Health Care Delivery Sys

Health Care Delivery System in India
Arun S Nath
Lecturer SCS College of Nursing Mangalore
2/09/2011
ARUN S NATH,ASST.PROFESSOR, SCS COLLEGE OF NURSING
2/09/2011
Introduction

The political economy context The organisational structure and delivery mechanism Health financing mechanisms Coverage patterns Current status of health and health care
2/09/2011
Concept of a Four-Level Health Care System
PATIENT
CARE TEAM Frontline care providers
ORGANIZATION
Infrastructure, resources
ENVIRONMENT Regulatory, market and policy framework

2/09/2011 ARUN S NATH,ASST.PROFESSOR, SCS COLLEGE OF NURSING
Source: Building a Better Delivery System, A New Engineering/Health Care Partnership, IOM, 2005
2/09/2011
The Political Economy Context

A democratic federal system which is subdivided into 28 States, 7 union territories and 593 districts In most of the states three local levels of government (Panchayati-raj) Per capita income US $440 435 million Indians are estimated to live on less than US $ 1 a day 36% of the total number of the worlds poor are in India Tax based health finance system with health insurance 80% health care expenditure born by patients and their families as out-of -pocket payment (fee for service and drugs) Expenditure on health care is second major cause of indebtedness among rural poor
ARUN S NATH,ASST.PROFESSOR, SCS COLLEGE OF NURSING 6
2/09/2011
System
A set of interrelated and independent parts designed to achieve a set of goals.
2/09/2011
Health system
Structure & function of countrys MOH 1. Resources 2. Management 3. Organization 4. Economic support 5. Service delivery
2/09/2011
National health system

Public Private Traditional Informal sectors Essential functions Service provision Resource generation Financing Leadership
2/09/2011 ARUN S NATH,ASST.PROFESSOR, SCS COLLEGE OF NURSING 9
Key to effective health system

Motivated staff Equipment Information Finance Adequate drugs for improving access Coverage Quality of health services
Evolution of health systems

Early health systems Traditional practices and medicine Effect of industrial revolution Politicization of workers in Germany UK National health system(1938) Bhore committee( 1946)
2/09/2011
11
Cont..

2/09/2011
Alma Atta declaration 1978 Primary health care themes Equity Social justice Community participation Prevention/promotion Intersectoral coordination Appropriate use of resources Sustainability
12
CONT.
Health economics brought in health care(1980-90) Efficiency & effectiveness Structural program adjustment Health sector reform Dominance of world bank over WHO
2/09/2011
13
CONT
1990-2000 One size does not fit all Recognition of key elements- equity, empowerment & poverty reduction Standardization & improving performance World health report 2003 Primary health care Access, equity ,community participation & intersectoral coordination
CONT
o
MDG 8 goals, 18 targets
2/09/2011
15
Determinants of health systems

Economic o Affordability ? o Availability ? political Priorities Appropriateness Accessibility Equity
Cultural Accessibility Utilization Participation
2/09/2011
17
Forces for changing health systems

2/09/2011
New emerging diseases Changing disease profile Technological & diagnostic advancements Longevity of life Expectation sof people Subsidies & cross subsidies Increasing non plan expenditure Competing priorities Improving awareness among people
18
Classification

Service delivery Nature of service Doctrine Tariditional medicine
2/09/2011
19
Based on service delivery

Public sector primary care PHC Sub centers Secondary care CHC Hospitals Tertiary care Teaching hospitals
Cont.
Private hospitals Trust hospitals Corporate hospitals Nursing homes Medical insurance Others NGOs ESI& railways Voluntary agencies Defense
Nature of service

Indigenous- rural General care Specialty Super specialty / corporate
2/09/2011
22
Based on doctrine
Official Allopathy Traditional AYUSH
2/09/2011
23
Characteristics of Indian Health System
Complex mixed health system

- Publicly financed government health system - Fee-levying private health sector
2/09/2011
24
Different Phases of Indian Health System Development

Pre-independence phase Development centred phase Comprehensive Primary Health Care phase Neoliberal economic and health sector reform phase Health systems phase
2/09/2011
25
Main Systems of Medicine

Western allopathic Ayurveda Unani Siddha Homeopathy
2/09/2011
26
Government Health System
Three levels of responsibilities-
Firsthealth is primarily a state responsibility

Second- the central government is responsible for developing and monitoring national standards and regulations - sponsoring various schemes for implementation by state governments - providing health services in union territories Thirdboth the centre and the states have a joint responsibility for programmes listed under the concurrent list.
2/09/2011
Administrative Structure
1. Central Ministries of Health and Family Welfare - Responsible for all health related programmes - Regulatory role for private sector 2. State Ministries of Health and Family Welfare 3. District Health Teams headed by Chief Medical and Health Officer
Service Delivery Structure
Sub Health Centres- staffed by a trained

female health worker and/or a male health worker for a population of 5000 in the plains and a population of 3000 in hilly and tribal areas.
Primary Health Centresstaffed by a medical officer and other paramedical staff for a population of 30,000 in the plains and a population of 20,000 in hilly, tribal and backward areas. A PHC centre supervises six to eight sub centres.
2/09/2011
29
Service Delivery Structure
Community health centres- with 30-50 beds and basic specialities covering a population of 80,000 to 120,000. The CHC acts as a referral centre for four to six PHCs. District/General hospitals- at district level with multi speciality facilities (City dispensaries) Medical colleges, All India institute of Medical Sciences and quasi government institutes
(NIHFW and SIHFWs)
2/09/2011
Health Financing Mechanisms..

Revenue generation by tax Out of pocket payments or direct payments Private insurance Social insurance External Aid supported schemes
2/09/2011
31
Spending on Health
Annually over 150,000 crores or US$34 billion, which is 6% of GDP (Government spending on health Is only 0.9% of GDP) Out of this only 15 % is publicly financed 4% from social insurance, 1% by private insurance remaining 80% is out of pocket spending ( 85% of which goes in private sector) Only 15% of the population is in organised sector and has some sort of social security the rest is left to the mercy of the market
2/09/2011
The Aspects of Neoliberal Economic Reforms Affecting Public Health

Increasing unregulated privatisation of the health care sector with little accountability to patients Cutting down government Health care expenditure Systematic deregulation of drug prices resulting in skyrocketing prices of drugs and rising cost of health services Selective intervention approach instead comprehensive primary health care Measure diseases in terms of cost effectiveness Techno centric approach( emphasis on content instead processes)
2/09/2011
33
Contradictions
India has the largest numbers of medical colleges in the world It produces the largest numbers of doctors among developing countries It gets medical Tourists from developed countries This country is fourth largest producer of drugs by volume in the world
2/09/2011
But... the current situation.

Only 43.5% children are fully immunised. 79.1% of children from 6 months to 5 years of age are anaemic. 56.1% ever married women aged 15-49 are anemic. Infant Mortality Rate is 58/1000 live births for the country with a low of 12 for Kerala and a high of 79 for Madhya Pradesh. Maternal Mortality Rate is 301 for the country with a low of 110 for Kerala and a high of 517 for UP and Uttaranchal in the 2001-03 period. Two thirds of the population lack access to essential drugs. 80% health care expenditure born by patients and their families as out-of -pocket payment (fee for service and drugs) Health inequalities across states, between urban and rural areas, and across the economic and gender divides have become worse Health, far from being accepted as a basic right of the people, is now being shaped into a saleable commodity 2/09/2011 ARUN S NATH,ASST.PROFESSOR, SCS 35
COLLEGE OF NURSING
Contd.

poor are being excluded from health services Increased indebtedness among poor (Expenditure on health care is second major cause of Indebtedness among rural poor) Difference across the economic class spectrum and by gender in the untreated illness has significantly increased Cutbacks by poor on food and other consumptions resulting increased illnesses and increasing malnutrition
2/09/2011
Health Inequities
The infant mortality Rate in the poorest 20% of the population is 2.5 times higher than that in the richest 20% of the population A child in the Low standard of living economic group is almost four times more likely to die in childhood than a child in a better of high standard living group A person from the poorest quintile of the population, despite more health problems, is six times less likely to access hospitlisation than a person from richest quintile.
2/09/2011
Health Inequities
A girl is 1.5 times more likely to die before reaching her fifth birthday The ratio of doctors to population in rural areas is almost six times lower than that for urban areas. Per person, government spending on public health is seven times lower in rural areas compared to government spending urban areas
2/09/2011
Inter-Sectoral Co-ordination
2/09/2011
Health is intrinsically related to development. However, the inter-linkages between health and development were brought to the limelight at the Alma Ata conference on Primary Health Care (PHC) in 1978. The Alma Ata conference not only gave a new impetus to the inter- linkages between health and development but also restated the fact that `Health for All' could not be achieved without inter-sectoral co-ordination.
Cont.
This restatement gave a new direction not only to those involved in promoting health but also to those participating in the process of community development.
2/09/2011
40
Cont.
The scholars, the policy makers and the development functionaries promoting an intersectoral approach to health tend to consider seriously three major sectors that are crucial for health and development. They are: Agriculture Education Environment
Guiding Principles
Development is basic to health Equity Equity in terms of health is that "every man, woman and child, no matter where he or she lives, has the right to enjoy good health and deserves to have access to health care services. Availability Accessibility
CONT.
Promoting economic capacity of the people (poor)
2/09/2011
43
Health and Agriculture

More than two thirds of the people in developing countries Some of the factors of agriculture that have direct influence on the health of the people are: 1. adequate farm income 2. income from agricultural labour 3. enough food (energy) for agricultural work 4. nutritional value of the food eaten 5. health hazards of agricultural technology
2/09/2011
45
Impact of Agriculture on Health

Policies: 1. Food crop vs cash crops 1.2. Shift in consumption (locally grown food vs meal processed in cities) 1.3. Investment (productive regions vs poor regions) 2. Land fertility 3. Crops with harmful effects (dangerous to health) e.g. health of farm labourers 4. Food with direct health hazards (toxic substances) 5. Agricultural products with major health hazards (tobacco and narcotics) 6. Equity in accessibility to food
Health and Environment

Poverty and Environment Poverty and Environment Water, Air, Land and Health
2/09/2011
47
Action for Co-ordination

The strategies are broadly categorized into four, they are: 1. Asset creation 2. Providing needed capital 3. Employment generation 4. Establishing marketing linkages
2/09/2011
48
Education and Health
2/09/2011
In some countries, states (Kerala in India) and communities, the fall in mortality, morbidity and birth rates is mostly due to the level of education and literacy than to mere economic growth. The positive impact of education on health is the result of improvement in personal and public hygiene, life style, environmental sanitation, appropriate nutrition, and better understanding and positive attitudes towards preventive, curative and promotive care.
49
HEALTH AND FAMILY WELFARE

The Union Ministry of Health & Family Welfare is instrumental and responsible for implementation of various programmes on a national scale in the areas of Health & Family Welfare, prevention and control of major communicable diseases and promotion of traditional and indigenous systems of medicines. Apart from these, this Ministry also assists States in preventing and controlling the spread of seasonal disease outbreaks and epidemics through technical assistance.
STRUCTURE
The Ministry comprises of four departments, namely, Department of Health & Family Welfare, Department of AYUSH, Department of Health Research and Department of AIDS Control. The Directorate General of Health Services (DGHS) is an attached office of the Department of Health & Family Welfare and has subordinate offices spread all over the country.
2/09/2011
A. Programmes on Health Sector:

Cancer Control Programme: Mental Health Programme: Emergency Facilities of State Hospitals located on National Highways: Prevention and Control of Diabetes, Cardiovascular Disease and Strokes: Central Government Health Scheme (CGHS): Health Ministers Discretionary Grant: Borne Disease Control Programme (NVBDCP):(vector borne diseases namely Malaria, Filaria, Kala-azar, Japanese Encephalitis (JE), Dengue and Chikungunya
CONT
Pradhan Mantri Swasthya Suraksha Yojana (PMSSY): (i) setting up of six AIIMS-like institutions and (ii) upgradation of 13 existing Government medical college institutions. Other Health Programmes: Other major health programmes are Prevention and Control of Deafness; Prevention and Control of Fluorosis; Rashtriya Arogya Nidhi, Leprosy Eradication Programme (NLEP); TB Control Programme (RNTCP); Programme for Control of Blindness (NPCB); and Iodine Dificiency Disorders Control Programme.
B. Rural Health Services:

146036 Sub-Centres, 23458 Primary Health Centres and 4276 Community Health Centres Indian Public Health Standards (IPHS): Mobile Medical Units/Health Camps: National Rural Health Mission (NRHM): (1) Increasing Participation and Ownership by the Community, (2) Improved Management Capacity (3) Flexible Financing (4) Innovations in human resources development for the health sector, and (5) Setting of standards and norms with monitoring.
C. Maternal Health Programmes:
Maternal Mortality Ratio (MMR): number of maternal deaths per 100,000 live births due to causes related to pregnancy Schemes for Improving Obstetric Care Services: Janani Suraksha Yojana (JSY): Village Health and Nutrition Day:
2/09/2011
55
D. Child Health Programmes:

Universal Immunization Programme: Pulse Polio Immunization:
2/09/2011
56
E. Family Welfare:

Checking of Female foeticide: Family Welfare Linked Health Insurance Scheme (FWLHIS):
2/09/2011
57
F. Ayurveda, Yoga and Naturopathy, Unani, Siddha, Homoeopathy (AYUSH):

G. Medical Education:

Medical Council of India (MCI): Dental Council of India (DCI): Central Council of Indian Medicine (CCIM): Central Council of Homoeopathy (CCH): Pharmacy Council of India: Indian Nursing Council:
2/09/2011
H. Health Organisations/Institutions:

2/09/2011
National Academy of Medical Sciences (NAMS): All India Institute of Medical Sciences (AIIMS): Central Bureau of Health Intelligence (CBHI): International Institute for Population Sciences (IIPS): National Institute of Health and Family Welfare (NIHFW): Indian Medicines Pharmaceutical Corporation Limited (IMPCL):
60
Information, Education and Communication
IEC can be defined as an approach which attempts to change or reinforce a set of behaviours in a target audience regarding a specific problem in a predefined period of time. It is multidisciplinary and client-centred in its approach, drawing from the fields of diffusion theory, social marketing, behaviour analysis, anthropology, and instructive design. IEC strategies involve planning, implementation, monitoring and evaluation.
CONT
When carefully carried out, health communication strategies help to foster positive health practices individually and institutionally, and can contribute to sustainable change toward healthy behavior
2/09/2011
62
Information, education and communication (IEC) combines strategies, approaches and methods that enable individuals, families, groups, organisations and communities to play active roles in achieving, protecting and sustaining their own health. Embodied in IEC is the process of learning that empowers people to make decisions, modify behaviours and change social conditions.
2/09/2011
Activities are developed based upon needs assessments, sound educational principles, and periodic evaluation using a clear set of goals and objectives.
2/09/2011
64
Channels
Channels might include interpersonal communication (such as individual discussions, counselling sessions or group discussions and community meetings and events) or mass media communication (such as radio, television and other forms of one-way communication, such as brochures, leaflets and posters, visual and audio visual presentations and some forms of electronic communication).
2/09/2011
Steps in Developing IEC Activities

Conduct a needs assessment. Set the goal. This is a broad statement of what you would like to see accomplished with the target audience in the end. Establish behavioural objectives that will contribute to achieving the goal.
2/09/2011
66
Cont
2/09/2011
Develop the IEC activities and involve as many other partners as possible. After their successful implementation, you should be able to have a significant impact on achieving the behavioural objectives. Identify potential barriers and ways of overcoming them. Identify potential partners, resources, and other forms of support for your activities and gain their sustained commitment. Establish an evaluation plan.
2/09/2011
68
Conselling
Counseling is a key component of an IEC programme. counselors should strive to ensure that every service user has the right to the following: Information: to learn about the benefits and availability of the services. Access: to obtain services regardless of gender, creed, colour, marital status or location.
2/09/2011
Cont
Choice: to understand and be able to apply all pertinent information to be able to make an informed choice, ask questions freely, and be answered in an honest, clear and comprehensive manner. Safety: a safe and effective service. Privacy: to have a private environment during counselling or services. Confidentiality: to be assured that any personal information will remain confidential.
2/09/2011
Dignity: to be treated with courtesy, consideration and attentiveness. Comfort: to feel comfortable when receiving services. Continuity: to receive services and supplies for as long as needed. Opinion: to express views on the services offered.
2/09/2011
72
Thank You.

Health Care Delivery Sys

Caricato da

Informazioni sul documento

Descrizione originale:

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

Health Care Delivery Sys

Caricato da

Copyright:

Formati disponibili

Health Care Delivery System in India

ARUN S NATH,ASST.PROFESSOR, SCS COLLEGE OF NURSING

ARUN S NATH,ASST.PROFESSOR, SCS COLLEGE OF NURSING

ARUN S NATH,ASST.PROFESSOR, SCS COLLEGE OF NURSING

Concept of a Four-Level Health Care System

CARE TEAM Frontline care providers

ENVIRONMENT Regulatory, market and policy framework

ARUN S NATH,ASST.PROFESSOR, SCS COLLEGE OF NURSING

The Political Economy Context

A set of interrelated and independent parts designed to achieve a set of goals.

ARUN S NATH,ASST.PROFESSOR, SCS COLLEGE OF NURSING

ARUN S NATH,ASST.PROFESSOR, SCS COLLEGE OF NURSING

National health system

2/09/2011 ARUN S NATH,ASST.PROFESSOR, SCS COLLEGE OF NURSING 9

Key to effective health system

2/09/2011 ARUN S NATH,ASST.PROFESSOR, SCS COLLEGE OF NURSING 10

Evolution of health systems

ARUN S NATH,ASST.PROFESSOR, SCS COLLEGE OF NURSING

ARUN S NATH,ASST.PROFESSOR, SCS COLLEGE OF NURSING

2/09/2011 ARUN S NATH,ASST.PROFESSOR, SCS COLLEGE OF NURSING 14

MDG 8 goals, 18 targets

ARUN S NATH,ASST.PROFESSOR, SCS COLLEGE OF NURSING

Determinants of health systems

2/09/2011 ARUN S NATH,ASST.PROFESSOR, SCS COLLEGE OF NURSING 16

Cultural Accessibility Utilization Participation

ARUN S NATH,ASST.PROFESSOR, SCS COLLEGE OF NURSING

Forces for changing health systems

Service delivery Nature of service Doctrine Tariditional medicine

ARUN S NATH,ASST.PROFESSOR, SCS COLLEGE OF NURSING

Based on service delivery

Indigenous- rural General care Specialty Super specialty / corporate

ARUN S NATH,ASST.PROFESSOR, SCS COLLEGE OF NURSING

ARUN S NATH,ASST.PROFESSOR, SCS COLLEGE OF NURSING

Characteristics of Indian Health System

Complex mixed health system

ARUN S NATH,ASST.PROFESSOR, SCS COLLEGE OF NURSING

Different Phases of Indian Health System Development

ARUN S NATH,ASST.PROFESSOR, SCS COLLEGE OF NURSING

Main Systems of Medicine

Western allopathic Ayurveda Unani Siddha Homeopathy

ARUN S NATH,ASST.PROFESSOR, SCS COLLEGE OF NURSING

Government Health System

Three levels of responsibilities-

Firsthealth is primarily a state responsibility

Service Delivery Structure

Sub Health Centres- staffed by a trained

ARUN S NATH,ASST.PROFESSOR, SCS COLLEGE OF NURSING

Service Delivery Structure

Health Financing Mechanisms..

ARUN S NATH,ASST.PROFESSOR, SCS COLLEGE OF NURSING

The Aspects of Neoliberal Economic Reforms Affecting Public Health

ARUN S NATH,ASST.PROFESSOR, SCS COLLEGE OF NURSING

But... the current situation.

ARUN S NATH,ASST.PROFESSOR, SCS COLLEGE OF NURSING

2/09/2011 ARUN S NATH,ASST.PROFESSOR, SCS COLLEGE OF NURSING 41

2/09/2011 ARUN S NATH,ASST.PROFESSOR, SCS COLLEGE OF NURSING 42

Promoting economic capacity of the people (poor)

ARUN S NATH,ASST.PROFESSOR, SCS COLLEGE OF NURSING

Health and Agriculture

ARUN S NATH,ASST.PROFESSOR, SCS COLLEGE OF NURSING

Impact of Agriculture on Health

2/09/2011 ARUN S NATH,ASST.PROFESSOR, SCS COLLEGE OF NURSING 46

Health and Environment