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#Yojana Nector – Health Sector of India !!! ?(Feb 2016)

Yojana Nector is an initiative where we are trying to filter out 80 page or more contents of Yojana magazine and give you the “cream” or “nector” of the whole magazine.The idea is to give you something, that you can retain, internalize and put in the exam papers. What we essentially pick is – the critical aspects and most important datasets along with statements that can add value to you answer. It has varied range of utility as far as UPSC exams are concerned. Use it wisely and Don’t forget to revise.

Also, we add few points on our own as well and will keep adding this section if we find anything interesting or substantial. What that means is, it is not confined only to YOJANA.

Health For ALL:-

1)The policy directions of the “Health for All” declaration became the stated policy of Government of India with the adoption of the National Health Policy Statement of1983.Financing of health care is one of the key factors in delivery of health care. Total health care expenditure in India is about 4 per cent of GDP and the government does run a large public health care services system. However, a large proportion of the population is forced to look for health care outside the system. Health care has become one of the most expensive services for a person belonging to middle and lower classes.

2)Similarly, gender health is critical to a nation’s well being. Addressing malnutrition in women, especially pregnant mothers and children is necessary to ensure gender justice in the country. When a major part of the population remains malnourished, economic development of the country is definitely impacted

3)India has had a tradition of health care, with many notable physicians like Dhanvantari, Jivika, Charaka and Susruta. This tradition has been carried on through various government schemes and programmes over the years.

Preston Curve:-

4) In 1975, Samuel Preston showed that if the health of nations as measured by life expectancy is plotted against the wealth of nations as measured by GDP per capita, then up to a point, there is a sharp increase in life expectancy for even the modest increase in GDP per capita. Then the curve suddenly flattens out – and after this point, large increases in public health expenditure are required for modest increase in life expectancy.

5)In his book “ the Great Escape” this year’s Nobel prize winning economist Angus Deaton explains that even after the bend in the Preston curve, there is a sustained correlation between health outcomes with growth– only that now it is a logarithmic relationship- for the same degree of increase one requires a fourfold increase of the GDP per capita.

Fertility Rate:-

6)Only seven states still continue to face a seriously high fertility rate-Uttar Pradesh, Bihar, Madhya Pradesh and Rajasthan– and to some extent in Jharkhand, Chhattisgarh and Meghalaya- but even in these, the rates of decline are encouraging

Child and Maternal death:-

7)There are still close to 46,500 maternal deaths and about 1.5 million deaths of children under 5 deaths each year, which is a high proportion of global maternal and child deaths. Quality and safety of health care is an issue. Though proportion of childbirths happening in a facility have improved dramatically, quality of care remains a challenge.

Vector Control:-

8)Progressive vector control is mixed. Filaria has decreased dramatically and new cases of elephantiasis are negligible. Malaria has also seen significant declines and with a range of new tools becoming available, a confidence is gathering to transit to a malaria elimination programme. Potentially this is a disease that could fall below the elimination threshold in 10 to 15 years. Kala-azar is an anachronism. it should have been eliminated by now, the deadline having been re-set repeatedly. However, it festers in some deep pockets in a few villages of two to three states, cocking a snook at all attempts to get rid of it. About 20,000 cases annually occur across four states- but the majority are from Bihar.

Meanwhile, new vector borne diseases have emerged- notably dengue and chikungunya. The good news is that deaths both in absolute numbers and as a proportion of all deaths, and even of all cases have declined significantly.

Non Communicable Diseases:-

9)Proportion of mortality due to non-communicable diseases now accounts for over 60 per cent of all deaths and due to injuries which account for almost 12 per cent of all deaths. (WHO 2014) The probability of dying during the most productive years (ages 30-70) from one of the four main NCDs is estimated to be as high as 26 per cent.

To understand its gravity, compare with Sweden where the corresponding figure is 10, UK where it would be 12, Thailand where it would be about 17. Expressed in another way, 62 per cent of male deaths due to the main NCDs would occur before the age of 70 in India, as compared to only 24 per cent in Sweden, 29 per cent in UK and 45 per cent in Thailand.

The proportions are similar in women with about 52 per cent of deaths in women due to NCDs taking place below the age of 70 as compared to only 15 per cent in Sweden.

10)India would have about 785 male deaths per 100,000 due to the main 4 NCDs- of which about 80 would be due to cancer, 30 due to diabetes, 189 due to chronic respiratory disease and 349 due to cardio vascular disease.

11)But when it comes to major risk factors for NCD- whether it is overweight and obesity, physical inactivity, alcohol or smoking- these risk factors are far more prevalent in the developed world. Why then does India have much higher prevalence rates of the disease? The answer lies not only in identifying the pathways through which social determinants play out with respect to NCDs in the developing world, but also in complete absence of primary health care that addresses these diseases. Private sector has no doubt expanded to fill these gaps- but market forces largely promote curative and preferably tertiary care. Market driven growth is unable to meaningfully address the needs of primary and secondary prevention – and it falls on the government to take up this role.

ASHAs:-

12)One of the innovations that most states opted for was the creation of a workforce of close to 900,000 community health volunteers, the ASHAs. They made a major contribution to bringing public health services closer to the community, and increasing its utilization and in health education.

Law on Health:-

13)The present legal environment surrounding health sector is very confusing with a plethora of laws at different levels of adoption and implementation by the centre and the states. It is necessary to harmonise and align them to the overall objective of providing equitable access to health services, especially to poor and socially disadvantaged sections of the society

UHC:-

14)The policy focus on providing Universal Health Coverage (UHC) is in line with the globally agreed target of UHC as a part of SDG on Health. Government of India agreed in principle to adopt UHC as a national goal, but is yet to provide adequate resources to make it happen on the ground.

15)India spends a total of 4 per cent of its GDP on health, which in itself is a significant amount. However, it is the fragmentation of financing and the regressive mode, which is predominantly, out-of-pocket at the point of care that raises the major concern. The large quantum of out-of-pocket expenditure at the point of care which constitutes 86 per cent of private financing of health is shown to have pushed an estimated 37 million into poverty each year.

16)Recent data from the NSSO shows that despite the availability of services in the public sector, private providers were the preferred source of health services due to reasons of unsatisfactory quality (45 per cent), long waiting times (27 per cent) and distant location of facilities (9 per cent), among other reasons.

17)A comparison of India with countries at similar income levels and stages of development indicates that our progress in achievement of outcomes has been slower than these countries. For example, IMR in India declined by 50 per cent from 1990 to 2012. However, the decline was steeper for countries such as Bangladesh (67 per cent) Nepal (66 per cent) and Cambodia (60 per cent)1 during the same period. In terms of public expenditure on health as a percentage of GDP, Bangladesh and India currently spend around 1.3 per cent of their GDP. However, the achievement of outcomes has been much faster for Bangladesh which showed an annual rate of decline for Under-5 mortality rate of 5.4 per cent from 1990 (144) to 2013 (41) as compared to the rate of decline for India which was 3.8 per cent (126 in 1990 to 53 in 2013).2 Therefore, at comparable levels of spending, the achievement of outcomes for India has been slower, indicating that merely raising the quantum of finance is not guaranteed to achieve the desired health outcomes.

Within public financing, allocative efficiency can be improved to reduce fragmentation as well as focus largely on primary and preventive care, which is vital for reducing disease burden as well as providing the highest returns on investment in terms of maintaining a healthy population. Methods to improve autonomy to public health facilities to generate additional funds and manage their funds as per requirement on their own must be further developed.

The Health Status and Care of our Tribal Population:-:-

18)The Scheduled Tribes (ST) constituted 8.6 per cent of the total population of India in 2011, amounting to about 10 crore in absolute number. Health of the ten crore marginalized and vulnerable people should become an important national concern. Their poor socio-economic and educational status is well known.

19)The nutritional status of ST children as well as of adults reveals a sad picture.

i) 53 per cent boys and 50 per cent girls in pre-school age were underweight, and 57 per cent boys and 52 per cent girls were stunted in height.

ii) 49.0 per cent of ST women had a body mass index less than 18.5 indicating chronic energy deficiency.

iii) Dietary intake of tribal households showed large deficiencies in protein, energy, fats, iron, vitamin A and riboflavin.

20)The diseases prevalent in tribal areas can be broadly classified into following categories.

A) The diseases of underdevelopment (malnutrition , communicable diseases, maternal and child health problems),

B) Disease atypically common in ST population (Sickle cell disease, animal bites, accidents) and

C) Diseases of modernity (Hypertension, addiction, mental stress).

21)It is often inappropriate for the scheduled areas, being a rubber stamp version of the national model primarily designed for the non-tribal areas. It does not take into account the different belief systems, different disease burden and health care needs as well as the difficulties in delivering health care in a geographically scattered, culturally different population surrounded by forests and other natural forces. It is surprising that no serious thought was earlier given to design a separate public health care plan for scheduled areas.

The other major difficulty in delivering public health care to tribal population is the lack of health care human resource willing, trained and equipped to work in scheduled areas. There is a shortage – vacancy, absenteeism or half heartedness – of doctors, nurses, technicians and managers in public health care system in scheduled areas.

Though buildings are built and health care institutions created in the form of health sub-centres, PHCs and CHCs – they often remain dysfunctional resulting in poor delivery of health care. This is further compounded by inadequate monitoring, poor quality of reporting, and accountability.

Unfriendly behaviour of the staff, language barrier, large distances, poor transport, low literacy and low health care seeking, – all lead to lower utilization of the existing health care institutions in scheduled areas.

Access to hospital care for serious cases remains very low in tribal areas. Thus, the public health care system in scheduled areas is characterized by low output, low quality and low outcome delivery system often targeting wrong priorities. Restructuring and strengthening it should be one of the highest priorities for the Ministries of Health and FW in states and at the centre. One reason for the inappropriately designed and poorly managed health care in scheduled areas is the near complete absence of participation of ST people or their representatives in shaping policies, making plans or implementing services in the health sector. This is true from the village level to the national level. In addition to the various handicaps listed above, there is a common perception and complaint that funds for health care in tribal areas are underutilized, diverted to other areas, or utllized inefficiently, and worst, siphoned off through corruption.

22)Social determinants of health – literacy, income, water, sanitation, fuel, food security and dietary diversity, gender sensitivity, transport and connectivity – play a very important role in determining the health outcomes. Hence, intersectoral coordination for improvement in other sectors is as important, if not more, as health care.

The social determinants of health range beyond income and education to include water, sanitation, nutrition, environment, gender, social stability and social status. Policies in agriculture and food systems as well as urban design and transport too profoundly affect health. So does the lack of energy security, especially in India where many women and children are badly affected by indoor air pollution from burning of solid biofuels like wood and dung. Many of these relationships were delineated by the WHO Commission on Social Determinants of Health (2005), which recommended that health equity gaps must be bridged within a generation, through determined action on the social determinants of health so that conditions conducive to health are created in all societies. Merely providing equality of opportunity to access health services is not enough, if social deprivation has already created a large lag in health status and limits real and ready access to health services. As British economist Tawney pointed out in his seminal book Equality, over 80 years ago, people need “not just an open road, but also an equal start” in a society that promises social justice.

SDG and Health:-

23)The prominence of health in the Millennium Development Goals (MDGs: 2000-2015) and in the Sustainable Development Goals (2016-2030), sequentially adopted by the United Nations, arises from the recognition that health is pivotal to equitable and sustainable development and is closely interconnected to other development sectors.

24)Kate Pickett and Wilkinson showed that, at similar levels of per capita income, countries with lower levels of income gaps within the population ( greater equality ) have better life expectancy and other health indicators than countries with higher income gaps within the population (lower equality). In their book The Spirit Level, they provide evidence of how even the rich in countries with less equality fare worse than their counterparts in countries with greater equality.

In their book The Spirit Level, they provide evidence of how even the rich in countries with less equality fare worse than their counterparts in countries with greater equality.

25)The bidirectional relationship between health and economic development was now firmly established. The Lancet Commission on Investing in Health (2013) later projected that low and middle income countries could gain 9 to 20 fold returns on economic investments in health.

26)Illness, in turn, often leads to impoverishment or financial shocks among the economically vulnerable sections (which includes a large segment of the middle class), if most of the health care costs are borne by families as ‘out of pocket spending’ (OOPS). It is estimated that nearly 100 million persons are pushed in to poverty world over each year by unaffordable expenditure on essential health care. About half of them are Indians.

Illness also leads to loss of jobs or earnings, often leads to distress sale of valued possessions and adversely affects the family spending on children’s education and nutrition. Similarly, a sick child is unable to fully access the benefits of education, with resultant disadvantage for later employment and income.

27)Th e SDGs are distinct improvement in many ways. First, the text was negotiated through an open and democratic inter-governmental process. Second, the goals are relevant to all countries. The goals cover several domains of development but integrate them within a framework of sustainable development that recognises the linkages. Fourth, environmental protection receives much needed attention, reminding us that the path to economic growth and global development need not and should not be detrimental to planetary health. Fifth, the health SDG corrects the shortcomings of the health MDGs by taking a life course approach to health and emphasising the role of health systems in delivering universal health coverage to promote health equity and provide financial protection against costs of health care.

28)The lone but lofty health goal of the 17 SDGs calls for “Healthy Lives for All and Wellbeing At All Ages”. While this sounds a bit vague, it does reflect a universal approach that extends to all people and promotes health in a positive way.

The nine targets attached to the health goal are specific in guiding action. They call for:

i)reducing maternal mortality to 70 (per 100,000 live births),

ii)under -5 child mortality to 25 and neonatal mortality to 12 (per 1000 live births) by 2030;

iii)ending the epidemics of AIDS, Malaria and TB,

iv)reducing premature deaths from noncommunicable diseases (in the age group 30-70 years),

v)halving deaths from road traffic accidents,

vi)reducing substance abuse and harm from air, water and soil pollution.

vii)It also calls for universal health coverage, with financial protection and access to essential drugs and vaccines, as well as

viii)unimpeded access to reproductive and sexual health services.

ix)Further, it calls for effective implementation of the WHO Framework Convention for Tobacco Control.

29)Health is the best summative indicator of success in all of the SDGs. Let the health of our people be the talisman of our success in this era of sustainable development.

Alma Ata Declaration:-

30)To put the conception of HFA in a historical perspective, UN envisaged a comprehensive and integrated primary health care for all in Alma Ata declaration in 1978 to promote equity and was driven by the community needs.

31)In fact, at Alma Ata (now Almati in Kazakistan) International Conference on ‘primary health care’ expressed the need for ‘urgent action by all governments, all health and development workers, and the world community to protect and promote the health for all the people of the world’.

Its main resolutions are as follows:

i) health, which is ‘a state of complete physical, mental and social well-being’, not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of ‘the highest possible level of health’ is a most important worldwide social goal;

ii) ‘the existing gross inequality in the health status of the people, particularly between developed and developing counties as well as within countries is politically, socially and economically unacceptable;

iii) economic and social development is of basic importance to the fullest attainment of health for all and to the reduction of the gap between the health status of the developing and developed countries;

iv) people have the right and duty to participate individually and collectively in the planning and implementation of their healthcare;

v) governments have a responsibility for adequate health of their people, to be attained by 2000;

vi) primary health care is key and essential, to be made available at a cost that community and country can afford;

vii) primary health care provides promotive, preventive, curative and rehabilitative services, and promotes maximum community and individual self-reliance and participation in planning, organization, operation and control of primary health care, making fullest use of local, national and other available resources;

viii) all governments should formulate national policies, strategies and plans of action to launch and sustain primary health care as a part of comprehensive national health system;

ix) all countries should cooperate in a spirit of partnership and service to insure primary health care for all people since the attainment of health by people in any one country directly concerns and benefits every other country;

x) an acceptable level of health for all for the people of the world by 2000 can be attained through a fuller and better use of world’s resources, a considerable part of which is now spent on armaments and military conflicts; a genuine policy of independence, peace, détente and disarmament could and should release additional resources, to be used for socioeconomic development including primary health care.

India vs The World:-

32)In India, we spend just about 1 per cent of GDP on health and our public expenditure is just 30 per cent whereas Japan spends 82 per cent, OECD (average) 73 per cent, Canada 70 per cent, Switzerland 65 per cent, US 48 per cent and even Thailand 72 per cent.

Consequently, the life expectancy at birth in Japan (82.7years), OECD (80.1), Canada (80.4), Switzerland (82.8), US (78.7) and Thailand (74.3) is much higher than that in India (66.3years).On the other hand, infant mortality rate in India (43.8 per thousand) is 20 times that in Japan (2.3per thousand), ten time that in OECD and Canada (4.1 and 4.4 respectively), 11 times that in Switzerland (3.8), 7.5 times that in US (6.1) and 4.5 times that in Thailand (9.9). Kerala has achieved the level of many developed countries both in health and education due to its priority to social sector over the years. Why can’t the rest of India achieve that?

33)UHC aims that ‘all people have access to needed promotive, preventive, curative and rehabilitative health services, of sufficient quality to be effective, while also ensuring that people do not suffer financial hardship when paying for these services’.

34)UHC has three dimensionspopulation coverage, health services coverage and financial protection coverage– and is often represented by a cube, referred as ‘UHC Cube’ or ‘UHC coverage box

35)UHC and INDIA – India was part of the resolution on UHC at the 2005 World Health Assembly as a member state. Though, the UHC was not being discussed in the country at that time, India had launched the National Rural Health Mission (NRHM) in April 2005, to improve health systems in India and improve health status of the people. Rashtriya Swasthya Bima Yojana (RSBY), which intends to provide financial coverage to below poverty line population for the cost of secondary level hospitalization and a few other financial protection schemes were launched.

According to World Health Organisation (2015), under-nutrition or malnutrition is the major cause of death in 45 per cent of all deaths among children below 5 years

1)Disease and Malnutrition have close links; in many ways, malnutrition is the largest single contributor to disease in the world, according to the UN’s Standing Committee on Nutrition (UNSCN). In some instances, ill health or disease could be a direct consequence of malnutrition, while in others, a key contributor.

2)Malnutrition at an early age leads to reduced physical and mental development during childhood. Stunting, for example, affects more than 147 million pre-schoolers in developing countries (UNSCN).

3)Worldwide, under-nutrition is responsible for 45 per cent of child deaths, directly or through diseases made more severe because of it. Even mildly under-weight children face twice the risk of death as compared to well nourished children.

4)Among micronutrients, Vitamin A deficiency compromises the immune system and leads to the death of approx. 1 million children each year.

5)Globally, severe iron deficiency is the cause of more than 60,000 deaths per year of women during pregnancy. Similarly, maternal folate deficiency leads to 250,000 severe birth defects and iodine deficiency in pregnancy causes mental impairment of almost 18 million infants per year and a lowering of `0-15 IQ points in school children. (India Health Report: Nutrition, 2015).

6)Iron deficiency weakens the maternal body, impairs intrauterine growth and increases the risk of both maternal and foetal morbidity and mor t a l i ty (Wor ld He a l t h Organization 2000a).

7)Malnutrition also has widespread economic ramifications. Problems related to anaemia, for example, including cognitive impairment in children and low productivity in adults, cost US$5 billion a year in South Asia alone. (Ross & Horton, 1998)

8)”Women’s deprivation in terms of nutrition and health care rebounds on society in the form of ill-health of their offspring — males and females alike.”.

9)The intergenerational cycle of growth failure, first described in 1992 explains how growth failure is transmitted across generations through the mother, thereby highlighting the importance of addressing women’s health and well being to bring about a significant change in the situation of malnutrition.

10)Stunted and/or anaemic adolescent mothers are more likely to have complications during childbirth and the postpartum period, as well as to give birth to premature and low-weight babies.

11)The first 1000 days – Child nutrition in the 1000 days between a woman’s pregnancy and her child’s second birthday sets the foundation for all the days that follow. Right nutrition during this window has a profound and lasting impact on the child’s ability to grow, learn and thrive, thereby contributing immensely to the country’s health and well being too.

12)Nutrition during pregnancy and in the first years of a child’s life provides the essential building blocks for brain development, healthy growth and a strong immune system.

13)Right Nutrition in the 1,000 day window helps:

a) Build a child’s brain and fuel their growth.

b) Improve a child’s school-readiness and educational achievement.

c) Reduce disparities in health, education, and earning potential.

d) Reduce a person’s risk of developing chronic diseases such as diabetes and heart disease later in life.

e) Save more than one million lives each year.

f) Boost a country’s GDP by as much as 12 per cent.

g) Break the intergenerational cycle of poverty.

14)Rapid Survey in Children shows that 38.7 per cent children under the age of 5 are stunted, 19.8 per cent are wasted and 42.5 per cent are under weight

15)Stunting is a measure of chronic under nutrition, wasting indicates acute under-nutrition and under-weight is a composite of these two conditions

16)This recently released India Health Report on Nutrition communicates 6 critical messages – Stunting, wasting and underweight rates of India’s children has declined, especially during the last decade, but still exceed levels observed in countries at similar income levels. – The rate of improvement in nutritional status has not kept pace with India’s significant gains in economic prosperity and agricultural productivity during recent decades. Stunting rates may decline with economic progress but economic growth cannot, by itself, reduce under nutrition and may contribute to over-weight and obesity. – Nutritional status and progress on reducing stunting vary markedly across India’s states indicating that state specific approaches are necessary to achieve further gains in reducing stunting. – The underlying reasons for India’s high rates of stunting and variability in progress are complex and inter-twined. Some of the drivers such as complementary feeding, women’s status and health, sanitation and social/ caste inequality are the major challenges – India will ignore the problem of under nutrition and its impact on child development at its peril and risk large economic, health and social consequences for future generations. – India’s under-nutrition problem is a serious threat to child development. Accelerating action at the state level is essential to change the course of the future for India’s children.

1)Globally, more than 70 per cent of almost 1.1 crore children die every year due to diarrhoea, malaria, neonatal infection, pneumonia, preterm delivery or lack of oxygen at birth. A more notable fact is that these deaths occur mainly in developing countries. As per the latest statistics, India contributes to about 21 per cent of the global burden of child deaths (Source: Progress for Children report, UNICEF).

2)While India has made laudable improvement in Infant Mortality Rate, even today, over 7,60,000 children die every year and many of these deaths occur due to preventable diseases. According to the Rapid survey of Children (RSOC 2013) data, India had 89 lakh spartially or unvaccinated children.

3)In December 2014, the Ministry of Health & Family Welfare (MoHFW) launched Mission Indradhanush (MI) as a special nationwide initiative to cover all unimmunized and partially immunized children that are left out during the routine immunization program.

4)What makes the Mission particularly unique is that it is a focused and systematic immunization drive. It is conducted under a mission mode as a catch-up campaign, with the goal of covering all children who have been left or missed out for immunization.

5)Illustrating the seven colours of rainbow, Mission Indradhanush covers seven diseases including diphtheria, pertussis, tetanus, polio, tuberculosis, measles and hepatitis-B.

KAYAKALP SCHEME:-

To recognise efforts of ensuring Quality Assurance at Public Health Facilities, the Ministry of Health & Family Welfare, Government of India has launched a National Initiative to give Awards ‘KAYAKALP’ to those public health facilities that demonstrate high levels of cleanliness, hygiene and infection control. The Objectives of award scheme are to promote cleanliness, hygiene and Infection Control Practices in public Health Care facilities; To incentivize and recognize such public healthcare facilities that show exemplary performance in adhering to standard protocols of cleanliness and infection control ;To inculcate a culture of ongoing assessment and peer review of performance related to hygiene, cleanliness and sanitation and to create and share sustainable practices related to improved cleanliness in public health facilities linked to positive health outcomes.

February 17, 2017

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