HEALTH CARE REFORMS IN ANDHRA PRADEsh

Andhra Pradesh state profile------

Introduction --- The state of Andhra Pradesh was formed on 1st November, 1956
under the States' reorganization scheme. It is the fifth largest State with an area of 2,
76, 754 sq. km, accounting for 8.4 % of India's territory and also the fifth most
populous state with a Population of 75 crores. The state has varied physiographic
features ranging from high hills, undulating plains to a coastal deltaic environment.
Administratively, Andhra Pradesh is divided into 23 districts, 79 revenue divisions,
1123 mandals, about 27000 villages and 264 towns. AP's economy grew at 7.2%
during 2006-07 -- the fourth consecutive year of 6% plus growth. The latest poverty
headcount ratio stands at 16%, compared to 23% for India . the third-highest credit
rating among the major Indian states; the third best investment climate in the country;
and the fourth-lowest corruption level among Indian states Andhra Pradesh was the
first Indian state to receive a multi-sector Bank operation - the Andhra Pradesh
Economic Restructuring Program for US$ 550 million in 1997 - aimed at helping the
state accelerate policy and institutional reforms across a wide range of sectors under a
common fiscal framework. It is also the only Indian state where the Bank has
disbursed three budget support operations - the First Andhra Pradesh Economic
Reform Loan (APERL-1) in March 2002, the Second APERL in February 2004, and
the Third APERL in January 2007 - that sought to support the state's development
program.
HEALTH STATUS AND DEMOGRAPHICS OF THE STATE--------------------------

During the last few decades there is a considerable improvement in the health status
of the population in the State.
Andhra Pradesh Population by the end 2010 AD will be 10 crores. There has been
positive change in the demographic indicators particularly in the Total Fertility Rate
(TFR). The causes for this good performance are the all round efforts made to deliver
quality services and to increase health consciousness particularly among the rural
women. The positive trends in Andhra Pradesh on comparing national family health
survey 1993 and 1999 are--

1. Crude Birth Rate reduced from 24.1 to 22.3 per 1000

2. Higher order births reduced from 41.0% to 31.2%

3. Couple Protection Rate increased from 45.3% to 59.6%

4. Total Fertility Rate reduced from 2.6 to 2.25 per women.

5. Women receiving ante-natal care increased from 86.6% to 92.7%

6. Safe deliveries increased from 49.3% to 65.2%

7. Infant Mortality Rate declined from 70.4 to 65.8 per 1000 live births

8. Full immunization risen from 45% to 58.7%

State population policy-

The gains in family planning programme have been sustained over the recent years
also.The population stabilization objectives which form part of the policy statement
are ----

Reduction in the fertility rate through-----

1. Promotion of use of spacing methods: minimum spacing of 2 years before

first birth and 3-5 years between 1st and 2nd births.

2. Promotion of use of terminal methods with concentration on couples with 2

children and above.
 3. Increasing the use of male contraceptive methods.

Reduction in MMR through--------

1. Increase in coverage of pregnant women with tetanus toxoid, IFA tablets and
other

ante-natal care from the current level of 86% to 100% by 2000 A.D

2. Increase in institutional deliveries (current level 32.9%) and domiciliary

deliveries by

medical and para medical personnel and trained traditional birth attendants

3. Improved referral systems for emergency obstetric care.

4. Increase in accessibility to quality services for medical termination of

pregnancies and for treatment of reproductive tract infections.

Reduction in IMR/CMR through----------

1. Eradication of polio cases and deaths by 1998.

2. Elimination of neo-natal tetanus by 1998.

3. Elimination of measles deaths by 1998.

4. Sustained universal immunization of children.

Resource allocation in health care sector----

The state government has increased the health expenditure from 1500 crores in 2001
to more than 80000 crores at present.
Health Finance Indicators---

Health Finance indicators provide an understanding of patterns of investments,

expenditure, sources of funding and proportion of allocation vis-à-vis other total
allocation. It also provides an important tool to understand health outcomes in relation
to the expenditure.
Health Finance Indicators include allocations under Five Year Plans, details of
expenditures on health, trends in public and private spending.
HEALTH CARE DELIVERY INFRASTRUCTURE IN ANDHRA PRADESH------

Primary Health Care delivery------

Service Facility number

Primary Health Centres 1386

Sub Centres 10568

Mobile medical units 45

Urbanfilariacontrol units 28

Filaria clinics 4

Filaria survey units 2

District TB Centres 24

Leprosy control units 104

Secondary Health Care delivery----

Service facility Number

District Hospitals 20

Area Hospitals 56

Community Health Centres 117

Others (MCH) 8

C.D. Hospitals 2

Civil Dispensaries 25

Total 228

Service facility Bed Strength

District Hospitals 5250

Area Hospitals 5600

Community Health Centres 4640

Speciality Hospitals 500

C.D. Hospitals 324

All institutions’ beds 16314

Staff available----

Medical 1900

Nursing 4199

Paramedical 2519

All others 2733

Total 11351

STATE GOVT. STRATEGIC PRINCIPLES-------

a. Universal access to primary and secondary health care.

b. Strengthening tertiary care in existing Government Hospitals.

c. Focus on communicable diseases.

d. Increasing role for Indian Systems of Medicine.

e. Strengthening process of institutional development.

f. Setting up self-supporting health insurance scheme.

g. Increase community participation.

h. Establishment of village level health workers and provide trained community

health workers in the village areas.

i. In the urban slums the system of link volunteers, each one catering to the basic
health needs of 20 families will be strengthened.

j. Institute a regular health camp approach where the PHC Medical Officer and his
staff will hold camps in a minimum of 2 villages every week.
STRATEGIES FOR PREVENTION AND CONTROL OF COMMUNICABLE
DISEASES

A) Communicable diseases have to be controlled through serious efforts by

Government machinery at field level involving Non-Governmental Organisations ,
Self-Help Groups and community. This is possible only if Panchayat Raj Bodies and
Municipal Bodies take effective steps for controlling mosquito breeding and supply of
safe drinking water to the people.
B) Government has decided to appoint two High Level Expert Committees to suggest
measures to control communicable diseases. A National workshop was conducted
whose recommendations are available in regard to measures to be taken to control
communicable diseases.

C) State Level Action Plan

Action plans are being prepared to tackle diseases like (a) tuberculosis (b) Blindness
(c) Leprosy and (d) Filaria.
Respective departments will identify the problem and prepare action plans to reduce
the levels of diseases by 20 percent every year. These plans have to be made at the
State level and later on District level plans have to be prepared
D) Training Programmes

Training programmes are also planned for all levels of staff and Non-government
organizations and self-help groups for prevention and control of communicable
diseases.

E) AIDS Prevention and Control Programme---------

a) Andhra Pradesh has a population of 7 million people. As of November 2000 the

State has reported 6463 HIV infections in Andhra Pradesh, out of which 67 people
have AIDS. The prevalence of HIV positive is 28.5% among the attendees of STD
Clinic and 2.25% among the attendees of Antenatal clinic.

b) The State has established 28 STD clinics to diagnose and treat STD patients out of
which 20 clinics are strengthened in terms of equipment and provision of medicines.
The incidence of STD in the state is showing an upward trend from 17942 cases in
1996, to 22627 cases in 2001 which is more than 25%.

c) The State Government is committed to bring awareness, knowledge and

understanding about HIV/AIDS, prevention and transmission in general population
and to bring about desired behavioural change of seeking information on HIV/AIDS
and condom use involving NGO’s, electronic and print media, out door publicity.

d) It is proposed to provide the AIDS Testing facilities in all the District Head
Quarters Hospitals. Necessary training will be imparted to the staff and posted to the
AIDS detection centres.
f) Training programmes also will be taken up for the Dai’s and RMP s who can play
vital role in educating the community about the HIV and AIDS disease.

Disposable syringes and needles and waste disposal system will be adopted in all the
Public Health Institutions as a policy.

Health sector Reforms in Andhra Pradesh are looked upon in accordance with
five year plans by central government.

The Eighth Five Year Plan (1992-1997) was the first plan document to state the
need for re-structuring of economic management systems, following the macro
developments of the 1990s. it introduced the concept of free medical care and people
were required to pay, even if partially, for the health services

The Ninth Five Year Plan (1997-2002) emphasized the need to review the response
of the public, voluntary and private sector health care providers as well as the
population themselves to the changing health scenario, to reorganize health services to
bring about greater efficiency and effectiveness and to introduce health system
reforms to enable the population to obtain optimum care at affordable cost .

The Ninth Plan sought to increase the involvement of voluntary, private organizations
and self-help groups in the provision of health care and ensure inter-sectoral
coordination in implementation of health programmes and health-related activities as
well as enable the Panchayati Raj Institutions (PRI) in planning and monitoring of
health programmes at the local level so as to bring about greater responsiveness to
health needs of the people and greater accountability; to promote inter-sectoral
coordination and utilise local and community resources for health care .

The Tenth Five Year Plan (2002-2007) touches upon reforms at primary, secondary
and tertiary level(3).

Compatibility of state govt. initiative with central govt. five

year plans-----

The goals, priorities, and the strategies, variations in the commitment are largely
decided through the political contingencies. There are competing demands on the
health systems. The evolution of the health systems is largely shaped by the culture,
history, and norms.
The Government has taken several steps for improving the public health care
institutions and Strengthening the primary health care infrastructure. However, the
situation is compounded by severe resource constraints - financial, technical and
human power related, which has resulted in policy makers as well as programme
managers at differing levels being faced with difficult choices
 One of the major reform initiatives underway is the Secondary Health System
Strengthening Project funded by the World Bank in seven states (Andhra Pradesh,
Karnataka, Punjab, West Bengal, Maharashtra, Orissa and Uttar Pradesh). The
projects include strengthening FRUs /CHCs and district hospitals so as to improve the
availability of emergency care services to patients, to reduce overcrowding at district
and tertiary care hospitals, construction works, procurement of equipment, increased
availability of ambulances, drugs; improvement in quality of services following skill
up gradation training in clinical management, changes in attitudes and behaviour of
health care providers; reduction in mismatches in health personnel / infrastructure;
improvement in hospital waste management, disease surveillance and response
system.
It is essential to assess both progress and problems in implementation of the reforms
in each state and to appropriately modify the content and pace of implementation.
In the Indian Constitution, health is a state responsibility. During Adjustment, many
state governments in India had recourse to Health Systems Development Project loans
from the World Bank for carrying out health sector reforms (HSR), of which one of
the key policies has been to raise public spending on health care from the abysmally
low levels seen up to then. The Health Systems Development Project seeks to develop
strategic management capacity; strengthen performance, accountability, and
efficiency; and build implementation capacity. Further, it seeks to improve clinical
service quality by renovating and expanding district, sub district, and community
hospitals and improving access to services. In ANDHRA PRADESH , around 15% of
the total project cost is borne by the state governments. All the project documents
note the low levels of funding for secondary hospitals in the reforming states. This is
attributed to the small share of overall public spending allotted to health, the limited
portion of total health spending going to hospitals, and, within this, a skewed
distribution of funds in favour of the tertiary hospitals.
Govt . of AP have took the responsibility which are: (i) to enhance the overall size of
the health budget; (ii) to redress imbalances in public expenditure between secondary
and tertiary care levels; (iii) to safeguard the operations and maintenance components
of current expenditure allocations for the secondary health-care sector; (iv) to charge
user fees for selected services; and (v) to address workforce issues. The Health
Systems Development Project initiated in state recognizes the need for enhanced
public spending on health and identifies it as the foremost policy reform to be
pursued.Andhra Pradesh is the first state to go with the HSR.

Within AP there are regional, social and gender disparities. Health outcomes are
worst among Scheduled Castes (16% of population) and Scheduled Tribes (7% of
population), especially those living in underserved areas in North tribal and South
drought prone districts, and for women. Effective delivery of quality basic health
services is hampered by demand and supply side issues, including poor health
infrastructure and staffing.
The reform history in health sector in the State can be traced to Andhra Pradesh
First Referral Health System Project, one of the first World Bank aided health system
projects in the country. This project, launched in 1995 had been implemented by AP
Vaidya Vidhana Parishad (APVVP). Agencies like World Bank and DFID are
supporting the reform process in the State. The Bank supported the AP Economic
Restructuring Project which included improvement of primary health care as one of
the component.
 The priority reforms focus on improved access to quality and responsive health
services, strengthened governance and management in health sector, improved
institutional mechanisms for community participation and systems for accountability;
and strengthened financial management systems.
The government of Andhra Pradesh Vision 2020 document identifies a seven-point
set of priorities for health sector reform:

1. providing universal access to primary healthcare;

2. encouraging private investment in tertiary healthcare;
3. focusing on specific programmes to promote family planning;
4. focusing on improving health levels in disadvantaged groups and backward
regions;
5. ensuring a strong prevention focus;
6. enhancing the performance of the public health system;
7. formulating a state information education and communication (IEC) programme to
broadcast information on preventive healthcare.

The Government of Andhra Pradesh is embarking on a major health sector reforms to

improve health care delivery in the State. D.F.I.D. has expressed its willingness to
support these initiatives with a grant of 100 Million pounds in five years (2006-2011).
The reform initiative will include measures to improve the effectiveness and
accountability of public health services, measures to focus on community centric
preventive healthcare system and enhance access to quality healthcare for the poorer
sections of the population
The sector support will build synergy with National Rural Health Mission (NRHM)
which is a health sector reform program of the central government for
decentralisation, pro-poor focus, strengthening service delivery.
The health sector support will be provided over three years (2007-08 - 2009- 10). It
aims at increased use of quality health services, especially by the poorest people and
in underserved areas. The main outputs will be:
a) Improved access to quality and responsive services, especially in remote and
interior areas;
b) Governance and management of health sector strengthened;
c) Institutional mechanisms for community participation and systems for
accountability in functioning; and Financial management systems strengthened and
improved public expenditure on health.

The performance of health services would be measured against-----------------

* greater effectiveness and improved outcomes of existing programs;

* improved efficiency in the allocation of resources;
* greater access and equity; and
* consumer satisfaction

REFORMS CLASSIFIED IN FIVE YEAR PLANS AND THEIR

IMPLEMENTATION BY THE STATE GOVT.----
1. Reorganization and restructuring of existing government health care system
–

Establishment of Andhra Pradesh Vaidya Vidhana Parishad

Strengthening of referral institutions and fixing of service norms
Improvement in drug supplies
Formation of Andhra Pradesh Health, Medical & Housing Infrastructure Development
Corporation (APHM&HIDC)
Strengthening of PHCs as 24-hour MCH centers
Establishment of Comprehensive Obstetric & Neonatal Care (CEmONC) centres

2. Changes in health system organisation, delivery and Management

Formation of Hospital Advisory Committee/ Hospital Development Societies for all

PHCs and FRUs/ teaching hospitals
Provision of free travel bus passes to pregnant women for antenatal check ups
Public Private Partnership

3. Changes in financing methods

Sukhibhava Scheme (Improvement of Institutional Delivery Services Scheme)

User fees

4. Reforms related to human resources

Integration and responsibilities of functionaries for planning, implementation and

monitoring of programmes of HM & FW department

5. Involving community in health service delivery and Provision

Women Health Volunteers Scheme

6. Reforms to quality of care

Performance indicators for grading the PHCs
Performance rating of secondary hospitals

GOALS OF HEALTH CARE PLANNING IN ANDHRA PRADESH------

i) Every person will have access to responsive basic health care and specialised

health care at affordable prices.

ii. Women will have safe and successful pregnancies

iii. Infant/child mortality due to ailments like Diarhoea will be reduced drastically.

iv. The spread of AIDS will be contained.

v. Communicable diseases like GE, Malaria and TB will be effectively prevented.

vi. Families will be small and better spaced

vii. Equitable access to quality health care will be ensured

viii Health sector will be equipped to deliver quality services for non-communicable
diseases . trauma and injury cases.

ix. Life expectancy levels will reach 68 years males and 70.6 years for females
from current 62 to 64 respectively.

x. Ensuring equality and access to affordable health care.

xi. Enhancing technical efficiency of key programs and clinical effectiveness.

xii. Ensuring micro/macro economic effectiveness in the use of resources

xiii. Improving quality of care /consumer satisfaction

INITIAL INITIATIVES----
The following steps were initiated which shall contribute to the overall improvements
in the health sector.

1. PHCs and secondary Hospitals Grading

2. All Systems of Medicine under one roof Ayurveda, Homeo ,Unani in DH, AH
& CHCs.

3. Master Health check up periodic speciality Medical camps.

4. Blood Banks in all DH, AH & CHCs on National Highway.

5. Health Check ups in schools and welfare hostels.

6. Incentives & Disincentives.

7. Affiliation for DNB (Family Medicine) in all District Hospitals.

8. To all advanced diagnostic facility including Telemedicine to all district level

through public private participation by taking the help of corporate sector.

9. Clean & green programmes and horticulture development in all hospitals.

GAPS IN HEALTH DELIVERY IN THE STATE---

 1. Inadequate ENVIRONMENTAL MONITORING ; environment being an
important factor in consideration for planning and implementing health
programmes.
2. Occupational safety is needed to be considered in detail.
3. Nutritional deficiencies must be targeted also like communicable diseases.
4. Inter sectoral coordination should be there.

Recommendations ---
1. Trained HR----------------- reduces cost
Improves service quality
Reduces service delivery time.
Better coordination
2. Incorporation of the technology driven system in health care system.
3. Planning, implementation and monitoring should be decentralized to ensure
adequate control at district level.

THANKYOU.