Yojana: February issue on Health and Well being for All
Analysis of the article:
The article covers the February issue of Yojana,2016 on the topic " Health and Well-being for all" (http://www.yojana.gov.in/) . It summarizes the issue completely with significant inputs from the following articles:
1. Health Sector in India: perspective and way forward by T Sundararaman
2. Evolution of Health Policy in India by J V R Prasada Rao
History : Charak, Susruta, Jivika, Dhanvantri
1. Preston curve: Relationship between Health(plotted as life expectancy) and Development (measured in GDP per capita)
Point of epidimiological transition: when non-communicable diseases start becoming the main cause of death, dwarfing decreasing numbers of deaths due maternal and common childhood diseases.
At this point, old problems persist while new have added on. India in at or around this point.
2. UHC : 3 dimensions: 1. Population coverage 2. Health services coverage 3. Financial protection coverage
1. Kayakalp scheme : by Ministry of health and family Welfare.
National initiative to give awards to those public health facilities that demonstrate high levels of cleanliness, hyegine and infection control practices in public health care facilities.
2. National Organ and Tissue Transplant organisation(NOTTO): by Ministry of health and family Welfare.
issued draft guidelines for Allocation criteria for deceased donor kidney transplant.
3. Mission Indradhanush: Vaccines for DPT, Polio, measles, Hep-B and Tb.
Plus vaccines against Haemophilius Influenzae type B and Japanese Encephalitis is also given in selected districts.
Vaccine against tetanus to pregnant women.
Target: Children< 2 years and pregnant women
Phase 1in 201 high focus districts: highest number of partially vaccinated and unvaccinated children.
Progress in health:
1. Reproductive and Child Health:
Earlier Decades: High IMR and MMR
=> Child survival and motherhood program
Reproductive and Child Health Programs
National Rural health Mission
IMR : MDG target: 140 per 100,000 live births: estimated outcome by 2015:141 from 560 in 1990.
MMR: MDG target: 42: estimated outcome by 2015: 42 from 126 in 1990
-female literacy(65.04%: 2011 census)
-safe drinking water( 94% of hamlets covered)
-focused programs like JSSY,JSY, ASHA, Dial 108 and 104, ambulance services, apoointment of additional nurses and ANMs at periphery.
-improved institutional deliveries
-established demand for contraceptive services
- no comparable improvements in sanitation
- no comparable improvements in child nutrition
- issues in quality and safety of healthcare
- Issue on delivery of safe sterilisation(Eg. tragic sterilisation deaths in Bilaspur, Chhatisgarh)
2. Communicable Diseases
National AIDS control program: 4th phase going on after succesful completion of the first 3. (select groups in India- male-female sex workers, transgenders, intravenous drug users- startegy was inclusivity of the program)
-addressed both preventive and curative aspects
-good quality health information
-successful in capping and reversing an epidemic
Pulse Polio Program:
Success in elimination
Challenge: exit policy from campaign modeand rising cost of sustaining the gains
Leprosy: Major reduction
Challenge: to articulate a strategy that can address the new case incidencesand disabilities that will continue to occur for many years after it has been eliminated.
Malaria: significant reduction
Elephantiasis: negligible cases
Kalazar: anachronistic continuance.
New vector borne diseases have emerged: Dengue and Chikungunya
TB: significant reduction in deaths.
Issue: reduction in new cases is less dramatic and spectre of multi-drug resistance becoming prominent.
Most deaths due to infectious diseases occur because of diarrhoea and respiratory infections.
3. Non-Communicable Diseases
Challenge of addressing them in India:
- Consciously excluded from all governmental provisions of primary health care (limited to IMR,MMR, immunization rates and family planning) for over 2 decades.
-market forces largely promote curative and preferably tertiary care. =>market driven growth is unable to meaningfully address the needs of primary and secondary prevention.
-National Disease control program against Non-Communicable Diseases - far from universal
-list of NCDs is long and it is not possible to construct multiple vertical programsthe way CDs were addressed.
=> 1. Rapid growth of private sector especially one doctor clinics or small nursing homes.
2. Corportaisation of high-end health services and an internal brain drain of specialists who are becoming hard to attract or retain in public sector. Very big industry and nears global best practices. But even the poor have to avail these leading to impoverishment due to healthcare costs.
Led to an emerging 'business model' on which the hospitals are based: giving incentive to doctors who are referring, prescribing more of certain drugs or diagnostics in return for incentives,etc.
4. Health Administration
National Health Mission: NRHM + NUHM
health: state subject
=> draw up annual health plans
Success of NRHM.
Recent: shift towards privatisation. Fund cutting to NHM due to:
a. flow of funds has changed from centre to empowered health societies to routing it through budgetary allocations(14th Finance commission)
b. supply side budgeting=> transaction costs and inefficiencies. Need to shift to responsive demand side allocation of funds
c. reluctance to invest in skilled public health workforce
National Health policies:
National Health Policy 1983
Emphasis on development of infrastructure, primary health care and development of a well-trained cadre of health care professionals.
National Health Policy, 2002:
Identified sub-optimal resource base as a serious impediment to secure minimam health standards for all.
1. Health spending as a proportion of GDP to be doubled from 1 to 2%.
2. Emphasised importance and spending on primary health care.
-Stagnant spending at 1% of GDP
-Achievement of targets of maternal and child health and some communication disease control targets
- short of achievements in controlling NCDs
- chronic shortage of adequate health care professionals
- impoverishment due of health care costs.
Draft National Health Policy 2015:
1. National health Rights Act
2. Raise public health expenditure to 2.5% of GDP
3. Creation of health cess on lines of education cess
4. Universal access to free drugs and diagnostics
-National programs provide universal coverage only for maternala nd child health(only 10% of mortality)
- >75% of communicable diseases are out of purview of national programs
- poor absorptive capacity in India
- Need of focus on implementation than increasing funding
Government response to challenge of impoverishment due to health care costs:
-Publically financed ART drugs for HIV
-All drugs and diagnostics in all vector borne disease programs -TB,leprosy, etc are free.
-free immunization and pregnancy related care
- new scheme to support states for free drugs and diagnostics will reduce Out-of-pocket expenditure(OOPE).
Rashtriya Swasthya Bima Yojana(MoLE to MoHFW) : cost of secondary level hospitalisation.
1. link finance to outcomes in area of payments to healthcare workers
Special concerns of tribal population, adolescents, women and North-East region
1. Higher infant and child mortality rates.
2. Unacceptable nutritional status
3. Diseases: a. Diseases of underdevelopment:malnutrition, communicable diseases, etc
b. Disease atypically common in ST population(Sickle cell anaemia, animal bites, etc)
c. Diseases of modernity(addiction, mental stress, etc.)
Challenges to public health in tribal areas:
1. One-shoe fit-all approach. Doesn't take specific needs of tribes like acceptability of treatment, specific diseases, forest environment, etc.
2. Lack of health care human resource willing , trained and equipped to serve tribal areas.
3. Poor infrastructure maintenance
4. Cultural mismatch between outside personnel posted there
5. Access to health care for serious cases is very low.
1. Public participation in program design.
2. Strengthen in an integrated manner the social determinants of health like literacy, income, water, sanitation, food security, etc.
3. Use of cleaner fuel.
4. Control on alcohol and tobacco
5. Integrating traditional healers and Dais in healthcare framework
6. Care to cultural sensitivity and local language.
7. Health must be availbale within a limited distance in Scheduled areas(Chinese axiom:"How far can a mother on foot travel with a stick and a baby")
Adoloscents age group: 10-19 years: > 20%
=> essential for meeting needs of demographic dividend, contraceptive needs, teenage pregnancy preventions, etc.
1. Rashtriya kishore Swasthya Karyakram(RKSK):
-expands the scope of adoloscent health from limited tpo sexual and reproductive health to nutrition, injuries, violence , NCDs, mental health and substance misuse.
- shift from clinical services to promotion and prevention based approach
- Community based interventions like outreach by counsellors, etc.
-involves parents and community.