shifted to neighbouring DOTS
centres, nursing homes located in the catchment.
There are 32 such nursing homes participating in the project. The DOTS provider at this
centre is a nurse or pharmacist; the provider’s work is supervised through Mahavir’s
chest clinic. Treatment observation is available early morning and late evening to suit
patients and treatment is free. Government provides drugs and donor funds pay
supporting staff in the chest clinic.
As of March 2000, 2463 symptomatics have been examined (male:1299; female: 1164);
60% have been referred by private practitioners. 1060 cases have been registered for
treatment (male:519; female:541). In view of the neighbourhood DOTS centres, there
have been no defaulters. Conversion and cure rates are in the range of 95%-98%. This is
considered an effective model for the TB Control Programme in urban areas where
public health infrastructure is weak.
Source: Directorate of Health Services, Andhra Pradesh
175
d
Transferring the management o' public health facilities to the private
sector, (almost always to the vo.untary sector), is a more recent form of
contracting to improve access anc efficiency. In Gujarat, the management
of all primary healthcare services in one district has been handed over to
SEWA Rural. Orissa and Karnataka have handed over management of
PHCs in tribal/remote areas to NGOs. These public institutions have
remained underutilized for various reasons, and the move is expected to
expand the coverage of services and improves cost-effectiveness. Handing
over the management of 192 newly created urban health posts to NGOs in
74 municipalities of AP has the added objective of cost-savings on capital
investments through the utilization of existing private sector resources.
Under the AIDS Control Programme, the management of interventions for
high-risk groups is handed over to voluntary organisations in view of their
commitment to meeting social mandates. Some governments have been
considering the transfer of hospital management to private providers, and
action initiated in one case in Mumbai and one in Kolkata. The majority
ownership of the hospitals and management is with private firms, with
government representation on the Board, and conditions regarding the
percentage of poor patients to be treated free. The Kolkata joint venture is
functional; the Mumbai initiative is yet to take off. The reluctance of most
governments to partner with tile for-prcfit private sector in joint ventures
has been the perceived risk of not meeting social mandates for equity.
Clearly, pilot attempts will have to be carefully studied and assessed
before such partnering is replicated on a larger scale.
An effective
regulatory and enforcement framework must also be in place to ensure that
contractual and social obligations are fulfilled.
Contracting for services with private sector providers requires capacities to
assess needs, formulate contract specifications, manage negotiations,
manage accounts and finance, set standards, monitor and regulate service
provision and evaluate outcomes. This capacity can either be developed
within the public sector, or contracted to specialist organizations with
proven management capacity: State Management Agencies have been
contracted to manage NGO interventions with high-risk groups in the
DFID-funded AIDS control initiatives in Kerala and AP. Many states have
been contracting out ancillary services - security, sanitation, laundry and
catering. There is as yet little evidence on the effects of these initiatives
on savings, equity or quality changes, and the limited available evidence
reveals that monitoring capacity is weak.
For example, none of the
Mumbai public municipal hospitals that have contracted out catering
services has monitored quantity and quality of food provided (40). With no
monitoring/regulation by either contractor or hospital management, there
are constant complaints of informal payments to contractual security staff
in AP. Several states are now considering contracting out of diagnostic
services. All this only emphasizes the need to develop capacities at state,
local and institutional levels to handle this new role, and in particular, to
design efficient contracts and monitor contractor compliance. Most
contracting initiatives in the states are currently funded through externally
aided projects. The sustainability of these initiatives once funding ceases
is an issue at hand.
176
Recruiting private providers into accrecitec networks with a programme
logo is an effective way to increase coverage, meeting priority services
and target groups. The international White Ribbon Alliance for maternal
health and the Green Star Network in Pakistan for family planning services
are two examples. In AP, in what could be the start of an accreditation
network for promoting access to a priority service, rates lower than the
market rates for a mother and child health package have been negotiated
with private nursing homes through the AP Private Nursing Homes
Association and the State Branch of the Indian Medical Association. The
rates will be publicized by participating nursing homes through a prominent
display board. Accreditation networks require adequate resources and a
body able to manage the scheme; they can be self-financing, but often
receive government support. This is one partnering initiative where Indian
experience is limited, and which can be effectively promoted through
voluntary organizations and professional bodies.
There is increasing international evidence of the effectiveness of social
marketing as a means to increase the demand and awareness of public
health products. Social marketing in India has covered some products with
public health benefits - mainly the contraceptive pill and condom. In recent
times, oral rehydration salts and Vitamin A are also being covered. Social
marketing can also increase access effectively. In Tanzania, the sale of
insecticide-treated mosquito nets at subsidized rates has increased the
demand and number of manufacturers, resulting in price reductions, wider
choice and greater awareness of efficacy (41).
In sum, contracting and partnering with the private sector could increase
access to essential and specialist health services and products, address
equity considerations by targeting underserved groups and improve cost
effectiveness - by reducing capital investments, using existing private
sector infrastructure and promoting improved utilization. The options for
future action are as follows:
•
•
•
•
•
•
urgent development of capacities at state, local and
institutional levels to oversee contracts with the private sector;
studying effects of different models of contracting
on
financial savings, efficiency, quality changes and health needs of
the poor;
promotion of new partnering initiatives with the private sector
for service delivery and management of public institutions;
attempting accreditation networks for identified services
through voluntary organizations/professional bodies
supporting social marketing initiatives for public health
products and assessing existing schemes for correctives;
enacting legislation that prescribes rural service in state
notified areas as eligibility criteria for post-graduate admission.
Quality, Costs and Accountability
177
Regulation: In recent times, there has been an increasing demand from
patients, advocacy groups, consumer federations and the general public
that the private sector be made accountable in terms of quality and costs
of healthcare. Like incentives, regulation controls the access, quality,
equity and costs of healthcare through government action, but with legal
backing reinforced by punitive measures. Though regulations for the Indian
health sector exist, they are too often inadequate or outdated.
Compounding this inadequacy is the problem of poor enforcement - arising
out of an inadequate regulatory framework, the lack of resources,
resistance from various professional groups, the lack of political will, and
‘regulatory capture’ through bribery. We restrict our assessment to
regulations enforcing quality and accountability parameters: standards for
medical establishments, medical practice and ethics, controlling costs, and
protecting consumer rights. However, current regulations cover a much
wider range and can be broadly classified into five categories.
•
Regulations defining a professional code of conduct - the Indian
Medical Council Act, 1956, the Indian Dental Council Act which
can take doctors off registry rolls for violation of rules, the MCI
Medical Code of Ethics;
• Regulations for minimum and uniform quality standards - the
Indian Medical Council Act, 1956; the Dentists Act, 1948; the
Nursing Council Act, 1947; the Pharmacy Act, 1948; the Indian
Medical Degrees Act, 1916, which maintains registry, recognises
institutions training
medical personnel,
prescribes uniform
standards for medical personnel training (standard curricula,
admission and examination standards); the Bureau of Indian
Standards, which sets standards for articles or processes and
addresses complaints about product quality.
• Regulation controlling sale, price and quality of drugs - Drugs
(Control) Act, 1950 which fixes maximum prices and quantities to
be sold; the Drugs and Cosmetics Act, 1940, the Dangerous Drugs
Act, 1930, which defines quality standards and prohibits import,
manufacture and sale of certain drugs;
• Regulation that register clinical establishments - Nursing Home
Registration Acts (Delhi. Maharashtra, West Bengal) which
maintain a register of private hospitals and cancel registration on
provisions not being met;
• Regulations protecting consumer rights - the Consumer Protection
Act, 1986 with a redressal mechanism that compensates for any
inadequacy in quality of medical or insurance services, or
exorbitant prices; Employees State Insurance Act and CGHS
Rules which address complaints of treatment, benefits, eligibility;
the Medical Termination of Pregnancy Act, 1971, conferring the
right to abortions on health grounds; the Prenatal Diagnostic
Techniques (Regulation and Prevention of Misuse) Act, 1994 and
the Transplantation of Human Organs Act, 1994, with its
mechanisms to prevent misuse of technology and commercial
dealings in human organs respectively. The Indian legal system
also provides other instruments such as the Law of Torts, the
178
u
Indian Contract Act and the Indian Penal Code, but these are
rarely used for protection of consumer rights on healthcare
issues.
Standards for Medical Establishments: Hospitals,
nursing
Hospitals,
nursing Ihomes,
dispensaries/clinics, diagnostic facilities and laboratories have proliferated
in India
muid without
wiuiuui regulations specifying minimum standards and norms. In
recent times, minimum standards in medical establishments have been
discussed at central government level with states and professional bodies,
and draft guidelines circulated to states. Since several states are in the
process of drafting legislation setting standards and norms, a review of
existing regulations and newer initiatives will provide useful lessons.
Existing
legislation
in
Delhi
and
Maharashtra
provide
for
registration/licensing and inspection by a designated authority, but do not
specify minimum standards for infrastructure, personnel, record-keeping,
reporting on public health issues, sanitation and hygiene. Legislation
enacted by the government of TN without consulting other stakeholders
was taken court. The Karnataka and AP initiatives in constituting
committees chaired by reputed medical professionals, representing the
interests of all stakeholders and consulting with them on draft legislation,
merits mention. AP has gone a step forward: the committee has formulated
the standards and rules for each type of medical establishment. Given the
fiscal situation in most states, governments may not be able to invest in
regulatory mechanisms to enforce these regulations. A feasible and
acceptable proposition is setting up an autonomous Appropriate Authority
chaired by a medical professional/judge/ administrator of repute, with
representation of all stakeholders including consumers.
Financial
autonomy could be ensured through appropriate registration fee charges.
Three wings could function under this Authority to facilitate quality!
management and promote accountability: i) registration/licensing of
medical establishments; ii) dissemination of the provisions of the act,
promotion of quality standards and accreditation; and iii) disciplinary
action.
The Authority could contract services of individuals or
organizations for specific tasks.
With public pressure building up, the time is now ripe to enact legislation
that will register/license facilities and promote accreditation systems,
crucial to standards and quality of healthcare. The following options will
facilitate speedy and effective enactment and implementation:
•
•
•
All professional stakeholder groups must be involved in the
consultative process to draft legislation for registration/licensing.
Rules
regarding
standards for all
types
of
medical
establishments should be drafted simultaneously so the
legislation can be implemented on being enacted. Stakeholders
could assume responsibility for drafting of rules.
An autonomous Appropriate Authority should be set up to
enforce regulations.
179
Il
•
Registration/licensing/inspection
fees
should
make
the
Authority self-financing. Organisational capacity to implement
and monitor regulation must be ensured.
• A provision mandating social obligations would motivate
private participation in public health programmes and service
delivery and address contentious issues such as the need to
accept
accident
and
medico-legal
cases
and
reporting
requirements. Rules should clearly outline the requirements of
information sharing on clinical care and outcomes.
• Widespread dissemination of rules and acts will help motivate
compliance.
• An accreditation system for medical establishments that could
also function through the Appropriate Authority should be
simultaneously developed. Financial incentives (government
referrals under CGHS, ESI and other schemes) to only accredited
hospitals/diagnostic
centres/labs
would
buttress
efficacy.
Maharashtra has formed a ‘Healthcare Accreditation Council’
comprising all stakeholders, including consumer organizations, to
evolve standards (physical, clinical and quality assurance),
assessment and grading parameters and procedures for an
accreditation system (42).
Costs: Rapidly escalating healthcare costs need to be contained, and
regulation is seen as one of the mechanisms. The difficulty in
determining charges in the absence of clear definition of appropriate
treatment for different conditions and settings, coupled with pressures
from powerful groups of private providers, all deter governments from
attempting to set prices for private healthcare. Direct out-of-pocket
payments and users’ lack of information to determine what constitutes
value for money, facilitates cost inflation. One method of controlling
costs is pre-payment or prospective payment schemes where financial
risks are shared among scheme members, and private providers are
paid for commitment to provide defined packages of care. Since in most
cases, over 50% of healthcare expenditure is on drugs, price control of
producer prices and/or distribution margins can control healthcare
costs. While governments may not have the capacity to set and regulate
price controls for health services, they can, at the very least, ensure
transparency in charging practices through regulation requiring
publication of prices. Publication of prices for treatment services,
diagnostic and lab services, room/bed and nursing charges by private
providers will not only assist the consumer to take decisions on how
much to buy and where to go, but will also have a favourable spin-off
effect. Once prices are published, the media, consumer groups and
other community based groups can promote awareness of consumer
rights, including fair pricing, which will bring pressure on private
providers to contain their prices. The use of inappropriate/unnecessary
high-cost investigations and procedures may be addressed through a
provision requiring mandatory review of complaints by the appropriate
authority. The ultimate objective would be to institute> a system of
medical audit. The options suggested are:
L
•
•
legislative provision for the prominent display of rates for
services, since prescription and enforcement of price limits may
not be feasible; and
legislative provision for the mandatory review of complaints
by the appropriate authority.
Medical Ethics: State legislation deals with matters of professional and
ethical conduct. The punitive provisions of the MCI and State Council Acts
allow for striking off the name of the guilty party from their rolls entirely or
for a specified period. Given the low level of registration and inadequate
monitoring systems in councils to ensure registration, the de-registration
provision has not been effective. The medical brotherhood syndrome, self
interest and survival in a highly competitive marketplace, seem to
compromise the laudable objective of self-regulation and compliance. The
options proposed to promote professional and ethical conduct are
•
•
•
to
make
an
exhaustive
list
of
professional
offences/misconduct (for example, the misuse of prenatal
diagnostic techniques), with specific punishments proposed for
each category of offence;
to refer complaints to the appropriate authority representing
medical and consumer interests, with a stipulated period to reach
a final judgement; and
to promote accreditation systems for ethical practice through
state councils or voluntary organizations.
Consumer Rights: The
Consumer
Protection
Act
(COPRA) was
promulgated in 1986 to promote and protect consumer rights through
consumer protection forums established at district, state and central
levels. Services rendered free, or under a contract for personal service,
are exempted from the purview of this Act. The Supreme Court has
recently ruled that any paid medical service is covered under COPRA.
Medical Associations have opposed COPRA on the grounds of possible
misuse. However, a review (43) of cases filed before the Consumer
Disputes and Redressal Commission in Gujarat reveals this fear to be
unfounded: 71% of cases since 1991 have been in favour of doctors.
Doctors also argue that the Act has resulted in the practice of defensive
medicine’ and in i) increasing costs of diagnostic services and doctors’
fees, and ii) inappropriate care through overuse of diagnostic services.
However, on the positive side, 64% of doctors surveyed in Ahmedabad
thought the Act protected consumer interests, and that information
sharing, time spent with patients and concern for quality have improved
(44). From the consumer point of view, a survey (45) of hospitals in Delhi,
Lucknow and Hyderabad shows 51% not satisfied with consumer redress
mechanisms under the Act, while 38% expressed satisfaction. Delay was
the major cause for dissatisfaction: in 93% of cases, judgements were
reached after the stipulated period of 90 days; 80% of cases took between
1-5 years. Consumer forum members ascribed delays to heavy workload
and inadequate supporting infrastructure. Another point of consumer
dissatisfaction was quantum of compensation: even in cases of severe
181
disability or death due to medical negligence, compensation was often
limited to cost of medical services provided. Access, particularly of women
and SCs and STs, is restricted, due to income constraints and a lack of
awareness. But despite its limitations, COPRA is a good example of using
consumer protection legislation to deal with medical malpractice and
negligence and has made provicers more responsive to consumer needs
and rights.
The survey of patient redress mechanisms in the three cities (46) reveals
no significant differences between public and private sectors (Tables 10.4
and 10.5). It confirms management inattention to consumers' concerns,
more pronounced in the public sector.
Table 10.4
Distribution of Facilities by Availability of Patient Redress Systems
Private
Public
T otal
Number of Facilities covered
Number of Facilities having Procedure
manual or guidelines for receiving and
processing complaints_________________
Number
of
Facilities
having
unit/individual responsible for dispute
settlement_____________________________
Number of Facilities having complaint
box/book
54
27
81
9
(17%)
4
(11%)
13
(15%)
32
(59%)
18
(67%)
50
(62%)
27
(50%)
14
41
(52%) | (51%)
Table 10.5
Distribution of Facilities with Some Consumer Redress Systems by
________________________ Frequency of Review
Frequency
Private
Public
N
%
_N_
%
Daily
18
67
_7_
50
2-7 days
5
19
_3_
21
>7days
4
14
4
29
T otal
27
100
14
100
Source: Bejon Misra, The Regulatory Framework for Consumer Redress in the Health Care
Sector in India, VOICE, 2000
Some specific options, based on the review of COPRA (47) and hospital
redress mechanisms to address consumer rights (48), include the
following:
•
•
•
Increasing the number of District Consumer Forums and State
Commissions on the basis of workload for redress within the
stipulated 90 days;
Amending the Consumer Protection Act to provide expert
medical assistance in negligence cases; identifying a panel of
doctors in each district/state to advise councils/commissions;
Instituting screening mechanisms so that only medical
negligence cases are placed before the forums and all other
cases referred to medical councils/appropriate authorities;
182
h
Compulsory provision of continuing
medical education
programmes for providers:
• Public definition of consumers’ rights: increasing consumer
knowledge and awareness of redress mechanisms and publicizing
healthcare norms and regulations through community education
campaigns
using
mass
media,
consumer
and
voluntary
organisations, public sector providers, local bodies, women and
other community user groups; and
• Institutionalizing complaint and redress mechanisms in
hospitals through the rules prescribing minimum standards.
•
Public Disclosure: Community and user education can reinforce regulation
of private providers, while empowering users to negotiate for better
information sharing, quality of care and cost-containment. Information and
feedback to providers on the rational use of drugs, standard treatment
protocols and pricing guidelines would increase their accountability.
Participatory processes between users and providers can also raise
awareness of quality issues in healthcare. The state must also use the
mechanism of information and dialogue to feed back into policy and
planning.
The Unqualified Practitioner: The complexity of the issue of unqualified
practitioners bears repetition. On the one hand, past experience illustrates
the difficulty of enforcing regulations to eliminate unqualified practitioners
from the healthcare market. A case in point is the difficulty of
implementing the recent judgement of the UP High Court calling for
identifying unqualified practitioners and framing criminal charges against
them. Elimination can also have negative consequences for the poor: in
AP, irate, protesting mobs surrounded a district collector who attempted to
shut down the practice of unqualified practitioners providing the limited
medical care available to them. On the other hand, it is clear that only
qualified persons should deliver medical care, at least eventually.
Awareness generation and strengthening both public and private sectors
will, in the long run, eliminate the demand for the services of unqualified
practitioners. However, in the interim, the damage must be contained and
it is in this context that the following strategies are proposed. These
recommendations are confined to the unqualified practitioner practising
formal systems of medicine and do not cover traditional practitioners, such
as faith healers and local medicine men and women. Further, these interim
measures are recommended only for under-served areas. There is no
justification for permitting unqualified practitioners in most urban areas
and well-served rural areas.
•
•
The government could train literate but unqualified practitioners of
formal systems of medicine in safe practices for the basic care of
specified minor illnesses, with standard guidelines for diagnosis,
treatment and the use of essential drugs.
Such trained practitioners could be given provisional registration
for a year, during which their compliance is closely watched so
that final registration may then be considered.
183
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•
•
Simultaneously,
a strong, local monitoring and enforcing
framework must be ensured for effective action against the
untrained, and to prosecute those whose practice have caused
injury to health or life.
Wide public disclosure, on the type of treatment and the list of
drugs such trained practitioners are authorized to dispense, must
also be ensured.
Appropriate legislation will have to provide the required supportive legal
framework. Local bodies or authorities considered appropriate by states
could take on this responsibility with financial support for training,
monitoring, enforcement and public disclosure. Professional bodies should
also be involved in monitoring and information disclosure, including
educating people on the advantages of qualified, professional care. The
decision to manage unqualified practitioners to restrict harmful practices is
contingent on health systems development in states. Kerala, for example,
could close down the practice of unqualified practitioners altogether, given
the reach and spread of its public and private health facilities. Ultimately,
however, managing the unqualified practitioner is an interim measure: the
states must hasten health systems development and awareness to
elimina’a the market for such services.
Dialogue and Consensus: If they are to be effective, regulations need
supplementing with institutional arrangements that foster partnerships and
promote trust between public and private sectors. The constitution of
effective coordination mechanisms such as public-private forums is a good
starting point; this will help to share information, address issues of
common concern and coordinate activities of public and private sectors.
Examples include Karnataka’s Task Force comprising NGOs, for-profit
organizations, academics and government: AP's high-level Committee of
representatives of all professional bodies, stakeholder associations and
government; and Maharashtra's forum with representatives of professional
bodies and consumer organisations. Membership could vary from state to
state, but should invariably include stakeholder associations, professional
bodies, NGO representatives, consumer groups, academics/health policy
researchers and appropriate, government representatives. Similar forums
could be set up at the district level to facilitate trust-building at the cutting
edge level and to make partnering effective.
With its potential in meeting critical healthcare needs and its history of
providing low-cost effective care, the voluntary sector must be involved in
shaping policy for their participation in the health sector. Some states may
prefer to have only one forum involving for-profit and not-for-profit
providers; an option is a separate mechanism at central and state levels to
enable the sharing of information, and collaboration for policy formulation
and action with the voluntary sector. These bodies could identify areas and
target populations in greatest need of primary health services, assist in
policy
formulation
including
the
incentives
and
administrative
relationships/procedures required to make action effective, define
parameters for screening NGOs, and ensure accountability. While the
184
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Department of Family Welfare has attempted such a imechanism through
its central committee and the state SCOVAs, these bodies have become
mere sanctioning authorities for NGO projects, thus limiting their scope
and effectiveness.
Private Healthcare Policy: An Agenda for Action
“Stewardship is ultimately concerned with oversight of the entire system,
avoiding myopia, tunnel vision and the turning of a blind eye to a system’s
failings.” (50) Engaging with the private sector in India has not been a part
of such ‘oversight’. The initiatives have been sporadic, in response to
perceived needs in the national, local or programme context, or as a
reaction to the demands of pressure groups. Contracting with the private
sector, for example, has generally been motivated by prescription in
externally aided projects. Not enough has been understood about the
entirety of the health system, about how the private sector works, and
how the state should intervene to better direct it. We have attempted to
distil information from existing studies on the private sectors current role
and to outline possible options to better direct and influence the private
sector in meeting the health sector goals (Figure 10.8). A public policy
inclusive of the private sector does not. and should not. mean a
withdrawal, or a limiting or reduction of the public sector provision of
service or funding. The public sector will have to continue to intervene to
offset market failure. Improving the quality and reach of public health
services is also one way to direct and influence the functioning of the
private sector.
185
H
Figure 10.8
A Framework for Policy and Action
Operation
Focus
Enabling environment through advocacy for
political and stakeholder support
Demand generation - Mobilise demand for
quality and affordable services
Management - Develop public sector’s
institutional capacity to:
• develop and monitor policy
• enforce
rules,
regulations
and
contractual obligations
• manage partnerships with the private
sector
• inform and educate consumers
• promote dialogue and consensus
Expand healthcare coverage to needy
areas and groups
Address the needs of the poor
Improve quality of healthcare services
Promote accountability
Contain healthcare costs
Improve effectiveness
Policy framework
Steer private sector to meet public health policy objectives
►
Mechanisms
t
Enforcing regulation and setting standards
Establishing accreditation systems
Enforcing obligations for the poor
Providing strategic incentives
Developing Partnerships
Defining rights and ensuring public
information and disclosure
Promoting dialogue
186
u
1
Notes
1.
Foreword by D.R. Gwatkin to Ramesh Bhat's, ’The Private/Public Mix in Healthcare
in India', IHPP, Washington, D.C.,1995.
2.
Griffiths, 1963 and John Hopkins University, 1970, q uoted in Rhode and
Viswanathan, The Rural Practitioner.
3.
Ibid.
4.
Ravi Duggal, The Private Health Sector in India - Nature, Trends and a Critique
2000.
5.
S. Nandraj, Private Health Sector: Concerns, Challenges and Options 2000
6.
Ibid.
7.
Directory of Hospitals in India, 1988.
8.
Rama Baru et al, State and Private Sector: Some Policy Options, 2000
9.
Muraleedharan, Private-Public Partnership in Health Care Sector in India. 2000.
10. Baru et al, 2000.
11. Sukanya, 1995, quoted in Muraleedharan, 2000.
12. Meera Chatterjee, Health for too many: India’s Experiments with Truth, from
Reaching Health for all, Rohde J.. Chatterjee Meera et al 1993, Oxford University
Press, Delhi.
13. Independent Commission on Health in India, VHAI.
14. Ajay Mahal et al, 1999, Decentralisation, Democratisation & Public Sector Delivery
of Services: Evidence from Rural India.
15. World Bank, 2000, Private Health Insurance and Public Health Goals. Report on a
National Seminar.
16. World Bank, Population and Human Resource Operation Division. 1 995. The Indian
Family Welfare Programme: Towards a Reproductive and Child Health Approach.
17. Rohde and Viswanathan.
18. Ibid.
19. Ajay Mahal et al, Who Benefits from Public Health Spreading in India, NCAER
2000.
20. M. Uplekar and A. George, Access to Healthcare in India, 1995.
21. Public-Private Partnerships in Health, background paper, World Bank. 2000.
22. Bhat, Ramesh, The Public/Private Mix in Health Care in India, IIM Ahmedabad. Health Policy and
Planning; 8(1): 43-56, Oxford University Press, 1993.
23. Duggal and Amin, FRCH, Cost of Healthcare: A Household Survey in an Indian
District, CEHAT, Mumbai, 1987.
24. Muraleedharan 2000.
25. S. Nandraj, Beyond the Law and the Lord: Quality of Private Healthcare, EPW, Vol
XXIX,July 2nd 1994. In Bombay, the cut-ratio is as high as 30-40% of the fees
charged. In some towns of Maharashtra, informal associations of doctors have
standardized the ratios of cuts to be given. Cut-practice inevitably leads to
unethical practices: unnecessary investigations and procedures, referrals and
hospitalisation.
26. Nandraj, 2000.
27. Muraleedharan, 2000.
28. Nandraj, Khot and Menon, 1999 quoted in Private Health Sector: Concerns,
Challenges and Options, 2000.
29. Baru et al 2000.
30. Krishnaswamy et al 1995, Greenalgh, 1987
31. Uplekar et al, 1 998.
32. Berman 2000.
33. Ibid.
34. Uplekar et al, 1 998.
35. Uplekar,Shepard,1 991.
36. Public-Private Partnerships in Health, background paper, World Bank, 2000.
37. Bhat, Ramesh, Public/Private Partnerships in Health Sector: Issues and
Prospects, Indian Institute of Management, Ahmedabad, 1999.
38. Ibid.
187
u
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
Na nd raj 2000.
Shatia and Mills, 1997, quoted in \andraj 2000.
Population Services International 4999.
Nandraj, Accreditation of Hospitals. Initiatives in India, 2001.
Shat, Ramesh, Regulation of the Private Health Sector in India, International
Journal of Health Planning and Management, Vol II, 253-274, (1996)
Ibid.
Bejon Misra, The Regulatory Framework for Consumer Redress in the Health
Sector in India, VOICE, 2000.
Ibid.
R. Bhatt 1996.
Bejon Misra 2000.
Hadiyono et al 1996, quoted in Working with Private Providers for Better
Healthcare.
Gro Harlem Brundtland, Director-General, WHR, WHO, 2000.
Baru et al, 2000.
F
ft
188
L
Annex 10.1
Physical Standards in the Private Health Sector - Findings of a Case Study
Of Rural Maharashtra
Sunil Nandraj, Ravi Duggal. CEHAT, 1997
Practitioners
Of practitioners surveyed one-fourth unqualified; 40% allopaths,
52.5% from
Indian systems, 7.5% homoeopaths
Though only 30% of sample were qualified allopaths, 79% practised only
allopathy
* Only 55% had appropriate registration; only 72.5% registered among qualified
practitioners
Only 38% maintained case records, mostly records of medicines administered
and amount collected/due
* Essential equipment and instruments (thermometers, sterilisers, examination
table, weighing machine, sheets, towels, wash basin) lacking in most clinics
Hospitals
None of the 49 hospitals surveyed registered by any authority, although the
Bombay Nursing Home Registration Act applies to all of Maharashtra
* 29% hospitals run by doctors trained in other systems of medicine but providing
allopathic cures
* Only three qualified nurses in entire sample
‘ Only 18% hospitals had minimum facilities for pathological tests; none had
blood banks or quick access to one. Only a quarter had uninterrupted power
supply, and not one had an ambulance. 71% of hospitals did not have a single
bedpan
* Though most hospitals providing surgical services had OTs, only 71% had an
operating table, 39% shadowless lamps, 10% an ECG monitor, 65% a steriliser,
56% cent an oxygen cylinder.
Annex 1 0.2
J
I
Private Practitioners and their Role in the Resurgence of Malaria in Mumbai:
Serving the Affected or Aiding an Epidemic?
Vinay Kamat, unpublished
An ethnographic study in Mumbai and Navi Mumbai used a sample of 48 private
practitioners. Findings suggest that many practitioners were poorly qualified and
did not support ongoing efforts of public health departments to bring the epidemic
under control. Most practitioners adopted diagnostic and treatment practices not
consistent with guidelines laid down by WHO and NMEP, the Indian National
Malaria Eradication Programme. Few practitioners in low-income areas used a
peripheral blood-smear test for diagnosis. Practitioners with poor clientele
resorted to one-day treatment that often included injectable antimalarials and
broad-spectrum antibiotics to febrile patients.
This mode of diagnosis and
treatment was justified by the claim that they were only responding to demands
from patients who could not afford a blood-smear test or a full prescription.
Practitioners, driven by profit motives and retention of patients, were exacerbating
patients’ health problems and jeopardising control of the epidemic in the two
cities.
189
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11
Health Systems
Introduction
National health systems are both complex and varied, and defining a
health system is not the simplest of tasks. Assessing its performance is
even more difficult, given the complex interplay of factors within and
without the health sector that impact on the health status of populations.
WHR 2000 defines a health system as including 'all the activities whose
primary purpose is to promote, restore or maintain health’. For the
purposes of this chapter, a narrower definition of health systems appears
convenient, such as the ‘combination of resources, organization, financing
and management that culminate in the delivery of health services to the
population’ (1), and we interpret 'health services’ as confined to
healthcare services. The focus in this chapter is on organization and
management of public healthcare delivery, a formidable challenge, given
the wide differentials between and within 28 heterogeneous states.
Information, analysis and strategic options are based primarily on
intensive studies of health systems' performance in 8 major states of India
(2), considered representative of the good, middling and poor performing
states in terms of health outcomes.
The overall goals of a health system (Figure 11.1) are to reduce mortality
and morbidity, ensure equity in health status, protect the poor against the
financial costs of illness and increase public satisfaction. Restricting our
assessment to healthcare systems, performance can be evaluated through
certain universally accepted measures:
❖ Equity, or the fair distribution of the financial burden for healthcare
between different income classes, and equal access to healthcare;
❖ Cost-effectiveness in improving the health status of a population, or
achievement of the best health outcomes with the least expenditure;
❖ Allocative efficiency, or the extent to which the allocation and use of
resources results in maximum benefits;
❖ Technical efficiency, or the combination of inputs which gives the
maximum outputs at the least cost;
❖ Risk pooling, or protection against huge financial losses caused by
catastrophic illnesses;
❖ Quality, or the provision of healthcare which conforms to aid-down
standards and results in patient satisfaction;
❖ Sustainability, or the availability of adequate financial and capital
resources for continuing long-term healthcare (3).
190
H
Figure 11.1
Goals of a Health System
i
Govern
Susiainabiiry
Mobilize
Provide
|
Accountability
Risk Pooling
HEALTHCARE
SYSTEM
State Health Sector
Quality
Finance
Provide
Private Health Sector
Efficiency
1
Finance
Lquin
Reduced mortality
& morbidity
Public
satisfaction
PEOPLE
\
\
/
Protection against
catastrophic cost
Protection foi
vulnerable
t
Education
Related Sectors
Water
/
Nutrition
*
Poverty Adeviauor
Sanitation
Health systems performance is assessed in this chapter by focusing on
health outcomes, equity, efficiency (allocative and technical),
accountability, quality and political governance in major states.
Analysis is restricted to mortality and fertility outcomes, as India lacks
a dependable system for measuring morbidity.
191
u
Health Systems Performance and Health Outcomes
The health status of a given population is a reflection of a health
system s performance. Health outcomes in the states of India vary
considerably: under-5 mortality rates range from 138 per 1000 live
births in MP to a remarkably low 19 per 1000 live births in Kerala.
There are equally large differences in fertility rates: only two of the 16
major states, Kerala and TN, have reached replacement levels of
fertility. Six major states of India, accounting for over 40% of India’s
population, have Total Fertility Rates (TFRs) which are =/>3, and
include the poorest states with the highest infant and child mortality
rates. Table 11.1 indicates under-5 mortality rates, fertility rates, and
nutritional status of children, and groups 15 major states in terms of
under-5 mortality performance. The grouping holds good for fertility
rates also, except for Maharashtra and Orissa, which fit in with the
group B states. The major reason for this discrepancy could be that
Maharashtra started out with a much higher TFR (5.6 in 1971) and
Orissa with a lower TFR (4.7 in 1971). An analysis of nutritional status
also reveals a similar pattern, with states having the highest infant and
child mortality rates displaying the highest levels of malnutrition among
children < 3 years. This pattern indicates the causal relationship
between malnutrition and mortality.
Table 11.1
Infant Mortality Rates, Total Fertility Rates, and Malnutrition in Major Indian
________ St a t e s
Population
Under-five
Total
Weight for Age Status
State
(millions)
Mortality
Fertility
of Children Under 3
2001*
1998 **
Rate 1998**
(% < - 2 SD)***
' 981.3
INDIA
949
37
47
Group : A Under-five mortality < 65
Kerala__________ *
31.8
18.8
1.8
27
Maharashra______ I
96.7
58.1
2.7
50
Tamil Nadu
T_____________________
62.11
63.3
2.0
37
Group : B Under-fiye mortality > 65 to < 100
West Bengal
~T
80.22
2.4
67.6
49
Karnataka
T
52.73
2.4
69.8
44
Punjab__________ [
24.28
72.1
2.6
29
Haryana_________
21.08
76.8
3.3
35
Gujarat_________
50.59
85.1
3.0
45
Andhra Pradesh
|
75.72
85.5
2.4
38
Group : C Under-five Mortality > ' 00_____
Orissa________
36.70
104.4
2.9
54
Bihar_________
109.77
105.1
4.3
54
Rajasthan_____
56.47
114.9
4.1
51
Uttar Pradesh
122.5
174,52
4.6
52
Madhya Pradesh
81.17
137.6
3.9
55
Source: * Census 2001; ** SRS, 2000, Registrar General General of India;
*” National Family Health Survey, 1 998-99
1
192
H
Thus an analysis of disparities in health outcomes shows that certain states
in India have consistently worse health outcomes. The questions that arise
are:
❖ Why have some states been more successful in achieving better health
outcomes?
❖ To what extent are health sector interventions responsible?
♦> How replicable are the approaches in better-performing states?
The oft-quoted hypothesis that poverty and illiteracy are the main
determinants of health outcomes is not borne out adequately by state figures
(Table 11.2). AP, with a female literacy rate lower than the rates in MP and
Orissa, has remarkably low fertility rates and relatively better mortality rates.
TN, with a much lower female literacy rate than Kerala, has shown significant
improvement in fertility and health indicators. So also Karnataka and West
Bengal. Differentials in poverty levels between the BIMARU (4) and other
states cannot fully explain the large-scale differentials in health -uicomes.
UP, with 31% of its population below the poverty line, has far worse health
outcomes than West Bengal, which has an almost comparable 27% of its
population below the poverty line. Similarly, the minimal differentials in
poverty levels in Rajasthan (15% below the poverty line) and Kerala (13%
below the poverty line) are not reflected in health outcomes, which are, in
relative terms, hugely disparate.
Table 11.2
Percentage Female Literacy & Percentage below Poverty Line
% below poverty line
% female literacy
All India____________________
26.10
Group A: Under-five MortaIity < 65
Kerala
12.72
Maharastra
25.02
Tamilnadu
21.12
Group B: Under-five Mortality > 65 to < 100
West Bengal
27\02
Karnataka
20.04
Punjab
6.16
Haryana
8.74
Gujarat
14.07
Andhra Pradesh
15.77
Group C: Under-five Mortality >100
Orissa
47.15
Bihar
42.60
Rajasthan
15.28
Uttar Pradesh
31.15
Madhya Pradesh
37.43
Source: SRS 1998 and Economic Survey of India 2001
54
87.86
67.51
64.55
60.22
57.45
63.55
56.31
58.60
51.17
50.97
33.57
44.34
42.99
52.50
193
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This is not to dispute that literacy and poverty levels have an impact on
health outcomes but to analyze whether there are other relevant and
critical determinants for improved health outcomes, A cross-sectional
regression analysis was carried out for 25 states to assess whether
differentials in health service delivery capacity have a significant
association with health outcomes. Under-5 mortality was the dependent
variable, and independent variables included female literacy (5),
percentage below poverty line and service coverage of mothers and
children under the RCH programme (6). Among the programme variables,
the percentage of women who received 3 ANC visits and who received IFA
tablets for 3 or more months, the percentage of births attended by a
health professional, children fully immunized, and children who received
ORT in case of diarrhea, have been used to assess their influence on
under-5 mortality. The best regression fit with the highest R^ value was
obtained with the following three variables:
Regression Results
___________Dependent variable: Under-5 mortality
Independent Variables
Coefficient
t-value
Constant
182.10
Female literacy rate
-0.6354*
1.96
% children fully immunised
-0.4390**
2.96
-0.7555**
1.31
% received ORT in case of diarrhoea
I
I
_______________________________
R2=0.78, F-value = 25.52
Note: * indicates signifiant at 5% level
Source: Satya Sekhar, IIHFW, 2001
Indicates significant at 10% level
The above three independent variables explained 78% of variation in the
under-5 mortality rate. A one percent increase in female literacy rate
could decrease under-5 mortality by 0.64%. A one percent increase in
children fully immunized could decrease under-5 mortality by 0.44%, and
a one per cent increase in ORT coverage of children could decrease
mortality by 0.76%. Since MCH preventive services are mostly delivered
in the public sector, public sector capacity is considered a relevant and
critical determinant of health outcomes. Jean Dreze and Haris Gazdar
advance the same hypothesis in an analysis of development experiences
in UP, Kerala and the southern states (7). The authors argue that the
relevant determinant of the development status of these states is the
reach and functioning of public services, and support this argument with a
comparative picture of select public services (Table 11.3).
194
Ii
Table 11.3
Select Indicators Relating to Public Services__________________
| Uttar Pradesh | South India I Kerala
Health________ ______________________________
Percentage of recent births (1992-3) preceded by
Tetanus vaccine
44
85
94
Ante-natal checkup_____________________________
30
73
97
Proportion of births taking place in medical institutions,
4
50
92
1991 (%)______________
Proportion of children aged 12-23 months who have
57
87
89
received some vaccination, 1992-3 (%)_____________
~2Q~
Proportion of villages with medical facilities, 1981 (%)
IT
' 96
Number of hospital beds per million persons. 1991
340
964
2,418
Education____________________________________
Proportion of rural settlements of 300 persons or more
47.7
87.6
75.2
having primary school, 1986 (%)__________________
Proportion of primary schools held in ‘open space’
17.2
3.4
0.0
1986a (%)_____________________________________
Proportion of rural children aged 12-14 who have ever j
been enrolled in a school, 1986-7 (%)
Female
32
72
98.2
Male
73
86
_______________
__________________________________________________________
99.6
Source: Jean Dreze, Haris Gazdar, Uttar Pradesh: The Burden of Inertia, UNU/WIDER, 1997
The authors argue that ‘resilient government inertia’ as far as public
provisioning of services is concerned, be it health, education or public
distribution systems, appears to be the relevant determinant for the
striking differentials in UP as compared to the southern states.
This
reinforces our hypothesis that public health sector capacity in terms of
provisioning of services is a critical determinant for improved health
outcomes.
Healthcare Systems and Equity
There have been large gains in health status since Independence, but the
poorest 20% of Indians have more than double the mortality rates, fertility
rates, and undernutrition levels of the richest 20%. State-wise figures of
mortality are not available for the quintile groups. However, percentage
coverage of health services among those with a high standard of living
(pucca house) (8), and low standard of living (kutcha house) (9), reported
in centrally sponsored, statewide surveys under the RCH programme, has
been used for analysis among the 8 states studied. Table 11.4 reveals
that states that have smaller differentials in service coverage between
these two groups have consistently better health outcomes. It is clear that
those health systems that direct their resources and energies to address
the health needs of the poor have a better overall health status. This is a
logical association, given the fact that the poor carry the larger burden of
disease.
195
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Table 11.4
Percentage Covered by ANC and Immunization Services, by Standard of Living
State
% ANC
% Full Immunization
Low
standard
High
standard
87.0
61.5
73.3
60.5
45.4
21.4
19.1
34.1
Ratio
Low:High
0.98
0.75
I
1.07
1.07
0.64
0.57
I
0.42
0.48
Kerala_______
85.1
Maharastra
46.2
Tamilnadu
78.1
Andhra Pradesh
64,7
Orissa________
29.1
Rajasthan_____
12.2
Uttar Pradesh
8.0
Madhya
16.2
Pradesh
Source: RCH State Surveys, 2000, UPS, Bomba)
Low
standard
High
standard
79.6
74.5
88.2
64.3
54.5
27,2
35.2
42.2
85.7
85.0
95.9
82.9
71.3
48.3
57.3
68.3
Ratio
Low: High
0.93
0.88
0.92
0.78
0.76
0.56
0.61
0.62
Social Access
In the Indian context, poverty has social dimensions and the lowest caste
groups are also generally the weakest economically. SCs and STs have
consistently worse health outcomes, and gender differentials also
continue to plague health outcomes with serious intergenerational
consequences. Table 11.5 reveals the state-wise differentials in service
coverage of SCs and STs as per RCH survey data. Those states which
have smaller differentials between service coverage of disadvantaged
groups and other groups have better health outcomes.
Table 11.5
Percentage covered by ANC and Immunization Services, by Caste
State
% ANC
I_________ % Full Immunization
SC/ST
Others
Ratio
SC/ST
Others
Ratio
SC/ST:Oth
SC/ST:Others
ers
Kerala________
82.9
87.5
0.95
79.1
89.0
0.89
Maharastra
48.2
57.8
0.83
73.8
82.3
0.90
Tamilnadu_____
79.9
73.8
1.08
90.2
91.9
0.98
Andhra Pradesh
67.0
70,4
63.1
1.06
76.4
0.92
Orissa________
28.2
36.0
0.78
50.
064.0
0.78
Rajasthan_____
15.0
17.3
0.87
27.8
41.8
0.67
Uttar Pradesh
9.0
12.0
0.75
39.8
45.1
0.88
Madhya Pradesh
48.2
__________
57,8___________
0.83
39.7
54.8
0.73
Source: RCH Surveys, 1998-99, UPS, Bombay
196
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Locational Access
A pre-requisite to good health outcomes is physical access to healthcare.
Kerala’s singular performance in health status can be attributed largely to
proximity to healthcare providers. A woman in Kerala has to walk about
1.5 km. to get to a sub-centre while her counterpart elsewhere in the
country has to cover almost double the distance. The radial distance of a
PHC is 3.4 km. in Kerala, while it is 6.8 km. in the rest of the country.
Similarly, a typical PHC in Kerala covers 37sq. km., compared to 143 sq.
km. elsewhere in the country. Kerala has a road length of 375 per 100 sq.
km. as compared to 75 km. for the rest of the country. NSS data shows
that the percentage of people who did not access healthcare for locational
reasons is higher in the poor performing states (Table 11.6).
Table 11.6
Percentage not Seeking Care due to Locational Reasons
r
State
Medical facility not
available in area
Tamilnadu______
________ 0.8________
Andhra Pradesh
________ 3.2________
Kerala__________
________ 5.7________
Rajasthan______
________ 7.1_________
Maharashtra
________ 8.2________
Uttar Pradesh
_______ 10.8________
Orissa__________
_______ 19.5________
Madhya Pradesh
19.8
Source: NSSO 1995-96
♦> Kerala boasts 26 public hospital beds per 10,000 population, while in
the rest of the country, it is a mere 7. If beds in the private sector and
ISM are included, Kerala has an impressive one bed per 265 persons,
a ratio even better than that of several developed countries. Of the 8
states studied, the better performers have a relatively better public bed
strength (Table 11.7). The key lesson for states is the pressing need to
improve deficiencies of locational and infrastructural inequities that
drive up health costs. A resource mapping exercise is required to be
taken up in each state, to rationalize distribution of facilities through
merger (merge closely located facilities) and re-location (an example :
close
down
urban
health
dispensaries
and
establish
Sub
centres/PHCs). Additionally, private sector services should be
contracted wherever possible, and public sector facilities established
only where private sector infrastructure/manpower is deficient.
197
u
Table 11.7
Beds per 10,000 Population in Public Hospita Is
State
1991
Kerala__________
26.5
Maharastra_____
10.0
Tamilnadu______
8.7
Andhra Pradesh
4.0
Orissa__________
4.6
Rajasthan______
4,7
Uttar Pradesh
3.4
Madhya Pradesh_____________ _ ___________
2.7
Source: Health Information of India. 1993. MHFW
Economic Access
The costs of healthcare have grown enormously in the country as a whole,
and the rise has been steeper for inpatient (IP) care than outpatient (OP)
care. While over 45% of the poorest quintile borrowed money/sold assets
for hospitalization, the figure is just over 30% for the richest quintile.
While there are differentials between the major states in terms of the poor
borrowing or selling assets for hospitalisation, the unfortunate fact is that
this phenomenon is high across states, be it Kerala or Uttar Pradesh
(Figure 11.2). There are also high levels of borrowings for hospitalization
in the public sector, perhaps because of diagnostic charges, drugs to be
bought, and informal payments made within these institutions. Thus the
public sector, which is supposed to provide insurance against catastrophic
costs of illnesses through free services, has been unable to do so. States
must recognize the need to provide insurance against costs of severe
illness, particularly for the poor, either through free services in public
health facilities or risk-pooling mechanisms.
Figure 11.2
Proportion of In-Patients Below the Poverty Line that Borrowed or Sold
Assets for Public and Private Hospitalizations, by State 1995-96
haraafw
Madtn hradr^
G^ra>
WeaBcnpl
■ Public
Unw Pradra*
Private
Harvwa
AU Irxfci
J
MmMn
Ktrala
B^r
MrrwuU
Taml Nad*
Andhra Fradnh
J
Noe# fa
0
10
20
30
40
50
60
70
KO
Source: NSSO 1995-96
198
Utilization of Health Services
That access to health services is a key mechanism for better health
outcomes is also indicated by utilization data: states that have high
utilization rates reveal lower mortality rates (Table 11.8).
Table 11.8
Number of Public & Private Hospitalizations per 100,000 persons
State
Total
India
_________________
1653
Group A: Under-five Mortality < 65
Kerala_____
7480
Maharastra
2519
Tamil Nadu
2138
Group B: Under-five Mortality > 65 to <
100____________
West Bengal
1441
Karnataka_____
1733
Punjab_________
1622
Haryana_______
2851
Gujarat________
^7,1
Andhra Pradesh_____________________
1595
Group C: Under-five Mortality > 100
Orissa____________
1320
Bihar______________
722
Rajasthan_________
1005
Uttar Pradesh_____
1004
Madhya Pradesh_____
1030
Source: NSSO 1995-96
The central role of high utilization rates has major policy implications. It
confirms the need to ensure access to health services and to focus on
interventions that will improve utilization of health facilities. It also
highlights the need to promote behavioural change that will motivate
people to seek appropriate care when ill. Overall for India, NSS data
reveals that 24% of the poorest quintile did not seek medical treatment
when they were ill, compared to 9% of the richest quintile. Kerala’s low
mortality rates are explained not only by increased access to healthcare
services, but by a population with a heightened awareness of ill health,
driven by health-seeking behaviour.
In sum:
♦> Geographic, social and economic access has a significant
association with health outcomes, and barriers to access operate
to the disadvantage of the poor. Utilization rates of health
services, considered a proxy for access, confirm the association.
199
H
❖ States more equitable in service coverage have better health
outcomes.
❖ States should focus on improving access/utilization rates of health
services.
❖ States should ensure protection of the poor against costs of
catastrophic illness through free public health services or risk
pooling mechanisms.
Allocative efficiency
The centre’s declining fiscal commitment to health is reflected in the
decreasing share of health expenditures compared to total expenditures.
(Also see Chapter 12). State governments, which fund around 75% of total
public health expenditure, have also not compensated the loss in the
centre’s decreased funding. An analysis of health budgets of eleven major
states (10) reveals that the share of health budgets declined sharply from
7.19% of total revenue budgets in 1985-86, to 5.76% in 1991-92, and
continues at approximately the same level (See Table 12.1). There has
been some improvement in certain states in 1998-99, attributed largely to
the increase necessitated by revision in pay scales following pay
commission recommendations.
As a consequence of the rising share of salaries, non-salary grants have
been reduced drastically, affecting the quality of services delivered
through public health institutions. (Table 12.2). The overall pattern
emerging across states is that governments spend largely on manpower
by way of salaries, while households are expected to spend on drugs,
diagnostics and other treatment facilities.
An analysis (11) of per capita public health spending (revenue
expenditure) (12) and allocations to the primary, secondary and tertiary
sectors in the 11 states studied reveals that health outcomes appear to be
strongly associated with higher per capita public health spending and with
higher allocations to the secondary sector. The analysis estimates simple
correlation coefficients between health spending and under-5 mortality,
infant mortality and life expectancy at birth (LEB). The matrix of estimated
correlation coefficients linking per capita health spending with under-5
mortality, IMR and life expectancy are presented in Tables 11.9A, 11.9B
and 11.9C. The coefficients presented in Tables 11.9A and B suggest that
total per capita spending and the per capita spending on secondary care
services are highly correlated with under-5 mortality and IMR in all the
four years. The signs of the coefficients, predictably, are negative. LEB
also has a high correlation with total per capita spending on health (Table
11.9C). Analysis of health expenditure in the primary, secondary and
tertiary sectors suggests that LEB is strongly associated with secondary
care services with the expected positive sign. The level and the structure
200
11
of spending on primary, secondary and tertiary care services for
individual states also corroborate the above findings. For instance,
Kerala has been consistently spending a larger proportion of its budget on
primary and secondary care services. On the contrary, the level and
structure of spending of other states have moved in favour of tertiary care
services.
Table 11.9A
Correlation Coefficients between Under-5 Mortality and Per Capita Health
Expenditure
Primary Care)
Year
Secondary
Tertiary Care
General
Per Capita
Expenditure
Care
Expenditure
Expenditure
Health
Expenditure
Expenditure j
1985-86
-0.0358
-0.6158
-0.0138
-0.3295
-0.6409
1991-92
-0.2793
-0.4848
-0.0716
-0.0960
-0.6243
1995-96
-0.2736
-0.7011
0.0049
-0.2569
-0.6751
1998-99
-0.1460
-0.5752
-0.1422
-0.1896
-0.5086
i
Note: N = 11 (states).
3
Table 11.9B
Correlation Coefficients between IMR and Per Capita Health Expenditure
Year
Primary
Care
Expenditure
Secondary
Care
Expenditure
Tertiary Care
Expenditure
General
Expenditure
Per Capita
Health
Expenditure
1985-86
-0.0127
-0.6378
-0.1165
-0.2851
-0.6761
1991-92
-0.2352
-0.5623
-0.1132
-0.0062
-0.6507
1995-96
-0.2326
-0.7909
-0.0723
-0.1647
-0.6993
1998-99
____
-0.0590
-0.6508
-0.1408
-0.1038
-0.4736
Note: N= 11 (states).
Table 11.9C
Correlation Coefficients between LEB (Female) and Per Capita Health Expenditure
Year
Primary Care
Expenditure
Secondary
Care
Expenditure
Tertiary Care
Expenditure
General
Expenditure
Per Capita
Health
Expenditure
0.1035
0.6180
0.0043
0.1652
0.6590
1995-96**
____________________________
0.1871
0.7453
0.1197
0.2060
Note: N = 11 (states).
Female LEB for 1991-96 related with expenditure during 1991-92
** Female LEB for 1996-01 related with expenditure during 1995-96
0.6820
1991-92*
I
An analysis of NSS data reveals that in terms of curative care, the poorest
20% of the population captured only 10% of public subsidy, whereas the
richest quintile captured 33% of public subsidy. (Also see Chapter 5 on
equity.) However, state differentials are significant: Kerala, Gujarat, TN
and Maharashtra expend almost equal amounts across each of the
quintiles, while other states exhibit a pro-rich stance. Bihar and Rajasthan
spend almost 5 times the amount on the richest compared to the amount
201
u
. ..... iSexpended
t fl|
expended on
on the
the poorest
poorest quintile.
quintile. Using
Using NSS
NSS data
data on
on utilization
utilization .m
,
government data on expenditure, a concentration index to conHlrt|!MH
C0l"l’rt||
equity performance in states has been created for each concent!
curve measuring the level of subsidy benefit inequality. (See Figure 5 (u
'’fl
The preceding analysis indicates a strong association between ht>(dih .|||
outcomes and equity in the public financing of healthcare. The pro»r|nhflB
leaning in group C states may be the result of minimal formal privnla fl|
sector presence, hence a lack of choice for consumers. Availability o/* «
private health services will persuade richer individuals to
tn :self-selugf »
private services, automatically facilitating targeting of publlQ |
subsidies for the poor. Kerala, TN and Maharashtra, which have
— -j ffairly
widespread private sector facilities, and are proven to be relatively more
equitous, are standing examples of this phenomenon.
■fl
In summary, the review reveals that:
''■w
❖ Public health expenditure shows a declining trend at central and state
levels in the share of total public expenditure.
❖ Salaries account for a major share of public expenditure in states,
averaging between 70-80% of total health expenditure. Non-salary^
operating grants have seen a drastic reduction, resulting in increased
health costs, lack of protection of the poor against costs of illness, and
a decreasing trend in utilization of public health services.
❖ States which spend greater proportions on health, which allocate a
larger share to both primary and secondary sectors, and which direct
public spending for the poor, have better health outcomes.
❖ The key lessons for states are:
• enhance public health spendingI toi primary and
secondary sectors,
particularly to Imeet essential
operating costs;
• address efficiency and equity concerns through re
alignment of allocations that will simultaneously
address the needs of primary and secondary levels of
care and of the poor;
• promote the establishment of private sector facilities in
under-served areas and poorer states to facilitate self
selection of private services by the better off.
Technical Efficiency
Technical efficiency relates to the way in which resources are organized
and used for delivery of specific programmes and services at the least
cost. Technical inefficiency implies that there will be gains if the
management and use of existing resources is reorganized. The problems
confronting public health service delivery in India are well known,
several of which can be effectively addressed by reorganizing and
managing existing resources better :
202
'■
-^=
K.
H
•
•
Scarce financial resources are being inefficiently used, not only in
terms of allocative patterns, but also in the management of fund flow
and monitoring.
People are unable to access healthcare not only due to geographic,
social or cost barriers, but inherent systemic and structural
weaknesses of the public healthcare system as well:
♦ compartmentalized structures and inadequate demarcation and
definition of roles at all levels of care;
♦ inadequate
planning,
management
and
monitoring
of
services/facilities, displaying insensitivity to local/ community
needs;
♦ ineffective or non-existent referral systems, resulting in under
utilization of PHCs, over-utilization of
hospital services,
duplication of services and cost-ineffective provision of services;
♦ inefficient distribution, use and management of human resources
so that people have to contend with
lack of key personnel,
unmotivated staff , absenteeism, long waiting times, inconvenient
clinic hours/outreach, service times, unauthorized
patient
charging;
♦ inefficient systems for purchasing drugs, supplies and services,
which fail to ensure quality and value for money;
♦ inadequate
systems
to promote
responsiveness,
enforce
accountability and assure quality; and
♦ inadequate attention to health education and public disclosure.
Institutional Issues
Health is a shared responsibility between centre and states. The Centre
takes the lead in financing some public health activities through centrally
sponsored schemes. But the share of state expenditure, and state
responsibility for programme implementation and service delivery bring
out emphatically that improvements in access, efficiency, equity,
accountability, quality and ultimately health outcomes, depend largely on
how well states perform.
Restructuring organization and management of public healthcare at state
level:
Organizational restructuring of state departments of health is critical for
improvement of technical efficiency in the public healthcare system.
Health departments
in all
states have a similar,
hierarchical,
compartmentalized organizational structure. The organizational structure
in AP more or less reflects the organization of health departments in
states across the country (Annex 11.1). The problems of this structure
include centralization of authority, ill-defined and overlapping roles,
compartmentalized functioning, a lack of accountability, poor motivation
203
and wastage of resources. Frequent changes of leadership at state,
directorate and district levels, result in a lack of continuity and
accountability in planning, management and provision of services. As at
the centre, responsibility for management of institutions and service
provision vests with officials across ail levels, including the policy-making
secretariat level, as a result of which
‘the department is run like a
casualty ward, responding to everyday emergencies.’ (13)
Unless organizational
and management structures are
changed,
changed,
sustainable improvements in efficiency, quality and accountability will not
be possible. The organizational structure must be revamped to
❖ shed executive functions at the secretariat level to focus on policy,
strategic planning, monitoring and evaluation;
❖ allow for technical expertise on public health, epidemiology, health
economics, health finance and healthcare management to inform
policy and decision-making;
❖ define roles clearly at all levels of the system and promote decision
making at the level where problems arise;
❖ promote integration of preventive, promotive and curative aspects of
healthcare;
❖ reduce unproductive cadres and levels to facilitate quick decision
making and action;
❖ enhance accountability for action, results and quality through
effective monitoring;
❖ contribute to team work and collaboration, including with other
systems of medicine, and related sectors; and
❖ mobilize political commitment and community partnership/ ownership
of
services/programmes
through
institution-building,
public
disclosure and health education.
Based on these principles, the restructuring of health departments in
states needs to be attempted in conformity with individual political and
administrative structures in each state. However, a framework is
suggested to indicate the broad direction of reform:
• At the secretariat level, ideally there should be one Minister and one
Secretary for health and medical services, with: (i) policy formulation
and planning (ii) strategic linkages with key departments (nutrition,
water, and sanitation in the main), and (Hi) monitoring and evaluation,
as key functions. This level should be divested of executive functions.
A Medical and Health Advisory Board/Council, including professionals
health economists,
(public health
specialists, health
epidemiologists,
healthcare
experts,
management
experts,
medical
educationists),
representatives of professional bodies, health research institutions,
elected representatives, NGOs, and consumer organizations should
support policy formulation and planning. Orissa has constituted a
Policy and Strategic Planning Unit (PSPU) at the state level,
comprising 7 professional members (14). A 16-member Advisory
Committee on Health Sector Reforms (government and non
government) has also been constituted. Karnataka has constituted a
204
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Task Force, with a similar composition, to support policy and planning
functions of the state.
• At the Directorate level, a Director-General of Health and Medical
Services (DGH& MS), with public health as the qualifying speciality,
should integrate and coordinate activities of the various directorates primary, secondary, tertiary and Indian systems. This should be a
selection post with a minimum tenure of three years. The DGH&MS will
have overall administrative and technical control over all directorates.
The role of the DGH&MS is for strategic planning, for integration and
coordination in implementation and monitoring of services/programmes
of all the directorates. He will be the link between the directorates and
the secretariat. The DGH&MS must be assisted by Strategic Cells
constituted for planning; surveillance; monitoring and evaluation
(including quality of care); human resource management and
development; health education.
• At the district level, a District Chief Health and Medical Officer
(DCH&MO) will have administrative and technical control over heads of
national disease control programmes, and all primary and secondary
leve' institutions. Wherever tertiary hospitals arv located, the
Superintendent will coordinate activities with the DCH&MO through the
Zilla Parishad or a District Health Committee. These district-level
Committees will have similar representation as the state-level Advisory
Board/Council and will participate in planning and supervision of
services/programmes at the district level. Wherever powers have
devolved to local bodies, the Standing Committees on Health would
assume this role.
• At the sub-district level, a Deputy Chief Health and Medical Officer
(Deputy CM&HO) should be in place for appropriate geographical
regions within the district, with administrative and technical control
over all primary and secondary institutions and national disease control
units in his jurisdiction. He will function from an appropriate sub-district
secondary hospital, which will be the administrative unit under which
all primary/secondary units in his jurisdiction function. This will
integrate the delivery of primary and secondary health services,
essential for an effective referral system, for improved efficiency, and
for improved utilization of primary level services. These sub-districtintegrated units will be linked to the district hospital, as well as to
teaching and speciality hospitals through geographically defined
catchment areas. An advisory committee at the sub-district level consisting of elected representatives, local body representatives,
leaders of self-help groups, NGOs, and doctors from secondary and
primary level institutions - will participate in planning and supervising
delivery of services/programmes.
• Health committees are also proposed for each health institution with
powers for day-to-day management so that political and community
participation and a sense of ownership is promoted.
205
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•
•
Delegation of both administrative and financial powers must
accompany reorganization of structures so that decision-making is
decentralized and services are responsive.
To support policy and planning for the tertiary level, including medical
education, states may constitute special cells, or Universities of Health
Sciences (as has already been done in AP, Karnataka and TN),
depending on the number of medical colleges in the state. These
bodies would be entrusted with the review of medical and para-medical
education and health manpower needs for initiating appropriate action.
Based on the preceding suggestions. Annex 11.2 suggests a framework of
the reorganized structure of state health departments, attempting to give
a broad direction to the restructuring reform proposed. While it is not
prescriptive, efficiency improvements demand that every state will
attempt restructuring models that plan for decentralized authority,
responsibility and decision making; integration of preventive,
promotive and curative services; and local community participation.
Financial Management
Centre:
Improving efficiency in the provision of health service is contingent
on reforming financial management systems to assure timely
releases, flexibility in use, and monitoring of fund utilization against
agreed performance indicators. The centre funds states through
centrally sponsored schemes to address specific national health and
family welfare priorities. Financing flows are extremely complex and
cumbersome, both between centre and states and within states
(framework in Annex 13.3) (15), resulting in inordinate delays and
unpredictability of releases, rendering planning exercises ineffectual, and
timely action next to impossible. An example is the release of central
funds for sputum negative drugs under the TB control programme. The
quantum of funds released from year to year is not made known to states
in time for streamlining of planning and procurement, and releases do not
conform to any fixed schedule. The centre also exercises rigid controls on
budget lines uniformly applicable throughout the country, and states are
unable to address their specific needs. Yet most states want the centre to
continue to fund national disease priorities, (with less rigid controls),
since centrally sponsored schemes focus on cost-effective interventions
with public health benefits. Releasing untied block grants to states could
carry with it the danger of the tertiary and curative sector cornering the
better portion of funds.
In recent times, state and district level societies have been established
with the precise objective of bypassing cumbersome financing procedures.
States have welcomed this move, which will secure programme funds,
206
H
eliminate delays, and promote flexibility in management and use.
However, financial management systems at state and district levels
must be simultaneously ensured for the efficient use of funds released to
societies.
State:
Exacerbating this situation is i) the further delay in release of funds at
state level, caused again by inefficient financial management systems,
and ii) short releases based on the fiscal situation in the state. As at the
centre, an incremental budget approach is used to estimate funds
requirement. Budgets tend to bear little relation to departmental
proposals, with non-salary expenditure reduced to keep in line with
available resources. In AP’s zero-based budgeting experiment, budgets
were ultimately cut to match the cloth and not the size of the need. The
flow of funds after budget approval is a time-consuming process and there
are considerable delays due to the sanctions required at various stages. A
framework (16) depicting fund flow and sanctioning levels in one state of
India considered representative of many other states is in Annex 11.4. AP
has initiated in 2001 a system of block releases every 6 months, with the
next 6-monthly release dependent on achievement of certain agreed
performance parametres, and allowing departments the flexibility of
utilizing non-salary grants as per need. The inevitable conclusion is that
every state must overhaul financial management systems for more
efficient programme management and service delivery. Fully qualified and
trained finance staff must be available at all levels, failing which
accounting and audit services must be contracted out to professional
agencies.
J
3
3
Priorities in Public Health Sector Policy and Planning
Setting priorities in health sector policy and planning is a matter of
intense debate. International opinion emphasizes the bias in favour of
hospital care and the need to reform health systems in favour of primary
care. Our analyses suggest that the state must focus on both the primary
and secondary sectors simultaneously, linked as they are for delivery of
basic health services. Maternal and neonatal mortality, for example,
cannot be addressed adequately without emphasis on hospitalized care at
the secondary level. Additionally, in the absence of risk-pooling
mechanisms for the poor, the emphasis on IP is considered appropriate.
Primary Healthcare
In terms of finance, states spend an average 40% on primary healthcare
(17). Some - AP and Maharashtra for instance - spend as much as 60%.
The primary health sector carries the largest share of staff. In terms of
infrastructure, the primary sector gets more than its share in most states
as per Planning Commission norms (15% of beds in the primary sector,
207
i
J
i1
70% in the secondary and 15% in the tertiary sectors). Meanwhile the
secondary sector suffers shortages (Table 11.10).
Table 11.10
Percentage Beds in the Primary, Secondary and Tertiary Sector
State___________
Primary | Secondary
Tertiary
Andhra Pradesh
16
46
38
Orissa__________
31
47
22
Maharastra_____
35
30
35
Kerala__________
23
39
38
Tamilnadu______
18
44
38
Rajasthan______
26
50
24
Madhya Pradesh
. 14
27.4
58.6
Uttar Pradesh
27
65
8
Source: State Health Systems Studies
Despite reasonable input levels in many states, and more than the
required number of beds, the primary level of care is the most unutilized
across states. Even TN, which has a relatively better functioning primary
sector, records on an average only 3 deliveries per month per PHC,
although the average bed strength is 6 per PHC. Under-utilization, waste
and ineffectiveness of primary health services, and over-utilization of
hospital services, centre around an irrational distribution and use of
resources at the primary level. In the Indian context, setting priorities will
have to address the following issues:
❖ a huge percentage of allocations being spent on salaries (90% in some
states) with little left to spare for operating costs, leading to
• lack of essential drugs, consumables and diagnostics
• lack of essential maintenance, including sanitation
• severe constraints in mobility and communications
❖ inefficient management of human resources on whom this salary is
spent, leading to
• absenteeism
• unproductive cadres
• mismatch between personnel and equipment
While every state must ensure adequate allocations towards operating
costs and basic facilities, the focus should be on strategies to improve
efficiency in health service production and PHC utilization. Among these
strategies are rationalizing distribution of beds, equipment and staff;
ensuring the presence of key personnel, (doctors ANMs, male workers,
lab technicians, staff nurses); and adding on medical services at the PHC
level to add value to its perceived utility (institutional deliveries, MTPs,
RTI treatment). The attempt should be to increase medical services at the
PHC level and take curative services closer to the people. Our experience
leads us to differ in this regard from donor agencies who have been
advocating that in-patient services in PHCs be eliminated altogether on
grounds of cost-effectiveness. This would seriously affect not only the
family welfare programme, but would also impact negatively upon the
perceived utility of the facility, and consequently on utilization. TN and AP
have converted certain PHCs to 24-hour centres to raise the level of
208
u
institutional deliveries. AP has announced a fixed day at the PHC for
treatment of reproductive tract problems, as is done for ante-natal
care, immunization and family planning. Several states have contracted
the services of private sector doctors/paramedics at PHCs to ensure the
availability of key personnel. Some have handed over the management of
PHCs to NGOs. These initiatives however, are at best sporadic, and do
not form part of a coherent, corrorehensive policy to re-distribute
resources and reorganize management to improve efficiency and
utilization rates at the primary and secondary level.
Secondary Level of Healthcare and Referral Systems
The focus on secondary care in the context of referral linkages with the
primary sector and the welfare objective of insuring the poor against costs
of illness is considered as essential as the focus on primary care. Five
states have negotiated project assistance with World Bank to invest in the
secondary level of care and improve allocational efficiency between
secondary and tertiary levels of care, access, efficiency and effectiveness
of service delivery in the first-referral hospitals, and the functioning of the
referral system. The projects are still under implementation and are yet to
be evaluated. However, current micro-level efficiency indicators for
projects in AP, Punjab and West Bengal compare creditably with countries
in the region, except for turnover rates (Table 11.11). The key lesson is
that with the required inputs, public hospital systems are capable of
continuous improvements in efficiency. Similar investments in the
secondary sector are recommended in other states.
Table 11.11
Micro-efficiency for Secondary (District) Hospitals
State
2000
Occupancy
Turnover
Average length of
Rate
Rate
Stay (ALPS)
Andhra Pradesh
73
53
_______ 5_______
Punjab________
94,21
25.53
5.62
West Bengal
85.52
34.21
4,55
Srilanka (1997)
93.5
74.4
4,7_
China(1986)
94
13.7
25.1______
Indonesia^
985)75__________________29.2
_____
___________________
9.4
Source: State Reports, June 2000. DFID Health Systems Resource Centre
The objective of strengthening referral systems under these projects,
however, has not been achieved. Inefficiencies such as duplication of
service functions, increased costs of providing primary care at the
secondary/tertiary level, under-utilization of the primary level due to
inadequate support from referral institutions, continue to plague the
system even in these states. Building up an effective referral system for
optimal utilization of resources at the three levels of care, involves
detailed and systematic planning and sustained action:
drawing up of clinical protocols for each level of care
ensuring required inputs at each level of care
209
i1
❖ mapping clearly the referral parnways and publicizing them among
facility staff and community
❖ instituting graded user fees to promote referrals: free services at the
primary level, charged at the secondary level, and charged even higher
at the tertiary level, with exemptions for the poor, and
❖ most important, reforming administrative structures: integrating primary
and secondary levels of care tnrough administrative and technical
controls at the level of the referral hospital. Such structural reform has
not been attempted in any state yet, and has only been enunciated in
the Vision 2020 document of AP. Upward linkages to tertiary level
institutions would also need to be defined.
Human Resource Management
The non-availability of key personnel in public health facilities due to
vacancies, absenteeism or shortages against norms, is often quoted as a
key reason for under-utilization of public health facilities. An analysis of
the shortages in manpower at the primary level (vacancies plus shortages
against population norms), reveals minimal differentials between states,
with all states reporting a shortfall of over 100% for both ANMs and
doctors.
In fact, Kerala reports a shortfall on par with the worst
performing states (Table 11.12). This suggests that more than shortfalls
of personnel, it is organization and management of existing human
resources that is the key to better performance. It also reinforces the
lesson that efficiency in use of existing resources should take
precedence over mobilizing additional resources.
Table 11.12
Health Manpower in Rural Areas - % Shortfall of ANMs & Doctors
SI. No
1.
j4^
5.
6.
1
State
i
% Shortfall*
of ANMs
Kerala_______
104.60 .
Maharashtra
106.00 _
Tamilnadu____
114.70
Andhra Pradesh
117.22
Orissa_______
100.82
Rajasthan____
102.18
Uttar Pradesh__
10048___
Madhya
Pradesh
___________________________
104,24
% Shortfall*
of doctors
124.45
100.00
100.00
117.22
121.08
115:16
117.4 8
140.02
‘Vacancies plus shortages of posts against population norms
. Source: Rural Health Statistics 2000, Ministry of Health and Family Welfare
A key strategy in improving efficiency through the use of existing
resources is the institution of systems to ensure availability of
doctors and key paramedics in PHCs. State governments have initiated
several measures to contain absenteeism and to staff posts in remote
areas (Box 11.1). Mandatory rural service prior to PG admission and
210
u
devolving powers to local authorities to fill vacant posts of doctors on
contract appear to pay dividends
Box 11.1
State Government Initiatives
•
•
•
•
•
Maharashtra, Orissa, and Karnataka have legislated for mandatory rural
service for all doctors who qualify for PG courses for a period of one year in
identified remote PHCs, prior to PG admission. Those who are not in
government service are given contract appointments for a period of one year.
In Kerala, a certain number of PG seats have been reserved for allotment to
in-service doctors serving in identified difficult rural areas, without the
rigours of an entrance examination.
AP has constituted a separate Tribal Health Service for over 300 earmarked
posts with a 5-year bond period, a monthly incentive allowance of Rs 1500,
and three years of tribal service (as compared to Syears for others) being the
eligibility criterion for PG courses.
Walk-in interviews to fill up chronic vacancies have been attempted in MP and
Gujarat with limited success.
Several state governments have also opted for contractual services of doctors
for filling up chronic vacancies. In Kerala, this power has been devolved to
panchayats, and the earlier 419 vacancies have been effectively reduced to
around 80.
Certain state governments have
I
permitted private practice by PHC
doctors, in the hope that it will motivate them to reside in headquarters
and be available at the PHCs during working hours. The TN experience
has not been happy, with increased absences of doctors from the public
facility, as it is more lucrative to spend time treating patients privately
(18). In Kerala, while doctors are, by and large, available during working
hours (the consequence of a vigilant community), they do not stay in the
residential accommodation provided to them; neglect hospital and
fieldwork to some extent; and indulge in unethical practices such as
referring patients from public sector facilities to their private clinics. This
experience prompted the government to attempt withdrawing this facility.
However, due to pressure from the doctors’ lobby, private practice
continues (19). The situation at the secondary and tertiary level is
somewhat better across states, as doctors generally reside in urban areas
where these facilities are located, though private practice lures them away
form legitimate duties, very often during working hours, often in spite of a
ban. The issue of permitting private practice by public sector doctors has
never been resolved because of certain underlying dichotomies: why
should doctors be treated any differently from other government servants
and permitted the luxury of earning a private income? Can the objective of
public service and the profit motive of private practice co-exist without the
latter overwhelming the former? Attempting answers to these tricky
questions is fraught with complexities. However, given the experience so
far in different states, some practical options relating to private practice
are suggested :
211
H
♦♦♦ At the primary level, private practice must be permitted only in
identified remote PHCs in under-developed areas where private
sector doctors are also not available. The list of remote PHCs
should be updated regularly.
v Non-monetary incentives should be offered: a) an increase in
PG seats for in-service candidates who serve in rural areas up
to 50% of total seats; b) a percentage of PG seats allotted
without an entrance examination for doctors who serve in
earmarked remote PHCs; and c) training in foreign countries.
v Doctors who are certified by local authorities as staying at
headquarters in rural areas, where the ban is in force, may be
compensated through a special rural service allowance.
♦♦♦ For secondary and tertiary level of care, evening pay-clinics
may be permitted in hospitals, with a proportion of earnings
being paid back to doctors as non-practicing compensatory
allowance.
An effective vigilance mechanism, including members of the
government doctors’ associations and professional bodies,
must enforce the ban and check erring compatriots.
Legislation declaring primary health services in notified areas
areas as the
priority service of government, with attractive scales of pay, could also be
considered. Several state governments have also suggested the
institution of a three-year course for rural doctors, which has not met with
the approval of the MCI so far.
A transparent transfer policy providing for rotation of doctors on a regular
and impartial basis, rather than one that depends on political patronage,
will mitigate the problems of absenteeism, of remote facilities staffing and
indiscipline to some extent (Box 11.2).
Box 11.2
•
•
•
•
AR has formulated draft rules, prescribing a transfer of doctors every three
years.
Doctors are allowed to choose their places of posting from the locations
notified, in order of merit, based on the grading given through a performance
monitoring system.
The procedure for transfer, termed as ‘counseling’, is also transparent, with
the list of doctors and grades, and the available locations, publicly displayed.
Each doctor will be called in order of merit, and the transfer order handed
over to him on the spot, as per his choice, by a Committee comprising of the
Directors of tertiary, secondary and primary levels of care
The draft rules have been referred to a Cabinet Sub Committee on Health for
approval.
212
Ii
Shortages of specialists to staff secondary (Figure 11.3) and tertiary level
institutions in states have reached alarming proportions. The institution of
short-term diploma courses, to be recognized by state governments, for
the main specialities of anesthesia, obstetrics and gynecology and
pediatrics, must be seriously considered. Orissa has in 1999 instituted a
3-month course to train doctors in anesthesia, to staff first referral units;
obstetric emergencies can now be attended to in community health
centres. TN has instituted a camp approach for specialist care in rural
areas (Box 11.3) For the tertiary level, long-term planning to increase PG
course capacity to address the needs of the public and private sectors
must be instituted.
Figure 11.3
Percentage Vacant Posts in Public Facilities in Rural Areas
M--------—
-
---------------------------------------------
- --
>1
-■
FFl
igK
I
MO (PMCI
••MWMr -
La» T««h
r.KiaKiii
Specialists include physicians, surgeons, obstetricians and gynecologists, and pediatricians
Source: Rural Health Statistics, Ministry of Health and Family Welfare
_____________ Box 13.1_______________________________
TN has launched a novel health camp approach called ‘Varumun Kappom Thittam’, to bring
specialist care closer to people in rural areas. These camps, providing a range of specialist and
diagnostic services on a single day, are organized at subcentre level, usually in school
premises. Typically, each camp consists of specialists from the following disciplines: general
medicine, pediatrics, ophthalmology dentistry, ENY, cardiology, dermatology and indigenous
medicine. A range of diagnostic services is also conducted on the spot: blood and sputum test,
ultrasound and ECG. In about 1000 places, X-ray services are also offered. Drugs are distributed
free of cost in all camps. An additional budget of about Rs.10 crores has been released for these
camps. A total of 8500 camps, covering about 8.5 million people have been conducted across
the state during a 14-month period up to February 2001. More than 70% of the people treated
were below the poverty line. About 4% of the 8.5 million people were identified for further
referral care. Of these, 24% actually availed of care. Some officials argue that the camp
approach is ‘an acceptance of the failure of the existing system’. Policymakers are divided about
the continuance of the camp approach for specialist care, with many considering it not
sustainable.
213
iJ
The flexibility of contractual appointments must be extended to cover
critical peripheral paramedical staff. Orissa has allowed for such
contractual apoointments through the District Health Committees. A
transparent transfer policy and incentives to reward good performance
must equally apply to these cadres. In fact, the policy for posting of ANMs
and male health workers should be that they are, as far as possible,
accommodated at the place of their choice/residence. TN has instituted a
reward system to address specific high-priority issues: a gold sovereign is
presented to every ANM in whose jurisdiction no infant death is reported.
One of the weakest links in the public health system chain is the
supervisory cadre, and particularly, the cadre between the PHC doctor
and the ANM, which is seen by most states as unproductive. No state,
however, has specifically addressed this issue. The need is for this cadre
to be rationalized: unnecessary posts must be suppressed; roles and
responsibilities of those considered necessary must be redefined, their
capacities rebuilt; and monitoring and evaluation systems holding them
accountable for specific outcomes must be instituted.
The perennial problem in all states is of clinicians holding administrative
posts, with inadequate administrative experience, and public health posts
without public health specialization. Kerala has recently initiated a
process whereby the cadre of doctors will be categorized as i) an
administrative cadre, consisting of doctors without speciality training, who
will be trained in public administration and hospital management, ii) a
public health specialist cadre, with public health as the speciality and Hi)
different cadres of specialities. Doctors will have to opt for categories and
will be promoted only in these posts. Senior administrative positions will
be staffed only from administrative cadre; the District Medical Officer and
Director Health Services by public health specialists. This initiative, which
addresses issues of management and leadership, is commended for
replication in other states.
While several initiatives have been taken for effective management of
human resources, certain systemic issues that contribute to low morale
and uncommitted staff remain unresolved across states and need to be
dealt with on a priority basis. These include low levels of remuneration;
promotion based on seniority not on merit; some cadres (particularly
supervisory) considered unproductive; failure to supervise and monitor
field performance effectively; failure to punish poor performance and
reward good performance.
Drug Procurement and Distribution Systems
Several surveys on consumer perceptions of public health services reveal
two major lacunae: non-availability of doctors and non-supply of drugs.
214
I
Drug costs and shortages are perennial problems, and optimal use of
budgets for drugs is imperative (Box 11.4).
c
&
Box 11.4
TN’s Centralized Drugs Procurement and Distribution System: A Model for
Improved Efficiencies
•
•
•
•
•
•
•
•
An essential list of drugs is drawn up by a panel of experts, subject to
periodic review.
Drugs are procured centrally through the TN Medical Services Corporation,
following strict procedures for pre-qualification, contracting and quality
checks; all drugs are strip-packed and procured from manufacturing firms
with GMP certificates and a minimum turnover of Rs 10 crores.
Samples from every consignment are tested in reputed laboratories through a
computerized number-based system and drugs distributed through district
warehouses.
A pass book system gives the head of the facility flexibility to lift the drugs
he requires from district stores.
10% of untied funds are released to PHCs and secondary and tertiary
hospitals for emergent needs.
Rational prescription of drugs is promoted through extensive training
programmes and monitoring of drug prescriptions.
Most importantly, TN allocates over Rs.100 crores towards drug supplies (far
higher than allocations made by other states).
The results: expenditure on non-essential drugs has been reduced and funds
released for essential and vital drugs; availability of quality drugs in over
2000 institutions in the state at reduced costs has improved dramatically; the
Corporation has financed a range of diagnostic equipment for public hospitals
in the state from savings generated through systems improvement.
J-
1
•I
4
Central procurement systems for supply in kind under the centrally
sponsored schemes need a similar overhaul as they are plagued with
delays, resulting in stock-outs at crucial time periods. The centre has
offered that states take over procurement and distribution functions under
the RCH Programme, but there is reluctance in every state (except TN) to
take over a task seen as troublesome and politically sensitive. It appears
feasible for the centre to keep the option for state procurement open, and
continuing to supply in kind wherever required.
Healthcare Delivery Systems for Disadvantaged Groups
>
4
kJ-
Ensuring access of healthcare services to disadvantaged groups is
integral to the effective and efficient functioning of a healthcare system.
Systems must be instituted to provide healthcare to the tribal and remote
regions of states, the availability of health facilities in such areas mapped
and the deficiencies made good. Outreach services provided through
public health facilities also suffers: an ANM required to walk up to 10 kms
is less likely to provide outreach services in such habitations. A key
strategy for such areas would be mobile health units as has been
attempted in Orissa. The appointment of CHWs in tribal areas, selected
from the habitation by the community, trained, and paid from state coffers
215
%
u
as has been done in AP is considered an effective strategy, and is
commended for replication.
The delivery of primary healthcare to the urban slum population is another
area of comparative neglect. Apart from scattered urban dispensaries and
family welfare centres, there is no formal system/infrastructure for
delivery of primary healthcare in urban areas. Cost effective interventions
can be made through the infrastructure and manpower already established
in the private sector. West Bengal, Karnataka and AP have instituted
effective public-private partnerships to address the health needs of the
urban poor. The management of the urban health project in Kolkata, West
Bengal, is through the local body. Services of doctors for basic and
specialist care are contracted from the private sector. AP has contracted
out the management of 192 urban health posts in 73 municipalities to
NGOs, who contract private sector medical and paramedical services.
Decentralization
a) Devolution of powers to local bodies:
Of the 8 states studied, all have attempted decentralization in one form or
the other, except TN. Kerala, Maharashtra, MP and UP have devolved
administrative and financial powers at the primary level to local bodies.
Rajasthan has devolved certain administrative and supervisory powers to
local bodies, but not financial powers. AP has chosen the mechanism of
the registered society at the facility level to promote stakeholder
participation, and Orissa the route of a District Health Society. The latter
states and TN have not handed over control of health institutions to
panchayats, possibly due to strong resistance from staff, and a perception
that more inequities could result due to control by different political
parties or local elite. The fact is that decentralization, without sufficient
preparation of local bodies to take on this expanded role, could have
conflicting results. In Kerala, where the decentralization initiative has
been relatively successful, local bodies and the people were prepared
through a six-phase programme of capacity building, over a period of one
and a half years (Box 11.5). The Kerala experience indicates that
decentralization has to be preceded by a long period of planning, defining
and clarifying responsibilities, capacity building and advocacy.
216
11
Box 11.5
The Kerala Experience of Decentralization
Six-phase programme of capacity building:
• First phase: intensive advocacy among people through Gram Sabhas
• Second phase: training elected reoresentatives through seminars over a
period of 3 days
• Third phase: forming and training task forces at local level to prepare
projects
• Fourth phase: formulating grassroot level plans by panchayats
• Fifth phase: preparing plans for block and district levels
• Sixth phase: plan appraisal by voluntary technical groups
• Results: Only after these painstaking efforts did devolution of powers take
place: management of all but 18 of 1300 institutions under the Directorate of
Health have been handed over to local bodies. 37% of the state development
budget was given to panchayats as untied funds on condition that 40% be
used in the productive sector. Many panchayats have focused on preventive
measures -- sanitation, garbage disposal, mosquito control and improvements
to primary healthcare facilities. With the involvement of doctors in planning, a
better working relationship is developing among doctors, health workers,
local body functionaries and the people.
MP has launched a similar decentralization programme. The policy
instruments of decentralization are 1) Gram Swaraj through a Health
Committee of stakeholders for direct community action on health,
including action on determinants like safe drinking water and sanitation.
2) Panchayat Raj which provides the framework for inter-sectoral action at
the panchayat level, and 3) District Govt, with an inter-sectoral mandate
for planning and action, prioritization and deployment of funds. The
government has also enunciated the Swasthya Jeevana Seva Guarantee
Yojana, which aims at establishing a system through which community
participation in the management of health services and improved
utilization of resources and facilities is ensured (Box 11.6).
Box 11.6
A people’s survey on health was conducted across the state in each of the 51,806
villages during February, 2001 and information gathered on the current status of
health provision, diseases and key determinants of health. This information is
the basis for formulation of the Village Level Health Plan.
These plans are
a99regated at the district level to form the district level plan. The Gram Sabha of
each village is given responsibility to constitute a Health Committee of
stakeholders to implement this plan at village level. This Committee will have a
minimum of 12 members of which 50% will belong to SCs, STs and OBCs and 33%
will be women members. The scheme envisages the provision of a core set of
services within a specified timeframe, which includes one trained Jana Swasthya
Rakshak in every village by June, 2002, one trained birth attendant in every
village, immunization and antenatal care, safe drinking water and sanitation and
nutrition cover for infants, children less than 3, and pregnant/lactating mothers.
The District Level Committee will execute the district level health action plan.
This Committee will have both an advisory group and an implementing group.
With the 73rd and 74,h constitutional amendments, the wheel has been
set in motion, and it appears to be only a matter of time before states
will, like Kerala and Maharashtra, devolve powers, both administrative
and financial, to local bodies. Experience in recent times in India has
shown that such devolution has had the salutary effect of encouraging
local bodies to consider health as integral to other development activities
and has greatly facilitated coordinated action on other determinants of
health like water and sanitation. Experience has also shown that capacity
building, of local bodies as well as the community, is an essential
prerequisite to reap the full benefits of decentralization.
b) Institutional Autonomy:
Delegation of administrative and financial powers to facility-level, to
promote efficiency, accountability, mobilization of resources and a
sense of ownership, has been attempted in several states with some
degree of success, and is recommended for replication. The state
governments of Kerala, MP, AP and Rajasthan have instituted systems to
facilitate hospital autonomy through the formation of societies /
committees at the hospital level. Kerala is one of the earliest proponents,
with the setting up of Hospital Development Committees in major public
hospitals in the early eighties. Members include representatives of
political parties, stakeholder groups in the locality, with a senior
administrator of the district as the chairman. These committees have been
authorized to collect parking fees, visitors’ fees, and user fees for
diagnostics, and retain the amounts for the development of the facility.
The major public hospitals have collected a reasonably good amount, an
example being the Trivandrum Medical College Hospital, which collected
nearly 10% of its total running costs, including salaries. AP has
constituted Hospital Development Societies for tertiary and district
hospitals with the district Collector as the chairman, Committees for sub
district secondary hospitals chaired by the local MLA, and Committees for
primary health centers chaired by the local body president. Apart from
fees as in the Kerala initiative, building maintenance grants, earlier with
the Public Works Department, are now released to these societies /
committees. Additionally, the State has prescribed fees for 1) internship
transfer from private medical colleges to government colleges, 2) clinical
attachment of private dental college students and 3) clinical attachment of
para-medical students in Govt, institutions (all free hitherto) and permitted
retention at the facility level. They have been authorized to charge user
fees and exemptions for the poor are left to their discretion. Rajasthan
has constituted Medical Relief Societies (MRS), functioning currently in 72
hospitals in the state. The state disbursed Rs.40 million as seed money to
these societies in 1995. A study (20) conducted in 1999 revealed that
revenues generated, on an average, account for 10-15% of the hospitals’
recurring budgets. In Jaipur's SMS hospital, it has touched a high of 26%.
An innovative source of finance that has been established by many
societies is the Lifeline Fluid Stores (LLFS) (Box 11.7).
218
Box 11.7
An LLFS is a pharmacy that operates within the premises of the public
hospital. A committee of doctors decides on the drugs and supplies that will
be stored. The decision is based on information regarding demand for the
product, the quality of the product, the market price, and the price at which
the wholesale supplier is willing to supply. The committee fixes the selling
price, after adding a reasonable percentage towards service charges. The
supplier manages the pharmacy, and he is expected to maintain supplies at
his own risk. The pharmacy pays a fixed amount to the hospital society
towards use of the premises. The prices charged at the LLFS are substantially
lower than the market. In 1996-97, the LLFS in Jaipur’s SMS Hospital sold
fluids and surgical items for Rs. 8.1 million, and the market rate of the same
supplies was Rs.16.6 million. The LLFS thus provided a relief of Rs. 8.5 million
to patients during the year. The hospital earned 0.6 million.
Exemptions are in place for the poor and procedures to decide
exemptions are discretionary and informal - based on casual questioning
and visible signs of poverty. The government has recently issued
Medicare Relief Cards to families below the poverty line, who are entitled
to free treatment. The percentage of population who has received these
cards is reported to be around 30%. Targeting the poor however remains
a contentious issue (in AR, 80% of the families hold the white card for
supply of subsidized rice), and has invariably resulted in either the
ineligible being included for subsidies or the eligible being excluded. MP
appears to have found a feasible solution (Box 11.8).
Box 11.8
The Rogi Kalyan Samlthi Initiative of MP has received widespread acclaim. A
project for cleaning and refurbishing the Maharishi Yashwant Rao Hospital at
ndore progressed into the constitution of a Rogi Kalyana Samithi
(Patient’s
Welfare Society) with private citizens’ participation in hospital management. The
Committee consists of people’s representatives, health and local district
officials, and major donors. The Rogi Kalyan Samithi levies user charges. The
charges for the general wards are nominal while those for patients in private
wards are not more than 50% of the rates in the private sector. Exemptions for
the poor are given based on self-declaration on a simple printed form. Contrary
to all expectation, the percentage of people who have used the self-declaration
facility is only around 2%. Given the success of this venture, the State has
established RKSs in 604 hospitals and health centers across the MP. More than
6,000 people are involved in running and managing health centers and hospitals
!nn^RAS-;3’7 CAr.°[eS haS been co,,ected through user charges and donations since
1996-97.
Although it faces teething problems, RKS has opened up the
management of health delivery systems to people and has created a sense of
ownership amongst citizens.
As public health institutions become more autonomous, there is need to
guard against the danger of fragmentation of service delivery, which has
negative consequences for effective referral services. Such fragmentation
can be avoided if the referral hospital is held responsible for overseeing
and managing lower level facilities within its catchment area.
219
One of the main objectives of the institutional autonomy initiative has
been the local mobilization of resources through user fees. Unfortunately,
this initiative is being promoted' as an instrument of fiscal policy, rather
than as an instrument of health policy: the aim of user fees should be
more to facilitate efficiency, equiry
<
and accountability than to raise
revenue. There are as yet no evidence-based studiesj on the impact of
user fees on improved efficiency and quality, or public sector support to
the poor.
Based on the experience of states, we highlight certain issues that need
to be addressed in relation to user fees:
❖ In Rajasthan and AP, hospital committees have been authorized
to collect user fees, set rates and decide exemptions. Some
hospitals are not charging user fees yet and users, therefore,
may not be able to distinguish between official and unofficial
fees. A clear government position becomes important.
❖ The exemption policy for the ooor must be clearly enunciated by
government. In addition to BPL cards, self-declaration appears
to be a reasonable and practical procedure.
❖ Rates and exemption procedures should be widely publicized,
and display boards put up in prominent locations in the facility.
❖ If an effective referral system is to be promoted, user charges
should be graded, with higher charges for similar services, at
the tertiary level.
❖ User fees should not be used as a replacement of regular
budgets.
❖ User fees should be evaluated to obtain quick feedback
regarding its impact on efficiency and equity objectives, and in
particular, its impact on utilization patterns by the poor and
disadvantaged groups.
Accountability
Accountability is not seriously pursued in most states despite lip service
paid to the importance of this objective, perhaps because of the
complexities involved: public servants are accountable to a host of
stakeholders, the rich and the powerful, the poor and the voiceless and
the criteria by which they are judged differ with the interest of each group.
Moreover, in
the absence of assured funding
and
supportive
infrastructure, systems designed to hold providers accountable to
performance parametres, tend to falter. But there is no doubt that despite
these complexities, setting standards for healthcare provision,
developing transparent and objective systems for monitoring
performance, and facilitating local controls hold the key to
improvement of the state’s health service delivery. AP has attempted
220
4
a performance monitoring assessment system for all the directorates
functioning under it, with output measures, based on which each
institution is given marks and graded. (See Annex 11.5 for the framework
of this system.) An attempt has been made to link performance to
individual career advancement through the issue of government orders
that the performance grade of facilities will be attached to the confidential
rolls of doctors. TN has set up a system of monitoring for PHCs under the
DANIDA-TNAHCP initiative, but the system does not grade performance
as in the AP case. Every state must institute performance monitoring and
grading systems for all directorates and all levels of care.
Independent evaluation of programmes and service delivery to assess
their utility and effectiveness in addressing goals and objectives, is a
key to improved performance and accountability. Reported figures of
immunization by state departments and the coverage levels reported
through the NFHS point to the need and criticality of independent
evaluation as a tool for assessing performance (Table 11.13).
Table 11.13
Reported Figures of Immunization, State Figures and NHFS 2
State
Full Immunization Coverage
% Ante-natal care
State data
NFHS2
State data
NFHS2
Kerala
W9~..
~80
“92
99
Maharastra
ioi
”78
“95"
90
Tamilnadu
102
‘ 89
“94
103
__
”59
“99~“
”44
“ 86
"80
”17
"62"
48
Andhra Pradesh
Orissa
Rajasthan
Madhya Pradesh
69
”22“
..
99
93
61
Source: State Government Reports NFHS -2
Several states have used NFHS findings to highlight over-reporting by the
department. Similarly, the RCH facility and household surveys, initiated by
the centre, have proved an excellent management tool for improved
performance. This initiative needs to be expanded to cover other
programmes in the health sector. The centre’s role in supporting states for
effective monitoring and evaluation systems to assess service coverage
and health outcomes is paramount.
The need to relate health systems performance to health outcomes, and
not merely to service outputs, is also critical to improved performance.
The issue of vital registration of births and deaths is too important not to
merit at least a passing mention. If all births and deaths were recorded,
reliable data on birth rates and cause of deaths would be available at the
221
11
district and sub-district level, so essential for policy and priority
setting in the health sector. In most states, registration of these
events vests with the revenue or panchayat raj department. The need to
activate systems to ensure full recording of vital events cannot be over
emphasized.
Simultaneously, it is imperative that the state institute systems for
public disclosure on issues relating to health systems performance,
both public and private, to increase awareness levels, to promote
health-seeking behaviour and to facilitate public action that will
motivate the system to perform optimally. It is also necessary that a
patient’s charter of rights be adopted in public health facilities in a
phased manner. Certain central government hospitals in New Delhi have
adopted a citizen’s charter of rights on a pilot basis to provide access
without discrimination and to ensure citizen's grievances are redressed.
Quality
Quality is a function of two factors: a) the quality of facilities or physical
standards and b) the quality of service (which includes clinical standards
and quality assurance systems). The recommendations relating to
legislation for minimum standards relating to private healthcare apply
equally to the public health sector.
Quality improvements (QI) are difficult to motivate in the public sector,
given the systemic deficiencies in ensuring accountability, rewarding good
performance and disciplining poor performers. The cost of poor quality
service in the private sector spells loss of business; the cost of poor
quality in the public sector spells no loss to its providers. There is need
therefore
to
link
quality
performance
with
personal
incentives/disincentives and job retention. This will require, in the first
instance, measuring of quality parametres, and an appropriate monitoring
mechanism.
In terms of measuring quality of care parametres, the National Family
Health Survey of 1998-99 has made a beginning, in respect of the RCH
Programme. Table 11.14 presents certain findings on the quality of care
for family planning services. The findings again indicate that the level of
patient satisfaction, on an average, appears to be higher in the better
performing states. These findings comprise an important pointer to the
level of public satisfaction within each state, and should motivate
remedial action.
222
Ii
Table 11.14_______________________
Quality of Care Indicators for FaciJiity Visits
State
% who said
% who said
% who said
Median
% who rated
staff spent I staff talked
waiting
staff
facility as
to them
time
enough time
respected
very clean
with them
nicely
their need for
privacy
Group A: Under-fiye mortality > 65
Kerala
29.8
95.2
98.1
96.5
88.1
Maharastra
14.9
84'6
97.7
94.2
83.2
Tamilnadu
29.7
83.1
93.5
85.8
79.4
Group B: Under-five mortality > 65 to < 100
West Bengal
29.8
84.8
l_ 63.7
24.4
54.9
Karnataka____
29.4
95.1
75.8
89.0
70.2
Punjab_______
14.4
98-1
J95
84.0
64.4
Haryana______
14,6
99.0
78.4
87.6
67.9
Gujarat_______
13.0
98.1_
_93.2
91.9
90.0
Andhra Pradesh
29.4
97.1
69.3'
84.4
68.2
Group C: Under-five mortality >100
Orissa________
19.2
90.8
62.9
57.0
46.8
Bihar_________
29.1
90.6
70.5
66.4
76.7
Rajasthan_____
9.5
96.0
45,9
85.8
39.3
Uttar Pradesh
24.9
54.([
95.5
69.9
51.3
Madhya Pradesh
19.4
94.7
65.9
71.4
57.1
Source: NFHS 2
State experiences in improving quality of care in public health institutions
are limited. Some states, which are implementing the World Bank-aided
First Referral Health Systems Projects, have initiated quality improvement
(QI) actions through the formation of QI Circles/Cells in the secondary
hospitals, the formulation of standard treatment guidelines and protocols
and instituting patient satisfaction surveys. Based on state experiences,
certain options are suggested to facilitate improvements in QOC:
❖ Institutionalize QI by establishing a) Quality Control Cells at
Directorate level to set standards for structure, process (prepare
detailed guidelines and protocols for treatment and referrals for
each service at each level) and outcome, b)Quality Control Circles
at each facility, identifying local teams and training them in QI
approaches and techniques, c) Quality Assurance Mechanisms
(clients’ charter of rights, complaints redressal mechanismsjand d)
instituting effective MIS for a two-way communication and utilization
of QOC evaluation results
❖ Provide the required logistical support
❖ Design methodology for assessing quality against the standards. For
example, develop supervisory check-lists, on the job supervision,
assess client records, patient flow analysis, use NFHS and other
survey findings,
institute
rapid surveys, OR,
focus group
discussions, to name a few
223
u
❖ Involve the community through the local bodies/women
groups to assist in QI and to ensure accountability
❖ Reward good facilities and effective QI actions
health
Convergence and Inter-sectoral Coordination
Systems to ensure inter-sectoral coordination for access to safe drinking
water, sanitation and a clean environment are critical to improvements in
health outcomes. In MP, for example, the Rajiv Gandhi Mission on Control
of Diarrheal Diseases has been implemented through the departments of
health, public health engineering and panchayat raj, as well as NGOs.
State experiences indicate that coordination arrangements need to be
institutionalized through the establishment of Cabinet Sub-Committees
and inter-departmental official committees at state and district levels with
clear mandates, authority and funds to take action. Devolving powers and
functions to panchayat raj institutions, for activities related to water
supply and drainage, for example, will address the problem of
compartmentalization at the implementation level.
Community Participation
A key strategy to improving health systems performance is community
involvement. AP’s initiative in institutionalizing community participation
through Advisory Committees at the PHC and sub-centre level - involving
not merely local bodies but women's and self-help groups representatives
- is worth replicating. Similarly, the MP experiment with the Village Health
Committees, carrying a fair representation of women and disadvantaged
communities, could be emulated. Additionally, in order to ensure
community participation, MP has legislated the Gram Sabha Act, which
mandates that a Gram Sabha should be established in every village for
community participation and local controls. Several states have a fairly
large spread of women's groups and, if nurtured, these groups can
facilitate community participation in health planning and health services
delivery, reduce gender disparities in accessing health services, alleviate
poverty and consequently, improve health.
Political commitment
Social reform movements, leading to the political assertion of
underprivileged caste groups, have created an environment of progressive
change and development, and facilitated equal access to social
opportunities in Kerala, TN, Maharashtra and West Bengal, all states with
better health outcomes. The experience in these states points to the
importance of political leadership, political initiative and public
action in bringing about transformation and ensuring that social
opportunities are within the reach of all, regardless of class or caste.
224
u
It is political leadership that has ensured substantive investments in
health and education in Kerala. Amartya Sen argues that determined
public action can ensure that “a region need not be imprisoned in the
fixity of history’ (21). The Malabar region, transferred from the Raj, was
very much behind Travancore and Cochin in terms of literacy, mortality
and life expectancy. But the initiative of successive governments, both
Communist and Congress, ensured that Malabar caught up with the rest of
Kerala. This offers a lesson on what can be done by determined political
and public action, even without favourable historical circumstances.
This again bears out our hypothesis that one of the most significant and
critical determinants of improved health status is the response of
governments and political leadership to the health needs of its
people. Implicit to the response of governments is the reach and
functioning of the public health services. The recent experiences
described in this chapter provide evidence that there is the awakening of
a determined response in many states, a response that holds out hope for
increased commitment to health sector reform and improved performance
of health systems.
Conclusion
While giving an <overview of' the
'
performance of the public healthcare
system in India and major states, we have asked why certain states have
performed better, while others appear to have failed. Having asked the
question, we have attempted to isolate and highlight those factors that
have led to improved health outcomes as a direction for reform. We have
also attempted to highlight recent initiatives in states that can be
replicated
for improved
performance of public
health
systems.
Generalization
of factors that will
improve
health
systems
performance, no doubt, have to be tempered with the knowledge that
there can be no prescriptive models or their uniform applicability for
all of India. The experiences and strategies presented in this chapter
must be carefully matched and tailored to address the problems
obtaining in and within regions of states, bearing in mind the
political and institutional environment, and the underlying principle
for success: widespread support from stakeholders.
225
1i
Notes :
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
M. Roemer, National Health Systems of the World, vol I, OUP, Oxford, 1991.
(i) Andhra Pradesh - Chatterjee, Rachel (2001), Health Systems in Andhra Pradesh
(ii) Orissa - Gupta, Meena (2001) Health Systems in Orissa
(iii) Maharashtra - Duggal, Ravi, (2001), Heaitn Systems in Maharashtra, CEHAT, Mumbai
(iv) Madhya Pradesh - Dixit, Sandeep (2001). Health Systems in Madhya Pradesh, SANKET,
Bhopal
(v) Rajasthan - Gupta, S.D. (2001), Health Systems in Rajasthan, IIHMR, Jaipur
(vi) Kerala - Vijaychandaran, V. (2001), Heaftn Empowerment of the People : The Kerala
Experience
(vii) Tamil Nadu - Muraleedharan, V. R. (2001). Public Healthcare System in Tamil Nadu: A Critical
Overview of its Strengths and Weaknesses. I IM, Chennai
(viii) Uttar Pradesh - Srivastava, V. K. (2001). Health Systems in Uttar Pradesh, King George's
College, Lucknow
The Economic Development Institute of the World Bank (EDI). Diagnostic Approaches to Assessing
Strengths, Weaknesses and Changes of Health Systems, 1997.
An acronym, which in Hindi means ‘sick’, constructed with the initial letters of the states in category
C (except Orissa), by Professor Ashish Bose, institute of Economic Growth, New Delhi.
Census 2001.
NFHS2.
Jean Dreze, Haris Gazdar, Uttar Pradesh: The Burden of Inertia, UNU, IDER, OUP, Delhi, 1997
A structure with walls and roof made of pucca or relatively “permanent" material such as cement,
concrete, oven-burnt bricks, stones, stone biocxs, jackboard, tiles, timber, galvanized tar, corrugated
iron sheets and asbestos sheets.
A structure with walls and roof made of non-pucca material such as, unburnt bricks, bamboo, mud.
grass, leaves, reeds and thatch.
V. Selvaraju, V.B. Annigeri, Trends in Public Spending on Health in India, 2001. The 11 states are
Andhra Pradesh, Gujarat, Haryana, Kerala. Maharashtra, Madhya Pradesh, Orissa, Rajasthan,
Tamiladu, Uttar Pradesh and West Bengal.
Ibid.
The analysis does not significantly underestimate health spending by not considering capital
expenditure, as annualised capital expenditure accounts for less than 10% of the revenue
expenditure.
V.R. Muraleedharan, Public Healthcare System in Tamilnadu: A Critical Overview of its Strengths
and Weaknesses, IIT, Madras, 2001.
A Health Sector Analyst, Project Planner. Health Economist, Social Development Analyst,
Infrastructure Development Planner, Materials and Operations Planner, and an Adviser, Health
Reforms.
Impact and Expenditure Review, Health Sector, Andhra Pradesh, DFID Health Systems Resource
Centre, 2001.
Ibid.
Selvaraju and Annigeri, 2001.
Harvard University, Health Sector Reform in Tamilnadu: Understanding the Role of the Public
Sector, 2001.
Vijaychandran, Health Empowerment of the People: The Kerala Experience, 2001.
S. Sharma and D. Hotchkiss, Developing Financial Autonomy in Public Hospitals in India:
Rajasthan’s Model, 2000.
Amartya Sen, Radical Needs and Moderate Reforms, Indian Development: Selected Regional
Perspectives, UNU/WIDER, 1996.
226
i1
Annex 11.1
Organogram of the Departmental Health and Family Welfare
Minister
Pnncipal Secretary
Secretary Health
Director Mdeceai Education
Tertiary Hospitals
Medical Colleges
J
Director Secondary Hospitals |
Distnct Level
Secondary Hospitals
Director Health
Distnct Level Pnmary
,
Careinstitutions upto PHC -
Director. ISM
All ISM Institutions
Commissionar ramify welfare »—■
Subcentres
j
Directo' IPM
Food adulteration /
Water Testing
Preventive Medicine Units
DG.DCA
All Drugs Control
Units
PD, Aids Control
Aids Control Socities
Director. IMS
All ESI units
Abbreviations:
ISM : Indian Systems of Medicine
IPM: Institute of Preventive Medicine
IMS: Insurance Medical Services
DCA: Drugs Control Administration
PD: Project Director
227
u
Annex 11.2
Proposed Administrative Structure
Policy, Planning
State Secretariat
Monitoring, &
Evaluation
University Health
Sciences *
S
T
A
Strategic Planning Cell
J▼
State. Trq. Inst
Director General,
Medical &
Health Services
T
E
L
Surveillance Svstems
+----
ISM
E
V
▼
Mnnitnrinn A Pvaluatinn
E
L
:
H RD Cell
R
E
G
I
O
N
A
L
Director Tertiary
Hospitals
Director Pnmary and Secondary Health
Services
Tertiary Hospital
Medical College
Director (Regional) (Advised
by a Regional Committee)
I
L
E
V
Reql. Trq. Inst
E
District Health
CnmmittftA
L
Director Family Welfare
District Chief Medical &
Add. DM&HO
Dt. TB Officer
Dt. Malaria Officer
Dt. Leprosy Officer
Dt. Blindness OfficeDt. Epidemiologist
Dist. Training Inst.
Health Officer
Suoerintendent District Hosoital
D
I
S
T
R
I
C
T
L
E
V
E
L
Divisional Health
Committee
Health >
Committee
* This is optional,
depending on the
Divisional Medical & Health
Officer
Sub>district Secondary Hospital
>
>
Health
Committee
PHC
4
>
First
Referral
4
Health
Committee
Sub Centre
number of medical
education institutions.
Leprosy
Unit
Village Health Committee
Community Health Worner
228
h
Annex 11.3
Public Expenditure on Health
Flow of Funds from Centre to State
Government of India
<
Donors
National Planning
Commission (Plan)
Consolidated Fund
(Non Plan)
Locally Raised
Revenue Taxes etc.,
>
State Government of
Andhra Pradesh
<
District
Municipalities
Public Expenditure
on Health
Ad Hoc Funds
for MPs, MLAs
User Fee Collections at
Government Facilities
Key
Reflected in Budget
Estimates
■*“
Outside budget
Source: DFID Health Systems Resource Centre, March 2001
229
1
Annex 11.4
Flow of Funds in Andhra Pradesh Health Sector
*
Budget Approval by state
legislature
_________ i________
Budget Approval by state legislature
_______________ ▼_______________
Finance Department gives concurrence
_________ i_________
Sanction Order bv Medical & Health Deoartment
___________i_______________
Directorate of Treasury & Accounts
Letter of Credit from Pay & Accounts officer which again goes back to
Finance Department
APWP Bank A/C
Cheque from Finance Department
Secretary Finance will clear the Cheque
Commissionarate / Governing Council will approve and in the
absence of governing council Commissioner will approve.
Money will be drawn from Public Departments A/Cs
i
Finally A/C debited to Government of A.P.
i
Detailed Head wise figures brought by the Commissioner/
Governing Committee
________________________ ▼_____________
Finance Officer releases to all the Institutions through district
coordinator of Health Services
Source: DFID Health Systems Resource Centre, March 2001
230
i
Level
Annex 11.5
______ Performance Monitoring Framework
Objectives
Output/Performance Indicators
Performance
Against Criteria
APWP
(Secondary
Hospitals)
Provision of
hospital
services
according to
guidelines on
range of
services and
level of
services
a) Output Measures
1. General Services : outpatient,
inpatient, bed
occupancy
2. Emergency Services : emergency OP,
Emergency IP, emergency major and
minor operations
3. Clinical Services : major/minor
operations ,
tubectomies and deliveries
4. Diagnostic Services : X rays , ECG ,
lab tests, USG
monthly reporting
against criteria
with grading
system
Tertiary
hospitals
Same as for
secondary
level
(b) Quality
results of quality
satisfaction
survey
Output indicators
agreed, but noncompliance from
hospitals to date
Provision of
medical
education as
per norms and
standards
fixed by
Medical
Council of
India
Medical
Education
PHC
Primary
Output measures same as for secondary
hospitals, but speciality-wise
Indicators agreed for asst., associate and
professors: no. of classes per month,
CME hours per month,
national/intemational papers published
per month
Provision of
a)Output measures relate to general
preventive and
services (OP),diagnostic services (lab
limited curative
tests),national control programmes
services and
(sterilisation, deliveries, ANC registration,
effective
full immunisations)and specific
implementation of communicable diseases (GE/malaria
vertical
deaths)
programmes.
b) Quality
monthly reporting
against criteria
with grading
system
quality surveys
under
consideration
231
u
12
Health Finance
Introduction (1)
Poor public health expenditures remain the predominant cause of the
unsatisfactory performance of the health system, though serious deficiencies
in efficient utilization of available resources also contribute substantially to
poor health outcomes. The declared policy, for the State to provide free
universal healthcare to the entire population, is totally divorced from ground
realities. India has one of the highest levels of private financing (87%), and
out-of-pocket expenses, estimated to be as high as 84.6% (2), dominate.
Only Cambodia, the Democratic Republic of Congo, Georgia, Myanmar and
Sierra Leone show a higher proportion of private financing (3). Out-of-pocket
payments, the most regressive method of financing health care, aggravates
poverty. It is impossible to make a dent on poverty alleviation without
addressing this link between the highly skewed pattern of health finance and
the perpetuation of poverty. The need for an appropriate health finance
framework to improve the health system, give the poor financial risk
protection against costs of serious illness, and shield them against the
double jeopardy of catastrophic illness and financial ruin cannot be
overemphasized.
Over a quarter of the population is reportedly below the official poverty line
(4), and those with the lowest incomes are generally in the worst of health
and have a greater need for health services. They also depend on manual
labour, and ill health directly affects their income. Illness then means
borrowing from private moneylenders at usurious interest rates; one serious
illness episode can lead to pauperization and indebtedness for generations.
A recent analysis by the World Bank concludes, “the hospitalized Indian
spends more than half of his total annual expenditures on buying health
care; more than 40% of hospitalized people borrow money or sell assets as
to cover expenses and 35% fall below the poverty line.” Out-of-pocket
medical costs alone may push 2.2% of the population below the poverty line
in one year (5).
Objectives of the Health Finance System
The ultimate objective of a healthcare delivery service, to quote the famous
words of Aneurin Bevan, is that the “rich and the poor are treated alike, that
poverty is not a disability, and wealth is not advantaged.”(6) It is the duty of
the State to provide access to universal healthcare and to ensure that no one
is denied healthcare, because of inability to pay, by providing some risk
protection to the poor against the costs of serious illness. The most efficient
way of providing this protection is to pool the risk between rich and poor,
young and old, and employed and unemployed, to enable cross
subsidization. The main instrument for achieving this objective is health
insurance (7), because illness cannot be predicted; hospitalization costs are
232
u
lumpy and cannot be planned; and the proportion of the sick requiring
hospitalization in any large population is small, permitting risk pooling.
Thus at a small cost, health insurance cover is possible for at least
hospitalization costs. Cross subsidization is not only vertical but' also
horizontal: the healthy pay for the illness costs of the sick in the same group.
Despite its desirability, health insurance may not be administratively feasible
in all situations, particularly for those in the informal sector and living in
remote areas. Hence, along with insurance, the State has to provide
healthcare services to all those who cannot pay. The State has almost
exclusive responsibility for providing public goods, which are invariably
neglected, even by those who can afford them. Even where insurance cover
is feasible, the State has to provide the legal and regulatory framework to
maximize benefits and minimize costs. Also, not every category of insurance
can be self-financing. The State then has to provide the necessary incentives
and subsidies for the coverage of the poor and the sick. Finally, mobilization
of resources for health should be fair. The access to health services should,
thus, depend upon individual need, and not on financial status.
The financing strategy has to be country specifc, depending on per capita
income, size of the formal sector, poverty levels and administrative capacity
(8). On account of its diverse socio-economic conditions and health
outcomes, India's health financing strategy needs to be state-specific, even
while following the broad framework of the national strategy.
Health Sector Spending Levels and Trends
In the absence of a systematic compilation of national health accounts, and
the adoption of differing classifications, expenditures have been variously
estimated. The latest study by the World Bank estimates that India spent
approximately 4.5% of GDP, or about $18 per capita on health in 1996,
below the average of 5.6% for low and middle income countries (9). India's
public health expenditure is estimated at 0.9% of GDP, well below the
average of 2.8% for low and middle income countries, and the global average
of 5.5% (10). Total health spending by the public sector in 1998-99 was
Rs.161 billion, or the equivalent of Rs.165 per capita (US$ 3.9 or Rs.97 at
93-94 constant prices) (11).
Selvaraju et al (12) have independently analyzed the trends in the health
expenditures of the centre and 16 major states for this Report (Figurel2.1).
(See Annex 12.1 for proportion of health expenditure to total expenditure for
16 major states and the central government.) The share of health
expenditure in the major states shows a significant decline in proportion of
health expenditure to total expenditure: from the range of 6 to 7% up to the
eighties, it came down to just over 5% in the 1990s (13). There are no
significant variations for the central government between 1974-75 and 199798; the share has always been close to 1.25%, except between 1982-83 and
1984-85 when it was closer to 1.60%. As far as real per capita public
spending on health at 1980-81 constant prices is concerned, there has been
a steady increase in all the 11 states in varying degrees (Table 12.1). The
233
i1
sole exception is UP, the most popu.ous state, and also one of the states
with poor health outcomes.
Figure 12.2 gives the trends of real per capita public spending on health of
selected major states, and their distribution among primary, secondary and
tertiary healthcare. Per capita public spending has increased in primary and
secondary levels of care by about 50% between 1985-86 and 1998-99; while
spending levels have increased by more than 100% during the same period
in the tertiary sector. This has serious implications for both equity and
efficiency of the health system.
Figure 12.1
Share of Health in State and Central Budget (in %)
8
7
6
5
4
3
2
1
0
S S 2 ? S
S sO) SCD 5CD CD3
CD
CD
m
CD
CD
CD
cd
co
O
CO
CO
CD
C
O
Ch
co
co
co
cd
O)
Ch
co
cS
CD
s
CD
O>
ro
cn
CT)
O>
CM
CD
O>
Ch
co
CD
CD
m
co
’r
in
CD
CD
CD
CD
CD
C
K.
CD
<©
&
CD
CO
<D
CD
CD
Share of Health Expenditure In States
• Share of Health Expenditure In Central Government
Source: Selvaraju et al, background paper, 2001
Table 12.1
Real Per-Capita Public Spending on Health
(Rs.)
1985-86
199192
1995-96
1998-99
1 Andhra Pradesh
20.44
21.03
21.92
31.88
2 Gujarat
24.32
30.51
28.77
45.44
3 Haryana
26.79
26.65
24.39
33.78
4 Kerala
25.97
32.15
30.98
35.05
5 Maharashtra
27.46
30.87
30.73
33.67
6 Madhya Pradesh
16.19
19.17
17.89
25.49
7 Orissa
16.95
23.26
19.54
28.28
8 Rajasthan
21.85
29.07
31.02
37.70
9 Tamil Nadu
15.38
21.61
32.09
42.42
10 -Uttar Pradesh
16.12
20.38
19.01
18.10
11 West Bengal
22.65
28.49
25.96
41.24
25.66
33.91
States
Average Spending_______________ 21.28___________ 25.74
Note: The figures are in constant prices 1980-81=100
Source: Selvaraju et al, background paper, 2001
234
H
Figure 12.2
Per-Capita Real Public Spending or health by Selected Major States (Rs.)
40
33.91
421
30 —
21.28
20------
23
25.75
25.66
323
2.81
7.15
11
4.53
3.43
10
I
12.34
8.15
9.69
■ 9.66
1990-91
1995-96
□ Others
□ Tertiary
■ Secondary
□ Primary
01985-86
1998-99
Note: For the classification of expenditure between Primaij, Secondary and Tertiary, see Annex 12.2.
Source: Selvaraju et al, background paper, 2001
An important factor affecting the quality of health services in the states has
been the substantial increase in the liability for salaries and pensions of
government employees - further aggravated subsequent to the report of the
Fifth Pay Commission. Though budget outlays have increased, the proportion
of salaries and wages in health spending is going up, particularly in the
poorer states. (See Table 12.2 for percentage share of salary and wages in
the total health spending of 11 States from 1985-86 to 1998-99.) The
situation seems to be particularly grave in MP, Rajasthan, Orissa and UP,
where salaries and wages alone consume around 80% of the total health
budget, leaving little for development activities, drugs and consumables.
Table 12.2
Percentage Share of Salaries and Wages in Total Public Spending on Health
States
1985-86
1991-92
1995-96
1998-99
1
Andhra Pradesh
55.98
51.80
63.22
50.28
2
Gujarat
31.76
35.13
42.13
38.82
3
Haryana
53.75
70.63
72.73
63.83
4
Kerala
63.54
70.90
66.57
70.06
5
Maharashtra
41.79
36.71
39.17
46.58
6
Madhya Pradesh
65.53
70.68
76.75
79.58
7
Orissa
65.14
72.08
73.22
82.39
8
Rajasthan
52.42
70.54
70.39
79.02
9
Tamil Nadu
48.23
65.82
64.80
74.00
10
Uttar Pradesh
50.66
68.15
69.06
80.10
11
West Bengal
_______________ 60.43
__________________ 72.53
66.76
Source: Selvaraju et al, background paper, 2001
77.04
235
Ii
In sum, investment in terms of pubrc nealth expenditure as a proportion of
total government expenditure is eitner stagnant or declining. World Bank
estimates seem to show the same stagnant levels in respect of total public
health expenditures as a proportion of GDP (Chapter 2, Figure 2.16) (14).
The analysis by Selvaraju et al also indicates worrisome trends in poorer
states: a decline in per capita spending in UP, an increase of the component
of the salaries and wages in MP, Orissa, Rajasthan and UP, and a
substantial increase in spending on tne tertiary sector.
Existing Mechanisms
Around the world, health services are financed through four main channels,
of which two are private - out-of-pocket payments and voluntary insurance;
and two are public - compulsory insurance (or social insurance) and funding
from general government revenues. Social insurance, either publicly
managed or heavily regulated by governments, also receives funding from
general government revenues, and is hence classified as public (15).
In India, the dominant mode is private. Private spending contributes as
much as 87% according to WHR 2000, and 82% according to the World Bank
(2001). The bulk is out-of-pocket, estimated at 84.6% by WHR 2000 and
75.2% by Peter Berman (1996) (16). The other private mode, voluntary
insurance, covers only 1.7 million people, an insignificant 0.16% of the total
population. The proportion of private spending on public and private facilities
varies significantly among the states: private spending is lowest in Rajasthan
and Bihar, and highest in Haryana, Punjab and Kerala. Punjab and Kerala
are also the highest in per capita public spending for 1995-96 (Figure 2.17),
although subsequent estimates for 11 states by Selvaraju et al (Table 12.1 j
indicate that Gujarat, TN and West Bengal have moved ahead in 1998-99.
The World Bank estimates that states tyoically account for around 75% of
total public finances for health (17). (See Table 12.3 for broad distribution of
health expenditure 1990-91 based on Peter Berman’s estimates.) As in the
private sector, there are major variations in per capita public health spending
(Table 12.1); these could aggravate the already glaring disparities in health
outcomes between better performing and the so-called BIMARU states (18).
Table 12.3
Estimates of Total Health Expenditure in India,1990-91
Source
Public Sector
Centre
States
Municipalities
ExUrnal Aid
Sub-total
Total(Rs. crores) | Pt caplta(Rs.)
*/» of total
% of GDP
554
4981
126
118
5779
6.6
59.3
1.5
1.4
68.8
2.1
18 6
0.5
0.5
21.5
0.1
1.1
<0.1
<0.1
1.3
ESIS contributions
Other sources
Sub-total
20160
319
202
361
21042
240.0
3.8
2.4
4.3
250.5
75.2
1.2
0.8
1.4
78.5
4.5
0.1
<0.1
0.1
4.7
Total
26821
319.3
100.0
6.0
Private Sector
Out-of-pocket
Private employers
Source : Peter Berman 1996. Reproduced from Health Insurance in India: Prognosis and
Prospectus by R.P.Ellis, Alam, and I.Gupta.
236
iI
Out-of-pocket payments account for most of health expenditure; public
contribution from centre, states, local bodies and external aid has been
variously estimated at 21.5% by Berman 1996 (Table 12.3) and by WHR
2000 at 13%. The bulk of public health expenditure is financed by revenues
from general taxation, widely acknowledged as the most progressive source
of finance. The share of social insurance, an important instrument of health
finance in India, is estimated at only 2%; a comparison with some other
countries (Bhat and Mavalankar 2000), brings out its inadequate
development (Table 12.4). Due to discriminatory pricing and exemptions to
the poor, user fees could also be progressive. However, the funds generated
constitute a very small proportion of health expenditure, except in Kerala,
Punjab, and Haryana (Table 12.5). Health insurance, which provides the
maximum coverage in most countries, has remained relatively undeveloped
in India (For salient features of current insurance, see Annex 12.3).
Table 12.4
Percentage of Total Health Expenditure Funded Through Public/Social Insurance
_______
and Direct Government Revenue
Country
Social Health Insurance
Government Budget
Algeria
Bolivia
China
Korea
Vietnam
India
37
20
31
23
2
2
36
33
13
10
20
18
Source: As cited in Naylor et al.1999. Reproduced from Dileep Mavalankar. Ramesh Bhat, Health
Insurance in India: Opportunities, Challenges and Concerns, November 2000.
Table 12.5
Cost Recovery and Health Expenditure by States,1996
India/States
Total Exp.
(Rs. Lakhs)
Andhra Pradesh
Bihar
Gujarat
Haryana
Himachal Pradesh
Karnataka
Kerala
Madhya Pradesh
Maharashtra
North East
Orissa
Punjab
Rajasthan
Tamil Nadu
Uttar Pradesh
West Bengal
47897.97
22130.44
33564.11
11957.45
11621.46
42614.04
31226.29
36218.31
45892.85
22695.49
19093.04
17693.15
43161.48
55983.65
84308.17
50801.52
Total User Fees Cost Recovery
(Rs. Lakhs)________ Ratio
734.92
229.75
438.14
1136.67
78.40
1180.41
4952.00
577.91
2126.99
386.37
183.21
1888.04
397.92
1238.33
2726.22
1063.42
1.53
1.03
1.31
9.51
0.67
2.77
15.86
1.60
4.63
1.70
0.96
10.67
0.92
2.21
3.23
2.09
Source: India: Raising the Sights - Better Health Systems for India’s Poor, World Bank
2001
237
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Advantages and Disadvantages of Different Modes of Financing
The assessment of strengths and weaknesses of each system is summarised
in Annex 12.4.
Private
•
Out-of-Pocket Payments: Easiest and most convenient to mobilize
resources, this theoretically allows the widest choice of providers. In
reality, patients are not well informed to make intelligent choices, and it is
the most regressive form of financing, impacting severely on the poor.
Fee-for-service mode of payment, which accompanies out-of-pocket
expenses, has an inbuilt tendency to escalate treatment costs.
• Voluntary Private Insurance: Its security and risk pooling gives it
advantages over out-of-pocket payments; but there are many associated
market failures, including cost escalation (Box 12.1). With public sector
monopoly leading to relatively poor products and marketing, voluntary
health insurance has had limited coverage in India. Competition will
increase with the deregulation of insurance and the entry of many private
players; this should increase coverage, particularly among the urban
affluent. But an independent regulatory mechanism for health insurance is
essential to derive optimal benefits and minimize different kinds of market
failures.
Market failures
Box 12.1
Market Failures in Financing Health
Consequences
Measures used to correct failures
Demand Side Limitations
Moral hazard
Overuse of services by patients.
Deductible, coinsurance, copayments etc.
Gatekeepers, Waiting lines_____________
Adverse selection
Little risk pooling.
Tax subsidy, compulsory universal coveragi
No insurance market will exist. Onl> Lifetime enrolment
insured. ____________________
Under-utilisation of he< Under use of services/treatments w Education, Information and Communication
care
lumpy costs by poor and also for
Free or subsidised care.
preventive care and diseases with
externalities.
Supply side Limitations
Supplier Induced Deme Increased demand by patients. Rai; Use provider payment mechanisms like sale
costs of care._________________ global budget, and case payments_______
Risk selection
No insurance for disabled, sick, poc Open enrolment, Community rating
(Skimming)
elderly_______________________ Risk adjusted premiums for individuals
Skimping
Deny benefits to the
sick
______________
Social Insurance
Exclusions
Exclude pre-existing conditions and Lifetime and compulsory insurance,
certain diseases for stipulated perio Guaranteed renewability
life of the contract._____________
Monopoly or insurance Excess profit, poor quality products Regulations
underproduction_____________
Source: Based on table from Garg 2000, quoted in background paper, 2001
238
u
•
Community Financing: These schemes are tailored to suit local needs,
and benefit from community involvement and low administrative costs.
They are usually capable of providing only primary health cover, though
they could complement social insurance by covering the rural selfemployed. But they require the kind of strong local leadership generally
provided by a dedicated NGO, cooperative or micro-credit society. So far,
these schemes have had limited coverage: Berman (1996) estimates a 5%
coverage; Ellis (1997) puts it at about 30 million. (See Annex 12.3 for
salient characteristics of selected NGO managed health insurance
schemes.)
Public
•
•
Tax Financed Services: By far the most progressive means of health
financing, government can direct spending toward targeted population and
priority
interventions.
In
practice,
ev^n
public
subsidies
are
disproportionately utilized by the affluent. Administrative costs are high;
services are vulnerable to political instability and poor governance. But
tax financed healthcare is essential for the poor who cannot be covered
by other health finance mechanisms.
Social Insurance: An important mechanism in industrialized as well as
developing countries, its advantages are:
• it can provide stable source of revenue for services;
• the flow of funds to the health sector is visible;
• it can help establish patients' rights to get good healthcare;
• it can combine risk pooling by allocating services according to
need, and distributing financial burden according to pay, ensuring
equity in finance and access;
• it can operate in pursuance of government health policy but
maintain a degree of independence from the government; and
• it can be associated with efficient provision of services.
The disadvantages of social insurance are:
• high administrative costs;
• problems of ensuring coverage for informal and agricultural
workers;
• the risk of moral hazard; and
• high-cost care, depending on payment mechanism to providers.
Given administrative complexities, this mechanism is relevant primarily to
the relatively small formal sector in India. The main instruments at present
are Employees State Insurance Scheme (ESIS), Central Government Health
Scheme (CGHS), and employer-based healthcare systems. Most public and
private, industrial and service establishments provide health cover to their
239
,ii
employees. In the public sector the biggest providers are the Railways and
the Ministry of Defence. Ellis et al (1997) estimate that roughly 15 million
persons could be covered under various types of employer-based financing.
In conjunction with social insurance, employer-based financing covers almost
all employees in the organized manufacturing sector as follows (19) :
ESIS
18%
Private Health Insurance
11%
Employer Based Reimbursement Schemes
35.3%
Lump sum Payment
10%
Employers Own Facilities
47%
Health Financing Paradigm
Framework to Assess Feasible Financing Model Conditions in developing
countries often preclude the use of financing mechanisms and management
arrangements used in industrialized countries (20). Knowing the revenue
raising ability of each group is necessary to understand the feasible
financing options for different sections of the population. Dividing the
population into different income and occupation groups helps to understand
i) the number of rich and poor and the ability to raise resources from them
and ii) the number of rich and poor households in formal and informal sectors
and the feasibility of different arrangements. An exercise to estimate the
population in each group divided by income, location (rural, urban), and
occupation (Garg 2001), concludes that 354 million people are employed,
with 28 million in the organized sector and 259 million in the unorganized
sector, covering a population of 772 million (Annex 12.5). Data on central
government employees has been interpolated to cover all groups of
employees (21) to divide the organized sector into high income, middle
income and low income categories. At best, these can provide a broad
indication of the magnitude and composition of population in each category,
and the potential for coverage under each instrument of health financing.
For unorganized sectors, data from the NSSO 5d,h round has been used to
determine each category and income group (22).
(See Annex 12.6 for
percentage distribution of employed by socio-economic status and main
industry classification for rural/urban areas; and Annex 12.7 for how
employees are paid for their healthcare.) Table 12.6 shows the percentage
distribution of persons by income group, employee status and main industry
classification. Basically, the analysis leads to the composition of the
population indicated in Table 12.7.
240
H
Table 12.6
Percentage Distribution of Persons by Income Group, Employment Status and
________________________ Main Industry Classification___________
ALL AREAS- Rural and Urban
High
Middle[Low
Organized**
Government
Agricultural
Manufacturing, Mining, etc.
Services, trade, transport, etc.
Unorganized Employment
Regular Salaried
Agriculture
Manufacturing, Mining, etc.
Services, trade, transport, etc.
Self Employed
Agriculture
Non Agriculture/manufacturing
Services, trade, transport, etc.
Casual Employment
Agriculture
Manufacturing, Mining, etc.
Services, trade, transport, etc.
Out of Labor force/Other HH*
Unorg and other households
Note :
-green |.
■
| Blue
I Yellow
Source: Charu Garg, 2001
Table 12.7
Percentage Distribution by Employment and Income Status
Sector
High
Income
Middle
Income
Low
Income
Total
Organized
0.5
5.5
2.8
8.8
Unorganized *
6.6
32.6
42.6
81.8
Out of labour force and
other household workers ☆
1.1
4.3
4.0
9.4
8.2
42.4
49.4
100.0
*
☆
Includes all regular salaried, self-employed, casual/marginal and home-based workers.
Includes all other households which do not have gainful employment.
Source: Derived from Garg 2001
Proposed Financing Framework
The following consists of broad directions that seem desirable and feasible;
but further work is required to develop a health finance framework based on
more reliable estimates of the costs involved in each mode of financing.
241
ii
Tax Revenue Based Health: Tax revenue is limited and there are many
competing claims. The median pe'cent of tax collection as percent of
national income is 18% (ranging from 8% to 44%) for low-income countries
while the median for high income is 48% (23). India is almost at the bottom
of this scale at 9.2% of GDP in 2000-2001 (24). There is a strong case for
increasing the share of health in resource allocation. But the extent of
reallocation depends on political will, the fiscal situation, and how
governments respond to the present unacceptable central and state levels of
fiscal deficits, around 10% of GDP (25). Advocating reallocation to health is
not enough in a country with a low tax base, a mounting debt liability, large
security concerns, and a legacy of ineffectively targeted subsidies. Generally
speaking, available tax resources should be used primarily for promotive and
preventive health; the healthcare of the poor, particularly the informal sector
outside the reach of insurance mechanisms; and for encouraging community
financing. Resources from dedicated sources must be raised to the extent
possible to eliminate competition, and provide stable and growing sources of
revenue. Simultaneously, steps must be taken to improve the targeting of
public subsidies toward healthcare of the poor:
•
Increase
allocation for public
health
and
primary
healthcare better utilized by low income families;
•
Utilize user fees at secondary and tertiary levels to reduce
the price advantage of public services with simultaneous
arrangements for exemptions for the poor;
•
Improve public service efficiency to increase utilization.
Options for different income groups:
The Rich: This population - distributed between formal and informal sectors,
urban and rural areas — should be covered by voluntary private insurance
because
• even the rich require security and risk pooling; their
participation could help cross subsidize the old and the sick,
and the less affluent;
• their substantial participation would strengthen the health
insurance sector and highlight the need for better regulation;
• it would help develop health maintenance organization (HMO)
type institutions, contributing to cost containment.
• it could contribute to freeing resources of public facilities
currently being used to provide secondary and tertiary care to
the rich.
While voluntary health insurance deserves government support, there is no
justification for the recent public subsidies (tax concessions). On the
contrary, there is a case for the cost of the regulatory authority being
financed by insurance companies by way of premium tax, as in the" United
States. Increased competition will automatically spread coverage of
voluntary health insurance and improve products and service quality. The
State’s role is primarily to develop an appropriate legislative framework;
appoint a dedicated and independent regulatory authority to monitor the
insurance sector; and formulate procedures and regulations to avoid well
242
i i
documented market failures. Ever in the absence of voluntary health
insurance, the rich could continue to depend upon out-of-pocket expenses
given their financial resilience.
Middle income: The objective should be to cover all formal sector employees,
but with social insurance primarily financed by contributions from employer
and employee; State participation should be, at best, nominal. Those in the
informal sector could join either voluntary health insurance schemes or
community finance schemes wherever feasible. If none of these options is
chosen, they could continue to rely on out-of-pocket expenses. The State
must draw them into one of the institutional financing options, not
necessarily by offering tax concessions or subsidies, but by making health
coverage in those schemes attractive. Middle income should also be required
to pay user fees for secondary and tertiary care in public healthcare
facilities.
Low Income:
•
Formal Sector: This sector is already covered by schemes such as ESIS,
CGHS and Employer Based Schemes. Serious deficiencies have been
documented about the coverage and service quality of ESIS and
CGHS; they also have high administrative costs. By replacing these
schemes with social insurance, the government could play facilitator
and financier, but not necessarily provider of services. Services for
social insurance could be contracted out, enhancing efficiency and
reducing costs. The manufacturing and services sector will grow with
industrialization and economic growth, and social insurance could play
an increasingly important role in the future. Approximately 10% of the
population is now covered by social insurance and employer-based
schemes. Around 21% of households can be covered under social
insurance as per categories that include all income groups - rich,
middle income and poor, wherever social insurance is feasible (Garg,'
Table 12.6). At present, state governments contribute 12.5% of the
medical expenditure by ESIS, subject to some limits; 20% of
expenditure is passed on to excess fund into ESI reserves. If high
income and middle income employees are included and premium made
income rated, government contribution in an expanded social insurance
scheme may be significantly reduced. Garg has suggested that a mere
5% contribution from the government may be sufficient, so that the
additional cost of scheme expansion does not impose a substantial
burden on government revenues.
•
Informal Sector: Most of the poor in the informal sector (46.6%)
deserve maximum assistance from the State, because administratively
they are beyond the reach of social insurance. Other than tax based
public healthcare, their only source of institutional finance is
community finance — with its limitations of dependence on the
initiatives of NGOs/cooperatives/micro-credit societies and strong local
leadership. China, considered a leader in community financing, has a
long history of cooperative medical schemes. A recent World Bank
243
H
study observed, “China’s experience with community financing
indicates that it may be a promising approach to reestablish risk
pooling arrangements for catastrophic medical expenses in China’s •
rural areas. Nonetheless, China is a large and heterogeneous country.
While community financing has many advantages in theory, it may
prove difficult to administer on a widespread basis.” (26) This applies
even more strongly to India. Although most current schemes rarely
receive government support, state governments should set up a
package of incentives for NGOs to develop such schemes in
designated areas; the government should also contribute a fixed
premium for every below poverty line (BPL) family covered by such
schemes. All donations to genuine community finance organizations
should be exempted from tax. Nevertheless, the bulk of the population
would still need to be provided health cover by the State. This implies
more efficient functioning of primary and secondary healthcare systems
with a strong referral link.
)
•
New Mechanisms - Sickness Funds: Such a fund could be created by a
suitable cess on both rural and urban property as well as on their
transfers. This is justified by equity considerations, ease of
administration and collection, and low incidence of land taxation in
rural areas. Besides, it completely exempts the poor. Collections could
be pooled state-wise, then allocated to district level societies
proportionate to the number of BPL families; the fund could be
augmented by tax exempted donations. The objective of this fund is to
cover all the hospitalization expenses of BPL families in public
facilities as well as designated private facilities. This assumes that a
system to identify BPL families already exists in each state for ongoing
schemes, including subsidized food grains from Public Distribution
System (PDS); if there are any lacunae in the system, they need be
rectified. Some compensation to cover at least part of wage loss and
other ancillary expenses (transport) should also be provided.
Estimating the costs of hospitalization cover to poor families is not
simple. On the basis of the 42nd Round NSS, T.N. Krishnan (27)
estimated the cost of hospitalization at Rs.600 per episode. On the
basis that around 4% of the population in the bottom 40% income group
need hospitalization annually, he worked out the cost for 300 million
population in the BPL category for hospitalization insurance coverage
up to Rs.5,000/- per annum at Rs.900/- crores (Rs.9 billion). Estimates
based on the NSS 42nd Round refer to 1986-87 costs; costs per
hospitalization episode have risen substantially since (Annex 12.8).
The average cost in 1995-96 is estimated at Rs.2,100 per episode at
current prices in public facilities. If 4% of the population require
hospitalization each year, the total cost for 12 million patients would be
around Rs.25 billion (Rs.2,500 crores). A calculation based on per
capita annual medical expenditure in ESIC of Rs.136, multiplied by a
population of 300 million, is Rs.40 billion (Rs.4,000 crores). However,
per capita expenditure in ESIC gets inflated by high administrative
244
ii
cost, which has substantial scope for economies. Hence the real cost
should be somewhere between these two figures.
Mobilization of Resources
Total health spending in 1998-99 is estimated at Rs.161 billion or Rs.16100
crores; to reach the lower middle income countries average of 2.2% of GDP,
public investment will have to be more than doubled. The strategy of
developing dedicated levies would provide sustained and dependable source
of finance to strengthen the health sector and insulate it, at least partially,
from fiscal crises, emergencies and political upheavals.
Central Level:
•
•
Reallocation from General Revenues: In view of the fiscal position and
the competing claims of different sectors, a quantum jump in
aiiocations for health does not seem feasible. But a 50% increase or an
additional Rs.2,000 crores can be derived, partly from General
Revenues, partly by reallocation from other programmes not making an
impact. That a number of development programmes are not yielding the
expected results is well known, and has been widely commented upon
in research studies, and evaluation and audit reports. Though it is not
possible for this Report to identify them specifically, there is no doubt
that reallocation of resources from such programmes to health is both
desirable and feasible. Thus, a credit of Rs.2000 crores has been
assumed from general revenues and reallocation from other sectors.
Increased External Assistance: External assistance to the health sector
from 1990 to 1995 (Table 12.8) shows that average disbursement has
been 216 million dollars; around Rs.1000 crores or Rs.10 per capita. In
view of population size, levels of income, poverty and BOD, this is
woefully inadequate. Despite its small proportion, external assistance
has played a key role in directing resources to priority areas. With a
better absorptive capacity and understanding of the importance of
investments in health, assistance can be expected to increase by about
three times in coming years. This means at least an additional Rs.2000
crores a year. Even so, it would remain at a very modest level of per
capita Rs.30 ($ 0.64).
Table 12.8
Summary of External Assistance for Health Sectors (in ' 000 $)
Total
1990
1991
1992
1993
1994
184310
152296
204766
152862
338011
1995
Total
from
1990-95
Average
from
1990-95
Average (in
Rs.millions)
Per capita
external
assistance
(in Rs.)
263359
1295604
215934
10116.51
9.85039699
Note : Exchange rate as on 11.5.2001 is $1 = Rs.46.85
'
Population of India for 2001=1027015247
Source : D.3.Gupta and Anil Gumber, background paper on External Assistance
245
11
Tax on Tobacco: This has two main components, basic excise duty
which is a central levy; and additional excise duty in lieu of sales tax levied and collected by the central government on behalf of states. In
1997-98, a special cess was also levied to support dedicated
programmes. (See Table 12.9 for the yield from taxes on tobacco in
1997-98 and 1998-99.) This is a buoyant source of revenue with a
mechanism already in place for the imposition of a cess. The linkage
between tobacco and disease is well established; taxation serves the
dual purpose of reducing consumption and yielding resources. At least
part of the revenue should be dedicated to preventive and promotive
health, particularly to controlling the risk factors for NCDs that will add
to the BOD in the near future. Even a 15% cess could contribute an
additional Rs.1,000 crores to health without disturbing existing sources
of revenue.
• Revenues from Disinvestment: The government has an ambitious
programme of disinvestment in public sector enterprises but it has had
a slow start due to political pressures, resistance from trade unions
and procedural difficulties. A separate ministry for disinvestment, and
the successful privatization of BALCO despite political opposition,
augurs well for rapid progress. The budget for 2001-02 sets a target
Rs.12,000 crores from this source, and out of this Rs.7,000 crores is
earmarked for restructuring public sector enterprises, and Rs.5,000
crores for investment in infrastructure and social sectors. Although
infrastructure is a high priority, it has many other supporting sources,
including cess on petroleum products and private investment; at least
Rs.2,000 crores must be earmarked annually for additional investment
in the health sector. These proposals alone could provide an additional
Rs.7,000 crores annually without significantly disturbing existing
budgetary allocations; this means more than doubling of central sector
investment (including external aid) in the health sector.
•
State Levies
Annex 11.9 shows the revenue receipts of states. Despite the fiscal situation
of most states, the following are options for additional resource mobilization
at the state level.
• Levy on Excise: The rationale behind suggesting a dedicated levy on
tobacco for health applies equally to a cess on state excise duties,
which predominantly relate to taxes on consumption of alcohol. Again
this is a buoyant source of revenue yielding about 15,000/- crores
annually; a 33% surcharge on existing excise revenue could yield 5000
crores annually.
• Property Tax: There are three categories of property related taxes.
Registration and stamps yield around 10,000 crores annually, and is a
tax on transfer of property with both a rural and urban component; even
a 20% surcharge could yield 2000 crores annually. The second source
is urban property taxes collected by local bodies. Based on a survey of
245 municipal bodies extending to 20 states by NIPFP for the 11,h
Finance Commission in February 2000, revenue estimates have been
246
ii
generated multiplying per capita tax yield with 1991 urban population,
which exhibit wide state-wise variations. The estimated income based
on 1997-98 per capita estimates works out to around 2300 crores. (See
Annex 12.10.) This is a rapidly growing source and the yield now would
exceed 2700 crores.
A 33% cess could provide Rs. 900 crores
annually for Sickness Funds and other healthcare services for the
urban poor. The third property tax category is land revenue, yielding
around 1500 crores a year; a 33% surcharge could yield 500 crores a
year. Thus these three sources of earmarked levies could yield around
3500 crores a year, sufficient to support Sickness Funds. The large
state-wise variations in the yield from property taxes could result in
some states being unable to provide sufficiently for Sickness Funds.
The centre would need to extend a helping hand to such states for a
countrywide coverage of the scheme.
User Fees: The yield from this source is now small, but capable of
substantial expansion as indicated by the experience of new initiatives
in MP and Rajasthan. The World Bank 2001 report identifies four main
hurdles to major expansion:
the lack of appropriate mechanism for user charge review;
i)
the minimum level cost recovery due to low fee structure and
ii)
inadequate collection mechanisms;
iii)
the difficulty of implementing targeting mechanisms to exempt
the poor from user charges; and
iv)
the lack of adequate mechanisms to ensure fund utilization at
point of collection.
Recent state initiatives show how these weaknesses can be overcome.
• Income from user fees to be credited to a hospital based fund
managed locally, with authority to review charges;
• User fee income to be additional to budget allocations for medical
facility;
• Exclusive use of fund for improvements in concerned medical
facility by the local management committee along broad
guidelines of state government.
• Identification cards for all BPL families entitling them to
automatic exemption; mechanisms for exemption of other indigent
families at the discretion of local committee.
The three main objectives of user fees are:
i)
discouraging overuse of public facilities by the affluent and correcting
some of the distortions in the use of public facilities;
ii)
improving quality of care, hence utilization of these facilities; and
iii)
involving the local community in managing public healthcare facilities
and fostering a sense of participation and ownership.
It has been argued that the levy of user fees is politically sensitive;
international literature has also shown that the imposition of user fees in
247
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many African countries led to significant reduction in utilization of public
facilities (28). The experience in India is. so far, quite different, and user
fees have not generally led to reduction in utilization. Where such levy has
been accompanied by local community participation, it has also been able to
overcome political resistance. In many cases, it has resulted in visible
improvement in the upkeep and quality of public medical facilities. The
important point is that if charges are simple, transparent, reasonable, and
collection mechanisms do not inconvenience patients, it should eventually be
possible to mobilize at least 10% of expenditure on secondary and tertiary
health care, yielding about Rs.600 crores on current estimates (29).
Table 12.9 sums up the additional resource mobilization proposals. Given
that the total public health expenditure of the centre and states is estimated
at around Rs.16,000 crores, these alone could lead to doubling of public
investment in health, taking it closer to the target of 2.2% GDP. In per capita
terms, this would still remain a modest Rs.311.00 or $ 6.60.
Conclusion
The above analysis attempts to establish a convincing case for a quantum
jump in State investment in health. Increased investment is an essential
condition for a significant improvement in the performance of the health
system. But it is not a sufficient condition. Major systemic reform
should accompany increased allocations to improve efficiency, quality,
and outreach of public health interventions. This combination of
increased investment and improved public healthcare is also crucial for
equity and for providing risk protection to the poor. The suggested order
of resource mobilization seems feasible without inviting serious political
risks. India has to move ahead quickly to set up institutional mechanisms
that will drastically reduce out-of-pocket payments for health to more
acceptable levels (>50%). This means that one of the foremost priorities of
central and state governments should be the major expansion of health
insurance schemes.
248
u
Table 12.9
Additional Resource Mobilization Proposals: A Summary
A.
Central Level:
Rs. in Crores
B.
1.
Additional support from general
revenues including reallocation
from other programmes
2,000.00
2.
Increased External Assistance
2,000.00
3.
Levy on Tobacco
1,000.00
4.
Allocation from Disinvestment Receipts
2,000.00
Total A
7,000.00
State Level:
Rs. in Crores
1.
Levy on State Excise
5,000.00
2.
Levy on Registration and Stamps
2,000.00
3.
Cess on Urban Property
900.00
4.
Cess on Land Revenue
500.00
5.
User Fees
600.00
Total A
9,000.00
Total A + B
16,000.00
Notes
1.
2.
3.
4.
5.
6.
7.
8.
9.
This chapter makes extensive use of background papers specially commissioned
for this Report. The papers (all 2001) include Trends in Public Spending on
Health in India by V. Selvaraju and V.B. Annigeri; Health Finance Paradigm in
India by Charu Garg; and Health Insurance for Informal Sector - Problems and
Prospects by Anil Cumber. Many of the estimates in this chapter have been
worked out specifically for the Report from original state and central budget
documents.
WHR 2000 (These estimates have been disputed by many countries including
India and do not match with state level estimations).
Ibid.
Based on NSSO-2001, which estimate the population below poverty line at
26.10%. However, this is disputed by many as a gross under-estimate caused by
a change in the methodology. NSSO 1993-94 estimates showed a figure of 36%.
World Bank 2001.
Aneurin Bevan 1952, quoted in WHR 2000.
T. N. Krishnan 1 997.
William Hsiao 2000.
The categorisation of countries in High Income, Middle Income and Low Income
follows classification of the World Development Reports.
Low Income is per
249
u
capita income less than S765, Midd e ncome is S765 to S9.385 and Hiqh Income
is $9,386 and above.
10. World Bank 2001.
11. Ibid.
12. Selvaraju et al, background paper, 2001.
13. There is a missing link in the figure as data for 1993-94 for the
centre was
unavailable.
14. World Bank 2001.
15. WDR 1993.
16. Peter Berman teaches International Health Economics at the Harvard School of
Public Health.
17. World Bank 2001.
18. BIMARU refers to the relatively backward states of Bihar, MP, Rajasthan, and UP
in North India.
19. Garg 2000, Duggal 1993, quoted in background paper by Garg, 2001.
20. Bengt Johnson and Philip Musgrove 1997.
21. Government employees in Group A, B & C have been treated as high income,
middle income and low income.
22. Per capita monthly expenditure of Rs.560 in rural and 1055 in urban and above is
classified as high income, Rs.265 - 560 in rural and Rs.410 - 1055 is middle
income and less than Rs.265 in rural and Rs.420 in urban is low income.
23. IMF Government Financing Statistics, 1998.
24. Economic Survey, 2000-2001.
25. Budget Speech of the Finance Minister, February, 2001.
26. China: Issues and Options in Health Financing, World Bank, 1996.
27. Hospitalisation Insurance - A Proposal, 1997. .
28. Dyna Arhin Tenkorang, November 2000.
29. The total public expenditure on health (both centre and states) is estimated at
around 16,000 crores and about three-fourths (12,000 crores) is attributable to
the states. Just over half of the state expenditure is'on secondary and tertiary
care (Figure 12.2) - which would work out to around 6000 crores. If a 10% cost
recovery is to be made from user fees, the yield would be around 600 crores.
250
h
Year
J
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Annex 12.1
Trends in Government Expenditure (Revenue and Capital)
1980-81 to 1998-99 (Rs.Lakhs)
16 Major States
Share of
Central Government
Share of
Health
|
Health
Health
Total
Health
Expenditure Expenditure ir.
Total
Central Govt. I
Expenditure
Expenditure Expenditure Expenditure
in States
1980- 81
1981- 82
1982- 83
1983- 84
1984- 85
1985- 86
1986- 87
1987- 88^
1988-89
1989- 90
1990- 91
1991- 92
1992- 93
1993- 94
106391.16
1697189.97
128990.48
1957776.71
152282.65 ^ 2263233.40
179339.60
2660615.93
203850.50
3180788.20
__232724.07
3588315.02
259316.19
4141910.44
303802.75
4816623.09
343164.95
5476233.01
387265.19
6324076.93
445229.93
7531682.13
485517.24
8920762.19
548201.93
9995688.62
633313.20
11276993.97
199£'9_5, -§^39620^ •13426662.20
1995- 96^
784284.43
14983995.39
1996- 97
883224.41
17204469.41
1997- 98^ 1019978.23
19330764.55
1998- 99^ 1194020.85
22306364.17
25970
35180
48620
60900
69310
79610
86550
96490
108890
114910
133000
149870
177560
2230201.97
2505496.82
3017949.32
3595229.01
4307954.89
5231187.29
6260316.35
6941811.78
7984868.95
9423714.86
10594742.15
11790874.64
13891583.80
243250
243270
262820
330320
18068203.75
19783536.51
22053078.86
27551164.63
19
Note : Central data for 1993-94 is not available.
Source : V. Selvaraju et al, background paper, 2001
6.27
6.59
6.73
6.74
6.41
6.49
6.26
6.31
6.27
6.12
5.91
5.44
5.48
5.62
5.17
5.23
5.13
5.28
5.35
251
1.16 |
1.40
1.61 |
1.69
1.61
1.52 |
1.38 |
1.39 I
1.36 |
1.22 '
1.26 |
1.27 i
1.28
I
1.35 .
1.23 I
1.19 |
1.20
H
Annex 12.2
Constituents of Primary, Secondary and Tertiary Care Services
Budget Heads of Health
Primary Care Services
Budget Heads of Health
Tertiary Care Services
1 Primary Health Centres
1 Attached to Teaching Institutions
2 Health Sub-Centres
2 Major Hospitals
3 Other Health Services
3 Tuberculosis Institutions
4 School Health Schemes
4 Allopathy - Medical Education, Training & Research
5 Public Health
6 Family welfare
Secondary Care Services
General
1 Employees State Insurance Scheme
1 Direction and Administration
2 Central Government Health Scheme
2 Health Statatistics, Research, Evaluation & Training
3 Hospital and Dispensaries
3 Medi.Stores Depot & Deptl.Drug Manufactures
4 Community Health Centres
4 Tribal Area Sub-Plan
5 Ayurveda - Other Systerms
5 Other Expenditures
6 Homeopathy - Other Systems
6 Assist.to local bodies, corporates, etc.
7 Unani - Other Systems
7 Machinery and Equipments - Family Welfare
8 Sidha - Other Systems
9 Other Systems_______
Source : Selvaraju et al, backgrounc caper 2001
252
H
Annex 12.3
____________ Salient Features of Some Insurance Schemes in India
Mandatory Social Insurance Schemes
Voluntary Private
Community baseu
Indicators
] Insurance- MEDICLAIM
________ ESIS_______ _______ CGHS
Insurance /NGOs
Types of
Factory sector
Employees of Central
Individuals and groups
People in the
beneficiaries
employees with income government- current
with persons aged 5 to
communities
less than Rs. 6500 per
and retired, some
75 years. Children
month. Their
autonomous and
between 3 months and
dependants are also
semi-govt,
5 years covered with
covered
organisations, MPs,
parents.
judges, freedom
fighters, journalists.
Coverage
About 35.3 million
About 4.4 million
1.7 m persons covered. About 30 million.
beneficiaries in 1998
beneficiaries in 1996
Groups more likely to
Normally quarter of
purchase policy.
the target group.
,
Table A15_______ i
Types of
Medical benefits, cash
All OP facilities,
Hospitalisation and
Mainly preventive
|
benefits
benefits.
preventive and
domiciliary
care. Also ambulatorvl
Preventive and
promotive care
hospitalisation
and inpatient care.
j
promotive care, and
available in
according to the sum
health education.
dispensaries.
insured. Exclusions and
IP facilities available
waiting period clause.
in government
Maternity benefits
hospitals and in
allowed with extra
approved private
premium.
hospitals on being
referred.___________
Financed by patient |
Premiums
4.75 % of employees
Varies from Rs. 15 to
Premiums based on
(financing of
wages by employers
Rs. 150 per month
age and sum insured.
collection, govt.
I
scheme)
1.75 % of their wages
based on salaries of
grants and donations I
by employees
the employees.
Premiums depend or. i
12.5 % of total
Mainly financed by
the scheme - flat rate!
expenses by state
Central Government
or income based.
i
governments________
funds._____________
Provider
Mainly salaries for
Salaries for doctors.
Indemnity type. Insured Mainly fee-for service |
payments
physicians in
Providers not allowed
pays to the provider
dispensaries and
private practice.
who is later reimbursed
referral hospitals.
Treatment in private
according to the sum
IMP paid on capitation
hospitals is
insured.
basis. Hospitals have
reimbursed on case
global budget financed
basis, subject to actual
by ESIC through state
expenditure and
governments.________ prescribed ceilings.
Administrative I About 21 % of revenue
Direct administrative
Generally High.
Generally low (3%- 1
Costs
I expenditure. For paying costs including travel
Low claim-premium
5% depending on the i
I wages for corporation
expenditure, office
ratio reflects that a
scheme)
1
employees, and
expenses, RRT - 5%
large proportion of
administering cash
of total expenditure.
funds are utilised for
I benefits, revenue
Part of salaries can
running the scheme or
recovery and
also be charged to
kept as profits.
i implementation in new
administrative costs.
' area.________________________
Source. Based on table from Garg 2000, quoted in background paper, 2001
I
I
I
I
253
Annex 12.3 a
Salient Characteristics of Select NGOs Managed Health Insurance Schemes
Voluntary Organizations/
Date started
_______ Location________[
Sevagram/
Hospital, 1945
Wardha, Maharasthra
Community
health program
1972
Bombay Mother and
child welfare society
(BMCWS)/
Chawla in Bombay
1947
Raigarh Ambikapur
Health Association
(RAHA)/
Raigarh, Madhya '
Pradesh
1969
Community
health services
started 1974
Christian Hospital/
Bissamaucuttak, Onssa
Hospital 1954,
out reach
community care
1980_________
19* century
CLWS - 1971
UPASI
Coocnoor. Tamil Nadu
Service proviaec
1. 500 bed hospital
2. Out reach community health
programme
Haelth activities, Two maternity
hospitals (40 beds each) with
child welfare centers. Non
health activities. Day care
centers, convaleacent home
Federation of 3 referral hospitals
and 65 independent health
centers with outreach
community care
120 bed hospital, community
project currently not operational
Association of tea growers run
comprehensive labour welfare
scheme (CLWS)
____
Goalpur Co-operative
Health Society
Shanthiniketan, West
Bengal____________
Students health home
West Bengal
1964
Dispensary, periodic community
health services
1955
Polyclinic plus 28 regional
clinics
Health Service
delivery/organization
Population
Served
Trained male VHW provides
I 19457
basic curative, preventive and
promotive health care. Mobile
| with doctor and ANM provides
i care every 2 months__________
. outpatient and inpatient
maternity care
. Outpatient paediatric care
including immunization
. RAHA functions include
I 400000
management of insurance
scheme, training ano support
for health centers.
. health centers staffed by
nurse provide outpatient care
run MCH clinic
. VHWs provide community
based care_______________
Outpatient/inpatient care,
specialties include obstetncs.
gyneacology, surgery.
ophthalmology____________
CLWS provides training.
250000
management support to health
programmes of individual tea
estates. Tea estates have
small cottage hospital and
outreach care provided by
local workers.__________
Doctor provides outpatient
I 1247
care twice weekly
Polyclinic has 20 beds
[ 550000
provides outpatient and
inpatient care; Regional clinics.
outpatient care only, health
education campaigns, blood
donation camps.__________
Doctors provide outpatient
I “
care weekly MCH clinic.
I Total Annua1
Cost (Rs )
69459
120175
(health and
non health
combined)
30000-50000
(cost range
of individual
health
centers of
which there
are 65)
1911740
(hospital
only)
300000
32000
2950745
I
Saheed Shabsankar
Saba Samithi (SSSS)
Burdwan, West Bengal
1978
Arvmd eye hospital
Madurai, Tanil Nadu
1976
Tribovandas Foundation
Anand, Gujarat
1980
SEWA
Ahemadabad, Gujarat
Union 1972,
health
programme 1984
CINI
1975
Daulatpur, West Bengal
Dispensary occupational health
activities, rural health
programme, school health
programme, fair price medicine
shop______________________
2 Urban hospitals (100 beds), 2
rural hospitals (500 beds),
outreach programme
Outpatient and inpatient eye
care
87780
10987700
Regular eye camps organized I_______
Community based health
CHWs provide basic curative, I 300000
programmelinked with milk
preventive and promotive care; |
cooperatives, regional
field supervisors provide
rehabilitation centers, Baiwadis
support to CHWs milk society
women's income generating
building used as base for
scheme____________________ coordinating health services.
Union of self employed women.
Health centers in urban slums
63000
Helps organize women into
and rural villages. CHWs
cooperatives of various traders,
provide basic care, doctors
provides credit facilities. Provide
provide support twice weekly.
health care as a support which
stocks rational generic drugs.
Community based health
CHWs provide MCH care
70000
programmes, dispensary and
through Mahila Mandals,
(Community
outreach rehabilitation centre.
doctors run daily OPD, weekly
health
Other activities: income
MCH clinic, supplementary
project)
generating schemes, farm,
feeding
health training, research____________________________
Source : Dave (1991), reproduced from Anil Gumber, background paper, 2001
254
1080000
(health and
non health
combined)
391850
(health
program
only)
1900000
Options
Government
Financed
Social
Insurance
Funds
Voluntary
Community
Finance
Annex 12.4
Assessment of Different Methods of Financing Healthcare in India
________________
Strengths
Weaknesses
Interventions suggested
-Can have high coverage
-Limited government budget
-Shift the delivery aspect from
-Can tax the rich and finance the poor -Tax base low. Difficult to assess the incomes for
government to private
-Can meet the objective of Equity in
those not earning regular wages and collect revenues/ providers or make the
finance- based on progressive tax
contribution from rural and unorganised sector
payments to the public
structure
-Rich can corner the benefits if there is no system to
provider more incentive based.
-There are incentives to control costs of
prevent them from doing so. Distribution of public
-Monitor and accredit private
care- Costs are controlled by having
subsidies would then b5 not equitable
providers
salaries and global budgets.
-No incentive to assure quality improves
- No problems of adverse selection, risk
-Consumer choice for providers is normally restricted
selection, skimping and supplier induced
-Risk of moral hazards for free care especially if the
demand.
quality improves.
-No profit incentives. Administrative costs
are low.________________
-Large pool of persons to spread risks
-Cannot provide universal coverage as it is difficult to -Shift provision to private
-Equity in finance as premiums are
collect premiums from rural & unorganised sector
providers or make payments
related to incomes, but contributions do
-Moral hazard can be prevalent, but can be controlled to the public providers more
not determine the extent of benefits and
with copayments and deductibles.
incentive based.
can be distributed according to needs.
-No adverse selection because of compulsory
-Have risk equalisation
-Costs can be controlled, as providers are insurance.
schemes to cover risks with
normally a part of the insurance funds.
-No incentives to assure good quality unless there are different risks and resources.
Even for other providers, suitable payment competing funds.
- Have medisave account/
system has to be in place.
- High Administrative costs
lifetime insurance
- stable source of revenue for services
- It can help to establish patients rights to
get good health care
_______________
-Low coverage but help to organise funds - Flat rate or community rated premium. Not
-Organise funds at local level
for relatively poor people
progressive.
by involving local
-Low cost, mostly spent on primary care
-Difficult to collect premiums from those not interested bodies/panchayat
- Access affected by geographical
in joining the scheme.
-Make the schemes more
proximity. Available services for all
- Moral Hazard in some schemes
attractive for everyone in the
- Incentive to control quality to lure more
-Adverse Selection, unless it is compulsory to join the
community to join
people to join
scheme
-Proper monitoring of the
- Generally very low administrative costs. -External support from government or donors-almost
schemes
necessary condition to sustain the schemes
- Risk selection and skimping generally low, as the idea
is to make it attractive for people to join.
255
Private
Insurance
-Greater freedom of choice for consumers - Very low coverage
-Cover maternal and OP care
to choose their provider
-Moral Hazard both in terms of number of visits and
- Limit exclusions and
-Incentive to provide good quality of care
costs.
guarantee renewals
-Tends to be inflationary in terms of costs of care.
-Have coinsurance,
-Adverse selection by people in age 18-45
deductibles, etc. to minimise
-Skimming exercised by varying premiums according to moral hazard
age and activity
-Have prepayments or direct
- OP care generally not covered because of high
link-up with providers
administrative costs
-Allow freedom of choice in
-SID under fee-for-service
different systems of medicine
-Regressive in financing, as premiums are risk rated.
-Have proper regulation and
Contributions determine the benefits.
monitoring to take care of
- Indemnity type of insurance makes it unattractive for consumers interests.
many. Poor cannot make large payments out-of-pocket
and reimbursed later.
-Exclusions for certain diseases and pre-existing
conditions
Jjigh profit incentives to the insures and providers
Out of pocket
Every one can seek care
Highly regressive in nature. Costs of care are the
Reduce the impact on thn
payments
Freedom of choice of providers
same to different income groups. Poor bear greater poor by helping them with tax
Incentives to improve quality by the
burden in terms of the proportion of their incomes
financed money.
providers
spent on health care.
Not everyone can afford.
There will be a tendency for under utilisation by the
poor and for preventive and curative care
There will be no incentive to control costs
Source : Charu Garg's Background Paper. 2001
256
u
Annex 12.5
Employment by Industry in Organized and Unorganized Sectors in India: 1997
_
t
_
(In Million)
Organised
Total organised ,
Employment by industry
Organised Organised,
Total
Unorganised
+
Public
Private I (Pub+Pvt)
unorganised !
Central Government
3.3
3.3
3.3|
__________ —I
State Government
6.5
7.5
__________ 7.5i
191.4’
0Agriculture, hunting etc.
0.5
0.9;
1.4
190.0
1Mining and quarrying
2&3- Manufacturing
4Electricity Gas and Water
5^ Construction
6Wholesale and retail trade
Transport, Storage
Communications_________________
8Finance, Insurance , real estate
9 - Community Social, Personal
services
0.9
1.6
1.0
1.1
0.2
3.1
QJ!
5-2|
<0.1,
1.3
iTotal main workers
|Marginal workers
19.4
1.0
6.7
1.0
1.2
0.5
3.2
3.2 __________ I.Oj
21.6
28.4;
1.0|
3.2
7.3 __________ 85I
23.8
24.3
4.9’
e.-ii
0.4;
1.7
0.7
2.6
2.4
8.7i
28.1
259.0
0-11
0.3;
0.1'
1.8
Home based workers
Unorganised total
Working Population
Unemployed
Total labour force
Source :
Ministry of labour (2000) Annual Report
Ministry of Finance (2001) Economic Survey
Reproduced from Charu Garg, background paper 2001
287.1
28.0
39.3;
326.3
354.4!
7.4
361.8
257
Annex 12.6
Percentage Distribution of Employed by Socio-economic Status under Employment Status, Main Industry Classification and for
—_______________________ Rural-Urban Areas____________________________
Rural
Urban
Persons Persons by
Persons by Persons by
Employment Status and Industrial
High
Middle
Low by activity household
activity
household
Classification
category*
status*
High
Middle
Low
category
status
_____ in millions
in
millions
Organised1'* ______
7'%
5.4
62.7
31.8
28.1
74.9
Government
••• -h
10.7
28.5
Agricultural
i .rv*-.
1.4 ~
3.7
Manufacturing, Mining, electricitv, etc.
26?4
________ 9.9
Services, trade, transport,
6.1
16.3
communication
•
Unorganised Employment
40 9|
8J
Regular Salaried
23.2
48.8
Agriculture_______
8.4
38.7
Manufacturing, Mining, electricity, etc.
23.3
51.2
Services, trade, transport,
27.8
50.4
communication________________
Self Employed
9
46.7
Agriculture
9
46
Non Agriculture/ manufacturing
7.2
42.5
Services, trade, transport,
11.6
47.9
communication___________
Casual Employment
2.8
29.5
Agriculture
28.<
3.4
Manufacturing, Mining, electricity, etc.
5.6
39.9
Services, trade, transport,
5.3
40.1
communication_______________
Out of Labour force/Other
12.3
46.9
Households*
All__________________________________
Households
5________________
35.2 |
,
■■
51.0
28
52.9
25.5
21.7
259.5
16.7
2.7
4
9.9
518.8
42.9
6.9
10.3
25.4
8.0
12.9
6.1
12.5
15.1
36.6
48.2|
35.6
48.6
49.8
55.4I
38.9
58.3
38.9
35.1
67
26.4
0.26
8.8
17.4
178.7
_82.4
_0.8
27.5
54.3
44.3
45
50.3
40.5
150.4
122.3
11.3
16.8
314.5
240.9
33
43.6
6
3.6
7.8
7.5
34.7
26.9
30.9
38.1
59.3
69.5
61.3
54.3
28.3
4.8
6.9
15.4
71.43
13 1
18.4
39.9
67.7
68.5
54.5
54?6
92.4
78.4
10.2
3.8
161.6
137.1
17.8
6.6
0.9
1.9,
2.5
2.5
17.3
8.2
20.6
18.7
81.8
89.9
76.9
78.7
12.3
3.1
5.7
3.4
24.9
6.3
11.5
6.9
40.8
325.5
66
6.9
40.3
52.8
126.1
14.3
585
585
4.9
35.5
59.6
193.1
193
59.8
Source: Table has been generated using the NSSO report 409 for 1993-94 data. Government of'India (1997)
T--
rigures are r^rnnriipd ncinn tahio a
—-
-
wr
W V-l I II I rd II l_J|
II IVJIO I • ZJ
oc
mooz-i______ .
~ — ~...w ..www
% y.f oiiu oiiiiudi icpvii Ministry
/ I
'
?/2h.e.N®S? LepOrt.<'99? an<J annual r_eP°rt Minis'n; °< 'at™ (2000) and Economic Survey (2001)
For the organised employment, we do not have the break up by rural and urban areas For organised
sector, the classification is either by industry or by public and private sector Employment figures under Governmont
are deducted from the services sector under industrial classification
•TXt™o™eoThTb7u2XUla'iOn d0Vered 3re eTa,ed in ,he °r9an'Sed 5eC’°r by C°nSiderin9 ,he ra,'0S
d and '°'al Varies in ,he unorgan,sed sector
..
column person!Tby actMty
'
n0' re9U'adV emP'Oye<)'
emplOyed'
»llyye“dld S,a,US inClUdeS a" n°n empl°yed Under ,he relevan' hOUSehOld S,alUS 01 lhe
The- indude students, infants, beggars, homemakers, pensioners etc. These
are put under the
"ousehofds in this cotumn wili include oniy those persons where no person in the household
All agricultural labour has been taken as the casual labour and other labour has been treated as regular employment in the rural areas
oource : Charu Garg, background paper, 2001
258
Annex 12.7
How Employees are Paid for their Healthcare
TaxSocial
(Private
F
Employers Out of
___________________ [Financed
Insurance insurance Schemes
------------ >
Pocket
Regular Salaried employment
Government
Defence, police etc.
Railways
Agriculture
Manufac- organized sector**
Manufac- unorganized sector**
Services
Self Employment
Agriculture
Non Agriculture
Casual wage Employment
Agriculture
Non Agriculture,***
Others not classified
anywhere++
Percent of total health
Expenditures
• These percentages are approximations and not based on any evidence.
Approx. P% of ,
health exp.*
__________ ]
5.1
2.6
2.2
1.1
10.4
9.5
8.6
24.4
9.3
11.6
5.9
9.3
100
Note : The darker the shade of the grey in the table, the higher is the contribution of the specified
source.
259
h
Annex 12.8
Utilization of Health Services and Average Expenditure Incurred for Treatment
__________________________ as Outpatient and Inpatient______________
1986-87
1993-94
1995-96
Rural
Urban
Rural
Urban
Rural
Urban
% of ailing persons not treated
18
11
12|
8
17
9
% treated as Outpatient(OP)
Public
26
28
42;
34
19
20
Private________
74
72:
58
66
81
80
% treated as inpatients (IP)
Public
60
60
61
60
44
43
Private_____________
40
40
39;
40
56
57
Average payment for OP treatment/episode (Rs)
(At current prices)
Public
74:
73
65
129
166
Private
78
811
123j
141
186
200
All____
76
79
93|
115
176
194
Average Payment for OP treatment/episode (Rs)
(at constant 86-87 prices)
Public______________________ _____ 73
74
27
35
48
64
Private
_____ 78
81
65
75
74
81
All
_____ 76
79
49
61
69
78
Average Total Expenditure for I 3 treatment/episode (Rs)
(at current prices)
Public
722
653|
559,
452
2080
2195
Private
1156
1570;
1876
2336
4300
5344
All_________________________
886
1007|
1076
1210
3202
3921
Average Total Expenditure for I P treatment/episode (Rs)
_______ (at constant 86-87 prices)
Public
722
653
297_____ 240
912
963
Private
1156
1570
998
1243
1886
2344
'All
1007,
886
572
644
1404|
1720
Note:
(i) Data for 1993-94 relates to the survey by NCAER and for 1986-87 and 1995-96
data relates to a surveyby NSSO in their 42nc and 52nd round.
(ii) Consumer Price Index was used to convert the data from current to constant
prices.
Source: Garg 2000.
For 1986-87 data: NSSO (1992)
(i)
(>«) For 1993-94: Garg (1998) Compiled from the tables in Shariff et al (1998)
51l
(iii)
GOI (1998)
260
11
Annex 12.9
Revenue Receipts of States (Rs. Crore)
Variation
Items
1
1997-98
(Accounts)
2
1998-99
(Budget
Estimates)
3
1998-99
(Revised
Estimates)
4
Total Revenue (I ♦ II)
170300.8
203106.0
(200136.4)
189118.4
I Tax Revenue (A*B)
121640.6
147094.4
(144918.5)
134419.8
1999-2000
(Buoget
Estimates)
Col.4 over Col.2
5
157138.3 !
Col.5 over Col.4
Amount
Percent
Amount
Percent
Amount
Percent
6
7
8
9
10
11
11.0
-13987.6
(-11018.0)
-6.9
(-•5)
31035.7
(25622.3)
16 4
(13.5)
12779.2
10.5
-12674.6
(-10498.7)
-8.6
(-7.2)
22768.5
(19458.6)
16.9
(14.5)
f
220*54.0 I 18817.6
(214'40.7) ;
(1538'34)
Col.4 over Col.3
-
A. Revenue from States
Taxes (I to iii)
81229.4
100393.0
(98217.1)
93530.7
111317.6
(108007.7)
12301.3
15.1
-686.3
(-4686.4)
-6.8
(-4-8)
17786.9
(14477.0)
19
(15.5)
(I) Taxes on Income (a+b)
1085.8
1235.3
(1235.9)
1363.2
1524 9
277 4
25.5
127.9
(127.3)
10.4
(10.3)
161.6
11 9
(a) Agricultural Income Tax
182.0
131.0
(131.6)
181.9
1976
-0.1
-0.1
50.9
(50.3)
38.9
(38.2)
15 7
86
(b) Tax on Professions.
Tr-;1es Callings and
Employment
903.8
1104.3
1181.3
13273
277.5
30 7
77.0
7.0
145 9
12 4
(ii) Taxs on Property and
Capital Transaction (a to c)
8313.7
10860.7
(10585.9)
9450.8
111984
(10980.9)
137.1
13.7
-1409.9
(-1135.1)
-13.0
(-10.7)
1747.6
(1530)
18 5
(16.2)
(a) Stamps and Registration
fees
7143.0
9118.8
(8879.5)
9078.0
9469.0
(9372.5)
935.0
13.1
-1040.8
(-801.6)
-11.4
(-9.0)
1391.0
(1294.5)
17.2
(16.0)
(b) Land Revenue
1090.6
1656.4
(1620.9)
1305.8
1651.2
(1530.2)
215.2
19.7
-350.6
(-315.1)
-21.2
(-19.4)
345.4
(224 4)
26 5
(17.20)
© Urban Immovable Property
Tax
80.2
85.5
67.0
78.2
(iii) Taxes on Commodities
and Services (a to g)
71829.9
88297.0
(86395.4)
82716.7
(a) Sales Tax *
48841.8
59643.9
(58825.0)
(b) State Exercise Duties
11270.7
|
-13.2
-164
-18.5
-21.6
11.1
166
98594 4
(95502.0)
10886.8
15.2
-5580.4
(-3678.7)
-6.3
(-4.3)
15877.7
(15785.3)
19.2
(15.5)
55930.0
65003.1
(64154.1)
7088.1
14.5
-3713.9
(-2895.0)
-6.2
(-4-9)
9373.1
(8224.1)
16.8
(14.7)
13628.6
(13568)
13680.9
16157.9
(16033.6)
2410.2
21.4
52.3
(112.2)
0.4
(0.8)
2477.0
(2352.7)
(17.2)
!
18.1
©Taxes on Vehicles
4853.9
5841.2
(5637.0)
5343.5
6317.9
(6173.2)
489.6
10.1
-497.7
(-293.5)
-8.5
(-5.2)
974.4
(829.7)
18.2
(15.5)
(d) Taxes on Passengers and
Goods
2003.9
2401.6
(2390.3)
2090.5
2677.1
86.6
4.3
-311.1
(-299.8)
-13.0
(-12.5)
586.6
28.1
(e) Electricity Duties
3194.2
4070.0
3853.7
4635.2
(4424.2)
659.5
20.6
-216.3
-5.3
781.5
20.3
(f) Entertainment Tax
664.6
710.9
680.4
757.0
(743.4)
15.8
2.4
-30.5
-4.3
76.6
11.3
(g) Other Taxes and Duties
1000.7
2000.9
(1193.5)
1137.3
2746.2
(1296.5)
137.0
13.7
-863.1
(-55.7)
-43.1
(-4.7)
1608.4
(158.7)
141.4
(14.0)
261
d
Items
1997-98
(Accounts)
1998-99
(Budget
Estimates
1998-99
(Revised
Estimates)
1999-2000
(Budget
Estimates)
Amount
1
2
3
4
5
6
7
B. Share in Central Taxes (a
to c)
40411.2
46701.4
40889.1
45870.7
477.9
(a) Income Tax
18171.2
18860.5
14980.0
17441.6
(b) Estate Duty
0.2
0.0
0.0
0.0
© Union Exercise Duties
22239.8
27840.9
25909.2
II Non*tax Revenue (C+D)
48660.2
56011.6
(55217.8)
C. Grants from the Centre
24222.5
D. States own Non-Tax
Revenue (a to f)
Col.4 over Col.2
Variation
Col.4 over Col.3
Percent Amount
Col.5 over Col.4
Percent
Amount
Percent
8
9
10
11
1.2
-5812.3
-12 4
4981.6
12.2
-3191.3
-17.6
-3880.6
-20.6
2461.7
164
28429.1
3669.4
16.5
-1931.7
-6.9
2519.9
9.7
54698.5
62965.8
(60862.3)
6038.4
12.4
-1313.0
(-519.3)
-2.3
(-0.9)
8267.2
(6163.7)
15.1
(11-3)
28306.2
30091.1
33701.1
5868.5
24.2
1784.9
6.3
3610.1
12.0
24437.6
27705.4
(26911.7)
24607.5
29264.7
(27161.2)
169 9
0.7
-3097.9
(2304.2)
-11.2
(-8.6)
4657.2
(2553.7)
18.9
(10.4)
(a) Interest Receipts
7909.8
6879.5
7513.3
7399 6
-396.5
■5.0
633.8
9.2
-113.7
-1.5
(b) Dividends and Profits
94.2
122.0
116.2
2174
22.0
23.4
-5.8
-4.8
101.2
87.1
© General Services
Of which:
State Lotteries
6419.5
6908.2
5114.0
6069 6
-1305.6
-20.3
-1794.2
-26.0
955.6
18.7
3257.7
3764.5
2246.7
3607.2
-1011.0
-31.0
-1517.8
-40.3
1360 4
60.6
(d) Social Services
1685.5
1546.3
1726.4
1775.9
40.9
2.4
180.1
11.6
49.5
2.9
(e) Economic Services
8327.8
12249.2
(11455.5)
10137.5
13802.1
(11698.6)
1809.7
21.7
-2111.7
(-1318.0)
-17.2
(-11-5)
3664.6
(1561.1)
36.1
(15.4)
0.8
0.1
0.1
0.1
-0.8
-87.5
(f) Fiscal Services
Note :
1 . Figures for Jammu and Kashmir and Nagaland for 1997-98 (Accounts) relate to Revised Estimates.
2. Figures outside brackets under the year 1998-99 (Budget Estimates) are adjusted for Rs.2969.6 crore
towards Additional Resource Mobilisation Measures proposed by the States.
Figures outside brackets under the year 1999-2000 (Budget Estimates) are adjusted for Rs.5413.4 crore
towards Additional Resource Mobilisation Measures proposed by the States.
Comprise General Sales Tax, Central Sales Tax, Sales Tax on motor spirit and Purchase Tax on
sugarcane,etc.
Source : State Governments' Budget Documents, reproduced from Reserve Bank of India Bulletin,Vol.IV
No. 1 .January 2000.
3.
i
262
Annex 12.10
Property Tax in Municipal Revenues
States
Per capita property tax
(in Rs)
Population
1991
(in
million)
1992-93
1997-98
Andhra Pradesh
Assam
Bihar
Gujarat
Harayana
Himachal Pradesh
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Orissa
Punjab
Rajasthan
Tamil Nadu
Uttar Pradesh
West Bengal
Manipur
Meghalaya
Tripura
86.94
9.52
12
17.19
44.41
208.89
37.17
42.41
22.82
83.34
2.05
19.83
13.58
86.32
21.65
132.5
0.22
37.41
10.57
141.79
11.75
29.51
165.9
60.6
237.41
57.62
62.74
29.64
146.64
2.54
25.66
30.1
83.43
27.33
206.3
2.23
51.09
27.69
17.88
2.48
11.35
14.24
4.05
0.44
13.90
7.68
15.33
30.54
4.23
5.99
10.06
19.07
27.60
18.70
15.33
30.54
India
65.79
105.68
Total property tax (in Rs.
million.)
1992-93
1997-98
0.03
1554.49
23.61
136.20
244.79
179.86
91.91
516.66
325.71
349.83
2545.20
8.67
118.78
136.61
1646.12
597.54
2477.75
3.37
1142.50
0.32
2535.21
29.14
334.94
2362.42
245.43
104.46
800.92
481.84
454.38
4478.39
10.74
153.70
302.81
1591.01
754.31
3857.81
34.19
1560.29
0.83
217.61
14316.56
22997.02
Source : Survey of 245 Municipalities conducted by the National Institute of Public Finance and Policy for
the 11th Finance Commission, 2000
263
H
13
External Assistance to the Health Sector
Introduction: An Overview
External assistance in India is small in terms of its proportion to the
GDP. In health, it has never been more than 1-3% of the total public
health spending in any given year. Yet external assistance has had a
profound impact on health: technical support obtained from such
assistance has made a significant contribution to hastening India's
demographic and epidemiological transition.
According to the UNDP’s Human Development Report (1992),
development assistance from industrialized countries was equivalent to
0.35% of their combined GNP against the 0.7% norm recommended by
the UN General Assembly. This assistance was, however, not uniformly
spread - the 10 countries accounting for more than 72% of the world’s
poor received hardly 27% of total Official Development Assistance
(ODA). During the last two decades, the total ODA to India increased
steadily from about $2 billion in 1980 to S9 billion in 1988, then came
down to about $1.5 billion in 1998. The present position is not radically
different. With its large numbers of the poor, India was a natural
candidate for external assistance. Yet, per capita, the ODA received
was $2.8 in 1992 and $1.6 to 1998, while Thailand got $13.5 and $11.3
respectively. In fact, for the same years, India received the lowest ODA
per capita in 1998 among selected countries (Table 13.1).
Table 13.1
ODA Received by Selected Countries
Country
Total
(US$m)
1992 1998
As % of GNP
Per Capita
1992
I 1998
1992
1998
$
Thailand
770
690
0.7
0.6
13.5
11.3
China
3045
2358
0.7
0.3
2.6
1.9
Sri Lanka
639
489
6.6
3.2
36.2
26.1
Indonesia
2075
1257
1.6
1.3
11.3
6.2
India
2430
1594
0.9
0.4
2.8
1.6
I
I
Source: Human Development Report. 2000
264
Ii
Till about 1992, more than half of the ODA was for the power sector,
and another 40% for industrial development and agriculture. The social
sector accounted for less than 8% (1); the estimate for the health sub
sector is not more than 3%. This appears to be changing for the years
1990-98 (Table 13.2).
Table 13.2
Percentage Health to Total ODA - 1990-1996
Indicator
1990-92
1993-95
1996-98
—|
9.6 bn
8.7 bn
9.3bn
Overall ODA
|
Amount for Health_________________________________
305 mn
268 mn
623 mn I
Source: D.B. Gupta, External Assistance to Health Sector, Background Paper, 2001
Since the mid-nineties, there has been an increase in the quantum of
funding; more importantly, there has been a perceptible shift in the
content of funding compared to earlier years. Till 1994, donor aid was
by and large in the area of family planning, primary healthcare and
MCH. Most of the 142 health projects under implementation were for
primary healthcare and immunization programmes, with a focus on
projects related to the strengthening of service delivery, capacity
building, training and IEC (2). From 1995, the portfolio for external
assistance changed in terms of size and scale of funding, indicating a
decline in the share of Family Welfare as a percentage of total donor
aid to health (Table 13.3).
Table 13.3
Project Profiles in Health - 1991-95
1991
1992
1993
1994
1995
(Planned)
I Sectoral Policy
11.8
16.3
13.4
30.9
58.8
Primary Health
43.4
40.9
32.6
33.3
15.1
UIP/Disease Control
33.7
33.9
50.5
31.2
25.2
■ Family Planning
9
7.6
3.2
2.1
0.58
I Hospitals
1.9
1.1
0.17
2.4
0.16
I All
100
100
100
100
100
Indicator
Total Health $m
__________________________
204
152
152
338
572
Source: India: Development Co-Operation Report 1994, UNDP, November 1995
265
u
Nature and Extent of Aid
During the initial years of development, external assistance to health
was in the form of grant in aid, largely from bilateral donors such as
USAID, DFID and SIDA, for specific programmes in ffamily
..j planning,
leprosy and malaria eradication. Assistance under the IDA of the
...j World
Bank constituted about 10-20% of total external aid flows to health,
and this was mainly utilized for the construction of sub -centers, postpartum facilities and family welfare centers (Table 13.4).
Table 13.4
Funding during 1970-80
S.No.
Agency
Amt/
$m.
% To
Total
Main Purpose
1.
USAID
493
57.4
Area Projects in FP
2.
UNICEF
134
15,6
Nutrition
3.
World Bank
91
—
10.7
Infrastructure
UNFPA
42
I 4.
Area projects
4.9
5.
FORD/ROCKFELOR
15
1.9
Family Planning
6.
SIDA, NORAD, DFID
26
3.2
FP/ Disease Control
.j
TOTAL
_________________________
100806
Source: R. Jaffrey, New Patterns In Health Sector Aid (3)
With the introduction of the India Population Projects in the early
eighties, the World Bank gradually emerged as the principal donor.
Funds were provided under these projects for the construction of health
centers, the provisioning of equipment and supplies, and the training of
health workers. Between 1980-90, the Bank funded 7 India Population
Projects for a total outlay of about $744m, increasing its share of total
aid to 45%. This period also saw an expansion in the lending portfolio
of other bilateral donors, who increased their assistance for disease
control programmes - leprosy, malaria, TB and blindness. A major
innovation was UNICEF fund support to establish the cold chain
infrastructure for the nationwide campaign against vaccine-preventable
diseases.
Till 1990, except for the control of malaria and leprosy, disease control
programmes did not receive the attention they deserved, partly
because of the precedence given to population stabilization by the
government; and partly because of the health sector’s low priority in
the development paradigm. Foreign aid was mobilized essentially for
technology and the economic sectors. The strategy changed with the
266
11
introduction of liberalization policies: ~acroeconomic compulsions and
the process of economic reform also triggered a series of
developments. The role of external assistance for health became more
pronounced with the convergence of several unrelated developments:
> the emergence of HIV/AIDS and the increasing concern with
controlling infectious and communicable diseases as a
consequence of globalization;
> the adverse balance of payments forcing India to mobilize
foreign exchange, preferably on concessional terms, which
was available for health;
with the collapse of the Soviet model, a redefinition of the
State's role as more primarily concerned with health and
education;
> the growing frustration of bilateral and multilateral donors
with the lack of adequate efficiencies in delivery systems,
resulting in poor implementation and low fund absorption;
and
> the IMF and World Bank strategy to push through the
process of structural adjustment with “a human face."
The real change in the nature, scale and depth of donor aid to health
began in 1992 with World Bank assistance for HIV/AIDS, followed in
quick succession with lending for the control of leprosy, cataract
blindness, malaria and TB. The Bank recently approved the second
phase of lending for leprosy and HIV/AIDS; substantial assistance has
also been given to reproductive health - which includes traditional
concerns with MCH, as well as the control and prevention of
reproductive tract infections. Proposals are also being considered at
present for IDA funds to establish a nationwide surveillance system
and capacity building for food and drug regulation. (See Table 13.5 for
a significant increase in Word Bank assistance in the last ten years
and a perceptible decrease in bilateral funding.)
The rapid expansion of primary healthcare facilities as a part of the
Minimum Needs Programme was at the cost of reduced investment in
district and sub-district hospitals, affecting the development of a
referral system. Poor-quality services resulted in the proliferation of
the private sector and consequent out-of-pocket expenditure on minor
ailments, communicable diseases, deliveries and respiratory infections.
Analyses of public health spending were followed up with the financing
of a series of State Health Systems Projects (SHSP). District hospitals
(4), area hospitals at the sub-district levels, and community health
centers (CHCs) at the block level are being upgraded and strengthened
through these projects (Table 13.6).
267
11
Table 13.5
External Assistance bv Major
in US $/m
—Donors
|
Agency
World Bank
Amt. in US $M
Nature of Project
I
2126
Disease
FW
16
RCH
UNFPA
43
Population
DFID
148
ITB, HIV /AIDS
USAID
415
FW, HIV/AIDS
EEC
191
Sector Investment-FW
Sub-Total
2939
i UNICEF
Control,
SHSP, i
_ _____ I
4
I
I
1
J
I Total Health________________________________
3031
Source: Compilation of ECTA, EEC. 2C00. Delhi. For Detailed List see Annex 13 1'
Table 13.6
List of World Bank Assisted State Health Systems Projects
(Amount in US $m)
State________ Year
Andhra Pradesh
1995
Amount
135
| Karnataka
1996
121
West Bengal
1996
155
I Punjab
1996
94
Orissa
1998
93
Maharashtra
1999
162
UP
2000
1100
Project Components
Distt/Area Hosp-74
CHCs1 -74____________
Distt/Area Hosp-128
CHCs’ - 74
Distt/Area Hosp-75
CHCs’- 131_____________
Distt /Area Hosp-59
CHC’s -91______________
Distt./AreaHosp-71
CHCs’- 85
Distt/Area Hosp-1 01
CHCs’-SS__________
Distt/Area Hosp-53
CHCs’ - 64
Source: MHFW, GOI
The State Health Systems Projects comprise an important milestone:
they have unintentionally shifted the role and direction of aid. The
projects have achieved several firsts:
• first massive infusion of capital in secondary care;
• the direct negotiation between the Bank and state governments that
prepared projects with few central inputs;
268
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•
•
the stipulation of some conditions on policy changes (user fees,
contracting out of services, institutional autonomy);
shifts in the aid policies of bilateral donors: donors seek to choose
project areas and focus on system issues such as the co-option of
private sector, NGOs and civil society; decentralization; client
satisfaction; and hospital autonomy.
Thus the DFID has gradually shifted lending to an area approach, with
assistance provided to projects in AP. Orissa, MP, West Bengal and
Kerala. DANIDA’s focus is on Karnataka, Orissa and MP. Both DANIDA
and DFID provide funds for disease control programmes (blindness,
TB, HIV/AIDS, leprosy); the EEC, a late entrant, focuses on the
improvement of delivery systems at the district level. USAID
concentrates funds on three major projects - HIV/AIDS (TN),
population control (UP), and the establishment of the National Institute
of Biologicals (NIB) for the quality assurance of vaccines. There has
been a convergence of all donors in the Polio Pulse Programme:
pooled bilateral and multilateral funding support the National
Immunization Days Initiative for polio eradication. Donors such as SIDA
or NORAD have mainly provided funds for special programmes such as
CSSM (5), and leprosy/polio eradication, through a consortium of
donors or through the WHO.
While all donors without exception have focused on primary healthcare,
only JICA (6) has assisted initiatives to bridge the investment gaps in
strengthening tertiary care. JICA has provided about $20m toward a
state-of-the-art Childrens’ Hospital in Delhi; towards super specialized
diagnostic and medical equipment in Osmania Medical Hospital,
Hyderabad; and towards funds for critical equipment such as CT Scans
and Linear Accelerators to over 15 Cancer Centers. JICA (and now
France), have substantially assisted the Sanjay Gandhi Hospital in UP
to establish a modern tertiary facility, and the NICED (7) in Kolkata in
its basic research on cholera. Finland has now offered to provide
interest-free loans for equipment in medical colleges in TN, Karnataka
and Assam.
Of all donor agencies, the WHO occupies a unique position as the
designated UN organization for health. In India, WHO assistance is on
a special footing as it is the only agency whose funds are outside the
budgetary mechanism. About $1 Smillion is provided on a two calendar
year basis for studies/surveys/evaluations; for the training of technical
personnel within or outside the country; for the procurement of small
equipment, essential drugs and medicines for emergencies; and for the
mobilization of technical expertise. For priority programmes, the WHO
provides funding under the Extra Budgetary Mechanism - on average,
about $30-50m every biennium. Of late, the WHO has sought to
strategize global health by focusing resources on identified priority
areas such as TB, HIV/AIDS, polio eradication, safe motherhood and
269
11
tobacco control, and by identifying parameters and indicators for
increasing the sensitivity of health systems to the needs of the poor.
The influence of the WHO on international health is disproportionate to
the quantum of assistance. It is the main certifying agency on all
matters of health standards and safety, setting global priorities and
international agenda in health, and mobilizing resources and political
support through advocacy and research. The profound influence of the
WHO on Indian health policy is indicated by the manner in which the
health agenda has been steered, from the priority given to the
eradication of communicable diseases, to selective primary healthcare
as a follow-up of the 1987 Alma Ata Conference, to the focus on
HIV/AIDS, polio eradication, tobacco control and the reform of health
systems. The WHO’s importance to developing countries can only
increase - as a forum to mobilize international consensus and
moderate the negative impact of global arrangements under WTO and
the Codex Alimentarius Commission; and to support the access of the
most deprived to the fruits of global technology and development. By
making a moral case for investing in health, the WHO has secured the
support of the G-8 countries in providing medicines, vaccines and
diagnostics to meet the target of 50% reduction in TB and malaria
mortality by 2010.
Sector Work:
The research undertaken on health financing and health system issues
has been a significant development: the World Bank took up an
assessment of public sector health expenditure at central and state
levels in 1992, and the financing of primary healthcare in 4 states.
These studies, carried out by NIPFP (8) and NCAER (9), contributed to
the understanding of the utilization of public funds at tertiary,
secondary and primary levels - between centre and the states,
between public health and medical care, and between rural and urban.
In 1992-93 followed disease burden estimations by the Administrative
Staff College of India. Such estimations, based on hospital data,
helped in understanding disparities in the epidemiological shifts taking
place in the country, laying the ground for differential approaches that
need to be adopted in health planning. The health sector work led to
greater lending by the Bank. More studies - on referral systems, on the
functional distribution of work at different levels, and on the physical
standards for facilities - were taken up by the state governments with
negligible central involvement. This approach set a trend. DFID also
took up sector work on these lines in West Bengal to improve
efficiencies in hospitals, the contracting of services, the financing of
PHCs, hospital autonomy, cost effectiveness studies, procurement
systems, and decentralization. The World Bank assisted set of studies
recently undertaken by Indian researchers - in insurance, benefit
incidence analysis, dynamics of the private sector, consumer law,
patient grievance redressal systems, pharmaceuticals - will have great
value for drafting legislation, for legal frameworks regulating the
270
iI
private sector, and for the protection of patients from market
distortions. Thus donor lending has gradually shifted from passive,
programmatic assistance to the central government, to a more direct,
active role in influencing and building the capacity of governments to
initiate health reform. These shifts reflect changes in the international
environment - the evolution from disease control to system issues and
governance.
Impact of External Assistance
The impact of external assistance on efforts in disease containment
and health policy has been significant and positive. In the initial years,
India depended a great deal on WHO technical expertise for small pox
eradication, malaria control and the development of technical capacity
in public health. The establishment of the Technology Mission for the
Universal Immunization
Programme (UIP) attracted
substantial
assistance from a UNICEF-led consortium of donors to establish a cold
chain and to supply associated inputs. This helped upgrade
infrastructure, and enabled campaigns against vaccine-preventable
diseases, significantly reducing the disease load among children. India
has virtually eliminated polio with the assistance provided on an
unprecedented scale for the Polio Pulse Campaign. These successes
have strengthened and expanded the original design of the MCH
programme into a comprehensive RCH (10) strategy, with a primary
focus on the reduction of maternal and child mortality. Externally
funded projects have also been more flexible of late, providing scope
for innovation: among examples of innovative features are the co
option of NGOs, the contracting of private service providers, hospital
autonomy to improve managerial efficiencies, and encouraging the
retention of user fees at the institutional level to enhance
sustainability.
External assistance has enabled technology transfer and influenced the
technical strategies adopted for containing disease. In the malaria
programme, attention has shifted from case finding and blood smear
examination to radical treatment. Changes have been introduced in the
technical strategies in DDT-resistant pockets, and personal protection
has been provided through the use of impregnated bed nets. In the TB
programme, the successful implementation of the DOTS strategy and
its rapid expansion are largely due to technical assistance from
external donors. This strategy can be strengthened with the
establishment of the Global Drugs Facility (11) to provide developing
countries with TB drugs as in the case of leprosy.
Advocacy for political and administrative support to HIV/AIDS is also
due to support from donor aid agencies; while leprosy eradication is
virtually on account of the coordinated global effort of NGOs, donor
countries and multilateral agencies. In the Blindness Control
Programme, external assistance has helped build infrastructure for eye
271
[I
care, doubled the number of cataract surgeries and drastically brougn:
down the cost of lOLs (12), expanding the access of the poor to
improved technology. The policy of establishing district level societies
to facilitate fund absorption, and enable greater accountability,
emerged from externally funded projects. Finally, in view of the inflow
of external assistance, the budgetary outlays for disease control have
increased substantially. In proportion to the total Central (Plan) budget
for Health and Family Welfare, external assistance has steadily
increased to about 35.8% (Table 13.7).
Table 13.7
Percentage of ODA to Central Health & Family Welfare Budget Plans (Rs./Crores)
Period
1990-91
1992-93
1994-95
1996- 97
1997- 98
1998- 99
1999- 00
2000- 01
2001- 02
i
Health
EAR % EAR FW Budget
EAP
Budget
275
25
9
I_____
302
68
23
1000
I 188
578
193
33
1430
352
722
323
45
1535
350
920
324
35
1829
513
1145
479
42
2489
1 763
1160
467
40
2920
676
1300
480
37
3520
| 1278
1450
629
4210 43
___________________
1402
Source: Department of Health, GOI (all figures rounded)
%
EAR
19__
24___ ■
23__
28__ ,
30__
23__
36
33 I
Over the years, donor assistance has evolved from specific project
lending, to programme assistance, to system improvements. The shifts
in focus have not been entirely free of conflict, or inconsistency, or
lack of clarity. Nor have they been entirely free of the problems caused
by the absence of a forward-looking strategy. The absence of a
strategic approach has been caused by inter-departmental tensions
and conflicts of interest; by resistance to change; and by differences in
perception among policymakers, project managers and donors about
the need for reform. Besides, a supporting environment and a broad
social consent for change is necessary for any restructuring or major
policy shift. This unevenness of outcomes has sometimes created
problems, but it has also offered valuable lessons.
> Hospitals at the block level have been upgraded under the
World Bank Assisted SHS Projects, entailing increases in
recurring costs. Since this addition to the non-plan
expenditure has come at a time of fiscal crisis, the
sustainability of the assets created is in doubt. The levying
of user fees to mobilize resources has also not solved the
problem everywhere due to a large number of free riders.
The conflict arises primarily where the implementing
agencies show alacrity in fulfilling the hardware part of the
project but ambivalence in the software part, on account of
a fundamental confusion regarding the full import of reform,
272
11
or on account of a lack of leadership to steer the process.
This could lead to a situation where the donor finds thaMhe
investments made are not yielding optimal returns, and that
the basic objective of protecting the poor’ remains
unrealized.
> The procurement systems of the donors, particularly of the
World Bank, are needlessly complicated, affecting the
primary task of technical persons at central and state levels
in providing technical guidance in the field.
> The
donors’
attempts
to
broad-base
programme
implementation, through the inclusion of locally elected
representatives and Panchayat Raj bodies, is viewed by
implementing agencies as an intrusion into areas of
governance not germane to the health sector.
r- External assistance is perceived as often creating islands
of excellence, where projects have their own separate
administrative set-ups and reporting systems, as in the
Polio
Pulse
or
DOTS
programmes.
Doubts
about
sustainability remain after the cessation of assistance.
> The lack of coordination among donors leads to the
duplication of aid, exacerbating the existing fragmented
structure of health. For example, every disease control
programme has a distinct district-level society with health
promotion budgets. Thus overall impact is diluted despite a
plethora of projects.
Utilization of External Assistance:
Compared to authorized assistance, utilization has on average
average been
been
below par, not because the country cannot absorb the funds but for
administrative and procedural reasons.
Mismatch between budget allocations indicated to the implementing
department and assistance agreements with donor agencies: To
avail external assistance, departmental budgets have to provide for
counterpart funding and the Planning Commission has to provide
plan outlays commensurate with commitments. Inadequate allocation
of budgets means low spending, thereby affecting absorption (Table
13.8).
• Inadequate preparation of projects: The IPP VI and IPP VIII projects
had little relevance to ground realities and had to be changed
considerably on implementation. In IPP VI, the training strategy had
to be changed; in IPP VIII, a project (for Metro cities) had a poor
start because municipal bodies had not been consulted in the first
place.
•
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Table 13.8
Budgetary Funding and External Aid for Disease Control Programmes
(Rs. in crores)
Utilized
Programme
Amount of Credit
Year/Period of
as or
%
Implementation
20.3.2001
Utilized
AIDS/HIV
Ph-1: US $ 84 m
1993-1998
Phase II : 1425 crores*
TB
Fully
utilized
100
1 999 (5 years)
160
11
342.42
1 997 (5 years)
216.64
62%
Leprosy
292.13
1 993 (6 years)
Fully
utilized
100%
Blindness
470
1994 (8 years)
296.1 1
63%
Malaria
891.04
1 997 (5 years)
182.35
!
20%
World Bank (1,155 crores) ; DFID (104 crores); USAID (166 crores) = 1,425 crores.
Source: MHFW, GOI
Multiple goals and sub-goals in excess of implementing agency
capacity:
Often,
projects
contain
concepts
beyond
the
comprehension of field officers. The concept of contracting out
requires skills in drafting out agreements, specifying deliverables as
well as providing penalties in case of default. Similarly, releasing
substantial funds to NGOs without appropriate
verification
procedures and indicators for progress evaluation can cause
problems.
• Unrealistic time frames: While the total duration of most projects is
five years, the procedures to obtain approvals before procuring
equipment or construction of civil work takes a year. No civil work
can be taken up without the prior approval of donor-appointed
architects. The procurement of any equipment or consumables under
the International Competitive Bidding process requires the World
Bank's clearance at least four times - after the finalization of
technical specifications, before placing the indent, after bid
evaluation and before placing orders. Unless the procedures are
simplified or unless projects provide a year for preparatory action,
projects will invariably be delayed or show low fund absorption.
• Inadequate matching of financing and scheduling of project
activities: Undue pressure on budget utilization and filing claims for
reimbursement can force programme managers to take up any
activity that absorbs funds, regardless of sequence. Though the civil
works may not have begun, equipment may be procured. By the time
the building is completed and the equipment installed, the warranty
period is over. Or training may precede availability of equipment; or
IEC is not taken up at all for want of infrastructure in place.
Processes are sacrificed in the anxiety to spend funds; in the long
•
274
H
Zjec^suTtXbmty
9^"56 'impact
mpaCt °
an adverse
onn the qUality °f °UtCOmeS and
’
^elay,inJilling W staff positions: At the time of implementation
there is hesitation in filling agreed staff positions for fear of placing
an unsustainable burden on finances in the long run
Such
prevarication in carrying out agreed components has an adverse
impact on fund utilization as well as programme quality. In the
Gataract Blindness Control Programme, the state governments'
inability to create posts - of eye surgeons, ophthalmic assistants
and nurses
not only resulted in savings, but also in the nonu i ization of operation theatres and operating microscopes The
thSU nna,S fhe fai|ure to meet targets. Similarly, the JICA project
the 300-bed, Rs.50 crore Kalavathi Saran Hospital, is not fully
operational even after a year of being commissioned, for want of the
required specialists and support staff. This has led to the under
utilization of capacity and equipment.
Delayed completion of projects due to system deficiencies: Project
completion takes an average of 7-8 years in India, double the period
in China. Thus India will have to quickly resolve some of these
factors to make more effective use of external assistance.
Lessons Learnt:
The overall decline in external assistance from bilateral donors needs
serious analysis, and a policy paper on external assistance outlining
India s strategy for donor aid is also required. To create a more
conducive environment for external assistance, it is necessary to
spend
more
time
on
project
preparation
and
increase
consultation with the stakeholders from the conception stage;
•
reform the system of financial planning and accounting: Once an
agreement is made, project funds must be kept apart, and directly
released on demand to project authorities. Recent steps to
constitute district and state-level societies has helped the quicker
absorption of funds and promoted the sharing of responsibility.
These societies must be strengthened with the appropriate capacity
and skills in monitoring, account keeping, project planning and
management.
•
modify financial systems: Under the current system of budgeting
(plan and non-plan), funds for the maintenance of assets get
transferred under non-plan, and get lost in salaries and wages for
example. The non-availability of timely and adequate funds for
maintenance is one of the reasons for the non-repair and non-use of
expensive equipment supplied by projects
•
identify the project team - technical, administrative and
accounting: The project team must be appointed well i.,
in advance,
after careful selection, and they must be trained thoroughly' on the
275
d
project aims, objectives a~ z procedures. They should then be
accountable for shortfalls sr.c not shifted from their positions till
project completion.
•
include preparatory time of a year in every project to complete
formalities (land acquisition, approval of building plans,
technical specifications for equipment, development of training
modules): This helps avoid cost over-runs or the low utilization of
assistance in the initial years. Budgeting should also be sequential
to ensure that training and other capacity building activities are
taken up after the infrastructure base is ready. This will again
require changes of budgeting and releasing of funds. The budget is
indicated under different minor subheads (grant in aid, commodity
assistance, central and state). Funds in central budgets, for
instance, can be released only in four equal installments during the
year. Instead, there should be flexibility to release allocated funds
when needed. In the blindness control programme, the construction
of operation theatres, the procurement of microscopes and the
training of doctors in IOL surgery could have been taken up on
priority in the initial years, followed by demand generation for these
services and beneficiary coverage. The absence of a sequential
approach has resulted in fragmentation, the repetition of activities
such as procurement year after year, and confusion in the field due
to the mismatch in the delivery of the mix of inputs.
•
identify and train the critical mass of technical persons required
at central and state levels: Providing adequate incentives will
ensure these technical persons do not leave government
employment after being trained.
•
train state and project level authorities: One reason for the slow
absorption of external assistance is the poor ability of the state and
project level authorities to prepare projects in a way acceptable to
donors.
•
focus on developing a
monitoring at every level.
good
system
of
MIS
and
sound
Future Directions
Donor assistance has contributed significantly to the health gains in
India. The priority accorded to disease control and MCH, the broad
basing of the population policy to make it more comprehensive, the
early warning about the HIV/AIDS epidemic, and the assistance being
received to eliminate leprosy and polic. are all significant contributions.
Donor assistance is likely to get even more focused in the future
because of the growing clarity and convergence in the prioritization of
areas and concerns. Communicable and infectious diseases must be
contained. Inequity within and among nations must be reduced. Health
systems must be strengthened to cope with emerging challenges. And
global health must be improved by ensuring the access of the poor to
276
h
the benefits of new technologies, health services and a better
environment at the household and community level. It is in this context
that the meeting of the main western donors in 1996 assumes
significance. At this meeting, donors committed themselves to a set of
global targets to be achieved by 2015, with the support of the IMF and
the World Bank. The ones relevant to health aim to reduce maternal
mortality rate by three-quarters; infant and child mortality by two-thirds;
to ensure universal access to reproductive health; and to achieve 50%
reduction in HIV infection among 15-24 year olds. This commitment has
introduced a new urgency among donors to rearrange agendas. The
WHO (13) has identified new trends that will influence health in the 21st
century, and consequently donor profile. They are
> widespread absolute and relative poverty
> demographic changes: aging and growth of cities
> epidemiological changes: continuing high incidence
>
>
>
>
of
diseases
global environmental threats to human survival
new technologies: information and tele-medicine services
advances in biotechnology
partnerships for health between private and public sectors
and civil society
globalization of trade, travel and spread of values and
ideas.
Conclusion
India will continue to be dependent on donor aid, to provide the level of
capital investment required to improve infrastructure at primary and
secondary levels. External assistance will also continue to serve as the
catalyst to the improvement of systemic efficiencies and universal
access to healthcare, through appropriate restructuring. External
assistance can help India evolve a sustainable and equitable health
system; if improperly utilized, assistance can also result in a
dependency syndrome. Evolving a long-term strategy for external
assistance will help optimal utilization. The priority will have to be
the poor and the poorer states. This is to ensure reduction in inequity
and inequality in health; and to help states in the pre-transition stage
of epidemiological evolution, with maximum disease burden on account
of infectious diseases, to come on par with the rest of the country. It is
equally important to find the right balance between programmes and
system improvements. Given the low resource base and the poor
state of finances in most parts of the country, institutional capacity has
to be developed and strengthened for maximum gains from external
assistance.
277
u
Notes
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
RBI Report on Currency and Finance, 1990-91.
D.B. Gupta, External Assistance to Health Sector and Its Contribution
background paper commissioned for this Report.
R. Jaffrey, New patterns in Health Sector Aid, IJHS, vol. 16, no.1, p. 126.
Districts in India typically have a population of about 3 million people, s sub
district a population of about a million, and a block about 120,000.
Child Survival and Safe Motherhood - an improved programme over the
earlier Maternal and Child Health (MCH) Programme.
JICA: Japan International Cooperation Agency, an OD agency of the
Government of Japan.
National Institute for Cholera and Enteric Diseases, a WHO collaborating
center in Calcutta, West Bengal.
National Institute of Public Finance and Policy.
National Council of Applied Economic Research.
Reproductive and Child Health.
As of now, India is not included with China in the GDF. India feels it would be
unwise to exclude these countries as they account for more than ha f the
world’s disease burden on account of TB.
Intra Ocular Lenses: a technique where the lenses are implanted inside the
eye. The quality of vision restored under this procedure is found to be far
superior compared to conventional methods. At the start of the project in
1994, lOLs had to be imported and were available for Rs.2000; since then
they cost less than Rs.100, bringing them within reach of the poor.
Health for All in the 218t Century, WHO.
278
k
Development
Partner
DFID
Annex 13.1
Lisdof Externally Funded Projects under Implementation in India
Programme Name
Geographic
Key activities and focus
Coverage State
Time frame
Geographic Coverage
Status
__________ Districts______
RNTCP
Andha Pradesh, Central
RNTCP in the whole of AP., training, strengthening of
Central TB Division
West Bengal Sexual
Health Project
West Bengal
4/2001 - 3/2005
Madhya Pradesh
Health Guarantee
Scheme
Madhya Pradesh
10/2000-9/2005
Orissa Health & FW
Project Phase III
Orissa
10/98-9/2003
UNFPA
NGO Projects in
health, family welfare
and control of AI DS
integrated Population
and Development
On going
Proposed
Ongoing
36850
Bhadrak, Keonjhar
EEC
10933
2921
9/1977-6/2001
Sexual Partnership
Project__________
Sector Investment
Programme
Funds foreign
currency
Funds INR
(lakhs)
Strengthening State Govt, ability for policy reform,
quality of service, training, IEC
2330
Ongoing
Andhra Pradesh, Gujarat,
Kerala, Orissa
Central, AP, Assam, Bihar,
Gujarat, Haryana, HP,
Kerala, MP, Maharashtra,
Orissa, UP, Rajasthan, NE
States (18)
. _21_districts(wil£ expand}
TN, Orissa, WB, Gujarat,
Maharashtra, AP,
Karnataka
Gujarat, MP, Kerala,
Maharashtra, Orissa,
Rajasthan
This Project is in the nature of support to the National
AIDS Control Project Phase II
Health Sector reform, improvement of management,
policy reviews, national reform activities (logistics,
urban health, tribal health, first referral services, social
marketing, training etc.), capacity building State and
district levels, district projects
Ongoing
Ongoing
10400
86000
3977
18037
UNICEF
USAID
RCH (Master Plan of
Operations 19992002)
Innovations in Family
Planning Services
AIDS Prevention and
Control (APAC)
84 months
AIDS Prevention and
Control Project
(APAC)
All India
All districts
Uttar Pradesh
28 districts
Maharashtra
Mumbai Urban, Pune,
Thane, Sangli rural
Tamil Nadu
State wide, 10 focus
districts
2/1995 - 2/2005
World Bank
Enhanced Malaria
Control Project
3/95 - 9/2001
90000
18060
4000
Ongoing
74160
Ongoing
Uttar Pradesh
35 districts
7/2000-12/2005
AP State Health
Systems Project
7200
All India
1/97 - 6/2002
UP Health Systems
Project
Ongoing
___
Support to NGOs, prevention and control of STDs,
research
AP. Bihar, Gujarat, MP,
Maharashtra, Rajasthan,
Orissa
9/97 - 6/2002
NTCP
Cold chain maintenance, FRUs, training, NIDs, IEC,
drug management, extension of programmes to urban
areas, reemerging diseases, IMCI, support to
institutes, surveillance and monitoring, baby-friendly
hospitals, revitalization of sub-centres
Expand service delivery to increase access, improve
quality, promote family planning
Ongoing
Improve availability of information and products for
STD control, capacity building at State/ municipal
level, research, pilots
Ongoing
_________
Policy reforms, strengthening and renovation of
existing assets, skill development, public-private
partnership
60 486
49500
Ongoing
Andhra Pradesh
60800
Ongoing
Karnataka State
Health Systems
Project
Karnataka
6/96- 12/2001
WB State Health
Systems Project
54600
Ongoing
West Bengal
Ongoing
69800
6/96-12/2001
Punjab State Health
Systems Project
Punjab
Ongoing
42500
6/96-12/2001
Orissa State Health
Systems Project
Orissa
9/98 - 8/2003
Maharashtra State
Health Systems
Project
Maharashtra
Ongoing
41557
Ongoing
72700
2/99 - 8/2004______
Immunization
Strengthening Project
All India
7/2000 - 6/2004
India Population
Project VIII
Delhi, AP, Karnataka,
West Bengal
Ongoing____________________
Establishment of Health Posts and referral facilities in
urban slums, training, IEC, community based
interventions and innovative schemes
Assam, Rajasthan,
Karnataka
Ongoing_________________ ____________________
Augmenting health and family welfare infrastructure,
training institutions, residential accommodation, better
programme management
8/1993-6/2001
India Population
Project IX
6/94 - 12/2001
Support to polio eradication, strengthening of routine
immunization, development of a strategic framework
for the immunization programme
Ongoing
64170
42201
41406
National AIDS Control
Programme Phase II
All India
11/99-9/2004______
Cataract
Blindness
Eradication
Programme
AP, MP, TN, Maharashtra,
Orissa, UP, Rajasthan
5/94 - 6/2001
National
Eradication
Programme
Blood safety, control of STDs, surveillance, care and
support of patients, IEC, condom promotion, targeted
interventions, AIDS policy
85500
Upgradation of ophthalmic services, expansion of
coverage in rural and tribal areas, District Blindness
Control Societies, training, MIS, health education
55400
Ongoing
Leprosy
All India
All districts
2/94 - 3/2000
RCH Project Phase I
All India
All districts and intensive
activity in 24 districts
Domiciliary multi drug therapy in endemic districts
through vertical staff, mobile services in moderately
endemic areas, high education, deformity and ulcer
care, medical rehabilitation
30200
Completed
Integrate and strengthen the interventions of the
CSSM Programme with fertility regulation and control
of RTIs. Expand Family Welfare services, make them
moro accessible and improve their quality. Includes a
component of district project.
111735
_____________________ _______ _______________
Ongoing
Source : As Compiled by the ECTA Consultants of the EEC, Delhi, 2000
H
14
Drug Policy and Regulations
Introduction
This chapter discusses those aspects of drug policy that directly impact
healthcare (1). A brief description of the pharmaceutical industry is
unavoidable in such a discussion, but the chapter does not attempt io deal
with the problems of the industry or its contribution to the economy. Only the
following aspects have been specifically addressed:
• the impact of the WTO mandated IPR regime on the availability
and prices of drugs;
• price controls, their impact and relevance;
• drug control regulations and their enforcement;
• the institutional infrastructure for quality control; and
• the rational use of drugs.
Pharmaceutical Industry in India
Though the WTO mandated legislation to recognize product patents will be
brought into force only in the year 2005, the pharmaceutical industry is
already feeling the impact of globalization. Indian companies such as Dr.
Reddy's Laboratories, Ranbaxy, Wockhardt, Sun Pharmaceuticals, and Cipla
have begun making significant investments in product research in
anticipation of the new IPR regime. Already there have been some important
successes: Ranbaxy has licensed a Novel Drug Delivery system (NDDS) to
Bayer for the product Ciprofloxacin. Dr. Reddy’s Laboratories has licensed
two New Chemical Entities (NCEs) to a Danish multinational company, Novo
Nordisk, to undertake clinical trials. Multinational companies (MNCs), such
as Pfizer, Glaxo and Smith Kline Beecham, are making aggressive plans to
introduce their latest drugs in the Indian market (2).
The global trends of mergers and acquisitions, and high investment in R&D with an increasing role for new technologies such as biotechnology,
genomics and combinatorial chemistry - are also likely to exert considerable
influence on Indian industry. The smaller companies, unable to keep pace
with newer technologies, may be bought over by larger players or utilized for
contract manufacturing. The industry is, thus, in the midst of a major
transformation.
Impact of TRIPS
The agreement on Trade Related Aspects of Intellectual Property Rights
(TRIPS) came into force with the formation of the World Trade Organization
(WTO) in January 1995. TRIPS requires all developing countries to provide a
twenty-year patent protection for novel, non-obvious and useful inventions,
whether products or processes, in all fields of technology including
283
11
pharmaceu ica s. The required national patent law amendments for
pharmaceuticals can be delayed up to January 2005 in developing countries
and economies in transition, and up to January 2006 in the least developed
onnJm65' ^oreover' In countries deferring formal patent grants up to
2005/6, exclusive marketing rights (EMRs), providing protection similar to
a given y product patents, must be granted to the patent applicant for
"Vy/rpe5 H°m .the date of marketing approval in these countries. Violations
of TRIPS obligations, judged as such by WTO dispute settlement bodies, can
lead to trade retaliation or compensation to affected WTO members (3) India
has so far recognized only process patents in pharmaceuticals; legislation
nXT iainQCaQWlth,WL° obll9ations is pending passage in Parliament. As of
December 999, only 16 WTO countries including India, continued to exclude
pharmaceuticals from product patent protection. India has no option but to
fall in line, but we should actively explore ways in which the advantages of
the new regime can be maximized and disadvantages minimized.
Product patents comprise a highly imperfect instrument to provide incentives
for new drug discoveries, which are very expensive, risky and time
consuming. Comanor estimates that the process of introducing a successful
thTn Sr2050Umil'liothM?SThan
33
as 10 or more years a"d cost more
an $250 million (4). The estimates for the development of new NCE in India
iV/nn" ?|U° edn!° bG US$ 90’100 million due t0 lower input costs. For every
10,000 New Chemical Entity (NCE) in discovery, 10 enter pre-clinical
Prnd
’ /'fnter hUman tr'alS’ and only one may be approved.
Product patents limit competition, grant monopoly power and encourage high
prices, clearly, they are detrimental to the immediate interests of the
consumer. Thus patent protection is perceived as a necessary evil - to
provide incentives to the pharmaceutical industry and keep alive their
interest in research that may lead to new tools to treat disease. When it
comes to the diseases of the poor, even patent protection alone is not seen
as a sufficient incentive despite the large size of the market, because of the
inadequacy of their purchasing power. In 1992, an estimated $55.8 billion
was invested in healthcare R&D. The governments of developed countries
and pharmaceutical companies financed 93% of the total and the health
's^sues of these regions received priority. Only an estimated 4% ($2.4 billion)
o. this total global R&D health expenditure budget was devoted to
communicable, maternal, peri-natal and nutritional disorders
Pecoul et al
^mmJhat| Only J3* (One per cent) of the 1223 new chemical entities
commercialized between 1975 and 1997 were specifically for tropical
diseases, and two of these 13 were updated versions of existing products
(5) The public policy question that arises is how to balance the desire to
make new drugs affordable to all those who need them - yet retain stronq
incentives to invent and develop new and better treatments (6).
in its formative years, the Indian pharmaceutical industry took full advantage
of the absence of product patents due to its technological strengths. Through
the process of reverse engineering, it was able to provide new drugs
introduced in the industrialized countries to the Indian consumer with a time
284
u
lag of only 5-10 years, and at a fraction of their cost. In the process, it has
become one of the strongest pharmaceutical industries in the developing
world, not only in terms of domestic market coverage but also exports. This
development, however, has not been without its negative consequences.
With its access to the easier path of reverse engineering, the industry
neglected investment in R&D almost completely. Only the 1995 agreement to
introduce a new IPR regime spurred industry leaders to serious initiatives in
research, so that the industry now seems poised to exploit the new
opportunities, reinforced by the natural Indian advantage in all knowledge
based activities. Above all, it can now make a significant contribution
towards research on the diseases of the poor if an appropriate policy
environment is created.
Having enjoyed the benefit of new drugs at affordable cost in the old regime,
the impact of TRIPS on the price of new patented drugs is bound to be
significant in India. But some mitigating features are likely to moderate this
impact.
•
Skills in reverse engineering will still be useful in producing
generics for drugs going off patents and in cases of compulsory
licensing.
Most life saving drugs are off patents, and there should be little
impact on their prices in the new regime.
In most cases, the monopoly power of patented drugs, are
contained by competition from other medicines that treat the
same condition.
All new patented medicines need not provide significant
therapeutic gains.
USFDA divides new drugs into three categories, A (significant), B (moderate)
and C (little or no therapeutic gain . Lu and Comanor (1998) found that out
of the 148 new drugs introduced in :he US between 1978 and 1987, only 13
had no close substitute in their therapeutic class. The prices also varied
significantly for each category. Only new breakthroughs became far more
expensive and out of reach of most of the population on account of the new
IPR regime. It also needs to be said that even now, newer drugs are
generally not within the reach of the common man, who settles for cheaper
alternatives regardless of their lower efficacy or side-effects. But what if a
new vaccine or drug of great public health significance - say a vaccine for
HIV/AIDS or TB or malaria - becomes out of reach for 10-15 years because
of patent protection? Avoidable morbidity and mortality would be needlessly
prolonged; its benefits would be denied to poor countries where the new
technology is most needed. The inrernational community and the national
government need to explore ways of making new discoveries of high public
health significance available at aTordable prices, without reducing the
incentives for research in these areas. How to achieve this is the big
question.
285
H
What policy options does the government have to minimize the adverse
impact of TRIPS? The first option is to have the entire TRIPS regime
reviewed by the WTO. In this case it is useful to recall that the Indian
government, recognizing the adverse impact of TRIPS, resisted it all along in
the Uruguay Round of negotiations, and accepted it only when India was
completely isolated and left with no alternative. Since 1995, there seems to
have been no new development to persuade industrialized countries to agree
to a wholesale review of TRIPS, subjected as they are to intense political
pressure from the pharmaceutical MNC lobby. Any initiative in this regard
seems both counter-productive and doomed to failure. However, it may be
possible to negotiate a better deal, limited to new discoveries of major public
health significance.
The other options within the four corners of the existing TRIPS reoime are
Compulsory Licensing and Parallel Trade. The latter attracted considerable
attention, consequent to the judicial challenge by multinationals to the
parallel importation of anti-retrovirals for AIDS patients by South Africa, from
middle-income countries such as Spain and Portugal. The judicial challenge
has since been withdrawn. Basically, the incentive to resort to Parallel Trade
arises out of the common practice of multinationals for differential prices of
drugs in different markets. In India, for instance, even patented drugs are
priced at much less due to various factors, such as poor purchasing power
strong competition from generics, and price controls. Further, our own
pharmaceutical companies are major exporters, and would like to enjoy the
flexibility of differential pricing depending upon the market conditions. The
discriminatory pricing regime is, thus, advantageous to India, and deserves
our support and encouragement. However, if the multinationals apprehend
the re-export of these cheaper drugs into more affluent markets this
desirable trend is likely to receive a setback. Parallel Trade in patented
articles is governed by what is called the exhaustion of rights doctrine. This
doctrine states that once the producer of a patented product has sold the
product, the patent-holders right to determine the conditions under which
the product is resold is exhausted (7). Neither the Paris Convention on
pa.ent rights nor the Uruguay Round Treaty establish any rules on Parallel
Trade, and the permissibility or otherwise of such trade is solely dependent
on the domestic laws of individual member countries. It seems quite clear
that overall, India stands to gain from discriminatory pricing, and should thus
be discouraging, both domestically and internationally, any practice
including Parallel Trade, which inhibits the same.
Compulsory Licensing deserves a fuller discussion. Article 31 of TRIPS
stipulates two basic preconditions for compulsory licensing:
1) The prospective licensee is unable to obtain, within ua reasonable
period of time, authorization from the patent holder■ to use the
patented innovation “on reasonable commercial terms and
conditions.” The failed negotiation clause can be waived~in ”the
case of national emergency or extreme urgency for non
commercial public use.
286
2) Compulsory License must be “predominantly for the supply of the
domestic market of the authorizing nation, and its user must pay
to the patent holder “adequate remuneration” taking into account
the economic value of the authorization.” There is wide variation
in the way responsible government agencies have set the amount
of compensation awarded to patent holders, when patents have
been subjected to compulsory licensing (8).
Article 40 also allows Compulsory Licensing in response to “an abuse of
intellectual rights having an adverse effect on competition in the relevant
market." Failure to supply or license a patented product at all, or supplying
at unreasonably high prices, might be treated as abusive (9).
It is apparent that the right to Compulsory Licensing is heavily
circumscribed, and that the rather vague formulation of relevant articles
could mean varying interpretations and conclusions. Only when the disputes
under these articles are settled in the WTO will some authoritative
interpretation emerge. But even at this point of time, it is quite clear that the
route of Compulsory Licensing does not provide an easy escape from the
TRIPS regime, and that any indiscriminate application could be challenged in
the relevant dispute settlement bodies of the WTO. However, selective use in
cases of new patented vaccines/drugs of major public health significance primarily for free distribution/application by public sector agencies - increase
the possibility of sustainability in the event of a challenge. In fact, a case
made in such a situation for easing the rigours of Compulsory Licensing
conditionalities is likely to strike a sympathetic chord in the affluent
countries. The realization that the globalized patent regime should not be
allowed to worsen the health prospects in poor countries has been growing,
and a number of initiatives have been set in motion by a variety of public
private partnerships, multilateral organizations and national governments
(10). The consensus statement of the Global Health Forum I, February 2000,
sums it up appropriately: “The move to globalize the protection of intellectual
property is not politically sustainable without, at the same time, making the
delivery of health technology more equitable."
Instead of leaving the identification of new products of major public health
significance to the whims and fancies of individual governments, it would be
appropriate to evolve an international mechanism that commands universal
credibility and acceptability. The WHO, for instance, could set up a body of
eminent professionals to periodically review patented products entering the
market, and identify those with major public health value. Once these are
identified, various options can be explored to make them available to poor
countries at affordable prices:
•
The conditions prescribed for Compulsory Licensing could be
relaxed and the patent holder compensated jointly by the
government of the licensee and the international community.
287
•
•
The patented product could be supplied to low income countries
at a marginal cost, while being sold at full market value in
industrialized countries (tiered pricing). As in the US, such
subsidized sales can be treated as tax deductible expenses,
encouraging pharmaceutical companies to supply them readily
and liberally.
Many multinational organizations, donor agencies and charitable
foundations could pick up the difference between the market
value and marginal cost to ensure access to new druas where
they are most needed.
Two essential conditions must be met to derive full benefits from Compulsory
Licensing:
1) Indian pharmaceutical companies must be able to quickly
reverse-engineer the new patented drug - a skill they have amply
demonstrated in the past.
2) Compulsory Licenses must be made commercially attractive to
the Indian company.
Fiscal
riscai concessions and exemption from price controls are necessary for
the fulfillment of the second condition. To optimize the benefits of
Compulsory Licensing, the license should be granted at the earliest stage
The longer the delay of Compulsory Licenses after the introduction of the
patented drug in the market, the less time the licensees have to recover
their start up costs, and the more difficult it is to achieve effective
competition among generic substitute suppliers (11). Hence the advantage
of setting up an expert body of professionals - to periodically review new
entrants in the market, identify those with potentially high public health
significance, and explore the possibilities of Compulsory Licensing.
Drug Price Control
Most countries control drug prices one way or the other. In India, we have
inherited a rather complex system that covered around 70% of the market
Pyorto the Drug Policy of 1994. It was administered directly by the Ministry
of Chemjcais and Fertilizers on the advice of the Bureau of Industrial Costs
and Prices (BICP). The system was characterized by delays and
arbitrariness, and it generated strong protests from the drug industry. The
Drug Policy of 1994 simplified the system considerably, and reduced its
coverage to be around 50% of the market (12). Also in pursuance of this
policy, an independent National Pharmaceutical Pricing Authority (NPPA)
which improved the system substantially, was established. Despite its much
publicized weaknesses, the system has served the country well. The prices
of drugs have risen much less than Wholesale and Consumer Price indices
and yet the industry has recorded robust growth (Figure 14.1).
Price control is on the basis of turnover and competition, and not related to
the essentiality of the drug. (See Figure 14.2 for a broad outline of Price
288
Control Regulations.) Broadly speaking, at'drug 'is subject to price control if
its annual turnover is more than Rs.40 million. Drugs with a turnover above
this minimum revenue level may be exempted, if there are at least five bulk
producers and at least 10 formulators, and if none have more than 40% of
the market. Any bulk drug with a turnover above Rs.10 million, with one
producer supplying 90% or more of the market, is also subject to price
control. Given this last criterion, all patented pharmaceuticals are subject to
price control unless they are widely licensed - an unlikely scenario (13). This
by itself can become a serious disincentive to investment in R&D and the
introduction of new drug discoveries. It can also discourage those obtaining
Compulsory Licenses.
Figure 14.1
Movement of Price Indices of Drugs and other Products
400
350
WPI : All
commodities Base
1881-82=100
300
250
'
200
WPI : Drugs and
Medicines Base
1981-82=100
150
* All India CPI Base
1982=100
100 50 •
0------------------------------------------------------------82-83 84-85 86-87 88-89 90-91 92-93 94-95 96-97
Source: OPPI Annual Report, Reproduced from The Indian Pharmaceutical Industry, ASCI, 2000
Figure 14.2
Price Control Regulations
If number of bulk
drug producers
Drug with
Turnover
>Rs.40
Million
>
If number of
formulators < 10
>
Insufficient
market
competition
If market share of
one producer
>
40%
Drug and all
its
formulation
brought
under price
control
Drug with
turnover
between Rs.10 40 million
If market share of
one producer > 90 %
>
Monopoly
Drug
Source: The Indian Pharmaceutical Industry, ASCI
289
Drug Policy and Administration
The administration of drugs and pharmaceuticals is divided between the
Ministry of Chemicals and Fertilizers (MCF) and the Ministry of Health and
Family Welfare (MHFW). The former is responsible for drug policy, regulation
of industry and price control, while the latter is responsible for laying down
standards, quality control, the introduction of new drugs and the enforcement
of relevant laws and regulations. This arrangement prevents the government
from taking a holistic view that takes into account the interests of both
industry and consumers. The policy of one ministry is often at cross
purposes with that of the other: MCF aggressively promoted the small scale
sector, leading to the establishment of over 20,000 manufacturing units with
adverse consequences for the quality of drugs. The smaller units are
generally unable to provide and maintain the infrastructure for quality
control, and are reportedly responsible for a majority of quality standards
violations (14). The stringent price control over drugs with a high turnover
creates disincentives for investments in the production of drugs related to
widely prevalent diseases, and drives investments towards elitist drugs with
small volumes but large margins. This is obviously quite contrary to what the
MHFW would like the incentive regime to do.
The J. L. Hathi Committee (1975), that provided the basic policy framework
for drugs for two decades till the Drug Policy of 1994, recognized this
dichotomy. It suggested setting up an independent National Drug Agency
that would take over all drug-related functions being performed by the two
Ministries at that time. The Drug Policy of 1994, while suggesting the setting
up of a National Drug Authority, confined its role to the functions presently
assigned to the Central Drug Standard Control Organization (CDSCO) in the
MHFW - prescribing standards, enforcing quality control and promoting
rational drug use. The National Drug Authority was to be a glorified and
strengthened CDSCO, but not like the FDA in the US, with its comprehensive
jurisdiction over all aspects of manufacture, sale, pricing and quality control.
The proposed NDA should be the single agency with jurisdiction over all
aspects of pharmaceutical industry: this will develop a long-term, holistic
vision and policy. It should be supported by a small cess on the manufacture
and import of pharmaceuticals, a cess that could be conveniently collected
along with excise and customs duties. Given the large turnover of both
domestic production and imports, the cess could be small enough not to
impose a noticeable burden on either the industry or the consumer. Yet it
could yield sufficient resources for a National Drug Fund, to be administered
by the proposed National Drug Authority to support all its operations. A
certain proportion could also be set aside to assist R&D on diseases of the
poor by the Indian pharmaceutical industry. The total estimated value of
bulk drugs and formulations manufactured in India was Rs.1,96,370 million in
1999-2000 (15); even a one per cent cess would yield Rs.1,963 million
annually. Similarly, the value of imports of bulk drugs, intermediates and
formulations, is estimated at Rs.31,280 million in 1998-99 (16), and a similar
290
ii
one per cent cess would yield Rs.312 million annually. Thus substantial
resources could be raised with a small one per cent cess to benefit both
industry and consumer. If the infrastructure for drug quality enforcement is to
be strengthened, the proposed NDA must be self-supporting. Otherwise the
entire reform programme will remain vulnerable to the vagaries of budgetary
allocations, which will vary with the perceptions of individual decision
makers in the MHFW. Public sector support must be forthcoming in many
ways to motivate the pharmaceutical industry to invest in R&D in diseases of
the poor such as TB and malaria. The proposed National Drug Fund could
provide one such avenue of support. The resources available to NDF can be
put to innovative use in many other ways. One example is support to Indian
pharmaceutical companies that receive Compulsory Licenses, to compensate
the patent holders in accordance with WTO regulations. The pharmaceutical
industry should be enabled to actively participate in the management of the
National Drug Fund.
The Regulatory System for Drugs
The Constitution of India places Drugs and Cosmetics in the Concurrent List,
which allows jurisdiction to both the centre and the states on this subject. In
the event of a conflict between central and the state laws, however, central
laws will always prevail. We have argued elsewhere in this Report in favour
of greater decentralization and an enhanced role for the states; but in the
case of drug regulation and enforcement, we would advocate a stronger
central role for three reasons:
A sub-standard/spurious drug manufactured in one state can
be sold and consumed in all parts of the country. Hence
enforcement of quality standards cannot be left to the mercy of
individual states.
The states are unlikely to find adequate resources for
investment in laboratories and infrastructure for enforcement
of drug laws without central help.
The states would not be able to provide, at their level, the
expertise required to lay down and monitor standards of drugs,
or to determine the rationality of new drug combinations.
The import, manufacture, distribution and sale of drugs and cosmetics in
India is regulated by the Drugs and Cosmetics Act of 1940. The Act specifies
that the central government is responsible for the constitution and
functioning of the Drugs Technical Advisory Board, which advises the Drugs
Controller General (DCG) on all technical matters; and the Drugs
Consultative Committee, which is the main institutional mechanism for
centre-state coordination. The central government has the power, in
consultation with the Drugs Technical Advisory Board, to make rules and to
specify the different types of offences in relation to import of drugs. The
responsibility of the state governments, as regards the manufacture,
distribution or sale of drugs, is described in Chapter IV of the Act. States
291
H
have been empowered to license any person to manufacture or sale of any
drug which is of standard quality and is not misbranded, adulterated or
spurious. Standards of quality have been defined under section 16(1 )(a) - it
is required that “the drug complies with the standards set forth in the Second
Schedule of the Act". The Second Schedule of the Act includes patent or
proprietory medicines, and states that “the standards, which are described
as in the formula or list of ingredients displayed in the prescribed manner on
the label or the container and such other standards as may be prescribed.”
Since no other standards, as specified, have been prescribed, the states
today have the power to permit use of any combination of drugs as long as
the constituents are displayed on the label of the container. Thus the states
can permit licensing of any number of such combination drugs without
examining the aspects of safety and efficacy, leave alone the question of the
rationality of a new combination.
The prevailing system has led to a chaotic situation with nearly 50,000 to
60,000 drugs licensed to be marketed in India. In fact, no authoritative figure
of the total number of drugs licensed in the country is available. The central
government, realizing the consequences of indiscriminate licensing of drugs,
provided, by an amendment in the Rules, for joint responsibility for the
licensing of vaccines, IV fluids and blood products. However, the need of the
hour is to amend the Act itself, to make it mandatory for the states to obtain
approval of the central government before licensing a new Fixed Dose
Combination (FDC) drug. Such approval should be given only after careful
assessment of the safety, efficacy, rationality and need of the new drug in
the market.
a
Even otherwise, the Drugs and Cosmetics Act 1940 has become outdated,
and needs to be replaced with a new law that takes into account changed
circumstances as well as the need for an enhanced role for the central
government. In 1940, most drugs were imported into the country and hence
the emphasis in the Act was merely on ensuring quality. The scenario has
since completely changed: the abundance of new drugs new treatment
options, technological innovations, the new TRIPS regime and the growth of
the pharmaceutical industry call for a new legal framework altogether.
The Central Drug Standard Control Organization (CDSCO) is the designated
organization at the centre to administer the Drugs and Cosmetics Act 1940
The main functions of CDSCO include the quality control of imported drugs;
the coordination of the activities of the state drug control authorities; the
approval of new drugs proposed for import into or manufacture in the
country; the laying down of regulatory measures and standards of drugs; and
acting as the central license-approving authority for blood and blood
products, large volume parenterals, sera and vaccines. The CDSCO
functions from 4 zonal offices, 3 sub-zonal offices and 7 port offices. The 4
central drug laboratories carry out tests of samples of specific classes of
drugs (17). The CDSCO is headed by the Drug Controller General who
functions under the Director General of Health Services.
292
The State Drug Controllers bear the responsibility for ensuring that
pharmaceutical manufacturers are following Good Manufacturing Practices
(GMP). By and large, the states have neither the organization nor the
inclination to enforce these standards, and their performance, as in most
health related matters, is extremely uneven. As a result, the market is full of
sub-standard and spurious drugs playing havoc with people’s health. The
checking of drugs is inadequate not only because of lack of staff and non
performing laboratories; but also because the samples to be taken by
enforcement staff have to be paid for, and quite often the budget available is
insufficient for this purpose. Even where a violation of the law is detected,
the weakness of the prosecution machinery, the slow disposal of cases by
courts, and the ineffective provisions of the law, continue to render the
deterrent practically, non-existent. What is required is a new law with teeth,
and a total overhaul of the enforcement machinery.
The licensing of chemists is also the responsibility of the State Drug
Controllers. Each chemist is supposed to employ a qualified pharmacist, but
this requirement is rarely met. The sale of prescription drugs over the
counter in violation of the law further compounds the problem created by the
hordes of unqualified practitioners and registered practitioners of other
systems of medicine freely prescribing allopathic drugs. The indiscriminate
use, and often, abuse, of prescription drugs poses serious health hazards to
uninformed patients, besides contributing to increasing resistance to anti
microbials. The efficient enforcement of laws in this regard will require very
strong monitoring and supervision by the proposed National Drug Authority.
It is also essential to have a system of monitoring the performance of all
drug-testing laboratories, both from the central and state governments, as
well as from the private sector, by independent experts of repute.
Accreditation by the National Accreditation Board for Analytic Laboratories
under the Ministry of Science of Technology must be made mandatory to
check this downslide.
Merely tinkering with the existing system is unlikely to improve the situation.
Only an independent National Drug Authority - supported by adequate
financial resources from the National Drug Fund, and authorized by a new
law arming it with exclusive licensing authority and providing deterrent
punishment to violators - can make a significant difference.
The Rational Use of Drugs
The problem of irrational drug use is not likely to go away even if all the laws
are strictly observed. This is because even registered and qualified medical
practitioners, unfortunately, resort to the grossly irrational use of drugs.
Basically this arises from inadequate attention to the subject in the medical
schools. But it is also aggravated by the total lack of emphasis on continuing
medical education - most practitioners never bother to keep abreast of the
latest technological developments save whatever information they receive
293
through representatives of pharmaceutical companies. Naturally tne latter, in
their aggressive attempts to push their products,
o^er-emphasize
effectiveness and minimize risks and side-effects.
The WHO first introduced the concept of rational use of drugs in 1973-75. In India,
however, it did not receive any attention for two decades. The first administration to take up
this cause seriously was Delhi, in 1994. A Drug Policy for Delhi was based on the concept
of Essential Drugs proposed by WHO, and developed and successfully implemented in
several countries such as the UK, Norway, Australia, Bangladesh and Iran. The WHO
India Essential Drug Programme was launched in Delhi in 1998 in
collaboration with the Delhi Society for Promotion of Rational Use of Drugs
(DSPRUD) - which was formed as a ‘triangle’ of political leaders,
bureaucrats and technical experts, dedicated to the cause of rational use of
drugs. The programme has expended rapidly over the last three years. While
the Central Ministry has remained cool to the programme, a number of states
have actively participated in it, including UP, Gujarat, Orissa and Kerala. The
Indian Railways, with its vast infrastructure of medical facilities, has shown
interest. A number of NGOs and professional organizations have organized
conferences and training workshops. However, the sustainability and
effectiveness of many of these initiatives is in doubt unless the relevant
governments and professional associations “own up" to the programme and
promote it actively.
Training physicians in both public and private sectors as part of Continuing
Medical Education (CME) is important in ensuring rational prescribing
practices. Unfortunately there is no formal CME requirement yet in India for
medical practitioners. The Indian Medical Council has now proposed that
registrations should be renewed after every five years, contingent on certain
minimal participation in CME activities. This is an important initiative that
deserves support. Professional associations, particularly the Indian Medical
Association, must, on a priority basis, take over the responsibility of
sustained training of its members on the rational use of drugs.
Conclusion
The drug scenario in India exhibits both significant strengths and
weaknesses. The strengths lie in technological skills, a robust and dynamic
pharmaceutical industry, and more recently, its R&D capabilities. The
weaknesses arise from the proliferation of manufacturing in small units,
licensing of irrational Fixed Dose Combinations, outdated laws and their poor
enforcement. With the enforcement of the WTO-mandated TRIPS regime, the
drug sector faces new challenges as well as opportunities. This makes it
important for the government to provide dynamic and far-sighted
leadership in leading the wide-ranging reforms; and putting in place, in
collaboration with the industry, the necessary institutional and legal
framework that will facilitate the process of adjustment to the globalized
regime.
294
Notes
1.
2.
3.
4.
5.
6.
7.
8.
9.
The background paper to this chapter was written by Professor Ranjit Roy
Choudhury, Emeritus Scientist, National Institute of Immunology, New Delhi,
and President, Delhi Society for the Promotion of Rational Use of Drugs
(DSPRUD).
The Indian Pharmaceutical Industry, ASCI, 2000.
F.M. Scherer and J. Watal, Post TRIPS Options for Access to Patented
Medicines in Developing Countries, unpublished paper for Working Group 4,
The Commission on Macroeconomics and Health, 2001.
W.S. Comanor, The Pharmaceutical Industry and the Needs of Developing
Countries, 1996.
Creating Global Markets for Neglected Drugs and Vaccines: A Challenge for
Public-Private Partnership, consensus statement organized by the Global
Forum for Health Research, Institute for Global Health, 2000.
Scherer and Watal 2001.
Ibid.
Ibid.
Ibid.
10. For a fuller discussion, see Creating Global Markets for Neglected Drugs and
Vaccines: A Challenge for Public-Private Partnerships, 2000.
11. Scherer and Watal 2001.
12. Langjouw 1998, as quoted in Ibid.
13. Scherer and Watal 2001.
14. ASCI 2000.
15. Ibid.
16. Ibid.
17. Annual Report 1999-2000, MHFW.
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15
Indian Systems of Medicine
Introduction
No discussion of the Indian health system can be complete without the
inclusion of the Indian Systems of Medicine (ISM). India has an
incomparably rich heritage in ancient systems of medicine that make up a
veritable treasure house of knowledge for both preventive and curative
healthcare. These systems, through their safe, effective and inexpensive
treatments, have the potential to make a significant contribution to the
healthcare of the common people. But their true potential is still largely
unrealized, despite a large and well-dispersed infrastructure.
The term ISM (1) comprises 6 different systems - ayurveda, siddha, unani,
yoga, naturopathy and homeopathy. In terms of registered practitioners,
ayurveda is the dominant system in ISM. Homeopathy, though German in
origin, has a large Indian clientele, and is second only to ayurveda among
the ISM.
Ayurveda
Ayurveda means the 'science of life’ in Sanskrit. It is one of the oldest and
the best documented among the ancient systems of medicine.
The
documentation of ayurveda is referred to in the Vedas (1500-500 BC), said
to be the oldest recorded wisdom in the world.
It derives its basic
principles from the Caraka Samhita (600 B.C.) and the Susruta Samhita
(500 BC). The approach is essentially philosophic, holistic and humanistic.
Ayurveda emphasizes life and health more than disease and treatment. It
presents a comprehensive life science and encompasses total health physical, mental and spiritual — in a holistic way. The system is based on
the laws of nature, and the individual human being is a minature replica of
the universe.
The individual and the universe are both essentially
panchamahabuta, or made up of the five basic physical factors or elements:
akasa (ether/space), vayu (air, motion), teja (fire/radiant energy), jala
(water/cohesive factor) and prthvi (earth/mass). The individual (purusa) and
the universe (loka) remain in constant interaction with each other, and as
long as this interaction is wholesome and optimal, the human being enjoys
good health.
Any disharmony in this interaction is the basic cause of
disease, and all treatments in ayurveda attempt to restore this harmony and
the normal balance of the five elements in body and mind. In this sense,
ayurveda is a system of medicine very close to nature.
The five physical attributes of pancamahabhuta constitute three major
biological components of the living body called tridosa, i.e. vata, pitta and
kapha. All ailments arise out of the imbalance of the three dosas or
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I
?hUTUIS’ 3nd the rOle Of medicine is
the body.
assist the natural healing powers of
It ‘s not possible to deal with the various aspects of this ancient system in
detail here (2). Suffice it to say that it is a complete and well-developed
promotive, preventive and curative system of medicine with eight major
clinical specialities: a) kayachikitsa (internal medicine), b) salya tantra
(surgery , c) salakya (ENT), d) kaumarabhrtya (pediatrics, obstetrics and
gynaecology), e) bhutvidya (psychiatry), f) agada tantra (toxicology), q)
rasayana tantra (nutrition, rejuvenation and geriatrics), and h) vajikarana
(sexology).
1
Ayurvedic drugs are usually soft medications, acting as molecular nutrients
or different organs and tissues. Their action is explained more in terms of
nutrition dynamics rather than actual pharmacodynamics. All preparations
are from natural sources; most of them are herbal, but the system also
makes extensive use of minerals and ashed metals.
Siddha
Siddha an equally ancient system, is similar to ayurveda in its fundamental
principles. But there is considerable difference in the way the two systems
have evolved. The siddha system got its name from the ancient masters,
wh°- besides practicing medicine, also performed many miraculous acts
Siddha means a master; thus the iname denoted the mastery of such
practices. The most famous of the Siddhas; was Nagarjuna, whose
rasatantra
T
..
... forms
A the basis of this
----- system. The literature of siddha is in
upbke Ayurveda, where the ancient texts are all in Sanskrit. The
system flourished
.------- 1 '.i n South India and Sri Lanka, and at present, it is
practiced primarily in the state of TN. The distinctive features of siddha
are its reliance on minerals and metallic compounds, and its emphasis on
rejuvenative therapies.
Unani
The unani system originated in the 4th-5,h century Z
* in Greece under the
B.C.
patronage of Hippocrates (377-460 B.C.) and Galen."It'gradually absorbed
the experience and wisdom of many ancient cultures, including those of
Egypt, Arabia, Persia, China, Syria, and of course, India. The system was
documented in Al anoon by Sheikh Bu-Ali Sina (980-1037 A D ) and in Al
havi by Razi (850-923 A.D.). The system is based on the humoural theory,
so that good health depends on the balance of the four humours, blood
phlegm, yellow bile and black bile. Like ayurveda, this is a holistic system
including promotive, preventive and curative interventions.
But unlike
ayurveda, it relies overwhelmingly on herbal preparations.
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Yoga
Yoga is not really a system of medicine. Its objectives are self-realization
and spiritual union with the all-pervasive divine cosmic power. But certain
intermediary practices and yogic attitudes have proved beneficial for
reducing stress, preventing many lifestyle-related diseases, and promoting
general health and well-being. It has also proved useful in the treatment of
many chronic and intractable ailments. Along with meditation, this is by far
the most popular ancient system globally.
Essentially, yoga is devoted to the integration of the physical, mental,
intellectual and spiritual dimensions of one’s being. The technology of the
practice of yoga is based on Patanjali’s Yoga Sutra (around 200 B.C.),
containing the scheme of astanga yoga (eight limbic yoga) with the ultimate
goal of attaining samadhi or union with the cosmic force. Meditation is an
essential ingredient of yoga. However, in common parlance, yoga is
associated with certain postures (asana) and breathing exercises
(pranayama), which have wide and varied beneficial influences on both
physical and mental health.
Naturopathy
Naturopathy is based on the fundamental principles of ayurveda. While
ayurveda uses medicines in addition to bio-purificatory and dietary
practices, naturopathy relies solely on the latter. The basic tenet of
naturopathy is to live according to the laws of nature: disease occurs due
to the accumulation of toxins in the body, and to cure the ailment, the body
is purified with the use of natural methods, dietary regulation and exercise.
A naturopath uses mud, water, heat and air as the instruments for therapy,
but never any drugs.
Homeopathy
Homeopathy is fundamentally different from other Indian systems, It is
based on a specialized method of treating diseases - administering
potentised drugs in very high dilutions, which have been empirically
established to have the power of relieving the very symptoms which they
normally cause in healthy human beings when administered in their gross
form. Homeopathy was discovered by a German physician, Dr. Christian
Frederic Hahnemann, in the 17th century. Homeopathy is also a holistic
system, and it treats the patient as a whole, not merely the diseased organ.
It is particularly useful for constitutional ailments for which modern
medicine has few remedies. It is safe, inexpensive and easy to use, and as
a result, many households maintain a small chest of homeopathic
medicines, which they use on their own for common ailments, particularly
those of children. Homeopathy is, by far, the most popular ISM system
across the country, although other systems have their areas of influence in
designated parts of the country.
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Underlying Similarities
While there are significant differences among the ISM systems, there are
some important underlying commonalities in basic
basic approaches and
fundamentals, particularly between ayurveda, siddha,
siddha. unani yoga and
naturopathy.
3
All the systems adopt a holistic approach, attempting to treat the
patient as a whole rather than the affected organs.
• The systems are more life-oriented than disease-oriented.
• All of them emphasize promotive and preventive aspects.
• All of them believe that disease is a consequence of disharmony
between man and nature that disturbs the balance between
biofactors/humours. The object of all therapy is the restoration of
this balance.
• All systems use natural substances,
substances, p.__'_...:
predominantly herbal
preparations used as nutritional supplements rather
—. _. than
drugs.
• All !systems emphasize appropriate diet.
• Ayurveda, siddha and unani rely, to a great extent, on pulse
reading for diagnosis.
•
Infrastructure
a ^ast infrastructure of hospitals, dispensaries, teaching
nshtufons and registered practitioners under different systems of ISM
(Annex 15.1). Different systems are dominant in different parts of the
country (Annexes 15.2 and15.3). Ayurveda is more popular in Kerala HP
SnnJ,3 ’ KarAData’ MP’ RaJasthan and Orissa.
Unani has a greater
ollowmg in AP, Karnataka. TN, Bihar, Maharashtra, MP, UP, Delhi and
Kajasthan. Homeopathy is more widely practiced in UP Kerala West
Bengal, Orissa AP, Maharashtra Punjab, TN, Bihar, Gujarat, and the North
eastern states (3).
Most state governments have set up parallel facilities of ISM - hospitals
and dispensaries that have significant outreach in rural areas. However
wdh the exception of rare cases, these facilities are not utilized for public
health programmes, and are completely independent of the rural health
infrastructure. In isolated cases, ISM doctors have been added to PHCs
thus giving patients a choice of systems.
The Potential of ISM
With its vast infrastructure and cultural acceptance it would be logical to
expect ISM to play a major role in Indian healthcare. But contrary to
expectations, recent surveys (4) seem to point towards a complete
dominance of allopathy, with over 90% of illness episodes being treated
with that system (see Chapter 2). These surveys also indicate that the
299
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practitioners of ISM are increasingly resorting to unauthorized treatment of
their patients with allopathic drugs.
All the same, the fact remains that ISM systems can
contribution to healthcare in the following areas:
make a
major
In the changing demographic and epidemiological scenario, longevity
has increased, and people are more vulnerable to chronic ailments
requiring long term and expensive therapies unaffordable in a poor
country. ISM can fill in this critical gap and provide safe and cost
effective treatment for many conditions.
• More important, the epidemiological transition has increased the
burden of NCDs, which has major cost implications in a poor country.
The best strategy to deal with this new challenge is to emphasize
promotive and preventive health and healthy lifestyles.
Many ISM
practices and therapies such as yoga are of great value in avoiding or
delaying the onset of NCDs.
• With their vast infrastructure and outreach, ISM could make a
significant contribution to public health programmes and supplement
healthcare facilities, particularly in under-served areas.
• The rich range of remedies in ISM could provide leads to the discovery
of safer and more effective drugs to support the human battle against
disease.
• ISM could provide a growing market for exports with the rising demand
for Complementary Alternative Medicine (CAM) in the industrialized
world.
•
Neglect of ISM in India
We are far from realizing the potential benefits of ISM, given the centuries
of its neglect in the country. With the advent of British rule, the indigenous
systems lost official patronage and support: the colonial masters
considered these systems unscientific and unreliable. Following the
example of their masters, the Indian elite shifted to modern medicine, and
consequently, ISM suffered a major setback with both the State and
affluent clients withdrawing their support. The result was an unequal
competition between modern medicine and ISM. The former got huge
investments in research and came out with new discoveries, while ISM
stagnated as it continued to depend only on the ancient texts. In fact, it is
only the guru-shishya parampara (teacher-pupil tradition) which kept these
systems alive, by passing on traditions from teacher to pupil in the absence
of any formal teaching institutions and official patronage.
There was some recognition of the potential of ISM after Independence, but
very little was done by way of follow-up. An institutional framework was
indeed established, to standardize education and drugs and to promote
research, but inadequate attention by policymakers and insufficient
financial support made these initiatives largely ineffective. ISM continued to
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be developed as a parallel stream, with no attempt to synthesize or
integrate the systems with modern medicine and assign them a role in
public health. Antagonistic attitudes ruled out any possibilities of
meaningful collaboration in research. The traditionalists argued that the
ancient texts, based as they were on the insights of seers, could not be
questioned. Also, since the traditional systems were based on different
principles altogether, they could not be subjected to the evaluation
protocols applicable to modern remedies. As a result, even when State
support was forthcoming, research was confined mainly to so called literary
research, or the deciphering and interpreting of ancient texts. Unlike the
situation in China, very few initiatives were taken to undertake scientific
evaluation of ISM remedies.
Alternative Medicine in Industrialized Countries
The second half of the19lh century saw the beginnings of a technological
revolution in modern medicine, with the germ theory of disease contributed
by the work of Pasteur and Koch, followed by the establishment of the
microbial origins of infections. Just the dissemination of information about
the simple rules of hygiene led to a dramatic fall in disease burden and
mortality. The introduction of sulphonamides in the 1930's helped the
development of chemotherapy, and later, penicillin made a major impact on
the control of infection related ailments. As a parallel stream, the
development of vaccines, beginning with Jenner's first vaccination two
centuries ago, brought down child mortality significantly.
This, coupled
with advances in surgery, seemed to promise that modern medicine had
answers to all health problems. Naturally, nobody thought it was worthwhile
to look at traditional medicine, since it was not validated by modern
science. As a result, most traditional medicine was clubbed with quackery.
Attitudes, however, began to change with the shift in the disease profile,
and with the realization of the limitations of modern medicine. With an
aging population, the burden of disease shifted to chronic constitutional
problems, for which there were, as yet, no solutions in modern medicine.
The confidence in the effectiveness of drugs began to wane, with microbial
evolution causing resistance to known potent drugs, and with the
emergence of new diseases. The harmful effects of the prolonged
administration of powerful drugs began to be documented. Research
established conclusively the strong linkage between lifestyles and many
NCDs. The faster pace of life led to stress being recognized as a major
factor in ill health, generating interest in traditional stress-relieving
techniques such as yoga and meditation.
All these factors have led to an explosion of interest in Complementary
Alternative Medicine (CAM) in western countries, an interest exceeding
even the popularity of oriental religious and spiritual movements. The
global market is now estimated at US$60 billion, and expected to grow to
the mind-boggling figure of $5 trillion by 2050. With recent developments in
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i1
genomics and biotechnology, mec.cal science is poised to take a giant leap
forward, which may yield relatively easy remedies for apparently intractable
}Utl°nal ailments- 11 is
to say how this would impact
CAM. All that we can say with some degree of assurance is that even if
such remedies do become available, they would probably remain out of
reach of the common people in poor countries. Hence irrespective of
whatever happens in the West, traditional remedies would remain relevant
in India in the foreseeable future.
The Impact of Western Interest on India
Since the West finds India’s treasure of traditional remedies interesting, the
Indian elite has also begun to perceive these remedies as valuable. This is
most welcome - to the extent that this perception encourages support from
the government and others to the realization of the true potential of ISM
This also means new commercial opportunities. But it presents, at the same
time, some new challenges. First, the tendency of western commercial
interests to patent traditional knowledge to enjoy monopoly rights needs to
be effectively countered. Second, the rising demand for herbal products
could
lead
to
over-exploitation
of scarce species,
consequently
endangering their existence and availability.
Creation of a Separate Department for ISM
The creation of a separate department in the Ministry of Health and Family
Welfare in 1995, in rresponse
- - --------- ---to ■ a long pending demand, seems to have
given new visibility and importance to'lSM.
------ This is reflected in a major
step-up in financial allocations (Figure 15.1). It has also led~to
some very
well
—I
intentioned
initiatives,
besides
strengthening
many
existing
programmes.
Figure 15.1
PLAN ALLOCATIONS FOR DEPARTMENT OF ISM & H
(in Rs. Crores)
400 ■
-----
382
386 35
350 ------300 -------
250 —
200 -
---
150 •
129.05
100-------
85.39
50 ■ ------
0 -
0.4
----
4
o
o
o "c" ®
m m
9.8
-15.83
€
II -
op
25.07
5SO
S r9
Q.
0
Source: MHFW, GOI
302
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Major Challenges
Failure to Concentrate on Identified Strengths:
One of the major weaknesses of ISM arises from its failure to concentrate
on its strengths, and in trying to dabble in areas where it lacks a
comparative advantage. ISM must clearly identify its strengths and
limitations, and concentrate on developing the former. This would lead to
better targeting of resources and concentration of both research and
training on their areas of specialization. Conversely, modern medicine
practitioners should also appreciate their limitations in dealing with many
chronic, constitutional ailments for which ISM has better weapons in its
armoury. This is already happening in India as well as abroad, and many
modern medicine practitioners encourage patients to
to try
try alternative
therapies. Once the comparative strengths of each systemi have been then
identified, the government should encourage the setting up of specialized
clinics for specified diseases under ISM.
Integration:
There has been ra great deal of debate on the question of integration of all
systems on the Chinese model, but very little progress has been made. The
disadvantages of uncoordinated development of parallel streams are
obvious. The large manpower and institutional resources of ISM are
completely divorced from public health activities, which is a huge waste in
a poor country. On the other hand, even where ISM remedies are potent
and cost effective, they are not being used in the healthcare institutions
FeUf.P°rted by public funds- Needless to say, a synergistic development of
ISM and modern medicine would be highly desirable for both systems But
how is such a synergy to be achieved?
Several alternatives have been suggested. Some scholars have advocated
complete integration on the Chinese model, with a common course of
medical education and a common pharmacopoeia, with the most cost
effective remedies of ISM being incorporated as first choice treatments in
modern medicine. The suggestion is that a common graduate course could
be followed by specialization for ISM at the post-graduate level (5). On the
face of it, this seems a neat solution, but both sides have serious
reservations. ISM specialists feel that it is not possible to integrate the two
streams without compromising its growth and development, since the
principles governing diagnosis and treatment are entirely different. They
are also apprehensive - not entirely without good reason - that such
integration could lead to the more popular and powerful allopathic system
totally overwhelming the ISM systems. They point out that the first step
should have been the integration of ayurveda, siddha and unani - all of
which have many similarities, but no initiative in this direction has been
possible because the traditionalists in ISM are dominant. The modern
medicine professionals are also not enthusiastic about ISM being made a
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part of the MBBS curriculum. They feel this would take away precious time
from the more pressing requirements of teaching modern medicine, which
has to enlarge its scope to accommodate expanding scientific horizons and
new diseases. They also suggest that teaching two entirely contrary sets of
theories would only confuse students. An integrated course that was
initiated many years back was abandoned as a result of opposition from
both sides. There is also legitimate opposition to the induction of ISM drugs
in modern medicine therapies before their safety and efficacy is established
on a scientific basis. It is not easy to discount the reservations held by
either side, and we believe that the proposal for complete integration is a
total non-starter.
The ICCSSR/ICMR Report (1981) examined this question and suggested a
synthesis of all systems to evolve a common national system:
•
•
•
Each indigenous system should be allowed to retain its identity,
while developing, at the same time, a national system of
healthcare in which all systems can make their own unique
contribution.
Just as ayurvedic colleges offer some education in western
medicine, colleges of modern medicine must offer brief courses
introducing students to relevant portions of indigenous systems.
The ultimate goal is for all institutions training medical and health
personnel to teach one synthesized system of medicine, with the
individual systems being offered as some of the specialization
courses at the post-graduate level.
Synthesis has to be a well-planned process with a singularly
efficient monitoring and evaluation system at the healthcare
delivery level.
Apart from all this, synthesis requires the right climate to evolve. All
public pronouncements about health must aim at convincing people of the
need to evolve a national system that would bring together the best in all
systems. Most important, an exchange of opinions among experts should
be initiated and an appropriate atmosphere for discussion created.
Broadly, such a synthesis would involve the following steps:
•
The curriculum in each stream should familiarize students with the
basic principles and important remedies in the other. The ISM courses
already include basic subjects of the modern medicine curriculum; what
they need to attempt is a better understanding of the systems within
the ISM fold, which alone could lead to the eventual integration of at
least ayurveda, siddha and unani. On the other hand, modern medicine
must incorporate familiarity with the basic principles and important
remedies of ISM in its curriculum.
•
An intensive effort must be launched to evaluate, by modern scientific
methods, the well-known remedies of ISM, and incorporate those that
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•
show a comparative advantage in Essential Drug Lists and treatment
protocols for public medical institutions.
All ISM practitioners in public institutions should be given short
courses to enable them to participate in major public health
programmes such as control of HIV/AIDS, TB, malaria, ARI and
diarrheal diseases. They should be trained to prescribe simple
allopathic remedies and refer complicated cases to medical doctors.
•
While the streams may continue on their parallel courses, there needs
to be strong cross representation on educational bodies from both
sides.
•
Eventually, a synthesized national health system must emerge as
envisaged in the ICSSR/ICMR report, incorporating the best of all
systems and utilizing all the available manpower of all systems to
maximum advantage for the achievement of national health goals. A
beginning seems to have been made by the introduction of some timetested ISM remedies in the RCH programme (6).
Research
The proposed paradigm requires a complete change in the way research
has been conducted in ISM. Separate autonomous bodies for ayurveda and
siddha (CCRAS)(7), unani (CCRUM)(8), homeopathy (CCRH)(9) and yoga
and naturopathy (CCRYN)(10) under the chairmanship of the Minister for
Health and Family Welfare, are mandated to promote and oversee research
in their respective fields. Although clinical research has also been pursued
'or lh,e..!ast 50 years’ albeit half-heartedly, the results do not command any
credibility due to an absence of scientific rigour and application. All known
remedies need to be scientifically evaluated on the basis of accepted
principles of research. To this end, ISM researchers need to be trained in
the methods of investigation, and ISM research bodies and the ICMR need
to collaborate more closely. Above all, the need is for a complete change in
the mindset and research culture.
There is another aspect of ISM research that deserves specific mention.
Based on ISM texts, some attempts have been made in the past to isolate
the active principle of herbs for purposes of new drug development . The
traditionalists
uauiuunaiisLs are opposed to this kind of research on the grounds that the
[solation of the active principle militates against the holistic approach of
ISM. It is possible that developing a drug on the basis of isolation of the
active principle may change the character of the original remedy and may
affect its efficacy and safety. Despite this view that such drugs cannot be
utilised in ISM treatment, this is a line of research that we need to pursue
vigorously, in both public and private sectors, because it is now widely
believed that these investigations could yield important new weapons for
fighting disease.
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Educational Standards
One major issue in ISM is the standardization of education, and this has
been engaging government attention for several decades. The Central
Council of Indian Medicine (COM), constituted in 1970, is the statutory
authority for laying down standards for ayurveda, siddha and unani, while
this function is discharged by the Central Council for Homeopathy (CCH)
for homeopathic institutions. Despite differences in teaching regimens,
laying down standards and prescribing curricula has not been as difficult as
the task of enforcing these standards. Most ISM institutions are poorly
equipped and have inadequate financial support. As a result, the Central
Government has had to intervene to provide financial support for various
programmes of upgradation. The centre has also established Natural
Institutes in each ISM discipline to develop a model educational institution.
However, most of these institutions, are far from fulfilling this objective.
Except for the Institute of Post-Graduate Teaching and Research in
Ayurveda, Jamnagar, none of the institutions can be considered to have
reached standards comparable to similar institutions in modern medicine.
Thus ISM education still has a long way to travel. To cater to the growing
international demand for CAM practitioners, a new breed of ISM manpower
- that is modern in outlook, scientific in approach and fluent in English needs to be developed.
Standardization of Drugs
The standardization of ISM drugs is a matter of even greater complexity.
With hundreds of texts and the varying interpretations and diverse
treatment modules followed by hereditary practitioners, the development of
the pharmacopoeias is indeed a daunting exercise. The Pharmacopoeia
Committees for ayurveda, unani, siddha and homeopathy, with the
assistance of the Pharmacopoeial Laboratory of Indian Medicine and the
Homeopathic Pharmacopoeia Laboratory at Ghaziabad, have been working
together to develop detailed pharmacopoeias for the last several decades,
but the task is still far from over. Even more difficult than the prescribing of
standards is their enforcement. Many practitioners dispense the medicines
themselves, and since most preparations are of organic origin, testing and
determining their exact composition presents immense problems. Although
ISM medicines are formally notified under the Drugs and Cosmetics Act, the
actual enforcement of standards is still only in name. A Drug Control Cell in
the Department of ISMH, MHFW, is coordinating legislation and its
enforcement with the office of the Drug Controller General. This is an area
which that needs particular attention in the future.
Medicinal Plants
The growing commercial interest in ISM remedies the world over has raised
concerns about over-exploitation of natural herbal resources. According to
a report of the Export Import Bank of India (1997), the value of the
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11
medicinal plants related trade in India is of the order of US$5.5 million, and
growing rapidly. Forests have traditionally been the source of medicinal
herbs and plants, but now these herbs are threatened in two ways: first, the
forest cover is fast shrinking; and second, the demand for these products
has been rising sharply. In the absence of timely action, certain species are
in danger of becoming extinct. The Ministry of Environment has already
recommended a ban on the use of 29 endangered species of medicinal
plants. Many of these plants are not capable of commercial cultivation away
from their natural habitat as they lose their therapeutic value. The
availability of medicinal plants can be improved only with coordinated
action of the Ministries of Health and Family Welfare and Environment and
the state governments. Besides launching a scheme for cultivation of
medicinal plants, a Medicinal Plants Brand has been constituted under the
Minister for Health and Family Welfare to coordinate all activities in this
regard.
Patents
The increased commercial interest in herbal products, coupled with the
introduction of the WTO mandated Intellectual Property Rights (IPR)
regime, has led to many well-known medicinal uses of plants being
patented abroad. This points to the need for vigilance, and for contesting
these patents in appropriate courts. Side by side, all the traditional
knowledge in this regard has to be quickly documented to contest such
claims. It is proposed to develop a Traditional Knowledge Digital Library
(TKDL), initially for Ayurveda. The TKDL will ensure that knowledge in the
public domain is available in patent compatible and easily retrievable form
to the patents examiner, which will help prevent claims of patent on non
original inventions (11). This is a well-timed new initiative by the Ministry.
Conclusion
ISM has to make up for centuries of neglect. Besides strengthening the
infrastructure, some major initiatives must be taken to promote the
synthesis of different systems, and to encourage the scientific evaluation of
traditional remedies. Above all, a change of mindset is required to make
ISM modern and forward looking in outlook without loosening its traditional
roots. The new slogan for ISM should be ‘tradition with modernity.’ Some
new initiatives of the central government encourage us to believe that ISM
has been set on the right course. With the right policy initiatives and
necessary reforms, ISM can not only make a contribution within India, but
also emerge as a leading source of alternative medicine the world over.
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Notes
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Though the term ISM is generally used to cover these 6 systems, only 3 of
them - ayurveda, siddha and yoga - are indigenous systems. Unani is of
Greek origin and came to India in medieval times. Naturopathy has some
elements of non-lndian origin; and homeopathy is of German origin.
For a fuller discussion, see Appendices, Ayurvedic Medicine, Its
Approaches and Principles by Ram Harsh Singh, Senior Professor and
Chief Consultant in the Department of Kayachikitsa (Internal Medicine).
Faculty of Ayurveda, Banaras Hindu University (BHU), Varanasi. This
chapter is based on a background paper on him.
Annual Report 2000-01, Ministry of Health and Family Welfare (MHFW).
NSS 42nd Round, NCAER Household Surveys, 1995.
R.H. Singh, BHU.
Annual Report 2000-01, MHFW.
Central Council for Research in Ayurveda and Siddha.
Central Council for Research in Unani Medicine.
Central Council for Research in Homeopathy.
Central Council for Research in Yoga and Naturopathy.
Annual Report 2000-01, MHFW.
308
u
Annex 15.1
Summary of Medical Care, Medical Manpower and Medical Education Facilities
available under Indian Systems of Medicine and Homeopathy as on 1.4.1999.
(Provisional Figures)
SI. No.
1
2
3
Facilities
Ayurveda Unani
Siddha
Yoga
8
101
42
2258
40313
14416
196
4872
970
224
1811
363
367528
41221
12915
Naturopathy Homoeopathy
Total
|
3004
60666
I
21
733
56
297
12836
7155
23028* I
388
189361
611413
4
Hospitals
Beds
Dispensaries
Registered
Practitioners*
5$
(I) Undergraduate
Colleges
196
40
2
149
387
(ii) Admission
Capacity
7070
1280
150
7610
16110
49
3
2
14
68
645
35
70
186
936
6$
(I) Post Graduate
Colleges
(ii) Admission
Capacity
I
I
I
I
J
Note :
: Nil Information
‘ : Includes 26 Amchi Dispensaries
** : Information as on 1.1.99.
$ : As on 1.10.2000 based on information furnished by CCIM/CCH
Source : Annual Report 2000-01, MHFW, GOI
309
i
H
)
Annex 15.2
Statewise Number of Registered ISM & Homoeopathic Practitioners* as on 1.1.1999
(Provisional Figures)_________
States
Ayurveda
Unani
Siddha
Naturopathy Homoeopathy
Total
)
Andhra Pradesh
Assam #
Bihar #
Gujarat
Haryana
Himachal Pradesh
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Orissa
Punjab
Rajasthan
Tamil Nadu
Uttar Pradesh
West Bengal
14621**
250
75711$
16223
18553
6798
10555
13080
47130
46519
3653
19924
26056
3366
55921
2873
4614**
NA
3250S
234
1656
454
679
55
427
2298
15
5610
1849
916
11963
4927#
ndia
367528
41221
298**
1
1345
67
2
11569
21
12915
388
8411
464
25669
3768
5664
1076
5871
7760
6794
27911
4733
7256
3975
16060
24711
36107
27944
714
104630
20225
25873
8328
17173
22240
54353
76728
8401
32790
31880
31932
92595
43907
189361
611413
Note :
#
No information has been received for the current year hence repeated for latest available
year.
: Nil information
NA : Not Available
: Source COM
$
Includes Institutionally Qualified & Non-institutionally Qualified Registered Practitioners.
**
: Information is available for one Board only.
Source : Annual Report 2000-01, MHFW.GOI.
310
iI
Annex 15.3
S^tewtee/Sy^emwi56 Number of Hospitals and Dispensaries with their Bed
Strength under Indian Systems of Medicine and Homoeopathy Functioning as on
____ _______________
1.4.1999. (Provisional Figures)
States
Andhra Pradesh
Assam #
Bihar #
Gujarat
Haryana
Himachal Pradesh
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Orissa
Punjab
Rajasthan
Tamil Nadu
Uttar Pradesh#
West Bengal#
India
______ Ayurveda
______ Unani
Hospitals
Hospitals
Di»p«nnri«»
7(390)
207
1
128
8(444)
2(130)
Dl»p«n»ariet
9(871)
45(1745)
9(840)
16(330)
124(6132)
109(2561)#
34(1160)
73(11713)
8(323)
11(771)#
90(1179)
4(267)
1671(9911)
3(215)
1437
329
522
539
414
1064
561
759#
2105
463
527
489#
3486
10
713
254
5(270)
1(54)
136(1186
2(110)
2258(40313)
14416
196(4872;
4(414)
Slddha
1(10)
20
3
11(202)
45
1#
56
1(60)
10(1400)
23
9
35#
79
6
148
970
Hospitals
Yoga______
Dispensaries
Naturopathy
Hospitals
Dispensaries
1(25)
2
2
1(1)
2
8
tprtals
Pispensa-Ms
Homoeopath''
Hospitals
1(135)
1(10)
1(10)
12(451)
1(30)#
5(25)
9#
35
338
224(1811)
363
8(101)
42
11
25(1480)
72(1440)
12(590)
77(5505)
30
2(22)
221(1716)
6(280)
3(105)
1(100)
9(730)
2’(733)
5(150)
6(185)
5(160)
2C
3(150)
36(399)
14(682)
297(12836)
715
Note :
---------- ------------ --------- L----------- -------------------------------------Figures within bracket indicates the Bed-strength
#
#
Nil information h3S h66" rece'Ved for ,he current *ear hence repeated for latest available
es
28b
75
1(
3
2
14
2*
27
503
10
12
41
1378
89?
3
1
56
Dlspen
I
I
yea
Source : Annual Report 2000-01, MHFW, GOI
'T
<
(
311
u
16
Health Research: Its Potential in India
The Global Context (1)
There is a widely acknowledged mismatch between the disease burden of
the poor countries, and the resources and research efforts devoted to
developing new tools to address them. Similarly, the wide disparities
between rich and poor countries, in terms of burden of disease and mortality
levels, have provoked serious global concern (Figure 16.1). There is an
increasing awareness, even in the industrialized countries, of the dangers
inherent in these growing inequalities in health status. One of the strategies
that could narrow this gap is research on diseases that predominantly affect
the poor. According to a recent study (2), new technology, an indicator that
includes medical breakthroughs, accounted for almost half the gains in
mortality reduction in low and middle income countries between 1960 and
1990. The Commission on Health Research for Development (1990), which
first investigated this issue, “found a gross mismatch between the burden of
illness, which is overwhelmingly in the third world, and investment in health
research, which is overwhelmingly focussed on the health problems of the
industrialized countries."(3) (Figure 16.2).
Figure 16.1
Burden of Diseases
Mortality
High
Income
8%
High
Income
15%
Low
and
Middle
Income
92%
Low
and
Middle
Income
85%
Source: WHR 1999
312
u
Figure 1 6.2
World Health: Contrast in Premature Mortality Burden and Allocation of Health
Research Funds (per cent)
Potential Years of Life Lost
MDeveloping
Countnes
93%
Industrialized
Countries
7%
^aa-
Research Expenditure by Purpose
Health
Problems of
Industrialized
Countries
95%
Health
Problems of
Developing
Countries
5%k
Source: Commission on Health Research for Development, 1990
The Ad-Hoc Committee on Health Research Relating to Future Intervention
Options (1996), which conducted an in-depth examination of these issues,
came to a similar conclusion: “Of a total of almost $56 billion invested in
health research in 1992, we estimate that 95% was invested in the health
problems that primarily pre-occupied the industrialized world, and just 5%
was devoted to the health needs of developing countries. Our assessments
of R&D spending on specific health problems showed, for example, that the
combined amount spent per> year on R&D into three leading conditions —
pneumonia, diarrheal disease and TB - totaled just US $133 million, or 0.2%
of the world’s total health R&D expenditure. Yet between them, these
diseases make up almost 1/5lh of global disease burden."
Admittedly, the development of infrastructure for high-quality health
research is expensive. Since the necessary facilities already exist in the
industrialized world, it is often argued that persuading the industrialized
countries to invest more in health research - and particularly on diseases of
the poor - would help sharpen the focus on this neglected area. While it is
nobody’s case that the industrialized countries, with their vast resources
and infrastructure, should not devote more attention and resources to the
problems of poor countries, we are constrained to point out that this
strategy alone cannot lead us towards our desired objective. Despite the
unambiguous conclusions and strong recommendations of both the
Commission on Health Research for Development, 1990, and the Ad-Hoc
Committee on Health Research Relating to Future Interventions Options,
1996, and their follow-up by the Global Health Forum, the pattern of
investment in health research does not seem to have significantly changed.
313
iI
According to a study (4) in 1992, funds for R&D came mainly from two
sources: governments (US $28.1 billion or 50.4%) and the pharmaceutical
industry (US $24.7 billion or 44.3%). The balance (US $3 billion or 5.4%)
came from the private not-for-profit sector (Figure 16.3). The Global Health
Forum I, 2000, has identified two key bottlenecks to greater investment in
health research devoted to the diseases of the poor:
•
•
insufficient funds and interest in identifying potential candidate
products for neglected diseases; and
the lack of commercial interest in developing and marketing
potentially promising discoveries.
Figure 16.3
Sources of Funds for Global Health R&D, 1992
Government,
low-income
and middle
income
countries
2.2%
Pharmaceu
tical Industry
44.3%
Government,
Established
market
Economies4
48.2%
Private
nonprofit
sector
5.4%
Source: Investing in Health Research and Development, WHO, Geneva. 1996 (5)
Earlier stages of discovery are highly speculative by their very nature, and it
is not easy for a single party to expropriate the benefits of this research. As
a result, private researchers are likely to under-invest in these stages,
relying on public organizations to fill in the gaps. Public organizations have
more latitude to base their allocative decisions on political rather than strict
commercial grounds. In practice, however, basic research tends to focus on
global diseases that are priorities in higher income countries such as
cancer, rather than on neglected diseases (6) - for the obvious reason that
public funding of research is guided primarily by political considerations,
which naturally emphasize diseases of immediate concern. Research on
diseases such as TB and malaria is concentrated in low- and middle-income
countries, but their resources are limited and their availability uncertain for
research groups to establish long-term, large-scale programmes. If this
imbalance is to be corrected, there is no option but to encourage the
314
H
developing countries themselves to invest substantially in research on
problems of their immediate concern.
The role of the private sector in research is primarily to convert scientific
ideas into marketable products. The expense and magnitude of resources
and experience required to conduct clinical trials is normally beyond the
means of public organizations. In selected therapeutic areas for R&D
private companies are guided by three main criteria (7):
• expected market size (number of patients and availability of
funds to purchase medicines);
• degree of unmet current and future medical needs; and
• probability of success.
From the commercial standpoint, most neglected diseases do not offer an
^nrhar?Vef?Larket desp,te perceived high need, primarily because of the
inability of the poor to pay for the new discoveries.
Hv^t
many ,neW initiatives t0 encourage
encourage the
the private
private sector
sector to
to
invest more in these acknowledged priority areas.
As
a
result,
many
new
areas. As a result,
cinh'fi Am
partna;shiPs (ppps) have been launched, most notably, the
A nq /?? 'anCr f01’ Vacc|nes and Immunizations (GAVI), the International
IDS X/accme (mtiative (IAVI), the Medicines for Malaria Venture (MMV) the
TB Diagnostics Initiative and the Global Alliance for Anti-TB Drug
reesuHsPmuen,|P«07heVed
a'One may nOt be able to achieve the desired
rlnJn / f
he. devel°Pin9 countries themselves strengthen their
affec? mo^nf^h63
deV°te 9reater resources to the diseases that
research rehls h'" P°pUlatl°7 Thls is also because “the practice of health
ec o on thp i
? on close contact with other areas of the health
sector, on the local epidemiological environment, and on
on clinical
as ninhni'3
t°C'al s,ciences that are tied to national frameworks as well
as global ones. Many of the needed solutions to the health problems of the
people in low income countries are more likely to be found by researchers
popuia,i°"s ,han
“b-s
Besides, the degree of commitment developing countries can bring to bear
on research on these neglected diseases is unlikely to be generated in the
Kh'aForeurnC|Un-^S °n " Sl,S'ained baS'S
'he words °f
Health Forum I
there are no first world’ solutions for ‘third world’
problems. Brazil, India and South Africa have been specifically identified as
oharmX t^i
international|y -cognized research
capabHibes and
pharmaceutical companies, that are in
a
position
to
make significant
in
contributions to the global effort (9).
India s Potential in Science and Technology
Mnt'fh? r'Ch heri.\age and tradition of scientific inquiry is well acknowledged
No able among its ancient contributions are the decimal system, the concept
ot the zero and the comprehensive treatises in health sciences compiled by
315
d
many teaching medical institutions, most notably, the All India Institute of
Medical Sciences (AllMS), Delhi, the Post Graduate Institute of Medical
Education and Research, Chandigarh, and the Christian Medical College,
Vellore make valuable contributions to medical research.
Box 16.1
Principal Institutions Contributing to Health Research Outside ICMR
Central Institute of Medicinal and Aromatic Plants (CMAP),
Lucknow
Central Drug Research Institute (CDRI), Lucknow
Centre for Genetic Engineering and Strain Manipulation, Madurai
Biochemical Engineering Research and Process Development
Centre (BERPDC), Institute of Microbrial Technology, Chandigarh
Centre for Cellular and Molecular Biology (CCMB), Hyderabad
National Institute of Immunology (Nil), Delhi
National Centre for Cell Sciences, Pune
International Centre for Genetic Engineering and Biotechnology,
New Delhi
ICMR:
The ICMR promotes bio-medical research in the country through intramural
research (through institutes totally funded by ICMR), and extra mural
research (through grants-in-aid given to projects in non-ICMR Institutes).
Intramural research is currently carried out through the Council's
• 21 permanent national research institutes/centres (Annex 16.4),
which are mission-oriented institutes located in different parts of
India. They address research on specific health topics such as TB,
leprosy, cholera and diarrheal diseases, viral diseases including
AIDS, vector control, nutrition, food and drug toxicology,
reproduction, immuno-hematology, oncology, and medical statistics.
• 6 Regional Medical Research Centres (Annex 16.5) which address
regional health problems and attempt to strengthen or generate
research capabilities in different geographical areas of the country.
Extramural research is promoted by ICMR through
• centers set up for advanced research (Annex 16.6) in different
research areas around existing expertise and infrastructure in
selected departments of medical colleges, universities and other
non-ICMR research institutes;
• task force studies that emphasize a time-bound, goal-oriented
approach, standardized and uniform methodologies, and often a
multi-centric structure; and
• open-ended research on the basis of applications for grants-in-aid,
received from scientists in non-ICMR research institutes located in
different parts of the country.
317
H
Finance:
Health research in India has, in general, been a neglected area. According
to the data for 1996-97 published by the Ministry of Science and
Technology, only 8% of the total public expenditure on R&D was for health
related research (Figure 16.4).
A study undertaken for the Ad Hoc
Committee (1996) by Almeida et al showed that there was a slight decline in
real terms in expenditure on health research (Figure 16.5).
Figure 1 6.4
Indian R&D Expenditure by Objectives, 1996-97
[10]
5%
hl
13%
[9]
19%
[2]
17%
[0]
5%
FT
♦
4%
♦
♦<
[3]
14%
(6)
8%
[5]
7%
(4]
8%
1 Space
2 Agriculture, Forestry,Fishing
3 Industry
4 Energy
5 Transport and Communication
6 Health Services Development
7 Environment
8 General Advancement of
Knowledge
9 Defence
10 Other: Exploration, Education,
Socio-economic Services and
other aims
Source: Ministry of Science and Technology, 1999
Figure 16.5
Central Government Health R&D Expenditure in India (Constant Prices)
Rs. (Million, 1980-81 Prices)
300
250
200
'■Xi
150
100
■
50
0
Wl
89-90
90-91
91-92
92-93
___Year
□ icmr nnon-allopathic
Note: ICMR includes one to two per cent soent on indigenous systems of medicine.
Source: MHFW, GOI. Reproduced from Health R&D Expenditure, India. 1995
318
h
Lheallocation?to'lrMW=''er’ cha"9ed for ,he be«er in recent years as far
^a"dCX; (Ta'^ViVA0^^' and ‘b6'6 haS
3
this augurs well for the future,
investments in ICMR and other health
research institutions need to be
stepped up substantially to bring them c.,
on par with international standards,
and make them capable of producing high-quality
' research in high-tech
a rea s.
Table 16.1
Financial Outlays for ICMR 1997-98 to 2001-2
Year___________ I
Rs. Millions
~~1997-98
1998-99
1~999-20Q0
2000- 01
2001- 02
--------------|
377.60
540.00
592.50
860.00
1020.00
Source: Lalit Kant, background "paper, ICMR, 2001
Important Achievements
hreVseearechn
'a''he Cred"
(Annex °16 2h)aVM had S°me n°table successes in the Vield"1 of diagnostics
(Annex 16.2). More recent initiatives include the National Institute of
resSTh
561 UP by MHFW t0 devel°P standards, quality control and
J20°mimoCnC'?ned T^e Deparlment of Biotechnology has launched a five
diverse L7XopuXnen°me '
a'iVe ‘0 S,Udy ,he penelic
°f
Weaknesses:
Despite their many achievements, Indian research institutions like most
Indian research institutions,
public sector agencies, are characterized by several weaknesses ’ including
• bureaucratic functioning
mciuaing
hierarchical management structures: civil
service tvoe caropr
structures that reward seniority rather than performance
’ C
nen^rallzatlon
authority: Many of these institutions are autonomous
h dli hT6'
6 ICMR’ headed by the Minister and the Secretary
hardly has any genuine autonomy. Only a thorough overhaul of the
in^XTnls^inhe^h" °f
inStitUti°nS Wi" V'^opt.mXLhs
*
HIvebimenis in health research.
an^ unstable funding. and poor compensation and incentives to
rnX rchers- stagnant levels of funding have led to the growth of fixed
,he S“ — - --y
319
iI
Health Research in the Private Sector
India has one of the largest and most technologically advanced
pharmaceutical industries among the developing countries. The total
production in 1999-2000 was Rs.37,770 million for bulk drugs and
Rs.1,58,600 million for formulations in 1999-2000. It is a major foreign
exchange earner with exports totaling Rs.56,662 million in 1998-99 (15).
The total Indian market is valued at $7.2 billion, and in terms of volume, it is
the world’s third largest market with over 20000 manufacturers. The industry
has shown its technological capabilities in reverse engineering by producing
generics at a fraction of the cost in international markets. However, it has
paid scant attention to research because of the absence of product patent
protection, and concentrated its energies on producing generic substitutes
for foreign patented and branded products. The Intellectual Property Regime
(IPR) is set to change with the introduction of product patents in conformity
with WTO mandated regulations. The industry is poised to play a major role
in drug discovery and development. Although the new product patent regime
will be applicable to India only from the year 2005, there has been, in
anticipation, a substantial increase in the R&D expenditure of major
pharmaceutical companies such as Ranbaxy Laboratories, Dr. Reddy’s
Laboratories, Wockhardt, Sun Pharmaceuticals and Cipla (16). The Indian
industry already commands a major advantage over its rivals in the West:
the cost of introducing a new chemical entity (NOE) in the market is
estimated at $250-500 million in the US, while the estimate is only $90-100
million in India (17). According to a recent study commissioned by the World
Bank, “India has the potential to become the hub of pharmaceutical
research."(18)
Modern R&D will become ever more complex and expensive with the
advances in sciences on several frontiers. The cost of conducting R&D at
the frontiers of knowledge has become prohibitively high. It is not possible
to develop all facilities under one umbrella, and the favoured strategy is to
develop core competency and look for complementary strengths elsewhere.
Some beginnings have already been made toward developing partnerships
between public sector and private sector research organizations/companies.
CDRI, Lucknow, for instance, is collaborating with Novo-Nordisk of Denmark
on a new molecule; Smith Kline Beecham is working in collaboration with
the Indian Institute of Chemical Technology (IICT).
Another important development that can benefit the Indian industry is the
outsourcing of research by MNCs. The expenditure on outsourcing research,
as a percentage of R&D expenditure, has already exceeded 16%, compared
to almost 8% in 1990. The worldwide contract research market reached US
$5 billion by 1998 (19). Globally, India has an advantage in all outsourcing
activities
because
of
its
well-trained,
highly
qualified
and
relatively
inexpensive manpower.
320
ii
bac}<9round of strengths and advantages in view that some
multi-nationals established research centers in ('
the country. Astra IDL has
set up an R&D Centre of international standards iin Bangalore; Eli Lily has
joined hands with Ranbaxy to conduct iresearch; Novo Nordisk A/S of
Denmark has teamed up with Dr. Reddy’s Laboratories for an anti-diabetic
drug. These companies and many more see the obvious advantages of
coming to India, and what is a trickle today is likely to grow into a flood
provided India establishes an appropriate policy framework. In the words of
the Global Health Forum I: “In the longer term there is
i a real possibility that
Brazil, China, India or other
other Middle
Income
countries
Middle Income countries with
with growing
pharmaceutical industries could make
significant contributions
make significant
contributions to the
development of products for neglected diseases. However, simply because
the companies are based in a country where neglected diseases exist does
not mean that they, operating as they do in the global economy, are more
likely to focus on these diseases than companies in the US and Europe."
The companies in India are equally driven by the profit motive; and already
there are indications that their ongoing research efforts are prioritizing new
mo ecu es for NCDs such as cancer and diabetes. If the resources and skills
of the Indon pharmaceutical industry are to be harnessed to research the
neglected
. . diseases
.
--- of
-• the Poor, the government needs to develop an
appropriate incentive framework.
Special Advantage and Opportunities:
Bes'des public sector research infrastructure, the pharmaceutical industry
and other strengths, there are some special advantages that India enjoys
over many countries of both the North and the South:
India has huge and diverse clinical material for research, giving
the country a unique opportunity to turn an acknowledged
disadvantage into a research advantage.
• India has a strong claim to being ran appropriate site for clinical
trials. As the companies seek to conduct globalI trials, contract
research organizations in India are ideally
’ '
placed to take
advantage of this opportunity.
• India has unparalleled bio-diversity, and the
me wealth
,
of its flora
and fauna make India an ideal site for research
-------- 1 on new biological
compounds.
• India has a rich and unmatched heritage of traditional systems of
of
medicine, which can provide leads for new discoveries for the
treatment of many apparently incurable chronic ailments.
• A large, diverse population steeped in tradition has ensured that
many rarer genetic disorders have survived in India, and this can
become the subject matter of valuable research.
• The future belongs to bio-informatics. The sequencing of the
human genome would hardly have been possible without the
strong inputs from information technology. India, with its strong
•
321
u
IT base, can take a lead in research areas which require strong
software inputs.
India is already a huge and fast growing
growing market for
pharmaceuticals, and new drug discoveries are generally assured
of good commercial returns.
Policy Framework
India could realize its true potential and take full advantage of its unique
capabilities in health research provided the Government creates a
favourable, enabling policy framework. Such a National Health Research
C
Policy would have to clearly establish both the
vision and: the future
directions of health research in the country. It would also have to creates an
incentive environment for both public and private sectors,
The main
elements of this policy framework could be as follows.
Public Sector:
•
The government has already agreed to the WTO mandated IPR regime,
and the necessary legislation awaits passage in Parliament. Enacting
this legislation without delay would end the current uncertainty.
• There must be substantial increase of public investment in basic and
strategic research, particularly directed towards new discoveries for
the neglected diseases of the poor.
• Priority must be given to health policy and systems research - so far a
neglected area with the exception of recent interest from the World
Bank and some bilateral donors. Special efforts are also required to
train
researchers
in
health
economics,
health
finance
and
epidemiology, disciplines in which there is only limited available
expertise.
• The international support for health research has so far been nominal;
Almeida et al (1995) estimated it at only 5% of total health R&D
expenditure in 1992-93. In view of India's potential to contribute,
external assistance for this purpose must make a quantum leap.
• Public sector institutions can produce a higher quality of research with
an appropriate management structure. The Ad-Hoc Committee 1996
examined this question in some depth. It emphasized
a) autonomous management
b) compensation policies to attract young and talented scientists
c) training of numbers large enough to allow for transfer to other
sectors
d) stable core funding, and an element of competitive funding
allocated to research projects and to individual and
institutional development
e) internationalization, including collaboration with institutions
from both North and South and
322
11
f) the use of electronic media for peer review and publication as
a first step towards reducing the regional bias in established
publishing formats.
As far as the ICMR is concerned, restructuring would need to be
on the following lines:
a) true
iiue autonomy,
duiunumy, with
wnn the
me Minister and Secretary replaced in the
governing body by eminent professionals; decentralization of
decision making to research institutions;
b) improve compensation, working environment and perquisites
to attract and retain talented scientists; develop career
progression system for scientists that rewards performance
rather than seniority;
c) add an international dimension to research efforts and
constitute an external scientific advisory committee for the
purpose; and
d) change the name of the body to the Indian Council for Health
Research, to broaden its mandate to include health policy and
systems research.
he development of research requires the removal of both demand and
supply side constraints. Increased investment, better infrastructure and
higher quality of scientific personnel have already been suggested as
means to cope with the supply side. But these suggestions can only
produce results with a growing demand for research inputs and their
improved utilization. This means the following steps must be takena) Promote a management culture in which decision making is
based on evidence and analyses.
b) Put in place institutional mechanisms for regular and close
interaction among policymakers, programme managers and
researchers, to set research agenda and utilize research
inputs. This would help focus the attention of public sector
agencies on neglected diseases; as well as on health
systems research, directed at the improvement of technical
efficiency and the delivery of various programmes and
services.
•
There needs to be a renewed
renewed emphasis
emphasis on research capacity
strengthening
infrastructure
...
, by improvement of ----------------- -- for the training of
scientists and new collaborations with institutions from both the North
and the South. In particular, capacity needs to be developed quickly to
undertake clinical trials for new molecules likely to be introduced for
various communicable diseases. A very close partnership with
international organizations such as the WHO Special Programme for
Research and Training in Tropical Diseases (TDR) and PPPs would be
necessary.
323
H
Private Sector:
The required push and pull mechanisms to provide incentives to the private
sector - to develop interest in research in general, and in neglected areas
in particular - has been well documented (Annex 16.3). All these
mechanisms need careful examination with the aim of stimulating research
in the desired direction by industry. Some recent government initiatives are
bound to have a salutary impact. The limit for foreign direct investment in
pharmaceuticals has been raised to 100%. Investment and expenditure on
research and development is already entitled to a weighted deduction of
150% in certain areas. In the current Budget (20), this has been extended to
biotechnology, clinical trials, filing patents and obtaining regulatory
approvals. This should provide the industry with a substantial incentive to
invest more in R&D.
Chapter 14 of this Report (21) refers to the government review of the price
control regime on drugs. It emphasizes that the review should consider the
need to give appropriate incentives for new discoveries, particularly in
priority areas of research. It also suggests a National Drug Fund through a
levy of a suitable cess on both imports as well as domestic production of
pharmaceuticals. This fund can be used to share expenses with private
industry on product development in designated priority areas. What is most
important is alliances among academia, research institutions and
industry. The key to the success of these endeavours lies in the use of
basic and strategic research outputs by industry, which must then take the
process a step further towards product development. The ICMR should
develop suitable mechanisms to facilitate such an alliance, and to mediate
between research outputs from academia and research institutions, and the
pharmaceutical
industry.
It should develop expertise for product
development to facilitate such transfer of knowledge on the same pattern as
TDR. Other important government initiatives would be the simplification of
regulatory mechanisms to undertake clinical trials, a transparent system of
granting approvals and monitoring, and a system to enforce the ethical
guidelines already developed by the ICMR.
Conclusion
Along with some other low and middle income countries, India could help
bridge the gap between the overwhelming need for research on the
neglected diseases of the poor on the one hand, and the totally inadequate
international research response on the other. An enlightened policy
framework, coupled with a close partnership between public and private
sectors, could seize this opportunity for India's benefit and indeed, for the
rest of the world. Health research could give a new dimension to India's
research efforts, while transforming the current image of the Indian
pharmaceutical industry as expert reverse engineers, to market leaders in
the introduction of new products. Like IT, health research could not only
boost India’s image, but also provide significant impetus to the
324
H
pharmaceutical industry and the economy. This is, of course, besides
making its contribution to the reduction of avoidable morbidity and mortality
in low-income countries. Health research may turn out to be by far the most
profitable, beneficial and cost-effective investment for India.
Notes
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
This chapter is based on a background paper prepared by Dr. Lalit Kant, Senior
Deputy Director General, ICMR, New Delhi.
WHR 1999.
Report of the Commission on Health Research for Development, 1990.
Catherine Michaud and C.J.L. Murray, Resources for Health Research and
Development in 1992, A Global Overview, CJL, 1996.
Represents industrialized countries.
Global Health Forum I, 2000.
Ibid.
The Ad-Hoc Committee on Health Research, 1996.
Global Health Forum I, 2000.
Lalit Kant, background paper, 2001.
Ibid.
Research and Development Statistics, 1996-97.
Dewang Mehta, Software Garden for World Users.
Lalit Kant, background paper, 2001.
Indian Pharmaceutical Industry, ASCI, 2000.
Ibid.
Ranjit Roy Chaudhary, background paper, 2001.
18. ASCI 2000.
19.
20.
21.
22.
Ibid.
Budget Speech of the Finance Minister, February, 2001.
Chapter 14 of this Report, Drug Policy and Regulations.
DOTS - Directly Observed Therapy Short Course for TB.
325
u
Annex 16.1
Significant Research Achievements of Indian Research Institut ons
•
•
•
•
•
•
•
The supervised administration of drugs developed by the ICMR’s ~B Research
Centre at Chennai was a forerunner of DOTS (22).
The pulsed approach for polio control originated from an ICMR supported study in
North Arcot District, Tamil Nadu.
The ICMR institutes, the Malaria Research Centre and the Vector Control Research
Centre, have demonstrated the feasibility of the integrated approach to vector
borne diseases, especially malaria and filariasis.
The National Institute of Nutrition developed technology for the double fortification
of common salt with iron and iodine to fight anemia and iodine deficiency disorders
together.
Researchers at the Shri Chitra Tirunal Institute of Medical Sciences and
Technology, Thiruvananthapuram, developed a mechanical heart valve selling at
one third the price of imported ones.
The CSIR generated the combined genetic and physical map of tne whole vcholerae genome.
The CSIR also pioneered the use of DNA fingerprinting in India by ceveloping an
exclusive indigenous probe.
Annex 16.2
Achievements of Research Institutions in Diagnostics
Product
Developed At
Filariasis detection kit
Mahatama Gandhi Institute of Medical
Sciences, Wardha
Pregnancy Slide Test
National Institute of Immunology (Nil), New
Delhi
Pregnancy DOT-ELISA
Hepatitis-B detection kit
Nil, New Delhi__________
I Nil, New Delhi
I
Leishmaniasis detection kit
| Central Drug Research Institute, Lucknow
Western Blot test for HIV I & II
Cancer Research Institute, Mumbai
ELISA test for Japanese
Encephalitits,
Dengue and West Nile
ICMR
Typhoid fever detection kit
All India Institute of Medical Sciences, New
L_____________________ Delhi
Source: Lalit Kant, background paper, 2001
326
i1
Annex 16.3
“Push” and “Pull” Interventions to Promote the Discovery / Development of
Drugs and Vaccines
Push interventions
Pull interventions
To lower costs and risks of
research and development
To remove barriers in the
development pipeline
To provide incentives for
development and manufacture,
by creating a market, providing
other economic rewards or
removing economic deterrents
Basic research funding
(from government or
philanthropy)
Regulatory harmonization
Improving delivery of existing
drugs and vaccines
Grants for product
development
R&D tax credits to companies
Expediting
regulatory/licensing
process
Lowering regulatory fees
for specified product
categories
R&D expense write-offs
Tax credits to investors
Simplification (not
lowering) of standards
Identification of public health
priorities for new projects
Product specifications/contingen
recommendations for use
Recommendations for use
(earlier)
Market assessment
Establishment of R&D
capacities in endemic
situations, e.g. Phase III
trial sites
Protocol assistance, as per
US Orphan Drug Act
Protocol assistance
Patent extension
Setting ethical guidelines
for conduct of research
involving human subjects
and/or international
collaboration
Support for R&D to identify
new indications for existing
entities :
• Financial
• Through mass screening
facilities
Consortia (public, private or
public/private)
• “horizontal” - discovery
• “vertical” - development/
manufacturing
Patent “exchange” (extension on
another product)
Market exclusivity
Prizes (for first to meet specified
product characteristics)
Market “assurances”
• purchase funds
• contingent loans and credits
“cost-plus” formulas
• requisition to buy
Legislation on product liability
litigation
Source: The 10/90 Report on Health Research, 2000
327
u
Annex 16.4
ICMR Permanent Institutes/Centres
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
National Institute of Nutrition, Hyderabad
National Institute of Virology, Pune
Institute of Research in Reproduction, Mumbai
Tuberculosis Research Centre, Chennai
Institute of Immunohaematology, Mumbai
National Institute of Cholera and Enteric Diseases, Calcutta
Institute of Pathology, New Delhi
National Institute of Occupational Health, Ahmedabad
Vector Control Research Centre, Pondicherry
National Centre for Laboratory Animal Sciences, Hyderabad.
Food and Drug Toxicology Research Centre, National Institute of Nutrition,
Hyderabad.
Central JALMA Institute for Leprosy, Agra
Malaria Research Centre, Delhi
Institute for Research in Medical Statistics, New Delhi
National Institute of Epidemiology, Chennai
Institute of Cytology and Preventive Oncology, Maulana Azad Medical College
Campus, New Delhi
Enterovirus Research Centre, Haffkine Institute, Mumbai
Rajendra Memorial Research Institute of Medical Sciences, Patna
Centre for Research in Medical Entomology, Madurai
ICMR Genetic Research Centre, Mumbai
National AIDS Research Institute. Pune
Annex 16.5
Regional Medical Research Centres
1.
2.
3.
4.
5.
6.
Regional Medical Research Centre, Bhubaneswar
Regional Medical Research Centre, Dibrugarh
Regional Medical Research Centre, Port Blair
Regional Medical Research Centre for Tribals, Jabalpur
Desert Medicine Research Centre, Jodhpur
Regional Medical Research Centre, Belgaum
Annex 16.6
ICMR Centres for Advanced Research
1.
ICMR-NIC Centre for Biomedical Information, National Informatics Centre, New
Delhi
2. Centre for Advanced Research on Standardisation, Quality Control and
Formulation of Selected Traditional
Remedies/Natural
Products, Regional
Research Laboratory, Jammu-Tawi
3. Centre for Advanced Research for Health Consequences of Earthquake Disaster
with Special Reference to Mental Health, B.J. Medical College and Sasoon
General Hospital, Pune
4. Centre for Advanced Research for Drug Development from Natural/Plant Products,
Central Drug Research Institute, Lucknow
5. Centre for Advanced Research for Clinical Pharmacology inTraditional Medicine,
Seth G.S. Medical College and K.E.M. Municipal Hospital,, Mumbai
328
H
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