Health – Policies and Outcomes

INTRODUCTION #

Like education, Health is another critical dimen- sion of human capability, and therefore needs as much greater attention in government’s development policy.

However, attainment of good health outcomes is not just a matter of providing curative care. We need to give much greater attention to ‘public health’, which focuses on preventive healthcare, but has traditionally suffered from neglect. We also need to focus much more on a provision of clean drinking water and sanitation, which can make a major con- tribution to improve health. This was the experience in industrialized countries over a hundred years ago, and this is also true for us today.

While the longer-term objective of Health Policy must be the provision of Universal Health Care (UHC), whereby anyone who wants is assured of access to a well defined set of health care enti- tlements irrespective of his financial status, the immediate policy objective is to follow an inclusive approach towards healthcare that encompassed–

• equitable    and    comprehensive    individual healthcare,
• improved sanitation,
• clean drinking water,
• nutritious food,
• good feeding practices, and
• development of delivery systems responsive to the needs of the people.

At the same time, since putting a UHC system

in place may take time, we need to start building an appropriate architecture towards that end.

At present, only less than 30% of outpatient and less than half of inpatient health care capacity of the country is in the public sector, and the majority of the population relies on private health care provision which often imposes a heavy financial burden. It is, therefore, essential to expand public sector capacity in health care especially in the rural areas.

NATIONAL RURAL HEALTH MISSION #

The NRHM, launched during the 10th Plan, made an important start in expanding health care facilities in rural areas. While additional infrastruc- ture has been created, there are large shortages of personnel, especially specialists in rural health facil- ities, reflecting the fact that trained human resources in health are in short supply and it takes many years to set up new medical colleges to train the required number of doctors.

Major Issues #

1. Massive shortage of healthcare professionals;
2. Over-reliance on Private healthcare, which is not affordable;
3. Neglect of ‘public health’

MAJOR INTERVENTIONS DURING THE 11TH PLAN #

National Rural Health Mission (NRHM) #

Launched in 2005 during the 10th Plan period,

this is a major flagship programme of the govern- ment in the health sector. It has been an important intervention to transform public health care into an accountable, accessible and affordable system of quality services during the 11th FYP period.

It aims at inclusive health and improved access to quality healthcare for those residing in rural areas, particularly women, children, and the poor, through- out the country with special focus on 18 states.

The mission seeks to achieve the objectives by promoting integration, decentralization, and encour- aging community participation in health programmes.

The mission covers most of the existing pro- grammes of the MHFW under an overreaching umbrella.

Rashtriya Swasthya Bima Yojana (RSBY) #

With a view to prevent indebtedness due to expenditure on health, the RSBY was launched in October 2007 to provide health insurance cover to BPL families. This has been an important step in supplementing the efforts being made to provide quality healthcare to the poor and underprivileged population.

It is an effort to provide protection to BPL households in the unorganized sector against finan- cial liabilities arising out of health problems that involve hospitalization.

It provides cashless health insurance cover up to Rs 30,000 per annum per family. The premium is paid by the Centre and state governments on a 75:25 sharing basis with the beneficiary paying only a registration fee

Janani Suraksha Yojana (JSY) #

Launched to promote institutional deliveries, the scheme provides cash incentives to expectant mothers who opt for institutional deliveries.

Pradhan Mantri Swasthya Suraksha Yojana (PMSSY) #

The programme is envisaged to correct the imbalances in availability of affordable or reliable tertiary level health care in the country in general and to augment facilities for quality medical educa- tion in the under- served states. This involves setting

up of AIIMS like institutions and upgrading certain existing institutions across various states.

Phase-I of PMSSY envisages establishment of six new AIIMS-like Institutions, upgradation of

13 state government medical college institutions. Phase-II provides for the establishment of two new AIIMS-like institutions in U.P. and WB and upgrading of 6 state government medical college institutions.

Redevelopment of hospitals/institutions #

While certain hospital/medical institutions of eminence would be redeveloped, upgradation of district hospitals is envisaged as a key intermediate strategy, till the vision of healthcare through PHCs and CHCs is fully realized.

Ayush #

Mainstreaming AYUSH into health services at all levels was also an important strategy for the 11th Plan.

Moreover, such interventions were also charac- terized by –

Special attention to marginalized groups: It promised special attention to the health of marginal- ized groups, such as adolescent girls, women of all ages, children below the age of three, older persons, the differently- abled, tribals, and SCs. Gender equity was to be an overarching concern.

Focus on ‘Public Health’-related services: It recognized that health outcomes depend not just on the access to curative healthcare, but also on strengthening ‘public health’-related services, par- ticularly access to clean drinking water, sanitation, and improved child-rearing practices, which in turn depend on education and empowerment of women.

At present, India’s health care system consists of a mix of public and private sector providers of health services. Networks of health care facilities at the primary, secondary and tertiary level, run mainly by State Governments, provide free or very low cost medical services.

There is also an extensive private health care sector, covering the entire spectrum from individual doctors and their clinics, to general hospitals and super specialty hospitals.

However, the system suffers from the following weaknesses.

ISSUES & CONCERNS (DETAILED) #

Availability of health care services – public and private sectors taken together – is quantitatively inadequate due to massive shortage of healthcare professionals:

At the start of the 11th Plan, the number of doctors per lakh of population was only 45, whereas, the desirable number is 85 per lakh population. Sim- ilarly, the number of Nurses and Auxiliary Nurse and Midwifes (ANMs) available was only 75 per lakh population whereas the desirable number is 255.

Affordability of health care is a serious problem for the vast majority of the population, especially in tertiary care and due to government’s over-reliance on private provision of healthcare:-

The lack of extensive and adequately funded pub- lic health services pushes large numbers of people to incur heavy out of pocket expenditures on services purchased from the private sector. Out of pocket expenditures arise even in public sector hospitals, since lack of medicines means that patients have to buy them. This results in a very high financial burden on families in case of severe illness. A large fraction of the out of pocket expenditure arises from outpatient care and purchase of medicines, which are mostly not covered even by the existing insurance schemes. In any case, the percentage of population covered by health insurance is very small. Moreover, the problem is likely to worsen in future.

Health care costs are expected to rise because, with rising life expectancy, a larger proportion of our population will become vulnerable to chronic Non Communicable Diseases (NCDs), which typically require expensive treatment. The public awareness of treatment possibilities is also increasing and which, in turn, increases the demand for medical care

Quality of healthcare services varies considera- bly in both the public and private sectors:

Many practitioners in the private sector are actually not qualified doctors. Regulatory standards for public and private hospitals are not adequately defined and, in any case, are ineffectively enforced.

Public expenditure on health remains very low #

The total expenditure on health care in India – taking public, private and household out-of-pocket

(OOP) expenditure – was about 4.1% of GDP in 2008–09, which is broadly comparable to other devel- oping countries, at similar levels of per capita income.

However, the public expenditure on health was only about 27 % of the total (i.e. of 4.1%) in 2008–09, which is very low by any standard.

Public expenditure on Core Health (both plan and non-plan and taking the Centre and States together) was about 0.93 % of GDP in 2007–08. It has increased to about 1.04 % during 2011–12. It needs to increase much more over the next decade.

When broader determinants of health (drinking water and sanitation, ICDS and Mid-Day Meal) are added, the total public spending on health in 11th Plan comes to 1.97 % of GDP.

The Centre cleared the long-awaited National Health Policy 2017, which promises to increase public health spending to 2.5% of GDP in a time- bound manner and guarantees health care services to all Indian citizens, particularly the underprivileged.

Neglect of ‘public health’ #

While there has been action on curative health- care, there has not been adequate and effective interventions in the sphere of public health that will include preventive healthcare, such as provision of safe drinking water supply, improved sanitation, immunization, nutritious food, hygiene, good feed- ing practices etc.

Health personnel not well-trained #

Setting up of 6 AIIMS like institutes and upgra- dation of 13 medical colleges has been taken up under PMSSY. Seventy-two State Government med- ical colleges has also been taken up for strengthen- ing to enhance their capacity for PG training. Huge gaps, however, remain in training capacity for all categories of health personnel.

Initiatives towards community empowerment, improving monitoring and accountability not effec- tive:

Though Rogi Kalyan Samitis (RKS) are in position in most public facilities, monthly Village Health and Nutrition Days are held in most villages, Jan Sunwais (public hearings) and Common Review Missions have been held, yet their potential in terms

of empowering communities, improving accounta- bility and responsiveness of public health facilities is yet to be fully realized.

Most public health institutions are not well- equipped for conducting deliveries:

To reduce MMR and IMR, institutional deliver- ies are being promoted by providing cash assistance to pregnant women under JSY. Poor women from remote districts in Bihar, Orissa, and other states are reportedly visiting institutions to avail JSY benefits. Though institutional deliveries have increased in rural (39.7 to 68 %) and urban areas (79 to 85 %) over the 2005–09 period, low levels of full Ante-Na- tal care and quality of care are areas of concern.

Except for parts of the southern states, most public health institutions are not well-equipped for conducting deliveries at the community or even at the block levels. The beneficiaries are often asked to purchase gloves, syringes, and medicines from the market. The general view, endorsed by visits to the field, is that the health centres and sub-divisional hospitals remain understaffed and are poorly run and maintained. A very large number are unhygienic and incapable of catering to patient loads. Women who deliver at the health facilities are discharged a few hours after the delivery. Sometimes, deliveries take place on the way to the health facility or even outside the locked labour rooms. Also, lack of coordination and mutual understanding between the ANMs and ASHAs result in the suffering of pregnant women.

Immunization cover is far from being universal: #

Full immunization in children has improved from 54.5 % in 2005 to 61 % in 2009 during the 11th Plan. Additions to the Universal Immunization Program include Hepatitis B, Japanese Encephalitis (JE) vaccine in endemic districts, and Pentavalent vaccine, which is a combination vaccine against Diphtheria, Pertussis, Tetanus, Hepatitis B and Hae- mophilus influenza B. Recently India has declared a ‘Polio-Free’ nation.

However, Immunization cover is far from uni- versal as envisioned in the 11th Plan, and remains particularly low in UP (41 %), MP (43 %), Bihar (49

%), Rajasthan (54 %), Gujarat (57 %) and Chhattis- garh (57 %), Assam (59 %) and Jharkhand (60 %).

Utilization of public facilities for chronic disease remains low #

Despite improvements in infrastructure, and personnel deployed, evaluation has reported that utilization of public facilities for chronic disease remains low in UP, MP and Jharkhand as compared to TN reflecting poor quality of service.

Moreover, despite efforts, lack of capacity and lack of flexibility in programmes forestall effective local level planning and execution based on local disease priorities. Wide variation in the performance of health facilities across states have been reported with TN topping and UP and MP at the bottom, pointing to the need for learning from best practices within the country through state level initiatives.

VISION FOR THE FUTURE #

Today in the sphere of public health, problems are enormous. There are lessons to be learnt from the experiences of other developing countries as also from those Indian states, Kerala and Tamil Nadu in particular, which have taken care of health of the people a lot better than the rest of India.

As far as the rest of the world is concerned, the countries that offer immediate lessons for India include China (most importantly), Brazil, Mexico and Thailand, among others.

In the field of public health most important thing is the importance of the commitment to universal health coverage for all, with a comprehensive vision of healthcare for the country as a whole. Brazil, Thailand and Mexico has reached this level in recent years and transformed the reach of healthcare for their people.

China’s experience is particularly interesting. In 1979 when China brought about economic reforms under Mao Zedong, it reversed the earlier univer- salism. But it had to pay a heavy price in terms of the progress of longevity and general health. China eventually realized this error in this denial and, from 2004, started moving rapidly back to universal commitment (it is already 95% there). Also, China does not leave the coverage of health in the hands of the private health insurance – the state is the major player to ensure this.

Thus, based on such experiences as also on

grounds of economic reasoning, i.e. the ‘public goods’ character of the health of the people, the role of asymmetric information, and the impact of inequality on the achievement of general health in a community and a nation, it would be perhaps wiser for the government to go about a major transforma- tion in India’s health care system.

Such a transformation may be achieved in at least two respects:

1. State must take upon itself the responsibility for direct provision of health services: – It is not to say that there is no role at all for the private sector in health care. Most health care systems in the world do leave room for pri- vate sector. Also, there is no denial that public accountability is lacking in the operation of the public sector. Never-the-less, this overar- ching objective of ensuring access to health services and other requirements of good health ‘to all members of the community ir- respective of their ability to pay’ (core princi- ple of universal health coverage as stated by Bhore Committee) is intrinsically a public re- sponsibility. Further, given the limitations of market arrangements and of private insurance in the field of healthcare, public provision of health services has an important foundation- al role to play in the realization of universal health coverage.
2. There is the need to go back to basics as far as public provision of healthcare services – both of preventive and curative kind – is concerned, with a renewed focus on primary health centers, village-level health workers, preventive health measures, and other means of ensuring timely health care on a regular basis.

While RSBY, the newly established scheme of subsidized health insurance for poor households, is a humane programme, better results can be achieved at far less cost through early and regular healthcare for all (supplemented by providing expensive inter- ventions if and when it is needed despite early and more systematic medical care for all).

For such measures to succeed, the need for ‘public investment’ is particularly strong in a range of activities aimed at preventing rather than curing

diseases, such as immunization, sanitation, public hygiene, waste disposal, disease surveillance, vector control, health education, food safety regulation, and so on (what is technically called as ‘public health’).

12TH PLAN STRATEGY #

The 12th Plan seeks to strengthen initiatives taken in the 11th Plan to expand the reach of health care and work towards the long term objective of establishing a system of Universal Health Cover- age (UHC) in the country. This means that each individual would have assured access to a defined essential range of medicines and treatment at an affordable price, which should be entirely free for a large percentage of the population.

This is a process that will span several plan periods. However, a start must be made towards achieving the long term goal immediately.

Ideally, the public health care system must be expanded to address the health needs of the vast majority of citizens, recognizing that upper-income groups may opt for private health care. The 12th Plan will therefore see the transformation of the NRHM into a National Health Mission (NHM), covering both rural and urban areas. Unlike rural residents, those in urban areas have access to private health care providers, but private health care is costly and large numbers of urban residents especially slum dwellers cannot afford it. An important component of the NHM will be the Urban Health Initiative for the Poor, providing public sector primary care facilities in select low-income urban areas. This will require additional resources in the public sector from the budgets of both the Centre and the States, and cities.

Declaration of Alma-Ata #

International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978 The International Conference on Primary Health Care, meeting in Alma-Ata this twelfth day of September in the year 1978, expressing the need for urgent action by all governments, all health and develop- ment workers, and the world community to protect and promote the health of all the people of the world, hereby makes the following Declaration:

1. The  Conference  strongly  reaffirms  that

health, which is a state of complete physical,

mental and social wellbeing, and not merely the absence of disease or infirmity, is a funda- mental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose re- alization requires the action of many other social and economic sectors in addition to the health sector.

• The existing gross inequality in the health status of the people particularly between de- veloped and developing countries as well as within countries is politically, socially and economically unacceptable and is, therefore, of common concern to all countries.
• Economic and social development, based on a New International Economic Order, is of basic importance to the fullest attainment of health for all and to the reduction of the gap between the health status of the developing and developed countries. The promotion and protection of the health of the people is essen- tial to sustained economic and social devel- opment and contributes to a better quality of life and to world peace.
• The people have the right and duty to partici- pate individually and collectively in the plan- ning and implementation of their health care.
• Governments have a responsibility for the health of their people which can be fulfilled only by the provision of adequate health and social measures. A main social target of gov- ernments, international organizations and the whole world community in the coming de- cades should be the attainment by all peoples of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life.
• Primary health care is the key to attaining this target as part of development in the spirit of social justice. Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their develop-

ment in the spirit of self-reliance and self- determination. It forms an integral part both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic develop- ment of the community. It is the first level of contact of individuals, the family and com- munity with the national health system bring- ing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process.

• Primary health care:
  • reflects and evolves from the economic conditions and socio cultural and politi- cal characteristics of the country and its communities and is based on the applica- tion of the relevant results of social, bio- medical and health services research and public health experience;
  • addresses the main health problems in the community, providing promotive, preventive, curative and rehabilitative services accordingly;
  • includes at least: education concerning prevailing health problems and the meth- ods of preventing and controlling them; promotion of food supply and proper nu- trition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infec- tious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and inju- ries; and provision of essential drugs;
  • involves, in addition to the health sector, all related sectors and aspects of national and community development, in particu- lar agriculture, animal husbandry, food, industry, education, housing, public works, communications and other sec- tors; and demands the coordinated efforts of all those sectors;
  • requires and promotes maximum com- munity and individual self-reliance and participation in the planning, organiza- tion, operation and control of primary

health care, making fullest use of local, national and other available resources; and to this end develops through appro- priate education the ability of communi- ties to participate;

• should be sustained by integrated, func- tional and mutually supportive referral systems, leading to the progressive im- provement of comprehensive health care for all, and giving priority to those most in need;
  • relies, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries and com- munity workers as applicable, as well as traditional practitioners as needed, suit- ably trained socially and technically to work as a health team and to respond to the expressed health needs of the com- munity.
• All governments should formulate nation- al policies, strategies and plans of action to launch and sustain primary health care as part of a comprehensive national health system and in coordination with other sectors. To this end, it will be necessary to exercise political will, to mobilize the country’s resources and to use available external resources rationally.
• All countries should cooperate in a spirit of partnership and service to ensure primary health care for all people since the attainment of health by people in any one country direct- ly concerns and benefits every other country. In this context the joint WHO/UNICEF report on primary health care constitutes a solid ba- sis for the further development and operation of primary health care throughout the world.

NATIONAL RURAL HEALTH MIS- SION – BACKGROUND, STRATE- GIES AND CHALLENGES FACED #

Background #

• As a part of its socially progressive Common Minimum Programme, the UPA Government launched the National Rural Health Mission (NRHM) in 2005.

• It aimed to undertake an ‘architectural correc- tion’ of the public health system to enable it to effectively absorb increased expenditure to provide accessible, affordable and account- able primary health care services to poor households in remote parts of rural India.
• A regional equity component requires the in- crease in central government plan outlay be channeled through a weighting system to- wards the development of health systems in eighteen ‘focus’ states with relatively poor health indicators, mostly the Empowered Ac- tion Group (EAG) states of the central north Indian belt and the northeast region of the country.

Objectives #

NRHM is the largest primary health care pro- gramme being run in any single country. Major objectives of NRHM include the following:

• to raise public spending on health, with im- provements in community financing and risk pooling;
• to provide access to primary healthcare ser- vices for the rural poor, with universal access for women and children;
• to see a concomitant reduction in IMR / MMR/TFR; to prevent and control communi- cable and non-communicable diseases; and
• to revitalize local health traditions.

In essence, these do not differ from health plan goals adopted by India over the last sixty years.

The Mission’s uniqueness lies primarily in the institutional instruments used to achieve these goals, foremost amongst which attempts at structurally reconfiguring the public health system to facili- tate decentralization and communalization, widely accepted as beneficial trends in the development sphere today. In recognition of the multidimensional causality of disease, to further promote inter-sectoral convergence in services which co-determine decent health outcomes, such as the provision of adequate food and nutrition, water, sanitation and hygiene; and to integrate previously segregated vertical disease-specific programmes at the national, state, district and block levels.

Strategies #

1. Creation and upgradation (on infrastructure / human resource / managerial fronts using un- tied funding) of SCs, PHCs,CHCs;
2. Revitalizing and mainstreaming AYUSH; Mission Flexible Pool untied funding;
3. Janani Suraksha Yojana (JSY);
4. Accredited Social Health Activists (ASHAs);
5. Involvement of community at decentralized levels through Hospital Development Soci- eties (HDS) or Rogi Kalyan Samitis (RKS)

/ Village Health and Sanitation Committees (VHSCs);

• Converging health, nutrition, water, sanita- tion and hygiene activities through District Health Plans;
• Integration of vertical health and family wel- fare programmes at national, state, district and block levels;
• Fostering public-private partnerships while regulating the private sector;
• Instituting Indian Public Health Standards.

Challenges and solutions #

The NRHM has injected new hope into the health care delivery system in India.

The Infant Mortality Rate declined from 58 per thousand live births in 2005 to 47 in 2010 and Maternal Mortality Ratio from 254 per one lakh deliveries in 2004-2006 to 212 in 2007-2009. The Janani Suraksha Yojana registered impressive gains with 1.13 crore women benefiting during 2010-11. Polio has been almost eradicated from the country. The World Health Organization has decided to take India off the list of countries with active endemic wild poliovirus transmission.

However, it continues to face diverse challenges, which need to be addressed if its goals are to be achieved in the near future.

1. Health as a State subject: The location of health in the State list rather than the concur- rent list poses major problems for service de- livery. This is also compounded by the fact that the NRHM funding is from the Centre while the implementation is by the State gov-

ernments. Health care delivery cannot be im- proved to provide a seamless service without the removal of these barriers.

• Project mode and problems: The NRHM is currently functioning as a project of the Government of India which was due to end in 2012. Its significant contribution to im- proving health care infrastructure and service delivery across the country will be frittered away if its funding ceases with the 11th Five Year Plan (FYP).
• The NRHM should be not only included in the 12th FYP but also be changed from its limited term project mode to a permanent solution to India’s health problems. Its sta- tus as a project makes the integration of the NRHM with the State health care systems problematic. The divisions run deep resulting in irrational distribution of human resource and infrastructure.
• The inertia of the old system and the low mo- rale and discipline of its staff continue to be major challenges.
• The NRHM has been able to add new infra- structure and personnel; however, its impact on re-inventing and re-invigorating systems seems to be limited, with much more effort being required. There is a need for a more co- ordinated approach which optimally utilizes resources.
• Improving governance: A comparison of data between States and within regions and social groups suggests marked variations in the NRHM process indicators, utilization of funds, improvements in health care delivery, health indices and in community participa- tion. Regions with prior good health indices have shown marked improvements, while those with prior poor indices have recorded much less change. This is true, despite a great- er NRHM focus on and inputs to poor-per- formance States. Improving governance and stewardship within the NRHM programmes mandates general improvement in the overall governance of States and regions.
• Increased funding: Health care costs for the average Indian usually results in catastrophic

out-of-pocket expenditure and is a well-rec- ognized cause of indebtedness in the country. The total health budget for India is about 1 per cent of the country’s GDP. Most devel- oped nations’ priorities is the health care and provide 5-10 per cent of their GDP. The 12th FYP should increase funding for health to the tune of 2-3 per cent as promised by the Gov- ernment.

• The diversion of funds, through private health insurance schemes for the care of rare disor- ders to be treated in corporate hospitals, takes away funding from the public health care system. The injection of such money into the public system would allow for the provision of universal health care, improve govern- ment health systems and provide for common health conditions benefiting larger numbers.
• Urban health: The NRHM has focused on rural health. Many parts of urban India have similar health care needs and currently have glaring deficiencies. The National Urban Health Mission should be accorded the same status as the NRHM. Both efforts should be coordinated and combined into a National Health Mission.
• Expand focus: The major focus of NRHM is on maternal and child health. While this is vi- tal, there is a need to expand the vision to oth- er common general health problems. There is evidence to suggest that other crucial govern- ment programmes (e.g. blindness) have taken a back seat.
• Cash transfers and outcome: The NRHM currently employs process indicators to mea- sure its implementation. The measures used are mainly related to finance, infrastructure and personnel. There is need to shift over to indicators of efficient functioning and ex- amine their impact on health outcomes. The initial high rates of mortality tend to reduce rapidly with early inputs but require fully functional, efficient and effective systems for sustained results.
• The Janani Suraksha Yojana, a conditional cash transfer scheme to incentivize the use of health services to reduce maternal and

neo-natal mortality among poor women, has become a success by encouraging institution- al deliveries. However, the evaluation of its success should be based on its impact on the health outcome of the mother and baby, rather than on financial process indicators.

1. Similarly, the diverse and difficult circum- stances of medical practice across the coun- try mandate a differential reinforcement for health professionals. There is need for differ- ential payments to health care staff who work in remote situations and difficult contexts.
2. Health information and monitoring: The NRHM has provided for infrastructure, per- sonnel and training for Health Management Information Systems. However, these are not optimally utilized. There is need to improve the information system as part of the process of monitoring health indices of populations and functioning of the public health care sys- tem. The NRHM already has a programme of community monitoring and social audit. This should be strengthened in order to monitor the use of funds and empower local commu- nities.
3. Social determinants and public health ap- proaches: The goals of the NRHM clearly state the need to impact on the social determi- nants of health by coordinating efforts to pro- vide clean water, sanitation, nutrition, hous- ing, education and employment. It should, in conjunction with other government pro- grammes, work towards the reduction of pov- erty, social exclusion and gender discrimina- tion, all of which have a significant impact on health. There is need to increase the synergy and coordination between government pro- grammes (e.g. the Integrated Child Develop- ment Scheme, the Mahatma Gandhi National Rural Employment Guarantee Act, etc.) and the NRHM.

WHAT IS RSBY? #

RSBY has been launched by Ministry of Labour and Employment, Government of India to provide health insurance coverage for Below Poverty Line (BPL) families. The objective of RSBY is to pro-

vide protection to BPL households from financial liabilities arising out of health shocks that involve hospitalization. Beneficiaries under RSBY are enti- tled to hospitalization coverage up to Rs. 30,000/

– for most of the diseases that require hospitalization. Government has even fixed the package rates for the hospitals for a large number of interventions. Pre-ex- isting conditions are covered from day one and there is no age limit. Coverage extends to five members of the family which includes the head of household, spouse and up to three dependents. Beneficiaries need to pay only Rs. 30/ – as registration fee while Central and State Government pays the premium to the insurer selected by the State Government on the basis of a competitive bidding.

Unique Features of RSBY #

The RSBY scheme is not the first attempt to provide health insurance to low income workers by the Government in India. The RSBY scheme, however, differs from these schemes in several important ways.

Empowering the beneficiary – RSBY provides the participating BPL household with freedom of choice between public and private hospitals and makes him a potential client worth attracting on account of the significant revenues that hospitals stand to earn through the scheme.

Business Model for all Stakeholders – The scheme has been designed as a business model for a social sector scheme with incentives built for each stakeholder. This business model design is condu- cive both in terms of expansion of the scheme as well as for its long run sustainability.

Insurers – The insurer is paid premium for each household enrolled for RSBY. Therefore, the insurer has the motivation to enroll as many households as possible from the BPL list. This will result in better coverage of targeted beneficiaries.

Hospitals – A hospital has the incentive to provide treatment to large number of beneficiaries as it is paid per beneficiary treated. Even public hospitals has the incentive to treat beneficiaries under RSBY as the money from the insurer will flow directly to the concerned public hospital which they can use for their own purposes. Insurers, in contrast, will monitor participating hospitals in order

to prevent unnecessary procedures or fraud resulting in excessive claims.

Intermediaries – The inclusion of intermediaries such as NGOs and MFIs which has a greater stake in assisting BPL households. The intermediaries will be paid for the services they render in reaching out to the beneficiaries.

Government – By paying only a maximum sum up to Rs. 750/ – per family per year, the Government is able to provide access to quality health care to the below poverty line population. It will also lead to a healthy competition between public and private providers which in turn will improve the functioning of the public health care providers.

Information Technology (IT) Intensive – For the first time IT applications are being used for social sector scheme on such a large scale. Every beneficiary family is issued a biometric enabled smart card containing their fingerprints and photo- graphs. All the hospitals empanelled under RSBY are IT enabled and connected to the server at the district level. This will ensure a smooth data flow regarding service utilization periodically.

Safe and foolproof – The use of biometric enabled smart card and a key management system makes this scheme safe and foolproof. The key management system of RSBY ensures that the card reaches the correct beneficiary and there remains accountability in terms of issuance of the smart card and its usage. The biometric enabled smart card ensures that only the real beneficiary can use the smart card.

Portability – The key feature of RSBY is that a beneficiary who has been enrolled in a particular district will be able to use his/ her smart card in any RSBY empanelled hospital across India. This makes the scheme truly unique and beneficial to the poor families that migrate from one place to the other. Cards can also be split for migrant workers to carry a share of the coverage with them separately.

Cash less and Paperless transactions – A ben- eficiary of RSBY gets cashless benefit in any of the empanelled hospitals. He/ she only needs to carry his/ her smart card and provide verification through his/ her finger print. For participating providers it is a paperless scheme as they do not need to send

all the papers related to treatment to the insurer. They send online claims to the insurer and get paid electronically.

Robust Monitoring and Evaluation – RSBY is evolving a robust monitoring and evaluation system. An elaborate backend data management system is being put in place which can track any transaction across India and provide periodic analytical reports. The basic information gathered by government and reported publicly should allow for mid-course improvements in the scheme. It may also contribute to competition during subsequent tender processes with the insurers by disseminating the data and reports.

Achievements of RSBY The scheme is today the world’s largest medical insurance programme cov- ering over 120 million poor people in the country.

Issues or Challenges #

1. Beneficiaries are often unsure of the benefits

delivered by their smart – card.

• It’s a struggle to find professionals (smart- card providers, hospital personnel, data ana- lysts, field workers) and train them.
• Maintaining quality of healthcare at accredit- ed hospitals.
• An unceasing stream of frauds.

The challenges of improving include the follow-

ing:

1. Improving targeting: RSBY largely targets poor beneficiaries as identified by BPL lists. These lists, however, are known to have sev- eral problems that also affect other entitle- ment schemes. The most recent list (compiled in 2002) is outdated; To its credit, RSBY has vigorously sought to remove those who are no longer poor from the rolls (false positives).
2. Improving the quality of care: In any insur- ance program, there are often countervailing forces that affect the quantity and quality of care. In RSBY, on the one hand insurers in- centives to reduce the quantity of health ser- vices used to maximize profits from premiums collected, which may manifest as increases in enrolment with minimal enrollee knowledge of RSBY’s benefits. On the other hand, doc-

tors are incentivized by fee-for-service to in- duce demand of unnecessary services, which are likely exacerbated by power differentials between doctors and their poor, illiterate pa- tients. (The power differential issue is a chal- lenge not only for RSBY but for any health- care program in India.) To improve quality of care, RSBY must both better inform and educate beneficiaries and redesign provider incentives. Throughout, RSBY should learn from its experimentation and adapt its strat- egies to reflect those experiences.

• Educating beneficiaries: Many enrollees lack knowledge of their rights and benefits— on both extremes of not knowing their bene- fits (from insurers not informing enrollees of their benefits) or alternatively using unneces- sary services (largely from the power differ- ential between doctors and patients).
• Redesigning provider incentives: Current payments to health-care providers are made on a fee-for-service basis, effectively incen- tivizing greater quantity but not quality of services (and representing a long-run risk to RSBY’s sustainability). Hence RSBY should structure its fee schedule to incentivize pre- vention and primary care; move away from a fee-for-service model by incorporating pay-for-performance measures.
• Create robust and adaptable institutions to ensure improvement: RSBY’s manage- ment information systems (MIS) represent a major shift in public health-care management in India, as described above. RSBY manage- ment must pay greater attention to the institu- tional arrangements and architecture, human resources, and incentives to ensure continu- ous improvement even with major leadership changes in RSBY.
• Ensure smarter, sustainable spending: Uni- versal health programs in all countries must control costs and get better value for money as citizens grow wealthier and increase their demand for health care. In India too, amidst inevitable growth in health-care expendi- tures, RSBY will need to expand its benefit package to its population to meet evolving

demand, all while ensuring smart, efficient,

and sustainable public spending.

Moving forward, India will need to design and implement fair priority-setting institutions to ensure that public dollars for health are spent in the most cost-effective and equitable manner.

Universal   Health   Coverage    in   India: Concept and measurement #

1.   What does universal health coverage mean? #

• Universal health coverage means that all peo- ple have access to the health services they need (prevention, promotion, treatment, reha- bilitation and palliative care) without the risk of financial hardship when paying for them.
  • This requires an efficient health system that provides the entire population with access to good quality services, health workers, medi- cines and technologies.
  • It also requires a financing system to protect people from financial hardship and impover- ishment from health care costs.
  • Access to health services ensures healthier people; while financial risk protection pre- vents people from being pushed into poverty.

2.   What is needed to achieve it? #

For a community or country to achieve universal health coverage, several factors must be in place including:

A strong, efficient, well-run health system that meets priority health needs through people-centered integrated care by:

• informing and encouraging people to stay healthy and prevent illness;
• detecting health conditions early;
• having the capacity to treat disease; and
• helping patients with rehabilitation
• ensuring    sensitive   palliative    care   where needed.

Affordability – a system for financing health services so people do not suffer financial hardship when using them.

Availability of essential medicines and technol- ogies to diagnose and treat medical problems.

A sufficient capacity of well-trained, motivated health workers to provide the services to meet patients’ needs based on the best available evidence.

Actions to address social determinants of health such as education, living conditions and household income which affect people’s health and their access to services.

3.   What services should be included in universal health coverage? #

Essential health services (including for HIV, tuberculosis, malaria, non-communicable diseases and mental health, sexual and reproductive health and child health) should be available to all who need them.

The priority should be to ensure access to the key interventions targeting the health Millennium Development Goals – births attended by a trained health worker, family planning, vaccinations, and prevention and treatment of diseases such as HIV, malaria and tuberculosis – while considering how to address the growing problem of non-communicable diseases.

4.   Are    the    most    vulnerable    people covered? #

In terms of financial protection, the most vulner- able people should have access to the health services they need, without restrictions. In all countries, it has been found that governments have to use general budget revenues to meet the health costs (and/or insurance premiums) of poor and vulnerable people.

Ensuring access to health facilities, workers and medicines in remote, rural areas is also important, as is providing special interventions for stigmatized populations.

Universal coverage is firmly based on the WHO Constitution of 1948 declaring health a fundamen- tal human right and on the Health for All agenda set by the Alma-Ata declaration in 1978. Equity is paramount. This means that countries need to track progress in providing access not just across the national population but within different groups (e.g. by income level, sex, age, place of residence, migrant status and ethnic origin).

5.   How can we measure universal health coverage? #

As universal health coverage is a combination of whether people obtain the health services they need and financial risk protection, measurement needs to include both components. Coverage of health services can be measured by the percentage of people receiving the services they need. For exam- ple women in fertile age groups accessing modern methods of family planning or children immunized.

On the other hand, financial risk protection can be evaluated by a reduction in the number of families pushed into poverty or placed under severe economic strain due to health costs. The impact of these steps on population health and household financial wellbeing can also be measured, as can many of the factors that make it easier to increase coverage. These include the availability of essential medicines.

6.   What is the impact of universal health coverage on the population? #

Universal health coverage has a direct impact on a population’s health and welfare. Access and use of health services enables people to be more productive and active contributors to their families and communities. At the same time, financial risk protection prevents people from being pushed into poverty when they have to pay for health services out of their own pockets.

Universal health coverage is thus a critical component of sustainable development and poverty reduction, and a key element of any effort to reduce social inequities. Universal coverage is the hallmark of a government’s commitment to improve the well- being of all its citizens.

NATIONAL HEALTH POLICY, 2017 #

National Health Policy, 2017 approved by Cabinet Focus on Preventive and Promotive Health Care and Universal access to good quality health care services.

The Union Cabinet chaired by the Prime Minis- ter Shri Narendra Modi in its meeting on 15.3.2017, has approved the National Health Policy, 2017 (NHP, 2017). The Policy seeks to reach everyone in a comprehensive integrated way to move towards

wellness. It aims at achieving universal health cov- erage and delivering quality health care services to all at affordable cost.

This Policy looks at problems and solutions holistically with private sector as strategic partners. It seeks to promote quality of care, focus is on emerging diseases and investment in promotive and preventive healthcare. The policy is patient centric and quality driven. It addresses health security and make in India for drugs and devices.

The main objective of the National Health Pol- icy 2017 is to achieve the highest possible level of good health and well-being, through a preventive and promotive health care orientation in all devel- opmental policies, and to achieve universal access to good quality health care services without anyone having to face financial hardship as a consequence.

In order to provide access and financial pro- tection at secondary and tertiary care levels, the policy proposes free drugs, free diagnostics and free emergency care services in all public hospitals.

The policy envisages strategic purchase of sec- ondary and tertiary care services as a short term measure to supplement and fill critical gaps in the health system.

The Policy recommends prioritizing the role of the Government in shaping health systems in all its dimensions. The roadmap of this new policy is predicated on public spending and provisioning of a public healthcare system that is comprehensive, integrated and accessible to all.

The NHP, 2017 advocates a positive and proac- tive engagement with the private sector for critical gap filling towards achieving national goals. It envisages private sector collaboration for strategic purchasing, capacity building, skill development programmes, awareness generation, developing sustainable networks for community to strengthen mental health services, and disaster management. The policy also advocates financial and non-incen- tives for encouraging the private sector participation.

The policy proposes raising public health expenditure to 2.5% of the GDP in a time bound manner. Policy envisages providing larger package of assured comprehensive primary health care through the Health and Wellness Centers’. This pol-

icy denotes important change from very selective to comprehensive primary health care package which includes geriatric health care, palliative care and rehabilitative care services. The policy advocates allocating major proportion (upto two-thirds or more) of resources to primary care followed by secondary and tertiary care. The policy aspires to provide at the district level most of the secondary care which is currently provided at a medical college hospital.

The policy assigns specific quantitative targets aimed at reduction of disease prevalence/incidence, for health status and programme impact, health system performance and system strengthening. It seeks to strengthen the health, surveillance system and establish registries for diseases of public health importance, by 2020. It also seeks to align other policies for medical devices and equipment with public health goals.

The primary aim of the National Health Policy, 2017, is to inform, clarify, strengthen and prioritize the role of the Government in shaping health sys- tems in all its dimensions- investment in health, organization and financing of healthcare services, prevention of diseases and promotion of good health through cross sectoral action, access to technologies, developing human resources, encouraging medical pluralism, building the knowledge base required for better health, financial protection strategies and regulation and progressive assurance for health. The policy emphasizes reorienting and strengthening the Public Health Institutions across the country, so as to provide universal access to free drugs, diagnostics and other essential healthcare.

The broad principles of the policy is centered on Professionalism, Integrity and Ethics, Equity, Affordability, Universality, Patient Centered & Quality of Care, Accountability and pluralism.

It seeks to ensure improved access and afforda- bility of quality secondary and tertiary care services through a combination of public hospitals and strategic purchasing in healthcare deficit areas from accredited non–governmental healthcare provid- ers, achieve significant reduction in out of pocket expenditure due to healthcare costs, reinforce trust in public healthcare system and influence operation and growth of private healthcare industry as well as medical technologies in alignment with public health goals.

The policy affirms commitment to pre-emptive care (aimed at pre-empting the occurrence of dis- eases) to achieve optimum levels of child and ado- lescent health. The policy envisages school health programmes as a major focus area as also health and hygiene being made a part of the school curriculum.

In order to leverage the pluralistic health care legacy, the policy recommends mainstreaming the different health systems. Towards mainstreaming the potential of AYUSH the policy envisages better access to AYUSH remedies through co-location in public facilities. Yoga would also be introduced much more widely in school and work places as part of promotion of good health.

The policy supports voluntary service in rural and under-served areas on pro-bono basis by recog- nized healthcare professionals under a ‘giving back to society’ initiative.

The policy advocates extensive deployment of digital tools for improving the efficiency and outcome of the healthcare system and proposes establishment of National Digital Health Authority (NDHA) to regulate, develop and deploy digital health across the continuum of care.

The policy advocates a progressively incremen- tal assurance based approach.

Background #

The National Health Policy, 2017 adopted an elaborate procedure for its formulation involving stakeholder consultations. Accordingly, the Gov- ernment of India formulated the Draft National Health Policy and placed it in public domain on 30th December, 2014. Thereafter following detailed consultations with the stakeholders and State Gov- ernments, based on the suggestions received, the Draft National Health Policy was further fine-tuned. It received the endorsement of the Central Council for Health & Family Welfare, the apex policy mak- ing body, in its Twelfth Conference held on 27th February, 2016.

The last health policy was formulated in 2002. The socio economic and epidemiological changes since then necessitated the formulation of a New National Health Policy to address the current and emerging challenges.