ECONOMICS ASSIGNMENTGOVERNMENT’S POLICY WITH RESPECT TO

HEALTHSYBcom.

Div: B

Roll No: 146, 147, 148, 149, and 150

ACKNOWLEDGEMENT

We are thankful to Prof. Ravikiran Garje for giving such a wonderful opportunity to explore the health challenges before our country & government’s initiatives to overcome it. Thank You.

INDEX1. Introduction2. Challenges confronting public health3. Roll of government within health sector4. Role of government in enabling intersectoral coordination toward public

health issues5. India’s health care initiatives6. Government’s health expenditure7. High level export group on health coverage8. 12th Five year plan9. Health issues10.Health care system11.conclusion

INTRODUCTION

The practice of public health has been dynamic in India, and has witnessed many hurdles in its attempt to affect the lives of the people of this country. Since independence, major public health problems like malaria, tuberculosis, leprosy, high maternal and child mortality and lately, human immunodeficiency virus (HIV) have been addressed through a concerted action of the government. Social development coupled with scientific advances and health care has led to a decrease in the mortality rates and birth rates. India has a universal health care system run by the constituent states and territories of India. The Constitution charges every state with "raising the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties". The National Health Policy was endorsed by the Parliament of India in 1983 and updated in 2002. Parallel to the public health sector, and indeed more popular than it, is the private medical sector in India. Both urban and rural Indian households tend to use the private medical sector more frequently than the public sector, as reflected in surveys. India has a life expectancy of 64/67 years (m/f), and an infant mortality rate of 46 per 1000 live births.

CHALLENGES CONFRONTING PUBLIC HEALTH

The new agenda for Public Health in India includes the epidemiological transition (rising burden of chronic non-communicable diseases), demographic transition (increasing elderly population) and environmental changes. The unfinished agenda of maternal and child mortality, HIV/AIDS pandemic and other communicable diseases still exerts immense strain on the overstretched health systems.

Silent epidemics: In India, the tobacco-attributable deaths range from 800,000 to 900,000/year, leading to huge social and economic losses. Mental, neurological and substance use disorders also cause a large burden of disease and disability. The rising toll of road deaths and injuries (2—5 million hospitalizations, over 100,000 deaths in 2005) makes it next in the list of silent epidemics. Behind these stark figures lies human suffering.

Health systems are grappling with the effects of existing communicable and non-communicable diseases and also with the increasing burden of emerging and re-emerging diseases (drug-resistant TB, malaria, SARS, avian flu and the current H1N1 pandemic). Inadequate financial resources for the health sector and inefficient utilization result in inequalities in health. As issues such as Trade-Related aspects of Intellectual Property Rights continue to be debated in international forums, the health systems will face new pressures. The causes of health inequalities lie in the social, economic and political mechanisms that lead to social stratification according to income, education, occupation, gender and race or ethnicity. Lack of adequate progress on these underlying social determinants of health has been acknowledged as a glaring failure of public health. In the era of globalization, numerous political, economic and social events worldwide influence the food and fuel prices of all countries; we are yet to recover from the far-reaching consequences of the global recession of 2008.

ROLE OF GOVERNMENT WITHIN THE HEALTH SECTOR

Health systemHealth system strengtheningImportant issues that the health systems must confront are lack of financial and material resources, health workforce issues and the stewardship challenge of implementing pro-equity health policies in a pluralistic environment. The National Rural Health Mission (NRHM) launched by the Government of India is a leap forward in establishing effective integration and convergence of health services and affecting architectural correction in the health care delivery system in India.

Health information systemThe Integrated Disease Surveillance Project was set up to establish a dedicated highway of information relating to disease occurrence required for prevention and containment at the community level, but the slow pace of implementation is due to poor efforts in involving critical actors outside the public sector. Health profiles published by the government should be used to help communities prioritize their health problems and to inform local decision making. Public health laboratories have a good capacity to support the government's diagnostic and research activities on health risks and threats, but are not being utilized efficiently. Mechanisms to monitor epidemiological challenges like mental health, occupational health and other environment risks are yet to be put in place.

Health research systemThere is a need for strengthening research infrastructure in the departments of community medicine in various institutes and to foster their partnerships with state health services.

Regulation and enforcement in public healthA good system of regulation is fundamental to successful public health outcomes. It reduces exposure to disease through enforcement of sanitary codes, e.g., water quality monitoring, slaughterhouse hygiene and food safety. Wide gaps exist in the enforcement, monitoring and evaluation, resulting in a weak public health system. This is partly due to poor financing for public health, lack of leadership and commitment of public health functionaries and

lack of community involvement. Revival of public health regulation through concerted efforts by the government is possible through updating and implementation of public health laws, consulting stakeholders and increasing public awareness of existing laws and their enforcement procedures.

Health promotionStopping the spread of STDs and HIV/AIDS, helping youth recognize the dangers of tobacco smoking and promoting physical activity. These are a few examples of behavior change communication that focus on ways that encourage people to make healthy choices. Development of community-wide education programs and other health promotion activities need to be strengthened. Much can be done to improve the effectiveness of health promotion by extending it to rural areas as well; observing days like “Diabetes day” and “Heart day” even in villages will help create awareness at the grassroots level.

Human resource development and capacity buildingThere are several shortfalls that need to be addressed in the development of human resources for public health services. There is a dire need to establish training facilities for public health specialists along with identifying the scope for their contribution in the field. The Public Health Foundation of India is a positive step to redress the limited institutional capacity in India by strengthening training, research and policy development in public health. Preservice training is essential to train the medical workforce in public health leadership and to impart skills required for the practice of public health. Changes in the undergraduate curriculum are vital for capacity building in emerging issues like geriatric care, adolescent health and mental health. Inservice training for medical officers is essential for imparting management skills and leadership qualities. Equally important is the need to increase the number of paramedical workers and training institutes in India.

Public health policyIdentification of health objectives and targets is one of the more visible strategies to direct the activities of the health sector, e.g. in the United States, the “Healthy People 2010” offers a simple but powerful idea by providing health objectives in a format that enables diverse groups to combine their efforts and work as a team. Similarly, in India, we need a road map to “better health for all” that can be used by states, communities, professional organizations and all sectors. It will also facilitate changes in resource

allocation for public health interventions and a platform for concerted intersectoral action, thereby enabling policy coherence.

Scope for further action in the health sectorSchool health, mental health, referral system and urban health remain as weak links in India's health system, despite featuring in the national health policy. School health programs have become almost defunct because of administrative, managerial and logistic problems. Mental health has remained elusive even after implementing the National Mental Health Program.On a positive note; innovative schemes through public-private partnerships

are being tried in various parts of the country in promoting referrals. Similarly, the much awaited National Urban Health Mission might offer solutions with regards to urban health.

ROLE OF GOVERNMENT IN ENABLING INTERSECTORAL COORDINATION TOWARD PUBLIC HEALTH ISSUESThe Ministry of Health needs to form stronger partnerships with other agents involved in public health, because many factors influencing the health outcomes are outside their direct jurisdiction. Making public health a shared value across the various sectors is a politically challenging strategy, but such collective action is crucial.

Social determinants of healthKerala is often quoted as an example in international forums for achieving a good status of public health by addressing the fundamental determinants of health: Investments in basic education, public health and primary care.

Living conditionsSafe drinking water and sanitation are critical determinants of health, which would directly contribute to 70-80% reduction in the burden of communicable diseases. Full coverage of drinking water supply and sanitation through existing programs, in both rural and urban areas, is achievable and affordable.

Urban planningProvision of urban basic services like water supply, sewerage and solid waste management needs special attention. The Jawaharlal Nehru National Urban Renewal Mission in 35 cities works to develop financially sustainable cities in

line with the Millennium Development Goals, which needs to be expanded to cover the entire country. Other issues to be addressed are housing and urban poverty alleviation.

Revival of rural infrastructure and livelihoodAction is required in the following areas: Promotion of agricultural mechanization, improving efficiency of investments, rationalizing subsidies and diversifying and providing better access to land, credit and skills.

EducationElementary education has received a major push through the Sarva Siksha Abhayan. In order to consolidate the gains achieved, a mission for secondary education is essential. “Right of children to Free and Compulsory education Bill 2009” seeks to provide education to children aged between 6 and 14 years, and is a right step forward in improving the literacy of the Indian population.

Nutrition and early child developmentRecent innovations like universalization of Integrated Child Development Services (ICDS) and setting up of mini-Anganwadi centers in deprived areas are examples of inclusive growth under the eleventh 5-year plan. The government needs to strengthen ICDS in poor-performing states based on experiences from other successful models, e.g., Tamil Nadu (upgrading kitchens with LPG connection, stove and pressure cooker and electrification; use of iron-fortified salt to address the burden of anemia). Micronutrient deficiency control measures like dietary diversification, horticultural intervention, food fortification, nutritional supplementation and other public health measures need intersectoral coordination with various departments, e.g., Women and Child Development, Health, Agriculture, Rural and Urban development.

Social security measuresThe social and economic spinoff of the Mahatma Gandhi Rural Employment Guarantee Scheme (MREGS) has the potential to change the complexion of rural India. It differs from other poverty-alleviation projects in the concept of citizenship and entitlement. However, employment opportunities and wages have taken the center stage, while development of infrastructure and community assets is neglected. This scheme has the necessary manpower to implement intersectoral projects, e.g., laying roads, water pipelines, social forestry, horticulture, anti-erosion projects and rain water harvesting. The

unlimited potential of social capital has to be effectively tapped by the government.

Food security measuresInnovations are required to strengthen the public distribution system to curb the inclusion and exclusion errors and increase the range of commodities for people living in very poor conditions. It is essential that the government puts forth action plans to increase domestic food grain production, raise consumer incomes to buy food and make agriculture remunerative.

Other social assistance programsThe Rashtriya Swasthiya Bima Yojana and Aam Admi Bhima Yojana are social security measures for the unorganized sector (91% of India's workforce). The National Old Age Pension scheme has provided social and income security to the growing elderly population in India.

Population stabilizationThere is all round realization that population stabilization is a must for ensuring quality of life for all citizens. Formulation of a National Policy and setting up of a National Commission on Population and Janasankhya Sthiratha Kosh reflect the deep commitment of the government. However, parallel developments in women empowerment, increasing institutional deliveries and strengthening health services and infrastructure hold the key to population control in the future.

Gender mainstreaming and empowermentWomen-specific interventions in all policies, programs and systems need to be launched. The government should take steps to sensitize service providers in various departments to issues of women. The Department of Women and Child Development must take necessary steps to implement the provisions of “Protection of Women from Domestic Violence Act, 2005.” Training for protection officers, establishment of counseling centers for women affected by violence and creating awareness in the community are vital steps. Poverty eradication programs and microcredit schemes need to be strengthened for economic and social empowerment of women.

Reducing the impact of climate change and disasters on health

Thermal extremes and weather disasters spread of vector-borne, food-borne and water-borne infections, food security and malnutrition and air quality with associated human health risks are the public health risks associated with climate change. Depletion of non-renewable sources of energy and water, deterioration of soil and water quality and the potential extinction of innumerable habitats and species are other effects. India's “National Action Plan on Climate Change” identifies eight core “national missions” through various ministries, focused on understanding climate change, energy efficiency, renewable energy and natural resource conservation. Although there are several issues concerning India's position under UNFCCC, it has agreed not to allow its per capita Greenhouse gas emissions to exceed the average per capita emissions of the developed countries, even as it pursues its social and economic development objectives.

The Ministry of Health, in coordination with other ministries, provides technical assistance in implementing disaster management and emergency preparedness measures. Deficient areas include carrying out rapid needs assessment, disseminating health information, food safety and environmental health after disasters and ensuring transparency and efficiency in the administration of aid after disasters. Implementation of Disaster Management Act, 2005 is essential for establishing institutional mechanisms for disaster management, ensuring an intersectoral approach to mitigation and undertaking holistic, coordinated and prompt response to disaster situations.

Community participationCommunity participation builds public support for policies and programs, generates compliance with regulations and helps alter personal health behaviors. One of the major strategic interventions under NRHM is the system of ensuring accountability and transparency through people's participation – the Rogi Kalyan Samitis. The Ministry of Health needs to define a clear policy on social participation and operational methods in facilitating community health projects. Potential areas of community participation could be lifestyle modification in chronic diseases through physical activity and diet modification, and primary prevention of alcohol dependence through active community-based methods like awareness creation and behavioral interventions.

Private sectors, civil societies and global partnershipsEffective addressing of public health challenges necessitates new forms of cooperation with private sectors (public-private partnership), civil societies, national health leaders, health workers, communities, other relevant sectors

and international health agencies (WHO, UNICEF, Bill and Melinda Gates foundation, World Bank).

Governance issuesIn order to ensure that the benefits of social security measures reach the intended sections of society, enumeration of Below Poverty Line families and other eligible sections is vital. Check mechanisms to stop pilferage of government funds and vigilance measures to stop corruption are governance issues that need to be attended. The government should take strict action in cases of diversion of funds and goods from social security schemes through law enforcement, community awareness and speedy redressal mechanisms. Social audits in MREGS through the Directorate of Social Audit in Andhra Pradesh and Rajasthan are early steps in bringing governance issues to the fore. This process needs strengthening through separate budgets, provisions for hosting audit results and powers for taking corrective action. Similar social auditing schemes can be emulated in other states and government programs like ICDS, which will improve accountability and community participation, leading to effective service delivery.

An introduction to India’s healthcare initiatives

Over the post-independence years India has launched several health programs. In this article we highlight a few such programs that have improved or have the potential to improve the health of India’s populace.

National Rural Health Mission (NRHM), Ministry of Health and Family Welfare

“Health is a State subject and the Government of India has always tried to work in partnership with States to meet people’s needs” wrote Mr. Ghulam Nabi Azad, Minister, Ministry of Health and Family Welfare, in a 5 year progress update of the NRHM. NRHM was launched in 2005 to provide accessible health services in rural areas. This agenda involved building infrastructure and healthcare staff with a female accredited social health activist (ASHA) in every village. The NRHM has been quite successful in achieving several of its projected targets. NRHM has significantly reduced the incidences of several diseases by increasing the number of health facilities (primary health centers and hospitals), care providers (ASHAs, doctors, nurses and paramedic staff) and community education. However, all of the NRHM’s expected outcomes have not materialized and there continues to be a critical shortage of trained medical professionals and access to medications.

National AIDS Control Organization (NACO), Department of AIDS

NACO aims to prevent HIV infection as well as offering support to HIV/AIDS patients. Its mission is accomplished by educating, counseling and testing services. Latest reports indicate that the number of new HIV infections has fallen by 50-60% and the current HIV/AIDS population, in India, is approximately 2 to 3.1million (3.4-9.4 million in 2002). However, infection rates continue to be high or increasing among certain subsets of the Indian population, that is, males (60%), those aged 15-49 years (89%), drug abusers (9%), homosexual males (6%) and female sex workers (5%).

Kerala Primary Health Care Model

In the 1990s, Kerala, aided by the high literacy rate (and hence high number of trained medical professionals) as well as organized local governance, embarked on a systematic approach of community involvement to establish a functional primary health care (PHC) centre in every village. Kerala attained an enviable drop in its infant and maternal death rates and increased life expectancy, at birth, to 70-76

years – well above the national average of 63-65 years. However, this model needs to be augmented with resources to address illnesses such as acute diarrhea diseases, measles, pneumonia, pulmonary tuberculosis and dengue.

High-potential game-changers

Besides inadequate infrastructure resources and medication inaccessibility the single-most weak point in India’s public health care change is the lack of qualified doctors and medical staff – a crucial connection between the patient and health services. Today, India produces only 50-60% of the doctors it requires for its medical needs of which only 2% join primary and community health centres to service 70% of its rural population. In order to address these shortages, the government has initiated and proposed several programs. A few of them are outlined below

Government Initiative

Purpose Issue(s) addressed

Telemedindia (Telemedicine in India)

Combines information and communication technologies (ICT) with Medical Science for clinical records, diagnostic tests, video consultations and medical education (several government and private healthcare networks established)

To increase healthcare services and education to rural (and remote) parts or under emergency conditions

Compulsory Licensing

Grant non-patent holder(s) permission to manufacture patented drugs not available at an affordable price (1st grant for cancer drug Nexavar in March 2012)

To increase accessibility to medications

Bachelor of Rural Health Care (BRHC)

A 3½ year rural health care course (proposed in Rajya Sabha)

To increase rural healthcare professionals

National Programme for Healthcare of the Elderly (NPHCE)

To be test-launched in 100 districts of the country in 2012-17.

To reduce the incidence of non-communicable illnesses in the elderly

National Programme for Prevention and Control of Cancer, Diabetes,

To be test-launched along with NPHCE in 100 districts of the country in 2012-17

To reduce the incidence of lifestyle/modern/developed world diseases

Cardiovascular Diseases and Stroke (NPCDCS)Free Medicines for All

Rs 28,560 crore plan to provide 348 medicines for all and must-prescribe generic drugs mandate to doctors (proposed 2012-2017)

To increase accessibility to medications

Healthcare for All by 2020

All residents will have healthcare coverage via a combination of public, employer and private sources. An entitlement package will include treatments, health promotion and disease prevention (proposed)

To uphold the fundamental right of all citizens to adequate health care

The Indian government is making a serious attempt to ensure the robust health of its citizens by implementing a variety of programs and schemes. The long-term success is eagerly awaited though difficult to predict.

Government’s Health expenditure

INTRODUCTIONIt is well known that health expenditure in India is dominated by private spending. To a large extent this is a reflection of the inadequate public spending that has been a constant if unfortunate feature of Indian development in the past half century. This is particularly unfortunate feature of the large positive externalities associated with health spending, which make health spending a clear merit good. The greater reliance on private delivery of health infrastructure & health services therefore means that overall these will be socially underprovided by private agents, & also denies adequate access to the poor. This in turn has adverse affects current social welfare & labour productivity, & of course harms future growth & development prospects.This is why the perceptions that government spending on health has been further undermined during the period of economic liberalization since the early 1990s create concern, & need to be investigated. This study seeks to examine the actual pattern of government spending on health & related areas (particularly, family welfare & child development) by both central & state governments. In this section, the theoretical arguments for public intervention & need for public expenditures in health are discussed, & the international experience in this regard is considered. In the following section, the broad patterns of aggregate health spending in India are analyzed, along with the shares of public & private expenditure & the significance of health spending in household budgets. The 3rd section contains an analysis of central government budgets on health, family welfare & child development over the period 1993-94 to 2003-04. The 4th section takes up the health budgets of state governments, with special attention to patterns in 15 major states. The 5th section considers some of the implications for health outcomes – not only life expectancy, infant mortality & similar indicator, but also evidence on morbidity. Some of the recently released results of NFHS-3 for 5 states are considered in relation to the evidence on government health expenditure in these states. The final section draws some preliminary conclusions & suggests areas of future research & specific question that merit more detailed investigation in the basis of these conclusions. THE THEORETICAL CASE FOR PUBLIC EXPENDITURE ON HEALTH There is a consensus among social scientists that health care is different from other goods & services, because of greater likelihood of ‘market failure’. The two main characteristics of health care which lead to market failure & thus necessitate state intervention are the presence of

externalities, the operation of market forces alone would lead to sub-optimal consumption & production of the relevant goods or service. This necessitates state intervention in order to ensure that sufficient resources are directed to the production of such goods or services, which in turn would result in an increase in the society’s welfare.It has been argued that such externalities are less evident for general health care services such as physician & hospital care & greater in the area broadly known as ‘public health’. The latter relate to interventions targeted at overall conditions of nutrition & sanitation that determine health, as well as communicable diseases which are passed either directly among humans or indirectly through the physical environment.An action taken by one person (e.g. ensuring clean, safe water, immunizing oneself against, or seeking treatment for, a communicable disease) generates direct health benefits for other individuals, through reduced rates of disease. Clearly, purely market-oriented or individually based activities would ignore the wider positive external effects, & therefore yield less than socially optimal levels of such activity. However, even general health care services hat apparently affect only individuals have positive externalities, not only because of the social costs of morbidity, but because inequalities in health care create other social concerns. These positive externalities make government intervention essential. Such intervention can take the form of price subsidies to encourage or spread the consumption of health care services, or direct public provision of such services.

The international experience

Health expenditure is highly unequal across the globe. As is to be expected, the developed countries spend the most on health per person. OECD countries accounted for less than 20% of the world’s population in the year 2000 but were responsible for almost 90% of the world’s health spending. Therefore 80% of world’s population spent only 10% of the total expenditure on health. This includes people in the Asia-Pacific as well as African & Latin American Countries. Africa accounts for about 25% of the global burden of disease but only about 2% of global health spending. (World Health Report, 2003). Similarly, health expenditure, both in terms of percentage of GDP spent on health & per capita health expenditure, is much higher in the developed countries, as evident from Table 1. The share of GDP spent on health ranges from a low of 1.6% in Azerbaijan to 13.9% in the USA. Similarly there is a very wide variation of per capita health expenditure across countries, which is typically extremely low in developing countries compared with most of the developed countries. The range in 2001 was from $14 in Ethiopia to $4877 in the USA.

SOURSE: World Health Report 2003, Human Development 2003 & UNTCAD Report 2002.

II. Patterns of health expenditure in India The first systematic analysis of the distribution of health spending in India by source of funds was published in the National Health Accounts of India, 2001-02. The results are shown in Chart 1, and confirm the widespread perception that private households account for the bulk of health expenditure. According to this estimate, households accounted for more than two-thirds of health spending in the country, and around three times the amount of all government expenditure taken together, by central, state and local governments. Employers (firms) account for only 5 per cent, but what is especially notable is the negligible role played by both external sources and others including NGOs. Despite the reported increase in foreign aid for dealing with HIV-AIDS and similar issues, all external sources taken together accounted for only 2 per cent of total health spending1, while NGOs accounted for only 0.3 per cent.

More recent estimates suggest that the role of households has increased even more substantially in the most recent period. According to the Report of the National Commission on Macroeconomics and Health, 2005, households undertook nearly three-fourths of all the health spending in the country. Public spending was only 22 per cent, and all other sources accounted for less than 5 per cent. As Table 2 shows, both the per capita spending and the share of households in this varied widely across states. Per capita spending in the state with the highest rate (Goa) is nearly 7 times that of per capita spending in the state with the lowest per capita spending (Meghalaya). Interestingly, the share of household spending is lowest in Meghalaya, but

was among the highest in Bihar which has relatively low per capita spending. There are many states where households undertake more than 80 per cent of all health spending, indicating an exceptionally high burden upon them. 1 However, some foreign aid – that going directly to governmental sources – is included in the health expenditure of central and state governments.

III. Central Government Health Expenditure Since 1993One of the more obvious indicators of inadequacy of public health spending in India is the very small amount of such spending relative to GDP. In developed countries, especially those with ageing populations, government health spending accounts for around 5% of GDP or more. Even in Asian developing countries excluding India, the average is around 3% of GDP. This makes it quite remarkable that India, which is currently seen internationally as an economic powerhouse & one of the success stories of global economic growth is the past decade, has government health expenditure amounting to less than 1% of GDP. Further, this ratio is not only low internationally, but is even low compared to past experience. As Chart 3 shows, even in the mid-1980s, health expenditure of central & state

government taken together was more than 1% of GDP, but now it is only around 0.9%. Further, it has fallen as low as around 0.8% in 2001-02. It is also significant that a greater proportion is taken up by revenue expenditure (essentially, the payment of salaries) rather than capital expenditure for creating much-needed basic physical infrastructure. Health is a concurrent subject under the Indian Constitution, but state governments are dominantly responsible for most health provision, both curative & public health aspects. However, in addition to direct central government spending on specific budget items, there is a range of centrally mandated expenditures which are also effectively spent by state governments, as well as some joint spending. While there are some specific central interventions, especially various “Missions” as well as high-end curative facilities, the bulk of the health provision that affects most of the citizenry is the result of spending by state governments. The National Rural Health Mission, which is a very recent central programme, involves only central expenditure. In contrast to public health, expenditure on family welfare by the central government appears to have increased in the aggregate as well as per capita. Within aggregate family welfare, the most important segment is family welfare services, which has accounted for around as increasing part of the total, from 38% in 1993-94 to 73% in 2006-07. Except for 2000-01, when both the aggregate & per capita spending on family welfare services fell, this broad category has shown a generally increasing trend, even in per capita terms.

IV. Health Expenditure of 14 state governments since 1993

According to the Indian Constitution, the health sector falls under the concurrent list & thus, the provision of public health care in India is a responsibility shares by both the Central & State governments. For state government health expenditure, the financing responsibility is this primarily that of the state government with some overlapping responsibilities in a series of centrally sponsored schemes. As noted earlier, state governments account for about two-thirds & the centre about one-third of the total public spending on health. However, there are of course large variations in this ratio across states.The total health budgetary allocation of any state government in India mainly consists of expenditures on the medical, public health & on the family welfare. In the allocation of medical health, the major head that are covered are the allocations on urban health services, rural health services & medical

education & training. The other major heads are the expenditures on the public health & family welfare. Here we analyze the behavior of the per capita health allocations under these major heads since 1993-94 to 2002-03 for 14 major states in India. (Bihar has been excluded because of data inadequacies.) In general, the budgetary head of family welfare showed much greater variation across the sub-periods than the other category. In states of Karnataka, Tamil Nadu, Uttar Pradesh & West Bengal, the rate of growth of budgetary allocations on Family Welfare increased in the second sub-period, despite declines in the rate of growth of total budgetary allocations. In Orissa, the opposite trend is clearly visible, with accelerated spending on medical & public health, but accelerated declines in spending on family welfare. Of course, what is more significant than aggregate spending is the per capita public spending on health & family welfare. This show very large variation across states, as is evident the absolute levels & change in per capita spending between 1993-94 & 2001-02 for the 14 states considered here. What is even more remarkable is the number of states that show a decline in real per capita spending under this head. In seven states- Assam, Gujarat, Haryana, Madhya Pradesh, Orissa, and Punjab & Uttar Pradesh – there were declines in per capita spending on family welfare in constant price terms. Once again, this decline has been sharpest in the Madhya Pradesh where the absolute level was already very low. But the declines are significant even in Punjab & Haryana, which are among wealthier states. Andhra Pradesh & Karnataka had growing allocations in terms, & relatively high per capita expenditure. In most of the states there is a wide rural-urban disparity in the per capita budgetary allocations of the state. The only exceptions to this are the states of Punjab & Rajasthan, where the real per-capita allocations in the rural & the urban health sectors have been almost at par. These two states the per capita allocations in the rural areas in the early 1990s even exceeded those in the urban areas, though marginally. However, subsequently urban has outpaced rural per capita expenditure even in these states, in line with the trend in other states and All-India. With reference to the rural-urban disparity, an interesting trend is exhibited by the state of Assam. While urban per capita allocations showed a declining trend, rural per capita allocation in the rural sector suggest a slightly rising

trend. Real per capita allocation for urban areas came down from Rs. 34.05 in 1993 to 11.49 in 2002-03. However, the same allocation for rural areas has gone up from Rs. 14.11 in 1993-94 to 18.57 in 2002-03, & is now significantly higher than the urban allocation.

V. Evidence on health outcomesIt is fairly obvious that these low & in several cases declining levels of spending on health & related items would have an impact on conditions of health among the citizenry, especially given that most of the population is poor & cannot afford to spend too much on health even if they are forced to spend more & more for private care. One major fallout of inadequate public spending that was highlighted in the first section is the high proportion of total health spending in India that is incurred by households, which is in sharp contrast to the picture in most other countries. Also, this pattern has worsened over time. The growing proportion of household consumption expenditure that is devoted to health, also noted in the first section, is at least partly if not substantially the result of inadequate or reduced public provision.

VI. Conclusions & directions for further researchThis is a preliminary study which has sought to consider the broad patterns of government spending on health & related areas in India in the recent past, & link them to observed health outcomes. The analysis has been conducted both at the central government level & for 14 major states. A number of important conclusions have been

High Level Expert Group on Universal Health Coverage

Pre-HLEG recommendations on Health for allThe idea of health care for all was present, though not explicitly, in the(i) BHORE COMMITTEE  Report of 1946; (ii) The Sokhey Committee report of 1948(iii) National Health Policy of Health 1983 and 2002.

India is also a signatory to the Universal Declaration of Human Rights that recognizes the right to a standard of living adequate for the health and well-being of himself and of his family…" The idea was

re-emphasized when India endorsed the "Health for All" declaration in Alma Ata in 1978 and endorsed the conclusions of the 1994 International Conference on Population and Development (ICPD) in Cairo

Formation, members, and mandateThe High-Level Expert Group (HLEG) on Universal victor (UHC) was constituted by the Planning Commission of India in October 2010, under the chairmanship of Prof. K. Srinath Reddy, with the mandate of developing a framework for providing easily accessible and affordable health care to all Indians. The other members of the expert group are: Abhay Bhang (Society for Education, Action and Research in Community Health), A.K. Shiva Kumar (member, National Advisory Council), Amarjeet Sinha (senior IAS officer), Anu Garg (Principal Secretary-cum-Commissioner (Health and Family Welfare department, Orissa), Gita Sen (Centre for Public Policy, IIM Bangalore), G.N. Rao (Chair of Eye Health, L.V. Prasad Eye Institute, Hyderabad), Jashodhara Dasgupta (SAHYOG, Lucknow), Leila Caleb Varkey (Public Health researcher), Govinda Rao (Director, National Institute of Public Finance and Policy), Mirai Chatterjee (Director, Social Security, SEWA), Nachiket Mor (Sughavazhu Healthcare), Vinod Paul (AIIMS), Yogesh Jain (Jan Swasthya Sahyog, Bilaspur), a representative of the Ministry of Health and Family Welfare, and N.K. Sethi (Advisor (Health), Planning Commission). Definition of Universal Health CoverageHLEG defined UHC for the purpose of report as follows:

 “Ensuring equitable access for all Indian citizens, resident in any part of the country, regardless of income level, social status, gender, caste, or religion, to affordable, accountable, appropriate health services of assured quality (promotive, preventive, curative, and rehabilitative) as well as public health services addressing the wider determinants of health delivered to individuals and populations, with the government being the guarantor and enabler, although not necessarily the only provider, of health and related services”

Recommendations of the High Level Expert Group (HLEG)The recommendations of the High Level Expert Group (HLEG) on Universal Health Coverage encompass the area of health financing, health services norms, human resources for health, community participation and citizen engagement, access to medicines, vaccines and technology and management and institutional reforms. The recommendations of the HLEG, inter-alia, include:Increase public expenditure on health to at least 2.5 percent of GDP by the end of the 12th Plan and to at least 3% of GDP by 2022. 

Ensure availability of free essential medicines by increasing public spending on drug procurement.

Purchase of all health care services under the Universal Health Coverage (UHC) system should be undertaken either directly by the Central and state governments through their Departments of Health or by quasi-governmental autonomous agencies established for the purpose.

All government funded insurance schemes should, over time, be integrated with the UHC system. All health insurance cards should, in due course, be replaced by National Health Entitlement Cards. The technical and other capacities developed by the Ministry of Labour for the Rashtriya Swasthya Bima Yojana should be leveraged as the core of UHC operations and transferred to the Ministry of Health and Family Welfare.

Develop a National Health Package that offers, as part of the entitlement of every citizen, essential health services at different levels of the health care delivery system.

Reorient health care provision to focus significantly on primary health care.

Strengthen District Hospitals. Ensure adequate numbers of trained health care providers and technical

health care workers at different levels by

a) giving primacy to the provision of primary health care b) Increasing Human Resources for Health (HRH) density to achieve

WHO norms of at least 23 health workers (doctors, nurses, and midwives).

Establish District Health Knowledge Institutes (DHKIs).  Establish the National Council for Human Resources in Health (NCHRH). Transform existing Village Health Committees (or Health and

Sanitation Committees) into participatory Health Councils. Ensure the rational use of drugs. Set up national and state drug supply logistics corporations. Empower the Ministry of Health and Family Welfare to strengthen the

drug regulatory system. Introduce All India and state level Public Health Service Cadres and a

specialized state level Health Systems Management Cadre in order to give greater attention to public health and also strengthen the management of the UHC system.

Establishment of National Health Regulatory and Development Authority (NHRDA).

National Drug Regulatory and Development Authority (NDRDA): The main aim of NDRDA should be to regulate pharmaceuticals and

medical devices and provide patients access to safe and cost effective products.

TWELFTH FIVE YEAR PLAN

StrategyBased on the recommendation of HLEG and other stakeholder consultations, the key elements of Twelfth Five Years plan strategy is outlined. The long term objective of this strategy is to establish a system of Universal Health Coverage (UHC) in the country. Following are the 12th plan period strategy:

1. Substantial expansion and strengthening of public sector health care system, freeing the vulnerable population from dependence on high cost and often unreachable private sector health care system.

2. Health sector expenditure by central government and state government, both plan and non-plan will have to be substantially increased by the twelfth five year plan. It was increased from 0.94 per cent of GDP in tenth plan to 1.04 per cent in eleventh plan. The provision of clean drinking water and sanitation as one of the principal factors in control of diseases is well established from the history of industrialized countries and it should have high priority in health related resource allocation. The expenditure on health should increase to 2.5 per cent of GDP by the end of Twelfth Five Year Plan.

3. Financial and managerial system will be redesigned to ensure efficient utilization of available resources and achieve better health outcome. Coordinated deliveries of services within and across sectors, delegation matched with accountability, fostering a spirit of innovation are some of the measures proposed.

4. Increasing the cooperation between private and public sector health care providers to achieve health goals. This will include contracting in of services for gap filling, and various forms of effectively regulated and managed Public-Private Partnership, while also ensuring that there is no compromise in terms of standards of delivery and that the incentive structure does not undermine health care objectives.

5. The present Rashtriya Swasthya Bhima Yojana (RSBY) which provides cash less in-patient treatment through an insurance based system should be reformed to enable access to a continuum of comprehensive primary, secondary and tertiary care. In twelfth plan period entire Below Poverty Line (BPL) population will be covered through RSBY scheme. In planning health care structure for the future, it is desirable to move from a 'fee-for-service' mechanism, to address the issue of fragmentation of services that works to the detriment of preventive and primary care and also to reduce the scope of fraud and induced demand.

6. In order to increase the availability of skilled human resources, a large expansion of medical schools, nursing colleges, and so on, is therefore is necessary and public sector medical schools must play a major role in the process. Special effort will be made to expand medical education in states which are under-served. In addition, a massive effort will be made to recruit and train paramedical and community level health workers.

7. The multiplicity of Central sector or Centrally Sponsored Schemes has constrained the flexibility of states to make need based plans or deploy their resources in the most efficient manner. The way forward is to focus on strengthening the pillars of the health system, so that it can prevent, detect and manage each of the unique challenges that different parts of the country face.

8. A series of prescription drugs reforms, promotion of essential, generic medicine and making these universally available free of cost to all patients in public facilities as a part of the Essential Health Package will be a priority.

9. Effective regulation in medical practice, public health, food and drugs is essential to safeguard people against risks and unethical practices. This is especially so given the information gaps in the health sector which make it difficult for individual to make reasoned choices.

10. The health system in the Twelfth Plan will continue to have a mix of public and private service providers. The public sector health services need to be strengthened to deliver both public health related and clinical services. The public and private sectors also need to coordinate for the delivery of a continuum of care. A strong

regulatory system would supervise the quality of services delivered. Standard treatment guidelines should form the basis of clinical care across public and private sectors, with the adequate monitoring by the regulatory bodies to improve the quality and control the cost of care.

CriticismThe 12th five year plan document on health has received a lot of criticism for its limited understanding of universal health care and failure to increase public expenditure on health. While the HLEG report recommends an increase in public expenditure on health from 1.58 per cent of GDP currently to 2.1 per cent of GDP by the end of 12th five year plan it is far lower than the global median of 5 per cent. The lack of extensive and adequately funded public health services pushes large numbers of people to incur heavy out of pocket expenditures on services purchased from the private sector. Out of pocket expenditures arise even in public sector hospitals, since lack of medicines means that patients have to buy them. This results in a very high financial burden on families in case of severe illness. Though, the 12th plan document express concern over high out-of-pocket (OOP) expenditure, it does not give any target or time frame for reducing this expense. OOP can be reduced only by increasing public expenditure on health and by setting up wide spread public health service providers. But the planning commission is planning to do this by regulating private health care providers.  It takes solace from the HLEG report which admits that, "the transformation of India’s health system to become an effective platform for UHC is an evolutionary process that will span several years".Instead of developing a better public health system with enhanced health budget, 12th five year plan document plans to hand over health care

system to private institutions. The 12th plan documents express concern over Rashtriya Swasthya Bhima Yojana being used as a medium to hand over public funds to private sector through insurance route. This has also incentivized unnecessary treatment which in due course will increase costs and premiums. There has being complaints about high transaction cost for this scheme due to insurance intermediaries. RSBY does not take into consideration state specific variation in disease profiles and health needs. Even though these things are acknowledged in the report, no alternative remedy is given. There is no reference to nutrition as key component of health and for universal Public Distribution System (PDS) in the plan document or HLEG recommendation. In the section of National Rural Health Mission (NRHM) in the document, the commitment to provide 30-50 bed Community Health Centers (CHC) per lakh population is missing from the main text. It was east for the government to recruit poor women as ASHA (Accredited Social Health Activist) workers but it has failed to bring doctors, nurses and specialist in this area. The ASHA workers who are coming from a poor background are given incentive based on performance. These people lose many days job undertaking their task as ASHA worker which is not incentivized properly. Even the 12th plan doesn't give any solace.

Quality

The quality of Indian healthcare is varied. In major urban areas, healthcare is of adequate quality, approaching and occasionally meeting Western standards. However, access to quality medical care is limited or unavailable in most rural areas, although rural medical practitioners are highly sought after by residents of rural areas as they are more financially affordable and geographically accessible than practitioners working in the formal public health care sector.

Health issuesMalnutritionAccording to a 2005 report, 42% of India’s children below the age of three were malnourished, which was greater than the statistics of sub-Saharan African region of 28%.Although India’s economy grew 50% from 2001–2006, its child-malnutrition rate only dropped 1%, lagging behind countries of similar growth rate. Malnutrition impedes the social and cognitive development of a child, reducing his educational attainment and income as an adult. These irreversible damages result in lower productivity. High infant mortality rate

Approximately 1.72 million children die each year before turning one. The under five mortality and infant mortality rates have been declining, from 202 and 190 deaths per thousand live births respectively in 1970 to 64 and 50 deaths per thousand live births in 2009. However, this decline is slowing. Reduced funding for immunization leaves only 43.5% of the young fully immunized. A study conducted by the Future Health Systems Consortium in Murshidabad, West Bengal indicates that barriers to immunization coverage are adverse geographic location, absent or inadequately trained health workers and low perceived need for immunization. Infrastructure like hospitals, roads, water and sanitation are lacking in rural areas. Shortages of healthcare providers, poor intra-partum and newborn care, diarrheal diseases and acute respiratory infections also contribute to the high infant mortality rate.

DiseasesDiseases such as dengue fever, hepatitis, tuberculosis, malaria and pneumonia continue to plague India due to increased resistance to drugs. In 2011, India developed a totally drug-resistant form of tuberculosis. India is ranked 3rd highest among countries with the amount of HIV-infected patients. Diarrheal diseases are the primary causes of early childhood mortality. These diseases can be attributed to poor sanitation and inadequate safe drinking water in India. India also has the world's highest incidence of However in 2012 India was polio-free for the first time in its history. This was achieved because of the Pulse Polio Programme started in 1995-96 by the government of India. Indians are also at particularly high risk for atherosclerosis and coronary artery disease. This may be attributed to a genetic predisposition to metabolic syndrome and adverse changes in coronary artery vasodilatations. NGOs such as the Indian Heart Association  and the Medwin Foundation have been created to raise awareness of this public health issue.

HepatitisBased on the prevalence of Hepatitis B carrier state in the general population, countries are classified as having high (8% or more), intermediate (2-7%), or low (less than 2%)  HepatitisB, virus(HBV) endemicity. India is at the intermediate endemic level of hepatitis B, with hepatitis B surface antigen (HBsAg) prevalence between 2% and 10% among the populations studied.  The prevalence does not vary significantly by region in the country. The number of HBsAg carriers in India has been estimated to be over 40 million (4 crore). The prevalence of Hepatitis C is estimated to be in the range of 1.8-2.5 per cent.

Poor SanitationAs more than 122 million households have no toilets, and 33% lack access to latrines, over 50% of the population (638 million) defecate in the open.(2008 estimate) This is relatively higher than Bangladesh and Brazil (7%) and China (4%). Although 211 million people gained access to improved sanitation from 1990–2008, only 31% use the facilities provided. Only 11% of Indian rural families dispose of stools safely whereas 80% of the population leave their stools in the open or throw them in the garbage. Open air defecation leads to the spread of disease and malnutrition through parasitic and bacterial infections. Safe drinking waterAccess to protected sources of drinking water has improved from 68% of the population in 1990 to 88% in 2008. However, only 26% of the slum population has access to safe drinking water, and 25% of the total population has drinking water on their premises. This problem is exacerbated by falling levels of groundwater caused mainly by increasing extraction for irrigation. Insufficient maintenance of the environment around water sources, groundwater pollution, excessive arsenic and fluoride in drinking water pose a major threat to India's health.

Female health issuesWomen's health in India involves numerous issues. Some of them include the following:

Malnutrition : The main cause of female malnutrition in India is the tradition requiring women to eat last, even during pregnancy and when they are lactating.

Breast Cancer : One of the most severe and increasing problems among women in India, resulting in higher mortality rates.

Stroke Polycystic ovarian disease (PCOD ) : PCOD increases the infertility rate in females.

This condition causes many small cysts to form in the ovaries, which can negatively affect a woman's ability to conceive.

Maternal Mortality : Indian maternal mortality rates in rural areas are one of the highest in the world.

Rural health

Rural India contains over 68% of India's total population, and half of all residents of rural areas live below the poverty line , struggling for better and easy access to health care and services. Health issues confronted by rural people are many and diverse – from severe malaria to uncontrolled diabetes, from a badly infected wound to cancer. Postpartum maternal illness is a serious problem in resource-poor settings and contributes to maternal mortality, particularly in rural India. A study conducted in 2009 found that 43.9% of mothers reported they experienced postpartum illnesses six weeks after delivery.

Health care system

Public and private sector

According to National Family Health Survey-3, the private medical sector remains the primary source of health care for 70% of households in urban areas and 63% of households in rural areas. Reliance on public and private health care sector varies significantly between states. Several reasons are cited for relying on private rather than public sector; the main reason at the national level is poor quality of care in the public sector, with more than 57% of households pointing to this as the reason for a preference for private health care. Other major reasons are distance of the public sector facility, long wait times, and inconvenient hours of operation. The study conducted by IMS Institute for Healthcare Informatics in 2013, across 12 states in over 14,000 households indicated a steady increase in the usage of private healthcare facilities over the last 25 years for both Out Patient and In Patient services, across rural and urban areas. National Rural Health Mission

A community health center in Kerala.The National Rural Health Mission (NRHM) was launched in April 2005 by the Government of India. The goal of the NRHM was to provide effective healthcare to rural people with a focus on 18 states which have poor public health indicators and/or weak infrastructure.

CONCLUSIONIn this changing world, with unique challenges that threaten the health and well-being of the population, it is imperative that the government and community collectively rise to the occasion and face these challenges simultaneously, inclusively and sustainably. Social determinants of health

and economic issues must be dealt with a consensus on ethical principles – universalism, justice, dignity, security and human rights. This approach will be of valuable service to humanity in realizing the dream of Right to Health. The ultimate yardstick for success would be if every Indian, from a remote hamlet in Bihar to the city of Mumbai, experiences the change.It is true that a lot has been achieved in the past: The milestones in the history of public health that have had a telling effect on millions of lives – launch of Expanded Program of Immunization in 1974, Primary Health Care enunciated at Alma Ata in 1978, eradication of Smallpox in 1979, launch of polio eradication in 1988, FCTC ratification in 2004 and COTPA Act of 2005, to name a few. It was a glorious past, but the future of a healthy India lies in mainstreaming the public health agenda in the framework of sustainable development. The ultimate goal of great nation would be one where the rural and urban divide has reduced to a thin line, with adequate access to clean energy and safe water, where the best of health care is available to all, where the governance is responsive, transparent and corruption free, where poverty and illiteracy have been eradicated and crimes against women and children are removed – a healthy nation that is one of the best places to live in.

BIBLIOGRAPHY

wikipedia.org economictimes.indiatimes.com government website www.ncbi.nlm.nih.gov