HEALTHCARE SYSTEMS IN INDIA

AMRITA SCHOOL OF DENTISTRY

1. HEALTHCARE SYSTEMS IN INDIA Seminar no: 9

2. CONTENTS Introduction Key events in evolution of healthcare system in India Organisation of healthcare system in India Primary healthcare in India Healthcare models  Role of insurance Major strategies to ensure quality of care Health disparities in India Electronic health records Major innovations and reforms Indian healthcare industry analysis Conclusion References 2

3. Source: World Development Indicators database DEMOGRAPHICS (2020) 3

4. National profile : Composition Total population – Approx. 1 Billion (2006) Health workers- 2 million Doctors- 39.6% Nurses and midwives- 0.5% Dentists- 1.2% Allopathic - 77.2% Ayurvedic, homeopathic or unani - 22.8% Pharmacists, ancillary health professionals, and traditional and faith healers- 28.8% National density Doctors - 79.7 per lakh population Nurses and midwives - 61.3 per lakh Dentists- 2.4 per lakh Male–female ratios Female- 38.0% Male–female ratio: 1:6, Doctors 5.1 4

5. Urban–rural disparities: Health workers in urban areas- 1 million Rural areas- 844 159 Urban–rural ratio of 1.45 Of all health workers, 59.2% were in urban areas and 40.8% were in rural areas Ratio of urban density to rural density for doctors - 3.8 Nurses and midwives- 4.0 Dentists- 9.9. Education and medical qualification: Allopathic doctors 31.4% were educated only up to secondary school level 57.3% did not have a medical qualification 83.4% of urban doctors had higher than secondary schooling compared to 45.9% of rural doctors 58.4% urban allopathic doctors had a medical qualification 18.8% of rural allopathic doctors 67.2% of females had a medical qualification compared to 37.7% of males. Nurses and midwives 67.1% had education only up to secondary school level. 11.3% of females had a medical qualification compared to 2.9% of males. 5

6. INTRODUCTION The health care system is intended to deliver the health care services. It constitutes the management sector and involves organizational matters; it operates in the context of the socioeconomic and political framework of the country. In India, it is represented by five major sectors or agencies which differ from each other by the health technology applied and by the source of funds for operation. 6

7. KEY EVENTS IN THE EVOLUTION OF INDIA’S HEATHCARE SYSTEM 7 1952-Community development Programme launched Central council of health constituted to coordinate health policies between central and state gov. 1958-Panchayati raj, three tier structure recommended Rajasthan was first state to introduce Panchayati raj

8. 8 Strengthening of administrative set up at different level from PHC to state health services. Separate staff for family planning Concept of people’s health in people’s hand Village health guide or community health volunteer. Integration of health services Elimination of private practice by gov. doctors Concept of people’s health in people’s hand Village health guide or community health volunteer.

9. 9 Ministry of A YUSH set up; to promote alternative medicine India declares its goal to eradicate TB by 2025 Ayushman Bharat- world’s largest public health insurance

10. ORGANISATION OF HEALTH SYSTEM IN INDIA 10

11. Organizational Structure In India India is union of 29 state and 7 union territories. Each state has developed it’s own system of health care delivery, independent of the central gov. The central gov. responsibility-policy making, planning, guiding, assisting, evaluating and coordinating work of all state ministers. The health system in India has 3 main links Central level Union ministry of health and family welfare The Directorate general of Health services The central council of Health and Family Welfare State level State Ministry of Health and Family Welfare State Health Directorate and Family Welfare Peripheral/local level 11

12. At central level 12

13. Directorate General of Health Services Principal adviser in both medical and public health matter Directorate-three main links Medical care and Hospitals Public Health General administration 13

14. Central Council of Health and Family Welfare Functions- To consider and recommend broad outline of policy regarding environment hygiene, nutrition and health education. To make proposal for legislations regarding medical and public health matter. To make recommendation to central gov. regarding distribution of grant. 14

15. At State level The State Health administration was started in1919 State list is responsibility of state including provision of Medical care Preventive health services. Pilgrimages within the state State Ministry of Health and Family Welfare Headed by Health Minister and Deputy Minister State Health Directorate and Family Welfare Administrative Officer-Director of Health Services Assisted by Deputy Director and Assistant Director Chief technical adviser relating to Medicine and Public Health 15

16. At district level 16

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18. Public Health Sector Primary Health Care Primary Health Centres Sub- Centres Hospitals / Health Centres Community Health Centres Rural Hospitals District Hospitals/ Health Centre Specialist Hospitals Teaching Hospitals Health Insurance Schemes Employees State Insurance(ESI) Central Government Health Scheme(CGHS) Ayushmann Bharath- NPHS Other Agencies Defence Services Railways Indigenous Systems Of India Ayurveda And Siddha Unani And Tibbi Homoeopathy Unregistered Practitioners Voluntary Health Agencies National Health Programmes Private Sector Private hospitals, polyclinics, nursing homes, and dispensaries General practitioners and clinics Health Care System in India 18

19. PRIMARY HEALTHCARE IN INDIA In 1977, the Government of India launched a Rural Health Scheme-on the principle of "placing people's health in people's hands". It is a three-tier system of health care delivery in rural areas based on the Shrivastav Committee in 1975. International conference at Alma-Ata in 1978, along with WHO set the goal “Health for All” by the year 2000, through primary health care approach. Government of India evolved a National Health Policy National Health Policy has a plan of action for reorienting and shaping the existing rural health infrastructure. 19

20. Village level One of the basic tenets of primary health care is universal coverage and equitable distribution of health resources. To implement this policy at the village level, the following schemes are in operation: Village Health Guides Scheme Training of local Dais ICDS Scheme (Integrated Child Development Services) ASHA scheme 20

21. Village Health Guides Introduced on 2nd October 1977 Scheme was launched in all states except Kerala, Karnataka, Tamil Nadu, Arunachal Pradesh and Jammu and Kashmir which had alternative systems (e.g., Mini-health Centers in Tamil Nadu) of providing health services at the village level. The Health Guides are chosen by the community in which they work. They serve as links between the community and the governmental infrastructure. After selection- a short training in the nearest PHC, sub centre or any other suitable place for the duration of 200 hours, over a period of 3 months. During the training period they receive a stipend of Rs. 200 per month. 21

22.  Local Dais An extensive Programme undertaken by the Rural Health Scheme, to train all categories of local dais (traditional birth attendants) to improve their concepts of maternal and child health and sterilization, under safe hygienic conditions reducing the maternal and infant mortality. The training is for 30 working days. Each dai is paid a stipend of Rs. 300 during her training period. Training is given at the PHC, subcenter or MCH (mother and child health) center for 2 days in a week, and on the remaining four days of the week they accompany the Health worker (Female) to the villages preferably in the dai's own area. During her training each dai is required to conduct at least 2 deliveries under the guidance and supervision of the HW (F), ANM or HA health assistant (F). 22

23. Anganwadi Worker ( Angan literally means a courtyard ) Under the ICDS (Integrated Child Development Services) Scheme, there are about 100 workers in each ICDS Project. As of date over 5320 ICDS blocks are functioning in the country. Trained in various aspects of health, nutrition, and child development for 4 months. S ervices rendered, includes health check­up, immunization, supplementary nutrition, health education, non-formal pre-school education and referral services. Along with Village Health Guides, the anganwadi workers are the community's primary link with the health services and all other services for young children. 23

24. Accredited Social Health Activist ( ASHA) scheme   The Government of India launched National Rural Health Mission (NRHM) in 2005 to address the health needs of rural population. ASHA’s : are volunteer health activists in the communities, creating awareness on health. mobilize the community towards local health service. increases utilization of the existing public health services. The general norm of selecting an ASHA is - ‘One ASHA per 1000 population’. ASHA must be primarily a woman resident of the village in the age group of 25 to 45 yrs. ASHA’s are selected by the District Health Society designate, a Block Nodal Officers, preferably Block Medical Officers, to facilitate the selection process. 24

25. Monitoring and evaluation: GOI has set up following indicators for monitoring ASHA. Process Indicators: Number of ASHAs selected by due process; Number of ASHAs trained, % of ASHAs attending review meetings after one year; Outcome Indicators: % of newborn who were weighed, and families counseled; % of children with diarrhoea who received ORS, % of deliveries with skilled assistance; % of institutional deliveries, % completely immunized in 12-23 months age group. % of unmet need for spacing contraception among BPL; % of fever cases who received chloroquine within first week in an malaria endemic area; Impact indicators : IMR; Child malnutrition rates; Number of cases of TB/leprosy cases detected as compared to previous year. 25

26. Sub- centre level: The sub- centre is the peripheral outpost of the existing health delivery system in rural areas. For every 5000 population in general and one for every 3000 population in hilly, tribal and backward areas. Functions are limited to mother and child health care, family planning and immunization. Each sub- centre is manned by one male and one female multipurpose health worker and is supervised by male and female health assistants. According to the revised norm, one female HA will supervise the work of 6 female HWs. The job descriptions of these workers have been published as manuals by the rural health division of the ministry of health and family welfare. 26

27. Primary Health Centre (PHC) The Bhore committee (1946) gave the concept of a PHC as a basic health unit, an integrated curative and preventive health care with preventive and promotive aspects of health care. The Central Council of Health at its first meeting held in January 1953 had recommended the establishment of primary health centers in community development block. The Mudaliar Committee in 1962 had recommended that the existing primary health centers should be strengthened and the population to be served by them to be scaled down to 40,000. The National Health Plan (1983) proposed that one PHC for every 30,000 rural population in the plains, and one PHC for every 20,000 population in hilly, tribal and backward areas for more effective coverage. 27

28. As on 31st March 2019, total primary health centers in the country is about 30,045 (Urban- 24,855 and rural- 5,190) Staffing pattern in PHC: At present in each community development block, there are 1 or more PHCs each of which covers 30,000 rural population. 3workers at the subcenter level and 9 or more workers at PHC level. Functions of the PHC The functions of PHC’s in India cover 8 "essential" elements of primary health care. They are: Medical care MCH including family planning Safe water supply and basic sanitation Prevention and control of locally endemic diseases Collection and reporting of vital statistics Education about health National Health Programmers - as relevant Referral services Training of health guides, health workers, local dais and health assistants Basic laboratory services 28

29. Community Health Centers As on 31st March 2019, 5335 community health centers were established by upgrading the primary health centers, each community health centre covering a population of to 1.20 lakh (one in each community development block) with 30 beds and specialists in different departments. For strengthening preventive and promotive aspects, a new non-medical post called community health officer has been created. The community health officer is selected from amongst the supervisory category of staff at the PHC and district level with minimum of 7 years experience in rural health programmers. The specialists at the community health center may refer a patient directly to the State level hospital or the nearest/ appropriate Medical College Hospital, as necessary, without the patient having to go first to the sub-divisional or District Hospital. There are 25 staff for CHC 29

30. FAMILY HEALTH CENTERS/ HEALTH AND WELLNESS CENTERS Caters to a population of 20000 to 30000 Provides curative care, preventive and promotive care, rehabilitative and palliative care to its beneficiaries Hub for coordination of all public health activities in an LSG area Renewing of “Family Doctor” concept Supervision & support of spokes (Sub centres ) Continuity of care established through e- health mechanism Other services includes: (Kerala) Pregnancy & childcare Management of NCDS : India Hypertension Management Initiative, Nayanamritam : screening for diabetic retinopathy Mental health: Sampoorna Manasikarogyam , Aswaas Clinics Amma Manass , School Mental Health Program Community based management of communicable diseases: Arogya Jagratha Campaign, Water Source Chlorination Wellness: Yoga training, play areas at workplaces Demand generation with Panchayati Raj Institutions ( PRI) involvement 30

31. MOHALLA CLINICS- AN INITIATIVE OF DELHI GOVERNMENT TO UNIVERSAL HEALTH COVERAGE Clinic was opened as part of a flagship Programme by the Delhi Government launched in July 2015. Services are free for people from all income levels; like consultation, medicines and diagnostic tests. Average distance of each clinic is within 5 km (14 clinics per assembly constituency) . Staffs include a medical officer, a pharmacists, an auxiliary nursing midwife, a lab technician and a security guard. Key features Increasing geographical access to the health service Making health services accessible Reducing the cost of care (indirect health care costs) Counselling and referral services New technology to meet local health needs Highly cost-effective intervention one-time cost of these 1,000 clinics (approximately Rs 200 crore) would be less than what is needed for setting up a secondary hospital. Approximately, 2,500 Mohalla clinics could be opened in the amount required to set up an AIIMS- like institution. 31

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37. Private Enterprises in Delivering Healthcare: PPP models in China Beijing New century International Children’s Hospital PPP model Phoenix Healthcare Group PPP healthcare models in India Assam Teleradiology Project of NRHM With Healthfore Technologies Karnataka Integrated Tele-medicine and Tele-health Project Other Government and private joint ventures: Teleradiology Solutions & Singapore Government Teleradiology Solutions & Tripura Government HEALTHCARE MODELS  37

38. ROLE OF INSURANCE Role of public health insurance: Total public and private health expenditures as a percentage of GDP are estimated at 3.9 percent, significantly lower than the world average of 9.9 percent. The public sector accounts for approximately one-quarter of health expenditures. Role of private health insurance: Thirty-six percent of insured individuals in India have private coverage, which covers only hospitalizations. Private insurance now accounts for nearly 4.4 percent of total current health expenditures. 38

39. MAJOR STRATEGIES TO ENSURE QUALITY OF CARE Quality of care is addressed through legal and policy measures defined by the central and state governments. India Public Health Standards (2008) Clinical Establishments (Registration and Regulation) Act of 2010 My Hospital (Mera-Aspataal) (2016) Labour Room Quality Improvement Initiative (LaQshya) (2017) National Patient Safety Implementation Framework (2018–2025). National Centre for Disease Control - national guidelines for the management and control of infectious diseases. Ministry of Health and Family Welfare has published N ational standard treatment guidelines - hospital planning, blood transfusion, and electronic health records. I n collaboration with state health departments- a comprehensive quality assurance framework for public health facilities and programs has been developed In 2017, a centralized tracking system for district hospital performance was introduced along with public rankings of hospitals in the system based on performance. 39

40. No centralized system exists for monitoring and evaluating health indicators and health status. In addition to targeting vulnerable populations under the national health protection scheme, there have been a number of initiatives over the years to afford care and to promote treatment-seeking behaviors. Examples include: The janani suraksha yojana, launched in 2005, is a centrally sponsored scheme to reduce maternal and neonatal mortality by promoting institutional delivery among poor pregnant women.It is one of the largest conditional cash transfer programs in the world. The health minister’s cancer patient fund provides financial assistance to patients suffering from cancer. Rashtriya arogya nidhi offers financial assistance to patients living below the poverty line who are suffering from life-threatening diseases. The health minister’s discretionary grant provides financial assistance to patients with significant hospital bills. Mission indradhanush provides universal immunization for all children under age 2 and pregnant women. HEALTH DISPARITIES IN INDIA 40

41. ELECTRONIC HEALTH RECORDS The Ministry of Health and Family Welfare published the first national standards for electronic health records (EHRs) in 2013. As of 2016, survey results have revealed that uptake of the system has been slow as compared to other middle- and high-income countries. Currently, there is no universal patient identifier. The National Health Protection Scheme presents a new opportunity to use IT to improve quality of care and detect fraud. The program will run on a state-of-the-art system with built-in intelligence and data-processing capabilities. The new National Health Authority has already set up the PM-JAY Dashboard and other IT systems for hospital empanelment, beneficiary identification, and transaction management. 41

42. Launching Ayushman Bharat, which encompasses the National Health Protection Scheme (Pradhan Mantri Jan Arogya Yojana), for coverage of tertiary care for vulnerable populations and Health and Wellness Centres initiative for the delivery of comprehensive and integrated primary care. Setting up the National Health Authority to implement the PM-JAY. Initiating the provision of universal sanitation coverage - Swachch Bharat Mission. Launching Intensified Mission Indradhanush 2.0 to achieve 90 percent vaccination coverage for children under 2. Providing clean cooking fuel under the Pradhan Mantri Ujjwala Yojana scheme. Providing nutritional and social support for all National Health Protection Scheme beneficiaries with tuberculosis. Replacing the Medical Council of India with the National Medical Commission and setting uniform standards for medical education. Creating a health technology assessment body (Health Technology Assessment in India) under the Department of Health Research to evaluate all medical technologies. MAJOR INNOVATIONS AND REFORMS 42

43. Indian healthcare sector is expected to reach US$ 193.83 billion by 2020and US$ 372 billion by 2022. Rising income level, greater health awareness, increased precedence of lifestyle diseases and improved access to insurance would be the key contributors to growth. In June 2021, gross written premiums of health insurance companies in the non-life insurance sector increased by 40% by rising demand for health insurance products amid the COVID-19 surge. As of July 2021, the number medical colleges in India stood at 558, 393 Ayurveda and 221 homeopathy Government recognized colleges. As of April 2021, over 75,500 Health and Wellness Centers were operationalized in India. As of February 2021, 420 e-Hospitals were established - central government's ‘Digital India’ initiative. By August 2021, the Health Ministry’s eSanjeevani telemedicine service crossed 9 million teleconsultations . The Indian government is planning to introduce a credit incentive programme worth Rs. 500 billion (US$ 6.8 billion) to boost the country’s healthcare infrastructure. The programme will allow firms to fund for expand hospital capacity or medical supplies with the government acting as a guarantor and strengthen COVID-19-related health infrastructure in smaller towns. INDIAN HEALTHCARE INDUSTRY ANALYSIS 43

44. Budget 2021 highlights India’s public expenditure on healthcare stood at 1.2% as a percentage of the GDP. The government announced Rs. 64,180 crore (US$ 8.80 billion) outlay for the healthcare sector over six years in the Union Budget 2021-22 to strengthen the existing ‘National Health Mission’ by developing capacities at all levls of healthcare systems for detection and cure of new & emerging diseases. The government announced its plans to launch ‘Mission Poshan 2.0’ to merge ‘Supplementary Nutrition Programme’ with ‘ Poshan Abhiyan’ (Nutrition Mission) in order to improve nutritional outcomes across 112 aspirational districts. The Government of India approved continuation of ‘National Health Mission’ with a budget of Rs. 37,130 crore (US$ 5.10 billion) . The Ministry of AYUSH was allocated Rs. 2,970 crore (US$ 407.84 million), up from Rs. 2,122 crore (US$ 291.39 million). Between April 2000 and March 2021, FDI inflows for drugs and pharmaceuticals sector stood at US$ 17.99 billion. 44

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46. Healthcare Industry in India 46

47. Strength Weakness Opportunity Threat Potentially huge market with growing urban middle class population Growing private hospital sector aiming to attract health tourists Affordable cost Covers preventive, curative services at large. Low per capita expenditure Lack of implementation of government policies and infrastructure. Excessive dependency on imports. Lack of motivated workforce Lack of monitoring and funds Lack of rehabilitation services Weak referral system Support system from R & D not available. Community participation Medical tourism Regulations to improve market for domestic manufactures. Gaps between demand and supply large population Geographically challenged Poverty Lack of regulations in medical disposables and surgical items leading to spurious products. Unorganized markets for medical disposables. CONCLUSION 47

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49. https://www.mohfw.gov.in/ https://data.worldbank.org/country/india Park, Park’s Textbook of Preventive &Social Medicine, 25th Edition, Jabalpur: Banarsidas Bhanot,2019. Gupta, Indrani , and Mrigesh Bhatia. "The Indian health care system." (2018). https://www.commonwealthfund.org/international-health-policy-center/countries/india Chokshi , M., Patil, B., Khanna, R., Neogi , S. B., Sharma, J., Paul, V. K., & Zodpey , S. (2016). Health systems in India. Journal of perinatology : official journal of the California Perinatal Association, 36(s3), S9–S12. https://doi.org/10.1038/jp.2016.184 https://www.ibef.org/industry/healthcare-india.aspx https://niti.gov.in/planningcommission.gov.in/docs/reports/genrep/bkpap2020/26_bg2020.pdf Murray, C.J. and Frenk , J., 2000. A framework for assessing the performance of health systems.  Bulletin of the world Health Organization ,  78 , pp.717-731. REFERENCES 49

50. https://arogyakeralam.gov.in/portfolio/family-health-centres/ https://mohallaclinic.in/ https://telradsol.com/role-of-private-enterprises-in-better-healthcare-services/ https://www.who.int/healthinfo/paper06.pdf https://www.who.int/healthinfo/systems/WHO_MBHSS_2010_full_web.pdf 50

51. Thank You