ECONOMICS ASSIGNMENT

GOVERNMENTS POLICY WITH RESPECT TO

HEALTH
SYBcom.
Div: B
Roll No: 146, 147, 148, 149, and 150

ACKNOWLEDGEMENT
We are thankful to Prof. Ravikiran Garje for giving such a wonderful opportunity to explore the health
challenges before our country & governments initiatives to overcome it. Thank You.
INDEX
1. Introduction
2. Challenges confronting public health
3. Roll of government within health sector
4. Role of government in enabling intersectoral coordination toward public
health issues
5. Indias health care initiatives
6. Governments health expenditure
7. High level export group on health coverage
8. 12
th

Five year plan
9. Health issues
10. Health care system
11. conclusion








INTRODUCTION
The practice of public health has been dynamic in India, and has witnessed many hurdles in its
attempt to affect the lives of the people of this country. Since independence, major public health
problems like malaria, tuberculosis, leprosy, high maternal and child mortality and lately, human
immunodeficiency virus (HIV) have been addressed through a concerted action of the
government. Social development coupled with scientific advances and health care has led to a
decrease in the mortality rates and birth rates. India has a universal health care system run by the
constituent states and territories of India. The Constitution charges every state with "raising the
level of nutrition and the standard of living of its people and the improvement of public health as
among its primary duties". The National Health Policy was endorsed by the Parliament of
India in 1983 and updated in 2002. Parallel to the public health sector, and indeed more popular
than it, is the private medical sector in India. Both urban and rural Indian households tend to use
the private medical sector more frequently than the public sector, as reflected in surveys. India
has a life expectancy of 64/67 years (m/f), and an infant mortality rate of 46 per 1000 live births.
CHALLENGES CONFRONTING PUBLIC HEALTH
The new agenda for Public Health in India includes the epidemiological transition (rising burden
of chronic non-communicable diseases), demographic transition (increasing elderly population)
and environmental changes. The unfinished agenda of maternal and child mortality, HIV/AIDS
pandemic and other communicable diseases still exerts immense strain on the overstretched
health systems.
Silent epidemics: In India, the tobacco-attributable deaths range from 800,000 to 900,000/year,
leading to huge social and economic losses. Mental, neurological and substance use disorders
also cause a large burden of disease and disability. The rising toll of road deaths and injuries
(25 million hospitalizations, over 100,000 deaths in 2005) makes it next in the list of silent
epidemics. Behind these stark figures lies human suffering.
Health systems are grappling with the effects of existing communicable and non-communicable
diseases and also with the increasing burden of emerging and re-emerging diseases (drug-
resistant TB, malaria, SARS, avian flu and the current H1N1 pandemic). Inadequate financial
resources for the health sector and inefficient utilization result in inequalities in health. As issues
such as Trade-Related aspects of Intellectual Property Rights continue to be debated in
international forums, the health systems will face new pressures. The causes of health
inequalities lie in the social, economic and political mechanisms that lead to social stratification
according to income, education, occupation, gender and race or ethnicity. Lack of adequate
progress on these underlying social determinants of health has been acknowledged as a glaring
failure of public health. In the era of globalization, numerous political, economic and social
events worldwide influence the food and fuel prices of all countries; we are yet to recover from
the far-reaching consequences of the global recession of 2008.
ROLE OF GOVERNMENT WITHIN THE HEALTH
SECTOR
Health system
Health system strengthening
Important issues that the health systems must confront are lack of financial and material
resources, health workforce issues and the stewardship challenge of implementing pro-
equity health policies in a pluralistic environment. The National Rural Health Mission
(NRHM) launched by the Government of India is a leap forward in establishing effective
integration and convergence of health services and affecting architectural correction in the
health care delivery system in India.
Health information system
The Integrated Disease Surveillance Project was set up to establish a dedicated highway of
information relating to disease occurrence required for prevention and containment at the
community level, but the slow pace of implementation is due to poor efforts in involving
critical actors outside the public sector. Health profiles published by the government should
be used to help communities prioritize their health problems and to inform local decision
making. Public health laboratories have a good capacity to support the government's
diagnostic and research activities on health risks and threats, but are not being utilized
efficiently. Mechanisms to monitor epidemiological challenges like mental health,
occupational health and other environment risks are yet to be put in place.
Health research system
There is a need for strengthening research infrastructure in the departments of community
medicine in various institutes and to foster their partnerships with state health services.
Regulation and enforcement in public health
A good system of regulation is fundamental to successful public health outcomes. It reduces
exposure to disease through enforcement of sanitary codes, e.g., water quality monitoring,
slaughterhouse hygiene and food safety. Wide gaps exist in the enforcement, monitoring
and evaluation, resulting in a weak public health system. This is partly due to poor financing
for public health, lack of leadership and commitment of public health functionaries and lack
of community involvement. Revival of public health regulation through concerted efforts by
the government is possible through updating and implementation of public health laws,
consulting stakeholders and increasing public awareness of existing laws and their
enforcement procedures.
Health promotion
Stopping the spread of STDs and HIV/AIDS, helping youth recognize the dangers of tobacco
smoking and promoting physical activity. These are a few examples of behavior change
communication that focus on ways that encourage people to make healthy choices.
Development of community-wide education programs and other health promotion activities
need to be strengthened. Much can be done to improve the effectiveness of health
promotion by extending it to rural areas as well; observing days like Diabetes day and
Heart day even in villages will help create awareness at the grassroots level.
Human resource development and capacity building
There are several shortfalls that need to be addressed in the development of human
resources for public health services. There is a dire need to establish training facilities for
public health specialists along with identifying the scope for their contribution in the field.
The Public Health Foundation of India is a positive step to redress the limited institutional
capacity in India by strengthening training, research and policy development in public
health. Preservice training is essential to train the medical workforce in public health
leadership and to impart skills required for the practice of public health. Changes in the
undergraduate curriculum are vital for capacity building in emerging issues like geriatric
care, adolescent health and mental health. Inservice training for medical officers is essential
for imparting management skills and leadership qualities. Equally important is the need to
increase the number of paramedical workers and training institutes in India.
Public health policy
Identification of health objectives and targets is one of the more visible strategies to direct
the activities of the health sector, e.g. in the United States, the Healthy People 2010 offers
a simple but powerful idea by providing health objectives in a format that enables diverse
groups to combine their efforts and work as a team. Similarly, in India, we need a road map
to better health for all that can be used by states, communities, professional organizations
and all sectors. It will also facilitate changes in resource allocation for public health
interventions and a platform for concerted intersectoral action, thereby enabling policy
coherence.
Scope for further action in the health sector
School health, mental health, referral system and urban health remain as weak links in
India's health system, despite featuring in the national health policy. School health
programs have become almost defunct because of administrative, managerial and logistic
problems. Mental health has remained elusive even after implementing the National Mental
Health Program.On a positive note; innovative schemes through public-private partnerships
are being tried in various parts of the country in promoting referrals. Similarly, the much
awaited National Urban Health Mission might offer solutions with regards to urban health.
ROLE OF GOVERNMENT IN ENABLING
INTERSECTORAL COORDINATION TOWARD PUBLIC
HEALTH ISSUES
The Ministry of Health needs to form stronger partnerships with other agents involved in
public health, because many factors influencing the health outcomes are outside their direct
jurisdiction. Making public health a shared value across the various sectors is a politically
challenging strategy, but such collective action is crucial.
Social determinants of health
Kerala is often quoted as an example in international forums for achieving a good status of
public health by addressing the fundamental determinants of health: Investments in basic
education, public health and primary care.
Living conditions
Safe drinking water and sanitation are critical determinants of health, which would directly
contribute to 70-80% reduction in the burden of communicable diseases. Full coverage of
drinking water supply and sanitation through existing programs, in both rural and urban
areas, is achievable and affordable.
Urban planning
Provision of urban basic services like water supply, sewerage and solid waste management
needs special attention. The Jawaharlal Nehru National Urban Renewal Mission in 35 cities
works to develop financially sustainable cities in line with the Millennium Development
Goals, which needs to be expanded to cover the entire country. Other issues to be addressed
are housing and urban poverty alleviation.
Revival of rural infrastructure and livelihood
Action is required in the following areas: Promotion of agricultural mechanization,
improving efficiency of investments, rationalizing subsidies and diversifying and providing
better access to land, credit and skills.
Education
Elementary education has received a major push through the Sarva Siksha Abhayan. In
order to consolidate the gains achieved, a mission for secondary education is essential.
Right of children to Free and Compulsory education Bill 2009 seeks to provide education
to children aged between 6 and 14 years, and is a right step forward in improving the
literacy of the Indian population.
Nutrition and early child development
Recent innovations like universalization of Integrated Child Development Services (ICDS)
and setting up of mini-Anganwadi centers in deprived areas are examples of inclusive
growth under the eleventh 5-year plan. The government needs to strengthen ICDS in poor-
performing states based on experiences from other successful models, e.g., Tamil Nadu
(upgrading kitchens with LPG connection, stove and pressure cooker and electrification; use
of iron-fortified salt to address the burden of anemia). Micronutrient deficiency control
measures like dietary diversification, horticultural intervention, food fortification,
nutritional supplementation and other public health measures need intersectoral
coordination with various departments, e.g., Women and Child Development, Health,
Agriculture, Rural and Urban development.
Social security measures
The social and economic spinoff of the Mahatma Gandhi Rural Employment Guarantee
Scheme (MREGS) has the potential to change the complexion of rural India. It differs from
other poverty-alleviation projects in the concept of citizenship and entitlement. However,
employment opportunities and wages have taken the center stage, while development of
infrastructure and community assets is neglected. This scheme has the necessary manpower
to implement intersectoral projects, e.g., laying roads, water pipelines, social forestry,
horticulture, anti-erosion projects and rain water harvesting. The unlimited potential of
social capital has to be effectively tapped by the government.
Food security measures
Innovations are required to strengthen the public distribution system to curb the inclusion
and exclusion errors and increase the range of commodities for people living in very poor
conditions. It is essential that the government puts forth action plans to increase domestic
food grain production, raise consumer incomes to buy food and make agriculture
remunerative.
Other social assistance programs
The Rashtriya Swasthiya Bima Yojana and Aam Admi Bhima Yojana are social security
measures for the unorganized sector (91% of India's workforce). The National Old Age
Pension scheme has provided social and income security to the growing elderly population
in India.


Population stabilization
There is all round realization that population stabilization is a must for ensuring quality of
life for all citizens. Formulation of a National Policy and setting up of a National
Commission on Population and Janasankhya Sthiratha Kosh reflect the deep commitment
of the government. However, parallel developments in women empowerment, increasing
institutional deliveries and strengthening health services and infrastructure hold the key to
population control in the future.
Gender mainstreaming and empowerment
Women-specific interventions in all policies, programs and systems need to be launched.
The government should take steps to sensitize service providers in various departments to
issues of women. The Department of Women and Child Development must take necessary
steps to implement the provisions of Protection of Women from Domestic Violence Act,
2005. Training for protection officers, establishment of counseling centers for women
affected by violence and creating awareness in the community are vital steps. Poverty
eradication programs and microcredit schemes need to be strengthened for economic and
social empowerment of women.
Reducing the impact of climate change and disasters on health
Thermal extremes and weather disasters spread of vector-borne, food-borne and water-
borne infections, food security and malnutrition and air quality with associated human
health risks are the public health risks associated with climate change. Depletion of non-
renewable sources of energy and water, deterioration of soil and water quality and the
potential extinction of innumerable habitats and species are other effects. India's National
Action Plan on Climate Change identifies eight core national missions through various
ministries, focused on understanding climate change, energy efficiency, renewable energy
and natural resource conservation. Although there are several issues concerning India's
position under UNFCCC, it has agreed not to allow its per capita Greenhouse gas emissions
to exceed the average per capita emissions of the developed countries, even as it pursues its
social and economic development objectives.
The Ministry of Health, in coordination with other ministries, provides technical assistance
in implementing disaster management and emergency preparedness measures. Deficient
areas include carrying out rapid needs assessment, disseminating health information, food
safety and environmental health after disasters and ensuring transparency and efficiency in
the administration of aid after disasters. Implementation of Disaster Management Act,
2005 is essential for establishing institutional mechanisms for disaster management,
ensuring an intersectoral approach to mitigation and undertaking holistic, coordinated and
prompt response to disaster situations.
Community participation
Community participation builds public support for policies and programs, generates
compliance with regulations and helps alter personal health behaviors. One of the major
strategic interventions under NRHM is the system of ensuring accountability and
transparency through people's participation the Rogi Kalyan Samitis. The Ministry of
Health needs to define a clear policy on social participation and operational methods in
facilitating community health projects. Potential areas of community participation could be
lifestyle modification in chronic diseases through physical activity and diet modification,
and primary prevention of alcohol dependence through active community-based methods
like awareness creation and behavioral interventions.
Private sectors, civil societies and global partnerships
Effective addressing of public health challenges necessitates new forms of cooperation with
private sectors (public-private partnership), civil societies, national health leaders, health
workers, communities, other relevant sectors and international health agencies (WHO,
UNICEF, Bill and Melinda Gates foundation, World Bank).
Governance issues
In order to ensure that the benefits of social security measures reach the intended sections
of society, enumeration of Below Poverty Line families and other eligible sections is vital.
Check mechanisms to stop pilferage of government funds and vigilance measures to stop
corruption are governance issues that need to be attended. The government should take
strict action in cases of diversion of funds and goods from social security schemes through
law enforcement, community awareness and speedy redressal mechanisms. Social audits in
MREGS through the Directorate of Social Audit in Andhra Pradesh and Rajasthan are early
steps in bringing governance issues to the fore. This process needs strengthening through
separate budgets, provisions for hosting audit results and powers for taking corrective
action. Similar social auditing schemes can be emulated in other states and government
programs like ICDS, which will improve accountability and community participation,
leading to effective service delivery.

An introduction to Indias healthcare initiatives
Over the post-independence years India has launched several health
programs. In this article we highlight a few such programs that have
improved or have the potential to improve the health of Indias
populace.
National Rural Health Mission (NRHM), Ministry of Health and
Family Welfare
Health is a State subject and the Government of India has always tried to work in
partnership with States to meet peoples needs wrote Mr. Ghulam Nabi Azad,
Minister, Ministry of Health and Family Welfare, in a 5 year progress update of the
NRHM. NRHM was launched in 2005 to provide accessible health services in rural
areas. This agenda involved building infrastructure and healthcare staff with a
female accredited social health activist (ASHA) in every village. The NRHM has
been quite successful in achieving several of its projected targets. NRHM has
significantly reduced the incidences of several diseases by increasing the
number of health facilities (primary health centers and hospitals), care providers
(ASHAs, doctors, nurses and paramedic staff) and community education.
However, all of the NRHMs expected outcomes have not materialized and there
continues to be a critical shortage of trained medical professionals and access to
medications.
National AIDS Control Organization (NACO), Department of AIDS
NACO aims to prevent HIV infection as well as offering support to HIV/AIDS
patients. Its mission is accomplished by educating, counseling and testing services.
Latest reports indicate that the number of new HIV infections has fallen by 50-
60% and the current HIV/AIDS population, in India, is approximately 2 to
3.1million (3.4-9.4 million in 2002). However, infection rates continue to be high
or increasing among certain subsets of the Indian population, that is, males (60%),
those aged 15-49 years (89%), drug abusers (9%), homosexual males (6%) and
female sex workers (5%).
Kerala Primary Health Care Model
In the 1990s, Kerala, aided by the high literacy rate (and hence high number of
trained medical professionals) as well as organized local governance, embarked on
a systematic approach of community involvement to establish a functional primary
health care (PHC) centre in every village. Kerala attained an enviable drop in its
infant and maternal death rates and increased life expectancy, at birth, to 70-76
years well above the national average of 63-65 years. However, this model
needs to be augmented with resources to address illnesses such as acute diarrhea
diseases, measles, pneumonia, pulmonary tuberculosis and dengue.
High-potential game-changers
Besides inadequate infrastructure resources and medication inaccessibility the
single-most weak point in Indias public health care change is the lack of qualified
doctors and medical staff a crucial connection between the patient and health
services. Today, India produces only 50-60% of the doctors it requires for its
medical needs of which only 2% join primary and community health centres to
service 70% of its rural population. In order to address these shortages, the
government has initiated and proposed several programs. A few of them are
outlined below
Government
Initiative
Purpose Issue(s) addressed
Telemedindia
(Telemedicine in
Combines information and
communication technologies (ICT)
To increase healthcare services
and education to rural (and
India)
with Medical Science for clinical
records, diagnostic tests, video
consultations and medical education
(several government and private
healthcare networks established)
remote) parts or under
emergency conditions
Compulsory
Licensing
Grant non-patent holder(s)
permission to manufacture patented
drugs not available at an affordable
price (1
st
grant for cancer drug
Nexavar in March 2012)
To increase accessibility to
medications
Bachelor of Rural
Health Care
(BRHC)
A 3 year rural health care course
(proposed in Rajya Sabha)
To increase rural healthcare
professionals
National
Programme for
Healthcare of the
Elderly (NPHCE)
To be test-launched in 100 districts
of the country in 2012-17.
To reduce the incidence of
non-communicable illnesses in
the elderly
National
Programme for
Prevention and
Control of Cancer,
Diabetes,
Cardiovascular
Diseases and Stroke
(NPCDCS)
To be test-launched along with
NPHCE in 100 districts of the
country in 2012-17
To reduce the incidence of
lifestyle/modern/developed
world diseases
Free Medicines for
All
Rs 28,560 crore plan to provide 348
medicines for all and must-prescribe
generic drugs mandate to doctors
(proposed 2012-2017)
To increase accessibility to
medications
Healthcare for All
by 2020
All residents will have healthcare
coverage via a combination of
public, employer and private sources.
An entitlement package will include
treatments, health promotion and
disease prevention (proposed)
To uphold the fundamental
right of all citizens to adequate
health care
The Indian government is making a serious attempt to ensure the robust health of
its citizens by implementing a variety of programs and schemes. The long-term
success is eagerly awaited though difficult to predict.


Governments Health expenditure

INTRODUCTION
It is well known that health expenditure in India is dominated by private spending.
To a large extent this is a reflection of the inadequate public spending that has been
a constant if unfortunate feature of Indian development in the past half century.
This is particularly unfortunate feature of the large positive externalities associated
with health spending, which make health spending a clear merit good. The greater
reliance on private delivery of health infrastructure & health services therefore
means that overall these will be socially underprovided by private agents, & also
denies adequate access to the poor. This in turn has adverse affects current social
welfare & labour productivity, & of course harms future growth & development
prospects.
This is why the perceptions that government spending on health has been further
undermined during the period of economic liberalization since the early 1990s
create concern, & need to be investigated. This study seeks to examine the actual
pattern of government spending on health & related areas (particularly, family
welfare & child development) by both central & state governments. In this section,
the theoretical arguments for public intervention & need for public expenditures in
health are discussed, & the international experience in this regard is considered. In
the following section, the broad patterns of aggregate health spending in India are
analyzed, along with the shares of public & private expenditure & the significance
of health spending in household budgets. The 3
rd
section contains an analysis of
central government budgets on health, family welfare & child development over the
period 1993-94 to 2003-04. The 4
th
section takes up the health budgets of state
governments, with special attention to patterns in 15 major states. The 5
th
section
considers some of the implications for health outcomes not only life expectancy,
infant mortality & similar indicator, but also evidence on morbidity. Some of the
recently released results of NFHS-3 for 5 states are considered in relation to the
evidence on government health expenditure in these states. The final section draws
some preliminary conclusions & suggests areas of future research & specific
question that merit more detailed investigation in the basis of these conclusions.

THE THEORETICAL CASE FOR PUBLIC EXPENDITURE
ON HEALTH

There is a consensus among social scientists that health care is different from other
goods & services, because of greater likelihood of market failure. The two main
characteristics of health care which lead to market failure & thus necessitate state
intervention are the presence of externalities, the operation of market forces alone
would lead to sub-optimal consumption & production of the relevant goods or
service. This necessitates state intervention in order to ensure that sufficient
resources are directed to the production of such goods or services, which in turn
would result in an increase in the societys welfare.
It has been argued that such externalities are less evident for general health care
services such as physician & hospital care & greater in the area broadly known as
public health. The latter relate to interventions targeted at overall conditions of
nutrition & sanitation that determine health, as well as communicable diseases
which are passed either directly among humans or indirectly through the physical
environment.
An action taken by one person (e.g. ensuring clean, safe water, immunizing oneself
against, or seeking treatment for, a communicable disease) generates direct health
benefits for other individuals, through reduced rates of disease. Clearly, purely
market-oriented or individually based activities would ignore the wider positive
external effects, & therefore yield less than socially optimal levels of such activity.
However, even general health care services hat apparently affect only individuals
have positive externalities, not only because of the social costs of morbidity, but
because inequalities in health care create other social concerns. These positive
externalities make government intervention essential. Such intervention can take
the form of price subsidies to encourage or spread the consumption of health care
services, or direct public provision of such services.
The international experience

Health expenditure is highly unequal across the globe. As is to be expected, the
developed countries spend the most on health per person. OECD countries
accounted for less than 20% of the worlds population in the year 2000 but were
responsible for almost 90% of the worlds health spending. Therefore 80% of worlds
population spent only 10% of the total expenditure on health. This includes people
in the Asia-Pacific as well as African & Latin American Countries. Africa accounts
for about 25% of the global burden of disease but only about 2% of global health
spending. (World Health Report, 2003).
Similarly, health expenditure, both in terms of percentage of GDP spent on health
& per capita health expenditure, is much higher in the developed countries, as
evident from Table 1. The share of GDP spent on health ranges from a low of 1.6%
in Azerbaijan to 13.9% in the USA. Similarly there is a very wide variation of per
capita health expenditure across countries, which is typically extremely low in
developing countries compared with most of the developed countries. The range in
2001 was from $14 in Ethiopia to $4877 in the USA.
SOURSE: World Health Report 2003, Human Development 2003 & UNTCAD
Report 2002.

II. Patterns of health expenditure in India
The first systematic analysis of the distribution of health spending in India by
source of funds was published in the National Health Accounts of India, 2001-02.
The results are shown in Chart 1, and confirm the widespread perception that
private households account for the bulk of health expenditure. According to this
estimate, households accounted for more than two-thirds of health spending in the
country, and around three times the amount of all government expenditure taken
together, by central, state and local governments. Employers (firms) account for
only 5 per cent, but what is especially notable is the negligible role played by both
external sources and others including NGOs. Despite the reported increase in
foreign aid for dealing with HIV-AIDS and similar issues, all external sources taken
together accounted for only 2 per cent of total health spending1, while NGOs
accounted for only 0.3 per cent.
More recent estimates suggest that the role of households has increased even more
substantially in the most recent period. According to the Report of the National
Commission on Macroeconomics and Health, 2005, households undertook nearly
three-fourths of all the health spending in the country. Public spending was only 22
per cent, and all other sources accounted for less than 5 per cent. As Table 2 shows,
both the per capita spending and the share of households in this varied widely
across states. Per capita spending in the state with the highest rate (Goa) is nearly
7 times that of per capita spending in the state with the lowest per capita spending
(Meghalaya). Interestingly, the share of household spending is lowest in Meghalaya,
but was among the highest in Bihar which has relatively low per capita spending.
There are many states where households undertake more than 80 per cent of all
health spending, indicating an exceptionally high burden upon them. 1 However,
some foreign aid that going directly to governmental sources is included in the
health expenditure of central and state governments.



III. Central Government Health Expenditure Since 1993
One of the more obvious indicators of inadequacy of public health spending in
India is the very small amount of such spending relative to GDP. In developed
countries, especially those with ageing populations, government health spending
accounts for around 5% of GDP or more. Even in Asian developing countries
excluding India, the average is around 3% of GDP. This makes it quite remarkable
that India, which is currently seen internationally as an economic powerhouse &
one of the success stories of global economic growth is the past decade, has
government health expenditure amounting to less than 1% of GDP. Further, this
ratio is not only low internationally, but is even low compared to past experience. As
Chart 3 shows, even in the mid-1980s, health expenditure of central & state
government taken together was more than 1% of GDP, but now it is only around
0.9%. Further, it has fallen as low as around 0.8% in 2001-02. It is also significant
that a greater proportion is taken up by revenue expenditure (essentially, the
payment of salaries) rather than capital expenditure for creating much-needed basic
physical infrastructure.
Health is a concurrent subject under the Indian Constitution, but state
governments are dominantly responsible for most health provision, both curative &
public health aspects. However, in addition to direct central government spending
on specific budget items, there is a range of centrally mandated expenditures which
are also effectively spent by state governments, as well as some joint spending.
While there are some specific central interventions, especially various Missions as
well as high-end curative facilities, the bulk of the health provision that affects
most of the citizenry is the result of spending by state governments. The National
Rural Health Mission, which is a very recent central programme, involves only
central expenditure. In contrast to public health, expenditure on family welfare by
the central government appears to have increased in the aggregate as well as per
capita. Within aggregate family welfare, the most important segment is family
welfare services, which has accounted for around as increasing part of the total,
from 38% in 1993-94 to 73% in 2006-07. Except for 2000-01, when both the
aggregate & per capita spending on family welfare services fell, this broad category
has shown a generally increasing trend, even in per capita terms.
IV. Health Expenditure of 14 state governments since 1993
According to the Indian Constitution, the health sector falls under the concurrent
list & thus, the provision of public health care in India is a responsibility shares by
both the Central & State governments. For state government health expenditure,
the financing responsibility is this primarily that of the state government with some
overlapping responsibilities in a series of centrally sponsored schemes. As noted
earlier, state governments account for about two-thirds & the centre about one-
third of the total public spending on health. However, there are of course large
variations in this ratio across states.
The total health budgetary allocation of any state government in India mainly
consists of expenditures on the medical, public health & on the family welfare. In
the allocation of medical health, the major head that are covered are the allocations
on urban health services, rural health services & medical education & training. The
other major heads are the expenditures on the public health & family welfare. Here
we analyze the behavior of the per capita health allocations under these major
heads since 1993-94 to 2002-03 for 14 major states in India. (Bihar has been
excluded because of data inadequacies.)
In general, the budgetary head of family welfare showed much greater variation
across the sub-periods than the other category. In states of Karnataka, Tamil Nadu,
Uttar Pradesh & West Bengal, the rate of growth of budgetary allocations on
Family Welfare increased in the second sub-period, despite declines in the rate of
growth of total budgetary allocations. In Orissa, the opposite trend is clearly visible,
with accelerated spending on medical & public health, but accelerated declines in
spending on family welfare.
Of course, what is more significant than aggregate spending is the per capita public
spending on health & family welfare. This show very large variation across states,
as is evident the absolute levels & change in per capita spending between 1993-94 &
2001-02 for the 14 states considered here.
What is even more remarkable is the number of states that show a decline in real
per capita spending under this head. In seven states- Assam, Gujarat, Haryana,
Madhya Pradesh, Orissa, and Punjab & Uttar Pradesh there were declines in per
capita spending on family welfare in constant price terms. Once again, this decline
has been sharpest in the Madhya Pradesh where the absolute level was already
very low. But the declines are significant even in Punjab & Haryana, which are
among wealthier states. Andhra Pradesh & Karnataka had growing allocations in
terms, & relatively high per capita expenditure.
In most of the states there is a wide rural-urban disparity in the per capita
budgetary allocations of the state. The only exceptions to this are the states of
Punjab & Rajasthan, where the real per-capita allocations in the rural & the urban
health sectors have been almost at par. These two states the per capita allocations
in the rural areas in the early 1990s even exceeded those in the urban areas, though
marginally. However, subsequently urban has outpaced rural per capita
expenditure even in these states, in line with the trend in other states and All-
India.
With reference to the rural-urban disparity, an interesting trend is exhibited by the
state of Assam. While urban per capita allocations showed a declining trend, rural
per capita allocation in the rural sector suggest a slightly rising trend. Real per
capita allocation for urban areas came down from Rs. 34.05 in 1993 to 11.49 in
2002-03. However, the same allocation for rural areas has gone up from Rs. 14.11 in
1993-94 to 18.57 in 2002-03, & is now significantly higher than the urban
allocation.
V. Evidence on health outcomes
It is fairly obvious that these low & in several cases declining levels of spending on
health & related items would have an impact on conditions of health among the
citizenry, especially given that most of the population is poor & cannot afford to
spend too much on health even if they are forced to spend more & more for private
care. One major fallout of inadequate public spending that was highlighted in the
first section is the high proportion of total health spending in India that is incurred
by households, which is in sharp contrast to the picture in most other countries.
Also, this pattern has worsened over time. The growing proportion of household
consumption expenditure that is devoted to health, also noted in the first section, is
at least partly if not substantially the result of inadequate or reduced public
provision.
VI. Conclusions & directions for further research
This is a preliminary study which has sought to consider the broad patterns of
government spending on health & related areas in India in the recent past, & link
them to observed health outcomes. The analysis has been conducted both at the
central government level & for 14 major states. A number of important conclusions
have been

High Level Expert Group on Universal
Health Coverage
Pre-HLEG recommendations on Health for all
The idea of health care for all was present, though not explicitly, in the
(i) BHORE COMMITTEE Report of 1946;
(ii) The Sokhey Committee report of 1948
(iii) National Health Policy of Health 1983 and 2002.
India is also a signatory to the Universal Declaration of Human Rights that
recognizes the right to a standard of living adequate for the health and well-
being of himself and of his family" The idea was re-emphasized when India
endorsed the "Health for All" declaration in Alma Ata in 1978 and endorsed
the conclusions of the 1994 International Conference on Population and
Development (ICPD) in Cairo
Formation, members, and mandate
The High-Level Expert Group (HLEG) on Universal victor (UHC) was constituted
by the Planning Commission of India in October 2010, under the chairmanship of
Prof. K. Srinath Reddy, with the mandate of developing a framework for providing
easily accessible and affordable health care to all Indians. The other members of the
expert group are: Abhay Bhang (Society for Education, Action and Research in
Community Health), A.K. Shiva Kumar (member, National Advisory Council),
Amarjeet Sinha (senior IAS officer), Anu Garg (Principal Secretary-cum-
Commissioner (Health and Family Welfare department, Orissa), Gita Sen (Centre
for Public Policy, IIM Bangalore), G.N. Rao (Chair of Eye Health, L.V. Prasad Eye
Institute, Hyderabad), Jashodhara Dasgupta (SAHYOG, Lucknow), Leila Caleb
Varkey (Public Health researcher), Govinda Rao (Director, National Institute of
Public Finance and Policy), Mirai Chatterjee (Director, Social Security, SEWA),
Nachiket Mor (Sughavazhu Healthcare), Vinod Paul (AIIMS), Yogesh Jain (Jan
Swasthya Sahyog, Bilaspur), a representative of the Ministry of Health and Family
Welfare, and N.K. Sethi (Advisor (Health), Planning Commission).
Definition of Universal Health Coverage
HLEG defined UHC for the purpose of report as follows:
Ensuring equitable access for all Indian citizens, resident in any part of the country,
regardless of income level, social status, gender, caste, or religion, to affordable,
accountable, appropriate health services of assured quality (promotive, preventive,
curative, and rehabilitative) as well as public health services addressing the wider
determinants of health delivered to individuals and populations, with the government
being the guarantor and enabler, although not necessarily the only provider, of health
and related services
Recommendations of the High Level Expert Group (HLEG)
The recommendations of the High Level Expert Group (HLEG) on Universal Health
Coverage encompass the area of health financing, health services norms, human
resources for health, community participation and citizen engagement, access to
medicines, vaccines and technology and management and institutional reforms. The
recommendations of the HLEG, inter-alia, include:
Increase public expenditure on health to at least 2.5 percent of GDP by the end of
the 12th Plan and to at least 3% of GDP by 2022.
Ensure availability of free essential medicines by increasing public spending on
drug procurement.
Purchase of all health care services under the Universal Health Coverage (UHC)
system should be undertaken either directly by the Central and state
governments through their Departments of Health or by quasi-governmental
autonomous agencies established for the purpose.
All government funded insurance schemes should, over time, be integrated with
the UHC system. All health insurance cards should, in due course, be replaced
by National Health Entitlement Cards. The technical and other capacities
developed by the Ministry of Labour for the Rashtriya Swasthya Bima Yojana
should be leveraged as the core of UHC operations and transferred to the
Ministry of Health and Family Welfare.
Develop a National Health Package that offers, as part of the entitlement of
every citizen, essential health services at different levels of the health care
delivery system.
Reorient health care provision to focus significantly on primary health care.
Strengthen District Hospitals.
Ensure adequate numbers of trained health care providers and technical health
care workers at different levels by
a) giving primacy to the provision of primary health care
b) Increasing Human Resources for Health (HRH) density to achieve
WHO norms of at least 23 health workers (doctors, nurses, and midwives).
Establish District Health Knowledge Institutes (DHKIs).
Establish the National Council for Human Resources in Health (NCHRH).
Transform existing Village Health Committees (or Health and Sanitation
Committees) into participatory Health Councils.
Ensure the rational use of drugs.
Set up national and state drug supply logistics corporations.
Empower the Ministry of Health and Family Welfare to strengthen the drug
regulatory system.
Introduce All India and state level Public Health Service Cadres and a
specialized state level Health Systems Management Cadre in order to give
greater attention to public health and also strengthen the management of
the UHC system.
Establishment of National Health Regulatory and Development Authority
(NHRDA).
National Drug Regulatory and Development Authority (NDRDA): The main
aim of NDRDA should be to regulate pharmaceuticals and medical devices
and provide patients access to safe and cost effective products.

TWELFTH FIVE YEAR PLAN

Strategy
Based on the recommendation of HLEG and other stakeholder consultations, the
key elements of Twelfth Five Years plan strategy is outlined. The long term
objective of this strategy is to establish a system of Universal Health Coverage
(UHC) in the country. Following are the 12th plan period strategy:
1. Substantial expansion and strengthening of public sector health care
system, freeing the vulnerable population from dependence on high cost
and often unreachable private sector health care system.
2. Health sector expenditure by central government and state government,
both plan and non-plan will have to be substantially increased by the
twelfth five year plan. It was increased from 0.94 per cent of GDP in
tenth plan to 1.04 per cent in eleventh plan. The provision of clean
drinking water and sanitation as one of the principal factors in control of
diseases is well established from the history of industrialized countries
and it should have high priority in health related resource allocation. The
expenditure on health should increase to 2.5 per cent of GDP by the end
of Twelfth Five Year Plan.
3. Financial and managerial system will be redesigned to ensure efficient
utilization of available resources and achieve better health outcome.
Coordinated deliveries of services within and across sectors, delegation
matched with accountability, fostering a spirit of innovation are some of
the measures proposed.
4. Increasing the cooperation between private and public sector health care
providers to achieve health goals. This will include contracting in of
services for gap filling, and various forms of effectively regulated and
managed Public-Private Partnership, while also ensuring that there is no
compromise in terms of standards of delivery and that the incentive
structure does not undermine health care objectives.
5. The present Rashtriya Swasthya Bhima Yojana (RSBY) which provides
cash less in-patient treatment through an insurance based system should
be reformed to enable access to a continuum of comprehensive primary,
secondary and tertiary care. In twelfth plan period entire Below Poverty
Line (BPL) population will be covered through RSBY scheme. In planning
health care structure for the future, it is desirable to move from a 'fee-for-
service' mechanism, to address the issue of fragmentation of services that
works to the detriment of preventive and primary care and also to reduce
the scope of fraud and induced demand.
6. In order to increase the availability of skilled human resources, a large
expansion of medical schools, nursing colleges, and so on, is therefore is
necessary and public sector medical schools must play a major role in the
process. Special effort will be made to expand medical education in states
which are under-served. In addition, a massive effort will be made to
recruit and train paramedical and community level health workers.
7. The multiplicity of Central sector or Centrally Sponsored Schemes has
constrained the flexibility of states to make need based plans or deploy
their resources in the most efficient manner. The way forward is to focus
on strengthening the pillars of the health system, so that it can prevent,
detect and manage each of the unique challenges that different parts of
the country face.
8. A series of prescription drugs reforms, promotion of essential, generic
medicine and making these universally available free of cost to all
patients in public facilities as a part of the Essential Health Package will
be a priority.
9. Effective regulation in medical practice, public health, food and drugs is
essential to safeguard people against risks and unethical practices. This
is especially so given the information gaps in the health sector which
make it difficult for individual to make reasoned choices.
10. The health system in the Twelfth Plan will continue to have a mix of
public and private service providers. The public sector health services
need to be strengthened to deliver both public health related and clinical
services. The public and private sectors also need to coordinate for the
delivery of a continuum of care. A strong regulatory system would
supervise the quality of services delivered. Standard treatment guidelines
should form the basis of clinical care across public and private sectors,
with the adequate monitoring by the regulatory bodies to improve the
quality and control the cost of care.


Criticism
The 12th five year plan document on health has received a lot of criticism for its
limited understanding of universal health care and failure to increase public
expenditure on health. While the HLEG report recommends an increase in
public expenditure on health from 1.58 per cent of GDP currently to 2.1 per cent
of GDP by the end of 12th five year plan it is far lower than the global median of
5 per cent. The lack of extensive and adequately funded public health services
pushes large numbers of people to incur heavy out of pocket expenditures on
services purchased from the private sector. Out of pocket expenditures arise
even in public sector hospitals, since lack of medicines means that patients have
to buy them. This results in a very high financial burden on families in case of
severe illness. Though, the 12th plan document express concern over high out-of-
pocket (OOP) expenditure, it does not give any target or time frame for reducing
this expense. OOP can be reduced only by increasing public expenditure on
health and by setting up wide spread public health service providers. But the
planning commission is planning to do this by regulating private health care
providers. It takes solace from the HLEG report which admits that, "the
transformation of Indias health system to become an effective platform for UHC
is an evolutionary process that will span several years".
Instead of developing a better public health system with enhanced health
budget, 12th five year plan document plans to hand over health care system to
private institutions. The 12th plan documents express concern over Rashtriya
Swasthya Bhima Yojana being used as a medium to hand over public funds to
private sector through insurance route. This has also incentivized unnecessary
treatment which in due course will increase costs and premiums. There has
being complaints about high transaction cost for this scheme due to insurance
intermediaries. RSBY does not take into consideration state specific variation in
disease profiles and health needs. Even though these things are acknowledged
in the report, no alternative remedy is given. There is no reference to nutrition
as key component of health and for universal Public Distribution System (PDS)
in the plan document or HLEG recommendation. In the section of National
Rural Health Mission (NRHM) in the document, the commitment to provide 30-
50 bed Community Health Centers (CHC) per lakh population is missing from
the main text. It was east for the government to recruit poor women as ASHA
(Accredited Social Health Activist) workers but it has failed to bring doctors,
nurses and specialist in this area. The ASHA workers who are coming from a
poor background are given incentive based on performance. These people lose
many days job undertaking their task as ASHA worker which is not incentivized
properly. Even the 12th plan doesn't give any solace.

Quality
The quality of Indian healthcare is varied. In major urban areas, healthcare is of
adequate quality, approaching and occasionally meeting Western standards.
However, access to quality medical care is limited or unavailable in most rural
areas, although rural medical practitioners are highly sought after by residents
of rural areas as they are more financially affordable and geographically
accessible than practitioners working in the formal public health care sector.
Health issues
Malnutrition
According to a 2005 report, 42% of Indias children below the age of three were
malnourished, which was greater than the statistics of sub-Saharan African
region of 28%.Although Indias economy grew 50% from 20012006, its child-
malnutrition rate only dropped 1%, lagging behind countries of similar growth
rate. Malnutrition impedes the social and cognitive development of a child,
reducing his educational attainment and income as an adult. These irreversible
damages result in lower productivity.
High infant mortality rate
Approximately 1.72 million children die each year before turning one. The under
five mortality and infant mortality rates have been declining, from 202 and 190
deaths per thousand live births respectively in 1970 to 64 and 50 deaths per
thousand live births in 2009. However, this decline is slowing. Reduced funding
for immunization leaves only 43.5% of the young fully immunized. A study
conducted by the Future Health Systems Consortium in Murshidabad, West
Bengal indicates that barriers to immunization coverage are adverse geographic
location, absent or inadequately trained health workers and low perceived need
for immunization. Infrastructure like hospitals, roads, water and sanitation are
lacking in rural areas. Shortages of healthcare providers, poor intra-partum and
newborn care, diarrheal diseases and acute respiratory infections also contribute
to the high infant mortality rate.
Diseases
Diseases such as dengue fever, hepatitis, tuberculosis, malaria and pneumonia
continue to plague India due to increased resistance to drugs. In 2011, India
developed a totally drug-resistant form of tuberculosis. India is ranked 3rd
highest among countries with the amount of HIV-infected patients. Diarrheal
diseases are the primary causes of early childhood mortality. These diseases can
be attributed to poor sanitation and inadequate safe drinking water in
India. India also has the world's highest incidence of However in 2012 India was
polio-free for the first time in its history. This was achieved because of the Pulse
Polio Programme started in 1995-96 by the government of India.
Indians are also at particularly high risk for atherosclerosis and coronary artery
disease. This may be attributed to a genetic predisposition to metabolic
syndrome and adverse changes in coronary artery vasodilatations. NGOs such
as the Indian Heart Association and the Medwin Foundation have been created
to raise awareness of this public health issue.

Hepatitis
Based on the prevalence of Hepatitis B carrier state in the general population,
countries are classified as having high (8% or more), intermediate (2-7%), or low
(less than 2%) HepatitisB, virus(HBV) endemicity. India is at the intermediate
endemic level of hepatitis B, with hepatitis B surface antigen (HBsAg)
prevalence between 2% and 10% among the populations studied. The
prevalence does not vary significantly by region in the country. The number of
HBsAg carriers in India has been estimated to be over 40 million (4 crore). The
prevalence of Hepatitis C is estimated to be in the range of 1.8-2.5 per cent.
Poor Sanitation
As more than 122 million households have no toilets, and 33% lack access to
latrines, over 50% of the population (638 million) defecate in the open.(2008
estimate) This is relatively higher than Bangladesh and Brazil (7%) and China
(4%). Although 211 million people gained access to improved sanitation from
19902008, only 31% use the facilities provided. Only 11% of Indian rural
families dispose of stools safely whereas 80% of the population leave their stools
in the open or throw them in the garbage. Open air defecation leads to the
spread of disease and malnutrition through parasitic and bacterial infections.
Safe drinking water
Access to protected sources of drinking water has improved from 68% of the
population in 1990 to 88% in 2008. However, only 26% of the slum population
has access to safe drinking water, and 25% of the total population has drinking
water on their premises. This problem is exacerbated by falling levels of
groundwater caused mainly by increasing extraction for irrigation. Insufficient
maintenance of the environment around water sources, groundwater pollution,
excessive arsenic and fluoride in drinking water pose a major threat to India's
health.



Female health issues
Women's health in India involves numerous issues. Some of them include the
following:
Malnutrition: The main cause of female malnutrition in India is the tradition requiring
women to eat last, even during pregnancy and when they are lactating.
Breast Cancer: One of the most severe and increasing problems among women in
India, resulting in higher mortality rates.
Stroke
Polycystic ovarian disease (PCOD): PCOD increases the infertility rate in females.
This condition causes many small cysts to form in the ovaries, which can negatively
affect a woman's ability to conceive.
Maternal Mortality: Indian maternal mortality rates in rural areas are one of the
highest in the world.

Rural health
Rural India contains over 68% of India's total population, and half of all residents of rural areas
live below the poverty line, struggling for better and easy access to health care and services.
Health issues confronted by rural people are many and diverse from severe malaria to
uncontrolled diabetes, from a badly infected wound to cancer. Postpartum maternal illness is a
serious problem in resource-poor settings and contributes to maternal mortality, particularly in
rural India. A study conducted in 2009 found that 43.9% of mothers reported they experienced
postpartum illnesses six weeks after delivery.

Health care system

Public and private sector

According to National Family Health Survey-3, the private medical sector remains the primary
source of health care for 70% of households in urban areas and 63% of households in rural
areas. Reliance on public and private health care sector varies significantly between states.
Several reasons are cited for relying on private rather than public sector; the main reason at the
national level is poor quality of care in the public sector, with more than 57% of households
pointing to this as the reason for a preference for private health care. Other major reasons are
distance of the public sector facility, long wait times, and inconvenient hours of operation. The
study conducted by IMS Institute for Healthcare Informatics in 2013, across 12 states in over
14,000 households indicated a steady increase in the usage of private healthcare facilities over
the last 25 years for both Out Patient and In Patient services, across rural and urban areas.
National Rural Health Mission


A community health center in Kerala.
The National Rural Health Mission (NRHM) was launched in April 2005 by the Government of
India. The goal of the NRHM was to provide effective healthcare to rural people with a focus on
18 states which have poor public health indicators and/or weak infrastructure.
CONCLUSION
In this changing world, with unique challenges that threaten the health and well-
being of the population, it is imperative that the government and community
collectively rise to the occasion and face these challenges simultaneously, inclusively
and sustainably. Social determinants of health and economic issues must be dealt
with a consensus on ethical principles universalism, justice, dignity, security and
human rights.
This approach will be of valuable service to humanity in realizing the dream of Right
to Health. The ultimate yardstick for success would be if every Indian, from a remote
hamlet in Bihar to the city of Mumbai, experiences the change.
It is true that a lot has been achieved in the past: The milestones in the history of
public health that have had a telling effect on millions of lives launch of Expanded
Program of Immunization in 1974, Primary Health Care enunciated at Alma Ata in
1978, eradication of Smallpox in 1979, launch of polio eradication in 1988, FCTC
ratification in 2004 and COTPA Act of 2005, to name a few.
It was a glorious past, but the future of a healthy India lies in mainstreaming the
public health agenda in the framework of sustainable development. The ultimate
goal of great nation would be one where the rural and urban divide has reduced to a
thin line, with adequate access to clean energy and safe water, where the best of
health care is available to all, where the governance is responsive, transparent and
corruption free, where poverty and illiteracy have been eradicated and crimes against
women and children are removed a healthy nation that is one of the best places to
live in.



BIBLIOGRAPHY
wikipedia.org
economictimes.indiatimes.com
government website
www.ncbi.nlm.nih.gov