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Hunger / HDI | Public Health
Public Health

Public Health

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The key findings of the Draft National Health Policy 2015 (published in December 2014), prepared by the Ministry of Health and Family Welfare are as follows (Please click here to download):

• The draft National Health Policy accepts and endorses the understanding that a full achievement of the goals and principles as defined would require an increased public health expenditure to 4% to 5% of the GDP. However, given that the NHP, 2002 target of 2% was not met, and taking into account the financial capacity of the country to provide this amount and the institutional capacity to utilize the increased funding in an effective manner, the present draft health policy proposes a potentially achievable target of raising public health expenditure to 2.5% of the GDP. It also notes that 40% of this would need to come from Central expenditures. At current prices, a target of 2.5% of GDP translates to Rs. 3800 per capita, representing an almost four fold increase in five years.

• The private sector today provides nearly 80% of outpatient care and about 60% of inpatient care. (The out-patient estimate would be significantly lower if we included only qualified providers. By NSSO estimates as much as 40% of the private care is likely to be by informal unqualified providers). 72% of all private health care enterprises are own-account-enterprises (OAEs), which are household run businesses providing health services without hiring a worker on a fairly regular basis.

• In terms of comparative efficiency, public sector is value for money as it accounts (based on the NSSO 60th round) for less than 30% of total expenditure, but provides for about 20% of outpatient care and 40% of in-patient care. This same expenditure also pays for 60% of end-of-life care (RGI estimates on hospital mortality), and almost 100% of preventive and promotive care and a substantial part of medical and nursing education as well.

• Thailand has almost the same total health expenditure as India but its proportion of public health expenditure is 77.7% of total health expenditures (which is 3.2% of the GDP) and this is spent through a form of strategic purchasing in which about 95% is purchased from public health care facilities- which is what gives it such a high efficiency. Brazil spends 9% of its GDP on health but of this public health expenditure constitutes 4.1% of the GDP (which is 45.7% of total health expenditure). This public health expenditure accounts for almost 75% of all health care provision. It would be ambitious if India could aspire to a public health expenditure of 4% of the GDP, but most expert groups have estimated 2.5% as being more realistic.

• As costs of care rise, affordability, as distinct from equity, requires emphasis. Health care costs of a household exceeding 10% of its total monthly consumption expenditures or 40% of its non-food consumption expenditure- is designated catastrophic health expenditures- and is declared as an unacceptable level of health care costs.

• Almost all hospitalization even in public hospitals leads to catastrophic health expenditures, and over 63 million persons are faced with poverty every year due to health care costs alone. It is because there is no financial protection for the vast majority of health care needs. In 2011-12, the share of out-of-pocket expenditure on health care as a proportion of total household monthly per capita expenditure was 6.9% in rural areas and 5.5% in urban areas. This led to an increasing number of households facing catastrophic expenditures due to health costs (18% of all households in 2011-12 as compared to 15% in 2004-05). Under NRHM, free care in public hospitals was extended to a select set of conditions – for maternity, newborn and infant care as part of the Janani Suraksha Yojana and, the Janani Shishu Suraksha Karyakram, and for disease control programmes. For all other services, user fees especially for diagnostics and “outside prescriptions” for drugs continued. Also, due to the selective approach, several essential services especially for chronic illness was not obtainable or at best only available at overcrowded district and medical college hospitals resulting in physical and financial hardship and poor quality of care.

• The Central Government under the Ministry of Labour & Employment, launched the Rashtriya Swasthya Bima Yojana (RSBY) in 2008. The population coverage under these various schemes increased from almost 55 million people in 2003-04 to about 370 million in 2014 (almost one-fourth of the population). Nearly two thirds (180 million) of this population are those in the Below Poverty Line (BPL) category. Evaluations show that schemes such as the RSBY, have improved utilization of hospital services, especially in private sector and among the poorest 20% of households and SC/ST households. However there are other problems. One problem is low awareness among the beneficiaries about the entitlement and how and when to use the RSBY card. Another is related to denial of services by private hospitals for many categories of illnesses, and over supply of some services.

• The private health care industry is valued at $40 billion and is projected to grow to $ 280 billion by 2020 as per market sources. The current growth rate of this perennially and most rapidly growing area of the economy, the healthcare industry, at 14% is projected to be 21% in the next decade. Even during the global recession of 2008, this sector remained relatively recession-proof. The private health care industry is complex and differentiated. It includes insurance and equipment, which accounts for about 15%, pharmaceuticals which accounts for over 25%, about 10% on diagnostics and about 50% is hospitals and clinical care. The private sector growth cannot be seen merely as a consequence of limited public sector investment. The Government has had an active policy in the last 25 years of building a positive economic climate for the health care industry. Amongst these measures are lower direct taxes; higher depreciation in medical equipment; Income Tax exemptions for 5 years for rural hospitals; custom duty exemptions for imported equipment that are lifesaving; Income Tax exemption for Health Insurance; and active engagement through publicly financed health insurance which now covers almost 27% of the population.

• Maternal mortality now accounts for 0.55% of all deaths and 4% of all female deaths in the 15 to 49 year age group.

• India is set to reach the Millennium Development Goals (MDG) with respect to maternal and child survival. The MDG target for Maternal Mortality Ratio (MMR) is 140 per 100,000 live births. From a baseline of 560 in 1990, the nation had achieved 178 by 2010-12, and at this rate of decline is estimated to reach an MMR of 141 by 2015.

• In the case of under-5 mortality rate (U5MR), the MDG target is 42. From a baseline of 126 in 1990, in 2012 the nation has an U5MR of 52 and an extrapolation of this rate would bring it to 42 by 2015. This is particularly creditable on a global scale where in 1990 India's MMR and U5MR were 47% and 40% above the international average respectively.

• Although over 90% of pregnant women receive one antenatal check up and 87% received full TT immunization, only about 68.7% of women have received the mandatory three antenatal check-ups. Again whereas most women had received iron and folic acid tablets, only 31% of pregnant women had consumed more than 100 IFA tablets. For institutional delivery, standard protocols are often not followed during labour and the postpartum period. Sterilization related deaths a preventable tragedy, are often a direct consequence of poor quality of care. Only 61% of children (12-23 months) have been fully immunized.

• In AIDS control, progress has been good with a decline from a 0.41% prevalence rate in 2001 to 0.27% in 2011 but this still leaves about 21 lakh persons living with HIV, with about 1.16 lakh new cases and 1.48 deaths in 2011. In tuberculosis the challenge is a prevalence of close to 211 cases and 19 deaths per 100,000 population and rising problems of multi-drug resistant tuberculosis. Though these are significant declines from the MDG baseline, India still contributes to 24% of all global new case detection.

• Over 75% of communicable diseases are not part of existing national programmes. Overall, communicable diseases contribute to 24.4% of the entire disease burden while maternal and neonatal ailments contribute to 13.8%. Non-communicable diseases (39.1%) and injuries (11.8%) now constitute the bulk of the country's disease burden. National Health Programmes for non-communicable diseases are very limited in coverage and scope, except perhaps in the case of the Blindness control programme.

• The gap between service availability and needs is widest in the case of mental illness- 43 facilities in the nation with a 0.47 psychologists per million people.

• The elderly i.e. the population above 60 years comprise 8.6% of the population (103.8 million) and they are also a vulnerable section. Those above 75 years (20.52 million) are most vulnerable and almost 8% of the elderly population is bed ridden or homebound (NSSO).
 

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