Health Policies and Programs in India
Content
- Introduction
- Healthcare Context in India
- International norms, sustainable development goal (SDG-3) and Universal health care UHC)
- National health policy
- Cost of healthcare and who is paying for it
- Health insurance
- Health surveys
- Mental health
Introduction
States in various parts of the world now bear the burden of ensuring the health of their populations in modern civilizations. A significant portion of public spending is devoted to providing health care to the populace in many advanced industrialized nations. Due to a variety of factors, social policy should prioritize health. Individuals' and groups' social and economic circumstances have a direct impact on their state of health. Therefore, numerous health deficiencies may also affect those who are poorer. These are the very people, nevertheless, who are also unable to afford pricey medical treatments, cutting-edge medications, and innovative scientific products. Additionally, they wouldn't have the specialized expertise required to comprehend the appropriateness of particular medical interventions and treatments. Deprived social groups, individuals living in distant areas, the poor, children, persons with disabilities, and the elderly would thus make up a vulnerable mass of people with urgent healthcare requirements but less capacity to learn about, have access to, or pay for healthcare services (see Baggott 2012).
There is a strong belief that people's ability to maintain their health should be seen as a human right and unrelated to their socioeconomic situation or environment (ibid). Immunisation, sanitation, reproductive health, public health, and other components are considered "public goods" in the context of healthcare and are not susceptible to market-based systems without governmental intervention. 1 In this module, we will learn about recent changes in the health sector, including the idea of Universal Health Coverage, as well as national health policies and international standards in the context of India. We'll also take a look at some of the most important health data that came from the national health survey exercises, as well as learn about current efforts to provide affordable health insurance for the poor and government health initiatives like the National Health Missions.
Healthcare Context in India
A national health service offering universal healthcare for all residents was established and advocated by the Health Survey and Development Committee (Bhore Committee) in a report submitted in 1946. The report's main points were the free supply of basic healthcare through a public health system. The Ministry of Health established the Mudalier Committee in 1959 to evaluate how effective the first and second five-year plans were. Following the Alma Ata Declaration in 1983, India drafted the country's first national healthcare plan. The second NHP was adopted in 2002. The National Rural Health Mission was introduced by the Ministry of Health and Family Welfare in 2005 in accordance with the National Health Policy of 2002. The mission of NRHM was to offer everyone access to high-quality, affordable healthcare. The National Urban Health Mission (NUHM) was established in 2014. The National Health Mission was formed by the union of NRHM and NUHM. Under the NHM, a number of cutting-edge programs were launched, and the healthcare system was enlarged. Increases in institutional births and a drop in infant and mother mortality rates in rural regions are linked to the NHM's expansion of healthcare facilities and conditional cash transfer programs (Janani Suraksha Yojana).
The primary, secondary, and tertiary healthcare facilities that make up the nation's three-tiered public health system are funded by the government. Sub Centers, Primary Health Centers, and Community Health Centers offer primary healthcare in rural areas. Local health workers provide services for maternity and child health care as well as disease control in subcentres that serve a population of 3000-5000 people. The Primary Health Centers, which serve 20,000–30,000 people and act as the referral center for 5–6 subcenters, offer curative and preventive care. Community health centers with thirty beds, a laboratory, and X-ray equipment are designed to serve 80,000–120,000 people. They are staffed by four health professionals and twenty-one paramedics. The secondary tier serving the rural population is district hospitals. The complex public healthcare system struggles to operate effectively because there are so few doctors available.
International norms, sustainable development goal (SDG-3) and Universal health care (UHC)
Good health and wellbeing is the third Sustainable Development Goal (SDG-3), which reaffirms global collaboration and commitment in the effort to lower morbidity and death. In sub-Saharan Africa, child deaths from avoidable diseases, maternal deaths, and teenage fatalities from HIV-AIDS remain a reason for worry despite reducing newborn and maternal mortality, deaths from HIV and Malaria, and child deaths from preventable diseases. Goal 3 of the Sustainable Development Goals (SDG) aims to address these problems by promoting universal healthcare, immunization campaigns, placing an emphasis on reproductive healthcare services, ensuring access to medications, and lowering the prevalence of communicable diseases like HIV-AIDS, tuberculosis, and malaria.
Globally, there has been an increasing focus on Universal Healthcare (UHC). The acceleration of the transition to universal access to high-quality, affordable healthcare services was mandated by UNGA Resolution in 2012. (WHO and WB 2015:6). According to a recent WHO report, universal healthcare is defined as "all people receiving the health services they require, including health initiatives designed to promote better health (like anti-tobacco policies), prevent illness (vaccinations), and to provide treatment, rehabilitation, and palliative care of sufficient quality to be effective...while making sure that these services do not subject user to financial hardship" (ibid:7). First, UHC aims to expand the availability of health services. Secondly, giving populations financial security makes it possible for them to get medical care.
Reducing the financial burden on households to pay for the high cost of healthcare is one of UHC's objectives. The cost that households pay directly to healthcare providers for whatever health services they consume is known as an out-of-pocket (OOP) payment. The category of OOP expenditure includes payments made to any sort of healthcare provider, including formal healthcare workers, informal/alternative practitioners, clinics, health centers, pharmacies, or hospitals. Typically, household indirect costs like transportation, food, and lodging are not taken into account when calculating OOP, despite the fact that they can place a significant financial strain on households (WHO and WB 2015:40). OOP payments typically decrease when government spending on healthcare rises. Compared to people who reside in high-income countries, those in low- and middle-income countries spend more money out of pocket on their health.
National health policy
A national health policy was established by the Indian government in 2017. Reducing maternal and infant mortality rates, extending life expectancy, lowering fertility rates, providing universal health coverage, and ensuring everyone has cheap access to diagnostic tools are some of the major concerns covered by the NHP 2017.
The NHP also suggests increasing public health spending as a percentage of GDP from the current 1% to 2.5%. The NHP also advocates for everyone's access to healthcare as a fundamental right. Combating non-communicable diseases is being prioritized more than in the past. Public-private partnerships are seen as the most effective way to provide everyone with quality healthcare at a reasonable price. Primary healthcare services will be paid for through taxes and health insurance (Roy 2017). Public sector provisioning will target disadvantaged groups like scheduled tribes and non-communicable and occupational disorders (ibid). The report's main focus is on contracting and purchasing services from various private suppliers, both for profit and nonprofit organizations. Primary care would receive a larger percentage of the health budget (around two thirds). Increasing life expectancy at birth from 67.5 years to 28 by 2019, lowering the under-five mortality rate to 23 by 2025, and hitting the 2020 global HIV target are some of the major goals emphasized by the NHP 2017.
Some analysts claim that the NHP 2017 demonstrates particular policy changes. Goals to update the primary healthcare system to provide more comprehensive care, including for non-communicable diseases, are among the declared policy changes that appear to reverse some of the steps achieved during the 1990s structural adjustment (Sundararaman 2017).
The National Health Program (NHP) 2017 transitions from the delivery of selective care at the primary level to more comprehensive treatment with connections to referral hospitals. Additionally, it eliminates user fees and cost recovery at public hospitals to provide everyone with free medications, diagnostics, and emergency care (ibid). Additionally, the policy seeks to build a cadre of public health managers and enhance personnel in remote public health facilities. The new strategy also gave health technology and research development a boost (ibid). The NHP also intends to improve district- and sub-district-level public hospitals, as well as some of them by turning them into teaching centers (EPW 2017). The NHP suggests that in order to enhance primary health care delivery, AYUSH practitioners and paramedical personnel should work together in primary health centers, and doctors should be required to practice in rural areas (EPW 2017). The Doha Declaration's advice to make vital medications accessible to all countries by avoiding patents and licenses—now included in SDG11—is not taken into account by the strategy (ibid). Additionally, it fails to establish health as a legal right, as specified in the draft policy for 2015.
The NHP 2017 has received criticism for the policy's increased emphasis on the private sector. In India, the national GDP is currently allocated 1.3% on health. Although the NHP 2017 plans to raise this percentage to 2.5%, the deadline for achieving this goal is 2025.
What should the government's function be in terms of basic healthcare in India? In discussions on health policy, the state's regulatory rather than its provisional role is being emphasized more and more. Through a multitude of regulatory measures, including hospital accreditation, digitized patient data, and the implementation of safety standards, state intervention should "complement" rather than "substitute" market solutions. According to some critics, "information asymmetry" causes market failures, and it is the responsibility of the state to offer safeguards against this occurrence.
The main question in the discussion over universal healthcare is how to make basic healthcare services accessible and affordable for everyone. Health insurance is one of the frequently employed tools for attaining this. Who would finance this health system and what kind of health system would be able to offer the services required to achieve universal healthcare? How may those with jobs in the unorganized sector sign up for social insurance? What types of contributions would be required of them? Tax funds as well as contributions from individuals, companies, and organizations can be used to pay for health insurance. Prerequisites for successful implementation include administrative competence to collect taxes and relative greater incomes. Basic healthcare for the underprivileged and at-risk populations requires transfers from the wealthy or the government (ibid). The lack of qualified healthcare workers in India, particularly in rural areas and their unequal distribution, would provide specific difficulties in ensuring enough coverage for everyone.
Cost of healthcare and who is paying for it
Millions of people have fallen into poverty as a result of high healthcare costs. "The absolute costs per outpatient visit in rural and urban areas increased between 1986–1987 and 2004, particularly harming the ability of the poorest individuals to obtain care," claim some analysts. Both the public and private sectors have seen an increase in costs, although the private sector has seen an increase far more quickly (> 100%). Drug costs have been rising over time at a rate that is at least twice as fast as the general price increase, accounting for 70–80% of out-of-pocket expenses for outpatients (Balarajan et al 2011).
In the period between 2004 and 2005, public spending on health, including outside funding, accounted for 22% of total spending while private spending accounted for 78%. Donor finance was once available for some types of targeted health programs, but has since been significantly decreased. Family planning, malaria, immunization, and other diseases are covered by these programs. Only 10% of the public funding and 2% of all government spending in the reference year came from outside contributors. India's public health spending is lower than those of its neighbors Sri Lanka, China, and Thailand. Comparing the same countries, the share of private expenditure in total health spending per person is significantly larger than the share of state expenditure.
Health insurance
In India, only 10% of households in 2004–05 had at least one family member with health insurance. Only a limited portion of the population (such as central government employees) is able to receive full medical insurance that includes outpatient and inpatient care under the Central Government Health Scheme, in addition to the modest and dispersed coverage offered by state and central programs. A group of persons who work in a factory with more than 10 employees are also covered by the Employees State Insurance Scheme. Only 7% of India's working population was employed in the organized sector in 2004–2005; the vast majority of its working population is employed in agriculture and the informal sector. Regularly paying into a medical insurance premium is neither practicable nor cheap for this segment of the impoverished and vulnerable population. Collecting modest amounts of premium from a big population would likewise be expensive. (ibid)
The Ministry of Labour and Employment launched the Rashtriya Swasthya Bima Yojana (RSBY) in 2008 as a health insurance program for families living below the poverty line and specific types of unorganized employees. In 2015–16, 41.3 million people signed up for this program. The program's goal is to promote healthcare service accessibility and cost. Under the Central Government Health Scheme and Employees State Insurance Scheme, respectively, a tiny portion of the general population, public sector employees, and industry workers can receive free health care (Gupta and Bhatia undated). 15 Less than 20% of the populace had any type of health insurance.
Health surveys
In order to plan and monitor health programs as well as develop health policies, acquiring health information is a crucial part of every country's health system. The National Family Health Survey (NFHS), the District Level Household Survey (DLHS), and the Annual Health Survey are a few of the surveys carried out in India (AHS). In comparison to the DLHS, the yearly health survey is carried out in India's least developed countries with a greater sample size . District-level information on mother and child health programs is obtained using the DLHS (ibid). The AHS is implemented by the office of the registrar general of India, and the first baseline survey was carried out in 2010–2011. All three surveys have primarily focused on reproductive, maternal, and child health (ibid).
In 1992–1993, 1998–1999, 2005–2006, and 2015–2016, the Ministry of Health and Family Welfare, in partnership with other organizations, performed four rounds of the National Family Health Survey (NFHS). The NFHS-4's objectives are to give information on significant indicators of the population, health, welfare of families, prevention of malaria, migration-HIV, and noncommunicable illnesses. In 640 districts, members of 601,509 households from 28583 sample units, including villages and urban regions, were interviewed in the local tongue using 4 survey schedules (household women, men, and bio-marker) (Ram et al 2017).
When compared to NFHS-3 results, NFHS-4 reveals improvements in institutional births and prenatal care, showing the impact of the government's JSSY and JSSK cash transfer programs on enhancing mother and child health. In both rural and urban areas, the percentage of women obtaining four or more prenatal care visits increased. Utilization of antenatal care was associated with mothers' socioeconomic status and was significantly greater among wealthy women, those with completed their secondary education, and those who did not belong to underprivileged social groups (SC, ST and OBC). With larger proportions among moms with better education levels and wealthier households, institutional birthing has improved for all. Between the two survey rounds, the average age at which women were getting married rose in every state. Only a very slight increase in the sex ratio was observed nationally for children under the age of six, going from 914 to 919. (female per thousand male). Delhi, Haryana, Punjab, Rajasthan, and Uttarakhand had the lowest sex ratios. Nationally, the average fertility rate has decreased from 2.7 to 2.2 children per woman. The proportion of children (12-23 months) who have received all recommended vaccinations rose from 44% to 62%. Immunization rates are correlated with household income, social class, and mothers' educational attainment (ibid). Although it has decreased compared to earlier survey rounds, the degree of malnutrition among youngsters has remained relatively high. Practices related to mother and child health are still shaped by additional household social inequities.
Maternal and child health have always been a primary focus of India's large-scale health surveys. The large proportion of illnesses affecting children under the age of 15 and problems affecting mothers in India's overall disease burden was one of the reasons for this focus. Non-communicable diseases, or NCDs, are causing a rising proportion of illnesses and deaths, though. Some commentators contend that existing health surveys are not gathering enough data on NCD in India (Dandona etal 2015)
Mental health
In the context of India, mental health is a relatively underserved area of healthcare services. According to recent estimates, 15% of the world's cases of mental, neurological, and substance use problems are in India. The National Institute of Mental Health (NIMHANS) conducted a survey in 2015–16 that included twelve states in India and found that, although different types of mental illnesses affected 10.6% of the population, there was a significant gap (60%) in the treatment of those conditions, a lack of mental health professionals in the nation, and low priority given to mental health in the government's health agenda. In addition, households often spent a significant amount of money on accessing mental health care in the absence of adequate public support. People with mental problems may not seek medical attention because they are socially stigmatized. According to the NIMHANS report, nearly 80% of those with mental health issues did not receive any therapy during the 12-month reference period. An effort has recently been made to address this misalignment between people's mental health needs and national health priorities.
The Mental Health Act of 1987 was replaced in 2016 by the Mental Healthcare Bill. The human rights and dignity of those who suffer from mental health conditions are emphasized in the new bill. By allowing for audits, licensing, tribunals, and registrations, it enables closer examination of mental health facilities. In certain cases, involuntary hospitalization is permitted, and mental health commissions have been established, to which appeals may be submitted. In addition to making the state accountable for providing healthcare and training mental health experts, the Bill also decriminalizes suicide. The lack of explicit instructions regarding the financing of the proposed provisions and recommendations is one of the criticisms leveled at the bill (Jacob 2016).
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