The Gist of Yojana: April 2016

The Gist of Yojana: April 2016

Health Sector in India: Perspective and Way Forward

The health sector In India is at the cross-roads. This is partly due to an interesting relationship between development and health, which is known as the Preston Curve. In 1975, Samuel Preston showed that if the health of nations as measured by life expectancy is plotted against the wealth of nations as measured by GDP per capita, then up to a point, there is a sharp increase in life expectancy for even the modest increase in GDP per capita. Then the curve suddenly flattens out - and after this point, large increases in public health expenditure are required for modest increase in life expectancy.

In the 2010 version of the Preston Curve, India today is at or near the bend on the curve, and this has major implications for policy. At the bend in the curve, the past problems of reproductive and child health and of communicable disease persist, but new problems have got added on. If public investment in health care does not increase, private investment would, but there is no certainty that this would lead to better health outcomes. If public investment increases, a choice has to be made between deploying it to strengthen public health system and purchasing care from private sector. If the case is latter then one needs to be ready to impose a strong regulatory regime and also increase public expenditure far above the 2.5 per cent of GDP that the current national health policy draft calls for (Sundararaman, Muraleedharan, and Mukhopadhyay 2016). All of these are difficult decisions - and this article elaborates and discusses these issues and challenges.

Progress in Reproductive and Child Health

In earlier decades, a major proportion of deaths were related to deaths in the young child- most of this happening below the age of 5. Pregnancy related deaths were also high. Both of these have decreased sharply, partly because the number of deaths per live birth have decreased greatly and partly because with fertility control, the number of children or pregnant women has itself declined sharply.

There are many reasons why India has been successful in achieving such a reduction. One important reason is the focused attention on the reduction of infant and maternal mortality over the last 25 years. First we had the child survival and safe motherhood programme in the early nineties, and then the reproductive and child health programmes in the late nineties and early part of the last decade.

The declaration of the Millennium Development Goals and India’s race to reach these goals has also contributed in small measure to achieve this. The Draft National Health Policy states: “The MDG target for Maternal Mortality Ratio (MMR) is 140 per 100,000 live births. From a baseline of 560 in 1990, the nation had achieved 178 by 2010-12, and at this rate of decline is estimated to reach an MMR ofl41 by2015. In the case ofunder-5 mortality rate (U5MR), the MDG target is 42. From a baseline of 126 in 1990, in 2012, the nation has an U5MRof52 and an extrapolation of this rate would bring it to 42 by 2015 (Draft National Health Policy 2015).”

It is important to note that these achievements were made without comparable improvements in sanitation or in child nutrition- two of the most important social determinants of health-where Indian levels of achievement lag far behind the global averages. In most nations infant mortality rates are seen as closely linked to levels of poverty and inequality. Indian reduction in poverty in these years is contested- with views expressed in both directions. However, what is clear is that these reductions in child and maternal survival had to be achieved by the health sector in the face of continuing adverse social determinants.

On the positive side, on two social determinants, India did some serious catching up with global standards. One was the supply of safe drinking water where over 94 per cent of hamlets are now covered (WHO 2015) and the other is women’s literacy where the latest census reveal that 65.04 per cent of females are literate now.

Growth rates would continue to be high for some more years- due to what is known as the population momentum. This refers to the fact that there would be many more women now entering and passing through the reproductive age due to past high fertility rates- and therefore more children continue to be born, even though the small family norm has been achieved, Only seven states still continue to face a seriously high fertility rate-Uttar Pradesh, Bihar, Madhya Pradesh and Rajasthan- and to some extent in Jharkhand, Chhattisgarh and Meghalaya- but even in these, the rates of decline are encouraging.

Much of the credit for the declines should go to the combination of health systems strengthening and maternity focused programmes like the JSY, JSSK, ASHA, Dial 108 and 104 ambulance services, and appointment of additional nurses and ANMs at the periphery- that happened with NRHM.

With the NRHM acting as the driver, the Eleventh Five Year Plan did lead to a two fold increase in health care spending (in real terms) and about a 3 times increase in nominal terms- but this is about 40 per cent less than its own financing targets. No doubt it could have done much better with better financial outlays- and with a greater and more sustained deployment of human resources, and with greater action on the three important social determinants- poverty, nutrition and sanitation.

The impact of NRHM and the previous two decades of public health systems interventions on the control of communicable disease is mixed. One programme that did relatively well was the National Aids Control Programme. A systematic campaign that addressed both preventive and curative aspects and that grounded itself on good quality health information and estimates was able to cap- and to a fair extent, reverse the epidemic. It is still too early to celebrate, the achievements are fragile, and set back is easy- but only has to compare with what the epidemic did to sub-Saharan Africa to appreciate how narrow and fortunate our escape has been from a similar fate.

Progress in vector control is mixed. Filaria has decreased dramatically and new cases of elephantiasis are negligible. Malaria has also seen significant declines and with a range of new tools becoming available, a confidence is gathering to transit to a malaria elimination programme. Potentially this is a disease that could fall below the elimination threshold in 10 to 15 years. Kala-azar is an anachronism. It should have been eliminated by now, the deadline having been re-set repeatedly. However, it festers in some deep pockets in a few villages of two to three states, cocking a snook at all attempts to get rid of it. About 20,000 cases annually occur across four states- but the majority are from Bihar. Meanwhile, new vector borne diseases have emerged- notably Dengue and Chikungunya. The good news is that deaths both in absolute numbers and as a proportion of all deaths, and even of all cases have declined significantly.

However, deaths due to all diseases under these national disease control programmes are less than 6 per cent of all mortality. Most deaths due to infectious disease are due to diarrhea and respiratory infections especially in children and a number of other germs that do not have the same epidemic potential- but have significant prevalence. Taking all communicable deaths together, they still account for less than 30 per cent of mortality.
The major and increasing proportion of mortality is due to non-communicable diseases which now account for over 60 per cent of all deaths and due to injuries which account for almost 12 per cent of all deaths. (WHO 2014) The probability of dying during the most productive years (ages 30-70) from one of the four main NCDs is estimated to be as high as 26 per cent. To understand its gravity, compare with Sweden where the corresponding figure is 10, UK where it would be 12, Thailand where it would be about 17. Expressed in another way, 62 per cent of male deaths due to the main NCDs would occur before the age of70 in India, as compared to only 24 per cent in Sweden, 29 per cent in UK and 45 per cent in Thailand. The proportions are similar in women with about 52 per cent of deaths in women due to NCDs taking place below the age of 70 as compared to only 15 per cent In Sweden.

But there is another major difference between India’s ability to address non communicable diseases and its ability to address infections and reproductive and child health. The requirements in terms of financial and human resources and management of care is much higher. More important due to having consciously excluding these diseases from all government provision of primary health care for over two decades, even the perception of how to address these problems at the primary health care is low. Most conversations about primary care get limited to IMR, MMR, immunization rates, and family planning. The system is not even geared to conceptually see these diseases as primarily part of a primary and not tertiary care mandate.

One must also note the contrast between communicable diseases and non-communicable disease with respect to risk factors. India’s progress in communicable disease is due to lack of significant gains in poverty, nutrition and sanitation- in all of which we are doing much poorer than the developed world and even many developing nations. But when it comes to major risk factors for NCD- whether it is overweight and obesity, physical inactivity, alcohol or smoking- these risk factors are far more prevalent in the developed world. Why then does India have much higher prevalence rates of the disease? The answer lies not only in identifying the pathways through which social determinants play out with respect to NCDs in the developing world, but also in complete absence of primary health care that addresses these diseases. Private sector has no doubt expanded to fill these gaps- but market forces largely promote curative and preferably tertiary care. Market driven growth is unable to meaningfully address the needs of primary and secondary prevention - and it falls on the government to take up this role.

The main vehicle of health systems strengthening was the National Rural Health Mission, now with integration of the National Urban Health Mission- renamed as the National Health Mission. Though health is a state subject, it was clear that a central push -both in financing and ideas was needed to break the logjam and get states moving onto strengthening their health systems. To respect the federal nature, states were required to draw up their annual project implementation plans, which would be sanctioned under a joint center- state coordination committee. Though, over time the rules got more and more rigid, states had considerable flexibility in drawing up their plans.

One of the innovations that most states opted for was the creation of a workforce of close to 900,000 community health volunteers, the ASHAs. They made a major contribution to bringing public health services closer to the community, and increasing its utilization and in health education. Another important National Health Mission (NHM) contribution was the addition of over 178,000 health workers to a public system that had depleted its workforce to sub-critical levels over a long period of neglect in the nineties. The NHM deployed over 18,000 ambulances for free emergency response and patient transport services.

Further, the National Health Police 2015, draft notes that “the failure of public investment in health to cover the entire spectrum of health care needs is reflected best in the worsening situation in terms of costs of care and impoverishment due to health care costs.” As the burden of diseases shifted to non-communicable diseases and as these were not covered by public health systems, except perhaps in the highly overcrowded government medical college hospitals, people had to shift to private health care. The shift is most pronounced in urban areas and for chronic illness. The immediate impact of this shift- which occurs even in relatively well performing states like Kerala and Tamil Nadu is a huge rise in out of pocket expenditures for health care.

This shift was also a cause and consequence of a rapid growth of private sector in health care as in industry. Whereas private health care had largely consisted of one doctor clinics or small nursing homes where owners were the investors and managers - and there were little differences between top management salaries and profits, a new type of private health care which is based on funds from investors whose main concern is maximizing return on investment gained ground. This private health care industry grows at almost 15 per cent CAGR- which is twice the growth rate of the service sector and about thrice the overall national growth rate. It even attracted considerable venture capital. Close on its heels is the private health insurance industry which after lowering of Foreign Direct Investment caps are bound to grow even faster. The private health care industry is valued at $40 billion and is projected to grow to $ 280 billion by 2020 as per market sources. Of this, about 50 per cent goes to hospital care that patients pay for- the rest to the pharmaceutical, medical device and insurance segments.

Given the size of the private sector-there is of course an urgent need to engage with it and ensure that it contributes to public health goals. Insurance is of course one of the best ways of doing so. But this requires to be complemented by much greater effort at regulation. All nations that have a health system based on purchasing health care from private providers have an extensive regulatory regime in place. To put such a system in place in India, is a challenge. The Clinical Establishments Act has made a very modest start- but even for implementing this, it has still to win the trust of the medical profession. Much larger trust and cooperation would be needed between the private provider and the government to put in place a regulatory structure that is adequate to ensure that publicly financed health insurance translates into meaningful levels of financial protection and access to care.

Beyond insurance and regulation there are other ways of guiding the growth of private sector. Grievance redressal mechanisms for private sector could help. So also would provisions of training and updating skills for the small providers and nursing homes. Engaging the not- for profit sections in partnerships that require a less rigorous regulation can also provide considerable benefits. Partnerships for ancillary or support services which complements rather than substitutes public care provisioning - like for example, the dial 108 services have also done well.

Conclusion

There is a need to persist, intensify and expand the efforts that were initiated under the National Health Mission, if we have to sustain the progress that the Mission achieved. In particular, we need to focus such expansion both in urban primary care and in the four large Hindi speaking states.

While there has to be a major effort in engaging the private sector in health care, this has to be based on stewardship and facilitator efforts that address different forms of information asymmetry and conflicts of interests - and empower people to make the right choice. A premature and unprepared shift to purchasing care without first putting in place, the regulatory mechanisms and getting politically ready for much higher levels of public investment is fraught with danger.

In strengthening public health systems, the challenge is of expanding the workforce, increasing investment and the quality of governance so that the challenges of Non- communicable diseases can be addressed without compromising the fragile advances we have made in RCH and communicable disease control.

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