The Gist of Kurukshetra: October 2015

Mission Indradhanush (Free Available)
National Health Policy-2015 A Catalyst For Sustainable Development In Primary Health Care (Free Available)
Steps to Correct Infant Mortality Rate (Only For The Subscribed Members)
National Pharmaceutical Pricing Authority and Drug Price Control in India (Only For The Subscribed Members)

Mission Indradhanush

The Ministry of Health & Family Welfare has launched “Mission Indradhanush”, depicting seven colours of the rainbow, to fully immunise more than 891akh children who are either unvaccinated or partially vaccinated; those that have not been covered during the rounds of routine immunisation for various reasons. They will be fully immunised against seven life-threatening but vaccine prevent-able diseases which include diphtheria, whooping cough, tetanus, polio, tuberculosis, measles and hepatitis-B. In addition, vaccination against Japanese Encephalitis and Haemophilus influenza type B will be provided in selected districts/states of the country. Pregnant women will also be immunised against tetanus.

The first round of the first phase started from 7 April 2015-World health Day- in 201 high focus districts in 28 states and carried for more than a week. This will be followed by three rounds of more than a week in the months of April, May June and July 2015, starting from 7th of each month. The 201 high focus districts account for nearly 50% of all unvaccinated or partially vaccinated children in the country. Of these, 82 districts are in just four states of UP, Bihar, Madhya Pradesh and Rajasthan and account for nearly 25% of all unvaccinated or partially vaccinated children of the country.

Within the districts, the Mission will focus on 4,00,000 high risk settlements identified as pockets with low coverage due to geographic, demographic, ethnic and other operational challenges. These include nomads and migrant labour working on roads, construction sites, riverbed mining areas, brick kilns, and those living in remote and inaccessible geographical areas and urban slums, and the underserved and hard to reach populations dwelling in forested and tribal areas.

Total of 297 districts will be targeted in the second phase to commence from September 2015. Achievements in the first round of first phase (7-16 April 20 15)

2.1 lakh sessions held
54.4lakh antigens administered
5.8lakh pregnant women immunised
2.5lakh pregnant women fully immunised
20.81akh children immunised
55% of these are from Uttar Pradesh
For approx. 20%, this was their first contact
Approx. 24% belong of <2 years of age
4.7lakh children fully immunised

The preparation and learning during the implementation of the first round have led to health systems strengthening in terms of drawing up detailed micro plans; designing sturdy framework for stringent monitoring and evaluation of the immunisation rounds in the states (more than 3600 state and central level monitors have been deputed); training of nearly 91akh frontline workers; identification and analysis of limiting factors in different states leading to creating effective structures to mitigate them.

The children immunized under Mission Indradhanush are in addition to the children who are immunized under the Universal lmmunisation Programme.

National Health Policy-2015 A Catalyst For Sustainable Development In Primary Health Care

This National Health Policy addresses the urgent need to improve the performance of health systems. It is being formulated at the last year of the Millennium Declaration and its Goals, in the global context of all nations committed to moving towards universal health coverage. National Health Policy is a declaration of the determination of the Government to cover economic growth to achieve health outcomes and an explicit acknowledgement that better health contributes immensely to improved productivity.

There are many infectious diseases which the system has failed to respond to - either in terms of prevention or access to treatment. Then there is a growing burden of non-communicable disease. The second important change in this context is the emergence of a robust health care industry growing at 15%compound annual growth rate (CAGR). Thirdly, incidence of catastrophic expenditure due to health care costs is growing and is now being estimated to be one of the major contributors to poverty. The drain on family incomes due to health care costs can neutralize the gains of income increases. The fourth change is that economic growth has increased the available fiscal capacity.

The primary aim of the National Health Policy, 2015, is to inform, clarify, strengthen and prioritize the role of the Government in shaping health systems in all its dimensions- investment in health, organization and financing of healthcare services, prevention of diseases and promotion of good health, developing human resources, encouraging medical pluralism, building the knowledge base required for better health, financial protection and regulation and legislation for health.

Despite years of strong economic growth and increased Government health spending in the 11th Five Year plan period, the total spending on healthcare in 2011 in the country was about 4.1% of GDP. Global evidence on health spending shows that unless a country spends at least 5-6% of its GDP on health and the major part of it is from Government expenditure, basic health care needs are seldom met. The Government spending on health care in India’s expenditure on health care is only 1.04% of GDP which is about 4 % of total Government expenditure. This translates in absolute terms to RS.957 per capita at current market prices. The Central Government share is Rs.325 (0.34% GDP) while State Government share translates to about RS.632 on per capita basis at base line scenario. Perhaps the single most important policy pronouncement of the National Health Policy 2002 articulated in the 10th, 11th and 12th Five Year Plans, and the NRHM framework was the decision to increase public health expenditure to 2 to 3 % of the GDP. Public health expenditure rose briskly in the first years of the NRHM, but at the peak of its performance it started stagnating at about 1.04 % of the GDP. The pinch of such stagnation is felt in the failure to expand workforce, even to train and retain them. This reluctance to provide for regular employment affects service delivery, regulatory functions, management functions and research and development functions of the Government.

According to NH Policy one of the most important strengths and at the same time challenges of governance in health is the distribution of responsibility and accountability between the Center and States. Though health is a State subject, the Centre has accountability to Parliament for central funding - which is about 36% of all public health expenditure and in some states over 50%. Further it has its obligations under a number of international conventions and treaties that it is party to. Further, disease control and family planning are in the concurrent list and these could be defined very widely. Finally though State ownership has been used by some states to become domain leaders and march ahead setting the example for others. The Centre has a responsibility to correct uneven development and provide more resources where vulnerability is more. The way forward is for equity sensitive resource allocation, strengthening institutional mechanisms for consultative decision-making and coordinated implementation and provision of capacity building and technical assistance to States. The main challenge at both Centre and States are strengthening the synergistic functioning of the directorate as the technical leadership and the civil services as the administrative leadership and coordinating both of these with the increasing number of State owned or fully state financed corporations, and registered societies ‘and autonomous or semi-autonomous institutions.

The ICDS success depends on the Anganwadi worker a woman who is the pilot of the programme. The scheme is government’s main weapon to combat child malnutrition. The expenditure towards health in India under NRHM is gradually showing increasing trend. The investment for NRHM in 2006 was Rs. 7786 crores in 2008-09 Rs. 11988 crores while in 2013-14 the out lay on NRHM was about Rs.16972 crores. However, India’s achievement on the Health front is not encouraging due to faulty implementation of public health policy (PHP).

One public health priority that needs urgent attention is the state of neglect of mental health issues. The gap between service availability and needs is widest here- 43 facilities in the nation with a 0.47 psychologists per million people. Improving this situation requires simultaneous action on mental health. Integration with the primary care approach so as to identify those in need of such services and refer them to the appropriate site and follow up with medication and tele-medicine linkages. This would also require specially trained general medical officers and nurses who are able to provide some degree of referral support at the secondary care level in a context where qualified psychiatrists will remain difficult to access for many years.

The key principle around which we build a policy on human resources for health is that workforce performance of the system would be best when we have the most appropriate person, in terms of both skills and motivation, for the right job in the right place, working within the right professional and incentive environment. A policy framework in human resources for health that is based on the above principle would need to align decisions regarding how and where to encourage growth of professional and technical educational institutions, how to finance professional and technical education, how to define professional boundaries and skill sets, how to shape the pedagogy of professional and technical education, how to frame entry policies into educational institutions, how to define and ensure quality of education and how to regulate the system so as to generate the right mix of skills at the right place.

India is the pharmacy to the developing world, but about half of its population does not have access to essential lifesaving medicines and the situation is worse when it comes to medical devices and in-vitro diagnostics. India has a great tradition and capacity for innovation in most areas, but despite having the technical capacity to manufacture any drug useful to the common people with ensured marketing facilities. Its role in new drug discovery and drug innovation including in bio-pharmaceuticals and biosimilar, even for its own health priorities is limited. India has a public health system with a stated commitment to providing universal access to free care, but out of pocket expenditures as a proportion on account of access to drugs and diagnostics is prohibitively highest in the world. These are the paradoxes that the national health policy addresses. Learning from the experience and the consensus amongst expert groups that have examined the issue of progress to universal health care, making available good quality, free essential and generic drugs and diagnostics, at public health care facilities is the most effective way at this present juncture. The drugs and diagnostics available free would include all that is needed for comprehensive primary care including all chronic illnesses in the assured set of services.
National Health Policy 2015 would play a significant role in improving Medicare and primary health care in India, provided the policy is implemented by the state and central governments with a total responsibility and a political will. The earlier health policies have faced innumerable constraints in implementation. The policy envisages proper implementation of frame work with approved financial allocations with measurable output targets and policy frame work. The implementation frame work wouId aIso reflect learning from past experience and identify administrative reforms required to govern public financing, institutional frame work, human resource policies to achieve sustainable development in the field of primary health care in India.