What ails India’s public health delivery system

17 Jun

Recently, the Cabinet approved the Ministry of Health and Family Welfare’s new programme, the National Urban Health Mission (NUHM), which seeks to focus on the public health needs of the urban poor. NUHM is the new scheme under the government’s overarching National Health Mission (NHM) programme.

The existing National Rural Health Mission (NRHM) is the other scheme under the NHM. NRHM was launched in April 2005 to provide comprehensive healthcare in rural areas. The programme focuses on 18 states. Each village with a population of 1,000 in these states are to have an Accredited Social Health Activist. NRHM proposes to (a) strengthen existing infrastructure; (b) prepare district health plans; (c) guide sanitation and hygiene projects; (d) strengthen disease control programmes; (e) foster public-private partnerships in healthcare; and (f) implement new finance mechanisms.

Although providing the urban poor with a well-functioning public health system is a dire necessity, it is unclear whether NUHM would succeed in doing so given the government’s poor track record in establishing a public health system in the country. Having said that, it is also true that India has come a long way from the time of independence in terms of providing health facilities to its citizens.

This post focusses on India’s present status in terms of health indicators and public health infrastructure based on the performance of NRHM. Since the NUHM would follow a similar model as NRHM, its chances of success may depend on addressing the bottlenecks in the NRHM.

India’s track-record so far…

Health indicators

India’s dysfunctional public health system has taken a toll on its citizens, especially the poor. Table 1 comparing India’s status with other countries on key health indicators shows that it lags behind many countries. However, public spending on health in India is among the lowest in the world at about 1.4% of the Gross Domestic Product (GDP). Also, households in India spend about 5-6% of their consumption expenditure on health.

Table 1: Health indicators of some countries

Country IMR MMR Life expectancy at birth Total Health Exp (as % of GDP)

M

F

India

44

212

62.6

64.2

4.6

Pakistan

71

320

66.9

67.5

2.6

Ghana

50

350

61.8

63.6

6.9

Bangladesh

49

570

65.8

68.1

3.4

China

22

45

71.8

75.3

4.6

Sri Lanka

12

58

70.8

78.2

4

Malaysia

8

62

72.5

77.2

4.8

USA

7

24

75.4

80.5

16.2

UK

5

12

77.4

81.7

9.3

Sweden

3

5

78.8

82.9

9.9

Sources:All India Progress under NRHM as on 31 Dec, 2012,” NRHM website; “World Population Prospects: the 2010 Revision,” UN, Dept of Economic and Social Affairs, 2011; “MDG Indicators,” UN; Databank of World Bank; 11th Five Year Plan, Planning Commission.

*Note: Infant Mortality Rate (IMR): Deaths per 1000 live births; Maternal Mortality Rate (MMR): Deaths per 100,000 live birth; Total Health Expenditure: Includes public and private expenditure.

Infrastructure

India has an elaborate public health infrastructure but it is mostly dysfunctional with neither proper infrastructure nor trained man-power. According to government norms, urban areas are supposed to have a two-tier system with Urban Health Centres for every 100,000 population, followed by general hospital. There are similar norms for rural areas. Table 2 gives an overview of the multi-tier network through which government health services are supposed to be delivered in rural areas.

Table 2: Norms for public health institutions in rural areas and the shortfall

Tiers Population and staff norms Services Status as of 2012
Sub-Health Centre Level(Gram Panchayat level) 1 Sub-Centre for a population of 5,000 in the plains and 3,000 in hilly areas.Staffed with Auxiliary Nurse Midwife and a male health worker. Perform tasks related to maternal and child health, nutrition, immunisation, diarrhoea control etc. Provided with basic drugs for minor ailments. 1,48,124 (shortfall of 35,762 Sub Centres)
Primary Health Centres (PHCs)(Cluster of Gram Panchayats) 1 PHC for a population of 30,000 in the plains and 20,000 in the hilly areas.Staffed with one Medical Officer and 14 other workers. Acts as a referral unit for 6 sub-centres and has 4-6 beds for patients. Provides a package of essential public health programmes. 23,887 (shortfall of 7,048 PHCs)
Community Health Centres (CHCs)(Block level) 1 CHC for a population of 1,20,000 in the plains and 80,000 in hilly areas.Staffed with 4 Medical Specialists and 21 paramedical and other staff. Has 30 in-door beds and serves as a referral centre for 4 PHCs. Provides facilities for emergency obstetrics care and specialist consultations. 4,809 (shortfall of 2766 CHCs)
District and Sub-District Hospitals(District level) 1 hospital for each district, which is linked to sub-district hospitals, CHCs, PHCs and Sub-Centres.Staff norms vary based on the size of the hospitals i.e. the number of beds. District hospitals generally have 75 to 500 beds. Sub-District hospitals have 31 to 50 beds. Services include OPD, indoor and emergency services. Provides consultation services with specialists. District hospitals provide secondary level referral services for institutions below district level. 627 district hospitals and 305 health facilities

Sources: Annual Report 2010-2011, Ministry of Health and Family Welfare; “Indian Public Health Standards for 201-300 Bedded District Hospitals: Guidelines,” January 2007, MoHFW; “All India Progress under NRHM as on 31 Dec, 2012,” NRHM website; NRHM MIS.

Availability of doctors

Even in places where the infrastructure is in place, there is a shortfall in trained doctors and support staff. Qualified doctors do not want to be posted to rural areas because of lack of educational facilities, irregular electricity supply, lack of potable water, safety issues and lack of well-equipped laboratories. Table 3 shows the percentage of vacancies of doctors at both the PHC and CHC level.

Table 3: Vacancies of doctors in PHCs and CHCs

State

% of vacancy in PHCs

% of vacancy in CHCs

ChhattisgarhWest BengalMaharashtraUttar PradeshMizoram

Madhya Pradesh

Gujarat

Andaman & Nicobar Islands

Odisha

Tamil Nadu

Himachal Pradesh

Uttarakhand

Manipur

Haryana

Sikkim

Meghalaya

Delhi

Goa

Karnataka

Kerala

Andhra Pradesh

Rajasthan

Arunachal Pradesh

Assam

Bihar

Chandigarh

Dadra & Nagar Haveli

Daman & Diu

Jammu & Kashmir

Jharkhand

Lakshadweep

Nagaland

Puducherry

Punjab

Tripura

India

71

44

37

36

35

34

31

30

28

27

22

22

20

19

19

18

14

11

10

7

3

0.4

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

24

90

0

34

NA

NA

88

0

100

62

0

NA

74

94

94

NA

0

0

67

NA

NA

27

49

NA

NA

60

50

0

0

53

81

0

NA

0

40

NA

59

Sources: National Rural Health Mission (available at http://nrhm-mis.nic.in/UI/RHS/RHS%202011/RHS%20-March%202011-%20Tables-%20Final%209.4.2012.pdf). The data for all states is as of March 2011 except Bihar, UP, Mizoram and Delhi where data is as of 2010

Food for thought for policy-makers…

The existing system does not approach the task of providing healthcare in a comprehensive manner. It takes a fragmented disease specific approach with limited scope for innovations. In addition to dysfunctional health infrastructure, there is lack of accountability and discipline in the whole system. Over the years various committees such as the Bhore Committee 1946, Jungalwalla Committee 1967, Bajaj Committee 1996, Mashelkar Committee 2003 and the National Commission on Macroeconomics and Health 2005 have suggested ways to strengthen the health sector. Based on the recommendations of these committees and other experts, below are some policy options the government can consider.

  • Given that out of pocket expenditure on health is very high for Indians, the government needs to focus on reducing household expenditure of the poor by financing comprehensive healthcare package. The Planning Commission’s report on Universal Health Coverage can be a starting point for framing a suitable package that has the most impact on the poor.
  • One of key reasons why the public healthcare system is dysfunctional is the lack of accountability and discipline among the stakeholders. Since government functionaries have security of tenure, there is very little incentive to perform on the job. Therefore, it is essential to establish institutional mechanisms for oversight functions as well as incentivize health personnel to perform well. Some experts have suggested that the community and locally elected bodies through Village Health Committees and empowered management committees be involved in overseeing the functioning of PHCs and CHCs. Similarly, a District Health Authority may be constituted with public representatives. Also, there needs to be performance based monitoring of health personnel.
  • The role of the private sector in providing health care is already well-established. The private sector includes a range of providers addressing different market segments (voluntary, not-for-profit, corporate, for-profit, trusts, and stand-alone specialist services). While there are a number of super-specialty hospitals such as Medinova, Max, Escorts, and Apollo, most providers are sole practitioners or small nursing homes with 1-20 beds. They serve urban or semi-urban clientele. According to some experts, there is need to enforce sufficient regulations on the private sector to ensure that the unqualified health providers or quacks are not able to harm the patients.
  • The focus of any health policy should be the quality of care provided to a patient. A recent study by experts at the World Bank has comprehensively shown that the problem lies not so much in access to public health care but of the quality of care being provided. According to these experts, so far, government policy has focussed primarily on increasing access to public health rather than devising ways to ensure that everyone gets access to quality care. The study suggests some solutions: (a) fundamentally reforming the way medical degrees are awarded and requiring doctors to go for re-certification periodically; (b) doctors may perform better if there is some performance based pay, better monitoring and a denser peer network; and (c) educating people about issues such as over-medication, sanitation, hygiene and waste management.
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2 Responses to “What ails India’s public health delivery system”

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  1. India’s Dysfunctional Public Health System | OccuWorld - June 16, 2013

    […] Kushik Sanyal at Polity In India Blog tries to find out what ails India’s public health delivery system. […]

  2. India’s Dysfunctional Public Health System · Global Voices - June 16, 2013

    […] Kushik Sanyal at Polity In India Blog tries to find out what ails India’s public health delivery system. […]

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