Public Health Care in India: Infrastructure, Expenditure, Human Resource and Performance State Institute of Health and Family Welfare, Jaipur 1
Infrastructure HR& Performance Issues 2
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a Health & Disease Disease Health Doctors, Drugs, Diagnostics Death Disability 4
Constitutional commitment: Health: State subject Central List International Health, Port Health Research Technical & Scientific Education State List All other Health issues Concurrent list Epidemics 5
Centralized planning,decentralized implementation Fiscal control of central Govt. Dictates t States t for Objectives & Priorities iti Health State t subject? 6
Five year Plan Period Major areas addressed I 1951-55 Infrastructure II 1956-61 Industry III 1961-66 Panchayat & Green Revolution IV 1969-74 Expenditure, Agriculture V 1974-79 Agriculture VI 1980-85 Health, Technology VII 1985-89 Poverty, Agriculture & Justice VIII 1992-97 Pop., Agriculture, Poverty IX 1997-02 Employment, Basic facilities X 2002-07 HRD, Industry, Technology XI 2007-12 Education, Health, Empowerment 7
Pop. Policy Draft 1976 Small pox free-july 5, 1975 & ICDS started MTPAct (1969) in force-1972 MTP Act-1969 Birth & Death Reg. Act-1969 Dept. of Family welfare -1966 Juggling Priorities 1947 HSDC-1946 NSEP-1962 NMCP to NMEPP-1958 CHEB-1956 BCG Vaccination-1951 NMCP & NFPP-1951 India joins WHO- 1948 8
ICDS renamed Integrated Mother and Child Development (IMCD) -1995 CSSM-1992 National Blood safety program- 1989 National Aids Control Program -1987 UIP-1985 NLCP-NLEP, 1983 NHP-1983 Alma Ata-Declaration (1977)-HFA-2000 NFWP-1977 9
NRHM-2005 National Health Policy- 2002 National Pop. Policy- 2000 RCH-1997 Family Planning Program made target free -1996 Beijing conference-1995 Legislation on Transplantation of human organs enacted 1995 ICPD-1994 10
Public Health Care in India Well developed administrative system Skills Reasonable Infrastructure Something is wrong Poor health outcomes Design Misdirected efforts 1999 Plague epidemic-loss of $ 1 billion (WHO) 11
Policies NHP-1983.NHP-2002 NPP-2000 12
NHP-1983 Re-orientation of Medical education Re-structuring and Re-organizing the then existing health care services Population stabilization Re-orientation of existing health personnel Role of practitioners of ISM in Health care delivery Goals - Achievement? CDR & Life expectancy 13
NHP-2002 Averages of health indices hide disparities large gap in facilities still persists shortfall in the number of SCs/PHCs/CHCs is of the order of 16 percent. (CHC-58%) Vertical implementation structure -extremely expensive the rural health staff has become a vertical structure exclusively for the implementation of family welfare activities Low utilization- 20 % seeking OPD services, <45 percent seeking indoor treatment, go to public hospitals. 14
Integrated disease control network Increase in postgraduate seats in Public Health & Family Medicine Decentralization-Role of LSG/ NGO Medical Grants commission Legislation for regulating clinical establishments/ medical institutions by 2003 15
Ten Great Public Health Achievements of the 20th Century Vaccination Motor-vehicle safety Safer workplaces Control of infectious diseases Decline in deaths from coronary heart disease and stroke Safer and healthier foods Healthier mothers and babies Family planning Fluoridation of drinking water Recognition of tobacco use as a health hazard Source: Center for Disease Control, Morbidity and Mortality Weekly Report, 48(12) 241-243 (April 2, 1999) 16
But we have known this for 64 years If it were possible to evaluate the loss, which this country annually suffers through the avoidable waste of valuable human material and the lowering of human efficiency through malnutrition and preventable morbidity, we feel that the results would be so startling that the whole country would be aroused and would not rest until a radical change has been brought about. 17
After 64 years of Health Services: Crude Death Rate Crude birth rate Life expectancy S.pox & G. worm eradicated Leprosy eliminated IMR Infrastructure expanded 18
NO Health Policy for 36 years Health left to Committees and Commissions i Each Committee addressed to a single specific issue. Comprehension was missing Majority of recommendations of every committee were reiterations ti of Bhore Committee. Individual Health Programs developed in isolation based on situational exigency. Uni-purpose workers later baptized as Multipurpose. Some Programs worked in complete isolation till 1980 (e.g. NTCP). Fragmented approach to Health 19
Goals to be achieved by 2000-2015 Eradicate Polio and Yaws 2005 Eliminate Leprosy 2005 Eliminate Kalazar 2010 Eliminate Lymphatic Filariasis 2015 Achieve Zero level growth of HIV/AIDS 2007 Reduce Mortality by 50% on account of TB, Malaria and Other Vector and Water Borne diseases 2010 Reduce Prevalence of Blindness to 0.5% 2010 Reduce IMR to 30/1000 And MMR to 100/Lakh 2010 Increase utilization of public health facilities from current Level of <20 to >75% 2010 Establish an integrated system of surveillance, National 2005 Health 20
Health Care Infrastructure 21
Sub Center over FYP 145272 130165 136258 137311 147069 84376 33509 47112 0 0 0 Source: RHS-2010 I II III IV V VI VII VIII IX X XI 22
PHC over FYP 18671 22149 22875 22370 23673 5283 5484 9115 2565 0 0 I II III IV V VI VII VIII IX X XI Source: RHS-2010 23
CHC over FYP 4535 4045 2633 3054 1910 761 0 0 0 0 214 I II III IV V VI VII VIII IX X XI Source: RHS-2010 24
Health facilities in govt. buildings 147069 India Rajasthan 84957 23673 19317 11487 10245 1517 1473 4535 376 4236 362 SC SC (govt. PHC PHC (govt. CHC CHC (govt. buildings) buildings) buildings) Source: RHS 2010 25
Health facilities 7823 India Rajasthan 850 1491 237 24 x 7 FRU Source: MoHFW; DM&HS (Raj.) 26
Population o : Infrastructure India Rajasthan 163725 117644 5049 3769 31364 28785 Population per SC Population per PHC Population per CHC Source :RHS-2010 27
Healthcare e Delivery e Status 54.1 57 72.9 70.4 76.2 75.8 India Rajasthan 61 53.8 26.5 14.6 Contraceptive Full ANC Prevalence Rate (any method) Source: DLHS 3; CES 2009 Institutional Delivery Skilled birth attendance for delivery Full Immunization 28
Healthcare Delivery Status ANC 12 week registration ANC 3 check ups Institutional Delivery Fully Immunized 873197 1148187 524165 1617630 536661 850831 1154485 867573 112484 722746 16117888 8 1572896 982837 1337321 1018842 1615685 1060600 1421039 1136597 15961566 1012571 1335568 1202596 1540318 853792 1255982 1207068 1368591 2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 Source: DM&HS, Rajasthan 29
Health Care Infrastructure: Rajasthan 199 7 33 6 12 Medical College District Hospital Satellite Hospital Sub-divisional Hospital City Dispensary Source: www.nrhmrajasthan.nic.in 30
Medical Colleges 84 2 Non-Recognized Recognized 251 8 India Rajasthan Source: MCI, 2011 31
Dental Colleges 106 4 Non-Recognized Recognized 188 10 India Rajasthan Source: DCI, 2011 32
Nursing Schools 2455 India Rajasthan 1295 1506 39 184 ANM GNM Source: www.indiannursingcouncil.org (Nov. 2011) B.Sc. 143 438 9 M.Sc. MSc 33
CHC- XI FYP vs. PG seats 4535 CHC XI-FYP India Rajasthan 2077 1924 1203 1286 1015 603 584 578 92 85 68 58 73 13 14 18 Source: MCI, 2011 34
Total beds (India) 514989 602490 621250 682886 469672 576793 1985 1990 1995 2000 2005 2010 Source: CBHI -HII/NHP 35
Medical Education : Rajasthan a Population : Medical College 6675000 Undergraduate Intake 1300 Post Graduate seats 740 UG:PG Seats 1.76 No. of Specialties 35 Source: CBHI, MCI 36
Health Expenditure 37
Share in health care spending 26.7% Private expenditure External flow Public expenditure 1.6% 71.6% Source: NHP 2010 38
Health Expenditure as % of total Plan Outlay 6.5 3.4 3.1 2.9 3.2 39 3.9 4.09 397 3.97 3.1 3.1 3.1 3.2 2.8 2.9 2.9 Source: NHP 2010 39
Who really pays? Opportunity cost - if we choose to do one thing, the cost of doing that is the value which would have been obtained from the best alternative choice Who pays - the person who does not receive treatment 40
Total Govt. Expenditure on Health 0.49 063 0.63 0.61 0.74 as % of GDP Source: CBHI, NHP, 2010 0.81 0.91 1.05 0.96 0.88 0.9 083 0.83 0.86 0.91 0.96 0.98 1.03 1.1 0.22 Planning Commission has decided to increase its spending on health to 2.5% of the GDP in the 12th Five Year Plan. 41
Per Capita Public Exp. on Health 202.22 214.62 184.56 183.56 112.21 38.63 19 37 0.61 1.36 2.48 3.47 6.22 11.1519.37 64.83 Source: NHP 2010 42
Status of Expenditure in FYPs Source: CBHI, NHP, 2010 43
Total Outlay Plan and Health (including AYUSH & FW) 2500000.0 2000000.0 Total plan outlay Health sector 160000 140000 120000 1500000.0 100000 80000 1000000.0 60000 500000.0 40000 20000 0.0 0 Source: NHP 2010 44
Percentage of total budget allocated to health 7 6 5 4 3 2 1 0 3.4 3.1 2.9 3.2 3.9 3.1 2.8 3.1 3.1 2.9 2.9 3.2 4.1 3.9 6.5 Source: NHP 2010 45
Budget outlay for Health - Rajasthan 147762.07 akhs mount in l A 102230.7 87171.1414 62870.95 1775.68 383.99 9493.06 20228.12 167.21 664.53 3336.79 I II III IV V VI VII VIII IX X XI Five Year plans Source: www.planning.rajasthan.gov.in 46
Health Care Spending (2004-05) 05) 73.5 70 India Rajasthan 22 24.5 4.5 5.5 Household exp. Government exp. Other health exp. Source: NCMH 2005 47
Health care spending India Rajasthan 959 575 242 186 Per capita public exp. Per capita private exp. Source: NHP 2010/ data in Rs. 48
Human Resource in Health 49
People are resource But To maintain this resource We need Resources 50
Doctors (Allopathic in India) 816629 577094 268700 393600 61800 83700 151100 1951 1961 1971 1981 1991 2001 2010 Source: CBHI-HII/NHP 51
Nurses (India) 1757416 18054 143887 1951 1981 2011 Source: Planning Commission of India/ Indian Nursing Council 52
Average eagepopulation opuato Serveded 603121 India Rajasthan 13531 10268 33722 Doctors Dentists Source: NHP 2010 53
Manpower Status 816629 India Rajasthan 752254 28513 85254 104603 3421 5992 364 139 31604 Reg. Allopathic doctors Allopathic doctors (in govt.) * Reg. Dentists Dentists (in govt.) * Reg. Ayush doctors Source: CBHI,NHP-2010/ * data for Rajasthan from DM&HS, Raj. 54
Manpower Status 25870 India Rajasthan 1763 1531 150 1939 97 1165 162 1311 83 Doctors at PHC Surgeons at CHC Obs&Gyn at CHC Physicians at CHC Pediatricians at CHC Source: RHS 2010 55
Manpower Status 1073638 India Rajasthan 576542 656101 190919 22239 20229 37667 52375 850 18214 Reg. ANM ANMs in govt. * Reg. GNM Reg. LHV Reg. Pharmacists Source: NHP 2010/ * data for Rajasthan from DM&HS Raj. 56
Health workforce and infrastructure - India Density per 10,000 population Physicians 6.0 Nursing and midwifery 13.0 staff Dentists 0.7 Pharmacists 5.2 Hospital beds 9 Source: World Health Report 2011 57
Health system ss performance 58
Goals to be achieved by 2000-2015 Eradicate Polio and Yaws 2005 Eliminate Leprosy 2005 Eliminate Kalazar 2010 Eliminate Lymphatic Filariasis 2015 Achieve Zero level growth of HIV/AIDS 2007 Reduce Mortality by 50% on account of TB, Malaria 2010 and Other Vector and Water Borne diseases Reduce Prevalence of Blindness to 0.5% 2010 Reduce IMR to 30/1000 And MMR to 100/Lakh 2010 Increase utilization of public health facilities from 2010 current Level of <20 to >75% Establish an integrated system of surveillance, 2005 National Health 59
Population and Growth: India 60
Population Growth- India 12101.9 10270.3 8463.9 2384 5481.6 2520.9 2789.8 3610.9 4392.3 3186.6 2513.2 6833.3 1901 1911 1921 1931 1941 1951 1961 1971 1981 1991 2001 2011 Source: Census of India/data in lakhs 61
Population growth - Rajasthan 68.62 56.47 44.01 15.97 20.15 25.76 34.36 1951 1961 1971 1981 1991 2001 2011 Source: Census; data in millions 62
Birth Rate (India) 41.7 41.2 37.2 33.9 29.5 29 22.1 1951 1961 1971 1981 1991 2001 2010 Source: SRS 2011 63
Birth Rate (Rajasthan) a 37.1 35 29.7 26.7 1981 1991 2001 2011 Source: Planning Commission/ Rajasthan Development Report; SRS 2011 64
Death Rate (India) 22.8 19 15 12.5 9.8 10 8.4 7.6 7.2 1951 1961 1971 1981 1991 1995 2001 2005 2011 Source: SRS 2011 65
Death Rate (Rajasthan) a 14.3 10.1 7.8 6.7 1981 1991 2001 2011 Source: Planning Commission/ Rajasthan Development Report; SRS 2011 66
Infant Mortality Rate (India) 134 146 138 110 80 58.5 47 1951 1961 1971 1981 1991 2001 2011 Source:SRS,2011 67
Infant Mortality ty Rate (Rajasthan) a 108 79 81 55 Source: SRS 1981 1991 2001 2011 68
Maternal a Mortality ty Ratio India Rajasthan 501 445 388 327 301 254 212 318 2001 2003 2006 2009 Source: SRS 69
Total Fertility Rate 3.4 36 3.6 38 3.8 India 3.2 Rajasthan 2.9 27 2.7 Source: NFHS NFHS 1 NFHS 2 NFHS 3 70
Health care in India Entitlements by policy and not rights Focus on preventive and promotive care Grossly under-provided facilities Poor investments hitherto Declining public expenditures and new investments Structural Adjustment programming under World Bank dictate 71
Major Programs National AIDS Control Program National Cancer Control Program National Diarrheal Disease Control Program National Filaria Control Program* National Family Welfare Program National Iodine Deficiency Disorders Control Program National Leprosy Eradication Program 72
National Malaria Eradication Program* National Program for Control of Blindness & Visual Impairment National Reproductive and Child Health Program National Program for surveillance Program for Communicable diseases National Tuberculosis Control Program (Revised) (* Programs are merged into National Vector Borne Disease Control Program since 2003-04) 73
Epidemiological Profile 74
Diarrhea Cases 11408666 10978417 10970089 10978459 10993639 10510476 10481238 10112845 8870507 9287758 9441456 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Source: CBHI,NHP-2010 and MOHFW 75
Diarrhea Deaths 2918 2787 3475 3433 2939 3176 3603 2147 2365 1818 1388 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Source: CBHI,NHP-2010 and MOHFW 76
Enteric Fever Cases 916161 789004 820360 685960 695114 1039311 1034642 490377 596684 471502 488033 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Source: CBHI,NHP-2010 and MOHFW 77
Measles Cases 63515 36711 36900 48181 40840 29808 2005 2006 2007 2008 2009 2010 Source: CBHI,NHP-2010 and MOHFW 78
Measles deaths 188 99 54 50 44 32 2005 2006 2007 2008 2009 2010 Source: CBHI,NHP-2010 and MOHFW 79
Polio cases and deaths 741 Cases 559 Deaths 238 116 1 4 30 76 42 1 1 0 2006 2007 2008 2009 2010 2011 Source: CBHI-NHP-different years/ for year 2011 data source National Polio Surveillance Project (WHO) 80
ARI Cases 27486422 26152951 26171496 26544613 25452972 25541645 24720144 2004 2005 2006 2007 2008 2009 2010 Source: CBHI,NHP-2010 and MOHFW 81
ARI Deaths 6948 3278 3455 5470 4681 4235 4286 4141 3736 2813 2612 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Source: CBHI,NHP-2010 and MOHFW 82
Neonatal tetanus Cases 821 937 899 811 620 373 2005 2006 2007 2008 2009 2010 Source: CBHI,NHP-2010 and MOHFW 83
Neonatal tetanus Deaths 116 100 80 56 31 11 2005 2006 2007 2008 2009 2010 Source: CBHI,NHP-2010 and MOHFW 84
Cases of Tetanus other than Neonatal 2981 2815 3218 2903 2051 1574 2005 2006 2007 2008 2009 2010 Source: CBHI,NHP-2010 and MOHFW 85
Deaths due to Tetanus other than Neonatal 340 365 325 253 160 139 2005 2006 2007 2008 2009 2010 Source: CBHI,NHP-2010 and MOHFW 86
Malaria Cases : India 2085484 8 1842019 1869403 1816569 1844413 1780777 1526210 1508927 1563574 1599986 1180502 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Source: CBHI,NHP-2010 and MOHFW For 2011 data upto Nov. 87
Malaria aa adeaths :India da 1704 1311 1005 973 1006 949 963 1055 1144 1023 430 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Source: CBHI,NHP-2010 and MOHFW For 2011 data upto Nov. 88
Dengue Cases : India 28292 15535 12754 12317 12561 3306 4153 944 1926 650 938 5534 2218 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Source: CBHI,NHP-2010 and MOHFW 89
Dengue Deaths : India 215 157 184 17 7 53 33 45 69 80 96 110 12 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Source: CBHI,NHP-2010 and MOHFW 90
TB Cases : India 1517363 1533309 1397498 1475587 1293083 1188412 1173992 906472 471658 623323 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Source: CBHI,NHP-2010 91
TB Deaths : India 64539 64824 66204 66345 56471 21076 27220 31455 37639 10463 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Source: CBHI,NHP-2010 92
Suspected Chikunganya Cases : India 59535 95091 73288 48176 6222 2007 2008 2009 2010 2011 Source: NRHM/ MoHFW 93
Kala Azar Cases : India 44533 39178 33598 28941 24212 17948 2006 2007 2008 2009 2010 2011 Source: NRHM/ MOHFW 94
Kala Azar Deaths : India 187 203 151 93 105 48 Source: NRHM/ MOHFW 2006 2007 2008 2009 2010 2011 95
Viral Hepatitis Cases : India 236493 153034 149262 135859 151287 161621 152623 124085 97827 92291 85164 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Source: CBHI,NHP-2010 96
Viral Hepatitis Deaths : India 1718 1038 1147 914 1006 1186 694 480 530 600 416 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Source: CBHI,NHP-2010 97
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