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The draft approach paper to the 12th Plan proposed the idea of universal healthcare in 2012, for the first time. The funding situation did not seem conducive enough this is why the government did not think to launch it— falling growth rate in wake of the western recession and many domestic factors. However, providing accessible, affordable and equitable quality health care, especially to the marginalised and vulnerable sections of the
population is one of the key objectives of the Government. There are innumerable challenges to the delivery of efficient health services in India, given the paucity of resources and the plethora of requirements in the health sector. Population health is also significantly influenced by social and environmental determinants such as age at marriage, nutrition, pollution, access to potable water and hygienic sanitation facilities.
The Indian health sector has a mix of both public and private providers of health services. The private sector and the quality of care provided is variable, ranging from informal providers (quacks) to individually run nursing homes to large polyclinics and multiplex hospitals. The regulation for cost and quality of care is largely absent in most f the states. In the case of public sector, the health services are delivered through a network of health facilities including ASHA (a volunteer health worker) at the community level, Health Sub-Center (HSC), Primary Health Centres (PHCs), Community Health Centres (CHCs), District Hospitals, Government Medical College Hospitals and the state and central government assisted Employees’ State Insurance (ESI) hospitals and dispensaries. Outreach and community level services are provided through coordination between ASHA, Anganwadi Workers (AWWs) and the Auxiliary Nurse Midwife (ANM) at the HSC.
The Key Indicators of social consumption in India: Health-2015, NSSO, 71st Round (January –June 2014) throws some interesting findings14—
• The private sector continues to play a significant role in the provision of outpatient and hospitalised care. However, it also points that there has been a nearly two-fold jump in the institutional deliveries since the last such survey.
• Further, over 60 per cent of all institutional deliveries are in the public sector and the Out of Pocket expenditures for childbirth in the public sector is about one-tenth that in the private sector. This is largely a result of sustained strengthening of health systems targeted towards maternal and child healthcare through programmes such as Janani Suraksha Yojana (JSY) and Janani Shishu Suraksha Karyakram (JSSK). This is also reflected in 50 per cent sharper decline in MMR in the country as compared to global average rate of decline from the baseline of MDG of 1990.
• The share of public providers in treatment of non-hospitalised patients is very low at 11.5 per cent at HSC, PHC including ASHAs and ANMs. This per centage is even lower for urban areas where the public provisioning of primary health care has been largely absent. This reflects confinement of primary care to selective primary care limited to Reproductive and Child Health (RCH) services. The National Urban Health Mission (NUHM) launched over a year back is trying to address the issue of inadequacy of public provisioning of primary health care in urban areas.
• India faces a challenge in the provision of affordable and accessible health care to the population. Average medical expenditure for treatment (excluding child birth) per hospitalised case if treated in private hospital was about four times than that of public hospital. On an average, Rs. 25,850 was spent for treatment per hospitalised case by people in the private facilities as against Rs. 6,120 in the public health facilities.
• The average total medical and other related non-medical expenditure per hospitalisation in rural and urban areas are Rs. 16,956 and Rs. 26,455 respectively.
• The average total medical expenditure for non- hospitalised treatment per ailing person in rural and urban areas is Rs. 509 and Rs. 639 respectively.
• The NSSO also reports that coverage by government-funded insurance schemes is 13.1 per cent of rural India and 12 per cent of urban population.
Health Indicators & Schemes: Health indicators have shown the trends of improvement in recent years mainly due to focussed steps taken by the governments. Some major highlights related to health indicators and health schemes, as per various government documents15, are as given below:
• As per Census 2011, the share of children (0-6 years) accounts for 13.6 per cent of the total population in the country. An estimated 26 million children are born every year in India.
• According to the NFHS (National Family Health Survey), the
immunisation coverage has improved substantially since NFHS-1 (1992-93), when only 36 per cent of children were fully vaccinated and 30 per cent had not been vaccinated at all. As per NFHS-4 (2015-16), the per centage of children fully immunised in the age group (12-23 months) is above 80 per cent in Sikkim and West Bengal. All the 12 states (from which the data are available) have more than 50 per cent children fully immunised. The per centage of children who are fully immunised is lower in urban areas compared to rural areas in majority of the States, indicating that although the private sector is more wide spread in urban areas, the availability of preventive health care is through the public health system, which needs strengthening in urban areas.
• High-risk patients like children and pregnant women do require special preventive healthcare services. Targeting coverage of all those children by 2020 who are either unvaccinated, or are partially vaccinated against seven vaccine-preventable diseases which include diphtheria, whooping cough, tetanus, polio, tuberculosis, measles and hepatitis B, Mission Indradhanush was launched in December 2014.
In addition, vaccination against Japanese Encephalitis and Haemophilus influenza type B will be provided in selected districts/states of the country. Pregnant women are also to be immunised against tetanus.
• India has one of the largest programmes of publicly financed ART (anti-retroviral therapy) drugs for HIV anywhere in the world. All drugs and diagnostics in all vector borne disease programmes, tuberculosis, leprosy, including rapid diagnostic kits and third generation anti-microbicidals are free and so are insecticide treated bed nets.
• Under the Rashtriya Bal Swasthya Karyakram (RBSK), support is being provided to States/UTs for child health screening and early intervention services through early detection and early management of common health conditions.
• National Iron Plus Initiative has been rolled out to address anaemia among children (6 months to 19 years) and women in reproductive age including pregnant and lactating women in both rural and urban areas
throughout the country. Anaemia among pregnant women continues to be high (has been a chronic problem in the country).
• Several programmes and new policy initiatives have been taken by the Government to ensure holistic development of children and socio- economic empowerment and development of women to secure gender equality in all spheres of social life. The scope and coverage of the schemes for women and child development have been expanding persistently as reflected in the magnitude of gender budget which increased from 2.79 per cent to 4.46 per cent as a per centage of total budgets in the Gender Budget Statement during the period 2005-06 to 2015-16.
• Though there has been substantial improvement in institutional births particularly in public sector, expenditure towards private institutional births is on the rise, indicating the need to sustain and even expand the efforts of the public health system by increased investments.
• Preventive health care has always been a priority area because of its long-term societal benefits, Government has taken several steps in the direction of preventive health care to reduce the burden of diseases in India. Some of the important programmes aimed at investigation/screening and treatment cover Malaria; Kala-azar; Filaria; Dengue; Japanese Encephalitis and Chikungunya; detection and treatment of Tuberculosis, Leprosy, HIV/AIDs; and cataract surgery for blindness control.
• Considering the rising incidence of Non-Communicable Diseases (NCDs), the GoI has initiated an integrated National Programme for Prevention and Control of Cancers, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) jointly by the Ministry of Health and Family Welfare and Ministry of AYUSH (Ayurveda, Yoga, Unani, Siddha and Homeopathy) on pilot basis in six districts.
• Various initiatives under the National Health Mission (NHM), which subsume the National Rural Health Mission (NRHM) for rural areas and the NUHM for urban areas with a population of more than 30,000, have been taken up for providing free health care through a nationwide network of public health facilities like CHCs, PHCs and Sub-Centres
(SCs).
• Dedicated skilled health personnel are a pre-requisite for efficient and effective delivery of health services. However, the availability of such personnel to meet various needs of the health sector is a huge challenge in India. The shortage of specialists, doctors, staff nurses, anaesthetists, and others, adversely affects the outreach of health services, especially in rural areas. As per an evaluation study of the NRHM (2011), there is a 95 per cent shortage of skilled health personnel in Jharkhand, around 80 per cent in Madhya Pradesh and 70 per cent in Uttar Pradesh. Assam reported only 11 per cent shortage, while Tamil Nadu did not report any shortage at all.
• Rural Health Statistics 2015 reports that at the all-India level, CHCs are short of surgeons by 83 per cent of the total requirement. Only 27 per cent of the sanctioned posts have been filled. Adequate skilled personnel are necessary for strengthening the health sector’s efficiency and delivery of services in rural areas.
Current situation: As per the Economic Survey 2016-17, despite the challenges faced by the government in providing affordable health services to the population, there have been some notable achievements in the health sector:
• Life expectancy has increased speedily and infant mortality and crude death rates have reduced sharply.
• Total fertility rate (TFR) has been steadily declining and was 2.3 (rural 2.5 & urban 1.8) by 2014.
• Infant Mortality Rate (IMR) has declined to 37 in 2015 from 44 in 2011. The challenge lies in addressing the huge gap between IMR in rural (41) and urban (25) areas.
• The Maternal Mortality Ratio (MMR) declined from 301 of 2001-03 to 167 in 2011-13 (per 100,000 live births). But wide regional disparities remains in it. Thus, India needs to focus on the states with MMR higher than the national average, by improving health and nutritional status of women.
• The high levels of anaemia prevalent among women in the age group
15-49 have a direct correlation with high levels of MMR. The National Health Mission has programmes to address the issue of anaemia through health and nutrition education to promote dietary diversification, inclusion of iron foliate rich food as well as food items that promote iron absorption.
Health policy of India aims at an integrated approach which will provide accessible, affordable and equitable quality health care to the marginalized and vulnerable sections. To reap benefits of the ‘demographic dividend’ India needs to work in the direction of providing ‘good health and well-being for all’. India is signatory to the UN’s sustainable development goals (SDGs) where the country commits to—ensure healthy lives and promote well being for all at all ages.
It is imperative for the governments to think in the direction of universal healthcare—the aim which was proposed by the 12th Plan
(2012-17)—but the Government could not announced it formally due to lack of funding issue. The NITI Aayog has been working in this direction and it is expected that some actions may be in the pipeline.
UHC Index: The Universal Health Coverage (UHC) index16 has been developed by the World Bank to measure the progress in the health sector in select countries. India ranks 143 among 190 countries in terms of per capita expenditure on health—for India it stands at $146 (at PPP). It has 157th position according to per capita government spending on health which is just about $44 (at PPP). India’s performance on the indicator on treatment of diarrhoea needs improvement in terms of enhancing the coverage. The impoverishment indicator reflects the financial risk protection coverage, with a higher per centage reflecting better coverage.
Housing Amenities: Public health is closely linked to housing amenities such as access to safe drinking water, sanitation facilities and hygiene. Consumption of contaminated drinking water, improper disposal of human excreta, lack of personal and food hygiene and improper disposal of solid and liquid waste have been causes of many diseases in developing countries like India. The present situation17 of the housing amenities are as given below:
• Around 70 per cent of India’s population (650 million) lives in rural and slum areas. It increases the possibility of exposure of the
population to water-borne and vector-borne diseases. This can also be attributed to the lack of basic sanitation facilities, unsafe water and unhygienic living conditions.
• Only 46.6 per cent of households in India have access to drinking water within their premises. A far lower, 43.5 per cent of households have access to tap water. Similarly, less than 50 per cent households have latrine facilities within the household premises.
• The disparity across states in terms of access to household amenities like tap water and latrine facilities is sharp. While access and coverage of latrine facilities is as high as 95 per cent in Kerala, 91 per cent in Mizoram and 89 per cent in Manipur, less than 25 per cent of households have access to latrine facilities within the household premises in Bihar, Chhattisgarh, Jharkhand and Odisha.
• In some states over 75 per cent of households have no latrine facilities
— in Bihar (77), Chhattisgarh (75), Jharkhand (78) and Odisha (78).
The Swachh Bharat Abhiyan aims at universal sanitation coverage and eliminate open defecation in India by 2 October 2019. It also aims to promote better hygiene amongst the population and improve cleanliness by initiating Solid and Liquid Waste Management (SLWM) projects in villages, towns and cities.
The progress in sanitation has witnessed a spurt since the launch of the Swachh Bharat Mission—sanitation coverage improved from 40.6 per cent to
48.8 per cent between October 2014 and December 2015, as per the latest NSSO data. The Swachh Bharat Mission will begin to show intended results if the constructed toilets are maintained after construction and also utilised by the beneficiaries.
In order to improve availability of drinking water in rural areas, the National Rural Drinking Water Programme (NRDWP) initiated a new project supported by the World Bank, the ‘Rural Water Supply and Sanitation Project–Low Income States’. The project aims to provide safe, 24 x 7 piped drinking water supply to 7.8 million rural population in four low-income States—Assam, Bihar, Uttar Pradesh and Jharkhand—that have the lowest piped water supply and sanitation facilities.